Presenting the keynote speech at the AOA conference, U.S. Surgeon General David Satcher, M.D., called for intensified efforts to combat obesity, which he identified as one of the few national health problems that are worsening. "Obesity is a major public health problem in this country and one that deserves much more attention than it has received," said Dr. Satcher, who is only the second surgeon general to concurrently hold the position of Assistant Secretary for Health.
Dr. Satcher, who heads the U.S. Public Health Service, said that the trend toward obesity seriously undermined his office’s efforts to improve the well-being of the population. "Unless we are able to deal with the problem of obesity, we are going to struggle significantly," he said.
A dramatic increase in obesity has been observed since the implementation, in 1990, of Healthy People 2000, a document which helps direct public health policy for federal and state governments. In an overview of U.S. health objectives from Healthy People 2000, Dr. Satcher acknowledged that obesity is among 20% of objectives moving in the wrong direction - away from progress. Other health conditions that are moving in the wrong direction are diabetes, asthma (especially asthma in children, which has tripled since1980), and physical inactivity. All of these areas are in some way associated with obesity. Approximately 60% of objectives are being attained, while another 20% cannot be measured.
"The American people have come to expect a special kind of leadership from the Surgeon General, especially in plowing new ground in terms of emphasis," stated Dr. Satcher. Drawing on history, he cited encouraging examples of public health crises that have been alleviated. Since 1900, life expectancy in the U.S. has increased by 30 years, small pox has been eradicated worldwide, polio has been eliminated from the Western Hemisphere, and measles is fading. Since 1980, deaths from injuries have dropped by 40%. Since 1990, deaths from cardiovascular disease have fallen by almost 20%, and there has been a dramatic decline in infant mortality, a decline in teenage pregnancy and homicides in the U.S.
Healthy People 2010 Goals
Healthy People 2010 has two goals, both of which, Dr. Satcher pointed out to be relevant to obesity. They are: 1) to eliminate disparities in health on the basis of race and ethnicity, and 2) to improve and increase the quality as well as quantity of life. The focus on quality of life requires attention to disability, including chronic low back pain, arthritis and obesity.
AOA started its mission to advocate for the listing of obesity as a Leading Health Indicator for Healthy People 2010 less than one year ago. Now, obesity is slated to be one of 12 Leading Health Indicators for Healthy People 2010 to be followed closely over a 10-year period, as recommended by the Institute of Medicine. An official announcement is forthcoming in January, 2000. According to Dr. Satcher, making recommendations to the public about their weight is a responsibility of the government.
More than half of the adults in the country today are overweight or obese, according to the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC). The prevalence of overweight and obesity in adults has increased in the last 15 years by more than 20%, and most of the increase is attributable to the obesity component. Dr. Satcher said that despite recent changes in the definition of obesity, the inadequacy of public health surveillance systems, and the confusion that sometimes occurs because of those changes, "there is no question about the fact that obesity is at an all time high in this country."
The prevalence of obesity among youth has more than doubled in the last 15 years, which is a major concern for the public health service. The dramatic increase in type 2 diabetes in U.S. children due to obesity appeared to be an incredulous fact to Dr. Satcher, who recalled being taught during his medical training to look for type 2 diabetes in adults over 30 or 40 years of age. Today, type 2 diabetes is diagnosed in children under 10 years of age, many of which live on American Indian reservations and in inner cities. Among teenagers, physical inactivity, poor nutrition and smoking have increased as well.
"The real key here is that as we look to the future, it’s very clear that some of the diseases that we feel that we are conquering in terms of chronic illnesses, have their root in childhood," said Dr. Satcher. "If we don’t get a handle on the risk factors in childhood, including being able to deal with the disease of obesity, then we have to look forward to a future in which there are going to be more and more people suffering from diabetes and hypertension and various forms of cardiovascular diseases."
Illustrating racial and ethnic disparities in health, overweight and obesity are particularly common among Hispanic, African American and Pacific Islander women. African American women and Hispanic women have the highest rates of obesity among U.S. adults, trends that have increased in recent years. These trends, as Dr. Satcher observed, propose very serious risks for cardiovascular disease, the cause of over 40% of American deaths, and diabetes.
Priorities for Health Care
Proposals from the Surgeon General’s office to improve health care include the following:
A Balanced Community Health System, which combines health promotion, disease prevention, early detection and universal access to care.
A Balanced Research Agenda, which supports research into basic biomedical areas, clinical and health services, and behavioral and community-based prevention.
According to Dr. Satcher, the Department of Health and Human Services (DHHS), is moving toward a more balanced system. However, Congress makes the funding decisions for DHHS and thus, needs to be better educated about the importance of a balanced community health system and a balanced research agenda.
With almost $1.3 trillion in spending per year (nearly $4,500 per capita), the U.S. health care system is larger than that of any other nation in the world. Yet, less than 3% is spent for prevention, and 44 million people remain uninsured. In addition, there are other people who are underinsured - who have insurance that is not adequate to cover what they need - and people who live in underserved communities, where there is a lack of service providers even for those with insurance.
In underserved communities, 67% of the people are African American and Hispanic, and yet they constitute less than 25% of the population. African Americans and Hispanics are also under-represented. Dr. Satcher emphasized that the health care system needs to reflect the community it serves. ³People need to feel that they can find people in the health care system who understand their culture, who speak their language and who are definitely sympathetic with the
struggles that they have in terms of lifestyles," he said.
In terms of prevention, the Surgeon General called it "humane," and "human medicine at its best." Dr. Satcher spoke on the focus of prevention and its need to save not only dollars, but also to spare unnecessary pain, suffering and death. Of approximately 2.2 million deaths per year, over half are directly attributable to human behavior including over 430,000 from smoking, over 300,000 from physical inactivity and poor nutrition, and over 100,000 from alcohol and other drug abuse. Dr. Satcher admitted to the difficulty of dealing with lifestyles and that the public health service struggles with health issues related to behavior.
Prescriptions for Behavior Change
As a strategy to improve health issues related to behavior, the Surgeon General developed prescriptions for the nation. Two prescriptions are listed below.
Moderate physical activity at least five days per week at 30 minutes per day. Dr. Satcher pointed out that prescriptions such as this one, derived from the Surgeon General’s Report on Physical Activity, are very good, but must be delivered directly to the
American people where they live, work and play. Physical activity in this country is decreasing particularly among children. The
CDC’s Youth Risk Behavioral Survey shows that the proportion of U.S. teenagers, in grades 9 to 12, taking physical education classes dropped from 45% in 1991 to 23% by 1997. Additionally, only one state in the country (Illinois) requires physical education in grades K to 12. Dr. Satcher suggested that more adults commit to becoming involved in youth recreational activities, an
area which he said has been waning in recent years.
Eat at least five servings of fruits and vegetables per day. (For weight loss, there are specific prescriptions to meet to assure proper nutrition.) The Surgeon General’s prescription was developed with the recognition that the American diet is high in fats and sweets, and deficient in grains, fruits and vegetables. While the prescription focuses on content, the Surgeon General
acknowledged that for weight loss a caloric deficit is necessary, and that the inclusion of physical activity is key to controlling
weight. Dr. Satcher stressed that people, both young and old, be aware that physical activity and nutrition bring benefits not only in
saving lives, but also in improving the quality of life.
In closing, Dr. Satcher remarked that AOA’s conference was an exampleof the partnerships that are needed to
meet the challenges of obesity in the 21st century. The public health community, the food industry, the restaurant industry, the worksite, schools, community organizations and sports organizations, among others, could join in such partnerships, he said.
These partnerships may help to move policy in the right direction and implement weight-control programs, especially at the community level. Encouraged by the conference, Dr. Satcher said that he "would like to remember this day as a time when we combine in a new way, across various disciplines to work toward dealing with the problem of obesity in this country as never before, and moving this country to a new state in public health relative to obesity."
