1.3. Increase the proportion of adults, adolescents, and children who understand that excess weight is caused by an interaction of genetic (inherited) and environmental (social and cultural) factors, which include metabolic (chemical reactions of biological molecules) and behavioral (psychological and emotional) components.

Overweight and obesity are multi-factorial in origin, reflecting inherited, metabolic, behavioral, environmental, cultural, and socioeconomic conditions. Approximately one-third of individual differences in body fat content, measured by BMI, could be due to genetics. Having biological family members with obesity increases the risk for an individual to develop obesity, and the magnitude of risk increases with the severity of a family member’s obesity. Individuals genetically prone to obesity must particularly learn about energy balance principles and implement lifelong weight management strategies.15

In some cases, weight gain is caused by one or more medical conditions that compromise the body’s metabolic function. Research is needed to further explore the causes and mechanisms of obesity. Societal understanding of the many causes of obesity may help to reduce stigma and discrimination associated with obesity, and may reduce eating disorders caused by negative body image. A more informed public may also deter false advertising of unproven and ineffective weight loss products and services.

1.4. Increase the proportion of overweight or obese adults, adolescents, and children who understand that even a modest amount of weight loss can reduce the severity of illness associated with excessive body fat.

Approximately 40% of women and 25% of men are attempting to lose weight at any given time, and 30% each actively seek to maintain current weight.16,17 The public and health professionals are often frustrated by failure to achieve weight loss or to maintain a successful weight loss. For many years, the goal of obesity therapy was to reduce excess weight to achieve an ideal body weight. In many cases, reaching ideal weight is an unattainable goal requiring a significant weight loss.18

Current clinical strategy focuses on reducing initial body weight by 10% to 15%. Meeting this goal can reduce weight-related complications including high blood pressure, diabetes and high cholesterol, and in many cases, can control social-psychological complications.18 A 5% to 10% reduction of body weight (a 5-unit BMI change) in severely obese surgical patients, has reportedly reduced both the duration of hospitalization and the incidence of postoperative procedures.19 Successful intentional weight losses have also resulted in reduced mortality.4

Not everyone should attempt to lose weight. Individuals at a healthy weight, with a healthy level of abdominal fat and no significant health complications should prevent weight gain through healthy behaviors and with advice from a health professional.18 Special populations who should avoid weight loss include most pregnant or lactating women, patients with various serious illnesses whose conditions may worsen from weight loss and persons with serious psychiatric illnesses.4

1.5. Increase the proportion of adults, adolescents, and children who understand that pharmacological and surgical interventions are medical treatment options for individuals with obesity, and that these interventions be discussed with appropriate medical professionals.

Pharmacotherapy, for weight loss and weight management, requires the use of medication. Pharmacotherapy is recommended, in combination with diet and physical activity, for individuals with a BMI of 30 or greater with no concomitant obesity-related risk factors or diseases, or individuals with a BMI of 27 or greater with concomitant obesity-related risk factors or diseases. Surgical therapy is recommended for well-informed, motivated patients whose weight loss efforts have failed with less invasive therapies, and who have a BMI of 40 or greater, or a BMI of 35 or greater with co-morbid conditions and acceptable operative risks.4

Medications for treating children with obesity have not yet been thoroughly studied or approved, but there is hope that pharmacotherapy will allow for safe and effective treatment of the most severe cases of childhood obesity. 20 The increase in pharmacotherapy to treat obesity-related diseases in children, such as diabetes and hypertension, has created the need to investigate the benefits of attacking the primary problem of obesity with medication.

1.6. Increase the proportion of adults and adolescents who understand how to set reasonable weight goals.

Setting reasonable weight loss goals involves the understanding that small to moderate weight loss over a prolonged period of time is more effective than regaining weight from a dramatic weight loss.4 Weight loss of more than 10% to 15% is difficult for most people to achieve or maintain through diet, exercise or medication. Providing patients with unattainable goals, without a means for reaching those goals, is unrealistic.18 Health care professionals can assist patients with setting and revising weight loss goals.

1.7. Increase the proportion of mothers who understand that maternal obesity is associated with risk of birth defects to infants.

The incidence of obesity during pregnancy is reported to be between 6% and 10%, and possibly as high as 17%. Maternal obesity has been associated with an increased incidence of neural tube defects (NTD), even in obese women who take folate.21 Women with a BMI of 31 or greater, compared with a reference group, have been found to be at an increased risk of having an infant with spina bifida, non-neural tube defects of the central nervous system, great vessel defects, ventral wall defects and other intestinal defects.22

Pregnant women should be instructed on determining healthy levels of weight gain at various stages of a pregnancy to prevent complications from maternal obesity. Healthy weight gain, education on appropriate nutrition, and type and intensity of physical activity are important components of a healthy pregnancy that health professionals must teach their patients and monitor closely.

Introduction

According to the National Institutes of Health, 55% or 97 million adults in the United States are overweight or obese. At least 33% (58 million) of adults are considered overweight (BMI of 25.0 - 29.9), and 22% (39 million) are obese (BMI > 30.0).4 As recent as 1980, the prevalence of both overweight and obesity has increased dramatically, and has since shown no sign of improvement.

Approximately 25% of children and adolescents are overweight, a figure which has doubled in 30 years. 23 Diabetes, hypertension and other obesity-related chronic diseases, prevalent among adults, are now becoming more common among youth. Excess weight during childhood and adolescence has been found to predict overweight for adults. This trend, along with prevalence data for youth and adults, suggests that quality and quantity of life are compromised if obesity is not contained.

Persons with obesity are at risk of developing one or more serious medical conditions. Obesity is associated with more than 30 medical conditions. Strong relationships have been scientifically established between obesity and at least 15 conditions, including arthritis, breast cancer, heart disease, colorectal cancer, type 2 diabetes, endometrial cancer, end-stage renal disease, galbladder disease, hypertension, liver disease, low back pain, renal cell cancer, obstructive sleep apnea, stroke, and urinary incontinence.1,4,5,13 Evidence continues to mount linking obesity and several other diseases, disorders, conditions, and complications.

Poor diet and inactivity, contributors of obesity, are responsible for between 300,000 and 587,000 deaths a year, making it the second leading cause of preventable death in the U.S.24 Lifelong management of obesity, using strategies such as lifestyle changes in diet and physical activity, drug therapy and surgery, is essential to improving health, maintaining an improved health status for a longer time, reducing absenteeism in the workplace, and reducing healthcare costs.

Objectives for Improving Weight Status

Number Objective

2.1 Stabilizing weight

2.2 Achieving and maintaining healthy weight

2.3 Prevalence of healthy weight

2.4 Obesity prevalence in adults

2.5 Overweight prevalence in adults

2.6 Obesity prevalence in children and adolescents

2.7 Physical Activity for adult weight control

2.8 Physical Activity for weight control in children

2.9 Nutrition for adult weight control

2.10 Nutrition for weight control in children

2.11 Compliance of recommendations for maternal weight gain

2.12 Obesity as a risk factor for diseases

2.13 Absenteeism in the workplace due to obesity

2.1. Increase the proportion of adults who stabilize their body weight or BMI by adopting or maintaining sound principles of weight maintenance.

Persons who are overweight or have obesity should first keep their weight from increasing before undertaking any well-established method of weight loss. Overweight persons or those with obesity, who have been unsuccessful at weight loss or maintenance of weight loss, should focus on sustaining a stable current body weight to prevent further weight gain. Adults, persons of about 21 years of age who have reached peak growth, who have a healthy weight, should stabilize or maintain their weight throughout life to prevent weight gain.25

2.2. Increase the proportion of adults, adolescents, and children who implement sound principles of achieving or maintaining a healthy weight, which includes healthful eating, regular physical activity, and behavioral strategies.

One of the factors involved in the causation of obesity is lifestyle. The most common lifestyle influences on obesity are poor dietary habits and physical inactivity. Strategies that address these factors are necessary for prevention and intervention.4

The U.S. Surgeon General has developed a prescription for the nation to improve health issues related to behavior, including 1) participating in moderate physical activity, at least five days per week at 30 minutes per day, and 2) eating at least five servings of fruits and vegetables per day. For weight loss, the Surgeon General suggests the need for a caloric deficit combined with physical activity. 3

Behavior therapy is a common intervention that encompasses principles and techniques used to modify eating and exercise habits. This therapy is designed to increase skills such as recognizing how many calories or fat grams are in foods, or how to increase physical activity. An important element of behavior therapy is also knowing that genetic predisposition contributes to obesity – that in some cases excess weight is more than simply eating too much or exercising too little. 4,18

2.3. Increase to at least 60 percent the prevalence of healthy weight, BMI equal to or greater than 19.0 and less than 25.0, among all people aged 20 and older. (Healthy People 2010 Draft objective. Baseline: from 1988 to 1994, 41 percent of all people aged 20 years and older were at a healthy weight, 39 percent of males and 44 percent of females) 2

Select Populations 1988-94

African American, non-Hispanic male aged 20+ 41%

American Indian/Alaska Native male aged 20+ Not available

Asian/Pacific Islander male aged 20+ Not available

Hispanic male aged 20+ Not available

Mexican American male aged 20+ 34%

White, non-Hispanic male aged 20+ 38%

African American, non-Hispanic female aged 20+ 30%

American Indian/Alaska Native female aged 20+ Not available

Asian/Pacific Islander female aged 20+ Not available

Hispanic female aged 20+ Not available

Mexican American female aged 20+ 32%

White, non-Hispanic female aged 20+ 47%

Male aged 20-39 47%

Male aged 40-59 31%

Male aged 60+ 33%

Female aged 20-39 52%

Female aged 40-59 39%

Female aged 60+ 36%

0-130% of poverty threshold 39%

>130% of poverty threshold 42%

Male with hypertension aged 20+ 24%

Male without hypertension aged 20+ 44%

Female with hypertension aged 20+ 28%

Female without hypertension aged 20+ 49%

Male with diabetes aged 20+ Not available

Male without diabetes aged 20+ Not available

Female with diabetes aged 20+ Not available

Female without diabetes aged 20+ Not available

Male with arthritis aged 20+ Not available

Male without arthritis aged 20+ Not available

Female with arthritis aged 20+ Not available

Female without arthritis aged 20+ Not available

Normal weight individuals have become a minority population. This trend has become an accepted norm at a time when the public health community has identified obesity as an epidemic. Public health initiatives are needed to prevent new cases of overweight and obesity and to treat overweight and obesity. 26,27 Weight management programs must be developed to address the needs of some persons, who are overweight or have obesity, that realistically may be unable to reach a healthy weight. In these cases, small to moderate weight losses can result in various health improvements. Levels of care, from self-help to medically supervised, can be determined by a patient’s BMI and medical history to achieve optimal weight for better long-term health and quality of life. 18

2.4. Reduce to less than 15 percent the obesity prevalence, BMI of 30.0 or above, among people aged 20 and older. (Healthy People 2010 Draft objective. Baseline: from 1988 to 1994, 22 percent of people aged 20 and older had BMIs >30.0 [20 percent of males and 25 percent of females]) 2

Select Populations 1988-94

African American, non-Hispanic male aged 20+ 21%

American Indian/Alaska Native male aged 20+ Not available

Asian/Pacific Islander male aged 20+ Not available

Hispanic male aged 20+ Not available

Mexican American male aged 20+ 21%

White, non-Hispanic male aged 20+ 20%

African American, non-Hispanic female aged 20+ 37%

American Indian/Alaska Native female aged 20+ Not available

Asian/Pacific Islander female aged 20+ Not available

Hispanic female aged 20+ Not available

Mexican American female aged 20+ 33%

White, non-Hispanic female aged 20+ 23%

Male aged 20-39 15%

Male aged 40-59 25%

Male aged 60+ 21%

Female aged 20-39 21%

Female aged 40-59 30%

Female aged 60+ 26%

0-130% of poverty threshold 26%

>130% of poverty threshold 21%

Male with hypertension aged 20+ 34%

Male without hypertension aged 20+ 15%

Female with hypertension aged 20+ 38%

Female without hypertension aged 20+ 21%

Male with diabetes aged 20+ Not available

Male without diabetes aged 20+ Not available

Female with diabetes aged 20+ Not available

Female without diabetes aged 20+ Not available

Male with arthritis aged 20+ Not available

Male without arthritis aged 20+ Not available

Female with arthritis aged 20+ Not available

Female without arthritis aged 20+ Not available

Obesity rates are at an all time high in the U.S., yet the World Health Organization has been called it one of the greatest neglected public health problems of our time.28 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. 3

The potential benefits from reduction in the prevalence of overweight and obesity are of considerable importance to improve public health and the economic state of the healthcare system.2 The total direct healthcare cost for adult patients with obesity is $238.3 billion, indicating the need for particular emphasis and attention to this major public health problem.29

2.5. Reduce the overweight prevalence, BMI equal to or greater than 25.1 and less than 29.9, among people aged 20 and older.*

Individuals who are overweight have a higher risk for developing co-morbid conditions than those of normal weight. Persons who are overweight are at a greater risk of becoming obese than those with a BMI less than 25, and are appropriate candidates for prevention or intervention programs.25

Slightly overweight persons may be able to keep weight down on their own by eating a healthy diet, increasing exercise, and getting advice from health care professionals. Overweight persons with abdominal fat levels above the norm, and health complications, may require a more aggressive level of care. At a BMI of 27 to 29, individuals can attempt to lose weight on their own, but may require the assistance of commercial programs, local hospitals, community programs or self-help groups.18

* Note: The percentage of the population in this objective will increase as the population of individuals with a BMI of 30 or above (objective 3A) decreases. Objective 2.1, “Stabilize Weight,” is intended to follow individuals who remained weight stable, to enable the tracking of those who have moved into other BMI categories.

2.6. Reduce to 5 percent or less the prevalence of obesity (at or above the sex- and age-specific 95th percentile of BMI from the revised NCHS/CDC growth charts) in children (aged 6-11) and adolescents (aged 12-19). (Healthy People 2010 Draft objective. Baseline: in 1988-94, 11 percent of all children and 10 percent of all adolescents were overweight or obese.) 2

Select Populations 1988-94

African American, non-Hispanic male aged 6-11 12%

American Indian/Alaska Native male aged 6-11 Not available

Asian/Pacific Islander male aged 6-11 Not available

Hispanic male aged 6-11 Not available

Mexican American male aged 6-11 17%

White, non-Hispanic male aged 6-11 10%

African American, non-Hispanic male aged 12-19 11%

American Indian/Alaska Native male aged 12-19 Not available

Asian/Pacific Islander male aged 12-19 Not available

Hispanic male aged 12-19 Not available

Mexican American male aged 12-19 14%

White, non-Hispanic male aged 12-19 11%

African American, non-Hispanic female aged 6-11 16%

American Indian/Alaska Native female aged 6-11 Not available

Asian/Pacific Islander female aged 6-11 Not available

Hispanic female aged 6-11 Not available

Mexican American female aged 6-11 14%

White, non-Hispanic female aged 6-11 9%

African American, non-Hispanic female aged 12-19 16%

American Indian/Alaska Native female aged 12-19 Not available

Asian/Pacific Islander female aged 12-19 Not available

Hispanic female aged 12-19 Not available

Mexican American female aged 12-19 13%

White, non-Hispanic female aged 12-19 8%

Male aged 6-11 11%

Male aged 12-19 11%

Female aged 6-11 10%

Female aged 12-19 9%

Children aged 6-11 at 1-130% poverty threshold 10%

Adolescents aged 12-19 at 1-130% poverty threshold 16%

Children aged 6-11 at >130% poverty threshold 11%

Adolescents aged 12-19 at >130% poverty threshold 8%

There is an increasing trend in the prevalence of obesity in children and adolescents. Overweight and obesity acquired during childhood or adolescence may persist into adulthood and increase the risk for some chronic diseases later in life. Children with obesity also experience psychological stress. The reduction of BMI should be achieved through emphasis on physical activity accompanied by properly balanced dietary intake so that growth is not impaired. 2

There is a prepubertal increase in subcutaneous fat that is lost during adolescence in boys, while in girls fat deposition continues. Thus, without measures of sexual maturity, measures of body fat and body weight are equally difficult to interpret in preadolescents and adolescents. When extrapolated to the adult age of 20 years, the sex- and age-specific 95th percentile of BMI from the revised NCHS/CDC growth curves approximates a BMI of 30. Therefore, the target for this objective for children and adolescents is set at no more than 5 percent to reduce the prevalence of obesity and to reduce the potential for overemphasis on thinness. 2

2.7. Increase the proportion of people aged 18 and older who follow sensible guidelines for the amount and type of physical activity that enhances weight loss or prevents weight gain.

A decrease in the amount of physical activity related to work, transportation and personal chores is believed to contribute to the high prevalence of overweight and obesity.28 Approximately 40% of Americans are not regularly active, and about 25% of Americans are entirely inactive. A main contributor to decreased activity is car dependence. In general, 84% of trips are taken by car, and 75% of short car trips are less than one mile. 27

Television viewing is another cause of sedentary lifestyles. The average amount of daily TV viewing has increased from two to three hours to five hours over a 20 year time period. 27

Strategies for physical activity in a weight management program include: the use of aerobic exercise (such as aerobic dancing, brisk walking, jogging, cycling, and swimming), beginning slowly and gradually increasing intensity, and selecting enjoyable activities that can be scheduled into a regular routine.4 Physical activity is also reported to be a key part of maintaining weight loss. 30

Other objectives associated with physical activity for adults are presented in Healthy People 2010.

2.8. Increase the proportion of children (aged 6-11) and adolescents (aged 12-17) who engage in regular physical activity to promote lifestyle behavior that enhances weight management.

Limited opportunities for physical activity, due in part to the lack of sidewalks or conveniently located recreational facilities, force children to play in the streets where they may get hit by a car. A decline in physical activity as children get older is an increasing trend, and is particularly worse in girls than boys. In the last 10 years, assessments of physical fitness indicate a decrease in the ability of a child to run a certain amount of time or achieve a certain physical activity level.20 The lowest levels of vigorous activity in children are reported among girls, non-Hispanic blacks and Mexican Americans. 31

Once mandatory, physical education programs are now lacking in schools. Among 9th to 12th graders, only one quarter of the students receive daily physical education. The quality of the programs should involve teaching skills related to lifetime activities. To provide resources that may be lacking, schools can seek to connect themselves to community recreational resources. To promote involvement, schools can make themselves the community resource after school hours and on weekends.27

Physical activity behaviors are encouraged in children to develop lifelong positive health patterns that will lower the risk of several chronic diseases, including obesity, and premature mortality. 32

Other objectives associated with physical activity, and children and adolescents, are presented in Healthy People 2010.

2.9. Increase the proportion of people aged 18 and older who follow sensible dietary guidelines that enhances weight loss or prevents weight gain.

The American diet is high in fats and sweets, and deficient in grains, fruits and vegetables. High-calorie, high-fat foods are readily available, and portion sizes have become larger, contributing to overweight and obesity. Adjustments in nutritional practices are necessary to promote healthy behaviors for healthy weight. 27

Dietary therapy for weight management involves instruction on how to adjust a diet to reduce the number of calories eaten. Reducing calories moderately is essential to achieve a slow but steady weight loss, which is also important for maintenance of weight loss. Strategies for dietary therapy include teachings about calorie content of different foods, food composition (fats, carbohydrates, and proteins), reading nutrition labels, types of foods to buy, and how to prepare foods. 4

Other nutritional objectives for adults are outlined in Healthy People 2010.

2.10. Increase the proportion of children (aged 6-11) and adolescents (aged 12-17) who follow sensible dietary guidelines that enhances weight management.

Nutritional habits have changed dramatically over 30 years as the prevalence of obesity has increased. The ease of the microwave has allowed kids to prepare meals without parental guidance. From the family budget, 35% is spent on fast foods. Soft drink consumption has increased to where it has now become 8% of a child’s daily caloric intake. Skipping meals is also a factor that may make it difficult for children to regulate their dietary intake. 20,27

Television viewing often replaces non-sedentary activities and promotes unhealthy diets through advertising of high caloric foods. Today 35% of adolescents report watching 5 or more hours of TV per day. The average child views 20,000 or more commercials per year of products, which are strategically placed in grocery stores at eye level for children. Food products advertised during children’s programming reflect an average of 2,500 calories and 106 fat grams per hour. During Saturday morning cartoon shows, an average of 12.5 food commercials are shown per hour. 20

Improvements are necessary for school nutrition programs, which are sometimes designed from a financial standpoint versus a health standpoint. Approximately 25% of schools have fast food vendors on campus, despite strong evidence that students would buy fruits, vegetables and other nutritious items if prices were reduced. More comprehensive programs, such as Planet Health, a federally funded research program, are needed. Planet Health concentrates on increasing physical activity, fruit and vegetable consumption, and decreasing high-fat food consumption and inactivity. The results of the program indicate a significant decrease of obesity prevalence among pre-adolescent girls. 27

Following sound nutritional practices is necessary for children and adolescents to develop lifelong positive health patterns that will lower the risk of several chronic diseases, including obesity, and premature mortality.27

Other nutritional objectives for children and adolescents are also outlined in Healthy People 2010.

2.11. Increase the proportion of mothers who achieve a weight gain consistent with the Institute of Medicine (IOM) guidelines during their pregnancies.

The importance of risk assessment based on pre-pregnancy weight and weight gain during pregnancy has been well established.33 Health professionals specializing in obstetrics should advise patients on proper levels of weight gain during pregnancy. Individualized healthy weight gain charts should be provided to all pregnant women, with routine instruction and monitoring of weight gain.

2.12. Increase the proportion of overweight and obese people with diseases, disorders, conditions, and complications associated with excessive weight who have adopted appropriate forms of weight management strategies to attain an appropriate body weight.

Obesity is a risk factor or an aggravating agent for more than 30 conditions. They are: arthritis (osteoarthritis and rheumatoid arthritis), birth defects, cancers (breast cancer in women, breast cancer in men, cancers of the esophagus and gastric cardia, colorectal cancer, endometrial cancer, renal cancer), carpal tunnel syndrome, cardiovascular disease, chronic venous insufficiency, daytime sleepiness, deep vein thrombosis, end stage renal disease, gallbladder disease, gout, heat disorders, hypertension, impaired immune response, impaired respiratory function, infections following wounds, liver disease, obstetric and gynecologic complications, pain, severe acute biliary and alcoholic pancreatitis, sleep apnea, stroke, surgical complications, traumatic injuries to teeth, type 2 diabetes, and urinary stress incontinence. 1,4,5,13

Obesity can negatively effect social, mental, and physical functioning, often impairing normal daily activities. As weight increases, physical impairment and functional disability due to bodily pain increase, and quality of life decreases, according to health-related quality of life (HRQL) survey data. Persons with a mean BMI as low as 29.2 have demonstrated significant impairment compared to the relative general population. Persons with a mean BMI of 38.1 have reported greater bodily pain and impairment to vitality; a mean BMI of 48.7 has been associated with significantly worse physical, social, and role functioning, worse perceived general health, and greater bodily pain.34

Reductions in weight can lead to improvements in many health markers associated with obesity.19 A weight loss of 10% to 15% can improve blood lipids, insulin resistance, and glucose tolerance, decrease total cholesterol and triglycerides and increase HDL cholesterol, which protects against heart disease.18,25 Persons with severe obesity, who experience significant weight loss as a result of surgery, often see major improvement in co-morbid conditions such as type 2 diabetes, hypertension, urinary incontinence, and obstructive sleep apnea. In many cases, patients no longer require medication for various co-morbid conditions, after surgery. 26

2.13. Reduce the number of employee work days missed due to obesity related medical conditions.

Obesity is associated with a greater tendency to be absent from work due to illness. The cost associated with absenteeism from obesity has been reported at approximately $387,800 for 1000 employees per year. The cost due to absenteeism is approximately $128,600 higher for employees with obesity, compared to their lean counterparts. Worksite weight wellness programs can help persons with obesity to manage their weight, which would reduce their disease risk, and the number of absent days from work.35

Introduction

Educating the public on the causes, prevention and treatment methods, and health risks of overweight and obesity, is critical to reversing the obesity epidemic. Population specific programs and messages should be culturally and linguistically appropriate to effectively translate information on obesity. Health professionals must be properly trained to follow an on-going process of evaluating, preventing, treating and managing overweight and obesity in their patients.36

The public health community agrees to the need for obesity education, yet little progress has been made in implementing the concept. Schools, worksites, doctor’s offices, managed care settings, and communities (health departments, social clubs and faith-based groups) are instrumental units for disseminating messages about obesity. Individuals, families, and communities must be mobilized to respond to the obesity epidemic. 3,27

Patient education is necessary to adequately control and prevent adverse health outcomes from chronic diseases. Research on hypertension and diabetes education, both of which are associated with obesity, indicates that even patients who have attended formal education programs failed to know the basics of their disease and self-management skills. Obesity requires appropriate and sufficient education for patients of all literacy levels. Achieving success in patient communication requires appropriate written materials, oral communication, and visual presentation. Patient education needs ingenuity and commitment of necessary resources.37

Practical education programs, modeled after successful campaigns such as the National Cholesterol Education Program, could raise awareness of the importance of healthy body weight to health.25

Objectives for Implementing Obesity Education Programs

Number Objective

3.1 Elementary, secondary, and undergraduate healthy weight programs

3.2 Educating parents about children’s healthy weight

3.3 Worksite weight management program availability

3.4 Worksite weight management program participation

3.5 Counseling and screening on obesity

3.6 Managed care and access to weight management programs

3.7 Healthy weight programs in communities

3.8 Reducing disparities through obesity education

3.9 Obesity education for primary care physicians

3.10 Smoking cessation & weight management programs

3.11 Worksite back injury prevention & weight management programs

3.12 Obesity, body image and eating disorder behaviors

3.1. Increase the proportion of elementary, secondary, and undergraduate students who receive age appropriate educational information on the importance of a healthy weight.

Schools and community leaders are called upon in efforts to prevent obesity in children. Schools should provide fundamental education on the importance of nutrition and physical activity in overall health. Integrating community and school programs is important to educate children after school as well as during school hours.38 The importance of healthy weight should also be incorporated into age-appropriate programs and messages that teach healthy behaviors and prevent childhood obesity.

3.2. Increase the proportion of parents of school-aged children who receive educational materials regarding healthy weight for children through social, cultural, and educational organizations and associations.

Parents must be made more aware of their role in preventing obesity in their children. A parent-oriented program, in which parents are taught to restrict high calorie foods in the household and increase levels of physical activity, has been found effective in the short-term reduction of body weight of obese children. Many parents also lose weight and improve cardiac health in the process.39 Family-based interventions to improve healthy behaviors can also encourage parents to become more involved in school and community programs. 38

3.3. Increase to at least 50 percent the proportion of worksites with 50 or more employees that offer weight management programs for employees. (Healthy People 2010 Draft objective. Baseline: in 1995, 14 percent of worksites offered weight management group classes, workshops, or lectures) 2

There is a need for greater emphasis in educating America’s workforce on obesity.40 Weight management programs can reduce costs to a company by decreasing absenteeism and increasing productivity.

Worksites with 750 or more employees have been found to be five times more likely to provide weight management activities than the worksites with 50 to 99 employees.40 Creating partnerships between large corporations and small businesses may offer opportunities to share critical resources that may assist in increasing adherence to weight management and other wellness programs.

3.4. Increase the proportion of all employees who participate in employer-sponsored weight management programs.

Companies that offer wellness programs in an effort to prevent illness and reduce employee absenteeism due to illness, find that participation and adherence are key problems when measuring the success of these programs. This is particularly the case with small worksites.41 Incentive programs or other innovative methods may motivate participation and adherence. Tracking programs for success may also help to determine its strengths, weaknesses, and the benefits it provides to employees and the company.

3.5. Increase the proportion of patients who are routinely screened for obesity risk factors and counseled on weight management strategies by managed care organizations, health care organizations, and clinicians.

In a routine doctor’s visit, over a one year period, less than half of adults with obesity report being advised to lose weight. Persons with obesity who report being advised are more likely to report trying to lose weight when compared to those not advised. Characteristics of persons most likely to receive advice include: females, middle-aged, higher education levels, higher levels of obesity, type 2 diabetes, perceiving to have poorer health, and residents of the northeast U.S. 42

Compliance with medical advice has been correlated with improved outcomes in patients with diabetes and hypertension. Hospitals and other health care organizations are instructed by the Joint Commission on Accreditation of Health Care Organizations to provide understandable instruction, assess knowledge, and document patient education efforts.36 This standard should be used to counsel patients on obesity. Health care professionals working together can contribute to improving the health of individuals affected by obesity.43

3.6. Increase the proportion of managed care organizations with health care plans that provide patients and family’s access to education on the importance of a healthy weight, access to weight management programs, and comprehensive coverage of obesity education, prevention, and intervention including surgical and pharmacological treatment.

High prevalence of obesity is associated with high rate of health service utilization and high costs.. BMI is associated with annual rates of outpatient visits and inpatient days, annual costs of outpatient visits, radiology, laboratory, and pharmacy services, and total cost of care (inpatient and outpatient). Opportunities to reduce health care expenditures lie in efforts involving weight reduction and prevention of weight gain.44

Organizations that assess and report on the quality of managed care plans to promote accountability should include performance measures to control obesity. Accountability of performance can increase adherence to clinical practice guidelines, improve initiatives for quality health plans, create disease management programs, increase physician and clinician participation in quality management, and change the way employers contract with health plans. 26

3.7. Increase the proportion of local and state health agencies that provide community education on the importance of a healthy weight, and access to weight management programs.

Obesity was identified by the Institute of Medicine (IOM) as an indicator for communities to use to work toward achieving public health goals.45 Community partnerships, involving the food industry, the restaurant industry, worksites, schools, and recreational departments, among others, can help to implement weight-control programs, and move policy in the right direction. 27

A balanced community health system requires four key components: health promotion, disease prevention, early detection and universal access to care. Overweight and obesity are factors in each component, and education programs must be implemented by local and state health agencies to achieve a balanced system.3 A comprehensive community-based approach should include social marketing campaigns to raise public awareness of obesity, healthy eating and the need for increased activity. 27

3.8. Increase the proportion of social organizations and faith-based groups that provide community education on the importance of a healthy weight and access to weight management programs with the specific objective of reaching women, racial and ethnic groups, and low income populations who are at increased risk of developing obesity.

Higher rates of obesity are found among minority populations than for whites, and higher among women than for men, according to the second National Health and Nutrition Examination Survey, (NHANES II), 1976-1980. 46,47 African Americans and Hispanics have a particularly high prevalence rate of obesity as well as Pacific Islanders, Native Americans, Alaska Natives, and Native Hawaiians.48,49

The prevalence of obesity in minority populations are, in some cases, three times higher than that of whites.50 Low-income women in some minority populations appear most likely to be overweight.51 Among youth, white adolescents in low income families were found to be approximately 2.6 times as likely to be overweight compared with middle- or high-income families.52

One goal for Healthy People 2010 is to eliminate racial and ethnic disparities in health. Overweight and obesity prevalence data clearly illustrates the existence of such disparities. Targeted programs with population specific messages are needed in places that reach and reflect the community it serves, such as social and faith-based organizations.

3.9 Increase the proportion of primary care providers who receive obesity education training for the purpose of routinely counseling patients.

Most patients seek medical help first from their primary care physician. Physicians can be a positive influence on the willingness of patients to manage their health problems. However, many primary care physicians lack the time or expertise to effectively deal with obesity. Physicians must recognize obesity as a disease, and that obesity treatment requires a chronic care model. Such a model can assist physicians in implementing chronic management of obesity into their practices. 53,42

A variety of health care professionals, such as nutritionists, exercise physiologists, physical education instructors, nurses, and psychologists, are important to the assessment, prevention, and intervention of obesity. Establishing positive relationships with other health care professionals is important for primary care physicians to stay abreast of current issues regarding obesity.4

Medical students and residents should receive specific training in obesity education to better counsel patients. Continuing education courses should be developed for physicians with established practices. 36

3.10. Increase the proportion of smoking cessation programs that provide concurrent weight management counseling.

The average amount of weight gained during smoking cessation is approximately 4 to 9 pounds. Weight gain during smoking cessation is a concern among smokers, and may discourage smokers from enrolling in smoking cessation programs. Availability and accessibility to a concurrent weight management program may encourage smokers to enroll in a smoking cessation program.54

Smoking initiation has been reported among adolescent girls in an effort to control their weight. Contemplation of smoking has been related to weight concerns in boys and girls, and a relationship has also been found between experimentation with cigarettes and weight control behaviors. 55 Smoking prevention programs for youths, particularly young girls, must address proper forms of weight management to deter smoking initiation.56

3.11. Increase the proportion of worksite back injury programs that provide concurrent weight management counseling.

Low-back pain affects approximately 80% of people in industrialized countries. A major step in the primary prevention of low-back pain management is identifying individuals most at risk.57 Among the characteristics of the “classic back patient” is excess weight, an abnormal forward curvature of the spine, sedentary lifestyle, weak abdominal muscles, tight hamstrings or hip flexors, weak or tight back muscles, and general tensions.41

Overweight persons with high levels of abdominal fat have been associated with a higher prevalence of chronic low back pain - a total of 12 or more weeks over a 12 month period. Symptoms of intervertebral disc herniation, low back pain over 12 months with radiating pain to the knees or feet, have also been reported. Women have indicated greater complaints of low back pain symptoms than men.57 Weight management counseling concurrent with a primary prevention program may assist in reducing the risk of low-back pain.41

3.12. Reduce the proportion of children and adolescents who engage in improper weight loss practices that may lead to eating disorder behaviors.

The association of physical attractiveness with thinness is a societal perception that fosters widespread pattern of dieting among most young women, most of whom need not lose weight.58,59 Persons with obesity, of all ages, suffer from social stigmatization and discrimination.4 Body shape and weight are core concerns of patients with eating disorders.58 The stigma of being overweight may be the most debilitating of all stigmatized conditions, and may promote inappropriate eating behaviors in an effort to achieve thinness.

Stigmatization can be detrimental to a person’s quality of life. Children reportedly have described obese peers as “lazy, dirty, stupid, ugly, cheats, and liars.” Obese adults have found themselves less likely to be admitted to prestigious schools, enter desirable professional positions, and receive equitable pay. Persons with obesity perceive discrimination and prejudice at work and in public to be a tremendous burden. Perceiving to be disrespected by physicians and other health professionals is also a sentiment of persons with obesity. 60,61,62

Dieting behaviors have been reported in children as young as 9 years old. Adolescent girls, who are restrained eaters, are reported to demonstrate high levels of worthlessness, body dissatisfaction, fear of weight gain, and are heavier and more physically developed than girls who are unrestrained eaters.63

Fifty-two percent of girls below normal weight, and 25% of boys, are estimated to believe that they are “too fat.” White girls are also more likely than African American girls to consider themselves overweight, and to attempt weight loss. African American girls are less likely to perceive overweight as unhealthy or unattractive.39,64 Carefully crafted messages designed to educate children and adolescents about healthy weight should call awareness to obesity as a medical problem, as well as body acceptance, and healthy lifelong behaviors.59

Introduction

The impact of obesity is manifest not only on the nation’s health, but also on the nation’s economy. The high economic cost of obesity is a clear contributor to today’s growing health care costs. Obesity has increased direct costs, due to greater use of medical services, and indirect costs, due to reduced productivity stemming from related illnesses and premature death. 65

Current, indirect strategies to control the incidence and prevalence of overweight and obesity, and its co-morbidities, have failed. Communities are in search of new initiatives that directly address the problem of obesity. New strategies for managing obesity must be integrated into the public health infrastructure, which includes community development. Constructing and properly maintaining sidewalks, parks and recreation areas, and securing safe streets for walking to schools and stores, can help to promote healthy lifestyles in communities.27

Obtaining health insurance is often difficult for individuals with obesity, who are frequently denied access due to their weight. When they do obtain insurance, most insurance plans fail to offer reimbursement for weight loss or weight maintenance services, including surgery and pharmacy benefits. 26

More research is needed to determine effective strategies in preventing obesity, and the scientific data must be translated into a usable measure that can be tracked for progress. Strategies, however, must be put into effect immediately while research is planned and conducted. 27

Establishing lines of communication between traditional health partnerships and non-traditional partnerships, in which public health extends to areas such as transportation, urban planning and environmental planning, is an important step toward developing communities able to manage the problem of obesity. 27

Objectives for Integrating Obesity Management into the Public Health Infrastructure

Number Objective

4.1 City planning for healthy weight communities

4.2 Access to health insurance for obesity

4.3 Measurement of obesity in data collection

4.4 Health communication regarding obesity

4.1. Increase the number of communities that require zoning and city planning that includes parks and recreation areas to provide individuals with resources to achieve or maintain a healthy weight.

The American culture is one that is obesity-promoting, with an overabundance of inexpensive, palatable, calorie-dense foods and an environment that promotes physical inactivity.2,4 Environmental changes that promote physical activity range from providing stairwell access to re-designing the layout of a community. Suburban sprawl has created a society of citizens who are automobile-centered, and communities with few sidewalks; schools, shopping, and recreational areas are no longer in walking distance. 27

In many parts of the country, neighborhoods, parks and recreational areas are considered unsafe. Increasing obesity, measured by BMI, has been associated with increased reporting of neighborhood safety concerns.27 In lower income areas, the lack of neighborhood safety is a significant barrier to physical activity, as is the lack of recreational opportunities, which is also associated with higher BMI. 27

4.2. Increase the proportion of patients who have coverage for clinical preventive services and treatment of obesity as part of their health insurance.

Health insurance companies often do not pay for the treatment of obesity. Individuals with obesity require more medications than persons of normal weight, yet they are often denied coverage or reimbursement for drugs to specifically treat obesity. 26

Likewise, coverage for surgical treatment of obesity is often denied or precluded by low reimbursement rates. Poor access to treatment remains regardless of the significant weight loss, long-term maintenance of weight loss, and relief from serious co-morbidities that result from surgery. 26

There is no justification for denial of benefits to treat obesity when considering the standards of health insurance otherwise available.66 Preventive programs should also be covered or reimbursed, since they can help to reduce disease risks associated with obesity, and minimize costs that are compounded once these diseases manifest themselves.35

4.3. Establish a standard measurement for data collection of obesity and its related variables for local, state, national and managed care health data systems.

Prevalence data for overweight and obesity are collected nationally. Such data has alerted public health officials to the state of obesity as an epidemic. This awareness requires the identification of new measures on how to control obesity that can be collected on local, state and national levels. Data on various aspects of obesity is limited and requires further exploration.

4.4. Increase health communication and partnerships regarding obesity between primary care physicians, clinics, hospitals, government health departments, health organizations, and businesses.

Many challenges exist in communicating messages to the public regarding obesity including the clutter of multiple messages, skepticism about experts, the negative climate surrounding weight management, and public confusion and misunderstandings about scientific results.67 Creating partnerships between primary care physicians, clinics, hospitals, government health departments (federal, state, local), health organizations, and businesses can be useful in developing messages that are consistent with scientific evidence and providing effective channels for distribution of these messages.

Related Objectives from Other Focus Areas

from Healthy People 2010 Objectives: Draft for Public Comment, September 15, 1998

At the end of each of the 26 focus areas (chapters) in Healthy People 2010 Objectives: Draft for Public Comment, a “listing of related objectives is provided to make relevant connections” between the chapters within the document. The link of objectives was designed to provide “a more complete set of measures, strategies, and interventions for each focus.” 2 At the printing of this publication, the final version of Healthy People 2010 was unavailable for public view. The related objectives that follow, accompanied by their assigned objective number, are in Healthy People 2010 Objectives: Draft for Public Comment. 2

Promote Healthy Behaviors

Chapter 1. Physical Activity and Fitness

Number Objectives

1 Leisure time physical activity

2 Sustained physical activity

3 Vigorous physical activity

4 Muscular strength and endurance

5 Flexibility

6 Vigorous physical activity, grades 9-12

7 Moderate physical activity, grades 9-12

8 Daily school physical education

9 Physical education requirement in schools

10 School physical education quality

11 Inclusion of physical activity in health education

12 Access to school physical activity facilities

13 Worksite physical activity and fitness

14 Clinician counseling about physical activity

Chapter 2. Nutrition

Number Objectives

4 Fat intake

5 Saturated fat intake

6 Vegetable and fruit intake

7 Grain product intake

10 Worksite nutrition education

11 Nutrition assessment and planning

12 Nutrition counseling

13 Meals and snacks at school

14 Nutrition education, elementary schools

15 Nutrition education, middle/junior high schools

16 Nutrition education, senior high schools

17 Worksite nutrition education

18 Nutrition assessment and planning

19 Nutrition counseling

Chapter 3. Tobacco Use

Number Objectives

10 Advice to quit smoking

12 Providers advising smoking cessation

15 Worksite smoking policies

Promote Healthy and Safe Communities

Chapter 4. Educational and Community-Based Programs

Number Objectives

7 Patient satisfaction with health care provider communication

10 Community health promotion initiatives

11 Culturally appropriate community health promotion programs

12 Elderly participation in community health promotion

Chapter 7. Injury/Violence Prevention

Unintentional Injuries

Number Objectives

13 Nonfatal motor vehicle injuries

14 Worksite stress reduction programs

Chapter 8. Occupational Safety and Health

Number Objectives

3 Workplace injury and illness surveillance

4 Overexertion or repetitive motion

Improve Systems for Personal and Public Health

Chapter 10. Access to Quality Health Services

Number Objectives

1 (A.1) Uninsured children and adults

2 (A.2) Insurance coverage

3 (A.3) Routine screening about lifestyle risk factors

4 (A.4) Reporting on service delivery

5 (A.5) Training to address health disparities

6 (B.1) Source of ongoing primary care

7 (B.2) Failure to obtain all needed health care

9 (B.4) Access to primary care providers in underserved areas

11 (B.6) Preventable hospitalization rates for chronic illness

13 (C.2) Insurance coverage

17 (C.6) Follow-up mental health services

18 (D.1) Functional assessments

19 (D.2) Primary care evaluation

20 (D.3) Access to the continuum of services

Chapter 12. Maternal, Infant, and Child Health

Number Objectives

10 Prenatal care

26 Neural tube defects

29 Breastfeeding

34 Training in genetic testing

35 Understanding of inherited sensitivities to disease

36 Genetic testing

Chapter 13. Medical Product Safety

Number Objectives

1 Monitoring of adverse drug reactions

2 Approval of medical products

3 Response from managed care organizations regarding adverse drug reactions

5 Drug alert systems

7 Complementary and alternative health care

8 Safety related labeling changes

9 Updates to drug alert systems

10 Patient information about prescriptions

Chapter 14. Public Health Infrastructure

Number Objectives

7 Tracking Healthy People 2010 objectives for select populations

8 Data collection for Healthy People 2010 objectives

9 Use of geocoding in health data systems

Chapter 15. Health Communication

Number Objectives

1 Public access to health information

4 Satisfaction with health information

Prevent and Reduce Diseases and Disorders

Chapter 16. Arthritis, Osteoarthritis, and Chronic Back Conditions

Arthritis

Number Objectives

10 Provision of Arthritis Education

Chronic Back Conditions

Number Objectives

15 Activity Limitations

Chapter 17. Cancer

Number Objectives

3 Breast cancer deaths

4 Cervical cancer deaths

5 Colorectal cancer deaths

9 Provider counseling about preventive measures

Chapter 18. Diabetes

Number Objectives

1 Type 2 diabetes

14 End-stage renal disease

Chapter 19. Disability and Secondary Conditions

Number Objectives

10 Compliance with Americans with Disabilities Act

11 Environmental barriers

Chapter 20. Heart Disease and Stroke

Number Objectives

1 Coronary heart disease deaths

6 High blood pressure

7 Controlled high blood pressure

11 Blood cholesterol levels

Chapter 23. Mental Health and Mental Disorders

Number Objectives

4 Mental disorders among children and adolescents

Chapter 24. Respiratory Diseases

Asthma

Number Objectives

6 Patient education

Obstructive Sleep Apnea

Number Objectives

18 Medical Evaluations

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