Sharing solutions for childhood obesity.

According to a 2004 report by the Institute of Medicine Committee on Prevention of Obesity in Children and Youth, approximately 9 million American children over 6 years of age are considered obese--that is, they have a body mass index (BMI) equal to or greater than the 95th percentile as calculated by the Centers for Disease Control and Prevention (CDC). Yet most experts believe the 9 million figure is minimal. Rates of obesity also are much higher among some populations and in certain geographic areas. And the prevalence of childhood obesity is growing exponentially. In the past three decades, it has more than doubled in children aged 2-5 and 12-19, and more than tripled in children aged 6-11.

There is currently a wide variety of activity at all levels aimed at reducing the epidemic of childhood obesity, as shown by the gathering of more than 700 experts from many fields in early June 2005 for Environmental Solutions to Obesity in America's Youth, a conference sponsored by the NIEHS. The meeting followed up on the success of a similar event held in 2004, which was aimed primarily at identifying research opportunities and needs to help design a research agenda related to environment and obesity. This year, the focus was on solutions.

"The goal of the conference was to try to identify the successful environmental interventions that have been developed across the country, and then to disseminate them more broadly," said primary organizer Allen Dearry, NIEHS associate director for research coordination, planning, and translation. "The major accomplishment was to bring together a very interdisciplinary group of experts in environmental health sciences, and in fields like planning and transportation, and policy makers to work together and think collaboratively, and to be able to define what makes one of these successful environmental interventions work."

The conference was supported in part by the Robert Wood Johnson Foundation. The planning committee included representatives from the NIH, the CDC, and the U.S. Department of Transportation, as well as from state and local health departments, academia, and the American Planning Association. Keynote speakers included NIEHS director David Schwartz, U.S. surgeon general Richard Carmona, CDC director Julie Gerberding, former National Football League star Lynn Swann (who is now the chairman of the President's Council on Physical Fitness and Sports), U.S. Department of Health and Human Services secretary Michael Leavitt, and Arkansas governor Mike Huckabee.

Pinpointing the Factors

As several participants pointed out, human genetics and biology don't change quickly enough to account for spiking obesity rates of the past 30 years, so a complex array of environmental factors that influence individual behavior is clearly at the root of the epidemic, in both children and adults. At a press conference announcing the forthcoming awarding of $5 million in NIH/CDC research grants addressing obesity and the environment, Schwartz said that defining the interface between environmental components and individual choices will be crucial to building a solid evidence base to support and refine efforts to stem the obesity tide.

"There's a fine balance between the environment and the individual that allows some people to make the choice for a more active and healthier life, and others to continue to eat the wrong types of foods or not be involved in physical fitness programs," Schwartz said. "That balance is very difficult to understand, and that's the focus of this research program and this conference."

The stakes involved are high. Obesity greatly increases a child's risk in adulthood of developing and dying from serious chronic conditions such as cardiovascular disease, type 2 diabetes mellitus, and certain cancers. Further, many children already suffer from adverse health effects related to their obesity.

Hypertension, until recently virtually unseen in young people, now strikes an estimated 4.5% of obese school-age children. Type 2 diabetes, also once considered rare in youngsters, is now showing up more frequently (the CDC is currently investigating incidence and prevalence). In addition, obese youth often suffer from impaired quality of life, emotional effects such as poor self-image, elevated cholesterol, orthopedic conditions, liver diseases, sleep apnea, and metabolic syndrome (a cluster of disorders that increases risk of heart disease and diabetes), among other negative outcomes. If left unchecked, the public health burden of childhood obesity will only continue to increase.

Finding Common Ground

Speaker David McCarron described the work of Shaping America's Youth (SAY), a public-private partnership that recently conducted a national survey of programs directed at physical activity and nutrition in children. SAY has established a national registry of such initiatives and is now approaching 2,500 program entries, with overall expenditures estimated at $3.9-7.1 billion. SAY's mission is to define the scope of those efforts and to make its information widely accessible. The goal is to foster dialogue at the community level, and ultimately develop a national action plan to combat childhood obesity.

"People are committed, but the problem is [the effort to address childhood obesity is] not organized, it's not being sustained, it's probably not directed at the right age group, and we need to take this commitment and interest and really get it focused ... on the very youngest children and their families," said McCarron, who is executive director of SAY. "We have to get to common goals, common language, common standards." He added, "They'll be modified community by community, and for each family they may be different, but we have to get to some very fundamental messages."

SAY will be conducting a series of town hall meetings over the next year in Memphis, Dallas, Philadelphia, and several California cities to get feedback from demographically representative community members. "It's not so much about teaching them something," McCarron explained. "We need to hear at a local level from the communities and the families as to what they see the problem as, what the barriers are. Otherwise, whatever we come away with from these national meetings might be totally disconnected."

The local socioeconomic environment, with often profound disparities in physical and financial access to healthy foods and physical activity, may contribute to the obesity epidemic, particularly among minority groups, who tend to suffer even higher obesity rates than the general population. Adam Drewnowski, director of the Center for Public Health Nutrition at the University of Washington, addressed this concept and showed that in his area of Washington state, geographic information system mapping of the distribution of obesity rates demonstrated an association of higher obesity rates with lower socioeconomic status and limited access to healthy foods. Using that type of methodology to tease out associations at the local level will be critical to successfully combating the problem, Drewnowski said.

Growing Smarter

The effect of sprawling development on sprawling waistlines was a subject of particular scrutiny at the conference. Roland Sturm, a senior economist at RAND, presented data from his recent unpublished national study of the impact of suburban sprawl on the development of chronic health conditions, including obesity. He found that greater sprawl was associated with an increase in chronic health problems, with the strongest associations with heart disease, abdominal and digestive problems, migraines and headaches, arthritis and joint pain, and trouble breathing. The study also suggested a relation between sprawl, reduced walking, and higher BMI.

"Smart growth" may be one approach that can help reverse these trends. Former Maryland governor Parris N. Glendening, who is now president of the nonprofit Smart Growth Leadership Institute, believes that incorporating opportunities for physical activity into built environment design is an important part of the mix to fight childhood obesity. "If we continue to build environments that discourage physical activity, we're going to continue to contribute to the problem," he said.

The Smart Growth Leadership Institute urges policy makers to take a broader, more long-term view of the potential impact of their decisions regarding the built environment and health. Policy changes encouraging mixed-use zoning and actual mixed land use--such as the shift of funds to public transit, the creation of sidewalks and bicycle paths, and the preservation of open spaces--are critical to the smart growth concept.

"If we can make the health and physical activity variables a part of the planning and land use discussion, we can have a significant impact," Glendening said. "It's not going to occur overnight, but we can see all across the country whole communities ... where this mixed-land-use urban walkability is taking place, creating a fun community where you want to be out and about."

A Variety of Venues

The battle against childhood obesity is being fought on many different fronts. The conference highlighted several nongovernmental initiatives that are addressing the problem in imaginative ways, with the goal of sharing what's working and what isn't.

Kaiser Permanente has adopted a strategy of emphasizing prevention of childhood obesity in its programs. Among other efforts, the company has trained more than 1,000 pediatricians and family physicians on ways to promote physical activity and dietary behavior change in patients and their families. The organization is also actively engaged in anti-obesity coalitions and partnerships through its Healthy Eating, Active Living (HEAL) program.

Girls on the Run, a 12-week program aimed at third- to fifth-grade girls, combines training for a five-kilometer run with life skills development and lessons to enhance self-esteem, all of which can help reduce or prevent obesity. Founded by Molly Barker in 1996, the program is now active in 120 U.S. and Canadian cities, with more than 50,000 girls participating.

The media environment is an influential element in the obesity landscape, in both negative and positive ways. New opportunities to entice young people toward unhealthy food choices are proliferating. Patti Miller, vice president of Children Now, a national child advocacy organization based in California, told attendees that the latest such threat is from interactive marketing. This often comes in the form of "advergames," online games promoted during TV shows that advertise unhealthy foods as part of the game. Children Now is lobbying the Federal Communications Commission to ban such practices in children's television programming.

Meanwhile, Sesame Street, with its large audience of preschool children, has launched a multiyear, content-driven initiative called Healthy Habits for Life. The program, which will be incorporated into all of Sesame Street's media outlets (television, video, books, magazines, and online), promotes healthy habits as being just as critical to early development as learning to read and write.

Food and beverage giant PepsiCo has recognized that there is a tremendous business opportunity in offering consumers more nutritious, healthful products, according to vice president of marketing for health and wellness Ellen Taaffe. Health-oriented products are now the company's fastest-growing sector and currently represent almost 40% of the company's portfolio. Taaffe described several initiatives PepsiCo has undertaken to promote health and fitness, including the Smart Spot program, in which a symbol on a product's packaging identifies it as a healthy choice.

Cathleen Toomey, vice president of communications at Stonyfield Farm, the nation's largest producer of organic yogurt, described that company's successful efforts to launch the first organic and healthy vending machines for schools. Produced in collaboration with the schools themselves, which receive the profits from sales, there are currently 32 machines in place at schools in seven states, with a waiting list of 930 schools.

Governmental efforts also received attention. These included state-level efforts in California and North Carolina as well as larger-scale programs such as Active Living by Design, a Robert Wood Johnson Foundation effort in 25 cities to increase physical activity through changes in community design, and America on the Move, a program working at the local, state, and national levels to encourage people of all ages to make small increases in walking and small decreases in caloric intake to prevent weight gain and improve health. In still another initiative, the Safe Routes to School program, several federal agencies including the U.S. Department of Transportation are working to make walking and biking to school safe and appealing to children.

Another session highlighted several new tools, measures, and methods that have been developed to help reliably assess environment-obesity connections, such as assessments of park characteristics, urban design walkability, and aspects of the "nutrition environments" (the quality and availability of foods, and types of food outlets in discrete settings such as schools and neighborhoods). These methodological advances will help to provide a much-needed validated evidence base for use in evaluating the effectiveness of obesity treatment and prevention programs. Many participants commented that more longitudinal research is needed to see what does and doesn't work for preventing obesity.

The conference also marked the launch of a major new trans-NIH initiative called We Can! (Ways to Enhance Children's Activity & Nutrition). Spearheaded by the National Heart, Lung, and Blood Institute, We Can! is a national public education outreach effort that will provide activities and programs that encourage good nutritional choices, more physical activity, and less television and computer screen time in 8- to 13-year-olds.

"What we're trying to do," said Carmona, "is have the American public appreciate that within their control, simple steps such as more physical activity and eating a healthy diet will reduce risk in their lives and improve their health status." There was a broad consensus at the conference that those simple steps are the best ways to both treat and prevent childhood obesity.

Whittling Away at Obesity

Although reversing the epidemic of childhood obesity will require long-term efforts and long-term commitments from all stakeholders, Dearry is optimistic that if certain aspects of the environment can be successfully modified, the explosive growth of childhood obesity can be at least reduced, if not eliminated, within the next 5-10 years. "I think these changes in the environment are not impossible," he says. "They can start with small steps rather than needing to be large-scale changes. Changes in the environment that enable people to have access to a better diet or more physical activity can start to lead to reversals in the trends we've seen."

Added Toomey: "The message I would encourage everyone to take away from this conference is that you can make small changes. You can start a Girls on the Run program, you can apply for a healthy vending machine. You can make the doors open, and we can whittle down childhood obesity piece by piece."