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SOLV I NG T H E PROBLE M OF CH I L DHOOD OBESI T Y W I T H I N A GENER AT ION White House Task Force on Childhood Obesity Report to the President M AY 2 010 Table of Contents The Challenge We Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 I. Early Childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 A. Prenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 B. Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 C. Chemical Exposures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 D. Screen Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 E. Early Care and Education . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 II. Empowering Parents and Caregivers . . . . . . . . . . . . . . . . . . . . . . . . 23 A. Making Nutrition Information Useful . . . . . . . . . . . . . . . . . . . . . . 23 B. Food Marketing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 C. Health Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 III. Healthy Food in Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 A. Quality School Meals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 B. Other Foods in Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 C. Food-Related Factors in the School Environment . . . . . . . . . . . . . . . . . 44 D. Food in Other Institutions . . . . . . . . . . . . . . . . . . . . . . . . . . 46 IV. Access to Healthy, Affordable Food . . . . . . . . . . . . . . . . . . . . . . . . 49 A. Physical Access to Healthy Food . . . . . . . . . . . . . . . . . . . . . . . . 49 B. Food Pricing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 C. Product Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 D. Hunger and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 V. Increasing Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 A. School-Based Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . 68 B. Expanded Day and Afterschool Activities . . . . . . . . . . . . . . . . . . . . 74 C. The “Built Environment” . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 D. Community Recreation Venues . . . . . . . . . . . . . . . . . . . . . . . . 82 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Summary of Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Letter to the President Dear Mr. President, I am pleased to present you with the White House Task Force on Childhood Obesity’s action plan for solving the problem of childhood obesity in a generation. Parents across America are deeply concerned about their children’s health and the epidemic of childhood obesity. One out of every three children is now overweight or obese, a condition that places them at greater risk of developing diabetes, heart disease, and cancer over the course of their lives. This is not the future we want for our children, and it is a burden our health care system cannot bear. Nearly $150 billion per year is now being spent to treat obesity-related medical conditions. Fortunately, there are clear, concrete steps we can take as a society to help our children reach adulthood at a healthy weight. As you requested in the Memorandum you signed on February 9, our new interagency Task Force on Childhood Obesity has spent the past 90 days carefully reviewing the research, and consulting experts as well as the broader public, to produce a set of recommended actions that, taken together, will put our country on track to solving the problem of childhood obesity. We heard from a broad array of Americans, and received more than 2,500 public comments with specific and creative suggestions. Twelve Federal agencies participated actively in the Task Force, and provided their ideas and expertise. They include the Departments of Agriculture, Defense, Education, Health and Human Services, Housing and Urban Development, Interior, Justice, and Transportation, as well as the Corporation for National and Community Service, the Environmental Protection Agency, the Federal Communications Commission, and the Federal Trade Commission. Our recommendations focus on the four priority areas set forth in the Memorandum, which also form the pillars of the First Lady’s Let’s Move! campaign: (1) empowering parents and caregivers; (2) providing healthy food in schools; (3) improving access to healthy, affordable foods; and (4) increasing physical activity. In addition, we have included a set of recommendations for actions that can be taken very early in a child’s life, when the risk of obesity first emerges. We cannot succeed in this effort alone. Our recommendations are not simply for Federal action, but also for how the private sector, state and local leaders, and parents themselves can help improve the health of our children. The Task Force will move quickly to develop a strategy for implementing this plan, working in partnership with the First Lady to engage stakeholders across society. Indeed, many Americans — including leaders in the public and private sectors — have already volunteered to join this effort, and are ready and waiting to put this plan in action. Sincerely, Melody Barnes Chair, Task Force on Childhood Obesity, and Director, Domestic Policy Council ★ 1 ★ The Challenge We Face The childhood obesity epidemic in America is a national health crisis. One in every three children (31.7%) ages 2-19 is overweight or obese.1 The life-threatening consequences of this epidemic create a compelling and critical call for action that cannot be ignored. Obesity is estimated to cause 112,000 deaths per year in the United States,2 and one third of all children born in the year 2000 are expected to develop diabetes during their lifetime.3 The current generation may even be on track to have a shorter lifespan than their parents.4 Along with the effects on our children’s health, childhood obesity imposes substantial economic costs. Each year, obese adults incur an estimated $1,429 more in medical expenses than their normal-weight peers.5 Overall, medical spending on adults that was attributed to obesity topped approximately $40 billion in 1998, and by 2008, increased to an estimated $147 billion.6 Excess weight is also costly during childhood, estimated at $3 billion per year in direct medical costs.7 Childhood obesity also creates potential implications for military readiness. More than one quarter of all Americans ages 17-24 are unqualified for military service because they are too heavy.8 As one military leader noted recently, “We have an obesity crisis in the country. There’s no question about it. These are the same young people we depend on to serve in times of need and ultimately protect this nation.” 9 While these statistics are striking, there is much reason to be hopeful. There is considerable knowledge about the risk factors associated with childhood obesity. Research and scientific information on the causes and consequences of childhood obesity form the platform on which to build our national policies and partner with the private sector to end the childhood obesity epidemic. Effective policies and tools to guide healthy eating and active living are within our grasp. This report will focus and expand on what we can do together to: 1. create a healthy start on life for our children, from pregnancy through early childhood; 2. empower parents and caregivers to make healthy choices for their families; 3. serve healthier food in schools; 4. ensure access to healthy, affordable food; and 5. increase opportunities for physical activity. What is Obesity? Obesity is defined as excess body fat. Because body fat is difficult to measure directly, obesity is often measured by body mass index (BMI), a common scientific way to screen for whether a person is underweight, normal weight, overweight, or obese. BMI adjusts weight for height,10 and while it is not a perfect indicator of obesity,11 it is a valuable tool for public health. Adults with a BMI between 25.0 and 29.9 are considered overweight, those with a BMI of 30 or more are considered obese, and those with a BMI of 40 or more are considered extremely obese.12 For children and adolescents, these BMI categories are further divided by sex and age because of the changes that occur ★ 3 ★ S O LV I N G T H E P R O B LE M O F C H I LD H O O D O B E S I T Y during growth and development. Growth charts from the Centers for Disease Control and Prevention (CDC) are used to calculate children’s BMI. Children and adolescents with a BMI between the 85th and 94th percentiles are generally considered overweight, and those with a BMI at or above the sex-and age-specific 95th percentile of population on this growth chart are typically considered obese. Determining what is a healthy weight for children is challenging, even with precise measures. BMI is often used as a screening tool, since a BMI in the overweight or obese range often, but not always, indicates that a child is at increased risk for health problems. A clinical assessment and other indicators must also be considered when evaluating a child’s overall health and development.13 Who Does Obesity Impact? Prevalence and Trends By gaining a deeper understanding of individuals who are impacted by obesity, we can better shape policies to combat it. Since 1980, obesity has become dramatically more common among Americans of all ages. Prevalence estimates of obesity in the U.S. are derived from the National Health and Nutrition Examination Survey (NHANES), conducted by the National Center for Health Statistics of the CDC. Between the survey periods 1976–80 and 2007–08, obesity has more than doubled among adults (rising from 15% to 34%), and more than tripled among children and adolescents (rising from 5% to 17%).14 The rapid increase in childhood obesity in the 1980s and 1990s has slowed, with no significant increase in recent years.15 However, among boys ages 6–19, very high BMI (at or above the 97th percentile) became more common between 1999–2000 and 2007–08; about 15% of boys in this age group are in this category.16 Growth in Childhood Obesity, 1971 to Present Percent of children aged 2-19 who are obese 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 1972 1976 1980 1984 1988 1992 1996 2000 2004 Source: CDC, National Center for Health Statistics, National Health and Nutrition Examination Surveys. Note: Obesity is defined as BMI ≥ gender- and weight-specific 95th percentile from the 2000 CDC Growth Charts ★ 4 ★ 2008 T he C h a llenge W e Face Race/Ethnic Disparities Childhood obesity is more common among certain racial and ethnic groups than others. Obesity rates are highest among non-Hispanic black girls and Hispanic boys. Obesity is particularly common among American Indian/Native Alaskan children. A study of four year-olds found that obesity was more than two times more common among American Indian/Native Alaskan children (31%) than among white (16%) or Asian (13%) children. This rate was higher than any other racial or ethnic group studied.17 29.2% 30% 25.5% 25% 19.8% 0% Non-Hispanic White Non-Hispanic Black GIRLS 5% BOYS 10% 14.5% GIRLS 15% 17.5% BOYS 16.7% GIRLS 20% BOYS Percent of children aged 12-19 who are obese Childhood Obesity Rates by Race, Ethnicity, and Gender, 2007-08 Hispanics Source: CDC, National Center for Health Statistics, National Health and Nutrition Examination Survey; Note: Obesity is defined as BMI ≥ gender- and weight-specific 95th percentile from the 2000 CDC Growth Charts Socioeconomic Disparities Among adults, obesity rates are sometimes associated with lower incomes, particularly among women. Women with higher incomes tend to have lower BMI, and the opposite is true, those with higher BMI have lower incomes.18 A study in the early 2000s found that about 38% of non-Hispanic white women who qualified for the Supplemental Nutrition Assistance Program (known then as food stamps), were obese, and about 26% of those above 350% of the poverty line were obese.19 Also, a recent study of American adults found lower rates of obesity among individuals with more education. Specifically, the study found that nearly 35% of adults with less than a high school degree were obese, compared to 21% of those with a bachelor’s degree or higher.20 The relationship between income and obesity in children is less consistent than among adult women,21and sometimes even points in the opposite direction. Another study from the early 2000s found that only among white girls were higher incomes associated with lower BMI. Among AfricanAmerican girls, the prevalence of obesity actually increased with higher socioeconomic status, suggesting that efforts to reduce ethnic disparities in obesity must target factors other than income and education, such as environmental, social, and cultural factors.22 ★ 5 ★ S O LV I N G T H E P R O B LE M O F C H I LD H O O D O B E S I T Y Regional Disparities Across the country, the prevalence of obesity has been found to be highest in southeast states such as Alabama, Mississippi, South Carolina, Tennessee, and West Virginia, as well as in Oklahoma. It is lowest in Colorado.23 Another study showed obesity was most common among adults in the Midwest and the South, as well as among adults who did not live in metropolitan areas.24 How Does Obesity Impact Our Health? Obese adults have an increased risk for many diseases, including type 2 diabetes, heart disease, some forms of arthritis, and several cancers.25 Overweight and obese children are more likely to become obese adults.26 Specifically, one study found that obese 6-8 year-olds were approximately ten times more likely to become obese adults than those with lower BMIs.27 The association may be stronger for obese adolescents than younger children.28 Obese children are also more likely to have increased risk of heart disease. 29 One study found that approximately 70% of obese children had high levels (greater than 90th percentile) of at least one key risk factor for heart disease, and approximately 30% had high levels of at least two risk factors.30 There is evidence that heart disease develops in early childhood and is exacerbated by obesity,31 and people as young as 21 have been found to display early physical signs of heart disease due to obesity.32 Obese children are also more likely to develop asthma.33 Obesity is the most significant risk factor for type 2 diabetes, a disease once called “adult onset diabetes” because it occurred almost exclusively in adults until childhood obesity started to rise substantially. The number of hospitalizations for type 2 diabetes among Americans in their 20s has gone up substantially, for example.34 A 2001 study found that more than 75% of children ages 10 and over with type 2 diabetes were obese.35 Type 2 diabetes occurs more frequently among some racial and ethnic minority groups, and rates among American Indians are particularly high.36 In addition to the physical health consequences, severely obese children report a lower health-related quality of life (a measure of their physical, emotional, educational, and social well-being). In fact, one study found that they have a similar quality of life as children diagnosed with cancer.37 Childhood obesity is a highly stigmatized condition, often associated with low self-esteem, and obese children are more likely than non-obese children to feel sad, lonely, and nervous.38 Obesity during childhood is also associated with some psychiatric disorders, including depression and binge-eating disorder, which may both contribute to and be adversely impacted by obesity.39 What Causes Obesity? Early Life A child’s risk of becoming obese may even begin before birth. Pregnant women who use tobacco, gain excessive weight, or have diabetes give birth to children who have an increased risk of being obese during their preschool years.40 Furthermore, although the evidence is not conclusive,41 rapid weight gain in early infancy has been shown to predict obesity later in life.42 Racial and ethnic differences in obesity may also be partly explained by differences in risk factors during the prenatal period and early life.43 ★ 6 ★