Lots to Lose: How America's Health and Obesity Crisis Threatens our Economic Future

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Jun 2012

Lot to Lo:How Americas Health andObesity Crisis Threatensour Economic Future

Halth PgamNutrition and Physical Activity Initiative


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BPC would like to thank the Robert Wood Johnson Foundation, the W.K. Kellogg

Foundation, and the Stuart Family Foundation or their generous support o the

Nutrition and Physical Activity Initiative.

D i s c L a i m e r

This report is the product o the Bipartisan Policy Centers Nutrition and Physical

Activity Initiative (NPAI). The ndings and recommendations expressed herein are

solely those o NPAI and do not necessarily represent the views or opinions o the

Bipartisan Policy Center, its ounders or its board o directors.


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Lot to Lo: How a Hlth nd Obty c Thtn ou eono Futu

Bruce Knight

Senior Advisor

Former Undersecretary or Marketing

and Regulatory Programs, USDA

Robin Schepper

Senior Advisor

Former Executive Director, Lets Move!

Matt Levy, MD, MPH

Advisor

Division Chie, Community Pediatrics,

Georgetown University Hospital

Health Policy Fellow 2010-2011, RWJF

Marika Tatsutani

Lead Writer and Editor

Nutrition and Physical Activity Initiative

STAFF MeMberS

Lisel Loy

Director, Nutrition and Physical

Activity Initiative

Leah Ralph

Policy Analyst

Amelia Shister

Administrative Assistant

Co-CHAirS

Dan Glickman

Senior Fellow, Bipartisan Policy Center;

Former Secretary o Agriculture;

Former Representative rom Kansas

Mike Leavitt

Chairman, Leavitt Partners;

Former Governor o Utah;

Former Secretary o Health and

Human Services

Donna E. Shalala

President o the University o Miami;

Former Secretary o Health and

Human Services

Ann M. Veneman

Former Executive Director o UNICEF;

Former Secretary o Agriculture


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Executive Summary . . . . . . . . . . . . . . . . . . . . 5

Chapter 1: Introduction . . . . . . . . . . . . . . . .19

Chapter 2: Americas Health Crisis . . . . . . . . 23

Chapter 3: Healthy Families . . . . . . . . . . . . . 31

Diet and Physical Activity Guidelines . . . . . . . . . . . . . 32

Nutrition Assistance Programs . . . . . . . . . . . . . . . . . . 34

Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Chapter 4: Healthy Schools . . . . . . . . . . . . . 41

Chapter 5: Healthy Workplaces . . . . . . . . . . 49

Case Study: Department of Defense Initiatives . . 54

Chapter 6: Healthy Communities . . . . . . . . . . 61

Community-based, Prevention-focused health care . . . 61

Large Institutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Community Programs and the Built Environment . . . . . 78

Chapter 7: Cross-Cutting Recommendations . . . 83

Public Awareness and Marketing . . . . . . . . . . . . . . . . 83

Food and Farm Policy . . . . . . . . . . . . . . . . . . . . . . . . . 86

Information Sharing and Analysis . . . . . . . . . . . . . . . . 89

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . 92

List of Acronyms . . . . . . . . . . . . . . . . . . . . . 94

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Acknowledgements . . . . . . . . . . . . . . . . . . 102

Table of Contents


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Our nation is in the midst o a public health crisis so proound

that is it undermining our national well-being, our economic

competitiveness and even our long-term national security. Fully

two-thirds o Americans are overweight or obese. One-third o

American children are overweight or obese. And among children

under the age o six, nearly one in ve is overweight or obese.I

Obese people are ar more likely to develop chronic diseaseslike diabetes, hypertension, asthma, heart disease and cancer.

Obese children are more likely to have one or more risk actors

or cardiovascular disease, to be prediabetic (i.e., at high risk or

developing diabetes), and to suer rom bone and joint problems,

sleep apnea, and social and psychological problems such as

stigmatization and poor sel-esteem. They are also very likely to

become obese adults.

In short, obesity is the most urgent public health problem in

America today. It is a primary reason why lie expectancy in

large parts o the United States is already several years lower

than in other advanced countries around the world. For millions

o Americans, it means many more years even decades

o sharply reduced quality o lie. More broadly, the costs o

obesity and chronic disease have become a major drag on our

economy. Escalating health care costs are themain driver o our

spiraling national debt, and obesity-related illness comprises an

increasingly large share o our massive health costs. The obesity

crisis is thereore not just a health crisis, but a major contributor

to our scal crisis. At home, individuals and amilies struggle with

the consequences and costs o obesity and disease on a daily

basis. But or our nation as a whole, the impacts o Americas

obesity epidemic jeopardize our global competitiveness and

national security, directly undermining our ability to cut the

ederal debt, prepare and sustain a highly productive workorce,

maintain our military strength, and compete eectively in the

global economy.

Turning the tide o this epidemic is challenging or several

reasons. First, changing behavior is never easy, particularly when

that behavior is rooted in much deeper changes in the way many

Americans live, work, play and eat. Second, public resources

to implement new policies and programs are constrained as

never beore. Given these twin challenges, the importance o

responsibility and leadership in combating obesity and chronic

disease cannot be overemphasized. Both are clearly needed

at the level o individuals and parents, who ultimately make the

decisions and set the examples that infuence not only their

own health but that o uture generations. But responsibility andleadership are also needed at the level o communities and key

institutions, including government. These institutions shape the

environment in which individual and amily decisions get made

and they can help bring about the broader changes needed

to ensure that all Americansincluding especially vulnerable

citizenshave access to inormation and options that support

and encourage healthy choices.

The Bipartisan Policy Center (BPC) launched its Nutrition and

Physical Activity Initiative based in large part on our concern

about the national debt and the clear role that escalating health

care costs play in our nations looming scal emergency. Obesity

and chronic disease are a critically important piece o this puzzle.

In searching or solutions, we have ocused on those areas that

we believe hold the most promise to bring about change on

the scale and within the timerame needed to respond to the

enormous scal, social, economic, and public health threat they

present. We recognize that eective responses to the current

epidemic will require action and change on the part o individuals

and amilies, as well as action and change on the part o a wide

variety o interests and organizations: large companies, advocacy

groups, community leaders, health proessionals, business

groups, and oundations, not to mention local, state and ederal

government. Success is only possible i all these entities work

together and bring creativity, innovation and ocused commitment

to the eort.

The good news is that we are already seeing an enormous

convergence o attention and initiative in this area. Many

important ideas are being tried some o them out o economic

or other necessity and oten with limited resources rom

healthier menus in Army mess halls to improved school lunch

Executive Summary


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Source: Derived rom inormation rom the Boston Foundation (June 2007).

ACCESS TO CARE 10%

GENETICS 20%

SERVICESMEDICAL

OTHER 8%

HEALTHY BEHAVIORS

HEALTHY BEHAVIORS 4%

ENVIRONMENT 20%

What Makes

Us Healthy

What We Spend

On Being Healthy+

88%


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programs and community-based preventive care services. This

report makes specic recommendations aimed at building on the

most promising eorts, with the benet o insights gained rom a

year o intensive research and outreach to groups and individuals

who are already working in all kinds o settings and in many

dierent ways to promote healthy nutrition and physical activity.

This Executive Summary, like the main report, is organizedto refect our broad categories or targets or action: amilies,

schools, workplaces, and communities. A th category o cross-

cutting recommendations addresses public awareness, ood and

arm policy, and inormation sharing.

Halthy Famls

For most people, healthy patterns o diet and physical activity

begin at home. Parents and caregivers, in particular, have a

strong infuence on what children eat and how active they are. In

act, recent studies indicate that the general health and obesityo parents is a powerul indicator or the health outcomes o

children. Moreover, these infuences start very early: a growing

body o research indicates that nutrition during the rst thousand

days starting during pregnancy and continuing to age two

plays a signicant role in determining an individuals health,

not only later in childhood but over his or her entire lietime.

BPCs recommendations or healthy amilies ocus on increasing

awareness o ederal diet and physical activity guidelines, aligning

ederal nutrition assistance programs with dietary guidelines, and

promoting breasteeding or the rst six months o an inants lie.

Healthy Families Recommendation #1: HHS and

USDA should extend federal guidelines for diet

and physical activity to all children under six and

enhance public awareness and understanding of

these guidelines.

Existing dietary guidelines, which are developed by the U.S.

Departments o Health and Human Services (HHS) and

Agriculture (USDA), apply to children and adults ages two and

up; current physical activity guidelines start at age six. Given the

importance o establishing healthy patterns or diet and activity

in very young children we recommend that HHS and USDA take

the ollowing specic actions:

Develop, implement and promote national dietary guidelines

or the rst thousand days, covering pregnant women and

children up to two years old;

Similarly, develop national physical activity guidelines or

children under six years old; and

Support these guidelines by developing an eective national

strategy or disseminating this inormation and educating

parents about the benets o rst oods and physical activity,

particularly or populations that are most at risk or poor

nutrition and health.

Healthy Families Recommendation #2: USDA should

ensure that all its nutrition assistance programsreect and support federal dietary guidelines.

The USDAs Food and Nutrition Service (FNS) operates 15

ederal nutrition assistance programs that together serve millions

o the nations most vulnerable citizens, including many o the

populations most at risk or poor nutrition, obesity and related

chronic diseases. Because these programs touch nearly one in

our Americans annually, they provide a critical opportunity or

educating people about the connections between diet, physical

activity and health. The major ederal ood programs include

the National School Lunch and School Breakast Programs, the

Special Supplemental Nutrition Program or Women, Inants and

Children (WIC) program, the Supplemental Nutrition Assistance

Program (SNAP), and the Child and Adult Care Food Program

(CACFP). To promote better childhood nutrition and health

through these programs, we recommend that HHS and USDA

take several steps to: (a) align messaging and education about

nutrition through these programs, particularly as they aect

pregnant women, new mothers, inants and young children;

(b) provide technical training to states and local USDA sta to


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that a national program be established to publicly recognize

businesses that demonstrate best practices in providing lactation

accommodations.

Halthy Schls

Because most children spend signicant amounts o time in

school or in childcare acilities outside the home, these settings

aord an important opportunity to infuence the health and

liestyle choices o the next generation. Studies also nd a

direct link between nutrition and physical activity and improved

perormance in school. For these reasons, opportunities to

promote better health through nutrition and physical activity in

school have received considerable attention rom policymakers,

health experts, and other stakeholders. The Healthy Hunger-Free

Kids Act passed by Congress in 2010 required USDA to update

nutrition standards or oods and beverages served in schools,

including oods and beverages sold through vending machinesand school stores. This was the rst update in 15 years. The

legislation also calls on schools to strengthen their wellness

policies to look at the overall health o students.

Historically, less attention has been given to nutrition and health

in childcare settings or preschool-aged (as opposed to school-

aged) children, but here too a growing number o initiatives and

programs have been launched in recent years. For example,

USDA is moving to update Child and Adult Care Food Program

(CACFP) meal guidelines, which apply to ood served in childcare

settings (among other venues). For schools and preschools, the

primary challenge at present is to scale up successul programs

and ully implement policy changes that have already been

introduced, including the Healthy Hunger-Free Kids Act.

Healthy Schools Recommendation #1: Childcare

providers should improve nutrition and physical

activity opportunities for preschool-aged children.

Nationwide, 12 million U.S. children under the age o six are in

childcare and, o these, 1.9 million are cared or in a amily day

improve program implementation and eectiveness; (c) conduct

research to gain a better understanding o program participation,

utilization and impacts; and (d) increase awareness o program

benets.

Healthy Families Recommendation #3: All key

institutions including hospitals, workplaces,communities, government and insurance providers

should support and promote breastfeeding with the

goal of substantially increasing U.S. breastfeeding

rates for the rst six months of an infants life.

Breasteeding is enormously benecial or both mother and child.

And or the child, these benets are long lasting: research nds

that breasted inants have improved health outcomes later in

lie, including lower rates o obesity and chronic disease.II A 2010

study published by the American Academy o Pediatrics ound

that i 90 percent o new mothers in the United States breasted

exclusively or six months, this change alone could deliver health

care cost savings on the order o $13 billion annually.III

Today, roughly three-quarters o new mothers in the United

States start outbreasteeding, but that rate drops o sharply once

mothers and inants leave the hospital: by three months, only 35

percent o inants are exclusively breasted and at six months,

the gure is less than 15 percent.IV And while not all mothers

breasteed, or those who do, institutional, amily and community

support can make the dierence between sustaining this practice

versus not. To support and promote breasteeding, hospitals

should ollow baby riendly practices, including discouragingthe use o ormula except where medically necessary, tracking

and reporting their maternity care practices, and providing ollow-

up support or breasteeding ater new mothers leave the hospital.

Both hospitals and the ederal WIC program should ollow the

World Health Organizations Code o Marketing o Breast Milk

Substitutes, which aims to limit unwarranted exposure to breast

milk substitutes and related advertising. Finally, employers have

an important role to play in providing nursing breaks and a private

place or mothers to express breast milk. We also recommend


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School gardens are an example o the kind o project that has

been shown to be highly eective as a teaching tool, that does

not require a very large commitment o resources, and that lends

itsel well to partnerships with outside organizations. Schools

should also look to outside sources o unding and support using

models such as the Alliance or a Healthier Generations Healthy

Schools Program, which provides technical assistance to helpparticipating schools improve ood quality and physical education

programs. This eort is similar to the USDAs Healthier U.S.

Schools Challenge, which provides small monetary incentives to

schools that meet rigorous standards or ood quality, participation

in meal programs, physical activities, and nutrition education.

Healthy Schools Recommendation #4: Federal, state

and local governments, along with private partners,

should explore all available avenues to increase

quality physical activity in schools.

Specically, schools should require 60 minutes o physical activity

per day as an integral part o their wellness policies. Children

spend much o their day in school and oten also participate

in ater-school programs, and promoting physical activity in

the school environment is critical to supporting physical and

mental tness in students. Given the unding challenges many

schools ace, all available options should be explored, including

but certainly not limited to physical education classes. Options

requently exist that are simple and not costly. Partnering

with other public and private institutions, incorporating health

inormation in school curricula, and innovating to maximize

returns rom existing resources will be critical to successullyimplementing these recommendations.

Halthy Wkplacs

For many Americans, the workplace is second only to home in

terms o time spent and impact on liestyle choices. Fortunately,

growing numbers o employers are seeing the connection

between healthier workers and healthier prots. This is because

obesity and chronic disease are strongly linked to lower employee

care setting.V While strides have been made to improve nutrition

and provide more opportunities or physical activity in school,

childcare and preschool settings are another critical area or

intervention. A growing body o research indicates that waiting

until kindergarten is too late. By age ve, one in ve children

is already overweight or obese. Given the importance o early

intervention, we must ensure that early childhood environmentsprovide the strongest start possible, including access to nutritious

ood and regular physical activity.

Healthy Schools Recommendation #2: Schools

should improve food and nutrition education by

aggressively implementing the Healthy Hunger-Free

Kids Act.

To assist states and school districts in implementing the above

recommendation, USDA should compile existing resources,

and supplement them where necessary, to establish a national

clearinghouse o tools and inormation. We also recommend that

the Centers or Disease Control (CDC) and the Department o

Education explore how they can provide resources to assist with

education and other elements o the transition.

For their part, states should develop implementation plans, with

a ocus on training and other support necessary or successul

implementation, to help schools aggressively embrace Healthy

Hunger-Free Kids Act requirements. Particular attention needs

to be paid to the training and technical assistance needs o small

and rural school districts where barriers to implementation have

typically been higher.

Healthy Schools Recommendation #3: Schools

should improve nutrition and physical activity

offerings, in partnership with the private sector.

Given current budget constraints at the ederal, state and local

levels, schools and school districts will have to innovate and

work with the private sector to expand the resources available to

support nutrition and physical activity in schools and to prioritize

the use o existing resources to achieve maximum benets.


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The ederal governments Oce o Personnel and Management

(OPM) currently spends $40 billion per year covering health care

costs or ederal employees. But because all employee-related

medical and pharmacy claims are paid centrally through OPM,

individual departments or agencies have no way o tracking their

particular health care costs. This reduces accountability as well

as incentives to promote employee health or disease prevention.Options or changing current practice so as to make department

or agency heads accountable or, or at least aware o, employee

health costs should be explored as a rst step toward modeling

leadership on the issue o workplace wellness in the ederal

government. Federal investments in data collection and tracking

to substantiate the benets achieved through dierent workplace

wellness demonstrations will be well justied i they point the way

toward replicable approaches that reduce costs and improve

perormance, not just in the ederal workorce but or rms and

their employees throughout the economy.

The U.S. Department o Deense (DoD) is providing particularly

strong leadership in this arena and has several initiatives

underway to improve health among service members and military

amilies. For example, the Army launched the Soldier Fueling

Initiative when it ound that attrition rates were higher among

new recruits because many o them had lower bone density

levels, incurred more injuries, and suered rom deciencies in

calcium, iron and various other vitamins and nutrients compared

to previous recruit cohorts. This initiative combines enhanced

physical education and training with healthier ood choices

and an inormation/awareness campaign to emphasize the

importance o good nutrition or soldier perormance. DoD has

worked with dietitians to improve ood oerings at military dining

acilities more broadly but it could do even more to promote

nutrition and physical activity, both on base through military

hospitals, schools and childcare centers and o base in

communities with a high proportion o military amilies. Because

our national security depends on a t and high-perorming

military, DoD is an employer with a particularly critical charge.

It also has the capacity, infuence and organization to change

productivity, higher rates o absenteeism and presenteeism

(when people are present, but not working eectively), and

higher health care costs. O course, employers are also uniquely

positioned to infuence workorce health, particularly since they

bear such a large share o employee health care costs (currently,

60 percent o Americans are insured through an employment-

based plan).VI Increasingly, research is nding positive, and insome cases quite dramatic, returns on employer investments

in workplace wellness.VII These programs also deliver less

measurable but still important (and valuable) benets, in terms o

improved employee satisaction and retention.

Healthy Workplaces Recommendation #1: CDC, in

partnership with private companies, should develop

a database of exemplary workplace wellness

programs with a rigorous cost/benet analysis to

help scale up existing best practices in both the

private sector and within government. The SmallBusiness Administration (SBA) should provide support

here.

A registry o workplace wellness and health promotion initiatives

that could be readily accessed by a variety o stakeholders would

put the workplace wellness movement on more solid ooting and

help employers identiy proven strategies and program designs

that are well-suited to their industry, size and organizational

structure. Additional steps that would support employer

investments in workplace wellness include developing tools and

resources to analyze the costs and impacts o wellness programs,

providing resources or pilot programs and program evaluations,and supporting certication and accreditation programs as a way

to lower barriers to participation and accelerate the dissemination

o best practices.

Healthy Workplaces Recommendation #2: The

federal government should both scale up successful

workplace wellness programs and continue

exploring innovative approaches.


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settings. Demand or these services already exists, but so ar

the supply o providers has not caught up. Third, we need

mechanisms to enable public and private reimbursement

or health conditions and services that are oten not covered

under the existing system.

Healthy Communities Recommendation #1:Nutrition and physical activity training should be

incorporated in all phases of medical education

medical schools, residency programs,

credentialing processes and continuing

education requirements.

Proessionals throughout the health care system are uniquely

positioned to inorm and motivate Americans on the subjects

o nutrition and physical activity. Americans see medical

proessionals nurses in particular as a trusted source o

inormation, and health care providers are the number one

go-to resource or parents who are concerned about their

childs weight. But the medical education and licensing

system in the United States is not currently set up to ensure

that health proessionals have the incentive and expertise

to deliver messages about weight, chronic disease, diet

and physical activity not only eectively but consistently. On

the contrary, the consensus among medical organizations

and experts is that nutrition education at all levels o

health training (undergraduate, post-graduate, ellowship,

licensing and board certication, and continuing education)

is uneven at best and oten inadequate. The goal o this

recommendation is to inuse the education and training oall health proessionals with nutrition and physical activity

inormation and behavioral methodologies or tools (such as

motivational interviewing), and to make basic competency

in these areas an integral part o certication and continuing

education requirements. Achieving this goal will require

leading expert organizations to partner in developing a

comprehensive national strategy and standards or nutrition

and physical activity education across the continuum o the

health proession.

business as usual in ways that aect the rest o government,

as well as institutions in our larger society. By applying many o

the tools described in this report rom supporting breasteeding

at maternity hospitals to providing healthier ood choices and

recognizing the important role o schools and amilies DoD

has an opportunity to substantially enhance the health and

perormance o service members and their amilies, while at thesame time leading the way or the rest o the country.

Halthy Cmmunts

Along with home, school and workplace, community plays a

central role in the liestyle choices that infuence peoples health

outcomes. Their local community is where most Americans

access the goods and services on which they rely, rom the

grocery store to the doctors oce; it is also where most o us

go to play, worship, recreate, eat out and be entertained. This

chapter discusses a wide-ranging set o recommendations,all o which are rooted in the community, broadly dened. For

organizational purposes, we divide this chapter into three major

subtopics: health care services, large institutions, and the built

environment.

1. Community-based, Prevention-focused Health Care

Rising health care costs have prompted growing interest in

disease prevention as a more eective and ultimately less

expensive way to keep Americans healthy. Good diet and an

active liestyle are clearly central to an approach that avors

promoting wellness and preventing disease over a model

that ocuses on treating health problems only ater they arise.

Our recommendations target three kinds o interventions that

are necessary to support the shit to a prevention-ocused

health care system. First, health care proessionals must be

better trained to provide care that addresses issues o diet,

physical activity, wellness and disease prevention. Second,

the base o available care resources and care providers

must be broadened to include non-traditional providers

who can deliver services in non-clinical, community-based


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wellness-ocused approach to health care. An example o

this approach is being pioneered by UnitedHealth Group

(UHG) and the YMCA, which have partnered to implement

a diabetes prevention program in which UHG reimburses

the YMCA or education, counseling and weight-loss services

according to perormance-based metrics (not simple

participation rates). Similarly, the ederal government isexamining potential ways to increase coverage or preventive

services through programs such as Medicare, Medicaid and

the Childrens Health Insurance Program (CHIP). Further

demonstration projects, whether public or private, are needed

to provide data on what works. We should reward those

services and providers who demonstrate the capacity to bend

the cost curve.

2. Large Institutions

Large institutions such as hospitals and universities, sports

and entertainment venues, hotels, and large government

departments or agencies (DoD, or example) serve meals to

thousands o people on a daily basis. A single major retailer

such as Walmart may sell ood to millions o customers

each day. These entities, private and public, have enormous

purchasing power and can leverage major changes in

the ood supply chain, both in terms o what kind o ood

is produced and in terms o where and how the ood is

distributed. As in schools and workplaces, interest in healthy

ood and wellness on the part o large institutions has been on

the rise in recent years. Innovative programs and partnerships

have been multiplying and there are a growing number osuccess stories to be considered and possibly emulated.

Several large hospitals, major retailers, universities, restaurant

and hotel chains, and large government agencies have

launched promising initiatives in recent years to improve

menu oerings and promote healthier ood choices.

Healthy Communities Recommendation #2: Non-

clinical, community-based care is a critical tool

in preventing obesity and chronic disease. We

need to train and deploy a prevention workforce

to deliver this kind of preventive care.

Recognizing that or many people, contact with traditionalhealth care proessionals such as doctors and nurses is

limited or sporadic, we recommend engaging a wider base

o resources and person-to-person interactions to deliver

messages about health and infuence liestyle behaviors.

Recent initiatives suggest that community health workers,

health coaches, dietitians and nutritionists, lactation

consultants, and others can be eective in working with

individuals and groups to change awareness and habits

around diet, physical activity and other health-relevant

behaviors. And their interventions, whether provided in

collaboration with a health proessional or not, can be

more cost eective than the same services delivered by a

traditionally trained doctor or nurse practitioner.VIII Expanding

this trained, community-based prevention workorce

and nding ways to reimburse or its services would oer

multiple benets by improving health outcomes, reducing

health care costs, and creating new job opportunities.

Standardized training programs and curricula are needed to

tap this potential.

Healthy Communities Recommendation #3:

Public and private insurers should structure

incentives to reward effective, community-based, prevention-oriented services that

have demonstrated capacity to reduce costs

signicantly over time.

Because many community-based, preventive health care

services are not currently covered by either public or private

insurers, creating new reimbursement mechanisms or

reorming existing ones to cover these types o services

is critical to realizing the potential benets o a broader,


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Healthy Communities Recommendation #6: Local

governments should leverage existing resources

and infrastructure assets to expand opportunities

for physical activity.

In communities that lack sae, adequate places or children,

youth and adults to exercise and play, or where schools donthave the acilities to support physical activity programs, joint

use agreements provide a mechanism to enable the shared

use o public acilities. Typically, this type o agreement would

be struck between two government entities, such as a school

district and a city or county. Joint use agreements have

been successully used in a number o locales to expand

the sport and recreational opportunities available to students

and members o the community. A variety o other low-cost

options and public-private partnerships have also been used

to promote healthy activity at the community levela good

example are the various walking initiatives, such as Everybody

Walk and Get Fit, that have been launched in neighborhoods

and at schools across America.

Healthy Communities Recommendation #7: Families

and local governments should make creative use of

technology to increase physical activity.

Modern technologies, including video games, mobile

phones and computers, are oten viewed as a major driver

behind todays more sedentary, less healthy liestyles.

Ater all, American children spend, on average, more than

seven hours a day in ront o a screen. Yet, given that thesetechnologies have become an inescapable and, or many

people, indispensable part o daily lie, we believe it is time

to rerame the debate. Opportunities to develop games that

require or encourage the user to be physically active are

expanding rapidly. Some such games already exist and others

are being developed. Newer ideas include linking pedometers

and accelerometers to games and prizes, using geo-cashing

and other geographic digital games to encourage kids to go

outside, and using social media to share inormation about


Large, private-sector institutions should procure

and serve healthier foods, using their signicant

market power to shift food supply chains and

make healthier options more available and cost-

competitive.


Public-sector institutions should continue to

lead by example, promoting healthy foods

and physical tness as a means to enhance

employee performance, both in the military and

within the civilian workforce.

3. Community Programs and the Built Environment

Community programs and the built environment play an

important role in supporting (or discouraging) a healthy level

o regular physical activity. In many parts o America, the builtenvironment refects and reinorces an automobile-centered

way o lie. Resource-strapped towns and cities have cut

back on recreational programs and acilities. And only those

with extra time and means have the option to join a health

club or gym. In some areas, its hard even or children to be

active; schools dont oer sports and activities, parks and

playgrounds may be inadequate or non-existent, and simply

playing outside may be too dangerous because o trac

or crime or both. In sum, considerable empirical evidence

exists to suggest that where people live and work has a much

greater impact on their health than their interactions with thehealth care sector or their genetic makeup. And while these

social determinants o health do have some correlation to

income levels, they aect all Americans living in all kinds o

communities. Our recommendations or promoting more

active liestyles at the community level ocus on three specic

areas o opportunity: (1) leveraging existing resources, (2)

utilizing technology in innovative ways, and (3) changing the

built environment over time.


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exutv suy

many advertising messages including particularly those

directed to children continue to promote unhealthy

oods. At the same time, research shows that many people

have diculty interpreting the health-related claims that

are oten used to market ood, either as part o ood

packaging or in advertisements.

In sum, more can and should be done to communicate

clear, consistent messages about the importance

o healthy diet and physical activity and to provide

consumers with the inormation to make healthier choices.

Expanded eorts in this realm should make use o new

advertising and media outlets, including not just TV, print,

radio and the internet, but also new and emerging social

media, kid-directed games, product packaging, and digital

media advertising.

Public Awareness and Marketing

Recommendation #1: The food industry should

adopt uniform standards for what constitutes

better for you foods using the Institute of

Medicine Phase 2 report as a starting point and

making sure industry standards are aligned with

the U.S. Dietary Guidelines.

We also call or an independent entity to monitor and evaluate

the impact the industrys voluntary Facts up Front proposal

is having on consumer choice, with the goal o measuring

whether consumers are using this inormation to change their

purchasing and consumption behaviors.

Public Awareness and Marketing

Recommendation #2: The Ad Council or similar

organizations should coordinate a multi-media

campaign to promote healthy diet and physical

activity, funded by leading private sector

companies in collaboration with federal agencies.

For both the nutrition and physical activity aspects o the

campaign, high prole and infuential messengers are

physical activity options (such as mobile apps that provide

inormation about good recreation or walking options).

Healthy Communities Recommendation #8: Local

governments should use the planning process

to change the built environment in ways that

promote active living.

Growing numbers o cities and towns are using the planning

process and zoning codes to shape the built environment in

ways that promote walking and bicycling, help residents stay

connected, and improve quality o lie. In many cases, mayors

and county and city council representatives are working with

architects and designers and with planning, transportation

and public health departments to create healthier buildings,

streets, and urban spaces based on the latest academic

research and best practices. As an alternative to imposing

new requirements, some cities have removed or changed

old zoning codes that work against the goal o encouraging

healthier, more active living. Other cities have incorporated

physical activity guidelines into their construction codes and

adopted policies that support outdoor play and exercise.

These include oering incentives to designers and developers

to build in ways that encourage walking, bicycling, and active

transportation and recreation.

Css-Cuttng rcmmndatns

1. Public Awareness and Marketing

The ood industry spends billions o dollars each year

marketing products to American consumers. According to the

Institute o Medicine (IOM), as much as $10 billion per year

is spent just to market ood specically to children. A number

o large ood and beverage companies, both individually and

in some cases as part o a larger initiative, have recently made

voluntary commitments to reduce their marketing to children,

and/or sought to improve the nutritional quality o their

product oerings. While these eorts are to be applauded, too


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We recommend taking specic actions, including: reviewing

existing government policies or opportunities to eliminate

barriers that may reduce the supply and increase the cost

o healthy oods; authorizing a generic ruit and vegetable

promotion board; improving transportation and distribution

systems to make resh produce more available and

aordable; and exploring ways to incentivize healthier oodchoices through ederal nutrition assistance programs.

Food and Farm Policy Recommendation #2: USDA

should identify and pursue further opportunities to

promote health and nutrition through its nutrition

assistance programs.

Federal nutrition assistance programs, like SNAP, WIC

and CACFP, reach millions o the nations most vulnerable

individuals and amilies each year including many people

at high risk or obesity and chronic disease. We recommend

continued support or these programs coupled with increased

eorts to align program guidelines and incentives with ederal

dietary guidelines. We also recommend urther research and

analysis to better understand the impacts o these programs

on dietary choices and health in the recipient population and

to inorm relevant policy debates going orward, such as the

current debate about whether certain ood items should be

excluded rom the SNAP program.

Food and Farm Policy Recommendation #3:

Congress should continue sustained support for

relevant research by ofces of USDA.

Research conducted by the USDAs Agricultural Research

Service (ARS), the National Institute o Food and Agriculture

(NIFA), and Economic Research Service (ERS) is valuable

to ensure that policymakers, stakeholders and the public

continue to have robust, up-to-date inormation on the

impacts o ood and arm policies.

critical. We recommend involving celebrities, athletes

and other public gures who resonate with audiences

and have the ability to inspire change.

Public Awareness and Marketing Recommendation

#3: Food retailers should adopt in-store marketing

and product placement strategies to promote thepurchase of healthier, lower calorie products.

Public Awareness and Marketing Recommendation

#4: States and localities should continue to innovate

and experiment with ways to change the prole of

foods in the marketplace.

As part o ongoing eorts in this area, additional inormation

generated by states and localities about the impact that

dierent state policies and local ordinances are having

on ood choices, portion sizes and other actors or the

general population and or children in particular would bea useul contribution to existing research in the eld.

2. Food and Farm Policy

Agriculture is a major sector o the U.S. economy and one

in which government decisions subsidies and incentives,

trade policies, etc. play a major role. Historically, arm and

agriculture policies were, at most, tangentially infuenced by

considerations o diet, nutrition and health. This has begun to

change. Growing awareness o the costs and impacts o high

rates o obesity and chronic disease in America are prompting

a broader look at our entire ood supply chain and at the

policies and programs that, along with consumer preerence,

determine what oods appear on grocery store shelves and,

ultimately, on our plates.

Food and Farm Policy Recommendation #1: USDA, in

collaboration with other stakeholders, should identify

and address barriers to increasing the affordability

and accessibility of fruits, vegetables and legumes.


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exutv suy

Cnclusn

While the statistics on obesity and chronic disease are truly

alarming, numbers alone cannot convey the ull human and

social costs o the health crisis we conront today in America.

The problem is clear and its impact on our uture both in

terms o the health, productivity and well-being o the currentgeneration and generations to come, and in terms o the

prosperity, competitiveness and scal integrity o our nation as a

whole is hard to overstate. Turning the tide o this epidemic will

require leadership, rst and oremost. All sectors o society must

be engaged and all must take responsibility rom individuals

and amilies to communities, institutions and government.

Together, our challenge will be to dene and implement policies,

strategies, incentives and actions that, by encouraging and

supporting healthy behaviors, can begin to slow and even

reverse the trajectory we are on. The complexity o the problem

demands a diversity o solutions; whats required is not a newtop-down program or a vast expenditure o public resources, but

a multiplicity o smaller steps and changes, at all levels o society,

that collectively translate to lasting, large-scale shits over time.

Results will rarely be quick, but progress must be steady. And as

we strive to reduce obesity, improve health, and slow the runaway

growth o health care costs in America, continued research and

data collection will be critical to inorm our eorts and make sure

we are investing in those strategies we know will work.

In this report, BPC has ocused on areas and opportunities

or intervention that we believe hold particular promise, both

because they can have a signicant impact and because

they can be implemented within existing rameworks and

structures. The good news is that many powerul examples

and inspiring programs are already underway. To achieve the

goal o signicantly reducing obesity and chronic disease in

America within the next generation, we must build on what is

already working, expand the reach o good programs, and greatly

accelerate the pace o change. The problem is complex but we

know at least some o the solutions. Now it is time to get to work.

3. Information Sharing and Analysis

One o the greatest challenges or all parties interested

in promoting healthy diet, physical activity, wellness, and

preventive care is accessing the wealth o data and ideas that

is being generated in this realm. From understanding what

programs are working well to what the latest research cantell us, there is an enormous need or better ways to share

knowledge and learn rom dierent eorts. Time and again,

as BPC reached out to dierent stakeholders we learned

about important, innovative, sometimes low-cost or even

cost-neutral programs that have achieved desired results

but are not widely known. And despite some eorts to pull

together some o this inormation, no central repository exists

or systematically collecting, organizing and disseminating

research, data and best practices or combating obesity and

chronic disease. Also needed are ongoing public-private

eorts to rigorously evaluate the costs and impacts o specic

public health interventions. Given the scale o the challenges

and current scal and political constraints, it will be critical

to demonstrate that prevention-based approaches can yield

tangible results.

Information-sharing recommendation #1: CDC

and HHS should continue robust efforts to collect

and disseminate information on food, physical

activity and health including information on the

social determinants of health and future costs

and Congress should continue to support these

monitoring and information-gathering functions.

Information-sharing recommendation #2:

Public- and private-sector organizations active

in this eld should partner to establish a national

clearinghouse on health-related nutrition and

physical activity initiatives. The clearinghouse

should provide links to further resources, technical

assistance, coordination and partnership

opportunities, and up-to-date research ndings.


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Notes

I. Ogden, Cynthia, Ph.D., and Margaret Carroll, M.S.P.H. Prevalence o Obesity

Among Children and Adolescents: United States Trends 1963-1965 Through

2007-2008. CDC.gov. Centers or Disease Control and Prevention, 4 June

2010. Retrieved rom http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/

obesity_child_07_08.htm

II. U.S. Department o Health and Human Services, Oce o the Surgeon General.

The Surgeon Generals Call to Action to Support Breasteeding. Washington, DC,

2011 P.1.

III. Bartick, Melissa, and Arnold Reinhold. The Burden o Suboptimal Breasteeding

in the United States: A Pediatric Cost Analysis.Pediatricsvol. 125 No. 5. 2010.

IV. Breasteeding Report Card 2011, United States: Outcome Indicators.CDC.gov.

Centers or Disease Control and Prevention, 1 August 2011. Retrieved romhttp://

www.cdc.gov/breasteeding/data/reportcard2.htm

V. Mulligan, Gail M., DeeAnn Brimhall, Jerry West, and Christopher Chapman.Child

Care and Early Education Arrangements o Inants, Toddlers and Preschoolers.

U.S. Department o Education. National Center or Education Statistics, National

Household Education Surveys Program, 2005 P. 4. Laughlin, Lynda. Whos

Minding the Kids? Child Care Arrangements: Spring 2005/Summer 2006.

Census.gov. U.S. Census Bureau, Aug. 2010. P. 2. Retrieved romhttp://www.

census.gov/prod/2010pubs/p70-121.pd

VI. Baicker, Katherine, David Cutler, and Zirui Song. Workplace Wellness Programs

Can Generate Savings. Health Aairs. February 2010.

VII. Ibid. See also Berry, Leonard L., Ann M. Mirabito, and William B. Baun. Whatsthe Hard Return on Employee Wellness Programs? Harvard Business Review.

VIII. Shearer, Gail, M.P.P. Issue Brie: Prevention Provisions in the Aordable

Care Act. APHA.org. American Public Health Association, Oct. 2010 P.4.

Retrieved rom http://www.apha.org/NR/rdonlyres/763D7507-2CC3-4828-AF84-

1010EA1304A4/0/FinalPreventionACAWeb.pd


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21/110


Our nation is in the midst o a health crisis. Fully two-thirds o Americans are overweight

or obese. One-third o American children are overweight or obese. And among children

under the age o six, nearly one in ve is overweight or obese.1 Fewer than 20 percent o

Americans meet ederal guidelines or a healthy level o regular physical activity.2 Chronic,

debilitating, expensive and oten lethal diseases such as diabetes and hypertension aect

millions o people, at younger and younger ages, and are especially prevalent in low-income

and minority communities.

The consequences o this crisis threaten not only the day-to-day well-being and quality-

o-lie o millions o Americans, but the uture prosperity and security o our country as

a whole. Chronic diseases linked to obesity, poor nutrition and a lack o physical activity

are major drivers o todays runaway health care costs. Already, these costs are crowding

out other critical investments and orcing lose-lose choices on households, businesses

and the government alike. At risk in the long run is not just the scal integrity o the U.S.

government, but the American peoples ability to grapple with challenges on multiple ronts.

Chronic poor health aects everything rom the academic perormance o U.S. students, to

the productivity o U.S. workers and the readiness o the U.S. military.

Behind these trends lie many changes, large and small, in the way Americans live, work,

eat and play. Compared to our parents and grandparents, most o us spend more time in

ront o computer or television screens and more time in the car. We are more likely to work

in sedentary occupations, less likely to live in neighborhoods where we can walk to work or

to the grocery store, and less likely to have time to prepare home-cooked ood or sit down

or amily meals. In low-income communities, kids may lack sae places to play outside and

Chapt 1: Introduction

Rates of obesity (BMI 30)

in the U.S. population

increased strikingly over

the last 30 years, more than

doubling for adults and

more than tripling for

children.

0

10

20

30

40

50

In 1972, 5% of

children and

14.5%of adults

were obese.

By 2008, 17% of

children and

34.3% of adults

were obese.

Percentage

ofU.

S.

Population

Sources: Centers or Disease Control and Prevention, National Center or Health Statistics (June 2010); Lets Move White

House Task Force on Childhood Obesity Report to the President (May 2010).


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chpt 1: intoduton

local stores may not stock resh ruits and vegetables. Everywhere, ast-prepared oods

many o them laden with ats and sugar are available in abundance and at prices

that make them cheaper per calorie than healthier options. Everywhere, a barrage o

advertising makes us crave the oods that we can least aord to eat. In this environment,

eating well, staying active, and maintaining a healthy weight is an uphill struggle or

many i not most Americans. And despite a media culture that celebrates being thin and

physically t, millions o Americans are losing the battle or long-term wellness many othem rom a young age.

Changing this picture indeed, merely shiting the odds presents an enormous

challenge. The actors involved are numerous, complex and rooted in the social,

economic, cultural and demographic realities o our time. No easy policy prescriptions

exist because solutions to the problem depend on choices about diet and physical

activity that are ultimately personal; they come down to the messages parents send their

kids, the decisions people make in the supermarket aisle, and everyones willingness

and ability to look out or his or her own health. But it is equally critical to recognize

that individual choices take place in a context and are powerully shaped by a host o

external infuences. That means government and other institutions have an important

role to play in ensuring that all citizens have at least the inormation and the opportunity

to pursue a healthy liestyle. Put simply, it shouldnt be more dicult in 21st century

America to eat well and stay active than to do the opposite. And or too many people in

too many places especially those in low-income and minority communities healthy

options are either out o reach or simply not available.

To turn the tide on Americas obesity and chronic disease epidemic, all sectors o society,

rom employers and government agencies to schools, health care providers and the

ood industry, will have to work together to support and encourage healthy choices.

Inormation, incentives and access to better ood and physical activity options can be

powerul tools or broad-based change and all o them must be brought to bear. The

stakes are high and the need or action is urgent not just to avoid crippling healthcare costs in the uture but to ensure that Americas workorce remains one o the most

productive and competitive in the world.

The Bipartisan Policy Center (BPC) launched its Nutrition and Physical Activity Initiative

in 2011 to explore potential levers or change in the ght against obesity and chronic

disease in America. The initiative is led by our ormer U.S. cabinet secretaries and

brings together a wide range o experts, policymakers and stakeholders. This report

reviews the challenges our nation conronts today in terms o nutrition, physical activity

and health; it also identies best practices, highlights specic success stories, and


23/110


advances a set o concrete policy recommendations designed to address these issues

rom multiple angles.

Throughout, our ocus is on specic actions that could be taken to reduce current

rates o obesity and chronic disease, and thereby ease the nancial strains and loss o

longevity and productivity that are the ultimate consequences o our deepening national

health crisis. These recommendations refect insights gained rom a year o intensiveresearch and outreach to experts and stakeholders who are actively addressing health

issues rom the perspective o nutrition and physical activity. An enormous amount o

good work is being done in this area and success stories abound rom an innovative

eort to help U.S. servicemen and women make healthier choices in Army mess halls to

school lunch programs that have improved the quality o ood being oered to children

while also reducing costs. But scaling up these success stories will be challenging,

especially when many o the major players including schools, cities and counties

lack the resources to expand promising programs. Moreover, policies that aim to

change behavior are oten intrinsically hard to implement. BPCs goal with this initiative

is not to duplicate or repeat eorts that are already working. Rather, it is to explore how

individuals, government and the private sector can build on the best o these eorts

with a combination o behavior changes, targeted interventions and policy reorms that,

over time, will have a lasting impact on the health o the American people and the uture

strength and security o our nation as a whole.

This report is organized as ollows: Chapter II provides background and context on

Americas current crisis o obesity and chronic disease, elaborating on several o the

points and themes raised in this introduction. Subsequent chapters (Chapters III

through VI) outline our recommendations. They are organized according to the level

(or unit) o society that is primarily being addressed in each case, recognizing that

these distinctions are not always clear cut and that, given the nature o the topic, some

overlap across dierent categories or target audiences is inevitable. We begin with

healthy amilies, which are the rst line o deense in ensuring that healthy attitudesand patterns o behavior with respect to ood and physical activity are established early

and passed on to the next generation. Additional chapters ocus on schools, which oer

some o the most important opportunities to reach young people outside the home; the

workplace, where most adults spend a large portion o their waking hours; and nally,

the community, which provides the setting in which most o the activities o daily lie

rom buying ood and accessing health care services to socializing, moving to school

and work, and engaging in recreational activities occur. A th category o cross-cutting

recommendations is covered in Chapter VII.


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1990 2010

No data


25/110


By several measures, obesity is already the single largest

threat to public health in America today. According to

the American Cancer Society, obesity is now responsible

or roughly as many cases o cancer as smoking.3 It also

aects a ar larger number o people; as we noted in the

introduction, well over hal the U.S. population two-

thirds o adults and one-third o children and adolescents is obese or overweight. Obesity is not only extremely

prevalent, it has alarming consequences or peoples

health. A 2001 study ound that obese people had a

67 percent higher chance o suering rom conditions

like diabetes, hypertension, asthma, heart disease and

cancer than normal-weight people o the same age and

social demographic.4 Obese people also spent much

more on medical services 36 percent more, on average,

than normal-weight individuals. In sum, obesity is a

major reason why nearly hal the U.S. population today

about 145 million people in total suers rom one ormore chronic diseases.5 These impacts are borne by all

segments o society, but they disproportionately aect low-

income households and communities o color.6 And the

resulting health care costs aect us all.

For children, the immediate and long-term eects o obesity

can be particularly devastating. In the short term, according

to the Centers or Disease Control and Prevention (CDC),

obese children are more likely to have one or more risk

actors or cardiovascular disease, to be prediabetic (i.e.,

at high risk or developing diabetes), and to suer rom

bone and joint problems, sleep apnea, and social andpsychological problems such as stigmatization and poor

sel-esteem.7 In act, due to the rapid increase in the number

o diabetic children, a disease that was once called adult

onset diabetes has now been renamed Type 2 diabetes. In

the longer run, obese children are much more likely to be

obese adults with all the costs and impacts this implies not

only in terms o contracting expensive and debilitating adult

chronic diseases but in terms o quality o lie and the ability

to realize their personal and proessional potential.

Fraction of U.S. Population that Is Overweight or Obese

100

90

80

70

60

50

40

30

20

10

0

Percent

Year

1960

-196

2

1963

-196

6

1966

-197

0

1971

-197

4

1976

-198

0

1988

-199

4

1999

-200

0

2003

-200

4

Overweight including obese, 20-74 years

Overweight but not obese, 20-74 years

Obese, 20-74 years Overweight, 6-11 years

Overweight,12-19 years

Todays crisis o obesity and chronic disease is alarming

in part because it emerged so rapidly: over little more

than the span o a single generation. Prior to 1960, rates

o obesity in the U.S. population were relatively stable

(around 13 percent); between 1960 and 1980 they

increased moderately but stayed well below 20 percent.

Since 1980, however, the percentage o Americans

who are overweight or obese has grown dramatically; in

addition, much o this increase has been concentrated in

the obese category, which grew by 61 percent between

1991 and 2000.8 Today 35.7 percent o Americans (more

than 78 million)9 are considered obese (within the latter

category, roughly nine million people are considered

Chapt 2: Americas Health Crisis

Source: Centers or Disease Control and Prevention, National Center or Health

Statistics (2006). Data rom National Health and Nutrition Examination Survey.

Today 35.7 percent of Americans(more than 78 million) areconsidered obese.


26/110

chpt 2: a Hlth c

severely obese).10 Roughly another third o the adult

population is considered overweight. In act, the U.S.

has the highest rates o obesity among 33 o the worlds

wealthiest countries.11 Current trends in childhood obesity

are especially worrisome, given the high correlation

between childhood and adult obesity and the longer-termimplications o a lietime o obesity. Overall, the incidence

o childhood obesity more than tripled in the United

States over the past 30 years: between 1980 and 2008,

the percentage o children aged six to 11 years who were

obese increased rom seven percent to nearly 20 percent,

while the percentage o adolescents aged 12 to 19 years

who were obese increased rom ve percent to 18 percent.

An important aspect o obesity and chronic disease is that

the prevalence o both is not evenly distributed across

the population. According to the CDC, non-Hispanic

blacks have the highest rates o obesity (44.1 percent)

compared with Mexican Americans (39.3 percent),

all Hispanics (37.9 percent) and non-Hispanic whites(32.6 percent). The relationship between socioeconomic

status and obesity is more complex. Among women,

the prevalence o obesity declines with higher income,

whereas the same is not necessarily true or men (among

non-Hispanic black and Mexican-American men, or

example, the prevalence o obesity actually increases with

higher income).Thus while there is a connection between

obesity and poverty, the act is that most obese people in

the United States are not low-income. On the contrary,

Diagnosed Diabetes Amoung Adults Age 20 Years and Older,

By Race/Ethnicity, 2007-2009

Billions

of2009

U.

S.

Dollars

Percent with Diagnosed Diabetes

Source: 2011 National Diabetes Fact Sheet. Centers for Disease Control and Prevention.

0

5

10

15

20

8%8%7%

12%

13%

16%

White,

Non-HispanicOverall Hispanic

Black,

Non-HispanicAsian

American

Indian/Alaska


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among both men and women, most obese adults in this

country are non-Hispanic whites with income at or above

130 percent o the poverty level.12 Just as important,

rates o obesity have been rising in recent years or all

ethnic groups, at all income levels, and in all categories

o educational attainment. The epidemic, in other words,

is unevenly distributed but it is aecting everyone. Andthough there is some evidence that the rate o increase in

obesity has begun to slow in recent years, the problem is

still growing in terms o numbers o adults and, perhaps

more importantly, childrenaected. Indeed, among some

groups (boys aged nine to 19, or example) the rate o

increase in obesity still appears be accelerating.13

As we noted in the introduction, there are many reasons

or the sharp increase in obesity in the U.S. population

over the last 30 years, and we are only beginning to

gain a sophisticated understanding o the role played

by dierent genetic, environmental and liestyle actors.

Recent research, or example, suggests that inadequate

sleep may be linked to weight gain and related chronic

health conditions.14 Researchers are also looking closely

at changes in the American diet and at the role o specic

oods. Sugar, or example, has been at the center o a

vigorous debate about whether it is disproportionately

responsible or the increase in obesity and chronic

disease seen over the last several decades. In the 1950s,

Americans consumed on average 110 pounds o sugar

per person per year. By 2000, this gure had increased

to more than 150 pounds per year, with much o thisincreased consumption coming in the orm o sweetened

beverages. Most public health experts agree that urther

research is needed to ully understand the role that sugar

in its dierent orms, including sucrose and high-ructose

corn syrup, plays in weight gain and chronic disease.15

Available data, meanwhile, conrm broad and striking

shits in both the eating habits and physical activity levels

o Americans over the last 30 to 40 years. Between 1977

and 1995, the percentage o meals eaten away rom home

nearly doubled, rom 16 to 29 percent, and the percentage

o meals eaten at ast ood restaurants specically

tripled rom three to nine percent.16 Data rom the

U.S. Department o Agriculture indicate that Americans

average daily caloric intake increased by 24.5 percent,

or about 530 calories, between 1970 and 2000.17 Evenas caloric intake has grown, there is broad anecdotal and

some empirical evidence that physical activity levels have

declined. A recent study that looked at the connection

between occupational physical activity and obesity ound

that in the early 1960s, almost hal the private-sector jobs

in the U.S. required at least moderate-intensity physical

activity. This compares to ewer than 20 percent o

current jobs demanding this level o energy expenditure.18

Meanwhile, despite a modest increase in the percentage

o adults who reported engaging in regular physical activity

between 2001 and 2005, the latest available CDC data stillindicate that less than hal the adult U.S. population meets

recommended guidelines or physical activity. Reliable

inormation on physical activity19 among children is harder

to nd, but the available data point to (1) a clear decline

in physical activity as kids enter adolescence and (2) large

amounts o time spent in ront o television or computer

screens. A study by the Kaiser Family Foundation ound

that todays eight- to 18-year-olds spend an average o

seven hours and 38 minutes per day (more than 53 hours

a week) using entertainment media.20

I the reasons behind obesity are varied and complex,so are its many costs and consequences not just or

individuals but or society as a whole. Numerous studies

have looked at the impacts o obesity, and the literature

on this subject is growing daily. Rather than attempt an

exhaustive summary in this short overview, we cite a ew

key ndings rom recent work.21 A 2010 article on the

economic costs o obesity in America reviews ndings in

our categories: direct medical costs, productivity costs,

transportation costs, and human capital costs. Productivity


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chpt 2: a Hlth c

costs include the costs o absenteeism, presenteeism

(when people are at work, but are not as productive as

they could be), disability, and premature mortality related

to obesity; transportation costs include the additional ueluse and environmental impact associated with transporting

heavier people; and human capital costs include adverse

impacts on educational attainment (including both quantity

and quality o schooling).

O these costs, direct medical cost is the metric that has

received the most attention. CDC has estimated that

spending on medical care or obesity-related illnesses

in America totals $147 billion per year.22 A more recent

estimate puts the gure as high as $190 billion annually.23

Another recent study by the Campaign to End Obesity

ound that i indirect costs are included, the annual cost is

close to $300 billion.24 The annual direct cost o childhood

obesity in America has been estimated at $14.3 billion, and

this gure would be much higher i it accounted or the highprobability that obese children will become obese adults.25

The very high cost o managing and treating many o the

chronic diseases associated with obesity helps to explain

the magnitude o these cost impacts. Diabetes is a good

example. According to one study, the annual cost o

treating a case o diagnosed diabetes averages $6,649

per year; or undiagnosed cases and prediabetes, annual

costs per case average $1,744 and $443.26 Another

study ound that expected lietime medical care costs

or patients who have one or more o ve weight-related

chronic diseases were 20 percent higher or people who

are overweight, 50 percent higher or people who are

obese, and nearly double or people who are severely

obese.27 And while many o these costs are borne by the

private sector, obesity also accounts or a growing burden

on public spending. A study using data rom 1998 and

2006 concluded that in the absence o obesity, Medicare

spending would be 8.5 percent lower and Medicaid

spending would be 11.8 percent lower.28

Interest in these gures is not merely academic. An

increasingly urgent debate is underway about theimplications o recent explosive growth in U.S. health care

spending, both in terms o the nations overall economic

outlook and in terms o impacts on the ederal decit and

debt. Again, the numbers are startling. As a percent o

GDP (gross domestic product), overall spending on health

care in America doubled between 1980 and 2010, rom

nine to 18 percent. Today, nearly one in every ve dollars

generated by the U.S. economy is going to health care

and expenditures are still growing.29 Multiple reasons

U.S. National Health Spending, 1965-2010

Billions

ofDellars

$3,000

$2,500

$2,000

$1,500

$1,000

$500

$0

65 70 75 80 85 90 95 00 05 10

Out of Pocket

Private Insurance

Medicare

Medicaid

Other Third-Party Payers

Source: Centers or Medicare and Medicaid Services, National HealthExpenditure Accounts (2011).

...expected lifetime medical care costsfor patients who have one or more ofve weight-related chronic diseaseswere 20 percent higher for people

who are overweight, 50 percenthigher for people who are obese, andnearly double for people who areseverely obese.


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have been advanced to explain the rapid escalation in

overall U.S. health care spending rom the increasing

sophistication o technology and greater use o prescription

drugs to administrative costs and the aging o the

population. But the rising incidence o chronic diseases,

many o them obesity-related, is clearly an important

part o the picture and likely plays a role in the act that

America, despite substantially higher per capita spending

on health care, lags well behind other wealthy developednations in terms o key health outcomes.30

I rising health care costs are a concern or the economy

as a whole, they amount to nothing short o a ticking

time bomb or the ederal budget. This is because costs

or Medicare and Medicaid the two major government-

provided health insurance programs have emerged

as the dominant drivers o Americas rapidly mounting

debt.31 Already, these two programs account or more than

Health Care Costs are the Primary Driver of the Debt

Source: Congressional Budget Office (August 2011).

%o

fGDP

Year

Health Care Spending

Discretionary Spending (Defense and Nondefense)

Other Mandatory Programs

Social Security

2021 2031 2041 20512011

0%

2%

4%

6%

8%

10%

12%

14%

...the combined cost of [Medicare andMedicaid] can be expected to nearlydouble to just over $1.3 trillion by2020. If that were to occur, federalexpenditures for these two programsalone would exceed current federalspending on all defense and non-defense discretionary programs.


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chpt 2: a Hlth c

one-th (21 percent) o ederal spending with combined

outlays exceeding $750 billion per year in FY2010 and

2011. Meanwhile, the Center or Medicare and Medicaid

Services has projected that the combined cost o these

programs can be expected to nearly double to just

over $1.3 trillion by 2020. I that were to occur, ederal

expenditures or these two programs alone would exceedcurrent ederal spending on all deense and non-deense

discretionary programs.

Dealing with the nations budget problems is obviously a

much bigger policy discussion; rising health care costs

arent the only driver (increased enrollment and expanded

eligibility account or much o the projected growth in

Medicare and Medicaid spending, or example) and

there is broad agreement that entitlement reorm will be

necessary to put the U.S. Treasury back on stable ooting.

By the same token, obesity and obesity-related chronic

disease arent the only drivers o growth in U.S. health care

costs; here too, many actors are in play. But reducing the

prevalence o obesity in America and avoiding some o

its costly consequences is surely a signicant part o the

answer to managing our nations daunting economic and

health care challenges going orward.

When BPC launched its Nutrition and Physical Activity

Initiative, we were prepared to nd that a great deal was

already going on in this realm. Nonetheless, we were

taken aback by the sheer number and variety o initiatives

currently underway. Many important ideas are being tried,some o them out o economic or other necessity and

oten with limited resources. But the good news is that

innovation, inspiration and leadership in the ght against

obesity and chronic disease are emerging at all levels o

government and civil society, including non-governmental

organizations and private companies. This report and our

recommendations do not try to capture all the potentially

promising ideas that are out there, nor do we want to ocus

on suggestions that others have already put orward or are

trying to implement. Rather, our aim has been to approach

the challenge rom multiple angles, seeking points o

leverage where specic actions have the potential to bring

about large-scale change. Naturally, this has led to a

ocus on especially vulnerable, disproportionately aected

populations (including children, low-income households,

and communities o color); on institutions with the potential

to infuence large numbers o people, rom schools and

large employers, to health care providers and the military;

and ultimately on policies that shape our ood and health

environment in not always obvious but powerul ways.

In selecting among different ideas and

recommendations, we applied six basic criteria:

1. Hold promise or signicant real-world impact, among large

numbers o people and particularly vulnerable groups

2. Address the disparate impacts o obesity and chronic

disease on dierent segments o the population

3. Emphasize incentives to encourage healthier choices and

behaviors

4. Build on existing successes that have demonstrated results

and lend themselves to replication

5. Require action rom an identiable decision maker, whether

in the private and NGO sectors, or in ederal, state, local or

tribal government

6. Can be measured using progress metrics to ensure

accountability

Current rates of obesity threaten toblight not only the life prospects ofmillions of individual Americans, butthe future prosperity and security of

our nation as a whole.


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In sum, obesity in America clearly constitutes a major

health crisis but it is also much more than that. For

reasons discussed in this chapter and throughout this

report, the dimensions o the crisis are economic, social,

scal and political, as well as medical. Current rates o

obesity threaten to blight not only the lie prospects o

millions o individual Americans, but the uture prosperityand security o our nation as a whole. Fortunately, this

threat is now getting a lot o attention. Researchers,

businesses, the medical community, policymakers

and health advocates share a sense o urgency about

improving our understanding o obesity and nding

more eective strategies to combat it. Their combined

eorts provide grounds or optimism that we can take

action to reduce obesity in America more thoughtully,

systematically and successully than we have in the past.

Doing so will require leadership rom all sectors o society,

greater awareness, a ocused policy commitment at all

levels o government, and some up-ront investment

o public and private resources. None o the above will

come easily, particularly in the context o a still-ragile

economy and intense budget pressure at the ederal,state and local level. Nonetheless, all Americans should

be able to unite behind the recognition that it is easier,

better and ultimately less costly to prevent obesity and

chronic disease than to resign ourselves to living with the

consequences.


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For most people, healthy patterns o diet and physical

activity begin at home. Parents and caregivers, in

particular, have a strong inluence on what children

eat and how active they are. In act, recent studies

indicate that the general health and obesity o parents

is a powerul indicator or the health outcomes o

children.32 Moreover, these inluences start very early;a growing body o research indicates that nutrition

during the irst thousand days o a childs lie starting

during pregnancy and continuing to age two plays a

signiicant role in determining that individuals health,

not only later in childhood but over his or her entire

lietime.Recent reports suggest that obesity during

pregnancy can be a risk actor or developing obesity,

diabetic, and cardiovascular diseases in the newborn

later in lie.33

Unortunately, the data indicate that obesity in early

childhood is already a major problem in the U.S. One

in ive American children is overweight or obese by age

six.34 According to the CDC, approximately 12.5 million

Americ

Lots to Lose: How America's Health and Obesity Crisis Threatens our Economic Future

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