Policy and Position Statements

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Prevention and Reduction of Obesity in the United States Position Statement

I. ASTHO Supports State Efforts to Prevent and Reduce Obesity

State and territorial health agencies, along with federal, state, and local governments, can provide the leadership necessary to prevent and reduce obesity, improving the health outcomes and quality of life of all Americans. National and federal strategies, such as the National Prevention Strategy and the Institute of Medicine’s Accelerating Progress in Obesity Prevention Report, serve as roadmaps for state health agencies to address healthy eating and active living policies and programs across various sectors. Programs such as CDC’s State and Local Public Health Actions to Prevent Obesity, Diabetes, and Heart Disease and Stroke (1422) and State Public Health Actions cooperative agreement (1305) provide funding and infrastructure resources to support healthy and safe communities that provide access to healthy foods, physical activity and clinical preventive services.1,2

II. ASTHO’s Recommendations for Preventing and Reducing Obesity

In recognition of the obesity epidemic in the United States, ASTHO recommends the following actions:

1. Support Infrastructure for State and Territorial Health Agencies to Address Obesity.

Partnerships

  • Promote partnerships across state, territorial, federal, and local governments, private sector partners and businesses, community groups, and healthcare systems that provide safe, culturally competent, and appropriate programs. These partnerships should transform communities by affecting policy and implementing initiatives, cross-cutting programs, and consistent targeted messages.
  • Promote partnerships within state and territorial health agencies to support coordination among all programs, such as nutrition and physical activity, heart disease and stroke prevention, injury and violence prevention, diabetes prevention and control, maternal and child health, the Behavioral Risk Factor Surveillance System, and other related chronic disease prevention programs. 
  • Promote partnerships across state and territorial health agencies that support obesity prevention policy and environmental change in cooperation with agencies overseeing education, transportation, housing, agriculture, healthcare, and other sectors.

Coordination

  • Foster engagement among multiple sectors, including state health agency leadership and to provide comprehensive systematic change to address issues such as food deserts, which encourage unhealthy eating and are most often found in low-income, rural, and minority neighborhoods.3
  • Address healthy eating and active living policies and programs with an effective, coordinated, sustainable infrastructure within state health agency programs.
  • Coordinate chronic disease programs to provide infrastructure for all programs in order to have adequate and coordinated leadership that supports communication, evaluation, surveillance, and management of related programs.

Leadership

  • Adopt comprehensive healthy workplace policies within health agencies and throughout state government with the support of state leadership, including implementing health risk assessments; healthy food procurement policies that include agency food purchasing, events and meetings, vending machines, and cafeterias; and other incentives for employees to improve their health.

2. Support Policy and Environmental Changes across the Lifespan.

National Guidelines

  • Implement policy, programmatic, and other system changes in accordance with the Dietary Guidelines for Americans and the Physical Activity Guidelines for Americans to ensure that healthy food and physical activity is accessible to all populations and consider regulatory approaches to implement and enforce obesity prevention measures.4,5 (For example, breastfeeding policies in government nutrition programs, such as the Women, Infants, and Children program and Adult Care Food program; encouraging and supporting hospitals to pass Baby-Friendly Hospital practices; and supporting adequate time and space for breastfeeding or expressing milk in all workplaces.)
  • Promote the food marketing principles developed by the U.S. Interagency Working Group that guides the food industry in determining which foods would be appropriate and desirable to market to children ages 2 to 17 to encourage a healthful diet and which foods the industry should voluntarily refrain from marketing to children.6
  • Encourage and enforce nutrition labeling in restaurants and similar establishments and vending policies that provide consumers with appropriate information at the point of purchase and encourage support for state health agencies to provide the regulatory structure to enforce these policies.

Education

  • Support early childhood education policies that describe access to healthy foods and beverages through the Child and Adult Food Care Program and state child care licensing standards that include nutrition and wellness guidelines, age-appropriate physical activity time and intensity, limited screen time, and meals and snacks that meet nutrition guidelines.
  • Support education policies that encourage healthy students through coordinated K-12 school health programs, adequate time and intensity of physical education and activity, access to healthy foods and beverages through the National School Lunch and Breakfast Program and throughout the school day that meet updated standards developed by USDA and the Dietary Guidelines 2010, and implementation of school wellness policies, farm to school programs, and joint use agreements.7

Improved Industry Standards

  • Promote worksite wellness policies and accreditation programs that encourage a healthy work environment, such as incentive programs for individuals to maintain healthy weight; inclusion of preventive services in routine clinical practice, including reimbursement for proven clinical preventive services; healthy foods and physical activity at meetings and events, and healthy foods in vending machines; and policies for breastfeeding or expressing milk in the workplace. Work closely with business and private sector partners to support efforts for spread and sustainability.
  • Support agriculture policies that shift federal subsidies; support less processed foods; increase access to affordable fresh fruit and vegetables through commodity programs; create agriculture policies that support healthy foods in food assistance programs; expand farmers markets and encourage the use of electronic benefit transfer at farmers markets; increase access to fresh fruit and vegetable through distribution to schools; and address the problem of food deserts.
  • Support transportation policies that boost partnerships with planners, transportation, and developers; support mixed-use, healthy communities that meet the needs of users of all ages and abilities; support key walking and biking programs and access to public transportation; support Safe Routes to Schools programs; encourage Complete Streets policies; and increase the use of Health Impact Assessments to analyze policies and programs.

3. Support Outreach and Education to Inform and Prepare Providers.

Incentives

  • Identify opportunities to assist and advocate for financial incentives for healthcare professionals and institutions, such as physicians, nurses, and other clinicians, hospitals, accountable care organizations, and insurers that track body mass index (BMI) and other health indicators. Offer evidence-based nutrition and physical activity counseling (including breastfeeding), develop targeted and culturally appropriate interventions, and provide leadership in community-based obesity prevention efforts. 
  • Provide training, educational materials, and technical assistance to communities, worksites, early care and education, and schools interested in offering healthy eating and physical activity programs and policies, especially targeting health disparities and other social determinants of health.

4. Support the Evaluation of Obesity Efforts

Data Collection

  • Practice routine data collection and use of public health surveillance data, including the Behavioral Risk Factor Surveillance System, the Youth Risk Behavior Surveillance System, electronic health information, and hospital discharge data to identify jurisdictions’ most pressing needs and efficiently target scarce resources.
  • Conduct collection of community design data as communities redesign environments to promote physical activity and access to nutritious foods.
  • Gather state-level quantitative and qualitative data on obesity disparities and the social and environmental factors that contribute to them to identify and prioritize populations with the greatest need.8  

Analysis and Tracking

  • Track progress of obesity rates in populations, schools, worksites, communities, and states and territories through public health metrics, including vital statistics, hospital discharge data, and health surveillance systems.
  • Utilize clear benchmark goals and measurement of overall rates of obesity according to the best attainable average level of “goodness” and the smallest feasible differences in obesity rates among individuals and groups, or “fairness.”

Evaluation

  • Engage state leadership in the development of robust health information exchange with the clinical sector to improve public health and clinical services.
  • Evaluate the feasibility of harmonizing state data collection with HHS data collection on race, ethnicity, sex, primary language, and disability status as required by Section 3101 of the Public Health Services Act.

III. Background

More than one-third of U.S. adults are obese.9 Approximately 17 percent of children and adolescents aged 2—19 years are obese.10 Being obese or overweight can lead to chronic diseases such as diabetes, cancer, and heart disease.11 This epidemic costs the nation $147 billion per year, in addition to other social and emotional costs.12 Governments and the private sector bear much of this burden.  Approximately 50 percent of obesity-related costs are paid through Medicare and Medicaid, while businesses spend approximately $12.7 billion annually on obesity-related illnesses through health insurance, disability, and paid sick leave.13,14

The causes of obesity are diverse and complex, including easy access to unhealthy foods in restaurants, schools, and worksites; lack of physical activity; and policy and environmental factors that do not support healthy lifestyles.15 Social determinants of health, including economic and social conditions such as poverty, influence the health of populations and contribute to obesity.16 Populations disproportionally affected by obesity include African American, Native American, Native Hawaiian/Pacific Islander and Latino individuals.17 Health inequities should be specifically addressed in obesity prevention efforts. Indeed, these underlying disparities have great costs to the American people, as well. The indirect costs of health inequities in the United States were $1.24 trillion between 2003 and 2006.18 ASTHO supports state and territorial health agencies to address the root causes of obesity and change the culture in the United States so that healthier lifestyles are supported and the healthy choice is the easy choice for everyone. A shift in the current system and culture is necessary to stop the obesity epidemic.


Approval History:

ASTHO Position Statements relate to specific issues that are time sensitive, narrowly defined, or are a further development or interpretation of ASTHO policy. Statements are developed and reviewed by appropriate Policy Committees and approved by the ASTHO Executive Committee. Position Statements are not voted on by the full ASTHO membership.

Prevention Policy Committee Review and Approval: August 2015
Board of Directors Review and Approval: September 2015
Policy Expires: September 2018

For further information about this position statement, please contact ASTHO Prevention Policy staff at prevention@astho.org. For ASTHO policies and additional publications related to this position statement, please visit www.astho.org/Policy-and-Position-Statements.


Notes

  1. National Prevention Council, National Prevention Strategy, Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011.
  2. IOM (Institute of Medicine). 2012. Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. Washington, DC: The National Academies Press.
  3. Larson, N.I., Story, M.T., & Nelson, M.C. (2009). Neighborhood environments: Disparities in access to healthy foods in the U.S. American Journal of Preventive Medicine, 36(1): 74-81.
  4. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010.
  5. U.S. Department of Health and Human Services, 2008 Physical Activity Guidelines for Americans. Available at http://www.health.gov/paguidelines/pdf/paguide.pdf.
  6. U.S. Interagency Working Group, Interagency Working Group on Food Marketed to Children: Preliminary Proposed Nutrition Principles to Guide Industry Self-Regulatory Efforts. Available at https://www.cspinet.org/new/pdf/IWG_food_marketing_proposed_guidelines_4.11.pdf.
  7. U.S. Department of Health and Human Services, 2008 Physical Activity Guidelines for Americans. Available at http://www.health.gov/paguidelines/pdf/paguide.pdf.
  8. National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity and Obesity, Health Equity Resource Toolkit for State Practitioners Addressing Obesity Disparities. Available at http://www.cdc.gov/Obesity/Health_Equity/pdf/toolkit.pdf.
  9. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of Childhood and Adult Obesity in the United States, 2011-2012. JAMA. 2014;311(8):806-814.
  10. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of Childhood and Adult Obesity in the United States, 2011-2012. JAMA. 2014;311(8):806-814.
  11. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Available at http://www.nhlbi.nih.gov/files/docs/guidelines/ob_gdlns.pdf.
  12. Finkelstein, E. A., J. G. Trogdon, J. W. Cohen, and W. Dietz. 2009. Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Affairs 28(5):w822-w831.
  13. Finkelstein, E. A., J. G. Trogdon, J. W. Cohen, and W. Dietz. 2009. Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Affairs 28(5):w822-w831.
  14. David Thompson, John Edelsberg, Karen L. Kinsey, and Gerry Oster (1998) Estimated Economic Costs of Obesity to U.S. Business. American Journal of Health Promotion: November/December 1998, Vol. 13, No. 2, pp. 120-127.
  15. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010.
  16. CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization.
  17. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; 2014. Available at http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf.
  18. TA. LaVeist, DJ. Gaskin, P. Richard. The Economic Burden of Health Inequities in the United States. Washington D.C.: Joint Center of Political and Economic Studies; September 2009.