Strategy Development Workshop for Public Education on Weight and Obesity September 24-25, 1992 Summary Report Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Bethesda, Maryland WORKSHOP PARTICIPANTS Speakers And Facilitators Diane Bild, M.D., M.P.H. Medical Officer Division of Epidemiology andClinical Applications National Heart, Lung, and Blood Institute National Institutes of Health Federal Building, Room 301 7550 Wisconsin Avenue Bethesda, MD 20892 Patricia J. Elmer, Ph.D., R.D. Assistant Professor Division of Epidemiology School of Public Health University of Minnesota 1300 South Second Street, Suite 300 Minneapolis, MN 55454-1015 Leonard H. Epstein, Ph.D. Professor of Psychiatry, Psychology, and Epidemiology Western Psychiatric Institute University of Pittsburgh 3811 O'Hara Street Pittsburgh, PA 15213-2593 Robert W. Jeffery, Ph.D. Professor Division of Epidemiology School of Public Health University of Minnesota 1300 South Second Street, Suite 300 Minneapolis, MN 55454-1015 Arthur S. Leon, M.D. Taylor Professor of Exercise Science and Health Enhancement School of Kinesiology University of Minnesota 110 Cooke Hall Minneapolis, MN 55455 JoAnn E. Manson, M.D., Dr.P.H. Associate Physician Assistant Professor of Medicine Harvard Medical School 900 Commonwealth East Boston, MA 02215 John C. McGrath Chief Communications and Marketing Section Communications and Public Information Branch Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A21 9000 Rockville Pike Bethesda, MD 20892 Eva Obarzanek, Ph.D., R.D. Nutritionist Prevention and Demonstration Research Branch Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute National Institutes of Health Federal Building, Room 604 7550 Wisconsin Avenue Bethesda, MD 20892 Pauline S. Powers, M.D. Professor of Psychiatry and Behavioral Medicine Department of Psychiatry College of Medicine University of South Florida 3515 East Fletcher Avenue Tampa, FL 33613 Cheryl Ritenbaugh, Ph.D., M.P.H. Associate Professor Department of Family and Community Medicine University of Arizona 2231 East Speedway Tucson, AZ 85719 Thomas Robinson, M.D., M.P.H. Robert Wood Johnson Clinical Scholar Director of Youth Studies Stanford Center for Research in Disease Prevention Stanford University School of Medicine 1000 Welch Road Palo Alto, CA 94304 James F. Sallis, Jr., Ph.D. Professor of Psychology Department of Psychology San Diego State University 6363 Alvarado Road, Suite 103-3 San Diego, CA 92128 Jeffery Sobal, Ph.D., M.P.H. Associate Professor Division of Nutritional Sciences Cornell University MVR Hall, Room 303 Ithaca, NY 14853 Bonnie Spring, Ph.D. Professor Psychology Department University of the Health Sciences Chicago Medical School Building 51 3333 Green Bay Road North Chicago, IL 60064 Janice Williams, Ph.D. Visiting Assistant Professor Stanford Center for Research in Disease Prevention Stanford University School of Medicine 1000 Welch Road Palo Alto, CA 94304-1885 Peter Wood, D.Sc., Ph.D. Professor of Medicine Stanford Center for Research in Disease Prevention 730 Welch Road, Suite B Palo Alto, CA 94304 NHLBI OEI TASK FORCE Karen Donato, M.S., R.D. Coordinator NHLBI Obesity Education Initiative Health Education Branch Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A18 9000 Rockville Pike Bethesda, MD 20892 Nancy Ernst, M.S., R.D. Nutrition Coordinator for NHLBI Office of the Director Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute National Institutes of Health Federal Building, Room 204 7550 Wisconsin Avenue Bethesda, MD 20892 Robert Garrison, M.S. Chief Field Studies and Biometry Branch Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute National Institutes of Health Federal Building, Room 3A12 7550 Wisconsin Avenue Bethesda, MD 20892 Millicent Higgins, M.D. Associate Director Epidemiology and Biometry Program Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute National Institutes of Health Federal Building, Room 2C08 7550 Wisconsin Avenue Bethesda, MD 20892 Dana Robin Hill, Ph.D. Social Science Analyst Behavioral Medicine Branch Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute National Institutes of Health Federal Building, Room 216 7550 Wisconsin Avenue Bethesda, MD 20892 Michael J. Horan, M.D., Sc.M. Associate Director for Cardiology Division of Heart and Vascular Diseases National Heart, Lung, and Blood Institute National Institutes of Health Federal Building, Room 318 7550 Wisconsin Avenue Bethesda, MD 20892 James Kiley, Ph.D. Chief Airways Diseases Branch Division of Lung Diseases National Heart, Lung, and Blood Institute National Institutes of Health Westwood Building, Room 6A15 5333 Westbard Avenue Bethesda, MD 20892 Eva Obarzanek, Ph.D., R.D. Nutritionist Prevention, Demonstration, and Research Branch Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute National Institutes of Health Federal Building, Room 604 7550 Wisconsin Avenue Bethesda, MD 20892 PARTICIPATING ORGANIZATIONS American Academy of Family Physicians Roger B. Rodrigue, M.D. Chairman Subcommittee on Public and Environmental Health American Academy of Family Physicians 8880 Ward Parkway Kansas City, MO 64114 American Academy of Pediatrics William Dietz, M.D., Ph.D. Director of Clinical Nutrition Pediatric Gastroenterology and Nutrition New England Medical Center Hospitals 750 Washington Street, Box 213 Boston, MA 02111 American Cancer Society Daniel W. Nixon, M.D. Vice President for Professional Education American Cancer Society 1599 Clifton Road, N.E. Atlanta, GA 30329 American Diabetes Association, Inc. Phyllis M. Barrier, M.S., R.D., C.D.E. Director, Council Affairs American Diabetes Association, Inc. National Service Center 1660 Duke Street Alexandria, VA 22314 American Dietetic Association Patricia Reeves, R.D. Representative American Dietetic Association 202 Kent Court Jeffersonton, VA 22724 American Heart Association Mary C. Winston, R.D., Ed.D. Senior Science Consultant Science Division American Heart Association Office of Scientific Affairs 7272 Greenville Avenue Dallas, TX 75231 American Home Economics Association Gladys Vaughn, Ph.D. Director Research and Education American Home Economics Association 1555 King Street Alexandria, VA 22314 American Society of Bariatric Physicians Hal Seim, M.D., M.P.H. Director CME American Society of Bariatric Physicians Professor Department of Family Practice University of Minnesota, 6-240 P.W.B. Box 381 UMHC Minneapolis, MN 55455 Association of State and Territorial Public Health Nutrition Directors Carol Loomis, M.S., M.P.H., L.D. Diana Schmidt, M.P.H., L.D. Representatives Association of State and Territorial Public Health Nutrition Directors Maryland Department of Health and Mental Hygiene 201 West Preston Street Baltimore, MD 21201 Centers for Disease Control and Prevention Jeanne Creech, Ph.D. Health Education Specialist Community Health Promotion Branch Centers for Disease Control and Prevention 4770 Buford Highway, NE (K-46) Atlanta, GA 30341-3724 Sarah Kuester, M.S. Public Health Nutritionist Division of Nutrition Centers for Disease Control and Prevention 4770 Buford Highway, NE (K-26) Atlanta, GA 30341-3724 Julie Will, Ph.D., M.P.H. Epidemiologist Division of Diabetes Translation Centers for Disease Control and Prevention 4770 Buford Highway, NE (K-10) Atlanta, GA 30341-3724 David F. Williamson, Ph.D. Epidemiologist Division of Nutrition Centers for Disease Control and Prevention 1600 Clifton Road, NE (K-26) Atlanta, GA 30333 Council on Size and Weight Discrimination, Inc. Nancy Summer Council Director Council on Size and Weight Discrimination, Inc. P.O. Box 238 Columbia, MD 21045 Federal Trade Commission Susan Cohn, J.D. Attorney Division of Advertising Practices Bureau of Consumer Protection Federal Trade Commission 601 Pennsylvania Avenue, N.W. Washington, DC 20580 Food and Drug Administration Alan Heaton, Ph.D. Consumer Scientist Division of Market Studies Center for Food Safety and Applied Nutrition Food and Drug Administration 200 C Street, SW (HFS-727) Washington, DC 20204 Frederick N. Hyman, D.D.S., M.P.H. Epidemiologist Clinical Nutrition Food and Drug Administration 200 C Street, SW (HFF-240) Washington, DC 20204 Alan S. Levy, Ph.D. Head of Consumer Research Staff Division of Consumer Studies Center for Food Safety and Applied Nutrition Food and Drug Administration 200 C Street, SW (HFS-727) Washington, DC 20204 Food Marketing Institute Susan T. Borra, R.D. Director Consumer Affairs Food Marketing Institute 800 Connecticut Avenue, NW Washington, DC 20006 Health Resources Services Administration Denise Sofka, M.P.H. Nutrition Consultant Maternal and Child Health Health Resources and Services Administration 5600 Fishers Lane, Room 18A39 Rockville, MD 20857 Indian Health Service Karen S. Strauss, M.S., R.D. Chief Nutrition and Dietetics Indian Health Service Parklawn Building, Room 6A-20 5600 Fishers Lane Rockville, MD 20857 International Food Information Council Claire Regan, M.S., R.D. Director of Nutrition International Food Information Council Suite 430 1100 Connecticut Avenue, NW Washington, DC 20036 National Association for Sport and Physical Education Paula Keyes Kun, M.S. Director of Public Relations National Association for Sport and Physical Education 1900 Association Drive Reston, VA 22091 National Association to Advance Fat Acceptance William Fabrey Founder National Association to Advance Fat Acceptance P.O. Box 403 Ivy, VA 22945 National Food Processors Association Regina Hildwine, M.A. Director Technical Regulatory Affairs National Food Processors Association 1401 New York Avenue, NW Washington, DC 20005 National Institutes of Health-- National Cancer Institute Carolyn Clifford, Ph.D. Acting Chief Diet and Cancer Branch National Cancer Institute Executive Plaza North, Room 212 6130 Executive Boulevard Rockville, MD 20852 National Institutes of Health-- National Institute of Child Health and Human Development Gilman D. Grave, M.D. Chief Endocrinology Nutrition and Growth Branch National Institute of Child Health and Human Development Executive Plaza North, Room 637 6130 Executive Boulevard Rockville, MD 20852 Joel Killen, Ph.D. Health Research Specialist Prevention Research Branch National Institute of Child Health and Human Development 6100 Executive Boulevard, Room 7B05-B Rockville, MD 20852 National Institutes of Health-- National Institute of Diabetes and Digestive and Kidney Diseases Van S. Hubbard, M.D., Ph.D. Director Nutritional Sciences Branch National Institute of Diabetes and Digestive and Kidney Diseases Westwood Building, Room 3A18B 5333 Westbard Avenue Bethesda, MD 20892 Elizabeth H. Singer, M.S. Director Office of Health Research Reports National Institute of Diabetes and Digestive and Kidney Diseases Building 31, Room 9A04 9000 Rockville Pike Bethesda, MD 20892 Susan Yanovski, M.D. Executive Secretary National Task Force on Prevention and Treatment of Obesity National Institute of Diabetes and Digestive and Kidney Diseases Building 10, Room 3S231 9000 Rockville Pike Bethesda, MD 20892 National Institutes of Health-- Nutrition Coordinating Committee Darla Danford, D.Sc., M.P.H., R.D. Director Division of Nutrition Research Coordination National Institutes of Health Building 31, Room 4B63 9000 Rockville Pike Bethesda, MD 20892 National Institutes of Health-- Office of Minority Programs Belinda Seto, Ph.D. Deputy Director Office of Minority Programs National Institutes of Health Building 1, Room 255 9000 Rockville Pike Bethesda, MD 20892 National Recreation and Parks Association Kathy Bartlett, C.L.P. Northeast Regional Director National Recreation and Parks Association Suite 1 1800 Silas Deane Highway Rocky Hill, CT 06067 National School Health Education Coalition, Inc. Karen VanLandegham, M.P.H. Director of Coalition Development National School Health Education Coalition, Inc. Suite 400 East 1001 G Street, NW Washington, DC 20001 NHLBI Ad Hoc Committee on Minority Populations Tanya Agurs, M.S., R.D. Member NHLBI Ad Hoc Committee on Minority Populations 2004 D Street, NE, Apt. 2 Washington, DC 20002 North American Association for the Study of Obesity Barbara C. Hansen, Ph.D. Professor of Physiology Obesity and Diabetes Research Center School of Medicine University of Maryland 10 South Pine Street, MSTF #600 Baltimore, MD 21201 President's Council on Physical Fitness and Sports Eileen Conover Representative President's Council on Physical Fitness and Sports Suite 250 701 Pennsylvania Avenue, NW Washington, DC 20004 Society for Nutrition Education Linda Smith, M.S. Representative Society for Nutrition Education 1220 Hemlock Street, NW Washington, DC 20012 Society for Public Health Education Gloria Nichols c/o Donald Fedder, Dr.P.H. Associate Professor and Director Community Pharmacy Programs University of Maryland School of Pharmacy Campus for Professors 20 North Pine Street Baltimore, MD 21201 U.S. Department of Agriculture-- Human Nutrition Information Service Anne M. Shaw, Ph.D. Nutritionist Human Nutrition Information Service 6505 Belcrest Road, Room 353 Hyattsville, MD 20782 U.S. Department of Health and Human Services Marilyn G. Stephenson, M.S., R.D. Nutrition Advisor Office of Disease Prevention and Health Promotion Department of Health and Human Services 330 C Street, SW, Room 2132 Washington, DC 20201 U.S. Public Health Service-- Office of Minority Health Betty Lee Hawks, M.A. Associate Director Division of Information Dissemination and External Liaison Office of Minority Health Rockwall II Building, Suite 800 5515 Security Lane Rockville, MD 20852 OTHER PARTICIPATING GUESTS Lilian Cheung, D.Sc., R.D. Director Harvard Nutrition and Fitness Project Center for Health Communication Harvard University School of Public Health 677 Huntington Avenue Boston, MA 02115 Reva Frankle, M.S., R.D. Private Consultant 323A Heritage Hills Sommers, NY 18509 Jeanne Goldberg, Ph.D., R.D. Assistant Professor of Nutrition School of Nutrition Tufts University 126 Curtis Street Medford, MA 02155 Robert Hoerr, M.D., Ph.D. Director Optifast Program Sandoz Nutrition Corporation 5100 Campbell Drive St. Louis Park, MN 55416 Sue Y.S. Kimm, M.D., M.P.H. Associate Professor for Clinical Epidemiology University of Pittsburgh School of Medicine 432 Morewood Avenue Pittsburgh, PA 15213 NHLBI STAFF P. Scott Allender, M.D. Scientific Project Officer Prevention and Demonstration Research Branch Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute National Institutes of Health Federal Building, Room 604 7550 Wisconsin Avenue Bethesda, MD 20892 Matilde M. Alvarado, R.N., M.S.N. Minority Health Specialist Health Education Branch Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A18 9000 Rockville Pike Bethesda, MD 20892 Glen Bennett, M.P.H. Coordinator NHLBI Smoking Education Program Health Education Branch Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A18 9000 Rockville Pike Bethesda, MD 20892 Joan E. Blair, R.N., M.P.H. Coordinator Women's Health/Workplace Initiative Health Education Branch Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A18 9000 Rockville Pike Bethesda, MD 20892 Clarice Brown, M.S. Coordinator Data Analysis and Program Evaluation Health Education Branch Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A18 9000 Rockville Pike Bethesda, MD 20892 James Cleeman, M.D. Coordinator National Cholesterol Education Program Office of the Director National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A05 9000 Rockville Pike Bethesda, MD 20892 Jeffrey A. Cutler, M.D., M.P.H. Chief Prevention and Demonstration Research Branch Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute National Institutes of Health Federal Building, Room 604 7550 Wisconsin Avenue Bethesda, MD 20892 Marguerite Evans, M.S., R.D. Nutritionist Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute National Institutes of Health Federal Building, Room 604 7550 Wisconsin Avenue Bethesda, MD 20892 Richard R. Fabsitz, M.A. Senior Research Investigator Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute National Institutes of Health Federal Building, Room 3A17 7550 Wisconsin Avenue Bethesda, MD 20892 Mary McDonald Hand, R.N., M.S. Coordinator National Heart Attack Alert Program Health Education Branch Office of Prevention, Education and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A18 9000 Rockville Pike Bethesda, MD 20892 Keith Hewitt Chief Information Services Section Communications and Public Information Branch Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A21 9000 Rockville Pike Bethesda, MD 20892 Claude Lenfant, M.D. Director National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 5A52 9000 Rockville Pike Bethesda, MD 20892 Terry Long Chief Communications and Public Information Branch Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A21 9000 Rockville Pike Bethesda, MD 20892 Gregory Morosco, Ph.D., M.P.H. Chief Health Education Branch Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A03 9000 Rockville Pike Bethesda, MD 20892 Eileen P. Newman, M.S., R.D. Nutrition Education Advisor Health Education Branch Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A18 9000 Rockville Pike Bethesda, MD 20892 Nancy J. Poole Chief of Program Operations Office of the Director Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A18 9000 Rockville Pike Bethesda, MD 20892 Edward J. Roccella, Ph.D., M.P.H. Coordinator National High Blood Pressure Education Program Office of the Director Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A05 9000 Rockville Pike Bethesda, MD 20892 Denise G. Simons-Morton, M.D., Ph.D. Medical Officer Prevention and Demonstration Research Branch Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute National Institutes of Health Federal Building, Room 604 7550 Wisconsin Avenue Bethesda, MD 20892 Elaine Stone, Ph.D., M.P.H. Program Administrator Child and Adolescent Trial for Cardiovascular Health (CATCH) Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute National Institutes of Health Federal Building, Room 604A 7550 Wisconsin Avenue Bethesda, MD 20892 Diane Striar Senior Press Liaison Communications and Public Information Branch Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A21 9000 Rockville Pike Bethesda, MD 20892 Louise Williams Public Affairs Specialist Communications and Public Information Branch Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A21 9000 Rockville Pike Bethesda, MD 20892 Richard A. Windsor, Ph.D., M.P.H. Former Director Office of Prevention, Education, and Control National Heart, Lung, and Blood Institute National Institutes of Health Building 31, Room 4A16 9000 Rockville Pike Bethesda, MD 20892 SUPPORT STAFF Patricia Moriarty, M.Ed., R.D. NHLBI OEI Manager R.O.W. Sciences, Inc. 1700 Research Boulevard Rockville, MD 20850 Anne Melly, M.S., R.D. University Research Corporation 7200 Wisconsin Avenue Bethesda, MD 20814 TABLE OF CONTENTS EXECUTIVE SUMMARY I. INTRODUCTION II. WORKSHOP OBJECTIVES III. PANEL PRESENTATIONS Panel 1: The Epidemiology of Obesity and Cardiovascular Disease Introduction Obesity in Children Obesity in Adults General Discussion References Panel 2: Strategies for Obesity Prevention Introduction School-Based Obesity Programs Family-Based Obesity Programs Community-Based Obesity Programs General Discussion References Panel 3: Issues in Educating the Public About Weight and Obesity Introduction Nutrition in Adolescence: Obesity and the Hazards of Treatment Smoking and Weight The Role of Physical Activity in the Prevention and Management of Obesity Sociocultural Aspects of Obesity General Discussion References Panel 4: Communication Strategies for Educating the Public Introduction and Overview Audience Segmentation as a Strategy for Targeting Adults Communication Strategies for Targeting Children and Adolescents References IV. SMALL GROUP REPORTS Small Group Report: Children Small Group Report: Adolescents Small Group Report: Adults Small Group Report: Older Adults Small Group Report: Minority Populations EXECUTIVE SUMMARY In the United States, the prevalence of obesity has been on the rise despite an increasing preoccupation with weight loss. According to preliminary data from the 1988-91 National Health and Nutrition Examination Survey (NHANES III),* the prevalence of overweight has increased from 25 to 33 percent during the past 10 years. The age-adjusted prevalence of overweight is 32 percent for men and 35 percent for women, compared with 24 percent for men and 27 percent for women in the NHANES II (1976-80). Although the NHANES III has yet to be analyzed for children, the NHANES I (1971-74) and the NHANES II both documented an increasing prevalence of obesity in children ages 6-17 years. Obesity contributes to at least half the chronic diseases in Western societies. Heart disease remains the number one killer of Americans, and obesity or overweight is known to influence the impact of this disease on the population. Obesity is associated with an increased risk for hypertension, diabetes, high total blood cholesterol, and low high density lipoprotein (HDL) cholesterol. Obesity is also an independent risk factor for coronary heart disease. In some studies, even mild to moderate overweight is associated with a substantial elevation in coronary risk. Other studies show the effects of weight gain to be dependent on the age of onset. A more complex issue is the relationship of weight and weight loss to all-cause mortality. Various studies demonstrate a U- or J-shaped curve with the highest and lowest levels of weight associated with the greatest mortality. Although studies show weight loss to be associated with improvements in blood pressure and blood cholesterol levels, weight loss also has been shown to be associated with higher mortality. It is unclear whether weight loss is causally related to the increase in mortality or weight loss and mortality are a consequence of illness. Millions of overweight Americans who are attempting to lose weight often are unsuccessful over the long term. Data show that many individuals regain one-third to two-thirds of intentionally lost weight within 1 year and regain the rest of the weight within 5 years. In addition, many people are engaging in weight loss practices without the necessary medical supervision or monitoring. The problem of obesity and overweight is multifaceted and involves complex questions that have no simple solutions. Attention needs to be focused on a variety of fronts, from the standpoint of treatment for those thousands of Americans who suffer from this condition and are at increased risk for not only heart disease but other diseases as well. Efforts to help prevent obesity in both children and adults must begin to help alleviate much of the pain and suffering that ultimately result. PANEL 1: THE EPIDEMIOLOGY OF OBESITY AND CARDIOVASCULAR DISEASE Obesity in Children Consensus has yet to be reached on both a standard definition and a standard measurement technique for determining obesity in children. Definitions used for adults cannot easily be applied to children. Because childhood obesity does appear to track into adulthood and obesity is related to elevated cardiovascular risk factors in children, health consequences are associated with childhood obesity. Etiology of obesity in childhood is complex and involves genetic, dietary, physical activity, and socioeconomic factors. Longitudinal studies with consistent use of the various measures to determine obesity would provide a better understanding of the etiology of obesity in children. Obesity in Adults The lack of a standard definition and standard measurement technique for determining overweight and obesity in adults makes it difficult to assess the impact of excess weight on health accurately. The NHANES data and definition provide a reference base for comparing studies and examining trends. The latest data from the NHANES III indicate that approximately one-third of the U.S. adult population (ages 20 to 74) is overweight (defined as body mass index greater than or equal to 27.8 for men and greater than or equal to 27.3 for women; these cutpoints represent the sex-specific 85th percentiles for persons ages 20 to 29 in the NHANES II). Adult obesity in the United States has been increasing in both men and women and in both African Americans and whites. Overweight is disproportionately higher in African-American and Mexican-American women. The age-adjusted prevalence of overweight is 50 percent among African-American women and 48 percent among Mexican- American women,compared to 33 percent among white women. Obesity is related to elevated cardiovascular risk and to mortality. Furthermore, weight gain exacerbates cardiovascular risk factors whereas weight loss improves these conditions. Maintaining weight loss over the long term, however, is difficult. Race, education, parity, acculturation, physical activity, caloric intake, and genetics are the etiologic factors that need to be considered. Increased attention to the prevention of obesity in early adulthood is needed, but determining what recommendations should be given to already obese adults is an equally great challenge. PANEL 2: STRATEGIES FOR OBESITY PREVENTION Interventions to help prevent obesity have included a variety of settings such as schools, clinics, families, communities, and other populationwide approaches. Interventions of this nature often consider age, gender, ethnicity, and geographic location. School-Based Obesity Programs School-based obesity programs offer the opportunity to reach a large number of children, especially younger children, on a daily basis for a number of years. They also offer multiple opportunities through the physical education curriculum, the school lunch program, other environmental changes, and the summer school program. School programs could tackle both prevention and treatment issues with complementary strategies and could initiate health education services for peer groups, families, and school staff. An important consideration for school-based programs is whether comprehensive programs can be implemented successfully over the long term in schools that already face limited resources. Nevertheless, schools remain an important vehicle for influencing the environment of many children. Family-Based Obesity Programs Family-based obesity programs in which both generations and all family members participate present a promising avenue for the prevention and treatment of obesity. Variables such as diet, food availability, and family environment including activity level and behavioral support can be manipulated so that the largest possible impact is felt by children and parents. Family-based obesity programs target the family's behaviors and environment and ensure that parents play an active role in the intervention. Community-Based Obesity Programs Because the problem of obesity is pervasive, affecting all segments of the population regardless of age, race, or gender, it can be viewed as a community problem that requires community-based interventions that can bring about change. Community-based programs potentially can reach large numbers of individuals at a reasonable cost. PANEL 3: ISSUES IN EDUCATING THE PUBLIC ABOUT WEIGHT AND OBESITY Cultural factors influence knowledge, attitudes, and behaviors regarding food consumption and activity patterns and thus can influence weight and even body shape. Our culture currently places greater emphasis on the food intake side of the energy balance equation, with limited importance given to energy expenditure. In fact, our language is deficient in terms to describe the desire to engage in physical activity. Language as well as many other cultural factors should be examined closely when educating the public about weight and obesity. Smoking and Weight Smoking and body weight have been linked for many years; many people who begin smoking lose weight, whereas many who quit smoking gain weight. The concern about weight for smokers can predict in part their success at quitting; current smokers are much more likely than ex-smokers to consider weight loss as important. If individuals do not expect weight gain after quitting smoking, they are more likely to quit. Therefore, public messages related to weight and smoking need to communicate the relative risks related to smoking versus the weight gain associated with cessation. Particular target audiences for messages are adolescent females and adult women. The Role of Physical Activity in the Prevention and Management of Obesity Modest increases in physical activity appear to assist weight control and offers other benefits such as changes in body composition, psychological well-being, and reduced risks for cardiovascular disease. Increased physical activity and improved fitness also contribute to an improved quality of life, particularly during aging. Both the general population and obese individuals, however, report numerous barriers to regular exercise, such as perceived lack of time, boredom, embarrassment, and inaccessibility of facilities. Ways of encouraging the public to incorporate physical activity into daily routines need to be explored. Sociocultural Aspects of Obesity Viewing obesity in the larger context of social and cultural values provides possibly the most important insights into the underlying factors. Social patterns, social explanations, and social consequences of obesity are all important considerations. Social development--helping societies change their value systems about thinness, physical activity, and low-fat diets--may be an important intervention goal. Education, resources, and the environment might be the best interventions. Insights and interventions from sociology would aid in efforts at dealing with obesity in the society. PANEL 4: COMMUNICATION STRATEGIES FOR EDUCATING THE PUBLIC Communicating messages to various audiences as part of a broad-based information campaign requires a multistage process. A communication strategy statement needs to be developed to summarize the health problem, identify primary and secondary target audiences, and develop possible messages and appropriate channels for the various target audiences. Success at communicating messages to the wide variety of audiences is more likely if multiple levels of social organizations are targeted. The most successful communication campaigns have used multiple yet complementary educational strategies. Targeting Adults Social marketing strategies are being used increasingly in health education to promote attitudes, behaviors, and lifestyles that can prevent illness or minimize its consequences. One important social marketing strategy is audience segmentation that permits a large, undifferentiated group to be broken down into smaller, homogeneous subgroups based on lifestyles, values, attitudes, behaviors, or other characteristics. This type of analysis allows campaign planners to better understand their target audience and therefore to better communicate appropriate messages to them. Targeting Children and Adolescents In terms of public education, a population-based approach rather than an individualized approach for high-risk audiences appears to be the most appropriate communication strategy for reaching obese children and adolescents. Healthful eating and physical activity should be emphasized rather than dieting. It is impossible to predict with certainty which children are at particularly high risk. Thus, different yet complementary educational strategies are essential to getting the message out to various target groups. Because of possible adverse effects from any type of communication campaign, some form of evaluation should be incorporated from the start. SMALL GROUP REPORTS Five potential target audiences for the educational messages from the National Heart, Lung, and Blood Institute Obesity Education Initiative (NHLBI OEI) were identified--children, adolescents, adults, older adults, and minority populations. Small groups discussed each of these audiences in terms of their unique characteristics, particularly as they relate to issues of weight or patterns of eating and physical activity. For each target audience, the small groups addressed content-appropriate messages, source credibility in the delivery of messages, motivational strategies that encourage action, and appropriate communication channels to deliver messages. Small Group Report: Children The entire population of children ages 2 to 11 was identified as the priority target audience for a population-based approach to primary prevention. This approach was more acceptable than targeting high-risk obese children to avoid possibly increasing chronic dieting and eating disorders as well as stigmatizing obese children. Messages should be tailored to the various developmental stages of children, and messages should be targeted simultaneously to those who influence children. Messages for children at high risk need to be developed separately and carefully. Two major public health messages were recommended for this priority target audience: (1) be more active and (2) eat less fat and eat healthier. A variety of ways to convey this information were suggested. Small Group Report: Adolescents As with children, the entire adolescent population (ages 11 to 17) was identified as the priority target audience with the emphasis on primary prevention. Again, concern was raised regarding national messages on obesity and weight that might further stigmatize high-risk adolescents. The importance of healthy eating combined with physical activity should be the cornerstone message not only focusing on preventing obesity but on other potential health benefits as well. The idea that there is a broad range of safe weights and acceptable shapes also needs to be conveyed. In terms of credible sources, peer groups have the most powerful influence on adolescents. Parents, role models, various members of the school staff, health providers, and the Government are also influential and could be used to educate adolescents and groups that communicate to adolescents. A variety of motivational strategies and appropriate channels of communication were suggested to encourage healthy eating and physical activity. However, to improve and enhance the effectiveness of messages and strategies targeted to adolescents, formative evaluation and research are needed regarding their health knowledge, the effectiveness of different messages, and the various methods of communication that produce the desired outcomes. Small Group Report: Adults All men and women, ages 18 to 65, particularly those of low socioeconomic status and with low education levels, were identified as the primary target audiences. Messages to these different audiences must encourage healthy eating behaviors and increased physical activity and must emphasize that weight gain is an unrecognized health hazard as people get older. Suggested strategies to reach these audiences ranged from the need for messages to be simple, positive, and attainable, to the need for environmental changes in restaurants and supermarkets. Health care providers and organizations were cited as a particularly credible sources that need to provide more information about issues related to weight. Small Group Report: Older Adults Americans over age 65 are a growing segment of the population. Overall characteristics of older adults include a preponderance of women, a broad range of educational levels and socioeconomic status, more leisure time, and a desire to remain independent. Advancing age also may bring decreased mobility, a decline in physical functions, higher rates of chronic disease, malnutrition, and social isolation. Concern or lack of concern among older adults about overweight must be put into the context of many other, perhaps more urgent, health issues. Older adults are less likely to be concerned about overweight and more likely to be concerned about undesired weight loss. Among this population, there is greater concern about health and less concern about appearance. Physical activity for older adults was noted as very important for many reasons including maintaining lean body mass and bone density and preserving strength and endurance. However, older adults have greater difficulty exercising combined with a great fear of injury. Motivational strategies for older adults need to consider numerous factors including health status, cultural differences, climatic and environmental concerns, fear of ill health, and cost. Suggested channels of communication included many advocacy, volunteer, and health organizations that address issues pertinent to older adults. Small Group Report: Minority Populations The four major minority populations in the United States--African Americans, Hispanic Americans, Asians and Pacific Islanders, and Native Americans--are the fastest growing segments in the total U.S. population. These groups also tend to exhibit similar demographic characteristics such as high poverty rates, high high-school dropout rates, limited access to health care and food, high levels of risk factors and incidence of disease, and variant health knowledge and practices. African-American women, ages 20 to 25, should be a priority target audience because of the particularly high prevalence of overweight and obesity in African- American women. Adolescent African-American girls also should be a priority target--in terms of primary prevention--because excessive weight for this population begins around puberty. The other minority groups also were noted as important targets of information concerning primary prevention of overweight. Because of traditional gender roles and strong family units prominent in minority cultures, messages about healthy eating should target women and messages about physical activity should target men. The overall goal should be to give these populations a sense of empowerment and to increase their self-esteem. In developing messages for different minority groups, it is essential to segment populations according to country of origin, how long they have been in the United States, and their degree of acculturation. Education efforts should begin with a campaign to raise awareness, followed by targeting individual lifestyles for change. REFERENCE Naitonal Center for Health Statistics. Health, United States, 1993. Hyattsville, MD: Centers for Disease Control and Prevention; 1994. INTRODUCTION The National Heart, Lung, and Blood Institute (NHLBI) has been a leader in developing and fostering educational messages, materials, and activities and disseminating them to both health care providers and the public to help reduce cardiovascular disease (CVD) morbidity and mortality. These educational activities evolve from the wide array of research investigations supported by the NHLBI, ranging from basic science at the cellular level to education and demonstration studies carried out in communities. For several decades, NHLBI-supported research on obesity has been fundamental to the understanding of overweight and obesity as they contribute to the cardiovascular disease burden of the Nation. The health implications of obesity have been documented and include an independent increased risk for CVD as well as increased risks for hypertension, diabetes, hypertriglyceridemia, low levels of high density lipoprotein (HDL) cholesterol, and high levels of total and low density lipoprotein (LDL) cholesterol. Sleep apnea and impaired lung function, gall bladder disease, gout, and degenerative joint disease or osteoarthritis can occur with more severe obesity. In addition, obesity is associated with an increased mortality from certain types of cancer. The distribution of body fat (upper body versus lower body) appears to influence these health risks as well. For some, the psychological burden of obesity is more distressing than the physical consequences combined. Based on this research and recognizing obesity as a major public health concern, Dr. Claude Lenfant, NHLBI director, inaugurated the NHLBI Obesity Education Initiative (NHLBI OEI) in January 1991. It is one of seven education programs coordinated by the Office of Prevention, Education, and Control. All of these programs are built on three foundations: a strong scientific basis; consensus building from a wide variety of professional organizations; and communications to targeted communities, patients, health care providers, and special populations such as minority groups or individuals with lower reading skills. Accordingly, the Strategy Development Workshop for Public Education on Weight and Obesity, held on September 24-25, 1992 in Bethesda, Maryland, brought together leading experts from various areas of obesity research, communication specialists, and representatives from 37 professional organizations and Federal agencies. As the first major activity sponsored by the OEI, this workshop sought to address some of the important educational challenges related to weight control and CVD. Karen Donato, coordinator of the NHLBI OEI, welcomed participants, guests, and NHLBI colleagues to the workshop and provided background on the initiative, the objectives of the workshop, and the charge to the working groups. The OEI was established by the Institute because of strong scientific evidence and need for educational messages and activities. The National High Blood Pressure Education Program (NHBPEP) was the first national education program, established in 1972. The Institute, in subsequent years, established four other national education programs based on the NHBPEP model. They include the National Cholesterol Education Program, the National Blood Resource Education Program, the National Asthma Education and Prevention Program, and the National Heart Attack Alert Program. In addition, the Institute has developed other types of educational programs and initiatives including the NHLBI Smoking Education Program and the NHLBI Obesity Education Initiative. Because many of the NHLBI education programs deal with obesity-related issues, the OEI has been designed to coordinate and enhance obesity education activities across the national education programs, to take steps to advance the understanding of the complicated issues involved, and to promote additional research needed to clarify some of the questions that remain. It also takes into account the keen interest of the NHLBI Ad Hoc Committee on Minority Populations on obesity-related health concerns of diverse minority groups in this country. The OEI also has recognized the need to work toward achieving the Healthy People 2000 Objectives for the Nation related to reducing the prevalence of overweight in the United States. One specific objective calls for a concerted effort to prevent the development of overweight in general, while facilitating weight reduction among the overweight. Five other national objectives focus on the impact of dietary habits and physical activity on the prevention of overweight. The OEI differs from the other NHLBI education programs in that it does not have a coordinating committee composed of numerous professional organizations. Instead, the OEI consists of a task force with representatives from the various research divisions of the Institute, many of whom play important roles in the other national education programs and thus help ensure consistent messages across programs. The task force also convenes special ad hoc expert advisory panels to address specific issues and to help guide the initiative. In fact, this workshop evolved from planning meetings held in August 1991 in which a group of experts discussed the determinants, consequences, and treatment issues related to obesity. Based on the recommendations from the planning meetings, the initiative has taken on both a high-risk strategy and a population-based strategy to educate professionals and the public. Both strategies are important in the management of obesity. The high-risk strategy targets individuals who are experiencing, or who are at high risk for, the adverse health effects and medical complications associated with obesity. In implementing the high-risk strategy, an expert panel will address the issues related to the identification, evaluation, and treatment of obesity, specifically in individuals with other risk factors for CVD and lung problems. The population-based strategy focuses on the prevention of obesity and its complications in the general public. From the many surveys already conducted, it is clear that the public has not only heard about weight control and obesity but has been inundated with information. However, the media often foster sociocultural ideals regarding body weight and physical appearance that are unrealistic for most people. In many instances, the messages that get communicated are not always accurate or realistic and often leave the public confused and vulnerable. Voluntary weight loss attempts by large segments of the American population are now typical. The National Institutes of Health (NIH) Technology Assessment Conference on Methods for Voluntary Weight Loss and Control was held in 1992. The experts also reported that one-third of the population is overweight, and as many as 40 percent of women and 24 percent of men are trying to lose weight at any one time. The panel noted that a distressing health paradox now exists in American society. On the one hand, the pursuit of thinness has led many people, particularly young women, who do not need to lose weight to engage in weight loss practices; on the other hand, treatment methods have failed those people who might otherwise have benefited from weight reduction. Because the issues surrounding obesity and overweight are complex and because the consequences of confusion can be serious, reaching a consensus on the messages that should be communicated and the audiences that should be targeted is imperative. The purpose of the NHLBI OEI is to educate the public about the relationship of overweight and physical inactivity to heart disease and lung function. The Strategy Development Workshop for Public Education on Weight and Obesity was convened to help devise an effective population-based strategy that would take into account the public's current perceptions, knowledge, attitudes, and behaviors regarding body weight in the hope of exerting a positive impact on reducing the high prevalence of obesity. WORKSHOP OBJECTIVES The purpose of the Strategy Development Workshop for Public Education on Weight and Obesity was to involve a group of knowledgeable professionals in a collaborative planning process to assist in identifying educational opportunities that could become part of a public education effort on obesity prevention. Four expert panel presentations followed by large and small group discussions provided the structure for the workshop. Participants were asked to consider: o the issues in educating the public about weight and physical activity and their relationship to cardiovascular and lung diseases; o the priority target audiences for the NHLBI Obesity Education Initiative; o the education needs of each target audience in terms of basic knowledge, skills, and behaviors regarding weight, overweight and obesity, and physical activity, and their relationship to cardiovascular and lung diseases; o the public education approaches that would most effectively communicate the information, attitudes, and skills that members of each target audience need in order to change their behaviors regarding weight, physical activity, and eating patterns; and o the communication channels that are appropriate for reaching each target audience and the roles that a wide range of organizations can play in disseminating public education messages and in developing local educational program activities. This report summarizes the activities of the workshop. PANEL PRESENTATIONS Panel 1: The Epidemiology of Obesity and Cardiovascular Disease Panel 2: Strategies for Obesity Prevention Panel 3: Issues in Educating the Public About Weight and Obesity Panel 4: Communication Strategies for Educating the Public PANEL 1: THE EPIDEMIOLOGY OF OBESITY AND CARDIOVASCULAR DISEASE The panel on the epidemiology of obesity and cardiovascular disease was chaired by Dr. JoAnn E. Manson, Brigham and Women's Hospital and Harvard Medical School. She provided an overview of the extent and complexity of the problem. Dr. Eva Obarzanek, NHLBI Division of Epidemiology and Clinical Applications, examined obesity in children by looking at definition and measurement issues, the health consequences related to cardiovascular risk factors, and etiological complexities. Dr. Diane Bild, NHLBI Division of Epidemiology and Clinical Applications, focused on obesity in adults and discussed health risks as well as demographic and etiological factors related to obesity. The panel concluded with general discussion and comments by attendees. INTRODUCTION--JoAnn E. Manson, M.D., Dr.P.H. Obesity contributes to at least half the chronic diseases in Western societies. In the United States, the prevalence of obesity has been slowly increasing despite an increasing preoccupation with weight loss. For African-American women, the prevalence of obesity is approaching near epidemic proportions (National Center for Health Statistics, 1987). Long-term success rates of weight loss efforts are equally discouraging. Data presented at the NIH Technology Assessment Conference on Methods for Voluntary Weight Loss and Control in March 1992 showed that many individuals regain one-third to two-thirds of intentionally lost weight within 1 year, with the rest of the weight returning within 5 years (National Institutes of Health, 1992). Statistics also support an increasing prevalence of obesity in the United States in children ages 6 to 11 years and a similar increase in children ages 12 to 17 years. Physical inactivity and diet appear to be leading contributing factors. According to Morbidity and Mortality Weekly Report, only 35 percent of U.S. high school students attend physical education classes daily, and only 13 percent consume the recommended five daily servings of fruits and vegetables (Centers for Disease Control, 1992). Obesity's association with insulin resistance--often referred to as syndrome X--is characterized by an elevated risk of glucose intolerance, high insulin levels, increased very low density lipoproteins (VLDL), elevated triglycerides, decreased HDL-cholesterol levels, and high blood pressure. Individuals at particularly high risk for this syndrome are those with abdominal obesity, or a waist-to-hip ratio of greater than 0.95 in men and greater than 0.80 in women (Bjorntorp, 1985). Various studies have linked body weight and mortality. An increased risk of all-cause mortality among the obese was demonstrated in the 1959 Build and Blood Pressure Study, the 1979 Build Study, and the 1979 American Cancer Society Study (Society of Actuaries, 1959; Society of Actuaries and Association of Life Insurance Medical Directors of America, 1980; Lew and Garfinkel, 1979). However, these same studies also showed a J-shaped curve, or an increasing risk of mortality among the lean. Cigarette smoking has been cited as one of the confounders in most previous studies because smoking is associated with lower body weight as well as increased mortality. Twenty-six-year followup data on Seventh-Day Adventists showed a clear linear association between body weight and all-cause mortality, with the leanest men having the lowest mortality (Lindsted et al., 1991). More research is required in this area to determine whether any health risks are associated with leanness as well as the magnitude of the risk associated with mild-to-moderate obesity (Manson et al., 1987). Prevention and treatment of obesity in children and adults involves complex questions that have no simple solutions. Of primary importance, attention needs to focus on the prevention of obesity in both children and adults. OBESITY IN CHILDREN--Eva Obarzanek, Ph.D., R.D. Describing the extent of the problem of obesity in children involves not only examination of the prevalence and distribution of obesity through childhood, but also consideration of its definition and measurement, relationship to cardiovascular risk factors, tracking into adulthood, and etiology. The following sections explore some of these complex issues. Definition and Measurement Issues The two main difficulties of accurately describing the epidemiology of obesity in children are related to issues of definition and measurement. Different methods of measuring obesity yield different results, different definitions, and different interpretations of the cardiovascular risks of pediatric obesity. Weight alone is not a good measure of obesity because of its dependency on height. Body mass index (BMI, kg/m2) has been used extensively in epidemiological studies because it is a measure of weight that is relatively independent of height, can be measured easily, and appears to be moderately well correlated with body fat in adults and children. For growing children, however, the interpretation of BMI is more of a problem because the rate of weight gain may not be in step with the rate of height gain. This means that BMI may fluctuate as children are tracked during their growing years. BMI also carries with it components of frame size and lean body mass that greatly increase--more so than fat--during childhood. A second measure frequently used to assess obesity is skinfold thickness. Skinfold measures have the advantage of being direct measures of fat; however, compared to measures of height and weight, they are less easily and less reliably measured. The 1976-80 National Health and Nutrition Examination Survey (NHANES II) (National Center for Health Statistics, 1987) data for 7,000 children between the ages of 2 and 18 years indicated that for both boys and girls BMI declines slightly in the early years and then begins to increase throughout the teenage years (figures 1 and 2). On the other hand, when body fat was measured using triceps skinfold (TSF) measurements, the results differ. For both boys and girls, TSF measures increase from early childhood through puberty, ages 9 to 12; TSF measures then decline during the teenage years for boys but continue to rise for girls (figures 3 and 4). Ethnic differences in TSF measures are evident in comparing the NHANES II data and the 1982-84 Hispanic Health and Nutrition Examination Survey (HHANES) data (National Center for Health Statistics, 1989). From age 2 through the teenage years, TSF measures were lower for African-American boys, and similar or slightly higher for Mexican-American boys, than they were for white boys. In all age groups, TSF measures for African-American girls were lower than they were for white girls, until the teenage years when they become larger than for white girls. For Mexican-American girls, TSF measures were similar or slightly higher than those of white girls. Prevalence Data In children, obesity--characterized by excess body fat--is often defined as greater than or equal to the 85th percentile for age and sex of TSF or BMI. Using the 85th percentile of TSF as a definition, Gortmaker and associates (1987) compared data from the Health Examination Surveys (HES) of the 1960s, the NHANES I (1971-74) and the NHANES II (1976-80) data. Using the HES as the reference population, across each succeeding survey, they found the prevalence of obesity increasing among children (figure 5). The NHANES II data showed the prevalence of obesity in children ages 6 to 11 years at 27 percent--an increase of 20 percent from the NHANES I--whereas in 12- to 17-year-olds, the prevalence of obesity was about 22 percent--an increase of about 9 percent. Data from the Bogalusa Heart Study also showed an increase in the prevalence of obesity, defined as the 85th percentile of the ponderal index (kg/m3), from 15 percent in 1973 to approximately 24 percent in 1984 in children ages 5 to 14 years (Shear et al., 1988). More recent work, however, has shown that the 85th percentile of TSF may not be indicative of obesity in all cases because a given percentile represents different levels of body fat at different ages (Lohman et al., 1989). For example, the 85th percentile of TSF for boys at age 6 corresponds to 15-percent body fat, whereas for boys at age 12, the 85th percentile corresponds to 23-percent body fat. To adjust for this, Lohman and colleagues proposed using percent body fat rather than percentiles of skinfolds or BMI to define obesity (Williams et al., 1992). They defined pediatric obesity as a body fat level greater than or equal to 25 percent for boys and greater than or equal to 30 percent for girls, derived from prediction equations using triceps and subscapular skinfolds, discussed later. Applying this definition to the NHANES II triceps and subscapular skinfolds data, the prevalence of obesity increases around the pubertal years for both boys and girls. The prevalence in obesity then declines sharply for boys throughout the teenage years but falls only slightly for girls. Figure 6 compares the prevalence of obesity in children (NHANES II data) using the TSF percentile method versus the percent body fat method. In children ages 6 to 11 years, the prevalence of obesity is 27 percent when using the 85th percentile of TSF definition compared to 11 percent when using the percent body fat definition. Similarly, for teenagers ages 12 to 17 years, the prevalence of obesity is 22 percent when the percentile method is used compared to nearly 14 percent when the percent body fat method is used. Further validation of percent body fat standards is required. Tracking of Obesity One of the health concerns regarding obesity in childhood is that obesity may continue into adulthood. Longitudinal studies have suggested that, although not all obese children become obese adults, obese children have a greater probability of remaining obese than would be expected by chance (Garn and LaVelle, 1985). In the Bogalusa Heart Study, for example, 49 percent of children ages 5 to 14 years who were initially obese (in the 90th percentile of TSF measurements) were obese in the 5-year followup, and 43 percent remained obese in the 8-year followup (Freedman et al., 1987). In the Tecumseh Community Health Survey, 26 percent remained obese after 20 years (Garn and LaVelle, 1985). This risk of remaining obese appears to be greater when obesity occurs later in childhood (Harsha et al., 1987). More research on the tracking of obesity is needed. Relation to Cardiovascular Risk Factors Studies have linked health consequences, including the development of risk factors for CVD, with childhood obesity (Aristimuno et al., 1984). Children who gain the most weight have the greatest increase in cardiovascular risk factors, and children in the upper quintile of body weight are more likely to develop two or more cardiovascular risk factors (Smoak et al., 1987). In addition, data from the Bogalusa Heart Study showed that central body fat (as measured by suprailiac and subscapular skinfold thickness) is related to adverse lipid profiles, independent of overall body fat (Freedman et al., 1989). Similar results also were found for blood pressure (Shear et al., 1988). Lohman and colleagues, using their proposed definition of obesity as percent body fat, have tried to determine a cut point or level of body fat that is associated with elevations in cardiovascular risk factors in children (Williams et al., 1992). If no relationship existed between obesity and cardiovascular risk factors, 20 percent of all children across all quintiles of percent body fat would develop high blood pressure. However, Lohman determined that 35 percent of boys were in the top quintile for blood pressure when body fat levels reached 25 percent. For girls, the frequency of high blood pressure increased when body fat levels reached 30 to 35 percent. Similar levels of percent body fat also were associated with the top quintile for total cholesterol levels. Etiology The etiology of obesity in children is complex. Familial and genetic factors are among those associated with obesity in children. For example, Mayer (1965) showed that offspring of two obese parents have an 80-percent chance of becoming obese, as compared to a 14-percent chance for offspring of two parents of normal weight. These data indicate that obesity is related to familial factors that are transmitted through heredity, through a shared environment, or through both. However, subsequent studies on twins and adoptees have shown that body fat is transmitted genetically to a moderate extent (Stunkard et al., 1986a, 1990; Bouchard et al., 1988; Sorenson et al., 1989). Studies have shown that the correlation for measures of body fat in pairs of relatives increases as the relationship gets closer. Furthermore, siblings by adoption have no significant correlation in body fat whereas related siblings do. The correlation increases with dizygotic twins and is highest for monozygotic twins (Bouchard et al., 1988). Bouchard has estimated that about 25 percent of the variation in body fat is genetic. Thus, much of the variation in body fat is due to environmental factors. Environmental factors that are expected to play a key role in body weight are diet and physical activity. A significant, direct relationship between energy intake and body weight has generally not been found in children (Rolland-Cachera and Bellisle, 1986). Studies relating physical activity with body weight are inconsistent (Sunnegardh et al., 1986). Furthermore, most studies do not show that obese children eat more than lean children (Durnin et al., 1974), and only a small number of studies show that obese children are less physically active than lean children (Tell and Vellar, 1988; Bullen et al., 1964). However, dietary and physical activity assessment methods are extremely imprecise, and caloric intake estimates especially have high intraindividual variation. Large errors of measurement and high individual variability make it difficult to detect significant relationships. Hours of television viewing have been linked to the prevalence of obesity. Dietz and Gortmaker (1985) found that, in a national sample of children ages 12 to 17 years, the prevalence of obesity (defined by the 85th percentile of TSF measurements) increased 1.9 percent for each hour per day spent watching television. Whether the increased prevalence of obesity is a result of decreased physical activity or of increased snack intake as a result of watching television needs to be investigated further. Socioeconomic status has been found to be related to obesity in adults. However, no overall trend is discernible in children. In a review by Sobal and Stunkard (1989), about one-third of the studies found a positive association, one-third a negative association, and one-third no association. Summary o A generally accepted definition of obesity in children is needed. o The measures that define obesity in children need to take into account the natural history of fat deposition related to normal growth and development. o Obese children have a higher probability of becoming obese adults, which may set the stage for premature CVD in adulthood. Furthermore, pediatric obesity is associated with cardiovascular risk factors in childhood. o Environmental factors are important in obesity in children because genetics account for only a portion of the variation in obesity. o Longitudinal studies with consistent use of the various measures would provide a better understanding of the etiology of obesity in children. OBESITY IN ADULTS--Diane Bild, M.D., M.P.H. An examination of obesity in adults needs to include an examination of the health risks and demographic factors associated with obesity, as well as other factors that may be causally related to obesity. Prevalence Difficulties of definition and measurement continue to be a problem in describing the epidemiology of obesity in adults. The NHANES II data and definition of obesity nevertheless provide a reference base for comparing studies and examining trends. Approximately one-fourth of the American population is overweight based on the NHANES II definition (greater than or equal to the sex-specific 85th percentile of BMI for 20- to 29-year-olds) (National Center for Health Statistics, 1981). As figure 7 illustrates, adult obesity in the United States has been increasing in both men and women and in both African Americans and whites. Of important note is the particularly high prevalence of obesity in African-American women. Weight and Mortality Data from three large studies--the 1959 Build and Blood Pressure Study, the 1979 Build Study, and the 1979 American Cancer Society Study--show an increase in mortality ratios for both men and women with increasing relative weights (figure 8). The J-shaped curve also indicates high mortality among those 20 percent below average weight. By failing to separate smokers from nonsmokers, the Build Studies overstate the mortality risks of having lower weight and understate the mortality risks of being overweight because smokers tend to weigh less and have higher mortality rates than nonsmokers. However, 28-year followup data from the Framingham Heart Study suggest increasing mortality with increasing weight, even after controlling for smoking (Higgins et al., 1988). Weight and Cardiovascular Risk The Framingham data demonstrated that higher quintiles of BMI are associated with increased levels of total cholesterol, systolic and diastolic blood pressure, glucose, and uric acid (Higgins et al., 1988). Furthermore, obesity was associated with an increased risk of coronary heart disease (CHD), independent of these risk factors. The Nurses Health Study of more than 120,000 registered nurses ages 30 to 55 found an increased risk of CHD associated with greater BMI (Manson et al., 1990). In this study, women with a BMI greater than or equal to 29 had almost double the risk of CHD compared to women with a BMI less than 21, after controlling for hypertension, diabetes, high serum cholesterol, and parental myocardial infarction. Weight Change and Cardiovascular Risk Five-year data from the Coronary Artery Risk Development in Young Adults (CARDIA) study of 5,000 men and women ages 18 to 30 years at baseline (Friedman et al., 1988) provided insight into the effects of weight loss, weight maintenance (within 5 pounds), and weight gain on cardiovascular risk factors. Those who lost weight (initial loss of 5 pounds without regain of more than 5 pounds over 5 years) showed decreases in blood pressure, whereas those who gained showed increases in blood pressure (figure 9). Significant changes in HDL-cholesterol levels also were noted: Those who lost weight raised their HDL-cholesterol levels, whereas those who gained lowered their HDL-cholesterol levels (figure 10). Weight, Race, and Socioeconomic Status According to cross-sectional data from the NHANES II, the mean weight of both white and African-American men increased with age until the forties and then reached a plateau, whereas the mean weight for women increased throughout adulthood to age 74 (National Center for Health Statistics, 1981). Data from the CARDIA study showed that weight is not related to education level in white men, but that African-American men who are better educated have slightly higher BMIs than their less educated counterparts (Burke et al., 1990). African-American and white women with more education or with higher incomes have lower BMIs than those women with less education or lower incomes. Etiology An examination of the factors influencing obesity in the CARDIA study revealed no relationship between skinfold thickness and caloric intake in either men or women (Slattery et al., 1992). The absence of an effect could be due to difficulty in measuring caloric intake and to the fact that people who weigh more may be less active and therefore require fewer calories. Skinfold thickness and level of physical activity were significantly related in both men and women and in both African Americans and whites (Slattery et al., 1992). BMI also was correlated with fitness, as measured by duration on a treadmill test (Sidney et al., 1992). Again, interpretation of cause and effect is difficult: Do those who are more fit weigh less because of increased energy expenditure? Or are those who weigh more less active and therefore less able to perform well on a fitness test? Attitudes and diet practices may play a role. In the CARDIA study, African-American women reported that they dieted, considered obesity harmful, and perceived themselves to be fat less often than did white women, despite the higher prevalence of obesity in African-American women (figure 11). Parity is also associated with BMI. Women who have more children and women who give birth at an earlier age tend to have higher BMIs (Burke et al., 1992). Genetic predisposition to obesity is an important factor. CARDIA data showed a definite relationship between parental obesity and skinfold thickness in offspring ages 18 to 30 years, with the relationship particularly strong when both parents are obese (Burke et al., 1991). A Danish study that compared adopted children to both their biological parents and adoptive parents also showed a strong correlation between children's BMIs and their biological parents' BMIs but not their adoptive parents' BMIs (Stunkard et al., 1986b). Priorities With many overweight individuals (46 percent of overweight men and 61 percent of overweight women) trying to lose weight and billions of dollars being spent annually on weight loss efforts, increased attention to the prevention of obesity is needed. An equally great challenge is determining what recommendations should be given to already obese individuals. GENERAL DISCUSSION Dr. JoAnn Manson stated that the benefits of long-term weight loss cannot yet be fully addressed because not enough individuals have sustained long-term weight loss. The evidence is clear, however, that weight loss has such cardiovascular benefits as lowering blood pressure and improving both lipid profiles and glucose tolerance. Furthermore, no clear evidence suggests adverse physiological effects from weight loss. The panel members were asked whether they knew of any race differences in the physiological effects of obesity, considering there are race differences in the perceptions of obesity. Dr. Manson was aware of possible differences with diabetes. After adjusting for BMI, African-American women--and perhaps African-American men--may be at greater risk than whites for developing glucose intolerance and diabetes. The panelists were unsure whether there were greater risks of obesity for other end points. The greater prevalence of hypertension in African-American women as compared with white women is explained chiefly by the greater prevalence of obesity in that population. Dr. David F. Williamson, Centers for Disease Control and Prevention, shared a recent article, "Childhood weight and growth rate as predictors of adult mortality" by Nieto and colleagues (1992), published in the American Journal of Epidemiology. The study showed that even in young children long-term health outcomes are adversely affected by obesity. Dr. Williamson also commented that examining longitudinal data, as opposed to cross-sectional data, is a better way to look at weight gain over time. Based on NHANES I followup data, both men and women gain weight, at a decreasing rate, up to their mid-fifties, and women gain more weight than men. After that, with increasing age, they both lose weight, but women lose more weight than men. Dr. Cheryl Ritenbaugh, University of Arizona, asked whether there are any data on cardiovascular risk in physically active individuals who weigh more. Dr. Manson cited the Nurses Health Study, which showed a strong independent effect of BMI and increasing CHD, after controlling for physical activity. Several epidemiological studies suggest that weight loss, whether by caloric restriction or physical activity, produces comparable effects on cardiovascular risk factors. Dr. Ritenbaugh responded that, from the standpoint of public health and prevention, consideration of what could be achieved by increasing levels of fitness without initial attention to weight loss was needed. Dr. Robert W. Jeffery, University of Minnesota, asked whether the CARDIA investigators have looked prospectively at the relationship of reported dieting to weight gain or loss, or at the relationship of dieting to cardiovascular risk factors, after controlling for body weight. Dr. Millicent Higgins, NHLBI, stated that the prevalence of dieting was related to the change in body weight; however, only a very small number of individuals had actually sustained weight loss. Much of these data have not yet been analyzed fully. Dr. Barbara C. Hansen, North American Association for the Study of Obesity, suggested that the intervention focus on primary prevention rather than on the promotion of weight loss, in light of the historical data on groups of people who have been calorically restricted (but not necessarily nutritionally deprived) and the studies that have been conducted in rodents. Dr. Manson agreed that the emphasis should be on primary prevention, not only because secondary prevention (reversing obesity) has such a dismal track record but also because of the questions that have been raised about the adverse health effects caused by weight loss and weight cycling. However, attention still must be given to the one-quarter to one-third of Americans who are already obese. Dr. Peter Wood, Stanford University, asked about the relationship between obesity and cardiovascular morbidity and mortality in people age 65 and older. Dr. Manson responded with Framingham data, which showed similar findings on cardiovascular morbidity and mortality and BMI in this age group. There is evidence that lower weight produces better cardiovascular risk profiles in the older population. The only disease risk that has been found to be associated with leanness in women is osteoporosis and related fractures. In men, no disease appears to be adversely influenced by leanness. William Fabrey, National Association To Advance Fat Acceptance, mentioned some research that showed that African-American men may suffer from higher rates of CVD that are attributable to oppression and asked whether any research has been conducted on the effects of high levels of stress and obesity. Dr. Bild stated that this was an area for further study but noted the difficulty in measuring psychosocial stress. Dr. Millicent Higgins, NHLBI, expanded upon the discussion of how leanness influences mortality. She mentioned that, in addition to osteoporosis, chronic obstructive lung disease and lung cancer are related to leanness, but it is likely that this association is due to the higher prevalence of smoking among the lean. Identifying the reasons for the weight loss, voluntary or involuntary, in many of the studies is difficult. The underlying disease process is most important, especially in older Americans. Nancy Summer, Council on Size and Weight Discrimination, requested clarification of a statement from the Technology Assessment Conference on Methods for Voluntary Weight Loss and Control that indicated that a 10-percent reduction in weight had positive effects on health. Dr. Manson responded that weight loss can often improve insulin sensitivity and glucose tolerance. In very obese individuals, glucose intolerance also is influenced positively by small reductions in body weight, but the condition is not necessarily normalized. Robert Garrison, NHLBI, made a final comment on the issue of obesity and the older population. He referred to a 1988 paper by Harris and colleagues (1988) on the Framingham Heart Study, published in the Journal of the American Medical Association, which showed a powerful positive relationship between weight and mortality in individuals over age 65, even after controlling for confounders (such as cigarette smoking). 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Anthropometric Data and Prevalence of Overweight for Hispanics, 1982-84. Series 11, No. 239. DHHS Pub. No. (PHS) 89-1689, Washington, D.C., 1989. National Center for Health Statistics. Najjar MF, Rowland M. Anthropometric Reference Data and Prevalence of Overweight, United States, 1976-80. Series 11, No. 238. DHHS Pub. No. (PHS) 87-1688, Washington, DC, 1987. National Institutes of Health. Technology Assessment Conference Panel. Methods for voluntary weight loss and control. Ann Intern Med 1992;116:942-949. Nieto FJ, Szklo M, Comstock GW. Childhood weight and growth rate as predictors of adult mortality. Am J Epidemiol 1992;136:201-213. Rolland-Cachera MF, Bellisle F. No correlation between adiposity and food intake: Why are working class children fatter? Am J Clin Nutr 1986;44:779-787. Shear CL, Freedman DS, Burke GL, Harsha DW, Webber LS, Berenson GS. Secular trends of obesity in early life: The Bogalusa Heart Study. Am J Public Health 1988;78:75-77. Sidney S, Haskell WL, Crow R, Sternfeld B, Oberman A, Armstrong MA, Cutter GR, Jacobs D, Jr, Savage PJ, Van Horn L. Symptom-limited graded treadmill exercise testing in young adults in the CARDIA study. Med Sci Sports Exerc 1992;24:177-183. Slattery ML, McDonald A, Bild DE, Caan BJ, Hilner JE, Jacobs DR, Liu K. Associations of body fat and its distribution with dietary intake, physical activity, alcohol, and smoking in blacks and whites. Am J Clin Nutr 1992;55:943-9. Smoak CG, Burke GL, Webber LS, Harsha DW, Srinivasan SR, Berenson GS. Relation of obesity to clustering of cardiovascular disease risk factors in children and young adults: The Bogalusa Heart Study. Am J Epidemiol 1987;125:364-372. Sobal J, Stunkard AJ. Socioeconomic status and obesity: A review of the literature. Psychol Bull 1989;105:260-275. Society of Actuaries. Build and Blood Pressure Study, 1959. Chicago: Society of Actuaries, 1959. Society of Actuaries and Association of Life Insurance Medical Directors of America. Build Study, 1979. Chicago: Society of Actuaries and Association of Life Insurance Medical Directors of America, 1980. Sorenson TIA, Price RA, Stunkard AJ, Schulsinger F. Genetics of obesity in adult adoptees and their biological siblings. Br Med J 1989;298:87-90. Stunkard AJ, Foch TT, Hrubec Z. A twin study of human obesity. JAMA 1986a;256:51-54. Stunkard AJ, Harris JR, Pedersen NL, McClearn GE. The body-mass index of twins who have been reared apart. N Engl J Med 1990;322:1483-1487. Stunkard AJ, Sorenson TIA, Hanis C, Teasdale TW, Chakraborty R, Schull WJ, Schulsinger F. An adoption study of human obesity. New Engl J Med 1986b;314:193-198. Sunnegardh J, Bratteby LE, Hagman U, Samuelson G, Sjolin S. Physical activity in relation to energy intake and body fat in 8- and 13-year-old children in Sweden. Acta Paediatr Scand 1986;75:955-963. Tell GS, Vellar OD. Physical fitness, physical activity, and cardiovascular disease risk factors in adolescents: The Oslo Youth Study. Prev Med 1988;17:12-24. Van Italie TB. Obesity: Adverse effects on health and longevity. Am J Clin Nutr 1979;32:2723-2733. Williams DP, Going SB, Lohman TG, Harsha DW, Srinivasan SR, Webber LS, Berenson GS. Body fatness and risk for elevated blood pressure, total cholesterol, and serum lipoprotein ratios in children and adolescents. Am J Public Health 1992;82:358-363. PANEL 2: STRATEGIES FOR OBESITY PREVENTION The panel on strategies for obesity prevention explored current school-, family-, and community-based strategies for preventing obesity and suggested directions for future research and activities. Dr. Patricia J. Elmer, University of Minnesota, chair of the panel, introduced the topic. Dr. James F. Sallis, Jr., San Diego State University, examined what is known about the results of school-based obesity prevention programs and discussed related research issues and priorities for school activities. Dr. Leonard H. Epstein, University of Pittsburgh, focused on epidemiological studies of family-based obesity programs and emphasized the importance of family involvement as well as exercise in long-term weight control. Dr. Robert W. Jeffery, University of Minnesota, described results from four community-based obesity programs and stressed the relationship of public health and the prevalence of obesity in the community. The panel concluded with general discussion and comments by participants. INTRODUCTION--Patricia J. Elmer, Ph.D., R.D. Obesity is a problem with many dimensions and leads to difficult questions such as how people with obesity can best be reached and how the development of obesity can best be prevented. School- and clinic-based programs as well as populationwide interventions are needed, and program effectiveness needs to be analyzed. Different approaches to intervention are offered in school-based programs, family-based programs, and community-based programs. What are the advantages and disadvantages of these approaches? Variables that have been used to identify key interventions include age and gender as well as ethnicity and geographic location. Additional insights into effective strategies for intervention may be provided in the differences between weight cycling and smoking cycling. Evidence suggests that individuals who quit smoking a number of times are more successful in ultimately stopping permanently; however, this is not true for individuals who lose weight a number of times. The reasons for this--that is, the behavioral and psychological components of weight cycling--need to be investigated. SCHOOL-BASED OBESITY PROGRAMS--James F. Sallis, Jr., Ph.D. A large number of children can be reached in school-based obesity programs, especially younger children. Comprehensive treatment and prevention programs can be conducted on a daily basis for many years, and relevant professionals are usually available to help monitor the programs. School-based obesity programs offer multiple opportunities, most commonly for educational and behavioral modification interventions, through the physical education curriculum, the school lunch program, environmental changes, and summer school programs. Comprehensive school-based obesity programs also may include health education services for peer groups, families, and school staff. School-based programs are, however, only one component of the overall health promotion model, and they are limited in the services they can provide. Treatment Programs Ward and Bar-Or (1986) and Parcel and associates (1988) reviewed 10 studies of school-based obesity treatment programs. Elementary and secondary school students who were overweight were selected for participation in the programs. In general, treatment consisted mostly of educational components (covering diet, physical activity, and behavior modification), but other components involved modified physical activities and school lunches. Mean treatment length was 15 weeks. Treatment programs, reported in changes in percentage of overweight participants, were more successful in elementary school children (a 12-percent reduction) than in secondary school students (a 5-percent reduction). However, which components were related to the success of the programs, and why the younger children were more successful than the older children, could not be determined. The length of treatment was not related to outcome. In addition, most treatment studies included only a few key components (diet and physical activity education), made no provisions for modifying the environment, had little parental involvement, and demonstrated no long-term effects. Prevention Programs Obesity was one of the risk factors tracked in seven studies of school-based cardiovascular risk reduction programs (see table 1). Interventions in these programs lasted from 7 weeks to 5 years and included 4,000 primary school students (in three programs) and 3,400 secondary school students (in four programs). Intervention components included modified physical education classes as well as education about diet and about physical activity. Only one primary school included in the studies modified its school lunches; three secondary schools involved parents. Table 1 shows the effects of school-based prevention programs. Of the seven programs, one in the primary grades (a physical education intervention) and two in the secondary grades had a significant effect on obesity. The table also illustrates that risk factors other than obesity (for example, blood pressure, lipids, smoking) tended to be influenced more significantly in all programs. However, none of the programs made much effort to combine education and environmental change. Most did not include either physical education and school lunch modification or involve parents, and they also did not emphasize behavioral skill training. Thus, they did not demonstrate the potential effectiveness of prevention programs for obesity that include most or all of the key components. Future studies of prevention need to address the implications of the modest changes in body fat in youth that these seven studies revealed as well as the effects of schoolwide prevention programs on obese youth. Because the number of school-based treatment programs appear to be decreasing while prevention programs are increasing, it may be time to put more emphasis on treatment programs. The best direction for intervention programs to take may be that demonstrated by the ongoing NHLBI Child and Adolescent Trial for Cardiovascular Health Study. This trial includes educational and environmental components in addition to family involvement and may indicate the effects of a prevention approach on the development of obesity. Key Research Issues Among key issues in researching school-based obesity programs are the selection, recruitment, and retention of the population targeted for treatment; the long-term effects of treatment; the feasibility and effectiveness of program components; and the quality of implementation of the interventions. Other research issues that must be considered are the optimal timing and duration of the intervention, the effectiveness of integrating simultaneous treatment and prevention programs, monitoring the effectiveness of diet and physical activity, and appropriate interventions for ethnic groups. Important related issues are how to implement obesity prevention and treatment programs in the schools (particularly given the already limited resources) and how to determine the most effective settings (schools versus clinics) for these programs. In addition, explorations of the limits of intervention effectiveness need to be made because no program to date has included all the components required to ensure quality implementation. One of the most promising features of schools as intervention settings is the possibility of long-term programs, and the cumulative effects of both treatment and prevention strategies over several years need to be examined. Priorities The number one priority for school-based programs should be modifying the composition of school lunches and ensuring the active participation of students in physical education classes. Modifications to these existing programs are definitely needed to make them more effective for obesity prevention and treatment. Behavior modification components need to be built into programs related to diet and physical activity. Other priorities include conducting parent education and establishing treatment programs for obese children. In furthering priorities, the psychosocial effects of treatment need to be considered to ensure that psychosocial functioning is enhanced and that no child is stigmatized. FAMILY-BASED OBESITY PROGRAMS--Leonard H. Epstein, Ph.D. Data from recent studies emphasize the importance of family-based obesity programs (Epstein and Wing, 1987). Results of epidemiological studies suggest that children of obese parents have a greater risk of developing obesity in adulthood than children with lean parents (Charney et al., 1976; Garn and LaVelle, 1985). Thus, family-based obesity programs that expect both generations and all family members to participate actively and make behavior changes can have more of an impact. Family-related variables--that is, factors common to multiple family members such as food storage, family environment, and behavior support--can be capitalized on and manipulated to produce family behavior changes. Among the studies demonstrating the need for family-based obesity programs are four epidemiological studies (Abraham and Nordsieck, 1960; Abraham et al., 1971; Stark et al., 1981; Garn and LaVelle, 1985) that showed that obese older children are more likely to retain obesity in adulthood and that the relative risk is particularly high for children ages 10 to 12 (see table 2). These data suggest that, as children become older, they have a greater relative risk for becoming obese adults and provide a good indication of the ages when interventions are needed. Table 2. Relative Risk by Age of Obese Children Who Become Obese Adults Percent who become Age of obese child obese adults Relative risk 0-6 months 14 2.3 0.5-5.5 years 20 3.4 7 years 41 3.7 10-12 years 70 6.0 In a 10-state nutrition study, Garn and Clark (1976) analyzed the triceps skinfold measures of boys and girls as a function of parental weight. Children of two obese parents were found to have much more body fat than children of two lean parents, and an interaction between parents and children was demonstrated: that is, an obese child with obese parents has a different risk than an obese child with lean parents. In another study, Charney and colleagues (1976) followed children with heavy or thin parents from age 6 months to adulthood. Results again suggested an interaction between parent and child and that treating obese children with obese parents was more important than treating obese children with lean parents. The percentage of children who became obese adults as a function of parental weight is shown in table 3. Table 3. Percentage of Children Who Become Obese Adults as a Function of Parental Weight Percent with Percent with heavy parents thin parents Heavy children who become obese adults 51 20 Thin children who become obese adults 15 11 Four 10-Year Followup Epidemiological Studies The four recent family-based 10-year treatment studies, one of which has been published (Epstein et al., 1990), involved children ages 6 to 12 years who were 20- percent overweight, in the 85th percentile of triceps skinfold, and had no psychiatric disorders. The children apparently had no reading disabilities (they had to keep food records). All had obese parents, except for the ones in whom the long-term effects of parental weight on child weight loss were being studied (Epstein et al., 1987). Treatments were once a week for 8 weeks and then once a month for 4 months. After 10 years of followup, the data showed that a significant number of children in the treatment programs maintained treatment effects, as compared to those children not in the treatment programs. As discussed below, these studies demonstrated the importance of active participation by all family members and of targeting family-related variables. o Study 1 (Epstein et al., 1990): Targeting children versus targeting children and parents--This study compared results when the child alone was targeted for treatment versus when both the child and parent were targeted. A nonspecific control group (in which no particular family member was targeted) also was included. The study used the Cooper lifestyle exercise program and focused on habit and weight change behaviors. The results suggest that involving the parent as an active participant has a large effect on long-term change. o Study 2 (Epstein et al., 1984): Diet versus diet and lifestyle--This study examined differences between emphasizing diet versus emphasizing diet and lifestyle modifications, including exercise. Parents were not included as active participants. This study showed no significant differences between the two interventions at the 10-year point. o Study 3 (Epstein et al., 1987): Positive versus negative family history--This study compared the effects of a positive family history (at least one heavy parent) with the effects of a negative family history (no heavy parents). Obese children performed more poorly with treatment when one parent was obese than when both parents were lean, even when the treatment was the same. Differences were noted at 1 year and maintained for 10 years. o Study 4 (Epstein et al., 1985): Lifestyle versus aerobic exercise--This study targeted both children and parents and compared the effects of a lifestyle exercise program (walking during daily activities), the effects of a more traditional aerobic exercise plan (a 2-mile run), and the effects of no exercise. The 10-year data showed long-term weight maintenance effects for both groups that exercised as compared to the group that did not exercise. Personalized System of Instruction Study A recent followup study of the treatment studies described above (Epstein et al., submitted [a]) was based on a competency-based education system called the Personalized System of Instruction (PSI). With the PSI, children learn at their own pace and must master basic skills before moving on to more complex skills. The study involved 6 months of weekly treatment and 6 months of maintenance meetings. A treatment effect (measured in percent over BMI change) appeared at 12 months in children and their parents but was not sustained at 2 years. This suggests that more personalized instruction is needed during the weight maintenance phase of the treatment program. Obesity and Television Watching Studies Research has investigated the correlation between prevalence of obesity and the number of hours spent watching television (Dietz and Gortmaker, 1985). Epstein and associates recently looked at whether decreasing sedentary activities--that is, cutting back on television viewing--had a positive effect on weight. Three treatment groups were included: diet plus increased exercise, diet plus decreased sedentary activity, and diet plus a combination of increased exercise and decreased sedentary activity. Reductions in primary sedentary behaviors (watching television) were reinforced to determine if decreasing the sedentary behavior would result in increased activity or in another sedentary behavior (such as reading a book). Treatment involved 4 months of weekly meetings and 2 months of maintenance. The diet plus decreased sedentary activity treatment showed the most powerful effect on percent overweight change--at both 6 months and 1 year (Epstein et al., submitted for publication [b]). The data suggest that children who received positive reinforcement in cutting back on sedentary behaviors and who were given a choice of behaviors were more likely to select and prefer active behaviors. The researchers suggest that children who are not given a choice of activities will eventually select more active behaviors but not necessarily enjoy them. Recommendations for Family-Based Obesity Programs o Parents must have an active role in the treatment program. o Exercise is the key to long-term weight control in all obesity programs. o The family's environment and behaviors must be targeted. o Specialized training in childhood behavior modification needs to be provided when treating the entire family. o Obesity treatment programs with dietary changes do not affect a child's growth. The 10-year followup studies demonstrated that children who participated in treatment programs were within 2 centimeters of the height of their same-sex parent. o Programs need to emphasize that preventing obesity also may prevent eating disorders and reduce cardiovascular risk factors. o Further study of the psychosocial effects of obesity treatment programs in children is needed. COMMUNITY-BASED OBESITY PROGRAMS--Robert W. Jeffery, Ph.D. Obesity is primarily an adult-onset disorder. It is several times more common in middle-aged adults than in young adults, and by age 50, nearly half of all adults are 20 percent or more above desirable weight. Susceptibility to obesity is widespread; particularly at risk are minorities (especially African-American women) and young adults of lower socioeconomic status. Obesity must be viewed as a community problem and intervention programs targeted appropriately. To affect public health, influencing the prevalence of obesity in the community is essential. To be successful, community intervention programs must: o reach a large number of young adults, particularly those at highest risk; o change eating and exercise habits that are related to obesity; and o be available at a reasonable cost. Progress in developing community-based programs is illustrated in four community intervention projects conducted by the University of Minnesota. Healthy Worker Project The first of these programs, the 1987-90 Healthy Worker Project (HWP), involved worksite health promotion (Jeffery et al., 1993). In this trial, 32 public and private worksites with a wide range of occupations were randomly assigned to a treatment group or a control group. The 16 worksites in the treatment group received free health promotion programs on weight control and smoking cessation. Onsite educational classes were offered four times over a 2-year period. A payroll incentive plan was used in which modest amounts of money were deducted from paychecks and returned contingent upon progress made toward the weight loss goal. About 20 percent of all employees participated in these classes (38 percent of overweight employees and 10 percent of normal-weight employees). Both weight loss and weight gain prevention were encouraged as a personal goal. The mean weight loss for HWP participants in weight loss classes averaged about 5 pounds over 6 months. The overall effect of the intervention on all employees was measured by changes in BMI. Average weight changes were small, and there were no differences between the 16 worksites in the treatment group and the 16 worksites in the control group. Invest in Your Health Study The second community intervention program was a weight loss and smoking cessation effort utilizing a direct mail and home correspondence strategy called Invest in Your Health (IYH) (Jeffery et al., 1990). Participants were recruited by mail and offered one of two programs: a $5 fee-for-service program consisting of a self-help manual and monthly newsletters or a program identical in content but incorporating a $60 incentive deposit that was fully refundable contingent upon reaching a weight loss goal. Weight loss goals were selected by the participants themselves, and weight gain prevention was encouraged as a program option. Evaluation was made through self-reported weights and heights using a return postcard. These reports were validated by actual measurement at baseline and 1-year followup in a subset of the sample. Responses were obtained from about 6 percent of households in the $5 fee-for-service program and from 1 percent in the program incorporating the $60 incentive deposit. Individuals participating in both programs lost modest amounts of weight, with men losing more weight than women. Individuals participating in the incentive-deposit program lost twice as much weight as those participating in the fee-for-service program, but only one-fifth as many participated. Thus, the overall community impact should be larger with the fee-for-service program. IYH demonstrated that a correspondence program not only can reach a large number of people at a reasonable cost but also can produce modest weight losses of a magnitude useful for populationwide obesity prevention efforts. Pound of Prevention Trial The Pound of Prevention (POP) trial was a correspondence course that focused on studying weight gain prevention rather than weight loss (Forster et al., 1988). The participants--219 normal-weight volunteers--were recruited by mail and randomly assigned to a treatment program for preventing weight gain or to a control group. The volunteers were more likely to be women and nonsmokers. The POP trial utilized monthly newsletters, a minicourse on weight control, and a deposit incentive system ($10 per month returned if no weight was gained). The POP trial also collaborated with a local health department to enhance generalizability to a community setting. The overall recruitment response rate was 13 percent. Over 12 months, the treatment program group lost an average of 1 kilogram, but there was no weight change for the control group. In the treatment group, 82 percent did not gain weight compared to 56 percent in the control group. The differences were statistically significant. Characteristics of treatment group participants that correlated with weight loss were male gender, older age, nonsmoking, no prior experience in weight control, and higher participation in the program activities. The POP trial demonstrated that weight gain prevention programs can be implemented successfully in communities at relatively low cost. Minnesota Heart Health Program The Minnesota Heart Health Program (MHHP), a 10-year project, was designed to evaluate the effectiveness of multicomponent interventions in reducing cardiovascular disease incidence and mortality (Leupker et al., submitted). Three matched community pairs (approximately 500,000 total individuals) participated. Interventions over 7 years included risk factor screening, use of mass media and adult education, and activities at worksites, schools, and restaurants. Goals of the program included cholesterol reduction, smoking cessation, blood pressure reduction, increased physical activity, and weight control. MHHP results showed dramatic weight gains (as measured by BMI) throughout the program in all communities, both before and after the educational activities were in place. The MHHP thus had no communitywide impact on obesity. Conclusions Community-based programs can indeed reach large numbers of adults and interest them in weight gain prevention programs. Short-term effects on weight are small but positive. However, the effectiveness of community-based programs in reducing the prevalence of obesity in whole communities has not yet been demonstrated. Additional research in this area is needed to examine better recruitment efforts that can attract the large numbers of participants required to demonstrate a communitywide effect. None of the community-based programs described here have demonstrated a true community effect. Additional studies of long-term effects are also needed. GENERAL DISCUSSION Dr. Eva Obarzanek, NHLBI Division of Epidemiology and Clinical Applications, asked whether environmental changes similar to those in schools for children have been implemented for adults. Dr. Jeffery suggested that such changes could be made via food labeling and marketing practices and that consumption of high-fat foods could be discouraged by adding an excise tax to foods based on their fat content and by regulating portion-size packaging. He argued that food manufacturers should not have unlimited marketing access to the public and that it is essential to educate the public so that people realize that the food supply is not entirely benign. In response to a question about any characteristics of parents or household environments that improved study outcomes, Dr. Epstein stated that, over the short term, there is a very high correlation between parent weight changes and child weight changes. However, over 5 to 10 years, parents generally go back to their original weight, even while the child maintains the weight change. After 10 years, there are no longer any treatment effects for parents. Modeling does not appear to be in effect because the child does not model the parent's weight gain. Promising areas for research are the influence of parental support on a young child's developing eating habits, the influence of roommate support for exercise on young adults, the influence and number of televisions in the household, and food-storing practices in the household. In response to a followup question concerning other parent or household characteristics affecting study outcomes (e.g., socioeconomic status and single parenthood), Dr. Epstein said that studies have not shown socioeconomic status to predict weight loss. Other characteristics that have an effect are the size of the family (children from large families do not do as well, particularly if older siblings are overweight) and the age of the child (older children ages 11 to 12 years do better than younger children ages 9 to 10 years). Dr. Elmer commented on the roles of physical activity and cultural norms in weight loss. In her studies, 25 percent of adults at baseline reported doing no leisure physical activity. Those able to increase their physical activity the most were already active. Those who maintained their weight, or who lost the most weight, maintained the most change in their leisure physical activity, and this maintenance was related to a valuing of and a preference for physical activity that had been established at an early age. Thus, how the cultural norms relating to physical activity can be influenced most effectively is an obvious concern in establishing any weight loss program. Dr. JoAnn Manson, Brigham and Women's Hospital and Harvard Medical School, noted that one of the limitations of worksite programs is that they do not reach unemployed women who are at greatest risk of weight gain. She asked whether any of the community-based programs had compared efficacy in preventing weight gain among women employed outside the home versus among women at home and, furthermore, whether there were any interventions targeting women at home. Dr. Jeffery replied that he knew of no interventions targeted to this group but that it is an area for future research. Dr. Elaine Stone, NHLBI, asked Dr. Epstein whether the issue of depression in children and parents had been studied. Dr. Epstein replied that the data are being reviewed and that the first 10-year followup showed a few children with psychological disorders, but that there was no untreated control group to use for comparison. However, the data that have been collected seem to show no greater prevalence of these conditions in obese children than in the general population. Dr. Stone commented on a school-based study conducted in North Carolina, in which a nurse-delivered American Heart Association program was implemented. The program first used the classroom curriculum approach and then a high-risk individualized approach for obese children. The nurse delivering the program dropped the high-risk approach, however, after noting that the children might be stigmatized because they were being separated out of the classroom. Dr. William Dietz, American Academy of Pediatrics, suggested that school lunch and television behaviors could be potentially valuable arenas for long-term interventions. Both overlap with other behaviors--school lunch with cholesterol and cancer prevention efforts, and television with prevention efforts aimed at alcohol consumption, violence, and aggression. Both are free of stigmatization because the focus is not on obesity. Dr. Dietz asked the panel whether they saw any indications that programs such as theirs have an adverse impact on those who were not successful. Dr. Epstein responded that the literature suggested that obese children develop internal problems (depression) versus external problems (aggression, violence, substance abuse); however, this literature is vague and confusing. His studies show that depression in obese children was linked to parental depression rather than to obesity. Dr. Sallis responded that he had not found any study that examined the psychosocial effects of school-based programs and that a few correlation studies showed a poorer self-image in obese children, but that depression or more serious symptoms were not seen. The issue of stigmatization was not addressed in the studies he had reviewed, but this could be due to the fact that some of these studies were conducted after school. William Fabrey, National Association To Advance Fat Acceptance, commented that treatment for children should not be stigmatizing and that sensitivity training is needed for individuals working with obese children. He added that payroll-based programs, as described by Dr. Jeffery, should be avoided because such programs may be a violation of human rights. Even if these programs are voluntary, too often participation is not really as voluntary as it may seem. Karen VanLandegham, National School Health Education Coalition, Inc., commented to Dr. Sallis that because school-based prevention programs should encompass kindergarten through 12th grade, be ongoing, and be incorporated into other health education programs, political issues were involved in efforts to implement the programs. Dr. Sallis acknowledged the limitations in school budgets and their effects on starting new programs and gave an example of a school system with this situation. Demonstration of the effectiveness of these programs remains critical due to the various constraints on their implementation. REFERENCES Abraham S, Collins G, Nordsieck M. Relationship of childhood weight status to morbidity in adults. Public Health Rep 1971;86:273-284. Abraham S, Nordsieck M. Relationship of excess weight in children and adults. Public Health Rep 1960;75:263-273. Bush PJ, Zuckerman AE, Theiss PK, Taggart VS, Horowitz C, Sheridan MJ, Walter HJ. Cardiovascular risk factor prevention in black schoolchildren: Two-year results of the "Know Your Body" program. Am J Epidemiol 1989;129:466-482. Charney E, Goodman HC, McBride M, Lyon B, Pratt R. Childhood antecedents of adult obesity. Do chubby infants become obese adults? N Engl J Med 1976;295:6-9. Dietz WH, Gortmaker SL. Do we fatten our children at the television set? Obesity and television viewing in children and adolescents. Pediatrics 1985;75:807-812. Dwyer T, Coonan WE, Leitch DR, Hetzel BS, Baghurst RA. An investigation of the effects of daily physical activity on the health of primary school students in South Australia. Int J Epidemiol 1983;12:308-313. Epstein LH, McKenzie SJ, Valoski A, Wing RR, Klein KR. Effects of mastery criteria and contingent reinforcement for habit change on child weight control. Behav Res Ther, submitted for publication (a). Epstein LH, Valoski A, Vara L, McCurley J, Wisniewski L, Kalarachian M, Klein KR, Shrager L. Comparative effects of decreasing sedentary behavior and increasing activity on weight change in obese children. Submitted for publication (b). Epstein LH, Valoski A, Wing RR, McCurley J. Ten-year follow-up of behavioral, family-based treatment for obese children. JAMA 1990;264:2519-2523. Epstein LH, Wing RR. Behavioral treatment of childhood obesity. Psychol Bull 1987;101:331-342. Epstein LH, Wing RR, Koeske R, Valoski A. A comparison of lifestyle exercise, aerobic exercise, and calisthenics on weight loss in obese children. Behav Ther 1985;16:345-356. Epstein LH, Wing RR, Koeske R, Valoski A. Effects of diet plus exercise on weight change in parents and children. J Consult Clin Psychol 1984;52:429-437. Epstein LH, Wing RR, Valoski A, Gooding W. Long-term effects of parent weight on child weight loss. Behav Ther 1987;18:219-226. Forster JL, Jeffery RW, Schmid TL, Kramer FM. Preventing weight gain in adults: A Pound of Prevention. Health Psychol 1988;7:515-525. Garn SM, Clark DC. Trends in fatness and the origins of obesity. Pediatrics 1976;57:443-456. Garn SM, LaVelle M. Two-decade follow-up of fatness in early childhood. Am J Dis Child 1985;139:181-185. Jeffery RW, Forster JL, French SA, Kelder SH, Lando HA, McGovern PG, Jacobs DR Jr, Baxter JE. The Healthy Worker Project: A worksite intervention for weight control and smoking cessation. Am J Public Health 1993;83:395-401. Jeffery RW, Hellerstedt WL, Schmid TL. Correspondence programs for smoking cessation and weight control: A comparison of two strategies in the Minnesota Heart Health Program. Health Psychol 1990;9:585-598. Killen JD, Telch MJ, Robinson TN, Maccoby N, Taylor CB, Farquhar JW. Cardiovascular disease risk reduction for tenth graders: A multiple-factor school-based approach. JAMA 1988;260:1728-1733. Leupker RV, Murray DM, Jacobs DR Jr, Mittelmark MB, Bracht N, Carlaw R, Crow R, Elmer P, Finnegan J, Folsom A, Grimm R, Hannan PJ, Jeffery RW, Lando H, McGovern P, Mullis R, Perry CL, Pechacek T, Pirie P, Sprafka JM, Weisbrod R, Blackburn H. Community education for cardiovascular disease prevention: Risk factor changes in the Minnesota Heart Health Program. Submitted for publication. Lionis C, Kafatos A, Vlachonikolis J, Vakaki M, Tzortzi M, Petraki A. The effects of a health education intervention program among Cretan adolescents. Prevent Med 1991;20:685-699. Parcel GS, Green LW, Bettes BA. School-based programs to prevent or reduce obesity. In: Krasnegor NA, Grave GD, Kretchmer N (eds.). Childhood Obesity: A Biobehavioral Perspective. Caldwell, NJ: Telford Press; 1988; pp. 143-157. Puska P, Vartiainen E, Pallonen U, Salonen JT, Poyhia P, Koskela K, McAlister A. The North Karelia youth project: Evaluation of two years of intervention on health behavior and CVD risk factors among 13- to 15-year old children. Prevent Med 1982;11:550-570. Stark O, Atkins E, Wolff OH, Douglas JWB. Longitudinal study of obesity in the National Survey of Health and Development. Br Med J 1981;283:13-17. Tell GS, Vellar OD. Noncommunicable disease risk factor intervention in Norwegian adolescents: The Oslo Youth Study. In: Hetzel B, Berenson GS (eds.). Cardiovascular Risk Factors in Childhood: Epidemiology and Prevention. New York: Elsevier; 1987; pp. 203-217. Walter HJ, Hofman A, Vaughan RD, Wynder EL. Modification of risk factors for coronary heart disease: Five-year results of a school-based intervention trial. N Engl J Med 1988;318:1093-1100. Ward DS, Bar-Or O. Role of the physician and physical education teacher in the treatment of obesity at school. Pediatrician 1986;13:44-51. PANEL 3: ISSUES IN EDUCATING THE PUBLIC ABOUT WEIGHT AND OBESITY The third panel examined issues in educating the public about weight and obesity. Dr. Cheryl Ritenbaugh, University of Arizona, chair of the panel, introduced the topic, emphasizing factors and issues that affect the needed emphasis on exercise. Dr. Pauline Powers, University of South Florida, discussed nutrition in adolescents. Dr. Bonnie Spring, Chicago Medical School and Veterans Affairs Medical Center, described the relationship of smoking and weight gain. Dr. Arthur S. Leon, University of Minnesota, explored the role of physical activity in the prevention and management of obesity. Dr. Jeffery Sobal, Cornell University, reviewed the sociocultural and demographic issues of obesity. The panel concluded with general discussion and comments by attendees. INTRODUCTION--Cheryl Ritenbaugh, Ph.D., M.P.H. Cultural factors influence knowledge, attitudes, and behavior regarding food consumption and activity patterns and thus influence body shape and fatness. One way to gain perspective on cultural influences is to examine our language. "Hunger" expresses our desire to eat; "supermarket" indicates a place where we can find items for food intake. But our language has no analogous word for our desire to exercise and a place where we can find whatever we need for exercise. For example, there are no words to complete the analogies "Hunger is to eating as ______ is to exercising," and "Supermarket is to food intake as ______ is to exercise." Our lack of language related to exercise, this cultural deficiency, has an effect on the first of four factors that affect obesity. o Exercise availability -- safety -- resources/location -- time o Food availability -- time for preparation -- knowledge -- income -- resources -- physical availability -- advertising and marketing of food o Knowledge and valuation of healthy lifestyles -- education -- experience -- socioeconomic status o Physiology -- energy balance -- adipose tissue Our culture currently places the greatest emphasis on the food intake side of the energy balance equation, with much more limited importance given to exercise. An evaluation of this cultural emphasis helps to make clear why no individual should be blamed when he or she has the knowledge to lose weight but does not act upon the knowledge. The cultural factors of language and what is emphasized must be considered in educating the public about weight and obesity. NUTRITION IN ADOLESCENCE: OBESITY AND THE HAZARDS OF TREATMENT--Pauline Powers, M.D. Adolescent eating behaviors are of great importance when considering educational messages to teenagers about body and weight. Adolescence is a time of growth; yet, paradoxically, widespread dieting occurs in this age group. Some data suggest that approximately 15 to 22 percent of adolescents are classified as obese (Laurier et al., 1992; Gortmacher et al., 1987), but 60 to 70 percent of teenage girls and 40 percent of teenage boys have dieted either to lose weight or to maintain weight (Hueneman et al., 1966; Dwyer et al., 1967; National Institutes of Health, 1992). Dissatisfaction with size and shape is very high among adolescent girls; Moore (1988) reported that 67 percent of adolescent girls and young women were dissatisfied with their weight. Moses et al. (1989) found that fear of obesity was common among girls irrespective of weight: 51 percent of the underweight adolescent girls they studied described themselves as extremely fearful of being overweight, and 36 percent were preoccupied with body fat. Weight consciousness occurs even in young children. Maloney et al. (1989) found that 45 percent of children in grades 3 to 6 want to be thinner. Obesity is defined as an excess of body fat, using a variety of standards. Most commonly, obesity has been defined using anthropometric measurements of height and weight. The common standards are the 1983 Metropolitan height-weight tables for adults or the results of the National Health Examination Survey (NHES) for children and adolescents. The Metropolitan height-weight tables list desirable weight ranges for height using three different frame sizes. Overweight has been defined as 10 percent above desirable weight and obesity defined as 20 percent above desirable weight. The NHES tables define the 50th percentile as the desirable weight, and obesity is defined as a certain percentage (typically 20 percent) above the desirable weight. Various body mass indices also have been used including the currently popular body mass index (BMI). The National Center for Heal