Confronting America's Childhood Obesity Epidemic

8/7/2019 Confronting America's Childhood Obesity Epidemic

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Confronting AmericasChildhood Obesity Epidemic

How the Health Care Reform Law Will HelpPrevent and Reduce Obesity

Ellen-Marie Whelan, Lesley Russell, and Sonia Sekhar May 2010


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Confronting AmericasChildhood Obesity EpidemicHow the Health Care Reform Law Will Help

Prevent and Reduce Obesity

Ellen-Marie Whelan, Lesley Russell, and Sonia Sekhar May 2010


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1 Fast Facts on Childhood Obesity

3 Introduction and summary

6 Provisions included in the Patient Protection and

Affordable Care Act that address childhood obesity

6 ChildhoodObesityDemonstrationProject

7 Nutritionlabeling

7 CommunityTransformationGrants

9 Broader measures in the Patient Protection and

Affordable Care Act to tackle childhood obesity

9 Preventionandpublichealth

15 Primarycareandcoordination

18 Community-basedCare

20 Maternalandchildhealth

22 Research:Doingwhatworksinobesityprevention

23 Dataprovisionsthatwillhelpwithtrackingandprovidingimproved

outcomestomeasureobesityprevention

25 What else is needed?

27 Beyond health care

29 Conclusion

30 Appendix: The White House Childhood Obesity Initiativ

32 Endnotes

34 About the authors

Contents


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1 Center for American Progress | Confronting Americas Childhood besity Epidemic

FastFactsonChildhoodObesity

Our nations children today are on track to have a lower

life expectancy than their parents

The obesity epidemic poses serious health problems for chil-

dren including cardiovascular disease, mental health problems,

bone and joint disorders, and diabetes.1 Consider that:

Children in some communities account for almost half of

new cases of type 2 diabetes [which had previously been

adult-onset].2

Hospitalizations of obese children and adolescents aged 2

to 19 nearly doubled between 1999 and 2005 for obesity-

related conditions such as asthma, diabetes, gallbladder

disease, pneumonia, skin infections, pregnancy complica-

tions, depression, and other mental disorders.3

Childhood obesity rates have more than tripled since 1980,

and current data show that almost one-third of children

over 2 years of age are already overweight or obese.4

Overall, unless eective action is taken now, this generation

of children could be the rst to have shorter, less healthy

lives than their parents.5

Rising rates of childhood obesity threaten the economic

and scal health of the nation

The growing number of obese children will soon join the

growing number of obese adults, imperiling the health of

millions of Americans but also adding new economic costsfrom the loss of labor productivity and increased health

care expenditures. Health economists estimate the indirect

costs of obesity are $4.3 billion a year for absenteeism and

$506 per obese worker per year for lower worker productiv-

ity.6 Within the health care system, studies nd that obesity

has likely accounted for up to $147 billion annually in direct

care costs in recent years.7 Consider that:

The estimated costs for hospitalizations due to obesity-

related conditions increased from $126 million in 2001 to al-

most $238 million in 2005, the last year for which complete

data are available.8

The cost to Medicaid for these hospitalizations more than

doubled from $53.6 million in 2001 to about $118 million

in 2005.9

Obese children also contribute to these health care costs.

Studies have found that obese children stay nearly a full

day (0.85 day) longer in the hospital and this has resulted

in $1,634 per patient in increased hospital charges.10

An increased emphasis on prevention and wellness is neces-sary to reduce the amount we spend on obesity-related

health services.

Children from racial and ethnic minority families and

low-income households are disproportionately over-

weight and obese

Obesity aicts children throughout the nation but certain

groups of Americans are disproportionately aected. Pov-

erty alone increases the likelihood of being overweight orobese, but other racial and ethnic factors also are important.

Consider that:


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Among families living below the federal poverty level, 44.8

percent of children are overweight or obese, while 22.8

percent of children living in families with incomes above

400 percent of poverty are overweight or obese.11 Recent data show that Hispanic and black high school chil-

dren have obesity rates of 16.6 percent and 18.3 percent,

respectively, which is signicantly higher than their white

counterparts (10.8 percent).12 The same disparities exist for

younger children.13

Children of racial and ethnic minorities are more likely to

live in low-income communities, which too often have

limited access to healthy food options, fewer parks, and

generally are less safe.

The environment exacerbates obesity, although sociocul-

tural factors likely also play a role.14

Our increased consumption of junk food is driving obesity

Increased overall food consumption and the decreasing

quality of foods are major factors that aect the prevalence

of childhood obesity. Both children and adults are eating

more foods that are high in fat and sugar, but low in overall

nutritional value.

15

Consider that:

In 2007, the average person consumed 400 more calories a

day than in 1985, and 600 calories more a day than in 1970.16

American adults and children consume, on average, one-

third of their calories from eating out.17

Children consume almost twice as many calories when

they eat a meal at a restaurant compared to a meal at

home. Not surprisingly, studies consistently link eating out

with obesity.18

The rising cost of healthy food options is also a contributing

factor to obesity. Consider that:

A recent Cornell University analysis shows that the ina-tion-adjusted price of fruits and vegetables rose 17 percent

between 1997 and 2003, while the price of a McDonalds

quarter-pounder and a Coca-Cola fell by 5.44 percent and

34.89 percent, respectively.19

Studies nd a strong relationship between the cost of fast

foods and the body mass index of children and adoles-

cents, especially in families of low- to middle-socioeco-

nomic status.20

Some combination of the eating out culture together with

the rising price of healthier foods is in part responsible for

the increasing rate of obesity.

The upshot

Successfully tackling childhood obesity will require a long-

term, large-scale commitment that combines individual

responsibility and action together with community-based

approaches. These eorts will take time to reverse a 30-year

obesity epidemic, but as we will demonstrate in this report,the results will accrue to the health and well-being of our

children, our society, and the scal health of our nation.


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Introductionandsummary

Obese American children and teenagers today are on track to have poor health through-

out their adult lives. Overall, this next generation o Americans could be the frst to have

shorter, less healthy lives than their parents.21 Childhood obesity rates have more than

tripled since 1980, and current data show that almost one-third o children over 2 years o

age are already overweight or obese.22

Obese children and adolescents are more likely to have risk actors associated with car-

diovascular disease and diabetes, be admied to the hospital, be diagnosed with a mental

health problem, and have bone and joint disorders than those who are not obese.23 Whats

worse or them and or our society, overweight adolescents are more likely to become

obese adults, with all the health problems that accompany obesity in adulthood.24 While

harming the health o millions o Americans, obesity is concurrently contributing greatly

to rising health care costsmore than a quarter o Americas health care costs estimated

to be related to obesity.25

Te undamental reason that children and adolescents become overweight and obese is

patently obviousan energy imbalance between the calories they consume and the calo-

ries they expend through activity. But the burgeoning number o overweight and obese

kids is aributable to a range o actors beyond this simple dietary dynamic. Te overarch-ing causes o this epidemic include a shi in diet toward the increased intake o energy-

dense oods that are high in at and sugars alongside a trend toward decreased physical

activity due to the spreading sedentary nature o many orms o play, changing modes o

transportation, and increasing urbanization, all o which promote a less active liestyle.26

But there are other actors, o course, that contribute to overweight or obese children

in our society encompassing biology and behavior, which are oen expressed within a

cultural, environmental, and social ramework.

As a consequence, obesity needs to be addressed as both a sociological and a physiological

issue, with the responsibility or tackling obesity extending well beyond health care to a

comprehensive societal approach. Te newly enacted comprehensive health reorm lawwill enable our nation to address the rapidly increasing childhood obesity and overweight

prevalence, which some project to double by 2030.27 Te new law, titled Te Patient

Protection and Aordable Care Act, or PPACA, contains a number o provisions to


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address childhood obesity in the context o health care and public health. Te purpose o

this paper is to describe areas within PPACA that have the potential to address childhood

obesity. Several o the more obvious provisions in the bill that tackle obesity are:

Improved nutrition labeling in ast ood restaurants, which will list calories and provide

inormation on other nutrients

Te Childhood Obesity Demonstration Project, which gives grants to community-based obesity intervention programs

Community ransormation Grants, which gives grants to community-based eorts to

prevent chronic diseases

Other parts o the new law take a more broader approach and have the potential to address

obesity because they are ocused on prevention and because in their implementation they

could make childhood obesity and its risk actors a ocus or kids, their parents, and their

caregivers. Tese provisions all into the ollowing general categories:

Prevention and public health programs that invest in broader, population-level obesity

intervention eorts Primary care and coordination eorts that emphasize prevention, a team-based

approach and paying or improved health Community-based care that target communities that are disproportionately obese

and overweight Maternal and child health that promote breasteeding and early-childhood nutrition Provisions ocusing on adult obesity that will likely impact the behavior o children Beer research and data collection to ensure we are doing what works to fght obesity

Each o these eorts can provide important routes to helping children who are overweight

or obese or at risk or being soeven when addressing childhood obesity is not theirspecifc purpose.

Te precise capabilities o these direct and indirect provisions in the new health care law

to address childhood obesity are circumscribed by the specifc authority and unding

provided or each o these provisions, and also by the ocus that is taken in their implemen-

tation. But taken together, the commitments made in the new law establish an important

oundation to beer tackle the epidemic o overweight and obese children and adolescents.

In the pages that ollow, we will examine some o these provisions to demonstrate how they

individually and then together can improve the health and well-being o the next genera-

tion o Americans while lowering the costs o health care signifcantly across our society.

O course, there are a number o areas beyond the new health care law that can play a

tremendous role in combating childhood obesity. Some o these areas pertain to ood

consumption and activities that take place during or right aer school, and others have

to do with the makeup o the broader community in which a child lives. Te quality o


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ood in schools, including school meals, vending machines, and a la carte snacks, has a

signifcant impact on childrens physical health, yet the nutritional value o most o these

available sources o ood or students is woeully inadequate. Reorms to ood in schools

were beyond the scope o the health care bill and thereore should be addressed in pend-

ing child nutrition reauthorization legislation now beore Congress.

Ten theres the activity side o the obesity equation. Requiring physical education duringschool and providing aer-school opportunities or physical activities are important steps

in regularizing such behavior in children. In a childs broader environment and commu-

nity, several eatures can lead to overweight and obese kids. Te saety and convenience o

parks and sidewalks can be tremendously inuential in making activities such as walking

to and rom school and playing aer school a routine.

Te availability o healthy ood outside o school hours also aects the rates o obesity and

the number o overweight kids in a community. Te absence o aordable, healthy ood

options oen leads to the purchase o cheaper oods o low-nutritional value, especially

in lower-income communities. Tese areas are knows as ood deserts, where malnutri-

tion and obesity go hand in hand due to the poor nutritional quality o available oods.

Lax regulations on the advertisement o unhealthy oods and drinks are problematic in

improving the eating habits o children and should be reviewed as we move orward.28

Tere are more dimensions to this problem than are noted here, but many o the above can

be inuenced by eective policies outside o health care.

President Obama calls childhood obesity one o the most urgent health issues that we ace

in this country. o help address this, First Lady Michelle Obama announced the nation

should eliminate the challenge o childhood obesity within a generation and launched

a nationwide campaignLets Move!to help achieve this. Te primary goal o the

campaign is to help children become more active and eat healthier so that children borntoday will reach adulthood at a healthy weight. Puing his words into action, and to kick o

Lets Move!, the president signed an Executive Order to create a Presidential ask Force on

Childhood Obesity.29 (For more inormation on the Presidential askorce on Obesity and

the Lets Move! Campaign, see the appendix on page 30.) Te taskorce is charged with

developing and submiing to the president an interagency plan that details a coordinated

strategy, identifes key benchmarks, and outlines an action plan by May 10, 2010.

Successully tackling obesity is a long-term, large-scale commitment that will require both

individual responsibility and action together with community-based approaches driven

by partnerships between government agencies and businesses, schools and public, private,

and nonproft aer-school acilities. Tese eorts will take time to reverse the long-stand-ing obesity epidemic, but as we will demonstrate in this report, the results will accrue to

the health and well-being o our children, our society, and the fscal health o our nation.

The availability o

healthy ood to

kids outside o t

school hours als

obviously afect

the rates o obe

and the numbe

overweight kids

a community.


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ProvisionsincludedinthePatientProtectionandAffordableCareActthataddresschildhoodobesity

Just having health insurance is an important actor in keeping people healthy, so provi-

sions in the new health reorm law that provide health insurance or 32 million Americans

will have a major impact on the health o our children and adolescents, and on our ability

to address the incidence o childhood obesity. Studies have shown that obese adults

and children with health care insurance are more likely to receive advice about eective

weight-loss interventions earlier than their nonobese counterparts (50 percent versus

32 percent or adults and 59 percent versus 41 percent or children).30

Te frst provisions o the new law we will discuss, take a rather obvious approach to com-

bating obesity. Tey are:

Te Childhood Obesity Demonstration Project Nutritional labeling laws Community ransormation Grants

Lets consider each o these provisions in turn.

ChildhoodObesityDemonstrationProject

One provision included in PPACA (Section 4306) appropriates $25 million in und-

ing or the Childhood Obesity Demonstration Project, which was established through

the Childrens Health Insurance Program Reauthorization Act o 2009 and adjusts the

demonstration time period to fscal years 2010 through 2014. Under this provision

o the law, the Secretary o the Department o Health and Human Services will award

grants to eligible entities to develop a comprehensive and systematic model or reducing

childhood obesity.

I this provision is similar to what is in CHIP, community-based entities that work

through schools, community health workers, and local health care delivery will likely beeligible to apply or Childhood Obesity Demonstration Project grants, and similar pro-

gram priorities, unding, and reporting guidelines will continue to apply.31


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I these demonstration projects are ound to be successul in reducing childhood obesity,

then legislative action will be required to expand and continue the grants. Some o the

programs expected to be unded through the Childhood Obesity Demonstration Project

may be similar to the School Nutrition Policy Initiative in Philadelphia that included

the ollowing components: nutrition education; nutrition policy; social marketing; and

parent outreach. Tat initiative ultimately demonstrated that a multicomponent school-

based intervention [could] be eective in curbing the development o overweight amongchildren in grades 4 through 6.32

Nutritionlabeling

Another provision in PPACA specifcally targeting obesity is the requirement o nutrition

labeling or menu items at chain restaurants. Te Food and Drug Administration now

requires nutrition labeling or most oods oered or sale in the United States, but restau-

rants were exempt rom these requirements until the passage o new health reorm law.33

Prior to the enactment o the law, however, 20 states and localities identifed the impor-

tance o knowing calorie counts and other nutrition acts or oods eaten in restaurants

and started to impose their own labeling requirements.34 Tis resulted in a patchwork o

menu labeling requirements across the country.

Te new law will require all chain restaurants with 20 or more locations to provide clear

labeling o the calorie counts o their standard menu items by March 2011 (Section

4205). By that date they must also display a succinct statement on the recommended

number o calories individuals should consume each day as well as provide wrien

nutrition inormation when requested, listing the calories, at, cholesterol, sodium,

carbohydrates, sugars, fber, and protein amounts. In addition to restaurants, similar

requirements will soon be in place or vending machines when the owner operates 20 ormore machines. Tey must display the number o calories in each vending machine ood

item in a way that prospective buyers can read the nutrition label on each item beore

purchasing the item.

Tis provision is important because American adults and children consume on average

one-third o their calories rom eating out, and children eat almost twice as many calories

when they eat a meal at a restaurant compared to a meal at home.35 Studies consistently

link eating out with obesity and higher caloric intakes.36 Studies also fnd, however, that

consumers who see calorie content prior to ordering their ood will choose meals with

ewer calories than those who do not see calorie inormation.37

CommunityTransformationGrants

Preventing obesity requires acknowledging that each community has its own unique

characteristics and needs, its own health-related concerns, eating preerences, and activ-

The new law

will require all

chain restauran

with 20 or more

locations to

provide clear

labeling o the

calorie counts

o their standard

menu items by

March 2011.


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ity paerns, as well as its own socioeconomic conditions, opportunities, and constraints

created by the built and natural environments. Community-based programs enable these

to be addressed and can be cost-eective.38 Such eorts could include something similar to

the Healthy Eating, Active Communities program unded by the Caliornia Endowment,

which engaged local government and private business to address childhood obesity by:

advocating or healthier oods and requiring physical activity in schools; working with

parks and recreation departments to promote aer-school activities; improving access tohealthy ood in communities and limiting promotion o unhealthy oods; providing sae

routes o travel to parks and schools in neighborhoods; and engaging health care providers

to emphasize prevention and promote healthy liestyles in their clinical practices.39

A new grant program was included in PPACA that recognizes the unique needs o di-

erent communities across our nation. Te new law authorizes unding or a program

o competitive Community ransormation Grants (Section 4201), which the HHS

secretary is to award to state and local governmental agencies and community-based

organizations or the implementation, evaluation, and dissemination o evidence-based

activities that promote individual and community health and prevent the incidence o

chronic disease. Tis would include programs to prevent and reduce the incidence o

chronic diseases associated with being overweight and obese, but also include programs

aimed at tobacco use, mental illness, or other activities that are consistent with the goals

o promoting healthy communities.

Grant recipients must develop a detailed plan that includes the policy, environmental,

programmatic, and, as appropriate, inrastructure changes needed to promote healthy liv-

ing and reduce disparities. Te grant recipients can use grant unds to implement a variety

o programs, policies, and inrastructure improvements to promote healthier liestyles.

Tese might include creating healthier school environments, worksite wellness programs

and incentives, and reducing racial and ethnic disparities in obesity. Te new law alsonotes that not less than 20 percent o these Community ransormation Grants must be

awarded to rural and rontier areas.

Given the potential these grants have to help develop a stronger evidence base o eective

preventive strategies, it is important that these grants are being implemented to make sure

there is sucient documentation on the outcomes and determine how to provide sustain-

ability and continuity or the successul grant programs.


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BroadermeasuresinthePatientProtectionandAffordableCareActtotacklechildhoodobesity

Te way the next set o provisions in PPACA address childhood obesity takes a broader

approach. Tey are, however, no less important in the eort to reduce the number o over-

weight and obese children and adolescents. In act, these programs combine with direct

antiobesity programs in the new law to create a comprehensive approach to this childhood

epidemic. Tese types o programs in the new law include:

Prevention and public health programs that invest in broader, population-level obesity

intervention eorts

Primary care and coordination eorts that emphasize prevention, a team-based

approach, and paying or improved health Community-based care that targets communities that are disproportionately obese

and overweight Maternal and child health programs that promote breasteeding and early-

childhood nutrition Provisions ocusing on adult obesity that will likely impact the behavior o children Beer research and data collection to ensure we are doing what works to fght obesity

Each o these eorts can provide important routes to helping children who are overweight

or obese or at risk or being so, even when addressing childhood obesity is not their spe-cifc purpose. Lets now consider each o them in turn.

Preventionandpublichealth

PPACA provides an increased ocus on prevention, health promotion, and public health

and invests signifcantly in these eorts. A sizeable proportion o this investment, how-

ever, must be made outside the health sector, in the social, economic, and environmental

abric o our society. Tats why it is so encouraging to see this approach adopted in health

care reorm legislation and through the newly established Presidential ask Force on

Childhood Obesity.40 Here are some o the provisions in the new law that promote preven-tion and beer public health.


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Provisionsthatdemonstrateanewcommitmenttopreventionandpublichealth

Te American Public Health Association states that preventing obesity in our children

is one o the most important public health issues acing the nation today.41 Rather

than change the individual behavior o one person at a time, the association argues that

population-level approaches can be used to translate public health research results into

science-based programs and policies that can change the toxic environments driving theobesity epidemic.

A revitalized public health strategy oers the most sustainable way to address current

health disparities and prevent chronic noncommunicable diseases, including specifcally

those or which being overweight or obese are risk actors. Te new health reorm law

does just that through the ollowing three provisions, which demonstrate an increased

commitment to prevention and public health.

Betteroverallfunding

Prevention and wellness initiatives tend to be grossly underunded in both clinical and

community seings. Childhood obesity is arguably inuenced more by broader public

health actors such as the availability o healthy oods and physical activity, so it is impera-

tive that in addressing this issue we make serious commitments to more robust prevention

and wellness unding outside the confnes o health institutions. PPACA starts to address

this problem by establishing a und that will allocate money to a variety o prevention and

wellness programs.

Te Prevention and Public Health Fund (Section 4002 o PPACA) makes a signifcant

investment in the nations provisions o prevention and public health. Tere is an appro-priation o $5 billion through 2014 and $2 billion or fscal year 2015. Te text o the legis-

lation indicates that the majority o this unding is allocated to specifc provisions outlined

below and that have to do with public health and prevention, as well as care delivery

Tese new investments are critical. Te 2009 edition o the rust or Americas Healths

report Shortchanging Americas Health: A State-By-State Look at How Public Health

Dollars Are Spentound that ederal spending or public health has been at or the

previous fve years, while states cut more than $392 million or public health programs

in 2009, leaving communities around the country struggling to deliver programs in this

area.42 Federal public health unding to states rom the CDC averaged out to only about

$19 per person in 2009, and the amount spent on preventing disease and improvinghealth in communities varied markedly rom state to state, rom about $13 in Virginia to

nearly $59 in Alaska.43 It will be imperative to ensure that the increased levels o invest-

ment in public health and prevention that are made in the health care reorm bill are

continued into the uture.

It is imperative t

we make seriou

commitments

to more robust

prevention and

wellness undin

outside the

connes o heal

institutions.


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Coordinationofprevention,healthpromotion,andpublichealthactivities

Tere is limited cross-governmental coordination today o prevention, health promotion,

and public health, which in turn means that the limited resources may be used ineec-

tively. Te new reorm law establishes several bodies that eature some o the coordination

needed to promote preventive health care, the promotion o healthy living, and public

health activities needed to make all this happen.

Te new law establishes a National Prevention, Health Promotion and Public Health

Council (Section 4001) chaired by the surgeon general and comprised o department

and agency heads rom across the ederal government. Te aim o the council is to

provide coordination and leadership at the ederal level on a national prevention, health

promotion, public health, and integrative health care strategy that incorporates the most

eective and achievable means o improving the health status o Americans and reducing

the incidence o preventable illness and disability. Te law makes particular reerence to

beer understanding how we as a nation need to reduce sedentary behavior and improve

nutrition. PPACA also establishes an Advisory Group on Prevention, Health Promotion,

and Integrative and Public Health, whose members, including health proessionals, are

appointed by the president.

Te council is required to submit annual reports to the president and relevant congres-

sional commiees describing council activities and national progress in meeting the

established priorities and goals. Te legislation specifes that these are to include specifc

initiatives to achieve the measurable goals o Healthy People 2010the nations targets

or health promotion and disease prevention measuresregarding nutrition and exercise,

thus ensuring that obesity must be a key ocus o the work o the council.

Another provision in PPACA (Section 4003) replaces the current U.S. Preventive Servicesask Force with two new taskorcesthe Preventive Services ask Force, and the other

the new Community Preventive Services ask Force. Tese two task orces will be com-

prised respectively o either clinical experts in primary care and prevention or community-

based public health experts who will be charged with reviewing the scientifc evidence

related to the eectiveness, appropriateness, and cost-eectiveness o clinical preven-

tive services and community preventive interventions, respectively, or the purpose o

developing recommendations or the relevant communities and policymakers. Both task

orces will be required to coordinate their activities with the other and with the Advisory

Commiee on Immunization Practices, which is administered by the CDC.

Tese coordinating groups are an important step in tackling issues such as obesity, andwill enable the development o eective cross-agency responses to this problem. Te

requirement or the establishment o priorities or work in prevention, health promo-


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tion, and public health will inevitably mean that childhood obesity will be targeted.

Tere will likely be some overlap between the work o these bodies and that o the

Presidential ask Force on Childhood Obesity, which will provide another opportunity

or coordination o the issues o childhood obesity.

Publichealthworkforce

ackling obesity is best done through a ocus on prevention and wellness at the commu-

nity level rather than treating patients once they are already overweight. Tat means the

public health workorce, such as city health commissioners and community health work-

ers, will play an important role in organizing and delivering these preventive strategies.

PPACA takes several steps to strengthen the public health workorce through recruitment

and training, as well as providing incentives to encourage public health proessionals to

work in high-need areas.

Te public health workorce recruitment and retention program in the new law (Section

5204) will address workorce shortages by oering loan repayment to public health

students and workers in exchange or working at least three years at a ederal, state, local,

or tribal public health agency. PPACA appropriates $195 million or fscal year 2010, and

unding as necessary or each o fscal years 2011 through 2015. With only fve years o

unding, this is an area that will need to be revisited to see what the continuing needs are.

Te new law (Section 5315) also directsthe surgeon general to establish a U.S. Public

Health Sciences track to train physicians, dentists, nurses, physician assistants, mental and

behavioral health specialists, and public health proessionals, emphasizing team-based

service in the administration o public health in epidemiology, and in emergency prepared-

ness and response. Students will receive tuition remission and a stipend and are acceptedas Commissioned Corps ocers in the U.S. Public Health Service with a two-year service

commitment or each year o school covered. Te Commissioned Corps is a team o highly

trained public health proessionalsincluding physicians, nurses, dietitians, and scientists,

among othersthat ocus on public health promotion, disease prevention, and advancing

public health science.

o derive maximum beneft rom these provisions there is a need or accompanying devel-

opment eorts around essential competencies or the public health practice, including

credentialing workers and accrediting agencies. Specialized competencies or the public

health workorce have been developed but national credentialing has only started.44

Wellnessprovisionsthatimpactfamilies

Te promotion o wellness and prevention works best when entire amilies and commu-

nities are engaged. While certain provisions in PPACA do not directly relate to child-

We are learning

tackling obesity

being overweig

best done throu

ocus on preven

and wellness at

community leve

rather than treat

patients oncethey are already

overweight.


16/38


hood obesity, they tackle obesity at a broader level. Programs that look to reduce adult

diabetes, or example, will target amilies at high risk or obesityindirectly inuencing

their children as the behaviors o parents, grandparents, and guardians are changed.

Behaviors related to diet and physical activity are established early in lie and modeled by

amily members.

Workplacewellness

Voluntary wellness programs implemented by employers and health insurance companies

have been shown to deliver positive outcomes and beneft both individuals and employer

group health insurance plans.45 But these programs are relatively new and there is limited

research on their overall long-term eectiveness in improving health outcomes. Such

programs oen oer individuals a specifc rewardcash incentives, rebates, discounts,

or modifed co-paymentsi they participate in the program and meet certain health

targets or standards.

Tere is language in PPACA that requires the CDC to study and evaluate employer-

based wellness practices and provide an educational campaign and technical assistance

to promote the benefts o worksite health promotion to employers (Section 4303).

Because these programs are so new, there are unds available in the new law or the

CDC to provide employers with technical assistance to help evaluate these programs.

By March o 2012 the CDC will conduct a national worksite survey to assess employer-

based health policies and programs, ollowed by a report to Congress that includes

recommendations or the implementation o eective employer-based health policies

and programs.

Te law also sets aside $200 million specifcally or small businesses (less than 100 employ-ees) who want to start such programs but are less like to have the resources. In addition,

Section 1201 o PPACA permits employers to vary insurance premiums by up to 30

percent or employee participation in certain health promotion and disease prevention

programs or or meeting certain health standards.

Tese programs are somewhat controversial because o concern that they will penalize

those who are not able to improve their health to meet certain standards due to medi-

cal conditions or fnancial constraints. Tereore, implementation o these provisions

needs to be done careully. Regulations, or example, should consider how to include

individuals who would like to participate but who are unable to meet the designated

health targets because o a specifc medical condition that makes it dicult or medicallyinadvisable to participate. However, when properly structured, wellness programs can

meet these objectives.


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Individualizedwellness

PPACA provides or a demonstration project o an individualized wellness plan at neigh-

borhood primary care health centers (Section 4206). Te new law authorizes unding as

necessary or a pilot program involving up to 10 community health centers to test the impact

o providing at-risk Americans, both children and adults who utilize such centers, with an

individualized wellness plan that is designed to reduce risk actors or preventable condi-tions. Te plan may include elements such as nutritional counseling, stress management, or

alcohol and smoking cessation counseling and services. Te risk actors must include weight,

tobacco and alcohol use, exercise rates, nutritional status, and blood pressure.

Tere is currently lile available evidence about the eectiveness o wellness plans in the

community seing and how these are best implemented, but it is likely that successul

programs will be very similar to those operating successully in the workplace, such as

the Cleveland Clinic Wellness Institute, which oers their employees wellness programs

that promote healthy living and has taken steps to make their acilities amenable to this

goal.46 Te advantage this program will have is that the individual wellness plans can be

devised to ensure that they are integrated with the medical care o the participants at the

same location. As noted above, instilling healthy behaviors in parents is an eective way to

pass good habits to their children, which is why such eorts have the potential to reduce

childhood obesity.

Educationandoutreachcampaign

In concert with the increase in community-based eorts to address obesity, there needs

to be increased public awareness around these issues. In act, the success o these new

initiatives will depend upon increased public awareness. Section 4004 o PPACA directsthe HHS secretary to convene a national public-private partnership or the purposes o

conducting a national prevention and health promotion outreach and education campaign.

Te goal o the campaign is to raise awareness o activities to promote health and prevent

disease across the lie spans o all Americans.

By no later than March 2011, the HHS secretary is to conduct a national media campaign

on health promotion and disease prevention that will ocus on nutrition, physical activ-

ity, and smoking cessation, using evidence-based social research. Te secretary will also

maintain an Internet site to provide evidence-based guidelines to health care providers

and consumers or nutrition, regular exercise, obesity reduction, smoking cessation, and

specifc chronic disease prevention, as well as a personalized prevention plan tool toenable individuals to determine their disease risks and obtain tailored guidance on health

promotion and disease prevention.

The HHS secreta

will conduct a

national media

campaign on he

promotion and

disease prevent

that will ocus o

nutrition, physic

activity, and

smoking cessati


18/38


In addition, the HHS secretary will provide guidance and relevant inormation to states

and public and private health care providers regarding preventive and obesity-related

services that are available to Medicaid enrollees, including obesity screening and counsel-

ing or children and adults. Each state would be required to design a public awareness cam-

paign to educate Medicaid enrollees regarding availability and coverage o such services.

Primarycareandcoordination

Te most important provisions to decrease U.S. rates o obesity will likelynotoccur within

the health care delivery system. Tat said, since everyone has (or should have) some sort

o relationship with a health care provider, not maximizing the ability to address obesity

and liestyle issues in the context o these health visits would be a huge missed opportu-

nity to improve childrens health and reduce health care costs.

One signifcant reason or making sure the health care delivery system maximizes its

opportunity to address obesity is because o the ultimate eect obesity has on health

care expenditures. Hospitalizations o obese children and adolescents aged 2 to 19 nearly

doubled between 1999 and 2005 or obesity-related conditions such as asthma, diabetes,

gallbladder disease, pneumonia, skin inections, pregnancy complications, depression, and

other mental disorders. Te estimated costs or these hospitalizations increased to almost

$238 million in 2005, the last year or which complete data is available, rom almost $126

million in 2001. Te cost to Medicaid or treating these diseases rose to $118 million rom

$53.6 million over the same period. 47

One o the biggest changes that will occur as a result o the passage o health care reorm

is an increased emphasis on basic primary care, preventive care services, and coordina-

tion o care. Because o proposed health care payment changes, there is optimism that thedelivery o health care will move away rom a collection o reimbursable services to a more

coordinated, comprehensive delivery o services with a ocus on improved overall health.

Tis change in the way health care is delivered will create an environment that will

encourage health care providers to address obesity. Beer coordinating care provided in

individual health care oces or between providers will help reinorce weight-loss strate-

gies. By paying or care dierently through a uller array o coordinated services, health

care practices will be able to deliver a dierent set o services and could expand their

practice to include a uller array o providers, such as community health visitors, dieti-

cians, and nutritionists.48

Beyond just providing insurance, and thereore expanding access to the health care system

or millions o Americans, there are additional ways to optimize everyones experience

with the health care delivery system to address the nations obesity challenge. Within

PPACA these include:


19/38


Elimination o co-pays and deductibles or preventive services that help to address

obesity within the current ee-or-service system (Section 1001)

Paying or new innovative, more comprehensive programs that address obesity within

the current health care delivery system (Section 4108)

Changing the way health care services are unded more broadly to recognize the timeinvolved in working with patients on behavioral change issues thereore encouraging

multidisciplinary and team-based approaches and outcome-based care (Sections 3021,

2702, 2703, 10333, and 3502).

All o these provisions o the new law will provide a key oundation to the ability to

prevent obesity in children and young adults.

Coverageofspecificpreventiveservices

It is evident rom the voluminous inormation on the impact o obesity on health that

good quality health care or children must include comprehensive assessment o obesity

risk and ongoing management o these risks throughout childhood and adolescence.

An important and oen overlooked provision in PPACA (Section 1001) requires that

all health insurance plans cover, without any cost-sharing requirements, a broad range

o preventive health services.49 Tis provision means there will be no co-payments or

deductibles when clinicians screen children aged 6 years and older or obesity and oer

them or reer them to comprehensive, intensive behavioral interventions to promote

improvement in weight status.

Continuous assessment by a health care provider or obesity risk, along with comprehen-

sive preventive interventions, are already Medicaid coverage requirements or all children

and youth up to age 21. W hat is needed is a strategic plan or translating these guidelines

into real service delivery action at the community level.50 Section 4004 o PPACA, the

acts Education and Outreach Campaign (described in an earlier section), will assist in

this goal by requiring the HHS secretary to provide guidance and relevant inormation to

states and private health care providers regarding preventive and obesity-related services

that are available to Medicaid enrollees, including obesity screening and counseling or

children. Each state is then required to design a public awareness campaign to educate

Medicaid enrollees regarding availability and coverage o such services.

Incentivesforcomprehensiveprogramstopreventchronicdiseases

Another provision in PPACA (Section 4108) encourages the provision o a larger, more

comprehensive package o services meant to be delivered as a set. Tese new projects

An important an

oten overlooke

provision o the

law requires tha

all health insura

plans cover, wit

any cost-sharing

requirements, a

broad range o

preventive healt

services.


20/38


are aimed at helping to prevent chronic diseasesmany o which are a direct or indirect

result o obesity. PPACA directs the HHS secretary to create a grant program or states

to start or continue programs that have demonstrated success in helping individuals lead

healthier liestyles, including losing weight and managing diabetes within the Medicaid

program. Tese projects must be comprehensive, evidence-based, meet healthy behaviors

targets, and continue or at least three years. Te new law appropriates $100 million in

unds or this program and it is expected that grants will be awarded beginning January 1,2011, or earlier i the program criteria have been developed.

As previously noted, obese children are more likely to be hospitalized with chronic ill-

nesses such as asthma, bone and joint disorders, and mental health disorders. And these

children grow into obese adults who suer rom increased rates o cardiovascular disease,

diabetes, some cancers, and musculoskeletal problems. Tese chronic diseases are the

most common, costly, and preventable o all health problems. In the United States about

83 percent o Medicaid spending is or people with chronic conditions.51 Initiatives to

tackle childhood obesity thereore have great potential to save money or Medicaid.

Payingdifferentlyforoverallprovisionofcare

Possibly the most important change that can be made within the health care system to

encourage an improved ocus and delivery o services to prevent and treat obesity is mov-

ing away rom paying or individual services and toward paying more or improved patient

outcomes. Tis also means recognizing the importance o team-based care and exibil-

ity in service delivery. In many instances its not the physician who should be or is best

equipped to provide obesity counseling and other services. Rather, it is may be a nurse,

dietitian, or even a properly trained community health worker.

PPACA makes some important changes in how health services are paid or which will

change the way care is delivered. Te goal o these payment changes will be to pay or

improved outcomes and or beer coordinated careinstead o a series o isolated

individual services. Te frst and maybe the most important provision in the new law that

accomplishes this is the creation o a new Center or Medicare and Medicaid Innovation

within the Center or Medicare and Medicaid Services (Section 3021). Tis center will

drive many o these new initiatives. Tis will include a demonstration project within

Medicaid (Section 2705) that will begin paying health care providers using a global capi-

tated payment structure instead o the traditional ee or service. Global capitation means

that networks o hospitals and physicians come together to receive single fxed monthly

payments or all patients and then divide the payment between themselves. Tis way theycan decide which services to deliver and who should provide them. For instance, they may

use more community health workers to go into neighborhoods to work with patients to

help them lose weight and help prevent diabetes.


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Tere is also a provision (Section 2703) that allows state Medicaid programs to pay

more or providers who agree to coordinate primary care services under a health home.

Health homes would be composed o a team o health proessionals who would provide a

comprehensive set o medical services, including care coordination.

Tere are other provisions that include a broader array o providers. Under Section 10333,

grants will be available or providers who come together to create Community-basedCollaborative Care Networks. Tis provision specifes that community health centers

and hospitals that provide care to large numbers o uninsured (so-called disproportional

share hospitals) should be part o these consortia to provide comprehensive coordinated

and integrated care to low-income populations.

And lastly, there is a provision that moves beyond Medicaid to include all health care

providers in such comprehensive community care coordination. In Section 3502 money

is allocated to establish community health teams to support the patient-centered medi-

cal home, which is similar to the health home described above. Tis provision would

provide an additional ee to providers who agree to coordinate and manage their patients

care. Tis would include the coordination o the appropriate use o complementary and

alternative services to those who request such services and 24-hour care management and

support during transitions in care seings.

By paying dierently or care it is expected that care will be delivered dierently. Giving

providers incentives to improve outcomes will encourage them to deliver care that

includes discussions about nutrition and eective weight-loss strategieswhich are not

currently reimbursed. Tis change in the incentive structure will encourage providers to

spend more time with all their patients, including children at risk or obesity.

Community-basedCare

Te new health reorm law recognizes that just extending health insurance coverage to all

Americans will not be sucient to ensure access to needed services, especially in those

areas that are medically underserved. Tats why PPACA makes signifcant investments in

community health centers and other acilities or the delivery o community-based care.

Te importance o these acilities in the fght to tackle childhood obesity is central as they

have the ability to reach out to low-income and minority amilies and other groups that

are disproportionately obese and overweight.52

A study published in 2005 that used 2001 data showed that children who use communityhealth centers are at a particularly high risk o being obese.53 Tis association between obe-

sity and the type o health delivery system used was present regardless o race, ethnicity, or

geographic characteristics. In part this may be because the medically underserved areas

where community health centers are located oen have limited access to healthy oods

Giving providers

incentives to

improve outcom

will encourage

them to deliver

better care.


22/38


and to opportunities or physical activity. Te authors o this study concluded that these

centers may oer opportune sites or pediatric obesity prevention because they are expe-

rienced in prevention and serve more than 4.7 million children.54 Here are some examples

o how the new law will create and und community-based care.

School-basedhealthcenters

Schools are a natural place to identiy health problems and oer solutions. Children spend

six to eight hours a day at school, making it a logical and convenient access point or obe-

sity prevention. Our nations established network o state and local primary and secondary

schools makes school-based intervention eorts one o the most cost-eective methods o

preventing childhood obesity.55 School-based programs eliminate transportation barri-

ers aced by other obesity prevention programs and provide health care in a seing that

students and amilies know and trust. Te strong connection with amilies is especially

important or interventions that target elementary school-aged children, as young chil-

dren have very lile control over their ood choices and physical activity options indepen-

dent o their parents decisions.

PPACA provides or the establishment and operation o school-based health centers

(Section 4101) to provide comprehensive primary health services, including reerrals

to, and ollow-up or, specialty care services. Te law appropriates $50 million or fscal

years 2010 to 2013 or grants or acilities, including construction and improvements,

and equipment. Tese unds may not be used or expenditures or personnel or to

provide health services. Since the unding stream or personnel and health services is

not guaranteed, urther action is necessary to ensure that the promise o school-based

clinics is realized.

Nurse-managedhealthclinics

Nurse-managed health clinics serve as crucial health care access points especially in areas

where there is high demand or primary care. Tese health centers are led by advanced

practice nurses, primarily nurse practitioners. Tey provide primary care, health promo-

tion, and disease prevention services to patients who are least likely to receive ongoing

health care services, including those who are uninsured, underinsured, living in poverty, or

members o racial and ethnic minority groups.

PPACA also strengthens the health care saety net by creating a $50 million grant programto support nurse-managed health clinics (Section 5208). Both the school-based and

nurse-managed clinics have the potential to address individuals particularly at-risk since

they are in neighborhood seings. Although they have this potential, they should also be

integrated within the larger primary care delivery system to avoid urther ragmented care.


23/38


Communityhealthworkforce

Community health workers are lay members o communities who work either or pay

or as volunteers in association with the local health care system in both urban and rural

environments. Tese workers usually share ethnicity, language, socioeconomic status, and

lie experiences with the community members they serve. Tey can oer interpretation

and translation services, provide culturally appropriate health education and inormation,assist people in accessing the care they need, give inormal counseling and guidance on

health behaviors, and advocate or individual and community health needs.

Te community health workorce is strengthened by PPACA (Section 5313) which

authorizes the HHS secretary to award grants to states, public health departments,

clinics, hospitals, ederally qualifed health centers, and other nonprofts to promote

positive health behaviors and outcomes in medically underserved areas through the use

o community health workers. Te law also clarifes the defnition and activities o com-

munity health workers.

Assuming that sucient unds are appropriated or these workers and their programs, this

oers a potentially very eective means o medically educating racial and ethnic minori-

ties in a culturally and linguistically appropriate way about childhood obesity, good nutri-

tion, and the advantages o breasteeding. Te use o peer counseling has consistently been

shown to help women decide to start and continue to breasteed their inants. 56

Maternalandchildhealth

Te link between breasteeding and combating obesity is now recognized by key govern-

ment agencies and proessional groups, including the CDC and the American Academy oPediatrics. A recent meta-analysis, which included 61 studies and nearly 300,000 partici-

pants, showed that breasteeding consistently reduced risks or overweight and obesity.57

Te greatest protection is seen when breasteeding is exclusive (no ormula or solid oods)

and continues or more than three months.58 Experts at the CDC estimate that 15 percent

to 20 percent o obesity could be prevented through breasteeding.59 Te World Health

Organization armedthat the long-term benefts o breasteeding include reducedrisks o

obesity and consequent type 2 diabetes, aswell as lower blood pressures and total choles-

terol levels inadulthood.60

Tats why it is important that provisions in PPACA to improve maternal and child health

do not miss any o the opportunities provided to address issues such as breasteeding andnutrition. Improved rates o breasteeding will reduce childhood obesity and could save

the nation billions o dollars. A recent study ound that i 90 percent o new mothers ol-

lowed guidelines or six months o exclusive breasteeding or their children, an estimated

911 deaths would be prevented annually and it would save the nation at least $13 billion

each year, including $592 million due to childhood obesity.61

Improved rates

breasteeding w

reduce childhoo

obesity and cou

save the nation

billions o dollar


24/38


Tere are three programs in PPACA where this emphasis on breasteeding is highlighted.

Te frst promotes breasteeding directly: Section 4207 o the new law mandates that

employers with more than 50 employees must provide break time and a place or breast-

eeding mothers to express milk. Tis is especially important or low-income women who

are more likely to have to return to work soon aer the birth o their child.

wo other provisions are ocused on supporting new mothers and provide opportunities tohighlight the importance o breasteeding and other benefcial liestyle habits that develop

early in lie. Te Home Visitation Program, in Section 2951 o the new law, requires states,

as a condition o receiving maternal and child health block grant unds to conduct a needs

assessment to identiy communities that are at risk or poor maternal and child health and

to submit a report describing how the state intends to address the identifed needs. Early

childhood home visitation programs typically seek to improve maternal and child health

through the delivery o services in the home. Tese services can address early childhood

physical, social, emotional, and cognitive development and amily-parent unctioning.

Home visits are generally provided by specially trained nurses. Although there are a

number o successul programs unctioning all over the country, there are many pockets

o the nation without such programs. o help address this disparity, PPACA appropriates

$1.5 billion or FY 2010 through FY 2014 or grants to states, Indian tribes and, in limited

circumstances, nonproft organizations to support the creation o new early childhood

home visitation programs in areas lacking these programs. Part o these monies will be set

aside or research and evaluation. Tis evaluation should include measures that help to

track behaviors (including breasteeding) that will help to prevent the onset o obesity.

Te Pregnancy Assistance Fund (Sections 10211-10214) creates a new competitive grant

program to states to help pregnant and parenting teens and women. Tis program also has

the potential, through appropriate implementation, to instill good liestyle and nutritionpractices into the lives o new mothers. Funds will be made are available to: institutions o

higher education, high schools, and community service centers and other state and local

agencies that work with adolescents and public awareness.

Although there is no mention o obesity prevention in the description o these grants, it

would again be a missed opportunity i early childhood interventions to prevent obesity

were not included in the implementation o this program.

Research:Doingwhatworksinobesityprevention

Most o the provisions included in PPACA and outlined in this paper are areas where the

health care system has the opportunity to provide service to prevent and occasionally

treat the obesity epidemic. One o the major limitations is knowing what works to prevent

at-risk youth rom becoming obese andeven more dicultdoing what works to help


25/38


obese children get down to healthier weights. Despite years o investigation and a signif-

cant investment o resources, we still cannot provide a clear pathway or obese individuals

to lose weight and keep it o.

Tis presents two opportunities or policymakers who are now beginning to implement

the provisions o the new health care law. First o all, what we do know works should be

maximized. Pediatricians have a responsibility to provide counseling to parents at every wellchild visit on items that have demonstrated to help prevent obesity. Te American Academy

o Pediatrics Commiee on Obesity Evaluation and reatment has issued a series o recom-

mendations related to preventive health services or at-risk children.62 Tese recommenda-

tions are based on clinical consensus regarding health care or children and adolescents. Te

recommended responsibilities o the pediatric provider include:

Early recognitions and routine assessments o childrens growth and body weight Early and strong support o breasteeding Encourage parents to promote healthy eating paerns Routine the promotion o physical activity

Simultaneous discouragement o television and video time

But as much as we know about what works, there is even more that we do not. Te research

on what type and how much exercise children need, or example, is ever changing.63

As mentioned above, Section 4003 o PPACA provides statutory guidance or the creation

and role o the existing Preventive Services ask Force. Tis task orce will review the

scientifc evidence related to the eectiveness, appropriateness, and cost-eectiveness

o clinical preventive services or the purpose o developing and updating recommenda-

tions or the health care community to be published in the Guide to Clinical Preventive

Services. Obesity prevention should be one o the frst areas to gather the scientifc evi-dence and broadly promote those fndings to the public and health proessionals.

Another provision in PPACA (Section 4301) directs the HHS secretary to provide und-

ing or research that optimizes the delivery o public health services. Tis will provide

unding or research that:

Examines evidence-based practices relating to prevention Analyzes the translation o interventions rom academic to real world seings Identifes eective strategies or organizing Finances or delivers public health services in real work community seings, including

comparing state and local health department structures and systems in terms o eec-tiveness and cost

Lastly, one area o great promise or learning more about the prevention and treatment

o obesity is comparative eectiveness research, known as Patient-Centered Outcomes


26/38


Research (Section 6301) o PPACA. Te new law mandates a new Patient-Centered

Outcomes Research Institute as a private, nonproft corporation to assist patients, clini-

cians, purchasers, and policymakers in making inormed health decisions by advancing the

quality and relevance o clinical evidence through research and evidence synthesis. Te

research will compare the health outcomes and clinical eectiveness, risks, and benefts o

two or more medical treatments, services, or items.

Dataprovisionsthatwillhelpwithtrackingandprovidingimprovedoutcomestomeasureobesityprevention

Keeping the American people and the health research community inormed on the

progress o eorts to tackle the obesity epidemic plays an important role in ensuring

that policies are both eective and appropriately targeted so that individuals understand

the impact o their actions. Te tracking and monitoring o a childs physical health, or

example, keeps parents inormed on the health o their children and gives researchers,

policymakers, and lawmakers data to guide their endeavors.

A number o provisions in the new health reorm law create opportunities or improving

the way data on obesity and its consequences are collected and evaluated. Tere are also

numerous requirements or reporting on this. Provisions in PPACA include:

A requirement that group health plans report their wellness and health promotion activi-

ties (Section 2717) Te identifcation o key national indicators o health and which data is most appropri-

ate measure o each indicator (Section 5601) Improved data collection in public programs in order to analyze health disparities

(Section 4302).

On the basis o HHS insurer reporting requirements, the HHS secretary is required to

determine whether reimbursement is an eective tool to encourage providers to promote

prevention and wellness in their patients. I reimbursement is ound to be an eective

vehicle or wellness and health promotion, then Section 2717 o the new law would

require the HHS secretary o to devise a reimbursement structure.

Determining how best to measure key national indicators, such as obesity and being

overweight, is important in developing methods to tackle those issues. Section 3012 o

PPACA establishes a commission to determine the appropriate measures or key national

indicators o health and to report these to the Congress annually. Te assumption here isthat the tracking o such indicators will inorm legislators on how to address the underly-

ing issues in a more targeted manner. Childhood obesity will likely be included as a key

national indicator since its prevalence has tripled in the last 30 years and aracted national

aention, so this provision promises greater legislative aention and, hopeully, more

action toward addressing this issue.


27/38


Te new law also has a provision (Section 4302) designed to create a beer understanding

o health disparities by instituting data collection requirements rom health care providers

participating in Medicaid and the Childrens Health Insurance Program that will mirror

those already required by Medicare. Tese data will be crucial in assessing the delivery and

eectiveness o preventive services to lower-income populations, who are also dispropor-

tionately obese and overweight.

In addition, the new law directs the HHS secretary, in collaboration with the CDC, to

prepare a biennial national report card on diabetes, and to the extent possible, or each

state (Section 10407). Each report card shall include trend analysis o aggregate health

outcomes related to individuals diagnosed with diabetes and pre-diabetes including:

Preventative care practices and quality o care Risk actors Outcomes or use by doctors and patients

Tese can then be used to track progress in meeting national goals or diabetes and inorm-

ing policy and program development.

Developing relevant data measures, methods to collect those data, and reporting back to

the public and Congress are vital to developing strategies to address our nations obesity

epidemic. Provisions in PPACA are crucial steps in increasing awareness o how our

delivery system can inuence the obesity and overweight epidemic among our children and

adolescents, and what actors (health care or otherwise) perpetuate this epidemic in certain

communities or demographic groups. Most importantly, the new law establishes a structure

through which Congress will get the evidence it needs to write and und targeted legislation.

Determining ho

best to measure

key national

indicators, such

as obesity and

being overweig

is important

in developing

methods to tack

those issues.


28/38


Whatelseisneeded?

While there is always more that can be done, realistically it can be argued that the provi-

sions in PPACA, in combination with current programs and authorities can, i properly

unded and aggressively implemented, utilize the resources o the health care and public

health systems to make a real impact on current rates o childhood obesity. But there were

several additional provisions in H.R. 3962, the House-passed health care reorm bill, that

were missing rom the fnal law that would have helped in the eort to address childhood

obesity. Tese include:

Research and demonstration projects on the use o fnancial and in-kind subsidies and

rewards to encourage individuals and communities to promote wellness, adopt healthy

behaviors, and use evidence-based preventive health services, with obesity highlighted

as a priority

Authority or the HHS secretary to spend $10 million a year on grants and contracts or

planning and implementing community-based programs or the prevention o obesity

among children and their amilies through improved nutrition and increased physical

activity, with preerence given to entities that will serve communities with high levels

o obesity or those that will plan or implement activities or the prevention o obesity in

school or workplace seings

Other issues that could have been considered and might be addressed in uture legisla-

tion include:

Te establishment o a clearinghouse to ensure that inormation about successul pro-

grams at the national, state, and local level and relevant data are added to the evidence

base and are readily available.

Recognition o the link between eating disorders such as bulimia and obesity. While

only 1 percent to 3 percent o the general population is aected by binge eating disorder,

a much higher prevalence, 25 percent or more, has been reported by patients who areobese or seeking help or weight loss.

Recognition o exercise and physical activity as an appropriate part o a prescription

rom a doctor to an overweight patient, together with a system whereby doctors are able

to reer patients to a ftness specialist and get reimbursed or their services.


29/38


Beer education o health care proessionals about screening patients or ftness and

physical activity levels and providing advice on behavioral changes.

Te establishment o special obesity treatment centers or children and their amilies

ideally linked to childrens hospitals.

Te new programs and initiatives in PPACA to tackle childhood obesity will build onand link into current programs now operated by the Department o Health and Human

Services. It will be essential to ensure that there is continuing eort and unding or these

programs where they are shown to be working, and a revitalization and reworking where

they are not. Te majority o HHSs obesity-related programs are overseen by the CDC. In

recent years unding or CDCs obesity-related programs has at-lined, even as the need

or these programs has grown (see able 1).

Table 1

CDC Needs More Funds to Fight Obesity

Center for Disease Control and Prevention appropriations in fiscal years 2007 to 2011

Division / ProgramAppropriated

FY 2007

Presidents

budget 2008

Appropriated

FY 2008

Presidents

budget 2009

Appropriated

FY 2009

Presidents

budget 2010

Appropriated

FY 2010

Presid

budge

Nutrition, Physical

Activity and Obesity64$40.6m $41.3m $42.2m $42.0m $44.3m $44.9m $44.9m $43.

School Health65 $54.8m $55.9m $54.3m $53.6m $57.6m $62.8m $57.6m $61.

Healthy Communities66, 67 $42.9m $26.4m $25.2m $15.5m $22.8m $22.5m $22.8m $22.

REACH-U.S.68 $33.6m $34.1m $33.9m $33.7m $35.6m $39.9m $39.6m $39.


30/38


Beyondhealthcare

Tere are other key initiatives that will be essential to tackling childhood obesity but

which are not within the scope o health reorm legislation. Arguably actors such as nutri-

tion, aordable access to healthy oods, and increased physical activity will , collectively,

have a greater impact on the progress o obesity than health care. Nutrition education

programs in particular need to be revised to provide less conusing messages to parents

and caregivers. Tis issue is being addressed in the context o the work that is being done

or the frst ladys Lets Move! initiative.

Te availability o nutritious oods in schools is an important frst step in curbing obesity

and being overweight. Te Child Nutrition and Special Supplemental Nutrition Program

or Women, Inants, and Children Act, which is currently being reauthorized in the

Congress, is a great opportunity to update ederal nutrition standards o school meals

so they are more nutritious and lower in calories. Tats why its important that this bill

should increase unding, as recommended by the Obama administration, to ensure that

schools are able to provide high-quality meals to the maximum number o students.

Accessing healthy ood is a challenge, especially in low-income communities, where high

costs and lack o conveniently located grocery stores oen lead residents to opt or the

low-cost, less-nutritious ood options. According to an analysis by John Cawley o CornellUniversity, the ination-adjusted price o ruits and vegetables rose 17 percent between

1997 and 2003, while the price o a McDonalds quarter-pounder and a Coca-Cola ell

by 5.44 percent and 34.89 percent, respectively.69 Cawley goes on to cite several studies

that link higher body mass index fgures among American children and adolescents to the

increased prices o ruits and vegetables. Te reason or such pricing biases is highly con-

tested, but urther investigation into agriculture policy is necessary in order to determine

how it impacts ood prices and consumption.

Funds are provided in the presidents FY 2011 budget or a new program, the Healthy

Food Financing Initiative, which will invest $400 million a year to bring grocery stores to

underserved areas and help places such as convenience stores and bodegas carry healthierood options. Bringing healthier ood options to underserved neighborhoods is part o the

agenda o the Lets Move! campaign.70 Tis is clearly an important step.


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Increasing physical activity is a necessary complement to encouraging healthy eating.

Changes to school curricula to boost physical activity and eorts to encourage the sur-

rounding neighborhoods to develop beore- and especially aer-school physical activity

could have a proound impact. Improving the quality and requency o physical activity is

crucial to regularizing such behavior in children. Making sure there are parks within walk-

ing distance rom schools, making walking to school and around a community sae (with

sidewalks, or example) are ways that we can promote positive physical activity behaviorand reduce obesity. Secretary o Interior Ken Salazar suggested making unding to build

parks contingent on their co-location with schools. Te reauthorization o Te Sae,

Accountable, Flexible, Ecient ransportation Equity Act: A Legacy or Users would also

provide an opportunity to address these issues.

Lastly, there are issues such as the regulation o the advertising o junk oods and drinks

to children and tax changes that some researchers believe can curb unhealthy behavior,

especially in children. Some health economists have suggested taxes on unhealthy oods,

such as a per-ounce tax on sugar-sweetened beverages, arguing that they could have a tre-

mendous impact on obesity epidemic.71 But others argue that such taxes are regressive and

should only be done with eorts to make healthier ood more aordable in low-income

communities. Te Federal rade Commission proposed imposing voluntary standards

related to marketing unhealthy ood to children, yet many experts argue that this does not

go ar enough. While an all-out ban is probably not easible in the U.S. (as it is in other

countries), more concrete restrictions are necessary to limit childhood exposure to these

advertisements.72 Te pervasiveness o obesity should leave all options air game.

Addressing some o these issues will require signifcant commitments rom all levels o

government, communities, and amilies, but the monetary and liestyle threats that obese

and overweight children and adolescents pose to our kids and our society are simply too

important or us to ignore. Coordinating bodies, such as the newly established askorceon Childhood Obesity, as part o the frst ladys Lets Move! campaign, will be instru-

mental in developing national priorities to prevent obesity. Te many dimensions to this

problem, though complicated, must all be addressed i we seriously want to change the

course o the obesity epidemic in our country.


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Conclusion

Childhood obesity is not a new problem. Research clearly shows it is a problem that has

been decades in the making. o the extent that health care reorm is about beer preven-

tion o chronic illnesses, improving health outcomes or all Americans and bending the

curve o burgeoning health care costs, it is intrinsically about reducing childhood obesity.

Te new health care reorm law conronts the dicult task o tackling this issue.

Te provisions in PPACA that address childhood obesity, both directly and indirectly, are

necessarily based on policies and programs that will be implemented within the health

care and public health systems because these represent the jurisdictional reach o the legis-

lation. But the true reach and eectiveness o these initiatives depends on how strategically,

aggressively, and ully they are implemented.

Achieving the long-term, sustainable changes that will be needed to reduce childhood

obesity will be dicult, resource-intensive, and time-consuming. Lawmakers in particular,

locked into short-term election cycles, will be rustrated that returns on the investments

made will not come quickly.

Nevertheless, it is imperative that everyonepoliticians, policymakers, health care

providers, and the American peoplerealizes that the enactment and implementationo health care reorm does not take childhood obesity o the agenda. Tere will be a con-

tinual need to ensure that authorized programs have needed unding, that the evidence-

base o these unded programs is sound and up to date, and that they reect national, state

and local priorities.

Moreover, as this paper highlights, health care reorm is only one acet o the multi-

pronged approach that will be necessary to really make a dierence in the rates o child-

hood obesity and ensure that todays children grow up as healthy adults. A range o other

initiatives will be needed in other jurisdictions to address nutrition programs, improve

environments and transport systems to encourage physical activity, provide obesity pro-

grams to the deense orces and veterans, and protect children rom inappropriate market-ing o certain oods and beverages. As President Obamas askorce on Childhood Obesity

recognizes, deeating childhood obesity will require action on across all o government

and a strong public-private partnership.


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Appendix:TheWhiteHouseChildhoodObesityInitiative

President Barack Obama has set a goal to solve the problem o childhood obesity within a

generation so that children born today will reach adulthood at a healthy weight. Te frst

lady, Michelle Obama, is leading a national public awareness eort to tackle the epidemic

o childhood obesity. Her program, Lets Move! has our pillars or action: 73

1. Helping parents make healthy amily choices

By the end o this year, the Food and Drug Administration will have completed guid-

ance or retailers and manuacturers to adopt new nutritionally sound and consumer

riendly ront-o-package labeling.

Te American Academy o Pediatrics, in collaboration with a broader medical com-

munity, will educate doctors and nurses across the country about obesity.

Te U.S. Department o Agriculture has created the frst-ever Food Atlas, an interac-

tive database that maps components o healthy ood environments down to the local

level across the country.

2. Healthier Schools

Te Healthier U.S. Schools Challenge Program establishes rigorous standards or

schools ood quality, participation in meal programs, physical activity, and nutrition

education and provides recognition or schools that meet these standards.

Reauthorization o the Child Nutritio

Confronting America's Childhood Obesity Epidemic

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