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Driving Action and Progress on Obesity Prevention and Treatment

Proceedings of a Workshop--In Brief September 2016

The Roundtable on Obesity Solutions of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine held a workshop in Washington, DC, on September 27, 2016, titled “Driving Action and Progress on Obesity Prevention and Treatment.” The workshop was designed to (1) review the progress that has been made in obesity prevention and treatment; (2) identify some of the levers that can drive significant future progress; and (3) discuss how gaps in the field can be filled.

This Proceedings of a Workshop—in Brief highlights key points made during the presentations and discussions and is not intended to provide a comprehensive summary of information shared during the workshop. The information and suggestions for future action summarized here refl ect the knowledge and opinions of individual workshop participants and should not be seen as the consensus of the workshop, Roundtable on Obesity Solutions, or the National Academies of Sciences, Engineering, and Medicine.

Trends and Prevalence of Overweight and Obesity

In the first presentation of the workshop, Captain Heidi Michels Blanck, chief of the Obesity Prevention and Control Branch at the Centers for Disease Control and Prevention (CDC), provided an overview of trends and prevalence in overweight and obesity in the United States to establish a context for the ensuing discussion. However, she pointed out that monitoring progress of obesity prevention and treatment goes beyond body mass index (BMI): policies, practices, knowledge, and individual behavior (e.g., fruit and vegetable consumption) all play a role. According to the most recent data from the National Health and Nutrition Examination Survey (NHANES), more than one-third of adults (ages 20 years and older) in the United States have obesity, with an increase of about 7 percentage points in the first 15 years of the 21st century (Figure 1). This percentage translates into 82.7 million U.S. adults with obesity. More than two-thirds of U.S. adults (71 percent) either have obesity or are overweight.

Figure 1 Trends in obesity prevalence among adults ages 20 and over (age adjusted) and children and youth ages 2–19 years: United States, 1999–2000 through 2013–2014.
a Significant increasing linear trend from 1999–2000 through 2013–2014.
b Test for linear trend for 2003–2004 through 2013–2014 not significant (p > 0.05).
NOTE: All adult estimates are age adjusted by the direct method to the 2000 U.S. Census population using the age groups 20–39, 40–59, and 60 and over.
SOURCES: Presented by Heidi Blanck, September 27, 2016. CDC/NCHS, NHANES, https://www.cdc.gov/nchs/data/databriefs/db219.htm (accessed November 14, 2016).

Blanck noted that obesity rates also have increased markedly among U.S. children and youth ages 2 to 19 over the past three decades (Figure 2). Among 12- to 19-year-olds, obesity nearly doubled between 1988-1994 and 2013-2014, and the rate rose appreciably for 6- to 11-year-olds and for 2- to 5-year-olds over the same period. Altogether, 12.7 million U.S. children and youth have obesity, according to the most recently available data. Markedly, severe obesity has risen in 12- to 19-year-olds from 2.6 percent in the early data to 9.1 percent in the most recent data. 

Figure 2 Prevalence of obesity, youth 2–19 years, by age, United States, 1988–1994 through 2013–2014. NOTE: Obesity defined as at or above the sex-specific 95th percentile of BMI-for-age CDC growth charts; extreme obesity defined as 120 percent of the sex-specific 95th percentile of BMI-for-age CDC growth charts. SOURCES: Presented by Heidi Blanck, September 27, 2016. CDC/NCHS, NHANES.

Importantly, Blanck noted the disparity that continues to exist in obesity rates across all ages—in children, youth, and adults—by race and ethnicity. Data show the highest rates of obesity among African Americans and Hispanics compared to non-Hispanic white and non-Hispanic Asian Americans. The racial and ethnic disparity in obesity rates is also evident in children ages 2-4 years in low-income populations. Additionally, obesity rates are higher in adult women compared to adult men.

According to national surveys, the increase in overall adult obesity rates has slowed in recent years, Blanck noted, and four states have even undergone a decrease in adult obesity rates in the most recent data. The rates appear to have stabilized for younger children since about 2003. Good news also has come from state-level data on changes in obesity rates among low-income 2- to 4-year-olds. According to the most recent data (from the Pediatric Nutrition Surveillance System), 19 states have seen small, but significant, declines in obesity among this population group, while only 3 have seen increases. Another promising trend can be seen in data from the New York City public schools generated by the use of Fitnessgrams, with rates of obesity declining slightly since 2006-2007 in children and youth ages 5-15 years.

“We’re starting to see some great success stories,” said Blanck. But she added that the data needed to reveal a full picture of obesity in the United States are still lacking. She identified areas that need improvement, including increasing the sample sizes for subgroups, decreasing the time it takes for collected data to become public, and improving the training data collectors receive to account for bias in self-reported data. Combining data from different sources, such as birth certificates and vital statistics data2, can help fill some of the current gaps in obesity surveillance, Blanck said. Also, new technologies such as electronic health records provide opportunities to aid in surveillance and improve public health. She concluded by reiterating what she stated in the beginning of her presentation—monitoring of obesity and obesity-related factors in addition to BMI/weight can provide additional information on the broad array of social influences that affect weight. Examples include state policies and practices in schools and childcare, policies and practices at the community level, consumption of fruits and vegetables, breastfeeding rates, and physical activity.

Importantly, Blanck noted the disparity that continues to exist in obesity rates across all ages—in children, youth, and adults—by race and ethnicity. Data show the highest rates of obesity among African Americans and Hispanics compared to non-Hispanic white and non-Hispanic Asian Americans. The racial and ethnic disparity in obesity rates is also evident in children ages 2-4 years in low-income populations. Additionally, obesity rates are higher in adult women compared to adult men.

According to national surveys, the increase in overall adult obesity rates has slowed in recent years, Blanck noted, and four states have even undergone a decrease in adult obesity rates in the most recent data. The rates appear to have stabilized for younger children since about 2003. Good news also has come from state-level data on changes in obesity rates among low-income 2- to 4-year-olds. According to the most recent data (from the Pediatric Nutrition Surveillance System), 19 states have seen small, but significant, declines in obesity among this population group, while only 3 have seen increases. Another promising trend can be seen in data from the New York City public schools generated by the use of Fitnessgrams, with rates of obesity declining slightly since 2006-2007 in children and youth ages 5-15 years.

“We’re starting to see some great success stories,” said Blanck. But she added that the data needed to reveal a full picture of obesity in the United States are still lacking. She identified areas that need improvement, including increasing the sample sizes for subgroups, decreasing the time it takes for collected data to become public, and improving the training data collectors receive to account for bias in self-reported data. Combining data from different sources, such as birth certificates and vital statistics data,can help fill some of the current gaps in obesity surveillance, Blanck said. Also, new technologies such as electronic health records provide opportunities to aid in surveillance and improve public health. She concluded by reiterating what she stated in the beginning of her presentation—monitoring of obesity and obesity-related factors in addition to BMI/weight can provide additional information on the broad array of social influences that affect weight. Examples include state policies and practices in schools and childcare, policies and practices at the community level, consumption of fruits and vegetables, breastfeeding rates, and physical activity.

Heidi Blanck, Centers for Disease Control and Prevention, presents an overview of trends and prevalence in overweight and obesity in the U.S.
Blanck responds to a question from the audience.

Two Decades of Obesity Prevention and Treatment

William (Bill) Dietz, director of the Sumner M. Redstone Global Center on Prevention and Wellness at George Washington University’s Milken Institute School of Public Health, moderated a wide-ranging discussion with three of the leading figures in identifying and responding to the obesity epidemic in the United States: David Satcher, founding director and senior advisor to the Satcher Health Leadership Institute at the Morehouse School of Medicine, and the 16th Surgeon General and 10th Assistant Secretary for Health of the United States; Jeffrey Koplan, vice president for global health at Emory University, and former CDC director; and Vice Admiral Vivek Murthy, 19th (and current) Surgeon General of the United States. They discussed the seminal work that identified obesity as an epidemic; early efforts to develop solutions to combat the problem, which laid the foundation for today’s efforts; and lessons that were learned at the time; as well as how to maintain momentum when dealing with a problem as complex as obesity. This allowed the speakers to set the groundwork for the discussions of levers for driving significant progress in obesity prevention and treatment later in the workshop.

In 1999 the Journal of the American Medical Association (JAMA) devoted an entire issue to obesity,2 including an article by Koplan and his colleagues that called attention to the spread of obesity during the previous decade. “I give JAMA and the American Medical Association a lot of credit, because they recognized the subject as important, and important in a long-range way,” Koplan said. “It was an effective kickoff to introducing this [obesity epidemic] to the press as a subject of interest and, of course, to professionals and the public as a subject of more than passing interest.”

In 2001 the Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity3 was released. It included recommendations for families, communities, schools, health care, media and communications, work sites, and the federal government. At the workshop, Satcher labeled what has happened in schools as the most important action since the release of the report. “We felt that the schools should be the great equalizers in the sense that, at school, every child should have an opportunity to experience good nutrition and physical activity.”

In 2005 an Institute of Medicine (IOM) committee, chaired by Koplan, released the report Preventing Childhood Obesity: Health in the Balance,4 which was followed up in 2007 by the report Progress in Preventing Childhood Obesity: How Do We Measure Up?5 after which Koplan became chair of the IOM Standing Committee on Childhood Obesity (the forerunner of the Roundtable on Obesity Solutions). Koplan identified these and other reports (notably the National Prevention Strategy), which recommended multiple approaches and collaborations among sectors to tackle obesity. To emphasize this point, foundations and other funders have been devoting large sums of money and energy to the issue, and key voluntary health organizations in the country have put obesity at the top of their priorities, as have individual communities and states, observed Koplan. These efforts still need to be better coordinated, measured, and evaluated, Koplan said. “But we have some potential best practices out there, and we have enumerable examples from cities and some states,” he said.

Satcher called attention to a prominent feature of obesity in the United States: the existence of persistent inequities among groups separated by income, location, race, ethnicity, gender, and other factors. Many of these inequities stem from social determinants of health, he stated, with the most important being education, income, and safety. Addressing the social determinants of health requires rebuilding a sense of community, Murthy said, so that people empathize with what others are experiencing and have a vested interest in the outcome and well-being of others. Yet relatively straightforward steps also are promising. For example, Murthy has been a leader as the Surgeon General of the United States in the effort to promote walking with the release of Step it Up! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities in September 2015. “Every now and then there are some simple elements that can be part of the solution that are accessible for people to take, and walking happens to be one of them.” Just 22 minutes of brisk activity, when done consistently, can lower a person’s risk of diabetes by 30 percent while also lowering the risk of cardiovascular disease and sudden death, he observed. Increasing the amount of walking people do requires that communities have safe places to walk and incentives that promote physical activity, but policies that help make communities walkable can be “a very powerful public health intervention.”

Several times the panelists drew parallels with tobacco control, an epidemic in which considerable progress has been made over the past 50 years. Though the problem (and therefore the solution) to tobacco control is not as complex as obesity prevention and treatment, the tobacco control campaign demonstrates how much is possible, explained Koplan. A few decades ago, said Koplan, the idea that people would not be able to smoke in the workplace was inconceivable, as was the idea that taxes could be much greater than the cost of making cigarettes. Yet since then these public policies have helped cut the rate of smoking in half in the United States. Lessons can be learned from the successful model of tobacco, but Murthy cautioned against placing the blame on one sector; instead, he suggested the need to work with all sectors to prevent and treat obesity.

The challenge with obesity prevention and treatment is to maintain momentum with a problem that took time to develop, has many contributing factors with uncertain and interacting effects, strikes disadvantaged groups the most, and will take time to solve, Koplan noted. In response, Murthy observed that people need to do three things to sustain their efforts in an epidemic. They need to believe that the issue is directly relevant to them. They need to see evidence of progress. Finally, they need to have a sense of clear agency, “that there are things they can do in their day-to-day lives that will make an impact.”

The panel discusses progress that has been made on obesity prevention and treatment.
The panel fields questions from the audience.

Early Care and Education

A panel of experts discussed what they see as the most promising approaches to drive significant progress in preventing and treating obesity through early care and education. Panelists identified potential areas of great opportunity and urgent issues in the field, and began to discuss ways to overcome barriers to action.

Debbie Chang, senior vice president of policy and prevention with Nemours Children’s Health System, began by stating that in the past decade and a half, a series of investments in research, policy changes at the state level, and identification of best practices has added early care and education to the focus of obesity prevention efforts around the country. To continue to move the field forward, she identified four critical factors that will drive significant progress in efforts to pursue and treat obesity in early care and education. First, she identified the need to work in collaboration with all sectors, partners, and systems. Next, she emphasized the importance of strong federal policies to provide opportunities for healthy eating and physical activity and the need to work closely with the private sector—including childcare centers. Finally, she stressed the need to focus attention on policy, practice, and research opportunities in three critical areas—regulatory approaches, equity, and family engagement.

Daithi Wolfe, early education policy analyst with the Wisconsin Council on Children and Families, demonstrated the interplay between state and federal policy in supporting the progress of obesity prevention in the early care and education setting. The Wisconsin Early Childhood Obesity Prevention Initiative features collective impact through a shared agenda and constant communication. In addition, the Initiative provides guidance documents and training for childcare providers that demonstrate how to help children eat better and become more active. The challenge now, said Wolfe, is to make such resources available to all 5,000 childcare centers in Wisconsin. In addition, many children in Wisconsin are not in the regulated childcare system. “We can do great policies, we can have wonderful childcare programs, we can train the teachers, but there are many kids who are either in unregulated care or at home or with friends and family. How do we reach those kids?” Wolfe asked. He emphasized opportunities to overcome these and other barriers, including working with local partners, peer-to-peer learning, and improving family engagement, especially in underserved communities.

Anna Mercer-McLean, executive director at the Community School for People under Six in Carrboro, NC, urged inclusion of the voice of the childcare community in policy discussions involving early care and education. Child care centers can inform and influence the development of state policies, which can lead to more widespread effects on practice change. This may occur through focus groups, interviews, or simple phone calls, but “first there has to be a conversation,” said Mercer-McLean. “I want to make sure that’s focused on everybody.”

Debbie Chang, Nemours Children's Health System, provides an overview of progress and future directions of obesity prevention in early care and edcuation settings.
The early care and education panel takes questions from moderator Jennifer Zuckerman, Blue Cross Blue Shield of North Carolina Foundation.

Business

The next panel of experts discussed the positive role that businesses can play in fighting obesity, including their influence on the products and services they sell; the employee health programs that they provide; and their relationships with their local communities. For example, the Healthy Weight Commitment Foundation, which was established in 2009 and now includes more than 300 organizations, established a goal by food and beverage companies to remove 1.5 trillion calories from the nation’s food supply. According to an independent evaluation by the Robert Wood Johnson Foundation, those companies exceeded their goal by 400 percent, removing 6.4 trillion calories from the nation’s food supply. The impact these companies have had “provides clear evidence as to why and how businesses can be a part of the solution,” said Becky Johnson, the foundation’s executive director.

Similarly, the National Business Group on Health, which represents many of the largest self-insured employers in the United States, has been helping to lead a shift toward a more holistic view of well-being that includes dimensions beyond physical health. These dimensions include, for example, financial security, emotional well-being, social and community connectednes, and job satisfaction, said LuAnn Heinen, the organization’s vice president of workforce well-being, productivity, and human capital. One result has been “a great expansion in the breadth, depth, and sophistication of what is being offered by large employers,” including physical activity challenges, tobacco cessation assistance, weight management programs, and fitness classes.

The Partnership for a Healthier America (PHA), which is an independent, non-profit, non-partisan organization of more than 200 members, has been working to fight childhood obesity in a variety of ways, reported Ryan Shadrick Wilson, the organization’s chief strategy officer and general counsel. Through individual agreements (or “contracts”) with PHA, partner companies have committed to changing business practices, investing in communities to promote physical activity, improving the accessibility and affordability of healthy foods, and working to change the demand for foods. Outside evaluations have shown this to be successful, said Shadrick Wilson.

As a final example, the Health Means Business Campaign of the U.S. Chamber of Commerce Foundation is seeking to educate the business community on the feedback loop between health and economic growth and to inspire businesses to invest in their communities. Companies are no longer separating off health and wellness programs and treating them as a corporate social responsibility, observed Elyse Cohen, director of the Health and Wellness Program at the Foundation’s Corporate Citizenship Center. Rather, companies are “embedding social impact around health, wellness, and food access into who they are” and, in the process, are discovering that their profits are in many cases staying the same or increasing.

Becky Johnson, Healthy Weight Commitment Foundation, introduces the Business Panel.
The panel takes questions from the moderator and audience about the role businesses can play in preventing obesity.

Physical Activity

Less than half of American adults meet the 2008 federal physical activity guidelines for aerobic activity, began James Sallis, distinguished professor of family medicine and public health at the University of California, San Diego. Furthermore, disparities mark levels of physical activity, with the percentage of those meeting the guidelines for aerobic physical activity higher for men than for women, lower for African Americans and Hispanics than for Asian Americans and whites, and declining with age while increasing with levels of education. Similarly, U.S. children overall are among the least physically active in the world, and similar disparities mark their levels of activity, observed Sallis.

On a more hopeful note, Sallis continued, some ideas for increasing physical activity, especially among children, have already been developed. Although no one intervention will increase physical activity for all groups, interventions in schools and early care and education settings, especially when combined, have been shown to be effective for children, Sallis observed. Despite this evidence of effectiveness, few physical activity programs are widely implemented. “Translation of research into practice is key,” Sallis concluded.

Harold Kohl, professor of epidemiology and kinesiology at the University of Texas Health Science Center, Houston School of Public Health, and the University of Texas, Austin, highlighted the potential for considering physical activity in all policies that affect children. “Our children come across the health sector, the education sector, the recreation sector virtually every day,” he said. “How do we make those more accessible and more relevant for participation in physical activity?”

Reducing disparities in access to physical activity programs is another component to increasing physical activity among youth. A study Sallis reviewed showed that low-income schools were less likely than their high-income counterparts to have a physical education teacher. This, Kohl said, is “unacceptable from a public health standpoint.” In that vein, Kohl advocated for making physical education a core subject like mathematics or reading, including a federally determined provision for measuring it. “Active kids learn better,” he argued, “and we should be putting an equal amount of attention to using schools to leverage that together.”

The presence of champions for physical activity, resources, and collaboration with stakeholders in the community are all important in improving physical activity among children and adults, said Christina Economos, co-founder and director of ChildObesity180 and professor at the Friedman School of Nutrition Science and Policy at Tufts University. However, “there are a lot of communities out there that haven’t been able to do that. How do we provide the resources, the inspiration, and the training to get other communities to do the same programming?” she asked. Economos also observed that more work is needed in the areas of dissemination, implementation, and translation. “We have really good recommendations and policies,” she said. “How do we actually put them into schools and communities and make sure that they are sustained over time?”

During his presentation, Sallis stressed how walkability—the design of a community so that people can walk from their home to other places they might want to go—can impact physical activity habits. Sallis pointed out that the number of people who walk for transportation is low—around 30 percent. Leisure walking is slightly more popular, said Sallis, but still only 40 to 50 percent of Americans engage in this physical activity, with some disparities among population groups. “The quality of the built environment can matter” for physical activity, Sallis observed. Once a city is laid out, it is hard to change, but short-term improvements to the environment are possible, such as changing streetscapes to encourage walking by adding housing, stores, crosswalks, trees, and other amenities. Engaging community members and elected officials in the redesign of neighborhoods can “create a shared vision and make things happen.”

Arnell Hinkle, founding executive director of Communities, Adolescents, Nutrition, and Fitness (CAN-Fit), argued that reframing physical activity and addressing equity can be part of the solution to improving access to physical activity opportunities. She said that it takes more than supportive infrastructure for people to become physically active. “People have to feel invited, feel welcomed, and find something they want to do.” For most people, weight loss will not be the selling point of physical activity, and could even discourage continued efforts. “You have to think about all the benefits of physical activity: social support, stress relief, longevity,” and then build programs that support those goals. In addition, bringing informed community members to the table and considering residence, race, ethnicity, culture, occupation, gender identity, sex, religion, education, socioeconomic status, social capital, age, and disability during program design and implementation can help build equity into the program, she asserted. 

James Sallis, University of California-San Diego, gives an overview of physical activity interventions for obesity prevention.
The panelists discuss physical activity interventions and take questions from the audience.

Treatment Challenges

Just as obesity is a complicated condition to prevent, it is a complicated condition to treat, explained David Fukuzawa, managing director for health and human services at the Kresge Foundation and moderator of the panel on challenges to obesity care. Since about the year 2000, the number of treatments available for obesity has risen rapidly, noted Caroline Apovian, professor of medicine and pediatrics at Boston University School of Medicine. However, very few patients who are eligible for surgical or drug treatments receive them. She gave several examples of barriers to treatment, including patients who do not accept the idea of surgical intervention for their weight problem; doctors who do not accept the risk of surgery for their patients; a lack of insurance coverage for drugs; patients’ unwillingness to undergo drug treatment; and physicians’ frequent failure to diagnose overweight and obesity or discuss weight management with patients. In addition, the treatment of patients with obesity is complicated by a range of socioeconomic, geographic, cultural, biological, and environmental differences.

Apovian called for inclusion of different groups in studies of new treatments, standards for culturally appropriate and tailored care, strategies that improve access to care for underserved populations, more training for clinicians, and more time for obesity medicine specialists to work with individual patients. Even today, she added, BMI generally is not being added to patient charts; many scales in doctors’ offices are inadequate because they often go only to 350; and clinics may lack equipment that can accommodate larger patients.

The pool of physicians trained to treat obesity is far from adequate compared to the numbers of people with the condition, observed Fukuzawa. At current levels of board-certified obesity specialists, each physician would have to serve approximately 11,000 patients, given that 17.6 million U.S. adults have severe obesity. Even if the pool of physicians able to treat obesity were considered to be all primary care physicians, each physician would need to treat about 90 people with severe obesity.

According to Don Bradley, associate consulting professor of community and family medicine at Duke University, only about a quarter of physicians say they know enough about nutrition to provide adequate care, and only an eighth of physician visits deal with nutrition and physical activity. In addition, coverage of preventive and educational services by the Centers for Medicare & Medicaid Services and other payers is spotty. A nutritionist or dietitian can provide counseling if a physician bills for it, but they are not allowed to move forward independently. “We’ve got the best trained people who have the least ability to be paid for their services,” explained Bradley.

All three panelists discussed a framework (Figure 3), described briefly by Fukuzawa, for integrating clinical and community systems of care to manage and treat obesity that combines care delivery systems with community systems. The challenge, he said, is to connect these components through various mechanisms to achieve the greatest possible effect. “It’s everything from structural ways of integrating this, to the kinds of people and personnel, and the policies that pull it all together,” he added. 


Figure 3  A framework for integrating community systems with health care delivery.
SOURCE: Presented by Don Bradley, September 27, 2016 (Adapted from Dietz et al. 2015. An integrated framework for the prevention and treatment of obesity and its related chronic diseases. Health Affairs 34(9):1456–1463, http://content.healthaffairs.org/content/34/9/1456.abstract [accessed November 14, 2016)]).

David Fukuzawa, Kresge Foundation, introduces the session on challenges in treating obesity.
The panelists field questions from the audience on the challenges and opportunities in treating obesity.

The Roles of the U.S. Department of Agriculture

Tom Vilsack, Secretary of the U.S. Department of Agriculture (USDA), gave a keynote address on the work USDA has done in this area. The department has made a concerted effort to change the foods consumed in preschools, schools, and homes, Vilsack began. It has worked to make nutrition-related changes in the composition of the food packages of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which now serves about half of all infants in the United States. The changes included the addition of fruits and vegetables to improve nutrition and introduce young children to a broader range of foods. Through the Healthy, Hunger-Free Kids Act, USDA worked to change the mix of foods served and sold in schools. Ninety-seven percent of school districts in the country now follow the new guidelines for school lunches, which reduce fat, sodium, and sugar, and introduce foods that would be both nutritious and delicious, reported Vilsack. In addition, the department has worked with schools to change the foods available in vending machines, make food marketing in schools consistent with the new standards for school lunches, and developed strategies to encourage smarter lunchroom choices. This work has contributed to a 16 percent increase in vegetable consumption in schools that have implemented the new standards, said Vilsack.

USDA has also worked to make nutritious choices for consumers simple and easier to make. After confessing that he had difficulty understanding the Food Guide Pyramid, Vilsack explained, “We wanted to identify for ordinary folks what a nutritious plate looked like.” The department replaced the Pyramid with MyPlate, which calls for meals to consist of half fruits and vegetables and half carbohydrates and protein, with dairy on the side. To incentivize nutritious choices among participants in the Supplemental Nutrition Assistance Program (SNAP), the department has partnered with foundations to create “double-buck” campaigns at farmer’s markets that allow participants to double the value of their benefits when purchasing fruits and vegetables. USDA has helped to expand local and regional food systems so that fruits, vegetables, and other healthy options are more readily available.

USDA is working with a broad range of partners to encourage a continuation of its successful programs. “We didn’t get into this situation overnight, and we're not going to get out of it overnight,” Vilsack concluded. But “if we stick with it and stay with it, we’ll see more significant benefits over time.”

The Honorable Tom Vilsack, U.S. Secretary of Agriculture, delivers his remarks on the role the USDA plays in preventing obesity.
Secretary of Agriculture Tom Vilsack
Secretary Vilsack responds to an audience question.

The Roles of Foundations

In the final panel of the workshop, four representatives of philanthropic organizations reflected on the lessons they have learned from past investments in obesity prevention and treatment and on their plans for future investments. Strengthening obesity prevention and treatment as a social movement would catapult the issue forward, said Marion Standish, vice president for enterprise programs at The California Endowment. Grassroots movements around the country are taking on issues related to obesity. If these groups came together, they could forge a much larger narrative around their work. “How do we begin to take steps to translate our focus on a disease into a focus on the social movement?” she asked.

Monica Hobbs Vinluan, senior program officer at the Robert Wood Johnson Foundation, agreed that bringing together disparate movements to advance work on obesity is “the key to our future.” In addition, the many intersections among social factors and health outcomes provide opportunities to weave together strategies to make greater progress. “To build a culture of health, we need lots of component pieces in place. We need to make sure that health is a shared value. We need to make sure that we’re fostering cross-sector collaboration. Plus, we need to create healthier communities while at the same time integrating our health services and systems. . . . Health is very much connected around the conditions of social, emotional, and physical health. How do we try to identify strategies and solutions that combine all of those efforts?”

The JPB Foundation has been working to identify and lower the barriers for escaping poverty, one of which is obesity, said the foundation’s president, Barbara Picower. “If we can get young people to grow up at normal weight, then they will have a chance of crossing that street and having a more successful life.” For example, the foundation has helped fund a program known as Healthy Harlem that combines nutrition, cooking, physical activity, and sports components for children and teens, with opportunities for parents to become involved. An evaluation of the project found promising and statistically significant results, Picower reported. However, she noted, “obesity is always going to be around.” Despite this, “we all need to continue to work tirelessly.”

Foundations can support communities that have been marginalized and take the long view, which enables them to be progenitors of long-term social movements, observed Fukuzawa with the Kresge Foundation. He noted that in his work with Kresge, he has seen health become a critical integrating factor in community development. In community development, which includes transportation planning, housing, economic development, and workforce development, “health is the organizing theme.” As an example, he pointed to the many places where health care institutions have become the foundation for community development and better health. He also pointed to the potential for foundations to fund leveraged investments that help induce other funders, both public and private, to invest in socially beneficial community programs.

At the end of the workshop, Bill Purcell,6 former mayor of Nashville, TN, cited the work of foundations as one reason “not just to be hopeful, but to be optimistic. . . . This country has a large number of people, many in this room, who understand what needs to be done and increasingly are closer to knowing how to do it. For that reason, I’m optimistic, hopeful, and encouraged.”

Marion Standish, The California Endowment, discusses the roles foundations can play in building, supporting, and accelerating obesity prevention efforts.
Bill Purcell, former mayor of Nashville, TN and chair of the Roundtable on Obesity Solutions, provides closing comments at the workshop.

1. National Vital Statistics System: http://www.cdc.gov/nchs/nvss (accessed November 14, 2016).

2. http://jamanetwork.com/journals/jama/fullarticle/192036 (accessed November 14, 2016).

3. https://www.ncbi.nlm.nih.gov/books/NBK44206/ (accessed November 14, 2016).

4. https://www.nap.edu/catalog/11015/preventing-childhood-obesity-health-in-the-balance (accessed November 14, 2016).

5. https://www.nap.edu/catalog/11722/progress-in-preventing-childhood-obesity-how-do-we-measure-up (accessed November 14, 2016).

6. Currently with Farmer Purcell White & Lassiter, PLLC.

DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Steve Olson as a factual summary of what occurred at the meeting. The statements made are those of the rapporteur or individual meeting participants and do not necessarily represent the views of all meeting participants, the planning committee, or the National Academies of Sciences, Engineering, and Medicine. The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the institution.
REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Becky Johnson, Healthy Weight Commitment Foundation; and Linda Thompson, Howard University. Lauren Shern, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.
SPONSORS: This workshop was partially supported by the Academy of Nutrition and Dietetics; Alliance for a Healthier Generation; American Academy of Pediatrics; American College of Sports Medicine; American Council on Exercise; American Heart Association; American Society for Nutrition; Bipartisan Policy Center; Blue Cross Blue Shield of North Carolina Foundation; The California Endowment; ChildObesity180/Tufts University; Edelman; General Mills Foundation; Greater Rochester Health Foundation; HealthPartners; Healthy Weight Commitment Foundation; The JPB Foundation; Kaiser Permanente; The Kresge Foundation; Mars, Inc.; Nemours Foundation; Nestlé Nutrition; Nestlé USA; Novo Nordisk; The Obesity Society; Partnership for a Healthier America; Reebok, International; Robert Wood Johnson Foundation; SaludAmerica!; and YMCA of the USA. 
For additional information regarding the meeting, visit nationalacademies.org/obesitysolutions.