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8/7/2019 Confronting America's Childhood Obesity Epidemic
1/38 www.americanprogress.o
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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2 Center for American Progress | Confronting Americas Childhood besity Epidemic
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.
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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
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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:
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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.
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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.
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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.
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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
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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
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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
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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.
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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.
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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.
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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.
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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