Suggested Citation: Garko, M.G. (2011, October). Overweight and obesity epidemic in America – Part XII: Why and how prevention is the best policy to help turn the tide. Health and Wellbeing Monthly. Retrieved (insert month, day, year), from www.letstalknutrition.com.
Overweight and Obesity Epidemic in America – Part XII: Why and
How Prevention Is the Best Policy To Help Turn The Tide
Michael G. Garko, Ph.D.
Host – Let’s Talk Nutrition
“Prevention is better than cure” (Desiderius Erasmus) is not just a clever idiom to suggest a way to turn the tide of the obesity epidemic. Rather, it captures the precise prescription to help lower the incidence and prevalence of overweight and obesity. In that regard, prevention is the single best strategy to start, sustain and succeed at slowing the inexorable increase in overweight and obesity taking place over the past three to four decades in America and other developed and undeveloped countries across the globe. That being said, “prevention is better than cure” so long as it works. Simply believing prevention will turn the tide of the obesity epidemic or creating and implementing a program of obesity prevention do not guarantee success. How and why people become overweight or obese and how and why prevention is the best policy are extraordinarily complex issues involving the intersection (and sometimes collision) of genetic, biological, psychological, socio-cultural and environmental factors.
The October, 2011, issue of Health and Wellbeing Monthly takes a look at obesity prevention with particular attention to distinguishing between prevention and treatment, children and youth as the primary targets of obesity prevention, the Institute of Medicine’s Committee on Prevention of Obesity in Children and Youth (referred to as the IOMC in the remainder of this article) action plan for obesity prevention, obesity prevention as a national public health priority, tradition model of prevention, population-wide approach to obesity prevention, evidence- and evaluation-based public health approach to obesity prevention, maintaining energy balance, goals of obesity prevention in children and youth and recommendations to prevent obesity prevention.
Prevention vs. Treatment of Obesity
Prevention and treatment are similar in that they both require intervention. It is the intent, nature and timing of the intervention which distinguishes prevention from treatment, at least in part. Prevention involves an intervention, whereby some sort of pre-emptive action(s) is/are invoked to avert something from occurring (e.g., preventing weight gain resulting in overweight or obesity). Treatment, on the other hand, involves an intervention in which nutritional, lifestyle, medical, surgical, dental or psychiatric procedures or protocols are applied to help the body cure itself or ameliorate an already existing disease or pathological condition and its symptoms (e.g., eliminating or decreasing the consumption of highly refined, processed, sugar-loaded, nutritionally depleted carbohydrates such as cookies, crackers, cakes, chips, candy, cereals and custards to reduce calorie intake so as to lose weight and keep it off) (see Venes, 2005).
In sum, prevention involves a before-the-fact intervention so as to stop something from occurring, while treatment involves an after-the-fact intervention to remedying something which has already occurred. When it comes to unhealthy weight gain, individuals, health-related professions, organizations, and institutions (governmental and private), communities and society as a whole can become involved or otherwise intervene before (i.e., prevent) or after (i.e., treat) people become overweight or obese. The former is a better option in halting the obesity epidemic in America and pandemic across the globe.
Beyond the difference in their overall intent and purpose, prevention and treatment are different in terms of their goals, motivations, level of difficulty, amount of time required for behavioral and attitudinal changes and rate of success. For example, with respect to overweight and obese, avoiding the gaining of weight is the suggested preventative goal, while losing weight and keeping it off is the suggested treatment goal. Motivationally speaking, wanting to remain physically fit or attractive might be a prevention-associated incentive to prevent weight gain, whereas needing to correct a health condition such as high blood pressure might be a treatment-associated motivation to lose weight and keep it off.
Compared to the prevention of obesity, treating unhealthy weight gain (i.e., losing weight and keeping it off) is more challenging all the way around and for all concerned from the overweight or obese individual, to health care professionals, organizations and institutions (governmental and private), to communities and society at large. One of the distinguishing features of obesity is that once it develops it is tough to treat. This is especially the case when it comes to adults because they possess ingrained, unhealthy dietary and lifestyle behaviors and attitudes, which were typically developed over a long period of time and in too many instances over the course of a lifetime. It is even a formidable challenge to treat obese children or otherwise succeed at getting them to lose weight and keep it off, never mind adults, habituated with unhealthy, weight-gaining dietary and lifestyle behaviors and attitudes.
Compared to treatment, most experts agree and existing evidence shows that prevention is a better long-term and more effective option in halting the rising increase in the prevalence in overweight and obesity in children and adults. Most experts agree that the prevention of overweight and obesity should be initiated as early in life as possible, starting with efforts to maintain nutritional status during pregnancy to protect the health of the fetus and mother (e.g., see Aranceta et al., 2009).
Children and Youth as the Primary Focus of Obesity Prevention
Healthy children and youth who have yet to become overweight or obese are the primary target for obesity prevention. This is not to suggest that preventing children and adolescents from becoming obese is an easy task. On the contrary, obesity is caused by a constellation of genetic, biological, psychological, sociological and environmental factors, which always leaves the lurking possibility for kids to become overweight or obese. Nevertheless, preventing obesity in healthy children and youth in the first place has a better likelihood of long-term success and is less costly in the long-run (see Institute of Medicine, 2005).
Action Plan Designed for Obesity Prevention
In 2001, the surgeon general of the United States announced the Call to Action to Prevent and Decrease Overweight and Obesity. The Centers for Disease Control and Prevention was asked to direct the Institute of Medicine (IOM) to develop an action plan designed to prevent obesity in children and youth in the United States. The 19-member Institute of Medicine Committee on Prevention of Obesity in Children and Youth (referred to as the IOMC in the remainder of this article) was charged with developing “a prevention-focused action plan to describe the prevalence of obesity in children and youth in the United States” (Institute of Medicine, 2005, p.xiii). Its primary task was to study the behavioral and cultural factors, social constructs and environmental factors responsible for childhood obesity. It was also charged with identifying promising obesity prevention approaches. The title of the report is, Preventing Childhood Obesity: Health in the Balance (see Institute of Medicine, 2005).
The IOMC’s report is among the most thorough and comprehensive evidenced-based treatments focusing on the prevention of childhood obesity. It lays out a 1. set of facts describing the extent and consequences stemming from childhood obesity, 2. precise, sound and research-supported recommendations constituting an action plan to prevent childhood obesity, 3. cogent, well-reasoned argument why childhood obesity is a national public health priority and 4. comprehensive set of obesity-prevention recommendations and related implementation strategies situated within different contexts from which action can be taken (i.e., industry, advertising, media and public education, local communities, schools and home).
The remainder of this article focuses on some of the important aspects of the IOMC’s report, which capture the sum and substance of its action plan for obesity prevention. The reader is encouraged to read the report for further insight and details.
Obesity Prevention as a National Public Health Priority
The IOMC stated the following concerning the importance of obesity prevention in the United States: “Prevention of obesity in children and youth should be a national public health priority” and that what is needed is “the political will to make childhood obesity prevention a national public health priority” (Institute of Medicine, 2005, p. 5). In light of its position, the IOMC offered the following recommendation, which is its first recommendation with strategies to implement it:
Recommendation 1: National Priority
Government at all levels should provide coordinated leadership for the prevention of obesity in children and youth. The President should request that the Secretary of the Department of Health and Human Services (DHHS) convene a high-level task force to ensure coordinated budgets, policies, and program requirements and to establish effective interdepartmental collaboration and priorities for action. An increased level and sustained commitment of federal and state funds and resources are needed.
To implement this recommendation, the federal government should:
- Strengthen research and program efforts addressing obesity prevention, with a focus on experimental behavioral research and community-based intervention research and on the rigorous evaluation of the effectiveness, cost-effectiveness, sustainability, and scaling up of effective prevention interventions
- Support extensive program and research efforts to prevent childhood obesity in high-risk populations with health disparities, with a focus both on behavioral and environmental approaches
- Support nutrition and physical activity grant programs, particularly in states with the highest prevalence of childhood obesity
- Strengthen support for relevant surveillance and monitoring efforts, particularly the National Health and Nutrition Examination Survey (NHANES)
- Undertake an independent assessment of federal nutrition assistance programs and agricultural policies to ensure that they pro-mote healthful dietary intake and physical activity levels for all children and youth
- Develop and evaluate pilot projects within the nutrition assistance programs that would promote healthful dietary intake and physical activity and scale up those found to be successful
To implement this recommendation, state and local governments should:
- Provide coordinated leadership and support for childhood obesity prevention efforts, particularly those focused on high-risk populations, by increasing resources and strengthening policies that promote opportunities for physical activity and healthful eating in communities, neighborhoods, and schools
- Support public health agencies and community coalitions in their collaborative efforts to promote and evaluate obesity prevention interventions (Institute of Medicine, 2005, pp. 6-7).
Traditional Model of Prevention
As defined above, prevention is a process of pre-emptive action(s) undertaken to avert something from occurring (e.g., disease or obesity). Different conceptual frameworks of prevention exist targeting the action/s to be taken to prevent something from happening. Two will be discussed so as to give more of a context to IOMC’s choice of conceptual framework for prevention.
Risk reduction model. One approach, the risk reduction model, organizes health-related prevention actions based on a particular segment of the population, which is at a particular level of risk for developing a disease or becoming obese. It consists of three categories. Universal prevention is where the entire population or general public and all individuals in specific risk-eligible groups (e.g., pregnant women, children or elderly) are the focus of preventative actions. Selective prevention is targeted at a particular a subgroup (identified by age, gender, occupation, family history, or other characteristics) of the population which has an above average risk of developing a particular disease or disorder but are at the moment healthy and well. Indicated prevention is directed at individuals who are high risk for developing a particular disease or disorder (See Institute of Medicine, 1994; Institute of Medicine, 2005).
Traditional model. Another approach organizes preventative actions around the idea of disease progression. It too consists of three categories. Primary prevention is intended to decrease the incidence of new cases of a disease or disorder in the entire population. Secondary prevention is designed to decrease the prevalence of existing cases of a disease or disorder in the population. Tertiary prevention sets out to decrease the amount of disability of a particular disease or disorder or otherwise reduce its health consequences.
The IOMC decided to implement primary prevention from the traditional model of prevention as part of its action plan to prevent obesity because it “emphasizes efforts that can help the majority of children who are at a healthy weight to maintain that status and not become obese” (Institute of Medicine, 2005, p. 82). Further, it adopted primary prevention to help create as much as possible population-based recommendations targeting the entire population rather than high-risk individuals. The IOMC did point out that obesity prevention needed to combine population-based actions with targeted actions for high-risk individuals and subgroups (see Institute of Medicine, 2005).
Consequently, based on what it considered the best available evidence, the IOMC identified “a primary prevention, population-based approach to be the most viable long-term strategy for reducing obesity and its chronic disease burdens” (Institute of Medicine, 2005, p. 107).
Evidence- and Evaluation-Based Public Health Approach to Obesity Prevention
The IOMC contends that obesity prevention is best undertaken using an evidence-based public health approach grounded on the best available evidence rather than yet to generated best possible evidence, with evaluation being included as a critical component of any implemented intervention or change to prevent obesity among children and youth in the United States.
Maintaining Energy Balance
Central to the IOM committee’s action plan for obesity prevention is the notion that any attempt to prevent childhood obesity must include “maintaining energy balance at a healthy weight while protecting overall health, growth and development, and nutritional status” (Institute of Medicine, 2005, p.3). The proposed balance is between energy (i.e., calories) consumed and energy expended to support in children and youth healthy growth and development, metabolism, thermogenesis and physical activity. In short, energy intake = energy expenditure is the basic formula to prevent obesity. Getting this equation to balance is a task easier said than done because there are a number of factors (e.g., genetic, biological, psychological, sociological and environmental) which can create an imbalance on either side of the equation and have an impact on the interconnected nature of the constellation of factors giving rise to children and youth becoming overweight or obese, including the quality and quantity of food they eat and their physical activity at home, school and other environments.
Goals of Obesity Prevention in Children and Youth
IOMC’s action plan to prevent obesity is constituted of specific goals and a set of recommendations designed to help achieve the goals relative to different segments of society. Below are IOMC’s goals to prevent obesity among children and youth in the United States:
Goals of Obesity Prevention in Children and Youth
The goal of obesity prevention in children and youth is to create—through directed social change—an environmental-behavioral synergy that promotes:
Guidelines for Americans
Because it may take a number of years to achieve and sustain these goals, intermediate goals are needed to assess progress toward reduction of obesity through policy and system changes. Examples include:
that promote energy balance at a healthy weight
supermarkets, grocery stores, and farmers markets located within walking
distance of the communities they serve
Balance (Institute of Medicine, 2005, p. 4).
Recommendations To Prevent Obesity
IOMC offered 10 recommendations and accompanying implementation strategies to prevent obesity among children and youth in America. The recommendations are organized around governmental and private sector stakeholders in preventing children and youth from becoming obese. The reader is encouraged to read the IOMC’s rationale for its recommendations and how they should be implemented. The first recommendation was presented above and the remaining nine recommendations and implementation strategies are as follows:
Recommendation 2: Industry
Industry should make obesity prevention in children and youth a priority by developing and promoting products, opportunities, and information that will encourage healthful eating behaviors and regular physical activity.
To implement this recommendation:
- Food and beverage industries should develop product and packaging innovations that consider energy density, nutrient density, and standard serving sizes to help consumers make healthful choices.
- Leisure, entertainment, and recreation industries should develop products and opportunities that promote regular physical activity and reduce sedentary behaviors.
- Full-service and fast food restaurants should expand healthier food options and provide calorie content and general nutrition information at point of purchase.
Recommendation 3: Nutrition Labeling
Nutrition labeling should be clear and useful so that parents and youth can make informed product comparisons and decisions to achieve and maintain energy balance at a healthy weight.
To implement this recommendation:
- The Food and Drug Administration should revise the Nutrition Facts panel to prominently display the total calorie content for items typically consumed at one eating occasion in addition to the standardized calorie serving and the percent Daily Value.
- The Food and Drug Administration should examine ways to allow greater flexibility in the use of evidence-based nutrient and health claims regarding the link between the nutritional properties or biological effects of foods and a reduced risk of obesity and related chronic diseases.
- Consumer research should be conducted to maximize use of the nutrition label and other food-guidance systems.
Recommendation 4: Advertising and Marketing
Industry should develop and strictly adhere to marketing and advertising guidelines that minimize the risk of obesity in children and youth.
To implement this recommendation:
- The Secretary of the DHHS should convene a national conference to develop guidelines for the advertising and marketing of foods, beverages, and sedentary entertainment directed at children and youth with attention to product placement, promotion, and content.
- Industry should implement the advertising and marketing guidelines.
- The Federal Trade Commission should have the authority and resources to monitor compliance with the food and beverage and sedentary entertainment advertising practices.
Recommendation 5: Multimedia and Public Relations Campaign
The DHHS should develop and evaluate a long-term national multimedia and public relations campaign focused on obesity prevention in children and youth.
To implement this recommendation:
- The campaign should be developed in coordination with other federal departments and agencies and with input from independent experts to focus on building support for policy changes; providing information to parents; and providing information to children and youth. Rigorous evaluation should be a critical component.
- Reinforcing messages should be provided in diverse media and effectively coordinated with other events and dissemination activities.
- The media should incorporate obesity issues into its content, including the promotion of positive role models.
Recommendation 6: Community Programs
Local governments, public health agencies, schools, and community organizations should collaboratively develop and promote programs that encourage healthful eating behaviors and regular physical activity, particularly for populations at high risk of childhood obesity. Community coalitions should be formed to facilitate and promote cross-cutting programs and community-wide efforts.
To implement this recommendation:
- Private and public efforts to eliminate health disparities should include obesity prevention as one of their primary areas of focus and should support community-based collaborative programs to address social, economic, and environmental barriers that contribute to the increased obesity prevalence among certain populations.
- Community child- and youth-centered organizations should promote healthful eating behaviors and regular physical activity through new and existing programs that will be sustained over the long term.
- Community evaluation tools should incorporate measures of the availability of opportunities for physical activity and healthful eating.
- Communities should improve access to supermarkets, farmers’ markets, and community gardens to expand healthful food options, particularly in low-income and underserved areas.
Recommendation 7: Built Environment
Local governments, private developers, and community groups should expand opportunities for physical activity including recreational facilities, parks, playgrounds, sidewalks, bike paths, routes for walking or bicycling to school, and safe streets and neighborhoods, especially for populations at high risk of childhood obesity.
To implement this recommendation:
Local governments, working with private developers and community groups, should:
- Revise comprehensive plans, zoning and subdivision ordinances, and other planning practices to increase availability and accessibility of opportunities for physical activity in new developments
- Prioritize capital improvement projects to increase opportunities for physical activity in existing areas
- Improve the street, sidewalk, and street-crossing safety of routes to school, develop programs to encourage walking and bicycling to school, and build schools within walking and bicycling distance of the neighborhoods they serve
Community groups should:
- Work with local governments to change their planning and capital improvement practices to give higher priority to opportunities for physical activity
The DHHS and the Department of Transportation should:
- Fund community-based research to examine the impact of changes to the built environment on the levels of physical activity in the relevant communities and populations.
Recommendation 8: Health Care
Pediatricians, family physicians, nurses, and other clinicians should engage in the prevention of childhood obesity. Health-care professional organizations, insurers, and accrediting groups should support individual and population-based obesity prevention efforts.
To implement this recommendation:
- Health-care professionals should routinely track BMI, offer relevant evidence-based counseling and guidance, serve as role models, and provide leadership in their communities for obesity prevention efforts.
- Professional organizations should disseminate evidence-based clinical guidance and establish programs on obesity prevention.
- Training programs and certifying entities should require obesity prevention knowledge and skills in their curricula and examinations.
- Insurers and accrediting organizations should provide incentives for maintaining healthy body weight and include screening and obesity preventive services in routine clinical practice and quality assessment measures.
Recommendation 9: Schools
Schools should provide a consistent environment that is conducive to healthful eating behaviors and regular physical activity.
To implement this recommendation:
The U.S. Department of Agriculture, state and local authorities, and schools should:
- Develop and implement nutritional standards for all competitive foods and beverages sold or served in schools
- Ensure that all school meals meet the Dietary Guidelines for Americans
- Develop, implement, and evaluate pilot programs to extend school meal funding in schools with a large percentage of children at high risk of obesity
State and local education authorities and schools should:
- Ensure that all children and youth participate in a minimum of 30 minutes of moderate to vigorous physical activity during the school day
- Expand opportunities for physical activity through physical education classes; intramural and interscholastic sports programs and other physical activity clubs, programs, and lessons; after-school use of school facilities; use of schools as community centers; and walking- and biking-to-school programs
- Enhance health curricula to devote adequate attention to nutrition, physical activity, reducing sedentary behaviors, and energy balance, and to include a behavioral skills focus
- Develop, implement, and enforce school policies to create schools that are advertising-free to the greatest possible extent
- Involve school health services in obesity prevention efforts
- Conduct annual assessments of each student’s weight, height, and gender- and age-specific BMI percentile and make this information available to parents
- Perform periodic assessments of each school’s policies and practices related to nutrition, physical activity, and obesity prevention
Federal and state departments of education and health and professional organizations should:
- Develop, implement, and evaluate pilot programs to explore innovative approaches to both staffing and teaching about wellness, healthful choices, nutrition, physical activity, and reducing sedentary behaviors. Innovative approaches to recruiting and training appropriate teachers are also needed
Recommendation 10: Home
Parents should promote healthful eating behaviors and regular physical activity for their children.
To implement this recommendation parents can:
- Choose exclusive breastfeeding as the method for feeding infants for the first four to six months of life
- Provide healthful food and beverage choices for children by carefully considering nutrient quality and energy density
- Assist and educate children in making healthful decisions regarding types of foods and beverages to consume, how often, and in what portion size
- Encourage and support regular physical activity
- Limit children’s television viewing and other recreational screen time to less than two hours per day
- Discuss weight status with their child’s health-care provider and monitor age- and gender-specific BMI percentile
- Serve as positive role models for their children regarding eating and physical-activity behaviors (See Institute of Medicine, 2005, pp. 8-15).
Obesity ranks among the most serious health public health threats in the 21st century. As an epidemic, it poses a formidable threat to the health and wellbeing of adults and especially children who are vital to creating and sustaining a healthy and fit nation. Such a nation is being undermined by an unprecedented increase in unhealthy and unfit overweight and obese children and youth who now suffer from adult diseases caused by obesity.
Institute of Medicine (1994). Reducing risks for mental disorders. Washington, DC: National Academy Press.
Institute of Medicine (2005). Preventing childhood obesity: Health in the Balance. Washington, DC: National Academic Press.
Kaplan, J.P., Liverman, C.T. & Kraak, V.I. (Eds.).
Venes, D. (2005). Taber’s Cyclopedic Medical Dictionary (20th edition). Philadelphia: F.A. Davis Company.
Suggested Citation: Garko, M.G. (2011, October). Overweight and obesity epidemic in America – Part XII: Why and how prevention Is the best policy to help turn the tide. Health and Wellbeing Monthly. Retrieved (insert month, day, year), from www.letstalknutrition.com.
 A copy of the IOMC’s report can be found online at http://www.nap.edu/openbook.php?record_id=11015&page=1. It can also be purchased in book form from The National Academic Press at same website.