The New York Times, Duff Wilson, July 27, 2010

When the Robert Wood Johnson Foundation decided in 1991 to take on Joe Camel, it became the nation’s largest private funding source for fighting smoking. The foundation spent $700 million to help knock the cartoon character out of advertisements, finance research and advocacy for higher cigarette taxes and smoke-free air laws and, ultimately, to aid in reducing the nation’s smoking rate almost by half.

But a few years ago, the Johnson foundation, based in Princeton, N.J., added another target to its mission, pledging to spend $500 million in five years to battle childhood obesity. As the antiobesity financing rose to $58 million last year, a new compilation from the foundation shows, the organization’s antismoking grants fell to $4 million.

The steep drop-off in private funds illustrates the competition under way for money as public health priorities shift. In the race for preventive health care dollars, from charities and from federal and state government sources, the tobacco warriors have become a big loser. And the nation’s battle to shed pounds has in its corner the White House, with Michelle Obama leading a new campaign against childhood obesity. Shortly after the first lady kicked off the “Let’s Move” program, the administration awarded more funds to fight obesity than tobacco through two big new money sources for preventive health. The funds, totaling $1.15 billion, came from economic stimulus and health care reform legislation. They still provided more than $200 million for tobacco-use prevention, but much more to grapple with obesity.

The changes in financing are also evident across the country. State governments have used tobacco’s billions to balance their budgets while cutting $150 million from antitobacco programs over the last two years. On the airways, obesity public service announcements are lining up while a “Truth” campaign about tobacco languishes for lack of money.

“Don’t forget tobacco,” pleaded a commentary this month in The New England Journal of Medicine.

One in five Americans still smokes.

But one in three is obese.

And competition for attention is growing between the two biggest issues in public health.

“I don’t see anybody else rushing into the vacuum,” says Dr. Steven A. Schroeder, former president of the Johnson foundation. “The sad thing is, smoking, despite all the harm it does, is left pretty much an orphan.”

Dr. James S. Marks, senior vice president of the foundation, said it had to pick its targets. “When we made the commitment to spend $500 million in obesity, we made the commitment to see if we couldn’t do for childhood obesity what we did in tobacco,” he said.

The decline in state funding to prevent smoking has distressed advocates. The 1998 Tobacco Master Settlement Agreement between 46 states and cigarette companies provided more than $200 billion through 2025. For a while it financed preventive programs like the “Truth” media campaign from the antismoking group American Legacy Foundation. But as states used money elsewhere, “Truth” spending declined, to a low of $35 million last year from $104 million in 2000.

“The industry outspends us in a day what we spend in a year,” said David Dobbins, chief operating officer of Legacy.

And even as states were raising taxes on cigarettes to record levels — a proven way to deter smoking — they were shifting that revenue to general funds. Both tobacco industry analysts and antismoking groups say that states have become addicted to tobacco money but are using less of it for prevention efforts.

“Overall funding on tobacco control is down because of dramatic cuts in state spending in recent years,” Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, said in an interview. “In the last several years we’ve seen the rapid progress in both adult and youth smoking rates slow to a crawl largely because of a decline in overall spending at the state level on tobacco prevention and cessation.”

State funding for antitobacco programs dropped to $567 million last year, from $717 million two years earlier, a 21 percent cut, according to an advocacy groups’ report titled “A Broken Promise to Our Children.”

While the federal government has made up for some of the state decline in antitobacco funding, it is spending even more on antiobesity efforts. And despite politic statements, there is undeniable competition for public health money.

“In our reaction to the obesity epidemic, sometimes we have taken our eye off other issues,” Terry F. Pechacek, of the Centers for Disease Control and Prevention office on smoking and health, said in a recent interview.

But Dr. Howard K. Koh, assistant secretary for health, focused on what he said was unprecedented funding from the federal government for both issues.

“Rather than pitting one disease against another, we want to uphold comprehensive prevention policies,” he said in a phone interview. Dr. Koh said the administration was directing $722 million to tobacco control and research this year and $821 million to obesity control and research.

The tobacco funding includes industry fees to set up a new regulatory office in the Food and Drug Administration. About half of the tobacco funding and most of the obesity funding is in research financed by the National Institutes of Health, illustrating the relative newness of obesity research.

In addition, the 2009 economic stimulus package included $650 million for “prevention and wellness strategies.” In February, state smoking quit lines received more than $44 million. In March, obesity programs received 62 percent of a $372 million award while tobacco programs received 38 percent.

Kathleen Sebelius, secretary of health and human services, made the awards in March a month after joining with Mrs. Obama to help kick off the first lady’s campaign against childhood obesity.

Stanton A. Glantz, director of the Center for Tobacco Control Research and Education at the University of California, San Francisco, asked, “Given that tobacco kills four times as many people as obesity does, why is the government putting more money into obesity?”

Kenneth E. Thorpe, a professor of health policy and obesity researcher at Emory University in Atlanta, defended the shifting resources, noting that obesity rates had doubled since 1985. And health problems related to being overweight now account for about 30 percent of the increase in health care spending, he said.

“The smoking rate, fortunately, has been coming down. Not far enough, but that’s moving in the right direction. Obesity is moving in the wrong direction,” he said.

Congress also created a $15 billion, 10-year Prevention and Public Health Investment Fund as a part of health care reform.

The first $250 million went in June to increase the number of primary care doctors, nurses and other health care workers — more to battle sickness than promote wellness, critics said. Jeff Levi, executive director of the Trust for America’s Health, a nonprofit advocacy group, said he was disappointed that the money was “diverted.”

Dr. Koh, the assistant secretary, an oncologist and formerly a Harvard professor and Massachusetts state health chief, said, “It was a one-time investment and we need those providers to deliver preventive services.”

Out of the second $250 million, $16 million went in June to obesity prevention and $16 million to tobacco cessation. Parts of other funds could be used for those purposes. But the nation’s leading antismoking groups had written Ms. Sebelius in April asking for about 30 percent of the total, which would have been $150 million.

Next year the prevention fund from health care reform rises to $750 million and to $1 billion after that, so the dueling organizations fighting smoking or obesity will be competing for a much larger pot of money.

Antismoking Efforts Lose Ground to Obesity Fight – NYTimes.com.

If you had to choose one public health problem to attack, which would it be: teenage smoking or childhood obesity?

To answer that question, you might want to pose another. Who will have the harder road in life, or indeed the longer one: the teenage puffer or the chubby child?
Pitting smoking against obesity is tricky because it can mean comparing apples and bonbons, but there is some suggestion that a kind of weird zero-sum game is actually going on. And some smoking opponents fear that a choice has been made — with obesity the winner, quite possibly for the wrong reasons.

“Obesity is the new kid on the block, relatively speaking,” said Kenneth E. Warner, dean of the University of Michigan’s school of public health. “Tobacco is old news.”

When it comes to smoking, said Stanton A. Glantz, director of the University of California at San Francisco’s Center for Tobacco Control Research and Education, “we really haven’t had anyone pushing it to the top of the agenda.” That is a problem. “It’s not that I am for obesity,” he said, but he finds it less than encouraging, for example, that the hugely influential Robert Wood Johnson Foundation is pulling back from its anti-smoking efforts while directing its money and resources to preventing childhood obesity.

Then there is Michelle Obama’s campaign, Let’s Move, to prevent childhood obesity. And in May, the White House Task Force on Childhood Obesity announced its goal — reduce the rate of childhood obesity, now 17 percent, to 5 percent by 2030.

With all this effort directed at childhood obesity, along comes a report saying that progress against teenage smoking has stalled. The report, from the Centers for Disease Control and Prevention, showed smoking among high school students at 19.5 percent in 2009. The goal had been to reduce it to 16 percent by 2010.

There are a variety of estimates for the death toll from obesity, Dr. Warner said, but, whatever it is, “the death toll from smoking is higher.”

Even if it were possible to calculate the lifetime health risks a fat child faces, combating obesity is not so easy. Jeffrey Friedman, an obesity researcher at Rockefeller University, notes that there are many assumptions about what will work — more healthful foods in schools, a soda tax, getting children to be more active. Yet no interventions, when tested in large studies, have caused a big difference in children’s or teenagers’ weights.

Suppose, though, there were a method, and suppose the nation had to make a choice between proven anti-obesity programs and proven anti-smoking programs. What would be best for a child with a predisposition to be obese and to smoke? Should you have programs that would prevent the child from gaining weight? Or should you wait until the child is a teenager and institute programs to prevent smoking?

“That’s a hard call,” said Kelly D. Brownell, director of the Rudd Center for Food Policy and Obesity at Yale University. When it comes to health, “it’s hard to think that anything could be worse than smoking,” he said. But obesity has a social stigma attached, which “carries a cost no matter what the medical consequences are.”

It’s an even harder call than that, Dr. Friedman says, because it is so difficult to assemble a group of children in whom obesity was actually prevented. Without such a group, investigators cannot rigorously assess long-term health benefits. Maybe someone with a genetic predisposition to be fat and get high blood pressure, for example, would get high blood pressure even if obesity were prevented. It might be like taking an aspirin when you have the flu — your fever might go down, but the infection is unchanged.

On the other hand, Dr. Friedman noted, the question of health benefits is answered for smoking. A person who stops will almost immediately substantially reduce the risk for heart disease. The person’s risk for lung cancer will be nearly frozen at whatever it was at the time smoking stopped. Half of teenage smokers quit.

But if smoking continues, heart disease risk remains high, and the risk of lung and other cancers continues to increase.

“I certainly don’t want to go on record as saying too much money is going into obesity prevention,” Dr. Friedman said. Yet “smoking very clearly represents a substantial health risk.”

Of course, no one wants to set up a contest for which is worse, smoking or obesity. They are the two main culprits when it comes to preventable deaths, Dr. Warner said. He also said that he did not think a shortage of money was an excuse to favor one prevention program over the other. “Yes, in some objective conceptual world there is tradeoff,” he said. But “let’s face it, there’s an awful lot of useless stuff we spend money on.”

James S. Marks, a vice president at Robert Wood Johnson, said the foundation was spending less on anti-smoking efforts but had not abandoned them. The foundation’s role, he said, is to get efforts started — as it did with smoking prevention. “Now we are doing it with obesity.”

Whether a Child Lights Up, or Chows Down – NYTimes.com.

What to do about the obesity epidemic? Here’s a thought: Substitute “tobacco” for “junk food.” That provides a pretty clear road map about what government authorities should be doing to safeguard public health.

Unfortunately, officials are instead just reheating the same old leftovers.

Dietary guidelines issued recently by the U.S. Department of Agriculture basically say Americans need to ease up on the salt, sugar and saturated fats, and instead eat more fruits and veggies.

In fact, more than two-thirds of adults over 20 are either overweight or obese, the CDC says. About a third of all American kids fall into that category.

“It’s not that we’re morons and have no idea what’s good for us,” said Harold Goldstein, executive director of the California Center for Public Health Advocacy, a nonprofit organization. “It’s the world around us. We’re influenced to eat by our environment.”

In other words, we might know in our heads that a Twinkie or a chocolate shake is a heart attack waiting to happen. But our gut just can’t resist the siren call of all that tasty sugar or fat. And so we eat.

And eat.

And eat.

Food and beverage companies have long argued that if their products are used in moderation, they don’t pose a danger to public health. They also say it’s unfair to blame them for causing the obesity epidemic.

“If we really want to solve this national public health challenge, we must focus on educating Americans through comprehensive approaches that include nutrition education based in fact and focusing on total diet and exercise,” Susan Neely, head of the American Beverage Assn., said in a statement.

Personal responsibility is certainly a factor — no one forces us to stuff our faces. But Goldstein and other health advocates say consumers are brazenly manipulated by an industry that spends billions of dollars annually getting us to consume what it knows is bad for us.

“Up to now, it’s been a complete free-for-all, with the food industry convincing us to eat more and more of their high-fat, high-salt, high-sugar products,” Goldstein said. “It’s time that this was addressed through public policy.”

And tobacco regulation shows the way.

The rate of adults who smoke peaked at 45% in 1954, according to Gallup. It remained around 40% through the early 1970s and then started dropping as awareness about the dangers of nicotine grew, and as state and federal officials enacted anti-smoking programs.

Today, the adult smoking rate is about 20%. The same percentage applies to older teens, while about 6% of younger teens are smokers, according to the CDC.

The answer seems obvious: If we want to protect ourselves from a deadly epidemic of heart disease, diabetes and other ailments, just as we’ve taken steps to protect ourselves from an epidemic of lung cancer, we need to act.

And that means strict — some might say draconian — measures to reduce consumption of what’s bad for us, and aggressive campaigns to get us to eat and behave in a healthier fashion.

“It doesn’t seem at all draconian to me,” said Toni Yancey, a professor of health sciences at the UCLA School of Public Health. “We need to change social norms to make certain foods less appealing, just as we made it less appealing to smoke.”

We’re already removing sugary sodas and junk food from schools, and we’re doing it to help kids be healthier. Surely the same rationale applies to the rest of society.

I’m not saying we close down all McDonald’s and Burger King outlets. I’m saying we significantly limit advertising and sponsorship by companies selling, as Goldstein put it, high-fat, high-salt, high-sugar products.

This has worked for tobacco. It’s worked (on a largely volunteer basis) for alcohol. It can work for junk food.

Yancey said a good place to start would be government buildings — eliminate all bad-for-you foods and beverages. Instead, make healthful alternatives available. Gradually, if the political will can be found, expand the junk food ban to all workplaces, just as smoking bans spread from the public to the private sector.

Meanwhile, we need to step up wellness efforts to get people to make healthier choices and exercise more. These programs should be funded by levies on the foods that contribute most to obesity, and the obvious place to start is soda.

The beverage industry fiercely opposes such ideas. The chief financial officer of Coca-Cola Co., Gary Fayard, said at an industry conference this month that soda makers need to band together to fight any new taxes on their products.

Researchers at Harvard University say soft drinks are a “major driver” of obesity in the United States, and that raising the price of a can of soda by about a third could cut consumption by as much as 26%.

Tax money could also be put to better use.

“Because we subsidize corn, it ends up as high-fructose corn syrup,” Yancey said. “Why not subsidize healthy foods instead?”

I asked her what she thinks the obesity rate will be 30 years from now.

“I think it will be even higher,” Yancey replied. “Adults will be fatter.”

But if we act now, she said, future generations of kids won’t be exposed to all the cues and temptations that contribute to runaway waistlines.

“Hopefully they’ll be less fat,” Yancey said. “That’s where we’ll turn the tide.”

Obesity and junk food: Taking a cue from tobacco control – latimes.com.

The Associated Press wrote today about employers that are offering their workers financial incentives for losing weight. Too bad they’re unlikely to work, the AP quotes some experts as saying, noting that while cash rewards have been shown to increase smoking quit rates, losing weight is a whole different ballgame. For one thing, you can toss your cigs forever, but food is a necessity.

Still, we were curious about how other strategies that have been used against tobacco might apply to the obesity problem:

Taxes: Cigarettes are taxed by the feds,  states and some localities (NYC has a $1.50 per pack tax). In the obesity arena, the debate has focused on sugary sodas and drinks. It’s unclear whether those taxes actually work to curb consumption, though, and the case for them is as much about plugging holes in state budgets as public health.

Marketing restrictions: The 1998 tobacco settlement was chock-full of  restrictions on marketing cigarettes to youth, and more curbs followed. There have been plenty of calls — including one from the White House’s recent report on childhood obesity — for food companies to pull back on their marketing of less-than-healthful foods to kids. ( Here’s how the Center for Science in the Public Interest rates different food and entertainment companies on their marketing practices.) Also important is making the alternatives — i.e. fruits, veggies, whole grains and low-fat dairy — more appealing, Steven Kelder, a professor of epidemiology at the University of Texas School of Public Health, tells the Health Blog. Right now there’s not a lot of marketing support behind those products compared to things like sugary cereals and sodas.

Aversion: If you’ve ridden the NYC subways, you’ve seen the grody health department ads showing soda being poured from a bottle and turning into a massive fat blob as it hits the glass. They’re similar to graphic print and TV ads that illustrate the health consequences of smoking — and are so stomach-turning that cigarette makers are suing NYC. That kind of anti-fat ad alone “isn’t going to reduce BMIs,” says Kelder. “But it does generate buzz, and gets people talking.”

Stigma: Dirty looks and bans in public areas reflect that smoking is now considered a disgusting, unhealthy habit rather than an acceptable social practice. But stigmatizing obesity “is definitely not the way to go with children” and is “wrong” for adults, too, says Kelder. Research has shown that it may actually discourage better eating habits as well as reducing motivation to exercise. More important are positive efforts like school- and community-based programs that teach kids about nutrition and physical activity, he says.

via If It Worked to Curb Smoking, Shouldn’t It Work to Curb Obesity? – Health Blog – WSJ.

Until last year, the residents of Albert Lea, Minn., were no healthier than any other Americans. Then the city became the first American town to sign on to the AARP/Blue Zones Vitality Project—the brainchild of writer Dan Buettner, whose 2008 book, The Blue Zones, detailed the health habits of the world’s longest-lived people. His goal was to bring the same benefits to middle America—not by forcing people to diet and exercise, but by changing their everyday environments in ways that encourage a healthier lifestyle.

What followed was a sort of townwide makeover. The city laid new sidewalks linking residential areas with schools and shopping centers. It built a recreational path around a lake and dug new plots for community gardens. Restaurants made healthy changes to their menus. Schools banned eating in hallways (reducing the opportunities for kids to munch on snack food) and stopped selling candy for fundraisers. (They sold wreaths instead.) More than 2,600 of the city’s 18,000 residents volunteered, too, selecting from more than a dozen heart-healthy measures—for example, ridding their kitchens of supersize dinner plates (which encourage larger portions) and forming “walking schoolbuses” to escort kids to school on foot.

The results were stunning. In six months, participants lost an average of 2.6 pounds and boosted their estimated life expectancy by 3.1 years. Even more impressive, health-care claims for city and school employees fell for the first time in a decade—by 32 percent over 10 months. And benefits didn’t accrue solely to volunteers. Thanks to the influence of social networks, says Buettner, “even the curmudgeons who didn’t want to be involved ended up modifying their behaviors.”

Isn’t it time we all followed Albert Lea’s example? Diet and exercise programs routinely fail not for lack of willpower, but because the society in which we live favors unhealthy behaviors. In 2006, cardiovascular disease cost $403 billion in medical bills and lost productivity. By 2025 an aging population is expected to drive up the total by as much as 54 percent. But creative government programs could help forestall the increases—and help our hearts, too. A few suggestions:

Sponsor “commitment contracts” to quit smoking. Yale economist Dean Karlan spearheaded a test program in the Philippines in which smokers who wanted to quit deposited the money they would have spent on cigarettes into a special bank account. After six months those who had succeeded got their money back, while those who had failed lost it. Such a program could be run here by public-health clinics and offer greater incentives, such as letting winners divvy up the money forfeited by losers. Even without such an enhancement, says Karlan, “Filipino participants were 39 percent more likely to quit than those who were not offered the option.

“Require graphic warnings on cigarette packages. It’s easy to disregard a black-box warning that smoking is “hazardous to your health.” It’s not so easy to dismiss a picture of gangrenous limbs, diseased hearts, or chests sawed open for autopsy. These are exactly the types of images that the law now requires on cigarette packages in Brazil. In Canada, such warning images must cover at least half the wrapping. In 2001, the year after the Canadian law took effect, 38 percent of smokers who tried to quit cited the images. Think of it as truth in advertising.

Subsidize whole grains, fruits, and vegetables in the food-stamp program. The underprivileged tend to have disastrously unhealthy diets, and no wonder: $1 will buy 100 calories of carrots—or 1,250 calories of cookies and chips. The government should offer incentives for buying produce. The Wholesome Wave Foundation has shown the way in 12 states, providing vouchers redeemable at farmers’ markets to people in the SNAP program (the official name for food stamps). “We’ve seen purchases of fruits and vegetables double and triple among recipients,” says president and CEO Michel Nischan.

Set targets for salt reduction. The average American consumes twice the recommended daily maximum of sodium, most of it from processed foods. The result: high blood pressure, heart attacks, and strokes. But New York City is leading a campaign to encourage food manufacturers to reduce added sodium over the next five years. Consumers will barely notice the changes because they will occur so gradually. The FDA should follow New York’s lead.

Incorporate physical education into No Child Left Behind. American children may be prepping like crazy for standardized tests, but they’re seriously lagging in physical fitness. Regular exercise improves mood, concentration, and academic achievement. It can also help reverse the growing trend toward type 2 diabetes and early heart disease in children and teenagers.

Require that sidewalks and bike lanes be part of every federally funded road project. The government already spends 1 percent of transportation dollars on such projects. It should increase the level to 2 to 3 percent. When sidewalks are built in neighborhoods and downtowns, people start walking. “The big win for city government is that anything built to a walkable scale leases out for three to five times more money, with more tax revenue on less infrastructure,” says Dan Burden, executive director of the Walkable and Livable Communities Institute. He recommends a “road diet” in which towns eliminate a lane or two of downtown traffic and substitute sidewalks. “When roads slim down, so do people,” he says.

It’s all reasonable. But Dan Buettner isn’t waiting for any of these measures to surmount the inevitable industry hurdles. This year he’s looking to scale up the Blue Zones Vitality Project to a city of 100,000 or more. “If this works, it could provide a template for the government that’s replicable across the country,” says his colleague Ben Leedle, CEO of Healthways, which is developing the next phase of the project. The challenges will be much steeper in large cities. But with measures like these, we could one day find ourselves growing fitter without specifically dieting or exercising. Finally, a New Year’s resolution we can all keep.

via How Public Policy Can Prevent Heart Disease – Newsweek.com.

Editorial J. Michael Gaziano, MD, MPH JAMA. 2010;303(3):(doi:10.1001/jama.2009.2025).

In 1900, Henry Ford unveiled the first car made in Detroit, the International Ladies’ Garment Workers Union was founded in New York, and San Francisco was placed under a federal quarantine to prevent the spread of bubonic plague. Infectious disease was a major concern, and the most common causes of death in the United States and in many parts of the world at the time were pneumonia and tuberculosis. Today, most individuals die of cardiovascular disease or cancer. This dramatic shift in the illnesses that cause the majority of death and disability has been divided into 4 stages known as the epidemiologic transition.^1-2 In the last 2 decades, however, a fifth stage, marked by an alarming increase in overweight and obesity and continueddecreases in physical activity, has emerged. This ongoing trend is addressed by 2 articles^3-4 in this issue of JAMA.

The first stage, which dominated most of human history, was characterized by pestilence and famine, when infectious disease and malnutrition kept average life expectancy at about 30 years. In the second stage, occurring in the late 19th and early 20th centuries in the United States and Europe, industrialization and urbanization led to increasing wealth and a corresponding increase in the availability of food, an era termed receding pandemics. As the century continued, public health systems and cleaner water supplies and sewage systems combined with better nutrition drove down deaths from infectious disease and malnutrition, leading to declining infant and child mortality and an increased life expectancy. The third stage, degenerative and human-made diseases, characterized by increasing mortality from cardiovascular disease and cancer, emerged in the mid 20th century. Smoking,decreased activity levels in the workplace and at home, and increased intake of animal products and fats resulted in increasing prevalence of elevated blood pressure and cholesterol levels. Age-adjusted cardiovascular disease and cancer rates were at their peak.

By the mid 1960s, the United States had entered the fourth stage of delayed degenerative diseases. Cardiovascular disease mortality declined, related to preventive strategies such as smoking cessation programs and effective blood pressure control, acute coronary care units, and technological advances that included coronary artery bypass surgery.⁵

Despite the many advances in preventive medicine and treatment that reduced cardiovascular disease, the new stage of the epidemiologic transition, the age of obesity and inactivity, emerged to threaten the progress made in postponing illness and death to later in adult life spans. The steady gains made in both quality of life and longevity by addressing risk factors such as smoking, hypertension, and dyslipidemia are threatened by the obesity epidemic.

Over the last 40 years, the proportion of the US population considered to be overweight (body mass index [BMI] 25.0) and obese (BMI 30.0) has steadily increased. In the 1960-1962 National Health Examination Survey, an estimated 31.6% of men and women met the definition for “pre-obesity” (BMI between 25.0 and 29.9), and 13.4% were obese.⁶ The latest prevalence and trends in obesity data from the National Health and Nutrition Examination Survey (NHANES), reported by Flegal and colleagues³ in this issue of JAMA, show that in 2007-2008, 68.0% of US adults were overweight, of whom 33.8% were obese. More men than women were overweight or obese, 72.3% compared with 64.1%.

If the increase in obesity were to continue on the same track, researchers recently predicted that by 2020 almost half of US adults would meet the World Health Organization criteria for obesity.⁷ Compared with the previous 10-year period, the latest NHANES data suggest that the steady upward trend in overweight and obesity may have slowed.³Even though this finding is certainly good news, the statistics are still staggering—most Americans are overweight and a third are obese—a sobering situation, given the wide variety of deleterious health effects strongly linked to excess weight. These include increased risk of coronary heart disease, ischemic stroke, hypertension, dyslipidemia, type 2 diabetes, joint disease, cancer, sleep apnea, asthma, and a host of other chronic conditions.

Analyses from a national survey of almost 10 000 US adults suggest that obesity is associated with more chronic disorders and poorer health-related quality of life than smoking or problem drinking.⁸ If left unchecked, overweight and obesity have the potential to rival smoking as a public health problem, potentially reversing the net benefit that declining smoking rates have had on the US population over the last 50 years.⁷ Excess weight carries not only an enormous personal burden but an economic one as well. Medical spending for obesity-related conditions accounted for an estimated 10% of total annual US medical expenses in 2008, or $147 billion, according to the Centers for Disease Control and Prevention (CDC).⁹

These adverse lifestyle habits apparently have been passed on to the next generations. The prevalence of overweight and obesity in children and adolescents has increased in parallel with that in adults, and obese children often become obese adults. Based on the 2007-2008 NHANES data, the report by Ogden et al⁴ indicates that almost 17% of school-aged children and adolescents are obese, defined as BMI for age at or above the previously established 95th percentile, and almost 32% are categorized as at or above the 85th percentile of BMI for age, the lowest CDC cut point. It appears that the prevalence of high BMI among children and adolescents reached a plateau between 1999 and 2006. However, 1 group, the very heaviest boys (97th percentile) aged 6 through 19 years, has not followed this trend but rather seems to be getting heavier over time.

Early obesity strongly predicts later cardiovascular disease, and excess weight may explain the dramatic increase in type 2 diabetes, a major risk factor for cardiovascular disease. A large Swedish study found that being overweight in late adolescence was comparable with light smoking (fewer than 11 cigarettes per day) in increasing the risk of premature death.¹⁰ In that study population, being obese in late adolescence was as hazardous as heavy smoking in increasing the risk of dying over a 38-year period. Efforts such as revamping school lunches to be healthier and ensuring daily physical activity as part of the school curriculum are under way in some areas, but much more needs to be done to stem the tide of childhood obesity.

Even the developing world is seeing dramatic increases in obesity in children as well as adults. Many countries may experience the obesity “epidemic” the United States currently faces earlier in their epidemiologic transitions. For instance, more than 20% of Chinese children between the ages of 7 and 17 years living in large cities are now overweight,¹¹ and 1 in 5 Chinese adults is overweight or obese.¹² Other data indicate that as many as 60% of South African women may be overweight or obese.¹³

Unlike cigarette smoking, hypertension, and dyslipidemia, there is little consensus on the ideal approach to weight management. Numerous safe and effective therapies are available to lower blood pressure and cholesterol levels, and various over-the-counter products as well as prescription-only medication can be used for smoking cessation. These interventions have contributed to the decline in rates of cardiovascular disease events. In contrast, no large-scale, longer-term trials have demonstrated reduction in clinical events through any weight management strategy. Recent clinical trials suggest that pharmacotherapy and bariatric surgery may hold some promise in promoting weight loss, but long-term success and long-term risks as well as cost-effectiveness have not been fully evaluated.¹⁴ Thus, the centerpiece of weight management is lifestyle changes; however, promoting lifestyle changes to encourage weight reduction has been disappointing.

Although 25% of US men and 43% of US women may attempt to lose weight in any given year, failure rates are exceedingly high. Effective treatment strategies generally involve a multifaceted approach, including dietary counseling, behavioral modification, increased physical activity, and psychosocial support that promotes long-term changes rather than fad diets that offer short-term weight reduction, only to return the individuals to their previous habits after the short-term goal is achieved.

The reports by Flegal et al³ and Ogden et al⁴ in this issue of JAMA offer a glimmer of hope that in the United States at least, the steady, decades-long increases in overweight and obesity may have slowed or perhaps reached a plateau. But even if these trends can be maintained, 68% of US adults are overweight or obese, and almost 32% of school-aged US children and adolescents are at or above the 85th percentile of BMI for age. Given the risk of obesity-related major health problems, a massive publichealth campaign to raise awareness about the effects of overweight and obesity is necessary. Such campaigns have been successful in communicating the dangers of smoking, hypertension, and dyslipidemia; educating physicians, other clinicians, and the public has yielded significant returns. Major research initiatives are needed to identify better management and treatment options. The longer the delay in taking aggressive action, the higher the likelihood that the significant progress achieved in decreasing chronic disease rates during the last 40 years will be negated, possibly even with a decrease in life expectancy.

JAMA — Fifth Phase of the Epidemiologic Transition: The Age of Obesity and Inactivity, January 13, 2010, Gaziano 0 (2010): 2009.2025.

Although fewer people are smoking — and therefore less likely to die from cigarette-related causes — the obesity epidemic may negate any gains in life span, according to a new study.

By 2020, the typical 18-year-old will gain 0.31 years due to the drop in smoking rates (above and beyond life span increases caused by other factors). But the increase in obesity rates during the same period will reduce life expectancy by 1.02 years, the researchers say.

During the next 10 years, in other words, we’ll lose 0.71 years of our life span, time that we would have gained if so many people weren’t overweight, according to the estimates published this week in the New England Journal of Medicine (NEJM).

In addition, the increase in quality-adjusted life expectancy — a measure that takes into account levels of disability and other quality-of-life factors — will be reduced by 1.32 years. If all U.S. adults were nonsmokers of normal weight, life expectancy would increase by 3.76 years, or 5.16 quality-adjusted years, according to the study.

Health.com: Make healthy lunches your kids will actually eat

“Life expectancy is not going to decline,” says the study’s lead author, Susan T. Stewart, Ph.D., a researcher at the National Bureau of Economic Research, in Cambridge, Massachusetts. “But it could have risen by that much more if it weren’t for the increases in obesity.”

Stewart and her colleagues forecast life expectancy through the year 2020 using national survey data. Smoking, a major risk factor for lung disease, heart disease, and cancer, has decreased by 20 percent in the United States in the past 15 years, according to the study.

Over the same period, obesity has increased by 48 percent. Obesity contributes to a host of serious health problems, including heart disease, diabetes, joint problems, stroke, and some sleep disorders.

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By 2020, the report predicts, smoking will decrease by 21 percent, but 45 percent of the population will be obese.

Prior research has examined the effects of obesity on longevity, but this study is the first to examine the combined effects of obesity and smoking.

“No one ever has really done quite this linkage between smoking and obesity,” says S. Jay Olshansky, Ph.D., a professor of epidemiology and biostatistics at the School of Public Health at the University of Illinois at Chicago. “Some people have suggested we’re on the verge of dramatic increases in life expectancy because of reductions in smoking, but these authors are saying, ‘Hold on a minute; the negative effect of obesity is much greater.’”

The extent of obesity’s impact on life span “might be a real eye-opener,” says Stewart.

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Many people will question how a sedentary lifestyle can be as unhealthy as a deadly habit such as smoking, she says, adding that this is exactly why she and her colleagues believe this research is important. “We wanted to bring attention to the health of a population [that] is already not as healthy as it could be, and will continue and worsen,” she says.

The study does have limitations. The authors based their projections on a steady rate of change in obesity, for instance.

However, “childhood obesity has been rising dramatically, so the trends in the future are going to change by how long people have been obese,” says Olshansky, who did not participate in the current research, but projected similar obesity trends in a 2005 paper in the NEJM. “Younger generations are going to carry the obesity with them much longer,” leading to additional or more serious weight-related health risks, he says.

“If we don’t intervene, we are in trouble,” Olshansky adds.

Reversing the obesity trends reported in the study will likely require a concerted public health campaign similar to the one that has reduced smoking rates.

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“There are larger social issues to be addressed in combating the roots of obesity,” Stewart says. “These roots include sedentary lifestyles, widespread availability of high-calorie food in large portions, and reduced time for at-home food preparation.”

“Fixing obesity is going to require a change in our modern relationship with food,” Olshansky says. “I’m hopeful that we [will] begin to see a turnaround in this childhood obesity epidemic.”

The smoking trends used in the study were based on data from the National Health Interview Survey, and the body-mass index (BMI) trends were derived from the National Health and Nutrition Examination Survey. BMI levels were classified according to the World Health Organization’s guidelines for obesity.

via Decrease in smoking extends life span, but obesity may curb gains – CNN.com.