The Challenge We Face 3
I.Early Childhood 11
A.Prenatal Care 11
B.Breastfeeding 13
C.Chemical Exposures 17
D.Screen Time 18
E.Early Care and Education 19
II.Empowering Parents and Caregivers 23
A.Making Nutrition Information Useful 23
B.Food Marketing 28
C.Health Care Services 33
III.Healthy Food in Schools 37
A.Quality School Meals 37
B.Other Foods in Schools 42
C.Food-Related Factors in the School Environment 44
D.Food in Other Institutions 46
IV.Access to Healthy, Affordable Food 49
A.Physical Access to Healthy Food 49
B.Food Pricing 55
C.Product Formulation 59
D.Hunger and Obesity 61
V.Increasing Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . .65
A.School-Based Approaches . . . . . . . . . . . . . . . . . . . . . . . . . .68
B.Expanded Day and Afterschool Activities . . . . . . . . . . . . . . . . . . . .74
C.The “Built Environment” . . . . . . . . . . . . . . . . . . . . . . . . . . .78
D.Community Recreation Venues . . . . . . . . . . . . . . . . . . . . . . . .82
SOLVING THE PROBLEM OF CHILDHOOD OBESITY WITHIN A GENERATION
White House Task Force on Childhood Obesity Report to the President
The Challenge We Face
The childhood obesity epidemic in America is a national health crisis. One in every three children
(31.7%) ages 2-19 is overweight or obese.1 The life-threatening consequences of this epidemic create
a compelling and critical call for action that cannot be ignored. Obesity is estimated to cause 112,000
deaths per year in the United States,2 and one third of all children born in the year 2000 are expected to
develop diabetes during their lifetime.3 The current generation may even be on track to have a shorter
lifespan than their parents.4
Along with the effects on our children’s health, childhood obesity imposes substantial economic costs.
Each year, obese adults incur an estimated $1,429 more in medical expenses than their normal-weight
peers.5 Overall, medical spending on adults that was attributed to obesity topped approximately $40
billion in 1998, and by 2008, increased to an estimated $147 billion.6 Excess weight is also costly during
childhood, estimated at $3 billion per year in direct medical costs.7
Childhood obesity also creates potential implications for military readiness. More than one quarter of all
Americans ages 17-24 are unqualified for military service because they are too heavy.8 As one military
leader noted recently, “We have an obesity crisis in the country. There’s no question about it. These are
the same young people we depend on to serve in times of need and ultimately protect this nation.” 9
While these statistics are striking, there is much reason to be hopeful. There is considerable knowledge
about the risk factors associated with childhood obesity. Research and scientific information on the
causes and consequences of childhood obesity form the platform on which to build our national policies
and partner with the private sector to end the childhood obesity epidemic. Effective policies and
tools to guide healthy eating and active living are within our grasp. This report will focus and expand
on what we can do together to:
1. create a healthy start on life for our children, from pregnancy through early childhood;
2. empower parents and caregivers to make healthy choices for their families;
3. serve healthier food in schools;
4. ensure access to healthy, affordable food; and
5. increase opportunities for physical activity.
What is Obesity?
Obesity is defined as excess body fat. Because body fat is difficult to measure directly, obesity is often
measured by body mass index (BMI), a common scientific way to screen for whether a person is underweight,
normal weight, overweight, or obese. BMI adjusts weight for height,10 and while it is not a perfect
indicator of obesity,11 it is a valuable tool for public health.
Adults with a BMI between 25.0 and 29.9 are considered overweight, those with a BMI of 30 or more are
considered obese, and those with a BMI of 40 or more are considered extremely obese.12 For children and
adolescents, these BMI categories are further divided by sex and age because of the changes that occur
SOLVING THE PROBLEM OF CHILDHOOD OBESITYThe childhood obesity epidemic in America is a national health crisis. One in every three children
(31.7%) ages 2-19 is overweight or obese.1 The life-threatening consequences of this epidemic create
a compelling and critical call for action that cannot be ignored. Obesity is estimated to cause 112,000
deaths per year in the United States,2 and one third of all children born in the year 2000 are expected to
develop diabetes during their lifetime.3 The current generation may even be on track to have a shorter
lifespan than their parents.4
Along with the effects on our children’s health, childhood obesity imposes substantial economic costs.
Each year, obese adults incur an estimated $1,429 more in medical expenses than their normal-weight
peers.5 Overall, medical spending on adults that was attributed to obesity topped approximately $40
billion in 1998, and by 2008, increased to an estimated $147 billion.6 Excess weight is also costly during
childhood, estimated at $3 billion per year in direct medical costs.7
Childhood obesity also creates potential implications for military readiness. More than one quarter of all
Americans ages 17-24 are unqualified for military service because they are too heavy.8 As one military
leader noted recently, “We have an obesity crisis in the country. There’s no question about it. These are
the same young people we depend on to serve in times of need and ultimately protect this nation.” 9
While these statistics are striking, there is much reason to be hopeful. There is considerable knowledge
about the risk factors associated with childhood obesity. Research and scientific information on the
causes and consequences of childhood obesity form the platform on which to build our national policies
and partner with the private sector to end the childhood obesity epidemic. Effective policies and
tools to guide healthy eating and active living are within our grasp. This report will focus and expand
on what we can do together to:
1. create a healthy start on life for our children, from pregnancy through early childhood;
2. empower parents and caregivers to make healthy choices for their families;
3. serve healthier food in schools;
4. ensure access to healthy, affordable food; and
5. increase opportunities for physical activity.
What is Obesity?
Obesity is defined as excess body fat. Because body fat is difficult to measure directly, obesity is often
measured by body mass index (BMI), a common scientific way to screen for whether a person is underweight,
normal weight, overweight, or obese. BMI adjusts weight for height,10 and while it is not a perfect
indicator of obesity,11 it is a valuable tool for public health.
Adults with a BMI between 25.0 and 29.9 are considered overweight, those with a BMI of 30 or more are
considered obese, and those with a BMI of 40 or more are considered extremely obese.12 For children and
adolescents, these BMI categories are further divided by sex and age because of the changes that occur
during growth and development. Growth charts from the Centers for Disease Control and Prevention (CDC) are used to calculate children’s BMI. Children and adolescents with a BMI between the 85th and 94th percentiles are generally considered overweight, and those with a BMI at or above the sex-and age-specific 95th percentile of population on this growth chart are typically considered obese.
Determining what is a healthy weight for children is challenging, even with precise measures. BMI is often used as a screening tool, since a BMI in the overweight or obese range often, but not always, indicates that a child is at increased risk for health problems. A clinical assessment and other indicators must also be considered when evaluating a child’s overall health and development.13
On the topic of Breastfeeding the report talks about several factors in detail- I have highlighted several points that I think are important and created a few foot notes of my comments at the bottom of the Breastfeeding section.
B. Breastfeeding
Children who are breastfed are at reduced risk of obesity.77 Studies have found that the likelihood of obesity is 22% lower among children who were breastfed.78 The strongest effects were observed among adolescents, meaning that the obesity-reducing benefits of breastfeeding extend many years into a child’s life. Another study determined that the risk of becoming overweight was reduced by 4% for each month of breastfeeding.79 This effect plateaued after nine months of breastfeeding.
Despite these health benefits (*1), although most (74%) babies start out breastfeeding, within three months, two-thirds (67%) have already received formula or other supplements. By six months of age, only 43% are still breastfeeding at all, and less than one quarter (23%) are breastfed at least 12 months.80 In addition, there is a disparity between the prevalence of breastfeeding among non-Hispanic black infants and those in other racial or ethnic groups. For instance, a recent CDC study showed a difference of greater than 20 percentage points in 13 states.81
SOLVING THE PROBLEM OF CHILDHOOD OBESITY
The protective effect of breastfeeding likely results from a combination of factors. First, infant formula contains nearly twice as much protein per serving as breast milk. This excess protein may stimulate insulin secretion in an unhealthy way.82 Second, the biological response to breast milk differs from that of formula. When feeding a baby, the mother’s milk prompts the baby’s liver to release a protein that helps regulate metabolism.83 Feeding formula instead of breast milk increases the baby’s concentrations of insulin in his or her blood, prolongs insulin response,84 and, even into childhood, is associated with unfavorable concentrations of leptin, a hormone that inhibits appetite and controls body fatness.85 Despite the well-known health benefits of breastfeeding and the preference of most pregnant women to breastfeed,86 numerous barriers make breastfeeding difficult. For first-time mothers, breastfeeding can be challenging, even for those who intend to breastfeed. For those who have less clear intent to breastfeed, cultural, social, or structural challenges can prevent breastfeeding initiation or continuation. For example, immediately after birth, many babies are unnecessarily given formula and separated from their mothers, making it harder to start and practice breastfeeding. Also, hospital staff are often insufficiently trained in breastfeeding support.
The Joint Commission on the Accreditation of Hospitals, the body that accredits hospitals and health care organizations for most State Medicaid and Medicare reimbursement, now expects hospitals to track and improve their rates of exclusive breastfeeding. Hospitals that meet specific criteria for optimal breastfeeding-related maternity care are designated as “Baby Friendly” by Baby-Friendly U.S.A. This non-governmental organization has been named by the U.S. Committee for UNICEF as the designating authority for UNICEF/WHO standards in the United States. Currently only 3% of births in America occur in Baby-Friendly facilities.87
While breastfeeding could be far more widespread than it is today, it is not a viable alternative for all mothers and babies. Specific guidance and support options should also be made available for those who cannot breastfeed. (*2) Parents and caregivers of babies also may benefit from guidance about when to start feeding them solid foods, since early introduction of solids (prior to six months) increases the risk for childhood obesity.88
The protective effect of breastfeeding likely results from a combination of factors. First, infant formula contains nearly twice as much protein per serving as breast milk. This excess protein may stimulate insulin secretion in an unhealthy way.82 Second, the biological response to breast milk differs from that of formula. When feeding a baby, the mother’s milk prompts the baby’s liver to release a protein that helps regulate metabolism.83 Feeding formula instead of breast milk increases the baby’s concentrations of insulin in his or her blood, prolongs insulin response,84 and, even into childhood, is associated with unfavorable concentrations of leptin, a hormone that inhibits appetite and controls body fatness.85 Despite the well-known health benefits of breastfeeding and the preference of most pregnant women to breastfeed,86 numerous barriers make breastfeeding difficult. For first-time mothers, breastfeeding can be challenging, even for those who intend to breastfeed. For those who have less clear intent to breastfeed, cultural, social, or structural challenges can prevent breastfeeding initiation or continuation. For example, immediately after birth, many babies are unnecessarily given formula and separated from their mothers, making it harder to start and practice breastfeeding. Also, hospital staff are often insufficiently trained in breastfeeding support.
The Joint Commission on the Accreditation of Hospitals, the body that accredits hospitals and health care organizations for most State Medicaid and Medicare reimbursement, now expects hospitals to track and improve their rates of exclusive breastfeeding. Hospitals that meet specific criteria for optimal breastfeeding-related maternity care are designated as “Baby Friendly” by Baby-Friendly U.S.A. This non-governmental organization has been named by the U.S. Committee for UNICEF as the designating authority for UNICEF/WHO standards in the United States. Currently only 3% of births in America occur in Baby-Friendly facilities.87
While breastfeeding could be far more widespread than it is today, it is not a viable alternative for all mothers and babies. Specific guidance and support options should also be made available for those who cannot breastfeed. (*2) Parents and caregivers of babies also may benefit from guidance about when to start feeding them solid foods, since early introduction of solids (prior to six months) increases the risk for childhood obesity.88
Workplace and Child Care Accommodations
Research has demonstrated that support is essential for helping mothers establish and continue breastfeeding as they return to work or school and make use of child care services.89 Many women return to work soon after their baby’s birth, yet 75% of employers do not offer accommodations for them to breastfeed or express milk at work.90
Changes are underway, however. Following the lead of states whose laws requiring employers to make accommodations, the recently-enacted Affordable Care Act requires employers to provide a reasonable break time and a place for breastfeeding mothers to express milk for one year after their child’s birth.91 Employers with fewer than 50 employees are not subject to these requirements if compliance would impose an undue hardship. The location cannot be a bathroom, and must be shielded from view and free from intrusion from co-workers and the public. The return on investment of companies that assist breastfeeding employees through appropriate support and accommodations is well-documented. Companies benefit through better employee retention, lower health care costs, and better work attendance.92
Support for breastfeeding in child care settings is important as well. Among women whose infants are cared for outside the home, irrespective of their intent to breastfeed, those who report better support for breastfeeding from early learning settings (such as refrigerated storage for breast milk, a commitment to feed it to the child, or privacy space for on-site breastfeeding) are more likely to breastfeed longer.93
Support Programs
In many communities, role models for breastfeeding are rare, and new mothers do not know where to turn for breastfeeding assistance. Volunteer networks of experienced breastfeeding mothers such as the La Leche League provide help for some mothers, but networks like this are not available in many communities. According to the CDC’s annual State Breastfeeding Report Card, there were 34 breastfeeding support groups per 100,000 live births in 2009, which means about one support group for every 3000 new babies. Peer support programs, such as the Peer Counselor program delivered as part of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), provide counseling skills, training, and support to experienced breastfeeding mothers so they can effectively support new mothers. (*3) Recently, federal funds were provided to further expand the availability of peer counseling in local WIC clinics. Prenatal counseling on breastfeeding can also have positive impacts on breastfeeding rates,94 and pre- and postnatal intervention together with peer counseling is most effective.95 (*3)
Recommendations
Recommendation 1.3: Hospitals and health care providers should use maternity care practices that empower new mothers to breastfeed, such as the Baby-Friendly hospital standards. Hospitals and health care providers should routinely provide evidence-based maternity care (*4) that empowers parents to make informed infant feeding decisions as active participants in their care, and improves new mothers’ ability to breastfeed successfully. Examples of specific practices and policies include: skin-to-skin contact between the mother and her baby; teaching mothers how to breastfeed; and early and frequent breastfeeding opportunities.
Hospitals, health care providers, and health insurers should also help ensure that new mothers receive proper information and support on breastfeeding when they are released from the hospital.(*3)
Recommendation 1.4: Health care providers and insurance companies should provide information to pregnant women and new mothers on breastfeeding, including the availability of educational classes, and connect pregnant women and new mothers to breastfeeding support programs to help them make an informed infant feeding decision.
Recommendation 1.5: Local health departments and community-based organizations, working with health care providers, insurance companies, and others should develop peer support programs that empower pregnant women and mothers to get the help and support they need from other mothers who have breastfed. Peer support networks should exist in all communities across the country, allowing all new mothers to easily identify and obtain help from trained breastfeeding peer counselors.(*5) Community organizations can foster the creation of peer support networks through expansion of programs like the WIC Breastfeeding Peer Counseling program. They can work with local breastfeeding coalitions to ensure existence of other peer support networks, such as La Leche League groups or Nursing Mothers Councils. They can also foster the creation of mother-to-mother support groups in community health centers and advertise these groups, particularly as part of the hospital discharge process.
Early Head Start (EHS) programs that enroll pregnant women, including pregnant teenagers, can also support community breastfeeding networks. EHS can provide home visits and reach out to pregnant and breastfeeding mothers to encourage and support breastfeeding, including by providing professional and peer opportunities to disseminate information and provide on-going support. Funding for evidence-based home visitation programs in the recently-enacted Affordable Care Act96 will complement this program.
Private companies, including those that market baby products, can also help support and promote these types of community supports for mothers.
Recommendation 1.6: Early childhood settings should support breastfeeding. Child care centers and providers, health care providers, and government agencies should provide accurate information about the storage and handling of breast milk. They should also make sure child care employees and providers know how to store, handle, and feed breast milk, and understand the importance of breastfeeding.
Benchmarks of Success
An increase in breastfeeding rates. Several government sources provide statistics on breastfeeding rates. The most comprehensive source of information is the National Immunization Survey, which provides annual national, state, and selected urban-area estimates of breastfeeding initiation, duration, and exclusivity. In addition to questions on breastfeeding, the survey asks about the introduction of infant formula and other supplementary foods. As noted above, according to the survey, currently 30% of babies age nine months or younger are breastfed. This should increase by 5% every two years, so that by 2015, half of babies are breastfed for at least nine months.
*1
No other health benefits are mentioned on the topic of breastfeeding. While I realize that this document is directed solely on Obesity, I think that not mentioning the other benefits lessons the overall importance of breastfeeding for the first 12 months of an infants life. Lets face it: most people realize that eating fast food as the vast proportion of their diet causes weight gain, yet they still do it. Focusing only on the obesity subject on the health benefits of breastfeeding is, I think, not going to sway many women who haven't breastfed before into changing their perspective.
*2
Yes, we all know that there are some women who are physically not able to exclusively breastfeed their infants- studies have proven though that 97% of women ARE capable of nursing their infants exclusively according to WHO breastfeeding guidelines. Making open ended statements such as:
" it is not a viable alternative for all mothers and babies. Specific guidance and support options should also be made available for those who cannot breastfeed." creates a giant loophole for healthcare providers and families and mothers to say "Oh, I just couldn't breastfeed.." When making these recommendations I firmly believe that the real numbers should be openly discussed.
*3
Peer support groups, and prenatal education and support are a great way to educate mothers and families on the importance of breastfeeding, but this Report glaringly overlooks the biggest problem with both of these support methods:
Who is going to train these groups? What criteria are they using? Who's information and techniques are they getting their information from in order to train the support staff/volunteers?
The biggest problem, besides the lack of professional support, is that the information given out is many times inaccurate, misleading, or downright false. Until there is an education program set up to properly educate the educators and medical professionals, Breastfeeding support will continue to fail to meet the goals recommended in this report. As a mother who has given birth in 4 different hospitals I can personally attest to the conflicting advice and support given by maternity professionals. I hear from new mothers regularly about the problems they faced when trying to find help with breastfeeding, stories that shock and appal me- mothers being told that their breasts are too big/small to breastfeed, their babies are too big/small to breastfeed, their nipples are not the right shape to breastfeed, they have to take medication/painkillers so they can't breastfeed, the baby is jaundiced and can't breastfeed... it goes on and on. Until Doctors, Nurses, Midwives (yes, even midwives) receive the proper training from an accredited program, breastfeeding will be constantly challenged.
*4
"Evidence Based Maternity Care".... Again a serious problem in hospitals- but it doesn't just start with educating the parents to make the best choices for infant feeding, as it is implied in the report. It goes Far beyond that. Evidence Based Maternity Care needs to include education of parents on the scope of medical intervention during childbirth and how they can effect breastfeeding, ie: inductions, epidurals and of course Caesarean Section (all of which are closely linked to each other) cause greater difficulties in establishing an early and lasting breastfeeding relationship. Evidence Based Maternity Care also needs to include the re-education of hospitals and doctors on the topics of Jaundice and blood sugar levels in the newborn- both of which are the number one reason given for unnecessary formula supplementation in newborn babies.
*5
More importantly, setting up systems of (properly trained) peer support across the country would also facilitate a change in the public perception of breastfeeding. The more we talk about breastfeeding, the more we see breastfeeding, and the more we work towards openly supporting breastfeeding, and quicker breastfeeding attitudes will change in the public eye and become more "acceptable".
The Obesity Report is very interesting, and really should be read from beginning to end (HERE to read the original and entire report)
It discusses many different topics- which, like the Breastfeeding topic, touches on subjects, but seems to miss some rather important points. But read it yourself and let me know what you think!!
