Alex Hawkes: How long has the issue of obesity been a strong focus for the Centres for Disease Control and Prevention (CDC) and how has that focus intensified in recent years?
Doctor William Dietz: Obesity started becoming a strong focus for the CDC about ten years ago. It was around that time I became division director and we began trying to make the policy arena recognise that obesity was a significant problem.
Although the focus has only intensified in recent years, I think one of the major turning points was when we published a series of maps in 1999 that highlighted just how many states in America have a significant problem with obesity. This changed the population’s perspective on whether obesity was an epidemic or not. After people saw the maps, it was no longer an issue of asking if there was a problem, but more of a case of asking what we do next.
AH: So what did you do next?
WD: The US population didn’t just decide in 1980 that it was going to start gaining weight – the rapid gain in weight was a consequence of the change in environment. The challenge for us therefore became about addressing those environmental changes so we established six population-based strategies to do just that.
These included increasing physical activity, encouraging breast feeding, increasing fruit and vegetable intake, reducing sugary sweets and beverages, reducing television time and reducing the intake of high-energy intensity food.
AH: In what ways did you engage these strategies into the day-to-day lives of American citizens?
WD: Common schemes found across many states involve removing sugary sweets and beverages from schools so they are less available to children or making breast feeding the default strategy in maternity care hospitals.
Some states have put forward their own initiatives to tackle their own unique problems, such as a policy initiated in Los Angeles to restrict the building of new fast food outlets in the South Los Angeles area, which already possess a high number of said outlets.
These are all good examples of the sorts of policies we think are relevant and support. The analogy here is tobacco – to control the use of tobacco to the extent that has been done today, tobacco was made less available to adolescents, the products became heavily taxed and their advertising became regulated. A combination of these interventions made the difference.
AH: So presumably the challenge of obesity differs heavily from one state to another; which states have therefore been particularly proactive in tackling the issue?
WD: I think the model states are North Carolina, New York, Massachusetts and Washington – simply because they have all adopted multi-component strategies that attack the issue from a number of different angles. Like tobacco, this epidemic is not likely to respond to a single intervention, but it may respond to multiple interventions. These states have not just recognised, for example, the need to reduce a child’s sugary sweets and beverage intake, but the need to do this alongside monitoring that child’s television watching times and increasing their physical education programmes.
AH: What research is carried out by the CDC in order to discover more about the lasting impact of obesity in the US and how to prevent it?
WD: We have done a fair amount of research into the natural history of obesity, particularly focusing on childhood obesity. This has given us significant reason to believe that about half of severe adulthood obesity begins in childhood.
We are certainly not alone in this sort of research, but I think where our focus differs is our need to identify what interventions can address certain behaviours.
We are very interested, for example, in penetrating the farming markets. One of the things we are developing is a fruit and vegetables report card that allows us to see how successful each state is in addressing its fruit and vegetable intake.
Another thing we are investigating is the idea of worksite-based interventions aimed at increasing nutrition and physical activity. We have created a tool called ‘Lean Works’ which helps small- and medium- sized employers calculate the cost of obesity in their workforce through a series of evaluations.
AH: In what ways do you work alongside the healthcare sector in trying to curb the obesity issue?
WD: Clearly the 30% of the US adult population that are obese require medical support, but they are not going to successfully recover unless there are also complimentary changes to their surrounding environment. So we believe any medical planning has to be done in partnership with communities.
AH: In particular, what are the financial implications for hospitals having to construct special facilities for treating the obese?
WD: It is a substantial cost because accommodating obese patients can be expensive. They require stronger and wider gurneys, floor-mounted rather than wall-mounted toilets and extra-sized beds.
AH: In your opinion, just how big is the risk of obesity to the US population and how important is it to curb obesity rates in the coming years?
WD: It is a very substantial risk not just to the health of the population but to the economy. Professor Ken Thorpe of Emory University published a report in 2004, which showed that 25% of the medical costs in the US between 1987 and 2001 were attributed to obesity. Furthermore, current estimates show that the medical cost of the obese accounts for over 16% of the nation’s GDP.
Obesity is a preventable problem and it seems we are just not investing very much in tackling the issue.
AH: Finally, how deep are the roots of obesity in US culture and how difficult is the challenge ahead in encouraging the American population to lead a healthier lifestyle?
DW: High-energy food has become more readily available in US society while at the same time a lot of the physical activity in our daily lives has been engineered out. I therefore don’t believe that persuading the population to change their lifestyle will be as successful as making the healthier choices the easier default choices.
In schools, for example, we need to make it easier to get water than drink sugary sweet beverages. With oil prices continuing to rise, we need to make it easier for people to take public transportation rather than drive their cars – as about a third of people who use publication transportation get their daily dose of physical activity through the use of it.
It is about making the healthier alternative lifestyle options the more convenient.