Nutrition and Overweight

Goal

Promote health and reduce chronic disease associated with diet and weight.

Overview

Issues and Trends

Nutrition is essential for growth and development, health, and well-being. Behaviors to promote health should start early in life with breastfeeding[1] and continue through life with the development of healthful eating habits. Nutritional, or dietary, factors contribute substantially to the burden of preventable illnesses and premature deaths in the United States.[2] Indeed, dietary factors are associated with 4 of the 10 leading causes of death: coronary heart disease (CHD), some types of cancer, stroke, and type 2 diabetes.[3] These health conditions are estimated to cost society over $200 billion each year in medical expenses and lost productivity.[4] Dietary factors also are associated with osteoporosis, which affects more than 25 million persons in the United States and is the major underlying cause of bone fractures in postmenopausal women and elderly persons.[5]

Many dietary components are involved in the relationship between nutrition and health. A primary concern is consuming too much saturated fat and too few vegetables, fruits, and grain products that are high in vitamins and minerals, carbohydrates (starch and dietary fiber), and other substances that are important to good health. The 2000 Dietary Guidelines for Americans recommend that, to stay healthy, persons aged 2 years and older should follow these ABCs for good health: Aim for fitness, Build a healthy base, and Choose sensibly. To aim for fitness, aim for a healthy weight and be physically active each day. To build a healthy base, let the Pyramid guide food choices; choose a variety of grains daily, especially whole grains; choose a variety of fruits and vegetables daily; and keep food safe to eat. To choose sensibly, choose a diet that is low in saturated fat and cholesterol and moderate in total fat; choose beverages and foods to moderate intake of sugars; choose and prepare foods with less salt; and if consuming alcoholic beverages, do so in moderation.[6] The Food Guide Pyramid, introduced in 1992, is an educational tool that conveys recommendations about the number of servings from different food groups each day and other principles of the Dietary Guidelines for Americans.[7] [Note: In text that follows in this chapter, Dietary Guidelines for Americans will refer to the 2000 Dietary Guidelines for Americans unless otherwise noted.]

The Dietary Guidelines for Americans also emphasize the need for adequate consumption of iron-rich and calcium-rich foods.6 Although some progress has been made since the 1970s in reducing the prevalence of iron deficiency among low-income children,[8] much more is needed to improve the health of children of all ages and of women who are pregnant or are of childbearing age. Since the start of this decade, consumption of calcium-rich foods, such as milk products, has generally decreased and is especially low among teenaged girls and young women.[9] Because important sources of calcium also can include other foods with calcium—occurring naturally or through fortification—as well as dietary supplements, the current emphasis is on tracking total calcium intake from all sources, as demonstrated by an objective in this focus area. In addition, in recent years there has been a concerted effort to increase the folic acid intake of females of childbearing age through fortification and other means to reduce the risk of neural tube defects.[10], [11] (See Focus Area 16. Maternal, Infant, and Child Health.)

In general, however, excesses and imbalances of some food components in the diet have replaced once commonplace nutrient deficiencies. Unfortunately, there has been an alarming increase in the number of overweight and obese persons.[12], [13] Overweight results when a person eats more calories from food (energy) than he or she expends, for example, through physical activity. This balance between energy intake and output is influenced by metabolic and genetic factors as well as behaviors affecting dietary intake and physical activity; environmental, cultural, and socioeconomic components also play a role.

When a body mass index (BMI) cut-point of 25 is used, nearly 55 percent of the U.S. adult population was defined as overweight or obese in 1988–94, compared to 46 percent in 1976–80.12, [14], [15] In particular, the proportion of adults defined as obese by a BMI of 30 or greater has increased from 14.5 percent to 22.5 percent.12 A similar increase in overweight and obesity also has been observed in children above age 6 years in both genders and in all population groups.[16]

Many diseases are associated with overweight and obesity. Persons who are overweight or obese are at increased risk for high blood pressure, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and some types of cancer. The health outcomes related to these diseases, however, often can be improved through weight loss or, at a minimum, no further weight gain. Total costs (medical costs and lost productivity) attributable to obesity alone amounted to an estimated $99 billion in 1995.[17]

Disparities

Disparities in health status indicators and risk factors for diet-related disease are evident in many segments of the population based on gender, age, race and ethnicity, and income. For example, overweight and obesity are observed in all population groups, but obesity is particularly common among Hispanic, African American, Native American, and Pacific Islander women. Furthermore, despite concerns about the increase in overweight and certain excesses in U.S. diets, segments of the population also suffer from undernutrition, including persons who are socially isolated and poor. Over the years, the recognition of the consequences of food insecurity (limited access to safe, nutritious food) has led to the development of national measures and surveys to evaluate food insecurity and hunger and to the ability to assess disparities among different population groups. With food security and other measures of undernutrition, such as growth retardation and iron deficiency, disparities are evident based not only on income but also on race and ethnicity.

In addition, there are concerns about the nutritional status of persons in hospitals, nursing homes, convalescent centers, and institutions; persons with disabilities, including physically, mentally, and developmentally disabled persons in community settings; children in child care facilities; persons living on reservations; persons in correctional facilities; and persons who are homeless. National data about these population groups are currently unavailable or limited. Data also are insufficient to target the fastest growing segment of the population, old and very old persons who live independently.

Opportunities

Establishing healthful dietary and physical activity behaviors needs to begin in childhood. Educating school-aged children about nutrition is important to help establish healthful eating habits early in life.[18], [19] Research suggests that parents who understand proper nutrition can help children in preschool choose healthful foods, but they have less influence on the choices of school-aged children.[20] Thus, the impact of nutrition education on health may be more effective if targeted directly at school-aged children. Unfortunately, a survey done in 1994 showed that only 69 percent of States and 80 percent of school districts required nutrition education for students in at least some grades from kindergarten through 12th grade.[21]

A well-designed curriculum that effectively addresses essential nutrition education topics can increase students’ knowledge about nutrition, help shape appropriate attitudes, and help develop the behavioral skills students need to plan, prepare, and select healthful meals and snacks.18, [22], [23] Curricula that encourage specific, healthful eating behaviors and provide students with the skills needed to adopt and maintain those behaviors have led to favorable changes in student dietary behaviors and cardiovascular disease risk factors.18, 22, 23 In order to enhance the effectiveness of these lessons, however, nutrition course work should be part of the core curriculum for the professional preparation of teachers of all grades and should be emphasized in continuing education activities for teachers.

Topics considered to be essential at the elementary, middle, junior high, and senior high school levels include using the Food Guide Pyramid; learning the benefits of healthful eating; making healthful food choices for meals and snacks; preparing healthy meals and snacks; using food labels; eating a variety of foods; eating more fruits, vegetables, and grains; eating foods low in saturated fat and total fat more often; eating more calcium-rich foods; balancing food intake and physical activity; accepting body size differences; and following food safety practices.18, [24] In addition, the following topics are considered to be essential at the middle, junior high, and senior high school levels: the Dietary Guidelines for Americans; eating disorders; healthy weight maintenance; influences on food choices such as families, culture, and media; and goals for dietary improvement.18

Nutrition education should be taught as part of a comprehensive school health education program, and essential nutrition education topics should be integrated into science and other curricula to reinforce principles and messages learned in the health units. Nutrition education is addressed within a school health education objective. (See Focus Area 7. Educational and Community-Based Programs.) In addition, students must have access to healthful food choices to enhance further the likelihood of adopting healthful dietary practices. For these reasons, monitoring students’ eating practices at school is important.

Although health promotion efforts should begin in childhood, they need to continue throughout adulthood. In particular, public education about the long-term health consequences and risks associated with overweight and how to achieve and maintain a healthy weight is necessary. While many persons attempt to lose weight, studies show that within 5 years a majority regain the weight.[25] To maintain weight loss, healthful dietary habits must be coupled with decreased sedentary behavior and increased physical activity and become permanent lifestyle changes. (See Focus Area 22. Physical Activity and Fitness.) Additionally, changes in the physical and social environment may help persons maintain the necessary long-term lifestyle changes for both diet and physical activity.

Policymakers and program planners at the national, State, and community levels can and should provide important leadership in fostering healthful diets and physical activity patterns among people in the United States. The family and others, such as health care practitioners, schools, worksites, institutional food services, and the media, can play a key role in this process. For example, registered dietitians and other qualified health care practitioners can improve health outcomes through efforts focused on nutrition screening, assessment, and primary and secondary prevention.

Food-related businesses also can help consumers achieve healthful diets by providing nutrition information for foods purchased in supermarkets, fast-food outlets, restaurants, and carryout operations. For example, the introduction of a new food label in 1993 has resulted in nutrition information on most processed packaged foods, along with credible health and nutrient content claims and standardized serving sizes.[26] While efforts were made in the 1990s to increase the availability of nutrition information, reduced-fat foods, and other healthful food choices in supermarkets, significant challenges remain on these fronts for away-from-home foods purchased at food service outlets. The importance of addressing these challenges is suggested by recent data indicating that nearly 40 percent of a family’s food budget is spent on away-from-home food, including food from restaurants and fast-food outlets.[27] One analysis found that away-from-home foods are generally higher in saturated fat, total fat, cholesterol, and sodium and lower in dietary fiber, iron, and calcium than at-home foods.27 Away-from-home sites include restaurants, fast-food outlets, school cafeterias, vending machines, and other food service outlets. This study also suggested that persons either eat larger amounts when they eat out, eat higher calorie foods, or both.

Many of the Healthy People 2010 objectives that address nutrition and overweight in the United States measure in some way the Nation’s progress toward implementing the recommendations of the Dietary Guidelines for Americans. The recommendations for food and nutrient intake are not intended to be met every day but rather on average over a span of time. Although the Healthy People 2010 dietary intake objectives address the proportion of the population that consumes a specified level of certain foods or nutrients, it is also important to track and report the average amount eaten by different population groups to help interpret progress on these objectives. Other objectives target aspects of undernutrition, including iron deficiency, growth retardation, and food security.

In summary, several actions are recognized as fundamental in achieving this focus area’s objectives:

n	Improving accessibility of nutrition information, nutrition education, nutrition counseling and related services, and healthful foods in a variety of settings and for all population groups.

n	Focusing on preventing chronic disease associated with diet and weight, beginning in youth.

n	Strengthening the link between nutrition and physical activity in health promotion.

n	Maintaining a strong national program for basic and applied nutrition research to provide a sound science base for dietary recommendations and effective interventions.

n	Maintaining a strong national nutrition monitoring program to provide accurate, reliable, timely, and comparable data to assess status and progress and to be responsive to unmet data needs and emerging issues.

n	Strengthening State and community data systems to be responsive to the data users at these levels.

n	Building and sustaining broad-based initiatives and commitment to these objectives by public and private sector partners at the national, State, and local levels.

Interim Progress Toward Year 2000 Objectives

Of the 27 nutrition objectives, targets for 5 have been met, including 2 related to the availability of reduced-fat foods and prevalence of growth retardation.[28] The majority of the objectives have shown some progress, including those related to total fruit, vegetable, and grain product intake and total fat and saturated fat intake; availability of nutrition labeling on foods; breastfeeding; nutrition education in schools; and availability of worksite nutrition and weight management programs. For certain other objectives, such as consumer actions to reduce salt intake and home-delivered meals to elderly persons, there has been little or no progress. And for others, such as intake of calcium-rich food and overweight and obesity, movement has been away from the targets. In particular, the proportion of adults and children who are overweight or obese has increased substantially, and this represents one of the biggest challenges for Healthy People 2010.

Note: Unless otherwise noted, data are from the Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000 Review, 1998–99.

 

Healthy People 2010—Summary of Objectives

Nutrition and Overweight

Goal: Promote health and reduce chronic disease associated with diet and weight.

Number	Objective Short Title
Weight Status and Growth
19-1	Healthy weight in adults
19-2	Obesity in adults
19-3	Overweight or obesity in children and adolescents
19-4	Growth retardation in children
Food and Nutrient Consumption
19-5	Fruit intake
19-6	Vegetable intake
19-7	Grain product intake
19-8	Saturated fat intake
19-9	Total fat intake
19-10	Sodium intake
19-11	Calcium intake
Iron Deficiency and Anemia
19-12	Iron deficiency in young children and in females of childbearing age
19-13	Anemia in low-income pregnant females
19-14	Iron deficiency in pregnant females
Schools, Worksites, and Nutrition Counseling
19-15	Meals and snacks at school
19-16	Worksite promotion of nutrition education and weight management
19-17	Nutrition counseling for medical conditions
Food Security
19-18	Food security

 

Healthy People 2010 Objectives

Weight Status and Growth

19-1.		Increase the proportion of adults who are at a healthy weight.

Target: 60 percent.

Baseline: 42 percent of adults aged 20 years and older were at a healthy weight (defined as a body mass index [BMI] equal to or greater than 18.5 and less than 25) in 1988–94 (age adjusted to the year 2000 standard population).

Target setting method: Better than the best.

Data source: National Health and Nutrition Examination Survey (NHANES), CDC, NCHS.

Adults Aged 20 Years and Older, 1988–94 (unless noted)	Healthy Weight
	19-1. Both Genders	Females*	Males*
	Percent
TOTAL	42	45	38
Race and ethnicity
American Indian or Alaska Native	DSU	DSU	DSU
Asian or Pacific Islander	DSU	DSU	DSU
Asian	DNC	DNC	DNC
Native Hawaiian and other Pacific Islander	DNC	DNC	DNC
Black or African American	34	29	40
White	42	47	37
Hispanic or Latino	DSU	DSU	DSU
Mexican American	30	31	30
Not Hispanic or Latino	43	47	39
Black or African American	34	29	40
White	43	49	38
Age
20 to 39 years	51	55	48
40 to 59 years	36	40	31
60 years and older	36	37	33
Family income level†
Lower income (<130 percent of poverty threshold)	38	33	44
Higher income (>130 percent of poverty threshold)	43	48	37
Disability status
Persons with disabilities	32 (1991–94)	35 (1991–94)	30 (1991–94)
Persons without disabilities	41 (1991–94)	45 (1991–94)	36 (1991–94)
Select populations
Persons with arthritis	36 (1991–94)	37 (1991–94)	34 (1991–94)
Persons without arthritis	43 (1991–94)	47 (1991–94)	40 (1991–94)
Persons with diabetes	26	DNA	DNA
Persons without diabetes	43	DNA	DNA
Persons with high blood pressure	27	29	26
Persons without high blood pressure	46	50	42

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
*Data for females and males are displayed to further characterize the issue.
^†A household income below 130 percent of poverty threshold is used by the Food Stamp Program.

19-2.		Reduce the proportion of adults who are obese.

Target: 15 percent.

Baseline: 23 percent of adults aged 20 years and older were identified as obese (defined as a BMI of 30 or more) in 1988–94 (age adjusted to the year 2000 standard population).

Target setting method: Better than the best.

Data source: National Health and Nutrition Examination Survey (NHANES), CDC, NCHS.

Adults Aged 20 Years and Older, 1988–94 (unless noted)	Obesity
	19-2. Both Genders	Females*	Males*
	Percent
TOTAL	23	25	20
Race and ethnicity
American Indian or Alaska Native	DSU	DSU	DSU
Asian or Pacific Islander	DSU	DSU	DSU
Asian	DNC	DNC	DNC
Native Hawaiian and other Pacific Islander	DNC	DNC	DNC
Black or African American	30	38	21
White	22	24	21
Hispanic or Latino	DSU	DSU	DSU
Mexican American	29	35	24
Not Hispanic or Latino	22	25	20
Black or African American	30	38	21
White	22	23	20
Age (not age adjusted)
20 to 39 years	18	21	15
40 to 59 years	28	30	25
60 years and older	24	26	21
Family income level†
Lower income (<130 percent of poverty threshold)	29	35	21
Higher income (>130 percent of poverty threshold)	22	23	20
Disability status
Persons with disabilities	30 (1991–94)	38 (1991–94)	21 (1991–94)
Persons without disabilities	23 (1991–94)	25 (1991–94)	22 (1991–94)
Select populations
Persons with arthritis	30	33	27
Persons without arthritis	21	23	19
Persons with diabetes	41	DNA	DNA
Persons without diabetes	22	DNA	DNA
Persons with high blood pressure	38	47	33
Persons without high blood pressure	18	20	16

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
*Data for females and males are displayed to further characterize the issue.
^†A household income below 130 percent of poverty threshold is used by the Food Stamp Program.

19-3.		Reduce the proportion of children and adolescents who are overweight or obese.

Target and baseline:

Objective	Reduction in Overweight or Obese Children and Adolescents*	1988–94 Baseline	2010 Target
		Percent
19-3a.	Children aged 6 to 11 years	11	5
19-3b.	Adolescents aged 12 to 19 years	11	5
19-3c.	Children and adolescents aged 6 to 19 years	11	5

*Defined as at or above the gender- and age-specific 95th percentile of BMI based on the revised CDC Growth Charts for the United States.

Target setting method: Better than the best.

Data source: National Health and Nutrition Examination Survey (NHANES), CDC, NCHS.

Children and Adolescents Aged 6 to 19 Years, 1988–94 (unless noted)	Overweight or Obese
	19-3a. Children Aged 6 to 11 Years	19-3b. Adolescents Aged 12 to 19 Years	19-3c. Children and Adolescents Aged 6 to 19 Years
	Percent
TOTAL	11	11	11
Race and ethnicity
American Indian or Alaska Native <