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Action on Obesity: Report of a Mayo Clinic National Summit

      In May 2004, representatives from local, state, and national public and private organizations met in Rochester, Minn, for the Action on Obesity Summit hosted by Mayo Clinic. The overall goal of this summit was to identify creative and effective strategies to increase the US population's physical activity and improve nutrition to reverse the increasing prevalence of obesity. Ideas generated from selected abstract presentations and breakout sessions were prioritized and incorporated into an action model (available at www.actiononobesity.org) deemed feasible for implementation into most communities. Highlights of the presentations included a company that reported lower than expected health care expenditures secondary to a work site wellness program, a national initiative to increase physical activity (www.americaonthemove.org), and innovative work site nutritional strategies. The implementation model that emerged contained certain themes. Coordinated action at all levels will be required to substantially impact the increasing prevalence of obesity. Educational messages should be simple, consistent, tailored, and linked to benefits. Healthy food options in vending machines and restaurants and increased opportunities for daily physical activity should be available in schools, work sites, and communities. Legislative and policy changes should promote physical activity and improve nutrition. Support for research should be encouraged and outcome measures for interventions documented. A second Action on Obesity Summit is planned for June 9 and 10, 2005, that will review the progress made in the intervening year and continue to refine the implementation model to help address the obesity epidemic, one of the greatest public health problems facing the United States.
      GEPNET (gastroenteropancreatic neuroendocrine tumor), PR (partial response), SST (somatostatin), SSTR (SST receptor)
      The Mayo Clinic Action on Obesity Summit convened in Rochester, Minn, on May 21, 2004, to discuss and explore novel methods to address the problem of obesity in the United States. Participants in the Mayo Clinic–sponsored meeting included representatives from diverse groups of local, state, and national public and private organizations. The overall goal of this 1-day summit was to identify creative and effective strategies to increase physical activity and improve nutrition in the US population to reverse the increasing prevalence of obesity. These strategies were evaluated for their utility within a comprehensive implementation model that includes individual, workplace, community, state, and national components.
      After background presentations, the format of the summit consisted of abstract presentations by attendees of selected action items, defined as a strategy or program that should ultimately directly or indirectly reduce the increasing trend in body weight among a sector of the US population. The summit included breakout sessions in which additional strategies were developed. Action items and strategies were then prioritized and ranked for their utility within an implementation model, with a focus on addressing obesity at the individual, local, state, and national levels.

      EPIDEMIOLOGY OF OBESITY

      The US Assistant Surgeon General Susan Blumenthal, MD, discussed the epidemiology and consequences of the obesity epidemic. During the past 2 to 3 decades, there has been an unprecedented increase in weight gain and obesity in the United States and around the world.
      Obesity: preventing and managing the global epidemic: report of a WHO consultation.
      According to self-reported data from the Behavioral Risk Factor Surveillance System, the prevalence of obesity is growing annually in the United States, and there are no signs of slowing.
      • Mokdad AH
      • Ford ES
      • Bowman BA
      • et al.
      Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001.
      Among children and adolescents, the prevalence of obesity has increased 2-fold to 3-fold between 1980 and 2000.
      • Ogden CL
      • Flegal KM
      • Carroll MD
      • Johnson CL
      Prevalence and trends in overweight among US children and adolescents, 1999-2000.
      The latest information using measured height and weight from the National Health and Nutrition Examination Survey reported a 64.5% prevalence of overweight (body mass index [BMI] ≥25 kg/m2) and a 30.5% prevalence of obesity (BMI ≥30 kg/m2) among Americans.
      • Hedley AA
      • Ogden CL
      • Johnson CL
      • Carroll MD
      • Curtin LR
      • Flegal KM
      Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002.
      The prevalence of class III obesity (BMI ≥40 kg/m2) almost tripled, from 0.8% to 2.2%, between 1990 and 2000.
      • Freedman DS
      • Khan LK
      • Serdula MK
      • Galuska DA
      • Dietz WH
      Trends and correlates of class 3 obesity in the United States from 1990 through 2000.
      Overweight and obesity are linked to a large number of comorbidities such as coronary heart disease, congestive heart failure, hypertension, type 2 diabetes mellitus, dyslipidemia, obstructive sleep apnea and other lung diseases, pulmonary hypertension, stroke, deep venous thrombosis, pulmonary embolism, venous insufficiency, degenerative joint disease, many cancers, nonalcoholic steatohepatitis, and gallbladder disease. Also, there is an increase in all-cause mortality associated with increasing obesity. The prevalence of the complications of obesity should increase after a short lag time. In fact, data from the Behavioral Risk Factor Surveillance System showed that the prevalence of diabetes mellitus (type 1 and type 2) increased from 4.9% in 1990 to 7.9% in 2000.
      • Mokdad AH
      • Ford ES
      • Bowman BA
      • et al.
      Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001.
      The combination of the 2 major determinants of obesity, lack of physical activity and suboptimal diet, is now second only to smoking as the leading preventable cause of death in the United States.
      • Mokdad AH
      • Marks JS
      • Stroup DF
      • Gerberding JL
      Actual causes of death in the United States, 2000 [published corrections appear in JAMA. 2005; 293:293-294 and 298].
      Major initiatives sponsored by government agencies and medical societies are targeting the emerging obesity epidemic. Examples include calls to action by the US Department of Health and Human Services
      and its components, including the US Surgeon General
      • US Department of Health and Human Services
      and the National Institutes of Health,
      • National Task Force on the Prevention and Treatment of Obesity
      Overweight, obesity, and health risk.
      as well as the American Heart Association.
      • Eckel RH
      • Krauss RM
      • AHA Nutrition Committee
      American Heart Association call to action: obesity as a major risk factor for coronary heart disease.
      It is hoped these calls to action will have a measurable impact on reducing obesity in the future. Assistant Surgeon General Blumenthal emphasized that a public health approach to mobilize all sectors of society is needed to effectively address the obesity epidemic.

      ECONOMICS OF OBESITY

      Eric Finkelstein, PhD, discussed the economic consequences of the immense and increasing prevalence of obesity. US health care costs increase as BMI increases.
      Obesity: preventing and managing the global epidemic: report of a WHO consultation.
      Obese adults aged 18 to 65 years have 36% higher health care costs compared with normal-weight individuals.
      • Sturm R
      The effects of obesity, smoking, and drinking on medical problems and costs.
      Direct costs are estimated at $52 billion to $79 billion per year and total costs between $99 billion and $117 billion (in 1995-2003 dollars, with the lower estimates in 1995 dollars).
      • US Department of Health and Human Services
      • Wolf AM
      • Colditz GA
      Current estimates of the economic cost of obesity in the United States.
      • Finkelstein EA
      • Fiebelkorn IC
      • Wang G
      National medical spending attributable to overweight and obesity: how much, and who's paying?.
      • Thompson D
      • Edelsberg J
      • Kinsey KL
      • Oster G
      Estimated economic costs of obesity to U.S. business.
      • Finkelstein EA
      • Fiebelkorn IC
      • Wang G
      State-level estimates of annual medical expenditures attributable to obesity.
      Obesity is responsible for more health care expenditures than any other contributory health condition, including smoking and problem drinking.
      • Sturm R
      The effects of obesity, smoking, and drinking on medical problems and costs.
      Businesses shoulder a large share of the cost of obesity—more than $12 billion per year or 5% of total health care expenditures—in payouts for medical care, absenteeism from work, and reduced productivity.
      • Finkelstein EA
      • Fiebelkorn IC
      • Wang G
      State-level estimates of annual medical expenditures attributable to obesity.
      Employees who are obese and sedentary have annual health care costs of $450 more than employees who are moderately active and of normal weight.
      • Wang F
      • McDonald T
      • Champagne LJ
      • Edington DW
      Relationship of body mass index and physical activity to health care costs among employees.
      Viewed from an economic perspective, people address their weight, including obesity, in a manner that produces the least up-front cost. The cost of consuming extra calories has decreased primarily because of technological innovations. Many energy-dense foods are less expensive, particularly if consumers “super size” food choices. Conversely, the cost of eating relatively healthy, lower-calorie foods is high, ie, fresh fruits and vegetables, small serving sizes, and whole-grain cereal products are generally more expensive for consumers than energy-dense foods. Technology has also decreased our need to perform spontaneous physical activity and expend calories in our daily lives— the “costs” of being inactive have decreased. Moreover, being inactive has benefits, eg, enjoyment from performing sedentary tasks such as playing computer games, “surfing” the Internet, and watching television. In summary, the early costs of staying lean have increased, and the early costs of becoming obese have declined. If the increase in obesity is viewed as a market failure, then the economic consequences may be the best argument for intervention. This is especially true at the state and national levels of government because approximately one half of collective US health care costs due to obesity are paid by Medicaid and Medicare.
      • Finkelstein EA
      • Fiebelkorn IC
      • Wang G
      National medical spending attributable to overweight and obesity: how much, and who's paying?.
      • Thompson D
      • Edelsberg J
      • Kinsey KL
      • Oster G
      Estimated economic costs of obesity to U.S. business.
      Finkelstein argued that obesity is both a personal and a societal issue and that interventions to treat obesity will need to be multifaceted, comprehensive, and tailored to the target population. Some people may be obese because of lack of information regarding the costs and benefits of their food consumption and physical activity decisions. Policies to increase information, such as nutrition labeling and general education, would allow this group to make better choices. Other people may be overweight by choice. For these people, the costs of treating their obesity may be too great in the current environment. However, because obesity is a societal economic issue, government intervention may be justified. To treat obesity effectively in this group of people, programs will need to address the costs and benefits of obesity-related behaviors. Another group of people may be obese because of behavioral or self-control issues. Interventions that use direct or indirect behavioral strategies may be most effective in this group.

      PROPOSED MODEL FOR PREVENTION AND CONTROL OF OBESITY

      Awareness of the problems associated with obesity is increasing, and current programs are targeted toward decreasing obesity in our health care systems, work sites, communities, states, and nation.
      Obesity: preventing and managing the global epidemic: report of a WHO consultation.
      However, at many different levels, compartmentalization and duplication prevent optimal effectiveness of these programs. Within and among organizations, barriers to communication may exist. Although several organizations may be working toward the same objective, each organization has its own culture, objectives, budget, resources, and level of commitment. For example, businesses such as the food industry struggle with making a profit vs providing products that help reduce energy intake. In addition, the rapid increase in obesity prevalence during a relatively short period in our history reflects multiple, diverse, and collectively powerful sources of influence; thus, no simple analysis will identify solutions. Coordination and communication among the various organizations working on this problem will be necessary to make progress in combating the problem of obesity in the US population.
      Addressing the obesity epidemic will require changing our culture and our lifestyle. To bring about weight-reducing health behaviors, work and play environments need to be altered, and input is needed from multiple sectors of the community in their design. The Minnesota Department of Health has developed a Community-Based Prevention Wheel that indicates the partners who could or should collaborate (Figure 1), instead of working independently on community initiatives.
      • Center for Health Promotion
      An example of the effective use of overlapping strategies is the community intervention model for tobacco-use prevention in California, Massachusetts, and Minnesota. Members of the New England Coalition for Health Promotion and Disease Prevention collaborated to develop a strategic plan to address the obesity epidemic.
      • NECON—The New England Coalition for Health Promotion and Disease Prevention
      Preventing & controlling obesity in New England—a strategic plan.
      Figure thumbnail gr1
      Figure 1Community-based prevention wheel, indicating the partners who would work on a community initiative. Adapted from www.actiononobesity.org.
      For the Action on Obesity Summit, a public health organizational framework (originally recommended to promote physical activity) was selected as a starting point and integrated with other initiatives to advance healthier nutrition choices.
      • King AC
      Clinical and community interventions to promote and support physical activity participation.
      This organizational framework encourages promotion of physical activity and improved nutrition at the personal, interpersonal, organizational, environmental, institutional, and legislative levels of intervention. From this theoretical framework, an implementation model was developed, with the intent of decreasing the prevalence of obesity by intervening in an integrated manner at multiple levels in the lives of individuals and within society (Figure 2.
      Figure thumbnail gr2
      Figure 2A bidirectional model of different levels of influence to address the obesity epidemic. Adapted from www.actiononobesity.org.

      PRESENTATIONS

      In planning a strategy to combat obesity, a task force at Mayo Clinic determined that a national Action on Obesity Summit was the best way to synthesize efforts at all levels, from the individual to the nation. It was anticipated that sharing ideas and action plans would result in greater synergy and empower participants to contribute to change. Organizations at all levels of human endeavor were invited to the summit, and each was asked to submit an abstract of a topic that represented its group's best approach to interventions, including strategies and barriers to implementation, dealing with obesity.
      Objectives of the summit (Table 1) were mailed to attendees in advance. A total of 51 organizations sent delegates and submitted 41 abstracts that were duplicated and shared with the summit participants. Of those abstracts, the summit planning committee selected 20 nonoverlapping action items for presentation at the plenary sessions. Attendees rated the 20 presentations on priority and ability to implement using a 5-point Likert scale, and they provided feedback on whether necessary resources were available to support action items.
      Table 1Objectives of the Action on Obesity Summit
      • Identify creative and effective ways to increase physical activity and improve the nutritional health of our communities
      • Integrate “action items” generated from the summit into a model for implementation into our communities
      • Identify which approaches (within the model) require ongoing collaboration among organizations to bring about change
      • Develop and use outcome measures preimplementation and postimplementation of the model
      Attendees rated the following abstract presentations as the highest priorities. Lincoln Plating Company, Lincoln, Neb, described their employee wellness program. Quarterly health and wellness evaluations with personal goals are accomplished for all employees. Key components of implementation include (1) management support, (2) equipment, space, and time to support physical activity, and (3) nutrition interventions. Of note, this company has observed lower than expected health care expenditures during the past few years compared to industry averages, which it attributed to its wellness program.
      The Partnership to Promote Healthy Eating and Active Living, Denver, Colo, discussed America on the Move (www.americaonthemove.org), a national initiative available free to individuals, organizations, and communities. This initiative encourages people to set goals and monitor changes related to weight management. Examples of common goals that are promoted include walking an extra 2000 steps per day and consuming 100 fewer calories per day. Subjects are encouraged to use pedometers to monitor steps and record their progress on the organization's Web site. A custom membership option is available at a nominal charge to large organizations that enables them to obtain aggregate data and monitor employees’ progress. Educational and motivational e-mail messages are sent to people who sign up, and supportive “competitions” is a strategy to increase participation and involvement.
      The University of Minnesota, Minneapolis, noted that many young people experience too much structure and control by adults in their sporting experiences. This, in turn, hinders participation, exercise, and learning of sport and game skills. Examples were presented of children participating in sporting activities yet performing little physical activity. It was suggested that children should be offered the chance to organize and play their own sandlot sports games under the supervision of adults, with the goals of increasing participation, spontaneous physical activity, and enjoyment of the sporting experience.
      The Association for the Advancement of Applied Sports Psychology, Middleton, Wis, discussed improving participant motivation and adherence for physical activity. Targeted areas included improving mental skills, promoting positive self-talk, focusing on enjoyment of the experience, providing social support, incorporating individual preferences, monitoring progress, tailoring programs to the target audience, and using follow-up programs to increase retention.
      The Mayo Clinic in Rochester, Minn, discussed dietary factors identified in the medical literature that contribute to weight gain, including increased portion size, dining out at restaurants, and consuming energy-dense foods such as refined carbohydrates, snacks, and soft drinks. Educational nutritional strategies to decrease energy intake were presented, including calorie labeling in cafeterias and publicly displaying the simple message that “calories count.” Having a range of healthy and palatable foods available in employee cafeterias and subsidizing the purchase of healthier foods, such as vegetables and fruits, were other strategies mentioned. It was recognized that personal choices can be influenced by availability and education. Barriers to implementation were also discussed, including misinformation, inadequate motivation, and economic, environmental, and organizational/system factors.
      The Minnesota Medical Alliance shared the educational resources it has developed for children, including Facts of Fizz, an index card on soft drink consumption, and the activity books Food Label Detective and Catching the Exercise Thief.

      BREAKOUT SESSIONS

      Breakout sessions were organized according to different levels of influence (Figure 2. Each session focused on generating new, creative ideas to decrease the prevalence of obesity specific to the discussion topic. The results of these sessions are summarized subsequently.

      Individuals and Health Care Providers

      Individuals and health care providers were encouraged to avoid the terms diet and exercise because of preconceived negative connotations. Health care systems should be organized to optimize identification and treatment of obesity and coordinate resources. Multidisciplinary and novel treatment approaches were encouraged. Family interventions and psychological health were emphasized.

      Schools, Communities, and Counties

      Mandatory physical education was encouraged at kindergarten through 12th-grade levels. In addition, supervised, safe, spontaneous after-school physical activities through youth and community groups should be promoted. Moreover, spontaneous, noncompetitive recreational physical activity options should be available for the entire community. To change cultural norms, educational efforts should be increased to raise awareness of overweight and obesity, along with strategies for prevention and treatment. City planners, landlords, and others should ensure that there are adequate walking and biking paths, stairs in buildings, playgrounds, and other opportunities for physical activity.
      Social marketing strategies should be used to increase awareness of portion size and decrease energy intake. Vending machines should have healthy choices, and calories should be labeled on restaurant menus. Within schools and community eating areas, a specified proportion of foods should be required to meet designated healthy criteria. Consumer-led nutrition and physical activity policy initiatives should be developed.

      Work Site

      Employees should be engaged to develop goals and strategies. Topics of focus should include education, incentives, promoting enjoyable activities, events, supportive “competitions,” feedback, and recognition. Healthy, low-calorie food options and appropriate portion sizes should be available in employee cafeterias. Printing calories and nutrient analyses on cash register receipts might provide a useful technique for nutrient-content education. On-site nutrition and health promotion educational classes could be considered. Increased physical activity at the work site should be actively promoted with a goal of 10,000 steps per day, monitored with the use of pedometers and distance markers within the facility if feasible. Facilities should be upgraded to provide a welcome and safe environment for physical activity. For example, stairwells can be painted, art work added, and background music installed. If possible, an onsite fitness center with utilization encouraged, particularly for beginners, could be used. Leadership of the organization should help facilitate a cultural shift by providing appropriate infrastructure, policies, and strategies, as well as setting an example through personal physical activity and nutritional practices and participation.

      State and National (Including the Media)

      The focus was on 5 main areas of activity: marketing and communications, policies (including legislation), research, education, and building coalitions. Education and communication messages should be simple, consistent, tailored to the audience, and linked to benefits. A simple and consistent message on balancing energy intake with energy expenditure (calories count) should be delivered. Certain high-risk populations should be targeted, such as children, parents, and those of low socioeconomic status, as well as obese individuals. The benefits of improved nutrition and increased physical activity on body weight should be emphasized, including lower health risks, improved quality of life, and decreased health care costs. Funding and other support for research should be encouraged. Outcome measures for all interventions should be documented. Legislative and policy changes should be explored to promote increased physical activity, reduced energy intake, and ongoing research. The different organizations working on these issues should more effectively coordinate their efforts.

      SYNTHESIS

      The Action on Obesity Summit provided a setting for the exchange of ideas to decrease obesity. Representatives from medicine, public health, professional organizations, academic institutions, government, and businesses (including the food industry) participated. Objectives for the summit were developed in advance (Table 1). The end result of the summit was the formulation of selected action items into an operational model, which helped meet the second objective (Table 1). A Web site was established (www.actiononobesity.org) to facilitate ongoing communication among working groups. Planned teleconferences among attendees, collaboratively written grants, and the next planned summit in 2005 are examples of ongoing collaboration. Progress toward meeting the fourth objective (Table 1) will not be known until the next summit in June 2005, when organizations return to report on their progress. Preoutcome and postoutcome measures related to the model will be used to assess improvements within the attendee's local environment.
      Before adjournment, the final implementation model was displayed, listing the top action items from the breakout sessions. Attendees rated the summit and whether the derived model met expectations. On a Likert scale from 1 (low) to 5 (high), the summit itself was rated 4.2 and the final model 3.8. The lower rating of the model can be interpreted in various ways. Possibilities include time limitations of the 1-day meeting or that people were less satisfied with the overall model or one aspect of it, such as prioritization, realistic implementation, doubts regarding effectiveness, or errors of omission or commission. Regardless, this provides an opportunity for evaluation and refinement of the current model, which will occur at the next planned summit.
      After the summit, a white paper identifying key findings of the summit was made available to the public (www.actiononobesity.org). The purpose of that document was to describe an action plan that is feasible for implementation into most communities.

      THE FUTURE

      A second Action on Obesity Summit hosted by Mayo Clinic is being planned for June 9 and 10, 2005. Attendees at the first summit will be encouraged to return, report on their progress, share ideas, and continue to refine the implementation model. We hope that new organizations will participate and submit action items. We also hope that, if we are to make progress in attempting to reverse the increasing prevalence of obesity, initiatives such as the Action on Obesity Summit will not only identify usable solutions for the population but also serve as a model for other novel solutions to address one of the greatest public health problems facing the United States and other nations.

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