Special Report

Special Report

Summary of the 2000 Surgeon General’s Listening Session: Toward a National Action Plan on Overweight and Obesity Yvonne Jackson,a William H. Dietz,b Charlene Sanders,b Lloyd J. Kolbe,c John J. Whyte,d Howell Wechsler,c Bruce S. Schneider,e Laura A. McNally,f Jean Charles-Azure,g Martina Vogel-Taylor,h Pamela Starke-Reed,i Van S. Hubbard,i Wendy L. Johnson-Taylor,i Richard P. Troiano,j Karen Donato,k Susan Yanovski,l Robert J. Kuczmarski,l Lynne Haverkos,m Kathryn McMurry,n Randolph F. Wykoff,n Violet Woo,o Allan S. Noonan,p Jonelle Rowe,q Kathy McCarty,q and Christine B. Spainr

Abstract U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES STEERING COMMITTEE. Summary of the 2000 Surgeon General’s listening session: toward a national action plan on overweight and obesity. Obes Res. 2002; 10:1299 –1305. Objective: To provide insight into discussions at the Surgeon General’s Listening Session, “Toward a National Action Plan on Overweight and Obesity,” and to complement The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Research Methods and Procedures: On December 7 and 8, 2000, representatives from federal, state, academic, and private sectors attended the Surgeon General’s Listening Session and were given an opportunity to recommend what to include in a national plan to address overweight and obesity. The public was invited to com-

Received for review August 20, 2002. Accepted for publication in final form September 15, 2002. a Administration on Aging, U.S. Department of Health and Human Services (DHHS), Washington, DC; b Division of Nutrition and Physical Activity and c Division of Adolescent and School Health, Centers for Disease Control and Prevention/DHHS, Atlanta, Georgia; d Center for Medicare and Medicaid Services, Agency for Healthcare Research and Quality/ DHHS, Baltimore, Maryland; e Food and Drug Administration/DHHS, Rockville, Maryland; f Health Resources and Services Administration/DHHS, Rockville, Maryland; g Indian Health Service, U.S. Department of Health and Human Services, Rockville, MD; h Office of the Director, i Division of Nutrition Research Coordination, j National Cancer Institute, k National Heart Lung and Blood Institute, l National Institute of Diabetes and Digestive and Kidney Diseases, and m National Institute of Child Health and Human Development, National Institutes of Health/DHHS, Bethesda, Maryland; and n Office of Disease Prevention and Health Promotion, o Office of Minority Health, p Office of the Surgeon General, q Office on Women’s Health, and r President’s Council on Physical Fitness and Sports, Office of Public Health and Science/DHHS, Washington, DC. Address correspondence to Wendy L. Johnson-Taylor, Ph.D., MPH, R.D., Public Health Nutrition and Health Policy Advisor, Division of Nutrition Research Coordination, National Institutes of Health, 2 Democracy Plaza, Room 640, 6707 Democracy Blvd., MSC 5461, Bethesda, MD 20892-5461. E-mail: [email protected] Copyright © 2002 NAASO

ment during a corresponding public comment period. The Surgeon General’s Listening Session was also broadcast on the Internet, allowing others to view the deliberations live or access the archived files. Significant discussion points from the Listening Session have been reviewed by representatives of the federal agencies and are the basis of this complementary document. Results: Examples of issues, strategies, and barriers to change are discussed within five thematic areas: schools, health care, family and community, worksite, and media. Suggested cooperative or collaborative actions for preventing and decreasing overweight and obesity are described. An annotated list of some programmatic partnerships is included. Discussion: The Surgeon General’s Listening Session provided an opportunity for representatives from family and community groups, schools, the media, the healthcare environment, and worksites to become partners and to unite around the common goal of preventing and decreasing overweight and obesity. The combination of approaches from these perspectives offers a rich resource of opportunity to combat the public health epidemic of overweight and obesity. Key words: schools, worksites, media, family and community, health care

Introduction The increasing prevalence of overweight and obesity among American adults and children has been identified as an epidemic by the Surgeon General and as one of the Leading Health Indicators for Healthy People 2010 (1,2). Among adults, overweight and obesity are associated with increased OBESITY RESEARCH Vol. 10 No. 12 December 2002

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risk for cardiovascular disease, type 2 diabetes, certain musculoskeletal disorders, and endometrial, colon, and postmenopausal breast cancers (3). Overweight children have an increased frequency of type 2 diabetes, dyslipidemia, hypertension, early maturation, and orthopedic problems (4). In addition, overweight children are more likely to become overweight adults than children who are not overweight. Adults who were overweight as children are at increased risk for poor health for longer periods of time than adults who were not overweight as children (5). An estimated 300,000 deaths per year are attributable to obesity (6). Obesity is associated with increased disability, decreased health-related quality of life, increased health care use, and increased mortality (7), all of which translate into increased health care costs to the American public. In 1995, the total direct and indirect health care costs attributable to overweight and obesity were estimated to be $99 billion dollars, equivalent to ⬃7% of the gross domestic product spent on health care (8). Obesity-related health care cost estimates for 2000 reached $117 billion (A. Wolfe, personal communication, July 2002). Even after accounting for inflation, this growth in cost is staggering. Overweight and obesity clearly pose a significant public health threat (9). A growing awareness of this threat has stimulated various discussions and activities. One important example is the 1998 publication of Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report, by the National Institutes of Health (10). This report is significant because it was the first report to outline evidence-based treatment guidelines for overweight and obese adults. Another example of an important activity was the National Nutrition Summit, held in May 2000 (11). During this Summit, the Secretary of the U.S. Department of Health and Human Services (DHHS) directed the Department to host a meeting led by the U.S. Surgeon General regarding the epidemic of obesity. On December 7 and 8, 2000, the Surgeon General convened a meeting in the form of a Listening Session on Overweight and Obesity. Approximately 1 year later, in December 2001, publication of the Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity (9) incorporated information gathered during the Listening Session, information from the corresponding public comment period, and information gathered from the National Nutrition Summit. The objective of this manuscript is to provide insight derived from listening session discussions to complement the “Call to Action.” A brief annotated list of examples of existing programs, consistent with the identified themes discussed at the listening session, is presented to illustrate various types of partnerships as well as potential actions.

The Listening Session The objectives of the 2000 Listening Session on Overweight and Obesity were as follows. 1300

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1. Initiate an inclusive process that could result in a national action plan. 2. Solicit suggestions regarding key elements of a national action plan. 3. Enable participants to share information and establish dialogue on strategies to reduce overweight and obesity. The listening session was organized in five thematic areas: schools, media, health care, worksites, and family and community. Panelists within each area shared their views on what should be included in a national action plan. Some of the challenges to be expected and suggestions for overcoming these challenges were identified. The audience was invited to comment and ask questions at the conclusion of each panel presentation. More than 170 representatives from the federal, state, academic, and private sectors attended the Listening Session. In addition, the Session was broadcast on the Internet, allowing others to view the deliberations live or subsequently access the archived files (12). The following sections identifies the five major settings for which activities and interventions were discussed. Schools1 Participants in the listening session reported that while using the school system to educate children on healthrelated issues such as overweight and obesity initially seems to be a natural fit, societal demands on schools are resulting in competing priorities. A recurring theme among the panelists discussing schools was the lack of shared priority for overweight and obesity prevention across the school environment. Whereas the food service staff may be focusing on ways to improve the nutritional content of school meals, principals and teachers may be focusing on increasing student test scores, and athletic coaches may wish to develop athletic programs that include a relatively small number of students. Both the short school year, which has not changed since the United States was primarily an agricultural society, and the limited school budgets reduce the amount of time and money that are available to address all of the competing demands placed on schools. These multiple priorities within the school environment are causing school administrators to make many difficult choices, some of which are highlighted below. School food service departments plan and prepare meals according to the recommendations of the Dietary Guidelines for Americans (13). However, food and beverage competitors in the form of vending machines, a la carte food lines within the school, nearby commercial food and restaurant facilities, and food served at other school-sponsored events

1 Presenters: American School Food Service Association, National Association for Sports and Physical Education, National Association of State Board of Educators, and Sporting Goods Manufacturers Association

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are not required to comply with the same guidelines. Some schools rely heavily on profits earned from commercial ventures within the school to fund extracurricular activities, ensuring that these competing food sources are likely to remain a part of the landscape. It was suggested that a national dialogue to identify alternative potential sources of funding for extracurricular activities is needed. Other suggestions included making vending machines less accessible; adopting price incentives for healthier foods, and establishing and enforcing healthful standards for foods served at other school-sponsored events. Another example of multiple priorities has resulted from greater focus on test scores as an assessment of principal, teacher, and student performance. Emphasis on improving test scores has caused some schools to reduce or eliminate physical education classes and reduce the length of time for lunch periods. Some participants stated that time previously spent in physical education class and recess often has been replaced by standardized test preparation. Many of the participants indicated their belief that physical activity positively affects academic outcomes and acknowledge that additional research is necessary to determine the nature of the relationship between academic performance and physical activity. The panel further stated that should such research be conducted, school decision-makers should be educated about the results of these studies and encouraged to include the issue of physical activity in ongoing debates on education reform. Participants also recommended that tobacco settlement money be used to hire physical education specialists and to purchase new equipment. Parents and community coalitions were thought to be the most influential advocates for physical activity. These parent-community coalitions should be educated about health risks associated with obesity to solicit their participation. There was considerable debate about whether increased focus on obesity prevention would increase the stigma associated with being overweight or increase the number of eating disorders. This debate also sparked a discussion on the nature of physical education classes. Some participants recalled unfavorable personal experiences in physical education classes while other participants tried to assure them that physical education is taught very differently now. It was suggested that parents, teachers, and coaches be educated about health-related risks of overweight and about “the National Standards for Physical Education.” Health Care2 Health care providers acknowledged their leading role for overweight and obesity prevention and treatment efforts and noted a number of barriers that prevented their efforts from

2 Presenters: American Academy of Pediatrics, American Dietetic Association, American Heart Association, Association of American Indian Physicians, National Black Nurses Association, and North American Association for the Study of Obesity

being successful. The leading barrier mentioned was the lack of reimbursement for treatment and prevention services for overweight and obese individuals. Panelists stated that without reimbursement, some providers are reluctant to spend time in repeated conversations with patients about healthful eating and physical activity. Decisions on how to spend health care dollars with this population are made more complex because of the multiple morbidities these patients have and the limited health care dollars available to treat them. Participants identified the need for research to develop effective treatments and prevention strategies for overweight and obesity. Evidence of effective therapy is needed not only to make a case for reimbursement but also for the education of providers. Another deterrent to discussing overweight and obesity with patients identified by the panel was the comfort level of health care providers. In some cases the providers said they were uncomfortable bringing up the issue with their patients and in other cases providers did not want to make the patients feel uncomfortable. For providers this issue is compounded by discussions with overweight parents about their overweight children. In some cases, providers expressed guilt about their belief that the patient was to blame for being overweight or obese. The fact that some providers acknowledged feelings that patients were to blame for being overweight or obese led to more intense discussion of the potential for undertreatment of and discrimination against patients. Some providers felt they lacked skills and knowledge regarding behavior change and nutrition. Early identification could increase physician comfort, and improve health outcomes of the patient. Earlier recognition by the physician of existence of or potential for overweight provides the physician an opportunity to address the problem before the problem becomes severe. Prevention of inappropriate weight gain is an important goal that needs to be emphasized to patients. Regardless of the weight status of patients entering into the health care system, the focus should always be placed on improving health outcomes. Weight management should be considered one step in that process. Another method to increase the comfort level of patients and providers is to improve provider training in weight management. One recommendation suggested incorporating behavior change theory and components of delivering culturally sensitive weight-management interventions within medical school curricula and as part of continuing medical education. There is a need to effectively disseminate evidence-based information to practicing physicians and to motivate them to use new methods of prevention and treatment of obesity. A final recommendation encouraged physicians to become champions of overweight and obesity interventions by advocating change in other environments, e.g., it was suggested that physicians could lead a national campaign to increase physical activity. OBESITY RESEARCH Vol. 10 No. 12 December 2002

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Worksites3 Just as schools present a logical place to educate children about overweight and obesity, worksites are logical places to educate adults. However, worksite panelists expressed a guarded willingness to accept this responsibility. They stated that more information is needed on the costs and benefits of worksite wellness programs that address overweight and obesity prevention and treatment before they could justify such programs. For example, increasing the number of wellness programs that incorporate physical activity might further increase liability insurance, and there was uncertainty about who would be liable if an employee is injured. Apprehension was expressed that emphasis on prevention and treatment of overweight and obesity may increase discrimination and thereby increase litigation. There was concern that if worksites become paternalistic, employees may chose other places to work. It was recognized that additional research is needed to address the liability costs and productivity benefits of worksite wellness programs as well as to identify health benefits that could be realized from program participation. Information gathered from the research should be shared with all employees to increase employee participation, to empower employees to make healthier choices, and to reduce discrimination. There was also a suggestion to formally recognize companies that establish worksite wellness programs or change workflow patterns to increase physical activity, an alternative perhaps most feasible for small companies. Worksites were encouraged to collaborate with community leaders to promote an environment conducive to healthy lifestyles. Substantial discussion focused on portion sizes served in worksite cafeterias and restaurants. It was suggested that restaurant/cafeteria management take more responsibility in the campaign against overweight and obesity by ensuring that portion sizes reflect the ones recommended by health care professionals. The representatives from the restaurant/ cafeteria management responded by stating they were responsible for meeting the desires of the consumers who are requesting more food for their money. Restaurants/cafeterias were encouraged to price healthier fare competitively or even lower than the less healthy items. The restaurant/ cafeteria representatives stated that when healthier choices are offered, regardless of price, they usually do not sell well, which negatively affects their profit. Despite the previous history of trying such measures, there was an expressed willingness by restaurant/cafeteria management to adjust service as the public demands. Thus, the public needs to be educated about appropriate portion sizes and empowered to advocate for change within the restaurant/cafeteria industry.

3

Presenters: Association of State and Territorial Directors of Health Promotion and Public Health, Council on Size and Weight Discrimination, National Restaurant Association, Northwest/Portland Indian Health Board, and Partnership for Prevention

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Family and Community4 Family and community panelists pointed out the need to approach the issue of overweight and obesity with sensitivity because people from various cultures may view weight status in different ways. Panelists stressed the need to consider how different cultures perceive weight when designing interventions. Understanding weight perceptions of different groups may help determine what language to include in the message. For example, some people find the term obesity quite offensive, whereas others do not. Knowledge and consideration of these differences when designing an intervention may increase the success of the intervention. Another point discussed was whether omission of the term obesity diluted the message. Although this issue was not resolved during the session, it was suggested that the target population view the language used as appropriate. For example, whereas it may be appropriate to use the term obesity with health care providers and scientific researchers, it might be more appropriate to use alternative terminology with other communities. It was further recommended that the message should not detract from the importance of selecting an appropriate messenger. For some communities, it is important to have a consistent, clear message delivered by familiar sources. Examples of familiar sources might include sports figures, TV celebrities, community activists, or members of the faith-based community. Panelists highlighted the influence of environmental factors on overweight and obesity and recommended adding environmental approaches to the plan. Some of the conditions supporting this view included the following: obesity and poverty coexist in some households; fewer open spaces and parks for play; fewer children are walking to school; and wellness programs are not affordable across population groups. It was suggested that school facilities be available after school hours for recreational use and that use of school facilities be accessible to everyone within the community regardless of ability to pay. Concerns were raised that the increased cost of keeping the facility open after hours might be a barrier. Also, questions were raised regarding liability if people were injured on the premises. Another suggestion was to develop additional parks and open spaces and to build more sidewalks using transportation funds. With these enhancements, people may be able to exercise within their own neighborhoods. In addition to increasing the availability of places to exercise, people need to feel safe. The public safety agencies are essential partners in any public health efforts because they help provide a safe environment. Finally the public needs to be educated about the influence of

4 Presenters: Association of State and Territorial Public Health Directors, National Alliance for Nutrition and Activity, National Recreation and Park Association, Partnership to Promote Healthy Eating and Active Living, Grocery Manufactures of America, and Regional Plan Association, New York

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environmental factors on overweight and obesity so they can become informed advocates for change. Media5 According to panelists, the public has come to respect the media as a source of health information. Problems arise, however, when there is fragmented communication between the scientific community and the media. For example the responsibility for interpreting research findings may fall on the media. However, because interpreting research findings may go beyond the expertise of the media, there is an increased risk of misinformation. One suggestion was to educate the media not only about the science of overweight and obesity but also about the dynamic nature of research and the changing state of knowledge. Another suggestion was to have the media and the scientific communities create more regular working relationships to decide jointly on the message and the most effective way to relay it to the public. The panelists believed that the media could be powerful allies in the battle against overweight and obesity. Media professionals bring to the table expertise in message tailoring and public appeal. They can teach public health professionals how to incorporate established marketing strategies into the delivery of health messages. During the media panel discussion, it was also suggested that the individual who delivers the message reflect or represent the target audience. As one listening session participant put it, “No one wants to watch a size 6 model that has never had a problem maintaining the recommended weight give advice on weight loss.” Proper selection of the message and the messenger may help reduce discrimination, promote self-acceptance, and provide a source of empowerment to individuals.

Partnerships to Drive Action The following activities are intended to provide brief annotated examples of various types of partnerships and a listing of some existing partnership driven programs. The types of partnerships highlighted include a State Public Health Program, an Industry-Funded Program, a Community-Based Program, and a Local Coalition Program. State Public Health Program: Campaign for a Healthy Maine (http://www.state.me.us/dhs/boh) A statewide initiative focused on three preventable risk factors—tobacco addiction, physical inactivity, and poor nutrition. The project is funded by tobacco settlement funds, funds from the Centers for Disease Control and Prevention, funds from the U.S. Department of Agriculture, and state funds. State funds were used at local levels for school- and community-based programs. Examples of some of the state-

5 Presenters: Health Watch, International Food Information Council, and Produce for Better Health Foundation

funded programs include training programs for counselors, a statewide hotline and cessation program, insurance support, media campaigns, and evaluation of various programs. The campaign included community and school interventions, media announcements, tobacco regulation enforcement, and evaluation. Campaign for a Healthy Maine was launched October 2000 with a 2-day summit hosted by the governor with the intent of rallying support from stakeholders across the State. Industry-Funded Program: Childhood Obesity Prevention Initiative (http://kidnetic.com) This initiative is administered by the International Food Information Council Foundation and primarily funded by the food, beverage, and agricultural industries. The Childhood Obesity Prevention Initiative will track consumer knowledge and perceptions and define appropriate messages and program elements. The term “obesity” may be excluded from campaign messages that focus on humor, small victories, performance, appearance, and acceptance, rather than health, and will be targeted toward children. The organizers recognize that childhood obesity is a very complex issue with many possible solutions and that partnerships are key to success. The Foundation plans to conduct in-depth consumer focus groups and ethnographic and qualitative research to build a successful communications program and provide the tools necessary to talk about the issues. Community-Based Program: Hochunk Youth Fitness Program The Hochunk Youth Fitness Program is housed in Wisconsin and is a partnership among health care professionals, youth services, social services, fitness and nutrition departments, the university, and area school districts. The program, which is funded by the Health Resources and Services Administration, is based on the local community culture and its youth. The program logo was developed from a local child’s drawing, and the program was designed to be simple and easy. The major goals of the program are to reduce the incidence of childhood obesity, prevent adult obesity, and set up an infrastructure that can be maintained to address children at risk for diabetes. The program consists of an after-school educational program, supermarket tours, adult classes, and nutrition assessment. Down-to-earth incentives such as scooters, cassette players, and sports equipment are an important part of the program. Double points toward these prizes are awarded to children for bringing their family members to the activities. Transportation is provided to increase access to the services. Daily communication within the partnership network has been essential to the success of the program in raising awareness in the community. OBESITY RESEARCH Vol. 10 No. 12 December 2002

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Local Coalition Program: Spokane’s BMI Awareness Campaign The Leadership Spokane Class of 1999 developed the Spokane BMI Awareness Campaign, which is a grass roots coalition. The mission of the campaign is to promote routine BMI evaluation and intervention and incorporate the National Institutes of Health’s clinical guidelines into health care practices. They recognized that most people are unaware of the significance of BMI as a health-risk indicator. Components of the campaign included a BMI chart to hang on scales that outlined classification and treatment algorithms. The charts along with copies of National Institutes of Health clinical guidelines were provided to every physician in the Spokane area. In addition, the information was made available to worksite wellness programs in the area. The leadership developed surveys to collect baseline and outcome data, a public awareness campaign, and a strategic plan for the community. The uniqueness of this project lies in the fact that it has progressed without a funding stream but continues to exist with endorsements and commitments from local business and community leaders and health care providers. Other Programs Presenters and attendees during the meeting also mentioned several other representative successful programs, including: ●

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Saint Louis Prevention Research Center—sponsored by CDC, the center has undertaken a heart healthy project for cardiovascular disease prevention of rural African Americans in Missouri PE4Life—a cooperative program sponsored by otherwise highly competitive manufacturers of sporting goods Hoops for Heart/Jump Ropes for Heart—sponsored by the American Heart Association, these programs encourage people to get moving by participating in jump rope competitions and basketball tournaments Zuni project—a weight management program developed by the Zuni Tribe and entirely funded and supported by the Tribe 5-A-Day Program—a public/private partnership of the National Cancer Institute, the Centers for Disease Control and Prevention, the United States Department of Agriculture, fruit and vegetable producers, and the food industry: a wellplanned and funded strategy, with the food and beverage industries spending $10 billion to market the program Project LEAN—a statewide initiative in California funded as a public/private partnership between the State and the Association of State and Territorial Public Health Nutrition Directors. The program sponsors community interventions for nutrition and physical activities through public policy and community action New York’s Eat Well, Play Hard—a public/private partnership supported by the Association of State and Territorial

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Public Health Nutrition Directors focusing policy, education, and funding to increase activity, decrease fat consumption, and increase consumption of fruits and vegetables.

Discussion Participants in the Surgeon General’s Listening Session were well aware of the multifactorial etiology of overweight and obesity: conditions resulting from complex interactions among genetics, physiology, culture, and environment. They emphasized not only the need for applying multiple intervention and prevention strategies to address the problems of overweight and obesity, but also the urgency with which these strategies need to be implemented. The backdrop of increased disease risk, increased morbidity, and increased health care costs necessitate the need for immediate strategic action. The Listening Session represented a unique opportunity to have many varying perspectives on the issue of weight management heard and considered in addressing this public health issue. Information from the National Nutrition Summit (11), the Listening session, and the accompanying public comment period served as the basis for the Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity (1). The intent of this article is to highlight some of the discussions held during the Listening Session. Although organized according to set of distinct settings, it is important to understand that the Listening Session was a broader and more dynamic process with many of the discussions overlapping. There were several common themes that emerged during the session. They were: the need for better communication among the stakeholders; the need for swift action to address the problem, recognizing that positive results of any actions may take decades or generations to realize; the need for more research on the etiology and appropriate interventions for overweight and obesity; the need for evaluation of the effectiveness of the interventions; and the importance of approaching overweight and obesity as a health issue and not an appearance issue. These themes were captured within the Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity with the CARE acronym where “C” represents communication, “A” represents action, “R” represents research, and “E” represents evaluation (1). Within the CARE framework, it is important to realize that multiple levels of action are required to successfully combat overweight and obesity. Efficient use of multiple levels of action requires multiple partners unified by a common goal. The Listening Session provided an opportunity for family and community groups, schools, media, representatives from the health care environment, and representatives from worksites to become partners and to unite around the common goal of preventing and decreasing overweight and obesity. Together the combination of approaches from these environments offers a better chance of combating this epidemic.

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Further information is available at: http://www.surgeongeneral.gov/topics/obesity/. 1.

2.

3. 4. 5. 6.

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References U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. Washington, DC: U.S. Government Printing Office; 2000. Visscher TL, Seidell, JC. The public health impact of obesity. Annu Rev Public Health. 2001;22:355–75. Deckelbaum R, Williams C. Childhood obesity: the health issue. Obes Res. 2001:S235–S9. Lytle L. Nutritional issues for adolescents. J Am Diet Assoc. 2002;102:S8 –S12. Allison D, Fontaine K, Manson J, Stevens J, VanItallie T. Annual deaths attributable to obesity in the United States. JAMA. 1999;282:1530 – 8. Doll H, Petersen SE, Stewart-Brown SL. Obesity and physical and emotional well-being: associations between body

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mass index, chronic illness and the physical and mental components of the SF-36 questionnaire. Obes Res. 2000;8:160 –70. Wolf AM, Colditz GA. Current estimates of economic costs of obesity in the United States. Obes Res. 1998;6:97–106. U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2002. National Institutes of Health. Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults: Evidence Report. NIH Publication. No. 98-4083. Bethesda, MD: DHHS, NIH-NHLBI, NIH. 1998. National Nutrition Summit, May 30, 2000. Results of the Obesity Discussion Groups. Obes Res. 2000;9:S41–S52. Office of the Surgeon General. Overweight and Obesity: The Surgeon General’s Call To Action To Prevent and Decrease Overweight and Obesity. 2002. http://www.surgeongeneral. gov/topics/obesity/ United Department of Agriculture, U.S. Department of Health and Human Services. December 1995. http://www. nal.usda.gov/fnic./dga/dguide95.html

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