Obesity in U.S. children and youth is an epidemic characterized by an unexpected and excess number of cases on a steady increase in recent decades. The epidemic is relatively new but widespread, and one that is disproportionately affecting those with the fewest resources to prevent it. Although it does not have the exotic nature or immediate mortality of severe acute respiratory syndrome, anthrax, or Ebola virus, it is harming a much broader cross section of our young people and may significantly undermine their health and well-being throughout their lives. Obesity can affect a child's health immediately through physical or psychological conditions such as type 2 diabetes, hypertension, steatohepatitis, depression, and stigma. Obesity can also affect a child's health in the longer term with additional illnesses that include arthritis, cancer, and cardiovascular disease.

Infectious disease epidemics require and usually receive immediate high-level attention, with resources invested to control the problem and prevent its recurrence. Childhood obesity must be treated with comparable urgency. As with other emerging health problems, our degree of knowledge and arsenal of effective interventions are quite limited. But we do not have the luxury of waiting to accumulate large bodies of evidence. Therefore, it behooves us to chart our course of action wisely based on what evidence we have—drawing from our dealings with analogous problems and the outcomes of natural experiments—and learn as we proceed. Complicating the process will be the multiple causes and correlates of childhood obesity and the need for many concurrent actions and interventions. Nevertheless, as we carefully evaluate our programs and policies in terms of efficacy, effectiveness, and cost utility, we can devise new and innovative approaches based on our experience, discard those that are less useful, promote those that work, and follow through accordingly.

Childhood obesity is complex because it has biological, behavioral, social, economic, environmental, and cultural causes, which collectively have created over decades an adverse environment for maintaining a healthy weight. This environment is characterized by:

• Urban and suburban designs that discourage walking and other physical activities
• Pressures on families to minimize food costs and acquisition and preparation time, resulting in frequent consumption of energy-dense convenience foods that are high in calories and fat
• Reduced access and affordability in some communities to fruits, vegetables, and other nutritious foods
• Decreased opportunities for physical activity at school and after school, and reduced walking or biking to and from school
• Competition for leisure time that was once spent playing outdoors with sedentary screen time—including watching television or playing computer and video games.

The result is that obesity from unhealthful eating and inactivity has rapidly become the social norm in many communities across America. In that respect, the nation is moving away from—instead of toward—the “healthy people in healthy communities” vision of Healthy People 2010. Although assigning blame for this situation may be easy, it is unlikely to be accurate or productive. In general, the average person does not make the conscious choice to become obese, despite the adverse health and social consequences. No industry aims to promote weight gain among its customers. Nonetheless, excess weight is gained slowly over time as companies develop and market foods and beverages to maximize revenues; community zoning and street-design decisions are influenced by numerous social and financial pressures; schools face scheduling constraints in fitting everything into the school day while facing the reality of budgetary limits; and individuals make small but cumulative behavioral decisions daily about eating and physical activity in the obesogenic environment that surrounds them.

Now that the nation has begun to realize the significant health, psychological, and societal costs of an unhealthy weight, it is time to re-examine its way of thinking and revise the social norms that are now accepted. This process should span virtually the entire spectrum of society, from corporate board rooms to federal agencies, from elected officials to health insurers and employee unions, from health and medical professionals to teachers and school administrators, from foundations and public service organizations to medical and public health researchers, and of course, it must involve entire communities and families, including parents, relatives, friends, and the children themselves. Although this challenge may appear to be overwhelming, there have been many examples over the past century—relating to smoking, seatbelts, and children's car seats, for example—of substantial shifts in the American culture, society's outlook, and, most important, in people's behavior and their health outcomes. Culture is not a static set of values and practices. It is continuously recreated as people adapt and redefine their values and behaviors to changing realities. These changes have occurred once there has been a collective understanding of the severity of the problem, its impact on health, and mobilization around the potential for improvement. Similar conditions now apply to childhood obesity, and the need for change should be particularly compelling in that the health of America's children is at stake.

As institutions, organizations, and individuals across the nation begin to make changes, social norms are also likely to change, so that obesity in children and youth will be acknowledged as an important and preventable health outcome and healthful eating and regular physical activity will be the accepted and encouraged standard.

Changing the social norms toward healthful lifestyles will have amplified benefits. Individual-level changes toward nutritious diets and increases in physical activity levels have short- and long-term potential for improved health and well-being. Likewise, the enhancements and improvements made to the built and social environments in our communities to improve access to healthful foods and opportunities for physical activity may also improve the safety of neighborhoods and street crossings and strengthen community cohesion.

Preventing childhood obesity should become engrained as a collective responsibility requiring individual, family, community, corporate, and governmental commitments. The key will be to bring changes to bear on this issue from many directions, at multiple levels, and through collaboration within and between many sectors. For example, shared responsibilities on issues such as increasing outdoor play opportunities and walking- or biking-to-school programs will require attention from zoning and planning commissions, public works departments, public safety and police agencies, school boards, parks commissions, community members, and parents.

This is a major societal health problem that will be minimally affected by isolated measures or selectively assigned responsibilities. It will also require a long-term commitment spanning many years and possibly decades because the epidemic has taken years to develop and will require persistent efforts and the investment of sustained resources to effectively ameliorate.

As with many health issues, there are high-risk populations, including low-income and ethnic minority communities, for which obesity prevention initiatives will need to be particularly focused. Resources will need to address a range of issues such as safety, language barriers, limited access to food and health services, income differentials, and the influence of culture on food selection and preferences for available physical activities.

Tough choices will have to be made at all levels of society. There will be trade-offs in convenience, in cost, in what's “easy,” in pushing one's self and one's organization, in choosing between priorities, in devising new laws and regulations, and in setting limits on individuals and on industries.

Science can best help by integrating a traditional biomedical approach to such health concerns with behavioral and social science research. Effective solutions lie not in a magical “eat all you want” pill but rather in intensive, often laborious, and long-term improvements in the environments that surround children in their homes, schools, communities, commercial markets, and modes of entertainment. While biology may often encourage us to eat more than we need to, biological solutions are not the answer from an ethical or practical perspective. Nor is genetics the primary problem or the sole determinant. Rather, it is the complex interplay among an individual's knowledge, attitudes, values, behaviors, and environments that play the most influential roles in promoting obesity.

In reviewing the available evidence to inform this report, there was an abundance of scientific studies on the causes and correlates of obesity but few studies testing potential solutions within diverse and complex social and environmental contexts, and no proven effective population-based solutions. Moreover, a concern of the committee is that even if many of the recommended actions are implemented, research should contain a better balance between studies that continue to address the underlying causes of the obesity epidemic and studies that test potential solutions—that is, identifying appropriate methodologies for effectively promoting healthful eating and physical activity and reducing sedentary behaviors that will support obesity prevention in children and youth.

NEXT STEPS FOR ACTION AND RESEARCH

Recognizing the multifactorial nature of the problem, the committee deliberated on how best to prioritize the next steps for the nation in preventing obesity in children and youth. The traditional method of prioritizing recommendations of this nature would be to base these decisions on the strength of the scientific evidence demonstrating that specific interventions have a direct impact on reducing obesity prevalence and to order the evidence-based approaches based on the balance between potential benefits and associated costs including potential risks. However, a robust evidence base is not yet available. Instead, we are in the midst of compiling that much needed evidence at the same time that there is an urgent need to respond to this epidemic of childhood obesity. Therefore, the committee used the best scientific evidence available—including studies with obesity as the outcome measure and studies on improving dietary behaviors, increasing physical activity levels, and reducing sedentary behaviors as well as years of experience and study on what has worked in addressing similar public health challenges—to develop the recommendations presented in this report. These recommendations constitute the committee's priorities and the recommended steps to achieve them.

As evidence was limited, yet the health concerns are immediate and warrant preventive action, it is an explicit part of the committee's recommendations that obesity prevention actions and initiatives should include evaluation efforts to help build the evidence base that continues to be needed to more effectively fight this epidemic.

From the report's ten recommendations, the committee has identified a set of immediate steps based on the short-term feasibility of the actions and the need to begin a well-rounded set of changes that recognize the diverse roles of multiple stakeholders (Table 9-1). In discussions and interactions that have already begun and will follow with this report, each community and stakeholder group will determine their own set of priorities and next steps. Furthermore, action is urged for all areas of the 10 recommendations, as the list in Table 9-1 is only meant as a starting point.

TABLE 9-1

Immediate Steps.

The committee was also asked to set forth research priorities. There is still much to be learned about the causes, correlates, prevention, and treatment of obesity in children and youth. Because the focus of this study is on prevention, the committee concentrated its efforts throughout the report on identifying areas of research that are priorities for progress toward preventing childhood obesity. The three research priorities discussed throughout the report are:

• Evaluation of obesity prevention interventions—The committee encourages the evaluation of interventions that focus on preventing obesity, improving dietary behaviors, increasing physical activity levels, and reducing sedentary behaviors. Specific policy, environmental, social, clinical, and behavioral intervention approaches should be examined for their feasibility, efficacy, effectiveness, and sustainability. Evaluations may be in the form of randomized controlled trials and quasi-experimental trials. Cost effectiveness research should be an important component of evaluation efforts.
• Behavioral research—The committee encourages experimental research examining the fundamental factors involved in changing dietary behaviors, physical activity levels, and sedentary behaviors. This research should inform new intervention strategies that are implemented and tested at individual, family, school, community, and population levels. This would include studies that focus on factors promoting motivation to change behavior, strategies to reinforce and sustain improved behavior, identification and removal of barriers to change, and specific ethnic and cultural influences on behavioral change.
• Community-based population-level research—The committee encourages experimental and observational research examining the most important established and novel factors that drive changes in population health, how they are embedded in the socioeconomic and built environments, how they impact obesity prevention, and how they affect society at large with regard to improving nutritional health, increasing physical activity, decreasing sedentary behaviors, and reducing obesity prevalence.

The recommendations that constitute this report's action plan to prevent childhood obesity commence what is anticipated to be an energetic and sustained effort. Some of the recommendations can be implemented immediately and will cost little, while others will take a large economic investment and require a longer time to implement and to see the benefits of the investment. Some will prove useful, either quickly or over the longer term, while others will prove unsuccessful. Knowing that it is impossible to produce an optimal solution a priori, we more appropriately adopt surveillance, trial, measurement, error, success, alteration, and dissemination as our course, to be embarked on immediately. Given that the health of today's children and future generations is at stake, we must proceed with all due urgency and vigor.