HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS THE LIFESPAN

Federal Initiatives to Address Overweight/Obesity

VAN HUBBARD: Good morning. That applause is for Denise. What I'd like to do is cover some of the concepts behind the future NIH and also some remarks on HHS obesity research. Some of these remarks are to identify some of the unknowns, the questions that we all have, but I'm also going to try to phrase it in terms that we are trying to come up with answers that will help your programs be better and succeed in helping us address this overall problem of overweight and obesity in this country.

As you know, HHS has a number of activities that relate to overweight and obesity starting with the Presidential Healthier U.S. Initiative that was launched in 2002 which emphasized regular physical activity, healthy diet, early preventative screenings, and adopting a healthy lifestyle through better choices.

Within HHS we've had the Steps to a Healthier U.S. and a number of related activities that also have followed upon the surgeon general's called to action to prevent and decrease overweight and obesity, and then other efforts including Healthy People 2010, and especially the nutrition and overweight focus area of which I am a co‑lead.

Why are we doing this? I think this slide depicts that reason. We need to shift our approach from a disease‑care system to a healthcare system. It's recognized that approximately 75 percent of our nation's healthcare costs are spent on chronic preventable diseases. And, thus, increased priority is being addressed to such issues as obesity, diabetes, asthma and their interrelationships.

Again, why are we here? We're here because overweight and obesity is associated with numerous medical complications. If it weren't for the health complications, we wouldn't have this as a public health problem. It may still be a personal problem in terms of your own perspective, but it would not be a public health problem without all of the medical complications. And I'm not going to go through and list verbally each of these on this slide.

Within the NIH it was recognized, especially by Dr. Zerhouni, that because of the importance and the relevance of obesity research and research on the associated comorbidities that NIH needed to step to the plate and play a major role in addressing the increasingly severe obesity epidemic and its implications for public health. And, thus, in 2003 he established NIH Obesity Research Task Force, which has been co‑chaired by the directors of the National Institute of Diabetes, Digestive and Kidney Diseases and the National Heart, Lung and Blood Institute.

However, this task force is made up of representatives of almost all of the organizations within the NIH, and this is just a laundry list of most of the institutes and centers. NIH now has 27 institutes and centers, and they all feel that they can play a part of the role in addressing this problem.

As part of the charge to that task force, we developed a strategic plan for NIH obesity research. This plan is now printed in the book shown here on this slide, but it will also remain on the web in a dynamic manner. As new information becomes available, as things are updated, the website identified here, www.obesityresearch.nih.gov, will be continually updated to reflect the most recent information. If you go to that website, it's a website that you should look at as one‑stop shopping for anything going on relating to obesity. In addition to having links to download the strategic plan itself, there are links to many of the other activities that are associated with NIH and, in some cases, other departments on this website. All of the initiatives are identified, all research solicitations are identified, and there is also a listing of workshops that are currently being planned, as well as having been recently held.

If you look at the workshops that have been held and you go into the
archival ‑‑ I mean on links that are maintained at the website, for many
of these workshops you can actually download the presentations that were provided at these workshops, and I think that you would find many of these useful as an educational tool for your own programs. And it's needless to say that everything on this website is in the public domain and, thus, can be used.
However, I would make one request. If you use a download of an individual's slides from one of these workshops, please at least give appropriate attribution to the individual that originally provided the slide.

With regard to the outcomes and goals that we are striving to reach, obviously we need further research towards preventing and treating obesity through lifestyle modification. We also need to work towards preventing and treating obesity with the use of pharmacological, surgical, and other medical approaches. Obesity is a chronic disease. It needs chronic intervention, chronic therapy. Short‑term therapy is not going to work. Once a person has obesity, it's a chronic disease and requires chronic therapy.

We need to break the link between what is viewed as obesity and its associated comorbidities. We know that there is a high correlation or association between obesity and many of the other comorbidities that were outlined on the earlier slide. What we don't know is the actual causal link between the two, and that has led to many of the debates that have created some confusion in both the public and the policymakers' eyes as to whether obesity should be considered a disease and what is the true relationship.

We need to have better mile markers of what relates to obesity as an etiology of many adverse health conditions. We commonly use BMI, Body Mass Index, which is a way of relating weight normalized for height, and it does have a good association. But BMI is an epidemiological tool. It is not, in and of itself, a diagnostic criterion for making a medical diagnosis.

I often use an analogy that if we were to ask how many people are old in this country, somebody has to decide what age to use as the most common way of answering that question. And often that is done, and as ‑‑ if we look at populations and you see shifts in numbers above a certain age, it tells you whether that society is aging or not. It does not necessarily tell you about what is going on in the individual. As an example, all people at the age of 75 do not have the same health risks, but as you age, as you get older, you are at increased risk of coming down with a number of diseases. Same with obesity. As your BMI increases, you, as an individual, have an increased risk of having associated comorbidities, but for everybody at the same BMI, you are not at the same health risk.

And, most importantly, we need to be aware of the cross‑cutting research needs, combining multidisciplinary/interdisciplinary skills to address this major public health problem.

We often ask the question: Why has the obesity prevalence increased, and what can be done about it? Is it related to the increased food portion size? I'm not sure. That's an easy answer to give. Part of the problem also in this country is that many of the public don't differentiate between portion size and serving size. What about the increase of availability of foods? The epidemic started in the late '70s and has been continuing since.

Think about some of the events that have occurred since that point in time. I remember in around 1970 when we had the first grocery store open 24 hours a day. There can be little things that add to this public health problem.

All technological advances have basically led to the decreased need to expend energy. So what is the role of decreased physical activity and, correspondingly, the increased sedentary behaviors?

And, finally, I mean, what are the other influences of the built environment? Think about it in your own daily lives. What active decision‑making processes do you use individually to select what food you eat or what activities you undertake? Do each of you consciously make a decision? That's what we're asking the U.S. public and the world to do: Consciously make a decision, and think about how you do that yourselves.

Some of the examples that we are trying to deal with it is improved research dealing with site‑specific approaches to treating especially pediatric obesity with the interventions taking place in the home, community centers, or other non‑healthcare settings. We are also trying to improve the treatment and prevention approaches in primary care settings, and this includes not only the pediatrician's office but the use of other affiliated healthcare providers.

We have several studies going on in middle school, trying to instill improved knowledge and habits. We also have educational programs. The NHLBI has a "We Can" program, and that's also linked on that website I gave you, and you can use materials provided there that is aimed at both children and parents. And we also have developed a middle school curriculum on energy balance that can be utilized in your local settings. And we continue to look at the influences of the built environment.

Some other examples. We have had all sorts of diets out there. Are any of one diet more beneficial than the other? We don't know. Obviously many people use varying approaches to lose weight, and we're trying to see if one offers an advantage over another. The probable answer is for different individuals, different diets will be best. The most recent observation that has been made is that probably a high protein has more of a consistent benefit in terms of curbing appetite than whether it's a high carbohydrate or a high fat or any other diet.

We are also looking at factors that occur during pregnancy or the prenatal events and their influence on the development of overweight and obesity. Over the last decade we have had major advances in our understanding of obesity as a biological disease. Leptin, which I'm sure that you've at least all heard about, was identified in 1994. Since that time it has really given credibility back to the science of obesity, and there have been a whole host of new metabolic pathways identified that are giving us at least further hope in identifying mechanisms through which we can intervene and address this problem.

With the increasing prevalence of the more severe obesity, and this is with BMIs of 40 or greater in general, there is an increasing utilization of bariatric surgery. I don't look at bariatric surgery as being an extreme form of therapy. It is an option. And for certain individuals, it may be the best option. And I think as an individual, as a group, as a country, we should not impose our own feelings on a given therapy on those of others. In many medical conditions there are multiple approaches to intervene, and usually that is taken up between the healthcare provider and the individual, and you work out what is best in that individualized case scenario.

And, again, surgery is an option that we have. For some people it may be the best option. But we are also undertaking further research studies both to learn about mechanisms dealing with appetite control as well as looking at the safety and efficacy issues.

We have to remember that obesity is a complex interplay of multiple factors. Throughout HHS we support research to provide the best available evidence‑based recommendations and identify research needs for the future. To reverse this obesity epidemic, we do require increased coordination between all HHS agencies, as well as those in the other federal domains.

The CDC is not here, but this is their mission with regard to obesity, to promote health and quality of life by preventing and controlling disease, injury, and disability. They do this through the different bullets, items that are listed here. Primarily they do a lot of monitoring and looking at the associations between conditions. They are a linkage to the state and local health departments and have methods to support the promotion of healthy behaviors and foster a safe and healthy environment as well as provide training.

Another one that we often go to is ARC, which helps to translate our research into evidence‑based approaches to deal with the quality of recommendations to make as we take on various diseases, including obesity. But we also need coordination throughout. And within HHS we have the other agencies listed
here ‑‑ FDA, the Indian Health Service, CMS ‑‑ as well as our partner on the platform here from HRSA. And then we extend out to the other federal agencies, including USDA and all the other federal partners.

There is now an interagency working group on obesity that has been formed within the Office of Science and Technology Policy within the Executive Office of the President. The whole charge of this group is to identify the best ways of all the agencies working together on this problem.

To solve they obesity epidemic, we need to emphasize the role of partnering, and each partner has to look at their programs and identify how what they are doing is providing added value to what is already in place. Your ultimate goal is to prevent disease and disability. Research is the key to success. And I thank you for having the opportunity to stand up here and talk with you.

Thank you.