1. Undernutrition and Obesity: the View from the Public Sector William H. Dietz, MD, PhD Division of Nutrition and Physical Activity CDC

2. Undernutrition and Obesity UndernutritionObesityWomen > men Ethnic differences SES gradientSES gradient in white women Children esp vulnerableAdults > children Large disease and financial burden Breastfeeding protects Food insecurityFood insecurity? UndernutritionObesityWomen > men Ethnic differences SES gradientSES gradient in white women Children esp vulnerableAdults > children Large disease and financial burden Breastfeeding protects Food insecurityFood insecurity?

3. Examples of the Elimination of Micronutrient Malnutrition in the United States Iodine deficiency Pellagra Neural tube defects Iodine deficiency Pellagra Neural tube defects

4. The Full Spectrum of Iodine Deficiency Reduced intellectual performance Goiter Cretinism

5. Iodized Salt in the United States Morton develops Iodized salt to help prevent goiters, which were common at the time. The Food and Drug Administration later requests that the product be labeled with the message, “This salt provides iodide, a necessary nutrient.” 1924

6. Salt Iodization in the US: Trend in Goiter Prevalence in Michigan WHO Monograph Series No. 44

7. Examples of the Elimination of Micronutrient Malnutrition in the United States Iodine deficiency Pellagra Neural tube defects Iodine deficiency Pellagra Neural tube defects

8. Mortality and Morbidity Rates per 100,000 Population Year Mandatory Enrichment Law Became Effective (1945) 1000 100 10 1 0.1 1925193519451955194019301950 Morbidity and Mortality Rates of Pellagra in Mississippi Voluntary Bread Enrichment Began (1938) Morbidity Mortality Source: AMJ Public Health 2000; 90:727

9. Examples of the Elimination of Micronutrient Malnutrition in the United States Iodine deficiency Pellagra Neural tube defects Iodine deficiency Pellagra Neural tube defects

10. Prevalence of spina bifida and anencephaly by year and quarter of birth for 24 surveillance programs (1995-99)

12. World Bank Rankings of Cost Effective Interventions

13. Copenhagen Consensus “Very Good Proposals” ChallengeOpportunity DiseasesControl of HIV/AIDS MalnutritionProviding micronutrients Subsidies & tradeTrade liberalization DiseasesControl of malaria ChallengeOpportunity DiseasesControl of HIV/AIDS MalnutritionProviding micronutrients Subsidies & tradeTrade liberalization DiseasesControl of malaria

14. Flour Fortification Initiative A Public-Private-Civic Investment in Each Nation

15. What Can Industry Do? New product development Help make the case for fortification Recognize success Develop and argue the ROI Use business to business networks Support a level playing field Market the approach New product development Help make the case for fortification Recognize success Develop and argue the ROI Use business to business networks Support a level playing field Market the approach

16. Source: International Obesity Task Force Global Prevalence of Obesity, 1988-94 Samoa (urban) Kuwait East Germany USA Saudi Arabia W. Germany Czech Republic England Canada Netherlands Australia Brazil Japan China WomenMen 806040200 406080 % population Age range 25-69 18+ 25-64 20-74 15+ 25-69 20-65 16-64 18-74 20-59 20-69 15-64 25-64 20+ 20-45

17. 19961991 2004 Obesity Trends* Among U.S. Adults 1991, 1996, 2004 No Data<10%10%-14%15%-19%20%-24%  25%

18. Consequences of Adult Obesity Psychosocial Cardiovascular – Hyperlipidemia – Diabetes mellitus – Hypertension – Respiratory – Cardiac Psychosocial Cardiovascular – Hyperlipidemia – Diabetes mellitus – Hypertension – Respiratory – Cardiac Medical – Polycystic ovary disease – Gall bladder disease – Osteoarthritis – Cancer Pregnancy and the postpartum Mortality Erectile dysfunction Medical – Polycystic ovary disease – Gall bladder disease – Osteoarthritis – Cancer Pregnancy and the postpartum Mortality Erectile dysfunction

19. Diabetes * Trends Among U.S. Adults, BRFSS 1990, 1996, and 2004 *Includes Gestational Diabetes 19901996 2004 No Data 10%

20. Duration of Diabetes and Nephropathy (Pima Indians) The duration of diabetes, rather than the age at diagnosis, is predictive of nephropathy (Krakoff. Diabetes Care 2003;26:76) Cumulative Incidence Nephropathy (%) 15 - 24 Y 35 - 44 Y 25 - 34 Y Duration (years)

22. Costs of Obesity Costs of illness Costs of absence from work Costs of reduced productivity Costs of injuries Costs of disability Costs of illness Costs of absence from work Costs of reduced productivity Costs of injuries Costs of disability

23. Annual Direct and Indirect Costs Attributable to Obesity in the United States (Billions of 1995 Dollars) Type 2 DM CHD Hypertension Gallbladder Breast Ca Endometrial Ca Colon Ca Osteoarthritis Total Type 2 DM CHD Hypertension Gallbladder Breast Ca Endometrial Ca Colon Ca Osteoarthritis Total Disease Direct Costs Indirect Costs $32.4 $ 7.0 $ 3.2 $ 2.6 $ 0.8 $ 0.3 $ 1.0 $ 4.3 $51.6 $32.4 $ 7.0 $ 3.2 $ 2.6 $ 0.8 $ 0.3 $ 1.0 $ 4.3 $51.6 $30.7 $ NA $ 0.1 $ 1.5 $ 0.5 $ 1.8 $ 12.9 $47.5 $30.7 $ NA $ 0.1 $ 1.5 $ 0.5 $ 1.8 $ 12.9 $47.5 Wolf and Colditz, Ob Res 1998;6:97

24. % Total Change in Spending by Top 10 Conditions 1987-2000 Heart disease Pulmonary conditions Mental disorders Cancer Hypertension Trauma Cerebrovascular disease Arthritis Diabetes Back problems Heart disease Pulmonary conditions Mental disorders Cancer Hypertension Trauma Cerebrovascular disease Arthritis Diabetes Back problems 30% 16% Thorpe et al. Health Affairs 2004; W4-437

25. Costs of Obesity Costs of illness Costs of absence from work Costs of reduced productivity Costs of injuries Costs of disability Costs of illness Costs of absence from work Costs of reduced productivity Costs of injuries Costs of disability

26. Effects of Obesity on Health and Disability among 50-69 yo Women with BMI > 35 Report poor health40.5% # Chronic conditions 2.31 Any ADL limitation21.4% Report health limits work45.7% Sturm et al. Health Affairs 2004;23:199 Report poor health40.5% # Chronic conditions 2.31 Any ADL limitation21.4% Report health limits work45.7% Sturm et al. Health Affairs 2004;23:199

27. Partners in the Prevention and Treatment of Obesity Medical Settings School Work Site Community Industry Medical Settings School Work Site Community Industry

28. Relationship Between Energy Requirements, Physical Activity, and Weight Energy Requirements Level of Physical Activity Energy Requirements Weight

29. What Can Industry Do? Recognize the threat Use business to business contacts Become model worksites – healthful choices, medical benefit packages New product development Create and meet consumer demand Use creative packaging Share non-proprietary market research Recognize the threat Use business to business contacts Become model worksites – healthful choices, medical benefit packages New product development Create and meet consumer demand Use creative packaging Share non-proprietary market research

30. Division of Nutrition and Physical Activity, Adolescent and School Health, and VERB Websites cdc.gov/nccdphp/dnpa cdc.gov/nccdphp/dash cdc.gov/youthcampaign VERBnow.com VERBparents.com healthierus.gov/steps cdc.gov/nccdphp/dnpa cdc.gov/nccdphp/dash cdc.gov/youthcampaign VERBnow.com VERBparents.com healthierus.gov/steps