1. Obesity and Other Diet- and Inactivity-Related Diseases:
National Impact, Costs, and Solutions
2003
National Alliance for Nutrition and Activity (NANA)
For more information, call Dr. Margo Wootan at

2. Summary
Two-thirds of premature deaths in the U.S. are due to poor nutrition, physical inactivity and tobacco use. Federal and state governments conduct effective programs to reduce tobacco use, but programs to promote healthy eating and physical activity and reduce obesity are limited.
Obesity is one of the greatest public health challenges of our time.
Overweight and obesity affect the majority of American adults (65%).
Obesity is the nation’s fastest rising public health problem. Obesity rates among U.S. adults increased by 75% between 1991 and 2001 and rates doubled in children and tripled in teens over the last 20 years.
The negative health consequences of rising obesity rates are already evident. Rates of diabetes (most of which is type 2, which is largely due to obesity, poor diet and inactivity) rose 60% between 1990 and 2001.
All states should be funded by the CDC as soon as possible to promote healthy eating and physical activity and reduce obesity. Currently, only twelve states are funded.

3. Unhealthy eating and physical inactivity cause 1/3 of premature deaths
Two-thirds of premature deaths are caused by poor nutrition, physical inactivity and tobacco. HHS estimates that unhealthy eating and inactivity cause about 1,200 deaths every day. That’s 5 times more than the number of people killed by guns, HIV, and drug use combined.1
Diet and inactivity are cross-cutting risk factors, contributing significantly to four out of the six leading causes of death.
Leading Causes of Death4
(Diet and inactivity are leading risk factors for causes of death shown in blue.)
Leading Contributors to Premature Death1
Diet and Physical Inactivity
310, ,000
Tobacco
260, ,000
Alcohol
70, ,000
Microbial Agents
90,000
Toxic Agents
60, ,000
Firearms
35,000
Sexual Behavior
30,000
Motor Vehicles
25,000
Drug Use
20,000
1. Heart Disease
710,760
Cancer
553,091
Stroke
167,661
4. Chronic Lower Respiratory Diseases
122,009
Accidents
97,900
Diabetes
69,301
7. Pneumonia and Influenza
65,313
8. Alzheimer’s Disease
49,558
Nephritis
37,251
Septicemia
31,224
Suicide
29,350
12. Chronic Liver Disease/Cirrhosis
26,552
13. High Blood Pressure
18,073
14. Homicide
16,765
15. Pneumonitis
16,636
60% of Americans are at risk for health problems related to lack of physical activity.2 Regular physical activity helps to prevent heart disease, colon cancer, obesity, diabetes, and high blood pressure.
Only 12% of Americans eat a healthy diet consistent with federal nutrition recommendations.3 The typical American diet is too high in saturated fat, salt, and refined sugar and too low in fruits, vegetables, whole grains, calcium, and fiber.

4. Obesity is one of the greatest health challenges of our time
Almost two-thirds (65%) of American adults are seriously overweight or obese.5 Obesity rates increased by 74% between 1991 and
Obesity rates have doubled in children and tripled in adolescents over the last two decades. One in seven young people are obese and one in three are overweight.8
Overweight shortens the life expectancy of a 40-year old adult by three years. Obesity shortens women’s lives by seven years and men’s lives by six years.7
Obesity increases the risk of heart disease, high blood pressure, diabetes, and other chronic diseases as much as does 20 years of aging.9 Both increase the number of chronic conditions by more than 50%.
Percentage of young people who are obese8
“We must have the… CDC intensify their efforts for early identification and early prevention of overweight and obesity, or we are going to have the first generation of children who are not going to live as long as their parents.” Dr. George Blackburn, associate director, Division of Nutrition, Harvard Medical School
*Data for are based on adolescents ages

5. Diabetes: Obesity’s Twin Epidemic
 Diabetes rates have risen along with obesity rates. Between 1990 and 2001, diabetes rates rose by 61%.6
 Type 2 diabetes can no longer be called “adult onset” diabetes because of rising rates in children. In a study conducted in Cincinnati, the incidence of type 2 diabetes in adolescents increased ten-fold between 1982 and
 Between 50% and 80% of diabetes cases are associated with unhealthy eating patterns and sedentary lifestyles.1,12
Diabetes Prevalence (percent of adults)
 Through physical activity and healthy eating, the onset of type 2 diabetes was reduced by 60% in at-risk individuals. (In comparison, the diabetes drug metformin reduced the onset of type 2 diabetes by 30%.)13
 Federal Medicare and Medicaid costs due to diabetes were $14.5 billion in
 Employers pay an average of $4,410 more per year for employee beneficiaries who have diabetes than for beneficiaries who do not have diabetes.15

6. Unhealthy eating and inactivity cause disability and can reduce quality of life
Number of Americans Affected by Diet- and Inactivity-Related Diseases
 Diabetes is a leading cause of serious disabilities such as blindness and amputation. Each year, 12,000 to 24,000 people with diabetes become blind, more than 100,000 receive treatment for kidney failure, and 82,000 undergo diabetes-related lower-extremity amputations.17
 The leading cause of permanent, premature disability in the U.S. labor force is coronary heart disease, which causes 19 percent of disability allowances distributed by the Social Security Administration.16
Seriously Overweight/Obese ,250,000
High Blood Pressure ,000,000
Diabetes ,000,000
Coronary Heart Disease ,900,000
Osteoporosis ,000,000
Cancer ,900,000
Stroke ,700,000
 Stroke is a leading cause of serious long-term disability million Americans have disabilities resulting from high blood pressure.20
 Most hip fractures are caused by osteoporosis.18, 21 Of people over age 50 who fracture a hip, 24% die within one year and 25% require long-term care.18 A broken hip is the second leading cause of admission to nursing homes.

7. Poor diet and inactivity raise health-care costs
Costs of Diet- and Inactivity-Related Diseases*
Health Care Costs Associated with Risk Factors9 (annual cost per capita)
Cancer $172 Billion
Coronary Heart Disease $130 Billion
Obesity $117 Billion
Diabetes $132 Billion
Stroke $51 Billion
High Blood Pressure $50 Billion
Osteoporosis18,** $17 Billion
*Estimates of annual direct + indirect costs. **Figure includes direct costs only.
Risk Factor
Increase in Inpatient and Ambulatory Care Costs
Obese
$395
Smoking (current or ever)
$230
20 Years’ Aging
$225
Problem Drinking
$150
Overweight
$125
According to the USDA, healthier diets could prevent at least $71 billion per year in medical costs, lost productivity, and lost lives.24 CDC estimates that if all physically inactive Americans became active, we would save $77 billion in annual medical costs.25
Diet- and inactivity-related diseases increase the out-of-pocket costs to families. For example, diabetes patients pay about $2,000 per year in drug store expenses.26
Medical costs of General Motors employees increased from $2225 to $3753 per year with increasing body mass index (BMI) of the employee (except for that of underweight employees).27
Health care spending is expected to rise by 25% by 2030, since the American population is aging. Chronic diseases are responsible for 75% of health care costs.28
Average annual Medicare costs are $940 lower for men and $1185 lower for women with low blood pressure or low cholesterol than for those with high blood pressure or cholesterol.29
Federal Medicaid & Medicare Costs,
Disease
Cost
Heart Disease
$43.1 billion
Cancer
$18.8 billion
Diabetes
$14.5 billion
Stroke
$7.0 billion

8. “Sick Care” versus Health Care
Factors influencing gain in life expectancy:
National spending for population-based prevention31
Since 1900, life expectancy has increased by 30 years. According to the CDC, only 5 of those years can be attributed to curative medicine; the remaining 25 years are due to public health and prevention measures.30
As a nation, we spend about $1.3 trillion each year on health care. Less than 2% of our health care expenditures are for population-based prevention activities.31 Per capita spending for chronic disease prevention and control is $1.21 per year.32 Although there are some programs in place for early detection of disease and managing disease complications, there are few programs to prevent disease in the first place (primary prevention).

9. “Adult” diseases in children
 Only 2% of children eat a healthy diet (i.e., a diet consistent with federal nutrition recommendations)33 and 35% are physically inactive.34 Three out of four American high school students do not eat the recommended 5 or more servings of fruits and vegetables each day.35 Three out of four children consume more saturated fat than is recommended in the Dietary Guidelines for Americans.36
25% of children ages 5 to10 years have high cholesterol, high blood pressure, or other early warning sign for heart disease.37
Autopsy studies of teenagers and young adults have shown that virtually all have fatty streaks in their arteries (which is the first step toward clogged arteries). One in ten study subjects had advanced fibrous plaques in their arteries.38
Due to rising rates among children, type 2 diabetes can no longer be called “adult onset” diabetes. As the number of young people with type 2 diabetes increases, diabetic complications like limb amputations, blindness, kidney failure, and heart disease will develop in people of younger ages (likely in their 30s and 40s).
From 1979 to 1999, annual hospital costs for treating obesity-related diseases in children rose three-fold (from $35 million to $127 million).39

10. Physical Activity & Nutrition Promotion Mass-Media Approaches
Programs that promote healthy eating and activity can be economical and effective
Physical Activity & Nutrition Promotion
Mass-Media Approaches
A physical activity and nutrition lifestyle intervention reduced participants’ risk of developing type 2 diabetes by 60 percent.
Saint Louis University's Prevention Research Center built 17 walking trails in rural communities in Missouri to provide safe and convenient places to exercise. Survey data show that 42% of community residents use the trails and 60% of trail users report that they have been more physically active since the trails were built.
A curriculum taught to middle school students in Massachusetts integrated health promotion messages into traditional lessons, such as math, science, and language arts. The curriculum effectively reduced obesity prevalence by 3.3% among girls (contrasting with a 2.2% increase in obesity prevalence in the control group), increased fruit and vegetable consumption among girls, and reduced hours of television viewing among both girls and boys.
A seven-week 1% Or Less campaign in Clarksburg, West Virginia, doubled the community's low-fat milk consumption from 18% to 41% of milk sales. The campaign used paid advertising, public relations, and community programs, and cost just 22 cents per person.
As a result of a 1999 mass media campaign by the Arizona Nutrition Network to promote fruit and vegetable intake to food stamp recipients, consumption of 5 or more servings of fruits and vegetables per day increased by 127% among individuals with incomes of less than $15,000 per year, and by 200% among individuals with incomes between $15,000 and $19,999 per year.
Wheeling Walks, an eight-week population-based campaign to promote walking in Wheeling, WV, used paid advertising and public relations activities supported by programs at worksites and at other community organizations. The campaign resulted in a 15% increase in the number of people who reported walking at least 30 minutes per day on 5 or more days per week as compared to the control city.
A campaign sponsored by the Florida Department of Health used advertising, advocacy and public relations to discourage youth smoking. The campaign resulted in a 19% reduction in smoking rates of middle school students and an 8% decline in smoking among high school students.

11. Strengthen the CDC’s physical activity, nutrition, and obesity programs
While one-third of premature deaths in the U.S. are attributable to poor nutrition and physical inactivity, funding for the CDC’s Division of Nutrition and Physical Activity (DNPA) represents less than 1% of the CDC’s total budget and is 4% of the CDC’s chronic disease budget.
FY 2003 funding for the CDC’s Division of Nutrition and Physical Activity is $34.4 million. The program includes funding for applied research, surveillance, national communications, 12 state-based programs (in CA, CO, CT, FL, MA, MI, MT, NC, PA, RI, TX, WA) funded at a planning level, and it is likely that three more states will be funded at the planning level and four more states will be funded at a basic implementation level with the additional resources the CDC has received for FY Also, DNPA conducts programs to reduce micronutrient deficiencies world-wide. In comparison, CDC’s program to discourage tobacco use has a FY 2003 budget of $101 million and provides funding for every state.
Although the nutrition and physical activity program has grown by $5-10 million per year over the last four years, at the current rate of growth it would take seven to 14 years to fund all states. Over the past decade, obesity rates have increased by 75% and diabetes rates by 60%.6
Support a FY 2004 appropriation of $65 million for the CDC to promote healthy eating and physical activity and to reduce obesity. Increased resources are needed to fund all states. $65 million would allow the CDC to fund 32 states at a planning level and ten states at a basic implementation level. The average award for the planning level grants is $400,000 per state, which supports the development of a state-wide plan for physical activity, nutrition and obesity, partnerships, and implementation and evaluation of demonstration interventions. The basic implementation grants enable states to expand their efforts to conduct effective interventions and to provide mini-grants for community-level programs. Funding is also needed to further develop, test, and disseminate practical interventions and effective policies, to conduct surveillance and communications campaigns, and to strengthen the CDC’s 5 A Day program.

12. Strengthen the CDC’s physical activity, nutrition, and obesity programs
Funding for the CDC’s Youth Media (VERB) Campaign decreased from $125 million in FY 2001 to $51 million in FY The campaign uses paid television, radio and print advertising, an interactive web site, and community events to encourage children to make healthy lifestyle choices, with an emphasis on physical activity.
Provide the CDC with a FY 2004 appropriation of $125 million to restore the Youth Media Campaign to promote physical activity to youth, and begin message and program development for a fruit and vegetable campaign.
The Department of Health and Human Services’ Steps to a Healthier US initiative has $15 million for FY 2003 to provide grants to communities to prevent diabetes, obesity, and asthma.
Support the President’s FY 2004 budget request of $100 million for the Steps to a Healthier US initiative to fund communities and states to reduce obesity, diabetes, and asthma.
The National Cancer Institute’s 5 A Day program has a FY 2003 communications budget of $3.5 million to promote the intake of fruits and vegetables. Fruit and vegetable intake is an important means of preventing cancer, heart disease, and other diseases.
“We need to act, individually and as a nation, to prevent obesity and diabetes.” - HHS Secretary Tommy Thompson, September 2001

13. References
1. McGinnis JM, Foege WH. “Actual Causes of Death in the United States.” Journal of the American Medical Association 1993, vol. 270, pp
2. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. Physical Activity and Good Nutrition: Essential Elements to Prevent Chronic Diseases and Obesity, At-a-Glance Atlanta: CDC, Accessed at on March 6, 2003.
3. Bowman S, et al. “The Healthy Eating Index: ” Washington, D.C.: U.S. Department of Agriculture, Center for Nutrition Policy and Promotion, 1998.
4. National Center for Health Statistics, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. “Deaths, Percent of Total Deaths, and Death Rates for the 15 Leading Causes of Death in 5-Year Age Groups, by Race and Sex: United States, 2000.” Hyattsville, MD: CDC, 2002.
5. Flegal K, et al. “Prevalence and Trends in Obesity among U.S. Adults, ” Journal of the American Medical Association 2002, vol. 288, pp
6. Mokdad A, et al. “Prevalence of Obesity, Diabetes, and Obesity-Related Health Risk Factors, 2001.” Journal of the American Medical Association 2003, vol. 289, pp
7. Peeters A, et al. “Obesity in Adulthood and Its Consequences for Life Expectancy: A Life-Table Analysis.” Annals of Internal Medicine 2003, vol. 138, pp
8. Ogden C, et al. “Prevalence and Trends in Overweight among U.S. Children and Adolescents, ” Journal of the American Medical Association 2002, vol. 288, pp
9. Sturm R. “The Effects of Obesity, Smoking, and Drinking on Medical Problems and Costs.” Health Affairs 2002, vol. 21, pp
10. Eating Well, Winter 2003, vol. 1, p. 5.
11. Pinhas-Hamiel O, et. al. “Increased Incidence of Non-insulin-dependent Diabetes Mellitus among Adolescents.” The Journal of Pediatrics 1996, vol. 128, pp
12. Hu F, et al. “Diet, Lifestyle, and the Risk of Type 2 Diabetes Mellitus in Women.” The New England Journal of Medicine, 2001, vol. 345, pp
13. Knowler W, et al. “Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin.” The New England Journal of Medicine 2002, vol. 346, pp
14. National Institutes of Health (NIH), Office of the Director, U.S. Department of Health and Human Services. Disease-Specific Estimates of Direct and Indirect Costs of Illness and NIH Support. Bethesda, MD: NIH, 2000.
15. Ramsey S, Summers K, Leong S, et al. “Productivity and Medical Costs of Diabetes in a Large Employer Population.” Diabetes Care 2002, vol. 25, pp
16. American Heart Association (AHA). Heart Disease and Stroke Statistics Update. Dallas, TX: AHA, 2002.
17. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Diabetes: Disabling, Deadly, and on the Rise, At-a-Glance Atlanta: CDC, 2002.
18. National Osteoporosis Foundation. Osteoporosis Disease Statistics: Fast Facts. Accessed at < on January 10, 2002.
19. American Cancer Society (ACS). Cancer Facts & Figures Atlanta, GA: ACS, 2003.
20. American Heart Association (AHA) Heart and Stroke Statistical Update. Dallas, TX: AHA, 1997.
21. Measured in adults over age 45.

14. References
22. 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.
23. American Diabetes Association. “Economic Costs of Diabetes in the U.S. in 2002.” Diabetes Care 2003, vol. 26, pp
24. Frazao E. “High Costs of Poor Eating Patterns in the United States.” In America’s Eating Habits: Changes and Consequences. Edited by Elizabeth Frazao. Washington, DC: Economic Research Service, U.S. Department of Agriculture, Agriculture Information Bulletin No. 750, pp
25. Pratt M, Macera CA, Wang G. “Higher Direct Medical Costs Associated with Physical Inactivity.” The Physician and Sportsmedicine 2000, vol. 28, pp
26. American Diabetes Association, 2003.
27. Wang F, et al. “The Relationship between National Heart, Lung, and Blood Institute Weight Guidelines and Concurrent Medical Costs in a Manufacturing Population.” American Journal of Health Promotion 2003, vol. 17, pp
28. CDC, U.S. Department of Health and Human Services. The Promise of Prevention. Atlanta: CDC, 2003.
29. Daviglus M, et al. “Benefit of a Favorable Cardiovascular Risk-Factor Profile in Middle Age with Respect to Medicare Costs.” The New England Journal of Medicine 1998, vol. 339, pp
30. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. Physical Activity and Good Nutrition: Essential Elements for Good Health, At-a-Glance Atlanta: CDC, Accessed at on January 18,
31. Office of the Surgeon General, U.S. Department of Health and Human Services. Personal communication with Cynthia Bennett, March 8, 2001.
32. “Resources and Priorities for Chronic Disease Prevention and Control, 1994.” Morbidity and Mortality Weekly Report 1997, vol. 46, pp
33. Munoz K, et al. “Food Intakes of U.S. Children and Adolescents Compared with Recommendations.” Pediatrics 1997, vol. 100, pp
34. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. Fact Sheet: Youth Risk Behavior Trends, Atlanta: CDC. Accessed at < on February 5, 2002.
35. Kann L, et al. Youth Risk Behavior Surveillance - United States, Morbidity and Mortality Weekly Report 2000, vol. 49, no. SS-5, pp
36. Agricultural Research Service, US Department of Agriculture. Food and Nutrient Intakes by Children , 1998 (1999). Table Set 17. Accessed at < on August 17, 2001.
37. Freedman DS, et al. “The Relation of Overweight to Cardiovascular Risk Factors Among Children and Adolescents: The Bogalusa Heart Study.” Pediatrics 1999, vol. 103, pp
38. Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. “Natural History of Aortic and Coronary Atherosclerotic Lesions in Youth; Findings from the PDAY Study.” Arteriosclerosis and Thrombosis 1993, vol. 13, pp
39. Wang G, Dietz W. "Economic Burden of Obesity in Youths Aged 6 to 17 Years: " Pediatrics 2002, vol. 109, pp. e81.
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