1. Childhood Obesity: Strategies to Halt a Growing Epidemic (and a few words on trans fats) Lynn Silver, MD, MPH Assistant Commissioner and Mary T. Bassett, MPH, MD Deputy Commissioner Health Promotion and Disease Prevention New York City Department of Health and Mental Hygiene US Conference for Mayors Washington DC January 25, 2007

2. Overview The New York City Experience –Building a healthy environment Access to healthy foods Opportunity for physical activity –Regulatory Approaches Physical Activity and Nutrition Requirements in Day Care Calorie Labeling Restriction of Trans Fat

3. Obesity Trends* Among U.S. Adults BRFSS, 1985 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

4. Obesity Trends* Among U.S. Adults BRFSS, 1986 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

5. Obesity Trends* Among U.S. Adults BRFSS, 1987 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

6. Obesity Trends* Among U.S. Adults BRFSS, 1988 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

7. Obesity Trends* Among U.S. Adults BRFSS, 1989 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

8. Obesity Trends* Among U.S. Adults BRFSS, 1990 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

9. Obesity Trends* Among U.S. Adults BRFSS, 1991 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

10. Obesity Trends* Among U.S. Adults BRFSS, 1992 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

11. Obesity Trends* Among U.S. Adults BRFSS, 1993 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

12. Obesity Trends* Among U.S. Adults BRFSS, 1994 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

13. Obesity Trends* Among U.S. Adults BRFSS, 1995 No Data <10% 10%–14%15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

14. Obesity Trends* Among U.S. Adults BRFSS, 1996 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

15. Obesity Trends* Among U.S. Adults BRFSS, 1997 No Data <10% 10%–14% 15%–19% ≥20 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

16. Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

17. Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

18. Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

19. Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

20. (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) Obesity Trends* Among U.S. Adults BRFSS, 2002 No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

21. Obesity Trends* Among U.S. Adults BRFSS, 2003 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

22. Obesity Trends* Among U.S. Adults BRFSS, 2004 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

23. Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

24. Obesity Begins Early O nly Half of NYC’s Elementary School Children Are at a Healthy Weight More than 4 in 10 are overweight or obese in Grades K-5

25. Percentage of High School Students Who were Overweight (selected U.S. states) YRBS, 2005

26. Why worry about childhood obesity? Strong predictor of obesity in adulthood Major early risk factor for much of adult morbidity and mortality – diabetes has doubled Health problems associated with obesity: –Type 2 diabetes (hyperinsulinism, insulin resistance, IGT) –Cancer –CVD (hypercholesterolemia, dyslipidemia, htn) –Depression, low self-esteem –Asthma, sleep apnea –Osteoarthritis SOURCES: American Academy of Pediatrics, 2003; Dietz & Gortmaker, 2001

27. Policy Approaches to Address Obesity Obesity is not just a problem of the individual, but also a problem rooted in environmental and community factors 2001 Surgeon General’s “Call to Action to Prevent and Decrease Overweight and Obesity” declared obesity a national priority SOURCES: U.S. DHHS, 2001; Galvez, Frieden & Landrigan, 2003

28. The New York City Experience Building a healthy environment –Access to healthy foods –Opportunity for physical activity Regulatory Approaches –Day care physical activity and nutrition –Calorie labeling –Trans fat (addresses heart disease risk)

29. Make it easier to make healthy choices! Schools –More physical activity –No soda/vending machines –1% milk Day Care Centers –More physical activity –No sugar sweetened drinks, 1% milk only –Limited TV Community Environment –Shape-Up programs in parks –Access to fresh fruits and vegetables –Improving the built environment

30. Overall Daycare Population in NYC Day Care Facility Type Total Facilities* SettingLaw/ Regulation Approx. Capacity** Group Day Care (GDC) – Permit 2,072Non-residentialNYC Health Code (Article 47) 98,696 Group Family Day Care (GFDC) – License 2,232Home of an unrelated family 18 NYCRR (part 416) 30,742 Family Day Care (FDC) – Registration 3,775Home of an unrelated family 18 NYCRR (part 417) 103,942 School Age (SA) – Registration 1,192Non-residential18 NYCRR (part 414) 121,966 TOTAL, all facility types 9,271355,346 * 2006 data ** 2002 data

31. Group Day Care Population in NYC There are 2,072 Group Day Care programs Serve about 100,000 infants, toddler and early childhood (ages 2 to 5).

32. Daycare regulations and the NYC Health Code: A Bit of History First day nursery in US opened in NYC in 1854 Day care was regulated within the Sanitary Code of the City of New York, beginning approx. 1910 Compliance with these regulations was not mandatory until 1943. As a side note, the regulations of 1943 required 2 hours of outdoor play and a hot meal at noon and a "daily allowance of at least a pint of milk a day". The Health Code was adopted March 23, 1959. New requirements to address obesity effective January 2007

33. Day Care: Physical Activity Regulations Establishes a required minimum number of physical activity minutes daily: –For ages 12 mos. and up, at least 60 min./day –For ages 3 and older, at least 30 min. of that time must be structured & guided activity SOURCES: CDC; National Association for Sport and Physical Education

34. Day Care: Limits on TV Establishes limits on TV & video viewing: –No TV, video and other visual recordings for children under two years of age –For ages 2 and older, limits TV, video and other visual recordings to no more than 60 minutes per day of educational programs or programs that engage child movement SOURCES: American Academy of Pediatrics; Institute of Medicine

35. Provide guidance on: –Appropriate kinds of foods & beverages - no sugar sweetened beverages allowed. 1% milk only after age 2. –Appropriate portion sizes for children (while remaining consistent with federal CACFP policy for meal & snack reimbursement) Day Care: Nutrition Standards SOURCES: Child and Adult Care Food Program; U.S. Dietary Guidelines for Americans, 2005

36. Implementation/Support Nutrition training efforts –to day care inspectors –to nutrition staff in community through the bureau of daycare Educational materials disseminated to children and parents through daycare staff SPARK training in early childhood settings

37. SPARK! Since 2003, DOHMH has partnered with the Sports, Play and Active Recreation for Kids! (SPARK) program Goal – train and equip all daycare centers (17% trained so far), schools, K-2 teachers, and after-schools in highest risk communities Since November 2003, SPARK training and equipment provided to over 2500 staff from more than 600 sites.

40. Healthy Bodega Initiative Brooklyn survey: Access to healthy foods –Conducted among 2 of the poorest neighborhoods in NYC 84% of food stores are bodegas 6% of food stores are supermarkets 28% provide limited fresh fruit, if any at all 33% sell reduced fat milk, but at higher prices 6% of bodegas sell any type of leafy vegetables Health food access is extremely poor –Similar findings in other high risk areas

41. Healthy Bodega Initiative Healthy Bodegas Initiative –1% milk campaign Partnership with bodegas to stock 1% milk, offer discounts and distribute health information –Fruits & vegetables campaigns (Pilot project) Bodega owners are provided with a free shipment of pre- packaged ready-to-eat apples and carrot snacks, if interested they can re-order from distributor Bodegas received a toolkit containing bi-lingual promotional items HD will conduct outreach and education to local schools, day cares and WIC centers

43. NYC Health Code Calorie Labeling Requires certain FSEs to post calorie content on menu boards and menus next to each menu item Applies to FSE who provide standardized menu items and for which calorie information is publicly available on or after March 1, 2007 Does not apply to FSEs that have not made calorie information publicly available FSEs have six months to comply - July 1,2007

44. Partial Phase-Out of Trans Fat in Restaurants Amendment to the NYC Health Code Approved December 2006 Phase I: July 2007 – Frying Oils and Spreads Phase II: July 2008 - All other uses

45. Trans Fat Increases Heart Disease Risk 5% or more of cardiac events due to trans fat More Dangerous than Saturated Fat No one will miss it Good (HDL) Bad (LDL) Cholesterol Cholesterol Trans fat Saturated fat

46. Major Food Sources of Artificial Trans Fat for U.S. Adults Data Source: http://www.fda.gov/fdac/features/2003/503_fats.html

47. Trans Fat Use Did Not Decline Despite Voluntary Campaign % Restaurants Using Trans Fat in Oils and Spread Where Use Could Be Determined Health Bulletin to 200,000 people Info & tools to food suppliers and to >20,000 NYC restaurants 7,800 restaurant operators trained 9,000 FSEs received additional info

48. Effective Public Health Requires Government Action Precedents: –Removing Lead – like trans fat it was unnecessary, repleaceable, and is not missed –Adding Folate –Seatbelt requirements –Limit exposure to second-hand smoke Individual action alone is not enough: –Can’t tell if food contains transfat –Poor judgement of calorie content –For many, exercise opportunities are limited –Access to healthy foods is not a personal choice

49. We are getting a lot of questions California Florida Connecticut Massachusetts New Jersey Pennsylvania Washington State Ohio Oregon Michigan Washington DC Illinois West Virginia Virginia

50. Strategies for Consideration Create the Environment –Increase access to healthy foods for everyone Target poor, high risk areas/neighborhoods Improve public procurement Regulate & improve food service in schools, day care centers, after-school, camps Encourage more drinking of water and no use of sugar sweetened beverages –Increase access to physical activity Structured physical activity and facilities in schools, communities, workplace Built environment modifications provides opportunity for safe and convenient exercise –Calorie labeling –Soda Tax

51. Thank you!