The last few decades have seen skyrocketing rates of overweight and obesity throughout the US. In Massachusetts more than 60% of adults are overweight as are 30% of school children. As a result chronic diseases are increasing as illustrated by the current diabetes rates, which have doubled in ten years. In response the Massachusetts Public Health Department and the [Governor] Patrick Administration began a comprehensive initiative in 2009 called Mass in Motion. Among its components: the passage of new regulations to display calories in the menus at fast food restaurants and to require that schools calculate and relay to parents the body mass indexes for their school children; the enrollment of thousands of workers in an employer-based Workplace Wellness Program; the design of an inter-active and innovative web and blog site (www.mass.gov/massinmotion); the signing of an executive order by Governor Patrick to mandate the purchase of healthy foods in state facilities; and the funding of a dozen city-wide, mayor-led wellness mobilization plans (with pooled funding from numerous foundations). The Massachusetts Public Health Commissioner, John Auerbach, will discuss the planning and implementation of this high priority endeavor.
Powerful biological mechanisms evolved to defend adequate nutrient supply and defend optimal levels of body weight/adiposity. Low levels of leptin indicating food deprivation and depleted fat stores have been identified as the strongest signals to restore energy balance by increasing energy intake and reducing energy expenditure. In concert with other signals from the gut and metabolically active tissues, low leptin powerfully activates multiple peripheral and brain systems. Not just neurons in the hypothalamus, but many other brain systems involved in finding potential food sources, smelling and tasting food, and learning to maximize rewarding effects of foods are affected by low leptin. Food restriction and fat depletion thus lead to a "hungry" brain, preoccupied with food. In contrast, upper limits of body weight/adiposity are not as strongly defended by high levels of leptin and other signals, as demonstrated by diet-induced obesity in animals and humans. This response asymmetry has been explained by either random genetic mutations pushing adiposity levels upwards after humans were no longer chased by predators, or by the selection of thrifty genes favoring food procurement, fuel efficiency, and increased fat stores. The modern environment is characterized by increased availability of large amounts of energy dense foods and increased presence of powerful food cues, together with minimal physical procurement costs and a sedentary lifestyle. Common obesity results when individual predisposition engraved by genetics, epigenetics, and/or early life experience does not match the environmental pressures towards positive energy balance. Therefore, increased adiposity in prone individuals should be seen as a normal physiological response to a changed environment, not in pathology of the regulatory system. The first line of defense should ideally lie in modifications to the environment and lifestyle and to the way we handle environmental stimuli. In prone individuals, the constant assault with appetizing stimuli in the modern environment strongly impacts cognitive, hedonic, and emotive functions in cortico-limbic brain areas and may simply overpower metabolic satiation signals. It will be crucial to understand the functional crosstalk between neural systems responding to metabolic and environmental stimuli, i.e. crosstalk between hypothalamic and cortico-limbic circuitry.
Read Hans-Rudolf Berthoud's bio
Childhood obesity has reached epidemic proportions, butwe have yet to develop effective interventions. New approaches to building interventions are discussed,and examples are provided to illustrate ways we can use what we know to identify and evaluative potential intervention components, and developing optimized interventions.
The Guiding Stars nutrition profiling program was begun in 2006 and is now implemented in over 1450 supermarkets throughout the Atlantic coast states. The proprietary algorithm underlying the 3-star rating system is grounded in evidence-based science using current guidelines established principally by the FDA, IOM, NIH, and USDA and is consistent with recommendations from the 2005 Dietary Guidelines for Americans. Food ingredient information is derived from the Nutrition Facts label and USDA nutrient database. All foods are periodically evaluated according to nutrient density per 100 kcal to allow for consistent measurement independent of variations in package and serving size. The algorithm balances positive (vitamins, minerals, fiber, whole grains) and negative (saturated fat, trans fat, cholesterol, added sodium and sugar) attributes of over 60,000 edible products, including packaged and fresh foods, produce and prepared meals, regardless of price, brand or manufacturer. Alcoholic beverages and products containing less than 5 kcal per serving are not rated. Preliminary analyses of the percent of total movement of food product purchases reveals a significant shift in several categories, including ready-to-eat cereals, ground beef, frozen dinners, milk, and yogurt, toward more nutrient dense choices identified by the Guiding Stars. The Guiding Stars program is now expanding beyond the supermarket into venues such as public schools and college dining halls.
Read Jeffrey B. Blumberg's bio
Obesity now affects 16% of children and adolescents in the United States. Despite recent plateaus in prevalence among Caucasian, African American and Mexican American children, and across all levels of severity, the natural history of childhood obesity and its impact on future medical costs, emphasize that complacency is not an option. In 2008, obesity related costs accounted for almost 10% of medical costs in the United States. Behavioral targets for obesity prevention and control include control of excessive weight gain, tobacco use and diabetes during pregnancy; increased physical activity, intake of fruits and vegetables, and rates of breastfeeding; and decreases in the intake of high energy density foods, sugar sweetened beverages, and television time. Public health strategies to influence these behaviors must rely on policy and environmental changes across multiple sectors, including medical, child care, schools, and community settings.
The Nutrient Rich Food Index (NRF) 9.3 is calculated as the sum of the Daily Values (DV) of nine nutrients to encourage (protein; fiber; vitamins A, C, and E; Ca; Mg; Fe; K) minus the sum of the DV of three nutrients to limit (saturated fat, Na, and added sugars: DV=50) per 100 calories. Using USDA's Food and Nutrient Database for Dietary Studies we calculated the NRF index for all calorie-containing foods consumed in NHANES 2001-2004. We then examined the usefulness of the NRF 9.3 index to predict diet quality and intake of nutrients/food groups to encourage. We also examined the association of NRF 9.3 diet scores with selected health parameters, namely body mass index (BMI), blood pressure (systolic and diastolic), and LDL-cholesterol. NRF 9.3 diet scores were positively associated (p<0.0001) with USDA's Healthy Eating Index (an objective measure of diet quality). Positive associations (p<0.0001) with intake were seen for many of the nutrients of concern in the US diet, namely vitamin A, E, C, calcium, magnesium and for food groups to encourage (e.g., fruit, vegetables, whole grains, etc.). There was a negative association (p<0.0001) of NRF 9.3 diet scores with energy intake and saturated fat intake. Higher NRF 9.3 diet scores were also associated (p=0.01) with lower BMI, systolic and diastolic blood pressure. In conclusion the NRF 9.3 index appears to be useful in promoting better diets and possibly even leading to better health.
The current obesity epidemic has affected even the youngest children in our societies, including in the first months of life. Infancy is a period of rapid growth in stature and in neurocognitive, motor, and social development. Weight gain in the first 6 months is primarily gain in fat, whereas fat-free mass accumulates preferentially after that age. These observations, combined with numerous animal experiments, raise the possibility that the early postnatal period may be critical to development of healthful energy homeostasis and thus prevention of obesity and related conditions.
Meta-analyses of several observational studies now show that rapid weight gain in the first half of infancy predicts later obesity as measured by body mass index. These associations are consistent for obesity at different ages and for people born in many decades of the 20th century. More recent epidemiologic studies have shown the same pattern for prediction of direct measures of adiposity and blood pressure. Follow-up studies of subsets of participants in feeding trials of premature and small-for-dates infants agree with these observations.
Despite the mounting consistency of results, several questions remain to be answered before clinical or public health implications are clear. These include the need
Social disadvantage is a hierarchical, multifactorial concept which is often operationalized as socioeconomic status and race/ethnicity. These factors are part of the social environment in which the developing child is immersed. Although research on social disadvantage's effects on health has increased dramatically over the past two decade, as the contribution of the social environment to the creation of health inequalities has gained recognition, the processes which explain how the social world, and in particular its structure, influences health are less well explored. During these same decades, rates of obesity among children, adolescents, and adults have soared. Rising rates of childhood and adolescent obesity have led to concerns of increasing prevalence and earlier onset of cardiovascular disease and Type 2 diabetes, all of which are differentially distributed by social status. This talk will discuss obesity disparities, including new theories of how social status creates differential risk for obesity and cardiovascular disease.
The increasing prevalence of obesity is altering the world landscape of modern day disease. While not all obese individuals are susceptible to medical complications, obesity does place individuals at increased risk for developing Type 2 Diabetes and cardiovascular disease as well as cancer. Fortunately, our understanding of the metabolic and genetic and environmental roles in promoting obesity and its associated disease complications is rapidly growing. For example, we now have new insights into how the hormone estrogen has been found to regulate both obesity and risk for diabetes and cardiovascular. We now understand that obesity can result in a pattern of increased inflammation in adipose tissue and liver that establishes a systemic state that can result in hyperlipidemia, diabetes, and cardiovascular disease. This talk will highlight recent advances in our understanding of obesity and its complications. By understanding the mechanism basis of obesity and its complications, we will be able to tailor nutritional and medical therapies.
From an evolutionary perspective the sun-induced production of vitamin D3 has been occurring on this planet for more than 750 million years in some of the earliest phytoplankton life forms. Throughout evolution vitamin D played a critical role in the evolution of land vertebrates. Humans have always depended on sun exposure as their major, if not sole, source of vitamin D3. This explains why there are very few natural dietary sources of vitamin D. The lack of appreciation of the beneficial effect of sunlight on skeletal health resulted in 200 year history of the devastating bone disease rickets. By 1900 it was reported that 80% of children in Boston and New York City had evidence of rickets. The appreciation that ultraviolet B radiation and sunlight could prevent and cure rickets led to the identification of vitamin D3 which was ultimately added to milk and other foods in the 1930s. This resulted in the rapid eradication of rickets. Since rickets is seldom seen, vitamin D deficiency was thought to have been conquered. However it is now recognized that vitamin D deficiency may be the most common nutritional deficiency in the world. It has been estimated that upwards of 50% of both children and adults in the United States, Europe, China, India, and even in the sunniest areas including Saudi Arabia, New Zealand and Australia are vitamin D deficient. The health consequences of vitamin D deficiency include increased risk of deadly cancers of the colon, prostate and breast, autoimmune diseases including type 1 diabetes, rheumatoid arthritis and multiple sclerosis, hypertension, congestive heart failure and myocardial infarction, as well as increased risk of infectious diseases including upper respiratory tract infections. Vitamin D deficiency has also been associated with increased risk of schizophrenia, preeclampsia and risk for having a cesarean section. The explanation for why vitamin D has such global potential health effects is in part due to the fact that every tissue and cell in the body has a vitamin D receptor. It has been estimated that upwards of 2,000 genes are directly or indirectly regulated by vitamin D. Once vitamin D is made in the skin or ingested in the diet it undergoes sequential hydroxylations, first in the liver to form 25-hydroxyvitamin D. This metabolite is the major circulating form of vitamin D that is used to determine the vitamin D status of a patient. However, 25-hydroxyvitamin D is biologically inert and requires a further hydroxylation in the kidneys to form 1,25-dihydroxyvitamin D which is the biologically active form. It interacts with its vitamin D receptor in the intestine, bones, kidneys and other tissues and organs in the body to regulate calcium and bone metabolism. However, it was perplexing that no matter how much vitamin D is produced in the skin or ingested in the diet the blood level of 1,25(OH)2 D remains stable and does not increase. The observation that the skin, prostate, brain among other tissues have the enzymatic machinery to produce 1,25(OH)2D has given us an insight as to why vitamin D deficiency has such wide ranging negative health consequences. Both activated B and T lymphocytes have a vitamin D receptor and respond to 1,25(OH)2D by modulating their immune activities. In addition macrophages produce 1,25(OH)2D. Once produced in the macrophage, 1,25(OH)2D increases the gene expression of the antimicrobial peptide cathelicidin which in turn kills intracellular mycobacterium tuberculosis.
Whole body exposure in a bathing suit to 1 minimal erythemal dose of simulated sunlight results in the production of approximately 15,000-20,000 IU of vitamin D3. Thus, our hunter gatherer forefathers were likely producing several thousand units of vitamin D a day which humans adapted to. This is consistent with the observation that on average humans use between 3,000 - 5,000 IU of vitamin D3 a day. Thus it is now clear why vitamin D deficiency is such a global health issue; you cannot get this amount of vitamin D from dietary sources. In the United States the population is becoming more vitamin D deficient because of increased obesity, increased sun protection and decreased dairy consumption. The adequate intake recommendations by the Institute of Medicine in 1997 are now recognized to be inadequate. 2,000 IU of vitamin D a day to prepubertal and pubertal girls not only resulted in improvement in their bone health, but also improved lean body mass. 1,100 IU of vitamin D3 with 1,500 mg of calcium a day in more than 1,000 postmenopausal women reduced their risk of all cancers by 60%. Postmenopausal women receiving 2,000 IU of vitamin D a day reduced their risk of upper respiratory tract infections by 90%. Although there has been great concern about the toxicity potential of vitamin D, neonates who ingested 2,000 IU of vitamin D a day without toxicity reduced their risk of developing type 1 diabetes by 78% 31 years later. Adults receiving 10,000 IU of vitamin D3 a day for at least five months showed no evidence of toxicity. Based on the now recognized vitamin D deficiency pandemic and its devastating health consequences there needs to be a reevaluation of recommending sensible sun exposure and increasing the number of foods fortified with vitamin D and to increase the amount of vitamin D per serving. Based on the recent literature children up to one year of age should receive at least 400 IU a day and 1,000 IU a day preferred. The safe upper limit should be increased to 5,000 IU a day. For children one year of age and older and all adults should receive at least 1,000 IU a day and up to 2,000IU of vitamin D a day is both safe and preferred. The safe upper limit for this age group should be increased to 10,000 IU vitamin D /d. Monitoring serum levels of 25-hydroxyvitamin D is the best method to determine a person's vitamin D status. For vitamin D deficiency its important to quickly correct the deficiency. 50,000 IU of vitamin D2 once a week for eight weeks often corrects the deficiency. To prevent recurrence 50,000 IU of vitamin D2 once every two weeks is effective in maintaining blood levels above 30ng/ml which is considered to be the lower limit of normal. Alternatively, vitamin D deficiency can be treated with 2000-4000 IU/d for 2 months and then for prevention, 1500-2000 IU/d is recommended. Obese children and adults may need twice as much since the excess body fat can sequester the vitamin D. The desired blood level of 25(OH)D is 30-100 ng/ml.
Excess dietary sodium is probably the single most harmful aspect of the average American diet. Despite decades of admonitions to lower sodium levels in prepared foods, food manufacturers and restaurants have done little---and Americans are consuming more sodium now than 30 years ago. With the British government making sodium reduction a high priority and new attention being paid to the problem in the United States, meaningful voluntary or regulatory action is likely in the next several years. The end result should be lower rates of hypertension, heart attacks, and strokes.
Read Michael F. Jacobson's bio
Nutrition science is increasingly being used to support communications around food and beverage products. Many marketers focus on the four P’s of marketing: product, price, place and promotion. Nutrition scientists often play a role in "product'—providing technical assistance on meeting consumer needs; and 'promotion'—communicating product benefits. An understanding of the needs of business can help bridge the gap between nutrition science and nutrition that sells. But, ultimately, the consumer decides to vote with their wallet. The goal is to make what the consumer needs the same as what they want.
With a fast-evolving database that soon will encompass upwards of 150,000 food and beverage products, the NuVal Nutritional Scoring System has produced one of the most extensive nutritional profiles of the U.S. food supply ever assembled. Its comprehensive analysis of more than 30 distinct nutrient factors also sets NuVal apart as the most thoroughly evidence-based guidance systems of its kind. Nancy McDermott, president of NuVal LLC, will address not only the progress and prospects of NuVal as a stand-alone system, but how NuVal can readily become the 'Intel Inside' of nutrition ranking, powering any and all systems that guide consumers toward better food choices.
Health in cities is related to transportation. Differing fundamental assumptions about transportation in cities evolve cities, over years, to have very different health outcomes. Ideas that conventional transportation professionals have believed are "givens" for decades are called into question because they are damaging the economic, social, and physical and health of the city. However, the damage can be stopped and reversed somewhat through healthy transportation practices. First, getting the "bones" right is essential; that is a connected street network provides the skeleton for a healthy, walkable, and vibrant city. Second, getting the right land use mix helps people meet their daily needs efficiently with minimal travel. Lastly, designing the street to suit the desired context is important on a detailed level. When these ideas are followed: cities become less polluted and more pleasant; more people walk, cycle, and use public transport; economic investment is attracted; and the social and physical health of the people improves.
The short term goal of the Smart Choices Program is to provide a simple front-of-the-pack icon system to direct shoppers to smart food choices in the supermarket. Medium term the goal is to have smarter choices contribute to a healthier diet and food manufacturers reformulate products to meet the Smart Choices nutrition criteria. Long term the goal is to evaluate if smarter choices in the supermarket translate into better health. The Smart Choices Program was developed by a coalition of scientists and nutrition educators; experts with dietary guidelines experience; public health organization; food manufacturers; retailers. Represents of Government organizations serve as observers. The process of establishing the Po4rogram was facilitated by the Keystone Group and it is now administered by the American Society for Nutrition and NSF International. For a product to qualify for the Smart Choices Program icon it first needs to be below the threshold for nutrients to limit (total fat; saturated fat; trans fat; cholesterol; sodium and "added sugars"). These "nutrients to limit" are directly from the 2005 Dietary Guidelines. If the product is below the threshold for these six nutrients then in most cases it has to have one or more nutrients and/or food groups to encourage. Again these nutrients and food groups are directly from the Dietary Guidelines. The nutrition criteria are transparent and based on consensus science and available at SmartChoicesProgram.com. Consumer science (both qualitative and quantitative) helped define the type of program and whether or not shoppers could identify a "smarter choice" within a given category. The quantitative research involved more than 2,000 individuals at 15 mall locations. Seventy five percent of respondents said that the SCP logo and calorie indicator would be helpful in making food and beverage choices, as well as identifying smarter options among the products available. ASN/NSF plan to evaluate the effectiveness of the program when it has been operational for a year, and will fully cooperate with established organizations such as FDA and the Institute of Medicine on sharing data for their evaluation plans. Some major differences between the Smart Choices Program and other programs include: It was developed using a coalition approach; there is an emphasis on calories as shown by the calorie indicator; nutrients to limit and encourage are limited to those stated by the 2005 Dietary Guidelines, and the nutrition criteria are transparent and based on consensus science.
In October 2008 the inaugural set of Physical Activity Guidelines for Americans were issued by the US Department of Health and Human Services. With current statistics suggesting that nearly 70% of U.S. adults do not participate in regular leisure-time physical activity along with the mounting evidence on the health benefits of physical activity, it is important to have sound guidelines for Americans to follow. Dr. Nelson will cover the following in her talk:
The Physical Activity Guidelines for Americans will help public and private organizations to develop evidence-based policies that enhance the fitness and health of the US population. Very importantly, the guidelines will help individuals develop their own physical activity plans.
For more information on the John Hancock Research on Physical Activity, Nutrition, and Obesity Prevention, go to: www.jhrc.nutrition.tufts.edu
For more information on the guidelines, go to: http://www.health.gov/PAguidelines