Nutrition, Physical Activity, and Obesity

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The Problem

During 2009–2010, approximately 17% of children and adolescents and 36% of adults were obese.⁴ US medical costs associated with adult obesity were approximately $147 billion in 2008.⁵

Policies & Practices

Secondary schools not selling less nutritious foods and beverages

Maintaining a healthy diet helps children and adolescents achieve optimal growth and reduces their risks for many health problems, including obesity.^1,6 Schools can provide environments that support students’ efforts to follow a healthy diet. In addition to providing school meals, many schools offer foods and beverages in other venues, such as school stores, canteens, snack bars, vending machines, and classrooms. The Institute of Medicine recommends nutrition standards for such foods and beverages,⁷ and CDC recommends that schools limit the availability of less nutritious foods and beverages and ensure that “only nutritious and appealing foods and beverages are provided in all food venues in schools . . . .”⁶

CDC’s School Health Profiles assesses whether secondary schools sell certain less nutritious foods and beverages by whether the schools allow sales of these items from vending machines or at the school store, canteen, or snack bar.¹⁶ For a school to be identified as not selling less nutritious foods and beverages, the school principal had to respond “no” to each item when asked whether students can purchase each of the following five items: 1) chocolate candy; 2) other kinds of candy; 3) salty snacks that are high in fat, such as regular potato chips; 4) cookies, crackers, cakes, pastries, or other baked goods that are high in fat; and 5) soda pop or fruit drinks that are not 100% juice. Data were provided for 45 states and the District of Columbia and represented only those states that participated in the survey and had an overall response rate of at least 70%.¹⁶

Percentages of secondary schools where less nutritious foods and beverages were not offered for sale, United States (2012)

(State count includes the District of Columbia.)

The rating categories reflect the extent to which secondary schools within a state limit the sale of less nutritious foods and beverages.¹⁶ As determined by the judgment of CDC subject matter experts, to achieve a yellow rating, the majority (>50%) of secondary schools in a state had to not allow the sale of the five items described above; a green rating required two-thirds (66.6%) or higher. However, all states with red ratings had at least some schools that limited sales, and even states with green ratings had room for improvement.

States were rated green, yellow, or red according to the following criteria:

Green	In 2012, >66.6% of secondary schools in the state did not sell less nutritious foods and beverages in selected venues.
Yellow	In 2012, 50.0%–66.5% of secondary schools in the state did not sell less nutritious foods and beverages in selected venues.
Red	In 2012, <50.0% of secondary schools in the state did not sell less nutritious foods and beverages in selected venues.

State nutrition standards policy for foods and beverages sold or provided by state government agencies

States can create environments that support healthy dietary behaviors by setting nutrition standards for foods and beverages sold or provided by government agencies. The Institute of Medicine recommends that government agencies implement “strong nutrition standards for all foods and beverages sold or provided through the government” and ensure “that healthy options are available in all places frequented by the public.”⁸

For purposes of this report, strong policies are those that meet the following criteria: 1) apply to at least 90% of government agencies in the state executive branch, 2) cover all food purchased, contracted, distributed, or sold by government agencies in the state executive branch, 3) provide quantifiable standards for foods or nutrients (e.g., set a maximum for the amount of sodium a food item can include), and 4) set minimal standards that limit sodium content, fat content, and the availability of high-calorie, low-nutrient foods and beverages.

Status of state policies on nutrition standards for foods and beverages sold or provided by government agencies, United States (2012)

Bar chart showing Status of state policies on nutrition standards for foods and beverages sold or provided by government agencies, United States (2012). Green: 0 states had a policy that met all criteria for %26ldquo;strong policies%26rdquo;. Yellow: 5 states had a policy that met some but not all criteria for %26ldquo;strong policies%26rdquo;. Red: 46 states did not have a policy. (State count includes the District of Columbia.)

(State count includes the District of Columbia.)

CDC subject matter experts conducted a search of the Westlaw database to assess the presence and quality of states’ nutrition standards policies for foods and beverages sold or provided by state government agencies.¹⁷ States were rated green, yellow, or red according to the following criteria:

Green	In 2012, the state’s nutrition standards policy for foods and beverages sold or provided by state government agencies met all criteria for “strong policies.”
Yellow	In 2012, the state’s nutrition standards policy for foods and beverages sold or provided by state government agencies met some but not all criteria for “strong policies.”
Red	In 2012, the state did not have a nutrition standards policy for foods and beverages sold or provided by state government agencies.

Health and Sustainability Guidelines for Federal Concessions and Vending Operations

Inclusion of nutrition and physical activity standards in state regulations of licensed childcare facilities

State regulations for licensed childcare facilities can help create environments that support healthy dietary behaviors, breastfeeding, and physical activity for young children.

The Institute of Medicine has recommended including specific requirements related to physical activity, sedentary activity, and child feeding in childcare regulations.⁹ Building upon a comprehensive set of national standards defined in 2011,¹⁰ the National Resource Center for Health and Safety in Child Care and Early Education has identified 47 licensing standards components considered to be high impact for obesity prevention. These components are related to infant feeding, nutrition, physical activity, and screen time in licensed childcare settings.¹¹

Inclusion of nutrition and physical activity standards in state regulations of licensed childcare facilities, United States (2012)

Bar chart showing Inclusion of nutrition and physical activity standards in state regulations of licensed childcare facilities, United States (2012). Green: In 0 states, the regulations for licensed childcare facilities included %26ge;80.0% of the 47 components of standards for infant feeding, nutrition, physical activity, and screen time . Yellow: In 0 states, the regulations included 70.0%%26ndash;79.9% of the 47 components . Red: In 50 states and the District of Columbia, the regulations included %26lt;70.0% of the 47 components .

Data were compiled from a report of the National Resource Center for Health and Safety in Child Care and Early Education.¹¹ The rating categories reflect the extent to which state regulations of licensed childcare facilities included recommended nutrition and physical activity standards, as determined by the judgment of CDC subject matter experts. States with a green rating most fully included the standards. However, many states with red ratings included some standards.

States were rated green, yellow, or red according to the following criteria:

Green	In 2012, the state’s regulations for licensed childcare facilities included >80.0% of the 47 recommended components of nutrition and physical activity standards.
Yellow	In 2012, the state’s regulations for licensed childcare facilities included 70.0%–79.9% of the 47 recommended components of nutrition and physical activity standards.
Red	In 2012, the state’s regulations for licensed childcare facilities included <70.0% of the 47 recommended components of nutrition and physical activity standards.

Caring for Our Children: National Health and Safety Performance Standards

State physical education time requirement for high school students

For children and adolescents, regular physical activity helps improve cardiorespiratory and muscular fitness, bone health, and cardiovascular and metabolic health biomarkers, and results in a healthier body composition.² Schools can help youth meet physical activity recommendations through comprehensive school physical activity programs, which should include quality physical education.⁶

The Community Preventive Services Task Force recommends the implementation of quality physical education programs that increase the length of, or activity levels in, school-based physical education classes.¹² This recommendation is based on strong evidence of such programs’ effectiveness in improving physical activity levels and physical fitness among school-aged children and adolescents.¹² CDC and the National Association for Sport and Physical Education recommend that high school students receive at least 225 minutes of physical education per week.^6,13 States and the District of Columbia can help increase physical activity among high school students by setting minimum requirements for time spent in physical education.

Status of state physical education time requirements for high school students, United States (2012)

(State count includes the District of Columbia.)

The rating categories reflect the extent to which the state had a mandate requiring high school students to participate in physical education for a minimum number of minutes per week, as reported by the physical education coordinator in that state.¹⁸ States were rated green or red according to the following criteria:

Green	In 2012, the state had a mandate for minutes per week that high school students must participate in physical education.
Red	In 2012, the state did not have a mandate for minutes per week that high school students must participate in physical education.

Average birth facility score for breastfeeding support

Breastfeeding is associated with health benefits for the child and the mother. Children who are breastfed are at lower risk for a number of health problems, including childhood infections, sudden infant death syndrome (SIDS), and obesity. Women who breastfeed have a lower risk of breast and ovarian cancer.¹⁹ Hospitals and birth centers can create environments that support the decision to breastfeed.

The US Surgeon General recommends that maternity care practices throughout the United States fully support breastfeeding.¹⁴ A review of evidence by the Cochrane Collaboration found that institutional changes in maternity care practices effectively increased breastfeeding initiation and duration rates.¹⁵

The state birth facility score for breastfeeding represents the average score across participating birth facilities in a state. Each participating birth facility, based on its response to a self-administered survey, was scored on multiple evidence-based practices that support breastfeeding across seven categories: 1) labor and delivery, 2) breastfeeding assistance, 3) mother-newborn contact, 4) newborn feeding practices, 5) breastfeeding support after discharge, 6) nurse/birth attendant breastfeeding training and education, and 7) structural and organizational factors related to breastfeeding.²⁰ The total score can range from 0 to 100, with a higher score representing more support. The national average score across all states was 70.

Status of state average birth facility scores for breastfeeding support, United States (2011)

(State count includes the District of Columbia.)

Average birth facility scores were obtained from the National Survey of Maternity Practices in Infant Nutrition and Care (mPINC).²⁰ The rating categories reflect the extent to which hospitals and birth centers within a state implement multiple evidence-based strategies that support breastfeeding as determined by the judgment of CDC subject matter experts. States with green ratings were most fully implementing the strategies. However, all states with red ratings were implementing some strategies, and even states with green ratings had opportunities for improvement.

States were rated green, yellow, or red according to the following criteria:

Green	In 2011, the state’s average birth facility score for breastfeeding support was >80.0%.
Yellow	In 2011, the state’s average birth facility score for breastfeeding support was 70.0%–79.9%.
Red	In 2011, the state’s average birth facility score for breastfeeding support was <70.0%.

Prevention Status Reports: Nutrition, Physical Activity, and Obesity, 2013

The files below are PDFs ranging in size from 100K to 500K.

Note: An erratum for the indicator entitled “Inclusion of nutrition and physical activity standards in state regulations of licensed childcare facilities” has been published for these reports.

Learn more and get involved

References

US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th edition. Washington, DC: US Government Printing Office; 2010.
US Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Washington, DC: US Department of Health and Human Services; 2008.
National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Bethesda, MD: National Institutes of Health; 1998.
Ogden CL, Carroll MD, Kit BC, et al. Prevalence of obesity in the United States, 2009–2010[PDF 527KB]. NCHS Data Brief 2012;82:1–8.
Finkelstein EA, Trogdon JG, Cohen JW, et al. Annual medical spending attributable to obesity: payer- and service-specific estimates. Health Affairs (Millwood) 2009;28(5):w822–31.
CDC. School health guidelines to promote healthy eating and physical activity[PDF 973K]. MMWR 2011;60(RR-5).
Institute of Medicine. Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth. Washington, DC: National Academies Press, 2007.
Institute of Medicine. Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. Washington, DC: National Academies Press; 2012.
Institute of Medicine. Early Childhood Obesity Prevention Policies. Washington, DC: National Academies Press; 2011.
American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs. 3rd edition. Elk Grove Village, IL: American Academy of Pediatrics; Washington, DC: American Public Health Association; 2011.
National Resource Center for Health and Safety in Child Care and Early Education. Achieving a State of Healthy Weight: 2012 Update[PDF 2.90MB]. Aurora, CO: University of Colorado Denver; 2013.
Task Force on Community Preventive Services. Recommendations to increase physical activity in communities[PDF 70KB]. American Journal of Preventive Medicine 2002;22(4S):67–72.
National Association for Sport and Physical Education. Physical Education Is Critical to Educating the Whole Child[PDF-109KB]. Reston, VA: National Association for Sport and Physical Education; 2011.
Office of the Surgeon General. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: US Department of Health and Human Services; 2011.
Fairbank L, O’Meara S, Renfrew MJ, et al. A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding. Health Technology Assessment 2000;4(25):1–171.
CDC. School Health Profiles 2012. Unpublished data.
CDC. Public Health Law Program. Unpublished analysis. November 2012.
National Association for Sport and Physical Education, American Heart Association. 2012 Shape of the Nation Report: Status of Physical Education in the USA[PDF 758KB]. Reston, VA: American Alliance for Health, Physical Education, Recreation, and Dance; 2012.
Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Evidence Report/Technology Assessment No. 153. AHRQ Publication No. 07-E007. Rockville, MD: Agency for Healthcare Research and Quality; 2007.
CDC. National Survey of Maternity Practices in Infant Nutrition and Care (mPINC). Atlanta, GA: US Department of Health and Human Services; 2011.