CDC's Winnable Battles: Improved Nutrition,Physical Activity,and Decreased Obesity

In fall 2010, the CDC, under Director Dr. Tom Frieden's leadership, identified six domestic winnable battles based on the magnitude of the public health burden and the ability to accelerate progress by expanding evidence-based practice. ¹ Nutrition, physical activity, and obesity along with food safety was identified as one of those battles in addition to human immunodeficiency virus, healthcare-associated infections, teen pregnancy, tobacco, and motor vehicle injuries. Since that time, the CDC has established 5-year goals, performance measures, and strategic plans for each winnable battle. ² Each battle area has identified optimal strategies and a process to leverage resources and partnerships to accelerate a measurable impact on health. CDC's current battle plan for nutrition, physical activity, and obesity focuses on working with partners in (1) improving maternity care practices to support women who choose to breastfeed, (2) reducing artificial transfat in the food supply, (3) reducing sodium in the food supply, (4) reducing consumption of calories from added sugars, and (5) improving the food, beverage, and activity environments of child care centers, schools, workplaces, and communities. Many of these focus areas and targets are also consistent with the nation's Healthy People 2020 objectives.

Winnable battles have a special set of operational processes at the CDC. Leadership in the Office of the Director meet quarterly on each battle area to review progress, solve roadblocks, and accelerate progress through the involvement of senior offices, such as policy, communications, and science. Responsible Divisions provide monthly updates on their plans and progress. Most important, the CDC works to support progress through health departments and the broader public health community. Some state and local health departments have also chosen Winnable Battles. For example, the Health and Human Services Agency for San Diego County, California, has also identified nutrition, obesity, and physical activity as a winnable battle and utilized local data to assess burden and priority action, ³ and the Colorado Department of Public Health and Environment has identified 10 winnable battles, including nutrition, physical activity, and obesity. ⁴ Colorado's specific strategies to fight this battle include the following: providing businesses with tools for creating incentives and welcoming environments for employees to be healthy and physically active; promoting best practices for schools to provide daily physical activity, adopt nutrition guidelines, and partner with farmers to serve fresh produce in meals; encouraging healthcare professionals to adopt Obesity Guidelines to provide healthy lifestyle advice to patients; and partnering with communities to design streets and neighborhoods to include bike paths and sidewalks and convenient linkages to parks, schools, grocery stores, and community gathering places.

Many health departments across the nation include nutrition, physical activity, and obesity as priorities for their work, and the CDC supports these efforts through technical assistance and funding. ⁵ Current support for state health department work on obesity prevention and control is housed within a new 5-year program that integrates work across diabetes, heart disease, obesity, and school health. The new program, called “State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health,” has a first-year investment of $68 million and provides basic-level funding to all states and enhanced funding to 32 states. ⁶ This will be the first time that all 50 states and Washington, DC have a 5-year program that includes coordinated school health and nutrition, physical activity, and obesity strategies to support prevention. In addition, CDC support for community-level programs has included Communities Putting Prevention to Work (2010–2013), the Racial and Ethnic Approaches to Community Health (REACH) National Networks, the REACH Obesity and Hypertension Demonstration Projects, and the Community Transformation Grants (CTG). ⁷ CTG supports community-level efforts to reduce chronic disease. All awardees work on tobacco-free living, active living and healthy eating, and clinical and community preventive services to prevent and control high blood pressure and high cholesterol. In 2011, CTG awarded $103 million to 61 state and local government agencies, tribes and territories, and nonprofit organizations in 36 states. In 2012, CTG Small Communities Grants awarded approximately $70 million to communities with a population size of less than 500,000 residents.

To better inform programmatic efforts, the CDC provides guidelines such as the School Health Guidelines to Promote Healthy Eating and Physical Activity ⁸ and supports extramural applied research, including work through the Prevention Research Centers and a Childhood Obesity Research Demonstration project. ⁹ The latter community-based study is assessing a multiple-level, multiple-setting integration of primary care and community-based interventions to prevent and control childhood obesity among underserved children in three communities. In addition to guidelines and research, the CDC conducts surveillance of obesity and obesity-related behaviors and environmental supports. In August 2013, the CDC used surveillance data to report a significant decline over time in childhood obesity rates among low-income children ages 2–4 years. ¹⁰ This Vital Signs report included 40 states, two territories, and the District of Columbia. During 2008–2011, statistically significant downward trends in obesity prevalence were observed in 18 states and the US Virgin Islands. Twenty states and Puerto Rico experienced no significant change, and obesity prevalence increased significantly only in three states. Though the improvements were modest, they were among the first downward trends found in a generation in multiple locations in the United States for this age group.

Many efforts may have contributed to these findings, including the implementation of nutrition and physical activity standards for early care and education (ECE) programs, ¹¹ federal policy changes, such as better alignment of the Special Supplemental Nutrition Program for Women, Infants and Children food package to the Dietary Guidelines for Americans, ¹² supportive efforts to improve healthier food options and physical activity offerings in communities and settings where children spend their time,^13–15 increases in breastfeeding duration, ¹⁶ and decreases in certain types of sugar-sweetened beverages. ¹⁷ Increased government and consensus reports, such as those by the Institute of Medicine, ¹⁸ and media attention have likely helped build awareness of childhood obesity as an issue. In addition, national initiatives such as those of the Robert Wood Johnson Foundation and Let's Move!, have brought together new partners and resources to help support individuals and communities.

To advance changes in the environments that affect our youngest citizens, the CDC is working with partners in creating learning community models for ECE (i.e., child care) and maternity care practices for breastfeeding. The CDC and partner Nemours are working in six states, bringing together collaborative teams of key ECE stakeholders in learning sessions to create action plans to implement best practices in child care settings for obesity prevention. A partnership with CDC, Baby-Friendly USA and the National Initiative for Children's Healthcare Quality, the learning model “Best Fed Beginnings” is a first-of-its-kind, quality improvement initiative to help hospitals improve maternity care and increase the number of “Baby-Friendly”–designated hospitals in the United States. In addition, the CDC also partners in spurring progress with other major funders through the National Collaborative on Childhood Obesity Research. ¹⁹

Although recent reports of small obesity declines are encouraging, much remains to be done. Childhood obesity remains high, with one of every eight preschoolers obese before age 6. Rates are even higher among some low-income and minority youth. ²⁰ Though the challenge is daunting, our combined efforts are making a difference. We each have a role to play in what can be done. ²¹ The question remains how best to bring down the rates further, in more places, and ensure that our children are afforded a healthy start in their homes, child care, schools, clinics, and communities.