Tobacco and alcohol have declined as causes of death in the United States but are rapidly being replaced as health risks by "diet/activity patterns," according to a senior scholar at the Institute of Medicine, the research organization that provides scientific medical advice to the federal government.

Dr. J. Michael McGinnis cited as examples of the effects of dietary and activity changes the facts that type II diabetes has increased four-fold over the past decade and there has been a rise from 5 percent to 15 percent in the number of children judged to be overweight. At the same time, he pointed out, there has been a dramatic decline in the numbers of students participating in daily school sports and overall soda consumption in the United States has increased 100 percent. The medical costs of obesity are now approaching $117 billion a year, and rising, McGinnis said.

There are some assumptions about what is causing the obesity epidemic, including whether poor diet or lack of exercise is the major culprit, but it’s unproductive to debate that point, McGinnis said. "It’s both," he pointed out. He also noted that in looking for solutions, many people believe that schools are "a larger part of the problem than the solution."

In the search for solutions to growing incidence of overweight and obesity, the following are some assumptions to be made, McGinnis said:

• Culture is expressed as choice, but derives from knowledge, options, and opportunities;
• Dietary improvements would include smaller portions, emphasis on fruits, vegetables, and whole grains; and minimizing use of sweetened/refined foods and trans and saturated fats;
• Activity improvements would include 60 minutes of modest activity or 20 to 30 minutes of vigorous activity three times a week;
• There is public policy support for those and other changes, but policy initiatives require reliable evidence and analytic groundwork;
• Parents, schools, and industry can be part of the solution, "with the right rules of engagement."

McGinnis listed 10 possible levers for change:

• Education (Get the message right);
• Regulatory standards (Ensure accurate, informative point-of-choice information for consumers, including on grocery store food labels, fast foods, and restaurant menus);
• Public monies (Invest public funds for better health, including support for nutritional value in school meals and support for physical education in schools);
• Local capacity (Provide tools and resources for local initiatives, including grants to support local food-related projects such as gardens and grants to support model zoning and building codes);
• Medical care (Enhance competence in nutrition and physical activity of health providers, including school nurses, and align reimbursement incentives in programs such as Medicaid);
• Industry codes of conduct (Specify expectations for key players);
• Incentives (Develop models for economic incentives, including U.S. Department of Agriculture incentives relative to vending machines in schools);
• Research (Build evidence on current practice and future progress, with particular attention to the impact of marketing on kids and the impact of healthy schools on academic performance);
• Accountability (Monitor the progress of school and other initiatives;
• Leadership (Use the bully pulpit, share information about what works).

Our Major Health Challenges

McGinnis listed the causes of death in the United States in the most recent year for which data are available, 2000, noting that a new category of risk, "medical errors" was added that year. The major causes of death in 2000, in order of frequency, were:

• tobacco (375,000)
• diet/activity patterns (350,000)
• alcohol (80,000)
• microbial agents (80,000)
• medical errors (70,000)
• toxic agents (60,000)
• firearms (30,000)
• motor vehicles (25,000)
• sexual behavior (20,000)
• illicit use of drugs (15,000).

Dr. McGinnis delivered his remarks at an invitational roundtable on the roles of school health professionals in childhood overweight prevention convened by the Center for Health and Health Care in Schools in Washington, D.C., April 27-28, 2006. The Center can be reached by e-mail at chhcs@gwu.edu

See also: Keeping Kids Healthy: Overweight, Nutrition & Physical Exercise at http://www.healthinschools.org/sh/obesity.asp.