This chapter will address the following American College of Graduate Medical Education competencies: medical knowledge and systems-based practice.

Medical Knowledge: Medical knowledge of the etiology, epidemiology, and sociobehavioral aspects of obesity is foundational to being an effective advocate at the national level. This chapter will help the pediatric health care provider understand available evidence-based approaches and resources that will allow them to craft both specific and broad-based obesity prevention and treatment policy strategies.

Systems-Based Practice: Knowledge of the wider system allows health care providers to participate in the larger advocacy effort to end childhood obesity. This chapter will help providers respond to the larger socioecological context and be able to effectively call on resources in the health care system to enhance their work in childhood obesity.

Pediatric health care providers have a crucial role to play in addressing childhood obesity at the national level. In the Institute of Medicine (IOM) report, “Accelerating Progress in Obesity Prevention,”¹ the health care sector was 1 of the 5 environments singled out as crucial in accelerating a solution to the obesity epidemic. It is not hard to appreciate the impact of obesity on population and individual health and on both the direct and indirect costs to the economy. More than 60% of US adults have overweight or obesity, a major driver of cardiovascular and metabolic disease. Over ⅓ of adults aged 40 to 59 years and ¾ of adults older than 60 years have either high blood pressure, coronary heart disease, heart failure, or stroke. Approximately 10% of adults have type 2 diabetes and 37% have prediabetes.² Over 30% of US children have overweight or obesity,³ representing a major reservoir of chronic illness with escalating costs for physician visits, hospitalizations, and medication.⁴ Just over 20% of US annual health care spending is accounted for by obesity-related expenditures,⁵ and it is estimated that reducing obesity-related comorbidities could save $24.7 billion annually.⁶ The human cost of obesity in terms of decreased function, discrimination, underemployment, and inability to support societal infrastructure (military, emergency, police, and fire) makes advocacy for solutions a societal imperative.

The ability of pediatric health care providers to focus on population health will be instrumental in finding societal solutions to the increasing shift toward positive energy balance in the population. For example, decreases in active transportation (walking or biking), decreases in the availability and intensity of physical education classes, and increased use of television and other electronic media are compromising the achievement of recommended levels of physical activity in the population.

Energy intake has escalated directly due to increased portion sizes, fast- food consumption, increased calories from sweetened beverages, and shift to snack food and sugary cereals driven by targeted marketing to children⁷ and indirectly due to policies and environmental influences such as density of fast- food restaurants and corner stores.⁸

At the population level, reversing the obesity epidemic will depend on societal will to reintegrate physical activity and healthy eating into societal norms. In 2001, The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity was issued and set the agenda for a nationwide public health response, addressing obesity at all levels of society.⁹ This effort will require a sustained advocacy effort.

Principles for effective advocacy begin with (1) understanding and being able to communicate the problem of childhood obesity to potential partners and policy makers, (2) understanding the advocacy process at the national level, (3) being familiar with policy strategies that have been effective in obesity prevention and treatment, and (4) being able to work collaboratively with other advocacy groups in sectors outside the health care system.

It is important to understand and be able to communicate the problem of childhood obesity to potential partners and policy makers. The following statements can be incorporated into a discussion with legislators and partners:

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  The ultimate cost of obesity is the dramatically reduced quality of life and potentially shorter life span for our current generation of children. Having overweight or obesity puts children at risk for an array of associated health problems.¹

  
  
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  Overweight and obesity increase one’s lifelong risk for type 2 diabetes, high blood pressure, osteoarthritis, stroke, certain kinds of cancer, and many other debilitating diseases.¹⁰

  
  
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  Researchers estimate that 1 of every 3 males and 2 of every 5 females born in the United States in the year 2000 will be diagnosed with diabetes,¹¹ creating additional urgency to find a solution.

  
  
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  Researchers predict that if current adolescent obesity rates continue, by 2035, there will be more than 100,000 additional cases of coronary heart disease attributable to obesity.^{12, 13, 14}

  
  
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  It is extremely important to remember that in addition to the significant physical health consequences, children with overweight and obesity also suffer detrimental social and emotional health consequences and have lower self-esteem, are more likely to be depressed, suffer from bullying and teasing, and have lower academic achievement.¹⁵

  
  
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  Disparities exist, and the prevalence of obesity is high in disadvantaged populations, leaving some groups at greater risk than others.

  
  
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  While individual health behaviors and personal choices do play a role in the rise of obesity, where a child lives and goes to school—where his or her individual health behaviors are carried out—have a significant impact on that child’s chances of developing obesity.

  
  
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  Place matters¹⁶ in many low-income communities; children grow up without access to a full service grocery store, limiting their family’s ability to purchase healthy foods. Instead, their neighborhood may have a plethora of fast-food restaurants providing easy access to low cost, unhealthy foods. Their neighborhood may also lack access to safe places to play, walk, or bike. There may be limited availability of low cost, affordable recreation facilities and affordable sports or physical activity programs.¹⁷

  
  
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  Individuals live within social systems and are therefore influenced by the many forces and factors at work within their communities. Those at greatest risk for overweight and obesity will be subject to the greatest pressures because of the greater lack of available healthy food and physical activity resources. Reducing overweight and obesity in these communities will require a comprehensive approach that takes into account factors related to culture, language, and the social and physical environment of the community.

  
  
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  A recent study conducted by the Centers for Disease Control and Prevention (CDC) found that nearly 15% of low-income children aged 2 to 4 years have obesity.¹⁸ This is critical, because roughly 40% of children live in low-income households.¹⁹ Obesity places an enormous burden on the health care system and the economy as a whole.

Speaking points that address cost issues should also include economic data when relevant.

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  Childhood obesity is estimated to cost $14 billion annually in direct health expenses based on the 2002 to 2005 2-year Medical Expenditure Panel Survey of 6 to 19 year olds which showed a $194 higher outpatient visit expenditure, $114 higher prescription drug expenditure, and $25 higher emergency room expenditure for children with obesity compared to children with normal weight.²⁰ Children covered by Medicaid account for $3 billion of those expenses.²¹

  
  
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  In 2005, the obesity-related hospital costs for children and adolescents were $238 million, nearly doubling between 2001 and 2005.²²

  
  
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  A 10-year-old child with obesity will have an excess lifetime medical cost of $19,000 compared with a normal weight 10-year-old child. For the cohort of 10-year-old children in the United States, this cost would be approximately $14 billion in direct medical costs.²³

It is important to understand the advocacy process at the national level. The legislative branch makes the laws. The executive branch carries out the laws and also has the power to set budgets. The judicial branch interprets the law. Elected officials at every level of government come from diverse backgrounds and may have little or no prior experience with health policy. Health care providers can help fill this gap with evidence, expertise, and experience. Most children’s health issues fall under the Department of Health and Human Services (DHHS). The departments of agriculture, transportation, education, and housing and urban development play key roles as well. Administrative officials as well as elected officials can be addressed to advocate for obesity policy change. There are times when health care providers may be called upon to give testimony at the state or federal level around a child obesity issue. Some tips excerpted from the Zero to Three Policy Center²⁴ are as follows:

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  Talk with experienced advocates in your organization about the kind of information and logistics needed to address the regulation or legislation under consideration.

  
  
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  As part of your professional organization, offer to testify on childhood obesity issues.

  
  
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  Develop a clear, cogent statement about the issue, including a story that relates the issue to a child’s real experience and which highlights your perspective as a health care provider.

  
  
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  Prepare your testimony in writing, with a copy for each person on the committee before whom you are testifying.

  
  
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  Sign in on arrival to get in the queue to testify and to get on the record.

  
  
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  Always begin your testimony by identifying yourself and the group you represent.

  
  
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  State if you are testifying in support, or opposition to, the pending proposal.

  
  
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  Illustrate how the pending proposal matters to children and childhood obesity (eg, tell a story about how the children you work with will be affected by the legislation, regulation, or public policy).

  
  
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  Conclude your testimony by requesting that the decision makers vote for or against the pending proposal.

  
  
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  Offer to be a resource to committee members for any questions.