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Special Report

Summary of the 2000 Surgeon General’s


Listening Session: Toward a National Action
Plan on Overweight and Obesity
Yvonne Jackson,a William H. Dietz,b Charlene Sanders,b Lloyd J. Kolbe,c John J. Whyte,d Howell Wechsler,c
Bruce S. Schneider,e Laura A. McNally,f Jean Charles-Azure,g Martina Vogel-Taylor,h Pamela Starke-Reed,i
Van S. Hubbard,i Wendy L. Johnson-Taylor,i Richard P. Troiano,j Karen Donato,k Susan Yanovski,l
Robert J. Kuczmarski,l Lynne Haverkos,m Kathryn McMurry,n Randolph F. Wykoff,n Violet Woo,o
Allan S. Noonan,p Jonelle Rowe,q Kathy McCarty,q and Christine B. Spainr

Abstract ment during a corresponding public comment period. The


U.S. DEPARTMENT OF HEALTH AND HUMAN Surgeon General’s Listening Session was also broadcast
SERVICES STEERING COMMITTEE. Summary of the on the Internet, allowing others to view the deliberations
2000 Surgeon General’s listening session: toward a national live or access the archived files. Significant discussion
action plan on overweight and obesity. Obes Res. 2002; points from the Listening Session have been reviewed by
10:1299 –1305. representatives of the federal agencies and are the basis
Objective: To provide insight into discussions at the Sur- of this complementary document.
geon General’s Listening Session, “Toward a National Ac- Results: Examples of issues, strategies, and barriers to
tion Plan on Overweight and Obesity,” and to complement change are discussed within five thematic areas: schools,
The Surgeon General’s Call to Action to Prevent and De- health care, family and community, worksite, and media.
crease Overweight and Obesity. Suggested cooperative or collaborative actions for pre-
Research Methods and Procedures: On December 7 and venting and decreasing overweight and obesity are de-
8, 2000, representatives from federal, state, academic, scribed. An annotated list of some programmatic partner-
and private sectors attended the Surgeon General’s Lis- ships is included.
tening Session and were given an opportunity to recom- Discussion: The Surgeon General’s Listening Session
provided an opportunity for representatives from family
mend what to include in a national plan to address
and community groups, schools, the media, the health-
overweight and obesity. The public was invited to com-
care environment, and worksites to become partners and
to unite around the common goal of preventing and
Received for review August 20, 2002.
decreasing overweight and obesity. The combination of
Accepted for publication in final form September 15, 2002. approaches from these perspectives offers a rich resource
a
Administration on Aging, U.S. Department of Health and Human Services (DHHS),
of opportunity to combat the public health epidemic of
Washington, DC; b Division of Nutrition and Physical Activity and c Division of Adolescent
and School Health, Centers for Disease Control and Prevention/DHHS, Atlanta, Georgia; overweight and obesity.
d
Center for Medicare and Medicaid Services, Agency for Healthcare Research and Quality/
DHHS, Baltimore, Maryland; e Food and Drug Administration/DHHS, Rockville, Maryland;
f
Health Resources and Services Administration/DHHS, Rockville, Maryland; g Indian Key words: schools, worksites, media, family and com-
Health Service, U.S. Department of Health and Human Services, Rockville, MD; h Office of munity, health care
the Director, i Division of Nutrition Research Coordination, j National Cancer Institute,
k
National Heart Lung and Blood Institute, l National Institute of Diabetes and Digestive and
Kidney Diseases, and m National Institute of Child Health and Human Development,
National Institutes of Health/DHHS, Bethesda, Maryland; and n Office of Disease Preven-
tion and Health Promotion, o Office of Minority Health, p Office of the Surgeon General,
q
Office on Women’s Health, and r President’s Council on Physical Fitness and Sports, Introduction
Office of Public Health and Science/DHHS, Washington, DC. The increasing prevalence of overweight and obesity among
Address correspondence to Wendy L. Johnson-Taylor, Ph.D., MPH, R.D., Public Health
Nutrition and Health Policy Advisor, Division of Nutrition Research Coordination, National American adults and children has been identified as an epi-
Institutes of Health, 2 Democracy Plaza, Room 640, 6707 Democracy Blvd., MSC 5461, demic by the Surgeon General and as one of the Leading
Bethesda, MD 20892-5461.
E-mail: wj50v@nih.gov
Health Indicators for Healthy People 2010 (1,2). Among
Copyright © 2002 NAASO adults, overweight and obesity are associated with increased

OBESITY RESEARCH Vol. 10 No. 12 December 2002 1299


Special Report, HHS Steering Committee

risk for cardiovascular disease, type 2 diabetes, certain mus- 1. Initiate an inclusive process that could result in a national
culoskeletal disorders, and endometrial, colon, and postmeno- action plan.
pausal breast cancers (3). Overweight children have an 2. Solicit suggestions regarding key elements of a national
increased frequency of type 2 diabetes, dyslipidemia, hyper- action plan.
tension, early maturation, and orthopedic problems (4). In 3. Enable participants to share information and establish
addition, overweight children are more likely to become over- dialogue on strategies to reduce overweight and obesity.
weight adults than children who are not overweight. Adults
who were overweight as children are at increased risk for poor The listening session was organized in five thematic
health for longer periods of time than adults who were not areas: schools, media, health care, worksites, and family and
overweight as children (5). An estimated 300,000 deaths per community. Panelists within each area shared their views on
year are attributable to obesity (6). what should be included in a national action plan. Some of
Obesity is associated with increased disability, decreased the challenges to be expected and suggestions for overcom-
health-related quality of life, increased health care use, and ing these challenges were identified.
increased mortality (7), all of which translate into increased The audience was invited to comment and ask questions
health care costs to the American public. In 1995, the total at the conclusion of each panel presentation. More than 170
direct and indirect health care costs attributable to over- representatives from the federal, state, academic, and pri-
weight and obesity were estimated to be $99 billion dollars, vate sectors attended the Listening Session. In addition, the
equivalent to ⬃7% of the gross domestic product spent on Session was broadcast on the Internet, allowing others to
health care (8). Obesity-related health care cost estimates view the deliberations live or subsequently access the ar-
for 2000 reached $117 billion (A. Wolfe, personal commu- chived files (12).
nication, July 2002). Even after accounting for inflation, The following sections identifies the five major settings
this growth in cost is staggering. for which activities and interventions were discussed.
Overweight and obesity clearly pose a significant public
health threat (9). A growing awareness of this threat has Schools1
stimulated various discussions and activities. One important Participants in the listening session reported that while
example is the 1998 publication of Clinical Guidelines on the using the school system to educate children on health-
Identification, Evaluation, and Treatment of Overweight and related issues such as overweight and obesity initially seems
Obesity in Adults: The Evidence Report, by the National to be a natural fit, societal demands on schools are resulting
Institutes of Health (10). This report is significant because it in competing priorities. A recurring theme among the pan-
was the first report to outline evidence-based treatment guide- elists discussing schools was the lack of shared priority for
lines for overweight and obese adults. Another example of an overweight and obesity prevention across the school envi-
important activity was the National Nutrition Summit, held in ronment. Whereas the food service staff may be focusing on
May 2000 (11). During this Summit, the Secretary of the U.S. ways to improve the nutritional content of school meals,
Department of Health and Human Services (DHHS) directed principals and teachers may be focusing on increasing stu-
the Department to host a meeting led by the U.S. Surgeon dent test scores, and athletic coaches may wish to develop
General regarding the epidemic of obesity. athletic programs that include a relatively small number of
On December 7 and 8, 2000, the Surgeon General convened students. Both the short school year, which has not changed
a meeting in the form of a Listening Session on Overweight since the United States was primarily an agricultural soci-
and Obesity. Approximately 1 year later, in December 2001, ety, and the limited school budgets reduce the amount of
publication of the Surgeon General’s Call to Action to Prevent time and money that are available to address all of the
and Decrease Overweight and Obesity (9) incorporated infor- competing demands placed on schools. These multiple pri-
mation gathered during the Listening Session, information orities within the school environment are causing school
from the corresponding public comment period, and informa- administrators to make many difficult choices, some of
tion gathered from the National Nutrition Summit. The objec- which are highlighted below.
tive of this manuscript is to provide insight derived from School food service departments plan and prepare meals
listening session discussions to complement the “Call to Ac- according to the recommendations of the Dietary Guidelines
tion.” A brief annotated list of examples of existing programs, for Americans (13). However, food and beverage competi-
consistent with the identified themes discussed at the listening tors in the form of vending machines, a la carte food lines
session, is presented to illustrate various types of partnerships within the school, nearby commercial food and restaurant
as well as potential actions. facilities, and food served at other school-sponsored events

The Listening Session 1


Presenters: American School Food Service Association, National Association for Sports
The objectives of the 2000 Listening Session on Over- and Physical Education, National Association of State Board of Educators, and Sporting
weight and Obesity were as follows. Goods Manufacturers Association

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are not required to comply with the same guidelines. Some being successful. The leading barrier mentioned was the
schools rely heavily on profits earned from commercial lack of reimbursement for treatment and prevention services
ventures within the school to fund extracurricular activities, for overweight and obese individuals. Panelists stated that
ensuring that these competing food sources are likely to without reimbursement, some providers are reluctant to
remain a part of the landscape. It was suggested that a spend time in repeated conversations with patients about
national dialogue to identify alternative potential sources of healthful eating and physical activity. Decisions on how to
funding for extracurricular activities is needed. Other sug- spend health care dollars with this population are made
gestions included making vending machines less accessible; more complex because of the multiple morbidities these
adopting price incentives for healthier foods, and establish- patients have and the limited health care dollars available to
ing and enforcing healthful standards for foods served at treat them. Participants identified the need for research to
other school-sponsored events. develop effective treatments and prevention strategies for
Another example of multiple priorities has resulted from overweight and obesity. Evidence of effective therapy is
greater focus on test scores as an assessment of principal, needed not only to make a case for reimbursement but also
teacher, and student performance. Emphasis on improving for the education of providers.
test scores has caused some schools to reduce or eliminate Another deterrent to discussing overweight and obesity
physical education classes and reduce the length of time for with patients identified by the panel was the comfort level
lunch periods. Some participants stated that time previously of health care providers. In some cases the providers said
spent in physical education class and recess often has been they were uncomfortable bringing up the issue with their
replaced by standardized test preparation. patients and in other cases providers did not want to make
Many of the participants indicated their belief that phys- the patients feel uncomfortable. For providers this issue is
ical activity positively affects academic outcomes and ac- compounded by discussions with overweight parents about
knowledge that additional research is necessary to deter- their overweight children. In some cases, providers ex-
mine the nature of the relationship between academic pressed guilt about their belief that the patient was to blame
performance and physical activity. The panel further stated that for being overweight or obese. The fact that some providers
should such research be conducted, school decision-makers acknowledged feelings that patients were to blame for being
should be educated about the results of these studies and overweight or obese led to more intense discussion of the
encouraged to include the issue of physical activity in ongoing potential for undertreatment of and discrimination against
debates on education reform. Participants also recommended patients. Some providers felt they lacked skills and knowl-
that tobacco settlement money be used to hire physical educa- edge regarding behavior change and nutrition.
tion specialists and to purchase new equipment. Parents and Early identification could increase physician comfort,
community coalitions were thought to be the most influen- and improve health outcomes of the patient. Earlier recog-
tial advocates for physical activity. These parent-commu- nition by the physician of existence of or potential for
nity coalitions should be educated about health risks asso- overweight provides the physician an opportunity to address
ciated with obesity to solicit their participation. the problem before the problem becomes severe. Prevention
There was considerable debate about whether increased of inappropriate weight gain is an important goal that needs
focus on obesity prevention would increase the stigma as- to be emphasized to patients. Regardless of the weight status
sociated with being overweight or increase the number of of patients entering into the health care system, the focus
eating disorders. This debate also sparked a discussion on should always be placed on improving health outcomes.
the nature of physical education classes. Some participants Weight management should be considered one step in that
recalled unfavorable personal experiences in physical edu- process.
cation classes while other participants tried to assure them Another method to increase the comfort level of patients
that physical education is taught very differently now. It was and providers is to improve provider training in weight
suggested that parents, teachers, and coaches be educated management. One recommendation suggested incorporating
about health-related risks of overweight and about “the behavior change theory and components of delivering cul-
National Standards for Physical Education.” turally sensitive weight-management interventions within
medical school curricula and as part of continuing medical
Health Care2 education. There is a need to effectively disseminate evi-
Health care providers acknowledged their leading role for dence-based information to practicing physicians and to
overweight and obesity prevention and treatment efforts and motivate them to use new methods of prevention and treat-
noted a number of barriers that prevented their efforts from ment of obesity. A final recommendation encouraged phy-
sicians to become champions of overweight and obesity
2
interventions by advocating change in other environments,
Presenters: American Academy of Pediatrics, American Dietetic Association, American
Heart Association, Association of American Indian Physicians, National Black Nurses
e.g., it was suggested that physicians could lead a national
Association, and North American Association for the Study of Obesity campaign to increase physical activity.

OBESITY RESEARCH Vol. 10 No. 12 December 2002 1301


Special Report, HHS Steering Committee

Worksites3 Family and Community4


Just as schools present a logical place to educate children Family and community panelists pointed out the need to ap-
about overweight and obesity, worksites are logical places proach the issue of overweight and obesity with sensitivity be-
to educate adults. However, worksite panelists expressed a cause people from various cultures may view weight status in
guarded willingness to accept this responsibility. They different ways. Panelists stressed the need to consider how differ-
stated that more information is needed on the costs and ent cultures perceive weight when designing interventions.
benefits of worksite wellness programs that address over- Understanding weight perceptions of different groups
weight and obesity prevention and treatment before they may help determine what language to include in the mes-
could justify such programs. For example, increasing the sage. For example, some people find the term obesity quite
number of wellness programs that incorporate physical ac- offensive, whereas others do not. Knowledge and consider-
tivity might further increase liability insurance, and there ation of these differences when designing an intervention
was uncertainty about who would be liable if an employee may increase the success of the intervention. Another point
is injured. Apprehension was expressed that emphasis on discussed was whether omission of the term obesity diluted
prevention and treatment of overweight and obesity may the message. Although this issue was not resolved during
increase discrimination and thereby increase litigation. the session, it was suggested that the target population view
There was concern that if worksites become paternalistic, the language used as appropriate. For example, whereas it
employees may chose other places to work. may be appropriate to use the term obesity with health care
It was recognized that additional research is needed to providers and scientific researchers, it might be more ap-
address the liability costs and productivity benefits of worksite propriate to use alternative terminology with other commu-
wellness programs as well as to identify health benefits that nities. It was further recommended that the message should
could be realized from program participation. Information not detract from the importance of selecting an appropriate
gathered from the research should be shared with all employ- messenger. For some communities, it is important to have a
ees to increase employee participation, to empower employees consistent, clear message delivered by familiar sources.
to make healthier choices, and to reduce discrimination. Examples of familiar sources might include sports figures,
There was also a suggestion to formally recognize com- TV celebrities, community activists, or members of the
panies that establish worksite wellness programs or change faith-based community.
workflow patterns to increase physical activity, an alterna- Panelists highlighted the influence of environmental fac-
tive perhaps most feasible for small companies. Worksites tors on overweight and obesity and recommended adding
environmental approaches to the plan. Some of the con-
were encouraged to collaborate with community leaders to
ditions supporting this view included the following: obe-
promote an environment conducive to healthy lifestyles.
sity and poverty coexist in some households; fewer open
Substantial discussion focused on portion sizes served in
spaces and parks for play; fewer children are walking to
worksite cafeterias and restaurants. It was suggested that
school; and wellness programs are not affordable across
restaurant/cafeteria management take more responsibility in
population groups.
the campaign against overweight and obesity by ensuring
It was suggested that school facilities be available after
that portion sizes reflect the ones recommended by health
school hours for recreational use and that use of school
care professionals. The representatives from the restaurant/
facilities be accessible to everyone within the community
cafeteria management responded by stating they were re-
regardless of ability to pay. Concerns were raised that the
sponsible for meeting the desires of the consumers who are
increased cost of keeping the facility open after hours might
requesting more food for their money. Restaurants/cafete-
be a barrier. Also, questions were raised regarding liability
rias were encouraged to price healthier fare competitively or
if people were injured on the premises. Another suggestion
even lower than the less healthy items. The restaurant/ was to develop additional parks and open spaces and to
cafeteria representatives stated that when healthier choices build more sidewalks using transportation funds. With these
are offered, regardless of price, they usually do not sell well, enhancements, people may be able to exercise within their
which negatively affects their profit. Despite the previous own neighborhoods. In addition to increasing the availabil-
history of trying such measures, there was an expressed ity of places to exercise, people need to feel safe. The public
willingness by restaurant/cafeteria management to adjust safety agencies are essential partners in any public health
service as the public demands. Thus, the public needs to be efforts because they help provide a safe environment. Fi-
educated about appropriate portion sizes and empowered to nally the public needs to be educated about the influence of
advocate for change within the restaurant/cafeteria industry.

4
Presenters: Association of State and Territorial Public Health Directors, National Alliance
3
Presenters: Association of State and Territorial Directors of Health Promotion and Public for Nutrition and Activity, National Recreation and Park Association, Partnership to Pro-
Health, Council on Size and Weight Discrimination, National Restaurant Association, mote Healthy Eating and Active Living, Grocery Manufactures of America, and Regional
Northwest/Portland Indian Health Board, and Partnership for Prevention Plan Association, New York

1302 OBESITY RESEARCH Vol. 10 No. 12 December 2002


Special Report, HHS Steering Committee

environmental factors on overweight and obesity so they funded programs include training programs for counselors,
can become informed advocates for change. a statewide hotline and cessation program, insurance sup-
port, media campaigns, and evaluation of various programs.
Media5 The campaign included community and school interven-
According to panelists, the public has come to respect the tions, media announcements, tobacco regulation enforce-
media as a source of health information. Problems arise, ment, and evaluation. Campaign for a Healthy Maine was
however, when there is fragmented communication between launched October 2000 with a 2-day summit hosted by the
the scientific community and the media. For example the governor with the intent of rallying support from stakehold-
responsibility for interpreting research findings may fall on ers across the State.
the media. However, because interpreting research findings
may go beyond the expertise of the media, there is an
increased risk of misinformation. One suggestion was to Industry-Funded Program: Childhood Obesity
educate the media not only about the science of overweight Prevention Initiative (http://kidnetic.com)
and obesity but also about the dynamic nature of research This initiative is administered by the International Food
and the changing state of knowledge. Another suggestion Information Council Foundation and primarily funded by
was to have the media and the scientific communities create the food, beverage, and agricultural industries. The Child-
more regular working relationships to decide jointly on the hood Obesity Prevention Initiative will track consumer
message and the most effective way to relay it to the public. knowledge and perceptions and define appropriate mes-
The panelists believed that the media could be powerful sages and program elements. The term “obesity” may be
allies in the battle against overweight and obesity. Media excluded from campaign messages that focus on humor,
professionals bring to the table expertise in message tailor- small victories, performance, appearance, and acceptance,
ing and public appeal. They can teach public health profes- rather than health, and will be targeted toward children. The
sionals how to incorporate established marketing strategies organizers recognize that childhood obesity is a very com-
into the delivery of health messages. During the media panel plex issue with many possible solutions and that partner-
discussion, it was also suggested that the individual who ships are key to success. The Foundation plans to conduct
delivers the message reflect or represent the target audience. in-depth consumer focus groups and ethnographic and qual-
As one listening session participant put it, “No one wants to itative research to build a successful communications
watch a size 6 model that has never had a problem main- program and provide the tools necessary to talk about
taining the recommended weight give advice on weight the issues.
loss.” Proper selection of the message and the messenger
may help reduce discrimination, promote self-acceptance,
and provide a source of empowerment to individuals. Community-Based Program: Hochunk Youth
Fitness Program
The Hochunk Youth Fitness Program is housed in Wiscon-
Partnerships to Drive Action sin and is a partnership among health care professionals, youth
The following activities are intended to provide brief services, social services, fitness and nutrition departments, the
annotated examples of various types of partnerships and a university, and area school districts. The program, which is
listing of some existing partnership driven programs. The funded by the Health Resources and Services Administration,
types of partnerships highlighted include a State Public is based on the local community culture and its youth. The
Health Program, an Industry-Funded Program, a Commu- program logo was developed from a local child’s drawing, and
nity-Based Program, and a Local Coalition Program. the program was designed to be simple and easy. The major
goals of the program are to reduce the incidence of childhood
State Public Health Program: Campaign for a Healthy obesity, prevent adult obesity, and set up an infrastructure that
Maine (http://www.state.me.us/dhs/boh) can be maintained to address children at risk for diabetes. The
A statewide initiative focused on three preventable risk program consists of an after-school educational program,
factors—tobacco addiction, physical inactivity, and poor supermarket tours, adult classes, and nutrition assessment.
nutrition. The project is funded by tobacco settlement funds, Down-to-earth incentives such as scooters, cassette players,
funds from the Centers for Disease Control and Prevention, and sports equipment are an important part of the program.
funds from the U.S. Department of Agriculture, and state Double points toward these prizes are awarded to children
funds. State funds were used at local levels for school- and
for bringing their family members to the activities. Trans-
community-based programs. Examples of some of the state-
portation is provided to increase access to the services.
Daily communication within the partnership network has
5
Presenters: Health Watch, International Food Information Council, and Produce for Better
been essential to the success of the program in raising
Health Foundation awareness in the community.

OBESITY RESEARCH Vol. 10 No. 12 December 2002 1303


Special Report, HHS Steering Committee

Local Coalition Program: Spokane’s BMI Public Health Nutrition Directors focusing policy, educa-
Awareness Campaign tion, and funding to increase activity, decrease fat consump-
The Leadership Spokane Class of 1999 developed the tion, and increase consumption of fruits and vegetables.
Spokane BMI Awareness Campaign, which is a grass roots
coalition. The mission of the campaign is to promote routine
Discussion
BMI evaluation and intervention and incorporate the Na-
Participants in the Surgeon General’s Listening Session
tional Institutes of Health’s clinical guidelines into health
were well aware of the multifactorial etiology of overweight
care practices. They recognized that most people are un-
and obesity: conditions resulting from complex interactions
aware of the significance of BMI as a health-risk indicator.
among genetics, physiology, culture, and environment.
Components of the campaign included a BMI chart to hang
They emphasized not only the need for applying multiple
on scales that outlined classification and treatment algo-
intervention and prevention strategies to address the prob-
rithms. The charts along with copies of National Institutes
lems of overweight and obesity, but also the urgency with
of Health clinical guidelines were provided to every physi-
which these strategies need to be implemented. The back-
cian in the Spokane area. In addition, the information was
drop of increased disease risk, increased morbidity, and
made available to worksite wellness programs in the area.
increased health care costs necessitate the need for imme-
The leadership developed surveys to collect baseline and
diate strategic action. The Listening Session represented a
outcome data, a public awareness campaign, and a strategic
unique opportunity to have many varying perspectives on
plan for the community. The uniqueness of this project
the issue of weight management heard and considered in
lies in the fact that it has progressed without a funding
addressing this public health issue. Information from the
stream but continues to exist with endorsements and com-
National Nutrition Summit (11), the Listening session, and
mitments from local business and community leaders and
the accompanying public comment period served as the
health care providers.
basis for the Surgeon General’s Call to Action to Prevent
and Decrease Overweight and Obesity (1).
Other Programs
The intent of this article is to highlight some of the
Presenters and attendees during the meeting also men-
discussions held during the Listening Session. Although
tioned several other representative successful programs,
organized according to set of distinct settings, it is important
including:
to understand that the Listening Session was a broader and
● Saint Louis Prevention Research Center—sponsored by more dynamic process with many of the discussions over-
CDC, the center has undertaken a heart healthy project for lapping. There were several common themes that emerged
cardiovascular disease prevention of rural African Amer- during the session. They were: the need for better commu-
icans in Missouri nication among the stakeholders; the need for swift action to
● PE4Life—a cooperative program sponsored by otherwise address the problem, recognizing that positive results of any
highly competitive manufacturers of sporting goods actions may take decades or generations to realize; the need
● Hoops for Heart/Jump Ropes for Heart—sponsored by for more research on the etiology and appropriate interven-
the American Heart Association, these programs encour- tions for overweight and obesity; the need for evaluation of
age people to get moving by participating in jump rope the effectiveness of the interventions; and the importance of
competitions and basketball tournaments approaching overweight and obesity as a health issue and
● Zuni project—a weight management program developed not an appearance issue.
by the Zuni Tribe and entirely funded and supported by These themes were captured within the Surgeon Gener-
the Tribe al’s Call to Action to Prevent and Decrease Overweight and
● 5-A-Day Program—a public/private partnership of the Na- Obesity with the CARE acronym where “C” represents
tional Cancer Institute, the Centers for Disease Control and communication, “A” represents action, “R” represents re-
Prevention, the United States Department of Agriculture, search, and “E” represents evaluation (1). Within the CARE
fruit and vegetable producers, and the food industry: a well- framework, it is important to realize that multiple levels of
planned and funded strategy, with the food and beverage action are required to successfully combat overweight and
industries spending $10 billion to market the program obesity. Efficient use of multiple levels of action requires
● Project LEAN—a statewide initiative in California multiple partners unified by a common goal. The Listening
funded as a public/private partnership between the State Session provided an opportunity for family and community
and the Association of State and Territorial Public Health groups, schools, media, representatives from the health care
Nutrition Directors. The program sponsors community environment, and representatives from worksites to become
interventions for nutrition and physical activities through partners and to unite around the common goal of preventing
public policy and community action and decreasing overweight and obesity. Together the com-
● New York’s Eat Well, Play Hard—a public/private partner- bination of approaches from these environments offers a
ship supported by the Association of State and Territorial better chance of combating this epidemic.

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Further information is available at: http://www.surgeon- mass index, chronic illness and the physical and mental compo-
general.gov/topics/obesity/. nents of the SF-36 questionnaire. Obes Res. 2000;8:160 –70.
8. Wolf AM, Colditz GA. Current estimates of economic costs
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