UNIVERSITY OF CALIFORNIA
COOPERATIVE EXTENSION

NUTRITION PERSPECTIVES

Volume 29, No. 6
November/December 2004

TABLE OF CONTENTS

HHS Announces Revised Medicare Obesity Coverage Policy
Child Growth Standards
Preventing Childhood Obesity: Health In the Balance
Is Diet-Controlled Diabetes Really Controlled?

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Sheri Zidenberg-Cherr, PhD, Editor Department of Nutrition University of California Davis, CA 95616

NUTRITION PERSPECTIVES is prepared by Sheri Zidenberg-Cherr, PhD, Nutrition Specialist, Cristy Hathaway, and staff. It is designed to provide research-based information on ongoing nutrition and food-related programs. It is published bimonthly (six times annually) as a service of the University of California Cooperative Extension and the United States Department of Agriculture. Subscription to NUTRITION PERSPECTIVES is available from UC Cooperative Extension, Department of Nutrition, University of California, Davis, California. Cost is ten dollars ($10.00) for a one-year subscription. Subscriptions and questions or comments on articles may be addressed to: NUTRITION PERSPECTIVES, Department of Nutrition, University of California, Davis, CA 95616-5270. Phone (916)752-3387; FAX, (916) 752-8905.

HHS ANNOUNCES REVISED MEDICARE OBESITY COVERAGE POLICY

The US Department of Health and Human Services (HHS) announced a new Medicare coverage policy that would remove barriers to covering antiobesity interventions if scientific and medical evidence demonstrate their effectiveness in improving Medicare beneficiaries’ health outcomes.

The new policy from HHS’ Centers for Medicare & Medicaid Services (CMS) removes language in the Medicare Coverage Issues Manual stating that obesity is not an illness. By law, Medicare covers specified medically necessary services for illness and injury. The previous manual stated that obesity was not an illness, so Medicare could not cover treatments for obesity-related diseases. This new step allows members of the public to request that Medicare review medical evidence to determine whether specific treatments related to obesity would be covered by Medicare.

The new policy does not affect the existing Medicare coverage of treatments of diseases resulting in or made worse by obesity, particularly currently covered surgical treatments for individuals who are morbidly obese. Detailed information on this process can be found on the Medicare coverage Web site at www.cms.gov/coverage.

Source: Nutrition Today; 39(5); September/October 2004; p. 193.

CHILD GROWTH STANDARDS

The World Health Organization (WHO) is developing new growth standards for infants and young children to help health workers make more accurate estimates of malnutrition. The hope is that improved benchmarks will help identify children as soon as they begin to show signs of becoming underweight or overweight, before the condition becomes severe. The new standards will be linked not only to height and weight but also to motor development assessments.

The project is needed because of inadequacies in the current international reference, which fails to reflect physiological growth, said Mercedes de Onis, MD, PhD, of the WHO’s Department of Nutrition and Development.

“The new standards will provide scientifically more robust tools to assess child growth, and a basis for improved advocacy on behalf of the world’s children,” the agency said. Earlier phases of the project evaluated the current growth standards and collected growth and development data of 8500 children from Brazil, Ghana, India, Norway, Oman, and the United States. The remaining two phases will include data analysis, the development of the standards and related training materials, and dissemination of the standards.

Source: Nutrition Today; 39(5); September/October 2004; p. 193.

PREVENTING CHILDHOOD OBESITY: HEALTH IN THE BALANCE

Reversing the rapid rise in obesity among American children and youth will require a multipronged approach by schools, families, communities, industry, and government that would be as comprehensive and ambitious as national antismoking efforts, according to a new report from the Institute of Medicine of the National Academies. While no single intervention or group acting alone can stop the epidemic of childhood obesity, the steps recommended by the committee that wrote the report all aim to increase and improve opportunities for children to engage in physical activity and eat a healthy diet.

“We must act now and we must do this as a nation,” said Jeffrey Koplan, vice president for academic health affairs at Emory University in Atlanta and former director of the Centers for Disease Control. “Obesity may be a personal issue, but at the same time, families, communities, and corporations all are adversely affected by obesity, and all bear responsibility for changing social norms to better promote healthier lifestyles,” Koplan added.

“We recognize that several of our recommendations challenge entrenched aspects of American life and business, but if we are not willing to make some fundamental shifts in our attitudes and actions, obesity’s toll on our nation’s health and well-being will only worsen,” he said.

Among specific steps recommended by the report is a call for schools to implement nutritional standards for all foods and beverages served on school grounds, including those from vending machines. The committee also recommended that schools expand opportunities for all students to engage in at least 30 minutes of moderate to vigorous physical activity each day.

The report also calls on the food, beverage, and entertainment industries to voluntarily develop and implement guidelines for advertising and marketing directed at children and youth. Congress should give the Federal Trade Commission the authority to monitor compliance with the guidelines and establish external review boards to prohibit ads that fail to comply. Restaurants should continue to expand their offerings of nutritious foods and beverages, and should provide calories content and other nutrition information.

Parents must play their part as well by providing healthy foods in the home and encouraging physical activity by limiting their children’s recreational television, video game, and computer time to less than two hours a day, among other means.

Community organizations and state and local governments can make a difference by implementing programs that promote nutrition and regular physical activity and by supporting the establishment or revision of zoning ordinances and comprehensive plans to include or enhance sidewalks, bike paths, parks, playgrounds, and other recreational facilities.

Schools’ influence on healthy eating and exercise

New policies are urgently needed to ensure that all foods and beverages available at schools are consistent with nutrition guidelines, the report says. There has been a rapid increase in the availability and marketing of foods such as vending-machine sodas and snacks and other high-calorie, low-nutrient foods and beverages that compete with those offered through federal school-meal programs, the report says.

A 2000 report from the Government Accountability Office found that competitive foods were sold in 98% of secondary schools, 74% in middle schools, and 43% of elementary schools.

Although the US Department of Agriculture requires schools meals to follow its Dietary Guidelines for Americans, federal restrictions on competitive foods and beverages are limited to prohibiting the sale of soft drinks and certain types of candy in cafeterias while meals are being served, although 21 states have imposed further restrictions.

To counter trends of decreasing physical activity among school-age children, schools should provide opportunities for students to engage in at least 30 minutes of moderate to vigorous physical activity daily, the report says.

Healthy eating and activity at home

Although many societal factors affect children’s eating and activity habits, parents can exert a profound influence on their children by promoting healthy food and an active lifestyle from an early age and serving as role models, the report say. Parents can encourage their children to develop a healthy varied diet by introducing new foods in a persistent but non-coercive fashion.

Studies show that repeated exposure is most critical during the early years of life and that it can take five to ten exposures to a new food before a child will accept it. In addition parents should consider smaller portion sizes, encourage children to stop eating when they feel full, and avoid using food as a reward.

Parents also should stock their homes with healthy products, particularly fruits and vegetables, to encourage their children to choose them as snacks. Many concerns have been raised about whether increased consumption of sweetened beverages, such as soft drinks and flavored drinks, is linked to the rise of childhood obesity. By the time they are 14 years old, 52% of boys and 32% of girls are drinking three or more eight-once servings of soda a day.

The links between sweetened beverage consumption and body mass index (BMI) are not definitive, the report notes. However, the committee recommended that children be encouraged to avoid sodas and other high-calorie, low-nutrient beverages because of concerns about excessive consumption of “empty calories” and displacement of beverages containing fewer calories and more nutrients.

Industry contributions to addressing obesity

The food and beverage industries spend $10 to $12 billion annually marketing directly to children and youth, the committee found. The average child views more than 40,000 television commercials each year, and more than half of television ads directed at kids promote high-calorie foods and beverages such as candy, snack foods, fast foods, soft drinks, and sweetened breakfast cereals. In addition, the entertainment industry promotes many products that encourage sedentary behaviors.

The Department of Health and Human Services should convene a national conference of industry, business and public health representatives as well as other stakeholders to establish standards for marketing foods, beverages, and sedentary entertainment, and guidelines for evaluating the effectiveness of the standards. The industries would be responsible for implementing the standards and guidelines.

Monitoring mechanisms and advertising codes should be used by the industries and external review groups, such as the Children’s Advertising Review Unit of the Better Business Bureau, to enforce the guidelines. Furthermore, Congress should empower the Federal Trade Commission with the regulatory authority to monitor compliance, scrutinize marketing practices, and establish external review boards to investigate complaints and to prohibit ads that may be deceptive or that have “particular appeal” and conflict with principles of healthful eating and physical activity.

Given Americans’ increasing reliance on prepared foods and restaurants for meals and snacks, food packages and restaurant menus or displays should enhance the nutrition information they provide, to help consumers make informed choices, the report says. The Nutrition Facts panels on food and beverages packages characterization of products as high or low in certain nutrients. More restaurants should expand their offerings to include healthier meal options and provide nutrition information on menus or at the point of sale. should prominently state the total calorie content for items typically consumed all at once, to dispel confusion created when a package contains more than one serving.

The US Food and Drug Administration should examine ways to give the food and beverage industry greater flexibility in making truthful, non-misleading nutrient or health claims about their products, such as characterization of products as high or low in certain nutrients. More restaurants should expand their offerings to include healthier meal options and provide nutrition information on menus or at the point of sale.

Involvement of health professionals

The report insurers and health plans should designate childhood obesity prevention as a priority health issue and should include screening and obesity prevention services in routine clinical practice, the report says. While insurers have largely focused on the treatment of obesity, the high cost of this treatment provides insurers with an incentive to prevent the condition.

Source: Nutrition Week; 34(20); October 11, 2004; pgs. 4-5.

IS DIET-CONTROLLED DIABETES REALLY CONTROLLED?

Tight control of type 2 diabetes reduces microvascular complications. Although many patients’ diabetes is managed by diet alone, without hypoglycemic medications, little information is available about the quality of care and clinical outcomes of such “diet-controlled” diabetic patients.

Researchers in the UK reviewed centralized electronic medical records of 253,618 patients from 42 ambulatory medical practices. Of the 7870 patients with type 2 diabetes, 2463 (31.3%) were managed without medication (interpractice variation, 16%-73%). Compared with patients who were managed with hypoglycemic medications, patients who were treated without medication were more than twice as likely to have hemoglobin A1c levels higher than 7.4%; were much less likely to have documentation of HbA1c levels, blood pressure, cholesterol levels, or smoking status; were less likely to have microalbuminuria testing or screening for foot pulses; were more likely to have elevated blood pressure (and less likely to be on antihyperten-sive medication); and were more likely to have high cholesterol levels (and less likely to be on lipid-lowering medication). Both groups had high rates of diabetes-related complications (68% of patients managed without, and 80% managed with medication).

Some patients with type 2 diabetes are able to achieve good glycemic control with diet and exercise alone. However, for many patients, the term “diet-controlled” suggests more optimism than science. Physicians should heed this study’s findings and confirm that, in patients who they are treating without medication, diabetes truly is well controlled, and they should monitor such patients adequately.

Source: Journal Watch; 24(18); September 15, 2004; p. 145.

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NUTRITION PERSPECTIVES
University of California
Department of Nutrition
One Shields Ave.
Davis, CA 95616-5270