Public health researchers have long known that obesity is pandemic – and its financial and human health costs are substantial.

About 35 percent of U.S. adults – 78.6 million people – are obese and therefore at greater risk of heart disease, stroke, type 2 diabetes, and certain types of cancer. The estimated annual medical cost of obesity in the U.S. is close to $148 billion.

[Photo: Drs. Alice Ammerman, Myles Faith, John Graham, Leslie Lytle and Liza Makowski]

In North Carolina, where the problem is acute, the need for innovative solutions is immediate. Between 25 percent and 30 percent of North Carolinians are too heavy, and North Carolina ranks forty-first among U.S. states in terms of the state’s residents being at a healthy weight.

Because obesity is a multi-faceted problem, it can be solved only by an integrated, interdisciplinary approach that translates research into meaningful and practical clinical and community solutions. At the University of North Carolina at Chapel Hill, more than 75 faculty members from 23 departments and seven UNC schools work together to make that happen, including researchers from fields as diverse as mass communications, city and regional planning, health behavior, nutrition, epidemiology, health behavior, biostatistics, psychology, medicine, biochemistry, and genetics.

In every department at the Gillings School of Global Public Health, faculty members and students conduct obesity-related research. The unique, collaborative atmosphere at UNC has allowed the School to be a global leader in understanding causes and consequences of obesity.

For example, at UNC, we are:

• Discovering new information about how fat is metabolized and uncovering links between metabolism and diabetes that could one day lead to reductions in the debilitation common with this disease;
• Pinpointing genes that make some animals crave physical activity while others avoid it, and are preparing to do the same in humans;
• Observing moms and babies to understand the effect of early interactions and feeding styles on the development of obesity;
• Tracking changing nutrition patterns around the world and assessing reasons for rapid increases in overweight and obesity;
• Developing and testing practical ways to change environments in child care centers to promote healthier habits in preschool children;
• Testing neighborhood programs that support children walking to school;
• Creating detailed maps of large sections of the country to understand how neighborhood characteristics influence physical activity and dietary habits of the people who live there;
• Creating and testing Internet programs tailored to individuals of different ages to influence lifestyle and food choices;
• Coordinating a national study of Hispanic obesity and diabetes;
• Developing tools to enable pediatricians to assess patients’ BMIs accurately;
• Launching church-based programs aimed at African-American women and their daughters, tested peer-delivered obesity prevention programs, and developed physical activity programs for middle-school girls in six states;
• Developing processes for partnering family medicine practitioners with community resources to help patients make healthier choices; and
• Discovering the particular risks that obese people face during flu epidemics, and the links between diet, exercise, and many cancers, and developing educational messages and campaigns to reduce these risks.

As a leader in moving from discoveries to community and policy solutions, the Gillings School’s focus is on solutions to real-world problems. School researchers influence local, state, national and global policies and strategies.

For example:

• Dr. June Stevens’ membership on national expert panels has resulted in guidelines for obesity prevention and treatment that will be used by practicing physicians around the country for the management of obese patients with cardiovascular disease.
• Dr. Barry Popkin’s book, The World is Fat, received national and international attention for its clear, dynamic explanation of how changes in America’s food production, eating habits, and activity levels have driven our obesity epidemic – an epidemic that is rapidly spreading across the globe. Dr. Popkin has worked with a number of national and international governments to reduce high-calorie beverages and develop policies regarding food labeling.
• Several faculty members participated in the development of the American Institute for Cancer Research report Food, Nutrition, Physical Activity and the Prevention of Cancer, which documents the effect of obesity on multiple cancers.
• Dr. Deborah Tate, associate professor of health behavior and nutrition, has developed and evaluated several of the first randomized trials using the Internet and email to deliver behavioral treatments for obesity and continues to conduct a programmatic series of studies to determine which features of Internet weight control programs contribute to efficacy. Her NIH-funded research has evaluated integrated programs using PDAs, the Internet, and e-counseling with a behavior therapist; an intervention for weight loss maintenance delivered via phone/in person or via email/Internet; and using Internet technology to deliver tailored interventions to increase exercise.
• Dr. Anna Maria Siega-Riz served on an Institute of Medicine panel that set new guidelines for the amount of weight women should gain during pregnancy.
• Dr. Alice Ammerman’s service on state-level committees and task forces has led to major changes in the state’s response to the epidemic of childhood obesity. Dr. Ammerman also has encouraged state leaders who are tackling the transition from tobacco to prioritize the development of healthy, environmentally and economically sustainable local food supplies.

Most recently:

• Dr. Ammerman is one of four UNC co-leaders of a new Regional Center of Excellence in Nutrition Education and Obesity Prevention to help nutritional assistance services improve obesity prevention efforts for families receiving those subsidies. The center, one of four funded by the U.S. Department of Agriculture’s National Institute of Food and Agriculture, will work with the supplemental nutrition assistance program-education (SNAP-Ed) and the expanded food and nutrition education program (EFNEP) to pool resources and develop and evaluate innovative strategies to help people eligible for these government subsidies make healthy choices within a limited budget.

“Until now, EFNEP and SNAP-Ed have largely worked in parallel to reduce obesity in low-income populations, but the focus of this center will be to better coordinate efforts, enhance intervention approaches and assess impact,” said Dr. Ammerman, who is professor of nutrition in the Gillings School and director of the UNC Center for Health Promotion and Disease Prevention (HPDP). “We will be able to gain valuable insights by
working together and strengthening the impact of all our activities to improve the health of children and families.”

Dr. Ammerman also co-leads a new research center funded by the U.S. Department of Agriculture to develop strategies to promote healthy food choices, particularly among the 50 million Americans receiving federal food benefits. The Duke-UNC USDA Center for Behaviorla Economics and Healthy Food Choice Researcher Center, established with a three-year, $1.9 million grant, is co-led by Dr. Matthew Harding, assistant professor at Duke University’s Sanford School of Public Policy.

Since 2007, the number of Americans using USDA’s Supplemental Nutrition Assistance Program (SNAP), popularly known as food stamps, has nearly doubled, reaching almost one-sixth of the U.S. population at an annual cost of $79 billion. In addition, 8.7 million Americans participate each month, on average, in the Women, Infants, and Children Nutrition Program (WIC), more than half of whom are children.

“Our research will begin with ‘listening sessions’ with WIC and SNAP customers, retailers and program administrators to understand what needs and barriers they are facing,” Dr. Ammerman said.

• In a study published in Pediatrics in November 2014, Dr. Myles Faith, associate professor of nutrition at the Gillings School, found that limiting children’s access to certain foods – “restrictive feeding” – is related to higher weight status in children. Faith said that highly controlling feeding practices, while well-intentioned, paradoxically may increase a child’s consumption of the withheld food by disrupting “satiety responsiveness’ (the ability to recognize when we are full) – and even may impede children’s learning of this skill.
• Dr. Liza Makowski, assistant professor of nutrition at the Gillings School, found that pregnancy can increase the risk of basal-like breast cancer, a triple-negative subtype of breast cancer, in obese mice. The study, published in October in PLOS One, also found that in mice that became obese during the postpartum period, the tumors for this type of cancer became extremely aggressive.“This is significant,” Dr. Makowski said, “because this type of breast cancer does not currently have specific drug therapies. However, the risk could be greatly mitigated by two key factors – keeping a healthy weight and breastfeeding. This is good news, as both tend to be within the mothers’ own control.”
• Dr. John Graham, senior investigator at the Gillings School’s N.C. Institute for Public Health and adjunct assistant professor in the School’s Public Health Leadership Program, is principal investigator for a new grant to help improve consumers’ selection of healthy foods and beverages. The project, funded by the Centers for Disease Control and Prevention’s Division of Nutrition, Physical Activity and Obesity and the National Network of Public Health Institutes will identify and assess marketing strategies and behavioral designs in hospitals and full-service grocery stores.“This project exemplifies the role of the N.C. Institute for Public Health as a convener of talents from around the School, the larger University, and with partner departments in other universities,” Dr. Graham said.The Institute will identify promising practices for follow-up research and pilot studies, conducting interviews, collecting and analyzing data, and reporting findings and recommendations.
• In a JAMA Pediatrics commentary in November 2014, Dr. Leslie Lytle, professor and chair of health behavior at the Gillings School, discussed recent efforts by state and federal programs designated to provide breakfast and lunch to students. Lytle discussed the buy-in by schools and subsequent effectiveness of these programs and made suggestions on how they can be more effective in the fight against childhood obesity.“School administrators have been slow to adopt the belief — and related policies and practices — that unhealthy foods that are high in sugar, fat and empty calories do not belong in a school and that providing fruit, vegetables and whole-grain products throughout the school is important,” Dr. Lytle said.

Dr. Lytle says that even though most schools have adopted the program, the transition still needs encouragement.

“The new federal policy may be a carrot at the end of the stick that drives schools to make these important changes,” she said. “In addition to the stick-and-carrot, substantial tangible help in making the switch and incentives to sweeten the deal from state and federal sources are likely needed.”

Dr. Lytle’s commentary was a response to an article by Dr. Yvonne Terry-McElrath, published in the same issue of the journal and titled “Potential Impact of National School Nutritional Environment Policies Cross-Sectional Associations with U.S. Secondary Student Overweight/Obesity, 2008-2012.”