CHILDHOOD

OBESITY IN

Chatham County

2012

Community Report

Overseen by

S AV A N N A H BUSINESS GROUP

Compiled by Eleanor Rooke Siemens Edited by Gary Rost Funded by a grant through United Healthcare Fund and NBCH/CCHI Designed by

MARKE TING

COMMUN I CAT IO NS

Foreword This guide has been prepared for the parents and leaders of our community to help us understand the issue of childhood obesity.

Childhood obesity is a major problem that impacts all aspects of a child’s life, and the crisis is getting worse. There is plenty for us all to do and everyone must be involved. It is SBG’s hope to start the conversation. But talk is not enough; this problem needs action. — Gary Rost, Executive Director, Savannah Business Group

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Executive Summary 0

What has changed in fifteen years?1

Children today get over half their calories in drinks. They do not play outside. They spend too much time in front of the television or game console. And what they eat is often fried, frozen, microwaved, or came through a car window.

45 40

GEORGIA’S CHILDHOOD OBESITY RATE

35 30 25 20 15 10

Due to such unhealthy habits we have 5 a rapidly increasing rate of obesity and 0 the first generation of children that 1997 2004 2012 will live shorter, less healthy lives than their parents.2 It is estimated that over 20% of school children in our country are overweight.3 One in three children in Chatham County are obese.4

1 in 3 children in Chatham County are obese .

2020

But “our children did not create this problem,” the Surgeon General states. “Adults did. Adults increased the portion size of children’s meals, developed the games and television that children find spellbinding, and chose the sedentary lifestyles that our children emulate. So adults must take the lead in solving this problem .”5

In an attempt to do just that, Savannah Business Group (SBG) applied for a community health planning grant last spring from the National Business Coalition on Health and the United Health Foundation. Savannah was one of six communities that received the grant, along with Chicago-based Midwest Business Group on Health; Indiana Employers Quality Health Alliance in Indianapolis; Memphis Business Group on Health in Memphis, Tennessee; Employers Coalition on Health of Rockford, Illinois; and St. Louis-Area Business Health Coalition. This was an employer coalition-only grant, but it required SBG to have community support. SBG called upon relationships it had built as part of their community health partnership strategy and pulled together partners willing to work on the plan. Meetings were held to discuss what health category would be focused on, determine the milestones, and develop an approach. America’s Health Rankings was used as the starting point in selecting a health measure, but early during the discussions the partners unanimously decided on child obesity to be the focus of this grant. A county-wide summit was conducted and was very successful. After the summit, the coalition visited the partners and other community groups to observe facilities, receive briefings on programs, and judge enthusiasm for a community-wide child obesity project. During these visits, it was determined that Savannah has the resources to support a project, and its partners consider this project in an early planning phase and, though the grant is ending, know that our work is just beginning. SBG had the pleasure to be the lead organization in this project, but could not have done it alone. We wish to thank our partners in this grant: Armstrong Atlantic State University; Chatham County Health Department; Chatham County Safety Net Planning Council; City of Savannah; Coastal Health Department; Healthy Savannah; Georgia Health Sciences University (Southeast Georgia Campus); Memorial University Medical Center; Savannah State University; and St. Joseph’s/Candler.

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Chatham County 2012 Community Report

A Call to Action It takes a community to raise a child - a healthy one, at least. The streets that need safer walking routes, the neighborhoods that need closer grocery stores, the fitness centers that need more affordable memberships - all impact the rate of obesity, and all affect and are responsibilities of the community.

One in three children are overweight in the county Chatham County has not escaped the national epidemic of childhood obesity - one in three children are overweight in the county6 - and the issue has become a serious threat to the community’s health and quality of life. Yet while it is a concern of many organizations in Chatham County, childhood obesity is not a major strategic priority of any of them. So far, there have only been separate voices speaking out on the issue. A summit undertaken by the Community Health Planning Committee in July, 2011 revealed there are resources already in existence, with many organizations and groups attempting to make serious community changes. These groups represent several sides of Chatham County, from government institutions to physicians, but working independently their influences will never be as strong as they would be united.

Whether you are an employer, healthcare provider, community-serving organization, educator, or parent, your voice is needed. The Community Health Partnership is an attempt to bring together Chatham County in the name of preventing and eliminating childhood obesity. The partnership provides a forum under which organizations and individuals from all of Chatham County’s municipalities can unite. No one organization or individual can defeat this problem on their own.

I’m an employer Why I Should Be Concerned Business leaders and corporations have a vested interest in childhood obesity. • Obesity impacts healthcare budgets - particularly now that children can stay on their parents’ insurance plan until the age of 26. For every two of your employees, there may be at least one child,7 and obese and overweight children have greater health issues and can be predicted to make up a large portion of healthcare costs. • Those children are going to eventually become your employees. Obese workers miss an estimated one week of work per year due to weight-related complications, and they spend 42% more per year for their medical care.8

How I Can Help

As a partner to improve the community’s health, you have unique platforms and advantages with which to utilize. Your potential contacts and influence within the community are a valuable resource to the Community Health Partnerships. Employees spend much of their daily lives in the workplace and are directly influenced by it. By making healthy eating and activity an important part of the workplace culture, you will impact their lives and those of their families. • Within your own business, you can establish healthier environments through resources like walking trails at worksites and the subsequent encouragement of physical activity during the workday, healthier cafeteria food, and information about community resources and programs for employees and their families.9 • You can also create new prevention programs and expanded support, such as coaching by diabetes health educators, offering incentives for participants and their children or applying value-based benefit designs.10

I’m a healthcare provider Why I Should Be Concerned As a hospital, physician, or other medical care provider, you are especially close to this epidemic. You come in contact with child obesity on a daily basis, and you know better than anyone the serious physical and mental complications it brings with it.

How I Can Help Hospitals, physicians, and other care providers have unparalleled medical knowledge regarding this issue. • As a physician, you can work to adopt programs, such as the American Academy of Pediatrics’ Bright Futures program, within your practice. • While medical professionals do participate in this and other collaboratives, they are often independent, with no unified voice through which to speak. There is also no universal care path for physicians to recommend to parents regarding their child’s obesity. Thus, a collaborative of physician practices within the Community Health Partnership would be a important addition.

I’m a communityserving organization Why I Should Be Concerned Whether you represent a church, government institution, community-based initiative, or youthserving organization, you may already be involved in solving this problem. You have strong relationships and influence in the community, and the health of the community - either Chatham County as a whole or a specific sector. It is important to you.

How I Can Help Keep up the good work, and make childhood obesity one of your stated priorities. • Incorporating obesity prevention messages into events, providing opportunities for safe and supervised activity for children, offering no- or low-cost physical activity opportunities and nutrition counseling, and supplying healthy food at community events are just some of the ways you can make obesity a priority.11 • Bring your resources and knowledge to the Community Health Partnership and join forces with other organizations to make your impact even bigger. • Government programs can have a particularly significant influence. Passing policies to change food environment, providing improved access to healthy foods, building more sidewalks, improving schools, and encouraging transportation fund use for mass transit are just some of the ways you can aid in the situation.12

I’m an educator Why I Should Be Concerned Second perhaps only to parents, schools and educators have the greatest opportunity to impact children specifically. Children spend much of their day at daycare and school, and the activities they are engaged in and the food they consume there has a big impact on their lives.

How I Can Help Educating children means more than just instructing them academically; health and well-being are also important subjects to teach. Chatham County public schools have already done an outstanding job of implementing the new USDA food laws into their cafeterias, providing healthier choices to children. • With FITNESSGRAMS© starting this year, it is important to talk directly to parents and children about how they should respond to those “grades”. Providing statistical information from S.H.A.P.E. will be helpful in obtaining essential community knowledge and in measuring the Community Health Partnership’s success. • Offering after-school programs and sports is a supervised way to allow children to engage in more physical activity. • The involvement of the Parent Teacher Alliance could bring a strong force to the Community Health Partnership.

I’m a parent Why I Should Be Concerned Parents impact children and obesity, in their own actions and in the encouragement of their children’s actions. As your children make decisions outside of the home, the habits you taught them will influence their choices. Thus the most effective way to prevent and treat childhood obesity is to embrace healthy routines in your family.

How I Can Help Parents and guardians serve as role models. It is important to maintain a healthy lifestyle so that your children will be more likely to follow it when they are on their own. • Eating meals as a family, restricting snacks and sugary drinks in your home, limiting television and computer time, practicing portion control in meals and snacks, making sure your child gets enough sleep, and supporting regular physical activity are all ways you can influence and help your family to live healthier lives. • In the early years, breastfeeding and later introduction to solid foods have also proven effective in reducing future obesity.13 • Parent participation is lacking from the collaborative meetings - a significant deficiency in the Community Health Partnership. Becoming active in organizations such as Healthy Savannah or PTA or other organizations will help your voice to be heard.

Contents Foreword i Executive Summary iii Call to Action v Demographic Overview   p. 3 Health Overview   p. 5 Socio-Behavioral Risk Factors p. 9 The Impact of Obesity p. 13 The Community Health Partnership: Who Are We? p. 17 Additional Acknowledgements p. 18 Terminology p. 19 List of Tables and Figures p. 21 References p. 23

There is a lack of concrete data for Chatham County, including data on childhood obesity. Yet even what limited information is available reveals a serious and growing problem in our county.

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Demographic Overview

POPULATION

According to census data, in 2010, the population of Chatham County, Georgia was 265,128 - a 14.3% increase from 2001.

AGE

Home to one of the busiest seaports in the world, vibrant metropolitan districts, and several prominent industries, Chatham County is a culturally diverse and thriving area with much to offer its residents. Outside of the Atlanta municipality, Chatham is the biggest of Georgia’s counties and one of the fastest growing. Yet high unemployment and low median incomes threaten to stunt its success by increasing the county’s risk for dangerous trends - including childhood obesity.

Though the median age in Chatham County is 34, children (those persons under the age of 18) make up 22.6% of the population, with 7.5% under 5 years of age.

2001

Population increase

Under 5 years of age

The average household size consists of 2.45 members, and the average family has 3.03 members.

0

60000 60000 60000 50000 50000 50000

40000 40000 40000 30000 30000 30000 20000 20000 20000 10000 10000 10000 0 0

State of aGeorgia

The median household income in Chatham County 50000 is $44,464 and the median family income is $54,617. These are lower than the state of Georgia’s averages, 40000 where the median household income is $49,466 and the median family income is $58,842. Strictly within 30000 the city of Savannah, the median household income is $33,778 and the median family income is $42,452. 20000 Families below the poverty line make up 10% of the 10000 population in Chatham County.

Average family size

Chatham County

60000

Savannah

Household

Under 18 years of age

Income

2010

0

fig. 1 - Median Household Income in 2010 3

Race/Ethnic Origin Education Unemployment Rate healthcare 4

Asian

Hispanic or Latino

The Chatham County populations are 55.2% Caucasian, 40.4% African American, 3.0% Hispanic or Latino, and 2.1% Asian. 4.6% of the population is foreign born and 6.2% speak a language other than English at home. African American

87.1% of those 25 and older in Chatham County are high school graduates, while 29% have a bachelor’s degree or higher.

Caucasian

Those under 25 years of age that are high school graduates

Those under 25 years of age with a Bachelor’s degree or higher

Unemployed

9.2% of the Chatham County population was unemployed in April 2012, slightly higher the national average.15

Employed

fig. 2 - Chatham County Unemployment Rate, April 2012

77.6% of Chatham County residents under the age of 65 had healthcare insurance in 2010 and 89.6% of those age 18 and under had healthcare.16 Chatham County residents under 65 years of age with health insurance

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Chatham County residents under 18 years of age with health insurance

Health Overview Obesity has been rapidly rising in the United States, with rates more than doubling since 1980 - from 15% to 30%.17 About one-third of U.S. adults are obese and two-thirds of U.S. adults are overweight.18 No state has a rate of obesity less than 20% and Georgia’s is at nearly 30%, with an obesity prevalence of 29.6%. In part because of its high obesity rate, Georgia ranked 37th out of the fifty states overall in the 2011 America’s Health Rankings . It ranked number 38 for Obesity.21 In addition, Georgia came in 40th for Outcomes, a category that measures such factors as the prevalence of diabetes, health disparity, cardiovascular rate, missed days due to illness, and the premature death rate.22

Where Georgia Weighs In

40 Outcomes Rank 38 Determinants Rank 37 Overall Rank 34 Diabetes Rank 27 Smoking Rank 38 Obesity Rank

The obesity epidemic is one of the most serious health problems facing the United States, Georgia, and Chatham County today. Worst of all, it threatens our youth and, therefore, the future of both our county and country.

Table 1 - America’s Health Rankings

In Chatham County specifically, about 29% of adults are obese.23

Per request, three prominent employers in the Chatham County area released weight and diabetes statistics of their companies to the Community Health Partnership. Regarding those employees who took a BMI health assessment, the numbers are as follows: Employees

Overweight

Obese

Company 1

1100

80%

not calculated

Company 2

1673

29.17%

43.75%

Company 3

895

33.18%

45.59%

5

But perhaps the most sobering statistics are those pertaining to youth. According to the National Health and Nutrition Examination Survey (NHANES), approximately 17% (or 12.5 million) of children and adolescents aged 2-19 years are obese nationwide.24 As with adults, there has been a steady increase in youth obesity through the decades, with childhood obesity more than tripling in the past 30 years. 40

Percent

30

20 6-11 years 10

12-19 years 2-5 years

0

Non-Hispanic white Non-Hispanic white

Prevalence (%)

10

Non-Hispanic whi

Mexican American Mexican American

1999–2000 2003–2004 2007–2008 2003–2004 2007–2008 2001–2002 2005–2006 2001–2002 2005–2006

45

Prevalence (%)

45

0

0

Survey year

Ages 6–19 yearsAges 6–19 years

Non-Hispanic white Non-Hispanic white Non-Hispanic black Non-Hispanic black Mexican American Mexican American

10

Ages 6–19 yearsAges 6–19 years

Non-Hispanic whi Non-Hispanic white Non-Hispanic blac Non-Hispanic black Mexican American Mexican American

0

1988–19941999–2000 2003–2004 1999–2000 2003–2004 2007 2007–2008 2001–2002 2005–2006 2001–2002 2005–2006

Survey year

CHILDHOOD 30

Survey year

10

1988–1994

Survey year

Survey year

Fig.40 5. Prevalence40 of Obesity Among Males, by Age Ages 20–39 years Ages 20–39 years Group and Race/Ethnicity

45

revalence (%)

20

0

60Prevalence of Obesity Fig. 4. Among Females, by Age Ages 20–39 years Ages 20–39 years Group and Race/Ethnicity

6

20

1999–2000 2003–2004 2007–2008 2003–2004 2007–2008 2001–2002 2005–2006 2001–2002 2005–2006

Survey year 60

30

30

1988–19941999–2000

1988–1994

Mexican American Mexican American

1988–19941999–2000 2003–2004 1999–2000 2003–2004 2007 2007–2008 2001–2002 2005–2006 2001–2002 2005–2006

1988–1994

Survey year

30 15

0

0

1988–1994 1999–2000

60

30

10

Prevalence (%)

0

60

45

Year Ages 2–5 years Ages

2003- 20072004 2008 200120052–5 years2006 2002

Non-Hispanic white Non-Hispanic black Within these obesity trends there are discrepancies among gender, race and ethnicities. Non-Hispanic black Non-Hispanic blac Non-Hispanic black

Survey year

15

Prevalence (%)

10

1988–1994

30

19932000

20 Children and Adolescents: Fig. 3. Trends in20Obesity Among United States, 1963-2008

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2012 Community Report

30

30 evalence (%)

0

1988-1994

30

30

Prevalence (%)

10

Ages 2–5 years Ages 2–5 years

1971-1974 1976-1980

evalence (%)

20

30

Approximately 17% (or 12.5 million) of children and 20 adolescents aged 2-19 years are obese nationwide.24 Prevalence (%)

30

19631965 19661970

IN Chatham County 20 20

These same trends are mirrored in Georgia, where 15% of children aged 2-4 years, 24% of third graders, 15% of middle school students, and 12% of high school students are obese.25 In fact, Georgia ranks 2nd in the states with the highest rates of obese 10- to-17-year-olds.26 A 2005 study of obesity among Georgia’s 3rd Grade Children also showed black children were more likely to be obese (25%) than white children (21%) and, in addition, girls were more likely to be obese (25%) than boys (22%).27 Chatham County reflects similar statistics. According to the Savannah/Chatham Community Indicators Database, the percentage of high school aged children who are unhealthily overweight was 24.9% in 2010. The rate was higher among females (30.4%) compared to males (19.5%) and among black students (32.4%) compared to white students (12%).28

Males 19.5%

OBESITY RATES

Females 30.4%

Black White Students Students 32.4% 12%

Fig. 6. Percentage of Chatham County High School Students with Unhealthy Weight, by Gender and Race

Georgia ranks 2nd in the states with the highest rates of obese 10- to-17year-olds.26

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Socio-Behavioral Risk Factors Obesity ultimately occurs when a person consumes more calories than he or she burns and the body is forced to store those extra calories as fat . Yet what leads someone to that point can stem from a combination of causes and contributing determinants.

Health Outcomes

Premature Mortality (50% of outcomes) Years of potential life lost - YPLL General Health Status (50% of outcomes) Self reported fair or poor health

Healthcare 10% of determinants

Access to care Quality of care Tobacco Diet and exercise

Health behavior 40% of determinants

Alcohol use High risk sexual behavior

Violence

Health Determinants

Education Socioeconomic factors 40% of determinants

Income Social disruption

Air quality Physical environment

10% of determinants

Water quality Built environment

Programs and Policies

Fig. 7. University of Wisconsin Population Health Institute’s Schematic on Determinants of Health

Early Childhood Hazards

Risks for obesity can appear even before a child is born. Prenatal risks largely revolve around a woman’s weight and health while pregnant. It is estimated that nearly half of women in the U.S. are obese or overweight when carrying, which (along with the related development of gestational diabetes) is found to increase the likelihood of their children becoming obese.30 According to a 2008 study in the American Journal of Clinical Nutrition, “the odds of overweight was 48% greater for children of mothers who gained more than the weight gain recommendations than for children of mothers who met the weight gain guidelines.”31 Babies born either too small or too big - often the result of having an overweight mother - are at a high risk for obesity.32 And after the birth, much of the so-called “baby fat” may not be quite so cute in actuality: excessive weight gain in the first six months is an indicator of further unhealthy weight gain down the road.38 While the current research is not concrete, breastfeeding versus bottle feeding, how early in life a child begins receiving solid food, and how much sleep a baby gets have been linked to early (and later) childhood obesity.34 9

Family and Genetics

Obesity runs in the family. To a certain degree this may be due to genetics, which can sometimes determine how much fat is stored, distributed, and burned off in a person.35 Far more impactful, however, are environmental factors, such as one’s family lifestyle. Family members usually share eating and activity habits and if one or both of a child’s parents are sedentary, unhealthy, or obese, the child’s risk of being so also is increased.36

Inactivity

Family members usually share eating and activity habits, and if one or both of a child’s parents are sedentary, unhealthy, or obese, the child’s risk of being so also is increased .

Exercise and physical activity are vital to burning calories. As reported by the Mayo Clinic, “with a sedentary lifestyle, you can easily take in more calories every day than you burn off through exercise and normal daily activities.”37 Recent studies show Georgia students are not getting enough exercise; the recommended amount of which is at least 60 minutes of physical activity every day.38 Only 44% of Georgia middle schools and 15% of high schools require students to attend daily physical education classes and, though the state does mandate some sort of physical education in grades K-8, daily recess is not a requirement.39 Thus unsurprisingly, in the 2010 Georgia Student Health Survey, only 52% of middle school students and 43% of high school students met the requirements for physical activity.40

Unhealthy Diet and Eating Habits

Perhaps the most obvious of the risks, eating patterns can highly increase one’s inclination toward obesity. Such harmful habits include: • eating fast food or “convenience foods”41 Middle School Students 52%

High School Students 43%

• skipping meals, especially breakfast42 • “portion distortion” or eating too much food43 • not eating enough fruits, vegetables, and whole grains, and receiving an imbalance of other food groups 44 • consuming too many empty calories; i.e. fruit drinks, sodas, specialty “coffee” drinks, cakes, and pastries45 • having a diet too high in calories46

Fig. 8. Percent of Youth Who Meet Requirements for Physical Activity in Georgia, 2010

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What You’re Served

What is Actually One Serving

333 calories 590 calories

Sleep

Sleep is proven to impact obesity rates in youth. Children who receive less than 10 hours of sleep at night have two times the likelihood to go from normal weight to overweight or from overweight to obese than children who receive 10 or more hours47. Not only does sleep affect a child’s energy level, it also impacts hormones and unhealthy eating habits. Shifts may occur in hormones such as leptin and ghrelin, increasing appetite and cravings for high-calorie, salty, sugary, and fatty foods.48

Overuse of Media 2.4 ounces 6.4 ounces

5 cups of popcorn 11 cups of popcorn

fig. 9 - Portion Distortion

Children spend an average of five and a half hours a day watching television, playing video games, and being on the computer.49 This is harmful for numerous reasons, but it has been positively linked to childhood obesity. According to one study, “29% of the cases of obesity could be prevented by reducing television viewing to 0 to 1 hours per week.”50 Reasons for the connection include: • the frequent advertising of unhealthy foods and eating habits51 • time children spend with media deducts from time they could be in physical activity­52 • watching television lowers children’s metabolic rates to a lower rate than when they are sleeping53 • excessive snacking often occurs when distracted by television or other media outlets54

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Social and Economic Issues

But changing one’s family lifestyle, eating better, exercising, and sleeping more is often far easier said than done. Many social and economic factors hinder our progress and make it harder for change. These factors can include: Communities Not Designed for Physical Activity55 • lack of public transportation • unsafe walking areas • lack of affordable indoor physical activity options

Economic Constraints58 • health insurance coverage for obesityprevention services is often unavailable • patients without health insurance rarely receive appropriate preventive services or followup care • “value sizing” of less nutritious foods • higher costs of many foods, such as fresh produce • expense of and taxes on gym memberships, exercise classes, equipment, facility use, and sports league fees • lower-income neighborhoods have fewer and smaller grocery stores and less access to affordable fruits and vegetables • both parents work full time, meaning more meals are eaten outside of the home and children’s eating and activity habits are not well-monitored

Marketing and Advertising56 • widespread advertising and marketing of less nutritious foods • onslaught of “fad” diets Workplaces and Schools Not Conducive to Health57 • long hours of sitting and limited opportunities for physical recreation discourage activity • unhealthy options in cafeterias or work lunch sites

Low income 28.9%

Minority Discrepancies59 • Certain racial and ethnic groups have a greater prevalence for obesity and other overweight symptoms and tendencies. This can stem from some or all the above issues or from family history. Minority young adults may be more likely to accept obesity and its complications because that’s what their parents and relatives did before them.

Not low income 17.1%

24.2%

17.4%

22.4%

Fig. 10. Percentage of Chatham County High School Students with Unhealthy Weight, by Income

Mexican American

Non-hispanic White

African American

Fig. 11. Percentage of Obese Children and Adolescents Ages 6-17, 2007-2008

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The Impact of Obesity Adult Overweight

Overweight adolescents have an increased risk of staying that way their entire lives. Children who are overweight have a 70% chance of becoming overweight or obese in adulthood, increasing to an 80% chance if one or more of their parents is also overweight.61

Psychosocial Consequences

Overweight youth are targets for social discrimination. Already a potentially awkward and difficult time, in middle school and high school obese children are frequently recipients of peer victimization62 . In addition, teachers and doctors alike are shown to stigmatize obese students and patients as idle and unintelligent, emotional and lacking in self-control.63 And, regardless of academic records or personality, obese students are less likely to be accepted into college,64 obtain their dream careers , or get married.66 This results in a dangerous cycle: overweight youth who are targets of discrimination often cope with the problem by eating more and are less likely to engage in physical activity.64 Suicidal thoughts and behaviors are also common among victims of weight teasing.68

Obese adolescents suffer from more than just a weight problem; obesity’s side effects can include serious health issues, mental illness, and financial repercussions. Obese children are 5 1/2 times more likely to have a poor quality of life than their healthy peers, while severely obese children are shown to have a lower quality of life than kids on chemotherapy.60

Health Risks

Obesity can put children at risk for serious illnesses that may affect them both in their youth and later as adults. More harmful than smoking or excessive drinking, being overweight negatively affects nearly every organ system in the body.69 Obesity and overweight are largely to blame for the recent surge in cases of heart disease and hypertension70 (one in 4 Americans now has heart disease and one in 3 has high blood pressure71 ), and have also been linked as contributing factors to over 20 chronic conditions, including arthritis, sleep apnea, asthma, and certain cancers 72

13

More harmful than smoking or excessive drinking, being overweight negatively affects nearly every organ system in the body.69

Obese children are shown to have high triglyceride levels and arteries more comparable to those of 45-year-old than of a youth.73 In fact, obesity and overweight impact many children and adolescents with conditions previously seen only in adults. Obesity is the leading cause of premature heart attack, and children who are overweight between the ages of 7 to 13 are at an increased risk of developing heart disease by age 25.74 And Type 2 diabetes, once referred to as “adult onset” diabetes is now occurring among U.S. children with increasing frequency: approximately 176, 500 youth under the age of 20 in the United States have Type 2 diabetes and at least 2 million aged 12-19 are pre-diabetic.75 Diabetes is at one of the highest rates in Georgia, where approximately 10% of the adult population has the disease (90% to 95% of which have Type 2).76 That number does not include those diagnosed with prediabetes, which currently affects at least 79 million Americans.77 Although there is no concrete data on diabetes specifically within Chatham County, in the employer data previously shown on page 5, 207 employees from Company 2 (or 12%) and 401 employees from Company 3 (15%) had diabetes. Company 1 did not provide diabetes information, but 34% of their screened employees had elevated blood sugar levels.80

Decreased Life Expectancies

Namely because of the health consequences, obese and overweight individuals often have sharply shortened life spans than those who are healthy and of correct weight. Cardiovascular disease and diabetes make up the first and seventh, respectively, leading causes of death in the United States; the first and eighth in Georgia; and the first and tenth in the Coastal Health District - including Chatham County.78 That is roughly the equivalent of 5 deaths a day in Georgia due to diabetes.79 For every death with diabetes as the primary cause, though, there are two deaths in which diabetes is a contributing cause.80 Ann Albright, director of the CDC’s Division of Diabetes Translation, states, “The longer you live with [diabetes], the more likely you are to develop the complications. If you develop diabetes at a young age, the chances are greater of complications at a young age” - and thus the potential for an earlier death.81 Diabetes will shorten the lives of men diagnosed at age 20 by an average of 17 years and women diagnosed at age 20 by an average of 18 years.82 According to the F as in Fat report published annually by the Robert Wood Johnson Foundation and Trust for America’s Health, “this generation of children could be the first to have shorter and unhealthier lives than their parents.”83

Financial Costs

The total economic cost of overweight and obesity is about $270 billion per year in the United States,84 and up to $73.1 billion per year for employers . That includes the cost of medical care, loss of worker productivity due to higher rates of death, loss of productivity due to disability of active workers, and loss of productivity due to total disability.85 A 2009 study by CDC found obese patients spent 42% more for their medical care in a year than people who are within a normal weight.86 Regarding children alone, the costs of hospitalizations related to childhood obesity increased from $125.9 million in 2001 to $237.6 million in 2005.87 On a more personal level, here are just some of the ways obesity can literally cost parents and their children:

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• Lower Wages and Less Hours: Because of weight bias and increased insurance premiums, employers have been shown to pay obese men and women an average of $3.41 per hour less than their peers.88 Over the course of a year, that means $7,093 in lost income.89 In addition, obese workers tend to lose about a week of work a year due to ailments related to their weight . • High Medical Costs: Overweight individuals can incur up to $495 more in medical bills than their leaner peers over the course of a year.91 • Travel Expenses: The heavier a person (or family) is, the more gas they burn in their cars. Nationwide, this has led to approximately $3.55 billion in increased annual gas expenditures. Air travel also costs more for obese individuals. Some airlines require overweight passengers to purchase more than one seat to accommodate their size. Transit has even been affected here in Chatham County, where the Savannah Belles Ferry riverboats recently had to decrease their passenger capacity from 100 to 86 passengers, due to the increased weight averages of customers.94

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The Community Health Partnership: Who Are We? The Community Health Partnership Advisory Committee

Paula Kreissler, Wound Care Center Kathryn Rebecca Martin, PhD, Vice Dean, Georgia Health Sciences University Nicole Oretsky, PhD, Savannah State University Paula Dessauer Reynolds, MD, MPH, Chatham County Safety Net Planning Council Gary Rost, Savannah Business Group James A. Streater, Jr., Ed.D. CHES, Armstrong Atlantic State University Diane Zabak Weems, MD, Coastal Health District The Community Health Partnership Stakeholders

Faye Markwalter, JC Bamford Sharon Herrera, Lummus Corporation David Deason, Colonial Oil David Perpinan, Critz Randy Kops, Fuji Vegetable Oil Mary Simmons, City of Savannah Missy Jarrott, Chatham Steel

S AV A N N A H BUSINESS GROUP

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Additional Acknowledgements In addition to our partners, SBG would like to thank the following individuals for their support and assistance with this report:

Jessica Adkins - Memorial University Medical Center Toni Conner - St Joseph’s/Candler Peter Doliber - West Broad Street YMCA Cristina Gibson - Coastal Health Department Peggy Johnson - Savannah Chatham County Public School System Altheria Maynard - Savannah Chatham County Public School System Drew McKenzie - St Joseph’s/Candler Christopher Newman - Armstrong Atlantic State University Joel Smoker - Coastal YMCA Melanie Willoughby - St Joseph’s/Candler

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Terminology Body Mass Index (BMI) - A number calculated from a person’s weight and height (and also gender and age for children) in order to provide a reliable indicator of body fatness.95

Empty Calories - Calories from solid fats and/or added sugars, which add calories to the food but few or no nutrients.96 Foods that contain a lot of empty calories include: cakes, cookies, pastries, sodas, sport drinks, fruit drinks, pizza, ice cream, sausages, hot dogs, bacon, and ribs.97 Fitness Gram - The Georgia Department of Education selected FITNESSGRAM(R), a comprehensive health-related physical fitness and activity assessment and computerized reporting system developed by The Cooper Institute. This system includes a complete battery of health-related fitness items that are scored using age and gender specific standards based on how fit children need to be for good health. The assessment includes body composition, abdominal strength, flexibility, and endurance. http://www.fitnessgram.net/Georgia/

Food Desert or Food Balance - Food deserts are areas that lack access to affordable fruits, vegetables, whole grains, and other foods that make up the full-range of a healthy diet.98 A 2009 study for Healthy Savannah undertaken by the Mari Gallagher Research and Consulting Group revealed there is a distinct lack of “food balance” in much of the Chatham County area. This implies that, while there might be food sources in the area (often in the form of basic convenience stores or fast food restaurants), there is a distinct lack of accessible healthy foods or ways to promote a balanced diet.99 In other words, it may be far easier to find ketchup than fresh tomatoes. Obese and Overweight - Overweight and obesity ultimately occur when a child consumes

more calories than he or she burns and the body is forced to store those extra calories as fat, resulting in a weight that is above normal for his or her particular age, gender, and height.100 Children are categorized as overweight when they are between the 85th and the 95th percentile for weight and are obese when their weight is equal to or greater than the 95th percentile.101

Prediabetes - Before people develop type 2 diabetes, they almost always have “prediabetes”—

blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes.102 There are 79 million people in the United States who have prediabetes.103 Recent research has shown that some long-term damage to the body, especially the heart and circulatory system, may already be occurring during prediabetes.104

SHAPE - The Georgia Student Health and Physical Education (SHAPE) Act was passed in the 2009

Georgia legislative session and is now Official Code of Georgia 20-2-777. Beginning in the 2011-2012 school year, the law requires each local school district to conduct an annual fitness assessment program for all students in grades 1 - 12 enrolled in Georgia public school physical education classes taught by certified physical education teachers. http://georgiashape.org/faq/

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Type 1 Diabetes - Type 1 diabetes is an autoimmune disease that may be caused by genetic, environmental, or other factors.105 It accounts for about 5% of diabetes cases.106 There is no known way to prevent it, and effective treatment requires the use of insulin.107 Type 1 diabetes is usually diagnosed in children and young adults.108 Type 2 Diabetes - Type 2 diabetes accounts for 90%–95% of diabetes cases and is usually

associated with older age, obesity and physical inactivity, family history of type 2 diabetes, or a personal history of gestational diabetes.109 Diabetes rates vary by race and ethnicity, with American Indian, Alaska Native, African American, Hispanic/Latino, and Asian/Pacific Islander adults about twice as likely as white adults to have type 2 diabetes.110 Type 2 diabetes can be prevented through healthy food choices, physical activity, and weight loss, and can be controlled with these same activities, but insulin or oral medication also may be necessary.111

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List of Tables and Figures Figure 1. Median Household Income in 2010 (April 2012) page 3

Figure 2. Chatham County Unemployment Rate, April 2012

page 4

Table 1. America’s Health Rankings

page 5

Figure 3. Trends in Obesity Among Children and Adolescents: United States, 1963-2008 page 6

Figure 4. Prevalence of Obesity Among Females, by Age Group and Race/Ethnicity

page 6

Figure 5. Prevalence of Obesity Among Males, by Age Group and Race/Ethnicity page 6

Figure 6. Percentage of Chatham County High School Students with Unhealthy Weight, by Gender and Race page 7

Figure 7. University of Wisconsin Population Health Institute’s Schematic on Determinants of Health page 9

Figure 8. Percent of Youth Who Meet Requirements for Physical Activity in Georgia, 2010

page 10

Figure 9. - Portion Distortion

page 11

Figure 10. - Percentage of Chatham County High School Students with Unhealthy Weight, by Income page 12

Figure 11. Percentage of Obese Children and Adolescents Ages 6-17, 2007-2008

page 12

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References 1“U.S. Obesity Trends - Trends by State.” CDC.gov. Centers for Disease Control and Prevention, 21 July 2011. Web. 2012. & Christopher Ruhm, 2007. “Current and Future Prevalence of Obesity and Severe Obesity in the United States,” Forum for Health Economics & Policy, Berkeley Electronic Press, vol. 10(2), pages 1086-1086. 2 F as in Fat: How Obesity Policies Are Failing in America 2011. Rep. Robert Wood Johnson Foundation and Trust for America’s Health, August 2008. Web. 2012. 3 “Childhood Obesity Facts.” CDC.gov. Centers for Disease Control and Prevention and RTI International, 15 Sept. 2011. Web. 2012. 4 Savannah::Chatham Community Indicators Database. Health and Wellness Community Indicator 3: High School Students with Unhealthy Weight. Armstrong Atlantic State University Public Service Center, 2010. Web. 5 Carmona, Richard H. “The Obesity Crisis in America.” Office of the Surgeon General (OSG). U.S. Department of Health and Human Services, 8 Jan. 2007. Web. 2012. 6 Savannah::Chatham Community Indicators Database. Health and Wellness Community Indicator 3: High School Students with Unhealthy Weight. Armstrong Atlantic State University Public Service Center, 2010. Web. 7 “Number of Employees with Dependents.” Message to Gary Rost. 27 Feb. 2012. E-mail. 8 “LEAN Works! A Workplace Obesity Prevention Program.” CDC.gov. Centers for Disease Control and Prevention, 16 Nov. 2011. Web. 2012. 9 Webber, Andrew. “Businesses As Partners to Improve Community Health.” American Journal of Preventive Medicine 40.1 (2011): 84-85. Print ^10 Ibid. 11 F as in Fat: How Obesity Policies Are Failing in America 2011. Rep. Robert Wood Johnson Foundation and Trust for America’s Health, July 2011. Web. 2012. ^12 Ibid. 13 “Obesity Risks Start Before Birth.” Latimes.com. Los Angeles Times, 08 Mar. 2010. Web. 2012. 14 Note: Unless otherwise cited, all statistical data on this page is taken from “Georgia and Chatham County.” State and County QuickFacts. US Census Bureau, 2010. Web. 2012. 15 “Georgia Unemployment.” Databases, Tables & Calculators by Subject. U.S. Census Bureau, 2011. Web. 2012. 16 Savannah::Chatham Community Indicators Database. Rep. Armstrong Atlantic State University Public Service Center, 2010. Web. 2012. 17 National Health and Nutrition Examination Survey. Rep. Centers for Disease Control and Prevention, 1976-1980, 2007-2008. Web. 2012. ^18 National Health and Nutrition Examination Survey. Rep. Centers for Disease Control and Prevention, 2009-2010. Web. 2012. 19 “U.S. Obesity Trends.” Overweight and Obesity. Centers for Disease Control and Prevention, 21 July 2011. Web. 2012. 20 “The Rankings: Georgia.” America’s Health Rankings. United Health Foundation, 2011. Web. 2012. ^21 Ibid. ^22 Ibid. 23 “2011: Chatham, Georgia.” County Health Rankings. Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute, 2011. Web. 2012. 24 National Health and Nutrition Examination Survey. Rep. Centers for Disease Control and Prevention, 2011. Web. 2012. 25 “2010 Georgia Data Summary: Obesity in Children and Youth.” Georgia Department of Public Health, 2010. Web. 2012. 26 F as in Fat: How Obesity Policies Are Failing in America 2011. Rep. Robert Wood Johnson Foundation and Trust for America’s Health, July 2011. Web. 2012. 27 Obesity in Georgia’s Children, 2005. Rep. Georgia Department of Human Resources and Georgia Department of Public Health, 2010. Web. 2012.

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28 Savannah::Chatham Community Indicators Database. Rep. Armstrong Atlantic State University Public Service Center, 2010. Web. 2012. 29 “Risk Factors.” Obesity. Mayo Clinic, 6 May 2011. Web. 2012. 30 “Obesity Risks Start Before Birth.” Latimes.com. Los Angeles Times, 08 Mar. 2010. Web. 2012. 31 Wrotniak, Brian H., Justine Shults, Samantha Butts, and Nicholas Stettler. Gestational Weight Gain and Risk of Overweight in the Offspring at Age 7 Year in a Multicenter, Multiethnic Cohort Study. Rep. no. 6. Vol. 87. 2008. The American Journal of Clinical Nutrition. American Society for Nutrition. Web. 2012. 32 “Obesity Risks Start Before Birth.” Latimes.com. Los Angeles Times, 08 Mar. 2010. Web. 2012. ^33 Ibid. ^34 Ibid. 35 “Risk Factors.” Obesity. Mayo Clinic, 6 May 2011. Web. 2012. 36 “Risk Factors.” Obesity. Mayo Clinic, 6 May 2011. Web. 2012. ^37 Ibid. 38 “Get Active.” LetsMove.gov. Let’s Move!, 2010. Web. 2012. 39 “2007 Georgia Data Summary: Obesity in Children and Youth.” Georgia Department of Public Health, 2007. Web. 2012. 40 “2010 Georgia Data Summary: Obesity in Children and Youth.” Georgia Department of Public Health, 2010. Web. 2012. 41 “Risk Factors.” Obesity. Mayo Clinic, 6 May 2011. Web. 2012. ^42 Ibid. ^43 Ibid. 44 F as in Fat: How Obesity Policies Are Failing in America 2011. Rep. Robert Wood Johnson Foundation and Trust for America’s Health, July 2011. Web. 2012. 45 “What Are Empty Calories?” ChooseMyPlate.gov. Choose My Plate. Web. 2012. 46 “Risk Factors.” Obesity. Mayo Clinic, 6 May 2011. Web. 2012. 47 Zimmerman, Frederick J., and Janice F. Bell. Shortened Nighttime Sleep Duration in Early Life and Subsequent Childhood Obesity. Rep. Archives of Pediatric and Adolescent Medicine, 2010. Web. 2012. 48 Neighmond, Patti. “In Young Kids, Lack of Sleep Linked to Obesity Later.” Morning Edition. NPR. 7 Sept. 2010. NPR.org. National Public Radio. Web. 2012. 49 The Role of Media in Childhood Obesity. Rep. The Henry J. Kaiser Family Foundation, 24 Feb. 2004. Web. 2012. ^50 Ibid. ^51 Ibid. ^52 Ibid. ^53 Ibid. ^54 Ibid. 55 F as in Fat: How Obesity Policies Are Failing in America 2011. Rep. Robert Wood Johnson Foundation and Trust for America’s Health, July 2011. Web. 2012. ^56 Ibid. ^57 Ibid. ^58 Ibid. 59 Marcus, Mary Brophy. “More Young Adults Are Living With Diabetes.” USAToday.com. USA Today, 23 June 2011. Web. 2012. 60 F as in Fat: How Obesity Policies Are Failing in America 2011. Rep. Robert Wood Johnson Foundation and Trust for America’s Health, August 2011. Web. 2012.

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61 “The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity.” SurgeonGeneral.gov. US Department of Health and Human Services, 11 Jan. 2007. Web. 2012. 62 F as in Fat: How Obesity Policies Are Failing in America 2011. Rep. Robert Wood Johnson Foundation and Trust for America’s Health, August 2011. Web. 2012. ^63 Ibid. ^64 Ibid. ^65 Ibid. 66 “The Price of Obesity.” Latimes.com. Los Angeles Times, 01 Aug. 2005. Web. 2012. 67 F as in Fat: How Obesity Policies Are Failing in America 2011. Rep. Robert Wood Johnson Foundation and Trust for America’s Health, August 2008. Web. 2012. ^68 Ibid. 69 Understanding Childhood Obesity - Statistical Sourcebook. Rep. American Heart Association, 2011. Web. 2012. ^70 Ibid. 71 F as in Fat: How Obesity Policies Are Failing in America 2011. Rep. Robert Wood Johnson Foundation and Trust for America’s Health, August 2008. Web. 2012. ^72 Ibid. 73 Understanding Childhood Obesity - Statistical Sourcebook. Rep. American Heart Association, 2011. Web. 2012. ^74 Ibid. 75 F as in Fat: How Obesity Policies Are Failing in America 2011. Rep. Robert Wood Johnson Foundation and Trust for America’s Health, August 2008. Web. 2012. 76 “2008 Georgia Program and Data Summary: Diabetes.” Georgia Department of Public Health, 2008. Web. 2012. 77 “Prediabetes.” Diabetes.org. American Diabetes Association, 2012. Web. 2012. 78 Coastal Health District Community Health Assessment 2010. Rep. Coastal Health District, 2009. Web. 2012. 79 “2005 Georgia Data Summary: Diabetes.” Georgia Department of Public Health, 2005. Web. 2012. ^80 Ibid. 81 Marcus, Mary Brophy. “More Young Adults Are Living With Diabetes.” USAToday.com. USA Today, 23 June 2011. Web. 2012. ^82 Ibid. 83 F as in Fat: How Obesity Policies Are Failing in America 2011. Rep. Robert Wood Johnson Foundation and Trust for America’s Health, August 2008. Web. 2012. 84 Behan, Donald F., and Samuel H. Cox, eds. Obesity and Its Relation to Mortality and Morbidity Costs. Rep. Committee on Life Insurance Research and Society of Actuaries, Dec. 2010. Web. 2012. 85 Hutchison, Courtney. “Obesity in the Workplace Costs the U.S. Billions.” Abc.go.com. ABC News Network, 08 Oct. 2010. Web. 2012. 86 Finkelstein, Eric A., Justin G. Trogdon, Joel W. Cohen, and William Dietz. Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Rep. no. 5. Vol. 28. 2009. HealthAffairs.org. Centers for Disease Control and Prevention and RTI International, Sept.-Oct. 2009. Web. 2012. 87 Holden, Diana. “Fact Check: The Cost of Obesity.” CNN.com. Cable News Network, 9 Feb. 2010. Web. 2012. 88 Peng, Tina. “Five Financial Costs of American Obesity.” The Daily Beast. Newsweek, 14 Aug. 2008. Web. 2012. ^89 Ibid. ^90 Ibid. ^91 Ibid. ^92 Ibid. ^93 Ibid.

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94 Curl, Eric. “America’s Weight Gain Impacts River Street Ferries.” Savannah Morning News 17 Dec. 2011: 1a+. Print. 95 “Healthy Weight: Assessing Your Weight: Body Mass Index (BMI).” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Web. 2012. 96 “What Are Empty Calories?” ChooseMyPlate.gov. Web. 2012. ^97 Ibid. 98 “Food Deserts.” CDC.gov. Centers for Disease Control and Prevention and RTI International, 5 July 2010. Web. 2012. 99 New Day in the Garden: A Food Desert and Food Balance Analysis in Savannah, Georgia. Rep. MariGallagher.com. Healthy Savannah and the Mari Gallagher Research and Consulting Group, Oct. 2009. Web. 2012. 100 “When Being Overweight Is a Health Problem.” KidsHealth. The Nemours Foundation’s Center for Children’s Health Media. Web. 2012. . 101 “Healthy Weight: Assessing Your Weight: BMI.” Centers for Disease Control and Prevention. Web. 2012. 102 “Prediabetes.” American Diabetes Association. Web. 2012. ^103 Ibid. ^104 Ibid. 105 “Diabetes - At A Glance.” Chronic Disease Prevention and Health Promotion. Centers for Disease Control and Prevention, 2011. Web. 2012. ^106 Ibid. ^107 Ibid. ^108 Ibid. ^109 Ibid. ^110 Ibid. ^111 Ibid.

* Additional credit goes to the following organizations for providing inspiration for this document: • • • • • •

Indian Health Service’s Healthy Weight for Life Licking County Community Health Improvement Plan The Surgeon General’s Vision for a Healthy and Fit Nation Center for Community Health Leadership Pasadena Public Health Department and MAP Campaign’s Community Health Action Plan The Southern Area of the Links, Incorporated Commission on Childhood Obesity Prevention

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