From: Kuntze, Patricia M
Sent: Monday, August 04, 2003 10:55 AM
To: Butler, Jennie C
Cc: Ortega, Gloria M
Subject: FW: follow up to Nutrition Roundtable

Importance: High



The following was sent to Dr. McClellan for the docket --- 2003N-0338 – for the Secretary’s Roundtable on Obesity/Nutrition.  If I receive any others for this docket, I’ll forward them to you for submission.  If you’d like me to do anything additional, just let me know.




-----Original Message-----
From: Walter Willett []
Sent: Friday, August 01, 2003 11:07 PM
Subject: follow up to Nutrition Roundtable


Dear Ms Kuntze,

Thank you for arranging the meeting with Secretary Thompson, Commissioner McClellan and others this week.  At their invitation, I am sending this followup note with further thoughts.  If this is the best way to convey feedback, could you please pass this on to them; if not please let me know how I should submit it.


Walter Willett


Mark B. McClellan, M.D., Ph.D.
Commissioner of the Food and Drug Administration

Dear Mark,

Thank you for inviting me to Secretary Thompson's Roundtable on Obesity/Nutrition earlier this week.  I'm taking up your invitation to provide further written comment on this major epidemic and how we might address it.  First, though, I do want to express my appreciation for the fact that you and Secretary Thompson are taking up this challenge and are looking broadly for the best solutions.  I would like to offer several comments, expanding on some points that were raised at the meeting.  As you are well aware, the causes of this epidemic are complex and multiple and a solution will also need to be many faceted.  In the strategic plan that we have developed for New England, in part supported by HHS, we developed subcommittees that addressed weight control from the standpoint of the following perspectives:

--health care providers


        --work sites
        --the media
        --the physical environment
        --the social environment

        What emerges is the picture that actions can and need to be taken at all levels from the federal government, down to the state, town, neighborhood, and family if we are to reverse the epidemic.  Great synergy is possible if these efforts are integrated.  Given your position, I will focus my comments on approaches that require actions at the national level, keeping in mind that other efforts at other levels will be equally important. 

1.      Food labeling.  You have already made important progress in this respect, especially with adding trans fat to the food label.  The next "frontier" is restaurant food, especially fast food, that is about half of what is eaten, but which has no label.  What to do about this deserves careful discussion and thought.  My initial thought, given that the overriding problem is obesity, is that the caloric content should be provided in a large and conspicuous manner on all foods that have a wrapper or container.  Some have suggested adding the total fat content, but this would be a mistake as this reinforces the incorrect notion that only fat calories count.  If there is to be more, it might be good to add saturated fat, trans fat, and sugars. 

2.      Aggressive advertising of junk food to children.  Unfortunately, the best of food labels will have little impact on childhood obesity.  Children are barraged by highly researched advertising that exploits their every weakness to promote consumption of  large amounts of beverages and junk foods (including breakfast cereals) primarily consisting of sugar, refined starches, and trans fats.   Children clearly need protection from this assault, and I see three solutions:  strict federal regulations about the kinds of foods that can be advertised to children, a rigorous voluntary industry-enforced standard, or law suits.  I strongly favor the first and believe that many parts of the food industry would agree to this.  The present system very much encourages a race to the bottom of nutritional value because the well-intended company will be seriously disadvantaged by promoting a healthy product that might cost slightly more to produce and be slightly less appealing to children conditioned to high levels of sweetness and salt.  However, if all companies had to compete on a level but high playing field, no company would be disadvantaged and children would benefit enormously.  I don't think it would be too hard for the Roundtable members to come to a consensus about the nutritional standard, which could be fairly simple.  For example, not more then 10% of calories from sugars (or no more than 5 calories/100 ml of beverage from added sugars), at least 50% of cereals as whole grains, no trans fat, salt not more than the daily value as a proportion of total caloric value.  Just these simple rules would have an enormous impact on what could be promoted to children.  A national survey recently conducted by the Harvard School of Public Health indicated a large majority of Americans support restrictions on advertising junk food and beverages to children.

3.      Development of materials for a national media campaign.  This would need to include messages in at least three areas:  the health consequences of overweight, eating strategies and activity patterns for healthy weight control, and motivational messages (e.g, if you love them, don't stuff them,  your family needs a healthy you, your kids need a good example...).  Our New England consortium has started work on the content of possible messages, but a real investment (but modest on a national scale) is needed to translate this to an effective social marketing campaign.  Clearly, the flavor of the messages will need to be segmented for various ethnic and SES groups.  I understand an effort has begun that will involve the ACS, AHA, and ADA as well as HHS.  I would encourage this to be as inclusive as possible so a unified portfolio of messages can be developed and used by groups at all levels.  This effort will require ongoing evaluation and refinement to be as effective as possible.  The expertise exists to do this, but has so far mainly been used by junk food and beverage purveyors. 

4.      Consider using federally supported health care programs to support weight control efforts.  At the moment, data indicate that counseling about weight control by physicians is like smoking was 30 years ago.  In a majority of encounters with obese or overweight patients, weight is not even discussed and often not measured.  This needs to become a routine like we do for blood pressure, smoking, and cholesterolit is much more important than any of these and more easily measured.  Our strategic plan has a very nice section on this topic, developed under the leadership of David Katz.  Through the development of education and standards of care regarding weight control for Medicare and Medicaid patients, HHS could contribute importantly in this area.

5.      Work with USDA to develop better guidance for healthy eating and improved federal food assistance programs.  The USDA food guide pyramid, the major federal tool for nutritional education, is fundamentally flawed as it promotes consumption of huge amounts of refined starch and is phobic about all fats.  This needs to be fixed urgently.  I was particularly saddened last week in a visit to the USDA commodity warehouse in an Indian community, the Osage Nation, in Oklahoma.  Most of the food was exactly that to promote diabetes:  refined starch, sugars, and trans fat.   This is an egregious practice in a community in which the majority of adults are diabetics (and which, incidentally, is coming to understand the terrible implications of these foods).

6.      Work with the Department of Transportation to promote policies that foster physical activity.  Those of us working to control obesity were stunned last week to hear that the transportation committee of the House of Representatives had totally killed funding for the Enhancement program that supports the Rails to Trails initiative, which has been enormously successful.  This has been the main federal program to support infrastructure to promote walking and biking for transportation and recreation.  Leadership is needed to convey the message to Congress that these investments are an essential part of a strategy for promoting physical activity and weight control.  As another terrible example, about 16 billion dollars (mostly federal) are being spent on the Central Artery improvement in Boston (the "Big Dig"), which will create a major open space on the surface.  Although there will be 8-10 lanes of traffic underground and six on the surface, there will no path for bicycles, even though this has the potential to make downtown Boston accessible by bicycle from nearly all directions.

7.      Although there are many more specific ways in which the federal government can help stem the obesity epidemic, I will end by suggesting that a strategic plan needs to be developed that can harness the creative energy of every employee to contribute to this goal.   Everyone can contribute, even if in little ways, for example by putting signs by elevators to encourage stairway use or by organizing buddy systems for walking during breaks.  I assume the Roundtable discussions are part of an effort to develop this plan.

I hope these thoughts will be helpful, and please let me know if I can be of any assistance in the future.


Walter Willett, M.D., Dr. P.H.
Chair, Dept of Nutrition
Harvard School of Public Health