Kimberly Gray: Welcome, everybody, and thank you for tuning into our virtual forum on Childhood Obesity and the Environment. We are broadcasting live here from the National Institute of Environmental Health Sciences in Research Triangle Park in sunny North Carolina. My name is Dr. Kimberly Gray. I help oversee the NIEHS Children’s Environmental Health portfolio and I’ll be the moderator for today’s events. We’re glad you could join us for this really important discussion about childhood obesity that, according to the CDC, affects over 17% of our children and adolescents aged 2 to 19 years of age. Today, though, we’ll be focusing more on the role of the environment on obesity. This virtual forum complements our ongoing series of community forums we’ve been having for over several years. At recent meetings we’ve talked about traffic pollution in Los Angeles, asthma in Boston, as well as Gulf oil spill in New Orleans. With this virtual forum we’ll extend the conversation to a national, and potentially even international, audience on a topic that has such global significance. Before I introduce the panel, I want to remind you that you have an opportunity to ask questions to the panel at any time. You can do this in three ways. One, go to the question box on our webcast page, or via email to [email protected], as well as on Twitter by using the hash tag #obesityforum. We’ll try to answer all of your questions, but because of the high turnout today it is possible that we might not get to everyone, and we apologize for that in advance. So let’s begin by having each of the panelists join me today to introduce themselves beginning to my far left, Christine Thayer. Christine Thayer: I’m Chris Thayer. I’m at the National Toxicology Program and I’m here because in 2011 we organized a workshop to try to assess the evidence linking environmental exposures to obesity. Andrew Rundle: My name is Andrew Rundle. I’m with Columbia University, and specifically the Columbia Center for Children’s Environmental Health. And I’ve spent the past ten years studying obesity, the last five years on childhood obesity. Karen Peterson: I’m Karen Peterson. I’m at the University of Michigan School of Public Health, and I focus on understanding what causes childhood obesity and what are the ways we might prevent and treat it. Larry Kushi: My name’s Larry Kushi and I’m at Kaiser Permanente Northern California in Oakland. And my research is focused currently on looking at predictors of obesity in puberty in girls as they go through their sexual transition. Gregory Diette: I’m Gregory Diette. I’m from Johns Hopkins University in Baltimore and the Center for Childhood Asthma in the Urban Environment. And my focus is on environmental causes of asthma and now more recently dietary patterns that make us more susceptible to environmental factors. Linda Birnbaum: And I’m Linda Birnbaum. I’m the Director of the National Institute of Environmental Health Sciences and the National Toxicology Program. Our mission is to discover how the environment affects people in order to promote healthier lives. So before we get to your questions, I’d like to provide a quick overview of today’s topics. We have an obesity epidemic. Prevalence is increasing in children, adolescents, and in adults worldwide. Today you can easily find news and articles about childhood obesity in every corner of the world and in every corner of our country. In 2011 no state had an obesity rate of less than 20%. We’re defining obesity as a BMI of 30 or higher. Eleven of our states and the District of Columbia had obesity rates between 20% and 30%, and 12 states had rates equal to or greater than 30%. Risk factors include diet, physical activity, underlying genetics, and your body’s metabolism. But these factors alone do not explain the rise in obesity. So we’re seeing another factor, a worrisome one. Our environment may also be playing a role here. And the research is showing this to be true. For example, chemical exposures such as persistent organic pollutants, air pollution, arsenic, have all been linked to obesity and to diabetes. Obesity research isn’t new at NIEHS. We’ve been doing it for years. But it’s a growing problem and I look forward to today’s discussion. Kimberly Gray: Thank you, Linda. We’re going to start immediately right with the questions that have been coming in for a couple days now. And the first question is really — “How do we define children’s obesity, obese versus overweight, and is it a certain BMI?” And I’m going to turn that over to Karen. Maybe you can tell us more about those definitions used by CDC. Karen Peterson: So in childhood the definitions that we use to classify children as overweight or as obese are done by comparing the growth of individual children with a population of healthy reference children that are shown on the growth charts that you see in your pediatricians’ offices. So, very simply, a child who is considered overweight is growing near the top of the growth chart, at or above the 85th percentile for healthy children of the same age and the same gender, up until the 95th percentile. And then, children who are considered obese are those who are growing at the very top of the growth chart, at or above the 95th percentile on the growth curves. Kimberly Gray: Thank you, Karen. Some other questions came around the area of, “How are chemicals affecting body weight?” What do we know and what particular chemicals? And I think we’re going to turn that over to Chris Thayer from our National Toxicology Program to talk about a workshop that she developed a year back. Christine Thayer: Yes, that’s really what we tried to address in the workshop. It was trying to sort of look through the evidence and trying to find the strongest candidates. And so what we did was, we combed pretty thoroughly the literature and then we convened a group of experts knowledgeable in obesity to help us interpret it. At that time, which was early in 2011, the strongest cases could be made in humans for maternal smoking during pregnancy and childhood obesity. And that conclusion was supported by animal data. There were also pretty strong for a class of chemicals, organotins, mostly based on animal models. But I think in terms of the biological plausability, it was really when you think about the cellular targets, the targets that regulate the way that fat cells develop and function, are the brain pathways that regulate feeding behavior. When we looked we found that there were a lot of chemicals that probably were worthy of looking further at, because they were affecting some of the cellular targets. But they haven’t been studied. Kimberly Gray: Other question, coming from School of Medicine at UCI, Irvine, California is, “What is some of the research that’s been conducted to date to inform the current issue of this forum of childhood obesity?” And I’m going to turn that over to Andrew. Andrew Rundle: It’s a great question. So this is a story that is really evolving. And I think the story hasn’t been fully written yet. We’ve shown that air pollution, specifically certain types of chemicals in air pollution, are associated with childhood obesity. And what we’ve seen is that prenatal exposure, so exposures when the mom is pregnant, are associated with obesity and higher BMI in children ages five and seven. And so we’ve focused there. We’re also doing work on other chemicals known as the phthalates, which is a chemical used to make plastics. The story, though, is intriguing and unfolding and I think over the next couple years we’re going to see a lot of data supporting — and probably also exonerating some chemicals, but supporting some chemicals are going to be associated with it, with obesity. Kimberly Gray: And then, from Sacramento, California there’s a question about, “Where can someone find more information about the obesity rates, by state, by demographic?” Andrew? I know you know that answer. Andrew Rundle: So the CDC has got great data on this, that you can look at maps and you can look at maps by year, so you can see state by state. And then, many of the states have their own resources. So I’m familiar with New York City and New York State resources. Many Departments of Health have this data online that you can use, so either as tables or also as maps or graphs. So there are federal resources and then often there are state and local resources, and mainly to be found on the Web. It’s pretty easy to find through various search engines. Kimberly Gray: Thank you. Another question from UTMB at Galveston, Texas — “Discuss some of the factors that have the Deep South off the charts for obesity and associated chronic illnesses. And what could be those potentially environmental factors?” Linda? Linda Birnbaum: I think it’s a question that we don’t have all the answers to. But we do know that some of it has to do with diet. But some of it may also have to do with some of the exposures that go on in these populations. But it’s really important to understand that obesity is associated not only with being very, very heavy, but it’s associated with increases in Type 2 diabetes and with a lot of increases in heart disease. Kimberly Gray: Thank you. And then, one for Larry Kushi — “What are other exposures and maternal factors that you think may affect childhood obesity?” Larry Kushi: So, in addition to the environmental chemicals that may play a role — as Andrew mentioned, PAHs — other things happen during the course of pregnancy, obviously, that change in maternal metabolism. For example, the general body size increases in the woman and glucose levels change. For example, we’ve conducted some studies suggesting that maternal glucose levels actually predict obesity rates subsequently in the daughters of these women. So the in utero general exposure to various metabolic changes can play an important role as well. Kimberly Gray: And the next question is, “Do prenatal exposures potentially predestine a child to be obese?” Karen, would you like to answer that question? Karen Peterson: Sure. It’s a really, really interesting question. And I believe all of the researchers on the panel, we could not overstate the importance of adequate prenatal nutrition, mothers’ lifestyle practices, minimizing exposure to toxicants. But the story is not over, so one’s experiences in utero I would say would not predestine us to obesity. There are many other sensitive periods in childhood where we need to consider providing safe environments for children and making sure that they can have healthy lifestyles. And there are many chances to grow up to be a healthy adult, as there are many chances to grow up to be an unhealthy adult. Kimberly Gray: Thank you. Earlier, Dr. Birnbaum talked about this rise in obesity here within the United States. There are some questions that have come in about other illnesses or conditions in childhood that maybe are at the same time rising as obesity. And I was going to direct that question to Greg. Gregory Diette: Oh, sure. So it’s a great point. And Linda mentioned that cardiovascular disease and diabetes are ones of interest. Our group’s very interested in respiratory diseases as well. And we’ve been struck by the fact that the obesity epidemic has risen exactly in parallel with that for asthma. And so asthma’s an inflammatory disease that makes people have respiratory symptoms. But we’ve been interested in whether or not some of the underlying risk factors that drive obesity are also the same risk factors that drive asthma. And to that extent we’re looking at the dietary pattern and the makeup of what people are eating, not just whether they become obese, but whether or not what they’re eating can create different illnesses, including asthma. Kimberly Gray: And then from Chicago, this is from — actually many questions came in on this specific topic of, “What are the relevant contaminants in the home and school environments?” There have been many, many stories, as we all know, in the news reporting that endocrine disrupting chemicals such as BPA play a role. And a lot of our community are asking, “Are these valid stories, and what can be done to reduce these exposures in the home and in the school environment?” Andrew? Andrew Rundle: Sure. My opinion is that sometimes the news media gets a little ahead of the science and takes what we think are hypotheses or questions and plays them as perhaps more factual than we currently know them to be. So there’s been a lot of interest in BPA and there’s a class of chemicals call the phthalates and thinking about how to avoid those chemicals, which I would support as a general idea of trying to avoid chemical exposures. And so there are being products made now that are phthalate-free, BPA-free, that you can have in your home, like water bottles and so on. But I would emphasize that this is a story or a field of research that we don’t know the answers on yet, but it is unfolding. Kimberly Gray: And to continue on that theme, from the University of California questions have come in about, “All the chemicals that are used in the child daycare setting, for example, caregivers are using disinfecting diaper-changing areas sometimes to 90 times a day. Is anyone looking at these chemicals and their effects?” Linda? Linda Birnbaum: So I think for many of the chemicals that are used in consumer products, there is some growing concern about some of them having effects, because exposure can be so overwhelming. So we have many grantees, in fact, people who NIEHS funds to look, to try to understand which of these chemicals may be associated with potentially adverse health effects. We are also developing ways to rapidly test not one or two chemicals at a time, but thousands of chemicals at a time, to identify which ones may be the bad actors. Kimberly Gray: Again, I’m just going to reiterate how you can ask questions. There’s been some confusion. You can do it three ways — through the question box on our webcast page; you can email us, [email protected]; as well as by Twitter, by using the hash tag #obesityforum. Our next question comes from the Bronx, where they really want to talk about, “What are the key elements in really decreasing childhood obesity? Is environment one critical way for us to look at?” Larry? Larry Kushi: Yes, so I do want to underscore the fact that body size is still, despite the interest in the environment, still driven by energy balance and dietary factors and physical activity. Now, that being said, it’s becoming increasingly important, we’re becoming much aware, as Linda said in her introduction, that there are other factors that impact how dietary factors are metabolized, how we actually expend energy when we’re active, how effective that is in losing weight. And it seems like it’s in those roles where environmental factors are probably going to be playing an important role. But I do want to emphasize that, yes, we should be physically active as a population. Yes, we should be choosing more healthful dietary patterns as a population. Kimberly Gray: And some questions came in about the role of obesity. We talked already about other conditions related to obesity, the rising. But — Greg, I’m going to turn this one over to you — “Is it possible that obesity could cause asthma or exacerbate asthma in that interplay between the diet and asthma exacerbation?” Gregory Diette: Yes, it’s a great question. So there’s a fundamental issue about whether or not the risk factors for each of those conditions are the same, or whether one can cause the other. And there’s certainly evidence that the diet may play a role and physical activity may play a role in both development of obesity, and development of asthma. There also are an increasing number of studies that are coming out now showing that in many cases that obesity comes before the diagnosis of asthma. So it raises the possibility that something about obesity itself makes someone prone to asthma. We also know that because asthma’s a breathing disorder that obesity can affect the breathing whether it’s mediated through asthma or not. So just having extra weight can make it harder to take a deep breath. It can make the lungs compressed and work less well. And so there’s some interactions between obesity and asthma that occur for mechanical reasons related to obesity. But there may be underlying risk factors that drive both of them as well. Kimberly Gray: Thank you. The next question comes from our Consortium to Lower Obesity in Chicago Children. And this I’m probably going to direct to Chris. And it’s, “What federal, state, and local opportunities are there to look at environmental exposure and obesity prevention? And how can advocates collaborate on the research or evaluation of the body of research?” Christine Thayer: Well, we try to do our part in trying to sort of leverage some of the federal research and the limited research dollars to look at the issue. But there are a number of sort of more informal collaboration. I think CHE has one. There are a number of more web-based collaboration efforts that might be worth engaging on. Unfortunately I don’t have a list of them in my mind. I’m not sure if you could help me out here? Kimberly Gray: I don’t. I’m drawing a blank. Maybe Larry knows. Larry Kushi: One point I’d like to make as far as that goes is more NIH research initiatives are actually requiring or encouraging the involvement of community organizations in the design, execution, evaluation of research projects. So, for example, one that I’m involved in that the NIEHS sponsors, which is part of their Breast Cancer and the Environment research program, explicitly required us — and we would have done it anyway — but explicitly required us to involve community partners who had an explicit interest in environmental factors in breast cancer causation. And so we worked hand in hand with people who aren’t necessarily trained as researchers, but they are at the table with us in every step of the way in our research projects. And so I think that’s becoming more of something that NIH has taken an interest in doing. Kimberly Gray: I agree completely. Even with the EPA and NIEHS initiative for the Children’s Environmental Health Centers, which some of you are involved in, it’s a required component. So although you may be looking in one direction for a question, the community also raises other issues that those researchers and clinicians can help address. So I think that is a really good forum, to always engaging the community in whichever aspect you can in the research and translation of the science. The next question here comes from the Kentucky Environment Foundation. “What are the appropriate messages to low-income parents, educators and healthcare providers and obesity prevention groups and policymakers on this topic?” Anyone want to take a stab at that? Greg? Gregory Diette: Sure. Well, I mean, one issue, because you mentioned that an issue for low-income groups is in terms of diet. One thing we’ve learned from our community advisory group is that many times people shop for things that are easy to cook, or they’ll go to convenience stores in order to buy foods. And it turns out that many times they’re spending more money on food that’s already prepared than they would if they shopped in stores and bought the whole foods and made their meals themselves. And I think it was an important lesson that I learned, is that there’s a generational issue that our community told us about, which is that our current generation of parents haven’t really learned how to shop and they haven’t really learned how to cook the way that our grandparents did. And so there are some fundamental things that I think people can do that actually save money but also eat healthier at the same time. Kimberly Gray: Karen? Karen Peterson: Yes. I think I would also add that there’s been very important work done by Centers for Disease Control Institute of Medicine, the US Department of Agriculture and other government agencies, as well as through the First Lady’s “Let’s Move” initiative that emphasize not only what Greg’s saying on the importance of healthy diet, but also overall healthy lifestyles. And there are a number of — a short list of very key behaviors that seem to be conducive to preventing obesity. So those include certain dietary changes with a primary emphasis in reducing foods higher in added sugar, reduction in screen time, adequate physical activity. And to those hopefully in a few years we can add some very explicit guidance about important contaminants to avoid as well. Kimberly Gray: Thank you. Larry Kushi: Sort of building on one aspect of the question of really asking about more the broader environment, there’s growing interest in what people refer to as the built environment, and sort of the neighborhood and characteristics of the areas in which people live in. So are there things like sidewalks which allow people to be physically active? Are there parks nearby? Are there good quality of places to get a variety of produce in your neighborhood? Or do we only have access in a nearby fashion to convenience stores that might have mostly just savory snacks? And it looks like from the research that’s been done in this area, that in fact your neighborhood makes a difference in terms of the rate of obesity that exists in those neighborhoods. So it seems like those types of characteristics, access to physical activity opportunities or lack of access to a variety of healthful foods, do make a difference in at least your ability to be able to engage in exactly the types of recommendations that Karen was just outlining. Kimberly Gray: Thanks. The next question is from the YMCA in Seattle. And I’m going to direct this to Dr. Birnbaum. “Do you think that the federal government resources committed to childhood obesity match the severity of the problem?” Linda Birnbaum: We always like to have more resources. We are currently at NIEHS funding about $7 million a year to look at issues of obesity research. That’s just one of the institutes of the NIH. And we’re a small institute. But I think that there are many, many different health conditions. I think that the real issue here is are there underlying causes, are there things that we can do that will prevent obesity? For example, if there are environmental triggers for obesity, if we can learn what they are and prevent them, then we won’t have to have a lot of health treatment. So I would love to see more effort going into this issue. And, in fact, NIEHS has just recently released another basically request for proposal, saying we are very, very interested in studying and understanding more about the role of what we — the role of chemicals in obesity and in Type 2 diabetes, and especially the role of early life exposures. Kimberly Gray: Thank you. The next question from Somerton, Arizona — “Have there been studies about pesticide exposure and how it relates to the obesity rates?” Linda Birnbaum: The answer is that there have been some studies that have been done. I think there are many, many different kinds of pesticides and I think we have to always be careful not to lump all pesticides into the same barrel. But there are some data suggesting that certain pesticides may, in fact, have an impact on obesity. Kimberly Gray: And I guess that follow-up would come from Edmonds, Washington where they want to know, “Is indoor dust a significant source of exposure to chemicals of concern?” Linda Birnbaum: So the answer there is yes. We’ve known for probably 30 or 40 years that lead in dust was a problem. And somehow it’s taken us 30 or 40 years to understand it’s not only lead that’s present in indoor dust. Many different chemicals are present in the dust in our homes and in our offices. And from those places we can get them into our bodies, especially young children, who may spend a lot of time crawling around the floor and putting everything they touch into their mouth. Kimberly Gray: Interesting. So some of these questions are coming in on particular contaminants, so I think I’m just going to follow that line of query. The next question is coming from Michigan. “Is lead still relevant in the US, where exposures have dropped dramatically? And what’s it relationship to childhood obesity?” Karen Peterson: Lead is a very, very interesting chemical and certainly in some senses we might consider the reduction in blood lead level in the US to be a public health victory. However, new research continues to come out that suggests that even at very low levels around the mean of the reference of the US population at present, there can be effects on developmental outcomes like cognition. In addition, we are doing some research, as others are, that suggests lead might have some influence on expression of genes related to physical growth, or possibly be related to the development of metabolic syndrome, a condition which is sometimes related to obesity but not necessarily. So we’re talking about high blood sugar and altered blood lipids. Kimberly Gray: And, Chris, did you see anything in your evaluation? Christine Thayer: I was actually going to go back to the pesticide question, in terms of the pesticides and obesity. And so this is interesting, because this question sort of really merges the issue of pesticides and obesity with pesticides and diabetes. There’s a larger literature linking pesticides with diabetes. Now, to the extent to which those associations, which are most strong for the organochlorine pesticides, the extent to which those associations hold true for gestational diabetes, then that becomes a risk factor for childhood obesity. Kimberly Gray: Interesting. That’s a good important fact. So from Knoxville, “What do we know about the molecular mechanisms?” Linda Birnbaum: Okay. So the answer is, we’re beginning to try to understand. We know that one thing that is associated with obesity is inflammation. And as Greg mentioned a little while ago, inflammation plays a role in many other health conditions, such as diabetes, such as heart disease, such as asthma, and so on. So that can be one part of the mechanism. We’re beginning to study what happens to the fat cell, to the adipocyte. And we’re beginning to understand that certain chemicals can alter the programming of adipocytes so that, for example, they may end up with many more fat cells, or many more — or very much larger fat cells. We can lose the normal controls. So I think we are trying to understand what are the pathways in the generation of fat. And if we understand those pathways, then maybe we can prevent interference with those pathways or we can intervene to prevent adverse effects. Kimberly Gray: Interesting. A question I think I’m going to turn over to Greg Diette from Puerto Rico is, “Considering our food supply has been changing over time and now a little bit more genetically modified, could this be a contributor?” Greg Diette: Well, I honestly don’t know, I mean, in terms of whether genetic modification has any impact on health related to obesity or to asthma or to other conditions. I think the basic question that asks, though, is — has there been a change in the way our food is created and the way it’s delivered and the way we consume it? And I think there’s almost no doubt that those factors are important, not just one specific factor, but the fact that we now eat a very different diet, prepared in a very different way than just one generation ago ate. And so I think it’s much more fundamental than just some single issue like genetic modification. But, really, how is it created, how is it combined, and then how do we eat it now? Larry Kushi: Yes. I think Greg was right on in that the way our food supply and the way we consume foods has really changed fairly dramatically, even if we’re not conscious of it individually. And so trying to find the right sort of trigger points or places where we could potentially make policy changes that could impact obesity rates is complex as a result. But as Karen alluded to earlier, even something as simple as decreasing the portion size of soft drinks that are available could potentially have a positive impact. So those types of measures are not necessarily sort of — those are well worth thinking about and looking at the impacts of. Andrew Rundle: Yes, I’d also like to emphasize the role of portion size is in thinking about how we’ve gone from the 1950s in our portion sizes until today. And we also did a nutritional analysis of recipes in well known published cookbooks through time, showing calories per serving in the recipes that we read and see in cookbooks has increased. So the number of calories that you’d get in a serving from a 1976 recipe versus a recipe today, the recipe today has more calories. So portion size is another part of this food system, this sort of larger issue of the food system, that I think is important. Kimberly Gray: Interesting. Another question from Oakland, California is, “What is the interaction between nutrition and diet in environmental chemicals?” Greg, to you? Gregory Diette: Well, I think Linda was hinting at some of that, which was the issue of inflammation, for example, and that we know that certain dietary patterns are associated with more systemic inflammation. And for the disease that I’m interested in, asthma, we worry about that, because a person who already has inflammation is then more vulnerable to the environmental factors that they inhale. And so somebody that has inflammation that’s already revved up will be potentially more vulnerable to inhaling a pollutant or an allergen. There’s also issues, too, which is we have defense mechanisms in our body. And one of the important defense mechanisms is the antioxidant system. We’ve known for years that people who eat certain fruits and vegetables seem to be healthier. And one idea is that that may fend off some of the insults that come in. So when somebody inhales something that might bother them otherwise, if they’ve had a healthy diet full of antioxidants, that might be a mechanism that can protect them. Karen Peterson: I might add something to that, which is that during certain sensitive periods of development there is new research that would suggest healthy diets, including ones rich in antioxidants, can protect against changes in the expression of gene — we refer to these as epigenetic changes — and, again, block of the harmful effects of toxicants. The other thing to keep in mind is that, also, if a diet is poor it can exacerbate potentially the effect of toxicants and their effect — their influence on the development of obesity again during sensitive periods. Linda Birnbaum: I’d like to add one more thing there, because I think we often forget that the food you eat in fact are chemicals. And chemicals can interact. And we know from our experimental studies, for example, with rats and mice, that a high fat diet can dramatically change the response to an environmental agent. So I think that’s something we have to understand, that what you eat is going to affect how you respond, and I should say, not only to an environmental chemical, but to the drugs that you may take for your health conditions. Kimberly Gray: Interesting. There’s a couple questions about Michelle Obama, our First Lady’s program aimed to stamp out childhood obesity. “Do you think it’s gone far enough? And what do you think about her ‘Move’ campaign?” Karen Peterson: I could comment. Kimberly Gray: Okay. Karen Peterson: I believe that this policy and educational initiative of the First Lady is a very significant and very important public health intervention, really on a national scale, and that it has not only provided very sound advice and widespread education about lifestyles that can prevent or reduce obesity at different points in the life cycle, but perhaps even more importantly has provided a focal point for policy and advocacy across the US. And there is some very recent evidence that obesity trends are starting to level off. And I think the “Let’s Move” campaign, as well as efforts by practitioners, parents, agencies across the US, are contributing to these trends that we hope will continue. Kimberly Gray: Several other questions have really been asking about the issue of looking not just at one single exposure and taking a more global systems approach. Does anyone want to comment on some of the new approaches that we’re using, not only here at the Institute but from our extramural perspective and our scientists out in the community? Andrew Rundle: I could. So the Children’s Center at Columbia University is taking sort of a larger, multilevel perspective in which we’re understanding that children are exposed to chemicals prenatally and then in their early life. But they’re embedded in these contexts of families, social groups, schools, and within neighborhoods. And neighborhoods have characteristics around poverty. They have built-in environment characteristics. So what we’re trying to do is bring all of that together through technology such as geographic information systems, laboratory analyses, thinking about social science applications to understanding behaviors, and trying to bring that altogether in one place, to think about obesity in children and taking it from what we like to think is a multilevel contextual point of view that takes into account all these different levels of influence on a child’s health. Larry Kushi: Yes, I think that’s a great example of really trying to look at the multiple levels by which different factors can potentially influence obesity and health outcomes. I think another sort of parallel challenge is that even within any one of these particular domains there are multiple chemicals or exposures that could interplay with obesity or health effects. And so, sort of the usual way, in a sense the stereotypical way that we conduct research, so to speak, is to look at individual compounds or individual exposures and individual outcomes. And I think, as we’ve pointed out, it seems like there are multiple exposures on multiple levels that have multiple health effects. And so, being able to decipher all that and make sense ultimately to guide policy and public health guidance is definitely a puzzle. But that’s part of what makes our lives exciting. Kimberly Gray: Yes, that’s true. Some other questions are coming in from the Bethesda, Maryland and other locations about “… NIH and our concerted efforts on looking at obesity. Is this research coordinated? What kinds of studies has NIEHS and others planned to do?” Linda, do you want to take a…? Linda Birnbaum: So the National Institutes of Diabetes, Digestion and Kidneys, DDK, NIDDK, last year released a strategy to deal with diabetes, which also obviously — and also a strategy with obesity. So there are some cross-NIH efforts to integrate the work that is going on in those areas. I think that there’s really a lot of work that is going on. At NIEHS we are really interested, as I said before, in looking at issues of what especially early life exposure, the roles that that may play in obesity. But we’re also interested in what goes on throughout our life, because there are many times during our life where we may be more susceptible than other times to exposures or to, for example, social factors. Karen Peterson: And, Kimberly, I would add one important resource, which is Trans-NIH’s NCCOR, so N-C-C-O-R, National Consortium on Child Obesity Research. And you can Google that; it’s a vast array of resources, both for researchers, practitioners, and the lay public. And a number of the links to NCCOR are coordinated through the new Johns Hopkins NIDDK-funded Center on Child Obesity. Kimberly Gray: Thanks. Some more questions are coming in for some non-chemical-related questions. Can we talk or discuss “the role of the built environment and its contribution to obesity, especially in relationship to physical activity?” And I think I’ll turn that over to Andrew. Andrew Rundle: Thank you. So we’ve been doing an awful lot of work in New York City around this idea of the built environment, but there’s also a lot of work going on nationally around this idea. We’ve been doing work on what we call neighborhood walkability, which is do we have the infrastructures in neighborhoods that make it possible for you to go and have a pedestrian lifestyle, where you walk. If you want to buy your groceries, you walk to a grocery store. If you want to take a walk for pleasure, there are safe sidewalks and things like this. And what we see is that providing environments that support walking and cycling and active transportation and the ability to get out and be active can be very important in promoting physical activity and can be important in helping us maintain a health body size. And I believe Larry has been doing some work in this area, too. Larry Kushi: Yes. I would basically just reiterate what you just said. Yes. Kimberly Gray: So kind of on the same line, “Are there social factors, like peer pressure and stress that we ought to also consider in this equation for children’s obesity that haven’t been discussed?” Karen Peterson: Yes, there are. This is a very important area of research. And on the stress side, there is some research being conducted at the University of Michigan and elsewhere that would suggest that living under chronic stress can actually affect our hormonal control of appetite and that some children actually may eat foods that are higher in added fats and/or added sugars to soothe themselves. So this provides some very promising avenues for interventions that might improve behavior in addition to improving healthy diets. And then, at different life stages, particularly in childhood, peer pressure and/or peer support can be helpful in encouraging other unhealthy diets or, even in adulthood, if people are wanting to make a change to a more healthful lifestyle, that peer support can help in this way. And I’m guessing it’s an important piece why neighborhoods are so terribly important in understanding the multilevel influence of this on obesity trends. Kimberly Gray: So questions are coming in about, “What are some of the changes that can happen in school that can implement — that may affect obesity?” And I guess that can be in a positive or a negative aspect. Greg Diette: I think it’s a great question. We’re talking a lot about diet and physical activity. I think that with the physical activity issue, I can just think about my own kids’ school, for example, where they at one point had gym class one day a week. And I think it reflects a national trend, which is that there’s a lot of emphasis for positive reasons on making test scores go up and making kids better learners and to have more knowledge. But I would say if there aren’t standards in place that schools can be rewarded for for physical activity goals or for other health behaviors, I think that schools get distracted from some of those other goals that they can contribute to. So I think that having programs in place that emphasize physical activity and don’t allow it be once a week, but to be a daily activity. Linda Birnbaum: I think there are some other issues, though, that have happened. About 30 years ago ketchup was declared a vegetable, and so that there’s been a real problem with, for example, school lunches and school breakfasts being very high calorie, high sugar foods. Some of that’s starting to change. I think there’s also been an issue because of financial constraints in the economy. I guess about 10 to 15 years ago schools started inviting in, for example, vendors into their school so that they would earn some extra money from that. But what was being sold in those vending machines was often sodas and Twinkies, which obviously aren’t going to be made any more. But I think the issue is many schools now are realizing that this was a problem and are beginning to remove those machines. So I think that that will be helpful, too. We have to have an environment in which our children are, instead of being exposed to unhealthy foods, are exposed to healthy foods. Kimberly Gray: So we have some questions coming in from Twitter. The first question is, “Is obesity leveling off anywhere?” Do we have that as a known fact? Linda Birnbaum: Colorado. I actually say that, and it may sound funny, but in a number of our Western states where people are more physically active, and whether that’s all the environment or the lifestyle, but in those states obesity has not increased dramatically like it has in other parts of our country. Andrew Rundle: There was a report from New York City using the FITNESSGRAM program, which is a program of fitness testing in the schools over a number of years. They’ve seen a leveling off in the public schools through the FITNESSGRAM program in obesity rates. So this is a very encouraging sign. Karen Peterson: And overall there is some evidence, as I mentioned earlier, that obesity rates are starting to level off across the US, particularly during childhood. But, at the same time, rates in certain groups seem to be changing or even increasing. And particularly there’s still a growth in the number of percentage of children that are very, very obese. And that percentage seems to be increasing, and, again, disparities by income and other socio-demographic characteristics. Andrew Rundle: And the idea that obesity is leveling off is a good sign, is an excellent sign. But it also is not sort of — we shouldn’t take our eye off the ball, knowing that it’s leveling off. Even if it leveled off and it stays the same, it’s too high. Linda Birnbaum: And I think we might want to realize that we are just one country in the world. And while maybe ten years ago obesity had not yet begun to be the problem in some of the less developed countries in the world, today the obesity rates are skyrocketing in many developing countries. Kimberly Gray: The next question is about body size and obesity and how is puberty related to those two factors. Larry? Larry Kushi: So one of the projects that I’m involved in is specifically looking at obesity and environmental factors and how that influences puberty. And I will say that certainly one of the major factors that drives age at onset of puberty, when breast development starts or public hair development starts, is obesity and then adiposity. So that clearly is one of the major initial proximal impacts of childhood obesity, is an earlier onset of puberty. So fat relationship is quite clear and has been seen by a number of researchers. And so what we are interested in is looking at, in addition to do environmental exposures also impact that, whether because they influence obesity rates or in addition to the obesity effect do they have an additional impact. And that’s an unfolding question right now. And it looks like there probably are some additional impacts of environmental factors. Kimberly Gray: Next question’s coming over Twitter. “What role does the chemical industry and [stewardship] have on reducing obesity?” Okay, I don’t see anyone going to take that, so I’m going to, executive decision, give it to Karen. Karen Peterson: I’m not sure I have an answer for that, but I think that might be a very important conversation to have with chemical companies, to initiate a dialogue as has been done with some of the food companies about the potential role of products and how they could be contributing to adverse health outcomes in our children. So I think that would be — the answer is yes, there’s a role. But what that role is will need to be defined through very deliberate conversations going forward between researchers, policymakers, and the companies themselves. Larry Kushi: Yes. I might say here that different nations have taken a somewhat different regulatory approach to the introduction of new chemicals or the regulation of existing chemicals that are in our general environment product stream, food product stream, whatever it is. And so what the right approach is I guess is one that there really should be more of an engagement of. But, as has been pointed out by some of the National Toxicology Program colleagues here, the vast majority of the chemicals that are introduced into our society for one reason or another have not been tested for health effects. And so, really understanding what those chemicals and how they end up being regulated is, I think, a big question. Part of it is really trying to understand the health effects. Should that come after these chemicals have been introduced or should that come before is a big question. Kimberly Gray: Chris, do you want to talk about — Christine Thayer: Yes, I just might add that I think many of the stakeholders in the chemical industry are in the same boat as us. This is an emerging area of research. And so these are not health effects that have been well studied for the past decades, and so I think they are watching and waiting. Linda Birnbaum: And I’d also like to point out that for many of the health effects we’re looking at, say, obesity, that has not been something that’s really been looked at before in kind of the standard testing that has been done. So that right now people who are going to test chemicals need to ask different questions than they were asking 30 and 40 years ago. Kimberly Gray: Next question is coming from Winston-Salem. And I think we’ve addressed some of this before, but, “How can community health agencies and childcare professionals use the research and the evidence that we have on environment and obesity and become more involved with potential prevention strategies?” Does anybody have a comment on particularly how they could be engaged? Andrew Rundle: I mostly work with what’s going on in New York City, but the Department of Health has been doing a lot of outreach to community groups. And then, our own Children’s Center, through its community groups that participate in the Children’s Center, have been doing a lot of work around this and trying to think about how to really translate the science into action and what they can then say to parents and caregivers and agencies about what to do. And this is an ongoing conversation, because the science develops and we learn more. These messages may change. But it is a process that is active and ongoing, certainly in New York City and certainly through the other children centers. Kimberly Gray: Coming over Twitter, “Where are the polyaromatic hydrocarbons coming from? And do we know enough about that science to try and reduce exposures?” And I think this is probably going to go back to Andrew. Andrew Rundle: So the good news here is we, as a country, have longstanding policies in place to try and reduce air pollution, try and reduce the PAHs. And so, this is something that we as a nation have been working on for a while, so this is the good news. Things like switching diesel buses to electric buses, for instance, is a way to reduce air pollution. So we’re already working on this issue. You can reduce your own exposure by avoiding tobacco smoke, not smoking yourself, not being around other people who are smoking, particularly when you are pregnant, which were recommendations that were already in place. The issue with childhood obesity in response to PAHs is just another reason why we should be avoiding exposure to these compounds. And these compounds are in diesel exhaust, cigarette smoke, things like this. Kimberly Gray: Next question is, “What’s the role of artificial colorings and flavorings? Do we have any body of science about the effect of those on obesity in children?” Andrew Rundle: I don’t think of this from the perspective of a chemical reaction. I think of this from the perspective of we have been doing an excellent job of making food very palatable, so that you enjoy eating it and you want to eat more of it. And so, I don’t know of any research that have treated flavorings and colorings from a chemical perspective, but more from a perspective of making good saltier and tastier and sweeter. And this has been part of this larger discussion about the food systems and how we produce food. So I think of it from that perspective more than from a classical environmental chemical perspective. Kimberly Gray: So we’ve talked a lot today about early life exposures, whether it’s in the prenatal period or during childhood that affect your likelihood of developing a disease like asthma or metabolic syndrome. There’s some questions here, “What other disease are we considering? What are some of the early-life exposures that [will affect] some — maybe even some cancerous end points that we haven’t talked about today? And, Larry, you’d probably be the best to answer that one. Larry Kushi: I can certainly start. As I mentioned, one of the projects that I’m involved in is specifically under the rubric of a program called The Breast Cancer Environment Research Program. The projects that we’re looking at, as I also mentioned, are looking at puberty in girls, with the underlying rationale that earlier onset of puberty is a long-term risk factor for developing breast cancer. The study itself is not of sufficient size to actually look at breast cancer. And we would also have to follow these girls for many decades in order to actually look at breast cancer per se. But because of these other clues that important events occur early, such as during puberty, we can make the inference that some of the associations that we will be seeing are likely to have an impact in the long run on breast cancer risk. I think it’s important to point out, again, as Linda had mentioned earlier on and others had, that other long-term chronic diseases are impacted by childhood obesity — cardiovascular disease, diabetes as a couple of major chronic illnesses. Linda Birnbaum: Kim, I’d like to add a comment or two about that, is that what we’re looking for now in our human populations in many cases are things that we have seen again in our experimental animal studies. So there is growing evidence that early-life exposure, for example, again, to rats and mice, but also to certain other species, can result in an increased incidence of different kinds of cancers, heart disease, diabetes, et cetera in our animals when they get older. But there’s really growing evidence also, not only in the experimental data but in the human data, too, for early life exposures leading to adverse health effects a long time on. We’ve known nutritionally that, for example, not actual starvation but some under-nutrition during development is associated 40, 50, 60 years later with increase in diabetes, obesity, heart disease, and cancer. And we’re now beginning to understand how that is coming about. So, again, what affects you before you’re born and when you’re a young child and when you’re going through puberty is going to affect you at middle age and old age as well. Kimberly Gray: That sounds like a national endorsement for a national birth cohort here in the United States. So, a question from Arizona is, “Could you please elaborate on the relationship between obesity and a depressed immune system?” And I think, Greg, you brought that up early with inflammation, but as it relates to the immune system. Greg Diette: Yes. And I guess I don’t know whether it’s obesity per se, as much as it is the nutritional factors that go into being a risk factor for obesity. But the point that I was making there was that part of what we eat protects us from problems. So not just the immune system per se, but part of the whole cascade of protection factors that we have when we’re exposed to something that will cause our body harm, if we’ve eaten foods that have those protective factors, then we fare better when we encounter something that otherwise would be dangerous. Kimberly Gray: From McLean, Virginia, back on the topic of physical education, “Any ideas on how we can get that back into our schools? Any recommendations?” Larry Kushi: It is a difficult question. I think the First Lady’s program is certainly a good effort of raising the awareness of it at the same time that we’re also putting other pressures on school systems to increase test scores, et cetera. Even when there are mandated requirements for a certain number of minutes of recess or physical activity, oftentimes schools don’t meet those mandated requirements and are not sort of penalized for not meeting that, because there are these other pressures that take more precedence. But I think that if we generally recognize that actually people who are more physically active and do engage in those, they are also more engaged in the classroom. The children are also more engaged in the classroom. And that we’re interested in raising the whole human being, whole child, and not just certain test-taking skills, that hopefully mandated amounts of classes or minutes over the course of a week or whatever, they’ll actually mean something. Linda Birnbaum: Kim, I think this is an opportunity, kind of an educational moment, where we can have an effect by bringing the communities together, bringing parents together, and having them demand more activity for their children’s schools. I mean, that’s how things change, you know, to say everything is local, and I think many things are. So we can have mandates that come down from above. But unless they’re understood and embraced by local communities they’re not really going to happen. Kimberly Gray: Understand. So some questions that were coming in kind of culminate into a discussion about really, “What’s the relative contribution of environmental chemicals on the role of obesity in children?” And does anyone really want to comment on how large, how small, and in the relationship to those bigger factors such as diet and lifestyle? Karen Peterson: I think it’s a really interesting and really important question and one that we are struggling with ourselves at the University of Michigan. Right now it’s difficult to know if the contribution of environmental toxicants is greater than diet and activity. I think the way I would think about it is actually to think of them as co-exposures, which is a scientific word. But, again, that a healthy lifestyle can be impacted by the environment and it’s important to have a nuanced understanding of that environment, that it’s behavioral, social, physical, and chemical. And I think it’s likely that we’ll find that a healthy lifestyle and unhealthy lifestyle, the interactions between toxicants and diets and likely physical activity, are very blended together. Kimberly Gray: Well, thank you, Karen. Well, this brings us to the end of our discussion. Thank you, panelists, for being here today and joining us here at NIEHS. Thank you, everyone out there. And they were all really, really good questions. We almost got through most of them. We had a big turnout today. I’m sorry that we didn’t get to everybody. This was a really great conversation and we were able to cover a lot of ground and a lot of issues. Our next community forum sponsored by the National Institute of Environmental Health Science is on safe seafood. That will be April 18th in Seattle, Washington. And then air pollution on June 18th in the Detroit area. You can find more information on our website at NIEHS.nih.gov, where you can find more details on the research that we conduct here at the Institute, and funding opportunities as well as our community involvement. Again, I want to thank everyone and please enjoy the rest of your day.