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23.
Doll R, Hill AB. Smoking and carcinoma of the lung. Br Med J.
1950;2:740–748.
24.
Teutsch SM, Churchill RE, eds. Principles and Practice of Publi
c Health Surveillance. New York: Oxford University
Press; 1994.
25.
Remington PL, Smith MY, Williamson DF, et al. Design, charac
teristics and usefulness of state-based behavioral risk
factor surveillance, 1981–87. Public Health Rep. 1988;103:366–
375.
26.
Kann L, Kinchen SA, Williams BI, et al. Youth risk behavior su
rveillance: United States, 1997. In: CDC surveillance

summaries (August 14). MMWR. 47(no. SS-3).
27.
Mosher WD. Design and operation of the 1995 national survey o
f family growth. Fam Plann Perspect. 1998;30:43–
46.
28.
Centers for Disease Control and Prevention. Summary of notifia
ble diseases, United States, 1997. MMWR.
1997;46(no. SS-54).
29.
Langmuir AD. The surveillance of communicable diseases of na
tional importance. N Engl J Med. 1963;268:182–192.
30.
Centers for Disease Control and Prevention. History perspective
s: history of CDC. MMWR. 1996;45:526–528.
31.
Roemer MI. Preparing public health leaders for the 1990s. Publi
c Health Rep. 1988;103: 443–451.
32.
Winkelstein W, French FE. The training of epidemiologists in s
chools of public health in the United States: a
historical note. Int J Epidemiol. 1973;2:415–416.
33.

Association of Schools of Public Health. Enrollment of U.S. sch
ools of public health 1987–1997.
http://www.asph.org/webstud1.gif. Accessed December 14, 1999
.
34.
Crawford BL. Graduate students in U.S. schools of public health
: comparison of 3 academic years. Public Health Rep.
1979;94:67–72.
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35.
Association of Schools of Public Health. Ten most frequently as
ked questions by perspective students.
http://www.asph.org/10quest.htm. Accessed December 14, 1999.
36.
U.S. Treasury Department/Public Health Service. History of cou
nty health organizations in the United States 1908–
1933. In: Public Health Bulletin (No. 222). Washington, DC: Pu

blic Health Service, 1936.
37.
Altman D, Morgan DH. The role of state and local government i
n health. Health Aff. 1983;2;7–31.
38.
Mountin JW, Flook E. Guide to Health Organization in the Unit
ed States, 1951. Washington, DC: Public Health
Service, Federal Security Agency, Bureau of State Services, 195
1; Public Health Service publication no. 196.
39.
Emerson H, Luginbuhl M. 1200 local public school departments
for the United States. Am J Public Health.
1945;35:898–904.
40.
Dyal WW. Ten organizational practices of public health: a histo
rical perspective. Am J Prev Med. 1995;11(suppl 2):6–
8.
41.
Institute of Medicine. The Future of Public Health. Washington,
DC: National Academy Press, 1988.
42.
Public Health Service. Healthy People 2000: National Health Pr
omotion and Disease Prevention Objectives: Full
Report, With Commentary. Washington, DC: U.S. Department o

f Health and Human Services, Public Health Service,
1991; Department of Health and Human Services publication no
. (Public Health Service) 91-50212.
43.
Centers for Disease Control and Prevention. Selected characteri
stics of local health departments: United States, 1992–
1993. MMWR. 1994;43:839–843.
44.
Centers for Disease Control and Prevention. Estimated expendit
ures for core public health functions: selected states,
October 1992–September 1993. MMWR. 1995;44: 421:427–429.
45.
Adapted from U.S. Department of Health and Human Services.
Healthy People 2010 Midcourse Review: Chapter 23,
Public Health Infrastructure. Washington, DC: Department of H
ealth and Human Services–Public Health Service;
2006.
Public Health Spotlight on Safer and Healthier Foods
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PUBLIC HEALTH ACHIEVEMENTS IN 20TH CENTURY AM
ERICA1
During the early 20th century, contaminated food, milk, and wat
er caused many food-borne infections, including
typhoid fever, TB, botulism, and scarlet fever. In 1906, Upton S
inclair described in his novel The Jungle the
unwholesome working environment in the Chicago meat-packin
g industry and the unsanitary conditions under which
food was produced. Public awareness dramatically increased an
d led to the passage of the Pure Food and Drug Act.2
After the sources and characteristics of food-borne diseases wer
e identified—long before vaccines or antibiotics—
they could be controlled by handwashing, sanitation, refrigerati
on, pasteurization, and pesticide application. Healthier
animal care, feeding, and processing also improved food supply
safety. In 1900, the incidence of typhoid fever was
approximately 100 per 100,000 population; by 1920, it had decr
eased to 33.8 and by 1950 to 1.7 (Figure 6-9). During
the 1940s, studies of autopsied muscle samples showed that 16
% of persons in the United States had trichinellosis;
300 to 400 cases were diagnosed every year, and 10 to 20 deaths
occurred.3 Since then, the rate of infection has
declined markedly; from 1991 through 1996, three deaths and an
average of 38 cases per year were reported.4
Figure 6-9 Incidence of typhoid fever, by year, United States, 1
920–1960.
Source: From Centers for Disease Control and Prevention. Achi
evements in public health, United States, 1900–
1999: safer and healthier
foods. MMWR. 1999;48 (40):905–913.

Nutritional sciences also were in their infancy at the start of the
century. Unknown was the concept that minerals and
vitamins were necessary to prevent diseases caused by dietary d
eficiencies. Recurring nutritional deficiency diseases,
including rickets, scurvy, beriberi, and pellagra, were thought to
be infectious diseases. By 1900, biochemists and
physiologists had identified protein, fat, and carbohydrates as th
e basic nutrients in food. By 1916, new data had led to
the discovery that food contained vitamins, and the lack of “vita
l amines” could cause disease. These scientific
discoveries and the resulting public health policies, such as foo
d fortification programs, led to substantial reductions in
nutritional deficiency diseases during the first half of the centur
y. The focus of nutrition programs shifted in the
second half of the century from disease prevention to control of
chronic conditions, such as cardiovascular disease and
obesity.
Food Safety
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Perishable foods contain nutrients that pathogenic microorganis
ms require to reproduce. Bacteria such as Salmonella
sp., Clostridium sp., and Staphylococcus sp. can multiply quickl
y to sufficient numbers to cause illness. Prompt
refrigeration slows bacterial growth and keeps food fresh and ed
ible.
At the turn of the 20th century, consumers kept food fresh by pl
acing it on a block of ice or, in cold weather, burying it
in the yard or storing it on a window sill outside. During the 19
20s, refrigerators with freezer compartments became
available for household use. Another process that reduced the in
cidence of disease was invented by Louis Pasteur—
pasteurization. Although the process was applied first in wine p
reservation, when milk producers adopted the process,
pasteurization eliminated a substantial vector of food-borne dise
ase. In 1924, the PHS created a document to assist
Alabama in developing a statewide milk sanitation program. Thi
s document evolved into the Grade A Pasteurized
Milk Ordinance, a voluntary agreement that established uniform
sanitation standards for the interstate shipment of
Grade A milk and now serves as the basis of milk safety laws in
the 50 states and Puerto Rico.5
Along with improved crop varieties, insecticides and herbicides
have increased crop yields, decreased food costs, and
enhanced the appearance of food. Without proper controls, howe
ver, the residues of some pesticides that remain on
foods can create potential health risks.6 Before 1910, no legislat

ion existed to ensure the safety of food and feed crops
that were sprayed and dusted with pesticides. In 1910, the first
pesticide legislation was designed to protect consumers
from impure or improperly labeled products. During the 1950s a
nd 1960s, pesticide regulation evolved to require
maximum allowable residue levels of pesticides on foods and to
deny registrations for unsafe or ineffective products.
During the 1970s, acting under these strengthened laws, the new
ly formed EPA removed DDT and several other
highly persistent pesticides from the marketplace. In 1996, the F
ood Quality Protection Act set a stricter safety
standard and required the review of older allowable residue leve
ls to determine whether they were safe. In 1999,
federal and state laws required that pesticides meet specific safe
ty standards; the EPA reviews and registers each
product before it can be used and sets levels and restrictions on
each product intended for food or feed crops.
Newly recognized food-borne pathogens have emerged in the U
nited States since the late 1970s; contributing factors
include changes in agricultural practices and food processing op
erations and the globalization of the food supply.
Seemingly healthy food animals can be reservoirs of human pat
hogens. During the 1980s, for example, an epidemic of
egg-associated Salmonella serotype Enteritidis infection spread
to an estimated 45% of the nation’s egg-laying flocks,
which resulted in a large increase in egg-associated food-borne i
llness within the United States.7,8 Escherichia coli
O157:H7, which can cause severe infections and death in human
s, produces no signs of illness in its nonhuman
hosts.9 In 1993, a severe outbreak of E. coli O157:H7 infections
attributed to consumption of undercooked ground
beef resulted in 501 cases of illness, 151 hospitalizations, and 3
deaths and led to a restructuring of the meat
inspection process.10 The most common food-borne infectious a
gent may be the calicivirus (a Norwalk-like virus),

which can pass from the unwashed hands of an infected food ha
ndler to the meal of a consumer. Animal husbandry
and meat production improvements that have contributed to redu
cing pathogens in the food supply include pathogen
eradication campaigns, the Hazard Analysis and Critical Control
Point,11 better animal feeding regulations,12 the use
of uncontaminated water in food processing,13 more effective f
ood preservatives,14 improved antimicrobial products
for sanitizing food processing equipment and facilities, and ade
quate surveillance of food-handling and preparation
methods.15 Hazard Analysis and Critical Control Point program
s also are mandatory for the seafood industry.16
Improved surveillance, applied research, and outbreak investiga
tions have elucidated the mechanisms of
contamination that are leading to new control measures for food
-borne pathogens. In meat-processing plants,17 the
incidence of Salmonella and Campylobacter infections has decre
ased; however, in 1998, apparently unrelated cases of
Listeria infections were linked when an epidemiologic investiga
tion indicated that isolates from all cases shared the
same genetic DNA fingerprint; approximately 100 cases and 22
deaths were traced to eating hot dogs and deli meats
produced in a single manufacturing plant.18 In 1998, a multistat
e outbreak of shigellosis was traced to imported
parsley.19 During 1997 to 1998 in the United States, outbreaks
of cyclosporiasis were associated with mesclun mix
lettuce, basil/basil-containing products, and Guatemalan raspber
ries.20 These instances highlight the need for
measures that prevent food contamination closer to its point of
production, particularly if the food is eaten raw or is
difficult to wash.21
Any 21st century improvement will be accelerated by new diagn
ostic techniques and the rapid exchange of
information through use of electronic networks and the Internet.

PulseNet, for example, is a network of laboratories in
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state health departments, the CDC, and food-regulatory agencies
. In this network, the genetic DNA fingerprints of
specific pathogens can be identified and shared electronically a
mong laboratories, enhancing the ability to detect,
investigate, and control geographically distant yet related outbr
eaks. Another example of technology is DPDx, a
computer network that identifies parasitic pathogens. By combin
ing PulseNet and DPDx with field epidemiologic
investigations, the public health system can rapidly identify and
control outbreaks. The CDC, the Food and Drug
Administration, the U.S. Department of Agriculture (USDA), ot
her federal agencies, and private organizations are
enhancing food safety by collaborating in education, training, re
search, technology, and transfer of information and by
considering food safety as a whole—from farm to table.
Nutrition
The discovery of essential nutrients and their roles in disease pr
evention has been instrumental in almost eliminating
nutritional deficiency diseases such as goiter, rickets, and pella
gra in the United States. During 1922 to 1927, with the
implementation of a statewide prevention program, the goiter ra
te in Michigan fell from 38.6% to 9%.22 In 1921,

rickets was considered the most common nutritional disease of c
hildren, affecting approximately 75% of infants in
New York City.23 In the 1940s, the fortification of milk with vi
tamin D was a critical step in rickets control.
Because of food restrictions and shortages during World War I,
scientific discoveries in nutrition were translated
quickly into public health policy; in 1917, the USDA issued the
first dietary recommendations based on five food
groups; in 1924, iodine was added to salt to prevent goiter. The
1921 to 1929 Maternal and Infancy Act enabled state
health departments to employ nutritionists, and during the 1930s
, the federal government developed food relief and
food commodity distribution programs, including school feeding
and nutrition education programs, and national food
consumption surveys.
Pellagra is a good example of the translation of scientific under
standing to public health action to prevent nutritional
deficiency. Pellagra, a classic dietary deficiency disease caused
by insufficient niacin, was noted in the South after the
Civil War. Then considered infectious, it was known as the dise
ase of the four Ds: diarrhea, dermatitis, dementia, and
death. The first outbreak was reported in 1907. In 1909, more th
an 1000 cases were estimated based on reports from
13 states. One year later, approximately 3000 cases were suspec
ted nationwide based on estimates from 30 states and
the District of Columbia. By the end of 1911, pellagra had been
reported in all but nine states, and prevalence
estimates had increased nearly ninefold.24 During 1906 to 1940,
approximately 3 million cases and approximately
100,000 deaths were attributed to pellagra.25 From 1914 until h
is death in 1929, Joseph Goldberger, a PHS physician,
conducted groundbreaking studies that demonstrated that pellagr
a was not infectious but was associated with poverty
and poor diet. Despite compelling evidence, his hypothesis rema

ined controversial and unconfirmed until 1937. The
near elimination of pellagra by the end of the 1940s has been att
ributed to improved diet and health associated with
economic recovery during the 1940s and to the enrichment of fl
our with niacin. Today, most physicians in the United
States have never seen pellagra, although outbreaks continue to
occur, particularly among refugees and during
emergencies in developing countries.26
The growth of publicly funded nutrition programs was accelerat
ed during the early 1940s because of reports that 25%
of draftees showed evidence of past or present malnutrition; a fr
equent cause of rejection from military service was
tooth decay or loss. In 1941, President Franklin D. Roosevelt co
nvened the National Nutrition Conference for
Defense, which led to the first recommended dietary allowances
of nutrients and resulted in issuance of War Order
Number One, a program to enrich wheat flour with vitamins and
iron. In 1998, the most recent food-fortification
program was initiated; folic acid, a water-soluble vitamin, was a
dded to cereal and grain products to prevent neural
tube defects.
Although the first half of the century was devoted to preventing
and controlling nutritional deficiency disease, the
focus of the second half has been on preventing chronic disease
with initiation of the Framingham Heart Study in
1949. This landmark study identified the contribution of diet an
d sedentary lifestyles to the development of
cardiovascular disease and the effect of elevated serum choleste
rol on the risk for coronary heart disease. With
increased awareness, public health nutrition programs have soug
ht strategies to improve diets. By the 1970s, food and
nutrition labeling and other consumer information programs sti
mulated the development of products low in fat,
saturated fat, and cholesterol. Since then, persons in the United

States have significantly decreased their dietary
intakes of total fat from approximately 40% of total calorie inta
ke in 1977 to 1978 to 33% in 1994 to 1996,
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approaching the recommended 30%;27 saturated fat intake and s
erum cholesterol levels also have decreased.28
Prevention efforts, including changes in diet and lifestyle and e
arly detection and improved treatment, have
contributed to impressive declines in mortality from heart disea
se and stroke.29,30
Populations with diets rich in fruits and vegetables have a subst
antially lower risk for many types of cancer. In 1991,
the National Cancer Institute and the Produce for Better Health

Foundation launched a program to encourage eating at
least five servings of fruits and vegetables daily. Although publi
c awareness of the “5 A Day” message has increased,
only approximately 36% of persons in the United States aged gr
eater than or equal to 2 years achieved the daily goal
of five or more servings of fruits and vegetables.29 A diet rich i
n fruits and vegetables that provide vitamins,
antioxidants (including carotenoids), other phytochemicals, and
fiber is associated with additional health benefits,
including decreased risk for cardiovascular disease.
21ST CENTURY PUBLIC HEALTH CHALLENGES
The most urgent challenge to nutritional health during the 21st c
entury will be obesity. In the United States, with an
abundant, inexpensive food supply and a largely sedentary popu
lation, overnutrition has become an important
contributor to morbidity and mortality in adults. As early as 190
2, USDA’s W.O. Atwater linked dietary intake to
health, noting that “the evils of overeating may not be felt at on
ce, but sooner or later they are sure to appear—
perhaps in an excessive amount of fatty tissue, perhaps in gener
al debility, perhaps in actual disease.”31 In U.S. adults,
overweight (body mass index [BMI] of greater than or equal to
25 kg/m2) and obesity (BMI greater than or equal to
30 kg/m2) have increased markedly, especially since the 1970s.
Figure 6-10 tracks changes since 1960 using National
Health and Nutrition Examination Survey data.32 Figure 6-11 d
emonstrates that this phenomenon is not limited to a
few states or regions of the United States. Obesity rates doubled
among American adults between 1980 and 2000,
whereas the prevalence of overweight and obesity combined inc
reased nearly 40%. More than two thirds of American
adults are overweight and/or obese.
Figure 6-10 Overweight and obesity, selected age categories, Un

ited
States, 1960–2006.
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Source: From Centers for Disease Control and Prevention, Natio
nal Center for Health Statistics, Health, United States 2009, Fig
ure 7.

Hyattsville, MD: NCHS; 2009. Data from the National Health E
xamination Survey and the National Health and Nutrition Exami
nation
Survey.
Figure 6-11 Percentage of adults aged 18 years or over who wer
e obese,*
by state—
Behavioral Risk Factor Surveillance System, United States,
1995, 2000, and 2005.
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Note: *Persons with a body mass index (BMI) greater than or eq
ual to 30.0; self-reported weight and height were used to calcula
te BMI.
Source: From Centers for Disease Control and Prevention. State
-specific prevalence of obesity among adults, United States, 200
5. MMWR.
2006;55(36): 985–988.
Overweight and obesity increase risk for and complications of h
ypertension, hyperlipidemia, diabetes, coronary heart

disease, osteoarthritis, and other chronic disorders; total costs at
tributable to obesity are an estimated $100 billion
annually.33 Obesity also is a growing problem in developing co
untries where it is associated with substantial
morbidity and where malnutrition, particularly deficiencies of ir
on, iodine, and vitamin A, affects approximately 2
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billion people. Increasing physical activity in the U.S. populatio
n is an important step, but effective prevention and
control of overweight and obesity will require concerted public
health action.34
Factors contributing to overweight and obesity are many but in t
he end result from consuming more calories than are
expended through physical activity. Genes, metabolism, behavio
r, environment, culture, and socioeconomic status can
all play roles in determining energy imbalance and body weight.
The rapid increase in the prevalence of overweight
and obesity among all age groups over recent decades argues tha
t genetic factors are not the primary factor involved.
Social, behavioral, cultural, and environmental factors are more

likely contributors. American society has undergone
major changes in food options and eating habits, including incre
ased portion sizes, prepackaged foods, fast food
restaurants, soft drinks, and more frequent snacking. Increased c
onsumption of calories has not been accompanied by
increased levels of physical activity. More than one fourth of A
merican adults report no leisure-time physical activity.
One positive trend, however, has been a steady decline in adult
blood cholesterol levels, as demonstrated in Figure 6-
12.
As the U.S. population ages, attention to both nutrition and food
safety will become increasingly important.
Challenges will include maintaining and improving nutritional s
tatus, because nutrient needs change with aging, and
ensuring food quality and safety, which is important to an older,
more vulnerable population. Continuing challenges
for public health action include reducing iron deficiency, especi
ally in infants, young children, and women of
childbearing age; improving initiation and duration of breastfee
ding; improving folate status for women of
childbearing age; and applying emerging knowledge about nutrit
ion on dietary patterns and behavior that promotes
health and reduce risk for chronic disease. Behavioral research i
ndicates that successful nutrition promotion activities
focus on specific behaviors, have a strong consumer orientation,
segment and target consumers, use multiple
reinforcing channels, and continually refine the messages.35 Th
ese techniques form a paradigm to achieve public
health goals and to communicate and motivate consumers to cha
nge their behavior.
Figure 6-12 Average total cholesterol level among men and wo
men aged
20–
74 years, National Health and Nutrition Examination Survey, U

nited
States, 1959–1962 to 2007–2008.
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Note: Graph points represent serum total cholesterol levels at th
e midpoint of the survey years for the National Health Examinat
ion Survey
conducted during 1959–
1962 and the National Health and Nutrition Examination Survey
s conducted during 1971–1974, 1976–1980,
1988–1994, 1999–2000, 2001–2002, 2003–2004, 2005–
2006, and 2007–
2008. Data were age adjusted by the direct method to the 2000
Census population estimates using the age groups 20–
39 years, 40–59 years, and 60–74 years.
Sources: From Centers for Disease Control and Prevention. Ave
rage total cholesterol level among men and women aged 20–
74 years,

National Health and Nutrition Examination Survey, United State
s, 1959–1962 to 2007–
2008. MMWR. 2009;58(37):1045. Data from
National Health Examination Survey, 1959–
1962; National Health and Nutrition Examination Surveys, 1971
–1974, 1976–1980, 1988–
1994, 1999–2000, 2001–2002, 2003–2004, 2005–
2006, and 2007–2008.
In the Guide to Community Preventive Services (Community Gu
ide), the Task Force on Community Preventive
Services assessed the effectiveness of selected population-based
interventions aimed at promoting healthy growth and
development in children and adolescents and supporting healthy
weights among adults.36 Only a few interventions are
recommended; others lacked sufficient evidence. In general, the
task force found multicomponent counseling or
coaching interventions to be effective in achieving or maintaini
ng weight loss. Also effective were behavioral
interventions to reduce screen time (time spent watching TV, vi
deotapes, or DVDs; playing video or computer games;
and surfing the Internet). These could be single-component or m
ulticomponent interventions that often focus on
changing screen time through classes aimed at improving childr
en’s or parents’ knowledge, attitudes, or skills.
Components of these interventions may include:
• Skills building, tips, goal setting, and reinforcement technique
s.
• Parent or family support through provision of information on e
nvironmental strategies to reduce access to
television, video games, and computers.
• A TV turnoff challenge in which participants are encouraged n
ot to watch TV for a specified number of days.
Another effective community intervention strategy involves wor

ksite nutrition and physical activity programs that
include one or more approaches to support behavioral change in
cluding informational and educational, behavioral and
social, and policy and environmental strategies. Such programs
may include:
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• Informational and educational strategies designed to increase
knowledge about a healthy diet and physical
activity using lectures, written materials (provided in print or o
nline), or educational software.
• Behavioral and social strategies that target the thoughts (e.g.,
awareness, self-efficacy) and social factors that
affect behavior changes through individual or group behavioral
counseling, skill-building activities such as cue
control, rewards or reinforcement, or inclusion of coworkers or
family members to build support systems.
• Policy and environmental approaches designed to make health
y choices easier and target the entire workforce
by changing physical or organizational structures through impro
ving access to healthy foods (e.g., changing
cafeteria options and vending machine content) and/or providin
g more opportunities to be physically active

(e.g., providing on-site facilities for exercise).
• Modifying rules and procedures for employees such as health i
nsurance benefits or costs or money for health
club membership.
• Worksite weight control strategies that may occur separately o
r as part of a comprehensive worksite wellness
program that addresses several health issues (e.g., smoking cess
ation, stress management, cholesterol
reduction).
The recognition of the obesity epidemic greatly influenced the
Healthy People process. One of the 2010 national
health objectives called for the prevalence of adult obesity to be
reduced to less than 15% by 2010. Recent data,
however, indicate the situation is getting worse rather than bette
r, both for children (Figure 6-13) and older age groups
(Figure 6-14). The prevalence of overweight among children has
been climbing steadily since 2000, while rates
among adults show no improvement since 2000, and have even b
een increasing for men.
Figure 6-13 Prevalence of overweight* among persons aged 2–
19 years, by
sex, National Health and Nutrition Examination Survey (NHAN
ES),
United States, 1999–2000 through 2003–2004.
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* Defined as having a body mass index (weight [kg]/height [m2]
) at or above the 95th percentile for age and sex based on the ref
erence
population of the CDC 2000 growth charts.
Source: From Centers for Disease Control and Prevention. Preva
lence of overweight among persons aged 2–
19 years, by sex, National
Health and Nutrition Examination Survey, United States, 1999–
2000 through 2003–2004. MMWR. 2006;55(45):1229.
Figure 6-14 Prevalence of obesity* among adults aged more tha
n 20 years
by gender, National Health and Nutrition Examination Survey,
United
States, 1999–2000 through 2003–2004.
* Defined as having a body mass index (weight [kg]/height [m2]
) >30.
Source: From Centers for Disease Control and Prevention. Preva
lence of obesity among adults aged >20 years, by sex, National
Health and
Nutrition Examination Survey, 1999–2000 through 2003–
2004. MMWR. 2006;55(44):1206.
The net result is that the lofty aspirations for obesity in the Heal

thy People process may not be realized and that the
nation is losing, rather than gaining, ground in the battle being
waged in the early decades of the 21st century. Figures
6-15 and 6-16 illustrate the challenges that lie ahead. The age-a
djusted percentage of adults aged ≥20 years who were
obese during 2003–
2006 varied by race/ethnicity among women, ranging from 53.3
% for non-Hispanic black women
to 41.8% for Mexican American women and 31.6% for non-Hisp
anic white women. Obesity levels were more similar
for Mexican American men (28.8%), non-Hisp anic black men (
35.0%), and non-Hispanic white men (32.0%). None
of the groups had met the Healthy People 2010 target of 15%. Fi
gure 6-16 further documents the gap between
achieved levels and year 2010 targets for adolescent and adult o
besity.
Figure 6-15 Prevalence* of obesity† among adults aged ≥20 yea
rs, by
race/ethnicity§ and sex, National Health and Nutrition Examinat
ion
Survey, United States, 2003–2006.
/ch06figfn17
/ch06fig15
/ch06fig16
/ch06fig16
/ch06figfn18
/ch06figfn19

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4!/4/2/44/88/[email protected]:52.9 13/13
* Prevalence estimates are age adjusted to the 2000 U.S. standar
d population.
† Defined as having a body mass index (weight [kg]/height [m2]
) ≥30.
§ The categories non-Hispanic black and non-Hispanic white inc
lude persons who reported only one race and exclude persons of
Hispanic
ethnicity. Persons of Mexican American ethnicity might be of a
ny race.
¶ 95% confidence interval.
Sources: From Centers for Disease Control and Prevention. Prev
alence of obesity among adults aged ≥20 Years, by race/ethnicit
y and sex,
National Health and Nutrition Examination Survey, United State
s, 2003–
2006. MMWR. 2009;58 (Data from National Health and Nutritio
n
Examination Survey, 2003–
2006. http://www.cdc.gov/nchs/nhanes.htm. Healthy People 201

0 database. http://wonder.cdc.gov/data2010.
US Department of Health and Human Services. Healthy People
2010. 2nd ed. With understanding and improving health and obj
ectives for
improving health. 2 vols. Washington, DC: U.S. Government Pri
nting Office; 2000. http://www.health.gov/healthypeople. Acces
sed May
31, 2010.
http://www.cdc.gov/nchs/nhanes.htm
http://wonder.cdc.gov/data2010
http://www.health.gov/healthypeople

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