Beginning

FIVE YEARS AFTER THE USSurgeon General’s report on obesity, has the nation made agood start on confronting the epidemic?

Some nutrition advocates saythat currently they are seeing themost prominent policy events ondiet in living memory. In 2005,at least 42 states passed or con-sidered some type of legislationon nutrition. In 2006, the Na-tional Governors Association hada major project on obesity thatwas designed to gather informa-tion from many segments of soci-ety on how states can makeprogress on confronting the epi-demic. Numerous school districtsaround the country, includingseveral in major cities, havechanged their policies to helpeliminate low-nutrient foods fromschools, both in terms of thecafeteria at lunchtime and atother school areas and activities.

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| Kathryn Foxhall

Advocates say all thosechanges are in stark contrast towhat they see at the nationallevel. In one example of thepolicy status, the per capitaconsumption of sweeteners thatadd calories increased by 43pounds, or 39%, between theperiod 1950–1959 and 2000.1

The 2001 Surgeon General’sreport said overweight and obe-sity could reverse many of thehealth gains of recent decades.2

But although these facts werewell known, 2 years ago U.S.government officials in 2004objected to a World HealthOrganization (WHO) reportthat said sugar should be limitedto 10% of calories.3,4 At thesame time, the sugar industryasked Congress to withholdfunding from the World HealthOrganization.5

In addition, the Food and DrugAdministration has declined to

BeginReports From the Battle on Obesity

to

require that the amounts ofadded sugars be listed on foodlabeling, although federal guide-lines and a number of school nu-trition policies say consumptionof added sugars should be lim-ited.6 In another indication ofcontinuing denial, the SugarAssociation, as of early 2006,stated on its Web page that sugardoes not cause obesity.7 Further-more, any legislation to actuallypromote better nutrition is notlikely to go far.

FROM THE BOTTOM UP

Conversely, Kelly Brownell, di-rector of the Yale Center for Eat-ing and Weight Disorders, saysthe new struggle against obesityis replete with decentralized ac-tivities that parallel those that ledto “one of the greatest publichealth victories,” the drop in to-bacco use. “These are happening

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at state and local levels and,again, this is exactly how wemade progress with tobacco, be-cause there was so much tobaccomoney in Washington that it wasparalyzed,” he says.

Leslie Mikkelsen, managing di-rector of the Prevention Institutein Oakland, California, says,“There has been just a mush-rooming of action of coalitionsthat have been formed aroundthe country, often led by publichealth departments, that are re-ally taking a look at what do weneed to do in community envi-ronments to support healthiereating and activity.”

“It is the most exciting time forme as a nutritionist,” she says.She notes that, within the past 5years, along with the growinglocal interest on improving nutri-tion, there has been a historicshift in emphasis toward chang-ing the food environment ratherthan just trying to teach peopleto eat healthier. Tracy Orleans,senior scientist with the RobertWood Johnson Foundation’s in-terest area on childhood obesity,says, “I think we have finallybegun to see how powerful theenvironment is. And, in the ab-sence of that understanding,I think we had overembraced,

as a nation, a personal responsi-bility explanation for the obesityproblem.” Nutritionists also stressthat, to a huge extent, the effortsto reduce obesity are workinghand-in-glove with movementsto increase exercise, with a fullrecognition that nutrition and ac-tivity are the 2 sides of the obe-sity equation.

THE BIG PUSH IN SCHOOLS

If there is a leading focus forthe antiobesity fight, it is theschools. Among the local efforts iswhat Orleans calls an “absolutegroundswell” for the creation of ahealthy food environment inschools, as well as for increasedphysical activity. Twenty-onestates passed legislation on nutri-tional standards in schools in2005 and 9 state boards of edu-cation gave school districts newrules or recommendations, ac-cording to the Health PolicyTracking Service.8 Leading schoolinitiatives include setting nutri-tional standards, restricting salesof “competitive foods and bever-ages” (any food served outside the

”

Ricardo Hernandez, a first-grader,uses 2 potatoes to determine theright portion sizes at BritainElementary in Irving, Texas.

“I think we have finally begun to see howpowerful the environment is. And, in the

absence of that understanding, I think wehad overembraced, as a nation, a personal

responsibility explanation for the obesity problem.

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something, she asserts, that in-dustry segments who market un-healthy foods have known for along time.

“Companies want to be inschools because they know thatchildhood is a time when foodpreferences are developingand becoming set and so theywant to sell their products inschools to cultivate brand loy-alty,” she says.

Among the efforts to changeschool policy, the most frequent,specific focus is on eliminating orcutting down on sugar-ladensodas and other sugary drinks.Those drinks, Wooten notes, havecome to be the biggest source ofcalories in adults’ and teens’ diets.At 7% of calories total energy in-take,12 she says they are “ahead ofbread, rice, meat—you know—realfood.” And at 140 calories ormore, she says, the excess energyin 1 such drink a day per personis enough to explain the obesityepidemic.

Efforts against provision of un-healthy drinks in schools re-ceived a real boost in May 2006

when major beverage companiesannounced that they would stopdistributing in schools, over thenext several years, the most un-healthy drinks, a commitmentbrokered with the AmericanHeart Association and the Clin-ton Foundation.13 A number ofschool districts are already mov-ing to get high-calorie drinks outof their schools.

Beyond the changes to softdrink policy, there was an addi-tional flurry of school activity in2006 engendered by Congres-sional mandates. A provision inthe Child Nutrition and WIC (theSpecial Supplemental Nutritionprogram for Women, Infants, andChildren) Reauthorization Act of2004 requires most school dis-tricts to develop and implementnutrition and activity policies bythe school year starting in fall2006. The mandate does not tellthe districts what to put in thepolicies. However, the process isencouraging some important dis-cussions, according to several ad-vocates, and many school dis-tricts have decided to replace

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Students walk past a soda vendingmachine in the Commons Area ofSpringfield High School inSpringfield, Illinois.

regular meal program), or ban-ning or limiting vending machinesales for poor nutritional foods.Twenty-five states considered leg-islation and 11 states passed billsin 2005 to mandate the inclusionof nutrition or physical activity in-struction in the health educationcurriculum. Nineteen states con-sidered legislation and 3 statespassed bills to require schools tomeasure students’ body massindex.8

Although causes of obesity areinfused in many aspects of life,health advocates say there aregood reasons to focus first onschools, even beyond the factthat obesity rates have tripled forelementary school–aged childrenand teens since the 1960s andare now more than 17% for bothgroups and apparently are stillrising quickly.9,10 First, an esti-mated 70% of overweight ado-lescents will become overweightadults.11 Second, eating habitsare often set in childhood, saysMargo Wootan, director of nutri-tion policy at the Center for Sci-ence in the Public Interest. That’s

“Companies want to be inschools because they know

that childhood is a timewhen food preferences aredeveloping and becoming

set and so they want to selltheir products in schools to

cultivate brand loyalty.

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sugary drinks and junk foodswith healthier options.

Alicia Moag-Stahlberg, directorof Action for Healthy Kids, notesthat the requirement for localpolicies came without funding, soresources and energy from thelocal communities will be neededto ensure that the documents con-tain realistic health-promotinggoals that can be met on a sus-tained basis.

EFFORTS IN OTHERAREAS

Beyond the limelight of theschools, measures to push restau-rants to post nutritional informa-tion on menus or menu boardswere introduced in 12 states in2005. One such measure spon-sored by Arkansas GovernorMike Huckabee gives specialrecognition to restaurants thatmake improvements such as offer-ing healthy menu options andposting nutrition information. Tenstates had bills introduced thatwould tax soft drinks and snacksto fund nutritional efforts.8 Anumber of states have startedpublic awareness campaigns, in-cluding a $9.6-million antiobesityinitiative in New York. Five statesheld obesity summits in 2005.8

In addition, says Mikkelsen,there has been a dramatic in-crease in the past few years inthe work and the diversity of ef-forts by community groups tocreate access to healthy foods.Groups are working on initiativesthat include setting up farmers’markets and community gardens,finding ways to attract supermar-kets to low-income urban areas,and providing support or trainingfor small neighborhood stores orconvenience markets to sellhealthier foods. Activists, Mikkel-son says, are exploring ideassuch as putting taxes on soda or

junk foods to raise money forhealthy foods or using zoning toencourage outlets with healthyfoods or discourage fast-foodoutlets.

STILL A MULTILAYEREDCRISIS

Despite these efforts, expertsstress that the nation really isat the very beginning of itsantiobesity work and sometimesprogress is still hindered. Wootanpoints out that in light of well-funded, sophisticated oppositionfrom soft drink and snack-foodindustries, a number of state billson nutrition failed to pass orwere significantly compromised.In order to pass legislation to cutdown on junk food in schools,some states have limited the re-strictions to elementary and mid-dle schools. But, she explains,high-school students are morelikely to have money to buyjunk food.

Faced with ubiquitous concernabout childhood obesity, manyfood companies are talking aboutself-regulation. However, in a re-cent scan of the children’s televi-sion network, “Nickelodeon,” theCenter for Science in the PublicInterest found that 88% of thefood ads were for foods of poornutritional value.14 Everywherein supermarkets, complainsWootan, are products obviouslymarketed to children, with car-toon characters on the packages,contest offers, or free toys. Nutri-tionists and market analysts sus-pect food marketers have in-creased their sponsorship ofsports and other physical activi-ties, even for preschoolers, tofocus more attention on the needfor more exercise, and awayfrom the problems of the foodproducts.15 Brownell says, “Thefood industry has enormous

political power. It has been suc-cessful, at least in the UnitedStates, in fighting off anything ofsubstance that would improvethe nation’s diet.”

In comparison to the limitednumber of state nutrition billsthat have actually passed, 20states—8 in 2005—have passedlaws limiting the ability of indi-viduals to sue restaurants or oth-ers for obesity.8 Other chal-lenges are becoming apparent.Moag-Stahlberg says that evenwith the surprisingly fastchanges in attitudes about nutri-tion and physical activity inschools in recent years, healthadvocates still have a lot tolearn from educators about theother challenges schools faceand how best to make improve-ments to promote health. In ad-dition, there are apparently fewprograms focused on adults whoare not low-income.

The Center for Science in thePublic Interest is working towardbuilding bipartisan support forfederal legislation for changes inchild nutrition, health promotion,and school lunch programs, butthe organization expects strongopposition from the food and beverage industries. The centerdoes not see a good opportunityfor passing such reforms before2008, when the federal child nu-trition bills are due to be reautho-rized, although Wootan asserts, “Ifthe industry would do the rightthing and agree to stop marketingand selling junk foods to kids, wecould pass the bill this year.”

THE CASE FOREFFECTIVENESS OFRESEARCH

There is also the question ofhow much anyone knows aboutthe effectiveness of current ef-forts. “The obesity epidemic

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snuck up on us. It was happening,but we were not paying it enoughheed,” Orleans says. She says theRobert Wood Johnson Foundationbelieves, “Environment and policyinterventions are critical to help-ing children and families achievedifferent dietary patterns andachieve different exercise pat-terns. But we have very little dataat this point to guide us aboutwhat the most feasible and effec-tive policy and environmentalchanges might be.”

Citing findings from a study inScience that, for adults, the in-crease in obesity could be causedby just 100 excess calories a dayper person,16 Orleans says weknow that small changes in con-sumption and daily physical ac-tivity could have profound im-pacts, but we don’t know how tomake those changes on a popula-tion level.

A goal of the Robert WoodJohnson Foundation’s obesityproject, says Orleans, is to put inplace an evidence base that willshow some of the solutions. Thefoundation has geared up re-search support to capitalize onthe changes communities aremaking by evaluating some ofthe projects, emphatically stress-ing that the funds are for study-ing change at the environmentalor social level. A recent call forproposals seeks projects thatidentify school policies with thegreatest potential.17 Some statesare doing their own research: theHealth Policy Tracking Servicenotes that, in 2005, 5 statespassed laws calling for taskforces or commissions to studywhat to do about the rising obe-sity rates. A total of 24 statesconsidered such legislation,meaning there could be moresuch laws in the near future.8

Despite the perceived lack ofaction in Washington, DC, on

policy, some federal agencies aretaking a lead role in research.The National Institutes of Healthcreated a taskforce in 2003 andcurrently has about 2 dozen callsfor research on topics rangingfrom diet composition and en-ergy balance to school-based in-terventions and the economics ofdiet.18 The Centers for DiseaseControl and Prevention (CDC)implemented a number of ef-forts, including conducting sur-veillance to assess school pro-grams and policies. In anotherexample, the CDC’s Steps to aHealthier US initiative awardedgrants to 40 communities to takeaction on factors that contributeto chronic disease, including obe-sity. Some community efforts in-clude safe areas to exercise,training in communities for advo-cacy, subsidies for startup costsfor bins and coolers to storefresh fruits and vegetables inlocal independent groceries, andworking with health careproviders to target behavioralchange in patients.19

In addition, in May 2006,the Department of Health andHuman Services and the FederalTrade Commission outlined anumber of recommendations forvoluntary industry changes infood marketing and other areasto help alleviate child obesity.20

UNDERSTANDING THEWORLD WE CREATED

Beginning efforts obviouslycould be more effective as theweb of causation becomes betterunderstood. But several expertscarefully note that the obesityphenomenon has so many over-lapping and coexisting factors thatit may take years to plumb. Giventhat no large human populationhas ever lived as people in indus-trialized countries have learned to

live in recent decades, there arewhole horizons of obesity-induc-ing factors to be encountered. Forone thing, says Brownell, “It’s re-ally only been, say, the last 50years that food has been reallyabundant in the United States,and that is way too fast forhuman physiology to adapt.”

As one example of the myriadchanges, Brownell points to thedevelopment in the 1970s ofhigh-fructose syrup, which ischeap to use. Its use, Brownellthinks, led the industry to sweetenfoods like never before, “becausethey can. It is inexpensive to doso and people like things whenthey are sweet.” He is now investi-gating whether American foodsare sweeter than comparablefoods in other countries. Otherscientists are researching whethersugar sets up an addictive process.A number of nutritionists say that,in contrast to earlier times, attrac-tive, often low-nutrient food iseverywhere and people often eatsweets 2 or 3 times a day.

Wootan points out that restau-rants have become providers of amajor portion of people’s daily in-take, rather than an occasionalmeal out. But, she says, those es-tablishments have not stepped upto their responsibility in that roleby providing nutrition information.

Moag-Stahlberg thinks chil-dren in today’s families oftenhave several different caregiversmaking choices for them duringthe day. Some children arechoosing their own food moreoften and at earlier ages, manytimes without the parents beingaware of what they are eating,she says. Children are not seeingtraditional meals being orga-nized, she says: “Everything hasoccurred in a slow way to takeaway those natural opportunitiesfor people to learn how to feedthemselves in a balanced way.”

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In the face of the complexitybehind the epidemic, organiza-tions on all levels admit they arestill feeling their way around.Mikkelsen says, “Probably weneed a combination of strategies,so that it is really easy whensomeone walks out their door toaccess healthy options. That iswhat is going to start the shift incommunity behavior.”

But even within the communityefforts, she says, people are justbeginning to understand how touse levers of power to change theenvironment. Actually loweringobesity levels is another question.

Woodie Kessel, child health sci-ence adviser in the Department ofHealth and Human Services Of-fice of Disease Prevention andHealth Promotion, told the Insti-tute of Medicine committee onchildhood obesity recently thatfederal agencies “have moved theflag forward in at least raising theconcern about what the problemis and the multiple contributingfactors.” But the hard part, hesays, is choosing where to put re-sources for “at least a reasonablereturn on the investment.” JeffreyKoplan, Emory University, whochaired that Institute of Medicinepanel on child obesity, says, “Wehave had complex public healthchallenges before. And what isimportant is to see this one not asa one-problem area. It’s not justsugar in foods, it’s not just vend-ing machines, it’s not just toomuch TV. It’s a lot of factors to-gether. And we need to addressall of them consistently, persist-ently, and with real energy overtime if we are going to sort outthis challenge.”

ACTING ON BEST-AVAILABLE EVIDENCE

Many advocates stress that theobesity problem is so urgent that

we cannot wait to act until the re-search is completed. The 2005Institute of Medicine report onchildhood obesity stated, “Know-ing that it is impossible to producean optimal solution a priori, wemore appropriately adopt surveil-lance, trial, measurement, error,success, alteration, and dissemina-tion as our course, to be em-barked on immediately. Giventhat the health of today’s childrenand future generations is at stake,we must proceed with all due ur-gency and vigor.”21

Koplan, for one, questionswhether the federal establishmenthas yet to take the problem seri-ously enough to target it with theconcentration of resources thatcan be mustered only at the fed-eral level. At a recent Institute ofMedicine committee hearing, hepressed federal health officials,noting that the nation has investedbillions of dollars in preventing potential epidemics of smallpoxand avian flu: “Is the departmenttalking about a commensurate in-vestment in something that iswreaking havoc currently, and islikely to for the next 30 years, inthis country?”

REASON FOR HOPE

Despite the complexity of theproblem, the sheer publicity mayhave already had an impact. Aspecial report on sugar from theUS Department of Agriculturesays consumption of caloricsweeteners has leveled off since1999, perhaps because of aware-ness of associated health risks orpossibly the emergence of low-calorie sweeteners.22 Survey num-bers indicate obesity and over-weight levels did not increase inwomen between 1999 to 2000and 2003 to 2004.10

Orleans says, “Our work in to-bacco as a nation has really set us

up brilliantly to begin to under-stand that it is policy and environ-mental levers that are shaping a lotof what we do.” In addition, shecontends, “We better understandwhat the solution looks like.” Weknow, she asserts, the drop insmoking over 2 decades was wonwith the help of indoor clean airlaws, taxes on tobacco products,and other community-levelchanges. She says we know the solution will include “working tocreate healthy environments andnot just educating the public.” Orleans also believes there is agreater sense of urgency than inthe first years of the tobacco battles, because the public under-stands that obesity affects children.

Koplan believes that right nowthe strongest aspect of the move-ment is simply the broad consen-sus that a movement is needed:“There is little debate among in-formed and reasonable peopleand among the community atlarge that obesity (1) is a healthproblem and, (2) is occurring inepidemic proportions.”

Nevertheless, Koplan indicateswe may be looking at a 20-yeartimeframe, easily: “It has takenus decades to reach the point weare at, due to changing patternsof physical activity and changespatterns of eating. And it is goingto take us at least that long toachieve a healthier lifestyle, if wework hard at it.”

About the AuthorKathryn Foxhall is a freelance reporterwith an emphasis on health policy.

Requests for reprints should be sent toKathryn Foxhall, 3921 Crittenden St.,Hyattsville, MD 20781 (e-mail: kfoxhall@ix.netcom.com).

This commentary was accepted June 29,2006.

doi:10.2105/AJPH.2006.096891

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2001–2002, Chapter 2. Available at:http://www.usda.gov/factbook. Accessed February 12, 2006.

2. US Department of Health andHuman Services. The Surgeon General’sCall to Action to Prevent and DecreaseOverweight and Obesity. ForewordFrom the Surgeon General. Available at:http://www.surgeongeneral.gov/topics/obesity. Accessed February 12, 2006.

3. Stein R. US says it will contestWHO plan to fight obesity but claim offaulty science is rejected by nutritionists.Washington Post. January 16, 2004, A3.

4. Dyer O. US government rejectsWHO’s attempts to improve diet. BMJ.January 24, 2004;328:185. Availableat: http://bmj.bmjjournals.com. Ac-cessed February 13, 2006.

5. Center for Responsive Politics. In-dustries: Background: Sugar. Availableat: http://www.opensecrets.org. Accessed February 14, 2006.

6. Center for Science in the Public In-terest. America: drowning in sugar.Available at: http://www.cspinet.org. Accessed February 14, 2006.

7. Sugar Association Web site. Avail-able at: http://www.sugar.org. AccessedMarch 8, 2006.

8. Health Policy Tracking Services.2005 state legislation and policies af-fecting child and adolescent nutritionand physical activity. Available at:http://www.rwjf.org/research. AccessedFebruary 12, 2006.

9. Ogden C L, Flegal K M, Carroll M D, Johnson C L. Prevalence andtrends in overweight among US childrenand adolescents, 1999-2000. JAMA.2002;288:1728–1732. Available at:http://www.jama.ama-assn.org. Accessed February 13, 2006.

10. Ogden C L, Carroll M D, Curtin L R, McDowell M A, Tabak C J, Flegal K M. Prevalence of overweight and obe-sity in the United States, 1999-2004.JAMA. 2006;295:1549–1555. Avail-able at: http://www.jama.ama-assn.org.Accessed April 15, 2006.

11. US Surgeon General. Fact sheet:overweight in children and adolescents.:Available at: http://www.surgeongeneral.gov/topics/obesity. Accessed February14, 2006.

12. Block G. Foods contributing toenergy intake in the US: data fromNHANES III and NHANES, 1999–2000: J Food Composition Analysis.2004;17:439–447. Available at:http://www.sciencedirect.com. AccessedFebruary 15, 2006.

13. Clinton Foundation. Healthy schoolbeverage guidelines. Available at:http://www.clintonfoundation.org. Ac-cessed May 23, 2006.

14. Center for Science in the Public Interest. Nickelodeon. Available at:http://www.cspinet.org/new/pdf/nickelodeon.pdf. Accessed February 12,2006.

15. Mayer C E. Work off thoseCheetos! Washington Post. November23, 2005, Section D.

16. Hill J O, Wyatt H R, Reed G W, Pe-ters J C. Obesity and the environment,:where do we go from here? Science.2003; 299:853–855. Available at:http://www.sciencemag.org. AccessedFebruary 13, 2006.

17. Robert Wood Johnson FoundationWeb site. Childhood obesity interestarea. Available at: http://www.rwjf.org/portfolios/interestarea. Accessed Febru-ary 13, 2006.

18. Obesity research page. National In-stitutes of Health Web site. Available at:http://www.obesityresearch.nih.gov. Ac-cessed February 14, 2006.

19. Overweight and obesity page. Cen-ters for Disease Control and PreventionWeb site. Available at: http://www.cdc.gov/nccdphp/dnpa/obesity. AccessedApril 15, 2006.

20. Federal Trade Commission. Per-spectives on marketing, self-regulationand childhood obesity: a report on ajoint workshop of the Federal TradeCommission and the Department ofHealth and Human Services. Availableat: http://www.ftc.gov/reports/index.htm. Accessed May 23, 2006.

21. Koplan J P, Liverman C T, Kraak V A,eds. Preventing Childhood Obesity: Healthin the Balance. Washington, DC: NationalAcademies Press; 2005:18. Available at:http://www.nap.edu. Accessed April 15,2006.

22. Haley S, Reed J, Lin B H, Cook A.Sweetener consumption in the UnitedStates: distribution by demographic andproduct characteristics. Washington, DC:Economic Research Service, US Depart-ment of Agriculture; 2005. Available at:http://www.ers.usda.gov/publications.Accessed February 14, 2006.

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