ChildhoodObesity inAmerica Today:SNAP out of It!

MARCH 23, 2013

Annabelle Allen, Shannon Carney, Chris Lee,Marie Jackman, & Krysia PohlEVANS SCHOOL OF PUBLIC AFFAIRSPOLICY SOLUTIONS COMPETITION TEAM 2013

The epidemic of childhood obesity is one of the most challenging issues facing America today. Rates of

obesity in children have tripled since 1980; as of 2008 nearly 17% of children aged two to nineteen years

in the United States were obese, 1 with low-income children impacted more severely than other socio-

economic groups. Both the physical and financial impacts of childhood obesity are considerable.

Research has shown that overweight and obese children typically become obese adults,2 with serious

health risks to the children both in their youth and in adulthood, which result in significantly higher

medical costs for obese individuals. 3 In recent years, this issue has drawn the attention of both policy

makers and the public at large, yet despite the marginal declines observed recently in certain regions of

the country, the overall rate of childhood obesity remains troubling. The following analysis explores the

causes for and potential policy solutions to the growing public health concern of childhood obesity in

America. We consider three potential federal-level policy solutions in addition to maintaining the status

quo, including:

1. Banning food advertisements from children’s television

2. Implementing a multi-state pilot of the 5-2-1-0 behavior change education program

3. Placing new restrictions on the Federal Supplemental Nutrition Assistance Program (SNAP

benefits)

Upon review, we recommend our third option, the adoption of tighter restrictions on food that can be

purchased with federal SNAP benefits. SNAP program modification is not only a cost-effective and

politically feasible policy solution, it is likely to have a considerable impact in reversing current trends of

childhood obesity for socio-economic groups that are most at risk. However, to broaden the range of

populations affected and to have a greater impact on this considerable issue, we also advise

implementation of the 5-2-1-0 program pilot as a second step. Finally, while we recommend pursuing a

ban on food advertisements from children’s television as the lowest priority, we suggest that the White

House Task Force consider the issue publicly in order to bring attention and industry pressure to

ultimately reduce children’s exposure to food advertisements. A problem as pervasive as childhood

obesity likely requires more than one policy approach to create meaningful change.

BACKGROUND

Over the past four decades the United States has seen a rapidly increasing prevalence of childhood and

adolescent obesity. Childhood obesity is medically defined as describing children and adolescents,

between the ages of two and nineteen years of age, whose body mass index (BMI) is at or exceeds the

official definition for children of the same age and sex.4 5 From 1976 to 1980 the prevalence of

childhood obesity was 5.5%: over three times lower than it was from 2007 to 2008, when it was

measured at 16.9%.6

The complexity of childhood obesity as a public health issue is compounded by both the multiple aspects

of the problem: behavioral and environmental factors contributing to obesity, differences among socio-

economic groups, and the varying state and federal level approaches to a solution. In order to fully

understand which policy alternatives hold the greatest potential to reverse this disturbing trend in

American children, we must first explore the scope of the problem and its political context.

The issue of childhood obesity has gained a place on the national agenda over the last several years.

While one Duke University study showed that as of 2005 most Americans were not seriously worried

about the economic or health consequences of obesity,7 more recent data suggests that 80% of

Americans now recognize obesity as a serious public health problem for the United States.8

Causes of Childhood Obesity

Directly speaking, childhood obesity is caused by the intake of too many calories in combination with

too little physical activity.9 However, a preponderance of evidence suggests that a variety of

environmental and social factors have played a role in youths’ increasing weight over the last thirty

years. Among factors that are believed to contribute to childhood obesity are the aggressive marketing

and constant availability of low-cost, high-calorie foods,10 decreased physical activity and increased

television and media use,11 and increased portion sizes in American meals.12 The increased consumption

of sugar sweetened beverages as a proportion of daily caloric intake has also been identified as a

significant contributor to the rise in rates of obesity. 13 By 1996, over 30% of carbohydrates consumed by

people older than 2 years old in the United States came from added-sugar caloric sweeteners.14

In addition to a changing American diet, increase in television viewership and cuts to physical education

programs in public schools have contributed to lower levels of activity among kids, providing them fewer

opportunities to burn off excess calories consumed. The impact of increased screen time may go

beyond just the encouragement of sedentary activity: a 2007 study concluded that increased hours of

TV time was correlated with increased calorie intake, with children tending to eat foods of a higher

energy density while watching television as well.15

Socio-Economic Trends in the Early Onset of Obesity

Although a nation-wide problem, rates of childhood obesity vary widely across states as well as among

different socio-economic groups. Poverty has been linked to diets that are higher in sugars and fats,16

and low-income Americans also suffer higher rates of obesity, diabetes, and heart disease.17 Low-

income socio-economic groups consume fewer fruits and vegetables than higher income groups.18

Among pre-school aged children, almost one-third of low-income kids between age 2 and 4 were

overweight or obese in 2009,19 and 14.8% of low income children aged 2 to 5 years old were obese as

compared with 12.4% of all 2 to 5 year olds in the US.20

Health Consequences and the Financial Cost of the Epidemic

The predictions of future obesity rates are staggering – of children born in the year 2000, one in three

will become a diabetic over his or her lifetime.21 Obesity also increases the risk for a host of other

serious conditions including heart and liver disease, arthritis, sleep apnea, and various types of cancer.22

Even today, health care practitioners are seeing more children with conditions like high blood pressure

typically found in adults.23

Along with the health risks associated with childhood obesity, the financial burden to families living with

the disease and to the public at large is tremendous. Covered by their parents’ insurance, the average

claims for obese children cost nearly twice as much non-obese children,24 financially impacting both

families and employers. The indirect costs of childhood obesity are also substantial, as the productivity

of parents with obese children may be lower due to absenteeism as a result of the medical needs of

their child.25 And since over 80% of overweight or obese children remain overweight or obese in

adulthood,26 the costs of childhood obesity only increase over time. In 2006 medical costs to obese

individuals were estimated as being $1,429 more per capita – roughly 42% higher – than for non-obese

persons.27 The total estimated medical spending on obesity at that time was calculated by one study to

be approximately $147 billion per year, implying that public sector spending would be 8.5% lower for

Medicare 11.8% lower for Medicaid without obesity related spending.28

Policy Efforts to Combat Childhood Obesity

In recent years, several efforts to combat high obesity rates have been made at the national policy level.

In 2001, the Surgeon General issued a Call to Action to “Prevent and Decrease Overweight and

Obesity”29 which, although not focusing specifically on childhood obesity, was intended to stimulate

action in all sectors to address this major health problem. The CDC has continued to track the

prevalence of childhood obesity through the National Health and Nutrition Examination Survey

(NHANES), as well as issuing policy briefs and funding programs in every state30 which range from

vending machine policies to recommending guidelines for school physical education programs.

Additionally, the CDC’s “Childhood Obesity Demonstration Project”, launched in 2011, will examine

which strategies are most effective to reduce obesity in children by building on existing community

projects over a four-year grant cycle.

Since 2010, Obama administration has used the White House to make childhood obesity a top priority.

First Lady Michelle Obama’s Let’s Move! Campaign has aimed to create a national action plan to

“maximize federal resources and set concrete benchmarks” toward achieving obesity reduction among

kids.31 This program builds on the Healthier US School Challenge (2004)32, offering incentive awards to

schools that have successfully promoted nutrition and physical activity.

In 2010, the President also signed the Healthy, Hunger-Free Kids Act, which directed USDA to update all

the core child focused meal programs including the National School Lunch Program, the School

Breakfast Program, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC),

the Summer Food Service Program and the Child and Adult Care Food Program with specific meal

guidance under the most recent nutritional guidelines. This legislation requires meal enhancements

including increased availability of fruits, vegetables, and whole grains, as well as reductions in sodium

content. 33

To accompany these efforts, President Obama created a White House Task Force on Childhood Obesity,

which seeks to develop a comprehensive inter-agency plan to reduce obesity among children to 5%

nationwide by 2030.34 The Task Force intends to evaluate the effects of current efforts to reduce

childhood obesity and to ensure plans are implemented, sustainable, and effective – an important role

now that rates of childhood obesity seem to be leveling off, especially in some major metropolitan

areas.35 In the future, this body could play an even larger part in coordinating messaging and efforts

across agencies, and to experiment and test different pilot programs throughout the country to ensure

implementation of the most promising approaches.

PROBLEM STATEMENT

Due to overconsumption of high-calorie foods and increasingly sedentary lifestyles, the incidence of

childhood obesity for children in America is far too high. In addition, America’s poorest children are

those most at risk of becoming obese – those children whose families have the fewest resources to

address the problem. If current trends continue, this epidemic of obesity will continue to cause chronic

health conditions throughout the populace and lead to increasingly disparate health and economic

outcomes between socioeconomic classes. These trends lead to lowered life expectancy and quality of

life for future generations as well as a financial burden of increased health care costs and lowered

productivity.

OBJECTIVES & CRITERIA

When considering the determinants of a successful federal policy to address childhood obesity, we use

the following objectives and criteria:

Efficacy of the policy option: the potential to decrease childhood obesity

Predicted political feasibility of the option

Projected public support of the option

Expected costs of the option, both in terms of policy implementation and potential cost savings

POLICY OPTION #1: Ban advertising of all food products on children’s television

Flashy advertising campaigns marketing processed, unhealthy foods get the attention of young

children across the county. The average child in America watches three to four hours of television a

day, and during that time is subjected to countless commercials for processed foods high in sugar

and fat. Worse, the children exposed to these ads are often unable to distinguish between

advertising and programming.36 For this option, we propose banning television advertisements of

all food and beverage products when 75% of the viewing population is under the age of 18 – an

action only the federal government has the authority to implement through legislation.

A ban on the advertising of food and drink products on television would be similar in nature to the

limitations that have been placed on the advertising and marketing of tobacco and alcohol in the US

and many other countries. Although alcohol and tobacco are hard to compare with food as they

are not necessary for life, consumption of unhealthy foods and excess weight negatively impact an

even greater proportion of the population. Encouragingly, in the US the rate of tobacco usage has

dropped steadily since cigarette advertising was banned from television in 1971. Although the drop

in use of tobacco could also be attributed to a suite of other policy changes - including taxation,

restrictions on use, and warning labels - we believe that the advertising ban could work similarly in

conjunction with current programs such as Let’s Move and the Healthy Hunger Free Kids Act.

Importantly, the decrease in usage of tobacco products has indeed led to lower rates of smoking-

related illness and decreased medical costs for the country.

Studies on alcohol advertising have shown a direct link between advertising and consumption

patterns.37 By changing the standards of food advertising we can limit the interest in food products

that are known to cause obesity. Bans on alcohol and tobacco advertising in other countries have

caused a reduction in sales,38 which we can assume means a reduction in consumption. It is hoped

that results from a ban on advertising of consumable food and drink products would have a similar

effect to the alcohol and tobacco advertising bans. While the advertising industry publicly states

that advertising to children is of questionable effectiveness as adults are ultimately the food

purchasing decision makers, the industry currently spends $11 billion dollars each year to advertise

to children.39

Analysis of Policy Option #1, Ban advertising of all food products on children’s television

Efficacy:

Moderate. Canada has had a similar ban of advertising on children’s television since 1980 resulted

in a 1.5 lb. reduction in kids’ average weights over 15 years40 - impressive given rising average

weights in other countries during that time period and potentially resulting in significant reduction

in weight gain from what may have otherwise occurred. We predict a more conservative impact in

the US in part because of today’s increase in non-traditional media versus television viewing.

Additionally, cultural differences around food consumption in the region may have led to lower

rates. However, advertising restrictions enacted today may have even more of an effect given the

increase in media exposure through the use of multiple mediums – one study showed that

multitasking has increased kids’ overall screen time by 2 ¼ hours over the last five years.41 Taking

these trends into account, we estimate that such a ban would still reduce childhood obesity in the

US by 2-4% over the next 20 years.

Political Feasibility:

Low. Though similar legislation to limit television advertising of food in some form has been passed

in several other countries, including Ireland, Sweden, Norway, Canada, and France; policy efforts in

the United States have generated overwhelming opposition and shown little political potential. In

2010, the FTC, CDC, FDA, and USDA put together an interagency committee to research and create

legislative proposals for regulations of advertising to children. However, Congress requested a cost-

benefit analysis of the recommendations in 2011, effectively bringing the committee’s work to a

halt.42

Public Support:

Low. From a social perspective, public support for restricting advertising is relatively low.43 Support

for this legislation may increase as education campaigns like Let’s Move drive home the effects of

advertising can be linked to food consumption and obesity.

Expected Cost:

Low. The most significant implementation cost to the federal government of implementing such a

ban would be the opportunity cost to enact the legislation. It would require significant political

capital to overcome food industry concerns and media conglomerates who stand to lose large

amounts of advertising revenue with such a scheme. Currently fast food companies alone spend $3

billion dollars on television ads.44 However, if advertising restrictions led to even a small drop in

obesity rates, potential savings to obesity-related health costs are significant because of the ban’s

potential to impact nearly the entire American childhood population. A 2-4% drop in the rate of

childhood obesity would reduce obesity-related health care costs by at least $3-6 billion per year.

POLICY OPTION #2: Pilot of the 5-2-1-0 Behavioral Change Program

The 5-2-1-0 behavioral change program provides a promising way to expand health care providers’

capacity to treat and prevent childhood obesity. The program encourages the adoption of healthy

habits by combining nutrition education with journaling, asking kids that participate to track four things:

the number of fruits and vegetables per day they eat (5), their hours of “screen time” (2), hours of

exercise (1), and the number of sweetened beverages drank per day (0), and is typically offered in a

bounded time period as short as one month.45

The 5-2-1-0 program originally developed in 1998 as part of a health initiative of Blue Cross Blue Shield

of Massachusetts, then further refined as the 5-2-1-0 campaign used by the Maine Youth Overweight

Collaborative in 2007.46 As of 2012, the program had spread through voluntary adoption to twenty-two

states.47 To date, 5-2-1-0 program implementation has typically been at the state or county level, where

local leaders have obtained grant money (often from the CDC or non-profits such as the Robert Wood

Johnson Foundation) to launch a program and offer facilitator trainings for teachers and community

leaders led by hospital dietitians. Using the existing messaging and supporting curriculum, the 5-2-1-0

program could have an even greater impact if it was coordinated and funded at the national level.

The establishment of Affordable Care Organizations (ACOs), a new type of organization that will be part

of states’ Health Exchanges created by the 2012 Affordable Care Act, provide a timely opportunity to

promulgate the program. ACOs, established so far in many states, are organizations that will be

responsible for delivering health care and health coverage for Medicaid-eligible populations.48 Since

ACOs will be accountable health outcomes for the populations they serve, the organizations will have an

incentive to offer programs that will reduce obesity-related health care costs. We propose a pilot for

ten states to offer the program primarily in its traditional fashion – through schools on a voluntary basis

– but also utilizing ACOs as an additional platform to disseminate 5-2-1-0 curriculum and program

facilitation through health-care providers (clinics and hospitals) in each state.

5-2-1-0 programs today have evolved in two simple ways that are likely to dramatically increase its

efficacy with youth: a shift in target audience and an increased emphasis on behavior tracking. Program

experts in Marion County, Oregon realized that targeting at-risk (i.e., overweight and obese) individuals,

the traditional clinical approach for treating obesity in children, was both unnecessary and

counterproductive. Leaders there changed strategy after realizing that from a clinical perspective,

treatment and prevention of childhood obesity are similar. The revised program encourages all children

to participate, focusing on promoting health and reducing risk of diabetes rather than weight control.

Program leaders found that addressing a broader audience has led to astounding program adoption.

The 5-2-1-0 program in Marion County has reached 23,600 people with its message over fourteen

months for less than $50,000 through a collaborative task force involving health departments, hospitals,

medical providers, non-profits, and medical volunteers.49

Additionally, while Marion County’s 5-2-1-0 program has incorporated the idea of behavior tracking

since its inception, other recent 5-2-1-0 implementations are following the trend to emphasize

journaling as a central component of the program. These programs provide age-appropriate

measurement tools: for example, a weekly card with icons that kids can fill in with crayon. Journaling is

an evidence-based recommendation per the American Dietetic Association and a behavior that supports

the continuation of healthy eating habits50, so we can expect that adding journaling to education will

increase the program’s efficacy.

Additionally, 5-2-1-0’s program design creates an ingenious opportunity to gather data to evaluate the

program’s efficacy. Each pilot state could provide an engagement website for participants or schools to

track behavior and even self-report weight. This data can be used to determine which groups benefit

most from the intervention, and whether or not the program should be expanded nationwide.

We have only to look at our own country’s history for a recent example of the power of community-

based education programs to create new social norms. The wildly successful “Keep America Beautiful”

campaign was launched in 1971 to address the problem of littering, which seemed at the time an

inevitable consequence of the expansion of the interstate highway system and increasingly American

mobile lifestyles. The campaign relied largely on public service advertising campaigns and community

education. 51 With Let’s Move! already in place, the addition of the 5-2-1-0 program could unify

messaging from health providers, who are in a position to provide clear action steps to help kids reduce

their risk of diabetes and other obesity-related chronic illness.

Analysis of Policy Option #2, Pilot of 5-2-1-0 Behavior Change Program

Efficacy:

Moderate. Program impacts tracked in the 2007 Maine implementation resulted in a 1.5% reduction in

obesity rates in participating regions.52 More recent results with new program design (as noted above)

show even greater initial promise. Initial 5-2-1-0 results from 2012 in Kitsap County, Washington, shows

dramatic reductions in tracked sugared beverage consumption.53 Adoption of the program in local

clinics has also been encouraging. Marion County, Oregon signed on 27 out of 41 clinics for the

program: a 65% engagement rate with no supporting marketing funds. Based on this data and the

expected popularity of the program, we predict a 2-3% reduction in rates in obesity over 20 years for

participating states.

Political Feasibility & Public Support:

High. Recent polls on the relative popularity of various policy options showed 80% of respondents

supported increased provision of nutritional guidelines to help people make better choices.54 The 5-2-1-

0 framework provides an attractive middle ground for the majority of Americans that consider obesity

an individual problem and the one-third that consider it an issue that government, schools, AND health

care providers should be involved in solving as a community.55 Essentially, 5-2-1-0 provides a way for

health care providers to issue a clear call to action – but one that relies on the effort of the individual for

success. Additionally, since 5-2-1-0 has already been adopted in small pockets across the nation, we can

expect relatively rapid program dissemination based not only on outcome incentives, but also the

existing network of awareness amongst health and nutrition practitioners. However, there may be

some pushback on use of teacher time to incorporate the program since it is not explicitly academic –

offering the program to schools on a voluntary basis will increase local political feasibility but potentially

reduce the program’s reach.

Expected Cost:

Moderate. Program costs vary, but many 5-2-1-0 programs have achieved wide adoption with very little

funding by relying on volunteer support from health practitioners and educators. Maine’s 2007 program

was funded with a $3.7 million grant from the CDC.56 Utilizing ACOs to disseminate program

information would allow the government to reach a significant number of children utilizing existing

administrative infrastructure. However, even a voluntary statewide offering in schools would clearly

need significant funding for facilitator trainings, materials, administration, and evaluation. A statewide

implementation for schools would require at least double the support of the Maine initiative for most

states, as we anticipate more demand with the new inclusive approach. Thus total cost for 10 states at

$7.5 million each would likely approach $75 million for the first year, and as more schools participate

costs would increase as well.

POLICY OPTION #3: Restrictions on the Supplemental Nutrition Assistance Program (SNAP)

The Food Stamp Act of 1964 was implemented at a time when hunger and malnutrition was one of the

most pressing public health and dietary issues facing the U.S. Fast forward nearly 60 years and what

was once known as Food Stamps became SNAP – the Supplemental Nutrition Assistance Program.

Authorized by Congress under the Food and Nutrition Act of 2008, SNAP provides food assistance to

46.6 million Americans, nearly half of who are children.57 However, the picture of food insecurity looks

different than it did 60 years ago. The program has adapted to a changed nutritional environment

where young children now consume a poor quality diet and the prevalence of overweight and obesity

among low-income children exceeds underweight children by seven to one.58

Administered by the USDA, SNAP is meant to “put healthy meals within reach”.59 But this is not

necessarily the case as evidenced by the growing rate of obesity among women and children receiving

SNAP benefits.60 SNAP allows participants to purchase foods, of which there are minimal restrictions

and excludes only the purchase of cigarettes, alcohol, vitamins and hot foods. Healthier foods, namely

whole grains, fruits, vegetables and lean meats, tend to be more expensive than highly processed and

frozen foods. The higher cost of healthy foods, combined with lack of accessibility and possibly

preference, may lead to SNAP families substituting their meals with less nutritious choices. 61 SNAP

allows for flexibility in purchase power and choice, which is arguably eroding diet quality and promoting

obesity and chronic obesity related illness among the low-income population.

In an effort to align federal programs with anti-obesity efforts, Congress should mandate beverage

restrictions under SNAP. Research has shown that each additional sweetened beverage consumed per

day has been found to increase a child’s odds of becoming obese by 60%, 62 63 leading to numerous

health conditions and negatively impacting these children’s quality of life. As the public sector bears the

cost of medical care for many SNAP recipients64, this program is a logical site for federal intervention.

Restricting soda purchases provides an opportunity to realign the SNAP with healthier choices. This will

ultimately reduce the magnitude of medical conditions associated with obesity,65 and immediately

impact a significant number of at-risk children.

The diet for SNAP participants paints an unhealthy picture:

Consumption of more soft drinks than non-SNAP participants. 66

a larger proportion of total calories from fats and added sugars are consumed as compared to

non-participants;67

fewer nutrient-rich foods are consumed such as fruits, vegetables, and whole-grain products;68

In a recent study of a large supermarket chain, soft drinks accounted for 6.9% of the grocery bill for

SNAP users, compared with 4.38% for the average shopper.69 In fact, SNAP pays for an estimated $4

billion in soft drinks per year (20 million servings per day).70 For the purpose of this policy analysis, we

suggest that soda and drinks not naturally sweetened be excluded from SNAP.

The concept of excluding foods from food assistance programs is not new. The special Supplemental

Nutrition Program for Women, Infants and Children (WIC) was revised in 2009 to provide a defined food

package, deemed most nutritious and beneficial for participants and is aligned with the Dietary

Guidelines for Americans.71 WIC restricts the purchase of soda and juices containing added sugar.

Evidence shows that overweight and obese children affected by the WIC changes, which included food

and beverage restrictions, changed their overall diet and subsequently lost up to 4% body fat.72

Additionally, the Healthy Hunger Free Kids Act of 2010 mandated specific healthier changes and outlined

what should be served in the National School Lunch Program, the School Breakfast Program, and the

Child and Adult Care Food Program, which significantly improved the nutritional quality of provided

meals. Presently, SNAP benefits are not limited to the purchase of any food or beverage, except as

described earlier.

Analysis of Policy Option #3, Restrictions on the Supplemental Nutrition Assistance Program (SNAP)

Efficacy:

Low to moderate. WIC food and beverage restrictions have had a positive impact on low-income

children; evidence demonstrates decreased BMI by up to 4% in overweight and obese children due to

changes in their WIC diets.73 Restricting soda under SNAP will impact 1.3% to 2.2% currently overweight

and obese children on SNAP, which may lead to decreases in BMI in this population as well. We also

believe restricting soda under SNAP will curb the rising trend of overweight and obese children in this

demographic, in addition to encouraging overall diet changes and attitudes towards soda.

Political Feasibility:

Moderate. Our recommendation to restrict soda under SNAP should be run as a pilot program in

politically willing states, of which there are at least nine. Nine states had already requested modification

to SNAP to restrict soda and other dessert foods, but were denied by the USDA. USDA rejected such

changes for reasons due to the belief of minimal implementation feasibility and evaluation concerns.

However, we believe that the treatment of this program as a pilot managed independently state to state

may address these issues.

Public Support:

Moderate. There is a current tide of national interest to manage the obesity crisis smartly. The

Administration has made it a national priority as evidenced the First Lady’s Let’s Move! campaign, but

also due to the growing concern in rising health care costs for obesity related diseases. However, as

with changes to any social program, there will be opposition. Restrictions to SNAP will invite resistance

from anti-hunger food groups and food security advocates which lobby for increased subsidies, not

restrictions. Finally, there is significant potential for backlash from lobbyists and conservatives against

restricting the freedom of choice and added regulation.

Expected Cost:

Low to moderate. Since this is an existing program, government costs would remain at $78 billion

annually. However, if restrictions on the purchase of soda decrease consumption, and curbs obesity

rates, there is a great potential to reduce obesity-related costs of Medicaid in the affected population.74

RECOMMENDATION

Based upon this review, we recommend a suite of policy options pursued in order of priority and

feasibility. The federal government should begin by adopting restrictions on foods available for

purchase with the SNAP program. We predict this policy change will help reverse childhood obesity

trends amongst the nation’s most susceptible socioeconomic demographic. Adopting restrictions to

SNAP would be less costly to implement than the 5-1-2-0 program and more politically feasible than a

ban on food advertising on children’s television. Implementing SNAP changes should also result in

immediate and increasing savings through reduction of obesity-related Medicaid health costs.

Modifications to SNAP would be a novel and impactful supplement to current federal policies addressing

childhood obesity in the broader population.

As a next step, we also recommend implementation of the ten-state pilot of the 5-2-1-0 behavior

change program. This program will provide an excellent way to operationalize the White House’s

nutrition education efforts in schools and clinical settings. 5-2-1-0, with its emphasis on behavior

tracking, is also well-designed for program evaluation. If the program’s promising early results

extrapolate amongst various regions and socioeconomic groups, 5-2-1-0 will provide an excellent basis

for nutrition education to create healthier social norms in schools across the country.

Finally, while we find promise in terms of efficacy in a federal ban on food advertisements from

children’s television, given other legislative priorities this policy option is best addressed as the last

priority of the three options. However, we do recommend continued discussion by the White House

Task Force of potential solutions in this arena. Bringing national attention to the role that media and the

food and beverage industry play in the problem of childhood obesity will put needed pressure on the

food industry to self-regulate. As a defining issue for the next generation and for our country, childhood

obesity clearly warrants increased attention, action, and leadership from policymakers at the federal

level.

REFERENCES

Special Thanks to these Evans School of Public Affairs Faculty and Students:

Professor Marieka Klawitter

Dean Sandra Archibald

Professor Joe Cook

Professor Marla Salmon

Jason Williams, Public Affairs PhD Candidate 2013

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used by the Center for Disease Control and other health science organizations to estimate obesity. A BMI that is less than the

5th percentile is considered underweight and above the 95th percentile is considered obese for people 20 and under.5 Center for Disease Control Website, http://www.cdc.gov/obesity/childhood/basics.html6 Ogden, C. and Carroll, M. Prevalence of Obesity Among Children and Adolescents: United States, Trends 1963-1965 Through2007-2008. Division of Health and Nutrition Examination Surveys.7 Oliver, J. and Lee, T. Public Opinion and the Politics of Obesity in America. Journal of Health Politics, Policy andLaw. 2005 Volume 30, Number 5: 923-9548 Trust for America’s Health Issue Report: F as in Fat: How Obesity Threatens Americas Future. June 2010.8 Institute of Medicine. Nutrition standards for food in schools: Leading the way toward healthier youth.http://www.iom.edu/Reports/2007/Nutrition-Standards-for-Foods-in-Schools-Leading-the-Way-toward-healthier-Youth.aspxAccessed Jan. 25, 2013.9 Ibid.10 Center for Science in the Public Interest, http://www.cspinet.org/new/pdf/food_marketing_to_children.pdf11 Center for Disease Control Website, http://www.cdc.gov/obesity/childhood/basics.html12 Ledikwe J, Ello-Martin J, Rolls B. Portion Sizes and the Obesity Epidemic. The Journal of Nutrition 2005, Vol. 135, No. 4 905-909.13 Malik V, Schulze M, Hu F. Intake of sugar-sweetened beverages and weight gain: a systematic review. The American Journalof Clinical Nutrition. 2006 August; 84(2): 274-288.14 Ibid.15 Temple J, Giacomelli A, Kent K, Reommich J, and Epstein L. Television watching increases motivated responding for food andenergy intake in children. The American Journal of Clinical Nutrition 2007, Vol. 85, No. 2, 355-361.16 Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs. Am J Clin Nutr. 2004;79(1):6–16.17 Shenkin, J.D., & Jacobson, M.F. (2010). Using the food stamp program and other methods to promote healthy diets for low-income consumers. American Journal of Public Health, 100(9)18

Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs. Am J Clin Nutr. 2004;79(1):6–16.19 Ibid.20 Trust for America’s Health Issue Report: F as in Fat: How Obesity Threatens Americas Future. June 2010.21 Wechsler, H. et al. The Role of Schools in Preventing Childhood Obesity. Dec. 2004. The State Education Standard.22 Trust for America’s Health Issue Report: F as in Fat: How Obesity Threatens Americas Future, June 2010.23 Ibid.24 Sepulveda MJ, Tait F, Zimmerman E, Edington D. Impact of childhood obesity on employers.Health Affairs 2010; 29:513-521.25 Ibid.26 Herman KM, Craig CL, Gauvin L, Katzmarzyk PT. Tracking of obesity and physical activity fromchildhood to adulthood: the Physical Activity Longitudinal Study. International Journal of PediatricObesity. 2009; 4:281-288.27 Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity:payer-and service-specific estimates. Health Affairs 2009: 5:w822-w831.28 Ibid.

28 Press Release: Overweight and Obesity Threaten US Health Gains. Dec. 13, 2001. HHS News, US Department of Health andHuman Services.28 Center for Disease Control Website, http://www.cdc.gov/obesity/stateprograms/fundedstates.html28 Let’s Move! Website, http://www.letsmove.gov/about28 The United States Department of Agriculture Website, http://www.fns.usda.gov/tn/healthierus/index.html28 White House Task Force on Childhood Obesity Report to the President: Solving the Problem of Childhood Obesity Within aGeneration. May 2010.28 National School Lunch Fact Sheet, United States Department of Agriculture, August 2012 (Alexandria, VA). Retrieved from

http://www.fns.usda.gov/cnd/lunch/AboutLunch/NSLPFactSheet.pdf29 Press Release: Overweight and Obesity Threaten US Health Gains. Dec. 13, 2001. HHS News, US Department of Health andHuman Services.30 Center for Disease Control Website, http://www.cdc.gov/obesity/stateprograms/fundedstates.html31 Let’s Move! Website, http://www.letsmove.gov/about32 The United States Department of Agriculture Website, http://www.fns.usda.gov/tn/healthierus/index.html33 National School Lunch Fact Sheet, United States Department of Agriculture, August 2012 (Alexandria, VA). Retrieved fromhttp://www.fns.usda.gov/cnd/lunch/AboutLunch/NSLPFactSheet.pdf34 White House Task Force on Childhood Obesity Report to the President: Solving the Problem of Childhood Obesity Within aGeneration. May 2010.35

Tavernise, Sabrina. “Obesity in Young Is Seen as Falling in Several Cities.” The New York Times, December 10, 2012, Pg A1.36 The American Psychological Association, “The Impact of Food And Advertising on Childhood Obesity.”http://www.apa.org/topics/kids-media/food.aspx37 Saffer, Henry. The Effects of Advertising on Alcohol and Tobacco Consumption via the National Bureau for EconomicResearch. http://www.nber.org/reporter/winter04/saffer.html38 Saffer, Henry. The Effects of Advertising on Alcohol and Tobacco Consumption via the National Bureau for EconomicResearch. http://www.nber.org/reporter/winter04/saffer.html39 Ciciora, Phil. Study: Quebec ban on fast-food ads reduced consumption of junk food.http://news.illinois.edu/news/12/0119junkfoodbans_KathyBaylis.html40 Dhar, Tirtha, and Kathy Baylis. "Fast-food consumption and the ban on advertising targeting children: the Quebecexperience." Journal of Marketing Research 48.5 (2011): 799-81341 Rideout, V., U. Foehr, and D. Roberts. “Generation M2: Media in the Lives of 8- to 18-Year-Olds.” Kaiser Family Foundation.Web: http://kff.org/entmedia/upload/8010.pdf42 “It Pays To Advertise: Junk Food Marketing To Children”. Food and Water Watch, November 2012. Retreived from website:http://www.foodandwaterwatch.org/43 Goren, Amir et al. "Predicting support for restricting food marketing to youth." Health Affairs 29.3 (2010): 419-424.44 Kaiser Family Foundation, “The Role of Media In Childhood Obesity”, February 2004. Retrieved fromhttp://www.kff.org/entmedia/upload/The-Role-Of-Media-in-Childhood-Obesity.pdf45 Ibid.46 Blue Cross Blue Shield of Massachusetts. (2005). 2005 Annual Report. Retrieved fromhttps://www.bluecrossma.com/visitor/about-us/annual-report/2005/.47 Bell, J., Rogers, V.W., Dietz, W.H. Ogden, C.L., Schuler, C., & Popovic, T. (2011). CDC grand rounds: Childhood obesity in theUnited States. Morbidity and Mortality Weekly Report (60)2, 42-26.48 Stecker, Eric C., M.D., M.P.H., “The Oregon ACO Experiment — Bold Design, Challenging Execution.” N Engl J Med 2013;368:982-985.49

Interview with Jeanine Stice, MPH, R.D., L.D., March 6, 2013. Mrs. Stice currently serves as the lead nutritional expert forMarion County’s I Love ME 5-2-1-0 program.50 Van Horn, Linda. "Factors Influencing Weight Gain, Weight Loss, and Obesity: More Findings, More Questions". Academy ofNutrition and Dietetics, Vol. 112, Issue 4, April 2012, p.465.51 Keep America Beautiful, Inc., http://www.kab.org/site/PageServer?pagename=about_history Accessed February 4, 2013.52 Hartman, Pat. “5-2-1-0 and the Let’s Go Initiative”, Childhood Obesity News. May 9, 2011. Retrieved fromhttp://childhoodobesitynews.com/2011/05/09/5-2-1-0-and-the-lets-go-initiative53 Kitsap County Public Health Department, Ready, Set, Go! Program:http://www.5210kitsap.com/documents/5210prepostresults_spring2012.pdf54

Neergard, Jennifer Agiestalauran, “Poll: Fight obesity crisis but lay off my junk food”, The Seattle Times, January 13, 2013(from the Associated Press).55 Ibid.56 Hartman, Pat. “5-2-1-0 and the Let’s Go Initiative”, Childhood Obesity News. May 9, 2011. Retrieved fromhttp://childhoodobesitynews.com/2011/05/09/5-2-1-0-and-the-lets-go-initiative

57 Ludwig, D.S. et al. Opportunities to Reduce Childhood Hunger and Obesity. JAMA. Dec. 26, 2012; 308(24): 2567-2568.58 Bronwell, K.D. and Ludwig, D.S. The Supplemental Nutrition Assistance Program, Soda and USDA Policy. JAMA. September28, 2011; 306(12): 1370-1371.59 SNAP’s tagline: http://www.fns.usda.gov/snap/roll-out/logo.pdf60 DeBono, N.L. et al. Does the Food Stamp Program Cause Obesity? A Realist Review and a Call for Place Based Research.Health and Place. 2012; 18(4): 747-756.61 Kimbro, R.T. and E. Rigby, E Federal Food Policy and Childhood Obesity: A Solution or Part of the Problem. Health Affairs.2010; 29(3): 411-41862 Guthrie, J.F. Food sources of Added Sweeteners In the Diets of Americans. Journal of the American Diet Association. 2000;100(1): 43-51.63 Ludwig, D.S., et al. Relation Between the Consumption of Sugar-Sweetened Drinks and Childhood Obesity: A Prospective,Observational Analysis. Lancet. 2001; 357(9255): 505-508.64 Finkelstein, E. A. et al. Annual Medical Spending Attributable to Obesity: Payer and Service Specific Estimates. Health Affairs.2009; 28(5): 822-831.65 Demas, A. et al. Spring 2010. School Meals: a nutritional and environmental perspective. Perspectives in Biology andMedicine. 53(2). 249-256.66 Shenkin, J.D. and Jacobson M.F. Using the Food Stamp Program and Other Methods to Promote Healthy Diets for LowIncome consumers. American Journal of Public Health. 2010; 100(9): 1562-1564.67 Cole N, Fox M. Diet Quality of American Young Children by WIC Participation Status: data from the National Health andNutrition Examination Survey, 1999-2004. In: USDA; 2008.68 Ibid.69 Ibid.70 Ibid.71 Ibid.72 Chiasson, M.A. et al. Changing WIC Changes What Children Eat. ‘Accepted Article’, doi: 10.1002/oby.2029573 Ibid.74 Total Medicaid spending on children in 2012: $50B x .118(obesity related costs) = savings of upwards 5.9B