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ED I TO RI AL

Obesity prevention: snapshot ofUS-based efforts

As a regional editor of the Nutrition Bulletin it gives megreat pleasure to write the editorial for this issue.

Obesity is always a topic of great concern to those in the

nutrition world, having huge implications for our healthand longevity across the globe. It is evident that some-

thing needs to change to alter the course of continuallyrising rates of overweight and obesity around the world.

As such, it is useful to look at programmes intended to

prevent and decrease obesity globally and to assess thecost and effectiveness of such programmes as more evi-dence becomes available.

The United States (US) Centers for Disease Controland Prevention (CDC) reports that over the past 20

years there has been a dramatic increase in obesity in theUS. More than one-third of US adults are obese

(35.7%), while the rate of childhood obesity (ages 219)has tripled since 1980 (CDC 2010). According to the

American Heart Association, about 1 in 3 kids in the USare overweight or obese. According to a report issued by

the Organization for Economic Co-operation and

Development out of Paris, more than half of Europeanadults are overweight or obese (European CommissionEurostat 2011). Obesity rates have doubled in the past

20 years for the 27 member states of the EuropeanUnion. It is estimated that 1 in 7 children in these

member states are obese. The disparity among countriesis significant, however. The prevalence of obesity is less

than 10% in Romania and Italy, but greater than 20%in the UK, Ireland and Malta.

A study in the American Journal of Preventive Medi-

cine (Finkelstein et al. 2012) was reported at the recent

Weight of the Nation Conference in Washington, DC.

Researchers predict that the percentage of obese Ameri-cans will rise from 36% of the adult population today to42% by 2030. Amidst this stark wake-up call the good

news, however, is that the rate of increasing obesity inadult Americans has slowed down somewhat compared

to that which has been recorded over the last 30 years.

Calorie labelling in the US

Many health experts agree that there is an opportunity

to devise strategies to use sales and marketing tech-niques to promote the adaptation of healthy habits. As

a result, point-of-purchase programmes, such as calorielabelling, are being examined in real-world settings

across the globe. In the US, calorie labelling on menus isjust one of the many policy approaches being imple-

mented and studied to combat the increasing prevalenceof overweight and obesity (Mokdad et al. 1999, 2000).

Because calorie labelling has been introduced in onlya handful of cities in the US, one may wonder if this has

really made consumers in those areas make healthierchoices. Has it had an effect on obesity rates in the US?

And if not, what other programmes or interventionshave had successes? Menu labelling as a partial solution

to obesity in the US stems from the idea that more ofAmericans daily calories are coming from food pur-

chased out of home; food that typically contains more

calories, fat and sodium than home-prepared foods

(Swartz et al. 2011). Food away from the home nowaccounts for over 30% of daily caloric intake and 50%of yearly food spending in the US (Swartz et al. 2011).

New York City was the first to introduce calorielabelling. The New York City Health Departments

regulation that required quick-service chain restaurantswith more than 15 outlets to post calorie counts on

menu boards went into effect on 19 July 2008. By 2009,similar labelling was required in localities such as Cali-

fornia, Oregon and Maine, as well as more than a dozenother US cities. Strong opposition from the National

Restaurant Association, which represents, educates and

promotes the restaurant industry, suggests that calorielabelling was not voluntary.

Calorie labelling in restaurants has also been the topic

of several research studies since its introduction in 2008.These studies mainly address whether the initiative has

improved consumers purchases. A systematic review ofthe literature suggested that, in both real-world and

experimental settings in the US, calorie menu labellingon quick-service restaurant menus has no effect or only

a modest effect on calorie ordering and consumption.

Correspondence: Kristen Ciuba, Nutrition Consultant, 122 13th

Street, SE, Washington, DC 20003, USA.

E-mail: kristenciuba@gmail.com

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The authors concluded that, the current evidence sug-gests that calorie labelling does not have the intended

effect of decreasing calorie purchasing or consumption(Swartz et al. 2011).

One of the strongest studies was performed by Finkel-stein et al. (2011) and looked at whether calorie labels

added to chain restaurant labels in King County, Wash-ington State, affected total monthly transactions and

calories per transaction in a real-world setting. The studyincluded 21 randomly selected fast-food restaurants. The

authors found no significant difference in sales volumebetween periods with or without calorie postings.

Longer-term, more rigorous studies may in fact beneeded to investigate whether long-term exposure to

such calorie labelling has an effect on overweight andobesity rates. In addition, further questions must be

addressed, including whether calorie labelling hascaused restaurants to reduce the caloric density of foods

and meals, as well as whether or not the public havegained a greater knowledge of calories in foods and

diets, which could in turn improve health and reducerates of obesity.

Other US initiatives

In light of the current statistics and research on obesity,

efforts are also underway to investigate other avenuesand point-of-sale programmes that may encourage

healthier food choices in the US. Not surprisingly, publichealth experts are focusing on obesity prevention,

noting that the best way to tackle the obesity crisis is toprevent people from becoming obese in the first place.

Given the finding from the landmark Bogalusa HeartStudy that 77% of obese children become obese adults

there is a particular emphasis on children (Freedman

et al. 2001).

Lets Move campaign

Michele Obamas Lets Move campaign (www.letsmove.gov), launched on 9 February 2010, aims to solve the

epidemic of childhood obesity within a generation.

Restaurants meals

One of the recommendations of the Lets Move cam-paign is that, restaurants and vending machines should

display calorie counts of all items offered (FDA 2011).So far, there is not much evidence across the US that this

recommendation has been followed although some posi-tive changes are evident. Healthier options are now

available in many fast-food restaurants, such as the

availability of low-fat milk and fruit with popular kidsmeals. The restaurant chain Darden has also made low-

fat milk and fresh produce a standard in its kids meals.

School food

Recently, strides have also been made on the school foodfront, where Mrs. Obama has placed a particular

emphasis on stopping the growing problem of child-hood obesity. In late 2010, the Healthy, Hunger-Free

Kids Act, as passed in Congress, increased funding forschool breakfasts and lunches above the inflation rate

for the first time in 30 years. The Act also gave theUnited States Department of Agriculture (USDA)

control of nutrition standards for all foods sold onschool property including those in vending machines

and it made the provision of free or reduced-price schoolmeals to children less cumbersome, ensuring that tens of

thousands more children will get the healthy food theyneed. The final rule for the USDAs Healthy, Hunger-

Free Kids Act was released earlier this year and setsstandards for critical improvements to school meals,

including:

ensuring students are offered both fruits and veg-etables every day of the week;

substantially increasing offerings of whole-grain-richfoods;

offering only fat-free or low-fat milk varieties; limiting calories based on the age of children being

served, to ensure proper portion size;

increasing the focus on reducing the amounts of satu-rated fat, trans fats and sodium (USDA 2012).

Physical activity

The Lets Move campaign is also taking on increasingphysical activity with the aim of enhancing opportuni-

ties for school-age children to be physically active. Assuch, a partnership with the US Olympic Committee

was just announced and will provide kids in the US withnew opportunities such as swimming lessons, gymnas-

tics clinics, free memberships at bike racing tracks and

much more (www.letsmove.gov). This is extremelyimportant and can be a springboard for programmes inthe US and globally to engage children and young adults

in physical activity as it is becoming increasingly evidentthat excessive sitting time is a health risk in and of itself

(J. Blundell & S. J. H. Biddle unpublished data).

Grow your own food

At the opposite end of the spectrum, being smaller in

size and closer reaching, there are grass-roots nutrition

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programmes cropping up in cities across the US. Forexample, FarmFresh Market is a Washington, DC-

based organization whose mission is to educate thepublic about food and environmental issues, and

to provide vital economic opportunities for localfarmers. Through grants to local schools, a pro-

gramme was born called FoodPrints. The FoodPrints(www.farmfreshmarket.org) programme builds an

edible schoolyard garden and integrates the garden intothe school curriculum (FoodPrints 2011). Elementary-

age schoolchildren who participate in the programmeas part of their studies learn about where their food

comes from and how important it is to eat fresh, nutri-tious, seasonal foods. FoodPrints also teaches impor-

tant life skills through project-based learning thatincludes hands-on experiences in the garden and the

teaching kitchen (www.farmfreshmarket.org). Thename FoodPrints is a spin-off term taken from the

carbon footprint terminology. Through FoodPrints,children learn about their food prints like a footprint

in the garden, a hand print in the soil and fingerprints inthe kitchen which are essential to growing, preparing

and eating fresh, seasonal foods that are good for per-sonal health, growth and development, as well as the

health of our planet. This approach to nutrition educa-tion with children is creative, engaging and positive,

albeit somewhat more difficult to evaluate because

formal research and evaluations are not in place. So far,unfortunately, neither weight nor body mass index data

are recorded in US public schools, but following these

measurements in a cohort over time may help us under-stand whether this type of programme is useful in low-ering overweight and obesity rates in elementary

schoolchildren.In conclusion, overcoming or halting obesity in the US

will likely be the result of a combination of many effortsto include a variety of health programmes and preven-

tative campaigns. Initiating behaviour change includeworkplace wellness programmes, educational cam-

paigns to promote healthier eating and increase physicalactivity, as well as more effective weight loss pro-

grammes could help. A special emphasis on children and

preventative measures across the population is prudent.Providing greater access to healthy foods both at schooland in local communities is a way to promote positive

behaviour change and can be brought about both fromthe top down, government to consumer, as well as from

the bottom up (e.g. growing fresh fruits and vegetablesin school gardens).

Countries around the globe can learn from the US andbegin programmes now to focus on improving kids

eating habits by providing access to healthier foods and

increasing physical activity in school-age children so asnot to find themselves in the same situation in years to

come. For the time being, the US will see obesity ratesrise, even if the growth is slowed. Success will be seen if

and when the next US generation proves to be healthierand experience lower rates of obesity and obesity-

related chronic diseases.

Kristen CiubaNutrition Consultant

Washington, DC, USA

References

Blundell J & Biddle SJH (unpublished data) Healthy eating and

physical activity: moving towards successful behaviour change

the great north run think tank 2010.

CDC (Centers for Disease Control and Prevention) (2010) Over-weight and obesity. Available at: http://www.cdc.gov/obesity/data/

index.html (accessed 29 May 2012).

European Commission Eurostat (2011) Overweight and obesity

BMI statistics. Available at: http://epp.eurostat.ec.europa.eu/

statistics_explained/index.php/Overweight_and_obesity_-

_BMI_statistics (accessed 29 May 2012).

FDA (Food and Drug Administration) (2011) FDA proposes draft

menu and vending machine labelling requirements, invites public

to comment on proposals. Available at: http://www.fda.gov/

NewsEvents?Newsroom/PressAnnouncements/ucm249474.htm

(accessed 29 May 2012).

Finkelstein EA, Strombotne KL, Chan NL et al. (2011)

Mandatory menu labeling in one fast-food chain in King

County, Washington. American Journal of Preventive Medicine40: 1227.

Finkelstein EA, Khavjou OA, Thompson H et al. (2012) Obesity

and severe obesity forecasts through 2030. American Journal of

Preventive Medicine 6: 56370.

FoodPrints (2011) Fresh farm markets. Available at: http://www.

freshfarmmarket.org/programs/foodprints.php (accessed 29 May

2012).

Freedman DS, Khan LK, Dietz WH et al. (2001) Relationship of

childhood obesity to coronary heart disease risk factors in adult-

hood: the Bogalusa heart study. Pediatrics 108: 7128.

Mokdad AH, Serdula MK, Dietz WH et al. (1999) The spread of

the obesity epidemic in the United States, 19911998. Journal of

the American Medical Association 282: 151922.Mokdad AH, Serdula MK, Dietz WH et al. (2000) The continuing

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Swartz JJ, Braxton D & Viera AJ (2011) Calorie menu labeling on

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the literature. International Journal of Behavioral Nutrition and

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USDA (United States Department of Agriculture) (2012) USDA

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2012/0023.htm (accessed 12 June 2012).

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