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Why food policy and obesity policy are not synonymous: The need to establish clear obesity policy in the United States

December 2015
International Journal of Obesity 39(12):1667-1668

DOI:10.1038/ijo.2015.191

Authors:

Fatima Cody Stanford

Massachusetts General Hospital

Theodore K Kyle

ConscienHealth

The impact of obesity on the health of Americans has led public health authorities to describe it as the ‘greatest single threat to public health in this century’.¹ The prevalence of overweight and obesity in adults (20 years) is 69% and 31.8% in children and adolescents (2–19 years).² Diverse and distinct national initiatives have sought to address obesity. These include the First Lady’s Let’s Move Campaign, Healthy People 2010 and 2020, the Institute of Medicine’s plan to measure progress in obesity prevention, the Strategic Plan for the National Institutes of Health Obesity Research and the American Medical Association’s acknowledgement of obesity as a disease at their 2013 annual meeting.

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EDITORIAL

Why food policy and obesity policy are not synonymous: the

need to establish clear obesity policy in the United States

International Journal of Obesity (2015) 39, 1667–1668; doi:10.1038/

ijo.2015.191

The impact of obesity on the health of Americans has led public

health authorities to describe it as the ‘greatest single threat to

public health in this century’.

The prevalence of overweight and

obesity in adults (⩾20 years) is 69% and 31.8% in children and

adolescents (2–19 years).

Diverse and distinct national initiatives

have sought to address obesity. These include the First Lady’s

Let’s Move Campaign, Healthy People 2010 and 2020, the

Institute of Medicine’s plan to measure progress in obesity

prevention, the Strategic Plan for the National Institutes of Health

Obesity Research and the American Medical Association’s

acknowledgement of obesity as a disease at their 2013 annual

meeting. Although these initiatives each have merit, the United

States has yet to develop comprehensive obesity policy. The US

experience differs from other developed countries—notably

England, France and Germany—which have developed multi-

sector approaches to tackle this disease under coherent national

strategies.

3,4

Much of US policy to address obesity is founded upon a widely

held belief that obesity is only attributable to excess intake of

calories and physical activity deﬁcits. The Scientiﬁc Report of the

2015 Dietary Guidelines Committee describes obesity as ‘a

persistent, prevalent, preventable health problem,’and charac-

terizes it as having ‘a nutritional origin.’Obesity is a complex

disease process in which numerous factors such as behavior (for

example, diet quality, exercise and sleep), genetics, physiology,

psychosocial and transgenerational factors affect energy intake

and expenditure.

5–7

Individuals may develop obesity when energy

intake (that is, feeding) exceeds energy expenditure (that is, basal

metabolism, adaptive thermogenesis and physical activity).

policymakers have denied the intricate nature of obesity,

strategies to address obesity largely rely upon food policy. Many

statewide and local initiatives have sought to reduce the

consumption of sugar sweetened beverages, display nutrition

facts in restaurants and increase consumption of fruits and

vegetables. Yet, these food policy initiatives, employed on a

population level, have yet to produce objectively veriﬁable effects

on obesity rates. For example, efforts to increase access to grocery

stores have not improved fruit and vegetable consumption or

reduced body mass index,

and the Los Angeles ‘fast food ban’

failed as the rates of persons with overweight and obesity

increased during the ban.

Although food policy initiatives may

have a role in obesity policy, they should be part of a larger policy

in which stakeholders from academia, government, industry,

technology, law, medicine, public health and education collabo-

rate on ways to reduce obesity rates and consequent health

impact.

National obesity policies in other developed countries provide

meaningful points of reference. In England, the primary obesity

policy is Healthy Lives, Healthy People: A Call to Action in Obesity

in England. In a trans-disciplinary approach, policymakers

collaborate with the Obesity Review Group, established to bring

together leaders in academics, industry, non-governmental

organizations and public health.

France launched their ﬁrst

obesity policy in 2001. Their current plan, the National Nutrition

and Health Programme 2011–2015, is a multi-sector effort

involving nine ministries and partners.

Germany also has a

federal cross-sector National Action Plan for the Prevention of

Poor Dietary Habits, Lack of Physical Activity, Overweight and

Related Disease, known as IN FORM (the German national initiative

to promote healthy diets and physical activity). Their ﬁve areas of

focus include the federal government, federal states and

communes, information on health (with particular attention to

diet and physical activity), quality of eating away-from-home, and

research.

The ‘multi-sector approach’is the common thread in

the national policies in England, France and Germany. Although

these plans are by no means perfect, they do provide reference

points which the United States might use to develop a federal

obesity policy (Table 1). Objective measures of outcomes from

these plans are sparse. Most evaluations have focused on changes

in behaviors but there is limited information available on the

effectiveness of these national policies on obesity prevalence.

12,13

For an example of a national policy on nutrition that has had a

measurable impact on health outcomes, one might consider the

experience with a multi-sector effort to reduce exceptionally high

sodium consumption in Finland that began in the 1970s.

This

effort involved diverse stakeholders, including the food industry,

and produced well-documented reductions in objective biological

markers of cardiovascular disease risk. Certainly reduction in the

health burden of obesity presents a more complex task, but this

experience may offer important insights for more effective

national obesity policies.

Never before in our nation’s history has a chronic disease

affected such a large portion of the population. Owing to the

tremendous breadth of the problem, strategies must be devel-

oped and deployed in innovative ways. Large corporations such as

Coca-Cola, McDonald’s and Nestlé, or agribusiness companies

such as Cargill and Monsanto will inevitably play a role—either to

help advance the work in this ﬁeld or to impede it. Such non-

traditional partners might serve as allies in more effective national

efforts to reduce obesity rates.

Evidence suggests some large corporations can have a

successful impact on the health of their consumers. Cargill,

one of the world’s leading distributors, marketers and proces-

sors of agricultural, food, ﬁnancial and industrial products and

the largest privately held company in the United States,

underwent a self-initiated strategic re-development of ‘nutrition

and health solutions’. Their goal was to improve baseline

nutrient levels and deliver health beneﬁts such as disease

resistance, therapeutics and wellness through establishing

partnerships with technology companies in food applications,

health and nutrition.

Substantial apprehension is commonly expressed about colla-

boration with food corporations because of high levels of distrust.

Drawing analogies to the tobacco industry, some observers have

suggested that the food industry will only frustrate efforts to

reduce obesity.

Yet recent studies have shown that food

corporations might play a signiﬁcant role in reduction of caloric

intake in the United States. The Healthy Weight Commitment

Foundation (HWCF), whose members include 16 of the nation’s

largest consumer packaged goods (CPG) food and beverage

manufacturers, pledged to collectively sell 1 trillion fewer

calories in the US marketplace by 2012 (against a 2007 baseline).

International Journal of Obesity (2015) 39, 1667–1668

www.nature.com/ijo

The 16 HWCF companies collectively sold ~ 6.4 trillion fewer

calories (–10.6%) in 2012 with a total reduction in CPG caloric sales

of 99 kcal per capita per day. An objective evaluation of food

industry compliance with calorie reduction pledges suggests the

food industry could contribute substantially to efforts to improve

American health.

Successful policies must incorporate diverse

perspectives to achieve signiﬁcant change in obesity in the United

States. The historical focus on behavioral efforts to address obesity

has produced limited results. Whether at an individual or

population level, efforts to change behavioral factors related to

obesity have yet to yield substantial changes in obesity

prevalence.

As the evidence base in obesity medicine grows,

better understanding of factors that play a role in obesity will

inform policy efforts and ground them in scientiﬁc understanding

of the disease process.

In no case to date has one policy prevailed as the ‘the solution’

to treat obesity and thus numerous failures along the way are

likely. Efforts to reduce the impact of obesity over the last 20 years

have focused almost exclusively on changing dietary and physical

activity behaviors—either at an individual or at a population level.

Little objective evidence for a meaningful impact upon obesity

prevalence can be found. We propose that a more complete

approach is needed to address the complex physiology of obesity,

its transgenerational effects and the importance of diverse

stakeholders, including the food industry.

CONFLICT OF INTEREST

FCS reports personal fees from American Academy of Nutrition and Dietetics

and Ebsco/Dynamed outside the submitted work.TKK reports personal fees

from Novo Nordisk, 3D Communications, EnteroMedics, and Eisai outside the

submitted work.

FC Stanford

1,2,3

and TK Kyle

4,5

MGH Weight Center, Department of Medicine, Division of

Gastroenterology, Massachusetts General Hospital,

Boston, MA, USA;

Department of Pediatrics, Mongan Institute of Health Policy,

Boston, MA, USA;

Harvard Medical School, Boston, MA, USA;

ConscienHealth, Pittsburgh, PA, USA and

Obesity Action Coalition, Tampa, FL, USA

E-mail: fstanford@mgh.harvard.edu

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1 US Department of Health and Human Services. Dietary Guidelines for Americans,

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3 Health EAftSoOaCCf. Obesity Perception and Policy: Multi-country review and

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2014/05/C3_EASO_Survey_A4_Web-FINAL.pdf (accessed on 28 April 2015).

4 Oyebode O, Mindell J. Use of data from the Health Survey for England in obesity

policy making and monitoring. Obes Rev 2013; 14:463–476.

5 Archer E. The childhood obesity epidemic as a result of nongenetic evolution: the

maternal resources hypothesis. Mayo Clinic Proc 2015; 90:77–92.

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Table 1. Key factors to consider in the development of federal obesity policy in the United States

1. Involve multiple sectors to address the problem (for example, academia, education, government, industry, law, medicine).

2. Learn from other developed countries that have implemented federal obesity policy.

3. Align obesity policy with measureable obesity targets over regular time frames.

4. Incorporate known factors that contribute to obesity (for example, behavior, genetics, physiology) in obesity policy development.

5. Review strategies employed in the ﬁght against tobacco that might be beneﬁcial in obesity policy.

6. Study successful local and state initiatives that might be enacted on a national scale.

7. Ensure that obesity policy evolves to reﬂect our understanding of the disease process.

8. Utilize research to inform strategies that might be successful on a population level.

9. Incorporate culturally appropriate strategies to inform obesity policy for racial and ethnic minorities.

Editorial

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Feb 2014
J Am Med Assoc

More than one-third of adults and 17% of youth in the United States are obese, although the prevalence remained stable between 2003-2004 and 2009-2010. To provide the most recent national estimates of childhood obesity, analyze trends in childhood obesity between 2003 and 2012, and provide detailed obesity trend analyses among adults. Weight and height or recumbent length were measured in 9120 participants in the 2011-2012 nationally representative National Health and Nutrition Examination Survey. In infants and toddlers from birth to 2 years, high weight for recumbent length was defined as weight for length at or above the 95th percentile of the sex-specific Centers for Disease Control and Prevention (CDC) growth charts. In children and adolescents aged 2 to 19 years, obesity was defined as a body mass index (BMI) at or above the 95th percentile of the sex-specific CDC BMI-for-age growth charts. In adults, obesity was defined as a BMI greater than or equal to 30. Analyses of trends in high weight for recumbent length or obesity prevalence were conducted overall and separately by age across 5 periods (2003-2004, 2005-2006, 2007-2008, 2009-2010, and 2011-2012). In 2011-2012, 8.1% (95% CI, 5.8%-11.1%) of infants and toddlers had high weight for recumbent length, and 16.9% (95% CI, 14.9%-19.2%) of 2- to 19-year-olds and 34.9% (95% CI, 32.0%-37.9%) of adults (age-adjusted) aged 20 years or older were obese. Overall, there was no significant change from 2003-2004 through 2011-2012 in high weight for recumbent length among infants and toddlers, obesity in 2- to 19-year-olds, or obesity in adults. Tests for an interaction between survey period and age found an interaction in children (P = .03) and women (P = .02). There was a significant decrease in obesity among 2- to 5-year-old children (from 13.9% to 8.4%; P = .03) and a significant increase in obesity among women aged 60 years and older (from 31.5% to 38.1%; P = .006). Overall, there have been no significant changes in obesity prevalence in youth or adults between 2003-2004 and 2011-2012. Obesity prevalence remains high and thus it is important to continue surveillance.

Diet and Obesity in Los Angeles County 2007–2012: Is there a measurable effect of the 2008 “Fast-Food Ban”?

Article

Mar 2015

We evaluate the impact of the "Los Angeles Fast-Food Ban", a zoning regulation that has restricted opening/remodeling of standalone fast-food restaurants in South Los Angeles since 2008. Food retail permits issued after the ban are more often for small food/convenience stores and less often for larger restaurants not part of a chain in South Los Angeles compared to other areas; there are no significant differences in the share of new fast-food chain outlets, other chain restaurants, or large food markets. About 10% of food outlets are new since the regulation, but there is little evidence that the composition has changed differentially across areas. Data from the California Health Interview Survey show that fast-food consumption and overweight/obesity rates have increased from 2007 to 2011/2012 in all areas. The increase in the combined prevalence of overweight and obesity since the ban has been significantly larger in South Los Angeles than elsewhere. A positive development has been a drop in soft drink consumption since 2007, but that drop is of similar magnitude in all areas. Copyright © 2015 Elsevier Ltd. All rights reserved.

Patchy progress on obesity prevention: Emerging examples, entrenched barriers, and new thinking

Article

Feb 2015

Despite isolated areas of improvement, no country to date has reversed its obesity epidemic. Governments, together with a broad range of stakeholders, need to act urgently to decrease the prevalence of obesity. In this Series paper, we review several regulatory and non-regulatory actions taken around the world to address obesity and discuss some of the reasons for the scarce and fitful progress. Additionally, we preview the papers in this Lancet Series, which each identify high-priority actions on key obesity issues and challenge some of the entrenched dichotomies that dominate the thinking about obesity and its solutions. Although obesity is acknowledged as a complex issue, many debates about its causes and solutions are centred around overly simple dichotomies that present seemingly competing perspectives. Examples of such dichotomies explored in this Series include personal versus collective responsibilities for actions, supply versus demand-type explanations for consumption of unhealthy food, government regulation versus industry self-regulation, top-down versus bottom-up drivers for change, treatment versus prevention priorities, and a focus on undernutrition versus overnutrition. We also explore the dichotomy of individual versus environmental drivers of obesity and conclude that people bear some personal responsibility for their health, but environmental factors can readily support or undermine the ability of people to act in their own self-interest. We propose a reframing of obesity that emphasises the reciprocal nature of the interaction between the environment and the individual. Today's food environments exploit people's biological, psychological, social, and economic vulnerabilities, making it easier for them to eat unhealthy foods. This reinforces preferences and demands for foods of poor nutritional quality, furthering the unhealthy food environments. Regulatory actions from governments and increased efforts from industry and civil society will be necessary to break these vicious cycles. Copyright © 2015 Elsevier Ltd. All rights reserved.

Treating obesity seriously: When recommendations for lifestyle change confront biological adaptations

Article

Feb 2015

Changing the Future of Obesity: Science, Policy, and Action

Article

Jan 2012

Over the past 3 decades, the prevalence of obesity has increased worldwide, affecting all countries and segments of society. Despite overwhelming evidence showing the devastating consequences of inaction on human health, the health care system, society, and the economy, there is no clear consensus on effective policy or programmatic strategies to combat obesity. The necessary actions to reverse current obesity patterns are well known. Sustained interventions are required at several levels, including the government, food industry, individual behavior, the education system, homes, and workplaces, as well as agriculture and food services. Efforts to address this growing problem have been sporadic and ineffective largely due to government apathy or inaction, opposition by the food industry, the high costs required, and cultural norms. The current policy is one of indecision and inaction. This review provides evidence on strategies for preventing obesity and links emerging scientific evidence on clinical efficacy and cost-effectiveness with concerns of policy makers on the feasibility of implementation and the sustainability of suggested interventions. The rise in obesity has been associated with effective marketing by the food industry of high calorie, highly processed, inexpensive food and beverages to adults and especially children. Regulation of the marketing of these food products has been a focus of policy strategies to combat obesity. Nearly all the food policies recommended as priority actions have been vigorously opposed by the food industry. Modeled forecasts suggest that projected rates of obesity will affect future life expectancy and have detrimental effects on the economy. Validated energy gap mathematical models have demonstrated the dynamic relationship of changes in dietary intake and physical activity to weight change. However, few rigorous studies have examined the cost-effectiveness of suggested interventions or policy changes, which should be a priority of policy makers for implementation. The recent development of a new systems approach to prevent obesity using quantitative modeling has important policy implications and shows the need for integrated multifaceted initiatives by governments and across several sectors (including the private sector, civil society, and international organizations) to develop an overall coordinated strategy. Governments must take an active leadership role in these initiatives, establish priorities in public policies and provide substantially more funding for obesity monitoring and prevention programs. In addition to the health sector, nonhealth sectors, such as agriculture, finance, trade, transportation, education, and urban planning, may have great influence in creating and sustaining policies and environments conducive to prevention. The recent UN High-Level Meeting on noncommunicable diseases was a call to action for the international community to take a leadership role in the fight against obesity. None of the UN member states have adequately addressed this problem. The framework of a global approach to obesity control encompasses a wide range of public health service policies, health promotion programs, and the socioeconomic determinants of health. It is unclear at present whether policy makers are willing or able to make the difficult choices required to meet this growing threat to human health, society, and the economy.

New Neighborhood Grocery Store Increased Awareness Of Food Access But Did Not Alter Dietary Habits Or Obesity

Article

Feb 2014
HEALTH AFFAIR

National and local policies to improve diet in low-income US populations include increasing physical access to grocery stores and supermarkets in underserved neighborhoods. In a pilot study that evaluated the impacts of opening a new supermarket in a Philadelphia community considered a "food desert"-part of the Pennsylvania Fresh Food Financing Initiative-we found that the intervention moderately improved residents' perceptions of food accessibility. However, it did not lead to changes in reported fruit and vegetable intake or body mass index. The effectiveness of interventions to improve physical access to food and reduce obesity by encouraging supermarkets to locate in underserved areas therefore remains unclear. Nevertheless, the present findings suggest that simply improving a community's retail food infrastructure may not produce desired changes in food purchasing and consumption patterns. Complementary policy changes and interventions may be needed to help consumers bridge the gap between perception and action. The replication of our findings in other settings and research into the factors that influence community residents' receptivity to improved food access are urgently required.

Use of data from the Health Survey for England in obesity policy making and monitoring

Article

Mar 2013
OBES REV

Health data and statistics are the foundation of health policy. Over the last 20 years, numerous government documents have been commissioned and published to inform obesity strategies in the UK. The Health Survey for England, an annual cross-sectional survey of a nationally representative random general population sample in England, collects information on health, lifestyle and socioeconomic factors, physical measurements and biological samples. Heights and weights measured by the Health Survey for England are believed to have played a major part in promoting, shaping and evaluating obesity strategies. A formal review of how these data have been used has not been conducted previously. This paper reviews government documents demonstrating the contribution of Health Survey for England examination data to every stage of the policy making process: Measurement data are needed and used by governments to produce evidence-based strategies to combat obesity.