Challenging Dogma - Spring 2011

Tuesday, May 10, 2011

Obesity in America: A Public Health Report Card & Action Plan – Paige Williamson

If public health report cards were issued to countries across the globe, the United States would not receive a passing grade with regards to body weight trends. Over the last twenty years, the most dramatic increase in obesity has been shown in the US. According to the Center for Disease Control (CDC), in 2009 thirty-three states had a prevalence of obesity that equaled 25% or greater including nine states with a prevalence greater than 30% (1). In addition, the prevalence of clinically severe obesity seems to be increasing at a faster rate than moderate obesity (2). With trends like this, it is not surprising that the US did not meet the Healthy People 2010 goal to reduce obesity to 15% of the population (3). An analysis using data from the National Health and Nutrition Examination Study (NHANES) projected that if the current trends continue by 2030, 86.3% of adults will be overweight or obese with 51.1% classified as obese. The prevalence of childhood obesity will also double. By 2048, the study estimates all American adults will be overweight or obese (4).

The upward trend of obesity has come with grave costs. Obesity is harmful to the population’s health, psychological well being, and results in steep economic consequences. In 1998, it was estimated that obesity accounted for 78.5 billion dollars (9.1%) of total US medical expenditures. By 2030, the cost is predicted to increase to 860.7-956.9 billion dollars (16-18% of total US health care costs) if the current trends continue (4).

In light of these findings, it is clear that the current public health approaches to combating the complex problem of obesity are inadequate. To start, the built environment has been identified as one of the major contributors to obesity; however, federal legislation aimed at addressing the unhealthy aspects of our environment is limited (5). This is unfortunate as legislation has the potential for instituting positive changes nationwide which would also benefit the country economically. Public policy could clearly impact this epidemic through several areas discussed below.

Portion Control

It has been shown that the rise in obesity rates in the United States have been paralleled by an increase in the consumption of food away from home. Americans spent 26% more of the food dollar on meals purchased outside the home from 1970 to 1996. (6). In addition, portions sizes of commercially available foods have been increasing. For example, twenty years ago a typical soda was portioned at 6.5 ounces, containing 85 kilocalories. Today, the portion has increased to 20 ounces and 250 kilocalories. An average cheeseburger twenty years ago had 333 kilocalories, and now it is estimated to have 590 kilocalories (7). The list of similar portion size increases is endless. With the growing portion sizes, in addition to the increase in eating away from home, it is not surprising that dietary surveys indicate an increase of 200 kilocalories per day per capita over the past few decades (8). Furthermore, it is probably not coincidental that France, whose portion sizes tend to be 25% smaller than the United States, also have lower rates of obesity (6).

How is the government addressing the portion distortion that our country now faces? The United States Department of Agriculture (USDA) does control what youths are served for school meals by dictating fat requirements which ultimately helps control portions. Since the Child Nutrition Reauthorization Healthy, Hunger Free Kids Act of 2010 was implemented, it has also been given the authority to set nutrition standards for all foods regularly sold in schools during the day (9). However, it appears public schools are where their regulations end. Portion control guidelines for the general population are used for educational purposes, but there has been no noted federal legislation implemented to combat this problem.

Physical Activity

Reductions in physical activity have occurred over the last few decades. This decrease has also been linked to the rise in obesity in the United States as it can result in a disproportional energy balance. There are several explanations for this change including the lack of physical activity in schools, reliance on motor vehicles instead of walking, and fewer physical demands at home and work due to modern technology. For example, the national Youth Behavior Risk Survey (YRBS), which surveyed youths from the 9th-12th grades, showed daily participation in physical education classes fell from 41.6% to 33.3% from 1991 to 2009. In addition, computer screen time for use of three hours or more increased from 22.1% in 2003 to 24.9% in 2009 (10). Although data from the Behavior Risk Factor Surveillance System (BRFSS) physical activity analyses (2001-2005) suggest an increase in physical activity among adults, (8.6% increase among women overall, and 3.5% among men) (11), the Healthy People 2010 goal of increasing the proportion of adults who engage in moderate to vigorous activity to at least 50% was not met (3).

Upon review, there are many government funded programs aimed at increasing physical activity in the country today. The USDA website boasts two programs, Small Steps, and We Can, which both have some promising physical activity components (12, 13). For example, Small Steps in Rockland County in New York offers the RC Walks Trail Tracker Program which encourages participation by offering an exchange (awarding prizes) for visiting the county’s parks. The more parks you visit, the more prizes you receive (13). Steps to a Healthier Clark County in Washington also seems to be doing well by increasing its residents’ access to physical activity (12). However, what is offered at these branches of the Small Steps program appears inconsistent with what is offered at other sites. Additionally, participation in these federal programs is voluntary, and several of the states that have the highest prevalence of obesity have a lower number of participating communities or are not involved at all. For instance, the state of Mississippi has the highest percentage of obesity (32% of adults in 2007), but is not listed as a grantee of the Small Steps program (1, 13). In fact, only 17 states are listed including states such as Colorado and California which have lower rates of obesity. Mississippi, Louisiana, and Alabama (the latter two states also have obesity rates greater than 30%) also have a lower number of We Can Intensive Community Sites which does not seem proportional to the prevalence of obesity in these states (1, 12).

As noted previously, physical activity during school has decreased. Proving it is possible to incorporate physical activity in school, the education department in New York City has implemented a citywide comprehensive education program offering classes based on FITNESSGRAM software to students at all grade levels (14). Unfortunately, only a few states require daily physical activity for grades K-12, and the quality of the activity also varies. The federal government has authority over what is offered or taught in public school due to the control it has over funding. The American Heart Association, which recommends 150 minutes per week of physical activity for elementary students, and 225 minutes per week for middle school students, is a strong supporter of federal mandates regarding physical activity in schools. However, to-date this legislation has not been instituted (15).

Food-related Advertising

Although regulated by the Federal Drug Administration (FDA), nutrition marketing on food labels can also be misleading. One recent study which surveyed the labels of packaged products (total of 56,900) in six grocery stories in North Dakota, found 49% of all products contained nutrition marketing. Forty-eight percent of those were high in saturated fat, sodium, and/or sugar (11%, 17%, 31%). Commonly used advertising statements were “good source of calcium; reduced, low, or fat free; and food company’s health symbol”. Products deemed to be promoted to children totaled 9,105 and 71% had nutrition marketing. Of those with marketing geared towards children, 59% were high in saturated fat, sodium, and/or sugar (13%, 13%, 49%) (16).

In light of these findings, the question remains, how is this possible? The regulations of the FDA do not account for the overall nutritional value of a product (17). An item may actually be a good source of calcium, but unhealthy on the whole, which allows corporations to use the art of framing to enhance the appeal of their products. For example, Lucky Charms breakfast cereal is advertised on the box as a good source of calcium and whole grains to help your child “grow up strong”. Imagine if it was marketed as “high in sugar” instead. Smart Choice, introduced in 2008, is an attempt by food companies for self-regulation. However, Consumer Reports analyzed 27 of the leading cereals of which eleven had as much sugar as a glazed doughnut, and some were high in salt or contained no fiber. Twenty-two of these cereals qualified for a Smart Choice label (17).

Food-related television advertising directed at children is also loosely regulated. A recent study indicated that a ban on food advertizing during children’s programs could decrease the prevalence of obesity by 6.5% (18). The Federal Trade Commission has recognized the impact food advertising can have on children for decades, noting in 1978 “television advertising for any product directed to children who are too young to appreciate the selling purpose of, or otherwise comprehend or evaluate, the advertising is inherently unfair and deceptive” (19). However, the commission’s attempt at regulation was met with fierce opposition by broadcasters, ad agencies, and food and toy companies. As a result, Congress passed the FTC Improvements Act of 1980 which prohibited the FTC from instituting any industry-wide regulations or bans for food advertising (19).

In 2005, the FTC and the Institute of Medicine (IOM) held a workshop, titled “Food Marketing to Kids”. In response to the urgings by the agencies for voluntary action after this workshop, the Children’s Food and Beverages Advertising Initiative (CFBAI) was launched by the Council of Better Business Bureaus in 2006. CFBAI initially included ten major food companies that promised to allot half of their child-targeting advertising to promote healthier choices. By 2009, the initiative included sixteen companies of which four (Coca-Cola, Cadbury Plc., Hershey Company, and Mars Inc.) pledged to not advertise food or beverages on programming aimed at children under 12 years old. However, each company is allowed to define what is nutritionally healthier, and also determine what constitutes as children’s programming. (20). It has been argued by the Center for Science in the Public Interest (CSPI) that the BBB’s program “gives the appearance of protecting children from deceptive advertising, but the guidelines are not enforceable and depend on voluntary action by a company. The major flaw is that the guidelines focus on narrow advertising techniques and not the nature of the products being advertized”. (19)

A recent study which evaluated changes in the amount and content of food advertising viewed from 2003 to 2007 by children and adolescents confirms the opinion of the CSPI. Trends involving the parent companies that are members of the CFBAI were also scrutinized. According to the study, although the overall number of food ads seen daily fell by 13.7% and 3.7% (11.5 and 13.1 ads per day) among children ages 2 to 5 and 6 to 11, exposure for adolescents increased. The reductions were explained by decreases in exposure to advertisements for sweets and beverages; however, the exposure to fast food ads increased among all age groups. The results from this study underscore the need for stricter federal legislation regarding advertising food-related products to children, adolescents, and teens to promote more significant population changes (20).

Public policy or legislation is not the only avenue available for instituting nationwide change. Public health campaigns that focus on behavioral modifications can be effective. However, many of the expensive government funded nutrition campaigns used currently are employing techniques aimed at individuals that do not seem to be effective. For example, the 5-a-Day program which is now being referred to as Fruits & Veggies More Matters has focused most of its resources on educating the population about the health benefits of a diet rich in fruits and vegetables (21). An example of one of the campaigns’ misguided commercials includes one featuring Bart Rockett, a magician, who encourages children to make their fruits and vegetables disappear like he did as a child by eating them. It also mentions that eating fruits and vegetables may lessen their risk for cancer (22). Complicated behaviors such as nutrition are not easy to modify with simple messages of health risk and benefits especially when aimed at children who are not future-oriented (23). Despite the efforts of 5-a-day, recent report published by the CDC based on data from the BRFSS shows no state has met the Healthy People 2010 targets for fruits and vegetables (75% of persons aged two years or older eating two or more servings of fruit daily, 50% of persons aged two or older eating three or more servings of vegetables daily) (24).

The USDA’s Food Labeling campaigns which include Make Your Calories Count, Spot the Block, and The Power of Choice are mostly centered around the same theme, individuals are responsible for their own choices (25-27). If you educate, people will change their behavior. BAM, Body & Mind is another program directed towards educating children about their health. It is internet based, and although interactive with cartoons, it also focuses on the individual without much regard for environmental influences (28).

As mentioned previously, federal and state legislation have the power to change the environment, thus changing social norms and influencing the obesity crisis on a larger scale. Changing the environment may be easier as noted in Emerging Theories in Health Promotion Practice and Research, “Corporate practices result from specific decisions and may be more readily changed than the underlying social and economic structures in which they are embedded.” Historically, interventions have been based on individual models of change, but given the marginal progress that has been made, public health groups are also realizing the importance of legislation and other group models (29). For example, the CDC’s Measures Project and the White House Task Force for Childhood Obesity both contained recommendations for changing the environment through public policy. (30-31). The TRUTH campaign which is an anti-smoking campaign for teenagers also had great success using the group theory of social marketing (32).

What exactly is social marketing theory? It is a program planning process that focuses on the “marketing mix” of product, price, place, and promotion. Product refers to the benefits associated with the desired behavior; price is the consumer’s view of the cost; place refers to where and when (environment and social context) the desired behavior will be performed; and promotion is the type of communication used. Additionally, the audience should be segmented into subgroups; their wants and needs should be researched; and the competition must also be known. Most importantly, all of these aspects must be taken into account to maximize the success of a campaign (32). Using the social marketing theory along with framing and legislation will help change some of the issues contributing to the obesity crisis. Below is a list of recommendations addressing the problems presented earlier.

  • To start, portion distortion should be addressed by mandating public service venues limit the portion sizes of all entrees and snack foods.
  • Tax incentives should be offered to all restaurants that follow the USDA guidelines for entrée portions. Social norms regarding the definition a normal portion are more likely to change if the public service venues and restaurants begin to change.
  • As recommended by the American Heart Association, physical activity should be mandated at all elementary (150 minutes per week), middle, and high schools (225 minutes per week) that receive government funding.
  • Each section of the Small Steps program should account for all parts of the marketing mix. For example, as mentioned previously, the Rockland County program identified the product well (in regards to physical activity), and offered an exchange. Conversely, the Clark County program seemed to have assessed the price and place well.
  • All states, especially those that have a prevalence of obesity over 30%, should be required to participate in government run physical activity programs.
  • Food-related television advertising to children should be banned.
  • If a complete ban on food-related advertising to children is rejected, advertisements framing food corporations as being uncaring, untrustworthy, and taking advantage of the population for the bottom line should be created. If the companies feel pressure from the public, maybe they will be more likely to enforce stricter self-regulations with health professionals input.
  • Healthy choice guidelines should be developed by the USDA for advertising overall nutritious products. A product should have to meet these guidelines to advertise on the front of product label.
  • The 5-a-Day program should also take the marketing mix into account. It uses health as the product or exchange for eating five fruits and/or vegetables daily. Health does not appear to be the main motivator of consumers. Segmenting the audience would be make it easier to research the wants and needs of a particular group. Additionally, it did not seem to account for the fact that eating five fruits and vegetables daily can be expensive. Also, are these products easy to find? Public health programs need to research the accessibility prior to initiating a campaign.
  • Campaigns should use catchy promotions like the Let’s Move program. Recruiting Beyonce, a popular celebrity, to create a music video aimed at increasing physical activity among children was an excellent idea for the advertising piece. Making sure the audience will relate to the spokesperson will help ensure success.
  • Finally, programs need to be a joint effort of all government agencies. Based upon a brief internet search, numerous nutrition and physical activity programs were found. However, many seem to have overlapping components while completely missing other important aspects. All government funded nutrition and physical activity programs should be evaluated to ensure funding is being utilized properly.

Obesity in the United States is a complex problem, and thus difficult to treat.

It is clear based on the statistics for weight trends that the approach of “educate the individual and he will change” is outdated. The environment in which we live has made it a difficult task to follow a healthy lifestyle even with all of the right educational tools. Our surroundings are hindering not only the treatment, but the prevention of obesity. Given this is not a problem for just one or two states but for the country as a whole, instituting legislation seems to be one of the best options for establishing change.

On the other hand, the resources allotted to the obesity crisis are being spent on some programs, such as the 5-a-Day, which are not successful or not well-planned. Other programs have some good aspects, but are missing vital components. We would do well to take a page from the corporations, who successfully utilize concepts such as social marketing, advertising, and framing, to help build superior public health programs. If public health messages were more appealing and well thought out; if resources were made available; and if legislation was implemented to help change the environment, maybe then the United States would receive a passing grade on its report card.


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