Preventing childhood obesity _ health in the balance_clone

4 A National Public Health Priority A lthough the general public has become increasingly aware of the personal health consequences of obesity, what may not yet be gen- erally apparent is the public health nature of the obesity epidemic and the consequent need for population-based approaches to address it. Obesity prevention should be public health in action at its broadest and most inclusive level, as is true for the ongoing efforts to prevent youth from smoking. For example, local communities are passing ordinances that ban or limit cigarette vending machines, schools and community youth organi- zations are discouraging or banning smoking, states are passing excise taxes to raise tobacco prices, the federal government is providing national leader- ship and the resources for research and programs, and the private sector is restricting smoking in workplaces (Box 4-1) (Economos et al., 2001; IOM, 2003). In addition, a broad, complementary, and continuing campaign aimed at reducing adult smoking continues to be conducted. The 2004 Surgeon General’s report on tobacco use emphasized that “a comprehen- sive approach—one that optimizes synergy from a mix of educational, clinical, regulatory, economic, and social strategies—has emerged as the guiding principle for effective efforts to reduce tobacco use” (DHHS, 2004). A similarly broad-based approach is needed for childhood obesity pre- vention. Across the country these efforts are beginning. As discussed throughout this report, current efforts range from new school board poli- cies and state legislation regarding school physical education requirements and nutrition standards for beverages and foods sold in schools to commu- nity initiatives to expand bike paths and improve recreational facilities. 125

126 PREVENTING CHILDHOOD OBESITY BOX 4-1 Comprehensive Efforts to Address Public Health Concerns Highway Safety: • Federal government: Safety regulations for new vehicles; highway design and safety regulations; establishment of the National Highway Traffic Safety Ad- ministration; state and community grant programs; research funding • State and local governments: Highway safety offices; primary enforcement of safety belt laws; alcohol-impaired-driving laws; requirements for licensing and driver education; motor vehicle inspections • Public support and advocacy: Citizen advocacy groups (e.g., Mothers Against Drunk Driving) • Research • Media campaigns • Education: Driver education; parent education regarding safety seats Tobacco: • Federal government: Airline smoking ban; warnings on tobacco packages; research funding; Surgeon Generals’ reports; establishment of the Office on Smoking and Health • State and local governments: Excise taxes, laws that establish smoke-free workplaces and public locations • Public support and advocacy: Grassroots efforts to prevent exposure to sec- ond hand smoke; community coalitions (e.g., ASSIST) • Research • Media campaigns • Education: School-based programs NOTE: This box denotes only selected examples of the multiple approaches used to address each public health problem. SOURCES: IOM, 1999, 2003; Economos et al., 2001. Parallel and synergistic efforts to prevent adult obesity, which will contrib- ute to improvements in health for the U.S. population at all ages, are also beginning. Grassroots efforts made by citizens and organizations will likely drive many of the obesity prevention efforts at the local level and can be instrumental in driving policies and legislation at the state and national levels (Economos et al., 2001). A policy analysis by Kersh and Morone (2002) shows that three of the seven common triggers for strong public action in response to a public health problem are beginning to be activated with respect to the U.S. obe- sity epidemic: social disapproval that shifts the social norm, evidence-based medical research, and self-help movements for overweight and obese indi- viduals. Other triggers that have worked successfully for public health problems such as tobacco, alcohol, and illicit-drug use (a widespread coor- dinated movement or campaign; fear of problem-related behaviors or re-

A NATIONAL PUBLIC HEALTH PRIORITY 127 lated culture, such as the drug culture; coordinated interest group advo- cacy; and targeting of groups or industries contributing to the problem) are not yet fully in place for obesity prevention or may not be relevant to this issue (Kersh and Morone, 2002; Haddad, 2003). The additional impetus that is needed is the political will to make childhood obesity prevention a national public health priority. Effective prevention efforts on a nationwide basis will require federal, state, and local governments to commit sufficient resources for surveillance, research, programs, evaluation, and dissemination. As the nation focuses on obesity as a health problem and begins to address the societal and cultural issues that contribute to excess weight, poor food choices, and inactivity, many different stakeholders will need to make difficult trade-offs and choices. Industries and businesses must re- examine many of their products and marketing strategies. Governments at the local, state, and national levels must consider this issue in setting priori- ties for programs and resources. Schools need to ensure that consistent messages regarding energy balance are a basic part of the school environ- ment. Community organizations and numerous other stakeholders must examine the ways in which local opportunities for a healthful diet and physical activity are made accessible, available, affordable, and acceptable to children, youth, and their parents. Families need to make their homes more conducive to a healthful diet and daily physical activity. Many of these changes will be challenging because they present Americans with difficult trade-offs. However, as institutions, organizations, and individuals across the nation begin to make changes, societal norms are likely to change as well; in the long term, we may become a nation where proper nutrition and physical activity that support energy balance at a healthy weight will become the standard. Within the United States and globally, attention is being focused on obesity prevention efforts. A number of interest groups, coalitions, national governments, and intergovernmental organizations have examined the ris- ing obesity and chronic disease problems in a variety of contexts, recog- nized its complicated nature, and proposed actions to reduce its prevalence both nationally and globally (e.g., WHO, 2000, 2003; DHHS, 2001; Health Council of the Netherlands, 2003; National Board of Health, 2003; New South Wales Department of Health, 2003; Canadian Institute for Health Information, 2004; Lobstein et al., 2004; Raine, 2004; United Kingdom Parliament, 2004; Willett and Domolky, 2004). Many of the strategies and action plans that have been developed from these efforts do not differ greatly from the recommendations in this report. The committee has gained insights from these efforts, and in this report draws together the evidence on obesity prevention, nutrition, and physical activity with the lessons learned from other public health issues (Box 4-2) to develop an action plan for childhood obesity prevention that is as informed, responsive, and realis-

128 PREVENTING CHILDHOOD OBESITY BOX 4-2 Lessons Learned from Other Public Health Issues and Potential Applicability to Obesity Prevention (see Appendix D) • Advertising—Although obesity prevention does not involve restricted products to minors as is pertinent for tobacco and alcohol product advertising, there are similar concerns regarding young children’s inability to detect persuasive intent. • Consumer information—Providing information to consumers has many paral- lels including the need for label information on tobacco, food, and drug prod- ucts. • Public education campaigns to convey public health messages such as those regarding youth smoking, and seat belt and child car seat use provide exam- ples for obesity prevention media campaigns. • Grassroots efforts and coalition building—Community organizations (in- cluding youth and civic organizations) are active in health promotion efforts and coalitions resulting from grassroots efforts have been successful in legislative and social changes (e.g., drunk driving laws). • School environment—Changes to promoting a healthier overall school envi- ronment have parallels in smoking bans in schools. Further, classroom educa- tion and particularly health education efforts focus on a number of health pro- motion topics including safety, HIV prevention, and violence prevention. • Health-care system—As with numerous other health promotion issues, the health-care system provides opportunities for parent and child education as well as for prevention interventions such as administering vaccines. • Changes in the physical environment—Modifications of highways, roads, and intersections to enhance pedestrian and traveler safety provide parallel examples for the funding, regulatory, and prioritization efforts required to en- hance opportunities for physical activity. • Government support and funding—The long-term commitment from both federal and state governments for research, surveillance, and program efforts on a number of public health issues (e.g., highway improvements, research centers, surveys) provides parallels for sustained efforts on obesity prevention. • Industry involvement—Numerous health-promoting products such as sun- screens are developed and marketed by industry. • Comprehensive approach—As indicated in Box 4-1, comprehensive ap- proaches have been used in enhancing highway safety and in preventing to- bacco use by youth. A similar comprehensive effort is suggested for obesity prevention. • Taxation and pricing—Obesity prevention efforts do not involve access to a restricted product for youth (as do tobacco and alcohol prevention efforts). Ex- cise taxes and pricing strategies have played an important role in tobacco con- trol efforts. However, it is more difficult to identify specific food and beverage products on which to impose taxes or tax breaks. • Litigation changed the tobacco control environment including the public’s view of the issue. It is unclear whether the same issues that led to litigation for tobacco are relevant to obesity prevention. • Access and opportunity—For restricted products, laws and regulations to restrict access to tobacco and alcohol have decreased availability. The ubiqui- tous nature of foods and beverages makes that a less feasible option for obe- sity prevention.

A NATIONAL PUBLIC HEALTH PRIORITY 129 tic as possible. The committee acknowledges, as have many other similar efforts, that obesity prevention is a complex issue, that a thorough under- standing of the causes and determinants of the obesity epidemic is lacking, and that progress will require changes not only in individual and family behaviors but also in the marketplace and the social and built environ- ments. No simple solutions are anticipated; therefore, multiple stakeholders need to make a long-term commitment to improve opportunities for health- ful nutrition and physical activity. Although this chapter focuses on actions that need to be taken by the federal, state, and local governments, it is essential to mobilize and involve the numerous private organizations that fund obesity prevention programs and initiatives. It is in the best interest of the nation’s children for all relevant stakeholders to make obesity prevention efforts a priority. The committee recognizes the importance of combined social delibera- tion, problem analysis, and social mobilization around the issue of child- hood obesity prevention at different levels and in various settings. This report and others that follow can set forth recommendations and broadly outline suggested actions; however, many of the next steps for progress on this issue will involve discussions and interactions of the implementers and innovators—the people, agencies, and organizations concerned about this issue and ready to work together to develop, implement, and evaluate approaches to prevent childhood obesity that fit the needs of their state, county, community, school, or neighborhood. LEADERSHIP, COORDINATION, AND PRIORITY SETTING A National Priority The federal government has a long-standing commitment to programs that address nutritional deficiencies (beginning in the 1930s) and encourage physical fitness, but only recently has obesity been targeted. Physical activ- ity and overweight/obesity are now designated as priority areas and leading health indicators in the nation’s health objectives, Healthy People 2010, developed by the Department of Health and Human Services (DHHS) in collaboration with state and territorial health officials and numerous na- tional membership organizations. The goal set by Healthy People 2010 is to reduce the proportion of children and adolescents who are obese to 5 percent by 2010 (DHHS, 2000). Obesity prevention is a cross-cutting issue that does not naturally fall under the purview of any one federal department. It encompasses health concerns central to the mission of DHHS; nutrition, nutrition education, and food-related issues for which the U.S. Department of Agriculture (USDA) has responsibilities; and school curriculum and school environ-