Learning Objectives

The reader will be able to:

• Describe how obesity is contributing to rising healthcare costs borne by all members of society and explain how that fact shapes public support for measures such as taxes or legislation to address obesity.
  
• Describe the social determinants of health and how they relate to obesity.
  
• List three major characteristics of a public health approach to a health problem and provide several examples of such an approach.
  
• Describe the “ecological model” for addressing obesity.
  
• Describe the difference between “internal validity” and “external validity” of public health interventions and discuss the challenges presented when an intervention is scaled up to reach a target population.
  
• Discuss ways in which other public health problems such as drunk driving or smoking provide useful “lessons learned” for addressing obesity.
  
• Identify factors that have contributed to successful public health initiatives in general that will likely apply to obesity in particular.
  
• Discuss how a public health approach to obesity would be undertaken that reflects the complexity of the factors contributing to obesity.

Introduction

A 2001 national survey found that almost 80% of Americans did not think that public health had touched their lives in any way (1). This is an astonishing statistic following the 20th-century advances in public health that have eradicated smallpox, established successful vaccination programs for measles and whooping cough, enacted laws on mandatory seat belt use, more rigorous standards for motor vehicle construction, and so on. But as David Tuller (1) has pointed out, the public health field is a victim of its own success: “When it works as it should, it’s invisible.” It becomes invisible when people buckle up in their automobiles without thinking about it. It is also invisible when it prevents bad things from happening, such as the recent stemming of the swine flu epidemic. Part of the problem is that people know little about the public health community, what a public health strategy is, or how it has touched their lives.

According to C. E. A. Winslow, “public health is the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals” (2). To this list we should add federal, state, and perhaps most important of all, local government officials, who develop legislation, regulations, programs, community resources, and policies that profoundly affect public health.

There are several defining characteristics of a public health approach to a health problem. First, it devises population-wide strategies to prevent disease rather than strategies that target the individual. Second, it relies on surveillance—the collection of data—to document the emergence, extent, and changes in prevalence of a health problem (see Chapter 1 for information on obesity surveillance). Third, it focuses on prevention rather than treatment of disease, although it can use treatment as a prevention strategy (e.g., to control the spread of an infectious disease such as tuberculosis). For obesity, an example of the use of treatment as a form of prevention is the treatment of overweight or obesity in order to prevent the development of type 2 diabetes or other comorbidities of obesity, or to prevent further weight gain.

Effective public health measures include vaccination programs to control infectious diseases; well-organized garbage collection and disposal programs; food safety standards; regulation of tobacco sales and enforcement of smoke-free zones in public places; community zoning to ensure the inclusion of green spaces, sidewalks, and bicycle lanes; hand washing to prevent the spread of disease; water and sewage treatment programs; fluoridation of water to prevent dental caries; and seat belt legislation. Since the mid-20th century, the prevalence of infectious diseases has decreased in developed countries such as the US. Thus the public health community has begun to focus more on the prevention of chronic diseases such as cancer, heart disease, type 2 diabetes and obesity.

In the US, treatment of chronic diseases accounts for over 75% of national healthcare expenditures (3). The contribution of obesity to chronic diseases is a major health concern because of its impact on healthcare costs, death, and disability (4). Obesity contributes significantly to half of the 10 leading causes of death in the US: heart disease, stroke, cancer (endometrial, breast, and colon), diabetes, and chronic lower respiratory diseases (5). The Congressional Budget Office reported that healthcare spending per capita on obese adults exceeded spending on normal weight adults by 38% in 2007 (6). Progress in addressing causal factors, such as excessive calorie consumption, physical inactivity, and poor food choices, has been slow. Obesity has reached epidemic proportions over the past three decades (see Chapter 1). It has been identified by the Institute of Medicine (IOM) and leading public health organizations as an urgent national public health priority (7; see also Chapter 27).

The primary purpose of this chapter is to examine the experience accrued by the public health community while tackling a variety of public health issues where there has been some success. The goal is to understand how this experience might inform current efforts to stem the obesity epidemic. Thus, the chapter reflects on previous public health efforts, identifies key factors and domains of potential use in obesity prevention, and reviews progress and challenges within each. Concluding principles are provided to inform the development of an effective public health approach to obesity prevention.

Public Health Lessons Learned

There is no shortage of theories, models, and approaches to help guide public health program planning. There are multiple health behavior theories (8) which are commonly used to guide public health efforts, as well as popular planning models (9) designed to diagnose health problems, identify the factors that contribute to these problems, and devise appropriate interventions. In 2002, the IOM (10) endorsed a broad approach to public health problems, recommending the adoption of an “ecological model,” where the individual is viewed within a larger context of family, community, and society. In 2005, the IOM recommended the application of an ecological framework specifically for childhood obesity prevention (7; see Chapter 27 for more information).

There is increasing interest in comprehensive public health interventions that strike a balance between efforts directed at the individual and efforts directed at changing the social and environmental context in which people live. The purpose here is not to propose a comprehensive intervention program for obesity, but rather to identify factors associated with success in other public health areas that may be applicable to obesity. We will consider coordinated, planned interventions as well as unplanned, but facilitative, social, cultural, economic, or regulatory factors.

The Search for Success

Despite notable successes in public health over the last century, there are few generally agreed approaches or interventions that can be simply applied to obesity. There are “best practices” for specific public health problems, but there is little research or insight into the extent to which these practices can be applied to other public health challenges. For example, the Centers for Disease Control and Prevention (CDC) has issued Best Practices for Comprehensive Tobacco Control (11) which describes five programmatic areas¹ that have been shown to be effective in reducing tobacco use. In practice, these five are typically delivered “comprehensively,” and it is difficult, if not impossible, to tease out the relative impact of any one program component. Evaluations have tended to focus on the overall program impact and on the relationship between financial investment in program activities and changes in health behaviors.

Data on the impact of comprehensive programs document changes in health behavior, as well as in producing positive health outcomes (12). Analysis has confirmed that the greater the investment in comprehensive programs composed of evidence-based strategies the larger the public health benefit (13, 14). Review articles have analyzed the effectiveness of public health interventions for a variety of public health problems, including dietary behavior, underage drinking, and motor vehicle injuries, to name just a few.

A review by Bowen and Beresford (15) concluded that while much has been learned about changing dietary practices clinically, the challenge is how to duplicate in community and public health settings the successes obtained from interventions aimed at the individual that have dominated the majority of the literature on obesity, lifestyle change, and weight management. We will discuss the merits of this broader approach and some of the barriers that must be overcome to implement it on a community-wide or population-wide basis.

The use of technology and engineering solutions to facilitate healthful dietary and lifestyle management is clearly relevant, and private sector efforts have focused on marketing devices that measure body fat content and metabolic rate, track diet, monitor calorie expenditure, and so on. Gielen and Sleet (16) reviewed the injury prevention literature and cautioned against over-reliance on engineering solutions alone, arguing that behavior change is also essential. These authors emphasize the need for interdisciplinary approaches to injury prevention, using behavioral science theory, coupled with engineering solutions (e.g., a handheld computer for logging food intake or physical activity); a similar approach will likely be needed in the case of obesity.

The focus on “internal validity”—the determination of the effectiveness of interventions in a particular setting—has greatly improved the practice of public health and facilitated the identification of effective strategies for addressing specific health problems. This focus on disease- or behavior-specific evidence has not, however, advanced our understanding of the “external validity” or the effectiveness of applying a given intervention across a variety of settings. Nor has it advanced our understanding of under what conditions, and for which populations, such interventions might work. Another challenge is how to “scale up” a successful practice for widespread implementation at a community, state, national, or eventually a global level. While there are studies focused on informing our understanding of the factors that facilitate the translation of evidence-based interventions into practice (17, 18), this is an area in which further research and analysis is needed as efforts to apply best practices to obesity are implemented.

Based on analysis of programs focused on lead, fluoride, auto safety, and tobacco, Isaacs and Schroeder (19) concluded that successful public health initiatives include a mixture of 1) highly credible scientific evidence, 2) campaigns with highly effective advocates, 3) a supportive partnership with the media, and 4) laws and regulations, often, but not always, at the federal level. Drawing on social movement and other sociological theories, Nathanson (20) analyzed the tobacco and gun control movements and concluded that successful, health-related social movements had the following elements in common: 1) a socially and scientifically credible threat to the public health; 2) mobilization of a diverse constituency; and 3) “the convergence of political opportunities with target vulnerabilities.” Public health efforts to address obesity meet some but not all of these criteria, as will be discussed below.

Fomenting Health-Related Social Change

Our health is affected by many factors, including where we live, our genetics, income, educational status, and social relationships. Collectively, these factors are considered social determinants of health (21). W. P. T. James was one of the first obesity experts who called for a sea-change at every level of society to address obesity (22). Economos and colleagues (23) conducted a global analysis of social change models by interviewing 34 key informants. These investigators concluded that a number of factors were associated with successful social change. These included having the issue being perceived as a crisis, a persuasive science base, important economic implications, strategic leadership, a coalition or mobilizing network, community and media advocacy, government involvement, media involvement, policy and environmental change, and a coordinated but flexible plan. Although not all of these criteria have been met with regard to obesity, progress is being made across many of these areas, as will be shown below. Our understanding of the negative health consequences and enormous cost of the obesity epidemic is growing and the critical need to stem the increased prevalence of obesity among children is serving as a point of mobilization. Consequently, the growing prevalence of childhood obesity may stimulate action to satisfy the other criteria identified above.

Although prominent nutrition scientists like W. H. Sebrell identified obesity as a serious public health issue as early as 1955 (24), the importance of the issue did not gain widespread recognition until decades later. The obesity epidemic was characterized as a crisis, and a national call to action to stem obesity was issued at the launch of Shape Up America! by former US Surgeon General C. Everett Koop in 1994 (25) and with the organization’s publication of the first set of evidence-based treatment guidelines (26) for adult obesity in 1996 (27). In 1998, the NIH guidelines for the treatment of adult obesity were published (28) and in 2001, former US Surgeon General David Satcher was the first sitting Surgeon General to issue a report and call to action on the obesity epidemic (29). In 2005, the IOM published Preventing Childhood Obesity: Health in the Balance (7), which framed the problem as national public health priority and made recommendations for action across societal sectors. The response from the federal government to the numerous reports on obesity has been slow.

In January 2008, British Prime Minister Gordon Brown acknowledged that a comprehensive national plan was needed to stem obesity in Britain and announced a multidimensional plan (30) to reverse levels of obesity. Although concerned about obesity in persons of all ages, the plan starts with a major focus on reducing levels of childhood obesity to those that prevailed in 2000, and aimed to accomplish this reversal by the year 2020.

Though long overdue, evidence of leadership on obesity by the US government is growing and reflected by several developments. In January 2010, the current US Surgeon General, Vice Admiral Regina M. Benjamin, released the report Vision for a Healthy and Fit Nation (31). Soon after, First Lady Michelle Obama announced her Let’s Move campaign focused on preventing childhood obesity (32). It provides a comprehensive approach for engaging every sector affecting the health of children and will provide schools, families, and communities with simple tools to help children be more active, eat better, and get healthy (32). Simultaneous with the launch of the campaign, President Barack Obama created the Task Force on Childhood Obesity (33) aimed at increasing coordination between the private sector, not-for-profits, agencies within the government, and other organizations to address the problem of childhood obesity. These efforts represent the first major national focus in the US on the epidemic of obesity and help to address the need for “strategic leadership” and “government involvement” identified by Economos and colleagues (23) as vital for social change.

Another factor noted by Economos and colleagues—policy and environmental change—is the focal point of a 10-year, $500 million national initiative by the Robert Wood Johnson Foundation to reverse childhood obesity by the year 2015 (see rwjf.org). The US Department of Health and Human Services (HHS) and CDC have also adopted policy and environmental change as a key approach for obesity prevention. In September 2009, HHS launched the Communities Putting Prevention to Work initiative, with support from the American Recovery and Reinvestment Act of 2009 (34). In March 2010, HHS awarded 23 obesity prevention grants totaling $230 million, to local public health departments across the nation. Grantee work plans were required to reflect policy and environmental change strategies. Additionally, the CDC’s Division of Nutrition, Physical Activity and Obesity (DNPAO) (35) was funded at $44 million for fiscal year 2010, for obesity programs underway in approximately half the states in the US. The growing focus on policy and legal approaches for obesity prevention is also reflected in the scholarly literature (36–39).

Despite this progress, it remains unclear whether state and local public health agencies, a key constituency for advancing prevention, have the resources and capacity necessary to successfully lead and properly evaluate policy and environmental change activities. For more than two decades, national studies have highlighted the decline in the nation’s public health infrastructure, pointing to funding deficiencies, critical workforce shortages, and a general lack of resources (40, 41). Many in the public health workforce possess training to fulfill functions that are vastly different from the advocacy and policy development activities that are increasingly communicated as priorities by federal officials.

No widely recognized coalition or mobilizing network devoted specifically to obesity has yet been identified, advocacy is currently ad hoc, and a coordinated, comprehensive national plan to address obesity in persons of all ages has not been developed for the US despite the IOM’s call for such a plan (7). Although the data linking obesity to poor health and burgeoning economic costs, including healthcare costs, in adults and children are legion, it is possible that deficiencies in the science base on childhood obesity prevention as described by the IOM report (7) explains the limited progress to date in stemming the epidemic.

Social factors, such as widely shared public outrage, can galvanize health-related social movements. An example is the formation in 1980 of Mothers Against Drunk Driving (MADD). This example illustrates how shared public outrage can reach a “tipping point” (42) for social change. For obesity, change based on widely shared public outrage seems unlikely—although concerns about childhood obesity have been growing and have resulted in some changes—initially at the state and community levels and more recently emerging at the national level. Considerable work remains before the nation can achieve satisfactory marks across the 10 criteria identified by Economos and colleagues (23) as important for successful social change.

Applying the Framework Convention on Tobacco Control to Obesity

In public health, tobacco control efforts have enjoyed notable success. Consequently, researchers at the World Health Organization (WHO) (43) looked at the Framework Convention on Tobacco Control (FCTC) in terms of its possible implications for improving global diets and physical activity levels. They concluded that strategies to improve diet and physical activity levels must be different from those employed for tobacco control, not only because the nature of the behaviors is different, but also because of possible private sector interactions between the public health community and the food and beverage industries, which are very different from interactions with the tobacco industry. They argued that a formal treaty approach is not warranted, but suggested that the organizing framework for the FCTC might be a useful model for the development of national plans and policies to address obesity. Specifically, Yach and colleagues (43) compared the public health consequences of practices of the tobacco and food industries, the nature of their respective products, and their marketing strategies. Table 3.1 lists on the left the factors they identified as relevant, a brief description of each factor, and on the right, our own concrete examples of how each factor might apply to obesity.

Table 3-1 Public Health Implications and Examples of Marketing Factors Identified by Yach and colleagues (43) and How the Factor Might Apply to Obesity

Factor (see ref. 43)	Description	Possible Example(s)
Price and tax measures	Can discourage consumption of unwholesome foods and beverages and/or encourage consumption of wholesome foods and beverages	Tax on soda or candy; subsidies for growers of fruits and vegetables in order to keep prices low
Labeling	Can provide product ingredient content information and nutrition information about calories and nutrients that can inform consumers and influence choices at point of sale	Nutrition labeling of food and beverage products; restaurant offerings; labeling of alcohol-containing beverages to provide calorie and other nutrient labeling
Educational campaigns	Can inform the media or directly inform consumers about the health consequences of obesity or generate consumer interest in actions to take	Shape Up America! (www.shapeup.org) to raise awareness of obesity as a health issue; America on the Move (americaonthemove.org) to promote physical activity and improved diet
Curbs on marketing	Can reduce targeting of vulnerable groups such as children by corporations that advertise through the TV, Internet and cell phones, and can establish regulations governing truthfulness of advertising and weight loss claims	The Children’s Advertising Review Unit (CARU) of the Council of Better Business Bureaus; FTC, FDA, USDA, CDC regulatory initiatives on weight loss products and marketing to children
Findings from clinical interventions	Can inform policy-makers, healthcare professionals and consumers about the science behind product claims; can influence physician prescriptions and consumer demand	FDA scientific criteria and requirements for marketing of foods and drugs, including product removal from the market
Product supply	Supply can influence prices of products	Government subsidies of corn and sugar that encourage growers to plant those crops, thereby keeping the cost of products such as soda low
Liability and corporate behavior	Can influence consumer perceptions of an industry or of corporate values	The Children’s Food & Beverage Advertising Initiative established by CARU to foster industry self-regulation on advertising to children; litigation to hold a corporation responsible for childhood obesity since children do not understand the persuasive intent of advertising
General supportive and facilitative measures	Can influence corporate behavior and consumers’ perceptions of corporate commitment to health	Congressional hearings, federal agency reviews intended to do fact-finding or raise understanding of an issue such as the effectiveness of commercial weight-loss programs or marketing of over-the-counter weight-loss drugs

Others have argued that a global health treaty would be useful for preventing obesity (44)—and possibly for other health problems—suggesting that formal agreements among governments, NGOs, and the commercial sector might best serve the public good and avoid the shortcomings associated with voluntary agreements. Such a treaty could address such issues as marketing to children or the truthfulness of advertising and claims on weight-loss products marketed to adults.

Brownell and Warner (45) agree with Yach and colleagues (43) that food is very different from tobacco and that the food industry and tobacco industries are markedly different in size and other characteristics. But they are impressed by the similarities between the two industries in response to concerns that their products cause harm and they predict that the food industry will claim the moral high ground in their commitment to self-regulation, but will not actually occupy it (45).

An Organizing Framework for Public Health Interventions

In the 2000 Surgeon General’s Report, Reducing Tobacco Use (46), a framework was developed to categorize the different types of tobacco control interventions. This framework reviewed the evidence that effective strategies can be identified within the following categories: 1) educational; 2) clinical; 3) legal; 4) economic; 5) regulatory; and 5) comprehensive. While this framework was developed for tobacco control, Mercer and colleagues (47) have suggested that it may be useful for categorizing interventions for other types of public health problems and it has already been used to analyze similarities and differences between tobacco control and the prevention of obesity. These authors analyzed the contribution of each component of the framework, and more importantly, the “synergistic effects” of all working together (47). Similarly, analyzing strategies to prevent underage drinking, Komro and Toomey (48) identified six settings or arenas, all of which were proven useful for alcohol prevention: 1) school; 2) extracurricular; 3) family; 4) policy; 5) community; and 6) multi-component.

Drawing on the tobacco control framework as well as other sources, the next section reviews findings from a variety of public health campaigns, particularly those public health experiences that have commercial dimensions or have been politically sensitive (e.g., underage alcohol consumption, injury prevention, etc.). The social determinants of health are those factors that influence patterns of disease and wellness: “the neighborhood we live in, our socioeconomic status, the quality of our food and water supplies, and our access to education” (21). With this in mind, the following section reviews five categories or domains considered relevant for the prevention of obesity. These are:

The Information Environment

The environment in which people are informed about public health issues is of critical importance, but is also fraught with controversy, particularly since the information environment is heavily shaped by the marketing of commercial products such as foods and beverages or movies and DVDs. The public health community tends to favor restrictions on commercial speech, if thought necessary, to ensure the public health. On the other hand, commercial interests view any restrictions on marketing as an infringement of their rights and assert that the constitutional right to freedom of speech applies to advertising. A thorough discussion on individual speech vs. commercial speech is beyond the scope of this chapter, but was central to the debate in the Food and Drug Administration (FDA)’s attempt to regulate tobacco products (49), as well as in more recent attempts to restrict advertising for tobacco, alcohol, and foods. A few elements of free speech are briefly discussed below.

Marketing and Advertising

While product advertising may result in a public health benefit when the advertising promotes healthful products (50) the majority of the debate about product marketing focuses on those products that may have harmful effects, particularly in children. Governments have the right to alter the informational environment, particularly when the information being conveyed is considered to be false, misleading, or deceptive. In the US, the regulatory authority in this area is shared by multiple federal agencies, but particularly by the FDA and the Federal Trade Commission (FTC). The marketing and advertising of alcohol-containing products is regulated by yet another agency, the Alcohol and Tobacco Tax and Trade Bureau (TTB), which is in the Department of the Treasury. Gostin (51) noted that the government’s power to alter the informational environment is one of the principal ways in which governments can “assure the conditions for people to be healthy.” It can do so in a number of ways:

• Mandating research and reports on obesity (see, as one example, 7).
  
• Establishing school food nutrition standards by USDA (see discussion of Child Nutrition Act 1966 below) or authoritative non-governmental bodies such as the IOM.
  
• Developing policy or legislation based on authoritative reports.
  
• Convening or establishing a council of experts to make policy recommendations on prevention.
  
• Sponsoring health education campaigns and other persuasive communications.
  
• Requiring product labeling or menu labeling in restaurants.
  
• Restricting harmful or misleading advertising.

Several of these factors are discussed briefly in Table 3-1; others will be discussed more fully below.

Most of the effort in altering the information environment has been directed toward curbing marketing of commercial products to children and adolescents, particularly when it is thought that the information being conveyed may be harmful or misleading to them (52). Because of this, the quality of the evidence documenting the effect(s) on children of informational efforts is intensely debated. Public health advocates argue that marketing efforts are a substantial contributory factor to youth risk behaviors, particularly in the areas of tobacco use, underage drinking, consumption of excessive amounts of high-fat, calorie-dense foods, as well as entertainment products that encourage a sedentary lifestyle. The manufacturers of these products (and their legal counsel) take the opposite position, claiming that there is insufficient empirical evidence to prove the precise effect of marketing on the relevant behaviors of children. At most, manufacturers may concede that marketing may influence the selection of a particular brand of a product, but argue that there is little evidence that marketing contributes to the initiation of use of a product or causes an overall increase in demand for that product; and that there is no evidence that a given product causes conditions such as lung cancer or obesity. Nonetheless, since publication of the IOM report on marketing to children (53), many if not most public health authorities agree that the overall weight of the scientific evidence points to the conclusion that marketing has deleterious effects on children and that prompt action is needed.

Here again, the lessons from tobacco control inform the obesity debate. The discovery that very young children were more likely to recognize Joe Camel than Mickey Mouse, and that adolescents were much more likely than adults to smoke the most heavily advertised brands, led regulators to attempt to restrict the information environment, particularly as it relates to young people (49). These battles have continued over the last decade, with litigation replacing public policy as the primary vehicle to restrict advertising and to award compensation for the harm caused. To a large extent, the 1998 Master Settlement Agreement (MSA) (54), an agreement between several tobacco product manufacturers and 46 states, attempted to resolve the debate over the marketing of tobacco, combining cash payments to states and voluntary limitations on marketing practices. However, most involved professionals believe that the problem continues and marketing for tobacco products is relatively unchecked. In 1999, following the MSA agreement with states, the US Department of Justice (55) filed suit against the tobacco industry under racketeering and organized crime statutes, including the claim that tobacco companies aggressively marketed cigarettes to children. This case went to trial in Federal District Court in September 2004 with closing arguments in June 2005. In August 2006, the presiding judge found the tobacco companies guilty of perpetrating fraud on the US public and required corrective action by the tobacco companies. In May 2009, the US Court of Appeals for the District of Columbia Circuit issued a unanimous opinion upholding Judge Kessler’s judgment (56). The US Supreme Court declined to hear appeals in the case, so the judgment stands.

There is good evidence that the advertising and marketing of food products influence both parental and child food choices (57). As mentioned earlier, the IOM has concluded that advertisements shape the product preferences and eating habits of children (7, 53). Moreover, their findings indicate that children under the age of eight years are generally unable to understand the persuasive intent of advertising. The ethical implications of commercial interests freely manipulating children this young are rarely considered or discussed, but will be developed below.

Empirical studies clearly document parents’ underestimation of their children’s television and media exposure (58), the wide range of food advertising techniques and channels used to reach children and adolescents (59), the overexposure of children to food and beverage advertisements on certain TV channels (60), the increase in the number of TV commercials viewed by children (61), the increase in ads for high-fat and high-sodium convenience foods (62), the increased risk of overweight associated with excessive TV viewing (63, 64), the effect of even brief exposure to TV commercials on food preferences of young children (65), and an association between TV viewing and the consumption of fast foods (66–67). However, two recent studies, one by Powell (68) and the other by the FTC (69), found that children’s exposure to TV food advertising did not increase between the 1970s and 2004. The FTC study did find that the mix of food advertisements had shifted, so that restaurant, fast-food, and snack advertisements are at a higher level than observed in 1977. The FTC report also found that advertisements for sedentary pursuits (e.g., TV programming, movies, and other screen and audio entertainment products) showed a marked increase between 1977 and 2004, and these findings continue to fuel the debate about what is causing childhood obesity—food or inactivity, or both.

The Kaiser Family Foundation (70) reviewed the evidence on the effect of all types of media on children’s dietary behavior and recommended the reduction or regulation of food advertisements targeted to children, among other policy options. The American Psychological Association (APA) (71) concluded that televised advertising messages can lead to unhealthy eating habits, particularly for children under eight years of age who are unable to distinguish advertising from programming and lack the skills and comprehension to critically evaluate advertised messages. The APA Report (71) went on to recommend:

“Restrict advertising primarily directed to young children of eight years and under. Policymakers need to take steps to better protect young children from exposure to advertising because of the inherent unfairness of advertising to audiences who lack the capability to evaluate biased sources of information found in television commercials.”

Currently, there are no legal restrictions on the marketing of calorie-dense, low-nutritional-quality foods or beverages to children. Some consider it to be “open season” on children, with cartoon characters, celebrities, promotional tie-ins, product placement, sponsorships, games, and toys all being used to appeal to children. For example, a June 22, 2010 announcement by the Center for Science in the Public Interest (CSPI) indicated that the Center is considering suing McDonald’s in order to stop the company from using toys to promote their Happy Meals to children (72). As of this writing, the CSPI lawsuit has not been filed and has been dismissed as frivolous by McDonald’s (73). Nonetheless, in May 2010, the Santa Clara County, CA Board of Supervisors passed an ordinance to prevent the use of toys to promote unhealthy meals to children (72).

None of these strategies is currently used to promote tobacco products to children, mainly because it is illegal to sell tobacco products to minors, some states prohibit the under-age use and possession of tobacco products, and the tobacco companies themselves have either voluntarily agreed not to market to children or have been prohibited from doing so as the result of the settlement of legal proceedings.

The IOM’s report on marketing to children (53) marshals the evidence suggesting that restrictions on the advertising of unhealthy foods, the promotion of healthy choices (e.g., fruits and vegetables), and possibly paid counter-advertising campaigns will improve the information environment and stem childhood obesity. In England, one component of the comprehensive program to reverse obesity (30) alluded to earlier calls on the food industry to adopt a “Healthy Food Code of Good Practice” (74). The Code is a component of the national program to address obesity in England (30) and calls for the reformulation of foods to meet certain nutritional standards; the “rebalance” of marketing, promotion, and point-of-sale placement of foods high in fat, salt, or sugar; and increased exposure to promotion of healthy options (30, 74).

Media Campaigns

Mass media efforts that build on sophisticated marketing approaches are a potentially effective way to improve dietary behavior and increase physical activity levels among young people and adults. A hard-hitting media campaign, costing more than $28 million since it was founded in 2005 (75) to reduce methamphetamine use, has been implemented in Montana (76). The problem is estimated to cost the state an estimated $200–300 million annually (75). Whether the Meth Project is successful in reducing initiation rates among teens is debated (75, 77). Nonetheless, the campaign will reportedly be replicated in Wyoming, Arizona, Idaho, Illinois, Colorado, Hawaii and Georgia (75) and will presumably be evaluated further.

In tobacco control, themes of tobacco industry manipulation, the documentation of adverse health effects of secondhand smoke on nonsmokers, and graphic depictions of the harm of smoking among real people have proven to be effective (78, 79). Designing a media campaign to address obesity that constructively motivates changes in behavior yet honors the strong emotions most people have about this sensitive issue is challenging. Although media strategies are used to promote fruit and vegetable consumption and increased physical activity, we have not identified suitable models for media campaigns to address obesity per se as of this writing.

The US government has made preliminary efforts to promote healthy eating and physical activity. Through the National Cancer Institute, they launched the 5-A-Day program to promote consumption of fruits and vegetables, a program that is now run through the CDC (and has been renamed Fruits & Veggies: More Matters). The government also funds the provision of fruits and vegetables in pilot school systems (80) throughout the US. These strategies have thus far failed to produce increased consumption of fruits and vegetables in that no state has met the Healthy People 2010 objectives for fruit and vegetable consumption (81). An analysis by Krebs-Smith and colleagues also found that intake of fruits and vegetables fell far short of recommended levels in all age groups (82). These data suggest that the USDA pilot program should be expanded, but current research is focusing on determining whether incentives can effectively promote consumption of healthier foods (including fruits and vegetables) by low-income individuals (83).

In the area of physical activity, the CDC launched the VERB campaign in 2002 to promote physical activity of “tweens” (i.e., children between the ages of 9 and 13). One-year results from VERB were positive (84). The campaign reached the majority of its target audience, and youth exposed to the campaign were found to participate in more free-time physical activity than youth nationally (84). It remains to be seen whether these findings can be replicated. The campaign ran for four years before the federal funding for the VERB program was withdrawn.

The US Department of Health and Human Services issued the first set of guidelines for physical activity that were meant to encourage physical activity among Americans aged six and older, just as the US Dietary Guidelines are intended to encourage and define healthy eating (85). The 2008 Physical Activity Guidelines for Americans are intended to educate people about the benefits of physical activity, explain how to do physical activity in a manner that meets the guidelines, and reduce activity-related injury. Public awareness of the existence of the new physical activity guidelines needs to be assessed. In May 2010, a large public–private partnership, including leading public health and health-focused organizations, published the National Physical Activity Plan (86). The Plan is a comprehensive set of policies, programs, and initiatives that aim to increase physical activity in all segments of the population. It includes recommendations across eight societal sectors. Both the physical activity guidelines and the national plan need to be evaluated for their impact on weight-related behaviors and BMI.

Warning Labels, Ingredient Disclosure, and Labeling

As part of enabling the public to be informed consumers, public health experts are calling for the full disclosure of nutrition information. In the US, food products currently have nutrition labels that list ingredients used in the food product, as well as nutrition information on calories, fat, and other nutritional parameters. A weakness of the US labeling system is that the nutrition label presents calories for one “serving” rather than for the entire contents of the package, even if consumption of the entire package is typical. Examples are bags of chips, packs of cookies, or bottled sweetened teas, sodas, or coffee drinks. The latter may deliver 150 calories per serving, but few people notice that a bottle or package contains 2.5 servings, delivering a total 375 calories, i.e., a quarter of the total daily calorie needs of a young teen. Foods purchased in restaurants and fast-food establishments have undergone “supersizing” over the past decades (87). Calorie and fat information per serving on restaurant menu boards or on menus was historically neither required by law nor typically offered. The exception was that some national fast-food establishments posted nutrition information on websites or made it available on request. A regulation passed by the New York City Board of Health (88), which has the force of law, mandates the provision of calorie information in certain chain restaurants and a similar law (SB1420) has been signed by the Governor of California and will be implemented fully in 2011 (89). Through the recently passed Healthcare Reform Bill, the Affordable Care Act alluded to earlier, calorie labeling of foods offered in chain restaurants with more than 20 locations nationwide will soon occur. This is an important change in policy that will change the information environment and, it is hoped, beneficially affect obesity, although that remains to be determined.

Specifically to curb obesity and guide consumer food choices, the UK is planning to use a “traffic light” system to rank foods (30). This system is intended to encourage the consumption of certain “green light” foods that are low in energy density and high in nutrient delivery, and discourage consumption of “red light” foods that are high in fat, saturated fat, sodium, or sugar.

In the US, Hannaford Brothers grocery stores and other organizations are currently using or planning to use a system of labeling foods based on their nutritional content (90). The Hannaford system rates foods based on nutritional parameters and assigns 0 stars to foods not meeting their criteria, 1 star for foods that do a reasonably good job of matching the criteria, 2 stars for foods that do a better job of matching, and 3 stars for those that most closely match the criteria (90). Although the Hannaford system has not, to our knowledge, been formally evaluated to measure the effect of the stars on consumer choices, it is possible that foods with more stars will be selected and foods with no star will be avoided. Nonetheless, the food industry has launched a host of programs to rank their own food products. The FDA has announced that it will be examining and possibly regulating these programs (91), but no details appear to be available at this time. According to one report, the IOM has been asked to undertake a review of food ranking systems for the FDA and the CDC (91) and held two workshops in 2010. The sensitivity of this issue could not be greater since food manufacturers do not want their products to receive adverse ratings. For programs such as the Hannaford system, this remains an area of potentially useful research as we learn how such systems guide consumer choices and product sales. But ultimately, the effects of such systems on food consumption and body weight will need to be evaluated.

Warning labels have been required on cigarette packages since the late 1960s; however, US warning labels have not kept pace with international standards and are generally not noticed by smokers. In Canada (where the practice originated) and more recently in a number of other countries, graphic and vivid warning labels are required on all tobacco products. Similar labels are required by member states that are signatories to the Framework Convention on Tobacco Control (92). These labels have been shown to attract the attention of smokers and contribute to their interest in quitting smoking, increasing quit attempts (93), and are associated with a reduction in cigarette smoking (94). Currently, there are no warning labels for food products, other than for certain safety labels on alcohol-containing products, and in some instances, for food products that may pose a high risk of infectious disease (e.g., uncooked shellfish). It is noteworthy that alcohol-containing products are the last consumer product category without nutrition or calorie labeling. From the perspective of weight control, this is an important policy lacuna since more than 60% of American adults drink alcoholic beverages, and for 27% of men and 11% of women, such intake is either moderate or heavy (95). For these people, alcohol is a significant source of calories and a potential contributor to obesity. Consumer organizations and Shape Up America! have conducted research documenting that consumers would welcome clear and comprehensive labeling of alcohol-containing beverages (96). Efforts have been made to communicate these research findings to the Alcohol and Tobacco Tax and Trade Bureau (TTB) during both the Bush and Obama administrations, but to no avail.

With respect to childhood obesity, the 2004 report of the American Psychological Association (71) on the effect of advertising on children concluded that any warnings, disclosures, or disclaimers about products advertised to children be communicated in clear language comprehensible to the intended audience (71). Given the political clout of the food and beverage industry (53), the complexity of obesity etiology (7), and the lack of agreement about the relative importance of sedentary lifestyles vs. excess consumption (7), the possibility of labels appearing on food products warning of the risk of obesity seems remote.

Access and Opportunity

In many parts of the US, especially rural or urban low-income communities, there is a striking lack of access to healthy foods, especially fresh produce. The presence of a supermarket is associated with a reduced risk of obesity (97) and this finding suggests that greater attention should be paid to healthy food access issues. Conversely, the ubiquitous availability and affordability of foods with a high sugar, fat, and sodium content is associated with the increase in the prevalence of overweight and obesity in the US and other developed countries. While empirical evidence on the precise contribution to obesity of widespread availability and easy access to certain types of food and beverage products is debated (7, 98), some restrictions on access for children, especially in schools, are being implemented (99) although the impact of these school-based interventions on pediatric obesity is unclear (see Chapters 26 and 27). To the extent that such efforts are thoroughly described, evaluated, and published, they may eventually lead to public health interventions for obesity prevention and remediation.

Access to recreational opportunities, parks, and sidewalks, dedicated pathways for walking and biking, and safe places to play is also an issue. The IOM and the Transportation Board of the National Academy of Sciences examined the effect of the built environment on physical activity (100) and their report concluded that, increasingly, our communities are designed with the automobile in mind rather than pedestrians and cyclists. This report documented ways in which community design and infrastructure can profoundly affect levels of physical activity (100). It highlighted the importance of policy-making, including the selection of school sites to facilitate walking to school, sensitive zoning that ensures safe neighborhoods with sidewalks, bike paths, and green spaces for recreation, and many other strategies to ensure that the environment in which we live and work is designed to facilitate and promote physical activity (100). Public health officials and activists can use this report to enlighten zoning and planning boards that community design and infrastructure can affect health and weight management by either promoting or hindering physical activity.

The Community Environment

Community efforts to restrict access to foods judged to be unwholesome may be informed by the tobacco experience. Because the sale, and frequently the possession, of tobacco products by minors is illegal, various tobacco use-reduction efforts have focused on enforcing tobacco access restrictions. Federal legislation has been promulgated to require states to enforce a prohibition on the sale of tobacco products to minors, and some stores voluntarily restrict access to tobacco products by keeping inventory behind the counter and requiring a personal interaction between the sales clerk and the customer to obtain the product. The evidence, however, is unclear about the effectiveness of enforcement of minors’ access laws in reducing the use of tobacco products (101). Minors have used other means (shoplifting, purchasing by friends, social acquisition) to obtain cigarettes. Regardless of whether these restrictions are effective by themselves, enforcement of laws to prevent the sale of tobacco products to minors sends a strong and consistent message on the hazard of tobacco use and should be considered a necessary, but not necessarily sufficient, action to reduce adolescent tobacco use.

Regarding calorie-dense, low nutritional quality foods, there is no restriction whatsoever on their retail and commercial availability in the community. As is the case with cigarettes, these snack and fast-food products are readily available in vending machines, gas stations, and convenience stores. In fact, nearly every retail and commercial outlet sells gums, candies, crackers, cookies, and soft drinks. Reviewing the literature on the influence of availability on food choices, French and colleagues (102) concluded that the relationship is inconsistent, particularly compared to the strong, well-documented, inverse relationship between price and food choice. Further research is needed to determine whether restricting commercial access and availability would be effective in reducing the consumption of calorie-dense and low nutritional quality foods. As long as these products can legally be sold to minors, it is unlikely that widespread restriction of access to these products is feasible, and even if it is, it might not have a significant public health effect. Nonetheless, some communities are using their zoning powers to limit the proliferation of fast-food restaurants (103).

Where food is purchased and consumed is changing. The published literature indicates that over the past few decades, and accelerating in the past few years, there have been increases in eating outside the home—particularly in fast-food restaurants (104–106), increases in portion size of all types of foods (107, 108), and increases in soft drink consumption (98, 109). Given the dampening effects of higher prices on demand, a more productive strategy supported by French and colleagues (102) alluded to earlier might be to subsidize fruits and vegetables and raise the price of less wholesome foods and beverages in order to shift food choices and consumption patterns. This strategy will be discussed further below, but as mentioned earlier, the lack of access to wholesome options is an enormous barrier that must also be addressed.

The School Environment

Schools are an important setting in which to encourage health-promoting obesity-preventing behaviors (7, 110). The CDC has issued guidelines for schools to prevent nicotine addiction. These include smoke-free policies, tobacco prevention policies, and smoking cessation assistance for teachers, staff, and students (111). Similar guidelines exist for nutrition in schools (112). There is some scientific evidence that manipulation of the school cafeteria and physical activity environment can improve the cardiovascular health of elementary school children (113). The literature in this area indicates that school-based interventions have produced healthful food choices among students, increased student knowledge and attitudes about physical activity and nutrition (7), increased physical activity (114), and reduced energy intake, fat intake, and sedentary behaviors (115). However, the presence of vending machines stocked with soda and candy, inadequate nutritional standards for cafeteria foods and other foods served in classrooms to celebrate holidays and birthdays, the use of food by teachers to reward students, the declining requirement for daily physical education in schools, and the lack of safe routes to school for walking or biking suggest that the school environment, along with the surrounding community, is a challenging setting in which to address childhood obesity.

The US Congress has mandated that local boards of education establish local wellness policies (116). The IOM has developed nutrition standards for foods in schools (117). The American Public Health Association (118) has called for the development of school policies for the promotion of healthy eating environments and the prohibition of sales of soft drinks and other foods of low nutritional value during the school day. The American Academy of Pediatrics (109) has called for school policies that restrict the sale of soft drinks. There has been some progress in establishing healthier school environments, as school districts nationwide are implementing federally-mandated wellness policies, though consistency across districts has been limited. In any event, there is no requirement for compliance with school wellness policies, nor a budget to ensure or even measure compliance.

The CDC recently reported progress in school nutrition services practices between 2000 and 2006, but noted that there remains considerable room for improvement (119). In 2006, the American Beverage Association (ABA) announced a voluntary policy intended to phase out the sale of full-calorie soft drinks in schools by the 2009–10 school year (120). According to the ABA’s 2010 progress report (121), total beverage calories shipped to schools between the 2004–5 and 2009–10 school years decreased by 88%. The report also notes that about 80% of all beverages delivered to schools were delivered to high schools, and shipments to high schools fell by slightly less (70%) than shipments to all schools. It should be noted that full-calorie sports drinks and diet carbonated soft drinks have shown a notable increase in high schools, from 12.8% in 2004 to 18.3% in 2009 and 7.3% in 2004 to 15.7% in 2009, respectively. Overall, there appears to be a drastic reduction in the sales of sugar-sweetened beverages in schools as a result of the voluntary efforts of the beverage industry (121). However, leading scholars have been critical of the ABA’s efforts and reports. Sharma and colleagues (122) point out that “the beverage industry has met 1 standard: periodic assessment to determine compliance (albeit funded by industry)” (122). Other key criteria have not been met. For example, the development of nutrition criteria for beverages sold in schools was not transparent, nor did the criteria include input from the scientific community. Additionally, no evaluation has taken place by any independent, non-industry-funded group; the long phase-in period does not require amendment of existing beverage contracts also known as pouring contracts; and, some questionable beverages (e.g., diet drinks, calorie-containing sports drinks) are not adequately regulated or limited. They conclude that the long-term effectiveness of beverage industry self-regulation is uncertain and add that ceding regulation to industry is highly risky because in some industries (e.g., tobacco), self-regulation has been an abject failure (122). Clearly, caution should be exercised as the public health community works with the food and beverage industry moving forward.

Legislation was introduced in both houses of the US Congress in the 109th Congress and again in the 111th Congress to amend the Child Nutrition Act of 1966 to improve the nutritional status and health of school children by updating the definition of “foods of minimal nutritional value.” First Lady Michelle Obama has endorsed this legislation, known as the Healthy, Hunger-Free Kids Act of 2010 (S.3307). This bill is discussed as protective of the federal investment in the national school lunch and breakfast programs, since the use of foods of minimal nutritional value is not permitted in these two USDA programs (123). As of September 2010, this bill had still not passed. The feeding programs are operating through a continuing resolution at this time.

Even if a bill is passed, it is still not clear that foods of minimal nutritional value will be defined more clearly. While there are current restrictions for meals served in schools, competitive foods are not subject to these restrictions and are widely available. Schools often sell these foods in school cafeterias (à la carte) as well as in vending machines, school stores, and snack bars. These outlets provide easy access by students to less healthy foods, such as candy, cookies, brownies, chips, and other sugary, salty, or high-fat products. One study focused on students’ consumption of competitive foods (excluding à la carte items) and found that on a typical day approximately 22% of students consumed competitive items (124). It was also noted that among these students there were significantly higher intakes of total energy (i.e., calories) and sugar, with lower intakes of iron, dietary fiber, and several B vitamins (124).

If passed, the Healthy, Hunger-Free Kids Act of 2010, in combination with other positive changes, may have a far-reaching effect on childhood obesity, especially for low-income children for whom the school breakfast and lunch programs deliver a quantitatively significant portion of their daily food intake. There is a clear need for additional research on the relative importance of the school environment in ameliorating the problem of childhood overweight and obesity (see Chapters 26 and 27).

Economic Factors

Gostin notes that, in addition to its potential for altering the informational environment, the government’s power to tax and spend is one of the major ways in which it can “assure the conditions for people to be healthy” (51). He goes on to note that the power to levy taxes can be leveraged to provide incentives to engage in healthy behaviors, and disincentives to practice risky ones, but warns that these taxes can also be inequitable and regressive.

Taxes, Behavior, and Public Health

Most of the public health experience with manipulating economic factors to encourage healthy behaviors or to discourage risky behaviors has been related to excise tax² policy on products like tobacco, gasoline, and alcohol. Because of the popularity of increasing tobacco taxes as a public health strategy and the parallels that are frequently drawn between tobacco tax policy and a possible similar tax scheme for certain foods and beverages (125–126), the following section highlights some of the specific aspects of the taxation of tobacco products.

Tobacco products, like most consumer products, have been shown to be price-sensitive; that is, as price increases, consumption decreases. Children have been shown to be most price-sensitive, with an approximate 7% decrease in consumption for every 10% increase in price (127). As a result of this well-established price elasticity, excise tax increases on tobacco products have been a common and popular way to reduce adolescent tobacco use and to increase much-needed state revenue. In 2009, 15 states increased their excise tax on tobacco (128). Some states have earmarked or dedicated a portion of the excise tax increase for tobacco prevention or health promotion programs. Revenues raised through this mechanism could be earmarked for childhood obesity prevention programs.

A frequently heard argument for not removing vending machines for snacks and soft drinks from schools is concern about the loss of much-needed revenue for schools. Funds raised through an excise tax mechanism might be used specifically to support schools and overcome resistance from school administrators and school boards to making necessary changes in the school environment.

It is likely that applying the same strategy to calorie-dense foods of minimal nutritional value would have the same effect as seen for tobacco: i.e., as price increases, consumption falls. The WHO has indicated its support for taxes that shape food purchasing patterns (129). However, it has proven more difficult to tax foods and beverages than tobacco products. Boehmer and colleagues found that soda and snack tax legislation was introduced 49 times by state legislatures between 2003 and 2005, but none was enacted (130). In the early to mid-1990s, several states enacted legislation that taxed sodas and snacks at a rate higher than other food products. In at least seven states, these measures were repealed due to the complexity involved in the collection and administration of the tax (131). In 2010, the Trust for America’s Health reported that 33 states had instituted a soda tax (132), up from 17 states in 2007 (133). In California, a provision to levy a 1 cent excise tax on soft drinks to compensate for the lost revenue from removing soft drinks from vending machines in schools had to be removed for the vending machine legislation to pass (131). Internationally, a plan introduced several years ago to tax foods such as dairy products, pastries, chocolates, pizzas, and burgers at a higher rate than other food products was briefly considered, then dismissed by the UK’s government as unworkable (134). Jacobson and Brownell (135) suggest that to avoid the possible negative reaction to levying large excise taxes on soft drinks and snack foods, municipalities should consider small tax increases, and that the proceeds from these increases be used to fund health promotion programs, including subsidizing the availability of healthier food choices. The American Public Health Association at its 2003 annual meeting adopted a similar policy recommendation (118).

In addition to considering excise taxes on calorie-dense foods of minimal nutritional value, incentives or subsidies to make fruits and vegetables more available and affordable could be considered. French and colleagues (102) reviewed the literature on the relationship between price and consumption of fruits and vegetables, and found a consistent pattern of price elasticity, namely that lower prices of such foods are associated with higher consumption. In their own empirical work, these researchers found the same pattern among adolescents and found it to be robust across different age groups and food types (102). This provocative finding suggests that changes in agricultural policy that affect prices that consumers pay for foods may be in order. Agriculture policy is considered below.

One other economic factor that could prove useful is price controls on pharmaceuticals and other devices and procedures that the FDA has approved for the treatment of obesity. The rising price of drugs and surgery is considered to be major contributor to the escalating healthcare costs in the US, and high prices represent a barrier to treatment among lower-income citizens who suffer disproportionately from obesity (see Chapter 1). It is unclear at this time how the Affordable Care Act will affect this issue.

The Role of Agriculture and Farming

As efforts progress in reducing tobacco use, concern has been expressed about the economic well-being of tobacco farmers and cigarette manufacturing workers and the communities in which they live. In the case of obesity, the stakes are even higher. The low cost of the vast array of products derived from subsidized crops such as corn and sugar (both sugar cane and sugar beets) are taken for granted by the consumer, but the rising cost of fuel is pushing prices up and farmers aggressively pursued their own interests, seeking to retain their subsidies as the Farm Bill was reauthorized in May 2008.

The question is: Do the interests of public health conflict with the interests of American farmers? The economic consequences of large shifts in consumption will be profound if, for example, Americans significantly decrease soda consumption and double or triple their fruit and vegetable intake to meet current dietary recommendations (136). The journalist Michael Pollan has stated that the “farm bill” is a misnomer because it is actually a “food bill” and it should be written with the interests of “eaters” as primary (137). Yet Pollan points out that there has been almost no debate on Capitol Hill about how the US agricultural system and crop subsidies are contributing to the obesity epidemic and what changes in agriculture are necessary to ameliorate it. Pollan is not the first to consider the connection between agricultural policy and public health. The eminent physician and nutritionist W. H. Sebrell articulated in 1943:

“[I]t is one of the primary responsibilities of the state to see its population has an opportunity to obtain a food supply adequate for health and that agricultural policies both national and international must be directed toward this end.” (138)

In addition to concerns that agricultural policies may be exacerbating the obesity epidemic by making unwholesome foods and beverages inexpensive relative to fruits, vegetables, and other more wholesome foods, there is also concern about federal dietary guidance. The US Dietary Guidelines, which are produced jointly every five years by the US Department of Agriculture and the Department of Health and Human Services, may not be doing enough to encourage Americans to make healthier food choices and moderate their food intake to stem obesity. This debate is a large one with profound implications for public health and American agriculture, but is beyond the scope of this chapter. However, preparing for reauthorization of the next farm bill (in 2013) is critical not just for efforts to stem obesity, but also for the environment and for climate change; it is rich territory for innovative policy-making and research.

The Legal and Regulatory Environment

Laws and regulations have become increasingly prominent and effective in improving the public health. Public health law has emerged as a strategic element in planning public health interventions (139), and the IOM has identified law and policy as one of the eight emerging themes for the future of public health training (10). Laws and regulations seem to be one of the few common themes spanning multiple reports, from the Ten Greatest Achievements in Public Health (140) to the Guide to Community Preventive Services (see www.thecommunityguide.org), and they also appear to be an essential factor in successful health-related social movements. The following section discusses the importance of laws, regulations, and litigation.

Laws

Laws have played a critical role in the achievement of many public health accomplishments in the 20th century. Starting with infectious disease control, tobacco control, and motor vehicle safety, and moving to public health preparedness, laws have made the critical difference for authorities trying to safeguard the public health. It should also be noted that the absence of legal authority has consistently served as an impediment to important public health initiatives. Mensah and colleagues (141) review the use of law as a tool for preventing chronic disease and reducing injury. Their wide-ranging analysis covers topics such as bans or restrictions on public smoking, laws on blood alcohol concentration, food fortification, and the FCTC discussed earlier.

The public health literature is replete with examples of the use of laws to promote public health, but it is not surprising that the food and beverage industry, as well as the media and entertainment industry, are resisting legislation. With 140 member companies, the Grocery Manufacturers of America (GMA) is the world’s largest association of food, beverage, and consumer product companies. In the US, these companies employ 2.5 million workers with collective annual sales of more than half a trillion dollars. Worldwide, they employ 14 million workers with annual sales in excess of $2 trillion. A 2008 search of the GMA website for materials related to obesity produced 192 documents (142). There is no question that obesity is a sensitive topic for GMA and with the industry they represent; and not surprisingly, GMA highlights voluntary guidelines rather than legislation for marketing foods to children.

With respect to laws specific to preventing obesity or childhood obesity, a number of bills have been introduced, but there is little federal legislation that has passed. A search of bills introduced in the 111th Congress using “obesity” as a search term yields about three dozen bills (143), but none has passed. The Healthy, Hunger-Free Kids Act (previously noted) represents a good opportunity to improve school nutrition, however, its fate has yet to be determined. Another bill for obesity prevention, the IMPACT Act, would provide health services to improve nutrition, increase physical activity, prevent obesity, and for other purposes. It has been introduced repeatedly in the House and in the Senate, every year since the 107th Congress, but to no avail. In May 2010, Congressman Ron Kind and other co-sponsors introduced a bill, The Healthy Choices Act [HR 5209], to address obesity. The bill is complex, addressing education, routine collection of data on BMI, training of healthcare professionals on the prevention and treatment of obesity, nutrition standards used in both child and adult feeding programs, transportation issues, and increasing access to affordable, wholesome foods in rural and low-income urban areas (144). Passage was not anticipated in 2010, but the bill will likely be reintroduced in the next Congress, as will many others.

Reflecting food and beverage industry influence, one or more bills intended to provide liability protection to food and soft drink manufacturers, distributors, advertisers, sellers, and trade associations has been introduced in the 108th, 109th, 110th, and 111th Congress. This bill would bar claims of injury relating to a person’s weight gain, obesity, or any health condition associated with weight gain or obesity (145). Because of this lack of engagement or lack of will to address obesity, and strong interest in protecting the food, beverage, and restaurant industries on the part of federal legislators, most of the regulatory legislative initiatives have occurred at the state level. Proposed legislation has focused on school and community-related topics (146). Trend analysis reveals a marked increase in legislative activity between 2003 and 2005, with 199 and 339 bills introduced nationwide for the respective years (130). The mean adoption rates were 20% in 2003 and 16% in 2005 (130).

Regarding the coverage of obesity treatment, one state-by-state analysis (147) of the coverage of obesity treatment under Medicaid and also under state insurance laws and regulations found that only eight state Medicaid programs covered all recommended treatments for adult obesity. Only 10 states reimburse for the treatment of pediatric obesity. It is noteworthy that 35 states give private insurers the right to raise rates for obese individuals covered in small group plans; 10 states accord that right to insurers offering individual plans; and two states allow obesity to be grounds to deny coverage under individual plans (147).

The legislative process with all its politics is often a difficult avenue for advancing measures intended to protect or promote the public health, especially if consensus among legislators cannot be achieved. Rather than attempt to resolve the details of its childhood obesity legislation in chambers, Arkansas’s legislature empowered a 15-member statewide Child Health Advisory Council to review existing evidence, balance competing interests, and make binding recommendations directly to the Arkansas State Board of Education (148); the recommendations have been implemented. Other states have established similar councils, committees, and task forces to develop plans and oversee efforts to address obesity treatment in adults (149) or to prevent childhood obesity (130), and three states (Florida, Michigan, and Arkansas) have appointed a Surgeon General with responsibilities that include addressing obesity. Despite the lack of success on the federal level, progress at the state level is being made.

Gostin (150) identified eight categories of legal interventions that might be considered in developing comprehensive obesity prevention strategies. These are: 1) required disclosure of nutritional information on food and beverage products; 2) tort liability (litigation against deceptive industry practices or false claims); 3) mandatory surveillance; 4) regulation of food marketing; 5) taxation; 6) school and workplace policies; 7) zoning to influence the built environment; and 8) food prohibition, such as banning trans fat (which does not cause obesity but does raise heart disease risk). But pursuing any of the above will likely be an uphill battle. For example, in January 2008, the New York City Board of Health voted to require calorie information on restaurant menus (151) in those restaurants with 15 or more outlets in the city. In response, the New York Restaurant Association sued the New York City Board of Health (152) in an attempt to block the measure, claiming it would violate its members’ First Amendment rights. As mentioned earlier, the Board of Health ultimately prevailed (88), but it was an expensive and time-consuming struggle.

In 2010, the US Congress passed healthcare reform—the Patient Protection and Affordability Care Act (153); it provides a meaningful opportunity for increased focus on obesity prevention. The bill calls for the provision of free preventive services for quitting smoking, losing weight, and eating healthfully to people covered by Medicare and to people enrolled in job-related health plans or individual health insurance policies created after March 23, 2010 (153). A detailed discussion of ACA is beyond the scope of this chapter, but there are four key provisions to monitor as the legislation unfolds over the next few years: 1) the extent to which people will have access to healthcare insurance and free preventive services for obesity screening and weight-loss counseling; 2) the role of the new National Prevention, Health Promotion, and Public Health Council to be chaired by the US Surgeon General with regard to obesity prevention; 3) the activities of the Prevention and Public Health Fund, which total $7 billion for investment between 2010 and 2015, with an additional $2 billion for each year thereafter; and 4) the impact on consumer choices of the new menu labeling provisions in chain restaurants with 20 or more outlets (153).

Regulation

Legislation often results in administrative actions to regulate the design and manufacture of products that might have an adverse effect on the public health. There does not appear to be a clear relationship between potential harm from products and the level of regulation. For example, food products are relatively tightly regulated, particularly by the FDA, as a result of the authority contained in the Food, Drug and Cosmetic Act. On the other hand, tobacco and gun design are virtually unregulated.

Although the public health community has made substantial progress in reducing tobacco use, tobacco products continue to be relatively unregulated, despite the protestations of the tobacco industry to the contrary (154). The 1990s saw unprecedented efforts to regulate tobacco products, with the FDA, under the direction of the President, exerting jurisdiction over tobacco products, only to be rebuffed by the Supreme Court, which ruled that Congress has not provided the FDA the explicit authority to regulate tobacco products (155). In 2009, a bill was signed by the President that gives the FDA the authority it needs to regulate tobacco products (156).

Food products, on the other hand, come under FDA authority and are clearly regulated in terms of certain aspects of health and safety, including manufacturing plant inspections, nutrition labeling, and health claims. However, the FDA does not currently regulate the nutritional content of food products, portion size, or marketing strategies. Currently, if a food product were to make an unjustified health claim, the FDA could act. Similarly, if the advertising were deemed to be false, misleading, or deceptive, the Federal Trade Commission (FTC) could take action. Pomeranz has argued that the FTC has the constitutional and statutory authority to regulate advertising to children provided that it focuses on “deceptive acts and practices” employed by the food and beverage industry when marketing to children. Her argument is that children do not understand the nature of advertising, nor do they realize that they are the target of advertising, therefore advertising to children is inherently deceptive and coercive. Consequently, she argues, such marketing should not be protected under the free speech provisions of the First Amendment (157). However, concerns of health experts about product marketing are not necessarily focused on health claims or deception, but on the strong appeal to children of calorie-dense foods and beverages of minimal nutrition value. So, it is unlikely that traditional FDA or FTC authority would help in the area of greatest concern: marketing to children of food products that are deemed unhealthful, or entertainment products such as movies and DVDs that encourage children to sit inside staring at screens.

If governmental regulation is not likely or possible, mandatory industry standards could be considered to guide minimum nutrient content, portion size, and marketing of products targeted to children. Industry self- or voluntary regulation is less likely to be effective (45, 158), yet such regulations represent the majority of new regulations related to food marketing to young people (159). In addition to federal regulation, local authorities have the ability to regulate food products, particularly in the areas of licensing, sampling, zoning restrictions, land use (160), and conditional use permits (161). Local restrictions on advertising may be more difficult in light of First Amendment considerations and free speech. Local efforts to regulate tobacco advertising have often been thwarted because of Federal preemptive legislation. The same pre-emption of local authority may not exist for local control over innovative strategies designed to limit the sale of calorie-dense foods of minimal nutrition value.

Litigation

In addition to laws and regulation, litigation has become a powerful tool in preventing product-related injuries and ensuring the public health in such areas as tobacco, gun violence, and lead paint. Vernick and colleagues (162) conclude that while litigation is not a perfect tool, it is an important one, and one that has made some products safer. Parmet and Daynard (163) reach similar conclusions and agree that litigation can deter dangerous activities and contribute to the public health. Both reviews acknowledge a dearth of empirical evidence on the actual impact of litigation, but agree it appears to have a modest and important role in protecting the public’s health. Others argue that product liability litigation has unacceptable social costs and may diminish the role of personal responsibility. As described below, litigation has played an extremely important role in tobacco control (164) and many see that experience as a model for preventing obesity (165).

For tobacco control, the 1990s were the era of tobacco litigation. A myriad of individual, class action, and state Attorney General suits transformed the tobacco control environment and resulted in lasting change in the way tobacco products are marketed and how the public views tobacco companies. The Master Settlement Agreement of November 1998 required the participating tobacco companies to agree to restrict certain marketing practices, disband trade associations, reform their corporate behavior, and provide hundreds of billions of dollars to settling states over the next 25 years (54). In addition to significant financial penalties, tobacco litigation in the 1990s resulted in an unprecedented level of document disclosure that has served as a treasure trove for scholarly research and, perhaps most importantly, changed the social-normative opinion of the general public toward tobacco companies (45, 166).

With respect to food-related litigation, there have been some attempts to sue fast-food restaurants as being at least partially responsible for the obesity of the youthful plaintiffs, and for other reasons, such as consumer safety (e.g., excessive temperature of coffee resulting in customer harm). To date, these efforts have been less than successful, but are widely seen as the vanguard of future litigation efforts (163) including the threatened CSPI suit against McDonald’s, mentioned earlier. In fact, professionals experienced in tobacco litigation have organized websites and conferences to develop strategies and resources to direct individual and class action efforts toward the problem of obesity (167).

At this point, it is not clear whether these efforts will follow the tobacco model and be successful in obtaining settlements or court victories. The process of discovery is likely to yield internal documents that could be damaging to the public’s perception of food and beverage companies. On the other hand, the current cases have been viewed by many as frivolous, reflecting widespread public sentiment that obesity is a matter of personal responsibility. Currently, there are no clear victories to speak of for plaintiffs in food-related cases. Twenty-three states have enacted legislation aimed at prohibiting lawsuits against food and beverage manufacturers for obesity-related health problems (131). This approach is consonant with the effort to provide immunity to manufacturers and distributors of potentially harmful products such as tobacco, alcohol, and guns. Public attitudes toward food marketing to children may be influenced by the content of corporate documents obtained through discovery, and federal efforts at tort reform are likely to shape the litigation environment over the next few years.

The Social Environment

The social environment—the way in which citizens, communities, the private sector, and governments interact to create norms and expectations—is a subtle but essential dimension of health-related social movements. Concern about the increase in alcohol-related motor vehicle fatalities created an environment receptive to increases in public involvement and supportive of public policies to reduce the harm caused by alcohol-impaired driving (168–169). The popularity of designated drivers, minimum legal drinking age, blood alcohol concentration laws, community traffic safety programs, and other interventions are a direct result of changing social norms. The desire of nonsmokers to be protected from exposure to secondhand smoke is a critical element in changing the tobacco control environment and reflects fundamental changes in how smoking is perceived today as compared to the 1960s when the Surgeon General’s report on smoking was published. As a result of advocacy for nonsmokers’ rights, most workplaces are smoke-free, serum nicotine levels have been reduced by nearly 75% in the last decade (170), and the social norms associated with smoking have been permanently changed. It is not clear, however, that the prevention of childhood obesity has an external dimension, or externality, that can serve as a parallel to nonsmokers’ exposure to secondhand smoke. One external factor worth considering is healthcare costs and the explosive yearly double-digit increases in the cost of health insurance. Another possible candidate is the very high risk of childhood obesity in the offspring of obese parents (171) and the evidence that this risk is preventable (172–174).

As healthcare costs escalate and insurance premiums increase year after year, it is argued that the higher insurance rates paid by normal-weight persons, in order to cover the higher costs of diseases and disability incurred by obese persons, are unfair. Several studies show that healthcare costs of obese persons are 25–35% higher than those of normal-weight persons (175, 176). One study (177) showed that the healthcare costs of the morbidly obese are higher still. Some are suggesting that obese individuals should pay higher insurance rates just as smokers currently pay higher insurance rates because of their smoking habits. Another example is the higher rates paid for auto insurance by men or sports car owners or persons with speeding tickets. To address obesity, “incentivized health programs” are being launched by some insurers offering reduced deductibles to people who maintain a low BMI and take yearly physicals (178). Innovative approaches are also being sought by worksites and large businesses that manage insurance programs for their employees (179). Some have argued that including coverage of surgical treatment for severe obesity is cost-effective (180), especially in persons with diabetes (181), and that consequently employer policies and individual policies should include such treatment as a standard health benefit.

Another factor is the growing prevalence of childhood obesity and the consequent rise in pediatric illness. This is triggering public involvement in efforts to change the social environment and highlighting the need for collective action. Given the rapid increase in the prevalence of childhood obesity, the “visibility” of the problem, and the seriousness of the problem for affected individuals, social and normative change is already beginning to occur (182). But there is no evidence that the prevalence of pediatric obesity is starting to decline and severe obesity in both adults (183) and children (184) is continuing to increase.

One of the biggest changes in the social environment for tobacco control is that some tobacco companies now acknowledge that their products are harmful and addictive. As a result of the Master Settlement Agreement and the long-term strategy to market reduced exposure (low-tar or nicotine) products, tobacco companies have become more candid about the harm caused by their products, both in public statements and on their websites. But the level of candor is not consistent among all companies, nor is it consistent in all instances, especially in litigation, where companies continue to deny that their product contributed to the specific harm claimed by the plaintiff. Demonstrating the harmful effects of the media and entertainment industry and food industry on the development of obesity in specific cases will be even more difficult.

Despite the justified concern about sedentary lifestyles and obesity, it has been pointed out that media companies are investing millions of dollars in the marketplace for online games (185). Viacom, the parent company of Nickelodeon and MTV, is investing $100 million in online game development (185). These games are not just for children: “With a series of customized sites for different age groups (preschoolers, tweens, teenage boys, moms), Nickelodeon calls itself ‘the biggest gaming network in the country’” (185). The possibly obsessive preoccupation of children with these games is a particular concern of those interested in obesity and other aspects of health and human development. Although no company has acknowledged that such games are addictive, it is noteworthy that MTV Networks acquired three sites to “strengthen its gaming brand in 2005 and 2006” (185). Perhaps “telling it like it is,” a site called “Addicting Games” is the most popular of the three, attracting 9.4 million unique visitors in February 2008 (185). Game sites are being referred to by the media industry as “casual,” which belies their possibly addictive nature, yet studies show that “one-third of Internet users play online games at least once a week,” and that users “devote hours to the games.” These sites are considered a potential treasure trove for advertisers, especially food advertisers who have “agreed to limit the nature and volume of television advertisements aimed at children” but have not extended those agreements to the Internet (185).

At this time, it is not clear how the food and restaurant industry will respond to social and public health pressures to limit marketing of unhealthful products to children and to assume at least partial responsibility for the epidemic of childhood obesity in the US and around the world (44). However, some change has begun, with companies such as Kraft and Mars pledging to change portion size and fat content in some of the products most popular with children (186). As mentioned earlier, the American Beverage Association has implemented voluntary guidelines to restrict access to sugar-sweetened beverages in schools. On the other hand, the FTC is proposing compulsory reporting of data on marketing to children by the major food and beverage industries in order to document changes in marketing practices from 2006 to 2009 (187). Like tobacco companies, the food industry likely will not respond monolithically. The response of companies that want to be perceived as leaders, or can carve out a “health” niche with their customers, will likely be different from the rest.

If the tobacco experience is any guide, food companies will do just enough to avoid government regulation, but will fall short of making structural changes in product design or marketing that will fundamentally alter their market position (45). To date, companies have been much more comfortable with educational campaigns emphasizing personal responsibility and the need for increased physical activity to address obesity rather than proposing mandatory policy or structural changes (188). As a case in point, one study found that the majority of new regulations on marketing to young people were self-regulation—that is, regulations led, funded, and administered by the industry concerned (157). The changes by industry that have occurred to date have resulted from the threat of litigation by consumers and as a result of the profusion of state and local policies that restrict the sale of sugar-sweetened beverages and foods of minimal nutritional value (159). There continues to be a need for pressure on industry to alter its business practices related to marketing foods to children.

In trying to anticipate possible changes in corporate behavior, it should be remembered that marketing and selling unhealthful food, as opposed to tobacco for minors, is legal, as is the marketing of online games, movies, DVDs, and websites. On the other hand, document discovery has not yet taken place, and if it does, it may change public opinion regarding the marketing of products to children, especially if research demonstrates a convincing link between unethical commercial manipulation of vulnerable young children and childhood obesity or other adverse health effects.

Collaborative approaches to preventing obesity are under discussion, and various governments are beginning to launch broad-based national strategies for tackling obesity (189). In fact, the WHO approved a Global Strategy for Diet, Physical Activity and Health (190) which calls for multi-sector collaboration to address the increasing global prevalence of obesity.

In March 2008, citing the “failures of the food industry to regulate itself,” the International Obesity Task Force joined with Consumers International in calling on the WHO and “national governments” to adopt an “International Code on Marketing of Food and Non-Alcoholic Beverages to Children” (191). Their public statement launching this initiative points out that current industry self-regulatory proposals are restricted mainly to the European Union and the US. They decry industry proposals since “even the most far reaching only cover children up to 12 years of age.” Furthermore, they argue that the major food, soft drink, and confectionery multinational companies spent $13 billion on advertising in 2006 in addition to “undisclosed sums” on online games, social networking sites, and the licensing of cartoon characters and celebrity tie-ins to promote their products (191). Recognizing the futility of counterbalancing the heavy advertising and promotion of unhealthful foods and beverages through various media, the code calls for dramatically revised marketing strategies including bans on:

• Use of radio and TV from 6 am to 9 pm
  
• Use of websites, social networking sites, mobile phones, etc.
  
• All promotional strategies in schools
  
• Use of free gifts, toys, or collectibles appealing to children
  
• Use of celebrities, cartoon characters, competitions

In the months and years to come, the WHO and other policy-making bodies will be considering the code and other recommendations concerning marketing to children. It remains to be seen how decisions taken by these groups will alter marketing practices in the US and elsewhere.

The Need for Research and Evaluation

Marketers of food products and beverages are constantly investing in consumer research to learn what sells and how to capture a larger market share. Explaining the enormous success of Red Bull (a caffeine-containing “energy drink”), which now enjoys a 60% market share of a category worth $10 billion annually, one report (192) explains that “niche marketing” is the powerful new concept:

“The niche getting the most attention is ‘natural energy.’ The message that a food is naturally healthy is one of the most persuasive in food marketing … Other new niches include mood and brain—a new trend but one which offers opportunities for strong niche brands founded on good science …” (192)

These are examples of how consumer research is routinely conducted and exploited by the food industry for product development and how science is invoked for the strategic marketing of products. Research is needed to help the public health community learn how to successfully market healthful foods (e.g., fruits, vegetables, and whole-grain foods) and beverages (e.g., water) and foster healthful eating (e.g., portion control) and daily exercise habits. Wansink (193, 194) has been a pioneer in this arena but this is where more innovative research and appropriately cross-trained researchers in marketing and nutrition and also marketing and exercise science are urgently needed.

Efforts to address contemporary public health problems are often difficult to evaluate for a number of reasons, including the urgency and need for a rapid response before a baseline can be measured, the lack of classical experimental design of interventions, the absence of an unexposed control group, the difficulty in measuring the impact of social factors, the rapid changes in social forces to promote health behaviors and shun unhealthy or unsafe behaviors, and other reasons (195). Despite these obstacles, evaluation research will allow us to determine what works and what does not, as well as provide other essential information on unintended consequences. Such information is urgently needed for the design and implementation of interventions intended to stem obesity.

Concluding Principles and Issues

In summary, there are several lessons to be learned from other successful public health initiatives, but there have been relatively few scholarly efforts to identify the types of interventions that have external validity and can be generalized across a number of public health problems. Most of the scholarship has focused on tobacco control and the lessons it may provide for preventing adult and childhood obesity, as reviewed in this chapter. Following are six issues that are central to the development of a sound public health approach to preventing obesity (196).

• Balance individual responsibility vs. collective action: One of the greatest challenges in our efforts to prevent obesity is to strike the right balance between individual vs. structural or environmental efforts to address obesity (197, 198). As with many public health problems, a critical issue is the role of regulatory or legal coercion vs. the protection of free speech and other individual rights, and striking the appropriate balance between commercial interests and the common good (199).
  
• Shape social norms about food and physical activity: No one could have predicted the magnitude of change in perceptions and public opinion that has occurred with tobacco, but similar changes are possible with respect to food and physical activity. Today, foods are “super-sized” to provide the most food or value for the dollar, with virtually no consideration for diet or health on the part of consumers. While there is nothing wrong in seeking “value,” it is not inconceivable that, in the future, health considerations will enter the equation in calculating “value” and the costs of illness will be part of the calculation of the price of a product. With two-thirds of US adults now classified as overweight, there is no question that overweight is now normative in the US. But obesity is not. Changes in social attitudes may be able to prevent that from becoming the case, especially if the impact of adult obesity on offspring is taken into consideration and becomes a platform for bringing about social change, and social pressure is increased for treatment of adult obesity.
  
• Consider, but don’t necessarily duplicate, other public health experiences: People need to eat, but do not need to smoke. In addition, it is illegal to sell tobacco products to minors, marketing to minors is prohibited, and safeguarding nonsmokers’ rights is a powerful social movement that has changed public norms related to smoking. None of these elements exists for preventing obesity. From a macro-perspective, and although progress has taken decades, tobacco control is relatively simple compared to the complexities presented by obesity. Accordingly, obesity prevention strategies will have to cope with this complexity.
  
• Consider all marketing and advertising channels: The role of the food industry is critical but uncertain. Part of the success of the tobacco control movement was achieved by attacking and marginalizing tobacco companies. It is unclear whether a similar strategy directed against media conglomerates or food companies is warranted or would be effective. This question will be answered in part by the extent to which these companies deal honestly and constructively with the obesity epidemic, including a candid assessment of their role in helping to create it (200). To the extent that commercial interests respond, if not lead, on behalf of the public good, they may obviate the need for government action. To the extent that they fail, government action will likely be demanded (43, 45). It appears clear to most that the overall environment in which food products are produced, marketed, and sold must continue to be improved (201). From the standpoint of physical activity and sedentary pursuits, the marketing practices and policies of the entertainment industry must also be examined.
  
• Collect evidence on best practices and effective interventions: The rise in obesity is well documented, but causal factors are less well understood. The relative contributions of dietary factors, the social, political and built environment, physical activity, inactivity and their interactions need to be better understood (202). Reports by the American Psychological Association (71) and the Kaiser Family Foundation (70) will advance our understanding of the role of the media in childhood obesity, but similar analyses are needed for other aspects of obesity prevention in all age groups. In addition to more studies of the role of fast foods, soft drinks, and dining outside the home, research is urgently needed on parenting, maternal and paternal obesity, intergenerational transmission of obesity risk, and how the social and built environment can be structured to contribute to the prevention of obesity. Once the relative effectiveness of various interventions is better known, there needs to be a concerted effort to disseminate and implement approaches that have been found to be effective. The lack of emphasis on the systematic diffusion of effective interventions has plagued multiple public health initiatives.
  
• Consider the global dimension: The epidemic of obesity was first documented in the US, but the WHO has noted the extent to which obesity is prevalent in other developed countries, as well as in the developing world (see Chapter 1). Domestic solutions should be thought through for their global implications, so that we do not solve our problem here by creating larger ones elsewhere (43, 190). Finally, because many of the companies involved are global in nature and products are marketed globally, international collaboration should be used to identify strategies and practices needed to stem the global epidemic.

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