capstone project final 2-11-2010
TRANSCRIPT
1
JAMA N ENGL JMED The Journal
of Health
Politics,
Policy and
Law
Other
Nature of
problem
*The rates of adult and
pediatric obesity in the US
and other developed nations have reached epidemic levels
in the last 4 decades1
*Pediatric obesity predicts
adult obesity and is
associated with a multitude
of chronic adverse health
outcomes1
*The epidemic of
pediatric obesity is of
great concern because of its pernicious effects on
future health6
*Children at younger
ages are being affected.
If unchecked pediatric
obesity will decrease life
expectancy and
adversely affect health of
current and future
generations7
* After
decades of
research, the rise in obesity
has been
recognized as
a major
medical and
public health
issue9
*Obesity rates are
rising so fast that in
the near future it will substitute tobacco as
the main cause of
preventable death in
the US10
Prevalence and
Incidence
*The prevalence of
overweight among 12-19, 6-
11 and 2-5 years old increased from 10.5%, 11.3%
and 7.2% in 1988-1994 to
15.5%, 15.3% and 10.4% in
1999-2000 respectively2
*Among non-Hispanic
Black and Mexican-
American adolescents the
prevalence rates of
overweight increased more
than 10 percent between
1998-1994 and 1999-20002 *In 2003-2004 there was a
significant increase in the
prevalence of overweight in
female children and
adolescents from 13.8% in
1999-2000 to 16% and from
14.0% to 18.2% in male
children and adolescents3
*Nearly one in three
children and adolescents
is overweight or obese and this rate approaches
one in two in some
minority groups8
*There has been an
increase in the
proportion of people
with severe obesity and
more prominent
increases affect children
and ethnic minorities7
*Prevalence
of obesity is
rising at alarming
rates and
simply
stabilizing
the growth of
this epidemic
would be an
important
achievement9
*The Robert Wood
Johnson Foundation
estimates that 25 million children
aged 17 and younger
are overweight
which represent a
third of the
population of this
age group11
*Obesity rates are
higher among
adolescents from
poor households and low income states13
Consequences *Pediatric obesity is
associated with risk of
development of a variety of chronic and costly diseases
such as cardiovascular,
kidney failure, pulmonary,
orthopedic, type 2 diabetes as
well as psychosocial
disorders resulting from
discrimination and negative
stereotypes 2
*In 2005 annual direct
costs estimated as a
result of treatment of obesity related chronic
ailments were estimated
in $100 billion7
* Obesity
causes a
myriad of chronic
ailments,
significantly
reduce
quality of life
and imposes
financial
burden on
society9
*Scientific findings
have shown that
overweight children are subject to
discrimination and
stereotyped as lazy,
inept and stupid
generating low self-
esteem and
engagement in high-
risk behaviours12
2
1 Gillman, Matthew W. “Risk of overweight among adolescents who were breastfed as infants”. JAMA, May 16,
2001-Vol.285, No.19. 2 Ogden, Cynthia L. “Prevalence and trends in overweight among US children and adolescents, 1999-2000”. JAMA October 9, 2002-Vol.288, No.14. 3 Ogden, Cynthia L. “Prevalence of overweight and obesity in the United States, 1999-2004”. JAMA, April 5, 2006-
Vol.295, No.13. 4 Nielsen, Samara J. “Patterns and trends in food portion sizes, 1977-1998”. JAMA, January 22/29, 2003-Vol.289,
No.4. 5 Friederich, MJ. “Researchers address childhood obesity through community-based programs”. JAMA, December
19, 2007-Vol.298, No.23. 6
Baker, Jennifer L. “Childhood body-mass index and the risk of coronary heart disease in adulthood”. N Engl J
Med, December 6, 2007-Vol.357, No.23. 7Olshansky, SJ. “A potential decline in life expectancy in the United States in the 21st century”. N Engl J Med,
March 17, 2005-Vol.352, No.11. 8 Ludwig, David S. “Childhood obesity – The shape of things to come”. New Engl J Med, December 6, 2007-Vol.357, No.23. 9Brownell, Kelly D. “The chronicling of obesity: Growing awareness of its social, economic and political contexts”.
Journal of Health Politics, Policy and Law, Vol. 30, No.5, October 2005. 10Kersh, Rogan and James Morone. “How the personal becomes political: prohibitions, public health, and obesity”.
Studies in American Political Development, 16 (Fall 2002), 162-175. 11Strom, Stephanie. “$500 million pledged to fight childhood obesity”. The New York Times, April 4, 2007. 12Ebbeling, Cara B., Dorota B.Pawlak, David S Ludwig. “Childhood obesity: public-health crisis, common sense
cure”. The Lancet, Vol. 360, August 10, 2002. 13Drewnowski, Adam and Nicole Darmon. “The economics of obesity: dietary energy density and energy cost”. Am
J Clin Nutr 2005; 82(suppl):265s-73s. 14Elinder, Liselotte S.” Obesity, hunger, and agriculture: the damaging role of subsidies”. BMJ Vol.331, 3 December 2005.
Causes, contributing
factors
*An important trend
towards the
“supersizing
phenomenon” for
snacks, soft drinks,
hamburgers, French
fries and Mexican
food contributes to
the pediatric obesity
epidemic4
*Food marketing to
children and youth
adversely affects
children’s health8
*The cause of
population weight
gain is a “toxic”
environment that
promotes obesity.
The Pima Indians of
Arizona provide a
clear example of the
excess of weight
gains associated with exposure to an
obesogenic
environment9
*Obesity is related
to poverty, low
education and
minority status 13
* In developed
countries
agricultural
subsidies create
overproduction of
food and leads to an imbalance between
supply and demand
which drives
overconsumption
and obesity 14
Rationale for
Government
intervention
*Community-based
projects are effective
to prevent weight
gain in young
children5
*Annual direct and
indirect costs caused by the obesity
epidemic are
estimated at $170
billion. Cost
containment is
essential to the
pocketbooks of all
Americans
* Overweight
children are subject
to prejudice, bias
and ridicule. These
correlate with low
self esteem,
disadvantage in health care and
educational settings
and engagement in
high-risk behaviors
*In order to gain
loyal customers, the
food industry invests
heavily on
marketing their
brands to children
who are unable to recognize
advertisement’s
persuasive
objectives. This
undermines parents
efforts to defend
their kids9
*Agricultural
subsidies weaken the
agricultural sectors
of poor countries
and drives
overproduction and
overconsumption in developed nations. A
reduction of
subsidies of certain
foods in developed
nations is important
to combat the global
paradox of both
obesity and hunger14
3
Pediatric obesity is a worldwide epidemic that has been rising at alarming rates1. Surgeon
General Richard H. Carmona’s 2003 testimony before the Subcommittee on Education Reform,
“The obesity crisis in America”, reported that in the year 2000 the annual direct costs attributable
to obesity were estimated at $117 billion2. Indirect costs such as missed work and future earning
losses are calculated at $56 billion annually3. Obesity is responsible for 7% of total annual health
care expenditures4 in the US and imposes extraordinary financial burden on society whether paid
through Medicare, Medicaid or private insurance. Obesity rates are rising so fast that in the near
future it will substitute tobacco as the main cause of preventable death in the US5. Pediatric
obesity predicts adult obesity and is associated with a multitude of chronic adverse outcomes6.
1 WHO technical report series.” Diet, nutrition and the prevention of chronic diseases”. World Health Organization,
Geneva 2003 2 Testimony before the Subcommittee on Education Reform, Committee on Education and the Work force, United
States House of Representatives. “The obesity crisis in America”. Statement of Richard H. Carmona, Surgeon
General, U.S.Public Health Service, Acting Assistant Secretary for Health, Department of Health and Human
Services 3 Haskins, Ron, Paxson, Christina, Donahue, Elisabeth.” Fighting obesity in the public schools”. The Future of
Children, Policy brief, Spring 2006 www.futureofchildren.org 4 Ziol-Guest, Kathleen M., Duncan, Greg J., Kalil, Ariel.” Early childhood poverty and adult body mass index”. American Journal of Public Health, March 2009,Vol.99, No.3 5 Kersh, Rogan and James Morone.” How the personal becomes political: prohibitions, public health and obesity”.
Studies in American Political Development,16 (Fall 2002),162-175 6 Gillman, Matthew W.” Risk of overweight among adolescents who were breastfed as infants”. JAMA, May 16,
2001-Vol.285, No.19
4
The epidemic has been reaching children at younger ages and if left unchecked it will decrease
life expectancy and adversely affect health of current and future generations7. The prevalence of
obesity in children and teenagers has more than doubled in the last 3 decades8. The Robert Wood
Johnson Foundation estimates that approximately 25 million American children aged 17 and
younger are obese and overweight, which represent almost a third of the 74 million children in
this age group9. Although the problem of pediatric obesity strikes across all ethnic and racial
groups, there is a predilection for low income and racial and ethnic minorities. The Centers for
Disease Control and Prevention reported that in 2000 the prevalence of obesity was 19% of non-
Hispanic black children and 20% of Mexican-American children, compared with 11% of non-
Hispanic white children10
.
7 Olshansky, SJ.” A potential decline in life expectancy in the United States in the 21st century”. New Engl J Med,
March 17, 2005-Vol.352, No.11. 8 Cali, Anna M.G., Caprio, Sonia. “Obesity in children and adolescents” J Clin Endocrinol Metab, November 2008, 93(11):S31-S36 9 Strom, Stephanie. “$500 million pledged to fight childhood obesity”. The New York Times, April 4, 2007 10 Caprio, Sonia, Daniels, Sthephen R., Drewnowski, Adam, Kaufman, Francine R., Palinkas, Lawrence A.,
Rosenbloom, Arian L., Schwimmer, Jeffrey B... “Influence of race, ethnicity and culture on childhood obesity:
implications for prevention and treatment”. Diabetes Care, Volume 31, number 11, November 2008
5
The rise in pediatric obesity prevalence rates occurred concurrently with the increase in the
numbers of Americans on food stamps, which has been estimated to be 31.5 million in
September 200811
. Low-income consumers within developed countries consume cheaper calorie-
dense, nutrient-poor foods12
. The association between poverty and obesity may be related to
income as well as the lack of healthy foods available in low-income neighborhoods and
neighborhoods too unsafe to propitiate outdoors physical activities. The Healthy People 2010
report revealed higher rates of obesity among adolescents from poor households when compared
with middle and high-income households13
. Scientific studies have shown an inverse relationship
between socioeconomic status and adult body mass index which appears as early as one year of
age4. Pediatric overweight and obesity have an extraordinary impact on physical and
psychological health. Precociously, children are being diagnosed with weight-related chronic
ailments including type 2 diabetes and hypertension, which were typically adult disorders, and
are at high risk for development of terribly incapacitating chronic conditions such as blindness,
depression, sleep apnea, asthma, heart disease, stroke, breast, colon and kidney cancers, limb
amputation, chronic kidney diseases, musculoskeletal disorders and gall bladder disease14
. The
number of American children submitted to bariatric surgery for the treatment of severe obesity
has recently tripled15
. Overweight children are subject to prejudice, bias, teasing, and ridicule.
11 Black, Jane. “Targeting obesity alongside hunger- Obama administration may look to tie food assistance to
improved nutrition”. Washington Post, December 24, 2008 12 Drewnowski, Adam. “Fat and sugar: an economic analysis”. The Journal of Nutrition, American Society for
Nutritional Sciences, 2003 13 Drewnoswski, Adam, Darmon, Nicole.” The economics of obesity: dietary energy density and energy cost”. Am J
Clin Nutr 2005;82(suppl):265S-73S 14 Ebbeling, Cara B., Pawlak, Dorota B., Ludwig, David S.” Childhood obesity: public health crisis, common sense
cure. The Lancet, Vol. 360, August 10,2002 15 Zeller, Tom.” Into the mouth of babes: childhood obesity”. The New York Times, March 6, 2007
6
These correlate with low self-esteem, disadvantage in health care and educational settings and
engagement in high-risk behaviors 14,16
.
According to the CDC in 2007 the highest rates of obesity among high school students were
observed in the states of Texas (16%), Mississippi (18%), Tennessee (17%), Kentucky (16%)
Oklahoma (15%) and West Virginia (15%)17
.
Percentage of high school students who were obese* — selected U.S. states, Youth Risk
Behavior Survey, 2007 Source: National Center for Chronic Disease Prevention and Health
Promotion
There are compelling and scientifically supported evidences of the powerful influences of
economic forces and an obesogenic environment in the development of childhood obesity.
Humans beings evolved to endure deprivation of food and this is at odds with the necessity to
diminish food intake when there is too much food available. Humans will be tempted to overeat
if subject to a variety of stimuli such as visual, spatial and gustative and all of these have been
associated with a decreased sense of satiety16
. The intrinsic opiate peptide system is triggered by
the content of fat and sugar in foods and along with economic and socio-cultural determinants
16 Schwartz, Marlene B., Brownell, Kelly D..” Actions necessary to prevent childhood obesity: creating the climate
for change” Journal of Law, Medicine and Ethics, Spring 2007 17 CDC – Health topics -Obese youth over time, 2007.http://www.cdc.gov/healthyyouth/obesity/obesity-youth.htm
7
appears to be important in shaping food preferences18
. There is strong evidence to support that
overeating is a form of substance abuse, which may play an important role in the rise of
childhood obesity epidemic. “Highly pleasurable food qualifies as an addictive substance per US
Food and Drug Administration criteria,” says Dr. Robert A. Pretlow, in a letter to the editor of
Pediatrics, the official journal of the American Academy of Pediatrics19
. In experimental studies,
when rats are given unrestricted access to a nutritious diet they are capable of self-regulation and
remain at a steady weight. Alternatively, when rats are exposed to a high sugar, fat and salty diet
their weight triples. The observed results suggest that rats internal self regulation mechanism can
be disrupted when there is exposure to high palatable foods16
and this could play a role in
humans.
Recent fast food litigation in New York City brought by a group of overweight children has
triggered a heated public debate on the body politics’ responsibility to fight obesity20
. In one suit
against McDonald’s the plaintiff claimed the company had engaged in deceptive advertising and
failed to disclose to consumers the potential health adverse outcomes of its products. The public
reaction after the first lawsuits brought against tobacco companies were received with the same
tone of disapproval and pessimistic legal predictions as these have. However, the stream of
public opinion later on changed direction to place responsibility for the adverse outcomes of
smoking on the tobacco industry.
Massive marketing campaigns from food industry deliberately target defenseless children who
are unable to differentiate advertising from reality and induce them to eat energy dense and low
nutrient “junk” foods. The Institute of Medicine report: “Food marketing to children and youth:
18 Drewnowski, Adam.” Energy intake and sensory properties of food”. Am J Clin Nutrition 1995;62(suppl):1081S-
5S 19 Pretlow, Robert A.. “Overweight and obesity in childhood”. Pediatrics 2008; 122;476 20 Mello, Michelle M., Rimm, Eric B., Studdert, David M.. “The McLawsuit: the fast food industry and legal
accountability for obesity”. Health Affairs, Vol.22, Number 6
8
threat or opportunity” provides scientific support to the hypothesis that these marketing practices
adversely affect children’s health21
. The American Psychological Association suggested that
advertising to children is unfair because of young children’s limited understanding of sales
messages and recommended government intervention to restrict marketing to children22
,23
. This
study found that other heavily advertised non-alimentary products, which encourage sedentary
behavior such as toys, games, screen/audio entertainments, etc may be associated with obesity21
.
A study conducted at the Department of Pediatrics, Columbia University found that body mass
index is predicted by TV viewing, as early as 1-4 years of age24
. The Kaiser Family Foundation’s
director of the program for the study of entertainment media and health said that children are
bombarded annually with approximately 40,000 TV ads, the majority of those for food, and that
marketers calculate that children under age 12 spend annually an average of $35 billion of their
own money and will influence approximately another $200 billion in domestic expenses25
.
Annual sales of foods to young consumers exceeded $27 billion in 2002 and food and beverage
industry spend yearly a sum of $12 billion altogether in order to reach children and youth26
.
More than 50% of TV ads that target children promote candy, salty snacks, fast food, soft drinks
and sweetened breakfast cereals22
. A recent study published in Hypertension, the official journal
of the American Heart Association, found that salt intake is an important determinant of sugar
21 Nestle, Marion. “Food marketing and childhood obesity – A matter of policy”. N Eng J Med 354:24, June 15,
2006 22 Ives, Nat.” The media business: advertising; a report the possibility that ads contribute to obesity in children; the
industry begs to differ”. The New York Times, February 25, 2004 23 Desrochers, Debra M., Holt, Debra J..” Children’s exposure to television advertising: implications for childhood
obesity”. Journal of Public Policy & Marketing, 2007, Vol. 26 (2), Fall 2007 24 Dennison, Barbara A., Erb Tara A., Jenkins Paul L..” Television viewing and television in bedroom associated
with overweight risk among low-income preschool children”. Pediatrics 2002; 109; 1028-1035. 25 Statement of Victoria J. Rideout, vice president and director, program for the study of entertainment media and
health, Henry J Kaiser Family Foundation. Before the Senate Committee on Commerce & Science and
Transportation. Subcommittee on Competition, Foreign Commerce, and Infrastructure 26 “Preventing childhood obesity: health in the balance”, 2005. Institute of Medicine of the National Academies.
www.iom.edu
9
sweetened soft drink consumption in childhood, which is a significant source of calorie intake27
.
Researchers recently discovered an association between proximity of fast food restaurants to
schools and childhood obesity28
. A study from the University of Crete, Greece found that high
sugar-added beverages in kindergarten children are also associated with increased risk of
development of pediatric obesity29
.
American spending on fast food has increased eighteen times since 1970 and portion sizes have
enlarged30
,31
. Fast and packaged foods are cheap, taste good, are ready to eat and involve almost
no preparation. The ubiquitous presence of unhealthful and cheap beverages and foods coupled
with sedentary behavior, which have been attributed to a cultural and technological shift, are
important contributors to the contemporary pediatric obesity epidemic16
. Weissert and Weissert
described that government corn production subsidies have lead to a decrease on the price and
overproduction of corn syrup, which has indirectly influenced the behavior of food industry.
High calorie fructose corn syrup is now found in thousands of food and soft drink products32
.
Several policy initiatives have begun in the USA. In the state of Massachusetts “Shape up
Somerville: Eat smart, play hard” is a community based project which started in 2002 and the
first year results published in 2007 showed that project reduced around one pound of weight gain
over 8 months for an 8 year old child33
. An intervention to reduce television viewing by
27 He, Feng J., Marrero, Naomi M., MacGregor, Graham A.. “Salt intake is related to soft drink consumption in
children and adolescents: a link to obesity?” Hypertension, March 2008; 51; 629-634 28 Davis, Brennan, Carpenter, Christopher. “Proximity of fast food restaurants to school and adolescent obesity”.
American Journal of Public Health, March 2009, Vol.99, No. 3 29 Linardakis, Manolis, Sarri, Katerina, Pateraki, Maria-Styliani, Sbokos, Manolis, Kafatos, Anthony. “Sugar-added
beverages consumption among kindergarten children of Crete: effects on nutritional status and risk of obesity”.
BMC Public Health 2008, 8:279 30 The National Alliance for Nutrition and Activity (NANA).” From wallet to waistline the hidden costs of
supersizing”. June 2002. [email protected] 31 Nielsen, Samara Joy, Popkin, Barry M..” Patterns and Trends in Food Portion Sizes, 1977-1988”. JAMA, January
22/29, 2003-Vol.289, No.4 32 Weissert CS and Weissert WG. Governing health: The Politics of Health Policy, 2nd ed., The Johns Hopkins
University Press, 2006, p. 323. 33 Devi, Sharmila. “Progress on childhood obesity patchy in the USA”. The Lancet Vol. 371, January 12, 2008
10
preschool children showed positive results34
. At Columbia University, a study evaluated the
results of the Healthy Start project designed to diminish fat content of snacks and meals served to
preschool children and results showed that the program was efficacious in reducing serum
cholesterol levels35
.
Studies conducted on Pima Indians have provided strong evidence of the crucial importance of
the environment on body weight. A study conducted in adult Pima-Indian populations in the
Sierra Madre Mountains of Mexico, compared to US Pima Indians from Arizona with both
groups sharing a common genetic background, and demonstrated the powerful influence of the
environment in the development of obesity and type 2 diabetes. The authors found that obesity
was 10 times more frequent in US Pima men and concluded by saying that “changes in lifestyle
associated with Westernization play a major role in the global epidemic of type 2 diabetes”36
.
In 1952, the American Heart Association had recognized obesity as a modifiable risk factor for
cardiovascular diseases. During the next half century, a number of federal agencies such as the
National Institutes of Health, National Cancer Institute, US Department of Health and Human
Services, US Department of Health, Education and Welfare, and private organizations dedicated
to health promotion or to prevention of chronic diseases associated with obesity such as
American Diabetes Association, American Cancer Society and American Heart Association,
released guidelines addressing physical activity and dietary patterns in order to prevent obesity.
Those were ordinary and inefficacious recommendations, which did not take into consideration
the importance of the environmental and socio-cultural changes on the rise of obesity and lacked
34 Dennison, Barbara A., Russo, Theresa J., Burdick, Patrick A., Jenkins, Paul L..” An intervention to reduce
television viewing by preschool children”. Arch Pediatr Adolesc Med Vol. 158, Feb 2004 35 Williams, Christine L., Strobino, Barbara A., Bollella, Marguerite, Brotanek, Jane.” Cardiovascular risk reduction
in preschool children: the “Healthy Start” project. Journal of American College of Nutrition, Vol. 23, No. 2, 117-123 36 Schulz, Leslie O., Bennet, Peter H., Ravussin, E., Kidd, Judith R.,Kidd, Kenneth K., Esparza, Julian, Valencia,
Mauro E. “Effects of traditional and Western environments on prevalence of type 2 diabetes in Pima Indians in
Mexico and the U.S.”. Diabetes Care, volume 29, number 8, August 2006
11
creativity by focusing only on individual behavior modification37
. In 1969, participants of the
White House Conference on Food, Nutrition and Health recommended a broad national public
health effort to combat the problem of physical inactivity. The 1977 Dietary Goals report
acknowledged societal influences on diet such as TV advertising and except for suggestions for
implementing educational programs, food labeling and research, did not mention other
government actions. In a 1977 report released by the National Institutes of Health on the problem
of obesity prevention, which represented an issue-framing shift from previous analysis, the
environmental and social causes of obesity were thoroughly acknowledged and suggestions for
government intervention and regulations were proposed37
. Subsequent reports based on old
mechanistic and reductionist paradigms did not take into consideration the environment and
societal factors associated with obesity. In the late 1980 and 1990s, the US Public Health Service
launched the Healthy People 2000 plan, which considered reduction of adult and adolescent
obesity a priority in the national health agenda. In 1994, the USDA proposed important changes
in the National School Meals Program, initiated in 1946 by President Harry Truman. Agriculture
Secretary Mike Espy, who was soon after forced out of office under accusations that he
improperly received gifts from lobbyists,38
set an agenda for a systematic transformation of
bureaucracy that had been kept unchanged since its foundation by President Abraham Lincoln39
.
The USDA’s School Nutrition Dietary Assessment (SNDA) found that meals served in schools
did not attend to the health necessities of American children and proposed improvement of
nutritional standards for breakfast and lunches served to more than 25 million schoolchildren
daily.
37 Nestle, Marion.” Halting the obesity epidemic: a public health policy approach”. 2000 US Department of Health
and Human Services; Public Health Rep 2000; 115: 12-24 January, 2000/February,2000 38 Miller, Bill. “Espy acquitted in gifts case”. Washington Post Staff Writer, December 3, 1998, page. A01 39 Haas, Ellen. “Our simple goal: Healthy kids”. Roll call, May 23, 1994
12
Public officials have not yet responded vigorously to the public concern on the epidemic of
obesity. After several years of bureaucratic persistence the issue of pediatric obesity moved to
the forefront of the US political agenda and on September 22 , 2000 the Senate passed Children’s
Health Act of 2000 (HR 4365), a bipartisan effort sponsored by Senator Bill First [R-Tenn.] and
Senator Edward M. Kennedy [ D-Mass.]. This comprehensive bill signed by President Clinton on
October 17, 2000 amended the Public Health Service Act enacted in 1946, reauthorized and
revised health programs for children and authorized research on childhood obesity40
. The most
important overweight/obesity measure is not an obesity bill per se. It is the Child Nutrition and
WIC Reauthorization Act (S.2507 signed into law 6/30/2004) passed by Congress and signed by
President Bush in 2004. After enactment of this bill, the issue of pediatric obesity became more
salient and its saliency has been sustained to date although there has been no forceful response
from public officials. The policy development of the issue of childhood obesity seems to be in
accord with prevailing models of agenda setting by public bureaucracy as described by Weissert
and Weissert 41
and has been characterized by disjointed incrementalism.42
A variety of patient advocacy and private organizations and support groups such as Campaign
for Action for Healthy Kids, KidShape, America on the move, Overeaters Anonymous,
Adolescent obesity groups, American Diabetes Association and critics of the food industry such
as Center for Science in the Public Interest (CSPI) are acting to bring the issue of childhood
obesity to public attention. The Robert Wood Johnson’s Foundation, which played a major role
in curbing tobacco use in the USA, pledged to spend more than $500 million in the next 5 years
40 Adams, Rebecca. “Senate OKs health programs”. CQ weekly, Sept.23, 2000 41 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., the Johns Hopkins
University Press, 2006, p. 196-197 42 Weissert WG. Lecture on “The Policymaking process”.
13
to fight pediatric obesity43
. Former President Clinton, who was overweight as a teenager and
waged his own battle against obesity, joined the American Heart Association in 2005 to create
the Alliance for a Healthier Generation to fight diabetes and childhood obesity44
.
The lobbyists for the food industry manifest the qualities of policy entrepreneurs such as
persistence, political connections, negotiating skills and the ability to push a solution forward as
described by Weissert and Weissert45
.They have used the tactics of trying to convince the public
that obesity is a matter of personal responsibility46
. This is in agreement with the ways the public
views the news relevant to health policymaking in general: default is against government
action42
.The Kaiser Family Foundation conducted a survey among 1,175 randomly selected
adults in the Bay Area of California and found the results described on the graph below47
.
43 Strom, Stephanie.” $500 million pledged to fight childhood obesity”. The New York Times, April 4, 2007 44 Severson, Kim. “A new Alliance in the fight against childhood obesity”. The New York Times, April 25, 2007 45 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., the Johns Hopkins
University Press, 2006, p. 335 46Cohen, Adam.” Editorial observer; The McNugget of truth in the law suits against fast food restaurants”. The New
York Times, February 3, 2003 47 San Jose Mercury News. The Henry J. Kaiser Family Foundation. Survey on childhood obesity. March 2004
14
The characteristics of agenda items chosen by the President are based on the following criteria:
historical achievement, reelection and ability to solve the nation’s problems48
. The President’s
public approval as revealed by the polls, the size of the President’s electoral margin and strength
of the President’s party in the House and Senate are critical components of his political capital
which is very important for moving an issue along on the public agenda49
. Former President
Bush in his second term issued a veto against the Food, Conservation and Energy Act of 2008
(HR 2419) sponsored by Rep. Collin Peterson [D-MN] on May 21, 2008. The President’s veto
was overridden by the Congress and on May 22, 2008, this bill became law. The law provides a
boost to bio-energy programs and specialty crops such as fruits and vegetables and imposes
limits on farm subsidies. President elect Barack Obama’s economic stimulus plan has taken
priority over health reform and his choice of Agriculture Secretary has recently said that he
would put “nutrition at the center of all food assistance programs”11.
This seems to indicate that
he will be involved in 2010 when Congress will vote for reauthorization of the Child Nutrition
and WIC Reauthorization act of 2004. Mr. Thomas Daschle, a former US Senate majority leader
and President Barack Obama’s nominee for Secretary of the Department of Health and Human
Services has recently withdrawn amid accusations of unpaid taxes50
.
Kersh and Morone explain in an article on the politics of obesity: “If American history is a guide,
rising social disapprobation, conclusive medical knowledge and further criticism of industry
(perhaps alongside attacks on obese individuals) may fan the flame of interest group activity -
including litigation – and result in far more government regulation of fatty foods. Such sanctions
would represent a nightmare for libertarians and food industry. To many public health advocates,
48 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., the Johns Hopkins
University Press, 2006, p. 91-95 49 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., the Johns Hopkins
University Press, 2006, p. 99-104 50 Zeleny, Jeff. “Daschle ends bid for post; Obama concedes mistake”. The New York Times, February 4 2009
15
they constitute necessary protection against what one writer terms “North Americans’ sedentary
suicide”. For now, the political battle has been joined”51
.
Since the publication of Surgeon General David Satcher’s 2001 “Call to action” on obesity52
,
academics, federal officials, journalists and public interest groups echoed the warning and
brought the research evidence to a broader audience. Over the last decade, the news media have
nourished the American psyche with a constant stream of childhood obesity-related stories and
the wave of news reporting on obesity’s dire consequences has grown as fast as the epidemic
itself53
.
Although the large majority of adults continue to believe it is the parent’s responsibility to watch
their children eating habits and for their weight problems54
a shift on current zeitgeist towards
pediatric obesity has been progressively observed55
. Most recent polls53, 54
have shown that
contrary to results of earlier surveys56
82% and 74% of Americans, respectively, are now
concerned about childhood obesity and adult obesity and 89% and 83%, respectively, consider
pediatric obesity and adult obesity to be a serious issue53
. This study by Evans et al analyzed the
public perceptions related to specific interventions designed to fight pediatric obesity and
revealed the following results: there is public support for most school-based interventions such
as restriction of “competitive food” sales on vending machines and on sales of food of minimal
nutritional value in school cafeterias even if these mean loss of school revenues; the public
51 Rogan Kersh and James Morone. “The Politics of Obesity: Seven steps to Government Action”. Health Affairs,
Vol. 21, Number 6, November/December 2002. 52 The Surgeon General’s call to action to prevent and decrease overweight and obesity. Rockville, Md.: Office of
the Surgeon General, 2001. http://www.surgeongeneral.gov/topics/obesity/ 53 Evans, Douglas W., Finkelstein, Eric A., Kamerow, Douglas B., Renaud, Jeanette M..”Public perceptions of
childhood obesity”. Am J Prev Med 2005;28(1) 54 Harris interactive. “Most of the American public, including a majority of parents, believe that childhood obesity in the US is a major problem". Wall Street Journal Online. February 15, 2005;1-4 55 Mello, Michelle M., Studdert, David M., Brennan, Troyen A.. “Obesity – The new frontier of public health law”.
N Engl J Med 354;24 June 15, 2006 56 Oliver, J., Lee, T..”Public opinion and the politics of America’s obesity epidemic”. Cambridge MA:Harvard
University, Kennedy School of Government, 2002 (working paper RWP02-017).
16
favors an increase in the amount of time children spend on physical activity if this doesn’t
adversely affect basic education; the public vehemently supports restriction of television fast
food advertising that targets children and although the majority of respondents were against any
form of tax-based legislation, 70.9% favored the above described actions if these meant an
increase of only $25 per year in income taxes.
Since 2001 when obesity has become a highly salient issue, both the administration and
Congress acknowledged the potential political consequences of addressing the problem.
Legislators may not be concerned about the amount of calories that people ingest, the food
industry aggressive marketing campaigns and food of minimal nutritional value sold in schools.
Legislators aim at reelection and at how much political capital can be obtained from legislation57
.
According to Weissert,58
there are some characteristics of problems taken seriously by legislators
and these are: the occurrence of an epidemic, an exciting issue which fits the American zeitgeist
of the moment and which is simultaneously not too complex or costly. A cause and effect
relationship on the issue is also crucial to policy development59
as well as availability of ready
solutions to the problem60
. Although the latest 2004 and 2005 polls53,54,61
have shown a trend in
the direction of change on the current zeitgeist towards the issue of childhood obesity and
obesity in general, the problem is multifactor and as such will require coordinated and
multifaceted approaches to solve and results won’t be clearly visible in a short term. Preventing
the next generation to be obese or overweight maybe an altruistic goal but this does not
correspond to the number one payoff most policy makers look for. Voters tend to support
57 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., Johns Hopkins
University Press, 2002, pp. 62 58 Weissert, WG. Lecture on the “Policymaking Process” 59Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., Johns Hopkins University
Press, 2002, pp. 322 60 Smith, Ronald. “Passing an effective obesity bill”. Journal of the American Dietetic Association September 2006
Volume 106 Number 9 61 San Jose Mercury News. The Henry J. Kaiser Family Foundation. Survey on childhood obesity. March 2004
17
candidates who promise rapid returns and tend to penalize those who propose sacrifices as
solutions to problems60
. A combination of these factors has contributed to the current legislative
state of lethargy on the issue of pediatric obesity.
Soon after the Surgeon General’s call in 2001, several bills were introduced in the House and
Senate. These measures authorized grants for research on innovative programs directed to the
issues of inadequate nutrition and exercise but did not offer comprehensive solutions to the
problem of obesity based on best evidence available. Two minor measures, which focused on
obesity, passed the House soon after the call. One was a Sense of the House resolution
(H.Res.438) which said that the House of Representatives acknowledged obesity as a major
health problem and supported the efforts of all organizations taking action to fight the problem
and called for commitment of all private, state and federal institutions to act in order to combat
the rising epidemic62
. The other measure was a Sense of Congress Resolution (H. Con. Res. 480)
which declared that Congress acknowledged the health risks inherent to childhood obesity and
urged parents, schools, civic groups and students to contribute to increased physical activity
among children in the United States. This resolution has never been voted in the Senate63
. The
Senate passed just one obesity-related bill on December 9, 2003, S.1172 - the Improved
Nutrition and Physical Activity (IMPACT) Act. This bill awarded grants to communities and
schools to provide health services for improved nutrition and encouragement of physical activity
and obesity prevention and provided funds for the training of health professionals. A companion
measure to S. 1172, H.R. 716 was introduced in the House on February 12, 2003 by Rep. Mary
Bono Mack [R-CA] and died in the House Committee on Energy and Commerce, Subcommittee
62 Library of Congress web site. Sense of House Resolution 438 (H. Res. 438). Available at:
http://thomas.loc.gov/cgi-bin/query/D?c107:2:./temp/~c107tNGIUt 63 Library of Congress web site. Sense of Congress Resolution 480 (H. Con. Res. 480). Available at:
http://thomas.loc.gov/cgi-bin/query/D?c108:1:./temp/~c108cv6Mad.
18
on Health64
. Still, even if the IMPACT Act had won passage in the House, funds would have not
been appropriated for it. Chairs of the Appropriations and Budget Committees were very critical
of the bill and they did not oppose the Senate passing S.1172 because there was an implicit
understanding that measure would not pass the House. According to Smith60
, Congress was not
willing at this time to disburse enough funding for research, access to care or for investments in a
nationwide infrastructure favorable to the enhancement of nutrition and physical activities.
Policy makers have not yet responded vigorously to the growing public concern about the
childhood obesity epidemic65
. Scarce legislation has been enacted and among these, the majority
emphasizes local over universal standards66
. This is in accord with the fact that the Republicans
held control of the White House, House and Senate, from 2001, when the pediatric issue was
brought to the political arena, until the110th
Congressional elections in 2006. Traditionally
Republicans are in favor of a smaller role of government67
and utilize the rhetoric of personal
responsibility to frame most problems and also this particular issue68
. In September 2006 during
the 109th Congress, there were more than 60 obesity-related bills and resolutions waiting for
further consideration. According to the Institute of Medicine of the National Academies,69
the
amount of funding and resources invested in federal, state and local governments and directed
towards efforts to prevent obesity is disproportionately low and in disagreement with the gravity
64 Library of Congress web site. Improved Nutrition and Physical Activity (IMPACT) Act (S.1172). Available at:
http://thomas.loc.gov/cgi-bin/query/z?c108:S.1172:. 65 Kersh, Rogan, Morone, James.”The politics of obesity: seven steps to government action”. Health Affairs,
Volume 21, Number 6 66 Tschannen-Moran, Bryn, Lewis, Eric, Farrel, Sarah P.”Childhood obesity: policy issues in 2003”. Journal of
Pediatric Nursing, Vol 18, No 6 (December), 2003 67 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., Johns Hopkins
University Press, 2002, pp.79 68 Kersh, Rogan, Morone, James.”Obesity, Courts and the new politics of public health”. Journal of Health Politics,
Policy and Law, Vol. 30, No.5, October 2005 69
Institute of Medicine of the National Academies.”What government can do to respond to childhood obesity. Progress in preventing childhood obesity: how do we measure up?” (2007) http://www.iom.edu/?id=37004
19
of this public health problem. Kersh and Morone describe Congress’s major response to obesity
as a “wealth of rhetoric deploring the crisis”68
.
The most important overweight/obesity bill is not an obesity measure per se. It is S.2507, the
Child Nutrition and WIC Reauthorization Act of 2004 signed by President Bush on June 30,
2004. S.2507 requires that all public and private schools participating in the USDA’s Child
Nutrition Programs create a local school wellness plan and mandates that school policies address
nutrition education, physical exercise and compliance with both national school meal nutrition
guidelines and with a plan to guarantee policy implementation, including the designation of
persons responsible for operating the program. While an important step in reviewing archaic
national nutritional principles, the law lacks mechanisms of enforcement and non-compliant
schools face no sanctions60
. The 42-0 vote on March 10, 2004 came after a struggle between
Republicans and Democrats over an amendment by Rep. Tim Ryan [D-OH] that would have
required that food sold in schools, which compete with meals offered through the National
School Lunch Program, be regulated according to updated federal standards of nutrition.
20
Rep. Tim Ryan’s proposed amendment would also have granted the Agriculture secretary with
authoritative power to set nutritional standards for all food sold on campuses. The secretary’s
authority had been curtailed since 1983 after a successful lawsuit by PepsiCo, which overturned
a measure barring the school sales of food with “minimum nutritional value” during school
hours70
. Democrats agree that the solution resides in restricting school sales of “junk food” in
school vending machines while Republicans favor that parents and school officials determine
nutritional criteria of food to be sold in schools71
. School food-service operators receive $2.57
for each meal served to a child who is eligible for a subsidized lunch and school officials insist
that they need additional funding to be able to comply with the new nutritional guidelines.
According to the results of a Department of Agriculture study on costs of meals released in April
2008, school lunchrooms are a “break-even proposition” nationwide but schools food service
directors say that this study underestimated their indirect costs with fuel72
.
Concerns over the prohibition of sales of “competitive food” during schools hours lie on the fact
that this could affect an extra income for schools of millions of dollars annually as a result of
suspension of marketing agreements with beverage and fast food companies71
. Schools are
infiltrated with unhealthy food advertisement and besides channel one and other educational
outlets, which are inundated with “junk” food propaganda, the food marketers have introduced a
new tactic to influence negatively the eating habits of children: the “bus radio”. A marketing
company supplies radio equipment for school buses based on the false premises that services will
70 Field, Kelly.”School lunch programs reauthorized”. CQ weekly – Education March 13, 2004 Page 645 71 Field, Kelly.”Rise in childhood obesity pulls lawmakers into the lunchroom”. CQ weekly – Health Jan 31, 2004 page 286 72 Sternstein, Aliya.”Food fight: Sparring over school snacks”. CQ weekly –September 15, 2008
21
decrease problems of behavior while “filling the airwaves with content that contains
advertisement”73
.
There has been no significant difference on the way Senate and House consider and support the
issue of pediatric obesity. Over the last decade, legislators have clearly been reluctant to solve
the problem and as pointed out before in this article a state of inertia dominates the current
political scenario on this issue. However, there are differences in Senate and House structure that
can influence the passage of a bill. Senators serve six-year terms, are generally millionaires who
self financed their political campaigns, are elected state wide and tend to see problems from a
broader and longer term perspective as opposed to members of the House. They have a greater
probability of serving on coveted committees and can achieve chair status faster than their House
counterparts. Besides that, Senators may put a “hold” or use a filibuster to stop the progression of
a bill, which can only be prevented with 60 votes74
.
Congressional Democrats and especially Senator Thomas Harkin [D-IW], Chairman of the
Senate Agriculture, Nutrition and Forestry Committee, acting as policy entrepreneur, have
diligently proposed more liberal pediatric obesity legislation but after the enactment of the Child
Nutrition and WIC Act of 2004, nothing has passed both chambers of Congress. Senator George
Miller [D-CA] introduced on October 30, 2003 the Healthy Children to Better Nutrition Act of
2003 (H.R. 3416) which authorizes the Institute of Medicine to recommend nutritional guidelines
for foods sold side by side with foods that are offered as part of the National School Lunch
program in school cafeterias. This bill died in the Subcommittee on Education Reform,
Committee on Education and the Workforce. Senator Thomas Harkins has said that the federal
73 Brescoll, Victoria L., Rogan, Kersh, Brownell, Kelly D..”Assessing the feasibility and impact of federal childhood
obesity policies”. The Annals of the American Academy, AAPSS, 615, January 2008 74 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., Johns Hopkins
University Press, 2002, pp. 24-25.
22
investment of $6.3 billion on the school lunch program has been undermined by the school sales
of “food of minimal nutritional value” 71
. Several bills recently sponsored by Senator Harkins
suggest a nascent commitment to combat childhood obesity on several fronts. S. 2108, Menu
Education and Labeling Act was introduced on February 24, 2004 and referred to the Committee
on Health, Education, Labor and Pensions. This bill requires that consumers receive information
about nutritional content of restaurant and vending machine food. S. 1074, Healthy Lifestyles
and Prevention America Act (HELP America Act) was introduced on May 18, 2005 and referred
to the Committee on Finance. This bill requires vending machines and certain restaurants to
provide nutritional information about food sold including number of calories and seek to restore
the ability of the Federal Trade Commission (FTC) to regulate the marketing of foods to
children. The FTC’s regulatory authority over food advertisement to children was curtailed by
Congress during the cavity epidemic of 198075
after a 1978 effort known as Children’s
Advertisement Rulemaking to restrict TV advertisement of sugary food to children55
. This
proposal generated fierce public opposition and accusations that the FTC was acting as a
“national nanny” and forceful response by representatives of food industry and marketing
companies. S.651, PLAY Every Day Act was introduced on February 15, 2007 and referred to
the Senate Health, Education, Labor and Pensions Committee. This bill requires the Secretary of
Health and Human Services to award grants to state health departments to promote physical
activities to children. S.2784, MEAL Act was introduced on March 13, 2008 and referred to the
Committee on Health, Education, Labor and Pensions. This bill amends the Federal Food, Drug,
and Cosmetic Act to extend the food labeling requirements of the Nutrition Labeling and
Education Act of 1990 to enable customers to make informed choices about the nutritional
content of menu items in large chain restaurants. This emerging flow of bills being incrementally
75 Gillers, Heather.”Harkin rails junk food ads”. Medill News Service April 6, 2005
23
introduced in both houses possibly reflects an imminent change in current zeitgeist as public
opinion surveys have demonstrated recently53, 54, 61
.
In April 2006 both chambers of Congress made a bipartisan effort with the introduction of the
Child Nutrition Promotion and School Lunch Protection Act of 2006 which amends the Child
Nutrition Act of 1966 to require the U.S Department of Agriculture to review the definition of
“food of minimal nutritional value” based on best scientific evidence and prohibits the sale of all
food sold outside the national school lunch program which fits this nutritional criteria, anywhere
and at any time in school campus with the only exception of food sold at school fundraisers76
.
H.R. 5617 has been referred to the House Committee on Education and the Workforce and
S.2592 is in the Senate Agriculture, Nutrition and Forestry Committee and both await further
deliberation.
The issue of pediatric obesity is multijurisdictional. Among the eight committees and six
subcommittees that are more influential on health legislation, Weissert and Weissert have
described two, which are policy committees and hold great power in matters of health policy77
:
the Senate Health, Education, Labor and Pensions Committee and the House Energy and
Commerce Committee. Senator Thomas Harkins [D-IW] who is a Chairman of the Senate
Agriculture, Nutrition and Forestry Committee has diligently introduced several bills recently but
only S.2592 has been referred to the Senate Agriculture, Nutrition and Forestry Committee.
Standing committees are “mini legislatures” that hold hearings, review and amend legislation,
represent their issues on the House floor and wield great power over bureaucracy and special
interest groups. In order to facilitate vote trading and make deals stick among different
76 Alderman, Jess, Smith, Jason A., Fried, Ellen L., Daynard, Richard A..”Application of Law to the Childhood
Obesity Epidemic”. Journal of Law, Medicine & Ethics Childhood Obesity Spring 2007 77 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., Johns Hopkins
University Press, 2002, pp. 29-43.
24
committee jurisdictions, encourage development of expertise, prevent the House from making
expensive political mistakes and diminish transaction costs members self select to certain
committee jurisdictions of their preference and a priori and post hoc powers are wielded to
committees. A priori power refers to control over agenda setting on the committee’ jurisdiction
issues and post hoc power refers to floor debate control, federal agencies supervision and
membership in Conference Committees78
. Committee chairs are key players in the legislative
process especially when legislation is not very significant to political parties. However, the Rules
and Budget committees may restrain opportunistic actions and the Speaker may not reappoint
members to committees that act opportunistically78
. Committees vary in power and House Way
and Means, Senate Finance, House and Senate Appropriations, House and Senate Budget and
House Rules are considered the most powerful and prestigious committees77
.
”The Role of Media in Childhood Obesity” statement of Victoria J. Rideout, Vice President and
Director, Program for the Study of Entertainment Media and Health, Henry J. Kaiser Family
Foundation was held before the Senate Committee on Commerce, Science & Transportation
Subcommittee on Competition, Foreign Commerce and Infrastructure on March 2,
2004.“Combating the Epidemic of Childhood Obesity” a statement of Lynn C. Swann,
President’s Council on Physical Fitness and Sports, Office of Public Health and Science, US
Department of Health and Human Services was held before the Senate Committee on Health,
Labor & Pensions on October 5, 2004. The testimony of the Senior Vice President and Director,
Health Group, The Robert Wood Johnson Foundation was given before the House Education and
Labor Subcommittee on Healthy Families and Communities, on May 10, 2007.
Concerned over a growing movement against “junk food” that could result in the same legal
nightmare that affected the tobacco industry in early days; the “food industry empire” rapidly
78 Weissert, WG. Lecture on ”Congress”.
25
recognized the threat for potential tort lawsuits and very diligently lobbied for a bill that would
immunize the industry from such litigation79
. The Personal Responsibility in Food Consumption
Act (H.R. 339), also referred to sarcastically as the “cheeseburger bill”, was introduced in the
House by Rep. Ric Keller [R-FL] on January 27, 2003 and passed the House of Representatives
on March 10, 2004 by a 276-139 vote. Amendment H.AMDT.475 proposed by Rep. Nick
Lampson [D-VA] that the bill would not apply civil actions brought by, or on behalf of a child or
person injured at or before the age of 8 failed by voice vote. During a hearing session on H.R.
339, Rep. Chris Cannon, Chairman of the Subcommittee on Commercial and Administrative
Law of the House Committee on the Judiciary said to the audience: “The tobacco industry once
faced lawsuits brought by 48 states, and it was ultimately forced to settle those cost-prohibitive
and potentially bankrupting cases for $246 billion. Lawyers demonized the tobacco industry
throughout that time, and today Ralph Nader compares fast food companies to terrorists, telling
The New York Times that the double cheeseburger is, quote, a weapon of mass destruction,
unquote”80
. Senate Majority Whip Mitch McConnel [R-FL] a sponsor of S.1428, the
Commonsense Consumption Act of 2003, a companion bill to H.R. 339 which was introduced in
the Senate on July 17, 2003 called the lawsuits against fast food restaurants ”abusive”. Besides
protection to restaurants, this bill also seeks immunization to packaged food makers, distributors,
advertisers and others against civil liability for health problems caused to an individual by the
consumption of fast foods. S.1428 remains in the Senate Committee on the Judiciary. According
to Weiss and Smith,81
the introduction of H.R. 339 and S.1428 in 2003 revealed two important
trends regarding the issue of the obesity epidemic in the United States: the American public did
79 Warner, Melanie.”The food industry empire strikes back”. The New York Times July 7, 2005 80Hearing before the Subcommittee on Commercial and Administrative Law of the Committee on the Judiciary
House of Representatives One Hundred Eighth Congress First Session on H.R. 339 June 19, 2003 81 Weiss, Rachell I., Smith, Jason A..”Legislative approaches to the obesity epidemic”. Journal of Public Health
Policy, Vol. 25, No. ¾ (2004), pp.379-390
26
not support “paternalistic” legislation at that time and the American government has a vested
interest in defending the well-subsidized agriculture industry.
According to the Center for Responsive Politics, candidates to the US Congress and Presidency
received more than $12 million between 1989 and 2000 from the sugar industry82
and food
processing and sales companies donated $4,636,835 to members of Congress83
. Nestle has
pointed out the enormous conflict of interests that affect government agencies84
.
Weissert and Weissert describe the roles of parties in health policy legislation and of ideology in
health care85
. Political parties enhance communication and exchanges among “like-minded”
members in both houses, and provide a place to talk about issues, congregate support and
negotiate collaboration. By providing cue to members, which is very helpful to neophyte
legislators, the legislative party reduces information overload. Political parties also help identify
issues that distinguish themselves from the other party. Nowadays political parties have been
characterized as “legislative cartels” which wield procedural powers including designating
committee members, using the legislative calendar and generating favorable rules to create
advantageous outcomes for the party85
. Ideology plays an important role in problem definition,
agenda setting for policy making and help legislators pick sides in the dispute over whether
government intervention is necessary86
. In health care as well as in other issues Democrats
usually defend the thesis of government intervention while the Republicans seek less government
involvement (except in social and religious issues) and apply the rhetoric of personal
82 Ebbeling, Cara B., Pawlak, Dorota B., Ludwig, David S..”Childhood obesity: public-health crisis, common sense
cure”. Lancet 2002, 360: 473-82 83 Tao,H.,Glazer,G..”Obesity: from a health issue to a political and policy issue”. Online Journal of Issues in
Nursing 2005; 10(2) 84 Nestle, Marion.”The ironic politics of obesity”. Science Vol 299 7 February 2003 85 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., Johns Hopkins
University Press, 2002, pp. 50-54 86 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., Johns Hopkins
University Press, 2002, pp.323-327
27
responsibility to propose solutions to most problems. In general the Republican way of policy
making and on this particular issue, tends to focus on individuals instead of any expanded
policies that might follow a comprehensive examination of the issue. Other factors also persuade
legislators voting behavior such as interest group pressure and constituency preferences and
leadership or presidential attention to a certain issue87
. Recently, there has been a trend towards
an increase in party loyalty as political parties have become less heterogeneous. This is a result
of stronger leadership along with the demise of Democratic conservative Southerners, which
voted once with Republicans88
. Majority party leadership is essential to the legislative process.
Speaker, Whips and Majority Leaders all interact to mobilize members to action, shape the
political agenda and define committee membership. Unlike the “Czar Reed” of the 1890’s,
today’s party leaders are more inclined to yield power to committees and subcommittee chairs
and are more receptive to constituency demands89
.
In the issue of childhood obesity, ideological disputes are presently in concert at both state and
federal levels as policy makers look for an appropriate equilibrium between public health and
individual liberty55, 90
.When Majority Leader Senator William Frist [R-TN] introduced S.1172,
the Improved Nutrition and Physical Activity Act (IMPACT) during the 108th Congress on June
3, 2003 he emphasized that measure “is not going to have sin or fat taxes and won’t be punitive
in any way”68
. The bill only offered grants to support “health behavior” and “active lifestyles”
87Weissert, WG. Lecture on “Congress”. 88 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., Johns Hopkins
University Press, 2002, pp. 52-53 89 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., Johns Hopkins
University Press, 2002, pp. 26-27 90 Haskins, Ron, Paxson, Christina, Donahue, Elisabeth.”Fighting obesity in public schools”. The Future of Children
Policy Brief Spring 2006 91Harris, Jennifer L., Pomeranz, Jennifer L., Lobstein, Tim, Brownell, Kelly D..”A crisis in the marketplace: how food marketing contributes to childhood obesity and what can be done”. Annu Rev Public Health 21 October 2008
28
and did not even win passage in the House. In sharp contrast, the Personal Responsibility in Food
Consumption Act (H.R.339) which would protect fast-food restaurants from obesity-related tort
claims passed the House (but was not brought to a vote in the Senate)68
. This so called
“cheeseburger bill” which was propelled by lobbying of the National Restaurant Association and
its states affiliates, was enacted by 24 states91
. This fact emphasizes both the industry political
power and the tactic of personal responsibility framing of the issue in order to shield industry.
One congressman supporting the bill stated: “This bill is about self-responsibility. If you eat too
much you get fat. It is your fault. Don’t try to blame somebody else”91
.
In order to fill for the current federal vacuum on childhood obesity legislation, state legislatures
have enacted several laws, which focus on childhood obesity prevention by increasing physical
activity and improving nutritional standards in school and community environments92
. A total of
42 state legislatures have enacted legislation, which requires nutritional regulation for schools,
and 27 states have passed at least one law that targets the issues of overweight and nutrition.
92 Boehmer, Tegan K., Brownson, Ross C., Haire-Joshu, Debra, Dreisinger, Mariah L. “Patterns of childhood
obesity prevention legislation in the United States”. Centers for Disease Control and Prevention
www.cdc.gov/pcd/issues/2007/jul/06_0082.htm
29
According to Kersh and Morone65
there are seven crucial steps in the policy development process
which are likely to trigger government action on a specific issue. With the “demon industry”
trigger already in play, along with other additional triggers such as mass movements and interest-
group pressure, the legislative inertia on the issue of childhood obesity may be defeated in the
near future.
Legislative History
• May 3, 2000 – H.R. 4365: Children’s Health Act of 2000, Last major action: October 17,
2000 became Public Law No. 106-310.
• June 6, 2002- H.Res.438: Expressing the sense of the House of Representatives that
improving men’s health through fitness and the reduction of obesity should be a priority,
June 11, 2002, passed the House of Representatives by roll call vote: 400-2 (Roll no.
220).
30
• January 27, 2003- H.R. 339: Personal Responsibility in Food Consumption Act, March 10,
2004, passed the House of Representatives by roll call vote: 276-139, 18 present/not
voting (Roll call no. 54), Last action: March 26, 2004, placed on Senate Legislative
Calendar under General Orders. Calendar No. 463.
• February 12, 2003 – H. R.716: IMPACT Act, Last action: February 26, 2003, House Energy
and Commerce referred to the Subcommittee on Health.
• June 3, 2003 – S. 1172: IMPACT Act, passed the Senate on December 9, 2003, Last action:
March 18, 2004: By Senator Gregg from Committee on Health, Education, Labor, and
Pensions filed written report under authority of the order of the Senate of 03/12/04.
• July17, 2003 – S. 1428: Commonsense Consumption Act of 2003, Last action:
October 16, 2003, referred to Committee on the Judiciary Subcommittee on
Administrative Oversight and Courts. Hearings held
• October 30, 2003 – H.R. 3416: Healthy Children through Better Nutrition Act of 2003, Last
action: December 1, 2003: referred to the House Education and the Workforce,
Subcommittee on Education Reform.
• February 24, 2004 – S. 2108: Menu Education and Labeling Act, Last action: February 24,
2004: read twice and referred to the Committee on Health, Education, Labor, and
Pensions.
• June 7, 2004 – S. 2507: Child Nutrition and WIC Reauthorization Act of 2004, Last action:
June 30, 2004: became Public Law No. 108-265.
• July 22, 2004 – H. Con. Res.480: Recognizing the spirit of Jacob Mock Doub and his
contribution to encouraging youth to be physically active and fit and expressing the sense
31
of Congress that “National Take a Kid Mountain Biking Day” should be established in
Jacob Mock Doub’s honor, Last action: October 6, 2004, received in the Senate.
• May 18, 2005 – S. 1074: Healthy Lifestyles and Prevention America Act, last action: May 18,
2005: read twice and referred to the Committee on Finance.
• April 6, 2006 – S. 2592: Child Nutrition Promotion and School Lunch Protection Act of 2006,
Last action: April 6, 2006: read twice and referred to the Committee on Agriculture,
Nutrition, and Forestry.
• April 6, 2006 – H.R. 5167: Child Nutrition Promotion and School Lunch Protection Act of
2006, Last action: May 24, 2006: referred to the House Education and the Workforce,
Subcommittee on Education Reform.
• February 15, 2007 – S. 651: PLAY Every Day Act, Last action: February 15, 2007: read
twice and referred to the Committee on Health, Education, Labor, and Pensions.
• March 13, 2008 – S. 2784: MEAL Act, Last action: March 13, 2008: read twice and referred
to the Committee on Health, Education, Labor, and Pensions.
The contributory role played by economically powerful interest groups to the crescent global
epidemic of pediatric obesity has lately come under scrutiny93
. Restaurant revenues in the United
States grew from $43 billion in 1970 to $558 billion today94
. Total expenditures on advertising
by US food and beverage industries has surpassed the amount spent by tobacco and other
93Mello, Michelle M., MPhil, Jennifer Pomeranz, Moran, Patricia. “The interplay of public health law and industry
self-regulation: the case of sugar-sweetened beverage sales in schools”. American Journal of Public Health, April
2008, Vol.98, No.4. 94Natl. Restaur. Assoc. 2008. Restaurant industry facts. http://www.restaurant.org
32
companies and adds up to $30 billion95
. Food is especially big business because everyone eats
and while the pediatric obesity epidemic expands the “food empire’s” profits escalate.
The “food empire” continues to fiercely oppose public health interventions aimed to modify
current practices and utilizes similar tactics as once used by the tobacco industry, which include
distortion of data and utilization of conflicting and unscientific evidence to maintain the anti-
regulatory status quo95
. The strongest opponents of government oversight on the issue of
pediatric obesity are the food industry’s anti-regulatory group Center for Consumer Freedom
(CCF), the Sugar Association, the National Soft Drink Association, the American Beverage
Association (ABA), the Association of National Advertisers, the American Advertisers
Federation, the American Association of Advertising Agencies, the Food Manufacturers
Association, the Snack Food Association, the Grocery Manufacturers of America and the
National Restaurant Association which represents McDonald’s and Burger King as well as
thousands of other restaurants96
. The Center for Consumer Freedom is funded by the food,
beverage and restaurant industries and has fought public health claims on the role of sugar-
sweetened drinks in fueling child obesity and on the deleterious health effects posed by
transfats97
. With an annual budget surpassing $3 million the CCF lobbies belligerently against
legislation to regulate marketing of “junk food” to children and academics who advocate for
healthy diets98
.
On the other side of the battle field, and in evident financial disadvantage, consumer advocacy
groups and private organizations such as Campaign for Action for Healthy Kids, KidShape,
95Chopra, Mickey, Darnton-Hill, Ian.”Tobacco and obesity epidemics: not so different after all?”. BMJ Volume 328
26 June 2004 96Barboza, David.”The media business: advertising; a warning in expanding waistlines”. The New York Times, July
10, 2003 97Zeller, Shawn, CQ Staff.”A hot tuna controversy”. CQ weekly – Vantage point Oct.30, 2006 – Page 2846 98Ludwig, David S., Nestle, Marion.”Can the food industry play a constructive role in the obesity epidemic?”.
JAMA 2008; 300(15):1808-1811.
33
America on the Move, Adolescent Obesity Groups, American Diabetes Association, the
Children’s Advertising Unit of the Council of Better Business Bureaus, the Public Health
Advocacy Institute (PHAI), the Center for Informed Food Choices and critics of the food
industry such as Center for Science in the Public Interest (CSPI) are acting to bring the issue of
pediatric obesity to the forefront of public attention. They strongly support stringent government
oversight of “junk food” sales and marketing to children. The Robert Wood Johnson Foundation,
which played a major role in curbing tobacco use in the US, pledged to spend more than $500
million in the next 5 years to fight pediatric obesity99
. Former President Clinton who was
overweight as a teenager and waged his own battle against obesity joined the American Heart
Association (AHA) in 2005 to create the Alliance for a Healthier Generation to fight diabetes
and childhood obesity100
.
Food supply is abundant in developed countries and provides 3,800 kilocalories per capita/day,
which is approximately twice as much as required by the average American adult101
. In order to
continue to obtain large profits in this overabundant food market the “food giants” are
aggressively investing on advertising and propagation of outlets, increasing serving
sizes102
,103
,104
,105
opening markets in developing countries and using the strategy of substitution.
This is characterized by replacement of agricultural products by simple industrialized and
inexpensive food components such as sugar, margarine, oils, salt and low quality fats leading to
99Strom, Stephanie.” $500 million pledged to fight childhood obesity”. The New York Times, April 4, 2007 100Severson, Kim. “A new Alliance in the fight against childhood obesity”. The New York Times, April 25, 2007 101Nestle, Marion.”The ironic politics of obesity”. Science Vol 299 7 February 2003 102Nielsen, Samara Joy, Popkin, Barry M..”Patterns and trends in food portion sizes, 1977-1998”. JAMA
2003;289(4):450-453 103Nestle, Marion.”Increasing portion sizes in American diets: more calories, more obesity”. Journal of the American Dietetic Association January 2003 Volume 103 Number 1 104Young, Lisa R., Nestle, Marion.”The contribution of expanding portion sizes to the US obesity epidemic”.
American Journal of Public Health February 2002, Vol 92, No. 2 105The National Alliance for Nutrition and Activity (NANA).”From wallet to waistline: the hidden costs of
supersizing”. [email protected] June 2002
34
the creation of “techno foods”95
. Scientists working for the industry have said that “food
manufacturers fear they have created a bio-chemical monster which undermines the body’s
ability to control intake”106
. The overeating effect is related to the physiological release of
endogenous morphine-like substances in response to food content of fat and sugar, which may
lead to food addiction107
.
Regarding membership, interest groups on both sides of the battlefield use selective benefits to
overcome the free rider problem. Membership benefits include material goods, purposive results
such as obtaining ideological objectives and the camaraderie of achieving policy goals108
.
Industry supporters use ideology and policy goals by appealing to American core values of
personal responsibility109
and emphasizing self-regulation of industry. Consumer interest groups
also utilize ideological and policy goals to attract members. They claim that the child obesity
epidemic has developed and grown as a consequence of social and environmental changes,
which influence individual choices, and they stress the importance of government regulation of
marketing and sales of “junk food” to children.
According to Weissert and Weissert, interest groups use both direct and grassroots lobbying to
achieve their objectives110
. In the issue of pediatric obesity both sides utilized both lobbying
strategies although industry groups benefited more from direct lobbying. Unrelenting pressure
from consumer advocacy groups has not moved national politics towards regulatory control due
106Matthews, Robert.”Revealed: food companies knew products were addictive”. Sunday Telegraph (London) July
13, 2003, Sunday 107Drewnowski, Adam.” Energy intake and sensory properties of food”. Am J Clin Nutrition 1995;62 (suppl):1081S-
5S 108Weissert CS and Weissert WG. Governing health: The Politics of Health Policy, 2nd ed., The Johns Hopkins
University Press, 2006, pp.138 109Cohen, Adam.”Editorial observer; the McNugget of truth in the lawsuits against fast-food restaurants”. The New York Times February 3, 2003
110Weissert CS and Weissert WG. Governing health: The Politics of Health Policy, 2nd ed., The Johns Hopkins
University Press, 2006, pp.134-141
35
to a cohesive, super financed and politically clever lobbying campaign by the food and beverage
industry.
In “Food Politics” Nestle, Marion describes the importance of profit-driven and food industry
selfish interests in shaping nutrition and health worldwide which are frequently in discrepancy
with public health best interests111
. The diabolic strategies utilized by the food giants to corrupt
schools and exploit the credulity of children are disclosed as well as the incestuous relationships
among government committees, bureaucrats, food manufacturers and professional organizations.
Alderman et al described the “capture” phenomenon or industry influence over government
decisions. This is likely to occur when industry and government representatives are intimately
associated or are the same people over time112
.
A commentary by Nestle on food company sponsorship of nutrition research and professional
activities raises the issue of irreconcilable conflict of interests between corporations and
professionals when financial ties are established113
. Peer reviewed nutrition journals such as the
Journal of Nutrition and the American Journal of Clinical Nutrition have disclosed sponsorship
from 28 companies including Coca-Cola, Gerber, Nestle/Carnation, Slim-Fast Foods, the Sugar
Association and Monsanto. In 1999, The Journal of the American Dietetic Association received
$3 million from food and supplement companies113
. In 1988, the American Heart Association
(AHA) engaged in a program to label certain foods as “heart healthy” in exchange for payment
of exorbitant fees by selected food companies. The United States Department of Agriculture
(USDA) opposed the enterprise based on the principles that healthy dietary patterns and not a
111Lawrence, Mark.”Food politics: how the food industry influences nutrition and health”. Journal compilation
Dietitians Association of Australia 2007 Book reviews 112Alderman, Jess, Smith, Jason A., Fried, Ellen L., Daynard, Richard A..”Application of Law to the Childhood
Obesity Epidemic”. Journal of Law, Medicine & Ethics Childhood Obesity Spring 2007
113Nestle, Marion.”Food company sponsorship of nutrition research and professional activities: a conflict of
interest?”. Public Health Nutrition: 4(5), 1015-1022
36
single healthy food are related to prevention of development of chronic diseases. Similar
objection was imposed by the Food and Drug Administration due to possible interference with
labeling rules. However, the AHA invited 2,300 makers of frozen foods, crackers and margarines
to apply for “heart healthy” certification113
.
Research on sponsorship effects have shown that grant recipients tend to publish research
findings and prescribe medications, which favor sponsor’s products113
. Lesser et al analyzed 206
scientific articles published over a 5 year period and concluded that the likelihood of a favorable
outcome to the industry was 4-8 times higher if the study was fully funded by these companies98
.
In order to persuade the public that industry cares about the issue of pediatric obesity PepsiCo
donated $11.6 million to YMCA and food companies continue to publicize their efforts to
promote sport activities in schools and youth organizations98
. Ludwig and Nestle explain that
“this focus on physical activity, characteristically without commensurate attention to diet quality,
appears disingenuous. A child can easily consume more calories from a soft drink than she
would expend at a sports event sponsored by a beverage company”.
According to the Center for Responsive Politics, candidates to the US Congress and Presidency
received more than $12 million114
between 1989 and 2000 from the sugar industry alone and
food processing and sales companies donated $4,636,835 to members of Congress115
.
If any of the child obesity bills that have been introduced in Congress were to be referred to
conference, committee members would probably be selected from the House Committee on
Energy and Commerce and the Senate Committee on Health, Education, Labor and Pensions.
114Ebbeling, Cara B., Pawlak, Dorota B., Ludwig, David S..”Childhood obesity: public-health crisis, common sense
cure”. Lancet 2002, 360: 473-82 115Tao, H., Glazer, G..”Obesity: from a health issue to a political and policy issue”. Online Journal in Nursing 2005; 10(2) 116 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., Johns Hopkins
University Press, 2002, p. 39. 117 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., Johns Hopkins
University Press, 2002, p. 171.
37
According to Weissert and Weissert “conference committee language cannot be amended: the
houses must vote the whole bill up or down. Conference committees can rewrite or change
legislation…Sometimes they add provisions out of the whole cloth”116
. If due to opportunistic
behavior a supporter of the bill was not selected to participate in the conference committee, a
powerful instrument in support of legislation would be lost during its final elaboration. If
legislation passed, the verbal content of the bill wouldn’t be clearly translated until bureaucratic
regulations had been written as part of post hoc powers awarded to conference committees.
According to Weissert and Weissert,117
regulations are defined as “rules designed to implement,
interpret or prescribe law or policy”. They are the guiding principles applied to translate the
vague language of Congress into concrete laws governing people’s actions. Several factors work
altogether to ensure compliance by agencies with Congress’ final determinations: the Federal
Administrative Procedure Act, comments by interest groups, hearings pertaining to proposed
regulations and judicial review118
.
Economists at the USDA estimate that important adjustments would occur in the processed food
and agricultural industries if people ate a more healthful diet101
. The threat of government
intervention on the issue of obesity explains why food producers contribute so liberally to
congressional campaigns and why federal agencies have been unsuccessful in taking the
initiative in response to the Surgeon General’s 2001 Call to Action. No other federal health
agency has intervened after the call which explains why the USDA whose primary mission is to
promote US agricultural products (“eat more”) simultaneously provides advice on diet and
118 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., Johns Hopkins
University Press, 2002, pp. 171-174.
38
health. In this case, Nestle points out to the evident conflict of interests, which has led to
“ambiguity of federal guidelines and the confusing nature of USDA’s food pyramid”101
.
Since 1946 when President Harry Truman initiated the National School Lunch Program (NSLP)
as a channel to transfer farm products purchased by the government “from warehouses to hungry
mouths”119
it has been subject to the competing interests of the food industry, farmers, educators,
nutritionists and children’s health advocates.
The Child Nutrition and WIC Reauthorization Act of 2004 requires that all public and private
schools participating in the USDA’s Child Nutrition Programs create a local school wellness
plan and mandates that school policies address nutrition education, physical exercise and
compliance with both national school meal nutrition guidelines and with a plan to guarantee
policy implementation. While an important step in reviewing archaic national nutritional
principles, the law lacks mechanisms of enforcement and non-compliant schools face no
sanctions120
. The 42-0 vote on March 10, 2004 came after a struggle between Republicans and
Democrats over an amendment by Rep. Tim Ryan [D-OH] that would have required that food
sold in schools, which compete with meals offered through the NSLP, be regulated according to
updated federal standards of nutrition. Rep. Tim Ryan’s proposed amendment would also have
granted the Agriculture secretary with authoritative power to set nutritional standards for all food
sold in campuses. The secretary’s authority had been curtailed since 1983 after a successful
lawsuit by PepsiCo, which overturned a measure barring the school sales of food with minimum
nutritional value (FMN) during school hours121
. This ban could affect extra income for schools
of millions of dollars annually as a result of suspension of marketing agreements with beverage
119 Alderman, Jess, Smith, Jason A., Fried, Ellen L., Daynard, Richard A. “Application of law to the childhood
obesity epidemic”. Journal of Law, Medicine & Ethics Childhood obesity Spring 2007 120 Smith, Ronald.”Passing an effective obesity bill”. Journal of the American Dietetic Association September 2006
Volume 106 Number 9 121 Field, Kelly.”School lunch programs reauthorized”. CQ weekly – Education March 13, 2004 Page 645
39
and fast food companies122
. Schools are infiltrated with unhealthy food advertisement and
besides channel one and other educational outlets, which are inundated with “junk food”
propaganda, the food marketers have introduced a new tactic to influence negatively the eating
habits of children: the “bus radio”. A marketing company supplies radio equipment for school
buses based on the false premises that services will decrease problems of behavior while “filling
the airwaves with content that contains advertisement”123
.
Regulatory efforts to modify the current school food environment have generated tremendous
lobbying pressures from industry at both federal and local levels. Democrats agree that the
solution resides in restricting school sales of FMN value in vending machines while Republicans
vehemently oppose the intrusion of a “nanny government”124
on matters of individual choices and
favor that parents and school officials determine nutritional criteria of food to be sold in
schools122
. These Republican views coincide with the food and beverage industry framework on
the issue of pediatric obesity. The industry persuades consumers that the environment is a result
of personal choices instead of a reflection of corporate goals. Appealing to core American values
of individualism, they encourage consumers to be suspicious of government intrusion in their
private lives hence diverting attention from industry’s own responsibility in creating existing
social conditions.
“It’s non sensical to say kids have a personal responsibility to resist the lures of advertising.
Parent’s choices about their children’s eating habits are undermined by “junk food” ads every
day” said Senator Thomas Harkins [D-IW]125
. This point of view is in accordance with current
122 Field, Kelly. “Rise in childhood obesity pulls lawmakers into the lunchroom”. CQ weekly – Health Jan 31, 2004 123 Brescoll, Kersh Rogan, Brownell, Kelly D.. “Assessing the feasibility and impact of federal childhood obesity
policies”. The Annals of the American Academy, AAPSS, 615, January 2008 124 Kersh, Rogan, Morone, James. “Obesity, Courts and the new politics of public health”. Journal of Health Politics,
Policy and Law, Vol. 30, No.5, October 2005 125 Gillers, Heather.”Harkins rails junk food ads”. Medill News Service April 6, 2005
40
American zeitgeist as observed in recent surveys126
and with demands from consumer advocacy
groups. However, food and marketing companies typically deny the negative impact of
marketing on children eating habits and claim that only brand choices are affected127
.
Congressional Democrats and especially Senator Harkins acting as policy entrepreneur have
diligently proposed more liberal pediatric obesity legislation but after the enactment of the Child
Nutrition and WIC Act of 2004, nothing has passed both chambers of Congress. The Healthy
Lifestyles and Prevention America Act (HELP America Act) was introduced on May 18, 2005
by Senator Harkins and requires vending machines and certain restaurants to provide nutritional
information about food sold including number of calories and seek to restore the ability of the
Federal Trade Commission (FTC) to regulate the marketing of foods to children. Since the
Ronald Reagan, administration there has been a tendency toward framing all issues in moral
terms of “personal responsibility”. As applied to the obesity problem this framework implies that
obesity is a personal failure of will, which provokes images of vice119
. Generalized deregulation
of industry was pursued during Reagan’s presidency and under this political climate, the FTC’s
regulatory authority over food advertisement to children was curtailed by Congress during the
cavity epidemic of 1980128
after a 1978 effort known as Children’s Advertisement Rulemaking
to restrict TV advertisement of sugary food to children. This proposal generated fierce public
opposition, accusations that the FTC was acting as a “national nanny” and forceful response by
representatives of food industry and marketing companies. The FTC Improvement Act of 1980
stripped the FTC’s regulatory authority and since this date oversight of children’s advertising has
126 Evans, Douglas W., Finkelstein, Eric A., Kamerow, Douglas B., Renaud, Jeanette M.. “Public perceptions of childhood obesity.” Am J Prev Med 2005; 28(1) 127 Harris, Jennifer L., Pomeranz, Jennifer L., Lobstein, Tim, Brownell, Kelly D.. “A crisis in the marketplace: how
food marketing contributes to obesity and what can be done”. Annu Rev Public Health 21 October 2008 7:29 128Mello, Michelle M., Studdert, David M., Brennan, Troyen A.. “Obesity –The new frontier of public health law”.
N Engl J Med 354;24 June 15, 2006
41
defaulted to self-regulatory Children’s Advertising Review Unit (CARU) created in 1974 by the
advertising industry119
. CARU is a tool that the marketing industry utilizes to resist potential
government regulations.
The federal government has not exercised any control over sugar sweetened beverage sales in
schools93
. In 1970 Congress amended the Child Nutrition Act to provide authoritative power to
the secretary of agriculture to regulate ”junk food” sales at schools. The restriction of sales of
competitive foods in the food service areas during meal periods and the secretary’s labeling of
“soda water” and other sweets as FMN value propelled litigation by the National Soft Drink
Association. Voicing opposition to a ban on school sugar-sweetened soda sales a spokesman for
the National Drink Association said that obesity is “about the couch and not the can”129
. The
designation of soda water in the category of FMN value was affirmed but the secretary of
agriculture authority over the issue was denied by court.
Concerned over a growing movement against “junk food” that could result in the same legal
nightmare that affected the tobacco industry in early days; the “food industry empire” rapidly
recognized the threat for potential tort lawsuits and very diligently lobbied for a bill that would
insulate the industry from such litigation130
. On Jan 27, 2003 the Personal Responsibility in Food
Consumption Act (H.R. 339), also referred to sarcastically as the “cheeseburger bill”, was
introduced in the House by Rep. Ric Keller [R-FL] whose district contains the headquarters of
two national restaurant chains131
. H.R. 339 was referred to the House Committee on the Judiciary
where Rep. Keller served as a member and passed the House of Representatives on March 10,
2004 by a 276-139 vote. Political action committees (PAC) contributions donated from food and
129 Fried, Ellen J., Nestle, Marion. “The growing political movement against soft drinks in schools” JAMA
2002;288(17):2181 130 Warner, Melanie. “The food industry empire strikes back”. The New York Times July 7, 2005 131 Meislik, Alyse. “Weighing in on the scales of justice: the obesity epidemic and litigation against the food
industry”. Arizona Law Review 2004 Vol. 46:781
42
beverage industries to Rep. Keller’s campaign added up to a total of $52,000 and ranked among
the top 5 contributors132
to his campaign. Amendment H.AMDT.475 proposed by Rep. Nick
Lampson [D-VA] that the bill would not apply to civil actions brought by, or on behalf of a child
or person injured at or before the age of 8 failed by voice vote. This so called “cheeseburger bill”
which was propelled by lobbying of the National Restaurant Association and its states affiliates,
was enacted by 24 states127
. This fact emphasizes both the industry political power and the tactic
of personal responsibility framing of the issue in order to shield industry. One Republican
congressman supporting the bill stated: “This bill is about self-responsibility. If you eat too much
you get fat. It is your fault. Don’t try to blame somebody else”. These arguments “resonate with
American values of individualism”133
and are in accordance with the ways the public views the
news relevant to health policymaking in general: default is against government action. Besides
protection to restaurants, this bill also seeks immunization to packaged food makers, distributors,
advertisers and others against civil liability for health problems caused to an individual by the
consumption of fast foods. According to Weiss and Smith, the introduction of H.R. 339 and a
companion bill, S.1428 in 2003, revealed two important trends regarding the issue of the obesity
epidemic in the United States: the American public did not support “paternalistic” legislation at
that time and the American government has a vested interest in defending the well-subsidized
agriculture industry134
.
On May 3, 2006, the Alliance for a Healthier Generation reached an agreement with Cadbury-
Scweppes, Coca-Cola and PepsiCo to restrict sales of sugar-sweetened beverages in schools to
be implemented at 100% of schools by 2009-2010. The accord is unsatisfactory because it allows
132 http://www.opensecrets.org/politicians/summary.php?cid=N00009614&cycle=2004 133 Brownell, Kelly. “The chronicling of obesity: growing awareness of its social, economic, and political contexts”.
Journalof Health Politics, Policy and Law Vol.30, No.5, October 2005 134 Weiss, Rachell I., Smith, Jason A. “Legislative approaches to the obesity epidemic”. Journal of Public Health
Policy, Vol.25, No. ¾ (2004), pp.379-390
43
the sales of a broad range of beverages including 100% juices and sports drinks in high schools,
it is not binding and requires further steps such as agreement by independent local distributors
and individual schools133
. The highly publicized deal with the Alliance brought positive publicity
to the fast-food companies in times of litigation and the possibility that this accord may persuade
some lawmakers that problem has been solved.
The current state of federal legislative inertia on the problem of pediatric obesity can be
attributed to powerful lobbying by food and beverage industry groups and lack of public support
of government intervention on the issue. However, a nascent flow of bills being introduced in
Congress by policy entrepreneur Senator Thomas Harkins and several others enacted in different
US states135
along with further litigation and rising social disapprobation on the issue126, 136
may
counteract the force of the food and beverage empires and provide hope that the current anti
regulatory status quo will soon be changed.
The 2005 Institute of Medicine (IOM) report “Preventing Childhood Obesity: Health in the
Balance”137
has called the child obesity epidemic “one of the most critical public health threats
of the 21st-century”. Over the past few decades the childhood obesity pandemic has emerged at
an accelerated pace as a result of a multiplicity of technological, socio-cultural and economic
factors which combined have profoundly affected our society and created an obesogenic
environment conducive to sedentary behaviors and unhealthful nutrition.137,138,139
135 Bohemer, Tegan K., Brownson, Ross C., Haire-Joshu, Debra, Dreisinger, Mariah L.. “Patterns of childhood
obesity prevention legislation in the United States”. Centers for Disease Control and Prevention
www.cdc.gov/pcd/issues/2007/jul/06 0082.htm 136 Harris interactive. “Most of the American public, including a majority of parents, believe that childhood obesity
in the US is a major problem”. Wall Street Journal online. February 15, 2005;1-4 136 Harris interactive. “Most of the American public, including a majority of parents, believe that childhood obesity in the US is a major problem”. Wall Street Journal online. February 15, 2005;1-4 137 Koplan JP, Liverman CT, Kraak VI, eds. “Preventing childhood obesity: health in the balance”. Washington,
D.C.:National Academies Press, 2005. 138 Hill JO, Wyatt HR, Reed GW, Peters JC. “Obesity and the environment: where to go from here?” Science, Feb
7,2003:853(3)
44
Pediatric obesity is an extremely complex and multifaceted issue for which a complete
understanding of its etiology is lacking and short term, inexpensive and simple solutions are not
likely to solve the problem.140,141,142
In the modern world a highly complex interaction between
biological, genetic, psychological, socio-cultural and environmental factors may propitiate an
increase in energy consumption and a decrease in energy expenditure which disequilibrates the
energy balance equation “energy intake=energy expenditure”137
ultimately leading to caloric gain
and the development of obesity.
Although a trend towards imminent changes on the trajectory of American zeitgeist towards the
issue of pediatric obesity have been recently documented, public opinion is still ambivalent over
the role of government intervention on the problem143,144,145,146,147,148,149
. The large majority of
American adults continue to believe that obesity is a private matter and that it is the parent’s
responsibility to watch for their children eating habits and for their weight problems144
.
According to Weissert150
there are some peculiarities of problems taken seriously by policy
makers and these are: the occurrence of an epidemic; a salient issue which presents “attractive
139 Tillotson JE. “America’s obesity:conflicting public polices, industrial economic development, and unintended
human consequences”. Ann Rev Nutr 2004, 24: 617-43 140
Ludwig DS, Pollack HA. “Obesity and the economy: from crisis to opportunity”. JAMA 2009;301(5):533-535. 141 Kumanyika SK. “Minisymposium on obesity: overview and some strategic considerations”. Ann Rev Public Health, 2001. 22:293-308. 142 Estabrooks PA, Fisher EB, Haymann LL. “What is needed to reverse the trends in childhood obesity? A call to
action”. Ann Behav Med 2008 36:209-216. 143 Evans DW, Finkelstein EA, Kamerow DB, Renaud JM. “Public perceptions of childhood obesity”. Am J Prev
Med 2005;28(1). 144 Harris interactive. “Most of the American public, including a majority of parents, believe that childhood obesity
in the US is a major problem”. Wall Street Journal Online February 15, 2005;1-4. 145 Evans DW, Renaud JM, Finkelstein E, Kamerow DB, Brown DS. “Changing perceptions of the childhood
obesity epidemic”. Am J Health Behav 2006;30(2):167-176. 146 Kersh R, Morone JA. “Obesity, courts, and the new politics of public health”. Journal of Health Politics, Policy
and Law, Vol. 30, No.5, October 2005. 147 San Jose Mercury News. The Henry J. Kaiser Family Foundation. Survey on childhood obesity. March 2004. 148 Harvard University. “Obesity as a public health issue: a look at solutions”. Poll conducted by Lake Snell Perry &
Associates, 2003. Harvard forums on health. 149 Zernike K. “The nation: food fight; Is obesity the responsibility of the body politic?”. The New York Times
November 9, 2003. 150 Weissert WG. Lecture on the “Policymaking process”.
45
features to compete for scarce attention”; a legitimized issue supported by academic studies
which is not multijurisdictional or highly ideological; a problem which is simultaneously
solvable by government and fits the American zeitgeist of the moment; a not too complex
problem for which there are prompt, incremental and inexpensive solutions and a well defined
cause and effect relationship151
. The child obesity problem presents few of the favorable
characteristics described above. However, it is concurrently a multifactor, multijurisdictional,
highly complex issue, which will require multilevel approaches to solve, and results won’t be
clearly visible in a short term. There is not enough political capital gained in proposing a solution
to a problem, which will not be rapidly and thoroughly solvable. Voters are likely to support
candidates who promise rapid returns and tend to penalize those who recommend sacrifices as
solutions to problems152
. An additional important obstacle for political action on the combat of
the obesity epidemic has been recently discovered: the fear of stigmatizing overweight people.153
These factors combined with the omnipresent influence of powerful interest groups154
and the
absence of a “ground-swell” of public opinion favoring government intervention152
have
contributed to the current lack of political will and the federal legislative state of torpor on the
problem of pediatric obesity. Policy entrepreneur Senator Thomas Harkin [D-IW] has introduced
several progressive bills to combat pediatric obesity on different fronts but since the enactment
of the unfunded Child Nutrition and WIC Act of 2004, nothing has passed both chambers of
151 Weissert CS and Weissert WG. Governing Health: The Politics of Health Policy, 2nd ed., Johns Hopkins
University, 2002, pp. 322 152 Smith R.”Passing an effective obesity bill”. Journal of the American Dietetic Association September 2006 Vol 106 No. 9. 153 Reeves R.”How fat became a political issue”. New Statesman August 18, 2003; 16,770; ABI/INFORM Global
pg. 16 154 US Senator Tom Harkin.”Preventing childhood obesity. The power of policy and political will”. American
Journal of Preventive Medicine 2007; 33(4S).
46
Congress152
. In contraposition, state legislators introduced nearly 200 bills to tackle the
nutritional standards of school foods155
.
A multidisciplinary and holistic approach to the issue of pediatric obesity and the involvement of
various stakeholders from different segments of society is warranted in order to fight this
epidemic on multiple fronts137, 141,156
. Large policy changes have been advocated in order to
produce a significant impact on the public health issue of child obesity157
. The IOM recommends
that “actions should be based on the best available evidence – as opposed to waiting for the best
possible evidence”137
. The following are recommendations from nutrition and policy experts on
solutions for the problem of child obesity137,139,158,159,160,161
: development of an intersectoral
national policy on obesity control; overhaul of farm subsidies in order to support nutrient-dense
foods rather than calorie-dense commodities; modification of certain rules of food assistance
programs to permit food stamps to be used at local farmers markets; improvements in urban
development and built environments in order to propitiate the development of recreational and
physical activities; establishment of local farm-to-community food distribution systems;
expansion of successful community programs devoting special attention to ethnic minority and
disadvantaged populations; encouragement of breastfeeding; point-of-purchase menu labeling
and taxation of unhealthy foods; re-establishment of the Federal Trade Commission (FTC)
regulatory authority over advertisement aimed at children and development of guidelines for
155 Longley CH, Sneed J.”Effects of federal legislation on wellness policy formation in school districts in the United
States”. Journal of the American Dietetic Association January 2009 Vol.109 No.1. 156 Huang TTK, Glass TA.”Transforming research strategies for understanding and preventing obesity”. JAMA
2008; 300(15):1811-1813. 157 Hampton T.”Pediatric obesity guidelines released”. JAMA 2008;300(19):2238 158 Nestle M.”The ironic politics of obesity”. Science Vol. 299 7 February 2003 159 McGinnis JM, Gootman JA, Kraak VI, eds.”Food marketing to children and youth: threat or opportunity?”Washington D.C.: National Academies Press, 2006. 160 Koplan JP, Liverman CT, Kraak VI, Wisham SL , eds.”Progress in preventing childhood obesity: how do we
measure up?”. Washington D.C.: National Academies Press, 2007. www.nap.edu 161 Breman M, Lavizzo-Mourey R.”Obesity prevention in the information age: caloric information at the point of
purchase”. JAMA 2008;300(4):433-435.
47
advertising and marketing of food, beverages and sedentary entertainment to children;
implementation of nutritional standards for all competitive foods and beverages sold at public
schools and development of nutrition education for staffing, teaching, parents and children; BMI
measure and report to parents; better funding for public school meal programs and for regular
physical education and after school recreational activities; implementation of public education
multimedia campaigns; grants for child obesity research focusing on experimental behavior,
community-based interventions and meticulous evaluation of the effectiveness, cost effectiveness
and sustainability of successful obesity prevention interventions; dissemination of promising
practices and a reform of campaign contribution legislation to decrease the influence of powerful
interest groups on matters of fundamental importance to public health and the economy.
The above-mentioned solutions to fight child obesity differ significantly according to levels of
comprehensiveness, effectiveness, equity, economic and political feasibility162
. Unfortunately,
scientific findings cannot per se determine policy priorities and not all of the experts “high
impact” proposed solutions are concurrently politically feasible. Nonetheless, some of the
solutions proposed which have been categorized by Brescoll et al162
as “high impact, low
feasibility” will also be discussed in this manuscript and efforts that should be mounted by
society in order to transform these into politically feasible solutions in the future will be
described.
The nation’s schools provide an immense opportunity for the implementation of interventions
aimed at prevention of pediatric obesity. There 53 million schoolchildren spend a significant
amount of their time, consume nearly 35% of their daily food intake and expend approximately
162 Brescoll VL, Kersh R, Brownell KD.”Assessing the feasibility and impact of federal childhood obesity policies”.
The Annals of the American Academy, AAPSS, 615, January 2008.
48
50% of their daily energy163
. The National School Lunch Program (NSLP) and the School
Breakfast Program (SBP) are entitlement programs, which play an important role in the nutrition
of US schoolchildren. Virtually all the 119,000 public schools across the nation participate in the
NSLP and more than 80% of these also offer the SBP164
. Under the NSLP, the United States
Department of Agriculture (USDA) gives public schools $2.57 for a free lunch, $2.17 for a
reduced-price lunch and 24 cents for a paid lunch. Children in families at or below 130 percent
of the federal poverty level (FPL) receive free meals whereas reduced price meals are served to
children in families between 130 and 185 percent of FPL. Children in families above 185 percent
of FPL receive a small per-meal subsidy for full-price meals as determined by the school165
. In
2007, the program cost approximately $9 billion166
. The majority of meals were served to low
income children164
. Reimbursement has been considered inadequate to cover food costs and to
serve a diverse and nutritious school lunch to 30 million and breakfast to 10 million US
schoolchildren. In addition, schools receive “commodity foods” which are literally leftovers
from American food producers and valued at over 20 cents per meal. These encompass
processed foods such as chicken nuggets, pizza, and high fat, low-grade meats and cheeses.
Sales of competitive foods including nutritionally poor à la carte meals and food and beverages
of minimal nutrition value (FMNV) as well as “pouring right” contracts established with
beverage companies generate an important flow of revenue for schools to pay for curricular,
academic and after school activities165
. The amount generated from “pouring contracts” has not
been disclosed by the beverage industry but it has been estimated to be less than 1% of their $70
163 Briefl RR, Crepinsek MK, Cabili C, Wilson A, Gleason PM.”School food environments and practices affect
dietary behaviors of US public school children”. Journal of the American Dietetic Association February 2009 Suppl
1 Vol. 109 No.2 164 Crepinsek MK, Gordon AR, McKinney PM, Condon EM.”Meals offered and served in US public schools: do
they meet nutrient standards?”. Journal of the American Dietetic Association February 2009 Suppl 1 Vol.109 No.2 165 Story M, Kaphingst KM, French S.”The role of schools in obesity prevention”. The Future of Children Vol 16
No.1 Spring 2006 166 Waters A, Heron K.”No lunch left behind”. The New York Times February 20, 2009
49
billion yearly sales167
. School sales of competitive foods displace student consumption of more
nutritious foods, undermine the nutritional goals of the NSLP, divert federal funding and
ultimately the net loss is absorbed by schools154,168
. Texas school food departments had an
annual reported loss of $60 million due to lost meal sales to vending sales165, 168
. A 2005
Government Accountability Office (GAO) report found that for the top 30% of US high schools
more than $125,000 per school/year was generated from competitive food sales169
. Under normal
circumstances schools can only increase revenues in three ways: by increasing NSLP
participation, by increasing prices of full price NSLP meals and by expanding the sales of
popular and unhealthful à la carte meals. The third option is usually chosen by food service
directors because the availability of competitive foods for sale undermines the first two options.
The USDA sets dietary guidelines for NSLP meals, which are not applicable to competitive
foods, which are sold ubiquitously in school campus. More than 50% of the US largest school
districts limit the school sales of competitive foods beyond federal and state regulations165
.
Eleven states – Arizona, California, Hawaii, Kansas, Kentucky, Louisiana, Maine, New Mexico,
South Carolina, Texas and West Virginia mandated nutritional guidelines for competitive
foods165
. The New York City Public School District banned candy, soda, and other sugary snacks
from all public school vending machines170
. The Los Angeles Unified School District passed a
soda ban in January 2004165
. Restriction of competitive food sales in Mississippi, Louisiana,
West Virginia and Georgia generated an increase in NSLP participation165
, which enhanced
school revenues. The states of Maine, California, Minnesota and Pennsylvania substituted sugary
167 Johnston LD, Delva J, O’Malley PM.”Soft drink availability, contracts, and revenues in American secondary
schools”. Am J Prev Med 2007;33(4S). 168 Fleischhaker S.”Food fight: the battle over redefining competitive foods”. Journal of School Health March 2007
Vol. 77 No. 3. 169 US Government Accountability Office, “School meal programs: competitive foods are widely available and
generate substantial revenues for schools”, Report No. GAO-05-563 August 2005. 170 Goodnough A.”Schools cut down on fat and sweets in menus”. The New York Times June 25, 2003
50
soft drinks with more healthful beverages without losing significant amount of profits165
. The
state of Arkansas has recently developed a comprehensive public school program to fight
pediatric obesity which includes BMI measure and reporting to parents, pouring contract revenue
disclosure, physical activity and health education requirements and restriction and elimination of
school sales of FMNV171
. Evaluations of these programs should be important to determine if
these interventions are successful.
Social disapprobation of the school food environment has been mounting and innovative school
nutrition programs have been developed as a result of grassroots nutrition initiatives across the
country such as “Make it happen! School Nutrition Success Stories”. These interventions have
modified the obesogenic environment in thirty-two US public schools by limiting access to
competitive foods and advertising healthful choices among other measures165
. Results have
demonstrated that children will purchase healthy foods when given the chance and given the
captive environment of many schools, sales of a more healthy mix will not have a significant
negative impact on profits172
.
In face of the toxic nutritional environment which permeates most of the US public schools,
Senator Thomas Harkins [D-IW] and a bipartisan coalition introduced legislation entitled S.
2592 – The Child Nutrition Promotion and School Lunch Protection Act of 2006 which amends
the Child Nutrition Act of 1966 to require broader authority for the USDA secretary to review
the definition of FMNV based on best scientific evidence and to regulate the sale of all FMNV
sold outside of the NSLP. Along with other measures already being implemented such as parent
outreach, nutrition education and social marketing this bill provides a “high impact” solution to
171 Ryan KW, Card-Higgison P, McCarthy SG, Justus MB, Thompson JW.”Arkansas fights fat: translating research
into policy to combat childhood and adolescent obesity”. Health Affairs July/August 2006 172 Anderson PM, Butcher KF, Levine PB.”Economic perspectives on childhood obesity”. Economic perspectives
3Q/2003 Federal Reserve Bank of Chicago
51
the pediatric obesity problem162,173,174
. Fierce opposition to any form of government oversight on
the issue would come from the food and beverage industry represented by the anti-regulatory
group Center for Consumer Freedom (CCF) and others168,175
. Consumer advocacy groups
represented by the Center for Science on the Public Interest (CSPI) would strongly support
stringent government oversight of “junk food” sales at public schools. Some parents believe that
regulations on sales of competitive foods are paternalistic and interfere with American core
values of personal responsibility and choice168
. However, others argue that in addition to
protections that the pediatric group requires, this point of view ignores several ways in which
individual weights may affect others well being – for example if the “non-obese are forced to
subsidize the obese”146,176
. Some contend that banning foods from campuses may encourage
students to leave school grounds putting them at risk from “traffic and enticements to
truancy”172
. This has not proven to be true in various state initiatives being implemented.
Policy experts agree that only small incremental steps will have a chance to become US law in
the near term162,177
. Given the fierce opposition from interest groups and the absence of a
“groundswell” of public opinion on this issue152
, S. 2592 is not politically feasible at the moment
however it has been considered a promising policy change162
.
In 2006, the IOM conducted a systematic literature review and final report said that marketing
influences the “preferences and purchase requests of children and consumption at least in the
short term”. Furthermore IOM experts concluded that food and beverage marketing is a “likely
173 Foster G, Sherman S, Borradile KE, Grundy KM, Vander Veur SS, Karpyn A, Kumanyika S, Shults J.”A policy-
based school intervention to prevent overweight and obesity”. Pediatrics 2008;121; e794-e802 174 Finkelstein DM, Hill EL, Whitwaker RC.”School food environments and policies in the US public schools”.
Pediatrics July 2008 Vol. 122 No. 1 175 Ludwig DS, Nestle M.”Can the food industry play a constructive role in the obesity epidemic”. JAMA 2008; 300(15):1808-1811. 176 Finkelstein E, French S, Variyam JN, Haines PS.”Pros and cons of proposed interventions to promote healthy
eating”. Am J Prev Med 2004; 27(3S) 177 Weissert CS, Weissert WG.”Governing Health: The politics of Health Policy”, 2nd ed., Johns Hopkins University
Press, 2002, pp. 336-337.
52
contributor to less healthful diets” and that it “may contribute to negative diet related health
outcomes and risk among children and youth”159
. Schools are infiltrated with unhealthy food
advertisement and besides channel one and other educational outlets, which are inundated with
“junk” food propaganda, the food marketers have introduced a new tactic to influence negatively
the eating habits of children: the “bus radio”. A marketing company supplies radio equipment
for school buses based on the false premises that services will decrease problems of behavior
while “filling the airwaves with content that contains advertisement”162
. In order to gain loyal
customers, the food industry invests more than $11 billion annually178
on marketing their brands
to children who are unable to recognize advertisements persuasive objectives. Given that
children and adolescents are at a developmental stage, consumer goods are influential in
determining their identities and the “symbolic value of products is more important than the actual
function of products” 176
. Children are exposed to nearly 40,000 food advertisements yearly and
the large majority of which are for candy, cereal and fast foods178
. Advertisement to children is
said to “exploit the uncertainty that children and adolescents feel about their identities by tying
attractive images to commercially branded products”176
. This undermines parent’s efforts to
defend their kids.179
Seeking to restore the ability of the Federal Trade Commission (FTC) to
regulate the marketing of foods to children, Senator Harkins [D-IW] introduced S. 1074, The
Healthy Lifestyles and Prevention America Act (HELP America Act). The FTC’s regulatory
authority over food advertisement to children was curtailed by Congress during the cavity
epidemic of 1980180
. Although controversial, regulation of food advertising to children is
considered by experts to be a highly effective solution to the issue of child obesity because it
178 Gostin LO.”Law as a tool to facilitate healthier lifestyles and prevent obesity”. JAMA 2007;297(1):87-90 179 Brownell KD.”The chronicling of obesity: growing awareness of its social economic and political contexts”.
Journal of Health Politics, Policy and Law” Vol 30 No. 5 October 2005 180 Mello MM, Studdert DM, Brennan TA.”Obesity- the new frontier of public health law”. N Engl J Med 354; 24
June 15, 2006
53
would help control the negative influences of advertising on children’s eating and purchasing
patterns and would limit the dissemination of deceptive propaganda to ingenuous kids.
Several foreign governments restrict TV advertising aimed at young children181
and additionally
19 states have legal restrictions on public schools food advertisement179
.
Industry stakeholders call upon “responsible” advertising through self-regulation, not statutory
regulation. The FTC Improvement Act of 1980 stripped the FTC’s regulatory authority and since
this date oversight of children’s advertising has defaulted to self-regulatory Children’s
Advertising Review Unit (CARU) created in 1974 by the advertising industry182
. CARU is a tool
that the marketing industry utilizes to resist potential government regulations.
Public controversy over regulation of food advertisement to children lies on the fact that
according to American core values legislation is paternalistic and that this could impinge on the
constitutional protection of freedom of commercial speech and affect an annual extra income for
schools of millions of dollars as a result of suspension of marketing agreements with beverage
and fast food companies183.
.Traditionally US Congress has tolerated little regulation of
commercial speech and among all industrialized countries only the US and New Zealand allow
direct to consumer pharmaceutical advertisement184
. The US Constitution permits regulation of
ambiguous messages aimed at children however, there is no agreement on what advertising
messages are deceptive or just alluring178
. In 1992, the Telephone Disclosure and Dispute
Resolution Act banned advertising of 1-900 phone numbers to children younger than age 12 and
in 1990, the Food and Drug Administration banned cigarettes advertisement aimed at children184
.
181 Hawkes C.”Regulating and litigating in the public interest”. American Journal of Public Health November
2007,Vol. 97, No.11 182 Alderman J, Smith JA, Fried EL, Daynard, RA.”Application of the law to the childhood obesity epidemic”.
Journal of Law, Medicine & Ethics Childhood obesity Spring 2007 183 Field K.”Rise in childhood epidemic pulls lawmakers into the lunchroom”. CQ weekly – Health Jan 31, 2004
page 286 184 Cawley J.”Markets and childhood obesity”. The Future of Children Vol 16, No.1 Spring 2006
54
According to Cawley184,
government intervention to address childhood obesity is justified on the
premises of “lack of information, youthful irrationality and the societal costs of obesity”. Given
the state’s responsibility to defend minors and the potential for exploitation of children’s
credulity, regulation of food advertisement to children may be politically acceptable but at the
present moment, it is not politically feasible given the fierce opposition from the “food and
beverage Empire” and lack of a “groundswell” of public support.
A third solution, which is regarded, by Brescoll et al as highly effective and highly feasible162
is
to expand funding for research on prevention and cost-effective interventions. This solution is
incremental, technically feasible, less controversial, doesn’t open turf battles, fits zeitgeist, is not
too bureaucratic, costly or vehemently opposed by the industry stakeholders. Less political
capital is required to appropriate additional resources for a program. According to Dalziel et al,
there are critical gaps in the literature especially regarding studies on the evaluation of long-term
outcomes of children after obesity prevention campaigns, which lead to insecurity in the
estimates of cost-effectiveness185
. Cawley points out to the scarcity of cost-effectiveness analysis
of anti-obesity programs184
. Brescoll et all explain that it is important to notice that the National
Institutes of Health obesity related grants have been awarded for biological and pharmacological
research and that little work on economic and social drivers of obesity has been funded.
As renewal of child nutrition programs are due this year by Congress, President Barack Obama
has proposed a $1billion per year increase in funding for child nutrition programs including
school lunches, nutrition research and evaluation and improvement of program oversight186
.
185 Dalziel K, Segal L.”Uncertainty in the economic analysis of school-based obesity prevention programs: urgent
need for quality evaluation”. Obesity Vol. 14 No. 9 September 2006 186 Marshall J. “Obama proposes $1 billion/year boost for child nutrition”. Thomsom Reuters February 26, 2009
55
S.2592, 109th
Congress S.1074,109th
Congress Fund research on prevention
and cost-effectiveness of
interventions
CONCEPT Amends the Child Nutrition
Act of 1966 to require the
USDA to review the definition
of “food of minimal nutritional
value” based on best scientific
evidence and prohibits the sale
of all food sold outside the
National School Lunch
Program which fits this
nutritional criteria, anywhere
and at any time in school
campus with the only
exception of food sold at
school fundraisers
Seeks to restore the
ability of the Federal
Trade Commission
(FTC) to regulate food
advertisement to
children.
Expands funding for research on
child obesity prevention,
evaluation of programs and cost-
effectiveness of interventions.
EFFECTIVENESS Innovative school nutrition
programs have been developed
across the country such as
“Make it happen! School
Nutrition Success Stories”.
These interventions have
modified the obesogenic
environment in 32 US public
schools by limiting access to
competitive foods and
advertising healthful choices.
Results have shown that
children will purchase healthy
foods when given the chance
and sales of a more healthy
mix did not have a significant
negative impact on
profits187,188
In 2006, the IOM
“Food marketing to
children: threat or
opportunity?” report
said that marketing
influences the
“preferences and
purchase requests of
children and
consumption at least
in the short term”.
IOM experts
concluded that food
and beverage
marketing is a “likely
contributor to less
healthful diets” and
that it “may contribute
to negative diet related
health outcomes and
risk among children
and youth”189
According to Dalziel et al there
are critical gaps in the literature
especially regarding studies on
the evaluation of long term
outcomes of children after
obesity prevention campaigns
which lead to insecurity in the
estimates of cost-effectiveness190
Cawley points out to the scarcity
of cost-effectiveness analysis of
anti-obesity programs191
187 Story M, Kaphingst KM, French S.”The role of schools in obesity prevention”. The Future of Children Vol 16
No.1 Spring 2006 188 Anderson PM, Butcher KF, Levine PB.”Economic perspectives on childhood obesity”. Economic perspectives 3Q/2003 Federal Reserve Bank of Chicago 189 McGinnis JM, Gootman JA, Kraak VI, eds.”Food marketing to children and youth: threat or
opportunity?”Washington D.C.: National Academies Press, 2006. 190 Dalziel K, Segal L.”Uncertainty in the economic analysis of school-based obesity prevention programs: urgent
need for quality evaluation”. Obesity Vol. 14 No. 9 September 2006
56
COSTS A 2005 Government
Accountability Office
(GAO) report found that for
the top 30% of US high
schools more than $125,000
per school/ year was
generated from competitive
food sales192
Texas school
food departments had an
annual reported loss of $60
million due to lost meal
sales to vending sales187,193
In order to gain
loyal customers, the
food industry
invests more than
$11 billion annually
on marketing their
brands to children194
President Barack Obama has
proposed a $1billion per year
increase in funding for child
nutrition programs including
school lunches, nutrition
research and evaluation and
improvement of program
oversight195
EQUITY Vertical equity Vertical equity Vertical equity
ADM BURDEN Schools FTC – “Who
cares?”
No
POLITICAL
FEASIBILITY
Proposal doesn’t fit
zeitgeist/seen as
paternalistic/not
incremental/strong
opposition from “food and
beverage empire”
LOW FEASIBILITY
Fierce opposition
from the
industry/seen as
paternalistic/ lack of
a “groundswell” of
public support196
LOW
FEASIBILITY
Proposal incremental/
technically feasible/not
controversial/doesn’t open
turf battles/fits zeitgeist/not
too bureaucratic, costly or
vehemently opposed by the
industry. Less political
capital required to
appropriate additional
resources for a program197
.
HIGH FEASIBILITY
191 Cawley J.”Markets and childhood obesity”. The Future of Children Vol 16, No.1 Spring 2006
192 US Government Accountability Office, “School Meal Programs: competitive foods are widely available and
generate substantial revenues for schools”, Report No. GAO-05-563 August 2005. 193Fleischhaker S.”Food fight: the battle over redefining competitive foods”. Journal of School Health March 2007
Vol. 77 No. 3. 194 Gostin LO.”Law as a tool to facilitate healthier lifestyles and prevent obesity”. JAMA 2007;297(1):87-90 195 Marshall J. “Obama proposes $1 billion/year boost for child nutrition”. Thomsom Reuters February 26, 2009 196 Smith R.”Passing an effective obesity bill”. Journal of the American Dietetic Association September 2006 Vol
106 No. 9. 197 Brescoll VL, Kersh R, Brownell KD.”Assessing the feasibility and impact of federal childhood obesity policies”.
The Annals of the American Academy, AAPSS, 615, January 2008.