Policy Memorandum

To: New York City Council From: Nabila Ibrahim, Freddy Leon & Sharita CastilloDate: December 3, 2015Subject: Combating childhood obesity in the long run

Executive Summary:Childhood Obesity is one of the biggest health problems in the United States. Lower income children in particular are heavily impacted by childhood obesity. There are many factors which contribute to their obesity. High calorie fast food consumption, lack of access to healthy foods and lack of physical activity are the leading factors causing childhood obesity among lower income children. To reduce childhood obesity we came up with four policy options to tackle the various aspect of the problem.  First, we suggest intensive labeling of fast food. Second, we promote an education campaign about the harms of childhood obesity which will reduce the consumption of high calorie fast foods. Third, we advocate for adding a third meal (a dinner) under the CACFP program at daycare centers will increase children's access to healthy foods. Finally, we recommend more exercise through mandatory physical education and activities in schools and daycare centers as well as building “play streets” in low income neighborhoods to expand physical activity outside of the school and daycare setting. Although all of these options help to reduce childhood obesity, adding a third meal under CACFP is the strongest policy and easiest to implement because we have the funds available for this program.  Labeling for fast foods and building “play streets” are long term projects and it will require cooperation among fast food restaurants, the Department of Health and Mental Hygiene, the NYC Parks Department, The Department of Transportation and the New York City Board of Education.

Problem:Childhood obesity is one of the major national health problems in the United States. Obesity usually happens when children gain excessive amount of body weight.  According to studies commissioned by the Let’s Move Organization, spearheaded by First Lady Michelle Obama, “childhood obesity has tripled in thirty years and currently one in three children are obese” (Let’s Move,2015).  Lower income families have large groups of obese kids. According to the article Prevalence of Childhood and Adult Obesity in the United States, 2011-2012, 31.8% of Hispanic children and 35.2% of Black children face obesity whereas only 28.5% white children are obese (Odgen, 2014).  Obesity will negatively impact children’s health, education, and social lives in the long run.

Causes of Childhood Obesity:Childhood obesity can be attributed to a number of factors.  The following policy options focuses on three key areas:  Calorie Consumption, Access to Healthy Foods and Increased Physical Activity.

Fast Food & Marketing:There are many reasons behind childhood obesity. However, high consumption of fast food is one of the leading reasons. Nearly 25% of children eating fast food every day are obese or overweight according to naturalsociety.com which cited a study done by the Centers for Disease

Control and Prevention. Higher percentages of children are having fast food today in order to obtain free games and toys along with their meals. Based on the article Food Marketing: Using Toys to Market Children’s Meals, fast food restaurants nearly spends 2 billion dollars every year to promote fast food. Within that amount 59% has been spent to buy toys and games for children. (Fast Food Market.Org).  Powerful advertisements from fast food restaurants usually influence children to buy their food. Children do not realize that they are actually consuming more calories than their body can process. Moreover, the parents of low-income families use these toys to make their children happy for a low cost. They are distracted from the harm behind this excessive fast food consumption. Based on the website of Counting Calories in Kids’ Meal, children who are age two to five should not have more than 410 calories per meal. The children who are six to eleven should not have more than 650 calories. However, their data show that most of the fast food restaurants exceed this calorie limit. For example, Burger King Kid’s meals have 795 calories, DQ Kids meal 1020, Subway Fresh Fit Kids Meal 565, McDonald’s Happy Meal 620, and Wendy’s 760 calories in their kid’s meal menus. These calories might be meaningless numbers to those children and their families, who aren’t knowledgeable of healthy eating and calorie counts. Therefore, they are storing excess fats in their bodies, increasing risk of childhood/ adult obesity.

Poverty and Access:Poverty is another cause of obesity. Besides toys, low-income families also buy fast food due to inaccessibility of healthy food. Healthy meals are usually low calorie fresh fruits, vegetables, whole grain foods and baked fish and meats. However, these foods tend be expensive compared to any fast food. Therefore, these families prefer fast food due to their economic conditions. Based on the article, Access of Healthy Affordable Food from Live Well website, “23.5 million people live in low income areas; just under half have incomes at or below 200% of the poverty line, and almost 1 million do not have access to a car” (LiveWell.org). Although New York City is known as the metropolitan city, they still have access to healthy food. According to the article, Food Stamps in Farmers Markets Project Progress Report, “three million New Yorkers live in neighborhoods with high need for fresh food outlets” (Council.NYC.gov). Therefore, fast food restaurants continue to expand in these areas where lower income families tends to live. The data from the National Center for Children in Poverty shows that “42% of children live in low income areas” (NCCP). These areas lack healthy grocery stores therefore, if the parents want to buy healthy food for children from their area, they are still unable to access it. Hence the inaccessibility of healthy food leads to high risk of childhood obesity.

Lack of Exercise:Lastly, lack of physical exercise is also another major cause of childhood obesity. Low-income families usually tend to work longer hours than others. For this reason, some parents are not able to take their children to a park to engage in vigorous physical activity. These children usually spend most of their spare time with their electronic devices at home. According to the journal article, Active Healthy Living: Prevention of Childhood Obesity through Increased Physical Activity, “33% of Mexican American and 43% of non-Hispanic black children watched at least 4 hours of television per day, and these children were less likely to participate in vigorous physical activity” (Academy of Pediatrics, 2006).  Children should burn extra calories in their bodies. However, more children are storing extra calories as fat, which will eventually increase the risk of childhood obesity in the long run.

Harms of Childhood Obesity:Childhood obesity can cause diseases and affect a child’s life. According to the Centers for Disease Control and Prevention “70% of obese children have at least one risk factor for cardiovascular disease in their early age”. Moreover, childhood obesity can cause a high risk of other severe diseases. Based on the studies of Let’s Move Organization, childhood obesity causes type 2 diabetes, metabolic syndrome, high cholesterol, high blood pressure, liver diseases, and sleep disorders (2015). The medications for those diseases take a toll on lower income families. Based on the article of Over a Lifetime, Childhood Obesity Costs $19,000 Per Child, childhood obesity cost “$19,000 per child when comparing lifetime cost to those of normal weight child” (Duke Global Health Institute, 2014). Although families tend to buy fast food due of their low costs, they eventually will spend more when medical expenses are factored in. This excessive medical cost can lead to more poverty in some families. Therefore, childhood obesity causes physical and economical damages.

Childhood obesity can also lower the self-confidence of children. Obese children can face prejudice about their looks, some people will judge them for being overweight and they might experience bullying from their peers. According to the article, Obese Kids More Vulnerable to Bullies “kids who were obese were 65 percent more likely to be bullied than their peers of normal weight” (Harding 2008). Because they are bullied for weight, these children feel stress about their lives. This situation sometimes might cause some of them to drop out of school. They are not usually able to get highly paid jobs with low education; therefore, they might remain in poverty for their lifetime.

Policy Options:Childhood obesity has become a national crisis in the United States. We cannot solve childhood obesity in a single day. There are still various steps we need to take to prevent this severe issue. We would like to share with you possible solutions to reduce childhood obesity specifically for children of low-income families.

Reduce Calorie Consumption through fast food labeling:In order to deter excessive calorie consumption among children we propose new labeling that would be prominently placed.  Currently NYC mandates calorie counts be placed on menu boards in chain restaurants.  President Obama's Affordable Health Care Law expands on this, mandating that chain restaurants (20 or more locations) post calorie counts. The New York Times cites studies which report that calorie posting do not change habits, and Sara Bleich an Associate Professor of John Hopkins School of Public Health explains that only 30% of consumers actually notice calorie labels on menus boards.  Calorie counts do not work if people are unaware of what are appropriate calories for meals, especially in the case of children meals.  A survey conducted by the International Food Information Council Foundation reported that, “Although 67% of Americans report taking calories into account when making food purchases, nearly nine out of 10 have no idea how many they actually need”.  Our proposal would make the calories more visible by placing the calories along with a warning on the actual packaging of children’s meals in fast food chain restaurants. The calorie/warning labels would follow a similar placement as cigarettes currency do. The labels would be required to cover 50% of the packaging, in text that is large and easily differentiated from the products regular labeling/design. The label would

indicate the number of calories that is currently recommended for children, with the number of calories contained in the meal purchased along with the message that regular consumption of food over this amount has been found to lead to childhood obesity.  

We expect that this form of labeling would provide a more direct message to parents, who are purchasing the food for their children. Informing them of the effects and harms of their food choices.  Aggressive direct messaging has been used in other industries and countries and has shown promising results.  An example is the graphic labeling of cigarettes in other countries such as Australia, Brazil, and Canada.  According to The Campaign for Tobacco-Free Kids, these countries reported increased public knowledge of the harmful effects of smoking and increases in people limiting their smoking.  We do expect substantial resistance from the fast food industry, this is where we are most excited to offer innovation in children's meals.  We plan to meet the industry half way and not demonize their menus, therefore we are offering an alternative to the aggressive labeling.  If fast food restaurants do not want to begin adding this information on the packaging they must adjust their children menu so that no meal exceeds the per meal calorie limit set forth by the Food and Drug Administration and the US Department for Health & Human Services.  This concept would require the fast food industry to innovate their current offerings in a way that reduces excessive calorie consumption in a single meal.

This proposal does not impose on parents’ decisions when purchasing children's meals, as the sugar tax did. Instead it motivates manufactures to sell food that has fewer calories, one factor to add in the fight against childhood obesity. Remember that childhood obesity is particularly high in low-income minority communities. Many times fast food is optimal due to its availability, price, and attractiveness to children with the aid of included toys; therefore reducing the amount of calories fast food contain helps families who don’t have many other options.  

Inform and Educate:As previously mentioned calorie counts on menus are useless if people are unaware of what are appropriate calories for meals, especially in the case of children meals.  A survey conducted by the International Food Information Council Foundation reported that, “Although 67% of Americans report taking calories into account when making food purchases, nearly nine out of 10 have no idea how many they actually need”.  Since our first policy option allows the graphic warning labels to be circumvented by complying with regulations that would lower calories in children's fast food meals we need to implement a calorie counting education and healthy eating campaign.  This campaign may consist of posters in our public transportation, television and radio advertisements.  This campaign would not generate new costs as the New York City Department of Health and Mental Hygiene already does campaigns to educate the effects of overconsumption of sugary drinks and promotes other healthy practices. However these campaigns take for granted that people understand how many calories they should consume or that they can easily calculate calories in meals.  This policy would add to the health campaigns already in place by adding to the scope they cover.  We would like the posters to tackle childhood obesity by explaining calories impact on childhood obesity, what calories are, how many should be consumed, calorie counts in typical meals, educate about proper portion sizes and possibly recommend applications which can provide quick and healthy recipes and calorie calculators.

Allow an additional third meal for children under CACFP Program:Poverty leads lower income families to work longer hours than other parents. The graph from the National Center for Children in Poverty shows that 45% of parents from lower income families work full time (NCCP). (See Appendix A). Parents usually put their children in child care centers for more than eight hours, so they can earn additional money for their families. The United States Census Bureau shows that 32.7 million children used day care centers in 2011 (Census.Gov). The food children receive at daycare centers highly impacts their health and food habit. The Federal Government introduced the Child and Adult Care Food Program (CACFP) under the United States Department of Agriculture Department in 1968 to provide healthy meals to low-income children at daycare centers.  Presently, childcare centers in the United States only provide two meals and one snack daily to lower income children. For this service, they receive reimbursements from government for the each meal they provide. To receive the government’s reimbursement, daycare centers need to follow a healthy meal pattern which includes fruits, vegetables, milk, bread and bread alternatives, meat and meat alternatives. (See Appendix B). For every age group, there are different serving sizes, and daycare centers need to follow these rules. Strict rules under CACFP ensure that low-income children are receiving two healthy meals -- breakfast and lunch -- while they are at day care centers. However, the concern remains for lower income families is to provide a healthy dinner for their children.

Dinner is a very important meal of the day to aid in children’s growth. The article “Access to Healthy Food and Why It Matters” states that there are 30 million people who live in low-income areas and do not have access to any supermarkets. Lower-income parents lack money and time; for dinner they usually buy inexpensive and unhealthy food from their neighborhood stores. And these stores mostly contain unhealthy food, which affects the food habits of these children in the long run. The article “Study Finds Children Eat Healthier at Daycare Centers Than at Home” claims that “for every increase in 200 calories consumed away from the center, the child's odds of being overweight increased by 20 percent” (Medical Press). Therefore, if the children who spend more than 8 hours a day receive an additional third meal -- dinner -- under CACFP program, then they will have more of a chance to eat healthy food and build up healthy food habits.

Washington DC provides a third meal in day care centers. Legislators came up with the Healthy Tots Act in 2014. (See Appendix C). According to this act, “Childhood obesity and hunger negatively affect health and economic outcomes and prevents children from reaching their full potential” (DC Hunger. Org). Policymakers have argued that this act is helping Washington DC to reduce obesity levels and lower the burden on lower income parents to provide a healthy dinner to their children.  Parents now have the option of using that money that did not spend on dinner to provide their children with other essential needs.

Based upon on Healthy Tot Act, in July 22, 2015, Senator Robert Casey introduced “Access to Healthy Food for Young Children Act of 2015” in Congress where he proposed adding an “option of a third meal service to serve children who are in care for more than eight hours per day” on the federal level (Food Action Research Center, 2015). However, Congress did not take any action to sign this bill into a law because it will increase federal expenses. However, in New

York State, the funds necessary to finance a third meal exist. Based on the data from the National Conference of State Legislatures, New York State served 295,653 children where it provided 124,940,273 meals in 2014, which annually cost them $198,386,589 dollars (NCSL.Org). However, in that same year, the New Department of Health shows that New York received 231.8 million funds for CACFP program (Health NY.Gov). Therefore, we have more savings than expenses, which we can use to add the third meal for those children who stay longer hours.

Based on the data from “the State of Obesity”, New York is ranked as number fifteen in the country for childhood obesity (State Of Obesity.Org). We urge the New York City Council to consider the serious childhood obesity issue and take an immediate action to implement an additional third meal for day care centers. Therefore, if we do not take an immediate step, then many lower income children will face obesity in their early age, which will impact their future negatively. On the website Child Health Care Watch, the article “Child Care Feeding Programs Support Young Children’s Healthy Development” claims that children who take CACFP meals are 28% less likely to have bad health conditions”(Child Health Care Watch. Org). Therefore, if the New York City Council can add an additional meal under CACFP program with the additional funds, then it will move us towards a healthier society. While this does not solve poverty and hunger, it reduces their negative impacts on children and families.

Increasing Physical Activity:It is a well-known fact that exercise is needed to combat obesity. According to the Shape America Organization, regular physical activity in childhood and adolescence improves strength and endurance, reduces anxiety and stress, helps control weight, builds healthy bones and muscles, and increases self-esteem. Contrary to conditions in the past, children spend more time indoor watching TV or playing video games, instead of actively engaging in physical activity outside the house. According to the New York City Department of Health and Mental Hygiene, 1 in 5 kindergarten students and 1 in 4 Head Start Children are obese.

The solution might appear to be simple, just exercise. But truth be told this is the hardest solutions to implement.  From a personal perspective, as full time employees, guardians and a students, there seem to not be enough time in the day to get things done so exercise is often neglected.  As previously mentioned, majority of the fast food chains have locations in low income neighborhoods. Within these neighborhoods reside the parents who work past 8 hours a day or overnight shifts and can’t make enough time to be with their children. These children are often left with their siblings or other family members to care for themselves the best way possible.  The reality is children spend more time at school and daycare centers with teachers and friends than they do at home. Hence a bulk of the work to combat childhood obesity needs to start at home then reinforced at schools and daycare centers. According to a Time article, only six states adhere to the standards from the National Association of Sports and Physical Education that school children participate in 150 minutes a week of physical activity, Only three states have 20 minutes mandatory elementary school recess a day. This is evidence that less time is allocated for students to be physically active at school and improve their health and wellness.

Since the introduction of President Bush’s No Child Left Behind policy, physical education had become less of a priority in schools as the administration and faculty are stressed to increase test scores because of the threat of losing teachers and schools being shut down. While any kind of

physical activity can help to promote a healthier lifestyle; from studies conducted and from my own observations, organized physical activity yields the most results. Organized physical activity needs to be reintroduced and made mandatory in the school system. By organized physical activity we mean that teachers should develop a full exercise plan for at least thirty minutes a day that encompasses exercises for flexibility, aerobic and muscular fitness. Just sending students out to play does not mean they will engage in vigorous to moderate physical activity. Many of them sit in corners or do less active things, which takes away from the purpose of the time allotted for physical education.

Living in a low-income neighborhood usually mean dealing with a lack of space. Most homes do not have a backyard or a safe place assigned for children to play. This is another reason why numerous children stay inside the house to entertain themselves. Parents are concerned about their children’s safety. To eliminate this problem, we suggest the implantation of play streets. According to the New York City Department of Health and Mental Hygiene, Play streets are car free zones on quieter blocks that provide children and communities with space for engaging in active play and physical activities. The current policy is that neighborhood residence need to petition for Play Streets in their neighborhood. However, we are suggesting that in addition to residence petitioning, the local government should have a responsibility to identify these less fortunate neighborhoods and create play streets for them. This takes the burden of parents to organize themselves to petition when they already have limited time to spare.

We believe play streets is a great policy to implement because it would be of no cost to the local government. They would simply identify a street that they can close down, that will not be a major disadvantage to the community, causing hardship. These play streets will provide more safety for children and peace of mind for their parents who should actively supervise them or ensure that they assign a responsible adult to supervise their children in their absence. With the implementation of Play Streets and mandatory Physical Education in schools we can have a full circuit program to combat childhood obesity. Children can be active in their neighborhood and have the value of exercise reinforced at school and child care centers.

Policy Recommendation:We are recommending that all four approaches be taken as one comprehensive childhood obesity initiative.  Simply choosing one policy option that targets one area will not be enough to combat this epidemic as it is the result of multiple factors; however it may be implemented in multiple stages.

We must increase our children's access to healthy food options and this is precisely why we recommend policy option three: (adding a third meal under CACFP). We already have great programs for low-income families that can be strengthened by including additional healthy meals. Children must be constantly exposed to these healthy meals if we are ever going to expand our children's palates in healthy and nutritious ways.  We recommend that this policy be implemented first as it would directly impact the diets of children. Combating childhood obesity with this policy first will immediately provide children with a healthy third meal.

Following up we recommend implementing policy option one (intensive labeling) which would increase the public's perception to the harms of fast food in a fashion similar to how the public is

warned to the dangers of smoking.  We also recommended to lower calories levels in fast foods. Food distributors have both the option and capability to prepare healthier meals as a standard if they do not want to be seen as contributors to childhood obesity.  This policy would directly benefit the already high portion of children of all ages who consume fast food.  Building off of policy option one we recommend policy option 2: (instituting an educational campaign) to inform the public of the harms of childhood obesity, using the campaign to debunk common misperceptions.  This policy would best be implemented coinciding with the implementation of policy option one.  It would be an excellent opportunity to advertise the benefits of policy option one as well as educate the broader audience to healthy eating habits for children. Many people are often unaware of what exactly an appropriate calorie count is.  This would require minimal capital as it would be added into the Department of Health's existing public health education campaign.

In the final stage we recommend implementing policy four: (increase physical activities). We must promote and foster exercise to children. Only vigorous physical activity following the recommended amount of time will aid in burning excess calories.  Policy four will implement a mandatory and structured exercise regimen to daycares and public schools as well as increase spaces for exercise in public spaces. Children need a comprehensive exercise program in our cities schools as well as access to safe and accessible locations where our children can exercise and be healthy.

These four policy options taken together will lead to decreases in childhood obesity, making our city and nation healthier.

Conclusion:Childhood obesity is now a national health problem in the United States. One in three children are obese, especially those who come from low income families. Childhood obesity is a health crisis we cannot ignore. The effects of childhood obesity affect everyone whether it's on a personal level or indirectly through higher taxpayer dollars as a result of increased medical spending. Childhood obesity costs the U.S. $19,000 per child.  Studies from the American Journal of Clinical Nutrition and the CDC have found that children who are obese are twice as likely to be obese as adults.  We know that the biggest culprits of childhood obesity are overconsumption of unhealthy/high calorie foods, lack of access to healthy food options and lack of physical exercise, which burn calories.

Recognizing that is a serious issue, and having informed you of some the causes of childhood obesity. We are counting on you to gradually call into action, the policies we have recommended.   We are conscious that in order to combat childhood obesity, we need to tackle the issue from all angles identified, hence we urge you to consider the recommendations proposed and enforce them to work as a collective system. We are eager to aide in the efforts to rebuild our community and United States at large. We cannot longer create excuses and allow children to become obese. Every child we allow to become obese today, is twice as likely to remain obese as an adult. We need to more actively educate and show children and adults that there is a better way to consume the foods they like, introduce them to healthy meals ultimately ensuring a nourishing, active and healthy life.

Appendix

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C

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