JAMA Forum: What Accounts for the Reduction in Obesity Rates for Preschool Children?

Lawrence Gostin, JD

Lawrence Gostin, JD

In a widely publicized study, Centers for Disease Control and Prevention researchers reported a statistically significant recent downward trend in obesity prevalence among US preschoolers in 18 states, based on data from 2008-2011. These findings have been followed by research published in JAMA showing a significant decline over the last decade in obesity prevalence among children aged 2 to 5 years. Although the media reported a dramatic 43% decline (calculated as a relative difference), the absolute difference was much more modest (a 5.5% decline from 14% in 2003-2004 to just over 8% in 2011-2012).

In other age groups, obesity rates remained at historic highs (and increased among women aged 60 years or older). Yet, the news reports signaled, perhaps prematurely, major advances in the fight against obesity.

To be sure, preschool children are an important demographic, as overweight in young children is a good predictor of weight status and obesity-related health problems in adulthood. And there is some indication that nutrition is trending in the right direction, with children consuming fewer calories in 2010 than they did a decade before. Importantly, eating fewer carbohydrates (including sugars) drove the calorie decline.

Assuming the data reflect a real advance in the fight against overweight and obesity, what might account for the reduction? And what policies might be most effective going forward?

Clearly, shifting something as complex as nutrition and physical activity is difficult, requiring engagement of a variety of stakeholders, including government, industry, civil society, and media. Personal behavior changes occur as people incorporate healthy habits into their daily lives.

Existing within a federalist system, US policies on nutrition and physical activity occur at the national, state, and local levels. Nationally, the nutritious foods promoted by the Special Supplemental Nutrition Program for Women, Infants, and Children (popularly known as WIC) have been selected to closely (although not fully) align with recommended dietary guidelines. At the same time, national initiatives, such as First Lady Michelle Obama’s Let’s Move program, have focused public attention on childhood obesity. Federal policies, however, are imbued with detrimental political influences, including agriculture and school policies reflecting the interests of industry rather than those of children. The farm bill subsidizes unhealthy products such as corn (think high-fructose corn syrup) rather than fruits and vegetables, and the school lunch program counts pizza (think tomato sauce) and french fries (think potatoes) as vegetables.

There is so much more that the federal government could do to improve childhood nutrition, and there is no area more important to address than the marketing of junk foods to children. As the Institute of Medicine pointed out, companies aggressively market unhealthy foods to children and adolescents, not only in television, but also on the Internet, through video games and in other digital platforms. Yet there are few, if any, rules against targeting these impressionable young minds. Companies’ voluntary measures are inadequate, and industry leaders claim it is really the responsibility of parents to monitor what their children are watching.

Most innovation is taking place at the state and local level, through such measures as nutrition and physical activity standards for early care and education. It makes sense to have states and cities act as “laboratories” to try, and to evaluate, new approaches. In fact, many federal initiatives either draw on (or, sadly, even undermine) creative local initiatives. New York City banned trans fat years ago, but the US Food and Drug Administration (FDA) only recently proposed that it might do so nationally. New York similarly introduced menu labeling—a concept then adopted in the Affordable Care Act (ACA). However, because the ACA sets a uniform national standard, it also preempts more stringent local labeling requirements, thus undermining innovation.

More recently, the FDA proposed altering food package labels. The proposed regulation—even if very late in coming—helps to clarify such things as serving size and added sugars. But it fails miserably in doing what is really needed: mandating food companies to provide prominent, comprehensible front-of-package labels. The United Kingdom encourages food companies to label their products with a voluntary “traffic light” system, which uses a vivid red label to flag excess fat, saturated fat, sugar, and salt content, with amber and green labels indicating medium and low levels of these nutrients, respectively. Prominent and clear labeling incentivizes industry to formulate healthy foods. What company wants to have 4 glaring red lights on the front of their package?

Municipal programs to improve nutrition have far outpaced federal action. The National Salt Reduction Initiative (NSRI) is a New York City-led public-private consortium of more than 90 health agencies and associations. Companies in the program voluntarily pledged to reduce sodium by 20% in overall sales within a given food category (eg, canned soup) by 2014. This still left ample room for high-sodium foods provided the producer offset these with low-sodium alternatives within the product category.  Many companies have joined NSRI, with 21 of them meeting sodium checkpoints in 2012.

It will be evident to any thoughtful observer that a major reason for expanding waistlines, especially among children, is larger portion sizes—with the biggest culprit being super-sized sugary drinks. Although a 12-ounce soda was considered “king-size” in 1950, it is now marketed as a child portion. A large Coca-Cola at McDonald’s is 32-ounces, whereas 7-Eleven’s “Double Gulp” contains 50 ounces, 600 calories, and no nutritional value. Yet, the only effort to date to curb portion size was the controversial limit on the sale of large sugar-sweetened beverages in New York City, imposed in 2012 by then-Mayor Bloomberg. The program, however, was unpopular, and the courts have thus far struck it down as mayoral overreach. Yet, creative policies to reduce portion sizes are critical to future success.

If one were to choose a single intervention that would be most likely to work, it might be taxation. Research suggests that even a relatively modest tax on sugary drinks, candy, and other decidedly unhealthy products might reduce consumption. Economic incentives, and disincentives, are powerful motivators of human behavior.

So what are the most important policies for the future to ensure that the decline in preschool obesity is a real trend that will stand the test of time? The truthful answer is that we do not know. But this much is nearly certain: if society were to adopt a suite of policies, sustained over a long period, the culture of overeating would change.

Look at tobacco as a model. It is nearly impossible to say which particular intervention worked in reducing prevalence so dramatically over the last several decades—taxes, laws ensuring smoke-free areas, package labeling, advertising bans, public education, and more. What we do know is that a broad range of policies can transform public perception, and ultimately human behavior. It can be done if there is a political will.

First Lady Michelle Obama recently announced a package of new obesity prevention measures under the Healthy, Hunger-Free Kids Act of 2010: a revamped version of the nutrition label on packaged food, new rules restricting junk food marketing in schools, and the expansion of a pilot program to feed nutritious meals to hungry children in need. From July 1, more than 22 000 schools that serve mainly low-income children will be eligible to serve free school meals to all students. Should these programs progress as planned, it would at least put the United States on the road to healthier, fitter children—a wonderful investment in our future.

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About the author: Lawrence O. Gostin, JD, is University Professor and Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, and Director of the World Health Organization Collaborating Center on Public Health Law and Human Rights. His most recent book is Global Health Law (Harvard University Press).

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

JAMA Forum: Separating the Science and Politics of “Obesity”

By Stacy M. Carter, PhD, MPH, and Helen L. Walls, PhD, MPH

the jama forum-logo may 11 2012Last month, JAMA published a systematic review and meta-analysis of the relationship between body mass index (BMI) and all-cause mortality. The researchers, led by Katherine M. Flegal, PhD, of the US Centers for Disease Control and Prevention, found that people who are categorized as being mildly obese according to their BMI had no increased risk of dying prematurely, and overweight people a slightly reduced risk of dying prematurely, compared with their normal-weight counterparts—a finding supported by previous studies.

In an accompanying editorial, 2 researchers said that the findings highlighted the limitations of increased BMI as an indicator of unhealthiness. Early coverage of the study in the mass media was restrained, emphasizing the authors’ main messages. Response in social media such as Twitter ranged from excited acceptance to confusion and voicing of familiar critiques, such as the limitations of observational studies or of using all-cause mortality as an outcome measure rather than morbidity or disability.

And then the response evolved and became heated. We have documented some of the exchange on Storify (link here). Storify is a tool that allows users to collect tweets, images, videos, and other elements about a particular subject from social media sites and use those elements to create a story stream about that subject. Continue reading