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Lessons Learned from Public Health Efforts and Their Relevance to Preventing Childhood ObesityMichael Eriksen, Sc.D.1

INTRODUCTION

As a nation, we are experiencing an epidemic of obesity that is unprecedented in its magnitude or rapidity. Overweight and obesity not only plague the majority of adults, but children are becoming increasingly overweight, with corresponding decrements in health status and quality of life.

While the problem clearly exists, the causes are less clear. There is little clarity about the relative importance of possible causative factors such as changes in dietary patterns, increases in fast food and soft drink consumption, increases in portion size, decreases in physical activity, increases in television viewing, or most likely, a mix of all these factors. Clearly, a thorough understanding of the precise causes of childhood obesity, and how these factors interact, would increase the probability of developing effective prevention and control strategies. In the absence of a precise understanding of the etiology of the problem, it may be useful to look at the lessons learned from other public health campaigns and to try to determine if these lessons have any relevance for the prevention of childhood obesity.

One way to better understand how to deal with a particular public health problem is to look at the experience in dealing with other public health issues, especially those where there has been a modicum of success.

1

Professor and Director, Institute of Public Health, Georgia State University, Atlanta, GA



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Preventing Childhood Obesity: Health in the Balance D Lessons Learned from Public Health Efforts and Their Relevance to Preventing Childhood ObesityMichael Eriksen, Sc.D.1 INTRODUCTION As a nation, we are experiencing an epidemic of obesity that is unprecedented in its magnitude or rapidity. Overweight and obesity not only plague the majority of adults, but children are becoming increasingly overweight, with corresponding decrements in health status and quality of life. While the problem clearly exists, the causes are less clear. There is little clarity about the relative importance of possible causative factors such as changes in dietary patterns, increases in fast food and soft drink consumption, increases in portion size, decreases in physical activity, increases in television viewing, or most likely, a mix of all these factors. Clearly, a thorough understanding of the precise causes of childhood obesity, and how these factors interact, would increase the probability of developing effective prevention and control strategies. In the absence of a precise understanding of the etiology of the problem, it may be useful to look at the lessons learned from other public health campaigns and to try to determine if these lessons have any relevance for the prevention of childhood obesity. One way to better understand how to deal with a particular public health problem is to look at the experience in dealing with other public health issues, especially those where there has been a modicum of success. 1 Professor and Director, Institute of Public Health, Georgia State University, Atlanta, GA

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Preventing Childhood Obesity: Health in the Balance For the purposes of this appendix, the experience with public health programs, such as tobacco control, injury prevention, underage alcohol use, gun control, and others are qualitatively examined with particular attention to their possible relevance for the prevention of childhood obesity. PUBLIC HEALTH LESSONS LEARNED The purpose of this paper is not to suggest specific intervention strategies to prevent childhood obesity, but rather to learn from other public health experiences and to glean lessons that might help inform efforts to prevent childhood obesity. There is certainly no shortage of theories, models, and approaches to help guide public health program planning. There are multiple health behavior theories that are commonly used to guide public health efforts (Glanz et al., 2002), and popular planning models have been designed to help diagnose health problems (Green and Kreuter, 2000), identify the factors that contribute to these problems, and devise appropriate interventions. In general, these theories and models recommend taking a broad view of changing health behaviors and conditions, suggesting multifactorial, comprehensive interventions that address multiple aspects of the problem. Recently, the Institute of Medicine (2002) endorsed this broad approach to public health interventions, recommending the adoption of an “ecological model” for viewing public health problems and interventions, where the individual is viewed within a larger context of family, community, and society. Overall, there is increasing interest in public health interventions being comprehensive, addressing the multiple factors that influence the health problem, and striving to strike a balance between efforts directed at the individual and the social-environmental context in which people live. It is likely that this approach will be as relevant for the prevention of childhood obesity as it is for other contemporary public health challenges. However, as previously stated, the purpose here is not to propose a comprehensive intervention program for childhood obesity, but rather to identify the factors associated with success in other public health areas, both as a result of planned interventions and also corresponding to social, cultural, or temporal factors. Despite the notable successes in public health over the past century, there are no generally agreed on approaches or interventions that can be applied to multiple public health problems, with the same intervention effect seen with different problems. There are general guidelines and recommendations, core functions for public health, but no generic model program, best practices, or common lessons learned that could be applied to most or all public health problems. There are “best practices” for specific public health problems, but little research or insight of the extent to which these categorical approaches are

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Preventing Childhood Obesity: Health in the Balance generalizable to other public health challenges. For example, the Centers for Disease Control and Prevention’s (CDC’s) Best Practices for Comprehensive Tobacco Control Programs (CDC, 1999a) describes nine programmatic areas (i.e., community programs, school programs, statewide programs, etc.) that have been shown to be effective in reducing tobacco use.2 In practice, these programs are typically delivered “comprehensively,” and it is difficult, if not impossible, to tease out the relative impact of specific program components within these comprehensive, real-life campaigns. For this reason, program evaluations of large-scale public health campaigns tend to assess the collective effort, rather than the impact of individual program components. Because of the difficulty in teasing out the effect of one component of a comprehensive program, evaluations have tended to focus on the overall program impact and on the relationship between financial investment in program activities and changes in health behaviors. Data on the impact of comprehensive programs is strong, both in terms of changes in health behavior, as well as in terms of health outcomes (CDC, 2000). Recent analysis has confirmed that the greater the investment in comprehensive programs, composed of evidence-based programs, the larger the public health benefit (Farrelly et al., 2003). In addition to tobacco control, recent review articles have analyzed the evidence for the effectiveness of public health interventions for a variety of public health problems, including dietary behavior, underage drinking, and motor vehicle injuries, to name just a few. For example, a recent review by Bowen and Beresford (2002) concluded that although much has been learned about trying to change dietary practices clinically, it is particularly important to learn how to transform the successes obtained from interventions aimed at the individual to community and public health settings. Gielen and Sleet (2003) reviewed the injury prevention literature and concluded that a simplistic belief that imparting information would result in behavior change and injury risk reduction resulted in an over-reliance on engineering solutions alone as the basis for injury prevention programs. These authors reinforce the need for interdisciplinary approaches to injury prevention, using behavioral science theory, coupled with engineering solutions. These observations from other public health problems (e.g., determining how to expand clinical success to communities, combining behavioral 2 For example, in 1999, the CDC’s Best Practices for Comprehensive Tobacco Control Programs was developed to guide state health departments in planning and allocating funds from the Master Settlement Agreement. The Best Practices document does not explicitly recommend policy or regulatory actions, such as an increase in the excise tax on tobacco products, or clean indoor air laws, because they did not require budget expenditures.

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Preventing Childhood Obesity: Health in the Balance and environmental approaches) are informative and relevant for the development of programs to prevent childhood obesity. Ten Greatest Public Health Achievements in the 20th Century To begin to understand the potential generalizability of “best practices” for specific health problems, it is useful to look at the evidence for the specific success stories and determine if there are any common elements, or lessons learned, that tend to span multiple problems. In 1999, acknowledging public health successes, CDC published a list of the ten greatest public health achievements of the 20th century (CDC, 1999b) (Box D-1). The subsequent Morbidity and Mortality Weekly Reports (MMWR) documented the reason these achievements were selected and described the progress made in each area in terms of death and disease prevented. Although efforts were made to account for the reasons for the progress, there was no systematic effort to attribute improvements in health status to specific interventions, and no attempt was made to determine if there were common interventions that contributed to the amelioration of multiple health problems. A preliminary review of the MMWR reports reveals a pattern of categories of interventions that appear to have played a role in accomplishing multiple achievements. The goal was to identify instances, across achievements, of community intervention categories found in the past to have strong evidence of effectiveness with multiple health behaviors or problems. As Table D-1 shows, intervention categories identified most frequently included community-wide campaigns, mass-media strategies, changes to BOX D-1 Ten Great Public Health Achievements United States, 1900-1999 Vaccination Motor vehicle safety Safer workplaces Control of infectious disease Decline in deaths from coronary heart disease and stroke Safer and healthier foods Healthier mothers and babies Family planning Fluoridation of drinking water Recognition of tobacco use as a health hazard

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Preventing Childhood Obesity: Health in the Balance TABLE D-1 Community Intervention Categories and 10 Greatest Public Health Achievements 1900-1999   Community-Wide Campaigns School-Based Interventions Mass-Media Strategies Laws and Regulations Provider Reminder Systems Reducing Costs to Patients Vaccination X   X X   X Motor-vehicle safety X X X X     Saferworkplaces X     X     Control of infectious diseases X   X X   X Decline indeaths from coronary heart disease and stroke X   X       Safer and healthier foods X X X X   X Healthier mothers and babies X   X X   X Family planning X     X   X Fluoridation of drinking water       X     Recognition of tobacco use as a health hazard       X X X

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Preventing Childhood Obesity: Health in the Balance laws and regulations, and reductions in patient costs. Those categories mentioned least frequently included school-based interventions, and provider reminder systems. In addition, some contextual factors were similar across achievements. For example, in nearly all cases, policy changes were followed by the emergence of new government leadership structures that were effective enforcers of the new policies and oversaw the development and implementation of new programs. Additionally, improved surveillance methods, control measures, technologies, and treatments, and expanding systems of service delivery and provider education, were frequently cited as driving factors in these achievements. The Guide to Community Preventive Services Intensive effort has been devoted to reviewing the evidence of effectiveness, first for clinical preventive services (AHRQ, 2002) and now for community preventive services (CDC, 2004c), but these efforts focus on the quality of evidence for specific diseases and health behaviors, rather than drawing conclusions, or generalizing, across health problems. The task force has completed the analysis of the evidence in nine major areas. More reports, including those central to preventing childhood obesity (e.g., school-based programs, community fruit and vegetable consumption, consumer literacy, and food and nutrition policy) have not yet been released (CDC, 2004c). Of the nine completed reports (most of which focused on adult health behaviors), the task force has determined that 34 interventions could be recommended based on “strong” scientific evidence, another 14 could be recommended as having “sufficient” scientific evidence, and for 42, there was insufficient evidence to make a recommendation. The Guide emphasizes that “…a determination that evidence is insufficient should not be confused with evidence of ineffectiveness.” There was relatively little overlap in the nearly 50 recommended interventions, primarily because the interventions studied were very specific to the health behavior or health condition studied. However, certain categories of interventions appear to have strong evidence of effectiveness for multiple health behaviors and problems. The interventions listed in Table D-2 appear to be effective in multiple areas. Thus, there are at least seven types of macrolevel interventions that appear to have evidence supporting their effectiveness for multiple public health problems. Other interventions that are effective for multiple behaviors and conditions may be identified in future work by the task force. Similarly, some of the types of interventions that currently have insufficient evidence may in fact have relevance for multiple health problems, but the current body of research is insufficient in relation to rules of evidence. As is

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Preventing Childhood Obesity: Health in the Balance TABLE D-2 Recommended Public Health Interventions Common to Multiple Health Behaviors and Conditions, The Guide to Community Preventive Services Type of Intervention Health Behavior or Condition Community-wide campaigns Physical activity** Motor vehicle occupant injuries* Oral health (water fluoridation)** School-based interventions Physical activity** Oral health (sealants)** Vaccine preventable diseases (requirement for school admission)* Skin cancer* Mass-media strategies Tobacco initiation and cessation** Motor vehicle occupant injuries** Laws and regulations Reducing exposure to secondhand smoke** Motor vehicle occupant injuries** Provider reminder systems Vaccine preventable diseases** Tobacco cessation* Reducing costs to patients Tobacco cessation* Vaccine preventable diseases** Home visits accine preventable diseases* Violence prevention** * Sufficient evidence. ** Strong evidence. SOURCE: CDC, 2004c. often the case, the requisite research is difficult to conduct, or has yet to be conducted. Based on the experience to date from The Guide to Community Preventive Services, it appears that comprehensive programs that involve communities, schools, mass media, health providers, and laws and regulations are most likely to be effective for a number of health problems. It is reasonable to assume that some or all of the types of interventions may have utility in preventing childhood obesity Lessons Learned Across Multiple Public Health Problems The focus on “internal validity” has greatly improved the practice of public health and the implementation of evidence-based approaches shown to be effective for specific health problems. This focus on disease- or behavior-specific evidence has not, however, advanced our understanding of the

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Preventing Childhood Obesity: Health in the Balance “external validity” or generalizability of interventions across multiple health problems. Namely, extant research has failed to determine if there are common approaches that may be effective across a variety of health problems. There is a clear need for “lessons learned” from public health interventions and an assessment of the generalizability of interventions, and a determination of under what conditions, and for which populations, they may work. While analysis of the same degree of rigor that has been applied to assessing the evidence for effectiveness of specific programs does not exist across multiple programs, some efforts have been made to analyze the experiences of successful public health campaigns, and to identify elements that appear to be associated with program success. Some of this work has been done by academic researchers and some advanced by the public health practice community, most notably the articulation of the Ten Essential Public Health Services (CDC, 2004a) and the National Public Health Performance Standards (CDC, 2004b). While these efforts to improve practice are noteworthy and of critical importance, the following section highlights some of the academic reviews focused on factors associated with successful health movements. For example, based on analysis of success with lead, fluoride, auto safety, and tobacco, Isaacs and Schroeder (2001) concluded that the ingredients of success for public health programs include a mixture of (1) highly credible scientific evidence, (2) campaigns with highly effective advocates, (3) a supportive partnership with the media, and (4) laws and regulations, often, but not always, at the federal level. Drawing on social movement and other sociological theories, Nathanson analyzed the tobacco and gun control movements and concluded that successful health-related social movements had the following elements in common: a socially and scientifically credible threat to the public health, mobilization of a diverse constituency, and “the convergence of political opportunities with target vulnerabilities.” Some researchers have looked for public health lessons that may be directly applicable to obesity or dietary change. Researchers at CDC analyzed the experience with the tobacco control movement in relation to possible implications for preventing obesity (Mercer et al., 2003). They used the intervention framework described in the 2000 Surgeon General’s Report, Reducing Tobacco Use, and reflected on the relevance of educational, clinical, regulatory, economic, and comprehensive interventions for the prevention of obesity (DHHS, 2000). Researchers at the World Health Organization (WHO) looked at the recently adopted Framework Convention on Tobacco Control (FCTC) in terms of its possible implications for improving global dietary and physical activity levels (Yach et al., 2003). These researchers concluded that strate-

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Preventing Childhood Obesity: Health in the Balance gies to improve diet and physical activity levels must be different from those employed for tobacco control, because the nature of the behaviors are different, but also in relation to possible private-sector interactions. According to the authors, a formal treaty approach is not warranted,3 but that the organizing framework for the FCTC may be useful for the development of national plans and policies. In their article, Yach and colleagues (2003) draw comparisons between tobacco and food strategies, using the template of the FCTC, including a discussion of (1) price and tax measures, (2) labeling and product content, (3) educational campaigns, (4) product marketing, (5) clinical interventions, (6) product supply, (7) liability and corporate behavior, and (8) supportive and facilitative measures. Economos and colleagues (2001) conducted a global analysis of social change models by interviewing 34 key informants. These investigators concluded that a number of factors are being associated with a successful social change. These factors included having the issue being perceived as a crisis, a persuasive science base, important economic implications, strategic leadership (spark plugs), a coalition or mobilizing network, community and media advocacy, government involvement, media involvement, policy and environmental change, and a coordinated, but flexible plan. A synthesis of these studies suggests a set of core factors that appear to be associated with successful health-related social change efforts. These core factors include: A persuasive science base documenting a socially and scientifically credible threat to the public health with important economic implications; A supportive partnership with the media; Strategic leadership and a prominent champion; A diverse constituency of highly effective advocates; and Enabling and reinforcing laws, regulations, and policies. It is not clear whether all these factors need to be present for each public health campaign, or if there is a preferred sequence of activities, although the order presented above corresponds roughly to the tobacco control movement and exhibits some face validity for these core concepts. In summary, some of the factors associated with successful public health campaigns are formal, planned interventions (e.g., mass-media campaigns, 3 However, an accompanying commentary (Daynard, 2003) suggested that consideration should be given to a treaty model for global obesity prevention, similar to the FCTC, if only for the increased awareness of civil society and governments of the problem resultant from treaty development and negotiations process.

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Preventing Childhood Obesity: Health in the Balance school-based programs), while other elements associated with success are cultural or social factors (e.g., leadership, advocacy, scientific evidence). Althougth these social factors are less likely to be planned in the same way as formal interventions are, they can and should be cultivated and combined with more traditional intervention strategies This mix of formal interventions, typically provided by the medical and public health communities, coupled with social change strategies, typically stimulated by advocacy organizations and civil society, are most likely to result in successful and sustained health-related social change. Empirical data are lacking, but some could argue that the two types of interventions are inextricably linked, and either alone is unlikely to achieve success. If anything, anecdotal evidence suggests that social factors (those less likely to be initiated by the health community) are more likely to be associated with success in health-related social movements, if only serving to create a “tipping point” for social change (Gladwell, 2000). AN ORGANIZING FRAMEWORK FOR PUBLIC HEALTH INTERVENTIONS To learn from the lessons of other public health experiences and determine whether there is any utility or relevance for preventing childhood obesity, it is useful to have a conceptual framework to organize the experiences, principles, and strategies. In the 2000 Surgeon General’s Report, Reducing Tobacco Use, a framework was developed to categorize the different types of tobacco control interventions (DHHS, 2000). This framework reviewed the evidence within the following categories: educational, clinical, legal, economic, regulatory, and comprehensive. Although it was developed for tobacco control, this framework may be useful in categorizing interventions for other types of public health problems and has already been used to analyze similarities and differences between tobacco control and the prevention of obesity (Mercer et al., 2003). Analyzing strategies to prevent underage drinking, Komro and Toomey (2002) identified six different types of alcohol prevention strategies: school, extracurricular, family, policy, community, and multicomponent. Drawing on and expanding the framework in the 2000 Surgeon General’s Report and from other sources, the next section reviews findings from a variety of public health campaigns, particularly efforts to reduce tobacco use, and other public health experiences that have commercial dimensions, or that have been politically sensitive (e.g., underage alcohol consumption, injury prevention). The following section reviews six categories of interventions that may have relevance for the prevention of childhood obesity. These categories are:

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Preventing Childhood Obesity: Health in the Balance The information environment Access and opportunity Economic factors The legal and regulatory environment Prevention and treatment programs The social environment The Information Environment The environment in which people are informed about public health issues is of critical importance, but also fraught with controversy, particularly when dealing with the marketing of commercial products. As a rule, the public health community tends to favor restrictions on commercial speech, if felt necessary to insure the public health. On the other hand, commercial interests tend to view any restrictions on marketing as infringements of their constitutional right to freedom of speech. A thorough discussion on individual speech versus commercial speech is beyond the scope of this paper; however, this tenet was a central argument in the Food and Drug Administration’s (FDA’s) attempt to regulate tobacco products (Kessler, 2001), and it remains an argument whenever legislators or regulators attempt to restrict the advertising for commercial products such as tobacco, alcohol, and foods. Although product advertising may result in a public health benefit when the advertising promotes healthy products (Ippolito and Mathios, 1995), the majority of the debate about product marketing focuses on those products that may have harmful effects, particularly among children. Despite the concerns of commercial interests, governments do have the right to alter the informational environment, particularly when the information being conveyed is considered to be false, misleading, or deceptive. In the United States, the regulatory authority in this area is shared by multiple federal agencies, but particularly by the FDA and the Federal Trade Commission (FTC). Gostin (2003) notes that government’s power to alter the informational environment is one of the major ways in which governments can “assure the conditions for people to be healthy.” The article goes on to describe that governments can alter the informational environment in a number of ways, including by sponsoring health education campaigns and other persuasive communications, requiring product labeling, and restricting harmful or misleading advertising. Most of the effort in altering the information environment has been done in relation to children and adolescents, particularly when it is believed that the information being conveyed may be harmful or misleading to children (Strasburger and Donnerstein, 1999). Because of this, the quality of the evidence documenting the effect of informational efforts, particularly

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Preventing Childhood Obesity: Health in the Balance environment receptive to increases in public involvement and support for public policies to reduce the harm caused by alcohol-impaired driving (DeJong and Hingson, 1998; Shults et al., 2001). The popularity of designated drivers, minimum legal drinking age, blood alcohol concentration laws, community traffic safety programs, and other interventions are a direct result of changing social norms. The desire of nonsmokers to be protected from exposure to secondhand smoke is a critical element in changing the tobacco control environment and how smoking is perceived in society. As a result of nonsmokers’ rights advocacy, most workplaces are smoke-free, serum cotinine levels have been reduced by nearly 75 percent in the last decade (CDC, 2003), and the social norms associated with smoking have been permanently changed. It is not clear, however, that the prevention of childhood obesity has a dimension that can serve as a parallel to nonsmokers’ exposure to secondhand smoke. There are a number of possible ways to engage the interest and involvement of society in the issue of childhood obesity in a similar way that it has been secured by other public health problems. One way, which is already happening, is the increasing public concern about the magnitude of the problem and the need for collective action. Given the rapid increase in the prevalence of childhood obesity, the “visibility” of the problem, and the seriousness of the problem for the affected individuals, social and normative change is already beginning to occur. Further, the social costs of obesity that are being borne by society as a whole, suggest the appropriateness of collective and policy interventions. One of the biggest changes in the social environment for tobacco control is that some tobacco companies are beginning to acknowledge that their products are harmful and addicting. Despite the decades of scientific evidence on the adverse health effects of tobacco use, tobacco companies, primarily for legal reasons, have denied the harm and addictiveness of tobacco products. As a result of the MSA, tobacco companies have begun to become more candid about the harm caused by their products, both in public statements and on their websites. But the level of candor is not consistent among all companies, nor is it consistent in all instances, especially in litigation, where companies tend to continue to deny that their product contributed to the harm claimed by the plaintiff. At this point in time, it is not clear how the food industry will respond to social and public health pressures to limit marketing of unhealthful products to children and to assume at least partial responsibility for the epidemic of childhood obesity in this country and around the world (Daynard, 2003). However, some change has already begun, with companies such as Kraft announcing changes in portion size and fat content in some of the products most popular with children. Like tobacco companies, it is likely that the food industry will not respond monolithically. Instead

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Preventing Childhood Obesity: Health in the Balance those market leaders that can afford to have market share frozen, or those companies that want to be perceived as a leader, or can carve out a “health” niche with their customers, will likely respond differently from other companies. If the tobacco experience is any guide, it is likely that the food companies will act just enough to avoid government regulation, but will fall short on making structural changes in product design or marketing that will fundamentally alter their marker position. To date, companies have been much more comfortable with educational campaigns emphasizing personal responsibility and the need for increased physical activity than with proposing major policy or structural changes.6 In trying to anticipate possible changes in corporate behavior, it should be remembered that marketing and selling unhealthy food, as opposed to tobacco for minors, is completely legal. On the other hand, document discovery has not yet taken place, and if it does, it may change public perceptions pertaining to the legality versus morality of marketing to children those products with known adverse health effects. The recognition for collaborative approaches to preventing obesity has already begun, and various governments are beginning to launch broad-based national strategies for tackling obesity (Mayor, 2004). In fact, the WHO approved a Global Strategy for Diet, Physical Activity and Health (WHO, 2004) that calls for multisectoral collaboration to address the increasing global prevalence of obesity. SUMMARY Efforts to address contemporary public health problems are often difficult to evaluate for a number of reasons including the urgency and need for a rapid response, the lack of classical experimental design, often not having an unexposed control group, difficulty in measuring social factors, and not understanding the dynamics between social forces and health behaviors (McQueen, 2002). While difficult, it is important to understand the factors that contribute to public health advances and the reasons for the failure of unsuccessful public health programs. This is particularly true as we face new problems that have complex, multifactorial, and often commercially linked dimensions. Rather than “reinventing the wheel,” making mistakes previously made, or overlooking interventions that have been shown to be effective, it 6 For example, see the website of the American Council on Food and Nutrition, http://www.acfn.org/about/, or the Center for Consumer Freedom, http://www.consumerfreedom.com/.

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Preventing Childhood Obesity: Health in the Balance is prudent to look at other public health experiences when developing strategies to reduce public health problems, such as the prevention of childhood obesity. In reviewing other public health experiences and determining if there are lessons for preventing childhood obesity, it is useful to compare and contrast the similarities and differences between the other public health problems and the causes of childhood obesity. For example, when one compares the prevention of tobacco use to the prevention of childhood obesity, the first and most obvious difference is that tobacco use, from a public health standpoint, is a behavior to be avoided; it presents a serious health risk and no health benefit. Diet and physical activity, on the other hand, are essentials of life, cannot be avoided, and must be kept in balance to ensure good health. Thus, for tobacco, there is the simple message of avoidance, whereas for diet and physical activity there is the much more complex message that includes concepts such as quality, quantity, frequency, and balance (Mercer et al., 2003; Yach et al., 2003). In summary, the “environmental classifications” of types of intervention strategies may serve as a useful template to determine the utility of different public health interventions for the prevention of childhood obesity. More broadly, categories such as these may be useful in conceptualizing intervention strategies for various public health problems. To increase the utility of this approach, and determine the relevance of specific public health interventions, it may be useful to further analyze the public health problem in terms of specific criteria to ascertain the similarity of certain problems and the likelihood that an approach that was successful with one public health problem, may be generalizable to another. Possible criteria for comparison could include: Description of the behavior (addictiveness, possible health benefits, legal aspects) Epidemiologic significance (number of deaths, disease burden) Clear understanding of etiology Feasibility of change Availability of effective interventions Level of public interest and awareness Extent to which public is affected by problem Salience to policy makers Nature of relation with product manufacturer Role of government Degree of product regulation International dimensions

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Preventing Childhood Obesity: Health in the Balance CONCLUDING PRINCIPLES AND IMPLICATIONS Individual Responsibility Versus Collective Action One of the greatest challenges in our efforts to prevent childhood obesity is to strike the right balance between individual versus structural or environmental efforts. With tobacco control, most observers believe that major progress was not achieved until clinical efforts in smoking cessation were subjugated to policy efforts to change the social environment. This same debate is central to our efforts in preventing childhood obesity (Kersh and Morone, 2002; Zernike, 2003). As with many public health problems, a critical issue is the role of coercion versus individual rights, and striking the appropriate balance between commercial interests and the common good (Gostin, 2000). Need to Change Social Norms About Food and Physical Activity Fifty years ago, smoking was the norm. The majority of men smoked, smoking was widely advertised on television and radio, and smoking could occur anywhere, including airplanes, schools, hospitals, and doctor’s offices. Today, the situation is reversed, with smoking no longer being normative, and nearly considered, if not a deviant behavior, at least one that is typically done in private. Fifty million Americans have quit smoking and there are more ex-smokers than current smokers. No one could have predicted the magnitude of change in perceptions and public opinion that has occurred with tobacco, but similar changes are possible with respect to food and physical activity. Today, foods are “super-sized” to provide the most food or value for the dollar, but with virtually no consideration for diet or health. While there is nothing wrong in seeking “value,” it is not inconceivable that, in the future, health considerations will enter the equation in calculating “value.” Similarly, nearly all smokers who quit, enjoyed smoking a great deal, but quit because they were more concerned about their health than they were about the pleasure of smoking. The same can be achieved with food. Learn from Other Public Health Experiences, But Don’t Necessarily Duplicate Much has been learned from the successes, and continuing challenges, in previous public health experiences. However, there are major differences in these earlier efforts and efforts to prevent childhood obesity. The differences are particularly striking for tobacco control. Most notably, people need to eat, but do not need to smoke. In addition, it is illegal to sell tobacco products to minors, marketing to minors is prohibited, and non-

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Preventing Childhood Obesity: Health in the Balance smokers’ rights is a powerful social movement that has changed public norms related to smoking. None of these elements exist for preventing childhood obesity. From a macroperspective, and although progress has taken decades, tobacco control is relatively simple compared to the complexities presented by childhood obesity. Accordingly, childhood obesity prevention strategies should be developed with an appreciation for this complexity. The Role of the Food Industry Is Critical but Uncertain Part of the success of the tobacco control movement has been the attacks on and marginalization of the tobacco companies. This was a fairly predictable strategy because of their intransigence over decades and the harm resulting from a product that, when used as intended, kills one out of two lifetime users. While predictable, this strategy has also been effective in changing social norms and focusing youth empowerment against tobacco industry tactics. At this point, it is unclear whether a similar strategy directed against food companies is warranted or would be effective. This question will be partially answered by the extent to which food companies deal honestly and constructively with the obesity epidemic, including a candid assessment of their role in helping to create it (Revill, 2003). To the extent that commercial interests respond, if not lead, on behalf of the public good, they may obviate the need for government action. To the extent that they fail, government action will be demanded (Yach et al., 2003). In either respect, it appears clear to most that the overall environment in which food products are produced, marketed, and sold, must be improved (Ebbeling et al., 2002). The Problem Is Multifactorial, and So Must Be the Solutions Based on the experience with many different public health problems (e.g., tobacco control, motor vehicle and firearm injuries), it seems clear that comprehensive and multifactorial approaches are required. At a minimum these approaches should address both the individual behaviors and the social environment in which these behaviors take place, particularly the marketing, price, availability, and accessibility related to both dietary and physical activity behaviors. It is important to avoid glib and simple solutions to complex and poorly understood problems. Need Evidence on Best Practices and Effective Interventions The rise in childhood obesity is well documented, but less well understood. The relationships among and relative contribution of dietary factors,

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Preventing Childhood Obesity: Health in the Balance the social environment, and physical activity need to be better understood to develop effective interventions (BMJ, 2004). Recent reports by the APA (2004) and the Kaiser Family Foundation (2004) advance the understanding of the role of the media in childhood obesity, but similar analyses are needed for other aspects of childhood obesity prevention, such as the role of fast foods and soft drinks, and how the social environment can be structured to contribute to the prevention of childhood obesity. For tobacco control, we may not know all the answers, but we know enough to make a difference. Research underlies tobacco control guidelines and recommendations, and similar research, recommendations, and guidelines are being developed for preventing childhood obesity. Once the relative effectiveness of various interventions is better known, there needs to be a concerted effort to disseminate and implement approaches that have been found to be effective. The lack of emphasis on the systematic diffusion of effective interventions has plagued multiple public health initiatives. Need to Consider the Global Dimension The epidemic of childhood obesity first appeared in the United States, but every indication is that it is beginning to appear in other developed countries, as well as in the developing world. The global implications of our domestic solutions should be considered, so we do not solve our problems by creating a larger one overseas (Yach et al., 2003; WHO, 2004). REFERENCES AAP (American Academy of Pediatrics). 2003. Prevention of pediatric overweight and obesity. Pediatrics 112(2):424-430. AAP. 2004. Policy statement: Soft drinks in schools. Pediatrics 113(1):152-154. AHRQ (Agency for Healthcare Research and Quality). 2002. Guide to Clinical Preventive Services. [Online]. Available: http://www.ahrq.gov/clinic/cps3dix.htm [accessed February 24, 2004]. APA (American Psychological Association). 2004. Report of the APA Task Force on Advertising and Children. [Online]. Available: http://www.apa.org/releases/childrenads.html [accessed February 24, 2004]. APHA (American Public Health Association). 2003. Food Marketing and Advertising Directed at Children and Adolescents: Implications for Overweight. Policy # 200317-1. Adopted November 2003. [Online]. Available: http://www.apha.org/legislative/policy/2003/2003-017.pdf [accessed February 24, 2004]. Ashe M, Jernigan D, Kline R, Galaz R. 2003. Land use planning and the control of alcohol, tobacco, firearms, and fast food restaurants. American Journal of Public Health 93(9):1404-1408. Bero L. 2003. Implications of the tobacco industry documents for public health and policy. Annual Review of Public Health 24:267-288. BMJ (British Medical Journal). 2004. Fighting obesity: Evidence of effectiveness will be needed to sustain policies. British Medical Journal 328:1327-1328.

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