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Summary

Institute of Medicine Regional Symposium

Progress in Preventing Childhood Obesity: Focus on Industry

In collaboration with the California Endowment

Supported by The Robert Wood Johnson Foundation

December 1, 2005

Beckman Center of the National Academies

Irvine, California


The nation faces a growing epidemic of childhood obesity that threatens the immediate health of our children and youth and their prospects of growing up to be healthy adults. During the past 30 years, obesity in the United States has more than doubled among children aged 2–5 years and adolescents aged 12–19 years, and it has more than tripled among children aged 6–11 years. Currently, more than 9 million children and youth over the age of 6 years are obese. The sequelae of obesity among children and youth are rising, including an increased risk of type 2 diabetes, hypertension, metabolic syndrome, asthma, and social and psychological consequences including low self-esteem and depression.

The changes needed to reverse the obesity trend must be robust enough to counteract the underlying factors that led to obesity. Effective change requires a population-based prevention approach and a comprehensive response from multiple sectors throughout the nation. At the individual level, this involves attaining an energy balance that equalizes food or energy consumption with energy expenditure through regular physical activity to achieve a healthy weight and maintain good nutrition. Yet this issue is not the responsibility of individuals alone, especially for children who have limited control over the social and environmental factors that influence their dietary intake and physical activity levels. The nation shares a collective responsibility to effectively address the obesity trend, and a clear focus of prevention efforts should involve the public and private sectors in the communities that affect the daily lives of our children and youth. Moreover, special focus must be placed on low-income, at-risk communities where obesity rates are



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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium Summary Institute of Medicine Regional Symposium Progress in Preventing Childhood Obesity: Focus on Industry In collaboration with the California Endowment Supported by The Robert Wood Johnson Foundation December 1, 2005 Beckman Center of the National Academies Irvine, California The nation faces a growing epidemic of childhood obesity that threatens the immediate health of our children and youth and their prospects of growing up to be healthy adults. During the past 30 years, obesity in the United States has more than doubled among children aged 2–5 years and adolescents aged 12–19 years, and it has more than tripled among children aged 6–11 years. Currently, more than 9 million children and youth over the age of 6 years are obese. The sequelae of obesity among children and youth are rising, including an increased risk of type 2 diabetes, hypertension, metabolic syndrome, asthma, and social and psychological consequences including low self-esteem and depression. The changes needed to reverse the obesity trend must be robust enough to counteract the underlying factors that led to obesity. Effective change requires a population-based prevention approach and a comprehensive response from multiple sectors throughout the nation. At the individual level, this involves attaining an energy balance that equalizes food or energy consumption with energy expenditure through regular physical activity to achieve a healthy weight and maintain good nutrition. Yet this issue is not the responsibility of individuals alone, especially for children who have limited control over the social and environmental factors that influence their dietary intake and physical activity levels. The nation shares a collective responsibility to effectively address the obesity trend, and a clear focus of prevention efforts should involve the public and private sectors in the communities that affect the daily lives of our children and youth. Moreover, special focus must be placed on low-income, at-risk communities where obesity rates are

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium highest, attributed in part to a lack of access to healthful foods, exposure to the marketing of less healthful foods and beverages, a paucity of safe or available venues for physical activity, and limited education about the benefits of proper nutrition and physical activity. Ethnic minorities that are at greatest risk for obesity and include African American, Hispanic, American Indians, and Asian/Pacific Islander children and youth, especially those living in low-income communities. In 2002, Congress charged the Institute of Medicine (IOM) with developing a prevention-focused action plan to reduce the number of obese children and youth in the United States. After analyzing the behavioral, social, cultural, and other environmental factors that contribute to childhood obesity and promising approaches for prevention efforts, the IOM released the report, Preventing Childhood Obesity: Health in the Balance (IOM, 2005). This report identified promising strategies for obesity prevention efforts and put forth a set of recommendations for a variety of stakeholders and sectors to implement obesity prevention strategies for government, industry, communities, schools, and home. The IOM committee developed its recommendations based on the best available evidence at the time by integrating information from the obesity prevention literature, the dietary and physical activity literature, and parallel evidence from other public health issues with an emphasis on and commitment to evaluate promising obesity prevention interventions. In 2005, with support from The Robert Wood Johnson Foundation (RWJF), the IOM is building on its previous work by conducting a study to assess progress toward the obesity prevention recommendations in the original report. The IOM, through its Food and Nutrition Board, has appointed a 13-member multidisciplinary committee with expertise in child health, obesity, nutrition, physical activity, food industry, community-based evaluation, public health, and public policy to conduct the study. In 2005, the committee organized three regional meetings in the midwest, southeastern, and western United States to galvanize obesity prevention efforts of local, state, and national decision-makers, community and school leaders, grassroots organizations, and industry representatives including the food, beverage, restaurant, leisure, recreation, and entertainment industries. These three meetings will involve disseminating the findings and recommendations of the original IOM report and catalyzing dialogues that highlight best practices and identify assets and barriers to moving forward with obesity prevention efforts in each selected region.

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium In collaboration with The California Endowment, the committee held its third regional symposium on December 1, 2005 in Irvine, California. Recognizing that the health of individuals is closely linked to the consumer marketplace and messages disseminated by the media, this symposium focused on the specific IOM report recommendations for stakeholders within industry and the media to explore how to create healthy marketplace and media for our children and youth (Box 1). The symposium included three plenary panels that focused on food and physical activity products, portfolio shifts, and packaging innovations; retailing healthy lifestyles with regard to food and physical activity; and the business response to childhood obesity. Participants also engaged in two break-out sessions. The first session focused on marketing communication strategies that promote both healthful products and physical activity opportunities. The second session focused on public and private education campaigns and industry self-regulation of advertising to children. A program agenda is at the end of this summary. The symposium provided a useful forum for stakeholders to explore viable strategies and exchange information about promising practices for addressing barriers to obesity prevention initiatives, and to identify how public health interests can coincide with the business interests of companies to have a positive impact on reversing the childhood obesity trend. This summary highlights the recurring themes for accelerating change and how industry collectively can move forward with obesity prevention efforts that emerged from the symposium. The themes include reverse the obesity trend; market health and nutrition; make a business commitment to health; change the food and physical activity environment; forge strategic partnerships; garner political support to ally public health and industry; educate stakeholders; collect, disseminate, and share local data; and evaluate programs and interventions. Approximately 90 individuals active in childhood obesity prevention efforts across the nation and in California representing a range of stakeholder perspectives and innovative practices in various sectors—including community leaders, physicians, health educators, members of the clergy, teachers, state and federal government officials, researchers, advocates, and representatives from business and the media—were invited to participate in the symposium. This summary, along with those of two other symposia summaries and a more detailed discussion of insights and regional examples, will be incorporated in the IOM

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium committee’s final report on progress in preventing childhood obesity that will be released in the fall of 2006. Reverse the Obesity Trend The United States as a nation is effective at marketing products and ideas. Industry has demonstrated the ability to effectively position products—foods, beverages, and activities to reach both targeted and extensive segments of the population worldwide to influence preferences and behaviors. By applying their marketing and advertising expertise, industry can be instrumental in constructively addressing childhood obesity prevention by developing and promoting healthful products, consistent healthy messages, and creating a healthy eating environment. Instead of simply raising young consumers’ and their parents’ awareness, marketing principles can be used to help identify and try to dismantle the barriers that prevent people from changing their behaviors to promote healthful dietary intake and physical activity. This involves using available marketing research to understand customers’ preferences, attitudes, intended and actual behaviors to devise strategies to facilitate long-term behavior changes. The keynote speaker at the Irvine symposium emphasized that in order to understand the dietary choices and consumption habits of children, youth, and their parents, it is important to understand the psychological factors that influence consumers’ purchasing behaviors: In general, expectation of taste is the most important influence on reported taste. When people think a food will taste better before they eat it, they tend to rate the taste as better. By contrast, experimental research conducted among consumers suggest that they rate products described as being healthful, such as a soy protein bar, as less tasty than if the food had no health attributes. Research also shows that people tend to eat larger quantities of a product if they believe it to be healthy for them—a phenomenon called the “health halo effect.” The reason for this is not entirely clear and may be multifactorial. Some individuals may regard the calories as better because they are “healthy” calories; some tend to believe that eating healthful foods counteracts the consumption of high-calorie foods; or others may simply underestimate the caloric content of healthful foods. Regardless of the underlying reasons, the outcome is that more calories are consumed, often in excess of

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium what one needs to maintain energy balance at a healthy weight, which will contribute to weight gain if the extra calories are not expended through physical activity. These unintended consequences could lead to setbacks in childhood obesity prevention if not accounted for and effectively addressed. Certain studies have found that people tend to eat more when given a larger versus a smaller package size, particularly with energy-dense foods, because the visual cue of a large package may translate into the belief that a larger portion size may be appropriate. As discussed in the IOM report and confirmed at the symposium, societal norms for what constitutes an appropriate portion size have been influenced by secular trends in the marketplace, and consumers are now exposed to larger quantities and larger portion sizes of food and beverage products than a few decades ago. Research has demonstrated that a certain segment of the population (especially overweight and obese consumers) overestimate the number of calories they burn during physical activity. As a consequence, they may overeat to compensate for what they believe to be a caloric deficit, causing weight gain. Certain investigators have observed that the size of food portions and overall caloric consumption can be influenced by the experience of food deprivation at any point in a person’s lifetime. Individuals who have either experienced hunger or food insecurity may tend to take larger portions than those who have not experienced these conditions. Socioeconomic status that is related to food insecurity may influence portion sizes consumed later in life, while race or ethnicity, may have no direct correlation. In summary, research shows that it is common for overweight or obese individuals to underestimate the amount of calories they consume while overestimating the amount of calories they expend. Consequently, efforts must be made to educate them about what constitutes an appropriate portion size and the caloric content of various foods and beverages, as well as the amount of calories that are typically expended during different activities. Many companies are using these research findings, along with their own marketing research findings, to respond to the childhood obesity issue. Companies that have been successful in this endeavor are attempting to design win-win solutions for both the companies and their

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium customers. These companies have a long-term relationship with their customers and have evolved to view themselves not just as food and beverage product purveyors but as solution providers, investing time and resources into identifying the needs and desires of their customers and responding competitively in the marketplace to meet consumers’ needs. 1. Package with smaller amounts of food For example, research demonstrates that a proportion of customers who are loyal to buying particular brands of foods and beverages from a given company may be willing to pay up to 15 percent more for products that enable them to better control the portions they consume. Some companies have responded by packaging their food and beverage products in smaller packages or containers that provide 100–150 calories, creating re-sealable pouches so that only a portion of the food can be consumed at a single eating occasion, and also by packaging foods in individual serving sizes. 2. Healthful foods in attractive packages Several large produce suppliers are making their fruit and vegetable products more attractive to children by cutting them into bite-sized pieces and packaging them in eye-catching wrappers and containers. Studies from Europe show that by using this approach, children tend to eat more servings of fruits and vegetables. 3. Reformulating products with new ingredients Another strategy that certain companies are using to reverse the obesity trend includes reformulating food and beverage products to reduce calories. Specific changes to achieve calorie reduction include adding more whole grains, soluble fiber, fruits, vegetables, or decreasing the amount of added sugars and total fat. 4. Cookbooks for health The cookbooks published by one food manufacturer are helping to reverse the obesity trend by becoming more health focused with the goal of providing convenient and nutritious recipes in conjunction with information about how families can adopt and maintain active lifestyles. Companies within the fast food or quick serve restaurant sector are also devising effective ways to reverse the obesity trend. Meals offered to children at quick serve restaurants, such as one leading restaurant that

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium presented at the symposium, have been redesigned to offer the choice of milk in “cool” plastic jugs instead of the traditional carton. Children’s meals currently offer healthier options such as sliced apples with a caramel dipping sauce instead of french fries. However, making fruit or other healthier options as the default side dish to the meal has not yet been implemented. Some chicken products have been reformulated to include only white meat to reduce the amount of fat and total calories. Additionally, the company representative indicated that “super-sized” portions have been removed from the menu to help customers better control their calorie intake, and menus currently offer a broader selection of fresh salads and items that contain low-fat yogurt, although these are more expensive than high-calorie options. These changes have resulted in this quick serve restaurant franchise becoming the largest purchaser of apples and salad greens in the United States. Nevertheless, there are several ongoing challenges. Sustaining sales will be contingent upon consumer demand. Additionally, special handling and packaging is required to keep perishable produce items fresh and appealing due to their shorter shelf life. Evaluations of these changes will be necessary to demonstrate if they change consumer demand over the long-term. In particular, evaluation measures should identify consumers’ stated barriers (e.g., price, taste, access) for changing their away-from-home eating behaviors. Emerging technologies may help to reverse the obesity trend by creating less expensive ways to incorporate healthy ingredients into foods and beverages and also by making convenient packaging less expensive. For example, it is very costly to use delicate salad greens to meet consumer demand while keeping the price of salads affordable for consumers. New technologies that manufacturers are developing to overcome these difficulties may assist in expanding the marketplace’s offering of fresh salads at affordable prices. In summary, changes toward reversing the obesity trend within the industry are numerous. The Grocery Manufacturers Association, a trade association comprised of global food, beverage, and consumer product companies, reported that since 2002, a substantial proportion of its member companies have improved the nutritional profiles of their products. More than half of the companies are changing packaging to offer single-serving sizes, a majority are promoting healthy lifestyles through a variety of activities, including the promotion of the new U.S. Department of Agriculture (USDA) food guidance system, MyPyramid.gov, which replaced the Food Guide Pyramid in 2005.

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium Market Health and Nutrition A complementary strategy to market health and nutrition includes the promotion of consuming fruits and vegetables and engaging in regular physical activity. Marketing healthful foods and beverages is challenging because many consumers do not rate healthful products as highly on taste as less nutritious foods and do not purchase them as frequently, thereby making it more difficult to increase the availability of healthful products on the shelves of grocery stores or other food retail outlets. Industry has found that many of the techniques that are successful in general marketing of foods and beverages can be applied to marketing healthful food choices as well as physical activity. The success may rest upon offering young consumers incentives; developing brand loyalty; using celebrity endorsement to instill a sense of fun, fashion, or healthy lifestyle; or simply making young people feel good about themselves for purchasing and consuming a specific product. Robust competition in the marketplace can help drive innovation and broaden offerings of healthier products. Some companies have responded to consumer demand for healthier products by investing resources to develop tasty, affordable, nutritious, and fun products that consumers will buy—whether it is healthful food and beverage products or physical activity products such as physical videogaming. This encourages other companies to respond with their own healthier offerings, the demand-driven cycle continues, and a wider selection of healthier foods and beverages and physical activity opportunities results. For example, rather than selling plain frozen vegetables, which may not be as appealing to children, one company that presented at the symposium, General Mills, indicated that it markets packaged vegetables with flavorful low-fat sauces to attract young consumers and their parents. This company is also striving to bring organic fruits, vegetables, and other products to the mainstream consumer marketplace to meet the growing consumer interest in natural or organic foods. Unprocessed foods, such as fruits and vegetables, are generally promoted less than processed food brands. However, certain companies are beginning to brand their produce and promote innovative features such as special varieties and new shapes or colors of fruits and vegetables that may help to build young consumers’ awareness and consumption as well as company sales and profits.

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium The few transnational companies that presented at the symposium are at the forefront of making positive changes. They indicated that consumers will be more likely to demand and purchase healthful products if they taste good, are convenient, and affordable. These companies view raising consumer awareness as an important precedent to generate greater demand for healthful products. However, many more companies have not yet begun to make changes that contribute to a collective industry-wide effort supporting childhood obesity prevention goals. A major challenge for all industry segments (e.g., food, beverage, restaurant, fitness, leisure, and entertainment) will be to develop marketing plans and communication strategies that are consistent with the efforts undertaken by the government and public health and consumer groups. Marketing research has identified several factors that are useful to consider when marketing health and nutrition to consumers. First, to overcome negative perceptions associated with healthful foods and beverages, incremental changes are very strategic and more likely to be accepted by consumers. Encouraging consumers to try a new healthful product, and to have a positive experience with the product, is more effective than urging them to buy a week’s or month’s supply of the product. Second, research suggests that nutritional gatekeepers, who are often but not always mothers, influence a large proportion of the eating decisions made by the family. This finding is based on what they purchase at the grocery store, the meals they prepare at home, how much money they give their children to purchase school lunches, and the type of snacks or lunches they prepare for their children. Directing marketing efforts at the nutritional gatekeeper of the family, rather than the entire family, may be an effective strategy to influence the household’s food purchasing and eating habits. Marketing to specific nutritional gatekeepers can have a substantial impact on the type of food and beverage products that families purchase and consume. One speaker described family cooks as those who can be classified as healthy and innovative (e.g., willing to try and use new products) or competitive (e.g., willing to use new products because they offer advantages over other products). These types of gatekeepers should be the prime targets for marketing campaigns that advocate the use of healthful products, as these are the types of cooks most likely to utilize such foods. Moreover, marketing messages can be tailored for these consumer segments (e.g., healthy and innovative or competitive) to best target each group. Finally, business executives have learned that positioning a food as healthful is

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium often not well accepted by consumers, because they may have negative impressions and expectations about how the product will taste. Marketing foods as fresh or energy boosting may improve their consumption. Similarly, advocating physical activity as a workout may place too much emphasis on having to engage in work. Rather, presenting physical activity as fun or an opportunity to relieve stress, boost energy, improve self-esteem about oneself, or spend time with one’s children and family creates a more positive perspective and behavior changes that individuals are more likely to adopt and sustain. In terms of marketing fitness as fun or fashionable, the largest quick serve restaurant franchise, McDonald’s Corporation, now uses its spokescharacter mascot to promote physical activity and a nationwide challenge to parents and children to incorporate more walking into their daily routines. In conjunction with this initiative, the company distributed “stepometers” to its customers to increase awareness about how many calories can be expended through walking. Several food, beverage, and restaurant companies have implemented programs in elementary schools that are designed to inspire third- and fifth-grade students to become more active during physical education class and recess through a hands-on exploration of fun and engaging games that children play around the world. Another company that presented at the symposium, General Mills, regularly supports the Presidential Active Lifestyle Award by donating funds to help children and youth improve their nutrition and fitness behaviors. The company supports up to 50,000 children a year to earn the award, which they achieve by completing one hour of physical activity five days a week for six weeks. Perhaps one of the most promising strategies for encouraging physical activity among older children and youth involves physical gaming, or videogames that require players to physically participate by moving their bodies to control the game. The symposium speaker from Harmonix Music Systems discussed the growing market for these type of games, indicating that they typically use peripheral tools such as cameras, large-control pads (e.g., dance pad), or special hand-held controllers that track the movements of players to guide the game. These games have the potential to be effective at reducing childhood obesity for two reasons: when children actively participate in the games, they not only move but may also snack less frequently in the process, which may be more common when youth play passive games or watch television. Moreover, by connecting physical gaming to the Internet, children and

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium youth can compete against other young people around the world, much like a virtual worldwide Olympics, which often creates an additional incentive of competition for them to play. Given the current and growing demand for these products, the producers of physical gaming are keeping pace with children’s and teens’ high standards for fun and entertainment by continuously innovating with new products. Companies are also designing more multipurpose peripheral tools that can be used for multiple types of games. To market more healthful food and beverage products that are lower in total calories, fat, salt, and added sugars or higher in specific nutrients, several companies have developed different labeling programs that are depicted by proprietary logos or icons to convey nutritional content information to consumers and help them identify better choices with each company’s branded product lines. For example, PepsiCo uses the SmartSpot™ logo to distinguish “good for you” and “better for you” products from the “fun for you” products, and Kraft Foods uses the Sensible Solution™ logo that meets specific nutrient criteria according to the Food and Drug Administration (FDA) and the Dietary Reference Intakes developed by the IOM of the National Academies. General Mills promotes 14 different Goodness Corner™ icons that meet specific FDA criteria, including its line of Green Giant® products to encourage the consumption of vegetables. The nutrient criteria define limits for calories, total fat, saturated fat, trans fat, cholesterol, added sugars, and sodium, and they identify products that are high in fiber, vitamins, and minerals. This type of product branding enables consumers to identify healthful products in the marketplace and the company that makes and promotes them. In theory, the healthy logos or icons may serve to build brand awareness and brand loyalty among consumers by making it easier for them to identify healthier product offerings. The icons have the potential to provide clear and positive messages, demonstrate the companies’ efforts toward expanding the healthier product portfolios, and providing healthful solutions to customers. Since the proprietary logos or icons introduced by food companies to communicate the nutritional qualities of their branded products to consumers have not been evaluated, it is not yet known how consumers understand them, and there may also be great variation regarding the consistency, accuracy, and effectiveness of these logos or icons. As noted at this symposium, an industry-wide logo or icon may be more useful to consumers for all company products to encourage the consumption of healthier products.

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium and the public for such a measure. As articulated by the IOM report, further research is needed into the effects of taxation and pricing strategies as a public health strategy for promoting improved dietary behaviors, physical activity, and reduced sedentary behaviors before pursuing them. Educate Stakeholders At-risk communities are often willing to accept changes that promote the health of community members. The key is providing them with the information they need. Preventing childhood obesity requires the ongoing education of children, families, communities, state and government officials, industry executives and corporate chief executive officers. Many people may fail to recognize an issue as a problem unless they are directly informed about it. Efforts must be made to inform people about the root causes of childhood obesity and the lifestyle changes needed to reverse the trend. To that end, stakeholders at various levels should be targeted for ongoing education about the risks of obesity, the values of a healthy lifestyle, and the health disparities that exist among different demographic groups. Additionally, companies should not undermine or compete with these healthful messages to educate the public. Providing nutrition information to consumers represents one way of educating individuals about the nutrient value of certain products and more generally about a balanced and healthful diet. Many companies printed the new food guidance system on product packages, which informs individuals about the types and amounts of foods appropriate for them. Some companies have gone a step further by making this information culturally relevant to particular minority groups (e.g., the Soul Food Pyramid for African-American consumers). Although the FDA’s Nutrition Facts panel has been a standard feature on all products marketed since 1994, the information may not be readily understandable by some individuals, nor is this type of labeling required for foods sold in restaurants. To that end, one major quick serve restaurant franchise will provide nutrition information on the wrappers and packages of all of its food items by the end of 2006—in addition to displaying this information in brochures, on the back of tray liners, and on their website—while also presenting the information in more user-friendly ways that even children can understand. An interactive tool on the company website allows customers to customize their meals according to their preferences, and

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium find out the nutritional content so that they know what the meal provides before ordering the items at the restaurant. McDonald’s Corporation has created a program that targets Hispanic/Latino families residing in six cities around the country. The program teaches both parents and children what foods comprise a healthy meal, how to make healthier food substitutions in their current menus, and easy strategies for increasing their physical activity levels. Making healthy choices the default option would make it easier for consumers to practice these strategies. Another company reaches out to American Indian children through a program that reacquaints them with foods based on what their ancestors consumed. In addition, the program promotes physical activity by teaching the children ancestral dances. A major athletic company, Nike, has taken a unique approach to education by teaching coaches to be more positive in their approach to sports. The aim is for coaches to understand how to maximize physical activity while making it fun at the same time. The goal of winning is de-emphasized in favor of deriving enjoyment from the game. Several companies strive to educate not only parents and children but medical and health professionals as well. One corporation has a long-standing program that provides information to medical professionals and nutritionists around the country on the nutritional profile of their products in addition to more general information about healthy lifestyles. This program used to be paper based, but it has since transitioned to the Internet to keep pace with emerging technologies and to expand access to interested stakeholders. Physicians can be influential health advocates if they are properly educated about the childhood obesity epidemic and steps that they can take within their practices to help prevent the problem. A major healthcare provider organization re-oriented, re-educated, and re-trained its health-care provider workforce—including physicians and nurses—about the issues of weight management and fitness and how to improve the overall health of clients. Many individuals at the symposium, however, expressed that additional physician education and action are needed if they are to be advocates for childhood obesity prevention efforts. For example, physicians could write more realistic prescriptions that involve physical activity and lower-calorie foods and beverages, rather than prescribing weight-loss medications or gastric bypass operations. Physicians could ensure that dietitians are an integral component of the health care team so that obese patients can be referred to such specialists before more medications or other procedures are required. Similarly, insurance

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium executives represent another target for education, especially with regard to preventive medicine. Under the current insurance reimbursement system, it is not uncommon for an obese person to be covered for a $30,000 gastric bypass operation, yet reimbursing patients $25 per month for a health club membership is currently without precedent. Collect, Disseminate, and Share Data To facilitate the childhood obesity prevention movement, trend data need to be collected on the prevalence of obesity, physical inactivity, and dietary problems at a variety of levels—neighborhoods, communities, counties, states, and national. With this information, appropriate interventions can be designed to help reduce the obesity trends. During the intervention process, it is essential that there are surveillance and monitoring mechanisms in place that will assist in evaluating progress with interventions and to refine efforts and objectives as needed. The collection and dissemination of local data can be an effective means of motivating change within communities. One policy group is collecting data in central Los Angeles by employing community health workers to gather information on the location of particular food stores within neighborhoods. These workers are also collecting information using a questionnaire developed by the USDA that assesses the quality and price of the food available in a given area to allow for cross-sectional comparisons. These data will be used to generate maps that delineate areas according to store density, food quality, and food pricing so that strategies can be devised to rectify inequities. A participant in one of the breakout sessions raised the important issue of engaging industry in meaningful discussions to share expensive and frequently unavailable market research data that will inform large-scale public health education and social marketing campaigns. One presenter expressed the need to better understand how the marketplace has changed for young people and adults, whether sales of healthier foods has increased, and whether exposure to healthful food and beverage advertising and promotion has increased. While acknowledging the proprietary nature of company data, the private sector could collectively support research and evaluation efforts. For example, industry could develop a mechanism for commercial marketing data to be available as a publicly accessible resource to build an evidence base that will facilitate understanding the dynamics that shape the health and nutrition attitudes and behaviors of children and youth at different ages

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium and under varying circumstances, and for informing a multi-faceted social marketing program promoting healthful diets and physical activity. The private sector and public health community could also collaborate on common outcome measures that can be tracked over time to assess if improvements in children’s and adolescents’ health are occurring. Evaluate Programs and Interventions Various initiatives and efforts addressing obesity among the nation’s children and youth share the common goal of creating environments that reduce obesity risk and promote healthy behaviors. For this reason, it is important to document new programs, policies, and practices that help to advance the obesity prevention cause over time. A major healthcare organization is tracking 15 distinct clinical outcome measures of its clients in an effort to inform and improve future practices. Within the business sector, it is often difficult to share and document the successful strategies of companies’ efforts to market nutrition across companies due to antitrust laws. While individual companies can gauge the efficacy of some of their outreach strategies by tracking sales, how much time people spend at health-promoting company websites, and counting how many people enroll for certain health-promoting programs, these findings largely constitute privileged information. Nevertheless, companies do track each other’s market share to determine which products are selling well. As such, those products or strategies identified as selling for one company will become prime targets for adoption and improvement within other companies, thereby driving competition. Most companies have not devised comprehensive plans for evaluating their outreach efforts but instead, partner with outside agencies to conduct external evaluations. This information is used to determine the best outcomes so that they can be applied to other communities. A major sports retailer that presented at the symposium collaborates with other organizations to identify and centralize data on efforts being taken throughout various sectors to identify best practices of physical activity programs focused on reversing the rapidly increasing prevalence of overweight and inactivity among children and adolescents. More than 1,800 organizations sponsoring obesity prevention programs have participated by taking a survey in which they detail their efforts, struggles, and successes. These data are input into a centralized registry in order to promote interactions, partnerships, and coordinated efforts

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium among the parties to improve the health of the nation’s children and youth. Concluding Comments Although there is a long road ahead of the nation to effectively address the growing childhood obesity rates, forging an alliance between the public health community and industry is a vitally important leverage point. By finding common cause and common ground, the sometimes uncomfortable relationship between the two stakeholder groups can potentially be transformed into one that promotes the greater good and health of our nation’s children and youth. Nurturing and strengthening this partnership will involve: Relaying consistent messages to children, youths, and adults. Ensuring transparency through the sharing of data between the public health community and industry. Making durable commitments to be involved in this effort for the long-term future. Obesity is an issue that needs to remain at the forefront of the nation’s attention. Ensuring homogeneity of commitment. Large corporations in particular need to ensure that the entire organization is engaged in obesity prevention efforts and not one isolated sector of the business. Honoring the free market system. It is incumbent on public health advocates to acknowledge the values and realities of the competitive marketplace and to recognize those corporations that are stepping forward to make positive changes. Understanding the interactions between marketing and consumer demand. Exploring avenues of impact. One area that has not been fully examined is the potential impact that business leaders can have in advocating for changes and initiatives that promote improvements in nutrition and increases in physical activity. Making a commitment to monitoring and evaluation. It is important to identify outcome and impact measures that public health and industry agree on and then to apply scrutiny to the evidence, and be willing to make evidence-based changes. The obesity epidemic in the United States has the potential to reverse major progress that had been made in the health of the nation’s children

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium and youth over the past several decades. It is a complicated, multifactorial problem involving our food supply and distribution system; restrictions and opportunities for physical activity; public policy and personal choice; and families, schools, communities, businesses and worksites, and all levels of government. It is important to note that in discussions of commercial concerns and the obesity epidemic, the overwhelming majority of the dialogue focuses on dietary intake and the food and beverage industry. More effort and attention are needed to engage corporate interests that support sedentary behaviors (e.g., professional spectator sports, highway construction concerns, and entertainment and media producers). Supporting active leisure to invest in the development and support of physical and sociocultural environmental change to achieve and sustain high levels of physical activity engagement at the population level are also needed. A concurrent and collaborative involvement of multiple sectors and stakeholders at all societal levels is required to change the collective societal norms that have contributed to the childhood obesity epidemic. As with instituting the mandatory use of seatbelts and initiatives that promote tobacco control and smoking prevention, our nation has the power to change societal norms in order to prevent childhood obesity. A true partnership is needed between the public health community and industry to change societal norms and promote the health and well-being of children and youth.

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium Program Agenda Institute of Medicine Symposium Progress in Preventing Childhood Obesity: Focus on Industry In collaboration with The California Endowment Supported by The Robert Wood Johnson Foundation December 1, 2005 Beckman Center of the National Academies Irvine, CA Opening Session Welcome James Marks, The Robert Wood Johnson Foundation Overview of the IOM Report and Meeting Goals Jeffrey Koplan, Emory University and Institute of Medicine (IOM) Committee on Progress in Preventing Childhood Obesity Welcome and Highlights from the California Governor’s Summit on Health, Nutrition, and Obesity Robert Ross, The California Endowment Ana Matosantos, State of California Health & Human Services Agency De-Marketing Obesity: An Analysis of the Current Profile and Future Prospects of Healthy Food and Beverage Products in the Marketplace Brian Wansink, Cornell University Plenary Panel—Presentations and Discussion Food and Physical Activity Products, Portfolio Shifts, and Packaging Innovations Moderators: Eduardo Sanchez, Texas Department of State Health Services and Russell Pate, University of South Carolina

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium Louise Finnerty, PepsiCo Paul Petruccelli, Kraft Foods Chris Shea, General Mills Joe BrisBois, Harmonix Music Systems Brian Wansink, Cornell University (Respondent) Plenary Panel—Presentations and Discussion Retailing Healthy Lifestyles: Food and Physical Activity Moderators: Antronette Yancey, UCLA School of Public Health and Jennifer Greene, University of Illinois, Urbana-Champaign Cathy Kapica, McDonald’s Corporation Rebecca Flournoy, PolicyLink Lorelei DiSogra, United Fresh Fruit and Vegetable Association Richard Jackson, University of California at Berkeley Roland Sturm, RAND Corporation (Respondent) Marketing Communications Strategies: Promoting Healthful Products and Physical Activity Opportunities Breakout Session #1: Presentations and Panel Discussion Entertainment Industry Moderators: Tom Robinson, Stanford University School of Medicine and Ann Bullock, Eastern Band of Cherokee Indians Jennifer Kotler, Sesame Workshop Mindy Stockfield, Cartoon Network Jorge Daboub, Univision Television Group

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium Vicki Beck, Hollywood, Health & Society Christy Glaubke, Children Now (Respondent) Breakout Session #2: Presentations and Panel Discussion Public and Private Education Campaigns and Industry Self-Regulation Moderators: Sue Foerster, California Department of Health Services and Ken Powell, IOM Committee on Progress in Preventing Childhood Obesity Jim Guthrie, National Advertising Review Council Rachel Geller, The Geppetto Group Heidi Arthur, The Ad Council Jan DeLyser, Produce for a Better Health Foundation and California Avocado Commission Sarah Samuels, Samuels and Associates (Respondent) Plenary Panel—Presentations and Discussion Business Response to Childhood Obesity Moderators: Jeffrey Koplan, Emory University and Douglas Kamerow, RTI International LuAnn Heinen, National Business Group on Health Ray Baxter, Kaiser Permanente Brock Leach, PepsiCo Lance Friedmann, Kraft Foods Richard Martin, Grocery Manufacturers Association Alicia Procello, Nike Closing Remarks Jeffrey Koplan, Emory University and IOM Committee on Progress in Preventing Childhood Obesity

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Progress in Preventing Childhood Obesity: Focus on Industry - Brief Summary: Institute of Medicine Regional Symposium BOX 1 IOM Report Recommendations for Industry Industry should make obesity prevention in children and youth a priority by developing and promoting products, opportunities, and information that will encourage healthful eating behaviors and regular physical activity. To implement this recommendation: Food and beverage industries should develop product and packaging innovations that consider energy density, nutrient density, and standard serving sizes to help consumers make healthful choices. Leisure, entertainment, and recreation industries should develop products and opportunities that promote regular physical activity and reduce sedentary behaviors. Full service and fast food restaurants should expand healthier food options and provide calorie content and general nutrition information at point of purchase. Nutrition labeling should be clear and useful so that parents and youth can make informed product comparisons and decisions to achieve and maintain energy balance at a healthy weight. To implement this recommendation: The Food and Drug Administration should revise the Nutrition Facts panel to prominently display the total calorie content for items typically consumed at one eating occasion in addition to the standardized calorie serving and the percent Daily Value. The Food and Drug Administration should examine ways to allow greater flexibility in the use of evidence-based nutrient and health claims regarding the link between the nutritional properties or biological effects of foods and a reduced risk of obesity and related chronic diseases. Consumer research should be conducted to maximize use of the nutrition label and other food guidance systems. Industry should develop and strictly adhere to marketing and advertising guidelines that minimize the risk of obesity in children and youth. To implement this recommendation: The Secretary of the Department of Health and Human Services should convene a national conference to develop guidelines for the advertising and marketing of foods, beverages, and sedentary entertainment directed at children and youth with attention to product placement, promotion, and content. Industry should implement the advertising and marketing guidelines. The Federal Trade Commission should have the authority and resources to monitor compliance with the food and beverage and sedentary entertainment advertising practices. SOURCE: IOM (Institute of Medicine). 2005. Preventing Childhood Obesity: Health in the Balance. Washington, DC: The National Academies Press.

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