Government Structures to Address Obesity
People in both the United States and the United Kingdom debate the appropriate role for their governments in addressing obesity. This debate reflects growing recognition that social, economic, and environmental determinants, not just individuals’ food and exercise choices, contribute to the obesity epidemic. Anne Jackson (Director for Child Well-being, UK Department for Children, Schools, and Families) and William Dietz (Director, Division of Nutrition, Physical Activity and Obesity, CDC), discussed how the national government in the United Kingdom generally has taken a more active role than that in the United States, although the latter also has many programs and policies addressing obesity.
A range of agencies and departments in both countries must deal with different aspects of the obesity problem, such as food assistance, public transportation, marketing, food access and quality, food labeling, and research. Subsequent panels explored some of these efforts in greater detail. The United Kingdom has attempted to bring these disparate activities and elements together under a national strategy, reflective of that country’s more vertically integrated system compared with that of the United States. In the United States, state and local governments have assumed a larger role in obesity interventions, in keeping with the decentralized decision making that characterizes many US health, education, and other policies. Philanthropies and nonprofits are also major funders of obesity prevention efforts and play leading roles in research and advocacy.
THREE ROLES FOR THE BRITISH GOVERNMENT
Jackson highlighted three roles the British government plays in preventing obesity: exercising leadership, creating a coalition for change, and offering delivery and support programs. (Because health and social policy are dealt with in Scotland, Wales, and Northern Ireland separately, the discussion was focused on England.)
The Foresight report (see Box 2-1 in Chapter 2) provides what Jackson termed “our platform” for action. It presents clear information that cannot be ignored about the severity of the problem at both the societal and individual levels if current trends continue. Based on these findings, in January 2008 the British government adopted the Healthy Weight, Healthy Lives strategy to reverse the rising tide of obesity and overweight in the population. Children are the initial focus, with an investment of £372 (approximately $600 million) being made over 3 years. Government leaders at all levels, from the Prime Minister down, have acknowledged obesity as a major national challenge, raising the profile of the problem, especially among children, as one that merits national attention.
The evidence is not conclusive on the best ways to fight obesity; many strategies, such as increased breastfeeding, increased physical activity, and more informative food labeling, may all play a role. Based on the Foresight report, the Healthy Weight, Healthy Lives strategy reflects the need to take a systematic and cross-cutting approach (see Box 3-1).
Creating a Coalition for Change
Jackson said the second broad role for the British government has involved creating a coalition for change to achieve society-wide improvements. A cross-government obesity unit—the Coalition for Better Health—reports jointly to the Department of Health and the Department for Children, Schools, and Families. It works not only with these departments but also with other agencies related to environment, planning, transport, and other salient areas. Childhood obesity is now a priority within the government’s Public Service Agreements (a set of government-wide goals for a 3-year period).
Beyond the national government, a coalition to fight obesity should encompass businesses, the third sector (nonprofits and other civic organizations), and the wider public. The Coalition for Better Health works with these groups, most notably on a society-wide campaign called Change4Life (described more fully in Chapter 6). In addition, an expert working group
The United Kingdom’s Healthy Weight, Healthy Lives
In introducing the Healthy Weight, Healthy Lives strategy, UK Health Secretary Alan Johnson stated, “It is not the Government’s role to hector or lecture people, but we do have a duty to support them in leading healthier lifestyles.” This philosophy is an underpinning of the strategy, which commits high-level leadership and resources to an initial goal of reducing childhood obesity to 2000 levels by 2020. The strategy recognizes the biological, cultural, and environmental factors that contribute to obesity and supports programs and policies in five broad areas:
SOURCE: UK Department of Health, 2008.
includes representatives of the academic community, many of whom were involved in producing the Foresight report; a network of regional obesity leads has been established to support public health directors; and knowledge sharing takes place across localities within each region through regional obesity strategies.
Offering Delivery and Support Programs
The third broad role for the British government is to provide programs and services designed to implement Healthy Weight, Healthy Lives. These programs and services are aimed at early prevention, healthier eating, more physical activity, provision of incentives and workplace support, and personalized support. Local delivery of programs has been strengthened by the provision of data and other research findings, information on best practices, peer support, and other assistance.
Initial Signs of Improvement
While acknowledging that early signs of progress should not be overstated, Jackson noted some promising indicators in addition to the possible leveling off of childhood obesity rates discussed earlier. These indicators
include higher rates of breastfeeding, fewer ads for unhealthy foods seen by children and adults, increases in fruit and vegetable consumption, and increased physical activity among adults. In April 2009, the government issued a 1-year update to Healthy Weight, Healthy Lives. It affirmed a commitment to maintaining momentum by helping people make healthier choices, creating an environment to promote healthy weight, supporting people in need of weight management advice, and strengthening the delivery of these services.
Yet while the evidence shows movement in the right direction, obesity remains a critical issue, and adults are the next major challenge. Concern remains, however, about the appropriate role of the state so that it is not seen as overstepping its bounds, especially with respect to adults. Finally, Jackson suggested that the increasing globalization of the food industry, marketing, and the media means that the United Kingdom and the United States may have further areas of accord to explore.
FEDERAL AND LOCAL EFFORTS IN THE UNITED STATES
In his remarks, Dietz dated the beginning of the focus on obesity prevention in the United States to 1999, when an editorial in the Journal of the American Medical Association, coauthored by Koplan, pointed to the problem as an epidemic. CDC began to publicize a series of maps showing how levels of obesity have grown each year by state (see Box 3-2). These maps have had a profound impact on the obesity debate in the United States.
In 2001, former Surgeon General David Satcher issued The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity, the first governmental call to address the problem. Although few legislative or policy initiatives occurred at the federal level at first, community efforts grew. Congress appropriated funds to CDC for efforts in 5 states (since increased to 25 states) related to nutrition, physical activity, and other aspects of the problem.
Today a higher priority accorded to obesity prevention by the Obama Administration and pending legislation in Congress are generating an increase in obesity prevention activity. In Congress, reauthorization of child nutrition programs can have a major impact on the food consumed in the United States, particularly among children at lower income levels. Similarly, reauthorization of federal transportation legislation can affect levels of physical activity through changes that influence walking, biking, and the use of public transit.
The fact that the Obama Administration is focusing on obesity as a way to control medical costs is, according to Dietz, a “bright light.” Obesity now accounts for 9 percent of the nation’s total health care budget, and costs associated with obesity have doubled during the last 8–9 years. In
The CDC Obesity Maps: Raising Awareness Through Visuals
CDC has developed an effective tool for combating obesity in the United States: a series of maps that show the increase in the prevalence of obesity by state and by year. The maps are a simple but powerful way to depict data from CDC’s Behavioral Risk Factor Surveillance System, which compiles information from state health departments. As the maps change color from year to year, the viewer can witness how obesity increasingly affects every state in the country. In 2008, 25 percent or more of the population in 32 states was obese; no state came close to this number in 1990.
SOURCE: Centers for Disease Control and Prevention (CDC). U.S. Obesity Trends. http://www.cdc.gov/obesity/data/trends.html.
recognition of the economic impact of the obesity problem, the American Recovery and Reinvestment Act funded obesity prevention efforts. The White House garden planted by the First Lady, her support for a farmers’ market near the White House, and similar activities also reflect the Administration’s commitment to addressing the problem.
A number of federal agencies and other entities have roles to play in addressing the epidemic. Within the US Department of Health and Human Services, the Administration for Children and Families oversees programs for preschool children in Headstart. The Centers for Medicare and Medicaid Services provides health funding for low-income families, another important opportunity for regulations that can contribute to obesity prevention and treatment. One of CDC’s roles is to monitor the epidemic and identify effective strategies that can be implemented at the state and community levels, such as pricing strategies to reduce the consumption of sugar-sweetened beverages and strategies designed to encourage an increase in physical activity and a decrease in television viewing. The Food and Drug Administration is interested in point-of-purchase labeling standards. Another important development is a group called the National Collaborative on Childhood Obesity Research (NCCOR), which brings together researchers from the National Institutes of Health, CDC, USDA, and RWJF on issues of particular interest and potential research investment in the field. Other entities with the potential to address obesity include the US Department of Education, which sets standards for school performance (although physical education is not part of those standards), and the Federal Trade Commission, which Congress has mandated to consider voluntary standards for foods advertised to children.
Philanthropies also play a major role in obesity prevention in the United States. As a notable example, RWJF is allocating $500 million over 5 years to efforts to reduce childhood obesity by 2015.
Finally, as noted earlier, the United Kingdom has a more vertically integrated system than that of the United States, with more national-level programs, while the United States is characterized by more state and local control. This difference implies different structures for the development of policies and programs to combat obesity. In the United States, top-down policy is more difficult to implement, but the country’s decentralized system also fosters innovation at the local level. At least 100 communities have initiated interventions directed at childhood obesity (three of these are discussed more fully in Chapter 7). However, good evaluation criteria are needed to determine what does and does not work.