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March 2009 (Volume 87)
Bradford H. Gray
Milbank Memorial Fund
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This issue of The Milbank Quarterly is devoted to obesity as a public policy issue. In the last few years, obesity has frequently been referred to as an “epidemic” or a “crisis,” for reasons described in the articles in this issue: the high and increasing rates of overweight and obesity among both adults and children, obesity as a risk factor for morbidity and mortality from a variety of diseases, and obesity as a significant contributor to health care costs. The eleven articles in this issue focus on both public and private policy options for addressing the high rates of obesity. They present new empirical studies; policy history; overviews of developments in particular arenas such as schools, workplaces, and the built environment; and analyses of different legal strategies and public policies.
A complexity of obesity as a public policy issue is that it results from individual behavior. Thus, the question of whether obesity should be viewed as a matter of personal responsibility or as a result of external causes is a recurrent theme. Acceptable policy options may depend on how the public sees the issue, a topic that is explored empirically by Colleen Barry, Victoria Brescoll, Kelly Brownell, and Mark Schlesinger in “Obesity Metaphors: How Beliefs about the Causes of Obesity Affect Support for Public Policy.” They report the results of a national survey exploring how people’s views of seven metaphors regarding the causes of obesity (e.g., as an addiction, as genetically caused, or as a result of industry manipulation) relate to their support for sixteen public policies that have been proposed legislatively in recent years. Some of these policies are aimed at helping or protecting citizens, whereas others are more punitive, raising the cost of engaging in behavior that may lead to obesity. Barry and her colleagues found that people’s political ideology and party affiliation were less important predictors of which obesity-related policies they support than were their views of the causes of obesity. Thus how advocates and opponents of various policy options manage to frame the causes of obesity will influence the public’s acceptance of future policy options.
In the next article in this issue, “Reducing Obesity: Motivating Action While Not Blaming the Victim,” Nancy Adler and Judith Stewart contrast the medical and public health approaches to obesity. The medical model treats obesity as an individual problem resulting from a combination of genetic factors and individual behavior, whereas the public health approach considers a much wider set of causative factors, many of which are examined in subsequent articles in this issue. Adler and Stewart argue that although both models are needed, both are incomplete. In particular, even though the public health model points to social and environmental interventions, individual behavior must change so that from a public health perspective, obesity can also be seen as a matter of personal responsibility. Adler and Stewart object not only to victim blaming arising from seeing individuals as responsible but also to public health approaches that ignore the role of individual choices. Drawing an analogy from the environmental justice concept, they propose a concept of “behavioral justice” that recognizes individual responsibility for behavior but also makes it the responsibility of society to provide equal opportunities to make healthier choices regarding diet and exercise.
The next several articles describe practical approaches to reducing the incidence of obesity in different contexts. In “Schools and Obesity Prevention: Creating School Environments and Policies to Promote Healthy Eating and Physical Activity,” Mary Story, Marilyn Nanney, and Marlene Schwartz observe that more children are overweight than ever before and that some caloric intake happens at school. This makes schools a promising locus of efforts to prevent or reduce childhood obesity. The authors describe several strategies and summarize the available evidence regarding the effectiveness of changing school policies pertaining to food and physical activity, measuring body mass index and informing parents, and conducting school-based wellness programs. They conclude with suggestions to accelerate change in reducing overweight and obesity among children.
The next article is “Addressing Obesity in the Workplace: The Role of Employers” by LuAnn Heinen and Helen Darling. Just as children spend a large share of their day in schools, most adults spend many hours each day at their workplaces. Accordingly, what they do while there can affect their weight. Because of concerns about the health and cost effects of obesity in their workforces, large employers have begun to adopt strategies to address this problem. Heinen and Darling summarize survey evidence regarding the health promotion and weight management approaches that employers have adopted, and they describe in more detail the approaches taken by four large employers. They conclude with advice for both employers and policymakers to enhance weight control and fitness in America’s workforce.
The built environment also plays a role in obesity. In “Physical Activity and Food Environments: Solutions to the Obesity Epidemic,” James Sallis and Karen Glanz provide an overview of evidence regarding environmental contributors to obesity and changes that might help address the problem. Because weight control is a matter of calories consumed and expended, the extent to which neighborhoods facilitate physical activity and healthful eating can help control people’s weight. Sallis and Glanz summarize and synthesize the evidence from recent review articles regarding neighborhood effects, and they suggest strategies for both addressing obesity and building a body of pertinent evidence.
One characteristic of neighborhoods is the advertising to which residents are exposed, a topic that is examined in one of the empirical studies in this issue, “A Cross-Sectional Prevalence Study of Ethnically Targeted and General Audience Outdoor Obesity-Related Advertising,” by Antronette Yancey and colleagues. Building on the research on the racial/ethnic and socioeconomic targeting of advertising, they studied outdoor advertising in different types of neighborhoods in four cities. They found that not only were residents of high-income neighborhoods exposed much less often to most types of obesity-promoting outdoor advertising but also that there were racial/ethnic differences in the types of advertising to which residents of low-income neighborhoods were exposed. This study fits with the behavioral justice perspective described by Adler and Stewart in their article in this issue. Possible regulatory responses, however, raise challenging legal issues.
The next two articles are concerned with legal approaches to high obesity rates, beginning with “Innovative Legal Approaches to Address Obesity” by Jennifer Pomeranz, Stephen Teret, Stephen Sugarman, Lainie Rutkow, and Kelly Brownell. Pomeranz and her colleagues concentrate on two general approaches: direct application of the law to known contributors to obesity and innovative legal approaches to change weak governmental regulation and ineffective public policy. They describe possible strategies for limiting food marketing to children, confronting the potential addictive properties of food, compelling industry speech (e.g., product labeling requirements), increasing government speech (e.g., public education programs), regulating conduct, using tort litigation, applying nuisance law as a litigation strategy, and considering performance-based regulation as an alternative to typical regulatory approaches.
Next, in “Public Health Law and the Prevention and Control of Obesity,” William Dietz, Donald Benken, and Alicia Hunter summarize the information and strategies presented at the Centers for Disease Control and Prevention’s National Summit on Legal Preparedness for Obesity Prevention and Control held in June 2008. After a brief review of the alarming data on obesity and the dietary and physical activity factors contributing to it, the authors describe the CDC’s use of the law to address obesity. This includes identifying the pertinent existing legal authorities, developing public health professionals’ ability to apply those laws, coordinating actions across jurisdictions, and disseminating information about best public health law practices. The potential of some existing legal authorities, such as the federal Farm Bill, the Transportation Bill, and the Federal Communications Commission, hasn’t been fully recognized and used. The authors also provide examples of pertinent legal authorities at the state and local level.
Lisa Powell and Frank Chaloupka’s “Food Prices and Obesity: Evidence and Policy Implications for Taxes and Subsidies” summarizes the large research literature on a highly controversial subject: the effects of taxes and subsidies affecting the relative cost of energy-dense, unhealthy foods and less dense, healthier foods. The authors conclude that the size of pricing interventions matters and that pricing strategies will have the greatest impact on children and adolescents, low-income populations, and those persons most at risk for overweight.
An important aspect of how political debates related to obesity will play out is the response of those parties whose economic interests may be affected by proposed policies. Kelly Brownell and Kenneth Warner examine a historical parallel in “The Perils of Ignoring History: Big Tobacco Played Dirty and Millions Died. How Similar Is Big Food?” They describe how the tobacco industry responded both to evidence revealing the detrimental health effects of its product and to public health efforts undertaken based on that evidence. Responses included using a “script” emphasizing personal responsibility, enlisting scientists to instill doubts about the research evidence, pledging self-regulation, devoting massive resources to lobbying, making “safer” products, and marketing to children.
Brownell and Warner acknowledge the differences between food and tobacco—food is necessary to life, whereas tobacco is not—and between the two industries, particularly the size and diversity of the food industry. Nonetheless, they found many similarities in how the two industries have responded to concerns that their products cause harm. They focus on four areas: the framing of issues in public debates, efforts to influence government and key organizations, attempts to create doubt about scientific evidence, and strategies for marketing their products. Last, the authors offer their own suggestions about how the food industry might help reduce the public health risks of its products in all four of these areas.
This issue ends with Rogan Kersh’s article, “The Politics of Obesity: A Current Assessment and Look Ahead.” Kersh returns to the importance of perceptions of personal responsibility to opening or restricting policy options for addressing high rates of obesity. He analyzes the politics of obesity by examining the experience with calorie menu labeling and school-based policies, as well as an existing but little used governmental authority to designate “foods of minimal nutritional value” and industry efforts to “reformulate” unhealthful products. Kersh is especially interested in the extent to which an “issue regime” has developed, in which advocates and policymakers separate into two camps united by philosophy, arguments become solidified, and options seen as realistic become restricted.
I will conclude by explaining how this issue of The Milbank Quarterly came about. We invited some of the submissions, and others arrived through the usual submission process, including several prepared for a conference at the University of Utah in October 2007, organized by economist Norman Waitzman, who originally suggested a special issue.
In thinking about obesity policy as the topic of a special issue, I was advised about topics and potential authors and reviewers by three researchers: psychologist Kelly Brownell of Yale University, political scientist Rogan Kersh of New York University, and economist Kenneth Warner of the University of Michigan. I am grateful for their good advice. The submissions that were invited as a result of our conversations were, of course, subject to the Quarterly’s usual peer review process.
Bradford H. Gray Editor, The Milbank Quarterly
Author(s): Bradford H. Gray
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Volume 87, Issue 1 (pages 1–5) DOI: 10.1111/j.1468-0009.2009.00545.x Published in 2009
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