Making Healthy Choices Easy Choices

Changing Policies, Changing the Environment

Obesity’s transformation from personal problem to public health crisis has spurred a search for solutions at every level of society. As the epidemic escalates globally, it’s become clear that remedies lie in an influential, but as yet, underused tool: policy and environmental change.

Public policy has been called “one of society’s most powerful mechanisms for change.” (1) Perhaps one of the best examples is the fight against smoking. Key policy weapons included limiting marketing on television, increasing taxes on tobacco products, and passing smoke-free air laws that banned smoking in public places. Smoking became less socially acceptable and more expensive —that is, the environment changed in ways that influenced people’s decisions to smoke or quit—and smoking rates dropped. These tactics worked so well in the anti-tobacco fight, other successful public health campaigns—seatbelts, vaccines, worker safety—have followed suit. (2-5)

Obesity’s health and economic effects are on a par with those of smoking. And, like smoking, “toxic” environmental influences are fueling the obesity epidemic—among them, the abundance of low-priced, high-calorie processed foods and sugary drinks; incessant food marketing to drive people to eat more; and technology advances that reduce the need for daily physical activity. To turn this epidemic around, we need action at multiple levels—from governments and industries, communities and neighborhoods, schools and worksites, and individuals and families. We need to change policies and create an environment where the default option is the healthy choice. (5-7)

Read about how different settings can make healthy choices easy choices: Families | Early Child Care | Schools | Healthcare | Worksites

Building the Evidence Base for Obesity Prevention

Worldwide, policymakers are looking for creative and effective ways to halt the obesity epidemic. Legislators are deciding whether to tax sugary drinks. School committee members are voting on whether to send home BMI report cards. Government agencies are weighing whether to curb junk food marketing to children. Since obesity is such a complex problem, it’s important to take a big-picture view of any changes, and to think through unintended consequences. (8) Limiting junk food ads on children’s television shows may not do much good if food manufacturers just shift their advertising to other prime-time shows that kids and parents watch.

Research evidence on how to prevent obesity is growing. (9) To date, though, relatively few studies have explored whether policy and environmental strategies work in different community settings and groups. (10) Many promising approaches have yet to be put to the test in research studies. And there’s been a dearth of obesity prevention trials in low- and middle-income countries. (9)

In clinical research, randomized controlled trials are considered the “gold standard” for scientific evidence. But randomized trials are time-consuming and costly—and for some policy changes, may be impossible to field. So it’s crucial to take a broader view of the evidence for obesity prevention, and make decisions on the best available evidence, rather than wait for the best possible evidence. (8,9)

“Natural experiments,” such as tracking the effects of obesity-related policy changes as they are being rolled out, can show what works in the real world. Ongoing research on obesity prevention policies related to food and physical activity will also help build the evidence base. (10)

Weighing the Costs of Obesity Prevention

Policymakers grappling with tight budgets not only want to know whether an obesity prevention effort works—they want to know which programs give the biggest payoff for the money spent. To date, few obesity prevention programs or policy changes have been put to the cost-benefit test. (9,11) But researchers have begun modeling what types of changes would be most effective and cost effective. (12,13) They’re finding that policy approaches return more value for the money than health promotion or clinic-based programs—and are easier to sustain. (6,9) Some community-based programs are cost-effective, but often work only in specific groups—and work only if the public funding continues to flow. (9)

Targets for Policy Change

Environmental causes of obesity cross community, national, and international lines. (5) Key drivers of the epidemic include technology advances that have cut the cost of processed foods and drinks, in turn, leading to larger portion sizes; relentless marketing of high-calorie, low-nutrient foods and drinks, especially to children; and a dramatic rise in the prices of more nutritious foods, such as fruits, vegetables, lean meats, and low-fat dairy products. (6,7) Other factors include less time for gym classes and recess at school; limited access to supermarkets in low-income areas; and a built environment that encourages driving rather than walking or biking. (5,7,14) Each of these factors is a target for policy change, and those changes can take many forms and work at many levels. (8)

To curb consumption of sugary drinks, for example, governments could levy a sugary drink excise tax and use the hefty proceeds to fund obesity prevention programs; restrict the use of food stamps to buy soda; regulate sugary drink marketing to children; or bar sugary drinks from being sold in government buildings or schools. Worksites could establish policies that limit high-sugar drinks or drink portion sizes in their cafeterias.

To promote active lifestyles, for example, federal and state goverments could require more gym classes and recess time at schools or in childcare centers. Communities could change zoning to encourage schools and shops to be built within easy walking distance of residential neighborhoods. Worksites could create policies that allow for flexible work time or breaks for physical activity.

Social marketing and health promotion campaigns, such as New York City’s “Pouring on the Pounds” campaign, can amplify the effect of these policy changes. (8)

Read more: healthy food environment | healthy activity environment

The Food and Beverage Industry

A powerful food and beverage industry is a major challenge to those who are trying to enact obesity prevention policies and legislative changes. (1,15-17) It aggressively lobbies federal and state legislatures, at least in the U.S., to enact statues prohibiting obesity-related lawsuits against food and beverage companies. (15,18) It also strongly resists legislative and regulatory approaches that encourage healthy eating if they put profits at risk, (18-20) and it seems to invest more resources into confusing consumers than helping them. (21,22) Some food and beverage manufacturers in the U.S. have announced voluntary efforts to improve the nutritional quality of foods, but voluntary efforts to curb food marketing to children have fallen flat. (7)

Read more: food marketing and obesity prevention

The Bottom Line: A Multifaceted Fix to a Complex Problem

It’s clear that turning around the obesity epidemic will require a multifaceted effort. Government, industry, education, urban planning, the media, the food and beverage industry, communities, and individuals all need to get involved.

The fight against smoking has shown us that policy and environmental changes at multiple levels can change social norms and ultimately change people’s behavior. But unlike the fight against smoking, obesity doesn’t have a single “villain” to blame. (8) Food is complicated, tied to cultural and religious traditions. It’s truly essential, and it’s not easily classified as good or bad. (8)

Still, there are many ways to influence public health. Behaviors are affected by organizational practices and policies, educational campaigns, and individual knowledge and skills. (8) Each offers opportunities to make an impact on obesity prevention and leave a legacy of healthy and enduring change.

Without this type of broad effort across multiple sectors of society, obesity will continue to exact an ever-higher toll worldwide—with far-reaching consequences. (5)

References

1. Walls HL, Peeters A, Proietto J, McNeil JJ. Public health campaigns and obesity—a critique. BMC Public Health. 2011;11:136.

2. Mello MM, Studdert DM, Brennan TA. Obesity—the new frontier of public health law. N Engl J Med. 2006;354:2601-10.

3. Lake A, Townshend T. Obesogenic environments: exploring the built and food environments. J R Soc Promot Health. 2006;126:262-7.

4. Homer C, Simpson LA. Childhood obesity: what’s health care policy got to do with it? Health Aff (Millwood). 2007;26:441-4.

5. McKinnon RA, Orleans CT, Kumanyika SK, et al. Considerations for an obesity policy research agenda. Am J Prev Med. 2009;36:351-7.

6. Swinburn BA, Sacks G, Hall KD, et al. The global obesity pandemic: shaped by global drivers and local environments. Lancet. 2011;378:804-14.

7. Levi J, Segal, LM, St. Laurent, R, Kohn, D. F as in Fat 2011: How Obesity Threatens America’s Future. Washington, D.C.: Trust for America’s Health/Robert Wood Johnson Foundation; 2011.

8. Institute of Medicine (IOM). Bridging the Evidence Gap in Obesity Prevention: A Framework to Inform Decision Making. Washington, DC; 2010.

9. Gortmaker SL, Swinburn BA, Levy D, et al. Changing the future of obesity: science, policy, and action. Lancet. 2011;378:838-47.

10. Brennan L, Castro S, Brownson RC, Claus J, Orleans CT. Accelerating evidence reviews and broadening evidence standards to identify effective, promising, and emerging policy and environmental strategies for prevention of childhood obesity. Annu Rev Public Health. 2011;32:199-223.

11. Thow AM, Jan S, Leeder S, Swinburn B. The effect of fiscal policy on diet, obesity and chronic disease: a systematic review. Bull World Health Organ. 2010;88:609-14.

12. Haby MM, Vos T, Carter R, et al. A new approach to assessing the health benefit from obesity interventions in children and adolescents: the assessing cost-effectiveness in obesity project. Int J Obes (Lond). 2006;30:1463-75.

13. Vos T, Carter R, Barendregt J, et al. Assessing Cost-Effectiveness in Prevention (ACE-Prevention). 2006. Accessed August 25, 2011.

14. Moore LV, Diez Roux AV. Associations of neighborhood characteristics with the location and type of food stores. Am J Public Health. 2006;96:325-31.

15. Wang SS, Brownell KD. Public policy and obesity: the need to marry science with advocacy. Psychiatr Clin North Am. 2005;28:235-52.

16. Hawkes C. Regulating and litigating in the public interest: regulating food marketing to young people worldwide: trends and policy drivers. Am J Public Health. 2007;97:1962-73.

17. Swinburn B, Sacks G, Lobstein T, et al. The ‘Sydney Principles’ for reducing the commercial promotion of foods and beverages to children. Public Health Nutr. 2008;11:881-6.

18. Kelley B, Smith JA. Legal approaches to the obesity epidemic: an introduction. J Public Health Policy. 2004;25:346-52.

19. Koplan JP, Brownell KD. Response of the food and beverage industry to the obesity threat. JAMA. 2010;304:1487-8.

20. Sharma LL, Teret SP, Brownell KD. The food industry and self-regulation: standards to promote success and to avoid public health failures. Am J Public Health. 2010;100:240-6.

21. Brownell KD, Koplan JP. Front-of-package nutrition labeling—an abuse of trust by the food industry? N Engl J Med. 2011;364:2373-5.

22. Walls HL, Peeters A, Loff B, Crammond BR. Why education and choice won’t solve the obesity problem. Am J Public Health. 2009;99:590-2.

Cutting out Sugary Drinks for Kids

Two new studies show that drinking fewer sugary drinks in the home or at school can lower fat and body weight gain in teens and children.

In the study of teens by Harvard University researchers, those who drank fewer sugary drinks in the home for one year gained less weight compared to those who did not change their sugary drink intake. Overweight and obese teens who regularly drank sugary drinks were provided a year of home-delivery of sugar-free beverages as well as education and behavioral counseling aimed at decreasing sugar-sweetened beverage consumption. At the end of the year, weight gain was significantly lower in the group that received sugar-free beverages than in the group that did not. However, a follow-up a year later showed that the weight difference between the two groups had become less significant. The findings imply that a long-term habit of cutting back sugary drinks is important for maintaining a healthy weight. An interesting finding is that for Hispanic teens, cutting back on sugary drinks in the home for one year led to a significant decrease in weight gain even after two years. (1)

In the study of normal-weight children, those who drank a cup of a given sugar-free, artificially sweetened drink each day at school gained less fat and weight than those who drank one cup of a sugary drink each day at school. The researchers suggest that the sugar-free group’s reduction in body fat could be an effect of ingesting fewer calories and a decrease in hunger as a result of tempered insulin spikes. “Children in the United States consume on average almost three times as many calories from sugar-sweetened beverages as the amount provided in our trial,” states the study. “We speculate that decreased consumption of such beverages might reduce the high prevalence of overweight in these children.” (2)

The outcomes of the two studies support public health guidelines for limiting sugar-sweetened beverage consumption. While replacing sugary drinks with non-nutritive or artificially-sweetened drinks can potentially help you lose weight, compensating by consuming more calories from other sources can negate this effect. It is not conclusive whether drinking artificially sweetened beverages will truly benefit your health and make you lose weight in the long-term. (3) For now, the best option is to encourage people to develop healthy beverage choices from a young age, whether at school or in the home. Read more about sugary drinks versus diet drinks here (link: https://www.hsph.harvard.edu/nutritionsource/healthy-drinks/sugary-vs-diet-drinks).

(1) Ebbeling CB, Ludwig DS, et al. A Randomized Trial of Sugar-Sweetened Beverages and Adolescent Body Weight. New England Journal of Medicine, 21 Sept 2012.

(2) Ruyter JC, Katan MB, et al. A Trial of Sugar-free or Sugar-Sweetened Beverages and Body Weight in Children. New England Journal of Medicine, 21 Sept 2012.

(3) Gardner C, Lichtenstein AH, et al. Nonnutritive Sweeteners: Current Use and Health Perspectives: A Scientific Statement from the American Heart Association and American Diabetes Association. Circulation, 9 July 2012; 126; 509-519.

Terms of Use

The aim of the Harvard School of Public Health Obesity Prevention Source Web site is to provide timely information about obesity’s global causes, consequences, prevention, and control, for the public, health and public health practitioners, business and community leaders, and policymakers. The contents of this Web site are not intended to offer personal medical advice. You should seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this Web site. The Web site’s obesity prevention policy recommendations are based primarily on a review of U.S. expert guidance, unless otherwise indicated; in other countries, different policy approaches may be needed to achieve improvements in food and physical activity environments, so that healthy choices are easy choices, for all.