Why food policy and obesity policy are not synonymous: the need to establish clear obesity policy in the United States

The impact of obesity on the health of Americans has led public health authorities to describe it as the ‘greatest single threat to public health in this century’.¹ The prevalence of overweight and obesity in adults (⩾20 years) is 69% and 31.8% in children and adolescents (2–19 years).² Diverse and distinct national initiatives have sought to address obesity. These include the First Lady’s Let’s Move Campaign, Healthy People 2010 and 2020, the Institute of Medicine’s plan to measure progress in obesity prevention, the Strategic Plan for the National Institutes of Health Obesity Research and the American Medical Association’s acknowledgement of obesity as a disease at their 2013 annual meeting. Although these initiatives each have merit, the United States has yet to develop comprehensive obesity policy. The US experience differs from other developed countries—notably England, France and Germany—which have developed multi-sector approaches to tackle this disease under coherent national strategies.^{3, 4}

Much of US policy to address obesity is founded upon a widely held belief that obesity is only attributable to excess intake of calories and physical activity deficits. The Scientific Report of the 2015 Dietary Guidelines Committee describes obesity as ‘a persistent, prevalent, preventable health problem,’ and characterizes it as having ‘a nutritional origin.’ Obesity is a complex disease process in which numerous factors such as behavior (for example, diet quality, exercise and sleep), genetics, physiology, psychosocial and transgenerational factors affect energy intake and expenditure.^{5, 6, 7} Individuals may develop obesity when energy intake (that is, feeding) exceeds energy expenditure (that is, basal metabolism, adaptive thermogenesis and physical activity).⁸ As policymakers have denied the intricate nature of obesity, strategies to address obesity largely rely upon food policy. Many statewide and local initiatives have sought to reduce the consumption of sugar sweetened beverages, display nutrition facts in restaurants and increase consumption of fruits and vegetables. Yet, these food policy initiatives, employed on a population level, have yet to produce objectively verifiable effects on obesity rates. For example, efforts to increase access to grocery stores have not improved fruit and vegetable consumption or reduced body mass index,⁹ and the Los Angeles ‘fast food ban’ failed as the rates of persons with overweight and obesity increased during the ban.¹⁰ Although food policy initiatives may have a role in obesity policy, they should be part of a larger policy in which stakeholders from academia, government, industry, technology, law, medicine, public health and education collaborate on ways to reduce obesity rates and consequent health impact.¹¹

National obesity policies in other developed countries provide meaningful points of reference. In England, the primary obesity policy is Healthy Lives, Healthy People: A Call to Action in Obesity in England. In a trans-disciplinary approach, policymakers collaborate with the Obesity Review Group, established to bring together leaders in academics, industry, non-governmental organizations and public health.³ France launched their first obesity policy in 2001. Their current plan, the National Nutrition and Health Programme 2011–2015, is a multi-sector effort involving nine ministries and partners.³ Germany also has a federal cross-sector National Action Plan for the Prevention of Poor Dietary Habits, Lack of Physical Activity, Overweight and Related Disease, known as IN FORM (the German national initiative to promote healthy diets and physical activity). Their five areas of focus include the federal government, federal states and communes, information on health (with particular attention to diet and physical activity), quality of eating away-from-home, and research.³ The ‘multi-sector approach’ is the common thread in the national policies in England, France and Germany. Although these plans are by no means perfect, they do provide reference points which the United States might use to develop a federal obesity policy (Table 1). Objective measures of outcomes from these plans are sparse. Most evaluations have focused on changes in behaviors but there is limited information available on the effectiveness of these national policies on obesity prevalence.^{12, 13} For an example of a national policy on nutrition that has had a measurable impact on health outcomes, one might consider the experience with a multi-sector effort to reduce exceptionally high sodium consumption in Finland that began in the 1970s.¹⁴ This effort involved diverse stakeholders, including the food industry, and produced well-documented reductions in objective biological markers of cardiovascular disease risk. Certainly reduction in the health burden of obesity presents a more complex task, but this experience may offer important insights for more effective national obesity policies.

Table 1 Key factors to consider in the development of federal obesity policy in the United States

Never before in our nation’s history has a chronic disease affected such a large portion of the population. Owing to the tremendous breadth of the problem, strategies must be developed and deployed in innovative ways. Large corporations such as Coca-Cola, McDonald’s and Nestlé, or agribusiness companies such as Cargill and Monsanto will inevitably play a role—either to help advance the work in this field or to impede it. Such non-traditional partners might serve as allies in more effective national efforts to reduce obesity rates.

Evidence suggests some large corporations can have a successful impact on the health of their consumers. Cargill, one of the world’s leading distributors, marketers and processors of agricultural, food, financial and industrial products and the largest privately held company in the United States, underwent a self-initiated strategic re-development of ‘nutrition and health solutions’. Their goal was to improve baseline nutrient levels and deliver health benefits such as disease resistance, therapeutics and wellness through establishing partnerships with technology companies in food applications, health and nutrition.¹⁵

Substantial apprehension is commonly expressed about collaboration with food corporations because of high levels of distrust. Drawing analogies to the tobacco industry, some observers have suggested that the food industry will only frustrate efforts to reduce obesity.¹⁶ Yet recent studies have shown that food corporations might play a significant role in reduction of caloric intake in the United States. The Healthy Weight Commitment Foundation (HWCF), whose members include 16 of the nation’s largest consumer packaged goods (CPG) food and beverage manufacturers, pledged to collectively sell 1 trillion fewer calories in the US marketplace by 2012 (against a 2007 baseline). The 16 HWCF companies collectively sold ~6.4 trillion fewer calories (–10.6%) in 2012 with a total reduction in CPG caloric sales of 99 kcal per capita per day. An objective evaluation of food industry compliance with calorie reduction pledges suggests the food industry could contribute substantially to efforts to improve American health.¹⁷ Successful policies must incorporate diverse perspectives to achieve significant change in obesity in the United States. The historical focus on behavioral efforts to address obesity has produced limited results. Whether at an individual or population level, efforts to change behavioral factors related to obesity have yet to yield substantial changes in obesity prevalence.¹⁸ As the evidence base in obesity medicine grows, better understanding of factors that play a role in obesity will inform policy efforts and ground them in scientific understanding of the disease process.

In no case to date has one policy prevailed as the ‘the solution’ to treat obesity and thus numerous failures along the way are likely. Efforts to reduce the impact of obesity over the last 20 years have focused almost exclusively on changing dietary and physical activity behaviors—either at an individual or at a population level. Little objective evidence for a meaningful impact upon obesity prevalence can be found. We propose that a more complete approach is needed to address the complex physiology of obesity, its transgenerational effects and the importance of diverse stakeholders, including the food industry.