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DOI: 10.1111/j.1467-3010.2012.01974.x

Obesity prevention: snapshot of US-based efforts

As a regional editor of the Nutrition Bulletin it gives me great pleasure to write the editorial for this issue. Obesity is always a topic of great concern to those in the nutrition world, having huge implications for our health and longevity across the globe. It is evident that something needs to change to alter the course of continually rising rates of overweight and obesity around the world. As such, it is useful to look at programmes intended to prevent and decrease obesity globally and to assess the cost and effectiveness of such programmes as more evidence becomes available. The United States (US) Centers for Disease Control and Prevention (CDC) reports that over the past 20 years there has been a dramatic increase in obesity in the US. More than one-third of US adults are obese (35.7%), while the rate of childhood obesity (ages 219) has tripled since 1980 (CDC 2010). According to the American Heart Association, about 1 in 3 kids in the US are overweight or obese. According to a report issued by the Organization for Economic Co-operation and Development out of Paris, more than half of European adults are overweight or obese (European Commission Eurostat 2011). Obesity rates have doubled in the past 20 years for the 27 member states of the European Union. It is estimated that 1 in 7 children in these member states are obese. The disparity among countries is signicant, however. The prevalence of obesity is less than 10% in Romania and Italy, but greater than 20% in the UK, Ireland and Malta. A study in the American Journal of Preventive Medicine (Finkelstein et al. 2012) was reported at the recent Weight of the Nation Conference in Washington, DC. Researchers predict that the percentage of obese Americans will rise from 36% of the adult population today to 42% by 2030. Amidst this stark wake-up call the good news, however, is that the rate of increasing obesity in adult Americans has slowed down somewhat compared to that which has been recorded over the last 30 years.

Calorie labelling in the US

Many health experts agree that there is an opportunity to devise strategies to use sales and marketing techniques to promote the adaptation of healthy habits. As a result, point-of-purchase programmes, such as calorie labelling, are being examined in real-world settings across the globe. In the US, calorie labelling on menus is just one of the many policy approaches being implemented and studied to combat the increasing prevalence of overweight and obesity (Mokdad et al. 1999, 2000). Because calorie labelling has been introduced in only a handful of cities in the US, one may wonder if this has really made consumers in those areas make healthier choices. Has it had an effect on obesity rates in the US? And if not, what other programmes or interventions have had successes? Menu labelling as a partial solution to obesity in the US stems from the idea that more of Americans daily calories are coming from food purchased out of home; food that typically contains more calories, fat and sodium than home-prepared foods (Swartz et al. 2011). Food away from the home now accounts for over 30% of daily caloric intake and 50% of yearly food spending in the US (Swartz et al. 2011). New York City was the rst to introduce calorie labelling. The New York City Health Departments regulation that required quick-service chain restaurants with more than 15 outlets to post calorie counts on menu boards went into effect on 19 July 2008. By 2009, similar labelling was required in localities such as California, Oregon and Maine, as well as more than a dozen other US cities. Strong opposition from the National Restaurant Association, which represents, educates and promotes the restaurant industry, suggests that calorie labelling was not voluntary. Calorie labelling in restaurants has also been the topic of several research studies since its introduction in 2008. These studies mainly address whether the initiative has improved consumers purchases. A systematic review of the literature suggested that, in both real-world and experimental settings in the US, calorie menu labelling on quick-service restaurant menus has no effect or only a modest effect on calorie ordering and consumption.

Correspondence: Kristen Ciuba, Nutrition Consultant, 122 13th Street, SE, Washington, DC 20003, USA. E-mail: kristenciuba@gmail.com

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The authors concluded that, the current evidence suggests that calorie labelling does not have the intended effect of decreasing calorie purchasing or consumption (Swartz et al. 2011). One of the strongest studies was performed by Finkelstein et al. (2011) and looked at whether calorie labels added to chain restaurant labels in King County, Washington State, affected total monthly transactions and calories per transaction in a real-world setting. The study included 21 randomly selected fast-food restaurants. The authors found no signicant difference in sales volume between periods with or without calorie postings. Longer-term, more rigorous studies may in fact be needed to investigate whether long-term exposure to such calorie labelling has an effect on overweight and obesity rates. In addition, further questions must be addressed, including whether calorie labelling has caused restaurants to reduce the caloric density of foods and meals, as well as whether or not the public have gained a greater knowledge of calories in foods and diets, which could in turn improve health and reduce rates of obesity.

availability of low-fat milk and fruit with popular kids meals. The restaurant chain Darden has also made lowfat milk and fresh produce a standard in its kids meals. School food Recently, strides have also been made on the school food front, where Mrs. Obama has placed a particular emphasis on stopping the growing problem of childhood obesity. In late 2010, the Healthy, Hunger-Free Kids Act, as passed in Congress, increased funding for school breakfasts and lunches above the ination rate for the rst time in 30 years. The Act also gave the United States Department of Agriculture (USDA) control of nutrition standards for all foods sold on school property including those in vending machines and it made the provision of free or reduced-price school meals to children less cumbersome, ensuring that tens of thousands more children will get the healthy food they need. The nal rule for the USDAs Healthy, HungerFree Kids Act was released earlier this year and sets standards for critical improvements to school meals, including: ensuring students are offered both fruits and vegetables every day of the week; substantially increasing offerings of whole-grain-rich foods; offering only fat-free or low-fat milk varieties; limiting calories based on the age of children being served, to ensure proper portion size; increasing the focus on reducing the amounts of saturated fat, trans fats and sodium (USDA 2012). Physical activity The Lets Move campaign is also taking on increasing physical activity with the aim of enhancing opportunities for school-age children to be physically active. As such, a partnership with the US Olympic Committee was just announced and will provide kids in the US with new opportunities such as swimming lessons, gymnastics clinics, free memberships at bike racing tracks and much more (www.letsmove.gov). This is extremely important and can be a springboard for programmes in the US and globally to engage children and young adults in physical activity as it is becoming increasingly evident that excessive sitting time is a health risk in and of itself (J. Blundell & S. J. H. Biddle unpublished data).

Other US initiatives
In light of the current statistics and research on obesity, efforts are also underway to investigate other avenues and point-of-sale programmes that may encourage healthier food choices in the US. Not surprisingly, public health experts are focusing on obesity prevention, noting that the best way to tackle the obesity crisis is to prevent people from becoming obese in the rst place. Given the nding from the landmark Bogalusa Heart Study that 77% of obese children become obese adults there is a particular emphasis on children (Freedman et al. 2001).

Lets Move campaign

Michele Obamas Lets Move campaign (www.letsmove. gov), launched on 9 February 2010, aims to solve the epidemic of childhood obesity within a generation. Restaurants meals One of the recommendations of the Lets Move campaign is that, restaurants and vending machines should display calorie counts of all items offered (FDA 2011). So far, there is not much evidence across the US that this recommendation has been followed although some positive changes are evident. Healthier options are now available in many fast-food restaurants, such as the

Grow your own food

At the opposite end of the spectrum, being smaller in size and closer reaching, there are grass-roots nutrition

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programmes cropping up in cities across the US. For example, FarmFresh Market is a Washington, DCbased organization whose mission is to educate the public about food and environmental issues, and to provide vital economic opportunities for local farmers. Through grants to local schools, a programme was born called FoodPrints. The FoodPrints (www.farmfreshmarket.org) programme builds an edible schoolyard garden and integrates the garden into the school curriculum (FoodPrints 2011). Elementaryage schoolchildren who participate in the programme as part of their studies learn about where their food comes from and how important it is to eat fresh, nutritious, seasonal foods. FoodPrints also teaches important life skills through project-based learning that includes hands-on experiences in the garden and the teaching kitchen (www.farmfreshmarket.org). The name FoodPrints is a spin-off term taken from the carbon footprint terminology. Through FoodPrints, children learn about their food prints like a footprint in the garden, a hand print in the soil and ngerprints in the kitchen which are essential to growing, preparing and eating fresh, seasonal foods that are good for personal health, growth and development, as well as the health of our planet. This approach to nutrition education with children is creative, engaging and positive, albeit somewhat more difcult to evaluate because formal research and evaluations are not in place. So far, unfortunately, neither weight nor body mass index data are recorded in US public schools, but following these measurements in a cohort over time may help us understand whether this type of programme is useful in lowering overweight and obesity rates in elementary schoolchildren. In conclusion, overcoming or halting obesity in the US will likely be the result of a combination of many efforts to include a variety of health programmes and preventative campaigns. Initiating behaviour change include workplace wellness programmes, educational campaigns to promote healthier eating and increase physical activity, as well as more effective weight loss programmes could help. A special emphasis on children and preventative measures across the population is prudent. Providing greater access to healthy foods both at school and in local communities is a way to promote positive behaviour change and can be brought about both from the top down, government to consumer, as well as from the bottom up (e.g. growing fresh fruits and vegetables in school gardens). Countries around the globe can learn from the US and begin programmes now to focus on improving kids eating habits by providing access to healthier foods and

increasing physical activity in school-age children so as not to nd themselves in the same situation in years to come. For the time being, the US will see obesity rates rise, even if the growth is slowed. Success will be seen if and when the next US generation proves to be healthier and experience lower rates of obesity and obesityrelated chronic diseases. Kristen Ciuba Nutrition Consultant Washington, DC, USA

Blundell J & Biddle SJH (unpublished data) Healthy eating and physical activity: moving towards successful behaviour change the great north run think tank 2010. CDC (Centers for Disease Control and Prevention) (2010) Overweight and obesity. Available at: http://www.cdc.gov/obesity/data/ index.html (accessed 29 May 2012). European Commission Eurostat (2011) Overweight and obesity BMI statistics. Available at: http://epp.eurostat.ec.europa.eu/ statistics_explained/index.php/Overweight_and_obesity__BMI_statistics (accessed 29 May 2012). FDA (Food and Drug Administration) (2011) FDA proposes draft menu and vending machine labelling requirements, invites public to comment on proposals. Available at: http://www.fda.gov/ NewsEvents?Newsroom/PressAnnouncements/ucm249474.htm (accessed 29 May 2012). Finkelstein EA, Strombotne KL, Chan NL et al. (2011) Mandatory menu labeling in one fast-food chain in King County, Washington. American Journal of Preventive Medicine 40: 1227. Finkelstein EA, Khavjou OA, Thompson H et al. (2012) Obesity and severe obesity forecasts through 2030. American Journal of Preventive Medicine 6: 56370. FoodPrints (2011) Fresh farm markets. Available at: http://www. freshfarmmarket.org/programs/foodprints.php (accessed 29 May 2012). Freedman DS, Khan LK, Dietz WH et al. (2001) Relationship of childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa heart study. Pediatrics 108: 7128. Mokdad AH, Serdula MK, Dietz WH et al. (1999) The spread of the obesity epidemic in the United States, 19911998. Journal of the American Medical Association 282: 151922. Mokdad AH, Serdula MK, Dietz WH et al. (2000) The continuing epidemic of obesity in the United States. Journal of the American Medical Association 284: 16501. Swartz JJ, Braxton D & Viera AJ (2011) Calorie menu labeling on quick-service restaurant menus: an updated systematic review of the literature. International Journal of Behavioral Nutrition and Physical Activity 8: 13542. USDA (United States Department of Agriculture) (2012) USDA unveils historic improvements to meals served in Americas schools. Available at: http://www.fns.usda.gov/cga/PressReleases/ 2012/0023.htm (accessed 12 June 2012).

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