Patchy progress on obesity prevention: emerging examples, entrenched barriers, and new thinking.

Despite isolated areas of improvement, no country to date has reversed its obesity epidemic. Governments, together with a broad range of stakeholders, need to act urgently to decrease the prevalence of obesity. In this Series paper, we review several regulatory and non-regulatory actions taken around the world to address obesity and discuss some of the reasons for the scarce and fitful progress. Additionally, we preview the papers in this Lancet Series, which each identify high-priority actions on key obesity issues and challenge some of the entrenched dichotomies that dominate the thinking about obesity and its solutions. Although obesity is acknowledged as a complex issue, many debates about its causes and solutions are centred around overly simple dichotomies that present seemingly competing perspectives. Examples of such dichotomies explored in this Series include personal versus collective responsibilities for actions, supply versus demand-type explanations for consumption of unhealthy food, government regulation versus industry self-regulation, top-down versus bottom-up drivers for change, treatment versus prevention priorities, and a focus on undernutrition versus overnutrition. We also explore the dichotomy of individual versus environmental drivers of obesity and conclude that people bear some personal responsibility for their health, but environmental factors can readily support or undermine the ability of people to act in their own self-interest. We propose a reframing of obesity that emphasises the reciprocal nature of the interaction between the environment and the individual. Today's food environments exploit people's biological, psychological, social, and economic vulnerabilities, making it easier for them to eat unhealthy foods. This reinforces preferences and demands for foods of poor nutritional quality, furthering the unhealthy food environments. Regulatory actions from governments and increased efforts from industry and civil society will be necessary to break these vicious cycles.

Mobilisation of public support for policy actions to prevent obesity.

Public mobilisation is needed to enact obesity-prevention policies and to mitigate reaction against their implementation. However, approaches in public health focus mainly on dialogue between public health professionals and political leaders. Strategies to increase popular demand for obesity-prevention policies include refinement and streamlining of public information, identification of effective obesity frames for each population, strengthening of media advocacy, building of citizen protest and engagement, and development of a receptive political environment with change agents embedded across organisations and sectors. Long-term support and investment in collaboration between diverse stakeholders to create shared value is also important. Each actor in an expanded coalition for obesity prevention can make specific contributions to engaging, mobilising, and coalescing the public. The shift from a top-down to a combined and integrated bottom-up and top-down approach would need an overhaul of current strategies and reprioritisation of resources.

A Transdisciplinary Approach to Public Health Law: The Emerging Practice of Legal Epidemiology.

Public health law has roots in both law and science. For more than a century, lawyers have helped develop and implement health laws; over the past 50 years, scientific evaluation of the health effects of laws and legal practices has achieved high levels of rigor and influence. We describe an emerging model of public health law that unites these two traditions. This transdisciplinary model adds scientific practices to the lawyerly functions of normative and doctrinal research, counseling, and representation. These practices include policy surveillance and empirical public health law research on the efficacy of legal interventions and the impact of laws and legal practices on health and health system operation. A transdisciplinary model of public health law, melding its legal and scientific facets, can help break down enduring cultural, disciplinary, and resource barriers that have prevented the full recognition and optimal role of law in public health.

State and municipal innovations in obesity policy: why localities remain a necessary laboratory for innovation.

Municipal and state governments are surging ahead in obesity prevention, providing a testing ground for innovative policies and shifting social norms in the process. Though high-profile measures such as New York City's soda portion rule attract significant media attention, we catalog the broader array of initiatives in less-known localities. Local innovation advances prevention policy, but faces legal and political constraints-constitutional challenges, preemption, charges of paternalism, lack of evidence, and widening health inequalities. These arguments can be met with astute framing, empirical evidence, and policy design, enabling local governments to remain at the forefront in transforming obesogenic environments.

Policies for healthier communities: historical, legal, and practical elements of the obesity prevention movement.

The U.S. population is facing an obesity crisis wrought with severe health and economic costs. Because social and environmental factors have a powerful influence over lifestyle choices, a national obesity prevention strategy must involve population-based interventions targeted at the places where people live, study, work, shop, and play. This means that policy, in addition to personal responsibility, must be part of the solution. This article first describes the emergence of and theory behind the obesity prevention movement. It then explains how government at all levels is empowered to develop obesity prevention policy. Finally, it explores eight attributes of a promising state or local obesity prevention policy and sets the obesity prevention movement in the context of a larger movement to promote healthy communities and prevent chronic disease.

The Racialized Marketing of Unhealthy Foods and Beverages: Perspectives and Potential Remedies.

We propose that marketing of unhealthy foods and beverages to Black and Latino consumers results from the intersection of a business model in which profits come primarily from marketing an unhealthy mix of products, standard targeted marketing strategies, and societal forces of structural racism, and contributes to health disparities.

A cross-sectional prevalence study of ethnically targeted and general audience outdoor obesity-related advertising.

CONTEXT: Commercial marketing is a critical but understudied element of the sociocultural environment influencing Americans' food and beverage preferences and purchases. This marketing also likely influences the utilization of goods and services related to physical activity and sedentary behavior. A growing literature documents the targeting of racial/ethnic and income groups in commercial advertisements in magazines, on billboards, and on television that may contribute to sociodemographic disparities in obesity and chronic disease risk and protective behaviors. This article examines whether African Americans, Latinos, and people living in low-income neighborhoods are disproportionately exposed to advertisements for high-calorie, low nutrient-dense foods and beverages and for sedentary entertainment and transportation and are relatively underexposed to advertising for nutritious foods and beverages and goods and services promoting physical activities. METHODS: Outdoor advertising density and content were compared in zip code areas selected to offer contrasts by area income and ethnicity in four cities: Los Angeles, Austin, New York City, and Philadelphia. FINDINGS: Large variations were observed in the amount, type, and value of advertising in the selected zip code areas. Living in an upper-income neighborhood, regardless of its residents' predominant ethnicity, is generally protective against exposure to most types of obesity-promoting outdoor advertising (food, fast food, sugary beverages, sedentary entertainment, and transportation). The density of advertising varied by zip code area race/ethnicity, with African American zip code areas having the highest advertising densities, Latino zip code areas having slightly lower densities, and white zip code areas having the lowest densities. CONCLUSIONS: The potential health and economic implications of differential exposure to obesity-related advertising are substantial. Although substantive legal questions remain about the government's ability to regulate advertising, the success of limiting tobacco advertising offers lessons for reducing the marketing contribution to the obesigenicity of urban environments.

Building the Legal Capacity of the Public Health Workforce: Introducing the Public Health Law Academy.

Knowledge of the law and its impact on health outcomes is increasingly important in public health practice. The CDC's Public Health Law Academy helps satisfy this need by providing online trainings, facilitator toolkits, and legal epidemiology tools to aid practitioners in learning about the law's role in promoting public health.

Legal risks to employers who allow smoking in the workplace.

There is mounting evidence that documents the dangers of exposure to secondhand smoke, including in the workplace. In states that permit workplace smoking, employers face significant legal risks from employees who are exposed to secondhand smoke on the job. Employers have been held liable for employee exposure to secondhand smoke in numerous cases, including those based on workers' compensation, state and federal disability law, and the duty to provide a safe workplace. Given this liability risk, employers should voluntarily adopt smoke-free workplace policies. Such policies do more than fulfill an employer's legal obligation to provide a safe workplace; they also reduce the risk of litigation, potentially reduce workers' compensation premiums, and protect employees from harm.

Local venues for change: legal strategies for healthy environments.

Mounting evidence documents the extraordinary toll on human health resulting from the consumption of unhealthy food products and physical inactivity. In response to America's growing obesity problem, local policymakers have been looking for legal strategies that can be adopted in their communities to encourage healthful behaviors. In order to provide practical tools to policymakers, this article examines four possible venues for local policy change to improve the health of a community: (1) the school environment (2) the built environment (3) community facilities and (4) the point of sale environment. Finally, the article examines the use of taxes or fees as a means of paying for nutrition policy work as well as potentially reducing the consumption of unhealthy products. This article illustrates that local laws and policies can be a valuable tool in changing a community's environment in order to improve nutritional options and increase opportunities for physical activity.

Tobacco use: the impact of prices.

Cigarette smoking continues to be a leading cause of death in the United States, imposing substantial measurable costs to society. Smoking killed over 440,000 people in the United States each year during the period 1995-1999. If current smoking trends continue, over 5 million people currently younger than 18 will die prematurely from tobacco-related diseases. Increases in excise taxes have been shown to be effective in reducing smoking among youth. However, the adoption of tax increases in any jurisdiction is susceptible to many challenges. Furthermore, smuggling of tobacco products and sales of tobacco products over the Internet threaten the effectiveness of tobacco tax increases. This article discusses the effectiveness of excise tax increases on prevention and reduction of smoking. It also discusses factors that influence the legislative adoption of such increases. Finally, it examines potential threats to the use of tobacco taxes as a prevention tool.

Reducing childhood obesity through U.S. federal policy: a microsimulation analysis.

BACKGROUND: Childhood obesity prevalence remains high in the U.S., especially among racial/ethnic minorities and low-income populations. Federal policy is important in improving public health given its broad reach. Information is needed about federal policies that could reduce childhood obesity rates and by how much. PURPOSE: To estimate the impact of three federal policies on childhood obesity prevalence in 2032, after 20 years of implementation. METHODS: Criteria were used to select the three following policies to reduce childhood obesity from 26 recommended policies: afterschool physical activity programs, a $0.01/ounce sugar-sweetened beverage (SSB) excise tax, and a ban on child-directed fast food TV advertising. For each policy, the literature was reviewed from January 2000 through July 2012 to find evidence of effectiveness and create average effect sizes. In 2012, a Markov microsimulation model estimated each policy's impact on diet or physical activity, and then BMI, in a simulated school-aged population in 2032. RESULTS: The microsimulation predicted that afterschool physical activity programs would reduce obesity the most among children aged 6-12 years (1.8 percentage points) and the advertising ban would reduce obesity the least (0.9 percentage points). The SSB excise tax would reduce obesity the most among adolescents aged 13-18 years (2.4 percentage points). All three policies would reduce obesity more among blacks and Hispanics than whites, with the SSB excise tax reducing obesity disparities the most. CONCLUSIONS: All three policies would reduce childhood obesity prevalence by 2032. However, a national $0.01/ounce SSB excise tax is the best option.

If sugar is addictive what does it mean for the law?

Newly emerging links between sugar and addiction raise challenging issues for public health policy. What was once a naturally occurring food ingredient is now a highly concentrated food additive. If foods containing artificially high levels of sugar are capable of triggering addictive behaviors, how should policymakers respond? What regulatory steps would be suitable and practical? This paper explores the concept and definition of addiction and presents evidence of the addictive potential of sugar. It also explores the legal implications if sufficient evidence demonstrates that sugar is indeed addictive.