washingtonpost.com
Inertia at the Top
Belated, Patchy Response Further Hamstrung By Inadequate Federal Attention, Experts Say

By Susan Levine and Lori Aratani
Washington Post Staff Writers
Monday, May 19, 2008

The problem at first was that the problem was ignored: For almost two decades, young people in the United States got fatter and fatter -- ate more, sat more -- and nobody seemed to notice. Not parents or schools, not medical groups or the government.

But since the alarm was finally sounded in the late 1990s, the problem has been the country's reaction: a fragmented, inchoate response that critics say has suffered particularly from inadequate direction and dollars at the federal level.

"The sense of this as a national health priority just doesn't come through," said Jeffrey P. Koplan of Emory University, a former director of the Centers for Disease Control and Prevention and chairman of the Institute of Medicine's 2004 study of childhood obesity. The top recommendation of that seminal report was for the government to convene a high-level, interdepartmental task force to guide a coordinated response. No such body has been assembled.

Contrast that with the offensive mounted in European countries: France mandated health warnings on televised food ads. Spanish officials reached agreement with industry leaders on tighter product labeling and marketing as well as reducing fat, salt and sugar in processed foods.

Britain has gone the farthest, restricting food ads on TV programs catering predominantly to children and pulling sweets and sweetened drinks from schools. Eighty-five percent of all grades have at least two hours of physical education a week. The 2011 goal is five hours.

"The whole of the government has signed up," Will Cavendish, director of health and well-being, said at a conference in Washington last month. Britain's Healthy Weight, Healthy Lives program is backed by $600 million in funding over three years.

There's no question that the U.S. epidemic won't be reversed by federal fiat alone; responsibility lies also with individuals, the health community, corporations, local governments and others. Still, health experts insist that strong leadership from the top is crucial. They see the Bush administration falling short of expectations and few real champions in Congress.

"This probably will contribute more to our health-care bill than anything else over the next 50 years," Koplan said.

The first signs of trouble appeared in the late 1970s as rates of overweight that had been relatively stable for years started to rise. In retrospect, they were reflecting societal, technological and policy shifts that would turn the youngest generation into the heaviest to date.

For starters, with more women working outside the home, families were eating more takeout or processed food. Spurred by the profit margins of volume production, fast-food restaurants pushed larger portions. Gadgets such as remote TV controls and video games meant children were planted for longer periods in front of televisions and computers. And on and on.

Through the 1990s, the waistline expansion accelerated. On campuses, once-rare vending machines multiplied as administrators signed exclusive contracts giving their schools a share of sales; the money was considered essential for band uniforms, sports equipment and other unfunded extras.

Soon, soda and chips were a ubiquitous part of millions of students' days. That it happened as many school systems minimized recess and physical education proved disastrous.

Federal officials defend their record, saying they have worked "resolutely and steadily" in the past eight years to combat obesity. They calculate that the Department of Health and Human Services has spent $4.5 billion on prevention, treatment and research since fiscal 2003, although programs that broadly address chronic disease are part of the total. Obesity-specific initiatives include Web-based public education campaigns, public service announcements, new dietary guidelines and, coming by late fall, first-time guidelines on physical activity.

Acting Surgeon General Steven K. Galson declared childhood obesity his main priority upon taking office last year and began traveling this spring to highlight jurisdictions that have been especially engaged. As head of an HHS council on the subject, he has received "incredible support" in focusing the department's attention, he said.

A White House spokeswoman said President Bush is equally concerned. Emily Lawrimore noted his speeches about fitness and the need for parents to be role models. He met with corporate executives last year to encourage advertising changes that would help youths make better food choices and stay active. "He thinks childhood obesity is a serious problem in our country that places a tremendous burden on American families, our economy and future generations," she said.

Yet the president has proceeded on often contradictory tracks. Although he launched an expansive HealthierUS project in 2002, he has tried to kill or cut some prominent federal efforts aimed at overweight children and teens. His 2009 budget, for example, would end a $75 million program to help schools and communities expand physical-education offerings and purchase equipment. It would maintain at current levels obesity grants to states, which have enough money to benefit just half the country.

Critics say the White House has not pushed the issue much beyond personal responsibility. They say the administration and lawmakers are not aggressively pressing for industry or food policy changes.

Only in December did the U.S. Department of Agriculture modify the Women, Infants and Children nutrition program to assist low-income families in buying fresh fruits and produce. The addition was blocked for a decade by politics and by industry sectors worried that WIC's food packages would contain less milk, eggs and cheese. Yet those traditional subsidies have helped to tip the scales. Nearly half of toddler and preschool WIC recipients are overweight or obese in some communities.

And the USDA's school breakfast and lunch program continues to sell whole milk and sweetened flavored milk. Mexico has eliminated both from its poverty programs and intends to do the same in schools.

Into the breach have stepped foundations committing hundreds of millions of dollars. State and local governments have also stepped up, passing myriad measures since 2005 to strengthen school nutrition standards and add recess and physical-education requirements. From churches and community centers to Scout troops, organizations large and small are trying to again get children moving or to teach them about better eating.

Influential groups have worked with food companies to limit marketing and availability of certain products to younger children. In the first major pact, the beverage industry acceded to removing many soft drinks from campus vending machines by the 2009-10 school year. "They understand they're under siege," said Kenneth R. Stanton, an assistant professor of finance at the University of Baltimore.

Stanton has become known for the UB Obesity Report Card, which he and colleagues first released in 2003. Few legislatures were debating anti-obesity bills then, much less enacting them. Three years later, Stanton found that more than half the states had approved panels on obesity, and a dozen had agreed to test students' height and weight to track body mass index.

But advocates say the limited power of persuasion and lesser state and local resources make forceful federal measures imperative. Jeffrey Levi urges an all-hands mobilization similar to what the government has demanded in advance of a possible flu pandemic.

"Obesity has potentially as great, if not greater, an impact on public health," said Levi, executive director of Trust for America's Health.

The USDA plays a central and often inconsistent role on the issue. It is the department behind the pyramid that shows Americans how fruits and vegetables should be consumed more than fatty foods, yet it supports companies' development of products that flout those guidelines. Pizza Hut's stuffed-crust pizza is among critics' ready examples.

"The conflict of interest is inherent in the USDA," said Kelly Brownell, professor of psychology at Yale University and co-founder of the Rudd Center for Food Policy and Obesity. "Their main task is to promote agriculture and food, and their secondary task is to establish nutrition policy."

Congress has paid tepid attention to childhood obesity and repeatedly has rejected efforts of Sen. Tom Harkin (D-Iowa) to establish national standards for what is sold in schools outside of USDA-regulated hot meals. And a measure by Sen. Edward M. Kennedy (D-Mass.), to create a federal commission on childhood obesity prevention, among other actions, wasn't even debated.

A congressional request did prompt the Federal Trade Commission to order food and beverage companies to provide details on their activities and expenditures on food marketing to youth. A report should be public by fall. But whatever the commission recommends will not go further than self-regulation. Three decades after the FTC proposed a ban on TV ads for sugary, child-targeted foods that might cause dental problems, it remains severely restricted in any additional restraints it is allowed to impose.

By Congress.

Tomorrow: In Metro {vbar} Half the children in some District wards where produce is not readily available are overweight. Suburbs seem to have it all but are heavy anyway. In Health {vbar} Inside a controversial "fat school." In KidsPost {vbar} An unusual fitness plan in Silver Spring.

View all comments that have been posted about this article.

© 2008 The Washington Post Company