REDUCING OBESITY
Policy Strategies from the Tobacco Wars
Carolyn L. Engelhard, MPA
Assistant Professor & Health Policy Analyst
University of Virginia School of Medicine
February 1, 2011
The growing prevalence of obesity over time
Obesity Trends* Among U.S. Adults
BRFSS, 1986
No Data
<10%
10%–14
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
Obesity Trends* Among U.S. Adults
BRFSS, 1987
No Data
<10%
10%–14
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
Obesity Trends* Among U.S. Adults
BRFSS, 1988
No Data
<10%
10%–14
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
Obesity Trends* Among U.S. Adults
BRFSS, 1990
No Data
<10%
10%–14
15%–19%
20%–24%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 1991
No Data
<10%
10%–14
15%–19%
20%–24%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 1992
No Data
<10%
10%–14
15%–19%
20%–24%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 1993
No Data
<10%
10%–14
15%–19%
20%–24%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 1995
No Data
<10%
10%–14
15%–19%
20%–24%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 1996
No Data
<10%
10%–14
15%–19%
20%–24%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 1997
No Data
<10%
10%–14
15%–19%
20%–24%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 1998
No Data
<10%
10%–14
15%–19%
20%–24%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2000
No Data
<10%
10%–14
15%–19%
20%–24%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2001
No Data
<10%
10%–14
15%–19%
20%–24%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2002
No Data
<10%
10%–14
15%–19%
20%–24%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2004
No Data
<10%
10%–14
15%–19%
20%–24%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2005
No Data
<10%
10%–14
15%–19%
20%–24%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2006
No Data
<10%
10%–14
15%–19%
20%–24%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Source: CDC Behavioral Risk Factor Surveillance Summary; http://aps.nccd.cdc.gov/brfss
25%–29%
≥30%
More than 1 in 3
adults in the U.S.
were obese by 2008
F as in Fat, 2009 http://healthyamericans.org/reports/obesity2009/Obesity2009Summary.pdf; National Center for Health Statistics, 2008
U.S. most obese country in the world
45% of U.S. adults are projected to be obese this year
https://www.mckinseyquarterly.com/PDFDownload.aspx?ar=2687
Consequences of Obesity - Adults
For the first time since the
Civil War, average life span
may shrink because of
obesity-related conditions

Obesity is related to 20 chronic
illnesses and results in 112,000
deaths/year in U.S. (2.6M globally)

U.S. spends $147 billion/year to
treat obesity

In the U.S., every point of BMI >30
adds $300 in per capita HC costs

U.S. would save $200 billion/year if
we weighed what we did in 1987

50% of obesity-related treatments
paid for by Medicare or Medicaid
Consequences of Obesity - Kids
• 10 million children and
adolescents are obese
• The average 10 year
old weighed 77 lbs in
1963; today 88 lbs
• 25% of all vegetables eaten in U.S.
are french fries or chips
• One out of four kids eat fast food at
least once a day
• Overweight adolescents have a 70%
chance of becoming an obese adult
Source: National Center for Health Statistics, 2006; Obesity in childhood is defined as BMI at 95 th percentile or above
Consequences of Obesity – Kids and Sugared Drinks
 Sugared
beverages are the No. 1
source of calories in the
American diet, representing 7%
for adults and 10% for children
and teenagers
 190 cal/day/capita come from
sugared beverages -- 120 calories
more than in late 1970s
 Risk of becoming obese
increases
by 60% for pre-teens for every
additional serving of sugarsweetened beverage per day
http://graphics8.nytimes.com/images/2010/02/14/weekinreview/14bittmann-grfk/14bittmann-grfk-popup.jpg
History of the success of tobacco control

Past 45 yrs, smoking rates have fallen -- 42.4% to 19.8% in 2007

In 1964, Surgeon General Luther Terry appointed committee:
Cigarette smoking is a health hazard of sufficient importance in the US to
warrant appropriate remedial action.

What worked?
 Most important, according to WHO: excise taxes
 Broadcast bans
 Public information campaigns
 Banned smoking in mainly indoor places
 Encouraged treatment modalities such as nicotine patches
 Measures to prevent youth from accessing tobacco
Lessons from other countries
Graphic, front-of-package labels cut Canadian tobacco
use by 5% in one year, the largest one year drop in a
decade
Similarities of tobacco and obesity
 Chronic disease and premature death
 Significant health care costs
 History of aggressive marketing
 Disproportionately represented in lower socio-economic
strata
 Social stigma
 Same neurological pathways involved in addiction
 Difficult to treat
Difference #1: Exercising can compensate for
overeating , somewhat
• 82% of obesity
from excess
calories
• 18% by lack of
exercise
• Adolescent
physical activity
stable over time
• Obesity the result
of overeating
rather than too
little exercise
Difference #2: Only some food is unhealthy
Researchers at Oxford University in UK developed a numerical nutrient
“score” balancing a 100 gram serving of a food’s risky elements – calories,
saturated fat, salt, and sugar – against the food’s nutritional benefits – fruit
and vegetable content, fiber, and protein
Used in UK, Australia, and New Zealand to ban advertising
Policy Interventions from the “Tobacco
Wars” #1 : Advertising Bans

A study of 22 OECD countries found that comprehensive bans on
tobacco advertising results in a 5-7% reduction in tobacco use

Food industry spends more on advertising than any other industry
-- $30 Billion ($10B on kids)

Children and youth view 12-21 commercials/day for snack foods
 More than 85% are for fattening food
 1/7th to 1/3rd of obesity in kids linked to food ads

Banning fast food advertising would reduce the number of
overweight children by 18% and teenagers by 14%
Policy Interventions from the “Tobacco Wars” #2 :
Clear and simple labeling

Half of American food budget spent on meals/snacks outside home
 33% of calories are from fast food restaurants
 Restaurant fast food consumption = 800 more calories per day
 Fast food patrons underestimate calories by half
In
restaurant chains above
a certain size, calories are
required on menus and
menu boards in
Philadelphia, NYC,
California, Maine,
Massachusetts, and Oregon
(nationwide beginning in 2011)
Policy Interventions from the “Tobacco Wars” #3:
Front-of-package “signpost” labeling
 Current
Australia
nutrition
consumers
“fact5xbox”
as likely
on foods
to identify
can
be
healthy
confusing
foodstow/
consumers
traffic light labels
use
front of
package
 Other
Tesco countries
stores (UK)
showed
a 41%
drop in
signpost
labels
unhealthy
food purchases after implementing
“Front of Package” signpost system

The FDA is considering moving to a green,
yellow, red “dot” system on foods
Policy Interventions from the “Tobacco Wars” #4:
Taxing fattening food
Sugar, rum and tobacco are commodities which
are nowhere necessities of life, which are
become objects of almost universal
consumption , and which are therefore
extremely proper subjects of taxation.
Adam Smith, Wealth of Nations, 1776
The UK has a 17.5% tax on sugared and high-fat foods, France
19.6%, and Canada 5%
Reasons to tax unhealthy foods like
sugared beverages

Reduce consumption – 10% (11 gal) w/ penny per ounce

Raise revenue – same penny = $10B/yr; $150B/10 yrs

Send message about dangers of fattening food

Correct market failure of externalities – costs borne by
taxpayers

Enact personal responsibility – accountability for extra
costs
Reasons against taxing unhealthy foods
Disadvantages low income households
 Inherent regressivity of the tax
 Lack of access to affordable healthy food in some lowincome communities; 5% of Americans have no car and
live > ½ mile away from supermarket
 Price – the big factor
– Fattening food is cheaper, per calorie. $10 will buy 2 pkg of
organic blueberries or a week’s worth of Mac and cheese
Tax subsidies for healthy foods

Taxes could be targeted to:
 Increase food stamp allotment for fruits and vegetables
 Support community-based initiatives to bring healthy,
affordable food to low-income communities

Studies suggest that lower-priced fruits and vegetables
will increase consumption of healthy foods and lower
BMI for low-income kids

Revenues could subsidize health coverage for lowincome people who lack health insurance
Are food taxes politically viable?

40 states have modest taxes on sugared beverages and snacks

Although anti-tax, Americans may support taxes for specific reasons
KFF Tracking Poll, June 2009
53% favored tax on
sugary drinks to finance
reform, but increased to
83% support with “raise
money for health care
reform while also tackling
the health problems that
stem from being
overweight”
What we proposed in our study: new taxes
10% tax on Fattening Foods* as classified by the UK model
* According to the UK “Rayner” model, 33% of foods would be subject to
taxation based on their score of “less healthy”; we derived a 0.931 “own
price elasticity” (the % by which consumption decreases in response to a 1%
increase in price of the food) when calculating consumption post-tax
What we proposed in our study: food subsidies
For even more progress* reducing obesity, we combined the tax
with a 10% subsidy to lower the cost of fruits and vegetables
*Research from the UK suggests that a combination of taxes on unhealthy foods
plus subsidies for healthy foods results in healthy eating consumption behavior
What we proposed in our study: food labeling
After one year, red items
decreased 5.3%, yellow
increased 30.7%, and green
rose 16.5%
What we proposed in our study: marketing changes
 50 countries regulate and/or
ban unhealthy food
advertising aimed at children
 In the U.S., a comprehensive
ban would confront a
constitutional challenge, but
restricting ads would help
 Some cities have used pro-
active marketing campaigns to
educate the public about the
dangers of unhealthy foods
http://cityroom.blogs.nytimes.com/2009/08/31/new-salvo-in-citys-war-on-sugary-drinks/?scp=1&sq=soda%20fat%20sewell&st=cse
Conclusion: policy and politics

Recent decades’ increase in obesity was not caused by a
change in human nature; it resulted from a change in the
environment in which people make food choices

Just like with smoking, policy makers will need to change
that environment

As with tobacco, the belief in individual liberty and the battle
against the industries that benefit from the sale of unhealthy
foods will make changing the environment difficult
Aggressive public policy interventions used to reduce
tobacco use could be used in fighting obesity
 Imposing excise or sales taxes on fattening
foods of little nutritional value
 Putting graphic, simple labels on the front of
packaged foods showing nutritional value
 Requiring restaurant chains to put simple
nutrition information on the menu next to item
(enacted in PPACA; compliance required by end of 2011)
 Restricting advertising and limiting the
marketing of fattening food
How to Influence Public Policy

Influencing public
policy in order to
reduce obesity will
require multiple
legislative, regulatory,
and community-based
strategies
http://www.coloradohealth.org/uploadedImages/Images/Health_Elevations/Winter_2010/public_policy_graphic.jpg
National coverage of our study
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LA Times health blog •
Forbes.com
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CNNMoney.com
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CNN Cafferty File blog •
CBSNews.com
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The Economist
Edmonton Sun
•
(Canada)
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NY Post
•
USA Today
Atlanta Journal
•
Constitution
News Journal
•
(Wilmington, Del)
•
Houston Chronicle
SF Chronicle
Hearst Newspapers
National Journal
LA Times
Fort Worth Star
Telegram
Orlando Sentinel
Youth Today
Winston Salem
Journal
Charlottesville
Newsplex
So . CA Public Radio
Kaiser Health News
Public reactions to our study

Fabulous idea! As a Registered Dietitian, I work with people every
day that talk about how they "have to" drink soda and eat fast
food because it is the only thing that fills them up and they can
afford. There is a ton of evidence that shows you can eat healthy
foods and spend very little money. A tax on the unhealthy foods
would help motivate people to find healthier foods to spend their
money on.

This is tyranny. Plain and simple. Who decides what is a “fatty”
food?...My friends, we need to say enough is enough! If we don’t
stop this we will be living in the United Socialist States of
America.
http://www.urban.org/UploadedPDF/411926_reducing_obesity.pdf
Questions?