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Preventing Childhood Obesity: Health in the Balance 5 Industry, Advertising, Media, and Public Education To lead a healthier and more active lifestyle, many young consumers and their parents will need to alter their food and beverage preferences and engage in fewer sedentary pursuits in order to achieve energy balance. Market forces may be very influential in changing both consumer and industry behaviors. The food, beverage, restaurant, entertainment, leisure, and recreation industries must share responsibility for childhood obesity prevention and can be instrumental in supporting this goal. Federal agencies such as the U.S. Department of Health and Human Services (DHHS), the U.S. Department of Agriculture (USDA), and the Federal Trade Commission (FTC) all have the potential to strengthen industry efforts through general support, technical assistance, research expertise, and regulatory guidance. In addition, government is an important source of positive reinforcement. It can recognize industry stakeholders who are willing to take the financial risks of developing new products and services consistent with the goals of healthful eating behaviors and regular physical activity, thereby setting examples for other private-sector entities to follow. INDUSTRY American children and youth represent dynamic and lucrative markets. For example, food and beverage sales to young consumers exceeded $27 billion in 2002 (U.S. Market for Kids’ Foods and Beverages, 2003). Simi-
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Preventing Childhood Obesity: Health in the Balance larly, young people are major consumers of the products and services of the entertainment, leisure, and recreation industries. Providing young consumers and their families with the knowledge and skills to make informed and prudent choices in these marketplaces could be a key obesity prevention strategy. Industry continuously develops new products and services in response to changing consumer demand, and its primary emphases—sales trends, marketing opportunities, product appeal, and expanding market share for specific product categories and product brands (Datamonitor, 2002; U.S. Market for Kids’ Foods and Beverages, 2003)—could be profitably shifted toward healthier and more active lifestyles. Although the private sector has not historically viewed its responsibility as changing consumers’ preferences toward healthier choices, changes are under way that acknowledge the essential role that industry may play in related policy dialogues, public/private partnerships, and research (Crockett et al., 2002). The increased media coverage of childhood obesity in recent years, and the consequent growth in public attention and potential for litigation have sensitized the food and beverage industries to examine the underlying causes of the problem and learn from the tobacco industry experiences (Daynard, 2003; Appendix D). Moreover, it provides an opportunity for many types of industries (e.g., food, beverage, entertainment, recreation) to explore new marketing opportunities (Datamonitor, 2002). To the extent that consumers want to purchase and consume a healthful diet, engage in physical activity, and maintain energy balance, private industry not only has a profit incentive but a public relations incentive to help them meet that goal and demonstrate that industry can be responsive to public concerns. The committee recognizes that children, youth, and their adult care providers are immersed in a modern milieu, including a commercial environment that could be shaped to encourage behaviors relevant to preventing obesity (Peters et al., 2002). Consumers may initially be unsure about what to eat for good health. They often make immediate trade-offs in taste, cost, and convenience for longer term health (Wansink, 2004). But numerous opportunities for influencing consumers’ purchase decisions present themselves as the food and beverage industries develop, package, label, promote, distribute, and price products and as retail food stores, full-service restaurants, and fast food establishments make similar sets of decisions. Each of these points offers opportunities for influencing consumers’ purchase decisions. Developing healthier food and beverage products or serving smaller portion sizes may be viewed by some private-sector businesses as risks rather than as opportunities; making changes in the absence of broad-based consumer demand, whatever the market, conceivably can be seen as a risk
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Preventing Childhood Obesity: Health in the Balance to the private sector. But in this case there is ample precedent. A variety of food-industry stakeholders have recently made positive changes by expanding healthier meal options for young consumers (Hurley and Liebman, 2004; Richwine, 2004), offering improved food products with reduced sugar content for children (PR Newswire, 2004), and reducing portion sizes at full-service and fast food restaurants (Hurley and Liebman, 2004). These changes can and should occur on a much larger scale. For that to happen, coordinated efforts among industry, government, and other sectors are needed to stimulate, support, and sustain consumer demand for healthful foods and beverages, appropriately portioned meals, and accurate and consistent nutritional information made readily available to the public. Similarly, the leisure, entertainment, and recreation industries are faced with the challenge of maintaining profitability while portraying active living1 as a desirable social norm for adults and children. These industries, which influence how leisure time is used, can create a wide range of new products and opportunities to increase energy expenditure through the incorporation of physical activity messages into sedentary pursuits (e.g., television commercials, video games and Internet websites that remind or prompt consumers to increase physical activity for a specified amount of time to balance screen time). This chapter presents a series of recommendations appropriate to the commercial environment in general and to various industries in particular. Food and Beverage Industry Product Development The food and beverage industries’ decisions are guided by key factors—including taste, palatability, cost, convenience, value, variety, availability, ethnic preferences, and safety—that drive consumer demand (FMI, 2003a,b; Wansink, 2004). The industry’s decisions are also constrained by other conditions. For example, product and meal size are significant drivers of consumers’ perceived value of the foods and beverages they purchase, whether for consumption at home or elsewhere (FMI, 2003a,b; Stewart et al., 2004; Wansink, 2004). Similarly, modern retail food stores offer tens of thousands of food and beverage items from which to choose. While more than 14,000 new food and beverage products enter the U.S. marketplace annually, less than 6 1 Active living is a way of life that integrates two types of physical activity—recreational or leisure activity (e.g., jogging, skateboarding, or playing basketball), and utilitarian or occupational activity (e.g., walking or bicycling to school or running errands)—into one’s daily routine.
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Preventing Childhood Obesity: Health in the Balance percent are innovative enough to be successful (Heasman and Mellentin, 2001). The majority of these new products fail for a variety of reasons including lack of consumer demand, cost, marketing strategies, or lack of positive reinforcement or support from other groups (such as the public health sector and health-care professionals) (Heasman and Mellentin, 2001). But failure in the past, particularly with regard to healthier food and beverage offerings, does not necessarily mean failure in the future. The financial success of diet carbonated beverages and the greater availability of reduced-calorie food and beverage products—buttressed in part by the reduced fat or saturated fat processed food products created by industry in response to the Healthy People 2000 objectives (NCHS, 2001)—are examples of how industry could be continually seeking new ways to meet consumer demand, earn a decent profit, and have its products positively affect public health. Thus significant profit incentives now exist for industry to develop reduced-calorie and low-energy-dense foods, thereby helping consumers achieve their dietary and energy balance goals. Movement in that direction has already begun; food and beverage industries are currently seeking opportunities in product development and product reformulation, with an emphasis on eating for health (Datamonitor, 2002; FMI, 2003a). New products are also developed, packaged, and marketed to ethnically diverse children and youth with attention to cultural taste preferences and attractive packaging (Williams et al., 1993). The committee recommends that as new products are developed or existing products are modified by the private sector, it should be imperative that energy balance, energy density, nutrient density, and standard serving sizes are primary considerations in the process. This can be assisted by government stakeholders providing general support, technical assistance, research expertise, and regulatory guidance. Energy Density of Foods As discussed in Chapter 3, the energy density of a given food is the amount of energy it stores per unit volume or mass. At 9 kilocalories2 stored per gram, fat has the highest energy density. Alcohol stores 7 kilocalories per gram, carbohydrates and protein both store 4, fiber stores 1.5-2.5, and water stores 0.0—i.e., it does not provide energy. Energy density is a determinant of the effects of foods and macronutrients on satiety (Rolls et 2 In this report the term “kilocalories” is used synonymously with “calories.”
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Preventing Childhood Obesity: Health in the Balance al., 2004a), and it may have a significant influence on regulating food intake and body weight as well (Drewnowski, 2003; Prentice and Jebb, 2003). High-energy-dense foods, such as potato chips and sweets, tend to be palatable but may not be satiating for consumers, calorie for calorie, thereby encouraging greater food consumption (Drewnowski, 1998; Prentice and Jebb, 2003). Humans may have a weak innate ability to recognize foods with a high energy density to down-regulate the amount of food consumed in order to maintain energy balance, thereby fostering a “passive overconsumption” of these types of foods (Prentice and Jebb, 2003). By contrast, low-energy-dense foods, such as fruits and vegetables, contain more fiber and water and less fat than high-energy-dense foods. As a result, they promote satiety and reduce energy intake but may be considered less palatable by some individuals (Drewnowski, 1998; Rolls et al., 2004b). Consumers typically ingest fewer calories when meals are low in energy density than high in energy density (Kral et al., 2002; Rolls et al., 2004b). There is a need for further research on the implications of dietary energy density on the short-term and long-term physiological regulation of satiety, and the role of energy density in total energy intake and achieving a healthy body weight. An analysis of the 1999-2000 National Health and Nutrition Examination Survey (NHANES) and NHANES III data revealed that three food groups—sweets and desserts, soft drinks, and alcoholic beverages—comprised nearly 25 percent of all calories consumed by Americans between 1988 and 2000. Salty snacks and fruit-flavored beverages accounted for another 5 percent, bringing the total calories contributed by high-energy-dense/low-nutrient-dense foods to be at least 30 percent of Americans’ total calorie intake during that period (Block, 2004). Nutrient composition data available from fast food company websites suggest that average menus are twice the energy density of recommended healthful diets (Prentice and Jebb, 2003). Developing low-energy-dense but palatable food products, which will help consumers achieve and maintain energy balance by reducing the probability of excessive energy consumption, has been a significant challenge for the food industry (Drewnowski, 1998). While acknowledging this challenge, the committee emphasizes the need to identify specific incentives that will help the industry develop such new products. In the meantime, manufacturers can modify existing products—for example, by replacing fat with protein, fruit or vegetable purée, fiber, water, or even air—to reduce energy density but maintain palatability without substantially reducing the product size or volume.
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Preventing Childhood Obesity: Health in the Balance Product Packaging and Portion Sizes Packaging is the “interface” between food-industry products and the consumer—that is, it is the public’s first point of contact—and food packages implicitly suggest portion sizes or food combinations (e.g., which foods are eaten together such as peanut butter and jelly). But a product package can be modified in three general ways—by size, visual appeal, and the type and amount of information it provides (such as the nutritional content according to the Nutrition Facts panel on food labels)—in order to assist consumers in making knowledgeable purchasing decisions and determining portion sizes for themselves. Because energy requirements vary both by age and body size (IOM, 2002), parents need to be aware of the appropriate amount of food that will help meet but not exceed their child’s own energy needs. In order to do so at present, however, they must overcome an established and unhealthy trend; research has revealed a progressive increase in portion sizes of many types of foods and beverages made available to Americans from 1977 to 1998 (Nielsen and Popkin, 2003; Smiciklas-Wright et al., 2003), the same period during which a rise in obesity prevalence has been observed (Nestle, 2003b; Rolls, 2003). Some research on the effects of food portion size has shown that children 3 years old and younger seem to be relatively unresponsive to the size of the portions of food that they are served (Rolls et al., 2000; see also Chapter 8). By contrast, the food intake of older children and adults is strongly influenced by portion size, with larger portions often promoting excess energy intake (McConahy et al., 2002; Rolls et al., 2002; Orlet Fisher et al., 2003). Children 3 to 5 years of age consumed more of an entrée and 15 percent more total energy at lunch when presented with portion sizes that were double an age-appropriate standard size (Orlet Fisher et al., 2003). Portions that are currently served and consumed at home, and particularly away from home, may be several times the USDA-recommended serving size or recommended caloric level3 (Orlet Fisher et al., 2003). In addition to food portion size, the frequency of eating and the types of foods consumed are important predictors of energy intake as children transition from being toddlers to preschoolers. One study that evaluated the relationship of food intake behaviors to total energy intake among 3 A serving size is a standardized unit of measure used to describe the total amount of foods recommended daily from each of the food groups from the Food Guide Pyramid (FGP) or a specific amount of food that contains the quantity of nutrients listed on the Nutrition Facts panel. A portion size is the amount of food an individual is served at home or away from home and chooses to consume for a meal or snack. Portions can be larger or smaller than serving sizes listed on the food label or the FGP (USDA, 1999).
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Preventing Childhood Obesity: Health in the Balance children aged 2 to 5 years who participated in the Continuing Survey of Food Intakes by Individuals (CSFII) 1994-1996, 1998 found that eating behaviors and body weight were positively related to energy intake (McConahy et al., 2004). Research also suggests that individuals tend to overconsume highenergy-dense foods beyond physiological satiety (Kral et al., 2004), especially when they are unaware that the portion sizes served to them have been substantially increased (Rolls et al., 2004a). Satiety signals are not triggered as effectively with high-energy-dense foods (Drewnowski, 1998), and large portions of them consumed on a regular basis are particularly problematic for achieving energy balance and weight management in older children and adults. A variety of physiological processes are involved in the regulation of dietary intake, satiety, energy metabolism, and weight. These include the neural pathways that regulate hunger and influence food intake, gastrointestinal mechanisms involved in providing signals to the brain about ingested food, and adipocyte-derived factors that provide information about energy stores, as well as the genetic and environmental factors that affect these physiological processes (see Chapters 3 and 8). There are a variety of external cues that may also influence dietary intake such as portion size and package size. For example, there is some evidence to support the hypothesis that larger food package sizes encourage greater consumption than smaller food package sizes (Wansink, 1996), and external cues such as packaging and container size may contribute to the volume of food consumed (Wansink and Park, 2000). Thus, although the committee recognizes the difficulties faced by the food industry in developing new packaging options for consumers, industry should explore, through research and test-marketing, the best approaches for modifying product packages—multipackages with smaller individual servings or standard serving sizes, or resealable packages—so that products palatable to consumers may remain profitable while promoting consumption of smaller portions. Moreover, the food industry should investigate other approaches for promoting consumption of smaller portion sizes and standard serving sizes. Leisure, Entertainment, and Recreation Industries Americans now enjoy more leisure time than they did a few decades ago. As discussed in Chapter 1, trend data collected by the Americans’ Use of Time Study through time use diaries indicated that adults’ free time increased by 14 percent between 1965 and 1985 to an average total of nearly 40 hours per week (Robinson and Godbey, 1999). Data from other population-based surveys, including the National Health Interview Survey,
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Preventing Childhood Obesity: Health in the Balance NHANES, Behavior Risk Factor Surveillance System (BRFSS), and the Family Interaction, Social Capital and Trends in Time Use Data (1998-1999), together with trend data on sports and recreational participation, suggest a significant increase in reported leisure-time physical activity in adults (Pratt et al., 1999; French et al., 2001a; Sturm, 2004). Cross-sectional data from the National Human Activity Pattern Survey, based on the responses of 7,515 adults between 1992 and 1994, assessed time use and daily energy expenditure patterns of adults. Results suggested that sedentary and low-intensity activities dominated while leisure-time, high-intensity activities accounted for less than 3 percent of energy expenditure (Dong et al., 2004). Americans are presented with trade-offs in how they allocate their time and money. Understanding how Americans in general, and children and youth in particular, use their leisure time will help to determine ways of promoting more physical activity into their lives. An analysis of time allocation and expenditure patterns for U.S. adults over the past several decades suggests that they are spending more time in leisure and travel or transportation and less time in productive home activities (e.g., meal preparation and cleanup) and occupational activities (Sturm, 2004). Leisure-time industries have exceeded gross domestic product growth for both active industries (e.g., bicycles, sporting goods, membership sports clubs) and sedentary industries (television, spectator sports). However, there has been a steeper growth in sedentary industries from 1987 to 2001—especially the growth of cable television and spectator sports (Sturm, 2004). Trend data for children (spanning from 1981 to 1997) have shown that they now have less discretionary or free time—defined as time not spent eating, sleeping, attending to personal care, or at school—than they used to because more of their time is spent away from home in school, after-school programs, or daycare. There is also a noted increase in the amount of time children spend in organized sports (Hofferth and Sandberg, 2001; Sturm, 2005a), but active transportation (e.g., bicycling or walking) is not a significant source of physical activity for children and youth (Sturm, 2005b). Modern technologies such as labor-saving home appliances have reduced the energy expended for home meal preparation and the amount of time needed to achieve the same task (Sturm, 2004). Other technological innovations such as home entertainment devices (including cable television, computers, video games) and automobiles have contributed to sedentary behaviors among Americans, causing them to expend less energy. This phenomenon of increased time spent in passive sedentary pursuits relative to active leisure activities has been associated with the rise in obesity (French et al., 2001a; Philipson and Posner, 2003). However, although the average American adult spends more than 20 hours per week watching television, videos, or digital video discs (DVDs), it is notable that the largest increase
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Preventing Childhood Obesity: Health in the Balance in television watching occurred prior to 1980, which preceded the obesity epidemic (Sturm, 2004). The leisure, entertainment, and recreation industries can help counter the physical inactivity trend by promoting active leisure-time pursuits, while at the same time developing new products and markets. The introduction of products that involve more physical activity by some industry leaders suggests that some already believe they can create a significant market for these types of products. Some companies have used popular athletic figures, who are potential role models for active and healthful lifestyles, to promote sedentary lifestyles. Instead, the industries could leverage their existing relationships with celebrities to convey messages that encourage physical activity and healthful living and reduce sedentary behaviors. Some potentially positive efforts are now under way. One athletic apparel manufacturer provides funding to build, upgrade, or refurbish sports courts and other athletic facilities throughout the United States; awards grants to nonprofit organizations and governmental partners; supports physical education classes in elementary schools; and is a partner in Shaping America’s Youth, a national cross-sectoral initiative for promoting physical activity and healthful lifestyles during childhood (Nike, 2004). Activity-based games offer opportunities for the leisure industry to market a product that promotes physical activity in children and youth. The evaluation of private-sector programs is crucial in order to assess if they are effective in increasing physical activity, especially among high-risk populations, and determine if they may have unanticipated and adverse consequences. Full-Service and Fast Food Restaurant Industry Increased consumption of food outside of the home has been one of the most marked changes in the American diet over the past several decades. In 1970, household income allotted to away-from-home foods accounted for 25 percent of total food spending; by 1999, it had reached nearly one-half (47 percent) of total food spending (Lin et al., 1999c). Total consumer spending on food dispensed for immediate consumption outside the home amounted to $415 billion in 2002 (Stewart et al., 2004). Similarly, a greater proportion of consumers’ nutrients is now derived from foods purchased outside the home. Consumption of away-from-home foods comprised 20 percent of children’s total calorie intake in 1977, rising to 32 percent in 1994-1996 (Lin et al., 1999b). For adults, such foods provided more than one-third (34 percent) of total calories in 1995 (Lin et al., 1999a). The frequency of dining out rose by more than two-thirds over the past two decades, from 16 percent in 1977-1978 to 27 percent in 1995 (Lin et
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Preventing Childhood Obesity: Health in the Balance al., 1999a). Restaurant industry sales for commercial and noncommercial services were projected to exceed $426 billion in 2003 (National Restaurant Association, 2003) and are forecasted to reach $440 billion in 2004 (National Restaurant Association, 2004). Moreover, consumer spending at restaurants is projected to continue growing over the next decade (Stewart et al., 2004). Full-service and fast food restaurants alike have been enjoying this boom—in 2003, full-service restaurant sales reached $153.2 billion and fast food restaurant sales reached nearly $121 billion (National Restaurant Association, 2003)—and it appears likely to continue. Assuming modest growth in household income and demographic changes, consumer per-capita spending between 2000 and 2020 is expected to rise by 18 percent at full-service restaurants and by 6 percent at fast food outlets (Stewart et al., 2004). Given the growing public concern about the rise in obesity, particularly childhood obesity, full service and fast food restaurants throughout the country have begun offering healthier food options. At present, however, most restaurants do not provide consumers with the calorie and selected nutrient content either of offered meals or individual food and beverage items4; this information would be useful for making more prudent menu decisions. While the culinary qualities of fast food meals tend to differ from those of full-service restaurants (Lin et al., 1999a), both of them are typically energy dense and served in large portions. Fast food consumption is associated with a diet that is high in total energy and energy density but low in micronutrient density. For example, an analysis of the CSFII 1994-1996 data for adult men and women revealed that a typical fast food meal provided more than one-third of their daily energy, total fat, and saturated fat intake; and that energy density increased while micronutrient density concurrently decreased with frequency of fast food consumption (Bowman and Vinyard, 2004). Published data are limited that compare the nutrient content of full-service restaurant meals for children. However, one review of the entrees offered to children at 20 table-service restaurants found fried chicken on every one of the children’s menus, a hamburger or cheeseburger on 85 percent of the menus, and french fries on all but one of the menus (Hurley and Liebman, 2004). At nearly one-half of the restaurant chains, french fries were the only side dish on the children’s menus, and while children could generally choose a beverage from among soft drinks, juice, or milk, 4 Under the Nutrition Labeling and Education Act of 1990, food products exempted from calorie and nutrient labeling include foods served for immediate consumption, ready-to-eat food not for immediate consumption (i.e., take-out foods), and foods produced by small businesses with annual sales below $500,000 (IOM, 2004).
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Preventing Childhood Obesity: Health in the Balance 10 of the restaurants offered free refills only for soft drinks (Hurley and Liebman, 2004). Children and youth aged 11 to 18 years visit fast food outlets an average of twice per week (Paeratakul et al., 2003), and this frequency is associated with increased intake of soft drinks, pizza, french fries, total fat, and total calories, as well as with reduced intake of vegetables, fruit, and milk (French et al., 2001b). In a study of 6,212 children and adolescents between the ages of 4 and 19 years of age participating in the CSFII, those who ate fast food consumed more total energy, more energy per gram of food (greater energy density), more total fat and carbohydrates, more added sugars, more sweetened beverages, less milk, and fewer fruits and non-starchy vegetables than those who did not consume fast food (Bowman et al., 2004). Adolescents aged 13 to 17 years were found to consume more fast food regardless of whether they were lean or obese. Moreover, obese adolescents were less likely to compensate for the extra energy consumed by adjusting their energy throughout the day than were their lean counterparts (Ebbeling et al., 2004). Expanding Healthier Meals and Food Choices Given these trends and data, full-service and fast food restaurants should continue to expand their healthier meal options and food choices—particularly for children and youth—through the inclusion of fruits, vegetables, low-fat milk, and calorie-free beverages among their offerings. It is also important for restaurants to expand options for healthier children’s meals, encourage parents to help their children make smarter eating choices, and remind parents of their rights as customers to substitute side dishes and customize meals to their satisfaction. Research is needed to monitor consumers’ and children’s responses to these expanded options. Restaurants should also initiate a voluntary, point-of-sale, nutrition-information campaign for consumers. Meanwhile, in accordance with the recommendations of the Food and Drug Administration (FDA) Obesity Working Group’s recommendations (FDA, 2004), consumers at restaurants should be encouraged to request information about the nutritional content of complete meals, foods, and beverages offered and consequently be provided with accurate, standardized, and understandable details at the point of sale. This nutritional information should include total calories, fat, cholesterol, and fiber, together with instruction on meaningfully interpreting these values within the context of typical consumers’ total energy and dietary needs. Nutrition labeling of restaurant meals and individual foods should take varying sizes or options into account and should be located near the price of the selections; this will ensure that the consumer is made aware of the
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Preventing Childhood Obesity: Health in the Balance state-level media campaigns (Siegel, 2002). In contrast, the National Youth Anti-Drug Media Campaign, sponsored by the White House Office of National Drug Control Policy, has not shown success thus far in influencing youth marijuana consumption, despite having spent more than $1 billion in advertising and other efforts (Hornik et al., 2003). The inconsistent results from these two areas do not lead to easy conclusions about whether media campaigns are promising for obesity-related behaviors. They do suggest that the success of such campaigns will depend on the outcome sought and the ways in which the campaigns are mounted and maintained. Industry-sponsored efforts to encourage increased levels of physical activity are currently under way (Nike, 2004), though the committee does not have any information about their possible influence of these efforts on youth behavior. The advantage of such industry-sponsored programs is that they do not require explicit public investment; however, reasonably enough, they will reflect their sponsors’ interests, which may not always coincide with the agendas of those primarily concerned with youth obesity. In circumstances where they might play a useful complementary role in a national effort, industry-sponsored efforts should certainly be encouraged. However, national authorities must understand that such campaigns are likely to be only one part of a broad effort, and should not be seen as an alternative to mounting an urgent public-sector campaign focused on behavioral objectives. Within the past two years, the Centers for Disease Control and Prevention (CDC) has launched the VERB campaign, a multi-ethnic media campaign based on social marketing principles and behavioral change models (Huhman, et al., 2004) with the goal of increasing and maintaining physical activity in tweens—youth aged 9 to 13 years. Parents and other influential sources on tweens (e.g., teachers and youth program leaders) are the secondary audiences of the VERB campaign. The CDC has conducted extensive formative research to design this social marketing campaign (Wong et al., 2004), which currently involves multiple media venues that include television, radio spots, print advertising, posters, the Internet, and out-of-home outlets such as movie theaters, billboards, and city buses (Wong et al., 2004). A recently released summary of the VERB campaign’s first-year results of a prospective study suggests a high recall of messages and some evidence that youth who had better campaign recall engaged in more physical activity than those who did not (Potter et al., 2004). It should be noted, however, that the extent to which the association between campaign recall and greater physical activity can be attributed to the campaign’s influence cannot be determined from these results. One cannot rule out the alternative explanation that youth who are more naturally oriented toward being more physically active are also more likely to recall the campaign messages.
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Preventing Childhood Obesity: Health in the Balance Given these preliminary, albeit positive results, and no other available evaluations of media campaigns, it is not possible at present to state that media campaigns can effectively increase physical activity in children aged 9 to 13 years. Next Steps The committee recognizes that there is limited evaluated experience in mass-media-centered interventions that address obesity prevention. Nonetheless, there is substantial experience in other related areas, along with the initial findings of positive evidence from some very recent obesity-focused efforts. In addition, the committee recognizes that most of its recommendations throughout the report require reaching the population at large, on a continuing basis, to generate popular support for policy changes and provide needed information to parents and youth about behaviors likely to reduce the risks of obesity. Only the mass media offer the possibility of reaching that sizeable and wide-ranging audience. Thus the committee recommends that DHHS, in coordination with other federal departments and agencies and with input from independent experts, develop, implement, and rigorously evaluate a broad-based, long-term, national multimedia and public relations campaign focused on obesity prevention in children and youth. This campaign would vary in its focus as the nature of the problem changes, including components focused on changing eating and physical activity behaviors among children, youth, and their parents as well as on raising support among the general public for policy actions. The outcome of this effort should be greater awareness of childhood obesity, increased public support for policy actions, and behavior change among parents and youth. The three areas of focus for the recommended media campaign would involve: A continuing public relations or media advocacy effort designed to build a political constituency for addressing youth obesity, and for supporting specific policy changes on national, state, or local levels. This will include print and broadcast media press briefings and outreach, media support for other organizations focused on obesity issues, and efforts to encourage commercial media to incorporate obesity issues and positive role modeling in their programming. A systematic and continuing campaign to provide parents with the types of information described in Chapter 8, including the importance of serving as role models and of establishing household policies and priorities regarding healthful eating and physical activity.
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Preventing Childhood Obesity: Health in the Balance A systematic and continuing campaign to reach youth who are themselves making energy balance decisions that affect their risk of obesity. The federal government’s recently launched VERB campaign is one example of a youth-focused campaign and presents an opportunity to examine the long-term impact of a multimedia campaign focused on promoting physical activity in youth, one component of preventing obesity. As noted above, preliminary results are positive for an early phase of the campaign. CDC has made substantial investment in this program and, given the positive first results, further investments should follow over a longer term. Regarding the systematic campaign to reach youth, the committee specifically endorses the continuation of VERB funding to ensure the possibility of fully realizing the social marketing campaign’s potential and to evaluate its long-term impact. This proposal is costly. Thus, based on a rigorous evaluation over the long term, resources should be redirected if results are not promising in meeting the three components of the campaign. In addition, the committee notes that physical activity is but one side of the energy equation. Additional resources should be provided for a complementary campaign focusing on energy-intake behaviors. Funding for the national multimedia and public relations campaign should include sufficient budgets to purchase media time for the campaign’s advertising, rather than relying on donated time, as well as to support the professional implementation and careful evaluation of the campaign’s effects. While DHHS’s Small Steps program intends to depend on contributed airtime under the auspices of the Advertising Council (DHHS, 2004), the committee suggests that it is not a promising route for frequently reaching the public. A recent Kaiser Family Foundation study showed that the average television station rarely plays such public service announcements during periods when most adults are in the viewing audience (Kaiser Family Foundation, 2002). Some campaigns have had success in obtaining donated time on stations where they had also purchased time (Randolph and Viswanath, 2004), but that is merely a strategy for stretching resources more effectively. In general, a campaign that depends on contributed time is quite unlikely to satisfy its objectives. Input should be sought from independent experts and representatives of other federal, state, and local agencies, nonprofit organizations, and, where appropriate, industry representatives to construct a broad and evolving strategy that includes all three of the areas of focus described above. These efforts, which need a long-term mandate from Congress, should be aimed at the general population and specific high-risk subgroups, and their staffs should be able to carefully assess targets of opportunity and rebalance their strategies as circumstances change.
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Preventing Childhood Obesity: Health in the Balance The committee realizes that many nonprofit organizations and other nongovernmental groups are involved in obesity prevention efforts. It encourages these organizations to undertake their own extensive media campaigns (print, electronic, Web-based, and other media) for addressing the obesity problem. Recommendation 5: Multimedia and Public Relations Campaign DHHS should develop and evaluate a long-term national multimedia and public relations campaign focused on obesity prevention in children and youth. To implement this recommendation: The campaign should be developed in coordination with other federal departments and agencies and with input from independent experts to focus on building support for policy changes, providing information to parents, and providing information to children and youth. Rigorous evaluation should be a critical component. Reinforcing messages should be provided in diverse media and effectively coordinated with other events and dissemination activities. The media should incorporate obesity issues into its content, including the promotion of positive role models. REFERENCES AAP (American Academy of Pediatrics). Committee on Communications. 1995. Children, adolescents, and advertising. Pediatrics 95(2):295-297. Achterberg C, McDonnell E, Bagby R. 1994. How to put the Food Guide Pyramid into practice. J Am Diet Assoc 94(9):1030-1035. ADA (American Dietetic Association). 2004. Position of the American Dietetic Association: Dietary guidance for healthy children ages 2 to 11 years. J Am Diet Assoc 104(4):660-677. Ballard-Barbash R. 2001. Designing surveillance systems to address emerging issues in diet and health. J Nutr 131(2S-1):437S-439S. Bauman AE, Bellew B, Owen N, Vita P. 2001. Impact of an Australian mass media campaign targeting physical activity in 1998. Am J Prev Med 21(1):41-47. Bauman A, McLean G, Hurdle D, Walker S, Boyd J, van Aalst I, Carr H. 2003. Evaluation of the national ‘Push Play’ campaign in New Zealand—Creating population awareness of physical activity. N Z Med J 116(1179):U535. Block G. 2004. Foods contributing to energy intake in the US: Data from NHANES III and NHANES 1999–2000. J Food Comp Analysis 17(3-4):439-447. Bowman SA, Vinyard BT. 2004. Fast food consumption of U.S. adults: Impact on energy and nutrient intakes and overweight status. J Am Coll Nutr 23(2):163-168.
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Representative terms from entire chapter: