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Summary O besity is a serious health problem in both the United States and the United Kingdom. As a chronic health condition, it contributes to diabetes, cardiovascular disease, and some cancers. Its prevalence is increasing among children and adults, in parallel with increased con- sumption of unhealthy foods and low physical activity levels (IOM, 2005). Although obesity has long been viewed principally as a matter of individual choice, recent research emphasizes the social, economic, and environmen- tal determinants of what is, essentially, a nationwide epidemic in the two countries. Moreover, there is a disconnect in both countries between that awareness and how people perceive obesity in relation to themselves and their families. Presenters from the United States and the United Kingdom discussed these challenges at a workshop held at the US Institute of Medicine (IOM) of the National Academies on October 22, 2009. They spoke about poli- cies and programs that are addressing the obesity epidemic across sectors, developing partnerships to leverage limited resources, and drawing on available evidence to promote healthy behaviors. Presenters called for more research to determine the most effective interventions and for continued cooperation across sectors to integrate, as one speaker described it, “health in all policies.” From healthier lunches for school children, to mixed-use develop- ment that encourages walking over driving, to labeling and other means of giving consumers easy-to-understand information with which to make better health decisions, many actions are being taken to combat obesity in the United States and the United Kingdom. While far from an exhaustive 

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 PERSPECTIVES FROM UK AND US POLICY MAKERS account, the workshop provided an opportunity to learn from these efforts and consider how they might be applied in different contexts. OVERVIEW OF THE PROBLEM To understand the current prevalence of obesity and project trends, epidemiologists Klim McPherson (UK National Heart Forum) and Cynthia Ogden (US Centers for Disease Control and Prevention [CDC]) presented data on obesity among children and adults in the two countries: • oth countries have seen the percentages of the population that are B overweight or obese increase in the last two decades, with sharp rises projected if current trends continue. • nited Kingdom averages are behind those of the United States by U 7 to 10 years, but the prevalence of obesity in both countries is on the rise. In addition, the average body mass index (BMI) among the entire population is increasing in both. • oth countries have seen a possible leveling off in the growth of B obesity rates among children in the last year or two, but more data are needed to confirm any longer-term improvement. • isparities exist among children and adults in both countries. D Examples were presented during the workshop not to compare or contrast, but to describe differences in the population. For instance, in the United Kingdom, data show some disparities in the prevalence of obesity by social class among women. In the United States, data show some disparities in children by ethnic group and education of the head of household. • ver the past several decades, levels of physical activity have O remained low in both countries, as has consumption of vegeta- bles, milk, and other healthy foods, while consumption of sugar- sweetened beverages and other, less healthy food has increased. This is the same time span during which the numbers of overweight and obese children and adults have risen dramatically. gOVERNMENT STRUCTURES TO ADDRESS OBESITY As research points to the social, economic, and environmental deter- minants of obesity, recognition that the government must play a role is increasing. Yet this role also is subject to debate as many people, including policy makers, continue to perceive obesity as a matter of individual choices about food and physical activity. Throughout the workshop, presenters from both countries acknowledged the need to find the most appropriate and effective role for government. On the panel on this topic, Anne Jackson

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 SUMMARY (UK Department for Children, Schools, and Families) and William Dietz (CDC) offered the following observations: • overnment programs and policies to address obesity in both G countries must come from a range of departments and agencies, including health, food assistance, transportation, and others. • he national government in the United Kingdom, reflecting its T more vertically integrated role relative to that in the United States, has developed a cross-government strategy called Healthy Weight, Healthy Lives. In the United States, many government entities are involved, but the efforts are more dispersed. • tate and local governments, in contrast, have been involved more S directly in obesity interventions in the United States. • oundations and nonprofit organizations have also taken an active F role, especially in the United States, in funding, research, and advo- cacy around obesity-related issues. SCHOOL MEAL POLICIES Judy Hargadon (UK School Food Trust) and Julie Paradis (US Depart- ment of Agriculture’s [USDA’s] Food and Nutrition Service) focused on school meals as a way to improve the diets of children. Although neither agency is involved in the direct day-to-day preparation of school meals for children, both play a large role in setting standards, providing funding (espe- cially to feed lower-income children), and trying to influence food choices available to students at other points during the school day. Hargadon and Paradis made the following additional points: • n the United Kingdom, changes to the school meal program I resulted from a television program featuring celebrity chef Jamie Oliver, which drew public attention to what schools were feeding children. In the United States, there has been no comparable “dis- ruptive innovation,” as Hargadon termed it, but recommendations from a recent IOM report are expected to result in changes. • oth agencies provide flexibility to schools within a set of guide- B lines. In the United Kingdom, newly revised guidelines for school food encompass both food- and nutrient-based standards. In the United States, food served to children through the National School Lunch Program must meet applicable recommendations of the Dietary Guidelines for Americans. Currently, schools have the option of choosing between food- and nutrient-based standards. • ood available to students goes well beyond what is served for F lunch. They can consume food for breakfast and snacks. They

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 PERSPECTIVES FROM UK AND US POLICY MAKERS can also choose from “competitive foods,” which are foods sold outside of the reimbursable meal programs, such as products sold in vending machines, à la carte cafeterias items, snack bars, and fundraisers. Students also have access to food sold in nearby shops and restaurants, over which schools have no control. PHYSICAL ACTIVITY AND THE BUILT ENVIRONMENT Another workshop panel emphasized strategies to increase people’s everyday physical activity by, for example, promoting walking, bik- ing, and use of public transit for commuting and shopping. Harriet Tregoning (Washington, DC, Office of Planning), Ailsa McGinty (UK Cross-Government Obesity Team), and Peter Ashcroft (UK Department of Health Southwest) noted that implementing such strategies often requires changes to the built environment. Accomplishing such changes in turn requires working with a broad range of government entities and partners responsible for planning, transportation, and economic policies. The panel also noted that: • he built environment can encourage or discourage physical activ- T ity through such factors as routes for walkers and cyclists; siting of houses, shops, and businesses; and availability and location of greenspaces. • lear, easy-to-interpret evidence on the effect of the built environ- C ment on physical activity and health is useful for communicating with professionals outside the health field. • hile it is often easier to incorporate health considerations into W new designs, there are also opportunities, even if piecemeal, to do so within existing developments. • ven small changes in people’s physical activity make a difference, E such as getting them out of their cars for short trips to offices and shops. NATIONAL PROgRAMS AND POLICIES Presenters in a third panel discussed a range of illustrative programs and policies aimed at addressing the obesity problem. Kevin Concannon (USDA) and Dana Carr (US Department of Education) described programs in their departments related to healthier eating and physical activity. From the UK side, Tim Smith (Food Standards Agency) discussed the agency’s efforts, especially around nutrition labeling and other voluntary programs with the private sector, while Susan Jebb (Chair of the cross-government

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 SUMMARY Expert Advisory Group on Obesity) explained the consumer-oriented Change4Life campaign. Points made in these presentations included the following: • urrent economic conditions mean that programs to feed those in C need are playing a larger part in the diet of many Americans. USDA runs 15 such programs, accounting for one-half its annual bud- get. The largest of these is the Supplemental Nutrition Assistance Program (SNAP, formerly Food Stamps), which serves 35 million people, including about one in four American children. • chool systems offer physical education classes and recesses/activity S breaks during the school week, but few consider these an integral part of education, especially as students progress from elementary through high school. • he UK Food Standards Agency efforts in salt reduction have T resulted in reformulated products, improved messaging about nutrition to consumers at the point of purchase, and other changes that can promote better health. • ampaigns to change behaviors, such as Change4Life, must be C based on science, but their messages must be framed in a way that resonates with consumers. One insight used to develop Change4Life, for example, is that although people recognize obesity as a national problem, research shows people do not relate what they see or hear about obesity to their own situation. LOCAL PROgRAMS AND POLICIES As noted earlier, many US states and localities are at the forefront of obesity prevention efforts. Attendees heard from speakers represent- ing three very different locales: Jonathan Fielding (Los Angeles County Department of Health), Lynn Silver (New York City Department of Health and Mental Hygiene), and Chip Johnson (Mayor of Hernando, Missis- sippi). Fielding spoke about the roles he sees for his department in work- ing with others to improve health outcomes in his highly diverse county. Silver explained the background, implementation, and evaluation plans for New York City’s menu labeling law, the first such law in the country. And Johnson shared how his small city (population 15,000) is taking advantage of many of the ideas, programs, and resources discussed throughout the day, especially those related to physical activity and the built environment. Using a range of case examples, the presenters also noted the need for local communities to:

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 PERSPECTIVES FROM UK AND US POLICY MAKERS • evelop a range of programs and services in recognition of the D diversity of the population and the fact that different interventions will reach different people. • se data to target resources and stimulate further action (with the U observation that more scientific evidence for the effectiveness of local interventions is needed). • odel healthy practices, from the contents of vending machines in M public buildings, to procurement of food for public institutions, to the mayor’s setting an example for the community. • ap into resources from multiple sources, such as philanthropies, T grants, and new commercial and residential development, espe- cially in this era of declining public revenues. CLOSINg REMARKS At the end of the day, Jackson and Dietz summarized some of the main messages of the workshop. They stressed that the only way to reach people in a way that causes them to change their behavior is to use language and a context that resonate with them. Identifying a person as “obese” and expecting that this tag will result in such changes is unrealistic and can even backfire. The presenters called for research that can help in determining the effectiveness of different interventions so that resources can be targeted to bring the most promising approaches to scale.