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3
Goals, Targets, and
Strategies for Change
Key Messages
• Now that obesity prevention efforts have some momentum, clarification of
goals and targets for change going forward is essential.
• Goals for children, adolescents, and adults focus on prevention, with identi-
fication of specific behavioral targets and key outcomes for individuals and
populations.
• An ecological model can be used to identify behavioral settings and sectors
of influence in which and by which actions can be taken to improve envi-
ronments for physical activity and healthful eating. Strategies for taking
action are multifaceted and interrelated and include policy and legislative
approaches, approaches that change organizational policies and practices
and environments in communities and neighborhoods, health communication
and social marketing approaches, and interventions in health care settings.
• Although there is not yet agreement on the set of specific strategies that
will be effective, existing frameworks and successful models of social
change can offer guidance on how to tackle the obesity epidemic utilizing a
systems approach.
• Several major practical and policy considerations require close attention
during the planning of strategies to accelerate obesity prevention, including
the realities of the way Americans live, issues related to freedom of choice,
food marketing to children and adolescents, potential adverse effects for
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people who are obese, and effects on high-risk racial/ethnic minority and
low-income populations.
• Measures with which to track progress are critical. Progress in achieving
obesity prevention can be assessed in the short term by indicators of change
in the environments that influence physical activity and eating.
I t is clear from the preceding chapters that tremendous strides have been made
in addressing the obesity epidemic, given the sheer amount of attention to the
problem and the number and coherence of efforts to address the epidemic and
bolster the scientific underpinnings and policy basis for taking action. Evidence
of the stabilization of obesity prevalence in at least some demographic groups
suggests that these deliberate initiatives to address the epidemic are on track, per-
haps in concert with other, spontaneous countering forces. Given the scope and
scale of what is needed and the inevitability of a time lag before true progress can
be estimated, however, the developments to date create a unique opportunity to
restate goals and refine targets and approaches in order to accelerate progress. As
reviewed in this chapter, the goals themselves are clear with respect to the desired
outcomes, as well as the types of behavioral changes that are relevant. There is
not yet agreement on what specific set of strategies and actions will best curb and
ultimately reverse the trends of increasing obesity prevalence. However, existing
frameworks and successful models of social change can offer guidance on how
to tackle the obesity epidemic and strongly indicate the need to take a systems
approach, as described in Chapter 4.
GOALS OF OBESITY PREVENTION
The overall goal of obesity prevention is to create, through directed societal
change, an environmental-behavioral synergy to foster the achievement and main-
tenance of healthy weight among individuals and in the population at large (IOM,
2005). This goal reflects a focus on prevention of obesity development, that is,
primary prevention. Primary prevention emphasizes strategies that increase the
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likelihood of shifting physical activity, eating, and weight management toward
energy balance in the population as a whole, including those groups and indi-
viduals at high risk of becoming obese. In this report, primary prevention is
viewed as relevant to the continuum of excess weight—prevention of the progres-
sion from normal weight to overweight, from overweight to obesity, and from
mild or moderate to more severe obesity.
The logic of beginning obesity prevention during childhood is self-evident.
At every life stage, from infancy onward, sustained excess weight and obesity
increase the risk of longer-term obesity. In adults, obesity prevention targets those
who enter adulthood with weight in the normal range, as well as those who may
already be somewhat overweight or obese, to limit the severity of obesity and
obesity-related health and social consequences. The need for effective preven-
tive strategies is heightened by the seemingly intractable nature of established
obesity, making the reduction of incidence—new cases of obesity—a priority.
Effective treatments for established obesity continue to be elusive despite decades
of research on treatment strategies, an active commercial weight loss industry,
and a majority of U.S. adults trying to lose or maintain their weight at any given
time. However, the need for prevention would persist even if effective treatments
were available. In the absence of prevention, there would be a continual influx of
people needing treatment (i.e., a majority of the population) such that the demand
for treatment would exceed the supply.
Goals for Children and Adolescents
Goals for children and adolescents outlined in the Institute of Medicine
(IOM) report Preventing Childhood Obesity: Health in the Balance (IOM, 2005)
continue to inform actions at the national and community levels (see Box 3-1).
For children and adolescents, obesity prevention means maintaining a healthy
weight trajectory and preventing excess weight gain while growing, developing,
and maturing (IOM, 2010). Goals include prevention of obesity and its adverse
consequences during childhood, as well as longer-term prevention of obesity in
adulthood, because children who are obese may remain so throughout life. Given
the general increase in media attention to obesity as a result of the epidemic (see
Chapter 2, Figures 2-7 and 2-8) and the potential for an increased focus on body
size to foster inappropriate weight concern or dieting (Davison et al., 2003; Ikeda
et al., 2006), an explicit goal has been added to those originally stated by the
IOM (2005) to highlight the importance of maintaining a positive body image and
avoiding excessive weight concern.
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BOX 3-1
Goals of Obesity Prevention in Children and
Adolescents
Individual Children and Adolescents
• A healthy weight trajectory, as defined by the Centers for Disease Control and
Prevention body mass index (BMI) charts
• A healthful diet (quality and quantity)
• Appropriate amounts and types of physical activity
• Achievement of physical, psychosocial, and cognitive growth and developmental
goals
• A healthy body image and the absence of potentially adverse weight concern or
restrictive eating behaviors
Population of Children and Adolescents
• Reduction in the incidence of childhood and adolescent obesity
• Reduction in the prevalence of childhood and adolescent obesity
• Reduction of mean population BMI levels
• Improvement in the proportion of children and adolescents with dietary quality
meeting the Dietary Guidelines for Americans
• Improvement in the proportion of children and adolescents meeting physical
activity guidelines
• Achievement of physical, psychological, and cognitive growth and develop-
mental goals
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Examples of Possible Intermediate Indexes of Progress Toward Obesity
Prevention in Children and Adolescents
• Increased number of children and adolescents who walk and bike to school
safely
• Improved access to and affordability of fruits and vegetables for low-income
populations
• Increased availability and use of community recreational facilities
• Increased play and physical activity opportunities
• Increased number of new industry products and advertising messages that pro-
mote energy balance at a healthy weight
• Increased availability and affordability of healthful foods and beverages at
supermarkets, grocery stores, and farmers’ markets located within walking dis-
tance of the communities they serve
• Changes in institutional and environmental policies that promote energy balance
SOURCE: Adapted from IOM, 2005, 2007.
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Goals for Adults
As noted in Chapter 2, the major human and societal consequences of obe-
sity culminate during the adult years, and these consequences can be mitigated by
stabilization of weight in the adult population. The payoff for intervening during
adulthood is immediate in reducing both human and societal costs by limiting the
development or exacerbation of obesity-related diseases during adulthood. There
is a payoff as well in the direct and indirect effects on the familial context for the
development of childhood obesity (Seidell et al., 2005).
Gradual weight gain during adulthood is typical and is commonly, although
erroneously, viewed as a part of normal aging (Lewis et al., 2000; Williamson et
al., 1990). A gradual weight gain of 1 or 2 pounds per year means a gain of 10
or 20 pounds in 10 years and twice that in a 20-year period. For example, adults
recruited from four geographic areas in the United States for the longitudinal
Coronary Artery Risk Development in Young Adults (CARDIA) study at ages 18
to 30 gained an estimated average of 1 to 2 pounds annually during the 10-year
period from 1985-1986 to 1995-1996 (Lewis et al., 2000). This weight gain shift-
ed many people from the healthy weight range into the overweight range, from the
overweight range into the obese range, or from a moderate to an extreme level of
obesity. As shown in Figure 3-1, this weight gain was associated with substantial
increases in the prevalence of overweight and obesity (body mass index [BMI] of
25 or greater) in both blacks and whites and both men and women: 52 percent to
76 percent of adults in these race/sex subgroups were in the healthy weight range
(BMI 18.5 to 24.9) at the start of this period, but only 28 percent to 58 percent
were in this range 10 years later; the prevalence of extreme obesity (BMI of 40 or
more) at least doubled in all subgroups (Lewis et al., 2000).
Goals of obesity prevention in adults are shown in Box 3-2. They are similar in
concept to those for children and adolescents but focus on the weight trajectories
and related behaviors associated with aging and, in women, reproduction. Weight
levels of adults and of children and adolescents are interrelated in that parents
and other adults are role models for children and adolescents. Moreover, maternal
obesity may have direct effects on the risk of obesity in children and adolescents
through gestational factors (IOM, 2009; Norman and Reynolds, 2011).
TARGETS FOR BEHAVIORAL AND ENVIRONMENTAL CHANGE
The available evidence points to a specific set of widely agreed-upon behavioral
changes that are likely to promote energy balance. These behaviors are identified
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BMI Category
18.5-24.9 (healthy weight) 25.0-29.9 30.0-34.9 (obese) 35.0-39.9 40 or more (extreme obesity)
0.4 1.2
1.3 2.0
100% 3.7
4.1 4.6
11.8
90%
80%
70%
60%
50%
40% 76.3
65.2
61.8
30% 58.4
52.2
40.4
20%
33.7
28.4
10%
0%
1985-86 1995-96 1985-86 1995-96 1985-86 1995-96 1985-86 1995-96
Women Men
Men Women
Black White
FIGURE 3-1 Ten-year changes in the distribution of body mass index in the Coronary Artery Risk
3-1.eps
Development in Young Adults (CARDIA) study.
SOURCE: Lewis et al., 2000.
as essential elements in obesity prevention for children, adolescents, and adults, as
appropriate to life stage (Box 3-3). For physical activity, targeted behaviors relate
to specified amounts of physical activity following guidelines for children, ado-
lescents, and adults and decreases in television viewing—a major form of physi-
cal inactivity. For eating behaviors, the focus is on overall dietary quality as well
as appropriate caloric consumption, achieved by increasing plant-based dietary
components; reducing the consumption of sugar-sweetened beverages and of high-
calorie, energy-dense foods; increasing breastfeeding and responsive child feeding;
and ensuring the intake of nutrients needed to promote optimal linear growth.
In general terms, the types of environmental changes needed to motivate and
support the indicated changes in individual behavior are directly related to the
types of changes identified in the preceding chapters as having led to popula-
tionwide increases in weight gain and obesity and listed in Boxes 3-1 and 3-2 as
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BOX 3-2
Goals of Obesity Prevention in Adults
Individual Adults
• Maintenance of weight during adult years, i.e., avoiding gradual incremental
weight gain with increasing age
• Maintenance of waist size during adult years, i.e., avoiding gradual accumulation
of fat around the abdomen
• Avoidance of weight regain after voluntary weight loss
• A high-quality diet with appropriate caloric intake (quality and quantity)
• Appropriate amounts and types of physical activity
• Appropriate prepregnancy weight, pregnancy weight gain, and subsequent post-
partum weight loss
• A healthy body image and the absence of potentially adverse weight concern or
restrictive eating behaviors
Population of Adults
• Reduction in the incidence of adult obesity
• Reduction in the prevalence of adult obesity
• Reduction of mean population body mass index (BMI) levels
• Improvement in the proportion of adults with dietary quality meeting the Dietary
Guidelines for Americans
• Improvement in the proportion of adults meeting physical activity guidelines
• A population with weight and fitness levels conducive to a productive society
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Examples of Possible Intermediate Indexes of Progress Toward Obesity
Prevention in Adults
• Increased number of adults who routinely use active means of transportation,
e.g., walking or cycling
• Improved access to and affordability of fruits and vegetables for low-income
populations
• Increased availability, affordability, and use of community recreational facilities
• Increased opportunities to be physically active at work
• Increased number of new industry products and advertising messages that pro-
mote energy balance at a healthy weight
• Increased availability and affordability of healthful foods and beverages at
supermarkets, grocery stores, and farmers’ markets located within walking dis-
tance of the communities they serve
• Community designs and social characteristics that encourage being physically
active outdoors
• Changes in institutional and environmental policies that promote energy balance
SOURCES: IOM, 1995; USDA/HHS, 2010.
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BOX 3-3
Target Individual Behaviors for Obesity Prevention
Activity-related
• Increase physical activity/promote an active lifestyle.
• Children and adolescents get at least 60 minutes of physical activity per day.
• Adults aim for 150 minutes of moderate-intensity or 75 minutes of
vigorous-intensity physical activity per week.
• Decrease television viewing.
Diet-related
• Increase the consumption of fruits and vegetables and legumes, whole
grains, and nuts.
• Limit calories from added sugars, solid fats, and alcohol.
• Decrease the consumption of sugar-sweetened beverages/soft drinks.
• Increase breastfeeding initiation, duration, and exclusivity.
• Reduce the consumption of high-calorie, energy-dense foods.
• Parents accept their child’s ability to regulate energy intake instead of eat-
ing until the plate is empty.
• Ensure appropriate micronutrient intake to promote optimal linear growth.
SOURCE: IOM, 2010.
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potential intermediate indicators of progress. Thus, the needed changes relate to
options for physical activity, factors that predispose to sedentary behavior, the
food supply, and food availability and promotion. Potential strategies for effecting
such changes are the focus of the remainder of this chapter.
A COMPREHENSIVE AND INTEGRATED APPROACH
TO PREVENTING AND ADDRESSING OBESITY
Identification of the behavioral and environmental variables that contribute
to the populationwide obesity epidemic and how they influence and interact with
each other is needed to determine which prevention efforts are the most promis-
ing. Both the 2005 IOM report and the follow-up report, Progress in Preventing
Childhood Obesity: How Do We Measure Up? (IOM, 2007) use an ecological
approach to identify leverage points for developing effective intervention strategies
to promote energy balance, and specifically address individual factors, behavioral
settings, sectors of society, and social norms and values that may constrain or
reinforce regular physical activity and healthful eating as the accepted and encour-
aged standard. Using the model shown in Figure 3-2, pathways can be drawn
to identify specific influences on the weight-related behaviors of individuals in
demographically diverse population groups, within and among the levels shown.
Each type of setting shown (top left) and each of the several sectors that can be
focal points for intervention (at right) are complex, and these settings and sectors
are interrelated. The different levels at which interventions may be undertaken
demonstrate how, if taken together, a set of actions across levels might interrelate.
Therefore, this figure illustrates the overall complexity of influences on obesity,
and shows that preventive actions must be comprehensive and can vary according
to the diversity and interrelationships that apply. Homes and families are often
listed under “behavioral settings,” which would be appropriate. As explained in
Chapter 1, however, the committee’s approach emphasizes changes in settings
and sectors that can accelerate obesity prevention by improving physical activity
options and healthful eating, as well as facilitators at both the family or household
and individual levels, taking into account their interdependence.
The influence of obesity on the economy, productivity, and population fit-
ness was highlighted in Chapter 2, emphasizing the importance of addressing the
epidemic not only for governments but also for businesses and the private sector.
The “sectors of influence” on obesity in Figure 3-2 have, therefore, been updated
from prior versions to highlight the potential contributions of businesses other
than those directly involved in the manufacturing of products related to physical
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Goals, Targets, and Strategies for Change
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quence, of particular importance for children and adolescents, is the inadvertent
generation or aggravation of poor body image, low self-esteem, preoccupation
with dieting, or inappropriate weight concern, which can impair healthy growth
and physical and psychosocial development (Griffiths et al., 2010).
Kersh and Morone (2002) point out the troubling reality that movements
toward government action on personal behaviors sometimes take an oversimplified
view that begins with public disapproval or demonization of the affected popula-
tion—e.g., alcoholics, drug users—as weak or irresponsible. Given the prevailing
attitudes about obesity and the fact that it is more prevalent in low-income and
minority communities, the same effect could occur in the case of the obesity epi-
demic. Policies and practices to address obesity must take this potential for harm
into account and incorporate appropriate safeguards, including the institution of
measures to track such outcomes. The case for addressing the obesity epidemic
cannot be made at the expense of obese people. Ethical arguments can be and have
been made against measures that penalize obese people. For example, when air-
lines began requiring passengers who were unable to fit safely into one seat to pay
full price for a second seat, many major airlines were sued for discrimination. The
Canadian Supreme Court formally prohibited airlines from charging obese passen-
gers for additional seats. Despite the opposition, however, some airlines have kept
such policies in place.
Careful consideration of the terminology used when discussing the topic and
images used to illustrate obesity is warranted to avoid reinforcing negative stereo-
types. In addition, making an effective case for universal interventions—that is,
environmental and policy-level changes that do not rely on screening and iden-
tification of children, adolescents, or adults who are at high risk of obesity or
are already obese (IOM, 1995)—will help mitigate potential adverse effects on
individuals.
Effects on Racial/Ethnic Minority and Low-Income Populations
The potential for negative stereotyping and social disapproval also applies
at the group level. Similar to the considerations for individuals, this means that
drawing attention to the high prevalence of obesity in racial/ethnic minority
or low-income populations, as in Chapter 1 of this report, must be done not
only carefully with respect to terminology and imagery but also accurately with
respect to evidence about what is driving the higher obesity rates in these groups.
Specifically, a coherent body of evidence implicates relatively greater exposure to
the types of environmental contributors that predispose to low levels of physical
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activity and excess energy intake in higher obesity rates among racial/ethnic
minority and low-income populations (Kumanyika et al., 2008). For example,
options for safe and affordable leisure-time physical activity are generally less
common in racial/ethnic minority and low-income communities (Gordon-Larsen et
al., 2006; Powell et al., 2006; Taylor et al., 2006). Likewise, food availability and
promotion are less favorable to healthy eating patterns in such communities (e.g.,
fewer supermarkets selling a greater variety of foods; more fast-food restaurants;
and more advertising of fast food and of high-calorie foods and beverages gener-
ally) (Grier and Kumanyika, 2008; Kumanyika and Grier, 2006; Taylor et al.,
2006; Yancey et al., 2009). Black and Latino children and adolescents are particu-
larly targeted by marketers of sugar-sweetened beverages and fast food, and their
vulnerability to such advertising may be increased by their developmental char-
acteristics, limitations on their ability to recognize when advertising is targeting
them, and certain techniques used in multicultural marketing (Grier, 2009; Grier
and Kumanyika, 2010; Powell et al., 2010; Tharp, 2001). It is unclear whether
there are systematic neighborhood differences in the cost of healthy foods in
racial/ethnic minority or low-income communities compared with other commu-
nities (Grier and Kumanyika, 2008; Krukowski et al., 2010). However, evidence
indicates that the lowest-cost foods may be the least healthy (Drewnowski, 2009).
Thus, households with limited resources may buy less healthy foods to stretch
their dollars. It is worth noting that among immigrant populations, the preva-
lence of obesity tends to increase with duration of residence in the United States
(Oza-Frank and Cunningham, 2010), a fact that also strongly implicates environ-
mental factors in excess weight gain.
Sociocultural influences are part of the environment affecting physical activity
and eating habits, and interact with other aspects of the environment (Swinburn
et al., 1999). Characteristics of physical activity or food marketing environments
and the high prevalence of obesity itself may influence social norms about physi-
cal activity and healthy eating, making higher weight, consumption of high-calorie
foods and beverages, and sedentary behavior seem normal and appropriate. Body
image norms that associate thinness with ill health and larger body sizes with
good health and robustness may decrease recognition of clinically significant
obesity and undercut motivation for weight control, particularly if large body
size is normative in the community (Brown and Konner, 1987; Diaz et al., 2007;
Kumanyika, 2008; Liburd et al., 1999). Ethnically targeted marketing, which
incorporates cultural preferences, imagery, and traditions and relationship build-
ing with the targeted communities (Tharp, 2001), may reinforce cultural attitudes
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and preferences that favor the consumption of high-fat or high-sugar foods if these
are the types of foods marketed. Some cultural preferences are based on foods
that may at one time have been difficult to obtain but may now be overabundant
in racial/ethnic minority communities (Kumanyika, 2006, 2008). With respect to
low-income or food-insecure populations, retail food promotions such as two-
for-one deals, 99 cent menus, or large portion sizes, which are for relatively less
healthful foods, may hold appeal (Power, 2005). Also, foods that are promoted as
normative and desirable for the general population may be attractive to consumers
in low-income populations as symbols of belonging or participating in mainstream
lifestyles (Power, 2005).
TRACKING PROGRESS IN THE CHANGE PROCESS
Examples of outcomes of interest for tracking progress in the process of
change include (1) the quality, scope, reach, and intensity of effects of obesity
prevention policies and programs, to answer the questions of what is being done
and whether enough of the appropriate types of interventions are occurring to
expect success and (2) improvements in intermediate measures of progress toward
goals, such as the indicators listed in Boxes 3-1 and 3-2. Assessments should
include measures relevant to reaching high-risk populations. Ideally, assessments
of progress through interim measures would be traceable to particular intervention
approaches and also to obesity outcomes.
The committee that produced Progress in Preventing Childhood Obesity: How
Do We Measure Up? (IOM, 2007) concluded that the infrastructure for assessing
progress was severely underdeveloped and inadequately conceptualized. That report
includes specific guidance on needed approaches and provides an evaluation frame-
work to facilitate adoption of these approaches. Several advances have since been
made in the development of concepts and tools for assessing the success of obesity
prevention efforts. These include the aforementioned IOM report on a framework
to inform decision making on obesity prevention (IOM, 2010), several ongoing
efforts to compile evidence on promising programs (Appendix B in IOM, 2010),
recommendations for improving the likelihood that ongoing policies and programs
can be well evaluated (Leviton et al., 2010), and the development of a detailed
framework and process for assessing the strength of evidence for various policy and
environmental change strategies undertaken to prevent childhood obesity (Brennan
et al., 2011). With respect to the ability to track progress on interim environmental
and policy changes and behavioral trends, the National Collaborative on Childhood
Obesity Research (NCCOR [http://www.nccor.org/css]) has developed publicly
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available, interactive online databases to facilitate the identification of relevant
resources—a catalogue of surveillance systems with data related to childhood obe-
sity prevention and a registry of research measures for assessing physical activity
and dietary intake (http://www.nccor.org/projects_registry_of_measures.html).
CONCLUSION
Although the obesity epidemic in the United States has been instrumental in
bringing worldwide attention to the problem—as noted in Chapter 1 and illus-
trated by Figures 2-7 and 2-8 in Chapter 2, showing the increases in global as well
as U.S. media attention to the problem—the epidemic extends across the globe.
Extensive analyses and strategizing on how to approach the epidemic have taken
and continue to take place in many countries, particularly in light of the implica-
tions of obesity for rising rates of cardiovascular diseases, diabetes, and other
noncommunicable diseases globally (OECD, 2010; Swinburn et al., 2011; WHO,
2011). Among the most comprehensive efforts to understand the obesity epidemic,
identify effective interventions, and formulate a national action plan was carried
out by the Foresight Group in the United Kingdom (Foresight, 2007), which iden-
tified a broad range of factors that influence obesity and relationships among key
factors in an effort to develop the most effective future responses to obesity for
that country.
The consensus among stakeholders engaged in trying to address the obesity
problem is that meaningful change on a societal level is needed if individuals’
attempts to change their physical activity and eating behaviors are to be effec-
tive (Foresight, 2007; White House Task Force on Childhood Obesity, 2010;
WHO, 2000). The needed societal changes must be achieved through a public
health approach that focuses on policy change and interventions in the environ-
ments in which people live, learn, work, and play. Complex realities associated
with the obesity epidemic include practical and policy considerations, some of
which may impede progress or lead to unintended adverse consequences that must
be addressed during the design, implementation, and evaluation of measures to
accelerate obesity prevention. These considerations include the nature of modern
lifestyles, uncertainty or ambivalence about whether or how governments or other
decision makers should use policy strategies to shift population physical activity
and eating behaviors, the tensions associated with attempts to regulate food
marketing to children and adolescents, and the potential adverse effects of obesity
prevention efforts on individuals and population subgroups that are most affected
by obesity.
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The relevant causal pathways, settings, and sectors for intervention in other
high-income countries (e.g., Australia, Canada, Europe, and New Zealand) bear
many similarities to those in the United States. Analyses and experiences from
these countries—for example, with respect to taxation; regulation of food adver-
tising; and school, health care, or whole-community interventions—or modeling
of cost-effectiveness may offer rich opportunities to inform U.S. strategies. The
committee recognized the potential value of learning from this broader experi-
ence. However, experiences in other countries underscore the importance of tailor-
ing and adapting strategies to policy mechanisms, environmental characteristics,
health care systems and other institutional infrastructures, and sociocultural
norms and values that apply nationally, regionally, and locally.
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