Changing the Obesity Landscape

Turn on the television. There it is—voluptuously plump, dripping with juice, beckoning you to take a bite.  Walk through the mall. There it is again, this time in a different incarnation: Aromas of sweet and savory waft your way, caress your olfactory receptors and lure you toward their source. 

Drive through town. It appears yet again, now in the form of fast-food restaurants that promise you a quick fix to your hunger, thirst or boredom.  

“It” is everywhere—at the mall, in the workplace, on TV and the Internet. We’re surrounded by an intoxicating surfeit of food that is cheap, calorie-laden and easy to prepare or obtain. Our “obesogenic environment” promotes a single theme: Eat. Drink. Consume.  

The effects are obvious: Two-thirds of American adults are overweight or obese. Obesity among American children has more than tripled in the past 30 years. And chronic diseases associated with obesity are rising. 

In response to this health crisis, Bloomberg School researchers are pursuing a broad range of strategies aimed at changing our social, cultural and physical landscape. Their goal: Paint a new canvas that encourages healthy eating and physical activity.

Change the food system

Try this: Walk into a grocery store with $20. With half your money, purchase packaged foods and snacks (macaroni and cheese in a box, cookies, chips). With the other half, buy fruits and vegetables. Then calculate the calories in each set of purchases.  

Chances are, your processed food dollars will buy you many times more calories, and far more of them will come in the form of fat and sugar, says Robert Lawrence, who credits Hopkins anthropologist Sid Mintz for the idea behind this thought experiment. 

Our agriculture system makes producing fat and sugar relatively inexpensive, notes Lawrence, MD, director of the School’s Center for a Livable Future (CLF). “We have a food industry that is scientifically designed to addict us to a combination of fat, sugar and sodium as high as it can be in calories,” he says. 

The solution: Change the system. Admittedly no small task, says Lawrence, the Center for a Livable Future Professor. He says he’d start with the Farm Bill. Many of his colleagues in health policy and nutrition agree. 

The omnibus bill governing much of the nation’s agriculture and food policy is currently at $284 billion, and large portions of that funding support select agriculture sectors. In 2009, corn producers received $3.9 billion, soybean producers $1.7 billion, and wheat producers $2.2 billion.  

Such funding may indirectly fuel the obesity epidemic, says Roni Neff, CLF research and policy director. Corn, for example, is cheap to produce, and therefore so is high-fructose corn syrup, the sweetener in most sodas. And increased soda consumption is a leading suspect in the search for culprits fueling the obesity epidemic. 

In addition, farm policy encourages overproduction, notes Neff, PhD ’06, MSc. American farmers produce almost 4,000 calories per person per day. “So there are profits to be made from convincing us to eat as much as possible of this surfeit,” she says. 

She and Lawrence say they’d like to shift that balance, so that more financial incentives go toward producing a healthy food supply, including support for farms that grow a mix of foods, such as grains, fruits and vegetables. Farm policies might also address the overproduction issue by promoting conservation and assuring farmers a more stable living, thus reducing their need to maximize production. 

Neff and others at the CLF are dissecting the different streams of funding in the Farm Bill to see where each goes—toward fruit and vegetable production, meat production, sustainable agriculture, etc. They are also developing a set of policy briefs describing how various parts of the bill affect public health and are working to develop farm policies that would better support public health. Preliminary hearings have begun on the current round of the Farm Bill, which is expected to come up for a vote in 2012. “There is more public health interest in the Farm Bill than ever before,” says Neff. 

Adds Lawrence, “We are starting to demonstrate a connection between a universal health problem and our food supply.”

Share the power to change 

On a steamy hot August afternoon, several thirsty teenagers walk into a West Baltimore corner store and head to the refrigerators, where cold soda, juice drinks and water await. As they open the refrigerator doors, they may—or may not—notice the fluorescent sign above: DID YOU KNOW THAT WORKING OFF A BOTTLE OF SODA OR FRUIT JUICE TAKES 50 MINUTES OF RUNNING? 

Many people apparently do not know, says Sara Bleich, an assistant professor in Health Policy and Management. But she is testing the idea that such nutritional information can persuade consumers, specifically teenagers, to cut down on the number of empty calories they consume. 

Bleich, PhD, admits that changing people’s behavior is a huge challenge, one made especially difficult given the marketing competition. Of the many billions of dollars spent on food advertising, almost 70 percent goes toward promoting convenience foods, candy, snacks, soft drinks, alcoholic beverages and desserts, according to one assessment, while ads for fruits and vegetables, grains or beans account for only 2 percent. Plus, in corner stores a can of soda costs as little as 60 cents, while a bottle of water is usually a dollar or more. 

Studies examining the persuasive power of information on food choices have shown mixed results. For instance, a report on a two-year-old New York City law requiring that franchise restaurants post calorie counts of their foods concluded that the law had no effect on the number of calories consumers purchased. A second study, however, showed that calories purchased did decline at one specific category of restaurants: coffee shops. 

In her study, Bleich and graduate student Desmond Flagg are targeting teenagers in a largely African-American neighborhood. Obesity among African-American teens is 25 percent. The success of her information campaign could depend upon the type of information conveyed. In their study, Bleich and Flagg are comparing different messages about sweetened drinks. 

In addition to the poster about running, other signs point out how many calories a bottle of soda or fruit juice has or what percentage of one’s daily recommended calories it contains. Flagg, a C. Sylvia and Eddie C. Brown Community Health Scholar, posts a sign and then records the beverages that teenagers purchase. At the end of the study, he and Bleich will compare the results for the different signs. 

Targeting sweet drinks is a tactical choice, says Bleich. These beverages are laden with sugar and calories. A 12-ounce bottle of cola, for instance, contains the equivalent of about 10 teaspoons of sugar. And sweetened drinks (mainly soda) make up 16 percent of the calories teens consume, says Bleich. “So if you can pull that out of the diet, it can have a big impact.”

Look outside the U.S. for models of success

It’s lunchtime in a Barcelona school. Instead of pulling sandwiches and chips from paper lunch bags, these children are cooking lunch themselves (under a teacher’s supervision), using fresh vegetables they just selected during a trip to the market.

Once they’ve finished their preparations, the children will be able to savor their lunches. In Barcelona, as in much of Europe, children have 90 minutes to eat. Contrast that with many U.S. schools, where the first lunch wave may roll into the cafeteria at 10:30 a.m., and students have only 20 minutes to bolt their meal. 

“In 20 minutes, you can’t even find out what you ate. You need time to enjoy the flavors and to recognize what you’re eating,” says Benjamin Caballero, professor of International Health and founder of the School’s Center for Human Nutrition. When kids can eat at a more leisurely pace, and if they can also help select and prepare their food, he says, “they appreciate it more and they care more about it”—which might translate into healthier eating. 

Caballero, MD, PhD, has visited Barcelona schools during lunchtime and observed child chefs preparing their meals. While the government-sponsored program does not specifically target obesity, it is one example of an initiative abroad that might hold lessons for the U.S. in battling its own obesity epidemic, he says. 

Another program, Agita Sao Paulo, was introduced in that city in 1996 to encourage Sao Paulo’s then-10 million residents to engage in 30 minutes of physical activity every day. Promoting movement in all sorts of venues, from city squares to bus stops, the program espouses the idea that even moderate exercise benefits health. As studies demonstrated Agita’s dramatic success, cities throughout Brazil adopted the plan, and now the WHO has launched its own “Move for Health” program. 

And in China, Bloomberg School nutritional epidemiologist Youfa Wang, MD, PhD, MS, is developing an intervention that will use the Internet and cell phones to transmit messages about healthy eating. The project, still in the early planning stages, will involve about 200 middle school students and their parents 

Clearly, not every strategy tried elsewhere will work in the U.S., and for a program to succeed, its designers must understand the constraints, such as tight budgets. American schools, for example, are stretched for funds and time, but Caballero says they might consolidate various health-related curricula and make nutrition education an important component. “We need to prioritize health,” he says. “What is the long-term legacy of school? It’s not just passing tests.”

Work it out in the workplace

Boxes of doughnuts on the counter. Pastries and chips in the vending machines. Bacon, eggs and soda in the refrigerator. That’s the “food environment” Stephan Cox typically finds when he walks through the Bel Air, Maryland, firehouse where he’s volunteered since 1968.  

For Cox, whose day job is serving as regional fire chief for the Navy Mid-Atlantic Region, it was a recipe for obesity and poor health. As of last fall, he was significantly overweight, on medication for high blood pressure and elevated cholesterol, and was borderline diabetic. So when he heard about a Bloomberg School project aimed at reducing cardiac risk factors among volunteer firefighters, he was keenly interested. 

Heart attacks are the number one cause of on-duty deaths among firefighters, says Keshia Pollack, PhD ’06, MPH, an assistant professor of Health Policy and Management who is directing the study. The three-year project, conducted in collaboration with the National Volunteer Fire Council, is sponsored by an Assistance to Firefighters Grant through the Federal Emergency Management Agency.

Dozens of other interventions and studies aimed at reducing obesity have been tested in various workplaces, says Pollack, and some have shown promising results. “It is important for a person to learn how to be healthy while at work since we spend so many of our waking hours at work,” says Pollack. Her ideal workplace would have vending machines that sell water and healthy snacks, bike racks, on-site gyms and opportunities for employees to take breaks for short walks. 

Pollack is currently exploring several strategies for improving the food environment at the firehouses in her study. One is a Farms-to-Firehouses program, in which vegetable farms located near the firehouses would deliver fresh produce directly to the stations. As part of the plan, Pollack envisions nutrition and cooking classes to help participants learn how to prepare healthy dishes with the produce they receive. 

She and Lawrence Cheskin, MD, director of the Johns Hopkins Weight Management Center, and two other co-investigators have also recruited volunteers among the firefighter leadership to serve as role models. Cox was their first recruit. Under Cheskin’s guidance, he’s improved his diet and increased his daily exercise routine. The changes weren’t radical, notes Cox, but they were enough to make a difference. One year in, he’s 40 pounds lighter and no longer needs medication for his blood pressure or cholesterol. He hopes his story will inspire others. 

Already, says Cox, people seem to be listening. “It’s not all that uncommon that I’ll walk into a fire station, and someone will say, ‘Hey, chief, you’re slimming down really good.’ And that feels good.”  

Ease the nutrition transition

This past July, a large barge set sail from the Brazilian town of Belem carrying a cargo of candy, ice cream, juices and other products bearing the Nestle brand. The barge—or "floating supermarket," as Nestle termed it—was scheduled to travel to 18 small cities to market Nestle products to 800,000 new customers who previously had no access to such items.

In a press release, Nestle Brazil CEO Ivan Zurita called the venture "a service to the population of the Amazon, who has streets and avenues in the form of rivers."

But as a nutritionist, Benjamin Caballero calls the plan a disservice. "It's predatory capitalism," says the professor of International Health. Since the people in the region have not been exposed to the packaged foods that characterize the Western diet, he notes, Nestles outreach could contribute to obesity and instigate the first stage of a pattern called the "nutrition transition."

The nutrition transition is a shift in a population's eating patterns and lifestyle that occurs as countries become more prosperous. Industrialization and economic growth generally usher in Westernized foods and habits—more fat, sugar and processed foods, and a more sedentary lifestyle.

All of these changes fuel obesity, says Caballero, who co-edited a book with Barry Popkin called The Nutrition Transition, Diet and Disease in the Developing World. Doctors and public health officials are concerned because as obesity climbs, so do its companion chronic diseases, such as high blood pressure, diabetes, stroke and heart disease.

In some countries experiencing rapid development, the impact is especially severe. Eight of the 10 countries with the fastest rising obesity rates are developing nations or newly industrialized, notes Caballero. For example, in China, Mexico, Thailand, Brazil and Morocco, obesity is increasing more rapidly than it is in the U.S. Paradoxically, several countries, such as Bangladesh, still struggling with high rates of malnutrition, are at the same time experiencing rising rates of obesity and chronic diseases associated with an unhealthy diet and inactive lifestyle. Worldwide, 60 percent of deaths are now attributed to chronic diseases (such as heart disease, diabetes and cancer) associated with obesity and lack of physical activity.

What can be done?

For one thing, Caballero would like to see companies such as Nestle take a step back and assess what people in remote regions truly need. Perhaps it's housing or education rather than candy. A scholarship with the Nestle imprimatur would benefit local people while still promoting the company's name, he notes.

Caballero would also like governments to get behind international efforts to promote a healthy diet and physical activity, such as a WHO endeavor called the Global Strategy on Diet, Physical Activity and Health. The strategy calls for nations and the private sector to support food and agriculture policies, marketing plans and education campaigns that encourage healthy eating and promote physical activity. It supports limiting sugar, fat and salt in the diet, and increasing the consumption of fruits, vegetables, whole grains and nuts.

There is a glimmer of good news: Some of the nations now struggling with a relatively new obesity epidemic are starting to address the problem, notes Caballero. Mexico, for example, has implemented a comprehensive program that combines efforts to attack poverty and curtail obesity.

Zone for health

In theory, it makes perfect sense: If people live in a place where it is safe to walk, jog or skateboard; if they have parks and playgrounds nearby, they'll be more active. Plus, if they live far from clusters of fast food restaurants and close to fully stocked grocery stores and farmers markets, they'll eat a healthier diet. Overall, their "built environment" will be more conducive to health.

Some communities have embraced that philosophy, and are starting to adjust zoning regulations with public health in mind. However, there's little data to show precisely what type of zoning would most effectively promote health, notes Brian Schwartz, MD, MS, professor of Environmental Health Sciences and co-director of the Program on Global Sustainability and Health.

To find some answers, Schwartz is conducting an exhaustive epidemiological study of the built environment and its impact on health. Working with the Geisinger Health System, he gathered a trove of data about the built and social environments in a large swath of central and northeastern Pennsylvania—data that include detailed information on food, physical activity, land use and social environments.

He then "geo-coded" about 50,000 children enrolled in the Geisinger Health System—that is, mapped each child to a specific latitude/longitude location, and then overlaid information about the children's health status (specifically, their body mass index, or BMI) on top of the environmental data. The study is ongoing, notes Schwartz. But his preliminary results suggest that the built environment does influence BMI, and that effect appears to vary depending on age.

For instance, living in densely populated neighborhoods is associated with a lower BMI in teenagers—but not in elementary and middle schoolers. Schwartz's interpretation? "Population density is a surrogate for compact development," he says. In such a community, schools, shops, recreation centers are more accessible and within walking distance for teens. But younger children are often not allowed the same freedom to traverse their neighborhoods. Other factors were associated with lower BMIs in this age group. For example, middle school children in neighborhoods that had a higher diversity of physical activity options had lower BMIs, Schwartz notes.

Meanwhile, in a separate project, researcher Keshia Pollack is focusing on one specific element of the built environment—the route to school. She has been documenting in detail the environment children encounter as they walk from their homes to six elementary schools in different parts of Baltimore. Walking to school affords a child a chance to exercise and burn calories. Research shows that young walkers are more physically active than those who travel to school by car. That route also reflects the safety of a child's neighborhood overall. If streets, parks and playgrounds aren't safe, then parents want to keep their kids indoors, and those children will be less physically active. Unfortunately, says Pollack, "some of these children are walking to school in the most hazardous neighborhoods."

Pollack is quantifying those risks. She is gathering data on various parameters that may affect children's safety as they walk to school,such as the number of abandoned homes along the route, and statistics on crimes committed in the vicinity, particularly near playgrounds.

Her findings, says Pollack, "are an opportunity to introduce some science into zoning decisions." Baltimore City, for example, is currently revising its zoning code. Some proposed changes, such as additional speed bumps, sidewalks and pedestrian signals—or even police patrols at strategic locations—could make the path to school safer and encourage kids to walk more.

If there is a common theme voiced by scientists seeking ways to curb obesity, it's that there is no single strategy for fixing our obesogenic environment. Change will require strategies on multiple fronts.

There is at least one sign that such efforts are starting to succeed: National survey data show that childhood obesity rates have started to level off in the U.S. and some other countries. It's not yet time to claim victory, however, says International Health associate professor Youfa Wang. He's taken a closer look at the U.S. data and has a more nuanced interpretation of what they reveal. "The decline is really mainly among young children, ages 2 to 5," says Wang.

If the decline is real, it's encouraging news. But the experts are unanimous that vigorous efforts are still urgently needed to inspire healthy eating and exercise habits.