8: No. 5, September 2011
Rogan Kersh, PhD; Donna F. Stroup, PhD, MSc; Wendell C. Taylor, PhD, MPH
Suggested citation for this article: Kersh R, Stroup DF, Taylor WC. Childhood obesity: a framework for policy approaches and ethical considerations. Prev Chronic Dis 2011:8(5):A93.
http://www.cdc.gov/pcd/issues/2011/sep/10_0273.htm. Accessed [date].
Although obesity rates among US children have increased during the past 3 decades, effective public policies have been limited, and the quest for workable solutions raises ethical questions. To address these concerns, in 2010,
the Robert Wood Johnson Foundation convened an expert panel to consider approaches to the ethics problems related to interventions for childhood obesity. On the basis of recommendations from the expert panel, we propose frameworks for policy approaches and
ethical aspects of interventions and evaluation. We present these frameworks in the context of other papers in this collection and make recommendations for public health practice.
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Childhood obesity in the United States presents major health challenges, but neither the medical industry, public health advocates, nor policy makers have identified effective ways of reversing increasing rates of obesity among youth. Policy debates often
focus on low energy expenditure attributable to increasingly inactive lifestyles. However, efforts to
increase physical activity among youth have limited benefits without simultaneous attention to decreasing caloric consumption. A study among
middle-school children reported that risk of obesity increased by 60% for every additional sugar-sweetened beverage consumed per day, regardless of levels of exercise (1).
Although obesity is linked to unhealthy diet and insufficient physical activity, prevention efforts and responsibility
for the problem remain controversial. Whose job is it to ensure that children have a healthy life: parents
and caregivers, schools, communities, the state? Children may be particularly vulnerable to harm because of their limited ability to make choices, dependence on adults for food and other goods, and susceptibility to marketing.
The quest for solutions raises many ethical questions explored in this collection. Do interventions involving children raise concerns different from those for adults? Does public policy attention to childhood obesity exacerbate body-weight concerns that can fuel stigma and potentially cause bulimia and anorexia? In situations where multiple, simultaneous interventions on different levels are needed, how might testing a single intervention communicate misleading results about the efficacy of
achieving sustainable reform?
In this commentary, we summarize recommendations of the expert panel. First,
we present a policy framework for interventions for childhood obesity. Second, we develop a framework for addressing ethical issues. Third, we review 3 policy approaches to support this framework. Finally,
we discuss the application of these frameworks for existing and planned interventions.
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Competing Policy Solutions
One perspective in US political discussions about childhood obesity emphasizes personal responsibility, holding that food consumption is an individual matter and that parents, and eventually adolescents themselves, are best situated to make consumption decisions (2,3). This view informs policy actions that emphasize improved access to volitional physical activity and healthy diets (4).
As concern over childhood obesity has increased, a competing policy framework has gained support. In an obesogenic environment, children may find their food choices influenced by availability, price, and marketing of high-fat, low-nutrient processed foods. Messages targeting youth start from an early age wherever they congregate, including at school (5). In this environmental view of childhood obesity, public officials have a responsibility to intervene through policies such as the
- Controlling the conditions of sale (eg, limiting what schools can offer).
- Restricting advertising of high-fat, low-nutrient foods that targets young children or
using other alternatives to increase awareness of what they are eating (eg, requiring calorie labels on menus).
- Subsidizing healthier alternatives (eg, fruits and vegetables) that have much higher per-calorie costs than do most other foods, many of which are or include ingredients (eg, corn syrup and sugar) that are subsidized under US farm policies.
- Restricting or banning certain ingredients (eg, trans fats).
Policy initiatives to control availability of competitive foods have been introduced at all levels of government. One congressional bill expands the list of foods of minimal nutritional value forbidden for sale in school cafeterias and on campus (6). An example at the state level is Connecticut’s Healthy Food Certification program, which provides monetary incentives to school districts that choose to implement state nutrition standards for all foods sold to students outside
reimbursable school meals (7). The effort to assess and advance policy changes as discussed in this collection raises legitimate ethical concerns, to which we now turn.
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A Framework for Ethical Issues
|Box. Characteristics of State Interventions for Childhood Obesity Under the Stewardship Model
Public health programs should
- Attempt to reduce risks for obesity that populations might impose on each
- Reduce causes of obesity through legislation or regulation that creates
environmental conditions that sustain good health (eg, access to healthy foods
and opportunities to be physically active).
- Emphasize attention to the health of children and other vulnerable
populations (eg, those with disabilities).
- Promote health not only by providing information but also with programs
that help populations maintain exercise and healthy diets.
- Make leading a healthy life easy.
- Ensure that populations have access to services.
- Strive for justice in health.
Public health programs should not
- Coerce populations into leading healthy lives.
- Develop and introduce interventions without the consent or participation
of those affected.
- Implement interventions that are intrusive or conflict with personal or
Adapted from: Nuffield Council on Bioethics
One ethical concern raised by these policy interventions is the association between individual autonomy and state authority. The libertarian perspective limits the authority of the state
to ensure individual freedom, whereas utilitarian and social-contract approaches allow individual interests to be secondary to increases in overall welfare. One theory for approaching this ethical concern is provided by John Stuart Mill’s harm principle: state intervention is justified when a person’s actions affect others (8). This principle recognizes the responsibility of the state to protect vulnerable populations from harming their own (or others’) health. This harm principle can be applied to interventions for childhood obesity through a stewardship model (9), which argues that the state is a steward to people and communities (Box). A reasonable application of this stewardship role is the constitutional principle of police and public health authority
explored by Harris and Graff in this collection (5).
The articles in this collection explore ethical questions about the role of
the state or other societal structures in stewardship. For example, as the state
attempts to protect school children by measuring and reporting body mass index
(BMI), how can concerns about privacy and stigmatization be addressed (10)?
Other questions concern the extent to which parents and other community members
are responsible for
providing children a safe environment and whether childhood obesity can be
child protection problem (similar to child abuse) needing societal intervention
(11). Governments must prevent their actions from affecting certain
communities disproportionately; for example, do taxes on sodas unjustly punish
persons of lower socioeconomic levels (12)? Are state-provided interventions
accessible to children with special health care needs (13)? How can we address
the stigma associated with the use of the term “obese” (14)? Although food industry officials argue that marketing cannot force consumers to do anything,
marketing continues to have a substantial impact. What should be the role of
media literacy and restrictions on use of cartoon characters, celebrities, or health claims (5)? What can we learn from the restrictions on tobacco marketing (12)?
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Examples of Application of the Framework
We present 3 examples of policy interventions for childhood obesity to illustrate the application of these frameworks in light of the ethical issues explored in this collection.
Menu calorie labeling
In 2008, no place in the United States required restaurants to post calorie
labels. Two years later, dozens of jurisdictions and the United States itself
have enacted menu-labeling laws (5). However, recent studies report that calorie
information may not be a determining consideration in food choices;
accessibility, taste, habit, perception, peer influence, and parental modeling also influence children’s food choices (11). Thus, menu calorie labeling alone may
not be effective, and communities considering this policy intervention would be well advised to consider the role of personal autonomy in implementing such interventions.
Soft drink tax
Forty states and many cities levy taxes on low-nutrition foods (12). As for taxes to decrease cigarette consumption, controlled experiments have shown that manipulations of price can yield changes in consumption (15).
The number of jurisdictions with soda taxes has declined in recent years concurrent with lobbying efforts by the beverage industry,
but taxes have reduced consumption and increased revenue for other health-related programs (16). Just as for menu calorie labeling, the health
benefits of a soda tax as a stand-alone intervention are less clear (17).
Interventions in schools
The United States has built a public education system on the principle that no child should be denied the right to an education on the basis of socioeconomics or other challenges, yet when a child becomes obese, that child struggles to achieve academic success because of stigma,
depression or anxiety, or absenteeism (18). Resources could be a factor in a school’s reliance on unregulated foods to generate revenue (19).
The ethical responsibility of schools to limit soft
drink sales and provide healthy meals and opportunities for physical activity and to combat the other adverse consequences of childhood obesity affecting education (20)
must also be considered.
The National School Lunch Program now serves more than 30 million students (approximately 60% of attendees) daily. Although students in this program consume more milk, fruits, and vegetables and have lower intakes of sweetened beverages and candy than other students, they also consume more sodium, fat and saturated fat, and calories
(21). Moreover, US school districts often contract with private beverage and food companies to sell less nutritious “competitive foods” in cafeterias and vending
machines. Thus, again, a stand-alone intervention may be ineffective, and the policy interventions planned for school settings must consider these competing forces.
The stewardship role of the state gives special attention to disadvantaged populations. Approximately 13% of children in the United States have a disability or chronic condition, and 6.4 million
children with disabilities are enrolled in public education. Children with
functional limitations and learning disabilities are more than twice as likely
to be obese as other children, and children from families with low socioeconomic
status are at higher risk for obesity (22). Parents, schools, health care settings, and communities
all have a role in ensuring that the risk for obesity among children with special needs is no greater than for other children (13).
Ethical review of research protocols typically emphasizes informed consent and confidentiality, the standard in most research regarding health-policy interventions for human behavior. In their role as policy makers, school administrators may implement activities affecting children. Although schools are not a research setting, concern may be raised about the extent to which families are truly informed about the activities, a matter presumably heightened by any layer of removal (eg, child
to parent or administrator) from the actual participant. The question of reporting BMI among school children illustrates this problem (10). School interventions that actively involve families are more likely to be effective (11) than stand-alone interventions in schools.
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Media reports may exacerbate eating disorders and other unhealthy weight-loss practices. Reformers eager to spread a healthy message (eg, about the dangers of smoking, drinking, or drug use) have traditionally demonized both the purveyors of undesirable substances and those who practice the risky behavior, often targeting members of comparatively dispossessed communities (23). Unlike tobacco or drugs, food is necessary for life, so the attention to reducing stigma is a necessary component of
any intervention (14).
This collection of papers supports the claim that the nature of evaluation research — testing a single intervention, often during the formative stage of implementation — may mislead policy makers and the public about the efficacy of achieving sustainable reform.
If one focuses on a single isolated intervention and holds other factors constant (as if that were possible), the policy change may appear to be ineffective. When evaluations of individual policies (eg, menu labels, soft
drink taxes, and removal of competitive foods in schools) fall short of
anticipated benefits, does this imply that we are promoting the wrong policies
or that no single intervention is likely to be successful in reversing the rates
of childhood obesity? Or is our evaluation framework insufficient for this
situation? A single type of medical treatment often fails to address a health
problem, and multiple, simultaneous interventions are often preferable. A
similar approach may be the most
promising means of systematically addressing childhood obesity.
The advancement and impact of policy evaluations of simultaneous interventions face 2 challenges. First, scholars should find ways to evaluate broad interventions in scientifically sound ways and must attend to collective concerns
more rigorously. Evidence-based approaches (those informed by the best available scientific evidence and reflecting community preferences and feasibility) are more likely to be effective at addressing causes of childhood obesity, interventions, and policies that
may work to confront those causes, in a manner acceptable to the community affected (24). Second, the separation of powers in the US legislative system, with its multiple veto points, combined with dedicated interest-group resistance to any attempts to regulate food or beverage policies, makes
approval of passing even a single program difficult, much less a multifaceted, coordinated national approach to childhood obesity.
Given the urgency of the childhood obesity problem and the difficulty of personal-responsibility approaches (25), the public policy arena is the most promising response. Yet, in the United States, the time-honored policy-making practices of incrementalism are proving inadequate for the present crisis (26). For public policy to enable a response, barriers to simultaneous interventions, a new view of the role of the state, and attention to the ethical issues raised in this collection
of articles will be needed.
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This article highlights ideas generated and conclusions reached at the Symposium on Ethical
Issues in Interventions for Childhood Obesity, sponsored by the Robert Wood
Johnson Foundation and Data for Solutions, Inc. The authors thank C. Kay Smith, MEd, who edited the papers
in this Special Topic collection.
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Corresponding Author: Donna F. Stroup, PhD, MSc, Data for Solutions, Inc, PO Box 894, Decatur, GA 30031-0894. Telephone: 404-218-0841. E-mail:
Author Affiliations: Rogan Kersh, New York University Wagner School, New York, New York; Wendell C. Taylor, The University of Texas Health Science Center at Houston, School of Public Health, Houston, Texas.
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- Ludwig DS, Peterson KE, Gortmaker SL.
Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet 2001;357(9255):505-8
- Kersh T, Elbel B. Childhood obesity: public health impact and policy responses. In: Bagchi D, editor. Global view on childhood obesity: current status, consequences and prevention. Maryland Heights (MO): Elsevier Publishing; 2010.
- Stroup DF, Johnson VR, Hahn RS, Proctor DC. Reversing the trend of childhood obesity. Prev Chronic Dis 2009;6(3):A83.
- Brownell KD, Kersh R, Ludwig DS, Post RC, Puhl RM, Schwartz MB, Willett WC.
Personal responsibility and obesity: a constructive approach to a controversial issue. Health Aff (Millwood) 2010;29(3):379-87.
- Harris JL, Graff SK. Protecting children from harmful food marketing: options for local government to make a difference. Prev Chronic Dis 2011;8(5):A92. http://www.cdc.gov/pcd/issues/2011/sep/10_0272.htm.
- Child Nutrition Promotion and School Lunch Protection Act of 2009, S 934, 111th Cong, 1st Sess (2009) (cf HR 1324, same title).
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- Nuffield Council on Bioethics. Public health: ethical issues. London (GB): Nuffield Council; 2007.
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- Perryman M. Ethical family interventions for childhood obesity. Prev Chronic Dis 2011;8(5):A99. http://www.cdc.gov/pcd/issues/2011/sep/11_0038.htm.
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- Minihan P, Must A, Andrewson B, Popper B. Children with special health care needs: acknowledging the dilemma of difference in policy responses to obesity. Prev Chronic Dis 2011;8(5):A95. http://www.cdc.gov/pcd/issues/2011/sep/10_0285.htm.
- Washington RL. Childhood obesity: issues of weight bias. Prev Chronic Dis 2011;8(5):A94. http://www.cdc.gov/pcd/issues/2011/sep/10_0281.htm.
- French SA, Story M, Jeffery RW, Snyder P, Eisenberg M, Sidebottom A,
Pricing strategy to promote fruit and vegetable purchase in high
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- Brownell KD, Farley T, Willett WC, Popkin BM, Chaloupka FJ, Thompson JW, Ludwig DS.
The public health and economic benefits of taxing sugar-sweetened beverages. N Engl J Med 2009;361(16):1599-605.
- Powell LM, Chriqui J, Chaloupka FJ.
Associations between state-level soda taxes and adolescent body mass index. J Adolesc Health 2009;45(3 Suppl):S57-63.
- Kearny CA.
School absenteeism and school refusal behavior in youth: a contemporary review. Clin Psychol Rev 2008;28(3):451-71.
- O’Malley PM, Johnston LD, Delva J, Bachman JG, Schulenberg JE.
Variation in obesity among American secondary school students by school and
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- Crawford PB, Gosliner W, Kayman H. The ethical basis for promoting nutritional health in public schools in the United States. Prev Chronic Dis 2011;8(5):A98.
- Musiker M. National school lunch program participation up 57 percent
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- Vieweg VR, Johnston CH, Lanier JO, Fernandez A, Pandurangi AK.
Correlation between high risk obesity groups and low socioeconomic status in children. South Med J 2007;100(1):8-13.
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A historical analysis of public health, the law, and stigmatized social groups: the need for both obesity and weight bias legislation. Obesity (Silver Spring) 2008;16(Suppl 2):S93-103.
- Fielding JE, Briss PA.
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