States battle obesity epidemic with new laws

Using tactics that have helped to reduce the number of smokers, states increasingly are considering bills that are designed to influence people's weight and to curb the obesity epidemic.

"States are where the action is," said Kelly Brownell, PhD, director of the Rudd Center for Food Policy and Obesity at Yale University in New Haven, Conn.

The legal remedies range from silly to serious. One of the more impractical possibilities, which was proposed in Mississippi in January, called for restaurants to be banned from serving obese diners. Even its sponsor, Republican Rep. John Read, said this measure was written to bring attention to the problem rather than to become law. It quickly died in committee after generating opposition from many quarters across the country.

"There's sense in legislating some things, but refusing to serve people is taking it a little bit too far," said Steven C. Brandon, MD, president of the Mississippi Academy of Family Physicians.

But other types of proposals, particularly those targeting children in the school setting, have had the most success and garnered the most support. American Medical Association policy calls for schools to incorporate evidence-based nutrition standards and address the benefits of exercise in the curriculum.

"We will do best if we target the young, and school is a place where we can get a great amount of benefit [by] increasing physical activity and access to healthy food," said Mary Armstrong, MD, an AMA delegate and a health officer for the Mississippi Dept. of Health, although she was speaking personally. "We develop habits early in life, and lots of times students teach their parents and all the adults around them what they learned in school."

This approach is favored by many states. According to the American Academy of Pediatrics' "2007 State Legislation Report," 27 states have passed laws on school nutrition since 2003. Laws on physical activity have been added by 24 states. Seven now mandate body mass index screening, and many more are considering doing so.

"[Measuring BMI] is a long overdue thing to do for students. It's important that this be educational and lead to parents taking more of an active role in trying to get students more active," said John Antalis, MD, a family physician and past president of the Medical Assn. of Georgia. That state is considering a bill, supported by MAG, that would include this information on report cards.

Legislation that would affect the world outside the school setting has faced far more difficulty. Last year, California considered a measure that would require restaurant menus to provide nutritional information. This action was supported by numerous medical societies, including the American Cancer Society and the AMA, although it generated backlash from the food industry. The Legislature ultimately passed it, but Republican Gov. Arnold Schwarzenegger vetoed it, arguing that it did not give restaurants enough flexibility in how this information would be presented. It has since been reintroduced, and efforts to enact it continue.

"We need to give consumers the information they need to make healthy choices. Restaurants should provide information on calories and the nutritional contents of the foods they sell," said AMA President Ron Davis, MD.

A taxing angle

A less popular approach, even among public health advocates, is taxing activities or foods that may be playing a role in the obesity epidemic.

"The key is the removal of barriers to engaging in sound nutrition and physical activity, and we're more on the incentive side than for taxes," said Richard Hamburg, MPA, director of government relations at Trust for America's Health, a national public health advocacy organization based in Washington, D.C.

Such taxes tend to be low. And, unlike those levied on tobacco products, which are high in order to deter consumption, food and activity taxes are primarily used to raise funds, some of which are used to battle obesity. For instance, New Mexico's Legislature is debating whether to add a 1% tax to the sales of television sets and video game consoles to finance a "No Child Left Inside" fund that would pay for outdoor educational programs. Also, at least 17 states and the District of Columbia have added taxes to soda and junk food.

Legislating against obesity is the "new frontier" of public health law, stated an editorial in the June 15, 2006, New England Journal of Medicine. Still, the biggest challenge facing backers of these efforts is the lack of evidence as to what, if anything, will work. Opponents have seized on that fact.

Obesity is also a far more complicated problem than smoking. "With tobacco, there's just one product, and a small number of companies involved," said Dr. Brownell. "With food, there's thousands of products and thousands of companies. It's hard to know exactly how to change."

Those who support such endeavors maintain, however, that many of them make sense, and the evidence will likely come in time.

"I don't think there's a lot of convincing evidence out there, but ... that's more a function of not having enough research being done and not testing programs that are likely to be effective," said Dr. Davis.