It has been over half a century since obesity has been linked to cardiovascular disease, and over thirty years since it was identified as the most important nutritional disease in affluent countries (Nestle & Jacobson, 2000). Yet, obesity has increased sharply among American adults, adolescents, and children. Nearly two out of three adult American are either overweight or obese. Among children and adolescents, overweight prevalence has tripled from five percent to fifteen percent between the 1970s and the millennium (Klegal, Carroll, & Ogden, 2002). Over nine million American children and adolescents are overweight and another nine million are close to being overweight, according to the 1999-2002 National Health and Nutrition Examination Survey (Harrison, 2005).
The emergence of obesity may be attributed to sociological, genetic, economic and political causes. The federal government has implicated schools, parents, advertisers, and genetics in the obesity epidemic. Policy decisions leading to "urban sprawl," created the dependence on driving which has changed the meaning of "walking" from a daily activity used to get from home to work, school, or market, to an "exercise." Policies formulated to support agriculture and protect consumers from high food prices led to overproduction and food surpluses (Pollan, 2003). The dramatic technological changes at the end of the twentieth century have allowed more Americans to work at home, further reducing daily activity (Klegal et al., 2002). Technology has also lowered costs of meal preparation, leading to greater variety and frequency of meals. The American diet has undergone a dramatic change with increased consumption of refined carbohydrates and decreased fiber intake that parallels the dramatic upward trend in prevalence of type II diabetes (Gross, Li, Ford, & Liu, 2004)
Obesity and overweight are associated with increased risk for heart disease, cancer, diabetes, osteoarthritis, and psychological morbidity (Kennedy, Chokkalingham, & Srinivasan, 2004; Library of Congress, 2004). Obesity costs billions of dollars annually in terms of health care expenditures and lost productivity and contributes significantly to the costs of health insurance, particularly Medicare and Medicaid (Finkelstein, Fiebelkorn, & Wang, 2003; Wolf & Colditz, 1998). All those who pay for insurance, both employers and employees thus have experienced increased costs. Furthermore, the higher prevalence of obesity among those with lower incomes and levels of education exacerbates problems of inadequate access to preventive care and risk reduction programs among the uninsured (Drewnowski & Spector, 2004).
These factors have exerted a substantial health burden on society. However, policy changes may decrease the health-related and economic costs currently associated with obesity. Predominant views influencing current arguments around policy development include beliefs that body weight is genetically determined, and that gaining weight is a moral issue, a sign of laziness, and lack of self-control. In fact, individuals who are overweight commonly experience psychological stress, reduced income, and discrimination (Library of Congress, 2004; Philipson, Dai, Helmchen, & Variyan, 2004). This prejudice exists among the majority of health care professionals as well as the general public. The negative attitudes of health care professionals can seriously impede the treatment of overweight and obese patients (Kristeller & Hoerr, 1997). While the effects of previous policies that have contributed to decreased physical activity and increased intake of "empty calories" are beginning to be acknowledged in the policy debates, current policy initiatives are more likely to focus on individual choices than sweeping economic and social changes.
Obesity finds its place on the political agenda along two pathways. The growth in the prevalence and costs related to obesity has finally reached an unacceptable level compelling legislators to address the underlying problems. Secondly, obesity is closely linked to tobacco addiction, an issue that already occupies a secure place on the policy agenda. Smoking, once seen as an individual choice, has become a major public health issue with a high degree of regulation. Obesity as a political issue has surpassed obesity as a health issue. Public concern has prompted state and federal legislators to compete for the role of the most compassionate and determined public trustees (Feldstein, 2001), by launching a new "war against obesity" in proposing regulations and laws that regulate sociological, economic, genetic, and political causes of obesity. There is no opposition to the goal of preventing childhood obesity, but rather a struggle to determine the extent of government involvement. For example do individual school systems determine if vending machines will continue to be stocked with soft drinks and snacks of dubious quality, or will the state legislature determine policy for all schools? Diet, activity, and environmental issues, as well as genetic and socioeconomic status, impact the issue. Thus addressing the obesity epidemic may require the changes beyond the areas of nutrition and daily activity.
There are several stakeholders in the legislative arena when considering obesity and health policy. Key stakeholders include the government, the food industry, health care providers, employers, and the middle class.
The government, the major payer of Medicare and Medicaid expenditures has a concentrated interest in holding down the rise in medical expenditures. Also, since obesity has become a visible public issue, both the administration and Congress realize the potential political advantages of addressing the issue. Congress may not care about the exact number of calories that people should consume, or the ubiquitous presence of "junk food" advertisement and vendor machines. But Congress does care about how much political capital may be achieved from legislation. By calculating which legislative positions provide the greatest amount of political support essential for reelection, legislators will propose and support laws most effective to achieve this goal.
The food industry recognized the threat of potential liability and successfully lobbied for a law to shield them from such action (Library of Congress, 2003). The industry’s approach to policy change is to alter but not diminish daily food consumption through changing the national dietary guidelines, and stressing and placing increased emphasis on physical activity. The recent publication of the Dietary Guidelines for Americans (United States Department of Agriculture, 2005) was preceded by heated debates on balancing recommendations for caloric restrictions and activity. Food makers have donated heavily to members of Congress. In 2004, food processing and sales companies gave $4,636,835; the dairy industry donated $1,398,911; and the sugar interests gave $1,379,484 (Mishra, 2004), far outweighing public health interest group contributions. While nutritionist, scientists, and other health advocates promote the need to "detoxify food environment," the food industry places stress on physical exercises, upon which higher levels of calories will be expended.
Health care providers have dual interests: prevention and treatment. Numerous professional organizations have issued position statements related to obesity. The International Council of Nurses (1999) position statement, "Reducing Environmental and Lifestyle-related Health Hazards," advocates that "nurses and national nursing associations should play a strategic role in helping reduce environmental and lifestyle-related health hazards by…promoting a positive lifestyle, including exercise, stress management, accident prevention, weight maintenance, and nutrition education that is sensitive to socio-economic status and cultural beliefs" (International Council of Nurses, paragraph 1). The National Association of School Nurses (2004), "Position Statement on Overweight Children and Adolescents," includes recommendations for screening, primary prevention, advocacy, legislation, funding, and research. The American Academy of Pediatrics issued a major policy statement urging the restriction of soft drinks in the nation’s schools (Markel, 2004). Meanwhile, successful efforts to obtain insurance coverage for obesity as a diagnosis may increase the demand for health care and lessen uncompensated care.
The role of employers and the middle class in the policy debate is linked to the willingness of these segments to accept a tax burden that may be seen as related to a behavioral and moral issue (Smith, 2004). As the health insurance costs of obesity continue to rise, employers need to choose between decreasing profit margins and passing back costs to consumers through higher premiums, thus decreasing take home wages.
There are two discordant sides in terms of the multiple legislative options on the table: one is that government has a limited role, and the other that it has a significant one. Supporters of the first view insist that overweight and obesity result from daily lifestyle choices. They believe adults should not only make positive choices for themselves, but also supervise their children in terms of nutrition and physical activity. They feel the government’s role is to provide health information and facilitate behavior changes through the support for education, research, and community-based interventions. Proponents of a more active government role argue that overweight and obesity result from a complex interplay of behavioral, environmental, and genetic factors, and that the government needs to undertake broad policy initiatives ranging from regulating the food environment and prescribing physical activity and nutrition for children, to supporting urban planning for increased physical activity through transportation and public safety provisions.
The American Nurses Association (ANA) has position statements on many issues that affect nursing practice, as well as specific disease entities. These position statements can be found at http://nursingworld.org. However, the ANA has no position statement specifically addressing obesity. The ANA must seize the moment as an organization that lobbies Congress and regulatory agencies on health care issues affecting nurses and the general public by developing a position statement on obesity. Nurses are able to promote policy changes from both the personal decision-making side of the argument as well as proposing and supporting government initiatives to promote prevention and treatment. This will increase visibility for the nursing profession and place us at the table as a stakeholder in policy decisions.
As patient advocates and public health professionals, we have a lot of work to do. Nurses are trusted by the public more than any other professional group and not seen as stakeholders looking out primarily for our own self-interest. Yet, it is in our own interest to be healthy, to ensure access to care for those who need it, and to develop interventions and policies that propose equitable and effective solutions. In our practice setting, nurses can advise patients about diseases that are caused by obesity and the importance of good nutrition and physical activity. We can influence decisions made in our institutions and communities, propose legislation, and lobby for appropriate initiatives. Finally, although it is often challenging, we can enhance our personal wellness and serve as role models by making healthy choices and taking opportunities to improve our own individual lifestyle!
Hong Tao, RN, MSN, PhD(c)
Email Address: firstname.lastname@example.org
Hong Tao is a PhD candidate in the Health Care Policy Program at the College of Nursing and Health Sciences (CNHS), at the University of Massachusetts Boston. Prior to coming to the United States in February of 2003, she was an associate professor and Director of Emergency Nursing in the College of Nursing, Second Military Medical University in the Peoples' Republic of China. She has actively contributed to the fields of emergency nursing and gerontological nursing in China, and is involved in the academic activity in the PhD program of CNHS. To date, she has published twenty-five articles and contributed chapters or written content to nine books.
Greer Glazer, PhD, RN, FAAN
Email Address: Greer.Glazer@umb.edu
Dr. Glazer is Dean and Professor of Nursing and Health Sciences at the University of Massachusetts Boston. Besides her many research activities in the field of women's health and stress, Dr. Glazer is the chair of ANA-PAC, the political arm of the American Nurses Association. She has previously been on health care committees at the state and national level. She served on the Board of Cuyahoga County (Ohio) Children's Trust Fund and recently completed four years on the Health Care Committee allocation panel for the United Way in Cuyahoga County. Dr. Glazer was a Robert Wood Johnson Executive Nurse Scholar from 2001 to 2004.
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