While increases in child obesity in recent decades 0870-9025/$–seefrontmatter©2012PublishedbyElsevierEspaña,S.L... The scope, magnitude and distribution of inequalities in child obesity
Trang 1w w w e l s e v i e r p t / r p s p
Special article
Nicholas Freudenberg
City University of New York School of Public Health, Hunter College, New York, United States
a r t i c l e i n f o
Article history:
Received8September2012
Accepted23October2012
Availableonline26January2013
Keywords:
Childobesity
Healthinequalities
Healthpolicy
a b s t r a c t Inequalitiesinchildobesitywithinandamongnationsresultfromunequaldistribution
ofresourcesandenvironmentsthatpreventunhealthyweightgain—healthyfood, oppor-tunities for physicalactivity,primary and preventivehealth care, and protectionfrom stressors.Whilesomedevelopednationshaverecentlyslowedtheincreaseinchild obe-sity,nonehassuccessfullyreversedthegrowingconcentrationofchildobesityamongthe pooranddisadvantaged.Thiscommentaryreviewstheevidenceonpatternsandcausesof unequaldistributionofchildobesityindevelopednationsandanalyzestheimplicationsfor thedevelopmentofinterventionstoreducetheseinequalities
©2012PublishedbyElsevierEspaña,S.L
Comentário: Reduzir desigualdades na obesidade da crianc¸a em países
Palavras-chave:
Obesidadeinfantil
Desigualdadesemsaúde
Políticasdesaúde
r e s u m o
Asdesigualdadesnaobesidadeinfantildentrodecadaeentreosdiversospaísesresultam
dadistribuic¸ãodesigualdosrecursosedeambientesqueprevinemoganhonãosaudável
depeso:alimentossaudáveis,oportunidadesparaapráticadeatividadefísica,cuidados
desaúdeprimáriosepreventivoseprotec¸ãodosfatoresdestress.Apesardealgunspaíses maisdesenvolvidosteremrecentementeconseguidodiminuiroaumentodaobesidadenas crianc¸as,nenhuminverteucomsucessoa concentrac¸ãocrescentedaobesidadeinfantil entreosmaispobresedesfavorecidos.Estecomentáriopretendereveraevidência exis-tentequeraoníveldospadrões,querdascausasdadistribuic¸ãodesigualdaobesidadenas crianc¸asempaísesdesenvolvidos,eanalisaasimplicac¸õesparaodesenvolvimentodas intervenc¸õescomvistaàreduc¸ãodessasdesigualdades
©2012PublicadoporElsevierEspaña,S.L.emnomedaEscolaNacionaldeSaúdePública
Introduction and background
Childobesityisaprobleminitselfandaharbinger of
seri-oushealth,social,andeconomicproblemsformanyoftoday’s
E-mailaddress:nfreuden@hunter.cuny.edu
overweightandobesechildren.Absenttransformative inter-ventionstoreducechildobesity,weriskleavingourchildren andgrandchildrenaworldinwhichtheirlifespansand qual-ityoflifeareworsethanforthecurrentgeneration,aterrible legacy While increases in child obesity in recent decades
0870-9025/$–seefrontmatter©2012PublishedbyElsevierEspaña,S.L
http://dx.doi.org/10.1016/j.rpsp.2012.10.004
Trang 2Children aged 5-17 years who are overweight (including obese), latest available estimates
Girls
Korea
11.3 16.3 16.7 16.2 12.9 13.1 14.1 17.5 24.6 22.6 14.7 23.6 17.0 22.9 23.5 32.9 22.0 28.7 22.0 25.5 28.9 22.7 28.6 28.2 28.1 32.4 35.0 45.0 5.9
13.6 20.6 24.2 23.1
10.3 12.4 13.1 14.4 14.7 14.9 15.2 16.2 16.9 17.6 17.9 19.1 19.5 21.4 21.6 22.6 24.0 24.4 25.5 25.9 26.1 26.6 27.1 28.8 29.0 30.9 35.9 37.0
4.5 17.7
18.3 19.3 21.1 50
Source: International Association for the Study of Obesity (2011).
Statlink: http://dx.doi.org/10.1787/888932523994
50
Turkey Poland Switzerland Japan Norway France Denmark Slovak Republic Czech Republic Germany Netherlands Finland Sweden OECD Portugal Spain Australia Slovenia Iceland Hungary Canada United Kingdom Chile New Zealand Mexico Italy United States Greece China South Africa India Russian Fed
Brazil
Boys
Fig 1 – Children aged 5–17 years who are overweight (including obese), latest available estimates.
haveaffected allsocial classes,countriesand cultures,the
burdenofobesityanditslifetimeadverseconsequencesare
notequallydistributed.Healthofficials,healthprofessionals,
researchersandpolicymakersinmanycountrieshavecalled
forcomprehensiveactiontoreducetheratesofchildobesity
butlessattentionhasbeenfocusedonactingtoreducethe
wideandgrowinginequalitiesinchildobesity
Giventhe risingratesofdiet-related non-communicable
diseasesinlow,middleandhighincomenations,anyfailure
tomakeinequalityreductionaprioritywillwidenthealready
largesocioeconomicandracial/ethnicgapsinoverall
prema-turemortalityandpreventableillnesses.Thus,takingaction
toreduceinequalitiesinratesofchildobesityisanessential
componentofachievingnationalandglobalgoalsofachieving
healthequality
In this commentary, I review what is known about the
scope,magnitudeanddistributionofchildobesitywithafocus
ondevelopednations;summarize the currentliteratureon
its causes; and then analyze the options for interventions
toreduce inequalitiesin childobesity The broader goal is
toinform the developmentof moreeffective interventions
toreducing inequalities in childobesity Given risingrates
ofchildobesityinmiddleincomeandemergingnations,the
experiencesinoftheUnitedStates,Europeandotherwealthy
countriesmayprovideinsightsthatcanhelpothercountries
avoidsomeofthegrowingburdenofchildobesity
The scope, magnitude and distribution
of inequalities in child obesity
Inthelastfewyears,severalreviewshavesummarizedwhat
isknownaboutthedistributionofchildobesitywithinand betweennations.AnupdatefromtheOrganizationfor Eco-nomicDevelopment,asshowninFig.1, reportsthat for5–
17 years oldgirls,the latestdataavailableshow thatrates
ofoverweight (includingobesity)range from4.5percentin Chinato37percentinGreece;forboysaged5–17therange
is5.9percentalsoinChina,to45percentinGreece.1Ofthe
33 countriesforwhichdataare reported,15 nationsreport rates of overweight of more than 20 percentfor girls and
20nationsreportratesofoverweightofmorethan20percent forboys.Inmostcountries,theOECDreportshows,boysaged 5–17havehigherratesofoverweightthangirls.InEngland, FranceandtheUnitedStatesbutnotinKorea,childrenshow socialinequalitiesinoverweightrates.Thereportconcludes that forchild obesityas well asadultobesity, “there isno clear sign of retrenchment ofthe epidemic, despitemajor policyefforts focusedonchildreninsomeofthe countries concerned.”1 (p.1)
In a study analyzing the relationship between income inequality and obesity in 19 European and North Ameri-can countries, Wilkinson and Pickettt found that that for
Trang 313–15 year olds, developed nations with higher levels of
incomeinequality havehigher rates of obesity among13–
15years.2 (p.93)Atthehighendoftheincomeinequality/teen
obesityassociationweretheUSA,PortugalandtheUK;atthe
lowendwereSweden,FinlandandNorway.Similar
relation-shipswerefoundforadultwomenandmen.3
Thesenationalratesmasksubstantialdifferenceswithin
nations.InChina,forexample,citiessuchasShanghaiand
Beijingreportdramaticallyhigherratesofchildobesitythan
doinlandcitiesorruralareas.4Todate,thesocialgradientin
childobesityinChinadoesnotfollowpatternsinobservedin
mosthigherincomenations
Several studies have examined demographic correlates
of child overweight in Europe For example, one study of
preschoolchildrenaged4–7insixnations(Germany,Belgium,
Bulgaria Greece,Poland, and Spain) found that childrenof
parentswithhigh body mass index(BMI) or low
socioeco-nomicstatuswereathigherriskofoverweightandobesity
thantheirrespectivecounterparts.5 Parentalinfluencescan
begenetic,metabolic(e.g.,overweightmothersarelesslikely
tobreastfeed),behavioral,orenvironmental(e.g.,lowincome
parentsaremorelikelytoliveinmoreobesogenic
commu-nities) Another review ofEuropean studies on differences
inoverweightamongchildrenfrommigrantandnative
ori-gin found that migrant children, especially non-European
migrants,wereathigherriskforoverweightandobesitythan
theirnativecounterparts.6
In the United States, a recent reviewfound “persistent
andhighlyvariable disparitiesinchildhoodoverweightand
obesity within and among states, associated with
socio-economic status, schooloutcomes, neighborhoods, type of
health insurance, and quality of care”.7 (p.347) According to
theNationalSurveyofChildren’sHealth,Black,Hispanicand
PacificIslanderchildrenaged10–17yearsold haveratesof
overweightandobesitysubstantiallyhigherthanwhiteand
Asianchildren.8Thesedifferencesinobesityratesalsotrack
differences in householdincome and educational
achieve-ment byrace/ethnicity, showingthe clustering ofdifferent
formsofinequality.Obesity andoverweight are also
corre-latedwithparentaleducationwithchildrenofparentswith
lesseducationhavinghigherratesthanchildrenofmore
edu-catedparents.From2003to2007,obesityprevalenceforall
10–17yearoldsincreasedby10percentbutforchildrenin
low-education, incomeor unemploymenthouseholds by 23–33
percent.9 Children with public insurance, single mothers,
livinginHispanicSpanish-languagehousehold,andin
neigh-borhoodswithnoparkorrecreationcenterhavehigherrates
of obesity/overweight than their respective counterparts.7
Anotherreviewreportedthatseveralstudiesfound
substan-tial differences inthe distribution of early liferisk factors
forchildobesitysuchasinfantfeedingpractices,sleep
dura-tion, child’s diet, and patterns of physical and sedentary
activities.10
Dothesesocioeconomic,racial/ethnicandgender
dispar-ities in rates of child obesity constitute an injustice? The
theories of philosophers Amartya Sen, Martha Nussbaum
and others suggest they do.11,12 In this view, social
con-ditions that deprive one sector of the population of the
opportunitytoachievetheirfullpotentialforwell-beingand
fullparticipation insociety are unjust Clearly, the health,
socialand economic consequencesofchild obesityburden individuals,familiesandcommunitiesforlife.Thus,the dif-ferential distribution of the conditions that contributes to obesityservetomaintainorexacerbatethesocialandhealth inequalitieswithinandamonglow,middleandhighincome nations.13
Drivers of inequality of child obesity
Public policy discussionsabout obesity often failto distin-guishbetweendriversofobesity(i.e.,prevalence)anddrivers
ofinequalitiesinobesity(i.e.,disparitiesorinequalities).Most basically,theprevalenceofobesitywillincreasewhengrowing proportionsofthepopulationincreaseconsumptionofhigh calorie,lownutrientfoodsanddecreasethephysicalactivity neededtoburnthesecalories.Thisdescribesthesituationin mostoftheworldtoday
However,inequalities inhealth– and obesity– are pro-duced when healthy and unhealthy living conditions and opportunity structures are differentially distributed among thepopulationsofdifferentnations,regionsorlocalities, lead-ing to differences in the rates of increase in obesity and thereforeinequalities initsdistribution Thusitispossible
toreducethe prevalenceofobesitywithout addressingthe distribution
Many national and municipal governments are taking actiontoaddressthemaindriversofelevatedBMIsbutfew areactingaggressivelytochangethedistribution.Theresult
ofsuchpoliciescanbethatthebetteroffbenefitmorefrom interventionsthanthepoor,thusactuallywideningthegap Forthoseseekingtoreducethehealthburdenofchildobesity, finding ways tochange the distribution ofobesogenic envi-ronmentsisasimportantasreducingtheprevalenceinthe populationasawhole
In both the United States and Europe, child obesity is becoming concentrated inlow incomecommunities.Given its role inthe etiologyofnon-communicablediseases, this suggests a vicious circle of increasing concentration of childobesity,earlyonsetofnon-communicablediseasesand wideningsocioeconomicinequalitiesinprematuremortality andpreventableillness
Differentialdistributionofthreeresources–food,physical activityopportunities,andhealthcare–hasbeenidentified
asmaindriversofinequalitiesinchildobesity.14These fac-torsoperateattheglobal,national,regional,communityand individuallevelstoproducedifferingratesofobesityamong differentsocialgroups.Tosummarize,marketforces,public policiesandsocialfactorsinteracttodifferentiallydistribute accesstoaffordablehealthyandunhealthyfood, opportuni-tiesforsafephysicalactivity,andaccesstotheprimaryand preventivehealth servicesthat canreducethe riskof obe-sity ThisdifferentialdistributionofwhatSwinburnetal.15
andothers havelabeled“obesogenicenvironments”creates inequalitiesinchildobesity
WilkinsonandPickett2proposeafourthdriverfor inequal-ities in obesity: social stressors associated with the social gradient and income inequality.They arguethat “the psy-chosocialeffectsofinequalitymaybeparticularlyimportant becausetheycaninfluenceallotherpathways:sedentarism,
Trang 4caloric intake, food choice and the physiological effects
of stress.”3 (p 673) They fault the more behavioral
explana-tions of obesity for their failure to address “the reasons
why people continue to live a sedentary lifestyle and to
eat an unhealthy diet, and how these behaviors provide
comfort.”
Driversofinequalitiesinchildobesitycanbeconsidered
the “cause of the causes”,16 the underlying determinants
of the multiple social and behavioral correlates of higher
BMIs.Understandingtheprecisemechanismsbywhicheach
ofthesedriversoperates ateach leveloforganization ata
particulartimeandplaceisacriticalfirststepineliminating
inequalitiesinchildobesity.Rankingthecausalimportance
andthefeasibilityofchangeateachlevelforeachdriveris
asecondcriticalstep.Thisanalysiscanleadtoprioritiesfor
action.Basedonsuchanalyses,healthofficialsandpolitical
leaderscangivethemostattentiontothemosteffectiveand
feasiblepolicies,programsandservices.Thisapproachhasthe
potentialtomakemeaningfulchangesinthemostpowerful
causalpathways
Health inequalities intersect with and are produced by
other formsof inequality such as income, education, and
transportation inequalities, creating a cascade of
inequali-tiesthatoperateacrossgenerations.Forexample,inadequate
schoolingdeprivesparentsoftheknowledgeandskillsto
pro-tecttheirchildrenagainstobesityandtheincometoafford
healthierfood andmoreopportunitiesforphysicalactivity
Low-incomeneighborhoodsmaylackhealthierfoodchoices
andalsothetransportationsystemsthatwouldmakeiteasy
forresidents totravelto supermarkets outside the
neigh-borhoodthatdoofferhealthier food.Higher ratesofcrime
in low-income neighborhoods may dissuade parents from
encouragingtheirchildrentoplayoutside,thusfurther
expos-ingthemtolongerhoursoftelevisiontime,itselfassociated
withsedentarismandunhealthydiets.Moreover,the
cumu-lativeburdensofpovertyandinequalitycreatestressorsthat
cascadedownthesocialgradient,concentratingamongthe
poorest.Aspreviouslydescribed,theseaccumulating
stress-orscanincreasebehaviorsassociatedwithobesity.Toreduce
inequalitiesinchildobesity,we’llneedtofindnewwaysto
interruptthiscascadeatvariouslevelsoforganization.Thus,
intersectoralapproachesthatincludefood,education,
crim-inaljustice,andtransportationsectorsareakeyelementof
effectiveresponses.17
Interventions to reduce child inequalities
Giventhecomplexityofthepathwaysandmechanismsthat
shapetheprevalenceanddistributionofchildobesityno
sin-gle intervention can reverse the trends of the last two or
threedecades.Rather,healthauthoritiesatalllevelsof
gov-ernment,inpartnershipwithothergovernment,civilsociety
andbusinesssectors,willneedtocreateaportfolioof
pol-icy,programmaticandeducationalinterventions.Mappingthe
systemsthatcontributetoinequalitiesinchildobesityandthe
relativecontributionsofsingleandmultipledeterminantswill
helptosetprioritiesforaction
Severalrecentreviewssummarizetheavailableevidence
oninterventionstoreducechildobesity.14,18,19Several have
focusedspecificallyon policyinterventionsand dissemina-tionandsustainabilityissues.20–24Theinterventionsshownto
beeffectiveconstitutethebuildingblocksforthemulti-level, multi-sectorportfoliosofinterventionsthatwillbeneededto reducechildobesity.Twokeypointsshouldinformthe cre-ationofthesemorecomprehensiveresponses.First,reducing the unequaldistributionofchildobesityamongpopulation groupsrequiresunderstandingandaddressingthepreviously describeddriversofinequalities,notsimplyitsindividuallevel determinants Second, a portfolio of interventions, like an investmentportfolio,must bebalancedamongsectorsand between long and short term and high risk, high payoff andlowerriskbutlowerpayoffapproaches.New methodolo-gieslikeportfolioreview25,26 andsystemsscience,27–29 both stillinearlystagesofdevelopment,willneedtobeappliedto thistask
The literature on child obesity and more broadly on healthinequalitiessuggestsseveralinterventiondimensions that portfolioplannersshouldconsider.Theseover-lapping but conceptuallydistinct dimensionsare bestconceivedas continua rather than dichotomies The five I will briefly consider here are: upstream vs downstream; targeted vs universal;localvs.national;educationvs.regulation;and vol-untary vs mandatory The taskfor plannersis toselect a portfolioofinterventionsthatincludeanappropriatebalance
ofthesecharacteristics
Upstream vs downstream: Change drivers of inequalities
Upstream interventions to reduce child obesity tackle the social forces that push some populations into social cir-cumstancesthatelevatetheriskforobesityandthatcreate obesogenicenvironments.Downstreamonesseektomitigate theconsequencesoftheseenvironments.Upstream interven-tionstoshrinkinequalitiesinchildobesitywithinoramong nations seek to modify the social forces that inequitably distribute poverty,marginalization,cumulativeexposureto stressors,accesstohealthyfood,exposuretounhealthyfood marketing,opportunitiesforphysicalactivityandaccessto theprimaryandpreventivehealthservicesthatcanreduce childobesity
Examplesofupstreaminterventionsincludetax,workand socialbenefitspoliciestoreduceincomeinequality,poverty, andsocialmarginalization,allfactorsrepeatedlyassociated with inequalities in child obesity They also include trade agreementsandregulationsthatlimittherightsofthefood industrytoproduceandmarketunhealthyfoodtochildren, often targeting low income populations.30,31 Downstream interventionstoreduceinequalitiesprovidepopulations expe-riencing higher rates of obesity with enhanced access to services and programs designed to reduce obesity at the individual level.Morebroadly, PaulFarmerhaslabeled this strategy the “preferentialoption forthe poor”, basing it in part on Christiantheology.32 By givingpopulations of chil-dren mostexposed tothe socialfactors thatcause obesity firstoptionsforhealthierfood,moreopportunitiesfor phys-icalactivityandenhancedaccesstopreventiveandprimary healthcare,healthauthoritiescanbegintowhittleawaythe handicapsimposedbylivinginamoreriskyenvironment
Trang 5Targeted vs universal
Targetedinterventionstoreducechildobesityfocuson
popu-lationsathighestriskwhileuniversalonesprovidebenefitsto
theentirepopulation.Toillustrate,somenationsand
munici-palitiesprovidefree,healthyschoolmealstoallchildrenwhile
others limit this offer only tothose livingin poverty The
firstapproachhastheadvantageofnormalizingthebenefit
andreducinganystigmaassociatedwithfreeschoolfood.In
practice,itoftenbenefitsthepoormost,becausetheyhaveless
accesstohealthyfood outsideschools Universalprograms
alsowinpoliticalsupportfromallsectorsofthepopulation,
makingthemlesssubjecttocutbacksintimesofeconomic
decline,preciselywhentheyaremostneeded
Targeted approaches are less expensive and focus
resourcesonthose mostinneedbutare especially
vulner-able during periodsof austerity Targeted approaches may
alsomagnifydiscriminationorsocialisolation.33Other
exam-plesoftargetedapproachesaredistributinghealthyfoodin
poorcommunities,zoningrestrictions onfastfood inhigh
obesityorhigh poverty neighborhoods,nutritioneducation
inlow incomecommunities,and newparks inhigh crime
areas.Universalapproachesincludelimitsonfoodadvertising
tochildren,calorielabelinginrestaurantsandfastfood
out-lets,mandatedandenforcedphysicalactivityinallschoolsor
progressivetaxestoreverseincomeinequality.Both
univer-salandtargetedapproachescancontributetoreductionsin
inequalitiesinchildobesity
Education vs regulation
Athirddimensionofinterventions isthe balance between
educationandregulation.Educationalinterventionsarebased
onthediagnosisthatindividualslackinformation,knowledge
orskillstoavoidobesity;theprescriptionistoprovidelearners
withthemissingingredient.Regulations,ontheotherhand,
diagnosetheproblemswithininstitutionsandorganizations
andprescribestate-mandatedorganizationalchangeasthe
remedy
Inpractice,thetwoapproaches canbecombined
Inter-ventionstooffercaloriepostingandnutritionlabelsonfood,
forexample,mandate commercial outletstoprovidethese
services to individuals, who will presumably make more
informed choices based on this information In addition,
studiesshowthatcalorielabelingmayleadorganizationsto
reformulateproducts,anorganizationalchange.34Campaigns
toeducate womenaboutthe benefitsofbreastfeedingand
therisksofinfantformulaandtoimprovenutrition
educa-tioninthe schoolsare educationalapproaches.Endingthe
distributionoffreeinfantformulainhealthsettings,banning
thepromotion ofobesogenic foodstochildren,and setting
standardsonfoodportionsizeandnutrientdensityillustrate
aregulatoryapproach.Ingeneral,regulatoryapproachesare
moreefficientthaneducationbecausetheybypassthe
diffi-culttaskofchangingmanyindividuals.However,regulations
alsoelicitmorepoliticaloppositionfrominterestgroupswho
maylose profitsasaresult.Regulatoryapproachesmay be
moreeffectiveinreachingvulnerablepopulations,whomay
lackthetime,resourcesorprioreducationalbackgroundto
takefulladvantageofeducationalinterventions
Local vs national
Afourthdilemmafacingplannersseekingtoreducechild obe-sityishowtofindtherightbalancebetweenworksatthelocal versustheregionalornationallevels.Driversofprevalence andunequaldistributionoperateatallthreelevelsand juris-dictionsvaryinhowresponsibilitiesforfood,physicalactivity and healthcarepoliciesare allocated.Ingeneral,operating
athigherlevelsoforganizationismoreefficient,asasingle policy change canbenefitthe country as awhole Inlarge countries,however,nationalgovernmentsmayhavedifficulty
inimplementingpoliciesnationwideandlocalorregional gov-ernments may resistnational mandates, especially if they arenotgivenadequateresourcestofulfilltheseobligations National policiesmayalsogeneratehigherlevelopposition fromspecialinterestgroups,e.g.,thefoodindustry,making policychangemoredifficult
Insomecases,localchangescansetthestagefornational ones In the United States, forexample, several cities and statesrequiredcalorielabelinginfastfoodchainrestaurants,
apolicythatthenbecamepartofthenationalAffordableCare Act.35Somelocalpoliciesthatmaycontributetoreductions
ininequalitiesinobesityareeffortstosubsidizesuper mar-kets and other stores that sellhealthy foods in poorarea; improvedaccesstobicycling,walkingandmasstransit,rather thanautomobiletravel;localinitiativestosupporturban agri-culture; and municipal taxes on sugarybeverages orother unhealthyproducts.Nationalpoliciesmaybemore appropri-ateforfunctionsthatusuallyoperateonlyatthenationallevel: rulesforfoodadvertisingtochildren,nationalstandardson sugarandfatforfoodformulation,andhealthcare reimburse-mentfornutritioncounseling
Both local and national interventions can contribute to reductionsininequalitiesinchildobesity.Perhapsthe great-estriskforlocalapproachesistofallintothe“localtrap”36in whichlocalauthoritiesassumethatfactorsdriving inequali-tiesinchildobesitycanbefullyaddressedatthelocallevel wheninfacttheyaregeneratedandoperateatalllevels
Voluntary vs mandatory
A fifth dimension to consider is voluntary approaches, in which companies and other organizations are encouraged
tochangeobesogenicpracticesversusmandatoryones (usu-allygovernmentregulation)thathavethepowerofthestate behindthem
The rationale forvoluntary approaches isthat they tap intotheexpertiseoftheorganizationsthatneedtomakethe changes(e.g.,thefoodindustryinformulationoffood prod-uctsforchildren);donotrequireanextensiveenforcement apparatus;anddonotunnecessarilyextendthepowerof gov-ernment.Theproponentsofregulatoryapproachesrespond that empirical investigations of voluntary standards often showlimitedeffectiveness,adherenceisdifficulttoestablish, and that theycede avitalpublic role inprotecting health
Inpractice,asshownrecentlyintheUnitedStates,despite lipservicetovoluntaryapproachestolimitingmarketingof unhealthyfoodtochildren,thefoodindustryoftenopposes evenvoluntarystandards.37
Trang 6special interests in setting obesity policy Thefood
indus-try has called forpublic private partnerships toset policy
whilesomeadvocatesandresearchershavearguedthatthis
presentsinherentconflictsofinterestsincefoodcompanies
are legally required to maximize profits, not protect child
health.38Theseadvocates suggestpublichealth
profession-alsandfoodcompaniescannegotiateagreementsbutneedto
acknowledgetheirsometimesconflictinginterests,not
pre-tendthatallshareacommongoal
Toward transformative policies and programs
Beyond these five dimensions of interventions to reduce
inequalitiesinchildobesityisabroaderclashbetweenthose
whoadvocateincrementalandtransformativechangesinour
approachtochildobesity.Intherealworld,arguethe
incre-mentalists,onlymodestchangeispoliticallyfeasible;reducing
foodintakebya50–100caloriesadayorincreasingdaily
phys-icalactivityby10minissufficient,ifsustainedtobringabout
measurabledeclinesinobesity.Adoptingthelanguageofharm
reduction,proponentsofincrementalchangeargueitisbetter
tomakesmallchangesthannoneatall.Theyalsoclaimthat
incrementalchangescanleadtoa“tippingpoint”inwhich
littlechangessnowballintomoremeaningfulones
Transformativereformersrespondthattodatethe
mod-estchangesinpoliciesandprogramsrelatedtochildobesity
havenotledtoreversalsoftheprevalenceordistributionof
childobesity,eveninplaceswithmorecomprehensive
pro-grams.Theyalsoworrythatincrementalchangesmayco-opt
thedemandformoremeaningfulchange
Windows of opportunity: Trapdoors of risk
Inthelastdecade,theproblemofchildobesityhasattracted
growingattentionfrompolicymakers,themedia,health
offi-cials and others International organizations, national and
municipalgovernmentsandcivilsocietygroupshavemade
the reductionofchild obesitya muchhigher prioritythan
inthe past.Somerecentevidencesuggests thattherateof
increasehasslowedorperhapsstabilizedinsomecountries,
apositivedevelopment.Butasyetreductionsininequalities
inchildobesity havenot beendocumented, and infact in
someplaces continuetowiden Tochange this distressing
realitywillrequireidentifyingnewwindowsofopportunity
forchangeaswellasemergingtrapdoorsthatcanjeopardize
possiblesuccesses.Byseizingtheformerandavoidingthe
lat-ter,itmaybepossibletocreatepoliciesthatcanshrinkcurrent
inequalitiesinchildobesity
Windows of opportunity
Astheeconomiccrisisof2008hasfurtherwidenedalready
high levels of income inequality in developed nations, a
growingchorusofcriticshaspointedoutitsadversemoral,
political,socialandeconomicconsequences.2,39,40Thiswider
awarenessofinequalitypresentspublicofficialsand health
authoritieswithanopportunitytoproposestructuraland
pol-icysolutionsandtocontesttheausterityalternative,described
inthenextsection.IntheUnitedStates,Europeandaround theworld,electedleaders,socialmovements,andgrassroots mobilizationsaredemandingthatpolicymakerstakeactionto reduceinequalities.Specifyingtheobesityandhealth-related costsinducedbyrisinginequalitycanquantifythe opportu-nitycostsofnotactingtoreduceinequality
Similarly, child obesity and especially the adult obesity and chronic diseases thatinevitably follow it contributeto therisingcostofhealthcare.TheUnitedStates,theUnited Kingdomandothernationsarestrugglingtore-organizetheir healthcaresystemstomaintainqualitywhileloweringcosts
In this climate,shrinking the flow ofdiet-related diseases intohealthcaresystemisapromisingstrategyforlowering costs Reducingobesity prevalencebydevelopingstrategies thatmostbenefitlow-incomechildrenhasseveraleconomic benefits:comparedtoadultstrategies,itmaximizes opportu-nitiesforcost-savingprevention;itimprovesthehealthofthe low-incomepopulationsmostlikelytodependonpublic fund-ingfortheirhealthcare,eveninhealthsystemsthathavea strongpublicsector;anditbenefitsmostthedisadvantaged populationsmostlikelytohaveahighburdenofothercostly healthproblems
Anotheropportunityforlinkingeffortstoreduce inequali-tiesinchildobesitywithotherpubliceffortsisthegrowing global movement to controlnon-communicable diseases.41
Child obesityisakeydriverofrisingrates ofNCDsinlow, middleandhighincomenations;reducingitsincidenceand its unequal distribution is a prime strategy for achieving the global goal of reducing the burden of NCDs A recent WHOreportforEuroperecognizestheimportanceof reduc-inginequalitiesinchildobesityaspartofaEuropeanstrategy forthepreventionandcontrolofNCDs.42
Finally,thegrowthofafoodjusticemovement,initiallyin developednationsbutnowaroundtheworld,canbecomean importantallyforthepolicychangesneededtoreducethe prevalence and unequal distribution ofchild obesity.43,44,45
Afoodjusticemovementthatunderstandsandcanexplain the linksbetweenobesity, foodinsecurity, noncommunica-blediseaseepidemics,climatechangeandunsustainablefood systems can bea powerfulforce for change, acatalystfor mobilizationatthecommunity,regional,nationalandglobal levels
Trapdoors of risk
Thecurrentmomentalsopresentschallengesthatcan under-mineanyprogressinreducinginequalitiesinthedistribution
ofchildobesity.Mostdramatically,theausterityideologythat hasemergedinresponsetothe2008globaleconomiccrisis threatens todeprivegovernmentsofthefundingand man-datetoactaggressivelyagainstchildobesity.46,47Asrestoring economicgrowth andfreeingmarket forcesbecomehigher prioritiesthanreducinginequalityorimprovinghealth,many governmentsupportedprogramscreatedinordertoreduce childobesityoritsfundamentaldriversareatriskofcutbacks
or elimination At the same time, multinational corpora-tionsandtheiralliesargueforderegulationandprivatization, deprivinggovernmentsoftheregulatorytoolsneededto pro-tect childrenfromaggressivemarketingofunhealthy food
IntheUSandtheUK,foodcorporationsandsomepolitical
Trang 7stan-dardsforhealthyfoodtothefoodindustryitself,amovethat
promisesmore,notlesschildobesity.37,38
Conclusion
Continuing increases in child obesity and the persistent
inequalitiesinitsdistributionthreatenpopulationhealthand
socialjusticeinlow,middleandhighincomenations.While
moreresearchisneededonthecausesandconsequencesof
inequalitiesinchildobesity,forthemostpart,weknowwhat
needstobedone.Theeconomicandpoliticalforcesthatcreate
moreobesogenicenvironmentsforallpeople,butespecially
thoselivingatlowerlevelsofthesocialgradient,needtobe
confronted.Nosingleinterventionwillachievetheseresults
Butbydevelopingaportfolioofpolicies,programsand
ser-vicesthatcantransformthefood,physicalactivityandhealth
careenvironmentsthat contributetothe increasing
preva-lenceandunequaldistributionofchildobesity,wecanbegin
toreversethealarmingtrendsofthelastthreedecades
Atthesametime,bymitigatingthesocialstressorsthat
accumulateamongthoselivingloweronthesocialgradient
andthatalsoincreasetheirriskforobesity,wecan
acceler-atethatreversal.Whatisneededisnotmoreevidencebut
thepoliticalwillandthemobilizationthatwillbeneededto
makethatchange.Fortunately,thistypeofchallengeisone
thatpublichealthanditsallieshavemetmanytimesbefore
Whatremainstobedoneistotranslatethelessonslearned
fromourpastsuccessestothetaskathand
Conflicts of interest
Theauthorhasnoconflictsofinteresttodeclare
r e f e r e n c e s
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