Defining Obesity
Obesity is defined in terms of a person’s weight and height. It is calculated based on a person’s Body Mass Index (BMI). A person’s weight in kilograms divided by the square of height in meters provides the BMI on a pre-determined scale provided by the Centers for Disease Control and Prevention (CDC).1 The BMI provides useful information in determining whether a person is underweight, healthy weight, overweight or obese. The CDC defines obesity as “weight that is higher than what is considered as a healthy weight for a given height.1 To measure childhood obesity, the CDC provides guidelines for BMI above the 85th percentile and below the 95th percentile.1
Support Data
Support data in this advocacy plan are drawn from the following sources:
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- The statistical data for the prevalence of obesity for children and adults were collected from the CDC’s NCHS report of 2015-2016 collected for research by Hales et. al.
- Obesity and related cost data were obtained from NLC’s report.
- Childhood obesity data in the Bronx public schools were collected from a research study conducted the Monroe College in conjunction with the NYC Department of Health and Mental Hygiene.
Incidence of obesity in the United States has increased by 70 percent over the last three decades for adults and by 85 percent over the same time for children. 2 Childhood obesity is recognized as a serious worldwide public health concern. The rise in the rate of obesity among school-aged children is becoming a national health emergency in the U.S. Findings from the CDC’s National Center for Health Statistics (NCHS) indicate that obesity prevalence is 18.4 percent among 6- to 11-year-olds, and is observed as historically the highest since 1999-2000.1 Despite cumulative efforts to address this national crisis, the trend in childhood obesity has steadily increased from 13.9 percent in 1999 to 18.5 percent in 2016.5
In New York City, approximately 20 percent of school-aged children K-8 are reported as being obese compared to the 17 percent nationally.7, 8 Incidence of childhood obesity is highest amongst Latino children at 25.8 percent while 22 percent is in Black children. Childhood obesity has been linked to a host of physical and psychosocial health complications that can be detrimental to health. A considerable amount of literature has shown the correlation between childhood obesity and medical/psychological consequences inclusive of; shorter life expectancy, adult obesity, cardiovascular disease, metabolic disorder, poor academic performance, depression, and low self-esteem. 4, 9 Moreover, National League of Cities (NLC) found that the economic cost of childhood obesity alone accounted for 14 billion in direct medical costs such as inpatient and outpatient health services.8 Obesity has reached epidemic proportions in underserved and low-income communities in NYC. For instance, in the Bronx, the third most densely populated county in the nation, where the average median income is $36,593 compared to $57,652 nationally, 31.7 percent of children are overweight or obese.6 A research study published by Monroe College found that 1 in 3 children in the Head Start program is obese, 1 in 4 children in public elementary school is obese, and 1 in 6 public high school students is obese in the Bronx.5 Children in the Bronx public schools with low-income families and underserved neighborhoods exhibit higher rates of obesity due to a lack of full-service grocery stores, pricy affordable healthy food options, ubiquitous advertisement of junk food, lack of outdoor space to pursue physical activity, and high density of fast food restaurants.
A Brief Story
When most people think of obesity, they often disregard the fact that “hunger and obesity are often flip sides to the same malnutrition coin.4 Hunger is certainly almost an exclusive symptom of poverty.4 It can be seen in the movie Precious when Precious steals a family-size bucket of fried chicken from a fast-food restaurant for breakfast. She eats it while running in a subsequent scene. She indulged in stealing food to satiate hunger because hunger and poverty are mutually inclusive. Like Precious, my friend John had struggled with obesity, hunger, poverty, bullying, and stigma throughout his life.
John and I were born and raised in the South Bronx. We lived a few blocks apart. John had two siblings from a single mother who worked two jobs to provide for the family. We went to a nearby public school. John was 203 pounds at age 12 and struggled with his weight for years and years. John would express he would not like to go to school because kids teased and embarrassed him by calling him names such as gorilla or chubby. He would cry when bullied or shamed. I tried to console her and be on his side but was not sure what to do. I told his mother one day that John feels lonely and scared at school because some kids tease him for being overweight. All I heard from his mother was, “I will talk to the principal; I don’t have time right now, have to run for work.” John would hide his emotions and try to control his diet, but we had limited choices available to us. The meals provided at school had one choice or two choices the most. It was choosing between pizza or ravioli, while most other days just the deep-fried chicken with milk. The pocket money we had could only buy us a soda can or a mini chocolate bar.
John is now in his mid-30 weighing around 300 pounds. He still lives in the same apartment with his mother. Reflecting on his childhood experience with bullying and teasing. He stated, “it is hard not to feel demotivated, down, and emotionally abused when someone calls you names because you do not look like them or because you are obese.” I encouraged him to share why had it been difficult for him to control his weight. He replied, “mom worked two jobs, she was barely home, and we barely had the means to buy healthier food. I had to cook most of the time for all of us. I would make French fries, peanut butter sandwiches, pasta, rice, or just microwave the frozen pizza.” John now suffers from chronic stress and has developed sleep apnea, high blood pressure, and type 2 diabetes.
There have been national and local efforts where policies and programs have made it easier for people in low-income communities to gain access to healthy foods and physical activity opportunities which have led to some improvements in childhood obesity rates. For instance, the Healthy, Hunger-Free Kids Act and Let’s Move! an initiative by the First Lady, Michelle Obama. However, efforts to educate people about eating healthy food, exercising daily, and avoiding sugary drinks will only succeed if the environment supports them, for instance, availability and accessibility to fruits and vegetables, bike trails, sidewalks, and neighborhood parks. The causes of childhood obesity vary from environmental factors, and socioeconomic status to personal choices. Therefore, it is important to frame childhood obesity as a broader social, economic, political, and environmental issue instead of an individual, personal, and behavioral eating disorder.
Advocacy Approach and Society’s View
An advocacy approach deprived of environmental factors limits the strategy to only address the appearance and health of an individual. Failure of this strategy stigmatizes an individual into self-loathing, self-blaming, and isolation. Incorporating environmental changes into advocacy shifts society’s emotion to accept the issue as a shared social, political, and economic issue. To strengthen society’s emotion that unhealthy nutrition is the major cause of childhood obesity, the advocacy efforts need a multidimensional construct that includes the emotional well-being of an individual already exposed to obesity and society’s acceptance that the issue is caused by the social, and economic determinants. For instance, in NYC, childhood obesity is more prevalent in communities already suffering from health and economic disparities. Approximately 21% of children from K-11 are reported as obese compared to 17% nationally.2, 8 Obesity is prevalent in areas, such as the Bronx at 24%, Jackson Heights at 26%, and Bushwick at 28%, compared to the Upper East Side 6%, Financial District 5%, Soho and Greenwich Village 5%.2, 8 Advocacy efforts to stimulate society’s emotional involvement to need to articulate the magnitude of childhood obesity in the context of social, economic, and environmental determinants responsible for obesity prevalence, specifically, in underserved and impoverished communities, and children in public schools aged K-11.
Similarly, a shift in society’s beliefs and values of individualism to visualize childhood obesity as a shared social responsibility necessitates linking the issue to the circumstances that surround an individual’s decision-making about what food to eat and in what quantities.3 Healthful eating and the surrounding environment are not synonymous. For instance, children at public or private schools are not responsible for the food available in their cafeterias or in the vending machines. It is society’s responsibility to create an environment in which good choices are not only possible but easier to make.3 Transference in advocacy from an individualistic view to the dominant American values of character and willpower can be a key to explaining the enormity of childhood obesity in its social context.3 Additionally, postulating childhood obesity and its association to the social, environmental, and economic determinants can further shift the society’s beliefs and values to accept the issue as a shared social issue that needs a new social contract, instead of an individual resolution.
Advocacy, Communication, and Policy Change Strategy
Individualizing the advocacy frame limits the causes of childhood obesity to individuals, often those who are afflicted with the problem, obscuring the broader population suffering from obesity prevalence. Incorporating environmental, social, economic, and political context into a systemic advocacy frame that broadens the focus and assigns the responsibility to environmental factors, government, and policies could prevent childhood obesity.
The government and the policymaking environment shift when health risks have been framed that link the problem to the settings and circumstances that surround individual decision-making about what food to eat, in what quantity, and whether the environment supports physical activity. New York State has taken a progressive stance by overwhelmingly passing bill S2724B in 2017 10 on combating the growing obesity in children, but more needs to be done on both state and local levels. The S2724B amends various sections of the Agriculture and Markets Law (AML) to educate students and parents on the importance of economic and health reasons to eat a balanced and nutritious diet. The bill merely attempts to integrate the Department of Agriculture and Markets’ ability to confront obesity through more explicit coordination with other government agencies, exonerating the state and local administration from their responsibility of creating an environment that goes beyond teaching individuals the importance of a healthy diet. To address obesity in a comprehensive manner, this advocacy plan recommends two amendments to the AML §30311 to be included in its objectives of decreasing obesity within the AML’s declaration of policy and purpose. The two amendments are:
A) Include combating obesity and nutrition issues in AML’s Farm to School in New York’s purpose statement to read, Through technical assistance and promotional support we help schools, “to combat obesity and nutrition issues; farms, distributors, and other supporting organizations provide students with nutritious, delicious, seasonally varied meals from foods produced by local farms and food processors.”
B) Include a statement read, “Increase cooperation between the Department of Agriculture and Markets and other agencies in encouraging the production and consumption of fresh, locally produced fruits and vegetables.”
The two amendments will help the NYS Department of Health’s Childhood Obesity Prevention Program 3 to develop campaigns promoting the consumption of low-calorie food and establish community-based obesity prevention education and physical activity programs. This advocacy plan to amend §30311 law aims at a regulatory approach on the State level which will delineate local agencies, involved businesses, and local governments to adopt similar policies.
The advocacy plan also focuses on involving, former NYC Council Member, and recently elected NYC Public Advocate, Jumaane Williams, in endorsing the policy changes and raising the childhood obesity issue with the NY State and local authorities. Secondly, the plan aims to involve Public Advocate in advocating comprehensive nutrition standards for all food purchases and distributions by NYC agencies and programs. Third, involve the Public advocates in urging the NYC mayor to provide children at schools with a choice to select milk or a bottle of water with meals. Finally, the plan aims to advocate for increased physical activity in school programs/classes.
The presented advocacy plan addresses childhood obesity at its root. It focuses on nutrition problems through upstream/downstream metaphors4 which entails prevention instead of treatment. It encompasses the environmental frame that puts the individual choice in a larger context of environmental influences and policy choices. Undoubtedly obesity in children has become an epidemic in underserved, low-income communities in the United States. It has largely been seen in the context of individualistic, overeating disorder, obscuring the underlying socioeconomic and environmental factors that contribute to nutrition problems in the first place. Obesity in children and adults is fuelled by socioeconomic status, life’s circumstances, free will, environmental factors, genetics, and ubiquitous advertisement and promotion of dense calorie-packed fast food, sugary drinks, and high-calorie junk food with reduced opportunities for physical activity. It is time that an equitable exception is made to the general rule of equality in broadening the focus from individualistic to a systemic frame that distributes the responsibility on a social scale involving policymakers, businesses, and society in general.
The narrow downstream, social context lens has too long been focused on nutrition issues as individual problems instead of related causes, such as environmental and socioeconomic concerns. There is little doubt among public health experts that childhood obesity has become a serious epidemic in underserved, impoverished communities. The CDC’s 2018 report concluded that in New York State the prevalence of obesity among Hispanics is between 25% to 30% while 30% to 35% in blacks.1 The statistics are staggering for children between the ages of 2 to 19 years; 18.5% or 13.5 million.1 Nearly 13.9% of children ages 2 to 5 years and 18.4% between ages 6 to 11 years are suffering from obesity prevalence in NY.1 The cost of the obesity epidemic is not just commensurate with dollars; it takes a toll on an entire generation’s well-being. In terms of dollars, the medical spending attributed to overweight and obesity in the United States was 10% or $147 billion in 2008.9 These facts raise questions for the public, policymakers, scholars, and public health advocates: what should be done, and by whom?
Public health advocates and scholars vociferously argue that government must use its legislative power to slim down an increasingly obese nation. However, they have not been able to convincingly articulate their message persuading policymakers and the general public to view the issue beyond the microscopic narrow lens of personal choices and personal responsibility. Public and policymakers’ perceptions will prevail, so long as the advocates fail to broaden the individualistic frame to a holistic systemic advocacy frame entailing the environmental and socioeconomic status as the root causes of obesity. The argument that government cannot infringe on personal choices holds very little support in the wake of successful government intervention of banning tobacco use in public places and restricting advertisement in the print and digital media. It is not uncommon in our society to readily blame individuals for making choices, even though there are other plausible factors to blame, such as socioeconomic status and environmental factors. Individuals make choices based on their environment or community. For instance, a person may choose not to walk, bike to the store, or work because of a lack of sidewalks or safe bike trails.
It is time that public health advocacy groups move from informational campaigns to advocating for an actionable public health policy in combating obesity on a larger scale. Public opinion and policy-making environment shift when health risks are framed in the context of upstream/downstream metaphors or prevention versus treatment methodology.3 Fostering community environments by ensuring healthy fruits, vegetables, and food are available will support communities, combating 1 billion dollars a year advertisement from the two leading fast-food restaurant chains will require political will and systemic advocacy focused on environmental and socioeconomic status.
Conclusion
Childhood obesity is a complex issue; mixed with life’s circumstances, socioeconomic status, free will, genetics, sedentary lifestyle, and a great deal of promotion and advertisement for fast food, sugary drinks, and high-calorie junk food. Shifting childhood advocacy approaches from downstream, individual, personal choices to a wider public health issue requires a societal understanding of neural networks that predict the likelihood of a disease’s prevalence and its impact on society. A successful advocacy approach must incorporate cultural values, environmental changes, and statistical data because society’s perception to view a social issue enormously depends on its social context, and the impact it has on society’s social norms. It is time that public health advocacy groups move from informational campaigns to advocating for an actionable public health policy in combating obesity on a larger scale. Public opinion and the policy-making environment shift when health risks are framed in the context of upstream/downstream metaphors. Fostering a community environment by ensuring healthy fruits, vegetables, and food is available will support communities, combating one billion dollars a year of the advertisement from the two leading-fast-food restaurant chains will require political will and systemic advocacy focused on environmental and socioeconomic status.
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