Advanced Technical Centers Obesity Is Caused by The Food Industry Essay

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COMMENTARIES to a patient’s financial situation advise giving friendly reminders, offering extended payment terms, or reducing or forgiving charges to indigent patients. Practice experts also advise writing off uncollectible accounts rather than sending them to futile and even bankrupting collection, not sending bills to collection precipitously or before talking with the patient, and not substituting bellicose collection for properly terminating a treatment relationship. In today’s world of high medical costs, large medical bureaucracies, and the unsolved problem of millions underinsured, physicians alone cannot rescue patients overwhelmed by medical bills. But the long-standing professional ethos of the relational physician still can honor the bonds of trust and care that tie patients to physicians, even in the emerging era of consumerism. Financial Disclosures: None reported. Funding/Support: This work was supported by a Robert Wood Johnson Foundation Investigator Award in Health Policy Research. Role of the Sponsor: The foundation had no role in the preparation or approval of this article. Disclaimer: The Robert Wood Johnson Foundation does not necessarily endorse the views expressed here. Additional Contribution: Janice Lawlor, MPH, provided valuable research assistance as part of her employment at Wake Forest University, Winston-Salem, North Carolina. REFERENCES 1. Cabot H. The Doctor’s Bill. New York, NY: Columbia University Press; 1935. 2. Committee on the Costs of Medical Care. Medical Care for the American People: The Final Report of the Committee on the Costs of Medical Care, Adopted October 31, 1932. Chicago, IL: University of Chicago Press; 1932. 3. Hall MA, Schneider CE. Patients as consumers: courts, contracts, and the new medical marketplace. Mich Law Rev. 2008;106(4):643-689. 4. Greene v Alachua General Hospital, 705 So 2d 953, 953 (Fla Dist Ct App 1998). 5. Cunningham PJ, May JH. A growing hole in the safety net: physician charity care declines again. Track Rep. March 13, 2006:1-4. 6. Hing E, Cherry DK, Woodwell DA. National Ambulatory Medical Care Survey: 2004 summary. Adv Data. 2006;374(374):1-33. 7. Asplin BR, Rhodes KV, Levy H, et al. Insurance status and access to urgent ambulatory care follow-up appointments. JAMA. 2005;294(10):1248-1254. 8. Terry K. Getting paid when patients have bare-bones coverage. Med Econ. 2008; 85(7):18-20, 22. 9. Brown M. Practice pointers: tame the account receivable beast. Med Econ. 2002; 79(22):64, 67, 68. 10. Hajny T. The what, why and when of collecting patient balances. J Med Pract Manage. 2003;19(1):32-34. 11. Snyder L, Leffler C. Ethics manual, fifth edition. Ann Intern Med. 2005; 142(7):560-582. 12. American Medical Association, Council on Ethical and Judicial Affairs. Code of Medical Ethics: Current Opinions With Annotations. Chicago, IL: American Medical Association; 2008. 13. Fabre J. Hip, hip, Hippocrates: extracts from the Hippocratic doctor. BMJ. 1997; 315(7123):1669-1670. 14. Baker RB, Caplan A, Emanuel L, Latham S. The American Medical Ethics Revolution: How the AMA’s Code of Ethics Has Transformed Physicians’ Relationships to Patients, Professionals, and Society. Baltimore, MD: Johns Hopkins University Press; 1999. 15. Cathell DW. The Physician Himself From Graduation to Old Age. Philadelphia, PA: Davis; 1882. Can the Food Industry Play a Constructive Role in the Obesity Epidemic? David S. Ludwig, MD, PhD Marion Nestle, PhD, MPH I N RESPONSE TO INCREASING RATES OF OBESITY, MANY FOOD companies have announced policies of corporate responsibility. McDonald’s claims, “[we] empower individuals to make informed choices about how to maintain the essential balance between energy intake (calories consumed as food) and energy expenditure (calories burned in physical activity).”1 Coca-Cola states, “we have launched new broad-based physical and nutrition education programs that reach even the least athletic students.”2 PepsiCo says, “we can play an important role in helping kids lead healthier lives by offering healthy product choices in schools, by developing healthy products that appeal to kids and by promoting programs that encourage kids to lead active lives.”3 Kraft says, “helping children and their families make heal thy food choices while encouraging physical activity has become part of how Kraft gives back to communities.”4 In light of such statements, should the food industry be welcomed as a constructive partner in the campaign against obesity? 1808 JAMA, October 15, 2008—Vol 300, No. 15 (Reprinted) The Dark Side of the Food Industry Simon5 examined food corporation practices in the United States, especially with regard to school nutrition, and concluded that companies “lobby vociferously against policies to improve children’s health; make misleading statements and misrepresent their policies at government meetings and in other public venues; and make public promises of corporate responsibility that sound good, but in reality amount to no more than [public relations].” At the request of the World Health Organization, Lewin et al6 compared the promises and actual practices of 2 leading food companies in the United States, documenting systematic discrepancies. Despite claims to the contrary, McDonald’s at least up to 2005 continued to use trans fats in cooking oil (and was required to pay settlement costs for deceptive advertising); to market unhealthful products to children with toys, games, movie tie-ins, and trips to Disney World; and to promote supersized versions of Happy Meals.6 Kraft, the second comAuthor Affiliations: Department of Medicine, Children’s Hospital, Boston, Massachusetts (Dr Ludwig); and Department of Nutrition, Food Studies, and Public Health, New York University, New York, New York (Dr Nestle). Corresponding Author: David S. Ludwig, MD, PhD, Children’s Hospital Boston, 300 Longwood Ave, Boston, MA 02115 ([email protected]). ©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Hostos Community College User on 04/15/2022 COMMENTARIES pany studied, remained heavily engaged in the marketing of unhealthful products to children despite promises to fight childhood obesity announced with great fanfare in 2003.6 The activities of the industry-sponsored group, Center for Consumer Freedom (CCF), merit particular attention. With an annual budget exceeding $3 million, the CCF lobbies aggressively against obesity-related public health campaigns, legislation to regulate marketing of junk food to children, and scientists who advocate for healthier diets. The CCF boasts that “[our] strategy is to shoot the messenger . . . We’ve got to attack [activists’] credibility as spokespersons.”7 According to the Center for Media and Democracy, the CCF is funded primarily through undisclosed donations from companies such as Coca-Cola, Cargill, Tyson Foods, and Wendy’s,8 allowing them to support unsavory lobbying practices while claiming to be responsible corporate citizens. Is the food industry simply not to be trusted? An Irreconcilable Conflict In a Western-style capitalistic economy, food corporations, like all corporations, must make the financial return to stockholders their first priority. Wall Street places corporations under great pressure not only to be profitable, but also to meet quarterly growth targets. But the food market in the United States is mature; it provides about 3900 kcal per capita each day, roughly twice the population’s energy needs. To expand profits in this environment, food companies have only 2 options: convince customers to eat more (contributing directly to obesity) or increase profit margins, especially by marketing reformulated or repackaged products (an indirect contribution). Nutritional experts generally agree that diets based predominantly on relatively unprocessed vegetables, fruits, and grains support good health. Although minimally processed foods protect against obesity and related diseases by virtue of their rich nutrient content and satiating properties, they have low profit margins. Far greater profits come from highly processed, commodity-derived products—fast food, snack foods, and beverages—primarily composed of refined starch, concentrated sugars, and low-quality fats. These already inexpensive products are made even more inexpensive by massive agricultural subsidies. Research links frequent consumption of highly processed foods to weight gain and increased risk for diet-related diseases.9 The inverse relationship of processing to nutritional quality is illustrated by the progressive decline in the satiating value of apple-containing foods, from the whole fruit to applesauce to apple juice,10 as profitability increases. Even though fast-food companies may offer healthier items, most of their profits come from french fries and soft drinks, explaining why fruit seldom appears in their advertisements. Thus, food industry strategies to increase revenues typically depend on “eat more” campaigns designed to promote larger portions, frequent snacking, and the normalization of sweets, soft drinks, snacks, and fast food as daily fare. Advice to eat less often, eat foods in smaller portions, and avoid high-calorie foods of low-nutritional quality undermines the fundamental business model of many companies. Pitfalls of the Collaborative Approach The food industry, considered a stakeholder in the campaign against obesity, is actively encouraged to participate in government-sponsored workshops, contribute to the formulation of national nutritional policy, affiliate with government-sponsored initiatives, and partner with scientists and professional associations. Moreover, the industry has been asked to establish voluntary codes of conduct for nutritional quality and marketing practices, sometimes in cooperation with public health organizations. However, this collaborative approach seems better suited to the interests of industry than to those of the public. To demonstrate concern about childhood obesity, food companies tout their efforts to promote sports in schools or youth organizations. For example, PepsiCo will donate $11.6 million over 5 years to the YMCA to support, among other events, an annual community day “to celebrate healthy living, encourage kids and families to get excited about physical fun and activity and . . . engage kids in play to be healthy.”11 This focus on physical activity, characteristically without commensurate attention to diet quality, appears disingenuous. A child can easily consume more calories from a soft drink than she would expend at a sports event sponsored by a beverage company. The food industry, with its enormous financial resources, has an especially insidious influence on the conduct of research and development of public health policy. Lesser et al12 analyzed 206 scientific articles published over a 5-year period that addressed the health effects of milk, fruit juices, and soft drinks. The likelihood of a conclusion favorable to the industry was 4-fold to 8-fold higher if the study received full rather than no industry funding, raising the possibility of systematic bias. Food companies also donate large sums of money to professional associations. In return for a donation to the American Dietetic Association (ADA), CocaCola becomes an ADA partner and receives “a national platform via ADA events and programs with prominent access to key influencers, thought leaders, and decision makers in the food and nutrition marketplace.”13 Some professional associations continue to accept fees to endorse sugary breakfast cereals and processed snack foods, even though this practice was considered potentially deceptive by state attorneys general nearly a decade ago.14 Although companies sometimes volunteer to establish nutritional standards or limit unfair marketing practices, such actions appear to have dubious public health benefit. In 2006, the American Heart Association and the William J. Clinton Foundation brokered an agreement with Coca-Cola, PepsiCo, and Cadbury Schweppes to remove sugary drinks from schools. From the start, public health experts expressed con- ©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Hostos Community College User on 04/15/2022 (Reprinted) JAMA, October 15, 2008—Vol 300, No. 15 1809 COMMENTARIES cern that the agreement made too many concessions to the companies and would undermine efforts to enact meaningful government regulations. Subsequent modifications to the agreement reintroduced caloric beverages—such as sugary vitamin waters and sports drinks—into schools, thereby limiting the initiative’s effectiveness.15 An Appropriate Division of Responsibilities In a market-driven economy, the manufacturer is free to sell poor-quality products and the customer is free to reject them. This supply-and-demand principle works well for many consumer goods, but not those that affect health, safety, or the greater social good. Like food products, cars have benefits and risks to individuals and society. The government imposes regulations, mandates, taxes, and incentives to encourage production of safer and less polluting vehicles. An informed public willingly pays more for such cars, and concerns for higher gasoline prices and climate change stimulate their sales. Society does not expect car companies to police themselves, nor allow them to market unsafe cars in exchange for initiatives to reduce accidental injuries from other causes. Modifiable dietary factors cause substantially more illness and death than automobile crashes. Left unchecked, the economic costs associated with obesity alone will affect the competitiveness of the US economy. Therefore, it is imperative to clarify the appropriate role of the food industry in relationship to other key segments of society. The government’s role is to regulate by establishing rigorous standards for nutrition at school (US Department of Agriculture), banning food marketing targeted to children (US Federal Trade Commission), and forbidding unsubstantiated health claims on food labels (US Food and Drug Administration). If commercials for erectile dysfunction medication must mention rare complications like prolonged erection, it seems that commercials for fast food should be required to warn about the likely consequences of consuming partially hydrogenated fat and too much sugar. The government also must ensure that nutritional policies are based on solid science, rather than special interests. Congress should mandate greater funding of nutritional research to help counter the influence of industry money; consider placing responsibility for dietary guidance with an independent body such as the Institute of Medicine; structure agricultural subsidies to support public health, not commodity producers; and reform campaign finance laws to prevent corporate political donations from leveraging the legislative process. Academia’s role is to investigate by rigorous scientific investigation of nutrition and health. To minimize the corrosive effects of financial conflicts of interest, universities should institute systems to ensure independent review of industrysponsored research, including critical oversight of hypotheses, design, data collection, data analysis, interpretation, and decisions to publish. 1810 JAMA, October 15, 2008—Vol 300, No. 15 (Reprinted) Public health organizations’ role is to educate so professional health associations must avoid partnerships, product endorsement fees, or other financial ties with industry that compromise their independence and public credibility. Advocacy groups should broker industry agreements only with broad-based support from the public health community. The public’s role is to dictate, with the fork, by making informed food purchases, and with the ballot, by electing politicians committed to enlightened government action in the area of nutrition and health. Industry’s role is to innovate. Corporations must be able to make a profit. However, the prevailing approach encourages lowest common denominator practices; if one company advertises to young children, other companies would be at a competitive disadvantage if they adhered to ethical marketing standards. By establishing clear rules of conduct— leveling the playing field upon which all companies compete—society can free the industry to focus on what it does best: finding creative ways to satisfy consumer needs, in this case making healthful food economical, convenient, and tasty. Conclusion With respect to obesity, the food industry has acted at times constructively, at times outrageously. But inferences from any one action miss a fundamental point: in a market-driven economy, industry tends to act opportunistically in the interests of maximizing profit. Problems arise when society fails to perceive this situation accurately. While visionary CEOs and enlightened food company cultures may exist, society cannot depend on them to address obesity voluntarily, any more than it can base national strategies to reduce highway fatalities and global warming solely on the goodwill of the automobile industry. Rather, appropriate checks and balances are needed to align the financial interests of the food industry with the goals of public health. Financial Disclosures: Dr Ludwig reported receiving royalties from a book about childhood obesity. Dr Nestle reported receiving royalties from books about food politics. REFERENCES 1. McDonald’s Corporation. Balanced active lifestyles: 2006 worldwide corporate responsibility report. http://www.mcdonalds.com/corp/values/balance /bal_framework__alt.html. Accessed August 12, 2008. 2. Coca-Cola Co. Corporate responsibility: active lifestyles. http://www .thecoca-colacompany.com/citizenship/fitness_active_lifestyles.html. Accessed August 12, 2008. 3. PepsiCo. Health and wellness: PepsiCo’s health and wellness philosophy. http: //www.pepsico.com/PEP_Citizenship/HealthWellness/philosophy/index.cfm. Accessed August 12, 2008. 4. Kraft. Health and wellness. http://www.kraft.com/Brands/healthandwellness/. Accessed August 12, 2008. 5. Simon M. Can food companies be trusted to self-regulate? an analysis of corporate lobbying and deception to undermine children’s health. Loyola Los Angel Law Rev. 2006;39:169-236. 6. Lewin A, Lindstrom L, Nestle M. Food industry promises to address childhood obesity: preliminary evaluation. J Public Health Policy. 2006;27:327-348. 7. Sargent G; American Prospect. Berman’s battle: Richard Berman claims to help the average consumer; in fact he works for corporate America. http://www .prospect.org/cs/articles?articleId=8984. Accessed September 3, 2008. ©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Hostos Community College User on 04/15/2022 COMMENTARIES 8. SourceWatch. Center for consumer freedom. http://www.sourcewatch.org /index.php?title=Center_for_Consumer_Freedom. Accessed August 12, 2008. 9. Pereira MA, Kartashov AI, Ebbeling CB, et al. Fast food habits, weight gain, and insulin resistance in a 15-year prospective analysis of the CARDIA study. Lancet. 2005;365(9453):36-42. 10. Haber GB, Heaton KW, Murphy D, Burroughs LF. Depletion and disruption of dietary fibre: effects on satiety, plasma-glucose, and serum-insulin. Lancet. 1977; 2(8040):679-682. 11. PepsiCo. PepsiCo joins with America’s YMCAs to help Americans live healthier lives. http://phx.corporate-ir.net/phoenix.zhtml?c=78265&p=irol-newsArticle& ID=828887&highlight. Accessed August 12, 2008. 12. Lesser LI, Ebbeling CB, Goozner M, Wypij D, Ludwig DS. Relationship be- tween funding source and conclusion among nutrition-related scientific articles. PLoS Med. 2007;4(1):e5. 13. American Dietetic Association. American Dietetic Association welcomes the Coca-Cola Co as an ADA partner. http://www.eatright.org/cps/rde/xchg/ada/hs .xsl/media_16174_ENU_HTML.htm. Accessed August 12, 2008. 14. State Attorney General NY. Media center: executive summary. http://www .oag.state.ny.us/media_center/reports/nonprofit/full_text.html. Accessed September 3, 2008. 15. Wootan MG; Center for Science in the Public Interest. Study shows progress in getting soft drinks out of schools, still two-thirds of school beverage sales are sugary drinks. http://www.cspinet.com/new/200709171.html. Accessed September 3, 2008. Transforming Research Strategies for Understanding and Preventing Obesity Terry T.-K. Huang, PhD, MPH Thomas A. Glass, PhD C URRENTLY, ONE-THIRD OF CHILDREN AND TWOthirds of adults in the United States are overweight or obese; this trend has persisted for the last decade and shows no sign of abatement.1,2 Obesity tracks from childhood into adulthood, with unfolding and serious medical and economic consequences throughout the life course. One recent estimate suggests that if the current trend continues, obesity will account for more than $860 billion, or more than 16%, of health care expenditures in the United States by 2030.3 The need to find effective population-level obesity prevention strategies is among the most profound challenges in public health. Altering fundamental behaviors that govern energy balance is impossible when behaviors related to eating and physical activity are treated in isolation from the broader social, physical, economic, and policy context. Although energy consumption and energy expenditure may be at the core of the energy balance equation, obesity is, in fact, a medical manifestation of the complex interplay of biology and social change. However, the majority of research on obesity prevention has ignored larger changes in the social, physical, economic, and policy environments that doubtless are involved. Instead, most prevention efforts to date have focused on individually targeted strategies such as health education and behavioral skills training that turn out to be largely ineffective and unsustainable. The time is now ripe, and more urgent than ever, to implement a new, multilevel approach to understanding the basis of the obesity epidemic and how to reverse it. Toward a Multilevel Obesity Research Strategy A multilevel research approach for obesity prevention frames obesity as a complex systems problem, for which food and physical activity behaviors are not only a matter of indi- vidual choice but also strongly influenced by multiple levels of socioenvironmental risks, ie, interpersonal level (family, peers, and social networks), community level (schools, worksites, institutions), and governmental level (local, state, national policies), as well as by the interaction with biological processes (from genes and molecular and cellular processes to organ systems).4 By evolutionary advantage, the human body has a powerful defense mechanism against undernutrition in conditions of scarcity. However, that same evolutionary advantage (the capacity to store excess energy as fat) has not equipped humans for life in an obesogenic environment. At the interpersonal level, this obesogenic environment may include highly permissive or controlled child feeding styles, family demands that are stressful and time constraining, or unhealthful social norms of diet and physical activity. At the community level, unhealthy foods sold through school, worksite, hospital, and other institutional cafeterias and vending machines contribute to poor diets. The lack of physical education in schools or time and opportunity for leisure exercise elsewhere contributes to sedentary behavior. At the governmental level, policies regarding food, agriculture, education, transportation, urban design, marketing, and trade all play a role in increasing the accessibility and availability of high-fat and high-sugar foods vs fresh fruits and vegetables and in decreasing opportunities for physical activity. The lack of access to preventive care is also a major concern. Historical US policies that led to social inequality and segregation have, in turn, resulted in inequalities in the built environment, leading to disproportionate rates of obesity among the poor and minorities.5 Author Affiliations: Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Dr Huang); and Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Dr Glass). Corresponding Author: Terry T.-K. Huang, PhD, MPH, Obesity Research Strategic Core, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6100 Executive Blvd, 4B11, Bethesda, MD 20892-7510 ([email protected]). ©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Hostos Community College User on 04/15/2022 (Reprinted) JAMA, October 15, 2008—Vol 300, No. 15 1811 Psy 110 Thesis term paper subtopics. Hypothesis: Obesity is caused by the food industry. Subtopics: • High Calories Fast Food Pros: Inexpensive, saves time, convenient, variety in menus, restaurants locations Cons: high calories, lower food quality, addictive, cause heart disease • Television and social media food advertisement Pros: convincing viewers to buy food, specials and promotions catches viewers’ attention, food looks better Cons: create food habits, make the viewer want to try the foods • Higher Taxes on Fast Food Pros: healthier life, encourage individuals to eat healthier, decrease obesity rate Cons: financial issues for low to no income family, job losses WRITING A THESIS TERM PAPER Like a debate, a position paper presents one side of an arguable opinion about an issue. The goal of a position paper is to convince the audience that your opinion is valid and defensible. Ideas that you are considering need to be carefully examined in choosing a topic, developing your argument, and organizing your paper. It is very important to ensure that you are addressing all sides of the issue and presenting it in a manner that is easy for your audience to understand. Your job is to take one side of the argument and persuade your audience that you have well-founded knowledge of the topic being presented. It is important to support your argument with evidence to ensure the validity of your claims, as well as to refute the counterclaims to show that you are well informed about both sides. Issue Criteria To take a side on a subject, you should first establish the arguability of a topic that interests you. Ask yourself the following questions to ensure that you will be able to present a strong argument: • Is it a real issue, with genuine controversy and uncertainty? • Can you identify at least two distinctive positions? • Are you personally interested in advocating one of these positions? • Is the scope of the issue narrow enough to be manageable? Stating Your Thesis A hypothesisis a one-sentence statement about your topic. It’s an assertion about your topic, something you claim to be true. Notice that a topic alone makes no such claim; it merely defines an area to be covered. To make your topic into a thesis statement, you need to make a claim about it, make it into a sentence. Look back over your materials-brainstorms, investigative notes, etc.–and think about what you believe to be true. Think about what your readers want or need to know. Then write a sentence, preferably at this point, a simple one, stating what will be the central idea of your paper. A good thesis asks to have more said about it. It demands some proof. Your job is to show your reader that your thesis is true. Remember, you can’t just pluck a thesis out of thin air. Even if you have remarkable insight concerning a topic, it won’t be worth much unless you can logically and persuasively support it in the body of your essay. A thesis is the evolutionary result of a thinking process, not a miraculous creation. 1 How to Pick a Good Topic and Develop a Thesis Library Professor Linda Miles will lead an in class workshop to help us identify topics which are important us and impact our lives. Analyzing and Researching an Issue and Developing an Argument Professor Miles will present her workshop to support students in making choices about using/trusting/doubting the information sources they have found. We will examine sources, points of view, qualifications, funding, purposes and sensibility of the information. We will also examine the mechanics of sourcing references we have used. Your position must be well supported. Counter arguments need to be identified as well. Supporting evidence includes the following: Type of Information Type of Source How to find these sources directories, introductory information encyclopedias, and overviews handbooks Use the Library catalogue in-depth studies books, government reports Library catalogue, Canadian Research Index, Government web sites scholarly articles academic journals Article indexes current issues newspapers, magazines Article indexes statistics government agencies and associations Statistics Canada, Canadian Research Index, journal articles position papers and analyses association and institute reports Library catalogue, web sites Many of these sources can be located online through the library catalogue and electronic databases, or on the Web. You may be able to retrieve the actual information electronically or you may have to visit a library to find the information in print. 2 Considering your audience and determining your viewpoint Once you have made your pro and con lists, compare the information side by side. Considering your audience, as well as your own viewpoint, choose the position you will take. Considering your audience does not mean playing up to the professor. To convince a particular person that your own views are sound, you have to consider his or her way of thinking. If you are writing a paper for a sociology professor obviously your analysis would be different from what it would be if you were writing for an economics, history, or communications professor. You will have to make specific decisions about the terms you should explain, the background information you should supply, and the details you need to convince that particular reader. In determining your viewpoint, ask yourself the following: • Is your topic interesting? Remember that originality counts. Be aware that your professor will probably read a number of essays on the same topic(s), so any paper that is inventive and original will not only stand out but will also be appreciated. • Can you manage the material within the specifications set by the instructor? • Does your topic assert something specific, prove it, and where applicable, propose a plan of action? • Do you have enough material or proof to support your opinion? Organization Sample Outline I. Introduction ___A. Introduce the topic ___B. Provide background on the topic to explain why it is important ___C. Assert the thesis (your view of the issue). More on thesis statements can be found below. Your introduction has a dual purpose: to indicate both the topic and your approach to it (your thesis statement), and to arouse your reader’s interest in what you have to say. One effective way of introducing a topic is to place it in context – to supply a kind of backdrop that will put it in perspective. You should discuss the area into which your topic fits, and then gradually lead into your specific field of discussion (re: your thesis statement). II. Your Argument ___A. Assert point #1 of your claims 3 _____1. Give your educated and informed opinion _____2. Provide support/proof using more than one source (preferably three) ___B. Assert point #2 of your claims _____1. Give your educated and informed opinion _____2. Provide support/proof using more than one source (preferably three) ___C. Assert point #3 of your claims _____1. Give your educated and informed opinion _____2. Provide support/proof using more than one source (preferably three) You may have more than 3 overall points to your argument, but you should not have fewer. III. Counter Argument ___A. Summarize the counterclaims ___B. Provide supporting information for counterclaims You can generate counterarguments by asking yourself what someone who disagrees with you might say about each of the points you’ve made or about your position as a whole. Once you have thought up some counterarguments, consider how you will respond to them–will you concede that your opponent has a point but explain why your audience should nonetheless accept your argument? Will you reject the counterargument and explain why it is mistaken? Either way, you will want to leave your reader with a sense that your argument is stronger than opposing arguments. When you are summarizing opposing arguments, be charitable. Present each argument fairly and objectively, rather than trying to make it look foolish. You want to show that you have seriously considered the many sides of the issue, and that you are not simply attacking or mocking your opponents. It is usually better to consider one or two serious counterarguments in some depth, rather than to give a long but superficial list of many different counterarguments and replies. IV. Re-Assert and Re-Affirm Your Argument ___A. Refute the counterclaims ___B. Give evidence for argument Be sure that your reply is consistent with your original argument. If considering a counterargument changes your position, you will need to go back and revise your original argument accordingly. 4 V. Conclusion ___A. Restate your argument ___B. Provide a plan of action but do not introduce new information The simplest and most basic conclusion is one that restates the thesis in different words and then discusses its implications. Writing with style and clarity Many students make the mistake of thinking that the content of their paper is all that matters. Although the content is important, it will not mean much if the reader can’t understand what you are trying to say. You may have some great ideas in your paper but if you cannot effectively communicate them, you will not receive a very good mark. Keep the following in mind when writing your paper. Diction Diction refers to the choice of words for the expression of ideas; the construction, disposition, and application of words in your essay, with regard to clearness, accuracy, variety, mode of expression and language. There is often a tendency for students to use fancy words and extravagant images in hopes that it will make them sound more intelligent when in fact the result is a confusing mess. Although this approach can sometimes be effective, it is advisable that you choose clear words and be as precise in the expression of your ideas as possible. Paragraphs Creating clear paragraphs is essential. Paragraphs come in so many sizes and patterns that no single formula could possibly cover them all. The two basic principles to remember are these: 1) 1) A paragraph is a means of developing and framing an idea or impression. As a general rule, you should address only one major idea per paragraph. 2) 2) The divisions between paragraphs aren’t random, but indicate a shift in focus. In other words you must carefully and clearly organize the order of your paragraphs so that they are logically positioned throughout your paper. Transitions will help you with this. 5 Transitions In academic writing your goal is to convey information clearly and concisely, if not to convert the reader to your way of thinking. Transitions help you to achieve these goals by establishing logical connections between sentences, paragraphs, and sections of your papers. In other words, transitions tell readers what to do with the information you present them. Whether single words, quick phrases or full sentences, they function as signs for readers that tell them how to think about, organize, and react to old and new ideas as they read through what you have written. 6 LOGICAL RELATIONSHIP TRANSITIONAL EXPRESSION Similarity also, in the same way, just as … so too, likewise, similarly Exception/Contrast but, however, in spite of, on the one hand … on the other hand, nevertheless, nonetheless, notwithstanding, in contrast, on the contrary, still, yet Sequence/Order first, second, third, … next, then, finally Time after, afterward, at last, before, currently, during, earlier, immediately, later, meanwhile, now, recently, simultaneously, subsequently, then Example for example, for instance, namely, specifically, to illustrate Emphasis even, indeed, in fact, of course, truly Place/Position above, adjacent, below, beyond, here, in front, in back, nearby, there Cause and Effect accordingly, consequently, hence, so, therefore, thus Additional Support or Evidence additionally, again, also, and, as well, besides, equally important, further, furthermore, in addition, moreover, then Conclusion/Summary finally, in a word, in brief, in conclusion, in the end, in the final analysis, on the whole, thus, to conclude, to summarize, in sum, in summary 7 Parameters for Thesis Paper Cover Page: Name of article, student name, professor’s name, class and section, date 1500 word minimum, not including cover page or citations page 1 inch borders – sides, top and bottom 12 font – Times Roman 1.5 inch line spacing No pictures No colors No lined borders At least 6 reference sources! Resourced accurately with citations and references – APA style Grammatically Correct, Spell Checked 8 9 HYPOTHESES Homosexuality is caused by parenting, families and friends. Watching pornography causes promiscuous behavior. Young children who watch violent videos and TV shows are more violent as adults. Marijuana is a gateway drug to other mood altering drugs. Obesity is caused by the food industry. Corporal punishment is an effective tool when raising children and should be legal. Students who eat breakfast perform better in school. Childhood vaccinations should be mandatory. Prostitution should be legal. Organ donors should be financially compensated. Homosexuality is a mental disorder. The recognition of the right to physician-assisted suicide is a protection of individual civil liberties and should be legal. Recreational use of mood altering chemicals may be part of a healthy life style. COMMENTARIES to a patient’s financial situation advise giving friendly reminders, offering extended payment terms, or reducing or forgiving charges to indigent patients. Practice experts also advise writing off uncollectible accounts rather than sending them to futile and even bankrupting collection, not sending bills to collection precipitously or before talking with the patient, and not substituting bellicose collection for properly terminating a treatment relationship. In today’s world of high medical costs, large medical bureaucracies, and the unsolved problem of millions underinsured, physicians alone cannot rescue patients overwhelmed by medical bills. But the long-standing professional ethos of the relational physician still can honor the bonds of trust and care that tie patients to physicians, even in the emerging era of consumerism. Financial Disclosures: None reported. Funding/Support: This work was supported by a Robert Wood Johnson Foundation Investigator Award in Health Policy Research. Role of the Sponsor: The foundation had no role in the preparation or approval of this article. Disclaimer: The Robert Wood Johnson Foundation does not necessarily endorse the views expressed here. Additional Contribution: Janice Lawlor, MPH, provided valuable research assistance as part of her employment at Wake Forest University, Winston-Salem, North Carolina. REFERENCES 1. Cabot H. The Doctor’s Bill. New York, NY: Columbia University Press; 1935. 2. Committee on the Costs of Medical Care. Medical Care for the American People: The Final Report of the Committee on the Costs of Medical Care, Adopted October 31, 1932. Chicago, IL: University of Chicago Press; 1932. 3. Hall MA, Schneider CE. Patients as consumers: courts, contracts, and the new medical marketplace. Mich Law Rev. 2008;106(4):643-689. 4. Greene v Alachua General Hospital, 705 So 2d 953, 953 (Fla Dist Ct App 1998). 5. Cunningham PJ, May JH. A growing hole in the safety net: physician charity care declines again. Track Rep. March 13, 2006:1-4. 6. Hing E, Cherry DK, Woodwell DA. National Ambulatory Medical Care Survey: 2004 summary. Adv Data. 2006;374(374):1-33. 7. Asplin BR, Rhodes KV, Levy H, et al. Insurance status and access to urgent ambulatory care follow-up appointments. JAMA. 2005;294(10):1248-1254. 8. Terry K. Getting paid when patients have bare-bones coverage. Med Econ. 2008; 85(7):18-20, 22. 9. Brown M. Practice pointers: tame the account receivable beast. Med Econ. 2002; 79(22):64, 67, 68. 10. Hajny T. The what, why and when of collecting patient balances. J Med Pract Manage. 2003;19(1):32-34. 11. Snyder L, Leffler C. Ethics manual, fifth edition. Ann Intern Med. 2005; 142(7):560-582. 12. American Medical Association, Council on Ethical and Judicial Affairs. Code of Medical Ethics: Current Opinions With Annotations. Chicago, IL: American Medical Association; 2008. 13. Fabre J. Hip, hip, Hippocrates: extracts from the Hippocratic doctor. BMJ. 1997; 315(7123):1669-1670. 14. Baker RB, Caplan A, Emanuel L, Latham S. The American Medical Ethics Revolution: How the AMA’s Code of Ethics Has Transformed Physicians’ Relationships to Patients, Professionals, and Society. Baltimore, MD: Johns Hopkins University Press; 1999. 15. Cathell DW. The Physician Himself From Graduation to Old Age. Philadelphia, PA: Davis; 1882. Can the Food Industry Play a Constructive Role in the Obesity Epidemic? David S. Ludwig, MD, PhD Marion Nestle, PhD, MPH I N RESPONSE TO INCREASING RATES OF OBESITY, MANY FOOD companies have announced policies of corporate responsibility. McDonald’s claims, “[we] empower individuals to make informed choices about how to maintain the essential balance between energy intake (calories consumed as food) and energy expenditure (calories burned in physical activity).”1 Coca-Cola states, “we have launched new broad-based physical and nutrition education programs that reach even the least athletic students.”2 PepsiCo says, “we can play an important role in helping kids lead healthier lives by offering healthy product choices in schools, by developing healthy products that appeal to kids and by promoting programs that encourage kids to lead active lives.”3 Kraft says, “helping children and their families make heal thy food choices while encouraging physical activity has become part of how Kraft gives back to communities.”4 In light of such statements, should the food industry be welcomed as a constructive partner in the campaign against obesity? 1808 JAMA, October 15, 2008—Vol 300, No. 15 (Reprinted) The Dark Side of the Food Industry Simon5 examined food corporation practices in the United States, especially with regard to school nutrition, and concluded that companies “lobby vociferously against policies to improve children’s health; make misleading statements and misrepresent their policies at government meetings and in other public venues; and make public promises of corporate responsibility that sound good, but in reality amount to no more than [public relations].” At the request of the World Health Organization, Lewin et al6 compared the promises and actual practices of 2 leading food companies in the United States, documenting systematic discrepancies. Despite claims to the contrary, McDonald’s at least up to 2005 continued to use trans fats in cooking oil (and was required to pay settlement costs for deceptive advertising); to market unhealthful products to children with toys, games, movie tie-ins, and trips to Disney World; and to promote supersized versions of Happy Meals.6 Kraft, the second comAuthor Affiliations: Department of Medicine, Children’s Hospital, Boston, Massachusetts (Dr Ludwig); and Department of Nutrition, Food Studies, and Public Health, New York University, New York, New York (Dr Nestle). Corresponding Author: David S. Ludwig, MD, PhD, Children’s Hospital Boston, 300 Longwood Ave, Boston, MA 02115 ([email protected]). ©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Hostos Community College User on 04/15/2022 COMMENTARIES pany studied, remained heavily engaged in the marketing of unhealthful products to children despite promises to fight childhood obesity announced with great fanfare in 2003.6 The activities of the industry-sponsored group, Center for Consumer Freedom (CCF), merit particular attention. With an annual budget exceeding $3 million, the CCF lobbies aggressively against obesity-related public health campaigns, legislation to regulate marketing of junk food to children, and scientists who advocate for healthier diets. The CCF boasts that “[our] strategy is to shoot the messenger . . . We’ve got to attack [activists’] credibility as spokespersons.”7 According to the Center for Media and Democracy, the CCF is funded primarily through undisclosed donations from companies such as Coca-Cola, Cargill, Tyson Foods, and Wendy’s,8 allowing them to support unsavory lobbying practices while claiming to be responsible corporate citizens. Is the food industry simply not to be trusted? An Irreconcilable Conflict In a Western-style capitalistic economy, food corporations, like all corporations, must make the financial return to stockholders their first priority. Wall Street places corporations under great pressure not only to be profitable, but also to meet quarterly growth targets. But the food market in the United States is mature; it provides about 3900 kcal per capita each day, roughly twice the population’s energy needs. To expand profits in this environment, food companies have only 2 options: convince customers to eat more (contributing directly to obesity) or increase profit margins, especially by marketing reformulated or repackaged products (an indirect contribution). Nutritional experts generally agree that diets based predominantly on relatively unprocessed vegetables, fruits, and grains support good health. Although minimally processed foods protect against obesity and related diseases by virtue of their rich nutrient content and satiating properties, they have low profit margins. Far greater profits come from highly processed, commodity-derived products—fast food, snack foods, and beverages—primarily composed of refined starch, concentrated sugars, and low-quality fats. These already inexpensive products are made even more inexpensive by massive agricultural subsidies. Research links frequent consumption of highly processed foods to weight gain and increased risk for diet-related diseases.9 The inverse relationship of processing to nutritional quality is illustrated by the progressive decline in the satiating value of apple-containing foods, from the whole fruit to applesauce to apple juice,10 as profitability increases. Even though fast-food companies may offer healthier items, most of their profits come from french fries and soft drinks, explaining why fruit seldom appears in their advertisements. Thus, food industry strategies to increase revenues typically depend on “eat more” campaigns designed to promote larger portions, frequent snacking, and the normalization of sweets, soft drinks, snacks, and fast food as daily fare. Advice to eat less often, eat foods in smaller portions, and avoid high-calorie foods of low-nutritional quality undermines the fundamental business model of many companies. Pitfalls of the Collaborative Approach The food industry, considered a stakeholder in the campaign against obesity, is actively encouraged to participate in government-sponsored workshops, contribute to the formulation of national nutritional policy, affiliate with government-sponsored initiatives, and partner with scientists and professional associations. Moreover, the industry has been asked to establish voluntary codes of conduct for nutritional quality and marketing practices, sometimes in cooperation with public health organizations. However, this collaborative approach seems better suited to the interests of industry than to those of the public. To demonstrate concern about childhood obesity, food companies tout their efforts to promote sports in schools or youth organizations. For example, PepsiCo will donate $11.6 million over 5 years to the YMCA to support, among other events, an annual community day “to celebrate healthy living, encourage kids and families to get excited about physical fun and activity and . . . engage kids in play to be healthy.”11 This focus on physical activity, characteristically without commensurate attention to diet quality, appears disingenuous. A child can easily consume more calories from a soft drink than she would expend at a sports event sponsored by a beverage company. The food industry, with its enormous financial resources, has an especially insidious influence on the conduct of research and development of public health policy. Lesser et al12 analyzed 206 scientific articles published over a 5-year period that addressed the health effects of milk, fruit juices, and soft drinks. The likelihood of a conclusion favorable to the industry was 4-fold to 8-fold higher if the study received full rather than no industry funding, raising the possibility of systematic bias. Food companies also donate large sums of money to professional associations. In return for a donation to the American Dietetic Association (ADA), CocaCola becomes an ADA partner and receives “a national platform via ADA events and programs with prominent access to key influencers, thought leaders, and decision makers in the food and nutrition marketplace.”13 Some professional associations continue to accept fees to endorse sugary breakfast cereals and processed snack foods, even though this practice was considered potentially deceptive by state attorneys general nearly a decade ago.14 Although companies sometimes volunteer to establish nutritional standards or limit unfair marketing practices, such actions appear to have dubious public health benefit. In 2006, the American Heart Association and the William J. Clinton Foundation brokered an agreement with Coca-Cola, PepsiCo, and Cadbury Schweppes to remove sugary drinks from schools. From the start, public health experts expressed con- ©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Hostos Community College User on 04/15/2022 (Reprinted) JAMA, October 15, 2008—Vol 300, No. 15 1809 COMMENTARIES cern that the agreement made too many concessions to the companies and would undermine efforts to enact meaningful government regulations. Subsequent modifications to the agreement reintroduced caloric beverages—such as sugary vitamin waters and sports drinks—into schools, thereby limiting the initiative’s effectiveness.15 An Appropriate Division of Responsibilities In a market-driven economy, the manufacturer is free to sell poor-quality products and the customer is free to reject them. This supply-and-demand principle works well for many consumer goods, but not those that affect health, safety, or the greater social good. Like food products, cars have benefits and risks to individuals and society. The government imposes regulations, mandates, taxes, and incentives to encourage production of safer and less polluting vehicles. An informed public willingly pays more for such cars, and concerns for higher gasoline prices and climate change stimulate their sales. Society does not expect car companies to police themselves, nor allow them to market unsafe cars in exchange for initiatives to reduce accidental injuries from other causes. Modifiable dietary factors cause substantially more illness and death than automobile crashes. Left unchecked, the economic costs associated with obesity alone will affect the competitiveness of the US economy. Therefore, it is imperative to clarify the appropriate role of the food industry in relationship to other key segments of society. The government’s role is to regulate by establishing rigorous standards for nutrition at school (US Department of Agriculture), banning food marketing targeted to children (US Federal Trade Commission), and forbidding unsubstantiated health claims on food labels (US Food and Drug Administration). If commercials for erectile dysfunction medication must mention rare complications like prolonged erection, it seems that commercials for fast food should be required to warn about the likely consequences of consuming partially hydrogenated fat and too much sugar. The government also must ensure that nutritional policies are based on solid science, rather than special interests. Congress should mandate greater funding of nutritional research to help counter the influence of industry money; consider placing responsibility for dietary guidance with an independent body such as the Institute of Medicine; structure agricultural subsidies to support public health, not commodity producers; and reform campaign finance laws to prevent corporate political donations from leveraging the legislative process. Academia’s role is to investigate by rigorous scientific investigation of nutrition and health. To minimize the corrosive effects of financial conflicts of interest, universities should institute systems to ensure independent review of industrysponsored research, including critical oversight of hypotheses, design, data collection, data analysis, interpretation, and decisions to publish. 1810 JAMA, October 15, 2008—Vol 300, No. 15 (Reprinted) Public health organizations’ role is to educate so professional health associations must avoid partnerships, product endorsement fees, or other financial ties with industry that compromise their independence and public credibility. Advocacy groups should broker industry agreements only with broad-based support from the public health community. The public’s role is to dictate, with the fork, by making informed food purchases, and with the ballot, by electing politicians committed to enlightened government action in the area of nutrition and health. Industry’s role is to innovate. Corporations must be able to make a profit. However, the prevailing approach encourages lowest common denominator practices; if one company advertises to young children, other companies would be at a competitive disadvantage if they adhered to ethical marketing standards. By establishing clear rules of conduct— leveling the playing field upon which all companies compete—society can free the industry to focus on what it does best: finding creative ways to satisfy consumer needs, in this case making healthful food economical, convenient, and tasty. Conclusion With respect to obesity, the food industry has acted at times constructively, at times outrageously. But inferences from any one action miss a fundamental point: in a market-driven economy, industry tends to act opportunistically in the interests of maximizing profit. Problems arise when society fails to perceive this situation accurately. While visionary CEOs and enlightened food company cultures may exist, society cannot depend on them to address obesity voluntarily, any more than it can base national strategies to reduce highway fatalities and global warming solely on the goodwill of the automobile industry. Rather, appropriate checks and balances are needed to align the financial interests of the food industry with the goals of public health. Financial Disclosures: Dr Ludwig reported receiving royalties from a book about childhood obesity. Dr Nestle reported receiving royalties from books about food politics. REFERENCES 1. McDonald’s Corporation. Balanced active lifestyles: 2006 worldwide corporate responsibility report. http://www.mcdonalds.com/corp/values/balance /bal_framework__alt.html. Accessed August 12, 2008. 2. Coca-Cola Co. Corporate responsibility: active lifestyles. http://www .thecoca-colacompany.com/citizenship/fitness_active_lifestyles.html. Accessed August 12, 2008. 3. PepsiCo. Health and wellness: PepsiCo’s health and wellness philosophy. http: //www.pepsico.com/PEP_Citizenship/HealthWellness/philosophy/index.cfm. Accessed August 12, 2008. 4. Kraft. Health and wellness. http://www.kraft.com/Brands/healthandwellness/. Accessed August 12, 2008. 5. Simon M. Can food companies be trusted to self-regulate? an analysis of corporate lobbying and deception to undermine children’s health. Loyola Los Angel Law Rev. 2006;39:169-236. 6. Lewin A, Lindstrom L, Nestle M. Food industry promises to address childhood obesity: preliminary evaluation. J Public Health Policy. 2006;27:327-348. 7. Sargent G; American Prospect. Berman’s battle: Richard Berman claims to help the average consumer; in fact he works for corporate America. http://www .prospect.org/cs/articles?articleId=8984. Accessed September 3, 2008. ©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Hostos Community College User on 04/15/2022 COMMENTARIES 8. SourceWatch. Center for consumer freedom. http://www.sourcewatch.org /index.php?title=Center_for_Consumer_Freedom. Accessed August 12, 2008. 9. Pereira MA, Kartashov AI, Ebbeling CB, et al. Fast food habits, weight gain, and insulin resistance in a 15-year prospective analysis of the CARDIA study. Lancet. 2005;365(9453):36-42. 10. Haber GB, Heaton KW, Murphy D, Burroughs LF. Depletion and disruption of dietary fibre: effects on satiety, plasma-glucose, and serum-insulin. Lancet. 1977; 2(8040):679-682. 11. PepsiCo. PepsiCo joins with America’s YMCAs to help Americans live healthier lives. http://phx.corporate-ir.net/phoenix.zhtml?c=78265&p=irol-newsArticle& ID=828887&highlight. Accessed August 12, 2008. 12. Lesser LI, Ebbeling CB, Goozner M, Wypij D, Ludwig DS. Relationship be- tween funding source and conclusion among nutrition-related scientific articles. PLoS Med. 2007;4(1):e5. 13. American Dietetic Association. American Dietetic Association welcomes the Coca-Cola Co as an ADA partner. http://www.eatright.org/cps/rde/xchg/ada/hs .xsl/media_16174_ENU_HTML.htm. Accessed August 12, 2008. 14. State Attorney General NY. Media center: executive summary. http://www .oag.state.ny.us/media_center/reports/nonprofit/full_text.html. Accessed September 3, 2008. 15. Wootan MG; Center for Science in the Public Interest. Study shows progress in getting soft drinks out of schools, still two-thirds of school beverage sales are sugary drinks. http://www.cspinet.com/new/200709171.html. Accessed September 3, 2008. Transforming Research Strategies for Understanding and Preventing Obesity Terry T.-K. Huang, PhD, MPH Thomas A. Glass, PhD C URRENTLY, ONE-THIRD OF CHILDREN AND TWOthirds of adults in the United States are overweight or obese; this trend has persisted for the last decade and shows no sign of abatement.1,2 Obesity tracks from childhood into adulthood, with unfolding and serious medical and economic consequences throughout the life course. One recent estimate suggests that if the current trend continues, obesity will account for more than $860 billion, or more than 16%, of health care expenditures in the United States by 2030.3 The need to find effective population-level obesity prevention strategies is among the most profound challenges in public health. Altering fundamental behaviors that govern energy balance is impossible when behaviors related to eating and physical activity are treated in isolation from the broader social, physical, economic, and policy context. Although energy consumption and energy expenditure may be at the core of the energy balance equation, obesity is, in fact, a medical manifestation of the complex interplay of biology and social change. However, the majority of research on obesity prevention has ignored larger changes in the social, physical, economic, and policy environments that doubtless are involved. Instead, most prevention efforts to date have focused on individually targeted strategies such as health education and behavioral skills training that turn out to be largely ineffective and unsustainable. The time is now ripe, and more urgent than ever, to implement a new, multilevel approach to understanding the basis of the obesity epidemic and how to reverse it. Toward a Multilevel Obesity Research Strategy A multilevel research approach for obesity prevention frames obesity as a complex systems problem, for which food and physical activity behaviors are not only a matter of indi- vidual choice but also strongly influenced by multiple levels of socioenvironmental risks, ie, interpersonal level (family, peers, and social networks), community level (schools, worksites, institutions), and governmental level (local, state, national policies), as well as by the interaction with biological processes (from genes and molecular and cellular processes to organ systems).4 By evolutionary advantage, the human body has a powerful defense mechanism against undernutrition in conditions of scarcity. However, that same evolutionary advantage (the capacity to store excess energy as fat) has not equipped humans for life in an obesogenic environment. At the interpersonal level, this obesogenic environment may include highly permissive or controlled child feeding styles, family demands that are stressful and time constraining, or unhealthful social norms of diet and physical activity. At the community level, unhealthy foods sold through school, worksite, hospital, and other institutional cafeterias and vending machines contribute to poor diets. The lack of physical education in schools or time and opportunity for leisure exercise elsewhere contributes to sedentary behavior. At the governmental level, policies regarding food, agriculture, education, transportation, urban design, marketing, and trade all play a role in increasing the accessibility and availability of high-fat and high-sugar foods vs fresh fruits and vegetables and in decreasing opportunities for physical activity. The lack of access to preventive care is also a major concern. Historical US policies that led to social inequality and segregation have, in turn, resulted in inequalities in the built environment, leading to disproportionate rates of obesity among the poor and minorities.5 Author Affiliations: Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Dr Huang); and Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Dr Glass). Corresponding Author: Terry T.-K. Huang, PhD, MPH, Obesity Research Strategic Core, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6100 Executive Blvd, 4B11, Bethesda, MD 20892-7510 ([email protected]). ©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Hostos Community College User on 04/15/2022 (Reprinted) JAMA, October 15, 2008—Vol 300, No. 15 1811 Solutions to obesity: perspectives from the food industry1– 4 Patricia Verduin, Sanjiv Agarwal, and Susan Waltman KEY WORDS Food industry, obesity, consumer choices, consumer attitude, dietary decisions, food labeling, healthy products INTRODUCTION Obesity has reached epidemic proportions in United States. Currently, more than 65% of Americans are overweight or obese (1). Obesity is correlated with several medical conditions, including type 2 diabetes, heart disease, high blood pressure, stroke, and certain types of cancer. Obesity and its related diseases are responsible for 앒400 000 deaths per year in the United States, paralleling the number of preventable deaths caused by smoking (2). Overweight in pediatric age groups has nearly tripled in the past 30 y (3). Today, an estimated 16.1% of adolescents (12–19 y of age) in the United States are overweight (body mass index 욷95th percentile for age) (4). Studies indicate that 50 –77% of these adolescents will become obese adults; 80% of those with one obese parent will do so (5– 8). Data show significantly lower quality of life scores for obese children compared with children of normal weight (9). They also show increased risk of obesity-related comorbidities, including degenerative joint disease (10, 11) and type 2 diabetes (5, 12–14). Obesity is a multifaceted health issue that involves biological, behavioral, and environmental sources. Energy imbalance sits at the core of the obesity problem, because weight gain results from consuming more calories than one expends. In America, a changing environment has increased food choices and changed eating habits. Many Americans are sedentary: more than one-half of US adults do not meet recommended levels of moderate physical activity, and one-fourth engage in no leisure time physical activity (15). Technological inventions have created many timeand labor-saving products. As a result, we have reduced the overall energy expenditure in our daily lives. Critical approaches to weight reduction involve behavior change related to diet and exercise. Stakeholders, including the food industry, government, academia, and health care providers, can work together to influence the consumer to make healthy lifestyle choices. ConAgra recognizes the influence the food industry has on consumer choices. ROLE OF THE CONSUMER Consumers are the most important player in the solution to the obesity epidemic because they make individualized choices about food and lifestyle. As stated by Philipson in this symposium (16), if the consumer can be influenced with comprehensible nutrition information and a variety of healthy food choices, perhaps individuals can begin to address weight gain on a personal level. In addition to cultural and psychological influences, four motivators have been identified that affect consumer decisions: taste, quality, convenience, and price. Although consumers indicate that healthy eating and good nutrition are increasingly important to them, sales and surveys show they are more concerned with taste, convenience, and price (17, 18). There exists a gap between consumer attitude and behavior that the food industry must consider. Moreover, consumers are confused with the conflicting messages regarding fat, carbohydrates, protein, and calories. Consumers need clarity and reliable nutrition information to make responsible dietary decisions. ROLE OF THE FOOD INDUSTRY The food industry should help the consumer make healthy food choices. Food manufacturers are sensitive to consumer tastes and expectations. Industry should be committed to giving clear, consistent, and honest product claims, as well as working with retailers and restaurants to offer consumers relevant information about the products they purchase. Industry should promote nutrition education at all levels, from public schools to medical schools, and enhance nutrition awareness at the consumer level. Industry can create new products that meet individual nutritional needs, reformulate existing products to be healthier, and provide controlled portion sizes. In doing so, industry faces the challenge of satisfying consumer expectations for taste, quality, and price. The hope is that industry can develop healthier 1 From ConAgra Foods Inc, Omaha, NE. Presented at the symposium “Science-Based Solutions to Obesity: What Are the Roles of Academia, Government, Industry, and Health Care?”, held in Boston, MA, March 10 –11, 2004 and Anaheim, CA, October 2, 2004. 3 Supported by ConAgra Foods Inc. 4 Address reprint requests and correspondence to P Verduin, ConAgra Foods Inc, 6 ConAgra Drive, Omaha, NE 68102. E-mail: [email protected] conagrafoods.com. 2 Am J Clin Nutr 2005;82(suppl):259S– 61S. Printed in USA. © 2005 American Society for Clinical Nutrition 259S Downloaded from ajcn.nutrition.org by guest on January 29, 2014 ABSTRACT Obesity has become an epidemic and an important public health concern. Because the problem is multidimensional, the solution will require an interdisciplinary approach involving the cooperation of the food industry with other stakeholders, such as the government, academia, and health care providers. The consumer is an important player in the solution to obesity because the consumer can make healthy lifestyle choices at the individual level. The food industry is committed to providing the consumer with healthy food options and reliable nutrition information. Am J Clin Nutr 2005;82(suppl): 259S– 61S. 260S VERDUIN ET AL products by partnering with science-based communities and the government. INDUSTRY COMMITMENT TO HEALTHY LIVING CONAGRA’S COMMITMENT TO THE COMMUNITY In addition to providing consumers with a multitude of healthy food options, ConAgra remains committed to helping the environment and communities in need. ConAgra’s “Feeding Children Better” foundation has funded over 160 Kids Cafes, providing logistics assistance and food donations for millions of “food insecure” American children. ConAgra has joined with the American Dietetic Association to promote Home Food Safety and to decrease the prevalence of food-borne diseases. COOPERATION WITH THE GOVERNMENT ConAgra stresses the importance of a close harmony between the food industry and other important stakeholders within the COOPERATION WITH ACADEMIA AND HEALTH CARE PROFESSIONALS ConAgra relies on the expertise of scientists and health care professionals within the medical field. Scientists have a unique insight to provide scientific data influencing the decisions of industry and consumers. Research scientists can work together with the food industry to generate nutritious foods and to promote reliable, science-based nutrition information. Academic institutions also play a key role in educating health care professionals, who will educate their patients and our consumers. The medical community is uniquely positioned and trusted by consumers, because consumers look for nutritional advice from knowledgeable and trustworthy professionals. Health care providers can encourage consumers to make individual lifestyle changes that will improve their health. The health care professional, in assuming such a role, can transform their interaction on this topic from clinical resolution to thoughtful prevention, thus helping consumers develop and reinforce strategies for eating and physical activity that reduce overall individual health care risk CONCLUSION To help fight the battle against obesity, the food industry must team up with the government, academia, and the medical community to help inform consumers, strengthen nutrition education, and develop healthier product choices. ConAgra aims to work in concert with these groups to continue providing consumers with a range of healthy food options. Giving consumers the best nutrition information and the best nutritional food options may empower them to make individualized lifestyle changes that will help overcome energy imbalance and, in the long term, may help curb our struggle with obesity. We acknowledge and thank George L Blackburn (Harvard Medical School, Boston, MA), Pat Kearney (PMK Associates, Alexandria, VA), and Mike Fernandez (ConAgra Foods Inc, Omaha, NE) for their request to write this review, their critical review, and valuable suggestions. REFERENCES 1. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999 –2000. JAMA 2002;288:1723–7. 2. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291:1238 – 45. 3. Inge TH, Garcia V, Daniels S, et al. A multidisciplinary approach to the adolescent bariatric surgical patient. J Pediatr Surg 2004;39:442–7. 4. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999 –2002. JAMA 2004;291:2847–50. Downloaded from ajcn.nutrition.org by guest on January 29, 2014 The food industry recognizes the challenges a consumer faces when making food choices. ConAgra has developed new food products and improved old favorites to offer consumers a large range of healthy food options. The variety within this range of healthy products provides consumers with the flexibility to satisfy different dietary needs and different lifestyles. The Healthy Choice product line began in 1988 and now has over 200 healthy products available. Healthy Choice provides consumers with low-calorie, nutritious meals, deli meats, breads, soups, and desserts. Healthy Choice “Flavor Adventures ” are frozen meals with exciting seasonings and ingredients that enhance taste without compromising healthful benefits and nutrients. Egg Beaters is another popular, tried-and-true item within the good-for-you product range. Egg Beaters is a real egg product that features no fat, no cholesterol, and half the calories of regular eggs, in addition to the ease of reusable packaging, which gives consumers another quick and healthy food option. The PAM line of no-stick cooking sprays now includes fat-free original, fat-free olive oil, and fat-free “for grilling” varieties, which promote healthier and hassle-free options for cooking and grilling. Fleischmann’s margarine products, targeted at health conscious consumers, offers Light, Unsalted, and No Trans fat cholesterol-free alternatives to butter. Hunt’s Tomatoes and their foodservice counterpart Angela Mia have teamed with the American Dietetic Association to promote the health benefits of tomatoes, which are rich in lycopene. Hunt’s also offers organic tomatoes. The Lightlife brand caters to vegetarian needs with meatless, soy-based products. ConAgra now features a new line called Life Choice for consumers who want meals low in carbohydrates. Ultragrain, a creation of the ConAgra Ingredients group, combines the nutritional value of whole grains with the taste and texture of refined grains to enrich the diets of consumers who prefer refined grains. ConAgra promotes healthy living in many other capacities, including a Healthy Choice website at www.healthychoice.com and a monthly email newsletter called “To Your Health” that features coupons, recipes, and nutritional tips. obesity epidemic, such as the government, academia, and health care providers. The government can help educate consumers to make healthier choices through food labeling, physical activity endorsement, and the support of community-based programs. The food industry should cooperate with the government to guarantee the production and availability of low-calorie, nutritious foods. This can be achieved by providing incentives to industry and also stimulating media participation in the prevention of obesity. The government should develop and support new food technology and improve communication across responsible parties and consumers. SOLUTIONS TO OBESITY 5. Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. Relationship of childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa Heart Study. Pediatrics 2001;108:712– 8. 6. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997;337:869 –73. 7. Guo SS, Huang C, Maynard LM, et al. Body mass index during childhood, adolescence and young adulthood in relation to adult overweight and adiposity: the Fels Longitudinal Study. Int J Obes Relat Metab Disord 2000;24:1628 –35. 8. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med 1993;22:167–77. 9. Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA 2003;289:1813–9. 10. Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics 1998;101:518 –25. 11. Karlson EW, Mandl LA, Aweh GN, Sangha O, Liang MH, Grodstein F. Total hip replacement due to osteoarthritis: the importance of age, obesity, and other modifiable risk factors. Am J Med 2003;114:93– 8. 261S 12. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med 1992;327:1350 –5. 13. Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA 2003;289:187–93. 14. Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury PR, Zeitler P. Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. J Pediatr 1996;128:608 –15. 15. Manson JE, Skerrett PJ, Greenland P, VanItallie TB. The escalating pandemics of obesity and sedentary lifestyle. A call to action for clinicians. Arch Intern Med 2004;164:249 –58. 16. Philipson T. Government perspective: food labeling. Am J Clin Nutr 2005;82(suppl):1720S–2S. 17. Lando AM, Labiner JM, Williams RA. Consumer’s use of food and restaurant labeling: focus group results. US FDA Center for Food Safety and Health Nutrition. Internet: http://vm.cfsan.fda.gov/앑frf/forum04/ G-05.HTM (accessed 30 September 2004). 18. US Food and Drug Administration. Consumer research on food labels. Internet: http://vm.cfsan.fda.gov/앑lrd/ab-label.html (accessed 30 September 2004). Downloaded from ajcn.nutrition.org by guest on January 29, 2014 Copyright of American Journal of Clinical Nutrition is the property of American Society for Nutrition and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. Published by Oxford University Press on behalf of the International Epidemiological Association Ó The Author 2005; all rights reserved. Advance Access publication 7 December 2005 International Journal of Epidemiology 2006;35:100–104 doi:10.1093/ije/dyi276 REVIEW Food environments and obesity— neighbourhood or nation? Steven Cummins1* and Sally Macintyre2 Accepted 7 November 2005 Obesity arises from an imbalance between energy input and output1 but in this commentary we focus exclusively on environmental issues in energy intake in the developed world. Our aim is both to provide an overview of recent findings on obesogenic environments2 and to point to cross national variations in their distribution. It has recently been suggested that individually focused interventions attempting to reduce obesity have had limited success,3 and that the widespread and increasing prevalence of obesity is inadequately explained by individual-level psychological and social factors associated with diet or physical activity.1,2,4,5 This suggestion is part of a broader critique of the over-emphasis on the role of individual health behaviours, which has tended to ignore the influence of the complex social and physical contexts in which individual behavioural decisions are made.4,6 Such critiques have led to a new focus on ‘environmental’ exposures that encourage excessive food intake and discourage physical activity.7–10 Obesity and SES Higher rates of obesity are likely to be found in those with the lowest incomes and the least education, particularly among women and certain ethnic groups.11–13 Some authors have viewed this association, with hunger and obesity co-existing side-by-side, as something of a paradox.14 This apparent paradox may be explained by the relatively low cost of energy dense foods,9,15 the high palatability of sweets and fats associated with higher energy intakes,16 and the association of lower incomes and food insecurity with lower intakes of fruit and vegetables.17–19 Recent observational studies have found that dietary patterns and obesity rates vary between neighbourhoods, with living in a low-income or deprived area independently associated with the prevalence of obesity and the consumption of a poor diet. Such associations have been consistently reported in countries such as the UK,20–24 The Netherlands,25,26 Sweden,27 Australia,28,29 1 2 Department of Geography at Queen Mary, University of London, Mile End Road, London, UK. MRC Social & Public Health Sciences Unit, 4 Lilybank Gardens, Glasgow, UK. * Corresponding author. Department of Geography, Queen Mary, University of London, Mile End Road, London E1 4NS, UK. E-mail: [email protected] US30–32, and Canada33. It has been suggested that this may be due to a process of ‘deprivation amplification’,34 whereby exposure to poor quality food environments amplifies individual risk factors for obesity such as low income, absence of transport, and poor cooking skills or knowledge. Environmental influences on diet are partly considered to involve two pathways: access to foods for home consumption from supermarkets and grocery stores, and access to ready made food for home and out-of-home consumption (e.g. takeaways, restaurants). In this commentary we review and assess the role of these two elements of the local food environment in producing the patterning of obesity by socioeconomic status. Evidence for the influence of grocery stores and supermarkets It has been suggested that the price and availability of food may be an important mediating factor in the relationship between neighbourhood environment, diet quality, and obesity.35 One recent study in the US found that the presence of supermarkets was associated with a lower prevalence of obesity.36 Studies in the US and Canada have found neighbourhood differences in the price and availability of food, with ‘healthier’ foods generally more expensive, and less readily available, in poorer than in wealthier communities. Accessibility to supermarkets is poorer in low-income neighbourhoods, with fewer supermarkets and more small independent grocery stores available to local residents.37–42 These independent stores tend to charge higher prices than supermarkets.37–39 Similar deficiencies in food access are observed in predominately African-American neighbourhoods.40,41 In one study supermarkets were, on average, 1.15 miles further away for residents of black compared with white neighbourhoods,43 leading to the suggestion that racially biased business decisions may well be in operation.44 Grocery stores in black neighbourhoods are also less likely to stock healthy food items or healthier versions of standard foods (e.g. low-fat, low-salt).45 Lack of access to supermarkets has also been reported in rural areas.46 Lesser allocation of shelf-space in community grocery stores to ‘healthier’ (low-fat and high-fibre) products has been associated with lower consumption of such foods among local residents.47 Proximity to a supermarket has been associated with higher fruit and vegetable intake and better diet quality among low-income households48 and pregnant women.49 For black neighbourhoods a significant dose–response relationship was found, with a 100 FOOD ENVIRONMENTS AND OBESITY 32% increase in fruit and vegetable intake for each additional supermarket in the area.50 African-American women shopping at supermarkets and speciality stores consumed fruit and vegetables more often, on average, than those shopping at independent grocers.51 The picture from North America is thus reasonably consistent; places inhabited by poorer people and black people have poorer access to ‘healthier’ foods. However, the picture outside North America is different, the UK research undertaken in the late 1980s and early 1990s did suggest similar inequalities, with high prices and poor availability being associated with area deprivation.52–54 However, these findings were derived from mainly small-scale local surveys and in some cases data have been misintepreted by policy-makers.55 More recently, larger and more robust empirical observational studies in major urban centres in the UK have found no independent association between neighbourhood food retail provision, individual diet, and fruit and vegetable intake56,57; no differences in food price, food availability, and access to supermarkets between deprived and affluent areas58–60; and reasonable availability of a range of ‘healthy’ foods across contrasting urban areas.58,61 Researchers have also found that, in England, few low-income consumers report any problems in using supermarkets, despite transport difficulties, or perceived problems in the choice of shops or fruit and vegetables.62 Studies in Northern Ireland found that even though consumers who used small stores within their local area were at a price disadvantage,63 there was little evidence that consumers regarded travelling to edge-of-town supermarkets as problematic.64 Similarly, a study in Brisbane, Australia, found no socioeconomic differences in shopping infrastructure for fruit and vegetables,65 and little difference in fruit and vegetable purchasing patterns between households in socioeconomically disadvantaged and advantaged areas once household income had been taken into account.28 A study in Eindhoven, The Netherlands, found increasing proximity to food stores with increasing neighbourhood deprivation.66 For the most part, evidence concerning the links between diet and the retail food environment has been purely observational and thus cannot determine the direction of causality. For example it may be that lower availability of healthier foodstuffs in poorer or black areas is due to low demand. However, two studies have attempted to evaluate the effects on fruit and vegetable intake of the introduction of supermarkets in deprived communities.67,68 In an uncontrolled before/after study undertaken in Leeds, England, some small improvements in fruit and vegetable consumption were found, with larger improvements found for individuals initially consuming two or fewer portions per day.68 Positive impacts were reported to be particularly pronounced for those who ‘switched’ to the new supermarket as their main food source compared with those who continued to use their existing provision. In comparison, a controlled before and after study in Glasgow (Scotland)67,69 found little evidence for any effect on fruit and vegetable consumption overall or for a ‘switchers’ subgroup. Fruit and vegetable consumption increased slightly in the area with the new superstore, but positive changes also occurred in the control area. The quasi-experimental design of the Glasgow study is important, as unadjusted changes within the intervention area were similar in magnitude to the Leeds study, suggesting that what was being observed was a product of 101 general secular (or other) change rather than a direct effect of the intervention itself. Evidence for the influence of fast-food and other outlets Foods purchased from fast-food outlets, restaurants, and other places are becoming an increasingly important part of people’s diet, particularly in the US.70–73 Such foods are up to 65% more energy dense than the average diet,74 and intakes of selected nutrients are lower in the population groups who consume more of them.75 Those consuming these foods tend to be heavier than those who do not, even after controlling for a range of sociodemographic variables, including income.76–78 Portion sizes of out-of-home meals are relatively large compared with home prepared foods.79 It has been suggested that fast-food outlets are more prevalent in poorer areas,80 and that this might help to explain higher rates of obesity in these neighbourhoods. A limited number of ecological and multi-level studies have investigated this hypothesis. Associations have been found between area deprivation and density of fast-food outlets in Melbourne, Australia, with poorer neighbourhoods having 2.5 times more fast-food outlets,81 and in New Orleans where there were more fast-food outlets in predominately black census tracts.82 Ecological correlations between obesity rates and the prevalence of fast-food outlets have been found for US states and account for ~6% of the variance in obesity in a model which explained 70% of the state-level geographic difference.83 In Los Angeles, poorer neighbourhoods with higher proportions of African Americans had fewer healthy options available in away-from-home outlets and more advertising and promotional prompts to consume unhealthy alternatives.84 CHD mortality and hospitalization has also been associated with regional fast-food service density in Canada.85 In England and Scotland, McDonald’s restaurants tend to be located in more deprived areas.86 However, conflicting findings have also been reported within each of these countries. No relationships between obesity and proximity to take-away outlets were found for adults in Victoria, Australia,87 and for children in Cincinnati, USA.88 Density of fast-food and other outlets was not found to be associated with area deprivation in Glasgow, UK,89 nor were density measures associated with area-based measures of wealth and racially based residential segregation in areas of the US.40 Fast-food restaurants were found to charge more for food in black neighbourhoods in New Jersey and Pennsylvannia, USA.90 Does living in North America make you fat? So what does this all mean? In the United States the observational evidence tends to support the idea that access to supermarkets and grocery stores is constrained for those who live in low-income or black neighbourhoods, and that consequent price and choice disincentives to healthy eating might help to explain higher rates of poor diet and of obesity. Outside the US the most recent observational studies suggest that this is not the case. Though experimental studies, undertaken in the UK, have produced mixed results, the study with the most 102 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY robust design did not find convincing evidence for an effect on diet of introducing a supermarket into a poor area.91 In general, current evidence for an effect of the out-of-home fast-food environment is mixed. Some US and UK studies indicate a plausible role for the fast-food environment in promoting neighbourhood differences in obesity, but these are counter-balanced by other, more negative, findings. Studies in this area tend to be primarily ecological in design and to be relatively few, so it is no surprise that consensus is difficult with a body of evidence that is only emerging now. Even though neighbourhood differences in obesity exist in many countries good evidence for a ‘contextual’ effect of the food environment is really only evident in North America. Why should this be the case? It is probably not that the food environment is important in the USA and Canada and unimportant elsewhere but rather that the environmental processes that explain geographic differences in obesity may be different. The social, cultural, economic, and regulatory environment that governs the provision, purchase, and consumption of food is likely to differ markedly between nations and these differences may be expressed at the neighbourhood level within countries. For example, residential segregation along socioeconomic and racial lines may be more pronounced in the USA and planning regulations less focused on compensating for such segregation than in the UK, continental Europe, or Australia. In Glasgow we found supermarkets more prevalent in poorer areas, possibly because of lower land prices and regulatory controls on new supermarkets in out-of-town sites.59 We found out-of-home food outlets concentrated in the City Centre, where there is a likelihood of high levels of demand during the daytime and evening and low levels of residential deprivation.89 In contrast, in the USA richer people have tended to move to the outskirts of cities leaving poorer and blacker neighbourhoods closer to the urban centre—a process of residential segregation colloquially known as ‘white-flight’.92,93 Though this process slowed in the 1990s some cities, such as Detroit, appear to have been subjected to a permanent spatial re-ordering leading to differential exposure to neighbourhood environmental risks on the basis of income and race. A recent report from The Brookings Institution suggests that, in Philadelphia, the ‘poor pay more’ because businesses perceive the personal and economic risks of operating in low-income communities as higher and thus charge higher prices to compensate for it.94,95 Similarly the magnitude and importance of the effects of the diet-related contextual determinants of obesity may also differ between countries. Outside North America, differences in the provision of opportunities to consume more or less healthy food may not be as important in promoting obesity as other determinants such as physical activity (which may be influenced by other environmental factors such as urban design and transport patterns). It should also be noted that, with few exceptions, studies in this field are cross-sectional. Although it is often assumed that there is a straightforward direction of causality from supply (availability and price) to behaviour (food purchasing and consumption), it may be that the processes are much more dynamic. Relationships may operate in the opposite direction or have positive or negative feedback loops; where there is no demand for healthier foods (because of preferences or lack of income, transport, or time) such foods are less likely to be stocked. Such supply restrictions may then reinforce residents’ negative perceptions of choice and availability. Conclusion Good, albeit mostly cross-sectional, evidence for neighbourhood level environmental influences on diet and obesity only exists for those who live in North American neighbourhoods, with the most consistent evidence available from US studies. The possibility that relationships between socioeconomic factors may be more observable in the US than in other developed nations has been hinted at by researchers who have noted that a contextual relationship between income-inequality and health found in the US is not found elsewhere.96,97 Intriguingly, this may point to a situation where residents of the US are particularly susceptible to the contextual determinants of health at the neighbourhood level or may suggest that macro-level processes currently make the US a very different place to live compared with other developed nations. Whatever the reason, much work is still required to determine whether the food- and diet-related environmental determinants of obesity will remain purely a US phenomenon or that other developed nations are playing ‘catch-up’—either in terms of the available evidence or in terms of the magnitude and existence of neighbourhood level contextual effects. 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