Download CHAPTER FIVE

CHAPTER FIVE. OBESITY AS A PUBLIC HEALTH
PROBLEM
Surgeon General, A Call to Action to Prevent & Decrease
Overweight & Obesity 1-17 (2001)
*
*
*
This Surgeon General's Call To Action seeks to engage leaders
from diverse groups in addressing a public health issue that is among
the most burdensome faced by the Nation: the health consequences of
overweight and obesity. This burden manifests itself in premature death
and disability, in health care costs, in lost productivity, and in
social stigmatization. The burden is not trivial. Studies show that the
risk of death rises with increasing weight. Even moderate weight excess
(10 to 20 pounds for a person of average height) increases the risk of
death, particularly among adults aged 30 to 64 years.
Overweight and obesity are caused by many factors. For each
individual, body weight is determined by a combination of genetic,
metabolic, behavioral, environmental, cultural, and socioeconomic
influences. Behavioral and environmental factors are large contributors
to overweight and obesity and provide the greatest opportunity for
actions and interventions designed for prevention and treatment.
For the vast majori
ty of individuals, overweight and obesity result from excess calorie
consumption and/or inadequate physical activity. Unhealthy dietary
habits and sedentary behavior together account for approximately
300,000 deaths every year. Thus, a healthy diet and regular physical
activity, consistent with the Dietary Guidelines for Americans, (see
Appendix to this chapter infra) should be promoted as the cornerstone
of any prevention or treatment effort. . . . Much work needs to be done
to ensure the nutrient adequacy of our diets while at the same time
avoiding excess calories. Dietary adequacy and moderation in energy
consumption are both important for maintaining or achieving a healthy
weight and for overall health.
Many adult Americans have not been meeting Federal physical
activity recommendations to accumulate at least 30 minutes o moderate
physical activity most days of the week. In 1997, less than one-third
of adults engaged in the recommended amount of physical activity.
Although nearly 65 percent of adolescents reported participating in
vigorous activity for 20 minutes or more on 3 or more out of 7 days,
national data are not available to assess whether children and
adolescents meet the Federal recommendations to accumulate at least 60
minutes of moderate physical activity most days of the week. Many
experts also believe that physical inactivity is an important part of
the energy imbalance responsible for the increasing prevalence of
overweight and obesity. Our society has become very sedentary; for
example, in 1999, 43 percent of students in grades 9 through 12 viewed
television more than 2 hours per day.
. . . .
MEASURING OVERWEIGHT AND OBESITY
The first challenge in addressing overweight and obesity lies in
adopting a common public health measure of these conditions. An expert
panel, convened by the National Institutes of Health (NIH) in 1998, has
utilized Body Mass Index (BMI) for defining overweight and obesity. BMI
is a practical measure that requires only two things: accurate measures
of an individual's weight and height. BMI is a measure of weight in
relation to height. BMI is calculated as weight in pounds divided by
the square of the height in inches, multiplied by 703 [to adjust for
comparisons to weights based on the metric system]. Alternatively, BMI
can be calculated as weight in kilograms divided by the square of the
height in meters.
Studies have shown that BMI is significantly correlated with
total body fat content for the majority of individuals. BMI has some
limitations, in that it can overestimate body fat in persons who are
very muscular, and it can underestimate body fat in persons who have
lost muscle mass, such as many elderly. Many organizations, including
over 50 scientific and medical organizations . . . support the use of a
BMI of 30 kg/m2 and 29.9 kg/m2 to identify overweight in adults. These
definitions are based on evidence that suggests health risks are
greater at or above a BMI of 25 kg/m2 compared to those at a BMI below
that level. The risk of death, although modest until a BMI of 30 kg/m2
is reached, increases with an increasing Body Mass Index.
. . . .
In children and adolescents, overweight has been defined as a
sex- and age-specific BMI at or above the 95th percentile, based on
revised Centers for Disease Control and Prevention (CDC) growth charts.
Neither a separate definition for obesity nor a definition for
overweight based on health outcomes or risk factors is defined for
children and adolescents.
. . . .
HEALTH RISKS
Epidemiological studies show an increase in mortality associated
with overweight and obesity. Individuals who are obese (BMI  30) have a
50 to 100 percent increase risk of premature death from all causes
compared to individuals with a BMI in the range of 20 to 25. An
estimated 300,000 deaths a year may be attributable to obesity.
Morbidity from obesity may be as great as from poverty, smoking,
or problem drinking. Overweight and obesity are associated with an
increased risk for coronary heart disease; type 2 diabetes;
endometrial, colon, postmenopausal breast, and other cancers; and
certain musculoskeletal disorders, such as knee osteoarthritis. Both
modest and large weight gains are associated with significantly
increased risk of disease. For example, a weight gain of 11 to 18
pounds increases a person's risk of developing type 2 diabetes to twice
that of individuals who have not gained weight, while those who gain 44
pounds or more have four times the risk of type 2 diabetes.
A gain of approximately 10 to 20 pounds results in an increased
risk of coronary heart disease (nonfatal myocardial infarction and
death) of 1.25 times in women and 1.6 times in men. Higher levels of
body weight gain of 22 pounds in men and 44 pounds in women result in
an increased coronary heart disease risk of 1.75 and 2.65,
respectively. In women with a BMI of 34 or greater, the risk of
developing endometrial cancer is increased by more than six times.
Overweight and obesity are also known to exacerbate many chronic
conditions such as hypertension and elevated cholesterol. Overweight
and obese individuals also may suffer from social stigmatization,
discrimination, and poor body image.
Although obesity-associated morbidities occur most frequently in
adults, important consequences of excess weight, as well as antecedents
of adult disease, occur in overweight children and adolescents.
Overweight children and adolescents are more likely to become
overweight or obese adults; this concern is greatest among adolescents.
Type 2 diabetes, high blood lipids, and hypertension, as well as early
maturation and orthopedic problems also occur with increased frequency
in overweight youth. A common consequence of childhood overweight is
psychosocial -- specifically discrimination.
These data on the morbidity and mortality associated with
overweight and obesity demonstrate the importance of the prevention of
weight gain, as well as the role of obesity treatment, in maintaining
and improving health and quality of life.
. . . .
ECONOMIC CONSEQUENCES
Overweight and obesity and their associated health problems have
substantial economic consequences for the U.S. health care system. The
increasing prevalence of overweight and obesity is associated with both
direct and indirect costs. . . .
In 1995, the total (direct and indirect) costs attributable to
obesity amounted to an estimated $99 billion. In 2000, the total cost
of obesity was estimated to be $117 billion ($61 billion direct and $56
billion indirect). Most of the cost associated with obesity is due to
type 2 diabetes, coronary heart disease, and hypertension.
EPIDEMIOLOGY
The United States is experiencing substantial increases in
overweight and obesity (as defined by a BMI  25 for adults) that cut
across all ages, racial and ethnic groups, and both genders. According
to self-reported measures of height and weight, obesity (BMI  30) has
been increasing in every state in the nation. Based on clinical height
and weight measurements in the 2000 National Health and Nutrition
Examination Survey (NHANES), 34 percent of U.S. adults aged 20 to 74
years are overweight (BMI 25 to 29.9), and an additional 27 percent are
obese (BMI  30). This contrasts with the late 1970s, when an estimated
32 percent of adults aged 20 to 74 years were overweight, and 15
percent were obese.
. . . .
The most recent data (1999) estimate that 13 percent of children
aged 6 to 11 years and 14 percent of adolescents aged 12-19 years are
overweight. During the past two decades, the percentage of children who
are overweight has nearly doubled (from 7 to 13 percent), and the
percentage of adolescents who are overweight has almost tripled (from 5
to 14 percent).
. . . .
DISPARITIES IN PREVALENCE
. . . Disparities in overweight and obesity prevalence exist in
many segments of the population based on race and ethnicity, gender,
age, and socioeconomic status. For example, overweight and obesity are
particularly common among minority groups and those with a lower family
income.
. . . .
In general, the prevalence of overweight and obesity is higher in
women who are members of racial and ethnic minority populations than in
non-Hispanic white women. Among men, Mexican/Americans have a higher
prevalence of overweight and obesity than non-Hispanic whites or nonHispanic blacks. For non-Hispanic men, the prevalence of overweight and
obesity among whites is slightly greater than among blacks.
Within racial groups, gender disparities exist, although not
always in the same direction. . . .
. . . .
In addition to racial and ethnic and gender disparities, the
prevalence of overweight and obesity also varies by age. Among both men
and women, the prevalence of overweight and obesity increases with
advancing age until the sixth decade, after which it starts to decline.
. . . .
Disparities in the prevalence of overweight and obesity also
exist based on socioeconomic status. For all racial and ethnic groups
combined, women of lower socioeconomic status (income  130 percent of
poverty threshold) are approximately 50 percent more likely to be obese
than those with higher socioeconomic status (income  130 percent of
poverty threshold). Men are about equally likely to be obese whether
they are in a low or high socioeconomic group.
. . . .
HEALTH BENEFITS OF WEIGHT LOSS
The recommendations to treat overweight and obesity are based on
two rationales. First, overweight and obesity are associated with an
increased risk of disease and death, as previously discussed. Second,
randomized controlled trials have shown that weight loss (as modest as
5 to 15 percent of excess total body weight) reduces the risk factors
for at least some diseases, particularly cardiovascular disease, in the
short term. Weight loss results in lower blood pressure, lower blood
sugar, and improved lipid levels. While few published studies have
examined the link between weight loss and reduced disease or death in
the long-term, current data, as well as scientific plausibility suggest
this link.
Studies have shown that reducing risk factors for heart disease,
such as blood pressure and blood cholesterol levels, lowers death rates
from heart disease and stroke. Therefore, it is highly probable that
weight loss that reduces these risk factors will reduce the number of
deaths from heart disease and stroke. Trials examining the direct
effects of weight loss on disease and death are currently under
way. . . .
Families and communities lie at the foundation of the solution to
the problems of overweight and obesity. Family members can share their
own knowledge and habits regarding a health diet and physical activity
with their children, friends and other community members. Emphasis
should be placed on family and community opportunities for
communication, education, and peer support surrounding the maintenance
of healthy dietary choices and physical activity patterns.
. . . .
Schools are identified as a key setting for public health
strategies to prevent and decrease the prevalence of overweight and
obesity. Most children spend a large portion of time in school. Schools
provide many opportunities to engage children in health eating and
physical activity and to reinforce health diet and physical activity
messages. Public health approaches in schools should extend beyond
health and physical education to include school policy, the school
physical and social environment, and links between schools and families
and communities. Schools and communities that are interested in
reducing overweight among the young people they serve can consider
various options. Decisions about which options to select should be made
at the local level.
. . . .
The health care system provides a powerful setting for
intervention aimed at reducing the prevalence of overweight and obesity
and their consequences. A majority of Americans interact with the
health care system at least once during any given year. Recommendations
by pediatric and adult health care providers can be influential in
patient dietary choices and physical activity patterns. In
collaboration with schools and worksites, health care providers and
institutions can reinforce the adoption and maintenance of healthy
lifestyle behaviors. Health care providers also can serve as effective
public policy advocates and further catalyze intervention efforts in
the family and community and in the media and communications settings.
. . . .
The media can provide essential functions in overweight and
obesity prevention efforts. From a public education and social
marketing standpoint, the media can disseminate health messages and
display health behaviors aimed at changing dietary habits and exercise
patterns. In addition, the media can provide a powerful forum for
community members who are addressing the social and environmental
influences on dietary and physical activity patterns.
. . . .
More than 100 million Americans spend the majority of their day
at a worksite. While at work, employees are often aggregated within
systems for communication, education and peer support. Thus, worksites
provide many opportunities to reinforce the adoption and maintenance of
healthy lifestyle behaviors. Public health approaches in worksites
should extend beyond health education and awareness to include worksite
policies, the physical and social environments of worksites, and their
links with the family and community setting.
. . . .
[The report then discusses the separate but related roles of the
individual, private organizations, and government in achieving progress
against overweight and obesity.]
. . . [T]he Surgeon General identifies the following activities
as national priorities for immediate action. Individuals, families,
communities, schools, worksites, health care, media, industry,
organizations, and government must determine their role and take action
to prevent and decrease overweight and obesity.
. . . .
The nation must take an informed, sensitive approach to
communicate with and educate the American people about health issues
related to overweight and obesity. Everyone must work together to:
-- Change the perception of overweight and obesity at all ages.
The primary concern should be one of health and not appearance.
-- Educate all expectant parents about the many benefits of
breastfeeding. Breastfed infants may be less likely to become
overweight as they grow older. Mothers who breastfeed may return to
pre-pregnancy weight more quickly.
-- Educate health care providers and health profession students
in the prevention and treatment of overweight and obesity across the
lifespan.
-- Provide culturally appropriate education in schools and
communities about healthy eating habits and regular physical activity,
based on the Dietary Guidelines for Americans [see appendix to this
chapter infra], for people of all ages. Emphasize the consumer's role
in making wise food and physical activity choices.
. . . .
The nation must take action to assist Americans in balancing
healthful eating with regular physical activity. Individuals and groups
across all settings must work in concert to:
-- Ensure daily, quality physical education in all school grades.
Such education can develop the knowledge, attitudes, skills, behaviors,
and confidence needed to be physically active for life.
-- Reduce time spent watching television and in other similar
sedentary behaviors.
-- Build physical activity into regular routines and playtime for
children and their families. Ensure that adults get at least 30 minutes
of moderate physical activity on most days of the week. Children should
aim for at least 60 minutes.
-- Create more opportunities for physical activity at worksites.
Encourage all employers to make facilities and opportunities available
for physical activity for all employees.
-- Make community facilities available and accessible for
physical activity for all people, including the elderly.
-- Promote healthier food choices, including at least five
servings of fruits and vegetables each day, and reasonable portion
sizes at home, in schools, at worksites, and in communities.
-- Ensure that schools provide healthful foods and beverages on
school campuses and at school events by:
(1) Enforcing existing U.S. Department of Agriculture
regulations that prohibit serving foods of minimal nutritional
value during mealtimes in school food service areas, including in
vending machines.
(2) Adopting policies specifying that all foods and
beverages available at school contribute toward eating patterns
that are consistent with the Dietary Guidelines for Americans.
(3) Providing more food options that are low in fat,
calories, and added sugars such as fruits, vegetables, whole
grains, and low-fat or nonfat dairy foods.
(4) Reducing access to foods high in fact, calories and
added sugars and to excessive portion sizes.
(5) Create mechanisms for appropriate reimbursement of the
prevention and treatment of overweight and obesity.
The nation must invest in research that improves our
understanding of the causes, prevention, and treatment of overweight
and obesity. A concerted effort should be made to:
-- Increase research on behavioral and environmental causes of
overweight and obesity.
-- Increase research and evaluation on prevention and treatment
interventions for overweight and obesity, and develop and disseminate
best practice guidelines.
-- Increase research on disparities in the prevalence of
overweight and obesity among racial and ethnic, gender, socioeconomic,
and age groups, and use this research to identify effective and
culturally appropriate interventions.
*
*
*
United Nations Food & Agriculture Organization/World Health
Organization, Joint Report on Diet, Nutrition, and the
Prevention of Chronic Diseases 61-71 (2003)
*
*
*
Almost all countries (high-income and low-income alike) are
experiencing an obesity epidemic, although with great variation between
and within countries. In low-income countries, obesity is more common
in middle-aged women, people of higher socioeconomic status and those
living in urban communities. In more affluent countries, obesity is not
only common in the middle-aged, but is becoming increasingly prevalent
among younger adults and children. Furthermore, it tends to be
associated with lower socioeconomic status, especially in women, and
the urban-rural differences are diminished or even reversed.
It has been estimated that the direct costs of obesity accounted
for 6.8 percent of total health care costs . . . in the United States
in 1995. Although direct costs in other industrialized countries are
slightly lower, they still consume a sizeable proportion of national
health budgets. Indirect costs, which are far greater than direct
costs, include work days lost, physician visits, disability pensions
and premature mortality. Intangible costs such as impaired quality of
life are also enormous. Because the risks of diabetes, cardiovascular
disease and hypertension rise continuously with increasing weight,
there is much overlap between the prevention of obesity and the
prevention of a variety of chronic diseases, especially type 2
diabetes. . . .
The increasing industrialization, urbanization, and mechanization
occurring in most countries around the world is associated with changes
in diet and behaviour, in particular, diets are becoming richer in
high-fat, high energy foods and lifestyles more sedentary. In many
developing countries undergoing economic transition, rising levels of
obesity often co-exist in the same population (or even the same
household) with chronic undernutrition. Increases in obesity over the
past 30 years have been paralleled by a dramatic rise in the prevalence
of diabetes.
Mortality rates increase with increasing degrees of overweight,
as measured by BMI. As BMI increases, so too does the proportion of
people with one or more comorbid conditions. . . . Eating behaviours
that have been linked to overweight and obesity include snacking/eating
frequency, binge-eating patterns, eating out, and (protectively)
exclusive breastfeeding. Nutrient factors under investigation include
fat, carbohydrate type (including refined carbohydrates such as sugar),
the glycaemic index of foods, and fibre. Environmental issues are
clearly important, especially as many environments become increasingly
"obesogenic" (obesity-promoting).
Physical activity is an important determinant of body weight. In
addition, physical activity and physical fitness (which relates to the
ability to perform physical activity) are important modifiers of
mortality and morbidity related to overweight and obesity. There is
firm evidence that moderate to high fitness levels provide a
substantially reduced risk of cardiovascular disease and all-cause
mortality and that these benefits apply to all BMI levels. Furthermore,
high fitness protects against mortality at all BMI levels in men with
diabetes. Low cardiovascular fitness is a serious and common
comorbidity of obesity, and a sizeable proportion of deaths in
overweight and obese populations are probably a result of low levels of
cardio-respiratory fitness rather than obesity per se. Fitness is, in
turn, influenced strongly by physical activity in addition to genetic
factors. These relationships emphasize the role of physical activity in
the prevention of overweight and obesity, independently of the effects
of physical activity on body weight.
. . . There is convincing evidence that regular physical activity
is protective against unhealthy weight gain whereas sedentary
lifestyles, particularly sedentary occupations and inactive recreation
such as watching television, promote it. Most epidemiological studies
show smaller risk of weight gain, overweight and obesity among persons
who currently engage regularly in moderate to large amounts of physical
activity. Studies measuring physical activity at baseline and
randomized trials of exercise programmes show more mixed results,
probably because of the low adherence to long-term changes. Therefore,
it is ongoing physical activity itself rather than previous physical
activity or enrollment in an exercise programme that is protective
against unhealthy weight gain. The recommendation for individuals to
accumulate at least 30 minutes of moderate-intensity physical activity
on most days is largely aimed at reducing cardiovascular diseases and
overall mortality. The amount needed to prevent unhealthy weight gain
is uncertain but is probably significantly greater than this.
Preventing weight gain after substantial weight loss probably requires
about 60-90 minutes per day. . . . Studies aimed at reducing sedentary
behaviours have focused primarily on reducing television viewing in
children. Reducing viewing times by about 30 minutes a day in children
in the United States appears feasible and is associated with reductions
in BMI.
. . . .
. . . [T]wo recent reviews of randomized trials have concluded
that the majority of studies show that a high intake of NSP (dietary
fibre) promotes weight loss. Pereira & Ludwig found that 12 out of 19
trials showed beneficial objective effects (including weight loss). In
their review of 11 studies . . . Howarth Saltzman & Roberts reported a
mean weight loss of 1.9 kg over 3.8 months. There were no differences
between fibre type or between fibre consumed in food or as supplements.
There is convincing evidence that a high intake of energy-dense
foods promotes weight gain. In high-income countries (and increasingly
in low income countries) these energy-dense foods are not only highly
processed (low NSP) but also micronutrient-poor, further diminishing
their nutritional value. Energy-dense foods tend to be high in fat
(e.g. butter, oils, fried foods), sugars or starch, while energy-dilute
foods have a high water content (e.g. fruits and vegetables). . . .
While energy from fat is no more fattening than the same amount of
energy from carbohydrate or protein, diets that are high in fat tend to
be energy-dense. An important exception to this is diets based
predominantly on energy-dilute foods (e.g. vegetables, legumes, fruits)
but which have a reasonably high percentage of energy as fat from added
oils.
The effectiveness over the long term of most dietary strategies
for weight loss, including low-fat diets, remains uncertain unless
accompanied by changes in behaviour affecting physical activity and
food habits. These latter changes at a public health level require an
environment supportive of healthy food choices and an active life. . .
. A variety of popular weight-loss diets that restrict food choices may
result in reduced energy intake and short term weight loss in
individuals but most do not have trial evidence of long-term
effectiveness and nutritional adequacy and therefore cannot be
recommended for populations.
Despite the obvious importance of the roles that parents and home
environments play on children's eating and physical activity
behaviours, there is very little hard evidence available to support
this view. It appears that access and exposure to a range of fruits and
vegetables in the home is important for the development of preferences
for these foods and that parental knowledge, attitudes, and behaviours
related to healthy diet and physical activity are important in creating
role models. More data are available on the impact of the school
environment on nutrition knowledge, on eating patterns and physical
activity at school, and on sedentary behaviours at home. Some studies,
but not all, have shown an effect of school-based interventions on
obesity prevention. . . .
Part of the consistent, strong relationships between television
viewing and obesity in children may relate to the food advertising to
which they are exposed. Fast food restaurants and foods and beverages
that are usually classified under the "eat least" category in dietary
guidelines are among the most heavily marketed products, especially on
television. Young children are often the target group for the
advertising of these products because they have a significant influence
on the foods bought by parents. The huge expenditure on marketing fastfoods and other "eat least" choices was considered to be a key factor
in the increased consumption of food prepared outside the home in
general and of energy-dense, micronutrient-poor foods in particular.
Young children are unable to distinguish programme content from the
persuasive intent of advertisements. The evidence that the heavy
marketing of these foods and beverages to young children causes obesity
is not unequivocal. [T]here is sufficient indirect evidence to warrant
this practice being placed in the "probable" category and thus becoming
a potential target for interventions.
Diets that are proportionally low in fat will be proportionally
higher in carbohydrate (including a variable amount of sugars) and are
associated with protection against unhealthy weight gain, although a
high intake of free sugars in beverages probably promotes weight gain.
The physiological effects of energy intake on satiation and satiety
appear to be quite different for energy in solid foods as opposed to
energy in fluids. Possibly because of reduced gastric distension and
faster transit times, the energy contained in fluids is less well
"detected" by the body and subsequent food intake is poorly adjusted to
account for the energy taken in through beverages. . . . The high and
increasing consumption of sugars-sweetened drinks by children in many
countries is of serious concern. It has been estimated that each
additional can or glass of sugars-sweetened drink that they consume
every day increases the risk of becoming obese by 60 percent. Most of
the evidence relates to soda drinks but many fruit drinks and cordials
are equally energy-dense and may promote weight gain if drunk in large
quantities. Overall, the evidence implicating a high intake of sugarssweetened drinks in promoting weight gain was considered moderately
strong.
Classically the pattern of the progression of obesity through a
population starts with middle-aged women in high-income groups but as
the epidemic progresses, obesity becomes more common in people
(especially women) in lower socioeconomic status groups. The
relationship may even be bi-directional, setting up a vicious cycle
(i.e. lower socioeconomic status promotes obesity, and obese people are
more likely to end up in groups with low socioeconomic status). The
mechanisms by which socioeconomic status influences food and activity
patterns are probably multiple and need elucidation. However, people
living in circumstances of low socioeconomic status may be more at the
mercy of the obesogenic environment because their eating and activity
behaviours are more likely to be the "default choices" on offer. The
evidence for an effect of low socioeconomic status on predisposing
people to obesity is consistent (in higher income countries) across a
number of cross-sectional and longitudinal studies, and was thus rated
as a "probable" cause of increased risk of obesity.
Breastfeeding as a protective factor against weight gain has been
examined in at least 20 studies involving nearly 40,000 subjects. . . .
There are probably multiple effects of confounding in these studies;
however, the reduction in the risk of developing obesity observed in
the two largest studies was substantial. Promoting breastfeeding has
many benefits, the prevention of childhood obesity probably being one
of them.
. . . Large portion sizes are a possible causative factor for
unhealthy weight gain. The marketing of "supersize" portions,
particularly in fastfood outlets, is now common practice in many
countries. There is some evidence that people poorly estimate portion
sizes and that subsequent energy compensation for a large meal is
incomplete and therefore is likely to lead to overconsumption.
In many countries, there has been a steady increase in the
proportion of food eaten that is prepared outside the home. In the
United States, the energy, total fat, saturated fat, cholesterol and
sodium content of foods prepared outside the home is significantly
higher than that of home prepared food. People in the United States who
tend to eat in restaurants have a higher BMI than those who tend to eat
at home.
Certain psychological parameters of eating patterns may influence
the risk of obesity. The "flexible restraint" pattern is associated
with lower risk of weight gain, whereas the "rigid restraint/periodic
disinhibition" pattern is associated with a higher risk.
. . . Studies have not shown consistent associations between
alcohol intake and obesity despite the high energy density of the
nutrient. . . .
. . . While a high eating frequency has been shown in some
studies to have a negative relationship with energy intake and weight
gain, the types of foods readily available as snack foods are often
high in fat and a high consumption of foods of this type might
predispose people to weight gain. The evidence regarding the impact of
early nutrition on subsequent obesity is also mixed, with some studies
showing relationships for high and low birth weights.
The prevention of obesity in infants and young children should be
considered of high priority. For infants and young children, the main
preventive strategies are:
-- the promotion of exclusive breastfeeding;
-- avoiding the use of added sugars and starches when feeding formula;
-- instructing mothers to accept their child's ability to regulate
energy intake rather than feeding until the plate is empty;
-- assuring the appropriate micronutrient intake needed to promote
optimal linear growth.
For children and adolescents, prevention of obesity implies the
need to:
-- promote an active lifestyle;
-- limit television viewing;
-- promote the intake of fruits and vegetables;
-- restrict the intake of energy-dense, micronutrient-poor foods (e.g.
packaged snacks);
-- restrict the intake of sugars-sweetened soft drinks.
Additional measures include modifying the environment to enhance
physical activity in schools and communities, creating more opportunities for family interaction (e.g. eating family meals), limiting the
exposure of young children to heavy marketing practices of energydense, micronutrient-poor foods, and providing the necessary information and skills to make healthy food choices.
In developing countries, special attention should be given to
avoidance of overfeeding stunted population groups. Nutrition
programmes designed to control or prevent undernutrition need to assess
stature in combination with weight to prevent providing excess energy
to children of low weight-for-age but normal weight-for-height. In
countries in economic transition, as populations become more sedentary
and able to access energy-dense foods, there is a need to maintain the
healthy components of traditional diets (e.g. high intake of
vegetables, fruits and NSP). Education provided to mothers and low
socioeconomic status communities that are food insecure should stress
that overweight and obesity do not represent good health.
Low-income groups globally and populations in countries in
economic transition often replace traditional micronutrient-rich foods
by heavily marketed, sugars-sweetened beverages (i.e. soft drinks) and
energy-dense, fatty, salty, and sugary foods. These trends, coupled
with reduced physical activity, are associated with the rising
prevalence of obesity. Strategies are needed to improve the quality of
diets by increasing consumption of fruits and vegetables, in addition
to increasing physical activity, in order to stem the epidemic of
obesity and associated diseases.
[The report then discusses the use of BWI as a crude but useful
means to measure the prevalence of obesity but notes the need to adjust
the standard for different cultures and body-types.]
A total of one hour per day of moderate-intensity activity, such
as walking on most days of the week, is probably needed to maintain a
healthy body weight, particularly for people with sedentary
occupations.
The fat and water content of foods are the main determinants of
the energy density of the diet. A lower consumption of energy-dense
(i.e. high-fat, high-sugars, and high-starch) foods and energy-dense
(i.e. high free sugars) drinks contributes to a reduction in total
energy intake. Conversely, a higher intake of energy-dilute foods (i.e.
vegetables and fruits) and foods high in NSP contributes to a reduction
in total energy intake and an improvement in micronutrient intake. It
should be noted, however, that very active groups who have diets high
in vegetables, legumes, fruits and wholegrain cereals, may sustain a
total fat intake of up to 35 percent without the risk of unhealthy
weight gain.
*
*
*
Kelly Brownell & Katherine Battle Horgen, Food Fight 3-13
(2004)
*
*
*
It came quickly, with little fanfare, and was out of control
before the nation notices. Obesity, diabetes, and other diseases caused
by poor diet and sedentary lifestyle now affect the health, happiness,
and vitality of millions of men, women, and, most tragically, children
and pose a major threat to the health care resources of the United
States. Most alarming has been the national inaction in the face of
crisis, the near-total surrender to a powerful food industry, and the
lack of innovation in preventing further havoc.
The Centers for Disease Control and Prevention (CDC) labels the
obesity problem an "epidemic." Within the United States, 64.5 percent
of Americans are either overweight or obese, with the number growing.
For many reasons, some obvious and some not, the increase in overweight
children is twice that seen in adults.
Other nations are in hot pursuit. Country after country follows
the American lead and grows heavier. Over consumption has replaced
malnutrition as the world's top food problem. From Banff to Buenos
Aires, from Siberia to the Sahara, the world need only look to America
to see its future. There are now clinics for obese children in Beijing.
Similar to a new virus without natural enemies, our lifestyle of
abundant food and inactivity faces little opposition. Quite the
contrary, powerful forces push it forward, spreading the problem to all
segments of the population. These forces are woven so tightly into our
social systems (economics, health care system, even education) that
change seems almost beyond imagination. Despite talk of an obesity
crisis, government reports, and Presidents pushing exercise, obesity is
increasing in all races, ages, income groups, and areas of the world.
. . . .
The picture with children is sad. Projecting ahead to their adult
years, today's children are targeted in a relentless way by the food
companies. Institutions such as schools that would like to protect
children instead must sell soft drinks and snack foods to function.
. . . .
It is easy to blame parents, but they face off every day with an
environment that grabs their children and won't let go. Children and
the parents who raise them do not get what they deserve -- conditions
that support healthy eating and physical activity. The environment wins
in most cases, and we have an epidemic to show for it.
By any definition, we face an emergency.
The reasons for this growing problem are simple and complex at
the same time. People eat too much and exercise too little, but this
easy truth masks a fascinating dance of genetics with modern lifestyle.
Economics, breakthroughs in technology, how our nation thinks about
food, and, of course, the powerful and sophisticated food industry, are
all actors in this tragic play. Our environment is textured with risk.
It intersects with genes in a way that makes an obese population a
predictable consequence of modern life.
Some individuals have the biological fortune or the skills to
resist this risk, leading to arguments that weight control is a matter
of personal responsibility. Choices people make are important, but the
nation has played the willpower and restraint cards for years and finds
itself trumped again and again by an environment that overwhelms the
resources of most people.
The cost of inaction will multiply human suffering, place our
nation at a strategic disadvantage, and have a massive impact on health
care costs.
. . . .
Picture yourself a child, rather a
penetrates your mother's egg, unleashing
events. What you will eat later in life,
for body weight, and how your physiology
have been partially fixed.
zygote. Your father's sperm
a cascade of biological
your upper and lower limits
responds to being sedentary
The lives of your ancestors, dating back many thousands of years,
reside in your genes. Unpredictable food supplies and looming
starvation were their everyday realities. Those who adapted ate
voraciously when food appeared, stored energy (as body fat) with
extreme efficiency, survived later scarcity, and contributed to the
gene pool from which you draw your DNA.
Married to this food biology are genes related to physical
activity. Extreme exertion was once required to hunt and gather food.
The body functioned optimally with bouts of heavy activity punctuated
by periods of rest needed to conserve energy. Modern culture has
removed strenuous exercise.
You are an exquisitely efficient calorie conservation machine.
Your genes match nicely with a scarce food supply, but not with modern
living conditions. As a child, you are about to be broadsided by a
"toxic" environment. Your body is unprepared for the plummeting need to
be physically active and cannot anticipate the impending confrontation
with Big -- Big Gulp, Bog Grab, Big Mac, Biggie Fries, Big everything.
If you could speak with your ancient ancestors, they would
explain that people eat a lot when food is abundant, particularly foods
high in fat, sugar, and calories, a fact proven by scientists thousands
of years later. These foods provide quick energy but more important,
are optimal for storing energy.
As you breathe for the first time outside the womb, your genes
are mismatched with modern conditions. The environment is distorted
beyond your body's ability to cope. It will pound you with inducements
to eat, make exertion unnecessary, and do little to defend you against
diseases that most threaten you.
Good fortune may bring you parents who are committed to healthy
eating. They keep junk food out of the home, have healthy foods
available, and teach you good nutrition. But then you go to play
groups, birthday parties, and school. You see billboards, watch TV, go
to movies, and travel the supermarket aisles where your favorite Disney
and Nickelodeon characters are linked with sugared cereals, snack
foods, and ice cream. Your parents now face Goliath.
. . . .
Biology comes undone when confronted by modern eating and
exercise conditions, what we call the toxic environment. Toxic is a
powerful word, but powerful language is needed to describe the
situation. . . .
. . . .
The second half of the energy equation, physical activity, has
also been affected in disastrous ways. Few children walk or bike to
school; there is little physical education; computers, video games, and
televisions keep children inside and inactive; and parents are
reluctant to let children roam free to play.
The American landscape has been altered in profound ways.
Cheeseburgers and French fries, drive-in windows and supersizes, soft
drinks and candy, potato chips and cheese curls, once unusual, are as
much our background as trees, grass, and clouds. We now take notice
when food isn't there. Gas stations without a mini-market look oldfashioned and unappealing.
. . . .
The world of fast food is only one of many changing influences
but may be the most dramatic. In his book Fast Food Nation, Eric
Schlosser notes that American spending on fast food went from $6
billion to $110 billion annually in the last 30 years. . . .
. . . .
Fast food is high in fat, calories and sugar; low in fiber; and
nearly devoid of fruits and vegetables beyond fried potatoes.
. . . .
Food, not just fast food, is everywhere. Think of the modern
drugstore. The items you need, like pain relievers, bandages, cough
remedies, and vitamins, not to mention the pharmacy, are in the rear of
the store, requiring you to pass through aisles of items you did not
intend to buy. Many people gravitate naturally to the center aisles,
home to a large collection of candies and foods. When you leave the
pharmacy and walk back along the far aisle, notice what you encounter.
Children are valuable consumers, affecting billions of dollars in
sales each year. Food marketing directed at children, almost
exclusively for unhealthy foods, is as sophisticated as marketing gets.
There are books, advertising journals, and conferences describing how
to best market to children. It is no surprise that we have a nation of
children consuming record amounts of sugar, soft drinks, fast foods,
and snack foods.
. . . .
Accessibility of bad food is coupled with a key economic reality:
unhealthy food is cheap. It is also convenient, fast, packaged
attractively, and tasty. Healthy foods are more difficult to get, less
convenient, and more expensive. If you came from Mars and knew nothing
but this about a country, an epidemic of obesity is exactly what you'd
predict.
This confluence of declining physical activity and in altered
eating environment, both in toxic proportions, has created a human
crisis.
. . . .
Food is big, but so are the companies making and selling it.
Massive agribusiness companies control a surprising amount of the food
chain, raising grave concerns with issues such as dwindling genetic
diversity in plants and farm animals, resistant strains of bacteria
resulting from the overuse of antibiotics, and undue influence on the
nation's nutrition and agriculture policy.
. . . .
A consequence of this consolidation is that enormous power and
influence rest in the hands of a few companies. Their presence in
Washington, D.C., is visible and felt in many ways, some more obvious
than others. What crops get subsidized, which commodities get shipped
to schools through the National School Lunch Program, what foods get
emphasized in the foot guide pyramid, and whether soft drinks are
permitted in schools are a few places where political influence can
affect the national nutrition environment. There are many, many cases
where business interests conflict with public health. People deserve to
know how and when this occurs and the impact it has on them and their
children.
. . . .
The word big applied to the food industry conjures up images of
Big Oil, Big Energy, Big Tobacco, and so on. The public image of such
industries is that a small number of giant companies led by ruthless
executives control an entire industry and manipulate the political
system, finances, and public opinion in self-serving ways that damage
the public's interests. You may draw your own conclusions about whether
the food industry deserves this label.
. . . .
Changing the environment is the obvious place to begin. The
deteriorating environment is the clear cause of the obesity epidemic
and must be the basis for its remedy. Attacking a problem by
considering its causes is logical and leads squarely to a public health
imperative -- prevention.
Prevention is appealing for several reasons:
1. With obesity the nation's most common major chronic health
problem, vast numbers of people could benefit.
2. Children are the logical focus when a disease begins early in
life. Food preferences, eating habits, and, possibly, brand loyalties
take shape in childhood, so the best opportunity for creating healthy
habits may exist in the early years.
3. Obesity is very difficult to treat, and most people who lose
weight do not keep it off. The most optimistic estimates are that 25
percent of people lose weight and maintain the loss, often requiring
many tries. This lack of success combines with the very high cost of
treatment to make most approaches cost-ineffective. We will never treat
this problem away.
4. The nation has a long history of supporting prevention to
protect its children. Child safety seats, childproof medicine bottles,
warnings on toys that are choking hazards, immunization requirements,
and the prohibition of tobacco sales to children are examples. Such
programs show good return on investment. Improving diet and physical
activity and preventing obesity rival any of these programs in
importance to public health.
*
*
*
Pelman v. McDonald’s
237 F. Supp. 2d 512 (S.D.N.Y. 2003)(“Pelman I”)
Sweet, Judge.
*
*
*
This action presents unique and challenging issues. The
plaintiffs have alleged that the practices of McDonalds in making and
selling their products are deceptive and that this deception has caused
the minors who have consumed McDonalds' products to injure their health
by becoming obese. Questions of personal responsibility, common
knowledge and public health are presented, and the role of society and
the courts in addressing such issues.
The issue of determining the breadth of personal responsibility
underlies much of the law: where should the line be drawn between an
individual's own responsibility to take care of herself, and society's
responsibility to ensure that others shield her? Laws are created in
those situations where individuals are somehow unable to protect
themselves and where society needs to provide a buffer between the
individual and some other entity -- whether herself, another individual
or a behemoth corporation that spans the globe. Thus Congress provided
that essentially all packaged foods sold at retail shall be
appropriately labeled and their contents described. [The Nutrition
Labeling and Education Act of 1990]. Also, as a matter of federal
regulation, all alcoholic beverages must warn pregnant women against
their use. Congress has gone further and made the possession and
consumption of certain products criminal because of their presumed
effect on the health of consumers. Other products have created health
hazards and resulted in extensive and expensive class action
litigation. . . . Public health is one, if not the, critical issue in
society.
This opinion is guided by the principle that legal consequences
should not attach to the consumption of hamburgers and other fast food
fare unless consumers are unaware of the dangers of eating such food. .
. . If consumers know (or reasonably should know) the potential ill
health effects of eating at McDonalds, they cannot blame McDonalds if
they, nonetheless, choose to satiate their appetite with a surfeit of
supersized McDonalds products. On the other hand, consumers cannot be
expected to protect against a danger that was solely within McDonalds'
knowledge. Thus, one necessary element of any potentially viable claim
must be that McDonalds' products involve a danger that is not within
the common knowledge of consumers. As discussed later, plaintiffs have
failed to allege with any specificity that such a danger exists.
McDonalds has also, rightfully, pointed out that this case, the
first of its kind to progress far enough along to reach the stage of a
dispositive motion, could spawn thousands of similar "McLawsuits"
against restaurants. Even if limited to that ilk of fare dubbed "fast
food," the potential for lawsuits is great: Americans now spend more
than $110 billion on fast food each year, and on any given day in the
United States, almost one in four adults visits a fast food restaurant.
[citation to Fast Food Nation] The potential for lawsuits is even
greater given the numbers of persons who eat food prepared at other
restaurants in addition to those serving fast food. . . .
The interplay of these issues and forces has created public
interest in this action, ranging from reports and letters to the Court
to television satire. Obesity, personal liberty, and public
accountability affect virtually every American consumer.
In terms of the pending motion by McDonalds to dismiss the
complaint, these principles require the complaint to be dismissed for
lack of specificity, with leave granted to replead within the limits
set forth below.
Facts
Ashley Pelman, a minor, and her mother and natural guardian
Roberta Pelman are residents of the Bronx, New York. . . . The [class
of] infant plaintiffs are consumers who have purchased and consumed the
defendants' products and, as a result thereof, have become overweight
and have developed diabetes, coronary heart disease, high blood
pressure, elevated cholesterol intake, and/or other detrimental and
adverse health effects as a result of the defendants' conduct and
business practices. Defendant McDonald's Corp. is a Delaware corporation
with its principal place of business at One McDonald's Plaza, Oak
Brook, Illinois. It does substantial business with outlets in the State
of New York, as well as throughout the fifty states and the world.
Defendant McDonalds of New York is a New York State corporation . . . .
It does substantial business with outlets and/or franchises in the
State of New York.
McDonalds is the owner, manager, franchisee, and operator of
defendants the Bruckner Boulevard and Jerome Avenue outlets. Ashley and
Roberta Pelman purchased and consumed food products at the Bruckner
Boulevard outlet. . . .
Obesity in Young Persons and its Effects
Today there are nearly twice as many overweight children and
almost three times as many overweight adolescents as there were in
1980. In 1999, an estimated 61 percent of U.S. adults were overweight
or obese and 13 percent of children aged 6 to 11 years and 14 percent
of adolescents aged 12 to 19 years were overweight. In 1980, those
figures for children were 7 percent for children aged 6 to 11 years and
5 percent for adolescents aged 12 to 19 years. Obese individuals have a
50 to 100 percent increased risk of premature death from all causes.
Approximately 300,000 deaths a year in the United States are currently
associated with overweight and obesity. . . . Obesity and overweight
classification are associated with increased risk for coronary heart
disease; type 2 diabetes; endometrial, colon, postmenopausal breast,
and other cancers; and certain musculoskeletal disorders, such as knee
osteoarthritis.
Studies have shown that both modest and large weight gains are
associated with significantly increased risk of diseases. . . .
Claims
The plaintiffs allege five causes of action as members of a
putative class action of minors residing in New York State who have
purchased and consumed McDonalds products. Counts I and II are based on
deceptive acts and practices in violation of the Consumer Protection
Act, New York General Business Law §§ 349 and 350 . . . . Count I
alleges that McDonalds failed to adequately disclose the ingredients
and/or health effects of ingesting certain of their food products with
high levels of cholesterol, fat, salt, and sugar; described their food
as nutritious; and engaged in marketing to entice consumers to purchase
"value meals" without disclosing the detrimental health effects
thereof. Count II focuses on marketing techniques geared toward
inducing children to purchase and ingest McDonalds' food products.
Count III sounds in negligence, alleging that McDonalds acted at least
negligently in selling food products that are high in cholesterol, fat,
salt and sugar when studies show that such foods cause obesity and
detrimental health effects. Count IV alleges that McDonalds failed to
warn the consumers of McDonalds' products of the ingredients, quantity,
qualities and levels of cholesterol, fat, salt and sugar content and
other ingredients in those products, and that a diet high in fat, salt,
sugar and cholesterol could lead to obesity and health problems.
Finally, Count V also sounds in negligence, alleging that McDonalds
acted negligently in marketing food products that were physically and
psychologically addictive.
Discussion
[The court then considers whether it should remand the case to
state court.]
This lawsuit is not the typical products liability case because,
as referred to above, the issue is over-consumption of products
created, manufactured, and advertised at a national level. A McDonalds'
Big Mac is the same at every outlet in the Bronx, New York; the same at
every outlet in the State of New York; and the same at every outlet
throughout the United States. Clearly what is at issue in this lawsuit
is the national menu and national policy of McDonalds Corp., and the
plaintiffs' real beef is with McDonalds Corp.
As a result, the motion to remand is denied.
[The court then discusses the defendants’ motion to dismiss the
case.]
Counts I and II allege that McDonalds violated the New York
Consumer Protection Act, §§ 349 and 350 by (1) deceptively advertising
their food as not unhealthful and failing to provide consumers with
nutritional information (Count I) and (2) inducing minors to eat at
McDonalds through deceptive marketing ploys (Count II).
Section 349 makes unlawful "[d]eceptive acts or practices in the
conduct of any business, trade, or commerce or in the furnishing of any
service in this state." Section 350 prohibits "[f]alse advertising in
the conduct of any business." To state a claim for deceptive practices
under either section, a plaintiff must show: (1) that the act,
practice, or advertisement was consumer-oriented; (2) that the act,
practice, or advertisement was misleading in a material respect, and
(3) that the plaintiff was injured as a result of the deceptive
practice, act, or advertisement.
[The court then rejects the defendants argument that the federal
nutritional labeling laws which exempts restaurants from the laws
applicable to retail products preempts any state law which relating to
the labeling of food.]
In Count I, plaintiffs allege that McDonalds violated the act
both by commission (e.g., stating that its products were nutritious,
encouraging consumers to "supersize" their meals without disclosing the
negative health effects) and by omission (e.g., failing to provide
nutritional information for products). Because the Complaint does not
identify a single instance of deceptive acts, Count I shall be
dismissed to the extent it alleges deceptive practices . . . .
[I]t is worth noting that, even in their opposition papers, the
plaintiffs only cite to two advertising campaigns ("McChicken
Everyday!" and "Big N' Tasty Everyday") and to a statement on the
McDonalds' website that "McDonalds can be part of any balanced diet and
lifestyle." These are specific examples of practices, act, or
advertisements and would survive a motion to dismiss based on lack of
specificity. Whether they would survive a motion to dismiss on the
substantive issue of whether such practices, act, and advertisements
are deceptive is less clear. The two campaigns encouraging daily forays
to McDonalds and the statement regarding making McDonalds a part of a
balanced diet, if read together, may be seen as contradictory -- a
balanced diet likely does not permit eating at McDonalds everyday.
However, the advertisements encouraging persons to eat at McDonalds
"everyday!" do not include any indication that doing so is part of a
well-balanced diet, and the plaintiffs fail to cite any advertisement
where McDonalds asserts that its products may be eaten for every meal
of every day without any ill consequences. Merely encouraging consumers
to eat its products "everyday" is mere puffery, at most, in the absence
of a claim that to do so will result in a specific effect on health. As
a result, the claims likely would not be actionable if alleged.
On December 11, 2002, the Court accepted from plaintiffs a number
of documents concerning actions taken against McDonalds' advertising
practices in the late 1980's by the state attorneys general from
several states, including New York State. While any claim based on the
advertisements at issue likely would be time barred, a review of those
advertisements and the state attorney generals' analysis of them may
assist plaintiffs in shaping a claim under the Consumer Protection Act.
For instance, by letter dated April 24, 1987 (the "Abrams Letter"),
Robert Abrams, the then-Attorney General of the State of New York,
addressed several specific allegedly deceptive claims in McDonalds
advertisements: 1. The advertisement discussing salt (sodium) content
in foods says, "Our sodium is down across the menu." (emphasis added)
This is not true. That same advertisement lists four products (regular
fries, regular cheeseburger, 6-piece McNuggets, and vanilla milkshake),
none of which have had their sodium content lowered in the past year.
2. The advertisement touting the "real" milk in McDonald's shakes says
that they contain "Wholesome milk, natural sweeteners, a fluid ounce of
flavoring, and stabilizers for consistency. And that's all." In fact,
that's not really all. McDonald's own ingredient booklet shows that a
typical shake, such as vanilla or strawberry, actually contains
artificial flavor and sodium benzoate and sodium hexametaphosphate, two
chemical preservatives. This advertisements tells only part of the
story. . . .
The second subset of Claim I focuses on McDonalds' failure to
label its foods with their nutritional content. Unlike above, the
plaintiffs clearly have outlined the allegedly deceptive practice: the
fact that McDonalds failed to post nutritional labeling on the products
and at points of purchase. However, because this is a purportedly
deceptive act based on an omission, it is not sufficient for the
plaintiffs to point to the omission alone. They must also show why the
omission was deceptive -- a duty they have shunned.
. . . .
The plaintiffs fail to allege that the information with regard to
the nutritional content of McDonalds' products was solely within
McDonalds' possession or that a consumer could not reasonably obtain
such information. It cannot be assumed that the nutritional content of
McDonalds' products and their usage was solely within the possession of
McDonalds. (Although the plaintiffs do not allege it as part of Count I
or II, the allegations contained in Count V -- that McDonalds serves
addictive products -- would present a closer question as to a deceptive
omission in violation of the Act, as such information is not available
to the public.)
Count II, which focuses on representations targeting children,
fails for the same reasons discussed above. The Complaint does not
identify a single specific advertisement, promotion, or statement
directed at infant consumers, and Count II must be dismissed in the
absence of such specificity.
The plaintiffs' common law claims against McDonalds sound in
negligence, alleging that McDonalds was negligent in manufacturing and
selling its products and negligent in failing to warn consumers of the
potential hazards of eating its products. . . .
Count III essentially alleges that McDonalds' products are
inherently dangerous because of the inclusion of high levels of
cholesterol, fat, salt, and sugar. McDonalds argues that because the
public is well aware that hamburgers, fries, and other fast food fare
have such attributes, McDonalds cannot be held liable.
. . . .
When asked at oral argument to distinguish this case from those
cases involving injuries purportedly caused by asbestos exposure,
counsel for the defendants stated that in this case, the dangers
complained of have been well-known for some time, while the dangers of
asbestos did not became apparent until years after exposure. The
Restatement provision cited above confirms this analysis, recognizing
that the dangers of over-consumption of items such as alcoholic
beverages, or typically high-in-fat foods such as butter, are wellknown. Thus any liability based on over-consumption is doomed if the
consequences of such over-consumption are common knowledge.
It is worth noting, however, that the Restatement provision cited
above included tobacco as an example of products such as whiskey and
butter, the unhealthy over-consumption of which could not lead to
liability. As the successful tobacco class action litigation and
settlements have shown, however, the fact that excessive smoking was
known to lead to health problems did not vitiate liability when, for
instance, tobacco companies had intentionally altered the nicotine
levels of cigarettes to induce addiction. . . .
Thus, in order to state a claim, the Complaint must allege either
that the attributes of McDonalds products are so extraordinarily
unhealthy that they are outside the reasonable contemplation of the
consuming public or that the products are so extraordinarily unhealthy
as to be dangerous in their intended use. The Complaint -- which merely
alleges that the foods contain high levels of cholesterol, fat, salt
and sugar, and that the foods are therefore unhealthy -- fails to reach
this bar. It is well-known that fast food in general, and McDonalds'
products in particular, contain high levels of cholesterol, fat, salt,
and sugar, and that such attributes are bad for one.
This rule makes sense in light of the policy issues discussed at
the outset of this opinion. If a person knows or should know that
eating copious orders of supersized McDonalds' products is unhealthy
and may result in weight gain (and its concomitant problems) because of
the high levels of cholesterol, fat, salt, and sugar, it is not the
place of the law to protect them from their own excesses. Nobody is
forced to eat at McDonalds (except, perhaps, parents of small children
who desire McDonalds' food, toy promotions, or playgrounds and demand
their parents' accompaniment).
. . . .
In an attempt to save their common law causes of action,
plaintiffs raise four arguments that are not alleged in the Complaint
to show that McDonalds has a duty toward plaintiffs: (1) McDonalds'
products have been processed to the point where they have become
completely different and more dangerous than the run-of-the-mill
products they resemble and than a reasonable consumer would expect; (2)
plaintiffs have an allergic sensitivity to McDonalds' products; (3)
McDonalds should know that consumers would misuse products (presumably
by eating in larger quantities or at greater frequencies than is
healthy); and (4) policy arguments based upon the Nutrition Labeling
and Education Act. While the Court may only consider allegations in the
Complaint for the purposes of this motion, these arguments are
important in determining whether the plaintiffs should have the right
to amend their complaint, as they point to potentially viable claims,
and thus will briefly be addressed.
For the first time in their opposition papers, the plaintiffs
attempt to show that over-consumption of McDonalds is different in kind
from, for instance, over-consumption of alcoholic beverages or butter
because the processing of McDonalds' food has created an entirely
different -- and more dangerous -- food than one would expect from a
hamburger, chicken finger, or French fry cooked at home or at any
restaurant other than McDonalds. They thus argue that McDonalds' food
is "dangerous to an extent beyond that which would be contemplated by
the ordinary consumer who purchases it, with the ordinary knowledge
common to the community as to its characteristics." . . .
Similarly, plaintiffs argue that McDonalds' products have been so
altered that their unhealthy attributes are now outside the ken of the
average reasonable consumer. They point to McDonalds' ingredient lists
to show that McDonalds' customers worldwide are getting much more than
what is commonly considered to be a chicken finger, a hamburger, or a
French fry. . . .
For instance, Chicken McNuggets, rather than being merely chicken
fried in a pan, are a McFrankenstein creation of various elements not
utilized by the home cook. . . .
In addition, Chicken McNuggets, while seemingly a healthier
option than McDonalds hamburgers because they have "chicken" in their
names, actually contain twice the fat per ounce as a hamburger. It is
at least a question of fact as to whether a reasonable consumer would
know -- without recourse to the McDonalds' website -- that a Chicken
McNugget contained so many ingredients other than chicken and provided
twice the fat of a hamburger.
Similarly, it is hardly common knowledge that McDonalds' French
fries are comprised, in addition to potatoes, of: partially
hydrogenated soybean oil, natural flavor (beef source), dextrose, and
sodium acid pyrophosphate (to preserve natural color); they are cooked
in partially hydrogenated vegetable oils, (“may contain partially
hydrogenated soybean oil and/or partially hydrogenated corn oil and/or
partially hydrogenated canola oil and/or cottonseed oil and/or corn
oil”); TBHQ and citric acid are added to preserve freshness;
Dimethylpolysiloxane is added as an anti-foaming agent.
This argument comes closest to overcoming the hurdle presented to
plaintiffs. If plaintiffs were able to flesh out this argument in an
amended complaint, it may establish that the dangers of McDonalds'
products were not commonly well known and thus that McDonalds had a
duty toward its customers. The argument also addresses McDonalds' list
of horribles, i.e., that a successful lawsuit would mean that "pizza
parlors, neighborhood diners, bakeries, grocery stores, and literally
anyone else in the food business (including mothers cooking at home),”
could potentially face liability. Most of the above entities do not
serve food that is processed to the extent that McDonalds' products are
processed, nor food that is uniform to the extent that McDonalds'
products are throughout the world. Rather, they serve plain-jane
hamburgers, fries and shakes -- meals that are high in cholesterol,
fat, salt and sugar, but about which there are no additional processes
that could be alleged to make the products even more dangerous. In
addition, there is the problem of causation; hardly any of the entities
listed above other than a parent cooking at home serves as many people
regularly as McDonalds and its ilk.
In response to this argument, McDonalds claims that, even if
true, it is also a matter of common knowledge that any processing that
its foods undergo serve to make them more harmful than unprocessed
foods. It is premature to speculate as to whether this argument will be
successful as a matter of law if the plaintiffs amend their complaint
to include these allegations, as neither argument has been more than
cursorily presented to the Court and certainly is not properly before
it. McDonalds' argument is insufficient, however, to convince this
Court that the plaintiffs should not have the opportunity to amend
their complaint to include these allegations.
Plaintiffs also argue in their papers, less successfully, that
McDonalds has a duty to plaintiffs because they have an "allergic
sensitivity" to McDonalds fare. . . .
Plaintiffs also attempt to ground a duty in a claim that eating
McDonalds with high frequency is a "misuse" of the product of which
McDonalds is aware. Again, such allegation was not in the Complaint,
and, in any case, plaintiffs fail to allege even in their papers that
what is at issue is a misuse "in the sense that it was outside the
scope of the apparent purpose for which the [products] were
manufactured." . . .
A better argument based on over-consumption would involve a claim
that McDonalds' products are unreasonably dangerous for their intended
use. The intended use of McDonalds' food is to be eaten, at some
frequency that presents a question of fact. If plaintiffs can allege
that McDonalds products' intended use is to be eaten for every meal of
every day, and that McDonalds is or should be aware that eating
McDonalds' products for every meal of every day is unreasonably
dangerous, they may be able to state a claim.
. . . .
Because Count III has failed to state a claim, it is dismissed.
McDonalds also argues that Count III should be dismissed because
the plaintiffs may not as a matter of law allege that the unhealthy
attributes of McDonalds' products were the proximate cause of their
obesity and other health problems.
In order to show proximate cause, a plaintiff must establish that
the defendant's conduct was a substantial cause in bringing about the
harm. . . .
Several factors are considered, including "the aggregate number
of actors involved which contribute towards the harm and the effect
which each has in producing it," and "whether the situation was acted
upon by other forces for which the defendant is not responsible." . . .
No reasonable person could find probable cause based on the facts
in the Complaint without resorting to "wild speculation." . . .
First, the Complaint does not specify how often the plaintiffs
ate at McDonalds. The class action proposed by plaintiffs could consist
entirely of persons who ate at McDonalds on one occasion. As a result,
any number of other factors then potentially could have affected the
plaintiffs' weight and health. In order to survive a motion to dismiss,
the Complaint at a minimum must establish that the plaintiffs ate at
McDonalds on a sufficient number of occasions such that a question of
fact is raised as to whether McDonalds' products played a significant
role in the plaintiffs' health problems. While the assignment of such a
frequency is beyond the competency of this Court at this time, it seems
like the frequency must be more than once per week -- a figure cited by
plaintiffs' counsel in oral argument as a potentially not unhealthy
figure. Naturally, the more often a plaintiff had eaten at McDonalds,
the stronger the likelihood that it was the McDonalds' food (as opposed
to other foods) that affected the plaintiffs' health.
Second, McDonalds points out that articles on which plaintiffs
rely in their Complaint suggest that a number of factors other than
diet may come into play in obesity and the health problems of which
plaintiffs complain. As a result, in order to allege that McDonalds'
products were a significant factor in the plaintiffs' obesity and
health problems, the Complaint must address these other variables and,
if possible, eliminate them or show that a McDiet is a substantial
factor despite these other variables. Similarly, with regard to the
plaintiffs' health problems that they claim resulted from their obesity
(which they allege resulted from their McDonalds habits) it would be
necessary to allege that such diseases were not merely hereditary or
caused by environmental or other factors.
Because the Complaint fails to allege that the danger of the
McDonalds' products were not well-known and fails to allege with
sufficient specificity that the McDonalds' products were a proximate
cause of the plaintiffs' obesity and health problems, Count III shall
be dismissed.
Count IV alleges a failure to warn of the unhealthy attributes of
McDonalds' products. While the cause of action differs from Count III,
McDonalds' arguments that this claim fails because the dangers of its
fare were well-known and that plaintiffs have failed to show proximate
cause are nonetheless applicable.
. . . .
As discussed above, the Complaint fails to allege that the
McDonalds' products consumed by the plaintiffs were dangerous in any
way other than that which was open and obvious to a reasonable
consumer. While the plaintiffs have presented the outline of a
substantial argument to the contrary in their papers, as discussed
supra, their theory is not supported in their Complaint, and thus
cannot save Count IV from dismissal. In addition, as also discussed
above, the Complaint does not allege with sufficient specificity that
the plaintiffs' consumption of McDonalds' products was a significant
factor in their obesity and related health problems. As a result, Count
IV must be dismissed.
The exact basis of Count V is unclear. It appears to be a
products liability claim, i.e., McDonalds' products are inherently
dangerous in that they are addictive. The claim may also be read to
allege that McDonalds failed to warn its customers that its products
were addictive. This claim, unlike the one above based on unhealthy
attributes, does not involve a danger that is so open and obvious, or
so commonly well-known, that McDonalds' customers would be expected to
know about it. In fact, such a hypothesis is even now the subject of
current investigations. . . . Such a finding would go far in explaining
why fast-food sales have climbed to more than $100 billion a year . . .
despite years of warnings to limit fats. Therefore, it does not run
into the same difficulties discussed above with regard to clarifying
that the unhealthy attributes are above and beyond what is normally
known about fast food.
While it is necessary to accept as true the allegation in the
Complaint that McDonalds' products are addictive for the purposes of
this motion, such allegation standing alone is, nonetheless,
insufficient as overly vague. The Complaint does not specify whether it
is the combination of fats and sugars in McDonalds products, that is
addictive, or whether there is some other additive, that works in the
same manner as nicotine in cigarettes, to induce addiction. Further,
there is no allegation as to whether McDonalds purposefully
manufactured products that have these addictive qualities. In addition,
the Complaint fails to specify whether a person can become addicted to
McDonalds' products after eating there one time or whether it requires
a steady diet of McDonalds in order to result in addiction. There is
also no allegation as to whether plaintiffs, as infants, are more
susceptible to the addiction than adults.
While some of these questions necessarily may not be answered
until discovery (should this claim be replead and survive a motion to
dismiss), and likely then only with the aid of expert witnesses, to
allow a complaint to survive merely because it alleges product
liability on the basis of addiction would be to allow any complaint
that alleges product liability based on the addictive nature of the
products to survive dismissal, even where such addiction is likely
never to be proven. As a result, a complaint must contain some
specificity in order to survive a motion to dismiss.
A claim that a product causes addiction and that reasonable
consumers are unaware of that danger must at the very least (1) allege
that the plaintiffs are addicted, with allegations revealing ways in
which their addiction may be observed, and (2) specify the basis of the
plaintiffs' belief that they and others became addicted to the product.
Further allegations addressing questions raised above would further
strengthen the claim. In the absence of any such specific allegations,
Count V must be dismissed.
In any case, as discussed
sufficiently that the addictive
plaintiffs' resulting ingestion
plaintiff's health problems. As
above, the Complaint fails to allege
nature of McDonalds' food and the
thereof is a proximate cause of the
a result, Count V is dismissed.
. . . [T]he plaintiffs may amend their complaint to address the
deficiencies listed above.
*
*
*
Pelman v. McDonald’s
2003 WL 2205277 (S.D.N.Y.)(“Pelman II”)
Sweet, Judge.
*
*
*
McDonald's Advertising Campaigns
In one survey of the frequency of purchases by visitors to
McDonald's restaurants, McDonald's found that 72% of its customers were
"Heavy Users," meaning they visit McDonald's at least once a week, and
that approximately 22% of its customers are "Super Heavy Users," or
"SHUs," meaning that they eat "at McDonald's ten times or more a
month." Super Heavy Users make up approximately 75% of McDonald's
sales. Many of McDonald's advertisements, therefore, are designed to
increase the consumption of Heavy Users or Super Heavy Users. The
plaintiffs allege that to achieve that goal, McDonald's engaged in
advertising campaigns which represented that McDonald's foods are
nutritious and can easily be part of a healthy lifestyle.
Advertising campaigns run by McDonald's from 1987 onward claimed
that it sold: "Good basic nutritious food.” “Food that's been the
foundation of well-balanced diets for generations.” “And will be for
generations to come." McDonald's also represented that it would be
"easy" to follow USDA and Health and Human Services guidelines for a
healthful diet "and still enjoy your meal at McDonald's." McDonald's
has described its beef as "nutritious" and "leaner than you think." And
it has described its French fries as "well within the established
guidelines for good nutrition." While making these broad claims about
its nutritious value, McDonald's has declined to make its nutrition
information readily available at its restaurants. In 1987, McDonald's
entered into a settlement agreement with the New York State Attorney
General in which it agreed to “provide [nutritional] information in
easily understood pamphlets or brochures which will be free to all
customers so they could take them with them for further study [and] to
place signs, including in-store advertising to inform customers who
walk in, and drive through information and notices would be placed
where drive-through customers could see them.” Despite this agreement,
the plaintiffs have alleged that nutritional information was not
adequately available to them for inspection upon request.
In the amended complaint, the plaintiffs alleged four causes of
action as members of a putative class action of minors residing in New
York State who have purchased and consumed McDonald's products. Shortly
before oral argument, however, the plaintiffs informed the Court that
they are dropping their fourth cause of action, which alleged
negligence by McDonald's because of its failure to warn plaintiffs of
the dangers and adverse health effects of eating processed foods from
McDonald's. The three remaining causes of action are based on deceptive
acts in practices in violation of the Consumer Protection Act . . . .
Count I alleges that McDonald's misled the plaintiffs, through
advertising campaigns and other publicity, that its food products were
nutritious, of a beneficial nutritional nature or effect, and/or were
easily part of a healthy lifestyle if consumed on a daily basis. Count
II alleges that McDonald's failed adequately to disclose the fact that
certain of its foods were substantially less healthier, as a result of
processing and ingredient additives, than represented by McDonald's in
its advertising campaigns and other publicity. Count III alleges that
McDonald's engaged in unfair and deceptive acts and practices by
representing to the New York Attorney General and to New York consumers
that it provides nutritional brochures and information at all of its
stores when in fact such information was and is not adequately
available to the plaintiffs at a significant number of McDonald's
outlets.
The plaintiffs allege that as a result of the deceptive acts and
practices enumerated in all three counts, they have suffered damages
including, but not limited to, an increased likelihood of the
development of obesity, diabetes, coronary heart disease, high blood
pressure, elevated cholesterol intake, related cancers, and/or
detrimental and adverse health effects and/or diseases.
. . . .
[The court then describes § 349 and § 350. It goes on to conclude
that any violation of the act cannot be claimed for actions before 1987
because of the statute of limitations.]
McDonald's argues that the consumer protection claims must be
dismissed because the plaintiffs do not "allege that any of them ever
saw even one of the McDonald's statements and advertisements described
in the Amended Complaint." The plaintiffs counter that they have
alleged that their misconceptions about the healthiness of McDonald's
food resulted from "a long-term deceptive campaign by Defendant of
misrepresenting the nutritional benefits of their foods over last
approximate [sic] fifteen (15) years." Plaintiffs are correct that it
is not necessary to allege reliance on defendant's deceptive practices
in the context of a § 349 claim. . . . To state a claim under § 350 for
false advertising, however, it is necessary to allege reliance on the
allegedly false advertisement.
While plaintiffs have alleged that McDonald's has made it
difficult to obtain nutritional information about its products, they
have not alleged that McDonald's controlled all relevant information.
Indeed, the complaint cites the complete ingredients of several
McDonald's products. Plaintiffs are therefore required to allege
reliance in order to survive a motion to dismiss. The plaintiffs' vague
allegations of reliance on a "long-term deceptive campaign" are
insufficient to fulfill the reliance requirement . . . . Even assuming
that the specific advertisements cited by the plaintiffs would be
considered deceptive, it cannot be determined that the other
advertisements upon which the plaintiffs are alleged to have relied are
also deceptive without citing at least one instance of such
advertisements. Absent an example of an alleged false advertisement on
which plaintiffs relied, the amended complaint states only a legal
conclusion -- that the campaign in its entirety is deceptive -- without
making a factual allegation. Such conclusory allegations are not
entitled to a presumption of truthfulness. . . .
. . . .
Making all reasonable inferences in favor of the plaintiffs, the
complaint implicitly alleges only one instance in which the infant
plaintiffs were aware of allegedly false advertisements. The plaintiffs
implicitly allege that they were aware of McDonald's national
advertising campaign announcing that it was switching to "100 percent
vegetable oil" in its French fries and hash browns, and that McDonald's
fries contained zero milligrams of cholesterol, when they claim that
they "would not have purchased or consumed said French fries or hash
browns, or purchased and consumed in such quantities," had McDonald's
disclosed the fact that these products "contain beef or extracts and
trans fatty acids." . . .
The most formidable hurdle for plaintiffs is to demonstrate that
they "suffered injury as a result of the deceptive act." . . .
. . . .
Even if plaintiffs were able sufficiently to allege that their
injuries were causally related to McDonald's representations about its
French fries and hash browns, that claim must still be dismissed
because the plaintiffs have not alleged that those advertisements were
objectively misleading.
The essence of the plaintiffs' claim of deception with regard to
McDonald's French fries and hash browns is that McDonald's represented
that its fries are cooked in "100 percent vegetable oil" and that they
contain zero milligrams of cholesterol whereas in reality they "contain
beef or extracts and trans fatty acids." However, the citations in the
amended complaint to McDonald's advertisements, and the appended copies
of the advertisements, do not bear out the plaintiffs' claims of
deception. The first citation is to an advertisement titled "How we're
getting a handle on cholesterol," alleged to have commenced in 1987 and
to have continued for several years thereafter. The text cited by the
plaintiffs states: “a regular order of French fries is surprising low
in cholesterol and saturated fat: only 9 mg of cholesterol and 4.6
grams of saturated fat. Well within established guidelines for good
nutrition.” The advertisement also states that McDonald's uses "a
specially blended beef and vegetable shortening to cook our world
famous French fries and hash browns."
The plaintiffs next allege that beginning on or around July 23,
1990, McDonald's announced that it would change its French fry recipe
and cook its fries in "100 percent vegetable oil," a change that
rendered its fries cholesterol-free. They allege that from the time of
the change until May 21, 2001, McDonald's never acknowledged "that it
has continued the use of beef tallow in the French fries and hash
browns cooking process." On its website, however, McDonald's is alleged
to have "admitted the truth about its French fries and hash browns": “A
small amount of beef flavoring is added during potato processing -- at
the plant. After the potatoes are washed and steam peeled, they are
cut, dried, par-fried and frozen. It is during the par-frying process
at the plant that the natural flavoring is used. These fries are then
shipped to our U.S. restaurants. Our French fries are cooked in
vegetable oil at our restaurants.”
. . . .
Plaintiffs further allege that McDonald's claims that its French
fries and hash browns are cholesterol-free is also misleading because
the oils in which those foods are cooked contain "trans fatty acids
responsible for raising detrimental blood cholesterol levels (LDL) in
individuals, leading to coronary heart disease." However, plaintiffs
have made no allegations that McDonald's made any representations about
the effect of its French fries on blood cholesterol levels.
Because the plaintiffs have failed to allege both that McDonald's
caused the plaintiffs' injuries or that McDonald's representations to
the public were deceptive, the motion to dismiss the complaint is
granted. . . .
*
*
*
Pelman v. McDonald’s Corp.
396 F.3d 508 (2d Cir. 2005)(“Pelman III”)
Rakoff, Judge.
*
*
*
In this diversity action, plaintiffs . . . by their respective
parents . . . appeal from the dismissal of Counts I-III of their
amended complaint. Each of the these counts purports to allege, on
behalf of a putative class of consumers, that defendant McDonald's
Corporation violated both § 349 and § 350 of the New York General
Business Law, commonly known as the New York Consumer Protection Act,
during the years 1987 through 2002.
Specifically, Count I alleges that the combined effect of
McDonald's various promotional representations during this period was
to create the false impression that its food products were
nutritionally beneficial and part of a healthy lifestyle if consumed
daily. Count II alleges that McDonald's failed adequately to disclose
that its use of certain additives and the manner of its food processing
rendered certain of its foods substantially less healthy than
represented. Count III alleges that McDonald's deceptively represented
that it would provide nutritional information to its New York customers
when in reality such information was not readily available at a
significant number of McDonald's outlets in New York visited by the
plaintiffs and others. The amended complaint further alleges that as a
result of these deceptive practices, plaintiffs, who ate at McDonald's
three to five times a week throughout the years in question, were "led
to believe that [McDonald's] foods were healthy and wholesome, not as
detrimental to their health as medical and scientific studies have
shown . . . [and] of a beneficial nutritional value," and that they
"would not have purchased and/or consumed the Defendant's
aforementioned products, in their entire[t]y, or on such frequency but
for the aforementioned alleged representations and campaigns." Finally,
the amended complaint alleges that, as a result, plaintiffs have
developed "obesity, diabetes, coronary heart disease, high blood
pressure, elevated cholesterol intake, related cancers, and/or other
detrimental and adverse health effects . . . ." What is missing from
the amended complaint, however, is any express allegation that any
plaintiff specifically relied to his/her detriment on any particular
representation made in any particular McDonald's advertisement or
promotional material. The district court concluded that, with one
exception, the absence of such a particularized allegation of reliance
warranted dismissal of the claims under § 350 which prohibits false
advertising. As to the exception -- involving McDonald's
representations that its French fries and hash browns are made with
100% vegetable oil and/or are cholesterol-free -- the district court
found that, while the amended complaint might be read to allege
implicit reliance by plaintiffs on such representations, the
representations themselves were objectively non-misleading.
Although plaintiffs' notice of appeal states that they challenge
the judgment "dismissing the Plaintiffs' Amended Complaint," their
brief on appeal contains no argument as to why the district court's
dismissal of the claims asserted under § 350 was incorrect.
Accordingly, we regard any challenge to the dismissal of the § 350
claims as abandoned.
Plaintiffs' appellate brief does, however, challenge the district
court's dismissal of the claims under § 349 which makes unlawful
"[d]eceptive acts or practices in the conduct of any business, trade,
or commerce, or in the furnishing of any service in this state." Unlike
a private action brought under § 350, a private action brought under §
349 does not require proof of actual reliance. Additionally, § 349
extends well beyond common-law fraud to cover a broad range of
deceptive practices . . . and because a private action under § 349 does
not require proof of the same essential elements (such as reliance) as
common-law fraud, an action under § 349 is not subject to the pleadingwith-particularity requirements . . . but need only meet the bare-bones
notice-pleading requirements . . . .
Although the district court recognized that § 349 does not
require proof of reliance, the district court nonetheless dismissed the
claims because it concluded that "[p]laintiffs have failed, however, to
draw an adequate causal connection between their consumption of
McDonald's food and their alleged injuries." Thus, the district court
found it fatal that the complaint did not answer such questions as:
What else did the plaintiffs eat? How much did they exercise? Is there
a family history of the diseases which are alleged to have been caused
by McDonald's products? Without this additional information, McDonald's
does not have sufficient information to determine if its foods are the
cause of plaintiffs' obesity, or if instead McDonald's foods are only a
contributing factor.
This, however, is the sort of information that is appropriately
the subject of discovery, rather than what is required to satisfy the
limited pleading requirements . . . .
So far as the § 349 claims are concerned, the amended complaint
more than meets the [minimum pleading] requirements . . . .
Accordingly, the district court's dismissal of those portions of
Counts I-III of the amended complaint as alleged violations of § 349
[is vacated].
*
*
*
Cheryl L. Hayne, Patricia A. Moran, & Mary M. Ford,
“Regulating Environments to Reduce Obesity,” 25 Journal of
Public Health Policy 391-99 (2005)
*
*
*
. . . [R]egulatory interventions can help create a food
environment more conducive to healthy dietary practices. Regulatory
interventions may come in many forms. In order to illustrate two
potential regulatory fulcra for legal levers, we will focus here on
product labeling and advertising restrictions, and two federal
agencies.
. . . .
Restaurant Food Labeling
The Food and Drug Administration has authority to regulate
nutritional labeling of processed foods in the United States. The
Federal Food, Drug and Cosmetic Act, however, exempts restaurants. They
are not required to disclose nutrition information. This exemption
seems out-of-date, as Americans now spend about half of their food
budget purchasing meals and drinks outside of the home. Exempting the
restaurant and fast-food industry from disclosing the content and
nutritional value makes it difficult for consumers to estimate the
energy content of the food they consume away from home. And food eaten
outside of the home is generally higher in fat and lower in other
nutrients than food prepared at home. Many popular table-service
restaurants serve 1000-2000 calories per meal, or 35% to 100% of a full
day's energy required for most adults. . . . Mandating point-of-sale
nutritional information for customers could combat increased portion
sizes and decreased nutritional value of fast-food and restaurant meals
as eating out becomes a larger part of U.S. food consumption. This
information might enable consumers to make informed dietary decisions.
It could also encourage restaurants to modify their ingredients and
menus to provide greater healthy and nutritious food and beverage
options to their customers.
Advertising
Food manufacturers' and restaurant chains' advertising encourages
consumers to purchase unhealthy foods and make poor dietary decisions.
Children are a particularly attractive marketing target. Their
increasing buying power and influence on goods purchased for the wider
household have encouraged the food industry to target children. In many
countries, advertising for energy-dense food targeting children has
increased relative to other age group targets. Considerable effort goes
into planning the seeds of brand loyalty with this vulnerable group.
High exposure of children to advertisements for foods high in fat
and sugar is believed to be a major contributor to obesity. "Eight in
ten adults agree that business marketing and advertising exploit
children by convincing them to buy things that are bad for them or that
they don't need." The study found these concerns highest in relation to
food and nutrition issues. Most foods advertised to children -- fast
food, sweets, ice creams, and carbonated drinks -- are highly
processed, high in fat and/or sugar and low in nutrients; providing
"empty calories." Food marketing has not only undermined parents'
dietary preferences, but these highly marketed foods in children's
diets contribute to early increasing weight and associated health
problems. Eighty percent of obese adolescents remain obese as adults,
primarily because dietary habits developed when young persist for a
lifetime. That advertising of these products is a direct cause of
children's weight and health problems appears to be widely accepted by
critics and by some policy makers. Advertising must be effective or why
else would the food industry spend so much on it?
In the United States alone, the U.S. food industry spends about
$11 billion annually on advertising in addition to another $22 billion
on other consumer promotions. Such expenditures dwarf the National
Cancer Institute's $1 million annual investment in its educational "5A-Day" campaign to increase fruit and vegetable consumption or the $1.5
million budget of the National Heart, Lung and Blood Institute's
National Cholesterol Education Campaign. . . .
Governments both here and elsewhere might intervene with
regulatory actions restricting food marketing practices to overcome
this market failure. No one has suggested that governments are likely
to spend enough on informational efforts to overcome current industry
advertising practices. Provided with balanced information and no longer
bombarded pervasively by advertisements for high-calorie, high-fat and
high-sugar products, perhaps consumers will have the ability to make
healthier food purchasing decisions.
Unlike the FDA, which would need legislative changes before
regulating restaurants, the Federal Communications Commission already
regulates radio and television broadcasting. Might it consider
requiring broadcasters to provide equal time for messages promoting
healthy eating and physical activity? Perhaps a greater opportunity
comes from restricting advertising of high-calorie, low-nutrient foods
on television programming commonly watched by children. If the FCC
prohibited "junk food" advertisers from targeting children under a
specific age, would children be less likely to purchase, or ask their
parents to purchase, unhealthy foods?
The United States could make substantial contributions to the
international obesity epidemic, were it to step up efforts to regulate
the industry and the food environment to promote healthier and more
informed consumer choice. Regulatory actions are already gaining
acceptance abroad. . . .
. . . .
The nutritional labeling of foods consumed away from home and
health-conscious advertising limitations are two areas that are worthy
of regulatory consideration. As discussed above, children have become
targets for aggressive advertising of unhealthy foods. Advertising,
however, is only one factor fuelling the overweight epidemic; certain
aspects of the school environment also encourage weight gain and
inactivity among children. The school environment offers some promising
opportunities for regulators.
THE SCHOOL ENVIRONMENT
Schools offer an opportunity to address the increasing incidence
and prevalence of overweight among children and adolescents. Because
children spend a high percentage of their formative years at school, a
healthy school environment could influence a child's eating and fitness
habits for years to come. . . .
The National School Lunch Program
The National School Lunch Program (NSLP), administered by the
United States Department of Agriculture (USDA), serves lunch to
approximately 2.5 million American children each school day. Schools
choosing to participate receive donated commodities and cash subsidies.
They are obliged to provide free or reduced-price lunches to eligible
low-income children. All lunches and snacks served under the NSLP must
meet federal nutritional guidelines: no more than 30% of calories may
be from total fat and no more than 10% from saturated fat; and the
lunch must contain one-third of Recommended Daily Allowances for
calories, protein, iron, calcium, and vitamins A and C.
Many school cafeterias also offer foods not currently regulated
by the USDA. Products sold á la carte or in vending machines, in
competition with the NSLP, generally lack comparable nutritional value.
Researchers studying 20 Minnesota secondary schools found that high-fat
foods such as chips, crackers and ice cream constituted 21.5% of the
available á la carte items; while a mere 4.5% of the á la carte items
were fruits and vegetables. Two-thirds of the schools examined had soft
drink contracts for vending machines. Adolescents have increased their
consumption of high-sugar soft drinks by 100% in the last 20 years. Not
surprisingly, this energy intake has been linked to weight gain.
Improvements to the NSLP could help combat the obesity epidemic.
Expanding NSLP authority to regulate á la carte items and vending may
be an avenue to control the types of foods offered to students. With
greater authority, it would be possible to replace high-fat and highsugar food with more nutritious choices.
Physical and Nutrition Education
One key regulatory opportunity at the state level lies in
improvements to physical and nutrition education programs. A recent
survey shows that state physical education mandates are usually general
and include only minimum recommendations leaving interpretations up to
local school districts. Resulting physical education programs often
fail to meet the recommendations of the Surgeon General and CDC for
daily physical education. A report published by the National Center for
Education Statistics shows similar deficits in nutrition education: In
grades kindergarten to eight only 50% of schools were required by state
or district mandates to provide nutrition education. This figure drops
to 40% for grades 9 and 10 and to 20% for grades 11 and 12. Failure to
fund nutrition and physical education ultimately results in increased
state and federal healthcare spending. State mandates to require daily
physical education and quality nutrition education in all primary and
secondary schools might reduce obesity, but could prove costly to
school districts.
Vending Contracts
Local schools have the power to make the greatest and most
immediate impact to combat overweight children and adolescents by
eliminating soft drink vending machines. Soft drink vending machines
have become a ubiquitous fixture in schools in the United States. In
Minnesota, 98% of secondary schools and 44% of elementary schools in
Kentucky have vending machines. Researchers have found that each daily
serving of a sugar-sweetened beverage increases the odds of becoming
obese by 1.6.
If vending machine contracts can be modified or eliminated so
that machines are either removed or promote healthy beverages, students
would have less access to sugary beverages and consumption would
decline. This is not unprecedented: The Los Angeles Board of Education
has taken action to eliminate the availability of soft drinks in all
elementary, middle and high schools and Texas has recently started
controlling soft drinks, as well.
But special consideration must be given to school budget
constraints and dependence on revenues from vending machines and other
food marketing. When Texas took a first step to regulate food choices
in the Texas Public School System by issuing new nutrition policies and
restricting the availability of soft drinks and high-fat foods, it
tried to offset any disruption to school fundraising with a program
from the Texas Department of Agriculture to help school districts learn
to raise funds without using food.
Limitations of Regulations in the School Environment
Students spend about 7 hours a day for 180 days a year in the
school environment and most consume at least one of three meals per day
in school. From 35% to 40% of adolescents' total energy intake is being
consumed in secondary school. Schools influence a child's eating,
drinking and fitness behavior. At home, many children live (and consume
most of their calories) in the company of family members who eat
poorly. Schools can temper this problem by involving parents in the
school's nutrition initiatives. Intense academic requirements and
limited budgets often leave little time for physical and nutrition
education. Children must be healthy and ready to learn, thus,
curriculum reform to improve academic results might well be approached
holistically, taking into account not only intellectual growth but
physical health and fitness.
. . . .
THE BUILT ENVIRONMENT
[The authors then discuss their views on the "built environment,"
the various aspects of a community's physical layout, which creates
opportunities for exercise and physical activity.]
*
*
*
The California Childhood Obesity Prevention Act of 2005
The Legislature finds and declares as follows:
In the past two decades obesity has doubled in children, and
tripled in adolescents. On average, 30 percent of California's children
are overweight, and in some school districts, anywhere from 40 to 50
percent of California's pupils are overweight. Only 2 percent of
California's adolescents, between the ages of 12 and 17 years,
inclusive, have eating habits that meet national dietary
recommendations. Only 23 percent of pupils in grades 5, 7, and 9 are
physically fit. Almost half of the children and adolescents diagnosed
with diabetes have the Type 2 form of the disease, which is strongly
linked to obesity and lack of exercise. One in four obese children have
early signs of Type 2 diabetes.
Overweight and physical inactivity costs California an estimated
24.6 billion dollars annually, approximately seven hundred fifty
dollars ($750) per person -- a cost that is expected to rise by another
32 percent by the year 2005. Poor nutrition and physical inactivity
account for more preventable deaths (28 percent) than anything other
than tobacco -- more than AIDS, violence, car crashes, alcohol, and
drugs combined. The long-term impact of childhood obesity on
California's economy, and on our children's increased risk of death
from heart disease, cancer, stroke, and diabetes will be staggering.
Approximately 300,000 deaths in the United States per year are
currently associated with obesity and overweight; the total direct and
indirect costs attributed to overweight and obesity amounted to 117
billion dollars in the year 2000. Obesity is linked to a larger
increase of chronic health conditions and accounts for a significantly
higher amount of health expenditures than those associated with
smoking, heavy drinking, or poverty.
Each additional daily serving of sugar-sweetened soda increases a
child's risk for obesity by 60 percent. Twenty years ago, boys consumed
more than twice as much milk as soft drinks, and girls consumed 50
percent more milk than soft drinks. By 1996, both boys and girls
consumed twice as many soft drinks as milk. Soft drinks now comprise
the leading source of added sugar in a child's diet. Teenage boys
consume twice the recommended amount of sugar each day, almost one-half
of which (44 percent) comes from soft drinks. Teenage girls consume
almost three times the recommended amount of sugar, 40 percent of which
comes from soft drinks.
A study of 9th and 10th grade girls found that those who drank
colas were five times more likely to develop bone fractures, and girls
who drank other carbonated beverages were three times more likely to
suffer bone fractures than nonconsumers of carbonated beverages.
Decreased milk consumption means that children are no longer getting
required amounts of calcium in their diets. The average teenage girl
now consumes 40 percent less calcium than she needs, putting her at
high risk of osteoporosis in her later years.
[The legislation then amended the pre-existing law concerning
sale of beverages to pupils at elementary, middle or junior high
schools, California Education Code § 49931.5 to read in part:]
(a)(1) Regardless of the time of day, only the following beverages may
be sold to a pupil at an elementary school:
(A) Fruit-based drinks that are composed of no less than 50
percent fruit juice and have no added sweetener.
(B) Vegetable-based drinks that are composed of no less than 50
percent vegetable juice and have no added sweetener.
(C) Drinking water with no added sweetener.
(D) Two-percent-fat milk, one-percent-fat milk, nonfat milk, soy
milk, rice milk, and other similar nondairy milk.
(a)(2) An elementary school may permit the sale of beverages that do
not comply with paragraph (1) as part of a school fundraising event in
any of the following circumstances:
(A) The items are sold by pupils of the school and the sale of
those items takes place off and away from the premises of the school.
(B) The items are sold by pupils of the school and the sale of
those items takes place one-half hour or more after the end of the
schoolday.
(a)(3) From one-half hour before the start of the schoolday to one-half
hour after the end of the schoolday, only the following beverages may
be sold to a pupil at a middle or junior high school:
(A) Fruit-based drinks that are composed of no less than 50
percent fruit juice and have no added sweetener.
(B) Vegetable-based drinks that are composed of no less than 50
percent vegetable juice and have no added sweetener.
(C) Drinking water with no added sweetener.
(D) Two-percent-fat milk, one-percent-fat milk, nonfat milk, soy
milk, rice milk, and other similar nondairy milk.
(E) An electrolyte replacement beverage that contains no more
than 42 grams of added sweetener per 20-ounce serving.
(a)(4) A middle or junior high school may permit the sale of beverages
that do not comply with paragraph (3) as part of a school event if the
sale of those items meets all of the following criteria:
(A) The sale occurs during a school-sponsored event and takes
place at the location of that event at least one-half hour after the
end of the schoolday.
(B) Vending machines, pupil stores, and cafeterias are used later
than one-half hour after the end of the schoolday.
(a)(5) This subdivision does not prohibit an elementary, or middle or
junior high school from making available through a vending machine any
beverage allowed under paragraph (1) or (3) at any time of day, or, in
middle and junior high schools, any beverage that does not comply with
paragraph (3) if the beverage only is available not later than one-half
hour before the start of the schoolday and not sooner than one-half
hour after the end of the schoolday.
(b)(1) Commencing July 1, 2007, no less than 50 percent of all
beverages sold to a pupil from one-half hour before the start of the
schoolday until one-half hour after the end of the schoolday shall be
those enumerated by paragraph (3).
(b)(2) Commencing July 1, 2009, all beverages sold to a pupil from onehalf hour before the start of the schoolday until one-half hour after
the end of the schoolday shall be those enumerated by paragraph (3).
(b)(3) Beverages allowed under this subdivision are all of the
following:
(A) Fruit-based drinks that are composed of no less than 50
percent fruit juice and have no added sweetener.
(B) Vegetable-based drinks that are composed of no less than 50
percent vegetable juice and have no added sweetener.
(C) Drinking water with no added sweetener.
(D) Two-percent-fat milk, one-percent-fat milk, nonfat milk, soy
milk, rice milk, and other similar nondairy milk.
(E) An electrolyte replacement beverage that contains no more
than 42 grams of added sweetener per 20-ounce serving.
*
*
*
Notes to Chapter Five
1. The problem of obesity in the United States is qualitatively
different from the problems described in previous chapters. To refer to
obesity as a public health problem blurs some key distinctions. Obesity
is neither a disease nor the result of one. It is not infectious, or,
more critically, something that directly causes harm to anyone other
the individual who is labeled “obese.” And it is a label. There are
some working definitions of who is overweight and who is obese, but
ultimately obesity is a judgment call and that judgment involves more
than what any objective measure can ascertain and quantify. As a
result, the causes of obesity, the resulting health and economic
consequences, and the possible remedial solutions are difficult even to
discuss let alone verify and assess.
Having said all that, one thing is clear: There is something
happening to people in the United States and, apparently, elsewhere,
that has to do with the way they live and eat and the net impact on
their health. Lots of us are, to use an interesting expression, “out of
shape.” And while even a moment’s reflection will make it clear that
the body’s “shape” is not a public health problem, what we all know at
some level is that our “shape” is a fairly clear and visible indicator
of some things that are surely problematic; if, as most of us believe,
there are more and more bodies “out of shape,” those problems are
increasing.
According to the Surgeon General’s report -- and a host of other
public health experts -- lack of “shape” or, to use the term most often
used in public discussion of the problem, obesity is a problem of
epidemic proportions in the United States. The prevalence of obesity
has increased substantially in the United States over the last two
decades and appears to be increasing. In 2000, over 30 percent of
American adults were described as obese (BMI index greater than 30)
nearly 60 million people. This condition is associated with higher
rates of heart disease, diabetes, and a number of other medical
conditions, and has resulted in nearly 300,000 premature deaths.
Converting those human cost figures into dollar costs, the CDC
has estimated that medical costs of treating illnesses were nearly $100
billion in 2004, rivaling the costs associated with smoking. Nearly
half of these costs are paid by Medicare and Medicaid.
For a more recent analysis of the obesity problem that reaffirms
the conclusions of the Surgeon General’s 2001 report, see the Institute
of Medicine, The Future of the Public’s Health in the 21st Century
(2003) at 76-83. For a more academic assessment of the data, see Ali H.
Mokdad, et al., “The Spread of the Obesity Epidemic in the United
States 1991-1998,” 282 JAMA 1519 (1999).
For a more detailed data on the distribution of obesity
among Americans: http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm
(last visited March 2005); http://www.surgeongeneral.gov/topics/obesity
(last visited March 2005); http://www.cdc.gov/nchs/products/pubs/ (last
visited march 2005).
For sources of information on a state-by-state basis, see
http://www.cdc.gov/washington/overview/obesity.html (last visited March
2005); http://www.cdc.gov/nccdphp/dnpa/obesity/state_programs (last
visited March 2005). For an assessment of the efforts by each state to
combat obesity, see the “Obesity Report Cards” found at
http://www.ubalt.edu/experts/obesity (last visited may 2005).
2. The trends concerning obesity among American children are even more
disturbing. According to a review of the literature by the IOM:
Trends in childhood and youth obesity mirror a similar
profound increase over the same approximate period in U.S. adults
as well as a concurrent rise internationally, in both developed
and developing countries. The obesity epidemic affects both boys
and girls and has occurred in all age, race, and ethic groups
throughout the United States. In addition to the increase in
obesity prevalence, the heaviest group of children is getting
heavier whereas the leanest group of children is staying lean.
What this means is that among younger age groups of children 6 to
11 years of age and, to a lesser extent, adolescents the lowest
part of the BWI distribution appears to have changed little over
time.
Institute of Medicine, Childhood Obesity in the United States: Facts
and Figures (September 2004). For more details and a further
specification of these “facts and figures,” see Institute of Medicine,
Preventing Childhood Obesity: Health in the Balance (2004) (found
documents can be found at http://www.iom.edu/ (last visited March
2005).
3. As reflected by the executive summary of the WHO/FAO report, the
problem of obesity is hardly confined to the United States. Americans
may be getting bigger and fatter, but the rest of the world is not far
behind -- and apparently for many of the same reasons. For the full
WHO/FAO report, see http://who.int/dietandphysicalactivity/publications
(last visited march 2005).
For a more detailed analysis of obesity among children in other
countries (and some suggestions about what should be done about it),
see Cara B. Ebbeling, et al., “Childhood Obesity: Public Health Crisis,
Common Sense Cure,” 360 Lancet 473 (2002).
4. Because of the nature of the problem -- i.e., obesity itself is not
a disease but rather associated with many diseases and adverse effects
on health -- the actual costs of obesity are hard to quantify;
nonetheless, the overall picture is fairly straightforward. For some
good efforts to summarize and assess the effects of obesity, see, Aviva
Must et al., “The Disease Burden Associated With Overweight and
Obesity,” 282 JAMA 1623 (1999); David B. Allison et al., “Annual Deaths
Attributable to Obesity in the United States,” 282 JAMA 1530 (1999);
A.M. Wolf & Graham A. Colditz, “Current estimates of the economic Costs
of Obesity in the United States,” 6 Obesity Research 97 (1998).
5. Note that the discussion of possible remedial solutions in the
Surgeon General’s report and, to a lesser extent, the WHO/FAO report
follows the same pattern later adopted in the IOM report discussed in
Chapter One: They envision a grand, cooperative partnership of everyone
involved -- government, business, food producers, schools, etc. -- that
would work together to solve the problem. There is little realistic
discussion of the role that some of these actors play in producing the
problem in the first place. Nor is there any realistic game plan for
what should happen if this fanciful coalition does not join hands in
cooperation.
The excerpt from Brownell, on the other hand, focuses on these
more controversial aspects of the problem. As Brownell and Horgen
argue, Americans don’t just eat too much and exercise too little
because many of them are stupid. They do so, in part, because of the
social and economic environment in which they live. And at least part
of that environment has been structured by the entities that directly
profit from Americans’ bad eating habits. Moreover, since they profit
from that environment, they will resist any changes in that
environment, whatever the merits of the public health-based
justifications for doing so. Thus advocacy of “grand cooperative
effort” to fight obesity is at least naïve -- if not politically
disingenuous.
Brownell and Horgen are hardly alone in their more realistic
analysis of the problem. For other interesting works with similar
political messages, see Eric Schlosser, Fast Food Nation
(2002)(particularly the chapter on the safety of meat generally and, in
particular, that used to prepare fast food); David G. Hogan, Selling
‘Em By the Sack (1998)(the history of White Castle hamburgers and their
pioneering of various means for increasing consumption of fast food);
Marion Nestle, Food Politics: How the Food Industry Influences
Nutrition and Health (2002).
For a useful source of current information on nutrition politics
and related matters, see http://www.cspinet.org/(the website of the
Nutrition Action Newsletter) (last visited March 2005). See also
http://www.phaionline (the website of the Public Health Advocacy
Institute) (last visited March 2005).
6. Are lawsuits such as Pelman viable? If they are, will they help
reduce obesity and its consequent results?
The answer to the first question is yet to be determined. Pelman
III left the plaintiff with a viable cause of action, at least
sufficient to survive summary judgment, but the plaintiff’s face
substantial problems of proof if they take their case to trial.
Moreover, the courts seem to have rejected most of the causes of action
except for those under the New York trade laws; there may not be
analogous legislation in other jurisdictions. On the other hand, both
the trial judge and the appellate judges seem to imply some sympathy
for the plaintiffs and some animus for the behavior of the defendants.
Louisiana and at least 12 other states have enacted laws since
1992 attempting to immunize the fast food industry from these sorts of
law suits. For a review of pending lawsuits, legislation intended to
immunize potential defendants, and references to other sources, see
http://www.banzhaf.net/obesity/links/ (last visited February 2005).
The legal literature has been sparse but not particularly
enthusiastic about these “chesseburger lawsuits.” See, e.g., Amy Vroom,
“Fast Food or Fat Food: Food Manufacturer Liability for Obesity,” 72
Defense Counsel Journal 56 (2005).
The public reaction to these lawsuits has paralleled the apparent
view of the state legislatures in Louisiana and other states; most
people think it is silly to claim that fast food purveyors have caused,
in the legal sense of the term, people to become obese. But are these
lawsuits as specious as they may appear at first glance? Are their
parallels to the tobacco litigation discussed in Chapter Four -- which
many people thought were silly until all of the facts came out? Can you
imagine some set of facts that may be discovered, comparable to the
revelations about the nicotine cover-up and other fraudulent practices
of the tobacco companies, that might make these lawsuits more factually
plausible or legally viable?
7. If privately initiated lawsuits are either not viable or not
effective in combating the problems of obesity, are there market-based
strategies that may resolve the problem? If Americans consumers started
demanding more healthy foods, surely the retail food and restaurant
industries would start selling more of them. But part of the problem is
that many people don’t know what is and is not healthy and lack the
information to make those decisions.
Would better nutritional labeling help resolve this problem? The
Food and Drug Administration has the authority to regulate the
nutritional labeling of processed foods, although food served in
restaurants is exempted from their authority. Should that exemption be
removed? Are the current efforts of the FDA appropriate or sufficient?
For a discussion, see Rebecca Fribush, “Putting Calories and Fat Counts
on the Table: Should Mandatory Nutritional Disclosure laws Apply to
Restaurant Foods?” 73 George Washington Law Review 377 (2005).
Or is the problem more a matter of the misinformation and the
other demand-inducing effects of food advertising? Should the
government regulate food advertising more closely? Alternatively,
should the government engage in more counter-advertising and consumer
education? Any effort to regulate food advertising, of course, would
have to overcome the same First Amendment concerns as discussed with
respect to the regulation of tobacco advertising in Chapter Four: It
would have to be carefully tailored to meet the demands of the socalled Central Hudson test. For a good discussion, see Rachel Weiss &
Jason Smith, “Legislative Approaches to the Obesity Epidemic,” 25
Journal of Public Health Policy 379, 383-385 (2005).
8. A few local communities and states have experimented with “fat
taxes,” taxes on soft drinks, fast foods, or other less-than-healthy
food. Apparently such taxes can be a good source of revenue and, as
“sin taxes,” are somewhat less controversial than other forms of
taxation. Whether they can have any effect on the consumption of these
foods is harder to assess. For an extended review of “fat taxes,” their
effects, and related matters, see Jeff Strnad, Conceptualizing the “Fat
Tax”: The Role of Food Taxes in Developed Economies (Working Paper July
2004) (available at http://ssrn.com/abstract_id=561321) (last visited
March 2005). According to Strnad,
As of the middle of 2000, 17 states and two major cities
imposed junk food taxes. Eight other states have imposed junk
food taxes in the past, but repealed them prior to 2000. . . .
. . . Advocates now propose extending these taxes as a way
to fund public health initiatives with respect to diet and
exercise. The envisioned initiatives would counter what the
advocates see as a “toxic environment” that provides access to
and encourages consumption of a diet high in fat, high in
calories, delicious, widely available, and low in cost. . . . The
advocates emphasize that the taxes would not have to be very
heavy, e.g., on the order of a penny per can of soda, in order to
raise substantial revenues, and they note that surveys indicates
substantial support for small taxes conditional on the revenues
being spent to fund health education programs.
Tying junk food taxes to health initiative expenditures may
create public appeal, but from a normative standpoint the
justification for connecting the tax and the expenditure is not
clear . . . .
A second set of tax proposals is much more ambitious. These
proposals often fall under the moniker of the “fat taxes” because
many of the proposed taxes would apply to fatty foods or to the
fat content of foods. Some of the proposals are not limited to
fat content. The most general simply call for taxing unhealthy
foods and subsidizing healthy foods. In contrast to junk food
taxes, fat taxes explicitly attempt to influence behavior to meet
public health goals. [S]uch taxes are concerned about the impact
of food taxes on consumption.
. . . Focusing on this goal raises the question of why the
government should interfere with individual choice with respect
to diet. . . .
Id. at 5-6.
9. In Adam Benforado, et al., “Broken Scales: Obesity and Justice in
America,” 53 Emory Law Journal 1645 (2004) the authors attempt to
assess the linkage between the availability of food, the efforts by
corporate entities to encourage its consumption, and the apparent
epidemic of obesity. They come to some interesting conclusions. As
reflected in the following paragraph, they too challenge the assumption
that obese people simply make bad decisions about what they choose to
eat:
The point of this excursion into the realities of human
eating has been to enable a critical realist analysis of the
obesity crisis. The experience of eating is driven in powerful
ways by the unseen realities of our interior situation and
because these realities are hidden, our conceptions of the obese
and overweight end up being tragically distorted. When we see fat
people eating, we assume that hunger has nothing to do with it
because we "know" that we feel hungry and eat when our bodies
need more food, and their bodies clearly do not need more food.
Eating by the obese and the overweight, we therefore mistakenly
conclude, must be driven not by legitimate hunger and food needs,
but by something less legitimate -- something like gluttony, or
at the very least, something arising from personal, dispositional
choice.
Id. at 1687-88.
10. As discussed in the Hayne article, the federal government has been
involved in underwriting better nutrition in the nation’s schools since
1946 when the first national school lunch program (NSLP) was enacted.
Since that time, the program has been expanded to include federal aid
for pre-school meals and “snacks,” and grown to become a multi-billion
undertaking serving tens of millions of children. While the program has
been publicized as an attempt to ensure that the nation’s children get
enough to eat, the program’s efforts to ensure that the meals that are
provided are, in fact, healthy have been limited and enforcement of the
program’s dietary standards has been limited.
According to amendments to the NSLP enacted in 2004, all
participating schools must establish “local wellness policies”
including goals for improving nutrition, physical activity, and
nutrition education by July 2006. See Pub. Law. No. 108-265, § 204.
Whether this will be still another unenforceable federal requirement
remains to be seen.
For additional description of the NSLP, related legislation, and
references to other sources, see http://www.schoolnutrition.org/Index
(last visited March 2005).
11. One issue that has drawn considerable public attention and some
political action is the extent to which soft drink and other fast-food
retailers have been allowed to advertise in schools, either as part of
the “Channel One” in-school television programming or through logos or
other advertisements on school facilities, athletic score boards, or
vending machines. During the last decade many schools -- as many as 75
percent nationwide -- have entered some sort of contractual arrangement
with one or another soda pop company, allowing advertising privileges
in return for cash or in-kind contributions. Should schools be able to
do this? Should this be considered as part of the education of students
or a matter of revenue raising?
For a relevant and provocative study that seems to indicate that
consumption of soda pop is an important and direct cause of obesity in
children, see David Ludwig, et al., “Relation Between Consumption of
Sugar-Sweetened Drinks and Childhood Obesity: A Prospective,
Observational Analysis,” 357 Lancet 505 (2001). Among other things, the
authors concluded that “the odds of becoming obese among children
increased 1.6 times for each additional can or glass of sugar-sweetened
drink that they consumed every day.” Id. at 507.
In what may be regarded as one hopeful sign, Coca-Cola, Pepsico,
and other soft drink companies announced in August of 2005 that they
had agreed to limit -- voluntarily -- the sale of soft drinks in
elementary, middle, and high schools. According to a statement
published August 17, 2005, and distributed through the media, no
carbonated soft drinks, diet or regular, will be sold in vending
machines in elementary schools; in middle schools regular carbonated
soft drinks will not be sold in vending machines, although diet soft
drinks, and “alternative drinks” such as bottled water, sports drinks,
and juice may be. In high schools, no more than half the vending
machines can be filled with carbonated soft drinks. Whether this policy
will be strictly followed or not, remains to be seen. More importantly,
whether it will have any measurable impact on the amount of soft drinks
consumed or, more importantly, the health status of school children,
also is yet to be determined.
In 2005, California passed legislation that may have mooted that
the voluntary efforts of the soft drink industry and gone several steps
further in efforts to improve the nutrition available in its public
schools.
12. Is obesity a public health problem in the sense that public health
agencies should be undertaking efforts comparable to those described in
earlier chapters? Beyond school-based programs targeting children, what
other public health measures are currently under consideration? For one
interesting effort to devise a comprehensive attack on obesity, see
Walter C. Willett & Serena Domolky, Strategic Plan for the Prevention
and Control of Overweight and Obesity in New England found at
http://www.neconinfo.org/docs/StrategicPlan (last visited March 2005).
For a related academic review, see Marion Nestle & Michael F.
Jacobson, “Halting the Obesity Epidemic: A Public Health Policy
Approach,” 115 Public Health Reports 12 (2000).
13. Everyone seems to agree that American eat too much of the wrong
foods -- and get too little exercise to burn their excess calories. But
what should Americans eat? For some standards to consider, see Appendix
A. For a complete version of these guidelines, see U.S. Dept. of
Agriculture and Dept. of Health and Human Services, Dietary Guidelines
of Americans (5th ed. 2000)(found at
http://www.health.gov/dietaryguidelines/dga2005/ (last visited March
2005).
Appendix to Chapter Five: U.S. Department of Agriculture &
U.S. Department of Health & Human Resources, Dietary
Guidelines for Americans 2005 (Executive Summary)
*
*
*
The Dietary Guidelines for Americans [Dietary Guidelines]
provides science-based advice to promote health and to reduce risk for
major chronic diseases through diet and physical activity. Major causes
of morbidity and mortality in the United States are related to poor
diet and a sedentary lifestyle. Some specific diseases linked to poor
diet and physical inactivity include cardiovascular disease, type 2
diabetes, hypertension, osteoporosis, and certain cancers. Furthermore,
poor diet and physical inactivity, resulting in an energy imbalance
(more calories consumed than expended), are the most important factors
contributing to the increase in overweight and obesity in this country.
Combined with physical activity, following a diet that does not provide
excess calories according to the recommendations in this document
should enhance the health of most individuals.
. . . .
The intent of the Dietary Guidelines is to summarize and
synthesize knowledge regarding individual nutrients and food components
into recommendations for a pattern of eating that can be adopted by the
public. In this publication, key recommendations are grouped under nine
inter-related focus areas. The recommendations are based on the
preponderance of scientific evidence for lowering risk of chronic
disease and promoting health. It is important to remember that these
are integrated messages that should be implemented as a whole. Taken
together, they encourage most Americans to eat fewer calories, be more
active, and make wiser food choices.
A basic premise of the Dietary Guidelines is that nutrient needs
should be met primarily through consuming foods. Foods provide an array
of nutrients and other compounds that may have beneficial effects on
health. In certain cases, fortified foods and dietary supplements may
be useful sources of one or more nutrients that otherwise might be
consumed in less than recommended amounts. However, dietary
supplements, while recommended in some cases, cannot replace a
healthful diet.
. . . .
Throughout most of this publication, examples use a 2,000-calorie
level as a reference for consistency with the Nutrition Facts Panel.
Although this level is used as a reference, recommended calorie intake
will differ for individuals based on age, gender, and activity level.
At each calorie level, individuals who eat nutrient-dense foods may be
able to meet their recommended nutrient intake without consuming their
full calorie allotment. The remaining calories -- the discretionary
calorie allowance -- allow individuals flexibility to consume some
foods and beverages that may contain added fats, added sugars and
alcohol.
. . . .
ADEQUATE NUTRIENTS WITHIN CALORIE NEEDS
Key Recommendations
Consume a variety of nutrient-dense foods and beverages within
and among the basic food groups while choosing foods that limit the
intake of saturated and trans fats, cholesterol, added sugars, salt,
and alcohol.
Meet recommended intakes within energy needs by adopting a
balanced eating pattern. . . .
Key Recommendations for Specific Population Groups
People over age 50.
Consume vitamin B12 in its crystalline form (i.e., fortified foods
or supplements).
Women of childbearing age who may become pregnant.
Eat foods high in heme-iron and/or consume iron-rich plant foods
or iron-fortified foods with an enhancer of iron absorption, such as
vitamin C-rich foods.
Women of childbearing age who may become pregnant and those in the
first trimester of pregnancy.
Consume adequate synthetic folic acid daily (from fortified foods
or supplements) in addition to food forms of folate from a varied diet.
Older adults, people with dark skin, and people exposed to insufficient
ultraviolet band radiation (i.e., sunlight).
Consume extra vitamin D from vitamin D-fortified foods and/or
supplements.
WEIGHT MANAGEMENT
Key Recommendations
To maintain body weight in a healthy range, balance calories from
foods and beverages with calories expended.
To prevent gradual weight gain over time, make small decreases in
food and beverage calories and increase physical activity.
Key Recommendations for Specific Population Groups
Those who need to lose weight.
Aim for a slow, steady weight loss by decreasing calorie intake
while maintaining an adequate nutrient intake and increasing physical
activity.
Overweight children.
Reduce the rate of body weight gain while allowing growth and
development. Consult a healthcare provider before placing a child on a
weight-reduction diet.
Pregnant women.
Ensure appropriate weight gain as specified by a healthcare
provider.
Breastfeeding women.
Moderate weight reduction is safe and does not compromise weight
gain of the nursing infant.
Overweight adults and overweight children with chronic diseases and/or
on medication.
Consult a healthcare provider about weight loss strategies prior
to starting a weight-reduction program to ensure appropriate management
of other health conditions.
PHYSICAL ACTIVITY
Key Recommendations
Engage in regular physical activity and reduce sedentary
activities to promote health, psychological well-being, and a healthy
body weight.
To reduce the risk of chronic disease in adulthood: Engage in at
least 30 minutes of moderate-intensity physical activity, above usual
activity, at work or home on most days of the week.
For most people, greater health benefits can be obtained by
engaging in physical activity of more vigorous intensity or longer
duration.
To help manage body weight and prevent gradual, unhealthy body
weight gain in adulthood: Engage in approximately 60 minutes of
moderate- to vigorous-intensity activity on most days of the week while
not exceeding calorie intake requirements.
To sustain weight loss in adulthood: Participate in at least 60
to 90 minutes of daily moderate-intensity physical activity while not
exceeding calorie intake requirements. Some people may need to consult
with a health care provider before participating in this level of
activity.
Achieve physical fitness by including cardiovascular
conditioning, stretching exercises for flexibility, and resistance
exercises or calisthenics for muscle strength and endurance.
Key Recommendations for Specific Population Groups
Children and adolescents.
Engage in at least 60 minutes of physical activity on most,
preferably all, days of the week.
Pregnant women.
In the absence of medical or obstetric complications, incorporate
30 minutes or more of moderate-intensity physical activity on most, if
not all, days of the week. Avoid activities with a high risk of falling
or abdominal trauma.
Breastfeeding women.
Be aware that neither acute nor regular exercise adversely
affects the mother's ability to successfully breastfeed.
Older adults.
Participate in regular physical activity to reduce functional
declines associated with aging and to achieve the other benefits of
physical activity identified for all adults.
FOOD GROUPS TO ENCOURAGE
Key Recommendations
Consume a sufficient amount of fruits and vegetables while
staying within energy needs. Two cups of fruit and 2 1/2 cups of
vegetables per day are recommended for a reference 2,000-calorie
intake, with higher or lower amounts depending on the calorie level.
Choose a variety of fruits and vegetables each day. In
particular, select from all five vegetable subgroups (dark green,
orange, legumes, starchy vegetables, and other vegetables) several
times a week.
Consume three or more ounce-equivalents of whole-grain products
per day, with the rest of the recommended grains coming from enriched
or whole-grain products. In general, at least half the grains should
come from whole grains.
Consume three cups per day of fat-free or low-fat milk or
equivalent milk products.
Key Recommendations for Specific Population Groups
Children and adolescents.
Consume whole-grain products often; at least half the grains
should be whole grains. Children two to eight years should consume two
cups per day of fat-free or low-fat milk or equivalent mile products.
Children nine years of age and older should consume three cups per day
of fat-free or low-fat milk or equivalent milk products.
FATS
Key Recommendations
Consume less than 10 percent of calories from saturated fatty
acids and less than 300 mg/day of cholesterol, and keep trans fatty
acid consumption as low as possible.
Keep total fat intake between 20 to 35 percent of calories, with
most fats coming from sources of polyunsaturated and monounsaturated
fatty acids, such as fish, nuts and vegetable oils.
Key Recommendations for Specific Population Groups
Children and adolescents.
Keep total fat intake between 30 to 35 percent of calories for
children 2 to 3 years of age and between 25 to 35 percent of calories
for children and adolescents 4 to 18 years of age, with most fats
coming from sources of polyunsaturated and monounsaturated fatty acids,
such as fish, nuts and vegetable oils.
CARBOHYDRATES
Key Recommendations
Choose fiber-rich fruits, vegetables, and whole grains often.
Choose and prepare foods and beverages with little added sugars
or caloric sweeteners. . . .
Reduce the incidence of dental caries by practicing good oral
hygiene and consuming sugar- and starch-containing foods and beverages
less frequently.
SODIUM AND POTASSIUM
Key Recommendations
Consume less than 2,300 mg (approximately) 1 tsp of salt) of
sodium per day.
Choose and prepare foods with little salt. At the same time,
consume potassium-rich foods, such as fruits and vegetables.
Key Recommendations for Specific Population Groups
Individuals with hypertension, blacks, and middle-aged and older
adults.
Aim to consume no more that 1,500 mg of sodium per day, and meet
the potassium recommendation (4,700 mg/day) with food.
ALCOHOLIC BEVERAGES
Key Recommendations
Those who choose to drink alcoholic beverages should do so
sensibly and in moderation -- defined as the consumption of up to one
drink per day for women and up to two drinks per day for men.
Alcoholic beverages should not be consumed by some individuals,
including those who cannot restrict their alcohol intake, women of
childbearing age who may become pregnant, pregnant and lactating women,
children and adolescents, individuals taking medications that can
interact with alcohol, and those with specific medical conditions.
Alcoholic beverages should be avoided by individuals engaging in
activities that require attention, skill or coordination, such as
driving or operating machinery.
FOOD SAFETY
Key Recommendations
To avoid microbial food borne illness:
Clean hands, food contact surfaces, and fruits and vegetables.
Meat and poultry should not be washed or rinsed. Separate raw,
cooked, and ready-to-eat foods while shopping, preparing or storing
foods.
Cook foods to a safe temperature to kill microorganisms.
Chill (refrigerate) perishable food promptly and defrost foods
properly.
Avoid raw (unpasteurized) milk or any products made from
unpasteurized milk, raw or partially cooked eggs, or foods containing
raw eggs, raw or undercooked meat and poultry, unpasteurized juices,
and raw sprouts.
Key Recommendations for Specific Population Groups
Infants and young children, pregnant women, older adults, and those who
are immunocompromised.
Do not eat or drink raw (unpasteurized) milk or any products made
from unpasteurized milk, raw or partially cooked eggs, or foods
containing raw eggs, raw or undercooked meat and poultry, raw or
undercooked fish or shellfish, unpasteurized juices, and raw sprouts.
Pregnant women, older adults and those who are immunocompromised.
Only eat certain deli meats and frankfurters that have been
reheated to steaming hot.
*
*
*