The Politics of Obesity: A Current Assessment and Look Ahead

Abstract

Context: The continuing rise in obesity rates across the United States has proved impervious to clinical treatment or public health exhortation, necessitating policy responses. Nearly a decade's worth of political debates may be hardening into an obesity issue regime, comprising established sets of cognitive frames, stakeholders, and policy options.

Methods: This article is a survey of reports on recently published studies.

Findings: Much of the political discussion regarding obesity is centered on two “frames,” personal-responsibility and environmental, yielding very different sets of policy responses. While policy efforts at the federal level have resulted in little action to date, state and/or local solutions such as calorie menu labeling and the expansion of regulations to reduce unhealthy foods at school may have more impact.

Conclusions: Obesity politics is evolving toward a relatively stable state of equilibrium, which could make comprehensive reforms to limit rising obesity rates less feasible. Therefore, to achieve meaningful change, rapid-response research identifying a set of promising reforms, combined with concerted lobbying action, will be necessary.

Obesity burst onto the U.S. national policy agenda in 2000/2001, initially fuelled by a widely disseminated set of maps by the Centers for Disease Control and Prevention (CDC) depicting sharply rising obesity rates nationwide, followed by the surgeon general's warning that obesity had become a “new national epidemic” (Mokdad et al. 2003; Oliver 2006; Satcher 2001). A snapshot of responses since then would include alarmed reactions from medical, media, and policy actors alike. The health establishment has rushed to devise medical treatments, from surgical to pharmaceutical, for obesity and its manifold health effects. Surging media attention to obesity and overweight features reports ranging from dire health alarms (“the current generation may be the first to live shorter lives than their parents—and obesity is to blame”; Belluck 2005, p. A1; see also Daniels 2006; Olshansky et al. 2005) to economic warnings (over $120 billion lost annually to obesity-related illnesses; see e.g., Bhattacharya and Sood 2006) to “lifestyle” stories of coffins, airplane seats, and hospital beds all made larger to suit the “supersizing of America” (St. John 2003, p. A13). Public officials at all levels have decried the “epidemic,” although statutory reforms have been concentrated in a few energetic local and state polities; the federal government has been noticeably slow to act. All the while obesity rates continue to rise, with thirty-seven states reporting significant year-to-year increases from 2007 to 2008, with none reporting a decrease (TFAH 2008).

This article explores obesity politics as it has evolved in recent years. First I discuss the sustained struggles over framing the topic now that public agendas have begun to solidify into an “issue regime” around obesity. Then I examine popular local and state policy options and review approaches that could have an impact on soaring obesity rates, along with an assessment of the likelihood of their widespread adoption. While promising policy approaches exist, the opportunity to take action may be closing fast. On most public health issues, policymaking features a bustle of activity followed by a period of quiescence as a regime coalesces—even when the underlying problems continue to mount. Antiobesity advocates who face declining interest from lawmakers will therefore need to devise creative ways to sustain a focus on this topic.

Obesity Politics: An Issue Regime Emerges

Urgent matters arising in the United States typically attract a dynamic, even chaotic, constellation of responses, with advocates and public officials variously offering opinions, lobbying legislators, and promoting solutions. Witness Washington's response to the financial meltdown during the latter months of 2008. Over time, such loose arrangements tend to harden into what some social scientists describe as an issue regime or policy regime (Kersh 2005; Orren and Skowronek 2004; Wilson 2000). Related scholarly work on issue networks and advocacy coalitions similarly describes the coalescence of new political agenda items into long-term stable power arrangements or, in common parlance, politics as usual (McFarland 2007). Three principal features characterize an issue regime's institutionalization: (1) swirling debates narrowing into a few primary frames, or basic descriptions of the issue that diffuse across jurisdictions; (2) the emergence of a relatively small group of stakeholders and public officials who dominate media coverage and legislative debates; and (3) legislative responses shrinking from dozens of options to a select handful. Issue regimes are an important source of political stability, especially at the national level, but they also can be a deterrent to innovative reforms. As policy historians have chronicled, on topics from environmental regulation to labor relations to medical malpractice reform, once an issue regime matures, it can be very difficult to alter the path of action (Banchoff 2005; Gonzalez 2001; Kersh 2005). Broad surveys of U.S. policymaking describe most issue realms as marked by “long periods of stasis interspersed with dramatic policy punctuations” (Jones, Sulkin, and Larsen 2003, p. 151).

Obesity politics remains novel enough at the time of this writing that a regime has not yet been established, but its constituent parts are already in view. Deliberation on the issue is organized primarily around two main argumentative frames, personal-responsibility and environmental. (According to one recent line of research reviewed later, however, a more nuanced if mostly latent public outlook could be aroused.) Legislative action is promoted by a specific cohort of lawmakers and interest-group allies, who have begun to narrow the range of potential solutions.

Familiar Voices

Over the past several years, a roster of established actors—from the food and beverage industries and affiliated lobbying organizations; a handful of public health and nutritional science advocates, led by the Obesity Society and the Center for Science in the Public Interest (CSPI); and a few larger medical-industry representatives, especially the American Diabetes Association, American Dietetic Association, and American Heart Association—have become the central interest-group players on obesity policy. A small group of policy-engaged academics, including Kelly Brownell, Marion Nestle, and Walter Willett, and public advocates like Michael Pollan and Eric Schlosser, also have been important contributors to debates on nutrition and obesity. Congressional action on this issue has been led by a small number of engaged figures, most notably Senator Tom Harkin (D-IA) and Representative Rosa DeLauro (D-CT). Former President Bill Clinton also has been a prominent, if sporadically engaged, voice and has committed a portion of his Clinton Global Initiative to antiobesity efforts in the United States and internationally.

An analysis of a large sample of media coverage of obesity politics since 2000 confirms this trend toward consolidation. Using national and regional newspapers, Capitol Hill news sources like the Congressional Quarterly and Roll Call, and nutrition and medical trade journals, I devised a measure of the national-politics network active on obesity policy, based on how often different groups and lawmakers were quoted or otherwise featured in the media's coverage. After expanding rapidly between 2000 and 2004 as the political salience of obesity spread, the network has consolidated—or, more accurately, coverage of the “players” involved has narrowed (Kersh 2009). This development signals the growing political expertise concerning a topic that was not widely viewed as a policy matter until the CDC maps and the surgeon general's report became national news. Democratic theorists also caution, however, that less deliberation and narrowed perspectives may accompany an issue's “professionalization” at the hands of the “political industry” (Loomis 2006; see also Bessette 1994).

Solidifying Frames

How issues are framed, or presented in public discussion, is important to which policy approaches are adopted as well as to whether a topic reaches the legislative agenda in the first place (Kingdon 1984). Over time, a host of competing perspectives tend to cohere around a few, or even just one or two, basic frames. The effect is to set boundaries around public debate and often to limit the number of feasible policy options. The following is a representative summary of the immense social science literature on this subject:

Actors who benefit from a given set of institutions and policies tend to rally around the status quo, reinforcing a path-dependent process …. They can also frame the terms of legislative debate by ruling in and out certain policy alternatives and generating rhetorical resources for defenders of incremental, as opposed to far reaching, policy change. (Banchoff 2005, pp. 201–2)

Two primary issue frames are evident in the debates about obesity politics (see, generally, Kersh and Morone 2005). The best-established and, until fairly recently, dominant frame is described in terms of personal responsibility, the view that avoiding unhealthy behaviors—in this case, overeating and/or consuming high-fat, low-nutrition foods—is primarily the concern of individual consumers. In a rights-based polity like the United States, personal-responsibility advocates claim, the first rule should be to protect freedom of choice, and little is more personal than the food choices we make. Obesity is hardly the first topic to be framed in this fashion: drinking, smoking, motorcycle helmet wearing, and many other practices have been defended in the language of individual rights (Goodin 1990). Accordingly, public health researchers have begun to explore the ethical and medical implications of personal-responsibility arguments (e.g., Guttman and Ressler 2001).

The “responsibility” perspective has had potent political effects. In a nation that has long viewed health as a proxy for success and even virtue, given the moral/religious cast so often coloring American political debates, the overweight individual's struggle with obesity is portrayed as a personal failure. Consequently, it can be difficult to mobilize even sympathetic people to combat an issue that is successfully portrayed as the afflicted's own fault. A personal-responsibility frame also points away from robust legislative solutions. Why should a polity premised on individual choice enlist government support for those unable to control their self-destructive appetites? It does not seem a coincidence that the legislation that made the most headway on Capitol Hill in recent years, a measure to forbid lawsuits against the food industry, was entitled the Personal Responsibility in Food Consumption Act (H.R. 554; 109th Cong., 1st sess.). Personal-responsibility advocates generally favor voluntary action by industry to address perceived problems. Policy solutions that arise from such arguments are typically “soft” measures like government-sanctioned nutrition education and exhortations to exercise.

A second, newer, frame for obesity issues has sprung from a different political ethic and gives rise to a more substantive collection of policy responses. Here the idea is that an unhealthy or obesogenic food environment at least partly encourages rising obesity rates. Expanding portion sizes; foods high in fat, sugar (or artificial sweeteners like corn syrup), and sodium; the ubiquitous availability of food at outlets ranging from gas stations and drug stores to bank lobbies and elementary schools; and the incessant advertising of high-fat, low-nutrition foods all combine to create what obesity/nutrition experts have termed a “toxic” food environment (Brownell and Horgen 2004). In contrast to the responsibility frame's portrait of freely choosing consumers, environmental accounts emphasize induced demand.

This obesogenic-environment view was once confined to a relative handful of antiobesity advocates and academic observers and had little traction among the wider public. One effect of the surgeon general's “Call to Action” and the CDC maps seems to have been a popularization of this alternative frame (Oliver 2006). Empirical measures of obesity framing have shown that by 2003, news coverage citing environmental claims had gained dramatically on personal-responsibility arguments (Lambert et al. 2007). Moreover, a 2004 study concluded that such views “do not merely appear in the margins of the news but have become regular themes of news stories” (Lawrence 2004, p. 69). Today, environmental frames turn up routinely, including in places unrelated to nutrition/obesity or even public health. One of many examples appeared in a management study otherwise concerned with “industry trade reputations,” whose author constructed a formal model that could “offer insights into how the fast food industry should deal collectively with rising levels of obesity in Western society caused in part by their own products” (Tucker 2008, p. 11). Such stray observations signal the establishment of a robust environmental frame alongside the older personal-responsibility account.

Attention to the once esoteric (or, at least, academic) concept of issue framing has spread into the policy realm as well. Food companies consciously devote effort to “framing management” (Darmon, Fitzpatrick, and Bronstein 2008), and advocacy groups offer talking points to counter personal-responsibility messages. One organization is urging its affiliates to recognize that “reframing and message development need to be connected with community organizing, constituency building, and detailed knowledge about policy development and the political process” and notes that “the field needs more research on the best way to reframe obesity” (Strategic Alliance 2006, p. 3).

Another article in this issue of The Milbank Quarterly, by a group of Yale colleagues, explores obesity policy frames in fine-grained detail, concluding that the American public is capable of considerably more nuanced understanding on this issue than these two broad frames allow (Barry et al. 2009). Their survey research suggests that substantial, partly overlapping, segments of the population hold several other perspectives, such as “food addiction,” “time crunch” (consumers too busy to prepare and eat healthier meals), and obesity as an inherited condition or disease. Some promising legislative options for addressing specific aspects of the rising rate of obesity, the authors speculate, could be advanced by carefully targeted framing messages and thereby win widespread public approval. The continued reinforcement of the two primary existing frames could foreclose such an approach, however. Media research suggests that the coverage of obesity policy is solidifying into contrasting environmental and individual-choice perspectives (Lambert et al. 2007; see also Finegood, Karanfil, and Matteson 2008), which is closing off opportunities to advance additional views, even those in evidence among the public. This narrowing of frames is a fundamental feature of issue regimes.

Limited National Policy Options

The U.S. government's responses to spiraling obesity rates are increasingly focusing on a few policy proposals, which reflect the dominant personal-responsibility and environmental frames. A wider assortment of frames are still evident at the state and local levels, as explored later in this article, and public officials around the globe have adopted a number of antiobesity efforts, including restrictions on junk-food advertising to children and taxes on unhealthful food products. Politics is famously the art of the possible, however, and America's national elective branches—Congress and the presidency—have not, to date, passed any significant reforms.

As noted earlier, responsibility advocates generally oppose regulatory responses to the spread of obesity, instead recommending nutrition education, encouraging exercise, and asking the food and beverage industry to promote healthy practices voluntarily. Such solutions date back decades and have been extensively evaluated. Most of the scientific evidence shows that nutrition lessons, exercise exhortations, and industry self-regulation have not slowed the rise of obesity. In regard to education, for example, a 2007 review of nearly sixty separate research studies found that only 7 percent of obesity-education programs had made an appreciable difference in schoolchildren's eating habits or body mass index (BMI) (Mendoza 2007). Whatever researchers might conclude, most Republican bills introduced on Capitol Hill since 2001, including one by then Senate Majority Leader William Frist, focused on exercise and education—along, again, with efforts to immunize the food industry against consumer-injury lawsuits. Executive-branch officials in the Bush administration similarly adhered primarily to “responsibility” messages on obesity issues, which have not yielded any substantial efforts at policy change. This approach is not unique to U.S. policymaking. Interviews with leading stakeholders in Spain, for example, also revealed a responsibility-influenced public dialogue focused on nutrition education and exercise promotion (González-Zapata, Ortiz-Moncada, and Alvarez-Dardet 2007).

More ambitious policy solutions stem from environmental frames. When the public sphere has been demonstrably affected by private action, the usual result is government intervention to protect vulnerable citizens, in this case especially children, whose “personal choices” regarding consumption are powerfully influenced by industry advertising (Daniels 2006). Various regulatory strategies have flowed from an environmental perspective, such as subsidizing healthy foods; restricting marketing and/or advertising; limiting sales of unhealthful foods; offering economic incentives like taxes on junk foods, which were adopted in several U.S. states and cities before successful food-industry lobbying reversed nearly all of them (Brownell and Horgen 2004); and federal litigation targeting producers of foods deemed dangerous to consumers' health. Democrats in Congress, especially Senator Harkin and Representative DeLauro, and some state and urban legislatures have promoted measures along such active-regulatory lines.

To date, these stronger environmental measures have won little support on Capitol Hill. In a national policymaking system rich with veto points and avenues of opposition, steering a proposal to approval is exceedingly difficult, even though the urgency voiced by surgeons general and other public officials about rising obesity rates may have raised expectations for legislative success. Concluded one policy-savvy observer after surveying Senate and House action on the topic: “Congress isn't likely to pass any measure that would result in lower obesity or overweight rates next year or even 10 years from now” (Smith 2006, p. 1353). Despite a stepped-up schedule of hearings and the opportunity for reforms presented by reauthorization of the Farm Bill, the Democratic-controlled 110th Congress was no more successful in moving legislation to address obesity than were its Republican predecessors. No measure—including a House resolution that would require no statutory action but merely declare the House's intent to “address complicated obesity issues” (H. Res. 1244; 110th Cong., 2d sess.)—even made it to a floor vote in either chamber.

Absent strong leadership from the executive branch, this stalemate could itself become a characteristic of an emerging obesity regime. It is, of course, difficult to extrapolate from an eight-year period featuring Republican control of the executive branch and, until 2007, Congress. But a trend away from elective-branch action is notable in many other public health arenas, such as HMO regulation and medical malpractice (Kersh and Morone 2005). Even the sweeping Master Settlement Agreement on tobacco was not initiated or achieved by Congress or the Clinton administration but was the result of legal action and, ultimately, an agreement among state attorneys general and the tobacco companies (Schroeder 2004). Advocates frustrated by the lack of activity on obesity have begun turning to the judicial system to fill this policymaking void (Mello, Studdert, and Brennan 2006).

Although issue regimes shape and guide policy action, they are not iron-clad influences. Changes within consistency are evident among other regimes, at opportune if only occasional moments: studies of “punctuated equilibrium,” a metaphor borrowed from species evolution, indicate how rare major policy shifts can be once an issue regime has achieved a steady state (Baumgartner and Jones 1993). The still-formative nature of obesity politics suggests that breakthroughs, both legislative and those that attract new lawmakers and interest groups to the issue, are possible. While action by the federal government has been minimal, some state and local jurisdictions have been more successful in adopting policies designed to slow the rise in obesity rates.

State and Local Policy Responses

Canvassing the extensive array of state and local policy approaches is beyond the scope of this article. Indeed, just on the topic of childhood obesity, the National Conference of State Legislatures lists more than fifty legislative measures that were introduced in at least one U.S. state in 2007 alone (NCSL 2008). Two innovations in particular are now, however, attracting attention from coast to coast, as well as from Congress: listing calories on menus and mandating healthier options in primary and secondary schools.

Calorie Menu Labeling

As of autumn 2008, six bills to mandate calorie labeling in chain restaurants had become law: in three large cities (New York, San Francisco, and Philadelphia), two West Coast counties (Santa Clara County, California, and Kings County, Washington), and the state of California. Twenty-seven states, plus Puerto Rico, are currently considering labeling laws (NCSL 2008), and similar legislation has also been introduced in Congress. Menu labeling represents a triumph of sorts for adherents to the “environmental” frame, since personal-responsibility advocates initially opposed any labeling and then later called for voluntary action by industry (McCann 2005).

While the proposed regulatory details differ, most state and city labeling bills require restaurants with more than a specified number of locations (ranging from five to twenty) or in a defined area (city, state, or even the entire United States) to post the caloric content of all regular menu items, in a prominent place and using the same font and format as the price. Philadelphia's law specifies that printed menus must list sodium, carbohydrate, trans fat, and saturated fat content as well. Public health advocates argue that calorie labels on menu boards will help consumers make healthier food choices (CSPI 2003).

New York City became the first location to successfully implement this legislation, in July 2008 (NYC DOHMH 2008). Mainstream media outlets in New York, as elsewhere, have mostly celebrated the results: two months after labeling was inaugurated, a New York Times story observed, “The resulting sticker shock has brought parts of a great city to its knees, often to do push-ups” (Severson 2008, p. D1). Questions remain about the effects in practice, however: whether consumers see or understand labeling information (Krukowski et al. 2006) and whether, once absorbed, the information makes any difference in their consumption practices. A study by New York City's health department surveyed Subway customers after that chain inaugurated menu labeling. Customers who reported seeing calorie labels purchased items containing an average of forty-eight fewer calories than those who did not see the information. Similarly, patrons who said that calorie information had affected their menu selection chose items with ninety-two fewer calories (NYC DOHMH 2008; see also Savage and Johnson 2006).

A national labeling law, which closely resembled the state and city legislation, was first introduced in both chambers of Congress in 2004 by Senator Harkin and Representative DeLauro. By the time of the 110th Congress's 2007/2008 sessions, based on an analysis of news coverage and time spent on committee hearings, calorie labeling had become the most prominent antiobesity legislation considered on Capitol Hill (Kersh 2009). The strong Harkin–DeLauro regulatory measure, termed the Menu Education and Labeling (MEAL) Act (S. 2784 and H.R. 3895; 110th Cong., 1st sess.), was joined in 2008 by a bill promoted by the food and beverage industry: the Labeling Education and Nutrition (LEAN) Act (H.R. 7187 and S. 3575; 110th Cong., 2nd sess.). Public health groups generally rate the MEAL legislation as considerably more likely than the LEAN measure to affect obesity rates (Severson 2008).

Further research on labeling will help determine whether longer-range health effects are positive, as when restaurant chains reduce portion sizes to cut calorie counts or substitute lower- for high-calorie food items; neutral, if ignored by consumers; or perhaps even negative, if they contribute to body-image concerns. (At least one jurisdiction that adopted a version of labeling—Harvard University, in its cafeterias on campus—later removed calorie information in response to concern about potential deleterious effects on students with eating disorders and body-image issues; see Hu 2008.) Experimental and empirical studies are under way to assess the effects of labeling, such as whether combining labeling with a public campaign about the FDA's recommended consumption level of two thousand calories per day has a stronger effect than labeling alone (Roberto et al. 2009).

Calorie labeling may well have a political impact, regardless of its effect on individual diets. Because a highly visible public controversy like the labeling battle raises the salience of obesity as a policy concern (Kersh and Morone 2005; see also Neuhouser 1999), it can help establish a precedent for official action by health commissioners or other city/state officials.

School Policies

Given the powerful health effects of obesity on children—and the rapidity of obesity's spread among children in the United States (Daniels 2006; Ludwig 2007)—a major state and local policy push has involved approaches to reduce obesity rates among school-age Americans. A “responsibility” frame suggests that policies should be limited to nutrition education for children and parents, along with the promotion of exercise. In contrast, environmental proposals in this arena range from banning junk-food advertising on children's television programs to litigation targeting producers that market low-nutrition snacks specifically to children.

Of the policies to date on this stronger regulatory roster, those that have achieved most widespread (if patchwork, given their local orientation) adoption are improved dietary practices in schools. Nearly 600 school districts across the United States have instituted some form of limits on sugar, fat, and/or sodium consumption in school cafeterias, and former President Clinton brokered a deal between soft drink companies and national education organizations in 2006 that resulted in voluntary bans on carbonated beverages in school vending machines (Zhu and Meier 2008; see also Seiders and Petty 2007).

As with calorie labeling, these efforts to address school nutrition are still in early stages of evaluation. But most such programs have been judged far more beneficial than nutrition education alone. One representative study assessed the two-year, multicomponent School Nutrition Policy Initiative (SNPI) in Pennsylvania, designed to reduce overweight and obesity among fourth through sixth graders in lower socioeconomic areas. The interventions included removing all sodas, sweetened drinks, and unhealthy snack foods from selected schools, “social marketing” to encourage the consumption of nutritious foods, and outreach to parents. Children in the SNPI initiative exhibited a 50 percent drop in incidence of obesity and overweight, compared with classmates who were not enrolled (Foster et al. 2008). Surveys of other such comprehensive programs show similarly encouraging results (Foster et al. 2008; Story, Kaphingst, and French 2006; Story, Nanney, and Schwartz 2009).

Can obesity rates be systematically addressed through school-level reforms? Perhaps these local “laboratories of democracy” can, district by district, stitch together a quilt of programs capable of reducing youth obesity nationwide over time. But a recent report by the Center for Science in the Public Interest graded all fifty states on their school nutrition policies and suggests that this goal may be far away, as the average grade was a D+ (Levine and Aratini 2008). The authors of the SNPI study also concluded that “stronger or additional interventions are needed” (Foster et al. 2008, p. e800; italics in original). Most of these interventions were in-school diet practices, and Foster and colleagues recommended “more aggressive nutrition policies,” without specification.

Analyses of school-based and other local or statewide reforms frequently conclude with a call for national action. As Senator Thomas Carper (D-DE) told his colleagues, “As a former governor, I know there are issues that can and should be handled at the state and local level, but healthy nutrition and obesity are national issues that cry for a national solution” (Congressional Record, September 25, 2008, S. 9483, italics in original). Although the U.S. national government has not passed significant reforms designed to reduce obesity rates, some promising approaches are on the horizon.

Looking Ahead: Promising Approaches

Policy answers to rising obesity rates have proliferated in the last few years (see, e.g., Nestle and Jacobson 2000). Most of these are wish lists, reflecting the authors' proclivities rather than empirically grounded evidence for a policy's practical benefits. The best proposals seek to measure solutions' potential impact or, less often, the likelihood that they could actually be adopted by Congress or a state/local legislature. A recent study looked at both these “impact” and “feasibility” dimensions, separately surveying groups of nutrition experts and policy professionals about a long list of popular antiobesity options, most of which targeted the spread of obesity among children and adolescents. Each item was also separately rated by the two groups (nutrition scientists on impact, policy officials on feasibility). The authors combined and classified these experts' responses, clustering the policies into cells: high impact/high feasibility, high impact/low feasibility, and so on through four quadrants (Brescoll, Kersh, and Brownell 2008).

Next I review two of those policy options in the most desirable quadrant (high impact/high feasibility). On one level, this pair constitutes still another wish list. Given the independent “impact/feasibility” judgments, however, there is some reason to conclude that these policies could make a significant difference. Moreover, since they were viewed positively by both nutrition scientists and policy experts, these approaches might be able to reshape the calcifying policy regime around obesity. For these reasons they deserve to be taken seriously by public health advocates.

Foods of Minimal Nutritional Value (FMNV)

In the 1960s and 1970s, during an earlier episode of national attention to food politics, Congress directed the U.S. secretary of agriculture to draw up a list of “foods of minimal nutritional value” (FMNV) judged unfit for children's consumption in public school cafeterias. (Nutrition scientists also call FMNV competitive foods, since they compete with healthier alternatives for children's caloric consumption.) After an intense political debate—including several rounds of legal challenges—lasting nearly a decade following the secretary's proposed rule, the FMNV list was reduced to four categories: soft drinks, water ices, chewing gum, and “certain candies.” This small set of prohibited items has remained unchanged since the list was promulgated in 1980 (Fleischhacker 2007; Stallings and Yaktine 2007).

With the covering legislation still in force, there is no statutory reason that the list could not be altered—perhaps even without any further affirmative action by Congress; the law is ambiguous on that point—to include additional high-fat/calorie, low-nutrition foods and beverages. Stronger still would be accompanying language prohibiting FMNV foods to be sold elsewhere on school grounds, as the old cafeteria-based restrictions were promulgated before the spread of soft-drink vending machines, fast-food chains, and other sources of “competitive foods.” Bills to revisit the outmoded FMNV list and to expand its coverage beyond the cafeteria were introduced in the past two sessions of Congress by Senator Harkin, with no action to date. Harkin's bill would also shift jurisdiction for defining “minimal nutrition” foods from the U.S. Department of Agriculture to the Food and Drug Administration (FDA).

Reformulation

One little-publicized move by a number of food producers, as “obesity epidemic” warnings have spread, has been the dietary reformulation of their products to reduce nutritional harm. The removal or reduction of saturated fat, salt, sugars, and unhealthful additives is aimed to diminish the incidence of obesity and associated illnesses, especially diabetes and heart disease. Although the health-promoting benefits of reformulation are not in question, food companies typically cite as barriers their cost and complexity rather than the lack of nutritional-scientific evidence for their benefits. Processed foods and beverages can, of course, be “reformulated” in numerous ways, such as adding caffeine. But as used here and by nutrition advocates, reformulation is the removal or reduction of ingredients that have been linked to rising obesity rates.

Reformulation efforts have mostly escaped media attention in the United States, and scholarly studies of reformulation are only just emerging. One study by a consulting firm, Insight Investment, reviewed the food industry's “best practices” in this area and found the reformulation approach to be promising but not systematically pursued. But one company, Unilever, received high marks for reviewing some 27,000 of its food items, specifically in the name of “fighting obesity.” Overall, this study found, European governments have been much more active than any U.S. jurisdiction in encouraging—though not, to date, mandating—reformulation efforts (Insight Investment 2008).

The Insight report critiqued U.S. companies for their ad hoc reformulation, removing smaller quantities of fats or sugars almost willy-nilly, without a thorough review of their food products. Such a conclusion points to the difficulty of casting reformulation as a purely voluntary proposition carried out by industry without oversight. The report concluded: “All companies do a bad job of reporting on the progress they have made in reformulating their products (and the impact that has had on their businesses) and indeed on their whole health and wellness programmes” (Insight Investment 2008, p. 6).

Government can assist in this reformulation effort in at least two ways. First, officials may influence the industry through a moral-suasion campaign, encouraging and then publicly rewarding companies that engage in systematic programs of reformulation for healthy alternatives. The FDA subsequently could conduct testing programs to ensure that healthful changes have actually been made. (Reformulating to eliminate certain ingredients, like saturated fat, while simultaneously adding sugar or salt does not improve overall nutritional content.) There is at least limited evidence that food and beverage companies may view such promotion in a positive light. Three PepsiCo officials recently published a defense of reformulation in an academic journal and called for “corporate and public sector partners” in their effort (Yach, Lucio, and Barroso 2007, p. 12).

A second potentially beneficial government action involves the capital expense that can accompany reformulation, which often requires new machinery or revised production and processing practices. Creating a low-interest federal loan program, or tax incentives, for legitimate reformulation efforts could further encourage companies to make nutritionally beneficial changes.

A potential danger with reformulation deserves mention as well: food safety risks. As one medical analysis noted, “Reformulation inevitably changes the intrinsic physico-chemical properties of the food, which may in turn support the growth of food-borne pathogens and ultimately their ability to cause disease” (Sleator and Hill 2007, p. 1323). Although to date the evidence is sparse, connecting microbiological food safety research with product reformulation would seem to be a necessary step if policymakers are to promote this process.

Neither encouraging voluntary industry reformulation nor expanding existing FMNV rules would require elaborate new regulatory legislation, which has proved to be almost impossible to pass in regard to obesity. Both policies also fit within existing obesity-politics boundaries, as they have the advantage of straddling the “responsibility” and “environment” frames. And each holds out promise of real impact on obesity rates.

Conclusion

Despite intense public attention and alarm, the continuing rise in U.S. obesity rates has thus far proved to be impervious to medical treatment or calls for sensible dietary practices and increased exercise. Policy responses, if only by default, seem essential. Yet a comprehensive national legislative program to address obesity, especially as an issue regime appears to be hardening around the topic, may remain difficult to achieve. Incremental approaches are the usual governmental response when sweeping reforms appear elusive (Baumgartner and Jones 1993), but no single innovation appears effective in addressing obesity's nationwide (and, increasingly, global) advance. As researcher Kelly Brownell affirmed, “the social, economic and political factors contributing to these problems are stampeding forces that will thwart single, easily concocted solutions” (Brownell 2007). At a minimum, a package of well-tested reforms would appear to be in order.

How can we best separate the more promising from the less helpful policy approaches to obesity's spread? Even though it is not common in most academic fields, a program of “rapid-response” research can be a valuable tool. Swift but thorough impact assessments are needed of policies that gain legislative favor, as calorie menu labeling and school nutrition reforms have done of late. “It's too complicated … there's insufficient scientific proof” is a familiar shibboleth of opponents of legislative reform, but also a legitimate concern, as policies that manage to win political support may be rolled out without scholarly review. Institutional funders like the Robert Wood Johnson Foundation have signaled their willingness to support fast-responding research (RWJF 2008), which should help policy entrepreneurs catch up to the thorny problems they are chasing.

Advances in genomic science also are important to beneficial change in this realm. As knowledge of the genetic component of obesity increases, researchers will be better able to devise policies that do not punitively stigmatize the obese in a population and, simultaneously, to respond to arguments by foes of policy action about the genetic basis of “most” obese individuals (see Bouchard 2007). Combining this awareness with swift testing—both empirical and/or experimental—of promising policy options like FMNV reform, calorie labeling (especially combined with the two thousand calorie daily-intake reminders), and reformulation, the outlines of a feasible program to alleviate rising obesity rates come into view.

Issue regimes are sustained across time in relatively consistent form until bursts of political change, often cutting across multiple policy realms, offer opportunities for transformation. These episodes of punctuated equilibrium are still only partly understood and not yet susceptible to prediction, although policy scientists are advancing in this direction (e.g., Robinson et al. 2007). As one such moment of systemic change occurs, or when a regime is still in its formative stages, skillful policy entrepreneurs can promote enduring reforms. Having a clear plan of action—a package of reforms, along with a strategy for advancing them—is essential to taking advantage of such “policy windows” when they open (Kingdon 1984).

Such decisive moves depend on successful political advocacy. Throughout U.S. history, strong policy responses to public-health crises ultimately have been achieved through sustained interest-group action (Kersh and Morone 2002). A combination of rapid-response research on promising policies and an astute lobbying campaign, sensitive to the evolving politics and science of obesity, could transform what appears to be a presently consolidating issue regime into a force for meaningful policy change.