Healthy reform, healthy cities: using law and policy to reduce obesity rates in underserved communities.

AuthorFry, Christine
PositionIntroduction through II. Using Law and Policy to End the Obesity Epidemic C. State and Local Policy to Address Obesity, p. 1265-1293

Introduction I. The Obesity Epidemic and Social Determinants of Health A. Rising Obesity Rates B. How the Social Determinants of Health Drive Obesity Disparities II. Using Law and Policy to End the Obesity Epidemic A. The Power to Regulate Public Health B. How the Affordable Care Act Supports Community-Based Obesity Prevention Strategies 1. The Affordable Care Act Establishes a National Prevention Strategy . 2. The Affordable Care Act Creates a Prevention and Public Health Fund 3. The Affordable Care Act Strengthens the Community Benefit Requirements for Nonprofit Hospitals C. State and Local Policy to Address Obesity . 1. Addressing Disparities Through Obesity Prevention Policy III. A Policy Framework for Addressing Disparities in Obesity Rates A. Evidence for Policymaking B. The Framework . 1. General or Universal Policies 2. Policies Based on Demographic Groups a. Policymaking Based on Race or Ethnicity . b. Policymaking Based on Income 3. Policies Based on Health Indicators or Unhealthy Products and Practices a. Policies Based on Health Indicators b. Policies Targeted at Practices and Products that Cause Negative Health Conditions 4. Policymaking Based on Neighborhood a. Policies that Encourage Integration C. Unintended Consequences Conclusion INTRODUCTION

South Los Angeles is a low-income African-American and Latino neighborhood with disproportionately high obesity rates--35% of the adult population is obese, compared to 22% in Los Angeles County as a whole. (1) South Los Angeles was once a thriving middle class African-American neighborhood, but it became impoverished when, as in many cities, jobs and higher-income residents left the urban core. (2) Fast food restaurants were abundant, yet residents had no access to a grocery store. (3) In 2008, residents decided to change that by pushing the Los Angeles city council to place a moratorium on new fast food restaurants in the neighborhood, while also offering a package of incentives to attract a new grocery store. (4) The incentive package successfully attracted at least four grocery store developments to the neighborhood. (5) The targeted strategy was considered controversial by some because it focused on an African American and Latino neighborhood and was perceived by outsiders as paternalistic. (6) But what many didn't realize is that neighborhood groups supported the fast food restrictions. (7)

The South Los Angeles example illustrates the challenges urban communities across the United States face. Obesity is one of many chronic conditions that people of color experience disproportionately, putting them at greater risk for many serious preventable diseases such as diabetes, heart disease and cancer. (8) In this Article, we focus on the national obesity epidemic and discuss ways to use policy interventions, such as those that improved access to healthy food in South Los Angeles, to reduce disparities experienced by underserved communities and specific racial and ethnic groups.

We start with an overview of the obesity epidemic and its underlying causes--the social determinants of health. Next, we review the role of government in ending the obesity epidemic, including a discussion of Affordable Care Act (ACA) provisions that support population-level interventions to address the epidemic. Enterprising local and state governments have been leading the way on obesity prevention for a decade. A number of provisions within the ACA, however, provide an unprecedented opportunity to "scale up" obesity prevention activities. The ACA specifically calls on policymakers in states and localities to identify strategies to reduce obesity rates among populations bearing the brunt of the epidemic, namely people of color and low-income people. Finally, we propose a framework for developing disparities-focused obesity prevention policies. Policymakers at all levels of government can use this tool to help them decide how to allocate their limited resources to policies that directly address disparities in obesity rates. This framework is intended to support communities and states that will be heeding the federal government's call to action on obesity and health disparities.

  1. THE OBESITY EPIDEMIC AND SOCIAL DETERMINANTS OF HEALTH

    Social and environmental factors, such as the proliferation of fast food restaurants or lack of safe sidewalks for walking, are different in different communities; these disparate conditions lead to worse health outcomes for people of color and people with low incomes. (9) In this section, we provide an overview of the obesity epidemic in the United States and how social and environmental factors increase the risk for obesity and related chronic diseases.

    1. Rising Obesity Rates

      Since the late 1970s, adult obesity rates (10) have more than doubled, (11) while the rates for children and adolescents have tripled in the same time period. (12) Currently, 17% of children and adolescents in the nation are obese, a proportion that has risen significantly since the 1980s. (13) Approximately 36% of adult men and women in the U.S. are obese, representing a significant increase in a twelve-year period for men, but not women. (14) Although adult obesity rates are still rising, the rate of increase is not as rapid as in previous decades. (15)

      Obesity is a national concern because it is a risk factor for cancer, diabetes, and a host of other debilitating and potentially deadly diseases. (16) Obese children are more likely to have asthma, diabetes, joint problems, and even early signs of heart disease. (17) They are also more likely to be obese adults. (18) Obesity puts adults at greater risk for an even longer list of diseases and conditions, including cancer, liver disease, and stroke. (19) Obese children are teased and bullied and, as a result, experience anxiety, depression, and many other mental health problems. (20) Obese adults are less likely to be hired and promoted and make less money than their healthy weight peers. (21) Treatment of obesity and related diseases costs the United States healthcare system an estimated $147 billion annually, which translates to approximately $1,400 in additional spending per obese person compared to people with healthy weights. (22) Obesity costs employers over $30 billion annually in lost productivity. (23)

      Some groups bear a greater burden of obesity than others. The most striking obesity disparities are those between whites, African Americans, and Latinos. Twenty-one percent of Latino children and adolescents and 24% of African-American children and adolescents are obese, while only 14% of white children are obese. (24) Disparities also exist for adults, with 50% of African Americans and 38% of Latinos being obese, compared to 35% of whites. (25) Variation in obesity rates across incomes is more complex. (26) With some exceptions, obesity rates generally decline as income increases for both adults and children. (27) Some studies, however, have found that obesity rates rise with income for African American and Latino men, which may reflect different body size norms for men or a greater likelihood that lower-income men have physically-demanding jobs. (28)

    2. How the Social Determinants of Health Drive Obesity Disparities

      Why have obesity rates increased so dramatically in the past several decades, and why do they vary among different racial and economic groups? Social and environmental conditions, ranging from income to race to air quality and more, are considered to be the main factors determining health outcomes. (29) These factors are known as the social determinants of health. (30) This concept has existed in global health circles for decades, (31) but has only recently been applied systematically in the United States. (32)

      The emphasis on social determinants of health in obesity prevention stems from a growing body of research linking socioeconomic status, race, and ethnicity to obesity...

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