Obesity Politics/Policy

Walking, Obesity and Urban Design in Chinese Neighborhoods

Walking, Obesity and Urban Design in Chinese Neighborhoods
Preventive Medicine, Vol. 39, supp., pp. S799-S85

Alfonzo, M., Z. Guo, L. Lin, and K. Day

Objective: We examined the connections (1) between the design of the built environment and walking, (2) between the design of the built environment and obesity, and (3) between walking and obesity and income in urban settings in China. 

Methods: Six neighborhoods with different built environment characteristics, located in the Chinese cities of Shanghai and Hangzhou, were studied. Data on walking and other physical activity and obesity levels from 1070 residents were collected through a street intercept survey conducted in 2013. Built environment features of 527 street segments were documented using the Irvine–Minnesota Inventory-China (IMI-C) environmental audit. Data were analyzed using the State of Place™ Index. 

Results: Walking rates, household income and Body Mass Index (BMI) were related; neighborhoods with a higher State of Place™ Index were associated with higher rates of walking. 

Conclusion: This study began to establish an evidence base for the association of built environment features with walking in the context of Chinese urban design. Findings confirmed that the associations between “walkable” built environment features and walking established in existing research in other countries, also held true in the case of Chinese neighborhoods.

Application of global positioning system methods for the study of obesity and hypertension risk among low-income housing residents in New York City: a spatial feasibility study

Application of global positioning system methods for the study of obesity and hypertension risk among low-income housing residents in New York City: a spatial feasibility study
Geospatial Health, Vol. 9, no. 1, pp. 57-70. DOI: http://dx.doi.org/10.4081/gh.2014.6

Duncan, D.T., S.D. Regan, D. Shelley, K. Day, R.R. Ruff, M. Al-Bayan, and B. Elbel

The purpose of this study was to evaluate the feasibility of using global positioning system (GPS) methods to understand the spatial context of obesity and hypertension risk among a sample of low-income housing residents in New York City (n = 120). GPS feasibility among participants was measured with a pre- and post-survey as well as adherence to a protocol which included returning the GPS device as well as objective data analysed from the GPS devices. We also conducted qualitative interviews with 21 of the participants. Most of the sample was overweight (26.7%) or obese (40.0%). Almost one-third (30.8%) was pre-hypertensive and 39.2% was hypertensive. Participants reported high ratings of GPS acceptability, ease of use and low levels of wear-related concerns in addition to few concerns related to safety, loss or appearance, which were maintained after the baseline GPS feasibility data collection. Results show that GPS feasibility increased over time. The overall GPS return rate was 95.6%. Out of the total of 114 participants with GPS, 112 (98.2%) delivered at least one hour of GPS data for one day and 84 (73.7%) delivered at least one hour on 7 or more days. The qualitative interviews indicated that overall, participants enjoyed wearing the GPS devices, that they were easy to use and charge and that they generally forgot about the GPS device when wearing it daily. Findings demonstrate that GPS devices may be used in spatial epidemiology research in low-income and potentially other key vulnerable populations to understand geospatial determinants of obesity, hypertension and other diseases that these populations disproportionately experience.

Promotion of Healthy Eating through Public Policy: A Controlled Experiment

Promotion of Healthy Eating through Public Policy: A Controlled Experiment
American Journal of Preventative Medicine. 2013; 45(1): 49-55. http://dx.doi.org/10.1016/j.amepre.2013.02.023

Elbel B, Taksler G, Mijanovich T, Abrams C, Dixon LB

To induce consumers to purchase healthier foods and beverages, some policymakers have suggested special taxes or labels on unhealthy products. The potential of such policies is unknown.

In a controlled field experiment, researchers tested whether consumers were more likely to purchase healthy products under such policies.

From October to December 2011, researchers opened a store at a large hospital that sold a variety of healthier and less-healthy foods and beverages. Purchases (N=3680) were analyzed under five conditions: a baseline with no special labeling or taxation, a 30% tax, highlighting the phrase “less healthy” on the price tag, and combinations of taxation and labeling. Purchases were analyzed in January–July 2012, at the single-item and transaction levels.

There was no significant difference between the various taxation conditions. Consumers were 11 percentage points more likely to purchase a healthier item under a 30% tax (95% CI=7%, 16%, p<0.001) and 6 percentage points more likely under labeling (95% CI=0%, 12%, p=0.04). By product type, consumers switched away from the purchase of less-healthy food under taxation (9 percentage point decrease, p<0.001) and into healthier beverages (6 percentage point increase, p=0.001); there were no effects for labeling. Conditions were associated with the purchase of 11–14 fewer calories (9%–11% in relative terms) and 2 fewer grams of sugar. Results remained significant controlling for all items purchased in a single transaction.

Taxation may induce consumers to purchase healthier foods and beverages. However, it is unclear whether the 15%–20% tax rates proposed in public policy discussions would be more effective than labeling products as less healthy.

Calorie Labeling, Fast Food Purchasing and Restaurant Visits

Calorie Labeling, Fast Food Purchasing and Restaurant Visits
Obesity, 21: 2172–2179. doi: 10.1002/oby.20550

Elbel, B., Mijanovich, T., Dixon, L. B., Abrams, C., Weitzman, B., Kersh, R., Auchincloss, A. H. and Ogedegbe, G.

Obesity is a pressing public health problem without proven population-wide solutions. Researchers sought to determine whether a city-mandated policy requiring calorie labeling at fast food restaurants was associated with consumer awareness of labels, calories purchased and fast food restaurant visits.

Design and Methods
Difference-in-differences design, with data collected from consumers outside fast food restaurants and via a random digit dial telephone survey, before (December 2009) and after (June 2010) labeling in Philadelphia (which implemented mandatory labeling) and Baltimore (matched comparison city). Measures included: self-reported use of calorie information, calories purchased determined via fast food receipts, and self-reported weekly fast-food visits.

The consumer sample was predominantly Black (71%), and high school educated (62%). Postlabeling, 38% of Philadelphia consumers noticed the calorie labels for a 33% point (P < 0.001) increase relative to Baltimore. Calories purchased and number of fast food visits did not change in either city over time.

While some consumers report noticing and using calorie information, no population level changes were noted in calories purchased or fast food visits. Other controlled studies are needed to examine the longer term impact of labeling as it becomes national law.

Overweight, obesity, and inactivity and urban design in rapidly growing Chinese cities

Overweight, obesity, and inactivity and urban design in rapidly growing Chinese cities
Health & Place, 21, 29-38. http://dx.doi.org/10.1016/j.healthplace.2012.12.009

Day, K, M Alfonzo, Y F Chen, Z Guo, and K K Lee

China faces rising rates of overweight, obesity, and physical inactivity among its citizens. Risk is highest in China’s rapidly growing cities and urban populations. Current urban development practices and policies in China heighten this risk. These include policies that support decentralization in land use planning; practices of neighborhood gating; and policies and practices tied to motor vehicle travel, transit planning, and bicycle and pedestrian infrastructure. In this paper, we review cultural, political, and economic issues that influence overweight, obesity, and inactivity in China. We examine key urban planning features and policies that shape urban environments that may compromise physical activity as part of everyday life, including walking and bicycling. We review the empirical research to identify planning and design strategies that support physical activity in other high-density cities in developing and developed countries. Finally, we identify successful strategies to increase physical activity in another growing, high-density city – New York City – to suggest strategies that may have relevance for rapidly urbanizing Chinese cities.

Association of Caesarean Delivery with Child Adiposity from Age 6 Weeks to 15 Years

Association of Caesarean Delivery with Child Adiposity from Age 6 Weeks to 15 Years
International Journal of Obesity, Jul;37(7):900-6.

Blustein, Jan, Teresa M Attina, Laura Cox, Mengling Liu, Andrew M Ryan, Martin M Blaser, Leonardo Trasande.

OBJECTIVES: To assess associations of caesarean section with body mass from birth through adolescence.

DESIGN: Longitudinal birth cohort study, following subjects up to 15 years of age.

SETTING AND PARTICIPANTS: Children born in 1991-1992 in Avon, UK who participated in the Avon Longitudinal Study of Parents and Children (ALSPAC) (n=10 219).

OUTCOME MEASURES: Primary outcome: standardized measures of body mass (weight-for length z-scores at 6 weeks, 10 and 20 months; and body mass index (BMI) z-scores at 38 months, 7, 9, 11 and 15 years). Secondary outcome: categorical overweight or obese (BMI 85th percentile) for age and gender, at 38 months, 7, 9, 11 and 15 years.

RESULTS: Of the 10 219 children, 926 (9.06%) were delivered by caesarean section. Those born by caesarean had lower-birth weights than those born vaginally (-46.1 g, 95% confidence interval(CI): 14.6-77.6 g; P=0.004). In mixed multivariable models adjusting for birth weight, gender, parental body mass, family sociodemographics, gestational factors and infant feeding patterns, caesarean delivery was consistently associated with increased adiposity, starting at 6 weeks (+0.11 s.d. units, 95% CI: 0.03-0.18; P=0.005), through age 15 (BMI z-score increment+0.10 s.d. units, 95% CI: 0.001-0.198; P=0.042). By age 11 caesarean-delivered children had 1.83 times the odds of overweight or obesity (95% CI: 1.24-2.70; P=0.002). When the sample was stratified by maternal pre-pregnancy weight, the association among children born of overweight/obese mothers was strong and long-lasting. In contrast, evidence of an association among children born of normal-weight mothers was weak.

CONCLUSION: Caesarean delivery is associated with increased body mass in childhood and adolescence. Research is needed to further characterize the association in children of normal weight women. Additional work is also needed to understand the mechanism underlying the association, which may involve relatively enduring changes in the intestinal microbiome.

Environmental and individual factors affecting menu labeling utilization: a qualitative research study

Environmental and individual factors affecting menu labeling utilization: a qualitative research study
Journal of the Academy of Nutrition and Dietetics. 2013 May;113(5):667-72. doi: 10.1016/j.jand.2012.11.011. Epub 2013 Feb 9.

Jennifer Schindler, Kamila Kiszko, Courtney Abrams, Nadia Islam, Brian Elbel

Obesity is a prominent public health concern that disproportionally affects low-income and minority populations. Recent policies mandating the posting of calories on menus in fast-food chain restaurants have not proven to uniformly influence food choice. This qualitative research study used focus groups to study individual and environmental factors affecting the use of these menu labels among low-income minority populations. Ten focus groups targeting low-income residents (n=105) were held at various community organizations throughout New York City over a 9-month period in 2011. The focus groups were conducted in Spanish, English, or a combination of both languages. In late 2011 and early 2012, transcripts were coded through the process of thematic analysis using Atlas.ti for naturally emerging themes, influences, and determinants of food choice. Few participants used menu labels, despite awareness. The most frequently cited as barriers to menu label use included: price and time constraints, confusion and lack of understanding about caloric values, as well as the priority of preference, hunger, and habitual ordering habits. Based on the individual and external influences on food choice that often take priority over calorie consideration, a modified approach may be necessary to make menu labels more effective and user-friendly.

Association between urinary bisphenol A concentration and obesity prevalence in children and adolescents.

Association between urinary bisphenol A concentration and obesity prevalence in children and adolescents.
JAMA. 2012 Sep 19;308(11):1113-21.

Trasande, Leonardo, Teresa M. Attinaand Jan Blustein.


Bisphenol A (BPA), a manufactured chemical, is found in canned food, polycarbonate-bottled liquids, and other consumer products. In adults, elevated urinary BPA concentrations are associated with obesity and incident coronary artery disease. BPA exposure is plausibly linked to childhood obesity, but evidence is lacking to date.


To examine associations between urinary BPA concentration and body mass outcomes in children.


Cross-sectional analysis of a nationally representative subsample of 2838 participants aged 6 through 19 years randomly selected for measurement of urinary BPA concentration in the 2003-2008 National Health and Nutrition Examination Surveys.


Body mass index (BMI), converted to sex- and age-standardized z scores and used to classify participants as overweight (BMI ≥85th percentile for age/sex) or obese (BMI ≥95th percentile).


Median urinary BPA concentration was 2.8 ng/mL (interquartile range, 1.5-5.6). Of the participants, 1047 (34.1% [SE, 1.5%]) were overweight and 590 (17.8% [SE, 1.3%]) were obese. Controlling for race/ethnicity, age, caregiver education, poverty to income ratio, sex, serum cotinine level, caloric intake, television watching, and urinary creatinine level, children in the lowest urinary BPA quartile had a lower estimated prevalence of obesity (10.3% [95% CI, 7.5%-13.1%]) than those in quartiles 2 (20.1% [95% CI, 14.5%-25.6%]), 3 (19.0% [95% CI, 13.7%-24.2%]), and 4 (22.3% [95% CI, 16.6%-27.9%]). Similar patterns of association were found in multivariable analyses examining the association between quartiled urinary BPA concentration and BMI z score and in analyses that examined the logarithm of urinary BPA concentration and the prevalence of obesity. Obesity was not associated with exposure to other environmental phenols commonly used in other consumer products, such as sunscreens and soaps. In stratified analysis, significant associations between urinary BPA concentrations and obesity were found among whites (P < .001) but not among blacks or Hispanics.


Urinary BPA concentration was significantly associated with obesity in this cross-sectional study of children and adolescents. Explanations of the association cannot rule out the possibility that obese children ingest food with higher BPA content or have greater adipose stores of BPA.

Inviting Consumers To Downsize Fast-Food Portions Significantly Reduces Calorie Consumption

Inviting Consumers To Downsize Fast-Food Portions Significantly Reduces Calorie Consumption
Health Affairs February 2012 vol. 31 no. 2 399-407. doi: 10.1377/hlthaff.2011.0224

Janet Schwartz, Jason Riis, Brian Elbel and Dan Ariely

Policies that mandate calorie labeling in fast-food and chain restaurants have had little or no observable impact on calorie consumption to date. In three field experiments, we tested an alternative approach: activating consumers’ self-control by having servers ask customers if they wanted to downsize portions of three starchy side dishes at a Chinese fast-food restaurant. We consistently found that 14–33 percent of customers accepted the downsizing offer, and they did so whether or not they were given a nominal twenty-five-cent discount. Overall, those who accepted smaller portions did not compensate by ordering more calories in their entrées, and the total calories served to them were, on average, reduced by more than 200. We also found that accepting the downsizing offer did not change the amount of uneaten food left at the end of the meal, so the calorie savings during purchasing translated into calorie savings during consumption. Labeling the calorie content of food during one of the experiments had no measurable impact on ordering behavior. If anything, the downsizing offer was less effective in changing customers’ ordering patterns with the calorie labeling present. These findings highlight the potential importance of portion-control interventions that specifically activate consumers’ self-control.

The economic burden placed on healthcare systems by childhood obesity

The economic burden placed on healthcare systems by childhood obesity
Expert Rev Pharmacoecon Outcomes Res. 2012 Feb;12(1):39-45.

Trasande L and Brian Elbel.

The obesity epidemic has transformed children's healthcare, such that diabetes, hypertension and the metabolic syndrome are phrases more commonly used by child health providers than ever before. This article reviews the economic consequences of this epidemic for healthcare delivery systems, both in the short term when obesity has been associated with increased utilization, and in the long term where increased likelihood of adult obesity and cardiovascular disease is well documented. Large investments through research and prevention are needed and are likely to provide strong returns in cost savings, and would optimally emerge through a cooperative effort between private and government payers alike. 


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