Ivwhy The Focus On Environments

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A broad approach is required for reducing obesity at a population level (10,11). Biological research will continue to map the metabolic and molecular pathways involved in the development of obesity and will therefore help to explain some of the differences in obesity risk among individuals. Identifying key molecules in the pathways may lead to the development of effective drugs to treat obesity, but unless costly, mass medication is undertaken for a large proportion of the pop ulation, there will be little impact on the population burden of obesity.

One of the primary weight loss interventions aimed at the host is education (including awareness raising, public education, and individual counseling and skills training). The expectation is that new knowledge will be turned into sustained behavior changes. This may be true for some individuals and appears to be a moderately successful approach for obese men (31). However, for most obese people and for population-based prevention, just knowing about what are the healthy choices is a relatively weak force for sustained behavior change (8,32). Education about healthy choices, therefore, appears necessary but not sufficient to reverse obesity.

The key role of environmental change is to ''make the healthy choices the easy choices.'' Unfortunately, the environments in relation to obesity have received little attention to date. Compare the vast human and financial efforts to sequence the human genome with the minor and nascent efforts to sequence the human environment. Yet environmental change can have a major, immediate, and lasting impact on behaviors, especially if it is a ''passive'' intervention that does not require an active decision by the individual, such as car-free central business districts or lower-fat french fries (see Sec. I.B) or potato chips (below) (33). Table 2 lists some of the key strengths of an environmental/systems-based approach underpinning the obesity prevention efforts.

Obesity, like diabetes and coronary heart disease, has higher prevalence rates among the lower-socioeconomic status (SES) populations in developed countries. Low income and low educational attainment bring reduced options for low-SES groups and a lower uptake of health messages about behavioral changes for a healthy future. One of the key strengths of an environmental focus is its potential impact among lower-SES groups. By influencing the ''default'' choices in key environments, there is a much greater potential to affect overall diet and physical activity patterns in lower-SES groups than by education strategies alone. Education-based campaigns are complementary to the environmental approach, but the priority needs to be on ensuring that the healthy choices are available first, before embarking upon such campaigns to educate people about taking up those choices.

One of the principles of environmental intervention is to effect small changes in high-volume foods. Take potato chips as an example where, say, 90% of the sales are in the regular, higher-fat chips (35% fat) and 10% of sales are in the lower-fat chips (25%). There are three main options for reducing the population's dietary fat burden from potato chips by 10%. The first is to reduce the total consumption of chips by 10%, which would probably require a major, sustained public education campaign by health authorities to eat fewer chips, no doubt in the face of stiff opposition from the potato chip manufacturers. The second is to expand the proportion of the sales of lower-fat chips to 44% of the market share. Food companies are already heavily marketing the ''healthier'' options to the high-income, high-education consumers in an effort to expand that market share. Such healthier options often come at a premium price and are marketed to the healthiest section of the community, making this a relatively ineffective option for reducing the fat intake oflow-income people who are at higher risk ofobesity. The third option is to reduce the fat content of higher-fat crips from 35% to 31%. This is technologically possible, would not be detectable by the consumer, and impacts on a large section of the community including low-income groups. The barriers to reducing the fat content of the high-volume potato chips are perhaps some increases in cost of production (changing plant and adding fans to blow off the fat after cooking) and the lack of a marketing angle to make it appear worthwhile to the manufacturers.

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