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The UB Obesity Report Card™: An Overview

Research by Ann Cotten, Kenneth R. Stanton, Zoltan J. Acs and Mary Lovegrove

There is no remaining doubt that obesity is a serious epidemic. A rapidly shrinking number of skeptics still argue that the issue is one of measurement and that the Body Mass Index (BMI) may not provide the truth. To dismiss those few remaining skeptics out of hand, one need only compare photographs of crowds or even family gatherings taken in the 1960s or 1970s to more current photographs. The problem is sadly, more than esthetic. Excessive weight is a precursor to a host of serious health problems such as diabetes and heart disease. Making matters worse, these health problems are often compounded by poverty and access to health care. Even though the causes of the epidemic may not be fully understood, given the seriousness of the problem, it is worth asking what steps our state governments are taking to combat obesity. Slowing the dramatic growth in obesity prevalence among children is especially important and should be a priority for legislators.

For the most part, state governments have had a delayed reaction to this health crisis but most states are finally trying to develop responses to the problem. For the purpose of comparison, we have created a report card for each state, based on efforts to pass obesity control measures at the state level. Currently, eight different types of legislation have been introduced and in some states, passed. The types are as follows:

nutrition standards—controlling the types of foods and beverages offered during school hours
vending machine usage—prohibiting types of foods and beverages sold in school and prohibiting access to vending machines at certain times
body mass index measured in school
recess and physical education—state-mandated additional recess and physical education time
obesity programs and education—programs established as part of curriculum
obesity research—legislative support for other institutions or groups to study obesity
obesity treatment in health insurance—expanding health insurance to cover obesity treatment where applicable
obesity commissions—legislature-established commissions designed to study obesity

In our report card assessment, successfully passing a law was necessary to obtain an “A.” However, since introducing legislation at least indicates some awareness and the presence of a will directed to controlling obesity, points were awarded even if the proposed legislation is not currently active. The grade for each state is a composite of the score for each of the eight types of legislation.

Report Card Results

In the 2006 edition of our UB Obesity Report Card, there is considerable good news. Most states are now attempting to tackle their obesity problem. California, New York and Tennessee each received an A for their efforts to control obesity. California and New York are ranked 36th and 38th respectively, in terms of obesity prevalence. Tennessee has a far more serious obesity problem and is ranked 8th highest in the country. Only three states (Idaho, Utah and Wyoming) received a failing grade of F for taking no action at all. According to the 2005 Centers for Disease Control (CDC) Behavioral Risk Factor Surveillance System (BRFSS) data, the obesity rates in Idaho, Utah and Wyoming were 24.5 percent, 21.2 percent and 24.2 percent. On this basis, the three states are ranked 24th, 42nd and 28th most obese, respectively. (Since the BRFSS data are collected via survey rather than direct measurement, they understate the true obesity prevalence.) Although it may be the case that legislators in Utah in particular, believe that the problem is not serious enough in their state to warrant attention,the BRFSS estimate of the national average obesity prevalence is a not too distant 24.4 percent. Of greater concern, the rapid pace of the increase in obesity prevalence that has taken place nationwide underscores the dangers of ambivalence. A growing number of states (19) have earned a grade of B overall and an equal number (19) received a C overall. Only 6 received a D.

Adding to the good news, some states are making grassroots efforts to halt the epidemic that are initiated at local government levels or via school boards or through other avenues. As examples, New York City has recently banned restaurants from using trans-fats and some states, such as New Jersey, have taken steps at the school board level to address childhood obesity. However, admirable as these efforts are, since we focus only on state legislation, our report card does not capture these local initiatives. The 2006 UB State Obesity Report Card shows more states earning higher scores than in the past which indicates that there is greater awareness of the need to address the obesity problem. But it is still the case that some of the states are lagging in taking corrective steps. Mississippi has the nation’s highest obesity rate, followed by Louisiana, West Virginia and South Carolina. Mississippi has passed legislation specifying requirements for recess and physical education, it has set obesity education programs and it has passed legislation to establish an obesity commission. But establishing a commission is unlikely to have the immediate effect that is possible with more direct diet and exercise interventions. West Virginia has acknowledged that the problem is very serious and requested the assistance of the CDC. Overall, the state has taken a much more aggressive stance at the state level, passing legislation in many of the key areas and working on additional proposals. For its efforts, West Virginia raised its score from an F in 2004, to a B in the 2006 report. In spite of the other obvious problems that Louisiana currently has to deal with, the state has taken as aggressive an approach as West Virginia. Michigan, ranked 15th for adult obesity and 19th for overweight children, has not passed any obesity control legislation at all.

Since the awareness and response developments in relation to the obesity epidemic are strongly reminiscent of the battle against tobacco addiction, we developed a second, childhood obesity report card for the states that focuses on the first five of the eight types of legislation previously listed. The first five specifically address efforts to control increases in obesity prevalence among children. (The rankings of childhood overweight prevalence are derived from Child and Adolescent Health Measurement Initiative (2005), National Survey of Children’s Health). In the fight to discourage tobacco use, efforts directed toward children were arguably the most influential.

In the control of childhood obesity, California, Illinois, Oklahoma, Pennsylvania, South Carolina and Tennessee each scored an A. In the first UB State Obesity Report Card (2004), not one state received an A, but Arkansas stood out as a state that understood the seriousness of the problem. And even though it did not have a 2006 legislative session, Arkansas still retains grades of B for both the childhood obesity report card and overall. For Governor Huckabee, the battle against obesity in Arkansas is personal. Having lost over 100 pounds, he is leading the charge to encourage healthier living choices at the individual level that again, are not necessarily captured in our Report Card. Arkansas is among the states that measure BMIs in the schools and the data collected will be of tremendous help in evaluating the effectiveness of state policy initiatives. It is even more encouraging that Arkansas now has a great deal of company. 21 states earned a B for childhood obesity control measures in the 2006 report card. The 23 remainng states have made little progress: 15 states earned a C, 5 received Ds and 3 (Nevada, Utah and Wyoming) received failing grades of F.

Given the importance of establishing healthy habits early in life, the Report Card results for childhood obesity control measures are arguably the most critical. State actions on this front are gradually becoming more encouraging. Most obviously, the shrinking number of states receiving failing grades is an undoubtedly positive sign.

Current Legislation

Looking at the legislation that has already been enacted, the most frequently occurring category is legislation to establish an obesity commission to explore the issues. Corresponding graphs from the previous report cards (links provided at top of page) show that legislating obesity commissions has been the most frequently occurring legislation since we began keeping track. 27 states currently have such legislation. Recess/physical education requirements and nutrition standards are the next most common types of legislation to address obesity prevalence. Both of these types of legislation are found in 24 states. 16 states have vending machine usage restrictions and 23 states have obesity education programs. Although the collection of data is an important part of finding the best solutions, only 7 states require that schools measure student BMIs. Measuring BMIs in the schools is important from a research standpoint, but has also encountered a great deal of resistance from various groups concerned about privacy issues and the implicit emphasis on body image. 7 states provide for obesity treatment in health insurance and 9 states have obesity research support programs.

Looking to the Future

States were scored on whether or not they enacted or proposed legislation to address obesity. While many states made progress in enacting legislation, a look at the legislation that was introduced but not yet enacted provides a glimpse into future trends. It is also of interest to look at the changes across time in proposed legislation. For that purpose, we have combined the information from 2004 to 2006 into one graph showing proposed legislation for the 2004-2006 period. In general, there is great interest in establishing public policies that support the reduction of obesity in children. Legislation has been proposed in 17 states mandating time for recess and physical education. Controlling access to less healthful foods and beverages also generated great interest. In 16 states, legislation was introduced to govern the use of vending machines. 10 states proposed laws to establish obesity commissions and 13 focused on setting nutrition standards or measuring the BMIs of schoolchildren. There are proposals in 8 states to mandate curricula to address nutrition education and obesity awareness and 10 states are mandating health insurance coverage of obesity treatments. Only 4 proposals address support for research.

State Government Representatives

If you have (or wish to obtain) additional information concerning legislation or proposed legislation in your state, please contact kstanton@ubalt.edu(no spam please). Please fully identify any legislation and include appropriate contact information. We also have an interest in collecting information on initiatives that take place at more local levels.

Acknowledgements

The authors gratefully acknowledge the extraordinarily high quality legal research provided by Mary W. Lovegrove and Joe Creed in support of the 2005 Obesity Report Card.

Background

The effects of obesity - once an issue to be settled between doctor and patient - have become practically ubiquitous in American life. Our culture is awash with mixed messages about "having it all" and "bigger is better", not to mention the circus-like atmosphere of weight loss, exercise regimens, and proper nutrition. To live in American society now is to experience everything from an entire television network dedicated to food and food-related news to constant and occasionally dire warnings about "good" and "bad" cholesterol, heart disease, diabetes, and a host of other obesity-related ailments. Being overweight is no longer simply a health problem - it is a symptom of a greater cultural shift that shows no sign of heeding.

Signs of this change are everywhere, and at the University of Baltimore, faculty researchers have taken note of the obesity crisis in the worlds of economics, business and finance, law, and public policy. While the current media clamor is focused on the tens of billions of dollars at stake in the behavior modification and medicalization of this issue, under the radar, even more important, and occasionally troubling moves are taking place. Airplane manufacturers and theater designers for example, are redesigning their products to accommodate larger people. Lawyers who once focused on smoking-related illnesses are searching for a means of establishing culpability of fast-food producers in the rise of obesity-related illnesses, especially in younger people. Disability claims related to obesity are on the rise and the linkages between obesity and other serious health problems such as type II diabetes are raising serious concerns.

The University of Baltimore has established a framework for researching and discussing obesity and its discontents. Faculty analyses from multidisciplinary perspectives provide a portrait of this complex problem, and, potential ways to resolve it. UB researchers explain the web of underlying causes as an "infrastructure of obesity", resulting from a variety of public policy decisions, economic factors and profit opportunities, in addition to the more obvious health and nutrition aspects of the epidemic. This infrastructure makes it unlikely that a singular solution is possible. Thus, an Obesity Initiative - multidisciplined, broadly examined, and intensely debated among qualified experts.