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Am Fam Physician. 2005;71(8):online-only-

to the editor: While the interventions listed in the article1 on obesity in children and adolescents by Fowler-Brown and Kahwati address clinical practice in depth, experience with tobacco control has shown that changing individual behavior requires structural and societal supports to achieve the desired results. The most effective solutions to the obesity epidemic will likely involve policies and environments that encourage healthy food and physical activity choices. Regulatory policies; consumer education that addresses marketing, health claims, and nutrition labeling; and school strategies will all be necessary to reverse current trends.

Changes to encourage physical activity can be implemented on a small scale. For instance, secure bike storage and shower facilities can be made available, and the location, safety, and appearance of stairwells can be improved. Community designs that locate neighborhoods convenient to shopping, work sites, libraries, and schools require more substantial long-term planning and political support. Child-oriented features that encourage physical activity include safe, available playgrounds and traffic infrastructure that increases the safety of walking or biking to school.

School vending machines and cafeterias that offer diverse, attractive, and well-priced alternatives to unhealthy foods have been shown to make nutritious choices more competitive.2 Compared with more affluent families, those living in high-poverty areas often have less access to low-cost nutritious food and depend on high-priced, calorie-dense processed foods from convenience stores. Zoning and tax incentives that encourage larger grocery stores to locate in less affluent neighborhoods are as important as nutrition education. Promotions such as the "5-A-Day" program to increase the consumption of fruits and vegetables do not work well if those foods are not available.

Financial pressures force hard choices on under-funded school. School nutrition programs may rely on revenue from snack sales, as do other worthy extracurricular programs. Emphasis on academic basics cuts into nutrition and physical activity curricula.3,4 Fortunately for policy makers, the societal costs of obesity help justify the costs of interventions. Public recognition also is shifting; some of the most financially strapped school districts have banned soda-pouring contracts because of the financial incentives to increase consumption among children and adolescents.

Increased awareness of the extent of obesity and its health consequences is inadequate to resolve the problem, as are education and weight reduction interventions for individuals. A comprehensive, population-based strategy, similar to the anti-tobacco strategies, will be needed. Analogous to the tobacco example, corporate interests have reasons and resources to oppose the regulation of marketing and sales, especially to children. Advocates must be willing to become politically active and adept. The positions of the American Academy of Family Physicians on nutrition and physical activity in schools are worthy guidelines, and family physicians are ideal champions for the necessary changes.5

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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