Introduction

Overweight and obesity affect approximately 170 million children around the world.1 This global public health problem is manifested in developed and developing countries and is associated with numerous diseases and accompanying health care costs.2 – 5 Childhood obesity is a risk factor for obesity in adulthood as well as for chronic conditions such as cardiovascular disease and metabolic disorders.6 – 8 The childhood obesity epidemic is driven by multiple, interrelated factors, including decreases in physical activity and increases in sedentary activities (e.g., watching television; playing video games) in addition to the rise of a food and beverage industry that markets energy-dense foods at relatively low costs, has increased the norm for portion sizes, and wields significant political influence in developed and developing countries.9 – 11

Public policy—particularly legislation and regulations—provides one means of addressing determinants of the childhood obesity epidemic at the micro-level (e.g., providing opportunities for physical activity) and at the macro-level (e.g., influencing practices of the companies that produce and market food). While childhood obesity prevention requires a multi-faceted approach, including behavior modification efforts and educational campaigns, legislation and regulation offer legally binding options to establish or revise programs, policies, and task forces.12 – 14

During the last decade, policy-makers throughout the world have become increasingly interested in addressing childhood obesity prevention.15,16 In the United States, several studies have confirmed an increase in the introduction and passage of legislation at the state level related to childhood obesity.17 – 19 From 2003 to 2005, Boehmer et al. found an enactment rate of 17% for state-level childhood obesity bills.18 According to a study conducted by Eyler et al., this rate increased to 27% from 2006 to 2009.19 In addition, May et al. identified an increased number of legislatively established childhood obesity task forces from 2006 to 2010 compared to the previous five years.20 These findings are further supported by U.S. and European public opinion polls that have found strong support for some public policy approaches to address childhood obesity, such as restrictions on advertising that targets children.21,22

Although these studies demonstrate that childhood obesity prevention has permeated the agendas of state legislatures, little is known about the factors that encourage or discourage policy-makers from taking action on childhood obesity. In 2013, Robbins et al. interviewed policy-makers throughout New York State and found that they viewed childhood obesity as a problem that merits legislative attention, but had concerns about limited governmental finances to support childhood obesity prevention work.23 A 2009 study by Dodson et al. used 16 interviews with state-level policy-makers to identify key enablers and barriers to the childhood obesity policy process.24 While they provide useful insights, the handful of studies that have considered policy-makers’ views of childhood obesity prevention policies have been limited by small sample sizes and geographic restrictions.23 – 26

Researchers have called for additional studies that examine views about policy-making and childhood obesity among different governmental branches and stakeholders, such as non-governmental organizations (NGOs).23 By including diverse stakeholders such as NGOs and academics, researchers can better understand—and subsequently disseminate to practitioners—the perspectives, experiences, and strategies of individuals who are engaged with childhood obesity prevention efforts in the U.S. and abroad. We conducted interviews with individuals from three groups—policy-makers, NGO representatives, and academics—from across the U.S. We asked about their perceptions of factors that encourage or discourage policy-makers from taking action to address childhood obesity. We identify common themes within and across groups and consider how these findings might inform the work of those seeking to advance childhood obesity prevention policies.

Methods

To explore perspectives about factors that encourage or discourage policy-makers from addressing childhood obesity, we conducted semi-structured interviews with U.S.-based policy-makers, NGO representatives, and academics. We defined a policy-maker as a member of a local or state government agency or legislative body with responsibility for drafting legislation or promulgating regulations, or a staff member who is very familiar with these processes. NGOs were defined as non-profit groups that are not affiliated with the government, and have a specific orientation at the local, regional, or national level. Finally, we defined academics as teachers or scholars employed in college or university settings and actively conducting research in the area of childhood obesity prevention. To identify potential participants from these three groups, we created a purposive sample of individuals working in the area of childhood obesity prevention with input from the Robert Wood Johnson Foundation and the American Heart Association.

Recruitment and data collection

We contacted individuals by email with a recruitment letter that explained the study, the purpose of the interview, and eligibility criteria. For individuals who expressed interest, we conducted semi-structured interviews that lasted from 20 to 45 min. The interviews were conducted from September 2014 to April 2015. All interviews were conducted by telephone in accordance with an interview guide that included the following domains: factors that encourage policy-makers’ support of childhood obesity prevention policies and factors that discourage policy-makers’ support of such policies. Each interview was recorded and transcribed. Interviewees received a gift card after the interview was completed.

Data analysis

To familiarize ourselves with the data, each transcript was read in its entirety. Brief summary matrices were then created in Microsoft Excel, to organize the data and to begin to identify themes and patterns emerging within each domain, from individual interviews and across interviews. These summary matrices included representative quotations. The matrices served as the basis for analytic memos that identified key themes through open coding for each stakeholder group and each domain. Members of the study team repeatedly reviewed these summary matrices and analytic memos to discuss interpretations of the data and to refine emerging themes. Our study procedures were reviewed and approved by an Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health.

Results

We conducted 43 interviews. Of the 55 individuals identified through the purposive sample, eight did not respond to our email invitation and four declined to participate. Those who declined expressed concern that their perspective would be redundant given interviews we had already conducted with colleagues or other stakeholders. We interviewed 12 policy-makers, 24 representatives of NGOs, and seven academics across 18 U.S. states and the District of Columbia. As described below, the themes that emerged were generally consistent among these three groups.

Factors that encourage policy-makers to support childhood obesity prevention policies

Interviewees identified four factors that encourage policy-makers to support childhood obesity prevention policies: (1) a policy’s positive implications for government finances, (2) the presence of an evidence base supporting a proposal, (3) use of partnerships and collaborations, particularly with the local community, and 4) policy-makers’ priorities and relationships (Table 1).

Table 1 Factors that encourage policy-makers to support childhood obesity prevention policies
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Across all three groups, interviewees viewed a policy’s positive implications on government finances as a factor that encouraged policy-makers’ support. Positive financial implications were perceived as taking many forms. NGO representatives, for example, noted that policy-makers respond well when a policy has the potential to create jobs, raise revenue, or is framed in terms of “economics and business.” A policy-maker interviewee explained that childhood obesity programs with a proven track record of success and positive financial ramifications are likely to be viewed favorably by policy-makers for additional funding.

Interviewees from the three groups mentioned the importance of a broad evidence base to gain policy-makers’ support for childhood obesity policies. One NGO representative explained, “Well, numbers matter. [Policy-makers] will ask about evidence and I think those who just initially are more and more inclined to support improving the school health environment are needing the data to reinforce that argument to those who would be naturally against it or have built up a resistance to any additional regulation.” In addition, one academic stated, “I have lots of experience with trying to move legislation without research and failing and then having the research…and succeeding.”

Across the three groups, interviewees emphasized the importance to policy-makers of partnerships and collaborations with the local community. One NGO representative stated, “Bringing together a diverse group of stakeholders to really tell policy-makers…[childhood obesity] is an important issue has been a key strategy.” A policy-maker interviewee suggested that policy-makers are more responsive to priorities identified by community members “and not something that at the staff level we determine are the community’s priorities.”

Interviewees in the NGO and academic groups identified policy-makers’ priorities and relationships as factors that encourage their support for childhood obesity prevention policies. NGO representatives noted that issues related to children’s health tend to be viewed as a high priority among policy-makers. In addition, one NGO representative explained the value of “reaching out to the legislators in a way that connects with what’s important to them and to their district.”

Factors that discourage policy-makers from supporting childhood obesity prevention policies

Interviewees identified four factors that discourage policy-makers from supporting childhood obesity prevention policies: (1) the political environment, (2) industry opposition, (3) policy-makers’ beliefs about childhood obesity, and (4) financial concerns (Table 2).

Table 2 Factors that discourage policy-makers from supporting childhood obesity prevention policies
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Interviewees from all three groups mentioned the potential for the political environment to discourage policy-makers’ support of childhood obesity policies. Several NGO representatives discussed the political environment in the context of policy-makers’ views about the role of government. One NGO representative explained, “What we find is that we have a majority party that is widely, ideologically opposed to a lot of government spending and government intervention, that is trying to minimize government to some extent and that makes it difficult to find support [for childhood obesity policies].” One policy-maker interviewee similarly noted that if the political climate is not conducive to childhood obesity prevention policies, then legislators are unlikely to put these measures forward. In addition, an academic interviewee mentioned that governmental gridlock, due to partisanship, can make it difficult to secure policy-makers’ support.

In the three stakeholder groups, interviewees discussed involvement of the food and beverage industries as furthering policy-makers’ opposition to childhood obesity policies. One academic stated, “The industry money. It’s simple.” Similarly, an NGO representative explained, “The industry has a lot at stake in [childhood obesity]. They’ve been in this for a long time. They’re very powerful and have a lot of friends and a lot of money.” A policy-maker interviewee concurred, noting, “The food industry heavily influences [policy-makers]….”

Across the three groups, interviewees viewed policy-makers’ beliefs about childhood obesity as potentially discouraging their support of childhood obesity prevention policies. According to one NGO representative, “Anytime you talk about policy related to food, people get really weird about it because it’s so personal to them.” Another NGO representative explained, “There is a mentality about obesity that it’s somebody’s fault.” Similarly, a policy-maker interviewee stated that, among policy-makers, “Sometimes you run into just personal biases.”

Interviewees in the policy-maker and NGO groups identified government financial concerns as hindering policy-makers’ support for childhood obesity prevention policies. One policy-maker interviewee stated, “Money, or the lack of money, is a very big factor in this.” Similarly, another policy-maker interviewee noted, “The reality comes back to the checkbook all the time.” An NGO representative expressed a similar sentiment: “What we hear from people is that there isn’t any money…money is always an issue.”

Discussion

Given its global prevalence, opportunities to prevent or mitigate childhood obesity must be identified and pursued. Practitioners and researchers have repeatedly recognized that public policies, such as legislation and regulation, are promising mechanisms to tackle childhood obesity.27,28 Despite this, the factors that influence policy-makers relative to childhood obesity prevention policies have received little attention. To address this gap, we conducted interviews with policy-makers, NGO representatives, and academics to identify factors that encourage and discourage policy-makers’ support for childhood obesity prevention policies.

Within all groups, a policy’s positive financial implications for government were viewed as a factor that encourages policy-maker support, while a policy’s new or additional costs were perceived to discourage such support. These findings, which are consistent with prior research and theories about factors that influence policy-makers generally,29 highlight the importance of developing childhood obesity prevention policies that are cost-neutral or have the potential to raise revenue. Policies that require school-based vending machines to stock water instead of sugar-sweetened beverages, for example, or that establish a childhood obesity task force do not necessarily require new funds. A task force can even be charged with identifying cost-neutral opportunities to address childhood obesity prevention. To this end, there is a need for researchers to generate better evidence about the fiscal impact of various policy alternatives aimed at addressing the problem of childhood obesity. This has been raised as a strategy for childhood obesity prevention policies in Europe—where scholars have noted the lack of a relevant evidence base—as a way to interest ministries of finance in funding successful programs.30,31

A second consensus emerged about the political environment. Beliefs favoring a limited role for government and concerns about the ‘nanny state’ (a term of British origin that conveys a view that a government or its policies are overprotective or interfering unduly with personal choice, see https://en.wikipedia.org/wiki/Nanny_state) were perceived as discouraging policy-makers from supporting policies intended to reduce childhood obesity. Because beliefs of this nature are difficult to change, some who are seeking to prevent childhood obesity may wish to consider solutions outside of the traditional public policy process. This might be accomplished by partnering with local groups for community clean up days, which can reinvigorate green spaces, bike paths, and recreational areas for children.32,33 According to many interviewees, policy-makers view local partnerships favorably. In addition, the World Health Organization has highlighted the importance of community-based partnerships and interventions within the broader policy-making process for childhood obesity prevention.1 Ultimately, these collaborations may provide the foundation for future childhood obesity prevention work within the traditional public policy arena when a more favorable political environment emerges.

A third area of consensus concerned the role of the food and beverage industry in the policy-making process. Interviewees from all three groups noted that industry actors may sway policy-makers and discourage efforts to prevent childhood obesity. While no single solution can combat pervasive industry influence in the U.S. and abroad, lessons can be learned from policy efforts that have succeeded despite industry opposition. Local policy-makers, who may be less subject to industry attention and influence than those at the regional, state, or national levels, are typically more willing to experiment with innovative obesity prevention opportunities such as healthy zoning or restricted advertising on school buses.34 – 36 In the mid-2000s, despite industry opposition, several localities in the U.S. enacted menu-labeling laws for restaurants. These local laws faced industry-initiated legal challenges that the local jurisdictions had anticipated.37 The localities prevailed in court, and the menu-labeling provisions in the federal Patient Protection and Affordable Care Act—which established menu-labeling requirements for restaurants throughout the U.S.—grew out of these local menu-labeling laws.38

A final area in which the groups coalesced concerns the role of research about childhood obesity in the policy-making process. All groups agreed that relevant research—ideally at the state or local level—may encourage policy-makers’ support of childhood obesity prevention policies. As previous studies have demonstrated, however, translating and disseminating research findings for policy-makers—and sharing these findings as soon as possible after the research is completed39—is a critical step for the data to have influence.40,41 Translational materials, such as brief memos or fact sheets, should present findings in a concise, straightforward manner. Importantly, because most policy-makers do not have a public health or research-oriented background, those sharing research with policy-makers should tailor their materials to avoid jargon.42 Childhood obesity researchers should also consider cultivating relationships with state and local policy-makers, to engage in a bidirectional information exchange.43 Although these relationships take time to develop, once established they can ensure that research agendas are informed by policy-makers’ needs and that evidence-based childhood obesity prevention policies are crafted.

While our study has numerous strengths, including representation from three stakeholder groups, a relatively large sample size, and geographic diversity, it also has several limitations. First, we used a purposive sample to identify potential interviewees. Individuals included in this sample had demonstrated some interest in childhood obesity, which suggests that they were more likely to agree to participate than individuals who had no prior experience with these issues. Second, it may be difficult to generalize our findings as interviewees’ relevant experiences and perceptions were shaped by the unique political climate of their state. Finally, we focused on factors that encourage or discourage policy-makers’ support for policies. Our findings do not provide insights about the implementation of childhood obesity prevention policies once they have been passed into law. This is a promising area for future research, particularly because implementation may differ for childhood versus adult obesity policies.

Conclusion

Public policy is a necessary component of any comprehensive approach to address childhood obesity. Among policy-makers, NGO representatives, and academics—three key groups—we identified generally consistent perceptions of factors that encourage and discourage policy-maker support. As public health practitioners, advocates, and others seek to advance childhood obesity prevention, the factors we identified offer insights into potentially effective ways to frame proposed policies and strategies to use when seeking to influence policy-makers.