Multilevel legal approaches to obesity prevention: A conceptual and methodological toolkit

Autoři: Sara E. Abiola aff001;  Michelle M. Mello aff002
Působiště autorů: Department of Health Policy & Management, Columbia Mailman School of Public Health, New York, New York, United States of America aff001;  Department of Health Research and Policy, Stanford School of Medicine, Stanford Law School, Palo Alto, California, United States of America aff002
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0220971



State lawmakers have explored numerous policy alternatives to reduce overweight and obesity. Evaluating effects of these laws is important but presents substantial methodological challenges. We present a conceptual framework that allows for classification of obesity prevention laws based on ecological level of influence and the underlying legal mechanism involved to guide analysis of the relationship between a substantial range of obesity prevention laws and BMI.


Obesity prevention laws (OPLs) for all 50 states and DC were obtained via primary legal research using the LexisNexis Advanced Legislative Services (ALS) database. For legal provisions that met inclusion criteria, reviewers abstracted information on bill state, citation, passage and effective dates, target population, and obesity prevention mechanism. Laws were categorized by ecological level of influence on weight-related behaviors and the legal mechanism utilized to change behavioral determinants of BMI.


Laws designed to increase community-level opportunities for physical activity were the most frequently enacted OPL while laws designed to alter nutrition standards for school meals or competitive foods were comparatively less common, appearing in only 16% and 34% of states, respectively.


Prior studies of obesity policies have focused on specific interventions. We identified and categorized state-level laws that operate at all ecological levels and found that laws passed during the initial burst of lawmaking were largely confined to measures aimed at increasing opportunities for physical activity. Creating public spaces for recreation is an important step to promoting healthier lifestyles to reduce obesity risk; more comprehensive, multilevel legal approaches should also be pursued.

Klíčová slova:

Behavioral and social aspects of health – Beverages – Body mass index – Childhood obesity – Nutrition – Obesity – Physical activity – Schools


1. Ogden CL, Carroll MD, Lawman HG, Fryar CD, Kruszon-Moran D, Kit BK et al. Trends in obesity prevalence among children and adolescents in the United States, 1988–1994 through 2013–2014. JAMA. 2016;315(21):2292–2299. doi: 10.1001/jama.2016.6361 27272581

2. Skinner AC, Ravanbakht SN, Skelton JA, Perrin EM, Armstrong SC. Prevalence of obesity and severe obesity in US children, 1999–2016. Pediatrics. 2018;141(3):e20173459. doi: 10.1542/peds.2017-3459 29483202

3. Wallander J, Kerbawy S, Toomey S, Lowry R, Elliott MN, Escobar-Chaves SL et al. Is obesity associated with reduced health-related quality of life in Latino, black and white children in the community?. Int J Obes Relat Metab Disord. 2013;37(7):920–925.

4. Nieman P, Leblanc CMA. Psychosocial aspects of child and adolescent obesity. Pediatric Child Health. 2012;17:205–208.

5. Tsai A, Williamson D, Glick H. Direct medical cost of overweight and obesity in the USA: a quantitative systematic review. Obesity Reviews. 2010;12(1):50–61.

6. Jounala M, Magnussen C, Berenson G, Venn A, Burns TL, Sabin MA et al. Childhood adiposity, adult adiposity, and cardiovascular risk factors. New England Journal of Medicine. 2011;365(20):1876–1885. doi: 10.1056/NEJMoa1010112 22087679

7. Andreyeva T, Luedicke J, Wang Y. State-level estimates of obesity-attributable costs of absenteeism. Journal of Occupational and Environmental Medicine. 2014;56(11):1120–1127. doi: 10.1097/JOM.0000000000000298 25376405

8. Gostin L. Public Health Law: Power, Duty, Restraint. 2nd ed. Berkeley, CA: University of California Press and Milbank Memorial Fund; 2008.

9. Graff S, Kappagoda M, Wooten H, McGowan AK, Ashe M. Policies for healthier communities: historical, legal, and practical elements of the obesity prevention movement. Ann Rev Public Health. 2012;33(1):307–324.

10. Mello MM, Studdert D, Brennan T. Obesity—the new frontier of public health law. New England Journal of Medicine. 2006;354(24):2601–2610. 16775242

11. Centers for Disease Control and Prevention. Division of Nutrition, Physical Activity, and Obesity. Chronic Disease State Policy Tracking System. Accessed August 3, 2015.

12. National Conference of State Legislatures. Chronic Disease Prevention and Health Promotion. Childhood Obesity 2010 Update of Legislative Policy Options. Accessed August 3, 2015.

13. Health Policy Tracking Service. State Actions to Promote Nutrition, Increase Physical Activity, and Prevent Obesity. Robert Wood Johnson Foundation. Accessed August 3, 2015.

14. National Association of State Boards of Education. State School Health Policy Database. Accessed August 3, 2015.

15. National Cancer Institute. Classification of Laws Associated with School Students. Accessed August 3, 2015.

16. Rudd Center for Food Policy & Obesity. Legislation Database. Accessed August 3, 2015.

17. Taber D, Chriqui J, Perna F, Powell L, Slater S, Chaloupka F. Association between state physical education (PE) requirements and PE participation, physical activity, and body mass index change. Preventive Medicine. 2013;57(5):629–633. doi: 10.1016/j.ypmed.2013.08.018 23978523

18. Taber D, Chriqui J, Perna F, Powell L, Chaloupka F. Weight status among adolescents in states that govern competitive food nutrition content. Pediatrics. 2012;130(3):437–444. doi: 10.1542/peds.2011-3353 22891223

19. Taber D, Chriqui J, Powell L, Chaloupka F. Association between state laws governing school meal nutrition content and student weight status. JAMA Pediatrics. 2013;167(6):513. doi: 10.1001/jamapediatrics.2013.399 23567869

20. Taber D, Stevens J, Evenson KR, Ward DS, Poole C, Maciejewski ML, et al. State policies targeting junk food in schools: racial/ethnic differences in the effect of policy change on soda consumption. Am J Public Health. 2011;101(9):1769–1775. doi: 10.2105/AJPH.2011.300221 21778484

21. Fletcher J, Frisvold D, Tefft N. Non-linear effects of soda taxes on consumption and weight outcomes. Health Econ. 2014;24(5):566–582. doi: 10.1002/hec.3045 24615758

22. Auld M, Powell L. Economics of food energy density and adolescent body weight. Economica. 2009;76(304):719–740.

23. Wagenaar A, Burris S. Public Health Law Research. San Francisco, CA: Jossey-Bass; 2013.

24. Burris S, Mays G, Douglas Scutchfield F, Ibrahim J. Moving from intersection to integration: public health law research and public health systems and services research. Milbank Quarterly. 2012;90(2):375–408. doi: 10.1111/j.1468-0009.2012.00667.x 22709392

25. Burris S, Wagenaar A, Swanson J, Ibrahim J, Wood J, Mello M. Making the case for laws that improve health: a framework for public health law research. Milbank Quarterly. 2010;88(2):169–210. doi: 10.1111/j.1468-0009.2010.00595.x 20579282

26. Tremper C, Thomas S, Wagenaar A. Measuring law for evaluation research. Evaluation Review. 2010;34(3):242–266. doi: 10.1177/0193841X10370018 20479214

27. Quinn L. Application of the social ecological model in folic acid public health initiatives. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2005;34(6):672–681. 16282224

28. McLeroy K, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Education & Behavior. 1988;15(4):351–377.

29. Weintraub D, Tirumalai E, Haydel K, Fujimoto M, Fulton J, Robinson T. Team sports for overweight children. Arch Pediatr Adolesc Med. 2008;162(3):232. doi: 10.1001/archpediatrics.2007.43 18316660

30. Elder K, Wolfe B. Bariatric surgery: a review of procedures and outcomes. Gastroenterology. 2007;132(6):2253–2271. 17498516

31. Fleury J, Lee S. The social ecological model and physical activity in African American women. American Journal of Community Psychology. 2006;37(1–2):129–140. 16680541

32. Sallis J, Glanz K. The role of built environments in physical activity, eating, and obesity in childhood. The Future of Children. 2006;16(1):89–108. 16532660

33. Hey DW. Development of a multi-disciplinary ecological model for childhood obesity. Kinesiology. 2004;1–387.

34. Egger G, Swinburn B, Rossner S. Dusting off the epidemiological triad: could it work with obesity? Obesity Reviews. 2003;4(2):115–119. 12760446

35. Davison K, Birch L. Childhood overweight: a contextual model and recommendations for future research. Obesity Reviews. 2001;2(3):159–171. 12120101

36. Gregson J, Foerster S, Orr R, Jones L, Benedict J, Clarke B, et al. System, environmental, and policy changes: using the social-ecological model as a framework for evaluating nutrition education and social marketing programs with low-income audiences. Journal of Nutrition Education. 2001;33:S4–S15. 12857540

37. Nix S, Mullis R. Evaluation of a family centered obesity intervention program. Journal of the American Dietetic Association.1999;99(9):A55.

38. Swinburn B, Egger G, Raza F. Dissecting obesogenic environments: the development and application of a framework for identifying and prioritizing environmental interventions for obesity. Preventive Medicine. 1999;29(6):563–570.

39. Egger G, Swinburn B. An "ecological" approach to the obesity pandemic. BMJ. 1997;315(7106):477–480. doi: 10.1136/bmj.315.7106.477 9284671

40. Sallis JF, Owen N. Ecological models of health behavior. Health Behavior and Health Education: Theory, Research, and Practice. 2008;4:465–485.

41. Quinn T. Evaluating the health effects of social interventions. BMJ. 2004;328:282–285. doi: 10.1136/bmj.328.7434.282 14751903

42. Booth M, Wake M, Armstrong T, Chey T, Hesketh K, Mathur S. The epidemiology of overweight and obesity among Australian children and adolescents, 1995–97. Australian and New Zealand Journal of Public Health. 2001;25(2):162–168. 11357914

43. Economos C, Hyatt RR. Community interventions: a brief overview and their application to the obesity epidemic. Journal of Law, Medicine & Ethics. 2007;35(1):131–137.

44. Krieger N, Chen J, Coull B, Beckfield J, Kiang MV, Waterman PD. Jim Crow and premature mortality among the us black and white population, 1960–2009. Epidemiology. 2014;25(4):494–504. doi: 10.1097/EDE.0000000000000104 24825344

45. Lukachko A, Hatzenbuehler M, Keyes K. Structural racism and myocardial infarction in the United States. Social Science & Medicine. 2014;103:42–50.

46. Mobley L, Root E, Finkelstein E, Khavjou O, Farris RP, Will JC. Environment, obesity, and cardiovascular disease risk in low-income women. American Journal of Preventive Medicine. 2006;30(4):327–332. 16530620

47. Chou S, Grossman M, Saffer H. An economic analysis of adult obesity: results from the Behavioral Risk Factor Surveillance System. Journal of Health Economics. 2004;23(3):565–587. 15120471

48. Institute of Medicine. Preventing Childhood Obesity: Health in the Balance. Washington, DC: National Academies Press; 2005.

49. Lindsay A, Sussner K, Kim J, Gortmaker S. The role of parents in preventing childhood obesity. The Future of Children. 2006;16(1):169–186. 16532663

50. Schlicker S, Borra S, Regan C. The weight and fitness status of United States children. Nutrition Reviews. 1994;52(1):11–17. 8139795

51. Nicklas T. Dietary studies of children and young adults (1973–1988). American Journal of the Medical Sciences. 1995;310(1):S109.

52. Dietz W, Robinson T. Assessment and treatment of childhood obesity. Pediatrics in Review. 1993;14(9):337–343. 8247968

53. Abiola S, Mello MM. Obesity Prevention Policies. LawAtlas. Accessed May 15, 2018.

54. StateScape Legislative & Regulatory Tracking. Bill Effective Dates. Accessed August 3, 2015.

55. Macinko J, Silver D. Improving state health policy assessment: an agenda for measurement and analysis. Am J Public Health 2012;102:1697–1075. doi: 10.2105/AJPH.2012.300716 22813417

56. Wagenaar A, Livingston M, Staras S. Effects of a 2009 Illinois alcohol tax increase on fatal motor vehicle crashes. Am J Public Health. 2015:e1–e6.

57. Choo E, Benz M, Zaller N, Warren O, Rising KL, McConnell KJ. The impact of state medical marijuana legislation on adolescent marijuana use. Journal of Adolescent Health. 2014;55(2):160–166. doi: 10.1016/j.jadohealth.2014.02.018 24742758

58. Harper S, Strumpf E, Burris S, Smith GD, Lynch J. The effect of mandatory seat belt laws on seat belt use by socioeconomic position. J Pol Anal Manage. 2013;33(1):141–161.

59. Pomeranz J, Chriqui J. The Supplemental Nutrition Assistance Program: analysis of program administration and food law definitions. Am J Prev Med. 2015; doi: 10.1016/j.amepre.2015.02.027 26091926

60. Trust for America’s Health. The State of Obesity 2018. Accessed June 7, 2019.

61. Eyler A, Nguyen L, Kong J. Patterns and predictors of enactment of state childhood obesity legislation in the united states: 2006–2009. Am J Public Health. 2012;102(12):2294–2302. doi: 10.2105/AJPH.2012.300763 23078482

62. Boehmer T, Luke D, Haire-Joshu D, Bates HS, Brownson RC. Preventing childhood obesity through state policy. American Journal of Preventive Medicine. 2008;34(4):333–340. doi: 10.1016/j.amepre.2008.01.003 18374247

63. Boehmer T, Brownson RC. Patterns of childhood obesity prevention legislation in the United States. Preventing Chronic Disease. 4(3):56.

64. Dodson E, Fleming C, Boehmer T. Preventing childhood obesity through state policy: qualitative assessment of enablers and barriers. Journal of Public Health Policy. 2009;30:S161–S176. doi: 10.1057/jphp.2008.57 19190572

65. Cawley J, Liu F. Correlates of state legislative action to prevent childhood obesity. Obesity. 2008;16(1):162–167. doi: 10.1038/oby.2007.3 18223629

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