Summary

If local government officials were asked to describe their vision of what a healthy community looks like, they would probably cite many similar characteristics: effective and active schools; safe neighborhoods; clean parks and public spaces; and readily accessible services such as playgrounds, recreational facilities, libraries, and grocery stores. They might also paint a picture of healthy, happy children playing outside with their friends, walking to school, and eating healthy meals and snacks with their families and schoolmates.

This vision of healthy communities—places that promote the health and well-being of their residents—is a guidepost for childhood obesity prevention efforts. Taking actions that can make this vision a reality for all communities will help reverse and end this national epidemic. Childhood obesity has increased dramatically over the last three decades, and conditions in many communities continue to act as barriers to healthy eating and adequate physical activity. Childhood obesity is a serious health problem that has adverse and potentially long-lasting consequences for individuals, families, and communities. Perhaps most shocking, life expectancy for today’s children may be shortened in the United States because of the impact of childhood obesity (Olshansky and Ludwig, 2005).

The good news is that actions can be taken to prevent childhood obesity. Many of these actions, both policy and programmatic, can and should be taken at the local level. Two previous Institute of Medicine (IOM) reports take a comprehensive look at childhood obesity, present conclusions about likely causes and solutions, and offer recommendations for next steps (IOM, 2005, 2007). Many of these recommendations touch on the vital role of government actions at all



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Summary I f local government officials were asked to describe their vision of what a healthy community looks like, they would probably cite many similar characteristics: effective and active schools; safe neighborhoods; clean parks and public spaces; and readily accessible services such as playgrounds, recreational facilities, ­libraries, and grocery stores. They might also paint a picture of healthy, happy children playing outside with their friends, walking to school, and eating healthy meals and snacks with their families and schoolmates. This vision of healthy communities—places that promote the health and well-being of their residents—is a guidepost for childhood obesity prevention efforts. Taking actions that can make this vision a reality for all communities will help reverse and end this national epidemic. Childhood obesity has increased dra- matically over the last three decades, and conditions in many communities con- tinue to act as barriers to healthy eating and adequate physical activity. Childhood obesity is a serious health problem that has adverse and potentially long-lasting consequences for individuals, families, and communities. Perhaps most shocking, life expectancy for today’s children may be shortened in the United States because of the impact of childhood obesity (Olshansky and Ludwig, 2005). The good news is that actions can be taken to prevent childhood obesity. Many of these actions, both policy and programmatic, can and should be taken at the local level. Two previous Institute of Medicine (IOM) reports take a com- prehensive look at childhood obesity, present conclusions about likely causes and solutions, and offer recommendations for next steps (IOM, 2005, 2007). Many of these recommendations touch on the vital role of government actions at all 

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l ­evels—federal, state, and local—in childhood obesity prevention. Local govern- ment leadership is critical to both reducing and preventing further increases in childhood obesity. The places in which people live, work, study, and play have a strong influence on their ability to consume healthy foods and beverages and engage in regular physical activity. Local governments make decisions every day that affect these environments. Thus, this report focuses on specific actions for local governments and is meant to be a tool for use by local government o ­ fficials—mayors, managers, commissioners, council members, or administrators; elected, appointed, or hired; at the city, town, township, or county level—in plan- ning, implementing, and refining childhood obesity efforts in their jurisdictions. In 2008, the IOM Standing Committee on Childhood Obesity identified local government actions as key to front-line efforts addressing obesity prevention and requested a study to examine the evidence on such local government efforts, with a focus on identifying promising practices and developing a set of recom- mended actions. That committee was inspired by the recommendations in the previous IOM reports on childhood obesity and by the clear need for more detail at the local government level on which specific actions have the potential to make a difference. The IOM Committee on Childhood Obesity Prevention Actions for Local Governments was formed to address this task. The committee entered this project knowing that evidence on the best childhood obesity prevention practices is still accumulating and is limited in many important areas. However, the com- mittee also knew that many local government officials want to act now on the best available information. The committee reviewed the published literature, examined reports from organizations that work with local government, invited presentations from experts on the role of local government in obesity prevention, and explored a variety of toolkits that have been developed for communities. The committee worked to develop actionable recommendations for promoting healthy eating and physical activity and guided its decisions toward actions that are within the jurisdiction of local governments; are likely to affect children directly; are based on the experi- ence of local governments or knowledgeable sources that work with local govern- ments; and have the potential to make positive contributions to the achievement of healthy eating and/or optimum physical activity based on research evidence or, where such evidence is lacking or limited, a logical connection with the achieve- ment of healthier eating and increased physical activity. The committee developed a set of criteria to consider in assessing the actions to recommend. Using the best evidence available, the committee took into account effectiveness and effect size;  Local Government Actions to Prevent Childhood Obesity

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outcomes, including those not directly related to obesity prevention; potential reach, impact, and cost; and feasibility (see Appendix C). In this report, healthy eating refers to consuming the types and amounts of foods, nutrients, and calories recommended by the Dietary Guidelines for Americans (HHS and USDA, 2005). In the area of physical activity, current rec- ommendations are for children to engage in such activity at least 60 minutes per day (HHS and USDA, 2008). The committee targeted its recommendations to the food and physical activ- ity environments outside the school walls and the school day. What takes place inside schools from the morning bell to the end of the last class and its impact on childhood obesity has been widely discussed (IOM, 2005, 2007; Story et al., 2006). By contrast, many other aspects of children’s environments, from the accessibility and maintenance of neighborhood playgrounds to the food and beverage choices offered in after-school programs, have not been discussed and publicized to the same extent. Therefore, the report generally focuses on nonschool issues. This focus does not imply that schools are unimportant in the prevention of childhood obesity. In fact, the involvement of schools in obesity prevention is vital; obesity prevention initiatives undertaken outside of schools will be stronger and have a greater impact if they are coordinated with and complement those of schools. In this report, the committee recommends nine healthy eating strategies and six physical activity strategies that local governments should consider. These strategies are organized under three healthy eating goals and three physical activ- ity goals. For each strategy, the report recommends a set of actions that have the potential to make a difference. The report also highlights 12 actions that the com- mittee believes have the greatest potential, based on an assessment of the available research evidence and a logical connection with the achievement of healthier eat- ing and increased physical activity. These 12 actions are highlighted in the list of goals, strategies, and actions at the end of this summary. Evidence points to multisectoral initiatives (involving government, schools, the private sector, nonprofit organizations, and families) as being most effec- tive in promoting and sustaining a healthy environment for children and youth (Economos et al., 2007; Sacks et al., 2008; Samuels and Associates, 2009). In many communities, however, policy makers may want to begin their obesity pre- vention efforts with some individual actions that they believe would be a good starting point, in preparation for later work on broader efforts. While overall strategies can be recommended in accordance with evidence- based research, this information must be balanced with the need for community Summary 

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participation in defining what is needed. The local context—including resources, demographics, culture, geographic location, and jurisdictional authority—will drive decisions on the policies and initiatives that can be implemented and sus- tained. While overall strategies can be recommended, and a range of potential actions to implement those strategies can be recommended, local officials and their community partners must use their own collective knowledge, judgment, and expertise to choose the best actions for their locality. Actions chosen must be a good fit for the community, and local government officials must be able to con- vince supporters and funders that these steps are important. As local government officials work to understand the characteristics, needs, and assets of their communities, it will be critically important to involve con- cerned community members in examining, recommending, and building support for particular actions. These community members should include, among many others, parents, youth, and health providers. In addition, it will be important to partner with neighborhood-based grassroots nonprofit organizations, since they often have established networks for communication and outreach to residents. Active leadership is also key, and many mayors, city council representatives, and others have already taken the initiative to be prominently engaged in leading com- munity efforts and involving community coalitions in promoting access to and availability of healthy choices and a healthy environment for their community. Particular attention should be paid to conditions that result in unequal access to opportunities for healthy foods and beverages and physical activ- ity. Factors such as poverty, poor housing, racial segregation, lack of access to q ­ uality education, and limited access to health care can influence access to healthy food and physical activity in negative ways. Understanding this interrelation- ship in the case of childhood obesity could lead local officials to note that many lower-income children in their jurisdiction do not engage in physical activity, and consequently to examine the equity of access to parks and recreational opportu- nities and safe neighborhoods and work to end these inequities. Local officials might observe inadequate consumption of fruits and vegetables among children in some parts of the community, and then consider and seek solutions to the unequal accessibility and affordability of healthy foods in these neighborhoods. Achieving health equity—“the fair distribution of health determinants, outcomes, and resources within and between segments of the population regardless of social standing” (CDC, 2007)—requires local governments to focus their obesity preven- tion efforts on historically disadvantaged communities with disproportionately high rates of obesity.  Local Government Actions to Prevent Childhood Obesity

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Finally, as obesity prevention actions are implemented, they will need to be evaluated. Local governments can contribute to the evidence base on what does and does not work by emphasizing and funding assessments of obesity prevention efforts. Partnerships with local universities can be particularly valuable in con- ducting these evaluations. Lessons learned through experimentation and formal evaluation can assist a community in making better decisions about future actions while helping other communities like them become more successful in preventing childhood obesity. REFERENCES CDC (Centers for Disease Control and Prevention). 2007 (unpublished). Health Equity Working Group. Atlanta, GA: CDC. Economos, C. D., R. R. Hyatt, J. P. Goldberg, A. Must, E. N. Naumova, J. J. Collins, and M. E. Nelson. 2007. A community intervention reduces BMI z-score in children: Shape Up Somerville first year results. Obesity 15(5):1325–1336. HHS and USDA (U.S. Department of Health and Human Services and U.S. Department of Agriculture). 2005. Dietary Guidelines for Americans 2005. http://www.healthierus. gov/dietaryguidelines (accessed February 25, 2009). HHS and USDA. 2008. Physical Activity Guidelines for Americans. http://www.health.gov/ paguidelines/guidelines/default.aspx (accessed May 19, 2009). IOM (Institute of Medicine). 2005. Preventing Childhood Obesity: Health in the Balance. Washington, DC: The National Academies Press. IOM. 2007. Progress in Preventing Childhood Obesity: How Do We Measure Up? Washington, DC: The National Academies Press. Olshansky, S. J., and D. S. Ludwig. 2005. Effect of obesity on life expectancy in the U.S. Food Technology 59(7):112. Sacks, G., B. A. Swinburn, and M. A. Lawrence. 2008. A systematic policy approach to changing the food system and physical activity environments to prevent obesity. Australia and New Zealand Health Policy 5. Samuels and Associates. 2009. Healthy Eating, Active Communities (HEAC) Phase 1 Evaluation Findings, 2005–2008. Executive Summary. http://samuelsandassociates.com/ samuels/index.php?option=com_content&view=article&id=27&Itemid=11 (accessed July 13, 2009). Story, M., K. M. Kaphingst, and S. French. 2006. The role of schools in obesity preven- tion. Future of Children 16(1):109–142. Summary 

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Actions for Healthy Eating (Bold denotes most promising action steps) GOAL 1: IMPROVE ACCESS TO AND CONSUMPTION OF HEALTHY, SAFE, AND AFFORDABLE FOODS Strategy 1: Retail Outlets Increase community access to healthy foods through supermarkets, grocery stores, and convenience/corner stores. Action Steps • Create incentive programs to attract supermarkets and grocery stores to underserved neighborhoods (e.g., tax credits, grant and loan programs, small business/economic devel- opment programs, and other economic incentives). • Realign bus routes or provide other transportation, such as mobile community vans or shuttles to ensure that residents can access supermarkets or grocery stores easily and affordably through public transportation. • Create incentive programs to enable current small food store owners in underserved areas to carry healthier, affordable food items (e.g., grants or loans to purchase refrigeration equipment to store fruits, vegetables, and fat-free/low-fat dairy; free publicity; a city awards program; or linkages to wholesale distributors). • Use zoning regulations to enable healthy food providers to locate in underserved neighborhoods (e.g., “as of right” and “conditional use permits”). • Enhance accessibility to grocery stores through public safety efforts, such as better outdoor lighting and police patrolling. Strategy 2: Restaurants Improve the availability and identification of healthful foods in restaurants. Action Steps • Require menu labeling in chain restaurants to provide consumers with calorie information on in-store menus and menu boards. • Encourage non-chain restaurants to provide consumers with calorie information on in-store menus and menu boards. • Offer incentives (e.g., recognition or endorsement) for restaurants that promote healthier options (for example, by increasing the offerings of healthier foods, serving age-appropriate portion sizes, or mak- ing the default standard options healthy—i.e., apples or carrots instead of French fries, and non-fat milk instead of soda in “kids’ meals”).  Local Government Actions to Prevent Childhood Obesity

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Strategy 3: Community Food Access Promote efforts to provide fruits and vegetables in a variety of settings, such as farmers’ markets, farm stands, mobile markets, community gardens, and youth- focused gardens. Action Steps • Encourage farmers markets to accept Special Supplemental Nutrition Program for Women, Infants and Children (WIC) food package vouchers and WIC Farmers Market Nutrition Program coupons; and encourage and make it possible for farmers markets to accept Supplemental Nutrition Assistance Program (or SNAP, formerly the Food Stamp Program) and WIC Program Electronic Benefit Transfer (EBT) cards by allocating funding for equipment that uses electronic methods of payment. • Improve funding for outreach, education, and transportation to encourage use of farmers’ markets and farm stands by residents of lower-income neighborhoods, and by WIC and SNAP recipients. • Introduce or modify land use policies/zoning regulations to promote, expand, and protect potential sites for community gardens and farmers’ markets, such as vacant city-owned land or unused parking lots. • Develop community-based group activities (e.g., community kitchens) that link procurement of afford- able, healthy food with improving skills in purchasing and preparing food. Strategy 4: Public Programs and Worksites Ensure that publicly run entities such as after-school programs, child care facilities, recreation centers, and local government worksites implement policies and practices to promote healthy foods and beverages and reduce or eliminate the availability of calorie-dense, nutrient-poor foods. Action Steps • Mandate and implement strong nutrition standards for foods and beverages available in government-run or regulated after-school programs, recreation centers, parks, and child care facilities (which includes limiting access to calorie-dense, nutrient-poor foods). • Ensure that local government agencies that operate cafeterias and vending options have strong nutri- tion standards in place wherever foods and beverages are sold or available. • Provide incentives or subsidies to government-run or -regulated programs and localities that provide healthy foods at competitive prices and limit calorie-dense, nutrient-poor foods (e.g., after-school pro- grams that provide fruits or vegetables every day, and eliminate calorie-dense, nutrient-poor foods in vending machines or as part of the program). Summary 

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Strategy 5: Government Nutrition Programs Increase participation in federal, state, and local government nutrition assistance programs (e.g., WIC, School Breakfast and Lunch Programs, the Child and Adult Care Food Program, the Afterschool Snacks Program, the Summer Food Service Program, SNAP). Action Steps • Put policies in place that require government-run and -regulated agencies responsible for administer- ing nutrition assistance programs to collaborate across agencies and programs to increase enrollment and participation in these programs (i.e., WIC agencies should ensure that those who are eligible are also participating in SNAP, etc.). • Ensure that child care and after-school program licensing agencies encourage utilization of the nutrition assistance programs and increase nutrition program enrollment (CACFP, Afterschool Snack Program, and the Summer Food Service Program). Strategy 6: Breastfeeding Encourage breastfeeding and promote breastfeeding-friendly communities. Action Steps • Adopt practices in city and county hospitals that are consistent with the Baby-Friendly Hospital Initiative USA (United Nations Children’s Fund/World Health Organization). This initiative promotes, protects, and supports breastfeeding through 10 steps to successful breastfeeding for hospitals. • Permit breastfeeding in public places and rescind any laws or regulations that discourage or do not allow breastfeeding in public places and encourage the creation of lactation rooms in public places. • Develop incentive programs to encourage government agencies to ensure breastfeeding-friendly worksites, including providing lactation rooms. • Allocate funding to WIC clinics to acquire breast pumps to loan to participants. Strategy 7: Access to Drinking Water Increase access to free, safe drinking water in public places to encourage consumption of water instead of sugar-sweetened beverages. Action Steps • Require that plain water be available in local government-operated and administered outdoor areas and other public places and facilities. • Adopt building codes to require access to, and maintenance of, fresh drinking water f ­ ountains (e.g., public restroom codes).  Local Government Actions to Prevent Childhood Obesity

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GOAL 2: REDUCE ACCESS TO AND CONSUMPTION OF CALORIE-DENSE, NUTRIENT-POOR FOODS Strategy 8: Policies and Ordinances Implement fiscal policies and local ordinances that discourage the consumption of calorie-dense, nutrient-poor foods and beverages (e.g., taxes, incentives, land use and zoning regulations). Action Steps • Implement a tax strategy to discourage consumption of foods and beverages that have minimal nutritional value, such as sugar-sweetened beverages. • Adopt land use and zoning policies that restrict fast food establishments near school grounds and public playgrounds. • Implement local ordinances to restrict mobile vending of calorie-dense, nutrient-poor foods near schools and public playgrounds. • Implement zoning designed to limit the density of fast food establishments in residential communities. • Eliminate advertising and marketing of calorie-dense, nutrient-poor foods and beverages near school grounds and public places frequently visited by youths. • Create incentive and recognition programs to encourage grocery stores and convenience stores to reduce point-of-sale marketing of calorie-dense, nutrient-poor foods (i.e., promote “candy-free” check out aisles and spaces). GOAL 3: RAISE AWARENESS ABOUT THE IMPORTANCE OF HEALTHY EATING TO PREVENT CHILDHOOD OBESITY Strategy 9: Media and Social Marketing Promote media and social marketing campaigns on healthy eating and childhood obesity prevention. Action Steps • Develop media campaigns, utilizing multiple channels (print, radio, Internet, television, social networking, and other promotional materials) to promote healthy eating (and active living) using consistent messages. • Design a media campaign that establishes community access to healthy foods as a health equity issue and reframes obesity as a consequence of environmental inequities and not just the result of poor per- sonal choices. • Develop counter-advertising media approaches against unhealthy products to reach youth as has been used in the tobacco and alcohol prevention fields. Summary 

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Actions for Increasing Physical Activity (Bold denotes most promising action steps) GOAL 1: ENCOURAGE PHYSICAL ACTIVITY Strategy 1: Built Environment Encourage walking and bicycling for transportation and recreation through improvements in the built environment. Action Steps • Adopt a pedestrian and bicycle master plan to develop a long-term vision for walking and bicycling in the community and guide implementation. • Plan, build, and maintain a network of sidewalks and street crossings that creates a safe and comfortable walking environment and that connects to schools, parks, and other d ­ estinations. • Plan, build, and retrofit streets so as to reduce vehicle speeds, accommodate bicyclists, and improve the walking environment. • Plan, build, and maintain a well-connected network of off-street trails and paths for pedestrians and bicyclists. • Increase destinations within walking and bicycling distance. • Collaborate with school districts and developers to build new schools in locations central to residential areas and away from heavily trafficked roads. Strategy 2: Programs for Walking and Biking Promote programs that support walking and bicycling for transportation and recreation. Action Steps • Adopt community policing strategies that improve safety and security of streets, especially in higher crime neighborhoods.* • Collaborate with schools to develop and implement a Safe Routes to School program to increase the number of children safely walking and bicycling to schools. • Improve access to bicycles, helmets, and related equipment for lower-income families, for example, through subsidies or repair programs. • Promote increased transit use through reduced fares for children, families, and students, and improved service to schools, parks, recreation centers, and other family destinations. • Implement a traffic enforcement program to improve safety for pedestrians and bicyclists. *Two action steps on community policing were combined for the most promising 12 action steps list. 10 Local Government Actions to Prevent Childhood Obesity

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Strategy 3: Recreational Physical Activity Promote other forms of recreational physical activity. Action Steps • Build and maintain parks and playgrounds that are safe and attractive for playing, and in close proximity to residential areas. • Adopt community policing strategies that improve safety and security for park use, espe- cially in higher crime neighborhoods.* • Improve access to public and private recreational facilities in communities with limited recreational options through reduced costs, increased operating hours, and development of culturally appropriate activities. • Create after-school activity programs (e.g., dance classes, city-sponsored sports, supervised play, and other publicly or privately supported active recreation). • Collaborate with school districts and other organizations to establish joint use of facilities agreements allowing playing fields, playgrounds, and recreation centers to be used by com- munity residents when schools are closed; if necessary, adopt regulatory and legislative policies to address liability issues that might block implementation. • Create and promote youth athletic leagues and increase access to fields, with special emphasis on income and gender equity. • Build and provide incentives to build recreation centers in neighborhoods. Strategy 4: Routine Physical Activity Promote policies that build physical activity into daily routines. Action Steps • Institute regulatory policies mandating minimum play space, physical equipment, and dura- tion of play in preschool, after-school, and child care programs. • Develop worksite policies and practices that build physical activity into routines (for example, exercise breaks at a certain time of day and in meetings or walking meetings). Target worksites with high per- centages of youth employees and government-run and -regulated worksites. • Create incentives for remote parking and drop-off zones and/or disincentives for nearby parking and drop-off zones at schools, public facilities, shopping malls, and other destinations. • Improve stairway access and appeal, especially in places frequented by children. *Two action steps on community policing were combined for the most promising 12 action steps list. Summary 11

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GOAL 2: DECREASE SEDENTARY BEHAVIOR Strategy 5: Screen Time Promote policies that reduce sedentary screen time. Action Steps • Adopt regulatory policies limiting screen time in preschool and after-school programs. GOAL 3: RAISE AWARENESS OF THE IMPORTANCE OF INCREASING PHYSICAL ACTIVITY Strategy 6: Media and Social Marketing Develop a social marketing campaign that emphasizes the multiple benefits for children and families of sustained physical activity. Action Steps • Develop media campaigns, utilizing multiple channels (print, radio, Internet, television, other promo- tional materials) to promote physical activity using consistent messages. • Design a media campaign that establishes physical activity as a health equity issue and reframes obe- sity as a consequence of environmental inequities and not just the result of poor personal choices. • Develop counter-advertising media approaches against sedentary activity to reach youth as has been done in the tobacco and alcohol prevention fields. 12 Local Government Actions to Prevent Childhood Obesity