2
Acting Locally

Whether rural, suburban, or urban, most communities in the United States are affected by rising rates of childhood obesity. Healthy eating and physical activity are strongly associated with obesity prevention and are essential to good health. The food and physical activity choices made every day affect short-and long-term health and are directly related to weight outcomes. Eating right and being physically active may reduce the risk for heart disease, high blood pressure, diabetes, osteoporosis, certain cancers, and being overweight or obese (HHS and USDA, 2005). These diseases and conditions impact individuals and their quality of life and are associated with increasing health care costs that place a burden on government and businesses. Childhood provides the opportunity to establish a solid foundation that can lead to healthy lifelong eating patterns (IOM, 2005). Prevention of childhood obesity is essential to the promotion of a healthier and more productive society (IOM, 2005). In addition, many diet-related chronic diseases have their origins during childhood and adolescence.

Local governments make many of the decisions that affect access to healthy food and opportunities for physical activity and therefore play an important role in preventing childhood obesity. Because many children in cities and towns nationwide are facing the health and emotional consequences of childhood obesity, it is incumbent upon local governments to strengthen the role they play in providing their children and youth with access to and availability of healthy choices.

Local government agencies have traditionally been the primary overseers and implementers of public health programs and policies. The functions of local governments include leadership, provision of program resources, funding, evalua-



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2 Acting Locally W hether rural, suburban, or urban, most communities in the United States are affected by rising rates of childhood obesity. Healthy eating and physi- cal activity are strongly associated with obesity prevention and are essential to good health. The food and physical activity choices made every day affect short- and long-term health and are directly related to weight outcomes. Eating right and being physically active may reduce the risk for heart disease, high blood pressure, diabetes, osteoporosis, certain cancers, and being overweight or obese (HHS and USDA, 2005). These diseases and conditions impact individuals and their ­quality of life and are associated with increasing health care costs that place a burden on government and businesses. Childhood provides the opportunity to establish a solid foundation that can lead to healthy lifelong eating patterns (IOM, 2005). Prevention of childhood obesity is essential to the promotion of a healthier and more productive society (IOM, 2005). In addition, many diet-related chronic dis- eases have their origins during childhood and adolescence. Local governments make many of the decisions that affect access to healthy food and opportunities for physical activity and therefore play an important role in preventing childhood obesity. Because many children in cities and towns nation- wide are facing the health and emotional consequences of childhood obesity, it is incumbent upon local governments to strengthen the role they play in providing their children and youth with access to and availability of healthy choices. Local government agencies have traditionally been the primary overseers and implementers of public health programs and policies. The functions of local governments include leadership, provision of program resources, funding, evalua- 25

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tion, monitoring and research, and dissemination and use of evidence from evalu- ations (IOM, 2007). Local governments across the nation comprise a variety of departments, including public health, public works, transportation, parks and recreation, public safety, planning, economic development, housing, and tourism. These departments’ policies and programs can affect childhood obesity directly and indirectly. For example, reducing vehicle traffic in a city for the purpose of reducing air pollution may also make it easier for people to walk to their destina- tions. Likewise, as noted in Chapter 1, policies and programs developed to prevent childhood obesity can meet other local government goals as well. For example, after-school recreation programs implemented to increase physical activity with obesity prevention in mind can help meet crime prevention goals by reducing opportunities for youth to be victims or perpetrators of crime. Since in some cases it is a great deal easier for a local government official to advocate for youth- related crime reduction measures than for childhood obesity prevention interven- tions, taking advantage of these multiple positive outcomes can be useful. Box 2-1 describes one city’s sustainability plan that, although not focused explicitly on childhood obesity, contains many childhood obesity prevention strategies. HOW LOCAL GOVERNMENTS CAN HELP Provide Leadership Local government leadership is critical to both reducing and preventing further increases in childhood obesity. Leadership requires galvanizing of political com- mitment, policy development, prioritized funding, and coordination of programs (Baker and Porter, 2005). Officials at the local level can work to adopt policies and pass ordinances that enable communities to have accessible and affordable options for healthy food and physical activity. Throughout the United States, mayors, city council members, and other local officials have initiated and led city- wide campaigns and followed through on commitments to lead community walks and other fitness activities, in addition to providing leadership through innova- tive policy and program changes. Box 2-2 describes the example of a mayor who spearheaded a comprehensive health campaign in his small, rural town. Support for community coalitions focused on improving wellness is an additional key leader­ship contribution. 26 Local Government Actions to Prevent Childhood Obesity

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Box 2-1 Dual Outcomes The City of Baltimore was named among the top ten most sustainable U.S. cities in SustainLane’s 2008 U.S. City Rankings. Among the factors making Baltimore a national leader was the creation of the Baltimore Office of Sustainability and Commission on Sustainability. Baltimore Councilman Jim Kraft sponsored legislation to create both the office and the commission. The 21-member commission represents community organizations, local nonprofits, labor, private industry, local institutions, and city government. It was charged with developing and implementing a comprehensive Sustainability Plan to help turn Baltimore into a cleaner, greener, healthier, and safer city. The plan is a roadmap for future legislation, educational programming, and public and private initiatives involving sustainability. The commission created working groups, community conversations, a youth strategy, and a sustain- ability forum to gather input from all sections and perspectives within Baltimore. Ultimately, more than 1,000 citizens were engaged over an eight-month period. The commission gathered and analyzed ideas, studied best practices, and developed goals for a more sustainable city. The resulting Sustainability Plan lays out 29 priority goals within seven chapters: Cleanliness, Pollution Prevention, Resource Conservation, Greening, Transportation, Education and Awareness, and Green Economy. Each of the 29 goals is accompanied by a set of recommended strategies. The plan lays out a broad agenda that, in addition to recommending strategies for reducing pollution and conserving energy, offers recommendations for creating a healthier community. Many of these strategies relate to food access, transportation, and the built environment and so may help reduce and prevent obesity. Implementation of the plan not only will make Baltimore a cleaner, greener, healthier, and safer city, but also has the potential to reduce and prevent childhood obesity. SOURCE: Baltimore Sustainability Plan, http://www.baltimorecity.gov/government/planning/sustainability. Implement Policies, Ordinances, and Programs Local governments are in a unique position to improve the health of their commu- nities by advancing local policies that have an impact on the availability of healthy foods and places for physical activity and that also limit less healthy options. Local governments have jurisdiction over land use, food marketing, community planning, and transportation. Today, communities with the highest rates of obesity often are places where residents have the fewest convenient opportunities to purchase Acting Locally 27

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Box 2-2 Comprehensive Obesity Prevention Efforts in a Rural Setting Shelby is a rural town in eastern Montana with a population of approximately 3,000. Mayor Larry Bonderud has held his position for 18 years. After several years of attending conferences and reading about the environment and its effects on public health, Mayor Bonderud was inspired to make some significant city-wide changes. Like most rural towns, Shelby does not have a large public health budget. However, with the leadership of the mayor, the community has been able to initiate and implement a number of obesity prevention strategies: • After surveying residents in the city newsletter, the mayor concluded that a fitness center was the first logical step for obesity prevention in Shelby. In partnership with a local hospital, he spearhead- ed an effort to install a fitness center in the local civic center and to hire a trainer. Memberships help sustain the center. The mayor and his community partners convinced major local employers to subsidize fitness center memberships for employees. •  mayor and his committee of stakeholders planned a 6-mile paved walking trail that links the The business district, residential neighborhoods, the Civic Center, the hospital, and schools to public lands. The trail was financed by the City of Shelby; the Community Transportation Enhancement Program; the Montana Fish, Wildlife and Parks Urban Recreational Trails Program; the Shelby Theme Committee; and in-kind contributions of labor and materials. Social marketing campaigns are being used to promote the trail. •  partnership with others, the local health department developed a low-cost surveillance system to In collect baseline data on breastfeeding rates in Shelby because of the strong association between breastfeeding and prevention of obesity later in life. The county public health nurse calls each new mother to see whether she needs information or resources. The nurse also asks if the mother is still breastfeeding, if she is feeding her child other foods, and if there are any factors that make it dif- ficult to continue breastfeeding. The nurse repeats her calls quarterly. The county uses this informa- tion to help health care providers learn what interventions might increase breastfeeding initiation and duration. • After surveying all Shelby households, Mayor Bonderud found that residents were overwhelmingly in favor of improving access to healthy foods in restaurants. He is working with Shelby restaurant managers and major food distributors to place healthier items on the menu. Once such items are in place, he hopes to conduct a promotional campaign aimed at encouraging residents to support those restaurants offering healthy food and to order the healthier items off the menu. SOURCE: Baehr, 2008. 28 Local Government Actions to Prevent Childhood Obesity

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n ­ utritious, affordable food and more opportunities to purchase less healthy choices (Flournoy and Treuhaft, 2005). As described in Chapter 4, relevant policy measures such as those focused on zoning of farmers’ markets, location of supermarkets, lim- itations on advertising of unhealthy products, and requirements for menu labeling in restaurants all have the potential to affect consumption of fruits and vegetables and/or weight. Box 2-3 details how New York City enacted its menu labeling legis- lation, becoming the first city in the United States to mandate such labeling. Similarly, Chapter 5 describes actions that local governments can take to increase physical activity through policy measures that affect the design of com- munities, access to parks and recreation facilities, and availability of sidewalks with safe pedestrian crossings. These actions affect the built environment, defined as all of the man-made elements of the physical environment, including buildings, infra- structure, and other physical elements created or modified by people, and the func- tional use, arrangement, and aesthetic qualities of these elements. The built envi- ronment can influence decisions on whether to be physically active. Evidence shows that people in activity-friendly environments are more likely to be physically active and have a lower risk of obesity (Frank et al., 2004). For example, children with sidewalks in their neighborhood and playgrounds in close proximity have more opportunities to be physically active. Local governments can influence community development and planning; zoning; and availability of, access to, and maintenance of parks and recreation facilities. In addition, reviewing transportation policies in a community can lead to improved access to opportunities for physical activity. Box 2-4 highlights the opportunities local governments have to provide support and resources to local organizations working to create healthy environments. DIFFERENT COMMUNITIES, DIFFERENT NEEDS As discussed in Chapter 1, each town, city, township, or community is unique, and only local government leaders can identify the policies and programs that accord with the resources and interests of their jurisdiction. Differences in geography, pop- ulation, resources, and size present both challenges and opportunities for childhood obesity prevention efforts. Furthermore, local governance structures vary, differing in the extent of the local government’s jurisdictional authority over schools, zoning, transportation policies, and many other issues. Sources of budget revenue and bud- get priorities and commitments also differ. Rural, suburban, and urban communities all have different needs with respect to childhood obesity prevention. According to the U.S. Census, Acting Locally 29

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Box 2-3 Menu Labeling Legislation New York City has a population of more than 8 million, with millions of meals served in restaurants every day. In 2006, the New York City Board of Health unanimously voted to require chain restaurants to place calorie information on menus as a way to inform consumers about the health content of the food choices on the menu. New York City was the first city in the United States to require such action by restaurants. Menu labeling initiatives are being introduced across the country, but thus far, only New York City, Philadelphia, Seattle, Multnomah County in Oregon, and the states of California and Massachusetts have passed such legislation, and only New York City and Seattle have seen menu label- ing go into effect. By April 2008, all chain restaurants in New York City with more than 15 outlets were required to include calorie information on menus and menu boards. Since the 1960s, expenditure on foods eaten away from home has steadily increased (ERS, 2008). Eating out is associated with higher calorie intake and obesity (Duffey, 2007). Children consume almost twice as many calories when they eat restaurant meals compared with meals at home (770 vs. 420 calories) (Thompson et al., 2004). Many health professionals believe that menu labeling is a way for our “eating out” society to gain insight into restaurant food choices, just as nutrition labeling did for packaged foods. Studies have shown that most people cannot successfully estimate the calorie content of menu items, even when it comes to “healthy-sounding” items such as salads (Burton et al., 2006). Proponents believe that a consumer will choose healthier food if given nutrition information at the point of purchase. Some restaurants may even change the size or ingredients of menu items if required to display nutrition information. Research is limited, but thus far supports this viewpoint. In a 2007 New York City survey, more than one-third of patrons at a popular fast-food restaurant that posts calorie information reported that this information affected their purchase. Patrons who saw the calorie information posted at the restaurant purchased, on average, food with 99 fewer calories compared with patrons who did not see that infor- mation posted (Basset et al., 2008). As more local health departments follow New York City’s lead, there will be additional research on this possible obesity prevention strategy. SOURCE: New York City Department of Health and Mental Hygiene, www.nyc.gov/html/doh. 30 Local Government Actions to Prevent Childhood Obesity

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Box 2-4 Encouraging Local Organizations to Be Fit Austin, the capital of Texas, is a midsized city with a culturally diverse population of about 718,000. Austin is known for being socially progressive and health conscious, with its popular hike-and-bike trail, many farmers’ markets, and the country’s first Whole Foods supermarket. So Mayor Will Wynn was sur- prised to see Austin’s poor ranking in a Men’s Fitness magazine list of fittest cities a few years ago. He was inspired to form the Mayor’s Fitness Council in October 2004 to help Austin become the fittest city in the country by 2010. The council works toward increasing physical activity and improving nutrition throughout Austin. It con- sists of three committees that meet frequently to develop and implement programs. One such program is the Partner Certification Program, which encourages local organizations to help their employees or members become more fit. Certified Partners can include virtually any organization. Membership includes resident advocates from the public and private sectors, neighborhoods, schools, businesses, health care entities, and the faith-based community. Organizations can be certified by increasing: • Access to smoke-free areas, fruits and vegetables, and opportunities for physical activity; • Social support in the form of people participating together and encouraging each other in healthy behaviors; • Incentives and rewards for people who engage in healthy behaviors; • Decision prompts such as “Take the Stairs” signs near the elevators; • Awareness through classes, e-mails, posters, etc.; and • System changes such as cafeteria menu improvements. The council developed the Austin Fitness Index, a survey tool that helps organizations monitor their employees’ or members’ health and track their improvements over time. The city assists companies that apply for the program in instituting programs and policy changes to help their employees become more fit. The city hopes that the benefits of increased employee health, such as better attitudes, ­productivity, and individual and organizational performance, will inspire many local organizations to become Certified Partners. SOURCE: The Austin Fitness Index, http://www.ci.austin.tx.us/afi/default.htm. Acting Locally 31

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a ­ pproximately 55 million people (an estimated 20 percent of the U.S. popula- tion) live in rural communities spread across 85 percent of the United States. Children living in rural areas are recognized as being at high risk for childhood obesity (Dillon and Rowland, 2008); currently, 16.5 percent of rural children and 20.4 percent of rural adults are obese (Patterson et al., 2004). Challenges faced by some rural community residents include relative poverty; the need to travel long distances, requiring increased automobile use; fewer walking or biking routes; a lack of public transportation; and a lack of supermarkets. Suburban communities are the fastest-growing areas in the United States. These communities have higher-density populations than rural communities, but may not always have convenient access to healthy food and opportunities for physical activity. Research has shown that several features of the suburban built environment, such as poor street connectivity and lack of sidewalks, are associated with decreased physical activity (Lopez and Hynes, 2006). However, new develop- ment offers the opportunity to plan healthier communities. The design of many new planned suburban communities includes “smart-growth” features such as sidewalks, parks, playgrounds, grocery stores and shops within walking distance, trails and bike paths, and easy access to public transportation. Urban communities often have dense neighborhoods with excellent street connectivity, and streets almost always have sidewalks. Yet these communities also have poor economic conditions, unsafe streets, lack of access to nutritious food or grocery stores, and a high density of fast-food restaurants. As each town or city government examines what it can do to promote health and wellness opportunities for its residents, it is important for local officials to consider the context and identify those strategies and actions most suited to their jurisdiction. Chapters 4 and 5 provide a broad array of actions from which local officials can choose to help initiate childhood obesity prevention efforts in their community. While a comprehensive approach is ideal, implementing even one or two actions could make an evident difference in the health of the community. STEPS IN PLANNING LOCAL CHILDHOOD OBESITY PREVENTION EFFORTS Local governments should consider the following steps as they plan childhood obesity prevention efforts: 1. Conduct a community assessment 2. Involve constituents 3. Identify top policy priorities best suited to local conditions 32 Local Government Actions to Prevent Childhood Obesity

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4. Identify funding sources 5. Think about program sustainability 6. Evaluate programs and policies 1.  Conduct a Community Assessment Local government officials should consider initiating their efforts by conducting a community assessment of access to healthy food and opportunities for physical activity to determine where the community stands with respect to providing an optimal environment to support the healthy weight of children. Examples of com- munity characteristics to include in this assessment are • Location of grocery stores and supermarkets • Location of fast-food restaurants • Location of corner stores • Location of vending machines • Location of farmers’ markets • Location of food carts • Location of water fountains in public facilities • Extent of advertising of unhealthy food • Statistics on and perceptions of safety • Ease and safety of walking to school • Location of walking and biking trails • Condition and connectivity of sidewalks • Condition and accessibility of youth activities and sports • Location and availability of public transportation to grocery stores and r ­ ecreational facilities • Participation rates in federal nutrition assistance programs • Location of community gardens Using this and other relevant information, local governments can identify what features that promote healthy weight already exist in their community and what is still needed. Policies and programs can then be created to meet those needs. In addition, it is important to identify resources and databases already in existence that can be used to learn more about the community. For example, information related to the health of the community can be drawn from a number of local government entities, including the zoning and planning department, the department of health, the tax assessor, schools and the transportation department, the county extension office, and mental health services. In addition, an academic Acting Locally 33

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Percent Percent Percent 7-12 0-19 0-8 13-17 20-26 9-11 18-23 27-32 12-18 Percent of New Yorkers Percent Obese Percent with Diabetes Who Did Not Eat Fruits or Vegetables on the Previous Day FIGURE 2-1  Neighborhoods where fruit and vegetable consumption is low have high rates of obesity and diabetes. SOURCE: New York Department of Health and Mental Hygiene, 2004 Community Health Survey. 2-1 partner from a local university or health department can provide necessary epide- miological or statistical support. Figure 2-1 and Box 2-5 illustrate the use of map- ping to assess community health statistics. 2.  Involve Constituents Community involvement is vital to implementing effective childhood obesity pre- vention efforts. If people feel free to speak and are listened to, they may reveal barriers to healthy eating and physical activity or identify critical community needs of which local government officials and staff are not aware. Local govern- ment officials and staff also should consider developing, co-convening, or support- ing a community partnership that can help determine needs, prioritize actions, and contribute to advancing community efforts on obesity prevention. Many national youth organizations with local chapters across the country could be helpful, such as the Boys and Girls Clubs, youth sports and recreation leagues, YMCA and YWCA, 4-H clubs, and Boy and Girl Scouts. In addition to or in conjunction with such partnerships, an interagency planning commission can include effective rep- resentation of the key local departments and agencies with jurisdiction for ensur- ing action and fostering sustained efforts. Box 2-6 provides a brief overview of the community engagement and partnership efforts found to be effective in King County, Washington. 34 Local Government Actions to Prevent Childhood Obesity

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Box 2-5 Communicating Community Statistics with Maps Maps allow local officials to relate characteristics of a community to its geographic layout. Considering that the place where one lives has a significant effect on health, it is helpful to understand and repre- sent data about that place visually. Mapping using geographic information systems has been shown to be a critical tool in performing a community assessment. Maps are an efficient, low-cost way to explain complex statistics associated with particular places, and from a different vantage point than is gained through words. In addition, when seemingly unrelated data are represented spatially, it is often pos- sible to make associations that might otherwise not have been apparent. Maps can highlight ­farmers’ m ­ arkets, access to food stores, parks, places to walk, public transportation routes, shops, access to health care, and other features that help provide for a healthy community. When performing an assessment of diet-related diseases, New York City collected data on fruit and vegetable consumption, obesity rates, and diabetes rates and represented those data spatially through maps. Comparison of these maps revealed a clear visual association between the neighborhoods that consumed the fewest fruits and vegetables and those with the highest rates of obesity and diabetes. This information provided a clear target for where the city should direct its Green Cart program, a program that encouraged street vendors to sell low-cost fruits and vegetables. Using maps of the city showing such factors as income, population density, automobile access, and access to fruits and veg- etables, the city also developed a map illustrating areas most in need of grocery stores. The Community Farm Alliance performed a similar investigation of Louisville, Kentucky. Through spatially represented data, the organization was able to demonstrate a significant lack of grocery stores in certain areas. Maps can be used as tools in communicating such data to important stakeholders. The Food Trust in Philadelphia created maps, much like those mentioned previously, indicating the critical areas of the city in need of supermarkets. Showing these maps helped engage public- and private-sector leaders in acting on this issue. SOURCES: Flournoy, 2009; Karpyn, 2009; Thomases, 2009. Acting Locally 35

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Box 2-6 Developing a Community Partnership The King County Food and Fitness Initiative is a community coalition formed in 2006. The vision for the initiative is “creating vibrant communities that support access to locally grown, healthy, affordable food and safe and inviting places for physical activity and play—for everyone.” This initiative is a strategy for social change not only to address healthy eating and physical activity, but also to move toward social and health equity and support families and children. Its mission is to foster collaborative leadership among diverse community partners so as to create long-term, innovative strat- egies that can establish equitable access to resources and choices that promote health. To this end, the initiative actively engages with communities and youth in planning, decision making, and activities. SOURCE: King County Food and Fitness Initiative, http://king.wsu.edu/foodandfarms/KCFFI.html. 3.  Identify Top Policy Priorities By assessing current food and physical activity environments and involving con- stituents in determining community needs, local government officials and staff can identify top policy priorities for their community. An assessment of the local environment for obesity prevention will help identify community assets, focus resources, and refine implementation plans. 4.  Identify Funding Sources Sufficient and sustained funding is needed for many new programs and initiatives. However, innovative use of leadership and convening opportunities can further obesity prevention efforts at low or nominal cost. For example, a mayor’s leader- ship, using the bully pulpit of his or her office, is “free” but can positively influ- ence the actions and culture of a community. A county commissioner’s support in convening concerned community members or providing support to fledgling coalitions can translate into strategic community actions for a relatively minimal investment. Developing and enacting policies and ordinances, including those that contribute to childhood obesity prevention, is part of the operating costs of local governments. As illustrated in Box 2-7, a potential first step in preventing and 36 Local Government Actions to Prevent Childhood Obesity

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Box 2-7 Organizing to Form a Food Policy Advisory Committee Access to healthy food for some neighborhoods in New Orleans has long been a problem, even before Hurricane Katrina, but the storm dramatically reduced access in many areas of the city. In 2006, about a year after the storm hit, fewer than half the supermarkets that had been open before the storm were operating. Recognizing the difficulties of accessing healthy foods and the potential to make long-term changes, several community groups began meeting to address the issue. One coalition of groups, Grow New Orleans, led by the New Orleans Food and Farm Network, sought to improve community food s ­ ecurity and expand the use of locally produced foods. A second group, the Healthy Eating Coalition, led by Tulane University’s Prevention Research Center, was focused on improving access to healthy foods. The two groups joined forces and, rather than form an autonomous food policy council, decided to work within the context of city government. Advice was sought and received from The Food Trust, an organization that has had substantial success in improving retail food access in Pennsylvania. Discussions began with members of the Special Development Projects and Economic Development Committee, a standing committee of the New Orleans City Council. The initial goal was to receive authorization to form an advisory committee to the City Council, a committee that would be charged with preparing a strategy report on how to improve retail access. In April 2007, eight organizations—the Tulane Prevention Research Center (PRC), the Second Harvest Food Bank of Greater New Orleans, the Renaissance Project, Steps to a Healthier Louisiana/New Orleans, the Louisiana Public Health Institute, the City of New Orleans Health Department, the New Orleans Food and Farm Network, and The Food Trust—made their case before the Economic Development Committee, which unanimously endorsed the idea. The full City Council approved a resolution authorizing creation of a Food Policy Advisory Committee, and charged it with making recommendations for addressing the lack of access to healthy food in New Orleans. The Council tasked Tulane’s Prevention Research Center with empaneling the committee and requested a final report within 8 months. Key members from each of the local organizations served as a staff for the Food Policy Advisory Committee. The committee itself was made up of 32 leaders from various sectors, including the private retail food sector, both chain and independent grocers; farmers’ markets and local agriculture; lending and grant-making institutions; retail suppliers and associations; nonprofit organizations focused on hunger, poverty, children, health, and local food; public health agencies and city government; and aca- demia. Four general meetings were held over the course of several months. An additional three themed meetings focused on the city’s planning process, on retail issues, and on regional food and farmers’ markets. By the fourth and final general meeting, a list of 10 recommendations had been drafted that summarized the committee’s discussions. continued Acting Locally 37

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Box 2-7 Continued In January 2008, a final report based on these recommendations was presented to the City Council. The City Council unanimously adopted a resolution expressing support for the recommendations and approving creation of a task force to develop strategies for their implementation. The task force, formed from the Food Policy Advisory Committee, has helped advance specific strategies for the city, focusing especially on a fresh food retail incentives program. The task force has also met with representatives of the New Orleans Police Department to discuss security for grocery stores and has recommended policies for inclusion in the city’s ongoing Master Plan Project. A central purpose of the task force is to maintain momentum and accountability for policy implementation. SOURCE: Diego Rose, Tulane University, http://www.sph.tulane.edu/PRC/Files/FPAC%20Report%20Final.pdf. reversing childhood obesity—the creation of a food, physical activity, or health policy council—requires minimal funding and can set the stage for successful pre- vention efforts. As discussed earlier, building on the goals and actions of other policy c ­ hanges can further the obesity prevention agenda. For example, advocating for policies and programs developed to meet goals in a city’s sustainability plan (Box 2-1) may provide funding for efforts that meet obesity prevention goals as well. A childhood obesity prevention effort is likely to find broader financial sup- port if it meets the diverse needs of other stakeholders in the community. In addi- tion, it is important to remember that federal nutrition assistance programs—such as the Supplemental Nutrition Assistance Program (SNAP) (formerly the Food Stamp Program), the Special Supplemental Nutrition Program for Women, Infants and Children, the Summer Food Service Program, Afterschool Snacks, and the Child and Adult Care Food Program—are dependable sources of federal funds that provide millions of dollars to communities across the country. These pro- grams can fund healthy meals and snacks—a foundation upon which children’s anti-obesity programs can be developed—for example, by providing nutritious meals and related nutrition education to children in summer recreation programs through the Summer Food Service Program, or using farmers’ markets (which allow for the use of SNAP benefits in purchasing food) to recruit community 38 Local Government Actions to Prevent Childhood Obesity

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members to be involved in broader childhood obesity prevention efforts. Other federal programs (e.g., the Centers for Disease Control and Prevention’s Healthy Communities Programs, housing assistance, health care benefits and community health centers, and transportation grants) can provide opportunities for imple- menting efforts directly relevant to childhood obesity prevention. Cultivation of funding sources should encompass careful attention to grant opportunities. This includes monitoring federal and state funding that is directly related to obesity prevention or that can help fund projects that meet several local government goals, including childhood obesity prevention. Community and locally based foundations are often a good place to start. Creative thinking is key to fundraising efforts, as the example in Box 2-8 demonstrates. It is often neces- sary to combine a number of funding streams to achieve an objective, and ­public– p ­ rivate partnerships may also be fruitful avenues to explore. Box 2-8 Finding Funding and Resources The Parks Department in Henderson, Texas, an east Texas county seat of almost 12,000 people, deter- mined there was significant interest among important groups, such as the school board and civic orga- nizations, in an expanded and improved walking and bicycle path network throughout the city. When confronted with the reality of a lack of resources in its budget, the department was able to locate resources from diverse sources. In addition to benefiting from city funds generated by sales taxes, the city learned of a grant from the Texas Parks and Wildlife Department, which provides park development grants to match 50 percent of local contributions. The city also needed access to land on which to build these paths. Instead of securing funding to buy the land, the city coordinated a “land swap” with a pri- vate land owner for land near the city’s park, in exchange for city-owned land elsewhere in Henderson. Fortunately, the department was able to count this land as an in-kind contribution toward its matched funding grant with the Parks and Wildlife Department. These creative funding solutions have been success­ful in making it possible to build several miles of paths, which the city intends to be only the beginning of a more extensive network to be completed by 2018. SOURCE: Barrow, 2009. Acting Locally 39

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5.  Think About Program Sustainability Childhood obesity is a health problem that does not develop in a short period of time, and preventing obesity requires healthy food choices and sustained physical activity throughout one’s lifetime. Changes in food and physical activity environ- ments require a culture change, which, while more difficult to accomplish, will have a more lasting impact than short-term promotional programs. The key to sustainability for childhood obesity efforts is, to the extent possible, to make them part of the community infrastructure. Policy changes that are embodied in law in the form of ordinances, regulations and standards, zoning laws, taxes, and the like are more likely to be sustainable. Changes in the built environment—for example, the building or repair of sidewalks or the development of parks and playgrounds— by their very nature are sustainable. Community involvement in identifying, priori- tizing, and effecting changes also plays an important role in sustainability because it encourages individuals, families, and organizations to take ownership of the changes and become invested in maintaining them for the long term. 6.  Evaluate Programs and Policies To ensure that obesity prevention initiatives reach the intended populations and have a positive impact, it is important to include provisions for evaluating their reach and effectiveness. Well-conducted evaluations allow policy makers to allo- cate limited resources to tackling the problem in the most efficient ways for their community. Furthermore, regular evaluation of obesity prevention actions allows local governments to adapt policies to changing demographics of the local popula- tion and provide the best use of resources. Information and lessons learned from these efforts can help local governments develop even better programs and poli- cies. Moreover, because evidence is lacking on the effectiveness of many promising childhood obesity prevention strategies, program and policy evaluations add to the knowledge base and allow other communities and program planners to see what does and does not work. In cases where full-scale evaluations are unlikely, requir- ing the establishment of a system to collect data on program operations makes future research and evaluation possible. Box 2-9 illustrates an innovative way of tracking obesity rates. Partnering with universities is an excellent way for a local government agency to collect information in the community and monitor and analyze ongoing efforts. For example, Somerville, Massachusetts, partnered with Tufts University to develop and evaluate a comprehensive childhood obesity initiative called Shape Up Somerville (see Box 2-10). 40 Local Government Actions to Prevent Childhood Obesity

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Box 2-9 Using Immunization Registries to Track Obesity Rates The state of Michigan and San Diego County, California, recently made the decision to use their exist- ing electronic immunization registries as a way to track obesity rates among children. The state and county will add data fields for height and weight to the web-based registry, which will be used to calculate body mass index (BMI), a commonly used measure for defining overweight and obesity. The data gathered from such systems can be extremely valuable in tracking the obesity epidemic and eval- uating the effectiveness of ongoing obesity intervention programs, something not currently ­possible in these jurisdictions. SOURCE: Altarum Institute, http://www.altarum.org. CALL TO ACTION Children need a healthy environment in which to learn, engage, and thrive in a community. Local government can be an integral part of the response to the child- hood obesity epidemic. At the local level, government has the authority to autho- rize and appropriate funds for policies and programs that promote healthy eating and active living. Many existing policies can be amended to increase their health impact. New programs and policies can be formulated based on the best avail- able evidence and examples from across the country. These programs and policies should be chosen based on the needs and characteristics of individual communi- ties. This report highlights a number of programs and policies in the form of case studies; many more such examples of local governments that are translating child- hood obesity prevention strategies into action could be cited. Chapters 4 and 5 present the most promising strategies and actions for consideration and evaluation by local governments. Acting Locally 41

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Box 2-10 Comprehensive Obesity Prevention Efforts in an Urban Setting Shape Up Somerville (SUS) is a city-wide campaign to increase daily physical activity and healthy eat- ing through programming, physical infrastructure improvements, and policy changes. It began as a c ­ ommunity-based research study at Tufts University targeting first to third graders. The study demon- strated that city-wide changes could have a positive effect on weight gain among children (Economos et al., 2007). The campaign now targets all segments of the community, including schools, city govern- ment, civic organizations, community groups, businesses, and others who live and work in Somerville, Massachusetts—a densely populated, ethnically diverse town of 77,000 located two miles north of Boston. Overall efforts and successes of the program since its inception include the following: •  Somerville School Food Service Department enhanced the quality and quantity of healthy foods The for students. • Teachers were trained to implement a new health curriculum in class and after school. • Walking school buses were implemented, crosswalks were repainted, and more crossing guards were hired to encourage walking to school. • Infrastructure improvements, such as bike lanes and paths, were made. • Parks were renovated and sites identified for new parks and open space. • Restaurants increased healthy options or altered portion sizes to become “Shape Up Somerville Approved.” Now, 5 years later, SUS is run by the City of Somerville, led by Mayor Joe Curtatone. The mayor has been a key proponent of the program since its inception. Today, a director and a coordinator work on active and healthy living programs supported by the health department and a task force that is a collaboration of more than 11 initiatives and 25 stakeholders involved in working on various interven- tions across the city. The task force is steeped in the city and community business cultures. The City of Somerville is working to educate elected officials and community leaders about SUS and is leveraging grant and city funds to maintain permanent SUS staffing positions. SUS has shown that a variety of community-wide changes can help prevent weight gain in young children. SOURCE: See www.somervillema.gov. 42 Local Government Actions to Prevent Childhood Obesity

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