4
Actions for Healthy Eating

The food and physical activity choices made every day affect short- and long-being physically active may reduce the risk for heart disease, high blood pressure, term health and are directly related to weight outcomes. Eating right and diabetes, osteoporosis, certain cancers, and being overweight or obese (HHS and USDA, 2005). These diseases and conditions impact the individual and his or her quality of life and are associated with increasing health care costs that place a burden on the 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.

Major changes in the nation’s food system and food and eating environments have occurred in recent decades, driven by technological advances; U.S. food and agricultural policies; population growth; and economic, social, and lifestyle changes (Story et al., 2008). Food is now readily available and accessible in many settings throughout the day. The current U.S. food supply contains a large amount of energy-dense foods, many of which consist of refined grains and foods high in fats and/or sugars and low in nutrients. Many of these foods are often available in increasingly large portion sizes at relatively low prices (Story et al., 2008). Americans are also eating out more often and consuming more calories away from home than ever before (Keystone Center, 2006). Moreover, families are eating fewer meals together (Neumark-Sztainer et al., 2003). In addition, the school food environment is radically different than it was a few decades ago,



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4 Actions for Healthy Eating T he 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 the individual and his or her quality of life and are associated with increasing health care costs that place a burden on the 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. Major changes in the nation’s food system and food and eating environ- ments have occurred in recent decades, driven by technological advances; U.S. food and agricultural policies; population growth; and economic, social, and life- style changes (Story et al., 2008). Food is now readily available and accessible in many settings throughout the day. The current U.S. food supply contains a large amount of energy-dense foods, many of which consist of refined grains and foods high in fats and/or sugars and low in nutrients. Many of these foods are often available in increasingly large portion sizes at relatively low prices (Story et al., 2008). Americans are also eating out more often and consuming more calories away from home than ever before (Keystone Center, 2006). Moreover, families are eating fewer meals together (Neumark-Sztainer et al., 2003). In addition, the school food environment is radically different than it was a few decades ago, 49

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with many schools now offering and promoting high-calorie, low-nutrition foods throughout the school day (Fox et al., 2009). Food marketing aimed at children using multiple channels, such as digital media, has drastically increased as well (IOM, 2006). Finally, an exodus of grocery stores and an influx of fast-food r ­ estaurants in lower-income urban areas have contributed to income and racial/ ethnic disparities in access to healthier foods (IOM, 2005). Together, these environmental changes have influenced what, where, and how much Americans eat and have played a large role in the current obesity epi- demic. As recommended in the Institute of Medicine (IOM) report Preventing Childhood Obesity: Health in the Balance, childhood obesity prevention should be public health in action at its broadest and most inclusive level and a national health priority (IOM, 2005). To be effective, obesity prevention efforts should use public health population-based approaches, including policy and environmental changes that affect large numbers of people. Solving the problem will require the efforts of many stakeholders, including those in the public and private sectors, working together for change. WHAT IS MEANT BY HEALTHY EATING AND HEALTHY FOODS? In developing working definitions for healthy eating and healthy foods, the com- mittee looked to the 2005 Dietary Guidelines for Americans (HHS and USDA, 2005). These guidelines, which are revised every five years and are based on the latest scientific evidence, provide information and advice for choosing a nutritious diet, maintaining a healthy weight, and achieving adequate exercise. The guide- lines include 16 key recommendations that focus on food and diet (see Box 4-1). The 2005 guidelines recommend that all healthy Americans aged 2 and older consume a variety of nutrient-dense foods and beverages within and among the basic food groups and limit the intake of saturated and trans fats, cholesterol, added sugars, and alcohol. Nutrient-dense foods are foods that provide substan- tial amounts of vitamins, minerals, and other health-promoting components, such as fiber, for relatively few calories. Foods that are low in nutrient density supply calories but no or small amounts of vitamins, minerals, and health-promoting components (HHS and USDA, 2005). The greater the consumption of foods and beverages that are low in nutrient density and high in fats and sugars, the more difficult it is to achieve energy balance (the balance between calories consumed and calories burned through physical activity and bodily processes) and still meet nutrient needs. The lack of energy balance can lead to unhealthy weight gain. Selecting foods that are consistent with the guidelines (i.e., fruits, vegetables, 50 Local Government Actions to Prevent Childhood Obesity

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Box 4-1 Recommendations of the Dietary Guidelines for Healthy Eating Adequate Nutrients Within Calorie Needs • Consume a variety of nutrient-dense foods and beverages within and among the basic food groups  while choosing foods that limit the intake of saturated and trans fats, cholesterol, added sugars, salt, and alcohol. • Meet recommended intakes within energy needs by adopting a balanced eating pattern, such as the  U.S. Department of Agriculture (USDA) Food Guide or the Dietary Approaches to Stop Hypertension (DASH) Eating Plan. Weight Management • To maintain body weight in a healthy range, balance calories from foods and beverages with calo-  ries expended. • To prevent gradual weight gain over time, make small decreases in food and beverage calories and  increase physical activity. Food Groups to Encourage • Consume a sufficient amount of fruits and vegetables while staying within energy needs. Two cups  of fruit and 2½ cups of vegetables per day are recommended for a reference 2,000-calorie intake, with higher or lower amounts depending on the calorie level. • Choose a variety of fruits and vegetables each day. In particular, select from all five vegetable  subgroups (dark green, orange, legumes, starchy vegetables, and other vegetables) several times a week. • Consume 3 or more ounce-equivalents of whole-grain products per day, with the rest of the recom-  mended grains coming from enriched or whole-grain products. In general, at least half the grains should come from whole grains. • Consume 3 cups per day of fat-free or low-fat milk or equivalent milk products.  Fats • Consume less than 10 percent of calories from saturated fatty acids and less than 300 mg/day of  cholesterol, and keep trans fatty acid consumption as low as possible. • Keep total fat intake between 20 to 35 percent of calories, with most fats coming from sources of  polyunsaturated and monounsaturated fatty acids, such as fish, nuts, and vegetable oils. • When selecting and preparing meat, poultry, dry beans, and milk or milk products, make choices  that are lean, low-fat, or fat-free. • Limit intake of fats and oils high in saturated and/or trans fatty acids, and choose products low in  such fats and oils. continued Actions for Healthy Eating 51

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Box 4-1 Continued Carbohydrates • Choose fiber-rich fruits, vegetables, and whole grains often.  • Choose and prepare foods and beverages with little added sugars or caloric sweeteners, such as  amounts suggested by the USDA Food Guide and the DASH Eating Plan. • Reduce the incidence of dental caries by practicing good oral hygiene and consuming sugar- and  starch-containing foods and beverages less frequently. Sodium And Potassium • Consume less than 2,300 mg (approximately 1 teaspoon of salt) of sodium per day. • Choose and prepare foods with little salt. At the same time, consume potassium-rich foods, such as  fruits and vegetables. SOURCE: HHS and USDA, 2005. whole grains, and low- or non-fat dairy products) and watching portion sizes is the best way to maintain a healthy weight while meeting nutrient needs. In accordance with the Dietary Guidelines, in this report healthy eating refers to eating the types and amounts of foods, nutrients, and calories recom- mended in those guidelines. Healthy foods refers to fruits and vegetables with minimal or no added sugar, fat, or salt; fat-free or low-fat dairy products; whole grains; and lean meats. Healthy foods are also rich in health-­promoting nutrients needed for overall wellness, such as fiber, vitamins, and minerals. These working definitions are tailored to the childhood obesity problem and the need to address dietary excesses and inadequacies associated with the cur- rent eating patterns of children and youth. There is no widely accepted definition of calorie-dense, nutrient-poor foods, nor is there consensus on which foods should be included in this cat- egory. The 2005 Dietary Guidelines for Americans introduced the concept of “discretionary” calories—the extra calories that are consumed during a day as added fat and/or sugars after enough healthy foods have been consumed to meet caloric and nutrient needs. Most discretionary calorie allowances are very small, between 100 and 300 calories, especially for those who are not 52 Local Government Actions to Prevent Childhood Obesity

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physically active. This report uses the term calorie-dense, nutrient-poor foods to refer to those foods and beverages that contribute few vitamins and minerals to the diet but contain substantial amounts of fat and/or sugar and are high in calories. Consumption of these foods, such as sugar-sweetened beverages, candy, and chips, may contribute to excess caloric intake and unwanted weight gain in children. Moreover, these foods may replace more nutritious foods, leading to decreased intake of some micronutrients (Kant, 2003; Swinburn et al., 2004). CREATING A HEALTHY EATING ENVIRONMENT Although food consumption is ultimately a matter of individual choice, local food environments influence the choices made by children, families, and com- munity members. In the 2001 Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity, former U.S. Surgeon General David Satcher stated, “Individual behavior change can occur only in a supportive environment with accessible and affordable healthy food choices and opportunities for regular physical activity” (HHS, 2001). Effective obesity prevention policy and practices that address changes to the environment can help individuals take responsibility for improving their food choices. The failure of individual-based nutrition and physical activity efforts can be explained, in part, because the environments where they have been implemented are not conducive to healthful choices (Booth et al., 2001). The healthy choice must also be the easy choice. A healthy eating environment is one in which families have access to super- markets or other places where they can obtain affordable healthy foods such as fruits and vegetables; healthy food is available and easy to identify in restaurants and public buildings; lower-income community members are informed about and participate in federal nutrition programs, such as the Supplemental Nutrition Assistance Program (SNAP, formerly called the Food Stamp Program); women feel supported and comfortable in breastfeeding; and there are ample water fountains in public places. This chapter reviews ways in which local governments can create an environment with these basic characteristics that supports healthy eating. DISPARITIES IN ACCESS TO HEALTHY FOODS As discussed in Chapter 3, the healthy choice is often the more difficult choice in some neighborhoods. Lower-income and minority neighborhoods and com- munities suffer disproportionately high rates of preventable, diet-related diseases, including obesity (Ford and Dzewaltowski, 2008; Morland and Evenson, 2009), Actions for Healthy Eating 53

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and inequalities in access to affordable, healthy, and nutritious food contribute to these disparities. Access to healthy food in many lower-income urban and rural areas is often lacking and is of particular concern because of the negative impact on dietary intake and obesity among a vulnerable population. Lower-income areas are less likely to have access to supermarkets and grocery stores that carry healthy foods compared with predominantly white, middle- and higher-income neighbor- hoods (Baker et al., 2006; Franco et al., 2008; Morland et al., 2002). Many stores in lower-income neighborhoods are smaller with a limited number of products and fewer healthy items such as fruits and vegetables, low-fat or non-fat dairy products, and whole grains. Public transportation to supermarkets is often lack- ing as well (Morland et al., 2002). Research suggests that neighborhood residents who have better access to supermarkets and limited access to convenience stores tend to have healthier diets and lower levels of obesity (Lopez, 2007; Morland et al., 2006; Powell et al., 2007). A poor food environment in lower-income areas may be exacerbated by an abundance of fast-food restaurants serving high-calorie, high-fat meals at relatively low prices (Lewis et al., 2005). The availability of fast- food restaurants and calorie-dense foods is greater in lower-income and minority neighborhoods (Baker et al., 2006; Larson et al., 2009). Few studies have evaluated strategies for reducing disparities by ­improving access to healthy, affordable foods and reducing access to high-calorie, low- n ­ utrition foods. Several strategies and actions have been proposed to attract super- markets to underserved neighborhoods, improve the availability of healthy foods such as fruits, vegetables and whole grain products, and reduce access to calorie- dense foods in fast food establishments and restaurants. As discussed in Chapter 3, to address childhood obesity, local governments should consider giving priority to neighborhoods and communities that lack access to healthy foods and/or have a relative excess of unhealthy foods. Rates of obesity and obesity-related illnesses tend to be higher in these communities (Morland and Evenson, 2009). THE ROLE OF LOCAL GOVERNMENTS IN PROMOTING HEALTHY EATING Local governments can have a strong and direct impact on people’s health and well-being and are well positioned to make positive changes in food environments in communities. Local governments can provide strategic leadership, such as pro- viding improved access to healthy foods in lower-income areas, using zoning laws to change local food environments, requiring menu labeling in restaurants, ­serving as a catalyst for community change by offering healthier foods at government facilities, developing the infrastructure necessary for obesity prevention policies 54 Local Government Actions to Prevent Childhood Obesity

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and programs to be implemented and evaluated at the local level, and commu- nicating the importance of healthy eating and obesity prevention to community members. Local governments can and should provide opportunities to change the community food environment to positively influence individual food choices by making the healthy choice the easy choice. Local governments have a role to play in both increasing access to healthy foods and reducing access to unhealthy foods. To date, and as reflected in this report, there are more access-enhancing strategies than those that might reduce access to unhealthy foods. However, local governments should also focus on strat- egies that reduce access to unhealthy foods, as these potentially may have more of an impact in reducing obesity than increasing access to healthy foods. For exam- ple, restricting access to sugar-sweetened beverages in after-school community programs may have more of an impact on reducing the consumption of excess calories and weight gain in youth than opening a farmers’ market once a week for five months or starting a community garden. Finally, while some initiatives may not have a direct impact on healthy eating behaviors, they may strengthen ties among diverse and important community stakeholders. Broad-based coalitions or organizational strengths developed through such activities can facilitate effective advocacy for subsequent initiatives that have more impact but are more difficult to implement. The healthy eating strategies and action steps recommended by the commit- tee for local governments’ consideration are organized around three goals: 1. Improve access to and consumption of healthy, safe, and affordable foods. 2. Reduce access to and consumption of calorie-dense, nutrient-poor foods. 3. Raise awareness about the importance of healthy eating to prevent child- hood obesity. This list of goals and the strategies and action steps discussed under each are not prioritized, but, as stated in the introduction, certain action steps are bolded as being most promising. Local community leaders, members, and policy makers will be in the best position to decide which strategies and action steps will be most feasible and appropriate for the needs and circumstances of their community. The decision will be based largely on such factors as resources, priorities, leadership, and demographics. Following are the goals, strategies, and action steps related to healthy eating. Actions for Healthy Eating 55

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GOAL 1: IMPROVE ACCESS TO AND CONSUMPTION OF HEALTHY, SAFE, AND AFFORDABLE FOOD Strategy 1: Retail Outlets Increase community access to healthy foods through supermarkets, grocery stores, and convenience/corner stores. Rationale People cannot consume a healthy diet unless healthy foods are available, afford- able, and convenient. Research suggests that neighborhood residents who have b ­ etter access to supermarkets and grocery stores tend to have healthier diets and lower ­levels of obesity (Larson et al., 2009; Lopez, 2007; Morland and Evenson, 2009; Story et al., 2008). Access to supermarkets and grocery stores can also lead to increased fruit and vegetable intake (Casagrande et al., 2009; Rose and Richards, 2004). The presence of small food store and corner stores also influences diet (Bodor et al., 2008). Residents of lower-income, minority, and rural neighborhoods are most likely to have poor access to supermarkets and other venues with healthy foods (Black and Macinko, 2008; Larson et al., 2009; Story et al., 2008). These indi­viduals are more likely to have a high body mass index (BMI) (Inagami et al., 2006). Evidence suggests that using urban planning land use policies to increase access to super­markets can decrease BMI in adolescents (Powell et al., 2007). The committee recognizes the complexities of some of the following action steps; some may require more time, resources, or support than others. It is impor- tant to consider groundwork that may make these action steps easier to imple- ment. For example, to attract supermarkets to underserved communities, local governments may need to create policies designed to help businesses and others navigate the complex development process. 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 development programs, and other economic incentives). • Realign bus routes or provide other transportation, such as mobile com- munity vans or shuttles to ensure that residents can access supermarkets or grocery stores easily and affordably through public transportation. 56 Local Government Actions to Prevent Childhood Obesity

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• 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 under- served 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. Rationale Americans are eating away from home more than ever before (French et al., 2001). Foods from away-from-home sources are higher in calories and fat com- pared with at-home foods (French et al., 2001). Eating out more frequently, especially at fast-food restaurants, is associated with obesity (Duffey, 2007; Rosenheck, 2008). Without clear, easy-to-use nutrition information at the point of ordering, it is difficult to make informed choices at restaurants. Preliminary findings from localities that have instituted menu labeling show that consumers may choose more healthy options when they are informed about the nutritional q ­ uality of offerings (Bassett et al., 2008; Harnack and French, 2008; Technomic Inc., 2009). Action Steps • Require menu labeling in chain restaurants to provide consumers with c ­ alorie information on in-store menus and menu boards. • Encourage non-chain restaurants to provide consumers with calorie informa- tion on in-store menus and menu boards. • Offer incentives (e.g., recognition or endorsement) for restaurants that pro- mote healthier options (for example, by increasing the offerings of healthier foods, serving age-appropriate portion sizes, or making the default standard options healthy—i.e., apples or carrots instead of French fries, and non-fat milk instead of soda in “kids’ meals”). Actions for Healthy Eating 57

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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. Rationale Increasing the availability of fruits and vegetables is an important means of improving the quality of the diet. Fruit and vegetables are relatively low in calories and, because of their high fiber and water content, can increase satiety and reduce overall calorie intake (Rolls et al., 2004). Substituting fruits and vegetables for higher calorie foods such as those high in fat and added sugars can be a compo- nent of a successful obesity prevention strategy (CDC, 2007). Evidence suggests that promoting farmers’ markets can increase fruit and vegetable intake (Herman et al., 2008; Kropf et al., 2007). Community gardens and garden-based nutrition intervention programs may also have the potential to promote increased fruit and vegetable intake (Alaimo et al., 2008) and may increase willingness to taste fruits and vegetables among youth (Robinson-O’Brien et al., 2009). 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 neigh- borhoods, 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 affordable, healthy food with improving skills in pur- chasing and preparing food. 58 Local Government Actions to Prevent Childhood Obesity

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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. Rationale National studies consistently show that the diets of children and adolescents do not meet national recommendations for good health, are contributing to over- weight and obesity, and are placing youth at risk for serious health consequences (HHS and USDA, 2005; IOM, 2005). Places where children gather and spend much of their time should contribute to a healthful food environment. Since many children spend time in after-school programs, child care, and recreation centers, making sure that the food served in these settings is healthy could help to improve their diets. Research suggests that the nutritional quality of meals and snacks in child care settings can be poor and activity levels may be inadequate (Ball et al., 2008; Padget and Briley, 2005; Story et al., 2006). Furthermore, children model the behavior of adults (Pearson et al., 2009). Ensuring that publicly run entities mandate strong nutrition standards in facilities and programs that serve children and adults would imply that healthy eating is an important issue. Local govern- ment agencies can serve as leaders and role models by adopting policies and prac- tices that promote healthy food choices in public places. 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 nutrition standards in place wherever foods and bever- ages 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 c ­ alorie-dense, nutrient-poor foods (e.g., after-school programs that provide Actions for Healthy Eating 59

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fruits or vegetables every day, and eliminate calorie-dense, nutrient-poor foods in vending machines or as part of the program). 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). Rationale Nutrition assistance programs provide children and lower-income people access to food for a healthful diet. They are not associated with increased weight in children or adults (Hofferth and Curtin, 2005; Ver Ploeg, 2009; Ver Ploeg et al., 2008). In fact, recent research from the School Nutrition Dietary Assessment Study-III showed that children who participated in the School Breakfast Program had a lower likelihood of overweight and obesity (Gleason and Dodd, 2009). Other research suggests similar associations with School Lunch, SNAP, and the WIC pro- gram (Bitler and Currie, 2004; Jones et al., 2003). Furthermore, recent revisions to the WIC food package increased the amount of whole grains, fruits, and veg- etables participants receive, making it even easier for lower-income mothers and children to eat the healthy foods recommended by the Dietary Guidelines. Action Steps • Put policies in place that require government-run and -regulated agencies responsible for administering 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 pro- gram enrollment (CACFP, the Afterschool Snack Program, and the Summer Food Service Program). 60 Local Government Actions to Prevent Childhood Obesity

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Strategy 6: Breastfeeding Encourage breastfeeding and promote breastfeeding-friendly communities. Rationale Breastfeeding has multiple health benefits for infants and mothers. Research shows that the longer a child breastfeeds, the less likely he or she is to be overweight. (Arenz et al., 2004; Moreno and Rodriguez, 2007). But despite national recom- mendations to increase breastfeeding initiation and duration rates, many barriers make it difficult for mothers to continue breastfeeding. Local governments can implement policies and programs that make it easier for mothers to breastfeed. For example, mothers that give birth in “baby-friendly hospitals” that practice the United Nations Children’s Fund/World Health Organization (UNICEF/WHO) ten steps to successful breastfeeding, part of the Baby-Friendly Hospital Initiative USA, are more likely to exclusively breastfeed (Declercq et al., 2009). Action Steps • Adopt practices in city and county hospitals that are consistent with the Baby-Friendly Hospital Initiative USA (UNICEF/WHO). This initiative pro- motes, protects, and supports breastfeeding through ten 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: Drinking Water Access Increase access to free, safe drinking water in public places to encourage water consumption in place of sugar-sweetened beverages. Actions for Healthy Eating 61

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Rationale Sugar-sweetened beverage intake is considered an important contributing factor to obesity in childhood (James and Kerr, 2005; Malik et al., 2009; Moreno and Rodriguez, 2007; Vartanian et al., 2007). Replacing sugar-sweetened beverages with water is associated with reductions in total energy intake for children and adolescents (Wang et al., 2009). Installing water fountains in public places and facilities can increase water intake and prevent and reduce overweight and obesity (Muckelbauer et al., 2009). 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 drink- ing water fountains (e.g., public restroom codes). GOAL 2: REDUCE ACCESS TO AND CONSUMPTION OF CALORIE-DENSE, NUTRIENT-POOR FOODS Strategy 8: Policies and Ordinances Implement fiscal policies and local ordinances to discourage the consumption of calorie-dense, nutrient-poor foods and beverages (e.g., taxes, incentives, land use and zoning regulations). Rationale Increasing access and consumption of healthy foods alone will not necessarily reduce excess caloric intake and body weight. Reducing access to and consump- tion of calorie-dense, nutrient-poor foods is also needed to decrease excess calories and help prevent obesity in children. These foods are often high in refined grains, added fats, and sugars and tend to be inexpensive and convenient (Monsivais and Drewnowski, 2007). Children today have near constant access to calorie-dense, nutrient-poor foods and beverages. Fast food restaurants and other purveyors of inexpensive, unhealthy food are often densely located in lower-income, urban neighborhoods (Baker et al., 2006). They are also often located near schools, which can increase obesity rates (Currie et al., 2009). Moreover, advertising of fast-food restaurants can also affect obesity rates (Chou et al., 2008). Taxing 62 Local Government Actions to Prevent Childhood Obesity

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c ­ alorie-dense, nutrient-poor foods is one method that might decrease consumption (Brownell and Frieden, 2009; Congressional Budget Office, 2008). Zoning and land use policies that regulate fast food restaurants may affect consumption as well (Ashe et al., 2003; Paquin, 2008). It is important to point out that there are local and state legal issues that need to be considered in any restriction of advertis- ing efforts or imposition of food and beverage taxes. In addition, jurisdiction over these issues can vary from community to community. 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, n ­ utrient-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, n ­ utrient-poor foods (i.e., promote “candy-free” check out aisles). 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. Rationale Media can be a key element to increase awareness and motivation and can be used to promote healthy eating, portion size awareness, eating fewer calorie- dense, nutrient-poor foods and to raise awareness of weight as a health issue. Actions for Healthy Eating 63

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High-frequency television and radio advertising, as well as signage, may stimulate improvements in attitudes toward a healthy diet (Beaudoin et al., 2007). A media approach may even cause a community to alter its dietary habits (Reger et al., 1999). Depending on the resources available, and the purpose of the campaign, both local development of campaigns and the adoption of national message cam- paigns may be useful. In keeping with the report’s focus on changes that local governments can make to improve the food and physical activity environments of children, it is important to point out that media and social marketing campaigns can improve these local environments by highlighting the reasons for improving children’s food and physical activity environments; and engaging the public in t ­ aking advantage of new resources in their environment such as farmers’ markets, new grocery stores, healthier choices at local businesses, etc. 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 environ- mental inequities and not just the result of poor personal choices. • Develop counter-advertising media approaches against unhealthy products to reach youth as has been used in the tobacco and alcohol prevention fields. REFERENCES Alaimo, K., E. Packnett, R. A. Miles, and D. J. Kruger. 2008. Fruit and vegetable intake among urban community gardeners. Journal of Nutrition Education and Behavior 40(2):94–101. Arenz, S., R. Ruckerl, B. Koletzko, and R. Von Kries. 2004. Breast-feeding and childhood obesity: A systematic review. International Journal of Obesity 28(10):1247–1256. Ashe, M., D. Jernigan, R. Kline, and R. Galaz. 2003. Land use planning and the control of alcohol, tobacco, firearms, and fast food restaurants. American Journal of Public Health 93(9):1404–1408. Baker, E. A., M. Schootman, E. Barnidge, and C. Kelly. 2006. The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines. Preventing Chronic Disease [electronic resource] 3(3). 64 Local Government Actions to Prevent Childhood Obesity

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