Summary

The May 2009 workshop brought together policy makers, advocates, researchers, program staff, and others seeking to understand how the environment affects the prevalence of obesity and to develop policies and programs based on this understanding. Presenters in three panels discussed how they use the relationship between environmental variables and health outcomes as obesity-related evidence in planning, implementing, and evaluating prevention efforts and in shaping policies that support such efforts. (See Appendix A for the workshop agenda.) Presenters drew on experiences as varied as the environments in which they work—from urban neighborhoods in Baltimore to rural central California, from grassroots-led research in Seattle to senior-level policy-making bodies in New York City. Comment and question periods after each panel session brought the audience’s rich knowledge and experience to bear on the discussion.

LESSONS FROM COMMUNITIES

Presenters in the first panel session focused on the role played by evidence in community-based initiatives in Santa Ana, California; Baltimore; central California; and Washington, DC. As described in Chapter 5, the following themes emerged from this on-the-ground experience:

  • Each location has unique characteristics that must be understood before programs or policies are developed. Each community has its own health-related concerns, eating preferences, and activity patterns, as well as socioeconomic conditions, opportunities, and con-



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Summary The May 2009 workshop brought together policy makers, advocates, researchers, program staff, and others seeking to understand how the envi- ronment affects the prevalence of obesity and to develop policies and programs based on this understanding. Presenters in three panels discussed how they use the relationship between environmental variables and health outcomes as obesity-related evidence in planning, implementing, and evalu- ating prevention efforts and in shaping policies that support such efforts. (See Appendix A for the workshop agenda.) Presenters drew on experiences as varied as the environments in which they work—from urban neighbor- hoods in Baltimore to rural central California, from grassroots-led research in Seattle to senior-level policy-making bodies in New York City. Comment and question periods after each panel session brought the audience’s rich knowledge and experience to bear on the discussion. LESSONS FROM COMMuNITIES Presenters in the first panel session focused on the role played by evi- dence in community-based initiatives in Santa Ana, California; Baltimore; central California; and Washington, DC. As described in Chapter 5, the following themes emerged from this on-the-ground experience: • Each location has unique characteristics that must be understood before programs or policies are developed. Each community has its own health-related concerns, eating preferences, and activity pat- terns, as well as socioeconomic conditions, opportunities, and con- 1

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20 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION straints created by the built and natural environments. Presenters explained how they have drawn on different data sets, inventoried existing programs, and talked with experts and community mem- bers to further their understanding of the local obesity problem, its causes, and potential solutions. In some cases, they noted that they would have benefited from more localized data than are currently available. • Obesity prevention fits within a broader context. All four presenters spoke of the need to define obesity prevention as a component of healthy living, rather than just as individuals’ attempts to lose weight. Obesity relates to issues as varied as public safety, edu- cation, and economic development. Successful approaches there- fore involve law enforcement agencies, planning agencies, schools, neighborhood associations, public health departments, and many other stakeholders. • Sustainability must be built into community-based obesity pre- vention efforts. While foundations and public entities focus vital resources and attention on the obesity problem, each presenter noted the need to look beyond such finite sources of funding. For example, the presenters reach out to churches and other community-based organizations, push to have public health depart- ments integrate obesity prevention into their regular services, and provide targeted assistance in leadership development and other skills to nonprofit organizations that can carry on the work. They value receptive elected officials, but also recognize that they must establish relationships that extend beyond the election cycle. • Obesity prevention is a long-term goal. As promising as many of these initiatives are, the presenters noted that eating and physical activity behaviors developed over generations will take many years to change. They stressed the need to view efforts to address the obesity epidemic as a movement and not a program with a narrow focus or fixed period for implementation. LESSONS FROM RESEARCH AND ADvOCACy ORgANIzATIONS The second panel consisted of representatives from nonprofit orga- nizations that serve as a bridge between community-based programs and policy makers. These organizations provide research and other support to communities while also building on community experience to advo- cate for resources and policies at the local, state, and national levels. As reported more fully in Chapter 6, the presenters made the following key points:

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21 SUMMARY • Decision makers have different frames of reference in dealing with obesity prevention. While some easily grasp the connection between obesity and community environments, others frame the issue solely as a matter of individual choice. Some see a clear role for government; others remain skeptical. Some expect to see clear financial benefits to obesity-related and other preventive health expenditures. Organizations must find ways to deal with these dif- ferent frames of reference. • Research is only one type of evidence upon which policy makers draw. Only in rare cases do research findings alone, however defini- tive, move policy; the expectation that science alone will lead to policy change is unrealistic. Policy makers are confronted with political considerations, views of trusted advisors and constituents, their own experiences, economic analyses, and numerous other inputs. A related point is the need to collect consistent health and economic data from those obesity programs that are in place to permit clearer conclusions about what is working and the cost implications. • The way the evidence is presented is critical. Policy makers are bar- raged with information. The organizations represented on the panel continually seek the most effective ways to build on the evidence to draw the attention of policy makers, the media, other opinion leaders, and the public. These methods include mapping and other visuals, easy-to-grasp metrics, brief summaries of relevant research, and personal stories and testimonials. • Research, action, and policy can be linked to increase impact. The presenters shared examples in which communities, instead of just serving as the subject of a research study, participated in collect- ing, analyzing, and disseminating the evidence. The community thus becomes more engaged in the research, and the result is often tangible changes in policies or programs. LESSONS FROM POLICy MAKERS In the final panel of the workshop, elected and appointed officials pre- sented their first-hand perspectives on how obesity- and other health-related evidence enters into the policy-making arena. As summarized in Chapter 7, the presenters shared valuable insights about what it is required to enact policies aimed at reducing childhood obesity. These insights included the following: • Local governments have a large role to play in obesity prevention. From recreation and open space, to the food served by public

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22 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION agencies, to planning and zoning issues, cities and counties are the entities that enact policies with a direct bearing on the health of their citizens. • Many types of evidence influence policy making. Echoing the previ- ous panels, these presenters confirmed that policy makers are con- fronted with an overwhelming number of issues and concerns. The fact that scientific evidence points to the need for a certain policy is rarely in itself sufficient to ensure enactment. Instead, advocates for such policies must form coalitions, present the evidence in a clear and timely manner, and look for champions both inside and outside of government. The level of evidence needed before a policy is enacted also depends on the costs, both monetary and political. Often, evidence is presented to justify a decision based on a par- ticular issue. It is helpful to policy makers if the context for local government, cost, and feasibility are all addressed when a policy decision is being advocated. • Accountability and constituent contacts are important inputs for local policy makers. In Minneapolis, the fact that the obesity rate is one of 20 indicators measured and reported on annually helps spur action and call attention to the issue. Local officials heed even relatively small numbers of phone calls or e-mails from voters in favor of or against an issue. OvERALL THEMES Taken as a whole, the presentations and discussions with the audi- ence conveyed the critical need to listen to and build on community voices in fighting childhood obesity. Approaches that involve a wide range of partners—including neighborhood groups, government agencies with a range of missions, and businesses—characterize many of the promising efforts discussed throughout the workshop sessions. As many speakers noted, a paradigm shift that recognizes the role of the community environ- ment in obesity prevention is emerging, but is far from universally accepted. Other common messages that emerged were highlighted in the workshop’s closing remarks and are summarized below: • The diversity of community efforts represents both a strength and a drawback. It sparks innovation and empowers people to work toward their own better health. However, this diversity also com- plicates efforts to measure impact and build the strongest pos- sible evidence base. The field must grapple with this dichotomy to achieve the ultimate outcomes of improved health and a reduction in obesity rates.

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2 SUMMARY • Obesity-related policy must occur “in all places” to form a long- term movement toward better health. The development of com- prehensive frameworks for community efforts to create healthy environments is under way. The need persists to educate, convince, and inform actors and decision makers in other sectors that health and health policy are their allies in changing the shape of commu- nity environments for the better. • Communication is key to this work. Communication is needed to develop a common understanding of obesity prevention and to articulate the shift from individual interventions to environmental change in combating the obesity epidemic. Differences in expec- tations and professional paradigms can lead to a breakdown in communication. Dialogue on how different sectors view evidence, for example, can help bridge these divides. The importance of com- munication also relates to how best to present research and other evidence to draw the attention of policy makers. • The question remains of whether a set of data should be collected consistently across communities. Some divergence of opinion arose about the use of body mass index (BMI) data in community- based interventions, yet no recommendation for an alternative has emerged. Another issue voiced by several speakers is whether assembling the entire chain of evidence—from environmental inter- ventions, to changes in food and physical activity behaviors, to changes in BMI—is necessary for every intervention. Moreover, many community residents have expressed that they do not want to serve constantly as the subject of research studies that lead to no visible improvement. • Community knowledge is an essential building block in reducing childhood obesity. Community knowledge is the cultural context. Local information about the population and knowledge about what programs are more likely to work or have been shown to work help form and set policy priorities for communities and dif- ferent contexts, from soccer fields in Santa Ana to green carts in New York City. Ongoing engagement of neighborhoods and resi- dents strengthens leadership and power within communities, which in turn helps create and sustain change.

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