7
Decision Makers: How Do Community Perspectives Influence Policy?

The final panel brought the workshop from efforts to change policies to policy makers themselves. While all six presenters were extremely supportive of the broad range of policies available to local governments to reduce childhood obesity, they presented real-world accounts of the challenges they face in enacting policies amid competing demands.

The presenters were both elected and appointed and from jurisdictions of various sizes—from Fairfax City, Virginia, with a population of 23,000, to New York City. The key messages they stressed 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 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 previous panels, these presenters confirmed that policy makers are confronted 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 brought to bear to justify a decision based on



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7 Decision Makers: How Do Community Perspectives Influence Policy? The final panel brought the workshop from efforts to change policies to policy makers themselves. While all six presenters were extremely support- ive of the broad range of policies available to local governments to reduce childhood obesity, they presented real-world accounts of the challenges they face in enacting policies amid competing demands. The presenters were both elected and appointed and from jurisdictions of various sizes—from Fairfax City, Virginia, with a population of 23,000, to New York City. The key messages they stressed 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 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 brought to bear to justify a decision based on 

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 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION other considerations, rather than being the primary reason behind a policy decision. • Accountability and constituent contacts are important inputs for local policy makers. In Minneapolis, the fact that the obesity rate is 1 of 20 indicators measured and reported on annually helps spur action and call attention to the issue. Local officials heed even rela- tively small numbers of phone calls or e-mails from voters in favor of or against an issue. Planning committee member Mary Story, Professor in the School of Public Health, University of Minnesota, moderated this panel. The panel’s three elected representatives articulated a clear role for local governments in obesity prevention efforts in various ways. According to Fairfax City Coun- cil member Daniel Drummond, local governments can promote healthier living by supporting needed infrastructure, offering recreational and other programs, and encouraging citizen involvement. Arlington County Board member J. Walter Tejada elaborated on how local zoning and other regula- tions can encourage smart growth, which in turn translates to amenities such as sidewalk connectivity and transportation options. George Leventhal, Montgomery County Council member, also favors an active role for county government, but noted some pitfalls in pressing for strong policies, includ- ing pushback from some constituents and even from the school system, which has other priorities. The panel’s appointed officials also shared valuable perspectives on the role of evidence in policy making. Benjamin Thomases, New York City Food Policy Coordinator, observed that costs (including political costs) play an important role in determining how much evidence is needed before a policy moves forward. Gretchen Musicant, Minneapolis Health Com- missioner, discussed the many types of evidence policy makers consider as much or more than scientific data. Finally, Pierre Vigilance, Director of the District of Columbia Department of Health, urged exposing a wide range of stakeholders to the evidence so they understand the public safety, edu- cational, and fiscal impacts of obesity. SuPPORT FOR RECREATION AND OPEN SPACE IN FAIRFAx CITy, vIRgINIA Mr. Drummond focused on how Fairfax City is trying to increase physical activity and fight obesity by supporting recreation for youth and families. Fairfax City is a small jurisdiction (a population of 23,000 within 6.3 square miles) surrounded by much larger Fairfax County. It has made a significant investment in parks and recreation, spending $3.5 million annu-

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 DECISION MAKERS ally and devoting 10 percent of its land mass to open space. Designating land as open space guarantees that it will not be developed, thus providing places for children and youth to play. The Role of Local government Drummond asserted that “local government really matters. We are the ones who have to implement.” The challenge is to adhere to the basics because “in government, we have a tendency to overcomplicate things.” Finding ways to keep children active is challenging, especially in a crowded school day. The best solution for a community will depend on its specific needs and pressures. According to a study conducted for the Metropolitan Washington Council of Governments, only one local jurisdiction provides the recom- “We need to get in the mended 45 minutes per day of activity vocabulary of kids that it is good for elementary school−aged children. to be healthy, because at one Drummond urged less testing and point in time, they are going to more appropriate ways of educating be voters.” children to ensure balance in their —Dan Drummond lives. Parental involvement and per- sonal responsibility are also important, and policy makers must be willing to spend money on initiatives to increase children’s physical activity. Drummond identified three areas in which local governments can play a role: infrastructure, programs, and opportunities for citizen involve- ment. Fairfax City invests in open space, parks, and recreation facilities; supports public−private partnerships to offer youth sports; and organizes after-school “functional fitness for kids” and other programs for children of all ages throughout the year. Trails Day, Bike-to-Work Day, the National Parks and Recreation Association’s Step Up to Health Day, and a task force for families are among the initiatives undertaken to engage the public in increasing their physical activity. The Importance of Starting young Policy makers often support anti-obesity measures based on their own or their family’s experiences, and Drummond acknowledged that per- sonal experience was one motivator for his strong support of recreational opportunities for youth. According to Drummond, teaching children about healthy lifestyles is as important as teaching them to read, write, and do math in preparing them for life.

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 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION RIgOR OF EvIDENCE IN NEW yORK FOOD POLICy As Food Policy Coordinator for the City of New York, Mr. Thomases holds a new position created within the Office of the Mayor to integrate responses to the paradoxical challenge that hunger and obesity coexist in many communities. The city’s Food Policy Task Force, which Thomases is responsible for convening, has developed four approaches to addressing that challenge: • Food supports—increasing enrollment in and utilization of Food Stamps, school lunches, the Child and Adult Care Food Program, and similar programs; • City policies—improving the nutritional value of food served by city agencies and contractors; • Retail access—helping to expand opportunities for low-income people to purchase healthier food; and • Healthy choices—using public awareness and education to help people make food choices that are better for their health. While city officials are committed to using evidence in policy decisions, cost is a key factor in determining the level of rigor necessary before a policy is enacted. Decision makers are more willing to try a program or policy if “The level of rigor [of evidence] it carries low or no costs (including required very much depends political costs) even without a large upon the cost…. The costlier [an body of evidence. In contrast, they intervention] gets, the more we need to know it is going to work.” want to see more extensive evidence —Benjamin Thomases before agreeing to more expensive options. City Agency Food Standards The city serves, on average, more than 1 million meals a day in its schools, prisons, and other facilities. The goals of new nutrition standards for these agencies are to create sustainable improvements in nutritional quality, reinforce public health messaging, reduce illness and mortality related to poor nutritional intake, and create a market for healthier institu- tional food. The standards target dietary improvements shown by evidence to prevent and control chronic disease, and they guide food purchases and preparation related to fat, sodium, fiber, and the like. A new standard now covers vending machines in the city’s 1,400 schools. Based on evidence on the intake of sweetened beverages, the new

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 DECISION MAKERS policy permits the sale of only water, seltzer, and lightly flavored beverages, with stricter standards for elementary and middle schools. Retail Access In another example of the use of evidence to inform policy making, Thomases referred to studies showing that access to healthy retail food affects eating patterns. The disparities in access to such food in New York, as elsewhere, have health and economic implications. A Supermarket Need Index was developed to identify neighborhoods with high obesity and diabetes rates, low consumption of fruits and vegetables, and reduced household income and access to health care, among other characteristics (see Figure 7-1). In these neighborhoods, residents obtain most of their food from corner stores or bodegas, very few of which stock fresh fruits and vegetables. As an example of a low-cost intervention that did not require a high level of evidence, the city is encouraging sidewalk vendors to sell fresh fruits and vegetables in underserved neighborhoods. Vendors had applied for permits to operate carts selling hotdogs and soft pretzels. The city contacted those on the waiting list to give them the option of staying on the list or selling fresh produce in a designated “green cart neighborhood” Assessing Need for New Grocery Stores � The Supermarket Need Index identifies high need neighborhoods where: — Diabetes and obesity Supermarket N eed I ndex rates are high Less — Consumption of fruits and Moderate vegetables is low High — Share of fresh food retailers is low — Capacity for new grocery stores exists — Population density is high — Household access to cars is low — Household incomes are low FIguRE 7-1 A Supermarket Need Index applied to New York City revealed high- need areas with limited access to healthy 4-1.eps Figure food. SOURCE: B. Thomases, New York with some ve Mayor. bitmap image City Office of the ctor type

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 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION without a wait. One thousand permits for green carts were issued in the five boroughs immediately. This initiative helped bring access to fresh fruits and vegetables to neighborhoods lacking grocery stores quickly while also solving the problem of long waiting lists for vendors. A more extensive and more costly initiative to address the need for supermarkets is being planned. Based on research conducted by The Food Trust, PolicyLink, Columbia University, and others, this initiative encompasses zoning incentives and tax and other financial incentives to “People who are making support new supermarkets in under- decisions in the health field, they served areas. In this case, evidence are sold. But when you raise the played a critical role in showing ini- stakes up to the level beyond that, you get to where people are tially skeptical economic develop- ment officials, deputy mayors, and not so sure.” —Benjamin Thomases others that access to a supermarket has a significant effect on obesity rates. Drummond stressed that while public health officials understand the importance of obesity prevention, the message needs to be conveyed to the broader community so that all stakeholders understand that obesity is not just a matter of individual choices. “CuLTuRE OF FITNESS” IN ARLINgTON, vIRgINIA Mr. Tejada discussed how his county’s programs and policies attempt to introduce a new paradigm through an initiative called Fit Arlington. “We are creating a culture of fitness in Arlington in almost everything we do,” he explained, citing as an example sidewalk connectivity to encourage walking. Publicizing What Already Exists Community discussions held with residents made clear that many did not know what the county was already doing to encourage fitness. The county is publicizing trails, recreational programs, and other offerings online and through the public-access cable television channel, but Tejada also stressed the “old-fashioned way” of using flyers at libraries and other locations. An attempt to enact county law to ban trans fats in restaurants turned out not to be possible because of Virginia law covering what local govern- ments can and cannot legislate. Instead, the county has launched a volun- tary campaign to encourage restaurants to exclude trans fats from their menus.

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 DECISION MAKERS Linking Evidence, Smart growth, and Health Tejada said that evidence from reputable organizations, such as NIH or CDC, is important as a basis for developing consensus among policy makers. Many different groups are getting involved. The National Asso- “It is important to get residents ciation of Hispanic County Officials, involved with what is already in which Tejada plays a leadership happening. Sometimes, we role, and the National Association of think because we are involved African American County Officials in this discussion, everybody have joined forces to combat obesity. else should know. This is not Within the Washington, DC, region, the case.” educators and elected officials will —J. Walter Tejada hold a regional summit on combat- ing obesity in fall 2009, based in part on findings from the Metropolitan Washington survey referred to previously by Drummond. Arlington County is 89 percent residential and 11 percent high-density “smart growth” around the Metro corridor. In this corridor, developers have participated in a voluntary program to gain additional density in exchange for investing in community benefits such as parks and sidewalks. People in government and leadership roles need to base decisions on the best evidence available, Drummond said, and the evidence makes clear that the country has a problem with obesity and diabetes. Development deci- sions need to be based on that evidence. Drummond also urged the design of development improvements to combat obesity for everyone, including children and people with disabilities. EFFORTS TO SPEAK OuT ON ObESITy PREvENTION IN MONTgOMERy COuNTy, MARyLAND Mr. Leventhal learned that visibility on the obesity issue carries political risks. When he criticized school fundraisers held at McDonald’s restaurants, he received a good deal of negative publicity. However, the controversy did lead the county’s PTA council to suggest alternatives to selling unhealthy food for fundraising purposes, although it did not set policy for individual school PTAs. Leventhal described some of the county’s efforts to support healthier living. The county council enacted a ban on trans fats served in restaurants; a requirement that chain restaurants list menu items’ nutritional content is pending. The county has developed a program called 7-3-3-1 for children and families with health risks associated with overweight and obesity. (The name of the program derives from the goal of 7 servings of fresh produce, 3 ounces of whole grains, 3 low-fat dairy servings, and 1 hour of physical

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0 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION activity per day.) The six-lesson program has been offered since 2005 in English and Spanish to families who participate in the county health plan for uninsured residents. Montgomery County is implementing the wellness plan required by the U.S. Department of Agriculture for districts participating in the School Lunch Program. Leventhal characterized the school system as a reluctant participant because “they see their role as educational; they don’t see their role as health based.” Nonetheless, he reported on accomplishments, including online listing of information on nutrients and allergens in school menu items and healthier items at lunch, in after-school programs, and in vending machines. Despite these accomplishments, Leventhal expressed frustration with the lack of good data, which he said impedes progress. The Maryland Ado- lescent Survey, Maryland Youth Tobacco Survey, and Youth Risk Behavior Survey (part of CDC’s Youth Risk Behavior Surveillance System) all provide data, but those data need to be consolidated. The Youth Risk Behavior Survey in particular is controversial because it includes questions about sexual activity. Until recently, parents had to consent actively for their chil- dren to participate, which resulted in low response rates and nonscientific samples. Now for the first time, the survey will be administered with passive rather than active consent (parents must opt out rather than opt in), which Leventhal hopes will result in a more representative response. The state has several committees and task forces working on obesity- related issues. Leventhal is not optimistic, however, that recommenda- tions aimed at schools, such as more time for physical education, will be implemented. EvIDENCE IN MINNESOTA HEALTH POLICy DECISIONS Minnesota regularly ranks high in national surveys of the healthiest states, but Ms. Musicant said the ranking masks significant health dispari- ties, including those in three parts of Minneapolis. The city is one of four federal Steps Program grantees that received funding for programs related to nutrition and exposure to tobacco. In addition, the city council adopted 20 sustainability indicators, including one for healthy weight. Musicant supports these indicators because the city must report progress on them publicly, so they provide for accountability. Local policy achievements have included ordinances to increase the number of farm stands operating in the city and efforts to improve food offerings at convenience stores. The State Health Improvement Program, a $47 million, 2-year program addressing physical activity, nutrition, and exposure to tobacco, was built on experience with the Steps grant. Musicant described it as a good start, but noted that tremendous pressure exists to

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1 DECISION MAKERS show that it has been a worthwhile investment. Work is in progress on several other policy initiatives. In discussing the role of evidence in policy making, Musicant clarified that she did not speak from her own perspective as a health expert, but from the point of view of an elected official dealing with a myriad of issues. In terms of obesity prevention, if a proposed strategy dovetails with a policy maker’s other objectives and personal opinions about healthy behaviors, his or her interest in taking action increases. If the strategy is singularly about improving health, evidence must be paired with community advocacy before a policy maker takes action. If little or no evidence for the effective- ness of a proposed policy exists, a local pilot or demonstration can help. In discussing the role of evidence in decision making, Musicant said she was revisiting the topic of her master’s thesis on health care cost con- tainment. In that research, she found no relationship between what policy makers said they needed in terms of evidence to make a decision and “Food and exercise are so how they actually made their deci- personalizable. Everybody sions. She said her experience tells has their own anecdote that her this occurs because the evidence they carry around with them is not available in a meaningful way constantly. That is the most when policy makers need it. Instead, powerful information for most they are influenced by the opinions of decision makers.” trusted advisors, constituents’ advo- —Gretchen Musicant cacy for the change, the strength of opponents’ arguments and their clout, and the decision maker’s own per- sonal and family experience with the issue. Evidence is used most often as a justification after a decision has been made, rather than as the reason for the decision. When they do seek evidence for health-related policy changes, policy makers need it to be localized to track the changes; timely; capable of being broken down in meaningful ways, such as by age or race; affordable; and reliable. Also helpful are anecdotal evidence, data on the magnitude of the problem, information showing how to balance civil liberties with health, and parallels with other successful public health efforts to change behaviors. Much remains to be discovered about the most effective ways to enact obesity-related policies. It is necessary to build evidence based on com- munity wisdom and to promote health-enhancing behaviors, in some cases helping groups rediscover their own traditional, more healthful ways. Health impact assessments, which have been used in Europe and Canada, may be effective in bringing new perspectives into planning and engaging the public. The government has many tools available. The question remains how best to use them to optimize health.

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2 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION Factors Influencing Policy Decisions • Opinions of trusted advisors • Advocacy by constituents • Strength of opponents’ arguments • Decision makers’ personal and family experiences REFRAMINg OF THE CONvERSATION IN WASHINgTON, DC Mr. Vigilance was the final speaker in this panel. He said it was refresh- ing to be among people who understand the obesity issue because convincing others of the role that agencies need to play in changing the environments in which people live, work, and play can be challenging. People, Places, and Policy The health field focuses on the conversation between a patient and a health care provider, but many people do not go to a doctor or do not heed their doctor’s advice. Instead of framing the discussion in terms of patients and providers, Vigilance urged speaking about people, places, and policy. By places, he meant not just physical locations but also “the place you are in your head around your own health and wellness.” Economics and Health Washington, DC, has the one of the highest rates of obesity in the nation, with significant disparities depending on the particular neighbor- hood. Vigilance noted that the same issues that affect economic develop- ment in a neighborhood also affect wellness. His department’s practice “The fiscal impact of obesity is something to make more clear to is to reach out to partners, such as the police department and the edu- people.” —Pierre Vigilance cation system, to involve them in health and wellness issues. According to Vigilance, New York serves as a model for what a city can do. To those who think food-related actions are too difficult, he noted they are similar to those relating to tobacco. The department’s community activity takes place on different levels, such as development of a District of Columbia obesity action plan and

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 DECISION MAKERS a children’s health action plan and efforts to increase the availability of grocery stores in underserved neighborhoods. As in other cities, corner stores are the main source of food in poorer neighborhoods. When Vigilance spoke with the owner of one local store, the owner said what he stocks is a function of what sells, not necessarily what is healthy. Vigilance urged teaching children, businesses, and stakeholders differently so more people will understand the impact of obesity on the workforce, educational out- comes, and long-term medical costs. DISCuSSION Questions and topics raised during the discussion that followed the panel presentations included the following: • The First Family and others as role models. One attendee expressed the belief that the Obama family serves as a positive model, with such examples as the children playing soccer and planting of a White House vegetable garden. Vigilance agreed but noted that not everything the First Family does applies to all parts of the country, citing as an example community gardens. Leventhal said the prob- lem is not a lack of messages about diet and exercise, but rather reaching the percentage of the population that is not receiving or acting on those messages. • Advice for working with policy makers who may not be receptive. Panelists responded to a question on dealing with unreceptive policy makers. Leventhal suggested not just going to particularly sympathetic officials because then the issue becomes branded as their special issue. Instead of working with one individual, he urged working with an entire council or other body. Tejada sug- gested finding ways to encourage citizen participation by asking the mayor and other elected representatives what the jurisdiction is doing to combat obesity and having information to give them. Coalitions raise the visibility of an issue, such as through a forum where people can discuss the issue and not just reinvent the wheel. Drummond agreed that community consensus is important. He also suggested following the “path of least resistance,” which he defined as agencies, such as parks and recreation or health, that would be most receptive to obesity prevention efforts. Local universities have facilities, such as recreation centers or depart- ments, that can offer community classes. Public−private partner- ships can get people active through sports, gardening, or other activities. Thomases noted that in local settings, small numbers of votes really matter. A few dozen voters in a district with 100,000

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 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION people who call an elected official about an issue can make a big difference. • Strategies for addressing opposition from the restaurant industry. A participant asked panelists how they dealt with opposition to menu labeling and banning of trans fats in restaurants. Thomases explained that the New York City Board of Health enacts these policies. It is separate from the City Council and not elected, which keeps it relatively insulated politically from the restaurant indus- try. However, the industry sued the city three times on the menu labeling initiative. The first time, the city lost and had to reshape the initiative. Thomases recommended that jurisdictions consider- ing menu labeling initiatives research these court cases because legal precedent was ultimately established. Leventhal said a menu labeling bill is still pending in Montgomery County. When the recession hit, he pulled back on trying to obtain its passage. In the meantime, he is collecting data on the costs it would require, such as new menus. Policy makers have heard only opposition to the bill; would-be supporters see the issue as somewhat obscure and have not rallied behind it. Leventhal noted that the industry did not offer much opposition to the trans fat ban beyond asking for time to make changes to their offerings. The experience with making restaurants smoke free has been instructive. The industry opposed the measure on financial grounds, but 3 years of data show, in fact, that restaurant revenues have increased. • Institutionalizing change. Vigilance emphasized the need to work with others besides elected officials, who eventually leave office; the issues outlive their terms. He suggested pressuring elected represen- tatives to put plans in place and fund them so they will continue past the politicians’ terms. • Levels of evidence for policy making. An audience member com- mented on what panelists had said throughout the workshop about evidence. When Karpyn discussed levels of evidence from a scien- tific point of view, expert opinion ranked last. In contrast, policy makers consider the opinions of experts to be highly valuable. It is important to have good science, but based on the workshop discus- sions, it is only part of what is needed to effect change.