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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary 7 Local Policies and Programs The actions and policies of local governments, in areas such as health services, land-use decisions, education, and recreational services, affect the prevalence of obesity for better or worse by making it easier or more difficult for people in local communities to eat better and increase their physical activity. Local governments also can spur or discourage community engagement in health issues (IOM, 2009a). Jonathan Fielding (Director of Public Health and Health Officer, Los Angeles County Department of Health), Lynn Silver (Assistant Health Commissioner, New York City Department of Health and Mental Hygiene), and Chip Johnson (Mayor, Hernando, Mississippi) described some of the ways in which their localities are promoting the health of their populations. Collectively, they identified the need to: develop a range of programs and services in recognition of the diversity of the population and the fact that different interventions will reach different people; use data to target resources and stimulate further action (with the observation that scientific evidence on the effectiveness of local interventions is lacking); model healthy workplace practices, from what is sold in vending machines in public buildings, to procurement, to local officials setting an example; and tap into resources from multiple sources, such as philanthropies, grants, and new developments, especially in this era of declining revenues.
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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary Fielding discussed five roles a health department can play in obesity efforts; Silver discussed New York City’s menu labeling law, the first such law in the nation; and Johnson addressed the role of a mayor in championing and encouraging the leveraging of resources to move people along the path toward better health. LOS ANGELES COUNTY: THE HEALTH DEPARTMENT AS A FOCAL POINT Los Angeles County encompasses 10 million residents, with more than 100 different languages being spoken by significant numbers of people. There is no one majority racial or ethnic group. The ethnic breakdown is 47 percent Latino, 30 percent white, 13 percent Asian/Pacific Islander, 9 percent African American, and 0.3 percent American Indiana/Alaskan native. Sixteen percent live in poverty, including about one in four children. Five Roles for the Health Department Fielding described the health department’s five roles related to preventing childhood obesity: surveillance, monitoring, and data collection; coordination and collaboration with a wide range of public and private partners; modeling of a healthy workplace; funding for pilot projects; and use of health impact assessments. Surveillance, Monitoring, and Data Collection Obesity among children and adults in the county, as elsewhere in the country, has become more prevalent in the last 10 years. Gestational diabetes, which has long-term effects on babies mothers are carrying, more than tripled in a 12-year period. Using a model developed for Healthy People 2020, Fielding described how the health department focuses on influencing better health outcomes across the life span for children and adults. Communities in Los Angeles that face the greatest economic hardships are also those with higher rates of obesity. The average prevalence of obesity in the county’s 10 wealthiest communities is 8 percent; in the poorest 10 communities, it is 31.5 percent. Some factors that contribute to the obesity epidemic are related to this disparity, such as the availability of safe places to play and access to healthy, affordable food, while others are more generalized.
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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary Coordination and Collaboration with Public and Private Partners The health department works across multiple sectors, including, among many others, local chambers of commerce and other employer groups, faith-based organizations, regional planners, social services agencies, and educational institutions. As an example, the department held conferences to bring together health officials, planners, and others in the built environment community. Public health staff have been trained so they can provide input to other sectors in a common language rather than in health jargon. Directors in the Departments of Public Health, Regional Planning, and Parks and Recreation will collaborate on an update to the county’s General Plan and will develop guidelines for developers for building healthy communities that promote physical activity. Modeling of a Healthy Workplace The health department can set an example for other agencies in the public sector, as well as private employers. Recent efforts have included a countywide worksite wellness program encompassing key physical activity and nutrition components; organized workplace-related physical activity, such as lunchtime walking groups and activity breaks during meetings; and a 100 percent healthy foods policy in county vending machines. Funding for Pilot Programs The Policies for Livable and Active Communities and Environments (PLACE) program was established in 2006 within the Division of Chronic Disease and Injury Prevention. Five projects are being funded for three years to institute policies that promote physical activity. For example, Culver City is linking the downtown area to a public transit station with bicycle- and pedestrian-friendly routes, and Long Beach is creating bike boulevards. Use of Health Impact Assessments Health impact assessments examine the potential health effects of a project or policy. Fielding described a few such assessments under way in Los Angeles County. Looking at menu labeling and food selection, for example, the health department estimated that if at least 10 percent of patrons used menu labeling to select a meal with just 100 fewer calories, 41 percent of the 7 million pounds of annual weight gain in the county would be prevented. Such data are important to show policy makers how even a small percentage of people making slightly better decisions can have an impact.
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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary Other local and statewide progress includes nutrition standards in schools; a trans fat ban in restaurants; and the California Complete Streets Act, aimed at reducing the number of cul-de-sacs in residential developments to increase walkability. Local Challenges and Changes Fielding identified some challenges faced in improving the food and physical activity environments. In terms of improving the food environment, he noted the limited base of evidence on effective community-level interventions; a lack of public support (to many, food is an individual choice); entrenched business interests that oppose change; and legal impediments, such as those who argue that the right of free speech protects food marketing. He suggested that environmental changes can improve conditions so that healthy choices become easy choices (see Table 7-1). Similarly, improving physical activity environments requires working across sectors, overcoming legal barriers and resistance by some business interests, and determining how to increase resources to facilitate biking and walking within transportation funding streams that have not traditionally prioritized these forms of movement. Again, Fielding identified necessary environmental changes, such as increasing parks and greenspaces and making them safe and people-friendly, to make physical activity the easy choice. Finally, Fielding commented on some additional challenges for his department and other local agencies seeking to address obesity: the need to influence non-health sector decisions so people will understand and take into account the health consequences of decisions made on transportation, taxation, and other issues; the need for changes in the organizational culture to address policies and systems, not just more services and programs; diminishing public health resources that require leveraging existing and seeking new funding, especially for prevention of chronic conditions such as obesity; competing demands, such as for emergency preparedness; and the need for a broader range of partnerships to develop a shared vision of the effects of health on all aspects of society. As noted, Fielding stressed the inadequacy of the research base for determining which interventions are effective in addressing the obesity problem. He urged greater study, noting that the quality of evidence can be high even without randomized controlled trials. He also urged the creation of a national action plan, coordinated by the Domestic Policy Council, that
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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary TABLE 7-1 Making Healthy Choices the Easy Choices in Los Angeles County Condition Environmental Change Lack of access to fresh, nutritious, affordable foods Provide incentives for markets and other businesses that provide healthy food options. Provide incentives for healthy food purchases among SNAP recipients. Use zoning tools to reduce the concentration of fast food and convenience stores not offering healthy options. Establish nutrition standards for food purchased in county-related programs and by vendors, and encourage outside agencies to do the same. Increased marketing of junk food Place limits on the marketing of junk food to children (e.g., around schools and parks, on billboards). Early childhood obesity Promote improved nutrition among preschool-aged children by establishing and enforcing nutrition guidelines in child care and preschool settings. Lack of park space and recreational areas Work with cities to increase parks and greenspaces. Encourage joint-use agreements between cities and schools. Communities not pedestrian- and bicycle-friendly Work with cities to incorporate health into local planning decisions and general plans. Promote the Safe Routes to School Program in disadvantaged communities. Promote the use of public transportation. Low levels of physical education in schools Work with schools to overcome barriers to physical education in schools, such as fiscal constraints and the perception that physical education will detract from academic success. SOURCE: J. Fielding, Los Angeles County Department of Health. would bring together the many policies and agencies with a role in addressing obesity and improving health. NEW YORK CITY: MENU LABELING TO PROMOTE HEALTH As mentioned earlier, New York City now has a menu labeling law mandating that the caloric content of foods in chain restaurants and carry-out establishments be prominently displayed. Silver discussed the law in the context of other city efforts to address obesity.
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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary Approach to Obesity Prevention The New York City health department focuses on what it can do to change the environmental default to make healthy choices easier for individuals, such as instituting seat belt laws or fluoridating the water. In the case of obesity prevention, the health department attempts to get New Yorkers moving, increase access to healthy foods, and reduce the consumption of unhealthy foods. Silver noted that many different interventions are needed to make an impact. Getting New Yorkers Moving These efforts include starting with children by creating environments in schools and day care centers that will increase physical activity. Almost 15,000 teachers and preschool workers have been trained and equipped to get kids moving. The health department is measuring BMI and assessing fitness levels (through an instrument called the NYC FITNESSGRAM) in over 750,000 children in the city’s public schools, with plans to extend the initiative to the city’s full public school population. It is also working with other departments on sustainable changes to the city’s physical environment, including bike paths and implementation of a new street design manual, and the city’s active design guidelines, an interagency policy aimed at promoting more pedestrian- and exercise-friendly designs, among other goals. Stair-use prompts encourage people to incorporate stair climbing, rather than riding elevators, into their daily activity. Increasing Access to Healthy Foods Citywide procurement and vending guidelines are serving as a model and resulting in the provision of healthier foods. The Healthy Bodegas Initiative encourages corner stores to stock, promote, and advertise fresh fruits and vegetables and other healthy foods (bodega is a term commonly used on the East Coast for a nonchain or corner food store, especially in the New York City region). Other interventions include Healthy Bucks, $2 vouchers that SNAP recipients can use to purchase produce more affordably at participating farmers’ markets, and Green Carts, which license sidewalk vendors exclusively to sell produce in underserved neighborhoods with micro-loans and technical assistance for Green Cart operators, as well as branding, marketing, and outreach to encourage residents of the Green Cart areas to purchase fresh produce from the carts.
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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary Decreasing the Consumption of Unhealthy Foods To decrease the consumption of unhealthy foods, New York City has instituted its menu labeling law, described below, as well as a trans fat ban in restaurants, and coordinates the national salt reduction initiative that’s working with food manufacturers to voluntarily reduce the amount of salt in their products, child care regulations covering meals and snacks for young children, and a media campaign on reducing the consumption of sugar-sweetened beverages. Menu Labeling Law Silver explained the origins, implementation, and preliminary results of the city’s menu labeling law. Expenditures nationwide on food eaten away from home, especially at fast food restaurants, had steadily increased, from less than 30 percent of the food dollar in 1962 to about 45 percent in 2002. Menu labeling was proposed in the legislatures of Maine and New York State in 2002, but without success. National legislation was proposed in Congress but also did not progress. According to Silver, however, New York City has two “secret weapons” that resulted in success: the mayor, who is very involved in public health, and the New York City Board of Health. The board is made up of 11 public health and medical experts appointed by the city council for 6-year terms. Members cannot be dismissed without cause, which allows them considerable freedom of action. The Board of Health had the authority to enact the menu labeling law. The department made several decisions related to how to formulate and implement the law. First, it decided to limit the labels to calories, excluding other nutrition information, since it believed that calories was the single most important piece of information and that people could be overwhelmed by too many numbers at once. A second decision was to require posting the information in a prominent place, what the industry calls the “prime real estate” on menu boards. The restaurant industry challenged the law in court twice, but the city won the second time after revising the first law. The law went into effect on March 31, 2008. Silver showed examples of menu boards and display shelves with calorie information clearly displayed. She reported that the change has been well received, and, anecdotally, New Yorkers have been talking about changes in their diet resulting from the calorie-labeling requirement. Beyond anecdotes, however, evaluation was built into the effort from the beginning (see Box 7-1), starting with a baseline before the law went into effect and looking at change several months and then a year later. Changes in what is ordered by customers have been examined, as well as changes in menus to offer items with lower caloric content. Information
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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary BOX 7-1 Calorie Labeling Results in New York City: Seeing and Using Information The country’s first calorie-posting regulation was enacted in New York City in December 2006 and, after several legal challenges, took effect in March 2008. An ambitious evaluation plan, which will provide information to the New York City Department of Health and Mental Hygiene, as well as others interested in the effects of menu labeling, is being carried out. An initial baseline study conducted before the law went into effect showed that only 4 percent of patrons reported seeing calorie information on menus (Subway restaurants were excluded). A study that took place in May to October 2008 showed that: The number of fast food customers who reported seeing calorie information increased from 38 percent to 72 percent. Among customers who saw the information, 27 percent reported using it. Based on the number of fast food meals served every day in New York City, these numbers translate to more than 1 million adults seeing the information every day and 280,000 using it to make food choices. regarding the latter effect is expected soon. Silver cited lessons learned from menu labeling thus far: The labeling is feasible to implement. Labels must be prominent on menu boards to be seen. Most patrons will see them. Thirteen to 20 percent will use them and purchase fewer calories. HERNANDO, MISSISSIPPI: CREATIVE LEADERSHIP ON A LIMITED BUDGET Mississippi has one of the highest rates of childhood obesity in the country. In Hernando, Mississippi, a city of about 15,000, Mayor Johnson and the Board of Aldermen oversee everything from garbage pickup to police and fire services, with a total city budget of $17 million. The high obesity rate in his state led Johnson to take an active role in seeking partnerships and new ideas for promoting health. In his presentation, Johnson discussed how even small changes at the local level can benefit people’s health. Over the past 4 years, he has used his position as mayor to seek creative and resourceful ways to create a healthier community, just the beginning, he said, of what he hopes the city can accomplish.
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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary Johnson stressed how communities must be creative in pursuing grants, partnerships, and other opportunities to make systemic changes. For example, the city has a new park. According to Johnson, “If we’d had to buy it, we couldn’t have afforded it.” However, developers provided 20 acres for the park because of Hernando’s open-space set-aside requirement. The city also has successfully applied for grants from The Robert Wood Johnson Foundation, Mississippi Fish and Wildlife, the National Center for Safe Routes to School, and many other public and private entities for trail and park improvements, greenways, and other measures to encourage physical activity. One investment that was initiated before Johnson’s term of office was the hiring of a full-time planner. Hernando is the smallest city in the state with this position, but it has been important as a way to work toward smart growth. Hernando’s achievements include partnerships that leverage dollars and human capital, state and national recognition that heightens local awareness, improvements in infrastructure without tax increases, and efforts in the local school district. At the same time, Johnson acknowledged many challenges. Mindsets and culture around food, exercise, and sharing the road with walkers and cyclists need to change. Johnson suggested that people who do not see obesity as an important issue need to be aware of its economic implications. Johnson is working with other mayors in the state to diffuse the healthy living message. He and the mayor of Somerville, Massachusetts, also co-chair a new national steering committee of the National League of Cities on combating childhood obesity. According to Johnson, mayors can and should use their positions to champion the prevention of childhood obesity. DISCUSSION During the question-and-answer session, Fielding stressed that a healthier society is not achievable without efforts to address social, physical, and environmental determinants. At the national level, he urged Congress and the Administration to convey the message that improving health and reducing health disparities and inequities should be an explicit goal of every local government department. Otherwise, it will be difficult to achieve the necessary improvements. Another observation made during the discussion was that Hernando is rural and thinly populated, while Somerville is one of the most densely populated areas in the country. This diversity is a strength of the National League of Cities committee. Regardless of the size of the community, as Johnson observed, it takes time for people to change. Education is essen-
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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary tial, not just for mayors but also for other city officials and the general population. Presenters were then asked whether they knew of any success stories of people working on the effect of violence and crime on physical activity as an obesity risk factor. Jebb said that in the United Kingdom, studies have found that children in more economically deprived areas are somewhat more physically active than those in more affluent neighborhoods. Jackson commented that in developing strategies, officials have heard parents say they want safe places for their children to play, as well as safe routes to get there. New York City, said Silver, has seen a decrease in urban violence and homicide, but public perception is that the level of danger is great. The health department is looking at street designs that will encourage more walking and cycling, which will also make the streets safer as they will be better populated. Providing lighting at night is a strategy to consider. Carr said CDC’s Division of Analysis of School Health is working on strategies to make children feel safe and protected at school. Physical education and recess can be times when bullying behaviors increase. The President’s budget includes $100 million for the Office of Safe and Drug-Free Schools and Communities to fund efforts to improve the school climate by fostering a safe, secure, drug-free learning environment, although the final appropriated amount may be less than that.