7

Communities and States

Three speakers addressed obesity solutions in communities and states. Leon Andrews, senior fellow at the National League of Cities (NLC), spoke about action at the local level—cities, towns, and counties. Cheryl Bartlett, commissioner of the Massachusetts Department of Public Health, described her state’s strategies for combating obesity. Finally, Marion Standish, director of community health at The California Endowment, presented on the power of policies to change the course of the epidemic.

ACTION AT THE LOCAL LEVEL

In partnership with the U.S. Department of Health and Human Services, NLC has been leading a collaborative partnership called Let’s Move! Cities, Towns, and Counties. This initiative incorporates five key components for healthy communities:

• engaging diverse stakeholders,
• implementing policies and strategies,
• forging a common vision,
• coordinating infrastructure, and
• sharing accountability.

Andrews outlined some of the steps taken by NLC’s Institute for Youth, Education, and Families to develop knowledge in the area of childhood obesity. The Institute has:

• created an action kit for leaders (available at http://www.nlc.org/iyef [accessed April 29, 2014]);
• completed 2 years of technical assistance with the School Superintendents Association;
• hosted workshops at NLC annual conferences and at the biannual Your City’s Families summit sessions;
• disseminated e-newsletters that highlight examples of city programs and national resources;
• worked closely with First Lady Michelle Obama on Let’s Move! Cities, Towns, and Counties;
• established the Municipal Network for Combating Obesity Steering Committee;
• conducted community wellness case studies in Charleston (South Carolina), Jackson (Tennessee), La Mesa (California), Oakland (California), and San Antonio (Texas); and
• partnered with YMCA USA on health communication.

NLC also has been providing local elected officials with technical assistance; supporting peer-learning opportunities; and offering customized guidance through webinars, conferences, calls, and other methods. In just a year and a half, said Andrews, NLC has been able to engage more than 400 local elected officials and communities across the country, even though it previously had been difficult to engage local leaders in conversations about obesity. An increasing number of mayors and other local elected officials are recognizing the economic value of healthy communities, noted Andrews.

Now this leadership needs to be sustained, Andrews emphasized. “Mayors come and go,” he said. “We are very mindful of that.” He cited several policies and strategies that can sustain city leadership:

• Balance strategies focused on developing and sustaining effective interventions that promote physical activity, access to healthy foods, and healthy eating among children and youth.
• Implement policies for recreational opportunities and improved access to healthy eating.
• Define a shared and comprehensive framework that reaches high-risk populations, establishes sustained partnerships with schools, makes the most of out-of-school time, promotes access to nutritious foods, uses parks and recreation, and reshapes the physical environment.
• Engage young people, parents, and the local media in sharing ownership of efforts to promote healthy communities.

Andrews then detailed a wide variety of strategies designed to provide recreational opportunities:

• joint-use agreements for recreation facilities;
• mandated physical activity requirements for city-funded youth programs;
• commitments to ensure that all children live within walking distance of a playground or recreation center;
• conversion of unused railways to trails;
• roadways designed to provide access for cars, pedestrians, and bicyclists (“complete streets”);
• conversion or rehabilitation of blighted areas into community gardens, parks, or green spaces;
• public–private partnerships with local gyms and recreation facilities to offer reduced-cost fees for low-income residents;
• city master plans that include provisions to encourage walking and biking;
• policies requiring the construction of new recreation facilities along trails or public transit routes to make them more accessible to residents;
• policies to ensure sidewalk continuity and direct routes for pedestrians and bicyclists to city centers and recreation areas; and
• streetscape design guidelines aimed at improving streetscapes to promote walkability and bikeability.

Andrews also highlighted an assortment of policies designed to increase access to fresh and healthy food:

• grants, loan programs, small business development programs, and tax incentives that encourage grocery stores to locate in underserved areas;
• zoning requirements that encourage supermarkets to move into densely populated urban and rural areas;
• local development plans that include grocery stores as a consideration in neighborhood development;
• public–private partnerships to identify and procure land for retail grocery stores;
• financial, promotional, and other incentives to encourage convenience store owners to offer healthier food options;
• policies requiring grocery and convenience store owners to accept electronic benefit transfer cards for Supplemental Nutrition Assistance Program (SNAP) benefits;
• policies to limit marketing of unhealthy food in grocery and convenience stores located near schools;
• incentives, grants, and subsidies to farmers’ market organizers to support new and existing farmers’ markets;
• policies requiring farmers’ markets to accept Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and SNAP benefits;
• land use protections for community gardens;
• incentives for mobile produce markets to locate in low-income areas;
• government and school procurement policies that favor local, healthy foods; and
• financial assistance to regional produce farmers for processing and distribution to governments and schools.

Finally, Andrews discussed the idea of false universalism (Powell, 2009). Many communities take a universal approach to obesity-related strategy, policy, programming, and evaluation. But universal approaches that are not sensitive to particular needs can have uneven impacts and even exacerbate inequalities. Goals need to be universal, but this is not necessarily the case for processes, said Andrews. Some policies need to target the populations most in need of help, an approach that has been labeled “targeted universalism.”

STRATEGIES IN MASSACHUSETTS

Massachusetts has been implementing many of the strategies discussed at the workshop through its Mass in Motion¹ program, said Bartlett. Initiated in 2008, Mass in Motion is a multifaceted state initiative focused on better eating and increased physical activity. Executive orders from the governor addressed nutrition standards for all food procured throughout the commonwealth and required body mass index (BMI) screening for all students in grades 1, 4, 7, and 10, with aggregate data being reported to the Department of Public Health. School nutrition regulations implemented in 2010 cover competitive foods and establish wellness committees in all school districts. Public information campaigns and a website provide tips to families, communities, schools, and worksites on what they can do to promote health and wellness in their settings.

The cornerstone of the program has been municipal wellness grants aimed at changing public health approaches to obesity, Bartlett said. Taking lessons from antismoking campaigns, the grants have emphasized policies, systems, and the built environment so that the healthy choice will be the easy choice. A public–private partnership among health foundations, Blue Cross and Blue Shield, and the Department of Public Health has provided pilot grants to communities to form coalitions that can assess the barriers to healthy eating and active living. With the assistance of Mass in Motion coordinators, these coalitions then can consider policies and programs that will benefit all sectors while promoting health. Individual initiatives have included corner store programs; farmers’ markets, including mobile farmers’ markets that go to public housing facilities; community gardens; the implementation of school nutrition standards; the building and repairing of sidewalks; the provision of lighting and safe activities in communities; joint-use agreements so that people in communities can make use of facilities at educational institutions; and the creation of new walking and biking trails.

Because of the early successes of this work, Massachusetts was able to apply for Community Transformation Grants and was the only state awarded two such grants. The Mass in Motion program expanded from 11 to 52 municipalities, representing about 33 percent of the state’s population. The grants also have enabled the program to establish clinical linkages that have made it possible to address chronic diseases and tobacco use.

Together, these strategies have been paying dividends, Bartlett said. BMI reporting has revealed significant reductions in obesity and overweight

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¹For more information, see http://www.mass.gov/eohhs/gov/departments/dph/programs/community-health/mass-in-motion (accessed April 29, 2014).

in the Mass in Motion communities. This is true of both genders, with the biggest reductions seen in grades 1 and 4.

Dealing with Challenges

Bartlett noted that Mass in Motion has had to deal with some controversy. The year before the workshop, Massachusetts rescinded the policy of sending a letter to parents notifying them of their child’s BMI score. Legislative efforts to eliminate the ability to perform BMI screening had led the governor to ask whether the letters made sense. Still, aggregate data from the BMI screenings are being retained, Bartlett reported, making it possible to continue following trends.

The school nutrition guidelines also created challenges, leading to legislative attempts to make changes. Parents have objected, for example, that the guidelines remove the ability to have celebrations in schools involving cupcakes and sweets. “It is important for us to come together so that we do not start to take some steps backwards when people try to legislate these good efforts away,” said Bartlett.

THE POWER OF POLICIES

Many programs, services, and activities that affect nutrition and physical activity are under way, observed Standish, but the overarching element that unites these efforts is policy. Good policies that are well implemented offer the greatest opportunities for sustainability and equity. Policies emphasize the “how” rather than the “what,” said Standish, which can “build the kind of momentum that will change the course of [the obesity] epidemic.”

Good policies are scalable; work that succeeds at the local level can be scaled up to the national level quickly. This has been seen with school meals, menu labeling, water in schools, competitive food regulations, and other innovations. This scaling up “broadens the impact of what we are trying to do by taking it to a population level that we could not imagine when we began,” said Standish.

Good policies also are enforceable. Especially when outcomes can be measured, policies can be a mechanism for implementing such changes as physical activity regulations.

Finally, good policies meaningfully engage communities. They can build sustainable momentum for change and create new leaders who can articulate issues in ways that are most relevant to a community. Scalability, enforceability, and engagement all are criteria that can be used in identifying the most powerful opportunities for change.

Standish also emphasized the need to adopt a health-in-all-policies

approach. If all policy making supports health, actions can engage multiple sectors and create indicators for success.

Sources of revenue for obesity prevention and treatment need to be protected and extended, noted Standish. But she also pointed to the need for new revenues, whether from taxes on sugar-sweetened beverage or other kinds of fees. Another option, she said, would be to create wellness trusts using hospital community benefit funds and other sources of coordinated funding.

Finally, Standish suggested that new constituencies need to be leveraged. People working on obesity issues often are quite isolated, but many constituencies care about the issue, even if they may talk about it in different ways. The health care sector is one such constituency, but others include sustainable food groups, community development organizations, disease advocacy groups (such as those focused on diabetes), climate change advocates, and education reformers. “These are all sectors that we need to engage more actively if we are going to be successful at the community and the statewide level,” Standish emphasized.

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