Policy Nutrition Example Obesity What is Policy Policy

Policy & Nutrition Example: Obesity

What is Policy?

Policy – Webster’s • Wise, expedient, or prudent conduct or management • A principle, plan, or course of action, as pursued by a government, organization, individual, etc.

Policy Making – Webster’s • The act or process of setting and directing the course of action to be pursued by a government, business, etc.

Examples of Policies State County MPO/RDC Legislation Ordinance Resolution Tax Ordinance Internal Policy Plans Design Manual From Thunderhead Alliance: Complete Streets Report City

Why do we need policy?

Intervention Categories with Strong Evidence of Effectiveness for the 10 greatest Achievements in Pubic Health: From IOM report: Preventing Childhood Obesity, 2005…

Community School Wide based Campaigns intervention Mass media Laws and strategies regulations Vaccination X Motor vehicle safety X Safer work places X Control of infectious disease X X Decline in deaths from CHD and stroke X X X X Reducing costs to patients X X X

Community School Mass Wide based media Campaigns intervention strategies Safer and healthier foods X Healthier mothers and babies X Family Planning X X X Reducing costs to patients X Water Fluoridation Recognition of tobacco as a health hazard Laws and regulations X X

Evaluation of Policy Change • Policy development should include plans for policy evaluation – Process evaluation: Was the policy actually carried out? – Outcome: Did the policy change have the intended outcome?

The example of obesity….

Levels of Influence in the Social-Ecological Model Structures, Policies, Systems Local, state, federal policies and laws to regulate/support healthy actions Institutions Rules, regulations, policies & informal structures Community Social Networks, Norms, Standards Interpersonal Family, peers, social networks, associations Individual Knowledge, attitudes, beliefs

Framework from 2003 meeting: • Robert Wood Johnson Foundation • Kaiser Permanente • Centers for Disease Control and Prevention • American Association of Health Plans • Washington Business Group on Health • 47 public and private sector professionals.

What does it take to make changes that lead to better health for the population?

Core Factors Associated with Health Related Change Efforts (IOM, Preventing Childhood Obesity, 2005) • A persuasive science base documenting a socially and scientifically credible threat to the public health with important economic implications. • A supportive partnership with the media • Strategic leadership and a prominent champion • A diverse constituency of highly effective advocates • Enabling and reinforcing laws, regulations and policies

Organizing Framework for Public Health Interventions (IOM, Preventing Childhood Obesity, 2005) • • • The information environment Access and opportunity Economic Factors The legal and regulatory environment Prevention and treatment programs The social environment

Information Environment Opportunities • Health ed campaigns and other persuasive communication • Require product labeling • Restrict harmful or misleading advertising

Access and Opportunity • Community environment – Restrict access like we have for tobacco? • School environment

Economic Factors • Government has power to tax and spend – Taxes on calorie dense, low nutritional quality foods? – Incentives or subsidies for fruits and vegetables?

Legal and Regulatory Environment • Pubic health law is one of 8 emerging themes identified by IOM as important to the future of pubic health training. Three components: – Laws – Regulation – Litigation

State Nutrition and Physical Activity Legislative Database http: //apps. nccd. cdc. gov/DNPALeg/ 2004 2005 All WA States State All states 2006 WA All States WA Nutrition bills introduced 172 8 280 4 6 1 Nutrition bills enacted 28 2 55 0 Physical Activity Bills introduced 214 8 340 6 11 1 Physical activity bills enacted 50 1 72 6 3 1 1

HB 1866 Washington 2004 Dead School policies HB 2680 Washington 2004 Dead School policies HB 2760 Washington 2004 Pending School policies HB 2994 Washington 2004 Pending Prohibits lawsuits SB 5436 Washington 2004 Enacted School policies SB 6214 Washington 2004 Pending WIC Farmers market expansion SB 6525 Washington 2004 Dead School policies SB 6601 Washington 2004 Enacted Prohibits lawsuits

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SB 5436 - 2004 • Requires state school directors convene advisory committee to develop model policy on: access nutritious foods and development, appropriate exercise. Policy to address nutritional content of foods and beverages and the availability and quality of health, nutrition, and physical education curricula. SPONSOR: Kohl-Welles

SB 6601 - 2004 • No distributor, manufacturer or seller of food and non-alcoholic beverages will be held liable for claims resulting from weight gain, obesity or related health conditions due to long-term consumption of a product. SPONSOR: Brandland, Companion Bill: HB 2994

HB 1254 - 2005 • In regards to a specialized "Share the Road" license plate. Proceeds beyond costs of implementation will be used towards contracting with a qualified nonprofit organization to promote bicycle safety and awareness education in communities throughout Washington. The organization must promote bicycle safety and awareness education in communities throughout Washington. The Washington state traffic safety commission shall establish a program for improving bicycle and pedestrian safety, and shall cooperate with the stakeholders and independent representatives to form an advisory committee to develop programs and create public private partnerships which promote bicycle and pedestrian safety. Sponsor: Wood

HB 1413 and SB 5396 - 2005 • Relates to expanding the criteria for habitat conservation programs, sets forth funding and guides the interagency committee for outdoor recreation. Defines trail as a means public ways constructed for and open to pedestrians, equestrians, or bicyclists, or any combination thereof, other than a sidewalk constructed as a part of a city street or county road for exclusive use of pedestrians. Not less than twenty percent of appropriations for habitat programs must be used for the renovation, or development of trails. Sponsor: Dunshee Companion bill: SB 5396

SB 5186 - 2005 • Provides for county and city plans, wherever possible, to include urban planning approaches that promote physical activity. Transportation planning in cities, towns, and counties should incorporate policy and infrastructure changes that promote non-motorized transit. State agencies applying for loans or grants must have incorporated elements in their plans that increase access to walking and biking in their communities. Superintendent of Public Instruction to promote adoption of school-based curricula and policies that provide quality physical education for all students. Sponsor: Franklin

SB 6003 - 2005 • Relating to commute trip reduction tax credit. Offered to employers and property owners who are taxable and provide financial incentives to their own or other employees for ride sharing, for using public transportation, for using car sharing, or for using nonmotorized commuting before July 1, 2013, are allowed a credit against taxes payable. Sponsor: Jacobsen

SB 6091 - 2005 • Relating to funding and appropriations for transportation. Sponsor

SB 6197 - 2006 • Creates the Governor's Interagency Council on Health Disparities to create an action plan and statewide policy to include health impact reviews that measure and address other social determinants of health that lead to disparities as well as teh contributing factors of health care that can have broad impacts on improving status, health literacy, physical activity, and nutrition. SPONSOR: Franklin

From Issue Brief – Kansas Health Institute

Regulation • “If the tobacco experience is any guide, it is likely that the food companies will act just enough t o avoid government regulation…. . to date companies have been much more comfortable with educational campaigns emphasizing personal responsibility and the need for increased physical activity, than proposing major policy or structural change. ” IOM, Preventing Childhood Obesity, 2005

Regulatory Options • FDA has authority to enforce laws about labeling and false claims, not to deal with nutritional adequacy. IOM, Preventing Childhood Obesity, 2005

Litigation • Powerful tool for tobacco, gun violence, lead paint • Initial attempts at fast food litigation have been “less than successful” • Future is unclear • Several states have passed legislation aimed at prohibiting lawsuits against food and beverage manufactures for obesity-related health problems. • Documents obtained through discovery could damage the public's perception of food companies. IOM, Preventing Childhood Obesity, 2005

The Social Environment: Policy and Norms for Health Promotion • Norms are: – standards or models – Voluntary or expected way of behaving • Norms drive policy • Policy can also drive norms

Steps that previous efforts have taken before norms on the role of Government changed (Kersh and Marone, 2002) • • Social disapproval Medical science Self-help Demonize the user Demonize an industry Mass movement Interest group action

How is policy really made? Basics of Kingdon’s model Agenda Setting Alternative Specification Coupling and Windows Policy Entrepreneurs Kingdon JW. Agendas, Alternatives, and Public Policies. 2002

Agenda Setting • Agenda = list of subjects to which officials are paying some serious attention at any given time Basics

Alternative Specification • Narrows the large set of possible alternatives to that set from which choices are actually made. Basics

3 streams of processes • Problem recognition • Policies: proposal formation • Politics Basics

Policy Participants • • Basics President Members of congress Civil servants Lobbyists Journalists Academics Others

Kinds of Participants • Visible: those who receive press and public attention – high level electeds and their appointees, the media, political parties, etc. – Affects the agenda • Hidden: academic specialists, career bureaucrats, congressional staffers – Affects the choice of alternative solutions Basics

Agenda Setting

Problems Why do some problems get attention? 1. Indicators – large magnitude or change 2. Focusing event – disaster, crisis, personal experience 3. Feedback about existing programs – evaluation, complaints, etc. Agenda Setting

Problem Recognition is Key Policy entrepreneurs invest resources: – Bringing their conception of problems to official’s attention – Convincing officials to see the problem the way they want it to be seen Agenda Setting

Decisions about Problem Recognition: Made through persuasion – Use indicators to argue that conditions should be defined as problems – Argue that proposals meet tests of feasibility or value acceptability Agenda Setting

Y O U R T I M E / H E A L T H The Year of Obesity Our perennial interest in losing weight became a national obsession in 2004 By MICHAEL D. LEMONICK

Google Hits for Obesity – 1/29/05 4/29/06 8, 650, 000 82, 600, 000 Obesity and “New York Times” 214, 000 3, 110, 000 Obesity and “Wall Street Journal” 49, 300 395, 000 Obesity and “Seattle Times” Obesity and CBS 13, 100 104, 000 97, 100 760, 000 Obesity

Politics Developments in the political arena are powerful agenda setters. – National mood – New administrations – New partisan/ideological distributions in congress – Interest groups that press (or fail to press) demands on government Agenda Setting

Political Decisions Consensus is built by bargaining – Trading provisions for support – Adding elected officials to coalitions by giving concessions – Compromising from ideal positions to those that will gain wider acceptance National mood and elected officials more important than interest groups for political decisions Agenda Setting

Obesity 'a threat' to U. S. security Surgeon general urges cultural shift Kim Severson, Chronicle Staff Writer Tuesday, January 7, 2003

Alternative Specification • Alternatives are generated and narrowed in the policy stream and by: • Hidden participants: Loosely knit communities of academics, researchers, consultants, career bureaucrats, congressional staffers, analysts who work for interest groups who: • Float ideas, criticize each other work, hone ideas, recombine ideas Alternative Specification

Generation of Policy Alternatives • Generation of policy alternatives analogous to natural selection • Order developed from chaos • Criteria include: – Technical feasibility – Congruence with values – Anticipation of future constraints (budget, public acceptability, politicians’ receptivity) Alternative Specification

The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity 2001

• Ensure daily, quality physical education for all school grades. Currently, only one state in the country -- Illinois -- requires physical education for grades K-12, while only about one in four teenagers nationwide take part in some form of physical education. • Ensure that more food options that are low in fat and calories, as well as fruits, vegetables, whole grains, and low-fat or non-fat dairy products, are available on school campuses and at school events. A modest step toward achieving this would be to enforce existing U. S. Department of Agriculture regulations that prohibit serving foods of minimal nutritional value during mealtimes in school food service areas, including in vending machines. • Make community facilities available for physical activity for all people, including on the weekends. • Create more opportunities for physical activity at work sites. • Reduce time spent watching television and in other sedentary behaviors. In 1999, 43 percent of high-school students reported watching two hours of TV or more a day.

• Educate all expectant parents about the benefits of breast -feeding. Studies indicate breast-fed infants may be less likely to become overweight as they grow older. • Change the perception of obesity so that health becomes the chief concern, not personal appearance. • Increase research on the behavioral and biological causes of overweight and obesity. Direct research toward prevention and treatment, and toward ethnic/racial health disparities. • Educate health care providers and health profession students on the prevention and treatment of overweight and obesity across the lifespan.

Preventing Childhood Obesity: Health in the Balance IOM, 2005

Federal Government • Establish an interdepartmental task force and coordinate federal actions • Develop nutrition standards for foods and beverages sold in schools • Fund state-based nutrition and physical-activity grants with strong evaluation components • Develop guidelines regarding advertising and marketing to children and youth by convening a national conference • Expand funding for prevention intervention research, experimental behavioral research, and community-based population research; strengthen support for surveillance, monitoring, and evaluation efforts

INDUSTRY AND MEDIA • Develop healthier food and beverage product and packaging innovations • Expand consumer nutrition information • Provide clear and consistent media messages

State and Local Governments • Expand promote opportunities for physical activity in the community • through changes to ordinances, capital improvement programs, and other planning • practices • • Work with communities to support partnerships and networks that expand • the availability of and access to healthful foods

Health Care Professionals • Routinely track body mass index (BMI) in children and youth and offer appropriate counseling and guidance to children and their families

Community and Non-profit Organizations • Provide opportunities for healthful eating and physical activity in existing and new community programs, particularly for highrisk populations

State and Local Education Authorities and Schools • Improve the nutritional quality of foods and beverages served and sold in • schools and as part of school-related activities • • Increase opportunities for frequent, more intensive, and engaging physical • activity during and after school • • Implement school-based interventions to reduce children's screen time • • Develop, implement, and evaluate innovative pilot programs for both • staffing and teaching about wellness, healthful eating, and physical activity

Parents and Families • Engage in and promote more healthful dietary intakes and active lifestyles (e. g. , increased physical activity, reduced television and other screen time, more healthful dietary behaviors)

“Softening-up” • Policy Entrepreneurs push for consideration in many ways and in many forums. • Most proposed alternatives have long gestational period • Recombination (coupling of already familiar elements) is more effective than mutation (wholly new forms). Alternative Specification

National Alliance for Nutrition and Activity NANA promotes within the legislative and executive branches of government a better understanding of the importance of healthy eating, physical activity, and obesity control to the nation's health and health-care costs. One of the primary goals of NANA is to cultivate champions for nutrition, physical activity, and obesity prevention in Congress and federal agencies. Efforts include supporting effective education programs, advocating adequate funding for programs, and promoting environmental changes that help Americans eat better and be more active. http: //cspinet. org/nutritionpolicy/nana. html NANA is made up of more than 300 organizations.

NANA Priorities • Model local school wellness policies • Strengthen national school lunch and other child nutrition programs • Strengthen national and state nutrition, physical activity and obesity programs

The “Streams” • The three streams have lives of their own. – Problems are recognized and defined – Policy proposals are developed according to their own incentives and selection criteria and are often waiting for a problem or political event they can be attached to – Political events flow along on their own schedule

Coupling the Streams • The probability of rising on the agenda is increased if all 3 streams are joined • Partial couplings between 2 streams are less likely to result in policy changes

Problems Policy Proposals Politics

Problems Policy Proposals Legislation or Change in Policy Politics

Window • Window of opportunity open when policy advocates can push their solutions • Advocates can wait for problems to “float” by that they can attach their solutions to or wait for the political stream to be advantageous. • Windows do not stay open long.

Policy Entrepreneurs • Willing to invest resources in return for future policies • Can be elected officials, career civil servants, lobbyists, academics, journalists • Entrepreneurs: – Highlight problem indicators to dramatize problem – Push for one kind of problem definition or another – invite electeds to see for themselves – “Soften up” by writing papers, giving testimony, holding hearings, getting press coverage, meeting endlessly…. .

Entrepreneurs Take Advantage of Open Windows • Can make the critical couplings when policy windows open. • Bring resources to the fray • Bring claims to a hearing • Political connections and negotiating skills add to ability to move policy forward • Sheer persistence is essential

POLICY OPTIONS to promote nutrition and activity Nutrition Labeling on Menus/Menu Boards at Chain Restaurants Decrease Marketing of Low-Nutrition Foods to Children Improve School Foods Increase Physical Activity in Schools Support Physical Activity through Transportation Policy Promote Fruit and Vegetable Intake Increase Resources for Nutrition and Physical Activity Programs (including Soft Drink Taxes)