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Institute of Medicine (Meeting 6)September 30, 2010
Dr. Harold GoldsteinExecutive Director
California Center for Public Health Advocacy
Public Health Strategies to Improve Health
Lessons for Obesity Prevention in California
Promote the establishment of public health policy at both
the state and local levels
Childhood Obesity Ø School Nutrition Standards (1999-2005)
Ø Physical Education Funding (2006)
Ø Food Access (2007 - )
Ø Menu Labeling in Chain Restaurants (2007-8)
Ø Sugar Loaded Beverages (2009 - )
OUTLINE
1. Challenges / Obstacles
2. Strategies
3. Lessons Learned
4. Your Questions
Major Public Health MovementsØ Sanitation / Infectious DiseaseØWorker SafetyØ Clear Air / Clean WaterØ Auto SafetyØ Drunk DrivingØ Lead PoisoningØ Violence PreventionØ Tobacco ControlØ Obesity / Chronic Disease
OBSTACLES
1. Opposition (Industry) Messages
2. Opposition (Industry) Money
3. Is it Government’s Role?
Obstacles
Industry Message #1
Personal Responsibility
The problem is simply a matter of
RE: legislation about child endangerment, obesity prevention, and the environment:“The California State Legislature is considering a string of bills this year that would impact your life. You might as well pass a blanket law saying the Legislature of the State of California hereby outlaws stupidity."
Assemblyman Chuck DeVoreFebruary 12, 2007
RE: legislation about child endangerment, obesity prevention, and the environment:“The California State Legislature is considering a string of bills this year that would impact your life. You might as well pass a blanket law saying the Legislature of the State of California hereby outlaws stupidity."
Assemblyman Chuck DeVoreFebruary 12, 2007
RE: legislation about child endangerment, obesity prevention, and the environment:“The California State Legislature is considering a string of bills this year that would impact your life. You might as well pass a blanket law saying the Legislature of the State of California hereby outlaws stupidity."
Assemblyman Chuck DeVoreFebruary 12, 2007
1999
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1999, 2009(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)
2009
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Personal Responsibility
The problem is simply a matter of
So education is the answer
Industry Message #1
“The National Restaurant Association believes that any successful effort to
address the obesity issue in the United States today must first address education.”
Sheila Cohn Weis, R.D.New York City Dept of Health hearing
November 30, 2006
Every individual chooses if and how he or she will use our productsEducation and awareness are the best ways to build personal responsibility.
Anheuser-BuschFull page ads in New York Times
November, 1991.
DRUNK DRIVING
Safety and education are the main components for addressing problems of this nature. You cannot legislate against
accidents happening.”
National Rifle Association, 1987Response to study of 88 children with gunshot injuries
CHILD SAFETY LOCKS ON GUNS
Nanny Government
Industry Message #1
"To let these lightweight babysitters take over would be absurd, self-destructive,
and categorically un-American.
2A. Name Calling
ConsumerFreedom.Org
2B. Government is Big Brother
We are firm believers in the right to have a good time. Defending
enjoyment is what we’re all about.
ConsumerFreedom.Org
2C. Big Business is Your Friend
“[Menu Labeling] is just a ‘feel good’ Band-Aid that ignores the true issues behind obesity ...”
Jot Condie, CEO (9/12/07).
2D. Big Business Knows Best
“It’s the couch, not the can.”
SODAS IN SCHOOLS
Tobacco executives testifying before congress that nicotine is not addictive (1994)
Ignores the Human Cost
“It is unreasonable to expect that people will change their behavior easily when so
many forces in the social, cultural, and physical environment conspire against
such change.”
“There is one and only one social responsibility of business . . . to
increase its profits so long as it stays within the rules of the game.“
Milton FriedmanNobel Prize in Economics, 1976
2. Industry Money
“There is one and only one social responsibility of business . . . to
increase its profits so long as it stays within the rules of the game.”
Milton FriedmanNobel Prize in Economics, 1976
2. Industry Money
Source: Los Angeles Times, 2/7/10
Soda Industry Lobbying Expenses
Response to NY State Soda Tax Proposal
Distrust of Government
1. Interested ONLY in the public good –beholden to no one / nothing else.
2. Uniquely positioned: data, training, credibility, partnerships abilities
3. Opportunity to advocate for and develop upstream / sustainable solutions
Overcoming the ObstaclesUNIQUE ROLE OF PUBLIC HEALTH
ADVOCACY MODEL:7 Components
State & LocalPolicy Reforms
Research
State & LocalPolicy Reforms
Ø Paint picture of problem from public health perspective (make it REAL)
Ø Include specific policy solutions
Ø Drive policy agenda
ADVOCACY RESEARCH
Three Examples
Local Data
Research
State & LocalPolicy Reforms
1. School Nutrition Standards
Funded by The California Vitamin Cases Consumer Settlement Fund
28.1%26.5%
20
30
2001 2004
Overweight Children in California(2001 – 2004)
28.1%26.5%
20
30
2001 2004
Overweight Children in California(2001 – 2004)
Benefits of Local DataØ Brings the problem “home”
Ø Makes state and community leaders accountable to their constituents
Ø Provides media with local angle
Ø Supports local organizing
August 25, 2005
Final votes on bills: August 31, 2005
2. Healthy Food Access
“EVERYONE – EVERY SINGLE ONE OF US –eats how much we eat largely because of
what’s around us. . . . We are almost never aware that it is happening to us.”
Brian Wansink, PhDCornell University Food Lab
“EVERYONE – EVERY SINGLE ONE OF US –eats how much we eat largely because of
what’s around us. . . . We are almost never aware that it is happening”
Brian Wansink, PhDCornell University Food Lab
Fast Food Restaurants
Fast Food Restaurants+ Convenience Stores
Fast Food Restaurants+ Convenience Stores
Fast Food Restaurants+ Convenience Stores
Grocery Stores
Fast Food Restaurants+ Convenience Stores
Grocery Stores + Produce Vendors
Fast Food Restaurants+ Convenience Stores
Grocery Stores + Produce Vendors
California: 4.18
Retail Food Environment Index
COUNTY RFEISan Bernardino 5.72Sacramento 5.66Fresno 5.34Orange 5.13Solano 5.08
. . . . . .San Mateo 2.79Sonoma 2.52Monterey 2.14San Luis Obispo 2.01Marin 1.85Santa Cruz 1.84
3. Menu Labeling
Menu LabelingPublic Opinion Poll
SUPPORT MANDATORY MENU LABELING84% of all registered voters78% Republicans, 88% Democrats
Test yourfast-food
IQ
Which Denny’s option has the least calories?
Ham & Cheddar Omelet 595 cal 36%
Country Fried Steak & Eggs 464 cal 11%
French Toast w/ Syrup & Marg 1,003 cal 15%
Pancakes w/ Syrup & Marg 650 cal 29%
Field Poll, 523 registered voters, April 2007
Which Denny’s option has the least calories?
Ham & Cheddar Omelet 595 cal 36%
Country Fried Steak & Eggs 464 cal 11%
French Toast w/ Syrup & Marg 1,003 cal 15%
Pancakes w/ Syrup & Marg 650 cal 29%
Field Poll, 523 registered voters, April 2007
Which Denny’s option has the least calories?
Ham & Cheddar Omelet 595 cal 36%
Country Fried Steak & Eggs 464 cal 11%
French Toast w/ Syrup & Marg 1,003 cal 15%
Pancakes w/ Syrup & Marg 650 cal 29%
Field Poll, 523 registered voters, April 2007
Which Denny’s option has the least calories?
Ham & Cheddar Omelet 595 cal 36%
Country Fried Steak & Eggs 464 cal 11%
French Toast w/ Syrup & Marg 1,003 cal 15%
Pancakes w/ Syrup & Marg 650 cal 29%
Field Poll, 523 registered voters, April 2007
What % of people failed all 4 questions?
How many of the 523 survey respondents got all 4 answers right?
68%
0
“Calorie sticker shock”
Law of the Land
State & Local Data
Research
State & LocalPolicy Reforms
ScientificAdvisoryPanels
State & Local Data
Research
State & LocalPolicy Reforms
National Consensus Panel on School Nutrition
Recommendations forCompetitive Food Standards
in California Schools
March 2002
The California Center for Public Health AdvocacyP .O. Box 2309
Davis, CA 95617Phone 530-297-6000 Fax 530-297-6200
National Panel of Experts
1. Advocacy research is ONE PART of a comprehensive campaign strategy
2. Power of local data / local angle
3. Benefit of expert input into policy recs
ResearchLessons Learned
ScientificAdvisoryPanels
State & Local Data
Research
State & LocalPolicy Reforms
MediaAdvocacy
ScientificAdvisoryPanels
State & Local Data
Research
State & LocalPolicy Reforms
Media Coverage
1. Professional PR firm
2. Development of specific messages
3. Local spokespeople
4. Training of all spokespeople
5. Alternative Media
Media Advocacy
3. Menu Labeling
MediaAdvocacy
ScientificAdvisoryPanels
State & Local Data
Research
State & LocalPolicy Reforms
Policy Maker
Education
MediaAdvocacy
ScientificAdvisoryPanels
State & Local Data
Research
State & LocalPolicy Reforms
Training and technical assistance to help city
officials adopt policies to promote healthy eating
and physical activity
+
Ø Survey of city officials to identify interests, needs, priorities
Ø Advisory panel of elected officials to review materials and messaging
Campaign Development
1. Healthy Food Access
2. Physical Activity
3. Employee Wellness
PRIORITY ISSUES
Already have the authority:ü Zoning & General Plansü As Employer and Funder
FOCUS ON:Mainstream American ValuesØ Quality of life: What kind of city do
you want for children and families?
Ø Economic development: Improve economic base
Ø Healthy workforce: ↓health care costs, ↑ productivity
No / Low Cost PoliciesPositive for Policy Makers
Endorsed by Trade Organization
Policy Maker
Education
MediaAdvocacy
ScientificAdvisoryPanels
State & Local Data
Research
State & LocalPolicy Reforms
CommunityMobilization
Policy Maker
Education
MediaAdvocacy
ScientificAdvisoryPanels
State & Local Data
Research
State & LocalPolicy Reforms
NUTRITION & PHYSICAL ACTIVITY POLICY CAMPAIGN
(1998 – 2010)
Mobilize grassroots Teams in Los Angeles County to educate policy makers about childhood obesity
Funded by The California Endowment
Building a Movement inBaldwin Park, CA
ØWork deeply with residents: full engagement
ØResidents know the changes they want / need
ØBring residents together with policy makers
ØWork with retailers → policy change
Baldwin Park Resident Advisory Committee
Plan community activities / trainings to help youth & families lead healthy lives
and advocate for local policies
Healthy Teens on the Move
High school students see for themselves how an unhealthy environment
contributes to obesity and diabetes . . .
in their own community.
And then tell their story to local policy makers
Youth and Residents Can…
Inspire.......Others to improve to make their community healthier
Connect......With others using technology: faster than ever before
Empower......Each other to advocate for change.
Ensure that we are linked to the heart of the community
Policy Reforms
Ø School food: standards adopted earlyØ Physical education: mandatedØAfter school programs: P.A. + healthy snacksØ Retail food: fast food moratorium Ø Park Master Plan: safer / youth-friendlyØ Marketing: limits on store window advertising
EFFECT: 11% decrease in childhood obesity over last two years
Partnership with local businessCorner Store Campaign
“Healthy Selections”Corner Store Campaign
Ø Residents “audit” stores
Ø Meet with store owners
Ø Stores opt in / out
Ø Healthy selections placards
Ø Healthy products to the front
Ø Merchant advisory group
Ø Publicity for participants
Converting Smart & Final
Converting Smart & Final
Partnership with local businessCorner Store Campaign
And the policy is . . .
Now working with elected officials to develop conditional use policy: As standard conditions of doing business in the city, Ø limit proportion of floor space devoted to
unhealthy foodsØ require proportion of floor space
devoted to fresh and healthy foods
BIG PICTURE:Health has become a
Priority in Baldwin Park
Ø Safe and nurturing place for kids and families Ø This is what government is MEANT to doØ Limited public funds for greatest public goodØ Places where healthy choices are possibleØ Health is a pillar of city life
The community built the political will
CommunityMobilization
Policy Maker
Education
MediaAdvocacy
ScientificAdvisoryPanels
State & Local Data
Research
State & LocalPolicy Reforms
PartnershipBuilding
CommunityMobilization
Policy Maker
Education
MediaAdvocacy
ScientificAdvisoryPanels
State & Local Data
Research
State & LocalPolicy Reforms
GovernorState Schools Superintendent
Every Major Health OrganizationEvery Major School OrganizationHealth Care Providers / Insurers
Ethnic OrganizationsConsumer Groups
School Food StandardsSupporters
GovernorState Schools Superintendent
Every Major Health OrganizationEvery Major School OrganizationHealth Care Providers / Insurers
Ethnic OrganizationsConsumer Groups
School Food StandardsSupporters
GovernorState Schools Superintendent
Every Major Health OrganizationEvery Major School OrganizationHealth Care Providers / Insurers
Ethnic OrganizationsConsumer Groups
School Food StandardsSupporters
State Policy MakersLocal Policy Makers
Local Health DepartmentsCommunity Advocates
Other Partners
PartnershipBuilding
CommunityMobilization
Policy Maker
Education
MediaAdvocacy
ScientificAdvisoryPanels
State & Local Data
Research
State & LocalPolicy Reforms
Next Step in Obesity Prevention:SUGAR LOADED BEVERAGES
0
50
100
150
200
250
300
Total Sweetened Beverages
kcal
/per
son/
day
Increase in Per Capita Calorie Intake from 1977-2001
278 cal/day
120cal/day
Equivalent of Equivalent of 43% of new 43% of new
caloriescalories
Single Largest Contributorto Obesity Epidemic
Increase in Per Capita Calorie Intake(1977 – 2001)
Surgeon General on Smoking: 1964
“…cigarette smoking contributes substantiallyto mortality from certain specific diseases
and to the overall death rate.”
Per Capita Cigarette Consumption1955-2002
Num
ber of cigarettes
1964
5,000
4,000
3,000
2,000
1,000
1955 1970 1980 19902002
US adults (18+ years)
Tobacco Policies
Ø Smoke-free schools, workplaces
Ø Extensive K-12 education
Ø Health care sector participation
Ø Advertising restrictions
ØWarning labels
Ø Tobacco taxes (CA Prop 99)- funding state/local programs- anti-tobacco ads
1988: $90 million/year for social norm change
1999: Results were clearØ 27% decrease in smokingØ 19% decrease in lung cancer deathsØ 10% lower than rest of country
“Seeing dramatic results like these is proof that what we have done in California has worked.”
Diana Bonta, State Health Director (2003)
PROPOSITION 99
Universal LessonsØ Solution is never only personal responsibility
Ø Education is often helpful, BUT
Ø Community environments must be changed so people can make healthy choices
Ø Federal, state, and local policies are essential
Ø Need advocates to build the political will
Ø Business will come along AFTER
Ø In the end: people WANT government’s help
in Order to form a more perfect Union, establish justice,
insure domestic tranquility, provide for the common defense, promote the general welfare,
and secure the blessings of liberty to ourselves and our posterity,
do ordain and establish this constitution for the United States of America.
Institute of Medicine (Meeting 6)September 30, 2010
Dr. Harold GoldsteinExecutive Director
California Center for Public Health Advocacy
Public Health Strategies to Improve Health
Lessons for Obesity Prevention in California