Abstract
Abstract
Background:
State- and local-level policies can influence children's diet quality and physical activity (PA) behaviors. The goal of this article is to understand the enacted state and local policy landscape in four communities reporting declines in childhood obesity.
Methods
Conclusion:
Similarities were noted between the four communities in the types of polices enacted. All four communities had state- and/or local-level policies that aimed to improve the nutrition environment and increase opportunities for PA in both the ECE and K-12 school settings. This article is a step in the process of determining what may have contributed to obesity declines in the selected communities.
Background
The social-ecological model (SEM) is a framework that recognizes the interwoven relationship between individuals and their environment. The SEM describes layers of public policy, organizational, community, individual, and interpersonal factors that may affect behavior and influence the health of individuals and communities. 1 Community health determinants often involves assets, such as access to healthy and affordable food, safe housing, and community design that promotes active living. Public policy decisions, which form the outer layer of the SEM, can have a profound effect on these issues. Policy is also an important lever in addressing childhood obesity.2,3 In this article, we describe enacted state and local policies that may have influenced children's nutrition and physical activity (PA) environments in four selected communities, Anchorage, Alaska; Granville County, North Carolina; New York City, New York; and Philadelphia, Pennsylvania. Each of these communities experienced small, yet significant declines in childhood obesity prevalence from 2003 to 2011.4–7
Methods
The Childhood Obesity Declines (COBD) Project involved systematically exploring factors that may have contributed to reported significant declines in childhood obesity in: Anchorage, Alaska; Granville County, North Carolina; New York City, New York; and Philadelphia, Pennsylvania. The method was exploratory and attempted to capture retrospectively strategies that occurred in these communities, along with contextual factors that may have influenced community initiatives, programs, or policies. A complete description of the COBD methodology is contained in the article by Kettel Khan et al. 8 ; however, a brief description is contained in this study. The COBD Team used an adaptation of the Systematic Screening and Assessment (SSA). 9 This included developing a set of inclusion/exclusion criteria to select the four sites from a pool of possible jurisdictions with documented declines in childhood obesity; a retrospective review of the strategies reported to be present during the period of the obesity decline, through an online survey called the “Inventory of Strategies”; and performing site visits and interviews with key informants. The final product of the COBD were site visit summaries, which outline findings from the key informant interviews in each site and are available at www.nccor.org/projects/obesity-declines.
National, state, and local policies are one of the tactics to influence children's diet quality and PA behaviors. Given that all sites in this review would have been exposed equally to national-level policy, this article has limited its focus to state- and local-level policies. All enacted policies that impact specific settings known to influence children's diet quality and PA behaviors were reviewed. For this article, since the impact of policies may take some time to occur and we wanted to focus on relatively recent changes in the community's policy environment, we captured newly enacted policies in the 5 years before the reported declines in each site. Thus, the time period for reviewing each site's enacted policies was unique. In-depth information on the declines in each site is contained in the article by Ottley et al. 10 In Anchorage, Alaska declines were seen between 2003 and 2011, thus the study period for Anchorage was 1998 to 2011. In Granville County, North Carolina declines were seen between 2005 and 2010, thus the study period for was 2000–2010. In New York City, the declines occurred between 2006 and 2011, thus the study period was 2001–2011. Finally, the declines in Philadelphia were noted between 2006 and 2010, thus the study period was 2001 to 2010.
The CDC's online Chronic Disease State Policy Tracking System uses a systematic process to identify legislative and administrative regulations from all 50 states and the District of Columbia by applying search strings to national legal search engines. 11 This systematic process is documented in the State Legislative and Regulatory Action to Prevent Obesity and Improve Nutrition and Physical Activity methodology report. 12 The database contains over 6000 state-level policies, including legislative and regulatory actions, related to chronic disease prevention and health promotion. Users are able to apply filters to narrow their search to include the specific settings that a bill or legislation affects, such as early care and education (ECE), community, medical, retail, school, or workplace. Users can also select various policy topics and key words, such as nutrition, PA, and obesity and filter by year and status (introduced, enacted, dead, and vetoed) of bills and regulations. For this article, our search was limited to enacted policies that impacted the ECE, and school settings primarily. Only one community-level strategy, the use of task forces/councils for child obesity, was included because of its relevance to child nutrition, PA, and childhood obesity. Policies were extracted from the CDC database and placed into an Excel file for further analysis.
Currently, there is not a publically available national database that systematically collects local policies enacted by municipal governments across the United States. To identify relevant local-level policies enacted at the local or state level in each of the four communities, the project team used the COBD Inventory, which was sent to stakeholders before their site visit and asked about their knowledge of policies enacted at the local level. This information was verified during site visit interviews with key informants.
All policies were coded using the following categories: setting (i.e., ECE, school, and community child obesity taskforce), jurisdictional level (i.e., state or local), and type [i.e., nutrition and PA standards in ECE or schools, appropriated funding, task force on childhood obesity, and measurement of fitness or BMI screening]. The categories used in this project were informed by the work of Eyler et al., who has done previous work on the enactment of state childhood obesity legislative actions in the United States. 13
This policy review describes the various types of policies enacted and any similarities or differences identified across the four communities. In a second companion article by Jernigan et al. we provide examples of community-level activities, initiatives, and programs that may have supported or reinforced state-level policies. 14
Results
A total of 39 policies were captured across the 4 sites, with the majority (37/39) originating at the state level, whereas 2 policies pertaining to the ECE setting were adopted at the local level through licensing or administrative regulatory activity during the respective study periods (Table 1). Tables 2 and 3 provide a description of state- and local-level policies by community. In Anchorage, Alaska there were 5 policies noted between 1998 and 2011. In Granville County, North Carolina 14 policies related to child nutrition and PA, were enacted in that state between 2001 and 2010. The state of New York and the jurisdiction of New York City had 12 policies related to obesity prevention and treatment, nutrition, and PA between 2001 and 2011. Finally, in Philadelphia, Pennsylvania there were 8 policies that identified all affecting the school and ECE settings from 2001 to 2011.
Summary of Policy Categories Enacted at the State and Local Level by Jurisdiction
ECE, early care, and education.
Summary of Enacted State Policies by Year and Jurisdiction
Data source: CDC's Chronic Disease State Policy Tracking System.
PE, physical education.
Summary of Enacted Local Policies by Year and Jurisdiction
When assessing enacted policies at the state and local level in each of the four communities, analysis was done to identify similarities in the policy landscape between communities experiencing declines in childhood obesity. Similarities were noted among the sites in a number of general categories, including appropriated funding and policies related to child obesity task forces, committees or studies and programs, fitness or BMI measurement, the ECE setting, and school nutrition and PA policies. Each of these key categories and examples of site policies are described below.
Appropriated Funding for Nutrition, PA, or Obesity Prevention Initiatives
A noteworthy finding was that all four sites were located in states that had legislatively appropriated funding to projects, programs, studies, or initiatives to address child obesity, including capital and built environment improvements that support safe PA for children and families, commissioned studies on childhood obesity, funds for institutes, agencies, or allocates funds for school nutrition. Across the sites, a total of seven appropriation bills were found that support child nutrition, child PA, or childhood obesity prevention efforts.
Policies Related to a Task Force, Joint Commission, Commissioned Study, or Program on Childhood Obesity
Recognizing the importance of the childhood obesity epidemic, three of four states (North Carolina, New York, Pennsylvania) established a joint government commission, legislative task force, research studies, or programs to combat childhood obesity in their state. These task forces/commissions studies/programs were charged with studying, recommending or carrying out strategies for addressing the complex problem of childhood obesity by encouraging healthy eating and increased PA among children. Many of these state policies included or required the cooperation and coordination of state agencies to facilitate recommendations to prevent and control childhood obesity in their state, such as the Pennsylvania bill that directed the State Secretary of Education to establish an interagency coordinating council for child health, nutrition, and physical education (PE). It is also important to note that most of these commissions or task forces took place before any reported decline, such as the 2001 Obesity Prevention Act in New York or the North Carolina Healthy Studies Act of 2004.
Policies Related to the Measurement of Child Body Mass Index or Fitness
Two of the four sites had legislation in which measurement of BMI and child physical fitness were components. The New York legislation required students to provide health certificates and required institutions, including day care centers and schools, to screen children 2 through 18 years of age for overweight and obesity, using BMI. A related appropriation bill provided funding to assist with this. North Carolina had legislation in 2010 that required the State Board of Education to develop guidelines for evidence-based fitness testing for students in public schools statewide in grades kindergarten through 8.
Policies Impacting the ECE Setting
Nutrition and PA standards
All sites had some type of ECE licensing or administrative regulation changes that impacted the foods served to young children and/or the amount of PA required for children in the ECE setting. For example, North Carolina made changes to their Child Care Regulations related to nutrition, PA, and screen time. The changes required meals and snacks in child care centers to comply with nutrient intake guidelines from the USDA's Child and Adult Care Food Program (CACFP) and further improved the nutrition standards in child care facilities by limiting juice intake and prohibiting soda, flavored milk, and food that does not meet nutritional requirements. They also mandated that 1 hour of PA be provided for children in child care centers and limited screen time for children. Alaska had similar regulatory changes requiring that all meals and snacks served to children in ECE settings meet nutritional requirements. Pennsylvania amended rules concerning time prekindergarten children spend in PE. In addition to ECE nutrition and PA policies initiated at the state level, two sites, Anchorage and New York City, used some type of local authority to go beyond the state child care licensing and administrative regulations. This resulted in even stronger regulations for children in child care in their local jurisdictions. For example, based on recommendations from the Mayor's Task Force on Obesity and Health, Anchorage went beyond the state licensing codes, requiring a greater frequency of outdoor play (twice a day) than the state (once per day). In New York City alone, where both nutrition and PA standards were increased through an amendment to the Health Code, this change affected ∼140,000 children in 2300 licensed ECE centers in the city. 15 Several articles have been written on policy change and the authors conclude that most centers were able to comply with the regulations.16,17
Policies Related to School PA and Nutrition Environments
PA requirements
Recognizing the importance of PA, all sites included some type of state-level policy change related to PA or PE requirements for school-aged children. From establishing new regulations concerning PE standards in Alaska to specifying the number of PE minutes for children in various grades in New York, states took action to increase the amount of time children are physically active—especially in the school setting. New York also had legislation authorizing the establishment and administration of safe routes to school programs. Another PA policy strategy is to promote agreements to increase community access for PA. North Carolina legislation passed in 2010, directed their State Board of Education to encourage local boards of education to enter into agreements with local governments and other entities to promote the joint use of their facilities by the local community for PA. This type of legislative action can aid in increasing PA for children and adults by allowing school and community members the opportunity to access safe places for PA.
Nutrition standards
Three out of the four sites had policies related to state-level legislative action around nutrition standards and policies in schools. For example, in New York a bill encouraged every school district to establish a child nutrition advisory committee to study all facets of the current nutritional policies of the district. In Pennsylvania, a bill encouraged nutritional guidelines for food and beverage sales in schools. State bills also mentioned establishing statewide standards for vending and/or competitive foods sold during the school day to improve the nutritional quality of foods available for children. Examples of how these state legislative policies were incorporated into school district policies are described by Ottley et al. 10
Farm to school
Three sites enacted a state policy to establish farm to school programs within their state. Farm to school programs can facilitate individual school and school district programming by encouraging the use of farm-fresh food in schools and providing education about food and agriculture. Some of the state policies promoted farmers' markets in communities as well, such as New York and Pennsylvania. Several of the state policies identified either a specific state agency, such as Department of Natural Resources or Agriculture, to facilitate state farm to school efforts or required that various state agencies work together to support farm to school efforts to purchase locally grown food.
Conclusion
Over the last decade there has been an increased emphasis on public policy actions to combat the childhood obesity epidemic 2 and researchers have documented an increase in the enactment rate of state-level bills with obesity prevention content between 2003 and 2005, where only 17% of bills were enacted compared with 2006 to 2009, when 27% of bills with obesity prevention content were enacted. 13 A report by the National Conference of State Legislators also states there was continued attention in the 2012–2013 legislative sessions by policy makers to support healthy eating and active living, especially among children who are school aged. 18 This review provides an opportunity to better understand commonalities in policies enacted between sites. At the state level, we found multiple policies that directly targeted healthy eating, such as farm to school policies and nutrition standards for schools and ECEs. We also found policies that targeted PA, including increasing PA opportunities and active play in ECEs and state-level policy actions such as school PE requirements and joint-use agreements. We saw commonalities around childhood obesity-specific actions such as the establishment of childhood obesity task forces, commissions, research studies, or programs to combat childhood obesity in their state. According to an assessment by May et al., 21 out of 50 states legislatively enacted childhood obesity task forces from 2001 to 2010, and these groups provided recommendations that often resulted in the development of additional policy actions. 19 Finally and very importantly, all four states appropriated funds to programs that directly or indirectly addressed childhood obesity. At the local level we found two sites implementing policy changes to the nutrition and PA requirements for children in ECE centers through local regulations.
How communities respond to these state policies may have impacted the outcomes documented in these sites. The SEM posits that health is determined by influences at multiple levels (e.g., public policy, community, organization, interpersonal, and intrapersonal factors). Because significant and dynamic interrelationships exist among these different levels of the SEM, implementing changes at various levels of the model may be effective in improving nutrition and PA behaviors, and the COBD project documents breadth of state policies seen in each site. Companion articles by Jernigan et al. 14 and Ottley et al. 10 go one step further to document the diverse nature of local-level activities, programs, and initiatives that were implemented in these four communities. Enacting state-level polices that improve nutrition and PA for children in schools and ECEs followed by local-level implementation support may have contributed to the declines reported in these communities.
The COBD and this policy review are subject to limitations. First, the policies enacted at the state level were systematically abstracted from a national legal search engine that collects policies from all 50 states and the District of Columbia; however, it is possible that policies could be missed during the abstraction process. We also did not assess the strength or extent of implementation of the legislative activities passed, including school meal or PA enactments, to see how well they meet recommendations by key groups such as the National Academies of Science and Engineering (formerly the IOM). Other groups, such as Bridging the Gap, 20 have assessed the strength of legislative actions passed at the state level. Finally, this review did not include more general community-level policies pertaining to the physical built environment such as policies related to sidewalks or zoning codes or other community-level policies that could also affect obesity.
A combination of policy enactment and programmatic reinforcements may have worked synergistically to bring about the decline seen in these four communities. Federal-, state-, and local-level policies can be a facilitator for community change. Furthermore, policy strategies as compared with target programs have the potential to impact larger numbers of the population often at a relatively lower cost. 21 However, further research is needed to better understand which policies have the greatest impact on childhood obesity, their costs, their possible impact on disparities, and how various policies contribute to sustainable community change both individually and when combined with other strategies. This project provides one step in understanding from an ecologic perspective the context occurring during a time of measured COBD by documenting those policies that were in place in four communities.
Footnotes
Acknowledgments
The NCCOR is a private and public partnership with the CDC, NIH, RWJF, and USDA that provided technical assistance for this study. FHI360 serves as the Coordinating Center for NCCOR. ICF served as the lead contractor for the study. The authors thank NCCOR members, Melissa Abelev, Veronica Uzoebo, and Ruth Morgan, of the Food and Nutrition Service of USDA for participation in the study advisory committee. The authors thank the many site key stakeholders for their time and cooperation with interviews and site program documentation and the study site visitors who conducted the interviews and drafted the site summary reports, specifically Stacey Willocks, MS, Stephanie Frost, PhD, Michael Greenberg, JD, MPH, Katherine Reddy, MS, and Joseph Fruh, BS. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC, NIH, DHHS, or any of the other project agencies. The Robert Wood Johnson Foundation funded this project (ID #71772—Analyzing the Signs of Progress in Childhood Obesity, Route 1 and College Road East, Princeton, NJ 08543-2316).
Author Disclosure Statement
No author has any commercial associations that might create a conflict of interest, and no competing financial interests exist.
The authors did not report any conflicts of interest or financial disclosures. The findings and conclusions of this report are those of the authors and do not represent the official position of the Centers for Disease Control and Prevention, ICF, Inc., the National Institutes of Health, or Robert Wood Johnson Foundation.