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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





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


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


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



Grocery Stores


Grocery Stores + Produce Vendors


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



















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


ScientificAdvisoryPanels

State & Local Data

Research


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

[email protected]

mailto:[email protected]

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


State & Local Data

Research


MediaAdvocacy


State & Local Data

Research


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


State & Local Data

Research


Policy Maker

Education

MediaAdvocacy


State & Local Data

Research


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


State & Local Data

Research


CommunityMobilization

Policy Maker

Education

MediaAdvocacy


State & Local Data

Research


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


Policy Maker

Education

MediaAdvocacy


State & Local Data

Research


PartnershipBuilding


Policy Maker

Education

MediaAdvocacy


State & Local Data

Research


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


Policy Maker

Education

MediaAdvocacy


State & Local Data

Research


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