Controlling obesity has become one of the highest priorities for public health practitioners in developed countries. In the absence of safe, effective and widely accessible high-risk approaches (e.g. drugs and surgery) attention has focussed on community-based approaches and social marketing campaigns as the most appropriate form of intervention. However there is limited evidence in support of substantial effectiveness of such interventions.
To date there is little evidence that community-based interventions and social marketing campaigns specifically targeting obesity provide substantial or lasting benefit. Concerns have been raised about potential negative effects created by a focus of these interventions on body shape and size, and of the associated media targeting of obesity.
A more appropriate strategy would be to enact high-level policy and legislative changes to alter the obesogenic environments in which we live by providing incentives for healthy eating and increased levels of physical activity. Research is also needed to improve treatments available for individuals already obese.
As obesity prevention becomes an increasing health priority in many countries, including Australia and New Zealand, the challenge that governments are now facing is how to adopt a systematic policy approach to increase healthy eating and regular physical activity. This article sets out a structure for systematically identifying areas for obesity prevention policy action across the food system and full range of physical activity environments. Areas amenable to policy intervention can be systematically identified by considering policy opportunities for each level of governance (local, state, national, international and organisational) in each sector of the food system (primary production, food processing, distribution, marketing, retail, catering and food service) and each sector that influences physical activity environments (infrastructure and planning, education, employment, transport, sport and recreation). Analysis grids are used to illustrate, in a structured fashion, the broad array of areas amenable to legal and regulatory intervention across all levels of governance and all relevant sectors. In the Australian context, potential regulatory policy intervention areas are widespread throughout the food system, e.g., land-use zoning (primary production within local government), food safety (food processing within state government), food labelling (retail within national government). Policy areas for influencing physical activity are predominantly local and state government responsibilities including, for example, walking and cycling environments (infrastructure and planning sector) and physical activity education in schools (education sector). The analysis structure presented in this article provides a tool to systematically identify policy gaps, barriers and opportunities for obesity prevention, as part of the process of developing and implementing a comprehensive obesity prevention strategy. It also serves to highlight the need for a coordinated approach to policy development and implementation across all levels of government in order to ensure complementary policy action.
The commercial drivers of the obesity epidemic are so influential that obesity can be considered a robust sign of commercial success – consumers are buying more food, more cars and more energy-saving machines. It is unlikely that these powerful economic forces will change sufficiently in response to consumer desires to eat less and move more or corporate desires to be more socially responsible. When the free market creates substantial population detriments and health inequalities, government policies are needed to change the ground rules in favour of population benefits.
Concerted action is needed from governments in four broad areas: provide leadership to set the agenda and show the way; advocate for a multi-sector response and establish the mechanisms for all sectors to engage and enhance action; develop and implement policies (including laws and regulations) to create healthier food and activity environments, and; secure increased and continued funding to reduce obesogenic environments and promote healthy eating and physical activity.
Policies, laws and regulations are often needed to drive the environmental and social changes that, eventually, will have a sustainable impact on reducing obesity. An 'obesity impact assessment' on legislation such as public liability, urban planning, transport, food safety, agriculture, and trade may identify 'rules' which contribute to obesogenic environments. In other areas, such as marketing to children, school food, and taxes/levies, there may be opportunities for regulations to actively support obesity prevention. Legislation in other areas such as to reduce climate change may also contribute to obesity prevention ('stealth interventions'). A political willingness to use policy instruments to drive change will probably be an early hallmark of successful obesity prevention.
As the emphasis on preventing obesity has grown, so have calls for interventions that extend beyond individual behaviors and address changes in environments and policies. Despite the need for policy action, little is known about policy approaches that are most effective at preventing obesity. The Centers for Disease Control and Prevention (CDC) and others are funding the implementation and evaluation of new obesity prevention policies, presenting a distinct opportunity to learn from these practice-based initiatives and build the body of evidence-based approaches. However, contributions from this policy activity are limited by the incomplete and inconsistent evaluation data collected on policy processes and outcomes. We present a framework developed by the CDC-funded Center of Excellence for Training and Research Translation that public health practitioners can use to evaluate policy interventions and identify the practice-based evidence needed to fill the gaps in effective policy approaches to obesity prevention.
The obesity epidemic cannot be reversed without substantial improvements in the food marketing environment that surrounds children. Food marketing targeted to children almost exclusively promotes calorie-dense, nutrient-poor foods and takes advantage of children's vulnerability to persuasive messages. Increasing scientific evidence reveals potentially profound effects of food marketing on children's lifelong eating behaviors and health. Much of this marketing occurs in nationwide media (eg, television, the Internet), but companies also directly target children in their own communities through the use of billboards and through local environments such as stores, restaurants, and schools. Given the harmful effect of this marketing environment on children's health and the industry's reluctance to make necessary changes to its food marketing practices, government at all levels has an obligation to act. This article focuses on policy options for municipalities that are seeking ways to limit harmful food marketing at the community level.
The objective of this study was to develop the Missouri Obesity, Nutrition, and Activity Policy Database, a geographically representative baseline of Missouri's existing obesity-related local policies on healthy eating and physical activity. The database is organized to reflect 7 local environments (government, community, health care, worksite, school, after school, and child care) and to describe the prevalence of obesity-related policies in these environments.
We employed a stratified nested cluster design using key informant interviews and review of public records to sample 2,356 sites across the 7 target environments for the presence or absence of obesity-related policies.
The school environment had the most policies (88%), followed by after school (47%) and health care (32%). Community, government, and child care environments reported smaller proportions of obesity-related policies but higher rates of funding for these policies. Worksite environments had low numbers of obesity-related policies and low funding levels (17% and 6%, respectively). Sixteen of the sampled counties had high obesity-related policy occurrence; 65 had moderate and 8 had low occurrences.
Except in Missouri schools, the presence of obesity-related policies is limited. More obesity-related policies are needed so that people have access to environments that support the model behaviors necessary to halt the obesity epidemic. The Missouri Obesity, Nutrition, and Activity Policy Database provides a benchmark for evaluating progress toward the development of obesity-related policies across multiple environments in Missouri.
Government actors have an important role to play in creating healthy public policies and supportive environments to facilitate access to safe, affordable, nutritious food. The purpose of this research was to examine Waterloo Region (Ontario, Canada) as a case study for “what works” with respect to facilitating access to healthy, local food through regional food system policy making. Policy and planning approaches were explored through multi-sectoral perspectives of: (a) the development and adoption of food policies as part of the comprehensive planning process; (b) barriers to food system planning; and (c) the role and motivation of the Region’s public health and planning departments in food system policy making. Forty-seven in-depth interviews with decision makers, experts in public health and planning, and local food system stakeholders provided rich insight into strategic government actions, as well as the local and historical context within which food system policies were developed. Grounded theory methods were used to identify key overarching themes including: “strategic positioning”, “partnerships” and “knowledge transfer” and related sub-themes (“aligned agendas”, “issue framing”, “visioning” and “legitimacy”). A conceptual framework to illustrate the process and features of food system policy making is presented and can be used as a starting point to engage multi-sectoral stakeholders in plans and actions to facilitate access to healthy food.
food policy; community food security; public health; government; land use planning; food access
In Australia there have been many calls for government action to halt the effects of unhealthy food marketing on children's health, yet implementation has not occurred. The attitudes of those involved in the policy-making process towards regulatory intervention governing unhealthy food marketing are not well understood. The objective of this research was to understand the perceptions of senior representatives from Australian state and territory governments, statutory authorities and non-government organisations regarding the feasibility of state-level government regulation of television marketing of unhealthy food to children in Australia.
Data from in-depth semi-structured interviews with senior representatives from state and territory government departments, statutory authorities and non-government organisations (n=22) were analysed to determine participants' views about regulation of television marketing of unhealthy food to children at the state government level. Data were analysed using content and thematic analyses.
Regulation of television marketing of unhealthy food to children was supported as a strategy for obesity prevention. Barriers to implementing regulation at the state level were: the perception that regulation of television advertising is a Commonwealth, not state/territory, responsibility; the power of the food industry and; the need for clear evidence that demonstrates the effectiveness of regulation. Evidence of community support for regulation was also cited as an important factor in determining feasibility.
The regulation of unhealthy food marketing to children is perceived to be a feasible strategy for obesity prevention however barriers to implementation at the state level exist. Those involved in state-level policy making generally indicated a preference for Commonwealth-led regulation. This research suggests that implementation of regulation of the television marketing of unhealthy food to children should ideally occur under the direction of the Commonwealth government. However, given that regulation is technically feasible at the state level, in the absence of Commonwealth action, states/territories could act independently. The relevance of our findings is likely to extend beyond Australia as unhealthy food marketing to children is a global issue.
Unhealthy food; Regulation; Government; Children; Marketing; Advertising
Policy and regulatory interventions aimed at creating environments more conducive to physical activity (PA) are an important component of strategies to improve population levels of PA. However, many potentially effective policies are not being broadly implemented. This study sought to identify potential policy/regulatory interventions targeting PA environments, and barriers/facilitators to their implementation at the Australian state/territory government level.
In-depth interviews were conducted with senior representatives from state/territory governments, statutory authorities and non-government organisations (n = 40) to examine participants': 1) suggestions for regulatory interventions to create environments more conducive to PA; 2) support for preselected regulatory interventions derived from a literature review. Thematic and constant comparative analyses were conducted.
Policy interventions most commonly suggested by participants fell into two areas: 1) urban planning and provision of infrastructure to promote active travel; 2) discouraging the use of private motorised vehicles. Of the eleven preselected interventions presented to participants, interventions relating to walkability/cycling and PA facilities received greatest support. Interventions involving subsidisation (of public transport, PA-equipment) and the provision of more public transport infrastructure received least support. These were perceived as not economically viable or unlikely to increase PA levels. Dominant barriers were: the powerful ‘road lobby’, weaknesses in the planning system and the cost of potential interventions. Facilitators were: the provision of evidence, collaboration across sectors, and synergies with climate change/environment agendas.
This study points to how difficult it will be to achieve policy change when there is a powerful ‘road lobby’ and government investment prioritises road infrastructure over PA-promoting infrastructure. It highlights the pivotal role of the planning and transport sectors in implementing PA-promoting policy, however suggests the need for clearer guidelines and responsibilities for state and local government levels in these areas. Health outcomes need to be given more direct consideration and greater priority within non-health sectors.
Childhood overweight and obesity is the most prevalent and, arguably, politically complex child health problem internationally. Governments, communities and industry have important roles to play, and are increasingly expected to deliver an evidence-informed system-wide prevention program. However, efforts are impeded by a lack of organisational access to and use of research evidence. This study aims to identify feasible, acceptable and ideally, effective knowledge translation (KT) strategies to increase evidence-informed decision-making in local governments, within the context of childhood obesity prevention as a national policy priority.
This paper describes the methods for KT4LG, a cluster randomised controlled trial which is exploratory in nature, given the limited evidence base and methodological advances. KT4LG aims to examine a program of KT strategies to increase the use of research evidence in informing public health decisions in local governments. KT4LG will also assess the feasibility and acceptability of the intervention. The intervention program comprises a facilitated program of evidence awareness, access to tailored research evidence, critical appraisal skills development, networking and evidence summaries and will be compared to provision of evidence summaries alone in the control program. 28 local governments were randomised to intervention or control, using computer generated numbers, stratified by budget tertile (high, medium or low). Questionnaires will be used to measure impact, costs, and outcomes, and key informant interviews will be used to examine processes, feasibility, and experiences. Policy tracer studies will be included to examine impact of intervention on policies within relevant government policy documents.
Knowledge translation intervention studies with a focus on public health and prevention are very few in number. Thus, this study will provide essential data on the experience of program implementation and evaluation of a system-integrated intervention program employed within the local government public health context. Standardised programs of system, organisational and individual KT strategies have not been described or rigorously evaluated. As such, the findings will make a significant contribution to understanding whether a facilitated program of KT strategies hold promise for facilitating evidence-informed public health decision making within complex multisectoral government organisations.
Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000953235
Healthy Kids, Healthy Communities (HKHC) is an initiative of the Robert Wood Johnson Foundation to prevent obesity among high-risk children by changing local policies, systems, and environments. In 2009, 105 community partnerships applied for funding from HKHC. Later that year, the Centers for Disease Control and Prevention (CDC) released recommended community strategies to prevent obesity by changing environments and policies. The objective of this analysis was to describe the strategies proposed by the 41 HKHC partnerships that received funding and compare them to the CDC recommendations.
We analyzed the funded proposals to assess the types and prevalence of the strategies proposed and mapped them onto the CDC recommendations.
The most prevalent strategies proposed by HKHC-funded partnerships were providing incentives to retailers to locate and serve healthier foods in underserved areas, improving mechanisms for purchasing food from farms, enhancing infrastructure that supports walking and cycling, and improving access to outdoor recreational facilities.
The strategies proposed by HKHC partnerships were well aligned with the CDC recommendations. The popular strategies proposed by HKHC partnerships were those for which there were existing examples of successful implementation. Our analysis provides an example of how information from communities, obtained through grant-writing efforts, can be used to assess the status of the field, guide future research, and provide direction for future investments.
The British government has been criticised for according industry interests too much weight in alcohol policy-making. Consequently, it has been argued that alcohol strategy in the UK is built around policies for which the evidence base is weak. This has clear implications for public health. The purpose of this commentary is to map recent developments in UK alcohol policy and related debates within the alcohol policy literature, thus laying the foundations for a systematic examination of the influence of the alcohol industry on alcohol policy. It highlights the changing structure of the industry and summarises what is known about the positions and strategies of industry actors towards alcohol policy. In so doing, it aims to contribute not just to debates about alcohol policy, but to a broader understanding of health policy processes and the relationships between government and other stakeholders. It advances a new research agenda focused on the role of corporate actors in the field of alcohol policy and public health more broadly.
politics; corporate actors; alcohol policy
There is only limited evidence available on how best to prevent childhood obesity and community-based interventions hold promise, as several successful interventions have now been published. The Victorian Government has recently funded six disadvantaged communities across Victoria, Australia for three years to promote healthy eating and physical activity for children, families, and adults in a community-based participatory manner. Five of these intervention communities are situated in Primary Care Partnerships and are the subject of this paper. The interventions will comprise a mixture of capacity-building, environmental, and whole-of-community approaches with targeted and population-level interventions. The specific intervention activities will be determined locally within each community through stakeholder and community consultation. Implementation of the interventions will occur through funded positions in primary care and local government. This paper describes the design of the evaluation of the five primary care partnership-based initiatives in the 'Go for your life' Health Promoting Communities: Being Active Eating Well (HPC:BAEW) initiative.
A mixed method and multi-level evaluation of the HPC:BAEW initiative will capture process, impact and outcome data and involve both local and state-wide evaluators. There will be a combined analysis across the five community intervention projects with outcomes compared to a comparison group using a cross-sectional, quasi-experimental design. The evaluation will capture process, weight status, socio-demographic, obesity-related behavioral and environmental data in intervention and comparison areas. This will be achieved using document analysis, paper-based questionnaires, interviews and direct measures of weight, height and waist circumference from participants (children, adolescents and adults).
This study will add significant evidence on how to prevent obesity at a population level in disadvantaged and ethnically diverse communities. The outcomes will have direct influence on policy and practice and guide the development and implementation of future obesity prevention efforts in Australia and internationally.
This paper aimed to identify the best way to engage, motivate and support early childhood services (ECS) and primary schools (PS) to create policy and practise changes to promote healthy eating and physical activity. This information would be used to develop a suitable program to implement within these children's settings to reduce the risk of childhood overweight and obesity.
The Medical Research Council's (UK) framework for the design and evaluation of complex interventions was used to guide the development of the healthy eating and physical activity program suitable for ECS and PS. Within this framework a range of evaluation methods, including stakeholder planning, in-depth interviews with ECS and PS staff and acceptability and feasibility trials in one local government area, were used to ascertain the best way to engage and support positive changes in these children's settings.
Both ECS and PS identified that they had a role to play to improve children's healthy eating and physical activity. ECS identified their role in promoting healthy eating and physical activity as important for children's health, and instilling healthy habits for life. PS felt that these were health issues, rather than educational issues; however, schools saw the link between healthy eating and physical activity and student learning outcomes. These settings identified that a program that provides a simple guide that recognises good practise in these settings, such as an award scheme using a health promoting schools approach, as a feasible and acceptable way for them to support children's healthy eating and physical activity.
Through the process of design and evaluation a program - Kids - 'Go for your life', was developed to promote and support children's healthy eating and physical activity and reduce the risk of childhood overweight and obesity. Kids - 'Go for your life' used an award program, based on a health promoting schools approach, which was demonstrated to be a suitable model to engage ECS and PS and was acceptable and feasible to create policy and practise changes to support healthy eating and physical activity for children.
The rapid rise in rates of overweight and obesity among adults and children in Australia and New Zealand has intensified debate about the most effective policies for obesity prevention. Law has much to contribute to this policy discussion, although its role is often misunderstood. The articles in this symposium follow on from a conference hosted in September 2006 by the Centre for Health Governance, Law & Ethics in the Faculty of Law, University of Sydney, titled: Obesity: should there be a law against it? In different ways, these articles provide a variety of perspectives on regulatory responses to obesity, including theoretical justifications for a legal approach, conceptual models that assist in making sense of law's role, as well as specific legal strategies for obesity prevention in various settings.
Interest in community-based interventions (CBIs) for health promotion is increasing, with a lot of recent activity in the field. This paper aims, from a state government perspective, to examine the experience of funding and managing six obesity prevention CBIs, to identify lessons learned and to consider the implications for future investment. Specifically, we focus on the planning, government support, evaluation, research and workforce development required.
The lessons presented in this paper come from analysis of key project documents, the experience of the authors in managing the projects and from feedback obtained from key program stakeholders.
CBIs require careful management, including sufficient planning time and clear governance structures. Selection of interventions should be based on evidence and tailored to local needs to ensure adequate penetration in the community. Workforce and community capacity must be assessed and addressed when selecting communities. Supporting the health promotion workforce to become adequately skilled and experienced in evaluation and research is also necessary before implementation.
Comprehensive evaluation of future projects is challenging on both technical and affordability grounds. Greater emphasis may be needed on process evaluation complemented by organisation-level measures of impact and monitoring of nutrition and physical activity behaviours.
CBIs offer potential as one of a mix of approaches to obesity prevention. If successful approaches are to be expanded, care must be taken to incorporate lessons from existing and past projects. To do this, government must show strong leadership and work in partnership with the research community and local practitioners.
Interventions to reduce childhood obesity entail ethical considerations. Although a rationale exists for government to intervene in a way that limits individual rights while protecting the public's health, a clear economic rationale also exists. The markets for goods and services that contribute to obesity are characterized by multiple failures that create an economic rationale for government to intervene (eg, consumers' lack of accurate information regarding obesogenic foods and beverages). If effective public policies for reducing obesity and its consequences are to be developed and implemented, individual rights and government interests must be balanced.
This article is the second in a two-part review of law's possible role in a regulatory approach to healthier nutrition and obesity prevention in Australia. As discussed in Part 1, law can intervene in support of obesity prevention at a variety of levels: by engaging with the health care system, by targeting individual behaviours, and by seeking to influence the broader, socio-economic and environmental factors that influence patterns of behaviour across the population. Part 1 argued that the most important opportunities for law lie in seeking to enhance the effectiveness of a population health approach.
Part 2 of this article aims to provide a systematic review of the legal strategies that are most likely to emerge, or are worth considering, as part of a suite of policies designed to prevent population weight gain and, more generally, healthier nutrition. While the impact of any one intervention may be modest, their cumulative impact could be significant and could also create the conditions for more effective public education campaigns. This article addresses the key contenders, with particular reference to Australia and the United States.
This paper explores why Canadian government policies, particularly those related to obesity, are ‘stuck’ at promoting individual lifestyle change. Key concepts within complexity and critical theories are considered a basis for understanding the continued emphasis on lifestyle factors in spite of strong evidence indicating that a change in the environment and conditions of poverty isare needed to tackle obesity. Opportunities to get ‘unstuck’ from individual-level lifestyle interventions are also suggested by critical concepts found within these two theories, although getting ‘unstuck’ will also require cross-sectoral collective action. Our discussion focuses on the Canadian context but will undoubtedly be relevant to other countries, where health promoters and others engage in similar struggles for fundamental government policy change.
complexity theory; critical theory; health policy; health promotion
Policies targeting obesogenic environments and behaviours are critical to counter rising obesity rates and lifestyle-related non-communicable diseases (NCDs). Policies are likely to be most effective and enduring when they are based on the best available evidence. Evidence-informed policy making is especially challenging in countries with limited resources. The Pacific TROPIC (Translational Research for Obesity Prevention in Communities) project aims to implement and evaluate a tailored knowledge-brokering approach to evidence-informed policy making to address obesity in Fiji, a Pacific nation challenged by increasingly high rates of obesity and concomitant NCDs.
The TROPIC project draws on the concept of ‘knowledge exchange’ between policy developers (individuals; organisations) and researchers to deliver a knowledge broking programme that maps policy environments, conducts workshops on evidence-informed policy making, supports the development of evidence-informed policy briefs, and embeds evidence-informed policy making into organisational culture. Recruitment of government and nongovernment organisational representatives will be based on potential to: develop policies relevant to obesity, reach broad audiences, and commit to resourcing staff and building a culture that supports evidence-informed policy development. Workshops will increase awareness of both obesity and policy cycles, as well as develop participants’ skills in accessing, assessing and applying relevant evidence to policy briefs. The knowledge-broking team will then support participants to: 1) develop evidence-informed policy briefs that are both commensurate with national and organisational plans and also informed by evidence from the Pacific Obesity Prevention in Communities project and elsewhere; and 2) collaborate with participating organisations to embed evidence-informed policy making structures and processes. This knowledge broking initiative will be evaluated via data from semi-structured interviews, a validated self-assessment tool, process diaries and outputs.
Public health interventions have rarely targeted evidence-informed policy making structures and processes to reduce obesity and NCDs. This study will empirically advance understanding of knowledge broking processes to extend evidence-informed policy making skills and develop a suite of national obesity-related policies that can potentially improve population health outcomes.
Policy; Obesity; Knowledge exchange; Knowledge broker; Pacific
The ecosystem service concept has emphasized the role of people within socio-ecological systems (SESs). In this paper, we review and discuss alternative ways of representing people, their behaviour and decision-making processes in SES models using an agent-based modelling (ABM) approach. We also explore how ABM can be empirically grounded using information from social survey. The capacity for ABM to be generalized beyond case studies represents a crucial next step in modelling SESs, although this comes with considerable intellectual challenges. We propose the notion of human functional types, as an analogy of plant functional types, to support the expansion (scaling) of ABM to larger areas. The expansion of scope also implies the need to represent institutional agents in SES models in order to account for alternative governance structures and policy feedbacks. Further development in the coupling of human-environment systems would contribute considerably to better application and use of the ecosystem service concept.
socio-ecological systems; agent-based modelling; social survey; spatial scaling; human behaviour; decision-making processes
To fulfil its role of coordinating health care, primary health care needs to be well integrated, internally and with other health and related services. In Australia, primary health care services are divided between public and private sectors, are responsible to different levels of government and work under a variety of funding arrangements, with no overarching policy to provide a common frame of reference for their activities.
Description of policy
Over the past decade, coordination of service provision has been improved by changes to the funding of private medical and allied health services for chronic conditions, by the development in some states of voluntary networks of services and by local initiatives, although these have had little impact on coordination of planning. Integrated primary health care centres are being established nationally and in some states, but these are too recent for their impact to be assessed. Reforms being considered by the federal government include bringing primary health care under one level of government with a national primary health care policy, establishing regional organisations to coordinate health planning, trialling voluntary registration of patients with general practices and reforming funding systems. If adopted, these could greatly improve integration within primary health care.
Careful change management and realistic expectations will be needed. Also other challenges remain, in particular the need for developing a more population and community oriented primary health care.
primary health care; health policy; integration; Australia
Research consistently shows that the majority of American children do not consume diets that meet the recommendations of the Dietary Guidelines for Americans, nor do they achieve adequate levels of daily physical activity. As a result, more children are overweight today than at any other time in U.S. history. Schools offer many opportunities to develop strategies to prevent obesity by creating environments in which children eat healthfully and engage regularly in physical activity.
This article discusses the role of schools in obesity prevention efforts. Current issues in schools’ food and physical activity environments are examined, as well as federal, state, and local policies related to food and physical activity standards in schools. The article is organized around four key areas: (1) school food environments and policies, (2) school physical activity environments and policies, (3) school body mass index measurements, and (4) school wellness policies. Recommendations for accelerating change also are addressed.
The article found that (1) competitive foods (foods sold outside of federally reimbursed school meals) are widely available in schools, especially secondary schools. Studies have related the availability of snacks and drinks sold in schools to students’ high intake of total calories, soft drinks, total fat and saturated fat, and lower intake of fruits and vegetables; (2) physical activity can be added to the school curriculum without academic consequences and also can offer physical, emotional, and social benefits. Policy leadership has come predominantly from the districts, then the states, and, to a much lesser extent, the federal government; (3) few studies have examined the effectiveness or impact of school-based BMI measurement programs; and (4) early comparative analyses of local school wellness policies suggest that the strongest policies are found in larger school districts and districts with a greater number of students eligible for a free or reduced-price lunch.
Studies show that schools have been making some progress in improving the school food and physical activity environments but that much more work is needed. Stronger policies are needed to provide healthier meals to students at schools; limit their access to low-nutrient, energy-dense foods during the school day; and increase the frequency, intensity, and duration of physical activity at school.
Schools; obesity prevention; nutrition and physical activity policies; children and adolescents
To help address the challenges posed by the obesity epidemic in the United States, the U.S. Congress authorized the Centers for Disease Control and Prevention to establish the Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases. In this article, we summarize the progress of the first 20 states funded by this program. The data presented are based on the information provided by the states in their semiannual progress monitoring reports on program activities from January through June 2004. The states have made progress in developing capacity and infrastructure for their programs, including leveraging financial resources and developing strong partnerships. In addition, they are planning and initiating environmental changes through legislation, and, although less frequently, through policies and other changes such as expanding physical activity opportunities. Collectively, the states are making progress in planning and implementing activities to prevent and control obesity and other chronic diseases.
This article describes recent events in the governance of standard-setting for 2 areas of US health policy — states' decisions about which prescription drugs to cover under Medicaid and other public programs and making health an aspect of foreign policy — and whether these events offer lessons for policy making. In prescription drug coverage, methodologic advances in research that evaluates health services and the politics of restraining the rate of growth in health expenditures enabled policy makers in most states to establish new public processes for assessing and applying evidence about the effectiveness of competing drugs. Their counterparts in foreign policy, in contrast, made few changes in existing processes for choosing which interventions to support. The history of governance in each area of policy making for health explains the selection of standards to evaluate evidence about interventions and whether and how to use this evidence to guide policy.