Policy & Nutrition
Example: Obesity
Conceptual Frameworks:
1. Kingdon Policy Model
2. IOM Obesity Prevention Organizing
Framework
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?
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
Intervention Categories with Strong Evidence
of Effectiveness for the 10 greatest
Achievements in Pubic Health: From IOM
report: Preventing Childhood Obesity,
2005…
Community
Wide
Campaigns
School
based
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
X
X
X
Reducing
costs to
patients
X
X
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
X
X
X
X
X
X
X
X
Reducing
costs to
patients
X
Water
Fluoridation
Recognition
of tobacco
as a health
hazard
Laws and
regulations
X
X
Kingdon JW. Agendas,
Alternatives, and Public Policies.
2002
Participants
The Streams
Agenda Setting
Alternative Specification
Coupling the Streams/ Windows
Participants
National 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
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…..
The “streams”
Problem
Recognition
Policy
Proposals
Politics
Problem
Recognition
Policy Proposals
Legislation or
Change in Policy
Politics
3 streams of processes
• Problem recognition
• Policies: proposal formation
• Politics
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.
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
Google Hits for Obesity –
1/29/05
2/20/07
1/13/07
8,650,000
31,100,000
~30,000,000
Obesity and “New
York Times”
214,000
932,000
401,000
Obesity and “Wall
Street Journal”
49,300
386,000
203,000
Obesity and
“Seattle Times”
13,100
91,700
97,100
Obesity and CBS
97,100
863,000
319,000
Obesity
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
YOUR TIME/HEALTH
The Year of Obesity
Our perennial interest in losing weight became a national obsession in 2004
By MICHAEL D. LEMONICK
Framing the Problem
http://www.frameworksinstitute.org/
•
Problems with the Dominant
Communications Approach to Childhood
Obesity:
1. It focuses on the individual as the cause of
the problem.
2. Parents are the only responsible actors in
the frame.
3. The problem is overwhelming.
4. Behavior change by parents and children is
the solution to the problem.
Examples of Causal Sequences that
Include Environments & Policies
• "Today's kids are generally getting less exercise as schools
decrease the amount of phys ed and recess time offered
each week, increasing their risk of becoming sedentary
adults.”
• "When parents don't have access to healthy food because
they live in a neighborhood where access to fresh produce
and other healthy foods is limited, this makes it almost
impossible to offer healthy diets at home. Initiatives such
as community gardens can help make healthy food
available to everyone."
• "The constant barrage of junk food ads directed at children
shapes their food preferences, leading to an increase in
consumption of unhealthy snacks, especially while
watching television.”
Policy Proposals: Alternative
Specification
• Narrows the large set of possible
alternatives to that set from which choices
are actually made.
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 works,
hone ideas, recombine ideas
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)
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
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
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
State and Local Governments
• Expand and 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 expandthe
availability of and access to healthful foods
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
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 Priorities
• Farm Bill Reauthorization
• Model local school wellness policies
• Strengthen national school lunch and
other child nutrition programs
• Strengthen national and state nutrition,
physical activity and obesity programs
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)
“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).
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
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
Lives of 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
Problem
Recognition
Policy
Proposals
Politics
Problem
Recognition
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.
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
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/
2001
2002
2003
Nutrition bills introduced
88
58
174
Nutrition bills enacted
32
15
35
167
148
240
28
33
55
Physical Activity
Bills introduced
Physical activity bills
enacted
State Nutrition and Physical Activity
Legislative Database
http://apps.nccd.cdc.gov/DNPALeg/
2007
2005
All
WA
States State
All
states
2006
WA
All
States
WA
Nutrition bills
introduced
172
8
280
4
220
1
Nutrition bills
enacted
28
2
55
0
38
1
Physical Activity
Bills introduced
214
8
340
6
273
6
Physical activity
bills enacted
50
1
72
6
47
2
State Nutrition and Physical Activity
Legislative Database
http://apps.nccd.cdc.gov/DNPALeg/
2007
All
WA
States State
All
states
Nutrition bills
introduced
289
9
Nutrition bills
enacted
24
2
Physical Activity
Bills introduced
248
8
Physical activity
bills enacted
22
0
WA
All
States
WA
State Nutrition Legislation Enacted
2001-2007
Category
Assistance Programs
Cafeteria Meals/Food Service (schools)
Nutrition Education
Farmers Market
Liability
Obesity /Overweight
Grocery Store/Food Market
Labeling (Ephedrine)
Restaurant (all about liability)
Worksite
# Bills
16
61
52
26
23
86
4
1
5
8
SB5436 - 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
SB6601 - 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: HB2994
HB1254 - 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: SB5396
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
SB6197 - 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
HB 1311 - 2007: Continuing the small farm
direct marketing assistance program.
(1) The small farm direct marketing assistance program is created.
(2) The director shall employ a small farm direct marketing 8 assistant.
(3) The small farm direct marketing assistance program shall assist
duty the program shall:
(a) Assist small farms in complying with federal, state, and local
rules and regulations as they apply to direct marketing of agricultural
products;
(b) Assist in developing infrastructure to increase direct
marketing opportunities for small farms;
(c) Provide information on direct marketing opportunities for small
farms;
(d) Promote localized food production systems;
(e) Increase access to information for farmers wishing to sell farm
products directly to consumers;
(f) Identify and help reduce market barriers facing small farms in
direct marketing;
(g) Assist in developing and submitting proposals to grant programs
to assist small farm direct marketing efforts; and
(h) Perform other functions that will assist small farms in
directly marketing their products.
SB 5093 - 2007:
Concerning access to
health care services for children
• Declares that it is the goal of Washington state
to ensure that: (1) By 2010, all K-12 districts
have school health advisory committees that
advise school administration and school board
members on policies, environmental changes,
and programs needed to support healthy food
choice and physical activity and childhood
fitness; and (2) By 2010, only healthy food and
beverages shall be available on school
campuses.
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
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?
Working Model: Developing Community Policies for Nutrition and Physical Activity
RESOURCES
State
Nutrition & PA
Plan
ACTIVITIES
OUTPUTS
Bring issues
to agenda
of policy
makers
Awareness: presentations,
reports, events, media
Generate
policy
proposals
Policy proposals included in
planning documents
Short Term
Funding
Technical
assistance &
training
Local
Policy
Entrepreneurs
Policy makers
OUTCOMES
Problems
recognized;
solutions
considered
Intermediate
Support
adoption of
policy
Policy adopted &
implemented
Monitor and
evaluate
outcomes
Ongoing reporting &
communication
Policy adopted &
implemented
Long Term
Policy modifies
environment