Policy and Environmental Changes
With overweight and obesity at epidemic levels among adults and children, traditional prevention strategies focusing on the individual would be inefficient and cost-prohibitive. There is widespread agreement that the food and physical activity environment rather than our biology is driving the epidemic. (Hill et al., 2003). To affect the behavior of populations and individuals, large scale, systemic and sustainable changes are needed that provide support for healthful food choices and increased physical activity in multiple population segments and settings. The goal is to promote policy and environmental changes where we live, work and learn that make it easy for everyone to eat healthfully and to be physically active. Research has shown that behavior change is more likely to endure when both the individual and the environment undergo change simultaneously (Lasater et al., 1984; Abrams 1991). The approach in New York, now and in the future, will be to focus on public policy, and on settings including home and family, schools, worksites, and communities that influence daily food and physical activity choices.
Schenectady's Promise: The Alliance for Youth
A countywide initiative spearheaded by United Way of Schenectady, the County Youth Bureau and BOCES of the Capital Region, and Kevin Karpowicz MD, MPH. The program serves two primary purposes: positive youth development and community collaboration in an organized fashion. Schenectady's Promise is affiliated with the national effort, America's Promise.
There are over 80 partners, both individuals and groups, that have signed a pledge to fulfill the five promises that serve as the organizing principle. The five promises are: Healthy Start, Caring Adults, Safe Places, Marketable Skills and Opportunities to Serve. Each of the five promises has a specific action team where the issue is explored at length. Local agencies, where youth are involved, pledge to become sites of promise where each of the five promises will be addressed. The information generated by the action teams is shared with the sites of promise.
Schenectady's Promise pledges to include youth at every table. By empowering youth and including them as a valuable partner, Schenectady's Promise will work toward the positive youth development that we seek; where youth will be more likely to have a positive image of themselves and pursue more positive health promoting lifestyles.
State Department of Transportation Partnership
The Healthy Heart Program partnered with the State Department of Transportation to conduct over 15 Walkable Community workshops throughout the state. A 4-hour workshop brought together local decision makers, health and planning professionals, and concerned citizens to learn more about how they can make their communities more pedestrian friendly. In several of these communities, projects to improve pedestrian safety have been initiated as a direct result of these workshops.
Under the heading of systems change two discreet areas are policy change and environmental intervention. Policy change affects laws, regulations and rules, both formal and informal (ASTDHPPHE/CDC 2001). Examples of policy change are federal laws and regulations that govern the nutrition content of school meals; state education standards for physical education; and organizational rules that provide time off during work hours for physical activity. Environmental interventions include changes to the economic, social or physical environments (ASTDHPPHE/CDC 2001). Examples of environmental change interventions include incorporating walking paths and recreation areas into new community development designs; making low-fat choices available in cafeterias; reduced pricing for healthful choices in vending machines; and economic incentives to bring supermarkets into low-income neighborhoods. The nature of environmental interventions means they are implemented and evaluated over a longer period of time than more individually-oriented interventions (Brownson et al., 2001). Because policy change and environmental interventions are bound into systems change they are sustainable over time.
The socio-ecological approach and the use of environmental and policy changes provide a context in which to frame the NYS's Obesity Prevention Plan's goals and strategies. A logic model (Appendix III: Logic Model) has been developed to illustrate how the work will be conducted in various settings with a wide array of organizations to produce the results intended to prevent and to reduce overweight and obesity in NYS. This model recognizes the social levels, target sectors, and settings in which decisions are made about food choices and physical activity.
The personal, social, cultural, financial and environmental influences on food selection and consumption that determine energy balance are complex. To a great extent, individual food choices depend on what is available to choose from whether at home, work, school, or retail food markets. Several studies have demonstrated that supermarkets, offering a wide variety of foods at lower cost are less likely to be located in low-income and minority neighborhoods (Morland et al., 2002). A multiphase inventory of selected markets in areas with a high percentage of Blacks contrasted with markets in higher-income areas with fewer Blacks revealed that markets in minority neighborhoods were significantly less likely to stock health-promoting foods. Markets in minority neighborhoods stocked a significantly lower variety and quality of fruits and vegetables. Products including low-fat milk, nonfat cheese, whole-grain pasta and breads, and low-fat meat and poultry items were also significantly less available (Sloane et al., 2003).
The food and nutrition environment of schools impacts student food choices. A study of seventh graders in 16 schools used a la carte item availability, school stores and vending machines, and amounts of fried potatoes served at school lunch as environmental markers. The availability of a la carte choices was inversely related to fruit and vegetable consumption and positively associated with total fat and saturated fat intake. Snack vending machines were negatively correlated with fruit consumption and fried potatoes were positively associated with fruit and vegetable intake (Kubik et al., 2003). Pricing and marketing healthful foods to compete with lower cost foods, such as those high in fat and sugar, can influence food selection. Price reductions and promotion of lower-fat snacks resulted in increased sales of these snacks in both schools and worksites. A 50% price reduction for fresh fruit and baby carrots in two secondary schools resulted in quadrupling fresh fruit sales and doubling baby carrot sales (French, 2003).
To achieve healthful school environments it is essential to articulate nutrition goals in the form of written school nutrition policies developed with input from students, families, staff and administration. While 65% of secondary principals in a Minnesota study believed it was important to have a school nutrition policy, only 32% reported having a policy. Principals were positive about a healthy school food environment, but 98% of schools had soft drink vending machines and 77% had contracts with soft drink companies (French et al., 2002). A joint position of the American Dietetic Association, Society for Nutrition Education, and American School Food Service Association asserts: "Comprehensive nutrition services must be provided to all of the nation's preschool through grade twelve students. These nutrition services shall be integrated with a coordinated, comprehensive school health program and implemented through a school nutrition policy" (Briggs et al., 2003).
Worksites are identified in Healthy People 2010 and in the Surgeon General's Action Plan to Prevent and Decrease Overweight and Obesity as strategic settings for health promotion and risk reduction activities to reduce chronic diseases and obesity among adults. Worksites provide access to more than 100 million workers who spend the majority of their day at work. Worksites provide an ideal environment to reinforce the adoption and maintenance of healthy behaviors. The Surgeon General's Action Plan recommends that worksite strategies to prevent and control overweight and obesity extend beyond traditional education and awareness to include worksite policies, the creation of supportive environments for healthy food and physical activity choices, and linkages that extend to families and communities (Surgeon General's Action Plan, 2001).
The United Nations (UN) Challenge
A grant from the Robert Wood Johnson Foundation from July 1, 2001 - June 30, 2004 supported the creation and implementation of a two-year, comprehensive worksite health promotion program at the UN headquarters in New York City. The United Nations Challenge intervention was based on aspects of the 2003 Commissioner's Challenge at the NYC DOHMH and included three main components: (1) Know your Numbers, (2) Healthy Eating Plan and (3) Move for Life and was the first to utilize the Wellness Resource Center, an online tailored workplace health promotion tool. Additionally, the intervention conducted workshops that dealt with financial management, stress management, nutrition, and physical activity. The Wellness Initiative at the UN follows a seven-step model developed by the Wellness Councils of America (WELCOA). This model incorporates best practices for implementing health promotion and disease prevention programs, and accommodates the unique characteristics at each worksite, including organizational health structure, employee health needs and interests, and institutional resources. The latter characteristics are especially important at the UN, one of the most diverse employers in New York City.
Environmental and policy strategies for achieving public health goals of increasing physical activity should be aimed at changing the physical and socio-political environments. The creation of healthful physical and organizational environments can be established through the development of public policy that supports healthy practices, creation of supportive environments, and strengthening of community action (Brownson et al., 2001).
Environmental interventions are conducted by traditional health professionals, but also involve many sectors that have not previously been associated with public health, such as community agencies and organizations, legislators, departments of transportation and planning, and the media. The goal is to create changes in social networks, organizational norms and policies, the physical environment, and laws (Brownson et al., 2001).
Strategies to increase physical activity often include providing access to facilities and programs not currently available, and supporting social environments that favor activity. A Missouri study showed that community-based activities such as exercise groups, healthy cooking demonstrations, blood pressure and cholesterol screenings, and cardiovascular disease education were effective in increasing physical activity (Brownson et al., 1996).
Other examples of environmental and policy approaches designed to increase physical activity include walking and bicycle trails, funding for public facilities, zoning and land use facilitating activity in neighborhoods, mall walking programs, building construction encouraging activity, policies and incentives promoting physical activity during the workday, and policies requiring comprehensive school health programs. School-based interventions focusing on policy and environmental change have been shown to improve eating and physical activity behaviors in children during school (Luepker et al., 1996). A health-related physical education curriculum substantially increased the time students spent being physically active during physical education classes (Sallis et al., 1997). Additionally, urban design and land-use planning strategies, and changes to transportation and travel policy and infrastructure that reduce dependence on motorized transport can increase physical activity (Brownson et al., 2001).
If successful programs are to be developed to increase physical activity among populations, then attention must be given not only to the behavior of the people but also to the environment in which they live. Safe, well-maintained recreational areas must be made available and accessible to the community. An increase in resource allocation must be made to populations with greater need and risk for chronic disease. These strategies must have a broad and sustainable impact across populations and communities. (Humpel et al., 2002) Furthermore, new surveillance systems need to be developed to capture environmental and policy indicators related to physical activity. To support community-based interventions for promoting physical activity, it is essential to develop systems that are more responsive to data needs at the local level (i.e., city, county, or neighborhood) (Brownson et al., 2001).
NYC Department of Health & Mental Hygiene's Worksite Health Promotion Program
In Spring 2002, the Worksite Wellness Survey (WWS), an 11-page self-reported needs assessment tool designed to examine health risks, culture, environment and behavioral risk factors was administered within the NYC DOHMH. Its purpose was to facilitate the design of a comprehensive, evidence-based worksite health promotion program. The survey was administered to a random sample of 1,400 employees at the NYC DOHMH with a 49% response rate. The survey revealed that the average demographic represented at the NYCDOHMH was middle-aged (average age was 43.5 years old), female (73%) and ethnically and culturally diverse (34% African-American, 31% White (Non-Hispanic), 18%Hispanic, 10% other, 5% Asian, and 2% Native American). Of all respondents, 98% had achieved a high school level of education or greater.
The results suggested that the majority of the NYCDOHMH employees have poor eating habits (82.7% consumed fewer than 4 servings of fruits and vegetables per day), are sedentary (73%) and overweight or obese (58%). Employees were largely uninformed about their basic health indices such as blood pressure and cholesterol levels. Interest in on-site health promotion was good with the majority of respondents desiring programming in the areas of physical activity (53%), health screenings (48%), nutrition (47%), and weight control (47%).
The information gained from the WWS was instrumental in the development of programmatic initiatives that specifically targeted the unhealthy behaviors of the NYC DOHMH employees, and guided the development of the current strategic plan for the Wellness at Work Program. Initiatives developed for the NYC DOHMH have served as models that the Wellness at Work Program has extended to work sites citywide. These programs intervene on the behavioral level by educating employees about their health risks and behaviors, and offering programming to help them improve their eating habits and increase their physical activity. The various programs address environmental barriers to health and wellness through the introduction of food policies to increase the availability of healthy foods, targeted media campaigns regarding nutrition and physical activity, and the promotion of opportunities for increased physical activity on-site.