1. Fighting Obesity in the United States with State Legislation Stephanie Chan, M.A., M.Phil. Pardee RAND Graduate School June 20, 2012 2012 USPHS Scientific & Training Symposium College Park, MD

2. Chan 2 6/12 Obesity Is a Serious Public Health Priority Excess weight is associated with increased risk of many chronic conditions Obesity prevalence has doubled for adults and tripled for children in the last 30 years Disparities exist, but prevalence increased across all socioeconomic groups Obesity cost $147 billion in 2009

3. Chan 3 6/12 The Environment Can Have a Profound Impact on Obesity Larger food portions increase consumption Higher availability of food reduces efforts to eat more More sophisticated food marketing increases the quantity and frequency of food consumption Sedentary lifestyle increases likelihood of weight gain

4. Chan 4 6/12 Given This, There Have Been Calls for an Ecological Approach – David Satcher, The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity,” 2001 “Many people believe that dealing with overweight and obesity is a personal responsibility. To some degree they are right, but it is also a community responsibility. When there are no safe, accessible places for children to play or adults to walk, jog, or ride a bike, that is a community responsibility. When school lunchrooms or office cafeterias do not provide healthy and appealing food choices, that is a community responsibility. When new or expectant mothers are not educated about the benefits of breastfeeding, that is a community responsibility. When we do not require daily physical education in our schools, that is also a community responsibility. There is much that we can and should do together.”

5. Chan 5 6/12 Macro-level environments (sectors) Macro-level environments (sectors) Legislative Action Is Part of Ecological Approach Physical environments (settings) Social environment (networks) Individual factors (personal) Individual factors (personal) Government and political structures and policies Food and beverage industry Food and agriculture policies Economic systems Food production and distribution systems Food assistance programs Health care systems Land use and transportation Story et al. (2008) Legislative, Regulatory or policy actions My research examined legislative approach

6. Chan 6 6/12 Today’s Research Addresses Three Questions What method do we use for describing state legislation used to prevent and reduce obesity? What do we find when we categorize state legislation to prevent and reduce obesity using that approach? What do we find when we compare state obesity legislation to research-based recommended policies for preventing and reducing obesity?

7. Chan 7 6/12 Method Is Based on Primary Data Collection Used Database of State Legislative and Regulatory Action (SLRA) as source of obesity legislation –Developed by Centers for Disease Control & Prevention (CDC) –Pertains to nutrition, physical activity, and obesity Defined new variables to describe legislative landscape –Developed categories for each variable –Performed iterative process of sorting text to identify emerging themes

8. Chan 8 6/12 Someone intervening (intervener) Someone being intervened on (target) By an intervention Data Collection Guided by Logical Framework Goal (Purpose) Goal (Purpose)

9. Chan 9 6/12 Someone intervening (intervener) Someone being intervened on (target) By an intervention Data Collection Guided by Logical Framework Goal (Purpose) Goal (Purpose) ConceptDescription Intervener Who or what entity operating or administering intervention Intervention What legislation is doing; intended action steps or path to get to desired change or outcome Target Who or what will be directly affected by intervention to achieve a desired outcome Purpose Desired or intended outcome legislation tries to accomplish

10. Chan 10 6/12 Limited Sample to Relevant Laws for 2001–2010 Number of Observations (CDC) N = 3,402 Number of Unique Bills N = 3,378 Number of Unique Bills N = 3,378 Enacted N = 1,409 Enacted N = 1,409 Pending N = 391 Pending N = 391 Dead N = 1,542 Dead N = 1,542 Vetoed N = 36 Vetoed N = 36 Purpose Relevant N = 1,004 Purpose Relevant N = 1,004 Purpose Unclear N = 128 Purpose Unclear N = 128 Purpose N/A N = 186 Purpose N/A N = 186

11. Chan 11 6/12 Today’s Research Addresses Three Questions What method do we use for describing state legislation used to prevent and reduce obesity? What do we find when we categorize state legislation to prevent and reduce obesity using that approach? What do we find when we compare state obesity legislation to research-based recommended policies for preventing and reducing obesity?

12. Chan 12 6/12 Interventions Seek Change in Different Ways Intervention CategoryDefinition Require and define rules Set requirement or standards; define rules, duties, or responsibilities; includes bans and restrictions Appropriate funds Allocate budget, funds, grants or other resources Establish new group Establish, create, or develop a new entity for a set purpose, e.g., taskforce, council, advisory board, programs AuthorizeAllow or give permission or authority to act Incentivize Give incentive to change behavior, e.g., taxes or tax credits Encourage Passive measures to cause behavior change, without any defined requirement or penalty

13. Chan 13 6/12 Interventions Analyzed Seek to Cause Change Mostly Through Requirements Intervention CategoryDefinition Percent of Bills Require and define rules Set requirement or standards; define rules, duties, or responsibilities; includes bans and restrictions 59% Appropriate funds Allocate budget, funds, grants or other resources14% Establish new group Establish, create, or develop a new entity for a set purpose, e.g., taskforce, council, advisory board, programs 10% AuthorizeAllow or give permission or authority to act8% Incentivize Give incentive to change behavior, e.g., taxes or tax credits 6% Encourage Passive measures to cause behavior change, without any defined requirement or penalty 3% Of 1,004 bills, 5% of bills were Unclear and 4% of bills were Miscellaneous.

14. Chan 14 6/12 Targets for Interventions Can Include Numerous Stakeholders Target CategoryDefinition Government Government entities (e.g., counties, cities, state departments or agencies, programs and committees) School School and school-related entities (e.g., school districts, boards, after-school or school athletic programs) People Specific sub-populations (e.g., students, mothers, bicyclists, drivers) Food-related Places Places that sell food (e.g., vending machines, restaurants, farmers markets, or farms) Other Miscellaneous, including non-profit organizations, non-government organizations, employers, landowners, or public spaces

15. Chan 15 6/12 Government Entities Are the Largest Group of Stakeholders Target CategoryDefinition Percent of Bills Government Government entities (e.g., counties, cities, state departments or agencies, programs and committees) 44% School School and school-related entities (e.g., school districts, boards, after-school or school athletic programs) 16% People Specific sub-populations (e.g., students, mothers, bicyclists, drivers) 8% Food-related Places Places that sell food (e.g., vending machines, restaurants, farmers markets, or farms) 8% Other Miscellaneous, including non-profit organizations, non-government organizations, employers, landowners, or public spaces 19%

16. Chan 16 6/12 Interventions Can Target Physical Activity, Nutrition, or Other Obesity Areas Purpose CategorySubcategory Physical Activity Active Transport Occupational Activity Recreation Physical Activity Miscellaneous Nutrition Promote Healthy Foods Discourage Unhealthy foods Food Information Food Miscellaneous Other Obesity

17. Chan 17 6/12 Most of Interventions Are Targeted to Physical Activity—Mostly Active Transport Purpose Category Percent of BillsSubcategory Percent of Purpose Category Physical Activity50% Active Transport61% Occupational Activity20% Recreation18% Physical Activity Miscellaneous 1% Nutrition35% Promote Healthy Foods72% Discourage Unhealthy Foods 5% Food Information4% Food Miscellaneous19% Other Obesity15%Other Obesity100%

18. Chan 18 6/12 Today’s Research Addresses Three Questions What method do we use for describing state legislation used to prevent and reduce obesity? What do we find when we categorize state legislation to prevent and reduce obesity using that approach? What do we find when we compare state obesity legislation to research-based recommended policies for preventing and reducing obesity?

19. Chan 19 6/12 CDC Recommends Strategies Based on Literature and Subject Experts Academic Literature Eligible articles: 94 Search Result: 270 Identified Strategies:179 Recommended Strategies: 24 Literature Review Expert Panel Ranked Strategies Group into 6 Categories

20. Chan 20 6/12 We Rank the CDC Categories in Terms of the Prevalence of the Laws Recommended Strategy 1. Create safe communities that support physical activity 2. Promote availability of affordable healthy food and beverages 3. Encourage physical activity or limit sedentary activity among children and youth 4. Support healthy food and beverage choices 5. Encourage breastfeeding 6. Encourage communities to organize for change

21. Chan 21 6/12 Less Than Half the Laws Match CDC Recommended Strategies Meets at Least One Recommended Strategy (46%)

22. Chan 22 6/12 Of the 46% of Laws That Do Match, Almost Half Support Physical Activity Recommended Strategy Distribution of Laws That Match 1. Create safe communities that support physical activity 47% 2. Promote availability of affordable healthy food and beverages 35% 3. Encourage physical activity or limit sedentary activity among children and youth 11% 4. Support healthy food and beverage choices5% 5. Encourage breastfeeding2% 6. Encourage communities to organize for change1%

23. Chan 23 6/12 Summary Obesity legislation seeks to cause change mostly through requirements Most of the targets being directly affected are government entities Physical activity is the largest intervention category Less than half of enacted laws meet the CDC’s recommended strategies Of those that do match, almost half of laws support support CDC’s recommendation on physical activity

24. Chan 24 6/12 Policy Implications We need to find ways to bridge the gap between research and policy Legislation can aim to influence other macro-level sectors Some areas lend themselves to legislative influence more than others Legislation is only one piece of the puzzle in preventing and reducing obesity

25. Contact: Stephanie Chan, schan@prgs.eduschan@prgs.edu

26. Chan 26 6/12 ADDITIONAL SLIDES

27. Chan 27 6/12 Macro-level environments (sectors) Macro-level environments (sectors) Legislative Action Is Part of Ecological Approach Physical environments (settings) Social environment (networks) Individual factors Government and political structures and policies Food and beverage industry Food and agriculture policies Economic systems Food production and distribution systems Food assistance programs Health care systems Land use and transportation Story et al. (2008) Legislative, Regulatory or policy actions My research examined legislative approach

28. Chan 28 6/12 http://sallis.ucsd.edu/Documents/Sallis%20Houston%20obesity%20confere nce%20040909.pdfhttp://sallis.ucsd.edu/Documents/Sallis%20Houston%20obesity%20confere nce%20040909.pdf [accessed 3/12/12]

29. Chan 29 6/12

30. Chan 30 6/12 Number of legislation Bills by Year and Status Status YearDeadEnactedPendingVetoedTotal 200105300 200202600 200308300 200404500 2005017500 200604000 2007012700 200864615067 20091299595322322248 2010237219544514 Total15421409391363378

31. Chan 31 6/12 Number of Legislative Bills by Census Region US Census Region Number of bills Percent of Bills Midwest66320% Northeast91827% South110033% West69721% Total3378100%

32. Chan 32 6/12 Number of Laws Enacted by Year Year Number of Laws Percent of Laws 2001 444% 2002 232% 2003 677% 2004 384% 2005 13313% 2006 303% 2007 9910% 2008 303% 2009 39740% 2010 14314% Total 1004100%

33. Chan 33 6/12 Number of Laws by Region US Census Region Number of Laws Percent of Laws Midwest 19019% Northeast 20520% South 37037% West 23924% Total 1004100%

34. Chan 34 6/12 Percent of Purpose Sub-Categories Purpose CategorySub-Category Percent of Bills Percent of Purpose Category Physical Activity Active Transport31%61% Occupational Activity10%20% Recreation9%18% Physical Activity Miscellaneous 0%1% Nutrition Promote healthy foods25%72% Discourage unhealthy foods 2%5% Food Information1%4% Food Miscellaneous7%19% Other Obesity 15%100%

35. Chan 35 6/12 Purpose Sub-Category with Definitions Purpose CategorySub-CategoryDefinition Percent of Bills Physical Activity Active Transport Promote physical activity during the times and place when moving between destinations, i.e. while commuting to school or work, or going to the market 31% Occupational Activity Promote physical activity during the times and places of occupation, i.e. at school or work 10% Recreation Promote physical activity during leisure time, i.e., going to the park or gym, or hiking 9% Physical Activity Miscellaneous Related to physical activity but doesn't fit in other PA categories above 0% Nutrition Promote healthy foods Increase access, availability, and affordability of fresh fruits and vegetables, unprocessed foods, and water 25% Discourage unhealthy foods Create barriers to access trans-fats, sugar-sweetened beverages, candy, snacks, and processed foods 2% Food Information Make information about food available, i.e., nutrition education or menu-labeling for calories, fat, sodium, gluten 1% Food Miscellaneous Related to food but doesn't fit in other Nutrition categories above 7% Other Obesity Other aspects of obesity that is not directly related to nutrition or physical activity, i.e., BMI or fitness testing, breastfeeding, research about obesity 15%

36. Chan 36 6/12 Criteria used by the Select Expert Panel to Rank Strategies

37. Chan 37 6/12 Percent of Match with Recommendation Before and After Year 2009

38. Chan 38 6/12

39. Chan 39 6/12 Match with Recommendations by Year

40. Chan 40 6/12 Purpose Vs. Match Recommended Strategies Purpose Meets At Least One Recommended Strategy NOYES Nutrition Promote healthy foods17%34% Discourage unhealthy foods1%3% Food Information3%0% Food Miscellaneous12%1% Physical Activity Active Transport26%37% Occupational Activity9%12% Recreation7%12% Physical Activity Miscellaneous1%0% Other Obesity 25%3% ALL Categories 100%

41. Chan 41 6/12 Purpose Vs. Match Recommended Strategies Purpose Meets At Least One Recommended Strategy NOYES Nutrition Promote healthy foods17%34% Discourage unhealthy foods1%3% Food Information3%0% Food Miscellaneous12%1% Physical Activity Active Transport26%37% Occupational Activity9%12% Recreation7%12% Physical Activity Miscellaneous1%0% Other Obesity 25%3% ALL Categories 100%

42. Chan 42 6/12 Intervention Vs. Match Recommended Strategies Intervention Meets At Least One Recommended Strategy NOYES Appropriate funds11%17% Authorize7%9% Encourage4%2% Incentivize7%5% Require and define rules57%61% Establish a new group11%9% Miscellaneous5%3% Unclear6%5%

43. Chan 43 6/12 Target Vs. Recommended Strategies Target Meets At Least One Recommended Strategy NOYES People7%9% School11%20% Food related places9%7% Other21%17% Government45%43% Missing10%

44. Chan 44 6/12 Progression of Prevention Strategies

45. Chan 45 6/12 Differences in decision making and persuasion among researchers and policymakers (Brownson et al 2006)

46. Chan 46 6/12 Given This, Researchers Are Shifting Toward an Ecological Model to Study Obesity Previous efforts that focus on the individual through education and behavior treatment have failed The focus also shifted from treatment to prevention There are multiple levels of influence for behavior

47. Chan 47 6/12 Limitations of the Data Referenced one data source of state legislation rather than cross-reference with other sources Search terms for SLRA Database determined by CDC SLRA Database used different search terms and included more legislative actions starting 2009 Not all legislation are created equal