Fighting Obesity in the United States with State Legislation

Stephanie Chan, M.A., M.Phil.Pardee RAND Graduate School

June 20, 20122012 USPHS Scientific & Training Symposium

College Park, MD

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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

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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

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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.”

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Macro-level environments (sectors)

Legislative Action Is Part of Ecological Approach

Physical environments (settings)

Social environment (networks)

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

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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?

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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

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Someone intervening (intervener)

Someone being

intervened on (target)

By an intervention

Data Collection Guided by Logical Framework

Goal(Purpose)

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Someone intervening (intervener)

Someone being

intervened on (target)

By an intervention

Data Collection Guided by Logical Framework

Goal(Purpose)

Concept Description

Intervener Who or what entity operating or administering intervention

InterventionWhat legislation is doing; intended action steps or path to get to desired change or outcome

TargetWho or what will be directly affected by intervention to achieve a desired outcome

Purpose Desired or intended outcome legislation tries to accomplish

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Limited Sample to Relevant Laws for 2001–2010

Number of Observations (CDC) N = 3,402

Number of Unique BillsN = 3,378

EnactedN = 1,409

PendingN = 391

DeadN = 1,542

VetoedN = 36

Purpose RelevantN = 1,004

Purpose UnclearN = 128

PurposeN/A

N = 186

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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?

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Interventions Seek Change in Different Ways

Intervention Category Definition

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

Authorize Allow 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

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Interventions Analyzed Seek to Cause Change Mostly Through Requirements

Intervention Category Definition

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 resources 14%

Establish new group

Establish, create, or develop a new entity for a set purpose, e.g., taskforce, council, advisory board, programs

10%

Authorize Allow or give permission or authority to act 8%

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.

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Targets for Interventions Can Include Numerous Stakeholders

Target Category Definition

GovernmentGovernment entities (e.g., counties, cities, state departments or agencies, programs and committees)

SchoolSchool 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

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Government Entities Are the Largest Group of Stakeholders

Target Category DefinitionPercent of

Bills

GovernmentGovernment entities (e.g., counties, cities, state departments or agencies, programs and committees)

44%

SchoolSchool 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%

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Interventions Can Target Physical Activity, Nutrition, or Other Obesity Areas

Purpose Category Subcategory

Physical Activity

Active Transport

Occupational Activity

Recreation

Physical Activity Miscellaneous

Nutrition

Promote Healthy Foods

Discourage Unhealthy foods

Food Information

Food Miscellaneous

Other Obesity Other Obesity

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Most of Interventions Are Targeted to Physical Activity—Mostly Active Transport

Purpose CategoryPercent of

Bills Subcategory

Percent of Purpose Category

Physical Activity 50%

Active Transport 61%

Occupational Activity 20%

Recreation 18%

Physical Activity Miscellaneous 1%

Nutrition 35%

Promote Healthy Foods 72%

Discourage Unhealthy Foods 5%

Food Information 4%

Food Miscellaneous 19%

Other Obesity 15% Other Obesity 100%

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?

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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

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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

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Less Than Half the Laws Match CDC Recommended Strategies

Does Not Meet

Any of the

Strate-gies

(54%)

Meets at Least One

Recommended Strategy

(46%)

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Of the 46% of Laws That Do Match, Almost Half Support Physical Activity

Recommended StrategyDistribution 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 choices 5%

5. Encourage breastfeeding 2%

6. Encourage communities to organize for change 1%

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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

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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

Contact: Stephanie Chan, schan@prgs.edu

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ADDITIONAL SLIDES

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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

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http://sallis.ucsd.edu/Documents/Sallis%20Houston%20obesity%20conference%20040909.pdf [accessed 3/12/12]

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Number of legislation Bills by Year and Status

Status Year Dead Enacted Pending Vetoed Total

                 2001 0 53 0 0 532002 0 26 0 0 262003 0 83 0 0 832004 0 45 0 0 452005 0 175 0 0 1752006 0 40 0 0 402007 0 127 0 0 1272008 6 46 15 0 672009 1299 595 322 32 22482010 237 219 54 4 514Total 1542 1409 391 36 3378

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Number of Legislative Bills by Census Region

US Census Region

Number of bills

Percent of Bills

Midwest 663 20%

Northeast 918 27%

South 1100 33%

West 697 21%

Total 3378 100%

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Number of Laws Enacted by Year

YearNumber of Laws Percent of Laws

2001 44 4%2002 23 2%2003 67 7%2004 38 4%2005 133 13%2006 30 3%2007 99 10%2008 30 3%2009 397 40%2010 143 14%

Total 1004 100%

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Number of Laws by Region

US Census Region

Number of Laws Percent of Laws

Midwest190 19%

Northeast205 20%

South370 37%

West239 24%

Total1004 100%

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Percent of Purpose Sub-Categories

Purpose Category Sub-CategoryPercent of

Bills

Percent of Purpose Category

Physical Activity

Active Transport 31% 61%

Occupational Activity 10% 20%

Recreation 9% 18%

Physical Activity Miscellaneous

0% 1%

Nutrition

Promote healthy foods 25% 72%

Discourage unhealthy foods

2% 5%

Food Information 1% 4%

Food Miscellaneous 7% 19%

Other Obesity Other Obesity 15% 100%

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Purpose Sub-Category with Definitions

Purpose Category Sub-Category DefinitionPercent of

Bills

Physical Activity

Active TransportPromote 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 ActivityPromote physical activity during the times and places of occupation, i.e. at school or work

10%

RecreationPromote 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 foodsIncrease 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 InformationMake information about food available, i.e., nutrition education or menu-labeling for calories, fat, sodium, gluten

1%

Food MiscellaneousRelated to food but doesn't fit in other Nutrition categories above

7%

Other Obesity Other ObesityOther aspects of obesity that is not directly related to nutrition or physical activity, i.e., BMI or fitness testing, breastfeeding, research about obesity

15%

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Criteria used by the Select Expert Panel to Rank Strategies

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Percent of Match with Recommendation Before and After Year 2009

Before 2009 2009 and On0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

57.9750

42.0350

Matches At Least One Recommended Strat-egy

Does Not Meet Any of the Strategies

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2001 2002 2003 2004 2005 2006 2007 2008 2009 20100%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Percent of Legislation Matching CDC Recommendation

Yes No

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Match with Recommendations by Year

YearNumber of billsPercent Number of billsPercent Number of billsPercent

2001 28 64% 16 36% 44 100%2002 13 57% 10 44% 23 100%2003 43 64% 24 36% 67 100%2004 29 76% 9 24% 38 100%2005 72 54% 61 46% 133 100%2006 10 33% 20 67% 30 100%2007 59 60% 40 40% 99 100%2008 15 50% 15 50% 30 100%2009 208 52% 189 48% 397 100%2010 62 43% 81 57% 143 100%Total 539 54% 465 46% 1004 100%

Matches Recommended StrategiesNo Yes Total

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Purpose Vs. Match Recommended Strategies

PurposeMeets At Least One

Recommended Strategy    NO YES

Nutrition

Promote healthy foods 17% 34%Discourage unhealthy foods 1% 3%Food Information 3% 0%Food Miscellaneous 12% 1%

Physical Activity

Active Transport 26% 37%Occupational Activity 9% 12%Recreation 7% 12%

Physical Activity Miscellaneous 1% 0%

Other ObesityOther Obesity 25% 3%

ALL Categories   100% 100%

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Purpose Vs. Match Recommended Strategies

PurposeMeets At Least One

Recommended Strategy    NO YES

Nutrition

Promote healthy foods 17% 34%Discourage unhealthy foods 1% 3%Food Information 3% 0%Food Miscellaneous 12% 1%

Physical Activity

Active Transport 26% 37%Occupational Activity 9% 12%Recreation 7% 12%

Physical Activity Miscellaneous 1% 0%

Other ObesityOther Obesity 25% 3%

ALL Categories   100% 100%

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Intervention Vs. Match Recommended Strategies

InterventionMeets At Least One

Recommended Strategy

  NO YES

Appropriate funds 11% 17%

Authorize 7% 9%

Encourage 4% 2%

Incentivize 7% 5%

Require and define rules 57% 61%

Establish a new group 11% 9%

Miscellaneous 5% 3%

Unclear 6% 5%

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Target Vs. Recommended Strategies

TargetMeets At Least One

Recommended Strategy

  NO YES

People 7% 9%

School 11% 20%

Food related places 9% 7%

Other 21% 17%

Government 45% 43%

Missing 10% 10%

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Progression of Prevention Strategies

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Differences in decision making and persuasion among researchers and policymakers

(Brownson et al 2006)

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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

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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