Philadelphia is being recognized as a city where childhood obesity rates are declining.
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With the many programs Philadelphia has had in place over the last decade, what is the consensus among city leadership regarding the cause of the drop in the rates of childhood obesity?
Dr. Schwarz: What we know is that the rates of childhood obesity have been falling over a number of years now. This is not a sudden change in the last year, for instance, but over the last few years. We believe, based on the timeline, that it is the result of a number of policies that were changed over the past 15 years, particularly in our schools. Since 1999, 200 schools have had nutrition education supported by Supplemental Nutrition Assistance Program (SNAP) funds. In 2004, the District implemented comprehensive changes in nutrition policies, impacting sugary beverages in vending machines, stores, and events at schools and setting snack and à la carte standards. In 2009, school kitchens got rid of fryers and shifted to low-fat milk from full-fat milk; and then, more recently, the creation of Wellness Councils for 170 schools, introducing breaks during the school day for exercise and fitness.
For many years, Philadelphia has also made major efforts to upgrade the quality of food that is available in communities, particularly poorer communities in town. Through the Fresh Food Financing Initiative, nearly 20 new supermarkets were established in communities, some of which have not had a local supermarket in generations. More recently, we have expanded farmers' markets and healthy corner stores.
At the same time, we have created more bicycle lanes, more accessible parks for exercise, and afterschool standards and opportunities for physical activity. In afterschool programming, we have also leveraged USDA funding to offer healthier, more complete meals to children.
Last, we implemented mass media campaigns highlighting the impacts of sugary beverages on children, particularly weight gain and type 2 diabetes.
According to your and your co-authors' child health data, Philadelphia has reported progress in closing the gap in racial disparities of childhood obesity.
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The study cites that Philadelphia achieved declines in obesity rates among African-American males and Hispanic females as well as reductions in obesity rates among students from lower-income families. To what do you attribute these socially positive trends?
Dr. Schwarz: There has been a concerted and deliberate effort to assure that strategies focus on communities that may otherwise have been left out and to undertake efforts at scale. The corner store effort, which has received a fair amount of good press, is a good example.
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It has engaged 650 corner stores from all across the city with a focus on neighborhoods with the highest rates of poverty. Through healthy corner stores and other efforts, we have increased access to healthy foods for over 60,000 low-income Philadelphians.
What we are seeing is that when things are done at scale, when concerted efforts are made to be inclusive, and perhaps overly inclusive of communities that have been disadvantaged, we see that all children benefit—not just children who might benefit from less-targeted retail-based strategies, for instance, or school-based strategies.
Are you expecting the decline in childhood obesity to continue in Philadelphia? Have you seen any recent data to indicate that it is?
Dr. Mallya: Yes, the data that we reported on were from 2006 to 2010.
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The data showed that there was a 5% reduction in obesity among all children between the ages of 5 and 18. There were larger decreases, as you alluded to, among African-American boys and Hispanic girls. So, we continue to look at more recent data among children. We do not have final analyses available yet, but as Dr. Schwarz mentioned, we think that those changes that we saw were really based on what has been going on in schools and communities for the past 10–15 years.
Over the last couple of years we have made this additional push, through Get Healthy Philly, to make healthy choices easier for people to engage in. So, our hope is that the additional degree of effort, and additional funding that we have received from federal, state, and local partners, will continue to drive these rates down.
With respect to adults, we do have more recent data from 2012 showing that for the first time in about 10 years or so, the prevalence of adult obesity did not go up, and it went down by a couple of tenths of a percentage point.
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But the main story might be that it is the start of a trend in the right direction among adults, as well.
What future research do you think would best inform childhood obesity prevention strategies?
Dr. Mallya: Two things come to mind: First, focusing on kids and then, second, on the broader population. We are seeing the biggest disparities actually by gender, related to physical activity among younger kids. So, in Philadelphia, girls are about five times less likely to get recommended amounts of physical activity than boys. I think that is a disparity that we were aware of, but we were surprised by the degree of the difference. We need to think about both policy and programmatic interventions to increase physical activity among kids generally, but then specifically among girls.
Second, we focus a lot on how to make healthy things more available, affordable, and accessible, but we know that a main driver of behavior around food and physical activity is the availability and marketing of unhealthy options and unhealthy products. Continued attention to those issues, developing monitoring systems that provide good data at the national level and local level is going to be really important.
Dr. Schwarz: The national focus on No Child Left Behind, which is clearly important, means that physical education is even further behind in districts like Philadelphia, in terms of both time in the curriculum and staffing. There is a need for research for educators, in particular, that looks at more ways to promote physical activity, physical activity through knowledge-based curricula, and lifelong education approaches for children around fitness. Then evaluating these programs and tying them to policy-relevant research would be particularly helpful.
If we think about how to get a handle on physical activity in communities, other than schools, it is hard to find the entity. We have found, for instance, on the nutrition side, that we can work with corner stores, supermarkets, farmers' markets, and other retail-related entities. There are not similar retail-related opportunities to promote physical activity in poorer communities.
There are entities—YMCAs, Boys and Girls Clubs, recreation centers—but what programming looks like around physical activity, I think, has been secondary to a fair amount of effort to promote school performance, which is important. We need good research-based and data-based approaches to the promotion of physical activity in community settings that are appropriate, where we know the time required, the dollar and other resource and training requirements, and are focused on lifelong learning about fitness. This could be a productive area for research.
While overall obesity rates may have leveled off recently, the rate of severe obesity has been on the rise.
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Are these the trends being seen in Philadelphia as well and, if so, what are your thoughts about causes and remedies?
Dr. Mallya: We actually saw declines in severe obesity among children, as well. That is the group of kids that is already suffering from both physical and probably psychosocial consequences of their obesity. It is everything from higher levels of cholesterol to being bullied and teased in school. So, we were encouraged to see that those levels were dropping, as well. However, it is still somewhere close to 8% of children who are severely obese. It is definitely still too high.
I think that group presents some really difficult challenges because they really and truly may have physical limitations to being more physically active. They not only need interventions in their schools and communities and homes, but they should be getting very good clinical care, as well. So thinking about those kids, the linkages between education, public health, and healthcare are particularly important.
How could some of the local actions that are most effective in Philadelphia be disseminated to have a wider benefit?
Dr. Schwarz: One of the questions that always comes up is about funding sources. For many of the things that we have done, there is an initial expense. There may not be huge ongoing expense, but there is an initial expense. My experience is that other communities are looking for solutions that do not have any cost. It is harder to find solutions without cost. There is a cost to teaching and training people, to organizing efforts, to bringing in best practices, to getting equipment, to printing coupons, to changing curricula, to having staff with expertise. One thing that we were fortunate to have was support from the federal, state, and local government. I do not want to set up communities to fail in their efforts if they have to do things on nonexistent budgets.
It is important to remember that many, particularly poorer, communities are still in recovery from the recession and families are in the same situation. It is going to be tough with resources. We know that poverty and increasing poverty does not help with food choices and may not help with physical activity choices or safety within communities that promote physical activity.
Resources are really important here. We believe that this is an important long-term investment that will, ultimately, have a return. But, in the public sector, long-term returns are often hard to finance.
Would you like to comment on, or recommend, strategy for collaborative or partnership efforts?
Dr. Schwarz: People have been generous as partners and willing to be supportive of this across our government. One thing that has been critical here is that City Planning has embraced the idea of preventing chronic disease and has been a great partner in a way that you could say is not terribly expensive.
But our city planners were trained in health impact assessment and they have been willing to both learn from us and teach us. I think we have created credibility by taking action through comprehensive planning efforts and zoning code revisions. Zoning codes can have a profound effect on promoting healthier lifestyles through more walkable communities and policies that incentivize fresh food retail. Those are two less expensive ways that government can make comprehensive change.
It is still too early for us to know what the impacts of those have been, specifically on obesity. But I think they are important signals and they are real in terms of making change in all neighborhoods, potentially, of a city or a community.
Dr. Mallya: Yes, I think that interagency collaboration is really important. If public health entities are not doing that, whether it is at the state level or local level, they really should be—one, because it is a set of colleagues that you can introduce to public health issues and vice versa. They can teach us about city planning or about transportation issues. Often we do have shared goals; we just come at it from slightly different perspectives.
The second thing is there might be some unique funding opportunities there, too. Just as we partner with the City Planning Commission, we have the same types of partnerships with the Office of Transportation. We identified safety for pedestrians and bicyclists as a big issue. We were able to work with the Transportation Agency to not only identify where there were high rates of crashes for walkers and bikers, but then we were able to use state transportation funds to start making low-cost safety improvements to those intersections and corridors—things such as countdown timers, pedestrian bump-outs, and restriping crosswalks. That happened because of partnerships and because of funds that are available in the transportation sector, which can be used to promote public health.
Are those the same types of strategies used to help get kids more active in walking and biking to school?
Dr. Mallya: Yes. For that we looked at the infrastructure, the roads and sidewalks, and the education and promotion. We worked in schools and trained teachers to provide pedestrian and bike safety education to all the 2nd and 5th graders in public schools. It ended up being more than 40,000 students that received in-school education and motivation.
At the same time, there were parents who were engaged in walking school bus programs and just making it easier and safer for kids to be out before and after school.
If you could add to your current strategies—anything you wanted to accelerate your progress and success—what would the addition be, and what stands in the way?
Dr. Schwarz: I would probably add more media time for public health messages. We believe the media messaging for unhealthy food and lifestyles is quite effective and pretty fleet of foot, both in terms of new product development and advertising of products and messaging and setting up expectations, particularly for children. So, for us, we would like more media time, more airtime, better campaigns, and the ability to change them frequently, all of that would be quite important.
Dr. Mallya: What goes hand-in-hand with that, which we do not have a lot of control over, locally, is how products are marketed to children and what sorts of sensible public health promoting limits can be put in place. There have been attempts in the past that industry has been pretty consistent about pushing back against—even voluntary standards. So we need more counter-messaging to promote better choices.
Dr. Schwarz: Yes, and better nutrition labeling on children's foods, with simple systems, such as Britain's traffic light approach—red/yellow/green—and having some way, outside of industry, to decide what products are aimed at children. But that kind of labeling is not possible without federal activity. We have quite a comprehensive labeling law in Philadelphia for calories and sodium and other things. We have some fairly decent preliminary data to show that it makes a difference, both to selection and to nutritional intake.
We think that there is a fair amount that the federal government could do in terms of improving labeling and information for the public, particularly around things that are available to children.
—Jamie Devereaux, Features Editor
For more information on Philadelphia's child health programs, visit FoodFitPhilly.org.
