Environmental Change Strategies To Promote Healthy Eating and Physical Activity and Reduce Disparities

Jamie Chriqui: This roundtable brings together experts in policy, systems, and environmental change strategies to discuss the role that such strategies can play in preventing obesity, with a particular eye toward reducing disparities in obesity and related conditions. The panel also identifies approaches for engaging the medical community in broader, population-based strategies for obesity prevention efforts, particularly in light of the American Medical Association's recognition of obesity as a disease. ¹

From your perspective, what are some of the key environmental factors or determinants that have led to the obesigenic environment in communities throughout the United States?

Kathryn Henderson: First, the availability of food 24 hours a day is a big change that we have seen over the last few decades. Not only is food available all the time, but the availability really cues us to think about food and eating in a way that we did not 30 or 40 years ago. A lot of research shows that our intake is driven by these cues to eat; that has been a really big factor.

Shiriki Kumanyika: There are actually multiple things working together. There is the ubiquitous availability of food and, in certain communities, the types of food that are ubiquitous are biased toward unhealthy foods. In addition, you have advertising that pushes people to those foods that are particularly available. Some of the advertising plays on cultural preferences and norms and uses characters and scenarios that are designed to appeal to particular groups, including certain ethnic groups.

Christina Economos: In the last couple of decades, the environment around us has also changed dramatically with respect to availability and accessibility of safe places to play and to be physically active. That has reduced the amount of recreational play that children and adults experience. Then, with the way we have built our schools and laid out our environments, there are not as many opportunities for children to be active. Some of that is related to crime rates in unsafe areas or the perception of danger and parents keeping children indoors.

With respect to the physical structure of schools, some of them are clearly in environments where there is no green space at all. If the school does not have a gymnasium or a blacktop and there is no green space, it is really hard for children to be active, unless structured activity is programmed into the classroom or in the halls or any kind of open space that exists, but it can be really challenging.

Dianne Ward: I certainly agree with my colleagues here. It seems that we have failed in community planning to coordinate our efforts so that one decision does not result in an unintended consequence. We often make decisions about school siting based on economics, “Where is cheap land?” Then, we put schools in certain areas and people have to drive to them. Eventually, communities develop around them, but there is really no planning.

We are not seeing health in all aspects of community planning. We see important components as very segregated—health is one thing, but then economics is something else, and transportation is a separate issue. Our failure to do that has resulted in a lot of poor decision making.

Harold Kohl: I could not agree more about the idea of unintended consequences. Schools make decisions for schools. Transportation departments plan around their transportation goals. Health departments seem to be planning and decision making for health without integrating into these other sectors. The whole process ignores the system in which children live.

It ignores the fact that children have to interact with the transportation sector, the education sector, the parks and recreation sector, and other sectors throughout their day. But, from a physical activity and obesity perspective, we have said, “It is the health department's duty to handle this.” One of the dangers with this perspective is relying on individually adapted behavior-change strategies to take care of the problem. I do not think that is the future of what we need to do.

In fact, the rationale for creating the disease status for obesity puts more responsibility on the individual than on the environment and it ignores the system in which the individual lives.

Jamie Chriqui: Let us move on to the concept that the environments within which we live often lead to disparities. The CDC recently issued a report that looked at disparities that exist across a range of health-related factors and issues and social determinants of health, including diabetes and obesity. ²

The CDC found that people in rural areas were four times as likely to lack access to at least one healthy food outlet in their census tract, as opposed to people living in more urban areas. From your experience and your research, can you identify other examples of how environments have led to disparities in physical activity, food access, food advertising, and/or child obesity more broadly?

Dianne Ward: Unfortunately, in our culture, we advertise to, or target, low-income individuals with solicitations that are not necessarily beneficial to them. For example, Wal-Mart was reported to have targeted ads for discounts on things such as Kool-Aid, soda, and low-nutritious snack foods. ³

Wal-Mart is an example of a retailer that really fits in all of these remote, rural areas; you can almost always find a Wal-Mart somewhere that serves those communities. It would be nice to see commercial leaders take an interest in moving their population upward in terms of better environments, better access, and healthier products, rather than playing to their customers' base economic requirements, which are to survive on the smallest amount of money possible, and often include the products that are really most poor for them.

Shiriki Kumanyika: To expand on what Dianne is saying, I will point to the issue of income. Income affects food access in a lot of ways. One that is very obvious is that it affects whether someone has a car and can get to a place that offers food that is healthier, at a better price, and has a better range of options.

With respect to the idea of getting bargains or deals, the types of foods that might be on sale or the ways that low-income consumers would look at stretching their dollars are likely to lead them to less-healthy foods. They may also be less willing to take a risk on some of the healthier foods, the perishables, because they do not know if they are going to be wasted.

Another major factor is advertising, not only related to food, but also related to physical activity. You have a scenario where, if the neighborhood is less favorable for being active outdoors, the appeal of activities that are advertised that allow people to sit in front of their TV or another kind of screen and do those activities inside is going to be greater in those communities. So, both the advertising of a lot of inexpensive, high-calorie foods and the advertising of sedentary entertainment options are working against the communities that experience disparities.

Christina Economos: I would like to discuss environments in general, including some of the areas I have worked, both rural and urban, and how the environments really impact the family unit. The overall family unit can feel like it does not have access to healthy food—because of the language spoken, low household income, time constraints, or culture-based barriers.

It is often pockets within communities that are impacted more than the community at large. When we talk about community, people often refer to it as a geographic area, but there are also communities of identity within different geographies that are sometimes impacted in a very different way and the disparities are often significant.

Harold Kohl: I agree. One thing that I came across during the recent effort at the Institute of Medicine (IOM) on physical activity and physical education in schools applies directly to this rural/urban and other disparities issue.

Schools could actually be a uniting factor for physical activity access. There are schools in urban areas and schools in rural areas. Right now, we are seeing, at least, case reports of schools in urban areas leasing or selling their playgrounds for parking garages in order to raise money. There is no question that there are access disparities and, children of Hispanic descent, in particular, do not have the same physical education opportunities or quality of physical education as other ethnic-majority schools, according to the literature. ⁴

However, the school can be a hub. The school has the physical resources and capabilities to be a place where, 60 minutes a day, physical activity can be achieved for all kids. It can start with physical education, but active transport to school, sports, classroom time, and recess time can be combined to reach physical activity goals.

One of the things that the committee that released the recent IOM report agreed upon was that school can be the unifying factor for physical activity for kids. ⁵ We have spent billions of dollars over the years on school breakfast and lunch programs and billions of dollars on health screenings for things like scoliosis, vision, and hearing, all on the presumption that healthier kids learn better.

The literature now is quite convincing that physically active kids learn better. ⁵ We should be able to put as much effort into promoting 60 minutes of physical activity a day as these other programs that promote health and learning for kids.

Jamie Chriqui: What systems-oriented policy and environmental strategies could be applied in schools, child care, and communities to accelerate progress in obesity prevention efforts? Further, how might those strategies help to reduce health disparities?

Kathryn Henderson: I agree with Harold, schools are one of our best venues for making these population-wide changes. Schools are regulated—especially school food—at the federal level, the state level, and the local level. There are many opportunities to effect change with strong policy-level standards.

The good thing about regulating public schools is that we are treating everyone equally. So, when we are regulating the food environment at the state or federal level, we are regulating it for children from all backgrounds; not over-regulating our poorer communities and then giving greater choice to others.

I would say the same thing is true for child care, to a lesser degree. We have more unregulated child care settings because of the way that they are licensed. But, we have that same capacity to reach many children with policies.

Jamie Chriqui: Building on this child care concept, because it is an emerging area, it is my understanding that a number of states are moving in the direction of establishing standards for physical activity and nutrition practices within licensed child care centers. Can anyone provide further insights?

Kathryn Henderson: It is moving along quickly, so you are absolutely right to describe it as an emerging area. I think one of the difficulties in child care is that we have a lot of children in unlicensed care or care that is a little bit harder to regulate and that is less true of schools. However, states are really taking the bull by the horns here—seeing that early intervention is key.

Jamie Chriqui: When we worked on Accelerating Progress in Obesity Prevention, we recognized that schools are one part of a much-larger system. ⁶ What are your thoughts on other environmental change or systems-wide strategies that could help to accelerate progress in obesity prevention, either from a community perspective or marketing, worksites, employers, physicians, and families?

Christina Economos: The afterschool environment can support and reinforce what kids are learning during the school day and provide additional opportunities for physical activity to accumulate the full 60 minutes per day. In disadvantaged areas, those programs can occur at the school, because schools are safe, they are designed for children, and they provide a physical structure where these programs can happen. In addition, they do not require additional transportation to get children elsewhere, so the school buildings can be leveraged as important physical structures to provide physical activity opportunities.

During the afterschool hours, we can supplement the students' nutrition education, physical activity education, and minutes of physical activity. We have to also make sure that policies within these environments are supportive, meaning that they limit advertising and marketing of unhealthy products and they support consumption of water and healthy snacks, and also provide academic enrichment opportunities.

This time can consist of 3–5 hours a day for children, oftentimes those living in disadvantaged areas, so optimizing their programming will prevent undermining the good work that is being done during school.

Jamie Chriqui: With respect to out-of-school time, are you talking about the summer months in addition to the academic year? In addition, I believe this involves more than simply agreements between the schools and community organizations. For example, am I correct in thinking that YMCAs participate in your ChildObesity180 initiative?

Christina Economos: That is correct. Sports leagues and other enrichment programs run by the National Council of La Raza and the National Urban League also participate in ChildObesity180's Healthy Kids Out of School Initiative. I agree wholeheartedly that schools are really important, and, yet, children are only there for 180 days a year for 6 hours a day. We have to reinforce healthy behaviors in all of these other environments, and I was highlighting the out-of-school time environment, which includes summer, school vacation, and weekends as well.

Dianne Ward: I would like to endorse Chris's systems approach work. She has been a great leader in this area. Schools, as Harold said, are really the center of community, and it is incumbent on the leadership in communities to demand that schools be health-promoting places. There is a movement that started in Europe, of the health-promoting schools concept, that is now established in many countries across the world and the United States is still slow to get behind this. ⁷ We are still not seeing health from a holistic perspective.

Shiriki Kumanyika: What Chris and Dianne have said is particularly true for communities that are under-resourced and that have multiple problems and multiple versions of the environmental factors that inhibit weight control and obesity prevention. We need to think about how important schools are relative to other issues in the community and whether we are putting too much on schools, asking them to compensate for a lot of things, and whether we can help schools by generating other types of resources in the community.

One of the things that happens in black communities, for example, is that companies that sell products such as soft drinks and fast food are providing resources and setting norms about what to eat because their sponsorship is associated with their brands; they are filling in gaps created by a lack of resources from either jobs or public sources. It is a delicate mix. To address disparities, we need to think about how a particular intervention or setting is important and what elements are needed to make it work in a specific community. A whole-systems approach needs to be tailored to the conditions that might converge in a particular setting.

Jamie Chriqui: A lot of our responses to this question have focused on environments specifically affecting the child—school, afterschool time, and child care settings. But, what about the parents? What are some strategies that could help parents to create a healthier environment so that children are exposed to healthier options throughout their day and evening and not just in structured settings?

Christina Economos: While we all agree that schools are incredibly important, in my experience, particularly working with immigrant families, these parents are not always well connected to the schools. In fact, they really step away from what is happening in the school and leave that to the school. This situation actually alienates parents more and makes them feel like they are not part of what their children are learning and experiencing.

Connecting the experience that children are having in the school, and the good resources they are getting, with parental education and support is really important and community-based organizations can bridge that gap, specifically organizations where they speak the language and understand the culture of parents who are coming to the United States or who have been alienated from the mainstream culture. It is a really important point, because what we can end up with is a home environment that is not as supportive for the child or is really disconnected from the positive input that they are getting during the school day.

We need to spread resources more to community-based organizations that serve lower-income and immigrant families, because, if we do not, we run the risk of widening the disparities gap.

Jamie Chriqui: Besides community-based organizations, what other sectors might be useful partners?

Christina Economos: Worksites, for sure. Some of the larger and more sophisticated worksites have wellness programs. However, to reach certain populations, such as those who work in the service industry that do not have access to these programs, we have to work with the healthcare system or even more progressive companies that offer worksite wellness programs.

Harold Kohl: One of the things that needs to be addressed is health literacy. It gets at a foundational issue of disparity and affects immigrant populations, others that may be speaking English as a second or third language, and those who are in lower socioeconomic status communities.

Health literacy is directly related to the childhood obesity environment as well as individual responsibility. It is about the ability to engage in the healthcare system and negotiate a healthcare system that even people who have college degrees and have been raised in this country have difficulty navigating.

Health literacy has the potential to address some of these disparities—whether it is self-care, finding a primary care doctor, or discovering where to go for care. It is especially an issue in Texas. Nearly 30% of the population is without any form of health insurance. ⁸ Those people are clearly at risk and having the literacy to be able to negotiate the health system is missing.

Jamie Chriqui: What are some of the key challenges that you have encountered or been made aware of relative to adoption and/or implementation of large-scale population-based strategies, such as policy or environmental changes? A lot of times, the concern is financial, but it is not just about money, is it?

Dianne Ward: No, it is not. What I see happening, and certainly North Carolina is a good example because of its historic philosophy of being independent, is the tension that exists between free will and the need for policies to affect the broad range of individuals.

Attempts by the North Carolina Child Care Commission to implement higher standards for food served were met with complaints not just from citizens, but also from members of the medical community who wanted to support the independence of the family and the individual to make decisions.

New York City has been able to make progress in addressing the obesity epidemic because the environment there is different in terms of the support the health department receives, that many other states and municipalities do not have, but I do sense that there is this tension within New York City. We need to create a different vision of what we are trying to do, rather than creating the perception that people's freedom and independence are being taken away. We need to recast these efforts to move communities along in a different way so that individuals do not feel like the nanny state is being foisted on them.

Shiriki Kumanyika: This also plays out at the community level for groups that may have some reason to be skeptical about government intervention and what is in their best interest. The ability of soft-drink companies, for example, to rally people against things like sugar-sweetened beverage taxes is partly because the companies may have better relationships with people in the communities than the policy makers or the public health advocates who are promoting the taxes. We may be seen as outsiders pushing rules on people. I don't think we have done enough grassroots work to build up the support for some of these policies in communities, especially communities that might be marginalized.

Jamie Chriqui: Kathy, you have done a lot of work in Connecticut as policy changes have been implemented at the school and child care levels throughout the state. What have been some of your experiences in terms of the key challenges and barriers to implementing changes in these arenas?

Kathryn Henderson: The idea that we want free choice and the idea that policies to facilitate health are perceived as controlling and constraining have certainly been issues to overcome.

Connecticut has some of the widest disparities within one state and one of the issues has been to help people understand that childhood obesity is an issue in every community. We have some communities where people just do not see it and so perception is an issue.

Another issue in some of the very underprivileged communities is to make the case that childhood obesity, of which the consequences are long term, is a major concern that they should be focused on. It is hard to justify to people that they should focus their energy on childhood obesity when violence is an issue or feeding their children at all is an issue. That has been a big barrier to implementing some of these policies as well.

Jamie Chriqui: Chris, in relation to your work with systems changes, what have been some of the pushbacks that you have had in your work within Somerville, MA, and elsewhere?

Christina Economos: Where I have been able to be successful with groups is by bringing different sectors to the table. The issue with that is it takes a long time to create a productive dialogue and develop trust between the different sectors in order to move something forward—there are misunderstandings, competing priorities, dollars are allocated sometimes to urgent areas, rather than things that will have even more dramatic long-term consequences.

Getting people to really understand the issue as a systemic long-term issue that impacts society at large takes a lot of time. However, it is more productive when you can get different sectors to work together, agree on something, and advance a policy or an environmental strategy.

Jamie Chriqui: Policy, environmental, and systems changes cannot happen overnight so, in the meantime, we are faced with the environments that we are currently living in and the policies that we have in place. In this context, I would like to bring into the discussion the American Medical Association's (AMA) recent recognition of obesity as a disease. ¹ There has been some pushback in the public health field that this could lead to a more individual patient-oriented approach to obesity prevention as opposed to a focus on population-wide approaches and policy, systems, and environmental change.

What are your experiences or perspectives on the role that physicians and the medical establishment can play in helping to facilitate obesity prevention strategies in our communities?

Shiriki Kumanyika: I am trying to take a positive view of this, in terms of the bigger picture, because the fact that the medical establishment has not been able to really offer effective treatment for obese children and adults is something that we have all been concerned about. We cannot prevent obesity entirely and there are already a lot of people who are obese; we need to not be narrow minded in the way that we look at things that happen within the healthcare system.

The bright spot that I saw in the announcement about the AMA policies was that they also passed a policy to ask employers to reduce sitting time—provide infrastructure to improve the ability of people to get up and move around. I think the AMA could be approached and encouraged to use their authority as physicians to advocate for policy and environmental changes as well as being able to treat obesity better.

Dianne Ward: I agree with Shiriki. I want to see this not as a negative action, but as an opportunity to shine a light on a condition that is very complicated and very difficult to treat and for which prevention is the best strategy.

I also want to underscore the importance of the medical community. It is ironic to me that it has perhaps felt underequipped to assume this role as a community leader, when the voice of the medical community is an important and respected one. I would want to reach out to primary care doctors so that they become engaged in community decisions by serving in wellness policy groups for schools or advocating for child care policies or encouraging parks and recreation centers to open up access to play areas because their patients need access to healthy communities.

There are probably few medical conditions where nutrition or physical activity is not related to the prevention and/or treatment of the condition. The medical community needs to be out there with a voice, speaking outside of the clinic and in the community, whether it is an urban, rural, or a suburban setting. We really need our physician community involved in helping change these attitudes.

Jamie Chriqui: Chris, in your work with immigrant populations, could this be addressed from a cultural perspective? Is there an issue of trust? Do these communities view physicians with high regard, as Dianne suggested? What role have physicians played with some of the groups with which you have worked?

Christina Economos: Physicians play a very big role. They are held in very high regard, and, although it is difficult, as we all know, to take advice and incorporate it into your individual life when you are in an obesigenic environment, the advice is still really important and holds a lot of weight.

To put another positive spin on the AMA declaring obesity a disease, it should help with the training curriculum for physicians now and in the future. That is not only training on the treatment side, but also on the prevention side, which, we all know, involves environmental and policy changes. I see it as an opportunity for future physicians to be trained differently, to get involved in research and policy, and to serve on committees locally, at the state level, and even in Washington DC. To note, this extends to training for nurses and other healthcare professionals that are often the point of contact with children and low-income populations who might not have access to a physician.

Kathryn Henderson: I agree; having physicians on local wellness school policy committees or local wellness councils has been key, because they are seen as leaders in the community. I am glad Chris brought up the issue of training. My physician colleagues will tell me they get very little training on even obesity treatment, let alone prevention and policy. I know the AMA really has interest in changing that, and my big hope is that, when coming up through the ranks, new physicians will have better training in all aspects of obesity treatment and prevention, but especially the policy and environmental piece.

Jamie Chriqui: Kathy, with your experience working with wellness councils, can you provide some tangible examples of the roles physicians have played?

Kathryn Henderson: I work in New Haven, Connecticut, which has a stellar local school wellness policy. The pediatrician on record for the school district was a leader in moving the wellness policy forward and making it strong and having it embrace those things that are important to obesity prevention. He was a physician with a master's in public health so he had a foot in the world of public health and was able to be a leader in the importance of environmental change in our local school district as well as a leader in recruiting physicians to the cause.

Jamie Chriqui: Was he instrumental in implementing the policy as well as having the policy adopted?

Kathryn Henderson: Absolutely, and he continues to be involved. All wellness policies are works in progress, so he continues to be very involved at the local level and that has been important. I do not think that this policy would have been as strong and certainly would not have been implemented to the same degree without that physician support.

Shiriki Kumanyika: I have done a lot of studies of obesity treatment and know that none of the treatments work unless people are able to change their behaviors. Even obesity surgery requires the ability to manage behaviors to be effective, and the ability to manage behaviors is directly linked to the environment that pushes you hard in the other direction.

We, in public health, who are advocates for policy and environmental change, can do a better job of making a link for the medical community between what they are attempting to do in the healthcare setting and what needs to happen in the community.

We can help make that link not just by saying that the medical community should advocate, but by explaining why.