The American population weighs too much. That is so well documented; it does not even need a citation. And for all the millions of pages of research and gray literature devoted to the topic and all the complex reasons for American obesity, we know that Americans tend to eat too much, and too much of the wrong things, while not exercising nearly enough.
With the girth of America growing, taking off fatty pounds and, more importantly, keeping them off will go a long way toward mitigating personal and family health catastrophes and future health care costs. Our propensity for excess weight is, to be sure, related to decisions by individuals. But these decisions are shaped and guided by what we encounter in the places where we work, learn, and play. A new environment around each of us, one less blessed with empty calories and more encouraging to movement and activity, will become us.
In the past few years, policy attempts to influence the inputs have been highly visible, from the recent success in reducing sodium in processed foods to the Affordable Care Act's requirement to place calories on menu boards and the 2010 Healthy Hunger-Free Kids Act, which promoted healthier meals in schools and in childcare centers. While the output side of the equation has not been ignored in research or in our culture, the role of policy in affecting physical activity is nowhere near as visible as the policy focus on nutrition.
This issue of the Journal of Public Health Management and Practice is a welcome examination of policy's role in altering the output side of the equation.
Engaging in regular physical activity is one of the most important things people of all ages can do to improve their health, well-being, and quality of life. The 2008 Physical Activity Guidelines for Americans recommend that adults and children participate in daily physical activity for a minimum of 30 and 60 minutes, respectively.1 However, despite the well-known benefits, most Americans are not meeting the recommendations and inactivity among adults and youth remains relatively high.
The health problems associated with physical inactivity have potentially large economic consequences for the US healthcare system. Sedentary lifestyles are responsible for an estimated $24 billion (2.4%) of all direct medical spending.2 In addition, lack of physical activity is a contributing factor in approximately 1 in 10 deaths each year.3 Since regular physical activity can prevent disease and promote health, it also has the potential to decrease the costs associated with health care. If more than 88 million inactive Americans older than 15 years increased their participation in moderate physical activity, national direct medical costs may be reduced by as much as $76.6 billion (estimate based on year 2000 dollars).4
In addition to health care costs, physical inactivity leads to lost wages and less productivity when people are unable to work because of illness and disability. A 2008 study found that a worksite wellness program aimed at reducing weight and improving health risk factors in obese employees produced a short-term return on investment of $1.17 per dollar spent.5 Investing in evidence-based worksite wellness initiatives, such as those described in HealthLead, US Healthiest's Workplace Accreditation Program, provides the opportunity to encourage and support employees to live healthier lives.6 ASTHO is accredited by the HealthLead program, as is the Monterey County (California) Public Health Department.
Building Support and Stakeholder Engagement
There is growing public awareness and support for creating healthy environments for physical activity. In “Spatial and Temporal Patterns of North Carolina Pedestrian and Bicycle Plans,” Aytur et al report on the infectiousness of policy—in other words, how surrounding communities take up the challenge of planning more physical activity–friendly environments if their neighboring municipalities have already done so. In 2010, the Robert Wood Johnson Foundation commissioned a Gallup poll of more than 1900 school principals across the country that studied recess and its effect on school performance.7 A 2013 Associated Press-NORC Center for Public Affairs Research poll showed that the general population supports physical activity policies in schools and other government policies but does not want policies that limit choices.8 Polls such as those conducted by Tabak et al in the article “Policies Perceptions Related to Physical Activity and Health Eating in Mississippi” are important tools for helping policy makers craft messages, policies, and programs to garner further support for physical activity. They illuminate the divide between the opinions of residents and the actions of policy makers.
As polls are a tool for understanding culture and public opinion, stakeholder engagement is critical for implementation across states and communities. Many policies and programs start with coalitions. In the article “Factors Related to Partner Involvement in Development of the US National Physical Activity Plan,” Bornstein et al help define key ingredients state and local policy makers can use to build effective coalitions and task forces. Research such as this helps prevent similar mistakes from occurring elsewhere while building a body of knowledge on how to be effective.
In recent years, it has become more apparent that the health of communities is determined by a multitude of factors beyond health care and, in many cases, beyond the scope of traditional public health activities. Public health practitioners, researchers, and policy makers have started to look more closely at the root causes of chronic diseases that face modern societies and are beginning to identify social and environmental circumstances as major contributors. The National Association of County & City Health Officials' (NACCHO's) Web-based Roots of Health Inequity course provides easy access to this concept.9 To create conditions that make health easier, systemic approaches will be helpful. Diverse sectors will need to continue to organize effectively together.
Governmental public health departments are not the only departments establishing policy that can have a direct impact on obesity levels in our communities. Ensuring that health outcomes are considered as a consequence of policy development in sister agencies, for example, those with responsibility for transportation, housing, planning, education, and agriculture policy, can have felicitous effects, too. In a similar vein, the private and nonprofit sectors can create conditions that will lighten our corporeal load. A Health in All Policies (HiAP) approach supports the National Prevention Strategy and Healthy People 2020 goals and enhances the capability of state and local health agencies to positively affect health outcomes, and it may also be effective in identifying gaps in evidence and achieving health equity. A fundamental tenet of HiAP is that it is possible to predict the health consequences of policies in the built and natural environments. Health impact assessments (HIAs) are one promising method to approach HiAP. Through a series of structured steps, HIAs provide a framework for identifying which projects and policies to target, assessing the health impacts of these policies, engaging key stakeholders, and providing health-based recommendations to decision makers. An HIA is particularly useful when making difficult decisions that require tradeoffs, as it provides a framework for incorporating both the scientific evidence and the affected community's priorities. The multidisciplinary and collaborative nature of HIAs necessitates partnerships between public health and other sectors. An HIA also prioritizes health equity core principles, including democracy, equity, ethical use of evidence, and participation.
For the last several years, ASTHO and NACCHO have been working to incorporate health considerations into a range of public decisions by promoting HIAs at state and local health departments and encouraging resource allocation for this intensive work. State and local health departments have used HIAs as a method to get multiple sectors collaborating around a single goal and purpose. One such issue is access to safe places to be physically active, a leading contributor to obesity and other chronic diseases.
Working with support from NACCHO, the Putnam County Department of Health, in Putnam, Missouri, for example, brought together local leaders and stakeholders to conduct a detailed community health assessment. Their work resulted in a master plan to improve 2 city parks and other aspects of community life including increased access to and use of attractive and safe locations for engaging in physical activity; improved sidewalks and crossing signals to make them more pedestrian-friendly; improved park food concessions to offer healthier food options; improved sidewalks and trails to increase walkability and bikability; and the redesign of park entrances to connect with neighborhoods and nearby destinations. In an especially interesting approach, local leaders constructed an evaluation plan to inform policy makers about the effect of these changes on park utilization and physical activity. Policy makers must be informed about the results of their decision making and, in areas such as childhood obesity, be sensitive to the lag time between when decisions are made and when it is reasonable to see the results hypothesized from the change.
Through an ASTHO project, the South Carolina Department of Health and the Environment, along with the South Carolina Institute of Medicine and Public Health, developed a network of interested stakeholders across the state to engage in conversation about how to best promote and use HIAs. The HIA Steering Committee examined the potential health impacts of the proposed “road diet,” or reconfiguration that reduces the number of travel lanes, of a downtown Spartanburg arterial road, Daniel Morgan Avenue. The proposed road diet would restructure the road to provide sidewalks for pedestrians and include a separated bicycle lane on one side. The HIA findings suggested that the proposed road diet and restriping would allow for increased safety for motorists, bicyclists, and pedestrians while increasing the opportunities for physical activity and access to goods and services that support a healthy lifestyle. This is a great example of how an HIA can be used to provide recommendations on how a policy or program can affect physical activity in a community. ASTHO has worked with 11 states to train them on how to implement HIAs, and in 4 of those states—California, Minnesota, Oregon, and Washington—approximately 40% of local health departments participated. In Montana, Ohio, Missouri, and Washington, NACCHO matched local health departments new to HIA with more experienced departments through an HIA Mentorship Program. Work, for example, focused on changes to the built environment through neighborhood development and transportation plans.
Specific Sectors for Change
According to a 2010 study on education policies in schools, 60% of states had a policy that included a general requirement for physical education at the high school level and 80% at the middle school level, compared with 88% at the elementary school level, although very few of these policies met national standards or recommendations.10 Before moving to stronger standards, it is important to understand how the current policies are working. In “Roles and Strategies of State Organizations Related to School-Based Physical Education and Physical Activity Policies,” Cradock et al studied how policies affecting physical education and activity in schools focused on implementation and training but a gap existed in enforcement and evaluation. NACCHO-assisted local health departments work with school districts and schools on, for example, wellness, physical activity, preschool, and assessment through ACHIEVE in the states of New York, Oregon, Illinois, Washington, Connecticut, California, North Carolina, Michigan, South Carolina, Nevada, Kentucky, and Virginia.
This gap between implementation and monitoring is a critical issue to begin addressing as more policies are considered. Despite success in some cross-sector activity, coordinating access to data among sectors still requires careful interpretation of law and trust. While some school districts are training teachers and staff to calculate body mass index measures for students, local health departments may not have access to those data because of real or perceived privacy concerns. However, access to these data can help form a more complete picture of a jurisdiction's health and inform system-wide analysis of root cause and solutions.
Worksites are another area with growing momentum for change. Supporting and investing in worksite wellness programs that promote the physical and emotional well-being of employees are ways for organizations to inspire employees to take responsibility for their own health while reducing health care costs, increasing productivity, and improving staff morale. An analysis of 28 studies showed an average return on investment of $3.48 per dollar in cost.11 The leadership of the Colorado Department of Public Health and Environment has instituted a number of innovative employee wellness initiatives to create a model program that promotes physical activity among employees. Initiatives include promoting the use of stairways, a 30-minute wellness break policy, the creation of a wellness room within the department, and partnering with the state transportation program to provide incentives for using alternative transportation methods. In addition, all supervisors and staff are encouraged to create an Individual Performance Goal related to wellness to be included in their annual performance evaluation to show their dedication to the health and well-being of their staff. Fourteen community coalitions in 9 states assisted by NACCHO are in the process of implementing policies and environmental approaches to support healthy living in workplaces.
“Making Strides Toward Active Living: The Policy Perspective” explains how Eyler et al created tools and measures to help public health care practitioners understand perceptions of worksite supports for physical activity and healthy eating. This validated self-report measure could be a more cost-effective measure than on-site observation and enable better understanding of how policies are being implemented.
Public health and sector partners are gaining traction through increased public support of physical activity promotion. More and more evidence shows that the policies developed can be evaluated and that they are working. At the same time, a gap exists in enforcing and monitoring the policies that are currently in place. By continuing to work on evidence-based policies related to both nutrition and physical activity, members of the public health system can work together synergistically to reverse obesity trends and the negative societal consequences that result from it.