In 2007, the Robert Wood Johnson Foundation (RWJF) announced a bold and unprecedented commitment of $500 million to reverse the epidemic of childhood obesity by 2015, especially in communities at greatest risk based on income, race, ethnicity, and geographic location. This was the foundation's largest prospective commitment ever made to one issue area.
Researchers, practitioners, and advocates from public health, health care, and related disciplines were beginning to coalesce around this growing threat to our nation's future. Indeed, US Surgeon General Dr Richard Carmona's 2004 testimony to Congress painted a grave picture of the future: “Because of the increasing rates of obesity, unhealthy eating habits, and physical inactivity, we may see the first generation that will be less healthy and have a shorter life expectancy than their parents,” he said.1
Previous obesity prevention initiatives targeting individually oriented behavior change strategies had limited success, and RWJF recognized the importance of taking a multidisciplinary, systems-based approach to addressing the epidemic. Tapping into lessons learned from its active living portfolio, which focused on increasing routine physical activity, as well as its long-standing commitment to tobacco use prevention through policy change, the foundation launched an array of complementary initiatives aimed at building the evidence base, testing advocacy approaches, and supporting on-the-ground action to reverse the childhood obesity epidemic.
Healthy Kids, Healthy Communities (HKHC), a 5-year $33.4 million national program, was one of the foundation's earliest such investments. The building on the successes of the RWJF-funded Active Living by Design (ALBD) national program (2002-2008) and the Healthy Eating by Design pilot project (2005-2007), HKHC was designed to address the policies, systems, and environments that make it easier for low-income children and their families to engage in physical activity and play and to access healthy food in their communities. As part of its strategy, RWJF funded 50 multidisciplinary partnerships across the country, with a special focus on 15 southern states where health disparities were most significant.
The selection of ALBD to lead HKHC was a testament to the organization's strength and leadership. Launched in 2002 as part of the UNC Gillings School of Global Public Health in Chapel Hill, North Carolina, and now a fiscally sponsored project of Third Sector New England, ALBD helps create community change by working with local, state, and national partners to build a culture of active living and healthy eating. ALBD's track record included success with earlier RWJF national programs; designing and implementing comprehensive grant-funded initiatives; coaching diverse community coalitions to achieve policy, systems, and environmental change successes; convening and supporting peer networks; and engaging with other philanthropic organizations and mission partners to build the healthy communities movement. HKHC leveraged ALBD's experience by addressing the systemic issues that contribute to physical inactivity and unhealthy eating, using a broader healthy community lens.
Working with RWJF and the foundation's portfolio of nearly 30 other major childhood obesity prevention programs,2 the HKHC national program office was responsible for a variety of activities, including developing and implementing program strategy, convening and staffing a national advisory committee to review proposals and make funding recommendations, providing ongoing technical assistance and consultation to grantees, developing and implementing a comprehensive peer learning network, partnering with Transtria, LLC, in the design and execution of the evaluation process and dissemination activities, and engaging with other RWJF grantees and partners to reverse the childhood obesity epidemic by 2015.
HKHC's grant-making launched in 2008 with the selection of 9 Leading Sites from a pool of 43 candidate communities identified by RWJF and other grant makers. Selection criteria for the Leading Sites included leadership in the field, track records of success, ability to serve as mentors to other grantees, and willingness to be ambassadors for the movement. These 4-year $400 000 awards were augmented with significant coaching and technical assistance from ALBD. To ensure local commitment and to promote sustainability, partnerships were required to secure an annual match of cash and/or in-kind support equal to 50% of RWJF funding. In all cases, Leading Sites far exceeded this requirement, with several of them securing the match for the entire grant period before the first year of funding had ended.
The second round of grant-making commenced in 2009, with the selection of 41 Round Two Sites, each receiving up to $360 000 over 4 years. In contrast to the Leading Sites, Round Two Sites were identified through an open call for proposals process, which resulted in 540 brief proposals. To ensure meaningful representation from 15 states with the highest rates of childhood obesity, special attention was given to prospective applicants from the South. As a result, approximately half of Round Two Sites were located in these states. Despite the selection of Round Two Sites coinciding with the economic downturn, all of them met or exceeded the 50% match requirement.
Overall, the portfolio of HKHC grantees represented a range of communities, including small rural areas, large cities, and multicounty regions; those with cold, snowy climates and very hot, arid ones; and communities with a high percentage of immigrants and non-English speakers. The HKHC grantees and key project staff were no less diverse. Lead agencies ranged from public health departments to advocacy organizations and foundations. Local HKHC leaders represented a wide array of professional backgrounds and perspectives as well, including community organizers, physicians, housing advocates, economic development professionals, and government officials. Similarly, grantees' primary areas of focus concentrated broadly on active living and healthy eating, but specific strategies and implementation approaches varied tremendously because of local context.
The successes of the HKHC grant program are well documented in this journal as well as through case studies and case reports, spotlights, leadership profiles, and other products available at www.healthykidshealthycommunities.org and http://www.transtria.com/hkhc.php. The HKHC community partnerships generated changes in their environments and policies that will last long after grant funding has ended. Examples of healthy eating successes include the establishment of farmers' markets and community gardens, healthier vending policies, food policy councils, nutrition standards in childcare settings and afterschool programs, and urban agriculture policies. Active living achievements include the creation or enhancement of parks and playgrounds, new bicycle and pedestrian infrastructure, complete streets and shared-use policies, and physical activity standards in childcare settings and afterschool programs. In total, HKHC grantees secured more than $141 million in additional cash and in-kind support to augment funding from RWJF—a greater than 4:1 return on the foundation's investment.
Just as interesting and meaningful are the lessons and observations gleaned from the process of community change. HKHC validated a number of assumptions and confirmed some new ones. An issue as complex and challenging as childhood obesity prevention requires a comprehensive approach, sustained over a number of years. While childhood obesity may not be a community's leading concern, addressing the upstream causes of obesity has significant cobenefits that can attract and engage new partners. Strong, collaborative leaders who are passionate about healthy communities and have the ability to work effectively across sectors are essential. Learning networks can create a multiplier effect as practitioners, advocates, community members, and elected officials are exposed to best practices and peers in other communities. Likewise, local leaders can disseminate learning and help others within their regions and states progress as advocates for healthy communities. Ongoing technical assistance and consultation from a trusted, experienced coach can provide a useful perspective for local practitioners as well as for grant makers and others who are interested in learning from and scaling the work. And perhaps most importantly, consistent and shared engagement from committed leaders, residents, and youth who understand the power of community change and have a collective vision for a healthier future can build a legacy that lasts long after grant funding ends.
At this writing, we have started seeing signs of progress, with rates of childhood obesity leveling off and even declining in some parts of the country, including several HKHC communities. While we have a long way to go to ensure these trends continue, are sustained, and close the health disparities gap, we find many reasons to be hopeful and proud as we reflect on the successes and lessons learned from this partnership.