Problem Addressed

• A growing epidemic: In 2007 and 2008, 33.8 percent of adults were obese, up from 30.5 percent 8 years earlier. In 2010, 63.8 percent of American adults were overweight or obese, and rates in California were only slightly lower (61.6 percent).^1,2 Rates of overweight and obese children have also risen; for example, the proportion of overweight California children in grades 5, 7, and 9 increased from 26.5 percent in 2001 to 28.1 percent in 2004.³
• Increased risk of illness, poor quality of life, and high health care costs: Obesity increases the risk of many costly health conditions that lower quality of life, including heart disease, diabetes, cancer, sleep apnea, and osteoarthritis. The average annual medical costs of obese individuals are more than $1,400 higher than those individuals with normal body weight; nationwide, these extra expenses add up to $147 billion in obesity-related costs each year.⁴ In California alone, overweight, obesity, and physical inactivity accounted for $41 billion in extra health care costs and lost productivity in 2006, nearly twice the level in 2000.⁵
• Failure of communities to encourage healthy behaviors: Overweight and obesity can be prevented and treated through healthy eating and regular physical activity, but the physical environment in many communities makes engaging in such behaviors difficult. Many neighborhoods lack grocery stores that sell healthful foods or safe places to get exercise. Instead, they have convenience stores and fast-food restaurants that offer high-fat, high-calorie foods (which tend to be less expensive than healthier choices), and often have lots of traffic, high crime, and few if any sidewalks, walking trails, or parks.⁶ As a result, residents are more likely to be obese and/or have chronic diseases. For example, Californians who live in areas where fast-food restaurants and convenience stores far outnumber grocery stories and produce vendors are more likely to become obese or have diabetes than those living in communities with healthier retail food options.⁷

Description of the Innovative Activity

• Awareness-building activities: Several HEAL activities promote awareness among city officials of the role of the physical environment in helping residents adopt more healthful behaviors, including the following:
  • Workshops and training: Over a 2-year period, HEAL staff conducted 27 training sessions to raise awareness of the obesity epidemic and the role of cities in addressing it. Most sessions have been held at League of California Cities events, which include special programs for new mayors and council members, a planner’s institute, and an annual conference that attracts leaders from the state’s 450 cities. Other sessions have been offered as online webinars or standalone events. In all cases, HEAL staff partner with city officials who demonstrate support for the program and participate as speakers. To date, representatives from nearly 275 cities have attended training sessions, which are ongoing. HEAL staff regularly check in with attendees to gauge their progress and offer additional support.
  • Educational materials: HEAL staff have published two articles on what cities can do to address the obesity epidemic for Western City magazine (a publication of the League of California Cities). The League's electronic newsletter and its many e-mail lists convey information about educational opportunities.
  • Face-to-face meetings with city officials: HEAL staff meet in person with local officials throughout the state to introduce the program and open a dialogue about each city’s needs and goals related to increasing quality of life for residents. So far, program staff have visited 120 California cities.
• Practical support for passing, implementing new policies: HEAL offers a variety of practical tools to assist city officials in adopting and implementing policies and resolutions designed to make it easier for residents to engage in healthier behaviors. These include a toolkit, online resources, and technical assistance. More details on each are provided below:
  • Toolkit: Available both online and in print, this kit includes a readiness assessment, fact sheets, and sample resolutions and policies to support residents in making healthier choices.
    • Readiness assessment: This three-question assessment determines what stage cities are in with respect to adopting new policies [i.e., whether they are still gathering information, ready to adopt a resolution that recognizes the importance of reversing the obesity trend, or prepared to adopt specific policies to create a healthier environment (such as zoning ordinances or business incentives)].
    • Fact sheets: A general fact sheet gives background on the obesity epidemic nationally and in California, while three others summarize how city policies can support residents in making healthy choices. Based on research from the California Center for Public Health Advocacy, these policy-related fact sheets cover three areas: land use, access to healthy foods, and employee wellness programs.
    • Sample resolution and policies: Recognizing that cities must decide for themselves what might work in their communities, these sample policies provide boilerplate language that can be tailored to fit a particular city’s needs. The policies offer a menu of policy options in the same areas covered by the fact sheets:
      • Land use: Sample policies cover support for walking and biking in city planning, equitable mixed-use and transit-oriented development, use of school property to promote physical activity, and use of vacant land to promote healthy eating. Examples include authorizing the creation of community gardens or new parks, increasing the number of locations available for farmers’ markets, requiring wider sidewalks, and improving street crossings to make the city more walkable.
      • Access to healthy food: Sample policies include targeting economic development, redevelopment, and planning resources to attract grocery stores; using zoning to protect and support farmers' markets and community gardens; limiting the number of fast-food restaurants near schools and playgrounds; and encouraging local restaurants to provide information on the calorie and fat content of menu items or to remove trans fats from recipes.
      • Employee wellness: Sample policies make it easier for city employees to get exercise or make other healthy choices. Options include letting workers take regular 10-minute exercise breaks, increasing the number of healthy options on cafeteria menus and in vending machines, and encouraging employees to take the stairs instead of the elevator.
  • Other online resources: In addition to the toolkit, the program Web site includes an interactive map that lets users click on HEAL cities to view resolutions or policies that have been adopted. In addition, monthly e-mail newsletters outline new developments, offer links to policies adopted by California cities, and describe grant opportunities to help cities reach their goals.
  • Technical assistance: After officials express interest in making changes, HEAL staff work with them to craft resolutions or policies that meet the city’s needs and goals. This technical assistance includes help with the following:
    • Identifying a local “champion”: Through training sessions and meetings, a local official generally emerges as a champion who can lead the effort and serve as the local liaison with HEAL staff.
    • Selecting two or three key goals: HEAL staff encourage local officials to focus on two or three achievable policy goals. Difficult economic times favor starting with resolutions that involve little or no cost, but nevertheless establish priorities and direction. For example, HEAL staff might work with cities to adopt a resolution urging city planners and parks personnel to “prioritize capital improvement projects to increase opportunities for physical activity in existing areas” or “expand community access to indoor and outdoor public facilities.” They might also work with city officials to map existing fast-food outlets, and then set limits on the issuance of future permits for such outlets in areas near schools or that already have many such establishments.
    • Attending local city council meetings: HEAL staff attend local city council meetings to help present proposed resolutions or policies, answer questions, and refine proposed language to make it acceptable to the city council.
    • Following up by e-mail and telephone: After a resolution passes, HEAL staff continue to support cities with its implementation and in developing new policies. These consultations generally take place by e-mail or telephone, although inperson meetings can be held as necessary.

References/Related Articles

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Innovator Disclosures

Results

• Many resolutions recognizing epidemic: To date, 78 California cities have passed resolutions recognizing the extent of the obesity epidemic in the State and the local community, with most of these resolutions setting out a roadmap for the adoption of specific policies in the future. These resolutions collectively contain commitments to establish 250 policies in the areas of land use, access to healthy food, and employee wellness. For example, with HEAL’s support, as of July 2012 75 cities committed to adopting an “instant recess” policy for city employees, which provides 1 10-minute physical activity break per day to city employees and a break during any meeting that lasts more than an hour.
• Many new policies: As of July 2012, 30 of the 78 cities passed HEAL resolutions and 2 additional cities have adopted 40 specific policies, including nutrition standards for food and beverages served and sold in city facilities, and programs and events to increase pedestrian and bicycle connectivity between residential neighborhoods, schools, and retail centers. Staff expect that more HEAL cities will pass resolutions and adopt specific policies.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Laying groundwork: Before officially launching the program, program staff spent 18 months conducting formative research, meeting with stakeholders, developing fact sheets, and strategizing about the best ways to achieve success.
• Conducting formative research: Staff conducted a 9-month survey of 480 cities to determine what policies they had already developed related to land use, access to healthy food, and employee wellness. They also interviewed 25 stakeholders representing a cross-section of California cities to discuss the challenges they have faced and success they have achieved. This research formed the basis for the sample policies, fact sheets, and other elements of the toolkit.
• Convening advisory group: HEAL invited the 25 stakeholders to form an advisory committee to guide the effort. This group gave feedback on the sample policies, including which seemed most achievable. Committee members also reviewed the fact sheets, helped develop training programs, and provided input on Web site design and program branding (including the HEAL logo).

Resources Used and Skills Needed

• Staffing: For the first 3 years, paid program staff included 2.5 full-time equivalent (FTE) staff. Since that time, 2 FTEs have staffed the program.
• Costs: The annual program budget totals $300,000, which covers staff compensation, travel expenses, computers, and other operating costs.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Develop strategic partnerships: As a long-established, nonpartisan group for cities, the League of California Cities brought credibility to the effort, with city officials being more willing to listen due to its involvement.
• Meet in person when possible: Although technology makes it easy to communicate over long distances, face-to-face sessions often prove more effective, particularly during the initial “getting-to-know-you” phase. Followup can be done by e-mail or telephone.
• Recognize uniqueness of each city: A one-size-fits-all solution will not work. City officials will be more willing to participate if they have time to explore the problem and remain free to adapt resolutions and policies to meet their city’s unique needs and strengths.
• Point to tobacco control effort as model: Local policies laid the framework for effective statewide programs and goals related to curbing tobacco use. Pointing to the success of this initiative can provide credibility and a precedent for the effort to curtail obesity.
• Align recommendations with credible sources: HEAL aligned its recommendations with those of well-known, well-respected organizations, including the Institute of Medicine, the Centers for Disease Control, the American Academy of Pediatrics, and the Robert Wood Johnson Foundation. This step made prospective participants more likely to support program goals.
• Adjust expectations to current climate: Program organizers originally expected that cities would adopt policies rather easily, based on the support shown by the 2004 and 2006 league resolutions. In a challenging economic climate, however, this expectation proved to be unrealistic. City officials suggested a two-step approach: First, cities would adopt resolutions underscoring the important role of cities in stemming the obesity epidemic and commit to pursue specific policy goals (rather than policies themselves) in the three key policy areas highlighted earlier. Next, HEAL staff would work with the cities to implement the policy goals.
• Focus on no- and low-cost policies: As recommended by its advisory committee, HEAL staff focused on ways to incorporate healthy choices through policies that did not require significant funds for program development. These policies can lay the groundwork for future projects, even in cities that presently lack funds for extensive new initiatives.
• Identify a champion in each city: A point person who believes in the project’s goals can help significantly in getting policy language adopted.

Sustaining This Innovation

• Build on success of initial cities: Program staff should help cities publicize their success and spread the word to others. For example, after hearing about HEAL’s initial accomplishments, representatives in other communities approached the organization seeking assistance in defining policy goals related to obesity prevention. Effective language used in early adopting cities can be replicated in other cities as well.
• Be willing and able to wear different hats: Depending on each city’s needs, staff may have to play the role of educator, facilitator, communicator, and/or catalyst.
• If possible, evaluate program impact on obesity rates: With funding from the California Endowment, the California Center for Public Health Advocacy plans to analyze data from 100 cities that have adopted policies to determine their impact on obesity rates. The cities will start collecting data in late 2011.

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