Policy%20

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Policy Nutrition

• Example Obesity
• Conceptual Frameworks
• Kingdon Policy Model
• IOM Obesity Prevention Organizing Framework

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What is Policy?
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Policy Websters

• Wise, expedient, or prudent conduct or management
• A principle, plan, or course of action, as
  pursued by a government, organization,
  individual, etc.

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Policy Making Websters

• The act or process of setting and directing the
  course of action to be pursued by a government,
  business, etc.

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Examples of Policies
State County MPO/RDC City
Legislation
Ordinance
Resolution
Tax Ordinance
Internal Policy
Plans
Design Manual
From Thunderhead Alliance Complete Streets Report
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Why do we need policy?
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Levels of Influence in the Social-Ecological Model
Structures, Policies, Systems Local, state,
federal policies and laws to regulate/support
healthy actions
Institutions Rules, regulations, policies
informal structures
Community Social Networks, Norms, Standards
Interpersonal Family, peers, social networks,
associations
Individual Knowledge, attitudes, beliefs
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Intervention Categories with Strong Evidence of
Effectiveness for the 10 greatest Achievements in
Pubic Health From IOM report Preventing
Childhood Obesity, 2005
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Community Wide Campaigns School based intervention Mass media strategies Laws and regulations Reducing costs to patients
Vaccination X X X X
Motor vehicle safety X X X X
Safer work places X X
Control of infectious disease X X X X
Decline in deaths from CHD and stroke X X X
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Community Wide Campaigns School based intervention Mass media strategies Laws and regulations Reducing costs to patients
Safer and healthier foods X X X X X
Healthier mothers and babies X X X X
Family Planning X X X
Water Fluoridation X
Recognition of tobacco as a health hazard X X X
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Kingdon JW. Agendas, Alternatives, and Public
Policies. 2002
Participants The Streams Agenda
Setting Alternative Specification Coupling the
Streams/ Windows
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Participants
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National Policy Participants

• President
• Members of congress
• Civil servants
• Lobbyists
• Journalists
• Academics
• Others

Basics
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Kinds of Participants

• Visible those who receive press and public
  attention high level electeds and their
  appointees, the media, political parties, etc.
• Affects the agenda
• Hidden academic specialists, career
  bureaucrats, congressional staffers
• Affects the choice of alternative solutions

Basics
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Policy Entrepreneurs

• Willing to invest resources in return for future
  policies
• Can be elected officials, career civil servants,
  lobbyists, academics, journalists
• Entrepreneurs
• Highlight problem indicators to dramatize problem
• Push for one kind of problem definition or
  another invite electeds to see for themselves
• Soften up by writing papers, giving testimony,
  holding hearings, getting press coverage, meeting
  endlessly..

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The streams
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Problems
Policy Proposals
Politics
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Problems
Policy Proposals
Politics
Legislation or Change in Policy
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3 streams of processes

• Problem recognition
• Policies proposal formation
• Politics

Basics
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Problems

• Why do some problems get attention?
• Indicators large magnitude or change
• Focusing event disaster, crisis, personal
  experience
• Feedback about existing programs evaluation,
  complaints, etc.

Agenda Setting
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Problem Recognition is Key

• Policy entrepreneurs invest resources
• Bringing their conception of problems to
  officials attention
• Convincing officials to see the problem the way
  they want it to be seen

Agenda Setting
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Google Hits for Obesity
1/29/05 2/20/07
Obesity 8,650,000 31,100,000
Obesity and New York Times 214,000 932,000
Obesity and Wall Street Journal 49,300 386,000
Obesity and Seattle Times 13,100 91,700
Obesity and CBS 97,100 863,000
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Decisions about Problem Recognition

• Made through persuasion
• Use indicators to argue that conditions should be
  defined as problems
• Argue that proposals meet tests of feasibility or
  value acceptability

Agenda Setting
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Y O U R  T I M E / H E A L T HThe Year of
ObesityOur perennial interest in losing weight
became a national obsession in 2004By MICHAEL D.
LEMONICK
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Politics

• Developments in the political arena are powerful
  agenda setters.
• National mood
• New administrations
• New partisan/ideological distributions in
  congress
• Interest groups that press (or fail to press)
  demands on government

Agenda Setting
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Political Decisions

• Consensus is built by bargaining
• Trading provisions for support
• Adding elected officials to coalitions by giving
  concessions
• Compromising from ideal positions to those that
  will gain wider acceptance
• National mood and elected officials more
  important than interest groups for political
  decisions

Agenda Setting
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Agenda Setting
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Agenda Setting

• Agenda list of subjects to which officials are
  paying some serious attention at any given time

Basics
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Obesity 'a threat' to U.S. security Surgeon
general urges cultural shift Kim Severson,
Chronicle Staff Writer Tuesday, January 7, 2003
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Alternative Specification

• Narrows the large set of possible alternatives to
  that set from which choices are actually made.

Basics
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Alternative Specification

• Alternatives are generated and narrowed in the
  policy stream and by
• Hidden participants Loosely knit communities of
  academics, researchers, consultants, career
  bureaucrats, congressional staffers, analysts who
  work for interest groups who
• Float ideas, criticize each other works, hone
  ideas, recombine ideas

Alternative Specification
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Generation of Policy Alternatives

• Generation of policy alternatives analogous to
  natural selection
• Order developed from chaos
• Criteria include
• Technical feasibility
• Congruence with values
• Anticipation of future constraints (budget,
  public acceptability, politicians receptivity)

Alternative Specification
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2001
The Surgeon General's Call to Action to Prevent
and Decrease Overweight and Obesity
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• Ensure daily, quality physical education for all
  school grades. Currently, only one state in the
  country -- Illinois -- requires physical
  education for grades K-12, while only about one
  in four teenagers nationwide take part in some
  form of physical education. 
• Ensure that more food options that are low in fat
  and calories, as well as fruits, vegetables,
  whole grains, and low-fat or non-fat dairy
  products, are available on school campuses and at
  school events. A modest step toward achieving
  this would be to enforce existing U.S. Department
  of Agriculture regulations that prohibit serving
  foods of minimal nutritional value during
  mealtimes in school food service areas, including
  in vending machines. 
• Make community facilities available for physical
  activity for all people, including on the
  weekends.  
• Create more opportunities for physical activity
  at work sites. 
• Reduce time spent watching television and in
  other sedentary behaviors. In 1999, 43 percent of
  high-school students reported watching two hours
  of TV or more a day. 

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• Educate all expectant parents about the benefits
  of breast-feeding. Studies indicate breast-fed
  infants may be less likely to become overweight
  as they grow older. 
• Change the perception of obesity so that health
  becomes the chief concern, not personal
  appearance. 
• Increase research on the behavioral and
  biological causes of overweight and obesity.
  Direct research toward prevention and treatment,
  and toward ethnic/racial health disparities. 
• Educate health care providers and health
  profession students on the prevention and
  treatment of overweight and obesity across the
  lifespan.

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Preventing Childhood Obesity Health in the
Balance
IOM, 2005
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Federal Government

• Establish an interdepartmental task force and
  coordinate federal actions
• Develop nutrition standards for foods and
  beverages sold in schools
• Fund state-based nutrition and physical-activity
  grants with strong evaluation components
• Develop guidelines regarding advertising and
  marketing to children and youth by convening a
  national conference
• Expand funding for prevention intervention
  research, experimental behavioral research, and
  community-based population research strengthen
  support for surveillance, monitoring, and
  evaluation efforts

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State and Local Governments

• Expand and promote opportunities for physical
  activity in the community through changes to
  ordinances, capital improvement programs, and
  other planning practices
• Work with communities to support partnerships and
  networks that expandthe availability of and
  access to healthful foods

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State and Local Education Authorities and Schools

• Improve the nutritional quality of foods and
  beverages served and sold in schools and as part
  of school-related activities
• Increase opportunities for frequent, more
  intensive, and engaging physical activity during
  and after school
• Implement school-based interventions to reduce
  children's screen time
• Develop, implement, and evaluate innovative pilot
  programs for both staffing and teaching about
  wellness, healthful eating, and physical activity

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Softening-up

• Policy Entrepreneurs push for consideration in
  many ways and in many forums.
• Most proposed alternatives have long gestational
  period
• Recombination (coupling of already familiar
  elements) is more effective than mutation (wholly
  new forms).

Alternative Specification
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National Alliance for Nutrition and Activity
NANA promotes within the legislative and
executive branches of government a better
understanding of the importance of healthy
eating, physical activity, and obesity control to
the nation's health and health-care costs. One of
the primary goals of NANA is to cultivate
champions for nutrition, physical activity, and
obesity prevention in Congress and federal
agencies. Efforts include supporting effective
education programs, advocating adequate funding
for programs, and promoting environmental changes
that help Americans eat better and be more active.
http//cspinet.org/nutritionpolicy/nana.html
NANA is made up of more than 300 organizations.
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NANA Priorities

• Model local school wellness policies
• Strengthen national school lunch and other child
  nutrition programs
• Strengthen national and state nutrition, physical
  activity and obesity programs

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POLICY OPTIONS to promote nutrition and
activity Nutrition Labeling on Menus/Menu Boards
at Chain Restaurants Decrease Marketing of
Low-Nutrition Foods to Children Improve School
Foods Increase Physical Activity in Schools
Support Physical Activity through Transportation
Policy Promote Fruit and Vegetable Intake
Increase Resources for Nutrition and Physical
Activity Programs (including Soft Drink Taxes)
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Lives of the Streams

• The three streams have lives of their own.
• Problems are recognized and defined
• Policy proposals are developed according to their
  own incentives and selection criteria and are
  often waiting for a problem or political event
  they can be attached to
• Political events flow along on their own
  schedule

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Coupling the Streams

• The probability of rising on the agenda is
  increased if all 3 streams are joined
• Partial couplings between 2 streams are less
  likely to result in policy changes

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Problems
Policy Proposals
Politics
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Problems
Policy Proposals
Politics
Legislation or Change in Policy
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Window

• Window of opportunity open when policy advocates
  can push their solutions
• Advocates can wait for problems to float by
  that they can attach their solutions to or wait
  for the political stream to be advantageous.
• Windows do not stay open long.

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Entrepreneurs Take Advantage of Open Windows

• Can make the critical couplings when policy
  windows open.
• Bring resources to the fray
• Bring claims to a hearing
• Political connections and negotiating skills add
  to ability to move policy forward
• Sheer persistence is essential

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Organizing Framework for Public Health
Interventions(IOM, Preventing Childhood Obesity,
2005)

• The information environment
• Access and opportunity
• Economic factors
• The legal and regulatory environment
• Prevention and treatment programs
• The social environment

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Information Environment Opportunities

• Health ed campaigns and other persuasive
  communication
• Require product labeling
• Restrict harmful or misleading advertising

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Access and Opportunity

• Community environment
• Restrict access like we have for tobacco?
• School environment

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Economic Factors

• Government has power to tax and spend
• Taxes on calorie dense, low nutritional quality
  foods?
• Incentives or subsidies for fruits and vegetables?

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Legal and Regulatory Environment

• Pubic health law is one of 8 emerging themes
  identified by IOM as important to the future of
  pubic health training. Three components
• Laws
• Regulation
• Litigation

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State Nutrition and Physical Activity Legislative
Database http//apps.nccd.cdc.gov/DNPALeg/
2001 2002 2003
Nutrition bills introduced 88 58 174
Nutrition bills enacted 32 15 35
Physical Activity Bills introduced 167 148 240
Physical activity bills enacted 28 33 55
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State Nutrition and Physical Activity Legislative
Database http//apps.nccd.cdc.gov/DNPALeg/
2004 2004 2005 2005 2006 2006
All States WA State All states WA All States WA
Nutrition bills introduced 172 8 280 4 220 1
Nutrition bills enacted 28 2 55 0 38 1
Physical Activity Bills introduced 214 8 340 6 273 6
Physical activity bills enacted 50 1 72 6 47 2
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State Nutrition Legislation Enacted 2001-2006
Category Bills
Assistance Programs 12
Cafeteria Meals/Food Service (schools) 49
Nutrition Education 46
Farmers Market 9
Liability 22
Access to Obesity Treatment Services 13
Grocery Store/Food Market 0
Labeling (Ephedrine) 1
Restaurant (all about liability) 5
Worksite (tax credits for certain benefits) 1
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SB5436 - 2004

• Requires state school directors convene advisory
  committee to develop model policy on access
  nutritious foods and development, appropriate
  exercise. Policy to address nutritional content
  of foods and beverages and the availability and
  quality of health, nutrition, and physical
  education curricula. SPONSOR Kohl-Welles

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SB6601 - 2004

• No distributor, manufacturer or seller of food
  and non-alcoholic beverages will be held liable
  for claims resulting from weight gain, obesity or
  related health conditions due to long-term
  consumption of a product. SPONSOR Brandland,
  Companion Bill HB2994

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HB1254 - 2005

• In regards to a specialized "Share the Road"
  license plate. Proceeds beyond costs of
  implementation will be used towards contracting
  with a qualified nonprofit organization to
  promote bicycle safety and awareness education in
  communities throughout Washington. The
  organization must promote bicycle safety and
  awareness education in communities throughout
  Washington. The Washington state traffic safety
  commission shall establish a program for
  improving bicycle and pedestrian safety, and
  shall cooperate with the stakeholders and
  independent representatives to form an advisory
  committee to develop programs and create public
  private partnerships which promote bicycle and
  pedestrian safety. Sponsor Wood

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HB 1413 and SB 5396- 2005

• Relates to expanding the criteria for habitat
  conservation programs, sets forth funding and
  guides the the interagency committee for outdoor
  recreation. Defines trail as a means public ways
  constructed for and open to pedestrians,
  equestrians, or bicyclists, or any combination
  thereof, other than a sidewalk constructed as a
  part of a city street or county road for
  exclusive use of pedestrians. Not less than
  twenty percent of appropriations for habitat
  programs must be used for the renovation, or
  development of trails. Sponsor Dunshee Companion
  bill SB5396

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SB 5186 - 2005

• Provides for county and city plans, wherever
  possible, to include urban planning approaches
  that promote physical activity. Transportation
  planning in cities, towns, and counties should
  incorporate policy and infrastructure changes
  that promote non-motorized transit. State
  agencies applying for loans or grants must have
  incorporated elements in their plans that
  increase access to walking and biking in their
  communities. Superintendent of Public Instruction
  to promote adoption of school-based curricula and
  policies that provide quality physical education
  for all students. Sponsor Franklin

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SB 6003 - 2005

• Relating to commute trip reduction tax credit.
  Offered to employers and property owners who are
  taxable and provide financial incentives to their
  own or other employees for ride sharing, for
  using public transportation, for using car
  sharing, or for using nonmotorized commuting
  before July 1, 2013, are allowed a credit against
  taxes payable. Sponsor Jacobsen

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SB6091- 2005

• Relating to funding and appropriations for
  transportation. Sponsor Haugen

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SB6197 - 2006

• Creates the Governor's Interagency Council on
  Health Disparities to create an action plan and
  statewide policy to include health impact reviews
  that measure and address other social
  determinants of health that lead to disparities
  as well as teh contributing factors of health
  care that can have broad impacts on improving
  status, health literacy, physical activity, and
  nutrition. SPONSOR Franklin

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Regulation

• If the tobacco experience is any guide, it is
  likely that the food companies will act just
  enough t o avoid government regulation..to date
  companies have been much more comfortable with
  educational campaigns emphasizing personal
  responsibility and the need for increased
  physical activity, than proposing major policy or
  structural change.

IOM, Preventing Childhood Obesity, 2005
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Regulatory Options

• FDA has authority to enforce laws about labeling
  and false claims, not to deal with nutritional
  adequacy.

IOM, Preventing Childhood Obesity, 2005
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Litigation

• Powerful tool for tobacco, gun violence, lead
  paint
• Initial attempts at fast food litigation have
  been less than successful
• Future is unclear
• Several states have passed legislation aimed at
  prohibiting lawsuits against food and beverage
  manufactures for obesity-related health problems.
• Documents obtained through discovery could damage
  the public's perception of food companies.

IOM, Preventing Childhood Obesity, 2005
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The Social Environment Policy and Norms for
Health Promotion

• Norms are
• standards or models
• Voluntary or expected way of behaving
• Norms drive policy
• Policy can also drive norms

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Steps that previous efforts have taken before
norms on the role of Government changed(Kersh
and Marone, 2002)

• Social disapproval
• Medical science
• Self-help
• Demonize the user
• Demonize an industry
• Mass movement
• Interest group action

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Evaluation of Policy Change

• Policy development should include plans for
  policy evaluation
• Process evaluation Was the policy actually
  carried out?
• Outcome Did the policy change have the intended
  outcome?