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Local policies related to restaurant menu labeling: Barriers, facilitating factors, and the role of local health departments

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Barriers, facilitating factors, and the role of local health departments A thesis presentation by Elizabeth Payne, MPH candidate Committee: Donna Johnson, PhD, RD (Chair) – PowerPoint PPT presentation

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Title: Local policies related to restaurant menu labeling: Barriers, facilitating factors, and the role of local health departments


1
Local policies related to restaurant menu
labeling Barriers, facilitating factors, and
the role of local health departments
  • A thesis presentation by
  • Elizabeth Payne, MPH candidate
  • Committee
  • Donna Johnson, PhD, RD (Chair)
  • Barbara Bruemmer, PhD, RD
  • University of Washington, Nutritional Sciences
  • February 25th, 2011

2
Introduction
  • Obesity and related chronic disease rates
    increasing despite decades of targeted individual
    level interventions1-7
  • Obesity approach that mirrors successful
    anti-tobacco work, focusing on environmental
    factors 1, 3, 8
  • Nutrition policies based on anti-tobacco work
  • change social norms to make unhealthy food less
    accessible, less desirable and less acceptable1

3
IntroductionThe restaurant food environment
  • Meals away from home increased with obesity
    rates, now account for 1/3 of calories
    consumed9,10
  • 3/4 of restaurant visits at fast-food other
    chain restaurants11
  • Fast-food associated with higher intake of
    calories saturated fat, higher BMI, increased
    risk of obesity, type 2 diabetes1-3
  • Hard to accurately estimate calories in
    meals15-17
  • Not voluntarily reducing portion sizes, or
    displaying nutrient information4-6

4
IntroductionMenu Labeling Policies
  • The restaurant industry has opposed attempts to
    regulate the provision of nutrition
    information7,8
  • Menu labeling legislation passed in many
    jurisdictions, NYC 1st in 2008 12,18, 20
  • In March 2010, passage of the Patient Protection
    and Affordable Health Care Act, made restaurant
    menu labeling federal law.18, 19

5
BackgroundThe effect of menu labeling unclear
Experimental studies Milich et al. 1976 Workplace cafeteria, modest effect
Experimental studies Cinciripini et al. 1984 University cafeteria, mixed effect
Experimental studies Mayer et al. 1987 Workplace cafeteria, no effect
Experimental studies Balfour et al. 1996 Workplace cafeteria, modest effect
Experimental studies Yamamoto et al. 2005 Adolescents, mixed effect
Experimental studies Burton et al. 2006 Mail survey, mixed effect
Experimental studies Harnek et al. 2008 Adolescents, modest effect
Experimental studies Roberto et al. 2010 RCT, significant effect
Studies in real-world situations Bassett et al. 2007 Subway restaurants, effect in some customers
Studies in real-world situations Dumanovsky et al. 2010 NYC post enforcement, 2-fold increase in reported use
Studies in real-world situations Elbel et al. 2009, 2011 NYC regulation, no effect
Studies in real-world situations Pulos et al. 2010 Pierce Co voluntary program, minimal effect
Studies in real-world situations Finkelstein et al. 2011 King Co regulation, no effect
6
Background1st menu labeling policy
  • Lessons from NYCs menu labeling
    regulation12,20,29
  • 1st passed 2006
  • BOH criticized for not including NYSRA
  • Big push-back from NYSRA
  • 1st lawsuit decided in NYSRAs favor
  • Revised regulation went into effect 2008
  • 2nd NYSRA lawsuit not successful

7
Background
3 counties in Washington State working to
improve the restaurant food environment using
different approaches to menu labeling
King
Pierce
Thurston
8
BackgroundThree menu labeling cases in
Washington State
  • 2nd jurisdiction to pass menu labeling
    regulation
  • Intense push-back from industry
  • Regulation went into effect Jan 2009
  • 1st study to date no impact on calories
    ordered30

King County
9
BackgroundThree menu labeling cases in
Washington State
  • SmartMenu voluntary, non-chain restaurants
  • Help w/ menus recipes, free nutrient analysis,
    advertising
  • 2 studies to date small impact on purchasing
    behavior31, incredibly resource intensive32

Pierce County
10
BackgroundThree menu labeling cases in
Washington State
  • NEA showed need for focus on kids meals
  • 2009 RWJF HE grant
  • Collaborative study w/ local franchise owner
  • 1st phase- add healthier items
  • 2nd phase- test marketing

Thurston County
11
Need for current study
  • Need more studies on policy process
  • Public health literature on policy development
    often lacks theoretical framing33, 34
  • Applying theories of policy change to real-world
    policy situations needed35
  • Opportunity to study interactions between local
    public health departments and industry

12
Study Purpose Aims
  • To determine the roles, relationships and
    barriers related to working with restaurants and
    to identify strategies that health departments
    can use to facilitate nutrition policy
    development.

13
Study Purpose Aims
  • Specific Aims
  • Examine the interactions among restaurant owners,
    the Washington Restaurant Association, and local
    health departments to determine political and
    contextual factors that are barriers or enablers
    to the provision of nutrition information in
    restaurants
  • Describe the role of local health departments in
    developing and implementing restaurant nutrition
    information policies

14
The Advocacy Coalition Framework
15
The Advocacy Coalition Framework
16
The Advocacy Coalition Framework
  • Relatively Stable Parameters
  • system-wide parameters, stable over long periods
    of time
  • Governmental, legal and economic systems
  • Attributes of policy issue that are enduring and
    frame the policy debate36

17
The Advocacy Coalition Framework
18
The Advocacy Coalition Framework
  • External Events
  • dynamic factors external to the policy subsystem
  • changes in
  • socioeconomic conditions
  • technology
  • public opinion
  • political power (i.e. critical elections)
  • and the impact of other policy decisions
    subsystems36

19
The Advocacy Coalition Framework
20
The Advocacy Coalition Framework
21
The Advocacy Coalition Framework
Policy Subsystem comprised of the set of actors
involved with a given policy issue subsystem
actors form advocacy coalitions based on shared
values or beliefs36
22
The Advocacy Coalition Framework
23
The Advocacy Coalition Framework
Policy Subsystem- beliefs overarching driver for
policy actors Deep core beliefs - deeply held
personal beliefs, unchangeable Policy core
beliefs - fundamental policy positions of an
advocacy coalition, resistant to change Secondary
beliefs - related to the administration and
implementation of policy, most susceptible to
change36
24
The Advocacy Coalition Framework
  • Policy-oriented learning
  • occurs as a result of
  • direct challenge to an advocacy coalition
    (opponent challenge or external events)
  • accumulated experience, the so-called
    enlightenment function of policy process that can
    take up to a decade or more36

25
Methods
  • Multiple-case, replication study design
  • Data collection
  • written documentation from each county
  • key informant interviews
  • public health employees, Board of Health members,
    restaurant owners, Washington Restaurant
    Association representative
  • Interviews by phone, and oral consent was
    obtained using procedures approved by the
    University of Washington Institutional Review
    Board in January 2010.
  • The interviews ranged from 20 to 100 minutes in
    length and were recorded to ensure complete data
    collection

26
Methods
Plus one interview with a Washington Restaurant
Association Representative
27
MethodsData Analysis
  • Interview transcripts reviewed for key concepts
    and themes
  • Coding structure developed, based on the
    constructs of the ACF
  • Atlas.ti qualitative data analysis software used
    to code and manage data37
  • Coded data explored both within and across cases,
    looking for patterns and linkages
  • Data from each case used to assess the fit to the
    Advocacy Coalition Framework

28
Results
  • Constraints and resources (barriers/enablers)
  • Relatively stable parameters
  • External events
  • Policy subsystem
  • Relationships
  • Beliefs- role of Health Department

29
Results- constraints and resources
  • Respondents in each county
  • obesity rates something must be done
  • increases in meals eaten away from home made
    restaurant environment an obvious choice
  • Its a given that restaurants are focused on
    profit, public health objectives often at odds

Relatively Stable Parameters Obesity rates Increased eating away from home Restaurants need to be profitable
30
Results- constraints and resources
  • ACF Construct King Pierce Thurston

External Events
King Political climate BOH Precedent policy in NYC Support from national organization
Pierce Economic recession Political climate BOH Industry push-back in NYC, King Co Federal legislation
Thurston Funding Political climate BOH Industry push-back in NYC, King Co
31
Results- constraints and resources
  • ACF Construct King Pierce
  • BOH played central role in development of menu
    labeling policy, very progressive, leader in
    obesity prevention for years
  • The BOH voted unanimously in favor of the menu
    labeling regulation
  • The BOH was united. We knew that there were
    objections coming forward from the restaurant
    industry. But we had very strong support from the
    community, and from the BOH and from the medical
    community. - BOH member

King Political climate/BOH Precedent policy in NYC Support from national organization
32
Results- constraints and resources
  • ACF Construct King Pierce Thurston
  • NYC regulation, lawsuits helped guide policy
    development
  • Support of Center for Science in the Public
    Interest (CSPI)
  • Respondents recalled that after Margo Wootan,
    Nutrition Policy Director at CSPI presented on
    menu labeling, moved forward with policy
  • So she gave that presentation and everything
    kind of changed. The BOH was quite taken with the
    information and presentation, so was David
    Flemming, Public Health Director and from there
    we started having meetings- PH employee

King Political climate/BOH Precedent policy in NYC Support from national organization
33
Results- constraints and resources
  • ACF Construct King Pierce
  • Economy in recession
  • Health department impacted
  • restructuring, loss of champion
  • requiring restaurants to take on additional costs
    would not play well politically

Pierce Economic recession Political climate/BOH Industry push-back in NYC, King Co Federal legislation
34
Results- constraints and resources
  • BOH generally supportive and progressive
  • Supportive of voluntary approach, less
    enthusiastic about the idea of passing menu
    labeling regulation
  • One BOH member described a BOH that is
    politically divided, with some members who are
    pretty conservative and the less government the
    better types

Pierce Economic recession Political climate/BOH Industry push-back in NYC, King Co Federal legislation
35
Results- constraints and resources
Pierce Economic recession Political climate/BOH Industry push-back in NYC, King Co Federal legislation
  • Concern about objections from industry was one
    reason didnt want to mandate menu labeling
  • BOH members described how the push-back from
    industry in King County and New York City helped
    shape their approach
  • Number one we didn't want to lose the support of
    industry. We also wanted to make sure that we
    werent seen as pushing something on the
    restaurants that the public would see as
    invasive. - BOH member

36
Results- constraints and resources
  • Large-scale cut backs, re-prioritization of
    tasks and time for new leadership to get up to
    speed on the work
  • By the time ready to move forward with policy,
    preemption by federal legislation was a concern

Pierce Economic recession Political climate/BOH Industry push-back in NYC, King Co Federal legislation
37
Results- constraints and resources
  • 100 grant funded budget
  • Robert Wood Johnson Foundation (RWJF) grant to
    work
  • on healthy kids menus- research project

Thurston Funding Political climate/BOH Industry push-back in NYC, King Co
38
Results- constraints and resources
  • Respondents described the BOH as very committed
    to
  • using a collaborative approach with industry
  • Advancing a menu labeling policy was never even
    on the
  • agenda
  • No way would our county commissioners or BOH
    basically support something like that menu
    labeling regulation either. It wouldnt even be
    an option here to do something like that. That's
    not how they look at it - PH employee

Thurston Funding Political climate/BOH Industry push-back in NYC, King Co
39
Results- constraints and resources
  • BOH is 3 county commissioners, elections every 4
    years
  • Thurstons population just over 250,000. One
    public health
  • employee said,
  • Even though were a pretty Democratic
    county, we have a mix- a very Republican mix,
    lots of military families lots of different
    things like that. You have to really be careful
    in terms of thinking through how people look at
    individualism and individual choices.- PH
    employee

Thurston Funding Political climate/BOH Industry push-back in NYC, King Co
40
Results- constraints and resources
  • Cautious in approach, didnt want WRA to think
    they were going for a policy
  • But, may have changed industry receptivity
  • when you call and say I want to talk about this
    healthy dining thing- they get right back to you!
    Which makes it easier to partner, have the
    conversation. What was going on in other places
    got their attention and they were more attentive
    to our discussions. - PH employee

Thurston Funding Political climate/BOH Industry push-back in NYC, King Co
41
Results- Policy Subsystem
  • ACF Construct King Pierce
  • HEAL- Healthy Eating Active Living

Policy Subsystem Actors
King Leaders Board of Health, Public Health DirectorStaff HEAL, environmental healthIndustry restaurant owners (chains), WRACommunity health organizations advocatesCenter for Science in the Public Interest
Pierce Leaders BOH, former HD manager, PH Director Staff HEAL, environmental health Industry owners (local, non-chain), WRA
Thurston Leaders BOH, senior HD leadership Staff HEAL, environmental health Industry local franchise owner, WRA
42
Results- Policy Subsystem
  • Advocacy Coalitions in King Co
  • 1st Phase contentious relationships
  • BOH members invite WRA to meetings, vote to pass
    regulation
  • WRA, restaurant owners feel ignored
  • There was no real open dialogue. It wasn't what
    do you guys think? It was this is what we want
    to do and we hope that youll get onboard. Well,
    how do we have the ownership, or how do we feel
    like this is the best way to go if we cant even
    comment? - WRA rep

43
Results- Policy Subsystem
  • Advocacy Coalitions in King Co
  • 2nd Phase changing relationships
  • HD starts stakeholder process
  • restaurant owners initially angry
  • Trust, relationships get re-built
  • By the time of last stakeholder process, went
    from a really adversarial, angry first meeting to
    people who were hugging goodbye, saying how good
    they felt about the process. - PH employee

44
Results- Policy Subsystem
  • Advocacy Coalitions in King Co
  • 2nd Phase changing relationships
  • WRA attempts statewide preemption
  • BOH fights for the policy
  • WA state legislature- compromise

45
Results- Policy Subsystem
  • WRA representative describes the process,
  • We ran a statewide labeling bill that would have
    created a consistent statewide standard. King
    County fought us the whole way through that, and
    so unfortunately that was very combative there.
    Through that though we got them to come to the
    table and sit down with us and talk through our
    concernsAnyway, out of that fortunately we
    turned into a relationship that became sort of
    positive. We continued working with them and we
    found an ordinance that our folks could agree
    upon.

46
Results- Policy Subsystem
  • Advocacy Coalitions in King Co
  • Evidence of policy-oriented learning
  • Result of direct challenge by opposing coalition
  • Pro-menu labeling coalition compromised on
    implementation strategies (secondary beliefs) in
    order to preserve the regulation (policy core
    beliefs)
  • We had to compromise, but we got the
    menu-labeling regulation so it was worth it! -PH
    employee

47
Results- Policy Subsystem
Policy Core Beliefs appropriate role of government, priority of regulation
King Unanimously endorsed the belief that it is an appropriate role of public health to use regulation when necessary to protect the health of the community
Pierce BOH and PH employees less united on the question of using regulation, role of PH to educate vs. role is to safeguard public health and regulation is appropriate
Thurston Role of public health is to ensure that people have choices, regulation only as last resort
48
Results- Policy Subsystem
  • ACF Advocacy coalitions form around shared
    policy core beliefs
  • Evidence of shared beliefs that favor public
    health policy development in King County
  • Beliefs in Pierce less unified
  • Thurston unified around beliefs that favor
    partnerships with industry rather than public
    health policy development

49
Results- key factors King Co
  • Policy Subsystem
  • Advocacy coalitions formed around shared policy
    beliefs
  • Pro-menu labeling coalition beliefs role of HD
    is to protect PH and use regulation as needed
  • Opposition coalition beliefs (data not shown)
    freedom from regulation priority
  • Evidence of policy oriented learning
  • Relatively stable parameters
  • obesity rates
  • meals away from home
  • restaurants need to be profitable

Constraints Resources
  • External events
  • Political climate supportive of regulation
  • NYC precedent policy
  • Support from CSPI

50
Results- key factors Pierce Co
  • Relatively stable parameters
  • obesity rates
  • meals away from home
  • restaurants need to be profitable
  • Policy Subsystem
  • HD restructure, loss of champion, new leadership
  • BOH, PH employees different beliefs about role
    of PH, use of regulation
  • BOH more supportive of voluntary program
  • Policy development process stalled by threat of
    preemption, new priorities

Constraints Resources
  • External events
  • Economic recession
  • Political climate not supportive of regulation
  • Push-back from industry in NYC, King CO
  • Federal legislation

51
Results- key factors Thurston Co
  • Relatively stable parameters
  • obesity rates
  • meals away from home
  • restaurants need to be profitable
  • Policy Subsystem
  • Grant driven funding limits strategies
  • BOH favors collaboration with industry
  • Role of HD is to provide choice
  • Policy development was never an option

Constraints Resources
  • External events
  • Funding
  • Political climate not supportive of regulation
  • Push-back from industry in NYC, King CO

52
Discussion
  • Results of this research suggest that key factors
    influencing the policy process include
  • the need for industry to be profitable
  • the impact of economic conditions both on
    industry and health departments
  • the presence of precedent or role-model policy
  • support from national groups
  • the political climate
  • leadership support for policy

53
DiscussionUsefulness of ACF
  • Findings are constant with other studies that
    have examined public health policy process and
    found the political climate, economic context and
    leadership to be important factors5, 7, 12
  • The Advocacy Coalition Framework has primarily
    been used to examine and describe anti-tobacco
    policy processes, but given the interest in using
    tobacco policy to develop new approaches to
    obesity using the ACF to understand what happened
    in each of these three counties is especially
    relevant33

54
Discussion
  • Implications for practice
  • Building an advocacy coalition aligned around
    shared beliefs helps weather inevitable push-back
    from policy opponents
  • Leadership support, policy-mentors and the
    support of other (national) organizations are key
  • Prepared policy advocates will look for favorable
    conditions and be ready to move on policy when
    the context shifts in their favor

55
Discussion
  • Limitations
  • Key informants who were not interviewed
  • Differences in interview process (King)
  • Time frame too short to see policy changes as
    described by ACF

56
Discussion
  • Recommendations for future research
  • Apply ACF to other policy initiatives for
    improving the food environment in restaurants
    (sodium, SSB)
  • Will likely involve many of the same factors and
    policy subsystem actors
  • Changes over time, decade or more

57
Conclusion
  • Environmental and policy approaches are an
    important part of the public health response to
    reduce obesity and related chronic diseases.
  • Food environments that make healthy food more
    accessible, acceptable and desirable make it
    easier for individuals to make healthy choices.
  • The menu labeling policy process in King County
    demonstrates that local health departments can
    advance public health aims through the formation
    of advocacy coalitions, making the most of the
    constraints and resources of the policy subsystem
    and building on leadership support.

58
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60
Acknowledgments
  • Thesis Committee
  • Donna Johnson
  • Barb Bruemmer
  • Steering Committee
  • Kirsten Frandsen- Tacoma-Pierce County Health
    Dept
  • Deborah Allen- Thurston County Public Health
    Social Services Dept
  • Donna Oberg- Public Health-Seattle King County
  • Molly McNees- Public Health-Seattle King County
  • Friends and family

61
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