Introduction I. The Obesity Epidemic and Social Determinants of Health A. Rising Obesity Rates B. How the Social Determinants of Health Drive Obesity Disparities II. Using Law and Policy to End the Obesity Epidemic A. The Power to Regulate Public Health B. How the Affordable Care Act Supports Community-Based Obesity Prevention Strategies 1. The Affordable Care Act Establishes a National Prevention Strategy . 2. The Affordable Care Act Creates a Prevention and Public Health Fund 3. The Affordable Care Act Strengthens the Community Benefit Requirements for Nonprofit Hospitals C. State and Local Policy to Address Obesity . 1. Addressing Disparities Through Obesity Prevention Policy III. A Policy Framework for Addressing Disparities in Obesity Rates A. Evidence for Policymaking B. The Framework . 1. General or Universal Policies 2. Policies Based on Demographic Groups a. Policymaking Based on Race or Ethnicity . b. Policymaking Based on Income 3. Policies Based on Health Indicators or Unhealthy Products and Practices a. Policies Based on Health Indicators b. Policies Targeted at Practices and Products that Cause Negative Health Conditions 4. Policymaking Based on Neighborhood a. Policies that Encourage Integration C. Unintended Consequences Conclusion
South Los Angeles is a low-income African-American and Latino neighborhood with disproportionately high obesity rates--35% of the adult population is obese, compared to 22% in Los Angeles County as a whole. (1) South Los Angeles was once a thriving middle class African-American neighborhood, but it became impoverished when, as in many cities, jobs and higher-income residents left the urban core. (2) Fast food restaurants were abundant, yet residents had no access to a grocery store. (3) In 2008, residents decided to change that by pushing the Los Angeles city council to place a moratorium on new fast food restaurants in the neighborhood, while also offering a package of incentives to attract a new grocery store. (4) The incentive package successfully attracted at least four grocery store developments to the neighborhood. (5) The targeted strategy was considered controversial by some because it focused on an African American and Latino neighborhood and was perceived by outsiders as paternalistic. (6) But what many didn't realize is that neighborhood groups supported the fast food restrictions. (7)
The South Los Angeles example illustrates the challenges urban communities across the United States face. Obesity is one of many chronic conditions that people of color experience disproportionately, putting them at greater risk for many serious preventable diseases such as diabetes, heart disease and cancer. (8) In this Article, we focus on the national obesity epidemic and discuss ways to use policy interventions, such as those that improved access to healthy food in South Los Angeles, to reduce disparities experienced by underserved communities and specific racial and ethnic groups.
We start with an overview of the obesity epidemic and its underlying causes--the social determinants of health. Next, we review the role of government in ending the obesity epidemic, including a discussion of Affordable Care Act (ACA) provisions that support population-level interventions to address the epidemic. Enterprising local and state governments have been leading the way on obesity prevention for a decade. A number of provisions within the ACA, however, provide an unprecedented opportunity to "scale up" obesity prevention activities. The ACA specifically calls on policymakers in states and localities to identify strategies to reduce obesity rates among populations bearing the brunt of the epidemic, namely people of color and low-income people. Finally, we propose a framework for developing disparities-focused obesity prevention policies. Policymakers at all levels of government can use this tool to help them decide how to allocate their limited resources to policies that directly address disparities in obesity rates. This framework is intended to support communities and states that will be heeding the federal government's call to action on obesity and health disparities.
I. THE OBESITY EPIDEMIC AND SOCIAL DETERMINANTS OF HEALTH
Social and environmental factors, such as the proliferation of fast food restaurants or lack of safe sidewalks for walking, are different in different communities; these disparate conditions lead to worse health outcomes for people of color and people with low incomes. (9) In this section, we provide an overview of the obesity epidemic in the United States and how social and environmental factors increase the risk for obesity and related chronic diseases.
A. Rising Obesity Rates
Since the late 1970s, adult obesity rates (10) have more than doubled, (11) while the rates for children and adolescents have tripled in the same time period. (12) Currently, 17% of children and adolescents in the nation are obese, a proportion that has risen significantly since the 1980s. (13) Approximately 36% of adult men and women in the U.S. are obese, representing a significant increase in a twelve-year period for men, but not women. (14) Although adult obesity rates are still rising, the rate of increase is not as rapid as in previous decades. (15)
Obesity is a national concern because it is a risk factor for cancer, diabetes, and a host of other debilitating and potentially deadly diseases. (16) Obese children are more likely to have asthma, diabetes, joint problems, and even early signs of heart disease. (17) They are also more likely to be obese adults. (18) Obesity puts adults at greater risk for an even longer list of diseases and conditions, including cancer, liver disease, and stroke. (19) Obese children are teased and bullied and, as a result, experience anxiety, depression, and many other mental health problems. (20) Obese adults are less likely to be hired and promoted and make less money than their healthy weight peers. (21) Treatment of obesity and related diseases costs the United States healthcare system an estimated $147 billion annually, which translates to approximately $1,400 in additional spending per obese person compared to people with healthy weights. (22) Obesity costs employers over $30 billion annually in lost productivity. (23)
Some groups bear a greater burden of obesity than others. The most striking obesity disparities are those between whites, African Americans, and Latinos. Twenty-one percent of Latino children and adolescents and 24% of African-American children and adolescents are obese, while only 14% of white children are obese. (24) Disparities also exist for adults, with 50% of African Americans and 38% of Latinos being obese, compared to 35% of whites. (25) Variation in obesity rates across incomes is more complex. (26) With some exceptions, obesity rates generally decline as income increases for both adults and children. (27) Some studies, however, have found that obesity rates rise with income for African American and Latino men, which may reflect different body size norms for men or a greater likelihood that lower-income men have physically-demanding jobs. (28)
B. How the Social Determinants of Health Drive Obesity Disparities
Why have obesity rates increased so dramatically in the past several decades, and why do they vary among different racial and economic groups? Social and environmental conditions, ranging from income to race to air quality and more, are considered to be the main factors determining health outcomes. (29) These factors are known as the social determinants of health. (30) This concept has existed in global health circles for decades, (31) but has only recently been applied systematically in the United States. (32)
The emphasis on social determinants of health in obesity prevention stems from a growing body of research linking socioeconomic status, race, and ethnicity to obesity. The differences in health outcomes according to these factors are known as health disparities. (33) By most measures, health improves consistently as socioeconomic status (i.e., income and education) rises, for nearly all racial and ethnic groups. (34) For example, infant mortality rates decline as maternal education levels increase for African American and white babies. (35) Life expectancy, diabetes rates, and heart disease rates all improve as incomes rise for African Americans, Latinos, and whites. (36)
Some health disparities experienced by people of color can be explained by differences in socioeconomic status. (37) But others cannot. Despite the positive health effects of education and income for all races and ethnicities, African Americans and Latinos at the highest education and income levels still have worse health than whites at the same, and even lower, education and income levels. (38) For example, infants born to African American mothers with at least a college degree have lower birth weights than infants born to white mothers without a high school degree. (39) Latinos born in the United States and African Americans have worse health than whites, even when researchers control for socioeconomic status. (40) Long-term disadvantage and discrimination likely explain these health disparities, although researchers are still exploring exactly how these experiences lead to poor health. (41)
Neighborhood quality is another social determinant of health that is intertwined with socioeconomic status, race, and ethnicity. (42) African Americans often live in highly segregated neighborhoods that have high levels of poverty and few amenities that promote health. Even higher-income African Americans are more likely than lower-income whites to live in neighborhoods with low-quality housing and limited services. (43) Residents of segregated areas often do not have access to recreational facilities or safe streets where they can be physically active. (44) Communities of color also have fewer supermarkets and more fast food restaurants. (45) Parks and grocery stores are health-promoting infrastructure and are associated with lower rates of obesity, diabetes, and other chronic conditions and diseases, but are not available in every neighborhood. (46) In the next sections, we consider how policy interventions can address the social determinants of health and reduce health disparities in the obesity epidemic.
II. USING LAW AND POLICY TO END THE OBESITY EPIDEMIC
The obesity prevention movement (47) has focused on changing environments that promote over-consumption of junk food and physical inactivity, with the goals of changing social norms (48) about personal nutrition and physical activity and, ultimately, reducing obesity rates. (49) These strategies--which are based on lessons learned from the earlier tobacco control movement (50)--use policy to change the context of people's lives, to "make healthy options the default choice, regardless of education, income, ... or other societal factors." (51) As the Centers for Disease Control and Prevention (CDC) director Thomas Frieden notes, "the defining characteristic of [these strategies] is that individuals would have to expend significant effort not to benefit from them." (52)
Traditionally, public health practitioners used education campaigns to inform the public about health threats and how to avoid them, with the goal of stopping risky behaviors, like unprotected sex and smoking. (53) For example, during the early years of the tobacco control movement, public health advocates learned that aggressive media campaigns showing the harms of smoking were more effective when combined with policy strategies that changed the environment by making it more difficult to smoke in public. (54) Namely, tobacco taxes and clean indoor air laws both have been shown to decrease smoking rates by ten percent or more by themselves, whereas media campaigns are most effective when combined with tobacco control policies. (55) There is growing evidence that this approach--known as social norm change (56)--is a more successful, and cost-effective, approach to reducing premature death and chronic disease rates. (57) In the obesity prevention context, local laws that prevent fast-food restaurants from being sited near schools, (58) limit portion sizes of sugary drinks, (59) and facilitate the development of grocery stores (60) serve to nudge people into thinking differently about the unhealthy social norms related to food that we have adopted as a society.
Before the passage of the ACA, a number of related but distinct obesity prevention efforts incorporated this social norm change approach. In 2010, for example, the CDC provided significant funding and technical assistance to communities developing obesity prevention initiatives through its Communities Putting Prevention to Work (CPPW) initiative, (61) which was funded by the American Recovery and Reinvestment Act of 2009 (commonly referred to as ARRA or the Stimulus Act). (62) ARRA set aside $650 million to be administered by the CDC for the purpose of carrying out "evidence-based clinical and community-based prevention and wellness strategies ... that deliver specific, measurable health outcomes that address chronic disease rates." (63) Through the CPPW initiative, the CDC funded fifty local communities across the country to implement prevention strategies to reduce obesity and tobacco use. (64) In total, the funded communities had more than 55 million residents, expanding the reach of prevention policy to a substantial proportion of the U.S. population. (65) At the same time, First Lady Michelle Obama's Let's Move campaign raised the profile of childhood obesity exponentially. (66)
Philanthropic initiatives targeting obesity predated the CPPW program. In particular, the Robert Wood Johnson Foundation (RWJF) identified childhood obesity prevention as one of its major program areas in the early 2000s and has since committed significant resources to reversing the alarming trends in obesity rates. (67) Recognizing the toll the epidemic takes on communities of color, RWJF has invested heavily in supporting public health research that focuses on these communities. (68) Thus, communities moved to action by the funding and vision articulated in the ACA have a firm foundation to build upon.
The obesity prevention movement's work, whether privately or publicly funded, centers around five broad goals, as described in a 2012 report by the Institute of Medicine (IOM), a prestigious national nonprofit that provides independent, evidence-based advice to governmental bodies (69):
* Increasing physical activity levels;
* Increasing access to healthy foods and beverages and limiting access to unhealthy foods and beverages;
* Changing messages about nutrition and physical activity, including limiting junk food marketing to children;
* Working with healthcare providers, insurers, and employers; and
* Improving nutrition and physical activity in schools.
As the IOM notes, this multi-faceted approach is necessary when addressing an epidemic like obesity, which is caused by many different external factors. (70) The laws and policies used to implement these goals address the role of environments (e.g., schools, neighborhoods, media) in the obesity epidemic. (71) For example, we know that people are more physically active when they have sidewalks. (72) Local policymakers can establish street design standards to ensure that safe sidewalks are available throughout the community to encourage residents to walk in their neighborhoods, increasing physical activity levels. (73)
In the next section, we provide a brief overview of the legal framework that regulates public health in the United States. This discussion is not meant to be a comprehensive discussion of the laws that govern public health in the United States. Rather, it serves to ground the later discussion of the ACA and the relationship between this landmark federal law and local obesity prevention policies.
A. The Power to Regulate Public Health
Most policy interventions designed to help people live, work, and play in healthier environments flow from the police power, which is the inherent authority of the state to protect and promote the health, safety, morals, and general welfare of the people. (74) Specifically, under the Tenth Amendment of the Constitution, "The powers not delegated to the United States by the Constitution, nor prohibited by it to the [s]tates, are reserved to the [s]tates respectively, or to the people." (75) As there is no federal police power enumerated in the U.S. Constitution, the police power resides with states. (76)
All states, to varying degrees, delegate their police power to local governments. (77) The ability to protect public health is a traditional function of the police power. (78) Thus states and many localities have the presumptive authority to pass public health laws. The laws typically address zoning, licensing, retail operations, and so on, and are generally subject to "rational basis review"--a legal standard that is very deferential to government actions. (79) The regulations need only bear a rational relationship to a legitimate government purpose. (80)
As states and localities explore how best to address their residents' needs related to their health and welfare under the police power, some of the most interesting policy innovations occur. Consequently, the initial impetus for action on a public health issue frequently comes from localities and states that want to be responsive to the needs of their communities. Massachusetts provides a relevant example of state-level policy innovation that led to federal action. In 2006, the state passed a law that transformed its healthcare system by expanding health insurance coverage to the state's uninsured population. (81) This law is widely regarded as the model for the ACA, although the federal law is much broader and includes a range of national initiatives that could not be contemplated under a single state's law. (82)
Although the federal government has no general police power, the enumerated powers that Congress and the president may exercise--such as Congress's ability to regulate interstate and international commerce--have been interpreted very broadly; (83) thus, there is often concurrent national and state regulation of public health. (84) Furthermore, the federal government uses its power to tax and spend to allocate resources to states and localities for public health activities. (85)
Health and Human Services (HHS) is the agency that oversees most of the programs that fund public health activities. HHS houses eighteen operating divisions, which include the CDC and the National Institutes of Health. (86) These national agencies have access to research and data that enable them to identify trends, share best practices, and coordinate efforts among states. (87) When confronting a national health threat like obesity, the federal government can use its resources to guide a national response by developing response plans, providing data to inform the response, and directing funding for state and local responses. (88) Armed with this funding and data, states and localities can implement plans and create policies that respond to the unique needs of their communities. As we explore later, the federal government established a national obesity prevention strategy through the ACA, recommending specific interventions based on the best available data and providing funding to states and communities to implement community-based interventions. This delegation of responsibilities reflects the importance of state and local control through the police power in public health policy development.
The ACA established a national framework that incorporates the obesity prevention goals identified above and supports the use of policy and law to change social norms and reverse the obesity epidemic. (89) It provides crucial national coordination of and funding for state and local responses. (90) Most importantly, it elevates health disparities as a problem of national concern that all states and localities should be addressing as part of public health practice. (91) In the next section, we delve into the specific ways that the ACA moves obesity prevention forward.
B. How the Affordable Care Act Supports Community-Based Obesity Prevention Strategies
The ACA, signed into law in 2010, represents the most significant regulatory overhaul of the United States healthcare system since the passage of Medicare and Medicaid in 1965. (92) Broadly speaking, it represents a sea change for the role of prevention in our healthcare system. Through the National Prevention Strategy and the Prevention and Public Health Fund, the federal government has now created and funded a national plan for prevention. The Strategy and the Fund identify obesity as a key national health threat.
As noted above, the federal government's power to protect public health comes primarily from the Commerce Clause of the U.S. Constitution, which states that Congress shall have the power "[t]o regulate Commerce with foreign Nations, and among the several States." (93) This power is reflected in the ACA provisions that increase access to health insurance; (94) it is also exercised in the law's groundbreaking provisions that provide robust funding for public health prevention. (95) In particular, for our purposes here, the ACA provides financial support to state and local governments that want to address the obesity epidemic, (96) as well as evidence-based interventions to improve nutrition and physical activity rates in communities. (97)
The ACA provisions that increase funding for population-based prevention efforts and articulate a vision of prevention as a national health priority hold the most promise for addressing disparities in obesity rates because of the broad impact these provisions can have. Thus, the discussion below focuses on three elements of the ACA that we believe are most relevant to addressing obesity rates in low-income communities of color.
1. The Affordable Care Act Establishes a National Prevention Strategy
The ACA establishes the National Prevention, Health Promotion, and Public Health Council (the "Council"), whose mandate is to provide federal coordination and leadership in prevention, wellness, and health promotion. (98) The Council is composed of the heads of seventeen federal agencies, including the Departments of Agriculture, Defense, and Education, and chaired by the Surgeon General. (99) The diversity of the agencies represented reflects the wide range of expertise needed to address the root causes of poor health at the population level.
In 2011, the Council developed a National Prevention and Health Promotion Strategy (the "Strategy"). (100) The Strategy lays out national priorities for wellness and prevention. (101) Although the concepts within the NPS are not particularly groundbreaking--most of the ideas have been implemented in one form or another by enterprising cities or states--the existence of the Strategy elevates the importance of prevention nationally and validates and coordinates these efforts. As Dr. Regina Benjamin, the United States Surgeon General, noted in her introduction:
The National Prevention Strategy will move us from a system of sick care to one based on wellness and prevention. It builds upon the state-of-the-art clinical services we have in this country and the remarkable progress that has been made toward understanding how to improve the health of individuals, families, and communities through prevention. (102)
The ACA requires that every year from 2010 to 2015, the Council must release an annual report to the President and Congress about the progress made in reaching the goals within the Strategy. (103)
The overarching goal of the Strategy is to increase the number of Americans who are healthy at every stage of life. It has four strategic directions: healthy and safe community environments; clinical and preventive services; empowered people; and the elimination of health disparities. (104) The strategic directions serve as guiding principles for priority areas, which include the promotion of healthy eating and active living, core obesity prevention approaches.
[FIGURE 1 OMITTED]
The Strategy makes a number of recommendations to promote healthy eating, including increasing access to healthy and affordable foods in communities. (106) Typically, the communities experiencing the highest obesity rates are those with high rates of poverty, limited healthy food outlets, and many fast-food restaurants. These neighborhoods are known as "food deserts", healthy food is readily available. (107) The Strategy highlights the Healthy Food Financing Initiative as an effective federal response to food deserts. (108) This initiative is a coordinated effort by the Departments of Treasury, Agriculture, and Health and Human Services to facilitate the construction of healthy food retail outlets and other projects that make healthy food available in high-poverty communities. (109) Different grant and loan programs within the three agencies provide financing and technical assistance to support the development of grocery stores and other outlets in underserved communities. (110) Additionally, the Strategy encourages state, tribal, local, and territorial governments to use their police power to help communities create healthy food environments by establishing zoning regulations that enable full-service supermarkets and farmers markets to locate in underserved neighborhoods, and by using zoning codes to discourage the disproportionately high availability of unhealthy foods in some communities. (111)
Land use policy, established by local governments under their police powers, also plays a critical role in the Strategy's active living recommendations. For example, the Strategy highlights the fact that "[p]hysical activity levels are lower in low-income communities and among children of color, due in part to people feeling unsafe in their communities. (112) One of its recommendations is that federal, state, and local community design guidelines should include features that encourage neighborhood safety, thereby increasing residents' willingness to be physically active outdoors. (113)
2. The Affordable Care Act Creates a Prevention and Public Health Fund
The ACA includes the first dedicated federal funding source for prevention and public health programs. The Prevention and Public Health Fund ("Fund") is designed to expand and sustain the necessary capacity to prevent disease, detect it early, manage conditions before they become severe, and provide states and communities the resources they need to promote healthy living. (114) Before now, there has never been dedicated funding of this magnitude for prevention activities. (115) This significant investment, which begins at $500 million per year and increases to $2 billion per year by 2022, will drastically improve and expand the capacity of public health efforts, saving thousands of lives and improving the health of many millions of Americans. (116) Although the Fund supports prevention initiatives at the federal and state level, the largest percentage of funding in 2011 and 2012--forty percent--went to local prevention activities. (117) This focus is in keeping with the strong emphasis on local control in public health prevention activities.
The Community Transformation Grant program (CTG), within the Fund, provides grants to state and local governments, community-based organizations, and tribes to implement and evaluate evidence-based community preventive activities aimed at reducing rates of chronic disease, addressing health disparities, and developing an evidence base for future prevention programming. (118) The CTG priorities overlap with the National Prevention Strategy, but the National Prevention Strategy is broader in scope. The CTG program prioritizes four areas: tobacco-free living; active living; healthy eating; and evidence-based quality clinical preventive services. (119)
3. The Affordable Care Act Strengthens the Community Benefit Requirements for Nonprofit Hospitals
The Affordable Care Act places new requirements on nonprofit hospitals. These requirements may lead nonprofit hospitals to focus more on community prevention efforts, rather than just providing healthcare.
Nonprofit hospitals account for more than half of all hospitals in the United States; therefore, they are important stakeholders in any attempt to improve health. (120) The new requirements under the ACA may provide an additional mechanism for funding community-based obesity prevention strategies. The Internal Revenue Service (IRS) requires that non-profit hospitals provide community benefits in order to maintain their favorable tax status. (121) The federal tax exemption is estimated to be as high as $21 billion annually. (122) Over the past decade, Congress has questioned whether nonprofit hospitals are providing adequate community benefit in exchange for the valuable tax exemption, both in terms of the quantity and type of community benefit provided. (123)
In response to these concerns, the ACA mandates a number of changes related to community benefits reporting that may provide opportunities to partner with hospitals to develop obesity prevention policy strategies. First, the ACA requires that every nonprofit hospital shall conduct a community health needs assessment (CHNA) at least once every three years in order to maintain their tax-exempt status. (124) Even before the passage of the ACA, many hospitals prepared CHNAs and developed community-based interventions; however, the ACA provisions ensure that this practice will become standard. A CHNA lays out the major health concerns of the community in which a hospital is located and typically provides information about how a hospital will address these concerns. Given the high rates of obesity in communities across the country, it is likely that many of these assessments will identify obesity or related conditions such as diabetes, heart disease, and strokes as priority areas for intervention. For example, the 2010 CHNAs of two large nonprofit hospitals in the two largest cities in the country (125)--New York Presbyterian Hospital in New York City and Cedars Sinai Hospital in Los Angeles--both identify obesity and related conditions in the top five health concerns in their respective communities. (126)
The ACA also requires that each nonprofit hospital create an implementation strategy for how it intends to meet the needs identified by its CHNA. (127) If a hospital does not adopt the implementation strategy and report to the IRS on how it is meeting the identified needs in a given year, it may face a $50,000 excise tax that year and every subsequent year of non-compliance. (128)
Changes by the IRS may support this new community prevention focus by nonprofit hospitals. In 2011, the IRS updated the instructions for nonprofit hospital reporting to state that "some community building activities may also meet the definition of community benefit." (129) The IRS stated that community-building activities include, but are "not limited to, efforts to support policies and programs to safeguard or improve public health, access to health care services, housing, the environment, and transportation." (130) Although the change to the IRS reporting form seems to suggest that nonprofit hospitals will be able to meet their community benefit obligations through community-based public health initiatives, it needs to clarify the meaning of "community-building activities." (131) Prominent public health experts have called on the IRS to clarify that it will give community benefit credit for evidence-based activities that fall within the four strategic directions of the National Prevention Strategy. (132) Given the importance of nonprofit hospitals in the healthcare sector and the billions of dollars that they must provide in community benefits, they could be an important leader in obesity prevention policy.
A number of the strategies highlighted in the recent CHNAs prepared by Cedar-Sinai and New York Presbyterian to address obesity rates are closely connected to policy interventions and provide examples to build upon. For instance, Cedar Sinai has put resources into health education programs in preschools and schools to address active living and healthy eating habits. (133) A hospital system like Cedar Sinai could further the impact of its interventions by partnering with local school districts to inform the development of school district wellness policies so that school district policy related to students' healthy habits reinforces the investments that Cedar Sinai is making through its health education programs.
New York Presbyterian has provided funding through its community benefit program for initiatives that focus on children's health and creating healthy school environments. (134) Funded coalitions working on issues related to student health have engaged, from time to time, in public policy activities. For example, staff testified at listening sessions hosted by the New York Council on Food Policy calling for policy changes that promote healthy foods in underserved neighborhoods; (135) staff also pushed for the passage of state legislation that addressed air quality near schools. (136) If all nonprofit hospitals incorporated public policy components into their community benefits' programs that address chronic diseases, the collective impact would be substantial.
In this section, we highlighted three key ACA provisions that provide unprecedented financial and strategic support for obesity prevention and health disparities interventions. Much of the policy development needed to support these interventions occurs at state and local levels. (137) These policies are the focus of the next sections of this Article.
C. State and Local Policy to Address Obesity
For over a decade, public health advocates have recognized the importance of state and local-level interventions to address the obesity epidemic. (138) State and local governments are implementing a variety of legal, policy, and voluntary strategies to change social norms and achieve obesity prevention goals. (139) These strategies define how public resources (time and money) are allocated, influence private decisions by individuals or businesses, or do both. Public resource policies determine, for example, where new parks are built, how streets are maintained, and what foods are in school vending machines. Obesity prevention policies that influence private decisions include sugar-sweetened beverage taxes, as well as zoning policies that allow farmers markets in residential neighborhoods or require developers to provide bicycle parking. (140)
As discussed earlier, these strategies can be organized into five broad goals of the obesity prevention movement. Below are examples of strategies being pursued at the state and local levels:
Goal Community/State example Increasing The North Carolina Department of Transportation is physical activity developing a Statewide Bicycle and Pedestrian Plan levels to identify ways the department can support bicycle and pedestrian infrastructure and to prioritize bicycle and pedestrian infrastructure projects. (141) Increasing Minneapolis, Minnesota adopted an ordinance that access to requires licensed grocery stores to stock specific healthy foods categories of staple foods that match the product and beverages mix stores are required to stock in order to accept federal Supplemental Nutritional Assistance Program benefits. (142) Changing Several school districts in suburban Denver messages about adopted school wellness policies that established nutrition and standards for foods that could be advertised in physical activity the schools. (143) Working with The state of Nebraska worked with its health healthcare insurance provider to reduce premiums for providers, employees and their families who enroll in a insurers, and wellness program and complete annual health employers screenings. The wellness program provides healthy lifestyle support, such as health coaching, to employees. (144) Improving The Pueblo of Jemez school district in New Mexico nutrition and implemented a policy requiring after-school physical activity programs to provide 45 minutes of physical in schools activity and a healthy snack each day. (145)
The exact mix of strategies necessary to decisively reduce obesity rates is still uncertain, (146) which means that policymakers must try new ideas and evaluate what works. Much of the innovation in public health policy occurs at the local level. (147) The Institute of Medicine has repeatedly recognized the leadership of local governments in the obesity prevention movement. (148) As the organization noted in a 2009 report,
Local governments are in a unique position to improve the health of their communities by advancing local policies that have an impact on the availability of healthy foods and places for physical activity and that also limit less healthy options. Local governments have jurisdiction over land use, food marketing, community planning, and transportation. (149)
Obesity prevention innovation at the local level requires local governments to have the authority to enact public health laws. Preemption has long been used to quash innovation at the local level. (150) Recently, the Mississippi legislature enacted a law intended to prevent local governments from passing laws that limit portion sizes of sugar-sweetened beverages. (151) This law was a direct response to New York City's groundbreaking portion size policy. (152) Preemptive laws, like the one in Mississippi, raise concern because the obesity prevention field is still evolving and thus requires evaluation of many different strategies. (153)…