A tale of two obesCities: the role of municipal governance in reducing childhood obesity in New York City and London

A qualitative study on multisector activities to prevent childhood obesity in the municipality of Seinäjoki, Finland

Background

Multisector activities are needed to prevent childhood obesity due to its multifactorial background. The first aim was to identify the activities that had been undertaken for obesity prevention and deduce their main targets. Second, we analyzed the public health policy approaches (upstream, midstream, and downstream) which were followed. Finally, we studied the perception of interviewees regarding their sectors’ roles in implementing the local obesity program.

Methods

Deductive content analysis was used to analyze semi-structured interviews with 34 key professionals (from seven administrative sectors) who had participated in multisector health promotion during 2009–2016 and five representatives of other core parties.

Results

Several midstream and upstream activities were targeted at making physical activity (PA) and healthy eating (HE) integral parts of children’s lifestyle. One long-term strategy was to create environments for PA accessible to every inhabitant and build and renovate the interiors and yards of schools and day-care centers. The healthiness of meals was increased progressively. In addition to midstream and upstream activities, as a downstream activity, an intervention targeting children at risk of obesity was implemented. The impact of management on the activities was considerable; childhood obesity prevention was included in the city strategy and systematically coordinated at the highest managerial level. Altogether, various sectors operated efficiently to promote obesity-preventing lifestyles; however, not all (important) sectors recognized their role in the multisector process.

Conclusion

Most of the activities to guide children towards obesity-preventing lifestyles were either at the midstream or upstream level. Among the latter, considerable work is aimed at creating opportunities to practice PA and making it a natural part of the daily life. The aim of familiarizing children with lifestyles that include PA and HE was shared across sectors, including sectors that had not yet acknowledged their role in obesity prevention. Strong support from city management and systematic coordination of the activity are important factors that contribute to the engagement of several administrative sectors in working towards a shared aim, such as the prevention of childhood obesity.

Municipal health promotion programs: is childhood obesity a concern at local level in Portugal?

Health promotion programs, targeted at distinct health outcomes such as childhood obesity, at local level are increasingly used worldwide. Therefore, there is a need to better understand the role of local governments (municipalities) as key public health promoters namely in the prevention of obesity in children. We aimed to provide some input regarding this issue in Portugal. First, we identified health-enhancing programs promoted by Portuguese municipalities in which children could participate. Then, we conducted a document analysis to provide clues about how municipalities conceptualized child health by retrieving information on which topics the programs were focused in, or acted upon, and identifying which socio-ecological model levels were addressed (or not) by each program. The 77 identified programs were promoted by 30 of the 308 Portuguese municipalities and only 11 programs addressed childhood obesity. Most programs focused in the individual health determinants and provided limited information which disabled its deeper analysis. Portuguese municipalities seem to disregard their potential as public health promoters. Childhood obesity is a major public health concern at national (and global) level but the same does not emerge locally. Municipalities are the closest government entities to the population, and it is their responsibility to ensure the population's quality of life, by addressing the social determinants and the physical environments. Therefore, municipalities should acknowledge health in their actions and delineate health improvement programs considering current evidence, specifically in the case of childhood obesity prevention that besides being a health problem in itself, is a risk factor for non-communicable diseases.

Barriers and facilitators to implementing a healthier food outlet initiative: perspectives from local governments

OBJECTIVE

Local governments have integral roles in contributing to public health. One recent focus has been on how local governments can impact community nutrition by engaging food service outlets to improve their food offer. The Healthier Catering Commitment (HCC) is an initiative where London local governments support takeaways and restaurants to meet centrally defined nutrition criteria on their food options. Using the case of HCC, the current study aims to provide (1) practical learnings of how local governments could facilitate and overcome barriers associated with implementing healthy food service initiatives in general, and (2) specific recommendations for enhancements for HCC.

DESIGN

Key informant, semi-structured interviews were conducted with local government staff involved in HCC, exploring barriers and facilitators to HCC implementation in food businesses. A thematic analysis approach was used, with results presented according to a logic pathway of ideal implementation in order to provide practical, focused insights.

SETTING

Local governments implementing HCC.

PARTICIPANTS

Twenty-two individuals supporting HCC implementation.

RESULTS

Facilitators to implementation included flexible approaches, shared resourcing and strategically engaging businesses with practical demonstrations. Barriers were limited resources, businesses fearing negative customer responses and low uptake in disadvantaged areas. Key suggestions to enhance implementation and impact included offering additional incentives, increasing HCC awareness and encouraging recruited businesses to make healthy changes beyond initiative requirements.

CONCLUSIONS

In order to facilitate the implementation of healthy food initiatives in food outlets, local governments would benefit from involving their environmental health team, employing community-tailored approaches and focusing on supporting businesses in disadvantaged areas.

Development and implementation of a local government survey to measure community supports for healthy eating and active living

The ability to make healthy choices is influenced by where one lives, works, shops, and plays. Locally enacted policies and standards can influence these surroundings but little is known about the prevalence of such policies and standards that support healthier behaviors. In this paper, we describe the development of a survey questionnaire designed to capture local level policy supports for healthy eating and active living and findings and lessons learned from a 2012 pilot in two states, Minnesota and California, including respondent burden, survey sampling and administration methods, and survey item feasibility issues. A 38-item, web-based, self-administered survey and sampling frame were developed to assess the prevalence of 22 types of healthy eating and active living policies in a representative sample of local governments in the two states. The majority of respondents indicated the survey required minimal effort to complete with half taking < 20 min to complete the survey. A non-response follow-up plan including emails and phone calls was required to achieve a 68% response rate (versus a 37% response rate for email only reminders). Local governments with larger residential populations reported having healthy eating and active living policies and standards more often than smaller governments. Policies that support active living were more common than those that support healthy eating and varied within the two states. The methods we developed are a feasible data collection tool for estimating the prevalence of municipal healthy eating and active living policies and standards at the state and national level.

Obesity Prevention in a City State: Lessons from New York City during the Bloomberg Administration

Objective

To illuminate the key components of multi-sector reform to address the obesogenic environment in New York City during the administration of Mayor Michael Bloomberg from 2002 to 2013, we conducted a case study consisting of interviews with and a critical analysis of the experiences of leading decision makers and implementers.

Method

Key informant interviews (N = 41) conducted in 2014 were recorded, transcribed, coded, and thematically analyzed. Participants included officials from the Health Department and other New York City Government agencies, academics, civil society members, and private sector executives.

Results

Participants described Mayor Bloomberg as a data-driven politician who wanted to improve the lives of New Yorkers. He appointed talented Commissioners and encouraged them and their staff to be bold, innovative, and collaborative. Multiple programs spanning multiple sectors, with varied approaches and targets, were supported. This study found that much of the work relied on loose coalitions across City Government, with single agencies responsible for their own agendas, some with health co-benefits. Many policies were implemented through non-legislative mechanisms such as executive orders and the Health Code. Despite support from academic and some civil society groups, strong lobbying from industry and an unfavorable media led to some reforms being modified, legally challenged or blocked completely, particularly food environment modifiers. In contrast, reforms of the physical environment were described as highly consultative across and outside government and resulted in slower but more sustained reform.

Conclusion

The Bloomberg administration was a “window of opportunity” with the imprimatur of the executive to progress a long-term, multi-faceted obesity prevention strategy, which has successfully reversed childhood trends. Through the involvement of external researchers and the extensive use of empirical data from a wide range of participants, this study offers a unique insight into the ways in which this was achieved. While some of the aspects of the reforms in New York City are unique to that setting at that time, there are important lessons that are transferable to other urban settings. These include: strong and consistent leadership; a commitment to innovative approaches and cross-sectoral collaboration; and a context to support and encourage this approach.

Implementation conditions for diet and physical activity interventions and policies: an umbrella review

BACKGROUND

This umbrella review aimed at identifying evidence-based conditions important for successful implementation of interventions and policies promoting a healthy diet, physical activity (PA), and a reduction in sedentary behaviors (SB). In particular, we examined if the implementation conditions identified were intervention-specific or policy-specific. This study was undertaken as part of the DEterminants of DIet and Physical Activity (DEDIPAC) Knowledge Hub, a joint action as part of the European Joint Programming Initiative a Healthy Diet for a Healthy Life.

METHODS

A systematic review of reviews and stakeholder documents was conducted. Data from nine scientific literature databases were analyzed (95 documents met the inclusion criteria). Additionally, published documentation of eight major stakeholders (e.g., World Health Organization) were systematically searched (17 documents met the inclusion criteria). The RE-AIM framework was used to categorize elicited conditions. Across the implementation conditions 25 % were identified in at least four documents and were subsequently classified as having obtained sufficient support.

RESULTS

We identified 312 potential conditions relevant for successful implementation; 83 of these received sufficient support. Using the RE-AIM framework eight implementation conditions that obtained support referred to the reach in the target population; five addressed efficacy of implementation processes; 24 concerned adoption by the target staff, setting, or institutions; 43 referred to consistency, costs, and adaptations made in the implementation process; three addressed maintenance of effects over time. The vast majority of implementation conditions (87.9 %; 73 of 83) were supported by documents referring to both interventions and policies. There were seven policy-specific implementation conditions, which focused on increasing complexities of coexisting policies/legal instruments and their consequences for implementation, as well as politicians' collaboration in implementation.

CONCLUSIONS

The use of the proposed list of 83 conditions for successful implementation may enhance the implementation of interventions and policies which pursue identification of the most successful actions aimed at improving diet, PA and reducing SB.

State and municipal innovations in obesity policy: why localities remain a necessary laboratory for innovation

Municipal and state governments are surging ahead in obesity prevention, providing a testing ground for innovative policies and shifting social norms in the process. Though high-profile measures such as New York City's soda portion rule attract significant media attention, we catalog the broader array of initiatives in less-known localities. Local innovation advances prevention policy, but faces legal and political constraints-constitutional challenges, preemption, charges of paternalism, lack of evidence, and widening health inequalities. These arguments can be met with astute framing, empirical evidence, and policy design, enabling local governments to remain at the forefront in transforming obesogenic environments.

The role of urban food policy in preventing diet-related non-communicable diseases in Cape Town and New York

OBJECTIVES

Cities are important settings for production and prevention of non-communicable diseases. This article proposes a conceptual framework for identification of opportunities to prevent diet-related non-communicable diseases in cities. It compares two cities, Cape Town in South Africa and New York City in the United States, to illustrate municipal, regional, national and global influences in three policy domains that influence NCDs: product formulation, shaping retail environments and institutional food practices, domains in which each city has taken action.

STUDY DESIGN

Comparative case study.

METHODS

Critical analysis of selected published studies and government and non-governmental reports on food policies and systems in Cape Town and New York City.

RESULTS

While Cape Town and New York City differ in governance, history and culture, both have food systems that make unhealthy food more available in low-income than higher income neighborhoods; cope with food environments in which unhealthy food is increasingly ubiquitous; and have political economies dominated by business and financial sectors. New York City has more authority and resources to take on local influences on food environments but neither city has made progress in addressing deeper social determinants of diet-related NCDs including income inequality, child poverty and the disproportionate political influence of wealthy elites.

CONCLUSIONS

Through their intimate connections with the daily lives of their residents, municipal governments have the potential to shape environments that promote health. Identifying the specific opportunities to prevent diet-related NCDs in a particular city requires intersectoral and multilevel analyses of the full range of influences on food environments.

Stakeholder perceptions of obesity-prevention strategies: a comparison of geographically diverse rural counties

Understanding barriers and facilitators to strategies directed at obesity-prevention policy change, particularly in rural, southern US counties where obesity is more prevalent, is important so that strategies deemed most winnable can be pursued. As such, community stakeholders and policy makers were interviewed using the Centers for Disease Control and Prevention's Common Community Measures for Obesity Prevention Assessment in 2 rural, geographically diverse regions of North Carolina. Stakeholder interviews revealed many similarities despite population differences and unique geographic challenges to each region. In both Western and Eastern North Carolina, strategies involving increasing opportunities for physical activity were deemed the most winnable, whereas strategies incentivizing businesses to locate in underserved areas and limiting advertisements of unhealthy food and beverages were deemed the least winnable. Differences among Western and Eastern North Carolina regions revolved around zoning, geographic constraints, and topographically influenced local food strategies. These findings add to the literature by systemically identifying similarities and differences among geographically diverse rural communities.

Ethics, equality and evidence in health promotion Danish guidelines for municipalities

AIM

The Danish National Board of Health has expressed its commitment to social equality in health, evidence-informed health promotion and public health ethics, and has issued guidelines for municipalities on health promotion, in Danish named prevention packages. The aim of this article is to analyse whether the Board of Health adheres to ideals of equality, evidence and ethics in these guidelines.

METHODS

An analysis to detect statements about equity, evidence and ethics in 10 health promotion packages directed at municipalities with the aim of guiding the municipalities towards evidence-informed disease prevention and health promotion.

RESULTS

Despite declared intentions of prioritizing social equality in health, these intentions are largely absent from most of the packages. When health inequalities are mentioned, focus is on the disadvantaged or the marginalized. Several interventions are recommended, where there is no evidence to support them, notwithstanding the ambition of interventions being evidence-informed. Ethical considerations are scanty, scattered and unsystematically integrated. Further, although some packages mention the importance of avoiding stigmatization, there is little indicating how this could be done.

CONCLUSIONS

Including reduction of health inequalities and evidence-informed and ethically defendable interventions in health promotion is a challenge, which is not yet fully met by the National Board of Health. When judged from liberal ethical principles, only few of the suggested interventions are acceptable, i.e., those concerning information, but from a paternalistic view, all interventions that may actually benefit the citizens are justified.

Engaging municipalities in community capacity building for childhood obesity control in urban settings

BACKGROUND

Reducing rates of child obesity requires an approach that transcends the medicalization of overweight. Family practice doctors and public health professionals need to work with other sectors to establish comprehensive approaches to obesity reduction.

OBJECTIVES

This study compares the approaches of three cities with different health and political systems (Lisbon, London and New York City) to promoting effective action to decrease child obesity.

METHODS

Using a comparative case study approach, participant observers in three intersectoral municipal collaborative on child obesity describe their challenges and accomplishments.

RESULTS

Municipal governments made child obesity a policy priority and coordinate efforts in different sectors. Public health provided relevant information on population characteristics and scientific evidence for decision-making, family practice monitored children's growth and assisted families to adopt healthy behaviors. These sectors, together with university-based researchers, also played an advocacy role, addressing inequalities, alerting the public and policy makers about damaging products or risky situations, and regulating private interests that threaten well-being, e.g., the food and beverage industry that promotes unhealthy products. Local, national and global networks of health providers, municipal agencies and researchers have helped to diagnose problems, coordinate action across sectors and levels, share and evaluate successes and failures, translate evidence into practice and promote social cohesion.

CONCLUSIONS

These cities have developed common approaches and face similar challenges in reducing high rates of child obesity, suggesting that it may be possible for cities in different parts of the world to learn from each other and thus accelerate progress.

Engaging tribal leaders in an American Indian healthy eating project through modified talking circles

Frequently used in the American Indian (AI) community and proven to be a valuable tool in health research, a talking circle is a method used by a group to discuss a topic in an egalitarian and nonconfrontational manner. Using community-based participatory research, a modified Talking Circle format was developed for engaging tribal leaders in an American Indian Healthy Eating Project in North Carolina. The culturally informed formative research approach enabled us to garner project support from 7 tribes, as well as insights on developing planning and policy strategies to improve access to healthy eating within each of the participating communities.