Healthy reform, healthy cities: using law and policy to reduce obesity rates in underserved communities.

• Author: Fry, Christine
• Position: II. Using Law and Policy to End the Obesity Epidemic C. State and Local Policy to Address Obesity 1. Addressing Disparities Through Obesity Prevention Policy through Conclusion, with footnotes, p. 1293-1321

1. Addressing Disparities Through Obesity Prevention Policy

   As noted above, obesity policies generally act by prioritizing public resources, influencing private decisions, or both. Obesity policy influences disparities through these same mechanisms. For example, local governments can reverse health disparities by prioritizing public resources to support healthy behavior on the part of those experiencing the negative effects of the disparity. An example appears in the context of crossing guards. Research shows that children who walk or bike to school experience lower rates of obesity than those who do not. (154) Crossing guards can make the experience of walking or biking to school safer (155) and can increase parents' willingness to allow children to walk or bicycle to school. (156) In Florida, crossing guards at intersections near schools are currently paid for by a state fund. (157) But in larger jurisdictions, like Miami-Dade County, the fund cannot cover the entire cost of a crossing guard and schools must close the funding gap or have fewer crossing guards than they need. Lower income schools in the City of Miami have particular difficulty closing this funding gap. (158) A change in state law would authorize the city to levy a surcharge on fines for school zone traffic offenses, enabling the jurisdiction to supply additional crossing guards to low-income neighborhoods and improve safety for children walking or biking to school. (159) This change in state law would give local jurisdictions a new potential source of revenue to support safer walks to school in low-income neighborhoods.

   Policies that influence private decisions can also affect disparities. Such policies generally create incentives for health-promoting activities or deterrents for disease-promoting activities. These incentives or deterrents can be for businesses or individuals. New York City offers tax and zoning incentives to grocery store owners who open or expand locations in food deserts, (160) addressing inequitable access to fresh fruits and vegetables. (161) Incentives such as these are intended to make neighborhoods with limited food access more attractive to business owners by decreasing the cost of development. (162) Other policies, like labeling menus with calorie counts and nutrition information, are intended to influence the behavior of individuals. (163)

   Policy change can also be a hybrid of these two categories, affecting both public and private actions. Taxing sugar-sweetened beverages to reduce their sale and consumption is an important obesity prevention strategy that affects both public and private actions. (164) Such taxes generally affect private behavior by increasing prices, thereby reducing consumption. (165) Sugar-sweetened beverage (SSB) taxes also affect public resources by generating revenue for the government. (166) A proposal in Vermont, for example, would have allocated one-third of the tax revenue raised to obesity prevention initiatives for low-income residents, including subsidies for fruit and vegetable purchases. (167)

   These tax proposals typically generate a strong reaction. Opponents of SSB taxes criticize them for being regressive, disproportionately hurting low-income people and people of color who can least afford it. (168) A regressive tax is one for which low-income people pay a higher percentage of their income than high-income people. (169) For instance, lower-income people spend a larger share of their income on food and beverages and consume more SSBs than their higher-income counterparts. (170) African Americans are more likely to be regular SSB drinkers. (171) Thus, opponents argue that a SSB tax would affect low-income people and people of color more than people who are wealthier and white. A similar argument was raised concerning tobacco taxes, but was successfully challenged by proponents, who pointed out that low-income people have a higher prevalence of smoking-related illnesses. (172) Likewise, SSB tax proponents argue that underserved communities and communities of color disproportionately bear the health burdens of SSB consumption. (173)

   Although there are signs of progress in reversing the epidemic, little progress has been made to eliminate, or even narrow, the health disparities experienced by low-income people and communities of color. (174) Disparities endure despite an overall flattening obesity rate trend. (175) For example, New York City recently saw a 6% drop in obesity rates for children in kindergarten through eighth grades. (176) Looking at the data more closely, however, the results are not as encouraging. Obesity rates for Latino and African-American students declined by 3% and 2%, respectively, while rates declined by 8% and 13% for Asian and white students, respectively. (177) Existing policy efforts do not appear to be sufficient to eliminate obesity disparities. In the next Part, we present a framework for identifying disparities-focused policies to improve nutrition, increase physical activity, and reduce obesity rates.

   3. A POLICY FRAMEWORK FOR ADDRESSING DISPARITIES IN OBESITY RATES

   As discussed above, policy change strategies are crucial for reducing obesity rates and eliminating disparities. Enterprising states and communities have tried a variety of approaches to addressing obesity disparities, with limited success. Federal policy now explicitly promotes and provides funding for public health interventions intended to reverse disparities, (178) which means that more and more jurisdictions around the country will be looking for ways to improve health equity among their residents.

   But the path to health equity via policy change is not clear. (179) Although health policy experts have explored health equity policy for decades, (180) their research generally has not focused on detailed implementation recommendations. In consequence, few resources exist to guide policymakers in drafting disparities-focused obesity prevention policies. (181) Policymakers and the public health community need information about how to craft obesity prevention policy to decrease disparities. (182)

   The task of identifying such tactics is not simple. There has been limited evaluation of obesity prevention policies themselves, and practitioners are still learning about how to effectively address obesity, much less how to use policy to address disparities. (183) Individual communities may report successful reduction of disparities, (184) but success may follow implementation of multiple obesity prevention strategies, making it difficult to pinpoint the most effective strategy or combination of strategies. Without rigorous evaluation, it is impossible to identify those factors leading to improvements.

   As a starting place, we note that most obesity prevention policies are not passed with the primary goal of reducing disparities among different groups. Even when disparities are not part of the public discourse, these policies nonetheless have an influence on health equity--increasing disparities, decreasing them, or maintaining the status quo. (185) Our proposed framework lays out a process by which policymakers can analyze how different policies might affect disparities, with the goal of prioritizing the policies that are most likely to decrease disparities. State and local obesity policy efforts over the last decade, even if most have not focused on disparities, provide lessons to inform this proposed framework. As policymakers and researchers learn from future policies, this framework will be refined and restructured, incorporating new assessments of which strategies work effectively under different conditions and against different problems.

   1. Evidence for Policymaking

      The types of policies identified in this framework have not been evaluated sufficiently to establish them as effective at reversing obesity trends and disparities. Few obesity prevention policies have a strong evidence base, (186) which makes it difficult for policymakers to know where to focus their attention. The Institute of Medicine recently examined the problem of limited evidence in the obesity prevention movement and concluded that the movement must not wait for randomized-control trials, considered the gold standard of evidence in research generally, to validate obesity prevention strategies. (187) Rather, the field must generate "practice-based evidence" by evaluating actual policies and programs being implemented across the United States. (188)

      This framework is a decision-making tool, not a guide to evidence-based policy. Ideally, it will be used to develop disparities-focused policies, which can then be evaluated and contribute to the evidence base on obesity prevention strategies. Obesity prevention policies and programs should always have a built-in evaluation component so that policymakers can learn whether their ideas are effective and make corrections to improve effectiveness.

      Policymakers should also use epidemiological data during the policymaking process. The policymaking approach described above requires that policymakers have access to local data on obesity rates and delve into such data in sufficient detail that a nuanced picture of the various factors affecting obesity rates in different demographic groups emerges. (189) Without this level of understanding, advocates may embrace policy options that are unsuccessful in decreasing disparities. (190)

      According to the IOM, these data characterize the problem and help justify solutions, even if the solutions themselves lack supportive evidence. (191) Fortunately, many components of needed data are available from local and state health departments.

   2. The Framework

      The framework covers five broad approaches to crafting policies that reduce obesity and related health disparities: (1) general policies; (2) policies focusing on the demographic group experiencing poor health, including policies based on race or ethnicity and policies based on income...