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Texas Department of State Health Services
Published with support from the Texas Health Foundation
Center for Policy and Innovation
Texas Obesity Policy Portfolio2006
Texas Obesity Policy Portfolio 2006
Texas Department of State Health ServicesCenter for Policy and InnovationPublished with support from the Texas Health Foundation
TEXAS DEPARTMENT OF STATE HEALTH SERVICES
EDUARDO J. SANCHEZ, M.D., M.P.H. COMMISSIONER
1100 W. 49th Street Austin, Texas 787561-888-963-7111 http://www.dshs.state.tx.us
Dear Partner in Health:
We can no longer ignore the growing obesity epidemic in Texas. It will take all of us to make a difference in this problem from government to business and industry to community organizations like schools to our families. We must invest our time and energy and our resources if we are truly willing to do something about this urgent reality.
We must purposefully adopt effective and promising obesity prevention and control policies, which impact the problem, inform decision makers and leaders about the best available evidence and create an environment where the healthier choice is the easier choice. We can’t afford to wait on funding alone to help solve this problem. And there is much we can do now in partnership together.
So how do we change the course of the obesity epidemic in Texas? The Texas Obesity Policy Portfolio is one tool we can use to influence the current trajectory of the obesity problem in Texas. This document chronicles our best health policy knowledge associated with obesity prevention and control. It reflects a common message generated by our academic centers, institutional and agency partners that we must work with the best available evidence to impactthe problem and we must disseminate these policies and practices as quickly and as effectively as possible.
The Portfolio gives a range of referenced policy options from effective to untested, categorized by type of policy and identified for use in multiple sectors and settings. It serves as a starting point for policy development and implementation around which we can all rally.
Please join me and those who contributed to this body of knowledge in making obesity prevention and control a committed, sustained public health priority for the State.
In Partnership,
Eduardo J. Sanchez, MD, MPH Commissioner of Health
Texas Obesity Policy Portfolio �
Texas Obesity Policy Portfolio��
Acknowledgements Many thanks are extended to the Texas Health Foundation and to all of our academic and state agency partners. The cutting edge work of the Washington State Department of Health is also acknowledged and appreciated. A great deal of gratitude is extended to Boyd Swinburn and colleagues from the Center for Physical Activity and Nutrition Research at Deakin University in Melbourne, Australia, whose pioneering efforts in translating evidence into action were invaluable to the Texas Obesity Study Group’s work. Without their efforts in describing the level of promise for categorizing potential policies, the Texas Obesity Policy Portfolio may not have come to fruition.
The Texas Department of State Health Services gratefully acknowledges the following individuals, agencies, and universities:
Texas A&M Health Science Center, School of Rural Public Health
Kenneth R. McLeroy, Ph.D. Associate Dean of Academic Affairs
Marcia Ory, Ph.D., M.P.H. Professor, Department of Social Behavioral Health
Thomas Tai-Seale, Dr.P.H., M.P.H. Assistant Professor, Department of Social Behavioral Health
University of North Texas Health Science Center, School of Public Health
Peter Hilsenrath, Ph.D. Professor, Department of Health Management and Policy
The University of Texas at Austin
Robin Atwood, Ed.D. Project Director, Department of Kinesiology and Health Education
Nell Gottleib, Ph.D. Professor, Department of Kinesiology and Health Education
David Warner, Ph.D. Professor, LBJ School of Public Affairs
The University of Texas Health Science Center, School of Public Health
Steven H. Kelder, Ph.D., M.P.H. Director, Center for Health Promotion and Prevention Research
Texas Department of Agriculture
Lisa Minton Chief of Staff
Texas Obesity Policy Portfolio ���
Texas Department of State Health Services Leadership, Staff, and Interns
Donna Nichols, M.S.Ed., C.H.E.S. Senior Prevention Policy Analyst Center for Policy and Innovation Texas Department of State Health Services
Kim Bandelier, M.P.H., R.D., L.D. Program Coordinator Nutrition, Physical Activity, and Obesity Prevention Texas Department of State Health Services
Rick Danko, Dr.P.H. Director Center for Policy and Innovation Texas Department of State Health Services
Eduardo J. Sanchez, M.D., M.P.H. Texas Commissioner of Health Texas Department of State Health Services
E. Michelle Baxter Health Policy Intern Center for Policy and Innovation Texas Department of State Health Services
Gregory Boyer Health Policy Intern Center for Policy and Innovation Texas Department of State Health Services
Ayanna Castro, M.P.H. Health Policy Intern Center for Policy and Innovation Texas Department of State Health Services
Steven Chang Public Health Intern Texas Department of State Health Services
Haroon Samar, M.P.H. Health Policy Intern Center for Policy and Innovation Texas Department of State Health Services
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ContentsAcknowledgements .........................................................................................���
Introduct�on ..................................................................................................... 1
Background ..................................................................................................... 3
Texas Obes�ty Pol�cy Portfol�o .......................................................................... 17
Append�x A: Recommendat�ons for Adult We�ght-Loss
and We�ght-Ga�n Prevent�on ...................................................................... 31
Append�x B: Ev�dence of Effect�veness Defin�t�ons .............................................. 41
Append�x C: Texas Obes�ty Pol�cy Matr�x .......................................................... 47
Texas Obes�ty Pol�cy Matr�x Conceptual Framework .......................................... 57
Glossary ....................................................................................................... 69
Background References ................................................................................... 71
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Texas Obesity Policy Portfoliov�
Introducing the Texas Obesity Policy PortfolioSo what’s the big deal about overweight and obesity? Why should government be interested in this personal health issue and should government be the only actor in the campaign to reduce the size of our waistlines? Can we really influence health behavior and ultimately the health of our state?
Obesity has reached epidemic proportions in Texas. In this case bigger is not better. More than one in four, or 27 percent of Texas adults are obese, and more than one in three Texas children are overweight, increasing their chance of becoming obese adults by 25 to 50 percent.1, 4, 5 Texas is one of 13 states whose percentage of obese adults exceeds 25 percent, and these percentages are expected to increase.2 Obesity is associated with health consequences such as heart disease, hypertension, various cancers, and diabetes, all of which can lead to premature death. Given the breadth of health implications associated with obesity, Texas has suffered heavy financial consequences, which have affected both the Texas economy and the health-care system.
Our physical health will impact our fiscal health. Cost data provided by the Phase I (see page 4) study report sounded the alarm for action. It was estimated that in 2001, overweight and obesity associated costs for Texas totaled $10.5 billion. Based on 2001 cost estimates and percentages of overweight and obese Texans, it was projected that by 2040, overweight- and obesity-related costs could be as high as $39 billion.4
It will take collaborative leadership and the commitment of health and business partners, communities, families and individuals alike to change the course of the obesity epidemic. To focus the state’s direction, the Texas Commissioner of Health, Eduardo J. Sanchez, M.D., M.P.H., convened the Texas Obesity Study Group in 2003 to answer three key questions related to the obesity epidemic in Texas:
1. Phase I — What is the financial burden of overweight and obesity in Texas?
2. Phase II — What policy options do we have for changing the course of the obesity epidemic in Texas?
3. Phase III — What are the costs associated with these policy options?
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Introduction
While obesity can be attributed to individual characteristics, interactions with the larger social, cultural, and environmental contexts in which individuals live have a powerful influence and must be targeted to reinforce individual positive health behavior and to promote a culture of health. This document concentrates on the Phase II study question by focusing on evidence-based health policy, which is aimed at broad population groups.
We must act on best-available evidence and invest our resources where we can make a difference. Individual behavior change is difficult to achieve without addressing the context in which people make decisions. We know that sustained behavior change requires long-term strategies at both the individual and community level. The Texas Obesity Study Group created the Texas Obesity Policy Portfolio (the Portfolio) to offer policy options to decision-makers and community leaders. All policies included in the Portfolio were selected based on evidence of effectiveness. The steps involved in the creation of the Portfolio led to the formation of a portfolio, which spans across all life stages, sectors and settings, and which aims to influence the adoption of healthy behaviors.
Figure 1. Steps to the Creation of the Texas Obesity Policy Portfolio
De�neEvidence
ofE�ectiveness
Compile a matrix that contains evidence-based policies that address obesity prevention and control.
Assess policies using a 3 x 3
Promise Table
Organize the
Policy Portfolio
While many questions remain to be answered around effective approaches to obesity prevention and control, there is much we can do together to make a difference in the health of our community and our state. The Portfolio is one tool we can use to galvanize commitment to the issue and to mobilize our communities around effective policy options. The Portfolio is a starting point for decision making not an end point. It should be considered a living, breathing document that will continue to build on evidence and new insights over time. Conceived by the Texas Obesity Study Group, the Portfolio offers policy-makers and leaders at the state, local, and private jurisdictions a comprehensive guide to prioritizing and adopting policies within the context of the communities in which Texans live, play, pray, work, and go to school.
Texas Obesity Policy Portfolio�
Making the Case for Obesity Prevention and Control Policy More than one in four, or 27 percent of Texas adults are obese.1 According to the 2006 Trust for America’s Health report, F as in Fat: How Obesity Policies are Failing in America, Texas is one of 13 states whose percentage of obese adults exceeds 25 percent.2 Weight standards are most commonly derived from the measurement of an individual’s body mass index (BMI), which correlates to the amount of body fat in the average individual. BMI is calculated by finding the ratio of weight to height (wt/[ht]2). A healthy BMI for most adults is between 18.5 and 24.9. Adults who have a BMI between 25 and 29.9 are typically overweight, and those who have a BMI of 30 or higher are considered obese.3
Figure 2.2,3 Standard Weight Status Categories Associated with BMI Ranges for Adults
Weight Status BMI range = (weight in pounds)
x (703)(height in inches) x (height in inches)
Normal 18.5–24.9
Overweight 25–29.9
Obese 30 or higher
According to 2005 data, 64.1 percent of adults in Texas are overweight or obese.1 Rates of overweight and obesity are not only a concern for the adult population but for children as well. Approximately one in three, or 35 percent of Texas school-age children are overweight.4 Percentages this high are alarming because overweight children have a 25 to 50 percent chance of progression to adult obesity and it may be as high as 78 percent in overweight adolescents.5
Trends indicate that between 1991 and 2001, the obesity rate among adults in Texas almost doubled from 13 percent to 25 percent.4 It is projected that by 2040, the percentage of obese adult Texans will jump to 35.2 percent.4 These statistics illustrate how rapidly the obesity epidemic is growing in Texas and will continue to grow if policy actions are not taken at the community, state, and national levels.
Overweight and obesity are associated with morbidity and premature death. Health implications of overweight and obesity include:4
Background
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• Coronary heart disease• Ischemic stroke• Congestive heart failure• Hypertension• Hypercholesterolemia• Type II diabetes• Osteoarthritis• Cancers: cervix, colon, endometrial, gallbladder, kidney, ovary, and postmenopausal
breast cancer
Given the breadth of health implications associated with overweight and obesity, Texas has suffered heavy financial consequences that have affected both the Texas economy and the health-care system.
In 2003 the Texas Commissioner of Health, Eduardo J. Sanchez, M.D., M.P.H., convened a Texas Obesity Study Group to begin to address the costs associated with obesity and to compile evidence-based policy options, as a means to prevent and control obesity in the state. Three key questions guide the work of the study group and have resulted in three distinct phases of study, two of which have now been completed:
1. Phase I — What is the financial burden of overweight and obesity in Texas?
2. Phase II — What policy options do we have for changing the course of the obesity epidemic in Texas?
3. Phase III — What are the cost associated with these policy options?
Phase I Study Question: What is the financial burden of overweight and obesity in Texas?To answer this question, the Texas Department of Health published a report in 2004 titled, The Burden of Overweight and Obesity in Texas 2000-2040, (http://www.dshs.state.tx.us/phn/pdf/Cost_Obesity_Report.pdf) with financial support from the Texas Medical Association and the Texas Department of Agriculture Food and Nutrition Division. Phase I study group members included:
• Texas Commissioner of Health, Texas Department of Health• Texas Commissioner of Agriculture, Texas Department of Agriculture• Investigators from the Texas State Data Center and Office of the State Demographers at the
Institute for Demographic and Socioeconomic Research, The University of Texas at San Antonio• Policy analysts and program and center directors from the Texas Department of State
Health Services• Academic leaders for The University of Texas Health Science Center, School of Public
Health in Houston• Academic leaders from the University of North Texas Health Science Center• Academic leaders from The University of Texas Lyndon Baines Johnson School of Public Affairs
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Estimates and projections were made for the years 2001 to 2040 to quantify the financial burden of the obesity epidemic in Texas. The report sounds the alarm on the overweight and obesity epidemic and encourages action by decision-makers, advocates, and policy-makers. Projections of direct costs such as health-care expenditures and indirect costs such as lost productivity were completed using data provided by the Texas State Data Center in the Institute for Demographic and Socioeconomic Research at The University of Texas at San Antonio. Weight status prevalence data was collected by the Texas Behavioral Risk Factor Surveillance System.4 It was estimated that in 2001, overweight- and obesity-associated costs for Texas totaled $10.5 billion. This amount is comparable to the $10 billion dollars that tobacco-related diseases cost the state of Texas in 1999.6 In response to the tobacco cost burden, $12.5 million per year was appropriated by the 77th Legislature to expand tobacco-use prevention and cessation.7 Similar attention must be given to the obesity epidemic. Based on 2001 cost estimates and percentages of overweight and obese Texans, it was projected that by 2040, overweight- and obesity-attributable costs could be as high as $39 billion.4 Figure 2 depicts the projected growth in obesity-attributable costs from 2001 to 2040.
Figure 2 .4 The Burden of Overweight and Obesity in Texas 2001–2040 — Projected Figures
TX Obesity-Attributable Costs
$39.0
$15.6
$10.5
$0 $10 $20 $30 $40 $50 $60
2040
2010
2001
Billions of Dollars (United States)
Phase II Study Question: What policy options do we have for changing the course of the obesity epidemic in Texas?Cost data provided by the Phase I report, The Burden of Overweight and Obesity Report indicates that action is needed to respond to this statewide epidemic. The purpose of this Phase II report is to determine which policy options can serve as driving forces in changing the course of the obesity epidemic in Texas. The Portfolio can be used by decision-makers in various settings and sectors and is considered to be a living, breathing document, which will need to be updated as new policy research is conducted and translated into action. This document represents the best intelligence and consensus on the obesity issue as identified, by the Texas Obesity Study Group members. Phase II Study Group members included:
• Texas Commissioner of Health, Texas Department of State Health Services• Policy analysts and program and center directors from the Texas Department of State
Health Services• Department administrators from the Texas Department of Agriculture
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• Academic leaders for The University of Texas Health Science Center, School of Public Health in Houston
• Academic leaders from the Texas A&M Health Science Center, School of Rural Public Health• Academic leaders from the Department of Kinesiology, The University of Texas at Austin• Academic leaders from the University of North Texas Health Science Center• Academic leaders from The University of Texas Lyndon Baines Johnson School of Public Affairs
The individuals involved in the study group contributed obesity research knowledge as well as program and policy expertise in the development of the Portfolio. The first step for the Phase II Texas Obesity Study Group involved creating a focal point, which would serve as the foundation for obesity prevention policy.
Creating a Focal Point: Societal and Environmental InfluencesHealthy eating, physical activity, and an overall balance of energy intake and expenditure can impact weight status. Energy intake and expenditure most commonly refer to a person’s food consumption and physical activity. Efforts to improve weight status have traditionally focused on individual behavioral change and clinical intervention. Agencies such as the World Health Organization, the USDA Dietary Guidelines Advisory Committee, and the Institute of Medicine have offered individual-level recommendations for weight loss and obesity prevention. Some of the most consistent recommendations are included in figure 4. “Appendix A” outlines these recommendations in greater detail.
Figure 4.8
Recommendations for Adult Weight Loss and Obesity Prevention• Eat a variety of foods including fruits and vegetables.• Reduce intake of sweetened soft drinks, juices, and alcohol.• Reduce caloric intake by 50 to 100 calories per day to prevent weight gain.• If overweight or obese, reduce caloric intake 500 to 1000 calories per day.• Eat less foods high in fat, sugar, or refined starch.• Eat more foods high in fiber (lentils, beans, collard greens, bran, raspberries).• Reduce portion size.• Gradually increase physical activity to at least 60 minutes a day to lose and maintain weight.• Reduce sedentary behavior.
Public health is about keeping people well, but includes efforts to reduce disability and increase quality of life. In addition to its emphasis on prevention, public health focuses our attention on working with populations of people, including families, neighborhoods, and communities, not just individuals. Such population-based approaches are most effective if coupled with societal reinforcement. Changes at the individual and population level, as well as societal reinforcement, are key to reducing the prevalence of overweight and obesity in Texas.
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This document focuses on the prevention of obesity. Public health is about the prevention of disease, while medicine and many of the health professions focus on the treatment of disease.
The social-ecological model, which is made up of five interdependent spheres, is used to understand all factors which support or hinder positive health behavior. In addition to the individual sphere, the model includes interpersonal, institutional, community, and public policy influences.
Figure 5.9 Social-Ecological Model
Social-Ecological Model
Individual
Interpersonal
Institutional
Community
Public Policy
The social-ecological model suggests that changes in individual characteristics are affected not only by personal factors (e.g., age, gender, genetic profile, values) but also by interactions with the larger social, cultural, and environmental contexts in which they live (e.g., family, school, community, physical environment).9 Personal factors that predispose a person to becoming overweight or obese are difficult to control or overcome, and are typically addressed directly to the individual at risk. On the contrary, environmental and social factors that support or hinder healthy decisions can be addressed by decision-makers and targeted through population-based interventions.
In 2004, the Institute of Medicine (IOM) in collaboration with the National Academy of Science formed a committee of national experts to provide recommendations for preventing childhood obesity and released a report titled, Preventing Childhood Obesity: Health in Balance. The subsequent 2006 IOM report focused on the evaluation of actions taken by all sectors of society and described the progress made on the first report’s recommendations.10 The IOM committee developed a model to aid in describing the complexity of the obesity epidemic. The model (figure 5) builds on the social-ecological model and includes individual- and population-related factors that influence an individual’s energy balance. Energy balance refers to a state in which energy intake is equivalent to energy expenditure, resulting in no net weight gain or weight loss.11
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Figure 6.10 Energy Balance
Social Norms and Values
Sectors of In�uence
BehavorialSettings
IndividualFactors
Food andBeverage Intake Phsyical Activity
Energy Intake Energy Expenditure
Energy Balance
Industries (e.g., food, beverage, restaurant) Agriculture Education Media Government Public Health Systems Health Care Industry Businesses Land Use and
Transportation Leisure and Recreation Community-and
Faith-Based Organizations Foundations and
Other Funders
Home & Family Schools & Child-Care Settings Communities Worksite Health care
Comprehensive Approach for Preventing and Addressing Childhood Obesity
Demographic Factors (e.g., age, sex, SES, race/ethnicity) Psychosocial Factors Gene Environment Interactions Other factors
This model illustrates that behavioral settings including homes, schools, worksites, and communities have a direct effect on individual health behavior and suggests that individual-level intervention needs to be supplemented with population-level intervention. Sectors of influence such as food industries, agriculture, education, media, government, public health, health care, land use, transportation, leisure and recreation, are identified as leverage points for changing the course of the obesity epidemic. These leverage points can be modified through policy development to establish healthy social norms and beliefs, thus helping individuals maintain positive health-behavior change. The Texas Obesity Study Group chose the IOM model and the social ecological model as focal points because they address the multiple influences of the obesity epidemic, thereby recognizing the obesity epidemic as a complex, multi-factorial problem requiring multiple policy options, which touch every setting and sector where we live, work, play, pray, and go to school.
Demonstrating the Point: A Community Prevention Policy ExampleMeet Jonathan M, also known as J. He is a 10-year-old boy who lives at home with his mother, grandfather, and two sisters. J’s father passed away when he was 5, so his mother supports the family by waking up at 5 a.m. to work two jobs. His mother is usually exhausted by the time she gets home at 6 p.m. A typical day for J and his sisters includes time at school, their urban neighborhood, their place of worship, and at home. J’s grandfather spends most of the day at home, and occasionally goes to the senior center when they have special events.
Now, imagine a day in the life of the M family, and consider the choices that J and his family make regarding nutrition and physical activity, and how these choices are influenced by the obesity-prevention policies that exist in the community in which they live. Figure 7 follows the M family as they experience a typical day in each of the three communities listed. Here’s how
Texas Obesity Policy Portfolio�
some of the obesity-prevention policies included in the Portfolio can play an important role in supporting healthy behavior.
Figure 7. Supporting Healthy Behaviors in the Community through Obesity Policy
Obesity Prevention Policy Community A Community B Community CRequire physical activity curriculum to provide moderate to intense physical activity in schools to increase fitness levels.
X X
The M children do not get any physical activity during the eight hours at school.
The M children do not get any physical activity during the eight hours at school.
The M children get regular physical activity and are fit and ready for school.
Implement traffic-calming measures for safer pedestrian and cycling areas. Increase sidewalks, lighting, and single lane roundabouts.
X
The M children have to carpool with classmates and don’t get to walk home or play outside after school.
The M children walk 15 minutes home safely and are able to play outside after school.
The M children walk 15 minutes home safely and are able to play outside after school.
Work with caregivers to initiate appropriate after-school care exercise/activities and programs, and put other community-based programs in place to influence weight-related behavior.
X X
The M children attend an after-school program at their place of worship that includes homework and sugar-laden snacks. J’s grandfather waits for the family at home while watching his favorite TV shows.
The M children attend an after-school program at their place of worship that includes homework and sugar-laden snacks. J’s grandfather waits for the family at home while watching his favorite TV shows.
The M children attend an after-school program at their place of worship that includes time for physical activity, homework and healthy snacks. J’s grandfather attends afternoon social and physical activity events at the senior center.
Include a wellness program, with a substantial physical activity component as part of the employee benefit package.
X
J’s mother does not have access to a wellness program that includes physical activity at her job or in her neighborhood. She does not exercise regularly and her children view this as normal.
J’s mother has access to a wellness program that includes a physical activity component at her job. J and his sisters are aware that their mother exercises regularly and view this as normal thus increasing the likelihood that they will exercise regularly.
J’s mother has access to a wellness program that includes a physical activity component at her job. J and his sisters are aware that their mother exercises regularly and view this as normal thus increasing the likelihood that they will exercise regularly.
Implement food pricing strategies that encourage buying healthy foods by raising the price for fatty foods and lowering the price for healthier foods within 5 percent of projected revenues.
X X
J’s mother saves money by buying highly processed foods that are cheaper. The M family does not eat well-balanced, healthy meals at home because all they have is what their mother can buy on her way home at the local neighborhood market.
J’s mother saves money by buying highly processed foods that are cheaper. The M family does not eat well-balanced, healthy meals at home because all they have is what their mother can buy on her way home at the local neighborhood market.
J’s mother is able to afford healthier food options and the M family is able to eat well-balanced, healthy meals at home.
X — Denotes that the obesity-prevention policy listed does not exist in that particular community
— indicates that the obesity-prevention policy listed does exist in that particular community.
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Community C illustrates how obesity-prevention policies can influence the health of families and individuals at schools, workplaces, places of worship, and the community environment. Community C provides J and his family with the greatest opportunity for increased physical activity and incentive to eat healthier foods, thus reinforcing such positive health behaviors. Increased physical activity and well-balanced meals can prevent and control overweight and obesity. Comprehensive policy interventions across all sectors and settings can facilitate making healthier choices, thereby creating social norms and a culture for health.
Overweight and obesity issues span across all age groups and life stages; therefore, interventions must be comprehensive in nature and address children, adolescents, adults, and the elderly. A comprehensive community approach involves interventions within an array of settings including children and adult day-care centers, schools, universities, worksites, and other community organizations like the Boys and Girls Club and fitness centers. Obesity-prevention policies can transform causative social factors into factors that are more protective against obesity and supportive of positive health behaviors.
Transforming Evidence into Action: The Texas Obesity Study Group PlatformStudy group efforts were concentrated on identifying a framework for moving evidence into action. The framework involved four steps that led to the creation of a portfolio containing evidence-based obesity policy options (see figure 1, page 2).
Evidence of EffectivenessGiven the challenge of developing a plan of action, the study group first made sure that there was a clear and consistent definition for evidence of effectiveness as applied to a policy intervention, which could be agreed upon by all study group members. In an effort to define evidence of effectiveness the study group referenced definitions from leading organizations and authorities as documented in “Appendix B.” Based on these findings, the study group focused on evidence of effectiveness as defined by Swinburn, New South Wales, and Washington State.5, 9, 12, 13
When looking for evidence, it is important to consider what affects the current selection of evidence-based policy solutions. According to Swinburn and colleagues, there are three main inhibitors to developing evidence-based policy solutions for obesity:12
1. The urgent call for action, now, has come before the development of a strong evidence base.
2. Many solutions seem idealistic, expensive, and are strongly opposed by stakeholders.
3. The results of current preventive interventions are not easily or quickly assessed.
Thus, courses of action to prevent obesity should be evidence-based and this means using the “best evidence available,” as distinct from the “best evidence possible.”14
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Evidence can be considered to be a body of facts, information, or data that provides a level of certainty that a proposition is true or valid.15 In recent years, the push to increase the effectiveness and efficiency of medical treatments has led researchers to explore the role of evidence in decision making. Evidence-based medicine (EBM) is making decisions based on research and demonstrated effectiveness and efficiency.12 This attention to measuring quality of interventions has led researchers to randomized controlled trials (RCT) because of their increased internal validity.16
As EBM has grown in use, public health researchers have begun to explore an evidence base for public health. As prevention methods have evolved, evidence-based public health has become the goal when developing policy options.16
Randomized controlled trials, the gold standard for EBM, fall short as the standard bearer for public health interventions because of their limited usability. Public health interventions in community settings are complicated by the uncontrolled variables that influence and confound the outcome. The evidence base for public health must cast a larger net and incorporate various types of evidence. The evidence base for obesity prevention needs many different types of evidence and often needs the informed opinions of stakeholders to ensure external validity and contextual relevance.12
A similar framework known as RE-AIM by Dzewaltowski and colleagues estimates and evaluates the impact of public health interventions by considering evidence of five factors.17, 18 They are:
R — reachE — efficacy/effectivenessA — adoptionI — implementationM — maintenance
The RE-AIM framework addresses issues such as the generalizability of an intervention to the target population (external validity), breadth of application, and contextual issues, while evaluating evidence-based interventions. This framework and the work of Swinburn and colleagues support the Obesity Study Group’s methodology for the creation of a portfolio of evidence-based obesity policies.
Swinburn and colleagues list the following as types of evidence relevant to obesity prevention in population settings:12
1. Observational epidemiology,
2. Experimental Studies,
3. Program/Policy evaluations,
4. Extrapolated analyses measuring effectiveness and cost, and
5. Evidence derived from experience such as theory and program logic, informed opinion, and the use of previously employed strategies for changing health-related behaviors.
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No hierarchy of evidence quality is offered for these types of evidence because their intrinsic strengths and weaknesses play out differently in each of the different questions posed for obesity prevention. The RCT, therefore, sits alongside other forms of evidence and each is judged on its ability to contribute to answering the question at hand.
The outputs include the descriptions of specific programs, policies, or other actions that could be undertaken to prevent unhealthy weight gain.
Once a definition was completed for evidence of effectiveness, the group identified possible policy options to be implemented in Texas and sought the evidence to support a portfolio of such. Discussions led the study group to adopt a decision-making framework based on the ideas outlined by Swinburn and the International Obesity Task Force.
The Matrix and Promise TableHealth promotion planning principles were used to classify interventions to form a matrix. Data for the matrix was gathered from academic literature and Internet searches. A theoretical understanding of the social-ecological model supported data for the matrix. The matrix was created to support a comprehensive approach to reducing the cost burden of obesity in Texas with an emphasis on schools, worksites, health-care practice settings, and communities across the lifespan (“Appendix C”).
In an effort to be inclusive, policy options were defined by age groups (from infants to the elderly), given obesity is not an age-discriminatory disease. Policy options outlined in the matrix were also organized by the settings in which they were implemented. These settings include: federal and state, media, schools, faith-based organizations, cities/counties, worksites, and health-care settings. Thus, the matrix became the core comprehensive document from which the Portfolio originated. The obesity study group compiled the matrix from a research base in obesity policy that began in 2000. The matrix provided the study group with a clear picture of research gaps in the knowledge base including areas where further research is needed and where there are opportunities for translation. This best-available evidence provided the genesis for the Portfolio.
Policies were assessed by potential population impact and the certainty of effectiveness.
a. Potential population impact in Texas communities was determined by:12
i. Efficacy — Impact of a policy under ideal conditions
ii. Reach — The proportion of relevant settings in which the policy of program is instituted
iii. Adoption — the uptake by individuals in the settings
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b. Determination of the certainty of effectiveness that the evidence-based policies and programs would have in Texas were based on:12
i. Quality of evidence
ii. Strength of intervention logic
iii. Sensitivity and uncertainty parameters in the modeling of the population impact
Once the level of population impact and certainty of evidence was determined, the “3 X 3 Promise Table” was used to assign a level of “promise” (high, medium, or low) to each policy option. A policy that was determined to have a high certainty of effectiveness and a high potential for population impact was categorized as “most promising.” On the other hand, a policy that was determined to have a low certainty of effectiveness and a low potential for population impact, was categorized as “least promising.” Figure 8 shows how policies can also be characterized from least promising to most promising. The “3 X 3 Promise Table” was used as a benchmark to categorize potential obesity policies because of its degree of specificity.
Figure 8.12 Promise Table for Categorizing Potential Interventions
Certainty of Effectiveness
Potential Population Impact
Low Moderate High
Quite high Promising Very promising Most promising
Medium Less promising Promising Very promising
Quite low Least promising Less promising Promising
While these levels of promise provided greater detail, it was in the interest of simplicity that the Texas Obesity Study Group adopted the Washington State Department of Health’s policy portfolio classification system. Washington State classifies policies as effective, promising, or untested. Figure 9 on page 14 shows the parallel between the scale of effectiveness proposed by Swinburn and by Washington State.
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Figure 9. Classification of Obesity Policies
3x3 Promise Table Classification of Obesity Policies
Washington State Department of Health Classification of Obesity Policies
Medium HighLow
Promising EffectiveUntested
least promising
less promising
promising
very promising
most promising
Portfolio of OptionsThe final product developed by the Texas Obesity Study Group was a portfolio containing current and proposed evidence-based policy options along with their respective levels of effectiveness (untested, promising, effective). A portfolio that includes various levels of interventions provides a basis for a comprehensive approach to decision making.
It is important to recognize that effective action on obesity will not be achieved by a single intervention. Therefore, a set of policy options that individually produce only a modest affect on energy balance may make an important contribution when combined with broader policy options. It may be possible to develop a detailed “menu” of such policy options, but it is important to realize that what is
Texas Obesity Policy Portfolio14
developed for one population may not apply to another due to the wide range of contextual factors that influence these policy options.12
Currently, obesity prevention and control efforts are frequently incomplete, uncoordinated, unevaluated and often not sustainable.19 Limitations of obesity research include:19
1. A lack of evidenced-based research to form the basis for health policy
2. Useful interventions which are not being properly evaluated
3. Interventions which are not prevention and population focused
Although it is clear that remedies will need to involve policies that change the relevant societal and environmental drivers in a direction that promotes healthy population weights, the ways to do this are not straightforward.12
The lack of a scientifically sound examination of obesity may have an impact on the absence of actions taken to combat the problem. This issue is a complex one and has resulted in policy paralysis and needs more solid scientific research. Individuals and communities have been left with insufficient and occasionally conflicting information about the magnitude of the problem and methods to manage their health.2
Based on these limitations, The Texas Obesity Study Group chose to develop an evidence-based portfolio of policy options. The purpose of this portfolio is to provide a “menu” of policy interventions, which stakeholders and leaders can choose to implement in their respective sector or setting. The nutrition and physical activity policies are categorized and the sector or setting for each policy is defined. Policy options can be implemented at the federal, state, local, and county levels, as well as through media outlets, schools, worksites, faith-based organizations, and health-care settings. For each policy, the level of effectiveness is provided as determined by the “3 x 3 Promise Table” with referenced evidence given per policy option.
The Portfolio serves to guide decision making in obesity prevention and control by recognizing both the value and the limitation of existing evidence and integrating other key consideration in determining action on obesity.12 Because the Portfolio spans a multitude of settings and sectors and is evidence-based and explicit, the policy options provided have a higher chance of actually being implemented and sustained.12
How does a Community Leader use the Texas Obesity Policy Portfolio?Community leaders have the task of deciding which policy options will work best for their respective communities. Policy options can be implemented at the federal, state, local, or county level, and through media, schools, worksites, faith-based organization, or at health-care settings. The Portfolio serves as a guide and a starting point for policy adoption. The first step in policy development and implementation is first understanding the scope of the
Texas Obesity Policy Portfolio 15
problem. A community assessment completed by key stakeholders will serve this purpose and should answer questions such as:
• What is the burden of this particular disease in this community?• What is the level of urgency?• What is the perceived need in this community?
Once a community assessment is complete, policy options need to be prioritized based on importance and feasibility. Determining the feasibility of a policy option involves taking into account the political environment and the practicality of, and potential barriers to, policy implementation.
The selection of policy options requires assessment of cost-utility, effectiveness and implementation implications. The filter criteria in figure 10 developed by Swinburn and colleagues can guide how policy options can be implemented in a given community. The Texas Obesity Policy Portfolio provides policy-makers at the state, local, and private jurisdiction a comprehensive guide to prioritizing and adopting policies that will be most effective in Texas communities.
Figure 10.12 Suggested Filter Criteria for Stakeholder Judgments on ImplementationFilter Criteria Description
Feasibility The ease of implementation considering such factors as the availability of a trained workforce; the strength of the organizations, networks, systems and leadership involved; existing pilot of demonstration programs.
Sustainability The durability of the intervention considering such factors as the degree of environmental or structural change; the level of policy support; the likelihood of behaviors, practices, attitudes, etc. becoming normalized; the level of ongoing funding support needed.
Effects on equity The likelihood that the intervention will affect the inequalities in the distribution of obesity in relation to socioeconomic status, ethnicity, locality, and gender.
Potential side effects
The potential for the intervention to result in positive or negative side effects such as on other health consequences, stigmatization, the environment, social capital, traffic congestion, household costs, other economic consequences.
Acceptability to stakeholders
The degree of acceptance of the intervention by the various stakeholders including parents and caretakers, teachers, health-care professionals, the general community, policy-makers, the private sector, government, and other third-party funders.
Texas Obesity Policy Portfolio16
The Texas Obesity Policy Portfolio is a compilation of current and proposed evidence-based obesity policy options along with their respective levels of effectiveness (untested, promising, effective). This portfolio serves as a guide and a starting point for policy adoption and includes various levels of intervention (varying levels of effectiveness and various sectors and settings for implementation), thus providing a basis for a comprehensive approach to decision-making. The policies included in the Portfolio are listed under one or more of the following policy categories:
• Healthy food• Recreation • Breastfeeding• Built Environment • City Planning/Transportation • Education • Media • Industry • Wellness
An “X” in the table beginning on page 19 denotes the sector or setting in which a policy option can be adopted. Each policy option can be adopted and implemented in at least one of the following sectors or settings:
• Federal/State• Media• Schools • Faith-based organizations• City• County• Worksites• Health care
Texas Obesity Policy Portfolio 17
Texas Obesity
Policy Portfolio
Texas Obesity Policy Portfolio1�
The evidence legend identifies and cross references the evidence found in “Appendix C: Texas Obesity Policy Matrix Conceptual Framework.” The cited references on the portfolio can be found on page 57–67.
Evid
ence
Lege
nd —
S - S
choo
l, FS-
Fede
ral/S
tate,
CCG
- City
and c
ounty
gove
rnmen
t, W
- Work
site,
H - H
ealth
care,
M - M
edia,
FB - F
aith-b
ased
orga
nizati
ons,
SS - A
ll sec
tors a
nd se
ttings
.
Effe
ctive
pol
icy o
ptio
ns —
a po
licy op
tion o
r the
envir
onme
ntal c
hang
e the
policy
is m
eant
to bri
ng ab
out w
as te
sted i
n one
or m
ore w
ell-de
signe
d scie
ntific
stud
ies an
d fou
nd to
affec
t nutr
ition a
nd/o
r phy
sical
activ
ity be
havio
r.9
Prom
ising
pol
icy o
ptio
ns —
the r
ation
ale su
pport
ing th
e poli
cy op
tion o
r the
spec
ific po
licy ap
proac
h was
teste
d in o
ne or
more
well
-desig
ned s
cienti
fic st
udies
and r
esult
s of e
ffecti
vene
ss are
ongo
ing.9
Unte
sted
pol
icy o
ptio
ns —
policy
optio
ns, w
hich a
re po
tentia
lly gr
eat id
eas,
but a
re un
tested
or ar
e sho
wn to
not h
ave d
efinit
ive re
sults
.9
Texa
s Obe
sity
Polic
y Po
rtfol
io
Polic
y Op
tions
Federal/State
Media
Schools
Faith-Based Organizations
City/County
Worksites
Health Care
Evid
ence
Leve
l of
Effe
ctive
ness
Heal
thy
Food
Pol
icies
Alloc
ate fu
nding
for t
he ex
pans
ion of
the W
IC far
mers’
mark
et pro
gram.
XX
Farm
ers’ m
arket
coup
ons i
ncrea
se fr
uit an
d veg
etable
cons
umpti
on.SS
Effec
tive
Alloc
ate fo
r the e
xpan
sion o
f the s
enior
farm
ers’ m
arket
nutrit
ional
progra
m.X
XPro
viding
farm
ers’ m
arket
coup
ons i
ncrea
ses f
ruit a
nd ve
getab
le co
nsum
ption
.SSEff
ectiv
e
Imple
ment
food-p
ricing
strat
egies
that
enco
urage
buyin
g hea
lthy f
oods
.X
XX
XSt
udies
have
show
n tha
t rais
ing th
e pric
e of f
atty f
oods
and l
oweri
ng th
e pric
e of
healt
hier f
oods
kept
withi
n five
perce
nt of
projec
ted re
venu
es.SS
Effec
tive
Alloc
ate fu
nding
to pr
ovide
equip
ment
to us
e elec
tronic
meth
ods o
f pa
ymen
t at f
armers
’ mark
ets.
XX
Allow
ing el
ectro
nic m
ethod
s of p
ayme
nt at
farme
rs’ m
arkets
shou
ld inc
rease
the
amou
nt of
healt
hy fo
od bo
ught
by us
ers of
food
stam
p prog
rams s
uch a
s the
Lo
ne S
tar Ca
rd.SS
Promi
sing
Provid
e inc
entiv
es fo
r groc
ery st
ores a
nd/o
r farm
ers’ m
arkets
to lo
cate
in un
derse
rved a
reas.
XX
Due t
o the
fact
that t
here
are fe
wer g
rocery
store
s in l
ow-in
come
comm
unitie
s, the
re are
fewe
r opp
ortun
ities t
o buy
healt
hy fo
od. F
ewer
numb
er of
place
s to
buy h
ealth
y foo
d lea
ds to
poor
dietar
y qua
lity, b
ut loc
ating
bette
r reta
ilers
in un
derse
rved a
reas c
an in
creas
e frui
t and
vege
table
cons
umpti
on.SS
Promi
sing
Provid
e or s
ubsid
ize tr
ansp
ortati
on to
farm
ers’ m
arkets
and g
rocery
sto
res.
XX
XDu
e to a
varie
ty of
factor
s, ind
ividu
als w
ho liv
e in l
ow-in
come
area
s hav
e les
s ac
cess
to gro
cery
stores
.SS
Promi
sing
Forbi
d the
sale
of foo
d tha
t com
petes
with
the n
ation
al sch
ool
break
fast a
nd lu
nch p
rogram
s.X
XX
Stud
ents
who p
articip
ate in
thes
e prog
rams h
ave m
ore ac
cess
to ke
y nutr
ients
due t
o the
nutrit
ional
cons
traint
s. St
uden
ts wh
o hav
e acce
ss to
à la c
arte,
snac
k ba
r, and
vend
ing m
achin
e item
s eat
fewer
fruits
and v
egeta
bles t
han t
hose
who
do
not.SS
Promi
sing
Mand
ate sa
lad ba
rs in
all sc
hools
.X
XX
Scho
ols th
at off
er sa
lad ba
rs ha
ve st
uden
ts wh
o con
sume
more
fruit
s and
ve
getab
les, a
s well
as ha
ve hi
gher
progra
m pa
rticipa
tion r
ates,
than t
hose
that
do no
t.SS, S
10
Promi
sing
Mand
ate th
e dev
elopm
ent a
nd ex
ecuti
on of
nutrit
ional
stand
ards f
or pre
schoo
ls an
d day
cares
so th
at foo
d and
drink
s ava
ilable
comp
ly wi
th the
Diet
ary G
uideli
nes f
or Am
erica
ns or
equiv
alent
stand
ards.
XX
Olde
r stud
ents
who h
ave g
reater
acce
ss to
unhe
althy
food
s con
sume
less
fruits
an
d veg
etable
s tha
n tho
se w
ho do
not h
ave a
ccess
to un
healt
hy fo
od.SS
, FS3
, S1,
S10
Promi
sing
Texas Obesity Policy Portfolio 19
Evid
ence
Lege
nd —
S - S
choo
l, FS-
Fede
ral/S
tate,
CCG
- City
and c
ounty
gove
rnmen
t, W
- Work
site,
H - H
ealth
care,
M - M
edia,
FB - F
aith-b
ased
orga
nizati
ons,
SS - A
ll sec
tors a
nd se
ttings
.
Effe
ctive
pol
icy o
ptio
ns —
a po
licy op
tion o
r the
envir
onme
ntal c
hang
e the
policy
is m
eant
to bri
ng ab
out w
as te
sted i
n one
or m
ore w
ell-de
signe
d scie
ntific
stud
ies an
d fou
nd to
affec
t nutr
ition a
nd/o
r phy
sical
activ
ity be
havio
r.9
Prom
ising
pol
icy o
ptio
ns —
the r
ation
ale su
pport
ing th
e poli
cy op
tion o
r the
spec
ific po
licy ap
proac
h was
teste
d in o
ne or
more
well
-desig
ned s
cienti
fic st
udies
and r
esult
s of e
ffecti
vene
ss are
ongo
ing.9
Unte
sted
pol
icy o
ptio
ns —
policy
optio
ns, w
hich a
re po
tentia
lly gr
eat id
eas,
but a
re un
tested
or ar
e sho
wn to
not h
ave d
efinit
ive re
sults
.9
Texa
s Obe
sity
Polic
y Po
rtfol
io
Polic
y Op
tions
Federal/State
Media
Schools
Faith-Based Organizations
City/County
Worksites
Health Care
Evid
ence
Leve
l of
Effe
ctive
ness
Mand
ate th
e dev
elopm
ent a
nd ex
ecuti
on of
nutrit
ional
stand
ards s
o all
food s
old on
scho
ol ca
mpus
es is
cons
isten
t with
a se
t of s
tanda
rds.
XX
X
Stud
ents
who p
articip
ate in
the n
ation
al sch
ool b
reakfa
st an
d lun
ch pr
ogram
s ha
ve m
ore ac
cess
to ke
y nutr
ients
due t
o the
nutrit
ional
cons
traint
s. St
uden
ts wh
o hav
e acce
ss to
à la c
arte,
snac
k bar,
and v
endin
g mac
hine i
tems e
at few
er fru
its an
d veg
etable
s tha
n tho
se w
ho do
not.SS
, S10
Promi
sing
Provid
e free
brea
kfast
and/
or lun
ch to
all s
tuden
ts, re
gardl
ess o
f the
ir eli
gibilit
y.X
XX
Stud
ents
who p
articip
ate in
the n
ation
al sch
ool b
reakfa
st an
d lun
ch pr
ogram
s ha
ve m
ore ac
cess
to ke
y nutr
ients
due t
o the
nutrit
ional
cons
traint
s. St
uden
ts wh
o hav
e acce
ss to
a la c
arte,
snac
k bar,
and v
endin
g mac
hine i
tems e
at few
er fru
its an
d veg
etable
s tha
n tho
se w
ho do
not.
Also,
stude
nts w
ho ar
e enti
tled t
o rec
eive f
ree or
redu
ced-p
rice m
eals
are m
ore lik
ely to
partic
ipate
in the
prog
ram.SS
Promi
sing
Requ
ire a
certa
in pe
rcenta
ge of
food
sold
in ca
feteri
as an
d ven
ding
mach
ines,
and o
ther s
ource
s of f
ood,
meet
certa
in ag
reed u
pon
guide
lines
.X
XX
XTh
e abs
ence
of he
althy
food
is a
large
obsta
cle to
eatin
g hea
lthy.
Offer
ing a
myria
d of h
ealth
y foo
d as w
ell as
prov
iding
educ
ation
, hea
lth pr
omoti
on, a
nd
price
ince
ntive
s will
affec
t foo
d sele
ction
.SS, W
2, W
8
Promi
sing
Create
hosp
ital p
olicie
s tha
t a ce
rtain
perce
ntage
of m
eals
and o
ther
food o
ffered
will
meet
certa
in ag
reed u
pon g
uideli
nes.
XX
XX
Offer
ing a
varie
ty of
food,
along
with
the a
pprop
riate
educ
ation
, hea
lth
promo
tion,
and/
or pri
ce in
centi
ves w
ill po
sitive
ly aff
ect f
ood s
electi
on.SS
Promi
sing
Imple
ment
a sale
s tax
for f
oods
that
have
mini
mal n
utritio
nal v
alue.
XA s
mall t
ax ca
n rais
e sub
stanti
al rev
enue
and i
mped
e eati
ng un
healt
hy fo
ods.
This
policy
is si
milar
to ta
xes o
n tob
acco
and a
lcoho
l whic
h can
influ
ence
amou
nts of
co
nsum
ption
.SS
Promi
sing
Acco
unt f
or he
alth b
y dev
elopin
g a he
alth k
nowl
edge
-base
.X
Deve
loping
a he
alth k
nowl
edge
-base
will
bring
atten
tion t
o the
man
y infl
uenc
es
over
a pers
on’s
healt
h whic
h will
curb
overw
eight
and o
besit
y.FS1
Promi
sing
Create
tax i
ncen
tives
to en
coura
ge sm
aller
store
owne
rs in
unde
rserve
d are
as to
prov
ide he
althie
r foo
d item
s.X
XPro
viding
ince
ntive
s to s
mall f
ood s
tores
, whic
h typ
ically
have
less
healt
hy fo
od,
will e
ncou
rage s
tores
to pr
ovide
healt
hier f
ood c
hoice
s.SS, F
S7
Untes
ted
Provid
e free
servi
ces s
uch a
s wate
r, was
te dis
posa
l, and
othe
r mu
nicipa
l reso
urces
to co
mmun
ity ga
rdens
.X
Treati
ng co
mmun
ity ga
rdens
like o
ther r
ecrea
tiona
l acti
vities
could
foste
r grea
ter
use.
Garde
ns ca
n enh
ance
phys
ical a
ctivit
y as w
ell as
fruit
and v
egeta
ble
cons
umpti
on.SS
Untes
ted
In the
comp
rehen
sive p
lan fo
r citie
s, pro
vide i
ncen
tives
for c
ommu
nity
garde
ns on
publi
c and
/or p
rivate
land
.X
Planti
ng co
mmun
ity ga
rdens
can e
nhan
ce bo
th ph
ysica
l acti
vity a
s well
as fr
uit
and v
egeta
ble co
nsum
ption
.SS
Untes
ted
Texas Obesity Policy Portfolio�0
Evid
ence
Lege
nd —
S - S
choo
l, FS-
Fede
ral/S
tate,
CCG
- City
and c
ounty
gove
rnmen
t, W
- Work
site,
H - H
ealth
care,
M - M
edia,
FB - F
aith-b
ased
orga
nizati
ons,
SS - A
ll sec
tors a
nd se
ttings
.
Effe
ctive
pol
icy o
ptio
ns —
a po
licy op
tion o
r the
envir
onme
ntal c
hang
e the
policy
is m
eant
to bri
ng ab
out w
as te
sted i
n one
or m
ore w
ell-de
signe
d scie
ntific
stud
ies an
d fou
nd to
affec
t nutr
ition a
nd/o
r phy
sical
activ
ity be
havio
r.9
Prom
ising
pol
icy o
ptio
ns —
the r
ation
ale su
pport
ing th
e poli
cy op
tion o
r the
spec
ific po
licy ap
proac
h was
teste
d in o
ne or
more
well
-desig
ned s
cienti
fic st
udies
and r
esult
s of e
ffecti
vene
ss are
ongo
ing.9
Unte
sted
pol
icy o
ptio
ns —
policy
optio
ns, w
hich a
re po
tentia
lly gr
eat id
eas,
but a
re un
tested
or ar
e sho
wn to
not h
ave d
efinit
ive re
sults
.9
Texa
s Obe
sity
Polic
y Po
rtfol
io
Polic
y Op
tions
Federal/State
Media
Schools
Faith-Based Organizations
City/County
Worksites
Health Care
Evid
ence
Leve
l of
Effe
ctive
ness
Requ
ire al
l food
purch
ased
with
gove
rnmen
t fun
ds m
eet c
ertain
agree
d-up
on nu
trition
al sta
ndard
s.X
XGo
vernm
ent f
unds
can s
uppo
rt he
althie
r eati
ng th
rough
requ
ireme
nts su
ch as
the
se.SS
, S1
Untes
ted
Provid
e add
itiona
l fund
ing fo
r the
expa
nsion
of th
e Sum
mer F
ood
Servi
ce Pr
ogram
for c
hildre
n.X
XPro
viding
addit
ional
state
fundin
g for
supp
ort of
the S
umme
r Foo
d Serv
ice
Progra
m wi
ll inc
rease
the l
ikelih
ood o
f foo
d sec
urity
for lo
w-inc
ome c
hildre
n.SS
Untes
ted
Prohib
it or s
et res
trictio
ns on
mark
eting
contr
acts
betw
een s
choo
ls an
d so
da co
mpan
ies.
XX
XPro
hibitin
g or li
mitin
g exc
lusive
contr
acts
disco
urage
the c
onsu
mptio
n of s
odas
in
schoo
ls. Co
nsum
ing so
das l
eads
to ex
cess
calor
ies, w
eight
gain,
and d
isplac
es
healt
hier f
oods
such
as m
ilk.SS
, S7
Untes
ted
Create
oppo
rtunit
ies to
have
rece
ss be
fore l
unch
, not
after
lunch
.X
XX
Provid
ing tim
e for
reces
s befo
re lun
ch w
ill all
ow st
uden
ts to
choo
se fu
ll mea
ls an
d de
creas
e cafe
teria
waste
from
stud
ents
leavin
g the
ir mea
l to pl
ay at
rece
ss.SS
Untes
ted
Scho
ol fun
draisin
g acti
vities
shou
ld no
t use
food
, or s
hould
only
use
foods
that
comp
ly wi
th str
ict di
etary
and p
ortion
guide
lines
.X
XX
Limitin
g the
kind
s of f
undra
ising a
ctivit
ies an
d the
type
s of f
ood,
if any
, tha
t can
be
sold,
can p
romote
healt
hier e
ating
in sc
hool-
aged
child
ren.SS
Untes
ted
Estab
lish cr
iteria
for a
nd pr
oced
ures t
o purc
hase
food
from
local
farme
rs.X
XPu
rchas
ing fo
od fr
om lo
cal fa
rmers
incre
ases
stud
ent in
teres
t and
satis
factio
n with
fre
sh fr
uits a
nd ve
getab
les. S
tuden
t usa
ge of
the s
choo
l sala
d bar
increa
ses w
ith
the se
rving
of lo
cal fr
uits a
nd ve
getab
les.SS
Untes
ted
Provid
e stud
ents
with
a rea
sona
ble am
ount
of tim
e to e
at lun
ch.
XAll
ocati
ng am
ple tim
e for
stude
nts to
eat w
ill all
ow th
em to
choo
se fu
ll mea
ls,
instea
d of s
nack
s whic
h are
usua
lly in
resp
onse
to fe
eling
s of h
unge
r .SS
Untes
ted
Serve
only
foods
mee
ting c
ertain
dieta
ry gu
idelin
es at
gathe
rings
, me
eting
s, se
mina
rs, an
d work
shop
s.X
XX
XX
XPro
viding
only
healt
hy fo
od at
mee
tings
will
enco
urage
peop
le to
eat h
ealth
fully.
SSUn
tested
Sell m
ilk in
scho
ols w
ith no
grea
ter th
an 1
% fat
.X
XX
Child
ren co
nsum
e a gr
eat d
eal o
f the
ir satu
rated
fat f
rom ei
ther w
hole
or 2%
mi
lk. Li
mitin
g ava
ilabil
ity to
only
1% m
ilk or
lean
er wi
ll hav
e sign
ifican
t effe
cts on
the
ir fat
intak
e.S9
Untes
ted
Estab
lish a
farme
rs’ m
arket
or co
mmun
ity su
pport
ed ag
ricult
ure dr
op-
off on
-site o
r nea
r the
work
site.
XX
X
Estab
lishing
a far
mers’
mark
et or
comm
unity
-supp
orted
agric
ulture
prog
ram cl
ose
to wo
rk wi
ll inc
rease
fruit
and v
egeta
ble co
nsum
ption
amon
g emp
loyee
s. Th
ose
who f
reque
nt far
mers’
mark
ets fe
el tha
t the
ir frui
t and
vege
table
cons
umpti
on
increa
ses d
ue to
thes
e visit
s.SS
Untes
ted
Texas Obesity Policy Portfolio �1
Evid
ence
Lege
nd —
S - S
choo
l, FS-
Fede
ral/S
tate,
CCG
- City
and c
ounty
gove
rnmen
t, W
- Work
site,
H - H
ealth
care,
M - M
edia,
FB - F
aith-b
ased
orga
nizati
ons,
SS - A
ll sec
tors a
nd se
ttings
.
Effe
ctive
pol
icy o
ptio
ns —
a po
licy op
tion o
r the
envir
onme
ntal c
hang
e the
policy
is m
eant
to bri
ng ab
out w
as te
sted i
n one
or m
ore w
ell-de
signe
d scie
ntific
stud
ies an
d fou
nd to
affec
t nutr
ition a
nd/o
r phy
sical
activ
ity be
havio
r.9
Prom
ising
pol
icy o
ptio
ns —
the r
ation
ale su
pport
ing th
e poli
cy op
tion o
r the
spec
ific po
licy ap
proac
h was
teste
d in o
ne or
more
well
-desig
ned s
cienti
fic st
udies
and r
esult
s of e
ffecti
vene
ss are
ongo
ing.9
Unte
sted
pol
icy o
ptio
ns —
policy
optio
ns, w
hich a
re po
tentia
lly gr
eat id
eas,
but a
re un
tested
or ar
e sho
wn to
not h
ave d
efinit
ive re
sults
.9
Texa
s Obe
sity
Polic
y Po
rtfol
io
Polic
y Op
tions
Federal/State
Media
Schools
Faith-Based Organizations
City/County
Worksites
Health Care
Evid
ence
Leve
l of
Effe
ctive
ness
Forbi
d foo
d and
beve
rage m
arketi
ng on
scho
ol gro
unds
and a
t scho
ol fun
ctions.
XX
X
Elimi
natin
g mark
eting
will
disco
urage
cons
umpti
on of
unhe
althy
food
. Chil
dren
expo
sed t
o foo
d end
orsem
ents
choo
se fo
ods t
hat a
re ad
vertis
ed m
ore of
ten th
an
those
that
are no
t adv
ertise
d. Als
o, mo
st foo
d adv
ertisin
g dire
cted a
t chil
dren i
s hig
h-sug
ar ce
reals,
fast
food,
and c
andy
.SS
Untes
ted
Provid
e free
garde
ning s
pace
for r
eside
nt us
e at a
partm
ent h
ousin
g co
mplex
es, in
cludin
g low
-inco
me ho
using
facili
ties.
XX
Allow
ing sp
ace t
o enc
ourag
e gard
ening
amon
g hou
sing r
eside
nts co
uld fo
ster
greate
r phy
sical
activ
ity an
d frui
t and
vege
table
cons
umpti
on.SS
Untes
ted
Requ
ire th
at the
basic
food
appli
catio
n proc
ess b
e sim
plifie
d.X
Easin
g the
basic
food
appli
catio
n proc
ess c
ould
captu
re tho
se el
igible
for t
his
progra
m, bu
t who
do no
t part
icipate
.SS
Untes
ted
Recr
eatio
n Po
licies
Create
new
walki
ng an
d biki
ng tr
ails,
parks
, and
recre
ation
facili
ties.
XX
XX
The c
reatio
n of a
nd im
prove
d acce
ss to
recrea
tiona
l facili
ties i
ncrea
ses p
hysic
al ac
tivity
. Acce
ss to
such
facili
ties p
ositiv
ely co
rrelat
es w
ith ac
tivity
, and
nega
tively
co
rrelat
es w
ith be
ing ov
erweig
ht.SS
, CCG
1
Effec
tive
Provid
e tran
sport
ation
ince
ntive
s to a
llow
acce
ss to
recrea
tiona
l facili
ties.
XX
XX
Impro
ving a
ccess
to rec
reatio
nal fa
cilitie
s for
more
phys
ical a
ctivit
y with
outre
ach
can i
ncrea
se th
e amo
unt o
f phy
sical
activ
ity. A
ccess
to su
ch fa
cilitie
s pos
itively
co
rrelat
es w
ith ac
tivity
, and
nega
tively
corre
lated
with
being
overw
eight.
SS
Effec
tive
Gran
t afte
r-hou
rs ac
cess
to sch
ools
and r
ecrea
tiona
l facili
ties.
XX
XTh
e crea
tion o
f and
impro
ved a
ccess
to pla
ces o
f phy
sical
activ
ity in
creas
es
phys
ical a
ctivit
y. Ac
cess
to su
ch fa
cilitie
s pos
itively
corre
lates
with
activ
ity, a
nd
nega
tively
corre
lates
with
being
overw
eight.
SS
Effec
tive
Alloc
ate fu
nding
for w
alking
and b
iking
map
s, inc
luding
conn
ectio
ns
betw
een p
aths.
XX
Reac
hing o
ut to
the pu
blic i
s an i
mport
ant a
spec
t to t
he su
ccess
of pro
grams
that
increa
se th
e acce
ssibil
ity an
d ava
ilabil
ity of
phys
ical a
ctivit
y.SS
Promi
sing
Estab
lish ta
x inc
entiv
es or
exce
ption
s for
priva
te do
natio
ns of
ea
seme
nts fo
r incre
asing
walk
ing an
d biki
ng tr
ails.
XX
Bette
r walk
ing an
d biki
ng in
frastr
uctur
es ar
e asso
ciated
with
more
indiv
idual
walki
ng an
d biki
ng tr
ips.SS
, FS7
Promi
sing
Requ
ire a
greate
r prop
ortion
of fe
deral
tran
sport
ation
reso
urces
to be
sp
ent o
n walk
ing an
d biki
ng tr
ails.
XBe
tter w
alking
and b
iking
infra
struc
tures
are a
ssocia
ted w
ith m
ore in
dividu
al wa
lking
and b
iking
trips
.SS
Promi
sing
Enac
t coll
abora
tive p
olicie
s amo
ng st
ate an
d loc
al en
tities
so st
ate an
d loc
al rec
reatio
n area
s prom
ote ph
ysica
l acti
vity.
XX
Acce
ss to
walki
ng an
d biki
ng tr
ails,
parks
, and
othe
r recre
ation
al ac
tivitie
s is l
inked
to
increa
sed p
hysic
al ac
tivity
and n
egati
vely
asso
ciated
to ov
erweig
ht.SS
, CCG
1
Promi
sing
Texas Obesity Policy Portfolio��
Evid
ence
Lege
nd —
S - S
choo
l, FS-
Fede
ral/S
tate,
CCG
- City
and c
ounty
gove
rnmen
t, W
- Work
site,
H - H
ealth
care,
M - M
edia,
FB - F
aith-b
ased
orga
nizati
ons,
SS - A
ll sec
tors a
nd se
ttings
.
Effe
ctive
pol
icy o
ptio
ns —
a po
licy op
tion o
r the
envir
onme
ntal c
hang
e the
policy
is m
eant
to bri
ng ab
out w
as te
sted i
n one
or m
ore w
ell-de
signe
d scie
ntific
stud
ies an
d fou
nd to
affec
t nutr
ition a
nd/o
r phy
sical
activ
ity be
havio
r.9
Prom
ising
pol
icy o
ptio
ns —
the r
ation
ale su
pport
ing th
e poli
cy op
tion o
r the
spec
ific po
licy ap
proac
h was
teste
d in o
ne or
more
well
-desig
ned s
cienti
fic st
udies
and r
esult
s of e
ffecti
vene
ss are
ongo
ing.9
Unte
sted
pol
icy o
ptio
ns —
policy
optio
ns, w
hich a
re po
tentia
lly gr
eat id
eas,
but a
re un
tested
or ar
e sho
wn to
not h
ave d
efinit
ive re
sults
.9
Texa
s Obe
sity
Polic
y Po
rtfol
io
Polic
y Op
tions
Federal/State
Media
Schools
Faith-Based Organizations
City/County
Worksites
Health Care
Evid
ence
Leve
l of
Effe
ctive
ness
Elimi
nate
sales
tax f
or the
purch
ase o
f exe
rcise
equip
ment
for in
dividu
als.
XOw
ning o
r hav
ing ac
cess
to ex
ercise
equip
ment
is lin
ked t
o inc
rease
d phy
sical
activ
ity.SS
, FS7
Promi
sing
Alloc
ate fu
nding
to in
creas
e phy
sical
activ
ity fa
cilitie
s in s
choo
ls.X
XX
Increa
sing a
ccessi
bility
to fa
cilitie
s to b
e phy
sicall
y acti
ve in
addit
ion to
inf
ormati
onal
outre
ach c
an in
creas
e phy
sical
activ
ity. M
aking
play
envir
onme
nts
more
aesth
etica
lly pl
easin
g has
been
linke
d to i
ncrea
sed p
hysic
al ac
tivity
.SS
Promi
sing
Acco
unt f
or he
alth b
y dev
elopin
g a he
alth k
nowl
edge
-base
.X
Deve
loping
a he
alth k
nowl
edge
-base
will
bring
atten
tion t
o the
man
y infl
uenc
es
over
a pers
on’s
healt
h whic
h will
curb
overw
eight
and o
besit
y.FS1
Promi
sing
Offer
finan
cial in
centi
ves t
o emp
loyee
s who
can d
ocum
ent p
articip
ating
in
regula
r phy
sical
activ
ity.
XX
XX
Fisca
l disc
ounts
, inclu
ding l
owere
d ins
uranc
e prem
iums,
may i
mprov
e pa
rticipa
tion i
n work
site w
ellne
ss pro
grams
.SS
Untes
ted
Brea
stfe
edin
g Po
licies
Create
polici
es th
at are
comp
liant
with
the U
NICE
F/W
HO ba
by-fri
endly
ho
spita
l guid
eline
s.X
XX
The i
mplem
entat
ion of
thes
e guid
eline
s tha
t are
outlin
ed in
the n
ine st
eps
provid
ed by
Unit
ed N
ation
s Chil
dren’s
Fund
/Worl
d Hea
lth O
rganiz
ation
incre
ases
bre
astfe
eding
initia
tion r
ates.SS
Effec
tive
Requ
ire em
ploye
rs to
provid
e paid
brea
k tim
e for
mothe
rs to
expre
ss bre
astm
ilk in
a pri
vate
locati
on, o
ther t
han a
bathr
oom
stall.
XX
X
Wome
n who
work
for e
mploy
ers w
ho al
low tim
e and
spac
e for
expre
ssing
bre
astm
ilk ar
e sho
wn to
brea
stfee
d at r
ates e
quiva
lent t
o wom
en no
t work
ing
outsi
de of
the h
ome.
Workp
laces
will
save
mon
ey by
decre
asing
abse
nteeis
m,
loweri
ng m
edica
l clai
ms, in
creas
ing pr
oduc
tivity
, and
indu
cing a
n earl
ier re
turn
amon
g new
moth
ers.SS
Promi
sing
Deve
lop in
centi
ve pr
ogram
s to e
ncou
rage e
mploy
ers to
ensu
re bre
astfe
eding
-frien
dly w
orksit
es.
XX
X
Wome
n who
work
for e
mploy
ers w
ho al
low tim
e and
spac
e for
expre
ssing
bre
astm
ilk ar
e sho
wn to
brea
stfee
d at r
ates e
quiva
lent t
o wom
en no
t work
ing
outsi
de of
the h
ome.
Workp
laces
will
save
mon
ey by
decre
asing
abse
nteeis
m,
loweri
ng m
edica
l clai
ms, in
creas
ing pr
oduc
tivity
, and
indu
cing a
n earl
ier re
turn
amon
g new
moth
ers.SS
Promi
sing
Provid
e flex
ible s
ched
ules,
lactat
ion ro
oms,
and a
ccess
for ne
w mo
thers
to lac
tation
cons
ultan
ts at
the w
orksit
e.X
XX
Wome
n who
work
for e
mploy
ers w
ho al
low tim
e and
spac
e for
expre
ssing
bre
astm
ilk ar
e sho
wn to
brea
stfee
d at r
ates e
quiva
lent t
o wom
en no
t work
ing
outsi
de of
the h
ome.
Workp
laces
will
save
mon
ey by
decre
asing
abse
nteeis
m,
loweri
ng m
edica
l clai
ms, in
creas
ing pr
oduc
tivity
, and
indu
cing a
n earl
ier re
turn
amon
g new
moth
ers.SS
, W3,
W15
Promi
sing
Texas Obesity Policy Portfolio �3
Evid
ence
Lege
nd —
S - S
choo
l, FS-
Fede
ral/S
tate,
CCG
- City
and c
ounty
gove
rnmen
t, W
- Work
site,
H - H
ealth
care,
M - M
edia,
FB - F
aith-b
ased
orga
nizati
ons,
SS - A
ll sec
tors a
nd se
ttings
.
Effe
ctive
pol
icy o
ptio
ns —
a po
licy op
tion o
r the
envir
onme
ntal c
hang
e the
policy
is m
eant
to bri
ng ab
out w
as te
sted i
n one
or m
ore w
ell-de
signe
d scie
ntific
stud
ies an
d fou
nd to
affec
t nutr
ition a
nd/o
r phy
sical
activ
ity be
havio
r.9
Prom
ising
pol
icy o
ptio
ns —
the r
ation
ale su
pport
ing th
e poli
cy op
tion o
r the
spec
ific po
licy ap
proac
h was
teste
d in o
ne or
more
well
-desig
ned s
cienti
fic st
udies
and r
esult
s of e
ffecti
vene
ss are
ongo
ing.9
Unte
sted
pol
icy o
ptio
ns —
policy
optio
ns, w
hich a
re po
tentia
lly gr
eat id
eas,
but a
re un
tested
or ar
e sho
wn to
not h
ave d
efinit
ive re
sults
.9
Texa
s Obe
sity
Polic
y Po
rtfol
io
Polic
y Op
tions
Federal/State
Media
Schools
Faith-Based Organizations
City/County
Worksites
Health Care
Evid
ence
Leve
l of
Effe
ctive
ness
Mand
ate or
prov
ide in
centi
ves t
o ins
uranc
e com
panie
s and
HMO
’s to
provid
e cov
erage
for t
eleph
one a
nd in
-perso
n lac
tation
cons
ultati
ons
postp
artum
.X
XX
XPro
viding
in-pe
rson a
nd/o
r tele
phon
e sup
port
increa
ses b
reastf
eedin
g dura
tion.SS
Promi
sing
Allow
for s
afe st
orage
and p
roced
ures f
or us
ing br
eastm
ilk, f
ollow
ing
paren
t’s in
struc
tions
for b
reastm
ilk us
age,
and p
rovidi
ng an
area
on-sit
e for
moth
ers to
expre
ss bre
astm
ilk at
child
-care
cente
rs.X
XX
Child
care
facilit
ies ca
n sup
port
a moth
er’s c
hoice
to br
eastf
eed b
y prov
iding
safe
breas
tmilk
stora
ge an
d proc
edure
s, an
d prov
iding
priva
te fac
ilities
whe
re mo
thers
can b
reastf
eed.SS
Untes
ted
Estab
lish ch
ild-ca
re fac
ilities
on-sit
e or c
lose t
o work
sites
so m
others
can
conti
nue t
o brea
stfee
d whil
e the
ir infa
nt is
in ch
ild ca
re.X
XX
Provid
ing ac
cessi
ble ch
ild-ca
re fac
ilities
will
facilit
ate a
worki
ng m
other’
s cho
ice to
bre
astfe
ed by
allow
ing m
others
to br
eastf
eed l
onge
r.SS
Untes
ted
Exem
pt bre
astfe
eding
moth
ers fr
om ju
ry du
ty.X
XTh
is ac
tion s
trives
to m
inimi
ze th
e disr
uptio
n of b
reastf
eedin
g moth
ers an
d has
alr
eady
been
enac
ted in
five s
tates
.SS
Untes
ted
Exem
pt ma
terial
s for
the pu
rpose
of br
eastf
eedin
g from
sales
tax.
XX
Decre
asing
the c
osts
of bre
astfe
eding
supp
lies b
y elim
inatin
g the
sales
tax
enco
urage
s more
moth
ers to
brea
stfee
d.SS, F
S7
Untes
ted
Mand
ate th
at all
healt
h-care
profe
ssion
als w
ho pr
ovide
mate
rnal a
nd
child
-care
servi
ces t
ake t
rainin
g in l
actat
ion su
pport
.X
XPro
viding
lacta
tion t
rainin
g to h
ealth
-care
provid
ers w
ill inc
rease
brea
stfee
ding.SS
, H5
Untes
ted
Allocat
e fun
ding t
o WIC
clinics
to ac
quire
brea
st pu
mps t
o loa
n to p
articip
ants.
XPro
viding
brea
st pu
mps t
o moth
ers w
ho pa
rticipa
te in
the W
IC pro
gram
will
enco
urage
the c
ontin
uatio
n of b
reastf
eedin
g afte
r retu
rning
to w
ork an
d/or
schoo
l.SS
Untes
ted
Built
Env
ironm
ent P
olici
esMa
ndate
that
new
hous
ing an
d com
merci
al de
velop
ments
insta
ll sid
ewalk
s and
inter
nal co
nnect
ions t
o form
pede
strian
and b
icycle
netw
orks.
XX
Bette
r walk
ing an
d biki
ng in
frastr
uctur
es ar
e asso
ciated
with
more
indiv
idual
walki
ng an
d biki
ng tr
ips.SS
Promi
sing
Forbi
d or c
reate
disinc
entive
s for
constr
ucting
cul-de
-sacs
and d
ead-e
nd ro
ads.
XX
Stree
t con
nectiv
ity is
a majo
r con
tributo
r to th
e “wa
lkabil
ity” o
f an a
rea w
hich i
s as
socia
ted po
sitive
ly wi
th wa
lking
and b
icycle
trips
.SS,
Promi
sing
Imple
ment
traffic
-calm
ing m
easu
res fo
r safe
r ped
estria
n and
cyclin
g area
s.X
XTra
ffic en
ginee
ring i
nitiat
ives s
uch a
s sing
le-lan
e rou
ndab
outs,
side
walks
, exc
lude
pede
strian
sign
al ph
asing
, ped
estria
n refu
ge is
lands
, and
incre
ased
inten
sity o
f roa
dway
lighti
ng ca
n dec
rease
pede
strian
-vehic
le cra
shes
.SS
Promi
sing
Texas Obesity Policy Portfolio�4
Evid
ence
Lege
nd —
S - S
choo
l, FS-
Fede
ral/S
tate,
CCG
- City
and c
ounty
gove
rnmen
t, W
- Work
site,
H - H
ealth
care,
M - M
edia,
FB - F
aith-b
ased
orga
nizati
ons,
SS - A
ll sec
tors a
nd se
ttings
.
Effe
ctive
pol
icy o
ptio
ns —
a po
licy op
tion o
r the
envir
onme
ntal c
hang
e the
policy
is m
eant
to bri
ng ab
out w
as te
sted i
n one
or m
ore w
ell-de
signe
d scie
ntific
stud
ies an
d fou
nd to
affec
t nutr
ition a
nd/o
r phy
sical
activ
ity be
havio
r.9
Prom
ising
pol
icy o
ptio
ns —
the r
ation
ale su
pport
ing th
e poli
cy op
tion o
r the
spec
ific po
licy ap
proac
h was
teste
d in o
ne or
more
well
-desig
ned s
cienti
fic st
udies
and r
esult
s of e
ffecti
vene
ss are
ongo
ing.9
Unte
sted
pol
icy o
ptio
ns —
policy
optio
ns, w
hich a
re po
tentia
lly gr
eat id
eas,
but a
re un
tested
or ar
e sho
wn to
not h
ave d
efinit
ive re
sults
.9
Texa
s Obe
sity
Polic
y Po
rtfol
io
Polic
y Op
tions
Federal/State
Media
Schools
Faith-Based Organizations
City/County
Worksites
Health Care
Evid
ence
Leve
l of
Effe
ctive
ness
Gran
t ince
ntive
s for
build
ers of
mult
ileve
l buil
dings
to m
ake s
tairw
ays
acce
ssible
and a
ttrac
tive.
XX
Makin
g stai
rway
s acce
ssible
and a
esthe
tic, in
addit
ion to
direc
tiona
l sign
s, an
d pla
ying m
usic
increa
ses s
tair u
se.SS
, W16
Promi
sing
Gran
t fina
ncial
ince
ntive
s for
instal
ling d
esign
featu
res in
new
build
ings
that e
ncou
rage p
hysic
al ac
tivity
.X
XX
Impro
ving a
ccessi
bility
to ar
eas o
f phy
sical
in ad
dition
to ed
ucati
onal
outre
ach c
an
increa
se ph
ysica
l acti
vity.SS
, W5
Promi
sing
Requ
ire m
unicip
al co
mpreh
ensiv
e plan
s tha
t pub
lic fac
ilities
be
impro
ved u
pon b
efore
new
facilit
ies ar
e con
struc
ted.
XX
Reinv
estin
g res
ource
s in e
xistin
g neig
hborh
oods
and f
acilit
ies co
uld fo
ster p
hysic
al ac
tivity
and c
ould
enco
urage
use o
f olde
r neig
hborh
oods
whic
h are
often
more
“w
alkab
le” th
an ne
w ne
ighbo
rhood
s.SS
Untes
ted
Mand
ate or
gran
t ince
ntive
s for
remod
eling
exist
ing sc
hool
build
ings,
over
cons
tructi
ng ne
w fac
ilities
.X
XX
Reno
vatin
g exis
ting s
choo
ls wi
ll lea
d to r
enov
ation
and r
edev
elopm
ent o
f more
de
nse n
eighb
orhoo
ds. H
igher
dens
ity an
d mixe
d-use
area
s are
linke
d to g
reater
ph
ysica
l acti
vity.SS
Untes
ted
Adop
t stan
dards
to m
inimi
ze th
e amo
unt o
f land
need
ed fo
r new
sch
ool b
uildin
gs.
XX
XDe
creas
ing th
e amo
unt o
f land
need
ed to
build
new
schoo
ls fac
ilities
can
enco
urage
scho
ols to
deve
lop in
more
dens
ely po
pulat
ed ar
eas w
hich a
re as
socia
ted w
ith m
ore ph
ysica
l acti
vity.SS
Untes
ted
Mand
ate, e
ncou
rage,
or pro
vide i
ncen
tives
in th
e sch
ool fa
cilitie
s Ma
nual
so w
hen s
choo
ls ren
ovate
or bu
ild ne
w fac
ilities
they
desig
n pa
rking
lots
to mi
nimize
inter
feren
ce w
ith bi
kers
and w
alkers
.X
XX
Placin
g emp
hasis
on no
nmoto
rized
comm
uting
in th
e des
ign of
scho
ols w
ill en
coura
ge ph
ysica
l acti
vity.SS
Untes
ted
Provid
e work
ers w
ith sh
ower
facilit
ies an
d flex
time t
o enc
ourag
e ph
ysica
l acti
vity d
uring
the d
ay.
XX
Provid
ing em
ploye
es w
ith sh
ower
facilit
ies an
d/or
flexti
me pr
ompts
emplo
yees
to
be m
ore ph
ysica
lly ac
tive.
Havin
g a fle
xible
sched
ule is
asso
ciated
with
mee
ting
phys
ical a
ctivit
y guid
eline
s.SS, W
3, W
15
Untes
ted
Instal
l bike
rack
s clos
e to w
orksit
es, s
hopp
ing ce
nters,
tran
sport
ation
hu
bs, a
nd ot
her p
laces
that
enco
urage
cyclin
g for
trans
porta
tion.
XX
Provid
ing pl
aces
for s
afely
secu
ring b
icycle
s will
enco
urage
bicy
cling.SS
Untes
ted
City
Pla
nnin
g/Tr
ansp
orta
tion
Polic
iesInc
orpora
te ne
twork
s of f
oot a
nd bi
cycle
paths
as al
terna
tives
to
roadw
ays i
n a co
mmun
ity’s
comp
rehen
sive p
lan.
XCre
ating
area
s for
increa
sed p
hysic
al ac
tivity
, with
the a
pprop
riate
outre
ach
meas
ures,
can i
ncrea
se ph
ysica
l acti
vity.
Also,
bette
r walk
ing an
d biki
ng
infras
tructu
res ar
e link
ed to
more
walk
ing an
d biki
ng tr
ips.SS
Effec
tive
Texas Obesity Policy Portfolio �5
Evid
ence
Lege
nd —
S - S
choo
l, FS-
Fede
ral/S
tate,
CCG
- City
and c
ounty
gove
rnmen
t, W
- Work
site,
H - H
ealth
care,
M - M
edia,
FB - F
aith-b
ased
orga
nizati
ons,
SS - A
ll sec
tors a
nd se
ttings
.
Effe
ctive
pol
icy o
ptio
ns —
a po
licy op
tion o
r the
envir
onme
ntal c
hang
e the
policy
is m
eant
to bri
ng ab
out w
as te
sted i
n one
or m
ore w
ell-de
signe
d scie
ntific
stud
ies an
d fou
nd to
affec
t nutr
ition a
nd/o
r phy
sical
activ
ity be
havio
r.9
Prom
ising
pol
icy o
ptio
ns —
the r
ation
ale su
pport
ing th
e poli
cy op
tion o
r the
spec
ific po
licy ap
proac
h was
teste
d in o
ne or
more
well
-desig
ned s
cienti
fic st
udies
and r
esult
s of e
ffecti
vene
ss are
ongo
ing.9
Unte
sted
pol
icy o
ptio
ns —
policy
optio
ns, w
hich a
re po
tentia
lly gr
eat id
eas,
but a
re un
tested
or ar
e sho
wn to
not h
ave d
efinit
ive re
sults
.9
Texa
s Obe
sity
Polic
y Po
rtfol
io
Polic
y Op
tions
Federal/State
Media
Schools
Faith-Based Organizations
City/County
Worksites
Health Care
Evid
ence
Leve
l of
Effe
ctive
ness
In mu
nicipa
l com
prehe
nsive
plan
s, de
velop
meth
ods t
o prom
ote gr
owth
near
trans
porta
tion h
ubs.
X
Mixe
d-use
neigh
borho
ods t
hat a
re clo
se to
shop
ping,
work,
and o
ther
nonre
siden
tial la
nd us
e are
linke
d with
incre
ased
walk
ing an
d biki
ng am
ong
reside
nts. C
ounti
es w
ith pe
rvasiv
e urba
n spra
wl ar
e link
ed to
high
er pre
valen
ce
rates
of ob
esity
, high
er BM
Is, an
d hyp
erten
sion.SS
Promi
sing
Promo
te mi
xed-u
se ne
ighbo
rhood
s thro
ugh z
oning
rules
, ince
ntive
and
disinc
entiv
es in
mun
icipal
comp
rehen
sive p
lans.
XX
Mixe
d-use
neigh
borho
ods t
hat a
re clo
se to
shop
ping,
work,
and o
ther
nonre
siden
tial la
nd us
e are
linke
d with
incre
ased
walk
ing an
d biki
ng am
ong
reside
nts. C
ounti
es w
ith pe
rvasiv
e urba
n spra
wl ar
e link
ed to
high
er pre
valen
ce
rates
of ob
esity
, high
er BM
Is, an
d hyp
erten
sion.SS
,
Promi
sing
Loca
te bu
sines
ses i
n area
s tha
t are
desig
nated
mixe
d-use
.
X
Mixe
d-use
neigh
borho
ods t
hat a
re clo
se to
shop
ping,
work,
and o
ther
nonre
siden
tial la
nd us
e are
linke
d with
incre
ased
walk
ing an
d biki
ng am
ong
reside
nts. C
ounti
es w
ith pe
rvasiv
e urba
n spra
wl ar
e link
ed to
high
er pre
valen
ce
rates
of ob
esity
, high
er BM
Is, an
d hyp
erten
sion.SS
Promi
sing
Alloc
ate m
ore fu
nding
to S
afe Ro
utes t
o Sch
ool p
rogram
s.X
XX
Activ
e tran
sport
ation
to an
d from
scho
ol co
ntribu
tes to
child
ren’s
daily
phys
ical
activ
ity, a
nd S
afe Ro
utes t
o Sch
ool p
rogram
s can
incre
ase t
he nu
mber
of stu
dents
wa
lking
or cy
cling t
o sch
ool.SS
Promi
sing
Make
tran
sport
ation
infra
struc
ture i
mprov
emen
ts a p
riority
to m
unicip
al co
mpreh
ensiv
e plan
s.
X
A larg
e obs
tacle
to wa
lking
or cy
cling t
o sch
ool is
dang
er fro
m tra
ffic. T
hus,
traffic
engin
eerin
g mea
sures
shou
ld be
insti
lled s
uch a
s sing
le-lan
e rou
ndab
outs,
sid
ewalk
s, ex
clude
pede
strian
sign
al ph
asing
, ped
estria
n refu
ge is
lands
, and
inc
rease
d inte
nsity
of ro
adwa
y ligh
ting c
an de
creas
e ped
estria
n-veh
icle cr
ashe
s. Als
o, be
tter in
frastr
uctur
e for
walki
ng an
d biki
ng is
asso
ciated
with
more
walk
ing
and b
iking
trips
.SS
Promi
sing
Enha
nce c
ommu
nity a
waren
ess o
f the
bene
fits of
activ
e tran
sport
ation
.X
XX
XX
XX
Activ
e tran
sport
will
increa
se a
comm
unity
’s op
portu
nities
for p
hysic
al ac
tivity
. Bu
ilding
a pro
motio
nal c
ampa
ign ar
ound
this
spec
ific ar
ea co
uld le
ad to
grea
ter
biking
and w
alking
trips
.SS
Promi
sing
Provid
e inc
entiv
es fo
r com
munit
y gard
ens o
n pub
lic an
d/or
priva
te lan
d.X
Planti
ng co
mmun
ity ga
rdens
can e
nhan
ce bo
th ph
ysica
l acti
vity a
s well
fruit
and
vege
table
cons
umpti
on.SS
Untes
ted
Texas Obesity Policy Portfolio�6
Evid
ence
Lege
nd —
S - S
choo
l, FS-
Fede
ral/S
tate,
CCG
- City
and c
ounty
gove
rnmen
t, W
- Work
site,
H - H
ealth
care,
M - M
edia,
FB - F
aith-b
ased
orga
nizati
ons,
SS - A
ll sec
tors a
nd se
ttings
.
Effe
ctive
pol
icy o
ptio
ns —
a po
licy op
tion o
r the
envir
onme
ntal c
hang
e the
policy
is m
eant
to bri
ng ab
out w
as te
sted i
n one
or m
ore w
ell-de
signe
d scie
ntific
stud
ies an
d fou
nd to
affec
t nutr
ition a
nd/o
r phy
sical
activ
ity be
havio
r.9
Prom
ising
pol
icy o
ptio
ns —
the r
ation
ale su
pport
ing th
e poli
cy op
tion o
r the
spec
ific po
licy ap
proac
h was
teste
d in o
ne or
more
well
-desig
ned s
cienti
fic st
udies
and r
esult
s of e
ffecti
vene
ss are
ongo
ing.9
Unte
sted
pol
icy o
ptio
ns —
policy
optio
ns, w
hich a
re po
tentia
lly gr
eat id
eas,
but a
re un
tested
or ar
e sho
wn to
not h
ave d
efinit
ive re
sults
.9
Texa
s Obe
sity
Polic
y Po
rtfol
io
Polic
y Op
tions
Federal/State
Media
Schools
Faith-Based Organizations
City/County
Worksites
Health Care
Evid
ence
Leve
l of
Effe
ctive
ness
Craft
a ped
estria
n and
/or b
icyclin
g mas
ter pl
an th
at de
tails
the ci
ty’s
plan t
o mak
e the
comm
unity
more
supp
ortive
to ph
ysica
l acti
vity.
XCra
fting a
mas
ter pl
an w
ill pro
vide a
road
map
for d
evelo
ping a
n infr
astru
cture
favora
ble to
phys
ical a
ctivit
y.SS
Untes
ted
Make
phys
ical a
ctivit
y a m
ajor p
riority
in m
unicip
al ma
ster p
lans b
y ma
ndati
ng al
l new
build
ing an
d tran
sport
ation
proje
cts co
nside
r the
im
pact
of an
d mak
e con
sidera
tions
for p
hysic
al ac
tivity
.X
Mand
ating
cons
iderat
ion of
the i
mpac
t of b
uildin
g and
tran
sport
ation
proje
cts on
ph
ysica
l acti
vity w
ill en
coura
ge a
bette
r atm
osph
ere fo
r phy
sical
activ
ity.SS
Untes
ted
Loca
te pa
rking
lots
away
from
pede
strian
and b
icycle
paths
.X
XX
XLo
catin
g park
ing lo
ts aw
ay fr
om w
alking
or bi
cycle
paths
will
enco
urage
more
ph
ysica
l acti
vity.
Walki
ng an
d biki
ng in
frastr
uctur
e has
been
linke
d to m
ore bi
king
and w
alking
trips
.SS
Untes
ted
Mand
ate an
d allo
cate
fundin
g for
walki
ng an
d biki
ng m
aps f
or rou
tes
to sch
ool.
XX
X
Provid
ing in
forma
tion t
o pare
nts ab
out s
afe ro
utes t
o and
from
scho
ol wi
ll inc
rease
the n
umbe
r of s
tuden
ts wa
lking
and b
iking
to sc
hool.
Also
, map
s are
effec
tive a
s part
of S
afe Ro
utes t
o Sch
ool p
rogram
s to i
ncrea
se th
e num
ber o
f stu
dents
walk
ing or
cyclin
g to s
choo
l.SS
Untes
ted
Create
ince
ntive
s or d
isince
ntive
s to e
ncou
rage f
acult
y, sta
ff, an
d stu
dents
to co
mmute
activ
ely.
XX
XGr
antin
g inc
entiv
es or
disin
centi
ves f
or co
mmuti
ng ac
tively
will
enco
urage
phys
ical
activ
ity.SS
Untes
ted
Educ
atio
n Po
licies
Requ
ire th
e phy
sical
educ
ation
curric
ulum
to pro
vide m
odera
te to
inten
se ph
ysica
l acti
vity.
XX
XInc
reasin
g the
amou
nt of
time t
hat s
tuden
ts sp
end o
n phy
sical
activ
ity w
hile i
n PE
classe
s can
incre
ase p
hysic
al ac
tivity
and fi
tness
levels
.SS, S
10, S
6, S
3, S
4
Effec
tive
Requ
ire al
l K-12
stud
ents
to en
roll in
daily
PE cl
asse
s in e
very
schoo
l ye
ar ter
m.X
XX
Increa
sing t
he am
ount
of tim
e stud
ents
spen
d in P
E clas
ses c
an ha
ve a
posit
ive
effec
t on p
hysic
al ac
tivity
and n
egati
ve ef
fects
on be
ing ov
erweig
ht.SS
, S10
, S6,
S3,
S4
Effec
tive
Mand
ate th
at ele
menta
ry sch
oolch
ildren
be pr
ovide
d at le
ast 3
0 mi
nutes
of re
cess
durin
g the
scho
ol da
y.X
XX
Eleme
ntary
schoo
lchild
ren sp
end a
t leas
t som
e of t
heir r
eces
s tim
e in m
odera
te to
vigoro
us ph
ysica
l acti
vity.SS
, S10
, S6,
S3,
S4
Promi
sing
Instat
e reg
ular t
rainin
g to P
E tea
chers
to en
hanc
e skil
ls for
incre
asing
ph
ysica
l acti
vity d
uring
PE cl
asse
s.X
XX
Augm
entin
g PE t
each
er’s s
kills
for in
creas
ing th
e amo
unt o
f tim
e tha
t stud
ents
are
phys
ically
activ
e is a
n effe
ctive
part
of the
curric
ulum.
SS, S
10, S
3, S
4
Promi
sing
Work
with
careg
ivers
to ini
tiate
appro
priate
after
-scho
ol ca
re ex
ercise
/ac
tivity
prog
rams.
XX
XX
Placin
g req
uirem
ents
in aft
er-sch
ool c
are se
ttings
can h
elp ov
ercom
e sed
entar
y be
havio
rs.SS
, S5,
S3,
S4
Promi
sing
Texas Obesity Policy Portfolio �7
Evid
ence
Lege
nd —
S - S
choo
l, FS-
Fede
ral/S
tate,
CCG
- City
and c
ounty
gove
rnmen
t, W
- Work
site,
H - H
ealth
care,
M - M
edia,
FB - F
aith-b
ased
orga
nizati
ons,
SS - A
ll sec
tors a
nd se
ttings
.
Effe
ctive
pol
icy o
ptio
ns —
a po
licy op
tion o
r the
envir
onme
ntal c
hang
e the
policy
is m
eant
to bri
ng ab
out w
as te
sted i
n one
or m
ore w
ell-de
signe
d scie
ntific
stud
ies an
d fou
nd to
affec
t nutr
ition a
nd/o
r phy
sical
activ
ity be
havio
r.9
Prom
ising
pol
icy o
ptio
ns —
the r
ation
ale su
pport
ing th
e poli
cy op
tion o
r the
spec
ific po
licy ap
proac
h was
teste
d in o
ne or
more
well
-desig
ned s
cienti
fic st
udies
and r
esult
s of e
ffecti
vene
ss are
ongo
ing.9
Unte
sted
pol
icy o
ptio
ns —
policy
optio
ns, w
hich a
re po
tentia
lly gr
eat id
eas,
but a
re un
tested
or ar
e sho
wn to
not h
ave d
efinit
ive re
sults
.9
Texa
s Obe
sity
Polic
y Po
rtfol
io
Polic
y Op
tions
Federal/State
Media
Schools
Faith-Based Organizations
City/County
Worksites
Health Care
Evid
ence
Leve
l of
Effe
ctive
ness
Mand
ate su
rveilla
nce o
f BMI
.X
XX
Mand
ating
the s
urveil
lance
of B
MI co
uld le
ad to
more
aware
ness
of ov
erweig
ht an
d obe
sity a
nd le
ss pre
valen
ce an
d inc
idenc
e rate
s.FS2
Promi
sing
Mand
ate th
e dev
elopm
ent a
nd im
pleme
ntatio
n of P
E curr
icula
which
em
phas
izes l
ife-lo
ng fit
ness
activ
ities o
ver t
raditio
nal s
ports
activ
ities.
XX
XPla
cing e
mpha
sis on
life-l
ong fi
tness
activ
ities o
ver t
eam
sport
s tea
ches
stud
ents
skills
and a
ctivit
ies to
use t
hroug
hout
their l
ives,
promp
ting t
hem
to be
more
ph
ysica
lly ac
tive.SS
, S10
, S3
Untes
ted
Train
perso
nnel,
eithe
r paid
or un
paid,
to te
ach c
hildre
n in t
he
comm
unity
appro
priate
eatin
g and
exerc
ising h
abits
.X
XX
XHa
ving t
raine
d pers
onne
l dev
oted t
o tea
ching
child
ren he
althy
life-s
tyles
can l
ead
to he
althie
r chil
dren.SS
, S6
Untes
ted
Create
spec
ial w
eight-
focus
ed se
rvice
s in-s
choo
l and
after
-scho
ol ca
re se
ttings
to ad
dress
need
s of a
lread
y ove
rweig
ht ch
ildren
.X
XX
XTa
rgetin
g chil
dren w
ho ar
e alre
ady o
verw
eight
can l
ead t
o hea
lthier
life-s
tyles
wi
th the
appro
priate
inter
venti
ons.SS
, S8,
S8,
S6
Untes
ted
Requ
ire ex
ercise
for c
hildre
n in c
hild c
are an
d kind
ergart
enX
XX
XGe
tting a
n earl
y star
t to h
ealth
y life
-style
s can
insti
ll hea
lthy h
abits
for m
any
years
.SS, S
10, S
6,S3
Untes
ted
Requ
ire sc
hools
to tr
ain he
alth-c
are pr
ofessi
onals
or pl
ace b
reastf
eedin
g tra
ining
into
the cu
rriculu
m.X
XX
XRe
quirin
g sch
ools
that t
rain h
ealth
profe
ssion
als to
plac
e brea
stfee
ding t
rainin
g int
o the
curric
ulum
would
resu
lt in h
igher
breas
tfeed
ing ra
tes.SS
, S3,
S4,
Untes
ted
Med
ia P
olici
esCre
ate an
d adh
ere to
mark
eting
and a
dvert
ising p
arame
ters t
o curt
ail
the ris
k of o
besit
y in c
hildre
n.X
XX
The f
edera
l gov
ernme
nt’s m
anda
ting a
nd en
forcin
g the
food
indu
stry t
o crea
te gu
idelin
es fo
r prom
oting
food
, bev
erage
s, an
d sed
entar
y ente
rtainm
ent t
argete
d to
child
ren w
ith re
gards
to pr
oduc
t plac
emen
t, pro
motio
n, an
d con
tent w
ill cu
rtail
child
ren’s
demo
nstra
ting s
eden
tary l
ife-st
yles a
nd po
or ea
ting.SS
, FS6
, M2,
M1,
CCG
4-6, H
1-2
Promi
sing
Incorp
orate
the us
e of b
ehav
ioral
brand
ing to
enco
urage
phys
ical
activ
ity lik
e the
VER
B ca
mpaig
n.X
XBe
havio
ral br
andin
g has
been
show
n to b
e effe
ctive
at co
mmun
icatin
g with
ch
ildren
. The
VER
B ca
mpaig
n effic
iently
harne
ssed a
ll form
s of m
edia
to co
mmun
icate
to ch
ildren
the b
enefi
ts of
phys
ical a
ctivit
y.SS, M
1, M
2, H
1-2
Promi
sing
Enac
t a co
mpreh
ensiv
e med
ia ca
mpaig
n to r
aise a
waren
ess a
bout
the
dang
ers of
obes
ity.
XX
XX
XX
XPu
blic o
pinion
chan
ged a
bout
tobac
co du
e to t
he ef
forts
of ad
voca
tes an
d the
dif
fusion
of in
forma
tion a
bout
its he
alth r
isks.
Initia
tives
towa
rds af
fectin
g soc
ial
opini
on w
ill lea
d to p
olicy
chan
ges.SS
, M2,
M1,
CCG4
–6,H
1–2
Untes
ted
Indu
stry
Pol
icies
Texas Obesity Policy Portfolio��
Evid
ence
Lege
nd —
S - S
choo
l, FS-
Fede
ral/S
tate,
CCG
- City
and c
ounty
gove
rnmen
t, W
- Work
site,
H - H
ealth
care,
M - M
edia,
FB - F
aith-b
ased
orga
nizati
ons,
SS - A
ll sec
tors a
nd se
ttings
.
Effe
ctive
pol
icy o
ptio
ns —
a po
licy op
tion o
r the
envir
onme
ntal c
hang
e the
policy
is m
eant
to bri
ng ab
out w
as te
sted i
n one
or m
ore w
ell-de
signe
d scie
ntific
stud
ies an
d fou
nd to
affec
t nutr
ition a
nd/o
r phy
sical
activ
ity be
havio
r.9
Prom
ising
pol
icy o
ptio
ns —
the r
ation
ale su
pport
ing th
e poli
cy op
tion o
r the
spec
ific po
licy ap
proac
h was
teste
d in o
ne or
more
well
-desig
ned s
cienti
fic st
udies
and r
esult
s of e
ffecti
vene
ss are
ongo
ing.9
Unte
sted
pol
icy o
ptio
ns —
policy
optio
ns, w
hich a
re po
tentia
lly gr
eat id
eas,
but a
re un
tested
or ar
e sho
wn to
not h
ave d
efinit
ive re
sults
.9
Texa
s Obe
sity
Polic
y Po
rtfol
io
Polic
y Op
tions
Federal/State
Media
Schools
Faith-Based Organizations
City/County
Worksites
Health Care
Evid
ence
Leve
l of
Effe
ctive
ness
Mand
ate th
at nu
trition
al lab
els ap
pear
on al
l fres
h mea
t and
poult
ry.X
XUs
ing nu
trition
al inf
ormati
on in
fluen
ces f
ood b
uying
decis
ions a
nd is
linke
d with
be
tter d
ietary
habit
s.SS
Promi
sing
Produ
ce an
d exe
cute
a lab
eling
syste
m to
identi
fy foo
d item
s tha
t mee
t ce
rtain
agree
d-upo
n guid
eline
s.X
XX
Provid
ing nu
trition
al inf
ormati
on af
fects
food s
electi
on.SS
Promi
sing
Post
nutrit
ional
inform
ation
on m
enus
, men
u boa
rds, a
nd fo
od so
ld in
works
ite ca
feteri
as.
XX
XX
Provid
ing nu
trition
al inf
ormati
on af
fects
food s
electi
on.SS
Promi
sing
Enac
t a nu
trition
labe
ling s
ystem
that
identi
fies f
ood t
hat m
eets
certa
in ag
reed u
pon g
uideli
nes.
XX
XX
Provid
ing nu
trition
al inf
ormati
on af
fects
food s
electi
on.SS
Promi
sing
Requ
ire re
staura
nts to
prov
ide nu
trition
al inf
ormati
on.
XX
XPro
viding
nutrit
ional
inform
ation
affec
ts foo
d sele
ction
.SSPro
misin
g
Provid
e inc
entiv
es fo
r res
tauran
ts an
d/or
groce
ry sto
res to
adop
t a
stand
ardize
d nutr
itiona
l labe
ling s
ystem
.X
XX
Cons
umers
use l
abels
with
healt
h clai
ms to
mak
e foo
d dec
isions
.SSPro
misin
g
Requ
ire nu
trition
al inf
ormati
on be
poste
d or a
ppea
r on f
ood l
abels
of al
l foo
d bou
ght a
nd se
rved i
n sch
ools.
XX
XPro
viding
nutrit
ional
inform
ation
affec
ts foo
d sele
ction
.SSPro
msing
Well
ness
Pol
icies
Provid
e inc
entiv
es fo
r emp
loyers
to of
fer w
ellne
ss pro
grams
.X
XX
Welln
ess p
rogram
s hav
e prov
en to
be ef
fectiv
e in l
oweri
ng ab
sente
eism
and
reduc
ing he
alth-c
are co
sts fo
r emp
loyers
.SS, C
CG 3
, W4,
W5,
W18
Promi
sing
Mand
ate or
prov
ide in
centi
ves t
o hea
lth in
suran
ce co
mpan
ies an
d HM
O’s t
o inc
lude p
reven
tative
servi
ces r
elated
to nu
trition
.X
XX
Beha
vioral
coun
selin
g prov
ided b
y a tr
ained
healt
h-care
prov
ider in
prim
ary ca
re is
effec
tive i
n cha
nging
eatin
g beh
avior
s. Als
o, co
mbine
d nutr
itiona
l and
phys
ical
activ
ity co
unse
ling m
ay pr
oduc
e weig
ht los
s in o
bese
patie
nts.SS
, FS4
, W4,
W7
Promi
sing
Offer
disco
unts
on a
sliding
scale
to em
ploye
rs ba
sed o
n the
emplo
yer’s
he
alth a
nd w
ellne
ss pro
grams
.X
XX
Works
ite w
ellne
ss pro
grams
are e
ffecti
ve an
d can
lowe
r abs
entee
ism, a
nd re
duce
he
alth-c
are co
sts of
emplo
yers.
SS, W
4, W
12
Promi
sing
Put c
ommu
nity-b
ased p
rogram
s in pl
ace to
influ
ence
weigh
t-relat
ed be
havio
r.X
XX
Empo
werin
g com
munit
ies to
take
the l
ead t
o dev
elopin
g weig
ht-los
s prog
rams
could
lead
to w
eight
loss.SS
, FS1
2, FS
14–1
5, FB
3, CC
G3, W
4, W
11-13
Promi
sing
Gran
t ince
ntive
s to e
mploy
ers to
prov
ide w
ellne
ss pro
grams
that
have
su
bstan
tial p
hysic
al ac
tivity
comp
onen
ts, su
ch as
inclu
ding s
ubsid
ized
healt
h-club
mem
bersh
ips.
XX
Welln
ess p
rogram
s hav
e prov
en to
be ef
fectiv
e in l
oweri
ng ab
sente
eism
and
reduc
ing he
alth c
are co
sts fo
r emp
loyers
. Also
, offe
ring fi
nanc
ial in
centi
ve is
lin
ked t
o more
partic
ipatio
n in w
orksit
e well
ness
progra
ms.SS
, W4,
W5-6
, W11
-14
Promi
sing
Texas Obesity Policy Portfolio �9
Evid
ence
Lege
nd —
S - S
choo
l, FS-
Fede
ral/S
tate,
CCG
- City
and c
ounty
gove
rnmen
t, W
- Work
site,
H - H
ealth
care,
M - M
edia,
FB - F
aith-b
ased
orga
nizati
ons,
SS - A
ll sec
tors a
nd se
ttings
.
Effe
ctive
pol
icy o
ptio
ns —
a po
licy op
tion o
r the
envir
onme
ntal c
hang
e the
policy
is m
eant
to bri
ng ab
out w
as te
sted i
n one
or m
ore w
ell-de
signe
d scie
ntific
stud
ies an
d fou
nd to
affec
t nutr
ition a
nd/o
r phy
sical
activ
ity be
havio
r.9
Prom
ising
pol
icy o
ptio
ns —
the r
ation
ale su
pport
ing th
e poli
cy op
tion o
r the
spec
ific po
licy ap
proac
h was
teste
d in o
ne or
more
well
-desig
ned s
cienti
fic st
udies
and r
esult
s of e
ffecti
vene
ss are
ongo
ing.9
Unte
sted
pol
icy o
ptio
ns —
policy
optio
ns, w
hich a
re po
tentia
lly gr
eat id
eas,
but a
re un
tested
or ar
e sho
wn to
not h
ave d
efinit
ive re
sults
.9
Texa
s Obe
sity
Polic
y Po
rtfol
io
Polic
y Op
tions
Federal/State
Media
Schools
Faith-Based Organizations
City/County
Worksites
Health Care
Evid
ence
Leve
l of
Effe
ctive
ness
Includ
e a w
ellne
ss pro
gram,
with
a su
bstan
tial p
hysic
al ac
tivity
co
mpon
ent,
as pa
rt of
the em
ploye
e ben
efit p
acka
ge.
XX
Welln
ess p
rogram
s hav
e prov
en to
be ef
fectiv
e in l
oweri
ng ab
sente
eism
and
reduc
ing he
alth c
are co
sts fo
r emp
loyers
.SS, W
4-6, W
11-14
Promi
sing
Imple
ment
best
practi
ce gu
idelin
es to
man
age o
besit
y.X
XPu
tting s
tanda
rds an
d ben
chma
rks in
to pla
ce w
ill em
powe
r hea
lth ca
re pro
viders
to
comb
at ob
esity
.SS
Promi
sing
Mand
ate or
prov
ide in
centi
ves f
or he
alth c
are pl
ans t
o inc
lude
preve
ntativ
e serv
ices r
elated
to ph
ysica
l acti
vity a
s part
of th
eir be
nefit
pack
ages
.X
XInd
ividu
al he
alth b
ehav
ior-ch
ange
prog
rams a
re eff
ectiv
e in i
ncrea
sing p
hysic
al ac
tivity
. Com
bined
phys
ical a
nd nu
trition
al co
unse
ling c
an pr
oduc
e weig
ht los
s in
obes
e peo
ple.SS
, W4-6
, W12
–15
Promi
sing
Gran
t fina
ncial
ince
ntive
s for
indivi
dual
purch
ase o
f exe
rcise
equip
ment
for he
alth-c
lub m
embe
rships
.X
Ownin
g or h
aving
acce
ss to
exerc
ise eq
uipme
nt is
linke
d to i
ncrea
sed p
hysic
al ac
tivity
. Also
, impro
ving a
ccessi
bility
to pl
aces
for p
hysic
al ac
tivity
comb
ined w
ith
educ
ation
al ou
treac
h can
incre
ase p
hysic
al ac
tivity
.SS, W
4, W
11–1
4
Promi
sing
Offer
disco
unts
on pr
emium
s for
emplo
yers
base
d on t
heir h
ealth
and
welln
ess i
nitiat
ives.
XX
XWo
rksite
well
ness
progra
ms ar
e effe
ctive
and c
an lo
wer a
bsen
teeism
and r
educ
e he
alth c
are co
sts of
emplo
yers.
SS, W
4, W
12–1
4
Promi
sing
Mand
ate su
rveilla
nce o
f BMI
.X
XX
Mand
ating
the s
urveil
lance
of B
MI co
uld le
ad to
more
aware
ness
of ov
erweig
ht an
d obe
sity a
nd lo
wer p
revale
nce a
nd in
ciden
ce ra
tes.FS
2
Promi
sing
Add B
ehav
ioral
Risk F
actor
Surv
eillan
ce S
ystem
ques
tions
conc
erning
ob
esity
aware
ness.
XX
Addin
g que
stion
s con
cerni
ng ob
esity
aware
ness
could
lead
to m
ore aw
arene
ss of
overw
eight
and o
besit
y and
lowe
r prev
alenc
e and
incid
ence
rates
FS10
Promi
sing
Instal
l stan
dards
that
includ
e scre
ening
indiv
iduals
rega
rding
phys
ical
activ
ity be
havio
rs.X
Routi
ne sc
reenin
g of p
atien
ts for
phys
ical a
ctivit
y beh
avior
enco
urage
s phy
sical
activ
ity.SS
, W11
-13
Untes
ted
Put t
rainin
g prog
rams i
nto pl
ace f
or pa
rents
to pla
n the
ir chil
dren’s
ac
tivity
times
to lim
it TV
and c
ompu
ter us
age.
XX
XX
Giving
paren
ts the
tools
to co
rrectl
y allo
cate
their c
hildre
n’s re
creati
onal
time
could
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urage
grea
ter am
ounts
of ph
ysica
l acti
vity.SS
W6
Untes
ted
Estab
lish co
mmun
ity m
arketi
ng pr
ogram
s on h
ealth
y eati
ng an
d ph
ysica
l acti
vity.
XX
XX
XIni
tiatin
g a m
arketi
ng ca
mpaig
n in c
ommu
nities
can l
ead t
o grea
ter am
ounts
of
phys
ical a
ctivit
y and
bette
r eati
ng ha
bits.SS
, FB2
, FB7
, H10
Untes
ted
Texas Obesity Policy Portfolio30
Recommendations for Adult Weight-Loss and Weight-Gain PreventionAppendix A introduces the most current and consistent recommendations for adult weight-loss and weight-gain prevention. The recommendations found in Appendix A were retrieved from reliable sources such as the U.S. Department of Agriculture Dietary Guidelines Advisory Committee, the Center for Disease and Control Prevention, and the American Medical Association. In order to effectively decrease the prevalence of obesity in Texas, population-based approaches must support individual recommendations for weight-loss and weight-gain prevention.
IntroductionFor more Americans to become less overweight, two things must happen: (1) individuals must change their behavior, and (2) society must facilitate these changes. Further, available evidence suggests that without behavioral and social change, most Americans will become overweight. Currently two-thirds of Americans are overweight or obese and the trend is for Americans to gain weight until the sixth decade of life. Thus, to maintain current weight, most Americans will need behavioral and social change.
Safety Guidelines for Losing WeightPrior to changing behavior to prevent weight gain or to lose weight, and based on the recommendations of senior health agencies, the Texas Obesity Study Group recommends three safety guidelines:
1. Eat a variety of foods. Diets that severely limit the proportion of carbohydrates, protein, and fat eaten are not healthy. Too few of any of these types of nutrients can be deleterious. Further, any changes that are made must be life-long; so it doesn’t make sense to adopt a diet that is so restrictive that it can’t be maintained.
2. If you have chronic diseases and/or are on medications, consult a health-care provider prior to trying to lose weight. It is not generally necessary for healthy people to consult a physician before adopting a moderate weight loss program.
3. It is not necessary for most people to consult a health-care provider before gradually increasing physical activity.
Texas Obesity Policy Portfolio 31
Appendix A
Scope and Method of the RecommendationsThe following recommendations are based on evidence presented in the policy recommendations of health agencies or from the Texas Obesity Study Group. The recommendations address what to do to lose weight or maintain current weight (Part 1) and how to do it (Part 2). Part 1 is prioritized by the strength of the evidence (strongest evidence is listed first). Part 2 lists the agency that recommended this action and doesn't give a prioritization. The recommendations were compiled by the group responsible for this report and the Texas Obesity Study Group.
Part 1: What to Do to Lose or Maintain Weight
Actions of Known Efficacy to Lose Weight or Prevent Weight Gain1. Most adult Americans should reduce their intake of calories 50 to
100 calories per day to prevent weight gain. If you are overweight or obese, reduce intake 500 to 1000 calories per day. This will mean restricting your intake of calories to between 800 to 1500 calories a day. Greater restrictions are not recommended.
2. Eat less foods high in fat, sugar, or refined starches. One of the major approaches to weight loss is to substitute foods of high calorie and low nutrient value — generally those high in fat, added sugars, or refined starches — with foods of low-calorie and high-nutrient value — generally those high in fiber, water, vitamins, minerals, and other beneficial substances.
3. Eat more foods high in fiber. High-fiber foods help people lose weight.
4. Reduce portion size. Individual food intake has increased 500 calories a day since 1970, generally through increased portion sizes. To lose weight, reverse the process.
5. Gradually increase physical activity to at least 60 minutes a day to lose and maintain weight loss. To lose weight, calorie restriction is more effective than exercise, but exercise will increase weight loss and bring other health benefits. To maintain weight loss or to preserve current weight, however, physical activity is essential.
Actions That Are Probably Effective in Losing Weight or Preventing Weight Gain
1. Eat more fruits and vegetables. This may work because fruits and vegetables have fewer calories than foods we would otherwise eat. They are also better for health.
2. Drink fewer sweetened soft drinks and juices. The calories in these variously sweetened drinks are quickly absorbed and quickly add weight.
Texas Obesity Policy Portfolio3�
Actions That Are Possibly Effective in Losing Weight or Preventing Weight Gain
1. Eat more home-cooked foods. We generally consume more calories when we eat out.
2. Eat foods with a low glycemic index. Foods that are slower to digest (ones that have a lower glycemic index) often contain fewer calories and may be better for health.
Actions for Which Evidence Is Insufficient to Recommend Losing Weight or Preventing Weight Gain
1. Eat more frequent, smaller meals.
2. Drink less alcohol. Alcohol contains calories; drinking too much will certainly affect weight. Moderate intake; however, appears beneficial for some adults.
Additional InterventionsThe Texas Obesity Study Group concurs with the recommendation of the National Heart, Lung, and Blood Institute, Clinical Guidelines to Treat Overweight and Obesity (1998: 86, 89) about pharmacological and surgical interventions.
“Weight-loss drugs approved by the Food and Drug Administration may only be used as part of a comprehensive weight-loss program, including dietary therapy and physical activity, for patients with a BMI of ≥30 with no concomitant obesity-related risk factors or diseases, and for patients with a BMI of ≥27 with concomitant obesity-related risk factors or diseases. Weight-loss drugs should never be used without concomitant lifestyle modifications. Continual assessment of drug therapy for efficacy and safety is necessary. If the drug is efficacious in helping the patient lose and/or maintain weight loss and there are no serious adverse effects, it can be continued. If not, it should be discontinued.”
“Weight-loss surgery is an option for carefully selected patients with clinically severe obesity (BMI ≥ 40 or ≥35 with comorbid conditions) when less invasive methods of weight loss have failed and the patient is at high risk for obesity-associated morbidity or mortality.”
Part 2: How You Can Lose WeightThese techniques are often recommended in clinical settings and can be adapted for individual use.
1. Start thinking straight about weight loss. This is sometimes called “cognitive restructuring” in the technical literature and is recommended by the National Institutes of Health for weight loss. In their explanation of this method the NIH writes (NHLBI 1998: 82): “Unrealistic goals and inaccurate beliefs about weight loss and body image need to be modified to help change self-defeating thoughts and feelings that undermine weight loss.” Part of cognitive restructuring involves re-education about the basics of weight loss, and thus the U.S. Preventive Services Task Force (2005: 110) recommends nutrition education and behaviorally-oriented counseling to help patients lose weight. This can
Texas Obesity Policy Portfolio 33
happen through a variety of methods — see Recommendation 2 — but at a minimum, the education should emphasize:
• Weight loss is possible and will improve health. The Surgeon General writes (2001: XIV): “Overweight and obesity must be approached as preventable and treatable problems with realistic and exciting opportunities to improve health and save lives.” Abundant evidence cited in the evidence report of the NHLBI indicates that people who are overweight or obese can lose a reasonable amount of weight, enough to improve risk profiles and derive clinical, physical, and psychological benefit within a fairly short time — six months to a year.
• Weight loss involves calorie reduction and increased physical activity.
• Weight loss can be maintained if the changes made are permanent. The right “diet” is one that is nutritionally sound and can be maintained lifelong. While the general pattern is for weight to be lost rapidly for the first six months during the active intervention phase and then to gradually be regained, a number of studies with maintenance plans have shown that people can maintain weight loss for a number of years and still show measurable clinical benefit (figure 11). The three graphs below show the pattern of weight loss over three, four, and five years in three different studies. In each case, the weight loss intervention group is represented by the lowest line on the graph, representing sustained weight loss. In each case, the control group is represented by the line at the top of the graph, showing weight gain over time.
Figure 11. Patterns of Weight Loss and Weight Gain
2.25
0
-2.25
-4.50
-6.75
Wei
ght,
kg
Years of Follow-up0.5 1 2 3
Control
NaNaCalCal
Three-Year Study (1)
kg (l
b)
2.7 (6)
2.7 (6)
1.8 (4)
1.8 (4)
0.9 (2)
0.9 (2)
Weight Change
Group 1
Group 2Group 3
Four-Year Study (3) Five-Year Study (3)
2
0
-2
-4
-6
-8
All three graphs show that when the weight gain that almost invariably happens over time in the control group is considered, the difference in weight between the groups is significant. A seemingly modest difference of 10 pounds can mean the difference in being healthy or not. The extra pounds can result in diseases like hypertension or diabetes and sometimes will require medication (which can be expensive and sometimes have unpleasant side effects). It's important to note that figure 11 represents average results (some participants lost more weight, some less).
• While there are genetically determined limits, the amount of weight lost will depend to a large degree on the effort invested in losing and maintaining it. The diet and physical activity interventions shown in the graphs above were not very intensive. More intensive intervention and maintenance plans will likely yield greater results. Consider this, the average registrant in the National Weight Control Registry has lost 60 pounds and has maintained that loss for roughly five years (see http://www.nwcr.ws/).
Texas Obesity Policy Portfolio34
2. Follow a structured program. The evidence strongly suggests that a substantial amount of structure may be needed to lose and maintain weight loss. The IOM, (Weighing the Options, 1995: chapter 3) indicates that this structure can be in the form of (1) Do-it-yourself programs formulated by individual dieters, authors, product promoters, or groups that are generally designed to be adopted as they are (i.e. not tailored to the individual); (2) non-clinical, often commercially-franchised programs that rely substantially on variably trained counselors; or (3) clinical programs provided by licensed professionals with varying degrees of training to treat overweight and obesity. The IOM does not recommend one type of structure over another, but programs should be based on both the safety and long-term efficacy of their recommendations. Generally, programs will follow the techniques listed below. The IOM advises (1995: 64) that treatment options depend “on the individual’s state of health, the amount of weight to lose, his or her evaluation of the need for outside help, and other considerations.” Individuals should find a program that fits their situation. The National Institutes of Health (NHLBI 1998: 74 ) notes that dietary interventions should last at least six months and that during this time frequent contact with health professionals often facilitates weight loss.
For individuals wishing to use commercially available programs, the American Medical Association provides a list of selected commercial weight loss programs. These include:
• Weight Watchers® http://www.weightwatchers.com
• Jenny Craig®: http://www.jennycraig.com
• TOPS®: Take Off Weight Sensibly: http://www.tops.org
• Overeaters Anonymous®: http://www.overeatersanonymous.org
• Nutrisystem®: www.nutrisystem.com
They also refer patients to five Internet weight loss programs designed by registered dieticians as starting points for structured weight loss:
• http://www.fitday.com
• http://www.dietwatch.com
• http://www.cyberdiet.com
• http://www.ediets.com
• http://www.shapeup.org
Registered dieticians can be located through the American Dietetic Association at http://www.eatright.org.
3. Set goals of what and how much you will eat before you sit down to eat. Reducing your intake of calories does not happen by accident; you must follow a structured program. As mentioned above, that program can be planned by yourself or with the assistance of others. Either way, knowing what and how much you will eat will have to be a part of your program. Presented below are three different strategies to reduce caloric intake.
Texas Obesity Policy Portfolio 35
A. Redesign your plate: The New American Plate Program, a science-based method to lose weight and reduce cancer risks, was developed by the American Institute for Cancer Research. It suggests that you should aim for meals made up of 2/3 (or more) vegetables, fruits whole grains or beans and 1/3 (or less) animal protein. In this program you don’t count calories, you simply fill up your plate as specified in figure 12:
Figure 12.
Gradually transition from the old Amercian plate ...
to a better plate ... to the New American plate
In transitioning toward a New American Plate, your intake of calories should drop while the quality of your diet improves. Brochures and other materials are available at http://www.aicr.org/publications/nap/index.lasso. This approach is consistent with a suggestion of the American Medical Association (Roadmaps for Clinical Practice, Assessment and Management of Adult Obesity: A primer for physicians: Dietary Management: 7) that it is easier and more effective in the long term to focus on dietary substitutions and portion sizes than to simply count calories. In redesigning your plate, the focus is on both portion control and substituting healthy foods (fruits and vegetables, whole grain cereals, beans, low-fat dairy, fish, and low-fat meats) for unhealthy food choices. The protein portion of the plate should be low-fat, and soy products can be substituted.
B. Know how many servings you can eat at each meal. This approach has been cited by the Institute of Medicine (Weighing the Options, 1995: 109) and is another alternative to counting calories. The Mayo Clinic has a useful food pyramid tool that specifies the number of servings of each food group you can have to lose weight, given your weight and gender (see http://www.mayoclinic.com/health/weight-loss/NU00595). The table on page 37, developed by the Texas Obesity Study Group, is adapted from the Mayo Clinic Guide for males between 150 and 250 pounds and females between 250 and 300 pounds who are trying to lose weight. On average, the meal pattern on page 37 will provide about 1400 calories/day, which will create slow safe weight loss for most people. Males between 251–300 pounds and females above 300 pounds will generally add one more serving of fruit, vegetable, whole grain and protein/dairy to the specified recommendations. Females who weigh less than 250 pounds and are trying to lose weight will need to subtract a serving of fruit, carbohydrate, and protein from what is presented on page 37.
Texas Obesity Policy Portfolio36
Figure 13. Sample Meal Plan, Servings Allowed Per MealFor males between 150–250 pounds, females between 250–300 poundsFood Group Breakfast Lunch Snack 1 Dinner Snack 2 Total
Fruit 1 2 1 4
Vegetable 2 2 4
Whole Grain 1 2 2 5
Low-Fat Dairy 1 1 2
Protein: Fish/legumes/poultry/eggs(Try to restrict meat or pork to only once a week, to eat no more than two eggs a week, and to eat fish at least twice a week) Occasional 1 1 2
Nuts/seeds/oils/sauces(Extra virgin olive oil or canola oil is preferred.) 1 1 1 3
Sweets One sweet of no more than 75 calories
Of course, if you use this approach, you must use proper serving sizes.
C. Know how many calories you can have at each meal. For example, if you are on a 1500 calorie diet, that can translate into 400 calories at breakfast, 500 calories at lunch and dinner, and a 100 calorie snack. The calories available in fast foods are generally available on-line at the company’s Web site. Alternatively, the nutrition breakdown of many fast foods is available at http://www.fatcalories.com/. For home cooking, easy-to-use healthy on-line recipes with calorie counters are provided by:
• The NHLBI at: http://www.nhlbi.nih.gov/health/public/heart/other/ktb_recipebk/
• The CDC’s 5-A-Day program at: http://www.cdc.gov/nccdphp/dnpa/5aday/recipes/index.htm
• The American Institute for Cancer Research at http://www.aicr.org/information/recipe/index.lasso
• The American Heart Association at http://www.deliciousdecisions.org/.
• The Mayo Clinic – see Healthy Recipes at http://www.mayoclinic.com/health/healthy-recipes/RE99999 ).
• Brigham and Women's Hospital at http://www.brighamandwomens.org/healtheweightforwomen/eating/menu_plans.asp .
The American Medical Association (Roadmaps for Clinical Practice, Assessment and Management of Adult Obesity: A Primer for Physicians: Dietary Management:10–11) suggests that meal replacements, that is, liquid meals, meal bars, or frozen meals, are effective for weight loss and long-term maintenance. They caution, however, that meal replacements do not teach patients how to make healthy diet choices.
The NHLBI provides sample one-day menus of reduced calorie diets for traditional American, southern, Asian-American, Mexican-American, and Lacto-Ovo vegetarian cuisines in their book, Clinical Guidelines. The menu for southern cuisine is reproduced on page 38:
Texas Obesity Policy Portfolio 37
Figure 14. Southern Cuisine Sample MenuSample Menu: Southern Cuisine,Reduced Calorie
1,600 Calories 1,200 CaloriesBreakfast
Oatmeal, prepared with 1 percent low-fat milk ½ cup ½ cupMilk, 1 percent low-fat ½ cup ½ cupEnglish Muffin 1 medium —Cream Cheese, light, 18 percent fat 1 T —Orange Juice ¾ cup ½ cupCoffee 1 cup 1 cupMilk, 1 percent low-fat 1 oz 1 oz
LunchBaked Chicken, without skin 2 oz 2 ozVegetable Oil 1 tsp ½ tspSalad
Lettuce ½ cup ½ cupTomato ½ cup ½ cupCucumber ½ cup ½ cup
Oil and Vinegar Dressing 2 tsp 1 tspWhite Rice, seasoned with ½ cup ¼ cup
margarine, diet ½ tsp ½ tspBaking Powder Biscuit, prepared with vegetable oil 1 small ½ small
Margarine 1 tsp 1 tspWater 1 cup 1 cup
DinnerLean Roast Beef 3 oz 2 ozOnion ¼ cup ¼ cupBeef Gravy, water-based 1 T 1 TTurnip Greens, seasoned with ½ cup ½ cup
Margarine, diet ½ tsp ½ tspSweet potato, baked 1 small 1 small
Margarine, diet ½ tsp ½ tspGround Cinnamon 1 tsp 1 tspBrown Sugar 1 tsp 1 tsp
Cornbread prepared with margarine,diet ½ medium slice ½ medium sliceHoneydew Melon ¼ medium ¼ mediumIced Tea, sweetened with sugar 1 cup 1 cup
SnackSaltine Crackers, unsalted tops 4 crackers 4 crackersMozzarella Cheese, part-skim, low-sodium 1 oz 1 oz
Calories: 1,633 Calories: 1,225Total Carb. percent calories:
53 Total Carb. percent calories:
50
Total Fat. percent calories:
28 Total Fat. percent calories:
31
*Sodium, mg: 1,231 *Sodium, mg: 867SFA, percent calories: 8 SFA, percent calories: 9Cholesterol, mg: 172 Cholesterol, mg: 142Protein, percent calories:
20 Protein, percent calories:
21
Texas Obesity Policy Portfolio3�
4. Write down what you eat and what you do. Keep a food and activity diary. This practice is part of what is called “self-monitoring.” Research shows that this simple act, if done conscientiously, will help you reduce caloric intake and increase physical activity when needed.
Self-monitoring has been recommended by the National Heart Lung and Blood Institute (NHLBI) in its Clinical Guidelines to treat overweight and obesity (1998: 81). It is also recommended by U.S. Preventive Services Task Force (2005: 110), and the agencies that support NHLBI guidelines, including the American Academy of Family Physicians, the American College of Preventive Medicine, and the American Medical Association.
Agencies differ in what they recommend you should write down and for how long it should be done. At minimum, you should write the time of day, what you ate, and the number of servings of each food you ate. A simple food diary is shown below:
Simple Food Diary:
Date _______/_______/______
Time Food No. of Servings
_________ ________________________________________ __________
_________ ________________________________________ __________
_________ ________________________________________ __________
_________ ________________________________________ __________
Filling out this diary often leads to voluntary caloric restriction as increased attention is focused on food intake. If, however, you need more information for your self-study, try recording how you feel each time you eat (e.g. hunger-level on a five-point scale before eating) or how food was cooked (fried, baked, broiled…) and/or the number of calories in each serving of food you ate. Remember that for weight loss, the goal is to eat between 800 to 1500 calories per day. Your caloric intake can be adjusted so you lose one to two pounds a week. Several on-line resources exist to help find the number of calories in a serving of food.
http://www.nutritiondata.com/index.html
http://nat.crgq.com/mynat/index.html
http://www.nal.usda.gov/fnic/foodcomp/search
Looking over your diary entries each day may help you identify times when you’re eating for the wrong reasons or eating too much. This may help you set better goals for the next day.
As to physical activity, at minimum, write down the type of activity and the number of minutes you do each activity every day. The goal is to build to at least an hour a day.
5. Weigh weekly. The American Medical Association (Roadmaps for Clinical Practice, Assessment and Management of Adult Obesity: A primer for physicians: Dietary
Texas Obesity Policy Portfolio 39
Management: 17) includes weighing yourself once or twice a week as part of a suggested self-monitoring practice for weight loss.
6. Recruit friends or make new ones to help lose weight. Social support has been proven to assist in weight loss and is recommended by the NHLBI (1998: 82). The U.S. Preventive Services Task Force (2005: 110,119) recommends group support for those in treatment to improve diet. In general, your strategy should be to set goals, like those mentioned above for diet, exercise, and weight loss, and to work together to achieve them and solve problems. A reward system can also be made a part of your social support system.
7. Identify and control the triggers of unnecessary eating. “Stimulus control” has been recommended by the NHLBI (1998: 82) and the AMA (Roadmaps for Clinical Practice, Assessment and Management of Adult Obesity: A Primer for Physicians: Dietary Management: 8) because research shows that it can work to reduce caloric intake. Triggers to unnecessary eating are varied. Buying and storing high-fat, high-sugar or high-starch foods in the house creates opportunities (triggers) for eating them. An enviornment where unhealthy foods or snacks are readily available, creates opportunities for unneccessary eating or even overindulgence.
8. Analyze and tackle barriers to weight loss or control. Problem-solving or training to overcome barriers is recommended by the NHLBI (1998: 82) and the U.S. Preventive Services Task Force (2005: 110) The American Medical Association (Food Weight Loss Tips, Roadmaps to Clinical Practice 2003) also lists a variety of common barriers that must be controlled (e.g., not having regular eating times, not reading food labels, not making small food substitutions to cut calories, not controlling “guilty pleasures,” not proportioning servings, and not controlling calories when dining out). Examining patterns in your food and activity diary is one way to identify times and places where you’ll need to develop a plan to change.
9. Use meaningful rewards to motivate positive action. This is called “contingency management” and is recommended by the NHLBI (1998: 82). Some people feel rewarded when they set and meet goals and need no further reward than having reached a reasonable short-term goal — like tomorrow I will not eat more than 1500 calories. Others may work harder for other rewards. The rewards should not, of course, be to eat!
10. Relieve stress, find another way to manage it. Research shows that stress triggers excess eating in some people and that it can be controlled through physical activity, meditation, or relaxation techniques (NHLBI 1998: 82). The American Medical Association (Food Weight Loss Tips, Roadmaps to Clinical Practice 2003) recommends substituting other activities for eating. If stress causes you to eat, try walking, gardening, riding, and even just talking to friends. All are preferred to eating, if you’re not really hungry.
Texas Obesity Policy Portfolio40
Texas Obesity Study Group Evidence of Effectiveness Definitions and Recommendations As Referenced by Leading Organizations/AuthoritiesAppendix B outlines the various definitions of “evidence of effectiveness” as it relates to obesity policy from leading organizations and authorities. Evidence of effectiveness is key to making decisions that demonstrate external validity and contextual relevance. By determining evidence of effectiveness decision-makers can estimate and evaluate the impact of public health interventions.
Appendix B
Texas Obesity Policy Portfolio 41
Texas Obesity Policy Portfolio4�
Texa
s O
besi
ty S
tudy
Gro
up
Evid
ence
of E
ffect
iven
ess
Defi
nitio
ns a
nd R
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datio
ns
as R
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Lea
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05
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Evid
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of E
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Unite
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De
partm
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of H
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and
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Octob
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i.e.,
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Hea
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in NS
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healt
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u/ob
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Conc
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that
there
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body
of re
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of w
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offers
the m
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of
contr
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obes
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his m
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peop
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nclud
ing an
adop
tion o
f “pro
misin
g” ev
idenc
e.
Provid
es pr
ioritie
s, ob
jectiv
es, a
ction
s, an
d how
actio
ns w
ill ma
ke a
differ
ence
in th
e obe
sity r
ate.
IOM
, Com
mitt
ee
on P
reve
ntio
n of
Obe
sity
in
Child
ren
and
Yout
h
Preve
nting
Child
hood
Obe
sity: H
ealth
in th
e Bala
nce S
eptem
ber 2
004
Exec
utive
Sum
mary
Actio
ns sh
ould
be ba
sed o
n the
best
avail
able
evide
nce
— as
oppo
sed t
o wait
ing fo
r the
best
possi
ble ev
idenc
e.Th
ere is
an ob
ligati
on to
accu
mulat
e app
ropria
te ev
idenc
e not
only
to jus
tify a
cours
e of a
ction
, but
to as
sess
wheth
er it h
as
made
a dif
feren
ce. T
heref
ore, e
valua
tion s
hould
be cr
itical
comp
onen
t of a
ny im
pleme
nted i
nterve
ntion
or ch
ange
.
NECO
N/Ha
rvar
d Sc
hool
of P
ublic
He
alth
Strat
egic
Plan f
or the
Prev
entio
n and
Contr
ol of
Overw
eight
and
Obes
ity in
New
Engla
nd
Exec
utive
Sum
mary
Provid
es ev
idenc
e to s
uppo
rt ac
tions
to be
take
n but
no
evide
nce o
f effe
ctive
ness
of ac
tions
take
n.Ca
lls to
actio
n of p
ublic/
priva
te pa
rtners
hips a
cross
the re
gion
to tak
e acti
on.
Texas Obesity Policy Portfolio 43
Orga
niza
tion
or
Auth
ority
Docu
men
t/Re
fere
nce
Evid
ence
of E
ffecti
vene
ssRe
com
men
datio
ns o
r Com
men
ts
Trus
t for
Am
erica
’s He
alth
F as i
n Fat:
How
Obe
sity P
olicie
s are
Failin
g in A
meric
a 200
5
Issue
Repo
rt: S
ectio
n 6 Re
comm
enda
tions
htt
p://w
ww.he
althy
ameri
cans
.org
One r
easo
n for
the sc
arcity
of ac
tion i
s the
lack
of m
ajor
scien
tific e
xami
natio
ns in
to ma
ny cr
ucial
issu
es re
lated
to
obes
ity. T
heref
ore, w
hen m
any p
olicie
s are
recom
mend
ed,
they a
re oft
en no
t acte
d upo
n due
to a
lack o
f unq
uesti
oned
ev
idenc
e tha
t can
be us
ed to
supp
ort de
cision
s.
TFAH
chall
enge
s the
rese
arch c
ommu
nity t
o mak
e find
ing
answ
ers to
the f
ollow
ing tw
o of fi
ve qu
estio
ns a
top pr
iority
:
1. W
hat a
re the
econ
omic
costs
of ob
esity
and t
he be
nefits
of
possi
ble po
licy ac
tions
?
2. W
ho is
resp
onsib
le for
obes
ity re
ducti
on?
TFAH
also
chall
enge
s poli
cy-m
akers
, bus
inesse
s, co
mmun
ities,
and i
ndivi
duals
to ta
ke in
forme
d acti
ons n
ow an
d stud
y the
ir effe
cts, e
ven w
hile m
any i
n-dep
th qu
estio
ns ar
e bein
g res
earch
ed.
The
Inte
rnat
iona
l As
socia
tion
for
the
Stud
y of
Ob
esity
Swinb
urn B
, Gill
T, Ku
many
ika S
. Obe
sity P
reven
tion:
A Prop
osed
Fra
mewo
rk for
Tran
slatin
g Evid
ence
into
Actio
n, Ob
esity
Revie
w.
2005
. 6:2
3-33.
Evide
nce o
f effe
ctive
ness
is no
t suffi
cient
by its
elf to
guide
ap
propri
ate de
cision
-mak
ing, a
nd tr
ue ev
idenc
e-bas
e poli
cy-
makin
g is p
robab
ly qu
ite ra
re. Th
erefor
e, ge
tting t
he pr
oces
s rig
ht an
d eng
aging
decis
ion-m
akers
from
the s
tart m
oves
tow
ards “
practi
ce-ba
sed e
viden
ce” w
hich i
s more
relev
ant
than t
he cl
assic
al ev
idenc
e-bas
ed pr
actic
e bec
ause
an
obes
ity-pr
even
tion p
lan ba
sed o
nly on
the l
imite
d pub
lished
tria
ls av
ailab
le wo
uld be
patch
y and
prob
ably
ineffe
ctive
. Th
e port
folio
appro
ach i
s bas
ed on
the p
rincip
les of
finan
cial
plann
ing, w
here
the fo
cus i
s on r
eturni
ng m
axim
um fin
ancia
l yie
ld on
the i
nves
tmen
t of r
esou
rces.
Key p
olicy
and p
rogram
issu
es w
ithin
frame
work:
• Bu
ilding
a ca
se fo
r acti
on
• Ide
ntifyi
ng co
ntribu
ting f
actor
s and
point
s of in
terve
ntion
• De
fining
the o
pport
unitie
s for
actio
n
• Ev
aluati
ng po
tentia
l inter
venti
ons
• Se
lectin
g a po
rtfolio
of sp
ecific
polici
es, pr
ogram
s, an
d actio
ns
Filter
crite
ria fo
r imple
menta
tion:
• Fe
asibi
lity
• Su
staina
bility
• Eff
ects
on Eq
uity
• Po
tentia
l side
effec
ts
• Ac
cepta
bility
to st
akeh
olders
Prev
entio
n In
stitu
te
(Oak
land
, Ca
lifor
nia)
Strat
egies
for a
ction
: Inte
gratin
g Nutr
ition a
nd Ph
ysica
l Acti
vity
Promo
tion T
o Rea
ch Lo
w-Inc
ome C
alifor
nians
http:/
/www
.prev
entio
ninsit
ute.or
g/nu
trapp
.htm
Appe
ndix
II: Co
mmun
ity In
terve
ntion
s and
Comm
unitie
s as In
terve
ntion
s
Phys
ical a
ctivit
y was
a se
cond
ary go
al of
three
mult
iple r
isk
factor
prog
rams,
and t
he S
tanfor
d stud
y acco
unted
for 8
pe
rcent
of the
educ
ation
al me
ssage
s. Ne
verth
eless,
there
wa
s som
e evid
ence
of ef
fectiv
enes
s. Th
e Stan
ford s
tudy
report
ed se
veral
sign
ifican
t effe
cts fo
r phy
sical
activ
ity, b
ut tho
se re
sults
were
inco
nsist
ent r
egard
ing ty
pe of
phys
ical
activ
ity an
d who
mad
e the
chan
ges.
The M
innes
ota st
udy
also r
eport
ed si
gnific
ant p
hysic
al ac
tivity
outco
mes,
but o
nly
durin
g the
first
three
years
. The
Pawt
ucke
t inter
venti
on di
d no
t rep
ort si
gnific
ant o
utcom
es.
Comb
ining
educa
tion,
envir
onme
ntal, a
nd po
licy in
terve
ntion
s may
be
more
effec
tive i
n inc
reasin
g phy
sical
activit
y in t
he co
mmun
ity.
Texas Obesity Policy Portfolio44
Orga
niza
tion
or
Auth
ority
Docu
men
t/Re
fere
nce
Evid
ence
of E
ffecti
vene
ssRe
com
men
datio
ns o
r Com
men
ts
W.K
. Kell
ogg
Foun
datio
nCh
ange
on th
e Hori
zon:
A Sca
n of t
he Am
erica
n Foo
d Syst
em.
Febru
ary 1,
2005
, Exe
cutive
Summ
ary: D
rivers
and R
ecomm
enda
tions
http:/
/www
.wkk
f.org/
Pubs
/Foo
dRur/
Chan
geon
theHo
rizon
_00
253_
0412
8.pd
f
No ev
idenc
e of e
ffecti
vene
ss pro
vided
only
an en
viron
menta
l sca
n with
pred
iction
s for
future
policy
direc
tions
.Dr
ivers
of Fu
ture F
ood S
ystem
Policy
:
• Na
tiona
l Hea
lth Cr
isis w
ill sh
ape f
ood p
olicy
• Fo
odse
rvice
will
be ki
ng
• Big
Guys
Could
be al
lies,
as no
nprofi
ts de
fine b
rands
• Fo
rget t
he Fa
rm B
ill, Lo
ok to
Loca
l Foo
d Clus
ters
• Po
ssibil
ity of
food
scare
and e
nergy
crisis
Robe
rt W
oods
Jo
hnso
n Fo
unda
tion
Healt
hy S
choo
ls for
Hea
lthy K
ids, R
WJ F
ound
ation
, Pyra
mid
Corpo
ration
, 200
3
Exec
utive
Sum
mary
http:/
/www
.rwjf.o
rg/file
s/pu
blica
tions
/othe
r/He
althy
Scho
ols.pd
f
Promi
sing A
pproa
ches
The S
trateg
ic All
iance
, a co
alitio
n of o
rganiz
ation
s in
Califo
rnia,
works
to in
creas
e phy
sical
activ
ity an
d hea
lthy
eatin
g in s
choo
ls thr
ough
policy
chan
ge.
Strat
egies
The u
ltimate
goal
of the
Stra
tegic
Allian
ce is
“to p
reven
t ch
ildho
od ob
esity
by m
aking
healt
hy fo
od ch
oices
easie
r an
d crea
ting m
ore ac
tive e
nviro
nmen
ts in
Califo
rnia’s
co
mmun
ities.”
(Sam
uels
and A
ssocia
tes, T
he St
rateg
ic All
iance:
Theo
ry of
Actio
n DRA
FT).
To ac
comp
lish th
is go
al, th
e Stra
tegic
Allian
ce fo
cuse
s on fi
ve
areas
of in
fluen
ce:
• Ch
ildren
’s En
viron
ments
• Go
vernm
ent
• He
alth C
are S
ystem
• Ind
ustry
Prac
tices
• Me
dia
Case
Stud
y of E
ffecti
vene
ss
To ac
hieve
policy
chan
ge w
ithin
these
focu
s area
s, the
St
rateg
ic All
iance
has d
efine
d a se
t of s
trateg
ies, m
ost o
f wh
ich ha
ve be
en us
ed to
achie
ve th
eir im
porta
nt ea
rly
succe
sses.
Thes
e stra
tegies
inclu
de:
• Re
searc
h: Co
nduc
t stud
ies, c
ollec
t data
, and
deve
lop
track
ing sy
stems
.
• St
anda
rds: D
evelo
p and
prom
ote st
anda
rds, g
uideli
nes,
and r
egula
tions
.
• Dis
semi
natio
n: Dis
semi
nate
study
resu
lts an
d prom
ote
strate
gies,
recom
mend
ation
s ,an
d stan
dards
.
• Co
llabo
ration
: Form
a str
ategic
colla
borat
ion an
d prov
ide
expe
rtise.
• Tra
ining
s: De
velop
and i
mplem
ent m
ateria
ls an
d trai
nings
.
• Le
aders
hip D
evelo
pmen
t: Pro
mote
comm
unity
and y
outh
enga
geme
nt, an
d adv
ocac
y.
• Or
ganiz
ation
al Ad
voca
cy: P
romote
policy
chan
ge an
d im
prove
d prac
tices
in or
ganiz
ation
s and
indu
stry.
• Ad
voca
cy: Su
pport
and p
romote
policy
chan
ges.
NIH
Obes
ity
Rese
arch
Task
Fo
rce
Strat
egic
Plan f
or NI
H Ob
esity
Rese
arch:
A Rep
ort of
the N
IH
Obes
ity Re
searc
h Tas
k Forc
e. US
DHHS
, NIH
, Pub
licatio
n Num
ber
04-54
93, A
ugus
t 200
4
http:/
/obe
sityres
earch
.nih.g
ov/a
bout/
Obesi
ty_En
tireDo
cumen
t.pdf
No de
finitio
n prov
ided.
Trans
lation
al res
earch
—pro
gressi
ng fr
om ba
sic sc
ience
to
clinica
l stud
ies an
d from
clini
cal tr
ial re
sults
to co
mmun
ity
interv
entio
ns—
is an
other
key c
ross-c
utting
rese
arch t
opic.
Fo
r exa
mple,
the N
IH w
ill stu
dy th
e effe
cts of
“soc
ial
expe
rimen
ts” su
ch as
rece
nt po
licy de
cision
s in s
ome s
choo
ls co
ncern
ing fo
od of
fering
s mad
e ava
ilable
to th
e stud
ents.
By
obtai
ning d
ata on
the o
utcom
e of s
uch p
olicy
decis
ions,
the
NIH
can h
elp po
licyma
kers
deve
lop fu
rther
actio
ns ba
sed o
n da
ta rat
her t
han o
n assu
mptio
ns.
Texas Obesity Policy Portfolio 45
Orga
niza
tion
or
Auth
ority
Docu
men
t/Re
fere
nce
Evid
ence
of E
ffecti
vene
ssRe
com
men
datio
ns o
r Com
men
ts
Was
hing
ton
Stat
e De
partm
ent o
f He
alth
Nutrit
ion an
d Phy
sical
Activ
ity: A
Policy
Reso
urce G
uide,
Febru
ary 2
005.
http:/
/www
.doh.w
a.gov
/cfh/
Nutrit
ionPA
/pub
licatio
ns/n
pa-
policy
-guide
Apply
ing a
scien
tific l
ens t
o the
policy
mak
ing pr
oces
s is
usefu
l for u
nders
tandin
g and
prior
itizing
policy
idea
s bas
ed
on w
hat s
hould
be m
ost e
ffecti
ve. H
owev
er, it
is im
porta
nt to
realiz
e tha
t scie
nce i
s not
the on
ly filt
er tha
t mus
t be a
pplie
d to
policy
deve
lopme
nt. Po
licy de
velop
ment
occu
rs wi
thin t
he
broad
er so
cial c
ontex
t and
shou
ld be
unde
rstoo
d with
in tha
t co
ntext
(pag
e 19)
.
Choo
sing a
policy
optio
n
• All
nonp
olicy
alter
nativ
es be
en tr
ied (p
olicy
chan
ge
nece
ssary)
• Effi
cacy
(info
rmed
by w
hat t
he re
searc
h worl
d tell
s us)
• Fe
asibi
lity of
imple
menta
tion
• Pro
gram
(doa
ble in
the r
eal w
orld)
• Bu
dget
(costs
and b
enefi
ts)
• So
cial ju
stice
(add
resse
s nee
ds of
all a
ffecte
d pop
ulatio
ns)
• Un
derst
andin
g pote
ntial
unint
ende
d con
sequ
ence
s
• Ab
ility t
o mea
sure
succe
ss (e
valua
tion)
• Un
derst
andin
g stak
ehold
er vie
ws (v
alues
, inter
ests)
• Po
litica
l feas
ibility
(like
lihoo
d of e
nactm
ent)
NHS
Heal
th
Deve
lopm
ent
Agen
cy, L
ondo
n,
Engl
and
Weigh
tman
, Ellis
, Gull
um, S
ande
r and
Turle
y. Gra
ding E
viden
ce an
d Reco
mmen
datio
ns fo
r Pub
lic He
alth I
nterve
ntion
s: De
velop
ing an
d Pilo
ting a
Fram
ework
. Sup
port
Unit f
or Re
searc
h Ev
idenc
e, Inf
ormati
on S
ervice
s, Ca
rdiff
Unive
rsity
and t
he H
ealth
De
velop
ment
Agen
cy, 2
005.
• St
rength
of ev
idenc
e of e
fficac
y bas
ed on
the r
esea
rch
desig
n and
the q
uality
and q
uanti
ty of
evide
nce
• Co
rrobo
rative
evide
nce f
rom ob
serva
tiona
l and
quali
tative
stu
dies f
or the
feas
ibility
and l
ikelih
ood o
f suc
cess
of an
int
erven
tion i
f imple
mente
d in t
he U
nited
King
dom
There
is ge
neral
agree
ment
that t
he RC
T has
the h
ighes
t int
ernal
valid
ity an
d, wh
ere fe
asibl
e, is
the re
searc
h des
ign
of ch
oice w
hen e
valua
ting e
ffecti
vene
ss. H
owev
er ma
ny
resea
rchers
belie
ve th
at RC
T is t
oo re
strict
ive fo
r som
e pub
lic he
alth i
nterve
ntion
s, pa
rticula
rly co
mmun
ity-ba
sed p
rogram
s. In
addit
ion, s
upple
menti
ng da
ta fro
m qu
antita
tive s
tudies
wi
th the
resu
lts of
quali
tative
rese
arch i
s reg
arded
as ke
y to
the su
ccessf
ul rep
licatio
n and
ultim
ate ef
fectiv
enes
s of
interv
entio
ns. (
Exec
utive
Sum
mary)
US S
urge
on
Gene
ral
The S
urgeo
n Gen
eral’s
Call T
o Acti
on To
Prev
ent a
nd De
creas
e Ov
erweig
ht an
d Obe
sity
U.S.
DEP
ARTM
ENT O
F HEA
LTH AN
D HU
MAN
SERV
ICES,
Publi
c He
alth S
ervice
, Offic
e of t
he S
urgeo
n Gen
eral, R
ockv
ille, M
D 20
01.
http:/
/www
.surge
onge
neral
.gov/
librar
y
• No
ne pr
ovide
d — a
call t
o acti
on on
lyKe
y Acti
ons
1. C
ommu
nicati
on: P
rovisio
n of in
forma
tion a
nd to
ols
to mo
tivate
and e
mpow
er de
cision
-mak
ers at
the
gove
rnmen
tal, o
rganiz
ation
al, co
mmun
ity, f
amily,
and
indivi
dual
levels
who
will
create
chan
ge to
ward
the
preve
ntion
and d
ecrea
se of
overw
eight
and o
besit
y.
2. A
ction
: Inte
rventi
ons a
nd ac
tivitie
s tha
t assi
st de
cision
-ma
kers
in pre
venti
ng an
d dec
reasin
g ove
rweig
ht an
d ob
esity
, indiv
iduall
y or c
ollec
tively
.
3. R
esea
rch an
d Eva
luatio
n: Inv
estig
ation
s to b
etter
unde
rstan
d the
caus
es of
overw
eight
and o
besit
y, to
asse
ss the
effec
tiven
ess o
f inter
venti
ons,
and t
o dev
elop
new
commu
nicati
on an
d actio
n stra
tegies
.
Texas Obesity Policy Portfolio46
Appendix C
Texas Obesity Policy Matrix Conceptual FrameworkThe purpose of the Obesity Policy Matrix was to arrange the obesity prevention and control policies gathered from academic literature and Internet searches into an organized format. Research data was characterized by age groups and settings/sectors, demonstrating the need for a comprehensive approach to reducing the burden of obesity in Texas.
Age Groups:
• 0–5 years• 6–9 years• 10–13 years• 14–18 years• 19–35 years• 36–50 years• 51–65 years• 65 + years
Settings:
• Federal/State• Media• Schools• Faith-based organizations• City• County• Worksites• Health care settings
Each column of the matrix includes reference citations which support each policy option. This appendix also includes a reference page, which categorizes each reference by setting and policy option. For example, an article that supports providing nutrition and physical activity programs
Texas Obesity Policy Portfolio 47
for school-age children is categorized under the School/College setting and sub-categorized under physical activity and nutrition program promotion.
Example:
I. School/College
a. Provide nutrition and physical activity programs to everyone
Nestle M. Increasing Portion Sizes in American Diets: More Calories, More Obesity. J Am Diet Assoc 2003. 103(1): 39-40.
References can be found on pages 57–67.
Texas Obesity Policy Portfolio4�
Texa
s O
besi
ty P
olic
y M
atrix
AgeSe
ttin
gs
Fede
ral &
Sta
te
Gove
rnm
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iaSc
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Or
gani
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nsCo
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ity
Gove
rnm
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ksite
sHe
alth
Car
e0-5 years
• Ac
coun
tabilit
y for
healt
h thr
ough
deve
lopme
nt of
a hea
lth kn
owled
ge
base
1
• Su
rveilla
nce m
anda
te
on B
MI2
• Da
y-care
cred
entia
ling
proce
ss an
d poli
cies3
• De
finitio
n of o
besit
y as
a hea
lth pr
oblem
for
insure
rs4
• Ac
credit
ation
of
provid
ers5
• Re
strict
ions o
n ad
vertis
ing6
• Ta
x brea
ks7
• De
velop
time a
nd
budg
et ca
mpaig
n for
media
cons
umpti
on1
• De
velop
kids
pro
gramm
ing to
chan
ge
norm
s and
attitu
des2
• Ide
ntify
Presch
ool
requir
emen
ts for
food
pu
rchas
e1
• De
velop
time a
nd
budg
et ca
mpaig
n2
• Su
pport
curric
ula
deve
lopme
nt3
• Pro
vide H
ealth
Prom
otion
an
d Dise
ase P
reven
tion
activ
ities t
o fac
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staff4
• De
velop
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e and
bu
dget
camp
aign t
o cu
rb me
dia’s
poten
tially
un
healt
hy in
fluen
ces o
n ch
ildren
1
• Ph
ysica
l acti
vity
progra
ms fo
r kids
and
adult
s2
• Su
pport
comm
unity
int
erven
tions
3
• Su
pport
parks
and
recrea
tion f
acilit
ies1
• En
gage
game
build
ers
and p
roduc
ers1
• Ho
me vi
sits t
o sup
port
youn
g moth
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• De
velop
time a
nd
budg
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on 2
• Pro
vide s
creen
ing an
d ref
erral3
• Co
nduc
t res
earch
in
weigh
t man
agem
ent4
Texas Obesity Policy Portfolio 49
AgeSe
ttin
gs
Fede
ral &
Sta
te
Gove
rnm
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Med
iaSc
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Or
gani
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deve
lopme
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a he
alth k
nowl
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base
1
• Su
rveilla
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anda
te
on B
MI2
• Da
y-care
cred
entia
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proce
ss an
d poli
cies3
• De
finitio
n of o
besity
as a
healt
h prob
lem fo
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ers4
• Ac
credit
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ovide
rs5
• Re
stricti
ons o
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g6
• Ta
x brea
ks7
• De
velop
time a
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mpaig
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media
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on1
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velop
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pro
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attitu
des2
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velop
time a
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• Su
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ula
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P/DP
activ
ities
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termi
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s5
• Pro
vide n
utritio
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ph
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vity p
rogram
to
every
one6
• Re
move
vend
ing
mach
ines7
• Sc
reen h
igh-ris
k kids
8
• Im
prove
food
servi
ce9
• Re
quire
PE10
• De
velop
a tim
e and
budg
et ca
mpaig
n to c
urb m
edia’
s po
tentia
lly un
healt
hy
influe
nces
on ch
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1
• Ph
ysica
l acti
vity p
rogram
s for
kids
and a
dults
2
• Su
pport
comm
unity
int
erven
tions
3
• Su
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and
recrea
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acilit
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• En
gage
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build
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and p
roduc
ers1
• De
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time a
nd
budg
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mpaig
n for
media
cons
umpti
on2
• Pro
vide s
creen
ing
and r
eferra
l3
• Co
nduc
t res
earch
in
weigh
t man
agem
ent4
Texas Obesity Policy Portfolio50
Age
Sett
ings
Fede
ral &
Sta
te
Gove
rnm
ent
Med
iaSc
hool
sFa
ith-b
ased
Or
gani
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10-13 years•
Acco
untab
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or he
alth
throu
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velop
ment
of a
healt
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wled
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se1
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rveilla
nce m
anda
te
on B
MI2
• Da
y-care
cred
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proce
ss an
d poli
cies3
• De
finitio
n of o
besit
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he
alth p
roblem
for in
surers
4
• Ac
credit
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of pr
ovide
rs5
• Re
stricti
ons o
n Adv
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g6
• Ta
x brea
ks7
• De
velop
time a
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budg
et ca
mpaig
n for
media
cons
umpti
on1
• De
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kids
progra
mming
to
chan
ge no
rms a
nd
attitu
des2
• De
velop
time a
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budg
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mpaig
n for
media
cons
umpti
on2
• Su
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ula
deve
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P/DP
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rogram
to
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one6
• Re
move
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mach
ines7
• Sc
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igh ris
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8
• Im
prove
food
servi
ce9
• Re
quire
PE10
• De
velop
time a
nd bu
dget
a ca
mpaig
n to c
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edia’
s po
tentia
lly un
healt
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influe
nces
on ch
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1
• Ph
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rogram
s for
kids
and a
dults
2
• Su
pport
comm
unity
int
erven
tions
3
• Su
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parks
and
recrea
tion f
acilit
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build
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roduc
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move
vend
ing
mach
ines2
• De
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time a
nd
budg
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on2
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vide s
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l3
• Co
nduc
t res
earch
in
weigh
t man
agem
ent4
• En
coura
ge br
eastf
eedin
g5
Texas Obesity Policy Portfolio 51
AgeSe
ttin
gs
Fede
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Sta
te
Gove
rnm
ent
Med
iaSc
hool
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Or
gani
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coun
tabilit
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deve
lopme
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a he
alth k
nowl
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base
1
• Su
rveilla
nce m
anda
te
on B
MI2
• Da
y-care
cred
entia
ling
proce
ss an
d poli
cies3
• De
finitio
n of o
besity
as a
healt
h prob
lem fo
r insur
ers4
• Ac
credit
ation
of Pr
ovide
rs5
• Re
stricti
ons o
n Adv
ertisin
g6
• Ta
x brea
ks7
• De
velop
time a
nd
budg
et ca
mpaig
n for
media
cons
umpti
on1
• De
velop
time a
nd
budg
et ca
mpaig
n for
media
cons
umpti
on2
• Su
pport
curric
ula
deve
lopme
nt3
• Pro
vide H
P/DP
activ
ities
to fac
ulty a
nd st
aff4
• De
termi
ne in
centi
ves
and r
equir
emen
ts for
aft
er-sch
ool p
rogram
s5
• Pro
vide n
utritio
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ph
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l acti
vity p
rogram
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every
one6
• Re
move
vend
ing
mach
ines7
• Sc
reen h
igh-ris
k kids
8
• Im
prove
food
servi
ce9
• Re
quire
PE10
• Bu
ilt en
viron
ment
issue
at
unive
rsity11
• Cla
sses o
n fam
ily liv
ing
and h
ealth
12
• De
velop
youn
g pare
nt op
portu
nities
13
• De
velop
a tim
e and
budg
et ca
mpaig
n to c
urb m
edia’
s po
tentia
lly un
healt
hy
influe
nces
on ch
ildren
1
• Ph
ysica
l acti
vity p
rogram
s for
kids
and a
dults
2
• Su
pport
comm
unity
int
erven
tions
3
• En
coura
ge br
eastf
eedin
g4
• De
velop
oppo
rtunit
ies fo
r yo
ung p
arent5
• Su
pport
parks
and
recrea
tion f
acilit
ies1
• En
gage
game
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and p
roduc
ers1
• Re
move
vend
ing
mach
ines2
• Pro
vide fl
ex tim
e3
• Pro
vide i
ncen
tives
4
• Pro
vide p
rogram
s/fac
ilities5
• Co
nduc
t edu
catio
nal
progra
ms6
• Pro
vide i
nsura
nce
cove
rage7
• Im
prove
food
servi
ce8
• Inc
lude f
amily
outre
ach9
• Ba
lance
work
hours
/job
de
mand
s10
• Pro
vide c
ouns
eling
11
• Co
mbine
exerc
ise
progra
m wi
th oth
er he
alth p
rogram
s12
• Cre
ate a
supp
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en
viron
ment
and c
ulture
13
• Fo
rm pa
rtners
hips
with
profes
siona
l and
ac
adem
ic gro
ups14
• Pro
vide t
ime15
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play p
oint-o
f-dec
ision
promp
ts to
enco
urage
us
e of s
tairs16
• De
velop
time a
nd
budg
et ca
mpaig
n for
media
cons
umpti
on2
• Pro
vide s
creen
ing
and r
eferra
l3
• Co
nduc
t res
earch
in
weigh
t man
agem
ent4
Texas Obesity Policy Portfolio5�
Age
Sett
ings
Fede
ral &
Sta
te
Gove
rnm
ent
Med
iaSc
hool
sFa
ith-b
ased
Or
gani
zatio
nsCo
unty
& C
ity
Gove
rnm
ent
Wor
ksite
sHe
alth
Car
e
19-35 years•
Acco
untab
ility f
or he
alth
throu
gh de
velop
ment
of a
healt
h kno
wled
ge ba
se1
• Su
rveilla
nce m
anda
te
on B
MI2
• Da
y-care
cred
entia
ling
proce
ss an
d poli
cies3
• De
finitio
n of o
besit
y as
a hea
lth pr
oblem
for
insure
rs4
• Ac
credit
ation
of pr
ovide
rs5
• Re
stricti
ons o
n Adv
ertisin
g6
• Ta
x brea
ks7
• Ad
d BRF
SS qu
estio
ns
regard
ing ob
esity
aw
arene
ss10
• Pro
vide a
ccess
and
referr
al so
urces
3
• De
velop
youn
g pare
nt op
portu
nities
13
• En
coura
ge
breas
tfeed
ing14
• Ph
ysica
l acti
vity p
rogram
s for
kids
and a
dults
2
• Su
pport
comm
unity
int
erven
tions
3
• En
coura
ge br
eastf
eedin
g4
• De
velop
youn
g pare
nt op
portu
nities
5
• Co
nduc
t scre
ening
ac
tivitie
s6
• De
velop
socia
l sup
port
interv
entio
n in a
co
mmun
ity se
tting7
• Su
pport
parks
and
recrea
tion f
acilit
ies1
• Pro
vide p
reven
tion
and e
arly d
etecti
on
oppo
rtunit
ies3
• Cre
ate he
alth
leade
rship
deve
lopme
nt op
portu
nities
4
• Or
ganiz
e mult
icomp
onen
t co
mmun
ity-w
ide PA
ed
ucati
on ca
mpaig
ns5
• Inc
rease
acce
ss to
place
s for
PA an
d info
rmati
onal
outre
ach6
• Re
move
vend
ing
mach
ines2
• Pro
vide fl
ex tim
e3
• Pro
vide i
ncen
tives
4
• Pro
vide p
rogram
s/fac
ilities5
• Co
nduc
t edu
catio
nal
progra
ms6
• Pro
vide i
nsura
nce
cove
rage7
• Im
prove
food
servi
ce8
• Inc
lude f
amily
outre
ach9
• Ba
lance
work
hours
/job
de
mand
s10
• Pro
vide c
ouns
eling
11
• Co
mbine
exerc
ise
progra
m wi
th oth
er he
alth p
rogram
s12
• Cre
ate a
supp
ortive
en
viron
ment
and c
ulture
13
• Fo
rm pa
rtners
hips
with
profes
siona
l and
ac
adem
ic gro
ups14
• Pro
vide t
ime15
• Dis
play p
oint-o
f-dec
ision
promp
ts to
enco
urage
us
e of s
tairs16
• Pro
vide s
creen
ing an
d ref
erral3
• Co
nduc
t res
earch
in
weigh
t man
agem
ent4
• En
coura
ge br
eastf
eedin
g5
• De
velop
youn
g pare
nt op
portu
nities
6
• De
velop
and s
uppo
rt ind
ividu
ally-a
dapte
d he
alth b
ehav
ior-ch
ange
pro
grams
9
Texas Obesity Policy Portfolio 53
AgeSe
ttin
gs
Fede
ral &
Sta
te
Gove
rnm
ent
Med
iaSc
hool
sFa
ith-b
ased
Or
gani
zatio
nsCo
unty
& C
ity
Gove
rnm
ent
Wor
ksite
sHe
alth
Car
e
36-50 years
• Ac
coun
tabilit
y for
healt
h thr
ough
deve
lopme
nt of
a he
alth k
nowl
edge
base
1
• Su
rveilla
nce m
anda
te on
BM
I2
• Da
y-care
cred
entia
ling
proce
ss an
d poli
cies3
• De
finitio
n of o
besit
y as
a hea
lth pr
oblem
for
insure
rs4
• Ac
credit
ation
of pr
ovide
rs5
• Ta
x brea
ks7
• Ad
d BRF
SS Q
uesti
ons
regard
ing ob
esity
aw
arene
ss10
• Pro
vide a
ccess
and
referr
al so
urces
3
• Ph
ysica
l acti
vity p
rogram
s for
kids
and a
dults
2
• Su
pport
comm
unity
int
erven
tions
3
• Co
nduc
t scre
ening
ac
tivitie
s6
• De
velop
socia
l sup
port
interv
entio
n in a
co
mmun
ity se
tting7
• Su
pport
parks
and
recrea
tion f
acilit
ies1
• Pro
vide p
reven
tion
and e
arly d
etecti
on
oppo
rtunit
ies3
• Cre
ate he
alth l
eade
rship
deve
lopme
nt op
portu
nities
4
• Or
ganiz
e mult
icomp
onen
t co
mmun
ity-w
ide PA
ed
ucati
on ca
mpaig
ns5
• Inc
rease
acce
ss to
place
s for
PA an
d info
rmati
onal
outre
ach6
• Re
move
vend
ing
mach
ines2
• Pro
vide fl
ex tim
e3
• Pro
vide i
ncen
tives
4
• Pro
vide p
rogram
s/fac
ilities
5
• Co
nduc
t edu
catio
nal
progra
ms6
• Pro
vide i
nsura
nce
cove
rage7
• Im
prove
food
servi
ce8
• Inc
lude f
amily
outre
ach9
• Ba
lance
work
hours
/job
de
mand
s10
• Pro
vide c
ouns
eling
11
• Co
mbine
exerc
ise
progra
m wi
th oth
er he
alth p
rogram
s12
• Cre
ate a
supp
ortive
en
viron
ment
and
cultu
re13
• Fo
rm pa
rtners
hips w
ith
profes
siona
l and
acad
emic
group
s14
• Pro
vide T
ime15
• Dis
play p
oint-o
f-dec
ision
promp
ts to
enco
urage
us
e of s
tairs16
• Pro
vide s
creen
ing an
d ref
erral3
• Co
nduc
t res
earch
in
weigh
t man
agem
ent4
• De
velop
and s
uppo
rt ind
ividu
ally-a
dapte
d he
alth b
ehav
ior ch
ange
-pro
grams
9
Texas Obesity Policy Portfolio54
Age
Sett
ings
Fede
ral &
Sta
te
Gove
rnm
ent
Med
iaSc
hool
sFa
ith-b
ased
Or
gani
zatio
nsCo
unty
& C
ity
Gove
rnm
ent
Wor
ksite
sHe
alth
Car
e
51-65 years•
Acco
untab
ility f
or he
alth
throu
gh de
velop
ment
of a
healt
h kno
wled
ge ba
se1
• Su
rveilla
nce m
anda
te on
BM
I2
• De
finitio
n of o
besit
y as a
he
alth p
roblem
for in
surers
4
• Ac
credit
ation
of pr
ovide
rs5
• Ta
x brea
ks7
• Fo
cus h
ow to
use T
itle III
fun
ds to
supp
ort he
alth
promo
tion8
• Cre
ate a
HEDI
S me
asure
to
hold
phys
icians
ac
coun
table9
• Ad
d BRF
SS qu
estio
ns
regard
ing ob
esity
aw
arene
ss10
• Pro
vide a
ccess
and
referr
al so
urces
3
• Ph
ysica
l acti
vity p
rogram
s for
kids
and a
dults
2
• Su
pport
comm
unity
int
erven
tions
3
• Co
nduc
t scre
ening
ac
tivitie
s6
• De
velop
socia
l sup
port
interv
entio
n in a
co
mmun
ity se
tting7
• Su
pport
parks
and
recrea
tion f
acilit
ies1
• Cre
ate he
alth
leade
rship
deve
lopme
nt op
portu
nities
4
• Or
ganiz
e mult
icomp
onen
t co
mmun
ity-w
ide PA
ed
ucati
on ca
mpaig
ns5
• Inc
rease
acce
ss to
place
s for
PA an
d info
rmati
onal
outre
ach6
• Re
move
vend
ing
mach
ines2
• Pro
vide fl
ex tim
e3
• Pro
vide i
ncen
tives
4
• Pro
vide p
rogram
s/fac
ilities5
• Co
nduc
t edu
catio
nal
progra
ms6
• Pro
vide i
nsura
nce
cove
rage7
• Im
prove
food
servi
ce8
• Inc
lude f
amily
outre
ach9
• Ba
lance
Work
hours
/job
de
mand
s10
• Pro
vide c
ouns
eling
11
• Co
mbine
exerc
ise
progra
m wi
th oth
er he
alth
progra
ms12
• Cre
ate a
supp
ortive
en
viron
ment
and c
ulture
13
• Fo
rm pa
rtners
hips
with
profes
siona
l and
ac
adem
ic gro
ups14
• Pro
vide t
ime15
• Dis
play p
oint-o
f-dec
ision
promp
ts to
enco
urage
us
e of s
tairs16
• Co
nduc
t res
earch
in
weigh
t man
agem
ent4
• Us
e N/P
A as a
vital
sign
7
• Cre
ate pr
escri
ption
s us
ing co
mmun
ity gu
ides8
• De
velop
and s
uppo
rt ind
ividu
ally-a
dapte
d he
alth b
ehav
ior-ch
ange
pro
grams
9
Texas Obesity Policy Portfolio 55
AgeSe
ttin
gs
Fede
ral &
Sta
te
Gove
rnm
ent
Med
iaSc
hool
sFa
ith-b
ased
Or
gani
zatio
nsCo
unty
& C
ity
Gove
rnm
ent
Wor
ksite
sHe
alth
Car
e
65+ years
• Ac
coun
tabilit
y for
healt
h thr
ough
deve
lopme
nt of
a he
alth k
nowl
edge
base
1
• Su
rveilla
nce m
anda
te on
BM
I2
• De
finitio
n of o
besit
y as
a hea
lth pr
oblem
for
insure
rs4
• Ac
credit
ation
of Pr
ovide
rs5
• Ta
x brea
ks7
• Fo
cus h
ow to
use T
itle III
fun
ds to
supp
ort he
alth
promo
tion8
• Cre
ate a
HEDI
S me
asure
to
hold
phys
icians
ac
coun
table9
• Ad
d BRF
SS qu
estio
ns
regard
ing ob
esity
aw
arene
ss10
• Pro
vide a
ccess
and
referr
al so
urces
3
• Ph
ysica
l acti
vity
progra
ms fo
r kids
and
adult
s2
• Su
pport
comm
unity
int
erven
tions
3
• Co
nduc
t scre
ening
ac
tivitie
s6
• De
velop
socia
l sup
port
interv
entio
n in a
co
mmun
ity se
tting7
• Su
pport
parks
and
recrea
tion f
acilit
ies1
• Cre
ate he
alth l
eade
rship
deve
lopme
nt op
portu
nities
4
• Or
ganiz
e mult
icomp
onen
t co
mmun
ity-w
ide PA
ed
ucati
on ca
mpaig
ns5
• Inc
rease
acce
ss to
place
s for
PA an
d info
rmati
onal
outre
ach6
• Re
move
vend
ing
mach
ines2
• Pro
vide fl
ex tim
e3
• Pro
vide i
ncen
tives
4
• Pro
vide p
rogram
s/fac
ilities5
• Co
nduc
t edu
catio
nal
progra
ms6
• Pro
vide i
nsura
nce
cove
rage7
• Im
prove
food
servi
ce8
• Inc
lude f
amily
outre
ach9
• Ba
lance
work
hours
/job
de
mand
s10
• Pro
vide c
ouns
eling
11
• Co
mbine
exerc
ise
progra
m wi
th oth
er he
alth p
rogram
s12
• Cre
ate a
supp
ortive
en
viron
ment
and c
ulture
13
• Fo
rm pa
rtners
hips
with
profes
siona
l and
ac
adem
ic gro
ups14
• Pro
vide t
ime15
• Dis
play p
oint-o
f-dec
ision
promp
ts to
enco
urage
us
e of s
tairs16
• Co
nduc
t res
earch
in
weigh
t man
agem
ent4
• Us
e N/P
A as a
vital
sign
7
• Cre
ate pr
escri
ption
s us
ing co
mmun
ity gu
ides8
• De
velop
and s
uppo
rt ind
ividu
ally-a
dapte
d he
alth b
ehav
ior ch
ange
pro
grams
9
Texas Obesity Policy Portfolio56
Texas Obesity Policy Matrix
Conceptual Framework
State/Federal Government1. Accountability for health through development of health knowledge base
Health Communications Division. AIM for a Healthy Weight. Texas Department of Health, Bureau of Nutrition Services. 2003. 1–52.
McGinnis J.M., Williams-Russo P., and Knickman J.R. The Case For More Active Policy Attention To Health Promotion. Health Affairs. 2002. 21(2): 78–92.
Mokdad A.H., Marks J.S., Stroup D.F., et al. Actual Causes of Death in the United States, 2000. JAMA 2004. 291: 1238–1245.
The Center for Weight and Health. Pediatric Overweight: A Review of the Literature. College of Natural Resources, University of California-Berkeley. June 2001. 1–127.
U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, M.D.: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General. 2001.
2. Surveillance mandate on BMI
Baranowski T., Cullen K.W., Nicklas T., et al. School-Based Obesity Prevention: A Blueprint for Taming the Epidemic. Am J Health Behav. 2002. 26(6): 486–493.
U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, M.D.: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General. 2001.
3. Day-care credentialing process and policies
The Henry J. Kaiser Family Foundation. Issue Briefs: The Role of Media in Childhood Obesity. February 2004. 1–12.
VanLandeghem K. Preventing Obesity in Youth through School-Based Efforts. Health Policy Studies Division, National Governors Association Center for Best Practices. February 2003. 1–7.
4. Definitions of obesity as a health problem for insurers
Ganz, M.L. The Economic Evaluation of Obesity Interventions: Its Time Has Come. Obes Res. 11: 1275–1277.
Texas Obesity Policy Portfolio 57
New England Coalition for Health Promotion and Disease Prevention. Strategic Plan for the Prevention and Control of Overweight and Obesity in New England. February 2003. 1–115.
Wang G, Dietz W.H. Economic Burden of Obesity in Youths Aged 6 to 17 Years: 1979–1999. Pediatrics 2002. 109(5): 1–6. Accessible Online at http://www.pediatrics.org/cgi/content/full/109/5/e82
5. Accreditation of providers
Weight Realities Division of the Society for Nutrition Education. Guidelines for Childhood Obesity Prevention Programs: Promoting Healthy Weight in Children. October 2002.
6. Restrictions on advertising
The Henry J. Kaiser Family Foundation. Issue Briefs: The Role of Media in Childhood Obesity. February 2004. 1–12.
7. Tax breaks
8. Focus on how to use Title III funds to support health promotion
9. Create a HEDIS measure to hold physicians accountable
10. Add BRFSS questions regarding obesity awareness
Health Communications Division. AIM for a Healthy Weight. Texas Department of Health, Bureau of Nutrition Services. 2003. 1–52.
The Center for Weight and Health. Pediatric Overweight: A Review of the Literature. College of Natural Resources, University of California-Berkeley. June 2001. 1–127.
Media1. Develop time and budget campaign for media consumption
The Henry J. Kaiser Family Foundation. Issue Briefs: The Role of Media in Childhood Obesity. February 2004. 1–12.
2. Develop kids programming to change norms and attitudes
The Center for Weight and Health. Pediatric Overweight: A Review of the Literature. College of Natural Resources, University of California-Berkeley. June 2001. 1–127.
The Henry J. Kaiser Family Foundation. Issue Briefs: The Role of Media in Childhood Obesity. February 2004. 1–12.
3. Provide access and referral sources
Texas Obesity Policy Portfolio5�
Schools/Colleges1. Identify preschool requirements for food purchase
2. Develop time and budget campaign for media consumption
The Henry J. Kaiser Family Foundation. Issue Briefs: The Role of Media in Childhood Obesity. February 2004. 1–12.
3. Support curricula development
Baranowski T., Cullen K.W., Nicklas T., et al. School-Based Obesity Prevention: A Blueprint for Taming the Epidemic. Am J Health Behav. 2002. 26(6): 486–493.
California Department of Education. Appendix 2: State Analysis Proves Physically Fit Kids Perform Better Academically. Report to the Governor and Legislature. January 2003. 9–22.
Ganz, M.L. The Economic Evaluation of Obesity Interventions: Its Time Has Come. Obes Res. 2003. 11(11): 1275–1277.
O’Dea J.A. Why Do Kids Eat Healthful Food? Perceived Benefits of and Barriers to Healthful Eating and Physical Activity Among Children and Adolescents. J Am Diet Assoc. 2003. 103(4): 497–504.
4. Provide HP/DP activities to faculty and staff
5. Determine incentives and requirements for after-school programs
Nutrition and Physical Activity Workgroup. Guidelines for Comprehensive Programs to Promote Healthy Eating and Physical Activity. 2002. 1–37.
The Center for Weight and Health. Pediatric Overweight: A Review of the Literature. College of Natural Resources, University of California-Berkeley. June 2001. 1–127 .
The Henry J. Kaiser Family Foundation. Issue Briefs: The Role of Media in Childhood Obesity. February 2004. 1–12.
Trost S.G., Pate R.R., Sallis J.F., et al. Age and Gender Differences in Objectively Measured Physical Activity in Youth. Med Sci Sports Exerc. 2002. 34(2): 350–355.
6. Provide nutrition and physical activity programs to everyone
Cavadini C., Siega-Rix A.M., Popkin B.M. US Adolescent Food Intake Trends from 1965 to 1996. Arch Dis Child. 2000. 83: 18–24.
Nestle M. Increasing Portion Sizes in American Diets: More Calories, More Obesity. J Am Diet Assoc. 2003. 103(1): 39–40.
The Henry J. Kaiser Family Foundation. Issue Briefs: The Role of Media in Childhood Obesity. February 2004. 1–12.
Texas Obesity Policy Portfolio 59
VanLandeghem K. Preventing Obesity in Youth through School-Based Efforts. Health Policy Studies Division, NGA Center for Best Practices. February 2003. 1–7.
7. Remove vending machines
Lin B.H., Ralston K. Competitive Foods: Soft Drinks vs. Milk. Food Assistance and Nutrition Research Report Number 34–7. Economic Research Service, US Department of Agriculture. July 2003: 1–4.
Nestle M., Jacobson M.F. Halting the Obesity Epidemic: A Public Health Policy Approach. Public Health Reports. Jan/Feb 2000. 115: 12–24
Nielsen S.J., Popkin B.M. Patterns and Trends in Food Portion Sizes, 1977–1998. JAMA 2003. 289(4): 450–453.
Rampersaud G.C., Bailey L.B., Kauwell G.P.A. National Survey Beverage Consumption Data for Children and Adolescents Indicate the Need to Encourage a Shift Toward More Nutritive Beverages. J Am Diet Assoc. 2003. 103(1): 97–100.
VanLandeghem K. Preventing Obesity in Youth through School-Based Efforts. Health Policy Studies Division, NGA Center for Best Practices. February 2003. 1–7.
8. Screen high-risk kids
Baranowski T., Cullen K.W., Nicklas T., et al. School-Based Obesity Prevention: A Blueprint for Taming the Epidemic. Am J Health Behav. 2002. 26(6): 486–493.
VanLandeghem K. Preventing Obesity in Youth through School-Based Efforts. Health Policy Studies Division, NGA Center for Best Practices. February 2003. 1–7.
9. Improve food service
Cavadini C., Siega-Rix A.M, Popkin B.M. U.S. Adolescent Food Intake Trends from 1965 to 1996. Arch Dis Child 2000. 83: 1.8–24.
Center for Nutrition Policy and Promotion. Childhood Obesity: Causes & Prevention: Symposium Proceedings. 27 October 1998. 1–129.
Lin B.H., Ralston K. Competitive Foods: Soft Drinks vs. Milk. Food Assistance and Nutrition Research Report Number 34–7. Economic Research Service, U.S. Department of Agriculture. July 2003. 1–4.
Nielsen S.J., Popkin B.M. Patterns and Trends in Food Portion Sizes, 1977–1998. JAMA 2003. 289(4): 450–453.
Nestle M., Jacobson M.F. Halting the Obesity Epidemic: A Public Health Policy Approach. Public Health Reports. Jan/Feb 2000. 115: 12–24.
Texas Obesity Policy Portfolio60
New England Coalition for Health Promotion and Disease Prevention. Strategic Plan for the Prevention and Control of Overweight and Obesity in New England. February 2003. 1–115.
The Center for Weight and Health. Pediatric Overweight: A Review of the Literature. College of Natural Resources, University of California-Berkeley. June 2001. 1–127 .
VanLandeghem K. Preventing Obesity in Youth through School-Based Efforts. Health Policy Studies Division, NGA Center for Best Practices. February 2003. 1–7.
Wootan, M., Johanson, J., & Powell, J.( June 2006) School Foods Report Card. Center For Science in the Public Interest. [Retrieved on July 17, 2006] from HYPERLINK “http://www.cspinet.org” www.cspinet.org
10. Require PE
Baranowski T., Cullen K.W., Nicklas T., et al. School-Based Obesity Prevention: A Blueprint for Taming the Epidemic. Am J Health Behav. 2002. 26(6): 486–493.
California Department of Education. Appendix 2: State Analysis Proves Physically Fit Kids Perform Better Academically. Report to the Governor and Legislature. January 2003. 19–22.
HHS News. Overweight and Obesity Threaten U.S. Health Gains: Communities Can Help Address the Problem, Surgeon General Says. U.S. Department of Health and Human Services. 13 December 2001. Accessible Online at www.hhs.gov/news.
Mokdad A.H., Marks J.S., Stroup D.F., et al. Actual Causes of Death in the United States, 2000. JAMA 2004. 291: 1238–1245.
Nestle M., Jacobson M.F. Halting the Obesity Epidemic: A Public Health Policy Approach. Public Health Reports. Jan/Feb 2000. 115: 12–24.
Task Force on Community Preventive Services. Recommendations to Increase Physical Activity in Communities. Am J of Prev Med. 2002. 22(4S): 67–72.
The Center for Weight and Health. Pediatric Overweight: A Review of the Literature. College of Natural Resources, University of California-Berkeley. June 2001. 1–127 .
Trost S.G., Pate R.R., Sallis J.F., et al. Age and Gender Differences in Objectively Measured Physical Activity in Youth. Med Sci Sports Exerc. 2002. 34(2): 350–355.
VanLandeghem K. Preventing Obesity in Youth through School-Based Efforts. Health Policy Studies Division, NGA Center for Best Practices. February 2003. 1–7.
11. Built environment issue at university
12. Classes on family living and health
Health Communications Division. AIM for a Healthy Weight. Texas Department of Health, Bureau of Nutrition Services. 2003. 1–52.
Texas Obesity Policy Portfolio 61
The Center for Weight and Health. Pediatric Overweight: A Review of the Literature. College of Natural Resources, University of California-Berkeley. June 2001. 1–127 .
VanLandeghem K. Preventing Obesity in Youth through School-Based Efforts. Health Policy Studies Division, NGA Center for Best Practices. February 2003. 1–7.
13. Develop young parent opportunities
14. Encourage breastfeeding
VanLandeghem K. Preventing Obesity in Youth through School-Based Efforts. Health Policy Studies Division, NGA Center for Best Practices. February 2003. 1–7.
The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Overweight and Obesity: A Vision for the Future.
Faith-Based Organizations1. Develop time and budget campaign
The Henry J. Kaiser Family Foundation. Issue Briefs: The Role of Media in Childhood Obesity. February 2004. 1–12.
2. Physical activity programs for kids and adults
Baranowski T., Cullen K.W., Nicklas T., et al. School-Based Obesity Prevention: A Blueprint for Taming the Epidemic. Am J Health Behav. 2002. 26(6): 486–493.
Flegal K.M., Carroll M.D., Ogden C.L., Johnson C.L. Prevalence and Trends in Obesity Among U.S. Adults, 1999–2000. JAMA. 2002. 288: 1723–1727.
HHS News. Overweight and Obesity Threaten U.S. Health Gains: Communities Can Help Address the Problem, Surgeon General Says. U.S. Department of Health and Human Services. 13 December 2001. Accessible Online at http://www.hhs.gov/news.
Mokdad A.H., Marks J.S., Stroup D.F., et al. Actual Causes of Death in the United States, 2000. JAMA 2004. 291: 1238–1245.
Nestle M., Jacobson M.F. Halting the Obesity Epidemic: A Public Health Policy Approach. Public Health Reports. Jan/Feb 2000. 115: 12–24.
Task Force on Community Preventive Services. Recommendations to Increase Physical Activity in Communities. Am J of Prev Med. 2002. 22(4S):67–72.
The Center for Weight and Health. Pediatric Overweight: A Review of the Literature. College of Natural Resources, University of California-Berkeley. June 2001. 1–127 .
Trost S.G., Pate R.R., Sallis J.F., et al. Age and Gender Differences in Objectively Measured Physical Activity in Youth. Med Sci Sports Exerc. 2002. 34(2): 350–355.
Texas Obesity Policy Portfolio6�
VanLandeghem K. Preventing Obesity in Youth through School-Based Efforts. Health Policy Studies Division, NGA Center for Best Practices. February 2003. 1–7.
3. Support community interventions
4. Encourage breastfeeding
The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Overweight and Obesity: A Vision for the Future.
VanLandeghem K. Preventing Obesity in Youth through School-Based Efforts. Health Policy Studies Division, NGA Center for Best Practices. February 2003. 1–7.
5. Develop young parent opportunities
6. Conduct screening activities
7. Develop social support intervention in a community setting
Task Force on Community Preventive Services. Recommendations to Increase Physical Activity in Communities. Am J of Prev Med. 2002. 22(4S): 67–72.
City/County Government1. Support parks and recreation facilities
Center for Nutrition Policy and Promotion. Childhood Obesity: Causes & Prevention: Symposium Proceedings. 27 October 1998. 1–129.
Nutrition and Physical Activity Workgroup. Guidelines for Comprehensive Programs to Promote Healthy Eating and Physical Activity. 2002. 1–37.
The Center for Weight and Health. Pediatric Overweight: A Review of the Literature. College of Natural Resources, University of California-Berkeley. June 2001. 1–127.
2. Provide incentives for built living environments
Center for Nutrition Policy and Promotion. Childhood Obesity: Causes & Prevention: Symposium Proceedings. 27 October 1998. 1–129.
Nutrition and Physical Activity Workgroup. Guidelines for Comprehensive Programs to Promote Healthy Eating and Physical Activity. 2002. 1–37.
The Center for Weight and Health. Pediatric Overweight: A Review of the Literature. College of Natural Resources, University of California-Berkeley. June 2001. 1–127.
3. Provide prevention and early detection opportunities
Baranowski T., Cullen K.W., Nicklas T., et al. School-Based Obesity Prevention: A Blueprint for Taming the Epidemic. Am J Health Behav. 2002. 26(6): 486–493.
Texas Obesity Policy Portfolio 63
VanLandeghem K. Preventing Obesity in Youth through School-Based Efforts. Health Policy Studies Division, NGA Center for Best Practices. February 2003. 1–7.
4. Create health leadership development opportunities
5. Organize multicomponent community-wide PA education campaigns
Task Force on Community Preventive Services. Recommendations to Increase Physical Activity in Communities. Am J of Prev Med. 2002. 22(4S): 67–72.
6. Increase access to places for PA and informational outreach
Task Force on Community Preventive Services. Recommendations to Increase Physical Activity in Communities. Am J of Prev Med. 2002. 22(4S): 67–72.
Worksites1. Engage game builders and producers
2. Remove vending machines
Nestle M., Jacobson M.F. Halting the Obesity Epidemic: A Public Health Policy Approach. Public Health Reports. Jan/Feb 2000. 115: 12–24
Nielsen S.J., Popkin B.M. Patterns and Trends in Food Portion Sizes, 1977–1998. JAMA. 2003. 289(4): 450–453.
Rampersaud G.C., Bailey L.B., Kauwell G.P.A. National Survey Beverage Consumption Data for Children and Adolescents Indicate the Need to Encourage a Shift Toward More Nutritive Beverages. J Am Diet Assoc. 2003. 103(1): 97–100.
3. Provide flex time
4. Provide incentives
New England Coalition for Health Promotion and Disease Prevention. Strategic Plan for the Prevention and Control of Overweight and Obesity in New England. February 2003. 1–115.
Reuters. Exercise Lowers Employers’ Health Costs. May 18.
Shannon S.L., Leonard B., Fridinger F. The Centers for Disease Control and Prevention Director’s Physical Activity Challenge: An Evaluation of a Worksite Health Promotion Intervention. Am J Health Promot. 2000. 15(1): 17–20.
5 . Provide programs/facilities
Kerr N.A., Yore M.M., Ham S.A., Dietz W.H. Increasing Stair Use in a Worksite Through Environmental Changes. Am J of Health Promot. 2004. 18(4): 312–315.
Texas Obesity Policy Portfolio64
Lowe G.S., Schellenberg G., Shannon H.S. Correlates of Employees’ Perceptions of a Healthy Work Environment. Am J Health Promot. 2003. 17(6): 390–399.
6. Conduct educational programs
Flegal K.M., Carroll M.D., Ogden C.L., Johnson C.L. Prevalence and Trends in Obesity Among U.S. Adults, 1999–2000. JAMA. 2002. 288: 1723–1727.
7. Provide insurance coverage
Ganz, M.L. The Economic Evaluation of Obesity Interventions: Its Time Has Come. Obes Res. 2003. 11: 1275–1277.
New England Coalition for Health Promotion and Disease Prevention. Strategic Plan for the Prevention and Control of Overweight and Obesity in New England. February 2003. 1–115.
Wang G., Dietz W.H. Economic Burden of Obesity in Youths Aged 6 to 17 Years: 1979–1999. Pediatrics 2002. 109(5):1–6. Accessible Online at http://www.pediatrics.org/cgi/content/full/109/5/e82.
8. Improve food service
National Institutes of Health. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. 1998. NIH Publication No. 98–4083: 1–228.
Nestle M., Jacobson M.F. Halting the Obesity Epidemic: A Public Health Policy Approach. Public Health Reports. Jan/Feb 2000. 115: 12–24.
Nielsen S.J., Popkin B.M. Patterns and Trends in Food Portion Sizes, 1977–1998. JAMA. 2003. 289(4): 450–453.
New England Coalition for Health Promotion and Disease Prevention. Strategic Plan for the Prevention and Control of Overweight and Obesity in New England. February 2003. 1–115.
Nutrition and Physical Activity Workgroup. Guidelines for Comprehensive Programs to Promote Healthy Eating and Physical Activity. 2002. 1–37.
9. Include family outreach
The Center for Weight and Health. Pediatric Overweight: A Review of the Literature. College of Natural Resources, University of California-Berkeley. June 2001. 1–127.
10. Balance work hours/job demands
11. Provide counseling
Shephard R.J. Worksite Fitness and Exercise Programs: A Review of Methodology and Health Impact. Am J of Health Promot. 1996. 10(6): 4 36–452.
Texas Obesity Policy Portfolio 65
12. Combine exercise program with other health program
Shephard R.J. Worksite Fitness and Exercise Programs: A Review of Methodology and Health Impact. Am J of Health Promot. 1996. 10(6): 436–452.
13. Create a supportive environment and culture
Wilson M.G., Griffin-Blake C.S., DeJoy D.M. Physical Activity in the Workplace. In M.P. O’Donnell (Ed.), Health Promotion in the Workplace. Albany, NY: Delmar. 2002. 244–273.
14. Form partnerships with professional and academic groups
Kaplan G.D., Brinkman-Kaplan V., Framer E.M. Worksite Weight Management. In M.P. O’Donnell (Ed.), Health Promotion in the Workplace. Albany, NY: Delmar. 2002. 293–337/
15. Provide time to participate
Kaplan G.D., Brinkman-Kaplan V., Framer E.M. Worksite Weight Management. In M.P O’Donnell (Ed.), Health Promotion in the Workplace. Albany, NY: Delmar. 2002. 293–337.
16. Display point-of-decision prompts to encourage use of stairs
Task Force on Community Preventive Services. Recommendations to Increase Physical Activity in Communities. Am J of Prev Med. 2002. 22(4S): 67–72.
Health care1. Home visits to support young mothers
2. Develop time and budget campaign
The Henry J. Kaiser Family Foundation. Issue Briefs: The Role of Media in Childhood Obesity. February 2004. 1–12.
3. Provide screening and referral
4. Conduct research on weight management
5. Encourage breastfeeding
The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Overweight and Obesity: A Vision for the Future.
VanLandeghem K. Preventing Obesity in Youth through School-Based Efforts. Health Policy Studies Division, NGA Center for Best Practices. February 2003. 1–7.
6 . Develop young parent opportunities
7. Use N/PA as vital sign
8. Create prescriptions using community guides
Texas Obesity Policy Portfolio66
9. Develop and support individually-adapted health behavior-change programs
Task Force on Community Preventive Services. Recommendations to Increase Physical Activity in Communities. Am J of Prev Med. 2002. 22(4S): 67–72.
All Sectors and SettingsKoplan, J., Liverman, C., Kraak, V. (Eds.) Preventing Childhood Obesity. Washington, D.C.: The National Academies Press. 2005.
Lobstein T. Comment: Preventing child obesity — an art and a science. Obesity Reviews. 2006. 7(1): 1-5.
New South Wales Department of Health. Prevention of Obesity in Children and Young People. North Sydney, NSW. 2003.
New South Wales Department of Health. Best Options for Promoting Healthy Weight and Preventing Weight Gain in NSW. North Sydney, NSW: Centre for Public Health Nutrition. 2005.
Wong, F., Huhman, M., Heitzler, C., Asury, L., Vretthauer-Mueller, R., McCarthy, S., Londe,. P., VERBTM-A Social Marketing Campaign to Increase Physical Activity Among Youth. Preventing Chronic Disease. 2004. 1(3): 1–7.
Handy, S., & K. Clifton. Planning and the Built Environment. Obesity Epidemiology and Prevention: A Handbook. S. Kumanyika and R. Braownson. New York: Springer.
Swinburn B., Gill T., Kumanyika S. Obesity Prevention: A proposed framework for translating evidence into action. Obesity Reviews 2005. 6: 23-33.
Texas Department of State Health Services. Strategic Plan for the Prevention of Obesity in Texas: 2005-2010. Austin, TX: Office of Nutrition, Physical Activity, and Obesity Prevention. 2005.
Washington State Department of Health. Nutrition and Physical Activity: A Policy Resource Guide. Olympia, WA: Office of Community Wellness and Prevention. 2005.
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Adoption — The uptake of a policy option by individuals in the various settings.12
BMI-for-age — In children, the BMI values vary with the age and sex of the child. The BMI in children is called BMI-for-age.3
Body Mass Index (BMI)3 — weight (kg)/height (m2).3
Comprehensive policy approaches — Policy intervention at a multitude of settings including but not limited to federal and state government, local governments, health care, workplace, media, faith-based organizations, and schools.9
Effective policy options — The policy idea or the environmental change the policy is meant to bring about were tested in one or more well-designed scientific studies found to affect nutrition and/or physical activity behavior.9
Efficacy — Impact of a policy under ideal conditions.12
Epidemic — The occurrence of a disease that is clearly in excess of the normal expectancy.22
Evidence — A body of facts or information that provides a level of certainty that a proposition is true or valid. Observation and experimental are the two main categories of evidence.
External Validity — A measure of the generalizability of the findings from the study population to the target population.22
Internal Validity — Internal validity measures the extent to which differences in an outcome between or among groups in a study can be attributed to the hypothesized effects of an exposure, an intervention, or other causal factor being investigated. A study is said to have internal validity when there has been proper selection of study groups and a lack of error in measurement.22
Matrix — A format adopted to characterize research data by age groups and settings and sectors.
Morbidity — The occurrence of an illness or illnesses in a population.22
Mortality — The occurrence of death in a population.22
Obesity — For an adult, a BMI of 30 or more.3
Glossary
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Overweight — For an adult, overweight refers to a BMI between 25 and 29.9. A child is considered overweight if they have a BMI-for-age between the 85 percentile and the 95 percentile.3
Portfolio — A selection of policy options based on the best available evidence including untested and promising strategies.
Prevalence — The number of existing cases of a disease or health condition in a population at some designated time.22
Promising policy options — The rationale supporting the policy idea or the specific policy approach was tested in a well-designed scientific study and results of efficacy are ongoing.9
Public Health — Public health focuses on the prevention of disease by keeping people well, but includes efforts to reduce disability and increase quality of life. In addition to its emphasis on prevention, public health focuses attention on working with populations of people, including families, neighborhoods, and communities, not just individuals.
Reach — Proportion of the population of relevant settings in which the policy or program is instituted.12
Untested policy options — Policy options that are potentially great ideas but are untested or are shown to not have definitive results.9
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Background References
Background References1. Texas Department of State Health Services, Texas Behavioral Risk Factor Surveillance
System. 2005. Online at http://www.dshs.state.tx.us/chs/brfss/query/brfss_form.shtm
2. Juliano C., Levi J., Sega L.M. F as in Fat: How Obesity Policies are Failing in America 2006. Trust for America’s Health Issue Report. 2006.
3. BMI — Body Mass Index: About BMI for Adults. CDC Accessed on July 12, 2006 from http://www.cdc.gov/nccdphp/dnpa/bmi/adult_BMI/about_adult_BMI.htm
4. Texas Department of State Health Services The Burden of Overweight and Obesity in Texas, 2000-2040. 2003.
5. New South Wales Department of Health. Prevention of Obesity in Children and Young People. North Sydney, NSW. 2003.
6. Texas Department of State Health Services. Tobacco Use is a Tremendous Burden to All Texans. Accessed July 14, 2006 from http://www.dshs.state.tx.us/tobacco/pdf/Factburdn.pdf
7. Texas Department of State Health Services. Progress on Achieving Texas Tobacco Reduction Goals: A Report to the 79th Legislature. Accessed July 14, 2006 from http://www.dshs.state.tx.us/tobacco/pdf/tobleg79.pdf
8. Unpublished summary, Tai-Seale T.: Recommendations from Agencies for Adult Weight Loss
9. Washington State Department of Health. Nutrition and Physical Activity: A Policy Resource Guide. Olympia, WA: Office of Community Wellness and Prevention. 2005.
10. Koplan, J., Liverman, C., Kraak, V, Wisham, SL. (Eds.) Progress in Preventing Childhood Obesity: How do we Measure Up? Washington, D.C.: The National Academies Press. 2006.
11. Koplan, J., Liverman, C., Kraak, V. (Eds.) Preventing Childhood Obesity: Health in the Balance. Washington, D.C.: The National Academies Press. 2005.
12. Swinburn B., Gill T., Kumanyika S. Obesity Prevention: A proposed framework for translating evidence into action. Obesity Reviews 2005. 6: 23-33
13. New South Wales Department of Health. Best Options for Promoting Healthy Weight and Preventing Weight Gain in NSW. North Sydney, NSW: Centre for Public Health Nutrition. 2005.
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14. Muir Gray J.A., Hayner R.D., Sakett D.L., Cool D.J., Guyat G.H. Transferring evidence from research into practice: 3. developing evidence-based clinical policy. American College of Physicians Journal Club. 1997. 126: A14-A16
15. Rychetnik L., Hawe P., Waters E., Barratt A., Frommer M. A glossary for evidence based public health. Journal of Epidemiol Community Health. 2004. 58: 538-545
16. Victora C., Habicht J., Bryce J. Evidence-based public health: moving beyond randomized trials. American Journal of Public Health. 2004. 64: 400-405.
17. Dzewaltowski D.A., Glasgow R.E., Klesges L.M., Estabrooks P.A., Brock E. RE-AIM: evidence-based standards and a Web resource to improve translation of research into practice. Annals of Behavioral Medicine. 2004. 28(2): 75-80.
18. Background information on RE-AIM Accessed on September 8, 2006 from http://www.re-aim.org/
19. Lobstein T. Comment: Preventing child obesity — an art and a science. Obesity Reviews. 2006. 7(1): 1-5
20. Texas Department of State Health Services. Strategic Plan for the Prevention of Obesity in Texas: 2005-2010. Austin, TX: Office of Nutrition, Physical Activity, and Obesity Prevention. 2005.
21. Wootan, M., Johanson, J., & Powell, J. School Foods Report Card. Center For Science in the Public Interest. June 2006 Retrieved on July 17, 2006 from http://www.cspinet.org
22. Friis, Robert, & Seller, Thomas. Epidemiology for Public Health Practice. Massachusetts: Jones and Bartlett. 2004.
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