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Local policies related to restaurant menu labeling:
Barriers, facilitating factors, and the role of local health departments
A thesis presentation by
Elizabeth Payne, MPH candidate
Committee:
Donna Johnson, PhD, RD (Chair)
Barbara Bruemmer, PhD, RD
University of Washington, Nutritional Sciences
February 25th, 2011
Introduction
• Obesity and related chronic disease rates increasing
despite decades of targeted individual level
interventions1-7
• Obesity approach that mirrors successful anti-tobacco
work, focusing on environmental factors 1, 3, 8
• Nutrition policies based on anti-tobacco work:
– change social norms to make unhealthy food less
accessible, less desirable and less acceptable1
IntroductionThe restaurant food environment
• Meals away from home increased with obesity rates, now account for ~1/3 of calories consumed9,10
• ~3/4 of restaurant visits at fast-food & other chain restaurants11
• Fast-food associated with higher intake of calories & saturated fat, higher BMI, increased risk of obesity, type 2 diabetes1-3
• Hard to accurately estimate calories in meals15-17
• Not voluntarily reducing portion sizes, or displaying nutrient information4-6
IntroductionMenu Labeling Policies
• The restaurant industry has opposed attempts to
regulate the provision of nutrition information7,8
• Menu labeling legislation passed in many
jurisdictions, NYC 1st in 2008 12,18, 20
• In March 2010, passage of the Patient Protection
and Affordable Health Care Act, made restaurant
menu labeling federal law.18, 19
BackgroundThe effect of menu labeling unclear
Experimental studies
Milich et al. 1976 Workplace cafeteria, modest effect
Cinciripini et al. 1984 University cafeteria, mixed effect
Mayer et al. 1987 Workplace cafeteria, no effect
Balfour et al. 1996 Workplace cafeteria, modest effect
Yamamoto et al. 2005 Adolescents, mixed effect
Burton et al. 2006 Mail survey, mixed effect
Harnek et al. 2008 Adolescents, modest effect
Roberto et al. 2010 RCT, significant effect
Studies in real-world situations
Bassett et al. 2007 Subway restaurants, effect in some customers
Dumanovsky et al. 2010 NYC post enforcement, 2-fold increase in reported use
Elbel et al. 2009, 2011 NYC regulation, no effect
Pulos et al. 2010 Pierce Co voluntary program, minimal effect
Finkelstein et al. 2011 King Co regulation, no effect
Background1st menu labeling policy
Lessons from NYC’s menu labeling regulation12,20,29
• 1st passed 2006
• BOH criticized for not including NYSRA
Big push-back from NYSRA
• 1st lawsuit decided in NYSRA’s favor
• Revised regulation went into effect 2008
• 2nd NYSRA lawsuit not successful
Background
King
Pierce
Thurston
3 counties in Washington Stateworking to improve the restaurant food environment using
different approaches to menu labeling
BackgroundThree menu labeling cases in Washington State
King County
• 2nd jurisdiction to pass
menu labeling regulation
• Intense push-back from
industry
• Regulation went into
effect Jan 2009
• 1st study to date: no
impact on calories
ordered30
BackgroundThree menu labeling cases in Washington State
Pierce County
• SmartMenu voluntary,
non-chain restaurants
• Help w/ menus &
recipes, free nutrient
analysis, advertising
• 2 studies to date: small
impact on purchasing
behavior31, incredibly
resource intensive32
BackgroundThree menu labeling cases in Washington State
• NEA showed need for
focus on kids meals
• 2009 RWJF HE grant
• Collaborative study w/
local franchise owner
• 1st phase- add healthier
items
• 2nd phase- test
marketing
Thurston County
Need for current study
• Need more studies on policy process
• Public health literature on policy development often lacks theoretical framing33, 34
• Applying theories of policy change to real-world policy situations needed35
• Opportunity to study interactions between local public health departments and industry
Study Purpose & Aims
To determine the roles, relationships and barriers related to working with restaurants and to identify strategies that health departments can use to facilitate nutrition policy development.
Study Purpose & Aims
Specific Aims
1.Examine the interactions among restaurant owners,
the Washington Restaurant Association, and local
health departments to determine political and
contextual factors that are barriers or enablers to
the provision of nutrition information in restaurants
2.Describe the role of local health departments in
developing and implementing restaurant nutrition
information policies
The Advocacy Coalition Framework
The Advocacy Coalition Framework
The Advocacy Coalition Framework
Relatively Stable Parameters
system-wide parameters, stable over long
periods of time
• Governmental, legal and economic systems
• Attributes of policy issue that are enduring and
frame the policy debate36
The Advocacy Coalition Framework
The Advocacy Coalition Framework
External Eventsdynamic factors external to the policy subsystem
changes in:• socioeconomic conditions • technology• public opinion • political power (i.e. critical elections)
and the impact of other policy decisions & subsystems36
The Advocacy Coalition Framework
The Advocacy Coalition Framework
The Advocacy Coalition Framework
Policy Subsystem
comprised of the set of actors involved with a given policy issue
subsystem actors form advocacy coalitions based on shared values or beliefs36
The Advocacy Coalition Framework
The Advocacy Coalition Framework
Policy Subsystem- beliefsoverarching driver for policy actors
Deep core beliefs - deeply held personal beliefs, unchangeablePolicy core beliefs - fundamental policy positions of an advocacy coalition, resistant to changeSecondary beliefs - related to the administration and implementation of policy, most susceptible to change36
The Advocacy Coalition Framework
Policy-oriented learningoccurs as a result of:• direct challenge to an advocacy coalition
(opponent challenge or external events) • accumulated experience, the so-called
enlightenment function of policy process that
can take up to a decade or more36
Methods
Multiple-case, replication study design
Data collection:• written documentation from each county • key informant interviews:
– public health employees, Board of Health members, restaurant owners, Washington Restaurant Association representative
• Interviews by phone, and oral consent was obtained using procedures approved by the University of Washington Institutional Review Board in January 2010.
• The interviews ranged from 20 to 100 minutes in length and were recorded to ensure complete data collection
Methods
Plus one interview with a Washington Restaurant Association Representative
MethodsData Analysis
• Interview transcripts reviewed for key concepts and themes
• Coding structure developed, based on the constructs of the ACF
• Atlas.ti qualitative data analysis software used to code and manage data37
• Coded data explored both within and across cases, looking for patterns and linkages
• Data from each case used to assess the fit to the Advocacy Coalition Framework
Results
Constraints and resources (barriers/enablers)
• Relatively stable parameters
• External events
Policy subsystem
• Relationships
• Beliefs- role of Health Department
Results- constraints and resources
Respondents in each county:• obesity rates = something must be done• increases in meals eaten away from home made
restaurant environment an obvious choice• Its a given that restaurants are focused on profit,
public health objectives often at odds
Relatively Stable Parameters
• Obesity rates• Increased eating away from home• Restaurants need to be profitable
Results- constraints and resources
ACF Construct King Pierce ThurstonExternal Events
KingPolitical climate BOHPrecedent policy in NYCSupport from national organization
Pierce
Economic recessionPolitical climate BOH Industry push-back in NYC, King Co Federal legislation
ThurstonFundingPolitical climate BOHIndustry push-back in NYC, King Co
Results- constraints and resources
KingPolitical climate/BOH Precedent policy in NYCSupport from national organization
Results- constraints and resources
KingPolitical climate/BOH Precedent policy in NYCSupport from national organization
Results- constraints and resources
• ACF Construct KingPierce
Economy in recession• Health department impacted:
- restructuring, loss of champion• requiring restaurants to take on additional costs
would not play well politically
Pierce
Economic recessionPolitical climate/BOHIndustry push-back in NYC, King CoFederal legislation
Results- constraints and resources
• BOH generally supportive and progressive
• Supportive of voluntary approach, less enthusiastic about
the idea of passing menu labeling regulation
• One BOH member described a BOH that is politically
divided, with some members who are pretty conservative
and “the less government the better” types
Pierce
Economic recessionPolitical climate/BOHIndustry push-back in NYC, King CoFederal legislation
Results- constraints and resources
Pierce
Economic recessionPolitical climate/BOHIndustry push-back in NYC, King CoFederal legislation
Results- constraints and resources
• Large-scale cut backs, re-prioritization of tasks and time for new leadership to get up to speed on the work
• By the time ready to move forward with policy, preemption
by federal legislation was a concern
Pierce
Economic recessionPolitical climate/BOHIndustry push-back in NYC, King CoFederal legislation
Results- constraints and resources
• 100% grant funded budget
• Robert Wood Johnson Foundation (RWJF) grant to work
on healthy kids menus- research project
ThurstonFundingPolitical climate/BOHIndustry push-back in NYC, King Co
Results- constraints and resources
• Respondents described the BOH as very committed to
using a collaborative approach with industry • Advancing a menu labeling policy was never even on the
agenda: “[N]o way would our county commissioners or BOH
basically support something like that [menu labeling regulation] either. It wouldn’t even be an option here to do something like that. That's not how they look at it” - PH employee
ThurstonFundingPolitical climate/BOHIndustry push-back in NYC, King Co
Results- constraints and resources
BOH is 3 county commissioners, elections every 4 years
Thurston’s population just over 250,000. One public health
employee said, “[E]ven though we’re a pretty Democratic county,
we have a mix- a very Republican mix, lots of military families lots of different things like that. You have to really be careful in terms of thinking through how people look at individualism and individual choices.”- PH employee
ThurstonFundingPolitical climate/BOHIndustry push-back in NYC, King Co
Results- constraints and resources
ThurstonFundingPolitical climate/BOHIndustry push-back in NYC, King Co
Results- Policy Subsystem
• ACF ConstructKing Pierce
HEAL- Healthy Eating Active Living
Policy Subsystem Actors
King
Leaders: Board of Health, Public Health DirectorStaff: HEAL*, environmental healthIndustry: restaurant owners (chains), WRACommunity: health organizations & advocatesCenter for Science in the Public Interest
PierceLeaders: BOH, former HD manager, PH Director Staff: HEAL*, environmental healthIndustry: owners (local, non-chain), WRA
ThurstonLeaders: BOH, senior HD leadershipStaff: HEAL*, environmental health Industry: local franchise owner, WRA
42
Results- Policy Subsystem
Advocacy Coalitions in King Co
1st Phase: contentious relationships• BOH members invite WRA to meetings,
vote to pass regulation • WRA, restaurant owners feel ignored:
“There was no real open dialogue. It wasn't ‘what do you guys think?’ It was this is what we want to do and we hope that you’ll get onboard. Well, how do we have the ownership, or how do we feel like this is the best way to go if we can’t even comment?” - WRA rep
43
Results- Policy Subsystem
44
Results- Policy Subsystem
Advocacy Coalitions in King Co
2nd Phase: changing relationships• WRA attempts statewide preemption• BOH fights for the policy • WA state legislature- “compromise”
45
Results- Policy Subsystem
WRA representative describes the process, “We ran a statewide labeling bill that would have created a consistent statewide standard. King County fought us the whole way through that, and so unfortunately that was very combative there. Through that though we got them to come to the table and sit down with us and talk through our concerns…Anyway, out of that fortunately we turned into a relationship that became sort of positive. We continued working with them and we found an ordinance that our folks could agree upon.”
46
Results- Policy Subsystem
47
Results- Policy Subsystem
Policy Core Beliefs: appropriate role of government, priority of regulation
KingUnanimously endorsed the belief that it is an appropriate role of public health to use regulation when necessary to protect the health of the community
PierceBOH and PH employees less united on the question of using regulation, role of PH to educate vs. role is to safeguard public health and regulation is appropriate
ThurstonRole of public health is to ensure that people have choices, regulation only as last resort
48
Results- Policy Subsystem
ACF: Advocacy coalitions form around shared policy core beliefs
• Evidence of shared beliefs that favor public health policy development in King County
• Beliefs in Pierce less unified
• Thurston unified around beliefs that favor partnerships with industry rather than public health policy development
49
Results- key factors King Co
Relatively stable parameters•obesity rates•meals away from home•restaurants need to be profitable
External events•Political climate supportive of regulation•NYC precedent policy•Support from CSPI
Policy Subsystem•Advocacy coalitions formed around shared policy beliefs
•Pro-menu labeling coalition beliefs: role of HD is to protect PH and use regulation as needed
•Opposition coalition beliefs (data not shown): freedom from regulation priority
•Evidence of policy oriented learning
Con
stra
ints
& R
esou
rces
50
Results- key factors Pierce Co
Relatively stable parameters•obesity rates•meals away from home•restaurants need to be profitable
External events•Economic recession•Political climate not supportive of regulation•Push-back from industry in NYC, King CO•Federal legislation
Policy Subsystem•HD restructure, loss of champion, new leadership
• BOH, PH employees different beliefs about role of PH, use of regulation
•BOH more supportive of voluntary program
•Policy development process stalled by threat of preemption, new priorities
Con
stra
ints
& R
esou
rces
51
Results- key factors Thurston Co
Relatively stable parameters•obesity rates•meals away from home•restaurants need to be profitable
External events•Funding•Political climate not supportive of regulation•Push-back from industry in NYC, King CO
Policy Subsystem•Grant driven funding limits strategies
• BOH favors collaboration with industry
•Role of HD is to provide choice
•Policy development was never an optionC
onst
rain
ts &
Res
ourc
es
52
Discussion
Results of this research suggest that key factors influencing the policy process include:
• the need for industry to be profitable
• the impact of economic conditions both on industry and health departments
• the presence of precedent or role-model policy
• support from national groups
• the political climate
• leadership support for policy
53
DiscussionUsefulness of ACF
•Findings are constant with other studies that have examined public health policy process and found the political climate, economic context and leadership to be important factors5, 7, 12
•The Advocacy Coalition Framework has primarily been used to examine and describe anti-tobacco policy processes, but given the interest in using tobacco policy to develop new approaches to obesity using the ACF to understand what happened in each of these three counties is especially relevant33
54
Discussion
Implications for practice:• Building an advocacy coalition aligned around
shared beliefs helps weather inevitable push-back from policy opponents
• Leadership support, policy-mentors and the support of other (national) organizations are key
• Prepared policy advocates will look for favorable conditions and be ready to move on policy when the context shifts in their favor
55
Discussion
Limitations
• Key informants who were not interviewed
• Differences in interview process (King)
• Time frame too short to see policy changes as described by ACF
56
Discussion
Recommendations for future research
• Apply ACF to other policy initiatives for improving the food environment in restaurants (sodium, SSB)
• Will likely involve many of the same factors and policy subsystem actors
• Changes over time, decade or more
57
Conclusion
• Environmental and policy approaches are an important part of the public health response to reduce obesity and related chronic diseases.
• Food environments that make healthy food more accessible, acceptable and desirable make it easier for individuals to make healthy choices.
• The menu labeling policy process in King County demonstrates that local health departments can advance public health aims through the formation of advocacy coalitions, making the most of the constraints and resources of the policy subsystem and building on leadership support.
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Acknowledgments
Thesis Committee
Donna Johnson
Barb Bruemmer
Steering Committee
Kirsten Frandsen- Tacoma-Pierce County Health Dept
Deborah Allen- Thurston County Public Health & Social Services Dept
Donna Oberg- Public Health-Seattle & King County
Molly McNees- Public Health-Seattle & King County
Friends and family
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