June 2008

Grant Results

SUMMARY

In 2001, the California Center for Public Health Advocacy published policy briefs about childhood obesity and fitness levels and diabetes mortality rates throughout California, and developed accompanying fact sheets individualized for each of California's 80 assembly and 40 senate districts.

Project staff worked with a biostatistician to analyze data from the 2001 California Physical Fitness Test administered to students in grades 5, 7 and 9 and California death certificates from 1996 to 2000.

Staff also convened two scientific advisory panels (one on overweight and unfit children and another on diabetes deaths).

Key Findings

  • High rates of overweight and physically unfit children exist in all California assembly and senate districts. Statewide, 26.5 percent of children are overweight and 39.6 percent are physically unfit.
  • Percentages of overweight children and diabetes-related deaths range widely among legislative districts, and those with higher diabetes-related death rates also tend to have a higher prevalence of overweight and physically unfit children.
  • African Americans, Latinos and American Indians/Alaskan Natives have the highest incidence of diabetes-related deaths.

Key Results

  • Center staff publicized the briefs and fact sheets and distributed them to lawmakers.
  • Members of the state legislature, public health departments, government agencies and community organizations throughout the state found the breakdown of data by legislative district to be very useful, according to Samuels & Associates, which conducted an evaluation of the project.
  • The policy briefs on overweight (comparing 2001 findings to 2004 findings) and on diabetes, and a map of overweight students by assembly district are posted on the Center Web site.

Funding
The Robert Wood Johnson Foundation (RWJF) provided $722,925 to support this unsolicited project from August 2002 through October 2004. The California Wellness Foundation ($200,000) and the California Endowment ($1.2 million) also provided support.

 See Grant Detail & Contact Information
 Back to the Table of Contents


THE PROBLEM

Two-thirds of all deaths in California result from three largely preventable chronic diseases — cardiovascular disease, cancer and diabetes, according to Harold M. Goldstein, the project director. At the same time, levels of childhood obesity and inactivity — among the risk factors for developing these diseases later in life — have increased dramatically in California and across the country.

If local legislators could see that high rates of many chronic diseases in their districts result from poor nutrition and physical activity habits among their constituents, then they might seek programs and policies to improve nutrition and physical activity patterns.

 Back to the Table of Contents


RWJF STRATEGY

The focus of RWJF's work in addressing childhood obesity is on children and families in low-income and minority populations, concentrating on ages three to 12, an age range that represents a critical period for developing lifelong habits. Because there are few known, effective strategies for addressing the problem, RWJF will use multifaceted approaches, to be developed with partners at many levels.

The initial goals are to support innovative school and community pilot projects to reduce childhood obesity and to address the huge gaps in knowledge about the causes of obesity in children, particularly environmental factors such as availability of junk food in schools and inadequate healthy food choices in local supermarkets.

The Childhood Obesity Team will also identify opportunities to build on and/or embed healthy eating and physical activity into existing child health initiatives funded by RWJF (e.g., the Center for Health and Health Care in Schools [see also Grant Results] and the Urban Health Initiative) and create opportunities to speak with and influence specific audiences regarding RWJF strategies.

 Back to the Table of Contents


THE PROJECT

The purpose of this project was to build support for polices and programs to promote healthy nutrition and physical activity for children and adolescents in California by informing state and local policy-makers about the link between levels of chronic disease in their districts and eating and physical activity patterns among their constituents.

The California Center for Public Health Advocacy published, disseminated and promoted the use of policy briefs and fact sheets describing childhood obesity and fitness levels, and diabetes mortality rates by state legislative district. The center, located in Davis, Calif., is a nonprofit, nonpartisan organization that seeks to raise awareness about public health issues and mobilize communities to promote the establishment of effective health policies.

Project staff and Chi Kao, Ph.D., a biostatistician from the University of California, San Francisco, working under a subcontract with the center, analyzed data from two sources, the 2001 California Physical Fitness Test administered to students in grades 5, 7 and 9, and California death certificates from 1996 to 2000.

Staff convened two scientific advisory panels, one for the topic of overweight and unfit children and one for diabetes deaths to ensure integrity of the information reported and to make policy recommendations to address the health challenges described in the briefs. Six to 10 professionals in the fields of nutrition, physical activity, physical education, diabetes and social marketing participated on each panel. See the Appendix for a list of panel members.

Each brief contained a set of recommendations based on the panel's advice about the type of policies and programs that the governor, legislators and various state agencies should take to improve children's nutrition and fitness levels. See Recommendations for a sample of those recommendations.

The center contracted with Samuels & Associates to write and edit the three policy briefs and two background reports. Samuels & Associates is a public health evaluation, research and policy consulting firm located in Oakland, Calif. The firm also conducted an evaluation of the release of the policy briefs and assessed their impact and use among stakeholders such as representatives from legislative offices and from community organizations throughout the state.

The center also hired Brown Miller Communications, a public relations firm located in Martinez, Calif., to handle the release of the policy briefs to the media. Brown Miller Communications developed a press kit, pitched the story to reporters and trained center staff and local advocates as media spokespersons.

 Back to the Table of Contents


RESULTS

The project accomplished the following:

  • Published the first legislative policy brief, An Epidemic of Overweight Children and Unfit Children in California Assembly Districts, in December 2002. It described childhood obesity and fitness levels in California's 80 assembly districts.
  • Published a follow-up brief that described the results in each of California's 40 Senate districts.
  • Released a third policy brief, An Early Warning Sign: Diabetes Deaths in California Legislative Districts, in February 2004. The brief describes diabetes-related death rates and the prevalence of overweight and unfit children by legislative district.
  • Distributed a copy of each policy brief to members of the state legislature along with individualized fact sheets highlighting findings for both childhood obesity and fitness and for diabetes deaths for each member's legislative district. Staff delivered the information to legislators by going door-to-door in the state capital and during one-on-one meetings.
  • California media outlets covered the briefs. According to the project director, most major newspapers in the state reported the findings and nine ran front-page stories. Television and radio stations also covered the findings, often as the lead story.

Findings

The following findings were reported in the three policy briefs:

  • High rates of overweight and unfit children existed in all California assembly and senate districts. Statewide, 26.5 percent of the children were overweight and 39.6 percent were unfit.
  • Percentages of overweight children ranged widely among legislative districts, from 16.9 percent to 36.8 percent, and the percentage of unfit children range from 19.1 percent to 54 percent. Los Angeles County legislative districts had particularly high rates of overweight and unfit children.
  • Rates for diabetes-related deaths varied likewise among legislative districts, and those with higher diabetes-related death rates also tended to have a higher prevalence of overweight and unfit children.
  • The highest diabetes-related death rates occurred in legislative districts in three regions — Los Angeles County, the Central Valley and the Southwest San Bernardino County.
  • African Americans, Latinos and American Indians/Alaskan Natives had the highest burden of diabetes-related deaths.

Recommendations

A sample of recommendations issued in the briefs to the governor, the legislature and public agencies follows:

  • Expand public and private insurance to:
    1. cover preventive care including, but not limited to, screening, education, obesity treatment and counseling on the benefits of healthy eating and physical activity.
    2. reimburse for obesity-related care and diabetes self-management education.
    3. cover diabetes supplies and prescription medications for persons with diabetes.
  • Improve school environments by:
    1. enforcing the state law that mandates 200–400 minutes of physical education every 10 days in grades 1–12.
    2. using only healthful foods as rewards and to be sold at fund-raisers.
    3. educating children about the importance of healthy eating and physical activity.
  • Improve community environments by:
    1. requiring chain restaurants to provide nutrition information on display boards and menus.
    2. requiring hospitals and other health care facilities to sell only healthful foods.
    3. implementing nutrition and physical activity standards in preschools, day care centers and Head Start, after-school and child care programs.
    4. designing communities in ways that promote healthy eating and physical activity.
  • Restrict marketing and advertising of unhealthful foods and beverages to children.
  • Conduct research to determine the conditions in communities that contribute to high diabetes-related death rates and high percentages of overweight and unfit children. Socioeconomic factors should be included in such research.

 Back to the Table of Contents


EVALUATION

The California Center for Public Health Advocacy subcontracted with Samuels & Associates to conduct an evaluation of the policy briefs. As part of the evaluation, Samuels & Associates surveyed stakeholders, such as members of the state legislature, public health departments, government agencies and community organizations throughout the state familiar with the policy briefs or with nutrition and physical activity and diabetes. The goal of the survey was to assess the impact and use of the policy briefs by these stakeholders.

Evaluation Findings

The evaluation findings include:

  • Respondents found the breakdown of unfit children by assembly district to be the most useful aspect of the brief An Epidemic of Overweight Children and Unfit Children in California Assembly Districts.
  • Respondents found the breakdown of death rates by legislative district and the breakdown by racial and ethic groups to be the most useful aspects of the brief An Early Warning Sign: Diabetes Deaths in California Legislative Districts.
  • Respondents were familiar with all three briefs and indicated the briefs motivated them to plan legislation and policy advocacy related to diabetes, obesity, nutrition and physical activity and incorporate information from the policy briefs into other, related activities such as local and regional forums for policy makers – including city council and school board members.
  • Respondents used the briefs to help inform and educate legislators about potential policy strategies.

Recommendations

The evaluators provided the following recommendations for future policy briefs:

  • Continue to release data broken down by legislative district. Data presented in this manner is easy to understand and provides clear direction for action at the local level.
  • Streamline the policy brief so only the most crucial data is incorporated. Policy-makers receive information from a number of different sources and want to see information presented in a manner that highlights the key elements of the issue.
  • Assure that recommendations provide readers with specific actions and that the brief focuses on the most important recommendations. Recommendations listed in the policy brief should be targeted to help local and statewide advocates focus their efforts on the most important changes that can be made at the local and state levels.
  • Include policy recommendations specific to each district, if possible. Legislators and community groups are looking for a way to make changes in their district or local communities. If recommendations can be tailored to the needs of each district, the work of policy-makers and local advocates will be simplified.
  • Involve community groups and other local representatives in writing future reports and formulating recommendations. Community organizations in particular would like greater involvement in the analysis and interpretation of the data and dissemination of findings.

Communications

The policy briefs received print, radio and television news coverage. According to Brown Miller Communications, findings from the overweight and unfit children and diabetes briefs reached an estimated audience of 20 million and 3.4 million people, respectively.

The center distributed more than 4,000 hard copies of each policy brief to policy-makers, educators, health professionals and obesity prevention advocates throughout California. Staff utilized a distribution network through the Strategic Alliance for Healthy Food and Activity Environments, a group of California organizations working to promote healthy eating and physical activity, and other partners such as the American Heart Association, California Medical Association and the California Women, Infants and Children (WIC) Association.

Staff made approximately 50 presentations on the findings to state legislative staff, national and regional organizations, such as the American Public Health Association and state and local organizations, such as the Santa Barbara Public Health Department.

The 2001 findings from the RWJF-supported study are compared to 2004 statistics at the project's Web site.

 Back to the Table of Contents


LESSONS LEARNED

  1. The media is interested in stories about the causes of childhood obesity and solutions to the diabetes epidemic. Staff at the center gained this insight when they spoke with more than 20 reporters following the release of the three policy briefs. (Project Director)
  2. Using an expert national scientific advisory panel to develop policy recommendations adds credibility to a project. When reporters, legislators and others approached staff about solutions to the problems of overweight and diabetes, staff was able to refer to the policy solutions that the advisory panels developed based on the project findings. (Project Director)
  3. Providing health-related data by legislative district is an effective tool to educate policy-makers, advocates, the media and the general public. The evaluations conducted by Samuels & Associates found that most stakeholders viewed this data to be very useful. (Project Director)
  4. The analysis of data by state legislative district is time consuming; adequate funding and staffing are essential. (Project Director)

 Back to the Table of Contents


AFTER THE GRANT

In November 2004, the center received $801,130 from the Vitamin Cases Consumer Settlement Fund to continue to develop legislative district policy briefs. The settlement fund came out of antitrust litigation regarding vitamin sales.

A law firm in San Francisco brought and settled the suit against the vitamin makers for $12.98 million and later issued a request for proposals from nonprofit groups to provide nutrition services and public health advocacy in California. Staff used the funds to conduct two studies in California communities.

The first study, published in August 2005, described the prevalence of overweight children in 2004 and compared the findings with those from the 2001 study conducted under this grant. Researchers noted that the growing levels of childhood obesity primarily resulted from unhealthy diets and low levels of physical activity among California youth.

In September 2005, due in part to these findings, the California legislature passed SB 965, which banned the sale of sodas and other sweetened beverages in state high schools, according to the center's 2008 Annual Report.

The second study, published in January 2007, examined the location of retail food outlets (grocery stores, convenience stores, restaurants and farmers' markets) and correlated the findings with those from all previous studies. Researchers found that in 2005, the state of California had more than four times the number of fast-food restaurants and convenience stores as supermarkets and produce vendors.

In April 2008, the center published a third study in partnership with PolicyLink and the UCLA Center for Health Policy Research. The study examined the relationship between local food environments and the incidence of obesity and diabetes.

The researchers created the Retail Food Environment Index, defined as the number of fast-food restaurants and convenience stores within a given distance of an individual home divided by the number of grocery stores and produce vendors within that same distance. A high index indicates that a person lives near a larger number of fast-food restaurants and convenience stores than grocery stores and produce vendors. The researchers found that:

  • California adults with a high index (5 or higher) had a 23 percent higher prevalence of diabetes and a 20 percent higher prevalence of obesity than adults with an index of 3 or lower.
  • A higher index was associated with a higher prevalence of obesity and diabetes for people living in both lower-income and higher-income communities.
  • The highest rates of obesity and diabetes are among people who live in lower-income and higher index communities.

In 2008, the center began a three-year project with the League of California Cities to train and support community leaders in developing local policies intended to encourage healthy eating and physical activity.

 Back to the Table of Contents


GRANT DETAILS & CONTACT INFORMATION

Project

Using Policy Briefs to Improve Population Health

Grantee

California Center for Public Health Advocacy (Davis,  CA)

  • Amount: $ 722,925
    Dates: August 2001 to October 2004
    ID#:  038118

Contact

Harold M. Goldstein
(530) 297-6000
hg@publichealthadvocacy.org

Web Site

http://www.publichealthadvocacy.org/growingepidemic.html

 Back to the Table of Contents


APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Scientific Advisory Panel for Overweight and Unfit Children in California

Kelli McCormack Brown, Ph.D., C.H.E.S., R.D.
Associate Professor
University of South Florida

Patricia Crawford, Dr.P.H., R.D.
Cooperative Extension Nutrition Specialist and Lecturer
University of California, Berkeley

Betty Hennessy, Ph.D.
Physical Education Consultant
Los Angeles County Office of Education

James Sallis, Ph.D.
Professor
Department of Psychology
San Diego State University

Gregory Welk, Ph.D.
Assistant Professor, Health Promotion and Exercise
Health & Human Performance
Iowa State University

Antronette Yancey, M.D., M.P.H.
Associate Professor
Department of Health Services
University of California, Los Angeles
School of Public Health

Study Advisers
Katherine Flegal, Ph.D., M.P.H.
Senior Research Epidemiologist
National Center for Health Statistics
Centers for Diseases Control and Prevention
Visiting Scholar
University of California, Berkeley

Marion Nestle, Ph.D., M.P.H.
Paulette Goddard Professor
Nutrition, Food Studies and Public Health
New York University


Appendix 2

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Scientific Advisory Panel for Diabetes Deaths in California

Ann Albright, Ph.D., R.N.
Specialist
University of California, San Francisco and
California Department of Health Services Diabetes Prevention and Control Programs

Debra Cohen, M.D.
Health Educator
Kaiser Permanente Santa Theresa Medical Center

Guadalupe Heredia, R.N., C.D.E.
Continuous Quality Improvement Director
Clinica De Salud, Brawley

Alka Kanaya, M.D.
Assistant Adjunct Professor
Division of General Internal Medicine
University of California, San Francisco
School of Medicine

Francine Kaufman, M.D.
Professor of Pediatrics
University of Southern California
Keck School of Medicine

Bill Releford, Jr., D.P.M.
Founder
Diabetes Amputation Prevention Foundation

Phyllis Preciado, M.D., R.N.
Physician and Fellow
Latino Center for Medical Research
University of California, San Francisco
School of Medicine

Joe Solowiejczk, R.N., M.S.W., C.D.E.
Diabetes Educator
Texas Diabetes Institute

Tress Stewart, R.N.
Public Health Nurse
Southeast Health Center, San Francisco

Chris Walker, M.P.H.
Executive Director, Project Dulce
Whittier Institute for Diabetes and Endocrinology

 Back to the Table of Contents


BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Reports

An Epidemic: Overweight and Unfit Children in California Assembly Districts. (Background Report) Davis, Calif.: California Center for Public Health Advocacy, 2002.

An Epidemic: Overweight and Unfit Children in California Assembly Districts: Legislative District Policy Brief No. 1. Davis, Calif.: California Center for Public Health Advocacy, 2002.

An Epidemic: Overweight and Unfit Children in California Senate Districts: Legislative District Policy Brief No. 2. Davis, Calif.: California Center for Public Health Advocacy, 2002.

An Epidemic: Overweight and Unfit Children in California Assembly Districts: 1st Assembly District. Davis, Calif.: California Center for Public Health Advocacy, 2002. (Fact Sheet repeated for Assembly Districts 2–80 and Senate Districts 1–40).

An Early Warning Sign: Diabetes Deaths in California Legislative Districts. (Background Report) Davis, Calif.: California Center for Public Health Advocacy, 2004.

An Early Warning Sign: Diabetes Deaths in California Legislative Districts: Legislative District Policy Brief No.3. Davis, Calif.: California Center for Public Health Advocacy, 2004.

An Early Warning Sign: Diabetes Deaths in California Legislative Districts: 1st Assembly District. Davis, Calif.: California Center for Public Health Advocacy, 2004. (Fact Sheet repeated for Assembly Districts 2–80 and Senate Districts 1–40).

Boyle M, Purcell M, Craypo L and Samuels S. Evaluation of the Fitnessgram Policy Brief: Summary of Findings. Oakland, Calif.: Samuels & Associates, 2003.

Boyle M, Purcell M, Craypo L and Samuels S. Evaluation of Diabetes Deaths by Legislative District Policy Brief: Summary of Findings. Oakland, Calif.: Samuels & Associates, 2003.

The Growing Epidemic: Child Overweight Rates on the Rise in California Assembly Districts. Davis, Calif.: California Center for Public Health Advocacy, 2005. Available online.

Searching for Healthy Food: The Food Landscape in California Cities and Counties. Davis, Calif.: California Center for Public Health Advocacy, 2007. Available online.

Designed for Disease: The Link Between Local Food Environments and Obesity and Diabetes. Davis, Calif.: California Center for Public Health Advocacy, 2008. Available online.

World Wide Web Sites

www.publichealthadvocacy.org/growingepidemic.html. Web site created to facilitate public access to findings, reports, policy briefs, maps and fact sheets comparing the prevalence of overweight children in California Assembly districts found in this study (for 2001) with those from a follow-up study that investigated overweight prevalence for 2004. Davis, Calif.: California Center for Public Health Advocacy, 2002.

 Back to the Table of Contents


Report prepared by: Barbara Matacera Barr
Reviewed by: Janet Heroux
Reviewed by: Molly McKaughan
Program Officer: Susan Hassmiller

Most Requested