Changing Policies and the Physical Environment So Children and Families Can Eat Well and Move More

    • February 14, 2012

An active, healthy childhood. When Sarah Strunk was growing up in a small town near Chicago, her mom made a healthy family dinner from scratch every night, often using tomatoes and green peppers from her dad's vegetable garden. Strunk often rode a tandem bike with her dad or a friend. She played basketball, volleyball, and softball year-round in school and park district leagues.

A different world today. It is not as easy today for children to eat healthy and be active. "Life is very different for my nieces and nephews, and millions of youth like them, whose exposure to food is often limited to what comes out of a box or a drive-through window," said Strunk. She also noted that it is harder to walk or bike around town than when she was young. At least partly as a result, more than 23 million young people in the United States—about one in three children and adolescents—are overweight or obese.

Forging a path to public health. After earning a BA in public policy from Duke University, Strunk wanted to work in health care but did not want to be a clinician. She enrolled in the master of health policy and administration program at the University of North Carolina at Chapel Hill. "My MHA program provided a broad skill set that I've used in all of my jobs since then: a strong focus on writing and analysis, strategic planning, and understanding how the health system functions," she said.

To gain experience, Strunk did a one-year fellowship at Bowman Gray/Baptist Hospital Medical Center (now the Wake Forest University Baptist Medical Center) in Winston-Salem, N.C., where she rotated through all of the departments and worked with the executive team. She stayed on for two more years in clinical strategic planning. For the next seven years, Strunk worked in strategy and business planning roles at Duke University Medical Center and Health System and at Blue Cross and Blue Shield of North Carolina.

But Strunk realized that she was not fulfilling her mission in life. "I learned a lot, but what I was doing felt too far removed from impacting public health," she said.

As an alumna of the Gillings School of Global Public Health at the University of North Carolina, Strunk had established a mentoring program to pair students with influential graduates for purposes of professional development. Her volunteer work eventually led Strunk back to the school in a more formal capacity, where as director of external affairs she worked on a $100 million fund-raising campaign to support public health education, research, and service.

Making the connection to active living through RWJF. In 2001, the Robert Wood Johnson Foundation (RWJF) selected the Gillings School of Global Public Health as the organizational home for Active Living by Design. This program was part of a suite of Active Living programs to increase routine physical activity through comprehensive changes in community environments. Once RWJF chose the Gillings school to manage the national program, Strunk was selected as the deputy director, in which role she was integral in co-designing and launching the initiative with RWJF staff "I was really intrigued by this emerging field and excited about the opportunity to work with RWJF, a pioneer in health and health care," she said.

In 2005, she became director of Active Living by Design, which by then had projects in 25 communities, and she helped launch and manage a related program, Healthy Eating by Design, in 12 of them. She is now director of RWJF's Healthy Kids, Healthy Communities, which is working through partnerships in 49 communities to promote children's physical activity and healthy eating.

Helping communities create policy and environmental change. In all three programs, the goal has been "to create environments that enable people to sustain healthy behaviors," said Strunk. Multidisciplinary partnerships in the communities base their work on local values, needs, and culture. Partnerships include faith-based groups, nonprofit and advocacy organizations, academic institutions, health care organizations, public health agencies, urban planning agencies, parks departments, and many others.

In Active Living by Design, which ran from 2001 to 2009, local partnerships focused on developing policies and programs to make physical activity part of everyday life, eliminating barriers to active living, and building awareness of the benefits of active living.

Communities created crosswalks, sidewalks, and bike lanes to make pedestrian and bicycle travel safer, and spearheaded or contributed to other projects to foster physical activity. Project staff and partners led or contributed to education and advocacy that resulted in new or enhanced ordinances and policies, and established permanent advisory boards on active living. The program showed that multidisciplinary partnerships can make policy and environmental changes to support active living in as few as five years.

Active Living by Design also helped spearhead a movement promoting the importance of community design in improving public health, and integrated other disciplines—such as planning, transportation, and parks and recreation—with public health. The program also introduced the idea of using policy and environmental change to enable children and families to make healthier choices, and created models for active living through the community partnerships. The partnerships helped leverage more than an additional $275 million in grants, direct contributions, funded government policies and in-kind contributions for active living programs—beyond the RWJF funding. (For more information on the program, read the Program Results Report.)

In Healthy Eating by Design, which ran from 2005 to 2007, 12 communities aimed to increase access to affordable, healthy food for children and families by changing local food and nutrition policies, half of them working in schools and half in community environments. Local partnerships worked with individual schools, districts and community partners to provide healthy food in cafeterias, offer cooking demonstrations or classes on preparing healthy food, develop community gardens, and more. (Read the Program Results Report.)

In Healthy Kids, Healthy Communities, launched in 2007, 49 communities are promoting changes in local policies, systems and the physical environment to support healthy living and prevent childhood obesity. The program, which will continue through 2013, emphasizes reaching children who are at highest risk for obesity based on race or ethnicity, family income, or geographic location. (Read the Progress Report.)

As of October 31, 2011, Healthy Kids, Healthy Communities partnerships had helped develop 85 policy changes and 144 changes to the physical environment to expand access to affordable healthy foods and opportunities for physical activity.

Jefferson County, Ala., for example, passed regulations supporting physical activity and good nutrition at more than 200 faith-based child-care centers previously exempt from regulation. In Rochester, N.Y., the Parks and Recreation Commission started a program to activate underused or unsafe parks. The new Grant County Food Policy Council in New Mexico will be recommending policy changes and implementing projects to encourage local food production and availability.

"We're helping to change environments and increase demand for healthier ones. We're starting to see changes in social norms," says Strunk. "Communities around the country are focusing on ways to reengineer their environments so healthier choices are accessible to everybody."

Leading a collaborative, committed team. Managing these large, complex programs includes providing hands-on and Web-based technical assistance to all the communities, monitoring their activities, and working closely with RWJF. To do all this and more, Strunk has put together a multidisciplinary team consisting of a dozen practitioners, many of whom have been working together since 2002. "Our staff are committed to this work through and through," she said.

To facilitate collaboration, the team has developed healthy eating and active living policies for the program office. For example, every Friday at 3:00 p.m., they gather outside for Frisbee, soccer, or another physical activity. Birthdays are celebrated creatively and without food.

As a result of their work with RWJF, a variety of other funders in North Carolina and nationwide have approached Strunk and her team to partner with them in the development of other grant programs, and to provide consultation, training, and technical assistance to additional communities. For example, the team designed and implemented Fit Community, a seven-year program initially funded by the North Carolina Health and Wellness Trust Fund, which supported 38 communities in their efforts to promote physical activity and healthy eating and awarded 36 Fit Community designations across the state.

Nurturing leaders. Active Living by Design and Healthy Kids, Healthy Communities have helped foster "incredible leaders" at the University of North Carolina, in communities, and beyond, says Strunk. These leaders are collaborating across disciplines, such as planning, transportation, and parks and recreation, to facilitate healthier choices.

This work has had a profound impact on the city planners and public health professionals now getting immersed in planning principles and language, according to Strunk. For example, in 2003, the University of North Carolina became one of the first universities to offer a dual-degree master's program in health behavior and regional planning. Several graduates of the program, have assumed leadership roles across the country.

"It's been rewarding seeing the growth of individuals on our team and leaders in the field," she says.

RWJF perspective. Through its childhood obesity work, RWJF wants to help all children and families eat well and move more—especially those in communities at highest risk for obesity. RWJF funds efforts such as Healthy Kids, Healthy Communities to change public policies and community environments in ways that promote better nutrition and physical activity.

"Sarah Strunk has continued to provide a level of leadership, commitment, passion, and humility to this program and the field that is unparalleled," said Jamie Bussel, program officer for Healthy Kids, Healthy Communities and other programs Strunk has managed for RWJF.

"I feel incredibly lucky having the chance to do this kind of work," says Strunk.