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									What factors affect the passage
 of state legislation to prevent
      childhood obesity?

                  Ellen Jones, PhD

                 Elizabeth Dodson,
 Saint Louis Univ. School of Public Health
  •   Chris Fleming (Mathematica Policy Research, Inc.)
  •   Tegan Boehmer (CDC)
  •   Debra Haire-Joshu
  •   Doug Luke
  •   Ross Brownson
  •   Ellen Jones
  •   Amy Eyler
  •   Leah Wentworth

 Childhood obesity epidemic

 Environmental and policy

 Individual states have much of the
  authority over public health policy
Art and Science

  Why policy interventions?
  changing the physical and sociopolitical
 opportunities, support, and cues
 may directly affect behaviors
  • Influence of price of tobacco on consumption
 or may alter social norms
  • Physically active people in public spaces
 Often more permanent than many public
  health programs focused on individual-level
  behavioral change
  • Important complement to individual-level programs
Schmid, Pratt, and Witmer. J Physical Activity Health 2006.
Childhood Obesity Policy Study
 Objective: Examine childhood
  obesity prevention legislation in all
  50 states, 2003-2005
             Phases 1 and 2:
1. Identify relevant legislation
  describe patterns intro/adoption
2. Explore predictors and contextual
  factors affecting bill enactment
Results Summary: Objective 1
 Descriptive statistics to describe
  patterns by time, place, and topic
 During 2003-2005
  • 123 of 717 (17%) bills were adopted
  • 71 of 134 (53%) resolutions were adopted

  • Introduced legislation increased 70%
  • Adopted legislation increased 38%

          Boehmer, et al. Preventing Chronic Disease 2007
            700 bills 2003-2005!
 Fewer than 20% enacted
 More likely if bi-partisan sponsors
 More likely in 2 year sessions
  (Boehmer, 2007 and 2008)

 Only 7% have a review of evidence
  (Hartsfield, 2007)

     Mississippi 2009 provisional
   HB=1,597 SB=3302
   About 300 health
   About 60 made it out of committee
   About 10 passed into law

          Bill Enactment (%) by Topic
                 Area, 2003-2005
                          0%   10%   20%   30%   40%
Physical Education/Activity
          Health Education
       Curriculum & Credit
           Local Authority
    Safe Routes to School
           BMI Reporting
    Model School Policies
         Farmers Markets
        Task Force/Study
          Snack/Soda Tax
     Walking/Biking Paths
      Statewide Initiatives
    Menu/Product Labeling
Bill Enactment (%) by State,
          Results Summary:
             Objective 2

 Bills were more likely to be introduced if:
   • Introduced in Senate vs. House
   • >1 sponsor from a single party

 Bills were more likely to be enacted if:
   • Budget bills – enacted 75% of time
   • Involved community walking/biking paths

 Bills were less likely to be enacted if:
   • Proposed a new law (vs. amendment)
   • Proposed to generate revenue through taxes or fines
   • Involved PE, health curriculum, nutrition/vending
          Boehmer, et al. American J of Preventive Medicine 2008.
           Phase 3: Purpose
• Identify factors of state legislative
  environment important for successful
  childhood obesity prevention legislation

• Describe significant barriers to passing &
  adopting childhood obesity prevention
        Phase 3: Methods
 Key informant interviews with state
  legislators and staffers
 Interview questions
 Sample selection
 Telephone interviews conducted: Dec
  05 – April 06
 Qualitative data analysis
        Results: Sample
 N=16: 11 legislators, 5 staffers

 Political party: 80% Democratic

 Backgrounds: law & ed (20% health)

 Time in state legislature: range=4-21
  years; mean=11.8 years

 Legislative responsibilities
    Interview Question #1

In your view, what factors support
or facilitate the introduction and
adoption of childhood obesity
prevention legislation?
    Results: Facilitators

     National Media Exposure

“[Which bills pass] depends on what
      makes it into the media.”
      Results: Facilitators
Introduction by senior legislators & those
           with personal interest
 “You need … committed legislators.
  Legislators who are going to say, „I‟m going
  to put myself on the line and push ...‟”
 “We said that we need to do something about
  the obesity issue instead of just inform the
  public…We just did basic fundamental
  thinking of, what can we do to help? And
  then: what can we do that will pass?”
          Other Facilitators
 Gaining support of key players

 Working in supportive political climate

 Attempting incremental changes
     Interview Question #2
In your view, what factors oppose or
inhibit the introduction and adoption of
childhood obesity prevention
         Results: Barriers

 “We cannot underestimate the power of the
  food lobby, the soda lobby, the restaurant
 “You can‟t blindside the lobbyists…I had this
  one…bill, we had as many lobbyists in the
  room as legislators…Lobbyists are there.
  They get paid and they can watch things a lot
  more carefully than public interest groups,
  which are not as well-funded.”
            Results: Barriers
      Misconceptions - outcomes for schools

“Representatives who voted no [on school junk
 food bill] indicated that their schools had
 encouraged them to vote no. Some of them implied
 that soft drink companies had put pressure on
 them as well. But most of them, even the ones who
 said they got pressure from the soda companies,
 all of them mentioned pressures from their school
 districts they represented, saying that their school
 districts feared they would lose money.”
      Interview Question #3
Legislation sometimes passes in increments
over a period of time, eventually leading to a
comprehensive set of bills vs. the initial
adoption of comprehensive bills. Do you
think that childhood obesity prevention
legislation is more likely to progress through
(1) a series of several incremental bills or (2)
a few comprehensive bills?
           Question 3 Results
 Childhood obesity prevention legislation is
  more likely to pass through:
  • Series of incremental bills (73%)
  • One comprehensive bill (18%)

 “I think incrementalism is the name of the
  game here in the legislature, given our fiscal
                     So what?
 What we already know:
   • Lobbyists
   • Incrementalism
   • Political climate

 What we can do:
   •   Learn to work within the system
   •   Learn from other areas of success (tobacco)
   •   Train community advocates to use media
   •   Educate constituents

 Other needs & priorities
   • More on the evidence base for child obesity policy
         e.g., IOM recommendations
   • Need for practice based evidence
   • Explore the generalizability of various policy approaches
 Build & advocate incrementally

 “If you can get things into the media, it‟s
  very helpful to legislators.”

 “…to pass legislation like this, you really
  want to make sure that the people who
  are going to be implementing it and the
  people who are affected by it are
  involved in your legislative planning.”
Why do States Differ in the
Level of Childhood Obesity
          Ellen Jones, PhD
Objectives – to examine influence of

   Type of legislature
   Legislator factors
   Political context
   Bill content
   Public support

                          Montana Capitol Rotunda
     Factors in State Obesity Policy

Legislative Factors        Public

              Context               Bill Content

                                              Legislator Factors
                               2 x 2 Table
              Low Obesity                     High Obesity

              SOUTH DAKOTA                   ARIZONA
              MONTANA                        KANSAS

              WASHINGTON                     LOUISIANA
              MAINE                          NEW YORK

              Division of Legislation Tertiles:
              Low Legislation=0-3 Adopted Bills—17 states
              Median=4-7—16 states
              High=8-30—17 states

              Division of Childhood Obesity Tertiles:
              Lower Childhood Obesity=lowest (9.6%) to 13.2%—14 states
              Median=13.3% to 16%—21 states
              High=16.1% to highest (21.9%)—15 states
               Obesity Index
2003 and 2007 NSCH
Consistent Tertiles

 9.6 - 13.2%
13.3 – 16%
16.1 – 21.9%

    Ranking of Policy Enacted
     2006,2007,2008,2009 enacted

 Low legislation = 0-3 bills
 Median legislation = 4-7 bills
 High legislation = 8-30 bills

      Descriptive Analysis – Legislators
   15 White, 3 Black, 2 Hispanic
   Children or grandchildren
   9 Males, 11 Females
   10 R, 10 D
   Senate Democrats
   8 Chair, VC; 12 members

                                    From left, New York’s Senator Joseph L. Bruno, Senator Hugh T. Farley,
                                    Gov. David A. Paterson and Assemblyman Sheldon Silver.
Senators Being Led in Physical Exercises by Physultopathy Founder Bernarr Macfadden,
1924: Black and White Photograph from the Library of Congress features American Work
Outs throughout history
    Descriptive Analysis – Legislative
   3 R Gov, 5 D Gov
   Party in House 3 D and 3 R
   Party in Senate 4 D and 3 R
   Term limits gov - 5 yes
   Term limits leg – 5 yes
   1 professional legislatures
   3 hybrid legislatures
   4 part time legislatures

                                  Washington Capitol Building
  Red States   White States    Blue States
Time 80%       Time 70%       Time 54%
Comp $68,599   Comp $35,326   Comp $15,984
Staff 8.9      Staff 3.1      Staff 1.2

NJ             AL   KY   OR    GA WV
CA       NY    AZ   LA   SC    ID   MT
IL       OH    AK   MD   TN    IN   NH
FL        PA   CO   MN   TX    KS  ND
NA        WI   CT   MO   VI    ME   SD
MI             DE   NE   WA    MS   UT
               HA   NC   AR    NV  WYO   IA   OK         NM RI VT
Category   Time   Compensation Staff

Red        80%    $68,599      8.9

White      70%    $35,326      3.1

Blue       54%    $15,984      1.2
                               NCSL, 2008

          Introduction Results

 Legislator role (in and out of session) influences
 Impetus for action not articulated
 Discomfort in state policy role
 Discomfort with evidence and results
 Philosophical support vs. policy action
         Introduction Quotes
 “there‟s support for prevention, but not for

 “In 10 yrs debate, several (bills) introduced
  but none passed…”

 “can you legislate obesity?”

 “well aware there is a problem; but the
  question is how to address it”
           Bill Content Results

   Unclear cost or new cost is barrier
   Need for immediate results
   No consensus around role of legislature
   Different definitions
   Different expectations of evidence/science
          Bill Content Quote
 “not a whole lot of it is science….I think a lot
  of it is anecdotal…”

 “the science is hard because policies are so

 …any proposed policies with start up money
  will be hard pressed”

 “cost is a make or break issue”
       Political Context Results

 Legislators expect but don‟t act
  on public health message
 No compelling social movement
 Opposition viewed as well
 Loss outweighs gain
 It‟s the economy…

                                     Maine’s Speaker of the House, Hannah
                                     Pingree announcing policies to curb obesity
      Political Context Quotes
 “several people introduced bills but no one
  is consistently pushing and prodding”…

 “no one comes to mind”

 “are you kidding me? Cost is a very critical
  issue – a deciding factor”

 “overwhelming budget deficit makes funding
  obesity policy difficult”
                   Different Motivators
      End User: Researcher          Legislator            Staff

Time in Job        long             shortest              short

Accountability     university       voters                decision makers

Constituents       funders          voters, party,        Chair, VC,
                   publishers       supporters            Members, party
External factors   funding,          media, money,        habit,
                   teaching, writing public support       relationships,
Time on issue      long             shortest              short

Data used          peer reviewed    Stories, real life,   internal/ external
                                    testimony, results    support, data
            Public Support Results
 Lack consensus on state role

 Unclear wishes of

 Uncertain evidence will work

 Not tied to current priorities

 Media messages inconsistent

 No tie to policy actions
 Engagement not seen as a
  desire of constituents
                                   Nonprofit Day in Montana Capitol Rotunda
        Public Support Quotes

 “…interest in home level, NOT the government…”

 “1) economy, 2) jobs, 3) housing market”

 “Messages would be important as long as they are
  giving me specific ideas what to do”

 “even if it saves money, it wouldn‟t be now, we have to
  balance a budget now…”
            High Leg vs Low leg
Split on term limits
More years in legislature
More likely to say there is ―evidence‖

Know supporters
Know opposition
Can name obesity champions in state
Believe there is support
                      So What?
 Importance of non-modifiable factors

 Legislator discomfort with role and

 Political context inhibits passage

 Philosophical support vs. policy

                                         Kansas Capitol Rotunda
    Factors in State Obesity Policy

Legislative Factors

              Political               Bill
              Context               Content

                                              Legislator Factors
Art and Science
         Next Study:

         Advocates in
          •   LA
          •   WA
          •   CO
          •   NY
          •   CA
          •   ME


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