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California Obesity Prevention Plan: A Vision for Tomorrow, Strategic Actions for Today

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Suggested Citation: California Obesity Prevention Plan: A Vision for Tomorrow, Strategic Actions for Today, Sacramento (CA): Department of Health Services; 2006.

Executive Summary

In recognition of California’s growing obesity epidemic, competing environmental forces and fragmented efforts, the legislature mandated that California Department of Health Services (CDHS) create this strategic plan to guide a statewide response to this crisis. (Budget Act of 2005, SB 77, Item # 4260.001.0001, Provision 7)

Case for Action: California, like much of the rest of the world, is experiencing an obesity epidemic for which there is no single cause or simple cure. The case for action to address this epidemic is based on three principal factors:

California’s Current Health Status - Poor nutrition and inactivity are causing serious health problems – including type 2 diabetes, heart disease, stroke, and cancer – now, and if left unchecked will lead to worsening conditions in the future.
Competing Environmental Forces – Choices that lead to poor nutrition and inactivity are often more available, affordable, and convenient than healthier options.
Fragmented, Uncoordinated Efforts – Many actions are being taken by government, industry, voluntary, and philanthropic sectors, but without concordance.
Call to Action: We have a vision for a healthier California. Governor Schwarzenegger developed a 10 Step Vision for a Healthy California and convened the Summit on Health, Nutrition and Obesity in September 2005 as a call to action to bring focus and momentum to the transformation that is needed to create a healthy California in which we all want to live. Through California’s internationally recognized tobacco control programs, we have experience and success in effecting a major societal change that resulted in significantly improved health for the people of our state. It was a difficult task but we did it. And we can do it again. As California has been a leader in reducing tobacco use, we can be a leader in the campaign to reduce obesity.

The Plan: This California Obesity Prevention Plan serves as a guide for each sector of society to take part in creating the shift to healthy eating and active living. This plan was constructed with input from a number of advisory groups, forums, and meetings including, the Governor’s Summit on Health, Nutrition, and Obesity, the Strategic Alliance, and the California Obesity Prevention Initiative. It identifies recommendations for action for all sectors to make sustainable changes in physical activity and food environments. The strategic actions are organized under these four goals:

Goal 1: Ensure state level leadership and coordination that reaches into communities across the state.
Goal 2: Create a statewide public education campaign that frames healthy eating and active living as California living.
Goal 3: Support local assistance grants and implement multi-sectoral policy strategies to create healthy eating and active living community environments.
Goal 4: Create and implement a statewide tracking and evaluation system.

This California Obesity Prevention Plan is meant to serve as a springboard for government, business, voluntary and philanthropic sectors to convert fragmentation into collaboration and synergy, to carefully align and invest resources, and to create a shared response to a societal crisis.

Case for Action

California, like much of the rest of the world, is experiencing an obesity epidemic for which there is no single cause or simple cure. The case for action to address this epidemic is based on three principal factors:

1. California’s Current Health Status – The Obesity Epidemic

California residents have gained 360 million pounds of excess weight in the past ten years, a rate that is among the fastest in the country. A third of our children, one in four teens, and over half of all adults are already overweight or obese.1, 2, 3 This epidemic affects virtually all age, income, educational, ethnic and disability groups, although rates are highest among Californians of Latino, American Indian, African American and Pacific Islander descent with lower incomes and disabilities. 4
Over the last 20 years, overweight levels have doubled in children and tripled in teens nationally. 5 With 22 percent of California children and teens overweight 6, the national Healthy People 2010 target reduction of overweight children and teens to five percent seems almost unattainable. 7 Most alarming is that between 40 – 80 percent of overweight children will become overweight adults. 8, 9
Rates of chronic disease and disability associated with poor diet and inactivity continue to escalate year after year. The real obesity toll comes with over half of all Californians at greater risk for heart disease, type 2 diabetes, high blood pressure, stroke, arthritis-related disabilities, depression, sleep disorders, and some cancers. Obese children are more than twice as likely to have type 2 diabetes as children of normal weight. If current trends continue, experts warn that one of three American children born in 2000 – and half of all children from ethnic/racially diverse populations – will suffer type 2 diabetes during his/her lifetime. 10 Today’s generation of children could become the first in modern history whose lifespan is less than that of their parents. 11
California’s costs attributable to physical inactivity, obesity and overweight in 2005 were projected to reach $28 billion for health care and lost work productivity. In contrast, a ten percent improvement – just one person of ten who becomes more active and maintains a healthy weight over a five-year period – could result in savings of nearly $13 billion. 12 Obesity-related health expenditures are estimated to have accounted for more than 25 percent of the growth of national health care spending between 1987 and 2001. 13 The public sector finances nearly half of all adult obesity medical spending through Medicaid and Medicare. 14 New medications and surgeries are available but at a cost that is hardly affordable. Bariatric surgery costs $20,000 to $50,000 and has significant risks and potential complications.
2. Competing Environmental Forces

While obesity results most directly from choices individuals make regarding physical activity and diet, strong environmental forces are at work that influence those choices. Every day individuals make food choices based in part on convenience and price. When many of California’s neighborhoods have an abundance of cheap, low-nutrient, high calorie food, and limited access to affordable fresh fruits and vegetables, meals reflect what is available. Too many low-income families must travel miles outside their communities to purchase healthy foods at reasonable prices. The higher the concentration of poverty within a community, the fewer the supermarkets. 15, 16, 17, 18 One study found that children who lived in metropolitan areas where fruits and vegetables were relatively expensive gained significantly more weight than children who lived where fruits and vegetables were cheaper. 19

Television influences what we eat. Nationally, $33 billion is spent on food marketing each year. Children view 40,000 commercials annually, resulting in the early formation of taste preferences and brand loyalties. 20 Television ads, the Internet, games, and strategic product placement strongly influence children to prefer and request high-calorie, low-nutrient foods and beverages. Over 80 percent of food products aimed at children are of poor nutritional quality. 21

Furthermore, the recommended 30 to 60 minutes of daily physical activity is much harder to attain if poor community planning results in neighborhoods that lack sidewalks and bike paths to encourage walking and biking. Most transit users get daily exercise through walking or cycling to the bus stop or train station. However, sprawl prevents many from taking public transit to work. Although many parents would like their children to walk or bike to school, the percentage of children doing so has dropped from 66 percent in 1974 to 13 percent in 2000 due to distance from school, crime or traffic danger. 22 Unsafe streets and the lack of safe play areas and parks keep children from being active outside. Those most at risk to be overweight – low-income, ethnically/racially diverse communities – have the least access to parks, bike trails, and public pools. 23, 24

3. Fragmented, Uncoordinated Efforts

Many factors influence the decisions that individuals make about what to eat and how active to be. Healthy choices can be made easier through ready access and affordability of healthy foods with neighborhoods, worksites, and schools that support active lifestyles. Increasingly, government and businesses, along with the voluntary and philanthropic sectors, are recognizing their roles and engaging in finding solutions to the obesity epidemic. Unfortunately, these efforts are not currently coordinated, and therefore do not achieve maximum impact.

All sectors across the state need to coordinate their fragmented efforts to create a systematic way to shift and realign resources, where possible. This will allow for strategic implementation of evidence-based efforts that will change the predicted obesity-laden future of California. Real change will occur when government, business, agriculture, schools, land use planners, developers, transportation, retailers, public safety, health care, and media begin to work together proactively and collaboratively to create environments that allow people to safely integrate everyday physical activity such as bicycling or walking into their lives and to easily access affordable, healthy foods.

In recognition of California’s growing obesity epidemic, competing environmental forces and fragmented, uncoordinated efforts across private and public sectors, the Legislature mandated that CDHS create this strategic plan to coordinate existing resources and to guide a statewide response to this obesity crisis. (Budget Act of 2005, SB 77, Item # 4260.001.0001, Provision 7.) The goals in this plan build on current programs, existing infrastructure, and best practices through engagement of business, philanthropic, voluntary, and government sectors as equal partners.

Call to Action

We have a vision for a healthier California. The 10 Step Vision for a Healthy California is a call to action for all Californians. It is an action plan for bringing focus and momentum to the transformation that is needed to create the healthy California in which we all want to live.

We imagine a California in which healthy eating and active living is the preferred and chosen course of action for Californians. We imagine that healthy eating and active living are the choices we make because we want to make them and because our environment makes them the easy choices.
A healthier California can be a reality. We have the tools to transform California into the healthiest state in the nation.

However, every sector of society will need to change in order to shift California to a healthier lifestyle. Shifts of this magnitude are not simple – change never is. But the rewards of a healthier life for us, our families, and our communities will make it worthwhile.

A Vision for California – 10 Steps Toward Healthy Living

To initiate this shift in all sectors in California, Governor Schwarzenegger developed the 10 Step Vision, and convened the multi-sectoral Summit on Health, Nutrition, and Obesity in September 2005. The Governor challenged public and private leaders to develop new initiatives that would provide Californians with healthy food options and opportunities for physical activity. Leading organizations located in California were recognized on the “Summit Honor Roll,” a designation reserved for those who responded to the Governor’s challenge to improve health outcomes by announcing new initiatives, aligned with the 10 Step Vision, that support healthy eating and physical activity. (See Appendix) The Summit exemplifies the collaborative effort needed to achieve the 10 Step Vision. Funding to support programs will come through multi-sectoral commitments, grants, foundations, initiatives, and government sources.

To continue the Summit process, the California Health and Human Services Agency (CHHS) has convened a Get Healthy California! Workgroup that has organized its work around four areas of emphasis – (1) educational campaign/social marketing, (2) physical education/physical activity, (3) access to healthy foods, and (4) role of health care/health care industry. CHHS has established strategic partnerships with stakeholders in other state agencies, in the business community, and in the voluntary and philanthropic sectors.

Beginning with the Summit and gaining momentum with the workgroup, this 10 Step Vision will continue to guide the transformation to a healthier California, involve people of all ages, and include every aspect of society. The State’s 10 Step Vision offers us a picture of the environment in which we will live and the kind of life we will lead when the following 10 steps are achieved.

Californians will understand the importance of physical activity and healthy eating, and they will make healthier choices based on their understanding.
Every day, every child will participate in physical activity.
California’s adults will be physically active every day.
Schools will only offer healthy foods and beverages to students.
Only healthy foods and beverages will be marketed to children ages 12 and under.
Produce and other fresh, healthy food items will be affordable and available in all neighborhoods.
Neighborhoods, communities, and buildings will support physical activity, including safe walking, stair climbing, and bicycling.
Healthy foods and beverages will be accessible, affordable, and promoted in grocery stores, restaurants, and entertainment venues.
Health insurers and health care providers will promote physical activity and healthy eating.
Employees will have access to physical activity and healthy food options.
Taking the lead on realizing the 10 Step Vision in 2005, the Governor sponsored and signed landmark legislation banning junk food from schools, extended to high schools a law banning sodas in elementary and middle schools, and provided funding for fresh fruits and vegetables in school meals. These laws are a first step in ridding the school environment, where children spend most of everyday, of the high calorie, low nutrient foods and beverages that contribute to childhood obesity.

To further demonstrate the Governor’s and state’s firm commitment to healthy eating and active living, the Governor signed a 2006 budget that supports his 10 Step Vision with the following investments:

$40 million in ongoing grants to hire more credentialed physical education (PE) teachers to help kids develop healthy, life-long exercise habits;
$500 million for the purchase of PE, arts, and/or music supplies and equipment to improve and expand the infrastructure of school programs;
$3 million to meet an increased demand for the School Breakfast Program and the California Fresh Start Pilot Program to increase the number of students receiving nutritious breakfasts that include more fruit and vegetable choices; and
$15 million to revitalize the School Garden Program so that students can experience the important educational benefits of growing fruits, vegetables, and plants.
The Governor and the state have engaged actively in obesity prevention, and this California Obesity Prevention Plan serves as a guide to further action for every individual and every sector to shift to healthy eating and active living and achieve the 10 Step Vision. The plan identifies policy strategies to make sustainable changes in the environment that will result in physical activity opportunities and access to healthy, affordable foods.

Strategic Approach: Environmental Change that Encourages Healthy Eating and Active Lifestyles

Through California’s internationally recognized tobacco control program, we have experience and success in effecting a major societal change that resulted in significantly improved health for the people of our state. It was a difficult task but we did it. And we can do it again. As California has been a leader in reducing tobacco use, we can be a leader in the campaign to reduce obesity.

Environmental Change Approach: The Plan’s Proposed Model

This plan uses an approach that focuses on environmental changes involving all sectors, through media, local programs, and policies to create social norm changes (a change in our perceptions of what is “normal” behavior) and help individuals make healthy choices in their daily lives. The foundation of this model is the concept that individuals are affected by the forces in their environment, and the recognition that education alone is often not sufficient to cause significant behavior changes. The process of change occurs by helping people recognize the health implications of particular behaviors through persistent and inescapable cues while offering local programs and policies that support individual change. For example, business efforts to improve access to fruits and vegetables in low income neighborhoods complemented by educational TV spots on healthy eating, will increase the likelihood that residents of those communities will make healthier food choices. As people incorporate more healthy foods into their daily meals, healthier eating becomes the expected or “normal” behavior. The model provides a framework that encourages voluntary change in every sector - individuals, families, communities, schools, businesses, and government.

Environmental Change Approach: The Tobacco Experience

Tobacco control efforts began at the federal level with recognition of the adverse health effects of tobacco use, the first step in the environmental change model. Awareness and education efforts continued with the 1963 U.S. Surgeon General’s report that documented tobacco use as harmful. Federal action required warning labels on cigarettes followed by a ban on television ads to break the association between glamorous lifestyles and smoking. While these efforts were important, they were not sufficient to change the behavior of a significant number of people.

In 1988, California voters passed Proposition 99, an initiative that provided an unprecedented health promotion fund for the state to build upon the environmental changes initiated at the federal level through a statewide comprehensive approach composed of four components:

Leadership and capacity building at the state level to ensure coordination with and between the state, regional and local media, program, and evaluation efforts;
A statewide media campaign that changed perceptions of smoking from a glamorous adult activity to a dangerous addictive habit, conveyed the devastating health effects of secondhand smoke on loved ones, highlighted the manipulative use of advertising to recruit new smokers, and framed other relevant issues;
Local assistance grants awarded to county lead agencies, school-based programs, and regional projects. These grants helped to create a local infrastructure, coordinate and organize multi-channel (schools, businesses, health care, community-based organizations, and media) overall education and prevention efforts, and create community environments that reduced tobacco access to minors, mitigated the effects of secondhand smoke, countered pro tobacco influences, and supported individual behavior change. As knowledge increased and attitudes changed, communities mobilized to effect local policy change, such as enacting smoke-free laws; and
Statewide tracking and evaluation to monitor health impacts, document population trends, and assess program performance and impact.
California led the way in creating the smoke-free environment as the preferred environment. After California dedicated tobacco control resources to the comprehensive program, the adult smoking prevalence in California declined by 38 percent and California lung cancer rates declined at nearly six times the rate of the decline in the nation. 25, 26 California high school students smoke about 41 percent less than their U.S. counterparts, which will translate into fewer health consequences from smoking-related illness. 27

Environmental Change Approach: Lessons for Obesity

California’s success in reducing tobacco use provides the model for environmental change that can lead to a California in which healthy eating and an active lifestyle are the social norm – not the exception.

The anti-tobacco efforts are instructive as a best practice approach but there are clear differences: we do not need to smoke to live; but we do need to eat and be active. While tobacco control efforts were aimed at discouraging behaviors, efforts to address obesity will need to focus on encouraging behaviors. The environment will need to shift first by providing access to healthy foods and active communities before it is reasonable to expect that significant numbers of Californians will change their eating and activity habits. Public health and medical professionals cannot do this alone. We need commitments from every sector – government, business, agriculture, education, architecture, transportation, and media – to change the way Californians eat and stay active.

Using the environmental change approach, this report offers a strategic plan for all sectors to work collaboratively to create an environment that supports healthy eating and active living as California’s way of life and shifts the tide in California’s obesity epidemic.

The Plan: Recommendations for Action

The following recommendations, based on the best practice tobacco experience, are derived from a number of advisory groups, forums, and meetings that reviewed options to create a healthier environment including, the Governor’s Summit on Health, Nutrition, and Obesity; the Strategic Alliance; and the California Obesity Prevention Initiative. CDHS believes that these recommendations offer the most promise to advance the 10 Step Vision to achieve a healthier California through engagement and collaboration with all sectors.

Goal 1: Ensure state level leadership and coordination that reaches into communities across the state.

Create a central point of contact within state government to serve as lead and liaison in working across and within different sectors – such as schools, entertainment, employers, health care – to create active living and healthy eating environments.

Why? Government plays a significant role in the health and well being of its constituents and is the natural locus of leadership in promoting comprehensive and effective approaches to improving the nutrition and physical activity of community members. State government has an important role in coordinating local efforts. Government leaders have the unique ability to convene key decision makers, facilitate information flow and collaboration, promote important issues, and promulgate policies and programs that improve community vitality.

Recommendations for Action:

1.1 The central point of contact within state government will serve as the “connector” of and liaison to other state departments, and state, regional, and local partners. In addition, the central point of contact will act as the catalyst to initiate policy and systems change to create an integrated, consistent approach to active living and healthy eating issues in California.

1.2 The central point of contact will convene public and private partners to identify existing gaps and programs. The central point of contact will asses interest ability and commitment to shifting and realigning policies, practices and resources to implement evidence-based efforts that create accessible and affordable active living and healthy eating environments across the state.

Goal 2: Create a statewide public education campaign that frames healthy eating and active living as California living.

Develop and implement a statewide media campaign, including public service announcements, to reach both adults and youth. The campaign will focus on countering the promotion of unhealthy foods; promoting “every day” activity at school, work, and play; reducing the appeal and availability of “junk food” to youth. In addition, the campaign will promote healthy eating and fun activity as the “in” lifestyle. Coordinated, multi-sectoral commitments will support the implementation of this campaign.

Why? A sustained statewide media campaign will promote healthier futures for Californians by educating them about the dangers of low-nutrient, high calorie eating habits and “couch potato” lifestyle, and the benefits of healthy food choices and regular physical activity.

Recommendation for Action:

2.1 Develop a sustained media campaign that serves as the frame for all state media communication designed to educate the public about the benefits of healthy food choices and a physically active lifestyle. The campaign will use tailored radio, television, billboard, and print advertising in communities throughout California. The advertising will be available in accessible formats, culturally and linguistically appropriate, and coordinated with community-based public education.

Goal 3: Support local assistance grants and implement multi-sectoral policy strategies to create healthy eating and active living community environments.

Improve access to, promotion of, and participation in healthy eating and active living by creating change in the physical and social environments.

Why? Changing behavior requires both knowledge and access to affordable, safe, convenient activity and healthy eating opportunities for all Californians. In the tobacco control model, grants to local lead agencies created the ground swell to change local laws to create smoke-free communities. With obesity, the issues are more complex. Change in community environments will require a connection to the statewide infrastructure and a coordinated, multi-sector (government, business, philanthropic and voluntary sector) response, with each partner changing policies and doing business differently. When healthier choices become more accessible, affordable, and socially acceptable, California will see a shift toward healthier lifestyles, reducing the prevalence of obesity.

Recommendations for Action

3.1 Award local assistance grants to local and regional projects to create a community infrastructure, serve as the community point of contact and liaison with the state central point of contact, coordinate and facilitate community level, multi-sector collaboration, and organize community-based public education/media, program, and evaluation efforts.

3.2 The following recommendations for action are proposed for each of seven sectors to consider enacting as their contribution to obesity prevention and control:

3.2a State and Local Government

Prioritize Prevention

Make prevention a top priority in state and local health departments.
Encourage full and equitable access to public facilities (community centers, schools, government buildings) that could house programs and services that increase the amount of daily physical activity for each community member.
Develop and disseminate state model worksite policies that provide access to options for healthy eating and physical activity.
Ensure that food assistance programs provide healthy foods.
Incentives and Funding

Consider incentives for businesses to offer physical activity, healthy food options, and lactation accommodations for employees.
Consider incentives for developing physical activity facilities, improved walkability, grocery stores, farmers markets, and other retail outlets for healthy foods, particularly in low-income communities.
Identify ongoing funding sources for maintenance, rehabilitation, and development of parks, including community gardens and neighborhood parks, and recreation facilities in all neighborhoods.
Planning, Land Use, and Transportation

Adopt and implement “walkable” community policies and build paths/trails to provide safe and convenient travel options for walking, bicycling, or using assistive devices, such as wheelchairs.
Use planning and zoning processes to promote appropriate design and land uses that support access to healthy foods and encourage walking and bicycling in all neighborhoods.
Ensure that public recreational facilities, supermarkets, and farmers’ markets are close to where people live and work as well as accessible from public transit routes.
Consider requiring that each city/county general plan contain a recreation element that includes access to, and availability of, facilities and park land.
3.2b All Employers

Establish guidelines for offering healthy food at meetings and events and encourage their use.
Provide incentives to employees who walk, bike, or use public transportation to commute to and from work and for work-related travel.
Encourage physical activity by promoting stairway use, providing bike racks, providing lockers and showers, and offering flex time or breaks for physical activity.
Encourage worksites to offer an array of affordable, healthy choices in their prepared and vending machine foods.
Maximize the use of local and regional foods in food-service operations.
Post and enforce organizational policies that support breastfeeding on site, consistent with state requirements for employers to provide break time and the use of a room for employees to express milk.
Encourage health plans to include prevention and wellness activities such as counseling, education, and access to weight-loss, weight maintenance, and physical activity programs.
3.2c Health Care Insurers and Providers

Promote prevention as the first step in responding to the obesity epidemic rather than bariatric surgery and pharmaceuticals that are interventions of last resort, particularly for children.
Support new mothers in prolonged and exclusive breastfeeding, which protects against childhood obesity.
Adopt and implement preventive standards of care that promote regular physical activity and healthy eating in a manner sensitive to culture, age, and abilities.
Provide continuing education credits for health practitioners participating in training in nutrition, physical activity, and breastfeeding education.
Ensure the availability of healthy choices in food service operations in health care facilities.
Maximize the use of fresh and regional foods in health care facility food service operations.
Promote incentives to health plan members who participate in wellness and prevention activities.
3.2d Families

Eat at least one healthy meal a day together as a family.
Choose fruits and vegetables, whole grains, beans, nuts and seeds, and non- or low-fat dairy products over high-calorie, low-nutrient foods.
Limit calorie intake by moderating portion size, limiting soft drinks and sweetened beverages, and limiting foods with high amounts of sugar and fat.
Reduce TV viewing and sedentary computer “gaming” time, especially for children and youth.
Participate in physical activity every day.
Participate in fun physical activity – playing, walking, hiking, sports – as a family.
3.2e Schools

Ensure that children receive quality physical education that meets minimum state standards for duration and frequency.
Make school recreational facilities available for after-hours use by the community, especially in neighborhoods that lack park and recreational facilities.
Institute healthy food and beverage standards for all meals, snacks, and beverages available in preschool, school, and after-school programs.
Advertise only healthy foods and beverages on school grounds and use alternatives to foods in fundraising, incentive, and other programs.
Maximize the availability of fresh and regional foods through initiatives such as farm-to-school programs.
Provide a nutritious breakfast using the federal School Breakfast Program in all schools.
3.2f Food and Beverage Industry

Food Manufacturers and Retailers

Advertise and promote healthy foods and beverages to children and youth using broadcast, print and electronic media; product tie-ins such as toys, sports and entertainment celebrity endorsements; and cartoon characters.
Eliminate indirect advertising through fundraising programs, incentive programs using contests or coupons, etc. at institutions serving children and youth (including schools, preschools, after-school programs, and recreation facilities).
Food Processors and Restaurants

Ensure that packaged single-serving snacks, beverages, and meals contain no more than one standard portion size per package.
Limit fat and sugar and add fruit and vegetables, especially to children-focused meals.
Post calorie information per serving on all menus and menu boards at restaurants and encourage healthy food options on all menus.
Retail Grocers

Promote produce and other fresh, healthy items in low-income neighborhoods and ethnically/racially diverse communities.
Encourage quality, variety, and affordability of produce and other fresh foods in neighborhoods throughout California.
Assist with access to grocery stores for seniors, people with disabilities, and low-income communities with limited transportation options.
Encourage more healthy choices and less “junk-food” placement at grocery checkout counters.
3.2g Entertainment and Professional Sports

Encourage the availability of affordable healthy foods and beverages at sports, movie, and other entertainment venues.
Consider investing in public physical activity facilities and programs in surrounding communities.
Encourage depictions of physically active people that include all ages, ethnicities, genders, body types, and abilities in television, film, and advertisements.
Use product placement to market healthy food and beverages in movies and television programs targeted to children and youth.
Expand the participation of professional athletes and facility/program administrators in promoting physical activity by providing facilities, equipment, and personnel for community use.
Goal 4: Create and implement a statewide tracking and evaluation system.

Enhance state “intelligence” capabilities through a systematic approach to tracking the health impacts of obesity and evaluating obesity prevention programs. Ensure standardized active living and healthy eating measurements on relevant California surveys and widely disseminate findings. Monitor complex state, regional, and local trends and develop policy, program, and environmental measures of progress.

Why? Obesity is recognized as a societal issue for public health practitioners, urban planners, health care providers, transportation, businesses, voluntary agencies, foundations, and other partners to collectively address. Available data are not adequate to monitor and study the scope and health impacts of obesity. By creating a coordinated and systematic approach to tracking and evaluating obesity, its risk factors, and health impacts, those who design state surveys can provide decision makers with comparable, standardized data that focus on accessibility and environmental barriers in addition to etiology, diagnosis, and lifestyle. Further, once data are gathered and analyzed, state government has the responsibility and ability to make the information available and accessible to the community, programs, and policymakers.

Recommendations for Action:

4.1 Conduct a data inventory and recommend a systematic approach to data collection on healthy eating and active living indicators.

4.2 Based on the data inventory (4.1), convene a task force to develop an evaluation and accountability agenda, to improve California data systems. This agenda will include the following:

Consensus on standardized measures of active living and healthy eating;
Studies that identify barriers to active living and healthy eating;
Studies that compare obesity rates for communities with access to healthy eating and active living environments and those without access to these environments;
Longitudinal studies that follow people with obesity and without obesity over time to track health impacts, obesity-related conditions, and health care costs.
4.3 Incorporate standardized health indicators such as physical activity, healthy eating, social norm change, and healthy community environment measures, into all relevant statewide surveys.

4.4 Lead obesity-related evaluation and accountability for California. This includes:

Providing and disseminating data and research in various formats (e.g., web sites, written publications, conferences);
Conducting on-going data analysis and reporting; and
Providing up-to-date and interactive data and information on the web.
Summary

The Governor initiated the shift towards creating a healthier California when he convened the Summit on Health, Nutrition, and Obesity in September 2005 and secured significant commitments from public and private leaders to take action to promote an environment that supports healthy eating and physical activity.

This California Obesity Prevention Plan can serve as a springboard for government, business, and voluntary and philanthropic sectors to convert fragmentation into collaboration and synergy, to carefully align and invest resources, and to create a shared response to a societal crisis.

Acknowledgements

This plan represents the combined efforts of several information gathering and planning processes including the following:

The Governor’s Summit on Health, Nutrition, and Obesity and the pre-Summit Listening Sessions around California gave business leaders, educators, government officials, and public health professionals an opportunity to focus on essential reforms and announce commitments for action in a variety of sectors. The Governor’s 10 Step Vision for a Healthy California provides both a guide and a challenge.

The Strategic Alliance “Taking Action for a Healthier California: Recommendations to Improve Healthy Food and Activity Options,” developed by a coalition of nutrition and physical activity advocates.

The California Obesity Prevention Advisory Group, composed of over 90 people, primarily external partners, included representatives from local health departments, public health advocacy groups, transportation planning groups, the California Department of Education, the faith community, city government, the American Academy of Pediatrics, the University of California Cooperative Extension, the Department of Parks and Recreation, volunteer organizations, and a number of other groups and organizations.

The Physical Activity and Nutrition Coordinating Committee composed of representatives from programs within CDHS that manage nutrition, physical activity, and obesity activities for the department.

The Nutrition and Physical Activity Action Team, formed within CDHS, as a broader coordinating obesity prevention group across a dozen divisions.

The Office on Disability and Health’s Living Healthy with a Disability Take Action! Advisory Committee, Universal Livability, A Dream for Tomorrow a Plan for Today, Strategic Plan 2005-2010 Strategic Plan.

The Women, Infants, and Children’s Supplemental Nutrition Program (WIC), “Transitioning to Healthy Eating and Active Living” resulted from a six-month strategic process with its partners to shape WIC’s direction for obesity prevention.

The Maternal, Child, and Adolescent Health Branch of CDHS (MCAH) Local Health Jurisdiction Obesity Survey 2006.

Appendix

Governor’s Summit on Health, Nutrition, and Obesity Honor Roll Fact Sheet
Governor Arnold Schwarzenegger’s Summit on Health, Nutrition and Obesity yielded immediate results that will improve the health and physical fitness of Californians and combat our state’s obesity crisis. The Governor’s September 15, 2005, Summit lived up to its “Action Summit” moniker as the leadership of many community organizations and of the largest companies doing business in California answered the Governor’s challenge and announced new initiatives that will provide California consumers with more healthy food options and opportunities for physical activity, and provide compelling educational information to inspire healthy choices.

Leading organizations located in California were recognized as members of its “Summit Honor Roll,” a designation reserved for those organizations that responded to the Governor’s call to meet California’s obesity epidemic with new and innovative initiatives to improve overall health outcomes. The Governor’s Summit Honor Roll recognized groups for their leadership, vision, and commitment to the health of all Californians, and for their contributions toward realizing the Governor’s vision for a Healthy California.

The following companies make up the Governor’s Summit Honor Roll. We also include brief descriptions of the most significant initiatives the companies announced in response to Governor Schwarzenegger’s call to respond to California’s obesity crisis. For more information on these initiatives, please contact the organizations directly.

Please note:

• The organizations are listed in alphabetical order.
• The initiatives detailed apply only to each organization’s California operations, unless otherwise noted

American Academy of Pediatrics

Provide doctors and family practitioners with tip sheets for parents and kids about obesity prevention
Distribute parent education materials to California pediatricians and family practitioners about how to talk to parents and patients about obesity issues, in partnership with Johnson & Johnson’s McNeil Nutritionals and LifeScan.
Blue Cross of California - Total California membership: 7 million

Measure Body Mass Index (BMI) as a vital sign and document in the patient medical record (Goal: 50 percent of providers in three years).
Work with the Integrated Healthcare Association to develop and implement appropriate performance tools to measure provider performance around obesity prevention and treatment.
Focus on childhood obesity by distributing resources including BMI wheels and the “Get Up and Get Moving!” family workbook to 13,000 physicians and developing medical education programs and reference materials for physicians.
Launching “Kids In Charge of Kalories” (KICK), a disease management program for members 6 to 12 years of age and their families.
Raise public awareness of the childhood obesity, improve nutrition, and increase physical activity through a health improvement program and strategic partnerships with organizations such as the Governor’s Council on Physical Fitness and Sports, California 5-A-Day, and local school districts.
Brenden Theatres

Introduce California Healthy Combo in California theatres. Combos offer a fresh and healthy option at the movies and will include bottled water, healthy trail mix, and fruit or salad bowl.
Run public service announcements for the Get Healthy California campaign before movies.
California Association of Health Plans (CAHP) - Total California membership: 21 million

CAHP’s commitment will total $30 million over the next three years and be implemented within its 35-member health plans, reaching 21 million health care consumers. Commitments include:

Create and distribute Provider Tool Kits to assist physicians in educating patients on issues of obesity
Targeted programs for providers to document and report body mass index (BMI) in medical records
Specialized Provider Tool Kits focused on adults and children
Provide disease management programs focused on obesity
Develop member incentives, education and outreach programs
See Blue Cross, HealthNet, Kaiser Permanente, LA Care and PacifiCare for more information on what the individual health plans are doing.
California State PTA

The California State PTA joined the National PTA to partner with Parents’ Action for Children in the creation and distribution of resources for local PTA units to use to foster healthier lifestyles for families through schools and homes.
Dole

Implement the School Salad Days pilot program:
Donate 50 full-service, portable salad bars to California public schools over the next two years.
Commit to help train food service staff on use of salad bars and engage students in eating fresh fruits and vegetables.
Develop a fundraising fruit basket as a healthy fundraising option.
Develop a school teachers’/administrators’ toolkit as an educational component to salad bars and encourage edible gardens in all schools.
El Pollo Loco

Eliminate trans fats in tortillas.
Introduce new tray liner and other promotional items to market and advertise healthy food options.
Introduce new healthy product: chicken tortilla soup.
Introduce new meal offerings that encourage healthy eating, such as the soup & salad combination meal, skinless chicken breast meal with steamed vegetables and others in the coming months.
Actively promote and market low fat product offerings.
Entertainment Industry Foundation

Partner with Get Healthy California and The California State Alliance to launch a multi-year public education campaign involving high-profile entertainers to inform the public on the impact of the obesity crisis on personal health and aid obesity prevention efforts.
HealthCorps

Inaugurate the HealthCorps Volunteer Program for California, program patterned after the Peace Corps that recruits and trains carefully selected volunteers to educate children across the nation on wellness awareness for a two-year period.
Education of all California volunteers will be lead by Touro College.
HealthNet - Total CA membership: 2.1 million

Offer Weight Watchers’ discounts, other weight management programs and selected fitness clubs to all members, and provide weight management services and health education to Medi-Cal and Healthy Families enrollees. (Estimate 4,000 members will participate)
Invest $1.5 million in grants to fight obesity among Medi-Cal and Healthy Families members, with an emphasis on childhood obesity prevention.
Launch “It's Your Life” online weight management program. (Reach: 40,000)
Sponsor culturally appropriate children’s activities geared toward healthy eating and send educational materials encouraging healthy eating and exercise to members and providers. (Materials to 1.5 million members and 48,000 providers)
Kaiser Permanente - Total California membership: 6.5 million

Commit $18.5 million over the next five years to community-based efforts to promote healthy eating and active living. ($9.5 million in grants to improve access to healthy food and physical activity; $9 million to support environmental and policy changes that create healthier schools, workplaces and neighborhoods.)
Incorporate “BMI as a Vital Sign” into its electronic medical record system.
Train 1,000 safety-net physicians and community health professionals to identify overweight individuals and provide appropriate patient advice and counseling.
Kraft

By the end of 2006, change marketing guidelines so that only products that meet Kraft's Sensible Solution nutrition standards will appear on Kraft websites that primarily reach children ages 6-11. This strengthens earlier voluntary marketing policy changes.
Introduce Nabisco 100% Whole Grain cookies and crackers, including Wheat Thins crackers and Fig Newtons cookies, each of which is baked with 100% whole grain and contains 0g trans fat per serving.
Pledge $2 million in grants over the next two years to support healthier lifestyles in California.
Launch a Health Coach program for employees, including over 3,500 California-based employees.
Integrated Healthcare Association

Adopted the Healthy Alternatives Vending Policy, calling for all member organizations to have 50% healthy food and beverage choices in vending machines, affecting more than 200,000 employees. By partnering with other business and trade groups, 1 million employees will be reached by Dec. 2005.
Create a new clinical metric designed to determine the proportion of overweight or obese patients counseled about diet and exercise. This new clinical measure will encourage over 335,000 doctors to screen counsel patients about obesity, nutrition and exercise.
LA Care - Total California enrollment: 800,000

Implement a comprehensive childhood obesity program that includes unique weight management programs for children that provide structured approaches to exercise and nutrition, family-based weight management services for children, and weight management and fitness programs for youth.
Develop a pilot program to teach families how to prepare healthy meals.
Work with "promotoras" and other community health workers to conduct culturally and linguistically appropriate outreach and education on obesity.
Measure BMI as a vital sign, and assess whether doctors are properly and regularly performing and documenting BMI measurements.
Distribute a comprehensive obesity prevention toolkit to reach 3,200 health care providers in Los Angeles County.
Latino Health Access

Launch a project to create a new park for families most heavily impacted by the obesity and inactivity epidemic in Santa Ana.
Create neighborhood Cooperativas that will offer supervision and opportunities for physical activity to low-income children living in communities that lack safe, accessible areas for play.
Implement community-based strategies to improve access to fruits and vegetables in low-income neighborhoods.
Implement a community-based program for overweight children that includes education for children and their parents, home visits, dietician services, and regular after school physical activity.
Provide leadership and advocacy training to mothers. Provide nutrition and fitness education, and advocacy training to youth.
Engage in strategic partnerships to achieve systemic changes such as increased access to safe open spaces, and changes in city regulations, school policies and community engagement.
Lewis Operating Corp.

Extend Lewis’ commitment to developing communities that promote healthy and active living to new communities in Riverside County, where Lewis will break ground in 2007 and 2008, as well as many other communities to be built in the next ten years.
Design an extremely pedestrian-oriented community plan that features a mixture of uses, compact forms, strong connectivity of streets and paths; pocket parks and larger parks; housing for a full mix of income levels; community gardens; provisions for public transit; nearby schools, so kids will have safe routes to school; physical structures to promote healthy living, such as community centers, swimming pools, and parks and gymnasiums used by schools and community members; and partner with counties and cities to create Healthy County/City activities.
McDonald’s

Introduce dedicated tray liners to Get Healthy California public messages for two months (more than 130 million impressions).
Promote healthy choices in Happy Meals to customers at point of purchase.
Provide point-of-purchase (POP) messaging opportunities to Get Healthy California both in-store and at drive-thru window.
PacifiCare - Total California members: 1.4 million

Increase measurement of BMI, track patients based on BMI risk scores, and add measurement of provider performance on anti-obesity initiatives to public report cards and incentive programs.
Increase preventive screening and health risk assessments for patients and employees by 50 percent.
Increase and track member participation in weight management services, including fitness programs and case management services. Specifically, within three years, increase patient enrollment in the “Taking Charge” fitness program by 15 percent and double participation in “Health Credits Program,” which provides incentives and tools for healthy living.
Initiate employee worksite wellness programs with expanded fitness choice, healthier vending machines and employee incentives for healthy choices.
Distribute a provider “toolkit” including BMI tables, assessment materials and patient and provider educational materials to every provider.
Ruiz Foods

Eliminate trans fats from all products.
Develop a new product line that meets child nutritional guidelines set by the Food and Drug Administration.
Improve company website to provide easy access to nutritional information.
Introduce comprehensive employee wellness and obesity prevention initiative, including healthier food options in its cafeteria, regular health fairs and clinics for employees and their families, improved health benefits, Weight Watchers program, master plan that promotes exercise and walking and providing bottled water to all employees.
Safeway

Expand Safeway’s ready to eat “Eating Right”™ product line to increase access to healthy food choices. These products will include special labeling and nutritional information to better inform consumer choices.
Launched in California, develop and market Safeway’s products with specially designed nutritional icons that help consumers make better and more informed eating choices. Safeway teamed up with health experts (such as UCSF Research Chair Dr. Dean Ornish) to develop those symbols.
Launch an initiative, beginning in California stores, to integrate natural and organic foods into every aisle, group healthy products, and make healthier option sections more readily identifiable.
Test consumer response to the integration of healthier products into every facet of the store, including the checkout aisles, in select California markets.
7-Eleven

California’s 7-Eleven stores will lead the nation with the rollout of PICK SMART™ products, a new proprietary selection of sandwiches and wraps with lower fat and calorie content.
Sandwiches and wraps, the next generation of 7-Eleven fresh foods, are made and delivered fresh daily to each store and must meet strict dietary guidelines to carry the PICK SMART™ label. These requirements are: (1) no more than 420 calories per serving, and (2) no more than 10 grams of fat per serving.
All PICK SMART™ sandwiches and wraps adhere to the American Dietetic Association’s recommendations.
Subway

Launch a new meal options that include a low-fat sub (6” for adults; 4” for kids), low-fat milk, apples and raisins.
Build meals around fixed serving sizes, are low in fat and calories, and contain critical nutrients like fiber, protein and calcium.
Launch new meals immediately in 1,700 Subway restaurants across California.
24 Hour Fitness

Partner with the California Governor’s Council on Physical Fitness & Sports to provide free 30-day memberships to 24 Hour Fitness for any high school student in California signing up for the first phase of the Governor’s challenge at www.activeca.org. Students completing the first phase of the Governor’s challenge receive an additional 90-day free membership to 24 Hour Fitness, thereby completing their “Free Semester.” At the end of the “Free Semester” program each student is given a customized, personal physical activity plan to help them stay active. The free memberships can be redeemed at all 24 Hour Fitness Centers in California (183 centers).
Partner with the Boys & Girls Clubs of California to donate equipment and training time to eight Boys & Girls Club locations. Provide free access to Boys & Girls Clubs in close proximity to 24 Hour Fitness Centers (50).
Westfield Shopping Centers

Promote healthy choice retailers in mall food courts and other in-mall restaurants by providing customers with easy-to-use guides to healthy choices on menus, table tents and tray liners.
Introduce Westfield Fitness Blast, a mall-based program that engages shoppers in healthy living seminars at Westfield shopping centers including mall walking programs, yoga demonstrations, tai-chi, healthy cooking classes and health checks.
Yahoo!

Develop daily messages to propagate Get Healthy California public education messages including voice and likenesses of campaign spokespeople.
Messages remain persistent on user desktops and provide information to Yahoo! users to inspire them to get healthy.

References

1 California Department of Health Services. California Children’s Healthy Eating and Exercise Practices Survey. http://www.dhs.ca.gov/ps/cdic/cpns/research/download/calcheeps/calcheeps-low.pdf, 2003

2 California Department of Health Services. California Teen Eating, Exercise, and Nutrition Survey. http://www.dhs.ca.gov/ps/cdic/cpns/research/calteens2000.html, 2000.

3 Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System, 2004.

4 California Health Interview Survey, 2003.

5 Centers for Disease Control and Prevention. Overweight Among U.S. Children and Adolescents. National Health and Nutrition Examination Survey. 2004

6 California Pediatric Nutrition Surveillance. 2003.

7 Healthy People 2010. Reduce the proportion of children who are overweight and obese, 2003.

8 Guo SS, Chumlea WC. Tracking of body mass index in children in relation to overweight in adulthood. American Journal of Clinical Nutrition. 70 (suppl):145S-148S, 1999.

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10 American Type 2 diabetes Association. www.type 2 diabetes.org, 2005.

11 Narayan V, et al. One in Three People Will Have Type 2 diabetes by the Year 2050. Journal of American Medical Association, News Release, 8 Oct 2003.

12 California Department of Health Services. The Economic costs of Physical Inactivity, Obesity, and Overweight in California Adults: Health Care, Workers’ Compensation, and Lost Productivity. http://www.dhs.ca.gov/ps/cdic/cpns/press/downloads/CostofObesityToplineReport.pdf, 2005.

13 Thorpe K, et al. The impact of obesity on rising medical spending. Health Affairs, W4-480, 2004.

14 Finkelstein E, et al. National medical spending attributable to overweight and obesity: How much and who’s paying? Health Affairs, W3-219, 2003.

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18 Ohls, et al, Food Stamp Participants’ Access to Food Retailers Final Report. Mathematica Policy Research submitted to USDA. July 1999.

19 Sturm R, Datar A. Body mass index in elementary school children, metropolitan area food prices, and food outlet density. Public Health, September 2, 2005.

20 Institute of Medicine. Food Marketing to Children and Youth: Threat or Opportunity? The National Academies Press, Washington, D.C., 2005.

21 Center for Science in the Public Interest. Guidelines for Responsible Food Marketing to Children, 2005.

22 Bureau of Transportation. National Household Travel Survey, http://www.bts.gov , 2001.

23 International City/County Management Association. Active living and social equity-creating communities for all residents: A guide for local governments. 2005.

24 Powell L, et al. The relationship between community physical activity settings and race, ethnicity and socioeconomic status. Evidence-Based Preventive Medicine, 1 (2):143, 2004.

25 California Department of Health Services. Behavioral Risk Factor Surveillance System (BRFS) 1984-1992; California BRFS and California Adult Tobacco Survey Data combined for 1993-2005, 2006.

26 California Department of Health Services. The Health and Economic Consequences of Cigarette Smoking in California, 2003.

27 California Department of Health Services. Youth Smoking Prevalence Fact Sheet, 2005.