Evolution in obesity and chronic disease prevention practice in California public health departments, 2010.

INTRODUCTION: Local health departments (LHDs) are dedicating resources and attention to preventing obesity and associated chronic diseases, thus expanding their work beyond traditional public health activities such as surveillance. This study investigated practices of local health departments in California to prevent obesity and chronic disease. METHODS: We conducted a web-based survey in 2010 with leaders in California's LHDs to obtain diverse perspectives on LHDs' practices to prevent obesity and chronic disease. The departmental response rate for the 2010 survey was 87% (53 of California's 61 LHDs). RESULTS: Although staff for preventing obesity and chronic disease decreased at 59% of LHDs and stayed the same at 26% of LHDs since 2006, LHDs still contributed the same (12%) or a higher (62%) level of effort in these areas. Factors contributing to internal changes to address obesity and chronic disease prevention included momentum in the field of obesity prevention, opportunities to learn from other health departments, participation in obesity and chronic disease prevention initiatives, and flexible funding streams for chronic disease prevention. LHDs that received foundation funding or had a lead person or organizational unit coordinating or taking the lead on activities related to obesity and chronic disease prevention were more likely than other LHDs to engage in some activities related to obesity prevention. CONCLUSION: California LHDs are increasing the intensity and breadth of obesity and chronic disease prevention. Findings provide a benchmark from which further changes in the activities and funding sources of LHD chronic disease prevention practice may be measured.

The California Endowment's Healthy Eating, Active Communities program: a midpoint review.

OBJECTIVES: We conducted a midpoint review of The California Endowment's Healthy Eating, Active Communities (HEAC) program, which works in 6 low-income California communities to prevent childhood obesity by changing children's environments. The HEAC program conducts interventions in 5 key childhood environments: schools, after-school programs, neighborhoods, health care, and marketing and advertising. METHODS: We measured changes in foods and beverages sold at schools and in neighborhoods in HEAC sites; changes in school and after-school physical activity programming and equipment; individual-level changes in children's attitudes and behaviors related to food and physical activity; and HEAC-related awareness and engagement on the part of community members, stakeholders, and policymakers. RESULTS: Children's environments changed to promote healthier lifestyles across a wide range of domains in all 5 key childhood environments for all 6 HEAC communities. Children in HEAC communities are also engaging in more healthy behaviors than they were before the program's implementation. CONCLUSIONS: HEAC sites successfully changed children's food and physical activity environments, making a healthy lifestyle a more viable option for low-income children and their families.

The Central California Regional Obesity Prevention Program: changing nutrition and physical activity environments in California's heartland.

The goals of the Central California Regional Obesity Prevention Program (CCROPP) are to promote safe places for physical activity, increase access to fresh fruits and vegetables, and support community and youth engagement in local and regional efforts to change nutrition and physical activity environments for obesity prevention. CCROPP has created a community-driven policy and environmental change model for obesity prevention with local and regional elements in low-income, disadvantaged ethnic and rural communities in a climate of poor resources and inadequate infrastructure. Evaluation data collected from 2005-2009 demonstrate that CCROPP has made progress in changing nutrition and physical activity environments by mobilizing community members, engaging and influencing policymakers, and forming organizational partnerships.

Lessons learned from evaluations of California's statewide school nutrition standards.

OBJECTIVES: We assessed the impact of legislation that established nutrition standards for foods and beverages that compete with reimbursable school meals in California. METHODS: We used documentation of available foods and beverages, sales accounts, and surveys of and interviews with students and food service workers to conduct 3 studies measuring pre- and postlegislation food and beverage availability, sales, and student consumption at 99 schools. RESULTS: Availability of nutrition standard-compliant foods and beverages increased. Availability of noncompliant items decreased, with the biggest reductions in sodas and other sweetened beverages, regular chips, and candy. At-school consumption of some noncompliant foods dropped; at-home consumption of selected noncompliant foods did not increase. Food and beverage sales decreased at most venues, and food service à la carte revenue losses were usually offset by increased meal program participation. Increased food service expenditures outpaced revenue increases. CONCLUSIONS: Regulation of competitive foods improved school food environments and student nutritional intake. Improvements were modest, partly because many compliant items are fat- and sugar-modified products of low nutritional value. Additional policies and actions are needed to achieve more substantive improvements in school nutrition environments and student nutrition and health.

Approaches to measuring the extent and impact of environmental change in three California community-level obesity prevention initiatives.

Despite growing support among public health researchers and practitioners for environmental approaches to obesity prevention, there is a lack of empirical evidence from intervention studies showing a favorable impact of either increased healthy food availability on healthy eating or changes in the built environment on physical activity. It is therefore critical that we carefully evaluate initiatives targeting the community environment to expand the evidence base for environmental interventions. We describe the approaches used to measure the extent and impact of environmental change in 3 community-level obesity-prevention initiatives in California. We focus on measuring changes in the community environment and assessing the impact of those changes on residents most directly exposed to the interventions.

Local public health departments in California: changing nutrition and physical activity environments for obesity prevention.

The purpose of this research was to assess California public health departments capacity, practices, and resources for changing nutrition and physical activity environments for obesity prevention. The researchers surveyed key public health department personnel representing all 61 health departments in California using a Web-based survey tool. The response rate for the survey was 62 percent. This represented a 93 percent health department response rate. Analysis was conducted on the individual respondent and public health department levels and stratified by metropolitan statistical area and foundation-funded versus not foundation-funded. Public health departments are engaged in obesity prevention including environmental and policy change approaches. The majority of respondents stated that monitoring obesity rates and providing leadership for obesity prevention are important roles for public health. Health departments are involved in advocacy for healthier eating and/or physical activity in school environments and the development and monitoring of city/county policies to improve the food and/or physical activity environments. Funding and staff skill may influence the degree of public health department engagement in obesity prevention. A majority of respondents rate their staffing capacity for improving nutrition and physical activity environments as inadequate. Access to flexible foundation funding may influence how public health departments engage in obesity prevention.

Salud Tiene Sabor: a model for healthier restaurants in a Latino community.

BACKGROUND: The prevalence of overweight and obesity in children has risen nationally in recent decades, and is exceptionally high in low-income communities of color such as South Los Angeles CA. Independently owned restaurants participating in the Salud Tiene Sabor program at ethnic foods marketplace Mercado La Paloma in South Los Angeles are responding to the childhood obesity crisis by posting calories for menu items and providing nutrition information to patrons. PURPOSE: To evaluate whether menu labeling and nutrition information at point of purchase have an influence on availability of healthy food options, patron awareness of calorie information, and restaurant owners' support of the program. METHODS: A case-study design using mixed methods included restaurant owner and stakeholder interviews, patron surveys, and environmental assessments. Data were collected using originally designed tools, and analyzed in 2009-2011. RESULTS: Healthy eating options were available at the Mercado La Paloma; restaurant owners and the larger community supported the Salud Tiene Sabor program; 33% of patrons reported calorie information-influenced purchase decisions. CONCLUSIONS: Owners of independent restaurants have an important role in improving access to healthy foods in low-income, Latino communities.

Does competitive food and beverage legislation hurt meal participation or revenues in high schools?

BACKGROUND: There is limited evidence to evaluate the influence of competitive food and beverage legislation on school meal program participation and revenues. METHODS: A representative sample of 56 California high schools was recruited to collect school-level data before (2006­2007) and the year after (2007­2008) policies regarding limiting competitive foods and beverages were required to be implemented. Data were obtained from school records, observations, and questionnaires. Paired t-tests assessed significance of change between the two time points. RESULTS: Average participation in lunch increased from 21.7% to 25.3% (p < 0.001), representing a 17.0% increase, while average participation in breakfast increased from 8.9% to 10.3% (p = 0.02), representing a 16.0% increase. There was a significant (23.0%) increase in average meal revenue, from $0.70 to $0.86 (per student per day) (p < 0.001). There was a nonsignificant decrease (18.0%) in average sales from à la carte foods, from $0.45 to $0.37 (per student per day). Compliance with food and beverage standards also increased significantly. At end point, compliance with beverage standards was higher (71.0%) than compliance with food standards (65.7%). CONCLUSION: Competitive food and beverage legislation can increase food service revenues when accompanied by increased rates of participation in the meal program. Future studies collecting expense data will be needed to determine impact on net revenues.

Engaging youth in improving their food and physical activity environments.

PURPOSE: To understand factors that build youth leadership through the Healthy Eating, Active Communities Program. METHODS: In Fall 2007, six focus groups were conducted with 36 youth. RESULTS: Leadership capacity was facilitated through teamwork, community assessments, and policy work. CONCLUSION: Youth gained leadership confidence while successfully advocating for community-level change.

Implementation of California state school competitive food and beverage standards.

BACKGROUND: Competitive foods and beverages are available on most US school campuses. States and school districts are adopting nutrition standards to regulate these products, but few studies have reported on the extent to which schools are able to adhere to competitive regulations. The purpose of this study was to describe the extent to which schools in disadvantaged communities were able to implement California competitive food and beverage standards. METHODS: Data on the competitive foods (n = 1019) and beverages (n = 572) offered for sale on 19 school campuses were collected in 2005 and 2008. Descriptive statistics were generated on overall adherence rates to school nutrition standards and adherence rates by venue and school level. Logistic regression models tested predictors of adherence by continuous and categorical variables (eg, venue, item selling price). RESULTS: Data show an increase from 2005 to 2008 in average adherence to the California standards. Several predictors had statistically significant associations with adherence or nonadherence. Adherence was higher for competitive foods sold in school stores than foods sold in vending machines. Higher selling price was associated with lower adherence. Competitive foods classified as entrees were more likely to adhere than snack items, and larger total size (in fluid ounces) beverages were associated with higher adherence. CONCLUSIONS: Schools have begun to implement competitive food and beverage policies. However, school environments, particularly in secondary schools, are not 100% compliant with school nutrition standards. These findings can inform policymakers and school officials about the feasibility of implementing competitive food standards in schools.

Food and beverage environment analysis and monitoring system: a reliability study in the school food and beverage environment.

States and school districts around the country are developing policies that set nutrition standards for competitive foods and beverages sold outside of the US Department of Agriculture's reimbursable school lunch program. However, few tools exist for monitoring the implementation of these new policies. The objective of this research was to develop a computerized assessment tool, the Food and Beverage Environment Analysis and Monitoring System (FoodBEAMS), to collect data on the competitive school food environment and to test the inter-rater reliability of the tool among research and nonresearch professionals. FoodBEAMS was used to collect data in spring 2007 on the competitive foods and beverages sold in 21 California high schools. Adherence of the foods and beverages to California's competitive food and beverage nutrition policies for schools (Senate Bills 12 and 965) was determined using the data collected by both research and nonresearch professionals. The inter-rater reliability between the data collectors was assessed using the intraclass correlation coefficient. Researcher vs researcher and researcher vs nonresearcher inter-rater reliability was high for both foods and beverages, with intraclass correlation coefficients ranging from .972 to .987. Results of this study provide evidence that FoodBEAMS is a promising tool for assessing and monitoring adherence to nutrition standards for competitive foods sold on school campuses and can be used reliably by both research and nonresearch professionals.

To what extent have high schools in California been able to implement state-mandated nutrition standards?

PURPOSE: To determine extent and factors associated with implementation of California's school nutrition standards 1 year after standards became active. METHODS: Information on competitive foods and beverages available in schools was collected from a representative sample of 56 public high schools in California. Adherence to nutrition standards was calculated for each item and summarized for each school by venue. The association between schools' sociodemographic characteristics and adherence to standards was determined by multivariate analysis. RESULTS: The majority of schools were adhering to the required beverage standards. None of the schools selling competitive foods were 100% adherent to the food standards. Adherence to both standards tended to be highest in food service venues. In univariate analyses, percent nonwhite enrollment, population density, percent free/reduced-price (FRP) meal eligibility, and school size were significantly correlated with the beverage adherence rate. Percent nonwhite enrollment and population density remained significant in the multivariate regression model. Percent nonwhite enrollment and percent FRP meal eligibility were significantly correlated with the food adherence rate in univariate analysis, but neither remained significant in the multiple regression model. CONCLUSIONS: California high schools are making progress toward implementation of the state nutrition standards. Beverage standards appear easier to achieve than nutrient-based food standards. Additional support is needed to provide schools with resources to implement and monitor these policies. Simpler standards and/or a reduction in the foods and beverages sold could better enable schools to achieve and monitor adherence.

Walking the talk: Fit WIC wellness programs improve self-efficacy in pediatric obesity prevention counseling.

Six sites of the California Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participated in a staff wellness pilot intervention designed to improve staff self-efficacy in counseling WIC clients about childhood overweight. A pre-post test design with intervention and control groups was used; outcome measures included staff perceptions of the intervention's effects on the workplace environment, their personal habits and health beliefs, and their counseling self-efficacy. Intervention site staff were more likely to report that the workplace environment supported their efforts to make healthy food choices (P <.001), be physically active (P <.01), make positive changes in counseling parents about their children's weight (P <.01), and feel more comfortable in encouraging WIC clients to do physical activities with their children (P <.05).