TESTIMONY OF LESLIE MIKKELSEN BEFORE THE SENATE APPROPRIATIONS COMMITTEE, SUBCOMMITTEE ON LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED AGENCIES

"Improving Nutrition and Health Through Lifestyle Modifications"

February 17, 2003
San Francisco, CA

My name is Leslie Mikkelsen. I am Managing Director of Prevention Institute. I would like to thank you for the opportunity to be part of this very important hearing to address a serious and growing health problem in the United States.

I am very enthusiastic that the Committee on Appropriations has recognized the gravity of this public health crisis and recommended significant funding to increase physical activity, improve nutrition, and reduce the prevalence of obesity and overweight.

I would like to share with you my perspective, gained through my work as a nutritionist and public health practitioner, on effective measures necessary to turn around the frightening statistics. There are numerous factors which influence individual food and activity choices. Changing the overall pattern of these choices requires a multifaceted approach that addresses not only individual knowledge, motivation, and skills, but also ensures the surrounding environment supports healthy behaviors.

This point was driven home for me in my work as the nutritionist for the food banks of New York City and Alameda County. An important lesson for me in this work occurred after I had led a particularly successful nutrition education session with mothers of young children, sponsored by a local community agency. The group was enthusiastic and quite interested in practical guidance about how best to nourish their children. Then lunch arrived. It consisted of a microwaved "Polish" hot dog, potato chips, cup cakes, and a fruit drink. At that moment, it was clear to me why education was only one element of the strategy to change the dietary habits of these families.

It might seem shocking that a community organization interested in nutrition would serve this lunch, but they were a small organization, without a kitchen and dependent on donations. The women who had participated in this class were operating with the same limited resources as this organization, and their ability to provide nutritious foods to their family was limited by what was accessible and affordable in their communities. This effect of the environment is not limited to low-income families, as I will discuss later on.

This experience highlighted why environmental changes are an important aspect of the strategies to achieve behavior change. It is important to recognize that people are not making decisions about what to eat and when to be active in a vacuum. Therefore it is important that public policy and health promotion efforts support the creation of an environment that makes healthy choices easy.

Turning around the obesity epidemic requires attention to this community environment along with attention to individual behavior change and provision of primary care. As noted in the Committee report, a population-based primary prevention strategy needs to include policy and environmental interventions.

A useful framework for visualizing this strategy is the Spectrum of Prevention, a public health planning tool that identifies six levels of action to achieve behavior change. This tool has been applied to major health concerns ranging from tobacco control to traffic safety, violence prevention, nutrition, and physical activity. It emphasizes the importance of including systems changes along with individual behavior change and community education.

It was the recognition of the need for environmental changes to go hand-in-hand with individual behavior change efforts that led Prevention Institute to join with other prominent public health organizations to found the Strategic Alliance for Healthy Food and Activity Environments. We also work in partnership with the National Alliance for Nutrition and Activity.

Unfortunately, in many California communities, high-fat and high-sugar foods and the marketing that promotes them have a prominent place in our schools and neighborhoods, and are frequently the lowest-cost options. Physical activity has been engineered out of our lives as community design favors transportation by car over walking and biking, and many parents are afraid to let their children play outside. While meeting physical activity goals is frequently visualized as engaging in scheduled exercise, it is frequently easier to increase activity by incorporating it through one's daily life.

The limited availability of healthy options is even more pronounced in low-income neighborhoods, where families must prioritize basic needs. Unfortunately, healthy behaviors are often viewed as a luxury; the survival mechanisms used to combat poor food access and unsafe neighborhoods (i.e., consuming high-fat, fast foods, and staying indoors rather than playing on the streets) establish patterns that put children at risk for developing chronic disease.

The Alliance has identified five key sectors where we believe joint action is needed to alter current eating and activity patterns and shift the environment towards supporting healthy behaviors. These include children's environments, government, industry practices, the health care system, and the media. A complete description of this approach is attached.

Today, I would like to highlight some of our areas of focus which are being implemented in communities across the country. I urge you to work to implement similar policies nationally. Some of the most promising approaches include:

1) Implementing nutrition standards for all foods sold in school, preschool, and after-school programs.

A key tenet of effective behavior change is to model and reinforce healthy behaviors. Unfortunately, schools frequently provide easy access to soft drinks, high-fat snack foods, and dessert through vending machines and a la carte lines. Brand-name fast food is even available in some high schools.

As public institutions dedicated to children's learning, schools should serve as a model for healthy practices rather than a conduit for unhealthy habits. These should apply to all institutions serving children from preschool, school, and after-school programs.

The Alliance was involved in securing the passage of Senate Bill 19 which establishes nutritional standards for foods sold outside the National School Breakfast and Lunch programs in elementary schools and middle schools. We are currently helping to ensure adequate technical assistance and evaluation of pilot projects taking place before the bill takes effect. At the same time, members have been involved in the passage of local school district measures to remove soda and in some cases junk food from all schools. There is great interest in this approach around the country, and we have heard from localities in states as diverse as Alaska, Hawaii, New York, and Pennsylvania that are moving towards similar restrictions. Where changes have been made, preliminary results are positive, with sales of water, 100% juice, and healthier snack choices yielding revenues equal or greater than those previous.

2) Cultivating active community environments

There are well-demonstrated links between community design and physical activity levels. Current land use trends have tended to increase automobile dependency and make walking and biking less practical, less convenient, less safe, and less pleasant. From 1960 to 1990, the percentage of workers with jobs outside their counties of residence tripled. During the same period, vehicle miles traveled rose dramatically while walking declined.ⁱ Mixed land use increases the number and percentage of walking and biking trips, generating up to four times as many walk trips for trips less than one mile.ⁱⁱ Access to neighborhood parks nearly doubled the likelihood that U.S. adults were physically active compared to those without access to parks. Concerns about neighborhood safety have been associated with lower activity rates among older adults.ⁱⁱⁱ

Nationwide, only 31% of children who live within one mile of school make the trip on foot; only 2% of school children who live within two miles of school travel by bike.^iv Parents are also afraid to allow their children to play outside and turn to safe, passive entertainment ranging from TV to home videos and computer games to occupy their children's free time. Children in the United States spend more hours watching television and videotapes and playing video games than sleeping; these passive leisure time activities are linked to increased risk for obesity.^v

The Strategic Alliance is supporting a number of local and state government policies that enhance active community environments, which would benefit from support at the federal level. Measures being taken by communities to alter environments to enhance physical activity include traffic calming and routine accommodation of bicyclists and pedestrians in all transportation projects. Opportunities exist to reward local governments that promote infill development and more walkable communities with transportation incentive grants. Funding of the Safe Routes to School program has enhanced walking to school for many children. Resources also need to be made available to support maintenance and development of parks and areas for active recreation.

3) Increasing access to nutritious foods in all neighborhoods

Anyone who has searched a convenience store for a healthy snack knows that options can be limited. Restaurants can also be a challenging place to find fruits and vegetables to contribute to 5 a day. Access to nutritious foods is even more challenging in low-income neighborhoods, where there are few supermarkets and small stores have limited quantities of high-priced fresh items.

Supermarkets have become the primary source of fresh produce for most grocery shoppers in the United States. Yet predominantly low-income neighborhoods in both central cities and rural areas are less likely to have supermarkets. A 1995 analysis of 21 major U.S. metropolitan areas found there were 30% fewer supermarkets in low-income areas than in higher-income areas; it also found low-income consumers were less likely to possess automobiles, further limiting their access to food choices.^vi Studies have consistently shown that prices at small grocery and convenience stores can exceed those at chain supermarkets by as much as 48% and smaller stores are also unlikely to offer the variety of products carried by most major supermarkets.^vii A recent University of North Carolina study has demonstrated the link between supermarket access and healthy diets, finding that residents in neighborhoods with higher concentration of supermarkets ate higher amounts of fruits and vegetables.^viii

There are models around the country for innovative approaches to increasing access to fresh produce, low-fat dairy, and protein items. These include joint community partnerships to site supermarkets in low-income neighborhoods, establishment of farmers' markets, and training and equipment provided to small retailers to successfully carry produce. At the same time, some community-based programs have sought to improve transportation to bring consumers to existing stores by coordinating transit services or providing van service or deliveries.

4) Making government and health care workplaces models for supportive environments

Most adults spend a large portion of the day at work. The organizational practices of their workplace can make a difference in their ability to achieve healthy behaviors. California adults reported difficulty accessing fruits and vegetables at work as a key barrier to increasing consumption.^ix

It is a concern when a local hospital served donuts as the only breakfast food at a meeting on health disparities, or when fast food outlets are located in the lobby. A far better example is set by the Health and Human Services offices in Rockville, Maryland, where we were pleased to discover a farmstand with an attractive array of local fruits and vegetables set out for tasting.

Health care and government institutions have a special responsibility to model wellness-encouraging organizational practices. These offices can serve as a model ensuring availability of healthy and appealing food options in cafeterias, vending machines, and whenever refreshments are served. Inspectors ensure the safety and accessibility of elevators while failing to ensure safe, hospitable stairways, which CDC has aptly described as "expensive pieces of exercise equipment." Activity levels can be enhanced through support for well-lit and safe stairwells, bike racks, lockers and showers, and incentives for walking or biking to work.

Government and health care staff should serve as spokespeople for healthy food and activity practices at work and be able to proudly describe how their own workplaces reflect such practices.

5) Restricting marketing to children

Children in the United States are estimated to view as many as 40,000 commercial messages each year on television.^x More than 50% of these ads are estimated to be for food, predominantly promoting soda, fast foods, high-sugar cereals, and high-calorie snacks. This advertising seeks to develop their brand loyalty to last a lifetime and even utilizes children's entertainment characters to promote food and beverage products. Even schools have become centers for commercial messages as soft drink companies have targeted schools for exclusive marketing contracts that prominently feature their products and sometimes lead school administrators to promote sales in order to increase revenue for the schools.^xi

The serious health consequences that are resulting from overconsumption require that we look once again at the appropriateness of marketing to children. Children below the age of eight are incapable of even distinguishing commercial from non-commercial messages.^xii At a minimum, promotion of unhealthy food and beverages should be eliminated from schools, which are public institutions. Further, we need to carefully consider the examples of other countries. Sweden and Norway prohibit advertising targeted to children under 12, and Australia does not allow ads during preschool programming.

In conclusion, I would like to say that it is very exciting to see an increase in funding to CDC devoted to nutrition and physical activity initiatives. Given the important contribution of environmental and policy changes, I would strongly recommend that a high proportion of these funds be devoted to nurturing the burgeoning movement for these changes at the state, local, and federal levels. Through the synergy of individual-behavior change efforts and environmental changes, we will be able to effectively shift community norms and reduce the burden of preventable disease, disability, and premature death.

Footnotes

ⁱ US Department of Transportation, Bureau of Transportation Statistics. Journey-To-Work Trends in the United States and its Major Metropolitan Areas 1960-1990 [online report]. National Transportation Library Web site. Available at: http://ntl.bts.gov/DOCS/473.html. Accessed February 17, 2003.

ⁱⁱ Holtzclaw J. Using Residential Patterns to Decrease Auto Dependence and Costs. San Francisco, Calif: Natural Resources Defense Council; 1994:16-23.

ⁱⁱⁱ Centers for Disease Control and Prevention. Neighborhood safety and the prevalence of physical inactivity -- selected states, 1996. MMWR. 1999; 48(7):143-146.

^iv Seeley A. Environment and systems changes to reduce childhood obesity. In: 2003 California Childhood Obesity Conference Speaker Handouts; January 6-8, 2003; San Diego, Calif. Presentation 1B.

^v Robinson TN. Reducing children's television viewing to prevent obesity: a randomized controlled trial. JAMA. 1999;282:1561-1567.

^vi Cotterill RW, Franklin AW. The Urban Grocery Store Gap. Storrs: Food Marketing Policy Center, University of Connecticut; 1995. Food Marketing Policy Issue Paper No. 8.

^vii Weinberg Z. No place to shop: food access lacking in the inner city. Race, Poverty & the Environment. Winter 2000.

^viii Morland K, Wing S, Diez Roux A (2002). The contextual effect of the local food environment on residents' diets: the atherosclerosis risk in communities study. American Journal of Public Health. 2002;92:1761-1767.

^ix Oppen M, Sugerman S, Foerster SB. Fruit and Vegetable Consumption in California Adults; Ten-Year Highlights from the California Dietary Practices Survey 1989-1999. California Department of Health Services, Cancer Prevention and Nutrition Section [online report]. 2002; Public Health Institute Web site. Available at: http://www.phi.org/publications/researchreport.pdf. Accessed February 17, 2003.

^x Strasburger VC. Children and TV advertising: nowhere to run, nowhere to hide. Journal of Developmental and Behavioral Pediatrics. June 2001;22:185-187.

^xi Nestle M. Soft drink pouring rights. Public Health Reports. 2000;115:308-319.

^xii American Academy of Pediatrics, Committee on Communication. Children, adolescents and advertising. Pediatrics. 1995;95:295-297.

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