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New England Coalition for Health Promotion & Disease Prevention

NECON Obesity Control Forum

NECON
(The New England Coalition for Health Promotion and Disease Prevention)
PREVENTION AND CONTROL OF OVERWEIGHT & OBESITY IN NEW ENGLAND
Conference Held February 11, 2003

DRAFT
EXECUTIVE SUMMARY

I. Introduction

New England, like the rest of the United States and many other countries, is currently experiencing a dramatic increase in overweight and obesity, which has many dire consequences for the health of our population.  To address this issue, NECON initiated a strategic planning process involving many persons from academia, state and local governments, community organizations and businesses.  This report summarizes the deliberations of this working group and highlights steps to take that are critical to the control of this epidemic.

The Epidemic

Obesity1 is not a new problem to the United States or other Western countries; however, the prevalence was fairly stable until the mid-1980's.  Subsequently, obesity rates increased steadily in both children and adults of all ages.  The increases were first observed in the Midwest, and rates are now highest in the Midwest and Southern states. The New England states have experienced among the lowest rates of obesity in the country, but this appears to reflect only a slight delay in the epidemic reaching our region rather than immunity.  At present, over 65% of the U.S. adult population is either overweight or obese as defined by a BMI of 25 or greater.

In addition to variation by region, rates of obesity among adults are approximately twice as high in low income groups compared to those with higher incomes. Among men, rates do not differ substantially by ethnicity, but among women rates are much higher among African Americans and many Latino groups.  Nevertheless, the rates are increasing within each of these groups, indicating that this is a growing problem for all segments of the population. 

Health consequences  

For many years, obesity was known to increase the risk of heart disease and diabetes and total mortality.  More recently, obesity has been found to increase the risks of cancers of the endometrium, colon, kidney, breast (after menopause), and esophagus. Overweight and obesity also increase risks of osteoarthritis and cataracts, and contribute importantly to disability and lower quality of life.  Individuals who are overweight but not obese also experience substantial increases in these conditions.  Furthermore, epidemiologic evidence indicates that many persons who have gained ten or more pounds since age 21 but who still have a BMI under 25, and are thus not technically overweight, are at elevated risk of many diseases.  Thus weight control is an issue for the large majority of Americans.  Overweight and obesity are estimated to be second only to smoking as avoidable causes of death, and that proportion of deaths due to obesity will grow with the continued increase in obesity prevalence.

Rationale for a strategic plan

In the last several years the rapid increase in overweight and obesity has received heightened attention as a threat to the health and well-being of our population, and many individuals and organizations in our region are now taking steps to combat the epidemic. However, NECON recognized that there is great potential for synergy with enhanced communication and coordination among various groups within states and among the New England states.  For example, carefully crafted informational messages that are conveyed by health care providers, put into practice by schools and worksites, and disseminated by the general media could be strongly reinforcing.  Further, there is much efficiency to be gained by sharing experience and material among those working toward the same end within the New England region.  Finally, a coordinated focus on obesity and weight control will be invaluable to generate the resources and involvement of our whole citizenry, which will be necessary to control the epidemic.  This report is offered as an initial step in this effort.


II.  Elements of Strategic Plan (a work in progress)

For the past year, eight subgroups2 have been working in tandem to develop a strategic plan to control and prevent overweight and obesity.  Discussions in each subgroup have cut across many disciplines ranging from individual behavioral psychology to land-use planning and mass media communications. 

Any in-depth study of the obesity epidemic inevitably leads individuals of disparate perspectives to the same conclusion: that the causes of overweight are complex, ranging from individual behavior to societal and environmental influences.  Reversing the epidemic will, therefore, require a multi-faceted, well-orchestrated campaign with complementary measures and methods drawn from a variety of disciplines and involving various age groups, socio-economic levels, urban, suburban and rural communities, educational institutions and public and private sectors. 

To accomplish our goal of "selling" good nutrition and active lifestyles to the majority of New Englanders, our strategic plan recommends three kinds of actions: (1) behavioral change (for individuals and "change agents"), (2) environmental modifications (in social and built environments) and (3) additional research (in medical and social sciences). 

The report recommends modeling and counseling by health care professionals, teachers, community leaders and elected representatives, along with direct and mass media communication about the importance of weight control and how to achieve and maintain a healthy weight.  It recommends changes in the physical, educational, social and legal environments to provide individuals with increased access to healthful foods and opportunities for physical activity.  Finally, the report recommends increased understanding of metabolic, psychological and social processes associated with successful weight control through funding of additional research and pilot projects.

Behavioral Changes

Informed Health Care Providers/Non-Judgmental Counseling

Health care providers are important agents of change in individual behavior.  The report recommends that physicians incorporate weight control into their practices as follows:

      (a) Recognize the epidemic of obesity as a by-product of environmental change rather than individual failure.

      (b) Provide non-judgmental and supportive weight control counseling to all patients.

      (c) Recognize evidence of weight control modalities that have proven effectiveness, and recognize false product and program claims. (See recommendation for creation of an information clearinghouse below.)

      (d) Recognize and convey to patients the importance of lifelong approaches to weight control that are consistent with overall health promotion, rather than short-term diets that may fail to address salient aspects of nutritional health (e.g., abundant intake of fresh vegetables and fruit).

The report recommends that every patient be counseled about the benefits of weight control rather than waiting until a patient develops an obesity-related disease.  NECON encourages all primary care providers to routinely measure BMI of both adults and children, in conjunction with non-judgmental feedback to patients regarding healthy weight.  Patients should be informed when their weight is not in a healthy range (BMI > 25), or (for adults) when BMI is less than 25 but weight is increasing from visit to visit.3 Patients for whom weight control is critical, as well as people with many related questions, may be referred to a dietitian for case-specific counseling. Such counseling should include education about physical activity.

The report recommends the creation of a regional clearinghouse, readily accessible to all providers, that will gather and distribute information about nutrition, physical activity, weight-control counseling, clinic-based resources and innovations.   The report suggests coordination of all New England public health departments, using their websites to collect, distribute and encourage weight control programs.  Non-profit associations, such as the Center for Obesity Research and Education (CORE), may facilitate this initiative. 

The report encourages clinicians to cultivate an inter-generational, family-based approach to weight control.  Specifically, the report urges doctors and other health care providers to convey to parents and other caregivers the importance of early engagement of children in lifestyle practices conducive to weight control. — healthful eating, regular physical activity, limited TV — as well as health-promoting practices for adult family members.  Again, we recommend non-judgmental evidence-based guidance, emphasizing health promotion rather than just weight control. 

To assure implementation of this recommendation, the report recommends that medical schools prepare future providers for effective weight control counseling, including multi-cultural competency, by dedicating time in training curricula to this goal and offering practicing physicians opportunities for continuing medical education in this field.  Further, we propose the development and distribution4 of appropriate materials to regional providers, state health departments, non-profit health care associations5 and health insurers.   Finally, the report encourages health care providers to practice healthful eating and regular physical activity, for their own sake, as well as to serve as an example for patients as to what is realistic and achievable.

Health-Conscious Teachers and Community Health Promotion Counselors

Teachers and parents play crucial roles in affecting beliefs and behavior about diet, physical activity and weight.  The report recommends that teachers be trained to transmit age-appropriate information about diet and physical activity; reinforce the messages delivered by health care professionals and public health organizations; and stimulate in children and adolescents the ability to think critically and carefully about their health choices and consequences.  It urges teachers to work with parents and community resources to achieve health promotion goals.  (See recommended changes in educational environment below.)

The report recommends that public health agencies, particularly community health centers in minority communities, hire and train health care professionals who are competent to counsel individuals about weight control.   The report urges health departments to make weight control a priority, leveraging all opportunities to promote physical activity and nutrition education programs by reaching out to schools, churches, healthcare providers and parents. 

Walk to School, Bicycle to Work, Take the Stairs

The report recommends that community leaders, town planners and employers encourage children, youth and adults to walk, bicycle or climb stairs as reasonable alternatives to mechanized transportation.  The goal is to incorporate as much physical activity as possible into daily routines, such as commuting to work, going to and from school and doing errands. 

The report urges transportation departments to introduce the following measures:

      (1) Educate drivers, bicyclists, pedestrians and law enforcement personnel about "Share the Road" laws and assure that driver training classes increase bicycle awareness among student drivers

      (2) Direct traffic police to ticket both bicyclists and motorists for infractions of the rules of the road 

      (3) Organize promotions such as "Bicycle to Work Week"

      (4) Hold "Bicycle-Driver Training" classes

One way to promote bicycling is to get prominent people on bicycles, touting the benefits and fun of "self-propelled" transportation.  (See recommended changes in physical environment below.)

Farmers' Markets and Multi-Cultural Wellness

The report recommends the expansion of the existing Farmers' Market Nutrition Program (FMNP) sponsored by the U. S. Department of Agriculture (USDA).  FMNP provides low-income families with vouchers to purchase fresh produce from USDA-approved farmers' markets, offering access to produce of the quality and variety rarely found in low-income neighborhood grocery stores.6 At present, FMNP has two components,7 one for women, infants and children and the other for seniors.

The program proposed would expand and enhance the existing programs in 2 ways:

      1) Change eligibility requirements so as to extend access to a greater number of low-income families; and

      2) Develop a wellness program that would educate participants about the health benefits of good nutrition and physical activity and increase awareness of fresh, locally grown foods.  The program would include multi-lingual, multi-cultural tapes, videos, recipes, calendars and posters.

The prevalence of overweight, obesity and super-obesity is greatest among low-income people who represent a variety of languages and cultures and a growing segment of New England's population.  The report recommends development of mass media communication through multi-ethnic, camera-ready, evidence-based messages on healthy eating and physical activity in English, Spanish 8 and Asian languages. 

Healthy Eating Pledge

The report recommends pilot testing of a "Healthy Eating Pledge" supported by a regional media campaign.  Parents, employers, community leaders, food managers, teachers and health care professionals would be asked to refrain from serving unhealthy food at home, for social functions, in cafeterias and other meal programs and to express that commitment through a written statement.  The proposed "Healthy Eating" pledge states that food served will meet specific nutrition criteria.  Pledge cards could be privately exchanged, posted or publicized.

Pledges protect teens from peer pressure.   Tobacco-free and drug-free pledges have been used successfully in schools.  Having signed a pledge a teen can say "no" and still be "cool."  Elected officials can also set an example by taking the pledge.

 Food industry associations are encouraged to establish guidelines consistent with generally accepted scientific evidence about the health effects of various ingredients and cooking methods and the benefits of disclosure to restaurant patrons.9

Environmental Modifications

These recommendations involve synergistic relationships among the built environment, communities, schools, workplaces and medical schools and associations.  The recommendations also call for changes in public health and infrastructure funding and the relevant legal framework.

Developing Safe and Friendly Pedestrian and Bicycle Transportation Systems

The report urges state governments to give high priority to bicycle and pedestrian education and infrastructure.  Specifically, it recommends adequate funding for the development of safe and attractive bicycle transportation systems, including bicycle paths. 

State departments of transportation should develop state-wide bicycle facilities and earmark funding for walk/bike-to-school programs in cities and towns.  Review of building permits should include pedestrian and bicycle-friendly features, such as bicycle parking, showers and accessible stairs. 

The report encourages states to apply for and use available federal funding for pedestrian and bicycle programs and facilities.  It is important for states to develop and implement systems for monitoring use of federal funds.  Therefore, the report suggests that state departments of transportation produce yearly reports, demonstrating efforts to identify opportunities for infrastructure improvement, negotiations with competing interests and appropriate use of available funds. 

The report recommends that cities, towns and intrastate regional organizations hire bicycle-pedestrian coordinators with the following responsibilities:

    • Establish and work with citizen advisory committees
    • Include multi-disciplinary expertise — town planners, environmentalists, engineers, architects and safety officers — in the planning process
    • Review all new street construction and renovation projects for promotion of physical activity
    • Submit grant proposals to ISTEA10 and pursue other sources of funding for enhanced facilities

The report recommends cooperation among school administrators, teachers, parents, police departments and planners to create safe routes for walking or bicycle riding to school and after-school programs, thereby increasing the number of children enjoying the health benefits of using their own energy for transportation.  Parents would be informed and kept up-to-date about such plans and, where there is a safe route, assisted in making arrangements for their children.

The report recommends the creation of a network of bicycle paths and routes knitting together all of New England.  Benefits would include increased use of bicycles for transportation, recreation and expansion of eco-tourism industry. 

A Unified School Nutrition-Physical Education Environment

The report recommends that state departments of education, in conjunction with their preventive health program, require school districts to create a student-parent "surround system" to promote good nutrition and physical activity.  This system would have the following components:

    • Unified food environment, ensuring that all foods sold or served in schools meet sound nutritional guidelines.  Students would receive age-appropriate information and instruction about the role of good nutrition and physical activity in weight control and the risks associated with poor nutrition, sedentary behavior and excess weight.  This environment would include:

         (a) Cafeteria food service, with certified food service directors
         (b) Vending machines
         (c) Health curriculum
         (d) Farmers' market in-school programs
       
    • Opportunities for supervised physical activity at specific times and places, as follows:

         (a) Every school day
         (b) In physical education classes with a qualified instructor
              (i) Elementary school (K- 5/6):  150 minutes/week
              (ii) Middle and secondary school: 225 minutes/week
       
    • Integrated Curriculum, for example:

         (a) "Eat Well and Keep Moving" for upper elementary school
         (b) "Planet Health" for middle school (6-8th grade students)
       
    • TV-Watching Disincentive – [description to come]
       
    • Before school, school breakfast and after-school activities – to come
       
    • Increased participation in programs for teachers, food service personnel and students, e.g. "Changing the Scene - TEAM Nutrition" 11 and VERB12
       
    • Opportunities for teachers and health educators to communicate with parents about the school's program and opportunities for parents to learn about risks associated with poor nutrition, sedentary behavior, television-viewing and excess weight and the relation of pediatric nutrition and physical activity to adult health.

Public-Private Partnerships and Shared Resources

The report recommends that communities, employers and schools work together toward the common goal of health promotion among children, youth and adults.  Worksites and schools are important venues for encouraging healthy lifestyles and educating families. 

States can set an example for the private sector by ensuring that government buildings are health-promoting environments.   For example, the report recommends that states require "point-of-decision prompts" to encourage stair use (versus elevator or escalator use) in all public buildings and transportation facilities.  State and community planners are urged to work with private businesses and real estate developers to make stairs accessible, safe and user-friendly.  Government cafeterias, vending machines, snack counters and hospitals can be modified to offer nutritious choices.   The report recommends improving access to fresh fruits and vegetables through private vendors in public space.

The report calls for public health agencies and organizations to work with employers to find economical ways to provide nutritious food at worksites and encourage sedentary workers to become more physically active, including incentives to use non-automotive transportation.  State agencies could work with small businesses to explore mechanisms for developing shared resources for physical activity and nutrition.  For example, a farmers' market could be situated at a location accessible to and supported by a group of businesses in a given geographical area.

Financial Incentives

(1) Health Care Providers
The report recommends that health insurance contracts, entered into between employers and insurers as well as self-insured corporations and physician groups, compensate clinicians for weight-control counseling.  Insurers are encouraged to reimburse clinicians for time spent conveying guidance to both adult and pediatric patients with regard to weight control.  Unfortunately, part of such reimbursable time will be needed to refute misleading claims for commercial diet products and programs.

(2) Certified Worksite Weight-Control and Health Promotion Programs
The report recommends the creation of a regional organization competent to set standards for worksite weight-management programs and empowered by state governments to certify programs that meet the standards.  The report suggests that insurers discount premiums for employers offering such programs and for individual participants.

Legislation to Promote Weight Control

The report supports state and federal legislation consistent with the recommendations contained in this report.

State Legislation

  • Sales Tax on Sweetened Soft Drinks (Soda), Candy and Confections
    The report recommends that the New England states adopt uniform laws taxing the sale of soft drinks and candy (repeal of exemptions tantamount to subsidies) wherever or however sold.
    13    [To come: Explanation of taxes/exemptions on soda in NE states. 14]
     
  • Food Content Disclosure and Labeling
    The report recommends that the New England states adopt uniform laws and definitions with respect to the disclosure and labeling of food not covered by USDA or FDA requirements, for example, foods served in fast-food chains.
     
  • Childhood Nutrition and Food Assistance Programs
    Obesity rates are particularly high in low-income populations.  Government programs that help poor people feed their families offer an opportunity to educate homemakers about diet  and other health promoting behaviors.  The proposed Act to End Child Hunger in Massachusetts (the  "Act") would increase access to nutrition programs for low-income families.
    15  The Act would provide nutrition assistance and education for school age children16 as well as mothers, infants and young children up to age 6. 17  The Act would fast-track nutrition assistance by creating a unified application and providing interpreters to help in completing applications.  The bill also provides for the development of a meaningful case management system.
     
  • Maine-Faircloth Obesity Package18
  • 1. Transportation Policy
    • Amend ME constitution to allow use of transportation revenues to fund a flexible, modern transportation policy
    • Modernize Maine transportation policy to reintegrate walking, running, biking and cross-country skiing into daily transportation choices
     

    2. Public School Nutrition and Physical Education
    • Promote healthy choices in public schools, including the replacement of candies and sugar sodas in school vending machines with healthy food options.  (Grandfather provision for existing contracts)
    • Analyze decrease in physical activity in public schools in last 30 years
    • Consider decreasing saturated fats, trans fats and refined grains in school diets consistent with Harvard School of Public Health Food Pyramid
    • Analyze advertising to children in public schools

    3. Consumer Disclosure
    • Provide consumers with information about the caloric content and nutritional content of food they purchase at chain restaurants (defined as having an outlet in Maine and twenty or more locations nationally.)

    4. Health Care Cost Containment
    • Study cost-saving potential of covering nutrition education and obesity prevention in health care.

 

Federal Legislation

    • Obesity Prevention Act
      The report urges that the New England congressional delegation support a bill
      19 introduced in the US Congress by Representative Michael Castle.20   The Obesity Prevention Act would create a Commission on Obesity Treatment and Prevention with membership from relevant federal agencies, non-profit organizations and the food and fitness industry.  Grants would go to state agencies for pilot projects in nutrition education and for obesity prevention activities in health programs for low-income children.  The Act would create a health and fitness awards program and include health education in after-school programs.
       
    • Extra-Curricula School Nutrition Programs21
      The report urges that the New England congressional delegation support bills that would increase opportunities for good nutrition, physical education and health education before school, in the school breakfast, after school programs and in the summer food service program.
       
    • Transfer of Agricultural Subsidies to Nutrition Improvement Fund
      At present the United States has programs that subsidize the production of sugar and corn syrup.   The federal government subsidizes sugar growers through direct payments, storage of excess sugar and trade quotas.
      22  In 2001 Sen. Judd Gregg (R-NH) introduced an amendment to phase out the sugar program and use any resulting savings to improve nutrition assistance.  A motion to hear the amendment was supported by a bi-partisan group of senators from New England.23

      The report urges that the New England congressional delegation recommend that a certain portion of the subsidies presently provided to sugar and corn syrup producers be dedicated to a social marketing fund to promote good nutrition and physical activity.
       
    • IMPACT24
      The Improved Nutrition and Physical Activity Act (IMPACT) would establish grants to encourage the following kinds of activities:
      25

      1) Healthy lifestyle educational curricula for diverse cultural populations along with appropriate training of health care professionals and community health workers

      2) Promotion of biking and walking and development of infrastructure

      3) Public-private partnerships to provide nutrition education and improve physical activity and food options in the workplace, day care facilities, senior centers, nursing homes and entire communities

      4) Tax incentives to encourage location of stores selling fresh fruits and vegetables in otherwise less-desirable neighborhoods and outreach programs to shift consumption patterns to more healthful foods
    • Many of the activities specified in IMPACT are already underway in New England.   The report recommends funding, enhancement and coordination of successful programs.

Research

The report urges states to monitor the cost of treating illnesses associated with excess weight.  Currently, overweight and obesity add 11% and 36%, respectively to dollars spent on health care services, and 3% and 77%, respectively, to spending on medications.26 Excess weight among adults under 65 years of age accounts for about 10% of total national health care spending.  The report recommends that a more detailed analysis of the cost of obesity  — including impacts on governmental budgets — be developed on a state-by-state basis, and that this be updated periodically. 

The report recommends that states produce a biennial "trends report" of leading indicators related to weight control, integrated with ongoing DHHS Region I health monitoring activities.  As a prerequisite, the report recommends funding for systematic collection and reporting of height and weight data on youth in grades K-8. 

In developing the trends report, existing surveillance systems, for example HMO data systems, would be identified and utilized, where appropriate.  The state reports would provide simple, timely and useful data for immediate program purposes.  Training and support in using data would be provided to people on the front lines of obesity prevention/control, such as school nurses, nutritionists, physicians and teachers.

Other research recommendations are:

    • Evaluate school physical education programs and develop pilot projects to determine what kinds of changes are effective in motivating students to pursue lifelong physical activity.
       
    • Study stairways in office buildings and transportation facilities to determine design factors and prompts that make stair usage an attractive alternative to escalators or elevators.  Develop pilot projects.
       
    • Study existing walkways, bike paths and pedestrian malls to determine level of usage, motivational factors and deterrents.  Develop pilot projects.
       
    • Develop objective ways to evaluate the effect of changes in the built environment on individual behavior 
       
    • Study eating patterns and weight in various families and cultures.
       
    • Evaluate the teaching of nutrition and weight control in medical schools, continuing education courses and other health care training curriculum.
       
    • Evaluate weight control social marketing campaigns, measuring changes in knowledge, attitudes, eating patterns and physical activity behavior. 
       
    • Evaluate pledges in anti-smoking and anti-drug campaigns and their applicability to weight control.
       
    • Evaluate the cost-benefit of alternative workplace interventions.
    •  

III. Conclusion

We know for certain that the obesity epidemic is due to a combination of individual behaviors and environmental factors that result in low levels of physical activity and overconsumption of calories.  From our experience with smoking control and the effectiveness of health promotion programs in other countries, we know this epidemic can be controlled.  However, this will require the concerted efforts of all elements of our society and the commitment of real resources, not only good intentions.  If we fail to act vigorously, we have every reason to believe that the epidemic will intensify and the burden of suffering and early death due to overweight and obesity will become greater.


1. In this report we use the World Health Organization definitions of obesity (body mass index, or BMI, of 30 or more) and overweight (BMI of 25 to 29.9). Body mass index is computed as weight in kilograms divided by height in meters squared, and can be considered as a measure of weight adjusted for height.

2. The subgroups and their coordinators are: Epidemiologic Surveillance (Karen Peterson, ScD), Health Care Providers (Jennifer Tremmel, MD, David Katz, MD and Lon Sherman, MD), Economics (pending), Worksite Health (Karen Emmons, PhD), School Nutrition and Physical Activity (Jean Wiecha, PhD and Bill Potts-Datema, MS), Food and the Social Environment (S. Bryn Austin, ScD), Physical Activity and the Environment (Phil Troped, Ph.D., MS) and Mass Media (Lilian Cheung, ScD, RD) 

3. All feedback regarding weight control should be non-judgmental, worded such as: "I routinely monitor weight in my practice, because, like blood pressure or cholesterol, weight is important to health.  Also like those measures, there is much about weight that you don't directly control, including genes and environmental factors.  Still, if you do your best to eat well and be physically active, better weight control is likely.  Your weight is currently…To control/lower your weight, I encourage you to eat a moderate and balanced diet abundant in whole grains, vegetables, and fruits; and to make physical activity a part of your daily routine.  Do you have any questions about this?"

4. Materials to be distributed via state medical societies, and state affiliates of the American College of Physicians (ACP-ASIM), American Academy of Pediatrics, American Association of Family Practice and health insurance companies.

5.  E.g. local and state branches of the American Cancer Society, American Diabetes Association, American Dietetic Association, American Heart Association, Blue CrossBlue Shield, HMOs.

6.  A recent study found that people with access to local markets selling good produce at reasonable prices ate one-third more fruits and vegetables than people living in neighborhoods with inferior choices and residents of predominantly white neighborhoods have far greater access, in the neighborhood as well as through automobile ownership, to supermarkets as residents of predominantly black neighborhoods.  Morland K, Wing S, Roux AD. The Contextual Effect of the Local Food Environment on Residents' Diets: The Atherosclerosis Risk in Communities Study, American Journal of Public Health.  2002. 92; 11:1761-1767.

7 The Women, Infants & Children (WIC) program safeguards the health of low-income women, infants and children up to age 5 who are at nutritional risk. The Farmers' Market Nutrition Program (FMNP), 42 USCS § 1786, (m) provides additional coupons to WIC participants that they can use to purchase fresh fruits and vegetables at participating farmers' markets.  In the Senior Farmers Market Nutrition Program, 7 USCS § 3007, grants are awarded to states to provide coupons to low-income seniors that may be exchanged for certain foods at farmers markets, roadside stands and community supported agriculture programs (CSA's).  Within each state different programs may evolve based on need, funding and local resources.  In FY2002 some $3 million from USDA, state, and local resources have been provided to over 100,000 low-income WIC families and vulnerable seniors in the region, enabling them to purchase fresh locally grown produce.  About 600 of the region's fruit and vegetable farmers received increased revenue from the programs. 

8 According to Nielsen media research 15% of viewers between ages 18-49 are Hispanics and about half of Hispanic-American households prefer watching programs in Spanish.  NY Times, 12/30/02.

9 Food and Drug Administration, US DHHS, Public Health Service. Food Labeling, Questions and Answers, Volume II, "A Guide for Restaurants and Other Retail Establishments."

10 Intermodal Surface Transportation Efficiency Act, (ISTEA).  ISTEA mandated the appointment of a bicycle and pedestrian coordinator in each state and the development of long-range transportation plans.  ISTEA's successor, TEA-21,  the Transportation Equity Act for the 21st Century, is up for renewal in '03.

11 Team Nutrition is the US Dept. of Agriculture's integrated, behavior-based comprehensive plan.

12 VERB is a youth media campaign developed by the US Dept. of Health and Human Services' Centers for Disease Control.

13 See Hanson JD and Logue KD. The Costs of Cigarettes: The Economic Case for Ex Post Incentive-Based Regulation. 107 Yale L.J. 1163. 1998 and Jacobson MF and Brownell KD, Small Taxes on Soft Drinks and Snack Foods to Promote Health. American Journal of Public Health. 2000. 90; 6: 854-857.

14 Connecticut taxes the sale of "soft drinks, sodas or beverages such as are ordinarily dispensed at bars and soda fountains … meals sold by an eating establishment or caterer and … meals furnished, prepared or served in such a form and in such portions that they are ready for immediate consumption."  A proposed amendment would remove "sugar products, candy, confectionery, cakes, pies, cookies and similar items" from the list of "food products" exempt from the sales tax.  2002 CT S.B. 611.   Maine excludes "soft drinks, iced tea, sodas or beverages such as are ordinarily dispensed at bars or soda fountains or in connection with bars or soda fountains … water, including mineral bottled and carbonated waters and ice … candy and confections; and prepared food from the list of  "grocery staples" exempt from the sales tax.  36 MRS [Taxation] § 1752, sub-section 3-B.  Maine HB 800 would add bottled water to the list of groceries exempt from the sales tax.  Rhode Island taxes the sale of  "soft drinks, sodas or beverages that are ordinarily dispensed at bars or soda fountains or in connection therewith" as well as "candy and confectionary" and "takeout." RI S.B. 2527, enacted 6/28/02 as RI Stat. _____

15 MA S722/H.B. 2183, H.D. 2238.  Originally drafted by Project Bread and introduced in 2001 with the assistance of The MA Children's Legislative Caucus, the Act passed the Senate in July 2002.  It has now been filed in a revised form and should be referred to committees in the spring 2003 session. 

16 As originally drafted the Act would direct the MA Dept. of Education (DOE) to 1) require public schools drawing attendance from areas with a high number of needy children to make school breakfast programs available at no cost to all children in the school (state reimbursement of costs to be determined), 2) administer the summer food service program funded by the state and USDA to provide meals to children from needy areas during summer school vacation and 3) administer the after school snack program funded by the state and USDA through child care centers serving children from needy areas.

17 The MA Dept. of Public Health (MDPH) administers the WIC program; and the Dept. of Transitional Assistance administers the food stamp program.  As originally drafted the Act would direct MDPH to extend the WIC program for an extra year to include children up to age 6, applying for a federal waiver if necessary.  Neighborhood kiosks would be set up where individuals could obtain information about health promotion and nutrition assistance.   Interpreters would be available to assist non-English speaking people.

18 Bills to be introduced by Rep. Sean Faircloth (D-ME) in 2003 session of state legislature.

19 HR 5659, introduced 10/16/02, referred to the House Committee on Education and the Workforce and the House Committee on Energy and Commerce.

20 Chair of the House Subcommittee on Education Reform and former governor of Delaware.

21 S. 2660 would increase the number of children participating in the summer food service program;  HR 4192 would establish pilot projects to support and evaluate the provision of before-school activities and increase participation in the school breakfast program.

22 See 1981 U.S. [cite to come, price support program for sugar beet and sugar cane producers and processors]; The Federal Agriculture Improvement and Reform Act of 1996 [cite to come]; Remy Jurenas, "IB95117: Sugar Policy Issues," Congressional Research Service Issue Brief for Congress, April 13, 2001 and US General Accounting Office, "Sugar Program: Supporting Sugar Prices Has Increased Users' Costs While Benefiting Producers" BAO/RCED-00-125, June 2000; "The Great Sugar Scam," NY Times, 1/11/02, p. _; and "The Hypocrisy of Farm Subsidies," NY Times, 12/1/02, p. _

23 S. 1731, Amendment 2466.

24 (S.2821 and HR 5412) IMPACT was introduced on July 30, 2002 by Senator Bill Frist, MD, (R-TN) Senate Majority Leader with bi-partisan co-sponsorship.  The bill is expected to be reintroduced this year.

25 Sections 301, 399AA and 399 BB of IMPACT

26  Sturm, Roland. The effects of obesity, smoking and drinking on medical problems and costs. Health Affairs. 2002. 21; 2:245-253.

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