Scott Gee, MD, FAAP Medical Director, Prevention & Health Information

1. Advocacy Strategies to Address Obesityin Your Community- Childhood Obesity Action Network -The Healthcare Campaign to Stop the Epidemic Scott Gee, MD, FAAP Medical Director, Prevention & Health Information Kaiser Permanente Northern California The speaker in this session has no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity. The speaker will not discuss or demonstrate pharmaceuticals and/or medical devices that are not approved by the FDA and/or medical or surgical procedures that involve an unapproved or "off-label" use of an approved device or pharmaceutical. Chicago, ILAugust 16, 2008

2. By the end of the workshop attendees will be able to… • Describe 3 evidence based environmental strategies to address obesity • Construct a 3 minute advocacy talk • Describe 3 roles of health professional advocacy

3. Evidence Based Environmental Strategies to Address Obesity

4. Are overweight children a personal or community issue? 1,068 random sample CA residents, telephone survey 10-11/2003 http://calendow.org/caobesityattitudes/index.htm

5. Pleasanton Pediatrics Bike Helmet Quality Improvement Project 1990 -1993

6. Community Health – An Evidence-Informed Approach • Collaborate with our communities to establish a specific, short-term health related goal (community data, needs assessment) • Identify evidence-based best practice(s) for achieving shared goal (Medline, Community Guide) • Collaborate with our communities to adapt this best practice to the community’s unique assets and constraints • Evaluate the project by using appropriate expertise Pediatrics April 2005;115:1142-1147

7. Which community physical activity interventions have good evidence? • Community-wide campaigns • Point-of-decision prompts • School-based physical education • Social support in community settings • Individually-adapted health behavior change • Creation and/or enhanced access to places for physical activity combined with informational outreach activities • Community-scale urban design/land-use policies & practices • Street-scale urban design/land-use policies and practices http://www.thecommunityguide.org

8. Which community physical activity interventions have insufficient evidence? • Classroom-based health education focused on information provision • Mass media campaigns • Health education w/ TV/video game turnoff component • College-age physical education/health education • Family-based social support http://www.thecommunityguide.org

9. School Strategies with Good Evidence • Implementation of a comprehensive food policy • Large food subsidies (> 50% cost reductions) • Multiple nutrition education activities with integrated curriculum including parent/family outreach • Improved physical education • Enhanced playgrounds • After-school programming • Multi-level comprehensive strategies http://www.cnr.berkeley.edu/cwh

10. A Community Intervention Reduces BMI z-score in Children: Shape Up Somerville First Year Results • A non-randomized controlled trial was conducted in three culturally diverse urban cities in Massachusetts. • Children (n = 1178) in grades 1 to 3 attending public elementary schools participated in an intervention • Focused on the before-, during-, afterschool, home, and community environments. Obesity Vol. 15 No. 5 May 2007 Pages 1325 - 1336

11. Shape Up Somerville First Year Results • At baseline, 44% (n = 385), 36% (n = 561), and 43% (n = 232) of children were above the 85th percentile for BMI z-score in the intervention and the two control communities, respectively. • In the intervention community BMI z-score decreased by -0.1005 (p = 0.001) compared with children in the control communities after controlling for baseline covariates. • A community-based environmental change intervention decreased BMI z-score in children at high risk for obesity.

12. Shape Up Somerville First Year Results Before School • Breakfast program • Walk to school campaign During School • Professional development for all school staff • School food service improvements • SUS classroom curriculum • Enhanced recess • School wellness policies

13. Shape Up Somerville First Year Results After School • SUS after-school curriculum • Professional development for program staff • Walk from school campaign Home • Parent outreach and education • Family events • Parent nutrition forums • Child’s “Health Report Card” mailed each year

14. Shape Up Somerville First Year Results Community • SUS Community Advisory Council • Ethnic-minority group collaborations • Support from local “community champions” • Walking/pedestrian training • City employee wellness campaign • “Farmers Market” initiative • SUS “approved” restaurants • City ordinances on walkability/bikeability • Annual SUS 5 K Family Fitness Fair • Regular local media placement • Resource guides • Local physician and clinic staff training

15. Physical Activity, Obesity and Safety • Access to safe parks helps increase physical activity among teenagers • Neighborhood safety ratings were independently associated with a higher risk of obesity at the age of 7 years • Public health efforts may benefit from policies directed toward improving both actual and perceived neighborhood safety UCLA – Health Policy Research Brief December 2005 (CHIS 2003) Arch Pediatr Adolesc Med. January 2006;160:25-31

16. Effective Speaking Techniques

17. Physicians for Healthy Communities Toolkit • Speaker Bureau Basics • Key Messages • Working with Schools • Grassroots Advocacy and Obesity Prevention • Research Articles • Forms • Resources http://www.calmedfoundation.org/projects/phyChampion.aspx

18. Effective Speaking Tips • Adapt your presentation to meet the needs of your audience • Practice… especially the beginning and end of your talk • Ask for audience participation “What are your ideas on how to get kids to eat healthier or be more active?” • Relax, use a conversational tone and have fun • Use powerful stories to convey your message • Use humor carefully, it is safest to joke about yourself • Expect tough questions and challenges • Acknowledge controversies and concerns • Redirect to other questions

19. Health Professionals as Advocates • Introduce yourself • Name, credentials, specialty, years of experience • Professional organizations if applicable • Thank the audience and organizers • Use examples from your practice to highlight your point of view • Be an expert: memorize key talking points • Use data and research to improve your credibility • Use the simplest (low-literacy) words possible, avoid jargon • Be confident but not overconfident

20. Organizing Your Talk • Introduction • Opening - Point of View • Key Point #1 - The Problem • Key Point #2 - The Solution • Key Point #3 - The Benefits • Closing - Reinforce Point of View

21. Organizing Your Talk • Opening • Use storytelling to convey your point • State what you are advocating for or state the conclusion • Key Point #1 - The Problem • Define the problem • Tailor the message to match the audience using community or race/ethnicity data • Key Point #2 - The Solution • Ask audience for their ideas for solutions • Give proposed solutions tailored to the audience/community

22. Organizing Your Talk • Key Point #3 - The Benefits • What’s in it for me? • Give proposed benefits tailored to the audience/community • Closing • Re-state what you are advocating for • Use storytelling to reinforce your recommendation and improve self-efficacy

23. Storytelling • Is personal, emotional and memorable • Can prove your point • Complements the use of evidence and data • Can be drawn from your personal or clinical experience • Types of Stories • Illustrating the problem • Overcoming challenges and solutions • Philosophy, mission or vision

24. Visual Aids • Visual aids can illustrate your point and create a more memorable presentation • Photos • Videos • Props • Examples of amount of sugar or fat content • Portion sizes Because of a lack of sidewalks and an adequate bike lane, the residents have to put their own signs out for the safety of their families and their children walk in the street with the risk of suffering an accident.

25. Methods of Communication • Legislators • Letter or E Mail • Phone Call • Visit or Meeting • Testify at a Legislative Hearing • School Board • Letters • Presentation at School Board • Using Media • Newspaper Articles or Editorials • Radio and TV • Community Education and Health Promotion

26. Key Messages • Since the 1970’s the number of obese children in the U.S. has tripled. • I think we’re looking at a first generation of children who may live less long than their parents as a result of the consequences of overweight and type 2 diabetes. • Once rare in children, Type 2 Diabetes is now 32% of new cases, a 10 fold increase from 1982-1994. • Health care for obese individuals costs an average of 37% more than for people of normal weight, adding an average of $732 to the annual medical bills of every American.

27. Tailoring Key Messages - What is in it for me? • Every audience has different knowledge, priorities and expectations • Example: School Principal • There is a considerable amount of evidence that improving nutrition and fitness is associated with improved academic performance in children. • Improving nutrition and fitness should increase school revenues. Severely overweight children miss four times as much school as normal-weight kids. If such health problems keep children out of school just one day per month, this could cost a large school district like Los Angeles about $15 million each year.

28. Finding Information and Research • U.C. Berkeley Center for Weight and Health http://www.cnr.berkeley.edu/cwh • Centers for Disease Control and Prevention http://www.cdc.gov/ • Institute of Medicine http://www.iom.edu • Guide to Community Preventive Services http://www.thecommunityguide.org • E. N. A. C. T. http://www.preventioninstitute.org/ • Childhood Obesity Action Network http://wwwNICHQ.org

29. Finding Data Sources • California Health Interview Survey (CHIS) • Overweight & Chronic Conditions • Health Behaviors • Adults and Children • http://www.chis.ucla.edu • Center for Public Health Advocacy • Overweight & Fitness • Children in 5th, 7th & 9th Grades • http://www.publichealthadvocacy.org

30. Childhood Obesity Action Network State Fact Sheets

32. Working with the Media • Media: Must Do... • Your homework - know your key points and media format • Practice delivering your introduction, message and presentation • Dress professionally and maintain eye contact with the host • Stay on message, insert your key points or story within the context of their questions • Media: Must Do Not… • Assume the reporter knows the subject • Ever tell a lie, provide incorrect data or stretch the truth • Try to cover too many subjects, ramble or use jargon • Become defensive or argumentative with a reporter Policy Link - www.policylink.org

33. Working with Schools • Identify a site champion • Identify the academic goals • Tailor your talk to meet the needs and cognitive ability of the children • Make contact with the school principal • Organize your presentation • Visual aids – fat, sugar , portion sizes • Video – “Supersize Me” • School Presentation Toolkit

34. Health Professional Advocacy

35. The Role of Health Professionals in Community Advocacy JAMA January 7, 2004 - Vol. 291, No. 1 pp. 94-98 • Provide quality care to individual patients in regular practice. • Improve the system of care delivered by group/organization. • Provide quality care to uninsured patients. • Improve insurance coverage, after-hours care and geographic distribution of services. • Environmental change in local schools and communities to address tobacco, injury prevention, and obesity. • Public policy to address same issues.

36. Public Roles of US Physicians • Mailed survey of 1,662 US physicians in 2003-2004 • Results • Over 90% rated community participation and political involvement as important • 54% had participated in a community event in the last 3 years • Nutrition, immunization, substance abuse and road safety issues were rated as very important • Older age, women, minorities and foreign medical graduates were more likely to rate advocacy as important JAMA 2006;296;2467-2475

37. Doctors Make Particularly Good Advocates • Polling information indicates that doctors are particularly effective messengers on obesity prevention issues. • People trust doctors because of their expertise and because they believe doctors do not have ulterior motives. • Doctors can use the unique respect they inspire to draw attention to the obesity epidemic. • Doctors‘ status in society makes them appealing to the media as authoritative spokespeople. The very presence of a doctor can attract reporters to an issue or event such as a press conference.

38. The Role of Health Professionals in Community Interventions and Advocacy • Subject matter expertise and credibility • Participation in community collaborative activities • Consultation and advocacy on policy recommendations and legislation • Presentations to government, school boards, teachers, parents and students • Training community health professionals • Media interventions Pediatrics Vol. 112 No. 4 October 2003, pp. e328-346 Pediatrics Vol. 115 No. 4 April 2005, pp. 1142-1147

39. Advocacy Overview • Advocacy • Identifying an issue • Drawing attention to the issue • Working towards a solution • Lobbying • Is a subset of advocacy which promotes or opposes specific legislation, political candidates, or ballot initiatives • Often government or foundation funds will not support lobbying activities Policy Link - www.policylink.org

40. Steps to Advocacy • Organizing and coalition building • Finding information/research • Policy and strategy development • Mobilizing and communications Policy Link - www.policylink.org

41. Step 1 - Organization and Coalition Building Effective Coalitions: The 8-Step Process • Analyze program objectives, determine whether to form a coalition • Recruit the right people • Devise preliminary objectives and activities • Convene the coalition • Anticipate necessary resources • Develop a successful structure • Maintain coalition vitality • Improve through evaluation Prevention Institute - www.preventioninstitute.org

42. Step 2 - Finding Information and Research • Why • To help understand the issues • To help identify priorities • To help make your argument • What • Accessible, credible, clear • Data and stories “Removing soda from school won’t help me lose weight. The only exercise I ever get is walking upstairs to this vending machine.” Policy Link - www.policylink.org

43. Step 3 - Policy and Strategy Development • Identifying targets, opposition and tactics • Primary targets: the people who have the power to give you what you want • Secondary targets: the people who can influence the primary targets (media) • Who has the power to organize an effective opposition? • Pick an action you believe has some chance of success • Know your priorities and the bottom line • The Problem • What issue will be your focus? • Is it big enough? Is it small enough? • The Solution • How much can you ask for? • The Process • The Players • Allies and opponents • Power mapping - strength of opposition or support

44. Step 4 - Mobilizing and Communications • Outreach Directly to Policymakers • Letters, phone calls, e-mails to decision-makers • Meet with decision-makers and/or their staff • Testify before a committee • Reach People Who Can Influence Policymakers • Outreach to other organizations for support • Educate the public through strategic events and media coverage • Produce fact sheets or reports • Protests and grassroots activities Policy Link - www.policylink.org

45. Legislative Process The Legislature maintains a legislative calendar governing the introduction and processing of the legislative measures during its two-year regular session.

46. State, County and Local Government Structure • Policies and built environment can be addressed at the State, County and City level. • Planning commissions can play a major role in land use and transportation issues.

47. School System Structure • Your first step as a school advocate is to send a letter to the school district’s school board. • Speaking to the School Board • Call the district’s board office and request to be placed on the agenda with an explanation of your subject matter. • Request to be placed on the next board meeting agenda after speaking during the three minute public comment time at a public board meeting.

48. Qualities of an Effective Health Professional Advocate • Has an important, relevant, personal or professional story to tell • Knows the facts (data) and where to find them • Leverages expertise—theirs and others‘ • Networks—with other advocates and with decision-makers • Is consistent and persistent • Is cooperative, courteous, and positive • Is solutions-oriented • Pays attention—to others, to the field, to policy developments, and to timing

49. Steps to Effective Health Professional Advocacy • Identify and understand the issue • Get the data • Partner and collaborate • Frame your message • Be descriptive • Propose solutions • Know your audience and tailor the messages for them • Leverage your expertise as a doctor • Choose your method(s) of communication

50. Physicians for Healthy Communities Advocacy & Obesity Toolkit • Sample Letter to Your Legislator • Phone Script for Calling a Policymaker • Tips for Planning Your Meeting with a Policymaker • How to Testify at Legislative Hearings • Sample Legislative/Committee Testimony • Introductory Letter to School Board • Guidelines for Full Presentation at a School Board Meeting • Using the Three Minute Public Comment Period • Sample Script: Three Minute Public Comment http://www.calmedfoundation.org/projects/phyChampion.aspx