INTRODUCTION

The prevalence of overweight and obesity in children is rapidly increasing in the United States. Recent estimates suggest that 17% of children aged 2–19 years are overweight (defined by having a body mass index at or above the 95th percentile for US children of same sex and age) (1). As childhood obesity continues to climb, researchers, public health practitioners, and policymakers seek effective means of improving energy balance (i.e., calories consumed equal to calories expended) and reducing the prevalence of obesity among youth in the United States. Although solutions are multifaceted, the utility of policy interventions to address rising obesity trends is widely touted by researchers (2, 3, 4). In particular, policies hold potential because of their ability to expand upon individual effects to influence entire populations. In this way, they might offer one of the most efficient means of improving and protecting public health (3, 5, 6).

Individual states retain much of the power to influence policies and regulations in the United States (7). Through legislative and regulatory actions, state governments are able to wield substantial power over specific actions that affect public health (7). In recent years, many state laws and regulations focusing on childhood obesity have been introduced. For example, between 2003 and 2005, over 230 pieces of legislation addressing school nutrition standards and vending machines, and over 190 addressing physical education and physical activity, were introduced at the state level (8). Table 1 provides a sample typology of common types of state legislation related to childhood obesity that have been recently introduced.

Table 1 - Common childhood obesity prevention legislation topic areas and potential stakeholders.

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In 2006, Schmid et al. proposed a framework for physical activity policy research that provides a useful means of conceptualizing policy research in general (4). Specifically, the framework suggests that researchers (1) identify policies, (2) examine determinants of policies, (3) study the development and implementation of policies, and (4) evaluate outcomes of policies. Previous work, which addressed the first two phases of this framework, described patterns in childhood obesity prevention legislation and used quantitative methods to identify several determinants of enacting legislation, such as bipartisan sponsorship, introduction in the senate, and amendments to existing bills, as well as state-level factors such as a 2-year legislative session and Democratic control of both legislative chambers (8, 9). Building on those efforts, this paper focuses on the second and third phases of the framework and relies upon qualitative research methods to further explore the determinants and development of legislation to prevent childhood obesity.

The process of policy formation is complex and poorly understood by researchers (10, 11). Because of this gap and the rich information about the political process potentially available through conversations with policymakers, this study utilized key-informant interviews (12). Key informants included both legislators and staffers. Legislative staffers often have a great deal of influence in forming the priorities of an elected official. This influence is observed in three key, interrelated areas: gathering information, setting the agenda, and crafting the specific legislative proposals (13). According to Kingdon, the policy process comprises three primary streams: problems, policies, and politics (14). The study of these streams and their participants may help researchers understand, communicate, and collaborate with policymakers.

This study sought to use lessons learned from state policymakers to improve understanding of the link between public health research and policy, and to inform the development and passage of future policies aiming to reduce the prevalence of childhood obesity.

METHODS

The research team conducted key-informant interviews among state-level policymakers representing a variety of political climates. States were selected with consideration of geographic location, adult obesity prevalence, and dominant political party during 2003–2005. Within states, leaders in obesity policy were identified by their history of introducing or sponsoring legislation related to childhood obesity prevention. A goal of 10–20 completed interviews was set to achieve content saturation (i.e., when similar comments are consistently repeated by key informants).

Trained interviewers conducted key-informant interviews by initially contacting legislators' staff via telephone, explaining the research project, and requesting an appointment during which the interviewer might speak with the legislator or staffer for approximately 20 min. Interviewers made at least three attempts to reach each participant. The purpose of a key-informant interview is to obtain descriptive data in an informal manner, often through a conversation between one respondent and one interviewer. The respondent typically has special knowledge or insight that may assist researchers in understanding information or observations in unfamiliar settings. Frequently, respondents are expected to respond to previously determined, structured, open-ended questions (15). The interviewers used a script to conduct one-on-one, semi-structured telephone interviews that included three demographic questions regarding the legislators' educational backgrounds and legislative responsibilities, followed by eight open-ended questions regarding their experience with childhood obesity legislation (16). The research team designed and revised the interview questions to meet the study objectives.

Interviews were completed between December 2005 and April 2006. Interviewers received oral consent from participants to tape record all interviews. The average interview administration time was 26 min (range, 17–60 min). All tape recordings were transcribed verbatim. Two independent coders then systematically analyzed the transcripts using focused coding qualitative techniques (17). This use of focused coding enabled coders to analyze transcripts using the same set of thematic categories (Table 2). The research team predetermined these categories in accordance with primary research aims. To ensure accuracy, a subsample of coding was conducted in duplicate (n=6). Only minimal discrepancies in coding were discovered; these were easily resolved, resulting in high inter-rater agreement (86%) (18).

Table 2 - In the words of policymakers: Primary factors affecting the passage of state-level legislation to prevent childhood obesity.

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RESULTS

Of 48 interview attempts, 16 were successfully completed with policymakers representing 11 states (Arkansas, California, Connecticut, Illinois, Maine, Massachusetts, Nevada, New Hampshire, South Carolina, Texas, and Washington). As designed, the states varied by political party (six Democratic, three Republican, and three split party), obesity prevalence (four low, four mid, and three high by tertiles), and geographic region (three West, one Midwest, three South, and four Northeast). Among the 16 participants, there were six staffers and 10 legislators; 80% were members of the Democratic Party. Approximately 20% of participants reported a formal health-related educational background; law and education were the most common. Participants reported working in or with the state legislature for a median of 12 years (range, 4–21 years).

Participants described a variety of legislative responsibilities and committee affiliations. Six participants indicated service with Health and Human Service Committees, and four legislators reported serving as Chair of this committee in their states. Three participants served on Public Health committees, one of whom was Chair. Two participants served on Judiciary Committees, and six reported service to various education committees, including several K-12 subcommittees.

The following results of the focused coding analysis are organized according to the primary themes of the key-informant interviews. Even with a modest number of informants, the responses were sufficient to identify common themes, which are presented in order of the frequency with which they were mentioned. Quotations from participants are also included where appropriate (Table 2).

Enablers

To introduce a discussion about enablers, participants were asked, "In your view, what factors support or facilitate the introduction and adoption of childhood obesity prevention legislation?" All 16 participants cited gaining the support or involvement of stakeholders to participate in the process of considering, drafting, and adopting childhood obesity prevention legislation as a significant enabler (Table 2). Specifically, participants described working with parents, physicians, schools, community members, and health departments to address childhood obesity successfully through legislation.

The next most commonly cited enabler was national media exposure of the issue. This was closely followed by the importance of timing in the introduction of legislation. Specifically, many cited the considerable role of the political climate (e.g., majority party, committee assignment, legislature's relationship with state agencies) in determining how legislative efforts are received by governing bodies. Finally, three participants mentioned the advantages that accompany childhood obesity prevention legislation when it is introduced by senior legislators, as well as by legislators with a strong personal interest who are willing to work creatively to address the problem of childhood obesity.

Barriers

Similarly, participants were invited to discuss barriers with the question, "In your view, what factors oppose or inhibit the introduction and adoption of childhood obesity prevention legislation?" Over half of participants discussed the difficulties posed by powerful lobbyists representing manufacturers of unhealthy foods and beverages (Table 2). The second most commonly cited barrier was misinformed constituents. Specifically, participants discussed the pervasive fears and misconceptions in many schools regarding negative outcomes of legislating school foods and altering school vending machine practices. Many participants described the importance of educating constituents about the benefits of legislation designed to prevent or reduce childhood obesity. Six participants also named cost as a barrier, referring specifically to costs related to school and community programs. However, one respondent noted that in the case of childhood obesity prevention, all concerned parties stand to gain when successful measures are taken.

Incremental vs. comprehensive bills

Another question posed to key informants was, "Do you think obesity legislation is more likely to progress through (1) a series of several incremental bills or (2) a few comprehensive bills?" Of those who answered this question, 73% stated their belief that legislation is much more likely to pass through incremental efforts. One respondent noted, "I think incrementalism is the name of the game here in the legislature, given our fiscal constraints." Only a few interviewees answered in favor of comprehensive bills, and of these, most described a comprehensive bill that provided for an incremental phase-in of proposed changes.

DISCUSSION

This paper describes factors commonly cited by legislators and staffers that enable or impede the enactment of childhood obesity prevention legislation at the state level. Some identified factors are familiar and can be applied to legislative efforts on a variety of issues (Table 1). For example, it is already known that cost is a concern prevalent in most legislative decision making, that garnering stakeholder support for new initiatives is vital for long-term success and sustainability, and that the political climate is important but often not modifiable (3, 8). However, some factors presented are unique to legislative efforts related to childhood obesity prevention. Moreover, some of these factors are modifiable and thus present clear opportunities for intervention. The qualitative data presented in this paper are useful in "triangulation" of findings (i.e., accumulation of evidence from a variety of sources to gain insight into a particular topic) from two previous quantitative studies (8, 9).

After lobbyists, the most commonly cited barrier to passing childhood obesity prevention legislation in states was the problem of misinformed constituents. Legislators and staffers repeatedly described how parents and school administrators opposed initiatives involving school vending machines. They explained how concerned citizens could inadvertently oppose promising legislation due to a poor understanding of the issues, the persuasive arguments of lobbyists, and fears of how local schools could suffer. Improving public education about such topics can both help constituents become informed voters as well as positively influence the public will (19). This, in turn, can dramatically affect political will and policy decisions. Therefore, efforts should be aimed at debunking myths and educating constituents, schools, and stakeholders about the problem of childhood obesity and possible policy solutions.

Other opportunities to conquer barriers and build upon those existing enablers mentioned by study participants include training community advocates to use the media, utilizing well-respected champions of the cause, advocating for issues incrementally, and learning from other areas that have seen success through policy interventions (e.g., tobacco policy) 3, 20, 21, 22). Because of the vital role of an integrated media campaign in any social change movement, childhood obesity prevention efforts must include building media coverage, especially at the local level (20). Similar to media exposure, having a well-respected individual advocate for childhood obesity prevention legislation can raise awareness about the issue and elicit support from a variety of people. Such individuals can be highly committed legislators (as mentioned by study participants), celebrities, or local leaders. In combination with these efforts, policymakers and advocates should remember the advantages of introducing policy changes incrementally, perhaps through budget bills or as amendments (9). Finally, successful policy movements, such as those addressing tobacco use, should be scrutinized for methods that can be applied to childhood obesity prevention efforts (21, 22).

Two study limitations deserve mention. Although the research team sought political and geographic diversity in states selected for study, coverage was not complete. Thus, the generalizability (i.e., external validity) of these findings and recommendations are limited to states with similar political climates. This is a general weakness in the childhood obesity literature (23). Also, the political climate is different in each state, and is ever-changing, depending on current local, state, national, and international events. Therefore, application of study findings should consider state-specific characteristics.

Within states, legislators and staffers were selected because of their prior work in childhood obesity prevention. This resulted in a majority of participants representing the Democratic Party. Further, the research team did not solicit information from legislators with opposing views or from key stakeholders (e.g., school administrators, parents, food vendors) affected by policy implementation. Thus, a broader perspective of viewpoints should be addressed in future studies.

Important next steps in the arena of childhood obesity prevention include building the evidence base for childhood obesity policy (24), and developing and understanding existing practice-based evidence. Researchers should use prospective studies to examine the effects of specific types of bills and content areas that actually affect population health when implemented appropriately (9). Surveillance systems should be developed to facilitate identification, monitoring, and evaluation of relevant policies. Finally, researchers should note that many legislators serving as Chairs of Health and Human Service Committees commonly lack formal public health or scientific training (backgrounds in law and education were most commonly cited in this study). Thus, concerted efforts should be made to translate relevant scientific evidence clearly for policymakers.

State-level policy holds promise in childhood obesity prevention. This study provides policymakers and practitioners with a set of enablers and barriers that should be considered when pursuing state-level policy enactment. In conclusion, it draws on relevant policy literature to suggest specific recommendations for those considering the introduction of childhood obesity prevention legislation (Table 3).

Table 3 - Recommendations for addressing childhood obesity through policy (3, 25, 26, 27).

Full table

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Acknowledgements

We are grateful for the contributions of Mariah Dreisinger and Hannalori Bates from St. Louis University School of Public Health and Dr. Tracy Orleans from the Robert Wood Johnson Foundation. Funding for this project was provided by the Robert Wood Johnson Foundation (Grant #053630) and the Centers for Disease Control and Prevention contract U48/DP000060 (Prevention Research Centers Program). Research was conducted at St. Louis University School of Public Health, St. Louis, Missouri, United States.

About the Authors

Elizabeth A. Dodson, Ph.D., M.P.H. is a Program Manager at the Prevention Research Center in St. Louis, George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA. E-mail: edodson@wustl.edu.

Chris Fleming, M.P.H. is a Policy Analyst with Mathematica Policy Research, Inc., Washington, DC, USA. E-mail: cflem17@yahoo.com.

Tegan K. Boehmer, Ph.D., M.P.H. is an Epidemiologist with the National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA. E-mail: tboehmer@cdc.gov.

Debra Haire-Joshu, Ph.D., is a Professor and Director at the Obesity Prevention and Policy Research Center, George Warren Brown School of Social Work and School of Medicine, Washington University in St. Louis, St. Louis, MO, USA. E-mail: djoshu@wustl.edu.

Douglas A. Luke, Ph.D., is a Professor and Director at the Center for Tobacco Policy Research, George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA. E-mail: dluke@wustl.edu.

Ross C. Brownson, Ph.D., is a Professor of Epidemiology, and Co-Director at the Prevention Research Center in St. Louis, George Warren Brown School of Social Work, Department of Surgery and Siteman Cancer Center, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA. E-mail: rbrownson@wustl.edu.