Childhood obesity government policy

Directly to directly to a to z directly to directly to page directly to site ight and obesity policy end on c disease state policy tracking database currently contains state-level legislation and regulation pertaining to nutrition, physical activity and obesity. It allows users to conduct searches by state, year, bill number, status, and health care and education policy review [pdf-4. Considers early care and education (ece) an important setting to implement childhood obesity prevention strategies. This policy review is intended to help educate public health practitioners, child care providers, and decision-makers about the current conditions that exist in their state and inform future efforts to prevent obesity in this setting. The report identifies potential actions in ece programs to prevent obesity, provides state-specific child care demographics, and highlights enacted state legislation and current licensing regulation that impact the nutrition and physical activity environments in ece y communities: what local governments can do to reduce and prevent obesity[ppt-8. Presentation, developed for use by local government staff, makes the case for investing in cdc's recommended community strategies and measurements to prevent obesity in the united states. It highlights how local governments can be part of the solution and provides specific examples of policy, systems and environmental approaches to creating healthier communities. Powerpoint last reviewed: august 19, last updated: august 19, on of nutrition, physical activity, and obesity, national center for chronic disease prevention and health ss in preventing childhood obesity: how do we measure up? Serves several vital functions in a national public health crisis such as the childhood obesity epidemic. First and foremost the government provides leadership, which it demonstrates by making the response to the obesity epidemic an urgent public health priority and coordinating the public- and private-sector response. Other necessary elements of an adequate government response to the obesity epidemic are a strong governmental workforce, an enhanced organizational capacity, and a robust information-gathering system to monitor progress and guide programs and policies (baker et al. Another key governmental function at the federal, state, and local levels is to improve the health status of the population and reduce inequities in health status among population groups (health canada, 2001; iom, 2003). Responding to the obesity epidemic, federal, state, and local government agencies across the nation share in the core public health responsibilities listed in box 4-1 (iom, 1988, 2003; naccho, 2005). Research and technical assistance for implementing, evaluating, and achieving national and regional objectives are primarily the responsibilities of the federal government, whereas program planning, implementation, and evaluation are state and local government responsibilities in partnership with other sectors (tfah, 2006). Major recommendations in the health in the balance report were that “government at all levels should provide coordinated leadership for ted citation:"4 government. Health mission and government n: the mission of public health is to fulfill society’s interest in ensuring the existence of conditions in which people can be functions: all levels of government are responsible for conducting health assessments, health policy development, and the assurance of health. State government is the central force in public health and is the public-sector entity that bears primary responsibility for l government t knowledge development and dissemination through data collection, research, and information ish national objectives and priorities on interstate and national health e technical assistance to support states and localities in determining objectives and carrying out actions on national and regional e funds to states to strengthen their capacity for services to achieve adequate minimum health services and achieve national health that its actions and services are in the interest of the entire nation, as in the case of epidemics, interstate environmental actions, and food and drug government t health assessments based on statewide an adequate statutory base for health activities in the ish health objectives, delegate responsibilities, and hold local governments tion of obesity in children and youth” and an “increased level and sustained commitment of federal and state funds and resources are needed” to sufficiently address the childhood obesity epidemic. Additionally, the report recommended that state and local government should “provide coordinated leadership and support for childhood obesity efforts, particularly for populations at high risk of childhood obesity, by increasing resources and strengthening policies that promote opportunities for physical activity and healthful eating” (iom, 2005a, p. Of the efforts that have already been implemented by federal, state, and local governments play an essential role in the response to childhood obesity in the united states. Organized statewide efforts for personal, educational, and environmental health; provide access to health services; and solve health tee the availability of a minimum set of health care t local health care service capacity, especially when disparities in local abilities exist with fiscal, administrative, technical capacity, and direct government , monitor, and provide surveillance for local health problems and resources with consideration of physical, behavioral, environmental, social, and economic t, investigate, minimize, and contain adverse health compliance with public health laws and planning and response for public health p policy and leadership to engage the community, ensure the equitable distribution of public resources, and develop public-private partnerships to deliver activities commensurate with community ent health promotion nate public health system efforts in an intentional, noncompetitive, and nonduplicative s health that high-quality services for the protection of public health, including personal health care, are accessible to all people; that the community receives proper consideration in the allocation of federal, state, and local resources for public health; and that the community and media are informed about how to obtain public health as a resource to local governing bodies, policy makers, community-based organizations, other governmental agencies, entities engaged in public health issues, and s: adapted from iom (1988, 2003); naccho (2005). With the potential to reverse the childhood obesity epidemic is vast, dynamic, and difficult to track systematically over time. Government can play a special role by augmenting its own capacity in such a way that it stimulates and enhances the capacities and activities of other sectors of society. In order to continue to focus attention on the childhood obesity epidemic and encourage sustained efforts from all sectors of society, government will need to consistently acknowledge the importance of preventing childhood addition to implementing and sustaining new programs, governmental agencies at all levels need to reexamine their existing policies and initia-. Agricultural policies including marketing practices, nutrition standards, agricultural subsidies, and procurement policies for agricultural commodity programs that affect the types and quantities of foods and beverages available in schools, communities, and through federal food assistance programs; land use policies that do not encourage mixed use of residential and business space and that subsequently discourage walking to neighborhood stores or businesses; and school policies that shorten the length of time in the school day devoted to healthy school meals and physical chapter provides an overview of the role of government at all levels in the response to the childhood obesity epidemic. It provides examples of the policies, programs, and activities undertaken by federal, state, and local governmental agencies to reverse the current obesity epidemic and prevent a future rise in childhood obesity rates. The chapter examines the approaches needed to effectively evaluate policies and interventions and explores the factors that constitute success for the governmental sector. The chapter also recommends next steps in assessing progress with regard to leadership; implementing and evaluating policies and interventions and developing evaluation capacity; enhancing surveillance, monitoring, and research efforts; and using and disseminating the evidence from evaluation severity of the obesity epidemic in the united states was first observed and publicized with data from the behavioral risk factor surveillance system (brfss). In 1991, brfss data showed that four states had adult obesity prevalence rates of 15 to 19 percent and that no states had rates of 20 percent or greater. By 2004, brfss showed that 7 states had adult obesity prevalence rates of 15 to19 percent, 33 states had adult obesity rates of 20 to 24 percent, and 9 states had adult obesity rates of 25 percent or greater (cdc, 2005a). National health and nutrition examination survey (nhanes), a cdc surveillance system that is based on personal interviews and a physical examination and that was initiated in 1971, also revealed a rapidly evolving obesity epidemic in children, adolescents, and adults (flegal et al.

These data, coupled with evidence that obesity is not merely a cosmetic issue but leads to an array of serious health problems and comorbidities (williams et al. Surgeon general issued the surgeon general’s call to action to prevent and decrease overweight and obesity to stimulate the development of specific agendas and actions targeting this growing public health problem (dhhs, 2001). 2002, the institute of medicine (iom) undertook a congressionally mandated study to develop a blueprint for a comprehensive action plan that is summarized in the report, preventing childhood obesity: health in the balance (iom, 2005a). The recommendations from that report focused on the actions needed by multiple stakeholders; the report called on government at all levels to take a leadership role and to bring resources to bear on this important health concern. The present iom committee recommends increased efforts to address the government recommendations of the health in the balance report (boxes 4-2 to 4-4) and to incorporate an evaluation component into all policies, programs, and explore the breadth of childhood obesity prevention activities currently under way in the government sector—and whether and how they are being evaluated—the committee reviewed and drew information from a variety of sources, including those described in chapter 1, as well as information and data from federal and state government surveillance and reporting systems, reports, and websites and from interviews conducted with selected state health officials; federal regulatory agencies; and federal representatives of the health, agriculture, and education sectors. A complete and systematic inventory of federal, state, and local government policies, programs, and activities relevant to childhood obesity prevention was beyond the charge of the committee and the scope of this progress report. However, a selected list of recent federal agency programs, initiatives, and surveillance systems relevant to childhood obesity prevention is compiled in appendix federal government has a responsibility to address public health crises including the childhood obesity epidemic through ensuring sufficient capacity to provide essential public health services; responding when a health threat is apparent across the entire country, region, or many states; providing assistance when the responses are beyond the jurisdictions of individual states; helping to formulate the public health goals of state ted citation:"4 government. For federal, state, and local government from the 2005 iom report preventing childhood obesity: health in the ment at all levels should provide coordinated leadership for the prevention of obesity in children and youth. An increased level and a sustained commitment of federal and state funds and resources are implement this recommendation, the federal government should:Strengthen research and program efforts addressing obesity prevention, with a focus on experimental behavioral research and community-based intervention research and on the rigorous evaluation of the effectiveness, cost-effectiveness, sustainability, and scaling up of prevention t extensive program and research efforts to prevent childhood obesity in high-risk populations with health disparities, with a focus on both behavioral and environmental t nutrition and physical activity grant programs, particularly in states with the highest prevalence of childhood then support for relevant surveillance and monitoring efforts, particularly the national health and nutrition examination survey (nhanes). An independent assessment of federal nutrition assistance programs and agricultural policies to ensure that they promote healthful dietary intake and physical activity levels for all children and p and evaluate pilot programs within the nutrition assistance programs that would promote healthful dietary intake and physical activity and scale up those found to be implement this recommendation, state and local governments should:Provide coordinated leadership and support for childhood obesity prevention efforts, particularly those focused on high-risk populations, by increasing resources and strengthening policies that promote opportunities for physical activity and healthful eating in communities, neighborhoods, and t public health agencies and community coalitions in their collaborative efforts to promote and evaluate obesity prevention governments, public health agencies, schools, and community organizations should collaboratively develop and promote programs that encourage healthful eating behaviors and regular physical activity, particularly for populations at high risk of childhood obesity. Community coalitions should be formed to facilitate and promote crosscutting programs and communitywide ted citation:"4 government. Department of health and human services from the 2005 iom report preventing childhood obesity: health in the ising and ry should develop and strictly adhere to marketing and advertising guidelines that minimize the risk of obesity in children and implement this recommendation:The secretary of the u. Department of health and human services should develop, implement, and evaluate a long-term national multimedia and public relations campaign focused on obesity prevention in children and implement this recommendation:The campaign should be developed in coordination with other federal departments and agencies and with input from independent experts to focus on building support for policy changes, providing information to parents, and providing information to children and youth. Rigorous evaluation should be a critical rcing messages should be provided in diverse media and effectively coordinated with other events and dissemination media should incorporate obesity issues into its content, including the promotion of positive role ion labeling should be clear and useful so that parents and youth can make informed product comparisons and decisions to achieve and maintain energy balance at a healthy implement this recommendation:The food and drug administration should revise the nutrition facts panel to prominently display the total calorie content for items typically consumed at one eating occasion in addition to the standardized calorie serving and the percent daily food and drug administration should examine ways to allow greater flexibility in the use of evidence-based nutrient and health claims regarding the link between the nutritional properties or biological effects of foods and a reduced risk of obesity and related chronic u. Department of transportation should:Fund community-based research to examine the impact of changes to the built environment on the levels of physical activity in the relevant communities and ted citation:"4 government. For other relevant federal agencies recommendations from the 2005 iom report preventing childhood obesity: health in the balance. Department of transportation community-based research to examine the impact of changes to the built environment on the levels of physical activity in the relevant communities and l trade commissionadvertising and ry should develop and strictly adhere to marketing and advertising guidelines that minimize the risk of obesity in children and implement this recommendation:The federal trade commission should have the authority and resources to monitor compliance with food and beverage and sedentary entertainment advertising practices. Department of agriculture, state and local authorities, and schools p and implement nutritional standards for all competitive foods and beverages sold or served in that all school meals meet the dietary guidelines for p, implement, and evaluate pilot programs to extend school meal funding in schools with a large percentage of children at high risk of ted citation:"4 government. Governments; and assisting states when they lack resources or expertise to adequately respond to a public health crisis (tfah, 2006). Examples of the federal agency programs, initiatives, and surveillance systems that support and monitor the prevention of obesity in u. It should be noted that this report is not a complete and systematic inventory of government programs and initiatives, as this was not the charge to the committee. Rather, the committee highlights some of the efforts that illustrate the key roles of government and that point to further work that can be done to increase the opportunities for children and youth to become more physically active and improve their eating patterns and ship is an essential function of the federal government as it determines the priorities for funding and brings its considerable resources to bear on the problem. Government leadership influences the actions of those working within the federal government and across other sectors. Food and drug administration (fda) should revise the nutrition facts panel on packaged food and beverage should allow industry to have greater flexibility to use evidence-based nutrient and health claims regarding the link ted citation:"4 government. Nutritional properties or the biological effects of foods and a reduced risk of obesity and related chronic should develop nutritional standards for competitive foods and beverages available in example of demonstrated federal leadership is an initial stakeholder workshop, jointly organized by ftc and dhhs, to develop guidelines for the advertising and marketing of foods, beverages, and sedentary entertainment to children and youth. In july 2005, ftc and dhhs held a joint workshop, marketing, self-regulation, and childhood obesity, that provided a forum for industry, academic, public health advocacy, and government stakeholders, as well as consumers, to examine the role of the private sector in addressing the rising childhood obesity rates. In april 2005, fda released two advance notices of proposed rulemaking to elicit stakeholder and public input about two recommendations of the fda obesity working group: the first action was to make calorie information more prominent on the nutrition facts label and the second action provides more information about serving sizes on packaged foods (fda, 2006). The iom committee awaits further progress that fda can make toward finalizing the rulemaking and exploring the use of evidence-based nutrient and health claims regarding the link between the nutritional properties or biological effects of foods and a reduced risk of obesity and related chronic efforts by usda and dhhs resulted in the release of the sixth edition of the dietary guidelines for americans 2005, which provide specific recommendations on the consumption of foods in different food groups, fats, carbohydrates, sodium and potassium, and alcoholic beverages; food safety; and physical activity (dhhs and usda, 2005). In 2004, congress initiated and passed the legislation, which requires school districts participating in the national school lunch program (nslp) or school breakfast program (sbp) to establish a local school wellness policy by the beginning of the 2006–2007 school year (cnwicra, 2004). The usda secretary, in coordination with the secretary of education and in consultation with the dhhs secretary, acting through cdc, are charged with providing technical assistance to establish healthy school nutrition environments, reducing childhood obesity, and preventing diet-related chronic diseases.

The act establishes a plan for measuring the implementation of the local school wellness policy, supported by $4 million in appropriated funds (cnwicra, 2004) (chapter 7). The study is in progress and when it is complete, the committee recommends that congress, usda, cdc, and other relevant agencies take expeditious action on developing national nutrition standards for competitive foods and beverages in federal government has also demonstrated leadership in setting specific goals for childhood obesity prevention. Dhhs incorporated into its strategic plan fy 2004–2009 an objective for the indian health service to decrease obesity rates among american indian/alaska native (ai/an) children by 10 percent during this 5-year period (dhhs, 2004). The committee noted that federal leadership fell short of an important recommendation in the health in the balance report, in that no progress was made toward the establishment of a presidentially appointed high-level task force to make childhood obesity prevention a national priority and to coordinate activities and budgets for this goal across federal agencies. Because childhood obesity prevention is a national priority that requires the collective efforts of many federal departments and agencies, ted citation:"4 government. Consistent with this consideration, substantial resources from a variety of federal government entities are designated for programs relevant to childhood obesity prevention. Throughout the country, the funding strategies that states and private partners use to support programs that promote healthy lifestyles and obesity prevention goals include making better use of existing resources, maximizing federal and state revenues, creating more flexibility in existing categorical funding, building public-private partnerships, and creating new dedicated revenue amount of federal support that the states receive varies substantially. Or competitive project grants, which target particular federal efforts such as obesity prevention, fund states on the basis of the merits of their grant applications, and are awarded for a specific time frame (e. Cdc’s nutrition and physical activity program to prevent obesity and other chronic diseases; usda’s special supplemental nutrition program for women, infants, and children [wic] and fresh fruit and vegetable program [ffvp]);. Assessing the overall progress in funding support for obesity prevention programs, however, it is important to ensure that double counting does not take place or that an increase in funding from one source (e. Of the numerous federally funded programs relevant to childhood obesity prevention, only a few are highlighted below or in subsequent chapters and appendix health in the balance report (iom, 2005a) recommended that the federal government undertake an independent assessment of federal nutrition assistance programs and agricultural policies to ensure that they promote healthful dietary intake and increase physical activity levels for all children and youth. The committee recommends that congress and usda expeditiously complete the revision of the contents of the wic food packages and thoroughly examine other relevant food and nutrition assistance programs so that they can be strengthened to fully address childhood obesity prevention goals and to monitor and evaluate relevant 1999, usda funded a childhood obesity prevention initiative called fit wic to support and evaluate social and environmental approaches to prevent and reduce obesity in preschool-aged children. Four state wic programs (california, kentucky, vermont, and virginia) and the inter-tribal council of arizona received funds for a 3-year period to identify ways in which the wic program could respond to the childhood obesity epidemic for program participants. However, the pilot program also found that parents demonstrated interest in receiving information on ways to promote healthy behaviors in their families, wic program staff requested information on effective methods to reach parents, and community groups expressed interest in working on the issue of childhood obesity prevention (usda, 2005b) (chapters 6 and 8). The committee encourages more extensive evaluations of the ffvp and dod fresh program that examine a variety of relevant outcomes to preventing childhood health in the balance report (iom, 2005a) recommended that dhhs develop, implement, and evaluate a long-term national multimedia and public relations campaign focused on obesity prevention in children and youth. Inherent in this recommendation was the need to develop a campaign, in coordination with other federal departments and agencies, and with input from independent experts to focus on building support for obesity prevention policy changes and providing information to parents as well as children and youth. The report emphasized the need for a rigorous evaluation to be a critical component of the campaign; that reinforcing messages be provided in diverse media and effectively coordinated with other events and dissemination activities; and that the media ted citation:"4 government. E evidence of success and widespread knowledge of the importance of physical activity in preventing childhood obesity, there was inadequate support in the administration and congress for continuing verb, and insufficient external support to encourage sustained funding. Over the 5-year period, the average cost of the verb campaign was $68 million/ted citation:"4 government. However, it was not included in the president’s fy 2006 budget and received no congressional support for continuation beyond fy 2006 because of competing policy priorities. The termination of an adequately funded, well-designed, and effective program to increase physical activity and combat childhood obesity calls into question the commitment to obesity prevention within government and by multiple stakeholders who could have supported the continuity of the verb ty building is a multidimensional process that improves the ability of individuals, groups, communities, organizations, and governments to meet their objectives or enhance performance to address population health. Health in the balance report recommended that the federal government support nutrition and physical activity grant programs, particularly in states with the highest prevalence of childhood obesity (iom, 2005a). Although specific definitions and measures of the capacities of federal, state, and local governments to adequately carry out the activities necessary to halt and reverse the childhood obesity epidemic are not readily available, the committee concluded that existing evidence suggests serious shortfalls. The health in the balance report recommended that the federal government should support ted citation:"4 government. Physical activity grant programs, particularly in states with the highest prevalence of childhood obesity (iom, 2005a). And physical activity program to prevent obesity and other chronic ’s nutrition and physical activity program to prevent obesity and other chronic diseases is an example of a federal initiative designed to build the capacity of states to prevent obesity in adults, children, and youth. Cdc has provided technical assistance and tools to help all states develop and evaluate their obesity prevention strategic plans (yee et al. An assessment is needed to identify the appropriate level of funding required to support all states and territories in capacity building and program implementation to prevent 4-2 cdc’s nutrition and physical activity program to prevent obesity and other chronic of states : robin hamre, nccdphp/cdc, personal communication, july 27, ted citation:"4 government. The evaluation found that the funded states had successfully involved partner organizations in planning and implementing interventions and cosponsored events aimed at improving body mass index (bmi) in children and adults; however, the evaluation also revealed potential service gaps, overlap with other programs aimed at preventing and controlling obesity, opportunities for additional services, and potential barriers to delivering services (cdc and rti, 2006). The steps program enables communities to develop an action plan, a community consortium, and an evaluation strategy that supports chronic disease prevention and health promotion to lower the prevalence of obesity, type 2 diabetes, and asthma through healthful eating, physical activity, and tobacco avoidance in disproportionately affected, at-risk and low-income populations including african americans, hispanics/latinos, american indians/alaska natives, asian americans, and pacific islanders (dhhs, 2005b,c).

Some states also encourage policy, systems, and environmental changes that increase access to foods and beverages that contribute to healthful diets and physical activity in low-income communities. The committee encourages further efforts to develop policies that foster opportunities for collaboration among usda programs relevant to childhood obesity ted citation:"4 government. Of federal surveillance activities that are conducted by cdc and that are used to monitor selected indicators and behavioral outcomes relevant to obesity in children and youth at national or state levels include (1) nhanes, which assesses the health and nutritional status of a nationally representative sample of u. Given the urgency of the childhood obesity epidemic, it is important to conduct frequent assessments of changes in the school environment. At present, however, no reporting systems are in place to identify how the precursors of childhood obesity are being addressed in the populations, organizations, and communities served by the wic program, fsp, or the school meals programs. Some larger state wic programs have developed reporting systems that could help identify effective approaches to address obesity in young children (national wic association, 2003). For example, new state registries for school wellness policies could be used to track progress toward achieving important obesity-related national goals. Noted earlier, both brfss and nhanes were the first surveillance systems to document the growing obesity epidemic in u. The funds appropriated to cdc’s nchs to support these surveys may fluctuate considerably across fiscal years, without representing substantial program ted citation:"4 government. Sufficient investment in health statistics and surveillance systems is essential to track a national public health crisis such as the obesity epidemic. Although these funds have been used to increase sample sizes necessary for these surveys and to provide information on population subgroups, including children and youth (dhhs, 2006), the committee concluded that substantial funding increases are needed not only to ensure the continuation of these important surveillance systems but also to enhance and expand data collection for the range of outcomes relevant to the childhood obesity ting and supporting obesity-related research are important governmental functions (iom, 2003). Research helps provide an understanding of the fundamental and intermediate causes of childhood obesity and the determinants of and the relationships between eating and physical activity behaviors. Ongoing research is examining the developmental changes of children and youth and the risk and protective factors that affect vulnerable periods during the life course relevant to childhood obesity. Given the complex interplay among environmental, social, economic, and behavioral factors that influence childhood obesity, considerably more research is necessary to inform an adequate and comprehensive response to the obesity ted citation:"4 government. 2005, the federal interagency working group on overweight and obesity research was formed to strengthen federal leadership in the area of obesity research. Its purpose is threefold: to facilitate constructive, coordinated research across diverse federal agencies and departments; identify areas in which interagency collaboration can extend progress in obesity prevention; and advise ostp’s committee on science about the research needs and opportunities related to overweight and obesity and associated adverse health effects (nstc, 2006). The intent of the working group is not to duplicate the research initiatives of other federal agencies, such as the nih obesity research task force (see below); rather, it is intended to enhance and strengthen the total federal research effort by interdepartmental collaboration (yanovski, 2006). The working group could serve as a component of the broader federal coordinating task force described earlier in this nih obesity research task force was established in fy 2003 to accelerate progress in obesity research across the nih institutes, centers, and offices and is another example of federal leadership in research. An important charge to the task force was the development and implementation of a strategic plan for nih obesity research (spiegel and alving, 2005), the coordination of obesity-related research activities across nih, and the development of new research efforts (nih, 2004; spiegel and alving, 2005). The strategic plan for nih obesity research focuses on goals for basic, clinical, and population-based obesity research and has the following strategies for achieving the goals:Identify modifiable behavioral and environmental factors that contribute to the development of obesity in children and adults through research for the prevention and treatment of obesity through lifestyle modification;. Genetic factors and biologic targets related to obesity and identify pharmacologic, medical, and surgical approaches for preventing and treating obesity; fy the connections between obesity and type 2 diabetes, cardiovascular diseases, cancer, and other diseases and approaches for addressing these chronic strategic plan focuses on enhancing crosscutting research by encouraging interdisciplinary research teams; focusing on specific populations such as children and racial/ethnic minorities; conducting translational research that progresses from basic science to clinical studies, trials, ted citation:"4 government. Is unclear what proportion of the nih research effort is dedicated to obesity prevention research and what proportion is dedicated to clinical research on treatment methods or basic research on the endocrine or metabolic mechanisms of obesity. The committee’s perspective is that similar challenges exist for effectively coordinating the strategic plan for nih obesity ’s prevention research center (prc) programs also play an important role in obesity prevention research. Seven prcs have projects that focus on obesity prevention such as preventing obesity in the united states. Other projects are guidelines for obesity prevention and control (yale university), adapting the coordinated approach to child health (catch) for obesity prevention and control (university of texas at houston), planet health—a health education program for school children (harvard university), dietary contributions to obesity and adolescents (harvard university), and impact of neighborhood design and availability of public transportation on physical activity and obesity among chicago youths (harvard university) (cdc, 2006c). A network of prcs, referred to as the physical activity policy research network, is collaborating to study policies and policy development pertaining to physical activity. Additionally, 7 prcs and 12 state health departments are collaborating with the center for weight and health at the university of california at berkeley to review the dietary and developmental influences on obesity (woodward-lopez et al. And local health in the balance report called for state and local governments to implement the report’s recommendations through the provision of coordinated leadership and support for childhood obesity efforts, particularly those focused on high-risk populations, by increasing resources and strengthening policies that promote opportunities for healthful eating and physical ted citation:"4 government. It encouraged the provision of support for public health agencies and local coalitions in their collaborative efforts to promote and evaluate obesity prevention interventions. State and local government agencies have traditionally and constitutionally been the primary overseers and implementers of public health activities.

The important functions of state and local governments mirror those of the federal government and include leadership; the provision of program resources, funding, and evaluation; the conduct of statewide and local surveillance, monitoring, and research; and the dissemination and use of the evidence resulting from states and communities throughout the nation are providing leadership through focused efforts to increase opportunities for physical activity and improve the dietary intake of children and youth. The national governors association made obesity prevention a priority as early as 2002 and has established a bipartisan task force of governors to provide further direction on this issue (nga, 2003, 2006). As administrators of state programs, governors are in a central position to promote the societal norms and a culture that supports physical activity, healthful eating, and obesity prevention in their states (nga, 2006). The council of state governments has developed a tool kit for policy options to promote healthy lifestyles and prevent obesity in youth (csg, 2006). Prevention was also identified as a priority for local governments in a resolution at the 72nd annual meeting of the u. In texas, for example, the state strategic plan includes measurable objectives and sector-specific strategies for families, schools and child-care centers, communities, worksites, ted citation:"4 government. States and local governments work to develop and implement action plans, it is important that they sustain an active task force or standing committee to coordinate and oversee the efforts related to preventing childhood obesity. Task forces or committees function in ways that are appropriate for state and local conditions and practices, in general, and are expected to coordinate and leverage resources, ensure the capacity of government agencies to conduct surveillance and monitoring of programs, and ensure that childhood obesity prevention activities are appropriately evaluated at all september 2005, the california governor’s summit for a healthy california brought together a diverse group of stakeholders to discuss the next steps for obesity prevention and health promotion in the state as outlined in a 10-point vision for healthy living (box 4-6). Number of states and communities have introduced or adopted bills and resolutions that represent legislative and policy actions related to childhood obesity prevention (boehmer et al. Promote physical activity in other that schools include nutrition, physical activity, and obesity prevention in health education ulum for health and physical education changes to the state’s curriculum related to health, nutrition, and physical education. Establish graduation e local districts with the ability to set policies and create committees that focus on reducing the prevalence of obesity among school-age children through the regulation of low-nutrient food and beverages and physical activity routes to e bicycle facilities, sidewalks, crossing guards, and traffic-calming measures to enable children to bicycle or walk safely to mass index (bmi). Or allow schools to measure, monitor, and report student’s bmi in conjunction with intervention strategies to help reduce childhood school e state agencies or state education officials to develop model school policies relating to nutrition and physical ted citation:"4 government. Council/ task ish a commission, committee, council, task force, or study to address obesity within schools or t and make appropriations for farmers’ market initiatives. Promote the implementation of locally grown nutritious foods in school ish initiatives, often though the state’s department of health, to reduce the prevalence of obesity among residents g/ biking t (through appropriations and regulations) physical activity through the creation or maintenance of bicycle trails, walking paths, and sidewalks. However, there are some proposals relevant to childhood obesity prevention through its influence on communities (e. The committee encourages the states to develop accountability mechanisms that provide the general public with information on the extent to which schools are meeting obesity prevention standards and evaluation results of innovative obesity prevention programs. Additionally, the committee supports increased legislative and other state and local government actions that will facilitate childhood obesity prevention efforts at the community, regional, and state m resources and state and local agencies have essential roles to play in designing, funding, implementing, and evaluating effective programs to support childhood obesity prevention goals. The obesity prevention efforts of local governments are complementary to those of the state and federal governments. Integration are the coordination of obesity prevention interventions through a local wic program, a community youth agency, and a local business or a corporate-sponsored community-based program. Utah’s blueprint to promote healthy weight for children, youth, and adults addresses actions by families, schools, communities, worksites, health care, media, and government that are needed including forming a team of leaders to assume active roles in addressing issues of overweight and obesity (bureau of health promotion, 2006). Times, however, the division of authority among governments at the federal, state, and local levels has led to inconsistencies, ineffective resource allocation, and uncertainty about the respective roles and responsibilities of the units at each level that is challenging for the task of effective coordination (baker et al. A sustained effort that includes adequate planning and cooperation among governmental agencies and departments and other stakeholder groups is needed so that the units at each of these levels can effectively work addition, the overall capacity to address childhood obesity is not enhanced when increases in federal funding are responded to by decreases at the state level. Current funding for obesity prevention is also often tied to funding for other public health issues; thus, decision makers at the state and local levels are challenged by coordinating funds from a variety of funding strategies and sources (finance project, 2004). To other states, california has only recently begun to recognize the need to develop policies related to nutrition, physical activity, and food security and an infrastructure to enhance those provided by the federal government or to fill gaps where the federal government does not meet the state’s needs in these areas. Like the federal government, california is starting to integrate the efforts of its categorical programs and establish cross-cutting approaches to address obesity prevention. Some federal requirements, however, do not allow programs to address crosscutting problems,Suggested citation:"4 government. Methods such as consumer empowerment and community development to create more livable communities are not yet fully employed in nutrition and physical activity promotion states are exploring or implementing innovative programs related to childhood obesity prevention, and evaluation of these initiatives is the critical next step. For example, in pennsylvania, the state department of health established pennsylvania advocates for nutrition and activity (pana), a coalition-based organization supported by state and federal funds that provides technical assistance and resources for obesity prevention efforts and that serves as a communication clearinghouse. In arkansas, efforts are under way to examine the link between receiving fsp benefits and childhood committee encourages the implementation and evaluation of innovative approaches and pilot programs that create incentives for the purchase of fruits and vegetables and other foods and beverages that contribute to healthful diets by participants in the fsp and other federal food assistance - and local-level surveillance and ng surveillance systems have provided sufficient information to justify the implementation of actions that can address the obesity epidemic at the federal and state levels, but these systems often do not provide sufficient data that allow careful monitoring of long-term trends or the assessment of progress at the state and local lly funded surveys may be designed to collect data at the national, state, and local levels; they may also collect only national data but provide technical assistance to state and local areas that collect state or local data. Cdc provides technical assistance to states and municipalities that conduct yrbs at the state or ted citation:"4 government.

The wic program provides information on the prevalence of obesity in high-risk groups from low-income families (iom, 2005b). States and localities also fund surveillance systems that can provide obesity-related data at state, county, and local levels. Chis provides data that allow the prevalence of obesity to be tracked at the county level, which is important in engaging local decision makers in this issue. Currently, several organizations track this information and provide online reports including cdc’s nutrition and physical activity legislative database (cdc, 2006e), the national conference of state legislatures summary of childhood obesity policy options (ncsl, 2006), the trust for america’s health annual report of federal and state policies and legislation (tfah, 2004, 2005), and netscan’s health policy tracking services for state legislation related to school nutrition and physical activity (netscan, 2005). Pacific islanders’ obesity rates more closely mirror those of latinos than those of asian americans, and in many asian subgroups, obesity-related comorbidities are associated with bmis lower than those for other populations (even bmis considered nonoverweight or obese). Such an effort could consist of a collaboration between the local department of public works and the local health department to collect data on bicycling and ng the evaluation framework to constitutes progress for government? Success of government efforts to prevent childhood obesity—and for all other sectors—will be determined by the reversal of the rise in the obesity and at-risk obesity prevalence for children and youth and a reduc-. Although the desire is to reverse this trend as quickly as possible, the achievement of long-term success to prevent childhood obesity may take several years or decades (as it did for tobacco-control efforts) and will require the sustained and coordinated implementation of a comprehensive and integrated spectrum of strategies and actions to produce the necessary changes in a variety of outcomes including structural, institutional, systemic, environmental, behavioral, and health outcomes. For the government sector, the achievement of short- and intermediate-term success will require evidence of leadership, strategic planning, political commitment, adequate funding, and capacity development, and a wide range of new, revised, or expanded policies, programs, surveillance and monitoring systems, partnerships and collaborations, and communications the federal government, leadership and political commitment are essential and are made tangible by the provision of increased resources to support surveillance and monitoring, innovative interventions, and program evaluation. Surveillance systems need to be expanded not only to include behavioral and health outcomes, but also to monitor levels of funding, research, public health capacity, programmatic activities, policy development and implementation, and structural, institutional, and systemic t approaches to assess government progress in childhood obesity tion is a priority for many federally and state-funded programs, which are generally required to conduct an evaluation and report on its results. Evaluation of government policies is more l agencies and departments are held accountable and are evaluated in several ways, although the level of specificity often does not allow a specific set of initiatives, such as childhood obesity prevention programs, to be the focus of the evaluation. Government accountability office (gao) frequently conducts evaluations of federal programs at the request of congress, some of which are relevant to childhood obesity prevention (gao, 2004c, 2005a). 2005 congressionally requested gao study focused on the collection of information on childhood obesity prevention program strategies and elements identified by experts as being “likely to contribute to success. For that assessment, gao surveyed 233 experts in academia, the private sector, and government at all levels and interviewed program officials. The gao assessment, which has had limited application, found that no comprehensive national inventory of childhood obesity programs exists at present and that there is no general consensus about the outcome measures that should be used to determine the success of programs for childhood obesity prevention (gao, 2005a) (chapter 2). Many of these federal agencies either currently support or have the potential to initiate or support childhood obesity prevention efforts. Moreover, obesity prevention was absent from the evaluations of many programs in several federal agencies that have obesity prevention programs and that could be integrating evaluation activities into the existing programs, including usda, and the u. General lack of consensus and clarity exists about the types of outcome measures that should be used to determine the effectiveness of childhood obesity prevention policies or programs. Additionally, no evaluative component exists that can be used to examine the leadership activities, political commitment, funding, and capacity development efforts adopted by federal government agencies to address childhood obesity in the united states. There is a need for objective public health expertise to provide this evaluative the state level, several organizations use report card approaches ted citation:"4 government. 4-1 the university of baltimore’s obesity report card™ ratings for state efforts to control childhood : the number within each state represents its rank from the highest prevalence (1) to the lowest prevalence (50) of obesity in adults. For example, the university of baltimore (ub) issued the ub obesity report card™ in 2004 and 2005 as an assessment of state efforts to pass obesity control policies (figure 4-1). Recess and physical education standards; vending machine usage; bmi measurement in schools; and obesity-related programs and education, research, treatment, or task forces) (university of baltimore, 2004, 2005b). Ub also developed a report card specifically for state efforts to control childhood obesity (university of baltimore, 2005a). Because the introduction of legislation may be an indicator of an increased awareness of the problem and the presence of a state’s political will to prevent or control obesity, points are awarded even if the proposed legislation is not currently active. On the basis of the 2005 ub obesity report card™, california was the only state to receive an “a” for its legislative efforts to control childhood obesity, whereas five states received an “f” for taking no legislative actions at all. The evaluation evaluation framework introduced in chapter 2 can be used to assess progress for government actions at all levels. Figure 4-2 highlights some of the strategies and actions to be considered when the extent to which government is demonstrating leadership and commitment in making childhood obesity prevention a national priority is evaluated. As discussed earlier in this chapter, federal and state high-level task forces could serve to coordinate and prioritize budgets, policies, and programs and serve as a basis for new ed outcomes that assess the adequacy of government leadership are shown in figure 4-2 and include assessments of the following:Policies and programs: assessments of whether a federal task force and 50 state-level task forces have been established, have developed and implemented strategic plans, and have produced annual progress reports showing that activities have been evaluated;. Assessments of whether childhood obesity prevention is incorporated into strategic research plans and activities across many federal agencies, such as cdc, nih, and usda;.

Funding levels for childhood obesity prevention are comparable to funding for efforts on health outcomes of similar disease burden and whether relevant activities and budgets are coordinated across agencies and categorical programs; oration: assessments of the implementation of memorandums of understanding and of intradepartmental and interagency y, the desirable health outcome that these changes could be linked to is an overall reduction in the prevalence of obesity in children and 4-3 provides a framework for evaluating government efforts to support capacity development for preventing childhood obesity. Programmatic activities for the prevention of childhood obesity will need to be expanded; and interventions will need to be implemented, monitored, and evaluated. The activities conducted by governmental and nongovernmental agencies will need to be coordinated for maximum efficiency. Assessments of whether state health departments have sufficient numbers of adequately trained staff to provide leadership and statewide training and whether all states meet the minimum staffing requirements recommended by cdc’s state-based nutrition and physical activity program to prevent obesity and other chronic diseases;. And monitoring: assessments of whether state and local health departments have adequate or improved surveillance systems to monitor trends in obesity, dietary patterns, and physical activity behaviors; ch: assessments of whether federally funded research that examines the causal relationships between exposure to specific physical and social environments and obesity is actively underway to reduce the prevalence of childhood ted citation:"4 government. The large number of federal programs related to preventing childhood obesity (appendix d) and the examples described earlier in the chapter suggest that some progress in addressing the childhood obesity epidemic has been made. The recommendation from the health in the balance report (iom, 2005a) that “the president should request that the secretary of dhhs convene a high-level task force to ensure coordinated budgets, policies, and program requirements and to establish interdepartmental collaboration and priorities for action” remains unfulfilled and should be a top gh leading administrative officials refer to the importance of the childhood obesity epidemic, the rhetoric has often not been matched with adequate resources to address it effectively. In addition to the activities identified above, the task force should also monitor federal obesity prevention activities and provide a biennial summary of relevant efforts across agencies, with particular attention given to the extent of federal resources appropriated for these efforts and evaluation results. The coordination of activities will improve efficiency but will not be sufficient without an infusion of resources to expand research and surveillance capabilities, increase agency capacity, facilitate the expansion of governmental and nongovernmental programs, and assure the evaluation of governmental policies, programs, and initiatives. Department of education, strengthen its leadership role by making childhood obesity prevention an urgent priority and reflecting this priority in the public statements, programs, research priorities, and budgets of federal departments and rmore, state and local governments should provide coordinated leadership and support for childhood obesity prevention efforts by increasing resources and strengthening policies that promote opportunities for physical activity and healthful eating in communities, neighborhoods, and schools. Local governments have the primary responsibility for shaping the built environment through general plans, land use ordinances, and capital improvement programs. Although changes to the built environment in communities can be part of obesity prevention efforts, many of the current efforts at the state and local levels have focused on improving nutrition and physical activity opportunities in schools. It is incumbent on state and local governments to also focus attention and funding on community-based programs and evaluations of those efforts (chapter 6). Sustain, and support evaluation and evaluation tion should be a key component of all interventions funded by federal, state, and local government. The capacities of federal, state, and local agencies to conduct activities and interventions to prevent childhood obesity need to be resources needed for capacity building of evaluation come from diverse funding streams, including a variety of federal and state agencies and departments, foundations, voluntary health organizations, and other sources. It is important that these resources be managed effectively and that funding for evaluation be increased to address the numerous childhood obesity prevention efforts that are planned and under way. The federal government is not expected to provide sole support for that capacity, but it is the responsibility of the federal government to monitor the capacity and to stimulate its development where necessary. Although cdc’s nutrition and physical activity program to prevent obesity and other chronic diseases and the steps to a healthierus initiative are examples of capacity development programs, federal funding has not increased over the past 3 years. There are few, if any, other examples of federal activities designed to enhance the capacity to implement and evaluate childhood obesity prevention activities. One component of this effort may build on the communities of excellence in nutrition, physical activity, and obesity prevention (cx3) database that is under development by the california department of health services (2006) (chapter 6; appendix d). Committee recommends additional support for existing and new programs to increase the capacities of federal, state, and local agencies to conduct and evaluate activities for the prevention of childhood obesity. The committee recommends that cdc, usda, and state agencies develop similar resources to guide childhood obesity prevention policies and interventions. Specifically, a key outcome indicators for evaluating childhood obesity prevention programs resource, which could be modeled after cdc’s guide for evaluating tobacco control efforts (cdc, 2005d), should be developed. Furthermore, supported by the evidence generated by the findings from childhood obesity prevention evaluations and research, a technical support and training component should be developed for program managers implementing and evaluating childhood obesity prevention activities and programs at the local e surveillance, monitoring, and llance is essential to maximizing the probability of success and the efficiency of childhood obesity prevention efforts. Federal surveillance systems are to be credited for alerting the nation to the national epidemic of obesity. Furthermore, surveillance of state and local policies, regulations, and practices that pertain to the prevention of childhood obesity provide an inadequate assessment of status or progress. As a first step, cdc, usda, and relevant state agencies should develop guidelines for the surveillance of policies and environmental outcomes pertaining to the prevention of childhood obesity. Federal support for intervention research is essential and could be channeled through cdc’s prcs to enable more intervention research and the development of a thematic network for the prevention of childhood largely untapped research opportunity is found in natural experiments2 (trb and iom, 2005) involving political, environmental, or social changes implemented for reasons that may or may not pertain to childhood obesity but that might be expected to affect dietary or physical activity behavior and childhood obesity. The federal interagency working group on overweight and obesity research should make the documentation of its progress publicly transparent, specify the areas of research that need to be emphasized, and prioritize obesity prevention and evaluation as areas for interagency y and ment is an integral part of the response to the childhood obesity epidemic. At the federal, state, and local levels, government has the authority and the resources to make childhood obesity prevention a public health priority and to act on that priority by authorizing and appropriating adequate funding, training personnel, and supporting technical capabilities directed to efforts that will increase opportunities for physical activity and improved diets for the population to engage in healthy s at all levels of government are evident and the committee could highlight here only selected policies, programs, and activities.

However, opportunities abound for improving coordination between government agencies; increasing or sustaining funding for programs proven to be effective; and enhancing surveillance, technical assistance, and evaluation capacity. Experiments are naturally occurring circumstances in which different populations are exposed or not exposed to a potential causal factor or intervention such that it resembles a true experiment in which study participants are assigned to exposed and unexposed ted citation:"4 government. Are urgently needed so that effective interventions can be scaled up, adapted to different contexts, and widely of the report’s four recommendations presented in chapter 2 is directly relevant to promoting leadership and collaboration and improving the evaluation efforts of government policies and interventions. The following text provides the report’s recommendations and summarizes the specific implementation actions for government that are endation 1: government, industry, communities, schools, and families should demonstrate leadership and commitment by mobilizing the resources required to identify, implement, evaluate, and disseminate effective policies and interventions that support childhood obesity prevention entation actions for l, state, and local government should each establish a high-level task force to identify priorities for action, coordinate public-sector efforts, and establish effective interdepartmental accomplish this,The president of the united states should request that the secretary of the dhhs convene a high-level task force involving the secretaries or senior officials from all relevant federal government departments and agencies (e. Departments of agriculture, education, defense, interior, and transportation; the federal communications commission; and the federal trade commission) to coordinate departmental budgets, policies, and research efforts and establish effective interdepartmental collaboration and priorities for governments should convene high-level task forces involving the state departments of health, education, agriculture; the land-grant cooperative extension services, and other relevant agencies. Childhood obesity prevention should be a priority that is reflected in each state government’s public statements, policies and programs, budgets, research efforts, and interagency government agencies should convene community- or regional-level task forces to provide coordinated leadership in preventing childhood obesity by increasing resources, collaborating with community stakeholders, and developing or strengthening policies and programs that promote opportunities for physical activity and healthful eating in communities and ted citation:"4 government. 2: policy makers, program planners, program implementers, and other interested stakeholders—within and across relevant sectors—should evaluate all childhood obesity prevention efforts, strengthen the evaluation capacity, and develop quality interventions that take into account diverse perspectives, that use culturally relevant approaches, and that meet the needs of diverse populations and entation actions for l and state government departments and agencies should consistently evaluate the effects of all actions taken to prevent childhood obesity and strengthen the evaluation capacity, paying particular attention to culturally relevant evaluation accomplish this,The actions of federal agencies, including policies that have been implemented, should be consistently evaluated to determine whether these actions and policies provide evidence of leadership and to identify the promising actions that are likely to be the most effective in preventing childhood u. Congress should increase federal support for capacity-building activities such as the cdc’s state-based nut1rition and physical activity program to prevent obesity and other chronic diseases and steps to a healthierus l and state agencies should assess and strengthen the capacities of state and territorial health departments to provide leadership and technical assistance, enhance surveillance efforts, and implement and evaluate programs to prevent childhood , other federal agencies, and private-sector partners should work toward evaluating existing media efforts (including small step and small step kids! With the goal of developing, coordinating, and evaluating a more comprehensive, long-term, national multimedia and public relations campaign focused on obesity prevention in children and endation 3: government, industry, communities, and schools should expand or develop relevant surveillance and monitoring systems and, as applicable, should engage in research to examine the impact of childhood obesity prevention policies, interventions, and actions on relevant outcomes, paying particular attention to the unique needs of diverse groups and high-risk populations. Additionally, parents and caregivers should monitor changes in their family’s food, beverage, and physical activity choices and their progress toward healthier ted citation:"4 government. Actions for ment at all levels should develop new surveillance systems or enhance existing surveillance systems to monitor relevant outcomes and trends and should increase funding for obesity prevention accomplish this,Federal and state government surveillance systems should monitor the full range of outcomes in the evaluation framework. Surveillance systems—such as nhanes, shpps, ymcls, yrbss, and nhts—should be expanded to include relevant obesity-related outcomes. Surveillance systems that monitor the precursors of dietary and physical activity behaviors, including policies that have been implemented and structural, institutional, and environmental outcomes should be expanded or states should have a mechanism in place to monitor childhood obesity prevalence, dietary factors, physical activity levels, and sedentary behaviors through population-based sampling over u. Efficacy, effectiveness, quasiexperimental, cost-effectiveness, sustainability, and scaling up research) to improve program implementation and outcomes for children and endation 4: government, industry, communities, schools, and families should foster information-sharing activities and disseminate evaluation and research findings through diverse communication channels and media to actively promote the use and scaling up of effective childhood obesity prevention policies and entation actions for ment at all levels should commit to the long-term support and dissemination of childhood obesity prevention policies and interventions that have been proven to be accomplish this,Federal, state, and local governments should publicly disseminate and promote the results of evaluations of childhood obesity prevention policies and federal government should provide a sustained commitment and long-term investment to adequately support and disseminate childhood obesity prevention interventions that are proven to be effective—such as the verb campaign. Federal government should provide sustained support for surveillance systems that are vital to the monitoring of trends and progress in response to the childhood obesity ives and rewards should be developed for state and local government agencies to coordinate efforts that improve obesity-related outcomes for children and council. Improving nutrition, physical activity, and obesity prevention: performance report of the nutrition and physical activity program to prevent obesity and other chronic diseases: july 1 through december 31, 2005. Perspectives on marketing, self-regulation & childhood obesity: a report on a joint workshop of the federal trade commission & the department of health and human services. Childhood obesity: most experts identified physical activity and the use of best practices as key to successful programs. System, environmental, and policy changes: using the social-ecological model as a framework for evaluating nutrition education and social marketing programs with low-income audiences. Presentation at the institute of medicine committee on progress in preventing childhood obesity meeting, washington, dc. Institute of medicine committee on progress in preventing childhood sl, williams-piehota p, sorensen a, roussel a, hersey j, hamre r. The nutrition and physical activity program to prevent obesity and other chronic diseases: monitoring progress in funded states. Remarkable increase in the prevalence of obesity among children and youth in the united states over a relatively short timespan represents one of the defining public health challenges of the 21st century. The country is beginning to recognize childhood obesity as a major public health epidemic that will incur substantial costs to the nation. There is a substantial underinvestment of resources to adequately address the scope of this obesity this early phase in addressing the epidemic, actions have begun on a number of levels to improve the dietary patterns and to increase the physical activity levels of young people. Schools, corporations, youth-related organizations, families, communities, foundations, and government agencies are working to implement a variety of policy changes, new programs, and other interventions. These efforts, however, generally remain fragmented and small in er, the lack of systematic monitoring and evaluation of interventions have hindered the development of an evidence base to identify, apply, and disseminate lessons learned and to support promising efforts to prevent childhood ss in preventing childhood obesity: how do we measure up? This book emphasizes a call to action for key stakeholders and sectors to commit to and demonstrate leadership in childhood obesity prevention, evaluates all policies and programs, monitors their progress, and encourages stakeholders to widely disseminate promising practices. This book will be of interest to federal, state, and local government agencies; educators and schools; public health and health care professionals; private-sector companies and industry trade groups; media; parents; and those involved in implementing community-based programs and consumer 're looking at openbook, 's online reading room since 1999. Sign up for email notifications and we'll let you know about new publications in your areas of interest when they're ncbi web site requires javascript to tionresourceshow toabout ncbi accesskeysmy ncbisign in to ncbisign l listaust new zealand health policyv.

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