Travel Corridors & Destinations: Promises in the Environment for Physical Activity
Anne Lusk, Ph.D. Visiting Scientist, HSPH

Dr. Willett introduced Dr. Anne Lusk, Visiting Scientist at Harvard School of Public Health, whose work is in improving physical activity and health through a better urban design.

Dr. Lusk spoke of having developed a feasibility study in Stowe, Vermont for a bicycle path in 1981, culminating in a 5.3 mile path completed by 1989, which led to her being asked to lecture throughout the U.S., Canada and Europe about bicycle paths.

Her slide presentation focused on travel corridors and destinations as enablers of physical activity:

Panel of Regional Health Officers: New England Addresses the Obesity Epidemic

Mr. Yaffe introduced Dr. David Katz, the moderator. Dr. Katz is an Associate Clinical Professor of Public Health and Medicine, and Director of the Medical Studies in Public Health at the Yale University School of Medicine. He co-founded and directs Yale's Prevention Research Center. He also founded and directs the Integrated Medicine Center in Derby, Conn.

The following is a synopsis of the panel discussion.

Connecticut: Renee D. Coleman-Mitchell, MPH, Director, Division of Health Education, Management and Surveillance

•   54.7% of Conn adult population is overweight and obese

•   From 1994-2001, 52% increase in obesity

•   80% at risk for health problems due to lack of physical activity

•   CDC grant provided staffing, advisory group, continuing education for many providers,  and 2 pilot projects in 2000-(1) LIFE (Ledyard Interested in Fitness and in Exercise); (2) HEALTH (Healthy Eating and Active Living to Help You)

•   Both pilot programs established community advisory committees, community assessments, community-based action plan for obesity prevention. Created signage for walking trails and fresh produce initiatives.

• Other programs include:

• Partnership with Center for Obesity Research and Education (CORE)
• UConn nutrition program (developed standards for vending and a la carte items)
• Medicare Managed Care Council Subcommittee
• Youth Risk Behavior Survey and Youth Tobacco Survey combined in Children's Health Survey
• WIC-Pediatric Nutrition Surveillance System and Pregnant Nutrition Surveillance System
• Statewide plan: Connecticut Plan for Health Promotion Through Health Eating and Active Living

Based on ecological model with following goals: increase infrastructure to support activities; expand activities to address overweight and obesity; increase general awareness of the issue. On community level identify issues, address policy & practice & environmental change; work with schools, healthcare field, food industries, and work sites.

Maine: Barbara A. Leonard, Director, Division of Community Health, Bureau of Health, Maine Department of Human Services

• CDC funding for physical activity and nutrition. Pilot programs: high school vending machines and a la carte project.

• Healthy Maine Partnerships -31 community school partnerships funded by tobacco settlement money

• Healthy Way to Awareness Campaign - using USDA food stamp nutrition dollars to address healthy weight through cutting back on soda consumption; reducing television and screen time; increasing physical activity.

• Physical Activity and Nutrition Action packets - promotes trail development, use of safe routes for walking and biking, developing policies to support healthy eating at group events

• Maine Child and Youth Weight Status Report

• LD 471 legislation to study obesity

• Healthy Maine Walks - web-based promotion of safe and accessible walking routes

• Soda and snack vending machine policy initiative

• Dietetic Association and School Food Service Association - position paper on nutrition services in Maine schools

• Physical Activity in Schools Initiative - proposing increased physical activity outside of formal physical activity

• Maine Harvard Prevention Research Center - group of pediatricians and family practice offices will be developing ways to intervene in offices with overweight children and their families.

Massachusetts: Sally Fogerty, BSN, Med, Asst. Commissioner and Director of the Center for Health Services, MA Department of Public Health

• Successful brochure describing all the state's nutrition programs (WIC, food stamps, children nutrition programs, farmers market info)

• Collaboration between Dept. of Public Health and Dept. of Education (vending machines in schools)

• Action for Healthy Kids - guidelines for foods and beverages in the schools

• Legislative support - limits types of school bus advertising

• Linking with various programs (i.e., Asthma, Tobacco)

• Promotion of prevention, increasing public awareness of obesity issue

• Blue Cross/Blue Shield partnership-521 and Go; highly successful school-based program that addresses weight and includes physical exercise

• The Nutrition Minute - website with weekly message addressing healthy foods

• Public Safety - walking paths

New Hampshire: Mary Ann Cooney, RN, Director, Office of Community and Public Health, NH Dept of Health and Human Services

• Social responsibility - how we market to children, lifestyle change

• Creating partnerships critically important and effective in NH

• No formalized public health system in the state, NH has had to energize communities to address problems

• Streamlined messages so same nutrition and physical activity message came from different categorical programs

• Physical Activity and Nutrition grant - individual communities link with their recreation departments which incorporate plans from the State Office of Health with a message of nutrition and physical activity

• Dept. of Health with Foundation for Healthy Communities - programs for children, walking and bicycling

• Injury Prevention Program and Kid Power

• Action for Healthy Kids and NH Healthy Schools

• University of NH research - found dramatic reduction in levels of physical activity in children from the time they entered school until first grade

Rhode Island: Ann Kelsey Thacher, M.S., Chief, Office of Health Promotion & Chronic Disease Prevention, RI Department of Health

• Irish Heart Foundation's Path to Health Program

• Healthy R.I. 2010 Program - physical activity: increase proportion of adults who engage in regular physical activity for at least 30 minutes per day; increase proportion of adolescents who engage in physical activity that promotes cardiorespiratory fitness 3 or more days a week for 20 or more minutes. Obesity: decreaste proportion of adolescents who are obese (25% in 2001); decrease proportion of adults who are obese (17% in 2000), goal of 14%. Increase proportion of people two years and older who consume at least five servings of fruits and vegetables daily.

• Road to Health Coalition - partnership with hospital systems; stair prompts  on taking stairways; fast food prompts (compare caloric intake of fast food to healthier alternatives)

• STEPS-approved, but not funded; Minority Health Promotion Center will work on this initiative

• CDC funding - Obesity Planning Council will address the state plan, based on disparities information, on six core communities with higher risk factors related to socioeconomic status

• RI Public Health Association - active advocate for healthy weight issue

• Healthy Schools Coalition (Action for Healthy Kids) - major policy advocacy group, addressing nutritional policies

• Special Senate Committee on Childhood Obesity - to develop legislative regulations

• Transportation Advisory Committee - increasing emphasis on bicycle lanes and sidewalks

Vermont: Paul E. Jarris, MD, MBA, Vermont Commissioner of Health

• 51% of Vermonters have a chronic illness

• 86% of Vermonters over 65 have a chronic illness

• Vermont addressing this through several public health initiatives

• Major reorganization with development of a system in which there are expert content areas in nutrition and activity, that cut across the categorical disease programs

• Fit & Healthy Kids Program

• An Act Relating to Nutritious Policy in Vermont Schools - legislation passed that deals with physical activity and nutrition. Will create community groups as advisory to school districts. Schools will develop model curriculum including a full food policy. Physical education-training kids to lead a healthy life through the school modeling and providing opportunities for healthy physical activity

• Create surveillance between publics health and education to monitor elementary school population

• WIC population-17% of 2-5 year olds are overweight, 26% of 8-12th graders overweight

• Public policy as change agent, provide tools for self management to promote activity and healthy lifestyles

• Provide governmental financial incentives to schools

Moderator: David L. Katz, MD, MPH, ACPM, FACP, Associate Clinical Professor of Public Health & Medicine, Yale University School of Medicine; Director, Yale Prevention Research Center

Moderator Katz asked: "How do we get the data we need regarding children and steer clear of our appropriate fear of stigmatizing them?"

Response: Obtain through school health data. Message is we are working on fitness and nutrition, lifestyle and behavior for all individuals, instead of against obesity, in order to avoid stigma.

Another question was whether we should focus on obtaining measures of height and weight in healthcare settings rather than school settings.

Responses ranged from getting the data exclusively from the healthcare systems to getting it from the schools; both have drawbacks. Dr. Katz suggested it needn't be either/or.

Question: "What can we in public health do to work with some of the forces (i.e., fast food restaurants) that engender an obesogenous environment?

Responses included money motivation versus health motivation, changing what brings human beings comfort and pleasure; national policy changes need to be made; learn social marketing to produce change; change what keeps the customers satisfied. In Connecticut, a public health foundation status allows Health Dept to apply for funds with large companies and partners with them.

Question: How do we implement the changes in environment to promote physical activity?

Responses: In NH, partnering with State Office of Planning to work with recreational facilities to make environmental changes that encourage physical activity. Collaboration between Dept of Health and Transportation. Social marketing is key.

Greetings from Hon. James H. Douglas, Governor of Vermont, Chair, NE Governors' Conference

Paul E. Jarris, MD, MBA, Vermont Commissioner of Health

Mr. Yaffe expressed appreciation to the Vermont Dept of Health in arranging the conference. He introduced Commissioner Jarris who thanked the group on behalf of Governor James Douglas, whose leadership and support on the issues of obesity, nutrition, and fitness with the Dept of Health in Vermont have been significant.

Keynote Address: The Nation's Response to the Challenge of Overweight

Captain Van S. Hubbard, MD, Ph.D., Director, National Institutes of Health Division of Nutrition Research Coordination; Chief, Nutritional Sciences Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health

Introduction: Capt. Michael Milner, MMS,PA-C, Regional Health Administrator, US DHHS/OPHS

Mr. Yaffe introduced Captain Michael Milner, who spoke of his work with Native American cultures, emphasizing the significance of diversity saying "we can build and weave in that thread of diversity throughout all of our discussions." Captain Milner introduced the keynote speaker, Dr. Van Hubbard.

Dr. Hubbard addressed the group with a slide presentation:

Following his presentation was a question and answer period.

Question: Why are we studying a variety of diets instead of just one basic health-promoting diet?

Response: In terms of obesity, all diets that work do so because of reduction in calories. We don't have a way of having people sustain the modification used to obtain the weight loss.  We can start with our best nutritional recommendations; yet each individual is unique and may require refinement for their particular situation.

Question regarding FHA's mission and how it runs counter to what the group is hoping to do.

Response: Each community can devise innovative ways of dealing with the issue. (i.e., No Car Day). Block off a few streets for bicycles and roller blades. Need availability of rest rooms for walkers. Link cul de sacs with walking paths or bike paths. Build a walking simulator.

Where Do We Go From Here?

Reports from Breakout Sessions

HEALTH CARE PROVIDERS

Facilitator: David Katz, MD, MPH, FACPM, FACP, Associate Clinical Professor of Public Health & Medicine, Yale University School of Medicine, Director, Yale Prevention Research Center

1.   Make BMI measurement routine.

The consensus was that this would best be achieved by engaging nurses and office managers to record BMI along with other vital signs.  In essence, the NECON focus should be to make BMI a vital sign for the region.  NECON should develop a template vital-sign intake form and BMI tracking form for clinicians throughout the region to adopt.  Making it web-based (see "Clearing House" below) would facilitate uptake by practice groups.  For pediatric practices, the BMI should be recorded on forms that include the pediatric growth charts.  General information on BMI and risk should be provided succinctly on the form. 

NECON should identify nurses willing to champion this cause in each of the 6 states.  There should be a parallel effort to get insurance companies to track BMI in charts as a quality control measure.

2. Monitor BMI in medical records

See # 5, below

3. Recognize and convey to patients the importance of lifelong approaches to weight control that are consistent with overall health promotion

This can be achieved in conjunction with #5 and #9, below.

4. Encourage clinicians to cultivate an inter-generational, family-based approach to weight control emphasizing overall health

This can be achieved in conjunction with #5 and #9, below.

5. Encourage insurers to reimburse physicians, dietitians, nurses and other members of the health care team for time spent evaluating and counseling patients with regard to weight control

The following is proposed.  NECON should use its contacts to invite a delegation of health care leaders from each state to a day-long workshop with representatives from the insurance industry.  Ideally, private insurers and Medicare/Medicaid would be represented.  NECON should propose a 2-5 year long regional pilot of reimbursement for weight control counseling.  The insurers will pay for the counseling, but will also be able to track the quality of the counseling using mutually agreeable criteria.  If the counseling fails to meet agreed-upon quality indictors, reimbursement may be denied.  NECON should provide resources to hire a team of health care economists to analyze the pilot and make projections about the longer-term cost-effectiveness of reimbursement for weight control counseling.

Both NECON's leverage, and exposure in the press, can/should be used to encourage insurance company participation. The insurance companies will be making a modest financial investment, as will NECON.  This is a way to overcome the impasse that lack of reimbursement is a barrier to counseling, and lack of counseling is a barrier to generating the needed evidence that counseling should be reimbursed.

6. Encourage all clinicians in New England to set a good example

This message can be emphasized on the clearinghouse web site (#9, below), and passed along from all participants in the NECON initiative to colleagues.

7. Prepare future providers for effective weight control counseling, including multi-cultural competency, by dedicating time in training curricula to this goal and offering practicing physicians opportunities for continuing medical education in this field

Addressing #5 and #9 will help generate support for this action.  NECON can also include curricula on its website for use by medical schools, other health care professional training programs, and medical residency programs.

8. Coordinate all of the departments of public health within New England using their existing Websites to collect, distribute and encourage weight control programs

See #9.

9. Create a regional clearing house

Establish a New England-wide Internet-based resource clearinghouse for obesity control.  NECON representatives should work with representatives in each health department to identify pertinent stake holders in each state.  There should be a pyramidal approach, so that within each state, the information provided gets down to very small geographic areas.  Funds will be needed for a dedicated team to construct the website, and input information from each site.

The URL should provide access to other web links, print materials, tracking forms for medical records, chat rooms for professional networking and troubleshooting, and calendars/inventories of events, programs, resources, and facilities at the local level.  There should be materials suitable for use by professionals, and materials to which the professionals can refer their patients/clients.

NECON should raise the necessary funds to construct the site.  Insurance companies, health departments, and/or clinical practice groups should assume financial responsibility for maintaining the site after its utility is demonstrated.  To achieve this, the site should be evaluated during a pilot period.  Information regarding the availability of the site can be conveyed to practitioners in each state via health departments and state medical societies.

Summary

The following sequence is proposed.  (1) Initiate development of the on-line clearinghouse; (2) use the clearinghouse as a basis for improving the quality of clinical counseling region-wide; (3) convene a meeting with insurers to pursue a pilot program of reimbursement for weight loss counseling; (4) once a commitment to the pilot program has been made, acquire the necessary resources to complete the on-line clearinghouse and hire the health care economics evaluation team; (5) rely on insurers, health departments, and state medical societies to promote the on-line clearinghouse; (6) use the on-line clearinghouse to convey messages about the content of counseling, and to provide tools/resources for tracking BMI; (7) convey messages to nurse managers about the availability of BMI tracking forms, and encourage their routine incorporation in medical records; (8) link reimbursement for counseling to basic quality-control indicators; (9) include teaching curricula among the clearinghouse resources; (10) notify medical and other health care professional schools and schools of public health (deans, and associate deans) of the initiative, and the availability of the clearinghouse, as a means of facilitating early uptake into teaching programs.  

SCHOOL NUTRITION & PHYSICAL ACTIVITY

Facilitator: William H. Potts-Datema, MS, Director, Partnerships for Children's Health, Harvard School of Public Health

1. Priority Actions for Government: Federal, State, Local (legislative and executive):

• Mobilize commitment for a unified health promoting nutrition and physical education environment that encourages weight control.

• Enforcement requirements and commit adequate resources to nutrition and physical education programs for pre-school through grade 12. Upgrade school food service, limit availability of soda and junk food and increase opportunities for children, faculty, and staff to be physically active.

• Expand the physical education curriculum and require certified physical education instructors. Teach children to play physically active games and lifetime sports, to walk or bicycle ride for short trips and to substitute these activities for TV and other electronic media. All students should have at least one opportunity for supervised physical activity every day and weekly time with a qualified instructor as follows:

-A minimum of 150 minutes/week for grades K through 5 or 6

-A minimum of 225 minutes/week for middle and secondary school students

• Partner with companies to make recreational facilities available to communities after school and on weekends. Pay special attention to inner-city neighborhoods and at-risk children.

2. Priority Actions for Volunteer Organizations:

* Hold an annual meeting for regional Coordinated School Health Programs.

* Provide students with safe ways to walk or bicycle to school.

* Reach out to families. Communicate with parents about weight control, including early childhood years, and emphasize the importance of spending time with children around he dinner able, taking a walk, or participating in a sport.

* Partner with companies to make recreational facilities available to communities after school and on the weekends. Pay special attention to inner-city neighborhoods and at-risk children.

• Support legislation to improve school food, nutrition and physical education, recreational facilities and before and after-school community programs;

3. Priority Actions for Educators:

• Mobilize commitment for a unified health promoting nutrition and physical education environment that encourages weight control.

• Enforce requirements and commit adequate resources to nutrition and physical education programs for pre-school through grade 12; upgrade school food service, limit availability of soda and junk food and increase opportunities for children, faculty and staff to be physically active.

• Expand the health education curriculum to include weight control and incorporate related information and skills in core subjects. Teach children about nutrition; the importance of fruits and vegetables, how to read labels, plan and prepare meals and be a nutrition-conscious shopper and eater. Partner with fanners' market programs.

• Expand the physical education curriculum and require certified physical education instructors. Teach children to play physically active games and lifetime sports, to walk or bicycle ride for short trips and to substitute these activities for TV and other electronic media- All students should have at least one opportunity for supervised physical activity every day and weekly time with a qualified instructor as follows:

- A minimum of 150 minutes/week for grades K through 5 or 6

- A minimum of 225 minutes/week for middle and secondary school students

• Conduct annual evaluations using the CDC-DASH School Health Index. Identify strengths and weaknesses and prioritize changes.

• Hold an annual meeting of regional Coordinated School Health Programs.

4. Priority Actions for Health Care Organizations and Providers:

• Mobilize commitment for a unified health promoting nutrition and physical education environment that encourages weight control.

• Reach out to families. Communicate with parents about weight control, including early childhood years, and emphasize the importance of spending time with children around the dinner table, taking a walk or participating in a sport.

5. Priority Actions for Food Industry:

• Enforce requirements and commit adequate resources to nutrition and physical education programs for pre-school through grade 12; Upgrade school food service, limit availability of soda and junk food and increase opportunities for children, faculty and staff to be physically active.

• Support legislation to improve school food, nutrition and physical education, recreational facilities and before and after-school community programs.

6. Priority Actions for Business and Worksites:

• Partner with companies to make recreational facilities available to communities after school and on the weekends. Pay special attention to inner-city neighborhoods and at-risk children.

 • Support legislation to improve school food, nutrition and physical education, recreational facilities, and before and after-school community programs;

7. Priority Actions for Media:

• Reach out to families. Communicate with parents about weight control including early childhood years, and emphasize the importance of spending time with children around the dinner table, taking a walk or participating in a sport.

8. Priority Actions for Academia:

• Conduct annual evaluations using the CDC-DASH School Health Index. Identify strengths and weaknesses and prioritize changes.

• Hold an annual meeting of regional Coordinated School Health Programs;

9. Priority Actions for Families and Individuals:

• Expand the physical education curriculum and require certified physical education instructors. Teach children to play physically active games and lifetime sports, to walk or bicycle ride for short trips and to substitute these activities for TV and other electronic media. All students should have at least one opportunity for supervised physical activity every day and weekly time with a qualified instructor as follows:

- A minimum of 150 minutes/week for grades K through 5 or 6

- A minimum of 225 minutes/week for middle and secondary school students

• Support legislation to improve school food nutrition, and physical education, recreational facilities and before and after-school community programs.

MASS MEDIA

Facilitator: Sari Kalin, Program Coordinator, Research Associate, Harvard School of Public Health

1. Pool state resources to develop and launch a large-scale regional media campaign to convey information on the importance of weight control, to promote Health Weight Control Guidelines and to disseminate motivating messages.

There are pros and cons to having the lead in this effort taken by state agencies or healthcare organizations (perhaps in a coalition with volunteer organizations); Perhaps the New England Governors' Conference could provide guidance around this.

• Consider changing pledge name to "Healthy Eating and Active Living Pledge," "Healthy Eating and Activity Pledge," or "Healthy Lifestyle Pledge."

• Consider changing name of "Healthy Weight Guidelines" to "Healthy Eating Guidelines" or "Healthy Lifestyle Guidelines."

• Specific suggestions for message development process.

• Use focus groups and surveys to understand the thinking of a diverse group of consumers (diverse in ethnicity, literacy and SES) and test message effectiveness.

• Target messages to high-risk audiences.

• Language of messages should reflect state population (in some states, French would be most useful) and varying literacy levels.

• Ensure that messages are unified, even though tailored to specific audiences.

• Use empowering messages, e;g;, "You can make choices about food,,,"

• Reinforce positive behavior rather than chastise negative behavior by emphasizing the benefits of healthy eating and active living and highlighting that physical activity and food can be fun.

• Be mindful of disordered eating and poor body image issues, which disproportionately affect women.

• Consider how the state-level campaigns will dovetail with Ad Council efforts.

2. Use mass media to advocate for changes in the built environment, such as Safe Routes to School, bicycle and walking paths with increased access for residents of low-income neighborhoods, smart growth planning and walkable cities.

• Mass media is not the only communications vehicle-make sure to look beyond public service announcements and consider other communications media/approaches.

• Emphasize activities with family.

• Be mindful of ability impairment-suggest variety of activity alternatives (not just walking)

• Since this action item requires advocacy, it must be part of a much broader effort.

3. Reinforce the regional campaign with community and workplace initiatives. Public officials, community leaders, celebrities, and CEOs should announce their support for above.

Remember that healthy eating and activity campaigns differ from anti-tobacco messaging in many ways: (1) complexity of message; (2) tobacco companies were seen as 'evil outsiders,' while purveyors of sodas and other unhealthy foods/activities are often local residents.

ECONOMICS

DATA FOR ACTION

Facilitators: Solomon Mezgebu, M.Sc., Evaluator/epidemiologist II, Nutrition & Physical Activity Unit, Mass Dept of Public Health; Maria Bettencourt, MPH, LDN, Director, Nutrition & Physical Activity Unit, Mass Dept of Public Health

1. Collaborate to support federal legislation to improve nutrition and enhance opportunities for physical activity.

State activity is significantly shaped by federal mandates and funding. Therefore, while independent state action is also needed, groups need to work together regionally to impact federal requirements and programs. This will require the strengthening, even the creation, of regional advocacy networks through which people can share successful models and experiences in shaping the policy context.

2. Enable the use of surveillance data by identifying (a) what is available, (b) what is accessible, and (c) how to use surveillance data for different purposes. Promote the use of consistent methods and comparable indicators across stets and surveillance data systems/sources, in order to integrate information. The methods and indicators should be complemented with periodic assessment of validity of self-report measures.

A key foundation for regional implementation would be a resource bank containing survey tools, descriptions of consistent and comparable methodologies for data collection, standards for indicators, outcome and impact data.

WORKPLACE HEALTH PROMOTION

FOOD AND SOCIAL ENVIRONMENT

Facilitators: S. Bryn Austin, Sc.D., Instructor in Pediatrics, Children's Hospital Div. Of Adolescent Medicine; Serena Domolky, JD, MPH, Dept. of Nutrition, Harvard School of Public Health

1. Develop lists of healthy, low calorie items for different locales, such as vending machines, cafeterias, workplace meetings.

2. Create a "healthy weight" icon to appear on food containers, food labels, menus, vending machines, supermarket items, TV and print ads.

3. Simplify the nutrition-healthy weight message and use social marketing techniques to reach New England households, communities and worksites.

4. Monitor and encourage "best practices" in worksites, including

• Food in ending machines, cafeterias and meetings

• Encouragement to commute by bicycle or food

• Exercise incentives, such as "take the stairs" prompts, discretionary exercise time, reimbursement for health club membership, onsite exercise facilities, showers, bicycle racks

• Preventive screening

• Non-judgmental social marketing

5. Expand Fruit and Vegetable Programs, including community-school interface, state and federal programs, such as WIC.

6. Encourage and develop interagency collaboration and partnerships among government agencies, advocacy groups, professional societies, community groups, and employers.

THE BUILT ENVIRONMENT

Facilitator: Phil Troped, MS, Ph.D., Research Associate, Harvard School of Public Health

1. That the mission statements for all transportation related governmental agencies (national, state and local) include a statement that they will promote and/or enhance non-motorized transportation/health and that all transportation projects will have a health impact assessment conducted prior to embarking on the project.

Transportation planning has to start from the premise that the ultimate goal is the overall well-being of people, not just their movement from one place to another. And to the extent that people moving is the issue, transportation planning should be responsible for affirmatively facilitating non-motorized methods as much as, if not more than cars.

2. That all state transportation agencies will have the state public health agency represented on their boards and advisory groups.

Incorporating representatives from the agency officially responsible for safeguarding public health will provide a built-in voice for these issues.

3. That all transportation projects will include routine accommodations for non-motorized modes.

Since transportation projects have such a hug effect on people's ability to get around using non-motorized modes, it is important that all street building or repair efforts include a commitment to "complete the street" by including facilities for pedestrians, "slow wheels," as well as "vehicular bicyclists."

4. That there will be a requirement that all municipalities that get state transportation funds must have a pedestrian/bicycle citizens' advisory committee.

Providing a structure that aggregates and legitimizes bike/ped citizen advocacy at the local level will create a constituency for long-term improvement in the way policy-makers deal with non-motor4ized transportation planning.

5. That the six New England states will implement a regional campaign to promote stair-climbing in public buildings and other facilities and that the NECON logo will be used to identify that this is a regional effort.

This can be started as a volunteer effort organized through existing agencies and groups.

Where Do We Go From Here?

Panel

Rep. Sean Faircloth, Maine State Legislature

Expressed appreciation for Bert Yaffe and Walter Willett. Sponsored a bill in Maine, LD104 related to healthy choices in schools and soda availability in the schools. He spoke of the freedom paradox: when he suggested to a high school student replacing junk food and soda in the school with health choices, the response was "you're taking away my freedom of choice" when in fact, the junk food is abundantly available in all the surrounding stores.

He also spoke of what he called "a conservative reversal"-students, vending machine reps, soda company reps say there is a "constitutional right to a whoopee pie in high schools." Our taxpayer-funded public schools should be promoting a sound mind in a sound body and healthy choices, a conservative set of values based on freedom.

He proposed a NECON manifesto of five freedoms:

(1) freedom of choice in transportation (dedicate 1% of all gas tax money to transportation alternatives)

(2) freedom for food information (list calories on menus)

(3) freedom for information for parents about children's health

(4) freedom from commercialization in public schools

(5) freedom from exploitation of children in child-targeted advertising

Rep. Peter Koutoujian, Co-Chair, Joint Committee on Health Care, MA State Legislature

On July 5, Massachusetts will be smoke-free in the workplace, due to legislation recently passed, which he feels is the most sweeping legislation in public health since inoculation and vaccination legislation of 40 and 50 years ago.

Public policy comes from the community, "bubbles up from the bottom." He used the example of biotech which has concentrated lobbying efforts on highest levels, which is ineffective. He emphasized the importance of working on the local level-school committees, city councils, PTOs. Smoking ban started in the municipalities, before becoming a statewide issue.

Rep. Koutoujian spoke of current obesity legislation addressing the following areas: no access to unhealthy foods and beverages during the school day; mandating physical education of 120 hours in schools, nutrition and wellness education (minimum of 50 hours), and a behavioral component through coordination of Departments of Mental Health, Education and Public Health. He requested feedback and suggestions from conferees on this piece of legislation.

Peg Harringon, Area Manager, Outreach, American Diabetes Association

She spoke of the epidemic of obesity and overweight coinciding with the epidemic of diabetes, stating "...obesity seems to be the linkage that ties these chronic diseases together." As a result, the American Diabetes Association, American Heart Association, and the American Cancer Society have joined forces around this issue, viewing it holistically. The combined resources, databases. and lobbying efforts of these organizations in collaboration with NECON will serve to further enhance the goals of the Strategic Plan for the Prevention and Control of Overweight and Obesity in New England.

David Katz, MD, MPH, FACPM, FACP, Associate Clinical Professor of Public Health & Medicine, Yale University School of Medicine, Director, Yale Prevention Research Center

Dr. Katz pointed out that "children growing up in the United States today are subject to more chronic disease and premature death from eating badly and being physically inactive than from exposure to tobacco, drugs, and alcohol combined." He quoted Margaret Mead, saying that change in the world only comes from "thoughtful citizens," and that we, as a nation of parents, ..."have the potential to be the single largest special interest group in the country." Change occurs at the grassroots level-change the food industry by changing the consumer; change the delivery of healthcare by changing the orientation of the patient; and change what happens in schools by changing the passions of the parents.

His practical suggestion is to take advantage of the brain trust at the conference and generate some "very simple logic models" that lead to the action items identified by each working group; then collaborate via email to come up with practical, workable action recommendations.

Closing Remarks and Next Steps

Bertram A. Yaffe, NECON Chair