Clinical and Health Affairs
Giving Health a Place at the Table
Two Years of Progress on Minnesota’s Obesity Plan
By William E. Burleson
Minnesota’s rising number of obese and overweight residents prompted the Minnesota Department of Health in 2008 to create a plan to reduce obesity and its associated health consequences. The plan attacks the problem from both an individual and a public health perspective. This article describes Minnesota’s obesity plan and reports on progress that has been made to date.
In fighting obesity, health care providers and public health organizations are tackling the same problem from complementary perspectives. Clinicians can make the difference between life and death for individual patients, at times intervening before the damage is done and, sadly, at other times, after a patient develops a chronic disease such as cardiovascular disease, diabetes, or cancer. The messages clinicians give their patients may be the key to making behavior changes necessary for them to extend and improve their lives. Public health seeks to work upstream with communities to reduce obesity rates and, thus, prevent chronic disease before it begins. This model assumes that health is a product not only of personal choice but also of environmental influences such as culture, community, relationships, the physical world, economics, and employment.
Addressing these social determinants of health is at the core of Minnesota’s obesity plan, the “Minnesota Plan to Reduce Obesity and Obesity-Related Chronic Diseases 2008-2013: Promoting Healthy Eating, Physical Activity and Healthy Weight.”
Developed by the Minnesota Department of Health’s Physical Activity and Nutrition (MnPAN) Program, the obesity plan is based on ideas and feedback from a broad range of stakeholders concerned about Minnesota’s rising rates of overweight and obesity, as well as the poor eating habits and physical inactivity that have contributed to them. Those stakeholders included representatives from state and local governments; transportation and parks and recreation organizations; academic institutions; early childhood and primary and secondary educational institutions; health care organizations and insurance companies; media outlets; businesses; and community development, nonprofit, and chronic disease prevention advocacy organizations. States across the country have created similar plans as a first step in developing a coordinated effort to reduce obesity and the chronic diseases that go with it.
Obesity in the United States and Minnesota has risen at alarming rates. Boys and girls, men and women, and all racial and ethnic groups are affected. According to the Behavioral Risk Factor Surveillance System survey, in 2006 nearly 25% of adults in Minnesota reported height and weight that classified them as obese (Body Mass Index or BMI>30)—a 2.5-fold increase since 1990 (Figure). In addition, 38% of Minnesota adults reported being overweight (BMI=25 to 29.9), meaning nearly two-thirds of adults in Minnesota are either overweight or obese.1
The health effects of obesity are well-known and are affecting an increasing number of people. Thirty-three percent of Minnesotans have high cholesterol, 22% have high blood pressure, and 6% have diabetes.2 In 2005, one in four Minnesota adults reported having been diagnosed by a physician with arthritis.2
Today’s obesity rate is to a large degree a symptom of the real problem: For 20 years, we’ve seen an increase in poor eating habits and physical inactivity. In Minnesota, 51% of adults do not achieve the recommended level of weekly physical activity of at least 150 minutes a week of moderately intense or 75 minutes a week of vigorous aerobic activity.3 We live in a time when exercise is something we must make a conscious effort to get. Whereas someone once might have walked five blocks to the street car and then four blocks from the street car stop to their destination, today they’re more likely to drive and look for a parking spot close to the door. More and more jobs involve sitting and looking at a computer screen, and fewer and fewer involve manual labor. Outside time has been increasingly replaced by time spent watching television, working on computers, and playing video games. According to the 2007 Minnesota Student Survey, 49% of 12th grade boys and 37% of 12th grade girls reported watching six hours or more of television or videos per week, and 32% of 12th grade boys reported playing computer or video games for six hours or more per week.3
During the same time period, our diets have deteriorated. In 2008, Americans spent $422 billion (41% of all food expenditures) eating out.4 Many of those meals consisted of foods that are high in calories and have little nutritional value. Forty-seven percent of 12th-grade girls and 65% of 12th-grade boys report drinking at least one soda a day.3 At the same time, portion size keeps increasing, with the size of sodas, for example, growing from 8 ounces to 16, 32, and up. We’re supersizing our way to poor health. In contrast, 81% of Minnesotans consume fewer than the recommended five servings of fruits and vegetables per day.2
Minnesota’s Obesity Plan
Awareness of these trends led to the creation of Minnesota’s obesity plan in 2008. The plan outlines the causes and effects of obesity and is a call to action, describing evidence-based solutions that attack the problem at multiple levels. In this arena, physicians and other health care professionals play a crucial role. Specifically, the plan calls for them to provide lactation support services to new mothers, measure and monitor all patients’ BMI, and provide counseling about weight loss, nutrition, and exercise.
The plan also emphasizes the need to address the root causes of obesity and the reasons Minnesotans do not engage in healthy behaviors. For example, many new mothers who want to breastfeed their babies, which has been proven to reduce the risk for obesity and chronic disease in adulthood, face barriers in the workplace. People have long been told to walk 30 minutes a day, but many cannot do so because they do not live in areas with sidewalks or have safe ways to cross the street. People might know eating more fruits and vegetables is a key to good health, but they do not live within a reasonable distance of a store that sells them. We can suggest people bike more, but to do that, they need safe places to ride.
Because individual behavior is often affected by social and environmental factors, the state’s obesity plan focuses on advocating for systemic change in schools, businesses, and the community. If we are to have a real and sustainable increase in physical activity, we need streets with sidewalks and safe crosswalks, more bike and walking paths, routes to school that are safe from traffic, and more. In order to improve the diets of Minnesotans over the long term, we need Farm-to-School initiatives that bring fresh produce to our school lunch programs and improved school policies regarding food, snacks, and sugar-sweetened beverages. We also need businesses to look at their catering policies and include more healthful foods in their offerings, and we need more farmers’ markets and community gardens. Health plans need to cover the cost of breastfeeding equipment, and health care institutions need to look at their policies regarding baby formula companies’ access to new mothers and how industry marketing and maternity support systems influence infant feeding practices.
Progress to Date
Two years into the obesity plan, MnPAN can report two overarching achievements. First, the plan has served to inform the Statewide Health Improvement Program (SHIP), a component of Minnesota’s 2008 health care reform legislation. All counties and many tribal governments that received SHIP grants from the state are now working to increase healthy behaviors and prevent the leading causes of illness and death: tobacco consumption and obesity. Their efforts are based in part on the evidence and recommendations presented in the plan. For example, the plan encourages and SHIP recipients now work to implement policies, ordinances, and zoning requirements that support pedestrian- and bicycle-friendly development. In addition, the plan calls for policies that support school gardens to increase the amount of fresh vegetables served in schools. As of this spring, all SHIP programs have moved from planning to implementation, meaning that in the near future we can expect to see more kids walking to school, greater availability of fruits and vegetables in schools and in neighborhoods, and access to safer pedestrian and bike routes.
The second achievement is that now, for the first time, health has a seat at the table in a variety of new arenas. MnPAN staff created a coalition of organizations involved in transportation and urban planning that includes representatives from the Minnesota Department of Transportation, the Pollution Control Agency, and the Department of Public Safety to ensure health is considered in future efforts. In addition, MnPAN staff are working with some of the largest employers in Minnesota including Target, Medtronic, Cargill, and General Mills to encourage workplace wellness. MnPAN staff also created a coalition of state agencies that have a direct impact on our food systems. The Healthy Eating Coalition includes four state agencies—the departments of Health, Education, Agriculture, and Human Services. In its first year, coalition members identified overlapping efforts concerning nutrition education and began working together on several projects. One involves the Department of Education and the Minnesota School Nutrition Association working with the University of Minnesota to plan a statewide workshop to educate food service personnel about Farm-to-School best practices in order to increase students’ consumption of fruits and vegetables. In another, the departments of Agriculture and Education are encouraging local food processors to add fresh produce to their canned and frozen offerings for schools.
Initiatives like the ones being done through the Healthy Eating Coalition can result in real, systemic change that will net measurable and sustainable health-improvement outcomes across Minnesota. But they are not all that is needed. By working with patients to increase their physical activity, improve their diets, and breastfeed their babies, physicians and other health care providers can influence health outcomes. For many patients, this individualized approach may make the difference between living a full life of good health or a life limited by chronic disease.
Making healthy living a priority for individuals is a key to reducing obesity. Keeping the health of the community in mind as we build our streets, educate our children, and pursue our work lives is another. We can improve the health of our population, and the Minnesota obesity plan is showing us the way. MM
William Burleson is communications coordinator for the Minnesota Physical Activity and Nutrition Program.
1. 2006 Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention. Available at: www.cdc.gov/brfss/ Accessed May 10, 2010.
2. 2007 Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention. Available at: www.cdc.gov/brfss/ Accessed May 10, 2010.
3. 2007 Minnesota Student Survey, Minnesota Department of Health. Available at: www.health.state.mn.us/divs/chs/mss/statewidetables/mss07statetablesfinal.pdf. Accessed May 18, 2010.
4. USDA. Food expenditures by families and individuals as a share of disposable personal income. Available at: www.ers.usda.gov/briefing/CPIFoodAndExpenditures/Data/table7.htm. Accessed May 18, 2010.