ROUNDTABLE DISCUSSION

Food Policy, Systems, and Environment:Strategies for Making Healthful Food

the Easiest Choice

Moderator: Angie Tagtow, MS, RD, LD1

Participants: Kate Clancy, PhD,2 Joan Gussow, MEd, EdD,3 Eduardo J. Sanchez, MD, MPH, FAAFP,4

Mary Story, PhD, RD,5 and Jennifer L. Wilkins, PhD, RD6

Angie Tagtow: The goal of this roundtable is to have a dis-cussion about the role of food policy, food systems and foodenvironments in assuring that all people, but especiallychildren, have regular access to healthful food. It is an op-portunity to share your expertise and the contributions thateach of you have made within the world of food systems. Iespecially would like you to share your vision of what is ahealthy, sustainable, or resilient food system. Secondly, wewant to discuss how practitioners can engage in this workand highlight tools and resources available to them. Joan,would you start by commenting on why there is increasedattention by clinicians and practitioners to food policy, foodsystems, and food environments and their role in health?

Joan Gussow: I remember speaking 30 years ago and saying,what did we think was going to happen to the children whogrew up being exposed to the kind of things they were seeingon television and the kinds of foods they were being en-couraged to eat? We now know how they grew up. We have ahealth crisis in this country and our children are the leadingedge. But there are a lot of overweight and obese adults too.We have serious problems in this country and I think peoplehave woken up to that. Now they are saying, ‘‘What canwe do?’’

Cynicism aside, I think the way we make healthful food theeasiest choice for all eaters, now and in the future, is to regulateinnovation. I think that the number of products in the super-market—the great majority of them things we don’t wantpeople to eat—makes it extremely hard. So my own feeling iswe are all struggling to try to figure out what to do to changethings. I salute people who try to work in the food marketplaceand we have people from planning groups, actually, workingon the environment now and seeing if they can involve

themselves in the obesity issue and so forth. We have a lot ofpeople engaged because we have such a serious problem.

Angie Tagtow: Great. Mary, Kate, or Jennifer?

Jennifer Wilkins: I really believe that there is increasingawareness that traditional approaches, such as providing in-formation about nutrient and energy content of food, justaren’t enough. At the January 31st 2011 news conferencewhere the new US Dietary Guidelines were unveiled, Secre-tary of Agriculture Tom Vilsack referred to adult, child, andadolescent obesity as a health crisis in the U.S. ‘‘that we can nolonger ignore.’’ The new Dietary Guidelines actually offernumerous strategies at the individual, institutional, andcommunity level that need to be employed to address theobesity crisis.1 There is more and more evidence that multi-level, integrated, and comprehensive approaches are needed.So, I think, given the resistance of obesity and other chronicdiseases to traditional program delivery strategies, cliniciansand practitioners are increasingly compelled to broaden theirscope of practice to include food policy, food systems, andfood environments as potential mechanisms for improvingpublic health.

But also, and this is probably just as much a reason for anincreasing focus on policy, systems, and food environments, isthe recognition that there are, other looming and compellingcrises that also cry out for a shift in diet. The obesity crisis is inthe midst of a constellation of interrelated crises. Climatechange, global energy supplies, and declining fish stocks areat the top of the list of global crises to which decisions abouthow much and what we eat contribute. Within this context,the issue of health and how to decrease over-consumptionand ensure access to healthy food for the nation’s children is

This roundtable discussion is modified from Childhood Obesity April 2011: 83–89 (www.liebertpub.com/chi). Modified with permission.1Owner, Environmental Nutrition Solutions, Elkhart, Iowa.2Food Systems Consultant, Senior Fellow, Minnesota Institute for Sustainable Agriculture, University of Minnesota, Minneapolis St. Paul,

Minnesota, and Visiting Scholar, Center for a Livable Future, Johns Hopkins School of Public Health, Baltimore, Maryland.3M.S. Rose Professor Emerita, Nutrition and Education, Teachers College, Columbia University, New York, New York.4Vice President and Chief Medical Officer, Blue Cross and Blue Shield of Texas, Richardson, Texas.5Professor, Division of Epidemiology and Community Health, Associate Dean for Student Life and Leadership, School of Public Health,

University of Minnesota, Minneapolis, Minnesota.6Senior Extension Associate and Lecturer, Community Coordinator, Cornell Dietetic Internship Program, Division of Nutritional Sciences,

Cornell University, Ithaca, New York.

BARIATRIC NURSING AND SURGICAL PATIENT CAREVolume 6, Number 4, 2011ª Mary Ann Liebert, Inc.DOI: 10.1089/bar.2011.9939

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quite complicated and begs the implementation of compre-hensive, thoughtful approaches.

Mary Story: There has been positive movement the lastfew years in terms of a focus on environmental and policyapproaches for obesity prevention. And there is more evi-dence-based research on environmental and policy researchthat we had not seen before.

Now there is growing recognition in the health and edu-cation fields that individual behavior change can only occur ina supportive environment that has access to affordable andhealthy food choices and opportunities versus collectivity.

In public health, there is evidence that just education aloneprobably has the smallest impact on interventions to affectoverall population health, and that changes to the social andphysical environment may have the most impact. There havebeen very positive changes compared to five years ago interms of changing the school food environment to have lessunhealthy food and beverages and more healthy foods andbeverages in vending machines. When you look at what thesituation was like in the mid-2000s at schools, some of theschool stores looked like mini-convenience stores.

However, there is still a need for continued changes inschools to improve school meals and have more qualityphysical education. But schools are one venue where there hasbeen incredible political, legislative action the past decade toimprove the food environment.

Kate Clancy: Jennifer, you used the phrase, and Mary just did,too, of wanting to improve access to healthier foods. I thinkthere is a caveat there and that is that we may want to improvethe access to a lot of healthier foods in a lot of different places,but I do not really think that is going to be enough. There are alot of other personal and other choices here.

The other thing I would add is that I hope that we will notgo through the whole conversation today without talkingabout physical activity. I know that you have brought to-gether nutritionists, but we are all nutritionists, obviously,who are thinking about climate change and also the physicalenvironment.

Angie Tagtow: What does the research say about how someof these policy, system, and environment changes may or maynot have an effect on diet-related diseases? Mary, let’s startwith you as you have done a lot of research in the area ofadvertising and marketing to children.

Mary Story: We just did a recent review looking at neigh-borhood food environments. We know that poor dietarypatterns and obesity are established risk factors for chronicdiseases. These risk factors are linked to neighborhood dep-rivation. Differences in neighborhood access to healthy foodhave an important influence on health.

In our review, we found that research is strong showing thatneighborhood residents who have better access to supermar-kets tend to have healthier diets and lower levels of obesity.

With neighborhood disparities in access to healthy foodand the link to health and wellbeing this speaks to the need todevelop strategies to bring healthy food into low-incomeneighborhoods. This is being done by bringing more grocerystores into low-income areas and through local efforts such ascommunity gardens and farmers’ markets and mobile fruitand vegetable vendors.

But while we need to increase access to healthy foods for allAmericans, we also have to decrease access to the unhealthyfoods. We need to look at what we can do to reduce sugar-sweetened beverages (SSBs) since there is a link betweensugar-sweetened beverages and weight gain. Schools havemade positive changes in removing sugary drinks and nowseveral states and localities are looking at taxes on SSBs.

Kate Clancy: Mary, do we have any data—and I think this isdirectly to the question of adult obesity, maybe, more thanchildren. But with the increase in, let us say, obesity across thepopulation, what do we know about the increased rate in themiddle class in comparison to low-income adults?

Mary Story: Obesity is prevalent among all Americanadults—with two-thirds of the population being obese oroverweight and one-third of children being overweight orobese. But the groups that are most affected are low-incomeand racial and ethnic minorities.

Angie Tagtow: Kate, do you want to talk more about cre-ating environments in which physical activity becomes partof a daily routine?

Kate Clancy: I think that it is really a question of resources andpolitical will, as well as a lot of other things, to make sure thatchanges are being made to address the issues. These include thelack of sidewalks in suburbs, no walkability to places to buyfood and no PE, and the list goes on and on. I do think it is a greatbenefit that Joan already mentioned that the planning com-munity has come into the conversation—actually, they came inabout ten years ago—in terms of looking at the effects of sprawlon health and other things like that. I will add that I do not thinkwe want to ever separate the food environment from whatpeople call the built environment or the active environment.

Jennifer Wilkins: To go back to the question of what researchcan offer, some of the recent work that the Rudd Center hasdone looking at the impact of changes in pricing, adding acertain level of tax to, say, sodas is quite compelling. The roleof pricing on intake of nutrient dense versus energy-denseoptions is, of course, complex, but using pricing through taxesor incentives may have a positive impact on intake in differentsectors of the population. That kind of research, I think, canhelp in terms of policy having to do with the basic pricing, ifyou will, maybe even in terms of subsidies for commoditiesand how that relates, then, to the very cheap price of emptycalories in the marketplace.

Joan Gussow: I have been particularly struck lately by theissue of inequality in this country. There was just a major piecein the Times showing that we were the worst of the worst interms of the Gini coefficient, that we have the most inequalityin terms of income. I do not really think, as Kate says, that wecannot not talk about exercise, we cannot not talk about moneyhere. We are talking about the people who are most at risk, thepeople who can least afford the foods we want them to eat,and we really have to recognize that we all need to find waysof addressing the question of income inequality as services arecut and the rich are making off with more and more money.We have to have some kind of force coming from belowsaying, ‘‘This will not do.’’

It has to do with whether people can exercise, if they livein neighborhoods where they cannot. We all know these

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things. They are all the reality. But the reality is, we just havethis incredibly unjust society, and it is making the poorestpeople sick.

Mary Story: Building on what Joan said, turning this into afood justice issue of a lack of access to healthy food in manylow-income neighborhoods.

Jennifer Wilkins: I would say that goes across the foodsystem, starting with the people that produce our food, thepeople that work on farms, the people in processing in-dustries. We have to think about justice throughout thefood system, and really address the inequalities when itcomes to food making, the money in the food system, andwho has the influence on policy in the food system. Untilthose things are really addressed, I do not think we aregoing to be directing policy in a way that is at its corebased on public health.

Angie Tagtow: That is actually a great segue into our nextquestion, and Jennifer you can lead off because you have al-ready touched on federal policy. When we think of foodsystem legislation we often think of the Farm Bill and ChildNutrition Reauthorization. How do you see those pieces offederal legislation as impacting the availability, quality,quantity, and the safety of our food system?

Jennifer Wilkins: One of the things I would like to lay out firstis a potential conflict or maybe contradiction, because we talkabout making healthy food really affordable and accessible,and generally what that brings to mind for people is reallyinexpensive fresh fruits and vegetables. But then if you look atthe production side of that, we have to consider, do we notwant food producers who are essential to assuring food accessand availability, to make a reasonable living? So we can talkabout reducing food prices, but maybe where public policycan come in is subsidizing the price.

We have many policy mechanisms in place already that, ifused differently, could really make a difference in terms ofaccess, availability, and affordability of good food for low-income consumers. I am thinking of the biggest of the big foodassistance programs—and Kate, you know what is coming, sowe can have our little disagreement again. If we look to thelargest title in the Farm Bill, the Nutrition Title, where SNAPis, the Supplemental Nutrition Assistance Program, we canfind a largely untapped opportunity to improve public healthwhile at the same time stimulate a more diversified sustain-able agriculture. Currently, there are no nutrition standards inSNAP, formerly the Food Stamp Program (i.e., no restrictionson the type or quality of food that can be purchased), and thefood system at the time that it started was a much differentsystem. The food supply did not have the high proportion ofempty calories that it does now, and it did not have the highproportion of shelf space devoted to foods that are very in-expensive but basically provide sugar and fat (i.e., processed,packaged foods).

Could we not take advantage of the fact that, as a nationwe—and thank goodness we still do—make significant,though still inadequate, investment in feeding the poor andmake a shift in SNAP policies so that it would push more of ahealthful ‘‘dietary profile,’’ if you will? We have models forthis already, especially with the WIC, Women, Infants, andChildren Program, where participants can use their WIC

vouchers only to buy foods that meet a nutrition standard thata few years ago (2007) was revised to meet the DietaryGuidelines. And more recently WIC has added specialvouchers each month that can be used only to buy fruits andvegetables. In these ways, the investment of public money tonutrition assistance has a better chance of nourishing the poor,not just filling them up. And another likely outcome of placinga similar nutrition standard on SNAP would be that thebenefit itself would become an effective nutrition educationtool—by steering participants toward more nutrient denseoptions over nutrient poor calorie-packed junk food, theirchoices in the marketplace would be more in line with theDietary Guidelines.

These mechanisms could spell positive shifts in the foodsystem at the same time since more and more Americans areenrolled in food assistance programs. According to theUSDA’s latest Food Assistance Landscape report, about 15percent of U.S. households are ‘‘food insecure’’ and thereforewill need this kind of help. Actually, the report suggestsnearly half of all U.S. kids will be on food stamps at somepoint during their childhood.

I’m not suggesting that developing a nutrition standard forSNAP would be easy. And food and nutrition professionalswould certainly disagree. But it certainly is worth consideringgiven the potential public health and food system benefits.

We also need to change our subsidy program, but I do noteven know where you start to do that, given the very pow-erful interests, even though it is dwindling in number, thatseem to have a grip on continuing the system of agriculturalsubsidies.

Joan Gussow: A lock. Not just a grip, a lock.

Kate Clancy: I want to bring up a couple of things and one isthat food that is the healthiest is what is coming out of prettymuch any farmer’s field unless there have been too manypesticides or fertilizers on that field. So much of the problem iswith manufacturing and with processing. I think we are giv-ing the Farm Bill a lot more attention than it requires, and notputting enough attention on manufacturers in terms of whathappens to perfectly healthy food after it goes out of thefarmer’s hands.

Another thing is that the USDA Economic Research Servicehas recently done some research, I think in reaction to theAmerican Medical Association article that made such a bigdeal about saying that the cost of fresh fruits and vegetableshad gone up so much over time and the cost of junk foods hasgone down. When ERS disaggregated the data, they foundthere were 12 or 15 types of fruits and vegetables where theprice, the real price, had not changed at all. I do not think a lotof people saw that analysis, and I think it is one of our jobs topay attention to the fact that the price has not changed formany fruits and vegetables, and also to try and figure out howto make that message clearer to people.

The other thing I want to point out is that even Daryll Ray,who is one of the more radical agricultural economists weknow, has argued that there is very little impact of subsidieson the extent of obesity or unhealthy diets in the country. Youdo not have to agree with that, but I think it is important thatnutritionists and people who are arguing about this read allthe studies and make some decisions about where we shouldput most of our energy in terms of trying to identify andaddress the right problem.

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Mary Story: I would like to mention another area of foodpolicy, and that is the Child Nutrition Reauthorization Bill.The Healthy, Hunger-Free Kids Act was just signed in De-cember 2010. This is historic in that it makes the most signif-icant investment in the national school lunch program in morethan 30 years. It shows the positive effects of increasing theavailability of foods that support good health for kids. Thisnew bill gives USDA the authority to develop nutritionstandards for all foods sold on school campuses throughoutthe school day. So the Child Nutrition Reauthorization Actthat is, again, every five years, like the Farm Bill, is a placewhere we really can focus our efforts.

I wanted to mention one other area that is not covered bythe Child Nutrition Act or the Farm Bill, but I think is abso-lutely critical if we want to reduce childhood obesity, and thatis the regulation of food marketing to children. The Institute ofMedicine (IOM) Food Marketing report, in 2005, found strongevidence that food and beverage marketing practices thattarget youth are out of balance with healthful diets and con-tribute to an environment that puts their health at risk.2 Un-less we address marketing to children of unhealthy foods, I donot think we are going to really reduce childhood obesity.

I just wanted to add that I remember, Joan Gussow, thatyou had an article on advertising of unhealthy foods to chil-dren in the Journal of Nutrition Education years ago.3

Joan Gussow: I remember being very scared when I pub-lished that article, because it broke all the rules and mentionedfoods and said some of them were bad. I was saying tosomeone this morning that what gave me my courage wasthat I got about 50 letters after that article came out frompeople saying, ‘‘Thank God somebody said it.’’ So it was clearthat people were feeling that way, and they felt rather helplessagainst this onslaught.

I am glad you brought this up, because I guess I feel a little likean old-timer in this whole thing. But it is appalling to me thedegree to which we have not really done anything about ex-cessive food marketing targeting children. I mean, what hashappened is, it [food marketing] has gone off television, becausechildren are not watching children’s television, they are watch-ing everybody’s television now. It has gone on to the internet, sochildren are being marketed to all the time. It has gone intoschools, onto school bags, into textbooks. It is everywhere. If youare learning to count, you count four pieces of Reese’s Pieces—itis unbelievable how pervasive the marketing is.

We do not seem, as a culture, to be capable of saying ourchildren ought to be protected from these kinds of exposureswhich are killing them. So I would be happy to hear fromanybody who has any ideas about how we begin to changethat. Interestingly enough, my article got reprinted at the timein the journal Clinical Pediatrics, and the title was, ‘‘It MakesEven Milk a Dessert’’ which was a great title for it.4 It was notthe title the Journal of Nutrition Education used.

Kate Clancy: I will just mention that I think 1974 or 1975 wasthe first year I published an article on the effects of televisionadvertising on kids’ food intake, and of course then we didthe food advertising rule at the Federal Trade Commission.I think now we need some incredible legal brains to figure outhow to not run into the First Amendment—which was thereason that it did not work the first time—with regard totelevision advertising, or advertising to kids. I have not seen

anybody tackle that in a really long time. It does not mean thatwe cannot try to really get to the political will, but themanufacturing sector is always going to go back to the FirstAmendment.

Joan Gussow: Do you remember what happened the first timethe Federal Trade Commission tried to regulate food adver-tising? They were shut down for two days because Congressdid not appropriate the money to keep the agency open.

Kate Clancy: And we at the Federal Trade Commission werecalled the ‘‘national nanny.’’

Joan Gussow: Yes, and the food marketers came to Wa-shington on that and just shut down the Federal TradeCommission. So we are not in a particularly wonderful en-vironment for doing any kind of regulation these days, but Ithink we all just have to keep trying.

Kate Clancy: Absolutely.

Angie Tagtow: Bridging the conversation from a federal-level activity down to a local or regional level—in 2009 theIOM released the publication ‘‘Local Government Actions toPrevent Childhood Obesity.’’5 Mary, you were on that com-mittee. So my question is what can local governments reallydo in all of these areas to support more healthful nutritionand physical activity behaviors, especially for children?

Mary Story: The Institute of Medicine report, which is on theIOM website, came out in September of 2009, and has evidence-informed strategies that communities could use. They arefocused both on actions for healthy eating and actions forincreasing physical activity. Under the actions for healthy eat-ing, there are two main goals: one is to improve access to andconsumption of healthy, safe, affordable foods through strate-gies like retail outlets, restaurants, community food access, andalso increasing breastfeeding; and two is to reduce access to andconsumption of calorie-dense, nutrient-poor foods, through taxstrategies or adopting land use and zoning policies.

Joan Gussow: Mary, has anybody used the idea of zoning sothat you cannot have fast food places and places to pick upjunk food near a school?

Mary Story: Yes, and the Robert Wood Johnson Foundation(RWJF) has devoted many resources to looking at environ-mental and policy approaches. For example, one excellentresource is the RWJF funded NPLAN (National Policy andLegal Analysis Network). NPLAN has developed local zon-ing templates that communities can use and these are on theirwebsite (www.nplanonline.org). Researchers are looking atcorner stores located in close proximity to schools that sellunhealthy foods and zoning issues. There are data to showthat fast food places often are located in close proximity toschools and that appears to be related to obesity risk.

Jennifer Wilkins: There is a really creative program that Ithink was proposed for New York City looking at the im-provement in grocery stores in the city. The retailers were of-fered incentives to have a certain amount of shelf space in thestore devoted to nutrient-dense foods to get the money to do theimprovements. So I think incentives like that can be very useful.

Another example in the Child Nutrition ReauthorizationAct supporting local action is support for farm-to-school

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programs, so that would be something that is also very usefulat the federal level that can have a local impact.

Angie Tagtow: Your thoughts, Eduardo, on what local gov-ernments can do to support not only nutrition but physicalactivity behaviors?

Eduardo Sanchez: There are actually a couple of other reportsthat came out at around the same time as the IOM report,another RWJ-supported healthy communities report came outand the CDC issued a report.

So in the IOM report there are 58 what we called actionsteps. Roughly half of them are in the food system area, androughly half of them deal with physical activity and the builtenvironment. The IOM report focused on food and built en-vironment strategies likely to directly affect children and thattake place outside of the school day. Twelve were identified as‘‘most promising.’’ Among the 12 are the following: Developmedia campaigns to promote healthy eating and active living;Attract supermarkets and grocery stores to underservedneighborhoods; Require menu labeling in chain restaurants;Mandate and implement strong nutrition standards for foodsand beverages in government-run or regulated after-schoolprograms; Adopt building codes to require access to, andmaintenance of water fountains; Build and maintain parksand playgrounds that are safe and attractive for playing, andclose to residential areas; and Institute policies mandatingminimum play space, physical equipment, and duration ofplay in preschool, after-school, and child-care programs.5

Just the other day, I spoke at a school community gardenevent in Dallas, and there was discussion about policies andzoning ordinances to make it easier for folks who want to putcommunity gardens in their communities to be able to do so.In some of the talks that I have done about local level actionsto address healthy eating and childhood obesity, one issuethat has come up that I do not think is addressed in the localgovernment actions report is the idea of lower water rates forthose organizations and individuals that are tending com-munity gardens. If I understood correctly, the consumer rateis different than the corporate rate—and that having an ex-emption, a waiver for the lowest possible rate, that in someplaces may already exist but in other places may require anexplicit policy, would also help community gardens.

Angie Tagtow: Does anyone else want to comment on whatlocal governments can do?

Mary Story: I think that local governments are really impor-tant and a lot of innovation happens at the local level that canthen go up to the state level and federal level. But I thinkhaving local governments involved is the best place to seewhat works and to come up with innovative things that oftencannot be accomplished at a state level, or a federal policylevel.

Angie Tagtow: So, Mary, how do practitioners get engaged?What can practitioners do at the local level to make foodpolicy, systems, and environmental changes that supporthealthful food choices?

Mary Story: It is probably easier to get involved at the locallevel than it is at the state level. Also, in the local government,the IOM report, there are recommendations to have local foodcouncils or healthy food, physical activity councils that really

can bring people together, and this would enable more impactat the community level.

Jennifer Wilkins: In terms of what practitioners can do, justbecoming aware of these different recommendations, theseideas, and these best practices is so important—getting foodsystem policies on the agenda of different community groupmeetings, working through cooperative extensions if theyexist in the community, and really becoming that local re-source for ideas and working with groups to inspire their ownversions of those strategies.

Joan Gussow: We cannot underestimate the effect—on thepotential to change children’s eating habits—of school gar-dens and community gardens. We know that they reallychange what people eat and that that is something practi-tioners can really promote.

Eduardo Sanchez: I would underscore the importance of (A)knowing what is going on in communities, (B) referring to thethree previously cited reports and (C) meeting the communitywhere it’s at in terms of its awareness and readiness to takeaction.

Rather than thinking that they need to be where you are, itis more important to ask ‘‘where are they?’’ If it is about en-gaging food and food-related policies, we need to ask, ‘‘whereare they with these issues?’’ Then, how do you sit together atthe table and mutually put food system and health benefits onthe table. Then perhaps create a bridge to even more healthfolks, nutritionists and health educators, for example, whosometimes are not thinking along the lines of a communitygarden or water fountains as strategies for health.

Kate Clancy: It seems to me that—and I am assuming dieti-tians are health practitioners, too—all of these people havedifferent roles, and one is the professional role. But probablymost of them are parents or they live in neighborhoods wherethey can use their positions and their knowledge by beinginside PTAs and being on neighborhood councils to put to-gether community gardens, et cetera. I could see them asseparate forces that would be really useful inside local areas.

Jennifer Wilkins: Building further on that, I think that a lot ofus in this movement who are interested in these areas do notlook like a lot of the members of the communities that arereally affected by the negative aspects of the food system. Sopart of the role of the practitioner, I think, is to engage dif-ferent audiences from the community in being that spokes-person, so that if you are not really of the same culture or thesame ethnicity, then building that capacity within thosegroups is, I think, critical to change, because you want them tobe leaders and change makers.

Eduardo Sanchez: Agreed, Jennifer. I had an experience that Iwant to share with you. At a talk that I gave at the Dallasschool with the school gardens program, I could not answer aquestion about why the vegetables grown in the school gar-den could not be served in the school cafeteria. But it turns outthat there was a school board member in the audience whoagreed to investigate what the barriers might be. Are theyreal? Are they perceived? And how would one go aboutchanging those barriers? Practical considerations, such asconsuming vegetables in the cafeteria, sometimes are notthought about and will not be thought about unless you put

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people around the table and start asking, ‘‘Okay, so you havegardens and you are growing food. Where do you want to gowith that?’’ These are the kinds of questions and issues wherehealth practitioners can help bring a perspective that maydrive a point like that home.

Jennifer Wilkins: Again, that relates to policy. These barriersmight be at the local level, state or federal, and may restrict theuse of locally grown or garden-grown food to be used in thecafeteria. I am not undermining or not saying that the im-portance of food safety is not there, it really is, but sometimespolicies can create barriers where they needn’t.

Angie Tagtow: There was a new document released—a jointeffort by the American Dietetic Association, the AmericanNurses Association, the American Planning Association, andthe American Public Health Association—that framed quiteconcisely the principles of a healthy, sustainable food sys-tem.6 How can communities or health practitioners use toolslike that to perpetuate change?

Jennifer Wilkins: I took this document to my departmentchair who thought it was so amazing, so I think that is a goodquestion. Disseminating through our networks is a first step.Then also operationalizing and taking that document andsaying, ‘‘So, what does this mean on the ground to us in thiscommunity?’’

Angie Tagtow: Do you have any other tools to share thatwould be very helpful for health practitioners?

Mary Story: One tool that I think is very helpful is the USDAFood Environment Atlas that you can find on the USDAEconomic Research Service website (http://www.ers.usda.gov/foodatlas). From this website one can get a spatialoverview of a community’s ability to access healthy food. Itincludes factors related to food choices, health and well-being,community characteristics at both the county and state level,and you can map grocery stores and chronic disease ratessuch as diabetes, obesity rates.

The other resource that I think is helpful for childhoodobesity is the Robert Wood Johnson Foundation Center toPrevent Childhood Obesity. It is www.reversechildhoodobesity.org. There is a lot of information there and resourcesfor practitioners. Also, the letsmove.gov website has a lot ofstrategies for practitioners, both at the local and state level.

Kate Clancy: I will add a ‘‘tool’’—a systems approach thatencourages multiple simultaneous interventions, in local ar-eas. I understand that more recently, foundations and othergrantors have been more willing to think about these whenthey would not do that before, because they would not knowwhat was actually working and what was not.

I cannot name a particular tool, but I think it is critical,especially with all these other issues coming along, for ex-ample this great increase in food prices that is going to con-tinue, because you do not have world reserves of grains; andclimate change, which, as we all know, is coming much fasterthan anybody thought. The tools that should be developedwill help people think about feedback loops and systemsanalysis. We also need to develop tools for people in localareas, starting with practitioners, to make it easier for them tosee the systems overlaps and the contradictions so that theycan be asking the right questions about what should be done.

Eduardo Sanchez: The Food Trust has done work in somespecific places. In December 2010, the Food Trust released areport, ‘‘Food for Every Child: The Need for More Super-markets in Houston,’’ that focused on Houston to raiseawareness about food system shortcomings in Texas and policysolutions.7 The work of the Food Trust coupled with the USDAFood Environment Atlas can be a powerful catalyst for change.

Kaiser Permanente is obviously doing some work on a verydifferent level and in a different way of thinking about this bytaking steps to procure food locally for its facilities and thepeople in them. There are going to be discussions in com-munities across the United States in the post-health reformenvironment about accountable care organizations, ACOs.On the one hand, we need to understand how an ACO isdefined, and, on the other hand, we will need to articulateclearly that the food system, because it can help or hinderhealth, should be considered part of an ACO.

To make this point more clearly, more than 50 millionAmericans have prediabetes. Healthy eating and physicalactivity can lower, by more than 50%, the conversion of pre-diabetes to full blown diabetes, a very serious disease. Foodpolicy, food systems, and food environments that makehealthy eating the easy and desired option are necessary topromote health and prevent and reverse obesity, prediabetes,diabetes, and a host of other chronic diseases.

Angie Tagtow: I want to thank each of you for taking timeout today and participating in this roundtable discussion.

Author Disclosure Statements

No competing financial interests exist for Angie Tagtow,Kate Clancy, Joan Gussow, Mary Story, and Jennifer Wilkins.Eduardo Sanchez is an employee of Blue Cross and BlueShield of Texas, a Division of Health Care Service Corpora-tion, a Mutual Reserve Company.

References

1. U.S. Department of Agriculture. Dietary Guidelines forAmericans, 2010. Released 1/31/11. Available at: www.cnpp.usda.gov/DGAs2010-PolicyDocument.htm Last ac-cessed March 29, 2011.

2. Institute of Medicine. Food Marketing to Children andYouth: Threat or Opportunity? Released December 5, 2005.Available at: www.iom.edu/Reports/2005/Food-Marketing-to-Children-and-Youth-Threat-or-Opportunity.aspx. Last ac-cessed March 29, 2011.

3. Gussow J. Counternutritional messages of TV ads aimed atchildren. J Nutr Educ. Spring 1972;4:48–52.

4. Gussow J. ‘‘It makes even milk a dessert.’’ A report on thecounternutritional messages of children’s television advertis-ing. Clin Pediatr. (Phila). 1973 Feb;12(2):68–71.

5. Institute of Medicine. Local Government Actions to PreventChildhood Obesity. Released September 1, 2009. Available at:www.iom.edu/Reports/2009/Local-Government-Actions-to-Prevent-Childhood-Obesity.aspx. Last accessed March 29, 2011.

6. American Planning Association. Principles of a Healthy, Sus-tainable Food System. www.planning.org/nationalcenters/health/foodprinciples. Last accessed March 29, 2011.

7. The Food Trust. Food For Every Child: The Need for MoreSupermarkets in Houston. December 2010. Available at:www.thefoodtrust.org/pdf/FoodForEveryChild—Houston.pdf. Last accessed March 29, 2011.

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