Lawrence Wallack , D R PH Dean and Professor of Public Health College of Urban and Public Affairs

1. Talking Public Health: America’s Second Language and What It Means for Public Health Nutrition Advocates Guiding the Winds of Change in Public Health Nutrition Association of State and Territorial Public Health Nutrition Directors Annual Meeting June 15, 2009 Lawrence Wallack, DRPH Dean and Professor of Public Health College of Urban and Public Affairs Portland State University Special thanks to Liana Winett, DRPH for her assistance with this presentation.

3. Obesity Trends* Among U.S. AdultsBRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

4. Obesity Trends* Among U.S. AdultsBRFSS, 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

5. Obesity Trends* Among U.S. AdultsBRFSS, 1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

6. Obesity Trends* Among U.S. AdultsBRFSS, 1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

7. Obesity Trends* Among U.S. AdultsBRFSS, 1998 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

8. Obesity Trends* Among U.S. AdultsBRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

9. Obesity Trends* Among U.S. AdultsBRFSS, 2002 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

10. Obesity Trends* Among U.S. AdultsBRFSS, 2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

11. Obesity Trends* Among U.S. AdultsBRFSS, 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

12. Obesity Trends Among U.S. AdultsBRFSS,1990 vs. 2007 1990 2007 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

15. Thanks to CCPHA for this cartoon

19. Following Shrek’s Advice To burn off the calories in one bowl of Shrek cereal, a 60-lb person would have to perform 2100 jumping jacks!

20. Two Stories about diabetes: what is the right balance? PUBLIC POLICY BEHAVIORAL Who are the characters? Who is at risk or harmed? Who is inflicting harm? What are the solutions? Who can advance the solutions? What are the underlying values? INDIVIUAL COMMUNITY

21. Some questionable beliefs • The facts will set you free. • The data speak for themselves. • We need to educate everyone. • We just need a catchier message/slogan. • I understand it so everyone else should. • Those who don’t support us don’t make sense.

22. Basic Public Health Question Will the public’s health improve primarily as a result of: individuals getting more and better knowledge about personal risk factors OR groups getting more skills and opportunities to participate in changing public policies?

24. Land of controversy: the upstream territory • Distant from perceived immediate causes • Perceived as minimizing individual responsibility • Addresses issues of social or public policy • Often confronts well financed corporate interests • Few short term indicators of success

25. “…20 years from now people will look back and say: ‘What were they thinking? They’re in the middle of an epidemic and kids are watching 20,000 hours of commercials for junk food.’” Dr. Thomas R. Frieden NYC Health Commissioner New York Times, 1/9/06

26. What are frames? • Frames are mental structures that help people understand the world, based on particular cues from outside themselves that activate assumptions and values they hold within themselves. Berkeley Media Studies Group

27. QRFSJTV

28. QRFSJTV

29. I JFAI TI IV FATJNC

30. I JFAI TI IV FATJNC

32. OBESITY and HEALTHY EATING… What do these mean?

33. Lakoff’s levels of analysis • Level 1: Big ideas and universal values like fairness, family, community, equality, and justice • Level 2: Issue types such as housing, civil rights, the environment, public health • Level 3: Specific issues such as rent subsidies, beer taxes, toxic waste sites Adapted from The Frameworks Institute http://www.frameworksinstitute.org

34. Childhood Obesity Arguments

35. Framing tension Dominant Values • Self-determination/Self discipline/Rugged individualism • Benefits based solely on effort • Limited obligation to collective good • Voluntary and moral nature of behavior • Limitedgovernment intervention Social Justice • Shared responsibility • Interconnectedness • Strong obligation to collective good • Basic benefits should be assured • Government involvement necessary Adapted from Beauchamp, 1976

36. The challenge to rebalance Community, policy, social, economic understanding Personal, behavioral, Individual/family understanding

37. Simplifying Model ChallengeJoe Grady and Axel AubrunCultural Logic LLC Take something that is familiar, easy to understand, rooted in explicit values and use it to explain your issue. It’s like …. Childhood development Kids are like sponges Kids are like modeling clay Nutrition You are what you eat What’s around us shapes us

38. How do you structure the environmental approach? “In many neighborhoods, there is little or no access to affordable healthy foods, and the lack of infrastructure and/or public safety issues make regular physical activity difficult to achieve. It is not surprising that people in these neighborhoods suffer from higher rates of overweight and obesity. These problems go beyond factors under the control of families and individuals to include conditions in our social and physical environments that encourage people to eat and drink unhealthy foods and beverages and limit their physical activity.”

39. What is the broader social/community issue? e.g. protection of children, ensuring high functioning communities • What is the shared responsibility for change? • e.g. parents, school boards, government nutrition programs, large grocery stores, restaurant chains • What needs to be done in policy terms?) e.g. Increase access to health food options, improve neighborhood design, change composition of school lunches, broaden food stamp eligibility • What are the practical and value appeals? e.g. Protect children, save lives, promote opportunity, protect the community • What elements can shape the story? e.g. visuals, media bites, social math, authentic voices Framing

40. What is the broader social/community issue? e.g. protection of children, support for families • What is the shared responsibility for change? e.g. parents, city council, non-profits, corporations • What needs to be done in policy terms? e.g. draw from menu physical activity and nutrition policies • What are the practical and value appeals? e.g. saves money/protects children, fairness for the community, shared responsibility • What story elements can shape the story? e.g. visuals, media bites, social math, authentic voices Framing

41. The After All Challenge • Obesity rates have risen dramatically in the US over the last 10 years. Of course people can avoid obesity and improve their health and chances for living longer by eating healthy food and exercising regularly. But personal choices about diet and activity aren’t the only factor in the rise of obesity. After all...

42. Message Development • What’s wrong? • We have disinvested in our children by not funding physical education. • Why does it matter? • This endangers the health of the next generation. • We have a responsibility to provide children a fair chance to be strong and successful. • What should be done? • 1) Physical education must be part of a overall healthy education. • 2) The legislature must provide adequate funds for complete education.

43. Message Development • What’s wrong? • We have left the food industry to determine the diet and health of our children. • Why does it matter? • This endangers the health of the next generation. • We have a responsibility to provide children a fair chance to be strong and successful. • What should be done? • 1) Limit availability of fast food outlets. • 2) Increase the availability of affordable, nutritious foods.

44. Power of the default frame

45. Reframing Questions • What stories are we telling? • What cues are we giving? • What values are we activating? • What actions are we advocating?

46. Moving ahead • Travel to the upstream territory • Advance research-based policy for change • Rebalance our stories to reflect policy issues and the upstream terrain • Root our stories in community and social justice values

47. Conclusion “If they can get you asking the wrong questions, they don't have to worry about answers.” Thomas Pynchon Gravity’s Rainbow