What Lessons Have Been Learned From Othe

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March 2001: (ll)S4O-S56

What Lessons Have Been Learned From Other Attempts to
Guide Social Change?

Christina D. Economos, Ph.D., Tufts University School ofNutrition Scienceand Policy, Boston, MA;
Ross C. Brownson, Ph.D., Saint Louis University School of Public Health, St. Louis, MO; Michael A.
DeAngelis, M.S., M.P.H., R.D., Porter Novelli, Washington, DC; Susan B. Foerster, M.P.H., R.D.,
California Department of Health Services, Sacramento,CA; Carol Tucker Foreman, Ph.D., The Food
Policy Institute, Consumer Federation ofAmerica, Washington, DC; Jennifer Gregson, M.P.H., C.H.E.S.,
California Department of Health Services, Sacramento, CA; Shinki K. Kumanyika, Ph.D., R.D., M.P.H.,
University of Pennsylvania School of Medicine; Russell R. Pate, Ph.D., School of Public Health, University
of South Carolina, Columbia, SC.
Introduction

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which change can occur, and therefore must be examined,
are generally described as individual, group, organizational, institutional, and societal. Much of the previous
work promoting changes in eating and physical activity
has focused on the individual, group, and occasionally
organizational levels. Many of the most recognized social
models that have succeeded in generating change, on the
other hand, have targeted change at the institutional (family, education, religion) and societal (economic and political systems) levels.

We are facing a public health crisis that is related to and
would respond to social forces. Obesity is at an all-time
high,' physical activity levels are insufficient: and eating
habits and intakes are inconsistent with recommendations
for optimal health.3Even before the recent growth in awareness of the upswing in obesity rates, it was estimated that
14% of U.S. deaths were attributable to poor eating and
lack of physical a ~ t i v i t yThis
. ~ estimate translates into
approximately 325,000 people who will lose their lives as
the result of poor diet and physical inactivity this year.sA
fraction of that may amount to 100 billion in related health
care expenditures.6It would be unconscionable not to argue for change.

Contemplatingthe multiple and diverse levels at which
change must occur may seem overwhelming. Whereas individual behavior has an impact on health, a population's
behavior is influenced by many subsystems of society:
the economy, the political system, social institutions, and
culture.' In order to realize change at the individual level,
we must understand how individual needs, wants, and
perceptions interplay with the larger environment, and
through social change we must create social subsystems
that support behavioral action and maintenance. Because
our current social landscape fails to promote healthy eating and active living, we must fight our public health crisis
with a reactive and powerful social change.

Social Movements
Some of the best examples of change are the results of
social movements. By definition, a social movement is
collective action with some continuity to promote or resist change at various levels within society: often striving to effect social change by changing policy and political structure," primarily through the development of protest. Movements generally have actions in which the populace is alerted, educated, and mobilized, over years and
decades, to challenge the power holders and the whole
society to redress social problems or grievances and to
restore critical values. In the area of contentious politics,
for example, the American civil rights movement, the peace

and feminist movements, and the revolts against
authoritarianism brought masses of people into the streets
demanding change."

Social Change
Social change is defined as the process of planned or
unplanned qualitative or quantitative alterations in social
phenomena.8 In order to understand how societies work
and change, we must be able to say under what conditions advances take place and which do and do not work
over time. The levels, or location in the social system, at

Social Transformations
Additionally, a great deal of energy has been invested to
achieve social transformations that today are taken for
granted. In the public health domain, organizing changes
in the areas of alcohol control, violence prevention, environmental protection, and homelessness abolition have
been the focus.12One of the best examples of social trans-

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Nutrition Reviews", Vol. 59,No. 3

formation to date is tobacco control. The initiative has
realized social norm change around tobacco use by focusing on shifts in the social environment of the local
communities at the grassroots 1 e ~ e l . lThe
~ impetus for
change began with “top down” scientific reports and policy
recommendations and came alive “from the bottom up.”
Such an approach takes the emphasis off changing individual behavior and focuses on how societal norms and
industry practices influence individual behavior. Tobacco
advocates have been successful in reframing issues to a
public policy perspective. Translating what is commonly
seen as an individual problem to a social public policy
issue shifts the focus from the person or segments with
the problem (blaming the individual) to the way we as a
society organize our physical and marketplace environments.‘*

By comparison, promoting healthy lifestyles through
change in diet and physical activity is a relatively undeveloped area of study, often going no further than traditional education and information delivery programs. These
do not systematically address cultural norms and pressures, marketplace forces, lack of resources, lack of cooperation, beliefs, community organization, and supporting
systems (i.e., health care, food service, common facilities).

SocialMarketing
One method by which movements are made operational is
through social marketing. By definition, social marketing
is the application of commercial marketing technologiesto
the analysis, planning, execution, and evaluation of programs designed to influence the voluntary behavior of
target audiences to improve their personal welfare and the
welfare of ~0ciety.l~
It employs mass media and social systems, often called “channels,” to reach large numbers of
individuals1°and attends to social communication, social
mobilization, and media advocacy to result in community
development, partnership, and systems change.” Social
marketing approaches are being used to achieve largescale behavioral change in many public health programs,
including tobacco control and breastfeeding. Social marketing may be used to guide social movements, transformations, and models resulting in social change.
Working Group 111 was charged with investigating
the lessons that have been learned from other attempts to

guide social change. The group reviewed the literature on
social change, social movements, social transformations,
and social marketing in the context of understanding the
relevance and applicability to creating change in nutrition
and physical activity.

review and analysis: tobacco, seatbeltskar seats, recycling, and breastfeeding. These models were chosen because of their similarity to nutrition and activity in that
each model required a shift in behavior by the general
population, involved business and industry, and resulted
in the adoption of new, increasingly dominant social
norms. In addition, the group examined several international nutrition, physical activity, and obesity models from
Australia, Canada, England, Finland, New Zealand, Norway, Sweden, the Netherlands, and the European Union
through the World Health Organization.The interdisciplinary working group was composed of experts in food and
nutrition, physical activity, and obesity prevention from
policy, public health, research, business, and academic
settings.
At the initial strategic planning meeting it was determined that a literature review, although essential to understanding the model’s history and milestones, would inadequately inform the working group of the process that
each model endured. Consequently, the working group
developed a survey with a fixed set of questions that they
used to conduct interviews with key informants from each

model. This process permitted the group to collect qualitative data systematically. The survey results were then
complemented and embellishedwith informationcontained
in published reports and documents. The survey consisted
of 13 questions addressing a broad range of issues: stimulus for change, original objectives of the movement/program, population segments targeted, behavior change
models used, planninglgoal-setting process used, influential people, role of government and nongovernment
groups, importance of legislation, opposition, effective
and noneffective strategies, evaluation process employed,
funding sources, professional activities, community
enablers and barriers, and transferable lessons and recommendations to The Partnership.’
A total of 34 interviews were conducted by telephone
from January 1-April 19,2000, each lasting approximately
1 hour. Interviewswere tape-recorded for subsequenttranscription. One working group member guided each of the
interviews with the help of a research assistant who took
notes and later transcribed the tapes. A content analysis
of key phrases and concepts in the transcripts was performed and important findings were highlighted and extracted. The process of summarizing the information resulted in the creation of two summary matrices (Tables 1
and 2). Table 1 summarizes the interviews conducted with
informants from the four social models (tobacco, seatbeltd
car seats, recycling, and breastfeeding) and Table 2 summarizes the international interviews with informants involved in nutrition, physical activity, and obesity efforts.
The matrices revealed cross-cutting themes that were discussed by the work group, synthesized as lessons learned
from other social change models (see below), and priori-

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Methods: Conducting a Unique Analysis of
Recognized Social Change Models

Working Group 111 selected four well-recognized contemporary social models (health and non-health related) for

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Table 1. Summary of the Four Social Models: Seatbelts, Breastfeeding,Tobacco Control, Recycling

Examples of
Movement Stimuli

Seatbelts
Insufficient safety seats = the
number one cause of infant deaths.
Large school bus crash (1971)
happened before seatbelt requirement.
Volvo study showed effectiveness of
seatbelts and increased sales of cars
with seatbelts.
Airline safety results.
Data on the number of auto deaths.
National Highway Safety Act and
Motor Vehicle Act.
Seatbelt laws.
Police and injury specialists.

Insurance industry saw a moral
obligation and economic interest in
pushing for car safety.
Auto safety concerns driven by
skyrocketing insurance rates: safety
influences cost.
Grassroots movements.
Bremfeeding
Decreased breastfeeding rates
despite known health benefits.
WHO breastfeeding report.
Surgeon General Reports on
breastfeeding.
Institute of Medicine Reports on
lactation.
Le Leche League: mother-tomother efforts.
Breastfeeding = lower infant
mortality.
Scientists educating government
Grassroots movements.

Tobacco
Dangers of secondhand smoke.
Surgeon General Reports on
tobacco.
Mandate for annual report on
tobacco.
Credible spokespeople.
Generating a negative reaction by
the public.
National campaign providing a
brand identity.
An established enemy.
Grassroots movements.
Scientists educating govenunent.
Recycling
Earth Day, 1970.
Long lsland garbage barge, mid1980s.
Waste identified as a clear,
dramatic, life-threatening problem
personally affecting consumers.
EPA reports on the solid waste
di1emma.
Resource Conservation and
Recovery Act.
Concerned citizens and activists at
the community level.
Volunteer organizations and
agencies.
Grassroots movements.
Paper industry saw benefit in the
raw materials.
“Bottle bill” promoted by container
industry.
Changing technology and sharing of
methods led to cost-effective
manufacturing.
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Original Objectives

Seatbelts
To get seatbelts into
cars and to have them
used.
To get safety restraints
for children.
To upgrade school bus
safety.
Brearrfeeding
Improve professional
. education-train
professionals to support
breastfeeding.
Develop public
education materials.
Strengthen support,
especially for new
mothers.
Initiate a national
promotion campaign.
Expand research.
Tobacco
Spread word that
tobacco is a health
hazard.
Control tobacco use.
Recycling
Create a network of
recycling advocates.

Planning &
Goal-setting Process

Sparkplugs and Organizations
Instrumental in Development

Seatbelts
Used research to plan
strategies.
Breasgeeding
Secure funds to provide
training to promote
breastfeeding.
Generate a series of
government reports
that set specific goals.
Tobacco
Top down approach
based on science/
authority.
Comprehensive state
initiatives via local
health departments.
Prescriptive legislation.
Recyhg
Evolutionary process.
Initially at local level.

Seatbelts
Physicians for Automotive Safety.
Insurance agencies.
American Insurance Association.
National Insurance Consumers
Association.
Key legislators in the 1960s.
Ralph Nader, consumer activist.
Elizabeth Dole, former Secretary of
Transportation.
Breasfeeding
Dr. Audrey Naylor, public health
expert and cofounder of Well Start,
International.
Barbara Heiser, National Alliance
for Breastfeeding Advocacy.
Minda Lazarov,-formerly of WIC
and UNICEF.
Carol Bryant, Best Start, University
of South Florida, College of Public
Health.
Dr. Ruth Lawrence, breastfeeding
author and researcher, University of
Rochester.
C. Everett Koop, former Surgeon
General.
Elizabeth Brannon, Ted Reiner, Bill
Smith, Alice Lockart.
Tobacco
C. Everett Koop, former Surgeon
General.
President Clinton.
David Kessler, former FDA
Commissioner.
Joseph Califano, Secretary,
Department of Health Education
and Welfare.
Mike Moore, Michigan Attorney
General.
Dr. Stan Glanz, University of
California San Francisco Medical
School.
Mike Pertschuck, The Advocacy
Institute.
Dr. Ron Davis, Henry Ford Health
System.
Recycling
Industry leaders, Trade Associations, nonprofits in the community,
environmentalists, lobbyists, state
agencies.

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Table 1. Summary of the Four Social Models: Seatbelts, Breastfeeding, Tobacco Control, Recycling (cont.)
Most Effective
Role of
Importance of
Strategies/
Selected
Government
Legislation
Opposition
Interventions
Funding Sources
Seatbelts
Generating key
reports.
Public health
surveillance: seatbelt
use.
Attention to disadvantaged.
Coalition development.
Consumer advocacy.
Bremgeeding
Education.
Staff in federal
agencies as stimulus to
keep issue before
government.
Funding the agency
that supports the issue:
WIC.
Training.
Coalition development.
Monitoring interventions.
Tobacco
Legislation: airline
smoking ban, mandate
for annual tobacco
report.
Generating key
reports.
President adopting
issue.
Forming national
clearinghouse for
smoking and health
(1965) and office on
smoking and health

Seatbelts
1985 Safety belts laws
increased use through
enforcement.
New Jersey law in
1992 required seatbelts
in buses.
Passing of laws that
look at car design (i.e.,
seatbelt and restraint
laws) increases use and
reduces fatalities.
Bremgeeding
Laws to breastfeed in
public.
Money earmarked to
promote breastfeeding
through WIC.
Tobacco
Warnings on tobacco
packages (1 965-

Seatbelts
School boards.
State transportation
boards.
Manufacturers and
government.
Minority groups
arguing that police
would target without
justification.
Automotive industry
(until airbags).
Civil libertarians.
Legislators who felt
seatbelt laws were
against personal rights
or did not want to
offend parties from
whom they received
funding.
National Motorists
Association (against
seatbelts and helmets).
Bremgeeding
Formula industry.
Lack of knowledge on
the part of physicians
and health professionals translates to lack of
support.
Advertising.
Believers that cost of
breastfeeding is too
high (especially blue
collar workers).
Cultural resistance and
social norms.
Tobacco
Tobacco industry.
Manufacturers.
Farmers.
Recycling
Hauling industry.
Manufacturing sector.
Scrap industry.
Private sector.

Seatbelts
Enforcement,
education, enacting
laws.
Education coupled with
policy change.
Seatbelt and airbag
media-focused
campaign.
Imposing fines on
noncompliant states.
Bremgeeding
Baby-friendly
hospitals.
Consumer advocacy
locally leading to
national change.
Le Leche League.
Social marketing.
Getting the issue
involved in a national
program (WIC).
Reports of the Surgeon
General.
Getting industry
involved.
Tobacco
Tobacco control
programs.
Education.
Smoking cessation
programs.
Constant and
consistent message.
Use of media.
Grassroots efforts:
local groundwork.
Capacity building.
Coalitions.
Focusing on an aspect
that got everyone
involved (secondhand
smoke).
Lawsuits.
FDA investigation.
Social norm change.
Public policy change.
Recycling
Ongoing education.
Communication and
outreach to motivate
individuals and increase
participation.
Use of schools.
State mandates.
Making it low cost.

Seatbelts
Coalition members'
donations.
Industry.
Insurance companies.
Highway Trust Fund.
National Highway
Traffic Safety
Administration.
Corporate donations.
Brewgeeding
USDAIWIC.
Medela.
Johnson and Johnson.
Ross labs (research).
UNICEF.
Tobacco
Centers for Disease
Control and Prevention.
Robert Wood Johnson
Foundation.
State taxes.
National Cancer
Institute.
American Legacy
Foundation.
The tobacco settlement.
Recycling
Taxes.
Fees-tipping and
landfills.

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1966).

Banning ads (1971).
Clean indoor legislation.
Tax doubling (1980s).
Smoke-free workplace
( 1 994).

(1978).

Education.
Public Health
surveillance: smoking
rates.
Training.
Policy creation.
Attention to disadvantaged.
Strategic planning.
Coalition development.
Zoning lawdpublic
safety ordinances.
Involvement and
influence of mayors
and city councilors.
Recycling
Legislation: Resouce
Conservation and
Recover Act.
Policy creation.
Coalition development.
Consumer advocacy.
Intergovernment/
interagency collaboration

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Table 1. Summary of the Four Social Models: Seatbelts, Breast-feeding,Tobacco Control, Recycling (cont.)
Kev Areas and Stem to Promote Healthv Eating and Active Living

.

Consider..
The importance of economic issues
That seminal events can be mobilizing
Framing messages positively
Recognizing the issue as a crisis
Targeting the population through a segmentation approach
Training community advocates to use the media
Making changes seem convenient, nonsacrificial, and low cost
Creating the perception that there is a viable solution
Involving industry and demonstrating a cost benefit
Pushing the food industry to set healthier standards and share data
Targeting children
Countering pro-junk food influences in the community
Decreasing the availability of fast food near schools
Research..
What motivates industry and consumers
The development of a Health Plan Employer Data and Information Set-like measure for nutrition and physical activity
Human behavior
Measures to be used for community and environmental markers
Where you are most likely to succeed
Make sure.
Public concern for the issue is widespread
Consumers are advocates
There is consensus among scientists
The message is right
Nutrition and physical activity are united
Mass communication is used
Government partners with nongovemrnent agencies
Key legislators, who are sensitive to the issue, are involved
Education is not done alone, but coupled with policy change
All partners benefit (e.g., government, industry, consumers)
Take action by..
Involving govemrnent: Federal to create guidelines; State to make laws; Local to take action
Changing the social and physical environment
Producing ongoinglsteady reports (similar to Surgeon General reports) that launch people into action
Developing national policy
Identifying “sparkplugs” that will serve as visionary leaders
Creating a plan with pieces working synergistically
Building coalitions and using a bottom up approach
Engaging the media (e.g., editorials, letters to the editor, ongoing, and active dialogue)
Organizefor action by
Preparing to leverage unanticipated events to advance or realize goals
Fostering collaborative relationships among agencies and organizations
Creating public private partnerships

.

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tized by their potential for influencing and guiding change
in nutrition and physical activity (the promotion of healthy
eating and active living).

Lessons Learned From Other Social Change
Models

A Crisis
Many of the informants cited the importance of their issue
being perceived as a crisis. They stressed the need for the
identification of a clear, dramatic, threatening problem that
would personally affect many individuals. A sense of increasing urgency resulted from multiple factors such as
seminal events, key reports, economic projections, and
other substantially influencing elements. In both the recycling and tobacco scenarios, there was an increase in
public awareness followed by mobilization through a seminal event-for example, the Long Island garbage barge
incident of 198716and the Surgeon General’s Report on
Involuntary Smoking of 1986.l’ Virtually all the interna-

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tional program leaders stated that the rising obesity rates
with their expected increases in disease rates and health
care costs were stimulating policy attention, if not action.
Clearly, advocates for diet and physical activity
change need to communicate the social crisis occurring
with eating and activity and create a sense of urgency to
mobilize the public.

Science Base: Research, Data, and Evidence
Motivating the public to change behavior is no small challenge, but providing people with the facts they need to
make informed choices is a part of the solution. Of greatest importance to the tobacco control movement’s enduring impact has been the construction of credible risks.
The movement drew on the authority of medicine and science to transform public perceptions of cigarettes.18Programs and strategies need to be based on sound science
and proven policy experience. Furthermore, expertise from
a wide range of disciplines should be used in designing
successful programs and policies to realize change in all

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Table 2. Summarv of International Nutrition. Phvsical Activitv. and Obesitv Movements/lnitiatives
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6
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Country

Australia

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Examples of
MovementStimuli

Original
Objectives

Population
Segments Targeted

Planning/Goalsetting Process

Obesitv Prevention
Government forming the
National Health and
Medical Research
Council (NHMRC) in
1994 to create National
Physical Activity
Guidelines (1999) and to
look at obesity.
An obesity report:
Healthy Weight Australia
in 1995, resulting in a
plan in 1997.
An initiative targeting
health care professionals
to address obesity with
individuals and communities.
Influence from the U.S.
Surgeon General’s Report
on Physical Activity and
Health.
Energy from the
Olympics.
* Physical activity had
come of age.
Gut-busters
A need to get men
involved in their own
health.

Obesitv Prevention
Obesitv Prevention
Get guidelines out into
The whole population,
with an emphasis on
the population to be used
as an indication of the
socially disadvantaged
activity level recomgroups, non-English
speaking populations,
mended for health.
indigenous and ethnic
Use a public health
populations, women with
model and encourage
young children, the
environmental change.
workplace, and schools.
Strive to have the
population meet 30
Gut-busters
minutedday of physical
Men, particularly those
over 40 years. Originally
activity and 5 fruits and
aimed at lower socioecovegetabledday.
nomic class men.
Gut-busters
Try to involve men in
their health in some way.

Obesitv Prevention
Forming the NHMRC to
write a report, which
resulted in the guidelines;
the report was called the
formal planning of the
guidelines.
Active Australia
involved coalition
building, countrywide
discussions, and strategic
planning in all states
around Australia to
identify key missions
and to facilitate work
from the bottom up.
Gut-busters
Based on commercial
success.

Nutrition
Industry wanted to
increase awareness of the
benefits of consuming
fruits and vegetables.
Findings fiom worldwide
cancer research.
Phvsical Act ivity
National nutrition
survey (government) in
the late 1960s showed
decreased energy
expenditure and
increased sedentary
lifestyles that would lead
to obesity. This led to
the 1972 physical
activity conference and
a bill in the 1970s to
fund a physical activity
mass media campaign.

Nutrition
nutrition
Nutrition
Reach people through
Primary target = 2 5 4 5 Increase fruit and
vegetable consumption.
year-old college-educated
television.
Phvsical Activity
women.
Formed an advisory
Develop media campaign
Secondary targets =
group.
children and males.
Phvsical Activity
to get people active.
.
.
Phvsical Activitv
Initially a mass media
Whole population.
campaign focused on
awareness, but the shift
has gone toward
intervention.

Individuals/
Organizations
Instrumental in
Development

Role of Government

Obesitv PreventioQ
Government agencies.
The National Heart
Foundation.
Academic researchers.
Transport agency.
Nutritionists.
Physicians.
A state governor who was
a hiking and swimming
fanatic.
Gut-busters
Initially the health
department, then Weight
Watchers.

Obesitv Prevention
Support and leadership by
the government is key,
but mainly as an
executive function.
Initiating the NHMRC
report and guidelines.
Supporting statewide
evaluation.
Proving small amounts of
funds.
Mandating physical
education.
Gut-busters
Not involved.

Nutrition
An advisory group of
dieticians and the
provincial health unit of
Canada.
Phvsical Activity
Government.

Nutrition
None-it is a grassroots
dissemination program.
Phvsical Activity
At all levels, but without
formal communication or
coordination.

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Canada

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Table 2. Summary of International Nutrition, PhysicalActivity, and Obesity Movements/lnitiatives (continued)

Country
England

Finland

Examples of
Movement Stimuli

Phvsical Activity
Data showing that
adults are not getting
recommended levels of
physical activity.
A political decision to
use physical activity to
demonstrate a positive
thing people can do for
their health.

..
m
f
from
t
competitive sports to
physical activity.
The evidence of the
health effects were the
driving force.

Population
Segments Targeted

Planning/Goalsetting Process

Phvsical Activitv
Promote moderate
intensity physical
activity -30 minutes/
day.

Phvsical Activity
All adults.
Key groups: 16-24-yearold women, 250-year-old
adults, disabled people,
and black and white
ethnic minority groups.

Phvsical Activity
Fostered partnerships.
Talked to exercise
groups, fitness clubs, and
local authorities that run
gyms to get them on
board. . Stimulated
demand for exercise by
stimulating the suppliers
of exercise facilities.

Phvsical Activity
To increase physical
activity levels.
To provide equal
opportunities for all.

Phvsical Activity
The whole population
with 40-60-year-olds as
the target group.

ical Activity
%king
at the national
level to allocate funds to
local communities and
let them be creative with
local resources and
possibilities.

..

Role of Government

Phvsical Activity
The Health Education
Authority in the
Department of Health.
Family doctors and
practice nurses.
Local authority leisure
offices (i.e., parks and
recreation).

Phvsical Activity
Very much in a leadership
role, but the health
professionals were key
players.
As an advisory role.
There was no authority
over health or local
authorities, only
suggestions that people
do things.

Phvsical Activity
The Ministry of Education.
Academics.
Ministry of Environment.
Transport.
Fitness and sports
organizations.
Heart and Lung Foundations.

Phvsical Activit
Government-prtvided
funding.

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New Zealand

Nutrition
The problem of obesity
and the need to increase
awareness and get action
at a central level.
A banding together of
the public and private
agencies (Heart
Foundation, Cancer
Society, Nutrition
Foundation, Dietetic
Association, and
Diabetes forum), who
recognized that obesity
was really heading in the
wrong direction.
Availability of survey
data.

putrition
For agencies to work
together to prevent
overlap and create
synergy.
Run a low-cost
campaign.
Keep the country’s
providers aware of the
campaign’s progress.

Nutrition
The whole country, with
an emphasis on men.
Phvsical Activity
Families.

putrition and Phvsicd
Activity
Formed steering
committees made up of
academics and practitioners, and ran the
campaign through
organizations.
Used an ecologic model
and environmental
framework.

Nutrition
The organizations in
“Agencies for Nutrition
Action.”
Phvsical Activity
The organizations in the
“Hillary Commission.”

Nutrition and Phvsical
Activity
The central, regional, and
local government bodies
have not had a role
because a public education
campaign doesn’t really
involve them.

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Original
Objectives

Individuals/
Organizations
Instrumentalin
Development

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D
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5.
5

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Table 2. Summary of International Nutrition, PhysicalActivity, and Obesity Movements/lnitiatives(continued)

9
3
3

m
a

2.
5

Country
Norway

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0,
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0

Examples of
Movement Stimuli

..
utrition

A long history of
nutrition policy with
roots in the 1930s.
The interest in social
medicine.
FAO/UN order in 1946
for each nation to build a
food and nutrition policy
and create a national
nutrition council.
A 1975 policy with goals
about diet evaluation and
campaigns targeting
individuals and society.
Phvsical Activity
Research literature
clearly identifying
physical inactivity as a
risk factor for the major
chronic diseases and
increasing obesity rates.
The National Council on
Nutrition and Physical
Activity was established
in 1999 with a mandate
to monitor and promote
physical activity in the
population.

Original
Objectives

flutrition
Make diet better for
everyone and reduce
disparities.
Reach nutrient goals (%
sugar, macronutrients,
fat quality).
Increase food production.
Phvsical Activity
Achieve 30 minutedday.

Population
Segments Targeted

flutrition
Reduce health disparities
within the population by
targeting vulnerable
groups, groups with
social differences, and
biologic groups like
children, and pregnant
and lactating women.
Phvsical Activity
The whole population,
but with a special focus
on youth and adolescence.

Planning/Goalsetting Process

Individuals/
Organizations
Instrumental in
Development

and Phvsical
Nut rition and P hvsical
Activity
Activity
Used theory-based
The Nutrition Council on
models to look at health,
Nutrition and Physical
individual factors, other
Activity (an expert
interpersonal factors,
council of primarily
and then the physical
academics).
and local environment.
The Ministry for Social
Affairs and Health.
Scientists.
Cancer and Heart
Foundations.
Offices that represent
different foods (fruits and
vegetables, meat, dairy,
and cereals).
Food chains.
Sports associations.

Role of Government

Nutrition and Phvsical
Activity
Regional level: building up
informants about
nutrition and physical
activity.
Local level: getting
health promotion officers
in the 20 counties that
have 400 municipalities.
City level: very difficult
owing to their own
priorities.

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Nutrition and Phvsical

AFtiVitV

Lack of good knowledge
and basic data.
Lack of professional
people working on these
issues.
A strong political
ambition to create a
union.

Nutrition and Phvsical
Activitv
Establish guidelines and
make them available to
policy makers.

Nutrition and Phvsica
Activitv
All people.

Nutrition and Phvsical
Activity
Began with academic
experts, then representatives from national
authorities were invited,
but in the end it was
more the local or
regional professionals
that were involved.

Nutrition and Phvsical
Activity
Businesses.
Industry.
Nonprofit groups.

Nutrition and Phvsical
Activity
N/A

2
CD

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Table 2. Summary of International Nutrition, PhysicalActivity, and Obesity Movements/lnitiatives (continued)

Country

The
Netherlands

World Health
Organization:
European
Region

Examples of
Movement Stimuli

Nutrition and Phvsical
Activity
Scientists noticing that
something was going
wrong with the nutrition
and physical activity
status.
Government putting
money into the problem.

Putrition
A declaration made by
the member states to
develop national action
plans made at the 1992
International Conference on Nutrition held in
Rome.

Original
Objectives
..
Nutrltloa

Decrease dietary fat
intake.
Increase fruit and
vegetable consumption.
Address functional foods.
CtlVlty
In the 1980s to increase
sports participation; now
to increase physically
active lifestyles.
* Achieve 30 minutedday
of moderate to vigorous
activity.

Population
Segments Targeted

..

Phvsical Activitv
Total population, but
with specified age groups
to avoid problems on the
top and bottom ends.

..

-

Nutrition
To reduce the burden of
food-related ill health in
Europe.
To reduce saturated fat
and increase fruits and
vegetables.
To address obesity by
increasing physical
activity.

-

Nutrition
A lifestyle approach
targeting critical periods.

Planning/Goalsetting Process

Settingapredesigned
plan with goals by the
Ministry of Sports
Health and Welfare that
was reviewed and
endorsed by society.
Used the Attitude-Social
influence-Self efficacy
Barriers Model (Kok)
model to influence
attitude change then
social influences,
including barrier
elimination.

Nutrition
None.

Individuals/
Organizations
Instrumental in
Development

..

CtlVlty
Academicduniversities.
Olympic Committee.
Companies (Shell, Dutch
Telephone).

Putrition
None specific.

Role of Government

Phvsical Act ivitv
Worked as a flywheel:
government made
statements in official
policy documents and got
things going.
Local governments
allocated part of their
budgets to physical
activity.

Nutrition
. Very enthusiastic and
recognized this as an
important area.

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3

Table 2. Summary of International Nutrition, Physical Activity, and Obesity Movements/lnitiatives (continued)
Most Effective
Country
Importance of Legislation
Opposition
Strategies/Interventions
Evaluation

m

Australia

Obesitv Preventioq
Nothing specific.

v Preveptrps
Initially the fitness
industry.

Obesitv Preventioq
Coordinating experts from
around the country to agree on
the scientific background.
Getting consumers to come up
with languagdmessage.
Sustainability of an effective
coalition.
Management high enough up to
make things happen.
Mass media’s impact on the
population’s awareness and
intention to do physical activity.
Engineering the environment to
make physical activity possible
and low-fat foods available.
Working with schools and
workplaces.

Obesitv PreveQtLQB
Surveillance systems that
monitor health.
G u t - b m
Two published studies on
participants.
Whether the program remains
financially viable.

Obesitv Prevention
Government funding.
Guidelines were a special appropriation of discretionary funds from the
federal government through the
Department of Health.
“Special funding” for collecting
telephone survey data.
Gut-busters
Always been self funding.

Canada

Putrik
Provincial mandates were
made to promote consump
tion of fruits and vegetables.
Phvsical Activity
The 1960s Fitness and
Amateur Sport Act has
received variable support for
reaching the entire population
through the years.

None.

Nutrition

Nutrition
Population questionnaire about
fruit and vegetable consumption.
Retail sales.
Disappearance data.
Phvsical Activity
Monitoring of physical activity
in the population.
Tracking systems of what is
offered and how people use them.

Nutrition
Industry support.
Phvsical Activity
Government.

Phvsical Act ivitv
The enabling role was carried out
by working with organizations
and encouraging them to
promote physical activity.

Phvsical Activity
Two large surveys: one on the
knowledge and awareness of
physical activity with four
professional groups; the other
was a longitudinal panel survey
on knowledge, attitudes, and
behavior about physical activity
done over the course of the
campaign with the population.

Phvsical Activity
Department of Health (9 million
pounds over 3 years, and 2 million
for the final year).

Phvsical Activity
The facilitation method: relying
on local people using local ideas
and resources that fit with people
in their communities.
Support systems at the national
level that fostered linkages.
Building on existing infrastructure.

Phvsical Activity
Annual survey of living habits
since 1978.
Process evaluation of the
movement.

Phvsical Activity
State controlled government money
through legislation.

2.

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Setting up a foundation.
Phvsical Activity
NIA

England

Bhvsical Activity
NIA

Phvsical Activity
The fitness industry
(perhaps they felt
threatened by the
moderate intensity
message).

Finland

Phvsical Activity
A very strong position in
legislation for both state and
local communities resulting in
the availability of a lot of
funds.

Phvsical Activity
None.

..

-

Selected Funding Sources

2
0

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Table 2. Summary of InternationalNutrition, PhysicalActivity, and Obesity Movements/lnitiatives (continued)
Most Effective
Country
Importanceof Legislation
Opposition
StrategiesLlnterventions
Evaluation
New Zealand

Norway

Sweden

None to date.

nutrition and Phvsical

Very important and can result
in laws and “strong recommendations.”

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p

2
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Selected Funding Sources

Nutrition and Phvsical Activity
Reducing the obesity conduciveness of the environment.
A framework called an ANGEL0
Framework (Analysis Grouped for
Environments Linked to Obesity)
as it relates to physical activity
and food intake.

Nutrition and Phvsical Act ivity
Periodic behavior surveys.

Nut rition and Phvsical Activity
Small amounts from the Health
Research Council, Health Foundation, and Ministry of Health.

Nutrition
Working together toward a
common goal: making healthy
products available to consumers.
A general feeling that information campaigns targeted towards
schools: populations, and
institutions combined with the
general policy of trying to make
it easier to get healthier foods
were effective.

Nutrition
A surveillance system for dietfood balance sheet, household
consumption, and national
dietary surveys are used to
evaluate the changes in the diet
and compare them with the goals
and the policies.
Mortality statistics (i.e., dramatic
decease in coronary heart
disease).
Small evaluations of the school
programs.
Phvsical Activity
Not monitored.
Nut rition and Phvsical Activity
None.

Nutrition
The government: the ministry for
social affairs and health.
Funding is roughly 40 million
crowns with a population of 4
million (10 crowns/person).

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Nutrition
Very important and currently
the strategy.
The price policy from 20
years ago is one example, but
it didn’t really do much and is
not used much today.

AFtiVitV

None to date.

..
utritiog

The milk producers
were reluctant in the
1970s and 1980s but
they are not today.

Nutrition
States with their own
policy of action plan.

Nutrition and Phvsical Activity
N/A

Nutrition and Phvsical Activity
From the member sates of the
European Union.

None.

The
Netherlands

m s i c a l Activity
The most powerful way to
influence behavior change.
Urban planning and bicycle
use for commuting (tax
incentive).

Phvsical Activity
None.

World Health
Organization:
European
Region

flutritipn
The European Union creates
directives that have to be
translated into law in the
member countries.
WHO promotes, advocates,
and lobbies.

Nutrition

Industry (i.e., salt,
sugar, infant formula).

Phvsical Activity
Incentives.

..

utrifipB
N/A

Phvsical Activity
Biennial report on physical
activity (like the U.S. M A N E S ) .
European surveys by WHO.

Nutrition
1999 baseline questionnaire sent
to member states asking about
policies, action plans and dietary
guidelines with plans to repeat in
2002 and 2005.

flutrition
Dutch Government and European
Commission.
Phvsical Activity
Dutch Olympic Committee.

Wo’sbudget.

3
.

0

3

2
2.
F

Macro Level
Interventions

Australia

Micro Level
Interventions

Qbesitv Prevention
Educating the smaller
businesses on healthier
cooking practices.
Government transport
subsidy on diesel fuel for
getting foods to the
outback for the aboriginal
population.
Gut-busters
Promotion through
commercial advertising.
Media advocacy.

Qbesitv Prevention
Local government backing
community groups who are
interested in making changes.

Nutrition
Mass media to educate the
consumer.
Using public service
announcements.
..
Phvsical Activity
NA
!

PutritioQ
Grassroots efforts with
health professionals
(dietitians, physicians) in
schools, food services,
cafeterias, and health
departments.. .
CtlVlty
Community groups fighting
for physical activity in
schools.

Outcomes in the
Local Community

Lessons Learned That Are Transferableto Promote
Healthy Eating and Active Living

Obesitv P r e v m
Enabling factors were mostly
environmental (i.e., public
space and infrastructure
influence were able to adopt
more rapidly).
Dependant upon local
politicians and their interests.
Gut-busters
Men getting involved after
talking to other men who
have been program, which is
less threatening.

Do not run awareness campaigns without a coordinated plan.
An interested group of individuals across health, bureaucratic, and
nongovemment sectors and consumer sectors needs to drive the process.
Involve consumer groups in developing guidelinedmessages and in
translating the information from scientific community to the average
person.
Do not treat the community as a whole, (i.e., males and females different).
Not everything works the same in every state.
The concept of priming family physicians without the strategy behind it is
not effective.
Make sure government does not move into other areas once they are
getting sustainable processes under their belts.
Interested organizations should take up specific projects or approaches to
compare and contrast effectiveness.
Men are very attentive to things that try to get him to do things in a
suspiciousway.

Nutrition
N/A
Phvsical Activity
Keeping kids off the streets
with night basketball
programs.
Strong coalitions.

Implementation is key.
Create networks as they will be sustainable long term.
Create a communication plan.
Deliver a concise message that is relevant to the target audience in a
repetitive manner.
Address the problems with our environment.
Involve multisector partners.
Link nutrition and physical activity.

Phvsical Activity
The creation of strong
alliances between different
sectors to promote physical
activity (i.e., health
promotion people and
transport people linking with
leisure people).

Be very clear about different levels of intervention, from policy change
down to individual behavior.
Outline a couple of interventions with a clear plan of action at each level.
Work with government agencies who can put the laws into place that will
make it easier for people to be physically active.
Focus more on daily exercise, rather than the number: “30 minutes.”

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Table 2. Surnmarv of International Nutrition. PhvsicalActivitv, and Obesitv Movernents/lnitiatives(continued)

5

6
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Canada

England

NIA

-

NIA

-

Finland

Phvsical Activity
Positioning physical
activity and diet as
cornerstones of obesity
campaigns.

Phvsical Activity
Influencing attitudes of
professionals, researchers,
and the public.

Phvsical Activitv
Emphasizing participation in
sports and low cost, safe
activities together as a
community.

Combine physical activity and nutrition.
Place emphasis on planning local, community work with potential for
sustainability.
Let local people use local ideas and resources that fit people in their
communities.
Take time to evaluate.
Use coalitions to convince politicians.

New Zealand

Nutrition and Phvsical
Activity
The area with the most
potential for change is in
the transport area.

Nutrition and Phvsical
Activity
Programs in schools,
workplaces, lunch bars,
cafeterias, and catering.

Putrition and Phvsi c d

Environment and policy change will get through to people.
Expectations must be modest.

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Modest benefits, only for the
duration of the program.

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Table 2. Summary of International Nutrition, Physical Activity, and Obesity Movements/lnitiatives(continued).
Macro Level
Micro Level
Outcomes in the
Lessons Learned That Are Transferableto Promote
Interventions
Interventions
Local Community
Healthy Eating andActive Living
flutritioq
School meals and education.
Cooperation with
restaurants (more brown
bread, fruits, and vegetables).
Collaborations with
Zimbabwe and the
Palestinian government
trying to set up nutrition
councils.
Close involvement with the
control authorities in terms
of functional food and gene
modification.

Sweden

Nutrition and P h v s i c a
Activitv
N/A

Nutrition and Phvs i c d

Phvsical Activity
* Mass media-national
morning broadcast with
exercise classes and
relevant issues for people
who want to start.
Professional education and
networking establishment.
Nutrition
A consultation with all 5 1
member states represented
to create awareness and
mobilize support.

The
Netherlands

World Health
Organization:
European
Region

2

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2.
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3

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Norway

utritipn
Providing school children
with a fruit or a vegetable at
lunch much like the school
milk programs.

Nutrition
Home economics in schools.
Nongovemment organizations as enabling factors.

Understand groups not traditionally studied.
Make messages simple for everyone.
Join diet and physical activity.
Set up infrastructure (i.e., roads for bicyclists).
Work with school organizations.

Nutrition and Phvsical
Activity
NJA

Draw upon the wealth of knowledge and expertise in the United States in
the areas of policy making, strategic planning, and guidelines.

Phvsical Act ivity
N/A

Phvsical Activity
Bringing elderly from their
home to the gym (door to
door).

Change the physical environment.
Facilitate people by making physical activity low cost.

Nutrition
N/A

Nutritiog
Trying to address food
insecurity by involving the
communities.
Encouraging people to grow
fruits and vegetables on city
land has been challenging
owing to the belief that the
land is contaminated.

Proactively link areas together (i.e., food, nutrition, environment) and
create intersectoral collaboration.
Get organized to create action.

Activitv
N/A

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communities and segments of the population. In other
countries, the 1996 Surgeon General’s Report on physical
activity and health was cited as redefining physical activity as a health issue that drives multiple chronic diseases,
not simply fitness and athletics, thereby affecting the
health of entire populations and increasing its importance
as a policy concern.
Ongoinglsteady Surgeon General’s reports (or others) that launch groups and individuals into action and
support the need for continued research and funding are
essential.
~~

tention and organized action to increase breastfeeding.
Our informants urged that such leaders be enlisted
for the areas of eating and activity.

Coalition Development
Critical to the success of social movements and transformations are mobilizing networks through which individuals with common objectives are brought together.18For
example, in Europe and Australia it has proven successful
to hold smaller conferences in which multiple representatives from each country or territory can meet each other,
share concerns, and start working together, rather than
having large international or countrywide meetings with
few representatives from any one political subdivision.
Similarly, in some countries nutrition and physical activity
advocates were beginning to join forces to have greater
impact for change. Innovative and highly energetic
grassroots movements often involve the creation and
maintenance of coalitions across states to build capacity,
to provide the groundwork for change at the community
level, and to impel legislative action.
Informants stressed the need to develop coalitions to
strengthen and move the physical activity and nutrition
agendas forward.

Economics
It was clear from many of the informants that economic
issues were critical to address. In recycling, the economics of technology were extremely important to making
change. For example, businesses recognized the financial
benefits of recycling and increased tipping fees deterred
dumping and encouraged recycling. In the tobacco scenario, the cost from the consequences of tobacco use has
been estimated at $50 million an nu all^,'^ models have been
developed to allow states and counties to project economic costs,Zoand the strategy to increase cigarette prices
has been highly effective in lowering rates of consumption.2122
Regarding seatbelts, there is an economic benefit
Advocacy
in terms of reduced inpatient charges for belt