(Illustration by Chiara Zarmati) 

In 2010, the Horizon Foundation staff took a routine look at local health data and noticed some troubling trends. Data indicated that most deaths in our community were related to heart disease, cancer, stroke, and/or diabetes. Trends showed increasing rates of hypertension and high cholesterol, alongside increasing rates of unhealthy weight. Worse yet, data also showed that local school-aged children had similar rates of unhealthy weight as those in neighboring counties and throughout the state. For an independent, place-based, health-focused philanthropy like ours, this was grim news.

Healthy Eating, Active Living

This collection of articles, produced for Grantmakers In Health and supported by the Colorado Health Foundation, explores the latest thinking from health funders, researchers, and advocates on healthy eating and active living (HEAL) and healthy communities.

The Horizon Foundation is based in Howard County, Maryland, and we focus our work on its approximately 321,000 residents. In any given year, Howard County has one of the highest median household incomes in the nation. About 95 percent of our residents are high school graduates, and a majority have bachelor’s and other higher-education degrees. According to Money magazine, two of our cities are among the best places to live in America, and our county has won awards for its open spaces, parks, sports culture, recreation facilities, and library system. Evidence suggests that these health determinants should provide relative protection against disease, and yet our local data indicated otherwise.

In response, the foundation launched a suite of Healthy Eating Active Living (HEAL) initiatives in 2012. Our plan included efforts to reform the school system’s wellness policy; reduce sugary drink consumption; improve school food; increase participation in federal school meals programs; enhance pediatricians’ skills related to the prevention, diagnosis, and treatment of childhood obesity; and make healthier food and drinks more widely available for children and families. Concurrently, we have been working to make physical activity more routine by improving equity in sports participation and increasing physical activity in schools and childcare facilities. We also routinely advocate for “complete streets”—properly designed roads and pathways that allow all walkers, bicyclists, transit users, and motorists to jointly use and safely get from one point to another. Over the years, we learned some useful lessons.

Plan for evaluation from the beginning.

If it’s worth doing HEAL work, it’s worth measuring its impact. Prior to launch, Horizon hired the Rudd Center for Food Policy and Obesity to help it design a sound evaluation plan and determine what data would be necessary to gauge impact. At the onset of our work, data systems were not robust enough to adequately detect HEAL changes. Working with community partners, we created new data systems that have enabled us to set baselines, prospectively track progress, and tweak our programming. For example, we administer a biennial, behavioral risk-factor survey that is used by county health groups as a joint planning tool. We also worked with the county’s school system to collect student weight status data and to conduct a student nutrition and physical activity survey. Our local provider groups conducted surveys of pediatricians, dentists, and hygienists about their HEAL-related practices. And we purchased data on aggregate local sugary drink sales from a private company to set our baseline consumption patterns. To date, about 10-15 percent of our HEAL program dollars are dedicated to evaluation.

Shrink the change.

In their 2010 book Switch: How to Change Things When Change Is Hard, Chip and Dan Heath describe how complex behavioral-change processes require intentional efforts to make hard changes more manageable—what the authors refer to as “shrinking the change.” Indeed, our focus groups suggested that behavior change would not come easily. Many participants bemoaned how public health experts ask them to do too much—cut sugar, fat, salt, and calories while simultaneously increasing rates of exercise. In response, focus group participants chose to make no behavioral changes. The results of this research, combined with evidence showing that nutrition environment changes may prove most effective in reducing childhood obesity,1 persuaded our organization to focus its public-facing work on reducing sugary drink consumption. Sugary drinks are the largest source of calories and added sugar in a child’s diet today, and daily consumption is a key contributor to heart disease, diabetes, and other chronic diseases.2 Further, changing what people personally drink or the drinks they purchase for home use may be easier to accomplish than changing their overall diets and exercise routines—especially if consistent community policies and messaging supports such changes. As stated above, we still do other HEAL work, but our media campaign and public messaging focuses on reducing sugary drink consumption as a simple but key step toward improving health. A recently published peer-reviewed article3 details our progress thus far—a 20 percent decrease in sugary drink sales when compared with a control community, and healthy weights are trending in the right direction for our community’s young children.

Advocate for HEAL policy and system change.

Investing in advocacy allowed the foundation and our grantees to properly build strong coalitions, organize residents on the ground, engage in social marketing and media advocacy, and win long-lasting improvements in our HEAL environment. Our active transportation initiatives combine community education with advocacy efforts to support the public funding, design, and construction of complete streets. Together with partners, we conducted four complete-streets community festivals that attracted almost 4,000 residents, who experienced what a redesigned complete street might look and feel like. We organized a strong coalition of more than 40 health, faith, business, and civic groups to advocate for increased county biking infrastructure spending to improve health, attract new employers, and better the environment. More than 2,000 local residents directly contacted their elected officials urging them to adequately fund active transportation, and safer walking and biking have been listed as top concerns of residents in recent county government listening sessions. As a result of these efforts, county bike infrastructure funding has nearly quadrupled over the past three years, and a strong complete-streets ordinance and pedestrian master plan are in the works.

Given that policy and systems changes drive HEAL impact, having open and trusting relationships with policymakers is important. Building and nurturing these relationships can lead to faster policy adoption and don’t necessarily require lobbying. The foundation has an advocacy policy, and trustees regularly consider how to best engage local elected officials. We schedule regular meetings and phone calls and have an annual breakfast to let elected officials know about the foundation’s work. We also invite our local elected officials to join us at community events. For example, local leaders recently participated in a walk audit of a neighborhood whose residents had complained about unsafe conditions for walking and biking. These officials directly experienced the unsafe conditions firsthand, spoke with residents about their active transportation needs, and now understand what can be done to address community concerns.

Work with state and regional partners to make HEAL changes more “sticky.”

At least 57 percent of our residents work and/or spend significant time outside the county. Pursuing consistent policy changes at the state or regional levels—especially in places where our residents work, learn, worship, and play— is often key to making change stick. For example, the foundation is a founder and lead partner of Sugar Free Kids Maryland, a statewide coalition working to reduce sugary drink consumption. Together with state partners, we made sure that innovations piloted here in Howard County were adopted across the state. Five neighboring governments adopted laws or policies to make healthier food and drinks more widely available on county property that were similar to the one first enacted by Howard County. Also, a local healthy childcare demonstration project later became state law. In both cases, the media extensively covered these policy changes and helped reinforce the importance of our local HEAL efforts.

So how can local communities continue to drive local HEAL change moving forward?

Establish a HEAL equity framework.

Research shows that some members of our communities face significant barriers to good health, overall wellness, and opportunity. This is particularly true for communities of color, who experience disproportionate levels of chronic disease, disability, and death. Retail redlining (i.e., when healthy food outlets avoid serving areas based on their ethnic-minority composition, rather than economic criteria), targeted marketing, and price differences between healthy and unhealthy food are just some examples of why it may be more difficult for people of color to maintain a healthy diet.4 We can reduce health disparities and work toward racial equity in health by advocating for policies and practices that dismantle long-standing health barriers and promise more equitable health outcomes for people of color; elevating the voices of leaders from communities of color; and strengthening the abilities and resources of community organizations to advance movements for social change. Being intentional about collecting disaggregated HEAL data by race is a critical first step. By engaging a diverse set of organizational partners and affected communities, we can pilot experiments and find long-lasting solutions to our problems.

Determine which HEAL policy interventions have the most promise.

Many national health organizations have published papers on promising HEAL policy interventions to reduce chronic disease, but the field is still young compared with other movements that produced defined sets of effective policies (e.g., tobacco-use prevention). We are probably years away from having definitive HEAL research about which policies are most effective. Until then, it’s up to local communities to take calculated risks in advocating for and adopting policies that seem promising and then evaluating them for effectiveness. It’s through this experimentation and evaluation that we have the best chance of reducing chronic disease.

Fight state preemption of local government policy.

State lawmakers in an increasing number of states are blocking cities, towns, and counties from passing laws that keep our families healthy and our environments clean, and/or create good jobs. Currently, 14 states have blocked local governments from passing certain HEAL policies at the local level. This is called preemption, and special-interest groups are behind it. When special-interest groups push state lawmakers to block local laws, it hurts the health, safety, and paychecks of our families, neighbors, and friends. As HEAL advocates, we must do all we can to protect the ability of local governments to pass these types of laws through constant vigilance, effective state and local organizing, and skillful media advocacy. Our ability to try new policy approaches to stem  diseases related to unhealthy eating and lack of activity may well depend on how well we fight state preemption of local laws.

Think long term.

It’s hard for foundations to invest in any topic over a long period of time. Other community priorities may eventually take precedence. Committed trustees’ terms expire or they experience issue fatigue. The Horizon Foundation, however, just finished its sixth year of significant HEAL programming with a commitment for at least another four. Staff has shown trustees, the community, and the field that our work is having an impact. In response, our trustees have made a strong commitment to further HEAL progress. The future of HEAL work depends on foundations, governments, and community groups taking a long view toward these problems and taking calculated risks to best solve them. It took decades for our nation to develop its chronic disease problems. And it will take many years of collective HEAL work to solve them. 

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Read more stories by Glenn E. Schneider & Nikki Highsmith Vernick.