Background: Childhood overweight and obesity is a significant and growing health concern that has reached epidemic proportions. It is estimated that 16 percent of U.S. children and adolescents, aged six to 19, are overweight and these rates are even higher in California and San Diego County. Latino and African American youth face higher rates of overweight than White and Asian youth.

Being overweight exposes children to serious health problems, now and in the future. Because overweight children are likely to become overweight adults, they are more likely to suffer from cardiovascular disease, cancer and diabetes in adulthood. These chronic diseases are largely preventable and account for two-thirds of all deaths in California. These and other conditions related to overweight and physical inactivity burden the state's economy with exorbitant and preventable long-term costs.

San Diego took on the challenge of reversing the growing childhood obesity trend. Spearheaded by the County of San Diego, the Childhood Obesity Initiative was created. An ecological model focusing on environmental changes, behaviors and policies to help individuals make healthier choices in their lives was developed via a community input process. Seven domain areas, each with specific strategies, were identified. Domain areas include:

• County and City Governments
• Healthcare Systems and Providers
• Schools
• Childcare, Preschools and Before-School and After-School programs
• Community-Based Organizations
• Faith-Based Organizations and Youth Organizations
• Media Outlets and the Marketing Industry
• Businesses

The following describes the "toolkit" used to achieve one policy strategy in the Government Domain:

Policy Solution: Ensure that vending machines on all county and city owned and/or leased land, space and facilities have healthy choices, and encourage community partners to do the same.

Policy Development Process:

1. Gather Data/Learn from Others - Determine what worked and describe challenges
   • Review Literature
   • Conduct Key Interviews
     • Nutrition Organizations
     • Other Communities that have implemented similar policies
     • Other County Departments
2. Inventory current status
   • Number of vending machines under County contract
   • Kinds of machines
   • Contracts/Leaseholders
   • "Customer revenue-sharing" options
3. Identify and secure buy-in of key decision-makers
   • Develop policy level stakeholders' advisory group with representatives from: County's Chief Administrative Office, County Counsel, Purchasing and Contracting, Elected Officials, General Services and Public Health Nutrition
   • Hold meetings, identify and explain proposals and solve problem
   • Review financial aspects
   • Hold "taste testings" of healthy choices
   • Draft and review multiple versions of the policy
4. Reach consensus on policy, implementation and enforcement
5. Create lists of healthy food and beverage options
6. Work with contractors/vendors
   • Create list of criteria for healthy options
   • Develop advertising policy
   • Develop policy for addition of new vending options
   • Issue Request for Proposal (RFP)
   • Consolidate number of contracts and award new contracts or develop contract amendments
7. Educate Users
• Hold Departments' taste tests
• Provide education/information
• Detail nutrition content of products on County website
8. Evaluate
• Create contract feedback report which includes percents and dollars of healthy food choices sold and income County earned on contracts
• Solicit customer feedback
9. Document results
• 400 county vending machines meet new healthy choices policy requirements
• 100% of foods and beverages sold in machines in county locations primarily used by children meet healthy choice criteria
• 50% of foods and beverages choices in vending machines on county property meet healthy choice criteria
• Percent of vending sales returned to County increased from 0 -15% to 40%
10. Share success with others

Lessons Learned :

• Learn from others - successes and failures
• Get highest level administrative buy-in and support before beginning
• Roll out slowly so problems can be worked out
• Adjust, modify as needed
• Include evaluations/feedback
• customer and vender acceptance/satisfaction
• revenue generation