What is the Problem? 

Obesity is a key risk factor for heart disease, type 2 diabetes, certain cancers and high blood pressure. Obesity-related chronic disease is on the rise and costing a fortune in this country.  

We have engineered physical activity and access to healthy food out of our daily lives in every domain from work to school to transportation and even our locations and modes of recreation.  As one researcher summed it up, 'obesity shows up at the doctor's office but the solution is a community solution,' (Carlos Crespo, Measuring Progress in Obesity Prevention, Institute of Medicine 2012, p. 103).  Community environment and policy shape our health.

Obesity is associated with higher healthcare costs -- about one-third higher among obese individuals.  Preventing obesity could avoid those expenditures.  For example, of the approximately $2 trillion spent annually on health care, about 75% of that is spent treating chronic diseases (March 30, 2011 Centers for Disease Control conference speech by Ursula Bauer). 

What is the Vision? 

• Active community environments are accessible to all peoples -- where citizens and visitors to Montana can enjoy active lifestyles and physical activity is a normal part of everyday living in every active living domain:  work/school, recreation, transportation, and household activities.

• Safe, Healthy and Complete Streets for All Montanans
  Today, many local governments and businesses are facing a crisis as they attempt to cope with the growing healthcare costs associated with chronic diseases, many of which are preventable. Individuals and families are also suffering from high healthcare costs and poor quality of life due to poor health.  Obesity and sedentary lifestyles are major contributors to chronic disease for both adults and children. A recent Institute of Medicine report states that the estimated annual cost of obesity related illness is $190.2 billion (in 2005 dollars), or nearly 21 percent of annual medical spending in the United States. Childhood obesity alone is responsible for $14.1 billion in direct medical costs.
   
  Solving the obesity epidemic is a complex issue and will require multi-faceted solutions and coordinated change at multiple levels—from individuals, to families, to communities, to society as a whole. Local governments have a role to play in creating places where children and adults can live healthy active lives. Studies have shown that people walk more in neighborhoods that are safe, walkable, and aesthetically pleasing. Improved pedestrian and cycling infrastructure may promote physical activity by making walking and cycling more appealing, easier and safer.
   
  A Complete Street is one that is designed and operated to safely accommodate all users, including: motorists, pedestrians, bicyclists, transit users, and people of all ages and abilities.  In order for Montana communities to better understand how to build more walkable, bicycle and transit friendly communities we have created the Montana Complete Streets Toolkit for Cities, Small Towns and Tribal Communities.
   
  Toolkit Purpose: Small/Rural Community Needs & Focus
  The purpose of this toolkit is to: 1) explain what is meant by a Complete Streets approach to designing and building a transportation network; 2) share the benefits of Complete Streets; 3) identify the various elements that make streets truly “complete” and describe the needed amenities to accommodate users of Montana’s roadways and 4) share innovative ways in which Montana’s cities, small towns and tribal communities are already working to complete their streets. This document will provide a resource to engineers, planners, elected officials, and residents who desire safe and efficient facilities for bicycling, walking and transit within their communities. This toolkit is organized into three sections - Planning Guidance, Case Studies in Montana communities, and Design Guidance.
   
  2012 Montana Complete Streets Toolkit for Cities, Small Towns and Tribal Communities
  

• Breastfeeding support is consistently available for every mom and baby in Montana.  While the decision to breastfeed is a personal one, evidence shows the importance of breastfeeding is so key for the health and wellbeing of mothers and children that hospitals, worksites and communities all over Montana (and the world) are working at the policy and system levels to remove barriers to breastfeeding. 

• Montana employers reduce the risk (and cost) of chronic disease among employees and their families through evidence-based worksite health programs that attack some of the biggest risk factors for chronic disease:  tobacco use, physical inactivity, poor nutrition, and obesity.

• Sugary beverage consumption is decreased so that obesity-related chronic diseases are decreased and overall health improves.

What is NAPA?

The Montana Nutrition and Physical Activity Program is one of 25 similar state health departments funded by the Centers for Disease Control and exists to take more sweeping population-based approaches (as differentiated from working person by person).  

The program focuses on environments where we can support communities through their local hospitals, schools, and local governments. These are mostly citizen-led efforts underway to create better and better daily opportunities for physical activity and healthful eating where we live, work and play.  

Our agreement with the federal Centers for Disease Control spells out that we will

1) work for effective policy and environmental changes,

2) develop and maintain strategic partnerships to leverage this important work, and

3) develop capacity to monitor and share relevant obesity-related, nutrition and physical activity data in Montana.  

The point is to prevent chronic disease such as type 2 diabetes and heart disease through policy and environmental changes that promote healthful eating and physical activity. 

Current points of focus include:  hospital policies that promote breastfeeding; local policies that encourage more active living/transportation; and healthy worksite policies.

How will we band together to create the health and wellness we want in our communities?  Passing effective policies will be key – standards that not only signal intentions but also set out specific and achievable objectives we can meet together.

What is the Situation and How did it Develop? 

In January 2012, the Centers for Disease Control and Prevention (CDC) reported the latest health care costs related to obesity:  about $147 billion annually, and, on average, someone who is obese costs $1400 more a year to care for. 

The root causes of the trends that led to this situation are complex.  Major societal forces and systems are driving more and more chronic disease among us.  

The story goes back a few decades at least and continues to unfold.  Between 1980 and the year 2000 there was a tripling of overweight and obesity among children in the U.S and a doubling among adults (2001 Surgeon General's Call to Action to Prevent and Reduce Overweight and Obesity). 

In 1996 another Surgeon General's report noted the dramatic decline of physical activity among the American people.  Citzens and their governmental representatives began to express more and more concern about the sedentary lifestyles and the implications of that related to chronic disease. 

On the nutrition side, Pamela Peeke, critical care doctor and Pew Foundation scholar in nutrition and metabolism pointed out, the evidence is very clear now:  "excessive fat deep inside the belly is highly associated with a pro-inflammatory state which increases the risk of diabetes, coronary vascular disease and certain cancers." (quote from the 2-7-12 radio show on Intelligence Squared U.S. "Obesity is the Government's Business.")

Mapping the prevalence of overweight and obesity in the US in 1990 showed 15% as the high mark.  Now, bringing that map up to date, no state has an obesity prevalence of less than 20% (2010 Behavioral Risk Factor Surveillance Survey -- BRFSS)

The 2011 Montana Youth Risk Behavior Survey indicated that 9% of Montana adolescents (grades 9-12) are obese -- students who were greater or equal to the 95th percentile for body mass index, by age and sex, based on reference data.  According to BRFSS the 2010 prevalence of obese Montana adults was 28.2% (up from less than 10% in 1985).  

Is good nutrition and physical activity all about reducing everyones' body mass index?  No.  Addressing these multi-layered issues will take citizen leadership, government leadership, infrastructure, policy decisions, and a lot of voluntary decisions by populations of people taking action where they live, work, and play.

Diabetes and heart disease are two of the top 5 preventable chronic disease killers.  Primary risk factors are obesity and lack of physical activity.   Our Centers for Disease Control name a number of forces and systems contributing to obesity trends:  agriculture, economics, racial and socioeconomic disparities, physical inactivity, and food and beverage marketing.  

It took decades of public decisions to get into this tough spot – decisions about how we do or don't design health into our schools, transportation systems and communities.