State and Municipal Innovations in Obesity Policy: Why Localities Remain a Necessary Laboratory for Innovation

Abstract

Municipal and state governments are surging ahead in obesity prevention, providing a testing ground for innovative policies and shifting social norms in the process.

Though high-profile measures such as New York City’s soda portion rule attract significant media attention, we catalog the broader array of initiatives in less-known localities. Local innovation advances prevention policy, but faces legal and political constraints—constitutional challenges, preemption, charges of paternalism, lack of evidence, and widening health inequalities.

These arguments can be met with astute framing, empirical evidence, and policy design, enabling local governments to remain at the forefront in transforming obesogenic environments.

Obesity poses a critical threat to population health. More than one third of Americans are obese and over two thirds overweight or obese, with high risks of cancer, diabetes, and cardiovascular disease.¹ Policymakers often look to the federal government for solutions, but shepherding obesity policies through Congress is fraught with interest group politics—e.g., agriculture, food, advertising, and retail corporate lobbying.² Even as the federal government inches forward with modest policy reforms under the Affordable Care Act (ACA; e.g., new funding for community-based prevention programs), federal action often comes with preemption that inhibits state and local experimentation.^3,4 In this current political environment, states and localities provide a natural laboratory for testing innovative policies, a concept first expressed in 1932 by Justice Brandeis in a widely cited Supreme Court opinion.^5,6 States and municipalities (referred to generically as “localities” or “local” action) are acting boldly in the realms of diet (e.g., nutritional labeling, trans fat bans, portion sizes, and zoning out fast foods) and physical activity (e.g., bike shares, walking paths, parks, and recreation) to make health the easier choice.⁷

Policies in high-profile mega-cities have stirred a national conversation and attracted stinging refutations—such as for New York City’s sugar-sweetened beverage portion limits.^8–10 Many such critiques (e.g., the “Nanny State”) reflect traditional political divisions, and even some public health advocates warn against getting ahead of public opinion.¹¹ But despite flamboyant headlines, there are hubs of policy innovation in small towns, cities, and states, and these less-heralded efforts are setting the stage for fundamental shifts in social norms and improved health outcomes. Here, we argue that local action is critical to creating environments conducive to good health, specifically in terms of cataloguing a broad array of municipal and state obesity prevention measures, describing the political and legal constraints on local policymaking, and explaining how creative reform of city and rural landscapes could transform obesogenic environments. Social transformations demand a full suite of policies, together with effective framing of health policies in the face of entrenched corporate interests and political ideologies.

INNOVATIVE STATE AND MUNICIPAL OBESITY PREVENTION POLICIES

In 2007, Mayor Mick Cornett stood before the elephant cage at Oklahoma City zoo and challenged residents to lose one million pounds.^12,13 He launched a Web site containing resources for weight loss, encouraging groups to add their pounds lost to an overall achievement tally.^12,14 Cornett found inspiration for the program from his own weight-loss battle and from learning that Oklahoma City ranked among America’s most obese locations.

Tapping into the city’s infrastructure development program, Cornett created opportunities for residents to increase their physical activity.¹⁵ Drawing on a 1% sales tax increase, business loans, and federal funding, he improved parks, sidewalks, trails, bike lanes, and sports facilities. He targeted neighborhoods with high rates of heart disease, offering free medicine and check-ups in exchange for taking exercise classes.¹⁵ In January 2012, Cornett announced that the city had cumulatively lost one million pounds,¹² reportedly generating a cultural shift toward healthier lifestyles and contributing to a revitalized economy.¹³

Oklahoma City’s story represents a growing trend of local experimentation to combat obesity and chronic disease. New York City’s innovations are well known—trans fat bans in restaurants (designed to prevent cardiovascular disease rather than obesity), calorie displays in franchise restaurants, bike shares, and new park designs.¹¹ The city’s portion size limit for sugary drinks attracted intense public criticism and was ultimately struck down by the state’s highest court.^11,16 But beyond such high-profile examples, scholars have not systematically examined a wide array of state and local policy initiatives.

Local action aims to reshape physical environments that powerfully influence personal lifestyles—making health the easier choice while facilitating new social norms.² These initiatives are designed to increase the availability and appeal of healthy food, decrease the marketing of unhealthy products, and redesign environments to facilitate physical activity.⁷ Public officials employ a suite of regulatory tools, including health information, taxes and economic incentives, altering the built environment, direct regulation, and dismantling laws that impede healthy lifestyles.¹⁷ Governments use litigation to raise awareness, prompt industry self-regulation, and generate legislation.² They also deploy novel forms of public health governance, such as self-regulation and public–private partnerships that erect a framework of incentives for voluntary industry action—as found in the “Let’s Move”¹⁸ and “Soda Free Summer” campaigns.¹⁹

Authority for local prevention initiatives comes from various sources, including laws promulgated by state and city legislative bodies, regulatory rules developed by health agencies, and policies developed by schools and other organizations.⁵ Here we use “policy” as an inclusive term that incorporates laws, regulations, executive orders, and other legal and regulatory instruments. We include both state and local initiatives in our discussion, categorizing policies according to whether their main focus is improving diet or encouraging physical activity.

Diet and Nutrition

Table 1 illustrates how governments target multiple points along the food supply chain in their attempts to reshape the food system. Production and manufacturing interventions include nutritional composition (reducing salt, sugar, and fat), with other policies encouraging local production through community gardens and urban agriculture. For example, under the Californian Urban Agriculture Incentive Zones Act, cities grant tax breaks to landowners in designated zones who commit their land to agricultural use for a 5-year minimum.²⁰

TABLE 1—

Local and State Interventions to Improve Nutrition

Food System Sectors	Example	Description
Production/manufacturing	New York City ban on trans fat89	A 2006 amendment to New York City’s Health Code requiring that all restaurants and mobile-food vendors discontinue use of trans fat in foods.
	California’s Urban Agriculture Incentive Zones Act 201420	Legislation reducing property taxes for landowners who commit their land to local urban agricultural use for 5 years or more.
Marketing	California’s SB 1000 Soda Warning Label Bill 201490	The proposed law would label sugar-sweetened beverages with a warning that consumption contributes to obesity, diabetes, and tooth decay.
	San Francisco County’s Healthy Food Incentives Ordinance22	A Health Code ordinance that prohibits free toys from being offered with children’s fast-food meals, unless meals meet set nutrition standards.
	Maine School Advertising Law91	The first state law prohibiting brand-specific advertising of unhealthy foods and beverages in schools.
Retail	Minneapolis Staple Foods Ordinance25	The law requires food and grocery stores to stock a minimum number of “staple foods” such as vegetables, fruits, and cereals.
	Philadelphia’s Healthy Corner Store Initiative92	This public–private initiative provides technical training and financial incentives to corner stores operating in food deserts.
Purchasing by consumers	Double Up Food Bucks SNAP Michigan93	An NGO initiative that increases the buying power of SNAP recipients by matching food purchases in farmers’ markets.
	King County’ s (WA) “Let’s Do This” Campaign94	A multilingual, multimedia public education campaign promoting healthy eating.
	Healthy Diné Nation Act95	The Act set an additional 2% sales tax on “junk food” sold within the Navajo Nation.
Purchasing by governments	MA State Agency Food Standards96	Standards requiring that state executive agencies follow dietary guidelines when providing foods and beverages (directly or through contract).
Developing government infrastructure to facilitate healthy local food systems	Food Policy Advisory Committee New Orleans97	Formed by the New Orleans City Council in 2007 to identify ways that city and state officials can support equitable access to fresh, healthy food.

Note. NGO = nongovernmental organization; SNAP = Supplemental Nutrition Assistance Program.

Localities are targeting the pervasive effects of unhealthy food and beverages in schools, as well as mandating calorie displays on menus. Voluntary partnerships between “Change the Future Western Virginia” and grocery store owners aim to create healthy check-out aisles.²¹ San Francisco and Santa Clara require restaurants offering free toys or games with children’s meals to meet nutritional standards.^22,23

Some local governments regulate food retailing, such as a Los Angeles prohibition on new fast-food restaurants in 3 regions with a high density of fast-food chains and liquor stores, but few grocery retailers (“food deserts”).²⁴ In 2008 Minneapolis pioneered a policy requiring grocery stores to stock a minimum number of “staple foods” as a condition of licensing.²⁵

Food assistance and education campaigns support individuals and families in purchasing healthier foods and beverages, while “fat taxes” (taxes on energy-dense products high in salt, saturated/trans fat or sugar) and portion size limits aim to shift purchasing choices away from unhealthy products. Policies also focus on food procurement and availability in schools, childcare centers and other government institutions. Colorado requires school districts to restrict sugary beverages in schools,²⁶ as does California’s “healthy beverage” law.²⁷ Finally, the appointment of food policy directors or councils creates government infrastructure that supports new initiatives.

Physical Activity

Like innovative policies to improve the food environment, urban planning, transportation, and architectural design seek to promote physical activity—as demonstrated in Table 2.²⁸ The Nashville Metropolitan Planning Organization (MPO) awards federal transportation funding, giving preference to infrastructure that improves health and promotes physical activity.²⁹ In 2013, Massachusetts issued a Healthy Transportation Policy Directive, requiring all projects funded or designed by the transportation department to “seek to increase and encourage more pedestrian, bicycle and transit trips.”³⁰

TABLE 2—

Local and State Interventions to Encourage Physical Activity

Activity Sectors	Example	Description
Active transportation	Capital Bikeshare, Washington, DC, Area98	The nation’s first and largest bike-sharing program, serving Washington, DC, and surrounding areas.
	Complete Streets Policy, Baldwin Park, CA99	Baldwin Park had the highest-rated complete streets policy in 2011, incorporating all 10 elements recommended by the National Complete Streets Coalition.
	Healthy Transportation Policy Directive, MA30	A directive requiring that MassDOT fund and design projects to encourage active transport.
	Safe Routes to School National Partnership, multiple states100	This organization collaborates with local partners to develop programs that help students walk or bike safely to and from school.
Physical activity and recreation	Joint-use agreement, City of Tucson, AZ101	The City and Tucson Unified School District opened up 12 school sites to the public, with the police department providing extra patrols around sites to ensure community safety.
	Atlanta Beltline, Atlanta, GA102	An ambitious project fusing economic development with transportation planning to create new small businesses, housing, parks, and transit along 22 miles of repurposed trails.
	Play Streets, multicity initiative103	An initiative that closes streets to traffic and opens up reclaimed space for children’s play and physical activity.
	Druid Hills Revitalization Project, Charlotte, NC104	A partnership between Charlotte Police and a local nonprofit that significantly improved safety in high-crime neighborhoods by creating a community taskforce, remodeling old housing stock, and raising funds for a community park.
	Sarah Vaughn Field of Dreams baseball park, Greenville, NC105	Renovations to Elm Street Park’s baseball park made it fully accessible to children with disabilities.

Note. DOT = Department of Transportation; MassDOT = Massachusetts Department of Transportation.

“Complete Streets” policies transform road design to cater to pedestrians and cyclists,³¹ while bike-sharing schemes encourage active transport.³² In addition to creating new parks and trails, joint-use ventures open up existing venues for physical activity and recreation. Crime prevention may promote obesity prevention by providing more walk-friendly, livable cities,³³ as may road safety initiatives such as the “New York City Pedestrian Safety Study and Action Plan”—an evidence-based policy addressing the preventable causes of pedestrian injuries and deaths.³⁴ Physical activity interventions often focus on school settings, for example, Safe Routes to School programs, and mandated periods for physical instruction or play.³⁵

THE VALUE OF LOCAL INNOVATION

Public health advocates recognize the close relationships between healthier populations and economic prosperity, arguing that healthy populations stimulate economic growth, lower health care costs, lure new businesses, and create jobs.³⁶ Attractive urban centers (e.g., bike shares, pedestrian-friendly streets, and parks) appeal to younger, highly skilled workers critical to development. As explained later, these economic gains can come at a cost, including displacement of low-income residents and gentrification—as younger workers drive up rents, sales prices and taxes, and drive out the very residents that need access to amenities and services.

Federalism—when it works as intended—can create synergies at all levels of government. The federal government has power to tax and spend, which supports urban infrastructure, promotes physical activity (e.g., mass transit, walking paths, and recreational facilities), and encourages healthy eating (e.g., the 2014 Farm Bill increases access to fruits and vegetables).^2,17,37 Under the Constitution, states retain inherent authority for legislation that promotes the health, safety and welfare of their populations, and can exercise these “police powers” to regulate businesses and encourage individuals to make healthier choices.¹⁷ Localities—through state delegations of power, such as “home rule”—are closer to the people, often able to enact bolder reforms.^2,4 Local governments can exercise their legislative and administrative rule-making powers to serve as laboratories of innovation.^5,6

State and local innovation is at the cutting edge of public health governance. Absent local action, there would be few opportunities to implement and evaluate novel interventions. Local policies can inform the political community about what works, while being tailored to the social, economic, cultural, and demographic features of a region. Local innovators sometimes get ahead of popular opinion, testing the boundaries of public acceptability and fostering shifts in social mores. Although tobacco control was initially divisive (e.g., smoke-free laws), it is now broadly accepted. So too, could cities stimulate social acceptance of contested nutritional policies, such as trans fat bans, menu labeling, and portion limits.⁵

Municipalities create policy models that can be emulated, so that prevention initiatives diffuse vertically (nationally and statewide) and horizontally (to other localities).⁵ Many cities, counties, and states adopted New York City’s 2008 menu board labeling, with policy diffusion culminating in the ACA’s calorie labeling for menus and menu boards in restaurants and food retailers operating nationwide.^5,7,38a,38b Although jurisdictional variability creates inconsistency, the history of tobacco control suggests it also spurs policy innovation.³⁹ Federalism encourages state and local governments to innovate, setting a benchmark for other jurisdictions; fosters the diffusion of successful models; and enables jurisdictions to “leapfrog” existing policy models by creating stronger and more comprehensive laws.^39,40

Local innovation is crucial in a political climate that stifles national action, with the federal government more likely to be constrained by industry lobbying, budgetary constraints, and partisan gridlock.⁴¹ The Federal Trade Commission, for example, researches and regulates food marketing, as well as bringing enforcement actions. However, food industry lobbying has stymied the agency, rendering it unable to effectively restrict the marketing of unhealthy foods to children.^2,42 Similarly, Congress blocked school meal requirements, so that pizza and french fries count as fruits and vegetables. In general, the federal government rarely is in the vanguard of obesity prevention, and federal (and state) preemption can even thwart local innovation.

Local leaders are closer to their constituents, enabling local politicians to be more responsive (and accountable) to their communities, acting as public health champions. Industry lobbyists are also less likely to target local officials.⁴¹ Advocates can generate bottom-up social mobilization. Residents clamoring for healthier foods spurred Los Angeles to limit the expansion of fast-food restaurants.⁴³ Local policy-making fosters community dialogue, education, and engagement, thus erecting a base of public understanding and “ownership” of policy solutions, to better ensure their sustainability.³

The ACA recognizes the value of local innovation, creating a national framework for obesity prevention.⁴³ The National Prevention Council, comprising representatives of 20 federal agencies, provides national leadership and coordination of prevention initiatives.⁴⁴ The 2011 National Prevention Strategy aims to promote health “at every stage of life,” fostering “healthy and safe community environments” and evidence-based local prevention.³⁶ The Prevention and Public Health Fund provides Community Transformation Grants (CTG) for local experimentation with chronic disease prevention.⁴⁵ Unfortunately CTG grants will be eliminated in the 2015 federal fiscal year, and it remains to be seen if the new Partnership to Improve Community Health (called PICH) and Racial and Ethnic Approaches to Community Health (called REACH) grants will provide strong opportunities for effective disease prevention programs. New federal support under the ACA aims to encourage local innovation in prevention policy,^46–48 although funding for prevention remains a fraction of what is spent on the treatment of chronic disease.⁴⁸

CONSTRAINTS ON LOCAL-LEVEL ACTION

Cities benefit from streamlined law-making such as unicameral legislatures, often with concentrated political majorities facilitating efficient policymaking.⁴¹ Local policymaking, however, faces political and legal constraints. Although most cities have expansive rule-making authority, some states delegate only narrow powers, constraining local action and creating variability.^2,4

Innovative public health policies can face constitutional challenges. Certainly, local governments can engage in economic regulations (e.g., zoning and licensing) with minimal constitutional oversight. In a bitterly contested decision, Kelo v. City of New London, the Supreme Court even allowed local government to use eminent domain to transfer private property to spur economic growth.⁴⁹ Several states, however, deny local governments land use authority.

The courts can strike down public health laws that tread on constitutional rights. In 2001, the tobacco industry successfully challenged a Massachusetts law banning tobacco advertising within 1000 feet of schools and playgrounds, arguing that the ban violated commercial free speech.⁵⁰ Similar constitutional pitfalls could extend to nutritional policies; for example, the food industry likely would challenge restrictions on billboard advertising for unhealthy foods and beverages near schools.^2,50 These first amendment hurdles help explain why few governments at any level have restricted food advertising outside of K–12 public schools.

Federal or state preemption can be a powerful tool either for, or against, the public’s health. “Floor” pre-emption that sets minimal standards can facilitate innovation. The US Department of Agriculture’s nutritional standards for school meals⁵¹ require state compliance but permit schools to improve nutritional quality. “Ceiling” preemption that caps standards or forbids localities from introducing more rigorous health measures can undermine local creativity.^3,4 The ACA’s menu labeling, for example, sets standards for restaurant chains and food outlets with 20 or more locations, preventing states and localities from introducing more stringent standards for restaurants covered by the Act.

Health innovations can create a backlash, prompting conservative states to stifle local action. Before the ACA’s enactment, for example, Georgia, Tennessee, and Utah expressly prohibited localities from mandating menu labeling.⁴ San Francisco and Santa Clara’s ban on free toys in children’s meals spurred Arizona, Florida, and Ohio to preempt similar local measures.² As local innovation advances, industry may lobby for preemption strategically against obesity-prevention, just as Big Tobacco undermined local tobacco control.^2–4

Political Barriers

Beyond legal constraints, cities face political barriers, particularly the paternalistic framing of obesity prevention. Tobacco control advocates were able to deflect the “Nanny State” critique by demonstrating the harms of second-hand smoke and the industry’s deceit. The media, however, often frames obesity prevention as entailing only self-regarding behavior and government intervention to encourage healthy eating and drinking as unnecessarily infringing individual freedom. The epitaph “Nanny Bloomberg” haunted Michael Bloomberg’s administration.^9,52 Critics also argue that there is no evidence indicating that policies will reduce obesity—a claim made by industry associations in legal proceedings against New York City’s soda portion ban.¹¹

Ethical Barriers

Relatedly, some obesity-prevention strategies disproportionately impact racial minorities and the poor, given their high burdens of chronic disease.^53,54 Soda taxes, for example, are regressive because they fall more heavily on lower-income groups who drink more soda and have fewer resources to absorb tax increases. New York City’s diabetes surveillance system largely monitors lower-income patients, raising similar charges of injustice and unequal privacy intrusions.¹¹ Yet, the greater injustice is when public officials fail to act—passively allowing disadvantaged groups to bear a disproportionate burden of debilitating chronic disease. The health benefits of obesity prevention significantly outweighs the relatively small limits on personal autonomy.¹¹

Effective policies can fail to reduce—and can even exacerbate—health disparities. Health policies tend to benefit higher-educated and higher-income groups, while failing to reach vulnerable communities.⁴³ Higher-income and well-educated communities are more likely to make successful behavior changes that improve health outcomes, as demonstrated with sharp declines in smoking among the middle class that have not extended to the poor.⁵⁵

Poor health outcomes are not simply the result of personal choice, but also of social, environmental, and economic barriers. Yet readjusting these structures risks unintended consequences. Health advocates urge locating schools near children’s home to encourage walking and cycling, but this could increase racial and economic segregation in schools.⁵⁶ Redesign of the urban landscape can increase gentrification, pushing low-income residents out of the inner city into areas with fewer parks and grocery stores, and little public transportation. Public health, then, risks improving quality of life for the well-off, while leaving the poor disadvantaged.^43,56,57

COUNTERING OBSTACLES TO LOCAL INNOVATION

Although innovative prevention policies face political and legal challenges, political opposition can be countered empirically or resolved through policy design.

Political Barriers

Backlash.

Some public health advocates express concern that forward-thinking policies risk political backlash, potentially hampering future creativity. Yet, the success of tobacco control shows how progressive action can spark social change, draw media attention to unethical corporate practices, and pave the way for profound health improvements.² Though there are real risks in bold governance, oftentimes a single elected official bolstered by engaged advocates can champion public health issues and bring along more reluctant colleagues to push the boundaries in prevention—even getting ahead of public opinion—to break through entrenched social mores.⁵⁸

Paternalism.

Obesity is too often perceived as a matter of choice and personal failings, yet arguably it can be reframed as a market failure, particularly pertaining to children, who lack the capacity for fully informed, rational decision making.⁵⁹ Research shows that policies addressing the environmental drivers of obesity are more cost-effective than individual-level interventions (e.g., dieting),⁶⁰ with many local-level programs showing promise.^61–63 Public health advocates should be cautious of engaging in dialogue that frames obesity in terms of personal choice,⁶⁴ given evidence that the fundamental drivers of chronic disease lie outside individual control,⁶⁵ and wide consensus that comprehensive, community-based strategies are needed to address the chronic disease epidemic.^48,66–68

Evidence.

Public health policies are often held to exacting evidential standards (e.g., a certainty or high probability of success). Proving effectiveness is difficult given the multiple social, economic, and cultural influences on human behavior, and given that many strategies often comprise a single package of policy interventions.^69,70 Society achieved enormous success in tobacco control from a combination of taxes, labeling, smoke-free laws, and advertising restrictions; apportioning a share of the decline to any single initiative is complex, while failing to account for multiple policies working in tandem.^2,11,71 Tobacco control benefited from substantial evidence establishing a causal link between smoking and multiple health hazards,⁷² while the causal chain between food consumption and obesity is more difficult to establish.⁷³ However, studies suggest that similar combinations of policies are needed for successful obesity prevention.^48,69,74

Community-level prevention policies are a relatively new area of intervention, and the results of evaluation studies are still emerging.⁷⁵ However, some local initiatives have produced demonstrable changes in health-related behavior and weight status.^61,62 Low-income schools in King County, Washington, experienced declines in obesity among students in grades 8, 10, and 12, after introducing nutrition standards for school meals and high-quality physical education programs in 2010. Obesity rates did not decline in county schools that failed to embark on similar initiatives.⁷⁶ Yet, despite the growing array of highly promising policies and practices many of the initiatives described here still lack causal evidence to support their efficacy and effectiveness in reducing obesity.^70,77

Local governments must progress with policy innovation despite gaps in the evidence base. Obesity prevention strategies “should be based on the best available evidence—as opposed to waiting for the best possible evidence.”⁷⁸ Policymakers should draw upon different types of evidence,^77,79 for example citing strong correlations between soda consumption and obesity to support experimental initiatives that seek to reduce soda consumption.² Policymakers must carefully evaluate the growing number of community initiatives targeting environmental change,⁷⁵ but ideally, with ongoing monitoring and evaluation the evidence base will build over time and allow underperforming interventions to be strengthened.⁴³

Ethical Barriers

Widening health inequalities.

Some public health measures, such as smoking reduction programs, may improve the health of the wealthy more than those in lower socioeconomic groups. Although it is not inherently unethical to improve the health of the affluent to a greater extent than the poor, it is preferable to narrow health disparities while retaining absolute gains.⁴³ Emerging literature proposes local-level strategies aimed at improving health outcomes in lower-income and less-educated communities,^43,80,81 and documents the success of community-based organizations in reducing urban health inequalities.^82,83

General policies can reduce health disparities, particularly when accompanied by resources directed to underserved populations, but targeted policies still may be necessary.⁴³ Interventions should focus on underserved populations experiencing high rates of obesity or poor health.⁴³ New York City’s Food Retail Expansion to Support Health (FRESH) initiative, for example, offered zoning and financial incentives to developers opening stores in underserved communities.⁸⁴ Targeted policies can generate controversy, appearing discriminatory or stigmatic. It is therefore essential to meaningfully engage affected communities, giving them the opportunity to participate in health governance.⁸⁵ Health impact assessments and community consultations can help pinpoint disparities and target interventions, as well as ensuring community support and enhancing effectiveness.⁴³ Inclusive policy processes may enable communities to become active participants in the obesity prevention agenda rather than passive objects of intervention—in turn potentially helping to address concerns about government paternalism.⁸⁶

Addressing socioeconomic determinants can be effective in changing nutritional and physical activity patterns, narrowing health inequalities.⁸² To ensure fair benefits for all community members, policymakers must pay attention to multiple non–health specific factors, such as residential segregation, public education, employment, and income support.^43,56,57 To reduce health care costs, for example, New York State invested in supportive housing targeted to high-risk homeless and unstably housed Medicaid recipients.⁸⁷ This initiative could reduce the state’s obesity burden given the high prevalence of excessive weight among the homeless.⁸⁸

UNLEASHING THE POWER OF STATE AND LOCAL GOVERNMENTS

Local and state governments are in the vanguard of obesity prevention, with new federal measures under the ACA fostering local-level innovation. Municipalities can test and diffuse innovative policies, given the manifest national political constraints. Yet localities encounter their own challenges, including preemption, public backlash, and nagging concerns about paternalism, evidence, and widening health inequalities. However, the difficulties localities face can be ameliorated by astute framing, marshaling evidence, ongoing evaluation, and community participation. A broad suite of interventions, together with a “health-in-all-policies” strategy can improve health and narrow disparities. Given the high value of local action, social mobilization, and political activism, municipal and state governments should lead the nation in obesity prevention, fulfilling their historic role as innovative laboratories.