. Author manuscript; available in PMC: 2017 Apr 28.

Published in final edited form as: Circulation. 2012 Dec 12;127(1):e6–e245. doi: 10.1161/CIR.0b013e31828124ad

Table 2-6.

Summary of Evidence-Based Population Approaches for Improving Diet, Increasing Physical Activity, and Reducing Tobacco Use^*

Diet
Media and education	Sustained, focused media and educational campaigns, using multiple modes, for increasing consumption of specific healthful foods or reducing consumption of specific less healthful foods or beverages, either alone (IIa B) or as part of multicomponent strategies (I B)^†^‡^§
Media and education	On-site supermarket and grocery store educational programs to support the purchase of healthier foods (IIa B)^†
Labeling and information	Mandated nutrition facts panels or front-of-pack labels/icons as a means to influence industry behavior and product formulations (IIa B)^†
Economic incentives	Subsidy strategies to lower prices of more healthful foods and beverages (I A)^†
	Tax strategies to increase prices of less healthful foods and beverages (IIa B)^†
	Changes in both agricultural subsidies and other related policies to create an infrastructure that facilitates production, transportation, and marketing of healthier foods, sustained over several decades (IIa B)^†
Schools	Multicomponent interventions focused on improving both diet and physical activity, including specialized educational curricula, trained teachers, supportive school policies, a formal PE program, healthy food and beverage options, and a parental/family component (I A)^†
	School garden programs, including nutrition and gardening education and hands-on gardening experiences (IIa A)^†
	Fresh fruit and vegetable programs that provide free fruits and vegetables to students during the school day (IIa A)^†
Workplaces	Comprehensive worksite wellness programs with nutrition, physical activity, and tobacco cessation/prevention components (IIa A)^†
Workplaces	Increased availability of healthier food/beverage options and/or strong nutrition standards for foods and beverages served, in combination with vending machine prompts, labels, or icons to make healthier choices (IIa B)^†
Local environment	Increased availability of supermarkets near homes (IIa B)^†^‡
Restrictions and mandates	Restrictions on television advertisements for less healthful foods or beverages advertised to children (I B)^†
	Restrictions on advertising and marketing of less healthful foods or beverages near schools and public places frequented by youths (IIa B)^†
	General nutrition standards for foods and beverages marketed and advertised to children in any fashion, including on-package promotion (IIa B)^†
	Regulatory policies to reduce specific nutrients in foods (eg, trans fats, salt, certain fats) (I B)^†^§
Physical activity
Labeling and information	Point-of-decision prompts to encourage use of stairs (IIa A)^†
Economic incentives	Increased gasoline taxes to increase active transport/commuting (IIa B)^†
Schools	Multicomponent interventions focused on improving both diet and physical activity, including specialized educational curricula, trained teachers, supportive school policies, a formal PE program, serving of healthy food and beverage options, and a parental/family component (IIa A)^†
	Increased availability and types of school playground spaces and equipment (I B)^†
	Increased number of PE classes, revised PE curricula to increase time in at least moderate activity, and trained PE teachers at schools (IIa A/IIb A^¶)^†
	Regular classroom physical activity breaks during academic lessons (IIa A)^†^§
Workplaces	Comprehensive worksite wellness programs with nutrition, physical activity, and tobacco cessation/prevention components (IIa A)^†
	Structured worksite programs that encourage activity and also provide a set time for physical activity during work hours (IIa B)^†
	Improving stairway access and appeal, potentially in combination with “skip-stop” elevators that skip some floors (IIa B)^†
	Adding new or updating worksite fitness centers (IIa B)^†
Local environment	Improved accessibility of recreation and exercise spaces and facilities (eg, building of parks and playgrounds, increasing operating hours, use of school facilities during nonschool hours) (IIa B)^†
	Improved land-use design (eg, integration and interrelationships of residential, school, work, retail, and public spaces) (IIa B)^†
	Improved sidewalk and street design to increase active commuting (walking or bicycling) to school by children (IIa B)^†
	Improved traffic safety (IIa B)^†
	Improved neighborhood aesthetics (to increase activity in adults) (IIa B)^†
	Improved walkability, a composite indicator that incorporates aspects of land-use mix, street connectivity, pedestrian infrastructure, aesthetics, traffic safety, and/or crime safety (IIa B)^†
Smoking
Media and education	Sustained, focused media and educational campaigns to reduce smoking, either alone (IIa B) or as part of larger multicomponent population-level strategies (I A)^†
Labeling and information	Cigarette package warnings, especially those that are graphic and health related (I B)^†^‡^§
Economic incentives	Higher taxes on tobacco products to reduce use and fund tobacco control programs (I A)^†^‡^§
Schools and workplaces	Comprehensive worksite wellness programs with nutrition, physical activity, and tobacco cessation/prevention components (IIa A)^†
Local environment	Reduced density of retail tobacco outlets around homes and schools (I B)^†
Local environment	Development of community telephone lines for cessation counseling and support services (I A)^†
Restrictions and mandates	Community (city, state, or federal) restrictions on smoking in public places (I A)^†
	Local workplace-specific restrictions on smoking (I A)^†^‡^§
	Stronger enforcement of local school-specific restrictions on smoking (IIa B)^†
	Local residence-specific restrictions on smoking (IIa B)^†^§
	Partial or complete restrictions on advertising and promotion of tobacco products (I B)^†

PE indicates physical education.

The specific population interventions listed here are either a Class I or IIa recommendation with an evidence grade of either A or B. The American Heart Association evidence grading system for class of recommendation and level of evidence is summarized in Table 2. Because implementation of population-level strategies does not require perfect evidence but rather consideration of risks versus benefits, associated costs, and alternate approaches, the absence of any specific strategy herein does not mean it should not also be considered for implementation. See the more detailed tables and text below for further information on the evidence for each of these interventions, as well as other strategies that were reviewed.

^†

At least some evidence from studies conducted in high-income Western regions and countries (eg, North America, Europe, Australia, New Zealand).

^‡

At least some evidence from studies conducted in high-income non-Western regions and countries (eg, Japan, Hong Kong, South Korea, Singapore).

^§

At least some evidence from studies conducted in low- or middle-income regions and countries (eg, Africa, China, Pakistan, India).

^||

Based on cross-sectional studies only; only 2 longitudinal studies have been performed, with no significant relations seen.

^¶

Evidence IIa A for improving physical activity; evidence IIb B for reducing adiposity.