摘要：In response to a nationwide rise in obesity, several states have passed legislation to improve school health environments. Among these was Arkansas's Act 1220 of 2003, the most comprehensive school-based childhood obesity legislation at that time. We used the Multiple Streams Framework to analyze factors that brought childhood obesity to the forefront of the Arkansas legislative agenda and resulted in the passage of Act 1220. When 3 streams (problem, policy, and political) are combined, a policy window is opened and policy entrepreneurs may advance their goals. We documented factors that produced a policy window and allowed entrepreneurs to enact comprehensive legislation. This historical analysis and the Multiple Streams Framework may serve as a roadmap for leaders seeking to influence health policy. In an unprecedented rise, the prevalence of overweight among US children has more than tripled over the past 3 decades. Recent National Health and Nutrition Examination Survey data (2003 through 2006) estimated that 32% of children and adolescents had a body mass index (BMI; defined as weight in kilograms divided by height in meters squared) for age at or above the 85th percentile. 1 When Ogden et al. used the 97th percentile as an identifier of those with the greatest body mass for age, they reported that more than 11% of US children and adolescents fit into that category. 1 Overweight in childhood is likely to persist into adulthood 2 , 3 and obesity predisposes for a number of diseases of both childhood and adulthood. 4 Adolescents with very high BMI have also been shown to have adult mortality rates up to 40% higher than those observed in adolescents with medium BMI. 4 Obesity interventions and prevention have, consequently, become a major priority for policymakers, health care professionals, economists, and the general public. 5 Prior to 2003, several states and the federal government had enacted limited legislation aimed at reducing and preventing childhood obesity. 6 Incremental school-based prevention efforts were largely focused on emphasizing and improving nutrition and physical education curricula, reinforcing classroom learning throughout the school environment, rewarding voluntary adoption of healthy nutrition and physical activity standards, and providing model vending policies and toolkits. 6 , 7 Arkansas policymakers recognized that halting the epidemic necessitated progressive steps to outpace increasing disease rates. With the passage of Act 1220 in 2003, Arkansas enacted comprehensive legislation to combat childhood obesity. Act 1220 included 6 components aimed at combating childhood obesity. First, a 15-member Child Health Advisory Committee was created and tasked with making recommendations to the State Board of Education and State Board of Health regarding physical activity and nutrition standards in public schools. Further, Act 1220 required school districts to establish Nutrition and Physical Activity Advisory Committees to guide the development of locally specific policies and programs. With Act 1220, Arkansas became the first state to enact statewide school-based BMI screening with reports to parents for all public school children in grades K through 12. Act 1220 both restricted student access to vending machines in public elementary schools and required that schools disclose vending contracts and publicly report vending revenues. Lastly, the Arkansas Department of Health was required to employ community health promotion specialists to provide technical assistance to schools in formulating and implementing the rules and regulations. 8 Thus, Act 1220 mandated some limited immediate action while establishing the mechanisms for short- and longer-term change at both state and local levels. In the policymaking process, incremental health policy change is the norm, as opposed to innovative, comprehensive reforms such as Act 1220. Legislators often face a multitude of issues, have little time to consider all the data they need to address them, and may have to choose from among a number of policy alternatives to address any given issue. Zahariadis observed that policymakers often “are less capable of choosing issues they would like to solve and more concerned with addressing the multitude of problems thrust upon them.” 9 (p75) Arkansas is no exception. In the 2003 Arkansas legislative session in particular, a large number of bills were introduced concerning education. How, then, did the single issue of childhood obesity rise to the forefront of an overburdened legislative agenda? Who garnered political attention for this issue and formulated policy solutions? What were the key events that led the Arkansas Legislature to abandon incremental legislation and adopt a bold, comprehensive policy initiative? We sought to answer these questions by documenting the factors and events that influenced the policy process allowing the passage of Arkansas's school-based childhood obesity legislation policy. This historical review and analysis of the policy process provides a roadmap for public health advocates interested in pursuing policies directed toward curbing the childhood obesity epidemic and other critical public health issues. By studying this policy process roadmap, public health advocates interested in shaping health policy can understand more fully their role in the process of setting agendas and formulating policy and can more effectively act when windows of opportunity arise.
