The United States has experienced a steady increase in obesity and overweight due to changes in the environment and lifestyle behaviors that have resulted in energy imbalances for the majority of adults. The causes of this energy imbalance are complex, and solutions must be comprehensive and multisectoral (1). In 2001 and 2002, a work group composed of representatives from the following areas developed the Washington State Nutrition and Physical Activity Plan: transportation, parks and recreation, education, industry, health care, food assistance programs, advocacy groups for active transportation, food security, environmental health, and physical activity (2). The purpose of the state plan is to provide a framework in which policy makers at the institutional, community, county, and state levels can work together to build and support environments that make it easier for Washington State residents to choose healthy foods and to be physically active. The plan includes six objectives and 15 evidence-based recommendations (Table 1).

To test the conceptual approaches and recommendations of the plan and to develop a model for communities across the state, the Washington State Department of Health conducted interviews in five small, geographically isolated cities and asked government leaders to write letters if they were interested in serving as a pilot site. The city of Moses Lake was chosen as the first Healthy Communities site, based on its demographics and readiness to make environmental changes.

Moses Lake is located in the Columbia Basin in central Washington State. Although the economic base of the city continues to be agricultural, the city also benefits from light industry and tourism. The city has a population of about 15,000, and the surrounding unincorporated area has an additional 14,000 people. Eighty percent of Moses Lake residents identify themselves as white, 2% as black or African American, 1% as American Indian or Alaska Native, 1% as Asian, and 3% as two or more races (3). Twenty-six percent identify themselves as Hispanic or Latino (3). In 2003, the unemployment rate was 9.6% (3). There are almost 7000 children enrolled in the Moses Lake School District; 54% are enrolled in the free and reduced-price lunch program (4). Moses Lake is in Grant County, which has a population of about 75,000. Table 2 provides Behaviorial Risk Factor Surveillance System (BRFSS) data for nutrition and physical activity behaviors and related health outcomes in Grant County and Washington State.

A timeline for the Healthy Communities Moses Lake plan through 2002 is presented in Table 3. The city of Moses Lake, the Moses Lake Business Association, the Grant County Public Health District, the National Park Service's (NPS's) Rivers, Trails, and Conservation Assistance Program, the Washington State Department of Health (DOH), and the University of Washington (UW) Center for Public Health Nutrition and Health Promotion Research Center provided initial leadership. Fifty-two Moses Lake leaders and residents came to the first meeting of the Healthy Communities advisory committee. Table 4 lists the agencies represented on the advisory committee. The first responsibilities of the advisory committee were to participate in an inventory and planning process, ensure representation of community interest groups in the planning process, and participate in a kick-off walk and health fair in July and a ceremonial presentation of the plan to the community in November.

A team of Healthy Communities Moses Lake volunteers completed an inventory of existing institutional, community, and municipal policies and environments in Moses Lake. The inventory tools were designed to collect information for each of the six nutrition and physical activity objectives of the state plan. Inventory results were presented to the advisory committee in August 2002 (5).

In September, an ad hoc work group composed of advisory committee members met to develop policies and actions for Healthy Communities Moses Lake. The meeting was facilitated by NPS staff. The group developed a vision statement: "Residents of the Moses Lake area enjoy an active, healthy lifestyle that includes nutritious foods, recreation, and positive interactions with each other." A SWOT (strengths, weaknesses, opportunities, and threats) analysis of the vision statement was performed. After reviewing the objectives and recommendations made in the state plan, the work group discussed and developed a list of possible strategies and actions. Through a voting process, the group selected three projects for the first year of the plan: 1) a connected, attractive, and safe path and trail system; 2) enhanced facilities for breastfeeding in the community; and 3) community gardens. The work group presented its action plan to the advisory committee 1 week later, and it was approved. A team was established for each of the three projects to develop short- and long-term goals and a timeline for meeting these goals. Since then, each of the three teams has met at least monthly, and the advisory committee has met twice annually.

During fall 2002, the three teams and advisory committee leaders wrote Healthy Communities Moses Lake: An Action Plan to Promote Nutrition and Physical Activity (6) with technical assistance from NPS, UW, and DOH staff. The plan included the vision statement and work plans for each of the three initial projects. The plan was presented to the community in a ceremony at the last farmers' market of the year in November and approved by the Moses Lake City Council and Grant County Public Health District in December.

A local leadership structure was established in early 2004 to develop a sense of responsibility for sustaining the program. Before then, most meetings of the advisory committee were facilitated by DOH staff. The core leadership group now develops agendas, facilitates meetings, recruits members, and promotes outreach and integration with other community efforts. The group includes one leader from each of the projects and one representative each from Moses Lake and the Grant County Public Health District, and a part-time staff member of the Moses Lake Business Bureau coordinates the group's activities.

Evaluation plans for Healthy Communities Moses Lake included the following: 

Table 5 provides information about cumulative actions taken as part of Healthy Communities Moses Lake. In August 2004, a random-digit–dial telephone survey of 350 (313 English-speaking, 37 Spanish-speaking) adults was conducted to assess the results of a diabetes awareness campaign in Moses Lake. In addition to questions designed to measure the effect of the diabetes awareness campaign, respondents were asked six questions about Healthy Communities Moses Lake; their answers are presented in Table 6. Actions taken by each of the community teams are highlighted in the following sections and outlined in Table 7.

Moses Lake was selected as a pilot site to test the objectives and recommendations of the Washington State Nutrition and Physical Activity Plan. The plan's focus is on changing policies and environments, and it is designed to be complementary to educational efforts to change individual behaviors. Some teams found it easier than others to implement the state plan's recommendations for environmental change. For example, building a connected system of trails is clearly a way to change environments, and planning and funding for trails is driven by policy. On the other hand, breastfeeding coalitions have a long history of providing support and education to individual women and health care providers, and it was more difficult for this group to improve breastfeeding policies and environments.

Sustainability of Healthy Communities Moses Lake depends on institutionalizing policy and environmental changes. The initiative has resulted in local government plans and budgets for trails and community gardens that will influence nutrition and physical activity choices of Moses Lake residents for years to come. Changes to hospital policies for breastfeeding would offer similar long-lasting benefits for the families of Moses Lake.

Because this pilot project was undertaken to determine whether the recommendations of the state plan were effective in communities, evaluation was an important component for UW and DOH staff. However, community members were often more interested in the work itself. As each of the three work teams developed their initial proposals, they were also asked to include measures of success for their objectives. After 2 years, some of the original team members were no longer involved, and information about some of the measures was not being collected. The short initial evaluation training and limited ongoing technical assistance to the teams was not enough to ensure that evaluation was fully integrated into the projects. As a result, UW and DOH staff are developing more effective community-based evaluation procedures for Healthy Communities projects.

The state plan calls on policy makers from multiple sectors to work together to build healthy environments, but the emphasis on inclusiveness also provides challenges to maintaining a strong coalition that stays focused on a common mission over time. After the three initial projects were selected, representatives of other community interests were less inclined to continue as active participants in Healthy Communities Moses Lake. Work has not yet moved beyond the three initial projects to include the wider variety of venues and approaches that were included in the first plan for Moses Lake. A concerted effort and skilled leadership from the Moses Lake community will be needed to sustain a focus on the common mission and integrate Healthy Communities into other community improvement efforts.

Healthy Communities Moses Lake was possible because the city had leaders and volunteers who had a strong interest in making Moses Lake a healthier place. The city has been ready for change, has made progress over a short period, and has demonstrated that many of the ideas from the Washington State Nutrition and Physical Activity Plan can be effective in local communities.