San Antonio is no stranger to being considered an unhealthy city. It is currently the 14th fattest city in the United States, according to a recent study by WalletHub. This represents a substantial improvement, considering that San Antonio ranked second in 2014.

The study compared 100 of the most populous U.S. metro areas across 17 key indicators of weight-related problems.

While many organizations have weighed in on San Antonio’s overall health, few aim to offer resolutions alongside their critique.

CityHealth, an initiative of the public health advocacy de Beaumont Foundation, determined its rankings, released in February, after a two-year assessment of how the nation’s 40 largest cities fare in nine policy areas: paid sick leave, alcohol sales control, food safety and restaurant inspection ratings, healthy food procurement, tobacco 21, high quality, universal pre-kindergarten, complete streets, and indoor air quality.

San Antonio, the seventh largest city in the U.S. by population, was included in CityHealth’s analysis and was recognized for efforts toward achieving healthy communities, but was given no overall medal.

The City of San Antonio is determined to improve that ranking.

Metro Health Director Colleen Bridger told the Rivard Report that she appreciates the CityHealth rankings because they provide concrete information on specific policy changes that can be made to improve health quality throughout the city.

“We see this as the power of information and accountability. [We are] creating transparency,” said Shelley Hearne, CityHealth’s principal investigator. “We tell cities, here is what others are doing, what you are doing, and it’s up to them how to fill in the blanks.”

“All we have done is a straightforward assessment of: does the city have this law, and if they do have it, how good is it against a gold standard,” Hearne explained.

Since the rankings were released, Hearne said a number of cities have sought to make improvements based on CityHealth’s assessments.

Kansas City, Missouri, was included in the CityHealth rankings and given a bronze medal. Hearne explained that like San Antonio, Kansas City has a local government that is putting health at the forefront of its policy initiatives, and sees “the big picture for creating a fair opportunity for everyone to live a healthy life.”

“Leaders have to come together to build a healthier city as a means for a more vital, economically thriving place to live, work, and play,” Hearne said.

Scott Hall, senior vice president of civic and community initiatives at the Kansas City Chamber of Commerce, said that the ranking are a great way for cities to evaluate the progress they are making on critical issues in public health.

“I think what is unique about CityHealth is that it isn’t just a rating system,” Hall said. “It’s a rating system with an opportunity for cities to leverage some support to achieve improved community health policy and outcomes.”

CityHealth works to refer city officials to organizations that may help them achieve their public health goals, and is currently in the process of issuing its first grants aimed at improving local community public health initiatives – efforts that Hall believes are “impressive.”

“We were excited to see that Kansas City was bronze, but recognize that [there is] room for improvement,” he said. “We are [using this information and] growing toward a gold designation.”

San Antonio is also making strides toward gold.

In September, Bridger announced plans to present a formal recommendation to City Council to raise the legal age to purchase tobacco products in San Antonio from 18 to 21. “When you look at what we haven’t yet achieved, [tobacco 21] is the single most important public health policy we can pass,” she said.

With the implementation of tobacco 21, San Antonio would achieve an overall bronze medal. Metro Health is gauging community support for tobacco 21 through an online survey that limits how many times people can respond. To participate in the survey, click here.

San Antonio got the highest rating due to the countywide law prohibiting smoking and e-cigarette use in workplaces and public areas. Dallas and El Paso are the only other Texas cities to receive that rating for indoor air quality policies.

For the category on universal, high-quality pre-K, San Antonio received a bronze medal. CityHealth’s assessment of pre-K quality is based on the National Institute of Early Education Research‘s 10 research-based quality standards benchmarks, along with an assessment of the level of enrollment in the city’s largest pre-K program. San Antonio met the standard for eight out of 10 benchmarks.

Pre-K 4 SA, the City-run pre-K program that was approved by San Antonio voters in 2012, has garnered national praise and been touted as a viable model for universal, high-quality pre-K education. Though critics often point to the high cost of the program, the benefits of early childhood education have been highlighted in several studies.

According to CityHealth data, 31 out of 40 cities received recognition for having high-quality pre-K, but no Texas city received the highest mark for such programs.

Hall said that the CityHealth data helped further his understanding of how the health of Kansas City residents is impacted by their access to educational opportunities, and will guide how his city chooses to improve.

“Early childhood education and its impact on community health is something that many people outside of the public health sector don’t realize,” he said, noting that it being part of health criteria will help spread awareness and understanding across professions. “Data shows that high-quality early education improves health outcomes not just for kids when they are young, but for people throughout their lives.”

Regarding complete streets, the public health category aimed at balancing people’s needs and safety across all forms of transportation, including walking, biking, public transit, and cars, San Antonio received a silver medal. The two benchmarks that the city did not meet within this category were having a department to oversee the implementation of transportation policies and having policies that require the development of performance measures.

Austin, Dallas, Fort Worth, and Houston received gold medals for complete streets. El Paso remains the only Texas city with no categorical medal regarding complete streets.

Addressing the categories where San Antonio currently has no medal, Bridger told the Rivard Report that the city plans to work to address what they can do within those areas.

Healthy food procurement addresses policies that ensure healthy food options are available on public property and highlights city efforts to aid residents in making choices that will help them achieve and maintain a healthy weight. Bridger said the City will have to write policies to reflect current initiatives in order to receive a category medal.

“Right now, the City does not allow sugar-sweetened beverages in its vending machines, and that policy is not reflected,” she said. “Once we make that change, we will get a silver medal.”

In order to receive a medal for food safety and restaurant inspection ratings, cities must require restaurants to disclose inspection results to the public. Bridger said the City already has a pilot program where restaurants can voluntarily choose to post their inspection score.

“What we are finding is that those [restaurants] who do well post their score,” Bridger said. “We want it posted in the restaurant – It doesn’t matter what the score is.”

The last three areas where San Antonio can make a health impact for its residents are categories that are preempted under Texas law, limiting cities in their ability to address concerns.

The alcohol sales control category refers to policies that control the number of alcohol sales outlets in an attempt can reduce crime, increase safety, and reduce spending on health care and criminal justice. In Texas, where alcohol may be purchased is a zoning concern, and, therefore, determined by the State. Bridger said that in order to address this category, San Antonio would have to work with colleagues across the state in all levels of government.

“You don’t want a ton of alcohol being sold by schools. That is something that a lot of people could get on board with,” Bridger said. To do so, the City would need to work with the State to allow municipalities to make changes locally, “perhaps by loosening restrictions,” she added.

The affordable housing and inclusionary zoning category would be the other area where the City would need to work with State leaders to address concerns.

Roseanna Garza

Roseanna Garza

Roseanna Garza reports on health and bioscience for the San Antonio Report.