8

The Federal Government

Key Points Highlighted by Individual Speakers

  • The Special Supplemental Nutrition Program for Women, Infants, and Children, the Child and Adult Care Food Program, the Supplemental Nutrition Assistance Program, the HealthierUS School Challenge, and initiatives established under the Healthy, Hunger-Free Kids Act of 2010 all include provisions designed to improve the nutritional quality of Americans’ diet. (Concannon)
  • The Physical Activity Guidelines for Americans, the work of the President’s Council on Fitness, Sports, and Nutrition; the Presidential Youth Fitness Program; the public health and prevention provisions of the Patient Protection and Affordable Care Act; Community Transformation Grants; and the Let’s Move! initiative all are helping to increase physical activity and reduce obesity among children and adults. (Koh)
  • As the health care sector redirects its attention to outcomes and the social determinants of health, obesity prevention and control can be emphasized. (Levi)
  • Greater collaboration among federal agencies can leverage available resources to change the community environments that shape nutrition and physical activity. (Levi)


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8 The Federal Government Key Points Highlighted by Individual Speakers • The Special Supplemental Nutrition Program for Women, Infants, and Children, the Child and Adult Care Food Pro- gram, the Supplemental Nutrition Assistance Program, the HealthierUS School Challenge, and initiatives established under the Healthy, Hunger-Free Kids Act of 2010 all include provi- sions designed to improve the nutritional quality of Americans’ diet. (Concannon) • The Physical Activity Guidelines for Americans, the work of the President’s Council on Fitness, Sports, and Nutrition; the Presidential Youth Fitness Program; the public health and pre- vention provisions of the Patient Protection and Affordable Care Act; Community Transformation Grants; and the Let’s Move! initiative all are helping to increase physical activity and reduce obesity among children and adults. (Koh) • As the health care sector redirects its attention to outcomes and the social determinants of health, obesity prevention and control can be emphasized. (Levi) • Greater collaboration among federal agencies can leverage available resources to change the community environments that shape nutrition and physical activity. (Levi) 51

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52 CURRENT STATE OF OBESITY SOLUTIONS Three speakers addressed obesity solutions within the federal govern- ment. Kevin Concannon, under secretary for food, nutrition, and consumer services at the U.S. Department of Agriculture (USDA), described the pro- grams of that agency. Howard Koh, assistant secretary for health at the U.S. Department of Health and Human Services (HHS), detailed that agency’s programs and policies related to physical activity. Finally, Jeff Levi, execu- tive director of the Trust for America’s Health, proposed principles and ideas for the roundtable to consider going forward. NUTRITION PROGRAMS AT USDA Concannon reviewed some of the USDA programs that have contrib- uted to the improvement in obesity rates seen in recent years. The first is the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which now serves 53 percent of all infants in the United States, including 75 percent of Hispanic infants. The program is having a major effect in promoting more breastfeeding, particularly among lower-income women. The program’s implementation of a new food pack- age that includes more fruits, vegetables, and whole grains also has had an impact on WIC households across the country, said Concannon. The Child and Adult Care Food Program (CACFP) serves about 3.5 million children in child care, representing about a third of all children who attend child care each day. The program has had an important influence on the nutrition of both children and adults, although Concannon said he is worried about the slow growth of the program, as well as the child care programs the program does not reach. The new meal patterns recently instituted for the School Lunch and School Breakfast Programs are affecting 31 million children across the country and 100,000 public and private schools. For the most part, they have worked well, said Concannon, although some elements had to be adjusted. In addition, new rules affecting competitive foods go into effect in 2014 for all schools that participate in the programs. The Supplemental Nutritional Assistance Program (SNAP) also is undergoing changes designed to combat obesity. A pilot program in west- ern Massachusetts, for example, has demonstrated that low-income people will respond to incentives to buy healthier foods, and a variation on that program is under way in Texas. SNAP serves 47 million people each month, nearly half of whom are children. Part of the recent increase in numbers served reflects economic problems, but states also have made efforts to pro- vide access for eligible families. The program now serves about 79 percent of those who are eligible in the United States, compared with just 50 percent in the relatively recent past. SNAP also has an education component, funded at about $400 million

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THE FEDERAL GOVERNMENT 53 annually, which focuses on nutrition. For example, it teaches people about the MyPlate program developed at USDA’s Center for Nutrition Policy and Promotion. Three million people have signed up on the center’s website to receive direct advice about their diet and their nutritional progress. The Healthy, Hunger-Free Kids Act of 2010, enacted with the support of First Lady Michelle Obama, also has been making a difference in the lives of students across the country, said Concannon. Enrollment in the School Breakfast Program has increased, as has the percentage of free and reduced-priced meals being served to students. Under the Healthy, Hunger- Free Kids Act, students are provided fruits and vegetables every day of the week, which was not the case in the past, along with more whole grains and low-fat or nonfat diary, within overall calorie limits. Many elementary schools across the country are participating in the Fresh Fruit and Vegetable Program, designed both to promote healthier eating and to introduce children to fruits and vegetables they might not otherwise encounter. In addition, under the HealthierUS School Challenge, 6,500 American schools have voluntarily met high standards for both well- ness policies and nutrition programs. In regard to the nutrition education component of SNAP, an amend- ment to the Healthy, Hunger-Free Kids Act required that the distribution of funds under the act reflect more closely the numbers of consumers receiv- ing benefits through the SNAP program. As a result, funds will gradually shift to a larger number of states. The amendment also made these funds more accessible for classroom education or for provider groups and policy advocacy. Concannon emphasized the need to accumulate evidence. If policies and programs are based on evidence, he said, people are more likely to accept them, despite the efforts of some groups to confuse the message. PHYSICAL ACTIVITY PROGRAMS AND POLICIES AT HHS Koh focused on programs and policies relevant to the physical activity side of the energy balance equation. HHS has established national frameworks for improving physical activ- ity. In 2008, the agency published its first Physical Activity Guidelines for Americans, and a Midcourse report was released in 2013.1 That report highlights opportunities for youth to be active and emphasizes areas in which research is especially strong, particularly in schools, preschools, child care centers, and the built environment. Increasingly, leaders are contrib- uting to advancing physical activity as a vital form of disease prevention. The President’s Council on Fitness, Sports, and Nutrition also has 1  Available at www.health.gov/paguidelines (accessed April 29, 2014).

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54 CURRENT STATE OF OBESITY SOLUTIONS catalyzed substantial change. In 2012, for example, the Council partnered with leaders in fitness education to launch the Presidential Youth Fit- ness Program, an updated and modernized version of the long-standing Youth Fitness Test. This new fitness program places a greater emphasis on personal health and fitness, and minimizes competition and comparisons between children. It provides professional development and support to physical educators, and encourages children to pursue healthy lifestyles through physical activity—not just as part of their school activities, but as a lifelong commitment. The Patient Protection and Affordable Care Act has the potential to have a major impact on obesity, said Koh. In addition to enrolling people into insurance, health care reform embodies a vision and a system of prevention and public health that have not yet been widely publicized. For example, all new private health care and Medicaid expansion plans cover obesity-related screening and behavioral counseling. Additionally, through the prevention and public health fund that is now entering its fifth year, recipients of Community Transformation Grants and their part- ners are implementing changes to improve the health of some 120 million Americans residing in those communities. These grants reflect the fact that strategies need to be based on populations, communities, and the broader society, said Koh. “Health does not just start in a doctor’s office,” he noted. “Health starts where people live, labor, learn, play and pray.” The First Lady’s Let’s Move! initiative also has been working to improve children’s health on a number of fronts and across a variety of sectors. In 2013, for example, the First Lady convened a meeting focused on market- ing healthier foods and beverages to children. One major outcome of that meeting was a new partnership agreement between Sesame Street and the Produce Marketing Association to promote fresh fruit and vegetable con- sumption among youth. Similarly, HHS, in partnership with the National League of Cities, has advanced the Let’s Move! Cities, Towns, and Counties initiative. No one person or group can solve this problem alone, Koh emphasized. But mayors, county executives, and other local elected officials can exert piv- otal leadership in creating community environments that promote physical activity and healthy eating for many. Let’s Move! Active Schools also has made great progress, in part by emphasizing the theme that healthy students do better academically. “Kids must learn to be active and must be active to learn,” said Koh. According to the Centers for Disease Control and Prevention (CDC), more than half of American adults do not engage in the cardiorespiratory physical activity they need, and only 20 percent meet recommendations for both aerobic and muscle strengthening activity. HHS and other agencies provide survey information and data to help determine status and trends

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THE FEDERAL GOVERNMENT 55 in physical activity, as well as which policies, programs, and other changes make a difference. More work is needed with regard to the policy and environmental survey information, suggested Koh. Koh emphasized the importance of leadership. People at the highest levels need to commit to an objective and then convey that commitment to people throughout their organization. As one major example, President Obama formed a White House task force in 2010 that brought federal departments and agencies together to develop an action plan for solving the problem of childhood obesity within a generation. All leaders in the field, especially local champions, need to be honored, recognized, fostered, and encouraged, Koh stressed. “If a key leader steps forward in every com- munity, brings everybody to the table, and says we are going to do this together,” he said, “such action can elevate commitment to a much higher level.” The health sector also needs to work and communicate more effectively with nontraditional partners that influence health, such as education, urban planning, transportation, and other segments of society, Koh noted. For example, neighborhoods that are walkable and bikeable can have many benefits for community residents, such as improved livability, economic revitalization, and social capital, in addition to better health. POTENTIAL PRINCIPLES AND ACTIONS Levi offered three principles on which those in the field may consider when taking action. First, multifaceted interventions are needed. When policy makers ask for just one solution for the obesity crisis, those most familiar can insist that no such magic bullet exists. Second, the distinction between primary and secondary prevention of obesity is not always clear, which is a good thing because it brings more interested parties to the table. For example, improving physical activity and nutrition can both prevent obesity and manage diabetes, and the interven- tions needed for either purpose are very similar or identical. Third, different communities face different challenges, which means that a multifaceted approach will look different in each community. This variation can pose difficulties for communications, but this difficulty can be reframed as an emphasis on local decision making. Thus, a Community Transformation Grant does not amount to the federal government’s telling a community what to do. Rather, it represents an opportunity to bring players to the table to determine what is best for a community. The health care financing system is changing, said Levi, which creates “an incredible opening for those of us who care about obesity preven- tion and control.” The change is pushing the health care system to focus

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56 CURRENT STATE OF OBESITY SOLUTIONS on outcomes while also emphasizing short-term returns on investment. Meanwhile, greater recognition of the social determinants of health within the health care system has revealed the importance of social services to health. People cannot exercise their personal responsibility for health unless they have an environment and the resources to do what they know they should do. Based on the above principles and this changing context, Levi offered three ideas for the obesity prevention community to consider. First, com- munities need more capacity to partner with the health care system. Com- munity Transformation Grants provide one framework for change, but others exist as well. What these frameworks have in common is the need for an integrator, a backbone organization that can bring the relevant play- ers together. Systematic investment in integrators is therefore necessary to create the partnerships that are needed, said Levi. Second, as the leading governmental payer for health care, the Centers for Medicare & Medicaid Services (CMS) needs to develop a more sophisti- cated understanding of the role of accountable care organizations and other experiments in health system design and delivery in addressing obesity and other population health problems, said Levi. CMS has made tremendous progress in providing financial support for community-level investments, but it needs to adjust its time frames to recognize the long-term returns of such investments. Finally, the National Prevention Council, which consists of 20 federal agencies that have come together to work on prevention and health issues, needs to stimulate much more direct collaboration among federal agencies, Levi suggested. Individual agencies have adopted a prevention lens, but they need to collaborate, merge funds, and together pursue the common goal of improving health and addressing their core missions. As agencies work across agency lines, they create a base of experience and expertise that can transcend shifts in leadership and change the culture within agencies. In this way, Levi concluded, the federal government can leverage its resources to change community environments and address the social determinants of health.