5

Perspectives from Outside the Armed Forces

Lieutenant Pamela Gregory, Navy nutrition program manager, announced that the workshop’s fourth session featured four speakers from organizations outside of the armed forces. They offered perspectives on initiatives to address obesity and overweight, shared success stories, and suggested opportunities to inspire future action.

CENTERS FOR DISEASE CONTROL AND PREVENTION

Captain Heidi Michels Blanck, chief of the Obesity Branch in the Division of Nutrition, Physical Activity, and Obesity (DNPAO) at the Centers for Disease Control and Prevention (CDC), also spoke as a member of the uniformed services. She informed the audience that there are 6,500 uniformed health officers in the Commissioned Corps of the U.S. Public Health Service, representing a number of health and science professions. She explained that members of the Commissioned Corps deploy nationally and internationally in support of public health responses to manmade and natural disasters in carrying out their public health, clinical, and leadership roles in federal government departments and agencies.

The CDC works with a number of other entities in the U.S. Department of Health and Human Services (HHS) that are situated around the country, Blanck continued. She described the DNPAO’s goal as leading the nation’s fight against the health and economic burden of chronic disease by promoting good nutrition, regular physical activity, and healthy weight for all Americans across the lifespan. With an annual budget of $95 million, or about 35 cents for every American, she said, “we are not going to do it alone.” She added that the division works with other federal partners to accelerate research, identify best practices, disseminate evidence-based guidelines, and provide implementation training and assistance. It also supports grassroots public health efforts by providing funding and subject-matter expertise to state, territory, tribal, and local health agencies; national organizations; universities; and communities.

Blanck highlighted the DNPAO’s use of scientific data and evidence to inform what communities and states can do to address obesity. As opposed to traditional clinical prevention programs that include screening, counseling, and weight clinics, she clarified that the DNPAO focuses on policy, systems, and environmental change in communities and institutions to improve the healthfulness of places where people live, work, play, and

pray. She also stressed that “not everyone has a fair chance at health … we are not starting with an equal ability to win the race,” conveying the importance of considering how interventions interact with social determinants of health, such as income, housing, and education.

Blanck went on to explain that, in addition to cross-agency communication to learn what others in HHS are doing, the DNPAO recently collaborated with the U.S. Department of Defense (DoD) to explore opportunities for addressing nutrition, physical activity, and obesity, including the Healthy Base Initiative and a DoD–CDC nutrition fellowship. The division has also worked with DoD and nine other federal departments to update the Federal Food Service Guidelines, which aim to help food service facilities implement the Dietary Guidelines for Americans. According to Blanck, the Food Service Guidelines have great potential to have an impact “because if we can improve food procurement in child care, schools, work sites, and DoD, we can change the demand for healthy foods and over time the crops that are grown.” She described another collaborative effort that involves working with other federal departments and the National Association of Community Health Centers to implement an affordable, evidence-based pediatric weight management and healthy lifestyle program for low-income children with obesity in Federally Qualified Health Centers.¹

The DNPAO’s funding in all 50 states has effected positive nationwide changes that reach Americans across the lifespan, Blanck stressed, from efforts related to breastfeeding, to early child care center policies, to school nutrition, to walkable and bikeable communities. “We are really proud to communicate the science,” she said, ending her presentation by highlighting the division’s infographics and interactive database of maps that can be used to illustrate data and trends (CDC, 2018).

MEMPHIS HEALTHY U

Marian Levy, associate dean in the School of Public Health at the University of Memphis, shared her experience promoting a culture of health in a university setting. She described Memphis Healthy U, an initiative to provide environmental and normative support for healthier eating and increased physical activity on campus. The impetus for the effort, she explained, was surprising health outcome data collected in 2011 at a university health fair. Nearly half of the students screened at the fair were classified as having overweight or obesity, she recounted, and 42 percent had prehypertensive or hypertensive systolic blood pressure readings. The uni-

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¹ Federally Qualified Health Centers are community-based health care providers that receive funds from the Health Resources and Services Administration’s Health Center Program to provide primary care services in underserved areas.

versity’s president was concerned and said that something had to be done to create a healthier campus environment for students, staff, and visitors.

According to Levy, the Memphis Healthy U effort warranted campus-wide collaboration, particularly with the university’s food service vendor. She described how support from campus leadership, such as the President’s Office and the Provost’s Office, drove the involvement of other departments and student groups. She explained that, launched with the help of the Communications and Marketing Department, the initiative featured group fitness activities, promotional deals for healthier foods, and signage to encourage healthier behaviors. She added that, with coordination provided by graduate assistants, responsibility for leading daily fitness activities, such as Zumba, yoga, and tai chi, was shared by 17 colleges and departments and the community.

Consumer habits changed somewhat from 2011 to 2013, Levy reported. Eating habits trended away from pizza, burgers, and fast foods, she elaborated, and venues selling salads and wraps saw a 120 percent increase in product sales counts. Soda sales declined 22 percent; bottled water sales increased 27 percent; candy bar sales declined 30 percent; and chip sales remained flat, although they were lower than in the year before the initiative was implemented.

Levy listed a few of the initiative’s success factors: support from top-level administration; promotion of healthier foods while maintaining cost neutrality to the food service vendor; and meeting people where they are, welcoming diverse perspectives, and tailoring activities accordingly. She also encouraged partnering with university Reserve Officer Training Corps (ROTC) programs to create a culture-of-health “pipeline” that can make its way into the military, and developing relationships with local colleges and university presidents and with schools of public health.

ACADEMY OF NUTRITION AND DIETETICS

Jeanne Blankenship, vice president of policy initiatives and advocacy at the Academy of Nutrition and Dietetics (AND), began her presentation by urging continued collaboration: “What we can do as an organization is really limited compared to what we can do when we partner with others,” she argued. She explained that AND represents more than 100,000 credentialed registered dietitians and other nutrition professionals in the United States. She highlighted the roles played by registered dieticians in various clinical and community settings, where they can impact obesity and overweight. She also highlighted certification programs offered by AND to help train its members to address obesity and weight management in both adult and pediatric populations.

Blankenship discussed opportunities to provide nutrition education through federal food and nutrition assistance programs, such as the Supple-

mental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which count many military members and families as recipients. She noted that many of AND’s members work with these programs’ beneficiaries to help them translate nutrition recommendations into everyday food choices, including breastfeeding initiation and continuation. In terms of school nutrition, she added, about 24 percent of students in DoD schools are eligible for free meals. She suggested that schools can help families maximize their food dollars by providing not only the standard school lunch but also breakfast and snacks, or even dinner as part of after-school programs.

Blankenship then described AND’s involvement in national efforts related to developing standards of care and competencies for obesity treatment, as well as improving access to care. As an example she cited the Treat and Reduce Obesity Act, which would improve access to care for obesity by allowing non–primary care practitioners, such as psychologists and registered dieticians, to provide and bill for services. She also mentioned the need to address weight bias and stigma, which she said occur even among the registered dietician profession and can be a barrier to providing quality care.

To conclude, Blankenship proposed that it would be helpful to hear from military personnel who struggle with weight problems and face possible discharge and separation. She suggested that their perspective on potential barriers to successfully utilizing the programs and services described by other speakers can help identify opportunities for improvement going forward.

U.S. DEPARTMENT OF AGRICULTURE’S NATIONAL INSTITUTE OF FOOD AND AGRICULTURE

Jane Clary Loveless, national program leader for nutrition/extension at the National Institute of Food and Agriculture, U.S. Department of Agriculture (USDA), discussed the department’s efforts to incorporate more fruits and vegetables into its programs through promotion in schools, grocery stores, communities, and work sites; to increase access to healthy, local, and affordable foods; and to improve food security. Reminding participants of food insecurity’s adverse health effects, she highlighted the association between food insecurity and overweight and obesity. Roughly 14 percent of American households experienced food insecurity or hunger during 2013 (Coleman-Jensen et al., 2014), she reported, and 15 percent of the U.S. population participates in SNAP. She advocated for communities to develop their own solutions for increasing access to healthy, local, and affordable foods, noting that only about 70 percent of all census tracts in the country currently have at least one store that offers a variety of affordable fruits and vegetables.

Clary Loveless next discussed two grant programs funded by the Farm Bill: the Community Food Projects (CFP) and the Food Insecurity Nutrition Incentive (FINI). The aim of CFP, she explained, is to meet the food needs of low-income individuals through food distribution, outreach to increase participation in federally assisted nutrition programs, and improved access to food, and to promote comprehensive responses to local food access, farm, and nutrition issues. She informed the audience that CFP awards have funded projects in more than 400 communities in 48 states during the program’s 22-year history, and the program successfully distributed nearly $50 million to 200 organizations in 47 states between 2008 and 2016. She added that the most recent (2014) Farm Bill increased program funding to $9 million, nearly double the $5 million annual funding level in the prior (2008) bill. According to Clary Loveless, grantee projects facilitate convening of local partners to form a comprehensive plan for addressing food insecurity in their community, and help provide local, culturally appropriate and healthy foods and nutrition education. As examples of grantee projects, she cited community food assessments, community gardens with market stands, farm-to-institution efforts, and mobile markets. Most applicants are from the West and East Coasts, she reported, but she expressed the hope that more southeastern states would become involved.

Clary Loveless then turned her attention to the FINI grant program, which debuted in 2014 with a $100 million commitment over 4 years. She identified its primary goal as supporting projects designed to increase the purchase and consumption of fruits and vegetables (including any variety of fresh, canned, dried, or frozen whole or cut fruits and vegetables without added sugars, fats or oils, and salt) among low-income SNAP participants by providing incentives at the point of purchase. She listed a number of permitted incentives: vouchers, coupons, and tokens for fruits and vegetables; direct point-of-sale discounts on fruits and vegetables; and providing other SNAP-eligible items for those who make fruit and vegetable purchases.

Finally, Clary Loveless shared two examples of successful FINI grant projects. One project that she said has increased fruit and vegetable consumption among SNAP recipients is providing a $10 credit toward the purchase of fruits and vegetables after $20 worth of fruits and vegetables have been purchased from a grocery store, farmers’ market, or mobile market. She also described another successful project—VeggieRx in Washington State—in which participating health care providers, community health workers, and community nutritionists “prescribe” fruits and vegetables to SNAP patients during primary care visits, group classes, and home visits. She noted that in 2017, 67 participating Federally Qualified Health Centers and WIC clinics in the state offered a $10 voucher during patient visits. The prescription is a paper voucher that patients can use like cash to buy fruits and vegetables at participating farmers’ markets and grocery stores.