Opportunities and Challenges for Government to Influence Eating Behavior

Transcription

1 Opportunities and Challenges for Government to Influence Eating Behavior Audrey Rowe, Administrator, Food and Nutrition Service and Jay Hirschman, Office of Research and Analysis, Food and Nutrition Service University of Colorado Developmental Psychobiologic Research Groups May 8,

2 Background: Hunger and Obesity 2

3 Food Insecurity A struggle to consistently feed all members of the household due to a lack of resources 2010: 17.2 million households : Increased sharply : Remained high 2009 to 2010: Unchanged Turning a corner on hunger Programs are working as designed 3

4 Hunger and Obesity Adults: 68% are overweight 34% of adults are obese Children and Adolescents: 1 out of every 5 are obese May lead to heart disease, Type 2 diabetes, asthma and other conditions Annual obesity related medical costs: $147 B 4

5 Combating Obesity Affordable Care Act: Preventive services for all ages Provide equal access to care for all Americans to reduce health disparities Nutrition assistance fights both hunger and obesity 5

6 Food and Nutrition Programs 6

7 America s Nutrition Safety Net Serves 1 in 4 Americans each year SNAP: Over 46 million participants WIC: Over 9 million each month School Lunch : 32 million students/school day School Breakfast: 12 million students/school day 7

8 Other Nutrition Safety Net Programs Fresh Fruit and Vegetable Program Child and Adult Care Food Program Summer Food Service Program Senior Farmers Market Nutrition Program and WIC Farmers Market Nutrition Program Others: Food Distribution Program on Indian Reservations (FDPIR) TEFAP The Emergency Food Assistance Program Commodity Supplemental Food Program Disaster Assistance 8

9 FNS Programs: FY2011 Funding and Participation Program Cost ($ M) Partic. (M) SNAP 75, National School Lunch Program 11, WIC 7, School Breakfast Program 3, Child & Adult Care Food Program 2, Nutrition Assistance for Puerto Rico 2,049 1 The Emergency Food Assistance Program m lbs Summer Food Service Program Commodity Supplemental Food Program Fresh Fruit and Vegetable Program 110 n/a Food Distribution Program on Indian Reservations Senior Farmers Market Nutrition Program WIC Farmers Market Nutrition Program Special Milk Program 12 67m ½ pints Source: FNS Keydata report and FY2012 Budget Explanatory Notes 9

10 Dietary Guidelines for Americans Basis for national nutrition policy USDA co lead with HHS Updated every 5 years 10

11 Obama Administration s Unprecedented Commitment The President is deeply committed to ensuring that all Americans, especially children, have access to a healthy diet First Lady s Let s Move! Healthy, Hunger Free Kids Act of

12 Let s Move! Goal: End childhood obesity within a generation Comprehensive Empowers parents Encourages healthy eating and increased physical activity Everyone can play a role 12

13 Why MyPlate? Healthy Eating Comes Down to the Choices We Make Easily used by everyone Simple reminder: Make healthy food choices Looks like your plate at mealtime Make fruits/vegetables half your plate Other important food groups for a healthy meal: Whole grains, lean proteins, and low fat dairy. 13

14 How Policy and Research Interact 14

15 Research Informs Policy Strong science informs FNS policy Small changes can have big impacts due to size and scope of programs Fundamental questions: How does the program work now? What will happen if changes are made? What is the cost? 15

16 Impacts of Policy Change Encourages more research Raises awareness of healthy eating in general public Fosters food industry interest in low fat and low sodium products Economic multiplier effect 16

17 How Policy and Research Interact: A Generic Model for FNS Programs 17

18 Basic & Clinical Research Human nutrient requirements Metabolic pathways for nutrients, energy Developmental nutrition Nutritional epigenetics Food composition Biological measures of nutritional status Survey methodology Etc. 18

19 Q. Basic & Clinical Research Human nutrient requirements Metabolic pathways for nutrients, energy Developmental nutrition Nutritional epigenetics Food composition Biological measures of nutritional status Survey methodology How do we get from the laboratory and clinical studies to improved programs? Improved Program Benefits 19

20 NHANES and other population surveys Basic & Clinical Research Human nutrient requirements Metabolic pathways for nutrients, energy Developmental nutrition Nutritional epigenetics Food composition Biological measures of nutritional status Survey methodology USDA/CNPP Nutrition Evidence Library Other Systematic Reviews Dietary Intake Analysis Food Pattern Modeling IOM Dietary Reference Intakes (DRIs) Report of the Dietary Guidelines Advisory Committee Public Comments Legal Requirements IOM Expert Committee Reports and Workshops Dietary Guidelines for Americans Improved Program Benefits Program Studies Final Rules Proposed Rules Program Experience 20

21 How Policy and Research Interact: Two Case Studies 21

22 Case Study #1: WIC Food Packages Serves pregnant and new moms, kids to age 5 Proven effective at getting kids off to a healthy start History of the WIC Food Package: Unchanged for 30 years A successful program; yet in early 2000s All stakeholders saw need to improve based on science But how? Let s take a look 22

23 WIC Enrollment by Category & Child Age April ,015, ,260 Not BF 2,366,706 1,844,473 1,388,462 1,207, BF 854, ,933 Pregnant Postpartum Infants Age 1 Age 2 Age 3 Age 4 Source: WIC Participant and Program Characteristics

24 WIC Enrollment by Category & Child Age April WIC serves about half of all infants in the US ,015, ,260 Not BF 2,366,706 1,844,473 1,388,462 1,207, BF 854, ,933 Pregnant Postpartum Infants Age 1 Age 2 Age 3 Age 4 Source: WIC Participant and Program Characteristics 2010 and FNS Office of Research and Analysis 24

25 WIC Enrollment by Category & Child Age April % 83% 17% of WIC infants not on WIC during pregnancy ,015, ,260 Not BF 2,366,706 1,844,473 1,388,462 1,207, BF 854, ,933 Pregnant Postpartum Infants Age 1 Age 2 Age 3 Age 4 Source: WIC Participant and Program Characteristics 2010, National Survey of WIC Participants-II and FNS Office of Research and Analysis 25

26 WIC Enrollment by Category & Child Age April About 40 percent of women having live births in the US participated in WIC during pregnancy 17% 83% 17% of WIC infants not on WIC during pregnancy ,015, ,260 Not BF 2,366,706 1,844,473 1,388,462 1,207, BF 854, ,933 Pregnant Postpartum Infants Age 1 Age 2 Age 3 Age 4 Source: WIC Participant and Program Characteristics 2010, National Survey of WIC Participants-II and FNS Office of Research and Analysis 26

27 Over Half of Pregnant Women Participating in WIC Enroll in the 1 st Trimester Trimester of WIC Enrollment 3 rd Trimester 9.8% 2 nd Trimester 36.7% 1 st Trimester 53.5% 1st 2nd 3rd Source: WIC Participant and Program Characteristics 2010 Among those 978,277 of 1,015,173 reporting; (excludes the 3.6% not report trimester of enrollment) 27

28 Additional Facts about Pregnant Women on WIC About 10% (9.9%) are less than 18 years of age Almost 30% (28.9%) of pregnant WIC participants have less than a high school diploma or GED 39% are Hispanic/Latino; 61% are not About 1/3 (32.7%) of the pregnant women on WIC identify their race as other or multi racial Source: National Survey of WIC Participants-II 28

29 Food Package Beginnings The WIC food packages were designed to supplement participants diets with foods rich in five target nutrients known to be lacking in the diets of the WIC target population vitamins A and C, calcium, iron and protein. 29

30 The WIC Food Package Example for Pregnant Women The historical WIC food package for pregnant women included: Milk Cheese Eggs Cereal (iron fortified) Fruit Juice Beans or Peanut Butter (added in ~1980) 30

31 History of WIC Foods Since 1980, the only significant change made in the WIC food packages occurred in 1992, when the set of foods provided for exclusively breastfeeding women was expanded 31

32 Why Revise the WIC Food Packages? Changes in the major health and nutrition risks faced by WIC s target population, including: diets lacking in whole grains and fruit and vegetables short duration of breastfeeding overweight and obesity Substantial shift in ethnic composition of WIC s target population 32

33 Review of WIC Food Packages 2003: USDA contracted with the Institute of Medicine (IOM) to independently review the WIC Food Packages USDA charged the IOM with: Reviewing the nutritional needs of the WIC population, and recommending cost neutral changes to the WIC food packages. Including professionals from specific backgrounds on the expert committee, including experts in pediatrics, breastfeeding, public health nutrition, dietary intake, economics, risk assessment, cultural diversity 33

34 Committee to Review the WIC Food Packages SUZANNE P. MURPHY (Chair), Cancer Research Center of Hawaii, University of Hawaii, Honolulu BARBARA L. DEVANEY, Mathematica Policy Research, Inc., Princeton, NJ GEORGE M. GRAY, Department of Health Policy and Management, School of Public Health, Harvard University, Boston, MA GAIL G. HARRISON, Department of Community Health Sciences, School of Public Health, University of California, Los Angeles HELEN H. JENSEN, Department of Economics and Center for Agricultural and Rural Development, College of Agriculture, Iowa State University, Ames LUCIA L. KAISER, Department of Nutrition, College of Agriculture and Environmental Sciences, University of California, Davis JEAN D. KINSEY, Department of Applied Economics and The Food Industry Center, College of Agricultural, Food and Environmental Sciences, University of Minnesota, St. Paul ANGELA M. ODOMS YOUNG, School of Allied Health Professions, College of Health and Human Sciences, Northern Illinois University, Dekalb KAREN E. PETERSON, Department of Society, Human Development and Health and Department of Nutrition, and Public Health Nutrition Program, School of Public Health, Harvard University, Boston, MA ANNA MARIA SIEGA RIZ, Department of Maternal and Child Health and Department of Nutrition, Carolina Population Center; Nutrition Epidemiology Core for the Clinical Nutrition Research Center, School of Public Health, University of North Carolina, Chapel Hill VIRGINIA A. STALLINGS, Nutrition Center, Division of Gastroenterology and Nutrition, Joseph Stokes Jr. Research Institute, Children s Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia CAROL WEST SUITOR, Nutrition Consultant, Northfield, VT Food and Nutrition Board Liaison NANCY F. KREBS, Department of Pediatrics, University of Colorado Health Science Center, Denver 34

35 The Institute of Medicine provided USDA with a sound scientific basis for developing a new set of food packages for the WIC Program. IOM Report with Recommendations (pre pub 2005; final 2006) 35

36 USDA Issued Proposed Rule August 2006 The proposed revisions largely reflected recommendations made by the IOM in its report USDA received over 46,000 comments on the proposed rule. In general, the proposed changes to the WIC food packages garnered broad support Comments received from the public were considered in developing the interim final rule 36

37 USDA Issued Interim Final Rule December 6, 2007 The New WIC Food Packages. 37

38 Summary of Major Changes Revises infant food packages to more actively promote and support breastfeeding Adds fruits and vegetables Adds soy based beverage and tofu as milk alternatives Adds whole grains (cereals, bread, and other whole grains, e.g. tortillas, brown rice) Reduces some food allowances, 38

39 Revised Food Packages Formula amounts tied to feeding practice and age of infant for Infants Juice eliminated and replaced with baby food fruits and vegetables 39

40 Provide Breastfeeding Incentives and Support Fully Breastfeeding Mothers: Receive the most variety and largest quantity of food, including $10 cashvalue voucher for fruits and vegetables Fully Breastfeeding Infants > 6 months: Receive larger quantities of baby food fruits and vegetables Receive baby food meat 40

41 Add Fruits and Vegetables Cash value vouchers ($6, $8, or $10) for fruits and vegetables for children and women Participants may choose from a wide variety of fruits and vegetables Fresh, frozen and canned allowed 41

42 Add New Milk and Dairy Alternatives Soy based beverage Tofu 42

43 Add Whole Grains Whole wheat or whole grain bread for children and women Whole grain options Brown Rice Soft Corn and Whole Grain Tortillas Oatmeal Bulgur Barley 43

44 How do the New Food Packages Address Health Outcomes? Addition of fruits, vegetables and whole grains is consistent with recommendations for food patterns that contribute to a healthy body weight. Revised packages provide less saturated fat and cholesterol, e.g., reduced quantities of milk, cheese; only skim or low fat milk allowed for children and women Emphasis on breastfeeding may contribute to a reduced risk of overweight in children 44

45 How do the New Food Packages Accommodate Diverse Populations? Wide choice of fruits and vegetables for ethnic variety Tortillas Brown rice and other whole grains Soy beverage Tofu 45

46 WIC Food Package Timeline Summary 2003: Contracted with IOM 2003: Published Advance Notice of Proposed Rulemaking (Sought public comment) 2005: IOM Report Pre published 2006: Published proposed rule (Received 46,000+ public comments ) 2007: Published interim final rule 2009: Nationwide implementation 2012: Planned date for Final Rule 46

47 WIC Food Package Today Based on sound science Promotes successful long term breastfeeding Flexible to accommodate cultural food preferences Offers variety of foods (fruits, vegetables and whole grains) Stimulates retailers to offer healthier foods to benefit whole community The changes to the WIC food packages hold potential for improving the nutrition and health of the nation s low-income pregnant women, new mothers, infants, and young children. Institute of Medicine,

48 Case Study #2 School Meal Patterns and Nutrition Standards 48

49 Participation in NSLP is much greater than SBP National School Lunch Program (NSLP) Available 96,000 schools 50 million students enrolled 180 days per year 63% participate (averages about 32 million per school day) School Breakfast Program (SBP) Available 84,000 schools 44 million students enrolled 180 days per year 26% participate (averages about 12 million per school day) Total FY2010 Federal Investment of $13 Billion Served 7 Billion Meals 49

50 Long Tradition of Scientific Studies of School Meals National Evaluation of the School Nutrition Programs ( ) first national FNS study to assess the effects of school meals in the U.S. SNDA I (SY ) included 24 hour recalls and highlighted high fat content of school meals and helped motivate the 1995 School Meals Initiative for Healthy Children (SMI). SNDA II (SY ) provided an early look at SMI implementation on meals offered and served 50 SNDA III (SY ) provides updated data to assess SMI and directions for the future. Includes 24 hour recalls SNDA IV (SY ) will provide updated information on school nutrition

51 SNDA Study Designs Final national sample available for analysis SNDA I SNDA II SNDA III SNDA IV SY SY SY SY SFAs 430 SFAs 129 SFAs 578 SFAs 544 Schools 1,075 Schools 397 Schools 882 Schools 3,349 Students No Students 2,314 Students No Students Offered Eaten Offered Served Offered Served Eaten Offered Served 51

52 NHANES and other population surveys Basic & Clinical Research Human nutrient requirements Metabolic pathways for nutrients, energy Developmental nutrition Nutritional epigenetics Food composition Biological measures of nutritional status Survey methodology USDA/CNPP Nutrition Evidence Library Other Systematic Reviews Dietary Intake Analysis Food Pattern Modeling IOM Dietary Reference Intakes (DRIs) Report of the Dietary Guidelines Advisory Committee Public Comments Legal Requirements IOM Expert Committee Reports and Workshops Dietary Guidelines for Americans Improved Program Benefits Program Studies Final Rules Proposed Rules Program Experience 52

53 Changes Since Previous School Meal Pattern Update in Recommended Dietary Allowances (RDAs about 270 pages) replaced with Dietary Reference Intakes (DRIs 4,000+pages) Advances in scientific approaches to dietary assessment and planning (2 IOM reports) New NHANES data revealed the child obesity epidemic Newer Dietary Guidelines for Americans emphasized importance of fat free and low fat dairy, whole grains and fruits & vegetables 53

54 Changes Since Previous School Meal Pattern Update in 1995 Program studies showed significant reduction in total fat and saturated fat, but Many schools did not meet the standard for saturated fat Meals were high in sodium, with few whole grains Generally, full compliance with the 1995 regulatory nutrient requirements was low 54

55 More Schools Met Saturated Fat Standard in Lunches Served in SY Percent of Schools Meeting Standard %* 15% 13% 24%* 0 Elementary Schools Secondary Schools SY SY SOURCES: SNDA III, Menu Survey, SY and SNDA II, Menu Survey, SY *Difference is statistically significant at 0.05 level. 55

56 IOM Report: School Meals: Building Blocks for Healthy Children FNS contracted with the Institute of Medicine Food and Nutrition Board to provide expert recommendations for updating school meals Findings from NHANES and the School Nutrition Dietary Assessment Study (SNDA III) were used extensively by the IOM committee IOM report with recommendations published in 2010 The proposed rule based on the IOM recommendations was published in the Federal Register on January 13,

57 Committee on Nutrition Standards for National School Lunch and Breakfast Programs VIRGINIA A. STALLINGS (Chair), The Children s Hospital of Philadelphia, University of Pennsylvania KAREN WEBER CULLEN, Children s Nutrition Research Center, Baylor College of Medicine, TX ROSEMARY DEDERICHS, Minneapolis Public Schools, Special School District No. 1, MN MARY KAY FOX, Mathematica Policy Research, Inc., Cambridge, MA LISA HARNACK, Division of Epidemiology and Community Health, University of Minnesota, MN GAIL G. HARRISON, School of Public Health, Center for Health Policy Research, University of California, Los Angeles MARY ARLINDA HILL, Jackson Public Schools, MS HELEN H. JENSEN, Department of Economics, Iowa State University, Ames RONALD E. KLEINMAN, Massachusetts General Hospital for Children, Harvard Medical School, Boston, MA GEORGE P. McCABE, College of Science, Purdue University, West Lafayette, IN SUZANNE P. MURPHY, Cancer Research Center of Hawaii, University of Hawaii, Honolulu ANGELA M. ODOMS YOUNG, Department of Kinesiology and Nutrition, University of Illinois at Chicago, IL YEONHWA PARK, Department of Food Science, University of Massachusetts, Amherst MARY JO TUCKWELL, inteam Associates, Ashland, WI 57

58 The Final Rule is Published Public comments: In early 2011, comments were received from over 132,000 individuals and organizations Final rule: Nutrition Standards in the National School Lunch and School Breakfast Programs published in the Federal Register on January 26,

59 Improved School Meal Standards Final rule Both fruits and vegetables offered each day More whole grains (phase in) Only fat free or low fat milk Limit calories based on child s age Reduce saturated fats, trans fats and Reduce sodium (phase in) 59

60 Meal Standards Final Rule Cost less than half of proposed standards Significantly modified breakfast pattern No daily meat or meat alternate required Clarified offer vs. serve requirement Allows smaller portions of fruits and vegetables Can be achieved without big cost increases HealthierUS School Challenge winners have done it 60

61 Meal Standards Final Rule Effective SY Additional implementation time 3 year phase in for breakfast changes Additional year for second sodium target Accommodate administrative constraints on schools and States 61

62 What s Next? Policy and Research at FNS 62

63 Healthy Hunger Free Kids Act School Lunch Improves nutritional quality New meal pattern standards Gives USDA authority over all food sold at school Increases performance based funding First time in 30 years Extra 6 cent per lunch Improves direct certification 63

64 HHFKA Implementation Interim Final Rule 6 cent increased reimbursement if meet standards Forthcoming Proposed Rules: Nutrition Standards for all foods sold in schools Updated Child and Adult Care Food Program (CACFP) Meal Patterns 64

65 6 Cents Proposed Rule Published April 27, 2012 Supports new meal standards by providing additional 6 cents to districts that meet new standards First increase in 30 years Starts this fall Incentive for districts to implement new standards 65

66 6 Cents Proposed Rule Significant investment in improving quality of school meals Provides guidelines for districts on how to demonstrate that their meals meet the standards 66

67 Nutrition Standards for Food in Schools Recent legislative authority to regulate foods outside the cafeteria Previously, other foods and school nutrition environment were State and local controlled Work closely with CDC 67

68 Nutrition Standards for Foods in Schools Apply to food items available for sale on school campus throughout the school day USDA must consider: Scientific recommendations Existing voluntary standards for beverages and snacks Existing State and local standards Practical application Exceptions for infrequent school sponsored fundraisers 68

69 CACFP Meal Patterns HHFKA requires USDA to: Update meal patterns by June 2012 Align the patterns with the DGAs and most recent scientific knowledge 69

70 CACFP Meal Patterns In addition, HHFKA: Allows for fluid milk substitution Requires water to be available all day Encourages physical activity and limiting of screen time Requires publication of nutrition handbook 70

71 CACFP Meal Pattern Timeline January and March 2011: Hosted stakeholder consultations May 2011: Issued implementation guidance on milk and water provisions Summer 2012: Proposed rule Fall 2013: Final rule 71

72 Research: Planning a WIC Research Agenda In 2010, FNS Commissioned IOM Workshop to obtain expert independent input on the future WIC research agenda: 1. address key research issues 2. address methodological issues 3. discuss solutions 90 experts met on July 20, 2010 Summary posted on the FNS website: Published/WIC/WIC.htm 72

73 Major Ongoing FNS Studies SNAP: Healthy Incentive Pilot Evaluation School Meals SNDA IV (under peer review; will publish in 2012) SN Program Operations Study Access Studies: Direct Certification with Medicaid Demonstration Evaluation Evaluation of the Community Eligibility Option Committee on National Statistics (CNSTAT) Uses on the American Community Survey for Community Eligibility Summer Food Service Program: Summer Food for Children Demonstration Evaluations WIC WIC Medicaid Cost Benefit Study WIC Infant and Toddler Feeding Practices Study 2 WIC Breastfeeding Peer Counseling Enhanced Intervention Evaluation 73

74 WIC Peri conceptional Grants In 2011, awarded a $1 m competitive grant to UCLA At least ½ of the funding must be used for sub grants Focus: Roles that WIC is playing and can play to improve nutrition in pre conceptional and periconceptional periods. UCLA has announced availability of funding Letters of intent due to UCLA May 25, 2012 Grant applications due to UCLA June 8, 2012 Find the full RFA at: 74

75 Research Plan Highlights Improve program access Impact of Affordable Care Act on SNAP Assess SNAP Outreach Improve nutrition and reduce obesity School Nutrition and Meal Costs (SNDA 5 + Meal Costs) Evaluate WIC Nutrition Education Improve program integrity Measure Improper Payments in School Meals Estimate Trafficking Rates in SNAP 2013: HHFKA $ for Child Care Nutrition and Wellness Study 75

76 Website Resources Food and Nutrition Service: Let s Move: MyPlate: SNAP: WIC: School Meals Programs: Find A Farmers Market: HealthierUS School Challenge FNS Studies: 76

77 Questions? 77