Tuesday, February 24, 2015

Active KidsHelping Americans eat smart and maintain a healthy weight is one of the strategic priorities of the U.S. Department of Agriculture’s Food and Nutrition Service (FNS), which administers the safety net programs that provide nutritious foods to millions of low-income Americans: the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), school breakfast and lunch programs, and other child nutrition programs. These programs support enrollees in a number of ways, including providing additional financial resources for purchasing healthy foods, offering healthy food at sites where children gather (e.g., school meals, child care centers, summer feeding programs), and educating families about healthy eating through nutrition education programs and interventions.

To receive these “categorical” program benefits, people must be eligible and apply for benefits; only people enrolled in the program can receive program benefits. For programs that provide financial assistance or direct food benefits, this makes sense; we do not want to pay for benefits for people or families who have not gone through the eligibility process and been determined to be legitimately entitled to the benefits.

But what if a benefit provided by FNS can help all low-income individuals; even those who have not have applied for or are not receiving direct financial or food benefits? Nutrition education helps families make healthy food choices whether they are spending SNAP or WIC benefits, have children who are receiving free or low-cost school meals, or have children in day care settings that provide healthy snacks and meals. Well-constructed nutrition education programs can help low-income families spend their food budget—both their benefits and their own money—wisely, on healthy food choices. Nutrition education is a powerful tool in the fight against childhood obesity and can be constructed to address individual knowledge and motivations as well as systemic and environmental barriers to healthy eating. 

Reducing childhood obesity among all low-income Americans is a major goal of food assistance programs, as well as many foundations and other health care organizations, including the Centers for Disease Control and Prevention (CDC) and state health departments. Combining and coordinating efforts among all entities working to reduce childhood obesity should be a goal for all concerned with this epidemic. 

So, what gets in the way? Two factors seem to be an issue.

First, because many of these programs are categorical, nutrition education funding can only be spent to help those within the specific program for which they are eligible. This division creates “silos” of funding that must be linked back to the eligible program participant. For example, WIC cannot spend nutrition education money to support SNAP nutrition education efforts unless the SNAP participant is also eligible for WIC (and vice versa). Programs that work to change systems and environmental factors must be directly related to the target audience in order to be accounted for as legitimate program expenses. As a result, combining efforts and maximizing nutrition education resources cannot be easily accomplished without an audit exception. Moreover, coordinating with foundation or CDC programs also becomes difficult in that those programs reach broader target audiences and do not fall directly into the “category” of the food assistance programs.

Second, many food assistance and nutrition programs are required to show that they are making a difference in changing behaviors; hence, program evaluations are funded to ensure that nutrition education interventions are “working.” If an individual nutrition education effort cannot prove that it has an impact, it may be discontinued. We have learned from other public health efforts, however, that combined programs often have a greater impact than individual programs.

Several years ago, I attended a CDC-sponsored public health conference at which the audience was asked, “Which of these efforts was the most effective in reducing smoking and tobacco use in America?” The list of possible answers included scary television ads showing the effects of cancers, policies that eliminated smoking from the work place, elimination of cigarette machines, nonsmoking policies in bars and restaurants, school-based tobacco prevention programs, smoking cessation programs in public health centers, and tobacco help lines. The answer, of course, was all of them. The combined effect of these initiatives was far greater than the individual impact.

We need to rethink how we fund childhood obesity prevention, bringing together key stakeholders and assisting with the design of best practice efforts to address the problem. Nutrition education efforts can lead the way if providers of food assistance programs are given an FNS “waiver” allowing them to work with other federal food assistance programs, the CDC, foundations, and state health department programs to combine funding to tackle this issue. An integrated, well-planned campaign—co-funded by various stakeholders—that addresses both individual and environmental factors should be given a chance. The combined impact will likely be greater than individual program efforts. In addition, examining the combined effect of all efforts to reduce childhood obesity, instead of evaluating individual programs, should be considered. 

I am not saying that programs do not currently cooperate or coordinate efforts. They do, often doing their best under challenging circumstances. But we need to make it easier for them by being open to the idea of a combined strategy that addresses the challenges of childhood obesity without worrying that someone who is not on SNAP, WIC, or another food assistance program received a positive nutrition message and learned something that changed their food shopping and eating behavior for the better.

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