Policy Evaluation of Healthy Hunger Free Kids Act of 2010_Brittney Gajewski_March 2015

Running Head: Health Care Policy Evaluation 1

Health Care Policy Evaluation

Brittney Gajewski

Collie Richard

Monica Sosa

Parthenia Williams

Robbin Winters

Capella University

MHA-5030

Instructor: Dr. Neil Mathur

Health Care Policy Evaluation 2

Health Care Policy Evaluation

Childhood Obesity has been a growing global trend. Initiatives such as The Healthy,

Hunger Free Kids Act of 2010 has been included to address this issue. As with many health care

policies, strategic planning and evaluation has demonstrated a need for possible policy

improvements. This paper will evaluate the driving forces behind the policy, evaluate the policy

from abroad, propose improvements, and synthesize financial components of the policy. The

analysis will also include the short-term and long-term effects of the policy and then analyze

operational recommendations.

Driving Forces behind a Domestic Health Care Policy in Need of Improvement and Provide

Insightful Analysis. (Brittney)

The driving forces behind this domestic health care policy analysis involve the concern of

children’s physical and nutritional health. With over 12.5 million youths already affected by

childhood obesity, concerns about the chronic condition continue to rise (Foltz et al., 2012). To

address obesity with children on an interpersonal level, Foltz et al., (2012) explained that school-

based interventions would allow focus to change the environment and reacted behaviors using a

socioecological approach. With greater means of physical activity and recovered nutrition,

intervention strategies for obesity can be promoted through health behaviors within the child’s

environment (Foltz et al., 2012). To effectively analyze the domains of a health policy one needs

to understand the likelihood an enhanced approach will be adopted through a policy (Brownson,

Chriqui, & Stamatakis, 2009).

The Healthy, Hunger Free Kids Act ( HHFKA) of 2010 has provided the opportunity to

address childhood obesity and was the first time that the national school lunch program received


increased funding in over thirty years (Mortazavi, 2011). This increase in funding may be an

incentive for schools to adopt the necessary standards appointed by the Secretary of Agriculture,

however they lack the necessary funding that would be allow for healthier fruits and vegetables

to be available in schools (Mortazavi, 2011). With funding increased by only six cents, schools

are still unable to budget for the dietary guidelines within the HHFKA. Even if funding

increased further, many schools would not be able to receive increased funding because schools

would still be unable to meet the necessary dietary guidelines within their budgets because of the

current market price for healthier fruits and vegetables (Mortazavi, 2011).

Finally, the increase made in federal funds, already surpasses proposed regulations of the

national school lunch program (Mortazavi, 2011). Fiscal challenges continue to combat a

significant change in addressing childhood obesity. The USDA estimates production costs to

meet the regulations within the HHFKA to be set at seven cents per meal (Mortazavi, 2011).

These estimates provide impractical budget options for schools to meet HHFKA nutritional

regulations (Mortazavi, 2011).

The current HHFKA aimed to limit junk food and eliminate foods with added sugars on

school campuses, the discretional guidelines are exerted to their own interpretation by the USDA

(Mortazavi, 2011). With guidelines left to be interpreted, competitive foods have created loop

holes that allow for high sugar based junk food to be sold during ‘school sponsored fundraisers’

(Mortazavi, 2011). These loopholes allow for a large amount of foods with little to no nutritional

value to remain unfettered and unsupervised (Mortazavi, 2011). The USDA’s discretional

guidelines innate vagueness and litigates loopholes within the competitive food market and

inherently neglects to define ‘frequency’ (Mortazavi, 2011).


In 2011, Motazavi explained that only 7%-15% of schools currently comply with the

national school lunch program nutritional requirements. Perhaps the most complex challenge

that faces the HHFKA is its enforcement and compliance. The USDA does not have a current

infrastructure available to cite school district nutritional programs that lacked responsibility

ensuring children’s nutritional needs (Motazavi, 2011). This challenge remains, as the USDA is

unable to inherently neglect the basic needs of children (Motazavi, 2011).

Evaluate a Health Care Policy from Abroad for Criteria to Integrate into Domestic Health

Care Reform (Collie)

Health care policy abroad that effect young children as in the United States is obesity.

Obesity has become a major problem in Pakistan and policies are being implemented to control

this problem. Warraich et al. stated “Obesity is becoming an increasingly prevalent problem in

Pakistan, as it has in other developing countries, with under nutrition remaining a problem

simultaneously” (Warraich et al., 2009). More and more countries are facing the rise in youth

becoming obesity. Pakistan compared to the Unites States has tried to implemented exercise into

the daily active of their youth. On behalf of the United States a policy was put in action to assist

and implement youth obesity to regain youth health. As stated by Garcia & Fenwick “The major

goals are, first, to help students learn the skills and knowledge to move more, eat well, stay

healthy, and do their best in school and in life; second, to alleviate unfair disparities based on

race, ethnicity, and income; and third, to engage, educate, and empower people to improve

public education and health” (Garcia & Fenwick et al, 2009). Once these goals are met students

should be able to incorporate these lifestyle changes into their daily routine. Pakistan also came

up with a policy to incorporate exercise and education to the students and community. Warraich


stated “Integrated approaches that promote intake of a balanced diet and increased physical

activity to both underweight and overweight children would be more cost-effective than separate

strategies for underweight and overweight children” (Warraich et al., 2009). Underweight youth

also need to apart of this plan, so that in the future they won’t face the challenge of being

obesity.

China also ranked high with having a problem with obesity. Boys in China ranked higher

than the girls with having an obesity issue. Burkitt mention in her findings “The country is now

No. 2 for obesity, with its number of obese residents outstripped only by the U.S. Its obesity rate

has skyrocket over the last three decades, resulting in 46 million obsess Chinese adults and 300

million who are overweight, according to a study by the University of Washington’s Institute for

Health Metrics and Evaluation” (Burkitt, 2014). The information provided in regards to the

Chinese is alarming, because most people would have thought that China was a healthy country.

Here’s a graph of youth obesity compared to other countries including the United States:


A stand has to be taken to get obesity under control in the United States and other countries. Our

youth is the future and we as lawmakers and citizens has to make an impact to education and

provide the necessary policies. Feeg stated “To implement this recommendation, the committee

believes the federal government should strengthen and support a variety of surveillance

activities, health education programs, and research activities, including an independent

assessment of federal nutrition assistance programs and agricultural policies (Feeg, 2004).

Proposes and Applies Strategic and Plausible Improvements to the Community Health and

National Health Care Policy (Brittney)

Due to insufficient funding schools are unable to meet the nutritional standards appointed

by the Secretary of Agriculture and are therefore unable to budget greater healthier fruits and

vegetables. Improvements can be made through the reallocation of subsidies through congress to

redistribute the production of nutritional and fresh foods. Shift in subsidies would lower the cost

production of nutritional foods. A change to the Farm Bill would need to involve congress to

allot subsidies that could be used to restore the national food stamp program, who’s funding was

recently cut for the HHFKA (Mortazavi, 2011).

These congressional changes would create an overarching obstacle for all school districts

to systematically receive fresh foods for children (Motazavi, 2011). To overcome this challenge

schools will need to work on a community level to implement programs and create partnerships

will local farmers to further educate children on the agricultural aspects supplementing

nutritional foods. Further, budget bound schools could create their own vegetable gardens to be

used as educational and nutritional resources. This would successfully employ modified food

practices, classroom-based nutrition education, and additional integrational opportunities for


physical education, and activities involving parents becoming engaged through school

newsletters (Patel, & Hampton, 2011).

The complete elimination of competitive foods within schools is not an attainable

solution. Because of this, there is a need for the Secretary of Agriculture to specifically define

the rules of ‘infrequent exceptions’ for high sugar based junk foods that are sold on school

campuses. With a strongly defined statute, Congress can better address the current competitive

food limitations within schools and on school campuses (Motazavi, 2011). Another intervention

that could effectively address the amount of competitive foods in schools includes increasing

access to drinking water. Coupled with educational promotions for drinking water, this can

effectively alter drinking preferences among students (Patel, & Hampton, 2011).

To address the lack of nutritional infrastructure being practiced by the USDA, congress

would need to provide a ‘floor’ rather than a ‘ceiling’ based regulation to term nutritional

regulations. A plausible solution involves nutritional standard liaisons on the state, county and

school district level. This multisectoral relationship would allow for local monetization of

school lunch programs and provide further options for compliance and enforcement of the

HHFKA dietary regulations.

To allow for a more efficient flow of federal budgeting sectoral changes need to be made

to determine the federal nutritional and dietary guidelines. Currently the department of

agriculture has an ‘inherent loyalty’ to its own agriculture sector and should not be making

determinations pertaining to federal dietary and nutritional guidelines (Motazavi, 2011). Rather,

the department for human services, science, and the coalition of health should be the principle

voices influencing health nutrition dietary guidelines.


Without stringent action to reallocate, redistribute, and better define the federal

regulations seen within the HHFKA, schools are left with impractical options to address

childhood obesity. Modifying the preparation structure of food ought to be viewed as a program

that can create jobs within the food service industry through the improvement of knowledge and

level of skilled labor (Motazavi, 2011). The current fiscal infrastructure for HHFKA

supplements’ training for food programs, but it is training is aimed on management instead of

training for food preparation. This change of focus to food preparation could benefit further

from schools that have their own gardens to grow fresh foods. These programs could be

combined to involve the education of proper food preparation. When food preparation is

involved within schools, children adopt better nutritional habits that are carried with them and

practiced within their homes (Motazavi, 2011).

Operational and Financial Components to the Policy (Monica)

The Healthy, Hunger-Free Kids Act of 2010 gave guidelines regulating “competitive”

foods with low nutritional value in schools (Turner & Chaloupka, 2012). One of the first things

to go was vending machines in schools that offered sugary drinks and candy. Although, the

availability of “competitive” food in schools through vending machines has decreased most

schools still face a major challenge in funding healthier food in the lunch line.

Recommendations in re-allocating subsidies into training and managing new food

requirements can benefit the nation in the long run. The following is a cost-benefit analysis of

implementing the new policies:


Studies have shown that an increase in the consumption of fruits and vegetables can

contribute to a reduction in major chronic diseases associated with obesity (Terry-McElrath,

O’Malley, & Johnston, 2014). Obesity has been linked to diseases such as diabetes and heart

disease. These diseases cost an estimated $150 billion to $200 billion annually in health care

expenditures (Kass et al, 2014). As demonstrated on the Cost-Analysis table, the net benefit of

implementing changes will outweigh the costs associated with managing chronic health

conditions. Having healthy food available can have a direct influence on behaviors associated

with the types of foods chosen by individuals, consequently decreasing the costs associated in

treating obesity ailments.


Implementation of new policies should also consider ethical implications that might need

to be addressed. Government regulations that dictate what children can and can’t eat at school

will have some individuals thinking that the government is overreaching its power over its

citizens (Kass, Hecht, Paul & Birnback, 2014). In order to address this issue, operational

planning that presents evidence based data to the public will play an important role in the

acceptance of the new policy (Kass et al, 2014). Perceived burdens to the public should also be

kept at a minimum by using opt-out strategies and financial disclosures (Kass et al, 2014). By

allowing public transparency into the cost-benefit analysis of implementing the new policies

individuals can make an educated decision as to support or oppose the policy.

Evaluate the short-term and long-term effects of proposed policy reforms in the health care system Healthy, Hunger-Free Kids Act of 2010 (Parthenia)

Improving child nutrition is the focal point of the Healthy, Hunger-Free Kids Act of

2010. The legislation authorizes funding and sets policy for USDA's core child nutrition

programs: the National School Lunch Program, the School Breakfast Program, the Special

Supplemental Nutrition Program for Women, Infants and Children (WIC), the Summer

Food Service Program, and the Child and Adult Care Food Program (United States Department

of Agriculture, 2014). The Healthy, Hunger-Free Kids Act of 2010 allows USDA, for the first

time in over 30 years, the opportunity to make real reforms to the school lunch and breakfast

programs by improving the critical nutrition and hunger safety net for millions of children.

(United States Department of Agriculture, 2014).

This proposed rule would require all local educational agencies participating in the

National School Lunch Program and/or the School Breakfast Program to meet expanded local

schools wellness policy requirements consistent with the new requirements set forth in section


204 of the Healthy, Hunger-Free Kids Act of 2010 (United States Department of Agriculture,

2010).

This proposed rule would establish the framework for the content of the local school

wellness policies, ensure stakeholder participation in the development of such policies, and

requires periodic assessment of compliance and reporting on the progress toward achieving the

goals of the local school wellness policy (United States Department of Agriculture, 2010). It

would also require local educational agencies, as part of the local school wellness policy, to

implement policies for the marketing of foods and beverages on the school campus during the

school day consistent with nutrition standards for Smart Snacks (United States Department of

Agriculture, 2010). The provisions of this proposed rulemaking would ensure local educational

agencies establish and implement local school wellness policies that meet minimum standards

designed to support a school environment that promotes sound nutrition and student health,

reduces childhood obesity, and provides transparency to the public on school wellness policy

content and implementation. (United States Department of Agriculture, 2010).

Policy makers, public health officials, and parents are concerned about the implications

of the increasing rate of childhood obesity in the U.S. such as behavioral, social, and

environmental risk factors contribute to childhood obesity. Research demonstrates that if the

trend is not reversed, childhood obesity will suffer from a number of health complications and

society will deal with rising healthcare costs (Letsmove.gov, 2010). Communities that have

already implemented the comprehensive approach promoted by the ecological framework have

seen a reduction in childhood obesity rates. (Crawford et al, 2013).


Social factors influence children’s risk of becoming obese. Social factors include race,

ethnicity, gender, class, and relationships with parents, siblings, and peers. Research shows that

family structure influences the risk for obesity. (Crawford et al, 2013).

Class and race also play a role in childhood obesity. Health disparities exist among

African Americans, Hispanics, American Indians, and other minority groups (Caprio et al, 2008).

Children in these racial minority groups experience higher rates of obesity than white children.

Researchers found that after adjusting for socioeconomic status and behavioral factors, African

American children and Hispanic children are 27% more likely to become obese than white

children. Children living in poverty are 69% more likely to be obese. (Caprio et al, 2008).

Schools play a critical role in promoting student health, preventing childhood obesity,

and combating problems associated with poor nutrition and physical inactivity. To formalize and

encourage this role, section 204 of the Child Nutrition and WIC Reauthorization Act of 2004

(Pub. L. 108-265), required each local educational agency (LEA) participating in the National

School Lunch Program (NSLP) and/or the School Breakfast Program (SBP) to establish a local

additional stakeholders into the development, implementation, and review of local school

wellness policies; and requires public updates on the content and implementation of the wellness

policies. (United Stated Department of Agriculture, 2014).

According to Capretta & O’Grady (2012), if policy fails to reduce childhood obesity,

American society will face serious consequences over the next 20 years. In the short term, these

consequences include increased child obesity diagnosis rates, increased risk for obesity-related

illness, and diminished academic performance. Children will also suffer increased risk for at

least one additional illness such as cardiovascular disease, elevated total cholesterol,


triglycerides, insulin, or blood pressure. Obese children often perform poorly academically due

to compromised physical and cognitive functioning (Capretta & O’Grady, 2012).

While the short-term effects of obesity are seen in the school systems, long term

implications exist because obese children are more likely to become obese adults. Adult obesity

increases costs for health care systems and creates an unhealthy labor force. (Crawford et al,

2013). Public insurance programs such as Medicare and Medicaid will be expected to cover

most of these costs. The economic implications for obese adults in the workforce are increased

absenteeism and loss of productivity (Crawford et al, 2013)

People argue that the component for childhood obesity is parents often do not have the

information to make healthy food choices for their children and children’s choices are often

dependent on those around them (Crawford et al, 2013). Parents argue that the cost to shopping

for health foods are more expensive and it is easier to get unhealthy foods that healthy foods.

Society has made eating unhealthy convenient because we promote unhealthy behaviors. This

includes an abundance of fast food restaurants in the U.S. Therefore policy interventions should

address this market failure by affecting the factors that contribute to childhood obesity (Crawford

et al, 2013).

In public health, especially with obesity, the public, private, and non-profit sectors are

essential for scalable and sustainable interventions (Crawford et al, 2013). The public sector

includes major policy factors such as local, state, and federal levels of government as well as

public schools and public universities. Private sector actors include the business community and

industries (Crawford et al, 2013).


The non-profit sector has the potential to mobilize and conduct large-scale programs. For

successful policy interventions, cooperation between the public, private, and non-profit sectors is

essential for political feasibility. (Crawford et al, 2013). The public sector can set the agenda and

provide funding. The non-profit sector is able to plan and develop large-scale programs while

private sector buy-in can promote long-term sustainable interventions in which this policy will

and can implement (Crawford et al, 2013).

Analyze Operational Recommendations and Strategic Implications of the Proposed

Health Care System (Robbin)

Childhood obesity has become the national health crisis epidemic, globally. One in every

three children (31.7) is overweight or obese for children ages 2 to 19 years of age. This issue has

become very forcibly especially when it can become life threatening outcome for most obese

individuals. In the United States, Obesity has caused 112,000 deaths and it poses a substantial

cost. There are many recommendations made in regards to this policy, one recommendation is

developing a school based program to address complex issues such as childhood obesity, this

requires the best practice guideline and evidence based intervention. There is very little evidence

or literature that supports school based intervention. Therefore, it becomes necessary for the

system to look at the national guidelines and recommendation for intervention based

programming.

Section 9A of the NSLA, 42u.s.c. 1758B, added by the HHFKA, requires LEA’s to

establish and local school wellness polices for all schools under the jurisdictions (United States

Department of Human Services, 2011). All nutrition guideline must be consistent because the

school plays a very important role in advocating student’s health, preventing child obesity, and

combating problems with kid’s poor nutrition habits. In 2004, the legislation placed the


responsibility of developing a local school wellness policy at the local level; therefore all school

under the jurisdiction of the LEA will be able to address the obesity issues (United States

Department of Human Services, 2011). The United States Department of Health and Humans

Services have designed, Healthy People 2020 which is a 10 year health specification that will

contribute to the guidelines for program development and evaluation. What these benchmarks

willful do is encourage collaboration across sectors, guide others toward making informed health

decisions and measure the impact of prevention activities (United States Department of Health

and Human Services, 2011).

One guideline is to partner with families and community members in the development and

implementation of health eating and physical activity policies, practices, and programs

Encourage communication between schools, families and community members to

promote the adoption of healthy eating and physical activities behaviors among students

(United States Department of Health and Human Services, 2011).

Involve families and community leaders on the school health council (United States

Department of Health and Human Services, 2011).

Develop and implement strategies for motivating families to participate in school-based

programs and activities that promote healthy eating and physical activity (United States

Department of Health and Human Services, 2011).

Access community resources to help provide healthy eating and physical activity

opportunities for students (United States Department of Health and Human Services,

2011).

Demonstrate cultural awareness in healthy eating and physical activity practices

throughout the school (United States Department of Health and Human Services, 2011).


The federal and state provides the largest portion of infrastructure for combating childhood

obesity. The two federal agencies that actually provide the oversight and regulation for school

health and nutrition are a listed: CDC and USDA (Sinott, 2011). The CDC is responsible for

developing strategies to improve the health of the helpless population such as children and

adults. One example of the CDC strategy is CSHP (Coordinated School Health Program) (Sinott,

2011). These are some strategies to improve the effectiveness and efficiency of SNAP. These

strategies are based upon literature review, expert’s recommendations, and prior experiences in

communities and states.

Changing one’s behavior is difficult, and changing a population of American behavior is

even more difficult because you a dealing with the nation as a whole. Research state that the

national data corroborates most children who come to after school programs are already hungry

(Sinott, 2011). Most of them do not have a hot meal awaiting them at home. Therefore, the main

goal of these programs is to expand the number of after school snacks and meals served in after

school programs. In 2010, the Healthy Hunger Free Act developed a federally funded after

school meal reimbursement program in all 50 states (Hungerfreemn.org, 2013). These proposed

strategies are to indicate the future we want for our children and its burden to healthcare.

Strategies are as indicated:

To improve access to health foods-set guideline requires SNAP vendors to carry

healthier options. If we improve our selection of healthier foods, it gives the participant

choices and it improves the food environment (Hungerfreemn.org, 2013).

Incentivizing purchases of healthy foods (fruits and vegetables)-research show this is

a monetary incentives that is more effective strategy in encouraging healthier food


consumption and it improves dietary behavior. Accept the SNAP benefits at the Farmer’s

market and allow online purchases using SNAP benefits (Hungerfreemn.org, 2013).

Restrict options for unhealthy foods.

Public Health approaches to expand SNAP Outreach-the USDA indicates this is the

most important aspect in the nation in regards to improving diets of low income

Americans. One-one or group education sessions to adopting multimedia approaches

which include social marketing campaign to reach the larger numbers, in using advancing

technology such as smart phones to deliver and evaluate nutrition education

(Hungerfreemn.org, 2013).

Health system analysis seeks to understand the determinants of health system performance

and to develop better policies and strategies for reform that improve that performance (Berman

& Bitran, 2011). The health system analysis involves gathering data on health system it is

recommended there is a great need for some development of collaborative learning resources by

World Bank and its partners (Berman & Bitran, 2011). Very few countries have taken it upon

themselves to cost out their recommendations because of the lack of information on

implementation costs limits the reader to judge the feasibility of what is recommended.


Table 1. From Problems to Causes to Solution

The main problems Problems 1: Low health status and unequal access to health services, clean water, sanitation, and education Problems 2: Low level of public spending on health, and available resources are not allocated efficiently and equitably Problem 3: Poor incentive for managers and providers in public provision health Problems 4: Delivery of health care is fragmented Problems 5: Potential of private sectors is not fully realized Cause 1: not all who are getting treated, particularly poor? Large segment of population lack adequate health insurance in some form of financial protection

Main recommendation: offering compulsory universal social health insurance (health fund) with optional supplemental private insurance

Cause 2: Primary health care system is underfunded and ineffective. Many health centers are understaffed, and huge gap in the distribution of health personnel

Staffing rural health facilities Strengthening delivery of primary care services Adopting the concept and practice of family practice of family medicine

Cause 3: general hospital are inefficiently run

Reorganizing public hospital and provide greater autonomy

Cause 4: There is little to no coordination between ministry of health and ministry of labor, who control most financing and provision of healthcare.

Consolidating and redefining institutional responsibilities role in policy formulation and regulatory oversight and MOL

Epidemiological surveillance and data collection Quality assurance and control

Cause 5: There is an inequitable distribution of public expenditures on health, and little is spent on preventive care/maternal and child health

Developing a package of essential services (maternal and child oriented) and target public spending

Target the delivery to the poor and underserved regions World Bank Data, 2003


Conclusion

Childhood obesity is a problem that can be addressed through multi-disciplinary

collaboration from the community and other governmental agencies. Research and empirical

evidence has demonstrated that unhealthy behaviors associated with the types of food chosen by

school aged children has resulted in chronic conditions that has proven more costly to treat.

Initiatives that involve education, community outreach programs, changes in advertising, and

incentives has shown to change behaviors that improve the health of children and the

community.


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Policy Evaluation of Healthy Hunger Free Kids Act of 2010_Brittney Gajewski_March 2015

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