process, findings and implications from two health impact assessments: informing farm to school...

Health Impact Assessment

1 To view the full report and references, please visit www.upstreampublichealth.org/f2sHIA

↑  School districts’ purchase of Oregon food

Environmental Health Outcomes Reimburse

School Districts

Food, Garden & Agriculture Educa>on

Grant Program

↑ Student gardening

Employment Outcomes

Diet & Nutri>on Outcomes

Social Capital Outcomes

↑ Food ac6vi6es in gardens, classroom & cafeteria

F2SSG K-‐12 Educa>on Program Outcomes

↑  School promo6on of new op6ons

↑ School menu op6ons

Farm to School and School Garden (F2S & SG) programs have gained momentum and visibility over the past decade for their potential contributions to stimulate local economies, foster healthy school food environments, support nutrition education, and build relationships among farmers and school districts.

Oregon House Bill (HB) 2800 would guarantee school districts could purchase Oregon produced, processed, packed and packaged foods with 15 cents for lunch and 7 cents for breakfast in reimbursement funds. The bill also ensures students learn how to choose healthy, local food options in their cafeteria through grants that support school gardens, agriculture and nutrition education.

From fall 2010 to spring 2011, Upstream Public Health collaborated with Farm to School and school garden stakeholders to conduct a Health Impact Assessment (HIA) on HB 2800, evaluating its potential effects on Oregonians’ health. This report summarizes the findings of that assessment. The goal of the HIA is to inform legislative decision-making on HB 2800, focusing on the bill’s impact upon five health determinants: 1. Employment, 2. Diet and Nutrition, 3. F2S & SG K-12 Education Opportunities, 4. Environmental Health and 5. Social Capital.

This HIA is supported by grants from the Health Impact Project (a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts) and the Northwest Health Foundation. The opinions are those of the authors and do not necessarily reflect the views of the Health Impact Project, the Robert Wood Johnson Foundation, The Pew Charitable Trusts or the Northwest Health Foundation.

Health Impact Assessment of HB 2800FARM TO SCHOOL AND SCHOOL GARDEN POLICYEXECUTIVE SUMMARY OF FINDINGS • MAY 2011

A health impact assessment (HIA) is an information-gathering tool used to inform policy decisions and promote decisions that are the most beneficial for

health. Understanding the health impacts of Farm to School and School Garden legislation is necessary

to craft sound policy.

The World Health Organization defines Health Impact Assessment as “a combination of procedures, methods, and tools by which a policy or project may

be judged as to its potential effects on the health of a population, and distribution of those effects within the

population.”

For more information, contact: Dr. Tia Henderson

[email protected]

ABOUT HEALTH IMPACT ASSESSMENTS

A review of research evidence and an economic analysis establish that

HB 2800 will have significant positive public health benefits.

KEY FINDINGS ON IMPACT OF HB 2800

HIA health determinant pathways resulting from HB 2800 elements

Farm to School reimbursement funds would: • Create and maintain jobs for Oregonians• Increase student participation in school meal programs• Improve household food security• Strengthen connections within Oregon’s food economy

Food, Garden & Agriculture grants would: • Increase childhood food preferences for fruits and vegetables• Shape long-term healthy diet choices that affect children’s learning & academic achievement while preventing obesity

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CURRENT CONDITIONS

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The meal reimbursement program would create jobs and stimulate economic growth.

HB 2800 would improve child diet and nutrition.

IMPA

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MAJOR FINDINGS

↑ Student gardening ↑ Educa.on on nutri.on, gardens and agriculture

Food, Garden & Agriculture Grant Program

↑ Youth self efficacy

↑ Youth preferences for fruits & vegetables

∆ Youth diet and nutri.on

↑ Learning, Knowledge, Achievement

↑ Physical ac.vity

↓ Youth overweight and obesity

↑ Food ac.vi.es in gardens, classroom & cafeteria

↑ Youth consump.on of fruits and vegetables

↑ Posi.ve behaviors

∆ Learning environment

• Oregon’s unemployment rate was 10.5% in Decem-ber 2010, higher than the national average of 9% .

• The recession has hurt Oregon’s farms: almost 2/3 of farms reported net losses. Small & mid-sized farms especially are struggling to compete.

• In 2009, Oregon was one of the hungriest states in the nation: 14% of households were food insecure and 6% of them were hungry.

• 19% of Oregon kids live in poverty.

• Kids on free and reduced meals are more likely to be from food insecure families.

• In the 2009-’10 school year 33% of kids eligible for free or reduced lunches did not participate.

• 22% of low-income kids did not graduate during the

2006-’08 school years.

• Current Oregon learning standards do not require children to learn where food comes from or how it is made.

• Cafeterias are not connected to classroom curriculum.

• 1 in 4 Oregon adolescents are overweight or obese.

• 2009: 58% of 11th graders eat three or less servings of fruits and vegetables a day.

Oregon has been an innovator in finding creative ways to provide its children with fresh and healthy school meals. Without statewide

infrastructure to support Farm to School efforts, limited funding for school meals can

offer only inconsistent options to support Oregon’s children and the farmers who feed them.

Protein: 46¢

Milk: 23¢

Vegetables:15¢

Fruits:15¢

Grains:10¢

2009-’10 estimates for school lunch budget in Oregon

Estimated economic effects of Oregon purchases during the first bieunnium ($19.6 million in reimbursements)

A 2.67 employment multiplier means that for every job created by school

districts purchasing local foods, additional economic activity would

create another 1.67 jobs.

Kind of Impact New Jobs (Full & Part-time)

Direct effect 101Indirect effect 101Induced Effect 67Total Effect 269Multiplier 2.67

Food, Garden and Agriculture education grants would increase kids’ understanding of what they eat,

how it is grown and how it affects their bodies.

• Employment leads to health: The unemployed are up to twice as likely to die earlier than others of the same age and sex.

• Students who participate in school meal programs learn better and have a better chance of academic achievement.

• HB 2800’s reimbursement and garden grant programs improve the quality and diversity of food offered during school meals.

• Studies of Farm to School initiatives show increases in meal par ticipation (for free, reduced, and full-priced meals) between 1.3% and 16%. This helps families buy more food at home, lowering household food insecurity.

• Research of F2S & SG programs report that children choose more fruits and vegetables - leading to potential increases in consumption.

• Studies show that children who spend time in the garden learn better, get physical activity and behave better in the classroom.



CURRENT CONDITIONS

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ESThe reimbursement program gives more

flexibility to buy sustainably produced food; this can impact environmental

health factors.

The reimbursement program will help farmers and nutrition staff build food

system connections; the grants will help students work better together.

Oregonians currently demand food produced and processed with alternative methods.

Between 2006 and 2008, the total land in organic production nearly doubled, an 86.7% increase from almost 70,000 to over 130,000 acres in response

to this demand.

Social capital is a bank of resources, such as job referrals, that individuals gain through strong relationships to others. This improves people’s health and access to opportunities.

If schools build connections with producers, other institutions can build upon these relationships, connecting with those who want to buy Oregon food.

RECOMMENDATIONS for HB 2800: CHANGES TO IMPROVE HEALTH1. The current policy allows food produced or processed in other states or countries to qualify for a

reimbursement. Amend HB 2800 to specify that schools can only get reimbursed for foods produced or processed in Oregon to increase economic activity in our state.

2. To improve health outcomes for vulnerable populations, specify that while grants are open to all school districts, Food, Agriculture and Garden education grants will be preferentially given to school districts serving:

◦ a low-income student population, defined where 40% are eligible for free or reduced meals, or,

◦ schools with a racially diverse student population, defined as 20% or more non-white, or

◦ schools in rural or urban areas with limited food access, defined as 12% or more of residents are low-income and live more than 10 miles from a grocery store.

3. To improve child health outcomes, specify funding criteria for Food, Agriculture and Garden education grants to support schools developing multiple-component programs that increase child health benefits. Garden grants should be preferentially awarded to programs working toward having at least one element in each of the following categories: Education, Promotion, Procurement and Community Involvement.

IMPA

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MAJOR FINDINGS cont’d.

• A stable product demand helps farmers and processors try new practices such as solar-heated greenhouses or integrated pest management plans. These practices reduce health issues from soil and water contamination.

• A more stable product demand also helps keep farmland in production, which can reduce greenhouse gasses. If all districts just served Oregon fruit or vegetables at lunch one day a month, it would support $756,000 in sales.

• Buying Oregon products does not reduce greenhouse gas emissions from transportation significantly, depend-ing on the food source.

• Preliminary studies indicate school garden participants have positive changes in social skills and their ability to work with others.

• “Supporting local farmers” is a reported primary benefit for Farm to School programs; research is needed to examine the impact on social isolation and depression.



Health Outcome or Health Determinant

Impact w/ HIA rec’s

Impact w/ HIA rec’s Distribution Quality of

Evidence Employment Impacts Employment Impacts Employment Impacts Employment Impacts Employment Impacts

Health & life expectancy Health & life expectancy pppp Farm sector and related jobs ****

Job creation Job creation ppp ~270 new jobs ****

Oregon product demand Oregon product demand pppp 100—197 School Districts4 ****

Workers’ ability to pay bills Workers’ ability to pay bills ppp ~270 new jobs ****

Economic activity Economic activity pppp 3.16 economic multiplier ****

Impacts on Child Diet and Nutrition Impacts on Child Diet and Nutrition Impacts on Child Diet and Nutrition Impacts on Child Diet and Nutrition Impacts on Child Diet and Nutrition

Meal program participation Meal program participation ppp 561,698 public school children1 ** Child learning & academic attainment Child learning & academic attainment ppp 561,698 public school children1 ****

Household food security Household food security pp 210,446 households2 ***

School meal nutrition School meal nutrition pp+ 561,698 public school children1 *

Child overweight & obesity Child overweight & obesity pp+ 1 in 4 children ** Farm to School and School Garden Education Impacts Farm to School and School Garden Education Impacts Farm to School and School Garden Education Impacts Farm to School and School Garden Education Impacts Farm to School and School Garden Education Impacts Gardening education Gardening education pppp ~15,000 new children3 **** Child fruit & vegetable consumption Child fruit & vegetable consumption ppp+ 561,698 school children1 ****

Agriculture & nutrition education Agriculture & nutrition education pp+ ~15,000 new children3 ***

Child nutrition knowledge Child nutrition knowledge pp+ ~15,000 new children3 ***

Nutrition staff knowledge Nutrition staff knowledge pp 100—197 School Districts ** Child achievement Child achievement pp ~15,000 new children3 * Child self-efficacy Child self-efficacy pp ~15,000 new children3 * Child physical activity Child physical activity pp ~15,000 new children3 * Impacts on Environmental Health Impacts on Environmental Health Impacts on Environmental Health Impacts on Environmental Health Impacts on Environmental Health Oregon fruit & vegetable crops maintained Oregon fruit & vegetable crops maintained pp

$756,000 — $15,120,000 in school purchases6 ***

Demand for food grown with sustainable practices Demand for food grown with sustainable practices p Oregon food sectors *

Greenhouse gas emissions from food transport Greenhouse gas emissions from food transport None 3,844,195 Oregonians5 **

Impacts on Social Capital Impacts on Social Capital Impacts on Social Capital Impacts on Social Capital Impacts on Social Capital Student relationships Student relationships pp ~15,000 new children3 * Producer, processor & school staff connections Producer, processor & school staff connections ppp ~100 School Districts ***

Parent school participation Parent school participation pp ~15,000 new children3 *

SUMMARY OF HEALTH OUTCOMES AND IMPACTS HIGHLIGHTS ON HB 2800 ($23 MILLION)

CONCLUSIONS

Strong impact on many Strong impact for few or small impact on many Moderate impact on medium number or strong impact on few Small impact on few None No effect

**** 10+ strong studies

*** 5 -10 strong studies or data analysis

** 5 or more studies of weak and moderate quality; or studies have mixed results * <5 studies and claim consistent with public health principles

LEGEND

1 Enrolled children in Oregon public school system, Oregon Department of

Education, 2009-10.2 Household Food Security in the

United States, 2009, US Dept. of Agriculture, Economic Research Service,

2010.

3 Low estimate based on 2007 ODE survey of reported participation in

school gardens; would be over two year grant time period.

4 Low estimate from 2010 Oregon Department Education number of

School Districts that purchase local.5 Certified estimate of Oregon

population from US Census data, Population Research Center, 2010.

6 Conservative estimates from: (280,000 school lunches served in

2009-10 x $.30 for fruits and vegetables) x 9 to 180 school days.

+ Indicates schools will have to take action beyond the reimbursement

program in the policy.

= See report for full summary table, including impacts without HIA policy

recommendations.

Health Outcome or Health Determinant Distribution Quality of

Evidence Employment Impacts Employment Impacts Employment Impacts Employment Impacts Employment Impacts

Health & life expectancy Health & life expectancy pppp Farm sector and related jobs ****

Job creation Job creation ppp ~270 new jobs ****

Oregon product demand Oregon product demand pppp 100 - 197 School Districts4 ****

Workers’ ability to pay bills Workers’ ability to pay bills ppp ~270 new jobs ****

Economic activity Economic activity pppp 3.16 economic multiplier ****

Impacts on Child Diet and Nutrition Impacts on Child Diet and Nutrition Impacts on Child Diet and Nutrition Impacts on Child Diet and Nutrition Impacts on Child Diet and Nutrition

Meal program participation Meal program participation ppp 561,698 public school children1 ** Child learning & academic attainment Child learning & academic attainment ppp 561,698 public school children1 ****

Household food security Household food security pp 210,446 households2 ***

School meal nutrition School meal nutrition pp+ 561,698 public school children1 *

Child overweight & obesity Child overweight & obesity pp+ 1 in 4 children ** Farm to School and School Garden Education Impacts Farm to School and School Garden Education Impacts Farm to School and School Garden Education Impacts Farm to School and School Garden Education Impacts Farm to School and School Garden Education Impacts Gardening education Gardening education pppp ~15,000 new children3 **** Child fruit & vegetable consumption Child fruit & vegetable consumption ppp+ 561,698 public school children1 ****

Agriculture & nutrition education Agriculture & nutrition education pp+ ~15,000 new children3 ***

Child nutrition knowledge Child nutrition knowledge pp+ ~15,000 new children3 ***

Nutrition staff knowledge Nutrition staff knowledge pp 100-197 School Districts ** Child achievement Child achievement pp ~15,000 new children3 * Child self-efficacy Child self-efficacy pp ~15,000 new children3 * Child physical activity Child physical activity pp ~15,000 new children3 * Impacts on Environmental Health Impacts on Environmental Health Impacts on Environmental Health Impacts on Environmental Health Impacts on Environmental Health Oregon fruit & vegetable crops maintained Oregon fruit & vegetable crops maintained pp

$756,000 - $15,120,000 in school purchases6 ***

Demand for food grown with sustainable practices Demand for food grown with sustainable practices p Oregon food sectors *

Climate change from food transport Climate change from food transport None 3,844,195 Oregonians5 **

Impacts on Social Capital Impacts on Social Capital Impacts on Social Capital Impacts on Social Capital Impacts on Social Capital Student relationships Student relationships pp ~15,000 new children3 * Producer, processor & school staff connections Producer, processor & school staff connections ppp ~100 School Districts ***

Parent school participation Parent school participation pp ~15,000 new children3 *

Magnitude of Impact w/ HIA Recs. =

100

100

Health Impact AssessmentNational Nutrition Standards for Snack and a la Carte Foods and Beverages Sold in Schools

3Health Impact Assessment: National Nutrition Standards for Snack and a la Carte Foods and Beverages

IntroductionThe foods and beverages available in schools have a significant impact on children’s diets and weight, with many students consuming more than half of their daily calories at school.1 In addition to meals, nearly all students can buy foods and beverages at school, often from multiple locations, including cafeteria a la carte lines, vending machines, and school stores. These snacks and drinks are technically called “competitive foods” because they compete with school meals for students’ spending; however, they are also referred to as “snack and a la carte foods and beverages” throughout this document.

Ensuring that schools sell nutritious foods is critical to improving children’s diets. This is one of the goals of the Healthy, Hunger-Free Kids Act (HHFKA), passed in 2010, which directs the U.S. Department of Agriculture (USDA) to update nutrition standards for all foods and beverages sold in schools during the school day by aligning them with the current dietary guidelines.

In an effort to inform USDA as it updates nutrition standards for foods and beverages that are sold outside of the school meal programs, and to better understand how standards might affect student health and school finances, the Kids’ Safe & Healthful Foods Project and the Health Impact Project, both collaborations of The Pew Charitable Trusts and the Robert Wood Johnson Foundation, worked with Upstream Public Health, a nonprofit research and policy organization, to conduct a health impact assessment (HIA).

Executive Summary


EXECUTIVE SUMMARY

Health Impact Assessment BackgroundAn HIA is a prospective research tool that guides decision makers in considering the possible health impacts, and in some cases financial considerations, of proposals. HIAs recommend actions to minimize adverse consequences and optimize beneficial effects.

The goals of this HIA are to:

•Synthesize relevant data to assess potential health impacts as school districts implement USDA’s updated national standards for snack and a la carte foods and beverages sold in schools.

•Inform national and state deliberation regarding the potential costs and benefits related to national snack and a la carte food and beverage standards in schools.

•Identify potential health disparities and inequities that could result from national snack and a la carte food and beverage standards.

•Make recommendations to USDA in order to maximize positive health outcomes and minimize potential health risks.

The research team followed the North American HIA Practice Standards Version 22 and the National Research Council Guidelines3 to develop each stage of this HIA. The most comprehensive literature review to date on competitive foods in schools, as well as original empirical analysis of school financial data was conducted for this HIA. The process also required extensive interviews and involvement of a wide array of experts and stakeholders from academia, industry, the public health community, and those individuals most affected at the ground level, such as teachers, students, and parents, in planning, researching, and peer reviewing the study.

Because USDA had not yet proposed updated standards at the time of this study, the HIA examines a scenario in which items would be required to meet the 2010 Dietary Guidelines for Americans (DGA).

See Figure ES.1 for a visual mapping that summarizes the research questions and outcomes examined in this HIA.

Summary of Snack Foods and Beverages Nutrition Standard Outcomes

Change

Increase

Decrease1 Fundraisers are not included.2 ES, MS, HS: Elementary school,

middle school, high school

Policy

ES, MS, HS snack foodand beverage availability

Access to healthy foods and beverages Access to unhealthy foods and beverages School snack foods meeting DGA

Purchase/consumption

A la carte sales Vending sales School store and snack bar sales

National nutrition standards for snack foods and beverages sold in schools

Diet and nutrition health outcomes

School services health outcomes from revenue

1

2

1 Fund-raisers are not included.2 ES, MS, HS: Elementary school, middle school, high school

FIGURE ES.1 Summary of Snack and a la Carte Food and Beverage Health Determinant Pathway

Change Increase Decrease


Change

Increase



Policy








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Change

Increase



Policy








1

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Change

Increase



Policy








1

2


EXECUTIVE SUMMARY

Key Questions and FindingsThis HIA considers several key research questions related to school food services, diet and nutrition, and vulnerable populations (including low income and ethnic minority students).

Diet and Nutrition: The impact of updated nutrition standards for snack foods and beverages sold in schools on children’s school-based diets was the main issue considered in this study. The analysis considered two primary nutritional concerns: (1) the total intake of calories from items sold in schools and (2) the consumption of high-calorie, low-nutrient snack foods and beverages versus healthier options. Specific questions included:

•Will the updated standards affect the availability of snacks and drinks sold in schools, student purchases of these items, and student consumption?

•Will changes in student consumption of snacks sold in schools affect different chronic disease health outcomes?

Finding: Student access to, purchase of, and consumption of unhealthy foods and beverages, and subsequently their risk for disease, decreases.

Research indicates that many schools currently sell high-calorie, low-nutrient snack foods and beverages to students of all ages, who consume them instead of healthier options. The HIA found that the implementation of strong snack and a la carte food and beverage policies that meet the 2010 DGA will decrease students’ access to, purchase of, and consumption of unhealthy foods and beverages while also likely increasing their access to, purchase of, and consumption of healthier items at school. Even small changes to students’ school-based diets—like replacing a candy bar with an apple—may reduce their risk of tooth decay, obesity, and chronic illness through decreased calorie, fat, and sugar intake at school. Additionally, the data suggests that strong snack and a la carte food and beverage policies tend to increase participation in the school meal programs, thus the risk of not having enough to eat also may decrease as children purchase school meals in place of less filling snacks.

School Services and Impact on Revenue: The impact of updated nutrition standards for snack and a la carte foods and beverages on student health and school district revenue were of primary concern as food sales are an important component of school budgets. Specific questions included:

•Will updated nutrition standards affect students’ participation in the school meals program and school food service revenue?

The increase in child weight observed between 1988 and 2002 may have been prevented by an average reduction of 110–165 calories per day. This is the difference between providing an elementary school student a 150-calorie snack rather than a 250-calorie snack, as indicated by the child’s daily energy needs.

—“Estimating the energy gap among US children: a counterfactual approach” by Y.C. Wang, et al (Pediatrics, Dec 2006)


EXECUTIVE SUMMARY

•Will updated standards affect school-district or other types of revenue that pay for school services?

•If revenue changes occur, will they affect student health via changes to enrichment learning opportunities and school-supported physical activity?

Finding: Districts would likely not see a decline in revenue.

The HIA analysis found that, when schools and districts adopted strong nutrition standards for snack and a la carte foods and beverages, they generally did not experience a decrease in revenue overall. In most instances, school food service revenues increased due to higher participation in school meal programs. However, in some cases, school districts experienced initial declines in revenue when strengthening nutrition standards. The HIA concluded that, over time, the negative impact on revenue could be minimized—and in some cases reversed—by implementing a range of strategies.i Limited data exists on the impact of snack food and beverage policies on fund-raising revenue for school groups, such as athletic teams and student government. More research is needed in this area in order to determine how such revenue changes might influence the provision of school services, such as physical activity and enrichment programming, and thus the related effect on students’ health.

Vulnerable Populations: A primary consideration of this analysis was how vulnerable populations—including students from lower-income families as well as those who are black or Hispanicii—might be affected by USDA’s snack and a la carte food and beverage policy. These vulnerable populations are more likely to have limited or uncertain access to adequate food;iii to be overweight or obese; to suffer from type 2 diabetes, hypertension, and other chronic diseases; and to have untreated dental caries, all of which are associated with reduced quality of life, more frequent school absences, and longer-term health problem.4-10

Finding: Vulnerable populations would benefit from stronger nutrition standards for snack foods and beverages sold in schools.

Updated nutrition standards that make healthier foods more available may have a particularly beneficial effect among vulnerable populations, who are at greater risk for nutrition-related health problems. Vulnerable populations also have higher risk of poor academic outcomes, such as lower test scores and higher dropout rates.11,12 Because a healthy diet is linked with improved school performance, stronger nutrition standards also may have a positive impact on academic indicators, especially among vulnerable populations. The HIA explored other vulnerable populations, such as children of Asian, Pacific Island, and American Indian descent, but data was too limited to draw conclusions.

iEffective strategies for reversing potential declines in revenue are discussed in Section 7.3 of the full report.iiHispanic is the term used throughout this HIA to refer to “a person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race,” as defined by the U.S. Office of Management and Budget. Other terms, such as Latino, may be used when citing specific literature findings.iiiAbout 15 percent of U.S. households are food insecure, defined by USDA as a household-level economic and social condition of limited or uncertain access to adequate food.


EXECUTIVE SUMMARY

Policy Recommendations The following policy recommendations are meant to inform USDA’s efforts to update nutrition standards for snack and a la carte foods and beverages sold in schools. The recommendations reflect the outcomes and the conclusions described above, are based upon the evidence summarized in this document, and are intended to maximize health benefits while minimizing risks. Although not the primary question considered in his HIA, the research reviewed indicates that the way schools implement improved nutrition standards through marketing, engaging students, and promoting school meals can play a significant role in how both students and the schools are impacted. Thus, in addition to the following policy recommendations to USDA, the full report highlights a range of promising practices for implementation.

Recommendation 1: USDA should establish nutrition standards for all foods sold regularly on school grounds outside of the school meal programs. These standards should include:

•a requirement that schools sell items from the Dietary Guidelines for Americans list of “foods to encourage;”

•age-appropriate calorie limits for items sold individually (snacks: 100 calories for elementary, 140 calories for middle, and 180 calories for high school students; entrée items: 300 calories for elementary and middle and 400 calories for high school students);

•a maximum of 35 percent of total calories from sugar;

•maximum limits for fats (no more than 35 percent of calories from total fat, 10 percent of calories from saturated fat, and less than or equal to 0.5 g of trans fat per serving); and

• incremental reductions in sodium, with a target time frame of 10 years, to achieve full alignment with the Dietary Guidelines for Americans.

Recommendation 2: USDA should establish nutrition standards for all beverages sold on school grounds. At a minimum, these standards should:

• limit beverages sold in elementary and middle schools to only water, low-fat and fat-free milk, and 100 percent fruit juice in appropriate portions, and

•establish calorie and serving size restrictions for all beverages sold in high schools so as to ensure calories obtained from sugar-sweetened beverages during the school day are minimal.

Recommendation 3: USDA should adopt policies and practices that ensure effective implementation of the standards. At a minimum, USDA should:

•provide technical assistance and training to schools and districts;

•provide clear guidance on how the terms infrequent, school day, and school campus as included in the Healthy, Hunger-Free Kids Act are to be addressed;

•ensure that nutrition standards are kept up to date with future iterations of the Dietary Guidelines for Americans; and

•collaborate with states and nongovernmental organizations to monitor the implementation of the standards.


EXECUTIVE SUMMARY

Concluding StatementThis HIA explores the potential impacts of national nutrition standards for competitive foods or foods sold in schools individually as snacks, a la carte items, and beverages. Research included an extensive literature review, interviews, stakeholder discussions, and financial analysis. Overall, the results indicate that strong nutrition standards could have a significant positive impact on the health of students with potentially increased benefits to those populations that are most vulnerable. In addition, if implemented effectively at the district and school levels, the changes can be made with little to no negative financial impact and in fact may even result in improved financial outcomes for schools and districts. Thus, USDA should establish updated standards and adopt practices—as recommended by this report—that are most likely to maximize positive health impacts while assisting schools in effectively implementing the changes.

Prepared by Dr. Tia Henderson of Upstream Public Health and Megan Lott of the Kids’ Safe and Healthful Foods Project PROGRAM EVALUATIONi HEALTH IMPACT ASSESSMENTii

Purpose Program evaluation is typically a retrospective tool used to gain information about program efficacy and to identify areas for program improvement. Evaluation is not only intended to look at "did it work" or not, but also for whom, where, and under what circumstances. Key Features Program evaluation typically includes the following: • Defines an aim, goals and objectives • Is guided by a conceptual framework to ask key questions • Uses assessment instruments such as surveys, interviews, a needs assessment,

performance monitoring, and literature reviews to collect information • Uses an evaluation matrix to track progress • Reports findings to program managers and staff to help strengthen the

program

Program evaluation identifies program strengths and deficiencies, provides data to support continuation, and provides evidence/justification for making changes. Evaluation provides information over the long term as the basis for program planning and for program redesign and improvement, such as revisiting program goals and/or resource allocation When to use • Determine how effectively meeting program goals and objectives • Determining impact of program through measurable outcomes • Determining program needs or gaps that aren’t being addressed • Develop evidence of client/customer satisfaction • Identify barriers to successful program implementation and delivery • Determining what, if any, changes could improve effectiveness • Determining whether or not resources are being used as intended • Determining if elements of the program are replicable in other settings

Who is involved Who participates depends on the structure of an organization and on the program you are evaluating. Some people to consider are: • Managers and directors (i.e. program, agency, development) • Program staff (all levels) • Evaluation consultant • Grant writer / foundation contact • Program participants • External stakeholders (such as government officials, funders, "sister" orgs.)

Purpose An HIA is a prospective research tool used to assess the potential health impacts of a defined project, plan, or policy. The HIA guides decision makers in considering how to maximize beneficial impacts to health and minimize adverse consequences. HIAs involve a wide array of stakeholders including potentially impacted communities to ensure that the process and results are as powerful as possible. Key Features An HIA typically involves six stages:

1. Screening – decide whether an HIA is feasible, timely, and would add value to a decision making process

2. Scoping – creates a plan and timeline for the HIA, guided by a logic model that links the proposal decision to health outcomes

3. Assessment – explores existing conditions and evaluates potential health impacts

4. Recommendations - creates evidence-based recommendations to reduce negative and optimize positive health impacts

5. Reporting – develops the HIA report to communicate findings and recommendations

6. Monitoring and Evaluation – evaluates the process of conducting the HIA, tracks the impacts of the HIA on the decision-making process, and monitors the impacts on long term health outcomes.

When to use • The proposed decision could have substantial negative or positive health

effects – especially if these are irreversible or catastrophic • The timing of the decision allows for changes based on new information • There is a good chance the HIA–based information will be used by decision

makers to alter the proposal • The potential for health effects to place a disproportionate burden on, or

strongly benefit, vulnerable populations • There is public concern about health effects of the proposal • The decision making process would not otherwise consider health

Who is involved • Decision makers (i.e. legislators, planners, project managers, developers) • Staff who will implement decision • People who will be impacted by the decision (i.e. stakeholders) • HIA consultants • Content and technical experts

Prepared by Dr. Tia Henderson of Upstream Public Health and Megan Lott of the Kids’ Safe and Healthful Foods Project

Program Evaluation Example HIA Example Evaluation on Sunnyvale Middle Schools’ Farm to School buy-local efforts In the fall of 2010, the members of the Wellness Team (includes a science teacher, the Vice Principal, two parents, the Wellness Coordinator and the district Nutrition Services Director) set a 5-year goal for the district to purchase 15% of their foods from state sources where feasible (produced and processed). The Kitchen Manager at the school also set a goal of one meal a month being as close to 100% local as possible. After the team set the goal, the district Business Manager worked with the district School Nutrition Service director to begin 1) entering monthly orders into an excel spreadsheet and 2) asking distributors to let them know on invoices which items were “local”. Aims of the Evaluation:

• Evaluate how far the District has progressed toward the 15% district goal, and the Kitchen Manager’s goal of one local meal a month.

• Determine any barriers the school and district have encountered in working toward these goals

• Problem-solve to help meet the goals in the next three years. • Use the results as part of a grant application to pay for new kitchen

equipment. Methods:

• Assess purchases using the sales records • Assess meals using previous menus • Interviews with the Kitchen Manager, Business Manager, the Nutrition

Service Director • Two page report discussed at the January 2013 Wellness Committee

meeting Who is involved:

• One parent and non-profit partner doing the evaluation • The Wellness Committee is advising on the process

Hawai’i County Agricultural Plan HIA The 2010 Hawai’i County Agriculture Development Plan, prepared for the Hawai’i County Department of Research and Development, is intended to guide the revitalization of agriculture as the basis for Hawai’i Island’s (big island) economic development. The draft plan included key policy activities to support agriculture and economic development. It was approved in 2011 by the City Council. In 2010, the Kohala Center, a non-profit organization, received a grant to complete an HIA on three policy components of the Plan to better understand, and inform residents and decision makers, on how the policies would affect public health. Aim of the HIA: The goal of the HIA is to inform legislative and regulatory decision-making so that these three Agriculture Plan policies are implemented in ways that maximize health benefits and minimize health risks for Hawai‘i Island residents. This HIA examines the impact of each of the three Agriculture Plan policies on five health outcomes or determinants of health, from the range of personal, social, economic, and environmental factors that can affect the health status of individuals or communities: 1. Food security 2. Obesity 3. Food-borne illness 4. Economy 5. Well-being and cultural connectedness Methods:

• Literature review • Secondary data • Input-output economic analysis

Who was involved:

• Impacted stakeholders including health coalition representatives, garden network representatives, farmers, residents and government agency representatives

For more information visit: http://kohalacenter.org/agplan.html

i Gelmon S.B., Foucek A., and Waterbury A., Program Evaluation: Principles and Practices, 2nd ed. (Portland, OR: Northwest Health Foundation, 2005). iiii National Research Council, Improving Health in the United States: The Role of Health Impact Assessment (Washington, D.C.: National Academies Press, 2011).

process, findings and implications from two health impact assessments: informing farm to school...

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