CHILDHOOD OBESITY April 2015 j Volume 11, Number 2 ª Mary Ann Liebert, Inc. DOI: 10.1089/chi.2015.1122
THE EXPERT WEIGHS IN
Heart Disease Prevention in Children: The Road to 2020 An interview with Laurie Whitsel, PhD, Director of Policy Research for the American Heart Association (AHA)
ization of the standards. Do you foresee what the impact will be from the changes that were put forth in the 2015 federal spending bill?
Introduction
T
he American Heart Association is a well-respected nonprofit agency and opinion leader on cardiovascular health strategies in the United States. They provide scientific statements and practice guidelines for healthcare professionals and the public as well as resources and tools for researchers. Here, Laurie Whitsel, PhD, director of policy research for the AHA, discusses why they believe the new school meal standards are working and should receive continued support in 2015; how worksite health care could benefit children; and the association’s 2020 goal, which is to improve the cardiovascular health of the nation by 20 percent by 2020.
Dr. Whitsel: The overarching point I will make is that we are always concerned when Congress begins to meddle with evidence-based standards. We think that implementation is the work of the respective regulatory agency, and there is ample evidence for the standards that are in place. That said, the US Department of Agriculture is talking to food service directors and understanding where there might be some need for adjustment and so forth. If schools are struggling in terms of availability of whole-grain foods, for instance, giving them a little more time to overcome some of those barriers is okay. For sodium, in the language of the spending bill, what was said is that the USDA cannot move further through reduction until they show more evidence for sodium reduction in children. We feel that there is already evidence for that sodium reduction. The Dietary Guidelines Advisory Committee report just reaffirmed the target for 2300 mg of sodium for a majority of the population and reaffirmed the importance of sodium reduction in children and adults.2 The final sodium targets in the school meal program are based on the 2300-mg recommendation; so we feel the science is there and that the USDA will be able to progress over time to that final target.
What is your view on the current status of the school food guidelines in the US? Dr. Whitsel: We have made tremendous progress since the Child Nutrition Reauthorization Act of 2010 across the school food environment. More than 90% of schools nationwide are implementing the standards. Bridging the Gap published a research brief in summer 2014 showing that, overall, kids are happy with the school meal standards.1 Now, we are doing a lot of work to maintain the great progress we’ve made; and I do believe the school environment has been transformed. It is still a work in progress to get the standards fully in place and to provide the resources, equipment, and reimbursement that school food service directors need to optimize implementation. But we have made great strides, and there have been many successes so far that I think that we have to celebrate. The challenge is going to be maintaining those gains through the next reauthorization, this year, in 2015, within the context of significant pushback in Congress.
The committee report you mention is the first to point to a specific sugar intake recommendation, correct? Dr. Whitsel: It was. And that is further to the point that the USDA will make adjustments to the guidelines where needed. Will schools be able to scale back on changes they have already made as far as sodium in foods they are offering? Dr. Whitsel: Well, no they cannot. They are already supposed to be at the tier 1 reduction and that is where they
The political environment is something that many people are wondering about as far as the reauthor111
112
have to stay. The language in the spending bill does not allow schools to backtrack at all. The sodium reduction was gradual over time to get to the final endpoint, and all that the bill says is that the USDA cannot move on to the next tier reduction until they show that there is enough science. How do you view the future in terms of school food? Dr. Whitsel: It is going to be a massive effort in the public health community to maintain the great progress we have made in the school environment. It will require working with all of our partners in education and the hunger community, among others. It is vital that we maintain our progress. An AHA statement, written by yourself and coauthors, on worksite healthcare delivery, discusses the importance of collaboration and partnership with arenas such as schools.3 How could children in particular benefit from an increased focus on worksite healthcare? Dr. Whitsel: The paper that you reference is one we wrote on health screening in the workplace, and there is a lot of discussion about that right now. Employers now have the ability to hold their employees accountable for health metrics under the Affordable Care Act and adjust healthcare premiums according to whether they meet those health metrics, in conjunction with a worksite wellness program. So a lot of employers are conducting health screenings and seeing where their workforce is in terms of health and then hopefully designing comprehensive programs to address the needs of their employees and helping them move toward better cardiovascular health. We support comprehensive worksite wellness programs, and we know that these programs are an important way to reach millions of adults who are in the workforce. We certainly want to be careful that those outcomes-based incentive programs do not decrease access to affordable quality healthcare. We wrote this paper to provide some guidance to employers on how to conduct screenings; to assure that they are in coordination with state and federal law. Also that they are taking into account the privacy issues that a lot of employees are concerned about with health screening, health risk assessment, and all the other issues that we raise in the paper. It is an area that the American Heart Association (AHA) has been working in for quite some time and we are going to continue to be doing a lot of work in the worksite wellness space. It is a way to reach children because a lot of employers are not only holding employees accountable, but also dependents who are on the healthcare plan. So often family members can have access to the resources that employers provide, and that is important. And employers, increasingly, are wanting to connect with their community. I think those community relationships and partnerships are so
INTERVIEW
critical not only to provide resources to their employees within the community, but also for employers to be role models within their community. For example, we wrote about shared use of school facilities to open up access to recreational facilities to the community. An employer might also consider working with a community on shared use opportunities if they have facilities or spaces that could be accessed and used by others; employers could sponsor the opportunity for those spaces to be opened. There are many different ways for employers to interact with the community and be role models for health. The AHA has traditionally been focused mostly on adults, as that is where the heart disease is; has that changed over time, and if so, why? Dr. Whitsel: We actually do have a whole strategic priority around children, and I would say our focus has been across the life span as we think about cardiovascular health. We have to reach kids because it is so hard to reverse risk factors like obesity, high blood pressure, cholesterol, and so on, after the fact. Instead of trying to change poor diets and physical inactivity, it is so much better if we can get to kids early and build a foundation of healthy lifestyle right from the beginning. For example, our Healthy Way to Grow program (www.healthywaytogrow.org) is offering technical assistance for early child care centers. We have been focused on nutrition standards in schools and early child care, physical activity, and physical education in schools, as well as food marketing and advertising to children. We also have a relationship with NFL Play 60, the National Football League’s campaign to encourage kids to be active for 60 minutes a day in order to help reverse the trend of childhood obesity. We are doing some work on congenital heart disease in children with pulse oximetry screening for newborns. And we have our CPR in Schools initiative, too, where we are training more than 1 million kids every year in CPR with our CPR in Schools legislation. So we have a lot that we are doing around kids, and we will continue to do that. It is extremely important to focus on prevention. We subscribe to the idea that most kids are born in cardiovascular health; unfortunately then, some lose it over time. We want to try to make sure that that does not happen. Is the AHA involved in any specific efforts to encourage a whole-family approach to heart disease prevention? Dr. Whitsel: Yes, so the fresh fruit and vegetable program in schools is a program that we advocated really strongly for in the Farm bill. That is a program that offers fruits and vegetables during the school day. What is great about that is kids then go home and ask for those same
CHILDHOOD OBESITY April 2015
fruits and vegetables, or when they are in the grocery store with their parents shopping, they recognize the food they ate and ask for it. There is a nice congruence there. We also have our school and community gardens program that helps families talk about how food is grown, and that is important. Then we have our recipe books for healthy food preparation, which allow families to be in the kitchen together and talk about healthy food and how to prepare healthy food. There are a number of ways we are trying to reach families, and that is so critical. There is an interesting study recently out comparing a fully plant-based diet and the AHA-recommended diet for obese children—with the plant-based diet seeing more improvements in health overall for the cohort studied.4 Will future AHA guidelines see further focus on plant-based diets? Dr. Whitsel: This is an interesting, though preliminary, study. We are always interested in longitudinal research, and it is really important to understand the impact of all the healthy foods in the diet. The AHA will continue to emphasize the importance of fruits, vegetables, whole grains, healthy oils, and seafood as a real focus for a healthy diet. We have our healthy diet components that we use to measure cardiovascular health. One thing that was not mentioned in this study is the importance of limiting added sugars and sugar-sweetened beverages in the diet. I do not think our dietary guidance is going to change markedly, but we will certainly continue to focus on those really important food groups. How does the AHA view physical activity in the larger health picture for children? Dr. Whitsel: We cannot underestimate the importance of regular exercise and avoiding long periods of sedentary behavior for kids and adults. Kids are sitting for a good part of the school day, and we know that does not help their academic performance. In fact, we have some pretty good research now showing the link between increased physical fitness and physical activity, and academic performance. It is to the school’s benefit actually to get kids up and moving throughout the day, with classroom breaks and
113
recess, and physical education as the cornerstone to build a foundation for lifelong physical activity. Does the AHA record progress in relation to children’s health in schools, or do you rely more on other venues to get that information? Dr. Whitsel: We have our Voices for Healthy Kids initiative, which is a partnership we have with the Robert Wood Johnson Foundation to address childhood obesity through state and local policy. It is a significant effort over the next 3 years, and part of that work is a significant amount of evaluation on our progress. That is where we are working to bolster the federal standards at the state and local level. We will be able to evaluate our progress on that front. We also rely on a lot of our public health partners who are doing evaluation, such as the Centers for Disease Control and Prevention, Pew Research Center, and others. Here at the American Heart Association, we are holding ourselves accountable for our 2020 Impact Goal, which is to improve the cardiovascular health of the nation by 20% and reduce mortality from heart disease and stroke by 20% by 2020. And that is for both children and adults.
References 1. Bridging the Gap. Student reactions during the first year of updated school lunch nutrition standards. July 2014. Available at www.rwjf .org/content/dam/farm/reports/issue_briefs/2014/rwjf414549 Last accessed March 9, 2015. 2. Office of Disease Prevention and Health Promotion. Scientific report of the 2015 Dietary Guidelines Advisory Committee. February 2015. Available at www.health.gov/dietaryguidelines/2015-scientificreport Last accessed March 9, 2015. 3. Arena R, Arnett DK, Terry PE, et al. AHA policy statement: The role of worksite health screening. Circulation 2014;130:719–734. Available at http://circ.ahajournals.org/content/130/8/719.full?sid = e3521307-c41e4b73-8c08-cc34b607e700 Last accessed March 9, 2015. 4. Macknin M, Kong T, Weier A, et al. Plant-based, no-added-fat or American Heart Association diets: Impact on cardiovascular risk in obese children with hypercholesterolemia and their parents. J Pediatr 2015 Feb 5. pii: S0022-3476(14)01227-X. doi: 10.1016/ j.jpeds.2014.12.058. [Epub ahead of print] Available at www.jpeds .com/pb/assets/raw/Health%20Advance/journals/ympd/Macknin.pdf Last accessed March 9, 2015.
—Jamie Devereaux, Features Editor
THE EXPERT WEIGHS IN
Heart Disease Prevention in Children: The Road to 2020 An interview with Laurie Whitsel, PhD, Director of Policy Research for the American Heart Association (AHA)
ization of the standards. Do you foresee what the impact will be from the changes that were put forth in the 2015 federal spending bill?
Introduction
T
he American Heart Association is a well-respected nonprofit agency and opinion leader on cardiovascular health strategies in the United States. They provide scientific statements and practice guidelines for healthcare professionals and the public as well as resources and tools for researchers. Here, Laurie Whitsel, PhD, director of policy research for the AHA, discusses why they believe the new school meal standards are working and should receive continued support in 2015; how worksite health care could benefit children; and the association’s 2020 goal, which is to improve the cardiovascular health of the nation by 20 percent by 2020.
Dr. Whitsel: The overarching point I will make is that we are always concerned when Congress begins to meddle with evidence-based standards. We think that implementation is the work of the respective regulatory agency, and there is ample evidence for the standards that are in place. That said, the US Department of Agriculture is talking to food service directors and understanding where there might be some need for adjustment and so forth. If schools are struggling in terms of availability of whole-grain foods, for instance, giving them a little more time to overcome some of those barriers is okay. For sodium, in the language of the spending bill, what was said is that the USDA cannot move further through reduction until they show more evidence for sodium reduction in children. We feel that there is already evidence for that sodium reduction. The Dietary Guidelines Advisory Committee report just reaffirmed the target for 2300 mg of sodium for a majority of the population and reaffirmed the importance of sodium reduction in children and adults.2 The final sodium targets in the school meal program are based on the 2300-mg recommendation; so we feel the science is there and that the USDA will be able to progress over time to that final target.
What is your view on the current status of the school food guidelines in the US? Dr. Whitsel: We have made tremendous progress since the Child Nutrition Reauthorization Act of 2010 across the school food environment. More than 90% of schools nationwide are implementing the standards. Bridging the Gap published a research brief in summer 2014 showing that, overall, kids are happy with the school meal standards.1 Now, we are doing a lot of work to maintain the great progress we’ve made; and I do believe the school environment has been transformed. It is still a work in progress to get the standards fully in place and to provide the resources, equipment, and reimbursement that school food service directors need to optimize implementation. But we have made great strides, and there have been many successes so far that I think that we have to celebrate. The challenge is going to be maintaining those gains through the next reauthorization, this year, in 2015, within the context of significant pushback in Congress.
The committee report you mention is the first to point to a specific sugar intake recommendation, correct? Dr. Whitsel: It was. And that is further to the point that the USDA will make adjustments to the guidelines where needed. Will schools be able to scale back on changes they have already made as far as sodium in foods they are offering? Dr. Whitsel: Well, no they cannot. They are already supposed to be at the tier 1 reduction and that is where they
The political environment is something that many people are wondering about as far as the reauthor111
112
have to stay. The language in the spending bill does not allow schools to backtrack at all. The sodium reduction was gradual over time to get to the final endpoint, and all that the bill says is that the USDA cannot move on to the next tier reduction until they show that there is enough science. How do you view the future in terms of school food? Dr. Whitsel: It is going to be a massive effort in the public health community to maintain the great progress we have made in the school environment. It will require working with all of our partners in education and the hunger community, among others. It is vital that we maintain our progress. An AHA statement, written by yourself and coauthors, on worksite healthcare delivery, discusses the importance of collaboration and partnership with arenas such as schools.3 How could children in particular benefit from an increased focus on worksite healthcare? Dr. Whitsel: The paper that you reference is one we wrote on health screening in the workplace, and there is a lot of discussion about that right now. Employers now have the ability to hold their employees accountable for health metrics under the Affordable Care Act and adjust healthcare premiums according to whether they meet those health metrics, in conjunction with a worksite wellness program. So a lot of employers are conducting health screenings and seeing where their workforce is in terms of health and then hopefully designing comprehensive programs to address the needs of their employees and helping them move toward better cardiovascular health. We support comprehensive worksite wellness programs, and we know that these programs are an important way to reach millions of adults who are in the workforce. We certainly want to be careful that those outcomes-based incentive programs do not decrease access to affordable quality healthcare. We wrote this paper to provide some guidance to employers on how to conduct screenings; to assure that they are in coordination with state and federal law. Also that they are taking into account the privacy issues that a lot of employees are concerned about with health screening, health risk assessment, and all the other issues that we raise in the paper. It is an area that the American Heart Association (AHA) has been working in for quite some time and we are going to continue to be doing a lot of work in the worksite wellness space. It is a way to reach children because a lot of employers are not only holding employees accountable, but also dependents who are on the healthcare plan. So often family members can have access to the resources that employers provide, and that is important. And employers, increasingly, are wanting to connect with their community. I think those community relationships and partnerships are so
INTERVIEW
critical not only to provide resources to their employees within the community, but also for employers to be role models within their community. For example, we wrote about shared use of school facilities to open up access to recreational facilities to the community. An employer might also consider working with a community on shared use opportunities if they have facilities or spaces that could be accessed and used by others; employers could sponsor the opportunity for those spaces to be opened. There are many different ways for employers to interact with the community and be role models for health. The AHA has traditionally been focused mostly on adults, as that is where the heart disease is; has that changed over time, and if so, why? Dr. Whitsel: We actually do have a whole strategic priority around children, and I would say our focus has been across the life span as we think about cardiovascular health. We have to reach kids because it is so hard to reverse risk factors like obesity, high blood pressure, cholesterol, and so on, after the fact. Instead of trying to change poor diets and physical inactivity, it is so much better if we can get to kids early and build a foundation of healthy lifestyle right from the beginning. For example, our Healthy Way to Grow program (www.healthywaytogrow.org) is offering technical assistance for early child care centers. We have been focused on nutrition standards in schools and early child care, physical activity, and physical education in schools, as well as food marketing and advertising to children. We also have a relationship with NFL Play 60, the National Football League’s campaign to encourage kids to be active for 60 minutes a day in order to help reverse the trend of childhood obesity. We are doing some work on congenital heart disease in children with pulse oximetry screening for newborns. And we have our CPR in Schools initiative, too, where we are training more than 1 million kids every year in CPR with our CPR in Schools legislation. So we have a lot that we are doing around kids, and we will continue to do that. It is extremely important to focus on prevention. We subscribe to the idea that most kids are born in cardiovascular health; unfortunately then, some lose it over time. We want to try to make sure that that does not happen. Is the AHA involved in any specific efforts to encourage a whole-family approach to heart disease prevention? Dr. Whitsel: Yes, so the fresh fruit and vegetable program in schools is a program that we advocated really strongly for in the Farm bill. That is a program that offers fruits and vegetables during the school day. What is great about that is kids then go home and ask for those same
CHILDHOOD OBESITY April 2015
fruits and vegetables, or when they are in the grocery store with their parents shopping, they recognize the food they ate and ask for it. There is a nice congruence there. We also have our school and community gardens program that helps families talk about how food is grown, and that is important. Then we have our recipe books for healthy food preparation, which allow families to be in the kitchen together and talk about healthy food and how to prepare healthy food. There are a number of ways we are trying to reach families, and that is so critical. There is an interesting study recently out comparing a fully plant-based diet and the AHA-recommended diet for obese children—with the plant-based diet seeing more improvements in health overall for the cohort studied.4 Will future AHA guidelines see further focus on plant-based diets? Dr. Whitsel: This is an interesting, though preliminary, study. We are always interested in longitudinal research, and it is really important to understand the impact of all the healthy foods in the diet. The AHA will continue to emphasize the importance of fruits, vegetables, whole grains, healthy oils, and seafood as a real focus for a healthy diet. We have our healthy diet components that we use to measure cardiovascular health. One thing that was not mentioned in this study is the importance of limiting added sugars and sugar-sweetened beverages in the diet. I do not think our dietary guidance is going to change markedly, but we will certainly continue to focus on those really important food groups. How does the AHA view physical activity in the larger health picture for children? Dr. Whitsel: We cannot underestimate the importance of regular exercise and avoiding long periods of sedentary behavior for kids and adults. Kids are sitting for a good part of the school day, and we know that does not help their academic performance. In fact, we have some pretty good research now showing the link between increased physical fitness and physical activity, and academic performance. It is to the school’s benefit actually to get kids up and moving throughout the day, with classroom breaks and
113
recess, and physical education as the cornerstone to build a foundation for lifelong physical activity. Does the AHA record progress in relation to children’s health in schools, or do you rely more on other venues to get that information? Dr. Whitsel: We have our Voices for Healthy Kids initiative, which is a partnership we have with the Robert Wood Johnson Foundation to address childhood obesity through state and local policy. It is a significant effort over the next 3 years, and part of that work is a significant amount of evaluation on our progress. That is where we are working to bolster the federal standards at the state and local level. We will be able to evaluate our progress on that front. We also rely on a lot of our public health partners who are doing evaluation, such as the Centers for Disease Control and Prevention, Pew Research Center, and others. Here at the American Heart Association, we are holding ourselves accountable for our 2020 Impact Goal, which is to improve the cardiovascular health of the nation by 20% and reduce mortality from heart disease and stroke by 20% by 2020. And that is for both children and adults.
References 1. Bridging the Gap. Student reactions during the first year of updated school lunch nutrition standards. July 2014. Available at www.rwjf .org/content/dam/farm/reports/issue_briefs/2014/rwjf414549 Last accessed March 9, 2015. 2. Office of Disease Prevention and Health Promotion. Scientific report of the 2015 Dietary Guidelines Advisory Committee. February 2015. Available at www.health.gov/dietaryguidelines/2015-scientificreport Last accessed March 9, 2015. 3. Arena R, Arnett DK, Terry PE, et al. AHA policy statement: The role of worksite health screening. Circulation 2014;130:719–734. Available at http://circ.ahajournals.org/content/130/8/719.full?sid = e3521307-c41e4b73-8c08-cc34b607e700 Last accessed March 9, 2015. 4. Macknin M, Kong T, Weier A, et al. Plant-based, no-added-fat or American Heart Association diets: Impact on cardiovascular risk in obese children with hypercholesterolemia and their parents. J Pediatr 2015 Feb 5. pii: S0022-3476(14)01227-X. doi: 10.1016/ j.jpeds.2014.12.058. [Epub ahead of print] Available at www.jpeds .com/pb/assets/raw/Health%20Advance/journals/ympd/Macknin.pdf Last accessed March 9, 2015.
—Jamie Devereaux, Features Editor
