The third session of the third workshop featured two presentations that examined policy solutions for nutrition security and obesity. Angela Odoms-Young, associate professor and director of the Food and Nutrition Education in Communities Program and New York State’s Expanded Food and Nutrition Education Program at Cornell University, moderated the session.
USDA PRIORITIES FOR IMPROVING NUTRITION SECURITY
Sara Bleich, senior advisor for COVID-19 in the Office of the Secretary at the U.S. Department of Agriculture (USDA), opened her remarks by stating that the COVID-19 pandemic has placed extraordinary stress on American families. According to U.S. Census data, 1 in 11 adults report food insecurity, a condition that strains worker productivity, health care spending, and military readiness (U.S. Census Bureau, 2022). Bleich added that food insecurity has disproportionate impacts on racial and ethnic minority, low-income, and rural and remote-dwelling populations.
Bleich proposed that these circumstances offer a unique opportunity for the country to build back better—to, for example, recover from the pandemic, pursue racial equity, rebuild the economy, address impacts of climate change, provide open markets and fair trade, and reinvigorate a competitive workforce. According to Bleich, USDA is supporting the pursuit of these goals by leveraging federal nutrition assistance programs to promote nutrition security. She explained that nutrition insecurity starts early in life and can result in diet-related chronic diseases that place financial strain on families and health care systems, and also negatively impact national security. To tackle both food and nutrition insecurity, Bleich said, USDA is working to strengthen its programs and remove barriers to participation to ensure consistent accessibility, availability, and affordability of foods and beverages that promote well-being and prevent (and if needed, treat) disease for all eligible individuals and families, with a particular focus on racial/ethnic minority, lower-income, and rural and remote populations.
Bleich highlighted positive outcomes among participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC),
which provides eligible mothers and their children (up to 5 years of age) with specialized nutrition resources and health care referrals. As examples of these outcomes, she cited improved birth weights, lower infant death rates, and fewer premature births (USDA, 2013, 2021a,b). She added that updates to WIC food packages implemented in 2009 were linked to increased consumption of whole grains, fruits, and vegetables and were correlated with a downward trend in obesity in a significant sample of preschool children (Andreyeva et al., 2012; Lu et al., 2016; Schultz et al., 2015; Zenk et al., 2014). Yet while WIC has been shown to be a powerful public health intervention to reduce racial disparities and maternal and child health outcomes, Bleich observed, only 57 percent of eligible women and their children are enrolled (USDA, 2021c).
Bleich reported that increasing WIC enrollment is a goal of a new initiative called WIC 390, supported by a $390 million investment in the program via the American Rescue Plan Act of 2021 (P.L. 117-2). She explained that this historic investment in WIC will be used for outreach, innovation, and modernization to improve program delivery and boost participation and benefit redemption among WIC-eligible women and their children. She added that USDA is also preparing to update WIC food packages to incorporate recommendations from a 2017 National Academies report (NASEM, 2017) and to align the program with the latest edition of the Dietary Guidelines for Americans (P.L. 101-445).
The American Rescue Plan also includes investments in children’s health through the Pandemic Electronic Benefits Transfer (P-EBT) program, which Bleich said provides families with an electronic debit card with which to purchase groceries for the value of the school meals missed as a result of pandemic-related school closures. These benefits are also available to younger children in certain Supplemental Nutrition Assistance Program (SNAP) households. Most states extend the P-EBT program into the summer months to fill the gap in school meal access, Bleich noted. She referenced the findings of a recent study indicating the program has a measurable impact on food insecurity, decreasing food hardship for low-income children by 33 percent in the week following issuance of the benefits (Bauer et al., 2020).
Bleich transitioned to reflecting on improvements in the nutritional quality of school meals since implementation of the Healthy, Hunger-Free Kids Act of 2010 (P.L. 111-296). She cited one analysis showing that during the past decade, school meals became the most nutritious food source for American children (Liu et al., 2021). She also referenced other analyses finding that school meals prepared under the updated nutrition standards contained higher proportions of vegetables, whole grains, and dairy foods and lower proportions of refined grains and empty calories relative to prior school meals (Hager and Turner, 2016; Johnson et al., 2016; Kinderknecht et al., 2020; USDA, 2021d).
Bleich acknowledged that changing children’s eating habits can be challenging, and schools may face obstacles to improving nutrition, but she assured participants that incremental changes can make a difference in the long run. USDA plans to propose changes that would update school meals in accordance with the 2020–2025 Dietary Guidelines for Americans, she reported, and will work with schools to implement the changes on reasonable timelines and maintain taste appeal. She added that the Biden-Harris Administration is considering financial incentives for schools to adopt practices that go beyond the meal standards, such as limiting added sugar, using more local and culturally appropriate foods, and sourcing ingredients from disadvantaged producers. She noted that USDA will evaluate the impact of any incentives on school meal participation, educational outcomes, and overall well-being.
Bleich observed that school nutrition professionals have remained committed to preparing and serving nutritious meals to the nation’s children during the pandemic, and stated that USDA has provided flexibilities, resources, and hands-on support to help them adapt to new models of operation and weather unpredictable changes to the food supply (USDA, 2022). As a recent example, she reported that USDA provided more than a billion dollars of funding assistance in fiscal year 2021 to help schools respond to supply chain disruptions as part of a comprehensive set of investments designed to address challenges in American agriculture (USDA, 2021e,f).
Bleich went on to discuss the reevaluation of the Thrifty Food Plan, which she called one of the most exciting and potentially high-impact efforts to improve nutrition security (USDA, 2021g). Because the Thrifty Food Plan is the foundation of SNAP benefit calculations, its reevaluation brought about the first permanent adjustment to SNAP benefits since that program’s introduction 45 years ago. Prior to the reevaluation, Bleich observed, nearly 9 out of 10 SNAP participants reported struggling to achieve a healthy diet, with the cost of healthy foods cited as the most common roadblock (Bleich and Fleischhacker, 2020). The revised plan budgets more money for recipients to purchase foods aligned with the latest edition of the Dietary Guidelines for Americans and accounts for shifts in the food marketplace. According to Bleich, this is a step in the right direction toward ensuring that Americans of all backgrounds can afford healthy food, although she acknowledged that USDA recognizes the need to do much more to ensure the fair and equitable application of its nutrition assistance programs.
Bleich ended her presentation by stating that the Biden-Harris Administration realizes that breaking the cycle of racial inequity is a journey that begins with listening. Thus, she said, spending more time with program recipients will help USDA understand how they interact with the programs and how it can better meet their needs, particularly for those who have
historically gone unseen and unheard. The ultimate result, Bleich maintained, will be to help narrow disparities and accelerate progress toward equity.
SALUD AMERICA!: FUELING ADVOCACY FOR SYSTEMS AND POLICY CHANGE FOR LATINX HEALTH EQUITY
Amelie Ramirez, director of Salud America! and professor of epidemiology and biostatistics at the University of Texas Health Science Center at San Antonio, shared Salud America!’s efforts to pursue health equity for Latinx.1 She began by noting that almost 18 percent of the U.S. population is Latinx—making this the largest minority population in the country—adding that the health inequities faced by this population relative to non-Hispanic White peers existed prior to the COVID-19 pandemic. Multiple conditions have contributed to these inequities, Ramirez stated, including higher rates of poverty and uninsurance; less access to early education; less stable housing; less safe neighborhood streets and transit options; fewer safe places to play; and disproportionate exposure to pollution, food deserts and swamps, and such adverse childhood experiences as racism and discrimination. According to Ramirez, these conditions reflect residential neighborhood disadvantages and wealth gaps that in turn are related to inequities in city planning and such historical discriminatory practices as redlining.
The first phase of Salud America!’s work spanned 2007–2012, Ramirez recounted, and was focused on creating a research agenda on healthy weight among Latinx children and funding 20 grantees to conduct pilot research on the agenda’s topics. She explained that this work established a research base from which to approach some of the systemic challenges that are being addressed in Phase 2 of the organization’s work. The work in this phase involves building a digital network of advocates and fueling them with culturally tailored and curated content, data, tools, and actions with which to activate systemic community changes that can enable health equity.
Ramirez elaborated on the process used to build the national digital network of Latinx health advocates, which she said includes more than 400,000 community leaders, parents, health care workers, and school personnel across the United States. She described how Salud America! built a multimedia digital communication infrastructure comprising a website, social media platforms, and an email campaign framed around its equity data and solutions. Within this infrastructure, she explained, the organization develops content designed to support network members’ advocacy for grassroots systems and policy changes by enhancing their self-efficacy—two constructs in social cognitive theory that lie at the heart of Salud America!’s efforts.
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1https://salud-america.org (accessed April 11, 2022).
Ramirez next described three steps in the network’s process for digital content curation. First, a team of four curators searches for content by topics. Second, after interviewing people who are working to improve health and equity in communities, the team crafts that information to provide easy-to-consume content featuring resources, policies, and heroes of change. The content is tailored to resonate with Latinx cultural values and residents of the geographic location where it is delivered, Ramirez observed. Third, the content is connected with audiences by being disseminated in readily downloadable and sharable forms, free of charge, via websites (blogs, videos, searchable infographics), email, social media, and in-person meetings. According to Ramirez, these materials are frequently used to build a case for systems and policy changes at the local level, along with Salud Hero case studies featuring real Latinx grassroots-change role models. Ramirez emphasized the importance of the case studies by listing five ways in which they increase self-efficacy among Latinx viewers: (1) they demonstrate mastery as they describe how the role models gained experience by taking on a new challenge and succeeding; (2) they provide role models to emulate; (3) they produce social persuasion by promoting engagement, amplifying feelings of empathy, and motivating viewers to act; (4) they produce psychological responses; and (5) they help viewers visualize future success and believe that it is achievable.
Ramirez next described Salud America!’s digital action packs, which are topic-specific toolkits of template materials, sample emails, and FAQs to help advocates make on-the-ground healthy systems and policy changes. She noted that technical assistance and coaching via phone or online are available for each action pack from the Salud America! curators who are experts in their topics.
Ramirez shared a few examples of how the action packs can support change in Latinx communities. In one case, a fifth grader and her teacher in San Antonio created an action pack modeled after their success in adding a water bottle fountain at their school, which improved children’s access to clean water during the school day and provided an alternative to sugary drinks. Another action pack described by Ramirez helped establish food pantries in schools attended by students who experience food insecurity. This pack included a guide to help school personnel work through the logistics of starting a school food pantry, such as accepting contributions from local stores and discretely redistributing them to students in need. In a third example, Ramirez recounted the development of a “trauma-sensitive school” action pack to help school personnel talk to their leadership about trauma, build support strategies for students who experience trauma, and create a system for identifying and supporting traumatized students. She referenced a similar program called Handle with Care, which helps schools coordinate with local police departments and receive alerts when police
encounter children at crime scenes. Schools can then provide immediate support to their students who have experienced trauma, she explained, as well as understand why a child might be exhibiting certain behaviors.
Ramirez next highlighted Salud America!’s Health Equity Report Card, which generates local data on housing, transit, health care, food access, and other topics. Network members use these data to advocate for healthy changes in their communities, she explained, and nonprofits have also used the report card to apply for community improvement grants.
In addition to content resources, Ramirez continued, Salud America! developed a crosstalk network called “SaludTues Tweetchats,” a live, interactive discussion on the Twitter social media platform. These chats, held once a month for 1 hour each, focus on various health-related topics. Salud America! partners with large organizations that are experts in the chat’s topics, Ramirez said, which helps expose more than 6 million Twitter accounts to the messages during that hour. She noted that a network analysis of the chat network found it to be a connecting node for large organizations, health groups, individual advocates, and key influencers (Ramirez et al., 2021). According to Ramirez, an internal evaluation of the organization’s digital communications structure and network activity found a strong relationship between the degree of engagement with the content offered and likelihood of taking advocacy action at the school, local, state, and federal levels. She added that another external evaluation of Salud America! found that its digital communications network had resulted in 275 policy wins in the areas of Latinx child health and general public health (Calloway et al., 2018).
In the final portion of her presentation, Ramirez discussed Salud’s recent application of its model to systemic racism and discrimination as root causes of obesity. She explained that racial and ethnic discrimination, such as differential treatment or underestimation of abilities by school personnel, impacts educational attainment and in turn future educational, health, social, and career opportunities for people of color. Lower educational attainment among Black and Latinx students is linked to increased risk of institutionalization, she added, along with poor physical and mental health and reduced lifetime earnings and economic potential (Mroczkowski and Sánchez, 2015).
Salud’s goal is a more cohesive culture for health equity, which Ramirez described as one in which everyone works individually and as a group to ensure that each person has a fair opportunity for health and wealth, as well as equitable access to basic resources required to achieve those goals. To that end, Salud has created new materials designed to increase social cohesion, which Ramirez said represents a society’s capacity to ensure the long-term physical and psychological well-being of its members. A cohesive society is an inclusive one that values individuals’ backgrounds,
she maintained, and is devoid of significant disparities in health, wealth, and income. In Ramirez’s view, intergroup contact, peer modeling, targeted social media messages, and awareness-provoking interventions can improve social cohesion and compassion toward minority and impoverished groups. She explained that Salud’s action pack to help counteract stereotypes—the “Find Out If You Have Implicit Bias” pack—helps users identify their implicit biases—defined as stereotypes that operate beyond one’s conscious control and affect understanding of and decisions about others—and take steps to overcome them. She also described another action pack designed to help communities adopt resolutions that declare racism to be a public health crisis and commit to specific actions for addressing it. In closing, Ramirez stated that Salud’s materials are intended primarily to stimulate conversation and provide ideas for using information to drive change.
PANEL AND AUDIENCE DISCUSSION
A panel discussion with Bleich and Ramirez followed their presentations. The two speakers answered questions about USDA efforts to improve nutrition security, opportunities for food retailers to advance nutrition security, and Salud America!’s lessons learned and future vision.
USDA Efforts to Improve Nutrition Security
Bleich recapped two components of USDA’s multipronged strategy for addressing nutrition security: (1) reevaluation of the Thrifty Food Plan, which addresses cost and practical barriers to SNAP participants choosing a nutritious diet; and (2) increasing WIC benefits for the purchase of fruits and vegetables by more than threefold, a temporary increase to boost recipients’ purchasing power for those foods. She added that USDA and external researchers will evaluate the impact of these and other program and policy changes.
Bleich also reiterated that the federal government is working on proposed updates to regulations governing WIC food packages to incorporate recommendations from the above-referenced 2017 National Academies report (NASEM, 2017) and align the packages with the 2020–2025 Dietary Guidelines for Americans. The updates also include administrative revisions or clarifications for food package requirements. Bleich estimated that the proposed updates would be published in spring 2022, with public comments invited via regulations.gov.
Lastly, Bleich noted that USDA’s efforts to prioritize food and nutrition security are being undertaken in parallel with efforts to promote racial equity. She urged stakeholders to capitalize on this federal momentum to make a difference in people’s lives.
Opportunities for Food Retailers to Advance Nutrition Security
Federal nutrition assistance programs work through several important partners, Bleich pointed out, and she stressed that food retailers can play a significant role in promoting nutrition security. For example, she said, they can work to strengthen supply chains so consumers do not encounter empty shelves when they walk into a store. Small corner stores could also play a role, Ramirez suggested, if given assistance in upgrading the healthfulness of the foods they make available to their community.
Salud America! Lessons Learned and Future Vision
Ramirez stated that Salud America! has found social media to be an effective communication channel, as well as an example of how easily both accurate information and misinformation or disinformation can be rapidly distributed. She noted that the organization must be careful about the individuals and organizations with which it partners and how their messages are disseminated, and also wishes to help youth distinguish truthful information. The network became the go-to source for Latinx information at the height of the COVID-19 pandemic, Ramirez added, because of its reputation for sharing quality information.
Ramirez confirmed that Salud America! is open to collaborating with other stakeholders interested in advancing health equity to help maintain its network’s momentum. The organization is intent on increasing collective efficacy, she reiterated, so as to empower individuals to come together in pursuit of more equitable communities. Ramirez stressed that Latinx want better access to basic resources, which has been impeded by inequitable laws and other structural barriers. She closed by suggesting that Salud will need an advisory committee to help guide its vision for expanding its reach.
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