School Lunches - an opportunity to improve health

What is the National School Lunch Program?

The National School Lunch Program (NSLP) feeds millions of children in schools every day. In 2012, 19.6 million children received free and reduced-price lunch, a qualification that is based on family income.

Source: http://www.fns.usda.gov/hussc/healthierus-school-challenge-tips-award-winners-get-started

Children with families at or below 130% of the Federal Poverty Level (FPL) qualify for free lunches (an annual income of $30,615 for a family of four).

Schools that chose to participate in the NSLP receive cash subsidies from the U.S. Department of Agriculture (USDA). For the 2013-2014 school year the reimbursement rates are:

• $2.93 for Free Lunches (each child’s lunch who is under 130% of FPL)
• $2.53 for Reduced Price Lunches (each child’s lunch who is under 185% of FPL)
• $.28 for Paid Lunches (each child’s lunch who is over 185% of FPL)

The National School Lunch Program Nutrition Standards

In January 2012, the Federal government issued updated NSLP nutrition standards. In part, the updated nutrition standards were in response to the rapid increase of obesity in children, particularly low-income children. Among low-income children, obesity rates increased 23% between 2003-2007, compared to a 10% increase among all U.S. children. Rates of severe obesity are roughly 1.5 times higher among poor children. For many of the children who receive free lunches, it is the only guaranteed meal they receive that day.Schools provide a great opportunity to impact childhood obesity. Not only are children required to attend school by law, but they also consume at least one meal five days a week at school.   The updated nutrition standards:

• Increase fruit and vegetables served
• Emphasize whole grains
• Allow only lower fat and nonfat milk
• Limit calories
• Reduce saturated fat and sodium

Source: http://healthymeals.nal.usda.gov/state-resources/build-healthy-lunch-reimbursable-meal-identification-system

Providing healthier items at lunch will at least provide many children one healthier meal everyday and that is a step in the right direction. However, I think the message and food environment in schools is more important than the actual nutrition quality. Kids learn by example and schools are a learning an environment. What are we telling our kids when they learn about the benefits of fruits and vegetables but in the lunchroom there is only pizza?

The Barriers to Providing Healthy School Lunches

As soon as the updated NSLP nutrition standards were released, many school districts nationwide expressed concerns. In September 2013, The Robert Wood Johnson Foundation and The Pew Charitable Trusts conducted an extensive survey of schools and the barriers faced while implementing the new nutrition guidelines. The barriers include:

1. Higher costs. It is too early in the new USDA school lunch guidelines to have data related to cost of school meals. Researchers disagree on the cost of fresh food compared to easy to re-heated, processed food. New research shows that a diet rich in fruits, vegetables, nuts, and fish costs about $1.50 more per person per day. If that increase in cost is applied to schools, it is substantial. However, there are innovative school lunch programs (listed below) that have proven it is possible to serve healthy meals on a budget. Another cost to consider is the increase in staff needed to cut, chop, and cook foods. If a school staff previously only reheated pizza, it is a large annual cost to hire more people in the kitchen. Schools are already cash-deprived.

2. Need to remodel or upgrade school kitchens. Many schools do not have full kitchens, but instead operate out of a district-wide central kitchen and deliver the foods to schools. This makes the preparation and storage of fresh foods difficult. For example nearly half of New York City schools lack cooking and fire-suppression equipment to cook on a stove and Seattle prepares all foods at district headquarters before being shipped out to schools. The USDA has strict rules for food storage for good reason, and, currently, many school districts do not have suitable kitchens.

Neat things schools are doing

Like I stated above, some innovative school have pushed past the barriers and are serving healthy lunches. Here are three examples.

1. Minneapolis Public Schools. In full disclosure, I am a product of the Minneapolis Public Schools (MPS) district, which is probably why I’ve been following their school lunch improvements. Many Minneapolis schools don’t have full kitchens so most of the food prep happens at a central nutrition center.  However, in 2012 the district hired Bertrand Weber who declared he was bringing real foods back to the schools. Since then Weber has banned irradiated meats, converted all high schools to cooking from scratch, set-up salad bars with seasonal ingredients, and focused on staff development. The menu for December looks great and certainly different from the meals I remember. Check it out here. Spoiler: the menu includes free-range turkey, arroz con pollo with brown rice, and thai red curry.
2. Baltimore School District. The Baltimore schools system was the first to implement meatless mondays back in 2009. Since then 18 school districts have followed Baltimore in instituting meatless mondays. The district also partners with local farmers and has a Great Kids Farm to teach kids about locally produced foods.
3. Farm to School Programs nationwide. According to the National Farm to School Network, there are 38,629 United States schools that have a farm to school program. Some schools have more extensive farm to school programs than others - from a day dedicated to farmers to school gardens. Earlier this year, Oregon awarded $1.2 million for Farm to School and School Garden Programs. A majority of the money will go to purchase locally grown foods to feed students with the remaining funds for education and gardens. Massachusetts is another example of a state with a vibrant Farm to School program. In the 2011-2012 school year, 231 schools and 114 farmers participated in the program.

The list above is short and there are endless examples of awesome things schools do everyday to provide healthy free lunches for students. Some people are convinced that kids aren’t going to eat healthier foods. Most kids like fruits and vegetables if they are prepared well and are the norm in their environment. School lunches are a huge opportunity to introduce new foods to children and unlike previous generations, the new foods should be healthy. Looking at the rates of obesity in this country, we have to provide healthier lunches, we have to teach kids what a normal lunch should be, and we have to provide the financial support to all school districts to do so.

World AIDS Day

Yesterday was world AIDS day so today’s post is in honor of all those who we have lost to HIV/AIDS and who are living with this disease.  If you are interested in finding out more about the virus itself, prevention, diagnosis, or living with HIV/AIDS, check out AIDS.gov which is run by the Department of Health and Human Services.

HIV/AIDS Worldwide

There are an estimated 35 million people living with HIV/AIDS worldwide, and though all continents and countries have suffered from this epidemic, low and middle income countries have been hit the hardest.  There is also a lack of access to prevention and treatment for the majority of those living with or at risk for HIV.   (Global Statistics - AIDS.gov)

HIV/AIDS in the United States

The CDC estimated that 1,148,200 people in the United States were living with HIV/AIDS in 2012 with about 18% of those people unaware of their infections.  Unsurprisingly, people of color are disproportionately affected by this disease.  Though 12% of the US population is black, 44% of people with HIV/AIDS are black and 44% of those newly diagnosed in 2012 were black.  Hispanics account for 16% of the US population but 19% of those living with HIV/AIDS and 21% of newly diagnosed cases.  

The Good News

We have made great strides when it comes to treating HIV/AIDS and in the last few years have even started hearing about people who may have been cured.  In Mississippi there is a child born with HIV who was given high doses of antiretrovirals almost immediately after delivery.  Two and a half years later, that child is functionally cured (this just means that the presence of the virus is so small that tests can’t detect it and treatment isn’t needed).  Since 2007, there has also been 3 adults who have been functionally cured of HIV/AIDS.  Timothy Ray Brown (The Berlin Patient) received a stem cell transplant in 2007 from a donor with a rare genetic mutation that is resistant to HIV infection and is still virus free to this day.  More recently, two men received bone marrow transplants that resulted in all traces of the virus disappearing within 6 to 9 months.  For most people living with HIV/AIDS, stem cell and bone marrow transplants aren’t worth the risk; however, these cases are advancing our understanding of the virus and hopefully leading us to a cure. (Patients HIV-free for now after transplant)

The Bad News

Austerity measures in other countries and sequestration in the US could stop our forward progress.  The US has long been the leader in biomedical research, but with sequestration, much of the funding for the National Institute for Health has been cut.  In fact, the NIH will lose $229 million in 2014 because of sequestration.  The means that 15,000 Americans will lose financing that helps them pay for antiretrovirals and 4,000 will lose housing support.  Again, these cuts will disproportionately affect people of color. (Sequestration 2014: Undermining the Response to HIV/AIDS in the US)

There is also the issue of the cost of antiretroviral drugs worldwide.  Pharmaceutical companies have done as much as they can to stop the creation of less expensive generic drugs in less wealthy countries (where the majority of HIV/AIDS sufferers live) which would allow many of those with HIV/AIDS to not only live with the disease, but also be less contagious.  The US government has unfortunately sided with the drug companies over the millions of people suffering from HIV/AIDS by threatening countries that do not honor patents with trade sanctions.  You may be thinking, “but the drug companies need to make a profit or they won’t do research and no one will be cured” and you would be right.  Companies do need to make a profit or they won’t continue creating drugs; however, last year, the top 11 global drug companies made $85 billion in profits - they can afford to make less.

Conclusion

In the words of Jonas Salk - founder of the first successful Polio vaccine - “there is no patent, could you patent the sun”.  For those who are living with HIV/AIDS, treatment is the sun.  

We are Thankful for Health Policies - Day 3

Day three of our Thanksgiving countdown is here.  We know many of you are already starting to cook in preparation for tomorrow’s big feast, but take a minute and check out some awesome health policies to be thankful for.

Emily is Thankful for...

Paid Sick Time Policies.

The United States lacks a national standard for sick time. Not only do millions lack paid sick days, million of people also lack a guarantee that they can’t be fired for being sick. One state, Connecticut (Public Act 11-52), has legislation requiring paid sick time. Seattle, Portland, San Francisco, Milwaukee, and Washington D.C. have passed city laws regarding paid sick time. Many more states and cities are actively working on paid sick day campaigns. To find out the details in legislature in states and cities, check this report.

According to the Economic Policy Institute, roughly 40% of private sector Americans do not have paid sick days or even policies that allow them to call in sick without fear of termination. Women, minorities, and low-income people are all less likely to have paid sick days.

Here are some benefits to paid sick time:

• Sick people do not prepare your food. Eighty-two percent of  workers who make less than $8.25 an hour do not have sick time. Yup, those are people that work at restaurants.
• People stay home when sick. People without sick time are 1.5 times more likely to go to work with a contagious infection. The American Public Health Association found that giving all employees paid sick days, the spread of the flu is reduced by 6%.
• The national economy is better. If employees were offered seven sick days a year, the national economy would save $160 billion a year from reduced turnover and increased productivity.
• Kids can stay home sick. Just like going to work sick, sending kids to school sick spread viruses. When a child can see a doctor in a timely fashion and rest, ER visits and chances of recurring illness goes down.
• Decreased healthcare costs. A study found that if all workers had paid sick days, 1.3 million ER visits could be prevented. ER visits are a huge cost and costs taxpayers billions. People without sick time either wait too long to go to the doctor (the illness becomes an emergency) or they are unable to go to the doctor during the clinic’s hours.

Paid sick days, including time off for ill family members, is essential. No one should be fired for a cold or because they had to bring a sick child to the doctor. Since low-income people, women and minority workers are less likely to have paid sick time, lack of policy around this issue  increases the health disparities already apparent in these groups.

Heather Is Thankful For…

The HIV Organ Policy Equity (HOPE) Act.  

The HOPE Act was introduced in February of this year as a bipartisan bill.  Both the House and Senate passed it unanimously and President Obama signed it into law this month.  The act allows the Department of Health and Human Services to research whether HIV positive to positive organ donation is feasible.  If the research shows that positive to positive donation is possible, the Act could save hundreds of lives.  It would help the hundreds of HIV positive patients waiting for organs get them faster, and it would shorten the list for non-HIV positive patients.  As a bonus, this Act also shows that there is still such a thing as bipartisanship in congress.  We haven’t seen both parties work together to pass a law in a while now, so this gives me hope.

We are Thankful for Health Policies - Day 2

In the spirit of Thanksgiving, we are continuing our list of health policies we are thankful for.  Today’s theme seems to be centered around being able to breathe.  Feel free to tell us about the health policies you are thankful for in the comments.

Emily is Thankful For...

Smoke free laws. A smoke free policy prohibits smoking in a specific space. States, local governments, counties, and workplaces can pass smoke free policies. Thirty-six states have smoke-free laws that prohibit smoking in restaurants, bars and/or workplaces - impacting 81.5 of the U.S. population.

According to the U.S. Surgeon General, secondhand smoke causes lung cancer and heart disease in non-smoking adults. In children, secondhand smoke increases the risk of infant death syndrome, low birth weight, respiratory and ear infections, and asthma attacks. There is no safe level of exposure to secondhand smoke and in the U.S. secondhand smoke kills about 50,000 people each year. Besides all the dangers of secondhand smoke, I am thankful that in the states I frequent (Illinois and Minnesota) I no longer need a special ‘bar’ coat and that I won’t come home from eating out smelling of smoke.

Heather is Thankful For…

The Clean Air Act.  This act went into effect on December 17th, 1963 and was amended significantly in 1970, 1977 and 1990 to add more regulatory controls.  The Act is a federal law that aims to control air pollution that is widely recognized as being harmful for public health.  When congress last amended the Act, they added a requirement that the costs and benefits of the act be studied.  The result is that we now know that not only has the act been successful in reducing some of the most common air pollutants (particulate, ozone, lead, carbon monoxide, nitrogen dioxide, and sulfur dioxide, as well as other pollutants), but it has also done so without harming the economy.  In fact, it may have helped it.  The EPA estimates that the Clean Air Act cost $0.5 trillion which is a lot of money; however, the benefits of the Act were estimated to be between $5.6 trillion on the low end and $49.4 trillion on the high end.  Even if the more conservative estimate is the right one, that is a $5.1 trillion net benefit.  

Even more importantly, by 2020, the 1990 amendment of the Act alone will have saved 4.2 million lives, 43.8 million asthma exacerbation events, 3.3 million heart attacks, 2.1 million hospital admissions, 2.2 million ER visits and 3.3 million lost work days.  There is also research to suggest that the Act has reduced chronic and acute bronchitis and has increased life expectancy at the time of birth by 7 months.

Policies We Are Thankful For - Day 1

Health policies improve lives every single day. These policies are varied and wide reaching - from national policies that set standards so that you have safe drinking water to school district policies that require that children receive health education.  In the spirit of the holiday, we have decided to countdown to Thanksgiving by sharing two of the health policies that we are most thankful for each day.

Emily is Thankful for...

Section 4207 of the Affordable Care Act which amended the Fair Labor Standards Act. This amendment requires that breast feeding mothers get break time and a private place to breast feed during the day. All employers in the United States must follow this law. Breastfeeding has many benefits for babies.  It lowers the risk of ear infections, stomach viruses, respiratory infections, asthma, obesity, and diabetes. For the mother, breastfeeding lowers the risk of diabetes, some cancers, and depression. For many women who are low income and struggling financially, breastfeeding is a free way to provide nourishment for their babies. 

Heather is Thankful for...

States that Legalized Same-Sex Marriage.  Currently, fourteen states (CA, CT, DE, IA, ME, MD, MA, MN, NH, NJ, NY, RI, VT and WA), the district of Columbia, eight counties in New Mexico,and eight Native American tribal jurisdictions have legalized gay marriage covering 38% of the US population.  Hawaii and Illinois also recently passed gay marriage which will officially begin on December 2, 2013 and June 1, 2014 respectively.  Although a greater number of states have banned same-sex marriage, I am also thankful for the fact that, according to a recent Gallup poll, more than 52% of the population supports gay marriage.  More importantly, more than 60% of the 18 to 34 group supports it which mean it is only a matter of time before the rest of the country legalizes it.

I am thankful for these state laws not only because I support equality in general, but also because some of the people I love the most are part of the LGBTQ community.  Even if you don’t share that with me, here’s why you should be thankful too.

     1.) States that allow gay marriage have lower divorce rates than states that don’t.  In fact, their divorce rates are a whopping 20% lower.  My home state of Massachusetts, the first state to legalize gay marriage has the lowest divorce rate.

     2.) Gay Marriage could boost the economy.  The Williams Institute estimates that Washington State will get a $88 million economic boost from wedding spending in the first three years after it legalized gay marriage.  There is also the economic benefit of allowing same-sex couples to get spousal health insurance benefits - same sex couples are much less likely to have health insurance than different sex couples. (The Economic Benefits of Same Sex Marriage)

   3.) Bans on Gay Marriage may increase STD’s by increasing homophobia and risky homosexual behaviors.  Feeling like you are a social outcast can take its toll on a person, so it isn’t surprising that same sex marriage bans increase the rate of syphilis (which is more common in men who have sex with men) and HIV.

E-Cigarettes: A Call for Policy Interventions

What are e-cigarettes?

E-cigarettes are battery powered devices that deliver nicotine in the form of a vapor. In appearance, e-cigarettes look like cigarettes. Below is a general depiction of an e-cigarette. 

In the United States, e-cigarettes can be legally sold to anyone and the FDA has not yet regulated e-cigarettes. However, some states and local governments do regulate e-cigarettes.  Since 2009, 25 states and the District of Columbia have passed measures to regulate the sale of e-cigarettes, including banning minors from purchasing them. In recent years, e-cigarettes have increased in popularity, both with users of traditional cigarettes and non-smokers. One reason for this may be that celebrities have been photoed smoking e-cigarettes. The below picture is from e-cigarette company Blue Smoke

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Wall Street predicts sales of e-cigarettes could reach $1 billion in 2013, doubling since 2012. According to the CDC, about one in five U.S. adult smokers and about 6 percent of the total adult population have tried an e-cigarette. So, are e-cigarettes a healthy way to quit smoking traditional cigarettes or are e-cigarettes just dangerous?

Are e-cigarettes less damaging than regular cigarettes?

Very little is known about the long term health effects of e-cigarettes. When e-cigarettes are used as a tool to quit smoking, there may be health benefits. The FDA, however, does not endorse the switch to e-cigarettes as a way to quit smoking. Many researchers believe that it is not nicotine that causes lung cancer, but the other chemicals in traditional cigarettes. The e-cigarette still provides the highly-addictive nicotine, but without the chemicals which seems like a good thing for those who currently smoke traditional cigarettes.  

The economic costs of smoking cigarettes are huge. Between 2000-2004, the CDC estimated that cigarette smoking was responsible for about $96 billion in medical expenses and $97 billion in loss of productivity. Cigarette smoking also is responsible for a lost of 5.1 million of potential years of life lost annually. The switch to e-cigarettes could therefore have economic benefits.

Without the toxic fumes of regular cigarettes, e-cigarettes do not create second-hand smoke to the degree regular cigarettes do. Secondhand smoke causes lung cancer and heart disease in nonsmoking individuals and can contribute to sudden infant death syndrome, respiratory infections, and asthma attacks.  Not harming innocent bystanders is a good thing.

Although all of that sounds promising,  it is important to note that in general, research does not indicate that e-cigarettes are more helpful than other, FDA-endorsed methods to quit smoking. According to the CDC, “There is currently no conclusive scientific evidence that e-cigarettes promote long-term cessation.”

Are e-cigarettes safe, even for non-smokers?

E-cigarettes still provide the body with a dose of nicotine, which is an addictive drug. Children can (and do) legally purchase e-cigarettes. Little is known about the health effects of nicotine on children, especially in the long term. Teens and children are trying e-cigarettes.  In 2012, the percent of high school students that reported ever using e-cigarettes increased to 10 percent, a 4.7 percent increase from 2011.  In total, 1.78 million U.S. middle and high school students had tried e-cigarettes in 2012. In the same study, 1 out of 5 middle schoolers that said they used e-cigarettes, said they do not use traditional cigarettes. Since e-cigarettes do contain nicotine, they are introducing a highly addictive drug to the child.

Conclusion

E-cigarettes can be helpful or e-cigarettes can be harmful, depending on the situation. What is clear is that policy is needed to regulate the purchase and consumption of e-cigarettes.

E-cigarettes - Policy solutions

1. Restrict sales of e-cigarettes from minors. In order to enforce the sale ban of e-cigarettes to minors, e-cigarettes would be kept behind the counter at retail stores and ID would be required for purchase. Similarly, there would have to be a fine for sale of e-cigarettes to a minor.  Several states have already passed laws restricting sales of e-cigarettes to those over 18. Since we don’t know the long-term effects of e-cigarettes, especially on developing lungs, a mandatory age to purchase e-cigarettes is necessary.

2. Ban e-cigarettes in certain areas. Many jurisdictions are ‘smoke free’ meaning they do not allow traditional smoking within a certain geographic area. An option would be to include e-cigarettes in that ban. The concern is that e-cigarettes look similar enough to regular cigarettes that people would become confused and think that smoking is allowed. A ban in certain areas would still allow those to use e-cigarettes as an alternative to regular cigarettes, just not in many public spaces.

Source

3. Taxation of e-cigarettes. Traditional cigarettes are highly taxed. The point of taxation is that it will deter people from purchasing. Some states have redefined their tax codes so that e-cigarettes are taxed like regular tobacco products. At this time, the FDA has not determined that e-cigarettes are a way to quit smoking and therefore not considered a therapy. However, it might not be wise to tax something that is used as a less deadly alternative to normal cigarettes.

4. Regulate advertising. E-cigarettes are not under the same FDA regulations as normal cigarettes. Therefore e-cigarettes are able to use the tactics they know boosts sales - celebrity sponsorship, adding flavors, and advertising to kids. Since e-cigarettes look the same as normal cigarettes, especially to children, it can be extremely damaging.

Here is the mascot of eJuiceMonkeys. It appears to be a cartoon monkey smoking a cigarette.

The future of e-cigarettes

A spokesperson for the FDA said that there is a proposed rule for e-cigarette regulation that was sent to the Office of Management and Budget and the Office of Information and Regulatory Affairs for review. The proposed rule is not yet open for public review. It seems appropriate to only allow those over age 18 to purchase e-cigarettes. There also has to be a serious effort to decrease any attempts to market to children. While waiting for the FDA, school districts need to address e-cigarettes both within school walls and the education curriculum. Most importantly, research needs to continue to uncover the health effects of e-cigarettes in the short-term and long-term.