Altarum Institute Policy Roundtable

Cosponsored by the National WIC Association

Can WIC Play a Role in Stemming the Childhood Obesity ?

March 23, 2010 U.S. House of Representatives Rayburn House Office Building, Room B‐340 , DC

Table of Contents

I. Background II. Introductory Remarks III. Summary of Roundtable Presentations IV. Question and Answer Session V. Appendices

Appendix A: Altarum Institute

Appendix B: National WIC Association

Appendix C: Roundtable Attendee List

Appendix D: Speaker Biographies

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

I. Background

Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

Childhood obesity is a crisis with little equal in the United States, yet one existing program may already be in a position to have an impact on the epidemic. At least half of all children in this country are touched by the Women, Infants, and Children (WIC) program at some point in their lives, and abundant evidence suggests that obesity disproportionately affects children targeted by this program. With a long history of successfully addressing early childhood nutritional needs, the WIC program is in a unique position to reach an already at‐risk population at a very young age and could be a vital tool in addressing childhood obesity. This Altarum Institute Policy Roundtable will consider the role of WIC in childhood obesity prevention, how the program is already addressing the childhood obesity epidemic, and what policy options are available to ensure WIC can be successful in addressing childhood obesity now and in the years to come.

Speakers and topics:

Maxine Hayes, State Health Officer, Washington State Department of Health Topic: The role of WIC as a leading public health nutrition program and its importance in reaching families with young children, and how WIC can serve as both a primary prevention program and a resource for entry into the public health and health care system

Patti Hauser, State WIC Program Director, Division of Public Health and Chair of the board of directors for the National WIC Association Topic: How WIC efforts fit into a statewide childhood obesity prevention strategy, and how WIC can coordinate with and complement State efforts to reach high‐risk children.

Susan Foerster, Chief, Network for a Healthy , California Department of Public Health Topic: How WIC can work well with other State‐level efforts to address childhood obesity issues as well as what might be done to address barriers that prevent strong program coordination.

Roundtable Moderator: Loren Bell, Area of Expertise Lead for Food Assistance and Nutrition, Altarum Institute Topic: Building on the success of WIC, how new approaches to nutrition education complement the new WIC food package and provide an overall strategy towards healthy eating and behavior change.

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

II. Introductory Remarks

Introduction: Jeff Moore and Congressman Ron Kind (D‐Wisconsin)

Jeff Moore, senior vice president and chief development officer for Altarum Institute, welcomed participants; thanked cosponsors, the NWA, and the Reverend Doug Greenaway; and introduced U.S. Representative Ron Kind from Wisconsin. Congressman Kind noted that the Roundtable was being held on a historic day: the day that the President signed sweeping legislation. He noted that for more than 100 years, America has had a health care system that does not work well and is not sustainable. The passage of health care reform pointed to the broader American tradition of contemplating and solving seemingly impossible problems. He said that health care reform must lead to a system that “works for all Americans,” a quality system that is affordable, secure, and no longer “an economic drag and an anchor on economic growth and job creation.” He added that passage of the legislation is, in fact, just a “start of the conversation and the work that we need to do to truly develop a health care system, rather than the sick care system we have.” This system must include better pre‐ and postnatal care; to that end, the work of WIC and its partnership‐building activities is an essential element. Through WIC, he suggested, we can “establish with young parents and young mothers as far as nutritional value in their children’s lives.”

Congressman Kind spoke to other legislative initiatives that will affect children’s health and nutrition, including the current farm bill and the “Fit Kids” legislation; both include a focus on creating environments in which “the healthy choice is the easy choice in our lives—that every time a child turns around, they’re receiving positive reinforcement about how to eat a healthy life and making good lifestyle choices and making sure that good, healthy food is an affordable, easy option in every one of our lives.” The work, he concluded, starts now.

Loren Bell, Altarum Institute

Institute fellow Loren Bell moderated the roundtable program. He is Altarum’s lead person for food assistance and nutrition programs. He described his own work as a “WIC‐ie”, which includes having served as a former State WIC Director.

Mr. Bell explained that the roundtable forum serves three purposes. First, it is designed to stimulate thinking on the broader topics of health care and food assistance policy among others, but also to stimulate discussion and talk about how these programs affect the lives of mothers, children, and families and how policy decisions affect those programs. Second, it is an opportunity to learn more from experts around the country and from participants. Finally, it provides an opportunity to meet and interact with colleagues and to hear more about their work and perspectives.

Mr. Bell provided an overview of the WIC program by addressing three questions: “What services does WIC provide? Who provides those services? How many people does WIC serve?”

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

Traditionally, WIC has provided supplemental foods, nutrition education, and referral to health and social service programs. In addition to these direct services to clients, it provides income and employment for thousands of retailers and retail grocers around the country. In addition, it provides an opportunity to influence the quality and availability of healthy foods in communities, because the WIC food package is one of the primary motivators and focus of food purchasing in this country.

WIC staff operate more than 12,000 local agencies nationwide. Programs can be found in centers, public health centers, hospital outpatient centers, community action agencies, Tribal health programs, community action agencies, and other nonprofit health and social service programs. In addition, Mr. Bell said, services are provided by grocery store clerks who answer WIC client questions and by partners with whom WIC works to coordinate and refer services. WIC serves more than 9 million pregnant women and children ages 0–5 annually. Recent changes in WIC food packages, as well as in its approach to providing services, present new opportunities. As Mr. Bell explained, the addition of fruits and vegetables, whole grains, and other healthy foods to the WIC food package brings WIC more in line with the messages and offerings of multiple programs around the country that have been promoting increased consumption of these foods. It also puts WIC in line with the messages that WIC has been implementing through nutrition education about increasing access to healthy food.

Another major change at WIC is the Food and Nutrition Service (FNS) Initiative for Value‐ Enhanced Nutrition Education. The Value‐Enhanced Nutrition Assessment (VENA) project targets helping WIC families to make behavior changes. Rather than telling a client to eat more fruits and vegetables, the VENA program focuses on motivating WIC clients to make changes by supporting healthy eating behaviors that make people “want to go out and eat fruits and vegetables.”

Finally, through its participation in the Campaign to End Childhood Hunger, WIC has taken on a prominent role as a provider of food assistance and nutrition, enhancing its influence in addressing the health issues of mothers and children. Mr. Bell also described the challenges WIC faces, including the significant challenge of fitting the WIC program into overall State strategies for preventing childhood obesity. States also face the challenge of working with a categorical program focused on a particular population in a particular period. He noted that the day’s speakers would discuss innovative State programs that promote integration of WIC with childhood obesity prevention.

III. Summary of Roundtable Presentations

Dr. Maxine Hayes, Washington Department of Health

Dr. Maxine Hayes introduced herself by noting that her presentation would be informed by two “biases”: one as a public and the other as a pediatrician. “I am very much influenced,” she said, “by some of those things that have shaped my experience over the

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

course of a long career.” Responding to the overarching question posed by the roundtable, “Can WIC play a role in stemming childhood obesity?”, she offered a resounding “Yes,” particularly because “WIC is primary prevention at its best.”

Dr. Hayes described some of the research findings surrounding WIC’s effects, noting that it prevents obesity and reduces premature births and low birth weight. Low birth weight is a risk factor for being overweight. WIC lowers and improves cognitive function. As a pediatrician, Dr. Hayes said, “I firmly believe… you have to get it right in the beginning. And getting it right in the beginning is getting it right.” Maternal nutrition has profound effects on the fetus, the newborn, and child development. “Research,” Dr. Hayes said, “has grounded us in understanding that there are developmental origins of health and disease. We now know that cardiovascular disease that we’re fighting downstream in the adults had the beginnings at the beginning.” These chronic conditions, she added, are part of the health care crisis the country now faces.

As a primary prevention program, WIC reaches the populations at greatest risk, thereby reaching a large proportion of the total population. More than half of the 4 million infants born each year in the United States are eligible for the WIC program; in fact, WIC serves almost half of all infants born each year. WIC serves a quarter of the Nation’s children between the ages of 1 and 4. These children, Dr. Hayes explained, are vulnerable because of either socioeconomic status or racial or ethnic makeup. Among WIC participants, 68.3% are at or below the Federal poverty line, compared to 12.5% of the general population. Thirty‐eight percent of the WIC participants are persons of color. Race and poverty are key factors in health care disparities. WIC is the primary program through which many families access a medical home.

WIC saves us money: For every dollar spent on the WIC program, $3.50 are saved. By reducing low birth weight, WIC saves States money on caring for a low‐birth‐weight baby. A normal, healthy birth costs around $7,200, but care for a very low‐birth‐weight baby can be as much as $200,000.

Through its focus on breastfeeding, WIC helps to promote better outcomes among mothers and children. Dr. Hayes noted the poor outcomes that are associated with bottle feeding, such as a 40% increase in type 2 maternal diabetes as well as an increase in type 2 diabetes in children. Data indicate that after 6 months, the majority of women are no longer exclusively breastfeeding: 43% of the general population at 6 months, versus 34% of the WIC population. She noted that changes in laws and public policies are essential to promoting breastfeeding more widely. She also noted that many partners—including hospitals, employers, and the media—are needed to promote breastfeeding more widely and for longer periods.

WIC has the potential to help combat childhood obesity by helping to prevent the risk factor of overweight and obesity among pregnant women. This is a special challenge, Dr. Hayes said, for women of color. She noted that not all hospitals are “breast friendly” and that employers need to provide environments in which breastfeeding mothers can pump milk. She also referred to

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

the importance of Michelle Obama’s new campaign, Let’s Move, and her hope that WIC can be a part of the initiative.

Dr. Hayes noted that the revised WIC food package offers the potential for improved health outcomes. The new rule is to concentrate on foods that are lower in calories, saturated fat, and cholesterol and higher in fiber, as well as foods of high‐nutrient density: fruits, vegetables, and whole grains. This change will make a difference in the campaign against obesity. In addition, new WIC food policies discourage the early introduction of formula and incentivize women to exclusively breastfeed by providing them with larger and more food benefits.

Dr. Hayes concluded by stating that WIC is truly a successful program and a key partner in working on childhood obesity prevention programs in the States. As the Let’s Move initiative takes shape, many partners are emerging, creating opportunities for WIC to expand its range of partners as well. She encouraged participants to “get in there and encourage our legislators and our Congress people to reauthorize this program by focusing on what WIC does best….”

Patti Hauser, National WIC Association

Patti Hauser concurred with Dr. Hayes’ assertion that WIC is a public health prevention program that “helps families find needed health and nutrition services and contributes to the good health of moms and young children while saving taxpayer dollars” and also gave a resounding “Yes!” to the question of whether WIC can play a role in ending childhood obesity.

The United States, Ms. Hauser noted, is in the midst of an obesity epidemic. She gave an overview of statistical trends in obesity. For the past 30 years, obesity has increased in all segments of the population regardless of age, gender, or ethnicity. Among women of childbearing age, the percentage of obesity nearly tripled, from 12.9% in 1980 to 34% in 2008. In preschool children 2–5 years old, the prevalence more than doubled, increasing from 5% in 1980 to 12.4% in 2006. Researchers predict that if the rate of overweight and obesity continues to grow at this current pace, 75% of adults and about 24% of children will be overweight or obese by 2015.

Ms. Hauser noted that although there is no evidence that women and children enrolled in WIC are more likely to be overweight compared to the U.S. general population, there is evidence that overweight and obesity disproportionately affects ethnic minorities and low‐income populations. Recent data indicates that the prevalence of overweight and obesity was highest among non‐Hispanic Blacks (78.2%) and Mexican‐American women (almost 77%) compared to non‐Hispanic White women at 61.2%. Women with incomes below the Federal poverty level were more than twice as likely to be obese as women in higher incomes. Ms. Hauser concluded that since WIC serves low‐income women and children—more than 60% of the total WIC participants are either Hispanic or Black—obesity and overweight will have a disproportionate effect on the WIC population.

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

WIC is in a unique position, because of the population it serves and how, to influence trends in overweight and obesity. Data show that the time surrounding and during a pregnancy is a critical period in preventing overweight and obesity among children. Children whose mothers were obese during early pregnancy were 2 ½ times more likely to be overweight during their preschool years. Seventy percent of overweight children will become overweight adults. WIC serves pregnant and postpartum women, helping them to achieve a healthy birth and attain a healthy weight before becoming pregnant again. Nutrition counseling during pregnancy helps women to achieve their ideal weight gain. Through its focus on breastfeeding, WIC supports, encourages, and enables women to breastfeed. Recognizing that children establish eating habits very early in life, WIC works with mothers to help them address concerns such as when to introduce solid foods , how to wean from the bottle, how to offer healthy snacks and meals, and how to address developmental eating issues.

WIC participants must be recertified or at least be seen every 6 months. This recertification is critical to the effectiveness of WIC, offering the program an opportunity to weigh and measure children and calculate their body mass index (BMI). WIC staff review their eating habits, counsel mothers appropriately, and schedule at least one additional nutrition education visit every 3 months—even more for high‐risk individuals.

The cornerstone of WIC, Ms. Hauser said, is its quality nutrition education program, which is participant‐centered and focuses on behavior change, offering and reinforcing individualized information at every visit.

WIC is an adjunct to health services, essentially linking WIC families with the health care services that they need. WIC staff refer families to health care providers and ensure that they are enrolled in Medicaid and the Supplemental Nutrition Assistance Program–Education (SNAP‐ Ed), the food stamp program, if eligible.

Breastfeeding is an investment in healthy weight, Ms. Hauser said. She noted that in the reauthorization legislation now under consideration, the NWA and many others are recommending that the words “breastfeeding promotion and support” be added to any references to nutrition education. “WIC should be seen as a nutrition and breastfeeding program and not a formula giveaway program,” she said.

The WIC Breastfeeding Peer Counselor Program saw increased national funding from about $15 million last year to $80 million this year. It is currently in the budget for $83 million, and the reauthorization is requesting $90 million. By supporting the Breastfeeding Peer Counseling Program, WIC is engaging in the opportunity to promote healthy weights for children. Ms. Hauser explained, “WIC is already a key player in the fight against obesity.” Two years ago, the NWA issued a paper describing the role of the WIC program in the prevention of maternal and child overweight and obesity. [Copies of the paper were distributed to roundtable attendees. Ed. Note.] That paper, along with its recommendations for effective strategies, has recently been updated. Recommended strategies include providing worksite wellness so that staff can model good behavior, educating on healthy eating and physical activity as the norm

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

and not just something that’s new to do, utilizing mass media, promoting research, and supporting public policy. Building partnerships and collaborations is also key, working not only with other health department agencies but with others outside the system.

As an example of such partnership, Ms. Hauser described a program underway in Wisconsin, funded by the Centers for Disease Control and Prevention (CDC) Nutrition and Physical Activity Grants. This project, a $900,000 grant, focuses on breastfeeding, environmental change, nutrition, and physical activity. Wisconsin is also receiving about $10 million in American Recovery and Reinvestment Act (ARRA) money for community health and wellness, programs that focus on nutrition, physical activity, and .

Ms. Hauser described the effects of the WIC Farmers’ Market Nutrition Program, which can help to increase access to healthy foods and their consumption by increasing the number of farmers’ markets available to the general community. Increasing the capacity for the Farmers’ Market Nutrition Program, which also establishes farmers’ markets, could help meet the goals of both initiatives. She also noted that the WIC reauthorization includes a recommendation to increase the fruit and vegetable monthly allotment for children from $6 to $8, another step in increasing access to fruits and vegetables.

Ms. Hauser suggested that WIC could be instrumental as a research partner by sharing the extensive data that it collects on BMI. With data on more than half the Nation’s infants and a quarter of its preschoolers, these data could be helpful to nutrition and food researchers. She noted that in Wisconsin, a program is being launched to collect BMI on the general population, and a similar national effort could be introduced using WIC data.

Ms. Hauser concluded that partnerships are “really a matter of keeping your eyes open for opportunities—for win‐win opportunities with the WIC program.” She noted that while collaboration is important, it is also important to maintain the integrity of the WIC program, which “does what it does best.”

Susan Foerster, California Department of Health Services

Susan Foerster described her experience working on SNAP‐Ed in California for the last 13 years; in California, the program is still referred to as “food stamps.” She also noted that she would occasionally refer to “FSNE,” Food Stamp Nutrition Education, around which the State has done policy work.

Ms. Foerster noted that WIC and SNAP‐Ed share a common mission, although WIC starts at the very beginning of life and food stamps pick up for school‐age and older children and their families. WIC and SNAP‐Ed are trying to accomplish dietary and physical activity change in the same population, specifically to eliminate food insecurity and hunger and to improve nutritional quality. Both programs also try to prevent and reduce obesity, the greatest health risk that clients face.

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

Ms. Foerster described similarities and differences between WIC and SNAP‐Ed. While WIC is more focused on individuals, SNAP‐Ed has focused much more on a community level and on a population base. WIC has been clinic centered in many ways and has a close linkage with health care delivery. SNAP‐Ed is delivered much more in community settings of all sorts. In California, Ms. Foerster estimates that SNAP‐Ed is delivered in approximately 10,000 different community settings, including schools, worksites, grocery stores, daycare, afterschool, and churches. WIC sets very high standards for the retailers that it allows to receive WIC vouchers. SNAP‐Ed is less stringent in its requirements. California has about 4,800 WIC‐certified food stores but 17,000 Electronic Benefit Transfer (EBT)‐certified retail outlets, which include liquor stores, minimarts, and a variety of other types of outlets.

WIC leadership typically comes from State health departments or intertribal organizations and is then delivered through health departments or nonprofits. SNAP‐Ed leaders are based in State agencies, which typically contract with a variety of different “implementers,” including county extensions; universities, typically in nutrition departments but sometimes medical schools; health departments; and nonprofits. For example, food bank associations are sometimes State implementers.

Nutrition education (nut‐ed) is integrated in both programs quite differently. In WIC, it is part of the design and structure, so money is set aside for it. In SNAP‐Ed, nut‐ed is more variable, because the program is based on a Federal financial participation model. States receive matching Federal funds for the work being done by local and State entities. Nut‐ed in SNAP‐Ed builds on programs that are already in place.

Like WIC, food stamps are an economic stimulus; every dollar in food stamps generates $1.84 in economic activity in the local community. This in turn is helpful for States as they grapple with the economic consequences of the economic downturn.

Finally, WIC has a “fabulous, fabulous image. It’s trusted. It’s been evaluated.” Food stamps, on the other hand, are stigmatized. Reinventing it as the Supplemental Nutrition Assistance Program, Ms. Foerster said, is a “great opportunity to try to change that image and connect it with things that really matter, meaning health and nutrition.”

She went on to describe collaborations between WIC and food stamps in California. A basic concept that both programs share is the idea that they must think in an “ecological way.” People make food and activity choices based on environmental factors, and interventions to change behaviors must work in “all those different…spheres of influence.” An array of interventions that have been tested and proven effective is essential to both WIC and Food Stamps.

California rebranded its food stamp program within the context of SNAP‐Ed and is now called the Network for a Healthy California, with four pillars: fruits and vegetables, physical activity, food security, and chronic disease prevention. The program seeks to empower champions and change agents. Rather than focusing on messages for individuals, as the State had previously

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

done in its 5 a Day program, the Network focuses on helping people to change the environment for families, communities, schools, workplaces, and so on. The program has developed a Food Stamp Office Resource Kit, which was designed originally for food stamp offices to try to end the stigma associated with them. WIC programs are using the Resource Kit as well, because food stamp participation among WIC clients is low. Such participation is to be encouraged, because it can help families to buy healthy food for older children and adults.

Food stamps undertake two major communication efforts annually on television, on the radio, outdoors, and in transit. The program conveys the message that healthy choices should be normal, easy choices.

Food stamps has rearranged its organization into regions, a configuration that WIC already used and with which food stamps are now more closely aligned. By operating in regions, the programs are able to be much more region focused or specific in their efforts, especially in terms of media outreach and collaboration.

Food stamps does work with some clinics, including a consortium of Federally Qualified Health Centers (FQHCs) that were already involved with WIC. FQHCs see their role as including helping families to get resources for which they are eligible and making families more aware of food stamp availability seemed a logical fit.

The food stamp program recognized the importance of the revised WIC food package as a way to promote more fruit and vegetable consumption among its clients. WIC has very specific rules about retailers who can receive its vouchers; however, since they regulate retailers, WIC can’t go in and provide training and technical assistance on things like nutrition education unless they do so for the whole State. The food stamp program has 11 regional specialists whose job is to work with EBT food stores, especially smaller ones, on commercially appropriate and nutrition education‐type promotion of fruits and vegetables. These materials are available for the WIC program to use to help with retailers who may not be accustomed to carrying fresh fruits and vegetables.

Food stamps also provides training so that its partners can conduct food demonstrations in stores. Ms. Foerster noted, “Tasting and trying are absolutely critical to behavior change.” While WIC offers such tastings in a clinic setting, food stamps is able to do it in retail and community settings, expanding the reach of WIC efforts.

Food stamps also supports in‐store merchandising, which includes cross‐promotion and co‐ branding between the Network and WIC. This collaboration, Ms. Foerster said, is going to enable both programs to be more powerful in order to build on education that children receive in schools and information that is sent home to parents.

The program supports other promotions as well. For instance, it sponsors an annual fruit and veggie fest whose goal is to sell out whatever fruits and vegetables are being promoted. The

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

effort targets the entire supply chain to promote fruits and vegetables to low‐income families. With WIC’s new food package, this effort can encourage fruit and vegetable consumption among a market segment that is not typically targeted.

Some 5 years ago, the Food and Nutrition Service required all States to have their Food and Nutrition Service programs work together on a project. California opted to focus on fruits and vegetables, as did 10 or 11 other States. The State Department of Education, the WIC program, Social Services, the University of California, and the State Department of Food and Agriculture partnered on this endeavor. Counties picked up on this initiative, and several worked on projects to engage county‐level partners in nutrition education activities. For example, Alameda County is now trying to develop a single application that would enable people who apply for WIC to automatically get signed up for school nutrition programs and Food Stamps.

Network data also indicate that fruit and vegetable consumption has increased among adults, while in the Nation as a whole, the rate has remained flat. The Network believes that this increase can be attributed to its activities. Ms. Foerster noted that the people with the highest incomes ($50,000 or more) in the Behavioral Risk Factor Surveillance System surveys always have the highest reported consumption. Interestingly, the rate has gone up the most for the lowest income categories; the middle income levels show no increase over time. The Network believes that its work has influenced lower‐income people to change their fruit and vegetable consumption habits.

Ms. Foerster described opportunities for food stamps to influence behavior change, describing a Fit Business Kit used as a worksite wellness tool. SNAP‐Ed operates in some 800 daycare settings with school‐age children, an area that represents opportunities for policy, systems, and environmental changes so that “the healthy choice becomes not only the easy choice but the expected choice.”

WIC’s core mission is nutrition and breastfeeding support. WIC combines early intervention, personalized nutrition services, and access to healthy foods in a way that is unique. While we do not know for certain exactly how this combination makes WIC so successful, we do know that breastfeeding promotion and support play a huge role in preventing obesity and stemming chronic disease.

In 2008, 59% percent of WIC mothers started breastfeeding, up from 41% in 1998. The median duration of breastfeeding was only 13 weeks.

Of all children born in the United States in 2006, 73% started breastfeeding, but only 43% continued to do so at 6 months. For children in the WIC program, the data for 2008 are 59% and 34%, respectively. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for 6 months and breastfeeding with complementary foods for at least 1 year.

Ms. Foerster concluded by discussing strategies or the policy levers that are needed for SNAP‐ Ed so that it can work with WIC and child nutrition programs more effectively, such as

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

Allowing SNAP‐Ed to increase the range of physical activities that it can demonstrate to sustain behavioral change; Increasing SNAP‐Ed participation to help prevent and eliminate hunger, in part by increasing participation in all nutrition assistance programs; Increasing access to healthy foods by increasing partnerships with business and industry by allowing industry, for instance, to make deals with retailers for lower prices on healthy foods for EBT shoppers; and Building on synergy—finding ways to use WIC, SNAP‐Ed, and ARRA funding in the most effective and smartest way possible.

IV. Question and Answer Session

Question

Can you please elaborate on the advertising‐for‐children aspect of nutrition and what California was doing around the issue around 2004 with their holding new media for children?

Susan Foerster, California Department of Health Services

Since we’ve had our children’s 5‐a‐Day campaign, we did advertising on children’s television, a little bit on radio, that was basically what you would do for any kind of advertising campaign, so starting with the kids—trying to make it cool and popular and fun to eat fruits and vegetables. And we think it really worked. It was not a counter‐advertising campaign; I think we might be going toward counter‐advertising. And particularly with youth empowerment and youths speaking up right now, kids are very powerful advocates for change on their own. So I think if I were doing advertising now, I would be thinking about the voices of youth. But until that time, we were able to do the buys as we needed to; but right now the rules are such that you can only purchase media in outlets, where over half of the audience is below 185% of the Federal poverty level. And there are no children’s outlets that meet that demographic.

Patti Hauser, National WIC Association

I’d like to mention another collaboration that the NWA did the year before last with Sesame Workshop, another win‐win situation, where we collaborated with them and they made Healthy Habits for Healthy Kids Kits that were focused toward families and young children to increase physical activity and fruit and vegetable consumption. So it didn’t cost the association anything; it was a win‐win for both areas.

Question

I come from a sociological perspective, and oftentimes we assume that you want access because certain grocery stores are available. They’re food deserts, and is completing—is variegating the way in terms of getting access to food outlets that we provide to

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

underprivileged populations. What are your thoughts in terms of getting access to food for underprivileged populations where retail stores might not exist or not carry the kinds of foods that we’ve been talking about or we have to travel long distances, or we may not have access by border towns and other places like that?

Dr. Maxine Hayes, Washington Department of Health

I just want to respond because it gives me an opportunity to say something else that hasn’t been said: We have got to see the obesity epidemic as multifactoral and multidimensional. We’re talking about WIC today, but a decade ago—well, it’s been over 10 years—I made a decision to take WIC out of maternal and child health and put it with chronic disease prevention. And I think that that was a smart move. It was way ahead of its time, but we’ve got to think of these types of programs as being chronic disease prevention, because the burden that we’re carrying in the United States right now is chronic disease, and we’ve got to stem that. So we’ve got to look at this problem differently.

Having said that, a lot of the work that’s going on in the chronic disease community now has to do with not programs and projects, but policy development. And that policy development means that we have to take the social‐ecological model and look at the whole array of things that influence and shape not only our decisions, but what type of health status the population has. And herein is the opportunity. That means we’re going to have to be more integrative in our approaches and get out of the silos.

This is a USDA program when it could have been a public health program. Public health said, “I don’t want it.” That was 36 years ago. Now the public health community recognizes we cannot do public health without this program, because this is the program that gives us the opportunity to work with the very populations that’s bringing us all down in the way of health status.

And it’s not their fault; it’s our fault. It’s changing—there is personal behavior, but every time I make that statement, I am so aware that every individual is surrounded by so many things for which we, as a collective society, has a responsibility for doing, and that’s creating environments. We have deserts that we can map. We can use our public health approach by measuring, documenting, mapping, and showing where the gaps are and how they need to be filled. And many times it’s changing policies, because sometimes it relates to zoning laws, where you just can’t set a farmers’ market in a place because of their laws about where they can be. Well, let’s change that if we have to. But that’s the point.

If you leave here with nothing else today—it is to recognize that obesity is not going to be resolved in the old paradigms and with just one entity. We’ve got to integrate. We’ve got to use all of our thinking and all of our programs. And in some cases, we have to be strong enough to change policies that create barriers. And we know not everything is equal; we know not everything is fair, and there are some populations that are having a disproportionate serving of unfairness. And we need to make it so that their opportunities are just as easy, [to Susan

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

Foerster] as you have demonstrated in California. We can do it, even if you’re low income. And that’s the challenge. Other nations have done it. It’s not just about the income. It’s really creating opportunities for people to do some of the same things as the higher‐income population. And with focus on policy, we can get there.

Patti Hauser, National WIC Association

The other community that the obesity prevention community needs to work with is the hunger prevention community, because there are a lot of the same goals and missions. Food‐insecure people are more likely to be overweight. And the food deserts and access to healthy foods and increasing fruits and vegetables are all missions and visions of the hunger prevention community as well. So we don’t have to work in a silo. Hunger prevention is working on the same things, so let’s not leave them out of the picture as well.

Susan Foerster, California Department of Health Services

We use GIS (Geographic Information System), and what we have been finding, which is really interesting, is that it’s not necessarily the presence of a full‐service supermarket that correlates with community obesity. Rather, we think it’s going to be extremely important to support the stores that—like the WIC‐only stores, the small stores—so that the small stores that are close to people in those food deserts are offering healthy food. That’s one strategy. So raising the standard for EBT participation, is really important.

The other piece is that we have to develop demand. And if you build it, people won’t necessarily come. That’s what we see with the middle class. They’ve got plenty of fruits and vegetables in the grocery stores, but are they eating them? No! And so we really have to do a lot more marketing, and marketing with all those different elements: the advertising; the promotion; the public relations; the making it within, a heartbeat of getting it, like Coke does. And so, I think that it is not just a simple answer, but I don’t think it’s a matter of just putting a supermarket in the center of a food desert. It’s much more nuanced than that.

Dr. Maxine Hayes, Washington Department of Health

I would agree with that. Several years ago, the Academy of Sciences had an international meeting on the problem of obesity. I was invited to participate along with people from all over the world. One of the things that I recognized that was sort of like an epiphany is that the obesity epidemic is being led worldwide by women. And it really underscores, to me, how much attention we have to pay to women’s health. We’ve neglected women’s health in this country, and we’ve neglected it to the point that the only time we’re having a conversation about women is as it relates to the pelvis. That is the only time. And yet women are the decisionmakers in terms of what foods are bought, how they are prepared—they are so central to what happens to families.

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

We need to do more in terms of reaching out and really making it convenient, because women have been duped worldwide. And in the developed countries, we’ve been duped because we’re busy and we’re tired and we are not cooking. We have bought into convenience foods whole time, and the marketers understand that; they know it. That’s why they’ve made a lot of money off of salt, sugar, and fat. I suggest that we can do the same types of things by making the healthier choices more convenient. If we had convenient, affordable, well‐packaged, and well‐ marketed—which they have learned to do with the wrong stuff, and we bought into it—we will do it again.

We must create that demand, and that’s why I see Michelle Obama playing an important role— and the first family, and all of our families in our States. I really do want you to pay attention to any policy anywhere and ask the question, “How is this policy affecting the single most important entity in terms of what happens to health status?” And that’s women! We are the decisionmakers on all the health matters. We are! And that’s not to the exclusion of men, but we are making those decisions. We decide who goes to the doctor for what. We decide what elements are really going to make us healthy or not. We’re the ones. So I think we have to really think about that, and all of our programs. Think about that.

Loren Bell, Altarum Institute

I would just add one other quick thing to that last item. As part of our obesity mission project work at Altarum, we’re doing a study of the impact of the new WIC food package on small grocery stores in four different States. We’re looking at whether or not stores that were on WIC before the new food package remained on, and whether or not they were able to add fruits and vegetables and whole grains, and what the quality of those are. But we’ve been hearing stories in other States where we’ve worked, and particularly with some Tribal programs, that the access to the new WIC foods is extremely difficult, particularly working with the Navajo Nation, who are talking about the fact that their WIC redemption values seem to be going down because you can’t find a fresh fruit or vegetable out in the middle of the desert on the Navajo Nation. We are very much concerned that the access issue for many of the populations who are at highest risk of obesity, as Native Americans are, might be problematic. So it’s something to be thinking about in terms of an ongoing look at the access to healthy foods in these kinds of markets and in these kinds of areas, where it’s very difficult for folks to find things.

Question

I’m the director of the Nutrition, Physical Activity, and Food Program for the Commonwealth of . As I do both obesity prevention and work on putting an end to childhood hunger [in Virginia] by 2015, there are a lot of common solutions to both obesity and hunger, such as access to healthy foods. What I’m having trouble finding is something under the economic development piece. We’re looking to use WIC and WIC EBT as a way to assure business for some small stores in the food deserts. But they need more than that; they need a way to take care of the produce and to get linked up. Obviously, I have a number of funding strings, none of

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

which are allowed to do that. And I can’t find anything that is. Somewhere we need a way to link the economic development and making the small stores that are in the communities have healthy food. But there doesn’t seem to be a source of funding to sort of link those pieces together.

Susan Foerster, California Department of Health Services What we’ve found kind of accidentally is that there were opportunities with SNAP‐Ed to help what we might call new farmers, urban farmers, and others who were doing some fresh processing; developing businesses with foods that were grown in community gardens or on the urban fringe. The Healthy Food Financing Initiative that’s been mentioned already—if I understand from The Food Trust, they really talk about a diversity of different kinds of retail outlets and a lot of sourcing systems. So you’ve got to pay attention to the economics in terms of farm‐to‐school, farm‐to‐institution—those systems.

We are doing a little bit of help, but the rules are limiting on sourcing systems to try to help smaller farmers be able to connect with the buyers, particularly when with fresh foods you have a crop, and then you don’t. And yet the institution needs an ongoing source of supply. So there needs to be some leadership in this area. It’s happening all over the country, partly because of CDC, to look at regional food systems that are also good for climate change, because we’re trying to reduce the number of food miles and the amount of cost and that goes into shipping a couple crates of strawberries from California to New York. We’d just as soon have New York grow its own strawberries because we need to double/triple consumption.

Dr. Maxine Hayes, Washington Department of Health

We need to eat locally. That’s what I have really observed. We need to support some of our food co‐ops in season. But it’s going to take the whole population to really get us there. It’s a cultural change, because we demand it. We’ve been so used to getting things out of season. We want it. But we have to learn how to eat locally, because that addresses some of the issues.

Comment

I was just in Philadelphia at their regional planning meeting. They were trying to do food system, and I wanted to share how happy they were that WIC had fruits and vegetables. They were just over‐the‐top happy. They were really seeing that WIC was going to have a big impact, and they really saw that essential to the whole Delaware Valley planning project. We did have a discussion on the issue of States having a choice of fresh, frozen, and canned. Would you just choose fresh and force people into a system that doesn’t work, in which case they can’t find it, or are you going to give some combination of fresh and frozen or fresh, frozen, and canned and then try to work with the systems as they exist? I do know that in California your SNAP‐Ed money’s really helped worked with some of the stores and see if they’re ready, and that’s a wonderful model. But I think that that discussion is happening in different places around the food system, because it doesn’t just have to be fresh to support a regional food system.

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

Question

I wanted to pick up on some things that were covered by Dr. Hayes’s presentation about the importance of policies, the workplace, the environment, the number of women working, and particularly on breastfeeding. What has been done or what might be recommended in the legislative arena to support the ease of breastfeeding in the workplace, and particularly where mothers are likely to be working. Dr. Maxine Hayes, Washington Department of Health

We’ve done a lot of work on this particular piece in Washington State. Over 5 years ago, the State health agency—and any of the State health agencies can choose to do this—actually developed for the business community things that they could do in order to become breast‐ friendly places. And we in Washington have provided incentives for businesses to do that, to really advertise that we are a breast‐friendly employer. And we developed nice stickers that people could use in their businesses, because it just doesn’t happen. You have to do something to create environments. It takes space and clean, hygienic environments for women to use their pumps. Way before we even were talking about this at a policy level statewide I actually came to the State and created an opportunity for women to bring their breastfeeding kits to work. We were the first WIC office to do that and I got a lot of grief for doing that, because it was at a time when the rest of the public wasn’t ready for those types of things. But it doesn’t just happen. There are policies that have to be examined and then guides given to employers to assist them in making their environments friendlier.

If you think about it, women—we’re the work engines in this country. And the women of childbearing age—any employer who thinks that they are not getting all that they could get in terms of productivity—if they don’t make the environment really more supportive, then they won’t get the productivity. Women are having to go back to work so soon, and that interrupts the breastfeeding diligence, unless there is support. So raising that understanding and also translating that back to the employer’s in terms of economic cost to him if he doesn’t do it and it’s going to cost him in the way of unnecessary medical expenses for the mother and the dependent. We have data now that shows that the breastfed babies don’t get as sick. You go down the whole list; there is an economic piece to this. And learning on the public health side how to frame this in the way of economic cost to the employers has been our bestseller, as well as understanding that women make up the workforce, and if they’re not supported, they’re going to lose out in terms of our productivity.

There are laws, and there are model laws that Altarum can pull together and disseminate because we now have laws—and Washington State is one of those—we have a whole series of laws to work on the policy piece. And I think everybody should know that there’s a big P and there’s a little P. The little P is, in our workspaces, we all should ask ourselves, “How is my employer responding to this? And what can I do, as I go back to work, to assure that policies are in place that support what it is we’re talking about?”, because it’s all a part of the obesity prevention and stemming the tide. They’re things that every person who has an employer can

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

really think about: “Am I a breast‐friendly place? How do I support the women, and particularly women of childbearing age, in my workplace? And can we help employees to understand what they can do to improve that?”

Comment

I would just add that Rep. Carolyn Maloney from New York has introduced legislation in repeated Congresses to incentivize the workplace to create breastfeeding‐friendly environments. It’s been reintroduced in the last session of this Congress, and then there are some cosponsors. And so, if you are interested in that legislation, be in touch with Rep. Carolyn Maloney and see if we can move it further down the field. Also, Corporate Voices for Working Families has helped to create the business case for corporations to appreciate why creating breastfeeding‐friendly work environments is helpful to their business case at the end of the day.

Patti Hauser, National WIC Association

Stay tuned for the NWA breastfeeding plan. There’ll be lots of resources available for the business case for breastfeeding policy, working with partners. We’re getting AAP on board. We need to get ACOG on board and also to fix broken breastfeeding‐broken hospitals. The goal is to have breastfeeding‐friendly hospitals that are supportive from the very beginning because that’s when it starts, right in the hospital. And we’re finding that many of those hospitals are broken with regard to their breastfeeding support. Stay tuned.

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

V. Appendices

Appendix A: Altarum Institute Altarum Institute is a nonprofit health systems research and consulting organization serving government and private‐sector clients. Altarum provides comprehensive research and tailored consulting services that help clients understand and solve complex systems problems that impact health and health care. Combining the analytical rigor of a research institution with the business agility of a consulting firm, the Institute is uniquely positioned to deliver practical, systems‐based solutions to its clients and funders. Altarum’s nonprofit status ensures that the public interest is always preeminent in its work.

Services and Offerings Altarum Institute is widely recognized for delivering research and solutions that are technically robust, pragmatic, and carefully aligned with the cultural norms of the populations being served. The Institute’s service offerings are grouped into the following five categories: Health Research and Analysis Health Program Development and Evaluation Health Care Strategy, Operations and Finance , Conference and Web Services Clinical Research Support and

Areas of Expertise Altarum applies its service offerings across a wide array of domains in which it has developed deep expertise: • Behavioral Health • Community Health • Food Assistance and Nutrition • Health Disparities and Intercultural Health • Health Information Technology • HIV/AIDS • Lean Six Sigma • Military and Veterans Health • Obesity and Overweight • Women, Children, and Adolescents

Altarum Institute Staff and Values With a history dating back more than 60 years, Altarum Institute offers unparalleled knowledge and practical expertise. Altarum’s more than 350 employees represent the best in health care policy, research, business and clinical process improvement, technical assistance, and program evaluation. The Institute’s staff is diverse in experience and background, but of one mind on its core values, including intellectual excellence, impeccable business ethics, and a commitment to client success.

For more information, please visit www.altarum.org.

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

Appendix B: National WIC Association

The Special Supplemental Nutrition Program for Women, infants and Children (WIC) has an extraordinary 35‐year record of preventing children’s health problems and improving their health, growth and development. WIC children enter school ready to learn and show better cognitive performance.

Quality nutrition services are the centerpiece of WIC...

nutrition and breastfeeding education nutritious foods, and healthcare access for low and moderate income women and children with, or at risk of developing, nutrition related health problems

WIC’s committed, results‐oriented, and entrepreneurial staff stretch resources to serve all eligible women and children while ensuring program effectiveness and integrity. The WIC program is available in each State, the District of Columbia, 36 Indian Tribal Organizations, Puerto Rico, the Virgin Islands, American Samoa, and Guam.

Research shows that poor nutrition during early childhood increases the chance of anemia, limits memory development and a child’s ability to learn, and add to health care costs. Poor nutrition during a baby's first five years will affect that baby for the rest of its life. During this critical period of a child’s development, WIC provides a safe, nurturing environment for education, health care and social service referrals, as well as free access to nutritious foods.

The National WIC Association (NWA) works on behalf of the WIC Program to gain bipartisan support in the US Congress, the support of successive Administrations and a broad coalition, including advocacy groups, health care and religious organizations and the CEOs of Fortune 500 corporations.

For more information, please visit www.nwica.org.

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

Appendix C: Roundtable Attendee List

Name Affiliation Nicholas Office of Rep. Grijalva Emily Art Grantmakers in Health Loren Bell Altarum Institute Ryan Bounsy Office of Senator John Kerry Tae Chong National WIC Association Chiquita Collins Altarum Institute Kaitlan Deal Senate HELP Committee Michelle Eichinger Delaware Division of Public Health Joe Faamuli Office of Rep. Faleomavaega Elizabeth Findling Altarum Institute Kate Fink Office of Rep. Steve Kagen Susan Foerster California Department of Public Health Betsy Frazao Economic Research Service Stephanie Gaufin Office of Senator Robert Bennett Margie Glick Office of Senator Sherrod Brown Carlissa Graham Office of Rep. Cohen Douglas Greenaway National WIC Association Martyn Griffen Office of Rep. Vic Snyder Heather Hartline‐Grafton Food Research and Action Center Patti Hauser Wisconsin Division of Public Health Maxine Hayes Washington State Department of Health Geraldine Henchy Food Research and Action Center Heidi Hertz Virginia Department of Health Roberta Hopkins Office of Rep. Adolphus Towns Spencer Howard Office of Rep. Brad Ellsworth Wandrille Hubert Office of Rep. Doc Hastings Debra Keith Providence Hospital/Center for Life Josh Kotzman National Council for Community Behavioral Healthcare Kathryn Larin U.S. Government Accountability Office Sarah Lifsey Altarum Institute Irene Lin Office of Rep. Betty McCollum Olivia Lindly Altarum Institute Marijka Lischak Altarum Institute Jamie Lockhart Office of Rep. Diana DeGette Lane Lofton Office of Rep. Bobby Bright Valerie Long Altarum Institute Janice Lynch Schuster Altarum Institute Karah Mantinan Altarum Institute Megan McHugh First Focus James Molina Legislative Correspondent Jeff Moore Altarum Institute Ruth Morgan Altarum Institute

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

Jenifer Nawrocki Office or Rep. Bill Young Jonathan Orr Altarum Institute Jacob Parker Office of Rep. Latham Ellen Pliska Association of State and Territorial Healthcare Officials Donna Porter Congressional Research Service Jennifer Renjel Office of Senator LeMieux Emily Riff Office of Rep. Nita Lowey Kara Rudolph Altarum Institute Devon Seibert Altarum Institute Kelly Seibert Office of Senator Tom Udall Donna Seward Virginia Department of Health Pete Stehouwer Office of Rep. Pete Hoekstra Albert Terrillion Association of State and Territorial Healthcare Officials Serena Vinter Trust for America’s Health Connie White ACOG Joanne White Delaware WIC Program Kelly Whitener Committee on Finance Debra Whitford USDA Food and Nutrition Service Ashley Wilson Oversight and Government Reform Judy Wilson USDA Food and Nutrition Service Beth Zimmerman Altarum Institute

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

Appendix D: Speaker Biographies

Maxine Hayes, MD, MPH Dr. Hayes is the State Health Officer for the Washington State Department of Health. As the state’s top public health doctor, her role includes advising the governor and the secretary of health on issues ranging from health promotion and chronic disease prevention, to emergency response, including pandemic influenza preparedness. She also works closely with the medical community, local health departments and community groups. Prior to her appointment as Health Officer, Dr. Hayes was the Assistant Secretary of Community and Family Health. Dr. Hayes is clinical professor of pediatrics at the University of Washington, School of Medicine, and on the MCH faculty of the School of Public Health.

Dr. Hayes was the 1999 Distinguished Alumna of the Year for the State University of New York School of Medicine at Buffalo and the Year 2000 recipient of the Stockton Kimball Award. In 2000 she was presented an honorary Doctorate of Science by former Acting Surgeon General and President of Spelman College, Dr. Audrey Manley. She is the recipient of many awards and honors for her work in maternal and child health, including the American Medical Association’s 2002 Dr. Nathan Davis Award and the 2003 Heroes in Health Care Lifetime Achievement Award through the Washington Health Foundation.

Dr. Hayes was elected to Institute of Medicine (IOM), October 2006 and inducted into the Institute in October of 2007. Dr. Hayes is also a fellow of the American Academy of Pediatrics. In November of 2007 she received the APHA Helen Rodriguez‐Trias Social Justice Award.

Patti Hauser, RD, CD, MPA Ms. Hauser currently serves as the WIC Program Director and Chief of the Nutrition and Physical Activity Section for the Wisconsin Division of Public Health. She is a registered dietitian, receiving her Bachelors in Dietetics from the University of Wisconsin – Stevens Point, and her Master’s in Public Administration from UW– Oshkosh. Ms. Hauser has worked in public health, specifically the WIC Program, for 30 years. She started a county WIC project in Portage County in 1979, when she paid the WIC grocery stores from her own checking account. Ms. Hauser has been the Wisconsin WIC Program Director since 1991.

Ms. Hauser has been an active member of the National WIC Association, serving in many capacities over the years; as Midwest Region Directors representative and on many committees and task forces. These include income documentation, immunization collaboration, disaster planning and response, obesity prevention, and the food package implementation task force. Each of these has provided a rich variety of experiences and friendships within the Association. They also provided the opportunity to learn from others and to bring the many years of local and state perspectives to the table.

In Wisconsin, Ms Hauser manages a mid‐size WIC Program of over 125,000 participants monthly. At the state level, she collaborates with several other health programs to enhance the services provided to WIC families, such as immunization, blood lead screening, and dental health. She has a reputation of trying to find the “win‐win” in the program collaboration, while protecting WIC Program funds, and integrity of the WIC Program’s nutrition goals.

Susan Foerster, MPH Susan Foerster received her BS and MPH degrees from the University of California, Berkeley. Her work began in Boston where she coordinated nutrition services in the Allston‐Brighton neighborhoods. She

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?

joined the California Department of Health in 1973 with Licensing and Certification and was promoted to lead nutrition development for adult health in 1976. She worked in aging, hypertension, diabetes control, health promotion and cancer prevention. Her experience starting large initiatives began in 1988 with the California 5 a Day for Better Health! Campaign. Adopted by the federal government and the nation’s fruit and vegetable industry in 1991, the National 5 A Day Program has been emulated by at least 25 countries. In 1996, she started the California Nutrition Network for Healthy, Active Families, now the largest state social marketing network of the USDA Food Stamp Program. She continued spinning off the Children’s 5 a Day Power Play! Campaign, the Latino 5 a Day Campaign, the California African American Campaign, along with retail and worksite initiatives. Her team of over 100 highly skilled professionals is rebranding these initiatives as the Network for a Healthy California Champions for Change.

After serving on the board of the American Cancer Society and with the Institute of Medicine’s Committee on Progress in Preventing Childhood Obesity, Foerster continues as the public member of the California Table Grape Commission and on the Executive Board of the California Dialog on Cancer. She was selected as a Healthy School Hero by the White House Conference on Healthy School Environments. She serves on the Action Board of the American Public Health Association and on the Partnership Steering Committee for the National Fruit and Vegetable Program.

Altarum Institute Policy Roundtable: Can WIC Play a Role in Stemming the Childhood Obesity Epidemic?