Process, Findings and Implications from Two Health Impact Assessments: Informing Farm to School Policy, Programs and Research Presenters were: Dr. Tia Henderson, Upstream Public Health Megan Lott, Kids' Safe and Healthful Foods Project, The Pew Charitable Trusts

1. Health Impact Assessment
EXECUTIVE SUMMARY
Health Impact Assessment of HB 2800
FARM TO SCHOOL AND SCHOOL GARDEN POLICY
E X E C U T I V E S U M M A RY O F F I N D I N G S • M AY 2 011
Farm to School and School Garden (F2S & SG) programs have gained
momentum and visibility over the past decade for their potential contributions
to stimulate local economies, foster healthy school food environments, support
nutrition education, and build relationships among farmers and school districts. A review of research evidence and
an economic analysis establish that
Oregon House Bill (HB) 2800 would guarantee school districts could HB 2800 will have significant
purchase Oregon produced, processed, packed and packaged foods with 15 positive public health benefits.
cents for lunch and 7 cents for breakfast in reimbursement funds. The bill
also ensures students learn how to choose healthy, local food options in their
cafeteria through grants that support school gardens, agriculture and nutrition
education. KEY FINDINGS ON IMPACT OF HB 2800
From fall 2010 to spring 2011, Upstream Public Health collaborated with Farm to School reimbursement funds would:
Farm to School and school garden stakeholders to conduct a Health Impact • Create and maintain jobs for Oregonians
Assessment (HIA) on HB 2800, evaluating its potential effects on Oregonians’ • Increase student participation in school
health. This report summarizes the findings of that assessment. The goal of meal programs
the HIA is to inform legislative decision-making on HB 2800, focusing on the • Improve household food security
bill’s impact upon five health determinants: 1. Employment, 2. Diet and • Strengthen connections within Oregon’s
Nutrition, 3. F2S & SG K-12 Education Opportunities, 4. Environmental food economy
Health and 5. Social Capital.
Food, Garden & Agriculture grants would:
This HIA is supported by grants from the Health Impact Project (a collaboration • Increase childhood food preferences for fruits
of the Robert Wood Johnson Foundation and The Pew Charitable Trusts) and and vegetables
the Northwest Health Foundation.The opinions are those of the authors and • Shape long-term healthy diet choices that
do not necessarily reflect the views of the Health Impact Project, the Robert affect children’s learning & academic
Wood Johnson Foundation, The Pew Charitable Trusts or the Northwest achievement while preventing obesity
Health Foundation.
ABOUT
HEALTH IMPACT ASSESSMENTS Employment
Outcomes
↑
School
districts’
purchase
of
Oregon
food
A health impact assessment (HIA) is an information- Environmental
Reimburse
Health
Outcomes
gathering tool used to inform policy decisions and
promote decisions that are the most beneficial for School
Districts
health. Understanding the health impacts of Farm to ↑
School
menu
op6ons
School and School Garden legislation is necessary
Diet
&
Nutri>on
to craft sound policy.
Outcomes
The World Health Organization defines Health ↑
School
promo6on
Impact Assessment as “a combination of procedures, of
new
op6ons
Food,
Garden
&
methods, and tools by which a policy or project may F2SSG
K-­‐12
Educa>on
Agriculture
be judged as to its potential effects on the health of a ↑
Food
ac6vi6es
in
Program
Outcomes
Educa>on
population, and distribution of those effects within the Grant
Program
gardens,
classroom
&
population.” cafeteria
Social
Capital
For more information, contact: Outcomes
Dr. Tia Henderson ↑
Student
gardening
tia@upstreampublichealth.org HIA health determinant pathways resulting from HB 2800 elements
1 To view the full report and references, please visit www.upstreampublichealth.org/f2sHIA

2. Health Impact Assessment
IMPACTS
MAJOR FINDINGS The meal reimbursement program would create jobs
and stimulate economic growth.
CURRENT CONDITIONS
• Employment leads to health: The unemployed are up to twice as likely to die
OUTCOMES
EMPLOYMENT
• Oregon’s unemployment
rate was 10.5% in Decem- earlier than others of the same age and sex.
ber 2010, higher than the Kind of Impact New Jobs A 2.67 employment multiplier means
national average of 9% . (Full & Part-time) that for every job created by school
• The recession has hurt districts purchasing local foods,
Direct effect 101
Oregon’s farms: almost 2/3 additional economic activity would
Indirect effect 101 create another 1.67 jobs.
of farms reported net losses.
Small & mid-sized farms Induced Effect 67
especially are struggling to Total Effect 269 Estimated economic effects of Oregon
compete. purchases during the first bieunnium
Multiplier 2.67 ($19.6 million in reimbursements)
• In 2009, Oregon was one of
the hungriest states in the HB 2800 would improve child diet and nutrition.
nation: 14% of households
DIET AND NUTRITION
OUTCOMES
were food insecure and 6% • Students who participate in school meal programs learn better and have a
of them were hungry. better chance of academic achievement.
• HB 2800’s reimbursement and garden grant programs improve the quality
• 19% of Oregon kids live in
and diversity of food offered during school meals.
poverty.
• Studies of Farm to School initiatives show increases in meal par ticipation
• Kids on free and reduced (for free, reduced, and full-priced meals) between 1.3% and 16%. This
meals are more likely to be helps families buy more food at home, lowering household food insecurity.
from food insecure families.
• In the 2009-’10 school year Oregon has been an innovator in finding Grains: Fruits: Vegetables:
10¢ 15¢ 15¢
33% of kids eligible for free creative ways to provide its children with fresh
or reduced lunches did not and healthy school meals. Without statewide
participate. infrastructure to support Farm to School
Protein: Milk:
efforts, limited funding for school meals can 46¢
• 22% of low-income kids offer only inconsistent options to support
23¢
did not graduate during the Oregon’s children and the farmers who feed them.
2006-’08 school years. 2009-’10 estimates for school lunch
budget in Oregon
EDUCATION OPPORTUNITIES
F2S & SG K-12
• Current Oregon learning Food, Garden and Agriculture education grants
standards do not require would increase kids’ understanding of what they eat,
children to learn where food
how it is grown and how it affects their bodies.
comes from or how it is
made. ↑
Posi.ve
behaviors
• Research of F2S & SG programs report that
• Cafeterias are not connected
children choose more fruits and vegetables - ↑
Physical
ac.vity
to classroom curriculum.
leading to potential increases ↑
Learning,
• 1 in 4 Oregon adolescents in consumption. ∆
Learning
Knowledge,
Achievement
are overweight or obese. environment
• 2009: 58% of 11th graders • Studies show ↑
Student
gardening
↑
Youth
self
efficacy
↑
Educa.on
eat three or less servings of Food,
Garden
that children &
Agriculture
on
nutri.on,
gardens
and
↑
Youth
preferences
fruits and vegetables a day. who spend Grant
Program
agriculture
↑
Food
ac.vi.es
in
for
fruits
&
vegetables
gardens,
classroom
&
time in the cafeteria
↑
Youth
consump.on
of
garden learn better, get physical fruits
and
vegetables
activity and behave better in the classroom. ∆
Youth
↓
Youth
diet
and
overweight
nutri.on
and
obesity
2 To view the full report and references, please visit www.upstreampublichealth.org/f2sHIA

3. Health Impact Assessment
IMPACTS
The reimbursement program gives more
MAJOR FINDINGS cont’d. flexibility to buy sustainably produced
food; this can impact environmental
CURRENT CONDITIONS health factors.
HEALTH OUTCOMES
ENVIRONMENTAL
• A stable product demand helps farmers and processors
Oregonians currently demand food produced try new practices such as solar-heated greenhouses
and processed with alternative methods. or integrated pest management plans. These practices
reduce health issues from soil and water contamination.
Between 2006 and 2008, the total land in organic
production nearly doubled, an 86.7% increase from • A more stable product demand also helps keep farmland
almost 70,000 to over 130,000 acres in response in production, which can reduce greenhouse gasses. If all
to this demand. districts just served Oregon fruit or vegetables at lunch
one day a month, it would support $756,000 in sales.
• Buying Oregon products does not reduce greenhouse
gas emissions from transportation significantly, depend-
ing on the food source.
OUTCOMES
SOCIAL CAPITAL
Social capital is a bank of resources, such as job The reimbursement program will help
referrals, that individuals gain through strong farmers and nutrition staff build food
relationships to others. This improves people’s system connections; the grants will help
health and access to opportunities. students work better together.
If schools build connections with producers, other • Preliminary studies indicate school garden participants
institutions can build upon these relationships, have positive changes in social skills and their ability to
connecting with those who want to buy Oregon work with others.
food. • “Supporting local farmers” is a reported primary benefit
for Farm to School programs; research is needed to
examine the impact on social isolation and depression.
RECOMMENDATIONS for HB 2800: CHANGES TO IMPROVE HEALTH
1. The current policy allows food produced or processed in other states or countries to qualify for a
reimbursement. Amend HB 2800 to specify that schools can only get reimbursed for foods produced
or processed in Oregon to increase economic activity in our state.
2. To improve health outcomes for vulnerable populations, specify that while grants are open to all
school districts, Food, Agriculture and Garden education grants will be preferentially given to school
districts serving:
◦◦ a low-income student population, defined where 40% are eligible for free or reduced meals, or,
◦◦ schools with a racially diverse student population, defined as 20% or more non-white, or
◦◦ schools in rural or urban areas with limited food access, defined as 12% or more of residents are low-
income and live more than 10 miles from a grocery store.
3. To improve child health outcomes, specify funding criteria for Food, Agriculture and Garden education
grants to support schools developing multiple-component programs that increase child health benefits.
Garden grants should be preferentially awarded to programs working toward having at least one
element in each of the following categories: Education, Promotion, Procurement and Community
Involvement.
3 To view the full report and references, please visit www.upstreampublichealth.org/f2sHIA

4. Health Impact Assessment
CONCLUSIONS
SUMMARY OF HEALTH OUTCOMES AND IMPACTS
HIGHLIGHTS ON HB 2800 ($23 MILLION)
Health Outcome or Magnitude w/ Impact
Impact of
= Distribution
Quality of
Health Determinant HIA rec’s
w/ HIA Recs. Evidence
Employment Impacts
Health Outcome or Quality of
Health Determinant & life expectancy
Health pppp Distribution and related jobs
Farm sector Evidence ****
Employment Impacts
Job creation ppp ~270 new jobs ****
LEGEND
Health & life expectancy pppp
Oregon product demand Farm sector and 197 School Districts4
pppp 100 — related jobs
100 **** ****
Job creation Workers’ ability to ppp
 Strong impact on many pay bills ~270 new jobs new jobs
ppp ~270 **** ****
 Strong impact for few or
small impact on many product demand activity
Oregon Economic 100 - 197 3.16 economic multiplier ****
pppp pppp School Districts4 ****
 Moderate impact on
medium number or strong Impacts on Child Diet and Nutrition
impact onWorkers’ ability to pay bills
few ppp ~270 new jobs ****
 Small impact on few
Meal program participation ppp 561,698 public school children1 **
None No effect Economic activity pppp
Child learning & academic 3.16 economic multiplier ****
attainment ppp 561,698 public school children
1 ****
**** 10+ strong Impacts on Child Diet and Nutrition
studies
*** 5 -10 strong studies or data
Household food security pp 210,446 households2 ***
Meal program participation ppp 561,698 public school children1 **
analysis School meal nutrition pp+ 561,698 public school children1 *
Child learning & academic
** 5 or more studies of weak
561,698 public school children1 ****
attainment
and moderate quality; or ppp
Child overweight & obesity pp+ 1 in 4 children **
studies have mixed results
* <5 studies and claim Farm to School and pp Garden Education Impacts
Household food security School 210,446 households2 ***
consistent with public Gardening education + pppp ~15,000 new children3 ****
School meal
health principles nutrition pp 561,698 public school children1 *
Child fruit & vegetable ppp + 561,698 school children **
1 ****
Child overweight & obesity
consumption pp+ 1 in 4 children
Farm to School Agriculture & nutrition
1 Enrolled children in Oregon public
school system, Oregon Department of and School Garden Education pp+
Impacts ~15,000 new children3 ***
Education, 2009-10.
education
Gardening educationnutrition knowledge
2 Household Food Security in the Child pppp ~15,000 new children3 children3
pp+ ~15,000 new **** ***
United States, 2009, US Dept. of vegetable
Child fruit & Nutrition staff knowledge+
Agriculture, Economic Research Service, ppp pp 100 school children1
561,698 public —197 School Districts
100 **** **
consumption 2010.
Child achievement pp ~15,000 new children 3 *
3 Low estimate based on 2007 ODE& nutrition
Agriculture
Child self-efficacy pp+ ~15,000 new children3 children3
pp ~15,000 new *** *
education
survey of reported participation in
school gardens; would be over two year
Child nutrition Child physical activity +
grant time period. knowledge pp ~15,000 new children3 children3
pp ~15,000 new *** *
Nutrition staff knowledge
4 Low estimate from 2010 Oregon Impacts on Environmental
pp Health100-197 School Districts **
Department Education number of
Oregon fruit & vegetable $756,000 — $15,120,000
Child achievement
School Districts that purchase local.
crops maintained pp ~15,000 newin school purchases6
pp children3 * ***
5 Certified estimate of Oregon
Child self-efficacy
population from US Census data, pp
Demand for food grown ~15,000 new children3 *
Population Research Center, 2010. p Oregon food sectors *
Child physical activity with sustainable practices
pp ~15,000 new children3 *
6 Conservative estimates from:
(280,000 school lunches served in Greenhouse gas emissions None 3,844,195 Oregonians5 **
2009-10 x $.30 for fruits and vegetables)Environmental Health
Impacts on from food transport
Oregon fruit &Impacts on Social Capital
vegetable
x 9 to 180 school days. $756,000 - $15,120,000 ***
pp
crops maintained
+ Indicates schools will have to take
Student relationships in school purchases6 children3
pp ~15,000 new *
action beyond the reimbursement
Demand for food grownprocessor &
Producer,
program in the policy.
p Oregon food sectors Districts
ppp ~100 School * ***
with sustainable practices connections
= See report for full summary table, school staff
Climate changeParent food participation
including impacts without HIA policy from school
transport
recommendations. None 3,844,195 ~15,000 new5children3
pp Oregonians ** *
Impacts on Social Capital
4 Student relationships report and pp
To view the full ~15,000 new children3 *
references, please visit www.upstreampublichealth.org/f2sHIA
Producer, processor & ~100 School Districts ***
school staff connections ppp

5. Health Impact Assessment
National Nutrition Standards for Snack
and a la Carte Foods and Beverages
Sold in Schools

6. Executive Summary
Introduction
The foods and beverages available in schools have a significant impact on children’s diets and weight,
with many students consuming more than half of their daily calories at school.1 In addition to meals,
nearly all students can buy foods and beverages at school, often from multiple locations, including
cafeteria a la carte lines, vending machines, and school stores. These snacks and drinks are technically
called “competitive foods” because they compete with school meals for students’ spending; however,
they are also referred to as “snack and a la carte foods and beverages” throughout this document.
Ensuring that schools sell nutritious foods is critical to improving children’s diets. This is one of the goals
of the Healthy, Hunger-Free Kids Act (HHFKA), passed in 2010, which directs the U.S. Department of
Agriculture (USDA) to update nutrition standards for all foods and beverages sold in schools during
the school day by aligning them with the current dietary guidelines.
In an effort to inform USDA as it updates nutrition standards for foods and beverages that are sold
outside of the school meal programs, and to better understand how standards might affect student
health and school finances, the Kids’ Safe & Healthful Foods Project and the Health Impact Project,
both collaborations of The Pew Charitable Trusts and the Robert Wood Johnson Foundation, worked
with Upstream Public Health, a nonprofit research and policy organization, to conduct a health impact
assessment (HIA).
Health Impact Assessment: National Nutrition Standards for Snack and a la Carte Foods and Beverages 3

7. EXECUTIVE SUMMARY
Health Impact Assessment Background
An HIA is a prospective research tool that guides decision makers in considering the possible health
impacts, and in some cases financial considerations, of proposals. HIAs recommend actions to minimize
adverse consequences and optimize beneficial effects.
ck Foods andHIA are to:
The goals of this Beverages
oods and Beverages assess potential
ard Outcomesrelevant data to for snack and a lahealth impacts as beverages sold implement USDA’s
s and Beveragesstandards
• Synthesize school districts
Outcomes national and state deliberation regarding the potential costs and benefits related to
updated national carte foods and in schools.
omes • Inform snack and a la carte food and beverage standards in schools.
national
Policy
• Identify potential health disparities and inequities that could result from national snack and
Policy a la carte food and beverage standards.
National nutrition standards for snack foods
olicy • Make recommendations to USDA in order to maximize positive health outcomes and minimize
and beverages sold in schools1
National nutrition standards for snack foods
potential health risks.
and beverages sold in schools1
tional nutrition standards for snack foods
d beverages sold in schools1 team followed the North American Snack Foods and Beverages
The research Summary of
ES, MS, HS snack food 2 Summary of Snack and a la Carte
HIA Practice Standards Version Nutrition Standard Outcomes
2 and the National
and beverage availability 2
ES, MS, HSCouncilfood
snack Guidelines3 to develop each FIGURE ES.1 Food and Beverage Health
Research Determinant Pathway
and beverage availability 2
ES, MS, HS snack foodHIA. The most comprehensive
stage of this to 2healthy foods and beverages
Access
and beverage availability unhealthy foods and beverages in
Access to
Access to healthy foodsdatebeverages
literature review to and on competitive foods Policy
School snack foods meeting DGA
Access to unhealthy as originalbeverages analysis of
schools, as well foods and empirical
Access to healthy foods and beverages National nutrition standards for snack foods
School snack foods meeting DGA
school financial data was conducted for this HIA. and beverages sold in schools 1
Access to unhealthy foods and beverages
School snackThe process also required extensive interviews
foods meeting DGA
Purchase/consumption ES, MS, HS snack food
and involvement of a wide array of experts and and beverage availability 2
Purchase/consumption
stakeholders carte sales
A la from academia, industry, the public Access to healthy foods and beverages
Purchase/consumption Vending sales
health community, and those individuals most Access to unhealthy foods and beverages
A la carte sales School snack foods meeting DGA
School ground level, such sales
affected at the store and snack bar as teachers,
Vending sales
A la carte sales
School store and snack bar sales
students, and parents, in planning, researching,
Vending sales Purchase/consumption
School store and snack bar salesthe study.
and peer reviewing
School services Diet and nutrition A la carte sales
Vending sales
health outcomes yet proposed updated
School services had Diet and health outcomes
Because USDA not School store and snack bar sales
nutrition
from revenue
health outcomes time of this study, the HIA
standards at the
School services health outcomes
Diet and nutrition
from revenue scenario in which items would be
examines ahealth outcomes
health outcomes School services Diet and nutrition
health outcomes health outcomes
rom revenuerequired to meet the 2010 Dietary Guidelines from revenue Change
for Americans (DGA). Change Increase
Cha
Change
Change Increase
Increase Decrease
Decrease Incre
See Figure ES.1 for a visual mapping that summarizes
Fundraisers are not included.
1
1 Fund-raisers are not included. Dec
ES, MS, HS: Elementary school,
2
Increase Decrease
the research questions and outcomes school, high school in
middle examined 2 ES, MS, HS: Elementary school, middle school, high school
Decrease
this HIA.
Health Impact Assessment: National Nutrition Standards for Snack and a la Carte Foods and Beverages 4

8. EXECUTIVE SUMMARY
Key Questions and Findings
This HIA considers several key research questions related to school food services, diet and nutrition,
and vulnerable populations (including low income and ethnic minority students).
Diet and Nutrition: The impact of updated nutrition standards for snack foods and beverages sold
in schools on children’s school-based diets was the main issue considered in this study. The analysis
considered two primary nutritional concerns: (1) the total intake of calories from items sold in schools
and (2) the consumption of high-calorie, low-nutrient snack foods and beverages versus healthier options.
Specific questions included:
• Will the updated standards affect the availability of snacks and drinks sold in schools, student
purchases of these items, and student consumption?
• Will changes in student consumption of snacks sold in schools affect different chronic disease
health outcomes?
Finding: Student access to, purchase of, and consumption of unhealthy foods and beverages,
and subsequently their risk for disease, decreases.
Research indicates that many schools
currently sell high-calorie, low-nutrient The increase in child weight observed between 1988 and 2002
snack foods and beverages to students may have been prevented by an average reduction of 110–165
of all ages, who consume them instead calories per day. This is the difference between providing an
of healthier options. The HIA found that elementary school student a 150-calorie snack rather than a
250-calorie snack, as indicated by the child’s daily energy needs.
the implementation of strong snack and
—“Estimating the energy gap among US children: a counterfactual
a la carte food and beverage policies
approach” by Y.C. Wang, et al (Pediatrics, Dec 2006)
that meet the 2010 DGA will decrease
students’ access to, purchase of, and
consumption of unhealthy foods and beverages while also likely increasing their access to, purchase of, and
consumption of healthier items at school. Even small changes to students’ school-based diets—like replacing
a candy bar with an apple—may reduce their risk of tooth decay, obesity, and chronic illness through
decreased calorie, fat, and sugar intake at school. Additionally, the data suggests that strong snack and a la
carte food and beverage policies tend to increase participation in the school meal programs, thus the risk of
not having enough to eat also may decrease as children purchase school meals in place of less filling snacks.
School Services and Impact on Revenue: The impact of updated nutrition standards for snack and a la
carte foods and beverages on student health and school district revenue were of primary concern as food
sales are an important component of school budgets. Specific questions included:
• Will updated nutrition standards affect students’ participation in the school meals program and
school food service revenue?
Health Impact Assessment: National Nutrition Standards for Snack and a la Carte Foods and Beverages 5

9. EXECUTIVE SUMMARY
• Will updated standards affect school-district or other types of revenue that pay for school services?
• If revenue changes occur, will they affect student health via changes to enrichment learning
opportunities and school-supported physical activity?
Finding: Districts would likely not see a decline in revenue.
The HIA analysis found that, when schools and districts adopted strong nutrition standards for snack and
a la carte foods and beverages, they generally did not experience a decrease in revenue overall. In most
instances, school food service revenues increased due to higher participation in school meal programs.
However, in some cases, school districts experienced initial declines in revenue when strengthening nutrition
standards. The HIA concluded that, over time, the negative impact on revenue could be minimized—and in
some cases reversed—by implementing a range of strategies.i Limited data exists on the impact of snack
food and beverage policies on fund-raising revenue for school groups, such as athletic teams and student
government. More research is needed in this area in order to determine how such revenue changes might
influence the provision of school services, such as physical activity and enrichment programming, and thus
the related effect on students’ health.
Vulnerable Populations: A primary consideration of this analysis was how vulnerable populations—including
students from lower-income families as well as those who are black or Hispanicii—might be affected by USDA’s
snack and a la carte food and beverage policy. These vulnerable populations are more likely to have limited or
uncertain access to adequate food;iii to be overweight or obese; to suffer from type 2 diabetes, hypertension,
and other chronic diseases; and to have untreated dental caries, all of which are associated with reduced
quality of life, more frequent school absences, and longer-term health problem.4-10
Finding: Vulnerable populations would benefit from stronger nutrition standards for snack foods
and beverages sold in schools.
Updated nutrition standards that make healthier foods more available may have a particularly beneficial
effect among vulnerable populations, who are at greater risk for nutrition-related health problems. Vulnerable
populations also have higher risk of poor academic outcomes, such as lower test scores and higher dropout
rates.11,12 Because a healthy diet is linked with improved school performance, stronger nutrition standards
also may have a positive impact on academic indicators, especially among vulnerable populations. The HIA
explored other vulnerable populations, such as children of Asian, Pacific Island, and American Indian descent,
but data was too limited to draw conclusions.
i
Effective strategies for reversing potential declines in revenue are discussed in Section 7.3 of the full report.
ii
Hispanic is the term used throughout this HIA to refer to “a person of Mexican, Puerto Rican, Cuban, South or Central American, or other
Spanish culture or origin, regardless of race,” as defined by the U.S. Office of Management and Budget. Other terms, such as Latino, may
be used when citing specific literature findings.
iii
About 15 percent of U.S. households are food insecure, defined by USDA as a household-level economic and social condition of limited
or uncertain access to adequate food.
Health Impact Assessment: National Nutrition Standards for Snack and a la Carte Foods and Beverages 6

10. EXECUTIVE SUMMARY
Policy Recommendations
The following policy recommendations are meant to inform USDA’s efforts to update nutrition standards
for snack and a la carte foods and beverages sold in schools. The recommendations reflect the outcomes
and the conclusions described above, are based upon the evidence summarized in this document, and are
intended to maximize health benefits while minimizing risks. Although not the primary question considered
in his HIA, the research reviewed indicates that the way schools implement improved nutrition standards
through marketing, engaging students, and promoting school meals can play a significant role in how
both students and the schools are impacted. Thus, in addition to the following policy recommendations
to USDA, the full report highlights a range of promising practices for implementation.
Recommendation 1: USDA should establish nutrition standards for all foods sold regularly on school
grounds outside of the school meal programs. These standards should include:
• a requirement that schools sell items from the Dietary Guidelines for Americans list of “foods
to encourage;”
• age-appropriate calorie limits for items sold individually (snacks: 100 calories for elementary,
140 calories for middle, and 180 calories for high school students; entrée items: 300 calories
for elementary and middle and 400 calories for high school students);
• a maximum of 35 percent of total calories from sugar;
• maximum limits for fats (no more than 35 percent of calories from total fat, 10 percent of calories
from saturated fat, and less than or equal to 0.5 g of trans fat per serving); and
• incremental reductions in sodium, with a target time frame of 10 years, to achieve full alignment
with the Dietary Guidelines for Americans.
Recommendation 2: USDA should establish nutrition standards for all beverages sold on school
grounds. At a minimum, these standards should:
• limit beverages sold in elementary and middle schools to only water, low-fat and fat-free milk,
and 100 percent fruit juice in appropriate portions, and
• establish calorie and serving size restrictions for all beverages sold in high schools so as to ensure
calories obtained from sugar-sweetened beverages during the school day are minimal.
Recommendation 3: USDA should adopt policies and practices that ensure effective implementation
of the standards. At a minimum, USDA should:
• provide technical assistance and training to schools and districts;
• provide clear guidance on how the terms infrequent, school day, and school campus as included
in the Healthy, Hunger-Free Kids Act are to be addressed;
• ensure that nutrition standards are kept up to date with future iterations of the Dietary Guidelines
for Americans; and
• collaborate with states and nongovernmental organizations to monitor the implementation of
the standards.
Health Impact Assessment: National Nutrition Standards for Snack and a la Carte Foods and Beverages 7

11. EXECUTIVE SUMMARY
Concluding Statement
This HIA explores the potential impacts of national nutrition standards for competitive foods or foods sold
in schools individually as snacks, a la carte items, and beverages. Research included an extensive literature
review, interviews, stakeholder discussions, and financial analysis. Overall, the results indicate that strong
nutrition standards could have a significant positive impact on the health of students with potentially
increased benefits to those populations that are most vulnerable. In addition, if implemented effectively
at the district and school levels, the changes can be made with little to no negative financial impact and
in fact may even result in improved financial outcomes for schools and districts. Thus, USDA should
establish updated standards and adopt practices—as recommended by this report—that are most likely
to maximize positive health impacts while assisting schools in effectively implementing the changes.
Health Impact Assessment: National Nutrition Standards for Snack and a la Carte Foods and Beverages 8

12. Prepared by Dr. Tia Henderson of Upstream Public Health and Megan Lott of the Kids’ Safe and Healthful Foods Project
PROGRAM EVALUATIONi HEALTH IMPACT ASSESSMENTii
Purpose Purpose
Program evaluation is typically a retrospective tool used to gain information about An HIA is a prospective research tool used to assess the potential health impacts
program efficacy and to identify areas for program improvement. Evaluation is of a defined project, plan, or policy. The HIA guides decision makers in
not only intended to look at "did it work" or not, but also for whom, where, and considering how to maximize beneficial impacts to health and minimize adverse
under what circumstances. consequences. HIAs involve a wide array of stakeholders including potentially
impacted communities to ensure that the process and results are as powerful as
Key Features possible.
Program evaluation typically includes the following:
• Defines an aim, goals and objectives Key Features
• Is guided by a conceptual framework to ask key questions An HIA typically involves six stages:
• Uses assessment instruments such as surveys, interviews, a needs assessment, 1. Screening – decide whether an HIA is feasible, timely, and would add value
performance monitoring, and literature reviews to collect information to a decision making process
2. Scoping – creates a plan and timeline for the HIA, guided by a logic model
• Uses an evaluation matrix to track progress
that links the proposal decision to health outcomes
• Reports findings to program managers and staff to help strengthen the 3. Assessment – explores existing conditions and evaluates potential health
program impacts
Program evaluation identifies program strengths and deficiencies, provides data to 4. Recommendations - creates evidence-based recommendations to reduce
negative and optimize positive health impacts
support continuation, and provides evidence/justification for making changes.
5. Reporting – develops the HIA report to communicate findings and
Evaluation provides information over the long term as the basis for program
recommendations
planning and for program redesign and improvement, such as revisiting program
6. Monitoring and Evaluation – evaluates the process of conducting the HIA,
goals and/or resource allocation
tracks the impacts of the HIA on the decision-making process, and
When to use monitors the impacts on long term health outcomes.
• Determine how effectively meeting program goals and objectives When to use
• Determining impact of program through measurable outcomes • The proposed decision could have substantial negative or positive health
• Determining program needs or gaps that aren’t being addressed effects – especially if these are irreversible or catastrophic
• Develop evidence of client/customer satisfaction • The timing of the decision allows for changes based on new information
• Identify barriers to successful program implementation and delivery • There is a good chance the HIA–based information will be used by decision
• Determining what, if any, changes could improve effectiveness makers to alter the proposal
• Determining whether or not resources are being used as intended • The potential for health effects to place a disproportionate burden on, or
• Determining if elements of the program are replicable in other settings strongly benefit, vulnerable populations
• There is public concern about health effects of the proposal
Who is involved
• The decision making process would not otherwise consider health
Who participates depends on the structure of an organization and on the program
you are evaluating. Some people to consider are: Who is involved
• Managers and directors (i.e. program, agency, development) • Decision makers (i.e. legislators, planners, project managers, developers)
• Program staff (all levels) • Staff who will implement decision
• Evaluation consultant • People who will be impacted by the decision (i.e. stakeholders)
• Grant writer / foundation contact • HIA consultants
• Program participants • Content and technical experts
• External stakeholders (such as government officials, funders, "sister" orgs.)

13. Prepared by Dr. Tia Henderson of Upstream Public Health and Megan Lott of the Kids’ Safe and Healthful Foods Project
Program Evaluation Example HIA Example
Evaluation on Sunnyvale Middle Schools’ Farm to School buy-local efforts Hawai’i County Agricultural Plan HIA
In the fall of 2010, the members of the Wellness Team (includes a science teacher, The 2010 Hawai’i County Agriculture Development Plan, prepared for the
the Vice Principal, two parents, the Wellness Coordinator and the district Hawai’i County Department of Research and Development, is intended to guide
Nutrition Services Director) set a 5-year goal for the district to purchase 15% of the revitalization of agriculture as the basis for Hawai’i Island’s (big island)
their foods from state sources where feasible (produced and processed). The economic development. The draft plan included key policy activities to support
Kitchen Manager at the school also set a goal of one meal a month being as close to agriculture and economic development. It was approved in 2011 by the City
100% local as possible. Council.
After the team set the goal, the district Business Manager worked with the district In 2010, the Kohala Center, a non-profit organization, received a grant to
School Nutrition Service director to begin 1) entering monthly orders into an complete an HIA on three policy components of the Plan to better understand,
excel spreadsheet and 2) asking distributors to let them know on invoices which and inform residents and decision makers, on how the policies would affect
items were “local”. public health.
Aims of the Evaluation: Aim of the HIA:
• Evaluate how far the District has progressed toward the 15% district The goal of the HIA is to inform legislative and regulatory decision-making so
goal, and the Kitchen Manager’s goal of one local meal a month. that these three Agriculture Plan policies are implemented in ways that maximize
• Determine any barriers the school and district have encountered in health benefits and minimize health risks for Hawai‘i Island residents. This HIA
working toward these goals examines the impact of each of the three Agriculture Plan policies on five health
• Problem-solve to help meet the goals in the next three years. outcomes or determinants of health, from the range of personal, social, economic,
and environmental factors that can affect the health status of individuals or
• Use the results as part of a grant application to pay for new kitchen
communities:
equipment.
1. Food security
2. Obesity
Methods:
3. Food-borne illness
• Assess purchases using the sales records 4. Economy
• Assess meals using previous menus 5. Well-being and cultural connectedness
• Interviews with the Kitchen Manager, Business Manager, the Nutrition
Service Director Methods:
• Two page report discussed at the January 2013 Wellness Committee • Literature review
meeting • Secondary data
• Input-output economic analysis
Who is involved:
• One parent and non-profit partner doing the evaluation Who was involved:
• The Wellness Committee is advising on the process • Impacted stakeholders including health coalition representatives, garden
network representatives, farmers, residents and government agency
representatives
For more information visit: http://kohalacenter.org/agplan.html
i
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