Changing Environment, Engaging Community:

An Effective, Feasible Approach to Childhood Obesity

Policy Solutions Challenge USA National Finals March 2013

Amber Ma, Matthew McCabe, Gayatri Sahgal, Dana Schwartz, and Kelsey Sherman*

Taubman Center for Public Policy & American Institutions

Brown University

Correspondence: Matthew McCabe (matthewianmccabe@gmail.com)

Executive Summary
Childhood obesity has tripled since 1980, costing the country around $14 billion in 2009. Childhood obesity can create a greater risk of diseases such as diabetes and heart disease, and can have detrimental psychological effects such as lowered self-esteem and body image issues. Our comprehensive solution changes childrens nutrition and activity environments, and engages parents with information about their childrens weight, all with the goal of preventing and reducing the prevalence of childhood obesity. We propose changing the food environment by reforming the Supplemental Nutrition Assistance Program to incentivize participants to choose healthier options. Our proposal also creates minimum physical education and physical activity standards in schools in order to change the activity environment. And finally, we propose screening and reporting students Body Mass Index to change the information environment in a way that will engage and empower parents.

A Snapshot of Childhood Obesity Today

According to the Center for Disease Control (2013), the prevalence of childhood obesity has tripled since 1980 to 17% of children ages 2-19, exacerbating the already considerable consequences of obesity on Americas health. More than ever, childhood obesity demands innovative solutions to address multifaceted causes involving the individual, family, community, and environment. Obesity is measured as a ratio of ones weight and height to calculate an age and gender-specific percentile that determines body mass index (BMI). Childhood obesity is defined by a BMI between the 85th and 95th percentile and, most simply put, is caused by eating too many calories and not getting enough physical activity. The underlying factors, costs, and solutions, however, are much more nuanced, and require a comprehensive approach to address this challenge. Childhood obesity warrants the priority of national policymakers, as well as individuals and communities alike. Its effects on the cost of health care and quality of life for affected individuals are profound. Annual direct health care costs (including annual prescription drug, emergency room, and outpatient costs) related to childhood obesity totaled $14.1 billion, plus inpatient costs of $237.6 million, according to a 2009 study (Cawley, 2010). These costs will continue to climb as obesity during childhood persists into adulthood. Total costs of obesity measured $147 billion in 2008 (Finkelstein, Trogdon, Cohen, & Dietz, 2009). Cawley & Meyerhoefer (2012) posit that medical costs for obese individuals were several thousand dollars higher than those who are not obese. Perhaps as significant is the effect obesity has on quality of life, such as value of lost work, and higher insurance premiums. Additionally, research suggests that childhood obesity is also a socioeconomic issue correlated with income, food access, and ethnicity. The prevalence of obesity in 2004 was 20% of African American children, 19% of Mexican American children, and 39% of Native American boys, compared with 16% of non-Hispanic white children (Caprio et al., 2008). There is also a socioeconomic gap in physical activity. In California, only 11% of male Latino teens and 18% of male African American teens engage in moderate physical activity at least five times a week, compared to 20% of male white teens (Grissom, 2005). In terms of food access, a multistate study cites findings that people with access to fresh food markets have lower rates of obesity. In California, obesity and diabetes rates are 20% higher for those living in the least healthy food environments, controlling for household income, race/ethnicity, age, gender, and physical activity levels (Treuhaft & Karpyn, 2010).

The Consequences of Not Acting

If the problem of obesity is not addressed nationally, its cost, both social and economic, will only increase. The habits vital to maintaining a healthy weight are built in childhood; likewise, the foundations for obesity are established early (Haskins, Paxson, & Donahue, 2006). About a third of obese preschool children, and about half of obese school-age children, will grow into obese adults. There is also evidence that childhood obesity has detrimental effects independent of adult BMI, suggesting the damage done in childhood persists into adulthood (Lakshman, Elks, & Ong, 2012). Being overweight strains nearly every aspect of physiology, affecting memory, mood, and respiratory and reproductive function. Obesity is also linked to a number of serious conditions including diabetes, heart disease, and certain types of cancer. A report finds that rates of type 2 diabetes and pre-diabetes among adolescents in the U.S. have jumped from 9% in 2000 to 23% in 2008 (Wang, McPherson, Marsh, Gortmaker, & Brown, 2011). These increased health risks facing the obese population have led to increased medical costs both to the individual and the public. Although most experts agree that the costs of obesity are substantial, it is more difficult to estimate actual costs. First, there are direct costs associated with obesity, such as counseling, surgery, and medication, and indirect costs, such as related health problems, missed work, and quality of life issues. Obesity explains 27% of the rise in health care spending between 1987 and 2001 (Cawley, 2010). One estimation model demonstrated that the obese, with a BMI over 30, have 36% higher average annual health care costs than the healthy-weight group, including 105% higher prescription costs and 39% higher primary-care costs. Hammond & Levin (2010) note that in 2008, the cost of medical obesity care was as high as $147 billion, or 10% of all medical spending. As more children grow up and join the pool of overweight adults, those costs will only increase. Secondly, indirect costs of obesity extend beyond medical treatment, factoring in the shorter life spans (by as much as 13 years) and the lower work productivity of a population hindered by obesity (Lalasz, 2013). An obese employee will have to take more days off from work, which costs the employer both in incomplete work and lost wages: Obesity-related absenteeism wastes $43 billion annually. Employers also are forced to pay higher life insurance premiums and pay out more compensation. Even if the employee is present, obesity contributes to presenteeism, inability to work at full capacity, estimated at over $500 per obese worker per year (Harvard School of Public Health, 2013). A good example of this problem is in the armed forces: Today, close to 30 percent of young Americans weigh too much to qualify for military service. More than one-third of adults in America are obese (Centers for Disease Control and Prevention, 2013). If current trends continue, an additional 65 million Americans will become obese by 2030, up to half of the entire country (Finkelstein & Trogdon, 2008). Obesity is a serious problem confronting the nation, and a solution targeting children must be considered, especially when habits established during childhood shape eating and exercise in adulthood. Despite the passage of the Affordable Care Act, there is still substantial concern about rising health care costs. Dealing with childhood obesity is one way to help control those costs and improve the lives of many Americans.

Finding Solutions
When addressing childrens issues, the natural tendency is to use the frame of parental responsibility. Policymakers seeking public policy solutions to childhood obesity should reframe the issue to include both parental and community responsibility (Duderstadt, 2009). This can be done by stressing the social costs of obesity and the vulnerable nature of children. Communities and governments are better equipped to address the environmental factors causing childhood obesity. As Dr. Thomas R. Frieden, director of the CDC, writes, the goal is to make peoples default choices healthy ones (Frieden, Dietz, & Collins, 2010). That being said, engaging with parents is vital to combating childhood obesity, and our proposals seeks to address both environmental factors and to foster parental involvement. Our teams solutions address both the individual and the environment he or she inhabits. For instance, we recognize that obesity is not only affected by a childs food consumption and activity level, but also surrounding environmental factors (quality of food in school, facilities for exercise, media), socioeconomics (ethnicity/race, parental involvement, access to quality food), and culture. The main criteria for our policy alternatives are effectiveness and political feasibility. Because there is consensus that current policies have failed to solve the problem, we focus on proposals not yet implemented on the federal level. However, all of our policies have precedent in prior policymaking, state and local efforts, or pilot programs. Evidence from these examples suggests that our proposals will have a positive impact. We decided early in the process to stay away from especially controversial policies that are not politically feasible on the national level, including increased taxation, advertising restrictions, and bans on certain foods or ingredients. For example, Mayor Bloombergs ban on large sodas was recently struck down by the courts, suggesting that such measures are not popular or feasible (Grynbaum, 2013). Our proposal has three elements, pertaining to nutrition, exercise, and information. Each of these elements contains a recommendation that attempts to change the existing environment in order to alleviate childhood obesity. Our proposal is designed to be implemented on the federal level, with the goal of passing a divided Congress, in order to be a starting point for systemic change.

Our Proposal:
Nutrition:
Recommendation: Reform the Supplemental Nutrition Assistance Program (SNAP) to promote the purchase of healthy foods and cap unhealthy food purchases Who It Targets Almost half of all SNAP recipients are children and over 70% of SNAP recipients live in households with children (Center on Budget and Policy Priorities, 2012). Although more data is needed to determine the relationship between SNAP and obesity, 45 million people are enrolled in SNAP, presenting a crucial opportunity to improve nutrition in the United States. Leung & Villamor (2011) conducted a study in California suggesting that obesity rates were 30% higher among SNAP participants than nonparticipants. SNAP and SSI participants also reported higher soda consumption than nonparticipants. It is unclear if the SNAP program itself is causing obesity, or if the programs composition is inherently of obese populations. In either case,

strengthening SNAP is an opportunity for the program to encourage healthy, nutritious food choices, especially in the important life stage of childhood. In the last 20 years, food prices for fats and sweets increased by 30%, whereas the cost of fresh produce has increased more than 100% (Monsivais, 2007). Food prices affect spending and consumption behavior: Findings from the USDA Economic Research Service cite that a 10% decrease in the price of fruits and vegetables results in up to a 5% increase in the purchase of these items (Dong & Lin, 2009). Increased fruit and vegetable consumption may or may not be linked to a decrease in overall calorie intake, but it has the potential to reduce the risk of obesityrelated diseases, such as heart disease, cancer, and diabetes (Vaschaspati, Wharton, DeWeese, & Tucker, 2011). What It Does Our proposed SNAP reform has two prongs: subsidies for fruits and vegetables, and capping the percent of monthly benefits SNAP participants can use to purchase high-sugar, highfat, and high-preservative foods, such as soda and candy (Ludwig, Blumenthal & Willett, 2012). For example, for every SNAP dollar spent on fruits and vegetables, a family would receive 10 cents back, deposited into their SNAP account. Likewise, only a certain percentage of SNAP benefits, such as 30%, could go towards the purchase of unhealthy foods and sugar-sweetened beverages. Our proposal also recommends that the USDA implement rigorous tracking of point-ofsale SNAP spending. This aggregate data will be able to support evaluation of how the program is contributing to diet quality and what adjustments should be made in subsidies and caps in order to promote healthy eating. The government is already experimenting with subsidies. The 2008 Farm Bill created the USDA Healthy Incentives Pilot Program, which provided participants in the SNAP program a subsidy on the purchase of fruits, vegetables, or other healthy foods (U.S. Department of Agriculture, 2013). This pilot provides 30 cents per dollar toward the purchase of such foods. An evaluation of the program is important before proceeding, in order to determine implementation challenges and the optimal subsidy and cap. In many cities across the nation, such as Providence, Rhode Island and New York City, nonprofits have secured grants to provide SNAP users with subsidies to spend on fruits and vegetables at farmers markets. The former alone has observed an increase of $35,000 bonus bucks spent on neighborhood-based farmers market produce by over 1,300 SNAP recipients between 2009 and 2011 (Farm Fresh Rhode Island). While our proposal focuses on SNAP reform, the logical next step is to enact measures such as these subsidies that give participants increased access to healthy food. What It Costs The following costs must be considered when exploring reformation of the SNAP program. The annual budget for the SNAP program totaled $78 billion in 2011 (Center on Budget and Policy Priorities, 2012). Covering healthy food subsidies of 10% on a national level is estimated to cost the federal government at least $580 million annually, or $6.1 billion over 20 years with a discount rate of 7% (Dong & Lin, 2009). We hope that promoting healthy eating in SNAP can catalyze short- and long-term cost savings in areas such a health care, worker productivity, and educational achievement for children (Center for the Study of the Presidency and Congress, 2012).

Physical Education and Physical Activity:

Recommendation: Create minimum national standards for physical education and physical activity in public schools. Who It Targets The Healthy, Hunger-Free Kids Act of 2010 requires that local education agencies create local school wellness policies that set goals for promoting nutrition and physical activity. It does not, however, create minimum requirements for physical education and activity in public schools. While education is a local issue, the federal government has taken an increasingly active role in this policy area. Just as the USDA is establishing baseline nutrition guidelines for schools, the federal government should establish baseline physical education guidelines. What It Does We propose a federal minimum of 100 minutes of weekly or about 67 total hours per 40week school year of physical activity for all elementary school students. In order to accommodate schools, our definition of activity is broad, and includes things like recess, physical education class, or even physical activity during class or while on breaks from class. We also propose requiring middle and high school students to complete 120 minutes a week or 80 total hours of physical activity each 40-week school year. This baseline would be low enough and flexible enough to avoid overburdening schools, but high enough to hopefully have substantive impact. The National Association for Sport and Physical Education (NASPE) and the American Heart Association (AHA) recommend that all elementary school students should participate in at least 150 minutes per week (100 hours per year) of physical education and that all middle and high school students should participate in 225 minutes (150 hours per 40 week school year) of physical education per week (National Association for Sport and Physical Education, 2011; Centers for Disease Control and Prevention, 2010). Our standards are lower than these guidelines in order to avoid too much pushback from school districts and states, but our proposal would encourage schools to meet these guidelines if possible. It is important to recognize that schools are under immense pressure to show academic achievement. However, physical education should not be discounted based on the perception of academic sacrifice (Ayers, 2013). Studies from the California Department of Education as well as the New York City Health and Department of Education reported a strong positive relationship between physical fitness and academic achievement (Grissom, 2005; New York City Department of Health, 2009). What It Costs Currently, the median budget for physical education in the United States is $764 per school per year. The federal government offers annual grants through the Carol M. White Physical Education Program, or PEP. PEP gave an estimated $80 million in 2012 to initiate or expand physical education in public schools. The grant is given through an application process that awards an average of $479,000 per school over a period of three years. A continuation of this grant could help school districts to reach the minimum requirement proposed by this policy, and the PEP program can be additionally expanded as needed. Recently, First Lady Michelle Obama announced a $70 million public-private partnership program that will provide schools with grant-funding to increase physical education (Steinhauer, 2013).

The CDC found that an average of 81% of schools require physical education; however, many do not meet the minimum amount of nationally recommended physical education (National Association for Sport and Physical Education, 2011). We can assume that every school that is required to have a physical education program has one, although there are undoubtedly exceptions. Using this assumption, we can model the costs if we chose to provide all the other public schools in the country with a physical education teacher. Using a $50,000 annual salary for an average teacher, this cost works out to about $990 million annually. This would cost about $10.5 billion over 20 years at a discount rate of 7%. Under our proposal, the federal government, state governments, and local districts would share the cost of meeting this mandate. This cost sharing is already happening to some extent with such programs as the PEP grants. We envision increased federal spending in order for states to meet the mandate. Rather than putting a concrete number on these federal appropriations, we chose to look at the entire cost of equipping the remaining schools in the nation with physical education teachers. This number can be considered both an underestimate and an overestimation. Some of the 81% of schools that require physical education will need more funding to meet our physical education/physical activity mandate. Many schools will not only need a physical education teacher, but also infrastructure improvements and new equipment. On the other side, our proposal does not require physical education, so some schools might choose to forgo a formal physical education teacher. Schools could share a physical education teacher to cut down on costs or use the money toward other innovative ways of meeting our requirement. In addition, the cognitive benefits of exercise mean that physical activity spending will hopefully improve learning outcomes, which is a benefit we do not quantify. We believe our cost model provides a reasonable estimation of the cost of equipping schools to meet our mandatory baseline standards for physical education and physical activity.

Information:
Recommendation: Create federal grants to encourage states to screen and report students BMI. Who It Targets Body Mass Index (BMI)an age and gender specific weight to height ratiois the commonly accepted measure of obesity. While there is evidence that BMI has flaws, it is a useful tool for doctors and parents to assess the issues regarding a childs weight (American Heart Association; Ayers, 2013). Since Arkansas established the first statewide BMI surveillance of students in schools, nearly 20 states have followed suit using different data collection models (Longjohn, Sheon, Card-Higginson, Nader, & Mason, 2010). Evidence from Arkansas indicates that 60% of parents underestimated their childs weight before the measure was enacted. One year after implementation, this number dropped to 53%. Gains among African Americans, a group at risk for obesity, were even greater: Specifically, African American parents improved from 30% accurate classification before the BMI measurement to 44% accurate after the first Child Health Report was distributed (West et al., 2008). This indicates that BMI tracking is effective at improving parental knowledge of childhood obesity. BMI screening in school and reporting to parents could be beneficial for several reasons. First, children can be diagnosed as overweight or obese without having to visit a primary care physician. Parents could also become familiar with their childs status and with the risks that are

associated with childhood obesity. This is especially helpful for those who do not have access to health care or would not normally take their child to the pediatrician. BMI screening in schools may help curb long-term effects by stressing early prevention. Better data about childhood obesity can help educators and policymakers determine what types of programs need to be created to help create a healthier school environment or community (Ohio Department of Education). There is a risk of stigmatization and parental pushback with this program. However, similar programs in Arkansas and Ohio have received little negative feedback from parents or educators (Ayers, 2013; Raczynski et al., 2009). When dealing with childrens issues, there are always concerns about protecting children from psychological harm. Schools have the necessary expertise to navigate these issues. The number of states that have adopted BMI tracking suggests these concerns are not fatal to the program, and these states provide a model for broader implementation. What It Does Our proposal asks that the federal government encourage school districts to adopt annual BMI reporting. Two House resolutions introduced in 2009, HR3955 and HR4053, proposed that the CDCs Division of Nutrition Physical Activity and Obesity and the National Center for Immunization and Respiratory Diseases administer grants for BMI surveillance programs (Longjohn et al., 2010). Our recommendation is that a similar grant system be adopted. Because BMI reporting has the potential to be controversial, especially over concerns about privacy and stigmatization, this plank in our proposal is not a mandate. States would apply for the grants, and be required to screen their students a certain number of times over the course of their school career, and provide the resulting information to parents. We will also require that states implementing these programs meet specific criteria pertaining to privacy issues, proper training, and linking families with primary care physicians and other resources (Ayers, 2013). We envision that schools would send home an annual report card for all students, listing a students BMI and resources concerning nutrition, exercise, and counseling services. To additionally combat pushback, parents will have the option to opt out of their childrens BMI screening. The Ohio model has shown, however, that when given the option, few parents actually opt out of the BMI screening (Ayers, 2013). School districts who screen and report students BMI will be required to report their findings to the federal government. This data will then be used by the presidents Childhood Obesity Task Force to establish local needs. We believe that the next step should be for the federal government to appropriate money for follow-up grants, and these grants would be aimed at encouraging partnerships with local health organizations and physicians or providing in-school counseling and nutrition services to children in schools with high rates of obesity. What It Costs We estimate that the total federal cost for issuing grants would equal $1.2 billion annually, which projected over 20 years, at a discount rate of 7%, is $13 billion. Our cost model is fairly simple, using school nurses as a proxy. The average national salary for a school nurse is $64,000 annually (Center for Education Reform, 2011; National Center for Education Statistics, 2011). About 75% of schools already have at least one full-time or part-time nurse on staff (Toppo, 2009). This model estimates cost by taking the remaining 25% of schools in the United States, about 25,000 schools, and awarding them up to $50,000 to cover the cost of a nurse

(Center for Education Reform, 2011). It is important to note that BMI screening is a simple procedure, only requiring an examiner to take down a childs height and weight. A nurse is not needed, which makes our cost model an overestimation. This overestimation was done partly to make the model robust, and partly to account for that logistical cost of data and reporting systems that will have to accompany BMI screening.

Looking at Costs and Benefits

The complex nature of childhood obesity makes it difficult to estimate costs and benefits. As we have touched upon, there are significant direct costs to the health insurance system, and to the nations largest health insurer, the federal government. According to the Harvard School of Public Health (2013), obesity-related conditions accounted for an estimated 8.5% of Medicare spending and 11.8% of Medicaid spending in 2006. Using these percentages and the current budgets of these programs, the share of obesity-related spending in Medicare was $47.1 billion last year, and $29.6 billion for Medicaid. Broader estimates about the total costs of obesity to society, including indirect costs, run as high as $450 billion annually (Hoffman, 2012). While it is true that these numbers are not tied exclusively to childhood obesity, evidence suggests that alleviating childhood obesity should mitigate the problem of obesity as a whole. Some back-of-the-envelope calculations suggest that our proposal, projected out 20 years, will cut down significantly on direct health care costs associated with obesity. Mardner, Chang, & Medstat (2006) suggest that, in 2004 dollars, the difference between obese and non-obese children in mean annual covered health care expenses is $2,635 for children on private insurance, and $4,284 for children on Medicaid. Averaging these groups, and adjusting for inflation, obese children are $4,217 more expensive annually. We estimate two projections of obesity and use them to develop two different models. Model 1 assumes a 0.75 annual percentage point increase in obesity based on the average increase using data from the CDC on the rates of childhood obesity from 1999-08 (Ogden, 2010). Model 2 assumes a 1.16 annual percentage point increase in obesity based on the projections taken from the OECD, which estimates that childhood obesity rates will reach 25% by 2020 (OECD). For this model, we will operate under the assumption that our policy solutions halt the increase in obesity after five years. In Arkansas, evidences suggests that their comprehensive childhood obesity bill halted the increase in obesity after three years, so we believe this is a reasonable assumption (Raczynski et al., 2009). The final piece of the analysis uses projections for the population of children in the United States (U.S. Census Bureau). It should be noted that all of these children are not covered under insurance. However, it is reasonable to assume that even uninsured children bear the costs of obesity, and applying the average covered health care expense to the entire population is a way to estimate those costs. Using these figures, the model reveals that over 20 years, the aggregate difference in health care expenses between a world where childhood obesity continues to rise, and one in which our policy solutions halt that rise after five years, is $329.5 billion for Model 1, (0.75 projected increase in obesity rate) and $509.6 billion for Model 2 (1.16 projected increase). This represents the potential benefits to society in terms of costs saved. Moreover, since many children are covered under Medicaid, a fair amount of those savings accrue directly to the federal government. Using a 7% discount rate, the present value of those savings is $119.7 billion and $185.2 billion under Model 1 and 2, respectively (see Appendix for more detail about our models).

These models are a rough estimation of the benefits that should flow from our proposed policy. We recognize that several elements, such as including all children in the calculation, averaging the increased health care costs borne by obese children, using obesity rates from several years ago, and projecting a constant linear increase in obesity, are potential issues with our model. However, our models remain very conservative in many ways, such as in the assumption that obesity rates will not decline, the high discount rate, and the fact that only direct health care costs are included. As we alluded to earlier, indirect health care costs are estimated to be several times greater than direct costs. The total costs of our proposals over 20 years using a discount rate of 7% is $29.6 billion. By simply comparing the present value savings of $119.7 billion (conservative estimate) with our relatively modest state and federal expenditures, our proposal illustrates that the benefits outweigh the costs.

Getting Our Proposal Passed

The current political climate, however, does not appear to favor a large, costly childhood obesity solution: President Obamas signature obesity legislation, the 2010 Hunger-Free Kids Act, only secured $4.5 billion in new appropriations for a period of ten years. Given the economic and social costs of childhood obesity, significant efforts are needed to raise awareness and place pressure on policymakers to allocate greater funding to address the problem. If obesity rates are reduced by as little as 5%, health care savings could exceed $29 billion a year (National Conference of State Legislatures, 2011). The public, and Congress, will have to be made aware of the costs of childhood obesity before action can be taken. Several states, including Alabama, California, Florida, Iowa, Maine, Massachusetts, Ohio, and Tennessee, have passed fairly comprehensive childhood obesity legislation. There have also been federal bills that have tried to alleviate the childhood obesity problem. Though these bills include a variety of provisions ranging from nutrition education for children and parents, to mandatory physical education, to restrictions on vending machines in schools, there has not been federal legislation that takes a comprehensive approach to childhood obesity. Arkansas Act 1220, passed in 2003, is a strong example of how comprehensive childhood obesity legislation should be passed. This bill was the most comprehensive school-based childhood obesity legislation passed at the time. Factors that have contributed to the passage of such bills include the presence of more than one sponsor, bipartisan sponsorship, model school policies, statewide initiatives, and task forces (Boehmer, Luke, Haire-Joshu, Bates, & Brownson, 2008). In order to ensure swift resolution a policy entrepreneur, who will be a champion for the cause, needs to be chosen. This policy entrepreneur should take advantage of the open policy window created by public campaigns like Lets Move!, spearheaded by Michelle Obama, and by the rise of health care costs. He should also gain bipartisan support similar to that gained by the Healthy, Hunger Free Kids Act and Arkansas Act 1220. In 2011, the New York Times reported that 60% of people who responded to their poll said the government should have a significant role in reducing childhood obesity (Grocery Manufacturers Association, 2011). They also reported that 51% of those agreeing were Republicans. Coalitions including federal and state legislators concerned about health and obesity, governors, parents, educators, local media, and public figures and organizations, should also be built in order to aid passage. There is likely to be pushback pertaining to different prongs of our proposal. The Processed Food Manufacturer Lobby, Food Marketing Institute, National Grocers Association,

Snack Food Association, along with companies such as Cargill, PepsiCo, and Kroger, lobbied Congress to oppose health-oriented improvements to SNAP in at least nine states (Simon, 2012). Because our SNAP reform aims to decrease how much SNAP participants spend on many unhealthy brands represented by these lobbies, it makes sense that there will be strong opposition from these groups. Some advocacy groups might have concerns about placing restrictions on the food choice for SNAP participants. Principals and superintendents may contest the physical education/physical activity and BMI tracking portions of our proposal because it imposes more mandates on an already taxed educational system. This is why we chose to make the physical activity requirements low, and made BMI tracking an optional grant-based program. Most schools have some kind of physical education program, and more and more states are adopting BMI tracking, which suggests that these programs might not be as burdensome as they might appear. There are significant groups that should support our proposals. It is likely that health care, patient, and insurance lobbies might be brought into a coalition if they believe our proposal will help make children healthier and lower health care costs. It will be important to work to gain parental support, especially for BMI tracking. Because our SNAP reform provides subsidies, in effect increasing participants purchasing power, there should be many advocacy groups that line up behind the reform. Finally, governors and mayorsthose executives more directly accountable for school performancewill have to be brought on board to ensure passage and successful implementation of increased physical activity and BMI tracking. It will be important that these groups believe federal funding is sufficient to help defray local costs. This broad coalition will help build support and counter opposition lobbying efforts.

Conclusion
The problem of obesity in America today has profound consequences for the health of our citizens and the national economy. The growing number of overweight children will only magnify those impacts over time, increasing the health care costs and reducing the overall efficiency of the workforce. Obesity arises from a number of complex factors, so any effective solution must be multifaceted and comprehensive. Our policy proposal addresses three target areas in order to promote sustainable, effective change: nutrition, physical activity, and information. By encouraging healthy food choices for SNAP participants, by updating school physical education and physical activity requirements, and by helping states track students BMI in order to inform parents, our policy proposal aims to create systemic solution to the childhood obesity epidemic.

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http://www.saferoutespartnership.org/blog/what-does-transportation-bill-mean-saferoutes-school Public Law 111-296: Healthy, Hunger-Free Kids Act of 2010 (124 Stat. 3183, Date: Dec. 13, 2013). Text from United States Public Laws. Retrieved January 7, 2013 from http://www.gpo.gov/fdsys/pkg/PLAW-111publ296/pdf/PLAW-111publ296.pdf Raczynski, J., Thompson, J., Phillips, M., Ryan, K., & Cleveland, H. (2009). Arkansas act 1220 of 2003 to reduce childhood obesity: its implementation and impact on child and adolescent body mass index. Journal of Public Health Policy, 30. doi:10.1057/jphp.2008.54 Rector, R. & Bradley, K. (2012) Reforming the Food Stamp Program. The Heritage Foundation. Retrieved from http://www.heritage.org/research/reports/2012/07/reforming-the-foodstamp-program Sharp, M., Harrison, P., & Morris, V. (2011). Childhood obesity: a policy perspective. ICAN: Infant, Child, & Adolescent Nutrition, 3(76). doi: 10.1177/1941406411402305 Siegel, M. & Biener, L. (2000). The impact of an antismoking media campaign on progression to established smoking: results of a longitudinal youth study. American Journal of Public Health, 90(3). Simon, M. (June 2012). Are corporations profiting from hungry Americans? Eat drink politics. Retrieved from www.eatdrinkpolitics.com/wpcontent/uploads/FoodStampsFollowtheMoneySimon.pdf Tavernise, Sabrina. (2013, February 23). Children are eating fewer calories. New York Times, pp. A15. Toppo, Greg. (2009, August 10). School nurses in short supply. USA Today. Retrieved from http://usatoday30.usatoday.com/news/health/2009-08-10-school-nurses_N.htm Treuhaft, S. & Karpyn, A. (2010). The grocery gap: who has access to healthy food and why it matters. Policy Link. Retrieved from www.policylink.org/atf/cf/%257B97C6D565-BB43406D-A6D5-ECA3BBF35AF0%257D/FINALGroceryGap.pdf U.S. Census Bureau. Current Population Reports - Table POP1. (Series P-25, No. 917). Retrieved from http://www.childstats.gov/americaschildren/tables/pop1.asp?popup=true U.S. Department of Agriculture. (1999). Data tables: food and nutrient intakes by individuals in the United States by income, 1994 1996. Retrieved from http://www.barc.usda.gov U.S. Department of Agriculture. (2013). Supplemental nutrition assistance program: Healthy incentives pilot. Retrieved from http://www.fns.usda.gov/snap/hip/ U.S. Federal Highway Administration. Safe routes to schools. Retrieved from http://safety.fhwa.dot.gov/saferoutes/funding/ U.S. Health and Human Services. Recovery act-funded programs. Retrieved from http://www.hhs.gov/recovery/programs/index.html#Prevention Ungar, Rick. (2012). Obesity now costs Americans more in health care spending than smoking. Forbes. Retrieved from http://www.forbes.com/sites/rickungar/2012/04/30/obesity-nowcosts-americans-more-in-health care-costs-than-smoking/. Vaschaspati, P.O., Wharton, C., DeWeese, R., & Tucker, W. (2011). Policy considerations for improving the supplemental nutrition assistance program. Arizona State University School of Nutrition & Health Promotion. Retrieved http://www.azdhs.gov/phs/bnp/nupao/documents/SNAP_White_Paper_12-14-11l.pdf

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West, D., Raczynski, J., Phillips, M., Bursac, Z., Gauss, C.H., & Montgomery, B. (2008). Parental recognition of overweight in school-age children. Obesity (Silver Springs), 16, 630636. doi:10.1038/oby.2007.108. White House. (2010). The child nutrition reauthorization healthy, Hunger-Free Kids Act of 2010. Retrieved January 24, 2013 from http://www.whitehouse.gov/sites/default/files/Child_Nutrition_Fact_Sheet_12_10_10.pdf

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Appendix
Benefit calculations, twenty-year projection Our projected cost and benefit calculations are based on two models: Model 1: We estimate a 0.75 annual percentage point increase in obesity. We calculate this average based on the rates of increase in obesity from 1999-2008 using the CDC figures for obesity rates from 1999-08. Model 2: We estimate a 1.16 annual percentage point increase in obesity. This is based on projections taken from the OECD, which estimates that childhood obesity rates in the US will reach 25% by 2020. For both Model 1 and 2 we compute the costs and benefits using the same method. The method is described in detail below: a) Population of obese children: Using both Model 1 and 2 we calculate the number of children who are obese. We base our population estimates on data obtained from U.S. Census Bureau, for the twenty-year period. b) Estimate of costs: In both our models we estimate costs under two situations; 1) Intervention: The effect on costs with obesity rates stabilizing in year 2018, i.e. we assume that by 2018 the obesity rates will stabilize. 2) Control: The effect on costs when obesity rates do not stabilize and continue to increase in the absence of intervention, over the twenty-year period. 3) The costs under both model is based on an average of the additional Medicaid and private costs spending on obese children vis--vis non-obese children (Mardner, Chang, & Medstat 2006). The estimated average spending for obese children we estimate as $4217. c) Total costs under intervention and control: We multiply the average costs of $4217 with the number of children who are obese to estimate the cost of obesity in each year, under both situations of intervention and control. d) Benefits: We then calculate the difference between the costs in each year under both situation of intervention and control to determine the total savings or benefits. e) Present value of benefits: Using the benefits or the total savings we then estimate their net present value using the official discount rate of 7%, which is used by the Office of Management and Budget.

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