Eat Well Play Hard: How NYS Developed and Integrated Key Nutrition Strategies into All Program Efforts Amy Koren-Roth, MS, RDN, CDN NYS Department of Health Division of Nutrition *EWPH intervention began to be devoloped by DON of NYSDOH in 1995, in response to the rise in both childhood and adult obesity. It is more of a philosophy and framework for a consistent response that addresses both sides of the “energy equation” (PA and nutrition) - starting with pre-schoolers, since waiting until school age is often too late for prevention in many cases.

The Problem: In 1995, 10% of NYS WIC participants age 2-5 were overweight Prevalence of obesity in NYS school children ranged from 13-20% Thanks to staff in our surveillance and analysis area, the issue of overweight in children came to our attention in the mid-90’s. By the turn of the century, everyone was talking about this trend.

The Approach: Bring together Division of Nutrition Programs to chart a course of action (1995) WIC/Farmer’s Market Commodity Supplemental Food Program Child and Adult Care Food Program Hunger Prevention and Nutrition Assistance Program

No Money... No Mandate... Just resolve! When we started this effort, we had no new funding and no mandate to make these changes. What we did have was a sincere desire, on the part of our Division leadership, to try to affect change. Just resolve!

What it took: Development of infrastructure to support program efforts Series of meetings of ~ 60 nutritionists over 2 years Consensus around goal and core strategies Flexibility to allow programs to incorporate strategies in their own way Coordination role given to Nutrition Policy and Health Promotion Unit. EWPH Annual Meetings held in 1997, 1998, 2000, 2001, 2002. Regional Partnership Meetings organized and held 2003 – 2005.

What we wanted to achieve: Develop positive behavioral strategies Establish consistent nutrition and physical activity recommendations in child nutrition and health programs Link and reinforce EWPH recommendations at the community level Our approach to the problem has some basic tenets: - Development of strategies that are positive, behavioral and represent life-long healthy choices (simple messages that aren’t confusing) - Consistently implement the strategies and promote the messages in program policies, guidelines, training and educational materials - families hear the same thing wherever the go - awarded 3 demonstration projects, which are in their final year and have become model communities

Eat Well Play Hard Goal To prevent childhood overweight and reduce long-term chronic disease risks through the promotion of physical activity and targeted dietary practices with children over the age of two. EWPH is a comprehensive public health intervention, aims to be positive and simple Goal: - prevent children from becoming overweight - reduce chronic disease risks such as high blood pressure, type 2 Diabetes, - through promotion of physical activity and targeted dietary practices with children over the age of 2 Alarming national trends: today’s kids not meeting their nutritional needs: recently released vital signs show that children ate slightly more fruit than vegetables, 6 in 10 didn’t eat enough fruit and 9 in 10 didn’t eat enough vegetables nationally. In NY WIC, we found that there has been an increase in vegetable consumption.

Original Eat Well Play Hard Strategies (1996-Present) Increase developmentally appropriate physical activity Increase consumption of 1% or less milk and low-fat dairy products Choice of strategies: wanted them to be simple, positive, address multiple chronic diseases (CVD), cancer, osteoporosis) The work that was done in the mid 90’s to identify key strategies to address still holds up almost 10 years later. Increase consumption of vegetables and fruits

Newest Eat Well Play Hard Strategies (2006-Present) Decrease exposure to television and other recreational screen time Increase the initiation and duration of exclusive breastfeeding

Eat Well Play Hard Implementation 1997 – EWPH incorporated into DON Programs 1999 – EWPH Community Projects initiated 2001 – Adoption of EWPH by NYS Partners for Children 2002 – Action for Healthy Kids collaboration 2003 – Incorporated into NYS Overweight & Obesity Prevention Program 2005 – Activ8Kids! Collaboration

Eat Well Play Hard Implementation 2006: The original EWPH goals and strategies were reviewed to determine if revisions/additions were needed. 2007: Subcommittees were formed to conduct an extensive literature review of newly proposed core strategies (breastfeeding, whole grains, TV time, healthy snacking and portion sizes).

Eat Well Play Hard Implementation 2008: DON Policy on Flavored Milk was developed Fruits and vegetables became a significant focus OPC made aware of the significant food package changes proposed by WIC DON Recipe Committee was formed to establish recipe standards

Eat Well Play Hard Implementation 2009: Focus was utilization of FNS messages surrounding fruit/vegetable and low-fat milk consumption WIC: increased breastfeeding promotion in hospitals and expanded peer counselor program Increased awareness of the Governor’s obesity prevention agenda and the NYS Council on Food Policy

Eat Well Play Hard Implementation 2010: Fruit and vegetable promotion FNS messaging (secondary targets) Obesity Prevention Council voted on priority issues to address in the coming year. Possibilities included: Breastfeeding Water Sodium Promotion of locally grown food

Highlights of Accomplishments Consistent Policies & Procedures Annual WIC Nutrition Services Plan focus on EWPH strategies WIC Healthy Lifestyles grants WIC Vegetable & Fruit demonstration project These are some examples of how our programs mesh the EWPH strategies with their core business automated system has low fat milk as default setting for children over age 2, family has to ask to get whole or reduced fat milk, findings show when the nutritionists recommend trying low fat milk, participants often will ask parents about children’s tv viewing, active play and food questions

Highlights of Accomplishments Consistent Policies & Procedures HPNAP minimum nutrition standard for emergency meals requires vegetables and fruits HPNAP Nutrition Policy Workgroup 10% for vegetables and fruit 2% for milk HPNAP has doubled the required percentage of HPNAP dollars to be spent on V&F and fluid milk by our direct service contractors and food banks.

Highlights of Accomplishments Consistent Policies & Procedures EWPH strategies incorporated into CACFP sponsor reviews and new sponsor training EWPH incorporated into “Crediting Foods Guide” and other CACFP publications Day care menu database

Highlights of Accomplishments Consistent Policies & Procedures Activ8Kids! School Tool Kit (2006) NYS Model Approach for Healthier Schools Local school wellness policies School nutrition guidelines Promoting PA in youth NYS supporting laws and regulations www.health.state.ny.us/prevention/obesity/activ8kids/toolkit

Highlights of Accomplishments Education & Training For program participants…. “Just Say Yes To Fruits & Vegetables” (SNAP-ED funded) WIC Nutrition Education Curriculum CACFP Team Nutrition Training Grant Fit WIC Eat Well Play Hard in Child Care Settings (SNAP-ED funded) The researchers found the following statistically significant results when they compared children in child care centers who received the EWPHCCS program to children in centers that did not receive the program:  Increase in children’s daily at-home consumption of vegetables  Increase in children’s at-home use of 1% or fat-free milk  Increase in reports of the rate of child-initiated vegetable snacking  Trend toward increased parental offerings of vegetables Past two years have started Farm to Pre-school component at certain day care centers and a sustainability piece – Champions.

Highlights of Accomplishments Education & Training For professionals…. EWPH Annual Meetings & Regional Partnership Meetings 1% or Less trainings & tool kits EWPH listserv –training and funding opportunities Fit WIC Schools SPIN On-line training through Cornell Nutrition Works Cornell Nutrition Works will be up by Summer 2006.

EWPH…Is it Working? Increased access to vegetables & fruit HPNAP emergency food network – Approx $5.1 million exclusively for V/F WIC Vegetable & Fruit Demonstration Project 88.6% of checks redeemed (FFY 2012)

EWPH…Is it Working? Just Say Yes to Fruits & Vegetables 84% of participants said they intend to prepare JSY recipes on their own 88% of participants said they intend to eat more F & V Farmer’s Market expansion – use of Health Bucks Data from the end of year 2012 NYC has had a Stellar Farmer’s Market component since 2002 and in 2011 started expansion of model in Rochester FM and will be adding two additional FMS upstate next summer. Partner with Food Banks and City HD to provide $2 Health Bucks to participants who complete the survey after class to increase purchasing power.

Prevalence of obesity among 2-4 year old children participating in WIC, NYS 2002 - 2011 New York was one of the 18 states, CDC mentioned that had some decline in childhood obesity rates based on 2011 PEDNESS data.

EWPH……… It’s working ! Can an approach like this work in your state too?