1 Health Affairs, 2010 A Statewide Strategy to Battle Child Obesity in Delaware Debbie I. Chang, MPH Vice President, Policy & Prevention

2 Nemours Integrated Child Health System  Nemours is a non-profit organization dedicated to children's health & health care  Nemours operates Alfred I. duPont Hospital for Children and outpatient facilities in the Delaware Valley and specialty care services in Northern/Central Florida. Building new state-of-the-art Children’s Hospital in Orlando area  Nemours offers a continuum of care as health and prevention services are coupled with research, education, advocacy, and clinical treatment  Nemours focuses on child health promotion and disease prevention to address root causes of health –First initiative is preventing childhood obesity –Complements and expands reach of clinicians using broader, community- based approach

3 Promoting Health and Prevention Traditional Medical Model Rigid adherence to biomedical view of health Focused primarily on acute episodic illness Focus on Individuals Cure as uncompromised goal Focus on disease Expanded Approach Incorporate a multifaceted view of health Chronic disease prevention and management Focus on communities/ populations Prevention as a primary goal Focus on health

4 Delaware Children  Nemours developed its child health promotion model in Delaware – expanding its mission from the 55,100 patients it serves, to serve the state’s entire population of 207,000 children  Childhood obesity affects every county in Delaware  In 2006, approximately 37% of Delaware children age 2-17 were overweight or obese  In 2008: –Overweight and obesity rates ranged from 40% to 46% across Delaware counties and the City of Wilmington –Overweight and obesity rates highest among non- white children at 49% (compared to 37% of white children)  Nemours’ goal is to statistically reduce the prevalence of childhood overweight and obesity in Delaware by 2015

55 Strategy  A prevention-oriented child health system builds upon, and extends beyond, traditional prevention in primary care to look at the population level  Strategy makes use of socio-ecological model, looks beyond the individual to examine a range of other factors that affect health outcomes at multiple levels  Spreading policy and practice changes: –Population health-focused model: Defined program goals around reducing prevalence of overweight and obesity –Strategies in multiple sectors: Exposure to consistent healthy choices/environments for behavior change, all around Almost None prescription –Strategic partnerships: Greatest potential impact, authority to make policy and practice changes, ability to leverage resources –Knowledge mobilization: Providing evidence-based materials and tools –Social marketing: Creating and accelerating social policy and behavior changes

6 The NHPS Model: Working with Over 200 Community Partners Changing the health status and well-being of the most children possible through the deployment of evidence based policies and practices. Seeking the highest sustainable impact with the most efficient use of resources. Policy and Practice Change Agenda Community Infrastructure Behavior Change Healthy Children to build and sustain that supports that leads to that evidence the usefulness of Policy and Practice Change Agenda Community Capacity Behavior Change Healthy Children to build and sustain the that support that leads to that evidence the usefulness of

7 Going to Where the Children Are With Almost None  Together We Can Make Delaware’s Kids the Healthiest in the Nation –Kids Can’t Do It Alone –5-2-1-Almost None  Integrated into all 4 sectors –Community –School –Child Care –Primary Care –Helping accelerate policy and practice changes

8 More than 140,000 Delaware Children Growing Up Healthy Due to Nemours  Changes in regulations and policies, supported by targeted and strategic activities, are making an impact on the lives of Delaware’s children – reaching more than 140,000 children –90,180 impacted through statewide school legislation –54,000 impacted through child care regulation changes

9 360 o of Child Health Promotion

10 Progress Results at the Population Level  Results from the 2008 DSCH, compared to the 2006 DSCH, suggest that the prevalence of overweight and obesity has leveled off for children ages years in Delaware –Overweight remained unchanged at 17%  Evidence indicates the prevalence of obesity and overweight has leveled off in all Delaware counties and within subpopulations  Disparities still remain among racial groups  Nemours’ initiative is on track to achieve its 2015 goal for some populations

11 Progress Results at the Population Level Differences between years is not statistically significant in any category.

12 Progress Results at the Population Level  Household awareness between of the Almost None campaign increased fourfold (5% to 19%)  When parents were aware of the Almost None message, significantly more children engaged in: –1 hour of physical activity per day (26% in 2008 versus 10% in 2006) –Moderate to vigorous physical activity for more than 20 minutes (33% in 2008 versus 21% in 2006)

13 School Sector Interventions  Strengthened and implemented wellness policies –Impact: 90,180 children per year (2006-present)  Learning Collaborative –Impact: 90,180 children per year (2007-present) –Provide assistance with the implementation of wellness policies (goals, action plans) and HB 471 –Tools, training, technical assistance  Implemented HB 372: FITNESSGRAM® –Impact: 30,000 children (2006-present) –Assessment of fitness measured in grades 4, 7,9 –BMI data optional by school  Implemented HB 471: 150 minutes of physical education/activity –Impact: 26,112 children –Pilot from  Implementation of CATCH in elementary/middle/charter –Impact: 43,213 children (2005-present)

14 School Sector Results  Fitness Measurements & Physical Activity Pilots –Fitness pilot of 150 minutes of physical activity:  Increased fitness level as measured by FITNESSGRAM® tests, 1.5 times more likely to achieve Healthy Fit Zone, an indicator of fitness  Higher levels of fitness for students in structured activity programs such as CATCH or Take 10! –Success sparked expansion of physical activity programs to:  86 schools; 62% of all elementary and middle schools  District Wellness Policies –Schools were 4 times as likely to report wellness policy implementation if district policy included specific Nemours-recommended content –Changes include healthy vending, evidence-based physical activity programs, fitness equipment, and activity breaks –Principles and staff identified the following facilitated implementation:  Technical assistance  Networking with other districts/schools  Support from other school administrators

15  Statewide regulatory change –Impact 54,000 children (2007-present) –Reduce sedentary behavior, promote health eating/physical activity –Child and Adult Care Food Program (CACFP) –Office of Child Care Licensing (OCCL)  Learning collaborative –Impact 2,750 children ( ) –Translate policy into practice and support implementation  Training around Healthy Habits for Life (HHFL), CACFP –Impact 20,000 HHFL children/ 24,000 CACFP children (2007-present )  Child care technical assistance pilot program –Impact 775 children ( )  University of Delaware’s Institute for Excellence in Early Childhood –Impact to be determined; up to 54,000 children (2010-future) –Continue learning collaborative Child Care Interventions

16  81% of centers participating in the collaborative made significant changes in healthy eating and physical activity practices: –Increased provider knowledge of childhood obesity as a problem –Family style meals, modeling positive behavior –Policies for parent provided food –Consuming whole grains,1% or nonfat milk, water –Consuming only 1 serving of 100% juice per day –Consuming limited sugary/fried foods –More structured physical activity indoors and outdoors –Participating in 20 minutes of vigorous activity, every 3 hours in care –Watching only 0 -1 hour of TV per day Child Care Results

17  Implementation of Expert Committee Recommendations on assessment, prevention, and treatment of childhood overweight –Impact 207,000 children (2007-present) –Used by primary care providers, DE AAP, Medical Society of Delaware, Delaware Academy of Family Physicians  Learning collaborative –Impact to be determined; up to 33,000 children (2010-future) –Provide tools, training, technical assistance for the implementation of Expert Committee Recommendations  Nemours primary care strategy –Impact 50,000 children (2008-present) –Measuring BMI, identification of childhood overweight, counseling on healthy lifestyles Primary Care Interventions

18  Commitments from medical community to promote the Expert Committee Recommendations  Prevention and health promotion built into Nemours Electronic Medical Record (EMR) –Nemours’ provider classification of BMI during well child visits doubled, 49% (2007) to 94% (2008) –Nemours’ providers offer lifestyle counseling to 95% of all patients (almost double the national reported rate of 54.5%)  Delaware Primary Care Quality Improvement Initiative 19 multidisciplinary primary care teams achieved high results: –98.2% of providers classified BMI or weight-for-length in 2009 (83% in 2007) –88.6% of providers provided counseling on healthy lifestyles in 2009 (72.7% in 2007) –88.1% of providers developed a care plan and family-management goals with obese/overweight patients who were ready to change in 2009 (74.2% in 2007) Primary Care Results

19 Lessons Learned  Sustaining policy and practice changes –Policy and practice change, together, in multiple sectors is critical –Policy can drive practice and practice can drive policy –Community capacity is critical to sustainability and to promoting, supporting and implementing change  Create strong partnerships –Develop strong relationships with influential organizations –Clearly define roles among partners, understand partners’ reasons for involvement –Provide partners with data, tools and training to make recommended changes  Focus on maintaining strategy –Clearly defined program goals are critical to success –Focus on a limited set of priority areas and sectors to avoid dilution of effort and impact  Design an evaluation that works –Acknowledge the strengths and limitations of the evaluation –Outcome measures (BMI) should remain a focal point –Align evaluation efforts with strategy –Achieving outcomes takes time - establish intermediate milestones to help track progress –Focus on demonstrating broad association and linkages where possible

20 Conclusion  Changes are being implemented in systems – schools, child care, primary care  Changes in healthy eating, physical activity, and health outcomes are taking place  Results provide evidence for the efficacy of a comprehensive prevention- oriented model  Investments have proven valuable –Established community collaboration and capacity to address child issues –Resources leveraged from multiple sources to affect child health  Public and private partnerships need to be further developed and replicated

21 Debbie I. Chang, MPH Vice President of Policy and Prevention Nemours 252 Chapman Road, Christiana Building, Suite 200, Newark, DE (p) (e)