Problem Addressed

• A growing epidemic: The prevalence of obesity (defined as a body mass index, or BMI, above the 94th percentile) among children and adolescents has increased rapidly in recent decades, both nationally and in Delaware:
  • Nationwide: Between 1976 to 1980 and 2007 to 2008, the prevalence of obesity more than tripled, rising from 5.0 to 19.4 percent in 2- to 5-year-olds, from 6.5 to 19.6 percent in 6- to 11-year-olds, and from 5.0 to 18.1 percent in 12- to 19-year-olds.²
  • Delaware: The prevalence of obesity among Delaware adults, which averaged between 10 and 14 percent in 1987, surpassed 30 percent by 2007.³ Although trend data are not available, similar increases in overweight/obesity appear to have occurred among Delaware youth. By 2006, approximately 17 percent of Delaware children age 2 to 17 were overweight (BMI between the 85th and 94th percentiles), with another 20.6 percent being obese.^1,4
• Poor health-related behaviors: High rates of overweight/obesity stem from poor health-related behaviors, including unhealthy diets and lack of physical activity. These poor behaviors, in turn, are largely the result of systems that fail to make the healthy choice the easy choice. Some improvements in health-related behaviors have occurred among Delaware youth in recent years, but ample room for improvement still exists, as outlined below:
  • Poor diet: A 2008 survey found that only 51.8 percent of Delaware parents report that their child (age 2 to 17) ate five or more servings of fruits and vegetables a day, while 55.2 percent consumed two or fewer sugary beverages a week.⁵
  • Lack of physical activity: The same survey found that 73.0 percent of Delaware parents reported that their child (age 2 to 17) engaged in 1 hour or more of daily physical activity, while two-thirds had 2 hours or less of screen time each day.⁵
• Severe health consequences: Overweight and obesity put children at current and future risk of serious health problems, including cardiovascular disease, type 2 diabetes, and mental health conditions such as anxiety and depression.⁶ Approximately 60 percent of obese children between the ages of 5 and 10 have at least one risk factor for cardiovascular disease, while 25 percent have two or more.⁷
• Lack of comprehensive, population-based approaches: Many factors at multiple levels (e.g., the individual/family, community, state, and society at large) have combined to create the epidemic, and no single factor is likely to reverse it. For example, primary care practices can counsel pediatric patients to adopt healthy lifestyle choices related to diet and exercise, but these efforts will likely fail unless schools and communities encourage such behaviors and have infrastructure in place to support them. As a result, many experts believe that the only solution is a broad-based, multifaceted strategy.¹ To date, however, few communities have embarked on such a strategy.

Description of the Innovative Activity

• Policies and practice changes targeted in key sectors: The core of the initiative includes policies and practices, along with tools and technical assistance, to encourage primary care providers, schools, childcare organizations, and other community-based organizations to make systems changes that help Delaware youth adopt healthier lifestyles. Key components, organized by stakeholder, are summarized below (related profiles provide additional details):
  • Primary care providers: At a statewide policy level, Nemours received commitments from the medical community to promote the Expert Committee Recommendations on the Prevention, Assessment, and Treatment of Childhood Overweight and Obesity.⁸ These recommendations acknowledge the role of health care providers and of social and environmental changes in preventing overweight and obesity. To that end, they advocate universal use of preventive health messages, early assessment, and early intervention rather than the traditional approach of addressing obesity only after its onset. Nemours has implemented these guidelines within its own system of primary care providers. To facilitate this process, Nemours integrated relevant health promotion guidelines and prompts into its electronic health record (EHR) system, and organized a learning collaborative for Nemours- and non-Nemours–affiliated practices. (See related profile for details.)
  • Schools and school districts: In a multipronged strategy, Nemours and its partners have leveraged a combination of school district policy change and individual school practice change to promote healthier behaviors among students. Key initiatives include a learning collaborative to assist with development of district wellness policies, assistance in implementing pilot programs to promote physical activity and measure fitness, and a statewide program to support schools in engaging students in 150 minutes of physical activity each week. (See related profile for details.)
  • Childcare providers: In 2007, Delaware adopted regulations that require childcare centers and family-based providers to adopt the desired 5-2-1-Almost None healthy lifestyle behavior changes. (See bullet below on social marketing campaign for details.) These standards have the potential to affect the 54,000 preschool children being cared for in licensed programs throughout the state. To assist in implementing the changes, Nemours initiated a Child Care Learning Collaborative that supports 28 large childcare centers with tools and materials to align their policies and practices with state regulations. (See related profile for details.)
  • Community organizations: Nemours works with a variety of community organizations, such as the YMCA, Boys and Girls Clubs, and 4H Clubs, to spread the 5-2-1-Almost None message and promote adoption of evidence-based programs. Nemours provides initial training to organizational leaders, who then manage initiatives on their own. For example, Nemours has worked with the Delaware Parks and Recreation Department to offer more healthy food options in park vending machines and has helped communities institute “community walk days” and incorporate the 5-2-1-Almost None message into public events.
• Social marketing campaign with a consistent, memorable message: To convey the urgency of the issue and to generally accelerate and support behavior change, Nemours launched a social marketing campaign with a consistent, easy-to-remember message aimed at encouraging healthy behaviors and motivating policymakers to support such behaviors. Nemours uses the message consistently across the initiative, including at public events and in print, television, media, and billboard marketing. Conveyed by the memorable phrase “5-2-1-Almost None,” the message encourages these daily behaviors:
  • Five: Eat at least five servings of fruits and vegetables.
  • Two: Engage in no more than 2 hours of television or computer recreational time.
  • One: Participate in at least 1 hour of moderate to vigorous physical activity.
  • Almost None: Consume almost no sugar-sweetened beverages.

References/Related Articles

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Results

• Healthier behaviors: Between 2006 and 2008, Delaware children between the ages of 2 and 17 adopted healthier behaviors related to three of the four goals outlined in the “5-2-1-Almost None” campaign.^5,9
  • Greater intake of fruits and vegetables: The proportion of children meeting the goal of 5 daily servings rose from 45.7 to 51.8 percent.
  • Less screen time: The proportion of children watching television or using the computer recreationally for less than 2 hours a day increased from 57.8 to 66.9 percent.
  • Fewer sugary beverages: The proportion of children consuming almost no sugar-sweetened beverages rose from 47.6 to 55.2 percent.
  • Decline in physical activity: The percentage of children meeting the physical activity guidelines fell from 86.2 percent to 73.1 percent. Nemours leaders believe this decline stems in part from the program’s strong initial focus (between 2006 and 2008) on healthier eating rather than increased physical activity. Since 2008, additional opportunities to advance physical activity have arisen. Consequently, any improvements in this area may not become evident until results from the 2011 survey become available.
• Halt in rise in overweight/obesity: Statewide telephone surveys of parents conducted in 2006 and 2008 found that the historically rapid growth in overweight and obesity among Delaware youth appears to have leveled off. The prevalence of overweight remained at 17 percent and the prevalence of obesity rose by a statistically insignificant amount overall and in all geographic and demographic categories.
• Greater public awareness, associated with more physical activity: Between 2006 and 2008, the number of Delaware households aware of the “5-2-1-Almost None” message rose from 5 to 16 percent. In households indicating awareness, 26 percent of children engaged in at least an hour of physical activity per day, well above the 10 percent figure in households not aware of the message. Similarly, 33 percent of children in “aware” households engaged in at least 20 minutes of moderate to vigorous physical activity daily, compared with 21 percent of children in other households.
• Progress within targeted sectors: The program has succeeded in encouraging key stakeholders to provide greater support to children and parents in adopting healthier lifestyles, including systems that support those lifestyles. Summary details are provided below, with more information available in the related profiles.
  • Greater support in primary care: Primary care providers involved in the learning collaborative better supported youth in adopting healthier lifestyles, including documenting BMI, providing lifestyle counseling, and developing care plans. (See related profile for details.)
  • More wellness policies in schools: Districts that worked with Nemours to develop their wellness policies and that used Nemours-recommended content had more success in getting individual schools to implement such policies. (See related profile for details.)
  • Positive impact in childcare: Childcare providers who participated in the learning collaborative had increased knowledge of childhood obesity and the importance of healthy behaviors, and implemented significant policy changes in their centers. (See related profile for details.)

Evidence Rating (What is this?)

• Trends in behaviors of Delaware youth, including increased consumption of fruits, vegetables, and sugary beverages, and reduced daily screen time.
• Trends in prevalence of overweight/obesity among Delaware youth between 2006 and 2008.
• Campaign message awareness among Delaware households.
• Summary evidence of increased efforts of primary care providers, schools, and childcare providers to support lifestyle changes among Delaware youth and to create systems that support those changes.

Context of the Innovation

Planning and Development Process

• Performing community needs assessment: In 2004, Nemours staff performed a thorough community needs assessment. As part of this process, they talked with community leaders about key issues and current efforts to address them, with the goal of building on (rather than duplicating) these initiatives. Staff decided to focus first on the growing problem of childhood obesity.
• Building internal and external capacity: Nemours leaders hired staff over a period of time. They also met with school boards and other community organizations to discuss how to collaborate to promote child health. Nemours leaders sometimes invited individuals with a strong reputation in the community to join Nemours.
• Creating community coalitions: Nemours helped create coalitions and other community-organizing entities dedicated to health promotion in each of Delaware’s three counties, starting in Sussex County, which had a long tradition of collaboration.
• Developing tools: In consultation with partners, program staff created implementation tools, such as Best Practices in Healthy Eating, Best Practices in Physical Activity, Healthy Habits for Life, and the Primary Care Toolkit, to help providers in schools, childcare, primary care and the community implement new policies and practice. (See the Tools and Other Resources section for more information.)
• Piloting programs: In 2004, Nemours identified program champions in schools and childcare centers and began piloting the use of the new tools and educational materials. The pilot programs helped Nemours gather feedback from frontline workers that could be used to create additional initiatives.
• Developing social marketing campaign and related tools: In 2005, Nemours staff developed the social marketing campaign focusing on the “5-2-1-Almost None” message. They incorporated the message into educational materials, teaching tools, and toolkits.
• Instituting advocacy efforts: Over time, Nemours realized that a focus on population health required widespread policy change. In collaboration with other community leaders, Nemours representatives began speaking with state and county government officials to advocate for policy changes to promote healthier behaviors for children.
• Creating learning collaboratives: As new policies and practices emerged, Nemours designed learning collaboratives to facilitate implementation in key settings.
• Designing evaluation to assess impact on outcomes: Nemours leaders recognized that sustainable, long-term change would not occur without an evaluation system that could measure program impact at both the systems and population level. To that end, Nemours designed a two-pronged evaluation strategy. The first collects data and measures changes within specific settings that support healthy outcomes related to 5-2-1-Almost None. The second involves use of population-level surveys to collect data from the parents of a representative sample of Delaware children from birth through age 17. These surveys gather data on parent/caregiver attitudes and knowledge and on children’s height and weight (to calculate BMI) and behaviors related to eating and physical activity. Known as the Delaware Survey of Children’s Health, the survey was conducted in 2006 and 2008, with a third survey planned for late 2011.

Resources Used and Skills Needed

• Staffing: As of March 2011, the Nemours Health and Prevention Services unit employs roughly 60 full-time individuals. Roughly 40 of these individuals focus on initiatives related to overweight/obesity. Different Nemours teams focus on program planning, policy initiatives, community partnerships, data collection, and program evaluation. In addition, partner organizations dedicate staff time to program activities. Development of such an initiative by other communities likely would not require as much staff time, because many of the tools and materials developed by Nemours and others have become publicly available to support the nation’s effort to reduce childhood overweight/obesity.
• Costs: Data on program costs are not available.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Support both policy and practice-based changes: Success with this type of population-based initiative depends on changes at the policy level (via regulation and/or legislation) and ground-level support (e.g., training and learning collaboratives) for organizations and individuals involved in implementation.
• Develop and reinforce a consistent message: A social marketing campaign can ensure a clear, consistent message for all program elements, conveying an action-oriented prescription for health that can influence the population as a whole.
• Build strong partnerships that leverage community experience: Strong partnerships with government agencies, community-based organizations, and providers can promote widespread changes in health-related behaviors. Program developers should clearly define partner roles, clarify reasons for involvement, and seek ideas and feedback from frontline participants on an ongoing basis. For example, healthy eating and physical activity recommendations that came out of a four-site pilot program for childcare providers helped to inform regulatory changes that now affect 54,000 Delaware children each year.
• Work with umbrella organizations to spread the message: Achieve economies of scale by working with umbrella organizations (e.g., school districts, provider associations, community coalitions) that represent the interests of large groups of children and that can build support, convey program messages, and disseminate materials to their members.
• Define goals and associated metrics: Clearly defined goals (such as reducing the prevalence of overweight/obesity) can help program developers design focused activities and define specific intermediate and long-term indicators to gauge success.
• Do not reinvent the wheel: Adapting existing toolkits and materials to the local culture and environment can help to expedite the adoption process and minimize expenditures.
• Ensure strong focus on evaluation: Effective evaluation is a critical component, so would-be adopters should clearly define goals and outcomes, which should be used to define the evaluation framework. At Nemours, the evaluation process focuses on assessing the overall impact of Delaware’s multisector interventions to promote good health policies and practices.
• Consider how to evaluate community prevention programs: Evaluation of community prevention programs must aim to identify broad associations and linkages. The inability to demonstrate direct causality indicates the need for a different standard of evidence. The goal should be to evaluate the holistic impact of a set of community-based interventions across a statewide population.

Sustaining This Innovation

• Keep support programs in place: Ongoing support is critical to helping schools/school districts, providers, childcare centers, and other “on-the-ground” organizations maintain success.
• Monitor progress, refine program as needed: Program developers should collect key data on an ongoing basis, periodically analyze the data to gauge program impact, and regularly ask key stakeholders for feedback about the results. These steps help maintain enthusiasm for the program and ensure prompt responses to any problems or concerns that emerge.
• Be opportunistic: External events may present an opportunity to create or expand policies and programs targeted at key stakeholders. For example, in response to a federal mandate that school districts develop wellness policies, Nemours set up practical programs to assist them in doing so. Nemours also used a scheduled update of Delaware childcare regulations and policies as an opportunity to advocate for a greater focus on promoting healthy behaviors.