Journal Entry #8: Research Shows Delaware Embraces Nutrition and Physical Activity Standards in Child Care

As noted in previous journal entries, one of the Childhood Obesity Prevention Mission Project’s key activities over the last year has been conducting a needs assessment of child care providers and parents in Delaware to inform the development of provider training on nutrition and physical activity standards for child care centers and homes. This study was conducted in partnership with Nemours Health and Prevention Services in Delaware and Delaware’s Child and Adult Food Care Program and Office of Child Care Licensing.

Delaware was the first state to implement comprehensive guidelines and standards for nutrition and physical activity in child care settings. These standards were developed as part of a larger state strategy for the prevention of childhood obesity by promoting healthy eating and physical activity behaviors early in childhood.

In May, Altarum and its partners released the findings of this study. These findings suggest that Delaware’s first-in-the-nation guidelines for nutrition and physical activity in child care are broadly accepted by both child care providers and parents, and that challenges to implementing the policies can be overcome with support. Study lead Vivian Gabor comments on the findings:

Delaware has taken a leadership role in the nation’s efforts to combat childhood obesity by promoting healthy behaviors in child care settings. This report documents how parents and providers have largely embraced these efforts and identifies ways the continued partnership between state agencies and groups like Nemours can foster the critically important engagement of both parents and providers.

Some key findings of the study include:

• Providers and parents understand and embrace requirements that child care providers serve healthier food and ensure that children are active;
• Providers are developing and using innovative strategies to implement the standards into daily practice;
• Implementation challenges are frequently related to limited available resources; and;
• Providers need additional training, technical assistance and tools to fully implement the standards.

The study’s findings summarize perspectives of child care providers and parents from across Delaware, and its recommendations may be useful to other cities and states looking to combat childhood obesity through changes to child care policies.The full report is available online.
 

Journal Entry #7:  Assessing State Readiness for Registry-Based BMI Surveillance

Through this mission project, Altarum has been working with partners in Michigan and San Diego County, Calif. to develop a novel approach to childhood obesity surveillance. The key feature of this work is the collection of body mass index (BMI) data via immunization registries.

Several bills have recently been introduced in the U.S. Congress to support state-level pilot projects designed to improve obesity surveillance through the use of immunization registries and to support the development and dissemination of this new model. However, there are few available data that policymakers or federal agencies can use to determine which and how many states are optimally positioned to participate in such a pilot project.

The Childhood Obesity Prevention Mission Project is working to fill this information gap. The project is conducting an assessment of all 50 states and the District of Columbia for their readiness to collect BMI data via an immunization system based on several factors identified by a panel of experts convened by Altarum in summer 2009.
Our multi-pronged approach is underway:

• Policy research has been completed for 50 states and D.C. to determine whether existing legislation would permit addition of BMI to registries and to assess states’ existing or proposed BMI surveillance policies. Legal experts from the National Policy and Legal Assistance Network to Prevent Childhood Obesity (NPLAN) and the University of Illinois-Chicago are now working with staff to interpret findings from our legal research.
• As of April 2010, the project team is getting ready to conduct more than 100 key informant interviews with state obesity prevention and immunization information system managers in all 50 states and the District of Columbia.
• The policy research and interview findings will be summarized into a report categorizing states according to several dimensions of readiness: high technical capacity of the state’s immunization information systems, permissiveness of state laws to conduct BMI surveillance via an immunization information system, and engaged practitioners looking to improve their surveillance efforts.

The findings from our study will be used to inform legislative and other efforts to support state-level registry-based BMI surveillance.
 

Journal Entry #6:  Reaching the Midway Point

With the conclusion of 2009, CHOMP has reached the mid-way point for Mission Project activities.  We have been able to achieve considerable successes in our five projects over the past year.  Here are some of our most notable project accomplishments:

Supporting development, implementation, and evaluation of model Body Mass Index (BMI) Surveillance System:

• Altarum staff has completed focus groups with primary care providers in both Michigan and San Diego County to identify their needs in optimizing the use of immunization registries to prompt  BMI  screening for prevention and treatment of overweight in children. Programming of the system is near complete in Michigan and 3 clinical sites have been recruited to pilot test the new system to further inform the statewide rollout of BMI surveillance capacity expected later this year.
• Ongoing technical assistance has been provided to partners to assist them in developing and optimizing their systems, including developing functional specifications and data quality standards reports. Recently, the project has collaborated with Altarum’s LEAN experts to facilitate the integration of BMI assessment into their clinical services.

Enhancing the role of Child Care Settings in Obesity Prevention – Delaware and Washington, DC.:

• Altarum staff partnered with Nemours Health and Prevention Services in Delaware to conduct a needs assessment of providers to inform the development of provider training on revised nutrition and physical activity standards for child care centers and homes.  Altarum completed 10 focus groups with 83 child care providers during this process.
• In collaboration with D.C. Hunger Solutions, 26 environmental scans of District child care centers were conducted to inform nutrition and physical activity policy discussions. Altarum also conducted one-on-one interviews with center staff.

Evaluation of Women, Infants and Children (WIC) vendor changes in response to the new WIC food package:

• The project is partnering with WIC Programs in four states-Colorado, New Hampshire, Pennsylvania, and Wisconsin- to conduct an extensive evaluation of the effects of the new WIC food package on small vendors.
• The first round of data collection resulted in the completion of 252 store inventories of food products at select urban and rural small grocer locations, as well as 45 key informant interviews with store vendors.

Evaluation of the Participant-Centered Education (PCE) Model for nutrition services:

• Three WIC clinics in Arizona were identified to participate in a year-long assessment and technical assistance process to maximize implementation of the PCE model.  Altarum staff have made several visits to provide training and technical support to clinic staff, and are currently assisting the clinics in implementing environmental supports consistent with clinic-wide PCE implementation.
• Altarum staff are implementing a training program for Oregon WIC Program staff that focuses on utilizing the Stages of Change theoretical model to tailor behavioral counseling and evaluate implementation of the PCE model.

Journal Entry #5:  Reporting to our National Advisory Committee

September 25^th was an important milestone for our project, as it was a significant check-in point with the Childhood Obesity Prevention Mission Project’s National Advisory Committee (NAC). On this day, Altarum reported to, and obtained input from, NAC members on the project’s five initiatives.  NAC members responded enthusiastically and noted how the project’s work is already beginning to make a mark in childhood obesity prevention efforts. They noted especially the growing linkages between the project’s initiatives and their own efforts, and described exciting synergies and opportunities for building on what this Mission Project has begun through collaborations among public and private organizations and agencies, including those represented by NAC members.

Although only halfway through the project, the NAC noted that the field of childhood obesity prevention is already benefiting from the work of the Childhood Obesity Prevention Mission Project. This is being accomplished through such activities as:

• Convening stakeholders who had previously not worked together before, for example, around state-based immunization and obesity registries, thereby strengthening systems linkages
• Obtaining the input of diverse stakeholders (e.g., child care providers, parents, grocers) to inform ongoing policy development and program implementation related to childhood obesity
• Developing articles for publication in peer-reviewed journals and strategies to share at health conferences and events
• Providing input to legislators in the crafting of legislation to strengthen childhood obesity surveillance systems

We are grateful to our NAC members, all of whom are providing invaluable input and enthusiastic support to this Mission Project.
 

Journal Entry #4: Determining State Readiness for BMI Surveillance

On July 27-29, 2009, several members of our Childhood Obesity Prevention Mission Project participated in the very exciting Weight of the Nation conference in Washington, D.C., an inaugural conference on obesity sponsored by the Centers for Disease Control and Prevention.  It brought together people from around the country working in both the public and private sectors to address this urgent national health issue.

In addition to doing a poster abstract on the Obesity Prevention Mission Project’s BMI (“body mass index”) surveillance support activities with partners from San Diego, our project team used the opportunity presented by this gathering to convene a meeting of national leaders on BMI surveillance activities to inform Altarum’s conduct of a planned 50-state environmental scan. This scan will identify those states that are best positioned to implement BMI surveillance in existing registries. The meeting included representatives of states and communities that have implemented either registry- or school-based BMI surveillance systems – including Arkansas, Illinois, Michigan, and San Diego – to learn from their experiences, as well as CDC representatives responsible for chronic disease activities and immunization registries, Trust for America’s Health, and others. The group provided valuable input to the development of an algorithm, based largely on existing data sources, for determining readiness of states to add BMI surveillance to existing immunization registries.  In the coming weeks, Altarum will continue to refine this algorithm to identify those states best positioned to move forward with implementation of immunization-based registries. 

Journal Entry #3: The Projects Are Moving Forward

The past few months have been very exciting ones for the Childhood Obesity Prevention Mission Project.  We have successfully launched all of the projects described in our last entry. They span 10 states and engage a diverse range of organizations representing both the public and private sectors: government agencies; nonprofit organizations; consumers; businesses; and foundations.

One of the project’s major recent events was the involvement on May 13, 2009 of Co-Project Director Matt Longjohn as a moderator for an Altarum Institute Policy Roundtable on Capitol Hill focusing on leveraging public health infrastructure to combat childhood obesity. This roundtable generated interest among legislators, the press, and child health organizations in the promise body mass index (BMI) surveillance systems hold for monitoring and reducing childhood obesity. A Webcast of this Roundtable is available for viewing (you must first be a registered site user in order to watch the video).

To complement the Policy Roundtable event, Co-Project Directors Drs. Matt Longjohn and Amy Sheon published an op-ed in the Detroit News that discussed the effort by the state of Michigan to collect body BMI information on children through its immunization registry and why this model should be replicated across the country as a means to fight childhood obesity. Their proposed methods have been further amplified in a blog entry on Altarum’s Health Policy Forum.

This summer, our team will be conducting a series of 10 focus groups with child care providers and parents of children in child care settings in Delaware. The purpose of these focus groups is to learn about the types of resources and training needed to implement new regulations for healthy foods and physical activity in child care settings. 

Important progress is also being made in our WIC-focused work.  Project staff are in the field in New Hampshire and Wisconsin collecting data from grocers to assess the impact of the new WIC food package on the availability of healthy foods in small stores, a primary source of food for WIC participants.

Our team is gratified to be working with so many stakeholders in diverse fields who share a dedication to, and enthusiasm for, reducing childhood obesity.

Journal Entry #2: The Core Projects Are Selected

The Childhood Obesity Prevention Mission Project has identified several projects addressing various domains within the broad early childhood systems-change framework: public health and health care, early learning and care, and food and nutrition systems. While projects are working in specific geographic settings, efforts will also be undertaken to ensure that effective systems changes are disseminated to national audiences.  Projects are now being launched and expected to conclude in June 2010. Brief descriptions of these projects are included below.

Supporting development, implementation, and evaluation of model Body Mass Index (BMI) Surveillance System. Altarum staff are working with partners in Michigan to add body mass index (BMI) surveillance capacity to the Michigan Care Improvement Registry (MCIR), an existing surveillance system that currently contains health records on more than 4.7 million Michigan children. The addition of BMI surveillance to the MCIR is a systems-level change that will arm public health agencies with the capacity to monitor childhood obesity trends in Michigan communities and evaluate the effects of public health interventions. 

The effort seeks to enhance the likelihood that Michigan primary care providers will comply with current national recommendations to screen all children for obesity for the purposes of early identification, prevention and treatment. Altarum staff will conduct a needs assessment with primary care providers to inform this process, and will assist the Michigan Department of Community Health in the design and implementation of adding BMI to MCIR. Following implementation of these modifications, Altarum plans to lead an evaluation of the effects of this systems change.

Enhancing the role of Child Care Settings in Obesity Prevention – Delaware and Washington, DC. Altarum staff are working in two areas to promote changes in regulations and practice regarding nutrition and physical activity in childcare settings. 

In Delaware, Altarum is partnering with Nemours Health and Prevention Services, the State Office of Child Care Licensing, and the Delaware Child and Adult Care Food Program who have recently established new regulations and standards to improve healthy eating and physical activity for children in child care centers and family day care homes. Altarum will work with these partners to develop a sustainable training and implementation plan and tools to address the needs of child care providers in implementing the new regulations.

In Washington, DC, Altarum is partnering with DC Hunger Solutions to conduct an environmental scan of 26 child development centers to assess their current nutrition and physical activity practices and priorities and identify their needs for training and other support.  The environmental scan findings will support enhanced nutrition guidelines for child development centers in the District of Columbia and the development of  a guide and training plan to support the new guidelines. DC Hunger Solution will also use the environmental scan report to educate policy makers and advocate for an Early Childhood Wellness Policy. To assist the District and other communities across the country in early childhood obesity prevention, Altarum will also be producing a national best practices report compiling  evidence-based practices, policies and training resources available to promote improved physical education and activity for children at child care facilities.

Evaluation of Women, Infants and Children (WIC) vendor changes in response to the new WIC food package. Altarum will work with several states to evaluate the impact of the new WIC program food package on small stores. The WIC food package was recently revised to include new provisions for healthy foods including fruits, vegetables, and whole grains. Small stores commonly located in urban areas and rural communities can be a primary source of food for WIC participants, yet they may face a variety of challenges in implementing the new food package due to limited inventory and availability of healthy foods. Altarum will evaluate the impact of this systems-level change on small stores and produce a report that includes case studies from stores in several states and recommendations for future systems-changes to encourage the participation of small food retailers in the WIC program.

Evaluation of the Participant-Centered Education (PCE) Model for nutrition services. Altarum will also be working to evaluate another systems-level change to the WIC Program, the implementation of the Participant-Centered Education model. This model is being implemented nationally in WIC clinics to improve the nutrition services provided to WIC participants. Its implementation represents a shift in the WIC program from a focus on numbers of individuals served to one that focuses on health outcomes.  Altarum will partner with several WIC clinics to monitor and evaluate the implementation of this model.  A report outlining best practices for implementation will be disseminated to WIC agencies across the country to assist in facilitation of this systems-change.

Journal Entry #1: The End of a Seven Month Planning Process

The Childhood Obesity Prevention Mission Project recently concluded a seven-month planning process with staff from a variety of disciplines across four Altarum offices. This participatory planning process resulted in the identification of a strategic framework for project implementation activities and five core projects.

The Childhood Obesity Prevention Mission Project is framed as an obesity prevention effort to catalyze and assess institution-level changes in systems affecting young children and their families. The emphasis on early childhood is compelling because of the importance of healthy biologic and behavioral development, but also because many systems overlap to serve children in this age group and their families. Evidence increasingly points to the need for early prevention of childhood obesity, as unhealthy behaviors learned young persist and lead to health risks later in life.

Many opportunities exist to change systems that affect young children’s opportunities for healthy eating and physical activity, and the Childhood Obesity Prevention Mission Project will support multiple projects. Our next journal entry will describe these exciting new endeavors.