1. Vonna Drayton, DrPH Gregory D. Benjamin, M.P.H. Hu An, M.S. Environmental factors associated with reduction in overweight and obesity among Delaware children age 6-17 years

2. Acknowledgements Likun Hou, MS Robert Colnes, PhD Michele Lempa, DrPH NHPS Policy, Evaluation, and Research Dept. This evaluation has been made possible in part by a grant from the Robert Wood Johnson Foundation (RWJF ID: 62078)

3. Presentation Objectives 1.Describe Nemours Health & Prevention Services (NHPS) multi-sector intervention to reduce overweight in Delawares children. 2.Identify factors associated with the reduction in overweight BMI (body mass index greater than the 85 th percentile) in DE children, 6-17 years. 3.Explain the development and use of NHPS Healthy Eating and Physical Activity (HEPA) Index.

4. NHPS Strategy Strategy based on the social ecological model Prevention-oriented child health system that includes the following components: –Strategies in multiple sectors: Exposure to consistent healthy messages/environments for behavior change –Strategic partnerships: Greatest potential impact, authority to make policy and practice changes, ability to leverage resources –Social marketing: Creating and accelerating social policy and behavior changes

5. A Day in the Life Multiple Sources of Influence in a Child s Day 12:00 AM 6:00 AM 3:00 PM9:00 AM 6:00 PM 9:00 PM Sleep Time with parent Child Care/ School Afterschool Primary Care Community/ Family 12:00 PM 8:00 AM

6. NHPS Healthy Eating and Physical Activity (HEPA) Initiative Policy and practice changes in child- serving organizations –Office of Child Care Licensing and child care centers –Department of Education and Delaware school districts –Primary healthcare providers –Youth-serving organizations (YMCA, 4-H) and after-school programs –Built Environment (e.g., Delaware Greenways, Delaware Parks & Recreation, DNREC)

7. NHPS 5-2-1-Almost None Message 5: Five or more fruits and vegetables consumed each day 2: Screen time is limited to less than 2 hours each day 1: Children are physically active for at least 1 hour each day Almost None: Sugar-sweetened beverages are limited to no more than 2 servings each week

8. Award Winning Media

9. Increasing Awareness of NHPS 5-2-1- Almost None Message In 2006, 5% of parents heard of and could recall NHPS 5-2-1-Almost None campaign. In 2008, 19% of parents heard of and could recall NHPS 5-2-1-Almost None campaign. 15.5 % of respondents talked to someone about this message. There was approximately a four-fold increase in awareness and recall between 2006 and 2008.

10. 2006 DSCH (N=164) & 2008 DSCH (N=528) HEPA behaviors of children whose parents were aware of NHPS 5-2-1-Almost None message: DSCH 2006 vs. 2008

11. Data Sources Population HEPA Awareness HEPA Behaviors BMI Systems Policy and Practice (Child Care and Schools) Delaware Survey of Childrens Health (DSCH), Electronic Medical Record (EMR) SHPPS, Wellness Policy Review, Provider Surveys, Document Reviews, and Legislation

12. DSCH Design and Sampling Random-digit-dialing (RDD) of DE households containing at least one child less than 18 yrs of age. Statewide sample (n=3055, response rate=57%) allowed comparisons among: Four specific locations: City of Wilmington New Castle County, excluding the City of Wilmington Kent County Sussex County Children of various age and racial groups: Birth through 5 yrs old 6 through 11 yrs old 12 through 17 yrs old African-American versus all other children Blumberg SJ, Olson L, Frankel MR, Osborn L, Srinath KP, Giambo P. Design and operation of the National Survey of Childrens Health, 2003. National Center for Health Statistics. Vital Health Stat 1(43). 2005.

13. DSCH Sample Distribution DSCH 2006DSCH 2008 New Castle County833775 City of Wilmington741742 Kent County721824 Sussex County760740 Delaware (total)30553081

14. Identify factors associated with the reduction in overweight and obese BMI (body mass index greater than or equal to the 85 th percentile) in DE children, 6- 17 years. Presentation Objective #2

15. Expert Committee Recommendations, June 6, 2007 Body Mass Index (BMI) Body Mass Index (BMI) is derived from a childs weight and height. BMI categories for children ages 2 and over: –Underweight < 5 th percentile –Healthy weight: 5 th BMI <85 th percentile (Reference Category) –Overweight or obese: 85 th percentile

17. Access to Fruits and Vegetables in the Community 20% of respondents indicated that it was very easy to walk or bike to a fast food restaurant 26% of respondents indicated that it was very easy to walk or bike to the place that sells fruits and vegetables.

18. Screen Time: Television 53% of children usually watch TV, watch video or play video games for 2 hours or less on an average weekday. 50% of children are allowed to watch TV, watch video or play video games for 2 hours or less on an average weekday. 24% of children are allowed to watch TV, watch video or play video games for 2 hours or less on an average weekend day.

19. School Physical Activity 20% of children ages 6- 17 participate in physical education or gym classes five days per week. 77% of school offer recess or a break where selected child can be physically active.

20. Parent Support of Physical Activity Parent or another adult engaged in PA with child 3 days per week on average. 69% of respondents always encouraged child to be physically active. –43% for at least 60 mins/day 48% of respondents always made sure child was physically active. –39% at least 60 mins/day

21. Walkability of Community 67% of respondents reported that their neighborhood was a very pleasant place to walk. 43% of respondents definitely disagreed that traffic makes it dangerous to walk in their neighborhood. 60% of respondents said yes to the presence of sidewalks. 36% of respondents definitely agreed that their neighborhood is safe from crime.

22. Primary Healthcare Provider Promotion of HEPA 84% of primary healthcare providers have discussed healthy eating and physical activity with respondent/child. 77% of primary healthcare providers have made recommendations about healthy eating and physical activity to respondent/child.

23. Explain the development and use of NHPS Healthy Eating and Physical Activity (HEPA) Index. Presentation Objective #3

24. HEPA Index Algorithm Factor 13: Access to fruits & vegetables in community Factor 3: Screen Time-TV Factor 6: Parental Support of Physical Activity Factor 9: School Physical Activity (6-17 yrs) Factor 10: Community Support Factor 11: Access to PA in Community Factor 12: Walkability of Community Use the dichotomization system to calculate items scores and construct factor scores for Ages 2-5 years and 6- 17 years Factor 14: Societal promotion of HE/PA Select the DSCH Questions and conduct Exploratory Factor Analyses for the HEPA Index based on the Social Ecological Model Sum the dichotomized factors scores to construct the HEPA Index Examine the predictive validity of the HEPA Index for BMI 85 th percentile

25. HEPA Index Factors

26. HEPA Index Range INDEX SCORE REFERENCE HEPA 8 Most healthy 7 6 5 4 3 2 1 0 Least healthy

27. Distribution of HEPA Index Factor Scores 53% of DE children ages 6-11 scored 6 to 8 on the HI. 41% of DE children ages 12-17 scored 6 to 8 on the HI.

28. Strengths and Limitations Strengths –Large sample size –Representative of the data for Delaware –Consistent with other findings from the NSCH –Contribution to the literature Limitations –Some survey items did not lend themselves to factor analyses. –A few factors contained less than three items. –Some survey items proved not to be good measures of NHPS 5-2-1-Almost None behaviors. –Causal inferences cannot be made between environmental factors and overweight/obesity.

29. http://www.growuphealthy.org For more info, please contact: Gregory D. Benjamin, M.P.H. Evaluation Scientist (p) 302-444-9163 (e) gbenjami@nemours.org