Tory Rogers, MD Barbara Bush Children’s Hospital at Maine Medical Center (207) October 7 th, 2013

What I want to talk about today?  What is Let’s Go! – The First 5 years – Birth to the awkward tween years  Let’s Go! – The Teen years  Evaluation Data – What is working  What we could have done better 2

Now…… What do you want me to talk about??? 3

Let’s Go! Core Principles  Environmental and policy change influences behavior change  Interconnectivity across settings is essential  Strategies are evidence based and continuously evaluated

Tools, Resources, and Trainings

Why Environmental/Policy Change? Policies Environments Activities

8 1.Provide healthy choices for snacks and celebrations; limit unhealthy choices. 2.Provide water and low fat-milk; limit or eliminate sugary beverages. 3.Provide non-food rewards. 4.Provide opportunities for children to get physical activity every day. 5.Limit screen time. Let’s Go! Key Strategies for Success – Priority Strategies

9 Let’s Go! Key Strategies for Success – Supporting Strategies 6. Participate in local, state and national initiatives that promote HEAL. 7. Engage community partners to help support and promote HEAL at your site. 8. Partner and educate families in adopting and maintaining a lifestyle that supports HEAL. 9. Implement a staff wellness program that includes HEAL. 10. Collaborate with food and nutrition programs to offer healthy food and beverage options.

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14 StoryWalks

Marketing Campaign

It Worked! Environments are Changing Policies are being Implemented Healthy Behaviors are increasing Obesity appears to be leveling off

Greater Portland Reach As of June 2011, Let’s Go! had engaged the following in the 12 Greater Portland communities: 56 schools educating more than 23,000 students; 8 district-wide school nutrition programs serving over 20,000 students; 34 child care programs caring for over 1,400 children; 28 after school recreation programs serving over 1,800 students; 29 healthcare sites; and 7 of Greater Portland’s largest employers.

60 Let’s Go! Sites (in Greater Portland) Reported Implementing Let’s Go! Strategies in *Strategy was implemented in year five or sustained from a previous year, in most classrooms or school- or program-wide.

Let’s Go! School Nutrition Initiative Let’s Go! led 35 schools in reaching the USDA’s Healthier US School Challenge. Healthier US School Challenge Criteria A different fruit and vegetable every day At least three dark green or orange vegetables per week Offer legumes at least once per week Offer whole grains three times per week Offer only low fat or fat free milk Offer nutrition education Provide at least 45 minutes of physical education per week Technical assistance, tools, and resources were provided by Let’s Go! during workgroup meetings, phone calls and s as they improved the nutritional quality of school meals. Only 2% of schools in the nation have achieved this award.

There are 14 Let’s Go! Practices in Greater Portland A recognized Let’s Go! Healthcare site must meet basic criteria for the following three components: 1.Connect to their community and the Let’s Go! community efforts Hang a Let’s Go! poster in waiting room and exam rooms 2.Accurately weigh and measure patients Determine Body Mass Index (BMI), BMI percentile, and weight classification in patients > 2 yrs. 3.Have a respectful conversation around weight Use the 5210 Healthy Habits Questionnaire

Parents’ Awareness Increased Significantly from 2007 to % Increase 293% Increase Note: In 2007 n=802; in 2009 n=800; in 2011 n= % Increase 422% Increase 422% Increase 293% Increase

Exposure to Let’s Go! in Multiple Settings Increased Parents’ Awareness of % Increase 153% Increase Note: In 2011 n= % Increase

Exposure to Let’s Go! in Multiple Settings Increased Parents’ Knowledge of Note: In 2011 n=801 51% Increase 51% Increase

Child’s Adherence with “5” and “0” Behaviors Increased Significantly from 2007 to 2011 Note: In 2007 n=802; in 2009 n=800; in 2011 n=801 63% Increase 18% Increase 63% Increase 18% Increase

Overweight and Obesity Prevalence for Ages 3-18 in Greater Portland Trended Down, While U.S. Rate Remained the Same 33% 32% 31% NOTE: NHANES data reflect 2006 and 2008 rates, and include ages Greater Portland: In 2006 n=3,051; in 2009 n=3,132.

Overweight and Obesity Prevalence Decreased for Females Age 3-5 in Greater Portland 63% Increase 18% Increase Note: In 2006 n=157; in 2009 n=133

Let’s Go! Our teen years - growing up and out 27

Let’s Go! Dissemination Statewide

Survey Response Rates 30

Let’s Go! Reach Across Four Sectors (Survey Participants) 31

Implementing Five Priority Strategies 32 *Implementation in schools and after school programs is in most or all classrooms; child care is program wide. **This year, the survey included questions about limiting unhealthy choices for snacks and celebrations, but those responses are not included in the analysis for this strategy; they will be included next year. ***The school and after school surveys did not include a question about milk; it’s a requirement for all schools participating in the national school meals program.

Implementing Five Supporting Strategies 33 *Implementation in schools and after school programs is in most or all classrooms; child care is program wide.

Policies are Changing (Schools & After School Programs)* Due to their involvement with Let’s Go! in the past year:  56% of schools did more to implement the district wellness policy and its recommendations around physical activity and healthy eating (n=166).  49% of schools reported their district strengthened their wellness policy to support the messages or strategies (n=166).  61% of after school programs either created, implemented or strengthened an existing wellness policy and its recommendations around physical activity and healthy eating (n=92). *This policy question was not included in the child care survey this year. 34

Healthcare Practices Meeting Basic Criteria 35

Reach of School Nutrition Workgroups 36

Nudging Kids Toward Healthy Choices Changes made as a result of school nutrition initiative: Decreased the portion size of a la carte items. Increased number of locations that fruit is available. Moved healthier items to high traffic areas. Offered cut up fruit such as apples and oranges. Put healthy options at eye level. Added new entrees or sides. Offered free samples of new menu items. Encouraged staff to use verbal reminders to encourage fruit and vegetable consumption. Required cash for a la carte or less healthy items. Note: Members of the Let’s Go! Somerset Workgroup completed a smarter lunchroom survey in May 2013 for 25 schools; response rate was 100%. Questions were grouped around six categories of best practices: manage portion size, increase convenience of healthier items, improve visibility, enhance taste expectations, utilize suggestive selling, and set smart pricing strategies. 37

Impact of School Nutrition Program Changes 38 Note: Members of the Let’s Go! Somerset Workgroup completed a smarter lunchroom survey in May 2013 for 25 schools; response rate was 100%.

Let’s Go! Recognition Program Sites of Distinction Eligibility for Schools, Child Care and After School Programs: Implement all 5 priority strategies: BRONZE 1-4 enforced written policies: SILVER All 5 enforced written policies: GOLD Note: Written policies will be reviewed by Let’s Go! staff. Eligibility for Healthcare Practices: Display a Let’s Go! poster in the waiting room and all exam rooms where pediatric patients are seen. All providers determine BMI for patients age two years and older. All providers use the Healthy Habits Questionnaire at well child visits. 39

Let’s Go! Sites of Distinction 40

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Let’s Go! Is Changing Environments  About 7 in 10 child care sites are providing healthy choices for snacks and celebrations and opportunities for recommended levels of physical activity.  Nearly all child care sites rarely or never use food to encourage positive behavior.  The vast majority of child care sites are limiting screen time.  More than two thirds of schools are providing healthy choices for snacks and celebrations and are limiting unhealthy choices.  More than 7 in 10 schools have implemented strategies around physical activity, water and sugar- sweetened beverages, and screen time.  In the past two years, purchase of whole grains and produce has increased in over 100 schools that have been part of the Let’s Go! school nutrition program.  About three-quarters of school nutrition programs are certified in the new federal meal pattern.  The vast majority of after school programs have implemented all five priority strategies.  Nearly all healthcare practices display the Let’s Go! poster in their waiting areas and routinely determine BMI for their pediatric patients.  Over three quarters of healthcare practices display the Let’s Go! poster in all exam rooms where children are seen.  In 7 in 10 healthcare practices, all providers routinely use the Healthy Habits survey. 42

Our Work is Not Done  More trainings are needed around wellness policies. – Schools located within the same school district in as many as 23 of 55 districts reported different policy information.  Increase the reach of School Nutrition Workgroups. – Establish workgroups across all regions of the state. – Continue trainings for Dissemination Partners to facilitate workgroups in their regions.  More trainings are needed in the healthcare sector. – Especially with larger practices (>5 clinicians). 43

Key Learnings…….  Consistency in message and approach is critical  Working across a community wherever kids live, learn, work and play is essential  It’s the environment, not the activities that matter most  Partnerships and Collaboration are paramount  Innovation and risk taking have been key to our success 44

Some of our challenges (mistakes)  Not fully understanding and acknowledging the current efforts on the ground  Moving too fast and getting ahead of people  Trying to please everybody  Making things too complicated  Not publishing sooner 45

Local and State Partners  Let’s Go! Dissemination Partners, including participating Healthy Maine Partnerships and health care systems  Participating Schools, Child Care Programs, Healthcare Practices, After School Programs, Employers and Communities  Maine Center for Disease Control and Prevention  Maine Department of Education  Maine Bureau of Parks and Lands  Maine Department of Health and Human Services, including Maine Head Star  University of Maine Cooperative Extension  Maine Dairy and Nutrition Council  Community based programs working to increase physical activity and healthy eating in Maine,) for ex. WinterKids  Maine After School Network

National Partners  National Initiative for Children’s Healthcare Quality (NICHQ)  Let’s Move  American Academy of Pediatrics (AAP)  American Medical Association (AMA)  National Convergence Partnership  Innovators and Risk Takers all over the country And You!

Let’s Go! Is Generously Funded by Our: Founding Partners Platinum Sponsors Additional Funders American Academy of Pediatrics/Healthy Active Living, Fairchild Semiconductor, Leonard C. & Mildred F. Ferguson Foundation, Maine Department of Health & Human Services/ARRA, The Rite Aid Foundation Gold Sponsors Silver Sponsors Walmart Jane’s Trust Bronze Sponsors The Bingham Program, Convergence Partnership, The Mattina R. Proctor Foundation, Sam L. Cohen Foundation Francis Hollis Brain Foundation, Poland Spring, Rite Aid Foundation, Visiting Board of BBCH, Estate of Mary R. Hodes

Comments Thoughts Questions 49