Problem Addressed

• A growing epidemic: The prevalence of obesity (defined as having a body mass index, or BMI, at or above the 95th percentile) among children and adolescents has grown significantly over the last several decades, both nationally and in Maine:
  • Nationwide: Between 1976–1980 and 2007–2008, the prevalence of obesity rose 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
  • Maine: Maine has not been immune from the overweight/obesity epidemic. Data from the National Conference of State Legislatures show that approximately 28 percent of Maine children age 10 to 17 were overweight or obese in 2007, more than double the 12.7 percent rate in 2003.³ A 2006 review of 3,000 charts representing roughly 50,000 Maine patients between the ages of 3 and 18 produced similar findings, with roughly a third (32.8 percent) being overweight or obese.¹
• Driven by poor health-related behaviors: High rates of overweight/obesity stem in large part from poor health-related behaviors, including unhealthy diets and lack of physical activity:
  • Poor diet: According to the 2009 Maine Integrated Youth Risk Survey, only 14.9 percent of high school students and 18.4 percent of children in grades 7 and 8 ate at least 5 servings of fruits and vegetables a day during the week before the survey.⁴
  • Lack of physical activity: The same survey found that less than half of Maine children met national physical activity guidelines during the prior week, while roughly a third watched 3 or more hours of television on the average school day.⁴
• Leading to severe health consequences: A critical public health issue, overweight and obesity put children at current and future risk of many serious health problems, including cardiovascular disease, type 2 diabetes, and mental health conditions such as anxiety and depression.⁵ Approximately 60 percent of obese children between the ages of 5 and 10 have at least one risk factor for cardiovascular disease, such as elevated total cholesterol, triglycerides, insulin, or blood pressure, while 25 percent have two or more such risk factors.⁶
• Lack of comprehensive, population-based approach: 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 sector is likely to reverse it. For example, primary care providers can counsel pediatric patients to adopt healthy lifestyle behaviors related to diet and exercise, but these efforts will likely fail unless parents, schools, child care centers, and communities provide an environment supportive of such behaviors. As a result, many experts believe that only a broad-based, multifaceted strategy can effectively address this population-wide health problem.¹ To date, however, few communities have embarked on such a strategy.

Description of the Innovative Activity

• Consistent, memorable message and associated social marketing campaign: To create urgency about the need to address childhood obesity, the program launched a social marketing campaign aimed at boosting awareness of the Let’s Go! brand, with an easy-to-remember, evidence-based message focused on encouraging healthy behaviors. The message—“5-2-1-0 Every Day”—is used consistently across all programs and initiatives. The program uses television, newspaper, cinema, bus, and Internet advertisements, as well as social media outlets such as Facebook and Twitter to convey the 5-2-1-0 message, which represents these daily behavior goals:
  
  • 5 or more fruits and vegetables.
  • 2 hours or less of recreational screen time. (Keep TV/computer out of the bedroom. No screen time under the age of 2.)
  • 1 hour or more of physical activity
  • 0 sugary drinks; drink more water and low-fat milk.

The marketing effort also drives users to a robust Let’s Go! Web site for up-to-date research, tools, and more information.

• Policy and advocacy work: The program regularly advocates for national, state, and local policies that promote the adoption of healthier behaviors by Maine youth. For example, Let’s Go! staff and partners advocated on a national level for the Healthy, Hunger-Free Kids Act of 2010, which authorizes funding and sets nutritional policy for its core child nutrition programs (including the National School Lunch Program and School Breakfast Program). On an ongoing basis, staff and partners write letters of support for state legislation consistent with the Let’s Go! mission, and they have testified in the State legislature on topics such as menu labeling, physical education, and school nutrition. Local advocacy efforts include attending school board and other meetings to advocate for healthy lifestyles among Maine youth.
• Initiatives by sector: The program provides practical support within each targeted sector to facilitate implementation of activities and policies to promote healthy lifestyles. Support includes detailed toolkits and onsite education and technical assistance, as outlined below:
  • Primary care physicians: Let’s Go! offers several forms of support to primary care physicians as they work to prevent, assess, and treat overweight and obesity in youth, including a toolkit with provider and patient tools that facilitate respectful conversations about physical activity and healthy eating during well-child visits using motivational interviewing techniques; posters for waiting rooms and examination rooms about Let’s Go! and the 5-2-1-0 messages; support in documenting document height, weight, and BMI for patients age 2 to 18; educational conferences on childhood obesity; and onsite technical assistance to help physicians embed tools into their everyday practice workflow. To date, 65 practices across Maine have received a toolkit and/or attended an educational outreach session. (For more information, see the related profile.)
  • Schools: The Let’s Go!’s “5-2-1-0 Goes to School” initiative includes 10 key strategies that can be embedded individually or collectively in school policies and practices to promote healthy behaviors. These strategies relate to specific nutrition and physical activity goals as well as to environmental changes. Schools use a toolkit, participate in online training, and receive onsite technical assistance from Let's Go! staff, who work with school representatives to select strategies that directly relate to their school’s needs. Schools also can apply for competitive mini-grants to help fund initiatives. Let’s Go! currently supports 345 schools (out of the 625 schools in Maine) that collectively educate 112,000 students. (For more information, see the related profile.)
  • Early childhood: Let's Go! has created a four-pronged approach for the early childhood sector, including educational outreach and presentations to child care sites, a “5-2-1-0 Goes to Child Care” toolkit, advocacy efforts designed to embed the 5-2-1-0 message in local and state child care regulations and standards, and activities to spread the 5-2-1-0 message in the 0- to 2-year-old population. Let’s Go! currently supports 163 child care centers (out of 2,200 in the state) that collectively care for more than 7,000 children. (For more information, see the related profile.)
  • After school: After-school providers—such as Boys and Girls Clubs, teen centers, and YMCAs—can access resources through the “5-2-1-0 Goes After School” toolkit, participate in staff educational sessions and conferences, and receive onsite technical assistance visits from Let’s Go! staff who help them implement the toolkit. Currently, 24 after-school recreation sites that reach more than 4,000 youth are participating in the program.
  • Workplace: Let’s Go! offers a workplace toolkit to help employers convey and reinforce the 5-2-1-0 message to employees. The toolkit offers handouts for parents, links to organizations that help employers develop wellness plans, and the Let’s Go! StairWELL packet (modeled  after the Centers for Disease Control StairWELL campaign), which has ready-to-use materials on how to use the work environment to promote physical activity.
  • Community organizations: Let’s Go! offers a community mini-grant program that helps fund local policy and environmental interventions that promote physical activity and healthy eating. Recipients have used the grants to fund a wide variety of healthy lifestyle-related activities; examples include regrading and building a bridge to enhance a community walking trail, incorporating physical activity into church groups, and developing a cultural dance program for children whose parents are from the Democratic Republic of Congo, Rwanda, and Burundi.

References/Related Articles

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Innovator Disclosures

Results

• Significant public awareness: In 2009 (3 years after the program’s launch), 43 percent of parents in the greater Portland area (which includes 12 communities) reported being aware of the “5-2-1-0” message, 49 percent reported hearing about the Let’s Go! campaign, and 28 percent had been exposed to the 5-2-1-0 message in three or more settings.
• Healthier behaviors: In 2009, 28 percent of children in the greater Portland area met at least three of the four recommended 5-2-1-0 behaviors, well above the 2007 rate of 22 percent. (These figures represent a 27 percent increase in the proportion of children meeting at least three of the four recommendations.) For children in higher-income households (above $75,000 annually), the percentage consuming five daily servings of fruits and vegetables increased from 18 percent to 26 percent over the same time period, while the percentage engaging in 2 hours or less of screen time (recreational time with a television or computer) rose from 43 percent to 53 percent.
• Halt in rise in overweight/obesity: A review of 3,000 charts representing roughly 50,000 Maine patients age 3 to 18 found that the prevalence of overweight and obesity declined slightly between 2006 (the year of program implementation) and 2009, from 32.8 percent to 31.3 percent.
• Significant progress within key sectors: The program has encouraged key stakeholders to provide greater support to children in adopting healthier lifestyles. Summary details are provided below, with more information available in the related profiles.
  • Greater documentation by primary care: Primary care providers receiving a Let’s Go! toolkit and/or educational intervention better supported youth in adopting healthier lifestyles. For example, by June 2010, 12,169 of these doctors’ patients had a documented Let’s Go “Healthy Weight Bundle” in their medical record, including height, weight, BMI, weight classification, blood pressure, and administration of a 5-2-1-0 survey. This figure represents a 44 percent increase from the previous year, when 8,434 patients had this information recorded. (For more information, see the related profile.)
  • Widespread implementation of strategies in schools: By the end of the 2009–2010 school year, 100 percent of participating schools in greater Portland had implemented at least 1 of the 10 targeted strategies, with most implementing 2 or more. In the Portland metropolitan area, 96 percent of elementary schools that had implemented at least two strategies in 2008–2009 maintained them the following year, and 44 percent adopted at least one additional strategy. In addition, during the 2009–2010 school year, all participating school districts improved the nutritional quality of school meals. (For more information, see the related profile.)
  • Widespread implementation of key strategies in child care: Among participating child care sites, 100 perecent implemented at least two of the key strategies during the 2009–2010 school year (the first year of the Let’s Go! child care program). (For more information, see the related profile.)

Evidence Rating (What is this?)

• Campaign message awareness among Maine parents.
• Trends in health-related behaviors among Maine youth, including daily screen time and consumption of fruits, vegetables, and sugary beverages.
• Trends in prevalence of overweight/obesity among Maine youth between 2006 and 2009.
• Summary evidence of increased efforts of primary care providers, schools, and child care providers to implement strategies that support lifestyle changes among Maine youth.

Context of the Innovation

Planning and Development Process

• Creating campaign, securing resource commitment: Leaders from the seven founding organizations developed the Let’s Go! initiative around the 5-2-1-0 message (used successfully by the Maine Youth Overweight Collaborative) and committed significant resources to building toolkits, educational opportunities, and other support for medical and nonmedical settings.
• Enhancing tools for primary care: Let’s Go! staff enhanced the tools for primary care physicians. The tools were tested by practices that had participated in the Maine Youth Overweight Collaborative.
• Developing school program: A pediatrician with the Barbara Bush Children's Hospital at Maine Medical Center (who has since become the Let’s Go!’s project director) developed and tested some “5-2-1-0 Goes to School” materials in her children’s school to see if the message could be adapted to that setting. This successful test led to the development of the Let’s Go!’s school initiative in 2006.
• Spreading to other sectors: Let’s Go! staff and other experts adapted the school toolkit and spread the program to after-school programs (2008) and child care settings (2009). The staff also created or adapted materials for the workplace environment and community sectors (with support from faith-based and public health organizations), enabling the program to spread to these sectors in 2009.

Resources Used and Skills Needed

• Staffing: The program includes a full-time director, five full-time program managers spread across nine topic areas (the six targeted sectors, along with school nutrition, data/evaluation and general management), two coordinators, and an administrative assistant.
• Costs: The founding partners, local businesses, and other foundations and organizations have invested $3.7 million in the first 5 years of program operations. Partners also provide in-kind donations consisting of staff assistance and materials.

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 guidelines, regulations, and/or legislation) and ground-level support (e.g., training and technical assistance) for organizations and individuals involved in implementation.
• Develop and reinforce 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.
• Stick to the evidence: Developing a program based on evidence can help ensure participant support. For example, all components of the 5-2-1-0 campaign come from established evidence that these behaviors can help reduce overweight/obesity.
• Create strong partnerships: Identify stakeholders with a similar mission who can help with toolkit creation and dissemination. Strong partnerships with business leaders, government agencies, community-based organizations, and providers can promote widespread changes in health-related behaviors. To facilitate dissemination, identify partner organizations that already serve targeted stakeholders, such as physician-hospital organizations (primary care physicians) and the United Way (child care settings).

Sustaining This Innovation

• Develop a strong dissemination model: Partner with organizations that can take ownership of dissemination activities. Partners can work with schools, physicians, and others in their local areas to spread the message and provide guidance on toolkit adoption.
• Provide usable data: Provide data to participants that they can use to meet other reporting requirements or needs. This approach helps to create real value for participants, thus keeping them interested in the program. For example, pediatricians can refer to their participation in Let’s Go! and their documentation of the Healthy Weight Bundle when reporting quality measures to local, state, or national organizations.
• Keep support programs in place: Ongoing technical support is critical to helping schools/school districts, providers, child care 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, recently enacted child care legislation in Maine will be used by Let’s Go! staff to promote the need for changes in policy and practices in child care settings
• Be in it for the long haul: Significant time and persistence are needed for success.