SummaryNemours, a children’s health system, spearheaded a multisector, collaborative, statewide initiative to halt and ultimately reverse the growing prevalence of childhood overweight and obesity in Delaware. The program combines policy and practice changes—supported by tools, technical assistance, and social marketing—in four key sectors: primary care, schools, childcare, and other community-based organizations. Key components for childcare include collaboration with state agencies on development of regulations promoting healthy eating, physical activity, and limited screen time for children in childcare settings, along with tools to support providers in adhering to these regulations. The program has increased childcare provider knowledge of childhood obesity and the importance of healthy behaviors, encouraged centers to make policy changes, and improved the health-related behaviors of children at these centers.Moderate: The evidence consists of pre- and post-implementation comparisons of childcare provider knowledge about childhood obesity and of the eating and physical activity habits of children in participating centers, along with post-implementation statistics on the percentage of participating centers making major policy changes.
Nemours spearheaded the initiative, partnering with many Delaware-based organizations and leaders. Major partners involved in the childcare initiative include the state's Child and Adult Care Food Program, the Office of Child Care Licensing, and childcare centers and family-based providers caring for 54,000 children annually.
Date First Implemented2006
Age > Child (6-12 years); Vulnerable Populations > Children; Age > Infant (1-23 months); Preschooler (2-5 years)
Problem AddressedChildhood overweight/obesity is a critical public health problem with devastating consequences. Childcare providers can play an important role in modeling—and providing opportunities to engage in—healthy behaviors that reduce the risk of overweight/obesity. However, such providers face many competing priorities during the day that make it difficult to play this role effectively without outside support.
- 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 1976-1980 and 2007-2008, the prevalence of obesity more than tripled, from 5.0 to 19.4 percent in 2- to 5-year-olds.1 Childhood obesity starts young, with almost one-fourth (24 percent) of children starting kindergarten already being overweight or at risk of becoming overweight.2 Research shows that a child’s weight at age 5 is a predictor of his or her weight at age 9.3 In fact, the “tipping point” in obesity may be as early as age 2 (and perhaps as early as 3 months), when the child begins learning how much and what to eat.4
- Delaware: Although trend data are not available, similar increases in overweight/obesity appear to have occurred among Delaware youth in recent decades. In 2008, roughly 29 percent of Delaware children between the ages of 2 and 5 (the target age for most childcare centers) were overweight or obese.5
- Poor health-related behaviors: High rates of overweight/obesity stem from both systems that fail to support making the healthy choice the easy choice and from poor health-related behaviors, including unhealthy diets and lack of physical activity. Although there have been increases in positive health behaviors, there is still room for improvement, as outlined below:
- Poor diet: In the 2008 Delaware Survey of Children’s Health, parents reported that 64.1 percent of children age 2 to 5 ate five or more fruits and vegetables daily. The same survey showed that 69.5 percent of children age 2 to 5 had two or fewer sugary beverages per week.6
- Lack of physical activity: The same survey found that 79.7 percent of children age 2 to 5 in Delaware had 1 or more hours of daily physical activity, and 78.1 percent had 2 hours or less of screen time each day.6
- Severe health consequences: Overweight and obesity puts 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.7
- Failure to support childcare system in doing its part: Nearly 74 percent of children between the ages of 3 and 6 (representing nearly 12 million children nationwide) are in some form of nonparental care, with over half being in center-based childcare.8 Childcare providers can play a critical role in modeling and promoting lifelong behaviors that reduce the risk of overweight/obesity. Yet they also face many competing demands and priorities on a daily basis and, consequently, need guidance and support to play this role effectively.
Description of the Innovative ActivityNemours spearheaded a multifaceted, collaborative statewide initiative that aims to halt and ultimately reverse the growing prevalence of childhood overweight and obesity in Delaware by promoting healthier eating and increased physical activity in four key settings. Key components for childcare providers include advocacy for new regulations related to physical activity, screen time, and nutrition, along with practical support to assist in implementing these regulations. Details on these key elements appear below:
For details about the larger Nemours initiative, see the related profile. For details about activities in other settings, see the related profile on primary care and see the related profile on schools.
- Statewide policy changes: In collaboration with others, Nemours advocated for regulatory and policy changes to encourage childcare centers to promote healthier behaviors in childcare settings. These changes affect the more than 54,000 Delaware children under the age of 12 who receive licensed center and family-based childcare (including after-school care) each day. Changes include the following:
- New physical activity regulations: In 2007, Nemours collaborated with the Delaware Office of Child Care Licensing to develop regulations for childcare providers related to physical activity and screen time. Changes mandate that childcare providers do the following:
- Provide at least 20 minutes of moderate to vigorous planned physical activity for every 3 hours of attendance.
- Limit infants to a maximum of 30 minutes in swings, strollers, or other confining equipment (while awake).
- Not allow children under age 2 to watch television, videos, or video games and limit use of such media to no more than 1 hour a day with older children (assuming parents give explicit consent to allow such viewing).
- New nutrition regulations: Nemours collaborated with the Office of Child Care Licensing for new nutrition regulations for childcare providers, later mandated by the Delaware Child and Adult Care Food Program, the state’s food subsidy program. The new regulations require all licensed childcare providers to do the following:
- Provide only one serving of juice a day to children over the age of 1. The serving must be 100-percent fruit juice (as opposed to alternatives with added sugar or high-fructose corn syrup). Those under the age of 1 cannot have any juice.
- Serve only real cheese (rather than cheese products or cheese food).
- Offer at least one whole grain product per day.
- Offer processed meats (such as hot dogs and deli meats) and sweet baked goods no more than once every 2 weeks.
- Serve only fat-free or 1-percent milk to children over the age of 2.
- Limit any prefried and fried food items to those that derive less than 35 percent of their calories from fat.
- Implementation support: Several programs support childcare providers in implementing these regulations, as outlined below:
- Tools and materials: In collaboration with others, Nemours produces and disseminates tools and materials to help childcare providers adhere to these requirements and make other policy changes. Examples include:
- “Healthy Habits for Life,” a toolkit incorporating resources to promote healthy eating and physical activity in preschoolers.
- “Best Practices for Healthy Eating,” a guide to assist childcare providers in implementing the nutrition regulations.
- Sample policies that childcare centers can include in parent handbooks and handouts about appropriate food for birthday celebrations and parties.
- Learning collaborative: In 2008, Nemours created a Child Care Learning Collaborative to help childcare provider teams (including the center director, teachers, and assistants) translate policy changes into practice. (The University of Delaware’s Institute for Excellence in Early Childhood, which offers professional development and training to childcare providers, now operates the learning collaborative.) The collaborative includes the following activities:
- Education and sharing of best practices: Periodic learning sessions cover policies to promote healthy behaviors in children. Regular teleconferences provide an opportunity for participants to share best practices and hear advice from national experts on child nutrition.
- Individualized action plans: Collaborative teams develop individualized action plans that outline the steps they will take to comply with the new standards and to generally support good nutrition and physical activity. To date, 28 participating centers (serving 2,750 children) have aligned their policies and activities with the state regulations. Examples of specific steps taken by collaborative participants include the following:
- Serving family-style meals, during which providers model positive behaviors.
- Developing and disseminating policies related to parent-provided food.
- Emphasizing the consumption of whole grains, 1-percent or nonfat milk, and water.
- Limiting consumption of sugary and fried foods.
- Providing more structured indoor and outdoor physical activity.
- Training: Nemours sponsors training programs for Child and Adult Care Food Program and Office of Child Care Licensing staff regarding nutrition and physical activity. In addition, Nemours works with the Institute for Excellence in Early Childhood to develop and implement training programs on healthy lifestyle choices to childcare providers.
- Telephone support: Providing technical assistance and training can be expensive, so Nemours has begun testing a toll-free telephone number that childcare providers can call with questions about policies and programs related to nutrition and physical activity, supported by a Team Nutrition grant from the Delaware Department of Education.
References/Related ArticlesChang DI, Gertel-Rosenberg A, Drayton VL, et al. A statewide strategy to battle child obesity in Delaware. Health Aff (Millwood). 2010;29(3):481-490. [PubMed]
Chang D, Bultman L, Drayton VL, et al. Beyond medical care: how health systems can address children’s needs through health promotion strategies. Health Aff (Millwood). 2007;26(2):466-73. [PubMed]
Contact the InnovatorDebbie I. Chang, MPH
Vice President, Policy and Prevention
252 Chapman Road, Christiana Building, Suite 200
Newark, DE 19702
Innovator DisclosuresMs. Chang reported that Nemours has received funding from the Center for Medicare and Medicaid Innovation's Health Care Innovation Challenge to investigate childhood asthma and the Centers for Disease Control and Prevention to spread its models related to early care and education as well as obesity prevention; in addition, information on funders is available in the Funding Sources section.
ResultsThe program increased childcare provider knowledge of childhood obesity and the importance of healthy behaviors, encouraged the vast majority of centers to make substantial policy changes, and improved the health-related behaviors of children attending these centers. (The overall initiative has led to favorable behavior changes that have helped to halt the increase in childhood overweight/obesity among Delaware youth; see the related profile for details.)
Moderate: The evidence consists of pre- and post-implementation comparisons of childcare provider knowledge about childhood obesity and of the eating and physical activity habits of children in participating centers, along with post-implementation statistics on the percentage of participating centers making major policy changes.
- Increased provider knowledge: Participating childcare providers showed increased awareness of the magnitude of the childhood obesity problem, the impact of childhood lifestyle choices on lifelong health, and the importance of adults as role models of healthy behaviors for children.9
- Policy changes within centers: Among childcare centers participating in the learning collaborative, 100 percent made major changes in the areas of healthy eating or physical activity and 81 percent made major policy changes to support healthy lifestyles in both areas that were sustained at least one year post collaborative.9
- Improved behaviors in children: The preschool children attending centers participating in the collaborative increased consumption of fruits and vegetables and milk, drank fewer sugary beverages, and spent more time engaged in physical activity (and less time in front of a screen).9
Context of the InnovationNemours, one of the nation’s leading pediatric health systems, is dedicated to achieving higher standards in children’s health by offering a spectrum of clinical treatment, research, policy and advocacy, and educational health and community-based prevention services to all families in the communities it serves. Nemours owns and operates the Alfred I. duPont Hospital for Children in Delaware and major children’s specialty clinics in the Delaware Valley and Florida. Nemours will open a new full-service children’s hospital in Orlando in 2012. Nemours also operates KidsHealth.org, the world’s most frequently visited pediatric health care Web site.
In 2003, Nemours leaders began considering how to increase the organization’s impact on pediatric health in the Delaware Valley, with the goal of going beyond the 55,000 patients served each year to the entire population of 207,000 children in the state. To spearhead this effort, Nemours created a separate operating unit in 2004 known as Nemours Health and Prevention Services. Given the importance of early childhood influences on the lifelong behaviors of the 54,000 children served by Delaware childcare providers, unit leaders decided to make encouraging policy and practice changes in these settings a top priority.
For more information on Nemours and the overall program, see the Context section in the related profile.
Planning and Development ProcessThe program’s development involved many concurrent steps, including the following:
- Advocating for policy change: In 2006, Nemours representatives contacted staff at the state Office of Child Care Licensing—who were in the process of updating regulations—to advocate for mandates related to physical activity and screen time. State officials agreed, and Nemours representatives provided input during development of the new regulations, which took effect in 2007. Nemours also worked with the state’s Child and Adult Care Food Program to set standards for food and beverages offered by childcare providers.
- Developing tools and materials: Nemours staff developed the aforementioned tools and materials, often in collaboration with others. For example, Nemours worked with Sesame Workshop to develop the “Healthy Habits for Life” and with the Child and Adult Care Food Program to develop the best practices guide.
- Piloting materials in childcare centers: Nemours contacted four childcare centers (which collectively cared for 775 children) to describe the initiative and gauge their interest in participating in a pilot program that offered technical assistance in implementing the regulatory changes, including the use of new tools and materials.
- Creating a learning collaborative: Nemours recruited learning collaborative participants through personal written and telephone outreach to centers that had participated in training sessions. In selecting participants, Nemours considered the size of the center as well as the population served. Each center that joined the collaborative committed to a year of participation, including attending five sessions and forming a “leadership team” consisting of the center owner or director and a manager or supervisor-level employee. Collaborative participants used tools developed by Nemours and others, with the goal of applying the best available resources.
- Developing and refining evaluation methodology: Nemours designed a methodology that aligns evaluation efforts with strategy and that captures both system- and population-level changes. To that end, Nemours revised the 2006 Delaware Child Care Provider Survey, with the updated version becoming the major systems-level instrument in the childcare field. Revisions were based on the methodological experience and data obtained from the 2006 version, the Nutrition and Physical Activity Self‐Assessment for Child Care (or NAP SACC) tool, direct observations, and focus groups with directors and teachers. The revised instrument provides information on director-level awareness of nutrition and physical activity standards, along with center-level implementation of policies and teacher-level implementation of practices related to nutrition and physical activity. The resulting survey was administered to 150 licensed childcare centers, representative of the 450 such centers throughout the state.
Resources Used and Skills Needed
- Staffing: Some of the 60 staff within Nemours Health and Prevention Services work on childcare-related aspects of the program. In addition, staff at childcare centers dedicates time to program-related activities. (For information about staffing for the overall initiative, see the related profile.)
- Costs: Data on program costs are not available.
Nemours funds program-related activities out of the operating budget for the Health and Prevention Services Unit. Childcare centers cover the labor and other expenses associated with their participation in program-related activities. As noted, the Department of Education provided a Team Nutrition grant to create training materials and delivery mechanisms, such as the telephone support line.
Tools and Other ResourcesMore information about this program is available at:
Nemours also has multiple tools to assist childcare providers in helping children adopt healthier lifestyles. These tools are available at:
Getting Started with This Innovation
- Support both policy and practice-based changes: Success with this type of population-based initiative depends on both high-level policy changes and ground-level support (e.g., training, learning collaboratives) for individual childcare providers so that they know how to implement the recommendations.
- Create economies of scale by working with umbrella organizations, such as the state licensing office or childcare professional organizations. These organizations can build support, convey program messages, and disseminate materials to individual providers.
- Highlight benefits of participation: Busy childcare providers must be convinced of the merits of participating in such a program. For example, Nemours representatives pointed out that participation would aid compliance with regulatory mandates.
- Define goals and associated metrics: Clearly defined goals and measures (e.g., whether a provider meets mandated requirements) can help program developers design focused activities and ensure that childcare providers can track and improve their performance.
- Identify champion in each center: Childcare providers who are passionate about reducing childhood overweight/obesity can help disseminate information and tools, and can build enthusiasm for new initiatives within each center.
Sustaining This Innovation
- Advocate for policy change: Regulations and laws obviously play a key role in supporting practice changes in childcare settings.
- Keep support programs in place, building on community capacity: Ongoing support is critical to helping childcare providers maintain success. For example, the learning collaborative can help providers sustain improvements and learn about innovative practices from colleagues.
- Leverage sustainable infrastructure: As noted, Nemours collaborates with the Delaware Institute for Excellence in Early Childhood. Housed at the University of Delaware, this organization serves as sustainable infrastructure for professional development and training. Nemours is transitioning many of its training programs to the institute so that it can continue to support early childhood professionals throughout the state.
- Monitor progress, refine program as needed: Program developers should collect key data from childcare providers on an ongoing basis, periodically analyze the data to gauge program impact and provider-specific performance, and regularly ask center leaders for feedback about the results. These steps help maintain enthusiasm 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, Nemours used a scheduled update of Delaware childcare regulations and policies as an opportunity to advocate for a greater focus on promoting healthy behaviors and then set up implementation support to help childcare providers comply with the update.
Ogden CL, Carroll MD, Flegal KM. High body mass index for age among US children and adolescents, 2003-2006. JAMA. 2008;299(20):2401-2405. [PubMed]
Daphne S, Gardner L, Hosking J, et al. Contribution of early weight gain to childhood overweight and metabolic health: a longitudinal study (EarlyBird 36). Pediatrics. 2009;123(1):e67-73. [PubMed]
Settler N, Kumanyika SK, Katz SH, et al. Rapid weight gain during infancy and obesity in young adulthood in a cohort of African Americans. Am J Clin Nutr. 2003;77:1374-1378. [PubMed]
5 Nemours Health & Prevention Services. Making Delaware Early Child Care Environments Healthier. Progress Report 2008.
6 2008 Delaware Survey of Children’s Health.
6 2008 Delaware Survey of Children’s Health.
8 Federal Interagency Forum on Child and Family Statistics. America’s Children: Key National Indicators of Well Being, 2002. Washington, DC: U.S. Government Printing Office; 2002.
Chang DI, Gertel-Rosenberg A, Drayton VL, et al. A statewide strategy to battle child obesity in Delaware. Health Aff (Millwood). 2010;29(3):481-490. [PubMed]
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Original publication: August 28, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 28, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: July 02, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.