Partnership Vignettes

Cornell NutritionWorks

www.nutritionworks.cornell.edu

The Online Course on Preventing Childhood Overweight is an interactive, web-based continuing professional education program for nutrition and health practitioners. As part of Cornell NutritionWorks, a new online course on "Preventing Childhood Overweight at Home, at School, and in the Community" is being developed, which will be pilot tested in the spring 2005. This course will build upon the growing number of offerings already available on Cornell NutritionWorks related to childhood overweight. Cornell NutritionWorks provides a convenient, accessible form of continuing education to busy professionals to increase their capacity to address nutrition issues such as childhood obesity at the community level.

Cornell NutritionWorks was developed by Cornell University Division of Nutritional Sciences faculty in 2002 to meet the professional development needs identified by community practitioners. In addition to the opportunity to interact with Cornell faculty members, Cornell NutritionWorks provides access to current nutrition research, references and tools that enhance practice, discussion forums for exchanging information with peers, and selfassessments for continuing professional education units. Membership in Cornell NutritionWorks became free in 2004. There are currently over 1,300 members, from all 50 states and 28 countries. There is a small fee for credits, which can be paid online. Current funding for Cornell NutritionWorks comes from Cornell Cooperative Extension, the College of Human Ecology at Cornell, and the Offices of the President and Provost at Cornell.

Cornell University
Division of Nutritional Sciences
Food and Nutrition Education in Communities

The Food and Nutrition Education in Communities programs include Cornell Cooperative Extension's (CCE) work through the Expanded Food and Nutrition Education Program (EFNEP) and Food Stamp Nutrition Education or Eat Smart New York (ESNY). The goal of these programs is to educate participants, using a skill-building approach that improves nutrition behaviors (dietary quality, food safety, and food resource management) and, to a lesser extent, physical activity behaviors. Both programs are currently expanding the focus on childhood obesity prevention. EFNEP will begin demonstration projects in a few counties during the next year to identify effective methods to impact the environment and personal behaviors necessary to achieve and maintain a healthy weight. The goal is to impact behaviors of adults who influence children. Cornell NutritionWorks online course, "Preventing Childhood Overweight at Home, at School, and in the Community," will be the training to prepare CCE staff to carry out this initiative.

NYS EFNEP is funded by USDA through the Cooperative State Research, Education, and Extension Service, receiving about $3 million per year. EFNEP has served NYS for 35 years and currently provides nutrition education to low-income families with children and to low-income youth in 35 counties in NYS and in four boroughs of New York City. Participants have incomes at or below 185% of the federal poverty line. Over 7000 families and 14,000 youth are reached each year through EFNEP. ESNY is funded by the Food and Nutrition Service of USDA, receiving about $10 million in federal dollars annually, which must be matched with an equal number of county and state dollars. ESNY has been in NYS for 10 years and currently provides nutrition education to food stamp recipients in 54 counties and New York City. Over 11,000 adults and 28,000 youth reached through ESNY. EFNEP and ESNY partner with a variety of agencies at the county and state level; examples include the state and county health departments, particularly WIC; the NYS Department of Agriculture and Markets; the NYS Office of Temporary and Disability Assistance and local Department of Social Service offices; public schools; child care programs (after school, day care, and summer camp); Head Start programs; food pantries; and various occupational training programs.

Low-fat Milk Promotion

Recent evidence indicates that lowfat dairy products and calcium play a role in preventing overweight and chronic diseases such as hypertension and diabetes. Unfortunately, intake of dairy products has declined over the past 20 years. Eat Well Play Hard (EWPH) demonstration projects in three communities have been successful in working with day care providers and schools to promote low-fat and fat free milk: Dutchess County EWPH worked with the City of Poughkeepsie School District which began purchasing 1% or fat free milk and discontinued the sale and purchase of whole or 2% milk in all 8 of their schools. In addition, two schools purchased milk machines to replace soda and other non-nutritious beverages. These policies affected 11,500 students.

Erie County conducted a Low Fat Milk Campaign and tracked the purchase inventory of milk over time. Of the 14 schools in the project area, four switched completely to 1% or fat free, affecting over 9000 students. Additionally through these efforts, the Summer Food Program selected 1% or fat free milk as the milk provided for the 220,000 meals served.

Jefferson County efforts resulted in the Fort Drum Military Base switching to low fat dairy products at the day care centers serving 900 children daily, and the replacement of whole or 2% milk with 1% and fat free milk for the 18,000 meals served during the Summer Food and Nutrition program.

Public/private partnerships to promote healthy eating

The Jefferson County Eat Well Play Hard demonstration project partnered with the Hannaford Market chain and the NYS Apple Grower's Association to implement an apple coupon redemption system during the fall harvest. The project distributed over 6,000 coupons with total sales of apples increasing by 11,000 pounds over the same time period for the previous year.

The Dutchess County Eat Well Play Hard demonstration project partnered with a local McDonald's to modify the Happy Meal Menu. The "Happy Meal Plus" included 1% or fat free milk or a 5 oz. low fat yogurt in place of a soft drink and added a choice of salad or fruit cup. A physical activity toy, such as a beach ball or jump rope was also included. A total of 943 Plus meals were sold during the promotion. Over a two month period, the number of Plus meals sold was 67% above the average sales for the Happy Meal. Sales of low fat milk for the McDonald's store were up by 19% over the same period during the previous year. Children selected the fruit cup 38% of the time; salad was selected 29% of the time.

Changing the School Nutrition Environment

School food service staff, vendor representatives, the Student Nutrition Club, and other school staff from Cicero-North Syracuse High School worked to make the school nutrition environment one that promotes healthy eating. Some of the changes implemented included elimination of high fat snacks (only snacks with 8 grams of fat or less allowed), reducing high fat entrees, changing how foods are prepared, and selecting lower fat ingredients. The results were quite positive: lunch sales increased by at least 65 students per day and sales of the now healthier a la carte selections, increased as well.

Schenectady's Promise: The Alliance for Youth

A countywide initiative spearheaded by United Way of Schenectady, the County Youth Bureau and BOCES of the Capital Region, and Kevin Karpowicz, MD, MPH. The program serves two primary purposes: positive youth development and community collaboration in an organized fashion. Schenectady's Promise is affiliated with the national effort, America's Promise.

There are over 80 partners, both individuals and groups, that have signed a pledge to fulfill the five promises that serve as the organizing principle. The five promises are Healthy Start, Caring Adults, Safe Places, Marketable Skills and Opportunities to Serve. Each of the five promises has a specific action team where the issue is explored at length. Local agencies, where youth are involved, pledge to become sites of promise where each of the five promises will be addressed. The information generated by the action teams is shared with the sites of promise.

Schenectady's Promise pledges to include youth at every table. By empowering youth and including them as a valuable partner, Schenectady's Promise will work toward the positive youth development, where youth will be more likely to have a positive image of themselves and pursue more positive health promoting lifestyles.

Steps to a Healthier NY

The goal of the Steps to a Healthier NY (Steps) program is to help individuals live longer, better and healthier lives by reducing the burden of diabetes, asthma and obesity by addressing three related risk factors - physical activity, poor nutrition, and tobacco use. New York State's Departments of Education and Health are partnering with four counties to implement effective strategies to maximize community and school resources and address the critical health issues and related risk factors.

In September 2003, New York State received a five year grant from the CDC to address these issues; seventy-five percent of these federal funds are provided directly to the four counties of Broome, Chautauqua, Jefferson and Rockland with a combined population of approximately 800,000 people. These counties were selected based on their need, demographics, and previous experience in developing and implementing effective community-based public health programs. The goals of Steps are achieved through the building of partnerships (community consortiums) between public and private organizations working in areas of disease prevention and medical, social, educational, business, religious and civic organizations. Evidence-based community and school-based interventions have been tailored to each individual county's needs and resources. A number of Steps interventions related to obesity, nutrition, and physical activity exist in the areas of Policy, School-Base, Community-Based, Workplace, Health Care. The Obesity Prevention Program works with the Steps to a HealthierUS Program including providing data and information for New York's four Steps counties and providing staff expertise in Steps counties. Together, the Obesity Prevention and Steps Programs sponsored social marketing training for stakeholders involved in both the Obesity intervention and the four Steps counties. The benefits of this included economy of scale in purchasing services and importantly, brought together staff of both programs and intervention sites to share information, network and create new partnerships to prevent diabetes in New York State.

The Broome County Healthy Heart Program

The Broome County Healthy Heart Program implemented an 8-week community-based campaign to increase walking among 40-65 year olds called "BC Walks." The campaign included paid media (TV, radio and print), as well as unpaid media coverage, a speakers' bureau, and numerous community events. A pre and post survey of a random sample of the target audience found that 47% of Broome Country respondents had increased their total weekly walking time compared to 35% in the comparison community, and 41% of Broome County respondents increased their weekly walking by at least 30 minutes compared with 30% in the comparison community.

Center for Obesity Research and Education- C.O.R.E

An initiative of SUNY Cortland whose purpose is to serve as a research and educational resource for endeavors on obesity and physical activity to reduce the burden of obesity in children and adults through research, education, and service. The centerpiece of CORE is the creation and maintenance of a statewide database regarding current and on-going physical demographics of children in grades K-6 within each of the 62 New York State Counties. The immediate outcome of this data collection will be an account of overweight status of our children in NYS.

Spearheaded by Philip J. Buckenmeyer, and Jeff Bauer, Ph.D. the CORE initiative became operational as of January 2005. The strength of CORE is its multidisciplinary composition that includes 14 faculty from various departments across campus. These departments support up to 1,400 student teachers across the state, which provide an immediate contact to several NYS regions.

State Department of Transportation Partnership

The Healthy Heart Program partnered with the State Department of Transportation to conduct over 15 Walkable Community workshops throughout the state. A 4-hour workshop brought together local decision makers, health and planning professionals, and concerned citizens to learn more about how they can make their communities more pedestrian friendly. In several of these communities, projects to improve pedestrian safety have been initiated as a direct result of these workshops.

Warren Washington County Healthy Heart Program

The Warren Washington County Healthy Heart Program has worked with local transportation partners to improve the Warren County Bikeway and the Feeder Canal Trail and to promote the use of the trails by hosting numerous trail-oriented events. Over the two-year period of their work, trail use doubled. The majority of users were on bicycles, but the number of walkers tripled.

Greenmarket 5-A-Day Partnership

Data reported in the 2002 NYC Community Health Survey showed that only 9.5% of NYC residents consumed five or more servings of fruits and vegetables on a given day. In some areas, the figure was as low as 4.7%. Programs that address barriers, such as availability and cost of produce in larger cities, are clearly needed. To address the issue, the Wellness at Work program developed a partnership with Greenmarket, an organization providing farmers' markets across the city. Program staff developed and distributed promotional kits to the farmers' markets, as well as to mobile fruit and vegetable vendors across the city. The kits contained an apron, produce bags, recipe cards and informational sheets, all branded with the 5-A-Day logo. Roughly 175 boxes were sent out throughout the 5 counties in NYC. In addition, staff canvassed the city and gave out an additional 200 boxes.

This initiative marked the first time the 5-A-Day message and program were promoted throughout NYC by the City Health Department. This program helped make initial efforts to develop a database of local fruit and vegetable vendors, which will facilitate future and continued outreach to these groups. Efforts to assess the effects on fruit and vegetable consumption of this simple promotion and collaboration are ongoing.

Individual Interventions for Physical Activity

Senior Exercise Self-Efficacy Pilot Program (SESEP): The SESEP was conducted in joint collaboration with the New York City Housing Authority (NYCHA), which provides health promotion and disease prevention services to underserved elderly adults in senior centers located at public housing projects. The project used short-term motivation-based interventions to encourage the elderly to adopt and maintain healthy behaviors. The project's aim was to affect individual behavior by helping older adults realize they were capable of performing exercises from which they could derive benefits. Self-efficacy was enhanced through education, observing role models, obtaining goals through systematic training sessions, receiving positive feedback in response to successful change, and positive reinterpretation of physical symptoms associated with the health behavior.

At 12 selected NYCHA senior centers, clear and easy-to-follow exercise instruction, as well as motivational training, was provided in the form of two classes per week for twelve weeks. One class per week focused on resistance training, while the other focused on aerobic training. All classes included educational, flexibility and motivational training components, with special attention given to older adults' unique physical and psychological barriers to exercise. A trained lay instructor from the seniors' community instructed the classes, providing a role model and a source of positive reinforcement. All classes incorporated individual goal setting into their curricula and prompted participants to exercise independently.

Two hundred forty four subjects were recruited at baseline and 166 (100 cases and 66 controls) participated in the baseline interview and follow-up data collection. The average age of participants was 73. The majority of participants were female (79%), African American (72%), unmarried (86%), retired (89%), and high school educated (67%). The evaluation revealed that there was a statistically significant improvement in the treatment group's mental health (F=6.0, p<.05), as opposed to that of the comparison group. Additionally, there was a statistically significant improvement in the treatment group's total mobility (F=7.0, p<.05) versus that of the comparison group. Data collection was facilitated through a partnership with the Nursing Program at New York University. Graduate nursing students were trained on data collection procedures and assisted in interviewing participants and taking baseline measurements. Although the self-efficacy measurement between both the intervention and comparison groups were not statistically significant, the intervention group's outcome expectations were statistically significant (F=10.4, p<.01). By utilizing a place-based setting such as a senior center, the data suggested that behavioral intervention increases healthy behaviors, particularly in this largely minority, female population. This study was limited because it did not monitor long-term behavioral changes. In addition, self-reporting of physical activity may not have been as reliable as other, more objective measures. Nonetheless, this study reveals the capacity for behavioral intervention to improve physical activity, improve nutrition, and general health.

Just Ask Us Restaurant Intervention

In 2002-2003, the Wellness at Work Program implemented a restaurant intervention with two major purposes: 1) to educate the public regarding healthy menu modifications in restaurants, and 2) to incorporate healthy nutrition messages into the curriculum of the Bureau of Food Safety and Community Sanitation. The Bureau of Food Safety and Community Sanitation, within the NYC DOHMH, is responsible for training and certifying all food handlers employed by NYC restaurants. The intervention, "Just Ask Us," aimed to provide restaurant patrons with the option to request basic healthy menu modifications such as sauce or dressing on the side, egg substitutes, and no salt added to their meals. The goal was to provide the consumer with ways to dine out and still maintain a healthy diet. The intervention consisted of two components. For food preparers, the intervention allowed for the incorporation of healthy nutrition guidelines into the city-mandated food protection course required for food preparers. Over 400 food handlers complete this class during any given month. For restaurants, implementation trainings were given to staff and promotional materials (menu labels, server pins, window decals, posters, and comment cards) were distributed.

The major proposed outcomes of this intervention were to evaluate whether the availability of healthy options influenced decisions to go to a particular restaurant, whether it increased the likelihood that patrons would ask for menu modifications, and if the servers assisted customers with menu modifications. Although evaluation of the program never occurred due to limited funding, several barriers that were encountered will prove useful for future attempts in implementing the program. For example, finding ways to market the restaurants to increase customer traffic and providing rewards to those vendors that successfully implement the program is essential for long-term participation. In conclusion, the program ensured a community level buy-in to disease prevention by linking mandated training to consumer choice.

The United Nations (UN) Challenge

A grant from the Robert Wood Johnson Foundation from July 1, 2001 - June 30, 2004 supported the creation and implementation of a two-year, comprehensive worksite health promotion program at the UN headquarters in New York City. The United Nations Challenge intervention was based on aspects of the 2003 Commissioner's Challenge at the NYC DOHMH and included three main components: (1) Know your Numbers, (2) Healthy Eating Plan and (3) Move for Life and was the first to utilize the Wellness Resource Center, an online tailored workplace health promotion tool. Additionally, the intervention conducted workshops that dealt with financial management, stress management, nutrition, and physical activity. The Wellness Initiative at the UN follows a seven-step model developed by the Wellness Councils of America (WELCOA). This model incorporates best practices for implementing health promotion and disease prevention programs, and accommodates the unique characteristics at each worksite, including organizational health structure, employee health needs and interests,and institutional resources. The latter characteristics are especially important at the UN, one of the most diverse employers in New York City.

Provider Education Project: Promoting the Use of Body Mass Index to Assess Weight Status in Pediatric Patients

Body Mass Index (BMI)-for-age percentile is the screening tool of choice in the assessment of weight status (both underweight and overweight) for children aged 2-20 years, as recommended by a number of national organizations, including the American Academy of Pediatrics, the Centers for Disease Control and Prevention and the Maternal and Child Health Bureau. Despite publication of guidelines and updated BMI-for-age growth charts, many health care providers have not implemented these current recommendations. A 2002 national survey of pediatricians revealed that only 12.5% of respondents routinely use BMI-for-age percentile with their pediatric patients. Based on the above recommendations, the New York State Department of Health Bureau of Child and Adolescent Health has developed a statewide educational mailing to promote the use of BMI for age percentile by NYS pediatric providers.

The project described here represents the pilot phase of this educational program. This pilot phase will be used to 1) describe the weight assessment methods most frequently employed by NYS providers, and 2) evaluate the impact and effectiveness of the educational mailing. Results from this evaluation project will be used to refine the educational materials prior to statewide distribution.

The NYC DOHMH Commissioner's Challenge

"The Commissioner's Challenge," an incentive-based, 3-month health promotion contest was introduced in May 2003 as a novel worksite intervention by the Wellness at Work Program for New York City Department of Health and Mental Hygiene (NYC DOHMH) employees. The challenge was the first intervention to be offered both on the Internet and via paper to employees. It provided employees with the opportunity to learn more about their health by being in a team and accruing points in order to win the grand prize of a healthy breakfast with Commissioner Thomas R. Frieden, MD, MPH. The intervention components of the challenge were developed directly in response to the needs assessment (WWS) that was completed by NYC DOHMH employees in 2002. The challenge consisted of three major programs: "Know Your Numbers," a campaign to encourage employees to visit their health care provider and have their blood pressure, cholesterol/HDL, BMI, height and weight checked; the "Move for Life" program which addressed physical activity by granting points to participants for completing various forms of physical activity; and a nutrition program that provided employees with online access to Berkeley Nutrition Screeners, which measure fruit/vegetable and fat intake and provide individualized feedback about ways to improve eating habits. As a part of the challenge, the Wellness at Work team collected data about the number of participants in each of the components and their health data. There was an overall average participation rate of 12.5% among employees. Of the 669 individuals who participated in the challenge, nearly half achieved or surpassed their fitness goals. 29% were at considerable risk due to high cholesterol levels. 25% were considered to be overweight (BMI 25.0-29.9), while 40% were obese (BMI greater than 30.0). The employee profile results revealed that many NYC DOHMH employees needed to lose weight and enhance their cardio-vascular fitness. This challenge will be repeated in March 2004 with the addition of a customized Healthy Eating Plan and employee smoking cessation program.

Healthy Heart Program

The Healthy Heart Program was a large worksite intervention project conducted aimed to prevent cardiovascular disease in high-risk, low wage-earning employees (average yearly income <$30,000/year). The program was established with a pilot grant from the New York State Department of Health (NYS DOH) between 1996 and 1999, and focused on implementing environmental interventions that encouraged physical activity, nutrition, stress relief, and smoking cessation. This program was initiated at 11 worksites and used an environmental surveying tool, the Heart Check Assessment to assess changes in the pre- and post-intervention environment for physical activity, heart healthy nutrition, and tobacco use. The data collected revealed significant gains in the environment such as increased opportunities for physical activity, healthy eating, and tobacco free environments, as well as administrative support to sustain these changes. Due to restrictions on the grant, environmental modifications were evaluated at the organizational level only, and no data was collected to assess individual level behavioral change.

In 1999 the NYC DOHMH received a 5-year worksite environmental health promotion grant from the NYS DOH in 1999. This grant expanded the worksite selection criteria to include not-for-profit and corporate worksites. One hundred seventeen sites (including 33 NYC DOHMH sites) were recruited; 107 sites (92%) were retained (defined as completing pre- and post-intervention surveys) throughout the length of the grant. Programming in the areas of physical activity and nutrition were tailored to each worksite depending on the needs and interests of the organization's employees. Worksites were required to create Wellness Teams composed of employees representing various sectors of the organization. These teams offered expertise in tailoring programming to their worksites and helped to promote a culture of wellness among the worksite's employees. The data on 100 of the worksites that assessed the effects of environmental change showed gains in all surveyed areas at follow-up. The most significant gains were in nutrition and physical activity, with a 2.7 and 2.3 fold increase, respectively. The grant did not allow provisions for the translation of individual behavioral changes.

NYC Department of Health and Mental Hygiene's Worksite Health Promotion Program

In Spring 2002, the Worksite Wellness Survey (WWS), an 11-page self-reported needs assessment tool designed to examine health risks, culture, environment and behavioral risk factors was administered within the NYC DOHMH. Its purpose was to facilitate the design of a comprehensive, evidence-based worksite health promotion program. The survey was administered to a random sample of 1,400 employees at the NYC DOHMH with a 49% response rate. The survey revealed that the average demographic represented at the NYCDOHMH was middle-aged (average age was 43.5 years old), female (73%) and ethnically and culturally diverse (34% African-American, 31% White (Non-Hispanic), 18% Hispanic, 10% other, 5% Asian, and 2% Native American). Of all respondents, 98% had achieved a high school level education or greater.

The results suggested that the majority of the NYC DOHMH employees have poor eating habits (82.7% consumed fewer than 4 servings of fruits and vegetables per day), are sedentary (73%) and overweight or obese (58%). Employees were largely uninformed about their basic health indices such as blood pressure and cholesterol levels. Interest in on-site health promotion was good with the majority of respondents desiring programming in the areas of physical activity (53%), health screenings (48%), nutrition (47%), and weight control (47%).

The information gained from the WWS was instrumental in the development of programmatic initiatives that specifically targeted the unhealthy behaviors of the NYC DOHMH employees, and guided the development of the current strategic plan for the Wellness at Work Program. Initiatives developed for the NYC DOHMH have served as models that the Wellness at Work Program has extended to work sites citywide. These programs intervene on the behavioral level by educating employees about their health risks and behaviors, and offering programming to help them improve their eating habits and increase their physical activity. The various programs address environmental barriers to health and wellness through the introduction of food policies to increase the availability of healthy foods, targeted media campaigns regarding nutrition and physical activity, and the promotion of opportunities for increased physical activity on-site.

NYC Department of Health and Mental Hygiene's Wellness at Work Program

The Wellness at Work (WAW) Program is housed in the Bureau of Chronic Disease Prevention within the Division of Health Promotion and Disease Prevention of the NYC DOHMH and was officially established in the Fall of 2001. The WAW Program was established to implement a comprehensive citywide health promotion initiative to provide technical assistance to businesses through information sharing, public education, networking, coalition building and policy formulation. The initial efforts were focused on worksites.

Preventing Excessive Weight Gain in Pregnancy:

An Approach to Promoting Healthy Body Weights in Childbearing Women
Christine M. Olson, Professor
Division of Nutritional Sciences,
Cornell University


Description of Program: The long term goal of this project is to decrease the amount of weight retained in the postpartum period by lower income, rural women who enter pregnancy with normal or high body mass indices (BMI). This goal was addressed by encouraging women to gain an amount of weight during pregnancy that is within the appropriate ranges recommended by the Institute of Medicine (IOM). The intervention was implemented in the hospital and clinic system of Bassett Healthcare serving eight counties in Upstate New York. Health care providers monitored women's gestational weight gain using adapted IOM gestational weight gain grids and drew their attention to the optimal range of gestational weight gain. Women were provided with a tool for self-monitoring of weight gain and encouraged to use it by health care providers. In addition, they received five action-promoting newsletters in the mail that include post cards on which they set goals and had the opportunity to ask questions that were answered in the next newsletter.

Evaluation of the Program: Two hundred eight pregnant women entered the intervention cohort and 179 were included in the analytical sample. These women were compared to 381 high and normal BMI women who participated in an observational study of postpartum weight retention in the same health care facility (historical control group). Overall, the intervention had no significant effect on the proportion of women who gained more weight in pregnancy than the IOM recommends (45 percent control group vs. 41 percent in the intervention group). However, among low income women, it had a significant effect on excessive gestational weight gain. Fifty-one percent of the low income control group women gained more than the recommended amount compared to 33 percent in the low income intervention group (p < 0.01). The impact of the intervention among low income women was present in both the normal and overweight groups. Women were followed until one year postpartum. In the low income sub-sample, overweight women in the intervention group were significantly less likely to retain 5 or more pounds than similar women in the control group (p = 0.04).

Partners: Bassett Healthcare in Cooperstown, NY and the Division of Nutritional Sciences, Cornell University.

Time Period: September 30, 1999 through August 31, 2003.

Amount and Source of Funding: $373,995 (direct costs), National Institutes of Health (Grant No. DK 57439)

Outcome: The intervention reduced excessive gestational weight gain and postpartum weight retention in low income women.

Publication: Olson CM, Strawderman MS, Reed RG. Efficacy of an intervention to prevent excessive gestational weight gain. American Journal of Obstetrics and Gynecology 191:530-536, 2004.

Jumping Rope After School to Get the Jump on Preventing Overweight and Obesity

Spear-headed by Connie Herzig, Cooperstown elementary school children have been jumping as part of the Red Hot Ropes for 13 years. An after school class of 3rd, 4th and 5th grade students, that challenges more than 1/2 of each class plus some 20 parent volunteers to learn at least 15 tricks - tricks that are fun, yet great exercise.

"Forced Learning": Cooperstown is known for baseball, but it's the jump rope that's "huge" at the school. Besides being fun and great exercise, Coach Connie Herzig says it's a real confidence builder. Children learn if they work hard, they can learn. Learning isn't seeing, it's doing it and practice.

Feeling Good Mileage Class

For 6 weeks in the spring, elementary children are challenged to walk, run, skip around a 1/4 mile track. Each lap is recorded by a paper punch on a card that's filled after accumulating 20 punches or 5 miles. For each 5 miles, children receive a colorful plastic foot to tie on to their sneaker laces. For those who complete 25 or 50 miles, they receive recognition and a plastic number for their sneakers at an award ceremony when everyone also received a certificate listing their mileage.

Be a Power Eater: The Good Food for Great Kids Program

Be a Power Eater: The Good Food for Great Kids Program is being launched in all Pre-K through 8th grade Buffalo public schools (approximately 31,000 students). An enhanced fruit and vegetable display will be placed in school lunch lines for a six-week period (January 24-March 4, 2005) where students will receive incentives and rewards for selecting a fruit or vegetable. The program where the opportunity for rewards and prizes increases proportionately to the number of times a student selects an item. The program will focus on changing behavior in children to lessen health trends in poor nutrition and overweight/obesity. The project will evaluate which approaches have the greatest behavioral outcomes, by school and grade, and results will be available by the end of 2005.

The Be a Power Eater program also has a research component. Variations of the basic program will be tried at the 65 schools. The schools are divided into three groups (A, B, C):

  • The "A" schools will be involved in the program that includes the main program + 4th grade nutrition curriculum* for two schools.

  • The "B" schools will participate in the main program + a school competition where the top 3 schools who have consumed the most fruits and vegetables win a special award + 4th grade nutrition curriculum* for two schools.

  • The "C" schools will participate in the main program + a "Promise Contract" where homeroom students will sign a poster in the classroom pledging to eat more healthfully + 4th grade nutrition curriculum* for two schools

* The curriculum will be completed prior to the program start.

According to Gretchen Fierle, the Project Coordinator, "the Healthy Heart Program's funding has allowed us to leverage other funds." Of the $450,000 cost of this project, $101,250 is from the Healthy Heart contract. More than 15 organizations and 12 funding agencies have developed this district-wide imitative. This intervention is the first of its kind in Western New York and no other urban community in the United States has undertaken a program of this magnitude, aligning existing community and media resources to address a community issue.

Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

WIC monitors weight during pregnancy and throughout the postpartum period (one year for breastfeeding women). Nutritional risk eligibility is determined based on federally- mandated nutritional risk criteria. Prenatal risks include pre-pregnancy overweight, and high maternal weight gain. Postpartum risks include breastfeeding less than 6 months postpartum with pre-pregnancy BMIs greater than or equal to 25, and breastfeeding more than 6 months postpartum with a post partum BMI greater than or equal to 25. The WIC BMI risk level has recently been lowered from 26.1 to 25. More women in the WIC program will now be identified as overweight, and therefore, more women will receive counseling or education.

PCAP/MOMS

Standards in the Prenatal Care Assistance Program (PCAP) and Medicaid Obstetric and Maternity Services (MOMS) programs call for routine assessment of weight and weightgain during the prenatal period. Women whose weight gain exceeds or falls below the curve recommended by the Institute of Medicine are referred to a nutritionist or dietician for counseling. DOH nurses monitor compliance with these program requirements and provide technical assistance to providers who are not meeting them.

Infant Feeding in the Hospital

In 1984 the hospital code in NYS was amended to require all hospitals with newborn nurseries to provide breastfeeding education and support to new mothers. In order to assure that staff throughout the state were versed in the basics of breastfeeding promotion and support, a series of training sessions was presented in each region of the state.

Breastfeeding Networks

In 1980 in order to address the extremely low rate of breastfeeding at hospital discharge the NYC Regional office of NYSDOH brought together a small group of health professionals and breastfeeding advocates. The success of the NYC group was the stimulus to start similar groups throughout the state. Today there are breastfeeding networks throughout the state that provide professional and consumer education, answer questions for mothers, and increase the positive visibility of breastfeeding in the community. Many of the breastfeeding networks are associated with the DOH-funded Comprehensive Prenatal/Perinatal Services Networks (see below).

Comprehensive Prenatal/Perinatal Services Networks (CPPSNs)

The CPPSNs are community-based organizations funded by NYSDOH to develop community assets to address the issues of infant mortality and low birth weight in areas of the state with high rates of poor pregnancy outcomes. As part of their work these 14 organizations provide consumer and provider education. Several of the networks including two in NYC and four in upstate are the primary sponsors of the breastfeeding networks described above.

Prenatal Care

The Prenatal Care Assistance Program and Medicaid Obstetric and Maternity Services (PCAP/MOMS) provide prenatal care to most of the low-income women in New York. The program standards for both call for education and counseling about breastfeeding during prenatal care. The NYSDOH provides oversight and technical assistance to PCAP clinics to promote adherence to these standards. In the 1990s, the department conducted workshops around the state providing training about breastfeeding promotion and support to PCAP nurses and other staff.

Community Health Workers (CHWs)

Community Health Workers (CHWs) provide individual outreach and support to childbearing families in high-risk regions of the state. The training that all new CHWs receive includes information about breastfeeding, and the program monitors breastfeeding rates among their clients.

Special Supplemental Nutrition Program for Women, Infants and Children (WIC):

The national WIC program initiated specific breastfeeding promotion and support activities in response to the decline in breastfeeding rates during the 1980s. Since 1989, the WIC program in New York State has incorporated breastfeeding promotion and support as part of its policy to encourage breastfeeding as the optimal infant feeding method to ensure the health and well-being of infants.

In 1991, NYS WIC introduced its first Peer Counseling pilot program, and that program's success led to similar efforts around the state. In 1994, an enhanced breastfeeding food package for exclusively breastfeeding women was established. Today, every WIC agency has a breastfeeding coordinator on staff, as mandated by the WIC contract deliverable. NYS WIC policy mandates WIC local agency protocols addressing need criteria, training, procurement and distribution of breast pumps to breastfeeding mothers. WIC local agencies must have a breastfeeding-friendly environment and staff trained in breastfeeding promotion and support. Currently, a statewide incentive is under way to provide Certified Lactation Counselor (CLC) training for WIC local agency staff. On an on-going basis, posters, brochures, and other materials designed to promote and support breastfeeding among low-income women are distributed to all local agencies. Over the past decade, breastfeeding initiation rates have doubled.

Breastfeeding and Human Lactation Study Center

Dr. Ruth Lawrence, an internationally known expert on breastfeeding, and the New York State Department of Health have provided continuing educational opportunities for physicians, midwives, nurse practitioners, and other health care providers about normal lactation and the management of breastfeeding in special circumstances. Best Practices Guidelines and policies for hospitals, managed care plans, ambulatory care facilities, workplaces, as childcare centers have been developed and distributed promoting and supporting breastfeeding. The guidelines are based on the consensus of ad hoc expert panels and in the case of the hospital guidelines, on the breastfeeding-promotion section of the New York State code of hospital regulations. The Center conducts research focused on breastfeeding behaviors and breastfeeding management.

Breastfeeding Grand Rounds

Physician education about normal lactation and about management of breastfeeding in special circumstances is a critical piece of breastfeeding promotion, since physicians influence families' breastfeeding decisions and experiences - either positively or negatively. Since 1995, the NYSDOH has produced an annual series of free satellite broadcasts, Breastfeeding Grand Rounds, providing continuing education about breastfeeding for physicians, midwives, nurse practitioners, and other health care providers. The broadcasts have a national audience of roughly 1000 health care providers, primarily in New York State.

Best Practices Guidelines

Policies and practices in a wide variety of institutions -- hospitals, managed care plans, ambulatory care facilities, workplaces, and childcare centers - - determine whether the environment is supportive of breastfeeding. Over the past decade, the NYSDOH has developed best practice guideline sets for each of the settings listed above to encourage adoption of policies and practices that promote and support breastfeeding. The hospital guidelines are based on the breastfeeding-promotion section of the New York State code of hospital regulations, and the others are based on the consensus of ad hoc expert panels.

Surveillance and feedback to providers

The health department has surveyed hospitals five times since 1992 to assess the rate of breastfeeding initiation, and three times during that period to assess their compliance with the best practice guidelines (described above). Once the department conducted a survey of managed care plans to assess their policies and practices. Following each survey, the department sent feedback to providers about their performance and how it compared with others in their region and statewide.

In addition to conducting these periodic surveys, the department has incorporated assessment of breastfeeding practices into ongoing monitoring and quality improvement efforts with managed care organizations.

Lactation Information Network

To promote communication about educational programs, policy questions, and other issues among breastfeeding networks around the state, the NYSDOH developed an e-mail list-serve -- the Lactation Information Network (LIN-L). Any interested individual can participate in the list-serve, posting announcements or questions that all other list-serve participants will receive and can respond to.

Cardiovascular Health Program

The NYS Cardiovascular Health Program, also known as the Healthy Heart Program (HHP), helps prevent and reduce overweight and obesity in NYS, leading risk factors to cardiovascular diseases. The HHP works to change environments and policies that will prevent and reduce heart disease and stroke in communities and worksites. Recently the OP program worked with the HHP program to leverage resources to implement CDC's Heart Healthy and Stroke-Free Worksites Toolkit ("Successful Business Strategies to Prevent Heart Disease and Stroke") through consultants, insurers and business leaders to help businesses employ health promotion and wellness programs and disease management services to reduce the effects of overweight and obesity and contain health care costs. An RFA is under development to provide seed money to ambulatory care providers to implement the chronic care model to improve treatment of people with hypertension.

The NYS Healthy Heart Program has worked for years to affect policies and environments to promote and to increase physical activity and healthy eating in communities in NYS. Worksites Wellness contractors that create opportunities for workers to be active and eat well, such as: establishing policies for walking breaks and healthy items in worksite cafeterias and vending machines, creating walking clubs, sponsoring Move For Life and other incentive programs, and setting up wellness committees to oversee future efforts. Move for Life is a physical activity program that worksite business managers can use to implement an easy-to-follow plan for an eight-to-ten week program that will increase the physical activity level of employees of all physical abilities, regardless of age, or current fitness or activity level. BC Walks was a community-based campaign to increase walking among older adults in Broome County, New York. It included a paid media component and significant increase in walking rates. Move for Life is a physical activity program that worksite business managers can use to implement an easy-to-follow plan for an eight-to-ten week program that will increase the physical activity level of employees of all physical abilities, regardless of age, or current fitness or activity level. Walkable Communities Workshops are training sessions for lay and professional community residents to provide them with ways to make it safer, easier and more pleasant for people to walk.

Diabetes Prevention and Control Program

Coordination with the New York State Health Department's Diabetes Prevention and Control Program has occurred through a number of venues including working together in developing this Plan and the Diabetes Plan for NYS. Program staff participates in planning and implementation work with the Steps to a HealthierUS Program including providing data and information for NYS's four Steps counties and providing staff expertise in Steps counties. Together, the OP and Steps Programs sponsored social marketing training for program staff and for people involved in both the OP intervention and the four Steps counties. The benefits of this included economy of scale in purchasing services and importantly, brought together staff of both programs and intervention sites to share information, network and create new partnerships to prevent diabetes in NYS.

Comprehensive Cancer Program

The Comprehensive Cancer Program is an active participant in the OP Plan development and implementation processes. The Obesity Prevention and Comprehensive Cancer Programs are investigating ways to best monitor and track plan implementation work electronically or through web-based approaches. Monitoring and tracking plan activities are critical to assessing progress, communicating results, sustaining and attracting continued resources and measuring success.

Arthritis and Disability and Health Program Address Overweight and Obesity Prevention

A significant program component of Arthritis and Disability and Health Programs is providing resources to community-based organizations to support peer-led training programs for people with arthritis and related conditions and people with disabilities. Training outcomes of such programs as Arthritis Self-Help Course (ASHC) and Living Well with a Disability include providing ways for participants to eat nutritiously and make exercise a regular part of their lives to decrease pain, reduce reliance on medications and overall improve quality of life. Although resources are limited, still these programs provide important links to typically underserved populations that are effected by overweight and obesity. Both programs are engaged in the OP plan development and implementation processes. The Arthritis Foundation (AF) sponsors many ASHC, PACE (People with Arthritis Can Exercise) and arthritis programs in New York State. The New York City AF Chapter currently works with managed care organizations offering these courses to participants to improve their physical fitness and reduce their reliance on medications.

TV Turnoff Week

Some communities and schools in New York participate in a TV Turnoff Week once a year to encourage families to turn off their televisions and participate in more recreational and physical activities for a week. This event has been shown to change the viewing habits of those who participated not only for seven days, but for much longer, sometimes even permanently, afterwards.

Reducing TV Viewing by Preschoolers

As part of the Department's Obesity Prevention Program, a public health evaluation is being conducted in the Arbor Hill community area in Albany, New York. Known as the Health and Fitness by Age 5 Intervention, this community-based intervention targets preschool children, their parents and childcare teachers and related caregivers to prevent overweight among preschool children. One of the main goals of the intervention is to reduce TV viewing time at daycare centers and at home through implementation of the "Fit 5 Kids" curriculum in Centers. Using social marketing techniques, this intervention will also facilitate a community-wide "TV Turnoff Week".

The Obesity Prevention Program

The Obesity Prevention Program worked with the NYS Education Department to provide NYS schools with web-based resources they can use to promote physical activity and healthy eating and to help them to respond to recent federal and state legislation that requires all school districts to create nutrition councils to promote healthy eating among students and staff. In concert with the Governor's Office, the Health Department is providing incentive and mini-grants to schools that have completed the School Health Index and a plan of action. These schools are eligible for a base grant and a mini-grant to help them to respond to one or more parts of their action plan that will lead to policy changes to support physical activity and healthy eating.

The NYS Cardiovascular Health Program

The NYS Cardiovascular Health Program, also known as the Healthy Heart Program (HHP), has worked to change environments and policies that will prevent and reduce health disease and stroke and its attendant morbidity and mortality. The program works in communities, schools, worksites and health care settings. Currently, the HHP funds 17 community-based provider organizations statewide that work to affect policies and environments to increase access to walking, running and bicycling and increase access to fresh fruits and vegetables and low-fat dairy products.

The Healthy Heart Program expanded the number of community-based providers that work in the school and worksite sectors. Providers work with schools and worksites to develop comprehensive policy approaches to improve cardiovascular health of populations in these settings such as making facilities accessible to children to increase physical activity, increasing healthful foods on school campus as measured by the School Health Index, promoting active lifestyles at worksites.

Schools + Professionals in Nutrition (SPIN)

Schools + Professionals in Nutrition (SPIN) Program, an outgrowth of the New York State Action for Healthy Kids Team, pairs school professionals with a volunteer nutritional professional who work together to improve nutrition among students in part through helping schools to complete the School Health Index (SHI) and an Action Plan. Matched schools and nutrition professionals have access to resources, support and technical assistance as needed to foster productive partnerships.

Statewide Policy Changes Supporting Obesity Prevention in Women, Infants and Children (WIC) Program

The WIC Program, which provides supplemental foods and nutrition education for over 450,000 low-income women, infants and children, supports the Eat Well Play Hard (EWPH) program objectives through changes to state policies and resources provided to WIC local agency staff and participants. For example, EWPH strategies were incorporated into the new automated WIC system. WIC food packages in the new system select 1% or less milk as the "default" food package for women and children over the age of two years. The WIC program has established a goal of low-fat/fat-free milk check issuance rate of 40% or greater for participants over the age of 2. In April 2004, 35% of the participants over age 2 received WIC checks specifying low-fat or fat-free milk.

Existing Surveillance Systems

The Obesity Prevention Program is working with well-established surveillance systems across multiple program areas to describe the burden of obesity in New York State. Using information from existing surveillance systems including the BRFSS, YRBS, PedNSS, PRAMS, and periodic surveys of elementary school children, new mothers, and hospitals this data will be a resource showing current prevalence trends in overweight and obesity among preschoolers, school-age children, adolescents and adults in the state. It will also present important information regarding risk and protective factors associated with obesity including physical activity, nutrition and breastfeeding practices. Also described will be rates of chronic conditions related to obesity, and the economic impact of obesity in New York State.

Enhancing Local Surveillance Systems

The Obesity Prevention Program is enhancing its local-level surveillance resource capacity by utilizing information from two existing surveillance activities and integration with other program areas. Expanded BRFSS is a statewide surveillance effort modeled after the annual statewide BRFSS to collect and report behavioral information of relevance to obesity prevention at the local level. In partnership with other programs, expanded BRFSS is now being used to better understand the extent and distribution of local-level obesity and overweight, nutrition, physical activity, and related chronic conditions. In addition, annual BRFSS surveys are being conducted in Broome, Chautauqua, Jefferson, and Rockland counties - the four intervention areas for Steps to a Healthier NY. These surveys will be used to monitor a number of issues of importance to obesity prevention including the prevalence of obesity and overweight, nutrition, physical activity, and related chronic conditions. In 2005, as a component of Steps to a Healthier NY these four counties will also begin biennial implementation of a local YRBS to report related information for youth.

Oral Health, Nutrition, and Physical Activity Survey

Building on the strength of previous success in conducting a series of surveys of school children in New York State, the Obesity Prevention Program is cosponsoring the Oral Health, Nutrition, and Physical Activity Survey of 3rd grade children. This representative survey conducted in areas of the state outside of New York City is following the model of previous similar collaborations conducted in 1988, 1990, and 1996 to report the prevalence of overweight, at-risk for overweight and related information among school-age children.

Surveillance of Breastfeeding Interventions

The Obesity Prevention Program is also enhancing its perinatal surveillance capacity to fill information gaps related to breastfeeding interventions to reduce obesity risk. Data about breastfeeding are collected in several ways. New York State's new Statewide Perinatal Data System collects data on breastfeeding initiation and exclusivity for all infants born in New York, excluding New York City births. Aggregate data on breastfeeding initiation have been collected for over ten years through periodic hospital surveys and through the CDC-sponsored Pregnancy Risk Assessment Monitoring System, which collects data from a sample of new mothers. In addition to breastfeeding initiation rates, PRAMS questions address continuation through the first few months postpartum, and reasons for discontinuing breastfeeding. The National Immunization Survey has recently added questions about breastfeeding initiation and duration, with data available on the state level.