Topic: Healthy Eating

Strategy Profile: Creating Healthier Early Care and Education Environments

Posted on September 22, 2023

The information in this resource is intended only to provide educational information. This profile describes the estimated benefits, activities, resources, and leadership needed to implement a strategy to improve child health. This information can be useful for planning and prioritization purposes.

  • Improving nutrition, physical activity, & screen time policies & practices for children ages 3-5 by incorporating the Nutrition & Physical Activity Self-Assessment for Child Care (NAP SACC) Program into state’s Quality Rating and Improvement Systems (QRIS) for early care and education programs.

What population benefits?

Children ages 3-5 attending licensed early care and education programs that participate in their state’s Quality Rating and Improvement Systems (QRIS).

What are the estimated benefits?

Relative to not implementing the strategy
Promote healthy child weight.

What activities and resources are needed?

Activities Resources Who Leads?
Train early care and education health professionals to work with early care and education programs • Time of state training consultant to train early care and education health professionals
• Time of early care and education health professionals to be trained		 State QRIS administrators
Provide consultation to early care and education program directors and staff for conducting self-assessments of program policies and practices, completing action plans, and implementing changes to improve nutrition, physical activity, and screen time environments in programs • Time of early care and education health professionals to provide consultation to early care and education programs
• Time of early care and education program directors and staff to participate in consultation		 Early care and education health professionals
Provide materials and equipment for implementing NAP SACC program • Cost for GO NAP SACC online license
• Physical activity equipment costs		 State QRIS administrators
Implement changes in early care and education programs to improve nutrition, physical activity, and screen time environments • Time of early care and education program directors to implement changes Early care and education program directors
Improve nutritional quality of meals served in early care and education programs • Food costs for improving nutritional quality of meals Early care and education program directors
Monitor compliance with NAP SACC program • Time of state-level QRIS Administrators to monitor compliance State QRIS administrators
Strategy Modification

In states where NAP SACC is already being implemented, the strategy could be modified to focus on increasing the number of early care and education programs that participate in NAP SACC. With this modification, the cost for the GO NAP SACC online license would not be needed, since it is a fixed annual cost paid per state (i.e., it does not depend on the number of participating programs). With this modification, the impact on health is expected to be similar, and the impact on reach and cost would vary according to the number of programs reached.

FOR ADDITIONAL INFORMATION

Gortmaker SL, Wang YC, Long MW, Giles CM, Ward ZJ, Barrett JL, Kenney EL, Sonneville KR, Afzal AS, Resch SC, Cradock AL. Three interventions that reduce childhood obesity are projected to save more than they cost to implement. Health Aff (Millwood). 2015 Nov;34(11):1932-9. doi: 10.1377/hlthaff.2015.0631. Supplemental Appendix with strategy details available at: https://www.healthaffairs.org/doi/suppl/10.1377/hlthaff.2015.0631/ suppl_file/2015-0631_gortmaker_appendix.pdf

Selected CHOICES research brief including cost-effectiveness metrics:

Adams B, Sutphin B, Betancourt K, Balamurugan A, Kim H, Bolton A, Barrett J, Reiner J, Cradock AL. Arkansas: Creating Healthier Child Care Environments: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) in the Quality Rating Improvement System (QRIS) {Issue Brief}. Arkansas Department of Health, Little Rock, AR, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; May 2021. Available at: https://choicesproject.org/publications/brief-napsacc-arkansas

Kenney EL, Giles CM, Flax CN, Gortmaker SL, Cradock AL, Ward ZJ, Foster S, Hammond W. New Hampshire: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) Intervention {Issue Brief}. New Hampshire Department of Health and Human Services, Concord, NH, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; October 2017. Available at: https:// choicesproject.org/publications/brief-napsacc-intervention-new-hampshire

Suggested Citation

CHOICES Strategy Profile: Creating Healthier Early Care and Education Environments. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; September 2023.

Funding

This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose. The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

Adapted from the TIDieR (Template for Intervention Description and Replication) Checklist

©2015 President and Fellows of Harvard College. All rights reserved. The CHOICES name, acronym and logo are marks of the President and Fellows of Harvard College.

Strategy Profile: Fast-Food Restaurant Calorie Labeling

Posted on September 21, 2023

The information in this resource is intended only to provide educational information. This profile describes the estimated benefits, activities, resources, and leadership needed to implement a strategy to improve child health. This information can be useful for planning and prioritization purposes.

  • Require fast-food chain restaurants with 20 or more locations to list calories for standard menu items on menu boards along with succinct statements concerning suggested daily caloric intake.

What population benefits?

All youth and adults ages 2 years and older.

What are the estimated benefits?

Relative to not implementing the strategy
Decrease daily energy intake and, in turn, promote healthy weight.

What activities and resources are needed?

Activities Resources Who Leads?
Manage rollout of restaurant calorie menu labeling and communicate policy change to restaurant chains • Time of Food and Drug Administration to manage rollout Food and Drug Administration
Analyze nutrient content information for each menu item • Cost of analyzing menu items, by sending food items to lab for nutrition analysis or entering recipes in a nutrition database Chain retail food establishment
Replace menus and menu boards to comply with policy • Cost of designing new menus (if applicable)
• Replacement menu and menu board costs		 Chain retail food establishment
Review rule requirements • Time for legal analyst to review rule requirements Chain retail food establishment
Monitor compliance with menu labeling policy • Time of public health department inspectors to monitor compliance Local public health department

FOR ADDITIONAL INFORMATION

Dupuis R, Block JP, Barrett JL, Long MW, Petimar J, Ward ZJ, Kenney EL, Musicus AA, Cannuscio CC, Williams DR, Bleich SN, Gortmaker SL. Cost-Effectiveness of Calorie Labeling at Large Fast-Food Chains Across the U.S. Am J Prev Med. doi:10.1016/j. amepre.2023.08.012. Epub 2023 Aug 14.

Suggested Citation

CHOICES Strategy Profile: Fast-Food Restaurant Calorie Labeling. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; September 2023.

Funding

This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose. The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

Adapted from the TIDieR (Template for Intervention Description and Replication) Checklist

©2015 President and Fellows of Harvard College. All rights reserved. The CHOICES name, acronym and logo are marks of the President and Fellows of Harvard College.

Cost-Effectiveness of Calorie Labeling at Large Fast-Food Chains Across the U.S.

Posted on August 14, 2023

This study evaluates the cost-effectiveness of calorie labeling at large U.S. fast-food chains.

Dupuis R, Block JP, Barrett JL, Long MW, Petimar J, Ward ZJ, Kenney EL, Musicus AA, Cannuscio CC, Williams DR, Bleich SN, Gortmaker SL. Cost-Effectiveness of Calorie Labeling at Large Fast-Food Chains Across the U.S. Am J Prev Med. doi:10.1016/j.amepre.2023.08.012. Epub 2023 Aug 14.

Abstract

Introduction

Calorie labeling of standard menu items has been implemented at large restaurant chains across the United States since 2018. The objective of this study was to evaluate the cost-effectiveness of calorie labeling at large U.S. fast-food chains.

Methods

This study evaluated the national implementation of calorie labeling at large fast-food chains from a modified societal perspective and projected its cost-effectiveness over a ten-year period (2018-2027) using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model. Using evidence from over 67 million fast-food restaurant transactions between 2015 and 2019, the impact of calorie labeling on calorie consumption and obesity incidence was projected. Benefits were estimated across all racial, ethnic, and income groups. Analyses were performed in 2022.

Results

Calorie labeling is estimated to be cost-saving, prevent 550,000 cases of obesity in 2027 alone (95% uncertainty interval (UI): 518,000; 586,000), including 41,500 (95% UI: 33,700; 50,800) cases of childhood obesity, and save $22.60 in health care costs for every $1 spent by society in implementation costs. Calorie labeling is also projected to prevent cases of obesity across all racial and ethnic groups (range between 126-185 cases per 100,000 people) and all income groups (range between 152-186 cases per 100,000 people).

Conclusions

Calorie labeling at large fast-food chains is estimated to be a cost-saving intervention to improve long-term population health. Calorie labeling is a low-cost intervention that is already implemented across the U.S. in large chain restaurants.

Funding

Research reported in this publication was supported by the National Heart, Lung, and Blood Institute under Award Number R01HL146625, by the National Institute of Diabetes and Digestive and Kidney Diseases under Award Number R01DK115492, by the Centers for Disease Control and Prevention under Award Number U48DP006376, and by the JPB Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders. The funders had any role in study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication.

Brief: Creating Healthier Afterschool Environments (OSNAP) in Boston, MA

Posted on July 28, 2023

Three kids at the playground

The information in this brief is intended only to provide educational information.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining the implementation of the Out of School Nutrition and Physical Activity (OSNAP) initiative that helps afterschool programs improve practices and policies that increase physical activity and consumption of healthy snacks.

The Issue

Every child should have opportunities to grow up healthy. Regular physical activity, healthy eating, and adequate hydration can help children maintain a healthy weight. Over 6,000 students in kindergarten to fifth grade participate in afterschool programs in Boston.1 These educational settings can provide essential opportunities for children to learn healthy eating habits and promote physical activity and wellness. However, not all programs offer the same opportunities for healthy eating and physical activity.2 Helping more afterschool programs adopt policies and practices that incorporate more physical activity, healthier snacks, and improved water access during program time can help ensure that all children in Boston’s afterschool programs have opportunities to grow up healthy.

About Creating Healthier Afterschool Environments

OSNAP is a proven initiative implemented in multiple communities that helps afterschool programs create environments that promote increased physical activity and consumption of healthy snacks.3-6 Creating healthier afterschool environments can contribute to higher quality afterschool programming. To implement this initiative, the Boston Public Health Commission would provide professional development opportunities for afterschool program leaders serving students in grades K-5. Afterschool staff leaders would participate in three learning collaborative sessions and receive technical assistance to assess7 and modify their programs’ practices and policies3 to meet the OSNAP nutrition and physical activity goals. The Boston Public Health Commission would supply program leaders with materials to support implementation and offer continuing education units for their participation.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2020-2029) of implementing the OSNAP program with the costs and outcomes associated with not implementing the program.

Creating healthier afterschool environments is an investment in the future. By the end of 2029:
If creating healthier afterschool environments (OSNAP) was implemented in Boston, 10,800 children would be reached over 10 years, $34,100 would be saved in health care costs, and it would cost $18.30 per child per year to implement.

Conclusions and Implications

Opportunities for physical activity and access to healthy foods in afterschool programs are important to parents2 and can help enhance the quality of afterschool programing. Over 10 years, this strategy could train more than 600 afterschool teachers and directors. By equipping afterschool leaders with these skills and resources, afterschool programs could adopt healthier practices and policies and we project that 10,800 children would benefit from more physical activity and improved diet. We project that 37 cases of obesity would be prevented and $34,100 in healthcare costs related to excess weight would be saved in 2029. We expect this strategy would cost $18.30 per child per year to implement in Boston and is projected to be cost-effective at commonly accepted thresholds8 based on net population health improvement related to excess weight ($72,100 per quality-adjusted life year gained).

In addition to promoting healthy weight, this strategy may also support children’s health in other ways. Regular physical activity, healthy eating, and adequate hydration can improve children’s mental and emotional well-being and their heart, lung, and bone health.9 These healthy behaviors can also strengthen students’ attention, memory,10,11 and cognitive functioning,10 all important components for learning and academic performance. Incorporating physical activity and healthy snacks in afterschool programs can help children nurture healthy habits and lay a strong foundation for overall health and well-being.

This strategy builds upon Boston Public Health Commission’s demonstrated success where, in 2015, more than 120 programs took steps to improve their screen time, physical activity, and nutrition practices through OSNAP, creating higher quality afterschool programs across Boston.11 Broader implementation could reach all afterschool programs in Boston, improving practices and policies that promote increased physical activity and consumption of healthy snacks, furthering the Boston Public Health Commission’s goal of creating policy and systems changes in childcare to promote the health of all Boston residents.

References

  1. Boston AfterSchool & Beyond. SY 21-22 Programs. In. Boston, MA: Boston AfterSchool & Beyond; 2021.

  2. Kids on the Move: Afterschool Programs Promoting Healthy Eating and Physical Activity. Washington, D.C.: America After 3pm, Afterschool Alliance; 2015.

  3. Kenney EL, Giles CM, deBlois ME, Gortmaker SL, Chinfatt S, Cradock AL. Improving nutrition and physical activity policies in afterschool programs: results from a group-randomized controlled trial. Prev Med. 2014;66:159-166. doi:10.1016/j.ypmed.2014.06.011

  4. Cradock AL, Barrett JL, Giles CM, et al. Promoting Physical Activity With the Out of School Nutrition and Physical Activity (OSNAP) Initiative: A Cluster-Randomized Controlled Trial. JAMA Pediatr. 2016;170(2):155-162.

  5. Lee RM, Giles CM, Cradock AL, Emmons KM, Okechukwu C, Kenney EL, Thayer J, Gortmaker SL. Impact of the Out-of-School Nutrition and Physical Activity (OSNAP) Group Randomized Controlled Trial on Children’s Food, Beverage, and Calorie Consumption among Snacks Served. J Acad Nutr Diet. 2018 Aug;118(8):1425-1437. doi: 10.1016/j.jand.2018.04.011.

  6. Lee RM, Barrett JL, Daly JG, Mozaffarian RS, Giles CM, Cradock AL, Gortmaker SL. Assessing the effectiveness of training models for national scale-up of an evidence-based nutrition and physical activity intervention: a group randomized trial. BMC Public Health. 2019 Nov 28;19(1):1587. doi: 10.1186/s12889-019-7902-y.

  7. Lee RM, Emmons KM, Okechukwu CA, Barrett JL, Kenney EL, Cradock AL, Giles CM, deBlois ME, Gortmaker SL. Validity of a practitioner-administered observational tool to measure physical activity, nutrition, and screen time in school-age programs. Int J Behav Nutr Phys Act. 2014 Nov 28;11:145. doi: 10.1186/s12966-014-0145-5.

  8. Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold. New England Journal of Medicine. 2014 Aug 28;371(9):796-7. DOI: 10.1056/NEJMp1405158. PMID: 25162885.

  9. Health Benefits of Physical Activity for Children. Centers for Disease Control and Prevention. https://www.cdc.gov/physicalactivity/basics/adults/health-benefits-of-physical-activity-for-children.html. Published Jan 12, 2022. Updated 2022-01-12T05:06:09Z. Accessed Dec 7, 2022.

  10. Childhood Nutrition Facts. Centers for Disease Control and Prevention. https://www.cdc.gov/healthyschools/nutrition/facts.htm. Published 2022. Updated 2022-08-05T03:49:26Z. Accessed Dec 12, 2022.

  11. Blanding N. Afterschool Programs in Boston, MA, Expand Opportunties for Obesity Prevention. Centers for Disease Control and Prevention; 2016. http://nccd.cdc.gov/nccdsuccessstories

Suggested Citation:

Carter S, Bovenzi M, Clarke J, Bolton AA, Reiner JF, Barrett JL, Cradock AL. Boston, MA: Creating Healthier Afterschool Environments (OSNAP) {Issue Brief}. Boston Public Health Commission, Massachusetts, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; July 2023.

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the Boston Public Health Commission through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

Use of Evidence-Based Interventions to Promote Healthy Weight, Nutrition, and Physical Activity in Community Health Improvement Plans from Large Local Health Departments

Posted on June 20, 2023

This study identifies evidence-based healthy weight, nutrition, and physical activity strategies related to obesity prevention in large local health department Community Health Improvement Plans.

Dupuis R, Reiner JF, Silver S, Barrett JL, Daly JG, Lee RM, Gortmaker SL, Cradock AL. Use of Evidence-Based Interventions to Promote Healthy Weight, Nutrition, and Physical Activity in Community Health Improvement Plans from Large Local Health Departments. J Public Health Manag Pract. 2023 Sep-Oct 01;29(5):640-645. doi: 10.1097/PHH.0000000000001778. Epub 2023 Jun 20.

Abstract

We sought to identify evidence-based healthy weight, nutrition, and physical activity strategies related to obesity prevention in large local health department (LHD) Community Health Improvement Plans (CHIPs). We analyzed the content of the most recent, publicly available plans from 72 accredited LHDs serving a population of at least 500 000 people. We matched CHIP strategies to the County Health Rankings and Roadmaps’ What Works for Health (WWFH) database of interventions. We identified 739 strategies across 55 plans, 62.5% of which matched a “WWFH intervention” rated for effectiveness on diet and exercise outcomes. Among the 20 most commonly identified WWFH interventions in CHIPs, 10 had the highest evidence for effectiveness while 4 were rated as likely to decrease health disparities according to WWFH. Future prioritization of strategies by health agencies could focus on strategies with the strongest evidence for promoting healthy weight, nutrition, and physical activity outcomes and reducing health disparities.

Funding

This study was supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP001946 and U48DP006376). The findings and conclusions are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or The JPB Foundation.

Strategy Profile: Creating Healthier Afterschool Environments

Posted on October 6, 2022

Young boy eating a green apple

The information in this resource is intended only to provide educational information. This profile describes the estimated benefits, activities, resources, and leadership needed to implement a strategy to improve child health. This information can be useful for planning and prioritization purposes.

  • Creating healthier afterschool environments is a strategy to improve nutrition and physical activity policies & practices through the Out of School Nutrition and Physical Activity (OSNAP) initiative for children in grades K-5 attending state-administered 21st Century Learning afterschool programs.

What population benefits?

Children in grades K-5 attending state-administered 21st Century Learning afterschool programs.

What are the estimated benefits?

Relative to not implementing the strategy
Increase vigorous physical activity and improve nutritional quality of snacks and beverages offered in afterschool programs, and, in turn, promote healthy child weight.

What activities and resources are needed?

Activities Resources Who Leads?
Issue regulations to improve nutrition and physical activity policies and practices in afterschool programs • Time to issue and communicate regulations State government
Provide training and technical assistance to regional Healthy Afterschool trainers on how to lead learning collaborative sessions • Time for state Healthy Afterschool coordinator to lead trainings
• Time for regional Healthy Afterschool trainers to be trained and receive technical assistance
• Travel costs
• Training material costs		 State healthy afterschool coordinator
Conduct regional learning collaboratives with afterschool program staff including training and technical assistance on goals and implementation activities • Time for regional Healthy Afterschool trainers to lead learning collaboratives and provide technical assistance
• Time for afterschool program staff to attend learning collaboratives and receive technical assistance
• Training material costs
• Travel costs		 Regional healthy afterschool trainer
Assess and implement actions to change program practices to meet Healthy Afterschool standards • Time for afterschool program staff to conduct program practice self-assessments and implement changes at their program
• Increase in food costs to provide snacks in compliance with nutrition standards to children attending Healthy Afterschool programs		 Afterschool program director
Develop CEU-accredited course for local program staff • Cost to create a CEU-accredited course State healthy afterschool coordinator
Provide educational materials and incentives to local program staff • Material and incentive costs State government
Monitor compliance to ensure afterschool programs are following programmatic requirements • Time for state monitoring and compliance staff to monitor compliance
• Travel costs		 State government monitoring and compliance staff
Establish a Healthy Afterschool recognition and monitoring website • Time to create and maintain website State government website developer
Strategy Modification

This strategy could be modified to benefit children who participate in out-of-school programs administered by other organizations (e.g., YMCA or Boys and Girls Club of America). With this modification, the activities necessary to carry out the voluntary recognition program may not be included (e.g., issuing regulations, creating a healthy afterschool nutrition website, and monitoring compliance). With this modification, the impact on health is expected to be similar, and the impact on reach and cost may vary.

FOR ADDITIONAL INFORMATION

Cradock AL, Barrett JL, Kenney EL, Giles CM, Ward ZJ, Long MW, Resch SC, Pipito AA, Wei ER, Gortmaker SL. Using cost-effectiveness analysis to prioritize policy and programmatic approaches to physical activity promotion and obesity prevention in childhood. Prev Med. 2017 Feb;95 Suppl: S17-S27. doi: 10.1016/j.ypmed.2016.10.017. Supplemental Appendix with strategy details available at: https://ars.els-cdn.com/ content/image/1-s2.0-S0091743516303395-mmc1.docx

Suggested Citation

CHOICES Strategy Profile: Creating Healthier Afterschool Environments. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; May 2023.

Funding

This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose. The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

Adapted from the TIDieR (Template for Intervention Description and Replication) Checklist

©2015 President and Fellows of Harvard College. All rights reserved. The CHOICES name, acronym and logo are marks of the President and Fellows of Harvard College.