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Healthy Beverage Partnership

State: CO Type: Model Practice Year: 2018

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Denver Public Health
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Healthy Beverage Partnership
Denver Public Health (DPH) is an innovative, nationally recognized public health department located in Denver, Colorado. DPH collaborates with partners to inform, educate, offer services, and promote policy change to make Denver a healthy community for all people. DPH is organizationally housed under Denver Health and Hospital Authority, a safety-net health care system. DPH leads the Healthy Beverage Partnership (HBP) to coordinate the public health agencies serving the seven-county Metro Denver region. These counties are Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas and Jefferson. Metro Denver's population of 2,959,219 identify as; 66% White, 16% Latino/Hispanic, 5% Black, 4% Asian, 9% as other, (2015 census) and is 60 percent of the state's population. Obesity related chronic conditions include type II diabetes, coronary heart disease, cancer, high blood pressure, and osteoarthritis; all result in poor quality of life, premature death and excess health care costs (Overweight and Obesity: Adult Obesity Causes and Consequences. 2016; https://www.cdc.gov/obesity/adult/causes.html Accessed 9/11/2017). Consumption of SSBs is the leading cause of obesity (McGuire S. Institute of Medicine: Accelerating progress in obesity prevention: solving the weight of the nation. Washington, DC: the National Academies Press. Adv Nutr. 2012;3(5):708-709). The HBP works regionally with a collective impact approach to decrease childhood obesity by reducing SSB consumption. The primary objectives are: 1) Document the availability of healthy food and beverages in daycare, school, hospital, government, worksite, and public venue settings; 2) Increase the adoption of healthy meeting, vending, and concession policy changes at the settings listed above; and 3) Implement a public information campaign on the dangers of SSBs and healthy alternatives to SSBs. Metro Denver Partnership for Health (MDPH), is a partnership of Metro Denver directors of six public health agencies and recognized as a 2017 Promising Practice Winner (https://www.naccho.org/resources/model-practices/2017-model-practice-winners Accessed 11/30/2017). MDPH formalized the HBP through a Memorandum of Collaboration signed by the participating local health agencies (LHAs) in 2014 and championed by DPH. DPH coordinated input from the six LHAs to develop and secure funding. In 2015, the HBP was awarded to begin implementation of a three year work plan to decrease childhood obesity through reducing SSB consumption in 2015. HBP has a successful track record of addressing overconsumption of SSBs which spans the region and the state. After securing funding, 11 local coalitions were formed and maintained to support the implementation of HBP's three objectives. HBP developed a nutrition environment and policy assessment and implemented it in more than 319 venues to establish a baseline of healthy and unhealthy food and beverage availability in Metro Denver public venues. HBP provided technical assistance to support venues with adopting policy and practice changes to increase the proportion of healthy foods and beverages. Sixty-one organizational practice and policy changes have been adopted. This also includes one healthy default beverage in children's meals ordinance and a SSB excise tax policy. HBP developed and implemented a public information campaign, Hidden Sugar” (www.hidden-sugar.org) to educate on the risks of SSBs. This campaign focuses on educating English and Spanish speaking parents and caregivers of young children ages 0-6 on the amount of sugar in drinks commonly served to children, the risks of SSB consumption, and alternatives to drinking SSBs. Additionally, the HBP created and promoted a Hidden Sugar campaign toolkit to provide free communications and marketing materials for use by partner organizations and hospitals to maximize the reach and impact of the campaign. MDPH prioritized HBP efforts to ensure appropriate staffing and infrastructure existed within their public health agencies to move the activities forward. MDPH also championed the campaign by approving the use of administrative funds to supplement the grant funded campaign media buy and outreach tactics. DPH facilitated the establishment of an operating agreement among HBP, which was also critical to ensuring decisions were reached, objectives were met, and peer learning occurred. Additionally, the involvement and engagement of local coalitions contributed to the success of the objectives. This regional approach ensures community residents and public venues receive a consistent message across county lines. The combined expertise in policy, health promotion, data analysis and community engagement from the partner agency representatives are powerful tools for achieving health equity in childhood obesity prevention across the region. Consolidating efforts and collaborating regionally yields greater impact on overall health and childhood obesity prevention than siloed activities. More information on the HBP, including our policy toolkit, campaign toolkit, results of nutrition and policy assessments, and DPH's SSB position statement, is available at: http://www.denverpublichealth.org/home/community-health-promotion/healthy-eating-active-living.
Childhood obesity remains a persistent problem. Data from the Colorado Body Mass Index (BMI) Monitoring System estimates that among Metro Denver youth ages 2-17 seen in outpatient clinics in 2012 through 2014, overweight and obesity rates range from 20% to 37%. A focus on SSBs as the leading cause of obesity can successfully turn the tide on childhood obesity. Communities discouraging SSB consumption is an important approach to reducing body mass index (https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5807a1.htm Accessed 11/27/2017). The U.S. Department of Health and Human Services recommends that no more than 10% of daily caloric intake should come from added sugars (Dietary Guidelines for Americans, 2015-2020. US Department of Health and Human Services and US Department of Agriculture Dec, 2015). Between 1999 and 2004, children in the U.S. consumed almost 11% of their daily calories from SSBs alone (Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988-2004. Pediatrics. 2008;121(6):e1604-1614). Longitudinal studies show the relationship between SSB consumption and weight gain among children (Malik VS WW, Hu FB. Sugar-sweetened beverages and BMI in children and adolescents: reanalyses of a meta-analysis. Am J Clin Nutr. 2009;89:438-439 and Ludwig DS PK, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001;357:505-508). There is a significant difference of SSB consumption by poverty level: 21% of children living in poverty reported drinking SSBs daily compared to 13.3% who are not living in poverty. Those who were uninsured or had Medicaid in 2013, 2014 or 2015 were more likely to consume SSBs daily compared to all other types of insurance. These relationships by demographic characteristics persist into adulthood in Colorado (VISION: Visual Information System for Identifying Opportunities and Needs. 2017; https://www.colorado.gov/pacific/cdphe/vision-data-tool. Accessed 8/22/2017 and Behavioral Risk Factor Surveillance System and Child Health Survey. 2017; https://www.colorado.gov/pacific/cdphe/behaviorsurvey Accessed 8/22/2017). The HBP has the potential to reach all 2,959,219 residents of the 7 counties. Target populations include Latino/Hispanic residents (654,500), Residents under 18 (702,463) and those in living in poverty (352,435). To date more than 5,176,293 individuals, visitors, and employees have been reached by the increase in healthy food and beverage policy adoption. The Hidden Sugar public information campaign has had more than 15 million impressions. Previously, there was not a collective impact informed approach among Metro Denver health agencies and we had historically worked independently to address obesity and chronic diseases. In 2013, DPH convened healthy eating and active living staff of Metro Denver public health agencies to discuss a coordinated, single-focused strategy to reduce childhood obesity in the region. This group agreed to meet monthly, focus on reducing consumption of SSBs, and seek funding to implement activities. DPH is a local public health agency with a long history of convening local public health and environment agencies and partners to support prevention and surveillance approaches to improve health outcomes. Denver Public Health initiated the formation of and leads the facilitation, grant writing, and administration of the HBP as identified in a Memorandum of Collaboration executed by the corresponding six Public and Environmental Health Directors on May 29, 2014. The regional collective effort to decrease SSB consumption includes two approaches: education to decrease consumption of SSBs and restricting availability of less healthy foods and beverages in public venues. This allows for a prioritization of resources, staffing, and efforts within the strategy that is most likely to decrease childhood obesity. The HBP coordinated regional approach allows for leveraging financial resources, tools, peer learning, and impact. The HBP developed and implemented common tools to assess nutrition policies and environments. HPD also makes comparisons across counties on common measures, shares lessons learned across policy adoption, partners on policy adoption with venues that have locations in multiple counties, and increases our public education reach through media buys and marketing activities. Furthermore, common standards and shared model polices allow for consistent measures of the impact of this work as well as a shared high standard across public venues. The HBP shares responsibility for enhancing health equity in obesity prevention and outcomes for all families. We accomplish this by addressing the social and economic factors that influence health to make the Metro Denver region healthy for all. Furthermore, HBP's community coalition model engages with communities for communities to choose the strategies that will work for them. This work transcends county boundaries. The Collective Impact Approach is an existing practice that calls for multiple organizations from different sectors to have a common agenda, shared measurement and alignment of effort. DPH creatively used and modified this approach to include multiple organizations from the same sector to have a shared understanding of the problem, establish a joint approach to solving it, collect and measure data consistently, encourage continuous communication, and convene as the HBP backbone organization to coordinate the participating public health agencies. The evidence based practice of reducing consumption of calories from added sugars (NWS-17.2) is an identified objective to achieve the Healthy People 2020 goal of healthy behaviors across all life stages (https://www.healthypeople.gov/2020/topics-objectives/topic/nutrition-and-weight-status/objectives Accessed 11/24/2017). Creating food and beverage environments that ensure that healthy food and beverage options are the routine easy choice is included in the IOM 2012 Accelerating Progress in Childhood Obesity. Adopting policies and implementing practices to reduce overconsumption of SSBs is an evidenced-based practice and proposed strategy to ensure children are achieving proper nutrition and a healthy weight status (https://www.thecommunityguide.org/findings/obesity-multicomponent-interventions-increase-availability-healthier-foods-and-beverages Accessed 11/27/2017 and https://www.nap.edu/read/13275/chapter/8#154 Accessed 11/24/2017).
Nutrition, Physical Activity, and Obesity
The HBP's goal is to work regionally with a collective impact approach to decrease childhood obesity by reducing SSB consumption. The HBP accomplishes this through three primary objectives: 1) Document the availability of healthy food and beverages in daycare, school, hospital, government, worksite, and public venue settings; 2) Increase the adoption of healthy meeting, vending, and concession policy changes at daycare, school, hospital, government, worksite, and public venue settings; and 3) Implement a public information campaign on the dangers of SSBs and healthy alternatives to SSBs. Eleven local coalitions were formed and maintained to support the completion of 319 nutrition and policy assessments and adoption of 61 policy and practice changes reaching more than five million residents and visitors. The public education campaign reached over 15 million residents. The objectives described below represent the activities conducted between July 1, 2015 to November 30, 2017. All objectives and annual evaluations were completed. Objective 1: Document the availability of healthy food and beverages in daycare, school, hospital, government, worksite, and public venue settings. Activities included: 1. Review national standards for healthy food and beverages. 2. Establish and agree upon a set of standards to categorize options as healthy or unhealthy in vending and concessions. 3. Develop an online tool to conduct nutrition assessments based on the agreed upon standards for healthy and unhealthy. 3. a) Calculate whether a product was healthy or unhealthy. 3. b) Include pre-populated nutrition information of common vending products. 3. c) Include the ability to add in nutrition information if the nutrition product information was not in the existing database. 3. d) Include an assessment to capture food and beverage policy/ies in place and adoption of new policies. 3. e) Include section to document existing marketing and promotion of healthy vs. unhealthy products. 4. Field test the assessment by local adult and youth coalition members. 5. Collect feedback from field test and modify to improve the assessment online tool. 6. Establish criteria to support identification and selection of settings. 6. a) Inclusion criteria: Located in the seven county Metro Denver region, primarily serving low-income and/or Latino/Hispanic populations, and parents and caregivers of children ages 0-6 years old. 6. b) Exclusion criteria: Federal worksites located in Metro Denver. 7. Identify settings to invite to participate in an assessment in their respective county/ies. 8. Conduct nutrition and policy assessments between February 2016 and May 2016. 9. Create reports to share the baseline results of the nutrition and policy assessments locally and in aggregate. 10. Share reports/results of the nutrition and policy assessments with the venues, local coalitions, and decision makers. 11. Conduct nutrition and policy reassessments in February 2017-May 2017. 12. Create reports to share the results of the nutrition and policy reassessments. 13. Share reports/results of the nutrition and policy reassessments with venues, local coalitions, and decision makers. 14. Plan final nutrition and policy reassessments to occur in February 2018-May 2018. Objective 2: Increase the adoption of healthy meeting, vending, and concession policy changes at daycare, school, hospital, government, worksite, and public venue settings. Activities included: 1. Review national templates of model policy language for healthy meeting, concessions, and vending policies. 2. Agree upon and establish model policy language healthy meeting, concessions, and vending policies, including strict nutrition standards. 3. Develop a model healthy beverage and food policy toolkit including example policies adopted by metro organizations and resources to achieve policy and practice changes. 4. Develop policy and practice changes that could be implemented at the setting where an assessment was conducted in coordination with local coalition members. 5. Establish a plan for the setting including goals, metrics, and a timeline for implementing policy/ies and practice changes. 6. Provide technical assistance to settings with support of the model healthy beverage and food policy toolkit. 7. Track progress on and adoption of nutrition policy and practice changes at the settings. 8. Communicate the progress and adoption of nutrition policy and practice changes at the settings to local coalition members and their community. Objective 3: Implement a public information campaign on the dangers of SSBs and healthy alternatives to SSBs. Activities included: 1. Develop an HBP communications committee with membership from each participating local health agency's public information officer. 2. Establish a communications committee operating agreement. 3. Release a Request for Proposals, interview marketing agency candidates, and select agency for subcontract. 4. Establish a subcontract with the marketing agency to develop a public information campaign on the dangers of SSBs and healthy alternatives to SSBs. 5. Develop a plan for market research of the identified target audience (Latino/Hispanic and /or low-income parents and caregivers of children 0-6). 6. Develop survey and focus group questions with input and feedback from the HBP communications committee. 7. Use results to develop the campaign (Hidden Sugar). 8. Develop materials for in person outreach and media campaign. 9. Create print, out-of-home, radio, digital, and TV advertisements. 10. Purchase and place media buys. 11. Include an online pledge to drink fewer SSBs on the campaign landing page to help reinforce the desired behavior change. 12. Create a Hidden Sugar campaign toolkit. 13. Distribute toolkit for partner and community organization implementation of the campaign to increase reach. 14. Run the campaign in the market twice (during 2016 and 2017). 15. Evaluate the campaign and pledge responses. Multiple stakeholders in addition to the local health agencies were involved to form a Regional Steering Committee as a primary mechanism for the Metro Denver collaboration. Statewide organizations, programs, and stakeholders such as LiveWell Colorado, Oral Health Colorado, the American Heart Association Southwest Affiliate, and community coalition representatives including youth and adults were engaged with HBP's efforts. DPH established formal subcontracts with Metro Denver LHAs including Boulder County Public Health, Broomfield Public Health and Environment, Denver Environmental Health, Jefferson County Public Health, and Tri-County Public Health who contributed letters of support to the HBP grant application. Furthermore, additional identified partner organizations and supporters from multiple sectors including obesity prevention, oral health, health care, and preventive health and community organizations provided letters of support of our application committing to their involvement. HBP established mechanisms for formalizing technical assistance relationships and policy change partnerships with the organizations that provided letters of support as well as with the identified settings of government, public venues, hospitals, schools, early childcare, and parks and recreation facilities/districts. The following describes the HBP stakeholders and roles. Boulder, Broomfield, Denver Environmental, Jefferson and Tri-County Health Agencies are: Subcontractors and Regional Steering Committee Members that facilitate coalitions including youth and adult members. They implement activities for healthy food and beverage policy adoption including but not limited to contributing to the development of assessment tools, toolkit development, evaluation and dissemination of Hidden Sugar campaign in respective county or counties. The Colorado Department of Public Health and Environment provides assistance with assessment development, model policy development, and policy implementation in alignment with the Colorado Healthy Hospital Compact. Partner organizations and supporters from multiple sectors (including obesity prevention, oral health, health care, and preventative health, and community) attend bi-annual Regional Steering Committee meetings and are an HBP Participant. They contribute to alignment of educational messaging campaigns on SSBs with statewide educational efforts and support partnerships with key leaders and decision makers across the seven counties. By engaging stakeholders from key allied organizations and programs, HBP and the stakeholders developed an aligned approach with such efforts as Colorado's Healthy Hospital Compact (https://www.colorado.gov/pacific/cdphe/healthy-hospital-compact Accessed 11/30/2017) and LiveWell's HEAL Cities and Towns Campaign (https://livewellcolorado.org/healthy-communities/heal-cities-towns-campaign/ Accessed 11/30/2017). HBP maximized resources with the utilization of nutrition environment and policy assessments which already occurred through the Compact's detailed assessment. These Healthy Hospital Compact assessments assisted with the development of an aligned nutrition environment and policy assessment for other institutional settings. Furthermore, with a core group of hospitals leading healthy food and beverage policy efforts, HPD was able to leverage existing momentum to increase policy adoption amongst additional hospitals and settings in Metro Denver. The LiveWell HEAL Cities and Towns Campaign maximized resources through the established engagement of and commitment to adopting healthy eating and active living policies by municipal leaders. Within the seven Metro Denver counties there are 14 HEAL Cities and Towns. Coordinated efforts with LiveWell's Campaign allowed for leveraging healthy food and beverage policy adoption support in these 14 municipalities within Metro Denver. Furthermore, the HBP connected with a local oral health foundation regarding the reduction of SSB consumption to prevent obesity and tooth decay. We intentionally aligned our respective public information campaign key messages to the target our priority populations. Lastly we coordinated our media plans to leverage our campaign resources by running the HBP campaign in the market when the oral health campaign was not in the market to maximize reach consistently during this time frame. Most importantly, the HBP built connections to the communities being prioritized by this practice. To address the critical link to community members, we identified adult and youth community coalitions and community groups to participate in the HBP's work. These identified coalitions, groups, and individuals were asked to provide input and assistance in: 1) Public information educational campaign promotion/campaign development and reach; 2) Identifying community groups to recruit parents and caregivers for focus groups to test messaging; and 3) informing the Regional Steering Committee as to which events the outreach materials could be used to promote the campaign. The community coalitions and groups also participated in the development of outreach and community engagement events locally. They proposed, designed, and implemented the activities and events that encourage consumption of healthy food and beverages in support of the proposed organizational policy adoption. The startup cost to implement this practice within a seven county region is $1.1 million annually for the three year practice implementation period. The following is a summary of the current year's budget. The administrative/operational/evaluation/communications/supplies/indirect costs are $356,623.42. The administrative costs include all personnel, contract employee fees, supplies and operating expenses, travel and indirect rate. Personnel for the administration of the HBP includes a 1.0 FTE HBP Coordinator, .65 FTE Program Assistant, .3 FTE Supervisor of Healthy Eating Active Living Program, .15 FTE Grants Administrator, .2 FTE Evaluator, .15 FTE Marketing Specialist, a .5 FTE Youth Health Specialist, .5 FTE contract Youth Advisory (a youth between the ages of 16-24) and .05 FTE Community Health Promotion Division Director serving as the Principal Investigator. The implementation cost at the LHAs is $644,626.00. Implementation costs at each LHA range from $48,000.00 to $265,000.00 based on the size county/ies served by the LHA and their policy adoption targets. The marketing agency subcontract is $116,000.00. The technical assistance provider is $4,000.00.
An evaluation plan was developed to assess completion of objectives and progress made toward completing program goals. The objectives of the program are: 1) Document the availability of healthy food and beverages in daycare, school, hospital, government, worksite, and public venue settings; 2) Increase the adoption of healthy meeting, vending, and concession policy changes at daycare, school, hospital, government, worksite, and public venue settings; and 3) Implement a public information campaign on the dangers of SSBs and healthy alternatives to SSBs. The evaluation plan assessed a number of important parameters including percent of healthy and unhealthy food available, setting type, policy/practice change type, reach, media impressions, and post pledge consumption habits to reduce SSB consumption behavior. Success of the practice was defined by meeting the targets set for assessment completion and policy adoption. All objectives were achieved in years 2015-2017. Following each year of implementation a final report is developed and shared with stakeholders. Data has also been presented at the Colorado Public Health in the Rockies Conference in Breckenridge, CO in September 2016, the American Public Health Association Conference in Denver, CO in November 2016 and the Colorado Public Health in the Rockies Conference in Keystone, CO in November 2017. HBP has made great strides in decreasing access to sugary beverages and unhealthy food in the seven county region. Year one (2015/2016) focused on assessing community institutions to gather baseline data on beverage and food environments and policies. Grant year two (2016/2017) focused on providing technical assistance including coaching and resources to community institutions for them to adopt model healthy beverage and food policies and practices to improve their nutrition environments. In year two, as a result of technical assistance provided by HBP, five city or county-wide vending policies or practices were adopted. Five city or county governments (Northglenn, Westminster, Lakewood, Broomfield municipal buildings, and Broomfield Recreational Services) adopted policies or practices that define minimum percent healthy requirements for both beverages and foods, and outline nutrition requirements. The policies cover all vending machines on city or county property. For example, the city of Westminster adopted a healthier vending policy that states that 100% of all snack and beverage items must meet Healthy Beverage Partnership's nutrition criteria, in all vending machines, at all city locations. The collective reach (number of staff and visitors) of the vending policy within the 12 Westminster municipal buildings is 981,368 individuals. As cities like Westminster continue to grow, these policies will cover future vending machines, which helps ensure that municipal government is prioritizing and maintaining a healthy beverage and food environment for employees and visitors. HBP also provided technical assistance to support the adoption of healthy meeting, healthier concessions, and healthier vending policies and practices at community institutions (e.g. hospitals, recreation centers, youth serving organizations, schools, etc.). HBP uses our policy accomplishments data in various ways. First, we use these data to illustrate improvements that community institutions make over time (from baseline (before policy change) to re-assessment (after the policy was implemented)) in regards to nutrition environments and policies. In addition to highlighting successes, these data also provide opportunities for additional improvements. Secondly, HBP uses data to track our progress and describe our accomplishments specific to policies and practices adopted. We share our results with local coalition members, county board of health members, and decision makers. We use these data to generate excitement about our work, and to gain buy-in from additional community organizations to join our efforts. Objective 1: Document the availability of healthy food and beverages in daycare, school, hospital, government, worksite, and public venue settings. Nutrition and policy data were entered manually into a REDCap online tool by LHA representatives and/or local adult and youth coalition members in 2015/2016. Data were analyzed by the HBP evaluator. Analysis in 2016 of the nutrition and policy assessments showed 319 nutrition and policy assessments occurred. The original target of 85 assessments was exceeded. Seventy-eight assessments captured only policy status and 242 were nutrition assessments. The breakdown of the type of settings assessed included: 40% Government, 32% Hospital/health clinic 10% Recreation Center, Park or Pool, 8% Cultural or Entertainment (Museum, Zoo), 6% School and 4% Other (library, senior community center). Based on the criteria for healthy and unhealthy, 84% of the settings assessed had unhealthy snacks and 16% healthy snacks. For beverages, 72% were unhealthy and 28% were healthy. The baseline of the nutrition assessments concluded that unhealthy food and beverage options are more available compared to healthy food options. Healthy beverage options were more available compared to healthy food options. Objective 2: Increase the adoption of healthy meeting, vending, and concession policy changes at daycare, school, hospital, government, worksite, and public venue settings. In 2016, eight policy and practice changes were adopted that restricted access to SSBs. The majority of policy and practice adoption occurred in healthy concessions (4) or healthy meeting changes (3). Vending policy and practices were lower in the first year (1). There were two changes to vending contracts or products, six venues where healthy food and beverages were offered in vending and concessions, and four venues modified their promotional merchandizing procedures/activities to promote healthy items. In 2017, the number of policies and practices adopted increased. Healthy concessions remained the most popular type of policy adopted (26) followed by healthy meeting (13) and vending (9). Moreover, there were 20 changes to vending contracts or products, 37 venues offered healthy foods and beverages in vending and concessions, and two venues modified their promotional merchandizing procedures/activities to promote healthy items. Since the last assessment in 2017, additional policy and practice changes have been adopted including a healthy children's meals ordinance for a total of 61 tracked policy and practice adoptions that restrict access to SSBs. Settings have reported no loss of profit from adopting healthy policy and practice changes. Objective 3: Implement a public information campaign on the dangers of SSBs and healthy alternatives to SSBs. The Hidden Sugar campaign included a website, printed materials, billboards, placement on bus shelters and buses, digital media, radio and TV advertisements. To date more than 15 million impressions have occurred since the onset of the campaign. The campaign website, hidden-sugar.org/azucaroculta.org, featured a 30 day healthy beverage pledge. This call to action was added to inspire the desired behavior change (e.g. drink healthy beverages instead of sugary drinks), to increase campaign engagement, and to attempt to measure behavior change. The pledge included a series of demographic and behavior questions and was available online from January to June 2017. HBP provided incentives to support pledging. Pledgees were entered into a drawing to win one of three family-plus memberships to: the Denver Zoo, the Denver Museum of Nature and Science, and the Children's Museum of Denver at Marsico Campus. The results of sugary drink behaviors as gathered from the pledge at baseline (when they pledged) and at follow-up (after the campaign via a follow-up survey) among those who took a pledge are summarized by the five key areas below. The campaign encouraged behavior change: There was a significant change in the amount of sugary drinks respondents served to their families after the campaign: 42% of respondents reported serving fewer sugary drinks to their families after pledging. Latino/Hispanic respondents made behavior change more often: More Latino/Hispanic respondents (53%) than non-Latino/Hispanic (38%) respondents reported serving fewer sugary drinks and more non-Latino/Hispanic respondents (58%) reported no change in behavior compared to Latino/Hispanic respondents (37%). The change was more difficult for Latino/Hispanic respondents: While 50% of respondents reported that it was very easy to limit sugary drink consumption, there was a significant difference between Latinos/Hispanics (40%) and non-Latinos/Hispanics (60%), and nearly a quarter of Latino/Hispanic respondents (22%) reported it was somewhat or very hard to reduce serving sugary drinks to their families compared to just 8% of non-Latino/Hispanic respondents. Easy access to sugary drinks was the most common barrier to change: The majority of respondents felt that abstaining from serving sugary drinks was most challenging because ‘sugary drinks are everywhere.' Other reasons included: 1) Unsavory tap water taste: 13% of Latino/Hispanic respondents, 5% of non-Latino/Hispanic respondents and 2) Higher cost of healthy drinks: 17% Latino/Hispanic respondents, 11% non-Latino/Hispanic respondents. Current healthy behavior helps reduce consumption: For both Latino/Hispanic (42%) and non-Latino/Hispanic (50%) respondents, the most commonly reported facilitator to serving their family healthy drinks was ‘my family is used to drinking healthy drinks.' Other reasons included: 1) Higher cost of sugary drinks (16% of Latino/Hispanic respondents; 11% of non-Latino/Hispanic respondents), 2) Perceived too sweet” taste of sugary drinks (20% of Latino/Hispanic respondents; 14% of non-Latino/Hispanic respondents) and 3) Tap water is free (22% of Latino/Hispanic respondents; 25% of non-Latino/Hispanic respondents). Overall this practice aims to decrease childhood obesity. Although not available for Metro Denver, there is evidence of improvements in Denver's youngest age group (Denver Childhood Obesity Monitoring Report, 2012-2016. Denver Public Health 2017 http://www.denverpublichealth.org/Portals/32/Public-Health-and-Wellness/Public-Health/Health-Information/Docs/DPH-Health-Information-and-Reports-2016-Denver-Childhood-Obesity-Report_Final_20170803.pdf?ver=2017-08-03-101748-433 Accessed 11/30/2017). In addition among Colorado children ages 2 to 4 seen in WIC clinics, there have been significant decreases from 2011 to 2016 in obesity (8.4% to 7.0%) and overweight status (14.5% to 13.3%) that are consistent with a national study among WIC recipients (Pan L FD, Sharma AJ, Castellanos-Brown K, Park S, Smith RB, Blanck HM. Trends in Obesity Among Participants Aged 2-4 Years in the Special Supplemental Nutrition Program for Women, Infants, and Children—United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64(45).). The above examples may be an initial indication the HBP collective impact informed approach of decreasing availability of SSBs is working. Modifications have not been made to the practice as a result of the data findings.
Collaborative regional efforts can leverage resources to collect baseline data on healthy food and beverage options in a variety of settings, support for nutrition policy and practice adoption, and resources to implement a public education campaign. The result is unified and consistent activities and educational messages across the region, a peer learning network to support policy adoption across the region, common data to compare across counties, and greater efficiency. The combined expertise in policy, health promotion, data analysis and community engagement from the partner agency representatives are powerful tools that can leverage childhood obesity prevention across the region. Partner commitments, backed by shared resources and collective action, demonstrate the power and impact of regional collaboration. This work transcends county boundaries. A cost benefit analysis was not conducted. Sufficient stakeholder commitment to sustain the practice is evident by the Colorado Department of Public Health and Environment specifying strategies to increase healthy food and beverages and limit unhealthy food and beverages in organizational settings within their last Request for Proposals for funding. Additionally, HBP has worked strategically to develop approaches to be sustainable. Two toolkits were developed to allow for the practice to continue. First, the Model Healthy Beverage and Food Policy toolkit (http://denverpublichealth.org/Portals/32/Public-Health-and-Wellness/Public-Health/Health-Promotion/Docs/HBP-Policy-and-Practice-Toolkit-Nov2017-final.pdf?ver=2017-12-04-084617-330) is a free toolkit available on Denver Public Health and partner websites as well as promoted as a resource by the Colorado Department of Public Health and Environment. It provides settings with the resources and information to implement policy and practice changes including: 1) model healthy meeting, healthier vending and healthier concessions policy templates, 2) policy implementation support materials, and 3) examples of policies adopted by Metro Denver organizations. Second, the Hidden Sugar Campaign Toolkit (http://www.denverpublichealth.org/Portals/32/Public-Health-and-Wellness/Public-Health/Health-Promotion/Docs/DPH-HBP-Year3ToolKit-FINAL.pdf?ver=2017-09-27-143616-760) is also free and available on Denver Public Health and partner websites as well as promoted as a resource by the Colorado Department of Public Health and Environment. It provides stakeholders, partners and any interested organization to further and sustain the reach of our campaign. The toolkit includes: 1) talking points for the campaign, 2) facts and statistics related to SSB consumption, and 3) tools and resources to create change. Anyone can request materials and graphics by emailing denverpublichealth@dhha.org. Sustainability of HBP is reliant on maintaining partnerships and local community coalitions as well as effectively securing funding to maintain local health agency positions dedicated to this effort. HBP worked to increase a proportion of funding to support positions within each local public health agency from grant funding to county operating budgets. Additionally, HBP has submitted a proposal to continue funding and evolve the regional collaborative effort to focus on policies limiting SSB consumption at the population level versus the current organizational level. Lastly, the HBP is prioritized under the Metro Denver Partnership for Health. MDPH has a successful track record of addressing public health issues that span the region and the state. Consolidating efforts and collaborating regionally yields greater impact on overall health than siloed activities. The commitment to HBP efforts within this regional approach will allow for dedicated efforts to continue.
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