There is strong evidence that breastfeeding promotion programs increase initiation, duration, and exclusivity of breastfeeding (Oliveira IBB, Leal LP, Coriolano-Marinus MW de L, et al. Meta-analysis of the effectiveness of educational interventions for breastfeeding promotion directed to the woman and her social network. Journal of Advanced Nursing. 2017;73(2):323-335. Link to original source (journal subscription may be required for access)Oliveira 2017, Cochrane-Balogun 2016, Patnode CD, Henninger ML, Senger CA, Perdue LA, Whitlock EP. Primary care interventions to support breastfeeding: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2016;316(16):1694-1705.Link to original source (journal subscription may be required for access)Patnode 2016, Haroon 2013, Cochrane-Renfrew 2012, Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database of Systematic Reviews. 2010;(3):CD004015.Link to original source (journal subscription may be required for access)Cochrane-Lewin 2010, Dyson 2010). Breastfeeding provides many health benefits to children, including fewer ear infections, lower respiratory tract infections, and gastrointestinal infections for infants (Stuebe 2009, Fisk 2011), and lower likelihood of childhood obesity, type 2 diabetes, and asthma (Giugliani 2015, Stuebe 2009, Harder 2005). Breastfeeding has also been shown to reduce rates of breast and ovarian cancer for mothers (AICR-CUP report 2017, Li 2014a, Stuebe 2009) and has been associated with lower rates of maternal hypertension, diabetes, and cardiovascular disease (Schwarz 2009).
Education interventions increase breastfeeding initiation rates (Dyson 2010), particularly among women with low incomes (Cochrane-Balogun 2016), and increase exclusive breastfeeding until babies are 6 months old (Oliveira IBB, Leal LP, Coriolano-Marinus MW de L, et al. Meta-analysis of the effectiveness of educational interventions for breastfeeding promotion directed to the woman and her social network. Journal of Advanced Nursing. 2017;73(2):323-335.Link to original source (journal subscription may be required for access)Oliveira 2017). Face-to-face support (Cochrane-Renfrew 2012) and tailored education (Cochrane-Renfrew 2012, Cochrane-Balogun 2016) increase the effectiveness of breastfeeding promotion programs. Combining pre- and post-natal interventions increases initiation and duration more than pre- or post-natal efforts alone (Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in primary care to promote breastfeeding: An evidence review for the US Preventive Services Task Force. Annals of Internal Medicine. 2008;149(8):565-82.Link to original source (journal subscription may be required for access)USPSTF-Chung 2008, USPSTF-Breastfeeding 2008).
Support from health professionals (Cochrane-Renfrew 2012, CDC-Breastfeeding 2013, USPSTF-Breastfeeding 2008), lay health workers (Cochrane-Renfrew 2012, Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database of Systematic Reviews. 2010;(3):CD004015.Link to original source (journal subscription may be required for access)Cochrane-Lewin 2010, Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in primary care to promote breastfeeding: An evidence review for the US Preventive Services Task Force. Annals of Internal Medicine. 2008;149(8):565-82.Link to original source (journal subscription may be required for access)USPSTF-Chung 2008, CDC-Breastfeeding 2013), and peers (Chapman 2010, Dyson 2010, CDC-Breastfeeding 2013, USPSTF-Breastfeeding 2008) have demonstrated positive effects, including increases in initiation, duration, and exclusivity of breastfeeding. For employed mothers, supportive work environments also increase the duration of breastfeeding (Dinour LM, Szaro JM. Employer-based programs to support breastfeeding among working mothers: A systematic review. Breastfeeding Medicine. 2017;12(3):131-141.Link to original source (journal subscription may be required for access)Dinour 2017, CDC-Breastfeeding 2013).
Components of the Baby Friendly Hospitals Initiative (BFHI), which includes 10 steps to support breastfeeding, have been shown to increase breastfeeding rates when implemented as a whole or individually (Wouk K, Tully KP, Labbok MH. Systematic review of evidence for Baby-Friendly Hospital Initiative Step 3: Prenatal breastfeeding education. Journal of Human Lactation. 2017;33(1):50-82.Link to original source (journal subscription may be required for access)Wouk 2017, Perez-Escamilla 2016, Dyson 2010, CDC-Breastfeeding 2013). Step 3 of BFHI, which combines breastfeeding education and interpersonal support, increases breastfeeding rates, especially when women’s partners or family are involved (Wouk K, Tully KP, Labbok MH. Systematic review of evidence for Baby-Friendly Hospital Initiative Step 3: Prenatal breastfeeding education. Journal of Human Lactation. 2017;33(1):50-82.Link to original source (journal subscription may be required for access)Wouk 2017). BFHI increases breastfeeding rates among mothers with lower education levels, which may reduce socio-economic disparities in breastfeeding rates (Hawkins 2015).
Cost-benefit analysis suggests that breastfeeding promotion programs are cost effective (Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: A pediatric cost analysis. Pediatrics. 2010;125(5):e1048-e1056.Link to original source (journal subscription may be required for access)Bartick 2010).
Home Visiting programs, specifically Nurse Family Partnership, have been shown to have a favorable effect on attempted breastfeeding. (Kitzman, H., Olds, D. L., Henderson, C. R., Hanks, C., Cole, R., Tatelbaum, R., et al. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. A randomized controlled trial. JAMA: The Journal of the American Medical Association, 278(8), 644–652. Also see Study Detail available online here: https://homvee.acf.hhs.gov/study-detail?title=WWHV003621%20%20%20%20%20 .)
The Guide to Community Preventive Services (The Community Guide) recommends health communication campaigns that use multiple channels, one of which must be mass media, combined with the distribution of free or reduced-price health-related products.1 Community-wide physical activity campaigns involve many community sectors, include highly visible, broad-based, multi-component strategies (e.g., social support, risk factor screening or health education) and may address cardiovascular disease risk factors2 (CG-Physical activity). There is strong scientific evidence that community wide campaigns effectively increase levels of physical activity and energy expenditure and increase knowledge about physical activity and self-reported intentions to be more physically active.There is some evidence that community-wide physical activity campaigns increase physical activity among children and adults (CG-Physical activity, Economos 2007), increase walking in intervention communities (Cochrane-Baker 2015), and may reduce sedentary time among adults (Heredia 2017).Based on strong evidence of effectiveness for producing intended behavior changes, the Community Preventive Services Task Force recommends health communication campaigns that use multiple channels, one of which must be mass media, combined with the distribution of free or reduced-price health-related products.
Sources:Community-wide physical activity campaigns:https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/community-wide-physical-activity-campaignsHealth Communication mass media in general:https://www.thecommunityguide.org/sites/default/files/assets/Health-Communication-Mass-Media.pdf
This is an overarching strategy, as wellness policies may have any of several evidence-based components, including:Active RecessThere is strong evidence that active recess increases physical activity for schoolchildren (Erwin 2014, Larson 2014, Janssen 2013, Howe 2012, HFRP-Sports4Kids). Active recess programs can lead to significant increases in moderate to vigorous activity; children can expend 100kcal/30 minutes of recess (Howe 2012).Competitive pricing for healthy foods (in schools)There is strong evidence that competitive pricing increases sales of healthy foods, including low-fat foods, fruits, vegetables, and water (Gittelsohn 2017, Grech 2015, Jaime 2009, Kocken 2012, An 2013, AHA-Mozaffarian 2012). Price discounts or subsidies for healthier foods can also increase healthier food consumption (Gittelsohn 2017, An 2013, AHA-Mozaffarian 2012).Extracurricular activities for physical activityThere is some evidence that increasing access to extracurricular sports, athletic activities, and active after school programs increases children’s physical activity during leisure time, especially when offered as part of a multi-component physical activity promotion program (Verstraete 2007, Wolch 2011, Lubans 2008, Ara 2006, CFLRI-Cameron 2005, Beets 2013, CDC PRC-YMCA afterschool, Barr-Anderson 2014). However, additional evidence is needed to confirm effects. Participation in extracurricular sports and activities is associated with higher physical activity levels for children and adolescents (CFLRI-Cameron 2005, Lubans 2008). Access to publicly provided recreation programs can reduce children’s risk of overweight and obesity (Wolch 2011). Overall, low income, public high school students in urban areas that participate in athletics (except football) have lower BMIs than their peers (Elkins 2004). Participation in at least three hours of sports per week appears to increase physical activity levels (Jago 2014), fitness, and total lean body mass for boys (Ara 2006).Farm to school programsThere is some evidence that farm to school programs increase knowledge about, willingness to try, and consumption of fruits and vegetables among school children (Jones 2015, Izumi 2015, Yoder 2014, Moss 2013, Slusser 2007, Evans 2012a, Scherr 2013, Wang 2010a, UNC-F2S, Evers 2015). Farm to school programs are a recommended strategy to improve dietary habits and nutrition (USDA-Ritchie 2011, CDC-Fruits and vegetables 2011, CDC-Dietz testimony 2009, TFAH-Levi 2014, Berlin 2013). However, additional evidence is needed to confirm effects.Fruit and vegetable taste-testingThere is some evidence that taste testing fruits and vegetables as part of a multi-component intervention increases fruit and vegetable consumption among children, adolescents, and adults (Snelling 2017, Knai 2006, Burchett 2003, French 2003, Davis 2009, Ciliska 2000, CDC-MS FFVP). Taste testing fruits and vegetables is a suggested strategy to improve nutrition (CDC-Fruits and vegetables 2011, WIPAN-Schools, WIPAN-Worksites).Healthy school lunch initiativesThere is some evidence that healthy school lunch initiatives increase healthy food selection and consumption, and improve students’ eating behaviors (Driessen 2014, Williamson 2013, Cohen 2013, Hanks 2013). Such initiatives can also improve childhood nutrition (Williamson 2013).Healthy vending machines optionsThere is some evidence that increasing healthy options in vending machines improves dietary behaviors (Story 2008, Cradock 2011, French 2001), especially when healthy options are made relatively less expensive than unhealthy options (French 2010). Price discounts for healthier foods have been shown to increase consumption of healthier foods (An 2013, Story 2008, AHA-Mozaffarian 2012). Vending machine nutrition standards and increased healthy vending options are suggested strategies to improve nutrition (IOM-Government obesity prevention 2009, CDC-Make a difference, CDC-Fruits and vegetables 2011, Wiecha 2006, Briefel 2009, Kubik 2003, Alaimo 2013). Additional evidence, especially studies focused solely on vending machines, is needed to confirm effects.Homework or extra credit for PE classThere is some evidence that assigning homework or extra credit for physical education (PE) class increases physical activity levels for schoolchildren (Duncan 2011, Smith 2003, Gabbei 2001) and college students (Claxton 2009). Assigning PE homework as part of a multi-component obesity prevention intervention can also improve children’s fitness (Meyer 2014) and weight status (Fairclough 2013) and increase physical activity levels (Lubans 2014).Multi-component school-based obesity prevention interventionsThere is strong evidence that multi-component school-based obesity prevention programs increase physical activity (Nixon 2012, Cochrane-Dobbins 2013, Demetriou 2012), and improve dietary habits (Kropski 2008, Van Cauwenberghe 2012, Cawley 2011). Such programs also improve weight status when implemented with high intensity and for long durations (Bleich 2018, Shirley 2015, AHA-Mozaffarian 2012, Khambalia 2012, Cochrane-Waters 2011, Katz 2008). However, there is significant variability in program design and effect (Brown 2009, Harris 2009a, CG-Obesity).Open gym timeOpen gym time is a suggested strategy to increase physical activity levels for children and adolescents (CDC MMWR-School health guidelines 2011, KP-Thriving schools). Open gym time has been associated with increased physical activity (Mora 2012, CG-Hoonah Alaska 2012).Physically active classroomsThere is strong evidence that physically active classrooms increase physical activity levels for students and moderately improve their on-task behavior and academic achievement (Kibbe 2011, Bartholomew 2011, Barr-Anderson 2011, Donnelly 2011, Norris 2015).Point of purchase prompts for healthy foodsThere is some evidence that point-of-purchase prompts increase the purchase and consumption of fruits and vegetables and other healthy foods (Freedman 2010, Buscher 2001, Reed 2011, Story 2008, Sonnenburg 2013), especially when implemented with other food environment improvements (Seymour 2004, AHA-Mozaffarian 2012). Used in conjunction with advertising and promotion of healthy foods, point-of-purchase prompts have been shown to increase healthy food selection (Escaron 2013).School breakfast programsThere is strong evidence that having access to school breakfast programs (SBP) increases academic engagement and achievement, especially among nutritionally deficient or malnourished children (Frisvold 2015, Hoyland 2009, Meyers 1989, Adolphus 2013). SBP effects can vary by participant characteristics and program type (e.g., universal, breakfast in the classroom, grab and go, etc.) (Bartfeld 2019). Access to school breakfast programs also increases healthy food consumption and can improve breakfast nutrition (Bhattacharya 2006, Murphy 2011, Ask 2006, ERS-Fox 2004, Frisvold 2015).School food & beverage restrictionsThere is some evidence that school food and beverage restrictions lead to healthier diets among children (Alaimo 2013, Ishdorj 2013, Datar 2017, Cradock 2011, Gonzalez 2009, Fernandes 2008, Jaime 2009, Larson 2010). Competitive foods are highly available in schools (Silden 2018). School policies to restrict competitive foods and beverages are associated with reduced in-school availability and in-school consumption of unhealthy foods and beverages (Chriqui 2014). Additional research is needed to confirm effects on overall consumption and weight outcomes (Silden 2018, Chriqui 2014).School fruit & vegetable gardensThere is strong evidence that school gardens modestly increase participating children’s vegetable consumption and willingness to try new vegetables (Savoie-Roskos 2017, Davis 2015b, AHA-Mozaffarian 2012, Langellotto 2012, Scherr 2013, Ratcliffe 2011, Parmer 2009, McAleese 2007, Rauzon 2010). Establishing school gardens is also a recommended strategy to promote healthy eating, improve nutrition, and reduce obesity (CDC-School-based obesity prevention, CDC MMWR-School health guidelines 2011, CDC-Fruits and vegetables 2011, IOM-Government obesity prevention 2009).School fundraiser restrictionsSchool fundraiser restrictions prohibiting the sale of unhealthy foods and beverages are a suggested strategy to decrease access to such foods, improve the school food environment, and support student health (USDA-School fundraisers, CDC-Smart snacks). One study suggests small school districts are less likely than large school districts to have established school fundraiser restrictions (Merlo 2018).School nutrition standardsThere is strong evidence that nutrition standards for school meals increase healthy food consumption, especially consumption of fruits and vegetables, and improve school food environments (Schwartz 2015, Cohen 2014a, Jaime 2009, Williamson 2013). Nutrition standards that focus on competitive foods can decrease unhealthy food consumption, increase the availability and consumption of healthier alternatives, and may modestly improve student dietary intake (Woodward-Lopez 2010, Snelling 2009, Schwartz 2009). Strengthening nutrition standards for competitive foods may increase effects on the school food environment and student nutrition (Woodward-Lopez 2010).School-based nutrition education programsThere is some evidence that school-based nutrition education programs increase healthy eating habits for children and adolescents (Wolfenden 2017, Meiklejohn 2016, Yip 2016, Wang 2013b, Langford 2014, Silveira 2011), including increasing fresh fruit and vegetable consumption (Wang 2013b, Langford 2014, Silveira 2011).School-based physical education enhancementsThere is strong evidence that enhancing school-based physical education (PE) increases physical activity and physical fitness among school-aged children (CG-Physical activity, Demetriou 2012, Cawley 2013, Lonsdale 2013, Sacchetti 2013, Story 2009). Enhancing or expanding PE classes as part of a multi-component school-based obesity prevention intervention has also been shown to increase physical activity and improve health (Nixon 2012, Cochrane-Waters 2011, Cochrane-Dobbins 2013).Screen time interventions for childrenThere is strong evidence that screen time interventions reduce sedentary screen time among children under 14 (CG-Obesity, Biddle 2014, Marsh 2014). Interventions that include nutrition and physical activity components have also been shown to increase physical activity and improve dietary habits and weight-related outcomes for participating children (CG-Obesity, Biddle 2014, Friedrich 2014). Overall, screen time interventions have small but significant effects on stationary screen use with or without nutrition and physical activity components (CG-Obesity, Biddle 2014, Friedrich 2014); additional evidence is needed to confirm effects on mobile device use.Water availability and promotion interventionsThere is some evidence that making water readily available and promoting its consumption increases water intake (Giles 2012, Loughridge 2005, Patel 2011, Muckelbauer 2009, Elbel 2015). Frequent water consumption can also have positive effects on eating and drinking decisions (Popkin 2005a, French 2001), improve physical health and body functions (Popkin 2010), and, potentially, reduce children’s risk of being overweight (Muckelbauer 2009). Increasing water availability is also a suggested strategy to improve nutrition and cognitive function in children and adolescents (IOM-Government obesity prevention 2009, CDC-Water access).
Sources:• Active Recess: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/active-recess• Competetive pricing: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/competitive-pricing-for-healthy-foods• Extracurricular activities for physical activity: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/extracurricular-activities-for-physical-activity• Farm to school programs: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/farm-to-school-programs• Fruit and vegetable taste-testing: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/fruit-vegetable-taste-testing• Healthy school lunch initiatives: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/healthy-school-lunch-initiatives• Healthy vending machines options: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/healthy-vending-machine-options• Homework or extra credit for PE class: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/homework-or-extra-credit-for-pe-class• Multi-component school-based obesity prevention interventions: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/multi-component-school-based-obesity-prevention-interventions• Open gym time: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/open-gym-time• Physically active classrooms: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/physically-active-classrooms• Point of purchase prompts for healthy foods: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/point-of-purchase-prompts-for-healthy-foods• School breakfast programs: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/school-breakfast-programs• School food & beverage restrictions: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/school-food-beverage-restrictions• School fruit & vegetable gardens: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/school-fruit-vegetable-gardens• School fundraiser restrictions: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/school-fundraiser-restrictions• School nutrition standards: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/school-nutrition-standards• School-based nutrition education programs: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/school-based-nutrition-education-programs• School-based physical education enhancements: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/school-based-physical-education-enhancements• Screen time interventions for children: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/screen-time-interventions-for-children• Water availability and promotion interventions: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/water-availability-promotion-interventions
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