Advancing Healthy Lifestyles:

Advancing Healthy Lifestyles

Chronic Disease, Health Equity, & COVID-19 (“Advancing Healthy Lifestyles” or “AHL”) is a statewide initiative launched in January 2021 by the Delaware Department of Health and Social Services, Division of Public Health (DPH). DPH’s Physical Activity, Nutrition and Obesity Prevention Program (PANO) introduced the initiative as Coronavirus 2019 (COVID-19) swept through the state, exacerbating health burdens already faced by many Delawareans. The PANO Program provides administrative staff support to the Delaware Cancer Consortium’s Cancer Risk Reduction Committee (CRRC). In December 2019, the CRRC launched the Healthy Lifestyles Subcommittee (HLSC) in response to Governor John Carney’s request to develop actionable policy recommendations to positively influence healthy lifestyles in Delaware. The HLSC efforts led to the recommendation of 14 policy recommendations for action in three population health strategic focus areas: 1) birth to age 18; 2) employee health and wellness; and 3) community wellness. The AHL initiative builds from the work of the HLSC and promotes the use of policy, systems, and environmental change (PSE) strategies to reduce obesity and other chronic conditions among Delawareans across the lifespan. Ideally, the AHL initiative is categorized into three component strategies: school, community, and workplace. This article highlights both completed and ongoing projects under the AHL Initiative that aim to address the burden of obesity in Delaware.

Background

The Coronavirus 2019 (COVID-19) pandemic presented significant health, social, and economic burdens in Delaware and globally. The pandemic took a disproportionate toll on the health and well-being of people of color and other underserved groups.¹ Every sector of society is working to identify solutions that address challenges resulting from the pandemic and to advance policies that focus on the health and wellness of Delaware’s most vulnerable populations. DPH, like the rest of the nation, is concerned with the higher prevalence of chronic health conditions among its aging population, communities of color, and those living with complex medical, behavioral health, and social needs. The state quickly learned through its COVID-19 response that communities of color had an increased risk of COVID-19 morbidity and mortality due to their higher prevalence of chronic health conditions. Communities of color were more likely to be exposed to infection while working, due to their overrepresentation in essential jobs in transportation, government, health care and food supply services, and in low wage or temporary jobs that did not allow telework or provide sick leave. It was evident that DPH needed to advance emerging policy, systems, and environmental change (PSE) strategies to improve health outcomes during the pandemic.

Obesity of adults and children is a serious chronic illness associated with the leading causes of death in the United States.² According to the Centers for Disease Control and Prevention (CDC), adults with obesity have a higher risk of chronic disease and premature death compared to those of normal weight.³ Children with obesity are at higher risk of developing mental health issues, social problems, and obesity in adulthood.³ Obesity is associated with a greater risk of other severe health conditions such as type 2 diabetes, heart disease, asthma, stroke, and multiple cancers.³

Obesity and many of its associated chronic diseases are complex and caused by several different factors. Obesity is a result of lifestyle choices and health risk behaviors such as poor nutrition and physical inactivity.⁴ Obesity is also influenced by the Social Determinants of Health (i.e., the conditions in which one lives, works, and plays). Health inequities and differences in Social Determinants of Health lead to disparities in obesity and chronic disease prevalence among racial, ethnic, and socioeconomic groups and among those in different geographical areas and with different physical abilities.⁵

The Delaware Department of Health and Social Services, Division of Public Health (DPH) launched the AHL initiative for two primary reasons: 1) to advance healthy lifestyles; and 2) to eliminate health disparities. The AHL initiative aims to facilitate the State’s systematic approach to addressing – structural and systemic inequities by strategizing how to work across sectors, address long-term health and social needs of a community, and remove structural barriers to health for socially vulnerable populations.

Delaware Data Highlights

In Delaware, and nationally, there are high rates of overweight and obese individuals, and the prevalence of obesity in Delaware is trending upward.⁶ According to the Delaware Behavioral Risk Factor Survey, in 2022, 37.9% of Delaware adults ages 18 years and older were obese, and 33.9% were overweight.⁶ High levels of obesity are also seen among Delaware youth. The Delaware Youth Risk Behavior Survey shows, in 2021, 32% of high school students were overweight or obese.⁷

Obesity is preventable and making simple lifestyles changes – such as choosing a healthy diet and achieving the recommended levels of physical activity – contribute to maintaining a healthy weight and preventing obesity. However, in 2019, only 24% of Delaware adults met the weekly recommended levels of both strength and aerobic activity.⁸ Additionally, 21% of Delaware adults reported eating less than one vegetable a day, and almost 40% report eating fruit less than once per day in 2021.⁹ In 2022, 23.5% of Delaware adults reported they did not participate in any physical activity or exercise in the last month.⁶ Data in 2021 show that Delaware youth were also not meeting the daily recommended levels of physical activity. More than half (58.8%) of high school students in Delaware reported not being physically active for at least 60 minutes every day during the past seven days.⁷

Obesity and an individual’s ability to make healthy choices are influenced by many factors, including individual-level risk factors and genetics and community and systems-level factors such as school environments, the natural and built environment, access to affordable healthy foods, and safe, convenient, and accessible places to engage in physical activity.¹⁰

Many Delaware residents suffer from chronic disease, and 10% have multiple chronic conditions. According to the Delaware Health Statistics Center, in 2020, chronic diseases accounted for seven of the 10 leading causes of death in Delaware, with more than 6,500 Delaware residents dying of chronic diseases (at least 61% of all deaths, Figure 1). Cardiovascular diseases and cancer accounted for 39% of deaths alone.¹¹

Figure 1.

Percentage of Leading Causes of Deaths, by Cause of Death, Delaware, 2020¹¹

*Bolded text indicates the cause of death is considered a chronic disease; **This includes all other causes of death not represented in the figure, including but not limited to influenza and pneumonia, chronic liver disease, assault (homicide), and intentional self-harm (suicide).

Given Delaware’s high prevalence and mortality rate of chronic conditions, the projected increase in the burden of chronic disease nationwide, and the implications for preventing and treating chronic diseases in the wake of COVID-19, it is important for DPH to continue to monitor chronic disease incidence, prevalence, and mortality. A multi-faceted approach addressing individual, community, and system-level factors is vital to promote healthy lifestyles, address health inequities, and reduce the burden of obesity in Delaware. Individuals and organizations from all sectors must come together to promote PSE strategies in multiple environments to reach Delawareans throughout the lifespan.

The PANO Program’s AHL initiative aligns with the goals and objectives of the U.S. Office of Disease Prevention and Health Promotion Healthy People 2030 initiative and follows evidence-based decisions and sound investments on collaborations across communities and sectors to improve the health of Delaware’s population.

Advancing Healthy Lifestyles

The Physical Activity, Nutrition, and Obesity Prevention (PANO) Program, within DPH’s Bureau of Health Promotion, uses a public health approach to address the role of physical activity and nutrition in improving health and chronic disease for all Delawareans. PANO’s vision is for all Delawareans to lead healthy lifestyles and its mission is to provide goals and strategies for government, media, communities, health care providers, schools, and worksites to decrease overweight prevalence and obesity in Delaware. The PANO program addresses high rates of obesity, physical inactivity, and poor nutrition through multiple initiatives that build capacity to implement evidence-based programmatic, and PSE strategies.

In January 2021, PANO launched a statewide initiative, Advancing Healthy Lifestyles: Chronic Disease, Health Equity, & COVID-19 (“Advancing Healthy Lifestyles” or “AHL”) in response to the high levels of obesity, chronic disease, physical inactivity, and poor nutrition in Delaware. AHL seeks to reduce obesity and other chronic conditions as part of an effort to achieve long-term health equity throughout Delaware. To accomplish this, AHL promotes the use of PSE strategies in schools, communities, and workplaces to reach Delawareans across the lifespan. The AHL initiative is categorized into three component strategies that are focused on the school, community, and workplace settings (Figure 2).¹²

Figure 2.

Goal and Strategies for the Advancing Healthy Lifestyles Initiative, Delaware, 2021¹²

Advancing Healthy Lifestyles Outcomes

All projects under the AHL Initiative are aligned with the Advancing Healthy Lifestyles outcomes:

• Increase healthy eating and healthy beverage consumption in the state across all settings.

• Increase physical activity in early childcare, schools, and community-based settings.

• Promote the adoption of physical education/physical activity (PE/PA) in schools.

• Promote the adoption of physical activity (PA) in early care and education (ECEs) and worksites.

• Increase population health and wellness programs/platforms in worksites in state, schools, and community-based settings (e.g., tobacco prevention, wellness challenges, education materials, and online modules focused on wellness and nutrition).

• Adopt strategies to improve community-clinical linkages.

• Increase use of lifestyles intervention programs in community settings for primary prevention of chronic diseases.

• Have policies, processes, and protocols in schools meet the management and care needs of students with chronic conditions (e.g., asthma, diabetes).

Statewide Action Plan

In summer 2022, the AHL Initiative produced a statewide action plan, which translates the 2021 Delaware Cancer Consortium’s Healthy Lifestyle Subcommittee (HLSC) policy recommendations into actionable strategies. The 14 HLSC recommendations (Figure 3) focus on policy and action in three key areas: 1) early childhood and school-age children (Birth to age 18); 2) workplace wellness (Employee Health); and 3) community interventions (Community Wellness). To develop the action plan, the PANO and the AHL team held discussion groups and interviews with 65 experts, program leaders, and providers from diverse Delaware agencies and organizations. These individuals shared their perspectives and discussed how to advance potential future action for each recommendation. The final action plan summarizes each HLSC recommendation, the recommendation’s potential to advance equity, and whether legislation or funding is needed to implement the recommendation. The action plan also includes factors and challenges that agencies can consider when implementing the recommendations.

Figure 3.

Fourteen Policy Recommendations of the Delaware Cancer Consortium’s Healthy Lifestyles Subcommittee,¹³ Delaware, 2021

AHL Learning Series

The PANO Program and AHL team facilitated three learning sessions as a part of its Learning Series, with more than 176 people attending all sessions combined between November 2022 and May 2023. The series included webinars on evidence-based approaches to building organizational capacity in key programs related to AHL priorities. The three webinars focused on community-school partnerships, workplace wellness, and nutrition and healthy eating among community partner programs. Table 1 summarizes the learning session topics.

Table 1. Content summaries, Advancing Healthy Lifestyles Learning Series, Delaware, November 2022-May 2023¹⁴.

Learning Session	Summary
Community-School Partnerships; Support During After School      November 17, 2022	The webinar showcased the Boys & Girls Clubs of Delaware’s work to deliver the Triple Play program to hundreds of school-age youths statewide. The panel reviewed the pilot phase of the project, the basics of the Triple Play curriculum, and problem-solving efforts to deliver programming and collect data while navigating staffing challenges, COVID-19 policies, and competing student priorities.
Workplace and Employee Wellness      March 3, 2023	The webinar focused on benefits to employers and employees, the current state of workplace health in the country, and available tools and resources from the Centers for Disease Control and Prevention (CDC). Panelists reviewed examples of workplace wellness efforts led by Delaware executive branch agencies and the workplace wellness resources from CDC, with DPH serving as a key partner in this effort. This session also addressed Delaware’s work in developing the Department of Human Resources’ (DHR’s) policy and toolkit to help executive branch agencies implement workplace wellness initiatives. The webinar provided an overview of the policy and toolkit.
Advancing Healthy Lifestyles in Delaware Community Partnerships      May 11, 2023	The webinar discussed the community-based nutrition initiatives of three community partners: the City of Newark; Delaware Breast Cancer Coalition; and University of Delaware Cooperative Extension. The webinar included presentations highlighting their ongoing work in addressing community needs, challenges, and lessons learned.

School-Community Partnership Demonstration Project

To improve the health and wellness of school-age students in Delaware, the AHL Initiative launched an innovative school-community partnership between youth serving organizations and public schools throughout Delaware. Triple Play is a national Boys and Girls Clubs healthy lifestyles program that seeks to improve youths’ knowledge of healthy habits, good nutrition, and physical fitness; increase the time they spend participating in physical activities each day; and strengthen their ability to interact positively with others and engage in healthy relationships.

In partnership with the PANO Program, the Boys and Girls Clubs of Delaware launched the Triple Play Program with elementary school-age youth in 2022 as an after-school program. The Wowzers! Program, a teen workforce initiative in which participants are hired and trained to run programs and lead lessons for younger club members, conduct Triple Play programming with the youth. Triple Play utilizes age-appropriate curricula to implement lessons with students in grades kindergarten through eighth grade. Since Triple Play’s launch in the spring of 2022, more than 1,000 students from schools in New Castle, Kent, and Sussex counties have participated.

Lessons within the Triple Play program are written to build the skills, attitudes, knowledge, and behaviors essential to live a healthy lifestyle, and to help students learn to sustain the health of the mind, body, and soul. Three categories of lessons are provided to address the Triple Play program’s goals: daily challenges, healthy habits, and social recreation.¹⁵

Building the Capacity of Community Partners

The AHL Initiative supports and strengthens the capacity of four primary community partners: the American Lung Association, University of Delaware Cooperative Extension, and two teams from Delaware State University (DSU). These organizations are launching PSE initiatives focused on accessing healthy food, creating opportunities for physical activity, and finding ways to prevent and manage chronic diseases. The PANO Program provides funding and technical assistance to all four partners, discussing their progress and developing promising solutions to challenges.¹⁶

• The American Lung Association is promoting lung-friendly schools and youth-serving environments by providing asthma and tobacco education and training to young people, their caregivers, and school staff.

• University of Delaware Cooperative Extension is improving access to healthy, local foods by connecting food growers and producers with local corner stores.

• DSU is building gross and fine motor skills for children with Autism through play-based activities and swim instruction and improving menu options for caregivers of children with Autism.

• DSU is providing summer and after-school programming for children that increases access to physical activity and healthy eating.

Advancing Healthy Lifestyles Mini-Grants

In fall 2022, the AHL Initiative launched a new mini-grant program, through which community partners receive funding and support for their community-based health interventions that promote PSE strategies related to physical activity or healthy eating and nutrition. The annual mini-grant program period is seven months, running from October to May. Mini-grant projects align with the outcomes of the AHL Initiative.

AHL mini-grants are awarded through a formal application and review process. Applicants must detail a proposed project that includes a description of the target population, intended reach, and goals and objectives that are aligned with the outcomes of the AHL Initiative. Mini-grants are funded by the DPH PANO Program through the Delaware Health Fund and can range up to $15,000. Organizations awarded mini-grants are required to submit progress reports throughout the project year to report on activities and project outcomes. Seven organizations were awarded an AHL mini-grant in year one (Table 2) and year two (Table 3) of the mini-grant program.

Table 2. Mini-grant project activities, Advancing Healthy Lifestyles Initiative, Delaware, October 2022-May 2023¹⁷.

4-H Cooperative Extension	Promote physical activity in schools, the community, and the workplace, including Walk with Ease, Walk Across Delaware, Walking Through the Holidays, and plogging (jogging while picking up litter).
Boys & Girls Clubs of Delaware	Provide educational opportunities on a mini-farm, including food education/ nutrition programs.
City of Newark	Construct a community garden to foster community and a healthy lifestyle.
Delaware Breast Cancer Coalition	Support a free, 12-week, open-to-the-public health education program geared toward people at risk for chronic disease, including breast cancer, with the goal of increasing physical activity and nutritional knowledge.
Inner City Cultural League	Support a community garden, nutrition education, and physical activity.
Worship Christian Center	Launch a healthy food and nutrition initiative that includes food preparation/nutrition classes and a walking club.
YMCA of Delaware	Recruit participants for the Lifelong Essentials for Activity and Nutrition program, which offers education and exercise for those struggling to obtain a healthy weight.

Table 3. Mini-grant project activities, Advancing Healthy Lifestyles Initiative, Delaware, October 2023-May 2024¹⁷.

4-H Cooperative Extension	Intends to increase chronic disease prevention and population health by continuing physical activity initiatives including walking clubs, plogging, and virtual youth fitness curricula.
Boys & Girls Clubs of Delaware	Aims to address food access and insecurity, hopes to coordinate community events, establish a produce stand, and enhance youth education in agriculture and nutrition.
Delaware State University	Aims to establish and assess programming focused on physical activity and nutrition for DSU students to deliver educational resources that empower students to make informed and healthier lifestyle choices.
Delaware Breast Cancer Coalition	Support a free, 12-week, open-to-the-public health education program geared toward people at risk for chronic disease, including breast cancer, with the goal of increasing physical activity and nutritional knowledge.
Inner City Cultural League	Aims to continue existing initiative to decrease obesity and chronic diseases which includes conducting physical activity classes, maintaining a community garden, and actively involving participants in education focused on nutrition and agriculture.
La Red Health Center	Intends to enhance access to healthy food, physical activity, and address food insecurity for prenatal/pediatric patients and mothers through distributing CSA produce shares and providing pregnancy nutrition classes and martial arts sessions.
West Side Family Healthcare	Intends to implement an off-road program as an extension of their Feeding Families Initiative. This program assists families in transitioning out of Feeding Families while ensuring access to healthy foods and sustaining their newfound healthy eating habits.

Improving Workplace and Employee Health

The PANO program collaborated with the Delaware Department of Human Resources (DHR)’s Statewide Benefits Office to develop a workplace wellness policy and accompanying toolkit for all executive branch agencies. The PANO and AHL team received input from 18 Delaware state agencies, as well as from an administrator from the CDC’s Workplace Health Program. DHR released the Workplace Wellness Policy and Procedures and Workplace Wellness Toolkit in June 2022. The policy provided guidance on the foundation and infrastructure for executive branch agencies to establish and maintain workplace wellness initiatives. The toolkit is designed to help agencies implement the workplace wellness policy and offers best practices for employers, tips, and tools. Shareable resources include a standardized liability waiver for participation in workplace fitness activities and a media release form.

The toolkit describes some benefits that agencies can gain from implementing these initiatives:

• Reduced health risks

• Improved health status and quality

• Improved productivity, morale, and retention

• Lower health care costs and disability

• Fewer workers’ compensation claims

• Reduced absences from illness or injury.

Following the release of the toolkit, the PANO and AHL team worked with select executive branch agencies to assess progress with their workplace wellness initiatives. Collectively, the team interviewed agency leaders from Delaware’s Department of Correction and the Delaware Department of Health and Social Services’ DPH and Division of Social Services to discuss current wellness offerings for the agencies’ employees, as well as facilitators of, and barriers to, the planning of activities and employee participation.

Advancing Healthy Lifestyles Conference

The Advancing Healthy Lifestyles Conference provides a platform for cross sectional sharing on national, regional, and local best practices, challenges, opportunities, and success stories. The goal of the AHL Conference is to strengthen efforts to reduce obesity and other chronic diseases amongst Delawareans and to serve as an opportunity to close gaps in health inequities, assess progress, and further strengthen the work of community stakeholders. Conference sessions are intended for government legislative and administrative policy makers in public health, nonprofit advocates of health and wellness, educators, medical caregivers and policy experts, and academic and medical researchers who are interested or engaged in health disparities, nutrition, chronic illness, and obesity prevention.¹⁸

The inaugural AHL conference was held on May 18, 2023, and focused on improving health through equity. The conference included one keynote speaker and 23 presenters. Of the 309 registrants, 264 attendees participated in a plenary panel session, three breakout panel sessions, and an interactive roundtable plenary session. Local and national subject matter experts presented how to improve health through equity, address systemic bias in health care, and improve health through community collaborations, as well as the trauma of racism and health disparities. There were 10 resource tables on display throughout the conference, with 18 table facilitators providing attendees with resources, education, and information on community services. The discussions led to 69 attendees from New Castle, Kent, and Sussex counties signing up for roundtable follow-up sessions to continue these conversations and begin the strategic planning process and formation of an AHL Coalition. Most conference attendees reported that sessions were “Very Good” or “Good.”

The Advancing Healthy Lifestyles Conference will serve as an annual convening for cross-sector collaboration, further strengthening the knowledge and skillset of Delaware partners to implement effective lifestyle change and obesity prevention initiatives. The second conference is planned for June 6, 2024, on the DSU campus.

Advancing Healthy Lifestyles Coalition

Following the inaugural AHL Conference in the spring of 2023 and follow-up roundtable discussions, the statewide Advancing Healthy Lifestyles Coalition was formed later that year with a collective impact approach to lead community and systems-level change. The vision is to uplift the well-being of all Delawareans and break down barriers to achieve healthy lifestyles. The mission is to bring together coalitions and partners to focus on healthy lifestyles and equity through the PANO lens to leverage and expand resources in the community.¹⁹

The AHL Coalition membership is made up of individuals from public and private multi-sector organizations. Coalition membership has representation from local health systems, universities, state agencies, non-profits, faith-based organizations, and youth-serving organizations.

The Coalition supports and promotes strategic planning, implementation, and evaluation of healthy lifestyle and obesity prevention initiatives. All members, projects, and decisions are guided by the Coalition’s four core values: inclusivity, building trust, collaboration, and collective action.¹⁹

The AHL Coalition identified five strategic priorities to help form action steps and guide the Coalition’s direction¹⁹:

• Collaboration and partnerships. Engage coalitions and key representatives across the health system with a PANO focus to serve as a repository, knowledge sharing, and networking vehicle.

• Community outreach engagement and access. Provide outreach opportunities to increase access to existing programs and services with a PANO focus, regardless of income, race, ethnicity, gender identification, age, ability, citizenship status, or geography.

• Program development linked to PANO. Identify gaps in services and programs that increase access to PANO related services that reduce health disparities, improve outcomes, and affect system or cultural change.

• Marketing and communications. Develop a marketing plan for existing programs linked to PANO and other coalitions that promote equity and help reduce health disparities.

• Policy, systems, and environmental change (PSE). Advocate for PSE strategies with a PANO focus that increase equitable access to health programs and services to increase access and reduce healthy disparities.

The AHL Coalition aims to identify and address current gaps in resources, services, and programs to lead community and systems-level change related to healthy lifestyles, chronic disease, and obesity prevention in Delaware.

Conclusion

The AHL initiative is an emerging initiative to propel efforts to improve health in Delaware. High rates of physical inactivity, poor nutrition, and obesity leads to the realization that public health efforts in the state to improve health and achieve health equity will require more broad population health approaches that address social, economic, and environmental factors that influence health. In a post-pandemic climate, DPH recognizes that it is necessary to take a multi-component approach to address this public health crisis. The PANO Program’s Advancing Healthy Lifestyles Initiative promotes the use of PSE strategies to reach Delawareans across the lifespan. AHL leverages multi-sector community collaborations to build capacity and utilize collective impact to increase healthy lifestyles and reduce the burden of obesity in Delaware.

As the PANO Program continues to facilitate and support the AHL initiative and the AHL Coalition infrastructure in Delaware, a culture of collaboration and trust is forming. This will undoubtedly lead to development and sustainability of shared goals, strategies, and ownership of lasting social and structural change. DPH foresees this change prompting heightened awareness of factors that focus on social determinants of health, elimination of health disparities, and improvement of overall health outcomes for Delaware residents.