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Nutrition and Physical Activity Initiative

Systems and Environmental Changes

Maternal, Child, and Adolescent Health (MCAH) programs have a unique role in addressing environmental system changes, which help to make healthy choices practical and accessible to all members of a community. Their work with various local and governmental organizations and the vast population they serve allow for many collaborations and partnerships to be formed and expertise to be shared. Focusing on environmental changes addressing nutrition, physical activity, and breastfeeding can lead to sustainable and cost-effective methods of promoting the well-being of the MCAH population.

Environmental and Systems Interventions Backgrounder (PDF)

The Tree Diagram highlights Resources. Click on the tree parts to navigate to the resources. The branches Branch of the trees represent the main focus areas of the toolkit and clicking on them will take you to general resources about that topic area. The leaves Leaf represent chosen intervention resources. The apples Low Hanging Fruit represent “low-hanging fruit” which are a course of action that can be undertaken relatively quick and easy as part of a wider range of changes or solutions to a problem. These projects are similar to those already implemented by Directors or other key informants thus designated as “low-hanging fruit.” They are optimal projects to begin with as other MCAH programs have been successful already doing them.


General Branch

Close-up of health professional with  mother breastfeeding infant lovingly in background
Environmental changes to promote healthy diet, physical activity and breastfeeding, such as those addressing roads, sidewalks, housing, parks, businesses, urban sprawl, and lactation accommodation, can have a significant effect on the health of the community. These environmental locales are also referred to as the “built environment.” Advice to breastfeed our babies or to eat well and exercise often does not take into account that the environment may not be conducive to these healthy activities. However, numerous organizations and authors have identified environmental changes as the most promising strategy for creating population-wide improvements in nutrition and physical activity. By addressing these specific environmental approaches, Maternal, Child, and Adolescent Health (MCAH) programs have a unique perspective and role in tackling the rise of chronic diseases such as obesity and diabetes as outlined in the state obesity plan. Specifically, MCAH can be change agents in improving the nutrition, physical activity, and breastfeeding environments in California.

Nutrition Branch

Family cooking in kitchen

There are four main types of nutrition environments: the community, consumer, organizational and information.2 The community nutrition environment includes the type, location, and accessibility of food outlets such as stores and restaurants. The consumer nutrition environment includes the availability of healthy options, price, promotion, placement and nutrition information. The organizational nutrition environment encompasses the home, school, work, and other affiliations. The information environment covers the media and advertising of food items.2 These environments are not mutually exclusive and often overlap one another. Conceptualizing these different environments and their variables is useful in establishing the type of food people are exposed and have access to, and allow for targeted interventions to address their specific needs.

Nutrition plays an important role in the prevention of chronic diseases, and changing the food people eat has been defined as “one of the major modifiable determinants of chronic diseases.” However, our current food system and environment do not encourage people to eat healthy. California Center for Public Health Advocacy’s 2007 study found that California has more than four times as many fast-food restaurants and convenience stores as grocery stores and produce vendors.  It has been demonstrated that access to high-calorie, low nutrition foods and convenience stores increases the risk of being overweight and obese.9 Obesity prevalence is highest for California adults who have high Retail Food Environment Indexes (RFEIs), which is the ratio of fast food-restaurants and convenience stores relative to grocery stores and produce vendors near their homes. Here are some ideas for interventions to change the food environments and make it easier for people to make healthier eating choices.

Physical Activity Branch

Father helping young son ride a bike outside

Encouraging daily physical activity as a means for improving overall health is one of the main branches of environmental change in MCAH programs. Strategies for increasing physical activity have included new curricula for school physical education, fitness and active lifestyle classes and programs at community recreation centers, and increasing the walkability of communities. Increasing walkability has been an especially important goal, as it has been shown that residents of walkable neighborhoods who have good access to recreation facilities are more likely to be physically active and less likely to be overweight or obese4, as described in the Environment and Systems Interventions Report. One study concluded that residents of easily walkable neighborhoods engage in an extra 70 minutes of physical activity each week and are 2.4 times more likely to meet physical activity recommendations than residents that live in less walkable neighborhoods. However, less than a third of adults in California reported participating in vigorous physical activity at least three times per week. Therefore, creating safe and inviting areas through which to walk and bike and pursuing joint-use agreements to ensure that recreational facilities are accessible to the community may increase physical activity levels and improve the well-being of the entire family.

Breastfeeding Branch

Mother breastfeeding her infant
Even during infancy, the environment can have the effect of protecting the health of our population. Breastfeeding has been shown to have positive effects on the physical and psychosocial health of mothers and babies. Women who breastfeed have reduced risks of breast and ovarian cancer, anemia, and osteoporosis, and babies who are breastfed experience a reduced risk of sudden infant death syndrome (SIDS), childhood cancer and diabetes. Thus, ensuring an environment that is conducive to and supportive of breastfeeding to the maximum extent possible for each individual mother is of great benefit to both babies, mothers, and society as a whole.

The California Breastfeeding Coalition recognizes businesses that comply with state and federal laws for lactation accommodation. All local health departments are encouraged to apply for this award. See their website for creative solutions some businesses have taken to support their breastfeeding employees!

California Hospitals have been working hard to change policies and procedures, educate staff and alter their physical facilities to support breastfeeding. Many are seeking the Baby-Friendly™ Designation. The Baby-Friendly™ Hospital Initiative (BFHI), launched in 1991, is an effort by United Nations Children's Fund (UNICEF) and the World Health Organization to ensure that all facilities that provide maternity care, whether free-standing or in a hospital, adopt evidence-based maternity care practices that support breastfeeding. Hospitals that receive the designation of “Baby Friendly Hospital” report an increase in exclusive breastfeeding initiation rates. Environmental changes in the hospital have a positive impact on increasing hospital exclusive breastfeeding initiation rates. For example, Labor and Delivery and even Operating Room areas can be altered to facilitate skin-to-skin contact immediately after birth. Hospitals can facilitate keeping mothers and babies in the same room, a procedure called “rooming-in.” Hospitals can also avoid implied endorsement of infant formula by not including industry-sponsored marketing formula packs in the materials mothers take home from the hospital.

“9 Steps To Breastfeeding Friendly: Guidelines for Community Health Centers and Outpatient Care Settings” are guidelines developed in collaboration with input from community health centers, the California Department of Public Health, the California WIC Association (CWA) and the California Breastfeeding Coalition (CBC) to support community health centers and outpatient care settings to:

By Federal and California law, employers are required to provide lactation accommodation to their employees, specifically by providing unpaid break time and access to a private space other than a bathroom for mothers to pump and store their milk38, as described in the Environment and Systems Intervention Report. Returning to work has been cited as one of the main factors that decrease the duration of breastfeeding, so addressing lactation accommodation in the workplace can be effective in reducing this disparity. Many studies have shown that workplace lactation support has positive impacts on the duration of breastfeeding for participating women40. Employers also benefit from providing worksite lactation support and accommodations through retention of experienced employees, reduction in sick time leave for children’s illnesses and lower health care and insurance costs.

A mother’s intention to work full time is associated with lower rates of breastfeeding initiation and shorter duration. It is therefore important that childcare settings be designed to support breastfeeding. Such environments may include staff educated on supporting the breastfeeding dyad and promoting surroundings that reduce the mother’s stress when she arrives, drops off and picks up her baby. This can be done through implementation of a designated area for mothers to express or breastfeed during drop-off/pick-up times or during breaks at work, if this is possible. Having a clean and well-identified area to store breast milk labeled with the child’s name will give the mother reassurance that her baby will get her milk. Staff members who provide accurate information and demonstrate confident support of breastfeeding empower mothers to initiate and continue breastfeeding after returning to work.

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