Multicomponent Initiatives

Multicomponent InitiativesSuccessful initiatives pursued through any of the opportunities individually can lead to important changes.  However, multiple opportunities pursued as part of a coordinated approach will likely be most effective at achieving desired goals concerning the weight and health status of 0- to 5-year-olds.  This page includes examples of states that successfully pursued multicomponent initiatives:  Delaware and New York.

Multicomponent Initiative State Example: Delaware

Delaware (DE) was one of the first states to implement a multilevel approach to prevent childhood obesity in the ECE setting that centered around comprehensive guidelines and standards for nutrition and physical activity including limits on screen time. Successful policy and practice changes were made through the following opportunities:

  •  Licensing and Administrative Regulation: Some of the key changes mandate 20 minutes or more of moderate to vigorous physical activity every 3 hours; limit time spent in confining equipment such as strollers or swings for awake infants to no more than 30 minutes; and prohibit screen time for children younger than 2 years and limit screen time for older children.
  • CACFP: Nutrition regulation changes included serving 1% or fat-free milk to children over 2 years of age; limiting juice to one serving of 100% juice and no juice allowed for infants under 1 year of age; limiting pre-fried and fried food, processed meats, and sugar in cereals; prohibiting non-real cheese; and requiring whole grains. Licensing regulations were tied to the CACFP requirements so they would have the same force as other licensing regulations. A Team Nutrition toolkit was developed to assist with the implementation of the new CACFP regulations and to support providers in integrating CACFP into their policies and practices.
  • QRIS: Passage of legislation implemented a voluntary QRIS, Delaware Stars for Early Success.
  • Funding and Finance: A funding collaboration of public and private funders was established to support several aspects of DE’s multicomponent initiative, particularly the QRIS and learning collaboratives for ECE providers.
  • Pre-service and Professional Development and Technical Assistance: The DE Institute of Excellence in Early Childhood was established by the DE Department of Education in partnership with the University of DE to improve the research, evaluation, and training infrastructure of the ECE system in the state. The Institute, through a contract with Nemours, developed obesity prevention training and technical assistance programs to educate ECE providers throughout the state about best, age-specific practices related to healthy eating, physical activity, and screen time reduction. Additionally, nutrition and physical activity were included in several existing training activities including CACFP-sponsored trainings, orientation for new providers required by licensing regulations, and required basic certification programs. Curricula for community college degree programs in ECE were also revised to include information on healthy eating, physical activity, and parent support to prevent obesity.
  • Facility-level interventions: A Child Care Learning Collaborative that empowered ECE facilities and staff to make long-term sustainable policy and practice changes was developed, along with several new tools for ECE providers to use to educate and engage infants and children in healthy eating habits, reduced screen time, and physical activity.
  • Early Learning Standards: Nutrition and physical activity were integrated into curriculum standards.

For more information on these approaches, go to the report Delaware’s Child Care Regulations Promote Healthy Child Development.

How It Came About

These changes were initiated by an array of public and private organizations, including corporations, beginning in 2004 and continuing to the present. Partners were motivated by the high obesity rates in children aged 2 to 5 years and a shared understanding of the importance of promoting healthy lifestyles early in life. One of the first formal efforts was the revision of ECE licensing by the OCCL. Shortly after that effort started, DE’s CACFP leadership (based at DOE) wanted to make DE’s CACFP regulations stronger than those mandated at the federal level. Also, Nemours Pediatric Health System, Division of Health and Prevention Services (NHPS), had identified reducing childhood obesity as a key focus and reached out to OCCL and CACFP to bring the organizations together to champion a multilevel approach to integrate obesity prevention efforts throughout the ECE system. OCCL established an advisory group to recommend new regulations for ECE centers. The legislature approved the proposed regulations for implementation in 2007. Revisions for child care homes were also revised and approved for implementation in 2009. Simultaneously with the OCCL regulatory revisions, DE’s Early Childhood Council, with numerous public and private partners, including the United Way, Nemours, and PNC Bank, began developing and implementing a Quality Rating System. Children and Families First, the ECE information and referral agency, provided technical assistance for ECE facilities who volunteered to participate in the quality rating system.


Several factors facilitated the changes implemented in DE. There was a lot of support for the changes from various sectors. As OCCL was leading a change in regulations, NHPS was supporting and advocating for changes. Additionally, the involvement of CACFP was critical for ensuring stronger regulations around nutrition. The state’s Early Childhood Council and United Way, with funding support from PNC Bank, were developing the Quality Rating and Improvement System (QRIS). Nemours helped these organizations build obesity prevention training and technical assistance into the QRIS. QRIS standards for healthy eating and physical activity were integrated into the Early Learning Foundations adopted by QRIS as curriculum standards.

The organizations realized the importance of training for ECE providers to implement the regulation changes. Funding from Nemours and a grant from USDA’s Team Nutrition allowed CACFP and NHPS to develop and disseminate tools for providers that included Best Practices for Healthy Eating: A Guide to Help Children Grow Up Healthy; First Years in the First State: Improving Nutrition & Physical Activity in Delaware Child Care; Planning Healthy Meals for Child Care; and the Healthy Habits for Life Teachers Tool Kit (in English and Spanish), developed by Nemours and Sesame Street Children’s Workshop. All tools are available for free download at These tools are used to provide extensive technical assistance and training to ECE providers. Cooperative Extension integrated nutrition and physical activity into their trainings. DE obtained feedback and input from providers at various junctures in the process.

DE faced several challenges when implementing their nutrition and physical activity guidelines. For example, providing healthy foods, developing menus with variety, and modifying recipes to meet new guidelines were challenges for providers as was the perceived higher cost of healthy foods. Technical assistance helped providers learn how to purchase healthier foods with minimal cost increases. For physical activity, making use of public space and limited outdoor play space is a challenge. More nutrition and physical activity challenges can be found in the report, Challenges and Opportunities Related to Implementation of Child Care Nutrition and Physical Activity Policies in Delaware. For an executive summary of the report, click here.

Lessons Learned

DE’s experience in the development and implementation of a multilevel approach provides lessons learned that may be useful to states moving forward.

  • Be sure to involve ECE providers in the conversation related to changes from the beginning. Their input is valuable and their support of the changes is critical.
  • When making changes to nutrition and physical activity regulations, clearly and consistently communicate the rationale for nutrition and physical activity standards to ECE providers.
  • Provide resources to ECE providers to educate and engage young children in healthy eating and age-appropriate physical activity.
  • Expand and improve training and technical assistance to ECE staff and provide opportunities for peer-to-peer information sharing.
  • Make trainings for the ECE workforce accessible to low-income communities, such as on public transportation routes, and offer incentives, such as CEUs/annual training hours given for attendance.
  • Provide training and easy-to-use materials for both ECE providers and licensing staff. Constant reinforcement is important. This means including nutrition and physical activity standards in the QRIS or in licensing requirements.
  • Align QRIS with enhanced nutrition and physical activity state standards to promote implementation of changes.

Additional information at Delaware’s Child Care Regulations Promote Healthy Child Development.

Multicomponent Approach State Example: New York

The New York State (NYS) Department of Health has implemented a multiprong approach to address childhood obesity in ECE settings. The opportunities successfully pursed in NYS include:

  • CACFP: The NY Child and Adult Care Food Program (NY-CACFP), within the NYS Department of Health (DOH), developed Healthy Infant and Healthy Child Meal Patterns by revising the federally regulated meal patterns to reflect evidence-based data on food practices associated with a reduced risk of obesity. Required and recommended changes were established to improve menus in ECE centers and day care home settings. Mandated changes included fat-free or low-fat milk for children older than 2 years of age, only unflavored milk for children younger than 5 years, no more than one serving of juice per day, and sweetened grain products no more than twice a week and only at snack or breakfast. Participating centers and homes have been trained on Healthy Meal Patterns. For more information, see here. NY-CACFP received USDA Team Nutrition grants and a Child Care Wellness grant to enhance their obesity prevention efforts. Team Nutrition Training grants allowed CACFP to focus on nutrition and environmental improvements in their menu, mealtime environment, nutrition and physical activity education, and policies. This was accomplished in ECE settings through ECE provider training and goal setting. The Child Care Wellness grant, awarded in fiscal year 2011, will allow NY-CACFP to provide an obesity prevention intervention to family day care home providers and the children in their care.
  • Funding and Finance: NYS used USDA’s Supplemental Nutrition Assistance Program –
    Education (SNAP-Ed) funds, which were supplemented with state obesity prevention funds to match the federal dollars to support implementation of facility-level interventions.
  • Pre-Service and Professional Development: NYS worked with the Early Childhood Education and Training Program, sponsored by the Office of Children and Family Services, to produce a 2½-hour statewide videoconference training for ECE providers. Program topics included beverages, menu planning, staff/child feeding interactions, and TV viewing and other screen use. To learn more, click here.
  • Facility-level Interventions: NYS developed several facility-level interventions, including:
    • Eat Well Play Hard in Child Care Settings (EWPHCCS). Through the end of federal fiscal year 2010, NY-CACFP had implemented EWPHCCS in 757 licensed, low-income ECE centers. Low-income ECE facilities are defined as those in which 50% or more of enrolled children live in households at or below 185% of the federal poverty level. This intervention is administered by regional Child Care Resource and Referral (CCR&R) agencies and by the New York City (NYC) Department of Health and Mental Hygiene.
    • NYS supports the use and implementation of NAP SACC on a statewide basis. Implementation of the NAP SACC intervention is accomplished through a contract with the NYS Early Care and Learning Council, and through multiple regional contracts funded by the state’s Creating Healthy Places to Live, Work and Play initiative. The NAP SACC intervention is designed for ECE centers to improve their nutrition and physical activity environments, policies, and practices through self-assessment, action planning, staff training, and targeted technical assistance. NYS developed an additional NAP SACC media-reduction module to assess and modify the screen viewing practices of participating centers. For more details, see here.
    • Breastfeeding Friendly Child Care Initiative: NY-CACFP developed standards for ECE centers and family day care homes to assist them in providing breastfeeding support to moms. Centers that meet these standards are designated as Breastfeeding Friendly Child Care Sites. For a description of this program and a list of participating sites, see this website. NYS enacted a Breast Feeding Mothers’ Bill of Rights that details mothers’ rights related to breastfeeding before and after their baby is born and includes hospital rights. For more information, go to Breastfeeding Promotion Guidelines for Childcare Centers and Breastfeeding Promotion Program.

How It Came About

To advance policies and practices in support of healthy eating, increased physical activity, reduced screen time, and breastfeeding support, the NYS DOH convened a task force of key leaders in ECE to examine opportunities for systemic improvements. The ongoing work of the task force, now known as the Obesity Prevention in Child Care Partnership, was integrated into the workgroup structure of the Early Childhood Advisory Council (ECAC). Involving key partners such as the NYS Office of Children and Family Services, the CACFP and Obesity Prevention Programs in the Department of Health, the NYS Early Care and Learning Council, the NYS Council on Children and Families, and the Head Start State Collaboration Project has been essential to focus attention on state-level policy change.


With the benefit of both state and federal funding, the NYS DOH implemented several obesity prevention interventions and initiatives focusing on ECE settings, which provided tangible examples of best practice implementation and demonstrated public health’s commitment to work with and invest in the ECE sector. The formation of the Obesity Prevention in Child Care Partnership was essential to engage early childhood stakeholders, including state agencies and organizations, in addressing early childhood obesity collectively and individually. Engaging key partners in guiding the partnership has already yielded proposed policy changes. And, affiliating the Partnership with the Promoting Healthy Development workgroup of the NYS Early Care and Learning Council (ECAC) provides ongoing opportunities to integrate nutrition, physical activity, screen time reduction, and breastfeeding support in the overall development of the state’s early childhood system.

ECE providers in New York identified several challenges to implementing obesity prevention initiatives that include lack of funding for staffing, training, and the purchase healthy foods; lack of space, equipment, and training for physical activity; lack of staff knowledge about how to implement appropriate practices; lack of adult role models among professional caregivers and parents; and a need for greater collaboration between providers and parents.

Lessons Learned

Having ECE partners and stakeholders engaged in the development and decision-making process is important to the successful implementation of initiatives and advancement of policies.

ECE providers need training and consultation on policy development and environmental and practice changes to successfully implement childhood obesity prevention standards and practices related to nutrition, breastfeeding, physical activity, and screen time limits.

Interventions and initiatives alone are not sufficient to raise the bar on obesity prevention practices in ECE. State-level policy must set the bar for performance. ECE interventions and initiatives targeting nutrition, physical activity, screen time, and breastfeeding support can promote and support ECE practice improvements to achieve state policy objectives.