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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. This toolkit provides resources in each of these areas for MCAH programs to utilize in setting goals and planning activities for the communities they serve.

Low hanging fruits are interventions that [MCAH] programs can easily promote. Look for the Low Hanging Fruit icon to see examples of low hanging fruit projects that local MCAH programs have successfully implemented.

Environmental and Systems Interventions Backgrounder (PDF)

GettyImages-463400853Environmental 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.

Funding OpportunitiesLeaf

Caltrans Active Transportation Funding Program  

The Active Transportation Program (ATP) is a combination of State and Federal funding sources, and covers a wide variety of project types, including non-infrastructure (NI) – education, encouragement, and enforcement activities that further the goals of the ATP. Non-infrastructure programs include those benefiting school students, older adults, or entire communities. 

Other Funding Sources with Active Transportation Elements 

While the Active Transportation Program has successfully funded projects across the State, the Program is incredibly oversubscribed and cannot meet all of the State's needs. Therefore, the California Transportation Commission (CTC) and Caltrans have developed a list of additional programs that fund active transportation projects and elements to serve as a resource for cities, counties, and agencies looking to fund valuable active transportation projects in their communities.

Presentation Leaf

Recorded Webinar: Systems and Environment Change to Improve the Health of MCAH Populations featuring Richard Jackson, MD, MPH, UCLA School of Public Health 

A Healthy Community for the Green Family (YouTube) : This video shows how policies, systems, and the environment (PSE) influence a family’s ability to make healthy choices. It can be used to help explain policy, systems, and environmental change interventions and the importance of including PSE work with direct education.


General Plans Leaf

Work with cities and counties to ensure that the General Plans include provisions for healthy eating and active living increases support for incorporating health equity initiatives related to food access, the built environment and active living into General Plans. This work ensures that health benefits and threats related to parks, green/open space, trees, food insecurity, and healthy food access are addressed. Some of the ways to promote this work is through use of state level media campaigns, resources, and other messaging strategies through digital and social media such as an opinion editorial, blog posts or a letter to the editor .


SMPR-I-001-PRLP-Family%20Cooking_511670857There 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.

Farmer’s Markets and WIC Low Hanging Fruit

The WIC Program supports the consumption of fresh, locally grown fruits and vegetables, and encourages shopping at farmers’ markets. Since May 2010, farmer’s markets in California have been able to apply for authorization to accept the Women Infants and Children (WIC) Fruit and Vegetable Check (FVC). Since 2010, over 450 farmer’s markets have been authorized to accept the WIC benefit. Learn more about participating farms and farmer’s markets. Maternal, Child and Adolescent programs can promote local use Farmers' Markets Research has shown that access to farmers' markets increases fruit and vegetable consumption among participants and that access to neighborhood supermarkets and farmers' markets reduces the risk of overweight and obesity. This is especially effective in low income communities where fresh produce is less accessible and more expensive. Farmers' markets can increase the availability of healthy foods and lower the overall food costs for the neighborhood. Since locally-grown produce is sold by local farmers, the cost of a middleman and transportation can be avoided making the sale prices competitive compared to grocery stores. Ultimately, farmers' markets can alter the community nutrition environment by making fresh fruits and vegetables more available and affordable, ensuring that more people have the opportunity to make healthier nutrition decisions.

Community Gardens Leaf

Research supports the use of community gardens to improve a population's nutritional status. One study reported that adults with a household member that participated in a community garden consumed fruits and vegetables 1.4 times more per day and were 3.5 times more likely to consume fruits and vegetables five times a day than those who did not participate. Another study reported that community gardeners consumed fruits and vegetables 5.7 times per day compared with 4.6 times per day for home gardeners and 3.9 times per day for non-gardeners, suggesting that community gardens may benefit the health of its participants more so than private home gardens. Community gardens can also increase one's willingness to try the fruits and vegetables grown in a garden, which could prove useful for younger picky eaters. By improving the community nutrition environment with these gardens, participants may increase their consumption of fruits and vegetables and thus improve their health outcomes.

Farm-to-Institution Leaf

Programs such as Farm-to-School change the food environment in a school setting and help to increase the intake of fruits and vegetables in children. It has been reported that, by changing the organizational nutrition environment through school lunches, children consume an increase of one serving of fruits a vegetables per day. In working with various stakeholders involved with farming, institutions such as schools can improve the nutrition, and therefore the health outcomes children as well as their families.


Water Access Leaf

Access to free and safe drinking water is essential to the health and well-being of communities. Work that supports creating access to free, safe drinking water (can includes working with partners to include water refilling stations, free water available in food service environments) and increasing the safety, taste, and appeal of water as a beverage choice. This work encourages consumption of water, especially in places of sugar-sweetened beverages (SSBs), and can help increase hydration and decrease risk for dental cavities, obesity and diabetes among community members.


Toolkits, all on NDWA website :

  • Managing Lead in Schools and Childcare (Horsley Witten)
  • Is My Water Safe? (Community Water Center)
  • Waterworks School Toolkit (CFPA)
  • Water Works (Howard)
  • 4h20 for UC CalFresh Parents Making Waves (CFPA)
  • Public water utilities for tap water safety and promotion

NUPA-SystemsEnvironmentEncouraging 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.

Safe Routes to School Leaf

Initiatives such as Safe Routes to School provide a safe way for children to exercise regularly by walking or biking to school. According to the Environment and Systems Intervention Report, the percentage of children 5-14 years of age walking or biking to school dropped from 48% to just 13% from 1969 to 200927. Environmental factors, such as distance to school, traffic-related danger, and crime danger or perceived safety, are likely to have played a major role in this decrease. Safe Routes to School addresses these issues through infrastructural and non-infrastructural interventions. Infrastructural interventions include grants for better crosswalks and signage, while non-infrastructural interventions may include Walk to School Day or organizing Walking School Buses so that groups of children have adult chaperones when walking to school. A California study referenced in the Environment and Systems Intervention Report showed that schools that implemented infrastructure interventions through Safe Routes to School had walking and bicycling increases in the range of 20 to 200%29. In Marin County’s second year of enacting the Safe Routes to School Program, participating schools reported an increase of 64% in school trips made by walking and 114% by biking. They reported a 39% decrease in trips by private vehicles carrying only one student. Moreover, a safety analysis estimated that the safety benefit of the program was an approximate 49% decrease in childhood bicycle and pedestrian collision rates.

Joint Use Agreements Leaf

Increasing levels of physical activity in a community does not always require long-term development projects, but can also be achieved by increasing access to existing recreational facilities. Establishing joint-use agreements, such as opening school yards to the community after school hours, is one way to reduce barriers to safe places and provide opportunities for engaging in physical activity. Joint-use agreements can be formal or informal partnerships between two entities – usually a school and a city – to share use of indoor and outdoor spaces such as gymnasiums and athletic fields. For example, a school could share their pool with a swim team or a school employee could unlock the school gate after hours so people in the community have access to the basketball courts. This agreement is ideal for rural or low-income populations that may otherwise lack access to physical activity facilities.

Pedestrian Safety and Walkability Leaf

Environments that encourage physical activities such as walking and biking are ideal for improving a community's health and preventing chronic illnesses. It is therefore important to ensure that the environment is conducive to this sort of daily physical activity. First, it is important to note that mixed land use, connectivity, safety, and aesthetic qualities all contribute to the "walkability" of a place7, as described in the Environment and Systems Intervention Report. "Walkability" refers to how safe, convenient, and usable facilities are for pedestrians and bikers to get to their destinations. Safe and attractive sidewalks that are destination-oriented, especially with required mixed-land use zoning so that people live near where they work, shop, and play, may encourage more members of communities to walk or bike as their primary mode of transportation.

  • The Active Transportation Safety Program (ATSP) assists local communities with creating, evaluating, and sustaining active transportation education and encouragement (non-infrastructure) programs, including Safe Routes to School (SRTS) programs, through targeted trainings, technical assistance, and resources.
  • California Walks is a state-wide voice that partners with state agencies, organizations and communities to establish and strengthen policies and practices that support pedestrian safety and healthy, walkable communities. Links to network affiliates and further resources available on website.
  • Pedestrian Safety Training : Power Point presentation sponsored by California Office of Traffic Safety and presented by CDPH describing “It’s All Up to Us” campaign.
  • Walkability Checklist (PDF) : A tool to help evaluate your community’s walkability and provides solutions for improvement. Developed in partnership by A Walkable America, Pedestrian and Bicycle Information Center, the US Department of Transportation, and the US Environmental Protection Agency (EPA).
  • Walk Friendly Communities : Applications for designating your community as Walk Friendly. The website also includes an assessment tool for determining how walkable your community is.
  • Walking 101: The Role of Maternal, Child, and Adolescent Health Programs :
    This webinar highlights the opportunities to promote walking for those working in Maternal, Child, and Adolescent Health.


Parks Leaf

Increasing access and physical activity in parks can help launch a culture of active communities and increase awareness and appreciation for parks and nature. Work with local parks can include specific programs like Parks Rx, Parks After Dark, and others, and includes partnership activities with parks departments and other partners to increase access to services, and safe recreation areas.


    Image1-93DPIEven 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.

CA Mother-Baby Friendly Workplace Awards Low Hanging Fruit

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!

Hospital Environments Leaf

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.

Clinic EnvironmentsLeaf

“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:

Worksite Environment Leaf

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.

Childcare Environments Leaf

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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