Provider-Selected Training Needs and Associations With Related Practices in Childcare Settings in Minnesota and Wisconsin.

BACKGROUND: Early care and education settings (ECE) are potential venues for young children to develop healthy lifestyle habits. The study assesses training needs and associations with relevant practices of licensed ECE providers across Minnesota and Wisconsin. METHODS: A random sample of 823 providers completed a 97-item survey assessing nutrition and physical activity (PA) practices and training needs. Logistic regression, adjusted for program type (center- and family home-based), and location (urban/rural) examined associations between the top 3 selected training needs and provider practices. RESULTS: Top training needs: (1) ways to effectively engage parents about healthy eating and PA, (2) low-cost ways to serve healthy foods, and (3) fun and easy nutrition education curricula. Providers who reported being not happy/somewhat happy vs happy/very happy with parent communication were more likely to need training to engage parents. Among providers who prepared food on-site, shopping at Farmer's Market had lower odds of needing training for serving healthy meals on a budget. Not having completed nutrition training in the past year providers were more likely to need training for fun and easy nutrition education curricula. CONCLUSIONS: Providers need additional training to improve communication with parents, healthy food shopping practices, and nutrition-related games.

Do High School Students Participate in Second Chance Breakfast Programs?

BACKGROUND: Breakfast consumption often decreases as youth get older. The School Breakfast Program (SBP) provides an opportunity to intervene and increase breakfast consumption, especially among high school students. METHODS: Project breakFAST implemented an expanded breakfast service at 12 high schools. In this longitudinal evaluation, school administrators provided SBP participation and demographic data on all ninth and 10th graders for two full consecutive school years. Students screened for eating breakfast <3 times/week were randomly selected to participate in the cohort study. The cohort completed a survey on perceived barriers, benefits, and breakfast habits. RESULTS: At baseline, all 12 schools had only traditional before school cafeteria SBP service. Mean participation was 16.3% and ranged from 7.9 to 38.1%. After the intervention, there was an increase in participation to 25.7% (p = .004) ranging from 14.1 to 47.5%. There was no change in breakfast participation before school (13.3%, p = .06). Students who traveled to school by car, bike, or walking at baseline were 4.5% less likely to participate in second chance breakfast at follow-up than those who took the bus to school (p = .006). CONCLUSION: Second chance breakfast is an option for increasing high school breakfast participation, especially for those riding the bus.

Breakfast Is Brain Food? The Effect on Grade Point Average of a Rural Group Randomized Program to Promote School Breakfast.

BACKGROUND: Adolescents frequently miss breakfast which may impact cognitive, academic, and health outcomes. This analysis describes the effect of a trial to assess school level changes to increase breakfast consumption on grade point average (GPA). METHODS: Sixteen rural Minnesota high schools were randomized to a policy and environmental change intervention or delayed intervention (control) group. Baseline screening identified, randomly selected and enrolled 9th and 10th grade students who eat breakfast ≤3 times per school week for assessment. Mean unweighted GPA was provided by 13 schools for 636 students. Student-level and administrative data were used for sociodemographic and free or reduced-price meals (FRPM). Linear mixed models and latent class analysis (LCA) were used to assess change in GPA. RESULTS: Students were 54% female, 76% white, and 34% received FRPM. Unweighted cumulative GPA mean = 2.82 (0.78) at baseline. There was no significant intervention effect on GPA postintervention or 1-year follow-up. LCA revealed two classes: "higher" (N = 495) and "lower" (N = 141) resource. There was an intervention effect among low-resource students from baseline to 1-year post only among the control condition (delayed intervention). CONCLUSIONS: In combination with the full study results, increasing breakfast consumption may have an impact particularly for low resource students.

The Economic Benefits of Reducing Racial Disparities in Health: The Case of Minnesota.

This paper estimates the benefits of eliminating racial disparities in mortality rates and work weeks lost due to illness. Using data from the American Community Survey (2005⁻2007) and Minnesota vital statistics (2011⁻2015), we explore economic methodologies for estimating the costs of health disparities. The data reveal large racial disparities in both mortality and labor market non-participation arising from preventable diseases and illnesses. Estimates show that if racial disparities in preventable deaths were eliminated, the annualized number of lives saved ranges from 475 to 812, which translates into $1.2 billion to $2.9 billion per year in economic savings (in 2017 medical care inflation-adjusted dollars). After eliminating the unexplained racial disparities in labor market participation, an additional 4,217 to 9185 Minnesota residents would have worked each year, which equals $247.43 million to $538.85 million in yearly net benefits to Minnesota.

A Group Randomized Intervention Trial Increases Participation in the School Breakfast Program in 16 Rural High Schools in Minnesota.

BACKGROUND: Breakfast consumption is associated with better diet quality and healthier weights, yet many adolescents miss breakfast. Nationally, 17.1% of students participate in the School Breakfast Program (SBP). Only 10% of high school students participate. OBJECTIVE: Our aim was to evaluate an environmental intervention to increase SBP participation in high schools. DESIGN: A group randomized trial was carried out from 2012 to 2015. PARTICIPANTS/SETTING: Ninth- and 10th-grade students enrolled in 16 rural schools in Minnesota (median 387 students) were randomized to intervention or control condition. INTERVENTION: A school-based intervention that included two key components was implemented over a 12-month period. One component focused on increasing SBP participation by increasing student access to school breakfast through changes in school breakfast service practices (eg, serving breakfast from a grab-n-go cart in the atrium; expanding breakfast service times). The other component focused on promoting school breakfast through student-directed marketing campaigns. MAIN OUTCOME MEASURE: Change in school-level participation in the SBP was assessed between baseline (among ninth and tenth graders) and follow-up (among tenth and eleventh graders). School meal and attendance records were used to assess change in school-level participation rates in the SBP. STATISTICAL ANALYSES: The Wilcoxon test was used for analysis of difference in change in mean SBP participation rate by experimental group. RESULTS: The median change in SBP participation rate between baseline and follow-up was 3% (interquartile range=13.5%) among the eight schools in the intervention group and 0.5% (interquartile range=0.7%) among the eight schools in the control group. This difference in change between groups was statistically significant (Wilcoxon test, P=0.03). The intervention effect increased throughout the intervention period, with change in mean SBP participation rate by the end of the school year reaching 10.3% (95% CI 3.0 to 17.6). However, among the intervention schools, the change in mean SBP participation rates was highly variable (range=-0.8% to 24.8%). CONCLUSIONS: Interventions designed to improve access to the SBP by reducing environmental and social barriers have potential to increase participation among high school students.

Provider Adherence to Nutrition and Physical Activity Best Practices Within Early Care and Education Settings in Minnesota, Helping to Reduce Early Childhood Health Disparities.

Licensed child care providers, and the early care and education settings in which they operate, are uniquely situated to influence children's healthy eating and physical activity through practices, attitudes, and supportive physical and social environments. However, preliminary research indicates that child-, family-, and provider-level characteristics affect adherence to best practices across early care and education settings. The current article used survey data ( n = 618) to characterize differences in child care providers' adherence to nutrition, physical activity, and mealtime best practices, based on child-, family- and provider-level characteristics, and to describe secular trends in adherence to nutrition and physical activity best practices between 2010 and 2016. Results indicate that differences exist across certain characteristics, including child race/ethnicity, family's use of child care assistance, language spoken at home, and provider educational attainment; however, it is notable that in most cases providers serving children of minority race and children in low-income families have a higher rate of compliance with the nutrition and physical activity best practices studied. Additionally, the comparison of adherence to best practices from 2010 to 2016 suggests that, while there was an increase in mean adherence from 2010 to 2016, overall trends in adherence across child-, family- and provider-level characteristics have been consistent across time. Public health professionals should continue to advocate for opportunities for providers to learn how to best incorporate best practices within their setting (e.g., education and training opportunities) as well as for the development and adoption of systems-level changes (e.g., expansion of food assistance programs) to reduce barriers to adherence to best practices.

Staff Training Interests, Barriers, and Preferences in Rural and Urban Child Care Programs in Minnesota.

OBJECTIVES: To describe any rural-urban differences in child care providers' (1) past training on the facilitation of child healthy eating and physical activity and (2) views relevant to the design of trainings. METHODS: Cross-sectional analysis of data from the 2016 Healthy Start, Healthy State survey of Minnesota child care providers (rural, n = 232; urban, n = 386). Licensed family home-based care providers and providers working at licensed centers responded online or by mail to measures of desired training content, barriers, and delivery mode preferences. RESULTS: Training barriers that were more often a concern for rural compared with urban providers included scheduling outside work hours, difficulties finding trainings, and travel (all P < .001). Rural and urban providers identified similar preferences with regard to training content and delivery. CONCLUSIONS AND IMPLICATIONS: The findings suggest it would be worthwhile for future research to examine whether rural providers' training participation is affected by uniquely relevant participation barriers.

Using Theory to Evaluate the Implementation and Integration of an Expanded School Breakfast Program in Rural Midwestern High Schools.

OBJECTIVE: Use Normalization Process Theory to evaluate the implementation and integration of the expanded School Breakfast Program (SBP). DESIGN: Interviews were conducted during the 2014-2015 school year. Normalization Process Theory guided the interview questions. SETTING: Rural high schools in Minnesota. PARTICIPANTS: Interviews were conducted with 12 foodservice directors and 11 principals from the Project Break-Fueling Academics and Strengthening Teens intervention. Four of the 12 schools were in their first year of providing the expanded SBP program to their students whereas 8 were in their second year. PHENOMENON OF INTEREST: Normalization Process Theory was used to evaluate the implementation and integration of the expanded SBP into rural Midwestern high schools. ANALYSIS: Three members of the research team used NVivo 10 software to code and analyze the interviews. Emerged themes were reported. RESULTS: Modifying the SBP aligned with values of the study participants (coherence). Support was obtained from staff, students, and community members (cognitive participation). Operational work occurred in each school to establish and integrate the modified SBP (collective action). The SBP expansion was assessed through student participation rates (reflexive monitoring). CONCLUSIONS AND IMPLICATIONS: Normalization Process Theory can be used to evaluate the implementation, embedding, and integration of a modified SBP into a school program. This evaluation can support other schools in modifying and embedding their SBPs into their school environment.

State Agency Support of Weight-Related School Policy Implementation.

BACKGROUND: In this study, we describe state agency strategies to support weight-related policy implementation in schools, and examine the association among state support, obesity prevalence, and strength of state policies governing school nutrition and physical education. METHODS: The 2012 School Health Policies and Practices Study describes prevalence of implementation support state agencies provided to schools/districts. Implementation support items were analyzed by weight-related policy area (eg, advertising, wellness policy) and by type of support (eg, technical assistance). Results were summed to create a total weight-related policy support score. Linear regression was used to examine associations between policy support and state youth obesity prevalence (2011-2012 National Survey for Children's Health), overall and stratified by state policy strength (2012 Classification of Laws Associated with School Students). RESULTS: States provided support most commonly for school meals and wellness policies (89% and 81%, respectively) and least often for after-school PE (26%). Most states (80%) provided technical assistance. The total weight-related policy support score had a significant positive association with state-level youth overweight/obesity prevalence (p = .03). CONCLUSION: State agencies appear to be responding to their youth obesity prevalence with technical support. Schools and state agencies should work in collaboration to provide a healthy school environment for all students.

Change in the implementation of healthy nutrition and physical activity best practices in Minnesota early care settings: A longitudinal cohort study (2010-2016).

The goal of the 'Healthy Start, Healthy State' study was to describe changes in the implementation of healthy nutrition and physical activity (PA) best practices in early child care and education (ECE) settings from 2010 to 2016. A cohort of 215 Minnesota licensed center- and family/home-based providers completed a survey describing 15 nutrition and 8 PA best practices that they "already do" in 2010 and again in 2016 were analyzed in 2016. There was a significant net implementation rate increase for 15 best practices (10 nutrition, 5 PA) in centers and 12 best practices (8 nutrition, 4 PA) in family/home-based programs. The 2010 nutrition and PA scores were negatively associated with mean change in 2016 indicating the decreased potential for improvement among sites with more best practices already implemented in 2010. Adjusted for 2010 nutrition score and other factors, centers implemented, on average, 1.45 more nutrition best practices from 2010 to 2016 than family/home based programs, and CACFP participating programs implemented, on average, 1.7 more nutrition best practices from 2010 to 2016 than non-CACFP participants. Urbanicity, provider education, and provider years of experience were not significantly associated with 2010-2016 change in nutrition score. The mean PA score change had a small but significant increase for each additional year of provider ECE experience after adjusting for the 2010 score. State-level surveillance of implemented best practices in ECE settings is useful. Findings identify opportunities for stakeholders to respond with targeted technical support and training and to consider potential future policy levers.

Refining and implementing the Food Assortment Scoring Tool (FAST) in food pantries.

OBJECTIVE: Hunger relief agencies have a limited capacity to monitor the nutritional quality of their food. Validated measures of food environments, such as the Healthy Eating Index-2010 (HEI-2010), are challenging to use due to their time intensity and requirement for precise nutrient information. A previous study used out-of-sample predictions to demonstrate that an alternative measure correlated well with the HEI-2010. The present study revised the Food Assortment Scoring Tool (FAST) to facilitate implementation and tested the tool's performance in a real-world food pantry setting. DESIGN: We developed a FAST measure with thirteen scored categories and thirty-one sub-categories. FAST scores were generated by sorting and weighing foods in categories, multiplying each category's weight share by a healthfulness parameter and summing the categories (range 0-100). FAST was implemented by recording all food products moved over five days. Researchers collected FAST and HEI-2010 scores for food availability and foods selected by clients, to calculate correlations. SETTING: Five food pantries in greater Minneapolis/St. Paul, Minnesota, USA. SUBJECTS: Food carts of sixty food pantry clients. RESULTS: The thirteen-category FAST correlated well with the HEI-2010 in prediction models (r = 0·68). FAST scores averaged 61·5 for food products moved, 63·8 for availability and 62·5 for client carts. As implemented in the real world, FAST demonstrated good correlation with the HEI-2010 (r = 0·66). CONCLUSIONS: The FAST is a flexible, valid tool to monitor the nutritional quality of food in pantries. Future studies are needed to test its use in monitoring improvements in food pantry nutritional quality over time.

A comparison of the vending environment among three rural subtypes of secondary schools.

The purpose of this study was to further explore the rural school food environment. This study assessed trends in prevalence of vending machines and vending items within and between Minnesota schools located in 3 rural subtypes: town/rural fringe, town/rural distant, and remote rural. Generalized estimating equation models were employed to analyze data from the 2006 through 2012 School Health Profiles Principal's Surveys (Profiles). All 3 rural subtypes had a statistically significant decrease in the prevalence of low nutrient energy dense (LNED) vending items between 2006 and 2012, with the exception of sports drinks. However, different vending practices were observed between rural subtypes, with town/rural fringe schools providing more LNED vending options and experiencing less positive change over time compared to town/rural distant and remote rural schools. Differences in vending machine practices emerge when rural schools are subtyped.

The Mastery Matrix for Integration Praxis: The development of a rubric for integration practice in addressing weight-related public health problems.

In response to the limitations of siloed weight-related intervention approaches, scholars have called for greater integration that is intentional, strategic, and thoughtful between researchers, health care clinicians, community members, and policy makers as a way to more effectively address weight and weight-related (e.g., obesity, diabetes, cardiovascular disease, cancer) public health problems. The Mastery Matrix for Integration Praxis was developed by the Healthy Eating and Activity across the Lifespan (HEAL) team in 2017 to advance the science and praxis of integration across the domains of research, clinical practice, community, and policy to address weight-related public health problems. Integrator functions were identified and developmental stages were created to generate a rubric for measuring mastery of integration. Creating a means to systematically define and evaluate integration praxis and expertise will allow for more individuals and teams to master integration in order to work towards promoting a culture of health.

Increasing Inequality in Physical Activity Among Minnesota Secondary Schools, 2001-2010.

BACKGROUND: Two Healthy People 2020 goals are to increase physical activity (PA) and to reduce disparities in PA. We explored whether PA at the school level changed over time in Minnesota schools and whether differences existed by demographic and socioeconomic factors. METHODS: We examine self-reported PA (n = 276,089 students; N = 276 schools) for 2001-2010 from the Minnesota Student Survey linked to school demographic data from the National Center for Education Statistics and the Rural-Urban Commuting Area Codes. We conducted analyses at the school level using multivariable linear regression with cluster-robust recommendation errors. RESULTS: Overall, students who met PA recommendations increased from 59.8% in 2001 to 66.3% in 2010 (P < .001). Large gains in PA occurred at schools with fewer racial/ethnic minority students (0%-60.1% in 2001 to 67.5% in 2010, P < .001), whereas gains in PA were comparatively small at schools with a high proportion of racial/ethnic minority students in 2001 (30%-59.2% in 2001 to 62.7% in 2010). CONCLUSIONS: We found increasing inequalities in school-level PA by racial/ethnic characteristics of their schools and communities among secondary school students. Future research should monitor patterns of PA over time and explore mechanisms for patterns of inequality.

A Low-Cost, Grab-and-Go Breakfast Intervention for Rural High School Students: Changes in School Breakfast Program Participation Among At-Risk Students in Minnesota.

OBJECTIVE: Evaluate the impact of a grab-and-go component embedded within a larger intervention designed to promote School Breakfast Program (SBP) participation. DESIGN: Secondary data analysis. SETTING: Rural Minnesota high schools. PARTICIPANTS: Eight schools were enrolled in the grab-and-go only intervention component. An at-risk sample of students (n = 364) who reported eating breakfast ≤3 d/wk at baseline was enrolled at these schools. INTERVENTIONS: Grab-and-go style breakfast carts and policies were introduced to allow all students to eat outside the cafeteria. MAIN OUTCOME MEASURES: Administrative records were used to determine percent SBP participation (proportion of non-absent days on which fully reimbursable meals were received) for each student and school-level averages. ANALYSIS: Linear mixed models. RESULTS: School-level increases in SBP participation from baseline to the school year of intervention implementation were observed for schools enrolled in the grab-and-go only component (13.0% to 22.6%). Student-level increases in SBP participation were observed among the at-risk sample (7.6% to 21.9%) and among subgroups defined by free- or reduced-price meal eligibility and ethnic or racial background. Participation in SBP increased among students eligible for free or reduced-price meals from 13.9% to 30.7% and among ineligible students from 4.3% to 17.2%. CONCLUSIONS AND IMPLICATIONS: Increasing access to the SBP and social support for eating breakfast are effective promotion strategies.

Using Obesity Research to Shape Obesity Policy in Minnesota: Stakeholder Insights and Feasibility of Recommendations.

OBJECTIVE: Preventing childhood obesity requires innovative, evidence-based policy approaches. This study examines the use of research evidence by obesity policy stakeholders in Minnesota and develops pilot tools for communicating timely evidence to policymakers. DESIGN, SETTING, AND PARTICIPANTS: From November 2012 to January 2013, semistructured interviews were conducted with 51 Minnesota stakeholders in childhood obesity prevention. Interviewees included 16 state legislators and staff; 16 personnel from the Minnesota Department of Education, Minnesota Department of Health, and Minnesota Department of Transportation; and 19 advocates for and against childhood obesity prevention legislation (response rate = 71%). MAIN OUTCOME MEASURES: Participants were asked their views on 3 themes: (1) Whether and how they used research evidence in their current decision-making processes; (2) barriers to using research evidence for policymaking; and (3) suggestions for improving the evidence translation process. All interviews were audio-recorded and transcribed. A team approach to qualitative analysis was used to summarize themes, compare findings across interviewees' professional roles, and highlight unexpected findings, areas of tension, or illuminating quotes. RESULTS: Stakeholders used research evidence to support policy decisions, educate the public, and overcome value-based arguments. Common challenges included the amount and complexity of research produced and limited relationships between researchers and decision makers. Responding to interviewee recommendations, we developed and assessed 2 pilot tools: a directory of research experts and a series of research webinars on topics related to childhood obesity. Stakeholders found these materials relevant and high-quality but expressed uncertainty about using them in making policy decisions. CONCLUSIONS: Stakeholders believe that research evidence should inform the design of programs and policies for childhood obesity prevention; however, many lack the time and resources to consult research consistently. Future efforts to facilitate evidence-informed policymaking should emphasize approaches to designing and presenting research that better meets the needs of policy and programmatic decision makers.

Altering the School Breakfast Environment Reduces Barriers to School Breakfast Participation Among Diverse Rural Youth.

BACKGROUND: The purpose is to determine if altering school breakfast policies and the school breakfast environment will positively impact adolescent beliefs of the barriers and benefits of eating breakfast. METHODS: There were 904 adolescents from 16 rural high schools, Minnesota, in the BreakFAST Study who reported eating breakfast fewer than 4 times per week at baseline. Schools were randomized to intervention (N = 8 schools) or delayed intervention (N = 8) condition. The intervention lasted 1 school year. Students completed an online survey of beliefs of barriers and benefits to eating breakfast at baseline and follow-up. Summative scales were created. Bivariate and multivariate linear regression, accounting for clustering by school, was performed using SAS. Sex interaction was tested. Models tested the effect of the intervention on change in summative scales from baseline to follow -up. RESULTS: Participants were 54% female, 69.1% white, 36.6% eligible for free or reduced-price meals (FRM) and 13.1% of families received public assistance. The change in reported barriers was significantly different in intervention versus control schools (Net difference = 1.0, p = .03). There was no intervention effect of perceived benefits. CONCLUSIONS: A school-based policy and environmental change intervention can successfully reduce perceived barriers to eating school breakfast.

School Breakfast Program Participation and Rural Adolescents' Purchasing Behaviors in Food Stores and Restaurants.

BACKGROUND: Little is known about adolescents' food purchasing behaviors in rural areas. This study examined whether purchasing food at stores/restaurants around schools was related to adolescents' participation in school breakfast programs and overall diet in rural Minnesota. METHODS: Breakfast-skippers enrolled in a group-randomized intervention in 2014 to 2015 (N = 404 from 8 schools) completed 24-hour dietary recalls and pre/post surveys assessing food establishment purchase frequency. Healthy Eating Index Scores (HEI-2010) were calculated for each student. Student-level school breakfast participation (SBP) was obtained from school food service records. Mixed-effects regression models estimated: (1) whether SBP was associated with store/restaurant use at baseline, (2) whether an increase in SBP was associated with a decrease in store/restaurant use, and (3) whether stores/restaurant use was associated with HEI-2010 scores at baseline. RESULTS: Students with increased SBP were more likely to decrease fast-food restaurant purchases on the way home from school (OR 1.017, 95% CI 1.005, 1.029), but were less likely to decrease purchases at food stores for breakfast (OR 0.979, 95% CI 0.959, 0.999). Food establishment use was associated with lower HEI-2010 dairy component scores (p = .017). CONCLUSIONS: Increasing participation in school breakfast may result in modest changes in purchases at food establishments.

What Can Be Learned from Existing Investigations of Weight-Related Practices and Policies with the Potential to Impact Disparities in US Child-Care Settings? A Narrative Review and Call for Surveillance and Evaluation Efforts.

Child-care settings and the combination of policies and regulations under which they operate may reduce or perpetuate disparities in weight-related health, depending on the environmental supports they provide for healthy eating and activity. The objectives of this review are to summarize research on state and local policies germane to weight-related health equity among young children in the United States and on how federal policies and regulations may provide supports for child-care providers serving families with the most limited resources. In addition, a third objective is to comprehensively review studies of whether there are differences in practices and policies within US child-care facilities according to the location or demographics of providers and children. The review found there is growing evidence addressing disparities in the social and physical child-care environments provided for young children, but scientific gaps are present in the current understanding of how resources should best be allocated and policies designed to promote health equity. Additional research is needed to address limitations of prior studies relating to the measurement of supports for weight-related health; complexities of categorizing socioeconomic position, ethnicity/race, and urban and rural areas; exclusion of legally nonlicensed care settings from most research; and the cross-sectional nature of most study designs. There is a particularly great need for the development of strong surveillance systems to allow for better monitoring and evaluation of state policies that may impact weight-related aspects of child-care environments, implementation at the program level, and needed implementation supports.

Healthy Eating and Activity Across the Lifespan (HEAL): A call to action to integrate research, clinical practice, policy, and community resources to address weight-related health disparities.

Despite intense nationwide efforts to improve healthy eating and physical activity across the lifespan, progress has plateaued. Moreover, health inequities remain. Frameworks that integrate research, clinical practice, policy, and community resources to address weight-related behaviors are needed. Implementation and evaluation of integration efforts also remain a challenge. The purpose of this paper is to: (1) Describe the planning and development process of an integrator entity, HEAL (Healthy Eating and Activity across the Lifespan); (2) present outcomes of the HEAL development process including the HEAL vision, mission, and values statements; (3) define the planned integrator functions of HEAL; and (4) describe the ongoing evaluation of the integration process. HEAL team members used a theoretically-driven, evidence-based, systemic, twelve-month planning process to guide the development of HEAL and to lay the foundation for short- and long-term integration initiatives. Key development activities included a review of the literature and case studies, identifying guiding principles and infrastructure needs, conducting stakeholder/key informant interviews, and continuous capacity building among team members. Outcomes/deliverables of the first year of HEAL included a mission, vision, and values statements; definitions of integration and integrator functions and roles; a set of long-range plans; and an integration evaluation plan. Application of the HEAL integration model is currently underway through community solicited initiatives. Overall, HEAL aims to lead real world integrative work that coalesce across research, clinical practice, and policy with community resources to inspire a culture of health equity aimed at improving healthy eating and physical activity across the lifespan.