Starting Early: Obesity Prevention in the Early Care & Education Setting

State: TX Type: Promising Practice Year: 2021

Harris County Public Health (HCPH) is the health department for Harris County, Texas the third most populous county in the United States. The HCPH jurisdiction includes approximately 2.2 million people within unincorporated areas and 30 municipalities, not including Houston. HCPH is responsible for the provision of comprehensive public health services, focusing on where people live, learn, work, worship, and play.  

Harris County is one of the most ethnically diverse areas in the US, with more than 145 different languages spoken. In 2017, Harris County was comprised of 42% Hispanic, 31% White, 19% Black, and 8% Asian/Other. A quarter of Harris County's population is foreign-born, making it the fifth largest foreign-born population in the US. 

Obesity is one of the nation's greatest public health challenges, affecting about 39.8% of US adults. According to the BRFSS data, the prevalence of adult obesity in Harris County is 32.8%. The 2018 Health of Houston Survey (HHS) found an increase in the obesity rates of teens aged 14-17 from 11% in 2010 to 16% in 2018, and showed that only half of children, 0 to 17 years, did at least 60 minutes of daily physical activity. Obesity in children is associated with many health complications, such as, diabetes, hypertension, and sleep disorders, and can affect the social and emotional development of children. Childhood obesity is an issue with multiple causes; therefore, the solutions must be addressed in multiple ways and by multiple sectors including early care and education (ECE).   

HCPH focuses on preventing childhood obesity through programs like WIC, Healthy Living Matters (HLM), and the Early Childhood Programs Unit (new unit that directly resulted from the HLM's ECE sector work). Created in 2011, HLM is a multi-sector collaborative aimed at curbing childhood obesity through policy, systems, and environmental change. Since the beginning, HLM has engaged the ECE sector and in 2016, established an ECE Action Team (the Action Team). This group, representing ~25 organizations, helped develop an action plan with strategies to improve nutrition and physical activity in the ECE sector, modeled after the CDC's Spectrum of Opportunities Framework for Obesity Prevention in ECE. The goals and objectives of the proposed practice include the following, all of which have been met: 

Goal 1: Increase obesity prevention training opportunities for ECE professionals  

-Develop a Call to Action encouraging conference organizers to offer more obesity prevention sessions 

-Host one yearly training opportunity focused on obesity prevention  

-Increase the pool of local Child Care Health Consultants  

Goal 2: Increase investments and opportunities for obesity prevention in ECE settings 

-Establish a partnership with the state to pilot ECE obesity prevention programs locally  

-Identify funding for obesity prevention within ECE sector  

-Support the development and implementation of a healthy child care recognition program  

Goal 3: Create a dedicated team to support the health needs of the ECE sector in Harris County 

-Obtain leadership support for a team dedicated to the ECE sector 

-Work with at least 20 local ECE programs per year 

Goal 4: Improve ECE policies related to nutrition and physical activity 

-Participate in state-level coalitions dedicated to obesity prevention in ECE 

-Support advocacy efforts to improve nutrition and physical activity in ECE   

Because of the hard work and dedication of the Action Team and staff, HCPH has a robust list of accomplishments that include: 

-Hosting 49 Action Team meetings with ~30 participants  

-Developing an Obesity Prevention Call to Action in partnership sent out yearly to trainers and conference organizers 

-Sending out 45 newsletter issues with obesity prevention resources to 1,290 ECE professionals 

-Presenting sessions at 25 ECE conferences, providing training to ~1000 individuals 

-Bringing more Child Care Health Consultant trainings to Harris County, resulting in ~30 new CCHCs 

-Partnering with the state health department to bring an ECE project aimed at preventing obesity by improving nature play to Harris County  

-Securing $175,000 from local grantor to implement outdoor enhancements at 7 ECE facilities 

-Partnering on the development of a state-wide healthy child care recognition program and piloting it in Harris County with 53 facilities 

-Helping to inform child care minimum standards which have been revised to include improvements to nutrition and physical activity standards 

-Developing a team of Early Childhood Health & Wellness Specialists  

The biggest strength of our work is the commitment of our Action Team. They inform our decisions and help us reach the ECE programs in Harris County. The support of county leadership has also played a critical role in the success of this practice. Harris County Judge Lina Hidalgo listed ECE as one of her priorities, which prompted HCPH to propose the expansion of our efforts and request funds to establish a dedicated EC Programs Unit.  

Early childhood is a critical time for developing healthy habits and we know that this work will prove to have tremendous impact in preventing childhood obesity. Focusing on ECE programs can ensure that children arrive at Kindergarten ready to learn, play, and succeed. Additionally, the CDC lists ECE programs as a High Impact in Five Years (HI-5) initiative due to being associated with reduction in obesity and BMI, child abuse and neglect, youth violence and emergency department visits. 

In order to improve health disparities, an equity lense is used when developing and implementing our this practice. Examples include:

-Including the voice of the sector in the decision-making process 

-Producing materials in English and Spanish 

-Prioritizing communities based on health disparities and social vulnerabilities 

-Recruiting ECE facilities that serve children/families who are at-risk  

-Identifying and sharing resources that are free or low-cost and providing our services at no-cost 

-Hiring multi-lingual staff, representative of the communities they support 


To learn more about HCPH, visit To learn more about HLM, visit 

In Harris County, 1 in 3 children are considered overweight or obese. Early-life experiences, such as lack of breast feeding, too-little sleep, and too-much television increase the risk of childhood obesity, as well as obesity later in life. According to the CDC, the early care and education (ECE) setting is one of the best places to implement obesity prevention efforts and promote standards that address nutrition and physical activity. Young children are developing taste preferences, learning to walk and play, and copying the healthy and unhealthy behaviors of their caregivers. With up to 75% of children spending time in ECE settings for an average of 35 hours per week, focusing on the ECE sector has tremendous potential to prevent obesity and ensure that all children arrive at Kindergarten ready to learn, play, succeed, and build a foundation for healthy living.  

Healthy Living Matters (HLM), a childhood obesity prevention collaborative led by Harris County Public Health (HCPH), identified ECE as one of its priority sectors early on and in 2016, the HLM ECE Action Team was established, utilizing the CDC's Spectrum of Opportunities Framework for Obesity Prevention in ECE as its guide. The HLM mission began with planning objectives based on two public health planning models, Mobilizing for Action through Planning and Partnerships (MAPP) and Protocol for Assessing Community Excellence in Environmental Health (PACE-EH). 

 The HLM Planning Objectives were to: 

Conduct various assessments specific to Harris County, including but not limited to evaluating barriers to active living and healthy eating 

Promote and provide learning opportunities related to childhood obesity and policy strategy  

Monitor ongoing federal, state and local legislation to track policy trends and developments  

Identify local issues and prioritize policies that have an impact on childhood obesity  

Develop a Community Action Plan to serve as a road map for policy implementation 

To prepare our Policy Scan, HLM assessed and researched policies and practices across sectors impacting childhood obesity, including ECE, and reviewed issues related to health, nutrition, physical activity, and obesity in child age groups. Issues were aligned, when possible, with existing or proposed state, county and city laws and ordinances. Community input was obtained through key informant interviews and community surveys. Further, stakeholders invited HLM to meetings where childhood obesity was discussed and where HLM could obtain feedback on priorities. Examples include forums hosted by early childhood advocacy groups, such as Early Matters, Texans Care for Children and Children at Risk. Here HLM was able to present on the topic of childhood obesity and listen to ECE sector representatives about their concerns and recommendations. The policy suggestions from community stakeholders were then added to the policy scan. 

Ultimately, 16 policies were prioritized by the stakeholders, community forums, and HLM. Of these policies, there are 4 that tie directly to the ECE sector: 

1. Advocate for low-fat, low-calorie drinks in schools and ECE facilities. 

2. Develop of guidelines to educate and incent administrators, teachers, ECE providers, and other staff to eat healthy and be physically active as role models for children. 

3.  Establish state, city, and/or county healthy schools and healthy ECE recognition programs. 

4. Promote outdoor classrooms and incorporate active learning into core curriculum to increase physical activity in schools and ECE facilities.  

HLM decided to learn more about the challenges faced by ECE professionals when providing healthy foods and physical activity opportunities to children in their care, and decided to send out a county-wide survey. Four hundred ninety-seven respondents, representing various positions within ECE responded to the survey. Key findings revealed that:  

  • Child care home respondents reported offering more fruits and vegetables to children in their care than respondents from child care centers 

  • Child care center respondents reported offering sweets/fatty/salty foods at a higher rate than they are offering fruits and vegetables 

  • The majority of child care providers reported making water readily available and refraining from offering sugary drinks to children 

  • Thirty-nine percent of child care providers reported offering 60 minutes of free play and 28.6% offered 60 minutes of structured play at least once per day 

  • Physical activity and nutrition training opportunities are rarely offered to teachers or staff 

  • Funds are a barrier to providing adequate equipment for physical activity 

Additionally, HLM conducted focus groups with thirty child care home providers to learn more about their views on the importance of nutrition and physical activity, their perceived roles, and the training needed to provide a healthier environment for children in their care. The findings from the focus groups suggests that providers need assistance with implementing healthier eating and physical activity opportunities in their facilities.  

When HCPH (though HLM) began to actively engage this sector and develop an action plan to help advance our policy priorities, the CDC's Spectrum of Opportunities was used as the guide. This framework helped organized the goals, objectives, and strategies adopted by the HLM – ECE Action Team. This framework also provided HCPH with common language with which to approach the Texas Department of State Health Services (DSHS) for partnership opportunities, which landed HCPH a spot on the Texas Early Care Obesity Prevention Committee. Opportunities like these are allowing HCPH to influence state-level decisions that would not be possible at a local level.  

Prior to this work there had been no coordinated obesity prevention efforts dedicated to the ECE sector in Harris County. This practice, now going on its 5th year, has gained tremendous support from both local and state-level partners. HCPH has been invited to present at national conferences to share its work in this area and guide others who are interested in working with this sector. HCPH has also been invited to sit on various local and state-level ECE committees to ensure that health is part of the conversation and definition of ‘quality early care and education'. 

With childhood obesity being a major public health concern, efforts should be made to ensure children have every opportunity to eat healthy food and be physically active. Starting early is imperative to developing healthy habits, which means the ECE sector needs to be a key partner in these efforts.  

There are 2,361 ECE facilities in Harris County serving children ages birth to 5. Most facilities are full-time and caring for children between the hours of 6 AM – 6 PM, ranging in capacity from 4 children to 999. The regulated ECE sector is required to adhere to minimum standards set forth by the State, which have historically prioritized safety over health. Though standards related to food and physical activity are included, there is much room for improvement. ECE facilities that participate in programs like the USDA's Child and Adult Care Food Program (CACFP) are required to meet best practices in child nutrition and physical activity, but only 900 facilities (38%) in Harris County participate in the CACPF. Texas has a voluntary Quality Rating & Improvement System (QRIS) called Texas Rising Star (TRS), which also includes standards for nutrition and physical activity that are higher than the minimum standards. However, in Harris County only 430 facilities (18%) participate in TRS. When not participating in these types of programs, it is up to the individual ECE facility to make changes that provide children with increased opportunities for health; changes which oftentimes come with high costs, push back from staff or parents, and little support from funders or policymakers.   

According to 2019 Census estimates, there are 4,713,325 people living in Harris County (including the City of Houston) and of those, 347,946 (7.4%) are children under the age of five. Harris County is one of the most racially and ethnically diverse places in the United States due to the unique combination of location, opportunity, and economy. The county population's racial and ethnic breakdown is as follows: 43.7% Hispanic; 28.5% White, not Hispanic; 18.5% Black or African American; and 7% Asian. The median household income in Harris County is $61,705, lower than the US income of $68,703. Household income in Harris County exhibits striking variations across zip codes and demographics. In Harris County, 27.4% of children live in households earning below the poverty level and 26.4% of children live in households receiving SSI, TANF, or SNAP benefits. A closer examination reflects the rate of children living below the poverty line is highest for Blacks, Hispanics and other races at 31% and lowest for Whites at 7.5%.  

While the main cause of childhood obesity is an imbalance of the number of calories consumed and the amount of physical activity, there are many environmental factors that influence a child's opportunities to maintain a healthy weight. Childhood overweight/obesity rates in Harris County are higher in communities with higher rates of minorities and people living in poverty. Often, these communities have less access to healthy food and fewer opportunities to engage in physical activity outdoors.  According to the State of Obesity report, 14.6% of Texas children ages 2 to 4 years participating in the WIC program have obesity, 59% of Texas children are eligible for the free/reduced-price lunch program, and 15% of Texas children are considered food insecure. In Harris County, 69% of children are eligible for the free or reduced-price lunch program and 21% are considered food insecure.   

There is less local early childhood data related to physical activity, however, according to a study by the Houston Parks and Recreation Department, 22% of Houston-area children report not participating in physical activity for at least 1 hour per week. Moreover, more than half of Houston area children under age 19 do not use parks. Though Harris County has an abundance of parks and green space, it is not evenly distributed based on the population. According to the Health of Houston Survey, 21% of Harris County residents report having no park within walking distance. Studies show that park use and physical activity are correlated with the proximity of a park to their residence; especially evident among young children ages 4-7.   

Nutrition and physical activity interventions in preschool & child care is a scientifically supported practice listed on the County Health Rankings and Roadmaps, meaning that it has been tested in many robust studies with consistently positive results ( There is strong evidence that nutrition interventions in ECE settings improve children's diets and physical activity interventions increase their activity levels. In some circumstances, they have also been shown to reduce children's weight, body fat, or body mass index (BMI). This evidence what supports the work being done by HCPH to increase healthy eating and physical activity in the ECE setting to prevent childhood obesity.  

The work began in 2016 through the establishment of the HLM ECE Action Team and continues to this day, growing in scope and reach. The innovative approaches taken include the establishment of creative partnerships, the willingness to pilot new programs, and the ability to seek out non-traditional funders (e.g. healthcare sector). At this time, HCPH reaches out to 1,290 ECE professionals in Harris County via the monthly resource newsletter, has trained over 1,000 individuals at ECE conferences and workshops, has committed 53 facilities to pilot a healthy child care recognition program, and has made outdoor play and learning enhancements worth $150,000 at 6 ECE facilities (with more to come).  

Harris County Public Health (HCPH) is the backbone organization for the Healthy Living Matters (HLM) collaborative and the HLM ECE Action Team (the Action Team). The Action Team consists of ECE professionals and representatives from organizations that implement policies or provide services to the ECE sector. Since its inception, the team, made up of ~25 organizations, has met on a monthly basis to strategize ways to support this sector. The organizations involved in the Action Team are: 

-Harris County Public Health: Local health authority for Harris County, TX and backbone organization for the HLM collaborative. Teams represented are HLM, Early Childhood Programs  Unit, and WIC.  

-Harris County Public Library: Represents twenty-six branch locations throughout Harris County and is the key partner for parent engagement.  

-Children's Learning Institute: Institute out of The University of Texas Health Science Center at Houston that applies cutting-edge research in child development and education to improve learning in children.  

-Collaborative for Children: Nonprofit that strengthens early education throughout Greater Houston through professional development and quality improvement initiatives.  

-Harris County Department of Education: Provides Head Start/Early Head Start programming and professional development to the ECE sector in Harris County.  

-Gulf Coast Community Service Association: Provides Head Start/Early Head Start programming and other social services in the Harris County area.  

-BakerRipley: Provides Head Start/Early Head Start programming and other social services in the Harris County area.  

-Texas Children in Nature: Network of local partner organizations and individuals who are working together to connect children and families with nature in Harris County.  

-Common Threads: Nonprofit dedicated to combating childhood obesity by educating children to understand and appreciate food.  

-SMART Family Literacy: Nonprofit dedicated to education for young children and their families through innovative hands-on activities in health, science, math, art, reading, and technology.  

-Texas Department of Family & Protective Services – Child Care Regulation: State agency responsible for regulating all child-care operations to protect the health, safety, and well-being of children in care.  

-Texas Department of State Health Services: State agency responsible for core public health functions and our partner on OLE! Texas and Texas Healthy Building Blocks (THBB).  

-Agape Christian Preschool: Local child care facility participating in OLE! Texas and THBB.  

-YMCA of Greater Houston: Local community-based organization offering child care and other health and wellness services in the Harris County area. 

-Houston Food Bank: Local food bank for the Harris County area, providing nutrition assistance, nutrition education, school-based programs, and SNAP application assistance.   

-Creative Trainers & Consultants: Organization dedicated to providing quality training and consultation to early childhood professionals in the area.  

-Harris County Precincts: Precinct partners help identify child health and wellness issues at a Precinct level and are key partners for community engagement.  

-First3Years: Nonprofit dedicated to educating, advocating, and collaborating to advance the healthy development of infants and toddlers. 

-University of Houston-Clear Lake: Local academic institution with an early childhood education degree program. 

-San Jacinto College: Local academic institution with a child development degree program and a child development lab school participating in the OLE! Texas project. 

-Houston Community College: Local academic institution with a child development degree program and a child development lab school. 

-Gulf Coast Chapter of the Texas Association for the Education of Young Children: Professional association that seeks to improve teaching and learning by building the early childhood profession and promoting awareness of issues affecting children and their families.  

-Children at Risk: Research and advocacy organization working to improve the health, safety and economic indicators impacting children, and educating public policy makers about their importance in improving the lives of children.  

-Education Service Center – Region 4: Region 4 Child Nutrition Services provides technical assistance and training designed to assist CACFP contracting entities. 

-Blossom Heights Child Development Center: Local ECE program dedicated to nature play and learning. They provide us with opportunities to inspire other facilities by granting tours and speaking of the benefits of nature preschools. 

-Healthy Tweaks: Local non-profit dedicated to connecting children to nature. 

-TBG Partners: Local landscape architecture firm trained in the OLE! Texas project and committed to providing OLE-related technical assistance. 

-Trainers & CCHCs:  Individuals not representing organization on the Action Team are independent ECE trainers or Child Care Health Consultants.  

All the work of the Action Team is coordinated by the HCPH Early Childhood Programs Manager and is executed by the Early Childhood Programs unit, made up of 3 Early Childhood Health & Wellness Specialists. All staff are located within the Nutrition & Chronic Disease Prevention Division at HCPH. The goals and objectives established by the ECE action plan are the following: 

Goal 1: Increase obesity prevention training opportunities for ECE professionals.  

Develop a Call to Action encouraging conference organizers to offer more obesity prevention sessions. In 2016, HCPH partnered with the Texas Early Childhood Professional Development System (TECPDS) to develop the Call to Action. This was sent out to all Texas registered trainers and conference organizers. On a yearly basis the Call to Action is sent out via the TECPDS and HLM newsletters. Since then, there has been an increase in the number of obesity prevention sessions being offered at ECE conferences (from 37 in 2018 to 65 in 2019). Since then, the conference organizers have kept HCPH informed of call for proposal opportunities and encouraged HCPH to share within public health networks, which has helped increase the number of these sessions. 

Host one yearly training opportunity focused on obesity prevention. HCPH staff and Action Team members submit proposals to present at any ECE conference taking place in Harris County and the larger statewide conferences. Since 2016, participation at these conferences has increased year after year (6 conferences in 2016, 7 in 2017, 8 in 2018, and 9 in 2019). In addition, the Gulf Coast Chapter of the Texas Association for the Education of Young Children has committed to making their yearly conference completely health-focused (Healthy Beginnings Conference) and HCPH has partnered to co-host this conference. Since 2018, HCPH also began sponsoring a yearly Nature Explore workshop for up to 50 ECE professionals. 

Increase the pool of local Child Care Health Consultants (CCHCs). HCPH partnered with the Texas Association for the Education of Young Children to host yearly CCHC workshop in Harris County. The first year there were 30 individuals in attendance and HCPH provided scholarships for 10 of those – 5 for Action Team members and 5 for HCPH employees. In addition, the state coordinators have agreed to continue to host a yearly workshop in Harris County in partnership with HCPH, hosting another one in 2019 and a virtual workshop in 2020. HCPH promotes these opportunities through the HLM newsletter and the Action Team's networks in order to ensure participation and increase the number of CCHCs in Harris County.   

Goal 2: Increase investments and opportunities for obesity prevention in ECE settings. 

Establish a partnership with the state to pilot ECE obesity prevention programs locally. In 2017, the Action Team was approached by the Texas Department of State Health Services to serve as the local coordinator for the OLE! Texas pilot project. Outdoor Learning Environment (OLE!) Texas is a statewide initiative that promotes healthful, nature-based outdoor spaces at ECE programs. As a result of this partnership, HCPH has recruited 7 ECE sites willing to be a part of the pilot and has engaged various nature-based partners to support these efforts. Since 2017, HCPH has also been a member of the Texas Early Care Obesity Prevention Committee. This committee decided to create a healthy child care recognition program for the state of Texas (Texas Healthy Building Blocks) and in 2018, obtained funding to implement it. HCPH became a partner on this project and has been supporting the pilot in Harris County. HCPH has recruited 53 ECE facilities to take part in the pilot and the HCPH team of EC Health & Wellness Specialists have been trained to provide technical assistance using the Go NapSacc tool. To meet these objectives HCPH was intentional in attending state-level meetings where obesity prevention in ECE was being discussed. These meetings helped establish the connections with the Obesity Prevention Program staff at the Texas Department of State Health Services.   

Identify funding for obesity prevention within ECE sector. HCPH has made sure to connect with partners who were investing in local communities and make the case for  investments in ECE. In 2017, HCPH applied for funding from MD Anderson Cancer Center (MDACC) to implement OLE! Texas with 3 ECE facilities in Pasadena, TX. In 2018, re-applied for 4 additional sites in Baytown, TX, with plans for expansion into a third community in 2021. To date HCPH has received $175,000 from MDACC to invest in ECE programs.     

Goal 3: Create a dedicated team to support the health needs of ECE sector in Harris County. 

Obtain leadership support for a team dedicated to supporting the ECE sector. In early 2019, HCPH submitted the yearly budget request to the county's Commissioners Court, receiving approval for funds with which to develop an Early Childhood Programs Unit made up of 4 EC Health & Wellness Specialists. This unit is dedicated to working directly with ECE facilities and implementing the action plan strategies. Due to agency priorities shifting as a result of COVID-19, the budget was reduced and only 3 specialists have been hired. Plans are to complete the team in 2021. 

Work with at least 20 local ECE programs per year. With HCPH supporting the State's healthy child care recognition program, each EC Health & Wellness Specialists has been trained as a TA provider and assigned 5 ECE facilities a piece. In addition, they have been identifying sites interested in being a part of the OLE! Texas project and provide them with OLE! Texas starter kits as well as other resources.     

Goal 4: Improve ECE policies related to nutrition and physical activity. 

Participate in state-level coalitions dedicated to obesity prevention in ECE. As a result of this work, HCPH was asked to sit on the Texas Department of State Health Service's Early Care Obesity Prevention Committee and the OLE! Texas State Leadership Team. These coalitions have been key to proposing state-level policies and programs related to obesity prevention in the ECE setting.    

Support advocacy efforts to improve nutrition and physical activity in ECE. HLM is a member of the Partnership for a Healthy Texas (PFAHT), an advocacy organization working to prevent childhood obesity at the state level. The PFAHT legislative agenda for 2019 included to update minimum standards for child care facilities for nutrition, active play, and screen time”. The successful advocacy efforts of PFAHT resulted in the passing of a bill that has lead to revisions to the minimum standards that include adhering to CACFP standards for nutrition and Caring for Our Children standards for physical activity. These changes went into effect September 2020.   

Some additional strategies of the HCPH EC Programs Unit include: 

-Promoting and encouraging participation in the Child and Adult Care Food Program 

-Promoting gardening and partnering to provided gardening education and resources 

-Promoting and encouraging outdoor learning environments and nature play & learning  

-Identifying and connecting ECE professionals and families to nutrition education programs, WIC and Summer Meals programs 

-Supporting neighborhood improvements that can facilitate active transportation and safe play 

-Identifying and connecting ECE professionals and families with parks, trails, and other shared use facilities for physical activity   


The following provides a summary of the costs for each practice component on a yearly basis: 

-Staffing: $370,000 

-OLE! Texas Implementation: $175,000 (from MDACC) and $15,000 (from Texas DSHS) 

-Monthly HLM ECE Action Team Meetings 

    -Refreshments  - $250 

    -Copies - $150 

-Travel for participation at state meetings and conferences -  $2,500 

-Communication: Constant Contact subscription for newsletter - $1,200 

-Evaluation: Survey Monkey account for post-training evaluations - $1,200 

-Capacity Building Support for Action Team members & ECE Professionals - $5,000 

During the development of the goals and objectives, and as they are revised each year, the Action Team is asked to answer how the activities support policy, system and environmental change and how the activities engage and serve the interests of the priority populations. The first question is answered by using the HLM policy priories as a guide and those activities that do not support these policies, are not considered. The second question is answered through the help of our Action Team members who represent the ECE profession. HCPH is fortunate to have 6 ECE Center Directors on the Action Team who represent different areas of Harris County. The Action Team is also asked to review the action plan strategies on a yearly basis and prioritize them based on the current needs of the ECE sector.  

The EC programs work is documented on a monthly basis in a report of Key Performance Indicators (KPIs) sent to the HCPH data warehouse team. This report serves as the primary data source for evaluating progress and capturing data, which is shared with County leadership.  KPIs include: 

-Establish a team of 4 EC Health & Wellness Specialists 

-Participate in at least in 3 EC Coalitions 

-Provide training at a minimum of 5 ECE conferences 

-Host at least 1 ECE workshop 

-Work directly with 20 ECE facilities 

-Identify at least 1 funding opportunity for ECE facilities   

Additional reports are developed and sent to funders to inform on the progress of initiatives like OLE! Texas and Texas Healthy Building Blocks. Key performance indicators for these include: 

OLE! Texas: 

-Implement at least 5 best practice indicators at each participating OLE! Texas site 

-Expand OLE! Texas to one new facility per year 

-Expand the number of landscape architects trained certified in OLE! Texas 

Texas Healthy Building Blocks: 

-Recruit at least 15 facilities to participate in the pilot  

-Conduct Go NapSacc assessments with each facility  

-Provide TA consultation with each facility to help them obtain a recognition level 


The data used for evaluation purposes is primary data collected by the HCPH staff on a monthly and/or quarterly basis. The Health of Houston Survey data, produced by The University of Texas School of Public Health is use to assess childhood obesity outcomes for Harris County. This survey has been conducted twice (2010 and 2018), with plans to continue. The data captures childhood obesity information and shows that the county average rose from 11% in 2010 to 16% in 2018. This data source, as well as WIC obesity data will be used to assess childhood obesity outcomes over time.  

As it relates to outputs and process evaluation, all of the goals and objectives of the practice are met every year and are increased each year by the Action Team as a tactic for continual improvement. Examples of these objectives include: 

Goal 1: Increase obesity prevention training opportunities for ECE professionals.

Host one yearly training opportunity focused on obesity prevention. HCPH has exceeded this measure by hosting at least five opportunities, to include conference sessions, the Healthy Beginnings Conference and the Nature Explore workshops. This data is captured in an internal report that also collects number of participants and percentage of attendees who report knowledge gain after each event. The average number of participants is 30 and 100% of attendees have reported knowledge gain after each session. This data is collected via a brief survey conducted after each training opportunity.  

There are 5 well-attended local ECE conferences (Gulf Coast Chapter of the Association for the Education of Young Children Conference, Houston Chapter of the AEYC Conference, Harris County AgriLife Extension Conference, R.T. Garcia Winter Conference, and Weekday Ministries Conference) and  6 statewide conferences (Texas Association for the Education of Young Children, Texas Licensed Child Care Association, Texas Professional Home Child Care Association, Texas Head Start Association, Texas School Ready Summer Institute, and Texas Early Learning Summit). The goal each year is to try to increase the number of obesity prevention-related sessions at each of these conferences. In 2018 HCPH started keeping track of the number of sessions related to healthy eating or physical activity, the number of conferences where HCPH presented on this topic, and the number of attendees in our session. Each year the numbers consistently increase with HCPH presenting at 6 conferences in 2016, 7 in 2017, 8 in 2018, and 9 in 2019.  

HCPH will also be providing monthly virtual training opportunities for ECE professionals starting in January 2021. Evaluation for these sessions will consist of tracking number of participants and post-assessment data. This information will be used to help improve future sessions.  

Goal 2: Increase investments and opportunities for obesity prevention in ECE settings.

Identify funding for obesity prevention within ECE sector. The intent behind this objective was to identify, apply for, and secure funding from at least one funding source per year. HCPH has been extremely successful at meeting this objective with funding secured from various sources to support the action plan strategies. In 2017, HCPH applied for and received funding from the Texas Department of State Health Services in the amount of $15,000 to engage stakeholders and provide training to local landscape architects to expand the OLE! Texas into Harris County. This award has been provided annually and is set to continue until 2022. That same year HCPH received $75,000 in funding from MD Anderson Cancer Center (MDACC) to support the implementation of OLE! Texas best practices at 3 ECE facilities in the community of Pasadena, TX. In 2018, HCPH received another award of $75,000 from MDACC to support another 3 facilities in Baytown, TX.  

Each participating site was required to complete a Go NapSacc assessment prior to any changes being made and then again once a year until the end of the grant. This assessment collects data on the physical activity and outdoor play practices and policies at each site. HCPH has seen improvements at all participating sites in the number of physical activity practices, policies, enhancements, and confidence and knowledge of the staff. Data on these initiatives is reported to each funder on a quarterly basis. Qualitative data is collected on a monthly basis as HCPH works with each facility to assess their satisfaction with the project and obtain anecdotal data about how the children enjoy the changes. All sites have reported positive experiences. 

In 2020, MDACC invited HCPH to sit on the steering community for a third community they are supporting with investments and an application has been submitted to continue to expand OLE! Texas to 4 new sites in the Acres Homes community in Houston. In 2020, HCPH applied for a Robert Wood Johnson Foundation grant to conduct research on early childhood nutrition programs, but was not selected for this award. HCPH also applied to a grant through the Garden Club of Greater Houston for $10,000 to support garden beds and gardening education at ECE facilities and a grant through No Kid Hungry for $25,000 to address food insecurity in early childhood. Both organizations will send out notifications of awards in early 2021.   


Goal 3: Create a dedicated team to support the health needs of ECE sector in Harris County. 

Work with at least 20 local ECE programs per year. The HCPH Early Childhood Health & Wellness Specialists have been tasked with identifying all the EC facilities in Harris County per Precinct, prioritizing the ones in communities with health disparities and social vulnerabilities. Once this list was finalized, the facilities were contacted and provided with information about the services provided by the team and the programs currently being offered, such as OLE! Texas and Texas Healthy Building Blocks. The team was identified at least 20 facilities to work with in the first year (5 per Precinct), which was easily met and exceeded. Each team member works with 5 facilities for the Texas Healthy Building Blocks project, 2 on the OLE! Texas project, and sends out resources and opportunities on a monthly basis to over 1,250 facilities via the monthly newsletter. This newsletter is another indicator of success as it has grown in reach by ~300 recipients a year since first sent out in 2016.    

Goal 4: Improve ECE policies related to nutrition and physical activity.

Support advocacy efforts to improve nutrition and physical activity in ECE.  This objective was deemed necessary because statewide policy is needed for wide-scale change to happen in ECE settings. Participation in statewide advocacy groups has resulted in revisions to the minimum standards that included adhering to CACFP standards for nutrition and Caring for Our Children standards for physical activity. These changes went into effect September 2020. This outcome is considered a huge success for obesity prevention and HCPH will be closely monitoring the impact it will have on children entering Kindergarten at a healthy weight.   

As mentioned in the overview, the hard work and dedication of the Action Team and HCPH staff have lead to a robust list of accomplishments related to this practice. Major accomplishments include: 

-Hosting 49 Action Team meetings with ~30 participants  

-Developing an Obesity Prevention Call to Action in partnership with the Texas EC Professional Development System and send out yearly to conference organizers 

-Sending out 45 newsletter issues with obesity prevention resources to 1,290 ECE professionals 

-Presenting sessions at 25 ECE conferences, providing training to ~1000 individuals 

-Partnering with the Texas Association for the Education of Young Children to bring more Child Care Health Consultant trainings to Harris County, resulting in ~30 new CCHCs 

-Partnering with the state health department to bring an ECE project aimed at preventing obesity by improving nature play to Harris County and secured $175,000 from local grantor to implement outdoor enhancements at 7 ECE facilities 

-Partnering on the development of a state-wide healthy ECE recognition program and piloting it in Harris County with 53 facilities 

-Helping inform child care minimum standards and in 2018 they were revised to include improvements to nutrition and physical activity standards 

-Developing a team of Early Childhood Health & Wellness Specialists 

With the establishment of the EC Programs Unit, made up of a team of EC Health & Wellness Specialists, HCPH is in a great position to sustain this practice. Both the agency and county leadership have prioritized supporting the ECE sector and value the work that has been done to date. HCPH is committed to preventing childhood obesity through county-wide  policy, systems, and environmental change across multiple sectors, including ECE.  

Critical actions to sustain this practice include:  

1.Continuing to intentionally engage Action Team members by seeking their guidance, providing them with yearly capacity building opportunities, and bringing in new members for additional perspectives 

2.Build off of leadership support of ECE efforts to expand the budget for the EC Programs Unit on a yearly basis. 

3.Continuing engagement with community members by way of regular participation in community forums, health fairs, and meetings where community members are active participants 

4.Continuing presentations at local and state conferences where information about childhood obesity and the ECE strategies can be presented to large groups of stakeholders 

5.Identifying and participating in additional coalitions specific to the sectors we wish to engage 

6.Identifying additional funding sources with which to expand this practice    

The structure of the Action Team has proven successful and will continue to provide strategic support and decision-making for this practice. In addition, several of the individuals on the Action Team are in leadership roles within their organizations and have implemented the strategies of this practice within their own organizations. For example, the YMCA of Greater Houston committed their ECE facilities to be a part of OLE! Texas and Texas Healthy Building Blocks when HCPH was recruiting participants.  Another example is the Harris County Public Library, whose representative applied for and received funding with which to implement OLE! Texas-like enhancements, giving children the opportunity to experience nature play and learning when visiting this particular library branch.  

In addition to the work of the Action Team, HCPH has dedicated significant time and effort engaging the ECE sector around other areas of health and development. Examples include the work HCPH has been doing since 2016 to promote The Raising of America documentary. HCPH hosted various screenings where the health considerations of public policy around young children and their families are discussed and policy recommendations were presented. HCPH also sits on various early childhood/child wellbeing coalitions, such as the Harris County ACE Coalition, Houston Infant Toddler Coalition, Gulf Coast Community Service Advisory Committee, San Jacinto College Child Development Advisory Committee, and the Harris County Child Fatality Review Team. These networks will also play a key role in developing new partnerships and sustaining our efforts to support the ECE sector. 

HCPH attributes the overall success of this practice to the participatory nature of its planning and early implementation activities, the continued engagement of Action Team members, and strategic approach to partnerships. This practice has fostered collaborative ownership of the issue of childhood obesity and a desire to tackle it in impactful ways across stakeholders and ECE professionals alike, regardless of whether or not HCPH is directly involved.  

Strategic partner development is key in seeing this practice being sustained, as Harris County is being sought as the implementation community for new obesity prevention efforts that are being rolled out by the state. The partnership with organizations like the Texas Department of State Health Services and MD Anderson Cancer Center are good examples of strategic collaboration that has resulted in continued investments and expansion of this work into multiple communities within Harris County. These examples demonstrate that HCPH is considered a trusted partner, dedicated to the ECE sector and the health of young children. 

In 2021, HCPH plans to engage additional funders to continue to expand this practice. This includes local and national philanthropic organizations. Additionally, HCPH will continue to work with the Partnership for a Healthy Texas to identify other opportunities for state-level policy change that can positively impact the ECE sector. This work will inform the HCPH advocacy efforts, to include action alerts and advocacy training for ECE professionals.  

The EC Programs Unit staff will continually assess the needs of the field to ensure that the practice is relevant and meets the needs of the EC sector in Harris County. Ongoing investments will be made to build the capacity of the team members so that they are equipped with knowledge of best practices and resources to support obesity prevention in ECE settings.