NCDPH dedicates resources to build the capacity of local health departments and local partnerships to address various health issues. Specific to healthful eating and physical activity, the NCDPH Physical Activity and Nutrition (PAN) Branch uses federal Preventive Health and Health Services Block Grant funds for the Statewide Health Promotion Program. This program supports policy and environmental change in 98 of North Carolina's 100 counties by building local capacity through funding, training, and technical assistance. In addition, local health departments, in collaboration with their partners, compete for grants of up to $20,000 annually to encourage physical activity and healthful eating in their communities by changing policies and environments.

The PAN Branch also uses CDC grant funding to cultivate and sustain state-level partnerships. Strong communication among state-level partners creates a more supportive statewide context for community-based initiatives. The most notable partnership is the Eat Smart, Move More North Carolina (ESMM-NC) leadership team, a multidisciplinary group of more than 60 statewide partner organizations. The PAN Branch provides staff support to the ESMM-NC leadership team, which guides the ESMM-NC movement (9) to increase opportunities for healthful eating and physical activity wherever people live, learn, earn, play, and pray.

In 2008, the PAN Branch, with support from North Carolina's state health director and chronic disease director, worked with ESMM-NC partners to advocate for state-supported, community-based projects to address childhood obesity. Partners used data such as the correlation between physical inactivity and academic performance and obesity-related health care costs to make a case for state funding to explore best practices in preventing childhood obesity. These partners created the COPDP plan based on the socioecological model, a multilevel, multisetting approach similar to the Shape Up Somerville project.

In state fiscal year 2008-2009, the North Carolina General Assembly awarded $1.9 million to NCDPH for COPDP. The funding was originally in the budget as recurring but was ultimately designated as nonrecurring. The North Carolina General Assembly directed NCDPH to allocate the entire $1.9 million directly to local health departments to implement COPDP; however, the North Carolina General Assembly did not allocate funding for the state to provide administration and technical assistance. Consequently, NCDPH identified other resources to fund a state coordinator for the project and an external evaluation.

The objective of COPDP was to implement a set of multilevel, multisetting interventions for preventing and reducing obesity among children in a community. For the demonstration project, the state's objective was to learn lessons in community-based obesity prevention, how to support obesity-prevention efforts, and how to apply lessons learned in counties across the state.

COPDP included 8 required and 4 optional community interventions (Table 1). Before the implementation of COPDP, each of the interventions had been implemented in some North Carolina communities, but no community had implemented all of them. The interventions targeted children and their adult role models in 6 settings: the community at-large, health care organizations, worksites, schools, child care centers, and religious organizations. COPDP incorporated 4 recommended strategies for physical activity, nutrition, and obesity prevention from the Guide to Community Preventive Services: 1) community-wide campaigns (10), 2) community-scale urban design and land-use policies (11), 3) worksite programs combining nutrition and physical activity (12), and 4) enhanced physical education classes in schools (13).

COPDP required simultaneous implementation of the interventions in 5 selected counties. A community-wide media campaign united each of the separate COPDP interventions under a single brand and ensured consistent obesity prevention messages. The counties used existing resources from the ESMM-NC statewide movement to raise awareness of the interventions and create a supportive environment for physical activity and healthful eating.

NCDPH used a 2-step, competitive application process to select counties to implement COPDP, beginning with a request for applications in July 2008. Twenty-nine counties submitted brief proposals describing their local partnerships, experiences collaborating on community-based projects, and plans to coordinate COPDP. Of these, 11 were invited to submit full applications with a detailed plan for implementing each of the interventions. The applications also included descriptions of the capacity of each county's project coordinator and key staff. NCDPH awarded grants of $380,000 to each of 5 selected counties beginning on October 1, 2008. In accordance with the state fiscal year, the grant period ended May 31, 2009, giving the counties 8 months to implement the program. The counties ranged in population from 34,296 to 172,223 (14) and were geographically distributed across the state.

NCDPH administered and provided technical assistance for COPDP. Preventive Health and Health Services Block Grant funds supported a full-time state coordinator at NCDPH. The state coordinator facilitated the involvement of state-level partners, developed a system for providing technical assistance, maintained constant contact with the county coordinators, and fostered sharing among the counties. These efforts ensured the efficient engagement of state-level expertise and resources, ongoing quality improvement, and problem solving to support the counties throughout COPDP. The state coordinator also monitored the counties' progress through site visits, monthly telephone calls, and reviews of written monthly summary reports.

Statewide partners assisted with COPDP by providing additional funding, technical assistance, and training (Table 2). For example, the North Carolina State Board of Education provided an additional $250,000 to school districts in the 5 counties to further support obesity prevention through coordinated school health programs as part of COPDP. In addition, COPDP counties were the first counties to participate in a new initiative to enhance physical education in schools across the state. Through this initiative, counties received technical assistance and training in an evidence-based physical education curriculum and in fitness-testing software. NCDPH developed a centralized technical assistance infrastructure (Figure) to support the counties with the COPDP interventions and to streamline this support as much as possible.

COPDP grants went to local health departments in each county, which collaborated with county partnerships to implement the project. County-level implementation was directed by a county coordinator who worked closely with the state coordinator to ensure the fulfillment of all grant requirements.

The county partnerships were well established before COPDP. Once funded, each partnership assessed its membership and added members as needed to include representation from all intervention settings. The number of agencies represented in each partnership ranged from 9 to 16. The partnerships garnered resources (eg, volunteer time, space for classes, access to organizations and individuals, support from local leaders and boards) through their existing connections and relationships.

NCDPH funded the evaluation of COPDP through the Prevention Research Center at the University of North Carolina-Chapel Hill. A full-time COPDP evaluator worked with the state and county coordinators to 1) collect output data describing implementation, 2) measure intermediate outcomes describing changes in the communities, 3) examine the role of county partnerships in facilitating the success of the project, and 4) identify potential long-term outcome measures. The COPDP evaluator also conducted interviews and focus groups, provided data analyses, and summarized findings. NCDPH engaged statewide partners in discussion of the evaluation results to share successes and opportunities for further collaboration. The institutional review board of the University of North Carolina at Chapel Hill approved the evaluation.

The existence of COPDP resulted in immediate policy and environmental changes in the community, health care organizations, worksites, schools, child care centers, and religious organizations (Table 3). In the 5 counties, 42 child care providers made changes that affected more than 2,400 children. Policy changes to support physical activity and healthful eating in hospital and school worksites affected more than 13,800 employees. Sixty-six children at risk for type 2 diabetes completed a 36-session prevention program; of the 25 children who began the program with high triglycerides, 22 reduced their triglycerides and 14 achieved a normal range. Additionally, more than 6 miles of greenways and sidewalks were constructed or designed. In some cases, the effect of these changes reached beyond county and even state lines. For instance, a child care center's request for skim and 1% milk led to new food purchasing and distribution policies, which provided more healthful milk options for affiliated child care centers across the nation.

The media campaign blanketed communities with consistent messages that tied interventions together. One woman claimed that seeing and hearing the same ESMM-NC messages in multiple places — both in the community and in her workplace — made her feel connected to a larger effort. NCDPH and the counties documented success stories like these to illustrate the personal effect on community members. These stories were used to educate policy makers and stakeholders.

The short time line, high visibility, and the large scale of COPDP presented challenges. Once the funding was awarded, NCDPH quickly leveraged support from state partners for the 5 counties in the form of additional funding, training, and technical assistance for COPDP. NCDPH's long-standing relationships and collaboration with state partners made this possible.

The 8-month time line for the COPDP presented several challenges. Incorporating grant activities, such as staff training and a new physical education curriculum for kindergarten through 8th grade, was challenging for schools because lesson plans and teacher professional development days had already been set for the year. Seasonal effects also limited progress; for example, farmers' markets closed for winter just as COPDP began.

NCDPH worked with counties to balance the need for fidelity in implementation with the need for flexibility to adapt interventions to the local context. County health departments were asked to adhere to specific grant requirements, even if they adapted activities. In some cases, counties were simply not able to implement the interventions as specified because of time and other constraints. For example, several counties adapted the enrollment criteria for 1 intervention because they could not otherwise recruit enough participants in the given time frame.

A community-based health initiative's duration affects its sustainability, and several years of implementation are needed to institutionalize the desired change (15). Although COPDP was designed for 5 years of funding, only 1 year of funding was initially awarded. NCDPH and the counties knew that continued funding was tentative; when a state fiscal crisis ensued in 2009, funding was not allocated for COPDP. Counties developed sustainability plans, but without additional resources, not all of the interventions could be continued. Likewise, funding was not available to evaluate the outcomes of COPDP beyond the 8-month time frame. Further evaluation of this project is needed to track the counties' continued efforts and measure long-term effects. Additional results, lessons learned, and success stories are available on the ESMM-NC website (www.EatSmartMoveMoreNC.com/ObesityDemo/ObesityDemo.html).