Obesity Prevention in Early Childhood: Strategies for Healthy Development Dianne S. Ward, EdD Department of Nutrition Gillings School of Global Public Health University of North Carolina at Chapel Hill

Outline Introduction Childhood obesity as a health problem Efforts to address childhood obesity prevention Development of the NAP SACC program Results from Pilot-testing of NAP SACC Results from baseline studies of NAP SACC Statewide evaluation of NAP SACC Best practices for Healthy Weight Development at Child Care NAP SACC dissemination Next steps

Childhood obesity is a serious public health problem in the US

21% of children ages 2-5 years are currently overweight or obese

The prevalence of childhood obesity is higher among ethnic minorities and children from low income families One of 7 low-income, preschool-aged children is obese, although trends may be slowing

Health Consequences Associated with Childhood Obesity Increased risk of developing Obesity in adulthood Type 2 diabetes Cardiovascular disease Certain cancers

Childhood Obesity and Academic Performance Childhood obesity Higher risk of micronutrient deficiencies e.g., iron, vitamin A Poor learning, cognition and school performance behavior problems

Background Poor dietary behaviors and physical inactivity increase risk for childhood obesity 61% of US children ≤6 years are in child care Foods and beverages consumed and physical activity in child care settings play a vital role in childhood obesity Intervention efforts in child care settings can be effective for: promoting healthful behaviors ensuring children develop healthful food preferences early in life

Background Limited childhood obesity prevention efforts target children <6 years old More studies have focused on school-age children Few interventions have focused on improving the nutrition and physical activity environments in childcare settings

Outline Introduction Childhood obesity as a health problem Efforts to address childhood obesity prevention Development of the NAP SACC program Results from Pilot-testing of NAP SACC Results from baseline studies of NAP SACC Statewide evaluation of NAP SACC Best practices for Healthy Weight Development at Child Care NAP SACC dissemination Next steps

The NAP SACC Program Nutrition And Physical Activity Self Assessment for Child Care

NAP SACC What’s it all about?

NAP SACC Development Team

Intervention Development Interviews Focus groups Standards review Advisory group formation Pilot testing

NAP SACC Components Self-Assessment Action Planning Workshop Delivery Technical Assistance Evaluate, Revise, Repeat

Step 1: Self-Assessment Facility director completes self- assessment instrument with help from key staff, such as the cook or program planner.

Step 2: Action Planning Provider-generated with Consultant support 3 Key Areas selected for improvement At least 1 nutrition and 1 physical activity key area selected

Sample Actions

Step 3: Workshop Delivery 5 workshops (approved for 5.5 CEUs)

Step 4: Provision of Technical Assistance This may be the most important step in the process!! In-person, telephone, This offers... Support Encouragement Additional information A reminder of goals

Step 5: Reassessment Evaluate Evaluate Centers complete follow-up self-assessment instrument to evaluate changes made during 6-month intervention Centers complete follow-up self-assessment instrument to evaluate changes made during 6-month intervention Revise Revise Repeat Repeat

Outline Introduction Childhood obesity as a health problem Efforts to address childhood obesity prevention Development of the NAP SACC program Results from Pilot-testing of NAP SACC Results from baseline studies of NAP SACC Statewide evaluation of NAP SACC Best practices for Healthy Weight Development at Child Care NAP SACC dissemination Next steps

Pilot-testing of NAP SACC To assess feasibility and acceptability of NAP SACC Randomized controlled trial Convenience sample n = 19 child care centers from 8 counties in NC (n=15 intervention centers; n = 4 comparison centers) NAP SACC intervention was conducted over a 6- month period at intervention centers

Results from Pilot-testing of NAP SACC Significant increase in self-assessment scores for nutrition, physical activity, and nutrition and physical activity combined after intervention Significant increase in self-assessment scores for nutrition, physical activity, and nutrition and physical activity combined after intervention Feasibility and acceptability of NAP SACC Feasibility and acceptability of NAP SACC NAP SACC consultants NAP SACC consultants 80% agreed that self-assessment tool was comprehensive 80% agreed that self-assessment tool was comprehensive 40% agreed, and 50% somewhat agreed that self- assessment was easy to understand 40% agreed, and 50% somewhat agreed that self- assessment was easy to understand 70% agreed that meetings with center directors were productive 70% agreed that meetings with center directors were productive 60% agreed, and 40% somewhat agreed that they felt confident that they could deliver the NAP SACC program 60% agreed, and 40% somewhat agreed that they felt confident that they could deliver the NAP SACC program

Results from Pilot-testing of NAP SACC Feasibility and acceptability of NAP SACC Reports from Directors of child care centers Self-assessment was fairly easy (36%) or very easy (64%) to use Self-assessment was very helpful (83%) or somewhat helpful (17%) measure of the centers’ nutrition environments Self-assessment was very helpful (50%) or somewhat helpful (50%) measure of centers’ physical activity environments 12 said they would recommend NAP SACC to other centers Changes in nutrition and physical activity policies and practices of their centers e.g., serving more fruits and vegetables

Outline Introduction Childhood obesity as a health problem Efforts to address childhood obesity prevention Development of the NAP SACC program Results from Pilot-testing of NAP SACC Results from baseline studies of NAP SACC Statewide evaluation of NAP SACC Best practices for Healthy Weight Development at Child Care NAP SACC dissemination Next steps

NAP SACC Baseline Studies: Diet Baseline studies assessed nutrition practices and physical activity environments in child care centers Study 1 To determine whether foods consumed by children aged 2-5 years in child care centers meet their MyPyramid recommendation Dietary observations were conducted in 1 classroom (n = 6 children) at each center n = 117 children

Results from NAP SACC Baseline Studies Summary of findings Children consumed less than recommended amounts of Whole grains Fruits Vegetables Children consumed excessive amounts of Added sugars from sweets and condiments Saturated fat from whole milk and high-fat or fried meats

NAP SACC Baseline Studies: Physical Activity Study 2 To determine the association between the social and physical activity environment in child care centers 1-day assessment using the Environment and Policy Assessment and Observation Instrument (EPAO) (n = 20 centers) EPAO is an expanded version of the self-assessment instrument used in NAP SACC Observed 4 children ages 3-5 year old at each center Reviewed documents e.g., lesson plans, parent and staff handbooks

Environment and Policy Assessment and Observation (EPAO)

NAP SACC Baseline Studies: PA Summary of findings Centers with higher physical activity environment scores on the EPAO had children who Were more physically active Spent less time in sedentary activities Had higher mean physical activity levels

Environmental factors associated with physical activity behaviors Active opportunities (opportunities that result in MVPA) Portable play equipment (e.g., jumping equipment, hula hoops, balls) Fixed play equipment (e.g., climbing structure, running space, indoor play space) Sedentary environment (e.g., television, computer, posters, books) Physical activity training and education (e.g., PE curriculum, training for staff and parents)

Outline Introduction Childhood obesity as a health problem Efforts to address childhood obesity prevention Development of the NAP SACC program Results from Pilot-testing of NAP SACC Results from baseline studies of NAP SACC Statewide evaluation of NAP SACC Best practices for Healthy Weight Development at Child Care NAP SACC dissemination Next steps

NAP SACC Evaluation Design A convenience sample of 96 child care centers recruited from 33 North Carolina (NC) counties A convenience sample of 96 child care centers recruited from 33 North Carolina (NC) counties Centers represented all three regions of NC (Western, Eastern, and Central Piedmont). Centers represented all three regions of NC (Western, Eastern, and Central Piedmont). Most (n=84) were part of an evaluation of the NAP SACC intervention (Ward et al., AJPM, 2008); 12 additional centers were part of an exploratory study to test the self- assessment instrument. Most (n=84) were part of an evaluation of the NAP SACC intervention (Ward et al., AJPM, 2008); 12 additional centers were part of an exploratory study to test the self- assessment instrument. Sample

Intention-to-Treat Model* 56 intervention vs. 26 comparison centers (2 centers closed) 56 intervention vs. 26 comparison centers (2 centers closed) Intervention centers increased in both nutrition and physical activity areas, but only nutrition approached significance (p=.06) Intervention centers increased in both nutrition and physical activity areas, but only nutrition approached significance (p=.06) When centers that did not start the intervention were eliminated (15), changes in the nutrition environment were significant (p<.01) When centers that did not start the intervention were eliminated (15), changes in the nutrition environment were significant (p<.01) *Does not include 2 centers that closed

Best Practice Guidelines for Nutrition 31 Best Practice Guidelines 8 key areas of the child care environment Fruits and Vegetables Meats, Fats, and Grains Beverages Feeding Practices Foods Outside of Meals and Snacks Supporting Healthy Eating Nutrition Education Nutrition Policies

25 Best Practice Guidelines 8 key areas of the child care environment Best Practice Guidelines for Physical Activity Active opportunities Fixed equipment Portable equipment Sedentary opportunities Sedentary environment Staff behavior Training and education PA policies

Best Practices for Healthy Weight Development in Child Care Conducted 2 studies to compare nutrition and physical activity in NC child care centers to best practice guidelines n = 96 child care centers from 33 NC counties Completed EPAO via one-day of observation in classrooms of 3-5y olds Reviewed center documents e.g., menus, parent handbooks, staff training manual

Best Practices for Healthy Weight Development in Child Care >50% of centers met best practice guideline to Offer fried or pre-fried potatoes <1time/week or never Make drinking water easily accessible to children Locate soda/other vending machines off-site Have staff encourage children to try new or less favored foods Have staff join children and eat same foods during meals Have formal nutrition policies that were followed

Best practices for Healthy Weight Development in Child Care Areas for concern <50% did not meet best practice guideline to Offer fruit and vegetables ≥2 times/day Offer high-fat meats <1 time/week or never Offer beans or lean meats >1 time/day Offer 100% fruit juice <2times/week Provide nutrition education opportunities for children and parents 50% served whole milk instead of low fat fat milk

Best practices for Healthy Weight Development in Child Care Most centers met best practice guidelines to provide Teacher-led activities Outdoor play Outdoor play space and fixed play equipment Portable play equipment Ensure children are not seated for more than 30 minutes at a time Areas for concern Most centers did not provide at least 120 minutes of activity 21% allowed children to watch >60 minutes of TV At most centers, teachers did not join in active play Most centers did not have formal written activity policies

Outline Introduction Childhood obesity as a health problem Efforts to address childhood obesity prevention Development of the NAP SACC program Results from Pilot-testing of NAP SACC Results from baseline studies of NAP SACC Statewide evaluation of NAP SACC Best practices for Healthy Weight Development at Child Care NAP SACC dissemination Next steps

NAP SACC Project States Using NAP SACC Intervention Materials

NAP SACC Program Identified as one of three model programs to address obesity prevention in child care. The other programs noted were Nemours Childhood Obesity Model, supported by the Nemours Health and Prevention Services and I am Moving, I am Learning, a health promotion and obesity prevention enhancement developed for Head Start.Nemours Childhood Obesity ModelI am Moving, I am Learning

NAP SACC was cited in Caring for our Children Guidelines National Resource Center for Health and Safety in Child Care and Early Education National Resource Center for Health and Safety in Child Care and Early Education

About 40% of the traffic on the CTRT site is seeking information about the NAP SACC program!

Next Steps Revise to include recommendations for infants and toddlers Modification of website to share barriers/promoters and success stories Possibility of adapting for family child care homes Possibility of linking child care healthy weight efforts to parents and home environment to promote healthy eating, regular physical activity, and healthy weight

Contact Us: Dianne Ward napsacc.org