Obesity Prevention in Early Childhood: Strategies for

Healthy Development

Dianne S. Ward, EdDDepartment 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 performancebehavior 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 ActivitySelfAssessment 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, email This offers...

Support Encouragement Additional information A reminder of goals

Step 5: Reassessment

EvaluateEvaluate Centers complete follow-up self-assessment instrument to Centers complete follow-up self-assessment instrument to

evaluate changes made during 6-month interventionevaluate changes made during 6-month intervention

ReviseRevise RepeatRepeat

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 Significant increase in self-assessment scores for nutrition, physical activity, and nutrition and physical nutrition, physical activity, and nutrition and physical activity combined after interventionactivity combined after intervention

Feasibility and acceptability of NAP SACCFeasibility and acceptability of NAP SACC NAP SACC consultantsNAP SACC consultants

80% agreed 80% agreed that self-assessment tool was comprehensivethat self-assessment tool was comprehensive 40% agreed40% agreed, and , and 50% somewhat agreed 50% somewhat agreed that self-that self-

assessment was easy to understandassessment was easy to understand 70% agreed 70% agreed that meetings with center directors were that meetings with center directors were

productiveproductive 60% agreed60% agreed, and , and 40% somewhat agreed 40% somewhat agreed that they felt that they felt

confident that they could deliver the NAP SACC programconfident 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 Environment and Policy Assessment and Observation (EPAO)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 NAP SACCSACC Evaluation Design Evaluation Design

A convenience sample of 96 child care A convenience sample of 96 child care centers recruited from 33 North Carolina centers recruited from 33 North Carolina (NC) counties(NC) counties

Centers represented all three regions of Centers represented all three regions of NC (Western, Eastern, and Central NC (Western, Eastern, and Central Piedmont). Piedmont).

Most (n=84) were part of an evaluation of Most (n=84) were part of an evaluation of the the NAP SACCNAP SACC intervention (Ward et al., intervention (Ward et al., AJPM, 2008); 12 additional centers were AJPM, 2008); 12 additional centers were part of an exploratory study to test the part of an exploratory study to test the self-assessment instrument. self-assessment instrument.

Sample

Intention-to-Treat Model*Intention-to-Treat Model* 56 intervention vs. 26 comparison centers (2 56 intervention vs. 26 comparison centers (2

centers closed)centers closed) Intervention centers increased in both nutrition Intervention centers increased in both nutrition

and physical activity areas, but only nutrition and physical activity areas, but only nutrition approached significance (p=.06)approached significance (p=.06)

When centers that did not start the intervention When centers that did not start the intervention were eliminated (15), changes in the nutrition were eliminated (15), changes in the nutrition environment were significant (p<.01)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 States Using NAP SACC Intervention MaterialsIntervention 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.

NAP SACC was cited in Caring for our Children Guidelines

National Resource Center for Health and Safety in Child Care and Early Education http://nrckids.org/CFOC/index.html

National Resource Center forHealth and Safety in Child Careand Early Education

http://center-trt.com/index.cfm

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:Contact Us:

www.napsacc.org

Dianne Wardnapsacc.org

919-843-0901