What Role can Child-care Settings Play in Obesity Prevention? A Review of the

Evidence and Call for Research Efforts

Nicole Larson, PhD, MPH, RD: University of Minnesota (UMN)

Dianne Ward, EdD: University of North Carolina

Sara Benjamin Neelon, PhD, MPH, RD: Duke University

Mary Story, PhD, RD: UMN

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION

Larson N et al. J Am Diet Assoc. 2011; 111 (September).

Serum Vitamin C (mg/dl) by Salad IntakePurpose

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION

Larson N et al. J Am Diet Assoc. 2011; 111 (September).

What Role can Child-care Settings Play in Obesity Prevention? A Review of the Evidence and Call for Research Efforts

1) Review studies of relevance to U.S. preschool children (2-5 years) enrolled in center-based care or family child-care homes that have addressed:• state regulations relating to nutrition and physical activity• child care practices and policies with the potential to influence

dietary intake and physical activity• the perceptions and practices of preschoolers’ parents with

implications for obesity prevention

2) Review interventions conducted in the U.S. and internationally that were designed to prevent obesity in child-care settings through the promotion of better nutrition, increased physical activity, or reduced time spent in sedentary activities

Serum Vitamin C (mg/dl) by Salad IntakeMethods

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION

Larson N et al. J Am Diet Assoc. 2011; 111 (September).

What Role can Child-care Settings Play in Obesity Prevention? A Review of the Evidence and Call for Research Efforts

• Conducted electronic literature search of two databases: PubMed and MEDLINE

• Key words: child care, preschool, nursery school, dietary intake, physical activity, sedentary activity, intervention, obesity, overweight

• Manual search of bibliographies included in identified studies

• Included studies published between January 2000 and July 2010

• Included intervention studies only if an evaluation of program impact or feasibility was completed

Serum Vitamin C (mg/dl) by Salad IntakeResults: State Regulations

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION

Larson N et al. J Am Diet Assoc. 2011; 111 (September).

What Role can Child-care Settings Play in Obesity Prevention? A Review of the Evidence and Call for Research Efforts

• Four recent reviews of state regulations found that most states lacked strong regulations related to healthy eating and physical activity (1-4).

• Child-care centers tended to be the most heavily regulated and have more specific regulations, followed by large family and group child-care homes (2).

• Small family child-care homes tended to have the fewest and most general regulations (2).

Serum Vitamin C (mg/dl) by Salad IntakeResults: Practices & Policies of Relevance

to Healthy Eating

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION

Larson N et al. J Am Diet Assoc. 2011; 111 (September).

What Role can Child-care Settings Play in Obesity Prevention? A Review of the Evidence and Call for Research Efforts

• 2 nationally-representative studies (5,6) and 4 smaller studies (7-10) have evaluated the nutritional quality of foods provided to preschool-aged children

• 7 studies (5,9,11-15) have assessed mealtime behaviors of child-care providers and education/training

• Results have identified opportunities for better promoting healthy eating relating to the provision of 1% or skim milk, fruits, and vegetables; training providers to help children pay attention to their internal signals of hunger and satiation; and providing nutrition education for children

Serum Vitamin C (mg/dl) by Salad IntakeResults: Practices, Policies, and

Environmental Factors of Relevance to Physical Activity

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION

Larson N et al. J Am Diet Assoc. 2011; 111 (September).

What Role can Child-care Settings Play in Obesity Prevention? A Review of the Evidence and Call for Research Efforts

• Children rarely achieve 60 minutes of moderate-to-vigorous physical activity during the child-care day (16, 17).

• Children’s physical activity levels vary considerably (up to 47%) depending upon the child-care facility they attend (18, 19-21).

• Factors that may account for this variation in physical activity include:− The amount of time allocated for active play, time spent outside,

and indoors activities (20, 22)− More space per child on the playground (23)− Having more trees, shrubbery, and open play areas (24)− Access to more portable equipment (e.g., balls) (20, 23, 25)− Teacher prompts (26)

Serum Vitamin C (mg/dl) by Salad IntakeResults: Perceptions & Practices of

Parents

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION

Larson N et al. J Am Diet Assoc. 2011; 111 (September).

What Role can Child-care Settings Play in Obesity Prevention? A Review of the Evidence and Call for Research Efforts

• Evidence suggests that many parents do not recognize a preschool-aged child is obese and a considerable proportion of parents of normal-weight children perceive their child to be underweight (27-29).

• Only 2 studies examining parent perceptions and behaviors relevant to the nutrition and physical activity environment in child-care settings were identified (30-31).

• Common recommendations from parents for promoting healthy eating and physical activity in center-based care settings include (30): − Serving more fruits and vegetables− Offering a greater variety of foods− Providing more structured and caregiver-led activities− Providing additional outdoor time

Serum Vitamin C (mg/dl) by Salad IntakeResults: Obesity Prevention Interventions

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION

Larson N et al. J Am Diet Assoc. 2011; 111 (September).

What Role can Child-care Settings Play in Obesity Prevention? A Review of the Evidence and Call for Research Efforts

• 18 interventions were identified:− 4 focused on nutrition outcomes − 7 focused on physical activity or sedentary activity outcomes− 7 addressed a combination of nutrition and activity outcomes

• Only 5 of the 18 interventions targeted environmental factors such as improvements in foodservice practices and playground environments.

• An assessment of impact on child weight status was completed for just 5 interventions, and only 2 studies (32, 33) showed some evidence of success in reducing risk for obesity.

• The 2 interventions found to have an impact on child weight status included multiple components to address nutrition, physical activity, and sedentary behaviors.

Serum Vitamin C (mg/dl) by Salad IntakeImplications for Future Research

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION

Larson N et al. J Am Diet Assoc. 2011; 111 (September).

What Role can Child-care Settings Play in Obesity Prevention? A Review of the Evidence and Call for Research Efforts

• Studies evaluating the impact of state regulations are needed to ensure that desired improvements are realized and there are no unintended consequences.

• There is a particular need for nationally-representative studies designed to identify influences on healthy eating and physical activity in family child-care homes.

• Additional research is needed regarding parental behaviors and perceptions to better inform the design of future interventions.

• There is a need to evaluate multi-component obesity prevention programs that address both nutrition and physical activity behaviors.

• Research is needed to develop valid and reliable measures of policies and other environmental outcomes in child-care settings.

Serum Vitamin C (mg/dl) by Salad IntakeReferences

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION

Larson N et al. J Am Diet Assoc. 2011; 111 (September).

What Role can Child-care Settings Play in Obesity Prevention? A Review of the Evidence and Call for Research Efforts

1) Benjamin S. Obesity prevention in child care: a review of U.S. state regulations. BMC Public Health. 2008;8:188. http://www.biomedcentral.com/1471-2458/8/188. Accessed May 2010.

2) Kaphingst K, Story M. Child care as an untapped setting for obesity prevention: state child care licensing regulations related to nutrition, physical activity, and media use for preschool-aged children in the United States. Prev Chronic Dis. 2009;6(1):A11. http://www.cdc.gov/pcd/issues/2009/jan/07_0240.htm. Accessed December 28, 2009.

3) Cradock A, O’Donnell E, Benjamin S, Walker E, Slining M. A review of state regulations to promote physical activity and safety on playgrounds in child care centers and family child care homes. J Phys Act Health. 2010;7:S108-S119.

4) Benjamin S, Copeland K, Cradock A, Neelon B, Walker E, Slining M, Gillman M. Menus in child care: a comparison of state regulations with national standards. J Am Diet Assoc. 2009;109:109-115.

5) Whitaker R, Gooze R, Hughes C, Finkelstein D. A national survey of obesity prevention practices in Head Start. Arch Pediatr Adolesc Med. 2009;163:1144-1150.

6) Crepinsek M, Burstein N, Lee E, Kennedy S, Hamilton W, Abt Associates Inc. Meals offered by tier 2 CACFP family child care providers - Effects of lower meal reimbursements. Washington D.C.: United States Department of Agriculture, Economic Research Service; 2002 March.

7) Ball S, Benjamin S, Ward D. Dietary intakes in North Carolina child-care centers: are children meeting current recommendations? J Am Diet Assoc. 2008;108:718-721.

8) Wu Y, Hertzler A, Miller S. Vitamin A, vitamin C, calcium and iron content of federally funded preschool lunches in Virginia. J Am Diet Assoc. 2001;101:348-351.

9) Trost S, Messner L, Fitzgerald K, Roths B. Nutrition and physical activity policies and practices in family child care homes. Am J Prev Med. 2009;37:537-540.

10) Padget A, Briley M. Dietary intakes at child-care centers in central Texas fail to meet Food Guide Pyramid Recommendations. J Am Diet Assoc. 2005;105:790-793.

Serum Vitamin C (mg/dl) by Salad IntakeReferences

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION

Larson N et al. J Am Diet Assoc. 2011; 111 (September).

What Role can Child-care Settings Play in Obesity Prevention? A Review of the Evidence and Call for Research Efforts

11) Gooze R, Hughes C, Finkelstein D, Whitaker R. Reaching staff, parents, and community partners to prevent childhood obesity in Head Start, 2008. Prev Chronic Dis. 2010;7:3. http://www.cdc.gov/pcd/issues/2010/May/09_0115.htm. Accessed July 31, 2010.

12) Sigman-Grant M, Christiansen E, Branen L, Fletcher J, Johnson S. About feeding children: mealtimes in child-care centers in four Western states. J Am Diet Assoc. 2008;108:340-346.

13) Gable S, Lutz S. Nutrition socialization experiences of children in the Head Start program. J Am Diet Assoc. 2001;101:572-577.

14) Ramsay S, Branen L, Fletcher J, Price E, Johnson S, Sigman-Grant M. "Are you done?" Child care providers' verbal communication at mealtimes that reinforce or hinder children's internal cues of hunger and satiation. J Nutr Educ Behav. 2010;42:265-270.

15) Freedman M, Alvarez K. Early childhood feeding: assessing knowledge, attitude, and practices of multi-ethnic child-care providers. J Am Diet Assoc. 2010;110:447-451.

16) Reilly J, Kelly L, Montgomery C, Williamson A, Fisher A, McColl J, Lo Conte R, Paton J, Grant S. Physical activity to prevent obesity in young children: cluster randomised controlled trial. BMJ. 2006;333:1041.

17) Cardon G, De Bourdeaudhuij IMM. Are preschool children active enough? Objectively measured physical activity levels. Res Q Exerc Sport. 2008;79:326-332.

18) Pate R, McIver K, Dowda M, Brown W, Addy C. Directly observed physical activity levels in preschool children. J Sch Health. 2008;78:438-444.

19) Pate R, Pfeiffer K, Trost S, Ziegler P, Dowda M. Physical activity among children attending preschools. Pediatrics. 2004;114:1258-1263.

20) Bower J, Hales D, Tate D, Rubin D, Benjamin S, Ward D. The childcare environment and children's physical activity. Am J Prev Med. 2008;34:23-29.

21) Finn K, Johannsen N, Specker B. Factors associated with physical activity in preschool children. J Pediatr. 2002;140:81-85.

Serum Vitamin C (mg/dl) by Salad IntakeReferences

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION

Larson N et al. J Am Diet Assoc. 2011; 111 (September).

What Role can Child-care Settings Play in Obesity Prevention? A Review of the Evidence and Call for Research Efforts

22) Dowda M, Pate R, Trot S, Joao M, Almeida C, Sirard J. Influences of preschool policies and practices on children's physical activity. J Community Health. 2004;29:183-196.

23) Cardon G, Van Cauwenberghe E, Labarque V, Haerens L, De Bourdeaudhuij I. The contribution of preschool playground factors in explaining children's physical activity during recess. Int J Behav Nutr Phys Act. 2008;5:11. http://www.ijbnpa.org/content/5/1/11. Accessed August 14, 2010.

24) Boldermann C, Blennow M, H HD, Mårtensson F, Raustorp A, Yuen L, Wester U. Impact of preschool environment upon children’s physical activity and sun exposure. Prev Med. 2006;42:301-308.

25) Dowda M, Brown W, McIver K, Pfeiffer K, O'Neill J, Addy C, Pate R. Policies and characteristics of the preschool environment and physical activity of young children. Pediatrics. 2009;123:e261-266.

26) Brown W, Googe H, McIver K, Rathel J. Effects of teacher-encouraged physical activity on preschool playgrounds. Journal of Early Intervention. 2009;31:126-145.

27) Harnack L, Lytle L, Himes J, Story M, Taylor G, Bishop D. Low awareness of overweight status among parents of preschool-aged children, Minnesota, 2004-2005. Prev Chronic Dis. 2009;6(2). http://www.cdc.gov/pcd/issues/2009/apr/08_0043.htm. Accessed July 10, 2010.

28) Baughcum A, Chamberlin L, Deeks C, Powers S, Whitaker R. Maternal perceptions of overweight preschool children. Pediatrics. 2000;106:1380-1386.

29) Nelson J, Carpenter K, Chiasson M. Diet, activity, and overweight among preschool-age children enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Prev Chronic Dis. 2006;3(2):A49. http://www.cdc.gov/pcd/issues/2006/apr/05_0135.htm. Accessed July 18, 2010.

30) Benjamin S, Haines J, Ball S, Ward D. Improving nutrition and physical activity in child care: what parents recommend. J Am Diet Assoc. 2008;108:1907-1911.

31) Sweitzer S, Briley M, Robert-Gray C. Do sack lunches provided by parents meet the nutritional needs of young children who attend child care? J Am Diet Assoc. 2009;109:141-144.

Serum Vitamin C (mg/dl) by Salad IntakeReferences

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION

Larson N et al. J Am Diet Assoc. 2011; 111 (September).

What Role can Child-care Settings Play in Obesity Prevention? A Review of the Evidence and Call for Research Efforts

32) Fitzgibbon M, Stolley M, Van Horn L, K KauferChristoffel, Dyer A. Two-year follow-up results for Hip-Hop to Health Jr.: A randomized controlled trial for overweight prevention in preschool minority children. J Pediatr. 2005;146:618-625.

33) Eliakim A, Nemet D, Balakirski Y, Epstein Y. The effects of nutritional-physical activity school-based intervention on fatness and fitness in preschool children. J Pediatr Endocrinol Metab. 2007;20:711-718.