PUBLIC HEALTH POLICY CHANGE · Physical Activity Research Children are sedentary 70-83% of time in child care (excluding nap) 2-3% of time (7-13 mins) in vigorous activity 3-15% of

PUBLIC HEALTH POLICY CHANGE

HEALTHY KIDS, HEALTHY CHILD CARE

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Introductions

Kimberly F. Stitzel,

MS, RD Vice-President, Nutrition

and Obesity Strategies

Consumer Health,

American Heart

Association

National Center

Introductions

Sara Benjamin Neelon,

PhD, MPH, RD Duke University Medical

Center and

Duke Global Health

Institute

Introductions

Natasha Frost Staff Attorney, Public Health Law Center

Introductions

Elizabeth Walker, MS Senior Director, Health

Improvement

Association of State and

Territorial Health Officials

Healthy Kids, Healthy Child Care Objectives

To identify the current state of the research,

including opportunities for improvement and

research gaps

To explain how state and local laws shape child

care strategies

To analyze existing resources and promising

interventions being used around the country

HEALTHY KIDS, HEALTHY CHILD CARE:

WHAT DOES THE RESEARCH TELL US?

Sara Benjamin Neelon, PhD, MPH, RD

Duke University Medical Center and

Duke Global Health Institute


Healthy Eating & Physical Activity in Child Care

Physical Activity Research

Healthy Eating Research

Interventions developed for Child Care

Policies targeting Child Care

Physical Activity Research

Children are sedentary 70-83% of time in child care (excluding nap)

2-3% of time (7-13 mins) in vigorous activity

3-15% of time (12-46 mins) in moderate or vigorous activity

Children more active:

when outdoors

when prompted by adults

Children exposed to average of 1.8 hours/day of tv in family

child care homes and 0.1 hours/day in centers

Pate 2004; Pate 2008; Brown 2009; Burdette 2005, Burdette 2004, McKenzie 1997;

McKenzie 1992, Sallis 1993.

Barriers to Physical Activity

Child:

Injuries

Getting dirty

Direct parent requests not to take child outside

Inappropriate clothing

Structual:

No outdoor playground

No indoor play space for days with inclement weather

Playground too small, not enough equipment

Standing water, snow, heat, smog alert

Copeland 2009; Copeland 2012.

Providers influence children’s dietary behaviors through

role modeling

Children more likely to accept new foods when providers

enthusiastically role model consumption of new foods

2009 survey of 50 centers in NC found:

In 33% of centers providers ate fast food during naptime

In 50% of centers providers drank soda or other sweetened

beverage during meals or naptime

Hendy 2000; Ward in progress.



Feeding responsibility shared by parents and providers

Children consume large percentage daily calories in child

care

Children consume inadequate whole grains and fiber

Majority of milk served is whole milk

Children consume inadequate fruits and vegetables

Vitamin A and iron may be insufficient

Padget 2005; Briley 1989; Ball 2007; Erinosho 2011; Sigman-Grant 2011.


2006 study of 84 centers in NC found that:

Children consumed 1/3 serving fruit and 1/4 serving

vegetables

Nearly 50% vegetables were fried potatoes

Less than 8% vegetables were dark green, orange, or red

Nearly 50% fruit canned in syrup

50% served juice once & 25% served juice twice daily

Ball 2007; Erinosho in progress; Benjamin Neelon 2012.

Breastfeeding Support

2009 survey of 167 centers in OH

43% centers reported at least one infant fed breast milk

12% of all enrolled infants fed breast milk

34% of centers reported ability to store milk overnight

Ability to store milk overnight associated with higher odds of

breast milk feeding

Copeland KA, PAS annual meeting, May 2011

Intervention Research

Nutrition and Physical Activity Self-Assessment for Child

Care (NAP SACC)

Baby NAP SACC

Hip Hop for Health, Junior

I am Moving, I am Learning

Romp and Chomp

Watch Me Grow

Intervention Research

Nutrition and Physical Activity Self-Assessment for Child

Care (NAP SACC)

Baby NAP SACC

Hip Hop for Health, Junior

I am Moving, I am Learning

Romp and Chomp

Watch Me Grow

Primary Aim:

Assess extent to which gardening intervention increases

child fruit & vegetable intake

Secondary Aim:

Assess extent to which intervention results in more fruits &

vegetables on child care center menu

Watch Me Grow Intervention: Study Aims

Watch Me Grow Intervention: Study design

Very small RCT of 4 child care centers in central NC

4-month-long intervention with fruit or vegetable of the month

classroom & outdoor curriculum

Child fruit and vegetable intake main outcome

Watch Me Grow Intervention: Components

Installation of fruit & vegetable garden (3 veg; 1 fruit)

Curriculum centered on fruit or vegetable of month

Technical assistance on low-cost ways to increase

fruits & vegetables

Gardening support

Watch Me Grow Intervention: Support for gardening

Monthly curriculum materials: Let us eat Lettuce

Watch Me Grow Intervention: Monthly curriculum

Watch Me Grow Intervention: Results

Intervention Control

Mean (Standard Deviation) Mean (Standard Deviation)

Servings PRE POST Diff PRE POST Diff

Vegetables

0.8 (0.7) 1.1 (0.7) 0.3 0.8 (0.4) 0.6 (0.3) -0.2

Dark

Vegetables

0.0 (0.0) 0.1 (0.1) 0.1 0.0 (0.0) 0.0 (0.0) 0.0

Fruits

1.0 (0.9) 0.7 (0.2) -0.3 0.3 (0.3) 0.5 (0.4) 0.2

Watch Me Grow Intervention: Results



Servings PRE POST Diff PRE POST Diff

Vegetables

0.8 (0.7) 1.1 (0.7) 0.3 0.8 (0.4) 0.6 (0.3) -0.2

Dark

Vegetables

0.0 (0.0) 0.1 (0.1) 0.1 0.0 (0.0) 0.0 (0.0) 0.0

Fruits

1.0 (0.9) 0.7 (0.2) -0.3 0.3 (0.3) 0.5 (0.4) 0.2

Primary Aim:

To test the feasibility and impact of an intervention targeting

children less than two years of age and their care providers to

enhance the nutrition, the physical activity and the overall

environments of child care centers.

Baby NAP SACC Intervention: Study Aims

Baby NAP SACC Intervention: Behavioral targets

Intervention Target Areas

Nutrition Physical Activity

Feeding Infants Activity for Infants

Feeding Toddlers Activity for Toddlers

Nutrition Education Physical Activity Education

Nutrition Environment Physical Activity Environment

Support for Breastfeeding

Baby NAP SACC Intervention: Intervention materials

Baby NAP SACC Intervention: Study design

RCT of 32 child care centers in greater Boston, MA area

6-month-long intervention with training & technical assistance

to encourage environmental changes within center

Center support for child healthy eating and physical

activity as main outcome (environmental assessment conducted

pre and post by trained/blinded observer)

Baby NAP SACC Intervention: Results



PRE POST Diff PRE POST Diff

Total

Score

139.1

(25.3)

147.3

(27.4)

8.3 145.5

(17.9)

145.4

(30.4)

-1.3

Nutrition

Score

56.5

(15.6)

66.1

(19.8)

9.8 64.4

(11.4)

66.4

(16.8)

2.6

Physical

Activity

Score

82.6

(15.3)

81.2

(13.9)

-1.4 81.1

(11.3)

79.0

(16.7)

-4.7

Baby NAP SACC Intervention: Results



PRE POST Diff PRE POST Diff

Total

Score

139.1

(25.3)

147.3

(27.4)

8.3 145.5

(17.9)

145.4

(30.4)

-1.3

Nutrition

Score

56.5

(15.6)

66.1

(19.8)

9.8 64.4

(11.4)

66.4

(16.8)

2.6

Physical

Activity

Score

82.6

(15.3)

81.2

(13.9)

-1.4 81.1

(11.3)

79.0

(16.7)

-4.7

Policy Research

Evaluation of New York City healthy eating and physical

activity regulations

Evaluation of MA physical activity regulation

L Beth Dixon, PhD, MPH

New York University

Temitope Erinosho, PhD University of North Carolina – Chapel Hill

Bureau of Chronic Disease Prevention

NYC Department of Health and Mental Hygiene

Evaluation of new NYC Nutrition & Physical Activity Regulations

Study Aim

Assess impact of new regulations requiring food served to meet

nutritional guidelines, limiting daily screen time to less than 60

minutes, and requiring 60 minutes of daily physical activity for

all children in child care centers in New York City

Study Design

One-group pre-test/post-test design evaluating “natural

experiment” in sample children 3-6 years from 40 centers

Outcome

Dietary intake and minutes of physical activity (moderate &

vigorous) via observation & accelerometers (n=240 children)


Regulations Took Effect

Jan 2007

Sep 2007 - May 2008 Apr 2005 - Dec 2005

Pre 1 Pre 2 Post 1 Post 3 Pre 3 Post 2


TIMELINE

BASELINE FOLLOW UP

Results pending.


Sara Benjamin Neelon, PhD, MPH, RD

Duke University

Matthew Gillman, MD, SM & Jonathan Finkelstein, MD, MPH

Harvard Medical School & Harvard Pilgrim Health Care

Harvard Medical School and Harvard Pilgrim Health Care

Robert Wood Johnson Foundation, Active Living Research

National Institutes of Health R21HD070822

Evaluation of new MA Physical Activity Regulation

Study Aim

Assess impact of new regulation requiring 60 minutes of daily

physical activity for all children in child care centers in Boston,

MA vs. Providence, RI

Study Design

Quasi-experimental two-group pre-test/post-test design

evaluating “natural experiment” in sample children 3-5 years

from 40 centers (20 in MA & 20 in RI)

Outcome

Minutes of physical activity (light, moderate, vigorous) via

observation (n=320 children) & accelerometers (n=50 children)


Regulation Took Effect

Jan 2010

Fall 2008 Fall 2009 Fall 2011 Spring 2012 Spring 2009 Fall 2012

Pre 1 Pre 2 Post 1 Post 3 Pre 3 Post 2


TIMELINE

BASELINE FOLLOW UP

MA RI Mean (SD)

Physical activity, minutes

Baseline 1 73.5 (21.4) 77.8 (22.5)

Baseline 2 98.1 (28.9) 81.9 (20.0)

Baseline 3 102.9 (35.3) 93.4 (16.5)

Sedentary activity,* minutes

Baseline 1 150.2 (25.4) 154.0 (41.6)

Baseline 2 140.3 (30.8) 158.6 (30.9)

Baseline 3 132.8 (34.6) 152.1 (28.8)

*Does not include minutes children spent eating and sleeping


Minutes of Sedentary

Time at Baseline

Minutes of Physical

Activity at Baseline


Final results available December 2012.


Thank you.


KNOWING THE LEGAL LANDSCAPE

Natasha Frost, JD

Staff Attorney, Public Health Law Center


The Public Health Law Center

Child Care Legal Landscape

Legislative Branch

Standards

Inspection

Powers

Enforcement

Powers •Criminal Penalties

•Civil Penalties

Enabling Statutes

Enabling Statute: Minn Stat.

§245A.09

Health and Human Services

Enabling Statutes: Minnesota

Enabling Statutes:

N.C. Stats.

§143B-168.3, §110-91, §110-90

Child Care Commission

Health and Human Services

Commission for Public Health

Enabling Statutes: North Carolina

North Carolina Statute § 110-91.

Limiting or prohibiting sweetened beverages

Limiting or prohibiting whole milk

Limiting or prohibiting juice

Creating exceptions, including for food allergies

Executive Branch

Statute authorizes regulations

Rules/Regulations

Rules/Regulation: Texas

Tex. Reg. 746.2207

May I use TV/video, computer, or video games for

activities with children?

(c) If you use TV/video, computer or video games as an

activity for children, you must ensure that they:

(1) Are related to the planned activities;

(2) Are age-appropriate; and

(3) Do not exceed two hours per day.

Judicial Branch

Court Cases

Child

Care

Cases

denial or revocation of license

criminal background check

requirements

liability for injury while in care

denial or revocation of license

criminal background check

requirements

liability for injury while in care

conflict between federal and/or

state standards and local law

Court Cases

State/Federal Local

Does the local

government

have the

authority to set

standards or

have laws that

could create

tension with

federal or state

child care

standards?

Local Authority: The Basics

ASSESSING THE POTENTIAL OF LOCAL

GOVERNMENTS TO IMPOSE STANDARDS

OF NUTRITION AND PHYSICAL

ACTIVITY FOR CHILD-CARE SETTINGS

Thanks to Sarah Hall and Kyle Buss for their research assistance.

This work was generously funded by a grant from the

Robert Wood Johnson Foundation through its Healthy

Eating Research program.

Color Coding System

Initial Findings: State Laws

Grant of local

authority: Alaska

Limit on local

authority: Minnesota

Preemption of local

authority: New York

Initial Findings: Local Regulation

New York City

Chicago

http://www.publichealthlawcenter.org/

topics/healthy-eating/child-care


HOW TO BRING THIS ALL TOGETHER

Elizabeth Walker, MS

Association of State and Territorial Health Officials (ASTHO)


Areas for Implementing Change

Regulations/Licensing

QRIS (Quality Rating Improvement System)

CACFP (Child and Adult Care Food Program)

Early Learning Standards

Pre-Service/Professional Development

Facility Level Interventions/Programs

Putting It Together

Decide upon behavior

with stakeholders

Investigate national

standards

Pilot promising practices

Address the system for change and

sustainability

Enacted State Wide Strategy

Implemented Community Strategy

Supported Child Care Building Practices

Leads to Classroom Practices

Leading to Improved Child Health

ConditionsKey Actions to Support Policy

DevelopmentAccountability

State Wide Strategy/Policy

Adapted Through-Line For Child Care Systems









Enacted State Wide Strategy

Implemented Community Strategy

Supported Child Care Building Practices

Leads to Classroom Practices

Leading to Improved Child Health



State Wide Strategy/Policy

Adapted Through-Line For Child Care Systems









Next Webinar in the Series

Addressing Health Disparities: Smoke-Free

Policies for Public Housing

Tuesday, July 3, 2012, 12:00 pm – 1:30 p.m. CDT

Visit www.publichealthlawcenter.org for more

information

http://www.publichealthlawcenter.org/

Panel Contact Information

Kimberly F. Stitzel, MS, RD, Vice-President, Nutrition and

Obesity Strategies Consumer Health, American Heart Association

National Center, [email protected], 214-706-1593

Sara Benjamin Neelon, PhD, MPH, RD, Department of

Community and Family Medicine, Duke University Medical

Center & Duke Global Health Institute, [email protected],

919.681.6920 or 919.613.6221

Natasha Frost, Staff Attorney, Public Health Law Center,

[email protected], 651-290-6454

Elizabeth Walker, MS, Sr. Director, Health Improvement,

ASTHO, [email protected], 571-527-3170

mailto:[email protected]




Questions?

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Documents

PUBLIC HEALTH POLICY CHANGE · Physical Activity Research Children are sedentary 70-83% of time in child care (excluding nap) 2-3% of time (7-13 mins) in vigorous activity 3-15% of