Section on Early Education and Child Care Hot Topics in Early Childhood Influencing Early Education and

Child Care: Research, Early Literacy, Obesity Prevention

Practical strategies for increasing children’s physical

activity in child care

Kristen Copeland, MD, FAAPNutrition Technical Panel Member, Caring for Our Children,

3rd Ed.Assistant Professor of Pediatrics

Division of General and Community PediatricsCincinnati Children’s Hospital Medical Center

Oct 3rd, 2010

Disclosures

• In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in my presentation.

This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA or if you will be discussing “off-label” uses of pharmaceuticals or devices.

Outline• Why do we need to increase physical activity in child care?

– Background on PA: link to obesity, current levels in child care

• What is going on? Why are levels so variable?: An insider’s view

– Focus groups w/ child care providers re: perceived benefits and barriers

– Telephone survey of PA environment

– Ongoing fieldwork in childcare centers

• How do we increase physical activity levels in child care?

– The new physical activity standards in Caring for Our Children

• Based on evidence and/or expert opinion

• Address common barriers

• Offer practical strategies

• Take home messages

Background: Obesity & PA, Child Care

• Over past 35 yrs, the % of preschoolers who are obese (>95th%ile for BMI) has tripled, school-age ~quintupled1

• Obesity linked to inadequate physical activity2-5

• 13 M children, 75% US 3-6yo in some form of child care

• Many spend long hours in child care: Only opportunity for exercise may be in child care

– Young children are completely dependent on their caregivers for opportunities to be active

1. Ogden CL, JAMA 2006. 2. Patrick K, et al Arch Pediatr Adolesc Med. 2004 ; 3. Robinson TN. Jama. 1999 4. Gortmaker SL et al Arch Pediatr Adolesc Med. Sep 1999; 5.Epstein LH, et al. Health Psychol. Mar 1995

Background: Physical activity levels in child care

• Children are sedentary for most (70-83%) of their time in child care, excluding nap1-2

– only small amount (2-3%) of time in vigorous activity

– only 12-46 min of moderate or vigorous activity over course of 6 hr day in child care1-2

• The amount of physical activity children get in child care varies widely, and depends mostly on the center attended (27-47% of

variance), not child factors (3-10% of variance combined)1-3

1. Pate RR et al Pediatrics. Nov 2004 2. Pate RR et al. J Sch Health. Aug 2008, 3.Finn K, et al J Pediatr. Jan 2002

Why are PA levels so low? Voices from the field

Our ongoing research in Cincinnati 2006-present

1) 9 focus groups* with 49 child care providers from 34 centers. 2006-8 • re: perceived benefits and barriers to PA in child care

2) Telephone survey of PA environment in childcare (ELEPhANTS) 2008-9• Playground, indoor gross-motor room, weather

policies for outdoor play

3) Ongoing fieldwork in childcare centers 2009-present

*Copeland KA et al, Int J of Behav Nutr and Phys Act. 2009

Focus Groups: Teachers’ perceptions of the health benefits of PA and outdoor time for young children

• Obesity prevention• Build healthy habits• Develop fundamental motor

skills• Children nap better**• Outdoor time:

– More room to run– Vitamin D**– Escape germs from indoors

(children less likely to get sick)**

• Add’l health benefits from the literature– Improved

fitness– Lower BP– Higher serum

HDL– Increased bone

mineral density– Improved sleep

**benefits also for teachers

Teachers’ perceptions of the socio-emotional benefits of physical activity and outdoor time

• Improved self-efficacy, self-confidence after mastering gross motor skills

• Improved peer relationships • Energy/stress relief, calm the

classroom**• Outdoor time:

– Improved mood**• ‘endorphins’

– More creative, expressive

• Add’l SE benefits from the literature– Anti-

depressive effects

**benefits also for teachers

Teachers’ perceptions of the learning benefits of physical activity and outdoor time

• Improved concentration, attention

• Hands-on “Active Learning” – concepts of time, distance,

language

• Outdoor time:– Sensory experiences

– Science

– Understanding concepts of society, citizenship

• Add’l learning benefits from the literature– Improved

concentration, attention

– Outdoor exposure for ADHD

Barriers to physical activity-child and parent

Finding from focus groups*Child: • injuries • getting dirty

Parent:• direct parent requests not to take child outside

– Child will get sick– Concerns about asthma

• indirect – dressing child in improper clothing (eg, nice/expensive

clothes, flip flops, or no coat in winter)

*Copeland KA et al, Int J of Behav Nutr and Phys Act. 2009

Barriers to physical activity- physical Findings from Telephone Survey*

Structural*• No outdoor playground• No indoor play-space for days with inclement weather• Playground too small, not enough equipment- Wide variability

across different centers

Weather: • Rain/Snow• Standing water, snow on playground• “Extreme” heat/ smog alert or cold

– Wide variability in minimum temperature, 32°F most common in Cincinnati*

*Telephone survey, ELEPhANTS

Barriers to physical activity- teachers Finding from focus groups

• Teachers’ preferences about the weather – “not a cold weather person"

• Don’t like going outside, getting dirty, sweaty, insects,

• Too much work involved – Putting on coats, sunscreen, setting up portable play

equipment

• Teacher has low self-efficacy– Not trained in “playground teaching”

• Teacher overweight, low self-esteem

Teacher as the gatekeeper to the playground

Barriers to physical activity- societal, policy

Finding from focus groups

• Focus on “academics” (at expense of outdoor/gross motor time)

• “Climbers are boring”--Playgrounds are safe but have little variety, minimally challenging, not fun for the children

• “Budgets are tight”—minimal investment available for physical activity facilities – False appeal of the fancy climber

New Physical Activity Standards

Released September, 2010

New PA guidelines in CFOC: Background

Previous editions of CFOC had no guideline to promote physical activity, focus on safety

• Based on evidence• Address common barriers• Offer practical strategies

– Informed by our focus groups and telephone survey

• Where evidence lacking, rely on expert opinion– PA, nutrition, public health, pediatric, and ECE

experts

Example of evidence-based:Outdoor occasions and structured and

time

• Evidence supporting:– Children are more active

• when outdoors 1-2

• when prompted by adults 1,3-5

• All children 0-6yrs should have daily: – 2-3 outdoor occasions, weather permitting; – >2 structured or adult-led movement activities

1Brown WH Child Development 2009; 2Burdette Arch Ped Adol Med 2005, 2004. 3 McKenzie 1997. 4 McKenzie, 1992, 5 Sallis 1993

Examples of structured activities-movement and learning

• Simon Says, Mother May I• “Get the Wiggles Out” • Dance party*• Acting out animals• Track team*, relay races• Community walk through the

neighborhood• Several good websites listed in CFOC

*Brown WH J of Early Intervention Mar 2009.

Example of moderate evidence:Time allotted for structured and

unstructured time

• Preschool-aged children are vigorously active in very short bursts (15-30 sec)* – Cannot sustain prolonged (>5 min) periods of vigorous

activity

• In adults, short bouts of vigorous activity (10 min) have health benefits (2008 PA Guidelines for Americans)

*Oliver, M. et al. Sports Med 37:1045-70.2007.

NASPE2002

USDA 2005

Dietary Guidelines

AAP2006

US Dept HHS

2008 PA guidelines

CFOC, 3rd ed2010

Unstructured time

Infants - -Focus on

age-approp

play, ex-ploration

, safe

Not enough data to

make rec.

2-3 outdoor occasions

Toddlers 60 min - 60-90 min

Preschoolers 60 min60 min,

most d/wk90-120 min

Structured time

Infantspromote

dev- N/A

Not enough data to

make rec.

2-3 outdoor occasions

Toddlers 30 min - -≥2 struct

occ, 5-10 min ea

Preschoolers 60 min - -

≥2 struct occ, 5-10 min

ea

Example of evidence lacking: Sedentary time

• Children should not be seated for >15 min at a time, except during meals or naps.

* Benjamin, S. E et al The nutrition and physical activity self-assessment for child care (NAP SACC). Rev ed.2007

NASPE2002

AAP2006

NAP SACC*2007/ Baby NAP** 2011

CFOC, 3rd ed2010

Sedentary time

Infants -

-

30 min** <15 min

Toddlers <60 min 30 min** <15 min

Preschoolers

<60 min <30 min* <15 min

Outdoor play: weather

• “STANDARD: Children should play outdoors daily when weather and environmental conditions do not pose a significant health or safety risk: – Wind chill factor at or below minus 15°F and

heat index at or above 90°F, as identified by the National Weather Service.”

Very different from 32°F!

Weather: practical strategies

• Barriers: – Teachers

unsure when appropriate to go out

– Parents’ request not to take children out

• Strategies:– Have a written policy in

the parent handbook that specifies the temps and precipitation conditions children permitted outdoors, & expected clothing

• Benefits of PA

• For “buy-in”

Catching a cold from the cold: practical strategies

• Barrier: – Belief that children

will get sick if exposed to cold air

• Strategies:– Educate parents &

child care providers about causes of winter illness (i.e., viruses)

– Review importance of frequent hand-washing

– Proper sanitation techniques, esp. during mealtimes

Asthma: practical strategies

• Barrier: – Children with Asthma

– Cold or Hot temperatures can trigger symptoms

– Indoor allergens (dust and dust mites) are common triggers, become elevated during the winter.

• Strategies:– Attention to air

circulation during winter

– Try to go outside: children can wear a scarf

– Work with child’s primary medical provider to maximally control asthma and develop a self-management plan

Conclusion: Take-home messages for pediatricians

• Policy maker/Advocate: Focus on holistic ways to increase physical activity in child-care– Early learning standards vs. PA, <15 min seated

• Researcher: Need for more and better evidence to inform guidelines, most based on (divergent) expert opinion

• Child care consultants: Teachers are the gatekeepers to the playground, ultimately decide what active opportunities children have– Importance of proper training, and support

Conclusion: Take-home messages for pediatricians

In the office: Discuss with parents:

1. Importance, benefits of daily physical activity

• Don’t just focus on the negative (TV, bike helmets)

2. Importance of good role-modeling

• Don’t let the weather be an excuse--Go outside!

3. Will not get sick if exposed to cold

4. Work with their children’s child-care setting to improve the physical environment and increase active opps.

Questions?

http://www.nemours.org/filebox/service/preventive/nhps/paguidelines.pdf

• For examples of policies, see the Nemours Health and Prevention Services guide on best practices for physical activity at: http://www.nemours.org/filebox/service/preventive/nhps/paguidelines.pdf

Practical strategies resources• Nutrition and Physical Activity Self Assessment for Child

Care - NAP SACC Program - http://www.napsacc.org

• “Color Me Healthy Preschoolers Moving and Eating”- http://www.colormehealthy.com

• “Move and Learn” physical activity curriculum from Kansas State University

• “I am Moving I am Learning” Intervention in Head Start - http://eclkc.ohs.acf.hhs.gov/hslc/ecdh/Health/ Nutrition/Nutrition%20Program%20Staff/IamMovingIam.htm

• Moving and Learning: The Physical Activity Specialists for Birth through Age 8 - http://www.movingandlearning.com

• “How to Lower Your Risk for Type 2 Diabetes “National Diabetes Education Program http://ndep.nih.gov/media/kids-tips-lower-risk.pdf