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Communities Putting Prevention to Work: Results of an Obesity Prevention Initiative in Child Care Facilities

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Bibliographic Details
Title:	Communities Putting Prevention to Work: Results of an Obesity Prevention Initiative in Child Care Facilities
Language:	English
Authors:	Natale, Ruby, Camejo, Stephanie, Sanders, Lee M.
Source:	Journal of Research in Childhood Education. 2016 30(3):306-319.
Availability:	Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals
Peer Reviewed:	Y
Page Count:	14
Publication Date:	2016
Sponsoring Agency:	Centers for Disease Control and Prevention (DHHS/PHS)
Contract Number:	1U58DP00240601
Document Type:	Journal Articles Reports - Research
Education Level:	Early Childhood Education Preschool Education
Descriptors:	Early Childhood Education, Preschool Children, Prevention, Obesity, Child Care Centers, Intervention, Educational Policy, Preschool Teachers, Teacher Attitudes, Attitude Change, Program Effectiveness, Life Style, Educational Practices, Outdoor Education, Physical Activities, Physical Activity Level, Food, Child Health, Health Behavior, Health Activities, Statistical Analysis, Nutrition
Geographic Terms:	Florida (Miami)
DOI:	10.1080/02568543.2016.1178672
ISSN:	0256-8543
Abstract:	Obesity is a significant public health issue affecting even our youngest children. Given that a significant amount of young children are enrolled in child care, the goal of this project was to evaluate the effectiveness of a child care facility-based obesity prevention program. Over 1,000 facilities participated in the study. The intervention consisted of teacher trainings and technical assistance focused around the implementation of four policies: snack, beverage, physical activity, and screen time. Changes in teacher's attitudes and beliefs, as well as improvements in healthy lifestyle practices, were assessed. Results revealed significant improvements in child care center practices, such as: (1) the amount of health-related lessons provided to students increased t(664) = -6.09, P < 0.00; (2) the amount of outdoor physical activity increased t(702) = -3.83, P < 0.000; (3) the amount of screen time decreased t(686) = -2.52, P < 0.01; (4) the amount of juice served decreased t(577) = -7.38, P < 0.000; and (5) the amount of junk food decreased t(568) = -2.73, P < 0.006. The findings from this study can be easily disseminated and potentially serve as a model for improving the quality of nutrition and physical activity practices in child care facilities.
Abstractor:	As Provided
Number of References:	40
Entry Date:	2016
Accession Number:	EJ1105044
Database:	ERIC
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FullText	Links: – Type: pdflink Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwFjjIspoCg_8KI3MI_TTm6YAAAA4zCB4AYJKoZIhvcNAQcGoIHSMIHPAgEAMIHJBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDI7C1pHGgBcQLkLh9wIBEICBmz0PI93jnKmbkWLPzXd87DGVv37zFIJ6KetRuCxhUE0LR0Ym9UhGnUOELBfbAxnZEuQfOWxFr29Xuh5HuNWCgrZlbtS5p3weTUFlkym2EaBawfyUV0k4Ar6hFlLedxP7BmPzftS5xTUTzGOXhIqzNcq-ER3dlXEQyFYup-DNi4ytIiftoZSSjIn5s9Lc2-0El_EYTJODDtkIcfqC Text: Availability: 1 Value: <anid>AN0116395678;40z01jul.16;2019Feb13.16:56;v2.2.500</anid> <title id="AN0116395678-1">Communities Putting Prevention to Work: Results of an Obesity Prevention Initiative in Child Care Facilities. </title> <p>Obesity is a significant public health issue affecting even our youngest children. Given that a significant amount of young children are enrolled in child care, the goal of this project was to evaluate the effectiveness of a child care facility-based obesity prevention program. Over 1,000 facilities participated in the study. The intervention consisted of teacher trainings and technical assistance focused around the implementation of four policies: snack, beverage, physical activity, and screen time. Changes in teacher's attitudes and beliefs, as well as improvements in healthy lifestyle practices, were assessed. Results revealed significant improvements in child care center practices, such as: (<reflink idref="bib1" id="ref1">1</reflink>) the amount of health-related lessons provided to students increased t(<reflink idref="bib664" id="ref2">664</reflink>) = −6.09, P &lt; 0.00; (<reflink idref="bib2" id="ref3">2</reflink>) the amount of outdoor physical activity increased t(<reflink idref="bib702" id="ref4">702</reflink>) = −3.83, P &lt; 0.000; (<reflink idref="bib3" id="ref5">3</reflink>) the amount of screen time decreased t(<reflink idref="bib686" id="ref6">686</reflink>) = −2.52, P &lt; 0.01; (<reflink idref="bib4" id="ref7">4</reflink>) the amount of juice served decreased t(<reflink idref="bib577" id="ref8">577</reflink>) = −7.38, P &lt; 0.000; and (<reflink idref="bib5" id="ref9">5</reflink>) the amount of junk food decreased t(<reflink idref="bib568" id="ref10">568</reflink>) = −2.73, P &lt; 0.006. The findings from this study can be easily disseminated and potentially serve as a model for improving the quality of nutrition and physical activity practices in child care facilities.</p> <p>Keywords: Early care and education; obesity prevention; preschool; young children</p> <p>Childhood overweight is an epidemic in the United States, with approximately 32% of children (23 million) described as overweight (body mass index [BMI] 85–95 percentile for age and sex) or obese (BMI &gt; 95 percentile for age and sex; Ogden, Carroll, &amp; Flegal, [<reflink idref="bib32" id="ref11">32</reflink>]). Among children ages 2 to 5 years, 24.4% are overweight or obese—nearly triple the rate during the early 1970s (Nader et al., [<reflink idref="bib27" id="ref12">27</reflink>]).</p> <p>These statistics are of particular concern because obese preschool-age children are 5 times more likely to be overweight during adolescence (Birch &amp; Anzman, [<reflink idref="bib6" id="ref13">6</reflink>]) and more than 4 times as likely to be obese adults when compared to their normal weight counterparts (Gluckman, Hanson, Cooper, &amp; Thornburg, [<reflink idref="bib18" id="ref14">18</reflink>]). These results show that, contrary to popular belief, children do not "grow out of" their "baby fat." In fact, evidence indicates that excessive weight gain in the first years of life can alter developing neural, metabolic, and behavioral systems in ways that increase the risk for obesity and chronic disease later in life (Gluckman et al., [<reflink idref="bib18" id="ref15">18</reflink>]; Institute of Medicine of the National Academies, [<reflink idref="bib20" id="ref16">20</reflink>]). Specifically, childhood obesity is a precursor to type 2 diabetes, cardiovascular disease, hypertension, stroke, osteoarthritis, asthma, and certain cancers (Institute of Medicine, [<reflink idref="bib20" id="ref17">20</reflink>]; Sun et al., [<reflink idref="bib38" id="ref18">38</reflink>]).</p> <p>Although few attempts have been made to prevent excess weight gain during the first years of life, this period may represent the best opportunity for obesity prevention. During early childhood, lifestyle behaviors that promote obesity are just being learned, and it is easier to establish new behaviors than to change existing ones. Research shows that engaging child care centers is one way to address obesity prevention. Specifically, child care settings provide an opportunity to modify many risk factors for childhood-onset obesity, including increased physical activity, provision of healthy nutrition, healthy lifestyle education, and decreased screen time.</p> <p>Most studies targeting obesity prevention among children have focused on the school-age and adolescent population. To date, the complexity of the early childhood obesity prevention intervention implementation process has not been well studied or understood. This is particularly true in low-resource settings and for populations traditionally underrepresented in obesity prevention research. Yet obesity is more prevalent among children who are poor and minority than among children who are wealthier and nonminority (Bowman, Gortmaker, Ebbeling, Pereira, &amp; Ludwig, [<reflink idref="bib7" id="ref19">7</reflink>]). Black and Hispanic children are at greater risk than White children for type 2 diabetes (Bowman et al., [<reflink idref="bib7" id="ref20">7</reflink>]). The prevalence of metabolic syndrome is highest among Hispanic and lowest among Black adolescents, with White adolescents in between (Cossrow &amp; Falkner, [<reflink idref="bib11" id="ref21">11</reflink>]; Cruz et al., [<reflink idref="bib12" id="ref22">12</reflink>]; Rodriguez-Moran, Salazar-Vazquez, Violante, &amp; Guerrero-Romero, [<reflink idref="bib36" id="ref23">36</reflink>]). Much less is known about ethnic disparities in the preschool-age group, especially within major ethnic categories such as Black and Hispanic (i.e., Caribbean Black, Central and South American).</p> <p>According to recent analysis from the Early Childhood Longitudinal Survey, the child-care setting itself also appears to be protective against obesity, particularly for Latino children (Maher, Li, Carter, &amp; Johnson, [<reflink idref="bib24" id="ref24">24</reflink>]). However, a review of 147 obesity intervention studies (Flynn et al., [<reflink idref="bib16" id="ref25">16</reflink>]) concluded there has been a paucity of rigorous studies testing population-based and multilevel intervention approaches specifically focused on modifying nutrition and physical activity. In a review of 38 school-based (not child care center–based) studies by Centers for Disease Control and Prevention Task Force, only 10 studies were judged to have adequate methodology (Katz et al., [<reflink idref="bib22" id="ref26">22</reflink>]). None of these studies examined individual intervention components, program duration or intensity, or mediating variables. From their review of the literature, the Working Group to Prevent Childhood Obesity concluded that the existing body of research provides no definitive answers concerning the optimal intervention approaches or settings for obesity prevention. In particular, they concluded that the role of parents and other family members, as well as parental lifestyle factors and their effects on child body weight, deserves more study and should be incorporated into interventions to change children's behaviors (Pratt, Stevens, &amp; Daniels, [<reflink idref="bib35" id="ref27">35</reflink>]).</p> <p>As a response to the epidemic of childhood obesity, we developed a community-based intervention targeting nutrition and physical activity within child care facilities throughout Miami-Dade County in Florida, USA. Specifically, the objective of this initiative was to improve the quality of nutrition and physical activity practices within child care facilities (i.e., child care centers and family child care homes). Given that eating and physical activity patterns are established during the preschool years (Ogden et al., [<reflink idref="bib33" id="ref28">33</reflink>]), it is essential to target prevention efforts during this critical period of weight gain (Bandura, [<reflink idref="bib5" id="ref29">5</reflink>]). Therefore, this project is a prevention study designed to keep children off the trajectory of becoming overweight.</p> <hd id="AN0116395678-2">Conceptual framework</hd> <p>This program was funded by the Centers for Disease Control and Prevention (CDC) as part of Communities Putting Prevention to Work initiative (CPPW). The conceptual framework for the intervention was based on social cognitive theory (SCT; Bandura, [<reflink idref="bib5" id="ref30">5</reflink>]), which postulates that children learn new behaviors by observing and imitating models such as parents, teachers, and peers. Specifically, the theoretical underpinnings selected from SCT (Bandura, [<reflink idref="bib5" id="ref31">5</reflink>]) include expectancies (the values and benefits placed on a particular outcome), self-control and performance (decisions made to achieve self-control), behavior capability/knowledge/skills acquisition to perform that behavior, environment and situation (actual and perceived), observational learning, and self-efficacy for specific behaviors. Accordingly, the program aimed to increase fruit and vegetable intake and physical activity levels (due to their known importance for good health) through implementation of an evidence-based nutrition and healthy living curriculum. This effort sought to answer the following research question: (<reflink idref="bib1" id="ref32">1</reflink>) Does the program improve the quality of nutrition and physical activity practices within child care facilities? (<reflink idref="bib2" id="ref33">2</reflink>) Does the program increase health behaviors of teachers (nutritional gatekeepers) who serve as models for young children? (<reflink idref="bib3" id="ref34">3</reflink>) Are there any cultural and environmental differences in program outcomes?</p> <hd id="AN0116395678-3">Intervention components</hd> <p>In an effort to establish an effective and sustainable intervention focused on increasing the availability of healthy foods and beverages in addition to increasing physical activity, CPPW has created a program that has three primary components: (<reflink idref="bib1" id="ref35">1</reflink>) adopt policy changes, (<reflink idref="bib2" id="ref36">2</reflink>) facilitate intensive nutritional consultations with a certified nutritionist to modify menus consistent with policy recommendations for healthy food and drink choices, and (<reflink idref="bib3" id="ref37">3</reflink>) provide caregivers skills through technical assistance to facilitate implementation of in-class activities to increase physical activity.</p> <hd id="AN0116395678-4">Policy changes</hd> <p>Centers adopted "best-practice policies" (critical for intervention maintenance and effective mediators of change) to regulate the types and quality of foods provided as part of the meals served. In addition, policies included evidence-based nutrition and healthy living education, increasing the amount of physical activity, and decreasing the amount of television viewing and computer time. The four policies were Snack Policy, Beverage Policy, Physical Activity Policy, and Screen Time Policy and were based on <emph>Caring for Our Children</emph> (3rd ed.) standards (American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education [APA APHA], [<reflink idref="bib3" id="ref38">3</reflink>]). All modifications were revenue neutral (do not have an additional cost) and have been shown to be effective in childhood obesity interventions. The meals and beverages were provided by caterers who worked with the HC2 nutritionist to ensure that the meals followed the policy guidelines yet still met U.S. Department of Agriculture nutrition requirements.</p> <p></p> <ulist> <item> Beverage Policy: Menus in intervention centers were modified to include low-fat (1%) or skim milk, water, and less juice. Low fat or skim milk was promoted only at lunch, and water was promoted as the primary beverage for staff and children, especially after physical activity.</item> <p></p> <item> Snack Policy: Menus in intervention centers were modified to include more fresh fruit (or canned fruit in water or 100% juice), fresh vegetables (or low-sodium canned vegetables), and fewer simple carbohydrate snacks (cookies, crackers, etc.). The centers also were encouraged to incorporate fresh fruits and vegetables for snack and meal time as often as possible. In addition, we provided food tastings to the children to expose them to new fruits and vegetables that they may have never tried before (e.g., kiwi, blackberries, rhubarb, edamame, and cauliflower).</item> <p></p> <item> Physical Activity Policy: Physical activity was promoted for at least 90 to 120 minutes per day. Teachers were offered structured physical activities in the classrooms that included music and movement CDs with songs and exercises. Teachers were also provided with rainy-day activities that could be used in the classroom and equipment that can be purchased inexpensively at local stores (jump ropes, hula hoops, balls, etc.).</item> <p></p> <item> Reduction of Screen Time Policy: The reduction of screen time was addressed by limiting television viewing, watching movies, and playing computer games to 30 minutes or fewer each week. The amount of screen time was documented.</item> </ulist> <hd id="AN0116395678-5">Menu changes</hd> <p>A registered dietician met with the child care centers and caterers to assist with menu changes/planning as related to (<reflink idref="bib1" id="ref39">1</reflink>) consistency with the Institute of Medicine of the National Academies (IOM, [<reflink idref="bib21" id="ref40">21</reflink>].) policy guidelines (i.e., fruits and vegetables with little added sugar, salt or fat, low fat or non-fat milk), (<reflink idref="bib2" id="ref41">2</reflink>) consistency with Dietary Guidelines for Americans and the Child and Adult Care Food Program meal patterns, and (<reflink idref="bib3" id="ref42">3</reflink>) cost-neutral recommendations to aid in sustainability.</p> <hd id="AN0116395678-6">Training and technical assistance</hd> <p>To assist facilities in implementing the policies, a two-tiered training program was implemented. A needs assessment was given to all participating centers that had them rate their current nutrition and physical activity practices. All facilities were offered Tier 1 training, which consisted of a 2-hour training focusing on ways to improve the nutrition and physical activity environment of the facility as well as snack, beverage, physical activity, and screen time-specific policy implementation. Centers needing additional assistance, based on low Needs Assessment scores, were offered Tier 2 training. Tier 2 consisted of bimonthly policy implementation technical assistance (TA) by the coaches over the course of the school year. The content of the TA was tailored to the specific needs of the centers and focused on identifying barriers to implementation of policies. For example, one center may have had TA that focused on menu changes, but another center may have focused on increasing outdoor play. As such, materials were also provided to the centers to assist with implementation (i.e., hula hoops/jump ropes/balls for centers with limited physical activity).</p> <hd id="AN0116395678-7">Method</hd> <p>Child care centers (out-of-home facilities) and family child care homes (in-home facilities) were recruited through the Department of Children and Families and were sampled from diverse neighborhoods in Miami-Dade County. <emph>Out-of-home child care facilities</emph> were defined as facilities not operating within a family home environment and <emph>in-home child care facilities</emph> were defined by operation within a home environment. Facilities were excluded if they did not serve children in the age range of 3 to 5 years. Although demographic data on each facility with respect to race and ethnicity are limited to a subset of our sample, the Children's Trust ([<reflink idref="bib9" id="ref43">9</reflink>]) found that 54% of children in Miami-Dade County are Hispanic, approximately 25% are Black non-Hispanic, and nearly 20% are White, non-Hispanic.</p> <p>Preliminary contact was made with participants from August 2010 to January 2012. Baseline data were collected through the administration of the Pre-Needs Assessment. A Post-Needs Assessment was collected upon completion of the program (not fewer than 45 days after a facility received training).</p> <p>Directors and staff from each facility completed a self-assessment that detailed their practices related to nutrition and physical activity. To measure physical activity practices, a Physical Activity Frequency Questionnaire was developed based on physical activity standards (APA APHA, [<reflink idref="bib2" id="ref44">2</reflink>], [<reflink idref="bib3" id="ref45">3</reflink>]; National Association for the Education of Young Children, [<reflink idref="bib30" id="ref46">30</reflink>]). The directors were instructed to identify the amount of time children spent in the following activities: (<reflink idref="bib1" id="ref47">1</reflink>) outdoor physical activity, (<reflink idref="bib2" id="ref48">2</reflink>) indoor physical activity, (<reflink idref="bib2" id="ref49">2</reflink>) viewing television, (<reflink idref="bib3" id="ref50">3</reflink>) utilizing computers, and (<reflink idref="bib4" id="ref51">4</reflink>) engagement in health-related lessons. Increased levels of outdoor physical activity, indoor physical activity, and involvement in health-related lessons resulted in high scores, whereas high levels of time spent viewing television and engaged in screen time were reverse coded.</p> <p>The Food Frequency Questionnaire was developed based on a modified version of the Harvard Service Food Frequency Questionnaire (HSFFQ; Willett et al., [<reflink idref="bib40" id="ref52">40</reflink>]). The HSFFQ is a self-administered assessment tool created to assess programs interested in nutrition and health practices. The HSFFQ includes assumed portion sizes and frequency scale for the intake of foods as well as the amount of physical activity practices within the center. It was designed for low-income populations and is a 5-minute self-report that captures general information about the nutrition practices of the participant (child care centers and family child care homes). The foods on the HSFFQ were compiled from a list of most commonly eaten foods and their average portion sizes for low-income communities. A modified version of this measure was utilized with foods and beverages that were of interest to this study. Child care facility directors were asked to estimate the frequency of servings for the following food and beverage items: whole milk, 2% milk, 1% milk, skim milk, juice, water, fresh fruit, vegetables, fruit cup with syrup, chips, crackers, rolls/bread, cookies, cake pastries, and ice cream. Serving frequency was then categorized and labeled <emph>good, average</emph>, or <emph>poor</emph> based upon the directors' reports. Items that promote optimal health (i.e., water, fruits, and vegetables) received higher scores with increased serving frequency, whereas items that are linked to poor nutrition (i.e., whole milk, juice, and cookies) received lower scores with increased serving frequency.</p> <p>Furthermore, an observation was conducted utilizing the Health Environment Rating Scale (HERS; Natale, Sanders, &amp; Uhlhorn, [<reflink idref="bib29" id="ref53">29</reflink>]). The HERS measured the level of policy implementation at each center and was completed by the Department of Children and Families during unannounced visits at the end of the intervention. This is a 7-point Likert-type scale, with 1 indicating that the <emph>policy was not implemented</emph>, 3 indicating <emph>some aspects of implementation</emph>, 5 indicating <emph>full implementation</emph>, and 7 indicating <emph>implementation beyond what was expected</emph> in the policies. The HERS consists of 12 items broken down into each of the four policies described above. A summary was given that was the average of each item composing the policy. A summary score of 5 or greater indicated that their center implemented that policy to sufficient standards. To receive a 5 of the Beverage Policy, the centers had to serve low-fat (1%) or skim milk, water, and less juice. To receive a score of 5 on the Snack Policy, centers had to serve more fresh fruit (or canned fruit in water or 100% juice), fresh vegetables (or low-sodium canned vegetables), and fewer simple carbohydrate snacks (cookies, crackers, etc.). To receive a 5 on the Physical Activity Policy, centers had to promote physical activity for at least 60 to 90 minutes per day. Lastly, a score of 5 on the Screen Time Policy indicated limiting television viewing, watching movies, and playing computer games to fewer than 30 minutes each week.</p> <p>In addition, child care providers completed a questionnaire regarding knowledge and self-efficacy related to making improvements in nutrition and physical activity. The Knowledge Survey was developed to determine if participants gained information as a result of the trainings. True/false questions were asked about statements such as (<reflink idref="bib1" id="ref54">1</reflink>) the rate of obesity has increased by 300%, (<reflink idref="bib2" id="ref55">2</reflink>) about three million Americans are overweight, (<reflink idref="bib3" id="ref56">3</reflink>) as many as one third of all Americans are considered obese, (<reflink idref="bib4" id="ref57">4</reflink>) obesity is linked to higher rates of cancer and stroke, (<reflink idref="bib5" id="ref58">5</reflink>) less than one third of children met minimum physical activity standards, (<reflink idref="bib6" id="ref59">6</reflink>) children who are overweight are not more likely to experience low self-esteem, (<reflink idref="bib7" id="ref60">7</reflink>) less than 10% of children spend less than 1 hour a day participating in physical activity, and (<reflink idref="bib8" id="ref61">8</reflink>) modeling is an important way to increase healthy behaviors in children.</p> <hd id="AN0116395678-8">Statistical analysis</hd> <p>Descriptive analysis included frequencies to assess the means, valid percentages, and categorical information for all obesogenic practices across all facilities. Paired-sample <emph>t</emph> tests were used for parametric characteristics to assess significant differences between pre- and postdata. In addition, one-way ANOVAs were utilized to determine differences in outcomes based on any mediating factors (i.e., cultural and environmental factors).</p> <p>Prior to analysis, data were reviewed to ensure that data had been input correctly using a two-step process of detection and correction. Detection included a thorough review of descriptive statistics. Missing data were identified, however, due to the large sample size of the study; all statistical analyses were run with the inclusion of missing data. Notably, inclusion is a common and preferred practice in statistical analysis of data sets with a large sample (Collins, Schafer, &amp; Kam, [<reflink idref="bib10" id="ref62">10</reflink>]). Missing data in this study were examined and appeared to be the result of participant error (e.g., inadvertent noncompletion of assessment items). To have valid data analyses, we only completed pre–post <emph>t</emph> test analyses on the complete data set of 331 participants. All analyses were conducted with the Statistical Package for the Social Sciences (SPSS version 18).</p> <hd id="AN0116395678-9">Results</hd> <p>All 1,400 child care facilities in Miami-Dade County (serving more than 20,000) were invited to participate in this project over an 18-month period. One thousand and seventy facilities completed baseline data (803 family child care homes, 267 child care centers), 331 facilities completed pre–post assessments, and 1,808 providers completed pre–post knowledge surveys. Facility-level demographics were collected on a subsample of facilities (<emph>n</emph> = 114). Approximately 50% of the sample was Hispanic, 17% was Non-Hispanic Black, 5% was White, and the remainder was of varying or mixed ethnicities. In addition, we examined results of facilities based on income zone. Facilities were delineated based on zip code with each zip code categorized by percent of household income less than $25,000. Five income zones were established: White ($25,000 ≤ 10%), green ($25,000 &lt; 10.1% – 20.0%), yellow ($25,000 &lt; 20.% – 30.0%), pink ($25,000 &lt; 30.1% – 40.0%), and red ($25,000 &gt; 40%). Approximately 20% of facilities were in high-poverty income zones. Approximately 90% of family child care homes had food prepared by the facility and 70% of child care centers had food prepared by outside caterers.</p> <hd id="AN0116395678-10">Child care facility outcomes</hd> <p></p> <hd id="AN0116395678-11">Baseline nutrition and physical activity practices</hd> <p>Overall, results of the Food Frequency Questionnaire revealed the majority of the facilities have good physical activity practices at baseline, with 56.7% rated as <emph>good</emph> in indoor and outdoor play. For physical activity, a rating of <emph>poor</emph> indicated that the center does not engage in any type of physical activity or engages in physical activity one time per month. A rating of <emph>average</emph> indicated that the center engaged in 30 minutes of physical activity one to three times per week. A rating of <emph>good</emph> was awarded to centers that had 60 to 90 minutes of scheduled physical activity, five times per week for their students. For screen time, <emph>poor</emph> indicated that centers permitted more than 60 minutes of screen time every day, a rating of <emph>average</emph> indicated that centers permitted 30 to 60 minutes of screen time every day, and a rating of <emph>good</emph> indicated that centers permitted only 30 minutes, one to three times per week.</p> <p>Physical activity results revealed that 95.5% of child care facilities were rated as <emph>good</emph> in outdoor play and 86.3% reported <emph>good</emph> levels of indoor play. However, facilities displayed lower initial levels of limiting television viewing and providing health-related lessons. Forty-six percent of facilities have reported 30 to 60 minutes or more of television every day while at their facility. In addition, almost one half (47.2%) of facilities reported brief (30 minutes) health lessons one time per month or one time per week, whereas the standard is 30 to 60 minutes five times per week (APA APHA, [<reflink idref="bib3" id="ref63">3</reflink>]).</p> <p>Nutrition practices were not as good as physical activity levels at baseline, suggesting centers needed more help in this area. Based on the Food Frequency Questionnaire, three categorical ratings were included. For health items, a rating of <emph>good</emph> indicated that the center served a particular healthy food item at a high rate of one to three times per day, a rating of <emph>average</emph> indicated serving one time per week, and a rating of <emph>poor</emph> indicated that the center served a particular healthy food at a low rate of item less than two times per month. For example, 50% were assessed as poor for serving 1% milk (meaning that the center served this item at a low rate). For unhealthy foods, three categories were defined: <emph>poor</emph> indicated that the center served the unhealthy item at a frequent rate of one to three times per day, <emph>average</emph> indicated serving three to five times per week, and <emph>good</emph> indicated that the center served the unhealthy item at an infrequent rate of less than one time per week.</p> <hd id="AN0116395678-12">Three-month outcomes (nutrition and physical activity practices)</hd> <p>Seven hundred and three facilities completed pre–post data utilizing the Food Frequency self-report questionnaire. Paired-samples <emph>t</emph> test results revealed significant improvement in physical activity practices, such as (<reflink idref="bib1" id="ref64">1</reflink>) the amount of health-related lessons provided to students increased, <emph>t</emph>(<reflink idref="bib664" id="ref65">664</reflink>) = −6.09, <emph>p</emph> &lt; .00; (<reflink idref="bib2" id="ref66">2</reflink>) the amount of outdoor physical activity increased, <emph>t</emph>(<reflink idref="bib702" id="ref67">702</reflink>) = −3.83, <emph>p</emph> &lt; .000; and (<reflink idref="bib3" id="ref68">3</reflink>) the amount of screen time decreased, <emph>t</emph>(<reflink idref="bib686" id="ref69">686</reflink>) = −2.52, <emph>p</emph> &lt; .01. In addition, improvements in nutrition practices were observed. Specifically, (<reflink idref="bib1" id="ref70">1</reflink>) the amount of whole milk served decreased, <emph>t</emph>(<reflink idref="bib517" id="ref71">517</reflink>) = −7.43, <emph>p</emph> &lt; .000; (<reflink idref="bib2" id="ref72">2</reflink>) the amount of 1% milk served increased, <emph>t</emph>(<reflink idref="bib546" id="ref73">546</reflink>) = −7.08, <emph>p</emph> &lt; .000; (<reflink idref="bib3" id="ref74">3</reflink>) the amount of juice served decreased, <emph>t</emph>(<reflink idref="bib577" id="ref75">577</reflink>) = −7.38, <emph>p</emph> &lt; .000; (<reflink idref="bib4" id="ref76">4</reflink>) the amount of fresh vegetables served increased, <emph>t</emph>(<reflink idref="bib586" id="ref77">586</reflink>) = −2.85, <emph>p</emph> &lt; .005; and (<reflink idref="bib5" id="ref78">5</reflink>) the amount of junk food served decreased, <emph>t</emph>(<reflink idref="bib568" id="ref79">568</reflink>) = −2.73, <emph>p</emph> &lt; .006.</p> <p>In addition to differences within centers, we also examined differences between centers. Figure 1 graphically displays the percentage of facilities that had good physical activity practices as baseline versus the percentage of centers that had good physical activity practices at postintervention. As reflected in the graph, 83% of facilities had good indoor physical activity at baseline (at least 60 minutes per day) whereas 91% demonstrated good indoor physical activity levels at postintervention.</p> <p>Graph: Figure 1. Percent of facilities rated as "good" at baseline verses postintervention on physical activity outcomes.</p> <p>Figure 2 graphically displays the percentage of facilities that had good nutrition practices as baseline versus the percentage of centers that had good nutrition practices at postintervention. A significant improvement was seen in the percent of facilities that reduced serving whole milk. For whole milk, 56% of were rated as <emph>good</emph> at baseline, whereas 74% of facilities were rated as <emph>good</emph> at postintervention (meaning more centers reduced the amount of whole milk served to students).</p> <p>Graph: Figure 2. Percent of facilities rated as good at baseline versus postintervention on nutrition practices.</p> <hd id="AN0116395678-13">Three-month outcomes (policy implementation)</hd> <p>To corroborate findings on self-report measures, an observation of child care nutrition and physical activity practices was conducted on 718 centers. The HERS measured the level of policy implementation at each center. A summary score of 5 or greater in each policy domain (Beverage, Snack, Screen Time, Physical Activity) indicated that their center implemented that policy to sufficient standards. At postassessment, 3 months after the program was implemented, 84% (<emph>n</emph> = 579) of centers observed had fully implemented the Beverage Policy, 76% (<emph>n</emph> = 536) of centers were implementing the Snack Policy, 99% (<emph>n</emph> = 713) were implementing the Physical Activity Policy, and 95% (<emph>n</emph> = 676) were successfully implementing the Screen Time policy.</p> <hd id="AN0116395678-14">Teacher outcomes</hd> <p>One thousand eight hundred and eight child care providers completed a questionnaire regarding knowledge and self-efficacy related to making improvements in nutrition and physical activity. Descriptive data reveal an increase in knowledge from pretraining assessment scores (<emph>M</emph> = 5.17) to posttraining assessment scores (<emph>M</emph> = 6.07). To investigate whether there are significant differences in participants' scores on the pretraining assessment and the posttraining assessment, dependent <emph>t</emph> tests were run. Results from the <emph>t</emph> test indicate a highly significant and positive increase in the posttraining assessment scores as compared to the pretraining assessment scores (<emph>t</emph> = −26.58, <emph>p</emph> &lt; .000).</p> <hd id="AN0116395678-15">Factors mediating outcomes</hd> <p>We conducted one-way ANOVAs to determine if cultural and economic variables mediated the response to the intervention. Results revealed racial differences (Black, White Non-Hispanic, Other, Mixed) on some of the nutrition and physical activity outcome variables. In particular, the predominant race found within the centers was related to differences on the amount of fresh fruit, <emph>F</emph>(<reflink idref="bib3" id="ref80">3</reflink>, 441) = 3.35, <emph>p</emph> = .019 served, and the amount of exposure to television/video, <emph>F</emph>(<reflink idref="bib3" id="ref81">3</reflink>, 459) = 2.99, <emph>p</emph> = .031. Centers that identified themselves as predominantly White had the lowest levels of screen time, whereas centers that identified themselves as predominantly Black/African American had the highest levels of screen time. In addition, centers with Black/African American identified as the primary race had the lowest levels of fresh fruit served, whereas all other races indicated approximately the same levels of fresh fruit served to the children.</p> <p>We also examined the predominant ethnicity of the centers (Hispanic/Cuban, Hispanic Puerto Rican, Hispanic Other, Haitian, non-Hispanic Black, non-Hispanic White) in relation to outcomes achieved. Differences were observed in the amount of fresh fruit, <emph>F</emph>(<reflink idref="bib9" id="ref82">9</reflink>, 432) = 1.92, <emph>p</emph> = .048 and junk food (crackers), <emph>F</emph>(<reflink idref="bib9" id="ref83">9</reflink>, 431) = 2.05, <emph>p</emph> = .03, ice cream, <emph>F</emph>(<reflink idref="bib9" id="ref84">9</reflink>,<reflink idref="bib433" id="ref85">433</reflink>) = 2.01, <emph>p</emph> = .038) served postintervention.</p> <p>Black Non-Hispanic and Haitian had the lowest levels of fresh fruit and White non-Hispanic and Hispanic Other (Central Americans) consumed the most. Hispanic Mexican and Haitian had the lowest levels of consuming junk food, whereas other ethnicities were about the same.</p> <p>One-way ANOVAs also revealed outcome differences based on the percentage of subsidized children enrolled in the facilities. Children who received subsidized child care must have a household income below the poverty line. Between-group differences were noted on outside activity, <emph>F</emph>(<reflink idref="bib72" id="ref86">72</reflink>, 296) = 1.33, <emph>p</emph> = .051 and junk food (chips) <emph>F</emph> (<reflink idref="bib72" id="ref87">72</reflink>, 283) = 1.55, <emph>p</emph> = .006; cake, <emph>F</emph>(<reflink idref="bib72" id="ref88">72</reflink>, 286) = 2.80, <emph>p</emph> = .000; ice cream, <emph>F</emph>(<reflink idref="bib72" id="ref89">72</reflink>, 285) = 1.29, <emph>p</emph> = .07; with centers with the highest percentage of subsidized children serving the most junk food and offering the least amount of outdoor physical activity.</p> <p>We also analyzed the data to determine if the income zone where the centers were located (based on five zones with the highest to lowest poverty levels) affected the outcomes results. Analyses revealed between-group differences in whole milk, <emph>F</emph>(<reflink idref="bib4" id="ref90">4</reflink>, 599) = 2.79, <emph>p</emph> = .026; fresh fruit, <emph>F</emph>(<reflink idref="bib4" id="ref91">4</reflink>, 616) = 3.50, <emph>p</emph> = .008; with TV approaching significance, <emph>F</emph>(<reflink idref="bib4" id="ref92">4</reflink>, 648) = 2.19, <emph>p</emph> = .06. For whole milk, the white zone (least poverty) was rated as serving the least amount of whole milk, whereas all other income zones were about the same. For fresh fruit served, the red zone (highest poverty) was rated as serving the least amount of fresh fruit, whereas the white zone was rated as serving the highest amount of fresh fruit.</p> <hd id="AN0116395678-16">Discussion</hd> <p>The period of early childhood represented the best opportunity for obesity prevention, as lifestyle behaviors that promote obesity are just being learned, and it is easier to establish new behaviors than to change existing ones. Child care settings offer a potentially powerful opportunity and infrastructure to implement such efforts, because (<reflink idref="bib1" id="ref93">1</reflink>) 70% of preschool-age children are enrolled in daily, out-of-home child care (Federal Interagency Forum on Child and Family Statistics, [<reflink idref="bib14" id="ref94">14</reflink>]); (<reflink idref="bib2" id="ref95">2</reflink>) children from low-income backgrounds consume 50% to 100% of their Recommended Dietary Allowances (according to standards established by the Child Care Food Program) in the child care setting (Fox, Glantz, Endahl, &amp; Wilde, [<reflink idref="bib17" id="ref96">17</reflink>]); (<reflink idref="bib3" id="ref97">3</reflink>) many children spend the majority of their waking hours out of home and in the child care setting (Fitzgibbon, Stolley, Dyer, VanHorn, &amp; KauferChristoffel, [<reflink idref="bib15" id="ref98">15</reflink>]); and (<reflink idref="bib4" id="ref99">4</reflink>) the University of Miami's recent pilot data (Natale et al., [<reflink idref="bib28" id="ref100">28</reflink>]) shows access to high-quality food is a significant disparity.</p> <p>At the beginning of the program, baseline observational data showed that, overall, none of the facilities had a nutrition and/or physical activity policy in place. In fact, facilities were struggling with serving appropriate type of milk to their preschool children and were lacking in the amount of physical activity provided to the children. At the end of the program, a significant improvement was seen in the amount of health-related lessons provided to students. In addition, facilities significantly increased the amount of outdoor physical activity they provide to the children. They also reduced the amount of juice served to the children. Finally, in the majority of centers serving children ages 2 to 5, whole milk was replaced with 1% milk as recommended in the APA APHA guidelines (APA APHA, [<reflink idref="bib3" id="ref101">3</reflink>]).</p> <p>The results of this study have been corroborated by other findings in the literature. Previous studies have noted success in preschool settings by increasing physical activities, reducing television viewing, and reducing the consumption of sweetened beverages (Dennison, Russo, Burdick, &amp; Jenkins, [<reflink idref="bib13" id="ref102">13</reflink>]; Fitzgibbon et al., [<reflink idref="bib15" id="ref103">15</reflink>]; Harvey-Berino &amp; Rourke, [<reflink idref="bib19" id="ref104">19</reflink>]; McGarvey et al., [<reflink idref="bib25" id="ref105">25</reflink>]; Mo-suwan, Pongprapai, Junjana, &amp; Puetaiboon, [<reflink idref="bib26" id="ref106">26</reflink>]; Stolley et al., [<reflink idref="bib37" id="ref107">37</reflink>]).</p> <p>Although research has demonstrated success on individual levels, a very limited amount of research has been conducted on implementing policies in child care facilities. This CPPW study was one of very few that tested making system-wide changes to a large number of centers across an entire county. The goal of the program was to ensure that at least 50% of the 1,000-plus facilities that were targeted implemented nutrition and physical activity policies. Results exceeded expectations, in that 84% of the centers observed fully implemented the Beverage Policy, 76% of the centers were implementing the Snack Policy, 99% of the centers implemented the Physical Activity Policy, and 95% of the centers successfully implemented the Screen Time policy. There are few programs like this that address policies on a system-wide level. One such program conducted policy recommendations in 24 child care centers and found that centers did not meet USDA Food Guide Pyramid for preschoolers. They recommended that centers need to be better equipped to provide quality nutrition to the children (Maalouf, [<reflink idref="bib23" id="ref108">23</reflink>]). Another policy-based program was based in West Australia, the Start Right–Eat Right program. This program worked with food service in line with government policies and regulations within child care facilities. They provided incentives to guide facilities to make policy changes. Eighty percent of centers made changes to their menus as a result of participating.</p> <p>Although policy changes were observed, it also should be noted that environmental and demographic factors were related to the nutritional and physical activity at the end of the intervention. In particular, the effects of the intervention were mediated by race, ethnicity, and levels of child subsidy. Racial differences were seen in the amount of fresh fruit served, and the amount of television/video children were exposed to at the end of the intervention. Centers who identified as serving mainly White children had the lowest levels of screen time, whereas centers that identified as serving mainly Black/African American children had the highest levels of screen time. In addition, centers with Black/African American as the identified predominant race had the lowest levels of fruit served, whereas all other races indicated approximately the same levels of fruit served to their children. We also examined the predominant ethnicity of the center (Hispanic Cuban, Hispanic Puerto Rican, Hispanic Other, Haitian, non-Hispanic Black, non-Hispanic White) to determine differences related to the outcomes. Similar to the racial findings, differences were seen in the amount of fresh fruit verses junk food provided to the children. Centers serving Black, non-Hispanic, and Haitian children, provided the lowest levels of fresh fruit. For junk foods, Hispanic Mexican and Haitian had the poorest levels of consuming junk food while other ethnicities were about the same.</p> <p>These findings are also reflected in the literature. African American children consume more fast food per day than their White counterparts (Bowman et al., [<reflink idref="bib7" id="ref109">7</reflink>]) and are less likely to participate in organized physical activities in a given week (Centers for Disease Control and Prevention, [<reflink idref="bib8" id="ref110">8</reflink>]). In addition, a higher percentage of African American children than non-Hispanic White children watched four or more hours of television per day, whereas Mexican American children were intermediate in television viewing time (Andersen, Crespo, Bartlett, Cheskin, &amp; Pratt, [<reflink idref="bib4" id="ref111">4</reflink>]). These differences in diet and activities may be partly explained by differences in average income levels between groups, with White families having higher median yearly incomes than African American and Hispanic families (Ng'andu &amp; Gianfortoni, [<reflink idref="bib31" id="ref112">31</reflink>])</p> <p>To examine the impact of differences in income, data were analyzed to see if there were different outcome results based on the percentage of children receiving subsidized child care. We would expect that centers serving children who are low income would have poorer nutrition due to the lower cost of poor nutrient items. In fact, we found that centers with the greater number of children who are low income had the highest levels of serving junk foods. In addition, centers serving children who are low income had the lowest levels of physical activity.</p> <p>We further analyzed the data to determine if the income zone (based on five zones with the highest to lowest poverty levels) where the centers were located impacted the outcomes results. Analyses revealed differences in whole milk (.026), fresh fruit (.008), and screen time approaching significance (<emph>p = </emph>.06). For whole milk consumption, the white zone tended to serve the least amount of whole milk, whereas all other zones served approximately the same amount. The reason for the differences could be an artifact of the sample size. There were fewer than four centers in the white zone, which may have skewed the sample. In addition, all centers served 2% milk, regardless of the zone. With regard to fresh fruit, the red zone tended to serve the least amount of fresh fruit, whereas the white zone tended to serve the greatest amount of fruit. This may speak to the accessibility issue in which children who live in economically depressed communities are less likely to have access to fresh fruits and vegetables (Alaimo, Olson, &amp; Frongillo, [<reflink idref="bib1" id="ref113">1</reflink>]). This is commensurate with results from our pilot study (Natale et al., [<reflink idref="bib29" id="ref114">29</reflink>]), based on an ethnic minority population of preschoolers, that 78% of children received dinner from a fast food restaurant at least once per week, whereas only 12% ate together as a family. Additionally, only 20% of the sample reported eating fruit three to four times a week (USDA recommendations are daily intake). Furthermore, TV viewing was more prominent in the pink and red low-income zones, corroborating the above findings (Natale et al., [<reflink idref="bib29" id="ref115">29</reflink>]). Studies have shown that residents of impoverished, unsafe neighborhoods are less likely to be physically active and are two BMI units heavier than those living in safer neighborhoods (Poston &amp; Foreyt, [<reflink idref="bib34" id="ref116">34</reflink>]).</p> <p>Given the significance of our current findings, it is important to note that caution should be taken when interpreting the results because demographic information was only captured on a sample of the facilities. Therefore, broad generalizations should not be made until further investigation is made. In addition, data were only collected at the child care center level; thus, individual data on the families was not included, but is an area that could further influence program outcomes. Lastly, there was a discrepancy between self-reported data and observational data. Given that self-reported data can be unreliable, an unannounced observation was conducted by the Department of Children and Families to address this issue.</p> <hd id="AN0116395678-17">Lessons learned</hd> <p>Given that ethnic disparities are well entrenched in the epidemic, with children who are minority disproportionately at risk of obesity and its health consequences for adulthood (Natale et al., [<reflink idref="bib28" id="ref117">28</reflink>]), it is important to address culture in obesity prevention programs. In light of cultural differences, our intervention with child care facilities serving Hispanic and African American populations must be culturally sensitive to be clinically effective. In doing so, the aim should not be to change people's food choices, but rather to modify their preparation techniques to promote more healthful nutrition. For example, we provided recipes and demonstrated techniques for steaming brown rice and cooking black beans with no fat. We also demonstrated how to bake chicken rather than fry it and how to use a colander for steaming vegetables. It is important to target the cognitive, cultural, and environmental barriers to a low-fat, high-fiber diet that includes more fruits and vegetables.</p> <hd id="AN0116395678-18">Implications and recommendations for child care facilities</hd> <p>Healthy People 2020 identifies "nutrition and weight status" as one of the major objectives to "promote health and reduce chronic disease risk through the consumption of healthful diets and achievement and maintenance of healthy body weights" (U.S. Department of Health and Human Services, [<reflink idref="bib39" id="ref118">39</reflink>], Overview section, para. 1). This objective emphasizes that efforts to change diet and weight should address the policies and environments that support these behaviors in settings such as schools (U.S. Department of Health and Human Services, [<reflink idref="bib39" id="ref119">39</reflink>]). This objective is particularly relevant in U.S. preschools and early childhood/child care environments (or "child care centers"), given that one in four U.S. children younger than age 5 is either overweight or obese. Based on these recommendations, all child care facilities should have nutrition and physical activity policies. In addition, quantitative and objective measurements (e.g., BMI) to assess the effectiveness of intervention practices are recommended.</p> <p>The polices listed above can serve as a guide for other facilities. The policies were developed based on Caring for Our Children (3rd ed.) standards (APA APHA, [<reflink idref="bib3" id="ref120">3</reflink>]) as well as best practice in the area of obesity prevention. Furthermore, effectively addressing obesity prevention with preschool children requires an understanding of the interplay between family social and cultural behaviors as well as beliefs and perception of healthy weight in childhood.</p> <hd id="AN0116395678-19">Conclusions</hd> <p>It is in the best interests of health care providers, educators, and parents to begin thinking about addressing childhood obesity as a priority for ensuring the healthy future of our community's children. Our large-scale CPPW program represents a unique opportunity to observe policy implementation in a multicultural community, while assisting child care centers in acquiring the tools needed to help combat the childhood obesity epidemic. Results of the HC2 program research suggest that this program was effective in changing child care center policies to increase daily physical activity and improve nutrition. Additionally, teachers participating in the HC2 program also showed statistically significant improvements in their knowledge and self-efficacy related to making improvements in nutrition and physical activity. This program demonstrates the importance, and success, of focusing on nutrition and healthy living efforts in educational settings that care for children ages 2 to 5 to ensure that they develop healthy attitudes and behaviors toward nutritious foods, physical activity, and healthy living. In doing so, this program also shed light on the importance of understanding the interplay between cultural and environmental factors that can affect program outcomes. Access to fresh fruits and cultural differences with respect to the amount of screen time promoted are potential barriers that should be addressed in future programs. The study findings are meant to assist practitioners in recognizing and identifying ethnic disparities and possible barriers to intervention when promoting policy change in child care facilities.</p> <hd id="AN0116395678-20">Acknowledgments</hd> <p>The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the U.S. Department of Health and Human Services or the Centers for Disease Control and Prevention. The authors would like to acknowledge our partners at the Miami-Dade County Department of Health—Dr. Lilian Rivera, Karen Weller, Bridget Smith, and Victoria McBee—as well as Alina Soto and the Department of Children and Families, Consulting Registered Dietitians, and all 1,140 participating child care facilities for their support and partnership throughout this program.</p> <hd id="AN0116395678-21">Funding</hd> <p>This research was supported in part by a cooperative agreement from Centers for Disease Control and Prevention's Communities Putting Prevention to Work program (1U58DP002406-01).</p> <ref id="AN0116395678-22"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Color versions of one or more of the figures in the article can be found online at <ulink href="http://www.tandfonline.com/ujrc">www.tandfonline.com/ujrc</ulink>.</bibtext> </blist> </ref> <ref id="AN0116395678-23"> <title> References </title> <blist> <bibtext> Alaimo, K., Olson, C. 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Header	DbId: eric DbLabel: ERIC An: EJ1105044 AccessLevel: 3 PubType: Academic Journal PubTypeId: academicJournal PreciseRelevancyScore: 0
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Items	– Name: Title Label: Title Group: Ti Data: Communities Putting Prevention to Work: Results of an Obesity Prevention Initiative in Child Care Facilities – Name: Language Label: Language Group: Lang Data: English – Name: Author Label: Authors Group: Au Data: <searchLink fieldCode="AR" term="%22Natale%2C+Ruby%22">Natale, Ruby</searchLink><br /><searchLink fieldCode="AR" term="%22Camejo%2C+Stephanie%22">Camejo, Stephanie</searchLink><br /><searchLink fieldCode="AR" term="%22Sanders%2C+Lee+M%2E%22">Sanders, Lee M.</searchLink> – Name: TitleSource Label: Source Group: Src Data: <searchLink fieldCode="SO" term="%22Journal+of+Research+in+Childhood+Education%22"><i>Journal of Research in Childhood Education</i></searchLink>. 2016 30(3):306-319. – Name: Avail Label: Availability Group: Avail Data: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals – Name: PeerReviewed Label: Peer Reviewed Group: SrcInfo Data: Y – Name: Pages Label: Page Count Group: Src Data: 14 – Name: DatePubCY Label: Publication Date Group: Date Data: 2016 – Name: SourceSuprt Label: Sponsoring Agency Group: SrcSuprt Data: Centers for Disease Control and Prevention (DHHS/PHS) – Name: NumberContract Label: Contract Number Group: NumCntrct Data: 1U58DP00240601 – Name: TypeDocument Label: Document Type Group: TypDoc Data: Journal Articles<br />Reports - Research – Name: Audience Label: Education Level Group: Audnce Data: <searchLink fieldCode="EL" term="%22Early+Childhood+Education%22">Early Childhood Education</searchLink><br /><searchLink fieldCode="EL" term="%22Preschool+Education%22">Preschool Education</searchLink> – Name: Subject Label: Descriptors Group: Su Data: <searchLink fieldCode="DE" term="%22Early+Childhood+Education%22">Early Childhood Education</searchLink><br /><searchLink fieldCode="DE" term="%22Preschool+Children%22">Preschool Children</searchLink><br /><searchLink fieldCode="DE" term="%22Prevention%22">Prevention</searchLink><br /><searchLink fieldCode="DE" term="%22Obesity%22">Obesity</searchLink><br /><searchLink fieldCode="DE" term="%22Child+Care+Centers%22">Child Care Centers</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Educational+Policy%22">Educational Policy</searchLink><br /><searchLink fieldCode="DE" term="%22Preschool+Teachers%22">Preschool Teachers</searchLink><br /><searchLink fieldCode="DE" term="%22Teacher+Attitudes%22">Teacher Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Attitude+Change%22">Attitude Change</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Life+Style%22">Life Style</searchLink><br /><searchLink fieldCode="DE" term="%22Educational+Practices%22">Educational Practices</searchLink><br /><searchLink fieldCode="DE" term="%22Outdoor+Education%22">Outdoor Education</searchLink><br /><searchLink fieldCode="DE" term="%22Physical+Activities%22">Physical Activities</searchLink><br /><searchLink fieldCode="DE" term="%22Physical+Activity+Level%22">Physical Activity Level</searchLink><br /><searchLink fieldCode="DE" term="%22Food%22">Food</searchLink><br /><searchLink fieldCode="DE" term="%22Child+Health%22">Child Health</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Behavior%22">Health Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Activities%22">Health Activities</searchLink><br /><searchLink fieldCode="DE" term="%22Statistical+Analysis%22">Statistical Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Nutrition%22">Nutrition</searchLink> – Name: Subject Label: Geographic Terms Group: Su Data: <searchLink fieldCode="DE" term="%22Florida+%28Miami%29%22">Florida (Miami)</searchLink> – Name: DOI Label: DOI Group: ID Data: 10.1080/02568543.2016.1178672 – Name: ISSN Label: ISSN Group: ISSN Data: 0256-8543 – Name: Abstract Label: Abstract Group: Ab Data: Obesity is a significant public health issue affecting even our youngest children. Given that a significant amount of young children are enrolled in child care, the goal of this project was to evaluate the effectiveness of a child care facility-based obesity prevention program. Over 1,000 facilities participated in the study. The intervention consisted of teacher trainings and technical assistance focused around the implementation of four policies: snack, beverage, physical activity, and screen time. Changes in teacher's attitudes and beliefs, as well as improvements in healthy lifestyle practices, were assessed. Results revealed significant improvements in child care center practices, such as: (1) the amount of health-related lessons provided to students increased t(664) = -6.09, P < 0.00; (2) the amount of outdoor physical activity increased t(702) = -3.83, P < 0.000; (3) the amount of screen time decreased t(686) = -2.52, P < 0.01; (4) the amount of juice served decreased t(577) = -7.38, P < 0.000; and (5) the amount of junk food decreased t(568) = -2.73, P < 0.006. The findings from this study can be easily disseminated and potentially serve as a model for improving the quality of nutrition and physical activity practices in child care facilities. – Name: AbstractInfo Label: Abstractor Group: Ab Data: As Provided – Name: Ref Label: Number of References Group: RefInfo Data: 40 – Name: DateEntry Label: Entry Date Group: Date Data: 2016 – Name: AN Label: Accession Number Group: ID Data: EJ1105044
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RecordInfo	BibRecord: BibEntity: Identifiers: – Type: doi Value: 10.1080/02568543.2016.1178672 Languages: – Text: English PhysicalDescription: Pagination: PageCount: 14 StartPage: 306 Subjects: – SubjectFull: Early Childhood Education Type: general – SubjectFull: Preschool Children Type: general – SubjectFull: Prevention Type: general – SubjectFull: Obesity Type: general – SubjectFull: Child Care Centers Type: general – SubjectFull: Intervention Type: general – SubjectFull: Educational Policy Type: general – SubjectFull: Preschool Teachers Type: general – SubjectFull: Teacher Attitudes Type: general – SubjectFull: Attitude Change Type: general – SubjectFull: Program Effectiveness Type: general – SubjectFull: Life Style Type: general – SubjectFull: Educational Practices Type: general – SubjectFull: Outdoor Education Type: general – SubjectFull: Physical Activities Type: general – SubjectFull: Physical Activity Level Type: general – SubjectFull: Food Type: general – SubjectFull: Child Health Type: general – SubjectFull: Health Behavior Type: general – SubjectFull: Health Activities Type: general – SubjectFull: Statistical Analysis Type: general – SubjectFull: Nutrition Type: general – SubjectFull: Florida (Miami) Type: general Titles: – TitleFull: Communities Putting Prevention to Work: Results of an Obesity Prevention Initiative in Child Care Facilities Type: main BibRelationships: HasContributorRelationships: – PersonEntity: Name: NameFull: Natale, Ruby – PersonEntity: Name: NameFull: Camejo, Stephanie – PersonEntity: Name: NameFull: Sanders, Lee M. IsPartOfRelationships: – BibEntity: Dates: – D: 01 M: 01 Type: published Y: 2016 Identifiers: – Type: issn-print Value: 0256-8543 Numbering: – Type: volume Value: 30 – Type: issue Value: 3 Titles: – TitleFull: Journal of Research in Childhood Education Type: main
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