1
Preventing Childhood Obesity in Early
Care and Education Programs:
How to implement a new set of national standards
in nutrition, physical activity, and screen time for
early childhood programs
National Association for the Education of
Young Children (NAEYC)
November 4, 2011, Orlando, FL
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University of Colorado College of Nursing
©2011 National Resource Center for Health and
Safety in Child Care and Early Education
National Resource Center for Health and Safety in
Child Care and Early Education (NRC)
2
Presenters
Marilyn J. Krajicek, EdD, RN, FAAN
Director of the National Resource Center for Health and Safety
in Child Care and Early Education
Danette Glassy, MD, FAAP
University of Washington, Clinical Professor
Mercer Island Pediatrics
Sandra Cianciolo
Project Coordinator for National Training Institute for
Child Care Health Consultants
University of North Carolina at Chapel Hill
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University of Colorado College of Nursing
©2011 National Resource Center for Health and
Safety in Child Care and Early Education
National Resource Center for Health and Safety in
Child Care and Early Education (NRC)
3
The Consortium:
• American Academy of Pediatrics (AAP)
• American Public Health Association (APHA)
• National Resource Center (NRC) for Health and Safety in
Child Care and Early Education (at University of Colorado)
• National Training Institute (NTI) (at University of North
Carolina Chapel Hill)
Funded through the Maternal and Child Health Bureau
Cooperative Agreement (MCHB)
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University of Colorado College of Nursing
©2011 National Resource Center for Health and
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National Resource Center for Health and Safety in
Child Care and Early Education (NRC)
4
NRC Mission:
To improve the quality of out-of-home
child care and early education programs
and support the health and safety of the
children they serve.
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University of Colorado College of Nursing
©2011 National Resource Center for Health and
Safety in Child Care and Early Education
National Resource Center for Health and Safety in
Child Care and Early Education (NRC)
5
The NRC supports the efforts of:
•
•
•
•
•
•
•
•
Child care providers
Early educators
Families/parents
Health professionals
Early childhood comprehensive systems
State child care regulatory agencies
State and local health departments
Policy makers
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©2011 National Resource Center for Health and
Safety in Child Care and Early Education
6
Caring for Our Children (CFOC) 3rd Ed.
Caring for Our Children
National Health and Safety Performance Standards for
Early Care and Education Programs
•
3rd edition Revision completed and
published in June 2011
•
4-year revision process
•
10 Technical Panels - 85 panel
members - Content Experts from
AAP, APHA, and subject specialists
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©2011 National Resource Center for Health and
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7
Caring for Our Children (CFOC) 3rd Ed.
• Definitive source on best practice in health and
safety in early care and education settings
• Evidence-based
• Expert consensus
• Model for health & safety practices
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©2011 National Resource Center for Health and
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8
Caring for Our Children (CFOC) 3rd Ed.
Contents:
Chapter 1: Staffing
Chapter 2: Program Activities
for Healthy
Development
Chapter 3: Health Promotion
and Protection
Chapter 4: Nutrition and Food
Service
Chapter 5: Facilities, Supplies,
Equipment &
Environmental
Health
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Chapter 6: Play Areas/
Playgrounds &
Transportation
Chapter 7: Infectious Disease
Chapter 8: Children With Special
Health Care Needs &
Disabilities
Chapter 9: Administration
Chapter 10: Licensing &
Community Action
University of Colorado College of Nursing
©2011 National Resource Center for Health and
Safety in Child Care and Early Education
Preventing Childhood Obesity in
Early Care And Education Programs
9
• First spin-off from CFOC
3rd edition
• Released July 2010
• Available in print
through American
Academy of Pediatrics
and online at
nrckids.org
• Spanish version
available online
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University of Colorado College of Nursing
©2011 National Resource Center for Health and
Safety in Child Care and Early Education
Preventing Childhood Obesity in
Early Care And Education Programs
10
• CFOC Nutrition Panel had primary responsibility
• Expert Panel members included:
Pediatricians
Maternal and Child Health Professionals
Nutritionists
Other Health Professionals
– Nursing, Social Work
Breastfeeding Experts
Physical Activity Experts
Child Development Specialists
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©2011 National Resource Center for Health and
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11
Obesity
• 1 in 3 low income children are obese or overweight by 5 years
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©2011 National Resource Center for Health and
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Health Consequences
• Seriously reduced quality of life
• Increased risk of chronic disease:
– Diabetes
– Hypertension and Cardiovascular disease
– GE reflux disease
– Obstructive sleep apnea, which can contribute to
learning problems and behavior problems
– Asthma
• Increased cost of health and medical care
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©2011 National Resource Center for Health and
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13
Obesity and Child Care
• Children in child care are more likely to be
obese – Maher, et al, Pediatrics 2008 Aug
• Children in child care are sedentary for most
of their time in child care (70-83%), excluding
naps- Pate, et al, Pediatrics 2004 Nov
– 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 care
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©2011 National Resource Center for Health and
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14
CFOC Standards
• NUTRITION
– variety of healthy foods
– promote positive mealtime environment
• PHYSICAL ACTIVITY
– daily indoor & outdoor activities
• SCREEN TIME
– limited
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©2011 National Resource Center for Health and
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How the Standards
Address the Problem
15
• promote eating a variety of healthy foods
• advocate breastfeeding of infants
• emphasize and promote daily physical activity
• limit access to screen time
• partner with families to promote healthy eating
practices and lifestyles
• encourage collaboration among families, caregivers,
and community health partners
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©2011 National Resource Center for Health and
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16
Caring for Our Children (CFOC) 3rd Ed.
Examples of New and Significant
Changes In CFOC 3rd Edition Related to
Childhood Obesity
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©2011 National Resource Center for Health and
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17
Encourage Breastfeeding
• Encourage mothers to breastfeed
at the child care program
– provide comfortable, private areas
• Train caregivers/teachers to support and
advocate for breastfeeding.
• Implement policies and procedures on handling
and feeding human milk safely – reduces
mother’s anxiety and promotes safety for
infants
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©2011 National Resource Center for Health and
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18
Nutrition
• Feed infants on cue by consistent
caregiver
• Accommodate use of soy formula
and soy milk when necessary
• Use 2% milk for children 12
months to 2 years, for whom
overweight or obesity is a concern
with written documentation from
health professional
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©2011 National Resource Center for Health and
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19
Nutrition
• Accommodate vegetarian diets
• Serve small size portions
• Availability of age-appropriate nutritious
snacks
• Caregivers are models of healthy eating
habits
• Provider sits with children during meal time
and encourages socialization
• Food is never used as a reward/punishment
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©2011 National Resource Center for Health and
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20
Nutrition
• Water available throughout the day
• No fruit juice for children under 12
months.
• 100% juice limited to 4-6 ounces for
children 1– 6 years of age
• Whole fruits encouraged
• Nutrition education offered to
children & parents
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University of Colorado College of Nursing
©2011 National Resource Center for Health and
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21
Physical Activity Standards
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©2011 National Resource Center for Health and
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22
Physical Activity
• Promote development of infant
movement skills – plenty of tummy time
• Promote active daily play for 1-6 year
olds with:
– 2-3 outdoor occasions
– 2 or more structured activities over course of
day (indoor and/or outdoor)
– Time for unstructured active play
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©2011 National Resource Center for Health and
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23
Physical Activity
Caregivers and teachers
encourage and participate in
physical activities:
• Lead structured activities
• Wear clothing that permits
safe and easy movement
• Prompt children to be active
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©2011 National Resource Center for Health and
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24
Physical Activity
Limit restrictions to movement of infants
• Limit time in infant equipment
(bouncy seats, swings, etc) and high
chairs to no more than 15 minutes
(except for meals & snacks)
• Cribs are only for sleeping or resting
• Restricting active play as a
punishment is not allowed
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©2011 National Resource Center for Health and
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25
Barriers to increased physical activity
Structural
• No outdoor playground
• No indoor play-space for days with inclement weather
• Playground too small, not enough equipment- Wide variability across
different centers
Teacher
• Gatekeeper of the playground
Weather:
• Rain/Snow
• Standing water, snow on playground
• “Extreme” heat/ smog alert or cold
– Wide variability in minimum temperature,
From Copeland, et al, Arch Pediatr Adol Med, May 2011
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©2011 National Resource Center for Health and
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26
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 degrees F
and heat index at or above 90°F, as identified by
the National Weather Service.”
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©2011 National Resource Center for Health and
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27
Screen Time Standards
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©2011 National Resource Center for Health and
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28
Screen Time
• No TV, video, DVD and computer use under 2
years of age
• 2 years and older:
– Only 30 minutes per week of media time and
only for educational/physical activity purposes
– Computer use – 15 minute increments; school
age children may have longer for homework.
• Caregivers as role models – no TV watching
during day
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University of Colorado College of Nursing
©2011 National Resource Center for Health and
Safety in Child Care and Early Education
29
Using the Standards
• National and State Campaigns can use to build
integrated nutrition and physical activity components
in their systems.
• Caregivers/teachers can use to develop and
implement practices and policies and use in staff
training.
• Families can support and join with caregivers/teachers
in the implementation of healthy practices. They can
also reinforce at home.
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University of Colorado College of Nursing
©2011 National Resource Center for Health and
Safety in Child Care and Early Education
30
Using the Standards
• Regulators can use to develop and/or improve state
regulations that support the prevention of obesity and
promote healthy habits.
• Health care professionals can assist families and
providers with sound evidence-based rationale for
implementing and following healthy lifestyles.
• Academic faculty can use standards as a resource to
prepare students for entering the early childhood
workplace.
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©2011 National Resource Center for Health and
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31
Achieving A State of Healthy Weight
NRC assessed child care
regulations of all States
and D.C. to determine
language in conformity
with standards
in Preventing
Childhood
Obesity (PCO).
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©2011 National Resource Center for Health and
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32
Achieving A State of Healthy Weight
Three topic areas:
•Infant Feeding
•Nutrition
•Physical Activity
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©2011 National Resource Center for Health and
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33
Achieving A State of Healthy Weight
Three child care types
• Child Care Centers
• Large Family
Child Care Homes
• Small Family
Child Care Homes
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University of Colorado College of Nursing
©2011 National Resource Center for Health and
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34
Achieving A State of Healthy Weight
Rating Methodology:
• Components Selected
• 275 PCO/CFOC components of standards derived
• Healthy Weight Advisory Committee rated components based
on impact on obesity if implemented in child care (see Appendix
C of report)
• Components divided into 3 content areas:
• Infant Feeding
• Nutrition
• Physical Activity/Screen Time
• Top 47 components selected for rating
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©2011 National Resource Center for Health and
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35
Achieving A State of Healthy Weight
Rating Methodology (cont.):
• States’ Documents Verified & Vetted
• Most recent regulations
• Obesity-pertinent content
• Rating Scales & Rules Established
• 4-point scale
• Tailored to each component
• Spreadsheets Designed to Record Ratings
• 118 States’ documents
• 3 child care types
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©2011 National Resource Center for Health and
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36
Achieving A State of Healthy Weight
Rating Methodology (cont.):
• Raters Trained and Reliability Tested
• Five 2-person teams, with 60 ratings each on same states and
same components
• Overall average Spearman’s rho coefficients = 0.964 (p>.001)
• Ratings over period of 3 months
• 16,638 individual ratings performed
• Post-rating review of all ratings for consistency
• For states with multiple documents, a final score per component
was calculated for each child care type
• Result = 6826 final ratings used for analysis
• Data Analyses
The Evaluation Center of the School of Education and Human
Development, University of Colorado Denver and NRC Staff
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©2011 National Resource Center for Health and
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Achieving A State of Healthy Weight
Overall Rating Schema:
Degree of conformity on a scale of 1-4 and color
coded on charts.
1 = state regulation contradicts the
component
2 = state regulation does not refer to the
component
3 = state regulation partially meets
component
4 = state regulation fully meets component
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38
Achieving A State of Healthy Weight
National Exemplary State
(tied with Mississippi)
Delaware
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•
Strongest in Infant Feeding for all
child care settings
Weakest in Nutrition for Small Family
Child Care
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DE Rating Composition
Per Topic Area
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
4 Ratings
3 Ratings
2 Ratings
1 Ratings
Infant Nutrition Physical
Feeding
Activity
©2011 National Resource Center for Health and
Safety in Child Care and Early Education
39
National Resources
NAP SACC:
The Nutrition and Physical Activity Self-Assessment for Child
Care (NAP SACC) program http://www.center-trt.org/index.cfm
• Research-tested intervention designed to enhance policies,
practices, and environments in child care by improving the:
•
•
•
•
nutritional quality of food served
amount and quality of physical activity
staff-child interactions
facility nutrition and physical activity policies and
practices and related environmental characteristics
• Primarily addresses the inter-personal and organizational
levels of the socioecologic model.
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National Resources
Let’s Move! Child Care
http://healthykidshealthyfuture.org
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©2011 National Resource Center for Health and
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National Resources
Motion Moments
•
Approx. 7 minutes/video
•
Demonstrates ideas for
incorporating physical activity
into child care programs for
infants, toddlers, and
preschoolers
•
41
Available at
http://nrckids.org/Motion_Mome
nts/index.htm
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©2011 National Resource Center for Health and
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National Resources
Healthy Child Care America
www.healthychildcare.org
Resources include:
Caregiver Newsletter
CFOC Standard of the Month
http://www.healthychildcare.org/ENewsCaregiver.html
#listserv
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CFOC, 3rd Edition
 Standard 1.6.0.1: A
facility should identify
and engage/partner
with a CCHC who is a
licensed health
professional with
education and
experience in child
and community
health.
The National Training Institute for Child Care Health Consultants
4/8/2015 43
What does a CCHC do?
 CCHCs have expert information,
resources, and referrals to offer.
 Through onsite and telephone
consultation, health education, and
technical assistance, CCHCs work with
child care facilities to help create
environments that support the healthy
development of young children.
The National Training Institute for Child Care Health Consultants
4/8/2015 44
CCHCs and
Nutrition/Physical Activity
 CCHCs can have a role in improving
nutrition and physical activity for children in
child care because they:
 Already established relationships
 Knowledge base
 Experience with training and TA
The National Training Institute for Child Care Health Consultants
4/8/2015 45
What can a CCHC do?
1. Partner with a center to self-assess.
2. Help the center identify a plan of action.
3. Provide training on nutrition and physical activity for
children, staff and parents/guardians.
4. Develop and distribute materials or incentives.
5. Provide technical assistance.
The National Training Institute for Child Care Health Consultants
4/8/2015 46
CCHCs Promote
 Breastfeeding
 Physical Activity
 Good Nutrition
The National Training Institute for Child Care Health Consultants
4/8/2015 47
Strategies and Interventions





Let’s Move!
NAP SACC
I Am Moving, I Am Learning
Color Me Healthy
Be Active Kids
The National Training Institute for Child Care Health Consultants
4/8/2015 48
SNAPP: Supporting Nutrition and
Active Physical Play
Friday, November 4th at 2:30pm
Orlando Convention Center
Room W311H
The National Training Institute for Child Care Health Consultants
4/8/2015 49
50
Policy Changes & National Initiatives
Licensing Toolkit
Action Sheets for potential
strengthening of child care
regulations and practices related to
preventing childhood obesity
Specific sheets for:
• Caregivers
• Legislators
• Licensing Agencies
All NRC resources available
at http://nrckids.org
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©2011 National Resource Center for Health and
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51
Policy Changes & National Initiatives
Child and Adult Care Food Program (CACFP)
Existing Meal Patterns:
2011 Meal Pattern Recommendations:
Inconsistent with new Dietary
• Consistent with new Dietary
Guidelines for Americans and
Guidelines for Americans and
MyPlate
MyPlate
• Pending adoption/publication
Available at: http://www.fns.usda.gov/cnd/
care/ProgramBasics/Meals/Meal_Patterns.htm
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Policy Changes & National Initiatives
Race to the Top—Early Learning Challenge
• State-level competitive grants Under U.S. Department of Education
(DOE) and U.S. Department of Health and Human Services (DHHS)
• To close the achievement gap for children with high needs and
support states that best prepare their young children for success in
kindergarten
http://www2.ed.gov/programs
/racetothetop/index.html
• Five key areas of reform:
1.
2.
3.
4.
5.
Successful State Systems (interagency and sustainable)
High-Quality, Accountable Programs (TQRIS)
Promoting Early Learning and Development Outcomes for Children
(utilize common standards and measures)
Great Early Childhood Education Workforce (standardized education
and professional development)
Measuring Outcomes and Progress (assess and inform progress)
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©2011 National Resource Center for Health and
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Policy Changes & National Initiatives
CDC & HHS Grant: CPPW
Communities Putting Prevention to Work
• Funding: Intense – Proven – Sustainable - Community
approaches to chronic disease prevention by:
•
•
•
•
Increasing physical activity
Improving nutrition
Decreasing overweight/obesity
Tobacco cessation
http://www.cdc.gov/Com
munitiesPuttingPrevention
toWork/about/index.htm
• Initiatives involve partnership of leaders from public health,
schools, cities, counties, local businesses, and citizens.
• 60 communities in 33 states and 3 tribes are involved in this grant
currently, 49 addressing obesity
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©2011 National Resource Center for Health and
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For more information, please contact the
National Resource Center for Health and Safety in Child Care
and Early Education:
Website- http://nrckids.org
Telephone - 1-800-598-5437
E-mail - info@nrckids.org
National Resource Center for Health and Safety in Child
Care and Early Education
13120 E. 19th Ave., F541
Aurora, CO 80045
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©2011 National Resource Center for Health and
Safety in Child Care and Early Education