Engaging Early Learning and Care Engaging Early Learning and Care Providers in Obesity Prevention Efforts:

Promising Practices and BarriersJane Lanigan, Washington State University Diane Bales, The University of Georgia

Today’s AgendaToday’s Agenda• Definitions of overweight and obesity• Prevalence of obesity• Causes and risks of childhood obesityy• Young children’s eating habits• ENHANCE frameworkENHANCE framework• Eat Healthy, Be Active• What’s next?• What s next?

Body Mass IndexyOverweight and obesity are measured in adults by Body Mass Index (BMI)Mass Index (BMI)

BMI = weight (in kg) divided by height (in m), squared. (BMI=kg/m2)(BMI=kg/m2)

An adult who is 5’5” tall and weighs 144 pounds has a BMI f 24BMI of 24.

Obesity Trends* Among U.S. AdultsBRFSS 1990 1999 2009

1999

BRFSS, 1990, 1999, 2009(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)

1990

2009

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Overweight and Obesity in ChildrenOverweight and Obesity in ChildrenFor children and adolescents (aged 2–19 years), g ythe BMI value is plotted on the CDC growth charts to determine the corresponding BMI for gage and gender.

Overweight is defined as a BMI at or above the 85th

percentile and lower than the 95th percentile.Obesity is defined as a BMI at or above the 95th

percentile for children of the same age and sex.

Prevalence of Childhood Obesityy

Childhood Obesity: Consequences

Health concernsHeart disease

An estimated 61% of overweight children have one risk factor

Type 2 diabetesIt is estimated that 1 in 3 American children born in 2000 will develop Type p yp 2 diabetes in their lifetime (JAMA, 2003)

AsthmaO th di blOrthopedic problemsSkin DisordersSleep apneaSleep apnea

Childhood Obesity: ConsequencesChildhood Obesity: ConsequencesOther Concerns

Decreases in school achievementPositive correlation between childhood

i ht d l t b toverweight and early-onset pubertyPsychological effects

Negative self-conceptNegative self conceptLow self-esteemTeasing by peersg y pLoneliness and social isolationSocial discriminationDepression

Causes of Childhood OverweightCauses of Childhood Overweight

Genetic tendency, based on differences in

AppetiteActivity levelActivity levelMetabolism rate

Proximal cause: taking in more l h h b d calories than the body usesEating too many caloriesNot getting enough physical activityg g g p y yLack of physical activity has more impact

Childhood Overweight FactsChildhood Overweight FactsNegative correlation between birth weight and risk of childhood overweight

Underweight newborns more likely to be overweight childrenlikely to be overweight children

Increases in childhood overweight

relate to family feeding practicese ate to a y ee g p act ces

Brainstorming Activity

How did we get ghere?What contributing What contributing factors can you think

fof?

Changes in Eating Patterns Changes in PA PatternsChanges in Eating Patterns•Portion Size•Marketing Influences•Processed Foods

Changes in PA Patterns•Screen Time•Safety Issues•Sedentary LifestyleProcessed Foods

•Fast Food•Access to Healthy Foods•Time Famine

y y•Built Environment•Reduced Opportunities for PA•Time Famine

•Low-Nutrition, Calorie-Dense Foods

OBESOGENIC OBESOGENIC ENVIRONMENT

Normalizing Larger Body Size

Portion Distortion

SANDWICHFRENCH FRIES SANDWICHFRENCH FRIES

Calorie Difference: 500 Calories 

610 calories6.9 ounces

210 calories2.4 ounces 

320 calories 820 calories

Calorie Difference: 400 Calories 

Source: NHLBI ‐ OEI

Media and other Sedentary ActivitiesMedia and other Sedentary Activities

Media use DisplacementMindless eating

Marketing influencesChild 2 5 d t 5 400 Children age 2-5 are exposed to 5,400 food ads per year and 18,000-20,000 paid ads.

Fast food restaurants

Sweets, snacks, desserts

Cereals

Points of Intervention: Earlier is BetterPoints of Intervention: Earlier is BetterMulti-level approach

Family Context

Community ContextCommunity supports for healthy eating and PASystems with which families interact

WICWIC

Extension nutrition programs

Medical care

E l L i d CEarly Learning and Care

RATIONALERATIONALE• We CAN reverse the trend and counter the current obesogenic

environment

• Need a systems approach

• Approximately half of US children 0-6 spend time in non-relative (13.9%) or center-based (36.1%) child care making hi i i l b i i this a critical obesity prevention context.

Community Partners Child Care SettingCommunity Partners Child Care SettingHead StartFor profit Centers

EOCFLearning Avenues p

Not-for-profit Community based child care centersCollege/University Lab

Learning AvenuesInnovative ServiceYWCA

College/University Lab schoolsCenters serving

l ti ith i l populations with special needsFamily Child Care Homes

Style FoodPreference Intake

Eating

Structured UnstructuredMVPA

Physical Activity

Healthy W i htWeight

Health Belief ModelChild id ld b t lik l t d t id b d Child care providers would be most likely to adopt evidence-based practices related to healthy child eating if they:

viewed the failure of children to meet nutrition standards as potentially damaging to children’s health and development;

believed they could make a meaningful difference in children’s eating habits;

were given the training and tools to effect change.

Transtheoretical Model behavior change is conceptualized as a continuum consisting of a five-

stage process. suggests that child care providers would be in varying stages of readiness with regards to change and require different kinds of g g qsupport to move them along the continuum.

SAMPLESAMPLE

• 663 children ages 3 5 attending • 663 children ages 3 - 5 attending ENHANCE child care sites• 50% were from low SES50% were from low SES• 44% were minority background• 58% were girlsg

• 99 lead child care providers/teachers • 59 staff assistants

• Mean age = 35.76; SD = 11.49• Mean experience = 8.48; SD = 7.07

82% h d ll 31% h d BA • 82% had some college; 31% had a BA or higher degree

INTERVENTIONINTERVENTION

Inclusive Site Wellness Committees identify annual improvement y pgoals.

ENHANCE supports their efforts by providing:Assessment of current practices and comparison with evidence-based practicesTraining and Resources Training and Resources Mini-grantsCheck-out KitsForum for sharing ideas

MeasuresMeasures

• Protocol for Mapping Current Policies and Practices

T1/Baseline

• Child Care Provider Obesity Prevention Survey

T2/End of Year 1

Prevention Survey

• Child Role Play/Interview Protocol

Child BMI

T3/End of Year 2

• Child BMI

Child Interviews

Key Findings and I li iInterviews

Intervention efforts should help i

Implications

caregivers: Become more intentional and explicit in their communication explicit in their communication related to healthy eating and physical activity benefitsDevelop key messages for delivery across contexts in which children which children Use evidence-based practices

Self-regulationgIntroducing new foods

Child Interviews

Key Findings and I li iInterviews

Media use was preferred over active

Implications

leisure pursuits.Content gaps included:

M ki h lth f d d Making healthy food and beverage choices outside mealtimeUnderstanding the benefits of Physical Activity

Young children can guide intervention efforts by serving as key informants and reflect the key informants and reflect the obesogenic environment

Provider Surveys

Key Findings and I li iSurveys

• Child care providers are uncertain of Implications

their role and potential efficacy in child obesity prevention.

• Understanding and countering Understanding and countering providers’ misconceptions is important.important.

F d t i i d d ti d i • Focused training and education during 1st year appeared effective.

Improvement in Feeding Practices and Nutrition EducationNutrition Education

Baseline-T1Paired t test

T1-T2Paired t test

Baseline-T2GLM Repeat

Measurest = 3.51; p = .003 t = 2.38; p = .036 F = 5.72; p = .005

Improvement in Physical Activity PracticesPractices

Baseline-T1Paired t test

T1-T2Paired t test

Baseline-T2GLM Repeat

MeasuresMeasurest = 2.73; p = .010 t = 2.84; p = .007 F = 3.91; p = .031

Improvement in Communicationp

Baseline-T1Paired t test

T1-T2Paired t test

Baseline-T2GLM Repeat Paired t test Paired t test GLM Repeat

Measurest = 2 29; p = 028 t = 1 95; p = 059 F = 3 05; p = 061t 2.29; p .028 t 1.95; p .059 F 3.05; p .061

Reduced Improved Greater Reduced

Misconceptions

Improved

EfficacyFeeding

knowledge

Improvements in:

Nutrition Education (R2 = .69)

Family Communication (R2 = .30).

F di P i (R2 27)Feeding Practices (R2 = .27)

I d Increased Adult Salience

Leadership

Improvements in Physical Activity

Practices Increased Barriers

Observations: ImplicationsObservations: Implications

N i i i l i h Non-prescriptive, inclusive approach appears effective in promoting healthy change.

Observations: ImplicationsObservations: Implications

State policy effectively regulates media useState policy effectively regulates media use.

Center policy assists providers

Id tif t f f di d h i l ti it th t Identify aspects of feeding and physical activity that are amenable to regulation

Small changes add up to culture change

Process matters

The potential for child care providers to serve as trusted advisors and conduits for information dissemination has yet to be fully realized.

Eat Healthy, Be Active: y,Addressing Childhood Overweight by Educating

Parents and Young Childreng

What Is Eat Healthy Be Active?A multi-level educational program for preschoolers

What Is Eat Healthy, Be Active?p g p

and their teachers

Goal: to reduce childhood obesity in preschoolers by : y p yincreasing children’s knowledge of healthy habits

Topics: nutrition and physical activityTopics: nutrition and physical activity

Methods: hands-on activities for children; family involvement teacher traininginvolvement; teacher training

Why Eat Healthy, Be Active?y y,Healthy (and unhealthy) habits form earlyform early.Adults create the food environment for childrenenvironment for children.Children learn by watching adults.adults.Children can influence adults’ behaviors.Two-pronged approach:

Educate adultsEducate children

Why Eat Healthy, Be Active?y y,

The early childhood classroom is an ideal place to y pteach about healthy habits.

Preschoolers have the cognitive capacity to learn about nutrition and physical activitynutrition and physical activity.Young children need hands-on exploration to learn essential concepts.C t h ld b i l d ifiConcepts should be simple and specific.

An integrated approach is most appropriate for ages 3 – 5.3 5.

The daily curriculum structures children’s learning.Preschoolers need multiple opportunities to practice the same conceptconcept.

Key Concepts for PreschoolersKey Concepts for Preschoolers

Eat breakfast

Eat a variety of foods (no “bad” food!)

Stop when you’re fullStop when you re full

Drink water

Be physically active

Key Methods for Teaching P h lPreschoolers

Reinforce the key conceptsy

Keep it simple!

Infuse concepts into every Infuse concepts into every part of the curriculum

Repeat repeat repeatRepeat, repeat, repeat

Be a positive role model

Components of Eat Healthy, Be A i

Integrated curriculum unit for ages Activeg g

3- 5

Family involvement materialsy

Training workshops for early childhood teachers and trainerschildhood teachers and trainers

Resource kit of non-consumable suppliessupplies

DVDs of songs for classroom use

Integrated Curriculum UnitDevelopmentally appropriate for ages 3 – 5

Integrated Curriculum Unity g

Hands-on activities in all curriculum areas

Activities pilot-tested with preschoolers and their Activities pilot tested with preschoolers and their teachers

Meant to be incorporated into the weekly Meant to be incorporated into the weekly curriculum

Fl ibilit f t h i h i ti itiFlexibility for teachers in choosing activities

Large Group ActivityLarge Group Activity

H lth B S “E t B kf t”Healthy Bear Says, “Eat Breakfast”Key Concept: Eat breakfast

Materials: Bear puppet, food models, paper and marker

Healthy Bear Says “Eat Breakfast”Healthy Bear Says, Eat Breakfast

Art ActivityArt Activity

Sill St t h A tSilly Stretch ArtKey Concept: Stretch your body

Materials: Large sheets of paper, drawing tools

“Stretch forward and draw a circle ”Stretch forward and draw a circle.

“Stretch down and draw behind you ”Stretch down and draw behind you.

Outdoor ActivityOutdoor Activity“I Want to Be Active” Obstacle CourseKey Concept: Move your body

Materials: Moveable materials available on the playground (hula hoops, cones, large blocks, etc.)

Family Involvement MaterialsIntended to help families reinforce nutrition and physical activity messages with children

y

physical activity messages with children

Educational family handouts

Interactive bulletin boards

Family night workshop

Activity calendar

Family backpack activitiesFamily backpack activities

Training WorkshopsDesigned to prepare teachers to use Eat Healthy, Be

Training Workshops

Active in their classroomBackground on childhood obesityActivity demonstrationsHands-on experience of activitiesExploration of family involvement materialsDiscussions of the teacher’s role during meals and goutdoor playParticipants receive the complete curriculum

Resource KitsDesigned to make implementation easy

Resource Kits

and cost-effective.Contain most non-consumable materials needed for the curriculum activitiesO d d l b l d b Organized and labeled by activityCan be checked out by trainers or child

idcare providersBorrower is responsible for return

tpostage

Music DVDs

S d h l f h

Music DVDs

Songs and rhymes are an integral part of the curriculum

T h t iti d ti it Teach nutrition and activity messagesRepeat key messages

DVD bl t h t t h th i kl DVDs enable teachers to teach the songs quickly and easilyPerformed and recorded by a Georgia children’s Performed and recorded by a Georgia children s artistDistributed at early childhood conferences and Distributed at early childhood conferences and directly to child care centers

E l ti f E t H lth B A tiMulti-stage evaluation of the curriculum unit, resource kit,

Evaluation of Eat Healthy, Be Active

and 3-hour training session

Measures

Pre-post measure of teachers’ nutrition and physical activity knowledge

Teachers’ evaluation of curriculum features

Teachers’ self-reported use of curriculum

Observation of teachers’ curriculum implementation

Children’s knowledge of basic concepts about breakfast

Children’s ability to sort foods into basic food groups

E l ti f E t H lth B A tiParticipants

Evaluation of Eat Healthy, Be Active

44 teachers and 175 children from 19 child care centers9 experimental centers10 control centers

Measurement Times

Preliminary center visit

Training workshop (pre- and post-surveys)

Implementation visit (experimental group only)

Follow-up visit (about a month after implementation)

Key Evaluation FindingsTeachers’ knowledge of healthy habits increased during the training

y g

during the training

Teachers described the curriculum and resource kit as flexible easy to use and developmentally kit as flexible, easy to use, and developmentally appropriate for preschoolers

T h lik l i l h Teachers were most likely to implement the activities they practiced in training

Challenges and BarriersChallenges and BarriersWide variation in the number of activities implemented and the quality of implementationTeachers were unlikely to try activities that they did

t ti d i t i inot practice during trainingTeachers did not read the curriculum!S t did t “d i l ” i Some centers did not “do curriculum” in summerFew food-related words used during mealtimesN t h ti iti t t h h l b t Not enough activities to teach preschoolers about breakfast and food groups

Revisions Currently Underwayy yAdditional activities to reinforce all five key conceptsconcepts2-week implementation schedule, with recommended activities each dayrecommended activities each daySimplified curriculum “cheat sheets” that teachers can keep nearby during the daycan keep nearby during the dayMulti-session training with more hands-on activity practicey pFollow-up evaluation of curriculum effectivenessAdditional family involvement toolsAdditional family involvement tools

So What?So What?How are you already addressing y y gchildhood obesity within the early childhood community?

What more could you do?

How could these ideas and resources How could these ideas and resources help you?

What other supports do you need?What other supports do you need?

Jane Lanigang

Assistant Professor and Human Development Specialist

Washington State University Vancouverg y

jlanigan@vancouver.wsu.edu

360-546-9715

Diane Bales

Associate Professor and Human Development Specialist

University of Georgia Cooperative Extension

dbales@uga.edu

706-542-7566