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research-article2014

HPPXXX10.1177/1524839914523429Health Promotion Practice / Month XXXXNatale et al. / Early Childhood Obesity Prevention Program

Obesity Prevention in Children

Effect of a Child Care Center-Based Obesity Prevention Program on Body Mass Index and Nutrition Practices Among Preschool-Aged Children Ruby A. Natale, PsyD, PhD1 Gabriela Lopez-Mitnik, MS, MPhil2 Susan B. Uhlhorn, PhD1 Lila Asfour, MS, MA3 Sarah E. Messiah, PhD, MPH2,3

This study examined the effect of an early childhood obesity prevention program on changes in Body Mass Index (BMI) z-score and nutrition practices. Eight child care centers were randomly assigned to an intervention or attention control arm. Participants were a multiethnic sample of children aged 2 to 5 years old (N = 307). Intervention centers received healthy menu changes and family-based education focused on increased physical activity and fresh produce intake, decreased intake of simple carbohydrate snacks, and decreased screen time. Control centers received an attention control program. Height, weight, and nutrition data were collected at baseline and at 3, 6, and 12 months. Analysis examined height, weight, and BMI z-score change by intervention condition (at baseline and at 3, 6, and 12 months). Pearson correlation analysis examined relationships among BMI z-scores and home activities and nutrition patterns in the intervention group. Child BMI z-score was significantly negatively correlated with the number of home activities completed at 6-month post intervention among intervention participants. Similarly, intervention children consumed less junk food, ate more fresh fruits and vegetables, drank less juice, and drank more 1% milk compared to children at control sites at 6 months

Health Promotion Practice September 2014 Vol. 15, No. (5) 695­–705 DOI: 10.1177/1524839914523429 © 2014 Society for Public Health Education

post baseline. Ninety-seven percent of those children who were normal weight at baseline were still normal weight 12 months later. Findings support child care centers as a promising setting to implement childhood obesity prevention programs in this age group. Keywords: early childhood; preschool age; obesity prevention; child care setting; overweight; childhood obesity

1

Division of Psychology, University of Miami Miller School of Medicine, Miami, FL, USA 2 Division of Pediatric Clinical Research, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA 3 Department of Epidemiology and Public Health, University of Miami Miller School of Medicine, Miami, FL, USA Authors’ Note: We thank the all child care center directors, staff, children, and families who participated in this project. This research was funded by the Miami-Dade County Children’s Trust (grant number 764-287). The University of Miami Institutional Review Board approved the study, and all participants provided informed consent. Please address correspondence to Ruby A. Natale, PsyD, PhD, Assistant Professor of Clinical Pediatrics, Division of Psychology, Department of Pediatrics, University of Miami Miller School of Medicine, Mailman Center for Child Development, 1601 N.W. 12 Avenue, Room 4012, Miami, FL 33136, USA; e-mail: [email protected].

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Introduction >> The U.S. Department of Health and Human Services (HHS) Healthy People 2020 Nutrition and Weight Status objective identifies the reduction of overweight and obesity during childhood as one of 10 leading public health priorities (HHS, 2010), but the prevalence of childhood overweight and obesity in the United States continues to be a major challenge, especially among ethnic minorities and low-income underserved subgroups (Ogden, Carroll, Kit, & Flegal, 2012). One in four U.S. children younger than the age of 5 is currently overweight or obese (≥85th percentile of Body Mass Index [BMI] for age and sex) (Ogden et al., 2012). Both non-Hispanic black and Hispanic boys and girls consistently have higher rates of obesity compared to their non-Hispanic white counterparts (Nader et al., 2006). Early childhood–onset obesity is of particular concern because studies have reported that children who had a BMI between the 85th and 95th percentiles during their preschool years were five times more likely to be overweight during adolescence (Nader et al., 2006) and were more than four times as likely to be obese adults compared to their normal-weight counterparts (Freedman et al., 2005). Furthermore, childhood obesity can be a precursor to such chronic conditions as diabetes, cardiovascular disease, hypertension, stroke, osteoarthritis, asthma, and certain cancers (Gluckman, Hanson, Cooper, & Thornburg, 2008; National Institute of Medicine [IOM], 2007). Because of this, there are concerns that childhood overweight will contribute to an earlier onset of overall morbidity and mortality in adulthood, making early intervention crucial (Sun, Liang, & Huang, 2008). This is particularly relevant among ethnic minority groups: As adults, they experience some of the highest rates of mortality from both diabetes and cardiovascular disease (Ogden, Carroll, & Flegal, 2008).

Background >> Young children are particularly at risk for obesity because they are fully dependent on adults for their nutritional needs in both the home (Lindsay, Sussner, Kim, & Gortmaker, 2006) and child care environments (McBean & Miller, 1999). This provides a unique opportunity to intervene by assigning parents and teachers to the role of nutritional gatekeepers or healthy lifestyle role models for the young children in their care. 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. Child care settings offer a potentially powerful infrastructure to

implement such efforts because (a) 70% of U.S. preschool-aged children are enrolled in daily, out-ofhome child care (Fitzgibbon, Stolley, Dyer, Van Horn, & KauferChristoffel, 2002); (b) many children from low-income backgrounds consume 50–75% of their Recommended Dietary Allowances (standards established by the Child Care Food Program) in the child care setting (Zenk et al., 2005); (c) many children spend the majority of their waking hours out of home and in the child care setting (Lindsey et al., 2006); and (d) access to high-quality food varies (McBean & Miller, 1999). When local food vendors work closely with center administrators and when centers work with the parents, better nutritional choices can be purchased, resulting in more nutritious meals offered to the children. To date, however, there have been limited primary prevention programs implemented in preschools that target center environmental factors (physical activity, screen time exposure levels, and dietary plans) and also include teacher as well as family curriculums among schools serving primarily multiethnic, low-income families. For example, the HipHop to Health study included a 14-week nutrition and physical activity program for lowincome preschool children. Parents were sent home newsletters and completed weekly homework assignments. This program did not include teacher-directed workshops or trainings, and it was initially developed for African American families (Fitzgibbon et al., 2002). When applied to Latino families, it was not found to be effective (Fitzgibbon et al., 2006), and so the current program included a technical assistance component that addressed cultural barriers when working with the Hispanic population. Eating Right Is Basic-2 is an 8–10-session program developed to teach adults with low incomes how to choose and prepare healthy meals (Coleman, 1995), but it does not include a child curriculum. The current program, Healthy Inside–Healthy Outside (HI-HO), built on the foundation of both of these programs by including preschool intervention, parent trainings, and also teacher trainings. In addition, it added to the existing programs by (a) using a multifaceted framework that made policy-level changes at the centers and revised menus, (b) increasing the length of the program to a 6-month period during the school year, and (c) developing technical assistance programming to overcome barriers for a more ethnically diverse sample in Miami-Dade County, Florida. Theoretical Framework.  Given that childhood obesity is a multidimensional problem requiring multidimensional solutions, experts suggested applying a

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socio-ecological model (SEM) framework to examine the multiple effects and interrelatedness of social elements that contribute to obesity (Glanz & Saelens, 2010; IOM, 2007). According to SEM, health behaviors (Sallis et al., 1992; Stokols, 1992, 2000) arise and are maintained through four interacting levels of influence: individual factors, interpersonal-level factors, community (schools and institutions), and the greater macrolevel structures/policy systems (Glanz & Saelens, 2010). Primary focus must be placed on factors within family, school, child care, and community environments that affect food intake and physical activity (Dietz & Gortmaker, 2001), emphasizing the role of the environment in relationship to health (Sloane et al., 2006). For programs to be effective, the nutritional gatekeepers (parents and teachers), the ones buying and supplying the food to children, must be involved actively. Therefore, it was essential to capture caregiver involvement as a key contributing factor. Setting. Miami-Dade County, Florida, is one of the only counties in the United States that is minority majority: 64% of its residents identify as Hispanic, and 20% as African American. Over 51% of its 2.3 million residents were born outside the United States (138 countries identified) (U.S. Census Bureau, 2013). Nearly a quarter of the population is younger than 18 years, more than 15% of the school-aged population has limited English proficiency (Spanish and Haitian Creole as their primary languages), the graduation rate is only 45%, and 22% of young adults have limited literacy skills. Rates of obesity are higher among ethnic-minority children in Miami-Dade County, compared with ethnic-minority children nationally (31% vs. 26%, respectively) (Rosenkrantz & Dzewaltowski, 2008). In addition, there are more than 1,400 child care centers in the county serving over 20,000 children (Children’s Trust, 2010); 18% live below the poverty line (U.S. Census Bureau, 2013). Study Aims. The purpose of this study was to assess the effectiveness of a multifaceted obesity prevention intervention on BMI and dietary and physical activity patterns of inner-city multiethnic preschool children. The primary aims of the study were to (a) increase the healthy eating habits and physical activity behaviors of 2-to-5-year-old children at the center and at home, and (b) ascertain the feasibility and efficacy of the intervention in racially and ethnically diverse child care centers. Overall, the program was designed to address

health disparities through an innovative communitybased model. A secondary aim was to maintain healthy BMIs. We hypothesized that those of normal weight would maintain this status and those overweight and obese would decrease BMI. Another secondary aim was to examine the impacts of parent involvement on child BMI.

Methods >> Design

A randomized controlled intervention trial (RCT) was used to examine the effect of the HI-HO program on healthy weight maintenance of children 2 to 5 years old, who were enrolled in eight subsidized child care centers in Miami-Dade County, Florida. Six centers randomized to the intervention group received on-site training and technical assistance related to a nutrition-based curriculum. Two centers were randomized to the attention control, which received similar levels of training and technical assistance with a safety education curriculum. Center study inclusion criteria consisted of (a) serve >30 children, (b) serve low-income children, and (c) ethnic makeup had to be reflective of the county as a whole (minority majority). Low income was determined based on whether or not the child received subsidized child care.

Participants A total of 307 children and their parents agreed to participate in the study, for a 98% response rate among centers. At baseline, the average age for boys was 3.82 years, the average age for girls was 3.91 years, and 51% of the sample were boys (N = 157). Thirty-six percent identified their child as black, 34% identified their child as white, 18% chose other, and 14% were unknown. The ethnicity of the sample mirrors that of Miami-Dade County, with 32% of the parents identifying their child as Hispanic/other, 25% as Hispanic/ Cuban, 22% as African American, and 2% as Caucasian. Thirty-five percent of the sample were primarily Spanish speaking and completed the measures in Spanish, and 65% of the sample were primarily English speaking and completed the measures in English (Table 1).

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Table 1 Descriptive Characteristics of Healthy Inside–Healthy Outside Early Childhood Obesity Prevention Program Participants by Study Arm (N = 307)

  Age   2 years   3 years   4 years   5 years Gender  Male  Female Race   Non-Hispanic black   Non-Hispanic white  Other  Unknown  Asian Ethnicity  Hispanic/other  Hispanic/Cuban   African American   Hispanic/Puerto Rican  Haitian  Hispanic/Mexican   Other Caribbean Black  Caucasian  Other  Unknown Place of Birth   United States   Outside the United States BMI Percentile Groups1  Normal  Overweight  Obese

Intervention n = 238

Control n = 69

N (%)

N (%)

34 85 87 32

(14.3) (35.7) (36.6) (13.5)

121 (50.8) 117 (49.2)

20 23 22 4

(29) (33.3) (31.9) (5.8)

36 (52.2) 33 (47.8)

80 80 44 33 1

(33.6) (33.6) (18.5) (13.9) (0.4)

29 (42.0) 23 (33.3) 11(15.9) 6 (8.7) 0

85 57 46 9 3 5 6 2 10 15

(35.7) (24) (19.3) (3.8) (1.3) (2.1) (2.5) (0.8) (4.2) (6.3)

14 19 21 1 5 1

(20.3) (27.5) (30.4) (1.5) (7.5) (1.4) 0 3 (4.4) 1 (1.5) 4 (5.8)

223 (93.7) 15 (6.3)

67 (97.1) 2 (2.9)

162 (69.5) 39 (16.7) 32 (13.7)

46 (68.7) 10 (14.9) 11 (16.4)

1

Normal = BMI 85th to 95th percentile for age and sex.

Procedure Data were collected by research assistants trained in interview administration and anthropometric measurement specifics. Training of five research

assistants consisted of 2-hour seminars during multiple days that contained lecture, demonstration, and practice, as well as in vivo observation of interview techniques and ongoing supervision. All participants were recruited at the child care center. Parents were approached during drop-off or pickup times. Consent forms were attached to the interview packets, and parent data were collected during the initial visit. Once consent forms were collected, the research assistants returned to the center within 2 weeks to collect each child’s height and weight. The anthropometric data for the child were collected at a separate time from the parent interview. Child BMI outcome measurements were taken at baseline and at 3, 6, and 12 months. The University of Miami (UM) Institutional Review Board approved the study, and all participants provided informed consent. Intervention The 6-month intervention presented a developmentally, culturally, and linguistically appropriate curriculum that targets preschoolers. Using the SEM framework, it also included a multidimensional approach with a child care teacher-based component, a family-based component, and environmental changes as described further in this section. The program was designed to be culturally sensitive, given the ethnic diversity of the families, teachers, and administrators and staff at participating schools. For example, the curriculum was written in English and translated into Spanish to accommodate primarily Spanish speakers. Although the specific goals of behavior change were similar to those of previously validated programs implemented among minority children (Fitzgibbon et al., 2002), curriculum modifications reflected the unique diversity of the study population. Food, and thus nutrition, is an integral component of culture. The specific intervention strategies were designed to account for this, such as modifying recipes to reflect cultural preferences. In addition, the technical assistance portion of the program targeted cultural, cognitive, and environmental barriers to accommodate a low-fat, high-fiber diet that included more fresh fruits and vegetables. Teacher Component. The teacher curriculum was modeled after a modified version of Hip-Hop to Health Jr. (Fitzgibbon et al., 2002) and included two trainings per center. Teachers and staff were trained on the role and rationale of the HI-HO program, taught implementation strategies, and provided lessons to use with the children. An additional component that was not included

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in Hip Hop was weekly technical assistance visits with the teachers and a HI-HO specialist to ensure the implementation of a low-fat, high-fiber diet that included more fruits and vegetables with an emphasis on cultural barriers. Parent Component.  The intervention’s parent curriculum was modeled after a modified version of the Eating Right Is Basic (Coleman, 1995) and Hip-Hop to Health Jr. (Fitzgibbon et al., 2002) programs. Specific components included a monthly educational dinner in which nutrition and physical activity were discussed, monthly newsletters, and at-home activities. The content of the parent dinners paralleled the information offered in the monthly newsletters but unlike the Hip Hop curriculum, issues were covered that are often of concern to parents of preschool children. These include how to introduce new foods and how to encourage eating more fruits and vegetables. Sessions were provided by registered dietitians who were of the same cultural background of the parents, and these sessions were tailored to be sensitive to the cultural needs of the family (i.e., taking into account diet preferences and cooking styles). In addition, dietitians addressed perceptions related to childhood weight status, which are often engrained in cultural beliefs such as “He will grow out of it” or the idea of “baby fat.” Parents were encouraged to reduce TV viewing, increase physical activity, and model healthy eating behaviors for their child at home. For each of the six at-home activities that each family completed, they received a healthy snack bag. At the end of the program, parents who attended three or more dinners received a certificate of completion. Center-Based Modifications Component. In keeping within the SEM model, an additional component not included in other curriculums was added that consisted of child care center environmental modifications. These included the development of policies to increase physical activity and healthy eating. Furthermore, a nutritionist worked with each child care center to modify menus to make them compliant with the policies and also to ensure that the U.S. Department of Agriculture (USDA) nutritional requirements were met. The nutritionist ensured that the modifications made to the centers’ daily menus were of equal cost as prior food purchases, while simultaneously lowering the daily consumption of saturated fats and trans fatty acids. Each center agreed on a drink policy that included providing water as the primary beverage, not allowing juice or sweetened beverages more than one

time per week, and changing from whole milk to 1% milk. The snack policy consisted of healthy snacks, such as fresh fruit and/or vegetables, as a substitute for cookies and other high-lipid snacks. The physical activity policy consisted of urging centers to increase physical activity to more than one hour per day and to decrease TV viewing to less than 60 minutes two times a week. The control group centers received a visit from an injury prevention education mobile. The mobile provided parents and teachers with hands-on safety education and information, as part of an ongoing injury prevention program at the University of Miami.

Measures >>

Sociodemographic Variables Demographic variables included the age, gender, race, and ethnicity of the children; geographic origins of ethnic status were collected for parents and teachers. In addition, parental education and the place of birth of both child and parent were collected. Anthropometric Variables Assessment of child body composition included height (by stadiometer), weight (by digital scale), and BMI (weight in kg/height in meters squared). Children were asked to remove their shoes and any heavy outer clothing prior to being measured and weighed. BMI was calculated as weight (kilograms) divided by height (meters squared), and was then converted to an age- and sex-adjusted percentile and z-score (Centers for Disease Control and Prevention [CDC], 2011). Nutrition and Physical Activity Questions extracted from the National Health and Nutrition Examination Survey (NHANES) instrument were adapted to measure both child food intake and physical activity levels of this population (CDC & National Center for Health Statistics [NCHS], 2013b). The NHANES is a nationally standardized, valid, and reliable nutrition assessment instrument developed by the NCHS and CDC, and it has been used with this age group (CDC & NCHS, 2013b, n.d.). Parents were asked to report how frequently their child engaged in moderate physical activity (causes light sweating and a slight to moderate increase in breathing or heart rate) during the past month, and the number of hours per day that their child watched TV, watched or played video games, and used a computer during the past 30 days.

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The Food Frequency Questionnaire (FFQ; CDC, 2008) was reduced to 16 items to specifically evaluate the effectiveness of the menu changes and weekly technical assistance in improving the nutritional milieu of the child care centers. This tool has been used extensively in the literature and has been found to be a reliable and valid way to capture nutrients served (Feskanich et al., 1993; Parrish, Marshall, Krebs, Rewers, & Norris, 2003; Subar et al., 2006; USDA, 2006). The FFQ was collected from parents and teachers. Review of lesson plans and observation of classrooms were used to assess the amount of physical activity and screen time at the child care centers. Parents who spoke primarily Spanish were administered measurers in their native language. It was the preference of the study team that measures be collected in person; however, at times, measures were collected by telephone when necessitated by the parent’s schedule. Parent Satisfaction and Involvement.  According to the SEM framework, parent involvement is a key feature. To measure parent involvement, parents’ attendance at parent dinners was captured via sign-in sheets and was recorded. Parent involvement was further tracked based on the number of parent activities that were turned in each month. Last, parents were asked to complete a 6-question satisfaction survey to rate how pleased they were with several aspects of the program.

Analysis >> BMI scores were converted to z-scores based on normative data for age and sex. Repeated measures analysis was conducted to compare anthropometric measurements between intervention and control groups at baseline and at 3-, 6, and 12-month follow-up. Pearson correlation coefficients were generated to examine the relationship between BMI z-scores at 6 and 12 months and parent participation via school activities (e.g., the number of dinners attended) and home activities completed in the intervention group. This same analysis explored the relationship between nutrition patterns on specific food items and parent activities completed in the intervention group. In addition, separate general linear models (GLM) were used to evaluate the association between treatment condition and changes in weight, height, and BMI from baseline to 6 months and from baseline to 12 months. To assess the association between parent–home intervention activities and BMI, as well as the association between these activities and the consumption of

various food items, additional models were run with all parent–home intervention activities as predictors. All models included age in months, race, and gender as potential confounders. Data were analyzed using Statistical Analysis Software (SAS, version 9; SAS Institute).

Results >>

Body Mass Index (BMI) Thirty-one percent of the entire sample had a BMI percentile for age and sex >85th percentile (16% were overweight [85th–95th percentile], and 14% were obese [>95th percentile]). The mean weight z-score increased in the control group from baseline to 12 months post intervention (0.69 to 0.78, respectively), whereas among the intervention group there was a modest increase from 0.38 to 0.45 during the same time period (not significant [NS]) (Table 2). Mean BMI z-score increased in both groups but substantially less so in the intervention group (0.60 to 0.76 in controls vs. 0.67 to 0.72 in intervention; NS). Ninety-seven percent of those children who were normal weight at baseline were still normal weight 12 months later (defined as the Our findings suggest that obesity prevention programs implemented in the child care center setting are feasible and represent an important venue in which to promote healthy eating behaviors and physical activity for young children who may be at risk for becoming overweight. Caregivers affect the nutritional habits of the children under their care not only by making choices regarding the types of foods that are available but also by influencing children’s attitudes and beliefs about that food. Yet health and nutrition are often overlooked in preschool curriculums. Our program results provide promising evidence that a comprehensive child care center–based obesity prevention program can be successful. References Adams, S. A., Matthews, C. E., Ebbeling, C. B., Moore, C. G., Cunningham, J. E., Fulton, J., & Hebert, J. R. (2005). The effect of social desirability and social approval on self-reports of physical activity. American Journal of Epidemiology, 161(4), 389–398. doi:10.1093/aje/kwi054 Branscum, P., & Sharma, M. (2011). A systematic analysis of childhood obesity prevention interventions targeting Hispanic children: Lessons learned from the previous decade. Obesity Reviews, 12(5), e151–e158. doi:10.1111/j.1467-789X.2010.00809.x Campbell, K., & Crawford, D. (2001). Family food environments as determinants of preschool aged children’s eating behaviours: Implication for obesity prevention policy. Australian Journal of Nutrition and Dietetics, 58, 19–25. Centers for Disease Control and Prevention (CDC). (2008). National Health and Nutrition Examination Survey: 2003–2004 data documentation, codebook, and frequencies: Food Frequency Questionnaire—output from DietCalc Software (FFQDC_C). Retrieved from http://www.cdc.gov/nchs/nhanes/ nhanes2003-2004/FFQDC_C.htm Centers for Disease Control and Prevention (CDC). (2011, September 13). BMI—Body Mass Index: BMI for children and teens. Retrieved from http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html Centers for Disease Control and Prevention and National Center for Health Statistics (CDC and NCHS). (2013a, October 30). National Health and Nutrition Examination Survey data. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Retrieved from http://wwwn.cdc.gov/nchs/nhanes/search/nhanes99_00.aspx Centers for Disease Control and Prevention and National Center for Health Statistics (CDC and NCHS). (2013b, October 31).

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Effect of a child care center-based obesity prevention program on body mass index and nutrition practices among preschool-aged children.

This study examined the effect of an early childhood obesity prevention program on changes in Body Mass Index (BMI) z-score and nutrition practices. E...
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