Research Brief Physical Activity Levels Among Children Attending Family Day Care Kelly R. Rice, PhD1; Stewart G. Trost, PhD2 ABSTRACT Objective: To objectively measure the physical activity (PA) levels of children attending family day care programs. Methods: A total of 114 children from 47 family day care centers wore an accelerometer for the duration of their time in care. Time in moderate-to-vigorous PA (MVPA) and total PA was calculated using previously validated cut points. Results: Children accumulated 5.8  3.2 minutes of MVPA and 10.4  4.4 minutes of total PA per hour of attendance. Boys exhibited significantly higher levels of PA than girls. Among healthy weight children, 4- and 5-year-olds exhibited significantly higher levels of PA than 2- and 3-year-olds. Overweight and obese 4- and 5-year-olds exhibited significantly lower levels of PA than their healthy weight counterparts. Conclusions and Implications: Children attending family day care participate in low levels of PA during the child care day. The results highlight the need for effective programs to promote PA in family day care. Key Words: preschool, accelerometry, sedentary behavior, active play (J Nutr Educ Behav. 2014;46:197-202.) Accepted September 2, 2013. Published online October 19, 2013.

INTRODUCTION The prevalence of obesity among children aged 2–5 years has increased dramatically over the past 3 decades. Data from the 2007–2008 National Health and Nutrition Examination Survey indicated that just over 21.4% of US children between the ages of 2 and 5 years are overweight or obese.1,2 The dramatic rise in childhood overweight has been deemed one of the most serious public health issues facing society today. Obese children are at in-creased risk for adult obesity and, relative to non-obese children, are at increased risk for significant health problems such as insulin resistance, hypertension, pulmonary disorders, gastroenterological problems, and psychological problems.3,4 Low levels of physical activity are an important contributing factor in the development and maintenance of childhood obesity.5 Janz and

colleagues6 studied the effects of physical activity participation at age 5 on body fatness, measured at ages 8 and 11. For boys and girls, daily moderate-to-vigorous physical activity (MVPA) was significantly and inversely related to fat mass at ages 8 and 11. Boys and girls in the highest quartile for MVPA at age 5 had significantly lower fat mass at ages 8 and 11 than did children in the lowest MVPA quartile at age 5. In 2011, 61% of US children aged # 5 years attended some form of child care on a regular basis.7,8 Whereas the majority of these children were cared for by a relative or attended centerbased care just over 12% were cared for exclusively by a family day care provider, defined as a non-relative who cares for 1 or more children in her or his home.7,8 Children attending family day care spend considerable amounts of time in this setting. On average, children with

1

Department of Physical Activity, Health, and Wellness, Eastern Oregon University, OR School of Human Movement Studies, The University of Queensland, St Lucia, Queensland, Australia Address for correspondence: Stewart G. Trost, PhD, School of Human Movement Studies, The University of Queensland, St. Lucia QLD 4072, Australia; Phone: (þ61) 73 365 6912; Fax: (þ61) 73 365 6877; E-mail: [email protected] Ó2014 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR http://dx.doi.org/10.1016/j.jneb.2013.09.001 2

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employed mothers spend 32 hours per week in family day care, whereas children with mothers not employed spend an average of 18 hours per week in family child care.8 Although it is an important setting to promote physical activity and prevent obesity in young children, little is known about the physical activity behaviors of children attending family day care. To date, only 1 published study examined the physical activity characteristics of children in this child care setting. Temple and colleagues9 objectively measured the physical activity levels of 64 children attending family day care in British Columbia, Canada. On average, children accumulated < 2 minutes of MVPA per hour of child care attendance and accumulated virtually no vigorous intensity physical activity across the child care day. Although the results of that study suggest that children attending family day care are insufficiently active, the extent to which the findings are generalizable to children attending family day care in the US is unknown. Furthermore, the small sample size did not allow the investigators to explore potentially important age group, gender, and weight-related differences in physical activity behavior. Therefore, the aims of this study were twofold: (1) to objectively measure the physical

197

198 Rice and Trost activity characteristics of a large and age diverse sample of children attending family day care in the northwestern US; and (2) to examine the influence of age, gender, and weight status on physical activity participation.

METHODS Participants and Settings Participants in the study were 2- to 5-year-old children attending family day care centers enrolled in the Healthy Home Child Care Project, an obesity prevention study for preschool-aged children and their families. Family day care centers were recruited from 5 regional child care Resource and Referral hubs serving 7 economically diverse counties in Oregon. Before selection, the sample was stratified by Resource and Referral hub and providers within each stratum were randomly sampled with a probability proportional to the total number of registered family day care centers operating in the hub. Initially, 63 family day care centers were enrolled in the study. Of those, 5 had too few children under their care when data collection began (< 4 children) and 2 others closed their business before data collection, which left a sample of 56 family day care centers. All children between the ages of 2 and 5 years attending these family day care centers were invited to take part in the activity monitoring portion of the study. The number of eligible children within each family day care center ranged from 1 to 6, with a median of 4 child participants per family day care center. The study was approved by the University of Queensland's institutional review board, and before participating, family day care providers and the children's parents provided written informed consent.

Physical Activity Assessment Physical activity was measured using the ActiGraph GT1M accelerometer (Pensacola, FL). Activity assessments were conducted during a randomly selected week. At the beginning of each monitoring day, the provider attached the accelerometer to the child's right hip via an adjustable

Journal of Nutrition Education and Behavior  Volume 46, Number 3, 2014 elastic belt, noting the time of attachment, the identification number of the child, and the identification number of the accelerometer on the activity monitoring log. When the child departed, the child care provider removed the accelerometer and noted the time of departure on the log. The ActiGraph accelerometer has been shown to be a valid instrument for assessing physical activity in preschool aged children.10

Data Reduction Stored activity counts were uploaded to a customized data reduction macro for the determination of daily time spent in MVPA and total PA (TPA) (sum of light, moderate, and vigorous physical activity). Counts were classified into the these intensity categories using the previously validated cut points developed by Van Cauwnberghe and colleagues.11 Non-wear time was estimated by summing the number of consecutive 0 counts accumulated in strings of $ 60 minutes.12 Children were included in the analyses if they had $ 2 days in which wear time was $ 75% of the attendance time. The 2-day inclusion criterion provided a reliability of > 0.70 for MVPA and TPA (intraclass correlation coefficient, 0.73–0.84). All variables were standardized for the duration of child care attendance by dividing each activity outcome by wear time.

Height and Weight Assessment Height was measured to the nearest 1 mm using a portable stadiometer (Seca 214; Seca, Chino, CA). Weight was measured to the nearest 0.1 kg using a portable digital scale (Seca 874). Body mass index was calculated as body weight in kilograms divided by height in meters squared. Children were classified as overweight or obese using the age- and sex-specific 85th and 95th percentiles from the Centers for Disease Control and Prevention growth charts.13

Statistical Analyses Group differences in the physical activity variables were evaluated for significance using a 3-way (gender  age group  weight status) factorial ANOVA. A binary age group variable

was created by combining 2- and 3-year-olds and 4- and 5-year-olds.

RESULTS Of the 56 family day care centers enrolled in the study, 47 completed the accelerometry protocol. The initial and monitoring samples were comparable with respect to median years of operation, number of children between the ages of 2 and 5 years, provider age, provider education, race/ethnicity, and participation in the Child and Adult Care Food Program (Table 1).14 Within the 47 family day care homes, a total of 191 children (mean age, 3.4  1.1 years; 49.5% male) were eligible for the activity monitoring study. Of this number, 124 children wore the accelerometer on at least 1 day and completed the height and weight assessments (mean age, 3.6  1.0 years; 53.2% male; 29% overweight or obese). After excluding participants with < 2 valid monitoring days (n ¼ 10), the final sample consisted of 114 children (60 boys and 54 girls). Exclusion of these participants had negligible impact on the demographics of the sample. Table 2 provides descriptive characteristics of the final monitoring sample. On average, children wore the accelerometer for 5.5  1.6 h/d. Across the entire sample, the average participation in MVPA and total PA was 5.8  3.2 and 10.4  4.4 min/h, respectively. Figure 1 displays gender differences in the physical activity variables. Relative to girls, boys exhibited significantly higher levels of MVPA and TPA during the child care day. Relative to age and weight status, both MVPA and TPA exhibited evidence of a significant age group by weight status interaction. The results are displayed in Figures 2 and 3, respectively. Among healthy weight children, 4- and 5-year-olds exhibited significantly higher levels of MVPA and TPA than 2- and 3-year-olds. No age-related differences were observed among overweight or obese children. Among 4- and 5-year-olds, overweight and obese children exhibited significantly lower levels of MVPA and TPA than their healthy weight counterparts. However, among 2- and 3-year-olds, MVPA and

Journal of Nutrition Education and Behavior  Volume 46, Number 3, 2014 Table 1. Initial and Monitoring Sample Demographic Information of Child Care Providers Characteristics of Family Child Care Providers Median years of operation Median number of children 2–5 y Provider age, y (%) < 30 30–34 35–39 $ 40

Initial Sample (n ¼ 56) 10 (IQR ¼ 5–15)

Monitoring Sample (n ¼ 47) 10 (IQR ¼ 5–15)

4 (IQR ¼ 3–5)

4 (IQR ¼ 3–5)

4 12 31 53

2 15 29 54

Highest level of education (%) High school diploma or general equivalency diploma Some college or associate degree Bachelor’s degree

69a

66a

16a 14a

20a 15a

Non-Hispanic white (%)

92

90

Participation in Child and Adult Care Food Program (%)

67

70

IQR indicates interquartile range. a Percentages may not add up to 100 due to rounding. TPA levels were similar and not significantly different.

DISCUSSION The findings from this study suggest that children attending family day Table 2. Demographic and Physical Characteristics of 2- to 5-Year-Olds Completing the Accelerometer Protocol

Characteristics of 2- to 5-Year-Olds Age, y 2 y (%) 3 y (%) 4 y (%) 5 y (%) Male (%) Height, cm

Final Sample (n ¼ 114) 3.7  1.1 25.4 35.9 28.1 10.6 52.6 100.6  9.6

Weight, kg

17.2  4.8

Body mass index, kg/m2

16.8  2.2

Body mass index percentile

63.3  27.8

Overweight or obese (%)

29.0

Mean  SD unless indicated by percentage.

care in the northwestern US participate in relatively low levels of physical activity during the child care day. On average, children accumulated approximately 6 minutes of MVPA and 10 minutes of physical activity of any kind per hour of child care attendance. This level falls well short of the 15 minutes of physical activity per hour of child care attendance recommended by the Institute of Medicine.15 Based on the mean monitoring duration of 5.5 h/d, the standardized activity rate for TPA equates to 55 min/d, which falls well short of the recommended 180 minutes of TPA daily.16-18 To date, just 1 other study described the activity levels of preschool-aged children attending family child care homes. Temple et al9 reported that 3- to 5-year-olds attending Canadian family day care averaged < 2 minutes of MVPA. It is possible that methodological differences in the assessment of physical activity may account for the discrepancy in findings. In the study by Temple et al, physical activity was measured using the Actical accelerometer, applying the intensity-related cut points developed by Pfeiffer and colleagues.19 Interestingly, the regression equation used to generate these cut points was found to systematically

Rice and Trost 199 underestimate energy expenditure in a cross-validation sample of preschool children. This raises the possibility that the resultant cut points may be artificially high, leading to underestimations of time spent in MVPA. The MVPA levels observed in the current study (approximately 6 min/h of attendance) differ marginally from those reported in centerbased studies using accelerometers to document physical activity levels. Pate and colleagues20 measured MVPA levels in 281 preschool children from 9 preschools in South Carolina. Mean participation in MVPA was 7.7  3.1 minutes per hour of attendance. Loprinzi and Trost21 quantified the MVPA levels of 156 children attending 13 Australian child care centers. On average, children accumulated 9.1 minutes of MVPA per hour of child care attendance. Sugiyama et al22 assessed MVPA in 89 children from 10 child care centers in Australia. On average, children accumulated 24.3  12.6 minutes of MVPA per day, with a mean wear time of 6.7 h/d. Standardizing the MVPA estimate for mean wear time, this equated to 3.6 minutes of MVPA per hour of child care attendance. Such variation in physical activity estimates may reflect true population-based differences; however, differences in the count thresholds or cut points used to estimate time spent in MVPA are a more likely explanation. In those studies, the cut points for MVPA ranged from 420 to 800 counts per 15 seconds. The existence of multiple and conflicting cut points makes comparing MVPA estimates from different studies difficult, if not impossible.23 Identification of the optimal cut points for MVPA in preschool-aged children thus remains a priority for future research. Consistent with the results of studies conducted in center-based child care settings, boys were more active than girls.20,21,24 Studies from the child development literature suggest that preschool-aged boys engage in more risk-taking behaviors, engage in rougher play, play in larger groups, and partake in more exploratory play than girls.25-27 In contrast, preschool-aged girls tend to adopt domestic roles during play, which has been associated with low levels of physical activity.28 Therefore, the

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Figure 1. Gender difference in the physical activity variables. *Significant difference at P < .05 based on 3-way (gender  age group  weight status) factorial ANOVA. MVPA indicates moderate-to-vigorous physical activity; TPA, total physical activity. higher levels of physical activity observed in boys relative to girls may be attributable, at least in part, to gender differences in play themes and play types. Previous studies examining weight-related differences in physical activity report that overweight and

obese preschool-aged children spend significantly less time in MVPA than their non-overweight peers.29-31 In the current study, overweight or obese 4- and 5-year-olds exhibited significantly lower levels of MVPA and TPA than their healthy weight counterparts. However, no weight-

Figure 2. Minutes of moderate-to-vigorous physical activity per hour by age and weight status. *Significantly different from healthy weight (HW) 2- and 3-year-olds (P < .05). #Significant weight status difference (P < .05). Results were obtained from a 3-way (gender  age group  weight status) factorial ANOVA. OW þ OB indicates overweight and obese groups.

related differences in physical activity were observed among 2- and 3-yearolds. It is unclear why weight status differences would be present in older rather than younger preschool children. Considering the age-related increase in MVPA and TPA observed among healthy weight children, and the positive association between age and physical activity reported in previous studies of preschool children,24 it is possible that excess adiposity may adversely affect a developmentally related increase in physical activity that occurs after age 3. Future longitudinal studies employing objective measures of physical activity should explore this hypothesis. The results of the current study reinforce the need for effective programs and policies to promote regular physical activity in family day care. To develop effective physical activity interventions, it is important to identify and understand the factors that explain or mediate physical activity behavior in family day care, and devise strategies to change those mediators.32 To date, the policy and environmental factors that influence physical activity in this setting are not well understood. However, a recent investigation identified provision of sufficient outdoor play time, use of portable play equipment, the presence of fixed play equipment (eg, swings, slides, climbing equipment), and adequate indoor play space, engaging in active play with children, and completing trainings on physical activity as factors associated with higher levels of physical activity in family day care.33 In addition to devising strategies that target these influences, future interventions should consider the unique challenges that family day care providers encounter when it comes to providing opportunities for physical activity during the child care day. These include, personal health limitations (eg, pregnancy), the difficulty of offering age-appropriate movement experiences and equipment for mixed-age groups, parents not providing appropriate clothing for outdoor play, lack of appropriate indoor spaces, and limited funds to purchase equipment and materials.34 The current study had a number of limitations that should be considered. First, physical activity assessments

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Figure 3. Minutes of total physical activity per hour age by weight status. *Significantly different from healthy weight (HW) 2- and 3-year-olds (P < .05). #Significant weight status difference (P < .05). Results were obtained from a 3-way (gender  age group  weight status) factorial ANOVA. OW þ OB indicates overweight and obese groups. were conducted during a 1-week period in the spring. Thus, to better understand the physical activity patterns of preschool children attending family day care, and examine potentially important seasonal variations in physical activity behavior, additional weeks of monitoring may be advisable in future studies. Second, although accelerometers provide valid estimates of physical activity in preschool children, the use of accelerometers has limitations. Accelerometers do not fully capture the increased energy cost of climbing over structures, walking up stairs, or riding tricycles. Third, weight status was based on the Centers for Disease Control and Prevention age- and sex-specific percentiles for body mass index, which may be limited in ability to accurately measure adiposity, especially in young children.35

IMPLICATIONS FOR RESEARCH AND PRACTICE Children attending family day care accumulate relatively small amounts of MVPA and TPA during the child care day. Future research should be

directed toward devising and evaluating interventions to promote physical activity and reduce sedentary behavior in family day care settings. Interventions must take care to consider the unique challenges that family day care providers face when it comes to providing regular physical activity in their home-based businesses.

ACKNOWLEDGMENTS Funding for this study was provided by grant 2009-55215-05311 from the National Institute of Food and Agriculture, United States Department of Agriculture.

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Rice and Trost 201 3. Freedman DS, Kettel L, Serdula MK, Dietz WH, Srinivasan SR, Berenson GS. The relation of childhood BMI to adult adiposity: the Bogalusa Heart Study. Pediatrics. 2005;115:22-27. 4. Nathan BM, Moran A. Metabolic complications of obesity in childhood and adolescence: more than just diabetes. Curr Opin Endocrinol Diabetes Obes. 2008;15:21-29. 5. Steinbeck KS. The importance of physical activity in the prevention of overweight and obesity in childhood: a review and an opinion. Obes Rev. 2001;2:117-130. 6. Janz KF, Kwon S, Letuchy EM, Eichenberger G, Burns TL, Torner JC. Sustained effect of early physical activity on body fat mass in older children. Am J Prev Med. 2009;37:35-40. 7. Forum on Child and Family Statistics. America’s Children: Key National Indicators of Well-being. Washington, DC: United States Government Printing Office; 2009. 8. Laughlin L. Who’s Minding the Kids? Child Care Arrangements: Spring 2011. Washington, DC: Current Population Reports, United States Census Bureau; 200270-135. http://www.census.gov/ prod/2013pubs/p70-135.pdf. Accessed August 28, 2013. 9. Temple VA, Naylor PJ, Rhodes RE, Higgins JW. Physical activity of children in family child care. Appl Physiol Nutr Metab. 2009;34:794-798. 10. Pate RR, O’Neill JR, Mitchell J. Measurement of physical activity in preschool children. Med Sci Sports Exerc. 2010;42:508-512. 11. Van Cauwenberghe E, Labarque V, Trost SG, De Bourdeaudhuij I, Cardon G. Calibration and comparison of accelerometer cut points in preschool children. Int J Pediatr Obesity. 2011;6: e582-e589. 12. Vale S, Santos R, Silva P, SoaresMiranda L, Mota J. Preschool children physical activity measurement: importance of epoch length choice. Pediatr Exerc Sci. 2009;21:413-420. 13. Kuczmarski RJ, Ogden CL, GrummerStrawn LM. CDC growth charts: United States. Advanced Data. 2000;314:1-27. 14. Child and Adult Care Programs. US Department of Agriculture, Food and Nutrition Service Web site. http:// www.fns.usda.gov/cnd/care/CACFP/ aboutcacfp.htm. Accessed August 28, 2013. 15. National Research Council. Early Childhood Obesity Prevention Policies. Washington, DC: National Academies Press; 2011.

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16. Department of Health, Physical Activity, Health Improvement and Protection. Start Active, Stay Active: A Report on Physical Activity for Health From the Four Home Countries Chief Medical Officers. London, United Kingdom: Department of Health; 2011. 17. Okely AD, Salmon J, Trost SG, Hinkley T. Discussion paper for the development of physical activity recommendations for children under five years. Canberra, Australia: Department of Health and Ageing, Government of Australia; 2008. 18. Tremblay MS, Leblanc AG, Carson V, et al. Canadian Physical Activity Guidelines for the Early Years (aged 0–4 years). Appl Physiol Nutr Metab. 2012;37:345-356. 19. Pfeiffer KA, McIver KL, Dowda M, Almeida M, Pate RR. Validation and calibration of the Actical accelerometer in preschool children. Med Sci Sports Exerc. 2006;38: 152-157. 20. Pate RR, Pfeiffer KA, Trost SG, Ziegler P, Dowda M. Physical activity among children attending preschools. Pediatrics. 2004;114:1258-1263. 21. Loprinzi PD, Trost SG. Parental influences on physical activity behavior in preschool children. Prev Med. 2010;50: 129-133. 22. Sugiyama T, Okely AD, Masters JM, Moore GT. Attributes of child care centers and outdoor play areas associated

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Erratum The March/April 2012 issue of the Journal of Nutrition Education and Behavior carried a Research Brief entitled Family Ties to Health Program: A

Randomized Intervention to Improve Vegetable Intake in Children (JNEB 2012;44:166-171. http://dx.doi.org/10. 1016/j.jneb.2011.06.009). Although

the grant was inadvertently omitted from the article, this study was funded in part by the National Institutes of Health under grant R24 HD050924.

Physical activity levels among children attending family day care.

To objectively measure the physical activity (PA) levels of children attending family day care programs...
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