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Early Care and Education

Key Points Highlighted by Individual Speakers

  • Licensing, regulation, quality rating and improvement systems, technical assistance and support for providers, new tools, and innovative programs all can improve nutrition and physical activity in early care and education (Chan Ward)
  • Integrating early care and education with public health and child health care systems would make efforts much more effective in helping children grow up healthy. (Chang)
  • Strengthening the linkages between providers and families would enable them to work together on shared goals. (Chang)
  • Regular monitoring of nutrition and physical activity policies and practices in early care and education would provide critical information to guide federal and state actions. (Ward)
  • Technical assistance provided to early care and education providers should include a standard message about the types of physical activity programs needed for infants, toddlers, and preschoolers (Ward)
  • Maximizing the impact of the Healthy, Hunger-Free Kids Act nutrition and wellness provisions to strengthen and expand the Child and Adult Care Food Program provides an important opportunity to address obesity in early care and education settings. (Henchy)


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3 Early Care and Education Key Points Highlighted by Individual Speakers • Licensing, regulation, quality rating and improvement systems, technical assistance and support for providers, new tools, and innovative programs all can improve nutrition and physical activity in early care and education. (Chang, Ward) • Integrating early care and education with public health and child health care systems would make efforts much more effec- tive in helping children grow up healthy. (Chang) • Strengthening the linkages between providers and families would enable them to work together on shared goals. (Chang) • Regular monitoring of nutrition and physical activity policies and practices in early care and education would provide critical information to guide federal and state actions. (Ward) • Technical assistance provided to early care and education pro- viders should include a standard message about the types of physical activity programs needed for infants, toddlers, and preschoolers. (Ward) • Maximizing the impact of the Healthy, Hunger-Free Kids Act nutrition and wellness provisions to strengthen and expand the Child and Adult Care Food Program provides an important opportunity to address obesity in early care and education set- tings. (Henchy) 15

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16 CURRENT STATE OF OBESITY SOLUTIONS Three speakers addressed obesity solutions in the early care and edu- cation setting. Debbie Chang, vice president of policy and prevention for Nemours Foundation, spoke about the status of obesity solutions and cur- rent needs. Dianne Ward, professor of nutrition at the University of North Carolina at Chapel Hill, explored the need for monitoring and technical assistance. Finally, Geri Henchy, director of nutrition policy and childhood programs at the Food Research and Action Center (FRAC), talked about ways of improving and expanding the Child and Adult Care Food Program (CACFP). STATUS AND CURRENT NEEDS Efforts to improve nutrition and physical activity and eliminate dis- parities have been expanding rapidly in the area of early care and educa- tion, said Chang. The Healthy Kids, Healthy Future Steering Committee, launched in 2009, brings together experts from early education and health to identify and diffuse policy, practice, and research related to the problem of obesity in children aged 0-5. The report Spectrum of Opportunities for Obesity Prevention in the Early Care and Education Setting (ECE)(CDC, 2012), released by the Centers for Disease Control and Prevention (CDC), delineates a comprehensive set of measures that states and communities can take to change early care and education environments.1 The CACFP has encouraged states to focus on early care and education.2 And programs such as Healthy Habits for Life,3 Color Me Healthy,4 Community Transfor- mation Grants,5 and the Early Care and Education Funders Collaborative6 promote change in this area. These and other initiatives have spread rapidly across the country, said Chang. When Nemours started working in this area in 2004, just a few states were focusing on early care and education; today, this is the case in most states. Early care and education involves the intersection of home, the school or educational setting, and the community. As a result, a wide range of 1  A briefing document is available at http://www.cdc.gov/obesity/downloads/Spectrum- of-Opportunities-for-Obesity-Prevention-in-Early-Care-and-Education-Setting_TAbriefing.pdf (accessed April 29, 2014). 2 For more information, see http://www.fns.usda.gov/cacfp/child-and-adult-care-food- program (accessed April 29, 2014). 3 For more information, see http://www.sesameworkshop.org/what-we-do/our-initiatives/ healthy-habits-for-life (accessed April 29, 2014). 4  For more information, see http://www.colormehealthy.com (accessed April 29, 2014). 5 For more information, see http://www.cdc.gov/nccdphp/dch/programs/community transformation (accessed April 29, 2014). 6 For more information, see http://thewomensfoundation.org/early-care-and-education- funders-collaborative (accessed April 29, 2014).

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EARLY CARE AND EDUCATION 17 policies can help create healthier early care and education environments. Licensing and regulation can promote both healthy eating and physical activity. Quality rating and improvement systems can help align early care and education with best practices in healthy eating and physical activity. And new tools for child care providers can help them integrate healthy eat- ing and physical activity into daily routines. Desirable Changes Several issues need particular attention as these and other initiatives move forward, Chang said. The first is sustainability. Policy changes, new regulations, and system-level changes all are needed to extend current initia- tives to future generations. In particular, written policies and regulations are more sustainable than voluntary programs, but if they are to be instituted, work will need to be done in all the states. Growing recognition of the link between health and education needs to be incorporated into early care and education policy and regulations, said Chang. Early care and education, public health, and child health care sys- tems need to be integrated to increase the reach of initiatives and to break down silos. The challenge to fostering such collaboration is not a lack of desire, suggested Chang, but competing pressures and priorities. With respect to system-level change, providers of child care are the greatest assets for sustainability. However, they need education, training, tools, and other types of support if progress is to be extended. Initiatives should build on existing systems rather than creating new ones, said Chang. In many places, for instance, systems for training and technical assistance for providers are already in place. New efforts can tap these existing sys- tems. For example, technical assistance could be folded into collaborative initiatives on physical activity. In addition, all—not just some or even most—states need to be engaged in such efforts. Programs that work need to be scaled up and diffused. For example, a collaborative in Delaware that has brought together groups of child care centers to engage in a structured learning process and has generated evidence of effectiveness is now being extended to other states with CDC’s help. At the same time, initiatives with demonstrated effectiveness need to be balanced with ongoing innovation. Innovation needs to be directed at how to accelerate change and how to use research to determine what works. Pilot programs, along with research evaluating new approaches, could support the extension and scale-up of innovations. In the area of research, more well-designed studies are needed to inform the implementation of effective strategies. Areas in need of attention, said Chang, include physical activity, particularly for children between birth and age 2; family and home settings; and disparities.

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18 CURRENT STATE OF OBESITY SOLUTIONS A Potential Breakthrough Action A breakthrough action, said Chang, could be to strengthen the linkages between early care and education providers and families. Both share the goal of improving the health and wellness of children, yet too often they are characterized by an “us versus them” mentality. Providers frequently do not see parents as partners, while many parents are overwhelmed by the demands of daily life. Child care centers need to be family friendly and open to partnerships with parents. A set of shared goals could help parents and providers work together. MONITORING AND TECHNICAL ASSISTANCE Ward described several major obesity prevention opportunities. Monitoring The first opportunity is to incorporate regular monitoring of nutrition and physical activity policies and practices into licensed early care and education settings in all states. Regular monitoring would greatly increase the available information about the obesity prevention efforts to which infants, toddlers, and preschoolers are exposed in these settings, Ward observed. That information would in turn enable state child care agencies and relevant federal agencies, such as the U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (HHS), to assist child care programs in working more effectively to prevent obesity in the children in their charge. In addition, some states are considering the inclusion of specific nutrition and physical activity standards in their quality rating improvement systems. More precise and timely information about current policies and practices would provide critical information to these agencies and would contribute to important federal and state changes and support the development of guidelines for obesity prevention. An early care and education monitoring initiative could be modeled after the school health policies and practices study that has been conducted periodically in schools since 1994. Key objectives of such a program might be to understand nutrition and physical activity practices in early care and education programs; identify the training and technical assistance needs of directors, owners, and staff; and determine how key policies and practices change over time. While such monitoring would represent an additional expense, it could be subsidized by sources of revenue such as a tax on sugar-sweetened beverages. It would be important for this monitoring program to include child care centers and family homes as well as Head Start programs, said Ward. Also,

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EARLY CARE AND EDUCATION 19 support and coordination of this monitoring effort should originate with the secretaries of USDA and HHS to help reduce potential redundancies with existing evaluation requirements. Physical Activity A second opportunity is for technical assistance provided by child care agencies, public health staffs, and USDA personnel to include a standard message about the types of physical activity programs that should be pro- vided for infants, toddlers, and preschoolers in organized child care. As noted in CDC’s Spectrum of Opportunities report, technical assistance that can affect obesity in child care settings currently is provided by a number of sources within states. Each state has a child care resource and referral agency with professionals who can be reached for help and support. Also available within the states are child care licensing consultants, and many states have child care health consultants. USDA provides CACFP consul- tants as well as cooperative extension agents. Health departments have county and state nutritionists as well as public health professionals who provide assistance to child care staff. Head Start and Early Head Start programs use consultants to provide preservice and in-service training to program staff and volunteers. All of these individuals could be trained to provide a consistent mes- sage about physical activity programs for child care centers and homes through workshops and one-on-one consultations, Ward said. Because no single agency currently provides guidance on physical activity programs in early care and education, a lead agency such as Child Care Aware7 should be identified to coordinate such an effort. It will be important to provide extra assistance and support for low-resourced early care and education facilities and those serving low-income families to help them achieve their physical activity program goals. Ward suggested that the physical activity programs for infants, tod- dlers, and preschoolers provided by early care and education facilities should include sufficient time for both child-directed and teacher-directed activities. In addition, facilities should encourage child care staff to play an active role in implementing the program. Attention should be given to the importance of play spaces both outdoors and indoors and to play equip- ment. These suggested actions are consistent with the Institute of Medicine’s (IOM’s) report Early Childhood Obesity Prevention Policies (2011a). 7For more information, see http://childcareaware.org (accessed April 29, 2014). 

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20 CURRENT STATE OF OBESITY SOLUTIONS Research Gaps In 2011, approximately 50 researchers and child care leaders par- ticipated in a conference sponsored by the Altarum Institute, the National Institutes of Health, Nemours Foundation, and the Robert Wood Johnson Foundation. The meeting identified a number of important research gaps with respect to obesity prevention in early care and education, said Ward. One of the identified needs was to examine the environmental and policy characteristics of early care and education programs to determine the char- acteristics that provide optimal diet and physical activity opportunities for preschoolers, and to evaluate the effectiveness of early care and education standards across states. The implementation of early care and education monitoring as discussed above would directly address this need. IMPROVING AND EXPANDING THE CHILD AND ADULT FOOD CARE PROGRAM Henchy focused her remarks on the importance of maximizing the impact of CACFP provisions in the Healthy, Hunger-Free Kids Act of 2010 to address obesity in early care and education settings. CACFP serves 3.5 million predominantly low-income children every day, she noted, which makes it an excellent vehicle for addressing health disparities by improving nutrition in early care and education. About 1.9 billion meals and snacks were distributed under CACFP in 2013, and the IOM has recommended that the program be expanded because of its contributions to healthy eat- ing (IOM, 2010a). The IOM also has pointed out that CACFP could be improved (IOM, 2010a). Under the Healthy, Hunger-Free Kids Act, the program must pro- vide education in nutrition and in increasing physical activity and decreas- ing screen time in CACFP child care. “That is an important and historic change,” said Henchy. Implementation of these requirements is ongoing. It is also designed to help providers get ready for the upcoming revised CACFP nutrition standards The Healthy, Hunger-Free Kids Act CACFP improvements bring nutri- tion education, standards, and resources to support child care providers serving low-income children to improve nutrition and wellness. This is important to reducing health disparities and addressing obesity in early care and education settings. The changes made will need to be supported at the national, state, and local levels, Henchy said. The program also needs to be expanded to cover low-income children who today are receiving poor- quality care. “Many days they are getting a lot of ramen and crackers and are parked in front of the TV. This is something that we all want to make sure does not go on anymore,” she said.

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EARLY CARE AND EDUCATION 21 Collaborating on Change In recent years, states have been holding summits to bring together stakeholders in early care and education, including nutrition experts, obe- sity advocates, antihunger advocates, industry representatives, researchers, and foundation personnel, to discuss how the changes in CACFP can help achieve shared goals for improving child care, addressing health disparities, and reducing obesity. These summits have resulted in recommendations for moving forward and commitments from all the parties. These action-related collaboratives are an excellent way to improve child care and reduce dis- parities among children, Henchy suggested. In addition, HHS has established new standards for training and educa- tion for all subsidized child care. Many informal care settings participate in the subsidy program, which connects them to training and education in nutrition and physical activity. FRAC also has been working for two decades to bring CACFP into informal-care homes, and in most states has been successful in doing so. This is an important way to provide oversight and support for informal care, said Henchy, because CACFP visits those homes at least three times a year to review nutrition standards and provide support and technical assistance. Finally, Henchy pointed out that the Obama administration is working to expand child care. Unless the expansion of child care is supported by sufficient resources, however, it could result in a reduction of quality and resources. Federal standards for child care could replace the “hodge-podge” of standards at the state level, Henchy said, just as federal standards have done at the school level, and businesses and industry could be powerful allies in working toward such standards. However, unless an expansion of child care is done with sufficient resources, one consequence can be a reduc- tion of quality and resources. She suggested that working toward federal standards could be an important activity for the Roundtable on Obesity Solutions, even as efforts to improve standards continue at the state and local levels.

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