In the second panel of the workshop, a group of experts on early care and education examined the broad range of steps that can be taken for
children aged 0–5 to establish lifelong behaviors that can prevent obesity. Debbie Chang, senior vice president of policy and prevention with Nemours Children’s Health System, described opportunities to prevent obesity in early care and education settings. Daithi Wolfe, early education policy analyst with the Wisconsin Council on Children and Families, spoke about progress and challenges in obesity prevention at the state level. Anna Mercer-McLean, executive director of the Community School for People under Six, a child care center in Carrboro, North Carolina, emphasized the importance of including the voices of providers in prevention efforts.
At the beginning of the 21st century, very little work was being done on obesity prevention in child care settings, Chang noted, but a series of developments over the past decade and a half have established early care and education as a key locus for childhood obesity prevention efforts. She suggested that the identification of best practices directed attention to what works and allowed those practices to be expanded, while policy changes at the state level, such as child care licensing changes, fostered healthy eating and active play. Despite this progress in scaling up best practices, however, a central question persists, said Chang: “How do we reach the most children in the shortest period of time with the highest-impact policy and practice changes in the most efficient way?”
“Starting early makes sense,” Chang argued. She recalled a previous Roundtable workshop, Obesity in the Early Childhood Years: State of the Science and Promising Solutions (NASEM, 2016),1 at which several modifiable risk factors for developing obesity at a young age, including taste and flavor preferences, sleep adequacy, and feeding practices, were explored. “In those critical early years—pregnancy to age 5—we need to embed those risk factors and protective factors in all that we do,” she asserted.
Chang emphasized four critical factors in efforts to promote healthy weight through early care and education. The first was collaboration. Chang cited the example of Healthy Kids, Healthy Future, a collaboration that has brought experts on early care and education and obesity prevention together to work on child care issues. To advance such cross-sectoral work, she suggested, it is important to build trust, forge partnerships, and continually reassess and reset system goals. “Multi, multi, multi—multiple partners, multiple sectors, multiple systems, and multiple strategies. It will take all of these components to get the change that we need,” she argued.
The second factor Chang emphasized was federal policy. “Over time,”
she observed, “we have embedded the opportunity for healthy eating and physical activity in a range of federal programs” that address child care. The U.S. Department of Education, for example, has focused on early childhood education through its Race to the Top—Early Learning Challenges program (ED, 2016), while the U.S. Department of Agriculture has adopted new standards for meals served through the Child and Adult Care Food Program, which reaches millions of children in child care centers (FNS, 2016) (see Chapter 7). Similarly, Chang noted, the Administration for Children and Families within the U.S. Department of Health and Human Services has integrated healthy eating and physical activity into its grantmaking (Office of Child Care, 2016).
The third factor Chang cited was involvement of the private sector. The Partnership for a Healthier America, for example, has garnered commitments from five national private child care companies to encourage healthier eating and physical activity within their centers (Partnership for a Healthier America, 2015). When these commitments are realized, Chang reported, they will reach nearly 1 million children in child care settings (Partnership for a Healthier America, 2015).
Finally, Chang emphasized the “spectrum of opportunities” for obesity prevention in early care and education settings identified by the Centers for Disease Control and Prevention (CDC) (see Figure 3-1). These “levers”
range from training for child care professionals to licensing standards, all of which can be used to address obesity prevention, she pointed out. She listed several “best bets” and how they can work to embed obesity prevention practices into child care settings. Regulations and accountability for compliance can change practices, she explained, while training, technical assistance, and self-assessment can improve programs. And best bets in content areas—such as serving fruits and vegetables at every meal, implementing standards for healthy foods and beverages, limiting screen
time, encouraging breastfeeding, and promoting physical activity—all can improve the health of children, she argued.
Keeping these four factors in mind, Chang suggested examples of opportunities in three categories—policy, practice, and research—in the areas of regulatory approaches, equity, and family engagement (see Box 3-1).
In addition to the opportunities listed in Box 3-1, Chang identified opportunities for action in the area of innovation:
- Explore how state and federal money can be used to support child care health consultants or other home-visiting program efforts.
- Create and support policies that will professionalize careers in early care and education.
- Advocate for funding to disseminate studies of programs that work.
- Explore opportunities for data sharing.
- Create the business case for early childhood intervention.
- Use technical solutions, such as cloud-based management systems, as models for creating administrative resource-sharing policies among facilities.
In closing, Chang emphasized the importance of sustaining policy advances that are made and not letting them roll back. Sustaining such advances will require continued advocacy, she suggested, which can also focus on what remains to be done. “There are additional policies and more opportunities for state flexibility to embed healthy eating and physical activity into the daily routines of child care,” she said, “as long as there’s input from both states and providers.”
In addition to federal initiatives, many state, local, and private-sector organizations are working on child care, Chang noted. “Virtually every state is focused on early care and education,” she said. “There has been a tremendous amount of progress in this area.”
Wolfe used the experiences of the Wisconsin Council on Children and Families as an example of the interplay between state and federal policy. The council is a statewide family and child advocacy organization founded in 1881. Its 2013 report The Race to Equity (Wisconsin Council on Children and Families, 2013) examines disparities in employment, health, education, incarceration, and other indicators in Dane County, which includes Madison. As an example of its findings, Wolfe pointed out that the poverty rate for white children in Dane County was 5 percent, while that for African American children was 75 percent. “We have a lot of work to do,” he asserted.
Wolfe described several initiatives in Wisconsin that are improving the lives of children. The Wisconsin Early Childhood Obesity Prevention Initiative, for example, brings together actors in early care and education to create collective impact through a shared agenda and continuous communication, he explained. The group has created toolkits to help child care providers incorporate physical activity and healthy eating into their centers.
An example is Active Early,2 which focuses on physical activity. In a pilot in 20 Wisconsin child care centers in which children wore accelerometers, the intervention led to a near-tripling of the amount of moderate to strenuous activity in which the children engaged (LaRowe et al., 2016). One of the biggest changes occurred going from one activity to the other, Wolfe noted. “Child care providers were taught to do things like, ‘We’re going to bunny hop to the next one,’ or ‘We’re going to march backwards,’ or ‘We’re going to clap hands,’ or ‘We’re going to sing a song,’” he reported. “It doesn’t have to be that you’re going out for an hour and running laps. . . . We’re trying to have it be there throughout the day.” The challenge now, he explained, is to implement these practices in the 5,000 child care centers in Wisconsin. “We need everybody to have this resource and to make it work,” he said.
Wolfe particularly emphasized local partners and peer-to-peer learning. Policy can go only so far, he said. Connecting it to the good work that is going on elsewhere can be even more important, he asserted, especially in the areas of equity and targeting of underserved populations. Such connections can provide increased capacity, support, and funding, he argued.
After years on the back burner, observed Wolfe, family engagement has been a recent focus of attention in Wisconsin. Advocates have worked, for example, to incorporate family engagement measures in the state quality rating and improvement systems (QRIS) for child care. To assist centers in adopting this new practice, the Wisconsin Early Childhood Obesity Prevention Initiative created a menu of family engagement activities from which centers could choose that would count toward the quality standards, Wolfe explained. In designing this menu, the initiative combined health and wellness activities with family engagement activities, such as by supporting a breastfeeding-friendly environment, which gives child care providers credit for both health and wellness and family engagement. Wisconsin advocates for obesity prevention in child care have also used the state’s QRIS to increase the amount of physical activity required each day in early care and education settings.
As a specific example of a positive change, Wolfe pointed to gardening. “Providers want to serve better food, they want to have more physical activity, they want to create a nutritious environment,” he observed. In a competition for funds to create and maintain gardens, more than 300 centers applied for only about 90 grants. “The demand is there,” said Wolfe. “If we had private funders or other sources, almost every child care provider in Wisconsin would love to have a garden.”
A great challenge to progress is “dismal” child care wages, Wolfe asserted. The median child care wage in Wisconsin is about $10 an hour, he
2 See https://activeearlyhealthybites.wordpress.com/the-guides (accessed February 8, 2017).
explained, which represents income below the poverty line. “If we want to make changes in children’s lives—and they’re spending 50 hours a week in child care—we need to pay for the teachers and we need to pay for the programs,” Wolfe argued.
Child care providers can also see increased regulation as burdensome, Wolfe pointed out, which has caused some to drop out of such programs as the Child and Adult Care Food Program, which recently updated its meal standards. “We want every child care provider to participate,” he said. “People are saying they’re leaving it because they don’t want three visits a year, they don’t want to fill out the paperwork, etc. What do we do about that?”
Another barrier Wolfe mentioned involves equity. Wisconsin is second in the nation in the number of organic farms, but local food is often more expensive to use in a child care setting. “Is that food going to low-income families in Milwaukee?” Wolfe asked. “Not for the most part, so we have work to do.” Greater equity will not be achieved on its own, he suggested. “We only can promote equity by being intentional, by being purposeful,” he said. He also argued for disaggregating data by race, ethnicity, and other social factors whenever possible to enable assessment of inequities.
A final barrier Wolfe cited is that many children in Wisconsin are not in the child care system. “We can do great policies, we can have wonderful child care programs, we can train the teachers, but there are many kids who are either in unregulated care or at home or with friends and family,” he observed. “How do we reach those kids?”
Mercer-McLean urged that the voices of the child care community be included in the conversation about obesity prevention. “Not too often do we get to come and speak in a setting such as this,” she noted.
The Community School for People under Six is a nonprofit child care center that provides quality early care and education for all children, especially those from low- and moderate-income families. It is a highly recognized program, said Mercer-McLean, but it continually asks how it can move to the next step in enabling children to be healthy. It operates under standards in the state of North Carolina that are designed to improve the quality of child care, including standards for physical activity and nutrition. “Those things have to happen at the policy level,” she argued, but with consideration for the needs of the child care provider.
North Carolina has a QRIS that itself is subject to improvement, said Mercer-McLean. “Who looks at those standards?” she asked. “Who looks at how to improve them, monitor them, to be accountable and provide funding and technical assistance for those standards?” Moreover, she noted,
these policies are not implemented across the board. “We have to keep pushing so those policy changes don’t just affect the upper level but at the bottom,” she asserted.
Mercer-McLean described her center’s continuous work on improving the quality of the care it provides. She pointed out that the changes it has implemented did not happen on their own. The Community School participated in Shape NC,3 a program sponsored by Blue Cross and Blue Shield of North Carolina that helps child care centers and their communities develop policies and build environments that support healthy children. The center’s involvement in Shape NC has encouraged it to implement several changes, Mercer-McLean reported. The Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) program4 has produced changes in nutrition for children at the Community School by increasing healthy eating. The Be Active Kids program has taught teachers how to engage their children and themselves in more physical activity, increasing the number of adult-led physical activities in which children are engaged, with the teachers themselves wearing Fitbit fitness bracelets. The school has also set up a breastfeeding space called Serenity Place that provides a setting for relaxation, reading, and being together. And the center has been gardening and bringing that food to the classroom to eat. “It’s that private nonprofit process and all of the people being involved in that process that’s made a change,” Mercer-McLean explained.
Implementing such positive changes requires substantial resources, Mercer-McLean noted, and this is an ongoing challenge for child care centers. For example, the Community School is looking to serve more organic food but is struggling to find suppliers that fit within its budget. Furthermore, Mercer-McLean observed, even five-star programs such as the Community School, much less one-star programs, may lack the resources to achieve certain improvements. “Those resources are not there for children and families everywhere,” she said. “When we think about the field, we need to think about how we can broaden that.”
Mercer-McLean concluded by reiterating her belief that every child care program and setting needs and deserves a voice in the policy process. This participation may occur through focus groups, interviews, or simple phone calls, but “first there has to be a conversation,” she argued. “I want to make sure that’s focused on everybody.”
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