HAPPIERchildren :

1. HAPPIERchildren: A multi-level 13-month daycare-based intervention By Emily Wong

2. What’s the problem? • Prevalence of childhood obesity has almost tripled in the past 30 years1 • 17% classified as obese (12.5 millionchildren)1 • Childhood overweight/obesity is associated with many negative health conditions2-4 • Children who are overweight or obese are more likely to become overweight or obese adults5, 6 • Most interventions target school-aged children7

3. What contributes to the problem? • Poor diets and lack of physical activity1 • Overweight/obese parents8 • Non-specific daycare curriculum requirements • Parents and other adult role-models influences on choices, including choices regarding food9 • Negative correlation between the number of working hours a mother has with the amount of fruits and vegetables her child(ren) regularly consume(s)10, 11

4. Where did all the children go? • Many working parents place their preschool-aged children in some form of center-based care • In the state of Massachusetts, about 70% of preschool-aged children are enrolled in a formal early education or care setting

5. HAPPIERchildren Healthy and Active Parents and Providersas Ideal Eating Role-models for Children

6. Theory-based Intervention • Socio-Ecological Framework • used to identify the multiple levels of influence • on the child’s eating behaviors and physical activity • - Child (individual) • Parents (interpersonal) • Daycare provider (interpersonal) • Daycare center environment (community) • Home environment (community) • Social Cognitive Theory • used to identify contributing factors for behavior change • Health Belief Model • used to identify contributing factors for behavior change • Theory of Planned Behavior • used to identify stages towards behavior change • Precaution Adoption Process Model • used to identify stages towards adoption of a behavior

7. Intervention Goal: To develop healthy eating behaviors and physical activity habits in children by: • Improving parent and provider role-modeling • increasing child knowledge • increasing child daily physical activity • creating a supportive environment

8. One month of Provider training 12 months of parent and provider workshops 12 months of daily 30-minute active child nutrition lessons Healthy eating and physical activity social marketing materials Four Components

9. Purpose is to learn: the material they will be teaching how to effectively teach and engage the children with the material Month of Provider Training • Providers will get practice teaching to other providers • All materials, lesson plans, and engaging activities will be planned and provided

10. Healthy Cooking and Obesity Prevention Workshops First 6 months – twice a month, Sat afternoon Last 6 months – once a month, Sat afternoon Various venues near the day care center with various topics and meal themes 5 main components: • obesity information session • “strategies to obesity prevention” info session • quick and easy recipe demo and cooking session • reflection time • fun family group activity

11. Key Workshop Elements Participants receive one free Tupperware, pen, and lined notebook paper journal Use Tupperware to take home leftovers from each cooking session for the spouse and children to taste Use journals to document spouse and children’s feedback and thoughts on workshops Free babysitting provided by research staff/interns during the workshop

12. Purpose is to: • increase knowledge, awareness, and behavioral capability, and therefore self-efficacy • increase awareness and the belief that their eating choices and physical activity habits have a major impact on their child’s nutrition and health How does it work, in theory? • Free Tupperware provides behavioral capability • Taking workshop meals home in the Tupperwares for spouses and children changes subjective norms

13. Purpose is to: efficiently combine exercise with nutrition learning focus on nutrition but require students to be physically active - ex. a scavenger hunt for fruits and vegetables, which would then be tasted at the end 30-minute Daily Active Child Nutrition Lesson

14. How does it work, in theory? Daily routine helps with maintenance and reinforcement of healthy messages Physical activity engagement helps with retaining and associating fun to healthy food messages Knowledge and association with fun increase behavioral intention to ask for healthy foods and expectations to have fun eating them at home

15. Healthy Food and Physical Activity Social Marketing Materials • Purpose is to: • enhance the home and childcare environment to be supportive of healthy eating and being active • posters • plastic active play toys • plastic food toys of fresh vegetables and fruits • puzzles that make salads • coloring sheets with princesses and superheroes eating fruits and vegetables

16. How does it work, in theory? • Having these around serve as reminders and form the idea of a social norm to eating healthy and being active

17. Primary Outcomes Outcome 1. Between Baseline and 12-months, children in the intervention group will have a significantly smaller increase in BMI than children in the control group Outcome 2. Between Baseline and 12-months, children in the intervention group will have a significantly greater increase in the frequency of requests per week for either fresh fruits or vegetables than children in the control group

18. Secondary Outcomes • Parents and Providers, from baseline to 12 months, will: • increase their own fresh fruit and vegetable intake • have increased self-efficacy to eat more fresh fruits and vegetables in their daily meals • include more moderate to vigorous physical activity in their weekly routine

19. Process and Outcome Evaluation • 30-minute Daily Active Nutrition Lessons • Provider Survey forms • Week of Observation • Parent and Provider Workshops • Self-assessment forms • Dietary Screener forms • Workshop attendance sheet • Primary Outcomes • Anthropometrics of children • FFV request frequency calendars • Secondary Outcomes • Self-assessment forms • Dietary Screener forms

20. To develop healthy eating behaviors and physical activity habits in children 13 month Daycare-based Intervention Target Population: Children between 2 and 5 years Employs 5 Theories: SEF, SCT, HBM, PAPM, and TPB Multi-Level approach Role-modeling via Parents and Providers Socially supportive environment Summary

21. Key Stakeholders

22. External Stakeholders • Local, State, and Federal government • control policies and requirements for licensing at daycare centers • day care centers are part of the early learning and education state department • Health education grant funding • - funding can allow for day care centers to purchase extra materials to facilitate daily nutrition lesson

23. Administrative Stakeholders • Owner or CEO of the day care facility or company • in charge of wide-spread policy changes • focused on business aspect of daycare • implement business model

24. Internal Stakeholders • Center director • manage and handle the every-day responsibilities for quality control • ensure that programs are meeting state requirements • arrange and organize overall center activities conducted in all classes • assess center resources and schedule • Providers • deliverers of education and role-modeling in daycare environment • Teaching assistants • - Assist deliverers of education

25. Local Stakeholders • Children • mostly dependent on their parents in making decisions • can be picky eaters • Parents • their money going to the daycare center • their child’s health

26. Potential Opposition • Providers may be greatly opposed to extra training sessions on the weekends outside of their work hours • Adding a nutrition lesson may take away from lessons Providers enjoy or free time they use to rest during the day • Administrations may not want to make curriculum changes • Parents may not wish to engage in outside weekend training sessions • Parents may not want their children observed in daycare by “reseachers”

27. References • Centers for disease control and prevention: overweight and obesity. (2011, October 21). Retrieved from http://www.cdc.gov/obesity/index.html • Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight to cardiovascular risk factors among children and adolescents: the Bogalusa Heart Study. Pediatrics. 1999;103(6 Pt 1):1175-1182. • Sinha R, Fisch G, Teague B, et al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. N Engl J Med. Mar 14 2002;346(11):802-810. • Weiss R, Dziura J, Burgert TS, et al. Obesity and the metabolic syndrome in children and adolescents. N Engl J Med. Jun 3 2004;350(23):2362-2374. • Baird J, Fisher D, Lucas P, Kleijnen J, Roberts H, Law C. Being big or growing fast: systematic review of size and growth in infancy and later obesity. BMJ. Oct 22 2005;331(7522):929. • MonteiroPO, Victora CG. Rapid growth in infancy and childhood and obesity in later life—a systematic review. Obes Rev. May 2005;6(2):143-154. • Monasta L, Batty GD, Cattaneo A, et al. Early-life determinants of overweight and obesity: a review of systematic reviews. Obes Rev. Mar 16. • Agras WS, Mascola AJ. Risk factors for childhood overweight. CurrOpinPediatr. Oct 2005;17(5):648-652. • Nutbeam D, Aarm L, Catford J. Understanding children’s health behavior: the implications for health promotion for young people. Soc Sci Med. 1989;29:317-325. • Brown JE, Broom DH, Nicholson JM, Bittman M. Do working mothers raise couch potato kids? Maternal employment and children’s lifestyle behaviours and weight in early childhood. Soc Sci Med. June 2010;70(11):1816-1824. • Hawkins SS, Cole TJ, Law C, Millennium Cohort Study Child Health Group. Examining the relationship between maternal employment and health behaviours in 5-year-old British children. J Epidemiol Community Health. Dec 2009;63(12):999-1004.