Collaborating for Impact: Family, School, Community and Policy-Based Strategies to Prevent Childhood Obesity

1. Collaborating for Impact: Family, School, Community and Policy-Based Strategies to Prevent Childhood Obesity Jessica A. Hoffman, PhD, NCSP Northeastern University

2. Why is childhood obesity prevention important? • Why are schools important venues to reach children and families in prevention? • How does school-based obesity prevention relate to school psychology? • Examples of prevention efforts from the field: • Healthy Kids, Healthy Futures • Farm to Family • Saturday Open Gym • NOURISH study Agenda

3. Obesity Trends Among U.S. AdultsBRFSS,1990, 1999, 2009 1999 1990 2009 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

5. Prevalence of Childhood ObesityLow-Income Preschool Children Aged 2 to <5 Years

6. Childhood obesity

9. Childhood Obesity Prevention: A Multi-Systemic Approach

10. National/Local Policies Community/ Neighborhood Childhood Obesity Prevention: A Social-Ecological Perspective

11. Nutrition • School meals • Most children eat 180-540 meals & snacks in school/year. • Competitive foods • Vending machines, a la carte, school stores, fundraisers, parties, special events • Food as reinforcement • Nutrition education • Physical activity • Physical education • Recess Schools as a Venue for Obesity Prevention

13. Aim: To create opportunities for wellness for Boston families with young children in an effort to address health disparities and prevent childhood obesity. • Began in 2009, Northeastern University and Boston Children’s Hospital work with Action for Boston Community Development (ABCD) Head Start and Boston Centers for Youth & Families (BCYF). • Founding support from Boston Children’s Hospital and Northeastern University.

14. To prevent obesity among children ages 3-8 living in vulnerable Boston neighborhoods by engaging families in the places children live (home), learn (preschool) and & play (community). HKHF Mission

15. Components • Component 1: Nutrition and Physical Activity Promotion in Home & Childcare (Head Start) • Farm to Family • Nutrition Education (We CAN! curriculum, cooking classes, supermarket and farmers’ market tours) • Walk Challenge • Component 2: Community-based Physical Activity Promotion for Young Children & Families (BCYF) • Open Gym

16. HKHF Goals • 1.To improve the capacity of early childhood providers to prevent childhood overweight and obesity among pre-school age children and their families. (Head Start)2.To increase opportunities for caregivers of young children to build skills that support healthful food choices, increased physical activity, and reduced recreational screen time. (Head Start & BCYF) • 3.To increase opportunities for young children to be physically active with their families in safe, accessible and age-appropriate settings. (BCYF)

17. HKHF Summary: Years 1-4

18. The National Farm to Preschool Movement

19. Connects local food producers and processors with early care and education • Local food- and garden-based education in the classroom, food service, and community What is Farm to Preschool?

20. Purchasing local foods for meals and snacks • Curricula and classroom activities • Farm field trips, farmer visits • Gardens • Cooking and tastings • Workshops and trainings • Parents, providers, others • Newsletters • Produce for home • Wellness policies • Evaluation What are Farm to Preschool Activities?

21. Farm to Family: Connecting food, preschool and family systems to make high quality vegetables accessible and affordable (Hoffman, Wirth, Brooks, Daminger, Carter, & Sceppa, 2013)

22. Increased parent self-efficacy to prepare good tasting F&V that their family will eat. Reciprocal Determinism F2F Based in Social Cognitive Theory

23. Subsidized CSA (Community Supported Agriculture) model • Goal: increase access to fresh, affordable vegetables in households with young children • Vegetables grown by local farm and delivered weekly to community sites • F2F video F2F Model Basics

24. Implemented in 2011, 2012, 2013 • 16 week program (July-October) • Families pay $6.25/week for $25 of produce • Can pay with SNAP or cash • Subsidized portion comes from sister shares, money raised by community partners and grants • Serves low income families in 3 Boston neighborhoods • Dorchester, Jamaica Plain, Roxbury F2F Model Basics

25. Weekly bilingual newsletters including recipes, nutrition info, and food preparation and storage tips • Supplementary nutrition and cooking workshops • Farm trips for children and families F2F Model Basics:Educational Components

26. 1-2 staff members/site; champion the program • Selected by the program director • Roles include: • Recruiting participants • Receiving and distributing weekly shares • Making reminder and pick up phone calls • Collecting payments • Administering annual survey • Receive a farm share • Annual training at the beginning of the season F2F Model Basics: Site Coordinators

27. Built from the ground up in collaboration with families, Head Start programs, local farmers and academic partners • Head Start parent surveys and focus groups used to obtain input • 93% of surveyed parents were interested in receiving vegetables through Head Start • 67% would be interested if vegetables were offered at a reduced price • 59% would be interested if they could use SNAP to pay for the vegetables Development of the F2F Model Source: Agrawal, Myles, Hoffman et al., 2011 Notes: Parent survey (N=139), parent focus groups (N=4)

28. Average # of families served/month: • 2011: 115 • 2012: 128 • 2013: 76 • SNAP/EBT usage: • 2011: 30% • 2012: 36% • 2013: 40% F2F by the Numbers Notes: 2013 figures are for July & August; There were fewer sites and fewer available shares in 2013 (80 in 2013; 130 in 2011 & 2012).

29. Introduction to F2F Source: 2012 F2F Year End Survey Note: N=86

30. Primary reason for participating in F2F: • Low price (n=44) • Desire to eat more fresh or local food (n=32) • Have more fruits and vegetables for their family (n=26) • Convenience of program (n=13) Motivation to Participate • Source: 2012 F2F Year End Survey • Notes: N=86; some respondents selected multiple motivations.

31. In 2011, parent pick up rates = 74% • In 2012, 51 families randomized to receive weekly text message reminders or no text reminders • On time pick up rates were lower for both groups, but slightly higher for text message group: • Text message = 69% • No text message = 62% • Overall pick up rates were high for both groups: • Text message = 96% • No text message = 92% Pick Up Rates Source: Cox, Hoffman & Shiyko, 2013

32. Assessment of Produce Source: 2012 F2F Year End Survey; Note: N=86

33. Consumption of a New Fruit/Vegetable Source: 2012 F2F Year End Survey Notes: N=86; new foods included eggplant, squash, yellow watermelon.

34. Changes in Vegetable Consumption Source: 2012 F2F Year End Survey Note: N=86

35. A lesson in every bag (n=7) • “I think there’s a lesson in every bag because you have to figure out, okay now what is this if you’ve never seen it before. Then you have to figure out how do you eat this? What do you eat it with?” • Takes more time but worth the benefits (n=4) • “It takes more time but you have to think about it’s more healthier. If you just open a can and just put it there, the taste is not the same. You don’t want to eat something that you’re not enjoying the taste. I see the difference with the lettuce. I just go to the store and buy lettuce and it’s different. This one, I put vinegar and a little bit of olive oil, little bit of salt, there’s so much in there. It’s different.” • More of a hassle (n=2) • “I just think it’s like more of a hassle when you don’t have the time cause right now I have a bag of it on top of the refrigerator rotting and like I have to clean that bag. I have to go through it and get what’s good out, get what’s not. So I think of the time factor.” Participant Experiences Source: Agrawal, Devine, Hoffman, Wirth, Castaneda-Sceppa (2013) Note: N=13

36. F2F has been implemented for 3 years • Model is feasible within preschool settings • Model is acceptable to families • Strengths • Low income families able to access fresh vegetables easily and affordably • Opportunities to link home and school food environments • Challenges • Funding • Providing support to site coordinators • Next steps • Continue to develop the evidence base for the model with more rigorous research studies • Identify additional sustainable funding mechanisms Summary

37. Saturday Open Gym: A Community Partnership to Promote Physical Activity among Families with Young Children

38. “The community and its built environment should promote physical activity for children from birth to age five.” (IOM Report, 2011)

39. Free, weekly play program for children ages 3-8 and their families. • Offered on Saturday mornings for 90 minutes at 2Boston Centers for Youth & Families community centers. • Three cycles (winter/spring, summer, fall) of nine sessions each. • Staffed by Northeastern University student volunteers. • Features a variety of activities and games to engage families in moderate to vigorous physical activity. • Saturday Open Gym Video Saturday Open Gym

40. 116 sessions across 13 cycles • > 425 unique families have attended • Attendance averages 57 people per week (adults and children) • Retention: • 34% of families have attended more than one cycle • 32% of families have attended half or more of the sessions in a given cycle Open Gym by the Numbers (Summer 2009-Summer 2013)

41. The majority of participants come from Roxbury and Dorchester • 29% of participants are Latino; 44% are African American. • 68% of adults are mothers; 24% are fathers. Open Gym Demographics

42. Child and Caregiver Activity Levels During Open Gym (Thomas, Hoffman, Dubois, Agrawal, Healey, Nethersole, & Sceppa, 2010)

43. Child and Caregiver Activity Levels During Open Gym • Children: • Vigorous PA during 37% of intervals • Walking or Vigorous PA for 55% of the intervals • Caregivers: • Vigorous PA during 16% of the intervals • Walking or Vigorous PA for 24% of the intervals • Not engaged for 49% of the intervals • 2010 observational findings led to structural changes at Open Gym • Pushed back bleachers • Reduced # of student activity leaders • Added Zumba (Thomas, Hoffman, Dubois, Agrawal, Healey, Nethersole, & Sceppa, 2010)

44. Find us online www.northeastern.edu/healthykids

45. The NOURISH STUDY:Nutrition Opportunities to Understand Reforms Involving Student Health Study Team: Eric Rimm, ScD, HSPH(PI) Juliana Cohen, ScD, HSPH (Co-I) Jessica Hoffman, PhD, Northeastern (Co-I) Lindsay Rosenfeld, ScD, Brandeis (Co-I) Lauren Smith, MD, MPH, MA DPH (Co-I) Funded by: Robert Wood Johnson Foundation

46. School food environment comprised of 2 components • Federally reimbursable school meals • Competitive foods • Include products sold in vending machines, a la carte cafeteria lines, school stores, school fundraisers • Widely available in most schools in the US • Tend to be low in nutrients and high in fat and sugar NOURISH Study

47. Competitive foods are largely unregulated • IOM report 2007 • State-by-state variation (CDC, 2012) • MA passed a school nutrition bill in 2010 (105 CMR 225.000) required new nutrition standards for all competitive foods and beverages served in MA schools • Began August 2012 • 30 minutes before and after the school day • Align closely with IOM recommendations • Strictest in US • Beginning August 2014 federal standards will be implemented (part of the Healthy Hunger Free Kids Act of 2010) NOURISH Study

50. Examine middle and high schools’ compliance with the new regulations • Examine children’s food consumption patterns • Examine effects on school food service revenue • Understand strategies that are associated with successful implementation and prevent revenue loss. NOURISH Study: Purpose