Setting: Early Care and Education & Out-of-School Time

The information in this brief is intended only to provide educational information.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining a strategy incorporating the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) assessment tools into Better Beginnings, Arkansas’ Quality Rating and Improvement System, to support quality early child care program opportunities and promote child health. 

The Issue

In Arkansas, three out of 10 kindergarteners entering school in 2018 had overweight or obesity.¹ The majority of today’s children will have obesity at age 35 if we don’t act.² Making sure children are growing up at a healthy weight from their very first days is a critical way to prevent obesity and future risk for obesity-related diseases like diabetes as adults. Conditions linked to obesity, previously only seen in adults, are appearing in Arkansas’ Medicaid-enrolled children.³ Early child care programs that support healthy nutrition and physical activity habits show great promise in promoting healthy weight.⁴

In Arkansas, more than half of children ages 2-5 attend a licensed child care program.⁵ Providing licensed child care programs with training opportunities and resources through Better Beginnings may be an effective strategy to improve the quality of child care programs and to ensure that the majority of children in Arkansas are off to a healthy start.

About NAP SACC

NAP SACC is an evidence-based, trusted strategy enabling child care centers to attain best practices regarding nutrition, active play, and screen time.⁴ To date, NAP SACC shows the best evidence for reducing childhood obesity risk in children under age 5.⁶ Early education program directors and staff complete self-assessments and receive training and technical assistance to implement practices, policies, and changes supporting healthy outcomes. Better Beginnings is designed to improve child care environments to support child health and development. Integrating NAP SACC into Better Beginnings can improve the quality of child care programs and ensure more children grow up healthy in Arkansas.

Comparing Costs and Outcomes

A CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2020-2030) of implementing NAP SACC with the costs and outcomes of not implementing the program.

Conclusions and Implications

Every child should have opportunities for a healthy start. A state-level initiative integrating NAP SACC into training and quality improvement through Better Beginnings could create healthier nutrition and physical activity environments in child care programs for 116,000 children over 10 years. This strategy would benefit 1,320 early care directors and staff with training and technical assistance to support using nutrition, active play, and screen time best practices at 659 child care programs. Over 10 years, children in Arkansas would have 8,720 more years lived at a healthy weight and 1,130 fewer children would have obesity in 2030 alone.

Many prevention strategies targeting children require an upfront investment because costly obesity-related health conditions generally present later in adulthood.⁷ While we project this strategy would cost $18 per child per year, shortchanging early prevention efforts may lead to costly and complicated treatment in the future. Already, the total annual costs of having obesity are estimated to be $6 million for the 30,000 25- to 29-year-olds enrolled in Medicaid—inclusive of Arkansas’ expansion population. This represents an excess annual cost of $200 per person due to obesity.³

Early child care programs also play a critical role in supporting healthy child development and children’s academic readiness.⁸ Investing in a strategy for quality improvement that provides the necessary training, technical assistance, and resources supports early educators in providing high-quality child care that nurtures healthy habits. Enabling early education leaders in Arkansas to use the best available evidence to prevent excess weight gain in children will support children’s healthy growth and development.

References

1. ACHI. (2019). Assessment of Childhood and Adolescent Obesity in Arkansas: Year 16 (Fall 2018–Spring 2019). Arkansas Center for Health Improvement. Little Rock, AR.

2. Ward Z, Long M, Resch S, Giles C, Cradock A, Gortmaker S. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. New England Journal of Medicine. 2017; 377(22): 2145-2153.

3. ACHI, Arkansas Medicaid. Comorbid Conditions and Medicaid Costs Associated with Childhood Obesity in Arkansas. 2019.

4. Alkon A, Crowley AA, Neelon SE, Hill S, Pan Y, Nguyen V, Rose R, Savage E, Forestieri N, Shipman L, Kotch JB. Nutrition and physical activity randomized control trial in child care centers improves knowledge, policies, and children’s body mass index. BMC Public Health. 2014;14:215.

5. Arkansas Department of Human Services, Division of Child Care and Early Childhood Education, Child Care Facilities Database. Unpublished data. 2020.

6. Kenney E, Cradock A, Resch S, Giles C, Gortmaker S. The Cost-Effectiveness of Interventions for Reducing Obesity among Young Children through Healthy Eating, Physical Activity, and Screen Time. Durham, NC: Healthy Eating Research; 2019. Available at: http://healthyeatingresearch.org

7. Gortmaker SL, Wang YC, Long MW, Giles CM, Ward ZJ, Barrett JL, …Cradock, AL. Three interventions that reduce childhood obesity are projected to save more than they cost to implement. Health Affairs. 2015; 34(11), 1932–1939.

8. Morrisey T. The Effects of Early Care And Education on Children’s Health. Health Affairs Health Policy Brief. 2019

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the Arkansas Department of Health through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

← Back to Resources

The information in this brief is intended for educational use only.

This brief provides a summary of the CHOICES Learning Collaborative Partnership simulation model of integrating Key 2 a Healthy Start, West Virginia’s implementation of Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC), into the state’s Tiered Reimbursement system, which provides subsidy incentives to child care centers meeting quality standards.

The Issue

Over the past four decades, childhood obesity has tripled.¹ In WV, obesity rates in 2-4 year old WIC participants increased from 14% up to 16.4% in 2014.² WV was one of four states that experienced increasing rates in this young population. Now labeled as an epidemic, health care costs for treating obesity-related health conditions such as heart disease and diabetes range from $147 billion to $210 billion per year.³ While multiple strategies are needed to reverse the epidemic, emerging prevention strategies directed at children show great promise for addressing the epidemic.⁴ A large body of evidence shows that healthy eating, physical activity, and limiting sugary drinks and screen time helps kids grow up at a healthy weight.

In West Virginia, 41% of 2-5 year olds attend a licensed child care center. Licensed centers can offer healthy, nurturing environments for children. Tiered Reimbursement can encourage and empower centers to voluntarily improve nutrition, physical activity, and screen time standards while increasing financial incentives.

About Key 2 A Healthy Start

Key 2 a Healthy Start is based on NAP SACC, an evidence-based intervention for helping child care centers attain best practices regarding nutrition, active play, and screen time.^5,6 The program enables child care directors and staff to complete self-assessments of their nutrition, active play, and screen time practices and receive training and technical assistance to implement changes that create healthier environments and policies. Integrating Key 2 a Healthy Start into West Virginia’s Tiered Reimbursement system would incentivize and support participation in the intervention and broaden its availability.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of integrating Key 2 a Healthy Start into Tiered Reimbursement over 10 years versus the costs and outcomes of not implementing the intervention. This model assumes that 44% of licensed child care centers will participate in Tiered Reimbursement and thus participate in Key 2 a Healthy Start.

Implementing Key 2 a Healthy Start in child care centers throughout West Virginia is an investment in the future:

Conclusions and Implications

Every child deserves a healthy start in life. This includes ensuring that all kids have access to healthy foods and drinks and to be physically active, no matter where they live or which child care they attend. A state-level initiative to bring Key 2 a Healthy Start to West Virginia’s child care centers through the Tiered Reimbursement system could prevent 593 cases of childhood obesity in the last year of the model. Additionally, healthy child care environments and policies would be implemented for over 38,000 children.

For every $1.00 spent on implementing Key 2 a Healthy Start, a savings of $0.10 in health care costs is estimated. These results reinforce the importance of Key 2 a Healthy Start as primary obesity prevention. Implementing small changes early for young children can help them develop healthy habits for life, thereby avoiding more costly and ineffective treatment options in the future.

Evidence is growing about how to help children achieve a healthy weight. Programs such as Key 2 a Healthy Start are laying the foundation for healthier futures by helping child care centers create environments and policies that nurture healthy habits. Leaders at the federal, state, and local level should use the best available evidence to determine which evidence-based interventions hold the most promise for children to develop and maintain a healthy weight.

References

1. Fryar CD, Carroll MD, Ogden CL, Prevalence of overweight and obesity among children and adolescents: United States, 1963-1965 through 2011-2012. Atlanta, GA: National Center for Health Statistics, 2014.
2. Pan L, Freedman DS, Sharma AJ, et al. Trends in Obesity Among Participants Aged 2-4 Years in the Special Supplemental Nutrition Program for Women, Infants, and Children – United States, 2000–2014. Morbidity and Mortality Weekly Report (MMWR) 2016;65:1256–1260. DOI.
3. Gortmaker SL, Wang YC, Long MW, Giles CM, Ward ZJ, Barrett JL, Kenney EL, Sonneville KR, Afzal AS, Resch SC, Cradock AL. Three interventions that reduce childhood obesity are projected to save more than they cost to implement. Health Aff (Millwood). 2015 Nov;34(11):1932-9.
4. West Virginia Bureau of Children and Families (2015).
5. Ward DS, Benjamin SE, Ammerman AS, Ball SC, Neelon BH, Bangdiwala SI. Nutrition and physical activity in child care: results from an environmental intervention. Am J Prev Med. 2008 Oct;35(4):352-6.
6. Alkon A, Crowley AA, Neelon SE, Hill S, Pan Y, Nguyen V, Rose R, Savage E, Forestieri N, Shipman L, Kotch JB. Nutrition and physical activity randomized control trial in child care centers improves knowledge, policies, and children’s body mass index. BMC Public Health. 2014 Mar 1;14:215.

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the West Virginia Department of Health and Human Resources through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only.

← Back to Resources