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

Brief: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) Intervention in Oklahoma

Posted on November 6, 2017

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

This brief summarizes the CHOICES Learning Collaborative Partnership simulation model of the impact of integrating the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) program into Oklahoma’s Reaching for the Stars Quality Rating and Improvement System. Child care programs achieving Level 2 or higher would complete NAP SACC.

The Issue

Over the past three decades, more and more people have developed obesity.1 Today, nearly nine percent of 2-5 year olds have obesity.2 Now labeled as an epidemic, health care costs for treating obesity-related health conditions such as heart disease and diabetes were $147 billion in 2008.3 While multiple strategies are needed to reverse the epidemic, emerging prevention strategies directed at children show great promise.4 A large body of evidence shows that healthy eating, physical activity, and limited time watching TV helps kids grow up at a healthy weight.

In Oklahoma, 41% of 2-5 year olds attend a licensed child care center or family child care home, and most of them attend a program involved in Reaching for the Stars.5 Child care programs can offer healthy, nurturing environments for children; Reaching for the Stars can encourage and empower programs to voluntarily improve nutrition, physical activity, and screen time standards.

About NAP SACC and Reaching for the Stars

NAP SACC is an evidence-based, trusted intervention for helping child care programs improve their practices regarding nutrition, active play, and screen time and has demonstrated impacts on reducing childhood obesity.6,7 In NAP SACC, child care directors 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. Integrating NAP SACC into Reaching for the Stars would incentivize and support participation in the program and broaden its availability.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of integrating NAP SACC into Reaching for the Stars over 10 years with costs and outcomes associated with not implementing the program. This model assumes that 67% of OK children in child care centers and 36% in family child care homes attend a program at Level 2 or higher in Reaching for the Stars and thus will benefit. The model also accounts for swapping out some existing childhood obesity trainings for NAP SACC, making NAP SACC implementation a less costly approach.

Implementing NAP SACC in child care programs throughout Oklahoma is an investment in the future. By the end of 2025:
Chart summarizing the conclusions and implications of the brief

Conclusions and Implications

Every child deserves a healthy start in life. This includes ensuring that all kids in child care have opportunities to eat healthy foods and be physically active, no matter where they live or where they go for child care. A state-level initiative to bring NAP SACC to Oklahoma’s child care programs through Reaching for the Stars could prevent almost 1,600 cases of childhood obesity in 2025 and ensure healthy child care environments for 140,000 of Oklahoma’s young children.

For every $1.00 spent on implementing NAP SACC in Reaching for the Stars, we would save $0.15 in health care costs. These results reinforce the importance of investing in prevention efforts, relative to other treatment interventions, to reduce the prevalence of obesity. Shortchanging prevention efforts can lead to more costly and complicated treatment options in the future, whereas introducing small changes to young children can help them develop healthy habits for life.

Evidence is growing about how to help children achieve a healthy weight. Programs such as NAP SACC are laying the foundation for a healthier future by helping child care providers create environments that nurture healthy habits. Leaders at the federal, state, and local level should use the best available evidence to determine which evidence-based programs and policies hold the most promise to help children eat healthier diets and be more active.

References

  1. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in Obesity Among Adults in the United States, 2005 to 2014. JAMA. 2016 Jun 7;315(21):2284-91.
  2. Ogden CL, Carroll MD, Lawman HG, Fryar CD, Kruszon-Moran D, Kit BK, Flegal KM. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016 Jun 7;315(21):2292-9.
  3. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Affairs. 2009;28(5).
  4. 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.
  5. Oklahoma Department of Health Services (DHS). Early Care & Education Licensing Database (2016)
  6. 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.
  7. 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.
Suggested Citation:

Macedo C, Case S, Simpson K, Khan F, U’ren S, Giles CM, Flax CN, Cradock AL, Gortmaker SL, Ward ZJ, Kenney EL. Oklahoma: Nutrition and Physical Activity Self-Assessment For Child Care (NAP SACC) Intervention {Issue Brief}. Oklahoma State Department of Health and Oklahoma State Department of Human Services, Oklahoma City, OK, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; October 2017.

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 Oklahoma Department of Health and Human Services through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. Funded by The JPB Foundation. Results are those of the authors and not the funders.

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Brief: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) Intervention in New Hampshire

Posted on October 16, 2017

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

This brief summarizes a CHOICES Learning Collaborative Partnership simulation model in New Hampshire examining a potential strategy to expand child care providers’ access to the Nutrition and Physical Activity Self-Assessment for Child Care (Go NAP SACC) by targeting the state’s largest providers via contracted training and technical assistance.

The Issue

Over the past three decades, more and more people have developed obesity.1 Today, nearly nine percent of 2-5 year olds have obesity.2 Now labeled as an epidemic, health care costs for treating obesity-related conditions such as heart disease and diabetes were $147 billion in 2008.3 While multiple strategies are needed to reverse the epidemic, emerging prevention strategies directed at children show great promise.4 A large body of evidence shows that healthy eating, physical activity, and less time watching TV helps kids grow up at a healthy weight.

In New Hampshire, 40% of 2-5 year olds attend licensed child care centers; 24% attend a large center or family child care program.5 Making NAP SACC more available can encourage and empower programs to voluntarily improve nutrition, physical activity, and screen time standards.

About NAP SACC and Expanding Access for NH Child Care Programs

Go NAP SACC is an evidence-based, trusted intervention that helps child care programs improve practices for nutrition, active play, and screen time and can reduce childhood obesity.6,7 Child care providers complete self-assessments of their nutrition, active play, and screen time practices and receive training and technical assistance to implement self-selected changes to create healthier environments. Increasing the number of provider slots offered through a contract with child care training and technical assistance specialists at Keene State College, managed by New Hampshire’s Department of Health and Human Services, Division of Public Health Services (DPHS), could broaden the current reach of the Go NAP SACC project, allowing more licensed child care programs to improve nutrition and physical activity policies and practices. Currently, Keene State works with 22 child care providers. Since 2010, over ninety licensed child care programs, caring for nearly 8,000 children, have participated in DPHS funded opportunities to improve 465 nutrition and physical activity policies and practices.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of expanding New Hampshire’s NAP SACC program led by partners at Keene State College over 10 years.

Implementing NAP SACC in New Hampshire’s largest child care programs is an investment in the future. By the end of 2025:
Impact and cost summary of expanding New Hampshire’s NAP SACC program

Conclusions and Implications

Every child deserves a healthy start in life. This includes ensuring that all kids in child care have opportunities to eat healthy foods and be physically active, no matter where they live or where they go for child care. A state-level initiative to bring NAP SACC to New Hampshire’s largest child care programs by expanding its current opportunities could prevent over 600 cases of childhood obesity in 2025 and ensure healthy child care environments for 40,000 young children.

A separate model examined the potential for expanding access to Go NAP SACC via the state’s Quality Rating Improvement System, which is a single-tiered system referred to as Licensed Plus. While such an initiative could be a useful policy tool for creating sustainable access to Go NAP SACC for NH child care providers, the results of that model indicated that fewer children (12,000) would be reached and fewer cases of obesity prevented in 2025 (100) at a slightly higher cost per child ($81). The results of the two models suggest that New Hampshire’s current contracted strategy targeting the state’s largest providers may be more cost-effective. Results from both models reinforce the importance of investing in prevention efforts to reduce the prevalence of obesity. Shortchanging prevention efforts can lead to more costly and complicated treatment options in the future, whereas introducing small changes to young children can help them develop healthy habits for life.

The first few years of childhood may be the best time to promote healthy eating behaviors in children. Programs such as Go NAP SACC lay the foundation by helping child care providers create environments to nurture healthy eating habits and increase opportunities for physical activity for all of the children.

References

  1. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in Obesity Among Adults in the United States, 2005 to 2014. JAMA. 2016 Jun 7;315(21):2284-91.
  2. Ogden CL, Carroll MD, Lawman HG, Fryar CD, Kruszon-Moran D, Kit BK, Flegal KM. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016 Jun 7;315(21):2292-9.
  3. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Affairs. 2009;28(5).
  4. 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):1932-9.5
  5. Child Care Aware. State Child Care Facts in the State of New Hampshire, 2016. Accessed 8/17/17 at: http://childcareaware.org/wp-content/uploads/2016/08/New-Hampshire.pdf; Personal communication from NH Division of Public Health Services.
  6. 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.
  7. 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.
  8. Birch, L., Savage, J. S., & Ventura, A. (2007). Influences on the Development of Children’s Eating Behaviours: From Infancy to Adolescence. Canadian Journal of Dietetic Practice and Research : A Publication of Dietitians of Canada = Revue Canadienne de La Pratique et de La Recherche En Dietetique : Une Publication Des Dietetistes Du Canada, 68(1), s1–s56.
Suggested Citation:

Kenney EL, Giles CM, Flax CN, Gortmaker SL, Cradock AL, Ward ZJ, Foster S, Hammond W. New Hampshire: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) Intervention {Issue Brief}. New Hampshire Department of Health and Human Services, Concord, NH, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; October 2017.

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 New Hampshire Department of Health and Human Services through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. Funded by The JPB Foundation. Results are those of the authors and not the funders. For more information, please visit: https://www.dhhs.nh.gov

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Brief: NAP SACC in Early Achievers in Washington State

Posted on October 15, 2017

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 the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) into Washington’s Quality Rating and Improvement System (QRIS), Early Achievers, which awards quality ratings to early care and education (ECE) programs meeting defined standards.

The Issue

Over the past three decades, more and more people have developed obesity.1 Today, nearly nine percent of 2-5 year olds have obesity.2 Health care costs for treating obesity-related health conditions such as heart disease and diabetes were $147 billion in 2008.3 Emerging prevention strategies directed at children show great promise for addressing this issue.4 A large body of evidence shows that healthy eating, physical activity, and limited screen media time (like watching TV or smartphones) helps kids grow up at a healthy weight.

In Washington, over a quarter of 2-5 year olds attend a licensed ECE program.5 Because QRIS systems like Early Achievers incentivize ECE programs to meet high standards and provide training, they are an ideal way to help ECE programs engage in improving nutrition, physical activity, and screen time practices. The Department of Early Learning invested $91 million in Early Achievers in 2016-17.5

About NAP SACC and QRIS

NAP SACC, based on the best available scientific evidence, helps ECE providers improve nutrition, active play, and screen time practices.6,7 QRIS programs encourage providers to improve in quality by using a voluntary and rewarding (rather than regulatory and punitive) approach and offers a mechanism for implementing a time-intensive program like NAP SACC. ECE directors complete self-assessments of existing practices and receive training and technical assistance to implement changes that create healthier environments. In Washington’s hypothetical model, completing NAP SACC would be an option for ECE providers seeking to achieve Early Achievers Level 3 status. State-contracted coaches would train providers and conduct technical assistance for meeting NAP SACC goals.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of integrating NAP SACC into Early Achievers over 10 years (2015-2025) with costs and outcomes associated with not implementing the program. The approach assumes that 72% licensed ECE centers participate in Early Achievers, and 25% of both center-based and home-based providers adopt NAP SACC.

Implementing NAP SACC in child care programs throughout Washington is an investment
in the future. By the end of 2025:
Chart summarizing the conclusions and implications of the brief

Conclusions and Implications

Every child deserves a healthy start in life. This includes ensuring that all kids in child care have opportunities to eat healthy foods and be physically active, no matter where they live or where they go for child care. A state-level initiative to bring the NAP SACC self-assessment and improvement process to Washington child care programs through the Early Achievers system could prevent over a thousand cases of childhood obesity in 2025 and ensure healthy child care environments for over 160,000 children. For every $1 spent implementing this strategy with child care centers, we would save $0.08 in health care costs as a result of decreased obesity prevalence. For every $1 spent implementing this strategy with family home providers, we would save $0.02 in health care costs as a result of decreased obesity prevalence

These results reinforce the importance of investing in prevention efforts, to reduce the prevalence of obesity. Shortchanging prevention efforts can lead to more costly and complicated treatment options in the future. Introducing small changes to young children can help them develop healthy habits for life.

Evidence is growing about how to help children achieve a healthy weight. Programs such as NAP SACC are laying the foundation for healthier generations by helping ECE providers create environments that nurture healthy habits. Leaders at the federal, state, and local level should use the best available evidence to help children eat healthier diets and be more active.

References

  1. Flegal, K.M., Kruszon-Moran, D., Carroll, M.D., Fryar, C.D., Ogden, C.L. (2016). Trends in Obesity Among Adults in the United States, 2005 to 2014. JAMA, 315(21), 2284-91.
  2. Ogden, C. L., Carroll, M. D., Lawman, H. G., Fryar, C. D., Kruszon-Moran, D., Kit, B. K., & Flegal, K. M. (2016). Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013–2014. JAMA, 315(21), 2292-2299.
  3. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Affairs. 2009;28(5).
  4. Gortmaker, S. L., Wang, Y. C., Long, M. W., Giles, C. M., Ward, Z. J., Barrett, J. L., …Cradock, A. L. (2015). Three interventions that reduce childhood obesity are projected to save more than they cost to implement. Health Affairs, 34(11), 1932–1939.
  5. DEL Early Achievers Data Dashboard and Market Rate Report, June 2015; Early Start Act Report.
  6. Ward, D.S., Benjamin S.E., Ammerman, A.S., Ball, S.C., Neelon, B.H., Bangdiwala, S.I. (2008). Nutrition and physical activity in child care: results from an environmental intervention. Am J Prev Med, 35(4):352-6.
  7. Alkon, A., Crowley, A.A., Neelon, S.E., Hill, S., Pan, Y., Nguyen, V., Rose, R., Savage, E., Forestieri, N., Shipman, L., Kotch, J.B. (2014). Nutrition and physical activity randomized control trial in child care centers improves knowledge, policies, and children’s body mass index. BMC Public Health, 14:215.
Suggested Citation:

Cradock AL, Gortmaker SL, Pipito A, Kenney EL, Giles CM. Washington: NAP SACC: Researching an Intervention to Create the Healthiest Next Generation [Issue Brief]. Washington State Department of Health, Olympia, WA, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; August 2017.

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 Washington State 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. Funded by The JPB Foundation. Results are those of the authors and not the funders. For more information, please visit: http://www.doh.wa.gov/CommunityandEnvironment/HealthiestNextGeneration/CHOICES

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Modeling the Cost-Effectiveness of Child Care Policy Changes in the U.S. 

Posted on July 31, 2015

CHOICES researchers found that implementing a multi-component regulatory policy in US childcare facilities would lead children to watch less TV, get more physical activity, and consume fewer sugary drinks, serving as a cost-effective strategy in reducing the childhood obesity epidemic.

Wright DR, Kenney EL, Giles CM, Long MW, Ward ZJ, Resch SC, Moodie ML, Carter RC, Wang YC, Sacks G, Swinburn BA, Gortmaker SL, Cradock AL. Modeling the Cost Effectiveness of Child Care Policy Changes in the U.S. Am J Prev Med. 2015 Jul;49(1):135-47. doi: 10.1016/j.amepre.2015.03.016.

Risk factors for obesity, including dietary habits, physical activity, and screen time behaviors develop in early childhood, persisting into late childhood and even into adulthood. Long-term habits are hard to change during adulthood, highlighting the importance of early intervention for obesity prevention. With nearly 70 percent of American preschool-aged children in out-of-home child care facilities, the setting serves as an ideal intervention target.

Children playing in daycare“Full day childcare programs are an educational environment responsible for providing children with snacks, meals, and daily opportunities for physical activity,” says lead author, Davene Wright, PhD, an Assistant Professor in the Department of Pediatrics at the University of Washington School of Medicine. “Many childcare programs fail to meet best practice standards for nutrition, physical activity, and screen time viewing. When 20 percent of preschool-aged children in the US are currently overweight or obese, this sector should be a key target for policy regulations to aid in the development of lifelong healthy behaviors.”

The study developed a hypothetical state-level regulatory policy intervention with three components:

  • The beverage component stipulated that water be made freely available throughout the program day, that sugar-sweetened beverages (SSBs) be replaced with water, that 100% juice be limited to 6 ounces per child per day, and that whole milk be replaced with reduced-fat milk.
  • The physical activity component required programs to provide opportunities for at least 90 minutes of moderate and vigorous physical activity (MVPA) over the course of the program day for children in full-time care.
  • The screen time component specified that television and computer time be educational in nature and limited to 30 minutes per week.

By using a simulation model, researchers found that these regulatory changes would reach 3.8 million US preschool-aged children, resulting in 21 hours of less screen time, 5 hours more of MVPA, 588 fewer ounces of whole milk, and 40 fewer ounces of SSBs annually per child. Implementation would cost $7.4 million annually, and result in 0.02 fewer BMI units per child at a cost of $58 per BMI unit avoided. Over a 10-year period, these effects would result in net healthcare cost savings of $372 million.

This is the first study to examine the potential economic impact of a multi-component child care-based obesity policy intervention. These regulations could have a small but meaningful impact on short-term BMI at a low cost, with promising potential to be cost-saving within only 10 years. This analysis provides important new information to policymakers regarding the benefits to the health of our nation’s children, and the substantial savings to healthcare expenditures that could be achieved.

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