Topic: Screen & TV Time

Limiting Television to Reduce Childhood Obesity: Cost-Effectiveness of Five Population Strategies

Posted on May 10, 2021

A CHOICES study finds that strategies to reduce television exposure could help reduce childhood obesity at a relatively low cost.

Kenney EL, Mozaffarian RS, Long MW, Barrett JL, Cradock AL, Giles CM, Ward ZJ, Gortmaker SL. Limiting Television to Reduce Childhood Obesity: Cost-Effectiveness of Five Population Strategies. Child Obes. 2021 May 10. doi: 10.1089/chi.2021.0016. Epub ahead of print. PMID: 33970695.

The study’s research team, led by Erica Kenney, found that strategies to reduce television exposure could help reduce childhood obesity on a population level. Television watching is one of the strongest risk factors for childhood obesity as children are highly influenced by television advertising and are exposed to many advertisements for unhealthy foods and beverages.

After systematically searching for evidence for intervention strategies that could be effective for reducing children’s TV viewing or advertising exposure if implemented at a population level, the study team used the CHOICES microsimulation model to estimate the cost, population reach, and impact on childhood obesity over 10 years (from 2020-2030) of five potential policy strategies. These strategies included: (1) eliminating the tax deductibility of food and beverage advertising; (2) targeting TV reduction during home visiting programs; (3) motivational interviewing to reduce home television time at Women, Infants, and Children (WIC) clinic visits; (4) adoption of a television-reduction curriculum in child care; and (5) limiting noneducational television in licensed child care settings.

They found that, of the five potential strategies, eliminating the tax benefit to companies of advertising unhealthy foods and beverages to children would reach the most children, prevent the most cases of obesity, and save more in future health care costs than it costs to implement. In addition, incorporating counseling to reduce TV viewing into the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and requiring licensed childcare settings to limit noneducational television were also noted as low-cost, practical intervention strategies. However, these strategies would be limited to young children in those specific settings.

The researchers concluded that strategies to limit television exposure across a range of settings could help contribute to other efforts to prevent childhood obesity in the population at a low cost. Policymakers and public health providers should consider using these kinds of strategies as part of a larger obesity prevention toolkit.

“Policy intervention strategies to reduce exposure to noneducational television time can reduce obesity risk, yet they aren’t widely implemented. This cost-effectiveness modeling study suggests that over 10 years, implementing such strategies could help improve population health at a high value.” – lead author, Erica Kenney

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Stories from the Field: Oklahoma Takes Action to Improve Child Health

Posted on May 29, 2020

The information in this Story from the Field is intended only to provide educational information.

In this story from the field, partners in Oklahoma worked with the CHOICES Team to see what would happen if they took actions in the Special Supplemental Program for Women, Infants, and Children (WIC) in Oklahoma that could help families reduce the time their young children spent watching TV, where they are frequently exposed to ads for unhealthy foods.

Identifying Priorities in Oklahoma

In 2014, Oklahoma Governor Mary Fallin requested a plan for using data and evidence to inform public health decision-making and minimize costs. Leaders from the state health and human services agencies came together and prioritized obesity as the most important issue to address.1

The Oklahoma State Department of Health (OSDH) and the Oklahoma Department of Human Services (OKDHS) identified the Special Supplemental Program for Women, Infants, and Children (WIC) as a key opportunity for focusing on obesity prevention because more than 40,000 Oklahoma children ages 2 to 4 (27%) participate in WIC – and nearly 15% of those children have obesity.2

Gathering Information for Action

In 2016, OSDH and OKDHS partnered with the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Project at the Harvard T.H. Chan School of Public Health’s Learning Collaborative Partnership (LCP). The CHOICES Project works with health agencies to create new evidence to inform decision-making. Using local data, state and local health agencies learn how to apply evaluations of effectiveness, reach, and cost to understand the relative cost-effectiveness of strategies to prevent and treat childhood obesity.

Strategy Selection

The Oklahoma CHOICES Team (OSDH and OKDHS) sought best-value-for-money strategies for preventing obesity among Oklahoma’s young children. The Oklahoma CHOICES Team attended a CHOICES training where they reviewed potential strategies with a strong evidence base. Limiting screen time is a recommended strategy to promote healthy weight among children.

The Intervention

In this scenario, WIC clinic staff would need to ask caregivers how much screen time their children view and talk with them about how to reduce that time. Prior research has shown this method to be effective.3 Reducing screen time can reduce the risk for obesity because of decreased exposure to unhealthy foods and drinks.

The Change Needed

The Oklahoma CHOICES Team, along with the OK WIC Service Team, determined that the WIC online electronic participant record needed modification so that WIC clinic staff could ask caregivers how much screen time their children view during WIC recertification visits, and provide tailored counseling to caregivers on how to reduce that time.

An infographic titled, "How much screen time should my child get?" It outlines screen time as television, computers, video games, and hand held devices like tablets, ipads, and smart phones).

Handout created by Oklahoma WIC Service given to participants during counseling sessions

 

Helping Change Happen

As part of the LCP, the CHOICES Team works with local stakeholders to make projections about what may happen when a program or policy is implemented. Through this collaboration, the partners determined that these program changes could result in 149,000 Oklahoma children adopting healthy screen time behaviors over 10 years and the prevention of 660 cases of childhood obesity in the final year. For every dollar spent putting this strategy into effect, $20.90 would be saved in obesity-related health care costs over 10 years. After reviewing these data and realizing how easy it would be to modify the WIC software, the Oklahoma Team decided to make the change. Screen time counseling in the Oklahoma WIC program was rolled out in 2017.

Steps Taken for Implementation

  • Modified the online system Public Health Oklahoma Client Information System (PHOCIS) to prompt WIC counselors to ask screen time question
  • Conducted staff training for WIC counselors
  • Created educational materials to use with families during counseling sessions
  • Asked participating families about their children’s screen time habits
  • Provided families the option to discuss screen time habits during the counseling session and/or to receive educational materials

Impact & Lessons Learned

Since 2017:
An infographic stating: "nearly 30,000 families received screentime guidance" and "75% are taking steps to reduce screentime."

We learned two key things: the very positive result of reducing screen time, and that this strategy was something we could not only model but implement, and we could do it fairly quickly.” – Terry Bryce, State WIC Director

References

  1. Oklahoma State Department of Health. Oklahoma Health 360° – Obesity Report. Retrieved from: https://www. ok.gov/health2/documents/Health%20360%20_OBESITY%20Final%20Report%2011.3.17.pdf 
  2. Communication with Oklahoma State Department of Health: WIC Service. (2017).
  3. Whaley SE, McGregor S, Jiang L, Gomez J, Harrison G, Jenks, E. A WIC-Based Intervention to Prevent Early Childhood Overweight. J Nutr Educ Behav. 2010;42(3 Suppl):S47-51.
Suggested Citation:

CHOICES Stories from the Field: Oklahoma Takes Action to Improve Child Health. Oklahoma State Department of Health & Oklahoma Department of Human Services, Oklahoma City, OK, and the CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; May 2020.

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Brief: Best Practice Guidelines for Healthy Childcare in Detroit

Posted on December 20, 2019

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

This brief summarizes a CHOICES Learning Collaborative Partnership model for Best Practice Guidelines for Healthy Childcare in Detroit, MI. We assume a proportion of licensed programs would voluntarily adopt guidelines to eliminate sugary drinks and limit screen time. Participation rates are based on the number of programs voluntarily achieving 3+ star ratings from Great Start to Quality Program.1

The Issue

All children deserve the opportunity to be healthy. However, if current trends in childhood obesity continue, most of today’s children will have obesity at age 35.2 The health impacts and health care costs of treating obesity-related conditions in adulthood, such as heart disease and diabetes, cost $147 billion in 2008.3 However, research shows that avoiding sugary drinks and viewing less TV can help kids grow up at a healthy weight.

Early childcare programs are essential partners in supporting healthy habit development. Approximately 11,000 2-5 year-olds attend licensed childcare centers and family homes in Detroit.4 Providing training and technical assistance on guidelines to eliminate sugary drinks and limit non-educational screen time to 30 minutes per week would positively impact the children attending licensed childcare programs.

About the Best Practice Guidelines for Healthy Childcare Model

Best Practice Guidelines for Healthy Childcare would be put forth by the Detroit Health Department. The United Way provides professional development for early childcare professionals and would offer new voluntary training and technical assistance opportunities to early childcare providers. In turn, providers would implement the guidelines in their programs. The guidelines would encourage early childcare programs to not serve sugary drinks and to reduce non-educational television time to 30 minutes per week during program time. We estimate that 62% of centers and 30% of family childcare homes would voluntarily adopt the guidelines.1

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2017-2027) of implementing Best Practice Guidelines for Healthy Childcare vs. not implementing the guidelines.

Implementing Best Practice Guidelines for Healthy Childcare is an investment in the future and would save early childcare programs money. By the end of 2027, the model projects:
over 19,000 children will be healthier, 43 cases of childhood obesity prevented, $1,150 saved per childcare center, $195 saved per family childcare home

Conclusions and Implications

Every child deserves a healthy start in life. This includes ensuring that all children in childcare have less exposure to beverages with added sugar and no nutritional value and have less exposure to screen time. Implementing Best Practice Guidelines for Healthy Childcare has the potential to reach 19,400 children ages 2-5 years in licensed childcare programs in Detroit. These children would consume fewer beverages with added sugar and view less screen time. In particular, children in family childcare homes would watch 2.3 fewer hours of screen time daily if the guidelines are met. This intervention would cost $107,000 to implement, though childcare program providers would save money when they are no longer serving sugary drinks. Overall, the CHOICES model estimates that there is a 97% chance that the intervention would be cost-saving. That is, it could save more due to the reduction in spending associated with serving sugary beverages than it may cost to implement.

The first few years of childhood can be an important time to promote healthy lifestyle behaviors. Implementing Best Practice Guidelines for Healthy Childcare could lay the foundation by ensuring that all children in childcare settings drink beverages that promote their health and have less exposure to screen time.

References

  1. Great Start to Quality Participation Data, July 1 2019. https://www.greatstarttoquality.org/great-start-quality-participation-data Accessed July 17 2019.
  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 Nov 30;377(22):2145-2153.
  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. Per previous estimates that 79% of children in day care are ages 2-5 years old out of the 0-5 year old population
Suggested Citation:

Hill AB, Mozaffarian RS, Barrett JL, Cradock AL. Detroit: Best Practice Guidelines for Healthy Childcare [Issue Brief]. Detroit Health Department and United Way for Southeastern Michigan, Detroit, MI, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; December 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 Detroit Health Department 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 West Virginia

Posted on September 28, 2018

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:If Key 2 a Healthy Start in child care centers were implemented throughout West Virginia, then over 38,000 children would be reached with healthier food and drinks, more active play, and less screen time over 10 years; 593 cases of childhood obesity would be prevented in 2025 (the final year of the model), and it would cost $69.80 per child to implement.

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.
Suggested Citation:

Jeffrey J, Giles C, Flax C, Cradock A, Gortmaker S, Ward Z, Kenney E. West Virginia Key 2 a Healthy Start Intervention [Issue Brief]. West Virginia Department of Health and Human Resources, Charleston, WV, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; April, 2018.

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.

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Brief: Childcare Policies Can Build a Healthier Future in Philadelphia

Posted on December 22, 2017

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

In June 2017, Philadelphia’s Board of Health passed a resolution recommending that ECE (early childhood education) providers limit screen time and sweet drinks, including juice, for the children in their care.1

If all Philadelphia ECE providers implemented these voluntary recommendations, hundreds of children would see improved health outcomes, and $2.82 million could be saved over the next 10 years.

Analysis

The Philadelphia Department of Public Health (PDPH) collaborated with a team of researchers at the Harvard T.H. Chan School of Public Health2 to perform a cost-effectiveness analysis of policies to limit screen time and eliminate sweet drinks in early childhood settings. A cost-effectiveness analysis compares the health impact and health care cost savings resulting from implementing an initiative with maintaining the status quo. The analysis predicts how much would be spent or saved by implementing a policy or program.

PDPH and the Harvard Chan School called on local and national data and the expertise of partners3 to project costs and outcomes specific to Philadelphia’s ECE landscape. Projected costs, including training and technical assistance for ECE providers, would total $638,000 over 10 years. Projected savings, primarily from serving water instead of sweet drinks, would be $3.28 million.4 Over the same 10 year period, these changes would reach 114,000 children and prevent 279 cases of childhood obesity.

ECE Provider Savings

There are 1,661 licensed ECE providers in Philadelphia. Based on data PDPH collected from a sample of these providers, the Harvard researchers estimated the current frequency of serving sugary drinks and 100% juice in Philadelphia child care programs, average serving sizes, and average ounces served per day. They then multiplied the average ounces served per day by the price per ounce of each drink (from the USDA’s CNPP food price database). Finally, they adjusted for the fact that, since 100% juice can be reimbursed as “fruit” for the Child and Adult Care Food Program (CACFP), programs that participate in CACFP would incur costs to replace juice with whole fruit at breakfast or lunch and whole grains at snack; this analysis assumes that programs that do not participate in CACFP make the same substitutions.

These calculations yielded an average cost saving per child per day of about $0.013 for eliminating sugary drinks and $0.05 per child per day for eliminating 100% juice (that’s about $674 saved per year for the average center).

Many ECE providers in Philadelphia (including nearly 84% of centers) have already eliminated sugary drinks. Some (including nearly 18% of centers) have already eliminated 100% juice.4 Even so, if all licensed ECE providers in Philadelphia eliminated sugary drinks and 100% juice entirely, they (and their food vendors and CACFP sponsors) would save $3.28 million over 10 years. If centers that do not participate in CACFP replaced that juice with free water, these savings would increase to $4.89 million over 10 years.

If this policy were implemented, then 114,00 children would be reached over 10 years, $2.82 million in net costs would be saved, and, on average, $674 would be saved per program.

Conclusions and Implications

Every child deserves a healthy start in life. Alarmingly, an estimated 33% of children born in 2000 and up to 50% of African American and Hispanic children will develop diabetes in their lifetimes.5 For many of these children, good nutrition (including fewer sweet drinks and less exposure to unhealthy food and beverage marketing online and on TV) can prevent or delay diabetes and other chronic conditions that are the leading causes of death and disability in our city.

Philadelphia’s licensed ECE providers serve around 40,000 children ages 2-5 each year. The Board of Health recommendations aim to support more providers in making small changes that will support healthier environments for all of these children and set them up for long, healthy lives.

The results of this cost-effectiveness analysis demonstrate the fiscal sense of the Board of Health’s recommendations to limit screen time and eliminate sweet drinks, including juice. The results reinforce the importance of investing in prevention efforts. Shortchanging prevention efforts can lead to more costly and complicated treatment options in the future, whereas teaching small changes to young children can help them develop healthy habits for life.

References

  1. City of Philadelphia Department of Public Health, Board of Health, Resolution on Childhood Obesity Prevention in Early Childhood Care, Approved June 8, 2017; http://www.phila.gov/health/pdfs/boardofhealth/Board%20of%20Health%20ECE%20Resolution%20Approved%20June%208%202017.pdf
    The full recommendations state:
    No sweetened drinks in early childhood settings
    No fruit juice (including 100% juice) in early childhood settings
    Water should be available, easily accessible to children throughout the day and offered with meals
    Screen time for children aged 2 years and older limited to 30 minutes per week
    No screen time for children under age 2 in early childhood settings
  2. The Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) at the Harvard T.H. Chan School of Public Health is working to help reverse the US obesity epidemic by identifying the most cost-effective childhood obesity interventions.
  3. Thank you especially to the Delaware Valley Association of Young Children, Mayor’s Office of Education, Public Health Management Corporation, and School District of Philadelphia.
  4. Full calculations are available from PDPH; contact Shannon Dryden at Shannon.Dryden@Phila.gov.
  5. Gregg EW et al Trends in lifetime risk and years of life lost due to diabetes in the USA, 1985-2011: a modeling study. The Lancet Diabetes and Endocrinology 2(11) 867-874 downloaded from: http://www.thelancet.com/action/showFullTextImages?pii=S2213-8587%2814%2970161-5
Suggested Citation:

Pharis M, Lawman H, Root M, Dryden S, Wagner A, Bettigole C, Mozaffarian, RS, Kenney EL, Cradock AL, Gortmaker SL, Giles CM, Ward ZJ. Philadelphia, PA: Childcare Policies Can Build a Better Future {Issue Brief}. Philadelphia Department of Public Health, Philadelphia, PA, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; December 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 Philadelphia Department of Public 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.

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Brief: Updated Requirements in Reaching for the Stars to Reduce Non-Educational Screen Time for Young Children in Family Child Care Homes in Oklahoma

Posted on November 6, 2017

Three kids at the playground

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 a hypothetical requirement in Oklahoma’s Quality Rating and Improvement System, Reaching for the Stars, that family child care providers at or above Level 1.5 limit non-educational screen time for 2-5 year olds to 30 minutes daily.

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 for addressing the epidemic.4 A large body of evidence shows that limiting time watching non-educational television helps kids grow up at a healthy weight. Research shows children watch nearly two hours of television daily at family child care programs.5

In Oklahoma, approximately 5.5% of 2-5 year olds attend a family child care program, and about 40% of those attend a program at Level 1.5 or higher in Reaching for the Stars.6 Quality improvement systems like Reaching for the Stars can support programs in creating a healthier screen time environment.

About the Policy to Help Licensing Care Programs to Reduce Screen Time

The policy to limit screen time in family child care settings to 30 minutes per day is based on national recommendations from pediatricians and child care and public health experts to limit screen time.7 Instituting the policy change through Reaching for the Stars would incentivize family child care programs to meet this standard, rather than mandating it. The policy change would also help support children’s development of healthy screen use habits.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of modifying the Reaching for the Stars standards to require the 30 min/day limit for family child care programs at level 1.5 or higher with costs and outcomes associated with not modifying the standards over 10 years.

Implementing screen time reduction policies in Oklahoma family child care programs is an investment in the future. By the end of 2025:
If screen time reduction policies in family child care programs were implemented in Oklahoma, then, by the end of 2025, 13,600 young children in Oklahoma would be reached and benefit from less screen time overall; 123 cases of childhood obesity would be prevented in 2025, the final year of the model; and $2.59 would be saved in health care costs per $1 invested in training family child care providers.

Conclusions and Implications

Every child deserves a healthy start in life. This includes ensuring that all children in child care have opportunities to be healthy, no matter where they live or where they go for child care. A state-level initiative to incentivize family child care providers to limit non-educational screen time in family child care settings could prevent 123 cases of childhood obesity in 2025 and ensure healthier child care environments for over 13,000 children.

What’s more, this inexpensive strategy would save Oklahoma money. For every $1.00 spent on implementing this screen time strategy, we would save $2.59 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 to reduce screen time in child care 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 levels should use the best available evidence to determine which evidence-based programs and policies hold the most promise to help children grow up at a healthy weight.

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 Affairs (Millwood). 2015 Nov;34(11):1932-9.
  5. Tandon, P. S., Zhou, C., Lozano, P., & Christakis, D. A. (2011). Preschoolers’ total daily screen time at home and by type of child care. The Journal of Pediatrics, 158(2), 297-300
  6. Oklahoma Department of Health Services (DHS). Early Care & Education Licensing Database (2016)
  7. American Academy Of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Caring for our children: National health and safety performance standards; Guidelines for early care and education programs. 3rd edition. Elk Grove Village, IL: American Academy of Pediatrics; 2011
Suggested Citation:

Case S, Simpson K, Khan F, U’ren S, Giles C, Kenney EL, Flax CN, Gortmaker SL, Ward ZJ, Cradock AL. Oklahoma: Updated Requirements in Reaching for the Stars to Reduce Non-Educational Screen Time for Young Children in Family Child Care Homes {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 by the Oklahoma State Department of Health through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health. 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 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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