Evaluation of a Physical Activity Regulation for Child Care in Massachusetts

The Effectiveness of Physical Activity Policies in Center-Based Childcare: A Systematic Review and Meta-Analysis

Purpose: Many young children spend a significant portion of time in center-based childcare settings; however, these children are often not sufficiently active during care. Promoting physical activity through policy implementation is one mechanism which has the potential to increase physical activity. The purpose of this systematic review and meta-analysis was to provide an overview of physical activity policies implemented in childcare centers and determine their effect on children's physical activity. Methods: Electronic searches were conducted in CINAHL, Medline, PsycINFO, EMBASE, Scopus, SPORTDiscus, and Sports Medicine and Education Database. Two reviewers independently examined 3,286 articles to find peer-reviewed, original studies that assessed the impact of physical activity policies on children's physical activity. Random effects meta-analyses were used to determine the impact of policies. Results: A total of 13 articles met the inclusion criteria; in which 12 unique policies were implemented. Results of the meta-analyses suggest that introducing new physical activity policies did not increase children's moderate-to-vigorous physical activity (MVPA); however, compared to centers without a formalized physical activity policy, children in centers with a formalized policy engaged in significantly more MVPA and total physical activity. Conclusions: Introducing new physical activity policies alone may not be sufficient to increase children's engagement in physical activity, and it may be important to combine with capacity-building initiatives for childcare staff and early childhood educators. Results reinforce the value of childcare centers implementing their own formalized physical activity policies to support children's physical activity, which highlights the importance of regulating physical activity practices in childcare. Registration: CRD42022326037.

A Narrative Review of Public Health Interventions for Childhood Obesity

PURPOSE OF REVIEW

Public health interventions that intervene on macrolevel systems hold the promise of reducing childhood obesity at the population level through prevention. The purpose of this review is to highlight some of the recent and best scientific evidence related to public health interventions for the prevention of childhood obesity. We provide a narrative review of scientific evidence for six categories of public health interventions and their impact on childhood obesity: federal nutrition assistance programs, programs implemented in early care and education centers, interventions to support healthy nutrition and physical activity in schools, community-based programs and policies, labeling policies and marketing to children, and taxes on sugar sweetened beverages (SSB).

RECENT FINDINGS

Federal nutrition assistance programs have the strongest evidence to support reduction in childhood obesity and serve populations with the highest prevalence of childhood obesity. Other interventions including SSB taxes, community-wide interventions, and interventions at schools and early care and education centers also show significant improvements in child weight status. Overall public health interventions have strong evidence to support widespread implementation in service of reducing childhood obesity rates at the population level. To effectively address the recalcitrant childhood obesity epidemic, multi-pronged solutions are needed. The current evidence for public health obesity interventions is consistent with the paradigm that recognizes the importance of macrolevel systems influences on childhood obesity: interventions that are most effective intervene at macrolevels.

Policy, systems, and environmental interventions addressing physical activity in early childhood education settings: A systematic review

Policy, systems, and environmental (PSE) approaches can facilitate physical activity in priority populations (e.g., racial and ethnic minority, low wealth groups) within early childhood education (ECE) settings. The purpose of this review was to 1) characterize the inclusion of priority populations within ECE physical activity interventions containing PSE approaches and 2) identify and describe interventions within these populations. Seven databases were systematically searched (January 2000-Febrary 2022) for ECE-based interventions focusing on children (0-6 years) that utilized at least one PSE approach. Eligible studies included a child physical activity or physical activity environment outcome and child or center-level population characteristics. Forty-four studies, representing 42 interventions were identified. For Aim 1, half of interventions included one PSE approach (21/42), with only 11/42 including three or more approaches. Physical environment changes [e.g., adding play equipment, modifying space (25/42)] were the most used PSE approaches followed by system [e.g., integrating activity into routines, (21/42)] and policy [e.g., outdoor time (20/42)] approaches. Nearly half of interventions were conducted in predominantly priority populations (18/42). Studies were primarily rated as good (51%) or fair (38%) methodological quality using the Downs and Black checklist. In Aim 2, of the 12 interventions assessing child physical activity in priority populations, 9/12 reported at least one physical activity outcome in the expected direction. Of the 11 interventions assessing the physical activity environment, 9/11 reported an effect in the expected direction. Findings indicate clear opportunities exist to target priority populations by incorporating PSE approaches in ECE physical activity interventions.

Moving from Policy to Practice for Early Childhood Obesity Prevention: A Nationwide Evaluation of State Implementation Strategies in Childcare

Policies requiring childcare settings to promote healthy eating, physical activity, and limited screentime have the potential to improve young children's health. However, policies may have limited impact without effective implementation strategies to promote policy adoption. In this mixed-methods study, we evaluated the type, quality, and dose of implementation strategies for state-level childcare licensing regulations focused on healthy eating, physical activity, or screentime using: (1) a survey of state licensing staff and technical assistance providers (n = 89) in 32 states; (2) a structured review of each state's childcare licensing and training websites for childcare providers; and (3) in-depth, semi-structured interviews with 31 childcare licensing administrators and technical assistance providers across 17 states. Implementation strategies for supporting childcare providers in adopting healthy eating, physical activity, and screentime regulations vary substantially by state, in quantity and structure. Childcare programs' financial challenges, staff turnover, and lack of adequate facilities were identified as key barriers to adoption. Access to federal food programs was seen as critical to implementing nutrition regulations. Implementation resources such as training and informational materials were rarely available in multiple languages or targeted to providers serving low-income or racially/ethnically diverse families. There is a substantial need for implementation supports for ensuring policies are successfully and equitably implemented in childcare.

The impact of new government childcare accreditation standards on children's in-care physical activity and sedentary time

BACKGROUND

A new physical activity and sedentary behaviour accreditation standard criterion for childcare settings was introduced by the provincial government in Alberta, Canada. The primary objective of this study was to examine if changes for in-care physical activity and sedentary time (ST) differed between centres in and around Edmonton, Alberta after implementing the new accreditation standards and non-accredited control centres in and around Ottawa, Ontario. Secondary objectives were to examine whether baseline age group (toddler, preschooler) or the childcare environment moderated any group differences in change of the primary outcomes. Furthermore, accreditation and control group differences in change of children's body mass index (BMI) Z-scores or cognitive development as well as educators' perceptions of the primary outcomes were explored.

METHODS

Participants were 252 toddlers (19-35 months) and preschoolers (36-60 months) in childcare centres from Alberta (n = 11) and Ontario (n = 8) in the supporting Healthy physical AcTive CHildcare setting (HATCH) study. In-care ST, light-intensity physical activity (LPA), and moderate- to vigorous-intensity physical activity (MVPA) were accelerometer-derived before and 6 months after the implementation of the new standards. At both time points, cognitive development (working memory, expressive vocabulary), heights, and weights were measured, and BMI Z-scores were calculated. Additionally, the childcare environment was observed using the Environment and Policy Assessment and Observation (EPAO) and Movement Environment Rating Scale (MOVERS) tools. Demographic characteristics were parent-reported and weather variables were derived from Environment Canada data. Mixed models were conducted.

RESULTS

In adjusted models (n = 241), change in children's in-care ST (B = -0.07, 95%CI: - 1.43,1.29), LPA (B = 0.08, 95%CI: - 0.89,1.05), and log-transformed MVPA (B = 0.01, 95%CI: - 0.09,0.11) were not significantly different between accreditation and control groups. Age group and the childcare environment were not moderators. Significant increases in BMI Z-score (B = 0.19, 95%CI: 0.03,0.35) and high working memory (OR = 3.24, 95%CI: 1.32,7.97) were observed in the accreditation group and significant increases in expressive vocabulary (B = 3.18, 95%CI: 0.05,6.30) were observed in the control group.

CONCLUSIONS

The new accreditation criterion may not significantly change physical activity or ST in childcare settings and therefore may not explain findings for BMI Z-scores and cognitive development. Additional training and resources may be needed.

Implementation of Minimum Nutrition Standards and Best Practices in Childcare Centers

BACKGROUND

The federal Child and Adult Care Food Program (CACFP) provides reimbursable meals to 4.6 million children annually and sets nutrition standards for foods served. Licensing regulations in many states extend these rules to nonparticipating programs.

OBJECTIVE

To evaluate the quality of meals and snacks served in Connecticut licensed childcare centers in 2019 and assess implementation of a state licensing requirement to adhere to CACFP minimum nutrition standards in all centers.

DESIGN

Cross-sectional survey.

PARTICIPANTS/SETTING

Two hundred licensed childcare centers in Connecticut in 2019.

MAIN OUTCOME MEASURES

Meal/snack quality was assessed based on menus. Foods/beverages listed were compared to the minimum CACFP nutrition standards and optional best practices. Surveys completed by center directors measured center characteristics.

STATISTICAL ANALYSIS

Logistic and linear multivariable regression models tested differences in centers' adherence to nutrition standards and best practices by CACFP participation status.

RESULTS

CACFP centers complied with more required nutrition standards than non-CACFP centers (an adjusted mean of 4.7 vs 3.4 standards among programs serving meals, P < 0.001), with particularly large mean differences for whole grains and low-fat milk. Implementation of optional best practices, except for beverages, was relatively low among all centers, especially for snacks. Compliance (adjusted mean number of minimum nutrition standards met) was greater among centers accredited by the National Association for the Education of Young Children and those using a registered dietitian or a sponsoring agency to prepare menus and receiving food from a vendor. Recent completion of nutrition training was associated with greater mean implementation of best practices.

CONCLUSIONS AND IMPLICATIONS

Better adherence to minimum nutrition standards and best practices among CACFP-participating childcare centers contributed to higher nutritional quality of meals and snacks offered. Snack quality would benefit most from greater compliance with nutrition standards. Providers outside of CACFP need additional supports in the implementation of licensing regulations to improve the food environment for young children.

Opportunities to Promote Healthy Weight Through Child Care Licensing Regulations: Trends in the United States, 2016-2020

BACKGROUND

Policies that support healthy nutrition and physical activity environments in early care and education (ECE) settings can help promote healthy weight in children. State child care licensing regulations are a critical mechanism for setting such policies.

OBJECTIVES

To develop a research instrument to evaluate the promotion of healthy child weight in state child care licensing regulations and assess the strength of the regulations over time.

DESIGN

For measure development, systematic reviews of evidence on the impact of healthy weight strategies relevant to the ECE environment were combined with expert stakeholder input to identify 15 healthy weight promotion policy standards and a coding tool to measure the strength and comprehensiveness of regulatory language matching these standards. For assessing the strength of regulations, the coding tool was applied to child care regulations nationwide in 2016 and again in 2020.

SUBJECTS/SETTING

Child care licensing regulations in 2016 and 2020 for all 50 US states plus Washington DC.

OUTCOME MEASURES

Strength and comprehensiveness scores for state licensing regulations.

STATISTICAL ANALYSES

Intraclass correlation coefficients were calculated to estimate interrater reliability of the coding tool. Paired t tests were used to compare scores within states from 2016 to 2020.

RESULTS

Interrater reliability for the coding tool had intraclass correlation coefficients of 0.81 for strength and 0.87 for comprehensiveness scores. Strength and comprehensiveness of states' healthy weight promotion policies increased significantly over time (P < .001). However, most states still lack important healthy weight policies in their licensing regulations, such as prohibiting serving sugary drinks.

CONCLUSIONS

This study presents a reliable research instrument for measuring the strength and comprehensiveness of healthy weight promotion standards in child care licensing regulations. States have increased their incorporation of strategies for healthy weight into state policy.

Healthy Eating Policy Improves Children's Diet Quality in Early Care and Education in South Carolina

Policies to promote healthy foods in early care and education (ECE) in the United States exist, but few have been prospectively evaluated. In South Carolina, a statewide program serving low-income children in ECE enacted new policies promoting healthy foods. We conducted an evaluation to measure changes in dietary intake among children in ECE exposed and not exposed to the new policy. Using direct observation, we assessed dietary intake in 112 children from 34 ECE centers in South Carolina and 90 children from 30 ECE centers in North Carolina (a state with no policy). We calculated Healthy Eating Index-2015 (HEI) scores to measure diet quality consumed before and after the policy was enacted. We fit mixed-effects linear models to estimate differences in HEI scores by state from baseline to post-policy, adjusting for child race, number of children enrolled, director education, center years in operation, participation in the Child and Adult Care Food Program (CACFP), and center profit status. The policy increased HEI scores for whole fruits, total fruits, and lean proteins, but decreased scores for dairy. Thus, the policy was associated with some enhancements in dietary intake, but additional support may help improve other components of diet.

A Menu to Evaluate Factors Influencing Implementation of Obesity Prevention Early Care and Education Regulations

CONTEXT

In recent years, several states have adopted new regulations concerning nutrition, physical activity, and screen time in early care and education (ECE) settings to help prevent childhood obesity.

OBJECTIVE

To disseminate a menu of factors that facilitate and/or impede implementation of obesity prevention regulations in ECE settings.

DESIGN

To create the menu, we condensed and categorized factors identified in the literature and through field work by placing them within domains. We applied the menu by conducting semistructured interviews during a pilot test assessing implementation of ECE regulations in Colorado.

SETTING AND PARTICIPANTS

We first interviewed state and local government agency leaders responsible for policy oversight, and state employees and contractors who acted as intermediaries to direct implementers. We then interviewed directors at ECE centers in the Denver, Colorado, area. We selected 21 ECE centers for a site visit on the basis of feasibility, percentage of low-income families, and diversity in race and ethnicity at each center. Seven centers participated.

MAIN OUTCOME MEASURES

Minor and major facilitators and impediments to implementation of childhood obesity prevention regulations in ECE settings.

RESULTS

The resulting menu includes 7 domains and 39 factors influential for implementation of ECE regulations. Of these 39 factors, interviewees identified 7 facilitating factors (4 major and 3 minor) and 2 impeding factors (both major). Major facilitating factors were buy-in from parents/caregivers, training and communication provided by governing authority and their contractors, and low level of change required by the regulations themselves. Major impeding factors were timing of implementation and balancing the demands of the regulations against other priorities.

CONCLUSIONS

The menu developed by our research team, combined with existing frameworks in dissemination and implementation research, can be used by researchers, practitioners, and policy makers to anticipate factors that facilitate and/or impede implementation of ECE policies to prevent childhood obesity.

State Regulations Promoting Infant Physical Activity in Early Care and Education

BACKGROUND

State policies have the potential to improve early care and education (ECE) settings, but little is known about the extent to which states are updating their licensing and administrative regulations, especially in response to national calls to action. In 2013, we assessed state regulations promoting infant physical activity in ECE and compared them with national recommendations. To assess change over time, we conducted this review again in 2018.

METHODS

We reviewed regulations for all US states for child care centers (centers) and family child care homes (homes) and compared them with three national recommendations: (1) provide daily tummy time; (2) use cribs, car seats, and high chairs for their primary purpose; and (3) limit the use of restrictive equipment (e.g., strollers). We performed exact McNemar's tests to compare the number of states meeting recommendations from 2013 to 2018 to evaluate whether states had made changes over this period.

RESULTS

From 2013 to 2018, we observed significant improvement in one recommendation for homes-to use cribs, car seats, and high chairs for their primary purpose (odds ratio 11.0; 95% CI 1.6-47.3; p = 0.006). We did not observe any other significant difference between 2013 and 2018 regulations.

CONCLUSIONS

Despite increased awareness of the importance of early-life physical activity, we observed only modest improvement in the number of states meeting infant physical activity recommendations over the past 5 years. In practice, ECE programs may be promoting infant physical activity, but may not be required to do so through state regulations.

Feasibility of a Multicomponent Program to Promote Physical Activity and Nutrition in Georgia Low-Income Early Care and Education Settings

BACKGROUND

This article describes the process and intermediate outcomes from a program implemented in 65 Early Care and Education (ECE) centers serving low-income families throughout Georgia during the 2014-2017 school years.

METHODS

The HealthMPowers' Empowering Healthy Choices in Schools, Homes, and Communities ECE program was based on the organization's previously successful elementary school program and aligns with current early childhood nutrition and physical activity recommendations. Participating centers worked with HealthMPowers for up to 3 years. A team from each center led changes by conducting annual self-assessments, creating and implementing improvement plans, and implementing nutrition and physical activity programs using educational resources and environmental cues. A monitoring and evaluation plan provided ongoing feedback to HealthMPowers and centers. Family and staff surveys provided insights into behaviors of children, families, and staff. Process measures included specific benchmarks (e.g., center leadership team formation, improvement plan implementation). Annual self-assessment results served as intermediate outcome measures.

RESULTS

As of 2017, 65 centers had enrolled in the program. All centers formed a health team and completed the baseline self-assessment and most implemented an improvement plan (88%). At the 1-year follow-up self-assessment, centers reported improvements from baseline including never offering food incentives for good behavior (75%-86%), conducting taste testing at least once a month (61%-79%), and rarely/never serving sugar-sweetened beverages (93%-96%).

CONCLUSIONS

Initial process measures from a multicomponent health promotion program in ECE were promising. An integrated continuous improvement approach to working with child care settings is feasible and likely effective.

Physical activity and screen-viewing policies in Canadian childcare centers

BACKGROUND

Physical activity (PA) offers numerous health benefits for young children; however, many children enrolled in childcare engage in low levels of PA and high levels of sedentary time. This study aimed to describe the prevalence and content of written PA and screen-viewing (SV) policies in Canadian childcare centers.

METHODS

Using a modified version of the Environment and Policy Assessment and Observation Self-Report (EPAO-SR) tool, an online survey was distributed to all directors/administrators of center-based childcare facilities across Canada. Reminder emails were sent to encourage survey completion and a strong response rate. Descriptive statistics were used to explore demographic characteristics and frequencies were run to examine the number of centers that implemented a PA or SV policy. Deductive content analysis was completed to identify common themes in participants' open-ended responses.

RESULTS

A total of 1158 childcare representatives participated in the study; 514 provided complete data. Of these, 295 (44%) centers indicated having a written PA policy (with the majority regulated at the provincial/territorial-level; n = 227; 42%). Content of these policies included amount of time: spent outdoors (n = 395; 63%); in teacher-led active play (n = 101; 16%); and PA education for children (n = 91; 16%). Additionally, 178 (29%) respondents reported a written policy regarding SV (with majority regulated at the center-level; n = 173; 34%) and primarily focusing on amount of time children watch television.

CONCLUSIONS

PA regulations are more common than SV policies in Canadian childcare centers; however, less than half implement a PA policy and only a third adopt SV regulations. An opportunity exists to advance practice by adopting proactive approaches to encouraging young children to be more active and less sedentary in childcare (i.e., through written policies). Supplementing policy with accessible resources, as well as consistent provision of early childhood educator (staff) training, represent important steps for putting said policies into action.

Childcare Providers' Possession or Use of Marijuana, Tobacco, or Alcohol While Caring for Children: A Comparison of US State Regulations

OBJECTIVES

To evaluate US state regulations regarding marijuana, tobacco, and alcohol to determine the extent to which states attempt to govern these substances in early care and education (ECE) settings.

METHODS

Two independent reviewers assessed regulations enacted by December 2016 for all states and the District of Columbia. Reviewers compared regulations to national standards on the possession or use of marijuana, tobacco, and alcohol in ECE settings.

RESULTS

Fewer states regulated marijuana than tobacco or alcohol in ECE settings. More states restricted the use of these 3 substances than they restricted the possession of them.

CONCLUSIONS

Most states address alcohol or tobacco possession or use in their regulations but should consider updating these provisions to align with national standards. Public Health Implications. Updating and strengthening state childcare regulations regarding marijuana, tobacco, and alcohol possession and use may help protect children in ECE settings, where many children spend a substantial portion of time. As more states legalize marijuana, they may consider updating their regulations and including precise language to better protect children from unintended pediatric marijuana exposure or impaired childcare providers.

Media and Young Minds: Comparing State Screen Media Use Regulations for Children Under 24 Months of Age in Early Care and Education to a National Standard

Introduction Excessive screen media use has been associated with a number of negative health outcomes in young children, including increased risk for obesity and comparatively lagging cognitive development. The purpose of this study was to assess state licensing regulations restricting screen media use for children under 24 months old in early care and education (ECE) and to compare regulations to a national standard. Methods We reviewed screen media use regulations for all US states for child care centers ("centers") and family child care homes ("homes") and compared these regulations to a national standard discouraging screen media use in children under 24 months of age. We assessed associations between state geographic region and year of last update with the presence of regulations consistent with the standard. In centers, 24 states had regulations limiting screen media use for children under 24 months of age and 19 states had regulations limiting screen media use in homes. Results More states in the South and fewer states in the Midwest had regulations limiting screen media use. The association between geographic region and regulations was not significant for centers (p = 0.06), but was for homes (p = 0.04). The year of last update (within the past 5 years versus older than 5 years) was not associated with regulations for centers (p = 0.18) or homes (p = 0.90). Discussion Many states lacked screen media use regulations for ECE. States should consider adding screen media use restrictions for children under 24 months based on current research data and current recommendations in future regulations updates.

State Variations in Infant Feeding Regulations for Child Care

OBJECTIVES

Early care and education (ECE) settings have become primary targets for policy change in recent years. In our 2008 study, we assessed state and regional variation in infant feeding regulations for ECE and compared them to national standards. We conducted the same regulatory review to assess change over time. Because all but 2 states have updated their regulations, we hypothesized that states would have made substantial improvements in the number of regulations supporting infant feeding in ECE.

METHODS

For this cross-sectional study, we reviewed infant feeding regulations for all US states for child care centers (centers) and family child care homes (homes). We compared regulations with 10 national standards and assessed the number of new regulations consistent with these standards since our previous review.

RESULTS

Comparing results from 2008 and 2016, we observed significant improvements in 7 of the 10 standards for centers and 4 of the 10 standards for homes. Delaware was the only state with regulations meeting 9 of the 10 standards for centers in 2008. In 2016, Delaware and Michigan had regulations meeting 8 of the 10 standards. Previously, Arkansas, the District of Columbia, Minnesota, Mississippi, Ohio, and South Carolina had regulations consistent with 4 of the 10 standards for homes. In 2016, Delaware, Mississippi, and Vermont had regulations meeting 7 of the 10 standards.

CONCLUSIONS

Evidence suggests that enacting new regulations may improve child health outcomes. Given that many states recently enacted regulations governing infant feeding, our findings point to the growing interest in this area.

Effects of a New State Policy on Physical Activity Practices in Child Care Centers in South Carolina

OBJECTIVES

We sought to determine the extent to which child care centers in South Carolina improved physical activity practices after a new policy took effect.

METHODS

In 2012, South Carolina adopted new mandatory physical activity standards within its child care quality enhancement program. This quasi-experimental study used North Carolina, a state not making policy changes, as the comparison. Participants were 34 child care centers in South Carolina and 30 centers in North Carolina. Researchers used the Environment and Policy Assessment and Observation (EPAO) tool to conduct center observations before and after policy implementation and then conducted repeated-measures linear regression with interaction between state and time for the Physical Activity Environment Total Score and the 8 subscale scores.

RESULTS

Compared with centers in North Carolina, EPAO subscale scores in South Carolina centers increased significantly for the Fixed Play Environment (P < .001) and Physical Activity Training and Education (P = .015). The state-by-time interaction of Physical Activity Environment Total Score approached statistical significance (P = .06).

CONCLUSIONS

Adoption of new physical activity standards in South Carolina child care centers was associated with improvements in practices aimed at increasing children's physical activity.