NGHC: Childhood Nutrition and Lifestyle Factors (2013)

Citation:
 
Study Design:
Class:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

To determine the feasibility, acceptability and reported environmental change of an intervention to improve the nutrition and physical activity environments in child care settings.

Inclusion Criteria:
  • Child care centers chosen from convenience sample of six intervention and two comparison counties 
  •  Child care centers included were based on:
    • Size of the center (between 20 and 150 children)
    • Participation in the Child and Adult Care Food Program
    • Rating of three, four or five stars on the North Carolina One-to-Five Star Rating System for quality child care.
  • All participants gave informed consent.
Exclusion Criteria:
  • Fewer than 20 children or more than 150 children
  • No participation in the Child and Adult Food Program
  • Rating of one or two stars on the North Carolina One-to-Five Star Rating System for quality child care
  • Open case of child abuse or neglect
  • Provided services to a special population of children only
  • Head Start center
  • Classified as a family child care home.
Description of Study Protocol:

Recruitment

  • Convenience sample of eight counties that had a previously established relationship with the North Carolina Department of Heath and Human Services from a former project
  • North Carolina's child care regulatory agency provided a list of eligible child care centers
  • Two centers were selected per county, with the exception of one large county that was given permission to have five participating centers
  • Matched on urban/rural status. 

Design

  • Cluster randomized trial
  • Counties were randomly allocated into either the intervention or the comparison group. 

Blinding

Scores were not shared with the center.

Intervention

  • Nutrition and Physical Activity Self assessment for Child Care (NAP SACC):
    • Goal to improve nutrition and physical activity policies and practices at the child care center and to enhance the overall center environment
    • Child care centers self-assess their nutrition and physical activity environments, select areas for improvement and make environmental changes with the help of a local health consultant
    • Employs components of social cognitive theory against a backdrop of the socioecological framework
    • Focuses on 15 key nutrition and physical activity areas:
      • Nutrition
        • Fruits and vegetables
        • Fried food and high-fat meats
        • Beverages
        • Menus and variety
        • Meals and snacks
        • Food items outside of regular meals and snacks
        • Supporting healthful eating
        • Nutrition education for children
        • Parents and staff
        • Nutrition policy.
      • Physical activity
        • Active play and inactive time
        • TV use and viewing
        • Play environment
        • Supporting physical activity
        • Physical activity education for children
        • Parents and staff
        • Physical activity policy
    • 10 trained child care health consultants (CCHC) implemented the intervention
      • Local health professionals (typically registered nurses) 
      • Employed by county-level agencies 
      • Attended a one-day training session on nutrition, physical activity and overweight in young children 
      • Provided with a tool kit which included:
        • Self-assessment instrument
        • Resource notebook with information on each of the 15 nutrition and physical activity areas on the self-assessment instrument
        • Packet of handout for center staff
        • Three workshops to be delivered to child care providers on CD with handouts
        • Brochure for parents and caregivers.
    • Both intervention and control centers received the self-assessment instrument in the mail and returned it, completed within two weeks
    • Comparison centers did not receive any training or technical assistance from a NAP SACC consultant
    • The consultant worked with the centers to develop an action plan to improve at least three areas from the self-assessment instrument
      • Directors were asked to select their priority areas for improvement
      • Consultants delivered three 30-minute workshops on childhood overweight, healthful eating and physical activity to center directors and interested staff
      • Ongoing technical assistance (visits and calls) was provided by the consultant.

Statistical Analysis

  • Difference in pre-test and post-test scores were compared using a signed rank test
  • No analysis was completed on the comparison group due to the small sample size.
Data Collection Summary:

Timing of Measurements

  • Self-assessment of centers:
    • Baseline
    • Immediately following the six-month intervention.
  • Workshop evaluations: Post-workshop (usually month three of intervention)
  • Telephone interviews with the center directors: One month post-intervention
  • Site visits for the randomly selected intervention centers: Four months post-intervention
  • Focus group evaluation of consultants: One month post-intervention.

Dependent Variables

  • Self-assessment
    • 29 nutrition and 15 physical activity questions that had either a demonstrated or a perceived relationship to childhood overweight
    • Completed by child care center directors, with assistance from key center staff
    • Instruments were scored by research staff
    • Overall score, a nutrition score and a physical activity score.
  • Workshop evaluation: Included quantitative and qualitative measures
  • Site visit
    • Six centers were randomly selected for site visits by research assistants to provide further documentation of center enhancements
    • Copies of menus, policies and lessons plans were collected
    • Photographs of the center were taken
    • Three staff members at the center were interviewed.
  • Focus group
    • With NAP SACC consultants
    • Provided feedback on the overall project.

Independent Variables

Nutrition and Physical Activity Self-assessment for Child Care (NAP SACC).

Description of Actual Data Sample:

Initial N

  • Child care centers that volunteered to participate:
    • 30 intervention (43% acceptance rate)
    • Five comparison (50% acceptance rate).
  • Child care centers selected to participate:
    • 19 intervention 
    • Four comparison.

Attrition (Final N)

  • 15 intervention child care centers 
  • Four comparison child care centers.

Anthropometrics

Intervention and comparison child care centers were similar.

Location

North Carolina. 

Summary of Results:

Key Findings

Child Care Center Scores on the NAP SACC Self-Assessment Instrument 

 

Baseline Score
Mean (SD)

Follow-Up Score
Mean (SD)

Difference  P-Value
Intervention Centers    
Nutrition 70.08 (4.77) 77.15 (5.25)   <0.001
Physical Activity 34.23 (3.19) 41.0 (3.29)   <0.001
Total Score 105.31 (5.25) 118.15 (6.03) 12.85 <0.001
Comparison Centers    
Nutrition 70.25 (3.59 75.25 (2.87)   N/A
Physical Activity 36.75 (4.27) 41.0 (1.83)   N/A
Total Score 108.5 (3.79) 116.25 (4.27) 7.75 N/A
  • Each question had three response categories
    • Assigned one, two or three points 
      • One = minimum standard
      • Two = good
      • Three = best practice.
  • Range of total scores possible: 44 to 132 points 
    • Nutrition score range possible: 29 to 87 points 
    • Physical activity score range possible: 15 to 45 points. 

Other Findings

Examples of self-assessment instrument question

  • Milk served to children ages two and older is usually:
    • One-point response: Whole
    • Two-point response: 2% reduced fat
    • Three-point response: 1% low-fat or skim.
  • Active play time is provided to all children:
    • One-point response: 30 minutes or less each day
    • Two-point response: 31 to 60 minutes each day
    • Three-point response: More than 60 minutes each day.

Examples of reported improvements at the centers

  • Switched to 1% milk for children over the age of two years
  • Began serving more fresh vegetables and fruits
  • Planned a physical activity training session for staff
  • Added more nutrition information to the parent newsletter.

Feedback from consultants

  • Self-assessment was comprehensive
    • 80% agree
    • 10% somewhat agree
    • 10% somewhat disagree.
  • Self-assessment was somewhat easy to understand
    • 40% agree
    • 50% somewhat agree
    • 10% somewhat disagree.
  • Felt meeting with center directors were productive
    • 70% agree
    • 20% somewhat agree
    • 10% neutral.
  • Felt confident in their ability to deliver the NAP SACC program
    • 60% agree
    • 40% somewhat agree.

Feedback from child care centers

  • Directors reported that the self-assessment was:
    • Fairly easy to use: 36%
    • Very easy to use: 64%.
      • Took an average of 26 minutes to complete (range 12 to 180 minutes)
    • Measure of nutrition environments:
      • Very helpful: 83%
      • Somewhat helpful: 17%.
    • Measure of physical activity environments:
      • Very helpful: 50%
      • Somewhat helpful: 50%.
  • Directors reported that the workshops were:
    • Clear and relevant: 92% agree
    • Provided useful information on childhood overweight, nutrition and physical activity: 88% agree
    • Recommend it to other child care centers
      • 12 would recommend
      • One stated that it would depend on characteristics of center.

Feedback from site visits

  • All six centers provided visual documentation of their reported nutrition and physical activity improvements
  • One center was not able to provide documentation for one of their four changes, although director stated that changes had been made.

Feedback from director telephone interviews

Most common improvement to nutrition and physical activity environments was switching from whole to reduced-fat milk for children over two years of age.

Author Conclusion:
  • The Nutrition and Physical Activity Self-Assessment for Child Care intervention improved child care centers' test scores on the self-assessment instrument and made tangible nutrition and physical activity environmental improvements, whereas the comparison centers demonstrated minimal change
  • This intervention represents a novel approach to overweight intervention with existing and relevant community professionals with excellent potential for creating supportive environments for developing child healthy weight behaviors.
Funding Source:
Government: Division of Public Health, North Carolina Department of Health and Human Services
Reviewer Comments:
  • Only 15 intervention and four comparison child care centers included
  • Authors note that although the pilot project was well received by both the child care centers and the NAP SACC consultants, the primary outcomes of the pilot were based heavily on self-report and the results should be interpreted with caution
  • In addition, the small sample size of intervention and especially comparison centers limits the ability to draw major conclusions from the study.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? ???
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? No
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? Yes
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? Yes
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) Yes
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? Yes
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? Yes
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? ???
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? ???
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? Yes
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes