Kristen Copeland, MD, FAAP Nutrition Technical Panel Member, Caring for Our Children, 3 rd Ed. Assistant Professor of

1. Section on Early Education and Child Care Hot Topics in Early Childhood Influencing Early Education and Child Care: Research, Early Literacy, Obesity PreventionPractical strategies for increasing children’s physical activity in child care Kristen Copeland, MD, FAAP Nutrition Technical Panel Member, Caring for Our Children, 3rd Ed. Assistant Professor of Pediatrics Division of General and Community Pediatrics Cincinnati Children’s Hospital Medical Center Oct 3rd, 2010

2. Disclosures • In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in my presentation. This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA or if you will be discussing “off-label” uses of pharmaceuticals or devices.

3. Outline • Why do we need to increase physical activity in child care? • Background on PA: link to obesity, current levels in child care • What is going on? Why are levels so variable?: An insider’s view • Focus groups w/ child care providers re: perceived benefits and barriers • Telephone survey of PA environment • Ongoing fieldwork in childcare centers • How do we increase physical activity levels in child care? • The new physical activity standards in Caring for Our Children • Based on evidence and/or expert opinion • Address common barriers • Offer practical strategies • Take home messages

4. Background: Obesity & PA, Child Care • Over past 35 yrs, the % of preschoolers who are obese (>95th%ile for BMI) has tripled, school-age ~quintupled1 • Obesity linked to inadequate physical activity2-5 • 13 M children, 75% US 3-6yo in some form of child care • Many spend long hours in child care: Only opportunity for exercise may be in child care • Young children are completely dependent on their caregivers for opportunities to be active 1. Ogden CL, JAMA 2006. 2. Patrick K, et al Arch Pediatr Adolesc Med. 2004 ; 3. Robinson TN. Jama. 1999 4. Gortmaker SL et al Arch Pediatr Adolesc Med. Sep 1999; 5.Epstein LH, et al. Health Psychol. Mar 1995

5. Background: Physical activity levels in child care • Children are sedentary for most (70-83%) of their time in child care, excluding nap1-2 • only small amount (2-3%) of time in vigorous activity • only 12-46 min of moderate or vigorous activity over course of 6 hr day in child care1-2 • The amount of physical activity children get in child care varies widely, and depends mostly on the center attended (27-47% of variance), not child factors (3-10% of variance combined)1-3 1. Pate RR et al Pediatrics. Nov 2004 2. Pate RR et al. J Sch Health. Aug 2008, 3.Finn K, et al J Pediatr. Jan 2002

6. Why are PA levels so low? Voices from the field Our ongoing research in Cincinnati2006-present • 9 focus groups* with 49 child care providers from 34 centers. 2006-8 • re: perceived benefits and barriers to PA in child care • Telephone survey of PA environment in childcare (ELEPhANTS) 2008-9 • Playground, indoor gross-motor room, weather policies for outdoor play • Ongoing fieldwork in childcare centers 2009-present *Copeland KA et al, Int J of Behav Nutr and Phys Act. 2009

7. Obesity prevention Build healthy habits Develop fundamental motor skills Children nap better** Outdoor time: More room to run Vitamin D** Escape germs from indoors (children less likely to get sick)** Add’l health benefits from the literature Improved fitness Lower BP Higher serum HDL Increased bone mineral density Improved sleep Focus Groups: Teachers’ perceptions of the health benefits of PA and outdoor time for young children **benefits also for teachers

8. Improved self-efficacy, self-confidence after mastering gross motor skills Improved peer relationships Energy/stress relief, calm the classroom** Outdoor time: Improved mood** ‘endorphins’ More creative, expressive Add’l SE benefits from the literature Anti-depressive effects Teachers’ perceptions of the socio-emotional benefits of physical activity and outdoor time **benefits also for teachers

9. Improved concentration, attention Hands-on “Active Learning” concepts of time, distance, language Outdoor time: Sensory experiences Science Understanding concepts of society, citizenship Add’l learning benefits from the literature Improved concentration, attention Outdoor exposure for ADHD Teachers’ perceptions of the learning benefits of physical activity and outdoor time

10. Child: injuries getting dirty Parent: direct parent requests not to take child outside Child will get sick Concerns about asthma indirect dressing child in improper clothing (eg, nice/expensive clothes, flip flops, or no coat in winter) Barriers to physical activity-child and parentFinding from focus groups* *Copeland KA et al, Int J of Behav Nutr and Phys Act. 2009

11. Structural* No outdoor playground No indoor play-space for days with inclement weather Playground too small, not enough equipment- Wide variability across different centers Weather: Rain/Snow Standing water, snow on playground “Extreme” heat/ smog alert or cold Wide variability in minimum temperature, 32°F most common in Cincinnati* Barriers to physical activity- physical Findings from Telephone Survey* *Telephone survey, ELEPhANTS

12. Teachers’ preferences about the weather “not a cold weather person" Don’t like going outside, getting dirty, sweaty, insects, Too much work involved Putting on coats, sunscreen, setting up portable play equipment Teacher has low self-efficacy Not trained in “playground teaching” Teacher overweight, low self-esteem Teacher as the gatekeeper to the playground Barriers to physical activity- teachers Finding from focus groups

13. Focus on “academics” (at expense of outdoor/gross motor time) “Climbers are boring”--Playgrounds are safe but have little variety, minimally challenging, not fun for the children “Budgets are tight”—minimal investment available for physical activity facilities False appeal of the fancy climber Barriers to physical activity- societal, policy Finding from focus groups

14. New Physical Activity Standards Released September, 2010

15. New PA guidelines in CFOC: Background Previous editions of CFOC had no guideline to promote physical activity, focus on safety • Based on evidence • Address common barriers • Offer practical strategies • Informed by our focus groups and telephone survey • Where evidence lacking, rely on expert opinion • PA, nutrition, public health, pediatric, and ECE experts

16. Example of evidence-based:Outdoor occasions and structured and time • Evidence supporting: • Children are more active • when outdoors 1-2 • when prompted by adults 1,3-5 • All children 0-6yrs should have daily: • 2-3 outdoor occasions, weather permitting; • >2 structured or adult-led movement activities 1Brown WH Child Development 2009; 2Burdette Arch Ped Adol Med 2005, 2004. 3 McKenzie 1997. 4 McKenzie, 1992, 5 Sallis 1993

17. Examples of structured activities-movement and learning • Simon Says, Mother May I • “Get the Wiggles Out” • Dance party* • Acting out animals • Track team*, relay races • Community walk through the neighborhood • Several good websites listed in CFOC *Brown WH J of Early Intervention Mar 2009.

18. Example of moderate evidence:Time allotted for structured and unstructured time • Preschool-aged children are vigorously active in very short bursts (15-30 sec)* • Cannot sustain prolonged (>5 min) periods of vigorous activity • In adults, short bouts of vigorous activity (10 min) have health benefits (2008 PA Guidelines for Americans) *Oliver, M. et al. Sports Med 37:1045-70.2007.

20. Example of evidence lacking: Sedentary time • Children should not be seated for >15 min at a time, except during meals or naps. * Benjamin, S. E et al The nutrition and physical activity self-assessment for child care (NAP SACC). Rev ed.2007

21. Outdoor play: weather • “STANDARD: Children should play outdoors daily when weather and environmental conditions do not pose a significant health or safety risk: • Wind chill factor at or below minus 15°F and heat index at or above 90°F, as identified by the National Weather Service.” Very different from 32°F!

22. Barriers: Teachers unsure when appropriate to go out Parents’ request not to take children out Strategies: Have a written policy in the parent handbook that specifies the temps and precipitation conditions children permitted outdoors, & expected clothing Benefits of PA For “buy-in” Weather: practical strategies

23. Barrier: Belief that children will get sick if exposed to cold air Strategies: Educate parents & child care providers about causes of winter illness (i.e., viruses) Review importance of frequent hand-washing Proper sanitation techniques, esp. during mealtimes Catching a cold from the cold: practical strategies

24. Barrier: Children with Asthma Cold or Hot temperatures can trigger symptoms Indoor allergens (dust and dust mites) are common triggers, become elevated during the winter. Strategies: Attention to air circulation during winter Try to go outside: children can wear a scarf Work with child’s primary medical provider to maximally control asthma and develop a self-management plan Asthma: practical strategies

25. Conclusion: Take-home messages for pediatricians • Policy maker/Advocate: Focus on holistic ways to increase physical activity in child-care • Early learning standards vs. PA, <15 min seated • Researcher: Need for more and better evidence to inform guidelines, most based on (divergent) expert opinion • Child care consultants: Teachers are the gatekeepers to the playground, ultimately decide what active opportunities children have • Importance of proper training, and support

26. Conclusion: Take-home messages for pediatricians In the office:Discuss with parents: • Importance, benefits of daily physical activity • Don’t just focus on the negative (TV, bike helmets) • Importance of good role-modeling • Don’t let the weather be an excuse--Go outside! • Will not get sick if exposed to cold • Work with their children’s child-care setting to improve the physical environment and increase active opps.

27. Questions?

29. http://www.nemours.org/filebox/service/preventive/nhps/paguidelines.pdfhttp://www.nemours.org/filebox/service/preventive/nhps/paguidelines.pdf

30. For examples of policies, see the Nemours Health and Prevention Services guide on best practices for physical activity at: http://www.nemours.org/filebox/service/preventive/nhps/paguidelines.pdf

31. Practical strategies resources • Nutrition and Physical Activity Self Assessment for Child Care - NAP SACC Program - http://www.napsacc.org • “Color Me Healthy Preschoolers Moving and Eating”- http://www.colormehealthy.com • “Move and Learn” physical activity curriculum from Kansas State University • “I am Moving I am Learning” Intervention in Head Start - http://eclkc.ohs.acf.hhs.gov/hslc/ecdh/Health/ Nutrition/Nutrition%20Program%20Staff/IamMovingIam.htm • Moving and Learning: The Physical Activity Specialists for Birth through Age 8 - http://www.movingandlearning.com • “How to Lower Your Risk for Type 2 Diabetes “National Diabetes Education Program http://ndep.nih.gov/media/kids-tips-lower-risk.pdf