Opening up Australian preschoolers' lunchboxes

Mealtimes in the context of poverty: Comparison of ECEC services providing food and those requiring food provided from home

BACKGROUND

In developed economies, most children attend Early Childhood Education and Care (ECEC) services before school entry, many from early life and across long days. For this reason, ECEC services present significant potential to provide food environments that positively influence eating behaviours and food preferences with attendant effect on life course trajectories of health and wellbeing. Yet there is evidence that feeding practices that limit optimal ongoing nutrition, such as pressure and restriction, are amplified in ECEC services serving disadvantaged communities. We sought to identify underlying explanatory mechanisms through observation of children's feeding experiences and educator explanations comparing, family-provided and service-provided meals.

METHOD

This study used qualitative analyses of educator interviews and observation records from 55 mealtimes in 10 ECEC services: 5 providing food and 5 requiring family food provision.

RESULTS

High levels of concern drove educator's controlling feeding practices at mealtimes but presented differently across meal provision modes. In centres that provided food, educators' concern focused on food variety, manifesting in pressure to 'try' foods. In centres requiring family-provided food, concern focused on nutrition quantity and quality and manifested as control of order of food consumption and pacing of intake to ensure food lasted across the day. Interview data suggested that conflict aversion limited optimal nutrition. In centres providing food, this was seen in menus that prioritized child food preferences. In centres requiring family meal provision, conflict aversion was seen as reticence to discuss lunchbox contents with families.

CONCLUSION

The findings direct attention to public health intervention. Currently, ECEC face significant barriers to realizing their potential to support child nutrition and establish positive life course trajectories of nutrition. To do so requires targeted supports that enable sufficient supply and quality of food in the context of poverty.

Content analysis of school websites: policies and programs to support healthy eating and the environment

Preschools and primary schools are important settings for the development of healthy eating habits and awareness of environmentally friendly practices. This study explored South Australian government schools' policies and programs in relation to healthy eating and environmentally friendly aspects of food choice (such as packaging), and whether any schools approached these issues in combination. Websites of 18 government preschools and primary schools in the Greater Adelaide region, stratified by low, medium and high socioeconomic status were reviewed for publicly available policies and other relevant content. A content analysis was undertaken, with policies and programs analysed deductively and thematically. Healthy eating (n = 8) and environment (n = 3) related policies were found on preschool websites only. The main themes observed across the three categories of interest (healthy eating, environmentally friendly practices and low-waste healthy foods) included the presence/absence of formal policy, promotional strategies and implementation. Expectations of children bringing healthy 'nude' foods that were environmentally friendly were mentioned informally on the websites but were not part of policy documents. Policies and programs around healthy eating and environmentally friendly practices (in combination) were lacking. There is scope to address this gap to improve health and sustainable outcomes within the school environment context.

An mHealth Intervention to Reduce the Packing of Discretionary Foods in Children's Lunch Boxes in Early Childhood Education and Care Services: Cluster Randomized Controlled Trial

Background

Interventions in early childhood education and care (ECEC) services have the potential to improve children’s diet at the population level.

Objective

This study aims to test the efficacy of a mobile health intervention in ECEC services to reduce parent packing of foods high in saturated fat, sugar, and sodium (discretionary foods) in children’s (aged 3-6 years) lunch boxes.

Methods

A cluster randomized controlled trial was undertaken with 355 parent and child dyads recruited by phone and in person from 17 ECEC services (8 [47%] intervention and 9 [53%] control services). Parents in the intervention group received a 10-week fully automated program targeting barriers to packing healthy lunch boxes delivered via an existing service communication app. The program included weekly push notifications, within-app messages, and links to further resources, including websites and videos. The control group did not receive any intervention. The primary outcomes were kilojoules from discretionary foods and associated nutrients (saturated fat, free sugars, and sodium) packed in children’s lunch boxes. Secondary outcomes included consumption of kilojoules from discretionary foods and related nutrients and the packing and consumption of serves of discretionary foods and core food groups. Photography and weights of foods in children’s lunch boxes were recorded by trained researchers before and after the trial to assess primary and secondary outcomes. Outcome assessors were blinded to service allocation. Feasibility, appropriateness, and acceptability were assessed via an ECEC service manager survey and a parent web-based survey. Use of the app was assessed via app analytics.

Results

Data on packed lunch box contents were collected for 88.8% (355/400) of consenting children at baseline and 84.3% (337/400) of children after the intervention. There was no significant difference between groups in kilojoule from discretionary foods packed (77.84 kJ, 95% CI −163.49 to 319.18; P=.53) or the other primary or secondary outcomes. The per-protocol analysis, including only data from children of parents who downloaded the app, also did not find any statistically significant change in primary (−1.98 kJ, 95% CI −343.87 to 339.90; P=.86) or secondary outcomes. Approximately 61.8% (102/165) of parents in the intervention group downloaded the app, and the mean service viewing rate of weekly within-app messages was 26% (SD 14.9). Parents who responded to the survey and participating services agreed that it was appropriate to receive lunch box information via the app (40/50, 80% and 6/8, 75%, respectively).

Conclusions

The intervention was unable to demonstrate an impact on kilojoules or associated nutrients from discretionary foods packed in children’s lunch boxes. Low app downloads and program message views indicate a need to explore how to improve factors related to implementation before further testing similar mobile health interventions in this setting.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618000133235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374379

Feasibility of a Web-Based Implementation Intervention to Improve Child Dietary Intake in Early Childhood Education and Care: Pilot Randomized Controlled Trial

Background

Internationally, the implementation of evidence-based healthy eating policies and practices within early childhood education and care (ECEC) settings that encourage children’s healthy diet is recommended. Despite the existence of evidence-based healthy eating practices, research indicates that current implementation rates are inadequate. Web-based approaches provide a potentially effective and less costly approach to support ECEC staff with implementing nutrition policies and practices.

Objective

The broad aim of this pilot randomized controlled trial is to assess the feasibility of assessing the impact of a web-based program together with health promotion officer (HPO) support on ECEC center implementation of healthy eating policies and practices. Specifically, we seek to describe the completion rate of study evaluation processes (participant consent and data collection rates); examine ECEC center uptake, acceptability, and appropriateness of the intervention and implementation strategies; understand the potential cost of delivering and receiving implementation support strategies; and describe the potential impact of the web-based intervention on the implementation of targeted healthy eating practices among centers in the intervention group.

Methods

A 6-month pilot implementation trial using a cluster-randomized controlled trial design was conducted in 22 ECEC centers within the Hunter New England region of New South Wales, Australia. Potentially eligible centers were distributed a recruitment package and telephoned by the research team to assess eligibility and obtain consent. Centers randomly allocated to the intervention group received access to a web-based program, together with HPO support (eg, educational outreach visit and local technical assistance) to implement 5 healthy eating practices. The web-based program incorporated audit with feedback, development of formal implementation blueprints, and educational materials to facilitate improvement in implementation. The centers allocated to the control group received the usual care.

Results

Of the 57 centers approached for the study, 22 (47%) provided consent to participate. Data collection components were completed by 100% (22/22) of the centers. High uptake for implementation strategies provided by HPOs (10/11, 91% to 11/11, 100%) and the web-based program (11/11, 100%) was observed. At follow-up, intervention centers had logged on to the program at an average of 5.18 (SD 2.52) times. The web-based program and implementation support strategies were highly acceptable (10/11, 91% to 11/11, 100%). Implementation of 4 healthy eating practices improved in the intervention group, ranging from 19% (2/11) to 64% (7/11).

Conclusions

This study provides promising pilot data to warrant the conduct of a fully powered implementation trial to assess the impact of the program on ECEC healthy eating practice implementation.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12619001158156; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378099

International Registered Report Identifier (IRRID)

RR2-10.1186/s40814-020-00707-w

Associations between food provision and feeding practices in socially disadvantaged childcare centres

Preschool children consume a large proportion of their daily food intake in their childcare settings. These settings, therefore, provide important opportunities for children to experience food socialisation, and related positive nutrition. Yet, the extent to which these opportunities are taken, particularly in socioeconomically disadvantaged areas where risk of poor nutrition is high, is not well documented. This study focused on 10 childcare centres in socially disadvantaged locations and examined daily feeding practices via direct in-situ observation (n = 189 children observed). Centres were randomly selected based on type of food provision: centre-provided (n = 5 centres) or family-provided (n = 5 centres). Analyses showed that where food was family-provided, educators were significantly more likely to use controlling feeding practices, including pressuring children to eat, restricting food choices and rushing children into finishing meals. These practices were particularly evident during mid-morning meals, where pressuring children to eat healthy foods first, was more often observed. Further research and interventions that target feeding practices in childcare are indicated and should consider how source of food provision impacts upon these practices.

Technological Devices and Their Effect on Preschool Children's Eating Habits in Communities of Mixed Socioeconomic Status in Istanbul; a Pilot Cross-Sectional Study

The use of technological devices is increasing in all age groups, especially in preschool-aged children. However, there is a limiting number of studies investigating the relationship between the use of technological devices, eating behavior, and weight status in preschool children. The aim of this study was (1) to describe total usage of technological devices, (2) to evaluate level of exclusive use of such devices by children, (3) to investigate children’s eating behaviors and diet in relation to screen time and type. A cross-sectional study was conducted with 104 children aged 2–5 years in Küçükçekmece and Bakırköy, Istanbul. Data collection consisted of a validated parental questionnaire on demographics and the child’s use of technology and eating behavior, while associations in children were examined using logistic regression analysis. The analysis of the obtained data uncovered a strong association between children’s TV and tablet/smart phone use and the foods consumed by children when using these devices (p = 0.0001; p = 0.012). Also, there was a significant association between children’s eating habits and TV, and tablet/smart phone durations of use (p = 0.015; p = 0.025), but not with computer duration of use (p > 0.05). Obesity and associated health problems can arise as results of suboptimal eating behavior, such as the ones observed in our study, which are also intensified with an increased duration of use of technological devices. The attitude of families towards prudent use of technological equipment is of great importance in impacting present and future health.

Foods provided to children in family day care: an observational study

OBJECTIVE

To assess the quality and quantity of foods and beverages provided to children aged 0-5 years in family day care and identify structural and sociodemographic factors associated with the nutritional quality of food provided.

DESIGN

A cross-sectional study measured the food and beverages provided to children using weighed food records. The number of serves from different food groups was calculated according to the Australian Guide to Healthy Eating, and a healthy food provision index score was created. Associations between structural and sociodemographic factors and healthy food provision index scores were analysed using linear mixed models.

SETTING

Family day care services in two large geographic areas in New South Wales, Australia.

PARTICIPANTS

One hundred and four children in thirty-three family day care services.

RESULTS

During attendance at childcare, most children met recommended servings of fruit but not dairy, vegetables, lean meat and meat alternatives and wholegrains. Discretionary foods exceeded recommendations. Children's age, socio-economic status and the type of main meal provided were significantly associated with the healthy food provision index score.

CONCLUSIONS

Foods provided to children in family day care are aligned with dietary recommendations for fruit but not vegetables, dairy, lean meat and meat alternatives, wholegrains or discretionary foods. Interventions to promote healthy eating are needed to support families and educators to improve the nutritional quality of food provided to children.

Food Photography as a Tool to Assess Type, Quantity, and Quality of Foods in Parent-Packed Lunches for Preschoolers

OBJECTIVE

Explore using food photography to assess packed lunches in a university-based Early Childhood Center and contextualize these photographs through parent interviews.

METHODS

An explanatory sequential design was used. Packed lunches were photographed to assess the type and quantity of foods offered and consumed by Child and Adult Food Care Program components (fruit, vegetable, grain, and protein) and quality of foods offered using the Healthy Meal Index. Parent interviews aimed to understand motivations and behaviors related to packing lunch.

RESULTS

Data were collected on 401 lunches. Only 16.2% of lunches met all Child and Adult Food Care Program requirements. Most lunches included fruit (84%) and grains (82%), whereas fewer included vegetables (44%). Portion sizes were large, especially for grains (2.7 ± 1.5 servings). In interviews (n = 24), parents expressed tension between offering healthful items and foods they knew their child would eat, as well as concern about children going hungry.

CONCLUSIONS AND IMPLICATIONS

Food photography is a feasible methodology to capture parent-packed lunches for preschoolers and may have utility in nutrition education, particularly related to age-appropriate portion sizes.

Home packed food for nursery children in United Arab Emirates provides suboptimal quality

BACKGROUND: Early childhood nutrition is associated with health outcomes later in life, hence developing health promoting habits from an early age is imperative. OBJECTIVE: The aim of this study was to assess the nutritional adequacy of home-packed food brought to the nurseries by attending children. METHODS: In a cross sectional study conducted in 7 nurseries in Abu Dhabi, United Arab Emirates 315 food-boxes were assessed through detailed food observations at the nurseries prior to mealtimes. The food content was evaluated using the Alberta Guidelines for nursery food, Canada. RESULTS: Most food boxes contained refined grains (77.5%), fruits (74.6%), sweet/full fat dairy products (77.5%), discretionary-calorie-food-items (70.6%). Emirati children were offered sweetened drinks significantly more (p < 0.001). Non-dairy protein sources, vegetables, low-fat-natural-dairy products were offered to 45.4%, 44.1% and 3.9% of children, respectively. Overall, 70.2% of the food-boxes contained not-recommended food and 63.1% of the children were served a very poor food combination. CONCLUSIONS: Despite frequent inclusion of recommended food, many food boxes were nutritionally inadequate due to their low content of whole grains, low-fat dairy products, vegetables and animal proteins and high content of sweet food and drinks. The inadequate dietary patterns necessitate developing nutrition guidelines for nurseries in Abu Dhabi.

A cross-sectional study of packed lunchbox foods and their consumption by children in early childhood education and care services

AIM

To (a) describe lunchbox foods packed and consumed by children attending early childhood education and care services; (b) compare the serves of foods packed and consumed with nutrition guideline recommendations; and (c) explore associations between parent characteristics and serves of food groups packed in lunchboxes.

METHODS

A cross sectional study was conducted on a sample of early childhood education and care services where parents provide food in the Hunter New England region of NSW, Australia. Lunchbox contents were assessed using photography and pre- and post-meal weights. Descriptive statistics were used to describe packing and consumption of core food groups and discretionary foods.

RESULTS

Data on food packed and consumed were collected for 355 children's lunchboxes from 17 services (preschools n = 14, long day care services n = 3). Less than half (44%) of lunchboxes contained vegetables, and 54% contained at least one serve of discretionary foods. Less than 1% of lunchboxes met all setting-specific nutrition guidelines. On average, children consumed 68% of lunchbox contents, with the lowest consumption rate being for vegetables. An association was found between parent education level and packing of discretionary foods (-0.36, P = <.01) but not for packing of fruit or vegetables.

CONCLUSIONS

Lunchboxes contained an over-representation of discretionary foods and under-representation of vegetables, and children had a low preference for consuming vegetables compared with other food groups. Interventions to support parent packing of lunchboxes in line with nutrition guidelines and strategies to expand child preference for foods such as vegetables are warranted.

Strategies to improve the implementation of healthy eating, physical activity and obesity prevention policies, practices or programmes within childcare services

BACKGROUND

Despite the existence of effective interventions and best-practice guideline recommendations for childcare services to implement evidence-based policies, practices and programmes to promote child healthy eating, physical activity and prevent unhealthy weight gain, many services fail to do so.

OBJECTIVES

The primary aim of the review was to examine the effectiveness of strategies aimed at improving the implementation of policies, practices or programmes by childcare services that promote child healthy eating, physical activity and/or obesity prevention. The secondary aims of the review were to: 1. Examine the cost or cost-effectiveness of such strategies; 2. Examine any adverse effects of such strategies on childcare services, service staff or children; 3. Examine the effect of such strategies on child diet, physical activity or weight status. 4. Describe the acceptability, adoption, penetration, sustainability and appropriateness of such implementation strategies.

SEARCH METHODS

We searched the following electronic databases on February 22 2019: Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, MEDLINE In Process, Embase, PsycINFO, ERIC, CINAHL and SCOPUS for relevant studies. We searched reference lists of included studies, handsearched two international implementation science journals, the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp/) and ClinicalTrials.gov (www.clinicaltrials.gov).

SELECTION CRITERIA

We included any study (randomised or nonrandomised) with a parallel control group that compared any strategy to improve the implementation of a healthy eating, physical activity or obesity prevention policy, practice or programme by staff of centre-based childcare services to no intervention, 'usual' practice or an alternative strategy. Centre-based childcare services included preschools, nurseries, long daycare services and kindergartens catering for children prior to compulsory schooling (typically up to the age of five to six years).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened study titles and abstracts, extracted study data and assessed risk of bias; we resolved discrepancies via consensus. We performed meta-analysis using a random-effects model where studies with suitable data and homogeneity were identified; otherwise, findings were described narratively.

MAIN RESULTS

Twenty-one studies, including 16 randomised and five nonrandomised, were included in the review. The studies sought to improve the implementation of policies, practices or programmes targeting healthy eating (six studies), physical activity (three studies) or both healthy eating and physical activity (12 studies). Studies were conducted in the United States (n = 12), Australia (n = 8) and Ireland (n = 1). Collectively, the 21 studies included a total of 1945 childcare services examining a range of implementation strategies including educational materials, educational meetings, audit and feedback, opinion leaders, small incentives or grants, educational outreach visits or academic detailing, reminders and tailored interventions. Most studies (n = 19) examined implementation strategies versus usual practice or minimal support control, and two compared alternative implementation strategies. For implementation outcomes, six studies (one RCT) were judged to be at high risk of bias overall. The review findings suggest that implementation strategies probably improve the implementation of policies, practices or programmes that promote child healthy eating, physical activity and/or obesity prevention in childcare services. Of the 19 studies that compared a strategy to usual practice or minimal support control, 11 studies (nine RCTs) used score-based measures of implementation (e.g. childcare service nutrition environment score). Nine of these studies were included in pooled analysis, which found an improvement in implementation outcomes (SMD 0.49; 95% CI 0.19 to 0.79; participants = 495; moderate-certainty evidence). Ten studies (seven RCTs) used dichotomous measures of implementation (e.g. proportion of childcare services implementing a policy or specific practice), with seven of these included in pooled analysis (OR 1.83; 95% CI 0.81 to 4.11; participants = 391; low-certainty evidence). Findings suggest that such interventions probably lead to little or no difference in child physical activity (four RCTs; moderate-certainty evidence) or weight status (three RCTs; moderate-certainty evidence), and may lead to little or no difference in child diet (two RCTs; low-certainty evidence). None of the studies reported the cost or cost-effectiveness of the intervention. Three studies assessed the adverse effects of the intervention on childcare service staff, children and parents, with all studies suggesting they have little to no difference in adverse effects (e.g. child injury) between groups (three RCTs; low-certainty evidence). Inconsistent quality of the evidence was identified across review outcomes and study designs, ranging from very low to moderate. The primary limitation of the review was the lack of conventional terminology in implementation science, which may have resulted in potentially relevant studies failing to be identified based on the search terms used.

AUTHORS' CONCLUSIONS

Current research suggests that implementation strategies probably improve the implementation of policies, practices or programmes by childcare services, and may have little or no effect on measures of adverse effects. However such strategies appear to have little to no impact on measures of child diet, physical activity or weight status.

Vegetable intake in Australian children and adolescents: the importance of consumption frequency, eating occasion and its association with dietary and sociodemographic factors

OBJECTIVE

We aimed to profile vegetable consumption and its association with dietary and sociodemographic factors.

DESIGN

Secondary analysis of a nationally representative nutrition survey. 'Vegetables' refers to non-discretionary 'vegetables and legumes/beans' as defined by the Australian Dietary Guidelines (ADG). Prevalence of vegetable consumption, frequency of intake, proportion meeting ADG recommendations, most popular food groups, intake at each reported eating occasion, and the profile of high and low vegetable consumers (based on the median servings) were determined.

SETTING

Australian 2011-2012 National Nutrition and Physical Activity Survey.

PARTICIPANTS

Children and adolescents aged 2 to 18 years (n 2812).

RESULTS

Vegetables were consumed by 83·0% (95% CI 81·6, 84·4%) of participants, but the median vegetable servings was less than a third of the ADG recommendations. 'Leaf and stalk vegetables' and 'potatoes' were the most popular vegetable-dense food groups at lunch and dinner, respectively. Sixty-four percent had vegetables once a day, and predominantly at dinner. Vegetable frequency was positively associated with daily vegetable servings and variety. Participants who consumed vegetables twice a day generally had vegetables at both lunch and dinner and had nearly double the servings (2·6, sd 1·9) of those who consumed them once (1·5, sd 1·5). High vegetable consumers were older, had higher total energy, but lower discretionary energy intake and were less likely to be at risk of metabolic complications.

CONCLUSION

Increasing the frequency of vegetable consumption may assist with increasing daily vegetable servings. A focus on consuming vegetables at lunch may assist with increasing both total servings and variety.

Cluster randomised controlled trial of an m-health intervention in centre-based childcare services to reduce the packing of discretionary foods in children's lunchboxes: study protocol for the 'SWAP IT Childcare' trial

INTRODUCTION

In many developed nations, including Australia, a substantial number of children aged under 5 years attend centre-based childcare services that require parents to pack food in lunchboxes. These lunchboxes often contain excessive amounts of unhealthy ('discretionary') foods. This study aims to assess the impact of a mobile health (m-health) intervention on reducing the packing of discretionary foods in children's childcare lunchboxes.

METHODS AND ANALYSIS

A cluster randomised controlled trial will be undertaken with parents from 18 centre-based childcare services in the Hunter New England region of New South Wales, Australia. Services will be randomised to receive either a 4-month m-health intervention called 'SWAP IT Childcare' or usual care. The development of the intervention was informed by the Behaviour Change Wheel model and will consist primarily of the provision of targeted information, lunchbox food guidelines and website links addressing parent barriers to packing healthy lunchboxes delivered through push notifications via an existing app used by childcare services to communicate with parents and carers. The primary outcomes of the trial will be energy (kilojoules) from discretionary foods packed in lunchboxes and the total energy (kilojoules), saturated fat (grams), total and added sugars (grams) and sodium (milligrams) from all foods packed in lunchboxes. Outcomes will be assessed by weighing and photographing all lunchbox food items at baseline and at the end of the intervention.

ETHICS AND DISSEMINATION

The study was approved by the Hunter New England Local Health District Human Ethics Committee (06/07/26/4.04) and ratified by the University of Newcastle, Human Research Ethics Committee (H-2008-0343). Evaluation and process data collected as part of the study will be disseminated in peer-reviewed publications and local, national and international presentations and will form part of PhD student theses.

TRIAL REGISTRATION NUMBER

ACTRN12618000133235; Pre-results.

A randomised controlled trial of performance review and facilitated feedback to increase implementation of healthy eating and physical activity-promoting policies and practices in centre-based childcare

BACKGROUND

While it is recommended that childcare services implement policies and practices to support obesity prevention, there remains limited evidence to inform policy and practice. The aim of this study is to examine the effectiveness of performance review and facilitated feedback in increasing the implementation of healthy eating and physical activity-promoting policies and practices in childcare services.

METHODS

The study was conducted with childcare services in the Hunter New England region of New South Wales, Australia. Eligible services were randomised to a wait-list control group or to receive the implementation strategy. The strategy targeted the implementation of written nutrition, physical activity, and small screen recreation policies; providing information to families regarding healthy eating, physical activity, and small screen time; providing twice weekly healthy eating learning experiences to children; providing water and plain milk only to children; providing fundamental movement skills activities for children every day; and limiting the use of electronic screen time for educational purposes and learning experiences. Intervention services received a performance review and facilitated feedback process five times over the 10 months that included an assessment of current practices, goal setting, identification of barriers to implementation, problem-solving, and resource provision. The primary outcome was the proportion of services implementing all six policies and practices, assessed by nominated supervisor completion of a computer-assisted telephone interview at baseline and 12-month follow-up.

RESULTS

One hundred and eight services took part. There were no significant differences in the proportion of services implementing all six practices at 12 months (mean difference 0.51; 95% CI 0.16 to 1.58; p = 0.24). There were also no differences between groups in the mean number of policies and practices implemented (mean difference 0.1; 95% CI - 0.4 to 0.6; p = 0.71), or the proportion implementing each of the six individual policies and practices at 12 months (OR range 0.57 to 1.85; p > 0.05).

CONCLUSIONS

Further support may be required to assist childcare services to make recommended changes to their policies and practices.

TRIAL REGISTRATION

The trial was registered retrospectively on 10 September 2014 with the Australian New Zealand Clinical Trials Registry ACTRN12614000972628 .

Dietary intake and physical activity levels of children attending Australian childcare services

AIM

The primary aim of this study was to describe the dietary intake and physical activity levels of children while attending childcare.

METHODS

A cross-sectional study was conducted with 18 centre-based childcare services in the Hunter region of New South Wales, Australia. Childcare service characteristics were assessed via telephone interview. Child dietary intake and physical activity levels were assessed during a one-day observation conducted at participating childcare services using previously validated tools.

RESULTS

Children consumed a mean of 0.2 serves of vegetables, 0.7 serves of fruit, 1.4 serves of grain (cereal) foods, 0.1 serves of lean meat and poultry, fish, eggs, nuts and seeds and legumes/beans, 0.6 serves of milk, yoghurt, cheese and alternatives, and 0.7 serves of discretionary foods during attendance at childcare. Of all child physical activity counts, 48.6% were classified as 'sedentary', and 22.3% classified as 'very active'. Bivariate analyses indicated that children attending services located in rural areas consumed significantly more serves of vegetables (0.3 serves (SD 0.7) vs 0.1 serves (SD 0.2), P = 0.05). Multivariate analyses indicated that services with large child enrolments had a significantly greater proportion of child counts classified as 'very active' (23.6% of child counts (95% CI 1.6, 29.5) vs 14.9% of child counts (95% CI 9.1, 20.6), P = 0.007).

CONCLUSIONS

There is considerable scope to improve the diet and activity behaviours of children during attendance at childcare. Future research is needed to identify effective strategies to best support childcare services in implementing policies and practices to improve such behaviours in children.

Strategies to improve the implementation of healthy eating, physical activity and obesity prevention policies, practices or programmes within childcare services

BACKGROUND

Despite the existence of effective interventions and best-practice guideline recommendations for childcare services to implement policies, practices and programmes to promote child healthy eating, physical activity and prevent unhealthy weight gain, many services fail to do so.

OBJECTIVES

The primary aim of the review was to examine the effectiveness of strategies aimed at improving the implementation of policies, practices or programmes by childcare services that promote child healthy eating, physical activity and/or obesity prevention. The secondary aims of the review were to:1. describe the impact of such strategies on childcare service staff knowledge, skills or attitudes;2. describe the cost or cost-effectiveness of such strategies;3. describe any adverse effects of such strategies on childcare services, service staff or children;4. examine the effect of such strategies on child diet, physical activity or weight status.

SEARCH METHODS

We searched the following electronic databases on 3 August 2015: the Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, ERIC, CINAHL and SCOPUS. We also searched reference lists of included trials, handsearched two international implementation science journals and searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp/) and ClinicalTrials.gov (www.clinicaltrials.gov).

SELECTION CRITERIA

We included any study (randomised or non-randomised) with a parallel control group that compared any strategy to improve the implementation of a healthy eating, physical activity or obesity prevention policy, practice or programme by staff of centre-based childcare services to no intervention, 'usual' practice or an alternative strategy.

DATA COLLECTION AND ANALYSIS

The review authors independently screened abstracts and titles, extracted trial data and assessed risk of bias in pairs; we resolved discrepancies via consensus. Heterogeneity across studies precluded pooling of data and undertaking quantitative assessment via meta-analysis. However, we narratively synthesised the trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).

MAIN RESULTS

We identified 10 trials as eligible and included them in the review. The trials sought to improve the implementation of policies and practices targeting healthy eating (two trials), physical activity (two trials) or both healthy eating and physical activity (six trials). Collectively the implementation strategies tested in the 10 trials included educational materials, educational meetings, audit and feedback, opinion leaders, small incentives or grants, educational outreach visits or academic detailing. A total of 1053 childcare services participated across all trials. Of the 10 trials, eight examined implementation strategies versus a usual practice control and two compared alternative implementation strategies. There was considerable study heterogeneity. We judged all studies as having high risk of bias for at least one domain.It is uncertain whether the strategies tested improved the implementation of policies, practices or programmes that promote child healthy eating, physical activity and/or obesity prevention. No intervention improved the implementation of all policies and practices targeted by the implementation strategies relative to a comparison group. Of the eight trials that compared an implementation strategy to usual practice or a no intervention control, however, seven reported improvements in the implementation of at least one of the targeted policies or practices relative to control. For these trials the effect on the primary implementation outcome was as follows: among the three trials that reported score-based measures of implementation the scores ranged from 1 to 5.1; across four trials reporting the proportion of staff or services implementing a specific policy or practice this ranged from 0% to 9.5%; and in three trials reporting the time (per day or week) staff or services spent implementing a policy or practice this ranged from 4.3 minutes to 7.7 minutes. The review findings also indicate that is it uncertain whether such interventions improve childcare service staff knowledge or attitudes (two trials), child physical activity (two trials), child weight status (two trials) or child diet (one trial). None of the included trials reported on the cost or cost-effectiveness of the intervention. One trial assessed the adverse effects of a physical activity intervention and found no difference in rates of child injury between groups. For all review outcomes, we rated the quality of the evidence as very low. The primary limitation of the review was the lack of conventional terminology in implementation science, which may have resulted in potentially relevant studies failing to be identified based on the search terms used in this review.

AUTHORS' CONCLUSIONS

Current research provides weak and inconsistent evidence of the effectiveness of such strategies in improving the implementation of policies and practices, childcare service staff knowledge or attitudes, or child diet, physical activity or weight status. Further research in the field is required.

Measurement of obesity prevention in childcare settings: A systematic review of current instruments

OBJECTIVE

The incidence of childhood obesity is highest among children entering kindergarten. Overweight and obesity in early childhood track through adulthood. Programs increasingly target children in early life for obesity prevention. However, the published literature lacks a review on tools available for measuring behaviour and environmental level change in child care. The objective is to describe measurement tools currently in use in evaluating obesity-prevention in preschool-aged children.

METHODS

Literature searches were conducted in PubMed using the keywords "early childhood obesity," "early childhood measurement," "early childhood nutrition" and "early childhood physical activity." Inclusion criteria included a discussion of: (1) obesity prevention, risk assessment or treatment in children ages 1-5 years; and (2) measurement of nutrition or physical activity.

RESULTS

One hundred thirty-four publications were selected for analysis. Data on measurement tools, population and outcomes were abstracted into tables. Tables are divided by individual and environmental level measures and further divided into physical activity, diet and physical health outcomes. Recommendations are made for weighing advantages and disadvantages of tools.

CONCLUSION

Despite rising numbers of interventions targeting obesity-prevention and treatment in preschool-aged children, there is no consensus for which tools represent a gold standard or threshold of accuracy.

Efficacy of the Lunch is in the Bag intervention to increase parents' packing of healthy bag lunches for young children: a cluster-randomized trial in early care and education centers

BACKGROUND

Lunches that parents pack for their young children to eat at school or the Early Care and Education (ECE) center fall short of recommended standards. Lunch is in the Bag is a multi-level behavioral nutrition intervention to increase parents' packing of fruit, vegetables, and whole grains in their children's lunches. Designed for implementation in ECE centers, the five-week long intervention is followed three months later with a one-week booster.

METHODS

Efficacy of Lunch is in the Bag was tested in cluster randomized trial. Participants were 633 families from 30 ECE centers (15 intervention, 15 control) across Austin, San Antonio, and Houston, Texas, USA. Primary outcomes were servings of fruit, vegetables, and whole grains observed in the children's parent-packed bag lunches. Servings of refined grains, meats/beans/eggs/nuts, dairy, chips, and sweets also were observed. Data were collected at baseline, post-intervention (6-week follow-up), pre-booster (22-weeks follow-up), and post-booster (28-week follow-up). Time-by-treatment interactions were analyzed separately for each of the food groups using multi-level models to compare changes from baseline. Analyses were adjusted for relevant demographic variables and clustering within centers and parents.

RESULTS

The intervention effected increases from baseline to 6-week follow-up in vegetables (0.17 servings, SE = 0.04, P < 0.001) and whole grains (0.30 servings, SE = 0.13, P = 0.018). The increase in whole grains was maintained through the 28-week follow-up (0.34 servings, SE = 0.13, P = 0.009). Fruit averaged more than 1.40 servings with no differences between groups or across time. The intervention prevented increase in sweets (-0.43 servings, SE = 0.11, P < .001, at the 22-week follow-up). Parents persisted, however, in packing small amounts of vegetables (averages of 0.41 to 0.52 servings) and large amounts of sweets and chips (averages of 1.75 to 1.99 servings).

CONCLUSIONS

The need for and positive effects of the Lunch is in the Bag intervention at ECE centers where parents send bag lunch for their preschool-aged children was confirmed. An important direction for future research is discovery of more options for leveraging the partnership of ECE centers and families to help young children learn to eat and enjoy vegetables and other healthy foods in preference to less healthy choices such as chips and sweets.

TRIAL REGISTRATION

The Clinical Trials Number is NCT01292434 .

Examining How Adding a Booster to a Behavioral Nutrition Intervention Prompts Parents to Pack More Vegetables and Whole Gains in Their Preschool Children's Sack Lunches

Data from a five-week intervention to increase parents' packing of vegetables and whole grains in their preschool children's sack lunches showed that, although changes occurred, habit strength was weak. To determine the effects of adding a one-week booster three months post-intervention, children's (N = 59 intervention and 48 control) lunches were observed at baseline (week 0), post-intervention (week 6), pre-booster (week 20), and post-booster (week 26). Servings of vegetables and whole grains were evaluated in repeated measures models and results inspected relative to patterns projected from different explanatory models of behavior change processes. Observed changes aligned with projections from the simple associative model of behavior change. Attention in future studies should focus on behavioral intervention elements that leverage stimulus-response associations to increase gratification parents receive from providing their children with healthy lunches.

Effectiveness of the Lunch is in the Bag program on communication between the parent, child and child-care provider around fruits, vegetables and whole grain foods: A group-randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of the parent- and early care education (ECE) center-based Lunch is in the Bag program on communication between parent, child, and their ECE center providers around fruits, vegetables and whole grain foods (FVWG).

METHOD

A total of n=30 ECE center; 577 parent-child dyads participated in this group-randomized controlled trial conducted from 2011 to 2013 in Texas (n=15 ECE center, 327 dyads intervention group; n=15 ECE center, 250 dyads comparison group). Parent-child and parent-ECE center provider communication was measured using a parent-reported survey administered at baseline and end of the five-week intervention period. Multilevel linear regression analysis was used to compare the pre-to-post intervention changes in the parent-child and parent-ECE center provider communication scales. Significance was set at p<0.05.

RESULTS

At baseline, parent-child and parent-ECE center provider communication scores were low. There was a significant increase post-intervention in the parent-ECE center provider communication around vegetables (Adjusted β=0.78, 95%CI: 0.13, 1.43, p=0.002), and around fruit (Adjusted β=0.62, 95%CI: 0.04, 0.20, p=0.04) among the parents in the intervention group as compared to those in the comparison group. There were no significant intervention effects on parent-child communication.

CONCLUSION

Lunch is in the Bag had significant positive effects on improving communication between the parents and ECE center providers around FVWG.

Effectiveness of an intervention to facilitate the implementation of healthy eating and physical activity policies and practices in childcare services: a randomised controlled trial

Background

The primary aim of this study was to evaluate the effectiveness of an intervention to increase the implementation of healthy eating and physical activity policies and practices by centre-based childcare services. The study also sought to determine if the intervention was effective in improving child dietary intake and increasing child physical activity levels while attending childcare.

Methods

A parallel group, randomised controlled trial was conducted in a sample of 128 childcare services. Intervention strategies included provision of implementation support staff, securing executive support, staff training, consensus processes, academic detailing visits, tools and resources, performance monitoring and feedback and a communications strategy. The primary outcome of the trial was the proportion of services implementing all seven healthy eating and physical activity policies and practices targeted by the intervention. Outcome data were collected via telephone surveys with nominated supervisors and room leaders at baseline and immediately post-intervention. Secondary trial outcomes included the differences between groups in the number of serves consumed by children for each food group within the Australian Guide to Healthy Eating and in the proportion of children engaged in sedentary, walking or very active physical activity assessed via observation in a random subsample of 36 services at follow-up.

Results

There was no significant difference between groups for the primary trial outcome (p = 0.44). Relative to the control group, a significantly larger proportion of intervention group services reported having a written nutrition and physical activity policy (p = 0.05) and providing adult-guided activities to develop fundamental movement skills (p = 0.01). There were no significant differences between groups at follow-up on measures of child dietary intake or physical activity.

Conclusions

The findings of the trial were equivocal. While there was no significant difference between groups for the primary trial outcome, the intervention did significantly increase the proportion of intervention group services implementing two of the seven healthy eating and physical activity policies and practices. High levels of implementation of a number of policies and practices at baseline, significant obesity prevention activity in the study region and higher than previously reported intra-class correlation of child behaviours may, in part, explain the trial findings.

Trial registration

Australian Clinical Trials Registry (reference ACTRN12612000927820).

A pragmatic randomised controlled trial of an implementation intervention to increase healthy eating and physical activity-promoting policies, and practices in centre-based childcare services: study protocol

BACKGROUND

Promotion of healthy eating and physical activity in early childhood is recommended as a global chronic disease prevention strategy. Centre-based childcare services represent a promising setting to provide children with opportunities to improve healthy eating and physical activity. Evidence to inform implementation of childcare obesity prevention guidelines into routine practice in childcare, however, is lacking. This study aims to assess the effectiveness of an intervention, delivered to childcare staff, aiming to increasing service implementation of healthy eating and physical activity-promoting policies and practices.

METHODS AND ANALYSIS

A pragmatic parallel group randomised controlled trial will be undertaken with 165 childcare services in the Hunter New England region of New South Wales, Australia. Services will be randomised to receive either a 10-month evidence-based performance review intervention with other resources to support practice change, or to a waitlist control group. The primary trial outcome is the proportion of services implementing all of the following recommended healthy eating and physical activity promoting practices: written nutrition, physical activity and small screen recreation policies; providing information to families regarding healthy eating (including breastfeeding), physical activity and small screen time; providing twice weekly healthy eating learning experiences to children; providing water and only plain milk to children; providing fundamental movement skills activities for children every day; and limiting and using electronic screen time more for educational purposes and learning experiences. Effectiveness will be assessed using a telephone interview of practice implementation with childcare staff at baseline and 12 months following baseline.

ETHICS AND DISSEMINATION

The study was approved by the Hunter New England Human Research Ethics Committee and the University of Newcastle Human Research Ethics Committee. Study findings will be disseminated widely through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry ACTRN12614000972628.

Development of a Method to Observe Preschoolers' Packed Lunches in Early Care and Education Centers

BACKGROUND

As early childhood education (ECE) centers become a more common setting for nutrition interventions, a variety of data collection methods are required, based on the center foodservice. ECE centers that require parents to send in meals and/or snacks from home present a unique challenge for accurate nutrition estimation and data collection. We present an observational methodology for recording the contents and temperature of preschool-aged children's lunchboxes and data to support a 2-day vs a 3-day collection period.

METHODS

Lunchbox observers were trained in visual estimation of foods based on Child and Adult Care Food Program and MyPlate servings and household recommended measures. Trainees weighed and measured foods commonly found in preschool-aged children's lunchboxes and practiced recording accurate descriptions and food temperatures. Training included test assessments of whole-grain bread products, mixed dishes such as macaroni and cheese, and a variety of sandwich preparations. Validity of the estimation method was tested by comparing estimated to actual amounts for several distinct food types. Reliability was assessed by computing the intraclass correlation coefficient for each observer as well as an interrater reliability coefficient across observers. To compare 2- and 3-day observations, 2 of the 3 days of observations were randomly selected for each child and analyzed as a separate dataset. Linear model estimated mean and standard error of whole grains, fruits and vegetables, and amounts of energy, carbohydrates, protein, total fat, saturated fat, dietary fiber, thiamin, riboflavin, niacin, vitamins A and C, calcium, iron, sodium, and dietary fiber per lunch were compared across the 2- and 3-day observation datasets.

RESULTS

The mean estimated amounts across 11 observers were statistically indistinguishable from the measured portion size for each of the 41 test foods, implying that the visual estimation measurement method was valid: intraobserver intraclass correlation coefficients ranged from 0.951 (95% CI 0.91 to 0.97) to 1.0. Across observers, the interrater reliability correlation coefficient was estimated at 0.979 (95% CI 0.957 to 0.993). Comparison of servings of fruits, vegetables, and whole grains showed no significant differences for serving size or mean energy and nutrient content between 2- and 3-day lunch observations.

CONCLUSIONS

The methodology is a valid and reliable option for use in research and practice that requires observing and assessing the contents and portion sizes of food items in preschool-aged children's lunchboxes in an ECE setting. The use of visual observation and estimation with Child and Adult Care Food Program and MyPlate serving sizes and household measures over 2 random days of data collection enables food handling to be minimized while obtaining an accurate record of the variety and quantities of foods that young children are exposed to at lunch time.

Making sense in a complex landscape: how the Cynefin Framework from Complex Adaptive Systems Theory can inform health promotion practice

Health promotion addresses issues from the simple (with well-known cause/effect links) to the highly complex (webs and loops of cause/effect with unpredictable, emergent properties). Yet there is no conceptual framework within its theory base to help identify approaches appropriate to the level of complexity. The default approach favours reductionism--the assumption that reducing a system to its parts will inform whole system behaviour. Such an approach can yield useful knowledge, yet is inadequate where issues have multiple interacting causes, such as social determinants of health. To address complex issues, there is a need for a conceptual framework that helps choose action that is appropriate to context. This paper presents the Cynefin Framework, informed by complexity science--the study of Complex Adaptive Systems (CAS). It introduces key CAS concepts and reviews the emergence and implications of 'complex' approaches within health promotion. It explains the framework and its use with examples from contemporary practice, and sets it within the context of related bodies of health promotion theory. The Cynefin Framework, especially when used as a sense-making tool, can help practitioners understand the complexity of issues, identify appropriate strategies and avoid the pitfalls of applying reductionist approaches to complex situations. The urgency to address critical issues such as climate change and the social determinants of health calls for us to engage with complexity science. The Cynefin Framework helps practitioners make the shift, and enables those already engaged in complex approaches to communicate the value and meaning of their work in a system that privileges reductionist approaches.