Intervention leads to improvements in the nutrient profile of snacks served in afterschool programs: a group randomized controlled trial

Widely adopted nutrition policies for afterschool programs (ASPs) focus on serving a fruit/vegetable daily and eliminating sugar-sweetened foods/beverages. The impact of these policies on the nutrient profile of snacks served is unclear. Evaluate changes in macro/micronutrient content of snacks served in ASPs. A 1-year group randomized controlled trial was conducted in 20 ASPs serving over 1700 elementary-age children. Intervention ASPs received a multistep adaptive framework intervention. Direct observation of snack served was collected and nutrient information determined using the USDA Nutrient Database, standardized to nutrients/100 kcal. By post-assessment, intervention ASPs reduced total kcal/snack served by 66 kcal (95CI -114 to -19 kcal) compared to control ASPs. Total fiber (+1.7 g/100 kcal), protein (+1.4 g/100 kcal), polyunsaturated fat (+1.2 g/100 kcal), phosphorous (+49.0 mg/100 kcal), potassium (+201.8 mg/100 kcal), and vitamin K (+21.5 μg/100 kcal) increased in intervention ASPs, while added sugars decreased (-5.0 g/100 kcal). Nutrition policies can lead to modest daily caloric reductions and improve select macro/micronutrients in snacks served. Long-term, these nutritional changes may contribute to healthy dietary habits.

Evaluation of a statewide dissemination and implementation of physical activity intervention in afterschool programs: a nonrandomized trial

In 2015, YMCA-operated afterschool programs (ASPs) across South Carolina pledged to achieve the national standard that calls for every child to accumulate 30 min/day of moderate-to-vigorous physical activity (MVPA) during program time. This study shares the first-year findings related to the dissemination, implementation, and outcomes associated with the statewide intervention to achieve the MVPA Standard. Twenty ASPs were sampled from all YMCA-operated ASPs (N = 97) and visited at baseline (spring 2015) and first-year follow-up (spring 2016). Programs were provided standardized professional development training to increase the MVPA children accumulated while attending ASPs. The training focused on extending the scheduled time for activity opportunities and modifying commonly played games to increase MVPA. The RE-AIM framework was used to evaluate the statewide intervention. Accelerometer-derived MVPA was the primary outcome. Implementation was evaluated via direct observation. Intent-to-treat (ITT) and as-treated comparisons were conducted in summer 2016. Reach/adoption was variable, with attendance at trainings ranging from 0 to 100% across ASPs. Effectiveness of the intervention using ITT models indicated no changes from baseline in the percentage of programs meeting the MVPA standard for boys or girls. Implementation levels also varied and were related to increases in both boys' and girls' MVPA for moderate and high implementers. Findings indicate improvements in MVPA can be made from attending the trainings and implementing some or all of the training components. Additional work is necessary to identify ways to ensure staff attend trainings to implement strategies and to identify which specific factors contributed to increases in MVPA.

Impact of a Community-Based Physical Activity Program on Fitness and Adiposity Among Overweight and Obese Children

This study tested whether overweight/obese children's attendance in a community-based physical activity (PA) program was associated with changes in cardiorespiratory fitness (CRF) and adiposity and whether in-program activity levels influenced those associations. Program sessions (offered twice/week, 2 hours/session, over 9 months) included structured exercise/sports. At baseline and follow-up, CRF was measured as Progressive Aerobic Cardiorespiratory Endurance Run (PACER) laps, height/weight were measured, and body mass index (BMI) was calculated. Attendance was recorded as sessions attended. Children wore pedometers in 10 representative sessions; in-program activity was calculated as mean steps/minute across sessions. Linear mixed models tested associations between attendance and changes in PACER score and BMI and the influence of in-program activity on those associations. A total of 101 participants (56% male, 93% Hispanic) completed baseline and one or two follow-up fitness/adiposity measurements. Attendance was associated with PACER change (β = .093, p = .01) but not BMI change (β = .00026, p = .97). There were significant interactions between attendance and in-program activity: Attendance more favorably affected PACER (p < .0001) and BMI (p = .03) as in-program activity levels increased. Attending community-based PA programs may improve CRF among overweight/obese children, particularly when participants are highly active during program time. Community practitioners should not only enroll overweight/obese children in PA programs but also promote adequate attendance/in-program activity levels.

Strategies to Increase After-School Program Staff Skills to Promote Healthy Eating and Physical Activity

Standards targeting children's healthy eating and physical activity (HEPA) in after-school programs call for staff to display or refrain from HEPA-promoting or -discouraging behaviors that are linked to children's HEPA. This study evaluated strategies to align staff behaviors with HEPA Standards. Staff at four after-school programs serving approximately 500 children participated in professional development training from January 2012 to May 2013. Site leaders also attended workshops and received technical support during the same time frame. Changes in staff behaviors were evaluated using the System for Observing Staff Promotion of Activity and Nutrition in a pre- (fall 2011) multiple-post (spring 2012, fall 2012, and spring 2013), no-control group study design. A total of 8,949 scans were completed across the four measurement periods. Of the 19 behaviors measured, 14 changed in the appropriate direction. For example, staff engaging in physical activity with children increased from 27% to 40% of scans and staff eating unhealthy foods decreased from 56% to 14% of days. Ongoing training and technical assistance can have a measureable impact on staff behaviors linked to child-level HEPA outcomes. Future research should explore the feasibility of disseminating ongoing trainings to after-school program staff on a large scale.

Making policy practice in afterschool programs: a randomized controlled trial on physical activity changes

INTRODUCTION

In the U.S., afterschool programs are asked to promote moderate to vigorous physical activity. One policy that has considerable public health importance is California's afterschool physical activity guidelines that indicate all children attending an afterschool program accumulate 30 minutes each day the program is operating. Few effective strategies exist for afterschool programs to meet this policy goal. The purpose of this study was to evaluate a multistep adaptive intervention designed to assist afterschool programs in meeting the 30-minute/day moderate to vigorous physical activity policy goal.

DESIGN

A 1-year group randomized controlled trial with baseline (spring 2013) and post-assessment (spring 2014). Data were analyzed 2014.

SETTING/PARTICIPANTS

Twenty afterschool programs, serving >1,700 children (aged 6-12 years), randomized to either an intervention (n=10) or control (n=10) group.

INTERVENTION

The employed framework, Strategies To Enhance Practice, focused on intentional programming of physical activity opportunities in each afterschool program's daily schedule and included professional development training to establish core physical activity competencies of staff and afterschool program leaders with ongoing technical assistance.

MAIN OUTCOME MEASURES

The primary outcome was accelerometry-derived proportion of children meeting the 30-minute/day moderate to vigorous physical activity policy.

RESULTS

Children attending intervention afterschool programs had an OR of 2.37 (95% CI=1.58, 3.54) to achieve the physical activity policy at post-assessment compared to control afterschool programs. Sex-specific models indicated that the percentage of intervention girls and boys achieving the physical activity policy increased from 16.7% to 21.4% (OR=2.85, 95% CI=1.43, 5.68) and 34.2% to 41.6% (OR=2.26, 95% CI=1.35, 3.80), respectively. At post-assessment, six intervention afterschool programs increased the proportion of boys achieving the physical activity policy to ≥45% compared to one control afterschool program, whereas three intervention afterschool programs increased the proportion of girls achieving physical activity policy to ≥30% compared to no control afterschool programs.

CONCLUSIONS

The Strategies To Enhance Practice intervention can make meaningful changes in the proportion of children meeting the moderate to vigorous physical activity policy within one school year. Additional efforts are required to enhance the impact of the intervention.

Physical activity opportunities in afterschool programs

Afterschool programs (ASPs) have potential to provide children moderate to vigorous physical activity (MVPA). The availability and types (e.g., free play or organized activities) of physical activity opportunities, their structure (e.g., presence of lines, elimination games), and staff behaviors (e.g., encouragement, engaged) can influence children's MVPA. This study explored these factors in 20 ASPs serving over 1,700 elementary-age children. The occurrence, types, and structure of physical activity opportunities, and staff behaviors were collected via the SOSPAN (System for Observing Staff Promotion of Physical Activity and Nutrition). A total of 4,660 SOSPAN scans were completed across 63 complete program days (1,733 during physical activity opportunities). Physical activity opportunities were observed on 60 program days across all 20 sites, with 73% of those opportunities classified as free play. ASPs scheduled an average of 66.3 minutes (range 15-150 minutes) of physical activity opportunities daily. Games played included basketball, tag, soccer, and football. Staff rarely engaged in physical activity promotion behaviors, and the structure of organized games discouraged MVPA. For example, staff verbally promoted physical activity in just 6.1% of scans, while organized games were more likely to involve lines and elimination. Professional development training may enhance staffs' physical activity promotion and the structure of activity opportunities.

Salty or sweet? Nutritional quality, consumption, and cost of snacks served in afterschool programs

BACKGROUND

Snacks served in afterschool programs (ASPs, 3-6 pm) represent an important opportunity to promote healthy eating. ASP policies suggest a fruit/vegetable is served daily, while sugar-sweetened foods/beverages and artificially flavored snacks are eliminated. Limited information exists on the types of snacks served in ASPs, if snacks meet existing nutrition policies, whether children eat the snacks, and their cost.

METHODS

Direct observation of snacks served and consumed was collected in 20 ASPs serving over 1700 elementary age children. The number of days that snacks were served/week was evaluated for compliance with nutrition policies. Costs of snacks were collected via receipts.

RESULTS

Programs served desserts and artificially flavored salty snacks on 2.7 and 2.1 days/week. Fruits and vegetables were served 0.6 and 0.1 days/week, respectively. Sugar-sweetened beverages were served 1.8 days/week. Of the children (N = 383) observed, 75% to 100% consumed the snack served, with 95% and 100% of served fruits/vegetables consumed. No ASP served fruit/vegetables daily, 18 served sugar-sweetened foods, 16 served artificially flavored snacks, and 14 served sugar-sweetened beverages. Desserts and salty snacks cost $0.27-$0.32/snack vs $0.38-$0.40/snack for vegetables/fruits.

CONCLUSIONS

The quality of snacks failed to meet nutrition policies and consists of predominately high-sugar and artificially flavored options. Strategies to improve snack offerings in ASPs while addressing price barriers are required.

How can schools help youth increase physical activity? An economic analysis comparing school-based programs

OBJECTIVE

For optimal health, physical activity should be an integral and routine part of daily life. Youth spend a significant amount of time at school yet rarely achieve the recommended 60 min of moderate and vigorous physical activity in physical education (PE) classes or recess. This study assessed the following types of school-based opportunities to improve physical activity for youth: after-school programs, before-school programs, PE classes, extended-day PE, and short physical activity breaks during the school day.

METHOD

An economic analysis conducted in 2013 compared school-based approaches to increasing physical activity. Analysis factors included costs, reach, effects on physical activity gains, cost-effectiveness, and other potentially augmenting benefits.

RESULTS

Two programs were significantly superior in terms of reach and cost per student: (1) extending the school day with mandatory PE participation and (2) offering short (10-minute) physical activity breaks during regular classroom hours. After-school program costs per student are high and the programs have a smaller reach, but they offer benefits (such as childcare) that may justify their higher costs. Before-school programs did not appear feasible.

CONCLUSION

Incorporating short physical activity breaks into the existing school day would be a cost-effective way to increase school-based activity. This type of program is inexpensive and has broad reach. Inserting activity breaks throughout the day is appropriate, especially when youth are otherwise largely sedentary.

Promoting physical activity in Out-of-School-Time programs: we built the bridge--can we walk over it?

This commentary describes physical activity standards for Out-of-School Time programs and argues that their widespread adoption presents important opportunities for research on their implementation and impact.

Effects of a policy-level intervention on children's pedometer-determined physical activity: preliminary findings from Movin' Afterschool

OBJECTIVES

Although evidence supports the benefits of incorporating physical activity (PA) after school and standards for quality after-school programs (ASPs) include PA, evaluation of policies to increase PA after school is nonexistent. The purpose of this study was to examine the effect of an evidence-informed policy-level ASP intervention on youth pedometer-determined PA.

DESIGN

This study was a quasi-experimental community-based intervention (Movin' Afterschool), with a pre-/posttest design, without a control.

SETTING

Movin' Afterschool took place in the after-school setting.

PARTICIPANTS

Participants were children (5-12 years old) attending 1 of 12 ASPs in Nebraska during the fall and spring of 2010-2011.

INTERVENTION

Movin' Afterschool was an evidence-informed policy-level intervention.

MAIN OUTCOME MEASURES

Physical activity was measured using pedometers.

RESULTS

Children averaged 3145 steps per day at baseline and 3042 steps per day at postassessment. There were no effects of sex, body mass index percentile, age, or the interaction of these covariates on steps. Three ASPs experienced substantial declines in PA compared with the remaining 9 ASPs. Excluding these 3 sites, there was an average increase in steps per day in the remaining 9 sites. No significant contribution was observed with the covariates.

CONCLUSION

This was the first study to provide evidence for the initial effectiveness of a policy-level intervention on youth PA participation while attending an ASP despite the failed attempt by some ASPs to improve PA. Further research may help determine the following: (1) the amount of support necessary to help ASPs modify their planning to meet policies, and (2) strategies that should be emphasized during staff training to ensure that staff are able to implement PA policies.

Process evaluation of an intervention to increase child activity levels in afterschool programs

BACKGROUND

Identifying effective strategies in Afterschool programs (ASPs) to increase children's moderate-to-vigorous physical activity (MVPA) in the ASP setting is crucial. This study describes the process evaluation outcomes from an intervention to reduce child sedentary time and increase MVPA in ASPs.

METHODS

Four ASPs participated in a quasi-experimental single-group pre-post study targeting child sedentary time and MVPA. The strategies implemented to help ASPs meet Physical Activity Standards consisted of detailed schedules, professional development trainings, on-site booster sessions, and technical assistance. Process evaluation related to staff behaviors was collected via systematic observation to identify the interventions impact on the physical and social environment of the ASP. Random-effects regression models examined the impact of the intervention on boys/girls observed sedentary behavior, MVPA, and changes in staff behaviors.

RESULTS

Increases in MVPA and reductions in sedentary behavior were observed during enrichment, academics, organized and free-play physical activities (PA). Corresponding changes in staff behaviors were observed during these ASP contexts. For example, staff reduced child idle-time during organized PA (38.9-1.8%) and provided energizers more often during enrichment (0.2-11.5%).

CONCLUSIONS

This study identified changes in staff behavior during ASP contexts that led to increases in child MVPA and decreases in child sedentary behavior.

Community partnership to address snack quality and cost in after-school programs

BACKGROUND

Policies call on after-school programs (ASPs) to serve more nutritious snacks. A major barrier for improving snack quality is cost. This study describes the impact on snack quality and expenditures from a community partnership between ASPs and local grocery stores.

METHODS

Four large-scale ASPs (serving ˜500 children, aged 6-12 years, each day) and a single local grocery store chain participated in this study. The nutritional quality of snacks served was recorded preintervention (18 weeks spring/fall 2011) and postintervention (7 weeks spring 2012) via direct observation, along with cost/child/snack/day.

RESULTS

Preintervention snacks were low-nutrient-density salty snacks (eg, chips, 3.0 servings/week), sugar-sweetened beverages (eg, powdered-lemonade, 1.9 servings/week), and desserts (eg, cookies, 2.1 servings/week), with only 0.4 servings/week of fruits and no vegetables. By postintervention, fruits (3.5 servings/week) and vegetables (1.2 servings/week) were increased, whereas sugar-sweetened beverages and desserts were eliminated. Snack expenditures were $0.26 versus $0.24 from preintervention to postintervention. Partnership savings versus purchasing snacks at full retail cost was 24.5% or $0.25/serving versus $0.34/serving.

CONCLUSIONS

This innovative partnership can serve as a model in communities where ASPs seek to identify low-cost alternatives to providing nutritious snacks.

Making healthy eating and physical activity policy practice: the design and overview of a group randomized controlled trial in afterschool programs

National and state organizations have developed policies calling upon afterschool programs (ASPs, 3-6 pm) to serve a fruit or vegetable (FV) each day for snack, while eliminating foods and beverages high in added-sugars, and to ensure children accumulate a minimum of 30 min/d of moderate-to-vigorous physical activity (MVPA). Few efficacious and cost-effective strategies exist to assist ASP providers in achieving these important public health goals. This paper reports on the design and conceptual framework of Making Healthy Eating and Physical Activity (HEPA) Policy Practice in ASPs, a 3-year group randomized controlled trial testing the effectiveness of strategies designed to improve snacks served and increase MVPA in children attending community-based ASPs. Twenty ASPs, serving over 1800 children (6-12 years) will be enrolled and match-paired based on enrollment size, average daily min/d MVPA, and days/week FV served, with ASPs randomized after baseline data collection to immediate intervention or a 1-year delayed group. The framework employed, STEPs (Strategies To Enhance Practice), focuses on intentional programming of HEPA in each ASPs' daily schedule, and includes a grocery store partnership to reduce price barriers to purchasing FV, professional development training to promote physical activity to develop core physical activity competencies, as well as ongoing technical support/assistance. Primary outcome measures include children's accelerometry-derived MVPA and time spend sedentary while attending an ASP, direct observation of staff HEPA promoting and inhibiting behaviors, types of snacks served, and child consumption of snacks, as well as, cost of snacks via receipts and detailed accounting of intervention delivery costs to estimate cost-effectiveness.

From policy to practice: strategies to meet physical activity standards in YMCA afterschool programs

BACKGROUND

In 2011, the U.S. Young Men's Christian Association (YMCA) adopted activity standards recommending that afterschool programs (ASPs) ensure all children engage in a minimum of 30 minutes of moderate to vigorous physical activity (MVPA) daily during the ASP. ASPs decide how to accomplish this standard, for which few effective strategies exist.

PURPOSE

To evaluate strategies designed to help ASPs meet the MVPA standard.

DESIGN

Single group intervention with pretest and three follow-up measures repeated-cross-sectional design with a subsample cohort.

SETTING/PARTICIPANTS

Four large-scale YMCA ASPs, serving approximately 500 children each day.

INTERVENTION

Community-based participatory development of strategies focused on modification of program schedules, professional development training, and weekly checklists to evaluate activity opportunities.

MAIN OUTCOME MEASURES

Accelerometry-derived MVPA classified as meet or fail-to-meet the 30 minutes' MVPA/day standard collected over a minimum of 4 nonconsecutive days at baseline (fall 2011) and three follow-up assessments (spring 2012, fall 2012, spring 2013). Random intercept logistic regression models evaluated the probability of meeting the standard for boys and girls, separately (analyzed summer 2013).

RESULTS

A total of 895 children (aged 5-12 years, 48.4% girls) representing 3654 daily measures were collected across the four assessments. The percentage of girls and boys meeting the MVPA standard at baseline was 13.3% and 28.0%, respectively. By spring 2013, this increased to 29.3% and 49.6%. These changes represented an increase in the odds of meeting the 30 minutes' MVPA/day standard by 1.5 (95% CI=1.1, 2.0) and 2.4 (95% CI=1.2, 4.8) for girls and boys, respectively.

CONCLUSIONS

The strategies developed herein represent an effective approach to enhancing current practice within YMCA ASPs to achieve existing MVPA standards. Additional work is necessary to evaluate the scalability of the strategies in a larger sample of ASPs.

Impact of Policy Environment Characteristics on Physical Activity and Sedentary Behaviors of Children Attending Afterschool Programs

State and national organizations recently developed policies focused on increasing physical activity (PA) in afterschool programs (ASPs). These policies emphasize “activity friendly” environment characteristics that, when present, should lead to higher levels of PA and reduce the amount of time children spend sedentary during an ASP. Currently, little is known about the impact of existing PA policies on children’s PA and sedentary behaviors in ASPs. A sample of 18 community-based ASPs serving 1,241 children (5-12 years) were audited for environment features outlined in existing PA policies (i.e., presence of a written policy to promote PA, collecting child feedback, staff training to promote PA and the quality of that training, holding parent workshops, use of PA curricula, evaluating PA, allocating time in the schedule for PA opportunities, and providing activities that appeal to both boys and girls). Children’s PA and sedentary behavior were measured via accelerometry. Unexpectedly, the presence of a written policy, collecting child feedback, and receiving 1 to 4 hours of staff training for PA was associated with an increase in time spent sedentary and a decrease in PA. Conversely, allocating 50% or more time in an ASP schedule for PA and providing activities that appealed to boys and girls was associated with a decrease of time spent sedentary and an increase in PA. The present state of practice in ASPs suggests that policy environment characteristics are largely unrelated to the amount of PA children accumulate while attending ASPs.

The healthy afterschool activity and nutrition documentation instrument

BACKGROUND

Policies call on afterschool programs to improve the physical activity and nutrition habits of youth attending. No tool exists to assess the extent to which the afterschool program environment meets physical activity and nutrition policies.

PURPOSE

To describe the development of the Healthy Afterschool Activity and Nutrition Documentation (HAAND) instrument, which consists of two subscales: Healthy Afterschool Program Index for Physical Activity (HAPI-PA) and the HAPI-Nutrition (HAPI-N).

METHODS

Thirty-nine afterschool programs took part in the HAAND evaluation during fall/spring 2010-2011. Inter-rater reliability data were collected at 20 afterschool programs during a single site visit via direct observation, personal interview, and written document review. Validity of the HAPI-PA was established by comparing HAPI-PA scores to pedometer steps collected in a subsample of 934 children attending 25 of the afterschool programs. Validity of the HAPI-N scores was compared against the mean number of times/week that fruits and vegetables (FV) and whole grains were served in the program.

RESULTS

Data were analyzed in June/July 2011. Inter-rater percent agreement was 85%-100% across all items. Increased pedometer steps were associated with the presence of a written policy related to physical activity, amount/quality of staff training, use of a physical activity curriculum, and offering activities that appeal to both genders. Higher servings of FV and whole grains per week were associated with the presence of a written policy regarding the nutritional quality of snacks.

CONCLUSIONS

The HAAND instrument is a reliable and valid measurement tool that can be used to assess the physical activity and nutritional environment of afterschool programs.