0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Article |

A National Survey of Obesity Prevention Practices in Head Start FREE

Robert C. Whitaker, MD, MPH; Rachel A. Gooze, MPH; Cayce C. Hughes, MPH; Daniel M. Finkelstein, PhD, EdM
[+] Author Affiliations

Author Affiliations: Departments of Public Health (Dr Whitaker, and Ms Gooze and Mr Hughes) and Pediatrics (Dr Whitaker), Center for Obesity Research and Education, Temple University, Philadelphia, Pennsylvania; and Mathematica Policy Research, Inc, Cambridge, Massachusetts (Dr Finkelstein).


Arch Pediatr Adolesc Med. 2009;163(12):1144-1150. doi:10.1001/archpediatrics.2009.209.
Text Size: A A A
Published online

Objective  To describe obesity prevention practices and environments in Head Start, the largest federally funded early childhood education program in the United States.

Design  Self-administered survey as part of the Study of Healthy Activity and Eating Practices and Environments in Head Start (SHAPES).

Setting  Head Start, 2008.

Participants  Directors of all 1810 Head Start programs, excluding those in US territories.

Outcome Measures  Descriptive measures of reported practices and environments related to healthy eating and gross motor activity.

Results  The 1583 (87%) programs responding to the survey enrolled 828 707 preschool children. Of these programs, 70% reported serving only nonfat or 1% fat milk. Ninety-four percent of programs reported that each day they served children some fruit other than 100% fruit juice; 97% reported serving some vegetable other than fried potatoes; and 91% reported both of these daily practices. Sixty-six percent of programs said they celebrated special events with healthy foods or nonfood treats, and 54% did not allow vending machines for staff. Having an on-site outdoor play area at every center was reported by 89% of programs. Seventy-four percent of programs reported that children were given structured (adult-led or -guided) gross motor activity for at least 30 minutes each day; 73% reported that children were given unstructured gross motor activity for at least 30 minutes each day, and 56% reported both of these daily practices.

Conclusion  Most Head Start programs report doing more to support healthy eating and gross motor activity than required by federal performance standards in these areas.

Head Start is the largest federally funded early childhood education program in the United States, serving almost 1 million children from socioeconomically disadvantaged families.1 Head Start uses a holistic approach to children's school readiness that goes beyond the domains of cognitive and socioemotional development to achieve outcomes in physical fitness, healthy nutrition, and gross motor skills.2 Therefore, Head Start has great potential to help address the problem of childhood obesity, which affects between 15% and 25% of the children it serves.36

Head Start programs must abide by federal program performance standards.7 These standards are intentionally broad to allow for the varied contexts in which programs are run. For example, while the standards do not use the term physical activity, they require programs to provide “sufficient time, indoor and outdoor space, equipment, materials and adult guidance for active play and movement that support the development of gross motor skills.”7 Regarding nutrition, the standards require that each child in a full-day program must receive meals and snacks that provide “one half to two-thirds of the child's daily nutritional needs” through foods “high in nutrients and low in fat, sugar and salt.”7 To cover the costs of the meals and snacks offered to children, Head Start programs must use funds from the US Department of Agriculture (USDA) by participating in either the Child and Adult Care Food Program8 or the National School Lunch and Breakfast Programs,9 adhering to the nutritional requirements of these USDA programs.

The Head Start Act of 2007 permits changes in the federal program performance standards including those that support “children's motor development and overall health and nutrition.”10 Meanwhile, efforts to prevent obesity are under way in Head Start.1113 Despite these favorable circumstances for programmatic change to address obesity in Head Start, there are no national data describing what Head Start programs are already doing in this area that might exceed what is required by the existing program performance standards. Therefore, we undertook a study to describe obesity prevention practices and environments in Head Start programs and to identify program characteristics associated with variability in these practices and environments.

OVERVIEW

Between February and April 2008 we administered a survey to all Head Start programs as part of the Study of Healthy Activity and Eating Practices and Environments in Head Start (SHAPES). The average program has approximately 6 centers, each with 50 to 60 children aged 3 and 4 years. The targeted survey respondents were program directors, who were encouraged to obtain assistance with the survey from their program's specialists in health and/or nutrition.

The survey was developed and administered in partnership with the US Department of Health and Human Services and the USDA. Administrative data and contact information for all 1890 programs were obtained from the Office of Head Start's 2007 Program Information Report.14 We excluded 50 programs in US territories, 27 that did not provide direct services to children, and 3 that provided all services outside of centers, leaving a final sample of 1810 programs. The study was approved by the Institutional Review Board of Temple University.

INSTRUMENT DEVELOPMENT AND SURVEY ADMINISTRATION

Some of the SHAPES survey items were adapted from existing instruments1518; others were based on guidelines or policies regarding nutrition and physical activity in childcare or early childhood education settings outside of Head Start.19,20 Drafts of the instrument were reviewed by federal staff and by several nonfederal content experts. The instrument was further refined based on cognitive interviews and pretesting with 7 Head Start program directors, each from different states. The final survey contained 90 items, could be completed in less than 30 minutes, and did not require program staff to conduct menu analysis or record review.

To reduce bias, we assured programs that their individual responses would not be shared with federal agencies, and we introduced the survey with the following statement: “This study is not an assessment of whether your program is meeting certain Head Start program performance standards. We expect that most programs have not adopted many of the practices described in this survey. This is because these practices are not currently an explicit part of Head Start's program performance standards.”

Program directors were mailed a paper survey. After sending reminders by electronic and postal-service mail, we reached nonresponding programs by telephone and allowed them to complete the survey over the telephone. Data from all completed surveys were linked to data on program characteristics contained in the Program Information Report.

ANALYTIC VARIABLES

This article is focused on 30 yes/no items regarding the presence of practices and environments related to healthy eating (15 items) and physical (gross motor) activity (15 items). From these 30 items, we created 2 summary scores. From the 15 items describing practices and environments related to healthy eating, we developed a healthy eating score. Similarly, we developed a gross motor score from the 15 items related to children's gross motor activity. Similar summary scores have been applied previously to descriptions of school food environments.21,22 Using a score addresses the inherent limitation of making multiple comparisons between several program characteristics and each of the 30 items. Each score had a value between 0 and 15 (1 point given for each “yes” response), with a higher score indicating a more favorable environment for obesity prevention. We did not compute scores for the 27 programs that were missing more than 3 items from either score. For the remaining 1556 programs, any missing items were assigned a value of 1 because programs were more likely than not to have any given practice or environment. Only 21 programs had missing data for more than 2 of the 30 items.

From the Program Information Report data, we created 8 categorical variables to describe program characteristics (Table 1) that we hypothesized might be associated with variation in the 2 scores. These variables were selected based on discussions with federal staff and prior research assessing sources of variation in the educational environments of Head Start programs2325 and in the physical activity levels of preschoolers in child care settings.2628 Geographic region and rural-urban location were derived from the program address. Because there were too few programs in some states to make meaningful comparisons between programs at the state level, we grouped programs by 9 geographic regions based on the US Census Bureau geographic divisions.29 We also grouped programs along a rural-urban continuum, linking the county of each program to its USDA rural-urban continuum code.30

Table Graphic Jump LocationTable 1. Characteristics of Head Start Programs
STATISTICAL ANALYSIS

We first described the program characteristics using the 8 variables derived from the Program Information Report. We also described the program context for providing meals and snacks using survey items about (1) the source (provider) of meals, (2) the location where meals were prepared, (3) the amount of perceived control over the food and beverages served, and (4) the percentage of food costs reimbursed by the USDA. We then described the 30 obesity prevention practices and environments in Head Start.

Using 1-way analysis of variance, we compared the mean healthy eating and gross motor scores across the levels of each program characteristic. Using multivariable linear regression models, with the healthy eating and gross motor scores as dependent variables, we derived the mean score at each level of a program characteristic after adjusting for the other program characteristics. We also used these regression models to identify the program characteristics that had a significant independent association with the score.

For program characteristics that were independently associated with a given score, we examined the association between that characteristic and each of the 15 binary variables that comprised the score. The purpose of these analyses was to explore whether some items in the score were more strongly associated with the program characteristic than others.

Surveys were completed by 1583 (87%) programs, with 188 programs completing the survey by telephone. In each stratum of the program characteristics shown in Table 1, the response rate was 81% or higher (data not shown). In 27% of programs, the program director completed the survey without assistance from other staff. Of the remaining programs, for whom this task was shared, the primary respondent was the following person: program director (41%), health and/or nutrition specialist (47%), or education specialist or other staff member (12%). Of the 1583 responding programs, the median number of students in each program was 314 and the median number of Head Start centers was 6. These programs enrolled 828 707 children across 13 607 centers, 89% and 90% of all Head Start children and centers, respectively.

Thirty-one percent of programs reported that the primary source of their meals was the food service program of a school or school district, while 55% hired cooks directly (Table 2). Approximately two-thirds of programs reported that they had “a great deal of control” over the types of foods and beverages served to children. More than 75% of programs reported that the USDA reimbursed them less than 100% “of the total costs for all meals and snacks served.” In those programs in which USDA reimbursement did not cover the full costs, 93% used money from their Head Start program budget to make up for some or all of the remaining costs.

Table Graphic Jump LocationTable 2. Contextual Characteristics of Head Start Programs Related to Serving Meals and Snacks

The prevalence of the 30 practices and environments that comprised the healthy eating and gross motor scores are shown in Table 3 and Table 4, respectively. Ninety-one percent of programs reported serving some fruit each day other than 100% juice and some vegetable other than fried potatoes. Fifty-six percent of programs provided children with at least 30 minutes per day of structured (adult-led or -guided) gross motor activity and at least 60 minutes per day of unstructured gross motor activity. Eighty-nine percent of programs reported that every center had an on-site play area. Of the programs without an on-site outdoor play area at every center, 77% reported that all of their centers had access to an off-site area within walking distance of the center.

Table Graphic Jump LocationTable 3. Fifteen Practices and Environments Related to Healthy Eating in Head Start Programs
Table Graphic Jump LocationTable 4. Fifteen Practices and Environments Related to Gross Motor Activity in Head Start Programs

The mean (SD) healthy eating and gross motor scores were 11.8 (2.0) and 11.2 (2.1), respectively. The healthy eating scores ranged from 4 to 15, and the gross motor scores ranged from 2 to 15. We considered differences between scores of more than 0.5 points (approximately 0.25 SD) to be meaningful. Geographic region was the program characteristic with the strongest independent relationship to both scores (Table 5). Healthy eating scores also had a strong independent association with the type of entity administering the program, indicating that those programs administered by a school system had lower (less healthy) scores. Programs administered by tribal governments had somewhat lower gross motor scores. We found no meaningful independent associations between either of the 2 scores and the characteristics of programs' teachers or students.

Table Graphic Jump LocationTable 5. Healthy Eating and Gross Motor Scores by Head Start Program Characteristicsa

Across the 9 geographic regions, the prevalence of the individual practice or environmental factor differed by 20% or more for 8 of the 15 healthy eating items (eTable 1) and for 7 of the 15 gross motor items (eTable 2). We divided the 9 regions into tertiles (3 groups of 3) based on the adjusted mean healthy eating scores in each region, and we did the same based on the adjusted mean gross motor scores (Table 5). Only 1 region (Pacific) was in the highest tertile for both the healthy eating and gross motor scores, and no regions were in the lowest tertile for both scores.

Because of the association between programs being administered by a school system and the healthy eating score, we examined whether being administered by a school system was related to whether a program obtained its meals from the food service program of a school or school district, and how this, in turn, was related to the program's healthy eating score. Of the programs administered by a school system, 88% used a school food service as the source of their meals, compared with 17% of programs not administered by a school system (P < .001). Programs that used a school food service as their source of meals had significantly lower healthy eating scores than programs that did not use a school food service (10.9 vs 12.2; P < .001). This difference was also observed in programs administered by a school system (10.7 vs 12.0; P < .001) and those not administered by a school system (11.3 vs 12.2; P < .001). Across all programs, those administered by a school system had mean (SD) healthy eating scores that were approximately 1 (0.5) point lower than those not administered by a school system (10.8 vs 12.0; P < .001). However, this difference was reduced to approximately half of a point when controlling for the source of meals (11.4 vs 11.9; P = .002). This finding suggests that the relationship between programs being administered by a school system and having a lower healthy eating score is mediated, in part, by the program's use of a school food service as the source of its meals.31

Programs that used a school food service as the source of their meals differed in several ways from those that did not. For 5 of the 15 practices and environments on the healthy eating score, the prevalence was at least 10% lower in programs that used a school food service (Table 6). In addition, programs that used a school food service were less likely to obtain 100% reimbursement of their food costs from the USDA (18% vs 25%; P = .001), less likely to perceive a “great deal of control” over the food and beverages served (22% vs 88%; P < .001), and less likely to have meals prepared at or adjacent to their Head Start centers (55% vs 70%; P < .001).

Table Graphic Jump LocationTable 6. Practices and Environments Related to Healthy Eating in Head Start by Whether Meals Are Provided by School or School Districta

In this national survey of all Head Start programs, we found that most programs reported practices and environments related to healthy eating and gross motor activity that went beyond the existing federal program performance standards in these areas. For example, while the performance standards have no quantitative guidelines for the amount of children's daily physical activity, more than half of programs reported that they provided at least 30 minutes of daily, structured gross motor activity and at least 60 minutes of unstructured gross motor activity. In the standards for meals served in Head Start, as outlined by the Child and Adult Care Food Program,8 100% fruit juice and fried potatoes are classified as a fruit and a vegetable, respectively, and whole milk can be served. However, most Head Start programs are serving a daily fruit other than 100% fruit juice, a daily vegetable other than fried potatoes, and lowfat milk (skim or 1% fat).

The variation we observed in obesity prevention practices by geographic region was not explained by any of the characteristics of the programs' staff or children. The variation might be due to geographic differences reflected in policies, broader sociocultural norms, or economic conditions. Such place-based factors, ranging from land-use mix32 to regional food preferences33 to income inequality,34 have been associated with variation in the prevalence of obesity. Similar factors may also shape the contexts in which individual Head Start programs are nested,35 making it more or less difficult for Head Start programs in some regions to support obesity prevention efforts.

Our data suggest that programs administered by a school system are very likely to use the food service program of that school system as the source of the meals they serve. Using the school food program, compared with not doing so, appears to be associated with at least 3 disadvantages: a less healthy eating environment, lower perceived control over the foods and beverages served, and a lower proportion of food costs being reimbursed. More needs to be known before making any programmatic recommendation based on these findings. There may be potential advantages that we did not identify associated with using the school food service. More importantly, there may be cost and quality advantages, unrelated to nutrition, for programs that are administered by a school system. It is not clear whether these programs have other options for obtaining their meals outside the school food service, such as by hiring cooks directly.

Despite the high response rate of the survey, which attempted to reach all Head Start programs, this study had several limitations. Programs may have reported practices that were expected in centers and classrooms but which were not always occurring there. We did not attempt to validate program reports of practices or environments with on-site observations or record reviews such as analysis of a program's meal menus or written staff guidelines. In completing the survey, most program directors received assistance from other management staff. However, in large programs with many centers, the respondents may still have lacked knowledge of specific practices related to obesity prevention. In addition, the survey required programs to characterize their average practices across centers. This made it more likely that programs with large between-center variability would misclassify their program practices. The healthy eating and gross motor scores combined variables that described different dimensions within these 2 broad domains (eg, type of milk served combined with teacher access to vending machines and minutes of structured physical activity combined with access to outdoor play areas). It is possible, therefore, that aggregating 30 items on practices and environments into 2 scores obscured some meaningful differences in these 30 individual items by program characteristics.

In the last several years, there has been great interest in the opportunities afforded by schools to prevent obesity,3638 and there have been several comprehensive assessments of eating and physical activity-related practices and environments in US public schools.21,3941 However, there are very few data describing obesity prevention practices and environments in either childcare or early childhood education settings.42,43 This is the first national report on practices and environments related to healthy eating and physical activity in Head Start. This report comes at a time when there is increasing consensus to make greater public investments in early childhood education44,45 and to begin childhood obesity prevention efforts early in life.37,46 As Head Start and other early childhood programs try to take advantage of their unique position to prevent childhood obesity, the results of this survey provide programs with a list of practices and environments that are potential targets for change and with a baseline against which these changes can be assessed.

Correspondence: Robert C. Whitaker, MD, MPH, Temple University, Center for Obesity Research and Education, 3223 N Broad St, Ste 175, Philadelphia, PA 19140 (rwhitaker@temple.edu).

Submitted for Publication: May 11, 2009; final revision received June 14, 2009; accepted June 15, 2009.

Author Contributions: Dr Whitaker had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Whitaker. Acquisition of data: Whitaker. Analysis and interpretation of data: Whitaker, Gooze, Hughes, and Finkelstein. Drafting of the manuscript: Whitaker, Gooze, and Hughes. Critical revision of the manuscript for important intellectual content: Whitaker, Gooze, Hughes, and Finkelstein. Statistical analysis: Whitaker. Obtained funding: Whitaker. Administrative, technical, and material support: Whitaker, Gooze, Hughes, and Finkelstein. Study supervision: Whitaker.

Financial Disclosure: None reported.

Funding/Support: This study was supported by Healthy Eating Research Program grant 63042 and Active Living Research Program grant 64114 from the Robert Wood Johnson Foundation, and it was carried out in partnership with the US Department of Health and Human Services and the US Department of Agriculture.

Disclaimer: The opinions expressed do not reflect those of either the Robert Wood Johnson Foundation or the US Government.

Additional Contributions: We thank the following individuals at Mathematica Policy Research, Inc, for their assistance in survey development and data collection: Linda Mendenko, Alison Guy, Elaine Hill, and Anna Comerford. We thank Sara Benjamin, MD, PhD, Marsha Dowda, DrPH, Kerry McIver, PhD, and Catherine Polanski for their helpful suggestions during survey development, and Prabhu Ponkshe, Amy Requa, MSN, CRNP, James Sallis, PhD, and Mary Story, PhD, for feedback on an earlier draft of this manuscript. The following federal staff provided critical review on drafts of the survey instrument and/or this manuscript: Julie Brewer, MPA, Keith Churchill, John Endhal, PhD, Joanne Guthrie, PhD, MPH, and Jay Hirschman, MPH, CNS, United States Department of Agriculture; Robin Brocato, MHS, Amanda Bryans, Laura Hoard, PhD, and Lauren Supplee, PhD, Department of Health and Human Services. Finally, we would like to thank the National Head Start Association for announcing the Study of Healthy Activity and Eating Practices and Environments in Head Start and the programs for completing the survey.

 About the Office of Head Start. US Department of Health and Human Services, Administration for Children and Families Web site. http://www.acf.hhs.gov/programs/ohs/about/index.html#factsheet. Accessed February 14, 2009
 The Head Start Child Outcomes Framework. US Department of Health and Human Services, Administration for Children and Families Web site. http://eclkc.ohs.acf.hhs.gov/hslc/ecdh/eecd/Assessment/Child%20Outcomes/edudev_art_00090_080905.html. Accessed February 13, 2009
Anderson  SEWhitaker  RC Prevalence of obesity among US preschool children in different racial and ethnic groups. Arch Pediatr Adolesc Med 2009;163 (4) 344- 348
PubMed Link to Article
Feese  MFranklin  FMurdock  M  et al.  Prevalence of obesity in children in Alabama and Texas participating in social programs. JAMA 2003;289 (14) 1780- 1781
PubMed Link to Article
 New York City vital signs: obesity in early childhood. New York City Department of Health and Mental Hygiene, Administration for Children's Services/Head Start Web site. http://www.nyc.gov/html/doh/downloads/pdf/survey/survey-2006childobesity.pdf. Published March 2006. Accessed May 1, 2006
Whitaker  RCOrzol  SM Obesity among US urban preschool children: relationships to race, ethnicity, and socioeconomic status. Arch Pediatr Adolesc Med 2006;160 (6) 578- 584
PubMed Link to Article
 Office of Head Start. Legislation and regulations: Head Start program performance standards (45 CFR part 1304). US Department of Health and Human Services, Administration for Children and Families Web site. http://www.acf.hhs.gov/programs/ohs/legislation/index.html. Accessed February 13, 2009
 Child and Adult Care Food Program: regulations (7 CFR Part 226). US Department of Agriculture, Food and Nutrition Service Web site. http://www.fns.usda.gov/cnd/Care/Regs-Policy/Regulations.htm. Accessed February 13, 2009
 School meals: program regulations (7 CFR Parts 210, 220). US Department of Agriculture, Food and Nutrition Service Web site. http://www.fns.usda.gov/cnd/governance/regulations.htm. Accessed February 13, 2009
 Head Start Act §641a, 42 USC §9801, Pub L No. 110- 1342007;Early Childhood Learning & Knowledge Center Web site. http://eclkc.ohs.acf.hhs.gov/hslc/Program%20Design%20and%20Management/Head%20Start%20Requirements/Head%20Start%20Act. Accessed February 14, 2009
Fitzgibbon  MLStolley  MRSchiffer  LVan Horn  LKaufer Christoffel  KDyer  A Hip-Hop to Health Jr. for Latino preschool children. Obesity (Silver Spring) 2006;14 (9) 1616- 1625
PubMed Link to Article
Fitzgibbon  MLStolley  MRSchiffer  LVan Horn  LKaufer Christoffel  KDyer  A Two-year follow-up results for Hip-Hop to Health Jr: a randomized controlled trial for overweight prevention in preschool minority children. J Pediatr 2005;146 (5) 618- 625
PubMed Link to Article
Finkelstein  DWhitaker  RCHill  EFox  MKMendenko  LBoller  K Results from the “I Am Moving, I Am Learning” stage 1 survey.  Princeton, NJ Mathematica Policy Research Inc2007;http://www.acf.hhs.gov/programs/opre/hs/eval_move_learn/reports/stage1_survey/stage1_survey.pdf. Accessed February 14, 2009
 Office of Head Start Program Information Report. Office of Head Start Web site. http://eclkc.ohs.acf.hhs.gov/PIR. Accessed February 18, 2009
Ammerman  ASWard  DSBenjamin  SE  et al.  An intervention to promote healthy weight: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) theory and design [published online ahead of print June 15, 2007]. Prev Chronic Dis 2007;4 (3) A67
PubMed
Benjamin  SENeelon  BBall  SCBangdiwala  SIAmmerman  ASWard  DS Reliability and validity of a nutrition and physical activity environmental self-assessment for child care. Int J Behav Nutr Phys Act 2007;429
PubMed Link to Article
DeBord  KHestenes  LLMoore  RCCosco  NG McGinnis  JR Preschool Outdoor Environment Measurement Scale-POEMS.  Winston Salem, NC Kaplan Inc2005;
Sigman-Grant  MChristiansen  EBranen  LFletcher  JJohnson  SL About feeding children: mealtimes in child-care centers in four western states. J Am Diet Assoc 2008;108 (2) 340- 346
PubMed Link to Article
New York City Board of Health, Notice of Adoption of Amendments to Article 47 of the New York City Health Code, Daycare Services.  New York, NY New York City Dept of Health and Mental Hygiene2006;
National Association for Sport and Physical Education, Active Start: a Statement of Physical Activity Guidelines for Children Birth to Five Years.  Reston, VA National Association for Sport and Physical Education2002;
Finkelstein  DMHill  ELWhitaker  RC School food environments and policies in US public schools. Pediatrics 2008;122 (1) e251- e259
PubMed Link to Article
Kubik  MYLytle  LAStory  M Schoolwide food practices are associated with body mass index in middle school students. Arch Pediatr Adolesc Med 2005;159 (12) 1111- 1114
PubMed Link to Article
Zill  NResnick  GKim  K  et al.  Head Start Performance Measures Center Family and Child Experiences Survey (FACES 2000) Technical Report.  Washington, DC US Department of Health and Human Services, Administration for Children and Families2006;http://www.acf.hhs.gov/programs/opre/hs/faces/reports/technical_2000_rpt/tech2k_final2.pdf. Accessed February 16, 2009
Zill  NResnick  GKim  K  et al.  Head start FACES 2000: a whole-child perspective on program performance.  Washington, DC US Department of Health and Human Services, Administration for Children and Families2003;http://www.acf.hhs.gov/programs/opre/hs/faces/reports/faces00_4thprogress/faces00_4thprogress.pdf. Accessed February 16, 2009
Love  JMeckstroth  ASprachman  S Measuring the quality of program environments in head start and other early childhood programs: a review and recommendations for future research.  Washington, DC National Center for Education Statistics, US Department of Education1997;http://nces.ed.gov/pubs97/9736.pdf. Accessed February 13, 2009
Bower  JKHales  DPTate  DFRubin  DABenjamin  SEWard  DS The childcare environment and children's physical activity. Am J Prev Med 2008;34 (1) 23- 29
PubMed Link to Article
Dowda  MBrown  WH McIver  KL  et al.  Policies and characteristics of the preschool environment and physical activity of young children. Pediatrics 2009;123 (2) e261- e266
PubMed Link to Article
Dowda  MPate  RRTrost  SGAlmeida  MJSirard  JR Influences of preschool policies and practices on children's physical activity. J Community Health 2004;29 (3) 183- 196
PubMed Link to Article
 Census regions and divisions of the United States. US Census Bureau Web site. http://www.census.gov/geo/www/us_regdiv.pdf. Accessed February 16, 2009
 Measuring rurality: rural-urban continuum codes. US Department of Agriculture, Economic Research Service Web site. http://www.ers.usda.gov/briefing/rurality/RuralUrbCon/. Accessed February 13, 2009
Baron  RMKenny  DA The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 1986;51 (6) 1173- 1182
PubMed Link to Article
Frank  LDAndresen  MASchmid  TL Obesity relationships with community design, physical activity, and time spent in cars. Am J Prev Med 2004;27 (2) 87- 96
PubMed Link to Article
Kumanyika  SK Environmental influences on childhood obesity: ethnic and cultural influences in context. Physiol Behav 2008;94 (1) 61- 70
PubMed Link to Article
Singh  GKKogan  MDvan Dyck  PC A multilevel analysis of state and regional disparities in childhood and adolescent obesity in the United States. J Community Health 2008;33 (2) 90- 102
PubMed Link to Article
Glass  TA McAtee  MJ Behavioral science at the crossroads in public health: extending horizons, envisioning the future. Soc Sci Med 2006;62 (7) 1650- 1671
PubMed Link to Article
Institute of Medicine, Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth.  Washington, DC National Academies Press2007;
Institute of Medicine, Preventing Childhood Obesity: Health in the Balance.  Washington, DC The National Academies Press2005;
American Academy of Pediatrics Committee on School Health, Soft drinks in schools. Pediatrics 2004;113 (1 pt 1) 152- 154
PubMed Link to Article
Gordon  AFox  MK School nutrition dietary assessment study III: summary of findings.  Alexandria, VA US Department of Agriculture, Food and Nutrition Service, Office of Research, Nutrition, and Analysis2007;http://www.fns.usda.gov/ora/MENU/Published/CNP/FILES/SNDAIII-SummaryofFindings.pdf. Accessed February 16, 2009
O'Toole  TPAnderson  SMiller  CGuthrie  J Nutrition services and foods and beverages available at school: results from the School Health Policies and Programs Study 2006. J Sch Health 2007;77 (8) 500- 521
PubMed Link to Article
Lee  SMBurgeson  CRFulton  JESpain  CG Physical education and physical activity: results from the School Health Policies and Programs Study 2006. J Sch Health 2007;77 (8) 435- 463
PubMed Link to Article
Benjamin  SECradock  AWalker  EMSlining  MGillman  MW Obesity prevention in child care: a review of US state regulations. BMC Public Health 2008;8188
PubMed Link to Article
Benjamin  SECopeland  KACradock  A  et al.  Menus in child care: a comparison of state regulations with national standards. J Am Diet Assoc 2009;109 (1) 109- 115
PubMed Link to Article
Heckman  JJ Schools, skills, and synapses: working paper 14064.  Cambridge, MA National Bureau of Economic Research2008;http://www.nber.org/papers/w14064.pdf. Accessed February 16, 2009
Perzel  JMUniversities Children's Policy Collaborative, Legislative Office for Research Liaison, Early childhood education: universal pre-K and other alternatives. http://ecti.hbg.psu.edu/docs/publication/EDinPA_Spring%202006_0213_06.pdf#page=21. Published Spring 2006. Accessed March 2, 2009
Barlow  SEExpert Committee, Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120 ((suppl 4)) S164- S192
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Characteristics of Head Start Programs
Table Graphic Jump LocationTable 2. Contextual Characteristics of Head Start Programs Related to Serving Meals and Snacks
Table Graphic Jump LocationTable 3. Fifteen Practices and Environments Related to Healthy Eating in Head Start Programs
Table Graphic Jump LocationTable 4. Fifteen Practices and Environments Related to Gross Motor Activity in Head Start Programs
Table Graphic Jump LocationTable 5. Healthy Eating and Gross Motor Scores by Head Start Program Characteristicsa
Table Graphic Jump LocationTable 6. Practices and Environments Related to Healthy Eating in Head Start by Whether Meals Are Provided by School or School Districta

References

 About the Office of Head Start. US Department of Health and Human Services, Administration for Children and Families Web site. http://www.acf.hhs.gov/programs/ohs/about/index.html#factsheet. Accessed February 14, 2009
 The Head Start Child Outcomes Framework. US Department of Health and Human Services, Administration for Children and Families Web site. http://eclkc.ohs.acf.hhs.gov/hslc/ecdh/eecd/Assessment/Child%20Outcomes/edudev_art_00090_080905.html. Accessed February 13, 2009
Anderson  SEWhitaker  RC Prevalence of obesity among US preschool children in different racial and ethnic groups. Arch Pediatr Adolesc Med 2009;163 (4) 344- 348
PubMed Link to Article
Feese  MFranklin  FMurdock  M  et al.  Prevalence of obesity in children in Alabama and Texas participating in social programs. JAMA 2003;289 (14) 1780- 1781
PubMed Link to Article
 New York City vital signs: obesity in early childhood. New York City Department of Health and Mental Hygiene, Administration for Children's Services/Head Start Web site. http://www.nyc.gov/html/doh/downloads/pdf/survey/survey-2006childobesity.pdf. Published March 2006. Accessed May 1, 2006
Whitaker  RCOrzol  SM Obesity among US urban preschool children: relationships to race, ethnicity, and socioeconomic status. Arch Pediatr Adolesc Med 2006;160 (6) 578- 584
PubMed Link to Article
 Office of Head Start. Legislation and regulations: Head Start program performance standards (45 CFR part 1304). US Department of Health and Human Services, Administration for Children and Families Web site. http://www.acf.hhs.gov/programs/ohs/legislation/index.html. Accessed February 13, 2009
 Child and Adult Care Food Program: regulations (7 CFR Part 226). US Department of Agriculture, Food and Nutrition Service Web site. http://www.fns.usda.gov/cnd/Care/Regs-Policy/Regulations.htm. Accessed February 13, 2009
 School meals: program regulations (7 CFR Parts 210, 220). US Department of Agriculture, Food and Nutrition Service Web site. http://www.fns.usda.gov/cnd/governance/regulations.htm. Accessed February 13, 2009
 Head Start Act §641a, 42 USC §9801, Pub L No. 110- 1342007;Early Childhood Learning & Knowledge Center Web site. http://eclkc.ohs.acf.hhs.gov/hslc/Program%20Design%20and%20Management/Head%20Start%20Requirements/Head%20Start%20Act. Accessed February 14, 2009
Fitzgibbon  MLStolley  MRSchiffer  LVan Horn  LKaufer Christoffel  KDyer  A Hip-Hop to Health Jr. for Latino preschool children. Obesity (Silver Spring) 2006;14 (9) 1616- 1625
PubMed Link to Article
Fitzgibbon  MLStolley  MRSchiffer  LVan Horn  LKaufer Christoffel  KDyer  A Two-year follow-up results for Hip-Hop to Health Jr: a randomized controlled trial for overweight prevention in preschool minority children. J Pediatr 2005;146 (5) 618- 625
PubMed Link to Article
Finkelstein  DWhitaker  RCHill  EFox  MKMendenko  LBoller  K Results from the “I Am Moving, I Am Learning” stage 1 survey.  Princeton, NJ Mathematica Policy Research Inc2007;http://www.acf.hhs.gov/programs/opre/hs/eval_move_learn/reports/stage1_survey/stage1_survey.pdf. Accessed February 14, 2009
 Office of Head Start Program Information Report. Office of Head Start Web site. http://eclkc.ohs.acf.hhs.gov/PIR. Accessed February 18, 2009
Ammerman  ASWard  DSBenjamin  SE  et al.  An intervention to promote healthy weight: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) theory and design [published online ahead of print June 15, 2007]. Prev Chronic Dis 2007;4 (3) A67
PubMed
Benjamin  SENeelon  BBall  SCBangdiwala  SIAmmerman  ASWard  DS Reliability and validity of a nutrition and physical activity environmental self-assessment for child care. Int J Behav Nutr Phys Act 2007;429
PubMed Link to Article
DeBord  KHestenes  LLMoore  RCCosco  NG McGinnis  JR Preschool Outdoor Environment Measurement Scale-POEMS.  Winston Salem, NC Kaplan Inc2005;
Sigman-Grant  MChristiansen  EBranen  LFletcher  JJohnson  SL About feeding children: mealtimes in child-care centers in four western states. J Am Diet Assoc 2008;108 (2) 340- 346
PubMed Link to Article
New York City Board of Health, Notice of Adoption of Amendments to Article 47 of the New York City Health Code, Daycare Services.  New York, NY New York City Dept of Health and Mental Hygiene2006;
National Association for Sport and Physical Education, Active Start: a Statement of Physical Activity Guidelines for Children Birth to Five Years.  Reston, VA National Association for Sport and Physical Education2002;
Finkelstein  DMHill  ELWhitaker  RC School food environments and policies in US public schools. Pediatrics 2008;122 (1) e251- e259
PubMed Link to Article
Kubik  MYLytle  LAStory  M Schoolwide food practices are associated with body mass index in middle school students. Arch Pediatr Adolesc Med 2005;159 (12) 1111- 1114
PubMed Link to Article
Zill  NResnick  GKim  K  et al.  Head Start Performance Measures Center Family and Child Experiences Survey (FACES 2000) Technical Report.  Washington, DC US Department of Health and Human Services, Administration for Children and Families2006;http://www.acf.hhs.gov/programs/opre/hs/faces/reports/technical_2000_rpt/tech2k_final2.pdf. Accessed February 16, 2009
Zill  NResnick  GKim  K  et al.  Head start FACES 2000: a whole-child perspective on program performance.  Washington, DC US Department of Health and Human Services, Administration for Children and Families2003;http://www.acf.hhs.gov/programs/opre/hs/faces/reports/faces00_4thprogress/faces00_4thprogress.pdf. Accessed February 16, 2009
Love  JMeckstroth  ASprachman  S Measuring the quality of program environments in head start and other early childhood programs: a review and recommendations for future research.  Washington, DC National Center for Education Statistics, US Department of Education1997;http://nces.ed.gov/pubs97/9736.pdf. Accessed February 13, 2009
Bower  JKHales  DPTate  DFRubin  DABenjamin  SEWard  DS The childcare environment and children's physical activity. Am J Prev Med 2008;34 (1) 23- 29
PubMed Link to Article
Dowda  MBrown  WH McIver  KL  et al.  Policies and characteristics of the preschool environment and physical activity of young children. Pediatrics 2009;123 (2) e261- e266
PubMed Link to Article
Dowda  MPate  RRTrost  SGAlmeida  MJSirard  JR Influences of preschool policies and practices on children's physical activity. J Community Health 2004;29 (3) 183- 196
PubMed Link to Article
 Census regions and divisions of the United States. US Census Bureau Web site. http://www.census.gov/geo/www/us_regdiv.pdf. Accessed February 16, 2009
 Measuring rurality: rural-urban continuum codes. US Department of Agriculture, Economic Research Service Web site. http://www.ers.usda.gov/briefing/rurality/RuralUrbCon/. Accessed February 13, 2009
Baron  RMKenny  DA The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 1986;51 (6) 1173- 1182
PubMed Link to Article
Frank  LDAndresen  MASchmid  TL Obesity relationships with community design, physical activity, and time spent in cars. Am J Prev Med 2004;27 (2) 87- 96
PubMed Link to Article
Kumanyika  SK Environmental influences on childhood obesity: ethnic and cultural influences in context. Physiol Behav 2008;94 (1) 61- 70
PubMed Link to Article
Singh  GKKogan  MDvan Dyck  PC A multilevel analysis of state and regional disparities in childhood and adolescent obesity in the United States. J Community Health 2008;33 (2) 90- 102
PubMed Link to Article
Glass  TA McAtee  MJ Behavioral science at the crossroads in public health: extending horizons, envisioning the future. Soc Sci Med 2006;62 (7) 1650- 1671
PubMed Link to Article
Institute of Medicine, Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth.  Washington, DC National Academies Press2007;
Institute of Medicine, Preventing Childhood Obesity: Health in the Balance.  Washington, DC The National Academies Press2005;
American Academy of Pediatrics Committee on School Health, Soft drinks in schools. Pediatrics 2004;113 (1 pt 1) 152- 154
PubMed Link to Article
Gordon  AFox  MK School nutrition dietary assessment study III: summary of findings.  Alexandria, VA US Department of Agriculture, Food and Nutrition Service, Office of Research, Nutrition, and Analysis2007;http://www.fns.usda.gov/ora/MENU/Published/CNP/FILES/SNDAIII-SummaryofFindings.pdf. Accessed February 16, 2009
O'Toole  TPAnderson  SMiller  CGuthrie  J Nutrition services and foods and beverages available at school: results from the School Health Policies and Programs Study 2006. J Sch Health 2007;77 (8) 500- 521
PubMed Link to Article
Lee  SMBurgeson  CRFulton  JESpain  CG Physical education and physical activity: results from the School Health Policies and Programs Study 2006. J Sch Health 2007;77 (8) 435- 463
PubMed Link to Article
Benjamin  SECradock  AWalker  EMSlining  MGillman  MW Obesity prevention in child care: a review of US state regulations. BMC Public Health 2008;8188
PubMed Link to Article
Benjamin  SECopeland  KACradock  A  et al.  Menus in child care: a comparison of state regulations with national standards. J Am Diet Assoc 2009;109 (1) 109- 115
PubMed Link to Article
Heckman  JJ Schools, skills, and synapses: working paper 14064.  Cambridge, MA National Bureau of Economic Research2008;http://www.nber.org/papers/w14064.pdf. Accessed February 16, 2009
Perzel  JMUniversities Children's Policy Collaborative, Legislative Office for Research Liaison, Early childhood education: universal pre-K and other alternatives. http://ecti.hbg.psu.edu/docs/publication/EDinPA_Spring%202006_0213_06.pdf#page=21. Published Spring 2006. Accessed March 2, 2009
Barlow  SEExpert Committee, Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120 ((suppl 4)) S164- S192
PubMed Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

A National Survey of Obesity Prevention Practices in Head Start
Arch Pediatr Adolesc Med.2009;163(12):1144-1150.eTables

eTables -Download PDF (38 MB). This file requires Adobe Reader®.
Supplemental Content

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 28

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles