Like Peas and Carrots: Combining Wellness Policy Implementation With Classroom Education for Obesity Prevention in the Childcare Setting

Abstract

Objectives:

We evaluated an intervention combining policy training and technical assistance for childcare teachers with a nutrition education curriculum to improve (1) the knowledge and self-efficacy of childcare teachers in implementing obesity prevention policies and practices, (2) the quantity and quality of nutrition and physical activity education, and (3) the childcare wellness environment.

Methods:

Thirteen teachers and 8 administrators (2 of whom were also teachers) from 8 childcare programs in Clarke County, Georgia, participated in the Healthy Child Care Georgia intervention during June-October 2015. The intervention included (1) training and technical assistance on obesity prevention policies, systems, and practices and (2) direct education by teachers using the Eat Healthy, Be Active curriculum. We assessed changes in program wellness policy adoption and teacher knowledge and self-efficacy from pre- to post-intervention through self-report questionnaires, interviews, and focus groups.

Results:

Teachers’ knowledge scores (maximum score = 100) rose significantly from a mean (SD) pre-intervention of 67.1 (14.6) to post-intervention of 83.2 (14.3) (P < .001). The mean score for “teaching nutrition and activity to children” (maximum score = 105) rose significantly from 86.9 (8.2) to 93.5 (5.2) (P = .011) and for “modeling and supporting children” (maximum score = 63) from 55.8 (5.1) to 59.5 (4.5) (P = .015). The mean (SD) scores for breastfeeding and infant feeding policy/practice adoption (maximum score = 6) increased significantly from 2.5 (1.8) to 3.7 (1.9) (P = .043) and for nutrition education policy/practice adoption (maximum score = 4) from 2.0 (1.3) to 3.3 (1.4) (P = .019). The combined approach enhanced classroom nutrition education and improved the adoption of best practices.

Conclusion:

Future studies should examine the effects of using a combined approach to promote nutrition and physical activity policies and practices in the early care and education setting.

Keywords

childhood obesity prevention childcare policy and education

A 2012 study on childhood obesity estimated that 20% of children in the United States were overweight or obese before kindergarten.¹ Low-income preschool-aged children² had higher rates of obesity and food insecurity and less access to healthy foods than children from higher-income families.³ To reduce childhood obesity, it is important to establish healthy habits early in life, when eating and physical activity habits are developing.⁴ Childcare is therefore an invaluable setting for early obesity prevention.⁵ The purpose of this pilot study was to assess the feasibility of a multilevel intervention for obesity prevention in the childcare setting in Georgia.

National organizations recommend policies for early childhood obesity prevention,⁶ and national obesity prevention standards have been developed for childcare programs.^7,8 To implement and sustain these policies, the Centers for Disease Control and Prevention recommends policy, systems, and environmental approaches⁶ that involve changing (1) the rules governing an organization, (2) the systems that are part of the organization, and (3) the physical environment of an organization. The results of these approaches for obesity prevention in childcare settings are promising.^9

–12

Although 13% of Georgia’s low-income children aged 2 to 4 were obese between 2008 and 2011,¹³ few studies have employed policy, systems, and environmental strategies to improve nutrition and physical activity in childcare in Georgia. One such study conducted in southwest Georgia found that a wellness policy initiative improved the environment at childcare centers.¹⁴ However, most studies that report the use of policy, systems, and environmental approaches in childcare do not include direct education for obesity prevention.

To increase adoption of recommended nutrition policies and practices in childcare settings, several states include nutrition standards in their comprehensive quality rating and improvement systems. Georgia’s Quality Rated program, administered by the Georgia Department of Early Care and Learning (DECAL), includes a Child Health, Nutrition, and Physical Activity domain to promote nutrition and physical activity policies and practices in participating childcare programs.¹⁵

Georgia Governor Nathan Deal’s childhood obesity initiative, Georgia Shape (www.georgiashape.org), supports nutrition and physical activity policies in childcare. The Shape partnership includes Georgia DECAL, the Georgia Department of Education, the Georgia Department of Public Health, and other public and private partners. Childcare programs in the Quality Rated program with a score of ≥85% on a measure of child health, nutrition, and physical activity are recognized as Shape awardees. Programs that earn the Shape Award can market this recognition to parents.

To build on these efforts, a team of University of Georgia nutrition and child development experts developed Healthy Child Care Georgia as a component of the University of Georgia Supplemental Nutrition Assistance Program—Education initiative, which is funded by the US Department of Agriculture to help low-income Georgians establish healthy eating habits and a physically active lifestyle. Healthy Child Care Georgia is a pilot study designed to prevent obesity among children in childcare programs by assessing the feasibility of a multilevel intervention combining policy, systems, and environmental approaches with direct education approaches to improve (1) the knowledge and self-efficacy of childcare teachers in implementing obesity prevention policies and practices, (2) the quantity and quality of nutrition and physical activity education, and (3) the childcare wellness environment. To our knowledge, this study is the first in Georgia to combine policy, systems, and environmental approaches with direct nutrition education to improve the wellness environment in childcare.

The design of the Healthy Child Care Georgia intervention is grounded in Bandura’s social cognitive theory. This theory explains how a person develops behavior patterns based on reciprocal determinism, a direct interplay among the person, the person’s behavior, and the environment.¹⁶ In the context of the childcare setting, reciprocal determinism relates to how the teachers’ behavior may be influenced by individual teacher characteristics (eg, knowledge, teaching skills) and the childcare environment.

In the Healthy Child Care Georgia intervention, children learned about nutrition and physical activity through another concept of social cognitive theory called observational modeling.¹⁶ For example, children can model healthy behavior when teachers demonstrate healthy nutrition and physical activity practices (eg, drinking water throughout the day), as well as when they are taught concepts about nutrition and physical activity (eg, making applesauce and dancing) through curriculum activities.

In addition to influencing behavior, the intervention aimed to improve teachers’ knowledge and self-efficacy, a core construct of social cognitive theory. Self-efficacy is a person’s belief in his or her ability to accomplish a goal.¹⁶ The intervention aimed to enhance teachers’ self-efficacy by teaching them skills to incorporate healthy lifestyle choices into daily classroom activities.

Methods

Study Design

The pilot study used a mixed-methods design, including pre- and post-intervention measures, to examine the effects of the intervention. Qualitative interviews and focus groups were used to explore barriers and facilitators to program implementation. The University of Georgia Institutional Review Board approved the study prior to data collection.

Sample

We invited 25 childcare programs for children aged 3-5 in Clarke County, Georgia, to participate in the study. Each program met ≥1 of the following criteria for serving children from low-income families: (1) it was enrolled in the federal Child and Adult Care Food Program¹⁷ or (2) ≥25% of its childcare slots were reserved for families receiving Temporary Assistance to Needy Families childcare subsidies.¹⁸ We chose Clarke County for this study because 38% of the population lives below the federal poverty level; 32% of residents are black or of Hispanic ethnicity; and poverty, food insecurity, and childhood obesity are prevalent.¹⁹

Twelve childcare programs agreed to participate in the study, 8 of which completed all phases of the study: 6 childcare centers and 2 family childcare providers (licensed to provide care for ≤6 children in their home). Thirteen teachers completed the pretests and posttests. The teachers had a mean of 7.1 (standard deviation [SD] = 7.9) years of childcare experience and a range of educational backgrounds: 6 had a high school diploma, 2 had an associate degree, 2 had a bachelor’s degree, 1 had a graduate degree, and 2 did not specify education level.

Intervention

The intervention took place during June-October 2015 and had 2 components: (1) teacher training and technical assistance focused on policy, systems, and environmental approaches to identify and improve adoption of at least 1 nutrition-related and 1 activity-related obesity prevention policy or practice and (2) direct education, through teachers implementing the Eat Healthy, Be Active 6-week curriculum,²⁰ with children aged 3-5.

Teacher training for policy, systems, and environmental approaches

Teachers attended 2 free 4-hour training sessions hosted by the Healthy Child Care Georgia research team. The first training session, held before teachers began implementing the 6-week Eat Healthy, Be Active curriculum, had 3 main goals: (1) expose teachers to obesity prevention policies and practices, (2) help teachers create action plans to improve nutrition and physical activity practices, and (3) familiarize teachers with the Eat Healthy, Be Active activities for the first 3 weeks of the 6-week curriculum. Teachers completed an action plan for each selected nutrition and physical activity practice, specifying completion dates and people responsible. Healthy Child Care Georgia project staff members reviewed copies of the action plans to assist teachers in goal setting and to provide resources to meet goals. Teachers also received a resource kit with nutrition and physical activity policy and practice handouts to help teachers meet and sustain identified wellness policies.

During the intervention, a graduate student in the Health Promotion and Behavior Program at the University of Georgia provided technical assistance to teachers through visits, telephone calls, and emails. To help teachers and families reinforce health messages and help providers move toward adopting selected practices, the Healthy Child Care Georgia research team also provided teachers with educational newsletters, recipes, take-home activities for families, and resources from Let’s Move! Child Care, a federal initiative that promotes obesity prevention best practices.²¹

The second training session, held after teachers completed the third week of the Eat Healthy, Be Active curriculum, was an opportunity to refine teachers’ action plans and familiarize teachers with the activities for the last 3 weeks of the curriculum. Both training sessions included discussion, hands-on practice with curriculum activities, individual and group problem solving, and opportunities for teachers to share their experiences. Researchers reviewed action plans with individual teachers and noted the dates that steps were completed. Teachers received continuing education credits to meet their annual licensing requirements and received nutrition education extenders (eg, puppets, water pitchers) as incentives for participation.

Direct education: Eat Healthy, Be Active curriculum

For 6 weeks, teachers incorporated the Eat Healthy, Be Active curriculum into their classroom curriculum, using teaching materials supplied by the researchers. Each week, teachers completed 4 hands-on developmentally appropriate activities (eg, making applesauce) with children and read a children’s book related to nutrition and physical activity (Table 1). Activities were organized around 5 key concepts that young children can understand about nutrition and physical activity: eating a variety of foods, being physically active, eating breakfast, stopping eating when full, and drinking water.

Table 1.

Eat Healthy, Be Active curriculum taught to children aged 3-5 in 8 childcare programs during a 6-week Healthy Child Care Georgia classroom intervention, Clarke County, Georgia, June-October 2015^a

Week	Key Concept Taught	Activities Included in Classroom Curriculum^b
1	Eat a variety of foods.	Healthy Bear^c says, “Choose MyPlate” (large group) Awesome Applesauce (science) Fishing for Healthy Food (math) Growing Bodies Song (music) Fruit and Vegetable Tasting (math) Eating the Alphabet: Fruits and Vegetables From A to Z by Lois Ehlert (children’s literature)
2	Be physically active.	Healthy Bear says, “Get Up and Go” (large group) Body Shapes (math) Bubble Wrap Dance (outdoor activity) My Healthy Body Song (music) Fruit and Vegetable Tasting (math) Get Up and Go by Nancy Carlson (children’s literature)
3	Eat breakfast.	Healthy Bear says, “Eat Breakfast” (large group) Breakfast Foods Lotto (math) Oatmeal Makes a Tasty Breakfast (science) Eat Your Breakfast Song (music) Fruit and Vegetable Tasting (math) If You Give a Pig a Pancake by Laura Numeroff (children’s literature)
4	Stop eating when you’re full.	Healthy Bear says, “Stop When You’re Full” (large group) Full or Empty? (math) Stop or Go (outdoor activity) If You’re Full and You Know It (music) Fruit and Vegetable Tasting (math) The Very Hungry Caterpillar by Eric Carle (children’s literature)
5	Eat a variety of foods.	Healthy Bear’s Healthy Lunch (large group) Food Groups Bingo (math) MyPlate Spin and Stretch (outdoor activity) Growing Bodies Song (music) Fruit and Vegetable Tasting (math) Go, Go, Grapes: A Fruit Chant by April Pulley Sayre (children’s literature)
6	Drink water.	Healthy Bear says, “Drink Water” (large group) Water With a Slice (science) Ice Cube Painting (art) Drink Your Water Song (music) Fruit and Vegetable Tasting (math) A Cool Drink of Water by Barbara Kerley (children’s literature)

^aAll activities are taken from Eat Healthy, Be Active,²⁰ a curriculum for children aged 3-5 in childcare. Activities are developmentally appropriate for young children and organized around 5 key concepts that young children can understand about nutrition and physical activity.

^bCopies of these and other Eat Healthy, Be Active activities are available at http://eathealthybeactive.net.

^cHealthy Bear is a bear puppet provided to classroom teachers by researchers to promote curriculum concepts to children.

To increase familiarity with healthy foods, children also had the opportunity to sample fruits and vegetables each week. Healthy Child Care Georgia staff members visited each program weekly to help with implementation, conduct classroom observations detailed by written summaries, and provide technical assistance as needed.

Study Measures

We used a variety of measures and methods to assess changes in program practices related to nutrition and physical activity. We collected data from program administrators and teachers at baseline and at the end of the intervention.

To measure adoption of recommended nutrition and physical activity policies and practices, we asked the administrator of each participating childcare program to complete a paper version of the Georgia Quality Rated Nutrition and Physical Activity Assessment,¹⁵ developed by Georgia DECAL, pre- and post-intervention. The assessment used a 3-level self-report scale (0 = least desirable practices, 1 = intermediate steps toward best practice, and 2 = full adoption of best practices) to measure a childcare program’s progress toward national nutrition and physical activity policies and practices for the childcare setting.⁸ The assessment evaluated 23 nutrition policies and practices across 9 nutrition domains (breastfeeding and infant feeding, eating environment, caregiver nutrition behaviors, nutrition education, foods to increase, foods to limit, beverages, caregiver and parent nutrition training, and nutrition policies) and 18 physical activity policies and practices across 7 domains (scheduled physical activity, caregiver physical activity behaviors, physical activity education, sedentary activity, screen time, caregiver and parent physical activity training, and physical activity policies).

To assess teachers’ knowledge and self-efficacy about obesity prevention policies and practices, we asked teachers to complete a paper version of the Confidence About Activity and Nutrition questionnaire, a previously validated measure²² that includes an 11-item multiple-choice survey of knowledge and a 48-item questionnaire with responses based on a 7-point Likert-type scale measuring teacher confidence (where 1 = not confident and 7 = highly confident) in 4 subscales: (1) implementing nutrition and physical activity policies, (2) teaching nutrition and physical activity to children, (3) modeling and supporting children’s healthy eating and activity, and (4) educating and involving parents in nutrition and physical activity. We conducted teacher focus groups and in-depth director interviews at the conclusion of the project, using questions about classroom successes and challenges to collect qualitative information about implementation of the intervention and to inform program improvement. For process evaluation, we also collected written summaries of weekly classroom observations from Healthy Child Care Georgia staff members.

Data Analysis

We conducted paired-sample t tests to compare program and teacher measures before and after the intervention, with P < .05 considered significant. We analyzed all quantitative data using SAS version 9.4.²³ We calculated the mean and SD of self-reported level of policy/practice adoption in the 9 nutrition domains and 7 physical activity domains for all 8 participating childcare programs. The mean score of policy/practice adoption was calculated by adding the maximum score of policies/practices adopted in each domain by each childcare program and dividing by the total number of childcare programs that reported having the policy. We used paired t tests to compare mean scores for self-reported policy/practice adoption for each domain pre- and post-intervention. We used thematic analysis to interpret the qualitative data to provide context and explanation for the quantitative findings.

Results

Policies and Practices

At the end of the intervention, childcare administrators reported that they had fully or partially adopted many wellness policies and best practices. All 8 childcare programs had fully adopted 6 policies or practices, and 6 programs had fully adopted 17 of a possible 41 additional policies or practices (Table 2).

Table 2.

Change in self-reported nutrition and physical activity policy and best practice^a adoption among 8 childcare programs participating in a 6-week Healthy Child Care Georgia policy training and technical assistance intervention, Clarke County, Georgia, June-October 2015

Nutrition and Physical Activity Policy and Practice Domains	Total No. of Nutrition Policies/Practices in Each Domain (Maximum Possible Score)^a	Pre-Intervention		Post-Intervention		P Value^c
Nutrition and Physical Activity Policy and Practice Domains		No. of Childcare Programs Reporting Having the Policy (n = 8)	Mean Score^b (SD)	No. of Childcare Programs Reporting Having the Policy (n = 8)	Mean Score^b (SD)	P Value^c
Nutrition policies and practices
Breastfeeding and infant feeding	3 (6)	6	2.5 (1.8)	7	3.7 (1.9)	.043
Eating environment	2 (4)	8	3.0 (1.1)	8	3.4 (1.1)	.197
Caregiver behaviors	3 (6)	8	5.3 (0.7)	8	5.3 (0.9)	>.99
Nutrition education	2 (4)	8	2.0 (1.3)	8	3.3 (1.4)	.019
Foods to increase	2 (4)	8	3.3 (0.9)	8	3.4 (1.2)	.785
Foods to limit	3 (6)	7	4.4 (2.2)	8	5.0 (1.3)	.386
Beverages	4 (8)	7	6.7 (1.6)	7	7.3 (1.0)	.103
Caregiver and parent nutrition training	1 (2)	8	1.1 (1.0)	8	1.6 (0.7)	.228
Nutrition policies	3 (6)	8	4.1 (2.3)	8	4.4 (1.8)	.798
Physical activity policies and practices
Scheduled physical activity	3 (6)	8	5.0 (0.9)	8	5.4 (0.7)	.080
Caregiver behaviors	3 (6)	8	5.5 (0.5)	8	5.5 (0.8)	>.99
Physical activity education	2 (4)	8	2.8 (0.9)	8	3.4 (0.9)	.095
Sedentary activity	2 (4)	7	3.7 (0.8)	8	3.9 (0.4)	.356
Screen time	2 (4)	7	3.6 (0.8)	8	3.8 (0.5)	.689
Caregiver and parent physical activity	4 (8)	7	3.4 (2.9)	8	4.3 (2.3)	.411
Physical activity policies	2 (4)	7	2.0 (2.0)	8	2.9 (1.5)	.093

^aBased on the Georgia Quality Rated Nutrition and Physical Activity Assessment, which uses a 3-level self-report scale to measure progress toward 23 national recommendations for nutrition and physical activity in the childcare setting (0 = no adoption, 1 = partial adoption, 2 = full adoption). For each domain, the maximum possible score is the number of policies multiplied by 2, which is the maximum score for each policy. For a comprehensive list of obesity prevention best practices for use in childcare, on which the assessment is based, see http://cfoc.nrckids.org/WebFiles/PreventingChildhoodObesity2nd.pdf.

^bThe mean score of policy/practice adoption was calculated by adding the maximum score of policies/practices adopted in each domain by each childcare program and dividing by total number of childcare programs that reported having the policy.

^cPaired t tests were used to compare mean scores for self-reported policy/practice adoption in each domain pre- and post-intervention. Significant at P < .05.

Self-reported policy/practice adoption increased significantly for 2 domains: (1) breastfeeding and infant feeding and (2) nutrition education. Mean (SD) scores for breastfeeding and infant feeding policy/practice adoption (maximum score = 6) rose significantly from 2.5 (1.8) pre-intervention to 3.7 (1.9) post-intervention (P = .043). In addition, mean (SD) scores for nutrition education policy/practice adoption (maximum score = 4) increased significantly from 2.0 (1.3) pre-intervention to 3.3 (1.4) post-intervention (P = .019). Mean scores for policy/practice adoption increased for all but 2 domains (caregiver nutrition behaviors and caregiver physical activity behaviors), which were unchanged from pre-intervention to post-intervention (Table 2).

Teacher Knowledge and Self-Efficacy in Implementing Best Practices

Teachers’ mean (SD) knowledge scores (maximum score = 100) rose significantly from 67.1 (14.6) pre-intervention to 83.2 (14.3) post-intervention (P < .001). Teachers’ confidence also increased across all 4 subscales. Mean (SD) scores for “teaching nutrition and activity to children” (maximum score = 105) increased from 86.9 (8.2) pre-intervention to 93.5 (5.2) post-intervention, and for “modeling and supporting children” (maximum score = 63) from 55.8 (5.1) pre-intervention to 59.5 (4.5) post-intervention (P = .015).

Key Successes

Teachers reported that receiving materials needed to implement activities with the children made the direct education component easy to complete. Teachers incorporated the activities into their weekly lesson plans, which simplified lesson planning. Teachers reported continuing to use classroom materials after the intervention to create new activities for teaching nutrition and physical activity. For example, teachers received a large vinyl MyPlate (ie, US Department of Agriculture illustration of the 5 food groups on a plate image) floor mat to sort food models into the 5 food groups. Several teachers created new games and activities using the floor mat, such as a beanbag toss. Programs also reported implementing new wellness practices (eg, creating a private breastfeeding room from an unused office, changing the schedule so children were not sitting for >15 minutes, planting a garden with children, introducing new fruits and vegetables). Families also reported to teachers that they had made changes at home (eg, replacing juice with milk or water, drinking water themselves to be role models).

Reported Barriers

Qualitative data revealed several barriers to implementing wellness best practices. First, participants indicated a lack of buy-in from directors, teachers, and parents, especially for center-wide changes (eg, resistance to implementing a celebration policy that limits unhealthy foods), which limited policy adoption of some policies. Second, participants indicated a lack of space to implement some changes (eg, space too small to create a private breastfeeding area). Third, participants noted health and safety concerns (eg, not providing water bottles because of concerns about spreading germs). Fourth, competing expectations made adopting wellness policies challenging (eg, programs trying to become Quality Rated must meet many standards across 5 key areas, which may have prevented programs from prioritizing nutrition and physical activity above other improvements). Finally, the perceived cost of improvements (eg, reluctance to change menus because of perception that healthier recipes will cost more) was a barrier for some programs.

Discussion

Our findings indicate that the combined approach of policy training and direct education could improve the nutrition and physical activity environment in the early care and education setting. Our intervention incorporated training, creating action plans, and coaching to provide guidance on implementing wellness policies and practices and to increase teacher self-efficacy. A similar study conducted in Georgia examined the use of policy training but did not include a direct education approach.¹⁴ Our study suggests that use of a combined approach can improve teachers’ knowledge of obesity prevention policies and self-efficacy to implement best practices, particularly in teaching and modeling. Although these areas improved significantly, some nutrition and physical activity domains did not improve. For example, teacher behaviors related to nutrition and physical activity showed no change from pre- to post-intervention. Future research should examine barriers that teachers may have to changing their own behaviors to enhance intervention implementation. Expert consensus suggests that addressing teacher health is a vital part of health promotion in the early care and education setting.⁴

The results of this pilot project provide valuable guidance about how to implement Healthy Child Care Georgia more effectively. One important lesson was the challenge of recruiting private childcare centers and family childcare providers to participate in Healthy Child Care Georgia. Teachers cited various reasons for a reluctance to participate, including suspicion of taking part in research, lack of time to attend training and implement the intervention, and competing demands for childcare quality improvement. These findings suggest the need for improved collaboration among childcare programs, researchers, and policy makers, as well as the need to consider the time constraints of childcare providers when designing interventions.

Limitations

This study had several limitations. First, the number of childcare centers and family childcare programs that met our selection criteria was low, and the pool of potential participants was small. Because so few programs participated in this pilot study, the results are not generalizable, and further studies with larger samples are needed. Second, some programs had high staff member turnover, and new teachers or substitute teachers who had not attended the training did not know how to implement the intervention. Future studies will include contingency plans for training new teachers, possibly through videos or online modules. Third, the study duration of 6 weeks did not allow adequate time to measure outcomes such as changes in body mass index and other markers of obesity. Longer-term studies are needed to determine the effects of this combined intervention on weight status.

Conclusion

This pilot study expands the knowledge base on obesity prevention in childcare by testing the use of policy, systems, and environment approaches in combination with direct education for children. Results from this formative study will inform a larger-scale study that will test a larger sample of programs serving low-income families. Findings suggest that policy training combined with direct classroom education is a model that is well accepted by teachers. Public health practitioners should consider using this combined approach to create change in the childcare setting.

Footnotes

Acknowledgments

The authors thank Funmilola Jemilugba, a graduate of the Human Development and Family Science Program at the University of Georgia, and Emily Tyus, a graduate of the Foods and Nutrition Program at the University of Georgia, for their assistance in data collection and data entry. We also thank the directors, teachers, parents, and children of our participating childcare programs for inviting us into their programs and providing valuable feedback to improve the training and intervention for future groups.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The US Department of Agriculture Supplemental Nutrition Assistance Program—Education funded this study.

References

Ogden

Carroll

Kit

. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806–814.

Centers for Disease Control and Prevention. Vital signs: obesity among low-income preschool-aged children—United States, 2008-2011. MMWR Morb Mortal Wkly Rep. 2013;62(31):629–634.

Kaur

Lamb

Ogden

. The association between food insecurity and obesity in children—the National Health and Nutrition Examination Survey. J Acad Nutr Diet. 2015;115(5):751–758.

Ward

Vaughn

Story

. Expert and stakeholder consensus on priorities for obesity prevention research in early care and education settings. Child Obes. 2013;9(2):116–124.

Larson

Ward

Neelon

Story

. What role can child-care settings play in obesity prevention? A review of the evidence and call for research efforts. J Am Diet Assoc. 2011;111(9):1343–1362.

Reynolds

Jackson Cotwright

Polhamus

Gertel-Rosenberg

Chang

. Obesity prevention in the early care and education setting: successful initiatives across a spectrum of opportunities. J Law Med Ethics. 2013;41(suppl 2):8–18.

Institute of Medicine. Early Childhood Obesity Prevention Policies. Washington, DC: National Academies Press; 2011.

American Academy of Pediatrics, American Public Health Association, and National Resource Center for Health and Safety in Child Care and Early Education. Preventing Childhood Obesity in Early Care and Education: Selected Standards From Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics and American Public Health Association; 2012.

Ritchie

Sharma

Gildengorin

Yoshida

Braff-Guajardo

Crawford

. Policy improves what beverages are served to young children in child care. J Acad Nutr Diet. 2015;115(5):724–730.

10.

Nonas

Silver

Kettel Khan

Leviton

. Rationale for New York City’s regulations on nutrition, physical activity, and screen time in early child care centers. Prev Chronic Dis. 2014;11:E182.

11.

Middleton

Henderson

Schwartz

. From policy to practice: implementation of water policies in child care centers in Connecticut. J Nutr Educ Behav. 2013;45(2):119–125.

12.

Ammerman

Ward

Benjamin

. An intervention to promote healthy weight: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) theory and design. Prev Chronic Dis. 2007;4(3):A67.

13.

National Center for Children in Poverty. Georgia early childhood profile. http://www.nccp.org/profiles/pdf/profile_early_childhood_GA.pdf. Accessed August 25, 2015.

14.

Lyn

Maalouf

Evers

Davis

Griffin

. Nutrition and physical activity in child care centers: the impact of a wellness policy initiative on environment and policy assessment and observation outcomes, 2011. Prev Chronic Dis. 2013;10:E83.

15.

Bright From the Start: Georgia Department of Early Care and Learning. Quality Rated child care. 2017. https://qualityrated.decal.ga.gov. Accessed August 24, 2015.

16.

Bandura

. The social and policy impact of social cognitive theory. In: Mark

Donaldson

Campbell

, eds. Social Psychology and Evaluation. New York, NY: Guilford Press; 2011:33–70.

17.

Institute of Medicine. Child and Adult Care Food Program: Aligning Dietary Guidance for All. Washington, DC: National Academies Press; 2011.

18.

US Department of Health and Human Services, Administration for Children and Families, Office of Family Assistance. Temporary Assistance for Needy Families program. Eleventh report to Congress. 2016. https://www.acf.hhs.gov/sites/default/files/ofa/eleventh_report_to_congress.pdf. Accessed June 26, 2017.

19.

Athens-Clarke County Unified Government. Athens-Clarke County by the numbers. 2017. https://www.athensclarkecounty.com/DocumentCenter/Home/View/535. Accessed June 13, 2017.

20.

Bales

Wallinga

Coleman

. Preparing child care providers to teach nutrition and physical activity to 3- to 5-year-olds: lessons learned from the Eat Healthy, Be Active Initiative. J Natl Extension Assoc Fam Consumer Sci. 2013;8:16–23.

21.

Nemours Foundation. Let’s Move! Child Care. 2017. https://healthykidshealthyfuture.org. Accessed November 5, 2015.

22.

Derscheid

Kim

Zittel

Umoren

Henry

. Teachers’ self-efficacy and knowledge of healthy nutrition and physical activity practices for preschoolers: instrument development and validation. J Res Child Educ. 2014;28(2):261–276.

23.

SAS Institute Inc. SAS Version 9.4. Cary, NC: SAS Institute Inc; 2014.