Parts of this chapter have been reproduced from Kipping et al.1 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.
Preschool children’s physical activity, nutrition and weight: a national priority
In England, 22.6% of children starting primary school are overweight or obese.2 Obesity rates increase with deprivation; 12.7% in the most deprived areas are obese, compared with 5.8% in the least deprived decile. It is predicted that 17% of children aged 2–11 years in England will be overweight in 2020 and a further 13% will be obese.3 Therefore, it is a priority that interventions are developed, tested and implemented with preschool-aged children to reduce their risk of developing obesity and chronic diseases.
Among children, physical activity (PA) is associated with lower levels of cardiometabolic risk factors, including blood lipids, blood pressure and improved psychological well-being.4 Patterns of PA track moderately from childhood to adulthood, suggesting that it is linked to both short- and long-term health among children.5 Furthermore, review evidence has identified that preschool children (aged 3 to 4.9 years) who had higher levels or increased amounts of PA were associated with improved measures of adiposity, motor skill development, psychosocial health and cardiometabolic health.6
The English Chief Medical Officer’s recommendations are that children < 5 years of age who are capable of walking should be physically active for at least 3 hours per day and sedentary time should be minimised.7 There is no guidance about screen time in the UK. In 2012, only 10% of 2- to 4-year-olds in England were classified as meeting the current guidelines for children < 5 years7 of at least 3 hours of PA per day. In addition, 3- to 4-year-olds in the UK are sedentary for an average of 10–11 hours per day.7,8
A diet that is high in fruit and vegetables and low in saturated fat has been associated with reduced risk of many forms of cancer, adult heart disease and all-cause mortality.9 Dietary patterns are often set during childhood. Children aged 1.5–10 years in the UK do not eat sufficient amounts of fruit and vegetables, and 32% of boys and 18% of girls are reported as having eaten no fruit during a 4-day period.10 The latest national recommendation is that intake of free sugars should provide no more than 5% of total energy intake for adults and children aged > 2 years.11 Intake of non-milk extrinsic sugars (NMES) is 12% of total daily energy intake for 1- to 3-year-olds and 13% for 4- to 10-year-olds.12 Soft drinks contribute 10% to the intake of NMES in 1- to 3-year-olds and 13% to the intake of NMES in 4- to 10-year-olds. Saturated fat intake is also higher than the recommended 11% of total daily energy intake, at 14.6% for 1- to 3-year-olds and 13.3% for 4- to 10-year-olds. Preschool-aged children in low-income populations are more likely to consume table sugar and soft drinks than those in more affluent groups.13
A study of the prevalence of dental caries among a sample of 5-year-old children in state-funded schools in England found that 24.7% of children had some obvious tooth decay in 2014/15.14 The average number of teeth that were decayed, missing or filled in the whole sample was 0.8, and among those with decay it was 3.4. There is a clear correlation between higher deprivation and dental decay (R2 = 0.47) at local authority level. Poor oral health can have a negative impact on sleeping, eating, speaking, playing and socialising for children.15 Furthermore, it is the most common reason for admission for hospital in children aged 5–9 years in England.16 A Public Health England commissioning toolkit for oral health reviewed the evidence for a wide range of oral health interventions and found that there was some evidence for the effectiveness of healthy food and drink policies in early childhood settings and recommended this approach.17 Furthermore, the review found that oral health training for the wider professional workforce appeared promising although there was a lack of randomised controlled trials (RCTs).
Three systematic reviews of obesity prevention, PA and nutrition in young children each identified a lack of studies in young children and a clear need for more research with robust study designs.18–20 The 2011 Cochrane review of obesity prevention in children identified research gaps for effective interventions for children aged 0–5 years.20 In addition, this review recommended that studies must better report the impacts on the environment, setting and sustainability. Studies should also test interventions that are guided by theory-based frameworks such as the socioecological model.
Rationale for a feasibility study on physical activity and improved nutrition in child-care settings
Child-care settings provide opportunities to deliver interventions at the population level.21 Ninety-seven per cent of children aged 3–4 years in England attend some form of government-funded early years education, of whom 39% attend day-care providers outside school settings.22 In England, government-funded child care for 3- and 4-year-olds increased from 15 to 30 hours/week in September 201723 (with certain conditions on parental employment), which has the potential to increase the amount of time children spend in child-care settings. However, not all child-care settings are health-promoting environments. Child-care settings provide scalable opportunities to deliver interventions at the population level.21 The 2012 Early Years Foundation Stage (EYFS) statutory framework sets the standards to ensure that children learn, develop and are kept healthy and safe.24 The EYFS includes somewhat limited standards for PA and healthy diet and requires nurseries to maintain a high staff to child ratio (1 : 4 for 2-year-olds, and 1 : 13 for 3- to 5-year-olds).24 This provides nursery staff with contact during mealtimes to apply the techniques of taste exposure, encouragement, praise, and modelling of healthy eating. Furthermore, the settings can constrain or enable PA. A systematic review of the role of peers in eating behaviours and PA found that there was some evidence to support the role of peers.25 Four out of the six PA studies reported that children were more active when peers were present. However, large peer group size was negatively associated with PA in two cross-sectional studies.26,27 All nutrition interventions in the review reported that children’s eating behaviours may be influenced by their peers.
The Children’s Food Trust published voluntary guidelines for food in early years settings in 2012.28 In addition, PA guidelines for young children in England were published in 2011.7 The English 2016 Childhood Obesity strategy is very limited with respect to preschool children,29 but local authorities in England and Wales are increasingly developing and implementing their own programmes to support healthy interventions in early years settings. We have reviewed the local authority websites for the Core Cities in England and found all (except one) have some form of healthy early years programme. In Wales, the Healthy and Sustainable Pre-School Scheme was started in 2011 on seven health topics: Nutrition and Oral Health; Physical Activity/Active Play; Mental and Emotional Health, Wellbeing and Relationships; Environment; Safety; Hygiene; and Workplace Health and Wellbeing.30 These programmes all include nutrition and some have additional health topics. However, none of these programmes has been evaluated for effectiveness through a RCT. Therefore, new approaches are required to prevent obesity and reduce inequalities in early years settings.
Assessment of PA in 3- to 5-year-old children at preschool has shown that they are physically inactive during most of their time in preschool, with only 3% of time engaged in moderate to vigorous physical activity (MVPA). MVPA is closely associated with cardiorespiratory fitness and body mass index (BMI) in adolescence; therefore, it is of concern that such a small proportion of time in preschool is spent in MVPA. Furthermore, about 80% of time is spent in sedentary activities.31 However, studies have found different levels; one study found that children aged 3–4 years in the UK (in particular boys) spent more time in MVPA and were less sedentary when in child care than when at home.32 The particular preschool that a child attends is a strong predictor of PA levels, and being outdoors is one of the most powerful correlates of PA in children.31 The lack of MVPA in preschool settings may be influenced by space constraints, a lack of equipment, a lack of policies and a lack of scheduled times for free play and outdoor play and a lack of staff training in PA promotion.19 A systematic review of interventions to increase PA in child-care settings concluded that regularly provided, structured PA programmes can increase the amount and intensity of PA undertaken.33
Larson et al.18 reviewed the regulations, practices, policies and interventions for promoting healthy eating and PA and for preventing obesity in children attending child care. The review identified a lack of strong regulation in child-care settings in relation to health behaviours, such as PA and diet. A 2016 Cochrane review of strategies to improve healthy eating, PA and obesity prevention in child-care services found that:
Weak and inconsistent evidence of the effectiveness of such strategies in improving the implementation of policies and practices, childcare service staff knowledge or attitudes, or child diet, physical activity or weight status. Further research in the field is required.
There is ample opportunity within child-care settings to improve nutritional quality, oral health, time engaged in PA and promotion of health behaviours by caregivers. Other than Nutrition And Physical Activity Self Assessment for Child Care (NAP SACC) (see NAP SACC), a small number of RCTs based in child-care settings that aim to improve nutrition and/or PA or sedentary time with 2- to 4-year-olds have been published (Table 1). The studies focused on education, staff development, and addressing child-care policies or opportunities for increasing PA. Many, but not all, of the studies reported small changes in children’s PA, sedentary time or nutrition in the short term. Only one intervention showed an effect on weight.40 There was a lack of long-term follow-up or demonstration of effect across a wide range of anthropometric and behavioural changes. Only four of the studies were in the UK and none of these targeted both diet and PA within child-care settings.
| Name of study/first author | Type of intervention | Setting; country (age range) | Results for the intervention arm compared with the control arm |
|---|---|---|---|
| Family Focused Active Play34 | Family-focused intervention to decrease sedentary time and increase PA for 10 weeks | Surestart Centres; England (3–4.9 years) | 1.5% and 4.3% less sedentary time during week and weekend days, respectively, and 4.5% and 13.1% more PA during week and weekend days, respectively |
| Active Play35 | 6-week local authority staff-led training (active play) to help preschool staff deliver 60-minute weekly sessions compared with a resource pack | Preschools attached to Surestart Centres; England (3–4.9 years) | Assessment of 162 children found no evidence for differences in total fundamental movement skill, object control skill or locomotor skills scores |
| Alhassan36 | An increase of 60 minutes per day in time spent outdoors for 2 days | Head Start Centers; USA (3–5 years) | No difference in total daily PA |
| Specker37 | Children assigned to gross motor or fine motor group for 1 year | Nursery; USA (3–5 years) | Time spent in vigorous activity was higher in the gross motor group at 18 months but not 24 months |
| Brocodile the Crocodile38 | Seven educational sessions encouraged to reduce time spent watching TV | Nursery; USA (2.6–5.5 years) | –4.7 hours per week television/video viewing (95% confidence interval –8.4 to –1.0 hours per week; p = 0.02) |
| CHERRY39 | An exploratory trial, focused on family-centred nutrition | Children’s Centres; England (1.5–5 years) | Positive, but non-significant, changes in fruit and vegetables, decreasing sugary drinks and snacks |
| Healthy Caregivers/Children40 | Curricula for teachers/parents, menu modifications and policies for nutrition, PA and screen time | Children’s Centres; USA (2–5 years) | Mean child BMI increased in control centres from 0.43 to 0.55 kg/m2 and smaller increases were seen in intervention centres (0.46 to 0.49 kg/m2). The environmental assessment (EPAO) total nutrition score improved in the intervention centres (12.4 to 13.5) with no change in control schools (12.5 to 12.6). Little changes in the EPAO PA scores |
| Hip-Hop to Health41 | Healthy eating and PA lessons for 14 weeks | Preschools; USA; (3–5 years) | More MVPA (difference between adjusted group means = 7.46 minutes per day, p = 0.02) and less total screen time (−27.8 minutes per day, p = 0.05). No differences in BMI, zBMI, or dietary intake |
| Move and Learn42 | Integration of PA into preschool half-day over 8 weeks | Preschools; USA; (3–5 years) | In 2 out of the 8 weeks, the levels of PA were higher than in the other weeks |
| Munch and Move43 | Professional development to promote healthy eating and PA among children | Preschools; Australia; (mean age 4.4 years) | FMS improved (p < 0.001) and the number of FMS sessions increased by 1.5 per week (p = 0.05). Sweetened drinks reduced by 0.13 servings (46 ml) (p = 0.05) |
| PAKT44,45 | 30-minute/day PA intervention delivered by preschool teachers, with homework over 1 year | Preschools; Germany; (mean age 4.7 years) | The intervention found no evidence for improvement in PA measured by accelerometers between groups |
| Preschool nutritional intervention46 | Sessions by nutritionists with some parent involvement. Activities covered different foods, preparing food and eating behaviour | Preschools; Germany; (3–6 years) | Fruit and vegetable intakes increased by 0.23 and 0.15 portions per day (p < 0.001 and p < 0.05, respectively). No changes in water or sugary drinks consumed |
| MAGIC47 | Nursery and home elements with enhanced PA programme and materials for home | Nursery; Scotland; (mean age 4.2 years) | No differences in BMI, PA or sedentary behaviour |
| SHAPES48 | Ecological PA intervention in preschools: preschool teachers trained to engage children in PA during (1) structured, teacher-led PA opportunities in the classroom; (2) structured and unstructured PA opportunities at recess; and (3) PA integrated into preacademic lessons | Preschools; USA; (4 years) | Children in intervention schools engaged in more MVPA than children in control schools (7.4 and 6.6 minutes per hour, respectively; p = 0.01). In the analysis by gender there was evidence of a difference for girls (6.8 vs. 6.1 minutes per hour of MVPA, respectively; p = 0.04) but not for boys (7.9 vs. 7.2 minutes per hour, respectively; p = 0.1) |
| Tigerkids49 | Modules on PA, fruit and vegetables and waste | Preschools; Germany; (3–5 years) | Higher consumption of fruit and vegetables at 6 months, which was sustained at 18 months |
| Toy box50,51 | Preschool-based, family-involved intervention to influence obesity-related behaviours in 4- to 6-year-olds in Europe | Preschools; six European countries; (4–6 years) | Evaluation of the effectiveness of the study of 472 preschool children (mean age 4.43 years) from 27 kindergartens in Flanders found small increases in PA in the whole sample. The greatest effects were found in boys and in preschoolers from high-SES kindergartens |
Ongoing randomised controlled trials
Internationally, several trials in early years settings or with families of preschool children are currently being conducted with the aim of improving nutrition and/or PA, which further demonstrates the importance of improving health for this age group:
- Jump Start is a multicomponent PA intervention for children aged 3–5 years in Australia. The intervention uses lessons in preschool and a home-based component with the primary outcome of total activity (accelerometer measured) during centre hours.52
- The Healthy Start-Départ Santé intervention is being tested in preschools with children aged 3–5 years in Canada. The intervention aims to enable parents and preschool staff to integrate PA and health eating into the day.53
- The DAGIS study (increased health and wellbeing in preschool) is a preschool intervention that is being developed with the aim of reducing inequalities in energy balance-related behaviours in preschoolers aged 3–5 years in Finland.54,55
- In Norway, a web-based programme to reduce food-related fears and promote healthy dietary habits in 1-year-olds is being studied through a trial design with two different interventions.56
- The physical Literacy in the Early Years (PLEY) Project in Nova Scotia (Canada) is aiming to determine if 3- to 5-year-old children who participate in active outdoor play in Childcare Centres, facilitated by educators trained in embedding loose parts into outdoor play spaces, develop greater physical literacy.57
- Smart Moms is a 6-month smartphone intervention in North Carolina (USA) that aims to reduce sugar-sweetened beverage and juice consumption among children aged 3–5 years with overweight or obese mothers.58
- The extended Infant Feeding, Activity and Nutrition Trial (InFANT Extend) is a trial in Australia testing a 33-month intervention using web-based materials and Facebook (Facebook, Inc., Menlo Park, CA, USA; www.facebook.com) with parents of infants, alongside the pre-existing six 2-hour sessions given quarterly to first-time parents.59
NAP SACC
The NAP SACC intervention was chosen to be adapted and piloted in the UK in this study.60 NAP SACC, which was developed in the USA, is focused on improving nutrition and PA environment, policies and practices in child-care centres through self-assessment and targeted technical assistance. It addresses PA, sedentary behaviours and nutrition by allowing providers to choose where they focus change. The NAP SACC approach, which uses data, evidence-based action-planning, choice, support, engagement and ownership, tailoring and sustained change, has been used in other UK public health interventions. RCTs of NAP SACC in the USA have demonstrated the feasibility and acceptability of the intervention, the effectiveness of improving the environmental audit nutrition score [11% improvement from a baseline Environment and Policy Assessment and Observation (EPAO) score of 8.6],60 increase in nursery staff’s knowledge of childhood obesity, healthy eating, personal health and working with families (all at a p < 0.05 level), decrease in children’s body mass index z-scores (zBMI) (p = 0.02)61 (a measure of relative weight adjusted for child age and sex) and an increase in accelerometer-measured PA by 17% (p < 0.05) and a 46.2% increase in vigorous activity (p < 0.05).62 NAP SACC was updated in 2014 and the revised online version, called ‘Go NAP SACC’, includes expanded best practices and is the version which NAP SACC UK is based on, excluding the materials for breastfeeding.63
NAP SACC is one of the few interventions that works with child-care providers to produce sustainable changes in the child-care environment and promote improvements in children’s activity levels and nutritional intake. NAP SACC has been widely adopted throughout the USA, which demonstrates that it is a model that, if shown to be effective, could easily be disseminated in the UK. NAP SACC has not previously been assessed for feasibility or acceptability of use in the UK or with direct measures of nutrition or BMI. In addition, some issues of fidelity to the intervention were encountered in the US trial, which were addressed through this feasibility study.
NAP SACC UK
The development and final version of NAP SACC UK (Nutrition And Physical Activity Self Assessment for Child Care UK version), following the phase 1 study, is outlined in detail in Chapter 2. To orientate the reader, the NAP SACC UK intervention, as used in the feasibility study, involved health visitors (called NAP SACC UK partners) supporting nursery staff to (1) review the nutrition, oral health, PA and screen time environment, policies and practices against best practice and national guidelines, (2) support staff to set goals and (3) provide targeted assistance over 5 months. Two workshops were delivered to nursery staff by local experts. A home intervention [website, short message service (SMS) and e-mails] was developed to support parents to set goals.
The subsequent chapters outline the methods and results for the two phases of the feasibility RCT and the two substudies. This is followed by the lessons learnt and discussion.