Underlying Theory and Evidence
Evidence Review Summary
Underlying Logic: Nearly 60% of children two to five years of age spend an average of 33 hours a week in a child care setting. Most of their daily food intake is consumed in this setting, making it an important environment to target with policies and programs that improve access and availability of healthy foods. Such administrative policies would have the potential to reach a large number of children with evidence-based strategies that are shown to not only improve the nutritional quality of foods consumed, but also prevent the onset of childhood obesity, especially when combined with efforts to increase physical activity. The ABC Grow Healthy administrative policy change includes both nutrition and physical activity standards in its efforts to improve the quality of care provided to children in South Carolina's child care programs.
- Decreasing Screen Time and Other Sedentary Behaviors — To improve weight-related outcomes, this strategy targets reducing the amount of time spent in sedentary behaviors. The ABC Grow Healthy policy specifically limits the amount of time children 2 years of age or younger spend in front of a screen (computer, TV, video, and DVD), in addition to increasing the standards for physical activity for all children through age 12.
- Changing Access and Availability to Favor Healthy Foods and Beverages — This strategy focuses on improving the access and availability of healthy foods. In this policy, the standards encourage offering more variety in vegetables, more daily offerings of fruits, and serving whole grains and skim or 1% milk. It also limits fried vegetables, high-fat meats, fruit juices, sugar-sweetened beverages, and other sweets. With these changes, children are exposed to healthier food choices, while decreasing the availability of unhealthy foods.
- Comprehensive Nutrition Programs in a Single Setting — This strategy uses multiple components in a single setting to target knowledge, skills, and/or attitudes to improve healthy behaviors. The ABC Grow Healthy policy targets child care centers (single setting) and includes nutrition components directed at both providers and children. For the child care providers, the policy includes requirements for annual nutrition training, and standards targeting the use of food as reward or punishment. Nutrition targets for the children include weekly opportunities for children to learn about nutrition and improving the offerings of healthier foods and beverages.
- School-Based Physical Activity and Physical Education — Although this strategy focuses on schools, the child care setting where the ABC program is implemented can be viewed in the context of schools. The physical activity standards in this policy target increasing the amount of time children are allowed to/encouraged to engage in active play (both indoors and outdoors). Standards for child care provider training in promoting movement and physical activity in children and having planned physical activities for children to engage in on a daily basis are also included.
Research Findings or Evaluation Outcomes: The South Carolina ABC Grow Healthy Initiative represents a partnership between two state agencies, DHEC and DSS. ABC Quality is a state-level child care quality rating and improvement system which includes programs that help eligible families pay for child care services so that they can work, attend school, or receive career training. As of this review, there were two phases where data was collected for this policy initiative — a formative phase which included a pilot implementation of the proposed nutrition and physical activity standards and a subsequent implementation phase of the revised and adopted standards. Findings and outcomes from each phase are summarized below.
Initial Implementation Phase (Year 1 of implementation, 2012-2013): A total of 518 child care centers, 93 with B+ and 425 with B rating, were reviewed to evaluate the extent of compliance with mandatory nutrition and physical activity standards. Because the total number of child care centers with a B+ or B level — or any other level — rating may fluctuate over the course of the year due to the voluntary nature of the program, the findings are based on the number of centers enrolled at the time of data collection. The nutrition and physical activity standards for centers at Level B+ and Level B are the same; however, centers cannot maintain or achieve B+ status if not compliant with all mandatory standards during the unannounced review. The following results are available based on the unannounced site visits conducted during year one of implementation:
- Physical activity policy — note that this is the only mandatory physical activity standard:
- Physical activity policies existed in 85% of B+ centers and 60% of B level centers. Overall, 65% of centers reviewed had physical activity policies.
- 69% of B+ centers and 47% of B centers had a physical activity policy that met the ABC Grow Healthy requirement. Overall, 51% of centers reviewed met the physical activity policy standard.
- Nutrition policy:
- Nutrition policies existed in 88% of B+ centers and 62% of B centers. Across B+ and B centers, 67% of reviewed centers had nutrition policies.
- 77% of B+ centers and 52% of B centers had a nutrition policy that met ABC Grow Healthy requirements. Overall, 56% of centers reviewed met the nutrition policy standard.
Below are data on the compliance of components of the nutrition policy:
- Skim or 1% milk was served to children 2 years and older in 81% of B+ centers and 72% of B level centers.
- Sugar sweetened beverages were not served in 83% of both B+ centers and B level centers.
- Juice was only served once per day in a serving size tailored to the age group's needs or less in 80% of B+ centers and 82% of B level centers.
- Fruits, Vegetables, and Grains:
- Fruit was served at least two times a day in 73% of B+ centers and 64% of B level centers.
- Vegetables other than white potatoes were served at least once a day in 73% of B+ centers and 71% of B level centers.
- Fried or pre-fried vegetables were served once a week or less in 83% of B+ centers and 85% of B level centers.
- Whole grain foods were served at least once a day in 72% of B+ centers and 60% of B level centers.
- High-Fat Meats and Sweet Foods:
- High-fat meats were served two times a week or less in 77% of B+ centers and 71% of B level centers.
- Sweet food items were served two times a week or less in 75% of B+ centers and 76% of B level centers.
Formative Phase (pilot evaluation): This initial phase included the development and refinement of the ABC Grow Healthy standards. Focus groups were conducted with center directors and other key stakeholders before and after implementation of the pilot with 19 Level B centers to assess the feasibility, clarity, and understanding of the standards. Each of the 19 participating child care centers received one unannounced monitoring visit, during which compliance with the piloted standards was assessed. Qualitative findings from the pilot evaluation showed:
- Many centers were not meeting existing meal pattern requirements.
- The language of some standards needed modification to be specific, actionable, and measurable.
- Staff assessing the centers for implementation of the standards needed better training to understand what the standards were and how to properly assess for compliance during monitoring visits.
These qualitative findings significantly informed the refinement of standards that were ultimately adopted and implemented after the pilot phase.