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HKHC Case Examples: Child Care and After-School Care

Philadelphia_2010 (7)May, 2012

Communities: Charleston, WV, Greenville, SC, Jefferson County, AL, Kingston, NY, Philadelphia, PA

With the rate of childhood obesity looming high, ensuring a healthy environment for children at an early age is a critical intervention. Child care and school-based care facilities offer a valuable opportunity to promote healthy eating and physical activity behaviors in children. The proportion of working mothers with young children has steadily increased, and as a result, child care is used more than ever. Sixty percent of children under 5 years old in the United States spend an average of 29 hours per week in some form of child care setting, such as day care, nursery school, preschool, or Head Start. More than half of youth ages 5 to 14 years old also spend regular time in a school-based care setting, such as before or after-school care.

According to the CDC, children may consume half to all of their recommended dietary allowances at a child care facility, based in or outside of a school. National studies have shown that the most common combination of meals and snacks provided more saturated fat and sodium than recommended health guidelines, and a distinct lack of fruit or vegetables. In addition, the nutritional content leaves out the recommended share of certain nutrients that are important for healthy brain development.

While the Dietary Guidelines for Americans recommend that children engage in at least 60 minutes of moderate to physical activity, studies have shown that children in out-of-school child care facilities are generally not meeting these exercise standards. In addition, surveys of child care facilities note that the policies and standards required of child care facilities greatly influences activity levels in children.

Eleven HKHC sites are working diligently to improve standards for healthy food and physical activity at child care centers and school-based care in their communities. While some communities implement standards set by national organizations (such as NAP SACC: the Nutrition And Physical Activity Self-Assessment for Child Care) others develop and implement new standards based on the capacities of their local centers and schools.

Case Examples

Charleston, West Virginia: Creative Implementation of Health and Nutrition Standards
When the CDC reported that 17% of children in the United States are obese, Dr. Jamie Jeffrey and her colleagues in Charleston felt this number was much lower than what they were observing in their patients. Dr. Jeffrey is the Medical Director of Children’s Medicine Center in Charleston, a residency teaching clinic which serves mostly Medicaid patients. She and her colleagues conducted a study of body mass index (BMI) among their patients and found that 44% of children ages 2 to 14 years had BMIs that were in the overweight and obese range. As a result, Dr. Jeffrey and her team were inspired to do something.

In looking where to start, they evaluated the age of onset of obesity. They found two distinct time periods when kids go from a healthy to an unhealthy BMI: ages 7 to 8, and ages 3 to 4. They were surprised by the latter. “We asked ourselves where are kids at this age?” says Dr. Jeffrey. The answer was child care, preschool, and aftercare centers.

The KEYS 4 HealthyKids child care committee is successfully addressing obesity in this age group. They are partnering with five child care centers and programs to improve nutrition and physical activity among the children they serve. These centers include Firsty Presbyterian Church preschool, YMCA preschool, YMCA after-school, Mom’s Helping Hand (a family child care center), and East End Family Resource Center (EEFRC, an after-school center).

The partnership discovered the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) toolkit whose standards they are now implementing. In 2011, the HKHC partnership held a successful NAP SACC train-the-trainer program for child care providers and directors (including the local director and staff of Head Start, and outreach workers for DHHR) from all over West Virginia. The training participants are now assisting their child care centers to improve nutrition and physical activity policies via NAP SACC best standards.

The KEYS partnership has helped child care centers implement the NAP SACC standards in unique and creative ways, often involving families, community members, and businesses. At Mom’s Helping Hand child care center, parents have become advocates for their children’s nutrition. They bring in fresh fruits, vegetables, and 100% juice or milk instead of soda, and they help cook dinner for the children. First Presbyterian church preschool now serves food “family style,” replaced sugary drinks with water, and switched from whole to skim milk. The preschool also introduced healthy celebrations to reduce the amount of unhealthy sweets.

After introducing fresh fruit and vegetables at First Presbyterian Church, the kids refuse to eat the canned fruit cocktail that used to be served. “It goes to show that we can teach our children to eat better and they will,” says Dr. Jeffrey, “People always think there’s going to be so much push-back. But this is an example that in this age group, if you feed it to them then they’ll like it.”

Greenville, South Carolina: A Successful Pilot Program to Improve Nutrition Standards
Through a partnership with the school district, out of school child care centers, and the City of Greenville, LiveWell Greenville, has established a year-long pilot program for after-school providers to improve the nutritional quality of snacks and meals served during their programs as well as to support children in being more physically active.

HKHC Greeneville partnered with members of the local school district, LiveWell Greenville After School/Child Care workgroup, and experts in nutrition to develop appropriate standards for healthy snacks served during child care. They developed a toolkit for centers willing to implement the pilot program, which includes nutritional standards, tools for planning and assessment, implementation resources (including local, state and web-based resources, snack menus, after-school standard and guidelines), and evaluation and celebration components.

They recruited five of the largest providers of after-school care to select at least one site in which to pilot the effort. A total of eight centers (one school-based and seven community-based) participated in the pilot. These centers serve different communities in Greenville County in order to compare the pilot’s implementation in each setting.

After hearing about the pilot opportunity, the City of Greenville requested that all out of school providers sponsored by the city take part in the pilot, and the City of Greenville provided funding to ensure the extra hours and materials were available. In July of 2012, they plan to evaluate and discuss the challenges and successes of the pilot program’s implementation, in order to promote it more widely.

Jefferson County, Alabama: Improving Health Guidelines at Child Care Centers County-Wide
In Jefferson County, AL, an estimated 17,600 children are in child care. While many centers follow county standards to protect the health and safety of children, about half of the centers have been exempt from regulation due to religious affiliation. This means 210 centers were not required to meet basic standards, including health, safety, tobacco use, or nutrition and physical activity. The partnership saw this as a major public health concern worth addressing. They established a Child Care Health and Wellness Work Group to develop and adopt standards to improve the nutritional quality snacks and meals, standards for physical activity, cleanliness, and safety regulations for all child care centers, including the religiously affiliated centers.

HKHC partners in Jefferson County worked with 100 child care centers to begin making nutrition and physical activity changes, and create momentum for the implementation of new standards. In October 2011, the Jefferson County Board of Health unanimously voted for the new standards.

The new standards include minimum daily requirements for active play, varying by age; limits on time spent watching television; requirements for the nutritional content of meals and snacks served at the center; background checks for employees; and prohibition of any smoking in child-care centers, or by employees during their shift at child care centers.

These standards became effective on January 2nd, 2012, and child care sites have one year to implement them completely. This year the partnership is working with Success By 6 and Childcare Resources on a referral system to provide technical assistance to the centers that need help in complying with the new standards. Assistance includes personalized consultations to the centers, books, parent handouts, activity ideas, snack suggestions and menus, and many hours of training. The Jefferson County Health Department, the lead agency of the Health Action Partnership, also leveraged CDC’s Communities Putting Prevention to Work (CPPW) grant, and awarded playgrounds to forty centers as an incentive for centers to take leadership in offering quality nutrition and physical activity.

The partnership finds the children to be very receptive to the changes in their centers: “the kids really like the fruits and vegetables, and are so proud to tell you which ones they’ve eaten,” says Katie Dean, Child Care Health and Development Specialist.  But not only are the children excited – the centers have been busy writing and changing policies and serving more healthful foods to their children. Says Katie, “It’s amazing how receptive many directors are; many just need a few suggestions and a little guidance to make some excellent changes in their program.” According to Kadie Whatley, HKHC Project Coordinator, the partnership serves as “an organized front to ask for policy change.”

Kingston, New York: Adopting a Healthy Afterschool Snack Policy
The Healthy Afterschool Snack (HAS) Committee of Kingston, New York, developed a model healthy snack policy for adoption by the Kingston City School District and their after-school programs. In 2010, the committee reviewed several healthy after-s-chool snack policies implemented in other communities. The committee chose to adapt the Choose Sensibly Guidelines, created by the New York School Nutrition Association, for Kingston. This policy is now being considered for the Kingston City School District’s Health and Wellness policy, and the HKHC partnership expects that the policy will be adopted by the Board of Education in early 2012. As part of this policy, the committee directs school and after-school program administrators to an online list of snack items that follow the Choose Sensibly Guidelines (  They can use this information when purchasing items for vending machines or programming.

The HKHC Kingston partnership is also working to make school gardens accessible during and after school hours in order to increase the amount of fresh vegetables and fruits that are served to children during school hours as well as during after-school care. Members of the Garden Committee of the Kingston partnership drafted the Kingston City School District School Garden Guidelines, which encourages principals to work collaboratively with parents, teachers, and local organizations to sustain food gardens and incorporate the use of garden produce in the school setting.

Currently the Kingston partnership is providing direct support to schools with gardens by inventorying individual school needs and assisting schools to access resources such as grants, tools, volunteers, and curriculum. The Garden Committee launches a Kingston City Gardens website in March 2012, which will support a network or school, community, and city gardeners.

Philadelphia, Pennsylvania: A Toolkit for Child Care Centers to Adopt Healthier Guidelines
Improved nutritional and physical activity standards in child care settings is central to HKHC Philadelphia’s mission. They are proposing revisions to the city’s Healthy Living guidelines for Out of School Time (OST) programs, which include child care and after-school care programs that operate outside of schools. OST programs must follow age-specific, place-based core standards and strategies. There are 185 OST sites total in the city of Philadelphia, serving children from kindergarten to high school. Under the new guidelines, sites would be required to follow new food and physical activity standards and strategies.

In addition to the standards, the HKHC Philadelphia partnership developed education toolkits consisting of best practice programs, age-specific strategies, and other innovative ways to implement the new recommended core standards in nutrition and physical activity.

The draft toolkit was approved by the city and implemented as a pilot program for three OST programs during the summer and nine in the fall of 2011. In addition, HKHC Philadelphia developed training and technical assistance (also approved by the city) to help OST child care programs during the implementation of the pilot. The pilot finished in December of 2011. Since it’s completion, the HKHC partnership compiled their recommendations based on the pilot program, which they presented to the city to be implemented in all 185 OST sites.

In March of 2012 the recommended guidelines were approved by the City of Philadelphia Department of Health. This is a significant policy-level change for the OST sites.

Lessons Learned
Child care and after-school setting are critical as an intervention for childhood obesity.  There are limited regulations or policies currently in place regarding healthy eating and active living. Some public run centers may fall under city regulations while private or religious centers have very little healthy policy oversight. Some of our grantees are using established guidelines for implementation and others are working with the child care providers to determine their capacity to change. Beyond just creating standards or making a policy change, some of the HKHC sites worked with centers to implement the policies via technical assistance or additional resources (toolkits, activity ideas, parent handouts etc.) Many HKHC Sites have partnered with school districts to do assessments and provide recommendations. Getting the buy-in of county commissioners or school district is key to implementation. The ultimate goal is for these settings to be an easy achievement to provide healthy food and activity for all participating children.

Other HKHC sites working in child care or after school care settings:

  • Watsonville/Pajaro Valley, CA
  • Grant County, NM
  • Hamilton County, OH
  • Milledgeville, GA
  • Washington, DC
  • Rochester, NY
  • Somerville, MA

Centers for Disease Control and Prevention

Food Research and Action Center

Healthy Eating Research (2007). Promoting Good Nutritional and Physical Activity in Child care Settings.

Story, Mary. Kaphingst, Karen M. French, Simone (2006). The Role of Child Care Settings in Obesity Prevention.