Realising the potential of early childhood education environments for obesity prevention

Abstract

Objectives: Young children increasingly attend out-of-home, group-based care, and early-life interventions appear to be the most efficacious and cost-effective to prevent obesity. Consequently, early childhood education (ECE) is recognized internationally as an important setting in governmental responses to obesity. This thesis evaluates the nutrition and physical activity environments for 3- and 4-year-olds in New Zealand ECE services, and determines the effect of ECE environments on the development of overweight and obesity in early childhood. Methods: An online survey in 2014 of 257 (30% of) ECE services in three regions of New Zealand collected information on nutrition and physical activity policy and practices. Features of the environment were evaluated against best practice for obesity prevention. Indicators were grouped into domains and summarized into a composite index, based on Harrison et al’s Six C’s ecological systems theory. Data were linked with the Growing Up in New Zealand longitudinal cohort to create a subsample of ~1000 children with which to explore 1) adherence to recommended nutrition-related behaviours in the home and ECE setting, and 2) associations between the quality of ECE nutrition and activity environments and body size at 4-years of age. Descriptive statistics with tests for difference (by type of service, neighbourhood deprivation, roll size, ratio of teachers to children, percentage of fully trained teachers, proportion of Māori and Pacific students), multivariate regression and multilevel modelling were employed to build a new Six Cs model representing the relationship between ECE environments and early childhood overweight. Results: Overall, there was wide variation in nutrition and activity environments across the ECE sector in New Zealand, not always attributable to service characteristics, although some statistical differences were found in policies and practices by type of service. Services enrolled in the Heart Foundation’s Healthy Heart Award performed statistically better on most indicators, including the composite index, compared to services not engaged with the programme. ECE managers reported having adequate equipment, space and time to promote physical activity in their service, however there was an absence of policy regarding active movement and few ‘physical activity champions’. Over 80% of services had a written healthy food or nutrition policy, but policies were not comprehensive or strongly-worded when compared with policies in similar studies in the US and Australia. Over half of services provided food daily to children, with one-third serving lunch and at least two snacks. Of the 57 full menus analysed, only 5% met all 10 nutrition guidelines (mean score of 6.8 out of 10). Teachers talked to children about food, and baked or cooked with children, at least weekly in 60% of services. Nine out of every 10 services had an edible garden. Food or beverages were sold for fundraising in the past 12 months by 37% of services. The most commonly reported barrier to promoting nutrition was a lack of support from parents and families (19% of all services). Adherence to recommended nutrition-related behaviours by ECE services (e.g. sitting with children to eat, talking to children about food, and not hurrying meals) had no relationship with adherence to these behaviours in the home. Children from deprived communities were more likely to attend a service with high adherence to recommended nutrition-related behaviours compared to children living in the least deprived communities (20% and 12% respectively), although there were no differences in adherence at home by socioeconomic position. In the multilevel modelling, 7% of the variation in child body size at 54-months of age was attributed to the ECE setting. However, there were no associations between body size at 4 years and any of the ECE-level indicators collected in the survey. Being Pacific ethnicity, having a mother that did not attend university, and living in an area of high deprivation all independently increased the risk of overweight at 4-years of age regardless of the quality of the ECE environment. Conclusions and implications: Statistical analyses in this thesis suggest that ECE services are unlikely to affect childhood obesity in isolation. However, ECE services are an essential setting for a comprehensive approach to obesity, to inspire and support parental and community efforts to provide healthy food and activity opportunities. The thesis elucidates four areas for action within the New Zealand ECE sector: 1. staff education and professional development in nutrition and physical activity; 2. strengthening nutrition and activity policies; 3. improving the quantity of serves of ‘everyday’ foods in ECE services on menus, in lunchboxes, and at celebrations; and 4. eliminating discretionary foods from meals and snacks (menus and lunchboxes), and having appropriate serving sizes for discretionary foods at celebrations if served. Additionally, a baseline scorecard of NZ’s implementation of recommendations from the World Health Organization’s Commission on Ending Childhood Obesity highlights the inadequacy of current government policy. Policy options include changes to ECE licensing regulations, prelicensing checks, education reviews, the self-review process, and monitoring or auditing of ECE services. With some of the highest childhood obesity rates in the world, there is “an urgent need to act now” to improve ECE environments in New Zealand, ensuring that they work in collaboration with parents, family and the wider community to uphold basic rights for children to adequate nutrition and the highest attainable standard of health.