Examining the Relationship Between Health Behaviors of Adults and Preschool Children.

INTRODUCTION: Children aged two to five years old are influenced by the behaviors of their guardians and Early Care Education (ECE) teachers. This study aims to determine the relationship between adults' and children's health behaviors in home and ECE settings. This study is novel in examining this correlation between multiple environments. METHOD: Surveys were conducted across 32 ECE centers. Guardians and teachers reported on their and their children's health behaviors within the home and ECE. Matched child-adult responses (n = 1,140) were analyzed from a representative sample of 32 ECE centers throughout Georgia. Frequency of consumption of fruits, vegetables, and water, as well as frequency of physical activity were measured. Spearman rho correlations were analyzed using SPSS software, with p < 0.05 indicating significance. RESULTS: Spearman rho correlations indicated significant positive correlations between guardian and child behavior (rho = 0.49 to 0.70, p < 0.001) for all data. Teacher and child correlations were inconsistently significant across categories (rho = -0.11 to 0.17, p < 0.001). DISCUSSION: The influence of guardian behavior modeling on child health outcomes is critical for improving ECE programming and child obesity outcomes. This research can be used to inform future health interventions for young children.

Physical activity and academic achievement: an analysis of potential student- and school-level moderators.

BACKGROUND: Many children do not engage in sufficient physical activity, and schools provide a unique venue for children to reach their recommended 60 daily minutes of moderate-to-vigorous physical activity (MVPA). Prior research examining effects of MVPA on academic achievement is inconclusive, and few studies have investigated potential moderators of this relationship. This study examined whether student-level characteristics (gender, race/ethnicity, free/reduced-price lunch status) and school-level characteristics (proportion of students qualifying for free/reduced-price lunch, physical activity environment and opportunities) moderate the relationship between MVPA and academic achievement. METHODS: In a large, diverse metropolitan public school district in Georgia, 4,936 students in Grade 4 were recruited from 40 elementary schools. Students wore accelerometers to measure school-day MVPA for a total of 15 days across three semesters (fall 2018, spring 2019, fall 2019). Academic achievement data, including course marks (grades) for math, reading, spelling, and standardized test scores in writing, math, reading, and Lexile (reading assessment), were collected at baseline (Grade 3, ages 8-9) and at follow-up in Grade 4 (ages 9-10). Standardized test scores were not measured in Grade 5 (ages 10-11) due to COVID-19-related disruptions. Multilevel modeling assessed whether student-level and/or school-level characteristics were moderators in the cross-sectional and longitudinal MVPA-academic achievement relationship. RESULTS: Cross sectional analyses indicated that the MVPA and AA relationship was moderated only by student Hispanic ethnicity for Grade 4 fall spelling marks (ß = -0.159 p < 0.001). The relationship for Grade 4 fall spelling marks was also moderated by school physical activity opportunities (ß = -0.128 (p < 0.001). Longitudinally, there was no significant moderation of the MVPA-academic achievement. A relationship by student gender, free/reduced-price lunch status, race/ethnicity; nor for school-level factors including proportion of students qualifying for free/reduced-price lunch, physical activity environment, and physical activity opportunities. CONCLUSIONS: Overall, our results did not suggest that student- or school-level characteristics moderate the MVPA-academic achievement relationship. While statistically significant results were observed for certain outcomes, practical differences were negligible. In this population, school-based MVPA does not appear to differently affect academic performance based on student gender, race/ethnicity, free/reduced-price lunch, nor school characteristics. TRIAL REGISTRATION: This study was registered with the National Institutes of Health (NIH) ClinicalTrials.gov system, with ID NCT03765047 . Registered 05 December 2018-Retrospectively registered.

The longitudinal association between objectively-measured school-day physical activity and academic achievement in US elementary school students.

BACKGROUND: It is recommended that school-aged children accrue 30 minutes of daily moderate-to-vigorous physical activity (MVPA) in school. Current literature is inconclusive about the long-term associations between school-based physical activity and academic achievement. In this study, we use a large sample and longitudinal design to rigorously evaluate whether school-day MVPA is associated with academic achievement. METHODS: In a diverse suburban public school district, 4936 Grade 4 students were recruited in 40 elementary schools. Students wore accelerometers to measure school-day MVPA for 15 days across three semesters. Academic performance data was collected across Grade 3 fall to Grade 5 spring, including teacher-assigned grades and standardized test scores. Multilevel modeling was conducted controlling for student demographics and school characteristics. RESULTS: Cross-sectional analyses found small negative associations in Grade 4. Grade 4 full-year mean daily school-day MVPA had ß = --0.066, ß = --0.063, ß = --0.066, and ß = --0.058 associations (p <  0.001) with Grade 4 math, reading, spelling, and writing grades respectively, and Grade 4 full-year mean daily school-day MVPA had ß = --0.206 and ß = --0.283 (p <  0.001) associations with Grade 4 math and English Language Arts (ELA) standardized test scores respectively out of approximately 500 points. Longitudinal analyses found no significant associations between Grade 4 full-year mean daily school-day MVPA and Grade 5 Fall course grades. Results also indicated small negative associations for students attaining 30+ minutes of daily school-day MVPA compared to those attaining less than 15 minutes, but only in Grade 4 Fall cross-sectional analyses where teacher-assigned reading, spelling, and writing grades were - 1.666, - 1.638, and - 1.993 points lower respectively (p <  0.001). CONCLUSION: The cross-sectional findings, while statistically significant in a negative direction, have a negligible association when translated practically. For example, even if students attained twice the recommended amount of school-day MVPA - which would constitute an approximately 300% increase from current levels - results suggest that grades would only decrease by 2 points on a 100-point scale. Furthermore, longitudinal analyses suggest school-day MVPA does not have a predictive association with course grades or standardized test scores. Findings suggest school-based MVPA implemented in accordance with recommendations does not meaningfully detract from academic progress. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03765047. Registered 05 December 2018 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03765047.

Study protocol for testing the association between physical activity and academic outcomes utilizing a cluster-randomized trial.

The Physical Activity Guidelines for Americans recommend adolescents engaging in 60 min of physical activity (PA) every day. Students should spend at least 30 min being active while at school. However, schools rarely provide that much PA time for students. This paper describes the planned analyses for a study evaluating the relationships between PA (measured as average daily minutes of Moderate to Vigorous Physical Activity [MVPA]) and educational outcomes of standardized test scores and classroom grades cross-sectionally in 4 th grade and longitudinally from 4 th to 5 th grade. Investigations of moderators (both student- and school-level), mediators, and potential dosage of average MVPA thresholds are outlined. To ensure a high level of variability in student PA, the Health Empowers You! program is implemented in a random sample of half of the participating schools. The intervention is designed to affect students' PA behaviors and health outcomes (cardiorespiratory fitness, body mass index). Utilizing accelerometer data from students in participating schools, the relationship between PA and health and academic outcomes (academic achievement test scores, reading lexile, grades, attendance, and tardiness) is evaluated. A total of 4968 grade 4 students across 40 schools (20 receiving intervention) participated (75% participation rate), and this cohort is being tracked from grade 4 through grade 5. In addition, implementation process and fidelity data are gathered. Given that school closures in response to COVID-19 pre-maturely terminated Spring 5 th grade data collection, modifications to the original analysis plan are discussed throughout.

Nutrition Policies, Practices, and Environments in Low-Income Georgia Elementary Schools, United States, 2015-2017.

BACKGROUND: A nutritious diet can prevent obesity and chronic disease and improve academic performance, yet many children have energy-dense, nutrient-poor diets. The objective of this study was to assess nutrition policies, practices, and environments in Georgia Supplemental Nutrition Assistance Program Education (SNAP-Ed) elementary schools and compare them across school-level demographic characteristics. METHODS: We distributed a cross-sectional online survey to administrators, grade level chairs, and nutrition managers from 113 Georgia SNAP-Ed elementary schools during 2015-2017. Logistic regression, one-way ANOVA, and Tukey's tests were performed to assess differences by free and reduced-price lunch eligibility and percentage black. Fisher's exact and Rao-Scott chi-square tests were performed to assess differences by school size and geography. RESULTS: The majority of schools established wellness policies and committees, provided nutrition education, and offered fresh fruits and/or vegetables daily. Fewer schools had policies limiting sugar-sweetened foods within classrooms or had established a school garden. There were minimal significant differences in survey responses across school-level demographics. CONCLUSIONS: Georgia SNAP-Ed elementary schools are providing healthy nutrition settings for their students in a number of areas, and can further improve by establishing more comprehensive wellness policies, a committee to enforce them, and engaging children in hands-on nutrition education activities.

Health Empowers You: Impact of a School-Based Physical Activity Program in Elementary School Students, Georgia, 2015-2016.

BACKGROUND: Most youth in the United States do not meet the recommended 60 minutes of daily physical activity (PA). The school environment offers an opportunity to engage students in PA. The purpose of this study was to evaluate the impact of a comprehensive school-based physical activity program on student PA across student-level and school-level characteristics. METHODS: PA levels from 3294 fourth grade students in 24 intervention schools and 7 control schools in metropolitan Atlanta, Georgia were measured during the 2015-2016 academic year. PA measures included daily steps in school, steps taken in physical education class (PE), and percent of PE class time spent in moderate-to-vigorous physical activity (MVPA). Intervention effectiveness was assessed using generalized estimating equations adjusting for sex and school-level socioeconomic status (SES). RESULTS: After adjusting for sex and school-level SES, intervention students had significantly higher increases in average daily steps (p < .05), steps taken in PE (p < .01), and percent of PE class spent in MVPA (p < .01) than control students. CONCLUSIONS: Our findings demonstrate the effectiveness of CSPAPs in increasing PA. Further research using randomized controlled trials of large-scale implementations, longer follow-up periods, and more diverse student sample is warranted.

Elementary school physical activity opportunities and physical fitness of students: A statewide cross-sectional study of schools.

BACKGROUND: Using a cross-sectional design, we assessed the relationship between the time schools provide for physical activity and the proportion of students achieving a healthy aerobic capacity or body mass index. METHODS: In 2013-2014, physical education and grade-level teachers from 905 of 1,244 Georgia elementary schools provided survey data about the frequency and duration of physical activity opportunities offered before, during, and after school. Log-binomial models related the weekly physical activity minutes provided by schools to the proportion of children in the FitnessGram healthy fitness zone for aerobic capacity or body mass index while adjusting for school characteristics and demographics. RESULTS: During-school physical activity time was not associated with student fitness, but schools with before-school physical activity programs had a moderately higher prevalence of healthy aerobic capacity (prevalence ratio among girls: 1.06; 99% confidence interval: 1.00-1.13; prevalence ratio among boys: 1.03; 99% confidence interval: 0.99-1.08). Each additional 30 minutes of recess per week was associated with no more than a 3%-higher proportion of students with healthy body mass indexes (prevalence ratio among girls: 1.01; 99% confidence interval: 1.00-1.03; prevalence ratio among boys: 1.01; 99% confidence interval: 0.99-1.03). CONCLUSIONS: The amount of physical activity time provided by schools is not strongly associated with school-aggregated student fitness. Future studies should be designed to assess the importance of school-based physical activity time on student fitness, relative to physical activity type and quality.

Impact of a Georgia elementary school-based intervention on physical activity opportunities: A quasi-experimental study.

OBJECTIVES: To assess the impact of Power Up for 30, a flexible, Comprehensive School Physical Activity Program-based state-wide elementary school initiative, on school physical activity opportunities (physical education, recess, in-class physical activity, before-school physical activity, and after-school physical activity) one year after Power Up for 30 training. DESIGN: Quasi-experimental. METHODS: In 2013, all 1333 public Georgia elementary schools were invited to complete the School Physical Activity Survey which assessed school physical activity opportunities. Upon survey completion, schools were invited to attend training. Of the 719 (54%) schools meeting survey response criteria, 300 schools attended training by 9/2014 and 419 schools did not. Between 3/2015-5/2015, 79 trained and 80 untrained schools were randomly selected to receive a follow-up survey assessing the frequency and duration of physical activity opportunities. Analyses, adjusted for baseline physical activity opportunities and school characteristics, compared weekly minutes of physical activity opportunities at follow-up between trained and untrained schools. RESULTS: In adjusted analyses at follow-up, trained schools provided 36 more minutes of weekly physical activity opportunities than untrained schools (99% confidence interval: 16-56), particularly during recess (mean difference: 8min per week; 99% confidence interval: 0-17), during in-class breaks (mean difference: 11min per week, 99% confidence interval: 3-20), and before school (mean difference: 8min per week, 99% confidence interval: 4-12). CONCLUSIONS: Flexible, multi-component interventions like Power Up for 30 increase physical activity opportunities. If future studies identify that school physical activity opportunities positively impact student physical activity, this model may be a feasible strategy for broad-scale implementation.

Feasibility of a Multicomponent Program to Promote Physical Activity and Nutrition in Georgia Low-Income Early Care and Education Settings.

BACKGROUND: This article describes the process and intermediate outcomes from a program implemented in 65 Early Care and Education (ECE) centers serving low-income families throughout Georgia during the 2014-2017 school years. METHODS: The HealthMPowers' Empowering Healthy Choices in Schools, Homes, and Communities ECE program was based on the organization's previously successful elementary school program and aligns with current early childhood nutrition and physical activity recommendations. Participating centers worked with HealthMPowers for up to 3 years. A team from each center led changes by conducting annual self-assessments, creating and implementing improvement plans, and implementing nutrition and physical activity programs using educational resources and environmental cues. A monitoring and evaluation plan provided ongoing feedback to HealthMPowers and centers. Family and staff surveys provided insights into behaviors of children, families, and staff. Process measures included specific benchmarks (e.g., center leadership team formation, improvement plan implementation). Annual self-assessment results served as intermediate outcome measures. RESULTS: As of 2017, 65 centers had enrolled in the program. All centers formed a health team and completed the baseline self-assessment and most implemented an improvement plan (88%). At the 1-year follow-up self-assessment, centers reported improvements from baseline including never offering food incentives for good behavior (75%-86%), conducting taste testing at least once a month (61%-79%), and rarely/never serving sugar-sweetened beverages (93%-96%). CONCLUSIONS: Initial process measures from a multicomponent health promotion program in ECE were promising. An integrated continuous improvement approach to working with child care settings is feasible and likely effective.

Impact of an Elementary School-Based Intervention on Physical Activity Time and Aerobic Capacity, Georgia, 2013-2014.

OBJECTIVES: The objectives of this study were to (1) determine the impact of a 1-year elementary school physical activity intervention on changes in teacher-reported school-based physical activity time and (2) assess the relationship between these changes and changes in student aerobic capacity. METHODS: HealthMPowers, a nonprofit organization, provided a multicomponent physical activity intervention to 3479 students in 39 schools in Georgia during 2013-2014. HealthMPowers administered a survey to faculty members before (August 2013) and after (May 2014) the intervention to measure student physical activity times. The organization collected pre- and post-intervention Progressive Aerobic Cardiovascular Endurance Run (PACER) laps (a measure of aerobic capacity that awards 1 lap for each completed 20-meter lap) for 2342 fourth-grade students. We performed linear regression to determine the relationship between school-level changes in teacher-reported school-based physical activity time and student aerobic capacity. RESULTS: The weekly estimated teacher-reported time in physical activity increased by 39 minutes from pre- to post-intervention: 21 minutes for recess, 17 minutes for classroom, and 1 minute for physical education. The mean number of student PACER laps increased by 3 laps from pre- to post-intervention, and 1515 of 2342 (65%) students increased the number of PACER laps completed. We observed a positive association between school-level changes in school-based physical activity time and school-level changes in PACER laps ( r = 0.38; 95% confidence interval, 0.29-0.46). CONCLUSIONS: These findings highlight the need for more prospective research into multicomponent physical activity interventions. Rigorous testing, including randomized controlled trials of large-scale implementations, is needed to examine how these school-based interventions might be used to improve the physical activity and fitness of larger populations of children.

Bridging Public Health and Education: Results of a School-Based Physical Activity Program to Increase Student Fitness.

OBJECTIVE: Power Up for 30 (PU30) is a schoolwide intervention that encourages schools to provide an additional 30 minutes of physical activity during the school day, beyond physical education. The objective of this study was to evaluate the impact of PU30 on Georgia public elementary schools and their students. METHODS: A total of 719 of 1320 public elementary schools in Georgia that were sent a baseline survey about school physical activity during October 2013 to September 2014 completed the survey, 160 of which were asked to complete a second survey. In the interim (March to June 2015), half (80) of these schools implemented the PU30 program. The interim surveys, which were completed during March to June 2015, assessed opportunities for student physical activity and staff member professional development focused on student physical activity. RESULTS: Compared with schools that had not implemented the program, more schools using the PU30 program reported offering before- and after-school physical activity programs. Forty-four of 78 (57%) PU30 schools compared with 20 of 53 (38%) non-PU30 schools offered before-school physical activity programs. Likewise, more PU30 schools than non-PU30 schools offered after-school physical activity programs (35% vs 16%), and a greater proportion of students at PU30 schools compared with non-PU30 schools met fitness benchmarks: recess 5 days per week (91% [288 of 323] vs 80% [273 of 341]), offering ≥11 minutes per day of classroom-based physical activity (39% [53 of 136] vs 25% [47 of 189] for kindergarten through second grade; 20% [37 of 187] vs 6% [9 of 152] for grades 3 through 5), and receiving physical activity-related professional development time (42% [136 of 323] vs 14% [48 of 341]). CONCLUSIONS: The surveys provided a statewide picture of the physical activity opportunities offered to students and staff members in Georgia elementary schools and demonstrated the effective use of a comprehensive, multicomponent program to offer more school-based physical activity opportunities and to improve student fitness.

Measurement of obesity prevention in childcare settings: A systematic review of current instruments.

OBJECTIVE: The incidence of childhood obesity is highest among children entering kindergarten. Overweight and obesity in early childhood track through adulthood. Programs increasingly target children in early life for obesity prevention. However, the published literature lacks a review on tools available for measuring behaviour and environmental level change in child care. The objective is to describe measurement tools currently in use in evaluating obesity-prevention in preschool-aged children. METHODS: Literature searches were conducted in PubMed using the keywords "early childhood obesity," "early childhood measurement," "early childhood nutrition" and "early childhood physical activity." Inclusion criteria included a discussion of: (1) obesity prevention, risk assessment or treatment in children ages 1-5 years; and (2) measurement of nutrition or physical activity. RESULTS: One hundred thirty-four publications were selected for analysis. Data on measurement tools, population and outcomes were abstracted into tables. Tables are divided by individual and environmental level measures and further divided into physical activity, diet and physical health outcomes. Recommendations are made for weighing advantages and disadvantages of tools. CONCLUSION: Despite rising numbers of interventions targeting obesity-prevention and treatment in preschool-aged children, there is no consensus for which tools represent a gold standard or threshold of accuracy.

Growing Fit: Georgia's model for engaging early care environments in preventing childhood obesity.

BACKGROUND: In the United States, one in three children is overweight or obese by their fifth birthday. In Georgia, 35 percent of children are overweight or obese. Contrary to popular belief, children who are overweight or obese are likely to be the same weight status as adults, making early childhood an essential time to address weight status. An estimated 380,000 Georgia children attend early care and education environments, such as licensed child care centers, Head Start, and pre-kindergarten programs, which provide an opportunity to reach large numbers of children, including those at risk for obesity and overweight. METHODS: To address this opportunity, the Georgia Department of Public Health, Georgia Shape - the Governor's Initiative to prevent childhood obesity, and HealthMPowers, Inc., created the Growing Fit training and toolkit to assist early childhood educators in creating policy, systems, and environmental changes that support good nutrition and physical activity. This report, the first related to this project, describes the training and its dissemination between January and December 2015. RESULTS: A total of 103 early childcare educators from 39 early childcare education centers (22 individual childcare systems) from 19 counties in Georgia were trained. Fifteen systems completed a pre and post-test assessment of their system, demonstrating slight improvements. Training for an additional 125 early childcare education centers is planned for 2016. CONCLUSIONS: Lessons learned from the first year of the training include the need for more robust assessment of adoption and implementation of policy, systems, and environmental changes in trained centers.

Response to commentary by Skinner et al. on Regression to the Mean (RTM) in Burke et al.

This letter is a response to commentary by Skinner et al. on an evaluation by Burke et al. of the HealthMPowers program, an elementary-school-based program developed to improve child health and wellness. In their commentary, Skinner et al. make the criticism that our results for changes in BMI-for-Age Z score were simply reflective of Regression to the Mean (RTM). In this response, we show that while some of our results are consistent with RTM, with adjustment we do still observe some small effects in BMI-for-Age Z score over the course of the school year. We conclude that while our evaluation was not definitive, we still believe that programs of similar design to HealthMPowers merit further rigorous study.

A holistic school-based intervention for improving health-related knowledge, body composition, and fitness in elementary school students: an evaluation of the HealthMPowers program.

BACKGROUND: Over the past 30 years, obesity in the United States has increased twofold in children and threefold in adolescents. In Georgia, nearly 17% of children aged 10 - 17 are obese. In response to the high prevalence of child obesity in Georgia and the potential deleterious consequences that this can have, HealthMPowers was founded in 1999 with the goal of preventing childhood obesity by improving health-enhancing behaviors in elementary schools, utilizing a holistic three-year program. This study measures the effectiveness of the HealthMPowers program in improving the school environment, student knowledge, behavior, cardiovascular fitness levels, and Body Mass Index (BMI). METHODS: The present analysis utilizes data from 40 schools that worked with HealthMPowers over the course of the 2012 - 2013 school year (including schools at each of the three years of the intervention period) and provided information on demographics, student knowledge and behaviors, BMI, performance on the PACER test of aerobic capacity, and school practices and policies (measured via school self-assessment with the HealthMPowers-developed instrument "Continuous Improvement Tracking Tool" or CITT), measured at the beginning and end of each school year. Paired two-sample T tests were used to compare continuous variables (e.g., student knowledge scores, BMI-for-age Z scores), while chi-squared tests were used to assess categorical variables (e.g., trichotomized PACER performance). RESULTS: Students across all grades and cohorts demonstrated improvements in knowledge and self-reported behaviors, with particularly significant improvements for third-graders in schools in the second year of the HealthMPowers program (p < 0.0001). Similarly, decreases were observed in BMI-for-Age Z scores for this cohort (and others) across grades and gender, with the most significant decreases for students overweight or obese at baseline (p < 0.0005). Students also showed significant increases in performance on the PACER test across grades and cohorts (p < 0.0001). Lastly, schools tended to improve their practices over time, as measured via the CITT instrument. CONCLUSIONS: The present report demonstrates the effectiveness of the HealthMPowers program in producing positive change in school policies and practices, student knowledge and behaviors, and student fitness and BMI, supporting the use of holistic interventions to address childhood obesity.