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Parks and Recreation: Centers for Eating and Physical Activity Behavior Interventions
C H A P T E R
22 Parks and Recreation: Centers for Eating and Physical Activity Behavior Interventions Danielle Hollar*, Kellie May†, and Allison Colman† *Healthy Networks Design and Research, Shepherdstown, WV, United States † National Recreation and Park Association, Ashburn, VA, United States
22.1 INTRODUCTION Summertime, a time when most people think of children running around and being healthy, is a very challenging time for some children with respect to weight gain and, paradoxically, child hunger. Many weight-related gains made during the school year are lost over summertime when many children experience rapid weight gain [1–6]. Certain subgroups appear to experience accelerated weight gain during the summer, in particular, black, Hispanic, and overweight children of all races/ethnicities [7]. In the summer months, children may be susceptible to rapid weight gain due to unstructured environments [1, 3] within which they live during the summer that may allow longer periods of sedentary behavior, including increased screen time usage (watching television or playing video games) [8]. Summertime environments may limit daily physical activity due to unsafe neighborhoods, limited access to recreation facilities or parks for physical activity, and/or extreme weather conditions [1]. Unstructured/unsupervised environments also allow for increased snacking and higher consumption of calorie-dense, less-nutritious foods and beverages than those consumed at school [1, 6, 8, 9]. Park and recreation (P&R) agencies are uniquely positioned to address these eating and physical activity issues, especially during the summer. Many P&R agencies provide children with nutritious meals and snacks as part of United States Department of Agriculture (USDA) programs, such as the USDA Summer Food Service Program. In fact, 57% of all P&R agencies provide summer or afterschool meals [10]. They also provide safe spaces for physical activity, resulting in higher levels of physical activity among children attending summer camps as compared to those who do not [11]. Finally, some agencies, as part of the Commit to Health (C2H) program, have been successful in developing and implementing a comprehensive approach to improving eating and physical activity behaviors among young children. These C2H agencies implement policies and practices that promote healthy eating by offering nutritious options during meal and snack times, reduced access to less-nutritious foods (vending for example), increased physical activity programming, and they provide evidence-based nutrition and health education during summers and other out-of-school time (OST) programming.
22.2 COMMIT TO HEALTH C2H, launched by the National Recreation and Park Association (NRPA) in 2014, was created to address childhood obesity and child hunger through the development of community-based partnerships to implement nutrition, physical activity, and policy interventions during OST. This type of collaboration takes a multilevel, multiagency approach to obesity prevention and treatment by creating “obesity prevention collaboratives,” whereby synergies of combining
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proven-effective programs operated by multidisciplinary collaborators are achieved. In so doing, collaborations are created locally and nationally. Local collaborations may include local P&R agencies, university cooperative extension, schools, and nonprofit organizations (YMCAs, Boys and Girls Clubs, etc.). Nationally, NRPA collaborates with nonprofit foundations and organizations (Alliance for a Healthier Generation, National Afterschool Association, Food Research and Action Center) and national foundations (The Walmart Foundation), among others. These multilevel, multiagency collaboration partners bring strong sets of skills (including nutrition education and outreach, program evaluation, and dissemination of best practices/results) and the potential for leveraging of skills and resources, to shape policies and programs affecting the health of diverse populations of children and families in sustainable ways during summer OST programs. Due to C2H initiatives, hundreds of thousands of children have been educated about healthy eating and physical activity habits in P&R sites that provide healthy environments in accordance with Healthy Eating and Physical Activity (HEPA) standards [12]. C2H includes multiple components, each aimed to improve the health and well-being of children and their families. This chapter describes the C2H components and presents the impact on overall health knowledge, as well as child, parent, and staff eating and physical activity behaviors.
22.2.1 Foods of the Month One component of C2H, the Foods of the Month (FoM), focuses on improving healthy eating and physical activity of children during summer camps through programming that teaches children about the importance of healthy eating and being active. This food-focused curriculum was developed during the last 4 years, with funding from The Walmart Foundation. The components of the FoM program have evolved significantly over the last 4 years from a program that required P&R sites to purchase kits of materials to the current program during the first 2 years, which provides materials, training, and online resources that are free to any group wishing to implement the program. Each phase of program development was evaluated for impact, feasibility, and replicability. The current FoM curricula are found on the NRPA website [13] and include components chosen based on efficacy, as proven in evaluation findings, some of which are presented in the Results section of this chapter. The C2H FoM curriculum profiles two nutrient-rich foods/food groups each month through a variety of activities to engage and educate children about nutrient-rich foods. Newsletters, worksheets/coloring sheets, experiential foodbased activities, USDA materials about the FoM, and recommendations for offering fun bouts of physical activity, often in ways that promote learning about the FoM, are provided on the C2H website. After a national webcast training for P&R staff, staff lead nutrition literacy activities in varying amounts, fitting the FoM programming into their regular summer camp activities/programming in ways that make sense at each P&R site. Thus some camps teach the FoM curricula in short bursts of lessons every day, whereas others teach it during longer blocks of time a couple of times a week. A Facilitator’s Guide for the FoM and the Community and Home Gardening component, described later, are also available on the NRPA C2H website [14].
22.2.2 Community and Home Gardening Programming In 2016–17, due to gardening interests voiced by P&R campers and staff, a Community and Home Gardening (CHG) program was created, also funded by the Walmart Foundation. The CHG program is comprised of a set of free materials [15] that cover gardening topics such as composting, garden design, tending, and harvesting. The aim of this component is to teach children and their parents how to garden at home and/or in community projects (including indoor gardens), the value of plant-based foods they can grow, budget-saving considerations when growing their own foods, etc. The CHG online curriculum and tools, which include monthly newsletters, gardening tip sheets, child-based gardening activities, coloring sheets, and seasonal gardening promotional materials [15], also help teach staff who lead the program how to lead gardening education, install community gardens and indoor gardens, and consider unique opportunities for utilizing harvests. This CHG program is in the process of being evaluated; results should be forthcoming in other publications.
22.3 METHODS 22.3.1 Evaluation Design and Participants An ongoing, formal evaluation has been taking place since C2H commenced in 2014. Operating under an institutional review board (IRB) approval from Sterling IRB, Atlanta, GA, each year a subset of P&R sites from across the V. PREVENTION AND TREATMENT
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United States, who are grantees of the C2H program, are chosen for the study. Each year, the sample of sites represents the great diversity of the United States with respect to race/ethnicity (based on standardized categories of the C2H administrative records), as well as geography, and always is chosen from a convenience sample. Inclusion criteria require that study sites conduct at least 6 weeks of full-day summer camps, include children in grades kindergarten through fifth grade, and require registration rather than drop-in participation in an attempt to ensure that most children attending camp would attend each day. The study population always includes fourth and fifth graders, who would be most likely to be able to participate independently in survey activities, parents in some years, and P&R staff each year. Data are collected annually using pre- and postchild, parent, and/or staff surveys. In some years, focus groups also are conducted to acquire qualitative data.
22.3.2 Measures and Instruments The primary outcome measures assess frequency of specific food consumption with the aim to assess overall improved healthy eating behaviors. Secondary outcome measures assess knowledge and familiarity/experience with healthy eating and living activities. Survey questions for assessing primary and secondary outcomes were developed specifically for this study to ensure appropriateness with regards to the context of the C2H nutrition literacy programming. For example, the FoM program focuses on very specific foods, thus questions were created to assess knowledge and behavior change with regards to those specific foods. Child surveys contain questions (Likert scale and Yes/No) measuring frequency of specific FoM food consumption, general knowledge of health and food, familiarity with healthy living activities (such as gardening, cooking), and a few questions about MyPlate. Child postsurveys also include open-ended questions at the end to capture some qualitative data. Staff surveys contain questions (Likert scale and Yes/No) measuring frequency of specific FoM food consumption, observation of children at their camp with regards to specific FoM food consumption, general knowledge of health and food, and familiarity/experience with healthy living activities (such as gardening, cooking). Staff postsurveys also include open-ended questions at the end to gather qualitative data. Child surveys are translated into Spanish and certified, as needed. Staff surveys do not need to be translated. Surveys in paper format are administered to children by P&R staff. Staff completed paper surveys as well.
22.3.3 Data Analysis Analyses typically include McNemar test (dichotomous data) or Wilcoxon signed rank test (ordinal data) with statistical significance at P < .05. Statistical analyses usually are performed with Microsoft Office Excel, 2013 (15.0.4989.1000).
22.4 RESULTS Results presented here include a sampling of our findings, organized by year. Prior to each set of results, we provide a summary of the type of intervention/programming provided during that summer camp year. As you can see, the type of intervention changed over the 4 years, primarily due to finding efficacy in programming that included free materials (versus programming that required purchase of materials). Throughout the years, children, parents, and staff learned a lot about nutrition and healthy living, and improved their eating and physical activity behaviors.
22.4.1 Summer 2014 Interventions: Nutrition and health education using The OrganWise Guys (OWG) [15], OWG FoM, and OWG physical activity. OrganWise Guys materials were purchased by NRPA and provided to sites. Some sites bought additional OWG materials, at their discretion. Results: During the summer of 2014, C2H operated in a total of 557 locations (257,000 children grades K-6). An evaluation of impact included pre-June and post-August surveys of a nationwide representative sample including 426 children, 92 staff, and 116 parents. Results were presented at a few conferences, including the Food and Nutrition Conference & Exposition of the Academy of Nutrition and Dietetics [16]. Results showed significant improvements in nutrition knowledge and eating behaviors. Among children, statistically significant improvements in correct responses regarding nutrition knowledge topics: main antioxidants/vitamins found in fruits/vegetables (14.8%–34.0%, McNemar Test; P ¼ .000), which type of cereal is best V. PREVENTION AND TREATMENT
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(57.7%–72.3%; P ¼ .000), which type of food is a protein (64.1%–72.5%; P ¼ .000), what foods have the most fiber (43.9%–65.3%; P ¼ .000), and what organ regulates sugar (39.7%–51.9%; P ¼ .002). Child eating behavior improvement was noted in the following: increases in fruits (z-2.801; P ¼ .005), bell peppers (z-2.483; P ¼ .013), spinach, and low-fat dairy. Among parents, eating behavior results showed the following: increases in consumption vegetables (z-score 2.22; P ¼ .026), bell peppers (z-2.166; P ¼ .030), spinach (z-3.213; P ¼ .001), summer squash (z-2.867; P ¼ .004), and fish (z-2.553; P ¼ .011). Smaller nonsignificant increases were reported in consumption of tropical fruits, stone fruits, and low-fat dairy. Staff reported similar nonsignificant increases in consumption of bell peppers, spinach, tropical fruits, stone fruits, summer squash, and lean proteins [16].
22.4.2 Summer 2015 Interventions: Nutrition and health education using a new set of free materials focusing on those from the USDA (nutrition and physical activity), a smaller set of OWG items, OWG FoM, and OWG physical activity. Results: During the summer of 2015, C2H operated in 782 locations (153,900 children grades K-6). An evaluation of impact included pre (June)- and post (August)-surveys of a nationwide representative sample including 182 staff from 14 cities, as well as focus groups with children, parents, and staff in 10 locations. Results on physical activity impact were presented at the 2017 Active Living Research Annual Conference [17]. Results showed the nutrition literacy programming components led to increase in health knowledge among children, as recognized by staff who reported significant increases in agreement from the beginning of summer to the end with a statement “children who attend your camp know what kinds of foods are the best for keeping their bodies healthy” (26% increase; all analyses used Wilcox Test; P < .05). This was echoed by staff observations of child eating behaviors that showed percent increases, from beginning to end of summer, in staff reports that they “agree” or “strongly agree” that children “like and eat” specific foods were: vegetables 37.7% (Wilcox Test, P ¼ .000), fruits 24.2% (Wilcox Test, P ¼ .000), milk 15.8% (Wilcox Test, P ¼ .009), stone fruit 15.7% (Wilcox Test, P ¼ .005), spinach 14.4% (Wilcox Test, P ¼ .000), tropical fruit 14.1% (Wilcox Test, P ¼ .000), bell peppers 13.3% (Wilcox Test, P ¼ .000), berries 13.0% (Wilcox Test, P ¼ .000), eggs 12.0% (Wilcox Test, P ¼ .001), and summer squash 11.6% (Wilcox Test, P ¼ .000). Results also showed that staff learned a lot too, which enhances their personal life, as well as their ability to lead nutrition and healthy living programs during summer camps. From the beginning to the end of summer, there were statistically significant increases in the respondents who know how to cook and prepare healthy foods (19.1%) (Wilcox Test, P ¼ .001), know what foods have lots of fiber (23.0%) (Wilcox Test, P ¼ .000), know the MyPlate food groups (21.9%) (Wilcox Test, P ¼ .000), how to plant a garden (16.3%) (Wilcox Test, P ¼ .000), exercise (9.8%) (Wilcox Test, P ¼ .039), and feel they are good role models regarding healthy eating (18.6%) (Wilcox Test, P ¼ .000). With regards to physical activity specifically, based on prepost surveys (Staff ¼ 182), health event exit surveys (adults ¼ 108), and focus groups (child, adult, and staff ) from 10 P&R sites, C2H programming led to the following changes in physical activity behaviors [17]: • Children: Reducing the amount of screen time due to focus on physical activity (PA) Educating parents about PA needs of children and parents • Parents: Increasing PA and PA as a family Reporting children getting involved in sports due to OST activities Learning about need for and new types of PA at events, filling gaps in PA knowledge • Staff: Observing improvements in fitness of children, due to HEPA emphases Learning and leading successful PA programming Feeling that increased focus on PA was feasible to implement
22.4.3 Summer 2016 Interventions: Nutrition and health education using a totally new, free C2H FoM curriculum, as well as free USDA nutrition education materials, free USDA physical activity materials, free materials from other health education sources, free newly revised monthly lesson guides (set includes two guides, one for grades K-2 and one for grades 3–5), and free webinars and online staff training (no OWG items included anymore).
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Results: During the summer of 2016, the C2H nutrition literacy program was implemented nationwide in >750 P&R locations, impacting approximately 187,000 children in grades K-6. An evaluation of impact took place in nine locations and included pre (June)- and post (August)-surveys of a nationwide representative sample including 309 fourth and fifth graders and 86 staff, as well as focus groups of children and staff. Because the results of summer 2016 impacts are under review for publication, specific outcomes cannot be reported here. However, overall, results show statistically significant improvements in eating behaviors of children attending summer camp at P&R sites, as well as eating behaviors of camp staff, after just a short 6- to 8-week nutrition literacy program. Campers also reported significant increases in knowledge of healthy eating and living. Some qualitative data from focus groups illustrate some of these findings. Children were asked during focus groups what they learned at camp about nutrition that they shared with their parents. Some of the responses from the children were as follows: • • • • •
“Told mom not to buy junk food so we don’t eat it.” “The food that my parents buy is pretty different now.” “My step-dad and me eat healthier now, camp helped.” “Went home and said I wanted a chicken wrap.” “Taught mom how to cook healthy food with portion sizes.”
During focus groups, parents echoed some of the statements of the children, explaining what they learned about food, based on what their children had told them. For example, • “When we went to the grocery store, I picked a cookie cereal. My daughter said, ‘That’s too unhealthy.’” • “Yes, my son talks to me about what he eats and tries to work on eating at home. He used to be very picky and now he’s started eating fruits and vegetables and especially whole wheat. Wants a vegetable garden.” • “We’ve tried different smoothies, good family activity.” • “I don’t know who taught my son about MyPlate, but he told me about it and that’s what I use at work, and we now use it at home.” Staff reported that lessons they teach are making it to the home. For example, “kids tell their parents about the foods and the parents ask us about recipes and things.” Staff at another P&R site echoed this by saying, “the kids are excited and taking the recipes home with them and parents are helping the kids make them at home.” They also see less junk food coming to camp, “I don’t see soda coming in or high fat foods come in anymore.”
22.4.4 Summer 2017 Interventions: Nutrition and health education using a totally new, free CHG program in addition to the free C2H FoM curriculum, free USDA nutrition education materials, free USDA physical activity materials, free newly revised monthly lesson guides (two sets of for grades K-2 and 3–5, one for FoM and one for CHG), and free webinar and online staff training (no OWG items included anymore). Results: Analyses of pre- and postsurvey data for summer 2017 are taking place currently and should be ready for publication later in 2018. Some qualitative data are available now, and so are presented here, including a few case studies of impact. Children learned a lot about the FoM foods and changed their eating and physical activity behaviors, as shown in some quotes provided by campers here. • “The vitamins lesson, learned that fruits have a lot of taste, didn’t know about the vitamins in vegetables before camp.” • “When we eat dinner, we have a bowl of fruit now too.” • “I learned to eat more veggies and fruits.” • “I learned fruits and vegetables are something you should eat everyday.” • “I learned that bell peppers have vitamin A and vitamin C.” • “I learned that lots of vegetables come in a lot of colors.” • “I learned that bell peppers have good stuff in them than they help you to heal [your] face and eyes.” • “Eat whole grain bread in my sandwiches.” • “I learned about stone fruits and how healthy they are.” • “It’s fun to go grocery shopping with parents – help pick out healthy foods that taste good!” • “Go outside more, used to stay inside more, feel more athletic.”
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Children also learned enough about nutrition and/or food preparation to take some of the lessons home to their families. • • • • • • • • • • • •
“Taught my mother, how to make a rainbow burrito!!! It was awesome!” “I taught my parents that I like a parfait.” “I told my parents about bell peppers and what they give us.” “I taught my parents that you can make very delicious foods with very healthy things.” “I am going to teach my parents how much is 1 serving.” “Taught my family how to plant new foods in the garden.” “I learned that cooking homemade foods are better than buying food from the store.” Taught family “how to water a garden.” Taught family “how to make eggs.” Taught family “about bell peppers and humus and berries.” Taught family about “fruit pizza and cinnamon chips.” “We made bell pepper dip.”
In focus groups at the end of the summer, staff shared that parents reported changes in their family’s eating plans and/or behaviors. Some examples shared here: • “One example of a mom who said that every Sunday evening their family now shops for fruits and vegetables for the week.” • Children asked for recipes, “so they can have their parents make the same food. Staff is making copies of recipes and handing them out to parents.” • A “grandma said kid is more conscious of what he’s eating, went to [fast food restaurant] and said can’t get this or that because it’s not good for him.” 22.4.4.1 Case Study 1: Richmond, VA In addition to the grant helping thousands of hungry children receive the vital meals and nutrients they need for healthy growth and development, the overall program also influences individual health in a variety of ways, including contributing to weight loss, providing avenues for social and emotional benefits, and lowering the risk of chronic disease. In Richmond, VA, the P&R department received a call from a camper’s parent following several weeks of participation in the nutrition education component of summer camp. The parents shared that the child had gone to the doctor at the beginning of the summer and it was reported that she had borderline high cholesterol—most likely due to the fact that the family was not eating very healthy. The family relied on fast food, sometimes twice a day, to feed their kids, rather than purchasing and serving a balanced diet. After attending the summer program and learning about healthy foods and physical activity, the child communicated to her parents the importance of changing their lifestyle. She went to the grocery store with a chart of fruits and vegetables (the FoM calendar) provided by the camp staff, and she and her parents purchased healthier foods instead of the previously purchased fried and processed foods. They decided as a family that, instead of eating out at fast food restaurants every day, they would cut back. Thanks to the FoM curriculum, this particular family is now consuming a more balanced diet, resulting in lower cholesterol levels and developing long-term health and wellness habits for the whole family. 22.4.4.2 Case Study 2: San Antonio, TX Another outcome attributed to the grant can be seen in the P&R staff members who were responsible for implementing the program. In many cases, especially during summer camp programs, staff members consist of high school and college-aged counselors who are still developing habits. The grant provided P&R staff with the skills needed to teach nutrition education to youth, and to be positive role models and change their own eating and drinking behaviors. One of the nutrition specialists hired by the City of San Antonio to provide nutrition education this past summer shared that she found the FoM curriculum valuable for her own personal health and wellness habits. She explained that the program was helpful for keeping her on her toes—bringing a healthy lunch to work, drinking water and not sugary beverages, and being active with the kids at camp were all part of the job. She learned new information about specific foods and food groups, and gained the skills necessary to provide nutrition education to children in an OST setting. This particular instructor mentioned that, thanks to her participation in the summer camp program, she’s interested in pursuing a future career in public health. The grant not only changed habits and lifestyle behaviors, but it provided an avenue for the next generation of leaders and workers to gain additional skills.
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22.4.4.3 Case Study 3: Brevard County, FL Although access to fresh foods is something many take for granted, many families are not able to provide such foods due to cost, transportation barriers, or a lack of knowledge. In Brevard County, Florida, the grantee said that implementing the FoM curriculum was one of the most enjoyed aspects of this grant. It exposed children to new foods and provided education about nutrition that they had not received before. At one of the sites in Brevard County, it was the first time some of the children had followed a recipe to cook. One camper shared with staff that she was excited to crack an egg for the first time! The children were excited to share their experiences and new knowledge with their parents, which led to the parents learning about nutrition from their children! Brevard County shared they were excited to see this impact that they were having on the children and their families—and the community as a whole. 22.4.4.4 Case Study 4: San Jose, CA In San Jose, California, the FoM and nutrition literacy curriculum turned out to be a solution to a problem the P&R agencies didn’t know they had. After the first week of summer camps, staff at all 10 sites utilizing the grant recognized that many of the children were arriving without having breakfast. This began a snowball effect, where the children were often moody or agitated, were inattentive, acted out, and were sluggish. As a group, staff decided that the cooking lessons being done along with nutrition literacy should take place no later than 10 a.m. as often as possible to help address this need. Scheduling the lessons early was a twofold solution. Kids were still engaged and in good spirits, and were interested in helping, and then reaping the benefits of their hard work by getting to eat the great foods they made. For example, whole wheat blueberry pancakes and scrambled eggs with bell peppers were two of the most wellreceived foods cooked within the camps. These were easy for staff to prep, easy for the kids to help with, and very appealing to the kids. Throughout the cooking process, the participants were given plain fruits and vegetables (i.e., blueberries and bell peppers) to taste the foods by themselves and compare the taste once the foods were cooked. On days where these lessons were held, staff was able to guarantee that the participants had a healthy and substantial breakfast. As a result, they were more attentive, engaged more readily in activities throughout the day, were in better moods, and had more energy compared to days where these lessons were not taught.
22.5 DISCUSSION The ongoing evaluations of a community-based obesity prevention program for elementary school-aged children attending summer camps where they receive USDA Summer Meals and participate in nutrition and healthy living educational programming described in this chapter show much promise for improving eating and physical activity behaviors. Overall, nutrition and overall health knowledge increased during the summer. Children themselves, as well as reports of proxies (their camp staff and/or parents), reported knowing more about specific foods, how to prepare nutritious foods (cooking and cold prep), what their bodies need to be healthy (good food and physical activity), and how to garden. Similar outcomes were found among staff and parents, both groups of which reported learning a lot about nutrition, foods, and the need for physical activity from their children and/or by being teachers of summer camp health education programs. Critical to the prevention and treatment of obesity are eating and physical activity behaviors. Both of these needs to be addressed to keep our bodies healthy. Results of the various evaluations of C2H show that campers took the knowledge they learned and put it into action; they began eating nutritious foods they had not eaten prior to camp, and/or they increased their consumption of the focus foods. They also reported being much more active during camp and at home. Parents confirmed these reports during focus groups, indicating that their children were much more active and that they as families have become more physically active. Finally, staff reports of consumption of new, and/or increased consumption of, foods they taught about during the lessons shows their eating behaviors improved as well. The authors concede that the results of each annual evaluation are limited, in part, because there was no control group for comparison. However, we feel that having no control group can be seen as somewhat customary for the pilot phase of a program, as is the case here, where the interventions were changed quite significantly from year to year, based on qualitative feedback and financial considerations for sustainability and replicability. Strengths of our evaluation plan help overcome this limitation, including the study population’s wide geographic and racial/ethnic representation of the U.S., and the large number of children, staff, and/or parents who completed both pre- and postsurveys when administered, and participated in focus groups as they were held.
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22.6 CONCLUSION In the end, what these results show is that summer camp staff at P&R agencies can be important change agents with regards to improving the eating behaviors of young children they serve. Even if staff are not formally credentialed in nutrition education (i.e., they do not have nutrition degrees/certifications), C2H nutrition literacy program virtual trainings and materials can be put into practice successfully and efficaciously, leading to significant eating and physical activity behavior change. C2H materials are used in different ways, in different blocks of time (a few minutes each day, or for an hour up to three times per week, for example), based on the time availability and local camp context and resources (kitchen on site or not, for example). Despite the varied approaches to curriculum implementation, the results show significant, positive impact. Thus community-based obesity prevention programs—which include a combination of USDA Summer Meals and provision of nutrition and healthy lifestyle education and physical activity—show promise in improving the eating and physical activity behaviors of young children, and thus in the prevention and treatment of childhood obesity. Community-based “obesity prevention collaboratives” bring together multilevel, multiagency collaboration among partners with strong sets of skills (including nutrition education and outreach, program evaluation, and dissemination of best practices/results) and the potential for leveraging of skills and resources, to shape policies and programs affecting the health of the diverse populations of children and families in sustainable ways during summer OST, and perhaps even all year long as part of year-round OST programs. In conclusion, the fact that significant improvements in eating behaviors of children and staff occurred each of the four summers, within just the short timeframe of a 6- to 8-week summer camp, makes the case for increasing the reach of this summer camp program, as well as similar programming in other out-of-school contexts year-round. The C2H program operates in some P&R agencies in the afterschool context, evaluation of these initiatives should be done to inform the research and practice communities in this setting. The C2H FoM curricula and materials are available for free online to any childcare provider, including summer camp operators, OST programs, home school parents/ leaders, classroom teachers, and anyone else interested in teaching children about nutrient-rich foods. We look forward to replication and expansion of C2H, ongoing research regarding impact, and to improving the health of children in such programs.
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[15] National Recreation and Park Association. Community and home gardening curriculum, Ashburn, VA, https://www.nrpa.org/our-work/ partnerships/initiatives/commit-to-health/community-home-gardening/. Accessed 1 June 2018. [16] Hollar D, Collum M, May K. Commit to health: a nationwide summer camp nutrition and feeding intervention improves nutrition knowledge and healthy eating behaviors of children, parents, and staff. Nashville, TN: Academy of Nutrition and Dietetics Food and Nutrition Conference & Expo; 2015. October 6. [17] Hollar D, Colman A, May K. Commit to health: policies and standards targeting increased physical activity during out-of-school times produce results. In: Active Living Research Annual Conference. Clearwater Beach, FL. February 26–March 1; 2017.
Further Reading [18] National Recreation and Park Association. Commit to health healthy eating and physical activity (HEPA) standards. Ashburn, VA, http:// www.nrpa.org/uploadedFiles/nrpaorg/Grants_and_Partners/Recreation_and_Health/Commit_to_Health_Resources/Commit-to-HealthHEPA-Standards%20(2).pdf. Accessed 4 January 2018. [19] The OrganWise Guys, Suwanee, GA, https://organwiseguys.com/. Accessed 1 June 2018.
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22 Parks and Recreation: Centers for Eating and Physical Activity Behavior Interventions Danielle Hollar*, Kellie May†, and Allison Colman† *Healthy Networks Design and Research, Shepherdstown, WV, United States † National Recreation and Park Association, Ashburn, VA, United States
22.1 INTRODUCTION Summertime, a time when most people think of children running around and being healthy, is a very challenging time for some children with respect to weight gain and, paradoxically, child hunger. Many weight-related gains made during the school year are lost over summertime when many children experience rapid weight gain [1–6]. Certain subgroups appear to experience accelerated weight gain during the summer, in particular, black, Hispanic, and overweight children of all races/ethnicities [7]. In the summer months, children may be susceptible to rapid weight gain due to unstructured environments [1, 3] within which they live during the summer that may allow longer periods of sedentary behavior, including increased screen time usage (watching television or playing video games) [8]. Summertime environments may limit daily physical activity due to unsafe neighborhoods, limited access to recreation facilities or parks for physical activity, and/or extreme weather conditions [1]. Unstructured/unsupervised environments also allow for increased snacking and higher consumption of calorie-dense, less-nutritious foods and beverages than those consumed at school [1, 6, 8, 9]. Park and recreation (P&R) agencies are uniquely positioned to address these eating and physical activity issues, especially during the summer. Many P&R agencies provide children with nutritious meals and snacks as part of United States Department of Agriculture (USDA) programs, such as the USDA Summer Food Service Program. In fact, 57% of all P&R agencies provide summer or afterschool meals [10]. They also provide safe spaces for physical activity, resulting in higher levels of physical activity among children attending summer camps as compared to those who do not [11]. Finally, some agencies, as part of the Commit to Health (C2H) program, have been successful in developing and implementing a comprehensive approach to improving eating and physical activity behaviors among young children. These C2H agencies implement policies and practices that promote healthy eating by offering nutritious options during meal and snack times, reduced access to less-nutritious foods (vending for example), increased physical activity programming, and they provide evidence-based nutrition and health education during summers and other out-of-school time (OST) programming.
22.2 COMMIT TO HEALTH C2H, launched by the National Recreation and Park Association (NRPA) in 2014, was created to address childhood obesity and child hunger through the development of community-based partnerships to implement nutrition, physical activity, and policy interventions during OST. This type of collaboration takes a multilevel, multiagency approach to obesity prevention and treatment by creating “obesity prevention collaboratives,” whereby synergies of combining
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proven-effective programs operated by multidisciplinary collaborators are achieved. In so doing, collaborations are created locally and nationally. Local collaborations may include local P&R agencies, university cooperative extension, schools, and nonprofit organizations (YMCAs, Boys and Girls Clubs, etc.). Nationally, NRPA collaborates with nonprofit foundations and organizations (Alliance for a Healthier Generation, National Afterschool Association, Food Research and Action Center) and national foundations (The Walmart Foundation), among others. These multilevel, multiagency collaboration partners bring strong sets of skills (including nutrition education and outreach, program evaluation, and dissemination of best practices/results) and the potential for leveraging of skills and resources, to shape policies and programs affecting the health of diverse populations of children and families in sustainable ways during summer OST programs. Due to C2H initiatives, hundreds of thousands of children have been educated about healthy eating and physical activity habits in P&R sites that provide healthy environments in accordance with Healthy Eating and Physical Activity (HEPA) standards [12]. C2H includes multiple components, each aimed to improve the health and well-being of children and their families. This chapter describes the C2H components and presents the impact on overall health knowledge, as well as child, parent, and staff eating and physical activity behaviors.
22.2.1 Foods of the Month One component of C2H, the Foods of the Month (FoM), focuses on improving healthy eating and physical activity of children during summer camps through programming that teaches children about the importance of healthy eating and being active. This food-focused curriculum was developed during the last 4 years, with funding from The Walmart Foundation. The components of the FoM program have evolved significantly over the last 4 years from a program that required P&R sites to purchase kits of materials to the current program during the first 2 years, which provides materials, training, and online resources that are free to any group wishing to implement the program. Each phase of program development was evaluated for impact, feasibility, and replicability. The current FoM curricula are found on the NRPA website [13] and include components chosen based on efficacy, as proven in evaluation findings, some of which are presented in the Results section of this chapter. The C2H FoM curriculum profiles two nutrient-rich foods/food groups each month through a variety of activities to engage and educate children about nutrient-rich foods. Newsletters, worksheets/coloring sheets, experiential foodbased activities, USDA materials about the FoM, and recommendations for offering fun bouts of physical activity, often in ways that promote learning about the FoM, are provided on the C2H website. After a national webcast training for P&R staff, staff lead nutrition literacy activities in varying amounts, fitting the FoM programming into their regular summer camp activities/programming in ways that make sense at each P&R site. Thus some camps teach the FoM curricula in short bursts of lessons every day, whereas others teach it during longer blocks of time a couple of times a week. A Facilitator’s Guide for the FoM and the Community and Home Gardening component, described later, are also available on the NRPA C2H website [14].
22.2.2 Community and Home Gardening Programming In 2016–17, due to gardening interests voiced by P&R campers and staff, a Community and Home Gardening (CHG) program was created, also funded by the Walmart Foundation. The CHG program is comprised of a set of free materials [15] that cover gardening topics such as composting, garden design, tending, and harvesting. The aim of this component is to teach children and their parents how to garden at home and/or in community projects (including indoor gardens), the value of plant-based foods they can grow, budget-saving considerations when growing their own foods, etc. The CHG online curriculum and tools, which include monthly newsletters, gardening tip sheets, child-based gardening activities, coloring sheets, and seasonal gardening promotional materials [15], also help teach staff who lead the program how to lead gardening education, install community gardens and indoor gardens, and consider unique opportunities for utilizing harvests. This CHG program is in the process of being evaluated; results should be forthcoming in other publications.
22.3 METHODS 22.3.1 Evaluation Design and Participants An ongoing, formal evaluation has been taking place since C2H commenced in 2014. Operating under an institutional review board (IRB) approval from Sterling IRB, Atlanta, GA, each year a subset of P&R sites from across the V. PREVENTION AND TREATMENT
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United States, who are grantees of the C2H program, are chosen for the study. Each year, the sample of sites represents the great diversity of the United States with respect to race/ethnicity (based on standardized categories of the C2H administrative records), as well as geography, and always is chosen from a convenience sample. Inclusion criteria require that study sites conduct at least 6 weeks of full-day summer camps, include children in grades kindergarten through fifth grade, and require registration rather than drop-in participation in an attempt to ensure that most children attending camp would attend each day. The study population always includes fourth and fifth graders, who would be most likely to be able to participate independently in survey activities, parents in some years, and P&R staff each year. Data are collected annually using pre- and postchild, parent, and/or staff surveys. In some years, focus groups also are conducted to acquire qualitative data.
22.3.2 Measures and Instruments The primary outcome measures assess frequency of specific food consumption with the aim to assess overall improved healthy eating behaviors. Secondary outcome measures assess knowledge and familiarity/experience with healthy eating and living activities. Survey questions for assessing primary and secondary outcomes were developed specifically for this study to ensure appropriateness with regards to the context of the C2H nutrition literacy programming. For example, the FoM program focuses on very specific foods, thus questions were created to assess knowledge and behavior change with regards to those specific foods. Child surveys contain questions (Likert scale and Yes/No) measuring frequency of specific FoM food consumption, general knowledge of health and food, familiarity with healthy living activities (such as gardening, cooking), and a few questions about MyPlate. Child postsurveys also include open-ended questions at the end to capture some qualitative data. Staff surveys contain questions (Likert scale and Yes/No) measuring frequency of specific FoM food consumption, observation of children at their camp with regards to specific FoM food consumption, general knowledge of health and food, and familiarity/experience with healthy living activities (such as gardening, cooking). Staff postsurveys also include open-ended questions at the end to gather qualitative data. Child surveys are translated into Spanish and certified, as needed. Staff surveys do not need to be translated. Surveys in paper format are administered to children by P&R staff. Staff completed paper surveys as well.
22.3.3 Data Analysis Analyses typically include McNemar test (dichotomous data) or Wilcoxon signed rank test (ordinal data) with statistical significance at P < .05. Statistical analyses usually are performed with Microsoft Office Excel, 2013 (15.0.4989.1000).
22.4 RESULTS Results presented here include a sampling of our findings, organized by year. Prior to each set of results, we provide a summary of the type of intervention/programming provided during that summer camp year. As you can see, the type of intervention changed over the 4 years, primarily due to finding efficacy in programming that included free materials (versus programming that required purchase of materials). Throughout the years, children, parents, and staff learned a lot about nutrition and healthy living, and improved their eating and physical activity behaviors.
22.4.1 Summer 2014 Interventions: Nutrition and health education using The OrganWise Guys (OWG) [15], OWG FoM, and OWG physical activity. OrganWise Guys materials were purchased by NRPA and provided to sites. Some sites bought additional OWG materials, at their discretion. Results: During the summer of 2014, C2H operated in a total of 557 locations (257,000 children grades K-6). An evaluation of impact included pre-June and post-August surveys of a nationwide representative sample including 426 children, 92 staff, and 116 parents. Results were presented at a few conferences, including the Food and Nutrition Conference & Exposition of the Academy of Nutrition and Dietetics [16]. Results showed significant improvements in nutrition knowledge and eating behaviors. Among children, statistically significant improvements in correct responses regarding nutrition knowledge topics: main antioxidants/vitamins found in fruits/vegetables (14.8%–34.0%, McNemar Test; P ¼ .000), which type of cereal is best V. PREVENTION AND TREATMENT
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(57.7%–72.3%; P ¼ .000), which type of food is a protein (64.1%–72.5%; P ¼ .000), what foods have the most fiber (43.9%–65.3%; P ¼ .000), and what organ regulates sugar (39.7%–51.9%; P ¼ .002). Child eating behavior improvement was noted in the following: increases in fruits (z-2.801; P ¼ .005), bell peppers (z-2.483; P ¼ .013), spinach, and low-fat dairy. Among parents, eating behavior results showed the following: increases in consumption vegetables (z-score 2.22; P ¼ .026), bell peppers (z-2.166; P ¼ .030), spinach (z-3.213; P ¼ .001), summer squash (z-2.867; P ¼ .004), and fish (z-2.553; P ¼ .011). Smaller nonsignificant increases were reported in consumption of tropical fruits, stone fruits, and low-fat dairy. Staff reported similar nonsignificant increases in consumption of bell peppers, spinach, tropical fruits, stone fruits, summer squash, and lean proteins [16].
22.4.2 Summer 2015 Interventions: Nutrition and health education using a new set of free materials focusing on those from the USDA (nutrition and physical activity), a smaller set of OWG items, OWG FoM, and OWG physical activity. Results: During the summer of 2015, C2H operated in 782 locations (153,900 children grades K-6). An evaluation of impact included pre (June)- and post (August)-surveys of a nationwide representative sample including 182 staff from 14 cities, as well as focus groups with children, parents, and staff in 10 locations. Results on physical activity impact were presented at the 2017 Active Living Research Annual Conference [17]. Results showed the nutrition literacy programming components led to increase in health knowledge among children, as recognized by staff who reported significant increases in agreement from the beginning of summer to the end with a statement “children who attend your camp know what kinds of foods are the best for keeping their bodies healthy” (26% increase; all analyses used Wilcox Test; P < .05). This was echoed by staff observations of child eating behaviors that showed percent increases, from beginning to end of summer, in staff reports that they “agree” or “strongly agree” that children “like and eat” specific foods were: vegetables 37.7% (Wilcox Test, P ¼ .000), fruits 24.2% (Wilcox Test, P ¼ .000), milk 15.8% (Wilcox Test, P ¼ .009), stone fruit 15.7% (Wilcox Test, P ¼ .005), spinach 14.4% (Wilcox Test, P ¼ .000), tropical fruit 14.1% (Wilcox Test, P ¼ .000), bell peppers 13.3% (Wilcox Test, P ¼ .000), berries 13.0% (Wilcox Test, P ¼ .000), eggs 12.0% (Wilcox Test, P ¼ .001), and summer squash 11.6% (Wilcox Test, P ¼ .000). Results also showed that staff learned a lot too, which enhances their personal life, as well as their ability to lead nutrition and healthy living programs during summer camps. From the beginning to the end of summer, there were statistically significant increases in the respondents who know how to cook and prepare healthy foods (19.1%) (Wilcox Test, P ¼ .001), know what foods have lots of fiber (23.0%) (Wilcox Test, P ¼ .000), know the MyPlate food groups (21.9%) (Wilcox Test, P ¼ .000), how to plant a garden (16.3%) (Wilcox Test, P ¼ .000), exercise (9.8%) (Wilcox Test, P ¼ .039), and feel they are good role models regarding healthy eating (18.6%) (Wilcox Test, P ¼ .000). With regards to physical activity specifically, based on prepost surveys (Staff ¼ 182), health event exit surveys (adults ¼ 108), and focus groups (child, adult, and staff ) from 10 P&R sites, C2H programming led to the following changes in physical activity behaviors [17]: • Children: Reducing the amount of screen time due to focus on physical activity (PA) Educating parents about PA needs of children and parents • Parents: Increasing PA and PA as a family Reporting children getting involved in sports due to OST activities Learning about need for and new types of PA at events, filling gaps in PA knowledge • Staff: Observing improvements in fitness of children, due to HEPA emphases Learning and leading successful PA programming Feeling that increased focus on PA was feasible to implement
22.4.3 Summer 2016 Interventions: Nutrition and health education using a totally new, free C2H FoM curriculum, as well as free USDA nutrition education materials, free USDA physical activity materials, free materials from other health education sources, free newly revised monthly lesson guides (set includes two guides, one for grades K-2 and one for grades 3–5), and free webinars and online staff training (no OWG items included anymore).
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Results: During the summer of 2016, the C2H nutrition literacy program was implemented nationwide in >750 P&R locations, impacting approximately 187,000 children in grades K-6. An evaluation of impact took place in nine locations and included pre (June)- and post (August)-surveys of a nationwide representative sample including 309 fourth and fifth graders and 86 staff, as well as focus groups of children and staff. Because the results of summer 2016 impacts are under review for publication, specific outcomes cannot be reported here. However, overall, results show statistically significant improvements in eating behaviors of children attending summer camp at P&R sites, as well as eating behaviors of camp staff, after just a short 6- to 8-week nutrition literacy program. Campers also reported significant increases in knowledge of healthy eating and living. Some qualitative data from focus groups illustrate some of these findings. Children were asked during focus groups what they learned at camp about nutrition that they shared with their parents. Some of the responses from the children were as follows: • • • • •
“Told mom not to buy junk food so we don’t eat it.” “The food that my parents buy is pretty different now.” “My step-dad and me eat healthier now, camp helped.” “Went home and said I wanted a chicken wrap.” “Taught mom how to cook healthy food with portion sizes.”
During focus groups, parents echoed some of the statements of the children, explaining what they learned about food, based on what their children had told them. For example, • “When we went to the grocery store, I picked a cookie cereal. My daughter said, ‘That’s too unhealthy.’” • “Yes, my son talks to me about what he eats and tries to work on eating at home. He used to be very picky and now he’s started eating fruits and vegetables and especially whole wheat. Wants a vegetable garden.” • “We’ve tried different smoothies, good family activity.” • “I don’t know who taught my son about MyPlate, but he told me about it and that’s what I use at work, and we now use it at home.” Staff reported that lessons they teach are making it to the home. For example, “kids tell their parents about the foods and the parents ask us about recipes and things.” Staff at another P&R site echoed this by saying, “the kids are excited and taking the recipes home with them and parents are helping the kids make them at home.” They also see less junk food coming to camp, “I don’t see soda coming in or high fat foods come in anymore.”
22.4.4 Summer 2017 Interventions: Nutrition and health education using a totally new, free CHG program in addition to the free C2H FoM curriculum, free USDA nutrition education materials, free USDA physical activity materials, free newly revised monthly lesson guides (two sets of for grades K-2 and 3–5, one for FoM and one for CHG), and free webinar and online staff training (no OWG items included anymore). Results: Analyses of pre- and postsurvey data for summer 2017 are taking place currently and should be ready for publication later in 2018. Some qualitative data are available now, and so are presented here, including a few case studies of impact. Children learned a lot about the FoM foods and changed their eating and physical activity behaviors, as shown in some quotes provided by campers here. • “The vitamins lesson, learned that fruits have a lot of taste, didn’t know about the vitamins in vegetables before camp.” • “When we eat dinner, we have a bowl of fruit now too.” • “I learned to eat more veggies and fruits.” • “I learned fruits and vegetables are something you should eat everyday.” • “I learned that bell peppers have vitamin A and vitamin C.” • “I learned that lots of vegetables come in a lot of colors.” • “I learned that bell peppers have good stuff in them than they help you to heal [your] face and eyes.” • “Eat whole grain bread in my sandwiches.” • “I learned about stone fruits and how healthy they are.” • “It’s fun to go grocery shopping with parents – help pick out healthy foods that taste good!” • “Go outside more, used to stay inside more, feel more athletic.”
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Children also learned enough about nutrition and/or food preparation to take some of the lessons home to their families. • • • • • • • • • • • •
“Taught my mother, how to make a rainbow burrito!!! It was awesome!” “I taught my parents that I like a parfait.” “I told my parents about bell peppers and what they give us.” “I taught my parents that you can make very delicious foods with very healthy things.” “I am going to teach my parents how much is 1 serving.” “Taught my family how to plant new foods in the garden.” “I learned that cooking homemade foods are better than buying food from the store.” Taught family “how to water a garden.” Taught family “how to make eggs.” Taught family “about bell peppers and humus and berries.” Taught family about “fruit pizza and cinnamon chips.” “We made bell pepper dip.”
In focus groups at the end of the summer, staff shared that parents reported changes in their family’s eating plans and/or behaviors. Some examples shared here: • “One example of a mom who said that every Sunday evening their family now shops for fruits and vegetables for the week.” • Children asked for recipes, “so they can have their parents make the same food. Staff is making copies of recipes and handing them out to parents.” • A “grandma said kid is more conscious of what he’s eating, went to [fast food restaurant] and said can’t get this or that because it’s not good for him.” 22.4.4.1 Case Study 1: Richmond, VA In addition to the grant helping thousands of hungry children receive the vital meals and nutrients they need for healthy growth and development, the overall program also influences individual health in a variety of ways, including contributing to weight loss, providing avenues for social and emotional benefits, and lowering the risk of chronic disease. In Richmond, VA, the P&R department received a call from a camper’s parent following several weeks of participation in the nutrition education component of summer camp. The parents shared that the child had gone to the doctor at the beginning of the summer and it was reported that she had borderline high cholesterol—most likely due to the fact that the family was not eating very healthy. The family relied on fast food, sometimes twice a day, to feed their kids, rather than purchasing and serving a balanced diet. After attending the summer program and learning about healthy foods and physical activity, the child communicated to her parents the importance of changing their lifestyle. She went to the grocery store with a chart of fruits and vegetables (the FoM calendar) provided by the camp staff, and she and her parents purchased healthier foods instead of the previously purchased fried and processed foods. They decided as a family that, instead of eating out at fast food restaurants every day, they would cut back. Thanks to the FoM curriculum, this particular family is now consuming a more balanced diet, resulting in lower cholesterol levels and developing long-term health and wellness habits for the whole family. 22.4.4.2 Case Study 2: San Antonio, TX Another outcome attributed to the grant can be seen in the P&R staff members who were responsible for implementing the program. In many cases, especially during summer camp programs, staff members consist of high school and college-aged counselors who are still developing habits. The grant provided P&R staff with the skills needed to teach nutrition education to youth, and to be positive role models and change their own eating and drinking behaviors. One of the nutrition specialists hired by the City of San Antonio to provide nutrition education this past summer shared that she found the FoM curriculum valuable for her own personal health and wellness habits. She explained that the program was helpful for keeping her on her toes—bringing a healthy lunch to work, drinking water and not sugary beverages, and being active with the kids at camp were all part of the job. She learned new information about specific foods and food groups, and gained the skills necessary to provide nutrition education to children in an OST setting. This particular instructor mentioned that, thanks to her participation in the summer camp program, she’s interested in pursuing a future career in public health. The grant not only changed habits and lifestyle behaviors, but it provided an avenue for the next generation of leaders and workers to gain additional skills.
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22.4.4.3 Case Study 3: Brevard County, FL Although access to fresh foods is something many take for granted, many families are not able to provide such foods due to cost, transportation barriers, or a lack of knowledge. In Brevard County, Florida, the grantee said that implementing the FoM curriculum was one of the most enjoyed aspects of this grant. It exposed children to new foods and provided education about nutrition that they had not received before. At one of the sites in Brevard County, it was the first time some of the children had followed a recipe to cook. One camper shared with staff that she was excited to crack an egg for the first time! The children were excited to share their experiences and new knowledge with their parents, which led to the parents learning about nutrition from their children! Brevard County shared they were excited to see this impact that they were having on the children and their families—and the community as a whole. 22.4.4.4 Case Study 4: San Jose, CA In San Jose, California, the FoM and nutrition literacy curriculum turned out to be a solution to a problem the P&R agencies didn’t know they had. After the first week of summer camps, staff at all 10 sites utilizing the grant recognized that many of the children were arriving without having breakfast. This began a snowball effect, where the children were often moody or agitated, were inattentive, acted out, and were sluggish. As a group, staff decided that the cooking lessons being done along with nutrition literacy should take place no later than 10 a.m. as often as possible to help address this need. Scheduling the lessons early was a twofold solution. Kids were still engaged and in good spirits, and were interested in helping, and then reaping the benefits of their hard work by getting to eat the great foods they made. For example, whole wheat blueberry pancakes and scrambled eggs with bell peppers were two of the most wellreceived foods cooked within the camps. These were easy for staff to prep, easy for the kids to help with, and very appealing to the kids. Throughout the cooking process, the participants were given plain fruits and vegetables (i.e., blueberries and bell peppers) to taste the foods by themselves and compare the taste once the foods were cooked. On days where these lessons were held, staff was able to guarantee that the participants had a healthy and substantial breakfast. As a result, they were more attentive, engaged more readily in activities throughout the day, were in better moods, and had more energy compared to days where these lessons were not taught.
22.5 DISCUSSION The ongoing evaluations of a community-based obesity prevention program for elementary school-aged children attending summer camps where they receive USDA Summer Meals and participate in nutrition and healthy living educational programming described in this chapter show much promise for improving eating and physical activity behaviors. Overall, nutrition and overall health knowledge increased during the summer. Children themselves, as well as reports of proxies (their camp staff and/or parents), reported knowing more about specific foods, how to prepare nutritious foods (cooking and cold prep), what their bodies need to be healthy (good food and physical activity), and how to garden. Similar outcomes were found among staff and parents, both groups of which reported learning a lot about nutrition, foods, and the need for physical activity from their children and/or by being teachers of summer camp health education programs. Critical to the prevention and treatment of obesity are eating and physical activity behaviors. Both of these needs to be addressed to keep our bodies healthy. Results of the various evaluations of C2H show that campers took the knowledge they learned and put it into action; they began eating nutritious foods they had not eaten prior to camp, and/or they increased their consumption of the focus foods. They also reported being much more active during camp and at home. Parents confirmed these reports during focus groups, indicating that their children were much more active and that they as families have become more physically active. Finally, staff reports of consumption of new, and/or increased consumption of, foods they taught about during the lessons shows their eating behaviors improved as well. The authors concede that the results of each annual evaluation are limited, in part, because there was no control group for comparison. However, we feel that having no control group can be seen as somewhat customary for the pilot phase of a program, as is the case here, where the interventions were changed quite significantly from year to year, based on qualitative feedback and financial considerations for sustainability and replicability. Strengths of our evaluation plan help overcome this limitation, including the study population’s wide geographic and racial/ethnic representation of the U.S., and the large number of children, staff, and/or parents who completed both pre- and postsurveys when administered, and participated in focus groups as they were held.
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22.6 CONCLUSION In the end, what these results show is that summer camp staff at P&R agencies can be important change agents with regards to improving the eating behaviors of young children they serve. Even if staff are not formally credentialed in nutrition education (i.e., they do not have nutrition degrees/certifications), C2H nutrition literacy program virtual trainings and materials can be put into practice successfully and efficaciously, leading to significant eating and physical activity behavior change. C2H materials are used in different ways, in different blocks of time (a few minutes each day, or for an hour up to three times per week, for example), based on the time availability and local camp context and resources (kitchen on site or not, for example). Despite the varied approaches to curriculum implementation, the results show significant, positive impact. Thus community-based obesity prevention programs—which include a combination of USDA Summer Meals and provision of nutrition and healthy lifestyle education and physical activity—show promise in improving the eating and physical activity behaviors of young children, and thus in the prevention and treatment of childhood obesity. Community-based “obesity prevention collaboratives” bring together multilevel, multiagency collaboration among partners with strong sets of skills (including nutrition education and outreach, program evaluation, and dissemination of best practices/results) and the potential for leveraging of skills and resources, to shape policies and programs affecting the health of the diverse populations of children and families in sustainable ways during summer OST, and perhaps even all year long as part of year-round OST programs. In conclusion, the fact that significant improvements in eating behaviors of children and staff occurred each of the four summers, within just the short timeframe of a 6- to 8-week summer camp, makes the case for increasing the reach of this summer camp program, as well as similar programming in other out-of-school contexts year-round. The C2H program operates in some P&R agencies in the afterschool context, evaluation of these initiatives should be done to inform the research and practice communities in this setting. The C2H FoM curricula and materials are available for free online to any childcare provider, including summer camp operators, OST programs, home school parents/ leaders, classroom teachers, and anyone else interested in teaching children about nutrient-rich foods. We look forward to replication and expansion of C2H, ongoing research regarding impact, and to improving the health of children in such programs.
References [1] von Hippel PT, Powell B, Downey DB, et al. The effect of school on overweight in childhood: gain in body mass index during the school year and during summer vacation. Am J Public Health 2007;97(4):696–702. [2] Christodoulos AD, Flouris AD, Tokmakidis SP. Obesity and physical fitness of pre-adolescent children during the academic year and the summer period: effects of organized physical activity. J Child Health Care 2006;10(3):199–212. [3] Carrel AL, McVean JJ, Clark RR, et al. School-based exercise improves fitness, body composition, insulin sensitivity, and markers of inflammation in non-obese children. J Pediatr Endocrinol Metab 2009;22(5):409–15. [4] Hollar D, Messiah S, Lopez-Mitnik G, et al. Elementary-aged children lose weight and blood pressure improvements (achieved during the school year) during summer vacation. Circulation 2009;119(10):e275. [5] Smith DT, Bartee RT, Dorozynski CM, et al. Prevalence of overweight and influence of out-of-school seasonal periods on body mass index among American Indian schoolchildren. Prev Chronic Dis 2009;6(1):A20. [6] Kobayashi M, Kobayashi M. The relationship between obesity and seasonal variation in body weight among elementary school children in Tokyo. Econ Hum Biol 2006;4(2):253–61. [7] Franckle R, Adler R, Davison K. Accelerated weight gain among children during summer versus school year and related racial/ethnic disparities: a systematic review. Prev Chronic Dis 2014;11:E101. https://doi.org/10.5888/pcd11.130355. [8] Bohnert AM, Ward AK, Burdette KA, et al. Active summers matter: evaluation of a community-based summertime program targeting obesogenic behaviors of low-income, ethnic minority girls. New Dir Youth Dev 2014;2014(143):133–50. https://doi.org/10.1002/yd.20107. [9] Moreno JP, Johnston CA, Woehler D. Changes in weight over the school year and summer vacation: results of a 5-year longitudinal study. J Sch Health 2013;83(7):473–7. https://doi.org/10.1111/josh.12054. [10] NRPA. Out-of-school time survey results, enriching the lives of children through parks and recreation, National Recreation and Park Association; 2016. http://www.nrpa.org/contentassets/c76ea3d5bcee4595a17aac298a5f2b7a/out-of-school-time-survey-results-report.pdf. Accessed 4 January 2018. [11] Tovar A, Lividini K, Economos CD, et al. School’s out: what are urban children doing? The summer activity study of Somerville youth (SASSY). BMC Pediatr 2010;10:16. https://doi.org/10.1186/1471-2431-10-16. [12] Wiecha JL, Hall G, Gannett E, Roth B. National After School Association standards for healthy eating and physical activity, https://www.niost. org/pdf/host/Healthy_Eating_and_Physical_Activity_Standards.pdf; 2011. Accessed 4 January 2018. [13] National Recreation and Park Association. Commit to health foods of the month curriculum, Ashburn, VA, http://www.nrpa.org/our-work/ partnerships/initiatives/commit-to-health/foods-of-the-month/. Accessed 4 January 2018. [14] National Recreation and Park Association. Facilitator’s guide, Ashburn, VA, https://www.nrpa.org/contentassets/9857e0b07c6243aea 8be636bbd275fd1/commit-to-health-facilitators-guide-2017.pdf.
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FURTHER READING
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[15] National Recreation and Park Association. Community and home gardening curriculum, Ashburn, VA, https://www.nrpa.org/our-work/ partnerships/initiatives/commit-to-health/community-home-gardening/. Accessed 1 June 2018. [16] Hollar D, Collum M, May K. Commit to health: a nationwide summer camp nutrition and feeding intervention improves nutrition knowledge and healthy eating behaviors of children, parents, and staff. Nashville, TN: Academy of Nutrition and Dietetics Food and Nutrition Conference & Expo; 2015. October 6. [17] Hollar D, Colman A, May K. Commit to health: policies and standards targeting increased physical activity during out-of-school times produce results. In: Active Living Research Annual Conference. Clearwater Beach, FL. February 26–March 1; 2017.
Further Reading [18] National Recreation and Park Association. Commit to health healthy eating and physical activity (HEPA) standards. Ashburn, VA, http:// www.nrpa.org/uploadedFiles/nrpaorg/Grants_and_Partners/Recreation_and_Health/Commit_to_Health_Resources/Commit-to-HealthHEPA-Standards%20(2).pdf. Accessed 4 January 2018. [19] The OrganWise Guys, Suwanee, GA, https://organwiseguys.com/. Accessed 1 June 2018.
V. PREVENTION AND TREATMENT