Background and Purpose of the Meeting Summary: The

AAP INSTITUTE FOR HEALTHY CHILDHOOD WEIGHT SHAPING THE HEALTH OF THE NEXT GENERATION: EARLY OBESITY PREVENTION POLICY ROUNDTABLE SERIES Final Meeting Report for Roundtable 2: Early Childhood (Ages 1-5)

Background and purpose of the meeting On November 9-10, 2015, The American Academy of Pediatrics (AAP) Institute for Healthy Childhood Weight (the Institute) convened a meeting of experts from a variety of fields and sectors to discuss and highlight the policy opportunities that affect children ages 1-5, focused on spheres of influence outside the home, with the greatest potential to prevent childhood obesity. Attachment 1 lists the meeting’s attendees.

This meeting was the second of three such roundtables to be convened by the Institute and sponsored by the Robert Wood Johnson Foundation (RWJF), as part of the AAP focus on healthy childhood weight and RWJF’s ongoing childhood obesity initiative, which seeks to insure that, by 2025, 85 percent of children will be at a healthy weight, no matter who they are or where they live. The goal of this series of meetings is to identify and prioritize the most strategic and powerful obesity prevention policy opportunities in the window between pregnancy and a child’s fifth birthday, with a focus on the populations at greatest risk.

The most effective way to meet this goal, noted Sandra Hassink, MD, FAAP, the chair of the roundtable series’ project advisory committee, is to identify “the things that will speak to families and communities most strategically and allow them to move forward.” Doing this, Hassink continued, requires focusing on children and families and all their evolving needs as children grow. This developmental approach, in turn, requires working across traditional sectoral and institutional boundaries—to begin to create what Hassink described as a “reinforcing system.” The family, Hassink concluded, is the final common unit of delivery: “as families change the child changes, and as families change, the community changes.”

Such a reinforcing system is especially critical for the most vulnerable populations. Sherri Killins, EdD, of the BUILD Initiative reminded roundtable participants that such “parents, children and families are dealing with multiple systems, and they’re all misaligned.” A very small percentage of children eligible for WIC, for example, remain with the program up to age 5. The demands of continuing in the program constitute a real barrier for families facing multitudes of demands; developing effective policy requires an effort to truly understand the situation families face. In efforts to build equity, both the ideas and the practical logistics matter. “We can get early childhood right,” Killins said, “but (not) if we don’t have multiple systems [figuratively] ‘in the room’.”

Summary: the policy recommendations from this roundtable With this context in mind, roundtable participants moved through a series of discussions and exercises (attachment 2 contains the meeting’s agenda). By the end of the second day, the participants identified:

 A set of 13 policy options, based on existing policies or policy recommendations, identified by roundtable participants as having strong potential to affect rates of obesity in children ages 1-5, either as currently written or with some revision (Box 1).  Five underlying aspects that influence a child’s ability to be healthy that need to be better addressed through policy. All of these affect rates of childhood obesity; each warrants greater focus and understanding (Box 2).  A set of 10 highlighted and more fully-developed policy options (Table 1).

At the end of the meeting, roundtable participants informally prioritized specific suggestions made in the group discussions of the proposed policies and of the aspects of the environment needing to be addressed through policy. Table 2 displays the results of this prioritization.

Context: what in the environment influences obesity rates in children? In developing these recommendations, roundtable participants began by investigating and discussing the factors identified as affecting rates of obesity in children ages 1-5:

 First, participants discussed what the evidence shows are factors in these years that protect against childhood obesity, and that, conversely, increase its risk.

 Then, experts provided background on the policy landscape for four key areas that influence obesity rates:

o The food and beverage environment o The physical activity environment o The marketing and media environment o The child care environment.

Protective and risk factors As its first task, roundtable participants reviewed and discussed a proposed set of evidence- based factors affecting children’s lives that may either protect against, or increase the risk of, childhood obesity (attachment 3).

In their conversations and written comments on this initial draft, roundtable participants approached the list in two ways. First, participants suggested revisions, additions and language changes; their key messages were:

 It is important to identify the specific aspects of non-center based early childcare and education that can make such settings a risk factor for obesity, rather than making a blanket statement about that type of childcare. “You need to call out what the ‘it’ is,” one participant explained.

 Many children are not cared for by parents; other caregivers need to be included.

 The language used to describe the types of caregiver styles identified as protective against obesity has important cultural implications; the wording needs to be chosen carefully, and “authoritative” may not be the best descriptor.

 Food insecurity and living in a place with poor access to healthy food needs to be considered a risk factor.

 Modeling is a powerful concept for children in this age group: parents, caregivers and peers modeling a healthy, active lifestyle all should be considered protective factors.

 Although the evidence of its effectiveness is mixed, breastfeeding may be a protective factor relevant for children in the younger part of this age group.

Second, participants stressed the importance of clarifying that these factors—both protective and risk—do not exist in a vacuum. Any display of such factors needs also to reflect their root causes: the social determinants of this particular aspect Box 1: Current policies to be reinforced of health. Participants highlighted poverty, racism, crime and unsafe 1. Ensure in-store marketing promotes healthful neighborhoods as examples of such eating by increasing availability, affordability, root causes. “This is the lens,” one prominence, and promotion of healthful foods and/or restricting or de-marketing unhealthy foods participant said, “that you need to be 2. Require access to safe, clean drinking water. looking through.” 3. Restrict the availability of less healthy foods in public service venues. The current policy landscape 4. Tax food and beverages with minimal nutritional With the goal of insuring that all value. roundtable participants were well- 5. Ensure built environment provides opportunities for informed about the current state of physical activity. obesity-prevention policies, four 6. Increased access for safe, attractive and speakers presented background developmentally appropriate places for physical activity. information on their areas of 7. Ensure geographic availability of supermarkets via expertise: incentives, zoning requirements or small business  Margo Wootan, DSc, of the programs. Center for Science in the Public 8. Restrict availability of sugar-sweetened beverages Interest, spoke about the food (cafeteria, vending machines, etc.) and beverage environment. 9. Government agencies should promote access to  Myron Floyd, PhD, of North affordable healthy foods for infants and young Carolina State University, children from birth to age 5 in all neighborhoods, spoke about the environment including those in low-income areas, by maximizing participation in federal nutrition assistance for physical activity. programs and increasing access to healthy foods at  Monica Baskin, PhD, of the the community level. University of Alabama at 10. Health and education professionals providing Birmingham, discussed the guidance to parents of young children and those marketing and media working with young children should be trained and environment. educated and have the right tools to increase  Meredith Reynolds, PhD, of the children’s healthy eating and counsel parents about Centers for Disease Control their children’s diet. and Prevention, presented the 11. To ensure that child care facilities provide a variety of healthy foods and age-appropriate portion sizes child care environment. in an environment that encourages children and staff to consume a healthy diet, child care Attachment 4 presents the highlights regulatory agencies should require that all meals, of these presentations. snacks, and beverages served by early childhood programs be consistent with the Child and Adult Care Food Program meal patterns and safe drinking Elevating existing policy water be available and accessible to the children. 12. Child care regulatory agencies should require child recommendations care providers and early childhood educators to With the background outlined above provide infants, toddlers, and preschool children as context, roundtable participants with opportunities to be physically active reviewed a list of 29 existing policy throughout the day. recommendations within these four 13. Adults working with children should limit screen domains that have the potential to time, including television, cell phone, or digital affect young children (attachment 5). media, to less than two hours per day for children aged two-five. Participants were asked to identify which of these 29 had the greatest

3 potential to affect obesity in this age group, especially among the most vulnerable populations. Participants identified some policies as “perfect as is,” and others as needing enhancement or modification. Through this process and subsequent discussion, participants highlighted 13 policies/policy recommendations for further consideration (Box 1, above).

Aspects of the environment needing to be better addressed through policy Participants then met in small groups to work together and develop lists of the factors affecting children ages 1-5, especially the most vulnerable of these children, that are not currently being addressed through existing policies or policy recommendations.

Attachment 6 contains the full list of factors developed during this exercise, as they were defined and grouped by roundtable participants.

Further evaluation of these groups led AAP and meeting staff to divide these factors into two groups: those that linked to the previously prioritized existing policies (and were forwarded for further discussion in this context: see page 6); and those that represented key aspects of the environment having a direct impact on rates of obesity in children ages 1-5, and needing to be better addressed through policy (see Box 2, below).

Participants then broke into five small groups, each Box 2: To be most effective, group answering addressing one of these key policy needs to better address: aspects. First, participants discussed, “What do we need to do so that families of children ages 1-5 can  Poverty raise a healthy child, with regard to (our aspect).”  Institutional racism Then they talked about how they envisioned their  Cultural competency topic informing policy and/or policy levers. The  Systems integration discussions were rich and powerful: important  The family’s voice and concepts from each included: empowerment

Poverty Potential policies need continuously to be viewed through a poverty-inflected lens; the most critical thing is that policies do not widen the existing gaps among income levels. The relationship of these two ideas becomes clear in any evaluation of tax policy as a way to incentivize healthy eating: taxes are regressive, and the revenues from taxes go to general funds, not health-related initiatives. Multigenerational considerations matter in poor families, as does managing the balance between low-wage work and maintaining eligibility for support programs. Social media is rapidly becoming a major influence in society in general; its impact on low-income populations is poorly understood.

Institutional racism Institutional racism is a way of embedding a sense of both racial domination and racial inferiority into society, and each new generation must cope with the burdens this imposes on finances, on housing, on health access: minority children have different expectations for their future because of this burden. Those working on health policy need to address institutional racism directly – it is a different thing than inequity and is not being widely discussed as such. The Institute of Medicine could possibly begin this conversation; a research agenda needs to be developed. Adverse childhood experiences (ACES), for example, are a known risk factor for childhood obesity. What is the role of institutional racism in ACES? We don’t know, and we need to know.

Cultural competency

4 Cultural competency refers to the lens through which people view and understand the world, and is not bound by race or ethnicity. It affects policy-making as (1) policy makers apply their own cultural outlooks, and (2) different cultural outlooks drive different definitions of desired outcomes, especially in relation to health and wellness. Actions are needed that build a sense of community across cultures; these actions need to approach cultural differences looking for the strengths they provide rather than highlighting deficits. Food marketing companies have successfully capitalized on cultural norms in different populations; health policy should aim to do the same.

Systems integration The current policy landscape is fragmented and as a result, programs use fragmented funding streams and eligibility systems that place an undue burden on vulnerable families. Options for improvement include instituting a core set of standards across programs; aligned monitoring; cross-training; and unified outcome measures. Alignment needs to occur vertically (across federal, state and local programs) and horizontally (across sectors) – and an initial necessary step is, as one participant said, “to realize what’s out there that needs to be integrated.” The federal government would be the logical convener for such an effort.

The family’s voice and empowerment The most important factor in engaging parents and other family members is to meet them where they are. Education and advocacy programs need to work harder at this. Specific issues include the power of food as a link to home for immigrant families, the difficulty of engaging people around the concepts of marketing and obesity, the delicate balance parents face when advocating for their children with child care providers, transparency about how a child care setting uses food, and the lack of clear and consistent information for parents on the place of diet in brain development. Universal home visiting to improve education would be very beneficial; other possible actions include more parental involvement in the design of food benefit programs, and community-based organizations acting as conveners to highlight parents’ and families’ needs.

General discussion In reviewing the results of this exercise overall, participants highlighted the ways in which these five aspects inter-relate and overlap:

 Systems are where things are happening, where institutional racism is perpetuated. Systems can’t continue to be viewed as abstract: training, incentives, support systems within systems all need to change.

 Poverty matters: Title 1 schools, for example, don’t have PTAs channeling the parents’ voice, and the great ideas getting implemented in privileged communities are not being replicated. In schools with economically and racially mixed populations, however, PTAs can be a source of segregation.

 It’s important to have meaningful opportunities for engagement that recognize the lives of people who are struggling with institutionalized racism, poverty, and a world that doesn’t recognize their culture. Parents are interested in programs that help them build their knowledge, if these come with a sense of collaboration and partnership with parents. Building these relationships takes time. Once parents become engaged, they become the best allies.

 Both poverty and racism need to be addressed in policy development. The common approach currently is to frame all policy as addressing poverty. This, however, as

5 one participant said, “allows you to glaze over key issues.” Data show better health outcomes for whites even when income or education levels are the same. “One of the things that can help,” another participant observed, “is targeting racism.”

 For many children ages 1-5, race and income do intersect. Children in lower-income families living in segregated communities will have worse health outcomes than will children in families with the same income living in more diverse area. Place matters: it affects physical activity, primary care, mental health, and a family’s having more hope for future.

Highlighted recommendations: the details Taking as background all the previous discussions in the meeting, roundtable participants formed five groups to clarify the details of their recommendations for the most strategic and powerful policies in each of five areas: beverages, technical assistance and training, physical activity, food access and marketing. (See page 4 for a description of the genesis of these topics.)

In this work, meeting facilitator Lisa Silverberg reminded participants to draw on the full range of experiences (lived and professional) in their group, and to stretch their thinking about what might be possible to achieve. “Push here in this room with your own folks,” Silverberg urged, “and then you can have a practical conversation later.”

Table 1, on the following pages, presents the details of each of the 10 new or revised recommended policies as defined by roundtable participants during this exercise.

Setting priorities The final step in the meeting involved roundtable participants’ indicating which of the environmental factors and proposed policies they felt would have the greatest impact. The process used was simple: participants used red dots to highlight valuable actions, and gold stars to indicate which single recommendation they would most strongly endorse. Table 2, below, shows the results of this exercise.

Conclusion The participants in this roundtable meeting clearly stated that helping vulnerable children ages 1-5 establish and maintain a healthy weight requires policies that address food availability, physical activity, marketing, training and technical assistance, and healthy beverages. Such policy initiatives, however, will not reach their full potential unless they approach their topics in ways that reflect how poverty, institutional racism, the need for cultural competency, a lack of systems integration, and the need to involve and engage parents and families affects the lives of the people these policy initiatives seek to reach.

In developing their own list of recommended policies, roundtable participants worked to build such approaches. The key themes underlying these recommendations include the integration of services and regulation; the strengthening of the types of child care settings in which vulnerable children are most likely to enroll; communication with families to build mutual understanding of policy goals and the specifics of their implementation; and sources of sustainable funding.

6 More research is needed, roundtable participants clearly said, into the institutional causes of racial inequity and racial disparities in health outcomes. Until these are acknowledged and understood, even strong policies will not reach their full potential.

Table 1: Key aspects of proposed policies

Policy Key considerations Target Protective/risk recommendation/ Rationale for at-risk audience/change Potential barriers factor addressed strategy populations agent Beverages Tax sugar-sweetened - Mitigates Tax should drive down - The tax is regressive. TA = Care providers - Beverage industry $$ beverages IF revenue consumption of sugary consumption and - The fight to spend the CA = State and local - Competition for is dedicated to drinks revenue can fund the revenue can be difficult governments revenue from both prevention/care and - Facilitates increased other policy change friends and opponents health for children ages consumption of water. work we do. - In most places, 1-5, targeting low and revenue can’t be moderate income dedicated in tax (note: will need to legislation. define “sugar- sweetened beverages”).

Restrict availability of Mitigates consumption Restricting access to Lower-income children Child care providers are Enforcement is difficult sugary drinks in of sugary drinks sugary beverages in are more likely to be in both target audience in home-based care. childcare facilities. Facilitates increased other settings, such as home-based care, and change agents. consumption of water hospitals, had led to where enforcement is State and local Facilitates provider role increased consumption most difficult. regulators also are model. of water. change agents.

Technical Assistance and Training Health and education Aim is to augment or A focus on coordination -Vulnerable populations Target audience: child Cross-sector professionals providing reduce as many of and training across especially need care providers, others collaboration is a guidance to families these as possible by disciplines so childcare consistent messages who train them (multi- barrier in and of itself. and caregivers of increasing caregiver providers can work - Training needs to be and cross-disciplinary). young children and knowledge, skills and cross-disciplinarily is done in a way that End users: families. those working with ability. the best way to address recognizes the impact Change agents: broad. young children should the greatest number of of culture on eating and be trained and protective/risk factors. weight educated in a multi- - Systems need to be and cross-disciplinary, flexible enough to way so they have the incorporate needs of all right tools to increase constituencies children’s healthy - With this, there is the eating and counsel potential for increased families and caregivers advocacy by members about their children’s of the vulnerable diets, physical activity population groups. and sleep patterns.

8 Physical Activity Reimbursement by - Active play - Health care delivery - Linking to Medicaid TA = Insurers, - Funding and insurers’ public (Medicare and - Access system has money (no creates a pathway to employers, Congress, buy-in: need to prove Medicaid) and private - Medicaid-at-risk funding for new active play, space and state governments, ROI (employers) payers for - Teaches role programs in LHFS developmental learning counties. - Criteria for an evidence-based modeling budget) - Having a safe Families have to “eligible” provider childhood obesity - Teaches daily - There’s a population- environment is key; participate. - Difficulty of prevention programs appropriate physical based return on reimbursement makes community-level data for at-risk children, or activity/active play investment, and state it more likely spaces CA = program collection (and impact evidence-based - Reinforces household Medicaid programs can will be maintained. implementers, insurers, on evaluation of such a physical activity routines for physical reap results. - This population needs employers, government program) programs that are activity - Supports families; long term at federal, state, local - Certification. developmentally - Addresses sedentary increases access in a sustainability, not pilot level. appropriate and family- behaviors tangible way. testing. based. - Starts early life-long - Moves health care Insurers pay for gains. into the community. healthy communities work.

Food Access Maximize participation in federal nutrition assistance programs: consolidate and streamline enrollment and renewal process; coordinate agencies; require and fund local program outreach, promotion and retention efforts to vulnerable populations. Recommend and Requiring adherence is incentivize adherence expensive, potentially to the Child and Adult onerous. Care Food Program Guidelines (group did not agree on making the guidelines a requirement for licensing). Universal child care & Regardless of the pre-school: family model, sites should childcare neighborhood participate in federal networks; the Head nutrition assistance Start model for family programs. services; technical assistance and funding for various coordinated models.

9 Marketing Restrict availability of - Increase consumption - Supports healthy - Reaches key TA = retailers - Cost, or implementing less healthy foods in of fruits, vegetables, eating without populations in a cost-neutral way public service venues water, increasing costs. - Need to increase CA = parents, - TA and distribution of - Model healthy eating - Model healthy demand for such community members, success stories Ensure in-store patterns environment. policies advocates, some - Generation of marketing promotes - Reduce intake of - Healthy defaults - More exposure to retailers, hospital consumer confusion healthful eating by sugar-sweetened - Increases demand for unhealthy food systems. around nutrition increasing availability, beverages, calorie- healthy foods marketing by children - Need evidence and affordability, dense foods, snacking, - Good reach of color (through Also federal, state and model policies for retail prominence and marketing of unhealthy - Low-cost policies increased exposure and local agencies and setting promotion of healthful foods. - Evidence-based targeted marketing). government. - Need definitions of foods. models exist for public spaces, and Ensure in-store healthy public places decisions on nutrition marketing promotes and food marketing to standards. healthful eating by children (need for restricting or de- retail). marketing unhealthy foods.

10 Table 2: Summary of Prioritization Exercise

Aspects of the Environment (Poverty, Institutional Racism, Cultural Competency, Systems Integration, Place of Parents/Family) Multiple gold stars Single gold star  Research agenda on institutional racism.  Incentives for neighborhood investment (IR). Multiple red dots Single red dots  Research agenda on institutional racism.  Top-down and bottom-up integration (federal, state, community)  Policies should not widen gaps (poverty). re: housing, education, USDA food programs, parks,  Blended standards, common measures and eligibility for funding transportation, health care (SI). (SI).  Child care, esp. considering workforce issues (poverty).  Theme: involvement of parents and people affected (place of  Cultural competency as a concept (definition). parents/family).  Cultural competency as needing to be considered through a “strengths” lens – strength-based policy.  Culturally-relevant training (with idea of support for the care provider) (CC).  “I am concerned that no one here can speak to American Indian/Alaskan Native experience.” (CC)  IOM report on institutional racism.  Incentives for neighborhood investment (IR). Policy Areas (Beverages, Food Access, Training/TA, Marketing, Physical Activity) Multiple gold stars Single gold star  Universal child care and pre-school.  Multidisciplinary training.  Integrated community-based training & practice models.  Government agencies should promote access to affordable  Tax sugar-sweetened beverages if revenue is dedicated to healthy foods for infants and young children from birth to age 5 prevention and health care for children 1-5, targeting low and in all neighborhoods, including those in low-income areas, by moderate income. maximizing participation in federal nutrition assistance programs  Reimbursement by public (Medicaid/Medicare) and private and increasing access to healthy foods at the community level. (employers) payers for evidence-based childhood obesity  Consolidate and streamline enrollment, renewal and access prevention programs for at-risk children (or evidence-based process (max. part. in federal nutrition programs). physical activity programs) that are developmentally-appropriate  Increase healthy food choices in public spaces. and family-based. Multiple red dots Single red dots  Tax sugar-sweetened beverages if revenue is dedicated to  Head start model – family services (sub bullet under universal prevention and health care for children 1-5, targeting low and child care/preschool). moderate income.  Regardless of model, should participate in federal nutrition  TA/training are essential but can’t occur in a vacuum without assistance programs (sub bullet under universal child providing access to resources to support the training’s care/preschool). implementation.  Training for physicians to inquire about/provide guidance on built  Multidisciplinary training. environment solutions to obesity (e.g., Park Rx program); ask  Integrated community-based training & practice models. about physical activity habits and barriers.

11  Increased access for safe, attractive and developmentally  Reimbursement by public (Medicaid/Medicare) and private appropriate places for physical activity. (employers) payers for evidence-based childhood obesity  Embed nutrition and physical activity questions into hospital prevention programs for at-risk children (or evidence-based community needs assessments and must partner with land use physical activity programs): developmentally-appropriate; planning, etc. family-based.  Government agencies should promote access to affordable  Coordinate agencies (e.g., interagency state council) as a way of healthy foods for infants and young children from birth to age 5 maximizing participation in federal nutrition assistance in all neighborhoods, including those in low-income areas, by programs. maximizing participation in federal nutrition assistance programs and increasing access to healthy foods at the community level.  Consolidate and streamline enrollment, renewal and access process (to max. part. in federal nutrition programs).  Require and fund local program outreach, promotion and retention efforts (for federal nutrition programs) to vulnerable populations.  Universal childcare and preschool.  Increase healthy food choices in public places.  Increase access and promotion of health food in retail.  Decrease marketing of unhealthy food to kids.

List of Attachments

1. Roundtable participants 2. Meeting agenda 3. Draft of evidence-based childhood obesity protective and risk factors as initially presented at the meeting 4. Highlights of the current policy landscape by area 5. Existing policies or policy recommendations relating to children ages 1-5 6. Policy gaps identified on day 1, as grouped by roundtable participants

13 Attachment 1

AAP Institute for Healthy Childhood Weight Shaping the Health of the Next Generation: Early Obesity Prevention Policy Roundtable Series Roundtable 2: Early Childhood November 9-10, 2015 Participant List

Participants Katie Adamson Y of the USA Laura Annunziata, MSN, FNP Zero to Three Monica Baskin, PhD University of Alabama at Birmingham Katherine Beckmann, PhD, MPH Administration for Children and Families Jeanette Betancourt, EdD Sesame Workshop Eva Daniels, MEd National Association of Family Child Care Verónica Figoli Denver Public Schools Myron Floyd, PhD North Carolina State University (Day 1 only) Lori Freeman, MBA Association of Maternal & Child Health Programs Natasha Frost, JD Public Health Law Center Allison Gertel-Rosenberg, MS Nemours Healthy Kids Healthy Futures Harold Goldstein, DrPH California Center for Public Health Advocacy Sara Hammerschmidt Urban Land Institute Carter Headrick American Heart Association Geraldine Henchy, MPH, RD Food Research and Action Center Marjorie Innocent, PhD National Association for the Advancement of Colored People Nadeen Israel, MA EverThrive Illinois Manel Kappagoda, JD, MPH ChangeLab Solutions Sherri Killins, EdD BUILD Initiative Blanca Leyva, MSEd, LCSW Prince William County Head Start Georgia Machell, PhD National WIC Association Patti Miller, MA Too Small To Fail Meredith Morrissette, MPH Maternal and Child Health Bureau Meredith Reynolds, PhD Centers for Disease Control and Prevention Florence Rivera, MPH American Academy of Pediatrics Jill Rosenthal, MPH National Academy for State Health Policy Yvette Sanchez Fuentes National Alliance for Hispanic Families Krista Scott, LCSW Child Care Aware of America Lacy Stephens, MS, RDN National Farm to School Network Tracy Wiedt, MPH National League of Cities (Day 2 only) Margo Wootan, DSc Center for Science in the Public Interest Amy Yaroch, PhD Gretchen Swanson Center for Nutrition

Project Advisory Committee Sandra Hassink, MD, FAAP (Chair) Angela Odoms-Young, PhD (Member) Lucy Sullivan, MBA (Member)

Consultants Lisa Silverberg, MA (Meeting Facilitator) Katherine Garrett, MBA (Technical Writer)

Program Staff – AAP Institute for Healthy Childhood Weight Alison Baker, MS Jeanne Lindros, MPH Corrie Pierce Mala Thapar, MPH

Program Staff – Robert Wood Johnson Foundation Jamie Bussel, MPH Karen Ellis Lauren Galarza Claire Gibbons, PhD, MPH

Additional Guests Madeline Curtis, AAP Tracy Fox, MPH, RD, Food, Nutrition and Policy Consultants Tamar Magarik Haro, AAP Linda Shak, MSW, The Packard Foundation Elizabeth Wenk, MA, Burness Communications Liane Wong, DrPH, The Packard Foundation

15 Attachment 2

AAP Institute for Healthy Childhood Weight Shaping the Health of the Next Generation: Early Obesity Prevention Policy Roundtable Series Roundtable 2: Early Childhood November 9-10, 2015 Agenda

Day 1, Monday, November 9: 11:00 a.m. Welcome, opening remarks, introductions and meeting overview 12:40 p.m. Lunch 1:40 p.m. Examining policy approaches to address early childhood obesity prevention: key areas of influence 2:40 p.m. Break 2:55 p.m. Elevating policy recommendations 3:45 p.m. Identifying gaps in policy and opportunities for innovations 5:00 p.m. Closing remarks 5:15 p.m. Reception 5:45 p.m. Keynote speaker: Tamar Magarik Haro, Assistant Director, AAP Department of Federal Affairs.

Day 2, Tuesday, November 10: 7:30 a.m. Breakfast available and Recap of Day 1 8:00 a.m. Welcome and update 8:15 a.m. Introductions, Part 3 of 3 8:30 a.m. Re-introduce categories; systems conversation (including break) 10:15 a.m. Report out and full group discussion. 11:15 a.m. “Comment” period 11:45 p.m. Lunch 12:45 p.m. Applying system conversations to “current” policies; report out on policy development/revisions. 2:20 p.m. Prioritizing, closing and next steps 3:00 p.m. Adjourn

16 Attachment 3

Draft of evidence-based childhood obesity protective and risk factors as initially presented at the meeting

Attachment 4 Highlights of the current policy landscape by area Considerations Overall Areas of Application to Productive for vulnerable landscape promise ages 1-5 future focus populations Food & -Effectiveness -Local laws and -Habits in -Issues affect all -Policies Beverage of product some state laws childhood set children; related to placement in regulating up lifetime importance of food retail settings product patterns of making sure all procurement -Children get placement eating, and parents have and sales in 25% of -Menu-labeling research shows access to equally public places: calories from laws (evidence food choices strong systems parks, eating out mixed) are often made promoting institutions, (content of -Instances unconsciously, healthy eating. schools. children’s where out of habit. -Stronger meals not persuasion has -Early nutrition changing worked experiences standards much). (Disney) help children -Strengthen define what self- food is. regulation.

Physical -Evidence that -Local/state/ -Playgrounds -Low-income -Increasing Activity proximity to federal partner- matter for this areas are less awareness of parks leads to ships to age group. likely to have a issue and more activity increase park, or a park existing and less availability with a programs incidence of -Park playground. (e.g., Healthy overweight. prescription -Crime has an Parks/Healthy program: link independent net People) between parks effect on use of -Normalizing and the health parks. the role of care sector. parks in health Marketing -$2 billion in -Seeing some -Food -Marketing -Self- & Media food marketing self-regulation advertising is targeted to regulation last year. and efforts to pervasive in minority youth. (other tie promotions children’s lives. -Food companies resource to healthier -Aim is to historically constraints eating options. create supportive of may make customers for minority this the most life. communities: effective strong bonds option) exist Childcare -Much -Evidence- -Children are - Children more -All ECE variation in based standards in early likely to be in settings to licensing and exist: IOM, childhood childcare settings meet IOM and administrative Caring for our education that are CFOC regulations Children (ECE) when unregulated or standards. -Weak links to (CFOC). food habits are less able to take - Capitalize on Federal Child forming advantage of state coalition and Adult Food -And at the federal food task forces Care program. time of highest initiatives. and councils. -Little uptake susceptibility or knowledge to adult role of federal modeling. healthy food programs.

18 Attachment 5

Existing policies or policy recommendations relating to children ages 1-5

Food and Beverage Environment

Protective and Risk Factors Food and Feeding Routines and Parenting

ar family meals meals family ar

feeding

and (meal routines maintain and Establish

Fruit and vegetable consumption consumption vegetable and Fruit of flavors, variety wide to a Introduced foods and textures, Self and (hunger fostered is eating Mindful satiety) times) snack breakfast Eating diet rich nutrient and fiber High snacking Continuous Regul home the of outside eaten Meals beverages sugary of Consumption consumption water Regular dense calorie and/or sugary of Consumption foods) nutrient low dense (energy and routines sleep maintain and Establish duration sleep appropriate styles parenting Authoritative living active healthy model Parents (ACEs) experiences childhood Adverse Policy Recommendations/Strategies Promote/identify the healthful menu x x x options x x x

Provide financial incentives to restaurants that provide healthier meal options

Offer at least one other individual item that has 200 calories or less, with limits on fats, sugars and sodium, and contains a serving of fruit, vegetables, whole grains, lean protein or low-fat dairy

Chain and quick-service restaurants should substantially reduce the number of calories served to children and substantially expand the number of affordable and competitively priced healthier options available for parents to choose from in their facilities. x x Require menu labeling in all restaurants. x x x x

Offer at least one full children’s meal (an entrée, side and beverage) that is 600 calories or less; contains two or more servings of fruit, vegetables, whole grains, lean protein and/or low-fat dairy; and limits sodium, fats and sugar

Implement zoning ordinances to limit the x x x x x x x x number of fast food establishments

Prohibit new fast-food restaurants from opening near schools. Provide tax breaks or community development grants to communities which limit the number of fast food retail outlets through zoning restrictions

Ensure geographic availability of x x x x x x x x x supermarkets via incentives, zoning requirements or small business programs Increase access to supermarkets via public safety efforts or adjusting transportation routes.

Ensure in-store marketing promotes healthful eating by increasing availability, affordability, prominence, and promotion of x x x x x x healthful foods and/or restricting or de- marketing unhealthy foods. Provide financial incentives to grocery and convenience stores that reduce point of sale marketing

Require “healthy checkout aisles,” free of obesogenic food and beverages.

Limit the total amount of store window space that can be covered by signs. Ensure consistent nutrition labeling for the front of packages, retail store shelves, and menus/menu boards that encourages healthy food choices

Require all mobile vending units and vending x x x x x x machines provide healthy food options and limit unhealthy options in public venues

Eliminate vending machines with low nutrient, high density foods

Require access to safe, clean drinking water x x x

Provide funding to communities to ensure access to safe, clean drinking water

Restrict availability of sugar-sweetened x x x beverages (cafeteria, vending machines, etc.)

Through leadership and guidance from federal and state governments, state and local education agencies should ensure the implementation and monitoring of x x x x x x x x x sequential food literacy and nutrition science education, spanning grades K-12, based on the food and nutrition recommendations in the Dietary Guidelines for Americans.

Modify land use policies/zoning regulations x x x x x x to encourage farmers’ markets

Government agencies should promote access to affordable healthy foods for infants and young children from birth to age 5 in all neighborhoods, including those in low- x x x x x x x x x x income areas, by maximizing participation in federal nutrition assistance programs and increasing access to healthy foods at the community level. Require farmers’ markets to accept WIC and SNAP

Restrict availability of less healthy foods in x x x x x x public service venues Tax food and beverages with minimal x x x x x x x x nutritional value

Physical Activity Environment

Protective and Risk Factors Physical activity Screen time Routines and Parenting

of screen time day per screen of

appropriate active play and and play active appropriate

Daily age Daily activity physical activity more yields play Outdoor daily (regular routines maintain and Establish activity physical restrain that devices in spent time much Too movement bedroom inthe Television 2 hours than More TV marketing to Exposure and routines sleep maintain and Establish duration sleep appropriate styles parenting Authoritative living active healthy model Parents Policy Recommendations/Strategies

x x x x x Ensure built environment provides opportunities for physical activity

Fund walk to school and bike to school programs in your communities (safe routes to school)

Create and maintain walking paths and bike paths (rails to trails, etc)

Require all new buildings include plans for sidewalks and open space Fund additional parks, green space, walking trails, etc.

Increased access for safe, attractive and developmentally appropriate places x x x x for physical activity

Adopt community policing strategies to improve safety and security

Promote increased transit use through reduced fares for children, families, and students, and improved service to schools, parks, recreation centers, and other family destinations.

Design playgrounds and activity open spaces to address developmental needs/limitations of young children

Establish regulations regarding proper lighting and maintenance of sidewalks

Implement tax policy to make health club and recreational program fees tax deductible from state income tax. 22

Establish joint use agreements to promote and encourage affordable and free physical activity opportunities Subsidize health club/fitness class

Marketing and Media Environment

Protective and Risk Factors Food and Feeding

fostered (hunger and (hunger fostered

feeding

and (meal routines maintain and Establish

Fruit and vegetable consumption consumption vegetable and Fruit of flavors, variety wide to a Introduced foods and textures, Self is eating Mindful satiety) times) snack breakfast Eating diet rich nutrient and fiber High snacking Continuous meals family Regular home the of outside eaten Meals beverages sugary of Consumption Policy Recommendations/Strategies Eliminate marketing for unhealthy foods and beverages x x x x

x x x Government should regulate food retail and package promotions directed at children (which are primarily or unhealthy food)

Fund sustained targeted physical activity and nutrition promotion social x x x marketing programs

Implement common standards for marketing foods and beverages to x x x x children

State and local governments should consider regulation of marketing in local x x x x communities, including in schools, publicly owned facilities, stores, restaurants and outdoor advertising. Local governments should enforce existing or adopt strong zoning restrictions on marketing, such as limits on signs in store windows

School bus advertising should be prohibited by school districts.

Eliminate any food and beverage marketing from schools and youth recreation leagues

Child Care Environment

Protective and Risk Factors Food and Feeding

fostered (hunger and (hunger fostered

feeding

and (meal routines maintain and Establish

x x x x x To ensure that child care facilities provide a variety of healthy foods and age- appropriate portion sizes in an environment that encourages children and staff to consume a healthy diet, child care regulatory agencies should require that all meals, snacks, and beverages served by early childhood programs be consistent with the Child and Adult Care Food Program meal patterns and safe drinking water be available and accessible to the children.

Standards exist for serving size, nutritional content, frequency of meals and snacks, and not using food as a reward or punishment.

x x State child care regulatory agencies should require that child care providers and early childhood educators practice responsive feeding.

24 Standards exist for family style meals, age appropriate eating utensils and tableware and proper seating.

Health and education professionals providing guidance to parents of young x x x x x x x x x children and those working with young children should be trained and educated and have the right tools to increase children’s healthy eating and counsel parents about their children’s diet.

Standards exist for formal nutrition information and education programs (for staff and families) that target food selection and preparation, nutrition skills and managing food budgets.

Child care regulatory agencies should require child care providers and early childhood educators to provide infants, toddlers, and preschool children with opportunities to be physically active throughout the day.

Standards exist for outdoor and indoor play (including time, equipment and materials), age-appropriate gross motor and movement skills development and a planned program of daily activities.

Child care regulatory agencies should require child care providers and early childhood educators to allow infants, toddlers, and preschoolers to move freely by limiting the use of equipment that restricts infants’ movement and by implementing appropriate strategies to ensure that the amount of time toddlers and preschoolers spend sitting or standing still is limited.

Standards exist for limiting duration and frequency of use of restrictive devices.

Adults working with children should limit screen time, including television, cell phone, or digital media, to less than two hours per day for children aged two−five.

Standards exist for limiting screen time (media and computers) throughout the day and no viewing during meal and snack time.

Child care regulatory agencies should require child care providers to adopt practices that promote age-appropriate sleep durations. Standards exist regarding sleep and rest time.

Communities should consider amending local zoning ordinances to remove obstacles to the provision of regulated group and family child care in all zoning districts, in locations that are appropriate and safe for children.

Communities should negotiate with developers and to offer incentives to provide space for child care in all types of projects, residential, office, mixed use, and commercial, including new construction and reuse.

26 Attachment 6

Policy gaps identified on day 1, as grouped by roundtable participants

The voice of families in the process – understanding demand Support parent advocacy (faith-based) Bi-generational engagement/impact. Idea that if we are only looking at kids we won’t achieve what we want to achieve. Alignment concept. Multigenerational

Housing policy/access

Policies related to activating park spaces

Institutional racism Make sure we align our work w/AAP work on toxic stress Racial equity lens Equity

Special populations (CSHN) Inclusion in all aspects: low-income, children with disabilities, language, cultural/ethnic

Cultural competency through everything Culture: social norms, preferences, priorities

Poverty Living wage Poverty: limited choices, social isolation, limited resources Poverty/economic security: ECE child care workforce, families

Alignment across programs, standards/funding Systems integration Alignment across segments of food environment Systems alignment Systems alignment and integrated eligibility

Funding and appropriations

Insure families have access to food literacy opportunities through childcare Review WIC benefit to make sure it works to age 5 Enhance food labeling to include nutritional values and serving size (including added sugar) for children: increase parental education and choice

Food access: food insecurity deserts Universal pre-school and year-round food programs

Targeted technical assistance

Corporate influence on public policy