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. 2 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,