Changes in YMCA Afterschool Programs Increase Children's Physical Activity and Healthy Food Options

Harvard University: Prevention Research Center on Nutrition and Physical Activity

Addresses CDC Winnable Battle: Nutrition, physical activity, and obesity
 

Case Study

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YMCA-Harvard Afterschool Food and Fitness Project

• YMCA learning collaboratives, an approach to bringing about organizational change, were found to be promising for translating obesity prevention science into practices for use in YMCA afterschool programs
• Learning collaboratives helped staff develop the skills needed to work toward creating a healthy afterschool environment by achieving simple health-related program standards
• Before and after studies of selected afterschool programs showed significant improvements in the healthfulness of snacks served and the physical activity levels of children in these programs

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Background

Approximately 17% (12.5 million) of U.S. children aged 2 to 19 years are obese.1 Obese children are more likely to have high blood pressure and high cholesterol (risk factors for cardiovascular disease); increased risk of diabetes; breathing problems, such as sleep apnea and asthma; and a greater risk of social and psychological problems, such as discrimination and poor self-esteem—problems that can continue into adulthood. Obese children are more likely to become obese adults; adult obesity is associated with many serious health conditions including heart disease, diabetes, and some cancers.2 Obesity generally results from a disparity between energy intake and energy expenditure and studies indicate that an energy imbalance of about 110–165 kcal a day is at the core of the childhood obesity problem.3 Thus, interventions that decrease children's excess caloric intake and increase their energy expenditure may help alleviate the obesity problem.

Context

The YMCA designed learning collaboratives consistent with the Institute for Healthcare Improvement (IHI) Breakthrough Series Collaborative model, a structured, short-term approach to achieving organizational change by bringing people together around a focused issue.4 With IHI coaching, the YMCA established a series of learning collaboratives between 2004 and 2009. An evaluation found that the learning collaboratives created "conditions that enabled and empowered staff to incorporate new standards for nutrition, physical activity, and parent engagement into existing programs."5 Staff developed skills to set goals and implemented small experiments to develop local best practices for achieving selected goals. Having established that the learning collaboratives held promise for bringing about organizational change, additional research was conducted to assess the effects of the learning collaboratives on changing health-related practices and behaviors in afterschool programs. In conjunction with improving program practices and policies, the Food & Fun After School curriculum (developed in a partnership between the Harvard Prevention Research Center [PRC] and the YMCA of the USA to promote nutrition and physical activity in out-of-school time) was delivered to children aged 5 to 12 years attending YMCA afterschool programs. When the curriculum was created in 2005, materials were field-tested at 10 YMCA afterschool settings in several states (including Massachusetts, North Carolina, Texas, Indiana, Kentucky, New Jersey, Washington, Florida, and Kansas) for acceptability, feasibility, and ease of use. A second edition (created in 2011) features lesson extensions to help sites adapt activities to the needs and interests of a diverse range of children. The curriculum, available free of charge at www.foodandfun.org, includes tip sheets, assessment guides, recipe packets, and snack planning tools to help staff make inexpensive, effective program changes.

The program was part of a large-scale initiative to improve border health. The Initiative included components targeting clinicians, schools, persons with diabetes and their families, and the community; Pasos Adelante was the community component. The program was developed in partnership with the Mariposa Community Health Center in Nogales, Arizona, the Regional Center for Border Health, Inc., the Western Arizona Area Health Education Center, and faculty and staff at the University of Arizona Mel and Enid Zuckerman College of Public Health.

Methods & Results

The YMCA and the Harvard PRC further collaborated to establish several standards for nutrition and physical activity for the YMCA's afterschool programs. Five of these standards concern healthy eating: offer fresh fruits or vegetables daily; do not serve foods containing trans fats; offer water as the primary beverage daily; do not serve sugar-sweetened beverages; and serve more whole grains instead of foods containing processed grains. Three standards relate to physical activity: include 30 minutes of moderate physical activity daily; offer 20 minutes of vigorous physical activity as an option 3 times a week; and encourage staff to participate in the activity with the children. Two additional standards concern screen time: eliminate broadcast and cable TV or movies; limit computer time to less than 1 hour each day. By participating in the learning collaboratives, program staff worked toward achieving these standards. Results related to the nutrition and physical activity standards are summarized below. Data for the screen time standards are not yet evaluated and further information about them is not included here at this time.

Healthy eating

• Menus of snacks and beverages served at 7 YMCA afterschool programs located in 5 states were collected over a 14-month period.6 The quality of snacks and beverages were analyzed at baseline (fall 2005), midway (spring 2006), and post-intervention (fall 2006). Compared to baseline values, at post- intervention, weekly servings of fruits and vegetables significantly increased (1.3 to 3.9, p=0.02), while significant decreases were seen in weekly servings of desserts (1.3 to 0.5, p=0.05), foods with added sugars (3.9 to 2.4, p=0.03), and foods with trans fats (2.6 to 0.7, p=0.01). Pre-intervention, one site served sugar-sweetened beverages; post- intervention, no sites did—instead, all sites served water. At baseline, each site had achieved at least 1 of the 5 healthy eating standards; post-intervention all sites had achieved at least 2 of the standards. Although not statistically significant, average calories in snacks and beverages offered decreased from 300.3 kcal before the intervention to 266.9 kcal after.
• An analysis of the price and healthfulness of snacks served in a sample of 32 YMCA afterschool programs in 4 U.S. metropolitan areas found that healthful snacks achieving the 5 healthy eating standards were 50% more expensive than less-healthful snacks.7 Fruits and canned or frozen vegetables contributed to significantly higher snack price. Analyses showed that replacing these items with low-priced fresh vegetables and replacing refined grains with whole grains would increase the healthfulness of snacks without causing increases in price. Analyses also identified a range of repeatedly served, inexpensive, healthful snacks that were served as part of regular, ongoing afterschool programs. Thus, healthful foods and snack combinations could be served at or below the price of less-healthful snacks. In particular, substituting tap water for 100% juice produced savings that could be used toward the purchase of healthful foods, such as apples.

Physical activity

• The physical activity intervention consisted of using the learning collaborative process and the Food & Fun After School curriculum.8 The intervention was implemented in 16 afterschool programs in four U.S. metropolitan areas. Sixteen matched control afterschool programs were selected from the same metropolitan areas for comparison. The control programs were those in place at the time the control was selected; the amount and level of physical activity of children in these programs varied. Children's physical activity was measured by accelerometers worn at baseline (fall 2006) and follow up (spring 2007). Children at intervention sites showed greater increases in minutes of combined moderate and vigorous physical activity (10.5 minutes more per day, p=0.017) than children in control sites. These differences translated into an average additional energy expenditure of 25 kcal a day for a child in an intervention setting.

Consequences and Potential Impact

Afterschool programs provide food, beverages, and physical activity to more than 8 million U.S. children each year.⁸ The types and amounts of snacks served at these programs contribute to a child's daily caloric intake, while the kind and duration of physical activities offered impact caloric expenditure. Given that afterschool programs may have greater flexibility in establishing new standards than school-based programs do, afterschool programs may be a key place to influence the eating and physical activity behaviors of children. The health-based standards developed by the Harvard PRC in collaboration with the YMCA appeared to help staff create healthful environments with respect to the foods and drinks served during the program and children's physical activity levels,^6-8 and were well received by staff.⁵ Wide implementation of the eating and physical activity standards in afterschool programs could meaningfully contribute to efforts to curb childhood obesity. In December 2011, the YMCA of the USA pledged to First Lady Michelle Obama and the Partnership for a Healthier America that 85% of YMCA Associations would adopt similar physical activity and healthy eating standards in early childhood and afterschool programs by 2015. The YMCA's pledge could impact the lives of 595,000 children across the United States.

References

1. Centers for Disease Control and Prevention. Data and Statistics: Obesity Rates Among All Children in the United States.http://www.cdc.gov/obesity/data/index.html. Accessed June 22, 2012 .
2. Centers for Disease Control and Prevention. Overweight and Obesity: Basics About Childhood Obesity. http://www.cdc.gov/obesity/childhood/basics.html. Accessed January 29, 2012.
3. Wang YC, Gortmaker SL, Sobol AM, Kuntz KM. Estimating the energy gap among US children: a counterfactual approach. Pediatrics. 2006;118(6):e1721-33.
4. Institute for Healthcare Improvement.The Breakthrough Series: IHI's Collaborative Model for Achieving Breakthrough Improvement. http://www.ihi.org/knowledge/Pages/IHIWhitePapers/
   TheBreakthroughSeriesIHIsCollaborativeModelforAchieving
   BreakthroughImprovement.aspx
5. Wiecha JL, Nelson TF, Roth BA, Glashagel J, Vaughan L. Disseminating health promotion practices in afterschool programs through YMCA learning collaboratives. American Journal of Health Promotion. 2010;24(3):190-8.
6. Mozaffarian RS, Wiecha JL, Roth BA, Nelson TF, Lee RM, Gortmaker SL. Impact of an organizational intervention designed to improve snack and beverage quality in YMCA after-school programs. American Journal of Public Health. 2010;100(5):925-32.
7. Mozaffarian RS, Andry A, Lee RM, Wiecha JL, Gortmaker SL. Price and healthfulness of snacks in 32YMCA after-school programs in 4 US metropolitan areas 2006–2008. Preventing Chronic Disease. 2012;9:110097.
8. Gortmaker SL, Lee RM, Mozaffarian RS, Sobol A, Nelson TF, Roth BA, Wiecha JL. Effect of an after-school intervention on increases in children's physical activity. Medicine & Science in Sports & Exercise. 2012;44(3):450-7.