A multilevel intervention to increase physical activity and improve healthy eating and physical literacy among young children (ages 3-5) attending early childcare centres: the Healthy Start-Départ Santé cluster randomised controlled trial study protocol

Bélanger et al. BMC Public Health (2016) 16:313 DOI 10.1186/s12889-016-2973-5 STUDY PROTOCOL Open Access A multilevel intervention to increase physical activity and improve healthy eating and physical literacy among young children (ages 3-5) attending early childcare centres: the Healthy Start-Départ Santé cluster randomised controlled trial study protocol Mathieu Bélanger1,2,3, Louise Humbert4, Hassan Vatanparast5, Stéphanie Ward1,2, Nazeem Muhajarine6, Amanda Froehlich Chow4, Rachel Engler-Stringer6, Denise Donovan2, Natalie Carrier7 and Anne Leis6* Abstract Background: Childhood obesity is a growing concern for public health. Given a majority of children in many countries spend approximately 30 h per week in early childcare centers, this environment represents a promising setting for implementing strategies to foster healthy behaviours for preventing and controlling childhood obesity. Healthy Start-Départ Santé was designed to promote physical activity, physical literacy, and healthy eating among preschoolers. The objectives of this study are to assess the effectiveness of the Healthy Start-Départ Santé intervention in improving physical activity levels, physical literacy, and healthy eating among preschoolers attending early childcare centers. Methods/Design: This study follows a cluster randomized controlled trial design in which the childcare centers are randomly assigned to receive the intervention or serve as usual care controls. The Healthy Start-Départ Santé intervention is comprised of interlinked components aiming to enable families and educators to integrate physical activity and healthy eating in the daily lives of young children by influencing factors at the intrapersonal, interpersonal, organizational, community, physical environment and policy levels. The intervention period, spanning 6-8 months, is preceded and followed by data collections. Participants are recruited from 61 childcare centers in two Canadian provinces, New Brunswick and Saskatchewan. Centers eligible for this study have to prepare and provide meals for lunch and have at least 20 children between the ages of 3 and 5. Centers are excluded if they have previously received a physical activity or nutrition promoting intervention. Eligible centers are stratified by province, geographical location (urban or rural) and language (English or French), then recruited and randomized using a one to one protocol for each stratum. Data collection is ongoing. The primary study outcomes are assessed using accelerometers (physical activity levels), the Test of Gross Motor Development-II (physical literacy), and digital photography-assisted weighted plate waste (food intake). (Continued on next page) * Correspondence: 6 Department of Community Health & Epidemiology, College of Medicine, University of Saskatchewan Health Sciences E Wing, 104 Clinic Place, Saskatoon, SK S7N 2Z4, Canada Full list of author information is available at the end of the article © 2016 Bélanger et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bélanger et al. BMC Public Health (2016) 16:313 Page 2 of 10 (Continued from previous page) Discussion: The multifaceted approach of Healthy Start-Départ Santé positions it well to improve the physical literacy and both dietary and physical activity behaviors of children attending early childcare centers. The results of this study will be of relevance given the overwhelming prevalence of overweight and obesity in children worldwide. Trial registration: NCT02375490 (ClinicalTrials.gov registry). Keywords: Childhood obesity, physical activity, physical literacy, food intake, eating habits, preschool, population health intervention Background Childhood obesity is one of the greatest challenges facing public health in the 21st century [1–3]. Weight in early childhood closely predicts weight in later childhood [4–6] and children under six who are obese are at four times more at risk of becoming obese adults than normal weight children [7, 8]. Further, being overweight during childhood increases the likelihood to have compromised emotional, psychological and social well-being [9]. Many factors come together to produce obesity, but it is primarily due to an imbalance between energy intake and energy expenditure [10]. Eating habits are established early in childhood and usually persist for many years [11]. Data show that only 29 % of Canadian preschool aged children meet recommendations for fruit and vegetable intake and 23 % for grain products [12]. Further, 79 % of 4-5 year olds consume food of little nutritional value (e.g., chips, french fries, candy, chocolate, soft drinks, cake and cookies) at least once a week [12] and other studies have demonstrated that empty calories are making up as much as 40 % of their total caloric intake [13, 14]. Similarly, a recent review found that children in early childcare centers (ECC) have low levels of physical activity, and that they are sedentary for much of the time [15]. It was estimated that children in childcare settings accumulate an average of only 7 to 13 min of moderate to vigorous physical activity during the course of a 7 h day [16]. Moreover, recent data show that many of them have poor physical literacy [17–21]. These data are troubling given that sedentary state and physical activity levels track over time [22–26]. Interventions designed to improve the physical activity and nutrition of preschoolers are needed to prevent and control childhood obesity [1, 27–29]. Since more than half of Canadian preschoolers spend an average of 29 h a week in ECC [30], this environment is a prime setting for implementing an array of strategies to foster healthy behaviours [31–36]. However, two systematic reviews on obesity prevention in children under 5 years, one on interventions [35] the other on preventive policies, practice and interventions in ECC [36], reported limited success in improving physical activity levels, dietary behaviour, or body composition. The authors suggest that the least successful interventions focused only on one or two outcomes, while the most successful interventions positively influenced factors such as knowledge, abilities and competence. According to the authors, this means that interventions should be grounded in comprehensive behaviour change models, be multifaceted and sustained over time [35]. Few interventions focused on physical activity and eating behaviours simultaneously, th (...truncated)