Introduction

There are two to three times as many obese children in the United States as there were 20 years ago (Ogden et al. 2002).  To arrest this trend, both the Surgeon General (U.S. Department of Health and Human Services 2001) and the Institute of Medicine (Institute of Medicine 2005) have suggested that efforts to prevent obesity should begin early in life.  A major reason for beginning prevention early is that the prevalence of obesity has increased even among preschoolers (Hedley et al. 2004; Ogden et al. 2002; Sherry et al. 2004), many of whom remain obese into adolescence (Freedman et al. 1987).

In the consideration of obesity prevention strategies for early childhood, there are compelling reasons to focus on children in racial/ethnic minority groups who live in low-income households. Among adults in the United States, there is a marked disparity among racial/ethnic groups in the prevalence of obesity (Ogden et al. 2006). It is not known at exactly what age the disparity begins, but it appears to be established by adolescence (Gordon-Larsen et al. 2003; Winkleby et al. 1999). However, the origin of this disparity may lie in the preschool years, because it is in this period of development that activity and dietary behaviors are shaped. Moreover, parents and other adults may influence young children’s weight through the types of eating behaviors that they model for children (Oliveria et al. 1992; Hood et al. 2000).

Head Start, with its almost one million low-income preschool children from diverse racial/ethnic backgrounds, is potentially an ideal setting for developing and implementing obesity prevention efforts.  Although there are no detailed studies of the prevalence of obesity in the Head Start population, it is likely that between 15 and 20 percent of enrolled children are obese (Story et al. 2006; Dennison et al. 2006; Whitaker and Orzol 2006).1

The Head Start Program Performance Standards define minimum requirements for health care, nutrition, physical activity, and other services (National Archives and Records Administration 2006).  For nutrition, these performance standards require that meals provide at least one-third of a child’s daily nutritional needs in center-based, part day programs, and one-half to two-thirds in center-based full day programs; that staff and children eat together family style and share the same menu; and that programs adhere to serving sizes and minimum standards for nutrient content and menu planning required by the U.S. Department of Agriculture’s National School Lunch and School Breakfast Program and Child and Adult Care Food Program.  For physical activity, programs are required to provide sufficient time, indoor and outdoor space, equipment, materials, and adult guidance to promote active play that supports the development of gross and fine motor skills.

Creative approaches to obesity prevention have begun in Head Start with a program enhancement called “I Am Moving, I Am Learning” (IM/IL), which is intended to increase the time children spend being physically active and to improve the quality of their structured movement and food choices.  Specifically, the three goals of IM/IL are (1) to increase the quantity of time children spend in moderate to vigorous physical activity (MVPA) during their daily routine, so that they meet national guidelines for physical activity; (2) to improve the quality of structured movement activities that are intentionally facilitated by teachers and adults; and (3) to promote healthy food choices for children each day.  Rather than a prescribed stand-alone curriculum, IM/IL offers a framework that programs can use to design a set of enhancements that will fit their unique programmatic needs and integrate obesity prevention into their Head Start routines and practices.

Head Start Region III developed IM/IL in 2004 in response to a request from the Office of Head Start.  IM/IL was designed to promote healthy behavior and prevent childhood obesity under the leadership of Nancy Elmore, Head Start Program Manager, Region III, Amy Requa, Pediatric Nurse Practitioner and Region III TA Health specialist and Dr. Linda Carson, Director of the West Virginia Motor Development Center, West Virginia University.  The resulting program enhancement was piloted with 17 Region III programs in FY 2005.  Based on the success of the pilot trainings, 53 more Head Start grantees in Region III were trained in the spring of 2006.  Additional Head Start programs have received training since the spring of 2006, bringing the total number of grantees trained in Region III to 105.  In early 2007, the Director of the Office of Head Start requested that all regions receive IM/IL training and, as of June 2007, 66 Region IX and 34 Region I programs have received the training.

In the spring of 2006, Head Start Region III initiated a broad implementation of IM/IL involving 53 programs.  The approach to this implementation was a training-of-trainers (TOT) model.  Each of the 53 programs sent a team of up to five representatives to the 2½‑day IM/IL training on nutrition and physical activity,2 with the expectation that the team members would return to train their colleagues.  The representatives usually included senior staff such as the program director, child development and education manager, health services manager, and family and community partnerships manager.  Each program’s team worked in small groups with teams from other programs.  At the training, representatives exchanged ideas about possible enhancements and had an opportunity to develop their own strategy for implementing IM/IL.  They also learned about methods for identifying needs for staff training and technical assistance, implementing and sustaining program enhancements, and assessing outcomes.  The trainers and Region III staff encouraged participants to tailor the IM/IL enhancements to their own programs.

The Office of Planning, Research, and Evaluation (OPRE) under the Administration for Children and Families (ACF) contracted with Mathematica Policy Research, Inc. (MPR) to conduct an implementation evaluation of the IM/IL enhancements in Region III.  The purpose of this study is to examine the extent to which grantees who participated in the spring 2006 regional TOT event are implementing IM/IL enhancements.  In the first stage, MPR conducted a survey of the 53 Head Start programs that had participated in the TOT event.  A questionnaire was sent to the individual staff member in each program who was designated to lead the implementation of IM/IL enhancement activities.  This questionnaire assessed the staff members’ perceptions of the spring 2006 TOT event and their experience implementing IM/IL in their programs during the year following that event.  In the next two stages of this evaluation, MPR will conduct telephone interviews with 30 programs whose staff attended the spring 2006 training to learn how programs implemented IM/IL (stage 2), and the research team will conduct site visits to 14 programs that demonstrate varying models of implementation to learn about the sustainability of the IM/IL enhancement (stage 3).  The data collected during these next two stages of the evaluation will complement the survey results and address some of the survey’s limitations.

This document reports on the findings from the stage 1 survey of the 53 Head Start programs that participated in the TOT event.  The report begins with a description of the survey methodology and a description of the data analysis.  It is followed by a description of the survey results, including the overall findings as well as findings by programs’ level of implementation.  It concludes with a summary of the key findings.