CARDIAC Kinder

Childhood obesity has reached epidemic proportions in the past decade, and its association with increased mortality, morbidity, and difficulty in the social environment makes it a major health concern. Early obesity-risk screening and intervention are critically important to help young children develop good diet and physical activity habits. Social learning models that take into account the cognitive development of the child, as well as family system approaches that capitalize on the influence family members may have on a child's behavior, have been the foundation of many successful obesity prevention programs. However, few such programs have been developed for children as young as kindergarten age.

CARDIAC Kinder is an obesity prevention intervention for kindergarteners that aims to (a) increase parents' awareness and understanding of healthy weight, dietary choices, and exercise habits among young children and how these factors as well as family history relate to cardiovascular risk, (b) encourage parents to provide their children with more opportunities for exercise, particularly by engaging in shared activities such as walking, and (c) reduce the proportion of children who are overweight or at risk of becoming overweight through these knowledge and behavior changes.

The intervention begins with an obesity screening, in which measurements of the child's height and weight are used to calculate his or her body mass index (BMI) using age-specific equations developed by the Center for Disease Control and Prevention. With parental consent, measurements are taken by a staff member in a room with no other children present to help the child feel comfortable. After the screening, parents are given a health report that includes their child's BMI, BMI percentile, and basic exercise and diet advice. Age-appropriate educational materials also are provided to the child and to the parents. The materials for children describe the nutritional food pyramid, healthy eating recommendations, and suggestions for enjoyable physical activities. Children with BMIs in the 85th percentile or higher receive information on ways to modify their diet to help reduce their BMI. The materials for parents describe good nutritional and exercise habits, discuss ways to encourage their child to develop good diet and exercise habits, and suggest activities that they can engage in with their child.

In addition, each child is given a pedometer to wear on the waist or at the hip (to be attached and removed with the help of a parent each day) for 4 weeks to track the number of steps taken from morning until bedtime. One pedometer is also provided for use by a parent. Parents are instructed to write down the number of steps taken by both the child and the adult, as shown on the pedometers at the end of the day, on separate step logs that are handed in at the end of the 4-week period. While parental activity is not a targeted outcome of the intervention, providing pedometers to parents is intended to provide greater awareness of the whole family's activity level, encourage physical activities that the family can engage in together (e.g., walking), and help parents serve as role models for the child, in keeping with the family systems-based social learning model. 

For school systems administering CARDIAC Kinder, the time required to take height and weight measurements, calculate BMI, and report results to parents will vary based on how broadly the program is administered. The intervention is designed to be used at home by families and their children, and they can engage as much or as little as they choose.

The intervention is targeted to children aged 4 to 6 years old and their parents.

The intervention has been administered through school systems and is designed for use by parents and children at home. 

Materials required for implementation include:

-- CARDIAC Kinder screening forms
-- Health Report and Screening Outcomes questionnaire
-- Flyer for parents explaining BMI calculations and norms
-- BMI educational toolkit
-- CARDIAC Kinder program description for teachers
-- CARDIAC Kinder physical activity pamphlet
-- Pedometer packets for parents that include a cover letter, two pedometers (one for parent and one for child), a step log, a star chart (reward system for children), and an instruction booklet for pedometer use (final questionnaire packet also included with packet)
-- Educational materials including a pamphlet on dietary and nutritional intake, a nutrition worksheet, a "Working Together to Improve Your Child's Health" pamphlet, and a "My Pyramid for Kids" brochure describing good diet and exercise habits
-- Parent questionnaire (baseline and posttest)

Children enrolled in kindergarten classes (aged 4 to 6 years) in four rural West Virginia counties were invited to participate in the study. The 4 counties were randomly selected from a set of 10 counties that were of interest to the West Virginia Rural Health and Education Partnership. Of the 29 schools in the four participating counties, 15 were randomly assigned to the control group and 14 were randomly assigned to the treatment group.

Teachers and all eligible students in the participating schools were provided a brief description of the screening process and intervention, and parental consent and screening forms were sent home with the students. Parents who agreed to have their children participate in the study provided informed consent and information on family demographics and cardiovascular risk factors. Of 875 children who were invited to participate, 437 children and their parents agreed to participate. Approximately 49% of the participating children were male and 51% were female. About 93% of participating children and 98% of their parents were White.

Children in the control group received one pedometer for their sole use, a one step log to record their steps taken each day, and age-appropriate information about diet and exercise guidelines for kindergarten-age children. Children in the treatment group received two pedometers, one for the child and for the self-identified participating parent, a step log, instruction set for parents on assisting their child with the pedometer and using the step log, and a more in depth information packet with age-appropriate diet and exercise guidelines for young children.  Recommendations for increasing the child's physical activity and improving diet were also included. For both the treatment and control groups, all participants who were given pedometers were asked to wear them daily over the 4-week study period.

While data on children's physical activity was collected using the step log, information on diet was collected via a checklist used by parents to record the number of fruits, vegetables, meat, breads, and sweets consumed by their child each day. Parents also were asked to fill out a questionnaire at baseline and posttest to assess parental encouragement of child physical activity and parental perceptions of the child's physical activity and diet. To assess parental encouragement of child physical activity, the questionnaire asked parents how often they encouraged their child to do physical activity or play outside in a typical week; the response options were 1=never, 2=once, 3=sometimes, 4=almost daily, and 5=daily. To assess parental perceptions of physical activity and diet, six items from the National Survey of Early Childhood Health were used. For example, parents were asked if they believed their children engaged in more than enough, about the right amount, or not enough physical activity. To assess child enjoyment of physical activity, parents were asked to rate their child's enjoyment of physical activity on a Likert-type scale that ranged from 1 ("physical activity is not enjoyable at all") to 5 ("physical activity is very enjoyable").

Effects on Diet

• At the end of the intervention, parent reports indicated that children in the treatment group consumed fewer sweets each week than did the children in the control group (8.4 vs. 9.1, p<.05). There were no statistically significant differences at posttest between the treatment and control groups for other types of foods (i.e., breads, fruits, vegetables, meat).

Effects on Physical Activity

• During the fourth and final week of the intervention, children in the treatment group took an average of 2,016 more steps than children in the control group (p<.04). No statistically significant differences were reported during the first 3 weeks of the study. 

• Parents of children in the treatment group reported encouraging their child to engage in physical activity more frequently after the intervention than they did at baseline (p<.05). There was no significant change in encouragement of activity among control group parents.

• There were no statistically significant differences between the treatment and control groups in parental perceptions of their child's physical activity level.