Home   |   About   |   Contact

Eat Well Play Hard in Child Care Settings

Evidence Summary

Underlying Theory: 

Eat Well Play Hard in Child Care Settings (EWPHCCS) utilizes the Social Ecological Model of behavior change - the individual’s (child’s) behavior is influenced by interpersonal and organizational factors. This is a multi-level intervention, with modifications occurring at the center-level (practices); staff-level (staff training); and home-level (information provided to parents in lessons and via parent newsletters sent home).

Evidence-based strategies1

  1. Comprehensive nutrition programs in a single settingThe EWPHCCS program addresses children’s increased consumption of fruits, vegetables, and milk through improved capacity of the child care staff to provide education to children; through direct education programs provided to parents; and through indirect education provided to parents through materials sent home with children.
  2. School (child care setting) nutrition programs to promote healthy eatingThe EWPHCCS curriculum is delivered by registered dietitians (RD) who teach nutrition and physical activity lessons to children and parents.  Child care center staff also receive at least two nutrition lessons, and they are encouraged to reinforce healthy messages from the EWPHCCS curriculum during child care center classes and mealtimes.
  3. Social support for healthy eatingEWPHCCS attempts to support parents/ caregivers as they try to provide healthy food for children. 

Research Findings or Evaluation Outcomes: 

The Eat Well Play Hard in Child Care Settings (EWPHCCS) intervention was developed by experienced public health practitioners at the New York State Department of Health (NYSDOH) which conducted focus groups with parents of children in centers participating in the Child and Adult Care Food Program (CACFP).  Additionally, to inform the EWPHCCS curriculum and implementation process, intervention developers gathered input from academic experts, conducted a literature review, reviewed existing programs in other states, and surveyed child care center staff.

In 2012, the Altarum Institute released the results of an evaluation of Eat Well Play Hard in Child Care Settings, funded by the U.S. Department of Agriculture (USDA), Food and Nutrition Service, Office of Research and Analysis.  The USDA-funded evaluation included process and outcome measures and analysis.  (The web link to the full evaluation report is provided in Additional Information.)

Process Outcomes:

In 2010, EWPHCCS reached 10,314 children at 246 childcare centers across New York State, at an estimated cost of $296.36 per child.  That cost does not include the large number of caregivers and childcare center staff that the intervention may have positively influenced. External evaluators conducted the process evaluation via surveys, focus groups and interviews with three groups: (i) EWPHCCS program-level staff, (ii) intervention site key informants (child care center directors and classroom teachers), and (iii) caregivers of the children participating in the program.  Additionally, external evaluators observed three child care sites to gain a better understanding of the classroom setting, classroom teachers’ role, participants’ interest, and whether the intervention was delivered as intended.  Process data described how well the intervention was implemented, the feasibility of the implementation, and the level of acceptability by center directors/staff and parents/caregivers.  Overall, the participants favor the intervention and, of those parents who responded, were enthusiastic in their praise.

Effectiveness Outcomes:

The USDA evaluation was specifically designed to measure nutrition outcomes; the physical activity component of EWPHCCS was not evaluated. 

A total of 24 childcare centers, 12 in New York City and 12 elsewhere in New York State were included in the USDA evaluation.  The 24 centers were divided into pairs and matched for center type (standard or Head Start), location (NYC or elsewhere in NY state), and size.  One of the paired centers was randomly assigned to receive the EWPHCCS intervention, while the other served as the control group. 

Data were collected via surveys filled out by parents/caregivers.  In the intervention group, 76% (n=552) of the caregivers returned the baseline survey, and 80% returned the follow-up survey.  There was a similarly high response rate in the control group: 74% returned the baseline survey, and 78% returned the follow-up.

The researchers found the following statistically significant results when they compared children in child care centers who received the EWPHCCS program to children in centers that did not receive the program:

  • Increase in children’s daily at-home consumption of vegetables
  • Increase in children’s at-home use of 1% or fat-free milk
  • Increase in reports of the rate of child-initiated vegetable snacking
  • Trend toward increased parental offerings of vegetables

The following outcomes were measured, but changes did not reach statistical significance:

Children’s at-home dietary behaviors:

  • Eating a variety of fruits or vegetables
  • Helping oneself to, or requesting fruit as a snack
  • Willingness to try new fruits or vegetables
  • Helping parents make snacks or meals
  • Eating low-fat or fat-free yogurt

Also measured, but changes not reaching statistical significance were:

Parent behaviors and household variables:

  • Offering fruit as a snack
  • Offering fruits or vegetables at dinner
  • Availability of fruits and vegetables
  • Availability of 1% or fat-free milk

The EWPHCCS program is associated with a positive change in several eating behaviors measured in this evaluation.  Given the national epidemic of overweight and obesity, it is important to identify programs that encourage healthy nutrition choices early in life.2


1 A full description of the intervention strategies used can be found here with references to the sources of evidence to support the strategies.

2 Story, M., Kaphingst, K.M., and S French. The Role of Child Care Settings in Obesity Prevention. (2006). The Future of Children, 16(1): pp. 143-168.