Early Childhood Indicators

Increased rate of children who participate in physical activity

Background

The Longitudinal Study of Australian Children, an initiative of the Australian Department of Family and Community Services, showed that a significant proportion of young Australian children under five years are not engaging in physical activity (AIFS, 2005). A very high proportion of Australian preschool children (89 per cent) watched television, DVDs or videos for more than two hours per day, while only two-thirds spent time running, walking or doing other exercise (average 1.9 hours).

Low physical activity is likely to have a long-term health impact as a result of reduced levels of fitness and has been shown to affect cardiovascular risk factors such as elevated blood pressure and impaired glucose response in children as young as 12 years (Baranowski et al., 1992). Studies have shown that physical inactivity is a major factor in the development of overweight and obesity (Batch and Baur, 2005) and an independent risk factor for coronary heart disease and diabetes (Stone et al. 1998). Both cross-sectional and longitudinal studies have shown a significant association between the amount of television viewing and overweight and obesity (Robinson, 2001).

There is also evidence that physical activity or inactivity tends to ‘track’ during childhood, so that less-active children remain less active than their peers (Pate et al., 1996). In a prospective study that followed preschool children into adolescence, Moore et al. (1995) found that preschool children with low activity levels gained more sub-cutaneous fat than children who were more active, and that physical activity and sedentary behaviours track into adolescence. Physical activity behaviours in childhood may also track into adulthood (Kelder et al., 1993) though the relationship is less strong.

Promoting physical activity and reducing sedentary activity at early ages is therefore important for improving children’s fitness and reducing the prevalence of overweight and obesity in Australian children. It is especially important that there is a strong evidence base for strategies to promote physical activity among young children, and that the settings in which these strategies can be delivered are clearly identified (Timperio, Salmon and Ball, 2004).

The evidence base

A wide variety of programs were reviewed for this project. The review showed that interventions aimed at increasing physical activity in children have focused on two approaches: increasing the amount and intensity of physical activity and decreasing sedentary activities (such as watching television and playing video games) with the aim of substituting opportunities for more active leisure in their place. In many of the studies, increased physical activity or reduced sedentary activity was a secondary or intervening outcome variable, with the primary outcome being changes in body weight, measures of subcutaneous fatness or body mass index (BMI).

Interventions can be further grouped according to settings, including school-based approaches, community approaches, and family-based interventions. The latter have included clinically-based intensive interventions for high-risk overweight and obese children that have focused on family environment and parenting skills, as well as reducing sedentary activities or increasing physical activity (Epstein et al., 2000; Harvey-Berino and Rourke, 2003).

Many interventions have been multi-factorial, for example, combining school and family-based interventions, and targeted at increasing physical activity or reducing sedentary activities. Some programs also have targeted dietary changes, such as children’s healthy eating or changes to the school canteen or meals program.

Selection of recommended interventions

The interventions recommended here are all located in school- or preschool-based settings, delivered by teachers within the curriculum.  However, other potentially promising interventions that aim to increase physical activity or reduce sedentary activities are also mentioned. 

There was general agreement among the large-scale reviews of programs aimed at increasing physical activity that the evidence-base for successful intervention was overwhelmingly strongest in the school-based setting.  School-based settings have an advantage over other settings in that schools provide the opportunity for broad ranging approaches that can be integrated with each other and into the general curriculum.  Schools also reach almost the whole child population.  In addition, the school setting provides the opportunity to deliver multifaceted programs that can focus on the individual child as well as the environment in which children work and play, and provide children the opportunity for modelling against their peers and their teachers (Dietz and Gortmaker 2001; Flynn et al. 2006).  Two school-based programs, SPARK and CATCH, are recommended in the Best Start catalogue.

The school-based intervention program, Sports Play and Active Recreation for Kids (SPARK), was designed to promote moderate to vigorous levels of physical activity, teach movement skills, and be enjoyable.  SPARK physical education (PE) classes, run three days per week, and are of 30 minutes duration, equally divided between health-fitness and skill fitness activities.  Health-related activity units include dance, games, walking/jogging, and jump rope, with intensity, duration and complexity progressively increasing over time.  Motivation is enhanced by students’ monthly self-assessment and recording of fitness levels.  The program includes a self-management program (30 minutes per week), linked to the curriculum, that teaches behaviour change skills to promote physical activity outside school.  Skills include self-monitoring, goal setting, stimulus control, self-reinforcement, self-instruction and problem solving.  Initially prizes are given but phased out over time to encourage self-reward.

SPARK also includes a family oriented approach.  Homework and newsletters aim to stimulate parent-child interaction and support for physical activity. 

The SPARK intervention was initially trialed amongst 955 Grade 4 and 5 children in seven primary (elementary) schools in San Diego, with mostly European American children.  At the end of the trial, intervention students were more physically active during PE classes, and also showed increased fitness (Sallis et al. 1997, 1999; McKenzie et al. 1997; Dowda et al. 2005). At the18 month follow-up, the trained classroom teachers continued to use the curriculum and maintained increased student physical activity levels.  Further follow-up of diffusion outcomes showed that 80% of respondents sustained use up to 4 years later, and equal levels of implementation were found in affluent and disadvantaged schools.  SPARK subsequently was disseminated nationally in the US with training in more than 3000 schools. In addition, the program was extended to include Kindergarten to 6th Grade PE (Owen et al. 2006).  The SPARK program has potential for usefulness among pre-school children, since it is being used already among children in their first year of school.  It is noteworthy that SPARK students showed the same or increased academic test scores compared to controls, although they spent fewer hours on the academic curriculum. 

SPARK was also adapted for American Indian primary school children through the adoption of a unit of American Indian games to increase cultural relevance.  There was also significant consultation with the American Indian communities during the implementation of the intervention (Going 2003).  Although a multicentered randomised trial found no statistically significant differences between students in the intervention and control schools, students in the intervention schools were 7-10% more active.  An important positive finding was the incorporation of culturally relevant activities into the SPARK program and the acceptance by the American Indian community (Gittelsohn et al. 2003).  SPARK therefore may have potential for adaptation to CALD and other groups.  

The Coordinated Approach to Child Health program (CATCH) comprises four school-based program components, two of which aim to promote physical activity, but also including a food service component and a tobacco control component.  The CATCH-Physical Education program is similar to SPARK, designed to increase children's moderate to vigorous physical activity during PE classes.  CATCH-PE provides a series of health-related physical fitness activities on cards.  Classroom curricula include specific programs (such as Hearty Heart and Friends, Go for Health) consisting of regular 30-40 min lessons spaced at intervals through the term.  The curricula target psychosocial factors and skills development focused on physical activity and eating.  Teachers attend 1-1.5 days of training per year.  The home curriculum involved activity packs complementing classroom curricula that included parent participation to complete and invitation to a 'family fun night' (www.CATCHTexas.org).

The CATCH program was tested in a randomised controlled field trial at four US centres (San Diego, Minneapolis, Houston, New Orleans) over two years, in 96 schools, with 56 intervention and 40 control primary (elementary) schools.  The trial included 5,106 3rd grade students (mean age 8.76 yrs at baseline), with considerable ethnic and geographical diversity.  However, participation at baseline was only 60%. Intervention schools were further randomised into 2 equal sub-groups: one received school-based program comprising school food service modifications, PE interventions, and CATCH curricula; the other received the same school-based program plus a family-based program.  The control group received usual PE curricula, PE, food services, but no CATCH components (Luepker et al. 1996; Nader et al. 1999; Perry et al. 1990).

At the end of the trial the primary physical activity outcome measure was whether moderate to vigorous physical activity reached 40% of PE class time, assessed by the SOFIT instrument.  A secondary physical activity outcome was self-reported time engaged in moderate to vigorous physical activity, assessed using the Self-administered Physical Activity Checklist developed and validated as part of the CATCH program.  The trial also assessed canteen food. The secondary study comparison, assessing the effect of the home/family component, examined differences in self-reported time engaged in moderate to vigorous physical activity, as well as other non-physical activity measures.  Participation in the programs was reported as consistently high.  Physical activity intensity in PE classes in intervention schools increased significantly more compared with control schools.  Time spent in PE classes at higher levels of activity increased significantly in intervention schools (Luepker et al. 1996; Nader et al. 1999; Perry et al. 1990). 

Follow up showed that the program, combining health education with behavioural components and school environmental modifications, can improve physical activity and nutrition-related behaviours over three years after the end of the intervention (Hoelscher et al. 2004).

By 2004 CATCH has been disseminated to over 1900 schools in Texas reaching an estimated 900,000 students.  School staff have expressed widespread satisfaction (Coleman et al. 2005; Owen et al. 2006).

SPARK and CATCH focus primarily on increasing physical activity.  The last 2 interventions focus upon reducing sedentary activities.

The Switch-Play intervention is a school based intervention that was trialled among 311 consenting Grade 5 primary school children from three government primary schools located in low socioeconomic suburbs of Melbourne (Salmon et al. 2005a and 2005b and Salmon et al. 2008).  Two main intervention components were incorporated into school curriculum: a behaviour modification (BM) group participated in 19 sessions that encouraged reduction in television, video and computer games and identified alternative physical activity activities and a fundamental motor skills (FMS) group participated in 19 lessons around mastery of 6 motor skills.  A combined group participated in all BM and FMS activities.  The intervention was based on Social Cognitive theory, Behavioural Choice Theory and Ecological theory, and incorporated components form SPARK and other interventions. It incorporated education and awareness-raising, self-monitoring, decision-making and behavioural choices, role playing, goal setting and contracts, and feedback/reinforcement (Salmon et al. 2008).

The Switch-Play intervention aimed to prevent excess weight gain among 10-year-old children, to prevent declines in physical activity, to reduce screen behaviours and to increase enjoyment of physical activity. The results reveal that there was a significant intervention effect from baseline to post intervention on age and sex-adjusted Body Mass Index (BMI) in the BM/FMS Group.  This result was maintained at 6 and 12 month follow-up periods.  The FMS group children recorded higher levels and greater enjoyment of physical activity whilst the BM children recorded higher levels of physical activity (Salmon et al. 2008).   

Moving from primary school to kindergarten, Romp and Chomp is another Victorian program.  It is a community-based obesity prevention demonstration project targeting children under five years of age in long day care, family day care, kindergartens and preschool settings in the Geelong region.  The program includes eight objectives that are summarized by four key messages (daily water, daily active play, daily fruit and vegetables, less screen time).  A social marketing campaign guides delivery of the messages to early childhood settings and families with pre-school children.  Active play resources are also made available to early childhood workers in the targeted settings, and training is included (WHO Collaborative Centre for Obesity Prevention, Deakin University 2005).

Presently 45 kindergartens and 7 long day care centres throughout the Geelong and Bellarine Peninsula have activated nutrition, drink and active play policies.  This process is supported by local community health workers.

The program is included in this catalogue, although it has not been evaluated, because it is an Australian program that has been developed and specifically targeted at the under fives, and is undergoing evaluation under the auspices of an internationally recognised research institution.

From an international perspective the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) is a program that is also specifically targeted in child care settings.  It was established in 2003 as an environmental intervention to address healthy weight for children in child care settings in North Carolina, US.

The goal of the NAP SACC intervention is to improve the diet and physical activity environment at child care centers to contribute to the marketability of the child care center, and to provide child care staff with continuing education in child nutrition and physical activity practices.

NAP SACC is a practice-based intervention designed to enhance policies, practices, and environments in child care by improving the:

• nutritional quality of food served
• amount and quality of physical activity
• staff-child interactions, and
• facility nutrition and physical activity policies and practices and related environmental characteristics.

The NAP SACC program contains a number of components, including a self-assessment instrument, continuing education workshops, collaborative action planning and technical assistance materials, and an extensive resource manual that includes copy-ready materials.  It has been developed to be an evidence- and theory-based intervention that is guided by a self-assessment completed by the child care center director and relevant staff (e.g., cook, lead teacher, assistant director).  Technical assistance and support for change are provided by NAP SACC consultants.  Ideally these individuals are already working in local communities who receive supplemental training and support materials to expand their role to include nutrition and physical activity (Ammerman et al. 2007).

The NAP SACC program shows promise of being a sustainable and easy-to-implement intervention. Currently, it is being evaluated in 33 counties and 96 child care centers in North Carolina.  Early evaluation results indicate Child care centers that received the intervention improved their nutrition and physical activity policies and practices.

Also of interest is the small study of 60 obese children, of whom 50 were followed up seven years later, reported by Golan and Crow (2004), which compared a parent-only targeted program compared with a control intervention where only children were targeted.  The Israeli study found the mean reduction in children’s overweight was 29% greater in the parent-only group compared to the children-only group.  The program for parents included 14 support and educational group sessions over 48 weeks, targeted at enhancing parenting skills in order to improve parents’ ability to create a healthy environment to support an increase in children’s physical activity and encourage healthy eating.  The authors suggest that focusing on parenting skills shifts the focus from weight issues to a focus on a healthy home environment, and builds children’s esteem.

Discussion

The review of published interventions to promote physical activity showed there is a critical shortage of programs aimed at preschool aged children, despite the stated importance of establishing increased physical activity patterns early in childhood. In Australia, 95 per cent of all preschoolers attended a school, kindergarten, preschool or day-care centre at least one day per week (AIFS, 2005). These would appear to be ideal settings in which to promote increased physical activity.

Only one program targeted at preschool children was tested in a trial of sufficient quality to consider recommending as a Best Start strategy: the TOP Start program, trialed in the MAGIC study in the UK (Reilly et al., 2006). Although this program was not found to have an impact on habitual physical activity of preschool aged children outside the preschool environment, it should be considered to have the potential to increase physical activity if introduced as part of the normal, regular curriculum in preschools. Several researchers have noted that regular and more frequent carefully structured physical education classes have the most potential for increasing the level of physical activity in children (Flynn et al., 2006).

While the SPARK, CATCH and ‘Switch-Play’ programs included in the Best Start catalogue here have been trialed in children from lower socio-economic areas, there are few trials of interventions to increase physical activity among children from CALD groups, especially recent immigrants. While SPARK has been adapted for American-Indians, and found culturally relevant and acceptable, it had limited success in demonstrating increased physical activity.

There have been almost no evidence-based interventions focused on the family environment, although a family and home-based approach would seem appropriate for promoting physical activity among very young children.

One other promising but currently untested program, the ‘Romp & Chomp’ intervention was included in this catalogue, because it is an Australian program being trialled in the Greater Geelong region. It is targeted specifically at preschool children and aims at increasing structured play at preschool, increased physical play and reduced television viewing at home. It also has been developed with social marketing principles as a framework, has developed resources, and is being evaluated in association with an internationally-recognised collaborative research centre at Deakin University.

References

Ammerman AS, Ward D, Benjamin SE, Ball, SC, Sommers JK,Molloy M and Dodds JM (2007) An Intervention to Promote Healthy Weight: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) Theory and Design. Preventing Chronic Disease (serial online) 2007 July. (http://www.cdc.gov/pcd/issues/2007/jul/toc.htm)

Australian Institute of Family Studies (2005) Growing up in Australia. The Longitudinal Study of Australian Children 2004 Annual Report. Commonwealth of Australia, Melbourne

Baranowski T, Bouchard C, Bar-Or O, Bricker T, Heath G and Kimm SYS (1992) Prevalence and cardiovascular benefits of physical activity and fitness in youth. Medicine and Science for Sport and Exercise, Vol. 24, pp. S237-247

Batch JA and Baur LA (2005) Management and prevention of obesity and its complications in children and adolescents. Medical Journal of Australia. Vol. 182, No.3, pp. 130-134

Coleman KJ, Tiller CL, Sanchez J, Heath EM, Oumar S, Milliken G and Dzewaltowski DA (2005) Prevention of the epidemic increase in child risk of overweight in low-income schools: the El Paso coordinated approach to child health. Archives of Pediatric and Adolescent Medicine, Vol. 159, pp. 217-224

Dietz WH and Gortmaker SL (2001) Preventing obesity in children and adolescents. Annual Review of Public Health Vol. 22, pp. 337-353

Dowda MC, Sallis JF, McKenzie TL, Rosengard PR and Kohl HW (2005) Evaluating the sustainability of SPARK physical education: A case study of translating research into practice. Research Quarterly for Exercise and Sport, Vol. 76, No. 1, pp.11-19.

Epstein LH, Paluch RA, Gordy C and Dorn J (2000) Decreasing sedentary behaviours in treating pediatric obesity. Archives of Pediatrics and Adolescent Medicine. Vol. 154, No. 3, pp. 220-226

Flynn MA, McNeill DA, Maloff B, Mutawingwa D, Wu M, Ford C and Tough SC (2006) Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with ‘best practice’ recommendations. Obesity Reviews Vol. 7, Suppl. 1, pp. 7-66

Gittelsohn J, Davis SM, Steckler A, Ethelbah B, Clay T, Metcalfe L and Holy Rock B (2003) Pathways: lessons learned and future directions for school-based interventions among American Indians. Preventive Medicine Vol. 37, pp. S107-S112

Going S, Thompson J, Cano S, Stewart D, Stone E, Harnack L, Hastings C, Norman J and Corbin C (2003) The effects of the Pathways obesity prevention program on physical activity in American Indian children. Preventive Medicine Vol. 37, pp.S62-S69

Golan M and Crow S (2004) Targeting parents exclusively in the treatment of childhood obesity: long term results. Obesity Research Vol. 12, No. 2, pp. 357-361

Harvey-Berino J and Rourke J (2003) Obesity prevention in preschool Native-American chldren: a pilot study using home visiting. Obesity Research. Vol. 11, pp. 606-611

Hoelscher DM, Fledman HA, Johnson CC, Lytle LA, Osganian SK, Parcel GS, Kelder SH, Stone EJ and Nader PR (2004) School-based health education programs can be maintained over time: results from the CATCH institutionalization study. Preventive Medicine Vol. 38, pp. 594-606

Kelder SH, Perry CL, and Klepp KI (1993) Community-wide youth exercise promotion: long-term outcomes of the Minnesota Heart Health Program and the Class of 1989 Study. Journal of School Health. Vol. 63, pp. 218-223

Luepker RV, Perry CL, McKinley SM, Nader PR, Parcel GS, Stone EJ, Webber LS, Elder JP, Feldman HA, Johnson CC, Kelder SH and Wu M (1996) Outcomes of a field trial to improve children’s dietary patterns and physical activity: the Child and Adolescent Trial for Cardiovascular Health (CATCH). Journal of the American Medical Association. Vol. 275, No. 10, pp. 768-776

McKenzie TL, Sallis JF, Kolody B and Faucette N (1997) Long-term effects of a physical education curriculum and staff development program: SPARK. Research Quarterly for Exercise and Sport, Vol. 68, No. 4, pp280-291

Moore LL, Nguyen U, Rothman KJ, Cupples LA and Ellison RC (1995) Preschool physical activity level and changes in body fatness in young children. American Journal of Epidemiology. Vol. 142, pp. 982-988

Nader PR, Stone EJ, Lytle LA, Perry CL, Osganian SK, Kelder S, Webber LS, Elder JP, Montgomery D, Feldman HA, Wu M, Johnson C, Parcel GS, and Luepker RV (1999). Three-year maintenance of improved diet and physical activity. The CATCH cohort. Archives of Pediatric and Adolescent Medicine, Vol. 153, pp. 695-704.

Owen N, Glanz K, Sallis JF and Kelder SH (2006) Evidence-based approaches to dissemination and diffusion of physical activity interventions. American Journal of Preventive Medicine, Vol. 31, No. 4S, pp S35-S44

Pate RR, Baranowski T, Dowde M, and Trost SG (1996) Tracking of physical activity in young children. Medicine and Science in Sports and Exercise. Vol. 28, No. 1, pp. 92-96

Perry CL, Stone EJ, Parcel GS, Ellison C, Nader PR, Webber LS and Luepker RV (1990) School-based cardiovascular health promotion: the child and adolescent trial for cardiovascular health (CATCH). Journal of School Health. Vol. 60, No. 8, pp 406-413

Reilly JJ, Kelly L, Montgomery C, Williamson A, Fisher A, McColl JH, La Conte R, Paton JY and Grant S (2006) Physical activity to prevent obesity in young children: cluster randomised controlled trial. British Medical Journal, Vol.333 (7577), pp.1041. (Accessed 29 September 2008). (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1647320)

Reilly JJ, Kelly L, Montgomery C, Williamson A, Fisher A, McColl JH, La Conte R, Paton JY and Grant S (2006) Physical activity to prevent obesity in young children: cluster randomised controlled trial. British Medical Journal, in press. doi:10.1136/bmj.38979.623773.55 (published 6 October 2006) (Accessed 19 October 2006)

Reilly JJ and McDowell ZC (2003) Physical activity interventions in the prevention and treatment of pediatric obesity: systematic review and critical appraisal. Proceedings of the Nutrition Society. Vol 62, pp. 611-619

Robinson TN (2001) Television viewing and childhood obesity. Pediatric Clinics of North America Vol. 48, pp.1017-1025

Sallis JF, McKenzie TL, Alcaraz JE, Kolody B, Faucette N and Hovell MF (1997), The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. American Journal of Public Health. Vol. 87, No. 8, pp 1328-1334

Sallis JF, McKenzie TL, Kolody B, Lewis M, Marshall S and Rosengard P (1999) Effects of health-related physical education on academic achievement: project SPARK. Research Quarterly ofr Exercise and Sport. Vol. 70, No. 2, pp. 127-134

Salmon J, Ball K, Crawford D, Booth M, Telford A, Hume C, Jolley D and Worsley A (2005a) Reducing sedentary behaviour and increasing physical activity among 10-year-old children: overview and process evaluation of the ‘Swith-Play’ intervention. Health Promotion International Vol. 20, No. 1, pp 7-17

Salmon J, Hume C, Ball K, Booth M, and Crawford D (2005b) Individual, social and home environment determinants of change in children’s television viewing: the Switch-Play intervention. Journal of Science and Medicine in Sport. Vol 9. No. 5, pp 378-356

Salmon J, Ball K, Hume C, Booth M and D Crawford (2008) Outcomes of a group-randomized trial to prevent excess weight gain, reduce screen behaviours and promote physical activity in 10-year-old children: Switch-Play. International Journal of Obesity, Vol.32, pp.601-612.

Stone EJ, McKenzie TL, Welk GJ and Booth ML (1998) Effects of physical activity interventions in youth: review and synthesis. American Journal of Preventive Medicine, Vol. 15, No. 4, pp. 298-315

Timperio A, Salmon J and Ball K (2004) Evidence-based strategies to promote physical activity among children, adolescents and young adults: review and update. Journal of Science and Medicine in Sport. Vol. 7, No.1, pp. 20-29

WHO Collaborative Centre for Obesity Prevention, Deakin University, (2005) SSOP Project – Romp and Chomp. 2005 Report. (http://www.deakin.edu.au/hmnbs/who-obesity/downloads/reports/rompandchomp2004pr.php). Accessed 11/10 October/2006

Key

Supporting evidence:

1. Well-supported practice — evaluated with a prospective randomised controlled trial.
2. Supported practice — evaluated with a comparison group and reported in a peer-reviewed publication.
3. Promising practice – evaluated with a comparison group.
4. Acceptable practice – evaluated with an independent assessment of outcomes, but no comparison group (such as pre and post-testing, post-testing only or qualitative methods) or historical comparison group (such as normative data).
5. Emerging practice – evaluated without an independent assessment of outcomes (such as formative evaluation, service evaluation conducted by host organisation).

Replication:
Has the intervention been implemented and independently evaluated at more than one site?  (yes or no)

Documentation:
Are the content and methods of the intervention well documented (such as provider training courses and user manuals) and standardised to control quality of service delivery?  (yes or no)

Theoretical basis:
Is the intervention based upon a well-accepted theory or developed from a continuing body of work in its field?  (yes or no)

Cultural reach:
Has the program been trialed with people in disadvantaged communities, Indigenous people or people from culturally and linguistically diverse backgrounds?  (LOW SES/INDIGENOUS/CALD)

	Supporting evidence	Replication	Documentation	Theoretical basis	Cultural reach
SPARK	1	Yes	Yes	Yes	LOW SES
CATCH	2	No	Yes	Yes	LOW SES; CALD
Switch-Play	2	No	No	Yes	LOW SES
Romp & Chomp	5	No	No	Yes	Universal
NAP SACC	2	Yes	Yes	Yes	Universal

 Recommended strategy 1 - SPARK

Name of Intervention	Sports Play and Active Recreation for Kids (SPARK)
Organisation	SPARK (US)
Brief literature review	SPARK was trialed via a quasi-experimental intervention (four schools) and controls (three schools), mostly European-American children, in grade four, with mean ages 9.49-9.62 years. At the end of the trial, intervention students were more physically active during PE classes, and showed increased fitness. 18-month follow-up showed trained classroom teachers continued to use the curriculum and maintained increased student physical activity levels. 80 per cent of respondents sustained use up to four years later, and equal levels of implementation were found in affluent and disadvantaged schools. Although the program was trialed in older primary school children, packages have been developed for early primary, kindergarten and preschool-aged children. Components of the program also have been adopted for the ‘Switch-Play intervention’ in Australia (see below).
How and why does this intervention work?	SPARK physical education (PE) classes, of 30 minutes duration, three days per week, are designed to promote moderate to vigorous levels of physical activity (MVPA), teach movement skills, and be enjoyable, with intensity, duration and complexity increasing over time. Motivation is enhanced by students’ monthly self-assessment and self-recording of fitness levels. SPARK includes a self-management program, that teaches behaviour change skills to promote physical activity outside school, and includes a family oriented approach, with homework and newsletters to stimulate parent-child interaction and support for physical activity. An adaptation of SPARK for American-Indian school children trialed in 41 schools showed an eight to10 per cent increase in physical activity (measured on one day, but not statistically significant).
On what population does this intervention work best?	Trialed in mostly European-American children but follow-up showed equal levels of implementation in disadvantaged schools. Program has been disseminated nationally in the US with training in over 3,000 schools. In addition, the program was extended to include kindergarten to grade six PE, and a component developed for preschool children. SPARK has been adapted (with culturally relevant games) and trialed in American Indian communities (‘Pathways’ program). The program also has been used in Australia (see ‘Switch-Play’ on following pages).
Where will this intervention work best?	School based intervention but including a home-based component. Trialed in school aged children aged but packages developed for preschool children. Packages have been developed for kindergarten and preschool children.
What is required to implement this intervention?	SPARK program package available in US. Package includes needs assessment, curricula, equipment packages, ongoing follow-up and facilitator training. Cost is unknown.
Resources and contact information	The SPARK Programs (http://www.sparkpe.org/contact.jsp) 438 Camino Del Rio South, Suite 110, San Diego, CA 92108 E-mail: (spark@sparkpe.org), phone US 619-293-7990 or 1-800-SPARK-PE
References	Dowda MC, Sallis JF, McKenzie TL, Rosengard PR and Kohl HW (2005) Evaluating the sustainability of SPARK physical education: A case study of translating research into practice. Research Quarterly for Exercise and Sport, Vol. 76, No. 1, pp.11-19.

Recommended strategy 2 - Top Start

Name of Intervention	MAGIC study intervention (‘TOP start’)
Organisation	University of Glasgow and British Heart Foundation: The Movement and Activity Glasgow Intervention in Children Study utilising ‘TOP Start’, an enhanced physical activity program for children in preschool (nursery school children in UK).
Brief literature review	The MAGIC trial was a cluster randomised controlled single blinded trial over 12 months, carried out in Scotland. Five hundred and fortyfive children in 18 randomly selected preschools, mean age 4.2 years at baseline, were compared to children in 18 randomly selected SEC matched control preschools, in which the normal preschool program was continued. All preschools in the trial were selected from a set of preschools that agreed to participate. Pilot study results at 12 weeks showed significant improvements in physical activity and fundamental motor skills with the intervention. Process evaluation showed the intervention was easily implemented in preschools, and enjoyed by teachers and children. The full trial found no significant effect on levels of habitual physical activity, or sedentary behaviour measured by accelerometry, or on body mass index. However, there was an improvement in children’s fundamental movement skills in the intervention group. While the trial had no measured significant impact on habitual physical activity outside of preschool, the TOP Start program is potentially useful as a preschool physical activity program with developed resource materials. The intervention is included because it is one of the few programs aimed at preschoolers and achieved initial promising results in a rigorous trial and has well developed resources that have been used internationally.
How and why does this intervention work?	The intervention involved introducing an enhanced physical activity program, ‘TOP start’ in 18 randomly selected preschools (nursery schools) in UK, with 18 randomly selected matched preschools as controls. The intervention included three 30-minute sessions per week over 24 weeks, plus home-based health education aimed at increasing physical activity outside of preschool through play and the reduction of sedentary behaviour. The preschool ‘TOP start’ program was intended to increase children’s levels of physical activity and improve their fundamental movement skills, and to meet the requirements of the ‘physical development and movement’ component of the preschool curriculum in Scotland. The preschoolbased intervention was delivered by two members of staff in each preschool who had attended three training sessions. The homebased element had two parts: each participating family received a resource pack with guidance on linking physical play at preschool and home, and two information brochures, one on ways of increasing physical activity at home, and one on ways to reduce the amount of time watching television. Posters were also displayed in the preschool for six weeks.
On what population does this intervention work best?	Preschool children
Where will this intervention work best?	TOP Start is a preschool-based intervention, with a very small familybased component.
What is required to implement this intervention?	Staff training and TOP Start equipment packages. Staff training is provided by Youth Sport Trust UK (availability in Australia is not known. However, TOP Start has been implemented in many countries outside the UK)

Recommended strategy 3 - Switch-Play

Name of Intervention	‘Switch-Play’ intervention
Organisation	Centre for Physical Activity and Nutrition Research, School of Exercise and Nutrition Sciences, Deakin University, Melbourne, Australia
Brief literature review	Australian study, with 397 children enrolled in grade five in three government primary schools at four campuses in low SEC suburbs of Melbourne (77 per cent of eligible pupils). The study is a clusterrandomised trial using a 2x2 factorial design: classes given one of four ‘treatments’: behaviour modification (BM), fundamental motor skills (FMS) development, combined BM and FMS, and a control. Assessment is being undertaken at baseline, immediately postintervention and six and 12 months post-intervention. Preliminary results show that more than half the children reported reducing TV viewing, but less than half reported increasing PA. Evaluation of the program is not complete, however ‘Switch-Play’ is included in the catalogue because preliminary results have been promising and reported in a peer-reviewed publication. Also ‘Switch-Play’ is based on a program that has been rigorously evaluated with excellent sustained results (see SPARK).
How and why does this intervention work?	Intervention components are aimed at reducing sedentary activities and substitution of physical activity, especially outside of school time, and were incorporated into school curriculum. The behaviour modification (BM) group participated in 19 sessions that encouraged reduction in TV, video and computer games and identified alternative physical activities. The fundamental motor skills (FMS) group participated in 19 lessons that focused on mastery of six motor skills. The combined group participated in all BM and FMS activities. The intervention was based on Social cognitive theory, behavioural choice theory and ecological theory, and incorporated components from SPARK, and other interventions, and incorporated education and awareness-raising, self-monitoring, decision-making and behavioural choices, role playing, goal setting and contracts, and feedback/reinforcement.
On what population does this intervention work best?	The intervention is being trialed among grade three primary school children in low SEC suburbs of Melbourne.
Where will this intervention work best?	School based intervention (primary school).
What is required to implement this intervention?	Trained teacher. The program was designed to be practical, incorporated into the school curriculum and does not require expensive equipment to implement.
Resources and contact information	Dr Jo Salmon, Centre for Physical Activity and Nutrition Research, School of Exercise and Nutrition Sciences, Deakin University, Burwood VIC 3125
References	Salmon J, Ball K, Crawford D, Booth M, Telford A, Hume C, Jolley D and Worsley A (2005) Reducing sedentary behaviour and increasing physical activity among 10-year-old children: overview and process evaluation of the ‘Switch-Play’ intervention. Health Promotion International Vol. 20, No. 1, pp 7-17 Salmon J, Hume C, Ball K, Booth M, and Crawford D (2005) Individual, social and home environment determinants of change in children’s television viewing: the Switch-Play intervention. Journal of Science and Medicine in Sport. Vol 9. No. 5, pp 378-356 Salmon J, Ball K, Hume C, Booth M and D Crawford (2008) Outcomes of a group-randomized trial to prevent excess weight gain, reduce screen behaviours and promote physical activity in 10-year-old children: Switch-Play. International Journal of Obesity, Vol.32, pp.601-612.

Recommended strategy 4 - Romp & Chomp

Name of Intervention	Romp & Chomp intervention
Organisation	The program is a partnership between Barwon Health, the City of Greater Geelong, Deakin University Sentinel Site for Obesity Prevention, Department of Human Services Barwon South Western Region, the Geelong Kindergarten Association and Leisure Networks.
Brief literature review	The Romp & Chomp program in the Greater Geelong Region, Victoria is targeted at children under five years of age in long day care, family day care, kindergartens and preschool settings, and their families. The program aims to increase active play and decrease TV viewing time at home, and increase structured active play in kindergarten and day care settings. The program is a partnership between health, education and private organisations, and involves a social marketing campaign and an active play program. The social marketing component aims to increase awareness among the target group through media releases, newsletters, merchandise, and presentations in targeted settings. Active play resources have been made available to early childhood workers in the targeted settings, and training will be included. The program is undergoing evaluation but results have not been published. The program is included in this catalogue, although it has not been evaluated, because it is an Australian program that has been developed and specifically targeted at the under fives, and is undergoing evaluation under the auspices of an internationally recognised research institution.
How and why does this intervention work?	The program is undergoing evaluation.
On what population does this intervention work best?	Romp & Chomp is targeted at children under five years of age and their families.
Where will this intervention work best?	The program is aimed at children in long day care, family day care, kindergartens and preschool settings.
What is required to implement this intervention?	Marketing materials, early childhood staff training, community partnerships.
Resources and contact information	Louise van Herwerden Project coordinator Phone: 03 5261 1100 louisev@barwonhealth.org.au
References	www.deakin.edu.au/hmnbs/whoobesity/downloads/reports/rompandchomp2004pr.php#intervention

Recommended strategy 5 - NAP SACC

Name of intervention	Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) program
Organisation	University of North Carolina at Chapel Hill
Brief literature review	NAP SACC uses an organizational assessment of 14 areas of nutrition and physical activity policy, practices and environments to identify the strengths and limitations of the child care facility. Following the self-assessment, a health consultant (i.e., child care health consultant, nurse, health educator or other trained professional) works with the child care facility staff to set goals for change and develop plans for follow-up actions to improve practice. Collaborative goal-setting is followed by staff training and targeted technical assistance to promote organizational change.
How and why does this intervention work?	Data available at the time of the review suggest that NAP SACC centres are more likely to make significant changes in nutrition policies together with positive changes in physical activity policies, environments and practices. Preliminary data from a research study indicate that NAP SACC may also have a modest impact on behaviour of children while in child care.
On what population does this intervention work best?	Young children attending child care.
Where will this intervention work best?	This intervention is targeted at child care settings. Children ages 2-5 years.
What is required to implement this intervention?	A NAP SACC tool kit, manual and background materials are available to provide technical assistance and to facilitate effective intervention in child care settings. All relevant materials are available online, see http://www.centertrt.org/index.cfm?fa=opinterventions.intervention&intervention=napsacc&page=intent The intervention is relatively easy to implement at a relatively low cost.
Resources and contact information	Corresponding Author: Sara E. Benjamin, PhD, MPH, Post-doctoral Research Fellow, Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Ave, 6th Floor, Boston, MA 02215. Telephone: 617-509-9794. E-mail: Sara_Benjamin@harvardpilgrim.org. NAP SACC (http://www.napsacc.org/) Program contact: Sarah Ball, UNC Center for Health Promotion and Disease Prevention. ball@email.unc.edu
References	Ammerman AS, Ward D, Benjamin SE, Ball, SC, Sommers JK,Molloy M and Dodds JM (2007) An Intervention to Promote Healthy Weight: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) Theory and Design. Preventing Chronic Disease (serial online) 2007 July. (http://www.cdc.gov/pcd/issues/2007/jul/toc.htm).