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Preventing Chronic Disease | Healthy Kids Out of School: Using Mixed Methods to Develop Principles for Promoting Healthy Eating and Physical Activity in Out-of-School Settings in the United States - CDC


Preventing Chronic Disease | Healthy Kids Out of School: Using Mixed Methods to Develop Principles for Promoting Healthy Eating and Physical Activity in Out-of-School Settings in the United States - CDC

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Healthy Kids Out of School: Using Mixed Methods to Develop Principles for Promoting Healthy Eating and Physical Activity in Out-of-School Settings in the United States

Sarah A. Sliwa, PhD; Shanti Sharma, PhD; William H. Dietz, MD, PhD; Peter R. Dolan, MBA; Miriam E. Nelson, PhD; Molly B. Newman, MS, RD; Maya Rockeymoore, PhD; Christina D. Economos, PhD

Suggested citation for this article: Sliwa SA, Sharma S, Dietz WH, Dolan PR, Nelson ME, Newman MB, et al. Healthy Kids Out of School: Using Mixed Methods to Develop Principles for Promoting Healthy Eating and Physical Activity in Out-of-School Settings in the United States. Prev Chronic Dis 2014;11:140207. DOI: http://dx.doi.org/10.5888/pcd11.140207External Web Site Icon.


Widespread practices supporting availability of healthful foods, beverages, and physical activity in out-of-school-time (OST) settings would further obesity prevention efforts. The objective of this article was to describe principles to guide policy development in support of healthy eating and physical activity practices in out-of-school settings to promote obesity prevention.
The Institute of Medicine’s L.E.A.D. framework (Locate Evidence, Evaluate it, Assemble it, and Inform Decisions) was used to identify practices relevant to children’s healthful eating in most OST settings: 1) locate and evaluate information from a national survey of children’s perceptions of healthful-food access; published research, reports, policies and guidelines; and roundtables with OST organizations’ administrators; 2) assemble information to prioritize actionable practices; and 3) inform programmatic direction.
Three evidence-informed guiding principles for short-duration OST resulted: 1) drink right: choose water instead of sugar-sweetened beverages; 2) move more: boost movement and physical activity in all programs; and 3) snack smart: fuel up on fruits and vegetables.
Healthy Kids Out of School was launched to support the dissemination and implementation of these guiding principles in short-duration OST settings, complementing efforts in other OST settings to shift norms around eating and physical activity.


Strategies to accelerate obesity prevention include modifying environments where children spend time in order to increase their opportunities for healthful eating and physical activity (1). Children’s consumption of fruits and vegetables (2) and their levels of physical activity continue to fall short of recommendations (3). Given their broad demographic reach and contact time with children, out-of-school time (OST) programs are well suited to improve children’s access to healthful foods and beverages and increase opportunities for physical activity (4–6). Consistent policies may help (4).
OST environments include before-school, after-school, and summer programs, which together engage millions of children, including large numbers of minority youths (7) who are at greater risk for obesity (8). These settings vary in their operational structures, leadership, and contact hours with children; they include long-duration after-school programs (which are typically operated 5 days per week for more than 3 hours a day by paid staff) and short-duration programs (which are often led by parents or unpaid volunteers, including youth sports and Scouts).
The Healthy Out-of-School Time Coalition developed voluntary standards for healthful eating and physical activity, which were adopted by the National Afterschool Association (9,10). The standards include 11 overarching guidelines and supporting standards that are well-suited for programs with established training opportunities. However, short-duration OST programs, especially those led by volunteers, have limited training opportunities. These programs would benefit from complementary standards that are easy to understand and implement.
This article describes the process used to identify, develop, and support the implementation of principles to improve children’s energy balance in short-duration OST settings. Mixed methods allowed researchers to integrate quantitative and qualitative data to quantify the reach of OST programs, policies, and guidelines and to engage stakeholders in prioritizing and tailoring a response.
The Tufts University institutional review board reviewed and approved this research.


The Robert Wood Johnson Foundation and The JPB Foundation provide strategic funding for ChildObesity180. The HKOS initiative in Maine, Massachusetts, and New Hampshire is supported by the Harvard Pilgrim Health Care Foundation. The authors thank Katie Smith for graphics and statistical support.

Author Information

Corresponding Author: Sarah A. Sliwa, PhD, Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111. Telephone: 617-636-3547. E-mail: sarah.sliwa@tufts.edu
Author Affiliations: Shanti Sharma, Peter R. Dolan, Molly B. Newman, Miriam E. Nelson, Christina D. Economos, Tufts University, Boston, Massachusetts; William H. Dietz, Tufts University, Boston, Massachusetts, and George Washington University, Washington, DC; Maya Rockeymoore, Tufts University, Boston, Massachusetts, and Global Policy Solutions, Washington DC.


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