Submitted to: Strategic Alliance for Health

Submitted by: Aasha M. Abdill, September 2010

Table of Contents

I. Executive Summary………………………………………………………………………2

II. Background……………………………………………………………………………….4

III. Introduction.............………………………………………………………………………5

IV. Methodology………………………………………………………………………………6

V. Findings……………………………………………………………………………………8

VI. Recommendations………………………………………………………………………..12

VII. Conclusions……………………………………………………………………………….14

VIII. References.……………………………………………………………………………......16

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After School Programs and Childhood Obesity
Strategic Alliance for Health
I. Executive Summary

Funded by Centers for Disease Control and Prevention, the Strategic Alliance
for Health, NYC (SAfH) aims to improve individual, family, and community
health outcomes in East and Central Harlem and the South Bronx. Seeking to
enhance knowledge on the potential role of after school programs on the health
outcomes of their participants, SAfH commissioned this research study to
examine the contributions of after school providers toward the physical and
nutritional well-being of neighborhood youth. This report highlights the
findings from a comprehensive analysis of interview data gathered from twenty
after school providers in East Harlem, Central Harlem and the South Bronx.
Key findings are summarized below.

After school programs offer opportunities for structured physical activity.

Duration times vary from as little as 30 minutes to 5 hours per week.
 All interviewed after school providers regularly offer physical activities
as part of their program schedules.
 The number of days and duration of these activities vary greatly among
organizations. Total minutes per week of moderate or rigorous physical
activity range from 30 minutes to 300 minutes with a mean duration
length of 118 minutes per week (approximately 2 hours weekly).
 Larger organizations with after school enrollments greater than 1000
students are slightly more likely to offer the typical child more
physically active programming throughout the week than programs
operated by smaller agencies.

After school programs offer snacks and meals regulated by the New York
State Department of Health and incorporate healthy-eating curricula in
programming.
 85% (17) of the sampled agencies offer snacks and full meals as part of
the Child and Adult Food Care Program (CACFP), a federally funded
initiative.
 One-third of the sample expressed concern about these meals due to
their perception of the unhealthiness of the food or their appeal to the
children.
 90% (18) of the organizations sampled incorporate educational curricula
focused on healthy eating behaviors and nutrition during the academic
year.
 Vending machines with healthy and unhealthy food and beverage
options are on site at half the agencies, however, many of these

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 organizations have policies which discourage or ban use of vending
machines during after school time.

Inadequate space/facilities, scarce funding and time constraints were

identified as the largest barriers to increasing levels of physical activity
during after school hours.
 Inadequate space or facilities was overwhelmingly identified as a major
barrier to increasing the amount of scheduled time for physical activity.
 Scarce funding in general operating support or grants that could be
allocated to sports activities greatly limits resources that can be spent to
develop and maintain physically-focused initiatives.
 Other identified barriers included time constraints given other
organizational priorities such as homework help and educational
enrichment activities and staff not trained to facilitate physical
education.

After school programs feel youth physical fitness is central to their missions
and seek partnerships for maximizing efforts toward youth wellness.
 100% of respondents responded that increasing levels of physical
activity is beneficial to their overall organizational missions.
 11 organizations (55%) listed obesity and matters concerning
overweight youth as a major health problem facing their student
population. An additional 4 organizations mentioned poor nutrition or
malnutrition as major concerns.
 80% of sample organizations are currently partnering or planning to
partner with other organizations, governmental agencies or businesses to
support student wellness.

Despite the challenges faced by after school programs in positively influencing

youth physical fitness and eating habits, on the whole, agencies have initiated a
myriad of programs and policies to impact youth health outcomes. In addition to
structural barriers like facilities and time constraints, agencies expressed their
attempts in resolving other challenges such as their perceptions of the cultural
insensitivity of some food guidelines, the added reluctance toward sports among
girls, and the lack of healthy food options (in addition to the surplus of
unhealthy food options) in the neighborhoods they serve.

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II. Background

While it is true that obesity is unhealthy at any age, a startling and disturbing
aspect of the growing obesity epidemic in the United States is a rise of obesity
among children. Tripling in prevalence since 1980 (Ogden et al., 2010), health
experts warn that this generation of children could have a shorter life
expectancy than their parents due to increased risks in associated illnesses such
as cardiovascular disease, heart disease, type 2 diabetes, stroke, and several
types of cancers (Olshansky et al., 2005). Unfortunately the sobering broad
stroke of obesity's consequences isn’t solely physical. Researchers have shown
associations between obesity and poor academic outcomes from as early as
kindergarten (Datar et al., 2004). Children who are obese are more likely to earn
lower grades and complete less years of schooling including college
matriculation. Although direct mechanisms aren't clear, the association of
obesity with psychosocial outcomes like low self-esteem and depression may
contribute to academic underperformance (Datar 2006 et al; Mellin et al., 2002).

While the problem is widespread, childhood obesity runs especially rampant in

communities with higher levels of poverty. Children from families of lower
socio-economic status and minority children are far more likely to be obese.
Even when controlling for race and class, children who grow up in
neighborhoods with badly maintained housing are statistically more likely to be
obese then children living in more advantaged neighborhoods (Bethell et al.,
2010).

The communities of East and Central Harlem and the South Bronx are not
immune to these regrettable correlations. Published reports by New York City
Department of Health and Mental Hygiene (Matte et al, 2007; Matte et al, 2007)
show that nearly 4 in 10 elementary students attending public schools are either
obese or overweight in the South Bronx and in East and Central Harlem.
Although some policymakers consider schools promising institutions in easing
the epidemic given the sheer amount of time children spent in school,
unfortunately schools have been unable to answer this calling. School district
policies on student wellness are often not aligned with national
recommendations for nutrition or physical activity (Chriqui et al, 2009).
Challenges of limited funding for physical education, heightened pressure to
increase standardized test scores, and general overcrowding may offer insights
into this misalignment. With few opportunities for physical education or
intramural sports during school hours additional strategies during out of school
time hours need to be explored.

This report examines after school programs and their capacity to tackle two
important ways to fight the obesity epidemic in children: healthy eating habits
and increased physical activity.

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III. Introduction

The purpose of this report is to examine the current priorities and offerings of
after school programs in the communities of East and Central Harlem and the
South Bronx. Explicit focus on physical and nutritional offerings of after school
providers enable the assessment of what role after school programs can
potentially play in helping students meet the physical activity guidelines set by
the Center for Disease Control (CDC). CDC recommends that children and
adolescents do 60 minutes (1 hour) or more of physical activity each day.

In the spring of 2010, Strategic Alliance for Health (SAfH) contracted with an
independent evaluator to develop a research design that would gauge after
school program priorities, outlooks and organizational activities as it directly
relates to the physical and nutritional well-being of their youth participants. This
report gives an overview of the findings from in-depth interviews of twenty
after school providers.

In addition to assessing the current offerings of after school programs, the study
seeks to draw lessons and best practices while highlighting obstacles providers
face in targeting youth physical fitness in their program strategies. It is the hope
of SAfH that the data presented in this report can be used to not only increase
understanding of current after school offerings in regards to youth physical
health, but to also initiate a dialogue on how after school programs can offer
moderate to vigorous daily physical activity programming to the children they
serve. This report examines the following questions:

 What are the opportunities for structured physical activities during after
school programming?

 What are the opportunities for healthy eating and developing healthy
eating habits during after school programming?

 What are the biggest barriers to providing more opportunities spent in

moderate and rigorous physical activity during after school programming?

 What are the approaches and experiences of after school providers in the
eating and fitness behaviors of their youth participants?

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IV. Methodology

The findings presented in this report are based largely on data collected from in-
depth interviews with after school providers. The universe of after school
providers for this study was compiled from two organizational sources: the
Department of Youth and Community Development (DYCD) and the
Partnership for After School Education (PASE). DYCD operates Out of School
Time (OST), the largest after school initiative in the nation. DYCD also
operates the Beacon and Cornerstone initiatives, after school programs hosted in
New York City Housing Authority (NYCHA) community centers and in public
schools. PASE is New York City’s largest network of after school practitioners.
While these directories include the majority of after school providers in NYC
they do not comprise all after school programs. Online directories of PASE and
DYCD were searched using the zip codes associated with SAfH targeted
communities of East and Central Harlem (10026, 10027,10029, 10030, 10035,
10037, 10039) and the South Bronx (1045, 10452, 10454, 10456, 10459,
10474).

Two hundred and thirteen (213) organizations operating approximately 317

after school sites in the South Bronx and East and Central Harlem were
catalogued. The study’s population was further reduced due to incorrect, out-
dated and unavailable contact information. After school providers who did not
serve elementary age students at the time of the study were also removed from
the sample. Fifty-three organizations were initially contacted via email or phone
for participation in this study. Follow-up phone calls were made to definitively
ascertain whether the organization had received the original solicitation letter or
were generally aware of the study. A communication exchange with thirty-
seven of the agencies was obtained. Of these organizations, twenty after school
providers were successfully recruited into the study yielding a response rate of
54%. Based on the original number of organizations recorded in the online
directories the sample represents approximately 9.3% of organizations
providing after school programs in the target area.

Below are selected demographic indicators of the end sample. Our after school
providers are fairly older agencies (minimum years of operation is 24) with
sizeable enrollments located in East and Central Harlem and the South Bronx
(Figures 1-3). An overwhelming majority host program sites within NYC public
schools (Figure 4). All providers in this sample are community or youth
nonprofit organizations which offer free services for most, if not all, of their
participants.

Data presented in this report are gleaned from phone interviews with employees
of participating organizations. Interview conversations lasted anywhere from 20
minutes to 57 minutes with a mean length time of 30 minutes. Interviewees held
various position titles: 11 were in organizational management positions, 4 were
directors at the program level and 5 were site coordinators.
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Figure 1 Sample Characteristics: Age of Agency Figure 2 Sample Characteristic: Community Served

<25 yrs
Serve
3 (15%) Serve East
South
> 50 yrs Bronx &Central
9 (45%) 14 (70%) Harlem
11 (55%)

25-49 yrs
8 (40%)
Serve Both
5 (25%)

Figure 3 Sample Characteristics: Youth Enrollment Figure 4 Sample Characteristics: Site Location Type

< 250 Ind

enrolled Sites (only)
2 (10%) 3
> 1000 (15%)
enrolled
8 (40%)
250-499
enrolled
7 (35%) Host Sites in
Public Schools
17
500-999
(85%)
enrolled
3 (15%)

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V. Findings

After school programs commonly offer opportunities for structured

physical activity, yet duration levels varies.
All of the interviewed after school providers offer some sort of structured
physical activity during program hours. Structured physical activity was defined
as physical activity led by staff which allowed students to participate in
moderate to rigorous movement. Activities occur as infrequently as once every
two weeks to five days per week, lasting in duration anywhere from 30 to 75
minutes per session. To compare time typically spent by a student in physically
active programming across organizations, an average number of minutes per
week was calculated from multiplying the number of days where physical
activity was offered by the number of minutes each session lasted. For
organizations who gave ranges of days or activity duration, midpoints were
taken. Fifty percent of after school providers offer 2 or more hours of physical
activity per week.

Figure 4 Average time per week of physical activity

9
8
7
# of Organizations

6
5
4
3
2
1
0
<1:00 hr 1-1:59 hrs 2-2:59 hrs 3-3:59 hrs 4-4:59 hrs
Time in hours and minutes

When probed about the types of activities offered, responses such as sports,
dance and informal games which involved running were mentioned. Across the
board, the type of physical activity offered varied between grades and groups
and throughout the year.

Organizations with large enrollments (greater than 1000 students) in their after
school programming were slightly more likely to offer the average child more
minutes per week of structured physical activity. These agencies often referred
to internal policy guidelines established around children physical fitness during
program hours.

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 Inadequate space/facilities, scarce funding and time constraints were
identified as the largest barriers for increasing levels of physical activity
during after school hours.
When asked to identify what were the biggest barriers to providing more time
for physical activity, study participants overwhelmingly responded that a lack of
space or inadequate facilities were by far the largest obstacle. Seventy-five
percent (15) of organizations responded space was a primary factor in why
structured physical activity presented a challenge. Sharing space with schools
and organizations presented scheduling difficulties especially for activities
requiring large indoor or outdoor space. Scarce funding for grants that could be
underwritten to cover physical activity and insufficient general operating
support limited organizations' abilities to allocate financial resources in support
of physically active programming. Eight organizations mentioned constraints of
time given numerous organizational priorities and the limited daily timeframe in
which they have to accomplish them. Organizations also commented on
difficulties with inexperienced and untrained staff and lack of sports equipment
as other barriers. One organization which offers 60 minutes of physical activity
five days a week did not list any barriers to increasing physical activities in the
after school setting.

Figure 5 Barriers to increasing physically active programming

16 15
14
12
10
10
8
8 7
6
4
2 1
0
Not central Inadequate Inadequate Time Other None
to mission Facilities Funding Constraints

After school programs spend the most time on homework help or academic
tutoring.
Every after school provider offer homework help or academic tutoring five days
per week. Sessions run anywhere from 30 to 60 minutes. On average, after
school providers spend a little less than 1 hour a day on activities directly
associated with school educational outcomes. An additional 30 minutes per day
is spent on other educational activities which include themed or project-based
activities focused on improving literacy, math or science skills. Approximately
45 minutes per day is spent eating, usually at the beginning of the program
while children are getting settled. Time dedicated to sports or activities
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 requiring significant movement averages about 25 minutes per day equivalent to
art and crafts activities.

Figure 6 Average time spent by Activity Type (hours/wk)

6.0
4.8
5.0

4.0
3.1
3.0 2.5
2.0 1.9
2.0

1.0

0.0
HW Help/ Snack Academic Sports Arts
Tutoring Enrichment

After school programs offer snacks and meals regulated by the New York
State Department of Health and incorporate healthy-eating curricula in
programming.
Seventeen organizations have some or all of their snacks and supper supported
by the Child and Adult Care Food Program (CACFP) which includes both a
snack and hot supper containing certain groups of foods in amounts appropriate
to the child's age. The CACFP initiative is supported through annual funding
granted to New York State Department of Health by the U.S. Department of
Agriculture (USDA).

Despite the fact that these meals are regulated by federal guidelines, six of these
organizations questioned the overall healthiness of the CACFP snack and
supper and/or the appeal of these meals to the children. The three organizations
who do not participate in governmental programs offer their own snacks cooked
on site. These three organizations are all located at independent standalone sites
and not in public schools. Organizations providing snacks on their own stated
they follow health regulation guidelines communicated by New York's
Department of Education and allow students to bring snacks from home.

In addition to provided snacks, 50% (10) of organizations have vending

machines on site that children could use to purchase snacks and beverages.
Vending options include both healthy and unhealthy selections. Many
organizations with vending machines on site mentioned an agency policy which
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 either discourage or ban use of vending machines during after school hours.
Despite these policies, it should be noted that compliance may not be absolute.

Eighteen agencies (90%) offer curricula aimed at teaching healthy eating habits
to students. Some agencies partner with external organizations to provide short-
term workshops while others arm their line staff with lesson plans focused on
this topic. The extent of educational activities about nutrition vary immensely
from a 30 minute session each semester to several workshop sessions over the
course of a 6-7 week program.

After school programs feel youth physical wellness is central to their

mission. Obesity and asthma are major concerns.
100% of respondents stated that increasing levels of physical activity is
beneficial to the overall organizational mission and would apply for funding that
allowed them to do so. However, concerns of time constraints especially given
other funded priorities were posed during interviews. Eleven organizations
listed obesity and problems concerning overweight youth as a major health
problem facing their student population. An additional four organizations
mentioned factors associated with poor nutrition such as inadequate knowledge
about healthy food options, lack of healthy food options in the neighborhood
and malnutrition. An abundance of fast food restaurants and bodegas offering
limited healthy food alternatives were also consistently noted. Eleven
organizations mentioned asthma as a major health concern followed by five
organizations stating that diabetes was a concern.

After school programs seek partnerships for maximizing efforts toward

youth wellness.
Fifty percent of sample organizations currently partner with other organizations,
governmental agencies or businesses to support student wellness for activities
such as short-term cooking classes, gardening programs, and after hours
sports/dance programs for parents and students. Of the 10 agencies not currently
in partnerships, six mentioned trying to start partnerships in the near future.

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VI. After School Practitioner Perceptions and Recommendations

Nutrition and Culture

Some agencies worry that drastic attempts in changing the ways families eat and
live may be culturally insensitive and ultimately futile in supporting families in
adopting healthier choices. Two agencies mentioned offering cooking classes
for parents where cultural foods were cooked and slightly healthier changes to
the preparation of well-known dishes were demonstrated. Both agencies felt
cooking classes like these were better received by parents than workshops
which generally discuss nutrition. Another agency indicated success in getting
their youth to eat better snacks by presenting youth with alternatives that may
not be the healthiest option but still healthier than the standard selection. For
example, instead of "demanding that a child eat an apple for snack", presenting
the child with a choice of an apple or baked chips still leaves a youth participant
with the autonomy of the selection process yet guides them away from fried
potato chips without presenting too much of an extreme change in snack
preference.

Parental Involvement
Children, especially those of elementary age do not often prepare the food they
eat. Organizations have realized that to impact youth eating and fitness
behaviors, they have to include parents in their targeted activities. Six
organizations mentioned facilitating workshops, cooking classes or sports/dance
classes for parents or the entire family after program hours and on weekends.

Girl Fitness
Four organizations noted that it is especially difficult to get girls to participate in
physical activity. Since reluctance towards sports tends to increase with age,
some after school providers are trying to instill a love of sports at earlier ages.
One organization mentioned a program initiative targeting girls to get them
excited about sports programming like basketball and volleyball. This
organization believed their initiative has helped to improve their girls’ attitudes
and participation in active programming.

Summer Programming
The majority of the sample organizations offer summer programming in
addition to after school programming. A few mentioned the benefits of the
summer in tackling the childhood obesity epidemic with longer sessions of
physically active programming simply because of the increased time per day
these programs have with the children. Despite advantages of time, obstacles are
still faced. Some include costs for securing licenses, insurance, and additional
staff to incorporate physical activities that excite children including swimming
and cycling. Two programs specifically mentioned having to drop swimming
from their summer schedules because of the high costs involved.

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 Nevertheless, summer presents additional opportunities for organizations in
their objective to improve youth healthiness. Efforts to better align summer and
after school programming to reinforce healthy habits all year around could
prove beneficial. For example, with more time to care for a garden over the
summer months, children can learn about food and nutrition while designing
plans for the garden during fall and spring. Also, since longer summer schedules
allow staff more time to engage children in sports, burgeoning interests can be
promoted or preserved during the school year with modified sports activities.
For instance, if during the summer soccer is promoted with games and
tournaments than during the school year 20-30 minute soccer drills to develop
skills may be more easily incorporated into a tight after school program
schedule.

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VII. Conclusions

It was evident during the course of this study that after school programs are
aware and concerned with the childhood obesity risks within the communities
they serve. Some of the larger organizations have position lines specifically
dedicated to initiatives around youth fitness both physical and nutritional.
Organizations overwhelmingly expressed a desire to offer more opportunities
for moderate to rigorous physical activity than the average two hours per week,
but constraints of space, funding and time present formidable barriers.
Nevertheless, after school programs do present opportunities for helping youth
meet the daily 60 minute physical activity guidelines set by the CDC. This study
provides evidence that some organizations are successfully incorporating high
levels of physical activity in their program schedules. There is also evidence for
opportunities to offer curricula designed to promote healthy eating behaviors.
Meal and snack options during after school programming are heavily influenced
by federal guidelines through CACFP so opportunities for nutritious meals are
substantial and can be highly influenced by governmental mandates.

Although after school programs have increasingly become a strategic option for
promoting healthy behaviors of school-age children, this additional institutional
priority will unfortunately compete with other demands that providers are
struggling to meet during the after school hours. One critical demand is the
motivation to help bridge racial and socio-economic gaps in educational
outcomes among students. With parents understandably insisting on more time
spent on homework help and grant-makers exclusively funding programs
showing results in the academic arena, after school programs have unfortunately
become entangled in the challenges faced by school districts to meet the
educational needs of their students.

Yet, a refocus on physical health of youth may be just what the field of out of
school time needs to realign their unique attributes to wellness outcomes.
Historically, after school programs have predominately focused on youth
development which includes character-building and extracurricular skill-
building in sports and arts. The current focus of after school programs on
educational outcomes is a relatively new phenomenon whose measurable
success is debatable. In order for after school programs to comfortably prioritize
health outcomes, shifts in grant and policy opportunities may be needed. The
question of whether or not after school programs can increase their offerings of
physical activity to meet CDC guidelines is a qualified yes. The answer,
however, is dependent on the willingness of stakeholders to support health
outcomes, in addition to academic outcomes, as a priority objective for after
schools programs.

It should be noted that this study was limited in some aspects of the research
design. The sample of organizations is small and captures older, more
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 established agencies in specific communities so results may not be widely
generalizable. Analysis of these data generated further questions that could be
explored. To this end, it is recommended that data presented within this report is
used as a foundation for additional questions and future investigation (see list
below).

Additional questions:
1. How can after school programs successfully evaluate their efforts to impact
the physical and nutritional well-being of their youth?
2. What are the resource opportunities for after school programs wanting to
prioritize increased physical activity within their programs?
3. How will increases in physical activity affect other programming?
4. Are specific types of after school programs better suited to impact the
epidemic of child obesity?
5. What training is available for after school staff in the facilitation of physical
activities and delivering nutrition-focused curricula?

Finally, the findings in this report will be presented to SAfH consortium

partners in Fall 2010 to inform a discussion of possible policy interventions.
Stemming from this dialogue, a policy recommendation to the appropriate New
York State and City agencies is anticipated.

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VIII. References

Bethell C, Simpson L, Stumbo Scott, Carle AC, Gombojav N. National, State, and Local
Disparities in Childhood Obesity. Health Affairs 2010; 29(3): 347-356

Chriqui JF, Schneider L, Chaloupka FJ, Ide K and Pugach O. Local Wellness Policies: Assessing
School District Strategies for Improving Children’s Health. School Years 2006-07 and 2007-08.
Chicago, IL: Bridging the Gap Program, Health Policy Center, Institute for Health Research and
Policy, University of Illinois at Chicago, 2009.

Datar A, Sturm R. Childhood overweight and elementary school outcomes. International Journal
of Obesity 2006; 30:1449-1460.

Datar A, Sturm R, Magnabosco JL Childhood overweight and academic performance: National

study of kindergartners and first-graders. Obesity Research 2004;12(1): 58-68.

Gortmaker SL, Must A, Perrin JM., Sobol AM, and Dietz WH. Social and economic consequences
of overweight in adolescence and young adulthood. The New England Journal of Medicine
1993;329(14): 1008-1012.

Matte T, Gordon C, Goodman A, Selenic D, Young C, Deitcher D. Obesity in East and Central
Harlem: A look across generations. New York, NY: New York City Department of Health and
Mental Hygiene, 2007.

Matte T, Ellis JA, Bedell J, Selenic D, Young C, Deitcher D. Obesity in the South Bronx: A look
across generations. New York, NY: New York City Department of Health and Mental Hygiene,
2007.

Mellin A, Neumark-Sztainer D, Story M., Ireland M, Resnick M. Unhealthy behaviors and

psychosocial difficulties among overweight adolescents: The potential impact of familial factors.
Journal of Adolescent Health 2002; 31 (2): 145-153.

Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in
US children and adolescents, 2007–2008. JAMA 2010;303(3):242–9.

Olshansky SJ, Passaro DJ, Hershow, RC, Layden, J, Carnes BA, Brody J, Hayflick L, Butler RN,
Allison DB, Ludwig DS. A Potential Decline in Life Expectancy in the United States in the 21st
Century. The New England Journal of Medicine 2005; 352(11).

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