Background and Purpose
Of 630,000 North Carolina children 2 to 5, more than 30% are overweight or obese (CDC, 2010) and approximately 240,000/38% are enrolled in almost 5,000 licensed childcare centers, where they receive most meals and spend the majority of their waking hours. A Natural Learning Initiative (NLI) 2002 statewide survey suggested the majority of center outdoors do not meet best practice criteria for physical activity and healthy eating. in 2007, the Division of Child Development and Early Education (DCDEE) replaced “playground” with the term Outdoor Learning Environment (OLE) in the licensing rules, prompting perception of the outdoors as a place for healthy development.Preventing Obesity by Design (POD) is a, multi-year, comprehensive statewide strategy for increasing early childhood physical activity and food awareness by improving diversity in childcare outdoor learning environments (http://naturalearning.org/content/preventing-obesity-design-pod-2).POD is driven by research evidence: a) children’s physical activity is strongly motivated by diverse outdoor environments (Cosco, 2006); b) active preschoolers retain higher levels of physical activity as school age children (Moore, et al.1995); c) active outdoor childhood tracks into and influences the preference for outdoor experiences in adulthood (Wells and White, 2002); d) the preschool and, more specifically, the preschool outdoors is a strong determinant of physical activity (Baranowski, et al., 1993; Sallis, et al., 1993), and gardening supports child engagement with fresh vegetables and fruit producing plants (Benjamin and Kelly, 2011). POD considers design of outdoor environments in early childhood as a preventive health intervention.

Description
NLI’s expertise in design assistance, training, and community engagement combined with the organizational infrastructure of the North Carolina Partnership for Children (Smart Start) was used to transform competitively selected 27 OLEs and support regional capacity building. Childcare center staff and 500 TAs and community members were trained in OLE design, implementation, programming, and management. Approximately 1,875 children attending participating centers benefitted from OLE naturalization. The project included the following activities:

1. Teacher training on the use of the outdoors to promote physical activity and healthy nutrition.
2. Train-the-trainers sessions for Smart Start technical assistance (TA) providers to improve understanding of the potential of designing and managing OLEs to support physical activity and healthy eating outcomes.
3. Participatory design assistance for preschool staff, parents, volunteers, and community members (extension agents, garden clubs, Rotary Club, etc.) to modify center outdoors to support children’s daily nutritional and physical activity needs.
4. Start-up incentives to buy plant materials and tools, and support to lead teachers to attend training sessions.
5. Ten webinars a year on relevant topics: design, construction, outdoor play, community involvement and fundraising, gardening, healthy eating.
6. On-call, on-site, and website-based technical assistance and resource dissemination.
7. Pre-post evaluation: childcare provider and Smart Start TA surveys, behavior mapping, photo documentation before-after renovation to document project progress.
8. Dissemination of information to ensure transfer of knowledge. The long-term goal is to generate and transfer knowledge to create a cultural re-alignment of care for young children emphasizing the importance of the outdoors as a preventive health strategy.

Lessons Learned
Design combined with community engagement and training of local TAs can be an effective preventive health intervention. After renovation, 68% POD centers reported positive change in children’s behavior; 40% reported new gardens and edible plant installations as greatest successes; behavior mapping showed 22% children more likely to be observed in moderate activity. Teacher custodial behavior reduced; duration and number of times outdoors in all seasons for all ages increased (including infants).Through community engagement, POD centers raised additional $70,000 in cash (beyond seed grants) and received countless donations and volunteer hours; 20 additional independent POD-like projects were developed in four counties serving 600 children.Demonstration sites continue to act as catalysts for change by other NC childcare providers and community groups

Conclusions and Implications
Comprehensive built environment strategies are key to preventive health in childcare. Dialog between built environment experts and state regulators resulted in training opportunities with licensing consultants and environmental assessors in OLE design and management (approx. 200 professionals in NC). Evidence-based OLE demonstration models and collaboration with state childcare agencies can stimulate regulators to propose built environment changes to licensing rules (currently under discussion). Best practice criteria based on in-depth assessment of OLE installations (expanding the existing Preschool Outdoor Environment Assessment Scale – DeBord et al. 2005) can guide educators and landscape designers/contractors to establish demonstration sites.

Next Steps
POD3 was launched in 2012 to transfer knowledge of evidence-based OLE “best practices,” to build capacity and extend reach through five Regional OLE Labs. to increase performance, targets include extension agents, landscape professionals, early childhood educators. to extend knowledge transfer, education modules will be adopted by community college programs in early childhood and landscape design/management. to expand technical assistance to implement OLE best practices, evidence-based design guidelines for physical activity and nutrition (gardening, edible landscapes) are being disseminated for adoption by early childhood educators, providers, regulators, and landscape designers/managers. On-going research and evaluation processes are implemented to assess impact and influence policy.

Support / Funding Source
Preventing Obesity by Design (POD) is supported by the Blue Cross and Blue Shield of North Carolina Foundation. Best practices are based on research by Cosco, N. (2006) Motivation to Move: Physical Activity Affordances in Preschool Children (PhD Dissertation).