Alkon 2014.

Study characteristics
Methods	Study name: Nutrition and physical activity self‐assessment for child care (NAP SACC) Study design: cluster‐RCT Intervention period: 7 months Follow‐up period (post‐intervention): nil Differences in baseline characteristics: reported Reliable outcomes: reported Protection against contamination: reported Unit of allocation: childcare centre Unit of analysis: individual (controlling for clustering effect)
Participants	N (controls baseline) = 292 N (controls follow‐up) = 110 N (interventions baseline) = 260 N (interventions follow‐up) = 99 Setting (and number by study group): 18 centres (N = 9 intervention; N = 9 control) Recruitment: convenience sample of childcare centres Geographic region: 3 states in USA, California (CA), Connecticut (CT), and North Carolina (NC) Percentage of eligible population enrolled: 43% Mean age: (intervention + control) 3‐5 Intervention: 31% 3, 50% 4, 18% 5 Control: 29% 3, 54% 4, 17% 5 Sex: intervention, 44% female; control, 48% female
Interventions	Nutrition and physical activity self‐assessment for child care (NAP SACC) was designed to enhance nutrition and PA environments in childcare settings by improving the nutritional quality of food and beverages, the amount and quality of PA, staff‐child interactions, and centre nutrition and PA policies and practices. Trained nurse childcare health consultants facilitated 5, one‐hour workshops for child care providers and other staff (e.g. cooks, administrators) at each of the intervention centres on the following: childhood obesity healthy eating for young children PA for young children personal health and wellness working with families to promote healthy behaviours. 7 of the intervention centres also received the parent workshop, “Raising Healthy Kids.” The CCHCs worked with the centre directors to write or update the centre’s nutrition and PA policies. They also provided at least monthly on‐site consultations and additional phone or email consultations and distributed posters and information sheets on nutrition and PAs. The posters were displayed in the childcare centres, and the information sheets were given to the childcare providers and parents. Examples of some common issues addressed during the consultation visits were the type of milk served, healthy snacks, and ideas for structured PA. The nurse CCHCs conducted a mean (SD) of 11 (3) on‐site visits and 8 (6) off‐site consultations per centre over the 7‐month intervention, in addition to the provider and parent workshops. Dietary and PA intervention vs control
Outcomes	Outcome measures Primary outcome: zBMI, % overweight, % obese Secondary outcomes: provider and parent knowledge survey, nutrition and PA policies, nutrition and PA practices Process evaluation: reported (fidelity)
Implementation‐related factors	Theoretical basis: NR Resources for intervention implementation: reported Who delivered the intervention: reported PROGRESS categories assessed at baseline: child: gender; parent: race/ethnicity, education, occupation, SES PROGRESS categories analysed at outcome: NR Outcomes relating to harms/unintended effects: NR Intervention included strategies to address diversity or disadvantage: NR Economic evaluation: NR
Notes	NCT01921842 Funding: grant #R40 MC 08727 through the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Research Program Each of the centres received USD 500 for its participation in the study. The intervention centre directors were asked to purchase equipment or supplies to support PA. The programme has been used by a number of states and incorporated into the US public health campaign Let’s Move.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Randomisation at childcare centre Quote: "The centers were matched on size and the proportion of children eligible for income subsidies and then randomly assigned to the NAP SACC intervention or control group."
Allocation concealment (selection bias)	Low risk	Randomisation done at childcare centre level Quote: "The centers were matched on size and the proportion of children eligible for income subsidies and then randomly assigned to the NAP SACC intervention or control group."
Blinding (performance bias and detection bias) All outcomes	Low risk	Research assistant blinded to group assignment completed the centre’s written policy assessments, centre‐level observational measures, and child‐level height and weight measurements
Incomplete outcome data (attrition bias) All outcomes	High risk	Although the pre‐intervention heights and weights included children randomly selected in each site and data were missing at random, there was an imbalance. The total at the pre‐intervention period, 268 of the 552 (49%) children enrolled in the study, was limited by availability of resources. There were more children (336) with post‐intervention heights and weights, but only children with matched data were included in the centre‐level analyses (209)
Selective reporting (reporting bias)	Low risk	Trial registration document checked. All outcomes reported
Other bias	Low risk	No other threats to validity noted
Other bias‐ timing of recruitment of clusters	Unclear risk	1 control centre, which withdrew when it was unable to complete the required number of study questionnaires, was replaced with a matched centre prior to intervention