What Role Can Child-Care Settings Play in Obesity ... Advance... · status in childhood (3,4). Approximately 80% of preschool-aged children with em-ployed mothers are in some form

RESEARCH

Review

Meets Learning Need Codes 4000, 4120, 4150, and 9020. To take the Continuing Professional Education quizfor this article, log in to ADA’s Online Business Center at www.eatright.org/obc, click the “Journal ArticleQuiz” button, click “Additional Journal CPE Articles,” and select this article’s title from a list of availablequizzes.

What Role Can Child-Care Settings Play inObesity Prevention? A Review of the Evidenceand Call for Research Efforts

UNDER EMBARGO UNTIL AUGUST 26, 2011, 12:01 AM ET

NICOLE LARSON, PhD, MPH, RD; DIANNE S. WARD, EdD; SARA BENJAMIN NEELON, PhD, MPH, RD; MARY STORY, PhD, RD

sfuastdphvasttJ

aahitsss

prMls

ABSTRACTGiven the widespread use of out-of-home child care andan all-time high prevalence of obesity among US pre-school-aged children, it is imperative to consider the op-portunities that child-care facilities may provide to re-duce childhood obesity. This review examines thescientific literature on state regulations, practices andpolicies, and interventions for promoting healthy eatingand physical activity, and for preventing obesity in pre-school-aged children attending child care. Research pub-lished between January 2000 and July 2010 was identi-fied by searching PubMed and MEDLINE databases, andby examining the bibliographies of relevant studies. Al-though the review focused on US child-care settings, in-terventions implemented in international settings werealso included. In total, 42 studies were identified for in-clusion in this review: four reviews of state regulations,18 studies of child-care practices and policies that mayinfluence eating or physical activity behaviors, two stud-ies of parental perceptions and practices relevant to obe-

N. Larson is a research associate and M. Story is a pro-fessor, Division of Epidemiology and CommunityHealth, School of Public Health, University of Minne-sota, Minneapolis. D. S. Ward is a professor, Depart-ment of Nutrition, School of Public Health, University ofNorth Carolina at Chapel Hill. S. B. Neelon is an assis-tant professor, Department of Community and FamilyMedicine, Duke University Medical Center and DukeGlobal Health Institute, Durham, NC.

Address correspondence to: Nicole Larson, PhD, MPH,RD, Division of Epidemiology and Community Health,School of Public Health, University of Minnesota, 1300S Second St, Suite 300, Minneapolis, MN 55454.E-mail: [email protected]

Manuscript accepted: October 22, 2010.Copyright © 2011 by the American Dietetic

Association.0002-8223/$36.00
doi: 10.1016/j.jada.2011.06.007
© 2011 by the American Dietetic Association

ity prevention, and 18 evaluated interventions. Findingsrom this review reveal that most states lack strong reg-lations for child-care settings related to healthy eatingnd physical activity. Recent assessments of child-careettings suggest opportunities for improving the nutri-ional quality of food provided to children, the time chil-ren are engaged in physical activity, and caregivers’romotion of children’s health behaviors and use ofealth education resources. A limited number of inter-entions have been designed to address these concerns,nd only two interventions have successfully demon-trated an effect on child weight status. Recommenda-ions are provided for future research addressing oppor-unities to prevent obesity in child-care settings.Am Diet Assoc. 2011;111:1343-1362.

The prevalence of obesity among US preschool-agedchildren is at an all-time high. More than 20% of thenation’s preschool-aged children (aged 2 to 5 years)

re overweight or obese (1). Because childhood obesity isssociated with increased risk for obesity during adult-ood and a spectrum of adverse health outcomes (2), the

dentification of risk factors and development of preven-ion efforts are public health priorities. Epidemiologictudies suggest child care experiences during the pre-chool years may have an important influence on weighttatus in childhood (3,4).Approximately 80% of preschool-aged children with em-

loyed mothers are in some form of nonparental care ar-angement for an average of almost 40 hours a week (5).ore than 63% of mothers with young children are in the

abor force and working parents generally choose amongeveral types of child-care arrangements or use multiple

Audio Podcast available online at www.adajournal.org

Journal of the AMERICAN DIETETIC ASSOCIATION 1343

https://www.eatright.org/obc

mailto:[email protected]

tca(atdt

ckpabcftpscsacwbssp

MSilacpsca(cpcrsisegcasitP

RSAt

scscsntcoriibfm

kcstfblfisowrNthNWnNf

lfnfdd(tzalfTcmfgi

CoPhme

arrangements (6). The majority of working parents enrollheir preschoolers in center-based care arrangements (eg,hild-care centers, preschools, Head Start programs) andpproximately 10% are enrolled in family child-care homes5). With such a high proportion of preschool children inttendance, it is imperative to consider the opportunitieshat these child-care facilities may provide to shape chil-ren’s dietary intake, physical activity, and sedentary ac-ivity behaviors to prevent excess weight gain.

Recent reviews have drawn attention to the role of child-are settings in preventing obesity (7), but to the authors’nowledge, a detailed and integrated review describing op-ortunities to promote better dietary intake and physicalctivity for obesity prevention in child-care facilities has noteen published. This article reviews studies of US preschoolhildren (aged 2 to 5 years) enrolled in center-based care oramily child-care homes that also addressed state regula-ions relating to nutrition and physical activity, child-careractices and policies with the potential to influence pre-choolers’ dietary intake and physical activity, and the per-eptions and practices of parents with implications for obe-ity prevention in child-care settings. In addition, thisrticle presents a comprehensive review of interventionsonducted in the United States and internationally thatere designed to prevent obesity through the promotion ofetter nutrition, increased physical activity, or reduced timepent in sedentary activities. The research studies pre-ented are discussed in terms of their limitations and im-lications for future research.

ETHODSearches in PubMed and MEDLINE were completed to

dentify relevant, peer-reviewed research studies pub-ished between January 2000 and July 2010. Relevantrticles were identified using the following key words:hild care, preschool, nursery school, dietary intake,hysical activity, sedentary activity, intervention, obe-ity, and overweight. To be included in this review, arti-les had to address at least one of the review objectivesnd describe research of relevance to preschool childrenaged 2 to 5 years) enrolled at child-care centers or familyhild-care homes. Articles describing state regulations,ractices and policies in child-care facilities, and the per-eptions and practices of parents were included only ifelevant to US preschool-aged children. Interventiontudies were included only if an evaluation of programmpact or feasibility was completed; however, relevanttudies completed outside the United States were notxcluded. Multiple publications evaluating the same pro-ram were considered together as evidence for the effi-acy of one intervention. The bibliographies of identifiedrticles were also reviewed to ensure that all relevanttudies were retrieved. In addition to peer-reviewed stud-es, reports for federal agencies were included to describehe most recent data on the Child and Adult Care Foodrogram (CACFP) and the Head Start Program (8,9).

ESULTState Regulationsprimary way to reach children in child-care settings is

hrough policy and regulations. Head Start programs are e

1344 September 2011 Volume 111 Number 9

ubject to federal performance standards; however, child-are facilities are regulated primarily by states. Eachtate establishes its own set of regulations for licensedhild-care facilities and sets some minimum enforcementtandards to assess compliance. Most states license aumber of different categories of child-care facilities, buthe majority of states differentiate between child-careenters and family child-care homes. Four recent reviewsf state regulations found that most states lacked strongegulations related to healthy eating and physical activ-ty (10-13). Child-care centers tended to be the most heav-ly regulated and have more specific regulations, followedy large family and group child-care homes (11). Smallamily child-care homes tended to have the fewest andost general regulations (11).One review examined state regulations and recorded

ey nutrition and physical activity items that related tohildhood obesity, including water is freely available,ugar-sweetened beverages are limited, foods of low nu-ritional value are limited, children are not forced to eat,ood is not used as a reward, support is provided forreastfeeding and provision of breast milk, screen time isimited, and physical activity is required daily (10). Thendings indicate considerable variation exists amongtates in regulations related to obesity. Tennessee had sixf the eight regulations for child-care centers, and Dela-are, Georgia, Indiana, and Nevada had five of the eight

egulations. In contrast, the District of Columbia, Idaho,ebraska, and Washington had none of the eight regula-

ions. For family child-care homes, Georgia and Nevadaad five of the eight regulations; Arizona, Mississippi,orth Carolina, Oregon, Tennessee, Texas, Vermont, andest Virginia had four of the eight regulations. Califor-

ia, the District of Columbia, Idaho, Iowa, Kansas, andebraska had none of the regulations related to obesity

or family child-care homes.Another review focused on child-care regulations re-

ated to physical activity and playground safety andound that many state regulations did not comply withational health and safety standards (12). The reviewocused on 17 standards outlined in Caring for Our Chil-ren: National Health and Safety Performance Stan-ards: Guidelines for Out-of-Home Child-Care Programs14). Caring for Our Children standards were createdhrough a joint effort by a number of national organi-ations, including the American Academy of Pediatricsnd the American Public Health Association. State regu-ations were found to address only six of the 17 standardsor child-care centers and five for family child-care homes.he results indicate state regulations did not pay suffi-ient attention to the size of outdoor play areas, equip-ent height, equipment inspections, and play area sur-

acing. In general, the results showed that states hadreater numbers of regulations to support physical activ-ty vs playground safety.

hild-Care Practices and Policies of Relevance to the Promotionf Healthy Eatingracticing healthy eating behaviors during early child-ood is critical to support optimal growth and develop-ent, to achieve and maintain a healthy weight, and to

nsure overall health (15). The preschool years are an
specially important time for developing eating skills and

learning to accept a variety of healthy foods. Mealtimesfor preschool children should therefore provide not onlysufficient energy and nutrients, but also a supportiveenvironment for practicing skills and trying unfamiliarfoods (16). Whereas child-care settings offer many occa-sions to promote healthy eating behaviors, recent studieshave identified opportunities for improving the nutri-tional quality of foods provided to children, mealtimebehaviors of caregivers, and provision of nutrition educa-tion (Figure 1).

Two nationally representative studies (17,18) and a fewsmaller studies (19-22) have evaluated the nutritionalquality of foods provided to children in child-care set-tings. In addition to following the CACFP guidelines,Head Start programs are required by federal perfor-mance standards to serve meals and snacks that provideone third to one half of daily nutrition needs of children inpart-day and full-day programs, respectively (23). Theperformance standards require that nutrition needs aremet through foods high in nutrients and low in fat, sugar,and salt. Although research evaluating adherence tothese standards was not identified, one nationally repre-sentative study (17) found that most Head Start pro-grams have instituted additional practices designed topromote healthy eating. For example, responses from1,583 program directors showed that 91% of Head Startprograms served some fruit each day other than 100%fruit juice and some vegetable other than fried potatoes(17). Nearly all program directors (95%) reported thatjuice drinks that are �100% fruit juice were never served.However, only 66% of programs celebrated holidays andspecial events with healthy foods or nonfood treats.

More than 51,000 child-care centers and 140,000 familychild-care homes participated in CACFP during 2009, butnot all programs are eligible to participate or receive thesame reimbursement rate (24). Reimbursement benefitsfor family child-care homes are targeted to low-incomechildren and programs located in lower-income areas re-ceive higher Tier I reimbursement rates. The only nation-ally representative study of family child-care homes thatwas published in the last 10 years focused on homes thatreceive lower Tier II reimbursement rates (18). Althoughthe results showed that CACFP meal pattern require-ments were met by the majority of those sampled, severalnutritional concerns were identified. One third of snacksand breakfast meals offered did not include any fruit orvegetable item, and the most common combinations ofmeals and snacks exceeded the recommended limit forsaturated fat.

Smaller studies in child-care centers and family child-care homes have identified similar concerns (19-22). Forexample, a survey of family child-care homes in Kansasfound only 14% of providers usually served milk that was1% or skim to children aged 2 years and older (21). An-other study in North Carolina, which conducted directobservations of children (aged 3 to 5 years) at 20 child-care centers, found that half of the milk consumed waswhole milk and 75% of the meat consumed was high in fat(19). Nearly 60% of observed children were served a sweetsnack (eg, cookies) and 7% were served a sweetened bev-erage (eg, fruit punch).

Seven studies have additionally identified room for im-
provements relating to the mealtime behaviors of child-
S

care providers and missed opportunities for promotinghealthy eating behaviors (17,21,25-29). Federal perfor-mance standards for Head Start programs help to ensurethat providers model healthy eating behaviors and atti-tudes for children (23). Two studies of Head Start pro-grams have accordingly found that providers supporthealthy eating by sitting with children at meals andeating the same foods (17,27). However, some observa-tional research suggests that Head Start providers maybenefit from additional training on feeding children. Onestudy recorded mealtime conversations of providers andchildren, and found that providers made few commentscuing children to pay attention to their internal signals ofhunger and satiation (28). Providers made 10 times morecomments about the amount of food taken or children’sfood intake with no reference to these internal signals.

Three studies have similarly examined expectations formealtime behavior and nutrition knowledge among care-givers in child-care centers and family child-care homes(21,26,29). The results showed that most programs expectcaregivers to sit down with children for meals and con-sume the same food. Of 297 family child-care homes thatresponded to one survey, 68% reported that children andthe caregiver sit down together for meals; 72% reportedthat the caregiver consumes the same foods as the chil-dren; and 90% reported that the caregiver talks withchildren about trying and enjoying healthy foods (21).Although most caregivers were found to support healthyeating at mealtimes, only 47% of caregivers providednutrition education for children by reading books or play-ing games with nutrition themes. Of further concern,fewer than half of family child-care providers receivedany annual training in nutrition.

Child-Care Practices, Policies, and Physical Environment Factorsof Relevance for the Promotion of Physical ActivityExperts agree that children should participate in gener-ous amounts of activity during early childhood (30). In-volvement in active play has numerous benefits, includ-ing the promotion of children’s social, emotional, andpsychological development (31-33). Although child-caresettings offer a number of opportunities to increase chil-dren’s physical activity (11), research suggests that activ-ity levels at child care appear to be quite low (34,35).

Using direct observation, Pate and colleagues (36)found that children in child-care centers engaged in mod-erate-to-vigorous physical activity during �3% of the ob-servation periods and were sedentary �80% of those pe-riods. These findings have been confirmed by otherresearchers noting that children rarely achieve 60 min-utes of moderate-to-vigorous physical activity during thechild-care day (37,38). However, children’s physical activ-ity levels vary considerably depending upon the child-care facility they attend (36,39-41). It is estimated thatthe child-care center may account for as much as 47% ofthe variation in children’s physical activity across theschool day (36,41).

Within the child-care setting, multiple spheres of influ-ence exist that could provide bases for physical activityopportunities. For example, a recent article (42) outlineda set of best practice guidelines for child care that couldbe implemented to promote physical activity by address-
ing activity provisions (time and setting), the physical
eptember 2011 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1345

m
Figure 1. Practices and policies in US child-care settings with the potential to influence the development of healthy eating behaviors. aRDAs�Recom-
ended Dietary Allowances. NOTE: Information from this figure is available online at www.adajournal.org as part of a PowerPoint presentation.


http://www.adajournal.org

m
ended Dietary Allowances. NOTE: Information from this figure is available online at www.adajournal.org as part of a PowerPoint presentation. (Continued)

September 2011 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1347


m
ended Dietary Allowances. NOTE: Information from this figure is available online at www.adajournal.org as part of a PowerPoint presentation. (Continued)



seao(fi

cBce

pusri

cc

m onlin

environment (outdoor/indoor space and equipment), staffbehavior, education and training, and policies. Althoughfew studies have been conducted that assess promotingchild-care–based physical activity using these spheres,some promising evidence does exist (Figure 2).

Children who attend child-care centers that provide moreopportunities for physical activity through the provision oftime for active play, time spent outside, and indoor activi-ties, obtain more physical activity than children who do notattend such centers (40,43). Time outdoors has consistentlybeen found to be a strong predictor of young children’sphysical activity levels (44). However, just increasing theamount of time devoted to physical activity may not beadequate for children to obtain optimal benefits at child care(45). More space per child on the playground and shorterrecess periods have been associated with more vigorousactivity (46). Therefore, it may be important for staff topromote activity during outdoor playtime or provide morefrequent recess periods throughout the day.

Few studies were found that described attributes of theoutdoor environment at child-care facilities (46,47); how-ever, new methodologies for examining the importance ofthese attributes are in development (48). Existing researchuggests that children attending centers with high outdoornvironment scores (having trees, shrubbery, and open playreas) are more active than children in centers with lowutdoor environment scores (47). Also, portable equipmenteg, balls, wheel toys) was associated with activity, whereasxed equipment was not (40,46,49).Research describing the influence of staff behavior on

hild activity levels also is limited. In a case study report,rown and colleagues (50) found an association between

hildren’s physical activity and teacher prompts. How-

Figure 1. Practices and policies in US child-care settings with the potenended Dietary Allowances. NOTE: Information from this figure is available

ver, in a study of 96 child-care centers (42), staff mem- a

S

bers were observed providing few prompts for activityand frequently withholding activity as punishment. Un-fortunately, child-care staff members who are unaware oftheir role in children’s activity may inadvertently contrib-ute to sedentary behavior. For example, teachers whosupervise play while sitting down or standing still mayattract children, especially girls, to join them in seden-tary conversation rather than active play (46).

Failure to develop and implement appropriate policiesmay create threats to activity time, as was noted in arecent qualitative study (51). Child-care policies can in-crease opportunities for physical activity by settingguidelines for the appropriate amount of time to allocatefor physical activity, required training and appropriatestaff behaviors, and appropriate physical settings.

Perceptions and Practices of ParentsCommunication between child-care providers and parentsis also important to prevent obesity and promote healthyweight in preschool children attending child care (16). Re-search indicates that parents are unlikely to recognize apreschool-aged child is obese and a considerable proportionof parents of normal-weight children perceive their child tobe underweight (52-54). These findings suggest parents ofreschool-aged children may be more often concerned withndernutrition than overnutrition. However, only a fewtudies have examined parent perceptions and behaviorselevant to the nutrition and physical activity environmentn child-care settings (55,56).

One study surveyed 508 parents of children attendinghild-care centers in North Carolina regarding their per-eptions of meal offerings and opportunities for physical

influence the development of healthy eating behaviors. aRDAs�Recom-e at www.adajournal.org as part of a PowerPoint presentation. (Continued)

tial to

ctivity (55). Although few parents in the study perceived



Figure 2. Practices, policies, and physical environment factors in US child-care settings with the potential to influence physical activity behaviors.aMPVA�moderate-to-vigorous physical activity. bEPAO�Environment and Policy Assessment and Observation. NOTE: Information from this figure
is available online at www.adajournal.org as part of a PowerPoint presentation.


Figure 2. Practices, policies, and physical environment factors in US child-care settings with the potential to influence physical activity behaviors.aMPVA�moderate-to-vigorous physical activity. bEPAO�Environment and Policy Assessment and Observation. NOTE: Information from this figure
is available online at www.adajournal.org as part of a PowerPoint presentation. (Continued)


ecwa

v

senta

the quality of meals or physical activity at their child-carecenter to be poor, parents provided insight into key areasof concern. The most common recommendations for improv-ing meals and snacks were to serve more fruits and vege-tables, offer a greater variety of foods, and decrease foods oflow nutritional quality. A small percentage of parents re-

Figure 2. Practices, policies, and physical environment factors in US caMPVA�moderate-to-vigorous physical activity. bEPAO�Environment ais available online at www.adajournal.org as part of a PowerPoint pre

ported concern that their child was not getting enough to t


at and recommended increasing portion sizes. The mostommon recommendations for improving physical activityere to provide more structured and provider-led activitiess well as additional outdoor time.A second study reported on the quality of lunches pro-

ided for children at child-care centers requiring parents

are settings with the potential to influence physical activity behaviors.olicy Assessment and Observation. NOTE: Information from this figuretion. (Continued)

hild-cnd P

o send sack lunches from home (56). All 49 parent par-


alittiatpt

ticipants reported the perception that lunch is an impor-tant opportunity to receive nutrients for the day, and 67%indicated they packed nutritious foods that they knewtheir child might not eat. However, direct observation ofsack lunch contents showed that nearly 50% of childrenwere provided lunches that had more than the recom-mended percentage of energy from fat and 70% were notprovided adequate servings of fruits and vegetables.

Obesity Prevention InterventionsObesity prevention interventions have been designed toimprove nutrition, physical activity, and weight outcomesfor children enrolled in Head Start programs (45,57-63)nd child-care centers/preschools (37,63-72), but no pub-ished interventions have specifically been designed formplementation in family child-care homes (Figure 3). Ofhe 18 interventions we identified, four focused on nutri-ion outcomes (59-61,72), seven focused on physical activ-ty or sedentary activity outcomes (37,45,58,64,66-68),nd seven addressed a combination of nutrition and ac-ivity outcomes (57,62,63,65,69-71). Most interventionsrovided curriculum enhancements or classroom educa-ion for children (37,57-60,63,65-68,71,72), and seven pro-

grams also included a component designed to educate andengage parents in making positive changes at home(37,57,59,60,63,65,72). Just five of the interventions tar-geted environmental factors such as improvements inclassroom policies (70), foodservice practices (59,61,69,70), and playground environments (64). Sixteen interven-tions in the United States were evaluated (45,57-70,72),one in Scotland (37), and one in Israel (71).

Evaluations of impact (37,45,57-61,64-72) were com-pleted for 16 of the 18 interventions and evaluations offeasibility (62,63) were completed for two other interven-tions. All four of the interventions for which evaluationswere designed to assess an influence on children’s meal-time behaviors, dietary preferences, or dietary qualityfound a positive effect (57,59-61). Of the 10 interventionsfor which evaluations were designed to assess an influ-ence on children’s physical activity or sedentary activitybehaviors (37,45,57,58,64-68,71), seven interventionsfound a positive effect (58,64-68,71). An assessment ofimpact on child weight status was completed for just fiveof the interventions (37,57,59,65,71), and only two stud-ies (57,71) showed some evidence of success in reducingrisk for obesity. The two interventions that showed aninfluence on child weight status included multiple com-ponents to address nutrition, physical activity, and sed-entary behaviors. Interventions that successfully im-proved nutrition or physical activity outcomes includedone or more of the following strategies: integrating addi-tional opportunities for physical activity into classroomcurriculum, modifying foodservice practices, providingclassroom-based nutrition education, and engaging par-ents through educational newsletters or activities.

A small number of studies have similarly evaluated theinfluence of interventions on child-care practices or poli-cies. All four of the interventions for which evaluationswere designed to assess an intervention’s influence on thenutrition environment in child-care settings found someevidence of a positive effect (61,69,70,73). For example, arandomized-controlled evaluation of the Nutrition and
Physical Activity Self-Assessment for Child Care inter-
S

vention found significant overall improvement in nutri-tion practices and policies among child-care centers thatfully participated as compared to control centers (70). The41 participating child-care centers implemented policiessuch as requiring that parents bring only healthful treatsfor celebrations and practices such as serving lower-fatmilk (1% or skim) to children aged 2 years and older. TheNutrition and Physical Activity Self-Assessment forChild Care intervention was also the only evaluated in-tervention to specifically target improvement in practicesand policies relating to physical activity as an outcome;however, evidence regarding its efficacy has been mixed(70,74,75).

DISCUSSIONThe aim of this review is to describe and evaluate re-search addressing opportunities and strategies for theprevention of obesity among preschool children in child-care settings. Despite widespread use of child care and anall-time high prevalence of obesity among preschool-agedchildren (1,5), most states lack strong regulations forchild-care settings related to healthy eating and physicalactivity. Recent assessments of child-care settings havefurther identified room for improvement in regards to thenutritional quality of foods provided to children, theamount of time children are engaged in physical activity,caregiver behaviors that may discourage healthy behav-iors, and missed opportunities for education. A limitednumber of interventions have been designed to addressthese concerns, and only two interventions (57,71)showed evidence of success in reducing risk for obesityamong child participants. Although considerable prog-ress has been made in the past 10 years to advanceunderstanding of the influence child-care environmentshave on diet and physical activity outcomes, there re-mains much to be learned. Additional research is neededto advance obesity prevention efforts in child-care set-tings and better promote the health of future generations.

Completed research describing state regulations forchild-care settings represents the first step in policy-based obesity prevention. Published reviews have pro-vided a baseline against which future progress may bemeasured (10-13). These reviews identified a number ofopportunities for enhancing state regulations by compar-ing existing regulations with relevant national standardsand recommendations from professional groups, includ-ing the American Dietetic Association, the AmericanAcademy of Pediatrics, and the American Public HealthAssociation. Although the results indicate stronger statelicensing regulations are needed for child-care facilities,research addressing the influence of state regulations onthe promotion of nutrition and physical activity was notavailable. Studies evaluating the influence of state regu-lations are needed to ensure that desired improvementsin nutrition and physical activity practices are realizedand there are no unintended consequences of developingstronger regulations. For example, research regardingthe influence of state regulations for child-to-staff ratioshas found that states with more stringent regulationshave fewer children enrolled in center-based care (76).Strict regulations for nutrition and physical activity prac-tices could similarly lead to a reduction in the number of
smaller family child-care homes that choose to be licensed

i
Figure 3. Interventions designed to promote better nutrition, improve physical activity, and prevent obesity in child-care settings. aBMI�body mass ndex. NOTE: Information from this figure is available online at www.adajournal.org as part of a PowerPoint presentation.


i
Figure 3. Interventions designed to promote better nutrition, improve physical activity, and prevent obesity in child-care settings. aBMI�body mass ndex. NOTE: Information from this figure is available online at www.adajournal.org as part of a PowerPoint presentation. (Continued)


i


i


i


i


due to excessive administrative burdens (11). In addition,the existence of regulations does not ensure the compli-ance of child-care providers or enforcement at the statelevel.

Completed studies describing child-care practices andpolicies that may influence dietary intake and physicalactivity behaviors have identified several key areas to beaddressed by interventions. However, the majority of re-viewed studies conducted assessments of Head Start pro-grams (17,25,27,28,77) and child-care centers (19,20,22,26,29). Only three studies were found that collected datafrom providers working in family child-care homes(18,21,29). Additional nationally representative studiesare needed to identify barriers to healthy eating andphysical activity in family child-care homes. In particu-lar, there is a need to evaluate the nutritional quality ofmeals and snacks served to children in CACFP-partici-pating homes. The most recent national study (18) is nowmore than 10 years old and was conducted only in Tier IIfamily child-care homes. Research in both Tier I and TierII sites is needed to update knowledge of how the nutri-tional content of meals and snacks compares to currentnational dietary recommendations such as the DietaryGuidelines for Americans and the Dietary Reference In-takes (78,79). As parents may often participate in menuplanning (25) and serve as persuasive advocates forchanges at child-care facilities to promote healthy eatingand physical activity (55), there is also a great need foradditional research regarding parental behaviors andperceptions to better inform future interventions.

In regard to obesity prevention interventions, there is apressing need for additional research to evaluate multi-component programs that address nutrition and physicalactivity behaviors. Obesity results when there is an im-balance between the energy children consume as food andbeverages and the energy they expend to support normalgrowth and physical activity (80). Therefore, interven-tions that address behaviors relating to both energy in-take and energy expenditure are likely to have the great-est influence. Of the 18 interventions reviewed here, justseven interventions included strategies designed to ad-dress both energy intake and energy expenditure. Theeffect of intervention strategies on weight status wasevaluated for only three of these seven interventions(57,65,71). Although it is likely that interventions inchild-care facilities will need to be complimented by en-vironmental changes in other settings to produce sus-tained changes in weight status, this initial work hasprovided some evidence that interventions in child-caresettings have the potential to influence the developmentof obesity among preschool-aged children.

Additional research is needed to determine the long-term feasibility of institutionalizing interventions and totest whether interventions found to be effective in onepopulation produce similar results in different groups.The Hip-Hop to Health Jr program was found to be effec-tive in Head Start centers serving primarily African-American preschoolers (57), but was not found to be ef-fective when tested at centers serving primarily Latinopreschoolers (81). Interventions found to effectively re-duce risk for obesity in one setting need to be carefullyadapted for diverse groups and different settings and
reevaluated to ensure that strategies are generalizable.

Because obesity disproportionately affects preschoolersin low-income and racial/ethnic minority communities(82-85), the development and evaluation of interventionsfor these youth should be a priority. Behavioral messagesdelivered in child-care settings should be consistent withmessages delivered in other community settings (eg,schools and community programs) to best promote theimplementation of healthy eating and activity behaviors.

Future evaluations of interventions could be strength-ened by the use of stronger designs, assessments of bodycomposition or weight status, and the development ofvalid and reliable outcome measures. Of the 16 interven-tions with completed impact evaluations (37,45,57-61,64-72), only seven evaluations used randomized controlleddesigns (37,57,65,66,68,70,71). Most of the reviewed eval-uations reported on pre-experimental designs, quasi-ex-perimental designs, or small samples. To facilitate theevaluation of interventions targeting environmental out-comes (eg, foodservice practices and physical activity pol-icies), additional work is needed to develop sensitive andreliable assessment tools. Interventions targeting envi-ronmental factors in child-care settings are important tosupport children and caregivers in changing their nutri-tion and physical activity behaviors, and may cost-effec-tively affect larger populations than interventions thatsolely target behavior and weight outcomes (86). Only oneobservational measure (the Environment and Policy As-sessment and Observation instrument) exists that specif-ically assesses nutrition and physical activity environ-ments at child-care settings (87). Although an initialevaluation of this tool determined the overall interob-server reliability is high, challenges were involved withthe assessment of factors such as staff behaviors, policies,and playground equipment. Additional work is needed tofurther develop this tool and other measures of environ-mental factors.

CONCLUSIONSEarly prevention is considered to be the most promisingstrategy for reducing obesity and the many serious healthconditions that may result as a consequence of excessiveweight gain during childhood (88). Eating and activitybehaviors formed during the preschool years have thepotential to prevent obesity in the short term and, ifcarried into adulthood, to set the stage for a lifetime ofbetter health. The majority of US parents depend onchild-care providers to support the development ofhealthful behaviors by providing their young childrenwith nutritious foods and regular physical activity (5).Research has identified many opportunities in childcaresettings to provide better support for healthy eating andphysical activity; however, there is an urgent need foradditional well-designed studies to inform the implemen-tation of effective interventions, regulations, and policiesto prevent childhood obesity. Significant improvements inthe eating and activity behaviors of preschool childrenwill likely depend on the combined strength of interven-tions and supportive policy changes.

STATEMENT OF POTENTIAL CONFLICT OF INTEREST:No potential conflict of interest was reported by the au-
thors.

2

2

2

2

2

2

3

3

3

3

3

3

3

3

3

3

4

4

4

4

4

4

4

4

4

FUNDING/SUPPORT: This manuscript was supportedin part by the Robert Wood Johnson Foundation HealthyEating Research Program.

References1. Ogden C, Carroll M, Curtin L, Lamb M, Flegal K. Prevalence of high

body mass index in US children and adolescents, 2007-2008. JAMA.2010;303:242-249.

2. Daniels S. Complications of obesity in children and adolescents. Int JObes. 2009;33(suppl):S60-S65.

3. Lumeng J, Gannon K, Appugliese D, Cabral H, Zuckerman B. Pre-school child care and risk of overweight in 6- to 12-year-old children.Int J Obes. 2005;29:60-66.

4. Maher E, Li G, Carter L, Johnson D. Preschool child care participa-tion and obesity at the start of kindergarten. Pediatrics. 2008;122:322-330.

5. Early Childhood Program Participation Survey of the NationalHousehold Education Surveys Program (ECPP-NHES:2005). Na-tional Center for Education Statistics Web site. http://nces.ed.gov/programs/digest/d09/tables/dt09_044.asp. Accessed August 3, 2010.

6. The state of America’s children 2010. Children’s Defense Fund Website. http://www.childrensdefense.org/child-research-data-publications/data/state-of-americas-children-2010-report.html. Accessed September26, 2010.

7. Story M, Kaphingst KM, French S. The role of child care settings inobesity prevention. Future Child. 2006;16:143-168.

8. Child and Adult Care Food Program Web site. http://www.fns.usda.gov/cnd/Care/. Accessed July, 2010.

9. About Head Start. Office of Head Start Web site. http://eclkc.ohs.acf.hhs.gov/hslc/About%20Head%20Start. Accessed August 1, 2010.

10. Benjamin S. Obesity prevention in child care: A review of U.S. stateregulations. BMC Public Health. 2008;8:188.

11. Kaphingst K, Story M. Child care as an untapped setting for obesityprevention: State child care licensing regulations related to nutrition,physical activity, and media use for preschool-aged children in theUnited States. Prev Chronic Dis. 2009;6:A11.

12. Cradock A, O’Donnell E, Benjamin S, Walker E, Slining M. A reviewof state regulations to promote physical activity and safety on play-grounds in child care centers and family child care homes. J Phys ActHealth. 2010;7(suppl):S108-S119.

13. Benjamin S, Copeland K, Cradock A, Neelon B, Walker E, Slining M,Gillman M. Menus in child care: A comparison of state regulationswith national standards. J Am Diet Assoc. 2009;109:109-115.

14. American Academy of Pediatrics, American Public Health Associa-tion, National Resource Center for Health and Safety in Child Careand Early Education. Caring for Our Children: National Health andSafety Performance Standards; Guidelines for Out-of-Home ChildCare Programs. 2nd ed. Elk Grove Village, IL: American Academy ofPediatrics and Washington, DC: American Public Health Association;2002.

15. Story M, Holt K, Sofka D, eds. Bright Futures in Practice: Nutrition.2nd ed. Arlington, VA: National Center for Education in Maternal andChild Health; 2002.

16. Position of The American Dietetic Association: Benchmarks for nutri-tion programs in child care settings. J Am Diet Assoc. 2005;105:979-986.

17. Whitaker R, Gooze R, Hughes C, Finkelstein D. A national survey ofobesity prevention practices in Head Start. Arch Pediatr Adolesc Med.2009;163:1144-1150.

18. Crepinsek M, Burstein N, Lee E, Kennedy S, Hamilton W, Abt Asso-ciates Inc. Meals offered by tier 2 CACFP family child care providers.Effects of lower meal reimbursements. Washington DC: US Dept ofAgriculture, Economic Research Service; 2002.

19. Ball S, Benjamin S, Ward D. Dietary intakes in North Carolinachild-care centers: Are children meeting current recommendations?J Am Diet Assoc. 2008;108:718-721.

20. Wu Y, Hertzler A, Miller S. Vitamin A, vitamin C, calcium and ironcontent of federally funded preschool lunches in Virginia. J Am DietAssoc. 2001;101:348-351.

21. Trost S, Messner L, Fitzgerald K, Roths B. Nutrition and physicalactivity policies and practices in family child care homes. Am J PrevMed. 2009;37:537-540.

22. Padget A, Briley M. Dietary intakes at child-care centers in centralTexas fail to meet Food Guide Pyramid Recommendations. J Am DietAssoc. 2005;105:790-793.

23. Head Start Program Performance Standards and other regulations.Office of Head Start Web site. http://eclkc.ohs.acf.hhs.gov/hslc/ 4

S

Program%20Design%20and%20Management/Head%20Start%20Requirements/Head%20Start%20Requirements. Accessed July 5,2010.

4. State of the states—state data profiles. Food Research and ActionCenter Web site. http://frac.org/map/. Accessed September 25, 2010.

5. Gooze R, Hughes C, Finkelstein D, Whitaker R. Reaching staff, par-ents, and community partners to prevent childhood obesity in HeadStart, 2008. Prev Chronic Dis. 2010;7:3.

6. Sigman-Grant M, Christiansen E, Branen L, Fletcher J, Johnson S.About feeding children: Mealtimes in child-care centers in four West-ern states. J Am Diet Assoc. 2008;108:340-346.

7. Gable S, Lutz S. Nutrition socialization experiences of children in theHead Start program. J Am Diet Assoc. 2001;101:572-577.

8. Ramsay S, Branen L, Fletcher J, Price E, Johnson S, Sigman-GrantM. “Are you done?” Child care providers’ verbal communication atmealtimes that reinforce or hinder children’s internal cues of hungerand satiation. J Nutr Educ Behav. 2010;42:265-270.

9. Freedman M, Alvarez K. Early childhood feeding: Assessing knowl-edge, attitude, and practices of multi-ethnic child-care providers.J Am Diet Assoc. 2010;110:447-451.

0. National Association for Sport and Physical Education. Active Start: AStatement of Physical Activity Guidelines for Children Birth to FiveYears. Reston, VA: NASPE Publications; 2002.

1. Burdette H, Whitaker R. Resurrecting free play in young children:Looking beyond fitness and fatness to attention, affiliation, and affect.Arch Pediatr Adolesc Med. 2005;159:46-50.

2. Eastman W. Physical activities for infants, toddlers, and preschool-ers. Early Child Educ J. 1997;24:161-164.

3. Timmons B, Naylor P, Pfeiffer K. Physical activity for preschoolchildren—How much and how? Can J Public Health. 2007;98(suppl):S122-S134.

4. Oliver M, Schofield G, Kolt G. Physical activity in preschoolers: Un-derstanding prevalence and measurement issues Sports Med. 2007;32:1045-1070.

5. Reilly J. Low levels of objectively measured physical activity in pre-schoolers in child care. Med Sci Sports Exerc. 2010;42:502-507.

6. Pate R, McIver K, Dowda M, Brown W, Addy C. Directly observedphysical activity levels in preschool children. J Sch Health. 2008;78:438-444.

7. Reilly J, Kelly L, Montgomery C, Williamson A, Fisher A, McColl J, LoConte R, Paton J, Grant S. Physical activity to prevent obesity inyoung children: Cluster randomised controlled trial. BMJ. 2006;333:1041.

8. Cardon G, De Bourdeaudhuij IMM. Are preschool children activeenough? Objectively measured physical activity levels. Res Q ExercSport. 2008;79:326-332.

9. Pate R, Pfeiffer K, Trost S, Ziegler P, Dowda M. Physical activityamong children attending preschools. Pediatrics. 2004;114:1258-1263.

0. Bower J, Hales D, Tate D, Rubin D, Benjamin S, Ward D. Thechildcare environment and children’s physical activity. Am J PrevMed. 2008;34:23-29.

1. Finn K, Johannsen N, Specker B. Factors associated with physicalactivity in preschool children. J Pediatr. 2002;140:81-85.

2. McWilliams C, Ball S, Benjamin S, Hales D, Vaughn A, Ward D.Best-practice guidelines for physical activity at child care. Pediatrics.2009;124:1650-1659.

3. Dowda M, Pate R, Trot S, Joao M, Almeida C, Sirard J. Influences ofpreschool policies and practices on children’s physical activity. J Com-munity Health. 2004;29:183-196.

4. Hinkley T, Crawford D, Salmon J, Okely A, Hesketh K. Preschoolchildren and physical activity. A review of correlates. Am J Prev Med.2008;34:435-441.

5. Alhassan S, Sirard J, Robinson T. The effects of increasing outdoorplay time on physical activity in Latino preschool children. Int J Pe-diatr Obes. 2007;2:153-158.

6. Cardon G, Van Cauwenberghe E, Labarque V, Haerens L, De Bour-deaudhuij I. The contribution of preschool playground factors in ex-plaining children’s physical activity during recess. Int J Behav NutrPhys Act. 2008;5:11. http://www.ijbnpa.org/content/5/1/11. AccessedAugust 14, 2010.

7. Boldermann C, Blennow M, Dal H, Mårtensson F, Raustorp A, YuenL, Wester U. Impact of preschool environment upon children’s phys-ical activity and sun exposure. Prev Med. 2006;42:301-308.

8. Cosco N, Moore R, Islam M. Behavior mapping: A method for linkingpreschool physical activity and outdoor design. Med Sci Sports Exerc.
2010;42:513-519.
9. Dowda M, Brown W, McIver K, Pfeiffer K, O’Neill J, Addy C, Pate R.


http://nces.ed.gov/programs/digest/d09/tables/dt09_044.asp

http://nces.ed.gov/programs/digest/d09/tables/dt09_044.asp

http://www.childrensdefense.org/child-research-data-publications/data/state-of-americas-children-2010-report.html

http://www.childrensdefense.org/child-research-data-publications/data/state-of-americas-children-2010-report.html

http://www.fns.usda.gov/cnd/Care/

http://www.fns.usda.gov/cnd/Care/

http://eclkc.ohs.acf.hhs.gov/hslc/About%20Head%20Start

http://eclkc.ohs.acf.hhs.gov/hslc/About%20Head%20Start

http://eclkc.ohs.acf.hhs.gov/hslc/Program%20Design%20and%20Management/Head%20Start%20Requirements/Head%20Start%20Requirements



http://frac.org/map/

http://www.ijbnpa.org/content/5/1/11

5

5

5

5

5

6

6

6

6

6

6

6

6

6

6

7

7

7

7

7

7

8

8

8

8

8

8

Policies and characteristics of the preschool environment and physicalactivity of young children. Pediatrics. 2009;123:e261-266.

50. Brown W, Googe H, McIver K, Rathel J. Effects of teacher-encouragedphysical activity on preschool playgrounds. J Early Interv. 2009;31:126-145.

51. Copeland K, Sherman S, Kendeigh C, Saelens S, Kalkwarf H. Flipflops, dress clothes, and no coat: Clothing barriers to children’s phys-ical activity in child-care centers identified from a qualitative study.Int J Behav Nutr Phys Act. 2009;6:74. http://www.ijbnpa.org/content/6/1/74. Accessed August 14, 2010.

52. Harnack L, Lytle L, Himes J, Story M, Taylor G, Bishop D. Lowawareness of overweight status among parents of preschool-aged chil-dren, Minnesota, 2004-2005. Prev Chronic Dis. 2009;6:A47.

53. Baughcum A, Chamberlin L, Deeks C, Powers S, Whitaker R. Mater-nal perceptions of overweight preschool children. Pediatrics. 2000;106:1380-1386.

54. Nelson J, Carpenter K, Chiasson M. Diet, activity, and overweightamong preschool-age children enrolled in the Special SupplementalNutrition Program for Women, Infants, and Children (WIC). PrevChronic Dis. 2006;3:A49. http://www.cdc.gov/pcd/issues/2006/apr/05_0135.htm. Accessed July 18, 2010.

5. Benjamin S, Haines J, Ball S, Ward D. Improving nutrition andphysical activity in child care: What parents recommend. J Am DietAssoc. 2008;108:1907-1911.

6. Sweitzer S, Briley M, Robert-Gray C. Do sack lunches provided byparents meet the nutritional needs of young children who attend childcare? J Am Diet Assoc. 2009;109:141-144.

7. Fitzgibbon M, Stolley M, Van Horn L, Kaufer-Christoffel K, Dyer A.Two-year follow-up results for Hip-Hop to Health Jr: A randomizedcontrolled trial for overweight prevention in preschool minority chil-dren. J Pediatr. 2005;146:618-625.

8. Williams C, Carter B, Kibbe D, Dennison D. Increasing physicalactivity in preschool children: A pilot study to evaluate Animal Track-ers. J Nutr Educ Behav. 2009;41:47-52.

9. Williams C, Strobino B, Bollella M, Brotanek J. Cardiovascular riskreduction in preschool children: The “Healthy Start” Project. J AmColl Nutr. 2004;23:117-123.

0. Johnson S, Bellows L, Beckstrom L, Anderson J. Evaluation of a socialmarketing campaign targeting preschool children. Am J Health Be-hav. 2007;31:44-55.

1. Endres J, Barter S, Theodora P, Welch P. Soy-enhanced lunch accep-tance by preschoolers. J Am Diet Assoc. 2003;103:346-351.

2. Finkelstein D, Whitaker R, Hill E, Fox M, Mendenko L, Boller K.Results from the “I Am Moving, I Am Learning” Stage 1 Survey.Princeton, NJ: Mathematica Policy Research, Inc; 2007.

3. Dunn C, Thomas C, Ward D, Pegram L, Webber K, Cullitan C. Designand implementation of a nutrition and physical activity curriculumfor child care settings. Prev Chronic Dis. 2006;3:A58.

4. Hannon J, Brown B. Increasing preschoolers’ physical activity inten-sities: An activity-friendly preschool playground intervention. PrevMed. 2008;46:532-536.

5. Dennison B, Russo T, Burdich P, Jenkins P. An intervention to reducetelevision viewing by preschool children. Arch Pediatr Adolesc Med.2004;158:170-176.

6. Trost S, Fees B, Dzewaltowski D. Feasibility and efficacy of a “Moveand Learn” physical activity curriculum in preschool children. J PhysAct Health. 2008;5:88-103.

7. Parish L, Rudisill M, St Onge PM. Mastery motivational climate:Influence on physical play and heart rate in African American tod-dlers. Res Q Exerc Sport. 2007;78:171-178.

8. Binkley T, Specker B. Increased periosteal circumference remainspresent 12 months after an exercise intervention in preschool chil-dren. Bone. 2004;35:1383-1388.

9. Gosliner W, James P, Yancey A, Ritchie L, Studer N, Crawford P.Impact of a worksite wellness program on the nutrition and physical

8


activity environment of child care centers. Am J Health Promot.2010;24:186-189.

0. Ward D, Benjamin S, Ammerman A, Ball S, Neelon B, Bangdiwala S.Nutrition and physical activity in child care: Results from an envi-ronmental intervention. Am J Prev Med. 2008;35:352-356.

1. Eliakim A, Nemet D, Balakirski Y, Epstein Y. The effects of nutri-tional-physical activity school-based intervention on fatness and fit-ness in preschool children. J Pediatr Endocrinol Metab. 2007;20:711-718.

2. Sweitzer S, Briley M, Roberts-Gray C, Hoelscher D, Harrist R, StaskelD, Almansour F. Lunch is in the Bag: Increasing fruits, vegetables,and whole grains in sack lunches of preschool-aged children. J AmDiet Assoc. 2010;110:1058-1064.

3. Williams C, Bollella M, Strobino B, Spark A, Nicklas T, Tolosi L, PittmanB. “Healthy Start”: Outcome of an intervention to promote a hearthealthy diet in preschool children J Am Coll Nutr. 2002;21:62-71.

4. Drummond R, Staten L, Sanford M, Davidson C, Ciocazan M, KhorK-N, Kaplan F. Steps to a healthier Arizona: A pebble in the pond:The ripple effect of an obesity prevention intervention targeting thechild care environment. Health Promot Pract. 2009;10(suppl):156S-167S.

75. Benjamin S, Ammerman A, Sommers J, Dodds J, Neelon B, Ward D.Nutrition and physical activity self-assessment for child care (NAPSACC): Results from a pilot intervention. J Nutr Educ Behav. 2007;39:142-149.

76. Rigby E, Ryan R, Brooks-Gunn J. Child care quality in different statepolicy contexts. J Policy Anal Manage. 2007;26:887-907.

77. Gupta R, Pascoe J, Blanchard T, Langkamp D, Duncan P, Gorski P,Southward L. Child health in child care: A multi-state survey of HeadStart and Non-Head Start child care directors. J Pediatr Health Care.2009;23:143-149.

78. Nutrition and Your Health: Dietary Guidelines for Americans 2005.US Dept of Health and Human Services Web site. http://www.health.gov/dietaryguidelines/. Accessed October 1, 2010.

9. Institute of Medicine, Food and Nutrition Board. Dietary ReferenceIntakes: Applications in Dietary Planning. Washington, DC: NationalAcademy Press; 2003.

0. Institute of Medicine, Committee on Prevention of Obesity in Chil-dren and Youth, Food and Nutrition Board, Board on Health Promo-tion and Disease Prevention. Preventing Childhood Obesity: Health inthe Balance. Washington, DC: National Academies Press; 2005.

1. Fitzgibbon M, Stolley M, Schiffer L, Van Horn L, Kaufer-ChristoffelK, Dyer A. Hip-Hop to Health Jr. for Latino preschool children.Obesity. 2006;14:1616-1624.

2. Anderson S, Whitaker R. Prevalence of obesity among US preschoolchildren in different racial and ethnic groups. Arch Pediatr AdolescMed. 2009;163:344-348.

3. Kimbro R, Brooks-Gunn J, McLanahan S. Racial and ethnic differen-tials in overweight and obesity among 3-year-old children. Am JPublic Health. 2007;97:298-305.

4. Sharma A, Grummer-Strawn L, Dalenius K, Galuska D, AnandappaM, Borland E, Mackintosh H, Smith R. Obesity prevalence amonglow-income, preschool-aged children—United States, 1998-2008.MMWR Morb Mortal Wkly Rep. 2009;58:769-773.

5. Anderson S, Whitaker R. Household routines and obesity in US pre-school-aged children. Pediatrics. 2010;125:420-428.

86. World Health Organization. Diet, nutrition, and the prevention ofchronic diseases. Report of a joint WHO/FAO expert consultation.Geneva, Switzerland: World Health Organization; 2003.

87. Ward D, Hales D, Haverly K, Marks J, Benjamin S, Ball S, Trost S. Aninstrument to assess the obesogenic environment of child care cen-ters. Am J Health Behav. 2008;32:380-386.

8. Dehghan M, Akhtar-Danesh N, Merchant A. Childhood obesity, prev-alence and prevention. Nutr J. 2005;4:24.



http://www.cdc.gov/pcd/issues/2006/apr/05_0135.htm

http://www.cdc.gov/pcd/issues/2006/apr/05_0135.htm

http://www.health.gov/dietaryguidelines/

http://www.health.gov/dietaryguidelines/

Documents

What Role Can Child-Care Settings Play in Obesity ... Advance... · status in childhood (3,4). Approximately 80% of preschool-aged children with em-ployed mothers are in some form