Obesity Prevention in Child Care: A Review of U.S. State Regulations

Comment: This report was done by Sara E Benjamin; Angie Cradock; Elizabeth M Walker; Meghan Slining; Matthew W Gillman BMC Public Health.

It is an open access report.

Here are some of the highlights:

Objective. To describe and contrast individual state nutrition and physical activity regulations related to childhood obesity for child care centers and family child care homes in the United States

Conclusion. Many states lack specific nutrition and physical activity regulations related to childhood obesity for child care facilities. If widely implemented, enhancing state regulations could help address the obesity epidemic in young children in the United States


Rates of obesity in children continue to rise in the United States and abroad. Even among preschool-aged children the prevalence of obesity is alarmingly high, with 26.2% of children aged 2 through 5 years in the United States classified as either overweight or obese.

Even in childhood, obesity is associated with a variety of adverse health consequences that can include Type II diabetes mellitus, hypertension and hyperlipidemia, asthma and sleep apnea, early maturation, lower self-esteem, and psychosocial stress.

Additional research has identified the preschool period as a critical time for growth, development, and risk of later obesity.

While there are genetic factors related to childhood obesity, diet and physical activity-related causes are modifiable and have therefore been targets of obesity prevention efforts and research.

Associations between dietary intake and obesity have been examined in numerous studies.Intake of sugar sweetened beverages and high fructose corn syrup may be contributors to the obesity epidemic, as the increases in consumption show a pattern consistent with the rise in obesity.

Other studies corroborate this finding and report that sweetened beverage consumption, including soft drinks and fruit juice, has increased in all children, including toddlers, and is related to childhood obesity.

Studies examining the relationship between fruit juice intake and childhood obesity have shown mixed results.

Adult behaviors may interfere with a child's ability to respect hunger and satiety cues. There is some evidence that restrictive feeding and forcing children to eat are related to childhood obesity. Moreover, using food as a reward may also have a negative effect on children's weight status.

Additionally, there is strong evidence that breastfeeding has a protective effect against later childhood and adolescent obesity.

Strong evidence also links childhood obesity to television viewing both through observational studies and randomized controlled trials. Even among preschool-aged children television viewing is associated with risk of obesity. Little is known about the contribution of computer use and its relationship to obesity in young children; one recent study found an association between computer use and adiposity in preschool-aged children.

In addition to television and other screen time, researchers have associated physical activity with obesity in young children, with low levels of physical activity observed among preschool-aged children, and in particular, preschool-aged girls. Burdette and Whitaker found that play, which can involve any type of physical movement, is on the decline among children of all ages and may contribute to increases in sedentary activity and obesity.

In the United States, regulation of child care facilities is the responsibility of the individual state and the District of Columbia, and each has an agency responsible for oversight and enforcement of these regulations.

As a result, regulations for child care facilities vary considerably by state.

Child care facilities may serve as home-away-from-home settings, where children adopt early nutrition, physical activity, and television viewing behaviors. These behaviors are often a result of interactions with parents and other caregivers. Young children in particular are more likely to be influenced by adults in an eating environment.

Moreover, preschool-aged children may consume 50% to 100% of their Recommended Dietary Allowances in child care settings, placing a great deal of responsibility on the child care facility to provide nutritionally adequate, healthful food.

Child care facilities are in a unique position to support and facilitate healthful eating and promote physical activity for young children

In the United States, regulation of child care facilities is the responsibility of the individual state and the District of Columbia, and each has an agency responsible for oversight and enforcement of these regulations.

As a result, regulations for child care facilities vary considerably by state.

We reviewed state regulations for reference to seven key nutrition and physical activity items related to childhood obesity. The items have a documented relationship to childhood obesity in the research literature, and are likely contributors to diet quality and activity level.

Items included in this review were:
1) Water is freely available
2) Sugar sweetened beverages are limited
3) Foods of low nutritional value are limited
4) Children are not forced to eat
5) Food is not used as a reward
6) Support is provided for breastfeeding and provision of breast milk
7) Screen time is limited
8) Physical activity is required daily (minutes per day).

In this review of state regulations for child care facilities in the United States, we found that most states had few nutrition and physical activity regulations related to obesity for child care centers and family child care homes.

state regulations for child care we found that most states had few regulations related to obesity for child care centers and family child care homes.

Judy's conclusions: Feeding children in a childcare situation, where children are out of the safety of their own homes, is an art. It should always be fun - that's the goal. New foods, fun foods, eating with friends, and the general comraderie at table should be a given. However, what providers and teachers are finding is that children come to us without knowing how to eat much besides low nutritional value foods and sweet drinks. Children are not even encouraged to eat because in many homes what they are served is not worth eating. Yes, the GS uses food as a reward because it is a simple pleasure and it's fun. Taking away simple rewards is not the key to reducing obesity. The key in my humble opinion to reducing obesity is the reduction of two things: soda pop and other sweet drinks, and increasing outdoor time.

The art of feeding children begins in the home. The reduction of "the expected sweet" is the goal. Not every food or drink needs to be sweet. The addition of sugar to regular food is something we all need to become aware of in hopes of reducing the idea that all things must be sweet. Beginning with drink. Water is the ultimate drink because it allows the body to re-hydrate without the additions of debilitating sugar and chemicals. But why do children resist water? Because most parents resist drinking water. Children want what their parents have.

"Mommy or daddy has a soda, and I want that too!" But mommy's soda has 4 tablespoons of sugar per soda - that tells you something. "They drink so much juice, I finally went over to a powdered juice drink." So why is sugar such a monster? It wears out the body's ability to metabolize that sugar and sooner or later the body will be insulin resistant and then the possibility for diabetes has a wide open playing field.

Reducing sugar in foods is another goal. The best sweetened yogurt has 6 teaspoons of sugar in the little cup. Some cold cereals name sugar as the first ingredient. Sugar is often put in water to boil corn!!! There is sugar in canned spaghetti and boxed macaroni and cheese. Why? When a child is exposed to too much sugar, he expects everything to be sweet, and consequently he won't eat things that don't have his archetype for sweet.

In childcare, our duty as providers and teachers is to explore a balance of what nature presents in its most natural state and encourage children to learn to eat those natural foods. There are some exceptions but exceptions need balance:

Piggy Pie is a favorite of our kids, and it's sweet like barbecue, but if you serve it with whole grain noodles and fresh vegetables and milk, the sweet meat finds its way into a balance.

Syrup on pancakes is also a favorite. Our pancakes are whole grain cakes with extra bran and other extra whole grains. I make our syrup, and it's mostly water, but because it's there and looks like syrup, the kids eat it up.

Chocolate cake: Our kids love our chocolate cake. It's homemade with whole wheat flour, reduced sugar, bran, lots of cinnamon and other spices, and sometimes its full of applesauce and pumpkin.

Think about the food your child eats. But more than that, think about the drinks your child drank today. More children gain weight because of what they drink than what they eat.