The problem. By the mid 2000s, nearly 25 percent of U.S. children ages two to five years were overweight or obese. The large number of children this age in child care—nearly 74 percent in 2002—put child-care providers in a unique position to support healthy eating and promote physical activity in young children.
But little was known about state regulations that governed child-care centers. Did states have regulations related to healthy eating requirements and physical activity? If so, what were these regulations?
The proposal. Sara E. Benjamin Neelon, Ph.D., M.P.H., R.D., is an assistant professor in the Department of Community and Family Medicine at Duke University School of Medicine and the Duke Global Health Institute. "My passion has always been children, from birth to five-year-olds," she said.
In 2002, Benjamin Neelon, a former nutritionist for Head Start and the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), became interested in learning what children eat in child care. At the time, she was a graduate student in the Department of Nutrition at the University of North Carolina at Chapel Hill.
"Child-care providers were telling me that various things were required by state regulations, such as serving whole milk to children, and I remember thinking, 'that can't be right,'" she recalled. "There were a lot of 'urban legends' about what providers were and were not allowed to do. I starting gathering and reading regulations to learn about North Carolina's child-care regulations and also to see how they compared with other states."
After receiving her Master in Public Health degree and her doctorate in nutrition from the schools of public health and medicine at the University of North Carolina at Chapel Hill, in 2007 Benjamin Neelon accepted a post-doctoral research fellowship at Harvard Medical School with the Department of Population Medicine's Obesity Prevention Program. She wanted to learn more about state regulations related to healthy eating and physical activity for child-care facilities and ways to improve them.
The project. In 2008, Benjamin Neelon and colleagues in Harvard's Department of Population Medicine, Jonathan Finkelstein, M.D., M.P.H., and Matthew Gillman, M.D., S.M., received a grant from the Robert Wood Johnson Foundation (RWJF) Healthy Eating Research program to do just that. Healthy Eating Research supports research on environmental and policy strategies to promote healthy eating among children to prevent childhood obesity.
From September 2008 through August 2009, Benjamin Neelon and Finkelstein worked together on the Healthy Eating Research project. They had three goals:
- To review state regulations related to healthy eating and physical activity for child-care facilities
- To develop healthy eating and physical activity regulations to guide the creation or revision of state child-care regulations to make them stronger
- To disseminate these model regulations to the states
Working with Finkelstein, Gillman and two part-time research assistants, Benjamin Neelon first researched healthy eating and physical activity standards for children ages 2 to 5, as the baseline for reviewing existing state regulations. Benjamin Neelon then reviewed child-care regulations in all 50 states, the District of Columbia, Puerto Rico, the Virgin Islands and the U.S. Department of Defense (hereafter referred to as states). She discovered that regulations vary considerably from state to state.
For the next phase of the study, Benjamin Neelon and her colleagues developed model healthy eating and physical activity regulations for child care, relying on input from a group experts in nutrition, physical activity, early child care and education, and policy and regulation that she assembled. These experts developed 10 model healthy eating regulations and 10 model physical activity regulations for child-care settings, focused on creating standards "with the greatest potential to improve weight status in children in child care," she said.
One model healthy eating regulation, for example, states that, "high fat, high sugar and high salt foods are served less than one time per week or are not served." And one model physical activity regulation is, "children are provided with 60 minutes of physical activity per day in care, a combination of both teacher-led and free play."
Benjamin Neelon and her colleagues used these 20 model regulations to evaluate each state's child-care regulations related to healthy eating and physical activity.
Results. Benjamin Neelon noted these key findings from the Healthy Eating Research study in a 2009 report posted on Duke University's Web site titled Preventing Obesity in the Child Care Setting: Evaluating State Regulations:
- Most states had few regulations related to obesity prevention for child-care centers and family child-care homes (where care is offered in an individual's home), leaving much room for improvement. No state had all 10 model healthy eating regulations or all 10 model physical activity regulations.
- When it came to healthy eating regulations, states had an average of 3.7 regulations for child-care centers and 2.9 regulations for family child-care homes. The states had even fewer physical activity regulations: An average of 3.5 regulations for child-care centers and 2.6 regulations for family child-care homes.
- Georgia and Nevada ranked highest for healthy eating and physical activity regulations. South Dakota, Puerto Rico and Idaho ranked lowest (Idaho has since revised its regulations).
Preventing Obesity in the Child Care Setting: Evaluating State Regulations also lists the 20 model healthy eating and physical activity regulations and the individual state rankings for healthy eating and physical activity regulations for each state.
Benjamin Neelon disseminated the report at conferences where she made presentations, such as at "Healthy Kids, Healthy Future: Promising Practices and Policies for Obesity Prevention and Health Promotion in Early Care and Education," a 2009 conference sponsored by RWJF, the Nemours Foundation, the Centers for Disease Control and Prevention, and the federal Maternal and Child Health Bureau.
Benjamin Neelon and her colleagues also developed individual report cards for each state, with an overall grade, separate grades for healthy eating and physical activity regulations, highlights of state strengths and weaknesses, brief findings from the nationwide study, and the 20 model healthy eating and physical activity regulations. She sent the state report cards to the appropriate officials in each state, and posted them online with the report and the model healthy eating and physical activity regulations.
One of the challenges in the study, according to Benjamin Neelon, is that states are continually updating their regulations. She called her data a "snap shot in time" but believes the study continues to have an impact; in 2011, she still receives calls from health departments, researchers and key state officials who want to understand how state regulations impact food served to children in child care.
Benjamin Neelon cautions, however, "that we have to be mindful of the financial ramifications of asking child-care facilities to spend more money on healthy food. If we make a regulation that requires child-care facilities to serve better food, we are straining the child-care facility and those additional costs could get passed on to parents or put some centers out of business."
Afterward. Benjamin Neelon joined the faculty at Duke University in 2009, where she continues to research children, healthy eating and physical activity. In 2011, she received an RWJF Active Living Research grant to evaluate a community campaign in North Carolina to encourage children and adults to be physically active. Their focus is on elementary school children. Active Living Research supports research to identify environmental factors and policies that influence physical activity. For more information see the Program Results Report.
Benjamin Neelon also notes that the researchers involved in Healthy Eating Research have created a national network of researchers interested in promoting healthy eating and physical activity in child-care facilities and often work together to publish their findings.
Benjamin Neelon served on an Institute of Medicine panel that produced a Consensus Report in June 2011, Early Childhood Obesity Prevention Policies.
RWJF perspective. The Healthy Eating Research program is part of the Foundation's efforts to reverse the childhood obesity epidemic by 2015. These efforts include improving access to affordable, healthy foods and increasing opportunities for physical activity in schools and communities across the nation.
"The Healthy Eating Research Program provides decision-makers and key policy-makers with evidence they can use to improve children's nutrition and access to healthy foods," says C. Tracy Orleans, Ph.D., Robert Wood Johnson Foundation senior scientist.
"Working in collaboration with other national research funders, we are working to build solid evidence for action, with a major focus on understanding and changing the policy and environmental drivers of childhood obesity epidemic, with a focus on the lower-income and racial/ethnic communities at highest risk. Our goal is to fund rigorous, solution-oriented studies, to build a diverse and robust network of researchers, and communicate findings effectively to inform policy and guide action. Dr. Mary Story's pioneering vision and leadership are critical to the program's success and national progress towards reversing the childhood obesity epidemic."