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EARLY CHILDHOOD OBESITY PREVENTION POLICIES Early Childhood Obesity Prevention Policies Committee on Obesity Prevention Policies for Young Children Leann L. Birch, Lynn Parker, and Annina Burns, Editors

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THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This study was supported by Grant No. 61747, between the National Academy of Sciences and The Robert Wood Johnson Foundation. Any opinions, findings, conclusions, or recom- mendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-21024-9 International Standard Book Number-10: 0-309-21024-0 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2011 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cul- tures and religions since the beginning of recorded history. The serpent adopted as a logo- type by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: Institute of Medicine (IOM). 2011. Early Childhood Obesity Prevention Policies. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distin- guished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is au- tonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to se- cure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the fed- eral government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering commu- nities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON OBESITY PREVENTION POLICIES FOR YOUNG CHILDREN LEANN L. BIRCH (Chair), Professor and Director, Center for Childhood Obesity Research, Pennsylvania State University, University Park, Pennsylvania ALICE AMMERMAN, Professor, Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill BETTINA M. BEECH, Professor, Public Health Sciences, Wake Forest University School of Medicine, Winston Salem, North Carolina SARA BENJAMIN NEELON, Assistant Professor, Department of Community and Family Medicine, Duke University Medical Center, Durham, North Carolina LAUREL J. BRANEN, Professor, Family and Consumer Sciences, University of Idaho School of Family and Consumer Sciences, Moscow DAVID V. B. BRITT, Retired President-Chief Executive Officer, Sesame Workshop, Amelia Island, Florida DEBRA HAIRE-JOSHU, Professor and Associate Dean for Research, Washington University in St. Louis, Missouri RONALD E. KLEINMAN, Physician in Chief, Department of Pediatrics, Massachusetts General Hospital, Boston SUSAN LANDRY, Professor, Department of Pediatrics, University of Texas, Houston Medical Center LYNNE OUDEKERK, Director, Child and Adult Care Food Program, New York State Department of Health, Albany RUSSELL R. PATE, Professor, Department of Exercise Science, University of South Carolina, Columbia DAVID A. SAVITZ, Professor, Department of Community Health, Brown University, Providence, Rhode Island WENDELIN SLUSSER, Associate Clinical Professor, Department of Pediatrics, University of California at Los Angeles Schools of Medicine and Public Health ELSIE M. TAVERAS, Co-Director, Obesity Prevention Program, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts ROBERT C. WHITAKER, Professor, Center for Obesity Research and Education, Temple University, Philadelphia, Pennsylvania v

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Study Staff LYNN PARKER, Study Director (from March 2011) ANNINA CATHERINE BURNS, Study Director (until February 2011) SHEILA MOATS, Associate Program Officer (from April 2011) NICOLE FERRING HOLOVACH, Research Associate (until March 2011) GUI LIU, Senior Program Assistant (from November 2010) SAUNDRA LEE, Senior Program Assistant (until October 2010) ANTON BANDY, Financial Officer GERALDINE KENNEDO, Administrative Assistant LINDA D. MEYERS, Director, Food and Nutrition Board vi

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The pur- pose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manu- script remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Sarah E. Barlow, Associate Professor of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Houston, Texas Debbie Chang, Vice President, Policy and Prevention, The Nemours Foundation, Washington, DC Myles Faith, Assistant Professor of Psychology, University of Pennsylvania School of Medicine, Philadelphia Doris Fredericks, Executive Director, Choices for Children, San Jose, California Bernard Guyer, Professor Emeritus, Department of Population, Family and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland Dale Kunkel, Professor of Communication, University of Arizona, Tucson vii

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Trish MacEnroe, Executive Director, Baby-Friendly USA, East Sandwich, Massachusetts Alan F. Meyers, Associate Professor, Department of Pediatrics, Boston University School of Medicine, Massachusetts Lisa Pawloski, Associate Professor and Chair, Global and Community Health, George Mason University, Fairfax, Virginia Virginia A. Stallings, Jean A. Cortner Endowed Chair in Gastroenterology and Nutrition, Children’s Hospital of Philadelphia, Pennsylvania Dianne S. Ward, Professor, Department of Nutrition, University of North Carolina at Chapel Hill Dawn Wilson, Professor, Department of Psychology, University of South Carolina, Sumter Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the report’s conclu- sions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Neal A. Vanselow, Professor Emeritus, Tulane University, and Elena O. Nightingale, Scholar-in- Residence, Institute of Medicine. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully consid- ered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. viii Reviewers

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Preface T he obesity epidemic has not spared even the nation’s youngest children; about 20 percent of children are already overweight or obese before they enter school, and rates are even higher among low-income children and among African American and Latino children. These statistics are of particular concern because, contrary to popular belief, children do not “grow out of” their “baby fat.” Evidence indicates that excessive weight gain in the first years of life can alter developing neural, metabolic, and behavioral systems in ways that increase the risk for obesity and chronic disease later in life. Although few attempts have been made to prevent obesity during the first years of life, this period may represent the best opportunity for obesity prevention. During infancy and early childhood, lifestyle behaviors that promote obesity are just being learned, and it is easier to establish new behaviors than to change existing ones. This report is one of a series of publications dedicated to providing suc- cinct information on childhood obesity prevention specifically for policy makers. Funded by The Robert Wood Johnson Foundation, the report addresses some of the same themes as previous Institute of Medicine (IOM) reports on obesity (including Local Government Actions to Prevent Childhood Obesity and Bridging the Evidence Gap in Obesity Prevention), but focuses on young children from birth to age 5. A number of key factors influence the risk for obesity in an infant or young child, including prenatal influences, eating patterns, physical activity and sedentary behavior, sleep patterns, and marketing and screen time. Young children are dependent on parents, caregivers, and others to provide environments that can ix

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help shape these factors in positive ways by, for example, supporting the develop- ment of lifestyle behaviors that promote growth and development, making healthy foods available in appropriate amounts, and providing safe places for active play. Moreover, all of these factors come into play in the policy environment that sur- rounds and influences parents and children and must be addressed in a coordinat- ed manner if progress is to be made against the early onset of childhood obesity. This report addresses all of these factors and offers policy recommenda- tions that together form an action plan for addressing obesity in young children. It focuses on the environments in which young children spend their time and is directed at the adults who shape those environments. Parents play the primary role in shaping children’s development and influencing their obesity risk through genetics and home environments. However, the focus of this report is on poli- cies that are developed and implemented by policy makers and by caregivers who interact with parents and young children. Thus the report’s recommendations are not made directly to parents but to these “intermediaries,” to ensure that early childhood obesity prevention policies are implemented in a way that complements and supports parents’ efforts to maintain healthy weight in their young children. In particular, it is the committee’s hope that the report will find its way to federal, state, and local government policy makers who work in areas that impact young children in infancy and early childhood. The committee attempted to make the report user-friendly so that what we have learned about obesity prevention for young children can be put to good use in efforts to improve the present and future health of the nation’s children. I want to express my sincere appreciation to the other committee members for their commitment to our task and the countless volunteer hours they con- tributed to this study and the development of the report. I also want to thank our workshop speakers for their insight and perspectives on preventing obesity in the first years of life. In addition, many thanks to Rona Briere for her editing of the report. Finally, I want to express my gratitude to the dedicated IOM staff who worked with the committee on this project: Annina Catherine Burns, study director; Nicole Ferring Holovach, research associate; Gui Liu, senior program assistant; Sheila Moats, associate program officer; Lynn Parker, scholar; and Linda Meyers, director, Food and Nutrition Board. Leann L. Birch, Chair Committee on Obesity Prevention Policies for Young Children x Preface

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Contents SUMMARY 1 1 INTRODUCTION 17 Obesity in Early Childhood, 19 Purpose and Scope of the Report, 22 Study Approach, 24 Organization of the Report, 30 References, 30 2 ASSESSING RISK FOR OBESITY IN YOUNG CHILDREN 35 Goal: Assess, Monitor, and Track Growth from Birth to Age 5, 35 Growth Monitoring, 35 Prenatal Influences, 45 References, 52 3 PHYSICAL ACTIVITY 59 Goal: Increase Physical Activity in Young Children, 60 Goal: Decrease Sedentary Behavior in Young Children, 70 Goal: Help Adults Increase Physical Activity and Decrease Sedentary Behavior in Young Children, 72 References, 76 xi

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4 HEALTHY EATING 85 Goal: Promote the Consumption of a Variety of Nutritious Foods, and Encourage and Support Breastfeeding During Infancy, 86 Goal: Create a Healthy Eating Environment That Is Responsive to Children’s Hunger and Fullness Cues, 98 Goal: Ensure Access to Affordable Healthy Foods for All Children, 101 Goal: Help Adults Increase Children’s Healthy Eating, 107 References, 108 5 MARKETING AND SCREEN TIME 119 Goal: Limit Young Children’s Screen Time and Exposure to Food and Beverage Marketing, 120 Goal: Use Social Marketing to Provide Consistent Information and Strategies for the Prevention of Obesity in Infancy and Early Childhood, 126 References, 129 6 SLEEP 135 Goal: Promote Age-Appropriate Sleep Durations Among Children, 135 References, 142 APPENDIXES A METHODS 149 B EMERGING ISSUES IN EARLY CHILDHOOD OBESITY PREVENTION 153 C GLOSSARY 157 D ACRONYMS 163 E WORKSHOP AGENDA AND SPEAKER BIOGRAPHICAL SKETCHES 165 F BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS 173 INDEX 183 xii Contents