Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 1
Summary
C hildhood obesity is a serious health problem that has adverse and long-lasting
consequences for individuals, families, and communities. The magnitude of
the problem has increased dramatically over the past three decades and, despite
some indications of a plateau in this growth, the numbers remain stubbornly high.
Efforts to prevent childhood obesity to date have focused largely on school-age
children, with relatively little attention to children under age 5. However, there is
a growing awareness that efforts to prevent childhood obesity must begin before
children ever enter the school system.
The first years of life are important to health and well-being throughout
the life span. Preventing obesity in infants and young children holds promise for
enabling significant gains toward both reversing the epidemic of childhood obe-
sity and reducing obesity in adulthood. According to data from the Centers for
Disease Control and Prevention, the obesity epidemic has not spared the nation’s
youngest children: about 10 percent of infants and toddlers have high weight-for-
length, and slightly more than 20 percent of children aged 2–5 are already over-
weight or obese. Contrary to the common notion that children will “grow out of
it,” childhood obesity tends to persist into later life and can increase the risk for
obesity-related disease in adulthood.
Environmental factors can profoundly affect children’s development and
obesity risk in the first years of life, when patterns of eating, physical activity,
and sleep are developing, patterns that continue to influence obesity, health, and
well-being throughout life. Accordingly, this report offers policy recommendations
1
OCR for page 2
designed to prevent obesity in infancy and early childhood by promoting healthy
early environments in settings outside the home where young children spend sub-
stantial time.1
STATEMENT OF TASK AND APPROACH
Given growing evidence on the importance of the early years for later health out-
comes, the Institute of Medicine’s (IOM’s) Standing Committee on Childhood
Obesity Prevention recommended a study to examine the evidence and provide
guidance on obesity prevention policies for young children from birth to age 5.
The Committee on Obesity Prevention Policies for Young Children was formed to
conduct this study. See Box S-1 for the committee’s full statement of task.
The committee formulated its recommendations using the best evidence
available, including both direct and indirect evidence about the likely impact of a
given policy on reducing childhood obesity. The committee reviewed the published
literature; examined reports from organizations that work with young children;
invited presentations from experts on a range of scientific, programmatic, and
policy issues related to children from birth to age 5; and explored a variety of
materials that have been developed for programs and practitioners. The committee
gave strong observational studies serious consideration and was also receptive to
evidence that a policy would be likely to affect a determinant of childhood obe-
sity even if not yet studied for its direct influence on obesity. Thus, for example,
the committee recommends policy changes that are expected to increase physical
activity or promote more healthy eating in children because such intermediate
outcomes are themselves associated with prevention of childhood obesity. The
committee also drew on the extensive experience and expertise of its members in
child development, obesity prevention, child health, nutrition, infant development,
physical activity, pediatrics, child psychology and behavior, child care regulations
and policy, food marketing and media, health disparities, family health, federal
and state children’s programs, and community health.
In addition to formulating policy recommendations, the committee identi-
fied potential actions that could be taken to implement those recommendations.
These actions lie within the purview of relevant decision makers, were determined
to be actionable based on a combination of precedent and committee members’
1In this report, the term “young children” refers to ages birth to 5 years.
Early Childhood Obesity Prevention Policies
2
OCR for page 3
Box S-1
Statement of Task
An ad hoc committee will review factors related to overweight and obesity in infants, toddlers, and
preschool children (birth to 5 years), with a focus on nutrition, physical activity, and sedentary behavior;
identify gaps in knowledge; and make recommendations on early childhood obesity prevention policies,
taking into account the differences between children birth to 2 years old and 2 to 5 years old.
In conducting its task, this committee will:
• Draw on primary and secondary sources to assess evidence on the:
— major factors affecting obesity risk in young children, including the relationship with caregiv-
ers, physical activity opportunities and barriers, access to healthy foods, social determinants,
and other important factors;
— major factors in the first 5 years that affect attitudes, preferences, and behaviors important to
overweight and obesity; and
— relationships between elevated weight status and excess weight gain in young children and
their health and well-being during childhood and risk for obesity-related comorbidities, across
the life course.
• Identify settings, existing programs, and policy opportunities for childhood obesity prevention
efforts in the first 5 years;
• Consider the inclusion of illustrative case studies; and
• Make recommendations on early childhood obesity prevention policies across a range of settings
and types of programs, taking into account potential distinctions between policy recommendations
for the first 2 years (birth to 2 years) and those developed for the next 3 years (2 to 5 years).
The primary audience of the report includes decision makers and stakeholders who have the opportu-
nity to influence the environments in which young children develop and grow.
judgment, and have the potential to make a positive contribution to the implemen-
tation of the committee’s recommendations.
In developing its recommendations, the committee recognized that parents
and families have the greatest influence on the development and behaviors that
shape health outcomes in children from birth to age 5. Parents and families make
decisions and take actions that determine their children’s daily schedule and rou-
tines. They provide and coordinate their children’s feeding, activity, and sleep and
can determine their exposure to marketing and television. Making regular visits to
3
Summary
OCR for page 4
health care providers and acting on feedback regarding a child’s health are usually
the responsibility of parents and families.
The committee’s task was to focus on policies that would promote and sup-
port obesity prevention among young children. The committee’s recommendations
target policies that influence the programs, institutions, settings, and environments
that shape children’s activities and behaviors. By definition, these policies are
likely to be developed and implemented by individuals and institutions outside of
the home setting. Thus the recommendations in this report target those who sup-
port parents and families in taking care of young children and those who can play
a role in improving young children’s environments outside of the home. These
include state and local regulators of child care, child care providers, health care
providers, and directors of federal and local child care and nutrition programs,
as well as members of the broader community that influence the environments of
young children. These policies can be an important part of the coordination of
care and consistent messages about child health that are critical to success in help-
ing families raise healthy children.
All young children share the need for healthy food, optimum physical activ-
ity, sufficient sleep, health care providers who monitor their growth for healthy
patterns and advise and assist their parents in following through, and protection
from the negative influences of too much sedentary behavior and marketing of
unhealthy foods and beverages to children. Nonetheless, in developing obesity
prevention recommendations and implementation strategies that will be effec-
tive for young children and their families, the committee recognized the potential
impact of negative social and economic factors in some communities that can act
as barriers to a recommendation’s success. The committee therefore attempted to
formulate recommendations to caregivers and policy makers that would be univer-
sal with respect to the optimal health of young children but also feasible through
creative adaptation in many different settings with families at all socioeconomic
levels.
CONTEXT FOR THE COMMITTEE’S RECOMMENDATIONS
This report and the committee’s recommendations address the assessment of obe-
sity risk through growth monitoring, as well as key factors that influence obesity
risk in young children—physical activity, healthy eating, marketing and screen
time, and sleep. Although the committee’s charge was to focus on children from
birth to age 5, the report also includes a discussion of prenatal influences to high-
Early Childhood Obesity Prevention Policies
4
OCR for page 5
light prior IOM recommendations and the fact that obesity prevention starts with
the health of the mother.
The first set of recommendations in the report has to do with the impor-
tance of assessing the risk for obesity in young children through growth monitor-
ing. Infants and young children are weighed and their length or height recorded as
part of routine well-child visits to the pediatrician or other health care provider.
These visits offer the earliest opportunity to track children who are at risk of over-
weight or obesity, and can provide the physician and the child’s parents with an
early opportunity to take preventive action.
Because energy expenditure through physical activity is one side of the ener-
gy balance equation that determines whether healthy weight can be developed and
maintained, the committee identified it as an important area to explore. Society
has changed in multiple ways that have reduced physical activity and increased
sedentary activities, and these trends are evident even in the youngest children.
The relationships among weight status, physical activity, and sedentary behavior
are not fully understood in young children, but some evidence suggests that higher
levels of physical activity are associated with a reduced risk of excessive weight
gain over time in younger children, and similar evidence is extensive in older chil-
dren and adults. The committee’s recommendations in this area call for increasing
young children’s physical activity and decreasing their sedentary behavior in child
care settings and call on health care providers and educators to counsel parents on
how to accomplish these goals at home. Recommendations for infants are includ-
ed in an effort to highlight the need to begin obesity prevention practices in early
life. In a related recommendation, the committee stresses that the built environ-
ment in communities can promote physical activity for young children and sug-
gests actions that can be taken to this end, including ensuring the availability of
indoor and outdoor recreation areas that encourage all children, including infants
and children with disabilities, to be physically active.
The committee’s recommendations for healthy eating begin with the pro-
motion of and support for breastfeeding. Although causality cannot be inferred,
breastfeeding is associated with a reduction in obesity risk in childhood. The next
set of recommendations has to do with the feeding of young children in child care
settings, because at least half of children under age 5 receive out-of-home care
while their parents work. Here the committee recommends that meal patterns con-
sistent with the federal Child and Adult Care Food Program (CACFP) be required
for these settings. The CACFP patterns are consistent with current dietary guide-
lines and nutrition recommendations for promoting health by reducing the preva-
5
Summary
OCR for page 6
lence of inadequate or excessive intake of food, nutrients, and calories. The com-
mittee also recommends that the practice of responsive feeding be required in child
care settings. Evidence supports the presence of self-regulation abilities in young
children, and the degree of responsiveness of caregivers to child feeding is associ-
ated with children’s continuing ability to regulate their caloric intake. To encour-
age translation of these recommendations to home settings, training for health and
education professionals in how to provide guidance to parents on healthy eating
also is recommended.
The committee’s recommendations call on government at all levels to sup-
port healthy eating among young children through guidelines and promotion
efforts. For example, the Dietary Guidelines for Americans form the basis for
nutrition recommendations for public and federal programs but do not include
guidelines for children under 2 years of age. Such guidelines also are critical as
a basis for national dietary intake studies. In addition, government agencies are
called upon to promote access to affordable healthy foods for all families, espe-
cially those with low incomes. Federal nutrition programs are effective in provid-
ing appropriate amounts of nutritious foods, but not all of those who may need
these programs are participating. In many neighborhoods, moreover, it is very dif-
ficult for families to find accessible and affordable healthy foods for their young
children.
The lives of young children are permeated by media—television, videos,
digital media, video games, mobile media, and the Internet. The committee rec-
ommends limitations on screen time for children 2 to 5 years old because of its
potential for contributing to childhood obesity. There is strong evidence that expo-
sure to television advertising is associated with adiposity in young children, and
substantial screen time also is associated with obesity. For these reasons, the com-
mittee recommends that health care providers counsel parents and other caregivers
of children not to permit television, computers, or other digital media devices in
children’s sleeping areas. Finally, a positive use of media is proposed—a sustained
social marketing campaign to provide consistent messages to parents and caregiv-
ers of young children on obesity prevention strategies. Such campaigns can be
effective for disseminating information and producing changes in behavior.
Finally, evidence suggests that a decrease in sleep duration in infancy, child-
hood, and adolescence has occurred over the past 20 years, with the most pro-
nounced decreases seen among children less than 3 years of age. Epidemiologic
evidence indicates that short sleep duration may be a risk factor for obesity among
Early Childhood Obesity Prevention Policies
6
OCR for page 7
young children. Thus, the committee calls on child care providers to adopt practic-
es that promote age-appropriate sleep duration and advocates training for health
and education professionals in how to counsel parents on this issue.
CONCLUSION
Obesity prevention requires the efforts of many sectors to improve relevant poli-
cies and practices. Interactions among institutions, programs, settings, and families
can be effective in promoting and sustaining a healthy environment for young
children. Infants, toddlers, and preschoolers are dependent upon the actions of the
adults who care for them, and they should be cared for in a manner that promotes
their healthy growth, development, and well-being throughout their day. The poli-
cies that influence young children’s environments inside and outside their homes
should make the healthy choices the easy choices for adults who care for them.
Finally, as new policies to prevent childhood obesity are implemented, it
will be important to evaluate them to (1) support further action where success can
be demonstrated, (2) reconsider policies when they fail to achieve the intended
outcome, and (3) identify any unintended adverse consequences. As new evidence
emerges, moreover, it will be important to examine the committee’s recommenda-
tions and make needed revisions. It is important to act today based on what is
known, while also undertaking the necessary research and policy evaluation to
ensure better informed and effective actions in the future.
7
Summary
OCR for page 8
RECOMMENDATIONS AND POTENTIAL ACTIONS
GOAL: ASSESS, MONITOR, AND TRACK GROWTH FROM BIRTH TO AGE 5.
Recommendation 2-11
Health care providers should measure weight and length or height in a
standardized way, plotted on World Health Organization growth charts (ages
0–23 months) or Centers for Disease Control and Prevention growth charts
(ages 24-59 months), as part of every well-child visit.
Recommendation 2-2
Health care professionals should consider (1) children’s attained weight-for-
length or body mass index at or above the 85th percentile, (2) children’s rate
of weight gain, and (3) parental weight status as risk factors in assessing which
young children are at highest risk of later obesity and its adverse consequences.
GOAL: INCREASE PHYSICAL ACTIVITY IN YOUNG CHILDREN.
Recommendation 3-1
Child care regulatory agencies should require child care providers and early
childhood educators to provide infants, toddlers, and preschool children with
opportunities to be physically active throughout the day.
For infants, potential actions include
• providing daily opportunities for infants to move freely under adult supervision to explore their
indoor and outdoor environments;
engaging with infants on the ground each day to optimize adult-infant interactions; and
•
• providing daily “tummy time” (time in the prone position) for infants less than 6 months of age.
1The committee’s recommendations are numbered according to the chapter in the main text of the report
in which they appear. Thus, for example, recommendation 2-1 is the first recommendation in Chapter 2.
Early Childhood Obesity Prevention Policies
8
OCR for page 9
For toddlers and preschool children, potential actions include
• providing opportunities for light, moderate, and vigorous physical activity for at least 15 minutes per
hour while children are in care;
• providing daily outdoor time for physical activity when possible;
• providing a combination of developmentally appropriate structured and unstructured physical activity
experiences;
• joining children in physical activity;
• integrating physical activity into activities designed to promote children’s cognitive and social
development;
• providing an outdoor environment with a variety of portable play equipment, a secure perimeter,
some shade, natural elements, an open grassy area, varying surfaces and terrain, and adequate space
per child;
• providing an indoor environment with a variety of portable play equipment and adequate space per
child;
• providing opportunities for children with disabilities to be physically active, including equipment that
meets the current standards for accessible design under the Americans with Disabilities Act;
• avoiding punishing children for being physically active; and
• avoiding withholding physical activity as punishment.
Recommendation 3-2
The community and its built environment should promote physical activity for
children from birth to age 5.
Potential actions include
• ensuring that indoor and outdoor recreation areas encourage all children, including infants, to be
physically active;
• allowing public access to indoor and outdoor recreation areas located in public education facilities;
and
• ensuring that indoor and outdoor recreation areas provide opportunities for physical activity that
meet current standards for accessible design under the Americans with Disabilities Act.
GOAL: DECREASE SEDENTARY BEHAVIOR IN YOUNG CHILDREN.
Recommendation 3-3
Child care regulatory agencies should require child care providers and early
childhood educators to allow infants, toddlers, and preschoolers to move
freely by limiting the use of equipment that restricts infants’ movement and by
9
Summary
OCR for page 10
implementing appropriate strategies to ensure that the amount of time toddlers
and preschoolers spend sitting or standing still is limited.
Potential actions include
• using cribs, car seats, and high chairs for their primary purpose only—cribs for sleeping, car seats for
vehicle travel, and high chairs for eating;
• limiting the use of equipment such as strollers, swings, and bouncer seats/chairs for holding infants
while they are awake;
• implementing activities for toddlers and preschoolers that limit sitting or standing to no more than 30
minutes at a time; and
• using strollers for toddlers and preschoolers only when necessary.
GOAL: HELP ADULTS INCREASE PHYSICAL ACTIVITY AND DECREASE
SEDENTARY BEHAVIOR IN YOUNG CHILDREN.
Recommendation 3-4
Health and education professionals providing guidance to parents of young
children and those working with young children should be trained in ways to
increase children’s physical activity and decrease their sedentary behavior, and
in how to counsel parents about their children’s physical activity.
Potential actions include
• colleges and universities that offer degree programs in child development, early childhood education,
nutrition, nursing, physical education, public health, and medicine requiring content within course-
work on how to increase physical activity and decrease sedentary behavior in young children;
• child care regulatory agencies encouraging child care and early childhood education programs to seek
consultation yearly from an expert in early childhood physical activity;
• child care regulatory agencies requiring child care providers and early childhood educators to be
trained in ways to encourage physical activity and decrease sedentary behavior in young children
through certification and continuing education; and
• national organizations that provide certification and continuing education for dietitians, physicians,
nurses, and other health professionals (including the American Dietetic Association and the American
Academy of Pediatrics) including content on how to counsel parents about children’s physical activity
and sedentary behaviors.
Early Childhood Obesity Prevention Policies
10
OCR for page 11
GOAL: PROMOTE THE CONSUMPTION OF A VARIETY OF NUTRITIOUS FOODS,
AND ENCOURAGE AND SUPPORT BREASTFEEDING DURING INFANCY.
Recommendation 4-1
Adults who work with infants and their families should promote and support
exclusive breastfeeding for 6 months and continuation of breastfeeding in
conjunction with complementary foods for 1 year or more.
Potential actions include
• hospitals and other health care delivery settings improving access to and availability of lactation care
and support by implementing the steps outlined in the Baby-Friendly Hospital Initiative and following
American Academy of Pediatrics policy recommendations;
• hospitals enforcing the World Health Organization’s International Code of Marketing of Breast Milk
Substitute (This step includes ensuring that hospitals’ informational materials show no pictures or text
that idealizes the use of breast milk substitutes; that health professionals give no samples of formula
to mothers [this can be complied with through the Baby-Friendly Hospital Initiative]; and that the
Federal Communications Commission, the Department of Health and Human Services, hospital admin-
istrators [through the Baby-Friendly Hospital Initiative], health professionals, and grocery and other
stores are required to follow Article 5, “The General Public and Mothers,” which states that there
should be no advertising or promotion to the general public of products within the scope of the code
[i.e., infant formula]);
• the Special Supplemental Nutrition Program for Women, Infants, and Children, the Child and Adult
Care Food Program, Early Head Start, other child care settings, and home visitation programs requiring
program staff to support breastfeeding; and
• employers reducing the barriers to breastfeeding through the establishment of worksite policies that
support lactation when mothers return to work.
Recommendation 4-2
To ensure that child care facilities provide a variety of healthy foods and age-
appropriate portion sizes in an environment that encourages children and staff
to consume a healthy diet, child care regulatory agencies should require
that all meals, snacks, and beverages served by early childhood programs be
consistent with the Child and Adult Care Food Program meal patterns and that
safe drinking water be available and accessible to the children.
11
Summary
OCR for page 12
Recommendation 4-3
The Department of Health and Human Services and the U.S. Department of
Agriculture should establish dietary guidelines for children from birth to age
2 years in future releases of the Dietary Guidelines for Americans.
GOAL: CREATE A HEALTHY EATING ENVIRONMENT THAT IS RESPONSIVE TO
CHILDREN’S HUNGER AND FULLNESS CUES.
Recommendation 4-4
State child care regulatory agencies should require that child care providers
and early childhood educators practice responsive feeding.
Potential actions include
• for infants—holding infants in one’s arms or sitting up on one’s lap while feeding and not propping
bottles, recognizing infant feeding cues (e.g., rooting, sucking), offering an age-appropriate volume
of breast milk or formula to infants and allowing infants to self-regulate their intake, and introducing
developmentally appropriate solid foods in age-appropriate portions and allowing all infants to self-
regulate their intake; and
• for toddlers/preschoolers—providing meals and snacks as part of a daily routine, requiring adults to
sit with and eat the same foods as the children, allowing children to serve themselves when serving
from common bowls (family-style service), providing age-appropriate portions and allowing children
to determine how much they eat when offering foods that are served in units (e.g., sandwiches), and
reinforcing children’s internal cues of hunger and fullness.
GOAL: ENSURE ACCESS TO AFFORDABLE HEALTHY FOODS FOR ALL
CHILDREN.
Recommendation 4-5
Government agencies should promote access to affordable healthy foods for
infants and young children from birth to age 5 in all neighborhoods, including
those in low-income areas, by maximizing participation in federal nutrition
assistance programs and increasing access to healthy foods at the community
level.
Early Childhood Obesity Prevention Policies
12
OCR for page 13
Potential actions include
• for children that qualify, the U.S. Department of Agriculture and state agencies maximizing participa-
tion in federal nutrition assistance programs serving children from birth to age 5, including the Special
Supplemental Nutrition Program for Women, Infants, and Children, the Child and Adult Care Food
Program, and the Supplemental Nutrition Assistance Program; and
• the federal government assisting state and local governments in increasing access to healthy foods.
GOAL: HELP ADULTS INCREASE CHILDREN’S HEALTHY EATING.
Recommendation 4-6
Health and education professionals providing guidance to parents of
young children and those working with young children should be trained and
educated and have the right tools to increase children’s healthy eating and
counsel parents about their children’s diet.
GOAL: LIMIT YOUNG CHILDREN’S SCREEN TIME AND EXPOSURE TO FOOD
AND BEVERAGE MARKETING.
Recommendation 5-1
Adults working with children should limit screen time, including television, cell
phones, or digital media, to less than 2 hours per day for children aged 2-5.
Potential actions include
• child care settings limiting screen time, including television, cell phones, or digital media, for pre-
schoolers (aged 2–5) to less than 30 minutes per day for children in half-day programs or less than 1
hour per day for those in full-day programs;
• health care providers counseling parents and children’s caregivers to permit no more than a total of
2 hours per day of screen time, including television, cell phones, or digital media, for preschoolers,
including time spent in child care settings and early childhood education programs;
• health care providers counseling parents to coordinate with child care providers and early childhood
education programs to ensure that total screen time limits are not exceeded between at-home and
child care or early education settings; and
• state and local government agencies providing training, tools, and technical assistance for child care
providers, early childhood education program teachers and assistants, health care providers, and com-
munity service agency personnel in how to provide effective counseling of parents regarding the
importance of reducing screen time for young children.
13
Summary
OCR for page 14
Recommendation 5-2
Health care providers should counsel parents and children’s caregivers not
to permit televisions, computers, or other digital media devices in children’s
bedrooms or other sleeping areas.
Recommendation 5-3
The Federal Trade Commission, the U.S. Department of Agriculture, the
Centers for Disease Control and Prevention, and the Food and Drug
Administration should continue their work to establish and monitor the
implementation of uniform voluntary national nutrition and marketing standards
for food and beverage products marketed to children.
GOAL: USE SOCIAL MARKETING TO PROVIDE CONSISTENT INFORMATION
AND STRATEGIES FOR THE PREVENTION OF CHILDHOOD OBESITY IN
I NFANCY AND EARLY CHILDHOOD.
Recommendation 5-4
The Secretary of Health and Human Services, in cooperation with state and
local government agencies and interested private entities, should establish a
sustained social marketing program to provide pregnant women and caregivers
of children from birth to age 5 with consistent, practical information on the risk
factors for obesity in young children and strategies for preventing overweight
and obesity in this population.
Early Childhood Obesity Prevention Policies
14
OCR for page 15
GOAL: PROMOTE AGE-APPROPRIATE SLEEP DURATIONS AMONG YOUNG
CHILDREN.
Recommendation 6-1
Child care regulatory agencies should require child care providers to adopt
practices that promote age-appropriate sleep durations among young children.
Potential actions include
• creating environments that ensure restful sleep, such as no screen media in rooms where children
sleep and low noise and light levels during napping;
• encouraging sleep-promoting behaviors and practices, such as calming nap routines;
• encouraging practices that promote child self-regulation of sleep, including putting infants to sleep
drowsy but awake; and
• seeking consultation yearly from an expert on healthy sleep durations and practices.
Recommendation 6-2
Health and education professionals should be trained in how to counsel
parents about their children’s age-appropriate sleep durations.
15
Summary
OCR for page 16
