Childhood 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 obesity 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 overweight 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
designed to prevent obesity in infancy and early childhood by promoting healthy early environments in settings outside the home where young children spend substantial time.1
STATEMENT OF TASK AND APPROACH
Given growing evidence on the importance of the early years for later health outcomes, 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 obesity 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 identified 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.
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 caregivers, 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 opportunity to influence the environments in which young children develop and grow.
judgment, and have the potential to make a positive contribution to the implementation 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 routines. They provide and coordinate their children’s feeding, activity, and sleep and can determine their exposure to marketing and television. Making regular visits to
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 support 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 support 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 helping families raise healthy children.
All young children share the need for healthy food, optimum physical activity, 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 effective 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 universal 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 obesity 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-
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 importance of assessing the risk for obesity in young children through growth monitoring. 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 overweight 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 energy 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 children 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 included 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 environment in communities can promote physical activity for young children and suggests 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 promotion 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 consistent with the federal Child and Adult Care Food Program (CACFP) be required for these settings. The CACFP patterns are consistent with current dietary guidelines and nutrition recommendations for promoting health by reducing the preva-
lence of inadequate or excessive intake of food, nutrients, and calories. The committee 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 associated with children’s continuing ability to regulate their caloric intake. To encourage 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 support 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, especially those with low incomes. Federal nutrition programs are effective in providing appropriate amounts of nutritious foods, but not all of those who may need these programs are participating. In many neighborhoods, moreover, it is very difficult 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 recommends 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 exposure to television advertising is associated with adiposity in young children, and substantial screen time also is associated with obesity. For these reasons, the committee 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 caregivers 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, childhood, and adolescence has occurred over the past 20 years, with the most pronounced 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
young children. Thus, the committee calls on child care providers to adopt practices that promote age-appropriate sleep duration and advocates training for health and education professionals in how to counsel parents on this issue.
Obesity prevention requires the efforts of many sectors to improve relevant policies 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 policies 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 recommendations 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.
RECOMMENDATIONS AND POTENTIAL ACTIONS
GOAL: ASSESS, MONITOR, AND TRACK GROWTH FROM BIRTH TO AGE 5.
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.
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.
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.
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.
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.
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
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.
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 coursework 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.
GOAL: PROMOTE THE CONSUMPTION OF A VARIETY OF NUTRITIOUS FOODS, AND ENCOURAGE AND SUPPORT BREASTFEEDING DURING INFANCY.
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 administrators [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.
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.
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.
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.
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.
Potential actions include
- for children that qualify, the U.S. Department of Agriculture and state agencies maximizing participation 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.
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.
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 preschoolers (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 community service agency personnel in how to provide effective counseling of parents regarding the importance of reducing screen time for young children.
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.
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 INFANCY AND EARLY CHILDHOOD.
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.
GOAL: PROMOTE AGE-APPROPRIATE SLEEP DURATIONS AMONG YOUNG CHILDREN.
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.
Health and education professionals should be trained in how to counsel parents about their children’s age-appropriate sleep durations.