Introduction
Childhood obesity is a significant public health concern, with recent data indicating that a substantial proportion of young children are overweight or obese. Specifically, alarming statistics reveal that approximately one in four children between the ages of 2 and 5 are currently facing issues of excess weight. This early onset of weight problems dramatically increases their risk of continuing to struggle with obesity into adolescence and adulthood, leading to a higher likelihood of developing serious, long-term health complications. Early childhood is now recognized as a pivotal stage in the development of obesity. Therefore, implementing effective interventions focused on promoting healthy eating habits and increasing physical activity during these formative years is crucial for establishing healthy weight trajectories and preventing future health issues.
Early care and education (ECE) programs play a vital role in obesity prevention efforts. These programs, encompassing child care centers and family child care homes, are essential settings for intervention. In the United States, ECE programs cater to a large segment of the young population, with estimates suggesting that they provide care for 30–40% of children under the age of 6. Children in these programs spend a considerable amount of time in these environments, averaging around 30 hours per week. This significant time investment underscores the profound influence ECE programs and their staff have in shaping children’s health behaviors. By carefully structuring the physical and social environments in which children eat, sleep, and play, ECE settings can be instrumental in reducing obesity risks and fostering healthier lifestyles from a young age.
Recognizing the critical need for structured guidelines, various organizations are actively promoting the adoption of policies within ECE programs that support healthy eating and physical activity. Two landmark reports exemplify this movement: “Caring for Our Children’s Preventing Childhood Obesity in Early Child Care and Education Programs” and the Institute of Medicine’s (IOM) Early Childhood Obesity Prevention Policies. “Caring for Our Children” offers comprehensive best practices for nutrition, physical activity, and screen time management across all types of ECE settings. Conversely, the IOM report provides an in-depth analysis of the evidence base and offers specific policy recommendations aimed at preventing obesity in children up to 5 years old. These initiatives highlight a growing consensus on the importance of ECE programs in tackling childhood obesity.
The increasing emphasis from the public health sector on ECE-based obesity prevention underscores a critical gap: the need for more robust research in this area. A 2011 systematic review highlighted the scarcity of intervention studies in child care settings, identifying only 18 such studies, all published since 2003. While reviews have noted a recent surge in research on obesity prevention in young children, particularly in ECE settings, the body of evidence remains limited. Despite growing interest and some progress, current research is still considered nascent. This scarcity of comprehensive research emphasizes the urgent need for more studies to establish a solid evidence base. Such a foundation is essential for identifying and implementing effective, evidence-based practices and policies at the local, state, and federal levels, ultimately contributing to Preventing Childhood Obesity In Early Care And Education Programs.
In response to this pressing need, a multidisciplinary group of experts convened in the fall of 2011 to define and prioritize future research directions for obesity prevention in ECE settings. The primary goals were threefold: (1) to identify crucial policy, environmental, and behavioral factors related to diet, nutrition, physical activity, and media use within ECE environments; (2) to propose effective study designs for both intervention and policy research aimed at enhancing nutrition and physical activity environments in ECE settings; and (3) to foster the development of early-career researchers and promote diversity within the research field. This conference was made possible through funding from the National Institutes of Health (NIH), specifically the National Heart, Lung, and Blood Institute (NHLBI) and the Office of Behavioral and Social Sciences Research (OBSSR), along with additional support from the Robert Wood Johnson Foundation (RWJF), the Nemours Foundation, and the Altarum Institute. This article aims to disseminate the key research issues and priorities that emerged from this pivotal meeting, providing a roadmap for future efforts to address childhood obesity through early care and education programs.
Methods
To effectively organize the expert meeting, a planning committee was established, comprising experts in obesity prevention, nutrition, physical activity, and child care. This committee, guided by the lead authors (D.W. and M.S.), was responsible for identifying relevant topics, inviting speakers, and selecting participants. The meeting took place in Arlington, Virginia, on September 26–27, 2011, and included 43 participants. Attendees represented a diverse group, including faculty from various universities, representatives from foundations focused on child obesity prevention, delegates from NIH and the United States Department of Health and Human Services, and key leaders in ECE.
The meeting program was structured into four key sessions: (1) Introduction and overview, (2) Measurement-related issues, (3) Intervention approaches, and (4) Policy. Following these sessions, participants engaged in roundtable discussions to delve deeper into research gaps within five specific areas: diet and physical activity measurement, policy and environmental measures, intervention design, policy research, and capacity building. Each roundtable group was tasked with identifying critical research issues that warranted further investigation in their designated area. Project staff were present throughout all sessions, including the roundtable discussions, to meticulously record notes and capture the nuances of the issues raised.
Presentations from each session, along with staff notes, were compiled to create a comprehensive summary of current knowledge and key challenges in each area. These summaries were then reviewed by authors (D.W., M.S., and A.V.), who had attended all sessions to ensure accuracy and completeness. The research priorities drafted by each roundtable were cross-referenced with staff notes to confirm that all recommendations were accurately captured.
Following the meeting, an anonymous online survey was distributed to all attendees, presenting the compiled list of research priorities. This list was organized into five categories, further divided into 11 subcategories: (1) Diet and physical activity measurement (general, diet-specific, and physical activity-specific issues), (2) Environment and policy measurement, (3) Interventions (general, community-level, organizational-level, interpersonal-level, and individual-level strategies), (4) Policy research, and (5) Capacity building. Participants were asked to select the three to five recommendations they deemed “highest priority” within each category (or subcategory) and rank them by importance (high to low). A weighted score was calculated for each research issue based on the frequency of selection and the assigned level of importance. A final priority score was then determined as a percentage of the maximum possible score. This rigorous process ensured that the identified research priorities reflected the collective expertise and consensus of the meeting participants, providing a strong foundation for future research directions in preventing childhood obesity in early care and education programs.
Results
Current Knowledge and Key Issues for Future Research
Measurement of Child Diet and Physical Activity Behaviors
Experts at the meeting discussed the most effective methods for assessing children’s dietary intake and physical activity levels within ECE settings. Their presentations included the strengths and weaknesses of each method, as well as crucial areas for future research. A summary of these points is provided in Table 1.
Table 1. Measuring Child Diet and Physical Activity and ECE Programs’ Policies, Practices, and Environment
| Measurement method and description | Strengths | Weaknesses |
|---|---|---|
| Assessment of Child Diet | ||
| Weighed/measured intakes: Trained data collectors measure all foods served to or taken by each child throughout the meal. | • Most precise assessment of child’s intake | • Most intrusive method and greatest chance for subject reactivity |
| • Particularly challenging for meals served family style | ||
| • Staffing requirements make this one of the most costly methods | ||
| Meal observation: Calculation of foods eaten by each child is based on visual estimates by trained observers. | • Reasonably precise method • Trained observers can assess up to 3 children at a time, thus reducing cost | • Some subject reactivity, but less than weighed intakes |
| Plate waste: Foods provided to classroom are measured before and after meal to calculate average child consumption. | • Least subject reactivity • Least expensive method for diet assessment | • Does not provide individual estimate of intake |
| Assessment of Child Physical Activity | ||
| Proxy reports: Parent or child care provider is asked to estimate a child’s past physical activity. | • Inexpensive | • Cruder method, less precision |
| • Low participant burden | ||
| Direct observation: Trained observers rate and record children’s physical activity during a designated period of time. | • Good reliability and adequate validity • Also able to capture contextual information | • Observation period is generally limited, therefore not able to capture habitual activity |
| Accelerometers | • Objective measure of physical activity • Considered to have good reliability and validity • Low subject burden • Able to assess habitual physical activity | • Captures large amount of data which must be reduced • Disagreements about cut points and interpretation of data • More costly than other methods |
| Measurement of ECE Policies and Environment | ||
| Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC): The NAP SACC self-assessment is a brief instrument that child care providers can use to evaluate their environment, policies, and practices. | • Quick and easy to use • Minimal participant burden • Inexpensive | • Designed as part of the NAP SACC program, intended primarily as a process measure not for evaluation of effectiveness. |
| Environment and Policy Assessment and Observation (EPAO): The EPAO protocol is a comprehensive measure of the child care environment, policies, and practices, and includes a document review (90 items) and onsite observation (102 items). | • This protocol was developed as an outcome measure to assess the impact of the NAP SACC intervention but has been used by other researchers. • It is the most comprehensive measure of its kind available. • It has demonstrated reliability and validity as a measure of nutrition and physical activity policies and environmental characteristics at child care. | • Expensive to implement • Requires special training and certification of data collectors |
| The Wellness Child Care Assessment Tool (WellCCAT): The WellCCAT focuses on assessing strength and comprehensiveness of policies using 65 items from a document review. | • It has demonstrated reliability and validity as a measure of nutrition and physical activity policies and environmental characteristics at child care. | • It is less comprehensive compared to the EPAO |
| • Less expensive to implement |
Alt Text: Table summarizing methods for measuring child diet and physical activity in early care and education settings, including weighed intakes, meal observation, plate waste, proxy reports, direct observation, accelerometers, NAP SACC, EPAO, and WellCCAT, detailing strengths and weaknesses of each method.
Weighed or measured intakes, meal observations, and plate waste were identified as effective methods for estimating children’s food intake. While more precise methods often provide better data, they are also more prone to influencing behavior (subject reactivity) and are more expensive to implement. Researchers must therefore carefully consider the balance between data accuracy, cost, and practical data collection issues to meet their research objectives. The development of technology to objectively assess children’s diets, similar to accelerometers for physical activity, would significantly advance the field. Furthermore, to ensure comparability across studies, researchers need to agree upon standardized, valid measures of child diet that evaluate both the quantity and quality of food intake.
Commonly used methods for assessing children’s physical activity include accelerometers, direct observation, and proxy reports. Accelerometers are often considered the gold standard due to their objectivity. However, challenges remain in data processing and interpretation. Even as the field works toward consensus on appropriate cut-points for preschool children’s activity levels, new analytical methods like pattern recognition are emerging, which are yet to be fully applied to data from this age group. Beyond measurement techniques, a critical research need is determining the most relevant physical activity behaviors to measure in young children. Children’s activity patterns differ from adults, making adult-centric measures like moderate-to-vigorous intensity physical activity potentially less suitable as primary outcomes for preschool studies. Assessing all non-sedentary intensity levels—light, moderate, and vigorous—may be more appropriate for this age group when aiming to prevent childhood obesity in early care and education programs.
Meeting attendees emphasized the importance of developing best-practice guidelines and improving assessment methods. Best-practice guidelines for diet and physical activity assessment in ECE settings should clearly define measurable behavior targets, offer guidance on selecting appropriate tools and methods, provide advice on data analysis and interpretation, specify expected intraclass correlations for children within a center, and determine the necessary sample size for reliable assessments. Desired improvements in assessment methods include integrating measures of diet and physical activity with environmental factors, incorporating evaluations of the sociocultural environment, provider behaviors, and knowledge, and creating methods suitable for use with infants and toddlers aged 0–2 years.
Measurement of Child Care Policies and Environment
Experts reviewed the limited existing tools for assessing ECE food and physical activity environments and policies, highlighting the novelty of this research area and the numerous unresolved issues. As with child diet and physical activity assessment, choosing an instrument involves balancing data quality with cost and practicality.
Tools such as the Environment and Policy Assessment and Observation (EPAO) and the Wellness Child Care Assessment Tool (WellCCAT) have demonstrated reliability and validity. However, they require substantial training and access to proprietary instruments and training protocols. This restricted access is partly intended to maintain the quality of protocol implementation. Attendees voiced a need for both enhancements and simplifications of existing tools. Those advocating for enhancements sought to refine items assessing complex constructs—like pressuring children to eat, responsive feeding practices, and family-style meals—by adding clearer definitions and more concrete examples to improve data accuracy. Additionally, users evaluating the impact of new policies or programs wanted to assess moderating variables such as training effectiveness, caregiver adoption of new practices, and perceived barriers. There was also a call to adapt and simplify these intensive, costly methods for broader use. As part of this adaptation, researchers need to investigate how well these instruments assess child care program compliance with best-practice guidelines for nutrition and physical activity, crucial for effectively preventing childhood obesity in early care and education programs.
Child Care–Based Interventions and Policy Research
More child care-based obesity prevention interventions are essential to build a robust research base that supports the development and implementation of evidence-based policies. Intervention studies conducted to date offer valuable lessons for future research, as summarized in Table 2. A 2011 systematic review identified only 18 child care-based interventions focused on nutrition, physical activity, and/or obesity prevention. While many studies showed positive effects on targeted behaviors, only two of the five studies that assessed weight outcomes reported positive results. Future interventions should adopt multilevel strategies and explore using child care programs as hubs to connect with families, pediatricians, and other support systems. Minority populations, disproportionately affected by obesity, are critical targets for future interventions. However, these efforts must be culturally tailored to meet the specific needs of these communities. Novel frameworks and behavior change theories, such as the Behavior Change Wheel, should guide intervention development. Researchers may need to explore frameworks and theories from outside their immediate fields to enhance intervention effectiveness in preventing childhood obesity in early care and education programs.
Future intervention and policy research would also benefit from acknowledging that traditional study designs and outcome measures may not be ideal for this age group and setting. High child turnover rates in intervention studies make traditional cohort designs impractical. Policy research often necessitates natural experiments. Traditional weight outcomes, like BMI, are harder to interpret due to children’s natural growth patterns and adiposity rebound. There is no consensus on alternative measures. Future studies should include cost-effectiveness measures and monitor for unintended consequences to guide the adoption of the most efficient policies and programs aimed at preventing childhood obesity in early care and education programs.
Table 2. Issues for ECE-Based Interventions and Policy Research
| Intervention approaches |
|---|
| • Few studies have assessed weight outcomes of child care–based interventions, and less than half (2 of 5) demonstrated positive outcomes. This failure to measure an impact on child weight may be the result of a variety of issues related to intervention approach, study design, and/or measurement. |
| • Successful interventions to affect children’s behavior may require more complex strategies, such as multilevel interventions guided by the Social Ecologic Model that target child (individual level), staff (inter-personal level), and policy and environment (organizational level). |
| • New theories or multiple theories need to be applied to address the unique structure of child care settings and the multiple targets of interest (e.g., child, staff, environment, policies, parent, community). This may require that researchers look beyond their immediate fields for potential frameworks and behavior change theories to employ. |
| • The most appropriate intervention length has not been determined. Existing interventions with a child-focused component have provided anywhere between 21 and 72 hours of intervention time. |
| • Child care workers are important in changing children’s behavior, but it is unclear what level of training is needed to effectively change staff behavior. These individuals have their own health challenges. Most are low-wage earners without insurance who are at high risk for health disparities. It may be critical to address staff’s own health issues before they take on new health promotion efforts. |
| • Parent engagement is another critical component because they can be important reinforcers and/or barriers for children’s behavior. However, few studies (child care or school) provide effective models for reaching parents that take into consideration the multiple demands on parents with young children (e.g., work schedules, limited resources, cultural intrusions, child demands). |
| • Type and structure of child care setting should be considered when planning interventions. Family child care homes are smaller operations run out of the provider’s own home. Centers and faith-based programs can vary largely in size, from just a few children to more than 100. Child care programs also vary in structure. Some programs offer year-round care while others run only 9 months; some offer full-time care and others offer only part-time care; some serve food and others do not. |
| • Although most child care programs are regulated at the state level, policies vary greatly from state to state. It may be impossible to create a universally accommodating intervention, but it is important for researchers to think through these issues so that they can make informed choices when designing their intervention and selecting inclusion/exclusion criteria. |
| Intervention study designs |
| • Children are naturally clustered within classrooms and centers. Depending on the intervention, children may need to be randomized by one of these groups. |
| • Traditional cohort designs are challenging because of the high turnover rates for children enrolled in child care. Unlike schools, enrollment in child care is optional (in the United States). It is very common for parents to move children in and out of programs often due to employment changes. A more appropriate strategy may be to intervene with the child care program and to assess repeated cross-sectional samples of children over time. |
| • When selecting an outcome, researchers should remember that children 2–5 years old are going through a period of rapid growth and development. Traditional indicators of weight for height (BMI, BMI percentage, BMI z-score) are crude measures for these children. Multiple measures of height and weight would allow modeling of weight gain trajectories, but this method has high participant burden and is more costly. Waist circumference and/or sum of skinfolds may be useful alternatives; however, both are technically challenging to collect, and no norms exist for comparisons. |
| • Other issues may be choice of outcome measure, faulty design and reporting, and lack of consideration for early life determinants (e.g., birth weight, rapid infant growth rate, sleep duration) (see below). |
| Considerations when working with minority populations |
| • Minority populations, particularly African Americans, American Indians, and Hispanics, suffer disproportionately high rates of obesity, thus making them important targets for public health intervention. Nearly half (47%) of the nation’s children younger than 5 years old are from a minority group, making child care–based interventions an important avenue to reach these populations. |
| • Segregation levels for African-American and Hispanic children are higher than for their adult counterparts, despite a general reduction in segregation over the last 10 years. |
| • African-American, American Indian, and Hispanic children also have disproportionately high poverty rates (between 31% and 35%). |
| • Despite the great need, many of the ECE studies regarding policies and practices have not even reported race/ethnicity of their participants. Among those that have, it seems that policies and practices vary depending on the race/ethnicity of the provider. For example, fewer Hispanic providers report eating meals together with children (24% compared to 86% of white and Asian providers); and Hispanic providers were more likely to report making children eat foods they think are good for them (85% compared to 69% of Asians and 44% of whites). |
| • While most ECE-based obesity prevention intervention studies report race/ethnicity, many find different outcomes depending on sample characteristics (e.g., Hip-Hop to Health, Jr). |
| Policy research |
| • When assessing the impact of local, state, and federal policies, there is a wide spectrum of outcomes possible, including environment, knowledge/attitudes/beliefs, behaviors, health indicators, and disease. |
| • Structural and environmental variables include such aspects as examining the legislation enacted, funds appropriated, institutional changes (e.g., tax credits), and environmental changes. |
| • Policies can also impact knowledge, attitudes, and social norms or may change individuals’ behaviors such as diet, physical activity, sedentariness, and breastfeeding; or behaviors and practices of the organization, such as food offerings. |
| • Policy makers and researchers also need to understand how the policy impacts health indicators like child BMI, or disease prevalence such as diabetes, stroke, and cancer. |
| • Randomized controlled trials are not generally practical in “real world” policy evaluation; therefore, other designs of varying degrees of strength must be employed. These include, at the lower end, single group and posttest-only designs, whereas higher-end designs include multiple time series data collection. |
| • Even in natural experiments, it is important to capture key demographic (or other) variables, to recruit a sample large enough to provide sufficient power, and to include adequate sampling of important subgroups. |
| • Policy research studies should consider what other possible groups, sites, or situations they care to generalize to. |
| • Process evaluation is also critical to insure internal validity. It is important to capture things like the extent to which the intervention was implemented, degree to which other events or experiences outside of the policy being evaluated may have affected behavior, whether enough time elapsed between implementation and the measurement of the intended effects, and any unintended effects. |
Alt Text: Table outlining critical issues for designing effective early care and education based interventions and policy research for childhood obesity prevention, addressing intervention approaches, study designs, minority population considerations, and policy research methodologies.
Research Priorities
During the roundtable discussions, 64 research issues were identified across five key areas: diet and physical activity measurement, policy and environment measurement, interventions, policy research, and capacity building. Out of 43 conference participants, 44% responded to the follow-up online survey to prioritize these research issues. Twenty-four of these issues received a priority score of 40% or higher, as detailed in Table 3. The highest-rated research areas within each category are highlighted below.
Table 3. Research Priorities for Early Care and Education
| Research area and research gap priority rating | Priority score (%) |
|---|---|
| Measurement of Child Diet and Physical Activity | |
| Develop standard and valid measures of the quality of children’s meals and snacks while in ECE programs. | 74 |
| Enhance measures of diet and physical activity at ECE programs for 0- to 2-year-old children. | 55 |
| Develop valid and reliable measure of ECE provider behaviors related to children’s dietary intake, physical activity, and obesity risk. | 54 |
| Explore use of technology to create an objective measure of dietary intake as well as feeding behaviors in ECE settings. | 53 |
| Apply pattern recognition approaches to accelerometer data from children under 5 years to predict sedentary, light, moderate, and vigorous physical activity and energy expenditure. | 53 |
| Explore optimal cut points for accelerometer data, particularly for sedentary behaviors (e.g., television viewing, other media use). | 47 |
| Measurement of Policy and Environment | |
| Develop a standard measure or rating system for ECE nutrition and physical activity policies. | 54 |
| Develop a set of indicators (e.g., checklist) that would predict if the ECE facility was complying with the best diet and physical activity practices for all age groups. | 44 |
| Examine the environmental and policy characteristics of ECE programs to determine those characteristics that provide optimal diet and physical activity opportunities for preschoolers. | 42 |
| Develop better measures for constructs within the ECE nutrition and physical activity environment (e.g., pressuring kids to eat, responsive feeding, family style, second servings, using food or physical activity as punishment or reward). | 41 |
| Develop guidelines or recommendations for what outcomes to measure when assessing policy impact. | 40 |
| Interventions | |
| Explore how finances and financial incentives impact intervention and policy efforts. | 68 |
| Develop and evaluate child obesity intervention strategies that include collaboration of health care providers as well as ECE programs to deliver key messages to families and their children. | 66 |
| Explore the relationship between screen time (passive, interactive, educational, and noneducational) and children’s physical activity. | 65 |
| Conduct multilevel interventions using statistical methods to evaluate impact of the components at different socioecological levels (ECE facility, staff, community, parents, individual child) both individually and collectively. | 61 |
| Explore differences in dietary and physical activity behaviors of children in home care settings compared to child care center or relative care. | 49 |
| Explore strategies for engaging parents, including fathers, as partners in ECE-based promotion of healthy behaviors. | 45 |
| Explore the minimal level of intervention needed to change BMI or other health outcomes. | 42 |
| Design interventions that are cost-effective and have potential to be sustainable and generalizable. | 40 |
| Policy | |
| Evaluate the effectiveness of ECE standards across states. | 58 |
| Evaluate the cost-benefit associated with ECE policies and identify which components are necessary to effect change. | 52 |
| Assess burdens associated with existing and/or new policies and regulations on ECE and determine at what point regulations become too burdensome for ECE providers to remain in business or licensed. | 43 |
| Capacity Building | |
| Translate and simplify measurement tools for use at the local level. | 44 |
| Develop strategies for measuring the effectiveness of ECE staff training on child obesity prevention. | 44 |
Alt Text: Table listing research priorities for early care and education in childhood obesity prevention, categorized by measurement of child diet and physical activity, policy and environment, interventions, policy, and capacity building, with priority scores for each research gap.
Key Research Priorities by Category:
-
Measurement of child diet and physical activity: The highest priority, scoring 74%, was the development of standard and valid measures for assessing the quality of children’s meals and snacks in ECE programs. Other high-priority areas (scores >50%) included improving measurement tools for children aged 0–2 years, creating reliable measures of provider behaviors related to diet and activity, utilizing technology for objective diet intake measurement, and applying pattern recognition to accelerometer data.
-
Measurement of policy and environment: Developing a standard rating system for nutrition and physical activity policies in ECE settings was the top priority in this category, scoring above 50%.
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Interventions: Several intervention-related priorities scored above 60%, including exploring the impact of financial incentives, integrating healthcare providers in interventions, investigating the role of screen time, and implementing multilevel intervention strategies.
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Policy: Evaluating the effectiveness of state-level ECE policies and assessing the cost-benefits of these policies were the highest priorities, both scoring above 50%.
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Capacity building: Neither of the issues in capacity building reached a score above 50%, indicating a need for further focus in this area to support the implementation of prevention strategies.
Discussion
The expert meeting successfully identified crucial issues related to measurement strategies, intervention designs, and policy approaches for obesity prevention research in ECE settings. Recurring themes included the necessity for evidence-based policies, challenges in securing funding, and the critical selection and measurement of appropriate outcomes. The Institute of Medicine’s report on Early Childhood Obesity Prevention Policies was acknowledged as presenting “evidence-informed” recommendations, highlighting the current lack of a strong evidence base for obesity prevention in child care settings. Many states have implemented policies aimed at improving nutrition and physical activity in child care in response to the childhood obesity crisis. However, the effectiveness of many of these policies remains untested. They might have no impact or, worse, unintended negative consequences. This dynamic environment, while potentially concerning, also provides unique opportunities for “natural experiments” that researchers should leverage to advance the field of preventing childhood obesity in early care and education programs.
Current funding mechanisms present a significant obstacle to building this necessary evidence base. Securing NIH funding can be a lengthy process, often taking two or more years from project conception to award, with only a small percentage of applications being successful. Foundations offer an alternative funding source, but these grants are typically smaller and shorter-term. Assessing the long-term impact of child care-based obesity prevention interventions requires tracking children into adolescence and adulthood, which is challenging within the current funding landscape. Evaluating the long-term effectiveness of new policies and programs is critical, and researchers globally are grappling with how to address this challenge.
There is substantial interest in defining target behaviors and outcomes for evaluating the impact of interventions and policies. Traditional measures of diet (kcal/day) and physical activity (minutes of moderate to vigorous physical activity) may not always be appropriate for children under 5. This age is characterized by rapid growth and development, and caloric intake fluctuates with growth spurts. Young children’s physical activity patterns are also distinct from adults. Focusing on providing opportunities for active play and measuring non-sedentary time might be more relevant targets and outcomes. Physical activity guidelines from the UK, Canada, and Australia for early childhood emphasize limiting sedentary time and promoting non-sedentary activities. Beyond weight, nutrition, and physical activity, researchers should consider incorporating developmental outcomes such as academic performance, cognitive ability, and quality of life. Studies in school-aged children have shown that overweight and obese children are more likely to have poorer academic performance and cognitive function. These educational disparities may be partly due to increased school absenteeism and behavioral issues associated with childhood overweight. Positive findings from interdisciplinary studies can foster collaborations between public health, child development, and education professionals, strengthening advocacy for disseminating effective obesity prevention programs and policies aimed at preventing childhood obesity in early care and education programs.
Conclusions
Creating environments that foster healthy eating and regular physical activity early in life, before poor habits become ingrained, is crucial for effective obesity prevention. However, research in ECE settings is still in its early stages. This expert meeting, bringing together researchers, national health agency leaders, and ECE professionals, used a conference format to explore critical research issues in diet and physical activity measurement, ECE environment and policy measurement, intervention and policy research, and strategies for reaching children from minority families. Through meticulous recording and analysis of conference discussions and roundtable sessions, 64 research gaps in this area were identified. A subsequent online survey further refined these into 24 priority research areas encompassing diet, physical activity, environment/policy measurement, intervention development and evaluation, policy research, and capacity building.
Increased efforts are needed to encourage funders, including federal agencies like NIH, CDC, and USDA, and foundations like RWJF and the American Heart Association, to recognize the vital role of early care and education settings in the fight against obesity. Further research in this area will be instrumental in identifying the most promising interventions and strategies to promote healthy eating and physical activity in child care settings, ultimately contributing to preventing childhood obesity in early care and education programs and improving long-term health outcomes for children.
Acknowledgments
This project was supported by grants from the NIH’s National Heart, Lung and Blood Institute and Office of Behavioral and Social Sciences Research (1R13HL108431), the Robert Wood Johnson Foundation’s Healthy Eating Research and Active Living Research programs, the Nemours Foundation, and the Altarum Institute. Additional support was provided by the University of North Carolina’s Center for Health Promotion and Disease Prevention, a member of the Prevention Research Centers Program of the CDC (#U48-DP000059). The content reflects the authors’ views and not necessarily those of the CDC.
The authors gratefully acknowledge the invaluable contributions of all conference participants, presenters, and discussion leaders, including Barbara Dennison, Lori Beth Dixon, Lisa Harnack, Kathryn Henderson, Robin McKinnon, Sara Benjamin Neelon, Angela Odoms-Young, Russell Pate, Lorrene Ritchie, James Sallis, Marlene Schwartz, and Stewart Trost.
Author Disclosure Statement
The authors declare no competing financial interests.
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