Summary

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’

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¹In this report, the term “young children” refers to ages birth to 5 years.

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.

CONCLUSION

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.

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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.

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