Obesity prevention in child care: A review of U.S. state regulations

We collected data on individual state regulations for child care facilities between January and August of 2007 from the National Resource Center for Health and Safety in Child Care website available at http://​nrc.​uchsc.​edu. The National Resource Center for Health and Safety in Child Care maintains a public access database of licensing regulations for all fifty US states and the District of Columbia. Regulations are updated when changes are made and reflect the most current regulations available from states.

We reviewed state regulations for reference to seven key nutrition and physical activity items related to childhood obesity. The items have a documented relationship to childhood obesity in the research literature, and are likely contributors to diet quality and activity level. Items included in this review were: 1) Water is freely available [76, 77]; 2) Sugar sweetened beverages are limited [18, 19, 28, 78‐82]; 3) Foods of low nutritional value are limited [81, 83, 84]; 4) Children are not forced to eat [29‐34]; 5) Food is not used as a reward [35, 36]; 6) Support is provided for breastfeeding and provision of breast milk [37‐40]; and 7) Screen time is limited [41‐45]; and 8) Physical activity is required daily (minutes per day) [48‐50].

During the review of state regulations, we found more than 50 nutrition and physical activity regulations. The majority of food-related regulations were more associated with food safety and sanitation and the majority of physical activity-related regulations were related to injury prevention. Of those regulations not related to food safety, sanitation, or injury prevention, we selected regulations more closely associated with obesity. A number of regulations were not included in this review (e.g., mandating provision of fruits and vegetables, prohibiting vending machines) because either the regulation was only mentioned in 1 or 2 states or the research literature was inconclusive on the relationship between the item and childhood obesity.

We reviewed regulations for child care facilities for all 50 US states and the District of Columbia between June and August of 2007. Most states license 2 classes of child care facilities: child care centers and family child care homes. Child care centers by definition care for greater numbers of children and typically have more employees than family child care homes. A second key difference is that family child care homes are located in the residence of the owner and operator of the child care facility, who is often the only provider of care. States have varying definitions for the maximum number of children allowed to receive care in a family child care home, but typically limit enrollment to six or fewer children. In certain cases, states refer to these classifications differently. Nine states have only 1 regulation that governs both child care centers and family child care homes, 16 states have a separate regulation for centers and one for family child care homes, and 26 states have regulations for more than 2 distinct classes of facilities. We grouped additional facility types into one of the 2 main classes (child care centers or family child care homes). For example, Hawaii issues a license for 4 types of facilities, which we grouped into 2 types as follows: "group child care centers" and "infant and toddler child care centers" were classified as child care centers, and "family child care homes" and "group child care homes" were classified as family child care homes.

Ensuring availability of water was the most common regulation. Forty-one states (80%) had regulations to ensure that water was available to all children in child care centers. Thirty-four (67%) required availability of water in family child care homes. In addition, the wording of this regulation tended to be very similar from state to state. Generally, states required water to be "freely available to all children at all times". In some cases, states required child care staff to offer water to children between meals and snacks or at frequent intervals (centers: GA, IN, LA, MN, MT, NV, NY, NC, OK, VA, WI; homes: LA, MN, NV, NY, NC, OK, VA) or during outdoor play or in warm weather (centers: PA, UT, VA, VT; homes: LA, PA, UT, VT). A few states either encouraged (centers: OR, WI; homes: WI, WV) or discouraged (centers: LA, WV) giving water to infants in child care.

Seven states (14%) restricted sugar sweetened beverages in both child care centers and family child care homes. A number of states specified that sugar sweetened beverages could not take the place of healthier beverages (centers: GA, NV, NM; homes: AZ, GA, NV, NM, TN) or could be served only on special occasions (centers: GA, NC; homes: GA, NC).

Although states define these foods differently, nine states (18%) limited foods of low nutritional value in centers while seven (14%) restricted those foods in family child care homes. North Carolina provided examples of foods with low nutritional value, listing gelled desserts, popcorn, desserts, and potato chips as foods that centers could serve only occasionally and not in place of nutritious foods. Tennessee restricted "highly inappropriate foods" or those foods high in sugar and high in fat. For family child care homes, but not centers, Arizona limited high fat, high sugar foods to no more than two times per week. West Virginia regulations stated that centers must limit snack foods with high sugar and salt. Two states provided examples of healthful foods that should be served in child care: Vermont encouraged family child care homes to emphasize unprocessed, low sugar, and low salt foods, while Missouri required child care centers to serve snacks of fruit juice, raw fruits and vegetables, milk, crackers, cheese, peanut butter, or "similar nutritious foods."

The second most common regulation prohibited forcing children to eat. We found this regulation most often under the heading of discipline, rather than nutrition or food service within state regulations. Thirty-two states (63%) did not allow providers to force children to eat in both child care centers and family child care homes.

Ten states (20%) did not allow food to be used as a reward in child care centers. Tennessee specified that desserts and other sweets should not be used as a reward in child care centers. Five states (10%) did not allow providers to use food as a reward in family child care homes. Since Washington state prohibited using food as a reward only when toilet training children, it was not included as having a regulation prohibiting using food as a reward.

We found regulations expressing support for breastfeeding and provision of breast milk in only 9 states (18%) for child care centers. Indiana, however, also required parents to have a written breastfeeding agreement on file, to provide breast milk in single serving sterilized bottles or sterile nurser bags labeled with the child's name, the date and the time collected, and to keep milk at 41 degrees or less during storage and transport. Three states (6%) included a statement of support for breastfeeding in their regulations for family child care homes.

Seventeen states (33%) regulated screen time in child care centers and 15 (29%) in family child care homes. For child care centers, 7 states limited the number of screen time hours children received in a day. Mississippi, New Mexico, and Delaware limited viewing to 1 hour, Alaska 1.5 hours, and Georgia and Tennessee required less than 2 hours of screen time per day. Texas limited screen time viewing to less than 5 hours per week. In addition, screen time was not allowed for children less than 2 years of age in Delaware or for infants in Mississippi child care centers. For family child care homes, 6 states set limits on daily screen time. Mississippi limited screen time viewing to 1 hour, Alaska 1.5 hours, and Delaware, Georgia, and Oregon limited screen time to 2 hours per day. Texas limited viewing to less than 5 hours per week. Screen time was not allowed for infants in family child care homes in Mississippi. Additionally, Delaware recently proposed to decrease screen time to 1 hour per day in family child care homes.

A number of states required child care facilities to offer children an alternative to television viewing (centers: GA, IL, IN, MI, TN, VT, WA, WV, WI; homes: GA, TN, VT, WA, WI), or specified that children were not required to watch television (centers: AL, IN, SC, WI; homes: SC, WI). Delaware and Colorado are the only 2 states to require parental permission to use television during child care hours.

Only 3 states required a specified number of minutes of physical activity per day. Alaska and Delaware mandated that children engage in 20 minutes of moderate to vigorous physical activity for every 3 hours the child care centers and family child care homes were open between the hours of 7:00 am and 7:00 pm. Currently, Massachusetts requires 30 minutes of daily physical activity for all children in family child care homes. However, Massachusetts recently proposed an increase to 60 minutes of physical activity daily that would be required for children in both child care centers and family child care homes. If this proposal is approved, the new regulation will take effect in late 2008.