Resources to Support Obesity Prevention Strategies in ECE

National-level statistics on childhood obesity, related behavioral risk factors and the role of the early care and education (ECE) setting in addressing this major public health problem may be useful in working with your stakeholders.

State Case Studies on Integrating Childhood Obesity into State ECE Systems

States that partnered with Nemours and the CDC on the National Early Care & Education Learning Collaboratives Project worked on Spectrum of Opportunity areas to embed childhood obesity prevention within their state ECE systems. These case studies highlight the successes and challenges as well as lessons learned in states that vary by location, population and type of partner.

Using the Spectrum of Opportunities to Support Childhood Obesity Prevention in Early Care and Education Settings: A Series of Case Studies

Case studies by state:



North/Central Florida

South Florida





New Jersey


Spectrum of Opportunity Area Case Studies on Integrating Childhood Obesity into State ECE Systems

Nemours and the CDC, via the National Early Care & Education Learning Collaboratives Project, worked with states for more than five years on integrating childhood obesity prevention into state early care and education systems. These case studies look at different ‘feathers’ of the CDC’s Spectrum of Opportunity and provide examples from these states and approaches to embed support for ECE providers with health eating, physical activity, breastfeeding and screen time best practices.

Child and Adult Care Food Program (CACFP)

Licensing and Administrative Regulations

Pre-Service and Professional Development

Quality Rating and Improvement Systems

Facts & Statistics Related to Childhood Obesity

  • Obesity rates among children ages 2 to 5 years doubled between 1976–1980 and 2001–2002. In 2009–2010, an estimated 26.7 percent of 2 to 5 year old children were already overweight or obese. (Source: Ogden, Carroll, Curtin, Lamb, Flegal. Prevalence of high body mass index in U.S. children and adolescents. JAMA 2010.)
  • According to the Centers for Disease Control and Prevention (CDC), children who are obese are at risk for high blood pressure and high cholesterol, impaired glucose tolerance, insulin resistance and type-2 diabetes. They are also at risk for poor self-esteem, breathing problems (such as sleep apnea and asthma), joint problems and fatty liver disease. Children who are obese are also more likely to become adults who are obese and at increased risk for chronic diseases–including heart disease, stroke, diabetes and arthritis — which can lead to illness, limitations in daily functioning, reduced quality of life and premature death.
  • The ECE setting — which includes child care centers, day care homes (also known as family child care), and Head Start and pre-kindergarten programs — is a critical place for obesity prevention efforts. (Source:  Story, Kaphingst, French. The role of child care settings in obesity prevention. Future Child 2006.)
  • Breastfeeding helps protect infants from becoming overweight in childhood, but according to the CDC only 47 percent of U.S. infants born in 2009 were breastfed at 6 months and 26 percent at 12 months of age.
  • The diets of young children in the United States are low in fruits, vegetables and whole grains and high in added sugars and saturated fats. Nearly half of 2- to 3- year-olds consume a sugar-sweetened beverage daily, and a quarter to a third consume whole rather than low-fat or nonfat milk. (Source: Fox, Reidy, Novak, Ziegler. Sources of energy and nutrients in the diets of infants and toddlers. J Am Diet Assoc 2006)
  • A few small studies have found that an estimated 70 percent 14 to 87 percent of children’s time in early care and education is spent being sedentary (i.e., sitting or lying down), and less than 3 percent may be spent engaging in moderate-to-vigorous physical activity. (Source: American Academy of Pediatrics, American Public Health Association, and National Resource Center for Health and Safety in Child Care and Early Education. Preventing Childhood Obesity in Early Care and Education, 3rd ed.)
  • In a recent study, 70 percent of infant through preschool-aged children in center-based ECE and 36 percent in home-based care watch television up to 3 hours a day while in child care. (Source: Christakis, Garrison. Preschool-Aged Children’s Television Viewing in Child Care Settings. Peds. 2009)

Childhood Obesity Prevention Worksheets

The CDC developed the Spectrum of Opportunities Framework for State Action to Prevent Obesity in the Early Care and Education Setting (Spectrum of Opportunities). The framework outlines how both standards and support for early care and education (ECE) providers to achieve these standards can be embedded into a state’s ECE system. The focus is on systems-level changes, as these have the potential for statewide impact. A series of complementary resources were developed to accompany the Spectrum of Opportunities and are listed below. The action steps and worksheets are a sequential and cyclical process and are presented in the order that is most appropriate for states who are new to this work. The best starting point for states already working in this area will be determined by the nature of their prior work and current partnerships.

Partnership Assessment Worksheet: Identify who should be at the table for planning state efforts to address early childhood obesity prevention.

Spectrum of Opportunities Assessment Worksheet: Catalogue your state or community efforts on addressing obesity prevention in the early care and education (ECE) setting to date and the success rates.

State Profile Template: Summarize information needed for your state partnership to make decisions regarding existing efforts and pursuing new opportunities in obesity prevention for ECE settings.

Equity Worksheet and Summary: Within your partnership group, it is important to understand the equity goals and considerations that inform each other’s work. Use this worksheet to document this information for easy reference during your state’s action planning process.

Spectrum of Opportunities Rating Worksheet: Identify new opportunities and current efforts in obesity prevention for ECE settings that might be improved. Rate the feasibility of each.

Action Plan Worksheet and Sample Logic Model: Create a specific plan to pursue new opportunities or strengthen existing efforts in obesity prevention for ECE settings.


For more information about the Spectrum of Opportunities and complementary worksheets, please listen to a recorded webinar on the CDC’s Revised Spectrum of Opportunities and Accompanying Worksheets .

CDC Networking Calls and Presentations

The Centers for Disease Control and Prevention (CDC) hosts regular calls and presentations with state and community stakeholders working on obesity prevention in ECE settings.

July 2019 — Professional Development Opportunities to Support Healthy Nutrition and Physical Activity in ECE Settings: Better Kid Care & Study of Health and Activity in Preschool Environments (SHAPES)

June 2019 — Supporting Breastfeeding in Early Care and Education Settings

April 2019 — Using Geographic Information System Mapping (GIS) to Better Understand State Coverage and Use of CACFP in Early Care and Education: Virginia & Alabama

February 2019 — Overview of ECE Interventions to Promote Physical Activity and the Coordinated Approach to Child Health Early Childhood (CATCH CEC)

January 2019 – Licensing & Regulations in Early Care and Education: Overview of Achieving a State of Healthy Weight 2017 report and highlights from Washington and Utah. (password: PassCode1138)

December 2018 – Early Care and Education Recognition Programs

November 2018 — Evidence -Based Interventions for Early Care and Education: Go NAP SACC

June 2018 — West Virginia KEYS 4 Healthy Kids: Multi-component Obesity Prevention Intervention in Early Care and Education + ECE Systems Level Change

May 2018 — Embedding Healthy Eating and Physical Activity into the Child Care Development Fund (CCDF)

April 2018 — Racial and Health Equity in Early Care and Education and the Reauthorization of the Child Care Development Block Grant (CCDBG)

March 2018 — CDC’s Revised Spectrum of Opportunities and Accompanying Worksheets

February 2018 — The Child Care Development Fund and How to Find Information in Your State’s Plan

January 2018 — A Year In Review: State Highlights and Accomplishments to Support Obesity Prevention in ECE

December 2017 — More Than Child’s Play: Including All Children in Physical Activity, featuring Dr. Diane H. Craft

November 2017 — Health Impact Assessment of the New CACFP Meal Patterns

October 2017 — Farm to Early Care and Education

September 2017 — Cornell B.E.N. Center: Smarter Mealtimes ECE Scorecard

August 2017 — The Public Health Law Center: Child Care Licensing, Regulations and Minnesota’s ECE Food System

July 2017 — Child Care Aware® of America: Early Care and Education Staff Wellness

June 2017 — The Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES)

June 2017 — Division of Nutrition, Physical Activity, and Obesity: Public Health Systems Supporting Healthier Child Care and Early Learning

April 2017 — Special Topic: Team Nutrition and Early Care and Education

April 2017 — ECE Facility-Level Interventions: Healthy Caregiver, Healthy Children and Coordinated Approach to Child Health Early Childhood (CATCH EC)

February 2017 — A Year in Review: State Progress Made in Obesity Prevention in Early Care and Education Settings 

January 2017 — New CACFP Meal Pattern and Early Implementation

November 2016 — Collaborative Partnerships and the Implementation of Arizona’s Empower Program

October 2016 — Nutrition and Physical Activity Self-Assessment for Child Care (Go NAPSACC): 5 State Pilot  

September 2016 — Farm to Early Care and Education

August 2016 — Physical Activity in Early Care and Education: Diane Craft and State Presentations

July 2016 — NRC Achieving a State of a Healthy Weight

June 2016 — National Early Care & Education Learning Collaboratives Project: A Partnership Between Centers for Disease Control & Prevention and Nemours

May 2016 — New CACFP Meal Patterns, 2016  (Please note: Audio recording begins at 1 min 30 sec)

April 2016 — Association of State Public Health Nutritionists (ASPHN) Collaborative Improvement and Innovation Network (CoIIN): Innovative Projects to Address Childhood Obesity 

March 2016 – “Review of the Evidence of ECE Interventions” — Recording / Slides

February  2016 – “Public Health Law Center: Partnering to Improve Child Care” — Recording / Slides

November 2015 – Recording / Slides: ECE at the American Heart Association – Slides: CDC ECE SIR Networking Updates 

October 2015 – “National Early Care Education Learning Collaboratives Project: Systems Level Work” and “Child Care Aware: Obesity in Children” — Recording / Slides

September 2015 – Getting Started with Farm to Preschool

July 2015 – “Promoting Physical Activity of Young Children: Three States’ Approaches to Promotion” — Recording / Slides

June 2015 — “Nutrition, Physical Activity and Electronic Media Use in the Child and Adult Care Food Program” — Recording / Slides

April 2015  — “State Partnerships” — Recording / Slides: Pulling Together State Partnerships and Advisory Committees – Slides: Partnership Development in Texas – Slides: Virginia’s ECELC Partnership

March 2015 – Recording / Slides: Statewide Survey of Nutrition and Physical Activity in Child Care: Washington and New Hampshire – Slides: Child Care Focus Groups and CRA Results

February 2015 — “Child Care and Development Block Grant (CCDBG) Reauthorization” and “State Early Learning Contacts” — Recording / Slides: Reauthorization of the Child Care and Development Fund – Resource: 2015 Directory of State Early Learning Contacts 

January 2015 – Recording / Slides: CDC/LMCC Data Sharing: 1305 Performance Measurement Data —Slides: Lessons Learned From Maryland’s Statewide Collaborations

May 2014 — “Penn State’s Better Kid Care Program” and “TOP Star: Enhancing Professional Development Through Partnerships” — Recording, please dial: (866) 391-8715

April 2014 — Maximizing Opportunities for Movement in Child Care Settings

March 2014 — “Public Health Law Center’s Assessment of the Potential of Local Governments to Impose Standards of Nutrition and Physical Activity for Child Care Settings” — Recording, please dial: (866) 395-1027

February 2014 — “Texas Department of Agriculture’s Farm to Preschool Initiative” — Recording, please dial: (866) 391-4453

January 2014 — “Revised Go NAP SACC” — Recording, please dial: (866) 840-7944

August 2013 — National Early Care and Education Collaboratives, an Approach to Childhood Obesity Prevention

Other Websites & Resources

Achieving a State of Healthy Weight: A national assessment of obesity prevention in child care regulations, updated annually.

Actions to Promote Healthy Kids, Healthy Futures — Local Efforts to Improve Children’s Health and Wellness (The Early Care and Education Innovations Webinar Series): Learn more about what local communities are doing to support young children and their families to prevent obesity in early childhood settings. (Note: Registration is required to view the recorded webinar.)

Actions to Promote Healthy Kids, Healthy Future — State Activities that Focus on Healthy Eating and Active Living in Early Childhood (The Early Care and Education Innovations Webinar Series): Learn more about what states are doing to support young children and their families to prevent early childhood obesity in early childhood settings.

CDC’s Weight of the Nation—Obesity Prevention in ECE Policy Review : This review provides state-specific child care demographics and highlights enacted legislation and current licensing regulations that impact the nutrition and physical activity environments in ECE facilities.

Child Care and Development Fund Plans: The Child Care and Development Fund (CCDF) Plan serves as the application for the Child Care and Development Block Grant (CCDBG) funds by providing a description of the grantee’s child care program and all services available to eligible families.

Childhood Obesity Prevention Toolkit for Rural Communities: This toolkit is intended to provide a range of science-informed, promising or emerging obesity prevention strategies to address childhood obesity in rural communities in five different sectors that serve children.

Early Childhood and Medicaid: Partnerships between the early childhood sector and health insurers can lessen the impacts of social determinants of health on child health outcomes.

Early Childhood State Advisory Council: The State Advisory Councils on Early Childhood Education and Care (SACs) are charged with developing a high-quality, comprehensive system of early childhood development and care.

Early Ages, Healthy Stages – Working Together to Create Healthier Early Childhood Environments: This presentation reviews the objectives and work of the Cuyahoga County (Ohio) Early Childhood Wellness Taskforce. They seek to increase the duration of breastfeeding, the availability of healthy foods and beverages, opportunities for daily activity, and family engagement around wellness behaviors.

Family Style Dining in Early Care: The Kentucky Department for Public Health recognizes family style dining as a best practice and produced this tip sheet for child care providers.

Farm to Preschool: Farm to Preschool’s goals are multi-level and include creating healthy lifestyles through good nutrition and experiential opportunities.

Giving Healthy Kids Healthy Futures—What Happens When Federal and State Initiatives Come to Local Communities and Programs (The Early Care and Education Innovations Webinar Series): Panelists describe their work to meet national recommendations and share their experiences and recommendations.

Growing Farm to Preschool in Your State Toolkit: Ecotrust shares the building blocks used to form a coalition to build support for farm to preschool state by state.

Interactive Child Care Licensing Map: The Public Health Law Center has completed an interactive 50-state map, which synthesizes data on how state child care licensing regulations match best practices for healthy eating, active play and screen time for young children.

Intervention Strategies — Obesity Prevention Targeting the ECE Setting: This list of twenty-six intervention strategies is based on the best available evidence for preventing obesity.

Local Food for Little Eaters—A Purchasing Toolbox for CACFP:  This toolbox is designed to help early care providers purchase local food for their programs.

Parents as Teachers: Parents as Teachers promotes the optimal early development, learning and health of young children by supporting and engaging their parents and caregivers.

Policies that Support Breastfeeding in Child Care Facilities: This document includes a table of typical elements of policies that support breastfeeding in childcare facilities, as well as policies and successes.

Review of Recognition Programs for Healthy Eating and Physical Activity in ECE: This document summarizes available information regarding state recognition or designation programs for obesity prevention in early care and education (ECE) settings.

Revising State Licensing Requirements—Readiness for Change: This document poses questions for states and territories to consider as they begin revising licensing requirements

Second Harvest Toolkit for Better Early Care and Education Meals: This toolkit helps food banks serve as caterers for early childhood programs and increase the quality of food served at an affordable cost.

State CACFP Best Practices: A list of best practices from the Child and Adult Care Food Program (CACFP) in states across the country

Summary of Obesity Prevention Standards in State Quality Rating and Improvement Systems (QRIS) and Licensing Regulations: The purpose of this summary is to identify how states are promoting healthy eating, breastfeeding, physical activity, and limited screen time in ECE through QRIS standards and licensing regulations.