Nutrition and physical activity interventions in preschool and child care offer young children opportunities to eat healthy foods and engage in physical activity throughout the day. Nutrition interventions provide fruits, vegetables, and other healthy foods as part of snacks, meals, taste-testing, and food preparation, frequently with basic nutrition education. Physical activity interventions provide opportunities for children to increase their physical activity, typically by training teachers to incorporate physical activity into daily routines, changing the physical environment, or offering more time for physical activity. Government regulations and state and organizational policies can support these interventions through guidelines for healthy food consumption, physical activity, and screen time, and support for playground improvements (Alhassan 2019*, ONeill 2016, AAP-Early care standards 2012), with additional support to help providers reach compliance (Benjamin Neelon 2016*).
Expected Beneficial Outcomes (Rated)
Increased physical activity
Improved weight status
Other Potential Beneficial Outcomes
Increased fruit & vegetable consumption
Improved physical fitness
Evidence of Effectiveness
There is strong evidence that nutrition interventions in preschool and child care improve children’s diets (Sisson 2016a*, Mikkelsen 2014, Grantham-McGregor 2014, Larson 2011*, Robinson 2014) and physical activity interventions increase their activity levels (Hnatiuk 2019, Sisson 2016a*, Finch 2016*, Gordon 2013*, Kreichauf 2012*, Larson 2011*, Ward 2010*, Robinson 2014). Such interventions may improve children’s weight outcomes (Ward 2017*, Ling 2016*, Morris 2015a*) and obesity-related behaviors such as screen use (Sisson 2016a*). However, variation in the design, duration, and implementation of these interventions can result in varied effects (Zhou 2014*, Mehtala 2014). Additional evidence is needed to determine if these interventions also reduce risk of overweight or obesity (Zhou 2014*, Jaime 2008*, Ward 2010*).
Adhering to nutrition guidelines in preschool and child care can decrease children’s fat intake and increase fruit and vegetable intake (Mikkelsen 2014, Jaime 2008*). Implementing physical activity interventions can increase participants’ fitness and motor skills (Ward 2010*). In some circumstances, nutrition and physical activity interventions have been shown to reduce children’s weight, body fat, or body mass index (BMI) (Ward 2017*, Ling 2016*, Morris 2015a*, Mikkelsen 2014, Bluford 2007, Zhou 2014*). Interventions that include strong parent engagement components are more effective at improving weight outcomes (Ward 2017*, Ling 2016*, Morris 2015a*), increasing physical activity (Finch 2016*, Sisson 2016a*) and improving nutrition (Sisson 2016a*) than interventions that do not engage parents. Multi-component, multi-level, comprehensive interventions are more effective in improving participants’ weight status than less comprehensive interventions, however, such interventions can be challenging to implement (Ward 2017*).
Interventions that increase time for physical activity, provide portable play equipment (e.g., balls and other objects), and include playground markings have been shown to increase moderate to vigorous physical activity (Kreichauf 2012*, Broekhuizen 2014, Temple 2014*). Adding portable play equipment has greater effects on physical activity than adding fixed play structures and equipment, since children tend to gather and stand still on or under fixed structures (Kreichauf 2012*). An intervention at rural Head Start programs that promoted specific activities (ball playing, dancing, active games, jumping, and walking) improved participating preschool children’s physical activity at home, including among Native American and Hispanic children (Cruz 2016*). In Massachusetts, state early education standards include a multi-component nutrition and physical activity intervention that is associated with increased children’s physical activity (Alhassan 2019*).
Interventions with adult-led physical activity, and which have children go outside regardless of weather, are more likely to meet best practice standards for physical activity and outdoor time (Tandon 2017). Incorporating lots of taste testing opportunities into interventions can increase vegetable consumption among 2-5 year olds (Nekitsing 2018) and removing TVs from child care centers reduces children’s screen time (Sisson 2016a*). Interventions that include structured activity, strong parent engagement components, expert facilitators, a grounding in theory (Finch 2016*), and environmental as well as child engagement components (Sisson 2016a*) may be more effective than those that do not. Researchers recommend that child care centers train teachers in how to integrate physical activity into learning to maximize effects (Kreichauf 2012*, Ward 2010*, Mehtala 2014). In general, staff training increases effectiveness of interventions (Sisson 2016a*) and teacher-led interventions may be more cost effective (Ling 2016*). The cost of healthy food and inclement weather are frequent challenges to meeting best practice standards for nutrition and physical activity interventions (Nanney 2017).
Some experts suggest more intensive parent engagement strategies can improve intervention effectiveness (Finch 2016*), for example, behavioral therapy, physical activity training, education lessons, group meetings, and physical activity and education sessions with their children (Ling 2016*). Consistent educational materials across preschool or care settings and homes improves effectiveness of interventions (Morris 2015a*). Experts recommend interventions last longer than six months and include tailoring for community needs and consideration of cultural contexts; without tailoring, interventions may be more effective among more advantaged socioeconomic groups (Hnatiuk 2019). Culturally sensitive interventions are implemented with a clear understanding of cultural values, generally with the help of bilingual and bicultural facilitators, and often include translated and literacy-appropriate materials, social support, and family-based activities (Mier 2010).
Impact on Disparities
The Public Health Law Center’s (PHLC) 50-state review of early childhood care and education regulations includes nutrition and physical activity standards; the on-line map is searchable by state (PHLC-Child care regulations). Terms and standards relating to nutrition, physical activity, and screen time vary widely across the country; however, very few states incorporate their standards into their statewide regulations (ALR-Frost 2015). The National Resource Center for Health and Safety in Child Care and Early Education (NRC) identifies 47 potential components for licensing standards that support healthy dietary behaviors and physical activity for young children (AAP-Early care standards 2012). As of 2018, Tennessee, North Carolina, and Nevada’s child care licensing regulations are the most supportive of healthy weight practices based on these 47 components (NRC HSCCEE-Healthy weight).
The national program Healthy Kids, Healthy Future (HKHF) offers childhood obesity prevention resources and tools in English and Spanish to assist child care and preschool providers, state and local leaders, and trainers (Nemours-Healthy Kids, Healthy Future). HKHF also supports the Early Care and Education Learning Collaborative (ECELC) in Alabama, Arizona, Florida, Indiana, Kansas, Kentucky, California, Missouri, New Jersey, and Virginia to introduce policy and program changes to improve healthy eating, breastfeeding supports, physical activity, and screen time in early child care and education settings (Nemours-ECELC). Illinois adopted a resolution in 2012 calling for daily, quality physical education in preschool and early child care centers, among other child obesity prevention measures (NCSL Winterfeld 2014a).
In some states, nutrition and physical activity interventions focus on developing curriculum and training early childhood care and education providers through non-profit and public sector partnerships, as in Idaho (CDHD-IdahoSTARS). The Minnesota Department of Health supports a two-step, train-the-trainer approach which includes follow-up technical assistance to early care and education providers implementing best practices (MDH-ECE). Cross-sector partnerships in early child care and education also exist in Hawaii (HI DOH-Healthy Child Care Hawaii), North Dakota (NDDHS-Early childhood), and Alaska, whose Department of Health resources include Tundra to Table nutrition videos for early childhood providers and families (AK DHSS-ECE).
The national Racial and Ethnic Approaches to Community Health (REACH) program offers grants to develop and support local, culturally appropriate programs to address health issues; grants can be used to fund activities in early childhood settings (CDC-REACH 2020). Free resources, such as self-assessment checklists for providers in Spanish and English, are available through the National Center for Cultural Competence (NCCC-Assessments).
ESMM NC-NAP SACC - Eat Smart, Move More North Carolina (ESMM NC). Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC).
WI DHS-Early care - Wisconsin Department of Health Services (WI DHS). Early care and education (early childhood) initiatives.
SHAPE America-PA guidelines - Society of Health and Physical Educators (SHAPE America). Physical activity guidelines.
ChangeLab-CA childcare - ChangeLab Solutions. California childcare settings: A webinar on the child care nutrition and physical activity environments.
ChangeLab-Model childcare statute - National Policy & Legal Analysis Network to Prevent Childhood Obesity (NPLAN). Model childcare licensing statute for obesity prevention. Oakland: ChangeLab Solutions; 2013.
AAP-HALF - American Academy of Pediatrics (AAP). Healthy Active Living for Families (HALF) program. Age specific content.
Food Trust-Preschool initiative 2011 - The Food Trust. The preschool initiative: Building a healthy foundation for life. 2011.
Together Counts-SFTS - Together Counts. Smart from the start (SFTS).
HOST-Healthy eating - Healthy Out-of-School Time (HOST) Coalition. Resources: Healthy eating.
HOST-PA - Healthy Out-of-School Time (HOST) Coalition. Resources: Physical activity (PA).
USDA-Preschoolers - United States Department of Agriculture (USDA). Nutrition education for preschoolers.
CDC-Health equity resources - Centers for Disease Control and Prevention (CDC). Health equity resource toolkit for state practitioners addressing obesity disparities.
CDC-ECE 2017 - Centers for Disease Control and Prevention (CDC). Fact Sheet: Helping young children thrive: Healthy practices in the early care and education (ECE) setting. June 2017.
Citations - Evidence
* Journal subscription may be required for access.
Sisson 2016a* - Sisson SB, Krampe M, Anundson K, Castle S. Obesity prevention and obesogenic behavior interventions in child care: A systematic review. Preventive Medicine. 2016;87(2016):57-69.
Mikkelsen 2014 - Mikkelsen MV, Husby S, Skov LR, Perez-Cueto FJ. A systematic review of types of healthy eating interventions in preschools. Nutrition Journal. 2014;13:56.
Grantham-McGregor 2014 - Grantham-McGregor SM, Fernald LCH, Kagawa RMC, Walker S. Effects of integrated child development and nutrition interventions on child development and nutritional status. Annals of the New York Academy of Sciences. 2014;1308:11–32.
Larson 2011* - Larson N, Ward DS, Neelon SB, Story M. What role can child-care settings play in obesity prevention? A review of the evidence and call for research efforts. Journal of the American Dietetic Association. 2011;111(9):1343–62.
Robinson 2014 - Robinson LE, Webster EK, Whitt-Glover MC, Ceaser TG, Alhassan S. Effectiveness of pre-school- and school-based interventions to impact weight-related behaviours in African American children and youth: A literature review. Obesity Reviews. 2014;15(S4):5-25.
Hnatiuk 2019 - Hnatiuk JA, Brown HE, Downing KL, et al. Interventions to increase physical activity in children 0–5 years old: a systematic review, meta-analysis and realist synthesis. Obesity Reviews. 2019;20(1):75-87.
Finch 2016* - Finch M, Jones J, Yoong S, Wiggers J, Wolfenden L. Effectiveness of centre-based childcare interventions in increasing child physical activity: A systematic review and meta-analysis for policymakers and practitioners. Obesity Reviews. 2016;17(5):412-428.
Gordon 2013* - Gordon ES, Tucker P, Burke SM, Carron AV. Effectiveness of physical activity interventions for preschoolers: A meta-analysis. Research Quarterly for Exercise and Sport. 2013;84:287-294.
Kreichauf 2012* - Kreichauf S, Wildgruber A, Krombholz H, et al. Critical narrative review to identify educational strategies promoting physical activity in preschool. Obesity Reviews. 2012;13(1):96-105.
Ward 2010* - Ward DS, Vaughn A, McWilliams C, Hales D. Interventions for increasing physical activity at child care. Medicine & Science in Sports & Exercise. 2010;42(3):526–34.
Ward 2017* - Ward DS, Welker E, Choate A, et al. Strength of obesity prevention interventions in early care and education settings: A systematic review. Preventive Medicine. 2017;95(2017):S37-S52.
Ling 2016* - Ling J, Robbins LB, Wen F. Interventions to prevent and manage overweight or obesity in preschool children: A systematic review. International Journal of Nursing Studies. 2016;53:270-289.
Morris 2015a* - Morris H, Skouteris H, Edwards S, Rutherford L. Obesity prevention interventions in early childhood education and care settings with parental involvement: a systematic review. Vol 185.; 2015.
Zhou 2014* - Zhou YE, Emerson JS, Levine RS, Kihlberg CJ, Hull PC. Childhood obesity prevention interventions in childcare settings: Systematic review of randomized and nonrandomized controlled trials. American Journal of Health Promotion. 2014;28(4):e92-103.
Mehtala 2014 - Mehtala MAK, Saakslahti AK, Inkinen ME, Poskiparta MEH. A socio-ecological approach to physical activity interventions in childcare: A systematic review. International Journal of Behavioral Nutrition and Physical Activity. 2014;11:22.
Jaime 2008* - Jaime PC, Lock K. Do school based food and nutrition policies improve diet and reduce obesity? Preventive Medicine. 2009;48(1):45–53.
Bluford 2007 - Bluford DA, Sherry B, Scanlon KS. Interventions to prevent or treat obesity in preschool children: A review of evaluated programs. Obesity. 2007;15(6):1356-72.
Broekhuizen 2014 - Broekhuizen K, Scholten AM, de Vries SI. The value of (pre)school playgrounds for children's physical activity level: A systematic review. International Journal of Behavioral Nutrition and Physical Activity. 2014;11:59.
Temple 2014* - Temple M, Robinson J. A systematic review of interventions to promote physical activity in the preschool setting. Journal for Specialists in Pediatric Nursing. 2014;19:274-284.
Cruz 2016* - Cruz TH, Davis SM, Myers OB, et al. Effects of an obesity prevention intervention on physical activity among preschool children: The CHILE study. Health Promotion Practice. 2016;17(5):693-701.
Alhassan 2019* - Alhassan S, St. Laurent CW, Burkart S, Greever CJ, Ahmadi MN. Feasibility of integrating physical activity into early education learning standards on preschooler’s physical activity levels. Journal of Physical Activity and Health. 2019;16(2):101-107.
Tandon 2017 - Tandon PS, Walters KM, Igoe BM, Payne EC, Johnson DB. Physical activity practices, policies and environments in Washington State child care settings: results of a statewide survey. 2018;21(3):571-582.
Nekitsing 2018 - Nekitsing C, Blundell-Birtill P, Cockroft JE, Hetherington MM. Systematic review and meta-analysis of strategies to increase vegetable consumption in preschool children aged 2–5 years. Appetite. 2018;127(April):138-154.
Nanney 2017 - Nanney MS, LaRowe TL, Davey C, et al. Obesity prevention in early child care settings: A bistate (Minnesota and Wisconsin) assessment of best practices, implementation difficulty, and barriers. Physiology & behavior. 2017;176(5):139-148.
Mier 2010 - Mier N, Ory MG, Medina AA. Anatomy of culturally sensitive interventions promoting nutrition and exercise in hispanics: A critical examination of existing literature. Health Promotion Practice. 2010;11(4):541-554.
Citations - Implementation Examples
* Journal subscription may be required for access.
PHLC-Child care regulations - Public Health Law Center (PHLC). Healthy child care 50-state review.
ALR-Frost 2015 - Frost N. Promoting physical activity in early care and education. 2015 Active Living Research (ALR) Annual Conference. 2015.
AAP-Early care standards 2012 - American Academy of Pediatrics (AAP), American Public Health Association (APHA), National Resource Center for Health and Safety in Child Care and Early Education (NRC). Preventing childhood obesity in early care and education programs: Second edition. 2012.
NRC HSCCEE-Healthy weight - National Resource Center for Health and Safety in Child Care and Early Education (NRC HSCCEE). Achieving a state of healthy weight 2018 report. Aurora, CO: University of Colorado Anschutz Medical Campus. 2019.
Nemours-Healthy Kids, Healthy Future - Nemours Children’s Health System. Healthy Kids, Healthy Future.
Nemours-ECELC - Nemours Children’s Health System. Collaboratives & the ECELC project.
NCSL Winterfeld 2014a - Winterfeld A. State actions to reduce and prevent childhood obesity in schools and communities: Summary and analysis of trends in legislation. National Conference of State Legislators (NCSL); 2014.
CDHD-IdahoSTARS - University of Idaho Center on Disabilities and Human Development (CDHD), Idaho Association for the Education of Young Children (Idaho AEYC), Idaho Department of Health and Welfare (ID DHW). IdahoSTARS: Quality child care matters.
MDH-ECE - Minnesota Department of Health (MDH). Early care and education.
HI DOH-Healthy Child Care Hawaii - Hawaii State Department of Health (HI DOH). Healthy Child Care Hawaii (HCCH).
NDDHS-Early childhood - North Dakota Department of Human Services (NDDHS). Early childhood services in North Dakota.
AK DHSS-ECE - Alaska Department of Health and Social Services (AK DHSS). Division of Public Health. Early care and education.
CDC-REACH 2020 - Centers for Disease Control and Prevention (CDC). Racial and Ethnic Approaches to Community Health (REACH).
NCCC-Assessments - National Center for Cultural Competence (NCCC), Georgetown University Center for Child and Human Development. Self-Assessments.
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