In this review of state regulations for child care facilities in the United States, we found that most states had few nutrition and physical activity regulations related to obesity for child care centers and family child care homes. Tennessee had 6 of the 8 obesity regulations for child care centers, and Delaware, Georgia, Indiana, and Nevada had 5 of the 8 regulations. On the other hand, the District of Columbia, Idaho, Nebraska and Washington had none of the 8. For family child care homes, Georgia and Nevada had 5 of the 8 regulations; Arizona, Mississippi, North Carolina, Oregon, Tennessee, Texas, Vermont, and West Virginia had 4 of the 8 regulations. California, the District of Columbia, Idaho, Iowa, Kansas, and Nebraska did not have any of the regulations for family child care homes.
In addition to the overall dearth of nutrition and physical activity regulations related to obesity, the regulations that do exist may be difficult to interpret by child care providers. The regulation related to water, for example, generally did not specify where and how water should be provided to children, only that it should be freely available. Other regulations may be difficult to decipher as well. A number of states prohibited forcing children to eat. This regulation, however, was mostly associated with discipline, and may not be applied to adult-child interactions during meals and snacks (e.g., requiring children to "clean their plates" or take a "no thank you" bite). This regulation may have a greater impact if states explicitly stated that this regulation applied to all eating occasions. The screen time and the physical activity regulations, however, may be easier to interpret and implement because they offer more precise guidelines.
We also examined regulations related to vending machines in child care facilities. We did not report results on vending machines because there is limited data linking vending machines to obesity in children. We did, however, find that only 4 states (8%) restricted or prohibited vending machines at the child care center. Two of these states, Mississippi and Georgia, also regulated vending machines in family child care homes. Alabama and Georgia prohibited vending machines in any areas used by children, while Louisiana required them to be outside of children's play areas. Mississippi required food in the vending machine to meet nutritional guidelines. We present this information on vending machines as a supplement to our review of nutrition and physical activity regulations related to obesity for child care facilities.
Given the overall absence of regulations or lack of clear and specific nutrition and physical activity regulations related to childhood obesity, a number of states could enhance their regulations for child care facilities. Reviewing and revising regulations on a regular basis helps ensure that regulations reflect current best practices related to childhood obesity. As additional evidence becomes available, states should revise regulations for both child care centers and family child care homes to reflect this new information. In this review, we found that 8 states had regulations dating back to the 1980s or 1990s. In a recent publication, Story et al. [75
] contend that inadequate nutrition and physical activity regulations represent a missed opportunity for childhood obesity prevention. Moreover, they argue that simple, easy to follow nutrition and physical activity regulations, such as prohibiting sugar-sweetened beverages and requiring physical activity daily may help promote healthy weight in young children in child care [75
]. If widely implemented, enhancing state regulations could be one way of improving weight-related nutrition and physical activity behaviors in preschool-aged children in the United States.
Generally, regulations for family child care homes tended to be less stringent than centers. In a few instances, however, regulations for family child care homes were more robust than child care centers. For example, Washington required homes but not centers to offer water at frequent intervals to children, and Arizona limited sugar sweetened beverages and foods of low nutritional value in family child care homes, but not in child care centers. Additionally, Oregon limited screen time in family child care homes but not centers. Although family child care homes are generally considered a more informal child care setting, states should provide the same regulations for both family child care homes and centers. This helps to ensure consistent quality of care, and minimizes variation among child care providers within a given state.
A limitation of this review is the ever-evolving nature of state regulations. States may have revised regulations for child care centers or family child care homes since our last review, or may be in the process of updating their regulations. Given the current national call-to-action to address childhood obesity in both schools and child care settings, states may be more likely than ever before to enact nutrition and physical activity regulations to help prevent obesity. In addition, cities or other geographic areas within a state have the power to regulate child care facilities in their jurisdiction. New York City, for example, recently enacted nutrition and physical activity regulations in Article 47 of the New York City health code that were more stringent than those for New York State. New York City is leading the way for other cities who may want to enact new regulations for child care facilities that go beyond their state regulations.