An estimated 12 million children aged 5 years or younger spend 22.5 hours per week in child care centers where they consume most of their daily calories (1,2). In the context of the national problem of childhood obesity and its growing prevalence in young children, experts have identified child care centers as an ideal setting for early intervention in childhood obesity (3–5). Childhood obesity is a consequence of environments that disrupt the balance of energy intake and energy expenditure (6). Obesogenic environments consist of social norms and environmental factors that facilitate unhealthy behaviors around diet and physical activity (7). The healthy weight environment of child care centers is influenced by the quality of foods served, the time children spend being physically active, caregiver behaviors, and the presence of nutrition and physical activity wellness policies (5).

Research shows that children in child care do not meet 2010 Dietary Guidelines for Americans recommendations and that few structured opportunities exist for physical activity (8–10). Less is known about how caregiver interactions with children affect eating and physical activity behaviors of children (11,12). Small and consistent changes to school environments can mitigate the prevalence of overweight in youth (13,14); however, more research is needed to provide evidence of effective approaches to improving nutrition and physical activity practices in child care facilities.

Reviews of interventions to prevent childhood obesity in child care settings demonstrate a rapidly growing research area (5,15). Most evaluated interventions are designed to affect the nutritional quality of foods, intensity of and opportunities for physical activity, and interactions of caregivers with children (5). A small number of studies have been conducted to improve child care nutrition and physical activity environments (2,16–18); to our knowledge, no programs have been evaluated previously that use local wellness policies to improve child care environments. The purpose of this study was to assess the effect of a wellness policy and training program on the physical activity and nutrition environment in 24 child care centers in Georgia.

At baseline, the average EPAO nutrition and physical activity total scores were 12.1 (standard deviation [SD] 1.8) and 10.8 (SD 1.3) (Table 3). Mean nutrition subscale scores ranged from 8.4 (nutrition training and education) to 15.4 (staff behavior). Mean physical activity subscale scores ranged from 5.5 (physical activity training and education) to 16.8 (physical activity policy score). When we compared baseline scores with posttest scores, we found significant improvements to both total nutrition and physical activity scores with mean differences of 1.9 (P < .001) for nutrition and 2.8 (P < .001) for physical activity.

Significant improvements from baseline to final observations were found for the nutrition environment means (difference: 3.6, P < .001). Nutrition training and education scores also improved significantly (difference: 8.5, P < .001). Physical activity subscales showed significant improvement from baseline to final observations of active play (difference: 2.1, P = .02), sedentary environment (difference: 3.0, P = .005), and portable environment (difference: 4.0, P = .002). The score addressing staff behavior and physical activity improved significantly (difference: 4.0, P = .004), as did physical activity training and education (difference: 8.9, P < .001).

Results suggest that adoption of wellness policies can improve the nutrition and physical activity environment in child care centers. This intervention focused on the adoption of wellness policies, increasing staff knowledge of physical activity and nutrition best practices through trainings, and guidance on the implementation of policies. Participating centers improved significantly on a range of EPAO domains: the physical activity environment, active play, sedentary environment, portable environment, staff behavior, and physical activity training and education. We also found significant improvements to the nutrition environment, nutrition training and education, and nutrition policy.

At baseline, most centers had a physical activity policy in place, which may explain why changes to the physical activity policy score were not observed. Results suggest, however, that having a physical activity policy may not correspond with actual physical activity practices; centers had areas with room for improvement, particularly the active play of children. A study that reviewed policies related to active playtime in child care centers found that although 48% of centers had active play policies, language was vague and included phrases such as “children go outside daily, weather permitting” (22). Researchers have suggested that children at preschool age should engage in 120 minutes of physical activity each day including at least 2 teacher-led activities and 2 outdoor activities (22,23). Our study suggests that the adoption of wellness policies and delivery of trainings focused on improving physical activity may increase structured and outdoor playtime.

The portable physical activity environment also improved significantly among participating centers. Centers improved physical activity environments by acquiring new equipment or making use of existing equipment. Portable play equipment, including items such as riding and push/pull toys, jumping toys, ball play, and floor play, has been shown to encourage children’s physical activity (18,24). Results from a study in 20 child care centers found that the availability of portable play equipment influenced physical activity more than availability of fixed equipment (24). Despite overall improvements to this score, the nature of changes to portable equipment used is unclear. Research is needed to identify the optimal combination of fixed and portable play items as well as how these play materials should be incorporated into playtimes to best promote physical activity.

Centers showed significant improvement in the behavior score related to staff joining in active play, making positive statements about physical activity to children, and not restricting activity as punishment. Together with research that demonstrates the impact of supportive staff behaviors on child physical activity and dietary behaviors, these results suggest that the adoption of wellness policies and delivery of staff trainings increased caregivers’ ability to participate in promoting healthy child behaviors (4,22).

The overall nutrition score for participants reflected significant improvements, yet there were fewer EPAO nutrition domains that significantly changed than physical activity EPAO domains. Centers continue to have an opportunity to improve healthy eating for children, particularly the servings of fresh fruits, vegetables, and whole grains. At baseline and at 12 months, the average fruits and vegetables and the average grains/low fat meals scores were low. Findings from this study are consistent with others that found that child care centers offered menus low in fresh fruits and vegetables and whole grains (9,25,26).

Although we found significant improvements in the nutrition environment, nutrition training and education, and nutrition policy, other scales did not improve. Centers in this study could enhance their overall mealtime and feeding environments to support healthy eating for young children (25,27). Although data linking training and education to improved health outcomes in child care settings are limited, education opportunities have the potential to help promote healthy eating in child care settings (25). Behaviors among caregivers are important for facilitating improvements to the nutritional environment (27,28). Specifically, caregivers affect children’s eating habits through role-modeling, and caregivers’ participation in mealtimes can encourage children to try new foods (11). In particular, providers could improve behavior scores by enhancing interactions with children related to hunger and satiety (27–29). All centers in this study were CACFP-funded. Other research has suggested that CACFP-participating centers have consistently more supportive feeding environments than nonparticipating centers (30), which may explain why supportive staff behaviors around nutrition did not change.

Overall, centers improved their total scores for nutrition and physical activity. The results of this study are strengthened because this is the first evaluation of a childhood obesity prevention program in child care centers in the state of Georgia. This study is one of few interventions designed to affect the child care environment by using local wellness policies related to nutrition and physical activity. The dropout rate of this program was very low (only 2 centers, 8%). We used a validated instrument and data collection was performed by 1 registered dietitian to ensure standardization of observational data.

Our study had limitations. The study lacked a large sample size and a methodology to objectively assess changes in children’s dietary intake and physical activity levels. Our ability to evaluate the direct effect of wellness policy implementation on child nutrition and physical activity was limited. Future studies should use a comparison group of centers to objectively evaluate this program while incorporating child-level health outcomes.

The child care setting provides a host of opportunities to improve the nutrition and physical activity environment. The findings of this study suggest that wellness policies implemented by child care center staff may contribute to a healthier child care environment. This study adds to the limited research base on wellness policies and the nutritional and physical activity environments in child care centers.