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Opportunities to Promote Healthy Weight Through Child Care Licensing Regulations: Trends in the United States, 2016-2020

Published:March 30, 2021DOI:



      Policies that support healthy nutrition and physical activity environments in early care and education (ECE) settings can help promote healthy weight in children. State child care licensing regulations are a critical mechanism for setting such policies.


      To develop a research instrument to evaluate the promotion of healthy child weight in state child care licensing regulations and assess the strength of the regulations over time.


      For measure development, systematic reviews of evidence on the impact of healthy weight strategies relevant to the ECE environment were combined with expert stakeholder input to identify 15 healthy weight promotion policy standards and a coding tool to measure the strength and comprehensiveness of regulatory language matching these standards. For assessing the strength of regulations, the coding tool was applied to child care regulations nationwide in 2016 and again in 2020.


      Child care licensing regulations in 2016 and 2020 for all 50 US states plus Washington DC.

      Outcome measures

      Strength and comprehensiveness scores for state licensing regulations.

      Statistical analyses

      Intraclass correlation coefficients were calculated to estimate interrater reliability of the coding tool. Paired t tests were used to compare scores within states from 2016 to 2020.


      Interrater reliability for the coding tool had intraclass correlation coefficients of 0.81 for strength and 0.87 for comprehensiveness scores. Strength and comprehensiveness of states’ healthy weight promotion policies increased significantly over time (P < .001). However, most states still lack important healthy weight policies in their licensing regulations, such as prohibiting serving sugary drinks.


      This study presents a reliable research instrument for measuring the strength and comprehensiveness of healthy weight promotion standards in child care licensing regulations. States have increased their incorporation of strategies for healthy weight into state policy.


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      E. L. Kenney is an assistant professor, Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA.


      R. S. Mozaffarian is a project manager, Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA.


      N. Frost is a staff attorney, Public Health Law Center, Mitchell Hamline School of Law, St Paul, MN.


      A. Ayers Looby is an MD candidate, University of Minnesota Medical School, Minneapolis.


      A. L. Cradock is a principal research scientist and deputy director at of the Harvard Prevention Research Center on Nutrition and Physical Activity at the Harvard T.H. Chan School of Public Health, Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA.