POLICY BRIEF
Babies’ Battle of the Bulge
Fighting Childhood Obesity for a Healthier Arizona

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Adult diseases are finding their way in to preschools
and elementary schools, emphasizing the key role
that early habits play in our long-term health and
well-being. The prevalence of obesity among 2- to
5-year-olds has more than tripled since the 1970s,
and multiple studies are showing increased levels of
high blood pressure and diabetes in grade schoolers. Poor nutrition has also been linked to developmental delays and dental problems in young kids.
If you think 2 or 3 years old is too young to start
fighting obesity, consider this: when researchers
gauged preschoolers’ attitudes about their overweight peers, the kids preferred to play with those
who were at a healthier weight. i In another study,
preschoolers used words like mean, lazy, ugly, stupid, and unhappy to describe overweight children. ii
There is no doubt: our kids are watching and
developing attitudes about healthy weight early on.
Early childhood represents a critical time when we
– parents, community leaders and policymakers –
have the best opportunity to instill habits in children
that will create a healthier future – for them and for
our state.
This policy brief outlines the problem of early childhood obesity, defines First Things First’s (FTF) role in
supporting healthy weight in young kids, and identifies possible solutions for families, early childhood
educators and communities.

supports or facilities for nursing mothers. vi The
American Academy of Pediatrics recommends
that children be breastfed for the first year of
life, whenever possible. Although there continues to be an increase nationally in the number
of women who breastfeed their children at
birth (77 percent in the most recent study), that
percentage decreases to about 47 percent at 6
months of age, and only about 25 percent at 12
months. vii

HOW BIG IS THE
PROBLEM?
As previously mentioned, the prevalence of obesity
among 2- to 5-year-olds has more than tripled since
the 1970s. Low-income children and minorities (who
tend to be disproportionately poor) are at greater
risk for childhood obesity. In the US, 14 percent of
low-income young children ages 2 to 4 are classified
as obese (having a Body Mass Index greater than 95
percent expected for height and weight). iii Almost
21 percent of Native American youngsters and
almost 18 percent of Hispanic kids 2 to 4 years old
are considered obese. iv In Arizona, among children
2 to 4 years old enrolled in the Women, Infant and
Children (WIC) program, 30 percent were either
overweight (16 percent or obese (14 percent). By
comparison, 33 percent of Hispanic children were
either overweight (17 percent) or obese (16 percent),
and 38 percent of American Indian/Alaskan Native
children were either overweight (18 percent) or
obese (20 percent). v
In addition to poverty, there are many social and
environmental factors that contribute to childhood
obesity. These factors include:
•

Lack of support for breastfeeding and barriers
to breastfeeding such as lack of knowledge,

•

increased consumption of low-nutrient foods,
such as soft drinks and foods high in fat and
sugar;

•

easy availability of fast food and non-nutritious
food, and larger portion sizes in fast- food
chains and restaurants;

•

aggressive marketing of junk food to children
and their families;

•

limited access to healthy and affordable foods
in low-income communities;

•

increased screen time (television and computer) in young children;

•

lack of physical activity; and,

•

a lack of access to safe spaces to play and
exercise, such as community playgrounds
and parks, and communities not designed to
encourage walking and physical activity. viii

While most of us can easily see the link between
eating too much, not exercising enough, and gaining
weight, there is another factor that contributes to
this growing problem: not eating enough – of the
right kinds of food, that is. Some children who are
overweight or obese are simply not getting the nutrition they need to grow up healthy.
In 2009, 22 percent of families with children under the age of six in the U.S. experienced food
insecurity, which is defined as not having access
to enough food for an active and healthy life. ix In
Arizona, the percentage of households receiving
food stamps almost doubled between 2007 and
2010 (6.9 percent to 13.2 percent, respectively). x , xi

Families that experience food insecurity tend to buy
more processed and fast foods that contribute to
overweight and obese children rather than lean cuts
of meat and fresh fruits and vegetables, which are
more expensive. Food security, especially access
to nutritious foods, is critical for ending both child
malnutrition and obesity.

WHY ARE OVERWEIGHT
KIDS A HEFTY PROBLEM
FOR ARIZONA?
Childhood obesity can have serious implications for
children’s learning, health and overall well-being.
Obesity is associated with delayed skill acquisition
in children as young as 2 to 3 years old. Overweight
or obese school age children are more likely to
miss more than two weeks of school in a year and
to repeat a grade in school. In one study, obese
children had rates of school absenteeism that were
20 percent greater than those of their non-obese
classmates. xii These patterns begin in infancy. At
a time when our state is focused on improving kids’
performance in school, we must consider the factors that keep our kids from showing up in the first
place.
In addition, overweight and obese children are more
likely to have high blood pressure, high cholesterol
and type 2 diabetes, which plce them at higher risk
for cardio vascular disease as adults. xiii In fact, if
childhood obesity trends continue, experts predict
it could cut two to five years off the lifespan of the
average child in America, making this the first generation to have a shorter life expectancy than their
parents. xiv

“ 30 percent of Arizona 2- to 4-year-olds
are overweight or obese. “

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FIRST THINGS FIRST’S
ROLE IN PROMOTING
HEALTHY WEIGHT FOR
YOUNG KIDS
The early years play a critical role in establishing
the foundation for a child’s educational success and
overall well-being. Recognizing this important fact,
Arizona voters in 2006 created First Things First (FTF)
to expand young children’s access to the services
that would help them arrive at kindergarten healthy
and prepared to succeed. In many Arizona communities, weight represents a significant health challenge for many kids 5 and younger. If not addressed,
that issue can also weigh heavily on their educational success. FTF helps to address these concerns
through strategies that increase young children’s
access to nutritious food, and that increase the
information that families and other caregivers have
in order to make the best food and activity choices
for young kids.
Through its Food Security strategy, First Things First
builds partnerships and provides funds to provide
food to families with young kids. This strategy builds
on existing food distribution networks like food
banks. The strategy supplements food distributed by
the organizations or distributes vouchers to families
to purchase food. Parent education on how to prepare nutritious food on a limited budget is included
in some locations. In fiscal year 2012, FTF’s Food
Security grantees distributed 466,453 food boxes to
families with kids 5 and younger.
In the current fiscal year, the First Things First
regional partnership councils that fund food security
strategies include: Central Maricopa, Central Phoenix, Cocopah Tribe, Gila River Indian Community,
Graham/Greenlee, Hualapai Tribe, La Paz/Mohave,
Navajo Nation, Northwest Maricopa, Pinal, Salt
River Pima Maricopa Indian Community, Southeast
Maricopa, Tohono O’odham Nation, Yavapai and
Yuma.

Through its Nutrition, Physical Activity and Obesity
Prevention strategy, First Things First focuses on
programs in three areas: parents and families, early
care and education settings, and communities.
Parent supports focus on parent education about
the nutritional needs of children, healthy activity,
and strategies to prevent childhood malnutrition
and obesity. In fiscal year 2012, 4,833 parents and
caregivers attended community-based classes on
nutrition, physical activity and obesity prevention in
a variety of community-based settings.
In early care and education settings, education and
training focuses on offering healthy food choices,
encouraging structured and unstructured play
time, and limiting screen time. First Things First
also supports efforts by the Arizona Department
of Health Services (DHS) to improve nutrition and
activity practices in licensed child care centers (see
EMPOWER box on Page 7).

“ Rates of childhood obesity have tripled
since the 1970s. “
In some of the First Things First regions, there are
community and child care gardens planned and
local policy discussions are being had related to
food deserts and increasing access to stores where
fresh fruits and vegetables are available.
In the current fiscal year, First Things First regional
partnership councils that fund a Nutrition, Physical
Activity and Obesity Prevention strategy include: Cochise, Colorado River Indian Tribes, Navajo Nation,
Navajo/Apache, Northwest & Southwest Maricopa,
and San Carlos Apache.

Next Steps for First Things First
1. In addition to the FTF connection with the
EMPOWER standards through DHS, a formal
partnership is being developed among FTF,
DHS and the Arizona Department of Economic
Security to maximize federal funding to improve
nutritional standards in child care settings.

insufficient amount. Only one in four said they ate
the recommended five or more servings of fruits and
vegetables each day. xv
Families and policymakers can:
•

2. FTF is developing a consistent message related to childhood nutrition across the programs
funded by FTF, including voluntary in-home
family support programs, community-based
family resource centers and programs that
improve the quality of child care. Using consistent language across all the programs that may
touch parents and caregivers will help ensure
that families and professionals working with our
youngest kids get the message about what it
takes to help kids develop habits that promote
healthy weight from the earliest stages of life.

IMPLICATIONS FOR
FAMILIES, POLICYMAKERS
AND COMMUNITIES
Young children’s eating and exercise habits are
affected by their environment at home and in their
communities. Because of this, strategies to enhance
nutrition and activity for young kids need to span the
home, early care and education programs, and the
broader community. In short, we all have a role to
play in preventing the battle of the bulge among kids
birth to 5 years old.

What Families and Policymakers
Can Do:
Families are the role models for children’s behaviors.
They select and prepare food and model a healthy
and active lifestyle. According to a 2010 survey, 10
percent of Arizona adults reported getting no physical activity at all and another 36 percent reported an

Support exclusive breastfeeding for the first
six months of a child’s life and continuation of
breastfeeding after the introduction of solid
foods at six months until 1 year of age or until
mutually desired. Mothers should be encouraged to initiate and continue breastfeeding
even when a mother returns to work. Policies
to provide designated space for breastfeeding areas within work places and child care
centers, as well as having a mechanism to store
breast milk in child care centers are important
supports. In addition to decreasing risk of
obesity, research shows that breastfed babies
have a decreased risk of Sudden Infant Death
Syndrome xvi and a significantly decreased risk
of developing Type 2 diabetes later in life. xvii

•

Educate and support families to include home
activities that focus on physical movement with
their children, including serving more nutritious
foods, reducing the use of high sugar drinks and
limiting their children’s time spent in in front of a
TV or computer.

•

Promote family-style meals and routine sleep
patterns. Research has shown that preschoolaged children exposed to three household
routines of regularly eating dinner as a family,
getting an adequate nighttime sleep, and limiting screen viewing time had a 40 percent lower
prevalence of obesity than children exposed to
none of these routines. xviii

•

And, ensure that families that qualify for the
WIC (Woman, Infants and Children) nutrition
program and SNAP (Supplemental Nutrition Assistance Program) are enrolled and know how
to use the WIC and SNAP benefits to access
healthy and affordable foods.

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What Early Care and Education
Providers Can Do
In Arizona, center-based early care and education
providers reported serving a little more than 100,000
children on an average day; this is about one in
every four children under the age of 6. xix In addition
60 percent of children who are under 6 years old
have both parents in the labor force; and they likely
spend all or some of their day being cared for by
family members, friends, or early care and education providers away from their homes. xx Not only do
these children receive daily meals in these settings,
they observe and learn habits of eating and activity
from their teachers and caregivers. Providing good
nutrition and promoting healthy behaviors in early
care and education settings are critical components
to combatting childhood obesity.

7

Center-based and home-based early care child
education providers can:
1. Incorporate the 10 EMPOWER elements
(see page 7) into their curriculum and activities
for children in child care. xxi
2. Support a mother’s ability to continue
breastfeeding infants and provide tools to store
breast milk on site.
3. Place an emphasis on healthy eating,
physical activity, and reinforcing positive body
image for children in the early care and education curriculum.
4. Increase opportunities for physical activity
and the development of fundamental movement
skills.
5. Improve the nutritional quality and diversity
of food offered to children.
6. Offer professional development to support
teachers and other staff in implementing health
promotion strategies and activities.
7. Offer farm-to-preschool opportunities connecting children and families to local produce
in their area.
8. And, offer on-site gardens or gardenbased curricula that connect children with their
source of their food to increase the likelihood
that they will try new fruits and vegetables.

“ Obesity has been linked to decreased skill
development, increased school absence and
poor school performance. “

Empower Pack Center Standards*
As part of its child care quality improvement efforts, FTF supports the EMPOWER Standards that DHS
is incorporating in to all licensed child care programs as a means to promote good health habits and
prevent childhood obesity. xxii This includes:
1) Encourage physical activity by scheduling at least 60 minutes of planned activity each day.
This can be broken up in shorter time periods throughout the day and should include “sun safe”
activities.
2) Limit kids’ screen time – including TV, computer and video games – to less than one hour per
day.
3)

Avoid more than 60 minutes of sedentary activity at a time, except when kids are sleeping.

4)

Offer water at least 4 times per day.

5)

Serve 1% or skim milk for all children over 2 years old.

6)

Limit fruit juice to 4 to 6 ounces per day, and serve only 100 percent fruit juice.

7) Serve meals family style and let children decide how much to eat. Avoid rewarding good
behavior or a clean plate with food of any kind.
8)

If able, participate in the USDA Child and Adults Care Food Program.

9)

Be a completely (24-hour) smoke-free home or campus.

10) At least four times per year, provide families with information about tobacco cessation and
second-hand smoke.

*Additional information is available at www.azdhs.gov

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What Communities Can Do
Communities are the places where children live and
play. Encouraging healthier community environments
promotes healthier lifestyle choices for kids and their
families.

Endnotes
i

Preschool Children: The Role of Control Attributions,” Journal of Pediatric Psychology, vol. 29 no. 8, Society of Pediatric Psychology.
ii

Ibid Musher-Eizenman, (2004).

iii

Health and Human Services Agency, Obesity Disparities Report at: http://aspe.hhs.gov/health/reports/child_obesity

iv

Center for Disease Control; National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity

Communities can:
•

•

•

Form community coalitions to promote healthier
food resources in the community, such as fruit
and vegetable choices in small grocery stores and
healthier choices in large chain grocery stores.
Include advocacy projects to promote healthier
community environments that encourage family
friendly physical activity, such as playgrounds,
walking trails, and community activities.
Implement community interventions such as child
care center gardens, farmers markets, community
gardens, and community planning that includes
healthier environments.

THE LAST BITE

Musher-Eizenman, D.R.; Holub, S.C.; Barnhart-Miller, A. Goldstein, S.E.; and, Edwards-Leeper, L., (2004). “Body Size Stigmatization in

and Obesity Prevention, ‘Obesity among low income preschool children’ 2009 Report http://www.cdc.gov/obesity/childhood/ and
http://www.cdc.gov/obesity/downloads/PedNSSFactSheet.pdf
v

Arizona Department of Health, The Obesity Epidemic, Dec. 2011 Report found at:

http://www.azdhs.gov/phs/bnp/nupao/documents/

ObesityInArizona_121611.pdf
vi

Nader, P.R., Huang, T.T., Gahagan, S., Kumanyika, S., Hammond, R.A., Christoffel, K.K. (2012, June). Next steps in obesity prevention:

vii

CDC National Immunization Surveys 2010 and 2011, Provisional Data, 2009 births. http://www.cdc.gov/breastfeeding/data/NIS_data/

altering early life systems to support healthy parents, infants, and toddlers. Child Obesity. 8(3):195-204.

index.htm
viii

Ritchie LD, Ivey SL, Woodward-Lopez G, Crawford PB. (2003). Alarming trends in pediatric overweight in the United States. Soc

ix

Feise, B. H., Gunderson, C., Koester, B., Washington, L.T. (2011) Household food insecurity: serious concerns for child development.

Preventive Medicine. 48(3):168-77.

Social Policy Report, 25:3; online ISSN 1075-7031 www.srcd.org/spr.html
x

Food Research and Action Center, Food Hardship in America 2010, Households with and without Children August 2011, accessed

xi

U. S. Census Bureau, American Community Survey, accessed September 30, 2011 at http://fact-finder.census.gov

xii

Ibid Ritchie, (2003).

xiii

Center for Disease Control; National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity

xiv

Ibid Nader, (2012).

xv

Ibid AZDHS, Obesity Epidemic (2011).

xvi

“Does Breastfeeding Reduce the Risk of Pediatrict Overweight?” National Center for Chronic Disease Prevention and Health Promotion,

xvii

“Breastfeeding, Diabetes, and Obesity.” Indian Health Service, Maternal Child Health. www.ihs.gov.

September 10, 2011 at http://frac.org/pdf/aug2011_food_hardship_report_children.pdf

and Obesity Prevention, http://www.cdc.gov/obesity/downloads/PedNSSFactSheet.pdf

Between birth and age 5, children are building habits
and forming attitudes that will stay with them their
entire lives. As caregivers and as individuals dedicated
to building better communities, we have the perfect
opportunity to reverse the disturbing trend of early
childhood obesity and instead give them a strong,
healthy start.

Division of Nutrition and Physical Activity, http://www.cdc.gov/nccdphp/dnpa/nutrition/pdf/breastfeeding_r2p.pdf

xviii Anderson, S.E. & Whitaker, R.C. (2012 March). Household Routines and Obesity in US Preschool-Aged Children. Pediatrics, 125 (3).
xix

Arizona Department of Economic Security Market Survey 2012 found at: https://www.azdes.gov/InternetFiles/Reports/pdf/

xx

Ibid US Census 2010 American Community Survey.

xxi

Arizona Department of Health Empower Pack Program at: http://azdhs.gov/empowerpack/

xxii

“State Efforts to Address Obesity Prevention in Child Care Quality Rating and Improvement Systems.” Altarum Institute Report, January

MarketRateSurvey2010.pdf and census 2010.

2012. www.altarum.org.

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