Recent reports from several countries have documented an increase in the prevalence of obesity among preschool children.^1–5 With its associated comorbid conditions⁶ and likelihood of persistence into adulthood,⁷ these trends pose a remarkable burden in terms of young children’s health and present and future health care costs. Therefore, the need to identify effective prevention of overweight and obesity among young children is urgent before a level of public health crisis is reached.

The importance of early child care settings—home/family, day care, kindergartens—in shaping children’s dietary intake, physical activity and energy balance, and consequently in combating the childhood obesity epidemic has been documented in a recent review⁸ and Chapter 30. The role of the home environment and parental dynamics in the development and maintenance of children’s healthy behaviors is multi-factorial. In addition, parental roles in preventing obesity change as their children move through critical developmental periods from before birth.⁹ An unfavorable prenatal environment (e.g., maternal undernutrition or overnutrition, smoking and diabetes mellitus) increases a future risk of developing obesity in the offspring.^8,10 During infancy, dietary factors such as the extent and duration of breastfeeding,^11–16 and the nutrient content and timing of introduction of complementary foods,^17,18 have been found to be associated with an increased risk of obesity in later childhood. Toshcke et al¹⁹ demonstrated that a combination of low meal frequency, decreased physical activity, watching television >1 h/day, formula feeding and smoking in pregnancy accounted for 48.2% of obese children aged 5–6 years. Modification of these risk factors will potentially yield a maximal achievable prevalence reduction of 1.5% for obesity (3.2% observed prevalence).¹⁹

As mothers increasingly work outside the home, the percentage of pre-school children being cared for outside the home has also increased. For that reason, parents and child-care providers are sharing responsibility in the formation of children’s healthy behaviors during these important early developmental years. Level of physical activity and quality of food in these centers^20,21 has the potential to contribute substantially to the observed acceleration of obesity among preschool children attending day care centers during the past two decades.²² A recent review of interventions in a variety of locations—home, day care, preschool, and clinic—to prevent or treat obesity among preschool children found seven studies of which four reported significant reduction in weight status or body fat.²³ Showing that interventions to reduce known risk factors from pregnancy through the early years in these settings has a great potential to prevent overweight and obesity in early childhood.

For this chapter we scanned and reviewed the published literature (e.g., PubMed and CINAHL) to select studies that were effective, and examined the key elements that were consistent across the studies. With input from both authors, the evidence was synthesized and integrated into recommendations. Although there is no specific focus on social inequalities, this chapter examines cultural and gender differences in intervention effects and also looks at both behavioral and environmental interventions to find equitable and sustainable solutions.

Concerning prenatal factors, a recent review of risk factors for overweight in preschool children found strong evidence for a direct association between childhood overweight and maternal pre-pregnancy body size, maternal weight gain and smoking during pregnancy.⁸ On the matter of interventions, there are currently four published studies on interventions to prevent excessive weight gain during pregnancy^24–27 and more than 50 randomized controlled studies on smoking cessation.^28–31 No studies evaluated the long-term effect on weight status of young children.

Only one of the four studies on gestational weight gain included birth weight as an outcome. Gray-Donald et al²⁴ based their design on social learning theory, compared 107 control subjects and 112 women who received diet and activity intervention during pregnancy in four Cree communities of James Bay, Quebec. Intervention consisted of regular, individual diet counseling, physical activity sessions and other activities related to nutrition, but did not result in differences in diet measured at 24–30 weeks’ gestation, and rate of weight gain over the second half of pregnancy (0.53 ± 0.32 kg per week vs. 0.53 ± 0.27 kg per week). Mean birth weights were also similar (3741 ± 523 g vs. 3686 ± 686 g).

A Cochrane review of interventions promoting smoking cessation published in 2004 shows that smoking cessation programs in pregnancy were effective at reducing the proportion of women who continued to smoke, and also reducing low birth weight and preterm birth.³¹ No studies investigated the effect on child obesity later in life.

Together, these studies demonstrate that pregnancy is an important time for intervention. At present, however, there are not enough studies to identify effective interventions during pregnancy for preventing obesity among infants and preschool children. More interventions need to be implemented and evaluated. Future studies should consider a multi-component approach and have a longer-term follow-up of child anthropometric outcome.

Numerous interventions have been conducted to promote breastfeeding.³² However, only one cluster-randomized trial of a breastfeeding promotion examined the effect on child weight status beyond infancy. From the total of 17,046 healthy breastfed infants enrolled in the Promotion of Breastfeeding Intervention Trial (PROBIT) in the Republic of Belarus, Kramer et al³³ followed 13,889 (81.5%) subjects with measurements of anthropometric variables and blood pressure at 6.5 years. The intervention led to a much greater prevalence of exclusive breast-feeding at three months in the experimental than in the control group (43.3% and 6.4%, respectively; P < 0.001) and a higher prevalence of any breastfeeding throughout infancy. At 6.5 years, no significant intervention effects were observed on anthropometric outcomes or blood pressure. This intervention, however, was designed to increase the degree and duration of breastfeeding and as a result of infant feeding supervision, mean weight-for-length z scores of PROBIT infants were well above the Centers for Disease Control and Prevention (CDC) reference throughout the first year.³⁴ With similar rapid weight gain in both groups, consequently, at 6.5 years no difference of anthropometric indices could be detected.

There is only one published report of randomized controlled trials using home/family setting to prevent overweight in young children.

Harvey-Berino and Rourke³⁵ evaluated the result of home visit to overweight Native American mothers (with body mass index > 25 kg/m²) of children aged 9 months to 3 years. Mothers were randomly assigned to receive weekly 1 hour home visits for 16 weeks from an indigenous peer educator who delivered a parenting skills program. For intervention group mothers (n = 20), the focus was on using the parenting skills to develop healthy eating and exercise behaviors in their children. Positive changes were reported between baseline and the 16-week follow-up for intervention compared with control group children (n = 20) with decreased weight-for-height z-scores (−0.27 vs. 0.31, P = 0.06), decreased total energy intake (−39.2 vs. 6.8 kcal/kg/day, P = 0.06) and reduced maternal use of restrictive child feeding practices (−0.22 vs. 0.08, P < 0.05). No differences were noted for children’s fat intake or physical activity, or for maternal BMI, diet or activity behaviors.

This study demonstrates that parents are receptive and capable of behavioral modification and, hence, weight reduction in preschool children. However, a small number of subjects and short duration limits its generalization. A recent review of interventions aimed at positively impacting on weight, physical activity, diet and sedentary behaviors in children from 0 to 5 years has found a number of family-based behavioral interventions, which showed some level of effectiveness to alter risk behaviors in young children.³⁶ Yet the interventions were predominately high-intensity, based on social behavioral theory, short term, of small sample sizes and did not include anthropometric assessments or cost–effectiveness analysis.³⁶ Clearly, more evaluated family-based or parent-based interventions targeting young children with a longer-term follow-up to demonstrate sustainability are needed. In addition, targeting parental behaviors may be more effective than interventions directed solely toward children, suggesting that modification of the child’s environment during early development may have a lasting effect.³⁷

Child-care settings offer untapped opportunities for developing and evaluating effective obesity prevention strategies to reach both children and their parents. Quite a few published obesity prevention studies among preschool children could be located. Among them, an intervention with diet and physical activity components is the common strategy and appears to achieve some level of effectiveness. Interventions to improve food and physical activity environment, curriculum and policies are also examined.

Dietary and/or physical activity/exercise interventions

Five reports have been published, from four child-care-based interventions aiming at healthy diet, increasing physical activity/exercise or reducing sedentary behavior to prevent obesity among preschool children.^38–42

Dennison et al³⁸ used a cluster randomized controlled trial to evaluate the efficacy of an intervention program delivered in preschool and day care facilities in rural upstate New York. The 39-week program was designed to change the television viewing, nutrition- and physical activity-related behaviors of the children aged 2.6 to 5.5 years using one-hour weekly sessions and involved eight intervention and eight control pre-school and day care facilities. The impacts assessed were behavioral (parent-reported) and anthropometric. It was found that after the intervention period, children in the intervention group (n = 90) decreased their television/video viewing by about 3 hours/week, whereas children in the control group (n = 73) increased their viewing by 1.6 hours/week, for a significant adjusted difference between the groups of −4.7 hours/week. In addition, the percentage of children watching television/videos more than 2 hours per day also decreased significantly among the intervention group, compared with an increase in the control group. Despite these behavioral changes, no statistically significant differences were found in children’s BMI or triceps skin-fold between groups.³⁸

Fitzgibbon et al assessed the impact of a randomized controlled trial with culturally proficient dietary/physical activity, the Hip-Hop to Health Jr, on changes in body mass index of 3- to 5-year-old minority children from schools randomized to a weight control intervention or to a control group that received a general health intervention.^39,40 Two cohorts of children participated in the trial: the first group of children attended 12 predominantly black preschools,³⁹ whereas the second cohort attended 12 predominantly Latino preschools.⁴⁰ Children in the six intervention schools received thrice-weekly lesson plans that incorporated two major components: (1) a 20-minute lesson that introduced a healthy eating or exercise concept with an activity, and (2) 20 minutes of ongoing physical activity for 14 weeks. Their parents received weekly newsletters with information mirroring the children’s curriculum. The control children in the other six centers received a general health intervention that did not address either diet or physical activity. The intervention children (99% Black) had significantly smaller increases in BMI compared with control children (80.7% Black, 12.7% Latino) at 1-year follow-up, 0.06 vs. 0.59 kg/m²; difference −0.53 kg/m² (95% CI − 0.91 to −0.14), P = 0.01; and at 2-year follow-up, 0.54 vs. 1.08 kg/m²; difference −0.54 kg/m² (95% CI −0.98 to −0.10), P = 0.02, with adjustment for baseline age and BMI. The only significant difference between intervention and control children in food intake/physical activity was the Year 1 difference in percentage of calories from saturated fat, 11.6% vs. 12.8% (P = 0.002). In the second cohort, with Latino children, there were no significant differences between intervention and control schools highlighting the need to modify intervention activities to the cultural context.

Mo-suwan et al⁴¹ examined the effect of a school-based aerobic exercise program on overweight indices of preschool children in Thailand. Half of the classes of second-year pupils of two schools were randomized into the intervention (mean age 4.5 ± 0.4 years, n = 145) or control (mean age 4.5 ± 0.4 years, n = 147) group. The intervention program included an extra 15-minute walk in the morning and a 20-minute aerobic exercise session in the afternoon three times per week. The exercise program was led by trained personnel and lasted about 30 weeks. This intervention program was provided in addition to the usual practices of the schools. At the initial evaluation at 29.6 weeks, a reduction of the prevalence of obesity in the intervention preschool children reached near statistical significance (P = 0.057). The study showed that intervention girls had a lower likelihood of having an increased BMI slope than control girls (odds ratio 0.32; 95%CI 0.18 to 0.56), while the opposite was true for boys (odds ratio 1.08; 95% CI 0.62 to 1.89). The significant difference may be related to gender roles and expectations in Thailand. At six months post-intervention, the prevalence of obesity in the control group decreased from 12.2% at baseline to 9.4% after the intervention, and was 10.8% at 29.6 weeks plus six months. In the exercise intervention group, the prevalence of obesity was 12.9% at baseline, 8.8% at 29.6 weeks and 10.2% six months later.⁴³

A randomized control trial carried out by Reilly et al⁴² examined the effect of an enhanced physical activity program implemented in nurseries in Scotland. The program consisted of three 30-minute sessions a week over 24 weeks, delivered by trained personnel, with additional home-based health education aimed to increase children’s physical activity through play and reduce sedentary behaviors. The total of 545 children from 36 nurseries in Glasgow, Scotland were randomized to either intervention (mean aged 4.2 ± 0.3 years, n = 268) or control group (mean aged 4.1 ± 0.3 years, n = 277). The evaluation found that the program had no significant effect on physical activity, sedentary behavior or body mass index. The only significant effect of the physical activity program was enhanced fundamental movement skills for intervention children compared to children in the control group at the six-month follow-up (P = 0.0027) after adjustment for sex and baseline performance.

These interventions achieved significant behavioral changes, yet only two produced some effects on prevention of obesity—one had a directed exercise program,⁴¹ the other included both diet and exercise components.³⁹ However, the effect was significant only among girls and not sustainable after six months post intervention in one study,⁴¹ while it was effective and sustainable only among Blacks³⁹ not the Latinos⁴⁰ in the other, suggesting that gender and cultural difference should be addressed in designing the intervention activities. The two studies that did not report significant reductions in weight status had similar intervention approaches and intensity, and a comparable number of participants in one study (but less in the other). However, the duration of follow-up was shorter. These equivocal results highlight the need for more studies to provide further evidence on effectiveness of these promising strategies.

Innovative educational program

For a young child, health and education are inseparable. There is no published evaluation of an educational program for young children on preventing obesity. The only published report, the “Color Me Healthy” intervention, evaluated program acceptability and implementation and children’s knowledge and some behaviors.⁴⁴ This educational program was implemented widely in North Carolina and was designed to increase physical activity and promote healthy eating in 4–5-year-old children through the development of fun, colorful and innovative educational materials. The content development was guided by social cognitive theory and the socio-ecological model. Trained child-care providers (1338 participants in 53 training sessions) delivered the program in a range of care settings and the eight-week follow-up evaluation showed that over 90% of providers reported increases in children’s physical activity, knowledge about movement and knowledge about healthy eating.⁴⁴ The train-the-trainer model in this intervention holds promise as a way of improving the child-care environment on a large scale and in a range of child-care settings. It will be important to determine the sustainability of the program and its ability to positively influence children’s risk and protective behaviors related to childhood obesity.

Interventions with an environmental focus

Child-care settings should provide an environment in which young children are offered nutritious foods and regular physical activity through structured and unstructured play, so that they learn these healthy lifestyle behaviors at an early age.²⁰ Thus child care plays a critical role in laying a foundation for healthy weight. Currently, there are four published studies of environmental interventions in child care.^45–48 One study reported self-assessment of the nutrition and physical activity child-care environment and its implementation, feasibility and acceptability; and found a variety of environmental improvements post-intervention.⁴⁵ Food and nutrition environments were the focus of interventions in the other studies.^46–48 Leahy et al⁴⁶ altered the energy density of a lunch entrée and determined the effect on 2- to 5-year-old children’s subsequent ad libitum intake of lunch. This intervention was found to be effective in reducing children’s energy intake from the entrée and total lunch energy intake. Matwiejczyk et al⁴⁷ evaluated an incentive initiative—the “Start Right Eat Right” award—that aimed to improve the nutrition provided to children attending child-care centers in South Australia. Substantial changes were reported in the food policies of the child-care centers and there was a resulting improvement in food provision and nutrition practices in these settings.

Children’s anthropometric measurement was included as the outcome in only one study. Williams et al⁴⁸ examined how a change in the school food service aimed at reducing saturated fat intake, without compromising energy intake or nutrient content of the available diet, modified serum cholesterol and weight status. The intervention was based on the Piaget Stage 2 Model, Social Learning Theory and High/Scope Active Learning. Nine Head Start Centers, which served predominantly minority children from families with incomes below the US poverty level. Children were assigned to one of the three study groups: a control group with a safety education curriculum but without food service modification (350 children aged 49.3 ± 6.1 months), an intervention group with food service modification plus a child/family nutrition education program (242 children aged 48.3 ± 6.9 months), or an intervention group with food service modification plus a safety curriculum (195 children aged 47.9 ± 6.4 months). Behavioral changes regarding participation either in the school meals program or in the take-home activities included in this program were not measured. At the end of the school year, there was a statistically significant difference in the change in weight–height ratio between the intervention and control groups among white children (n = 130), mean difference 0.034 (95% CI 0.023 to 0.045). However, no differences were observed for Black or Latino children. Despite some limitations, these results are encouraging in that a relatively simple intervention aimed at changing an important environmental component of school health (the food service) can have direct effects on energy intake and promote a healthier rate of weight gain as well as reduce a major CVD risk factor in a young minority population.

These approaches hold promise for creating communities that promote healthy weight for young children. They have the ability to shift social norms with regards to the policies and practices in child-care centers and subsequently affect individual behavior change in a way that is meaningful and sustainable. These studies now need to go further to evaluate the effectiveness of these environmental changes themselves, in order to reduce unhealthy weight gain in the children attending these centers over time.

The early childhood period holds promise as a time in which obesity prevention may be most effective. Interventions during pregnancy to promote optimum birth weight and interventions during early childhood to promote healthy eating and physical activity have a great potential to prevent childhood obesity.

Despite ample evidence on modifiable risk factors of overweight in early childhood which are amenable to effective prevention programs, relatively few published interventions focused on changes in weight status among infants and preschool children. In addition to the paucity of current published studies, the heterogeneous nature of the settings, methodologies, intervention strategies, definitions of obesity and outcome measures make it difficult to determine the most effective strategy or make recommendations on how to prevent obesity in the early childhood period. Despite the limitations of the available evidence, findings from these interventions provide a basis for further development of effective intervention strategies. Two of the four effective interventions included parent education programs^33,39 and another sent materials home to parents on a weekly basis.⁴⁸ As supported by the recent review of Bluford et al,²³ it seems sensible to recommend that interventions for children include parents and other adult role models (e.g., teachers) rather than children alone. However, more work is needed to examine how active parental involvement needs to be in intervention programs for young children.

Diet and exercise are the common strategies used. Gender and cultural differences were found to influence the effectiveness of the interventions,^39–41 thus an intervention program should be designed in a way to appropriately address inequalities, gender, ethnic and cultural aspects. Moreover, given the dynamicity of child development abilities during the early years, the nutrition and the physical activity components of the interventions also need to be tailored to age-specific abilities.²³

Consideration also needs to be given to the duration of intervention programs as the evidence demonstrates the need for a longer follow-up period of 1–2 years to assess change in weight status and increase the likelihood of adequately evaluating program impacts and sustainability.²³

In conclusion, given the potential for early intervention to have long-lasting impacts on individual and population health, more interventions need to be implemented and comprehensively evaluated to determine their effectiveness on reducing the prevalence of childhood obesity. A focus on interventions that involve the family and create sustainable environmental changes to promote quality nutrition and physical activity should be a priority.

1 Bundred P, Kitchiner D, Buchan L: Prevalence of overweight and obese children between 1989 and 1998: population based series of cross-sectional studies. BMJ 2001; 322: 313–314.

2 Herpertz-Dahlmann B, Geller F, Böhle C, Khalil C, Trost-Brinkhues G, Ziegler A, et al: Secular trends in body mass index measurements in preschool children from the City of Aachen, Germany. Eur J Pediatr 2003; 162: 104–109.

3 Ogden CL, Troiano RP, Briefel RR, Kuczmarski RJ, Flegal KM, Johnson CL, et al: Prevalence of overweight among preschool children in the United States, 1971 through 1994. Pediatrics 1997; 99: e1.

4 Reilly JJ, Dorosty A, Emmett PM: Prevalence of overweight and obesity in British children: cohort study. BMJ 1999; 319: ••–1039.

5 Sherry B, Mei Z, Scanlon KS, Mokdad AH, Grummer-Strawn LM: Trends in state-specific prevalence of over-weight and underweight in 2- through 4-year-old children from low-income families from 1989 through 2000. Arch Pediatr Adolesc Med 2004; 158: 1116–1124.

6 Baker S, Barlow S, Cochran W, Fuchs G, Klish W, Krebs N, et al: Overweight children and adolescents: a clinical report of the North American society for pediatric gastroenterology, hepatology and nutrition. J Pediatr Gastroenterol Nutr 2005; 40: 533–543.

7 Freedman DS, Srinivasan S, Valdez RA Williamson DF, Berenson GS: Secular increase in relative weight and adiposity among children over two decades: the Bogalusa heart Study. Pediatrics 1997; 99: 420–426.

8 Hawkins SS, Law C: A review of risk factors for overweight in preschool children: a policy perspective. Int J Pediatr Obes 2006; 1(4): 195–209.

9 Lindsay AC, Sussner KM, Kim J, Gortmaker S: The role of parents in preventing childhood obesity. Future Child 2006; 16: 169–186.

10 Whitaker RC, Dietz WW: Role of the prenatal environment in the development of obesity. J Pediatr 1998; 132: 768–776.

11 Arenz S, Ruckerl R, Koletzko B, von Kries R: Breast-feeding and childhood obesity—a systematic review. Int J Obes 2004; 28: 1247–1256.

12 Agras SW, Kraemer HC, Berkowitz RI, Hammer LD: Influence of early feeding style on adiposity at 6 years of age. J Pediatr 1990; 116: 805–809.

13 Gilman MW, Rifas-Shiman SS, Camargo CA, Jr., Berkey CS, Frazier AL, Rockett HR, et al: Risk of overweight among adolescents who were breastfed as infants. JAMA 2001; 285: 2461–2467.

14 Hediger ML, Ooverpeck M, Kuczmarski RJ, Ruan WJ: Association between infant breastfeeding and overweight in young children. JAMA 2001; 285: 2453–2460.

15 von Kries R, Koletzko B, Sauerwald T, von Mutius E, Barnert D, Grunert V, et al: Breast feeding and obesity: cross sectional study. BMJ 1999; 319: 147–150.

16 Owen CG, Martin RM, Whincup PH, Davey-Smith G, Gilman MW, Cook DG: The effect of breastfeeding on mean body mass index throughout life: a quantitative review of published and unpublished observational evidence. Am J Clin Nutr 2005; 82: 1298–1307.

17 Owen CG, Martin RM, Whuncup PH, Smith GD, Cook DG: Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence. Pediatrics 2005; 115: 1367–1377.

18 Toschke AM, Kuchenhoff H, Koletzko B, von Kries R: Meal frequency and childhood obesity. Obes Res 2005; 13: 1932–1938.

19 Toschke AM, Ruckinger S, Bohler E, Von Kries R: Adjusted population attributable fractions and preventable potential of risk factors for childhood obesity. Public Health Nutr 2007; 10(9): 902–906.

20 Story M, Kaphingst KM, French S: The role of child care settings in obesity prevention. Future Child 2006; 16(1): 143–168.

21 Vasquez F, Salazar G, Andrade M, Vasquez L, Diaz E: Energy balance and physical activity in obese children attending day-care centres. Eur J Clin Nutr 2006; 60(9): 1115–1121.

22 Velasquez MM, Salazar G, Vio F, Hernandez J, Rojas J: Nutritional status and body composition in Chilean pre-school children attending day care centers. Food Nutr Bull 2002; 23(3 Suppl.): 250–253.

23 Bluford DA, Sherry B, Scanlon KS: Interventions to prevent or treat obesity in preschool children: a review of evaluated programs. Obesity 2007; 15(6): 1356–1372.

24 Gray-Donald K, Robinson E, David K, Renaud L, Rodrigues S: Intervening to reduce weight gain in pregnancy and gestational diabetes mellitus in Cree communities: an evaluation. Can Med Assoc J 2000; 163: 1247–1251.

25 Kinnunen TI, Pasanen Fogelholm M, Aittasalo M, et al: Preventing excessive weight gain during pregnancy—a controlled trial in primary health care. Eur J Clin Nutr 2007; 61(7): 884–891.

26 Olson CM, Strawderman MS, Reed RG: Efficacy of an intervention to prevent excessive gestational weight gain. Am J Obstet Gynecol 2004; 191(2): 530–536.

27 Polley BA, Wing RR, Sims CJ: Randomized controlled trial to prevent excessive weight gain in pregnant women. Int J Obes Relat Metab Disord 2002; 26(11): 1494–1502.

28 Panjari M, Bel R, Bishop S, Astbury J, Rice G, Doery J: A randomized controlled trial of a smoking cessation intervention during pregnancy. Aust N Z J Obstet Gynaecol 1999; 39(3): 312–317.

29 Polanska K, Hanke W, Sobala W, John B, Lowe JB. Efficacy and effectiveness of the smoking cessation program for pregnant women. Int J Occup Med Environ Health 2004; 17(3): 369–377.

30 Wisborg K, Henriksen T, Jespersen LB, Secher NJ: Nicotine patches for pregnant smokers: a randomized controlled study. Obstet Gynecol 2000; 96: 967–971.

31 Lumley J, Oliver SS, Chamberlain C, Oakley L: Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2004; 4 (Art. No.: CD001055). doi: 10.1002/14651858.CD001055.pub2

32 Dyson L, McCormick FM, Renfrew MJ: Interventions for promoting the initiation of breastfeeding. Cochrane Database Syst Rev 2005; 2 (Art. No.: CD001688). doi: 10.1002/14651858. CD001688.pub2

33 Kramer MS, Matush L, Vanilovich I et al: Effects of prolonged and exclusive breastfeeding on child height, weight, adiposity, and blood pressure at age 6.5 y: evidence from a large randomized trial. Am J Clin Nutr 2007; 86(6): 1717–1721.

34 Kramer MS, Guo T, Platt RW, Sevkovskaya Z, Dzikovich I, Collet J-P, et al: Infant growth and health outcomes associated with 3 compared with 6 mo of exclusive breastfeeding. Am J Clin Nutr 2003; 78: 291–295.

35 Harvey-Berino J, Rourke J: Obesity prevention in preschool native-american children: a pilot study using home visiting. Obes Res 2003; 11(5): 606–611.

36 Campbell KJ, Hesketh KD: Strategies which aim to positively impact on weight, physical activity, diet and sedentary behaviours in children from zero to five years. A systematic review of the literature. Obes Rev 2007; 8(4): 327–338.

37 Golan M, Crow S: Targeting parents exclusively in the treatment of childhood obesity: long-term results. Obes Res 2004; 12(2): 357–361.

38 Dennison BA, Russo TJ, Burdick PA, Jenkins PL: An intervention to reduce television viewing by preschool children. Arch Pediatr Adolesc Med 2004; 158(2): 170–176.

39 Fitzgibbon ML, Stolley MR, Dyer AR, VanHorn L, KauferChristoffel K: A community-based obesity prevention program for minority children: rationale and study design for Hip-Hop to Health Jr. Prev Med 2002; 34(2): 289–297.

40 Fitzgibbon ML, Stolley MR, Schiffer L, Van Horn L, KauferChristoffel K, Dyer A: Hip-Hop to Health Jr. for Latino preschool children. Obesity (Silver Spring) 2006; 14(9): 1616–1625.

41 Mo-suwan L, Pongprapai S, Junjana C, Puetpaiboon A: Effects of a controlled trial of a school-based exercise program on the obesity indexes of preschool children. Am J Clin Nutr 1998; 68: 1006–1011.

42 Reilly JJ, Kelly L, Montgomery C, Williamson A, Fisher A, McColl JH, et al: Physical activity to prevent obesity in young children: cluster randomised controlled trial. BMJ 2006; 333: 1041.

43 Summerbell CD, Waters E, Edmunds LD, Kelly S, Brown T, Campbell KJ: Interventions for preventing obesity in children. Cochrane Database Syst Rev 2005; 3 (Art. No.: CD001871).

44 Dunn C, Thomas C, Ward D, Pegram L, Webber K, Cullitan C: Design and implementation of a nutrition and physical activity curriculum for child care settings. Prev Chronic Dis 2006; 3(2): A58.

45 Benjamin SE, Ammerman A, Sommers J, Dodds J, Neelon B, Ward DS, et al: Self-assessment for child care (NAP SACC): results from a pilot intervention. J Nutr Educ Behav 2007; 39(3): 142–149.

46 Leahy KE, Birch LL, Rolls BJ: Reducing the energy density of an entree decreases children’s energy intake at lunch. J Am Diet Assoc 2008; 108(1): 41–48.

47 Matwiejczyk L, Colmer K, McWhinnie J-A: An evaluation of a nutrition intervention at childcare centres in South Australia. Health Promot J Austr 2007; 18: 159–162.

48 Williams CL, Strobino B, Bollella M, Brotanek J: Cardiovascular risk reduction in preschool children: the “Healthy Start” project. J Am Coll Nutr 2004; 23(2): 117–123.