Although substantial evidence shows a positive association between nonparental child care arrangements and higher child weight status,1–6 the question of causality has remained wide open until now. In this issue of Pediatrics, Isong et al7 take some creative approaches to their analysis of cohort data to better understand the nature of the association. When using conventional models, analyses resulted in findings similar to previous studies: children in nonparental child care have a higher risk of subsequent obesity than children in parental care. However, when using models that adjust for the unmeasured confounders endemic to any nonexperimental study, no such association was found. The authors conclude that “unobserved” differences in family circumstances may contribute to parents’ selection of child care, which then confounds the association between child care and weight status.7 This article is interesting, has face validity, and certainly will help assuage working parents’ guilt: placing children in child care may not, in fact, put their children at risk for obesity. All this is reassuring, but leaves us with many unanswered questions ripe for research to guide policy and pediatric guidance.
The authors suggest further exploration of the factors impacting parents’ child care decisions.7 A recent literature review explored the child care decision-making process and identified numerous factors affecting parental child care decisions, including parent preferences and priorities, as well as common constraints and facilitators.8 Indeed, “health and safety” emerged as an important consideration. However, nowhere does the report mention dietary practices or physical activity options, or their contribution to health or obesity prevention, as factors. The only mention of diet is the idea that parents might like child care foods to reflect their own cultural preferences. The report, in combination with Isong et al’s7 article, call for further research to explore how the child care decision-making process is affected, if at all, by dietary and physical activity preferences. Are parents concerned about these issues and making early childhood care choices accordingly (ie, incorporating them into a subconscious sense of health)? Importantly, if so, do the care opportunities offering healthy meal and snack choices and generous time for physical activity cost prohibitively more than care options with less healthy offerings? If so, surely this is another stunning example of how poverty and obesity find an ultimately powerful intersection and how “choice” is not really choice after all.
The other important question the article raises is what role pediatricians can play in mitigating the effects of child care arrangement and weight status. The literature suggests that low-income parents, in particular, depend on people they trust to recommend child care options.8 Though this primarily includes family and friends, they are often receptive to suggestions from trusted professionals, such as pediatricians.9,10 A greater emphasis on the role of the pediatrician in recommending child care options may be critical to raising parents’ awareness of quality options available to them; the pediatrician may serve as an “informed advisor,” using their familiarity with the families’ individualized context and situation to promote care options. Pediatricians can also advise parents seeking high-quality child care arrangements to use resources like the Quality Rating and Improvement System to assess the quality of the child care program.8
In addition to providing child care selection guidance to parents, pediatricians can be important community advocates to improve quality child care standards, especially in regards to health promotion efforts surrounding eating and activity behaviors. Parents are restricted in their selection of arrangements by the options available to them; low-income parents perceive having limited options available and consider few when making their child care decisions. Raising licensure and Quality Rating and Improvement System standards would increase the availability of higher quality child care programs. It is important to make these programs not only available, but also more accessible, particularly to lower income families, where there already exists a disparity in childhood obesity rates.8
Isong et al7 show that it is not simply child care being “nonparental” that confers the obesity risk often observed with traditional models, but rather that unobserved, and at this point unknown, confounders drive the association between child care arrangement and child weight status. The facts that 61% of children are in some type of nonparental child care arrangement11 and that children in full-time, center-based care consume about half of their daily dietary intake on site and may receive most of their physical activity there as well4 show why these settings are crucial for promoting healthy eating and activity behaviors.12
Although the findings of Isong et al7 make it difficult to draw conclusions about what might be the most effective way to prevent obesity as it relates to child care arrangements, likely a wide net needs to be cast: a net that includes encouraging pediatrician advocacy for quality improvements and also emphasizes the role of pediatrician guidance in child care selection. Regardless of what the driving factor in the relationship is, it is important for providers to support the creation and expansion of environments that encourage healthy eating and physical activity, and to aid families in making decisions that fit their family context while promoting health. That net must also be a safety net that promotes policies aimed at improving quality standards in dietary and physical activity, such that no family has to choose between health and price.
- Accepted August 30, 2016.
- Address correspondence to Eliana M. Perrin, MD, MPH, Department of Pediatrics, 333 South Columbia St, 231 MacNider Building, CB 7225, Chapel Hill, NC 27599-7225. E-mail:
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2016-1539.
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- Copyright © 2016 by the American Academy of Pediatrics