Additional strategies to prevent obesity and promote healthy eating, physical activity, and breastfeeding are supported by scientific evidence or expert judgment (2–9). Examples include requiring daily physical education in schools (5), designing communities to support physical activity (7), and improving the availability and promotion of healthier foods in the retail environment (2).
Percentage of secondary schools (middle schools and high schools) in the state that did not allow students to purchase less nutritious foods and beverages from vending machines, school stores, canteens, and snack bars.
| Rating | Percentage of secondary schools |
| Green | ≥66.6% |
| Yellow | 50.0%–66.5% |
| Red | <50.0% |
How These Ratings Were Determined
These ratings reflect the extent to which states’ secondary schools limited the sale of less nutritious foods and beverages. For a school to be identified as not selling less nutritious foods and beverages, the school principal had to respond “no” to each of the following five items on the CDC School Health Profiles principal questionnaire when asked whether students can purchase that item: 1) chocolate candy; 2) other kinds of candy; 3) salty snacks that are not low in fat, such as regular potato chips; 4) cookies, crackers, cakes, pastries, or other baked goods that are not low in fat; and 5) soda pop or fruit drinks that are not 100% juice (10). Data were collected prior to implementation of the Smart Snacks in School regulation and do not reflect impact of the regulation on school nutrition standards.
A state nutrition standards policy for sale of foods and beverages that meets the following criteria: 1) provides or references quantifiable nutrition standards (e.g., sets a maximum for the amount of sodium a food item can include) addressing four or more of the following nine foods or nutrients: fruits, vegetables, whole grains, water, added sugars, sodium, trans fat, saturated fat, and calories/portion sizes; 2) applies to all property and facilities owned, leased, or operated by the state executive branch; and 3) applies to two or more food service venues (e.g., vending machines, cafeterias, snack bars).
| Rating | State’s nutrition standards policy for sale of foods and beverages |
| Green | Provided or referenced quantifiable nutrition standards AND applied to two or more food service venues on state executive branch property |
| Yellow | Provided or referenced quantifiable nutrition standards AND applied to a single food service venue on state executive branch property |
| Red | Did not provide or reference quantifiable nutrition standards, did not apply to state executive branch property, OR no policy existed |
How These Ratings Were Determined
These ratings reflect whether states had a nutrition standards policy for sale of foods and beverages and the extent to which the policy meets the following three criteria: 1) provides or references quantifiable nutrition standards (11,12), 2) applies to all state executive branch property, and 3) applies to two or more food service venues.
A policy was defined as a regulation, statute, or executive order. Policies were identified by searching WestlawNext© (an online legal research system) for statutes and regulations and LexisNexis® (an online database) for executive orders. Ratings indicate the presence of a policy, not whether it was implemented. For the purposes of this report, correctional facilities, schools, nursing homes, and personal care homes were excluded from the analyses.
Inclusion of some or all of the 47 components of national standards considered to have a high impact for obesity prevention into state licensing regulations of childcare facilities.
| Rating | Number of components included in state licensing regulations |
| Green | ≥38 |
| Yellow | 24-37 |
| Red | <24 |
How These Ratings Were Determined
These ratings reflect the extent to which state licensing regulations for childcare facilities included the 47 recommended components of national standards considered to have a high impact for obesity prevention. Data were compiled from a report of the National Resource Center for Health and Safety in Child Care and Early Education (13). A state was considered to have included a component if its regulations for childcare centers, large family childcare homes, and small family childcare homes fully met the requirements of the component.
The average score for breastfeeding support in the state's participating birth facilities.
| Rating | State average birth facility score |
| Green | ≥80 |
| Yellow | 70–79 |
| Red | <70 |
How These Ratings Were Determined
These ratings reflect the extent to which birth facilities (e.g., hospitals and birth centers) within each state implemented multiple evidence-based strategies that support breastfeeding. State average birth facility scores were obtained from CDC’s National Survey of Maternity Practices in Infant Nutrition and Care (mPINC) (14). Each birth facility that responded to a self-administered survey was scored on multiple evidence-based practices that support breastfeeding across seven categories: 1) labor and delivery, 2) breastfeeding assistance, 3) mother-newborn contact, 4) newborn feeding practices, 5) breastfeeding support after discharge, 6) nurse/birth attendant breastfeeding training and education, and 7) structural and organizational factors related to breastfeeding. The total score can range from 0 to 100, with a higher score representing more support. The national average score across all states was 75.
**State count includes District of Columbia.
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