ONEt Shining Stars Childcare Family in San Francisco, infants and preschool children celebrate birthday with quinoa cake sweet only with sweet potatoes.
There is no juice in the snacks. Instead, children sip water with aromas of berries or cucumbers.
And they make a thirst, dance salsa and run around the threshold of the center.
Children may not know that they are participating in a research-supported obesity prevention program. They just know they "adore it," says owner Shining Stars Zonia Torres.
Researchers say early hygiene hugs are an essential ingredient in tackling an urgent problem: Preventing excessive weight gain in very young children.
Researchers have long known that heavy children often grow to become heavy teens and adults. However, the latest survey, a study followed by 50,000 German children, found a particularly high risk when children are very fast between two and six years.
An early weight gain "is the strongest predictor of subsequent obesity in adolescence," says Michael Freemark, a pediatric professor at the Duke University School of Medicine.
And the longer the child stays heavy, the more likely it is to keep the pounds, says Freemark, who wrote a syntax accompanying the study, published this month New England Journal of Medicine.
Many obese adults have never been obese, he says, but obese children and adolescents are at a very high risk of becoming obese adults.
Researchers do not make how much of the extra risk is genetic and how much it is driven by unhealthy habits and exposure to fast food, comfortable sofas and charming screens. It is likely, Freemark says, that an early weight gain changes the body in ways that make it harder to control weight later.
For the next 9 months, the USA TODAY intends to explore the key health challenges faced by people in the 50 states. This story is the second in this series. The first was about Alzheimer's.
The findings are at a time when obesity rates in the United States continue to rise. Nearly 40% of adults are now obese, according to the federal Centers for Disease Control and Prevention. Previous hopes of reducing childhood have been jeopardized by a recent study that found that 15% of children aged 2 to 5 were obese in 2015-16, from 11% in 2013-14.
A different and more encouraging survey by the Federal Special Nutrition Program for Women, Infants and Children (WIC) found that the obesity rate of 2 to 4 low-income children enrolled in the program fell to 14.5% in 2014, from 15.9% in 2010. The next round of WIC data since 2016 has not yet been released.
Whatever the exact number, Freemark wrote in his draft, it is clear that "we are now witnessing an evolving epidemic of childhood obesity" that puts young people at risk for possible complications ranging from type 2 diabetes to fatty liver disease.
And now we know, he says, that the first years are a critical window – and perhaps the best time to avoid future damage.
Parents are the key to prevention – but they face barriers
Alvin Eden, a pediatrician at Forest Hills, New York, and a pediatric clinical professor at Weill-Cornell Medical Center, has been involved for more than 40 years. He wrote his first book on obesity prevention in the mid-70s. the most recent is Preventing obesity for children: Before it's too late: Program for young children and preschool children.
"Many years ago, when I first started, I went to California and I visited Disneyland," Eden remembers. "As I walked along, I began to notice families where the mother and father were obese, and there would be three or four children behind them who were also obese.
"Then I went back and started to observe the same thing in my practice."
The number of obese parents and children in his office continues to increase, he says. He says he is trying to help high-risk families with simple science-based advice: Cut juices, add fruits and vegetables, take your child out to play, restrict television, sleep is a priority.
It also talks about the health consequences.
"There is more and more evidence that even one child in four or five people suffering from obese has already developed high cholesterol, higher blood pressure," he says. "The child is not going to suffer a heart attack now but is ready for it."
But even when parents are aware of the dangers, they may have difficulty following the guidelines set by pediatricians, dietitians and fitness teams.
John Auerbach is President and CEO of Trust for America's Health, a non-profit organization headquartered in Washington.
"Parents want their children to be healthy, but sometimes there are significant obstacles that can not be overcome," he says.
Fresh fruits and vegetables may be more expensive than snacks, he says. And many families, he says, do not live in neighborhoods where sidewalks, playgrounds and other benefits make physical activity an easy choice.
Auerbach says that communities, food traders and policy makers could do more to help.
Even the promising elements from the WIC show uneven progression. The percentage of obesity among children in this program ranged from 8.2% in Utah to 20% in Virginia in 2014. While rates have fallen to 31 states since 2010 – partly due to a healthier food mix introduced into the program in 2009 – four were up (Ohio, West Virginia, North Carolina and Nebraska), the CDC said and did not change to others.
Childcare centers can make a difference
One way in which states differ: how many obesity prevention practices require in childcare centers. For example, while all states require health care programs for licensed providers, only half of them have to follow US dietary guidelines, according to a recent report by the Auerbach team and the Robert Wood Johnson Foundation. Only nine states and the District of Columbia require at least one hour of moderate to intense physical activity in programs throughout the day. And only four states and health centers say they have to provide a private room for nursing mothers.
Utah, the state with the lowest childhood obesity rate in the WIC program, has 8 out of nine such policies recommended by the report.
Dianne Ward is a nutritionist at the University of North Carolina at Chapel Hill.
"Most parents want the best for their children," he says.
Ward has helped develop some of the best known obesity prevention practices in childcare centers. The program that Torres uses in San Francisco, called Healthy Apple, is run by the Children's Council of the City and uses materials developed in North Carolina.
The central element is a set of questionnaires used by providers to assess how well they incorporate healthy practices such as the abundant supply of water, vegetables and country play.
Providers choose the goals they want to follow and can attend workshops to learn how. They can earn awards for progress.
A pilot study published in 2017 found that the program slows down the weight gain in the children involved.
Ward says it's impossible to say how many childcare providers have changed their best practices as a result of such programs and the highest profile they have won during the campaign of former former Miss Michelle Obama's Let's Move.
But regardless of the progress that has been made, he says, "we have not done enough yet".
San Francisco, mother Lindsay Mason says she was lucky to find Torres's childcare center for her three-year-old daughter, Clare. Other places he considered were still "serving chicken fingers and hamburgers daily".
The Mason family has no history of obesity, he says, but has a history of diabetes. So she's happy her daughter learns a lot of good habits.
"We are confident that they feed on the right foods and know that they are not just standing in front of a television," says Mason. "She moves and learns to play and have fun with what kids do … It has a rich knowledge."