In the early 2000s, states began developing Quality Rating and Improvement Systems (QRIS) as a structural approach to improve the quality of Early Care and Education (ECE) programs. QRIS are voluntary or required systems designed to reach large numbers of ECE providers, particularly those serving lower-income children receiving child-care subsidies. The topics covered by QRIS (e.g., curriculum, workforce development, health and safety) vary by state. This study aimed to learn about strategies to promote healthy eating, breastfeeding, physical activity, and limit screen time (referred to as “HEPA”) in state QRIS implementation. The purpose of this report is to provide data, recommendations, and case study examples to state-level administrators and stakeholders on how to more effectively use QRIS as a lever for change in childhood obesity prevention. It also identifies opportunities for continued research to advance childhood obesity prevention in ECE settings. This report summarizes information learned from 24 states that have identified practices related to HEPA they want to promote via the state QRIS. Case studies from seven states (Arizona, Georgia, Idaho, Indiana, New Jersey, Oklahoma, and Wisconsin) highlight strategies to support ECE providers’ childhood obesity prevention efforts.