Childcare in Infancy and Later Obesity: a Narrative Review of Longitudinal Studies

Confirmatory factor analysis of the infant feeding styles questionnaire in infant and toddler child care teachers

Early childhood is a critical time of development. Caregiver feeding style, including of child care providers, has been implicated in influencing children's food preferences and obesity. A better understanding of the determinants of child care providers' feeding styles is important as children increasingly receive daily care and nutrition in child care centers. Valid instruments to measure provider feeding styles specifically for infants are needed. This study's objective was to validate, for use with child care providers, the Infant Feeding Styles Questionnaire (IFSQ), an instrument originally designed for parents of infants and toddlers. Study data came from the Baby Nutrition and Physical Activity Self-Assessment for Child Care (Baby NAP SACC) study, a cluster randomized trial, designed to evaluate the efficacy of a six-month-long obesity prevention intervention in child care centers. The IFSQ was administered at baseline and follow-up to infant and toddler teacher participants (n = 244). Scores for baseline IFSQ teacher responses (n = 219) were calculated for the 13 sub-constructs across the five feeding styles. We tested reliability with Cronbach's alpha coefficients and performed confirmatory factor analysis to examine factor loadings and goodness of fit characteristics, modifying constructs to achieve best fit. Reliability coefficients ranged from 0.42 to 0.82 for all sub-constructs. Goodness of fit indices for the final model ranged from: root mean square error of approximation (RMSEA) 0.000-0.082; comparative fit index (CFI) 0.943-1.000; Tucker-Lewis index (TLI) 0.906-1.000; and standardized root mean squared error (SRMR) 0.006-0.130. In a sample of racially diverse infant and toddler child care teachers, final models of the laissez-faire, pressuring, and responsive constructs and the restrictive-diet quality sub-construct performed well. Overall model fit was poor for the indulgence construct, but good for solely its corresponding belief items.

Examination of dietary intake of UK preschool children by varying carers: evidence from the 2008-2016 UK National Diet and Nutrition Survey

Early years caregivers can play a key role in young children's eating and the prevention of childhood obesity. The UK National Diet and Nutrition Survey (NDNS) is a large representative survey collecting detailed food and nutrition consumption data. Using these data, the aim of this study was to investigate the relationship between dietary intake of preschool children in the UK aged 2 to 4 years and accompanying adult/s. Nutrition consumption data from 1218 preschool children from years 1 to 8 of the 2008-2016 NDNS were accessed. Dietary data were captured using 3 or 4 day estimated food diaries. Regression analyses revealed significant differences in consumption when children were not accompanied by their parents. Compared with when children were with parents, children consumed significantly more energy dense meals (0·32 kJ/g, 95% CI 0·1-0·6 kJ/g), energy (62 kJ/g, (95% CI 27-97 kJ)) Na (19 mg, (95 % CI 6, 32)), added sugars (0·6 g, (95 % CI 0·1, 1·1)), vegetables (3 g, (95 % CI 1, 4)), total grams (12 g, (95 % CI 3, 21)) and saturated fat (0·2 g, (95 % CI 0·1, 0·4)) per eating occasion when accompanied by wider family. When children were accompanied by a formal childcare provider, they consumed significantly lower energy dense meals (-0·9 kJ/g, (95% CI -1·4 - -0·3 kJ/g)), less added sugars (-1·6 g, (95 % CI -2·4, -0·8)) and more fruit (12 g, (95 % CI 3, 21)) per eating occasion than when they were with their parents. The results demonstrate that non-parental caregivers might be an important target to promote healthy eating in young children. Further research is needed to establish which caregivers would benefit most.

Feeding and Activity Environments for Infants and Toddlers in Childcare Centers and Family Childcare Homes in Southeastern New England

Few studies have documented the food and physical activity (PA) environments of childcare settings caring for children <24 months of age, although they may be key contributors to developing child PA and diet patterns. We used an adapted Environment and Policy Assessment and Observation tool to assess the food and activity environments for infants and toddlers in childcare centers (n = 21) and family childcare homes (FCCH) (n = 20) and explored differences by childcare type. Many similarities were found between childcare site types; however, centers used more recommended feeding practices than FCCH (e.g., 100% of center providers talked with toddlers about feelings of hunger or fullness compared to 18% of family childcare providers (FCCP), p < 0.01). Differences in non-recommended feeding practices (e.g., spoon feeding, bottle propping and encouraging unhealthy foods) were mixed between childcare types. Toddlers in centers spent more time playing at higher PA levels than those in FCCH (61 vs. 13 min, p < 0.001). Screen time was observed in FCCH, but not in centers. Differences between childcare types may indicate differential influences on infant and toddler feeding and PA behaviors, which could predict disparate obesity risk. Future research should further observe these behaviors in a larger sample of centers and FCCH to inform childcare interventions and policies.

Involvement of Non-Parental Caregivers in Obesity Prevention Interventions among 0-3-Year-Old Children: A Scoping Review

INTRODUCTION

We examined the scope of literature including non-parental caregiver involvement in child obesity prevention interventions.

METHODS

We conducted a scoping review following the Arksey and O'Malley framework, including only studies reporting the effect of an intervention on growth, weight, or early childhood obesity risk among children ages 0 to three years, published between 2000 and 2021. Interventions that did not include non-parental caregivers (adults regularly involved in childcare other than parents) were excluded.

RESULTS

Of the 14 studies that met the inclusion criteria, all were published between 2013 and 2020, and most interventions (n = 9) were implemented in the United States. Eight of the 14 interventions purposefully included other non-parental caregivers: five included both parents and non-parental caregivers, and the remaining three included only non-parental caregivers. Most interventions (n = 9) showed no significant impact on anthropometric outcomes. All interventions found improvements in at least one behavioral outcome (e.g., food groups intake (n = 5), parental feeding practices (n = 3), and screen time (n = 2)). This review can inform future interventions that plan to involve non-parental caregivers, which may be beneficial in shaping early health behaviors and preventing obesity early in life.

Effect of preschool childcare on school-aged children's adiposity in Quebec, Canada

BACKGROUND

Regulated public childcare must follow nutrition and physical activity guidelines, but the impact of public childcare on childhood adiposity is unclear.

OBJECTIVES

To estimate the effects of universal preschool childcare on children's BMI in elementary school in Quebec, Canada, and whether the effects differed in children from more or less advantaged families.

METHODS

For 1657 children enrolled in the Quebec Longitudinal Study of Child Development (1998-2010), BMI z-scores (BMIz) from 6 to 13 years were regressed on the childcare used from 2 to 5 years, adjusted for pre-childcare variables. Average treatment effects were estimated using the Bayesian multilevel linear regression and g-computation for four childcare profiles: 1) parental care or full-time care (35 hours/week) in a 2) centre-based, 3) regulated home-based or 4) unregulated home-based arrangement.

RESULTS

Had all participants attended centre-based care, mean BMIz in kindergarten would have been 0.38 (95% credible interval [CrI] 0.23, 0.52), which was 0.40 (95% CrI 0.14, 0.65) SD higher than regulated home-based, 0.20 (95% CrI -0.04, 0.43) SD higher than unregulated home-based and 0.36 (95% CrI 0.11, 0.60) SD higher than parental care. By 12 years, mean BMIz had increased for all childcare profiles, but differences between childcare profiles had diminished.

CONCLUSIONS

Although centre-based childcare was associated with an earlier rise in BMI, compared with informal care, it had no large, enduring effect, overall, or for less advantaged children, in particular.

Racial Disparities in Obesity Treatment Among Children and Adolescents

PURPOSE OF REVIEW

With the growing obesity epidemic among children and adolescents, the evaluation of disease origin to slow disease progression is necessary. Racial disparities which are evident amid prevalence and treatment must be studied to counteract disease propagation.

RECENT FINDINGS

Disparities are pronounced among Black and Hispanic pediatric patients prior to conception and birth due to genetic composition and fetal environment. Postnatal environment and psychosocial influences can further increase a child/adolescent's propensity to increased weight. Current treatment options including nutrition, physical activity, behavior modification, pharmacotherapy, and surgery are underutilized in communities of color due to limited access to care and cost. Data is limited to demonstrate disparities among treatment of obesity in children and adolescents. The reviewed studies show the role of race on disease treatment. Increased research efforts, especially in pharmacotherapy and metabolic and bariatric surgery (MBS), will help combat obesity in pediatric communities of color.

Evaluation of the impact of the Healthy Start/Départ Santé intervention on improving menu planning practices and improving the congruence between planned menus and actual food served in Saskatchewan childcare centres

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The majority of centres did not comply with the recommended nutrition guidelines.

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More than 50% of centres listed processed foods in amounts exceeding recommendations.

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The interventions may effectively improve the accuracy and reliability of menus.

The objective of this study was to evaluate the impact of the Healthy Start/Départ Santé (HS/DS) intervention program on improving menu planning practices and improving the congruence between planned menus and actual food served in licensed childcare centres in Saskatchewan.

Overall, 39 licensed childcare centres in the province of Saskatchewan, Canada, were selected through a cluster randomized control trial to evaluate the impact of the HS/DS intervention. The pre and post intervention food menus of these centres were analyzed and compared to the Saskatchewan Childcare Nutrition Guidelines (SCNG). The food and beverages served at lunch were observed and digitally recorded using digital plate-waste measures. The congruence between the planned menus and the actual food served was assessed. Descriptive analyses and non-parametric tests were performed to determine the impact of the intervention.

The results of this study indicated that there was no significant difference between the groups regarding the distribution and proportion of centres that adhered to the SCNG. The centres that received the intervention demonstrated significant improvements in adherence to their written menus, with the proportions of match between the items that served and listed (p-value = 0.029), and additional items served (p-value = 0.014). Within each group, intervention and usual practice, there were significant differences in centres that met the foods to limit guideline among the usual practice centres (p-value = 0.035). Findings from this study indicated that the HS/DS intervention had a positive impact on improving the adherence of the participating centres to the centres’ planned menus.

HS/DS trial registration number: NCT02375490.

Which Meso-Level Characteristics of Early Childhood Education and Care Centers Are Associated with Health, Health Behavior, and Well-Being of Young Children? Findings of a Scoping Review

Characteristics of early childhood education and care (ECEC) centers might be relevant for children's health. This scoping review aims to provide an overview of the association between meso-level characteristics (MLCs) of ECEC centers with children's health, health behavior, and wellbeing. Five databases were searched for quantitative and qualitative research articles published in English or German since 1 January 2000 on health, health behavior, and wellbeing of children aged 0 to 6 years considering MLCs of ECEC centers. Two authors screened 10,396 potentially eligible manuscripts and identified 117 papers, including 3077 examinations of the association between MLCs and children's health indicators (Kappas > 0.91). Five categories of MLCs were identified: (1) structural characteristics, (2) equipment/furnishings, (3) location, (4) facilities/environment, (5) culture/activities/policies/practices, and 6) staff. Only very few studies found an association of MLCs with body weight/obesity, and general health and wellbeing. Especially physical activity and mental health were related to MLCs. In general, the location (rural vs. urban, neighborhood status) seemed to be a relevant health aspect. MLCs of ECEC centers appeared relevant for child health indicators to different degrees. Future research should focus on these associations, in detail, to identify concrete ECEC indicators that can support health promotion in early childhood.

Dietary Contributors to Food Group Intake in Preschool Children Attending Family Childcare Homes: Differences between Latino and Non-Latino Providers

While there are several factors that contribute to the diet quality of children in childcare, one contributing factor in Family Childcare Homes (FCCHs) is the provider's ethnicity. However, research examining the food items provided in this setting is limited; in particular, with regards to differences between FCCHs of Latino and non-Latino providers. The aim of this study was to identify and describe the food items that contribute to food group intake in preschool-aged children attending FCCHs, and to examine differences by provider ethnicity. This secondary data analysis used baseline data from Healthy Start/Comienzos Sanos: a cluster-randomized trial. Children's dietary intake was collected using the Dietary Observation in Child Care method and entered into Nutrition Data System for Research software. Food groups were based on the Nutrition Coordinating Center classification. Contribution of food items to their respective food group was calculated as a proportion, using ratio of means and presented as a percentage. Ethnic differences were tested with ANCOVA (p < 0.05) with Bonferroni adjustments for multiple comparisons. All providers (n = 120) were female and 67.5% were Latino. Most fruit consumed by children was in the form of juice (85%), three-fourths of the grains consumed were refined (75%), and half of the sweets consumed were syrup/honey/jelly (50%). Most of the vegetables consumed were non-starchy (61%), nearly three-fourths of dairy consumed was low-fat (71%), and vegetable oils contributed the most to the fats group (89%). Food items differed by provider's ethnicity, with children cared for by non-Latino providers consuming a higher proportion of fruit juice, animal fats and a lower proportion of legumes (p < 0.001 for all). Children with Latino providers consumed a lower proportion of non-starchy vegetables, low-fat dairy, and nuts/seeds (p < 0.001 for all). FCCH providers could offer more whole fruits and grains and a greater variety of vegetables. Differences by ethnicity suggest providers could benefit from culturally tailored recommendations.

Associations of childcare type, age at start, and intensity with body mass index trajectories from 10 to 42 years of age in the 1970 British Cohort Study

BACKGROUND

Attending childcare is related to greater childhood obesity risk, but there are few long-term follow-up studies. We aimed to examine the associations of childcare type, age at start, and intensity with body mass index body mass index (BMI) trajectories from ages 10 to 42 years.

METHODS

The sample comprised 8234 individuals in the 1970 British Cohort Study, who had data on childcare attendance (no, yes), type (formal, informal), age at start (4-5, 3-3.99, 0-2.99 years old), and intensity (1, 2, 3, 4-5 days/week) reported at age 5 years and 32 563 BMI observations. Multilevel linear spline models were used to estimate the association of each exposure with the sample-average BMI trajectory, with covariate adjustment. A combined age at start and intensity exposure was also examined.

RESULTS

Attending vs not attending and the type of childcare (none vs formal/informal) were not strongly related to BMI trajectories. Among participants who attended childcare 1 to 2 days a week, those who started when 3 to 3.99 years old had a 0.197 (-0.004, 0.399) kg/m² higher BMI at age 10 years than those who started when 4 to 5 years old, and those who started when 0 to 2.99 years old had a 0.289 (0.049, 0.529) kg/m² higher BMI. A similar dose-response pattern for intensity was observed when holding age at start constant. By age 42 years, individuals who started childcare at age 0 to 2.99 years and attended 3 to 5 days/week had a 1.356 kg/m² (0.637, 2.075) higher BMI than individuals who started at age 4 to 5 years and attended 1 to 2 days/week.

CONCLUSIONS

Children who start childcare earlier and/or attend more frequently may have greater long-term obesity risk.

Early Child Care and Weight Status in a Cohort of Predominantly Black Infants in the Southeastern United States

Background: Previous studies show inconsistent relations between child care and obesity, but few assessed longitudinal associations during infancy and even fewer included racially diverse children. We examined associations of time infants spent in child care, both overall and in different types of care, with weight status at 6 and 12 months. Methods: We examined 664 infants living in central North Carolina. We conducted adjusted multivariable linear regressions examining (1) child care from birth to 6 months and 6-month weight-for-length (WFL) z-score, and (2) child care from birth to 12 months and 12-month WFL z-score. We assessed any child care and child care by type, including relative care, informal care by a nonrelative, formal child care, and a combination of care (e.g., relative and informal care). Results: Nearly 70% of infants were black and 49% were female. After adjustment for potential confounders, any child care was not associated with WFL z-score at 6 months (0.07; 95% confidence intervals [CI] -0.02 to 0.16; p = 0.13) or 12 months (0.05; 95% CI -0.02 to 0.12; p = 0.19). However, greater combination care was associated with higher WFL z-score at 6 months (0.68; 95% CI 0.23-1.13; p = 0.003) and greater care by a relative was associated with higher WFL z-score at 12 months (0.16; 95% CI 0.05-0.26; p = 0.005). Conclusions: Although we did not observe associations with any child care, combination care and relative care during infancy were associated with higher weight. Interventions aimed at preventing excessive weight gain in early life may target relatives who provide regular care for infants.

Relationship Between Early Childhood Non-Parental Childcare and Diet, Physical Activity, Sedentary Behaviour, and Sleep: A Systematic Review of Longitudinal Studies

The rising prevalence of childhood obesity is a global public health concern. Evidence suggests that exposure to non-parental childcare before age six years is associated with development of obesity, diet, and activity behaviours (physical activity, sedentary behaviour, and sleep). However, findings are inconsistent and mostly from cross-sectional studies, making it difficult to identify the direction of causation in associations. This review identified and synthesised the published research on longitudinal associations between non-parental childcare during early childhood, diet, and activity behaviours. Seven databases were searched, and results were independently double-screened through title/abstract and full-text stages. Included studies were evaluated for risk of bias. Of the 18,793 references screened, 13 met eligibility criteria and were included in the review. These presented results on 89 tested childcare/outcome associations, 63 testing diet outcomes (59% null, remainder mixed), and 26 testing activity behaviour outcomes (85% null, remainder mixed). The scarce available literature indicates little and mixed evidence of a longitudinal association. This reflects a paucity of research, rather than clear evidence of no effect. There is an urgent need for studies investigating the longitudinal associations of non-parental childcare on diet and activity behaviours to assess potential lasting effects and mechanisms; whether and how effects vary by provider; and differences by intensity, duration, and population sub-groups.

Association Between Mothers' Problematic Internet Use and the Thinness of Their Children

This study aimed to clarify the association between mothers' problematic Internet use (PIU) and the thinness of their children. We analyzed data collected from health examinations of young children aged 4 months, 1.5 years, and 3 years of age performed in Matsue city, Japan, between April 2016 and March 2017. The subjects comprised 1,685 (866 boys, 819 girls) children aged 4 months, 1,728 (898 boys, 830 girls) aged 1.5 years, and 1,672 (802 boys, 870 girls) aged 3 years. Logistic regression analysis was used to clarify the association between mothers' PIU (Young's Diagnostic Questionnaire for Internet Addiction score: ≥4) and the thinness (body mass index: <15) of their children after adjusting for covariates such as birth weight, nutritional form, parental smoking status, maternal age, skipping breakfast, eating snacks, sleeping late, outdoor play, and daytime caregiver. Analysis after stratification by sex and age revealed that the mothers' PIU was significantly associated with their children's thinness only in boys aged 4 months or 1.5 years (odds ratio [OR] = 3.16, 95% confidence interval [CI] = 1.00-9.96 and OR = 2.68, 95% CI = 1.04-6.89, respectively). Mothers' PIU may promote thinness among boys aged <3 years. As the nutritional status of children aged <3 years is affected by maternal feeding attitudes, our findings suggested that mothers who exhibit PIU do not provide adequate care for their children, particularly regarding feeding. In contrast, no association between mothers' PIU and their children's thinness was observed in girls.

A qualitative insight into informal childcare and childhood obesity in children aged 0-5 years in the UK

BACKGROUND

Previous studies in various countries have found that informal childcare (provided by relatives, friends etc.) was associated with an increased risk of obesity in children aged 0-5 years. However, no qualitative research has been done to explore possible reasons for such a relationship and potential interventions to tackle it. We conducted a qualitative study with both parents and informal carers to explore their 1) experiences in receiving or giving informal childcare for British children aged 0-5 years; 2) perceived explanations of the relationship between informal childcare and childhood obesity and 3) preferred intervention ideas and delivery strategies for preventing obesity among those children under informal care.

METHODS

Four in-depth focus groups with a total of 14 participants (7 parents, 7 informal caregivers) were conducted in Birmingham and Edinburgh (1 parent group and 1 informal caregiver group in each city). Data were audio recorded, transcribed verbatim and analysed using a thematic approach.

RESULTS

The significance of informal care to parents, carers, and society was recognised (theme one). Informal carers were identified to have practical and emotional support roles for the parents (theme two). Informal care was perceived to contribute to childhood obesity in four ways (theme three): cross-generation conflict preventing adoption of healthy practices; the trade-off for parents between receiving childcare and maintaining control; reduced energy capacity of carers; and increased snacking. Potential intervention ideas and delivery strategies (theme four) were identified. Examples of identified ideas included providing carers with up-to-date weaning advice, and suggestions of healthy snacks and ways to increase physical activity level in informal care. The suggestion of utilising existing primary care platforms (e.g. health visitor check-ups) to reach and deliver low-cost information based interventions, to all children aged 0-5 years who receive informal care, was highlighted.

CONCLUSIONS

This exploratory qualitative study provided novel insights into potential explanations for the evidenced link between informal care and childhood obesity in children aged 0-5 years, despite a small size and limited participants in each focus group. Our findings support the idea of and inform the development towards an information based and low-cost intervention delivered through existing primary care platforms.

How does the UK childcare energy-balance environment influence anthropometry of children aged 3-4 years? A cross-sectional exploration

OBJECTIVES

To assess the association between time spent in care, the childcare energy-balance environment, and preschool-aged children's body mass index z-score (z-BMI), waist-to-height ratio (WHR) and sum of skinfold thickness (SST).

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Children aged 3-4 years were recruited from 30 childcare centres in Cambridgeshire (UK) in 2013.

MAIN OUTCOME MEASURES

Objectively measured height and weight was used to calculate z-BMI; waist circumference and height were used to generate WHR; subscapular and tricep skinfolds were used to calculate SST. Associations between childcare attendance, the nutrition, physical activity, and overall childcare environment, and three anthropometric outcomes were explored using two-level hierarchical regression models, adjusting for demographic and family based confounders.

RESULTS

Valid data were available for 196 children (49% female). Time spent in care, the nutrition, physical activity and overall childcare environment were not associated with children's z-BMI, WHR and SST.

CONCLUSIONS

Childcare environment and level of attendance were not associated with UK preschool-aged children's anthropometry. The childcare environment has been central to intervention efforts to prevent/reduce early childhood obesity, yet other factors, including child-level, family level, wider environmental and policy-level factors warrant substantial attention when considering obesity prevention strategies for young children.

State Variations in Infant Feeding Regulations for Child Care

OBJECTIVES

Early care and education (ECE) settings have become primary targets for policy change in recent years. In our 2008 study, we assessed state and regional variation in infant feeding regulations for ECE and compared them to national standards. We conducted the same regulatory review to assess change over time. Because all but 2 states have updated their regulations, we hypothesized that states would have made substantial improvements in the number of regulations supporting infant feeding in ECE.

METHODS

For this cross-sectional study, we reviewed infant feeding regulations for all US states for child care centers (centers) and family child care homes (homes). We compared regulations with 10 national standards and assessed the number of new regulations consistent with these standards since our previous review.

RESULTS

Comparing results from 2008 and 2016, we observed significant improvements in 7 of the 10 standards for centers and 4 of the 10 standards for homes. Delaware was the only state with regulations meeting 9 of the 10 standards for centers in 2008. In 2016, Delaware and Michigan had regulations meeting 8 of the 10 standards. Previously, Arkansas, the District of Columbia, Minnesota, Mississippi, Ohio, and South Carolina had regulations consistent with 4 of the 10 standards for homes. In 2016, Delaware, Mississippi, and Vermont had regulations meeting 7 of the 10 standards.

CONCLUSIONS

Evidence suggests that enacting new regulations may improve child health outcomes. Given that many states recently enacted regulations governing infant feeding, our findings point to the growing interest in this area.