Comparing the nutrition environment and practices of home- and centre-based child-care facilities

Food environment research in Canada: a rapid review of methodologies and measures deployed between 2010 and 2021

Numerous research methodologies have been used to examine food environments. Existing reviews synthesizing food environment measures have examined a limited number of domains or settings and none have specifically targeted Canada. This rapid review aimed to 1) map research methodologies and measures that have been used to assess food environments; 2) examine what food environment dimensions and equity related-factors have been assessed; and 3) identify research gaps and priorities to guide future research. A systematic search of primary articles evaluating the Canadian food environment in a real-world setting was conducted. Publications in English or French published in peer-reviewed journals between January 1 2010 and June 17 2021 and indexed in Web of Science, CAB Abstracts and Ovid MEDLINE were considered. The search strategy adapted an internationally-adopted food environment monitoring framework covering 7 domains (Food Marketing; Labelling; Prices; Provision; Composition; Retail; and Trade and Investment). The final sample included 220 articles. Overall, Trade and Investment (1%, n = 2), Labelling (7%, n = 15) and, to a lesser extent, Prices (14%, n = 30) were the least studied domains in Canada. Among Provision articles, healthcare (2%, n = 1) settings were underrepresented compared to school (67%, n = 28) and recreation and sport (24%, n = 10) settings, as was the food service industry (14%, n = 6) compared to grocery stores (86%, n = 36) in the Composition domain. The study identified a vast selection of measures employed in Canada overall and within single domains. Equity-related factors were only examined in half of articles (n = 108), mostly related to Retail (n = 81). A number of gaps remain that prevent a holistic and systems-level analysis of food environments in Canada. As Canada continues to implement policies to improve the quality of food environments in order to improve dietary patterns, targeted research to address identified gaps and harmonize methods across studies will help evaluate policy impact over time.

Nutrition Practices of Family Child Care Home Providers and Children's Diet Quality

OBJECTIVE

To examine the relationship between the diet quality of children aged 2-5 years cared for in family child care homes (FCCHs) with provider adherence to nutrition best practices.

DESIGN

Cross-sectional analysis.

PARTICIPANTS

Family child care home providers (n = 120, 100% female, 67.5% Latinx) and children (n = 370, 51% female, 58% Latinx) enrolled in a cluster-randomized trial.

MAIN OUTCOME MEASURES

Data were collected over 2 days at each FCCH. The Environment and Policy Assessment and Observation tool was used to document whether providers exhibited nutrition practices on the basis of the Nutrition and Physical Activity Self-Assessment for Child Care. Each practice was scored as either present or absent. Children's food intake was observed using Diet Observation at Child Care and analyzed with the Healthy Eating Index-2015.

ANALYSIS

Multilevel linear regression models assessed the association between providers exhibiting best practices regarding nutrition and children's diet quality. The model accounted for clustering by FCCH and controlled for provider ethnicity, income level, and multiple comparisons.

RESULTS

Children in FCCHs in which more of the best practices were implemented had higher diet quality (B = 1.05; 95% confidence interval [CI], 0.12-1.99; P = 0.03). Specifically, children whose providers promoted autonomous feeding (B = 27.52; 95% CI, 21.02-34.02; P < 0.001) and provided nutrition education (B = 7.76; 95% CI, 3.29-12.23; P = 0.001) had higher total Healthy Eating Index scores.

CONCLUSIONS AND IMPLICATIONS

Future interventions and policies could support FCCH providers in implementing important practices such as autonomy feeding practices, talking informally to children about nutrition, and providing healthful foods and beverages.

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.

Creating "Plates" to Evaluate Canadians' Dietary Intake in Relation to the 2019 Canada's Food Guide

Purpose: Explore Canadians' dietary intake in relation to the 2019 Canada's Food Guide (CFG) Plate using novel volume-based food analyses, by age and meal occasion.Methods: Foods reported in 24-hour recalls by 20,456 Canadians in the 2015 Canadian Community Health Survey - Nutrition were classified as: Vegetables and Fruits, Whole Grain Foods, Protein Foods, Non-Whole Grain Foods or Other Foods (high in fat, sugar, sodium). Food volumes were used to calculate percent contributions of each grouping to total intake, stratified by age (1-6; 7-12; 13-17; 18-64; 65+years) and meal (breakfast, lunch, supper, snack), applying sample survey weights and bootstrapping.Results: By volume, the Canadian population diet included: 29% Vegetables and Fruits, 22% Protein Foods, 7% Whole Grains, 24% Non-Whole Grain Foods, and 18% Other Foods. Intakes of Protein Foods (1-6 years) and Other Foods (7-12; 13-17 years) were higher in children than adults by volume, relative to total intake. Whole Grains intake was highest at breakfast. Other Foods intake was highest at snack.Conclusions: The volume-based population diet of Canadians reported on a single day includes a substantial proportion of non-recommended foods. There are opportunities to design interventions that target specific foods, ages, and meals to align intake with recommendations.

Assessment of Feeding Practices and Mealtime Environments in Australian Family Daycare Services

OBJECTIVE

Assess educators' feeding practices and mealtime environments in family daycare services and examine the factors associated with educators' feeding practices and mealtime environments.

METHODS

Cross-sectional observational study of family daycare services (n = 33) in Australia. Best practices for mealtime environments and educator feeding practices were assessed during each mealtime using the Environment Policy Assessment and Observation instrument. Correlates assessed via survey included: socioeconomic status, main language spoken at home, early childhood career experience, and nutrition professional development. Descriptive statistics and independent t tests were calculated.

RESULTS

Educators typically had higher scores, indicating better practices, for (the absence of) negative practices compared with positive practices. The only positive practice meeting best-practice standards was educators sitting with children during the meal. There were no significant correlations for educators' feeding practices or mealtime environment.

CONCLUSIONS AND IMPLICATIONS

Educators may benefit from professional development targeting positive feeding practices and supportive mealtime environments.

Quality of Nutrition Environments, Menus and Foods Served, and Food Program Achievement in Oklahoma Family Child Care Homes

Child care environments foster children's healthy eating habits by providing exposure to healthy foods and feeding practices. We assessed the healthfulness of nutrition environments, menu/meal quality, and the achievement of Child and Adult Care Food Program (CACFP) guidelines and best practices in Oklahoma CACFP-enrolled family child care homes (FCCHs) (n = 51). Two-day classroom observations were conducted. Healthfulness of classroom nutrition environments was assessed using the Environment and Policy Assessment and Observation (EPAO). Foods served to and consumed by children were quantified using the Dietary Observations in Child Care (DOCC) tool. Nutrient analysis was performed to determine total energy for foods listed on menus, served to, and consumed by children. Menu and meal food variety and CACFP Guideline Achievement Scores were determined. Average nutrition environment score was 11.7 ± 1.2 (61.5% of maximum possible score). Energy (kcals) from menus and consumed by children was insufficient to meet two-thirds of their daily reference intake. Children were exposed to 1.7 vegetables and 1.3 fruits per meal. CACFP Guideline Achievement Scores were 66.3% ± 7.8 for menus and 59.3% ± 7.6 for mealtimes. Similar to previous research, our findings indicate a need for improved FCCH nutrition practices. Tailored interventions for FCCHs are needed.

Changing the preschool setting to promote healthy energy balance-related behaviours of preschoolers: a qualitative and quantitative process evaluation of the SuperFIT approach

Background

The Early Care and Education (ECE) setting plays an important role in the promotion of a healthy lifestyle in young children. SuperFIT is a comprehensive, integrated intervention approach designed to promote healthy energy balance-related behaviours in preschoolers. Insight in the process of implementation and the context in which SuperFIT was implemented supports the understanding of how the intervention works in practice. This process evaluation examined factors that influenced the implementation and maintenance, as well as the (perceived) changes in the ECE setting.

Methods

A mixed-methods study was conducted. SuperFIT was implemented at twelve preschools in the south of the Netherlands. The process evaluation was performed among preschool teachers, managers of the preschool organisation, and implementers. Semi-structured in-depth (group) interviews, quantitative process questionnaires, the Child-care Food and Activity Practices Questionnaire (CFAPQ) and the Environmental and Policy Assessment and Observation (EPAO) were used to evaluate the implementation and maintenance of SuperFIT and the changes in the preschool setting. The interviews were analysed using a theoretical framework based on the Implementation Framework of Fleuren and Damschröder’s Consolidated Framework for Implementation Research. Descriptive analyses were performed on the quantitative data.

Results

Various intervention activities were implemented in the preschool setting. Although the intention to maintain SuperFIT was present, this was hindered by time constraints and lack of financial resources. Important factors that influenced implementation and maintenance were incongruence with current practice, limited perceived capabilities to integrate SuperFIT in daily practice, group composition at the preschools, and the perceived top-down implementation. Organizational vision and societal attention regarding healthy behaviour in general were perceived to be supportive for implementation and maintenance. Predominantly, favourable changes were seen in the nutrition- and physical activity-related practices of preschool teachers and other aspects of the social preschool environment such as the use of play materials. Limited changes were observed in the physical preschool environment.

Conclusions

Several factors influenced the implementation and maintenance of SuperFIT in the preschool setting. Some factors evolved over time from hindering to facilitating, emphasising the importance of allowing sufficient time for intervention implementation. SuperFIT changed mainly the social preschool environment.

Trial registration

Clinicaltrials.gov, NCT03021980, date registered: January 16, 2017, prospectively registered

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01161-9.

Family Child Care Providers' Nutrition Practices and Policies: Happy Healthy Homes

OBJECTIVE

Determine the impact of family child care home providers' nutrition knowledge, confidence, and perceived barriers on program nutrition best practices and written nutrition policies.

METHODS

Cross-sectional analysis of self-reported surveys of 49 female providers in Oklahoma City analyzed with Spearman correlation, multivariate linear and logistic regression (α < 0.05).

RESULTS

Confidence and barriers were significantly correlated (r_s(47) = -0.4, P = 0.004). Independent variables explained 36% of practices (r² = 0.357). Nutrition knowledge (standard β = 0.442, P = 0.001) and confidence (standard β = 0.358, P = 0.008) were significantly associated with practices; barriers were not. No significant association between independent variables and written policies resulted.

CONCLUSIONS AND IMPLICATIONS

Provider nutrition knowledge and confidence appear to be suitable targets to improve nutrition practices. Further research can evaluate possible influences on the presence and quality of family child care home written nutrition policies and specific nutrition policy topics associated with healthier nutrition practices.

Gaps in Nutrition Policy Implementation in Childcare Centres in The Edmonton Metropolitan Region: A Cross-Sectional Survey

Purpose: To describe (i) nutrition policies in childcare centres, (ii) the resources and processes used to enable policy implementation, and (iii) the association between policy implementation and childcare centres' or administrators' characteristics.Methods: Between October 2018 and June 2019 a web-based survey that addressed nutrition policy, policy implementation, and sociodemographic characteristics was sent to eligible childcare programs (centre-based and provided meals) in the Edmonton (Alberta) metropolitan region. The survey was pretested and pilot tested. Statistical tests examined the relationship between policy implementation with centres' and administrators' characteristics.Results: Of 312 childcare centres that received the survey invitation, 43 completed it. The majority of centres had a nutrition policy in place (94%). On average, centres had about 9 of the 17 implementation resources and processes assessed. Most often administrators reported actively encouraging the implementation of the nutrition policy (n = 35; 87%) and least often writing evaluation reports of the implementation of the nutrition policy (n = 9; 22%). Administrator's education level was associated with implementation total score (p = 0.009; Kruskal-Wallis).Conclusion: Most childcare centres had a nutrition policy in place, but many lacked resources and processes to enable policy implementation. Additional support is required to improve nutrition policy development and implementation.

An Overview of Research Opportunities to Increase the Impact of Nutrition Intervention Research in Early Childhood and Education Care Settings According to the RE-AIM Framework

Objective: To highlight opportunities for future nutrition intervention research within early childhood and education care (ECEC) settings, with a focus on generating evidence that has applicability to real-world policy and practice. Methods: An overview of opportunities to progress the field was developed by the authors using a collaborative writing approach and informed by recent research in the field. The group developed a list of recommendations aligned with the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework. Pairs of authors drafted individual sections of the manuscript, which were then reviewed by a separate pair. The first and senior author consolidated all sections of the manuscript and sought critical input on the draft iterations of the manuscript. Results: Interventions that employ digital platforms (reach) in ECEC settings, as well as research in the family day care setting (effectiveness) were identified as areas of opportunities. Research understanding the determinants of and effective strategies for dissemination (adoption), the implementation of nutrition programs, in addition to de-implementation (implementation) of inappropriate nutrition practices, is warranted. For maintenance, there is a need to better understand sustainability and the sustainment of interventions, in addition to undertaking policy-relevant research. Conclusions: The ECEC setting is prime for innovative and practical nutrition intervention research.

A Study of the Food Environment at Australian Family Day Care

Overweight and obesity in childhood is a significant public health issue. Family day care (FDC) offers a setting where good eating habits can be nurtured in young children, yet often the food environment is unhealthy. This study aims to determine FDC educators' knowledge and confidence about nutrition and the barriers and enablers to supporting healthy food environments. Australian FDC educators were recruited to a mixed methods study using self-administered e-surveys and qualitative in-depth interviews. The survey data (n = 188) revealed good knowledge about sugary foods, but poor knowledge of protein-rich foods. Nutrition knowledge was not associated with confidence to make nutrition recommendations. Interviews (n = 9) revealed parents' dietary choices and educators' personal beliefs as barriers to healthy food environments, although importantly, the FDC educator role was identified as being pivotal in supporting the health and wellbeing of children and their families. This study highlights that FDC-specific nutrition education and support is vital to ensure children at FDC and their families are exposed to healthy food environments. Research to investigate specific avenues for nutrition education promotion programs specifically designed to support the unique role played by FDC educators is needed, in order to support the long-term health and welfare of the next generation of Australians.

Interventions to promote healthy environments in family child care homes in Oklahoma-Happy Healthy Homes: study protocol for a randomized controlled trial

BACKGROUND

Early childhood is a critical period of development. Caregivers, including providers of early care and education (ECE), have a substantial influence on the health of young children. Family child care homes (FCCHs), which are small, licensed ECE businesses operated out of the residences of providers, are important settings for promoting child health. However, to date, few interventions to promote the health of children have been developed for FCCHs. The purpose of this article is to describe the protocol for Happy Healthy Homes, a pilot interdisciplinary, community-based study to improve FCCH environments and the health of children in Oklahoma. We describe the development and evaluation of two interventions to be tested in a matched attention randomized controlled trial: 1) a nutrition intervention aimed at enhancing the nutritional quality of meals served to young children, incorporating the Child and Adult Care Food Program best practices, and improving nutritional self-efficacy of providers; and 2) an environmental intervention aimed at increasing providers' environmental health literacy, self-efficacy for integrated pest management (IPM), and awareness of less toxic cleaning practices and FCCH provider cleaning behaviors.

METHODS

Both interventions are informed by common theoretical principles and are matched in attention (i.e., 6 h), format (i.e., two individual 90-min educational home visits and a 3-h small group class) and materials (i.e., tool kit of educational materials and supplies tailored to the allocated intervention). A randomized trial of both interventions is currently underway with 52 FCCH providers in the Oklahoma City metropolitan area who participate in the Child and Adult Care Food Program. Observed and self-reported measures will be collected at baseline, and 3 months and 12 months after baseline measurements. Randomization to one of the two interventions will occur after baseline data collection.

DISCUSSION

This study aims to support FCCH providers in creating healthier FCCH environments for nutrition and environmental health. Successful completion will provide critical information about the nutritional quality and the environmental health of children in FCCHs, as well as much needed evidence about the efficacy of two community-based interventions to improve the nutrition and environmental health of children in home-based ECE settings.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03560050 . Retrospectively registered on 23 May 2018.

Nutrition-Related Practices of Family Child Care Providers and Differences by Ethnicity

BACKGROUND

Child care settings play an important role in shaping children's eating behaviors; yet few studies have included family child care homes (FCCHs). We examined provider-reported nutrition-related practices in FCCHs and observed adherence to nutrition guidelines from the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC), exploring differences by provider ethnicity.

METHODS

We assessed baseline data from a cluster-randomized trial, including surveys with FCCH providers and observational data collected at the FCCH. We examined provider-reported nutrition-related practices and if providers met NAP SACC guidelines using observational data. Differences by ethnicity were assessed using chi-square and multivariate log-linear analysis adjusting for education.

RESULTS

Providers completed a telephone survey (n = 166, 100% female and 72% Hispanic) and participated in 2 full-day observations (n = 119). Many providers reported engaging in positive nutrition-related practices. Significant differences by ethnicity included the following: Hispanic providers less likely to report feeding practices that were responsive to children's self-regulation, but also less likely to report eating and drinking unhealthy foods/beverages in front of children and having screens on during meals and more likely to report seeking nutrition trainings. Using observational data, only 10 of 26 NAP SACC practices were met by >60% of providers. Few ethnic differences in meeting guidelines were found (7 of 26 practices).

CONCLUSIONS

While providers engage in some positive nutrition practices, improvement is needed to ensure that all providers actually meet evidence-based guidelines. Ethnic differences in certain practices underscore the need for culturally relevant trainings.

TRIAL REGISTRATION NUMBER

NCT02452645.

Modifying the Environment and Policy Assessment and Observation (EPAO) to better capture feeding practices of family childcare home providers

OBJECTIVE

To describe the modification and validation of an existing instrument, the Environment and Policy Assessment and Observation (EPAO), to better capture provider feeding practices.

DESIGN

Modifications to the EPAO were made, validity assessed through expert review, pilot tested and then used to collect follow-up data during a two-day home visit from an ongoing cluster-randomized trial. Exploratory factor analysis investigated the underlying factor structure of the feeding practices. To test predictive validity of the factors, multilevel mixed models examined associations between factors and child's diet quality as captured by the Healthy Eating Index-2010 (HEI-2010) score (measured via the Dietary Observation in Childcare Protocol).

SETTING

Family childcare homes (FCCH) in Rhode Island and North Carolina, USA.ParticipantsThe modified EPAO was pilot tested with fifty-three FCCH and then used to collect data in 133 FCCH.

RESULTS

The final three-factor solution ('coercive control and indulgent feeding practices', 'autonomy support practices', 'negative role modelling') captured 43 % of total variance. In multilevel mixed models adjusted for covariates, 'autonomy support practices' was positively associated with children's diet quality. A 1-unit increase in the use of 'autonomy support practices' was associated with a 9·4-unit increase in child HEI-2010 score (P=0·001).

CONCLUSIONS

Similar to the parenting literature, constructs which describe coercive controlling practices and those which describe autonomy-supportive practices emerged. Given that diets of pre-schoolers in the USA remain suboptimal, teaching childcare providers about supportive feeding practices may help improve children's diet quality.

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.