Child-care use and the association with body mass index and overweight in children from 7 months to 2 years of age

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.

Associations of Childcare Arrangements with Adiposity Measures in a Multi-Ethnic Asian Cohort: The GUSTO Study

Childcare arrangements shape behavioural patterns that influence the risk of childhood obesity. However, little is known of its influence on childhood obesity in Singapore. We aim to examine the associations between childcare arrangements at the age of 5 years and childhood adiposity at age 6 years. Children from the GUSTO study were grouped into three childcare arrangements at age 5: full-time centre-based childcare (FC), partial centre-based with parental care (PCP), and partial centre-based with non-parents (grandparents and domestic helpers) as caregivers (PCN). Diet, physical activity and sedentary behaviour information were collected at age 5, while anthropometric measurements were collected at age 6. Associations were analysed using multivariable regression models. Among 540 children, those in PCN had higher BMI z-scores (β: 0.34; 95% CI: 0.01, 0.66), greater sum of skinfold thicknesses (mm) (β: 3.75; 95% CI: 0.53, 6.97) and were 3.55 times (95% CI: 1.78, 7.05) more likely to be overweight/obese than those in FC. Adiposity measures in PCP children did not differ from those in FC. PCN children were reported to have more screen time and greater fast-food intake. Children in PCN tended to have higher adiposity measures. Greater engagement of non-parental caregivers should be considered in interventions targeting child obesity.

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.

Grow well/Crecer bien: a protocol for research on infant feeding practices in low-income families

BACKGROUND

The prevalence of obesity among children remains high. Given obesity's significant lifelong consequences, there is great interest in preventing obesity early in life. There is a need to better understand the relation of common infant feeding styles and practices to obesity in infants using longitudinal study designs. There is also an urgent need to understand the role of caregivers other than mothers in feeding. A better understanding of variation in feeding styles and practices can inform the identification of risk groups and the tailoring of interventions to them.

METHODS

In partnership with Early Head Start programs across four counties in southern California, mothers and infants will be enrolled in a two-year longitudinal study collecting survey and anthropometric data. A subsample of mothers and their selected other caregivers will participate in qualitative research involving feeding diaries and dyadic interviews. The results will be used to develop and test an enhanced nutrition education program.

DISCUSSION

We outline a study methodology to examine feeding styles and practices and their association with early childhood obesity risk and enhance an existing intervention to promote healthy infant feeding and growth among children in low-income families.

Nutrition Knowledge and Perspectives of Physical Activity for Pre-Schoolers amongst Early Childhood Education and Care Teachers

Caregivers’ nutrition and physical activity knowledge is recognised as being important for children’s health and body size. Identifying knowledge gaps amongst caregivers may inform professional development and obesity-prevention strategies in childcare settings. This cross-sectional validated online questionnaire aimed to measure current early childhood education and care (ECEC) teachers’ nutrition knowledge for pre-schoolers (2–5-year-olds) and related perspectives. Teachers’ (n = 386) knowledge of nutrition was lacking: The overall score was 22.56 ± 2.83 (mean ± SD), or 61% correct. Increased years of experience significantly predicted an increase in knowing that national nutrition and physical activity guidelines exist (B = 0.02 [95% CI, 0.00–0.03], r² = 0.13, p = 0.033). Teachers’ increased agreement in feeling they were confident talking about nutrition to parents significantly predicted an increase in overall nutrition knowledge scores (B = 0.34 [95% CI, 0.06–0.63], r² = 0.15, p = 0.019). The belief that ECEC teachers play a vital role in promoting pre-schoolers’ healthy eating and physical activity was widespread. Common knowledge barriers included a lack of staff training, confidence, and resources. ECEC teachers may lack nutrition knowledge for pre-schoolers, particularly in regard to basic nutrition recommendations (servings, food/beverage choices, and portion sizes).

Healthy Eating Policy Improves Children's Diet Quality in Early Care and Education in South Carolina

Policies to promote healthy foods in early care and education (ECE) in the United States exist, but few have been prospectively evaluated. In South Carolina, a statewide program serving low-income children in ECE enacted new policies promoting healthy foods. We conducted an evaluation to measure changes in dietary intake among children in ECE exposed and not exposed to the new policy. Using direct observation, we assessed dietary intake in 112 children from 34 ECE centers in South Carolina and 90 children from 30 ECE centers in North Carolina (a state with no policy). We calculated Healthy Eating Index-2015 (HEI) scores to measure diet quality consumed before and after the policy was enacted. We fit mixed-effects linear models to estimate differences in HEI scores by state from baseline to post-policy, adjusting for child race, number of children enrolled, director education, center years in operation, participation in the Child and Adult Care Food Program (CACFP), and center profit status. The policy increased HEI scores for whole fruits, total fruits, and lean proteins, but decreased scores for dairy. Thus, the policy was associated with some enhancements in dietary intake, but additional support may help improve other components of diet.

Centre-based care is a significant predictor of lower body mass index in early childhood: Longitudinal evidence from Chile

BACKGROUND

The prevalence of childhood overweight has increased by approximately 50% in the past three decades, becoming a major public health concern worldwide. In Chile, an upper middle-income country, about 38% of children between two and four years of age are overweight, almost double the average in Latin America and the Caribbean. Various environmental and individual factors, and their interactions, affect childhood weight. Emerging evidence suggests childcare may also matter. Because the public provision of centre-based care is growing, childcare may be a useful policy tool to help prevent childhood overweight.

METHODS

Using a nationally representative longitudinal survey of ~ 15 000 children in Chile (2010 and 2012), we estimated whether the type of child care (centre-based or maternal) a child attended at age 24 to 36 months was a significant predictor of the child's sex-and-age-specific body-mass-index (BMI) at age 36-48 months. We restricted our sample to children in full-time maternal care at baseline (12-24 months of age; n = 1273), but tested the robustness of results with the full sample. We compared children in centre-based care and in maternal care using difference-in-difference estimators and propensity score matching, and adjusted our estimates using child, family, and neighborhood characteristics.

RESULTS

Children attending centre-based care had 0.27 SD lower BMI than children in maternal care at follow-up (P < 0.05). We found suggestive evidence this association may be modulated by the child's socioeconomic status and by how frequently the child watched television: we found smaller BMI changes for children at the bottom 80% of socioeconomic status (P < 0.05) and also for children who frequently watched television (P < 0.10). Our results were robust to various model specifications.

CONCLUSIONS

Our findings suggest centre-based care programs, with adequate regulation and enforcement, may be a useful support to help curb the early childhood overweight epidemic, in addition to known effects in labor supply and child development.

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.

Communication With Family Child Care Providers and Feeding Preschool-Aged Children: Parental Perspectives

OBJECTIVE

To describe parent communication about child nutrition-related topics with family child care providers (FCCPs).

DESIGN

Five focus groups conducted from December, 2016 to July, 2017.

PARTICIPANTS

Parents (n = 25) of 2- to 5-year-old children attending family child care homes in Rhode Island.

PHENOMENON OF INTEREST

How and what parents communicate about with FCCPs related to feeding young children.

ANALYSIS

Recordings were transcribed verbatim. Two independent coders employed content analysis to analyze transcripts. Reflections, emerging themes, and final themes were discussed.

RESULTS

Participants were recruited through FCCPs and were mostly Hispanic and female. Parents mainly communicated with FCCPs in person. Communication with FCCPs related to how and what children were fed did not occur frequently, and parents usually inquired about how much children ate.

CONCLUSIONS AND IMPLICATIONS

Parents did not engage in frequent child nutrition-related communication with their FCCP. However, parents trusted FCCPs to provide healthy and sufficient food to children. More research is needed to identify effective strategies that facilitate child nutrition communication between parents and FCCPs.

Systematic review of interventions in the childcare setting with direct parental involvement: effectiveness on child weight status and energy balance-related behaviours

BACKGROUND

The early years are a crucial period to promote healthy energy balance-related behaviours in children and prevent overweight and obesity. The childcare setting is important for health-promoting interventions. Increasingly, attention has been paid to parental involvement in childcare-based interventions. The aim of this systematic review is to evaluate the effectiveness of these interventions with direct parental involvement on the children's weight status and behavioural outcomes.

METHODS

A systematic search was conducted in four electronic databases to include studies up until January 2019. Studies written in English, describing results on relevant outcomes (weight status, physical activity, sedentary behaviour and/or nutrition-related behaviour) of childcare-based interventions with direct parental involvement were included. Studies not adopting a pre-post-test design or reporting on pilot studies were excluded. To improve comparability, effect sizes (Cohen's d) were calculated. Information on different types of environment targeted (e.g., social, physical, political and economic) was extracted in order to narratively examine potential working principles of effective interventions.

RESULTS

A total of 22 studies, describing 17 different interventions, were included. With regard to the intervention group, 61.1% found some favourable results on weight status, 73.3% on physical activity, 88.9% on sedentary behaviour, and all on nutrition-related behaviour. There were studies that also showed unfavourable results. Only a small number of studies was able to show significant differences between the intervention and control group (22.2% weight status, 60.0% physical activity, 66.6% sedentary behaviour, 76.9% nutrition behaviour). Effect sizes, if available, were predominantly small to moderate, with some exceptions with large effect sizes. The interventions predominantly targeted the socio-cultural and physical environments in both the childcare and home settings. Including changes in the political environment in the intervention and a higher level of intensity of parental involvement appeared to positively impact intervention effectiveness.

CONCLUSION

Childcare-based interventions with direct parental involvement show promising effects on the children's energy balance-related behaviours. However, evidence on effectiveness is limited, particularly for weight-related outcomes. Better understanding of how to reach and involve parents may be essential for strengthening intervention effectiveness.

Healthy Nutrition and Physical Activity in Childcare: Views from Childcare Managers, Childcare Workers and Parents on Influential Factors

Childhood obesity is an important public health issue influenced by both personal and environmental factors. The childcare setting plays an important role in children’s energy balance-related behaviours (EBRB), such as physical activity, sedentary behaviour and healthy nutrition. This study aimed to explore facilitators and barriers of healthy EBRB in childcare in a comprehensive way, from the perspective of three crucial stakeholders: childcare managers, childcare workers and parents. A qualitative study was performed using semi-structured interviews. Content analysis was performed using the ‘Environmental Research framework for weight Gain prevention’ (EnRG framework) to guide the analysis. Forty-eight interviews were held with a total of 65 participants (9 childcare managers, 23 childcare workers and 33 parents). Influential factors in all types of environment (physical, sociocultural, economic and political) were mentioned. Although a need for change was not always expressed, the interviews revealed opportunities for improvement of healthy EBRB in childcare. These opportunities were related to the sociocultural, physical and political environment. Childcare workers and managers expressed an influence of the home setting on the childcare setting, resulting in a need for more congruence between these settings. There are opportunities for improvement in the childcare setting to promote healthy EBRB in young children in the Netherlands. It appears important to align intervention components between the childcare and home setting.

Energy balance-related parenting and child-care practices: The importance of meso-system consistency

Background

Our knowledge of the role of parental and child-care staff behavior in the development and prevention of obesity is rapidly increasing. Potential interaction between both settings in so-called meso-systems, as hypothesized by the ecological systems perspective, is however often ignored. Specifically, inconsistency between home and child-care is hypothesized to have negative effects on child outcomes.

Methods

Participants were recruited through 23 child-care centers in the Netherlands. Data regarding 161 child-parent-child-care staff triads were available. Parenting and child care practices were assessed using validated questionnaires for parents (Child Feeding Practices Questionnaire, Preschooler Physical Activity Parenting Practices instrument) and child-care staff (Child-care Food and Activity Practices Questionnaire), using similar items in both settings. Absolute difference scores between parents and child-care staff were calculated for each triad as a measure of meso-system consistency. Child outcomes were physical activity (as assessed by accelerometry), dietary intake (from the parental questionnaire), and measured BMI z-scores. Paired t-tests were used to examine consistency between practices in both settings. Linear regression analyses were used to explore the association of parenting practices, child-care practices and difference scores on the one hand, and child outcomes on the other.

Results

Significant differences between settings were found for almost all practices, and in most cases child-care staff scores more favorable on the practices than parents. Inconsistencies were mostly associated with unhealthy dietary intake and lower physical activity levels, but not with BMI.

Conclusion

The current study showed that inconsistencies in parenting and child-care practices exist, and that these inconsistencies seem to be associated with unhealthy behavior in children. The results underline the importance of studying meso-system influences on behavior in general, and children’s energy balance-related behavior specifically.

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.

Childcare before age 6 and body mass index at age 7 years in a cohort of Danish children

BACKGROUND

Previous studies show inconsistent associations between childcare and obesity.

AIMS

Our prior work demonstrated that childcare in infancy was associated with higher weight in a cohort of Danish children. Here, we extend this work and examine childcare through 6 years and body mass index (BMI) at age 7 years.

MATERIALS AND METHODS

We examined 24 714 children in the Danish National Birth Cohort who were also in the Childcare Database. We conducted multivariable linear regressions examining children prior to age 6, overall and by type (daycare, crèche, age-integrated and kindergarten), and BMI z-score at 7 years, stratifying on maternal socio-occupational status.

RESULTS

A total of 19 760 (80.0%) children attended childcare before age 6. Childcare prior to age 6 was associated with BMI z-score at 7 years (0.004 units per each additional 6 months of care; 95% CI: 0.001, 0.008; p = 0.01). Childcare in a kindergarten was the only type of care associated with BMI (0.009 units; 95% CI: 0.003, 0.02; p = 0.01). For children of higher socio-occupational status mothers, childcare was associated with a 0.008 unit increase in BMI (95% CI: 0.004, 0.01; p > 0.001).

CONCLUSIONS

Childcare was weakly associated with later BMI. This relationship was more pronounced in children from higher socio-occupational status mothers and children in kindergarten care.

Childcare Environment and Japanese Children Who Are Overweight in Early Childhood

BACKGROUND

Maternal employment may affect child care styles and contribute to the increasing prevalence of overweight children. We explored the potential risk factors for becoming overweight during early childhood, especially in the child care environment.

METHODS

We conducted a retrospective cohort study using data from health check-up services from 2007 to 2015 in Kobe, Japan. The main outcome was being overweight at age 3 years, which was defined by the International Obesity Task Force cutoffs. Environmental, maternal, and infantile factors were examined as possible risk factors for childhood overweight.

RESULTS

Of 31,463 infants, 1315 (4.2%) were classified as overweight at age 3 years. Compared with children who were cared for by their mothers during the day at 4 and 18 months, the adjusted odds ratio (aOR) for becoming overweight for those who were not cared for by their mothers was 1.52: 95% confidence interval (CI), 1.16-1.99. Long sleep duration was associated with lower risk of childhood overweight: aOR, 0.79; 95% CI, 0.66-0.96.

CONCLUSION

Less daytime care by mothers and shorter sleep duration were associated with increased risk of becoming overweight during childhood. Further studies are needed to determine on how the effect of those factors may be diminished with respect to childhood overweight.

Modeling Pediatric Body Mass Index and Neighborhood Environment at Different Spatial Scales

In public health research, it has been well established that geographic location plays an important role in influencing health outcomes. In recent years, there has been an increased emphasis on the impact of neighborhood or contextual factors as potential risk factors for childhood obesity. Some neighborhood factors relevant to childhood obesity include access to food sources, access to recreational facilities, neighborhood safety, and socioeconomic status (SES) variables. It is common for neighborhood or area-level variables to be available at multiple spatial scales (SS) or geographic units, such as the census block group and census tract, and selection of the spatial scale for area-level variables can be considered as a model selection problem. In this paper, we model the variation in body mass index (BMI) in a study of pediatric patients of the Virginia Commonwealth University (VCU) Medical Center, while considering the selection of spatial scale for a set of neighborhood-level variables available at multiple spatial scales using four recently proposed spatial scale selection algorithms: SS forward stepwise regression, SS incremental forward stagewise regression, SS least angle regression (LARS), and SS lasso. For pediatric BMI, we found evidence of significant positive associations with visit age and black race at the individual level, percent Hispanic white at the census block group level, percent Hispanic black at the census tract level, and percent vacant housing at the census tract level. We also found significant negative associations with population density at the census tract level, median household income at the census tract level, percent renter at the census tract level, and exercise equipment expenditures at the census block group level. The SS algorithms selected covariates at different spatial scales, producing better goodness-of-fit in comparison to traditional models, where all area-level covariates were modeled at the same scale. These findings underscore the importance of considering spatial scale when performing model selection.

The association between childcare arrangements and risk of overweight and obesity in childhood: a systematic review

Over 80% of preschool-aged children experience non-parental childcare. Childcare type has the potential to influence weight outcomes, but its impact on childhood overweight/obesity is not well established. This review aims to (i) systematically evaluate the effects of childcare type on childhood overweight/obesity risk and (ii) investigate the impact of childcare intensity and age at commencement. Five electronic databases were searched for observational studies quantifying an association between childcare type ≤5 years and weight outcomes <18 years. Twenty-four studies were included (n = 127,529 children). Thirteen studies reported increased risk of overweight/obesity in children attending informal care (n = 9) or centre care (n = 4) vs. parental care. Seven studies reported decreased risk of overweight/obesity for children in centre vs. 'non-centre' care (parental and informal). Four studies reported no association between informal or centre care and overweight/obesity. Early (<3 years) informal care, especially by a relative, was associated with increased risk of overweight/obesity. Higher intensity childcare, especially when commenced early (<1 year), increased overweight/obesity risk. Later (≥3 years) centre care was associated with decreased risk of overweight/obesity. Early informal care, earlier commencement age and higher intensity represent a risk for childhood obesity. Exploration of the obesogenic aspects of these contexts is essential to inform preventative measures.

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

PURPOSE OF REVIEW

The purpose of this review was to summarize the current literature on the longitudinal relationship between non-parental childcare during infancy and later obesity.

RECENT FINDINGS

Eleven studies met the inclusion criteria, comprising 74 associations relevant to the review. Studies were highly heterogeneous in terms of defining childcare, categorizing different types of childcare, assessing obesity, and age at measurement of outcome and exposure. Most of the associations were either non-significant (42 associations, 57%) or showed a significant association between increased exposure to childcare and greater obesity (30 associations, 41%). There were very few examples of associations indicating that childcare was associated with lower obesity.

SUMMARY

There is limited research on the longitudinal relationship between childcare in infancy and later obesity. Existing studies showed mixed results, similar to recent reviews reporting on cross-sectional studies and older ages. The different definitions of childcare and wide variety of measures of exposure make comparisons between studies challenging.

Do childcare menus meet nutrition guidelines? Quantity, variety and quality of food provided in New Zealand Early Childhood Education services

OBJECTIVE

To describe food provision and evaluate menus in New Zealand childcare services, determining associations with service characteristics and/or cost of menu.

METHODS

Licensed services in three regions of New Zealand participated in an online survey, uploading a weekly menu where applicable. Menus were scored for compliance with guidelines on quantity, variety and quality of foods served. Bivariate and multivariate associations between menu score and service characteristics were analysed.

RESULTS

A total of 257 services participated (30% of 847 services invited). Food was provided daily in 56%, with 34% providing lunch and snacks daily. Of the 57 full menus analysed, only three (5%) met all 10 scoring criteria (mean score of 6.8/10). Higher menu scores were statistically associated with employing a cook, high and low (not medium) neighbourhood deprivation, the Heart Foundation's Healthy Heart Award program; there was no association with food costs. The Healthy Heart Award remained statistically associated with higher menu score after adjustment for other service characteristics.

CONCLUSION

Most menus did not meet current nutrition guidelines for quantity, variety, and limiting 'sometimes' and 'occasional' foods. Implications for public health: This study provides a baseline for monitoring menu compliance in New Zealand and evidence for nutrition promotion and menu improvement programmes in early education.

Child Care Exposure Influences Childhood Adiposity at 2 Years: Analysis from the ROLO Study

BACKGROUND

The first 2 years of life are instrumental for childhood physical development. Factors contributing to childhood obesity are difficult to determine; child care exposure is one to consider, by influencing food preference and physical activity development.

OBJECTIVE

To investigate the association of child care exposure with adiposity at 2 years.

METHODS

Data were collected as part of the secondary analysis of the prospective ROLO study (randomized control trial of low glycemic index diet) in Dublin, Ireland. Mothers were recruited antenatally and followed up at 2 years postpartum. Maternal and childhood anthropometric data and lifestyle questionnaires, reporting on child care attendance (defined as nonparental care), exposure (weeks), and infant-feeding practices, were collected.

RESULTS

Anthropometric measures and lifestyle data were collected for 273 mothers and children aged 2 years, 52.7% of whom attended child care. Child care was predominately provided by a nonrelative (83.7%), either in a crèche (57%) or by a childminder (26.7%). More than half (56.2%) of the children attended child care part-time (≤30 hours/week). Central adiposity measures (abdominal circumference, waist:height ratio) and total adiposity (sum of all skin folds) were significantly elevated in children with increasing time in child care. Children provided with "meals and snacks" had elevated adiposity measures versus those given "snacks or no food." No difference in the infant-feeding practices was identified between the child care groups.

CONCLUSIONS

Children attending child care have higher total and central adiposity, proportional to exposure. More research is required to investigate this link to appropriately design health promotion and obesity prevention programs targeting children at 2 years.

Cohort profile for the Nurture Observational Study examining associations of multiple caregivers on infant growth in the Southeastern USA

PURPOSE

Childcare has been associated with obesity in children in cross-sectional and longitudinal studies, although some observed no association. Few studies have focused on care during infancy, a period when children may be especially vulnerable.

PARTICIPANTS

The Nurture Study is an observational birth cohort designed to assess longitudinal associations of childcare and the presence of multiple caregivers on infant adiposity and weight trajectories throughout the first year of life. We examine as potential mediators feeding, physical activity, sleep and stress. We completed recruitment in 2015. Of the 860 women who enrolled during pregnancy, 799 delivered a single live infant who met our inclusion criteria. Of those, 666 mothers (77.4%) agreed to participate in the study for themselves and their infants.

FINDINGS TO DATE

Among the 666 women in the study, 472 (71%) identified as black, 127 (19%) as white, 7 (1%) as Asian or Asian American, 6 (1%) as Native American and 49 (7%) as other race or more than one race; 43 (7%) identified as Hispanic/Latina. Just under half (48%) had a high school diploma or less, 61% had household incomes <$20 000/year and 59% were married or living with a partner. The mean (SD) infant gestational age was 41.28 weeks (2.29) and birth weight for gestational age z-score was -0.31 (0.93). Just under half (49%) of infants were females, 69% received some human milk and 40% were exclusively breast fed at hospital discharge. Data collection began in 2013, is currently underway, and is scheduled to conclude in late 2016.

FUTURE PLANS

Results will help assess the magnitude of associations between childcare in infancy and subsequent obesity. Findings will also inform intervention and policy efforts to improve childcare environments and help prevent obesity in settings where many infants spend time.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov, NCT01788644.

Before-school and after-school childcare and children's risk of obesity

BACKGROUND

In the USA, half of children are regularly cared for before or after school by someone other than a parent.

OBJECTIVE

Describe the relationship between childcare arrangements and obesity among school-aged children.

METHODS

Data are from the fifth-grade wave of the Early Childhood Longitudinal Study - Kindergarten Cohort 1998-1999, a nationally representative study of US children who were in kindergarten in 1998-1999 or first grade in 1999, collected in spring 2004 (analytic sample = 9617). We estimated survey-adjusted logistic regression models to examine the association between childcare arrangements before and after school and obesity.

RESULTS

The prevalence of obesity was highest among fifth graders who received care from multiple sources and lowest among children who received care from adults not related to them in either the child's or the caregiver's home [29.9%, 95% confidence interval {CI}: 18.7%, 44.3%; and 17.3%, 95% CI: 12.1%, 24.0%]. Childcare arrangement was not an independent risk factor for obesity for most children. However, Hispanic children who were cared for by a person who was not a relative had significantly higher odds of obesity compared with non-Hispanics in similar care arrangements (odds ratio: 5.11, 95% CI: 2.00, 13.06).

CONCLUSION

Type of childcare before or after school was not an independent risk factor for obesity in most fifth graders, but implications of childcare for Hispanic children should be explored further.

Strength of obesity prevention interventions in early care and education settings: A systematic review

2010-2015; INTERNATIONAL: Given the high levels of obesity in young children, numbers of children in out-of-home care, and data suggesting a link between early care and education (ECE) participation and overweight/obesity, obesity prevention in ECE settings is critical. As the field has progressed, a number of interventions have been reviewed yet there is a need to summarize the data using more sophisticated analyses to answer questions on the effectiveness of interventions. We conducted a systematic review of obesity prevention interventions in center-based ECE settings published between 2010 and 2015. Our goal was to identify promising intervention characteristics associated with successful behavioral and anthropometric outcomes. A rigorous search strategy resulted in 43 interventions that met inclusion criteria. We developed a coding strategy to assess intervention strength, used a validated study quality assessment tool, and presented detailed descriptive information about interventions (e.g., target behaviors, intervention strategies, and mode of delivery). Intervention strength was positively correlated with reporting of positive anthropometric outcomes for physical activity, diet, and combined interventions, and parent engagement components increased the strength of these relationships. Study quality was modestly related to percent successful healthy eating outcomes. Relationships between intervention strength and behavioral outcomes demonstrated negative relationships for all behavioral outcomes. Specific components of intervention strength (number of intervention strategies, potential impact of strategies, frequency of use, and duration of intervention) were correlated with some of the anthropometric and parent engagement outcomes. The review provided tentative evidence that multi-component, multi-level ECE interventions with parental engagement are most likely to be effective with anthropometric outcomes.

Independent effect of type of breastfeeding on overweight and obesity in children aged 12-24 months

This study aimed to analyze the effect of type of breastfeeding on the nutritional status of children between 12-24 months of age. This cohort study included 435 children born in 2012 in a public hospital in Joinville, Santa Catarina State, Brazil. Two years after delivery the mothers and their children were contacted in their homes for a new investigation of demographic, economic, nutritional, and anthropometric data. In the unadjusted analysis, children who were not exclusively breastfed were more likely to be overweight (including obesity) at 2 years of age (OR = 1.6; p = 0.049) than exclusively breastfed children. After adjusting for several covariates, children who were not exclusively breastfed had a 12% higher risk of overweight including obesity compared to unadjusted analysis (OR = 2.6 vs. OR = 1.8; p = 0.043). In addition, birthweight was also an independent determinant of overweight including obesity (OR = 2.5; p = 0.002). The practice of exclusive breastfeeding can reduce the risk of overweight in children from developing countries such as Brazil.

Childcare Attendance and Obesity Risk

BACKGROUND AND OBJECTIVES

Several observational studies have revealed that children who receive nonparental childcare are at increased risk of obesity. However, this may be due to unmeasured confounding or selection into different types of childcare. It is not well established whether this association reflects a causal effect of childcare attendance on obesity risk. We examined the effect of attending childcare on children's BMI z scores, using nationally representative data of ∼10 700 children followed from age 9 months through kindergarten entry.

METHODS

We first employed ordinary least squares regression to evaluate longitudinal associations between childcare attendance at 24 months and BMI z scores at kindergarten entry, controlling for child, family, and neighborhood characteristics. Because type of childcare is associated with unobserved confounding factors, we repeated the analysis by using 2 quasi-experimental approaches: (1) individual fixed effect models, which control for all observed and unobserved time-invariant confounders; and (2) instrumental variable (IV) analysis.

RESULTS

At 24 months, 48.7% of children were in nonparental childcare, and 35.1% of children were overweight/obese at kindergarten entry. In ordinary least squares models, compared with children in parental care, children in nonparental childcare at 24 months had higher BMI z scores at kindergarten entry (0.08 [SE 0.03], P = .01). By contrast, fixed effects and IV models revealed no significant effect of childcare on BMI z score (fixed effects model: β = 0.02 [SE 0.02], P = .62); IV model: β = 1.12 [SE 0.76], P = .14).

CONCLUSIONS

We found no consistent associations between nonparental childcare and obesity. Previously reported significant associations may be confounded by unobserved family circumstances resulting in selection into different types of childcare.

The association between childcare and risk of childhood overweight and obesity in children aged 5 years and under: a systematic review

The aim of this paper was to systematically review the published evidence on the relationship between the type of childcare and risk of childhood overweight or obesity. The databases PubMed, MEDLINE, Cochrane Library and EMBASE were searched using combinations of the various search terms to identify eligible observational studies published between 2000 and May 2016 in English. Fifteen publications from 7 countries matched the inclusion criteria. The most commonly reported childcare arrangements were centre-based (e.g. crèche) and informal care (e.g. relatives, neighbours, friends). Informal care was most frequently associated with an increased risk of childhood overweight and obesity. Associations were also found for other lifestyle variables such as low maternal education, high birth-weight, maternal employment, ethnicity, maternal overweight/obesity and father's Body Mass Index (BMI).

CONCLUSION

The relationship between childcare and childhood overweight/obesity is multi-faceted with many aspects linked to childhood adiposity, in particular the age of initiation to care, type of care (i.e. informal care) and shorter breastfeeding duration were related with infant adiposity.

WHAT IS KNOWN

• Lifestyle factors during early years affect health outcomes in adulthood, particularly in children with low birth weight. • Pre-school stage influences children's body composition and growth. What is new: • This is the first systematic review of observational studies examining the association between childcare and childhood overweight and obesity in preschool children. • 'Informal' care is linked to early introduction to solid foods, less physical activity and obesity.

Risk Factors for Childhood Obesity in the First 1,000 Days: A Systematic Review

CONTEXT

Mounting evidence suggests that the origins of childhood obesity and related disparities can be found as early as the "first 1,000 days"-the period from conception to age 2 years. The main goal of this study is to systematically review existing evidence for modifiable childhood obesity risk factors present from conception to age 2 years.

EVIDENCE ACQUISITION

PubMed, Embase, and Web of Science were searched for studies published between January 1, 1980, and December 12, 2014, of childhood obesity risk factors present during the first 1,000 days. Prospective, original human subject, English-language research with exposure occurrence during the first 1,000 days and with the outcome of childhood overweight or obesity (BMI ≥85th percentile for age and sex) collected between age 6 months and 18 years were analyzed between December 13, 2014, and March 15, 2015.

EVIDENCE SYNTHESIS

Of 5,952 identified citations, 282 studies met inclusion criteria. Several risk factors during the first 1,000 days were consistently associated with later childhood obesity. These included higher maternal pre-pregnancy BMI, prenatal tobacco exposure, maternal excess gestational weight gain, high infant birth weight, and accelerated infant weight gain. Fewer studies also supported gestational diabetes, child care attendance, low strength of maternal-infant relationship, low SES, curtailed infant sleep, inappropriate bottle use, introduction of solid food intake before age 4 months, and infant antibiotic exposure as risk factors for childhood obesity.

CONCLUSIONS

Modifiable risk factors in the first 1,000 days can inform future research and policy priorities and intervention efforts to prevent childhood obesity.

Obesogenic environments in tribally-affiliated childcare centers and corresponding obesity rates in preschool children

BACKGROUND

Determine the relationship between obesogenic characteristics of childcare and child adiposity in tribally-affiliated centers in Oklahoma.

METHODS

The two-day Environment and Policy Assessment and Observation (EPAO) included a total environment (TE), nutrition (N), and physical activity (PA) score and took place in 11 centers across Oklahoma. Eighty-two preschool children (3-5 years) participated. Child height and weight were measured and overweight status (≥ 85th percentile for age and sex) was determined. Regression models, fit using Generalized Estimating Equations methodology to account for clustering by center were used and adjusted for center characteristics.

RESULTS

Participants were 3.8 (0.8) years old, 55% male, 67% American Indian (AI) and 38% overweight. A healthier TE and PA was associated with a reduced odds of overweight, which remained significant after adjusting for some center characteristics, but not all. A healthier TE, N, and PA was associated with lower BMI percentile, which remained significant after some center-level adjustments, but not all. Lower sedentary opportunity and sedentary time were no longer associated with reduced odds of overweight following adjustment. Lower opportunity for high sugar and high fat foods and minutes of active play were associated with reduced odds of overweight in some adjusted models.

CONCLUSIONS

Collectively unadjusted and adjusted models demonstrate that some aspects of a healthier childcare center environment are associated with reduced odds of overweight and lower BMI percentile in preschool children attending tribally-affiliated childcare in Oklahoma. Future research should examine the association of childcare and health behaviors and further explore the role of potential confounders.

Childcare use and overweight in Finland: cross-sectional and retrospective associations among 3- and 5-year-old children

BACKGROUND

Different types of non-parental childcare have been found to associate with childhood overweight in several, but not all studies. Studies on the matter are mainly North American.

OBJECTIVES

The objective of our study was to examine associations between childcare use and overweight in Finland.

METHODS

The cross-sectional and partly retrospective data consists of 1683 3- and 5-year-old children participating in the Child Health Monitoring Development project (LATE-project) conducted in 2007-2009 in Finland. Children were measured at health check-ups and information on child's age when entering childcare, the number of childcare places the child has had, current type of childcare (parental, informal, [group] family childcare, childcare centre) and the current amount of childcare (hours) were gathered. Parents' body mass indices, family educational level, family structure, maternal smoking during pregnancy and child's birth weight were treated as covariates.

RESULTS

Beginning childcare before age 1 (adjusted model: odds ratio [OR] 2.53, 95% confidence interval [CI] 1.41-4.52) and, for girls only, number of childcare places (adjusted model: OR 1.33, 95% CI 1.11-1.60), were associated with an increased risk of overweight. The current type of childcare or the time currently spent in childcare was not associated with overweight.

CONCLUSION

Beginning childcare before age 1, which is quite rare in Finland, and having attended several childcare places were associated with overweight even when adjusting for family socioeconomic status and other family background variables. The significance of these findings needs to be further studied.

Patterns of early dietary exposures have implications for maternal and child weight outcomes

OBJECTIVE

This article examines relations between patterns of dietary exposures at 9 months and infant and maternal weight status at 1 year postpartum.

METHODS

Participants were part of the Infant Feeding Practices Study II and included 1807 mothers participating through the first year postpartum. All data were self-reported monthly by mothers. Latent class analysis was conducted to identify patterns of infant dietary exposures at 9 months. Factors that predicted dietary pattern class membership were examined including infant sleep and parity. Dietary pattern membership was used to predict child and maternal weight outcomes at 1 year postpartum.

RESULTS

Five patterns of dietary exposures were identified, characterized by differences in milk-feeding and solid foods at 9 months: "Breastfed Fruits and Vegetables," "Breastfed Low Variety," "Formula-Fed Fruits and Vegetables," "Formula-Fed Low Variety," and "Mixed High Energy Density." Infants in the Mixed High Energy Density dietary pattern were more likely to be overweight at 1 year.

CONCLUSIONS

Dietary classes that capture different combinations of several aspects of infant feeding may be more useful than single dietary predictors, for example, breastfeeding, formula-feeding, or early introduction to solids, to describe differences in infants' early dietary experience and risk for overweight.

The Child-care Food and Activity Practices Questionnaire (CFAPQ): development and first validation steps

OBJECTIVE

To develop and validate a questionnaire to measure food-related and activity-related practices of child-care staff, based on existing, validated parenting practices questionnaires.

DESIGN

A selection of items from the Comprehensive Feeding Practices Questionnaire (CFPQ) and the Preschooler Physical Activity Parenting Practices (PPAPP) questionnaire was made to include items most suitable for the child-care setting. The converted questionnaire was pre-tested among child-care staff during cognitive interviews and pilot-tested among a larger sample of child-care staff. Factor analyses with Varimax rotation and internal consistencies were used to examine the scales. Spearman correlations, t tests and ANOVA were used to examine associations between the scales and staff's background characteristics (e.g. years of experience, gender).

SETTING

Child-care centres in the Netherlands.

SUBJECTS

The qualitative pre-test included ten child-care staff members. The quantitative pilot test included 178 child-care staff members.

RESULTS

The new questionnaire, the Child-care Food and Activity Practices Questionnaire (CFAPQ), consists of sixty-three items (forty food-related and twenty-three activity-related items), divided over twelve scales (seven food-related and five activity-related scales). The CFAPQ scales are to a large extent similar to the original CFPQ and PPAPP scales. The CFAPQ scales show sufficient internal consistency with Cronbach's α ranging between 0·53 and 0·96, and average corrected item-total correlations within acceptable ranges (0·30-0·89). Several of the scales were significantly associated with child-care staff's background characteristics.

CONCLUSIONS

Scale psychometrics of the CFAPQ indicate it is a valid questionnaire that assesses child-care staff's practices related to both food and activities.

Dietary intake of children attending full-time child care: What are they eating away from the child-care center?

BACKGROUND

The Academy of Nutrition and Dietetics recommends children attending full-time child care obtain one-half to two-thirds of daily nutrient needs during their time at the child-care center, leaving one-third to one-half to be consumed away from the center. Although there are guidelines to optimize dietary intake of children attending child care, little is known about what these children consume away from the center.

OBJECTIVE

To describe the dietary intake away from the child-care center for preschool-aged children relative to the expected one-third to one-half proportion of recommended intake, and to examine the relationships between energy intake away from the center with weight status, food group consumption, and low-income status.

DESIGN

Cross-sectional study conducted between November 2009 and January 2011.

PARTICIPANTS/SETTING

Participants (n=339) attended 30 randomly selected, licensed, full-time child-care centers in Hamilton County, OH.

MAIN OUTCOME MEASURES

Child weight status and dietary intake (food/beverages consumed outside the child-care setting from the time of pickup from the center to the child's bedtime), including energy and servings of fruits, vegetables, milk, 100% juice, sugar-sweetened beverages, and snack foods.

STATISTICAL ANALYSES PERFORMED

Generalized linear mixed models were used to examine independent associations of food group servings and low-income status to energy intake and energy intake to child weight status.

RESULTS

The mean energy intake consumed away from the center (685±17 kcal) was more than the recommended target range (433 to 650 kcal). Intakes of fruits, vegetables, and milk were less than recommended. Food group servings and overweight/obesity status were positively associated with energy intake while away from the center.

CONCLUSIONS

Preschool-aged children consume more energy and less fruits, vegetables, and milk outside of child-care centers than recommended. Overweight status was associated with children's dietary intake after leaving the child-care center. It may be beneficial to include parents in obesity prevention efforts targeting children attending child-care centers.

Eating out of home and dietary adequacy in preschool children

The present study aims to describe dietary intake and dietary adequacy according to eating location in preschool children. A sub-sample of 2414 children from the Generation XXI birth cohort (Porto, Portugal), evaluated during the follow-up between 2009 and 2011, was included. Dietary intake was assessed by 3 d food diaries and four groups of children were defined according to the eating location: 'Home' ( ≥ 80% of meals at home), 'Other homes', 'Preschool' and 'Restaurants'. A dietary adequacy index was developed based on general recommendations for children; a higher score represents a better dietary adequacy. The comparison of nutrients and foods daily intake according to the eating location groups was performed by ANOVA and ANCOVA to adjust for potential confounders. Children classified in 'Preschool' group ate significantly more vegetables, fruit, bread and fish, and less meat, compared to children classified into the 'Home' group. Children classified in the 'Restaurants' group ate more cakes, salty snacks and fruit juices than children in 'Home' group; and less vegetables, dairy products and pasta/rice/potatoes. In 'Restaurants' children obtained the lowest mean score of the dietary adequacy index (15.5, 95% CI 14.8, 16.3) and in 'Preschool' children had the highest mean score (18.3, 95% CI 18.1, 18.4), corresponding to a better dietary adequacy. Preschools seem to have a relevant role in promoting the intake of healthy foods in preschool children. The consumption in restaurants/coffee shops seems to contribute to energy-dense food intake and reduced consumption of nutrient-dense foods.

Use of food practices by childcare staff and the association with dietary intake of children at childcare

The study explored the associations between various childcare staff food practices and children’s dietary intake at childcare. A total of 398 one- to four-year-old children and 24 childcare staff members from 24 Dutch childcare centers participated in the study. Children’s dietary intake (fruit, vegetable, sweet snack, savory snack, water, and sweet drink intake) at childcare was registered on two weekdays, using observations by dieticians and childcare staff. Thirteen childcare staff practices were assessed using questionnaires administered by dieticians. Data were analyzed using multilevel regression analyses. Children consumed relatively much fruit and many sweet snacks at childcare, and they mainly drank sweet drinks. Various staff practices were associated with children’s dietary intake. When staff explained what they were doing to the children during food preparation, children ate significantly more fruit. Children ate less sweet snacks when they were allowed to help prepare the meals. When staff encouraged children to continue eating, they ate more vegetables. In conclusion, the study showed the importance of childcare staff food practices for children’s food intake at childcare. More research is needed to examine the specific conditions under which food practices can have a positive impact on children’s dietary intake.

Early child care and obesity at 12 months of age in the Danish National Birth Cohort

Background/Objectives

Evidence suggests that the child care environment may be more obesogenic than the family home, and previous studies have found that child care use may be associated with obesity in children. Few studies, however, have focused on child care during infancy, which may be an especially vulnerable period. This study examined child care use in infancy and weight status at 12 months of age in a country where paid maternity leave is common and early child care is not as prevalent as in other developed countries.

Subjects/Methods

We studied 27821 children born to mothers participating in the Danish National Birth Cohort (DNBC), a longitudinal study of pregnant women enrolled between 1997 and 2002, who were also included in the Childcare Database, a national record of child care use in Denmark. The exposure was days in child care from birth to 12 months. The outcomes were sex-specific body mass index (BMI) z-score and overweight/obesity (BMI ≥85^th percentile based on the World Health Organization classification) at 12 months. We conducted multivariable linear and logistic regression analyses examining child care use and weight outcomes.

Results

A total of 17721 (63.7%) children attended child care during their first year of life. After adjustment for potential confounders, a 30-day increment of child care was associated with a modestly higher BMI z-score at 12 months (0.03 units; 95% CI: 0.01, 0.05; p=0.003). Similarly, child care use was associated with increased odds of being overweight/obese at 12 months of age (OR 1.05; 95% CI: 1.01, 1.10; p=0.047).

Conclusions

Child care in the first year of life was associated with slightly higher weight at 12 months, suggesting that child care settings may be important targets for obesity prevention in infancy.

The next step in health behavior research: the need for ecological moderation analyses - an application to diet and physical activity at childcare

BACKGROUND

The ecological perspective holds that human behavior depends on the interaction of different environmental factors and personal characteristics, but it lacks validation and operationalization. In the current paper, an ecological view was adopted to examine the interactive impact of several ecological systems on children's dietary intake and physical activity at childcare or similar facilities. The ecological view was operationalized into three types of interaction: 1) interaction between types of childcare environment (physical, social, political, economic); 2) interaction between micro-systems (the childcare and home environment) in meso-systems; and 3) interaction between childcare environment and child characteristics. The predictive value of each of these interactions was tested based on a systematic review of the literature.

DISCUSSION

Several studies support the hypothesis that the influence of the childcare environment on children's physical activity and diet is moderated by child characteristics (age, gender), but interaction between environmental types as well as between micro-systems is hardly examined in the field of behavioral nutrition and physical activity. Qualitative studies and general child development research provide some valuable insights, but we advocate quantitative research adopting an ecological perspective on environmental influences.

SUMMARY

Empirical studies operationalizing a true ecological view on diet and physical activity are scarce. Theorizing and assessment of interaction is advocated to become common practice rather than an exception in behavioral nutrition and physical activity research, in order to move the field forward.

Dietary intake by Dutch 1- to 3-year-old children at childcare and at home

The goal of the current study was to assess dietary intake in a large sample (N=1016) of Dutch toddlers (1-3 years old), both at childcare and at home. Dietary intake during two weekdays was recorded using an observation format applied by childcare staff for intake at childcare, and partially pre-coded dietary journals filled out by parents for intake at home. Children's intake of energy, macronutrients and energy balance-related food groups (fruit, vegetables, sweet snacks, savoury snacks) were compared with Dutch dietary guidelines. In addition, differences between the dietary intake by various subgroups (based on gender, age, childcare attendance, socio-economic status of childcare centre) were explored using multilevel regression analyses, adjusting for nesting of children within centres. Energy intake was high relative to dietary guidelines, and children consumed more or less equal amounts of energy at home and at childcare. Dietary fibre, fruit and vegetable and snack intakes were low. Intake at childcare mainly consisted of carbohydrates, while intake at home contained more proteins and fat. The findings imply various opportunities for childcare centres to improve children's dietary intake, such as providing fruit and vegetables at snacking moments. In addition, the findings underline the importance of assessing dietary intake over a whole day, both at childcare and at home, to allow intake to be compared with dietary guidelines.

Risk factors for overweight/obesity in preschool children: an ecological approach

BACKGROUND

Identification of risk factors is critical to preventing the childhood obesity epidemic. Risk factors that contribute to obesity are multifactorial. However, limited research has focused on identifying obesity risk factors using an ecological approach.

METHODS

Baseline self-report survey data from the STRONG Kids program were used. The sample consisted of 329 parent-child dyads recruited from childcare programs in east-central Illinois. Child height and weight were measured and converted to age- and sex-specific z-scores using standard growth charts. An ecological model provided the theoretical framework for the selection of 22 previously reported childhood obesity risk factors. Multiple logistic regression analyses were used to identify risk factors.

RESULTS

Of 22 potential risk factors, three were found to be significantly associated with child overweight/obesity. These included child nighttime sleep duration (χ(2)=8.56; p=0.003), parent BMI (χ(2)=5.62; p=0.01), and parental restrictive feeding for weight control (χ(2)=4.77; p=0.02). Children who slept for 8 hours and less were 2.2 times more likely to be overweight/obese [95% confidence interval (CI): 1.3-3.7), whereas children with an overweight/obese parent were 1.9 times more likely to be overweight/obese (95% CI: 1.12-3.2). Finally, children whose parents used restrictive feeding practices were 1.75 times more likely to be overweight/obese (95% CI: 1.06-2.9).

CONCLUSIONS

Using an ecological approach, we conclude that childhood obesity prevention efforts may benefit from targeting the key risk factors of child sleep duration, parent BMI, and parental restrictive feeding practices as focus areas for obesity prevention.

Childcare and overweight or obesity over 10 years of follow-up

OBJECTIVE

To investigate the predictive association between preschool childcare arrangements and overweight/obesity in childhood.

STUDY DESIGN

Children were enrolled in a prospective birth cohort in Quebec, Canada (n = 1649). Information about childcare obtained via questionnaires to the mothers at ages 1.5, 2.5, 3.5, and 4 years was used to compute a main childcare arrangement exposure variable (center-based/family-based/care by a relative/nanny). Body mass index was derived from measured weights and heights at ages 4, 6, 7, 8, and 10 years and children were classified as overweight/obese versus normal weight. Generalized estimating equations were used to model the effect of main childcare arrangement (center-based/family-based/relative/nanny) (vs parental care) on overweight/obesity adjusting for several potential confounding factors.

RESULTS

Compared with parental care, children who attended a center-based childcare (OR: 1.65, 95% CI: 1.13-2.41) or were cared for by a relative (OR: 1.50; 95% CI: 0.95-2.38, although with greater uncertainty) had higher odds of being overweight/obese in childhood (4-10 years). Analyses of number of hours additionally suggested that each increment of 5 hours spent in either center-based or relative childcare increased the odds of overweight/obesity in the first decade of life by 9%. Associations were not explained by a wide range of confounding factors, including socioeconomic position, breastfeeding, maternal employment, and maternal body mass index.

CONCLUSION

Overweight/obesity was more frequently observed in children who received non-parental care in center-based settings or care by a relative other than the parent. "Obesogeonic" features of these childcare arrangements should be investigated in future studies.

Play equipment, physical activity opportunities, and children's activity levels at childcare

This study investigated the association between physical activity facilities at childcare (e.g., play equipment) and physical activity of 2- and 3-year olds. Observations of physical activity intensity were performed among 175 children at 9 childcare centers in The Netherlands, using the OSRAC-P. The physical activity facilities were assessed for indoors and outdoors separately, using the EPAO instrument. Regular (single-level) multivariate and multilevel linear regression analyses examined the association of the facilities and child characteristics (age and sex) with children's activity levels. Various physical activity facilities were available in all childcare centers (e.g., balls). Riding toys and a small playing area were associated with lower indoor physical activity levels. Outdoor physical activity levels were positively associated with the availability of portable jumping equipment and the presence of a structured track on the playground. Portable slides, fixed swinging equipment, and sandboxes were negatively associated with outdoor activity levels. In addition, the 3-year old children were more active outdoors than the 2-year olds. In conclusion, not all physical activity facilities at childcare were indeed positively associated with children's activity levels. The current findings provide concrete leads for childcare providers regarding which factors they can improve in the physical environment to facilitate children's physical activity.

Is informal child care associated with childhood obesity? Evidence from Hong Kong's "Children of 1997" birth cohort

BACKGROUND

In Western populations, informal child care is associated with childhood obesity. However, informal child care and obesity share social patterning making evidence from other settings valuable.

METHODS

We used multivariable linear and logistic regression models to estimate the association of child care at 6 months and at 3, 5 and 11 years with body mass index (BMI) z-score and overweight (including obesity) at 11 years in a Hong Kong Chinese birth cohort. We assessed whether associations varied with sex or socio-economic position (SEP). We used multiple imputation for missing exposures and confounders.

RESULTS

Of the original 8327 cohort members, 7933 are alive, participating and living in Hong Kong. At ~11 years, 6796 had their BMI clinically assessed. Higher SEP was associated with informal care. After imputation, informal care at each of 3, 5 or 11 years was separately associated with higher BMI z-score [3 years 0.10, 95% confidence interval (CI) 0.03-0.18, 5 years 0.12, 95% CI 0.04-0.21, 11 years 0.17, 95% CI 0.04-0.31] and with the presence of overweight [odds ratio (OR) 3 years 1.19, 95% CI 1.03-1.37, 5 years OR 1.20, 95% CI 1.03-1.40, 11 years OR 1.21, 95% CI 1.02-1.45], adjusted for sex, SEP and birth weight z-score. Current informal care had the strongest association. However, informal child care at 5 years also contributed. There was no evidence of differences by sex or SEP.

CONCLUSIONS

In a developed, non-Western setting, informal child care was associated with childhood obesity. Modifiable attributes of informal child care warrant investigation for obesity prevention.

The development of socio-economic health differences in childhood: results of the Dutch longitudinal PIAMA birth cohort

BACKGROUND

People with higher socio-economic status (SES) are generally in better health. Less is known about when these socio-economic health differences set in during childhood and how they develop over time. The goal of this study was to prospectively study the development of socio-economic health differences in the Netherlands, and to investigate possible explanations for socio-economic variation in childhood health.

METHODS

Data from the Dutch Prevention and Incidence of Asthma and Mite Allergy (PIAMA) birth cohort study were used for the analyses. The PIAMA study followed 3,963 Dutch children during their first eight years of life. Common childhood health problems (i.e. eczema, asthma symptoms, general health, frequent respiratory infections, overweight, and obesity) were assessed annually using questionnaires. Maternal educational level was used to indicate SES. Possible explanatory lifestyle determinants (breastfeeding, smoking during pregnancy, smoking during the first three months, and day-care centre attendance) and biological determinants (maternal age at birth, birthweight, and older siblings) were analysed using generalized estimating equations.

RESULTS

This study shows that socio-economic differences in a broad range of health problems are already present early in life, and persist during childhood. Children from families with low socio-economic backgrounds experience more asthma symptoms (odds ratio (OR) 1.27; 95% Confidence Interval (CI) 1.08-1.49), poorer general health (OR 1.36; 95% CI 1.16-1.60), more frequent respiratory infections (OR 1.57; 95% CI 1.35-1.83), more overweight (OR 1.42; 95% CI 1.16-1.73), and more obesity (OR 2.82; 95% CI 1.80-4.41). The most important contributors to the observed childhood socio-economic health disparities are socio-economic differences in maternal age at birth, breastfeeding, and day-care centre attendance.

CONCLUSIONS

Socio-economic health disparities already occur very early in life. Socio-economic disadvantage takes its toll on child health before birth, and continues to do so during childhood. Therefore, action to reduce health disparities needs to start very early in life, and should also address socio-economic differences in maternal age at birth, breastfeeding habits, and day-care centre attendance.