Testing Variations on Family-Style Feeding To Increase Whole Fruit and Vegetable Consumption among Preschoolers in Child Care

Mealtime best practices and infection control in early care and education centres during COVID-19

BACKGROUND

Most young children in the United States attend early care and education (ECE) programmes, where they consume the majority of daily calories. Best practices to support children's healthy eating include teachers sitting together with children, eating the same food, and appropriately supporting children in serving and feeding themselves. To understand how the COVID-19 pandemic changed mealtime practices in ECE, this study (1) describes what adaptations ECE directors and teachers made to mealtimes to include best practices, and (2) identifies common adaptations made to comply with COVID-19 infection control guidelines.

METHODS

This cross-sectional, mixed-methods study utilized survey and interview questions based on the trust model and social cognitive theory. More than 7000 surveys were distributed to ECE directors and teachers in Florida. Surveys were completed by 759 directors and 431 teachers. Also, 29 follow-up interviews with teachers were completed. Participants were asked to describe their mealtimes before and during COVID-19. Descriptive statistics and frequencies were used to analyse survey data, and thematic analysis was applied to interview data.

RESULTS

Less than 5% of survey respondents reported children serving themselves, a pre-COVID best practice. Interviews identified three common adaptations: (1) modification-best practices were incorporated into new routines, such as eating together but sitting farther away, (2) elimination-routines changed so that best practices were no longer possible, such as teachers wearing masks and standing during meals, and (3) minimal change-minimal changes due to COVID-19 occurred and consequently mealtime practices did not change.

CONCLUSIONS

Current recommendations do not allow children to self-serve, which previously was a key best practice. ECE centres that have successfully integrated COVID-19 modifications and maintained mealtime best practices-perhaps in a new form-can serve as examples for others. These findings are generalizable to ECE centres in Florida and could be compared with other states.

Improving the school food environment for the prevention of childhood obesity: What works and what doesn't

The food environment has a significant influence on dietary choices, and interventions designed to modify the food environment could contribute to the prevention of childhood obesity. Many interventions have been implemented at the school level, but effectiveness in addressing childhood obesity remains unclear. We undertook a systematic review, a meta-analysis, and meta-regression analyses to assess the effectiveness of interventions on the food environment within and around schools to improve dietary intake and prevent childhood obesity. Estimates were pooled in a random-effects meta-analysis with stratification by anthropometric or dietary intake outcome. Risk of bias was formally assessed. One hundred papers were included. Interventions had a significant and meaningful effect on adiposity (body mass index [BMI] z score, standard mean difference: -0.12, 95% confidence interval: 0.15, 0.10) and fruit consumption (portions per day, standard mean difference: +0.19, 95% confidence interval: 0.16, 0.22) but not on vegetable intake. Risk of bias assessment indicated that n = 43 (81%) of non-randomized controlled studies presented a high risk of bias in the study design by not accounting for a control. Attrition bias (n = 34, 79%) and low protection of potential contamination (n = 41, 95%) presented the highest risk of bias for randomized controlled trials. Changes in the school food environment could improve children's dietary behavior and BMI, but policy actions are needed to improve surrounding school food environments to sustain healthy dietary intake and BMI.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions to increase consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2020. We searched Proquest Dissertations and Theses in November 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 80 trials with 218 trial arms and 12,965 participants. Fifty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 23 of the 80 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption, equivalent to an increase of 5.30 grams as-desired consumption of vegetables (SMD 0.50, 95% CI 0.29 to 0.71; 19 trials, 2140 participants; mean post-intervention follow-up = 8.3 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.32, 95% CI 0.09 to 0.55; 9 trials, 2961 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.13, 95% CI -0.02 to 0.28; 11 trials, 3050 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) or unintended adverse consequences of interventions (2 trials), limiting our ability to assess these outcomes. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 80 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited in terms of quality of evidence and magnitude of effect. Of the types of interventions identified, there was moderate-quality evidence that multicomponent interventions probably lead to, and low-quality evidence that child-feeding practice may lead to, only small increases in fruit and vegetable consumption in children aged five years and under. It is uncertain whether parent nutrition education or child nutrition education interventions alone are effective in increasing fruit and vegetable consumption in children aged five years and under. Our confidence in effect estimates for all intervention approaches, with the exception of multicomponent interventions, is limited on the basis of the very low to low-quality evidence. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Impact of the 2017 Child and Adult Care Food Program Meal Pattern Requirement Change on Menu Quality in Tribal Early Care Environments: The Food Resource Equity and Sustainability for Health Study

BACKGROUND

Native American (NA) children have a high prevalence of obesity contributing to lifespan health disparities. Dietary intake is important to promote healthy weight gain, growth, and development. In 2017, the USDA enforced changes to the Child and Adult Care Food Program (CACFP). The CACFP provides reimbursement to qualifying Early Care and Education (ECE) programs that serve foods that uphold the program's nutrition requirements.

OBJECTIVE

This study had the following 2 objectives: 1) Describe a novel index to evaluate ECE menus based on revised CACFP requirements (accounting for food substitutions) and best practices for 3- to-5-y-old children, and 2) analyze CACFP requirement and best practice compliance and nutrient changes in 9 NA ECE programs before and after enforcement of the revised CACFP requirements.

METHODS

This longitudinal study is within a larger community-based participatory research study. Menus and meals served were evaluated for 1 wk at each of 9 programs before and after enforcement of the revised meal patterns. Nutrient analysis, CACFP requirement and best practice compliance, and substitution quality were evaluated. Differences were determined using a paired t-test or Wilcoxon matched test. This trial was registered at clinicaltrials.gov as NCT03251950.

RESULTS

Total grams of fiber consumed increased (5.0 ± 1.2 compared with 5.9 ± 0.8 g, P = 0.04) and total grams of sugar consumed decreased (53.8 ± 12.6 compared with 48.4 ± 7.9 g, P = 0.024), although room for further improvement exists. Although total grams of fat remained unchanged, grams of saturated fat significantly increased (7.8 ± 1.4 compared with 10.5 ± 3.4, P = 0.041). Other nutrients remained unchanged. Overall CACFP requirement and best practice compliance scores improved, although this finding was not statistically significant. No significant changes in food quality associated with substitutions occurred.

CONCLUSIONS

This study provides early evidence to support the beneficial impact of the revised CACFP requirements. Understanding barriers to compliance within rural NA communities would be an important next step in enhancing the health of vulnerable children.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 August 2019. We searched Proquest Dissertations and Theses in May 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 78 trials with 214 trial arms and 13,746 participants. Forty-eight trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 20 of the 78 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is very low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 4.45 g as-desired consumption of vegetables (SMD 0.42, 95% CI 0.23 to 0.60; 18 trials, 2004 participants; mean post-intervention follow-up = 8.2 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.34, 95% CI 0.10 to 0.57; 9 trials, 3022 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.36 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; 11 trials, 3078 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) and unintended adverse consequences of interventions (2 trials), limiting their assessment. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 78 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low-quality evidence that child-feeding practice may lead to, and moderate-quality evidence that multicomponent interventions probably lead to small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Assessing dinner meals offered at home among preschoolers from low-income families with the Remote Food Photography Method

BACKGROUND

The high prevalence of obesity among preschoolers may be partially explained by the type and quantity of foods offered by parents and left unconsumed by preschoolers.

OBJECTIVES

(a) To compare foods offered and consumed at dinner to the Dietary Guidelines for Americans (DGAs) and the Child and Adult Care Food Program (CACFP) standards and (b) to examine the types, quantities, and nutrient composition of foods offered to and consumed by preschoolers and their plate waste.

METHODS

Participants were recruited from six Head Start/preschool centres. The Remote Food Photography Method was used to document dinner meals over 1 week (n = 153 meals). Energy and nutrients for foods offered, consumed, and plate waste were calculated. Foods offered and consumed were compared with the DGAs and CACFP standards.

RESULTS

Foods and beverages offered at dinner equaled 506 kcal, which is 36% of the DGA-recommended total daily energy intake. Meals offered and consumed were high in fat and sodium and low in fibre. Adherence to CACFP standards was low for fruits (25%) and milk (2%) and moderate for vegetables (63%). Mean plate waste (29%) was similar across food types.

CONCLUSIONS

Opportunities exist to improve preschoolers' adherence to the DGAs and CACFP standards by enhancing the quality of dinner meals offered to them.

Interventions Aimed at Increasing Dairy and/or Calcium Consumption of Preschool-Aged Children: A Systematic Literature Review

Dairy product consumption is important during childhood, as dairy products provide nutrients to support growth and development. However, a high proportion of children globally are not meeting recommended daily intakes, which may have long-term health implications. Accumulating evidence suggests that interventions aimed at instilling healthy lifestyle habits are most effective when initiated during the preschool years. Therefore, the purpose of the review was to identify the characteristics of effective dairy and/or calcium interventions targeting preschool-aged children. A systematic literature review identified 14 intervention studies published between 1998⁻2018 addressing dairy/calcium intakes in the preschool population (1.5 to 5 years). Intervention reporting was assessed using intervention intensity, behavior change techniques and Workgroup for Intervention Development and Evaluation Research (WIDER), with the quality of studies evaluated using risk of bias and Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Five of the 14 studies included in the review reported significant improvements in children's dairy (4/5) or calcium (1/5) intake. Characteristics that may enable intervention effectiveness include the delivery of interventions in one setting (preschool facility), using specific behavior change techniques (environmental restructuring and teach to use prompts/cues), and targeting both parent and child. Overall, the interventions assessed demonstrated variable success and highlighted the need for developing effective interventions designed to increase dairy and/or calcium intakes in preschool-aged children.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2018. We searched Proquest Dissertations and Theses in November 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 63 trials with 178 trial arms and 11,698 participants. Thirty-nine trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fourteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Nine studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake.We judged 14 of the 63 included trials as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining studies.There is very low quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 3.50 g as-desired consumption of vegetables (SMD 0.33, 95% CI 0.13 to 0.54; participants = 1741; studies = 13). Multicomponent interventions versus no intervention may have a very small effect on child consumption of fruit and vegetables (SMD 0.35, 95% CI 0.04 to 0.66; participants = 2009; studies = 5; low-quality evidence), equivalent to an increase of 0.37 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; participants = 3078; studies = 11; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions. Studies reported receiving governmental or charitable funds, except for four studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 63 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low- and low-quality evidence respectively that child-feeding practice and multicomponent interventions may lead to very small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up is required and future research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

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.

Tribally Affiliated Child-Care Center Environment and Obesogenic Behaviors in Young Children

BACKGROUND

Child-care centers are an integral part of life for many families with young children. American Indian children are at elevated health risk because of higher levels of obesity and associated health behaviors.

OBJECTIVE

Our aim was to assess the child-care environment and children's physical activity (PA) and dietary intake in young children attending tribally affiliated child care.

DESIGN

We conducted a cross-sectional study.

PARTICIPANTS/SETTING

Participants were from 11 tribally affiliated child-care centers across Oklahoma and included 82 children aged 3 to 5 years old.

MAIN OUTCOME MEASURES

Classroom observations were conducted using the Environmental and Policy Assessment Observation to measure PA and nutrition environments. Children wore an ActiGraph GT3X accelerometer and lunchtime plate waste was observed.

STATISTICAL ANALYSES

Descriptive statistics, including mean±standard deviation and frequencies, were calculated for the children's behaviors and environment.

RESULTS

The total environment score was 23.9±5.2 (maximum=43). The nutrition score was 12.5±3.1 (maximum=21). The PA score was 11.7±2.2 (maximum=22). The participants were 3.8±0.1 years old, 55% were male, 67% were American Indian, and 38% were overweight or obese. Accelerometers were worn for 5.9±1.7 hours, excluding naptime. Children accumulated 4.3±2.2 min/h of moderate to vigorous PA, 4,294±1,883 steps/day, and 12.1±3.7 steps/min. At lunch, children were served 510±241 kcal, and consumed 387±239 kcal. Lunches consisted of 47% carbohydrate, 20% protein, and 33% fat. Total number of F/V served was 2.9±1.9 and consumed was 2.3±1.8, while whole grains served and consumed were 0.3±0.4 and 0.2±0.4, respectively, and lean proteins served and consumed were 0.3±0.4 and 0.2±0.4, respectively.

CONCLUSIONS

This study describes obesogenic aspects of the child-care environment and identifies areas for improvement. Children did not accumulate adequate PA or consume calories or fat excessively. Children consumed multiple F/V; however, more whole grains and lean proteins could be provided. Future research might investigate how the healthfulness of the child-care environment can be improved by counseling providers on nutrition and PA strategies to prevent obesity.

Obesity prevention and obesogenic behavior interventions in child care: A systematic review

OBJECTIVE

Review peer-reviewed interventions designed to reduce obesity and improve obesogenic behaviors, including physical activity, diet, and screen time, at child care centers. Interventions components and outcomes, study design, duration, use of behavioral theory, and level of social ecological influence are detailed.

METHODS

Article searches were conducted from March 2014, October 2014, March 2015, January 2016 across three databases. Eligible interventions were conducted in child care settings, included 3-to-5-year-old children, included an outcome measure of obesity or obesogenic behavior, and published in English. Study design quality was assessed using Stetler's Level of Quantitative Evidence.

RESULTS

All unique records were screened (n=4589): 237 articles were assessed for eligibility. Of these, 97 articles describing 71 interventions met inclusion criteria. Forty-four articles included multi-level interventions. Twenty-nine interventions included an outcome measure of obesity. Forty-one interventions included physical activity. Forty-five included diet. Eight included screen time. Fifty-five percent of interventions were Level II (randomized controlled trials), while 37% were Level III (quasi-experimental or pre-post only study design), and 8% were Level IV (non-experimental or natural experiments). Most interventions had the intended effect on the target: obesity 48% (n=14), physical activity 73% (n=30), diet 87% (n=39), and screen time 63% (n=5).

CONCLUSION

Summarizing intervention strategies and assessing their effectiveness contributes to the existing literature and may provide direction for practitioners and researchers working with young children in child care. Most interventions produced the targeted changes in obesity and obesity-associated behaviors, supporting current and future efforts to collaborate with early-care centers and professionals for obesity prevention.