Obesity prevention in child care: a review of U.S. state regulations

A Narrative Review of Public Health Interventions for Childhood Obesity

PURPOSE OF REVIEW

Public health interventions that intervene on macrolevel systems hold the promise of reducing childhood obesity at the population level through prevention. The purpose of this review is to highlight some of the recent and best scientific evidence related to public health interventions for the prevention of childhood obesity. We provide a narrative review of scientific evidence for six categories of public health interventions and their impact on childhood obesity: federal nutrition assistance programs, programs implemented in early care and education centers, interventions to support healthy nutrition and physical activity in schools, community-based programs and policies, labeling policies and marketing to children, and taxes on sugar sweetened beverages (SSB).

RECENT FINDINGS

Federal nutrition assistance programs have the strongest evidence to support reduction in childhood obesity and serve populations with the highest prevalence of childhood obesity. Other interventions including SSB taxes, community-wide interventions, and interventions at schools and early care and education centers also show significant improvements in child weight status. Overall public health interventions have strong evidence to support widespread implementation in service of reducing childhood obesity rates at the population level. To effectively address the recalcitrant childhood obesity epidemic, multi-pronged solutions are needed. The current evidence for public health obesity interventions is consistent with the paradigm that recognizes the importance of macrolevel systems influences on childhood obesity: interventions that are most effective intervene at macrolevels.

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

OBJECTIVE

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

DESIGN

Cross-sectional analysis.

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

ANALYSIS

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

RESULTS

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

CONCLUSIONS AND IMPLICATIONS

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

Food Waste, Preference, and Cost: Perceived Barriers and Self-Reported Food Service Best Practices in Family Child Care Homes

Background: Family Child Care Homes (FCCHs) are a setting where providers care for children at their own residence. FCCHs face unique challenges and children may not always receive optimal nutrition and have higher risk of obesity compared to other programs. The objective of this study was to determine differences in food service best practices scores between FCCHs who did/did not perceive barriers to serving healthy meals. Methods: FCCHs (n = 167) self-reported demographics, and perceived barriers to serving healthy foods. Nutrition and Physical Activity Self-Assessment for Child Care was used to assess food served with 1 (indicating poor practice) to 4 (indicating best practice). Means, standard deviations, and t-tests were conducted to determine differences in scores between FCCHs with and without perceived barriers. Adjusted alpha was 0.013. Results: FCCHs perceiving food waste as a barrier had significantly lower scores for total food and beverage (p = 0.006, 3.2 ± 0.3 vs. 3.4 ± 0.3); fruits and vegetables (p = 0.003, 3.1 ± 0.5 vs. 3.3 ± 0.5), whole fruits (p = 0.048, 3.1 ± 1.2 vs. 3.4 ± 0.9), and nonstarchy vegetables (p = 0.007, 2.8 ± 0.9 vs. 3.2 ± 0.9). Providers perceiving food preferences as a barrier had significantly lower scores compared to those who did not (p = 0.008, 2.9 ± 0.9 vs. 3.3 ± 0.9). No significant differences found in best practices among providers with vs. without perceived barrier of food costs. Conclusion: Food waste is an understudied barrier in FCCHs to serve healthy meals. Research is needed to explore these perceived barriers in FCCHs to improve best practices around meals.

Implementation of Minimum Nutrition Standards and Best Practices in Childcare Centers

BACKGROUND

The federal Child and Adult Care Food Program (CACFP) provides reimbursable meals to 4.6 million children annually and sets nutrition standards for foods served. Licensing regulations in many states extend these rules to nonparticipating programs.

OBJECTIVE

To evaluate the quality of meals and snacks served in Connecticut licensed childcare centers in 2019 and assess implementation of a state licensing requirement to adhere to CACFP minimum nutrition standards in all centers.

DESIGN

Cross-sectional survey.

PARTICIPANTS/SETTING

Two hundred licensed childcare centers in Connecticut in 2019.

MAIN OUTCOME MEASURES

Meal/snack quality was assessed based on menus. Foods/beverages listed were compared to the minimum CACFP nutrition standards and optional best practices. Surveys completed by center directors measured center characteristics.

STATISTICAL ANALYSIS

Logistic and linear multivariable regression models tested differences in centers' adherence to nutrition standards and best practices by CACFP participation status.

RESULTS

CACFP centers complied with more required nutrition standards than non-CACFP centers (an adjusted mean of 4.7 vs 3.4 standards among programs serving meals, P < 0.001), with particularly large mean differences for whole grains and low-fat milk. Implementation of optional best practices, except for beverages, was relatively low among all centers, especially for snacks. Compliance (adjusted mean number of minimum nutrition standards met) was greater among centers accredited by the National Association for the Education of Young Children and those using a registered dietitian or a sponsoring agency to prepare menus and receiving food from a vendor. Recent completion of nutrition training was associated with greater mean implementation of best practices.

CONCLUSIONS AND IMPLICATIONS

Better adherence to minimum nutrition standards and best practices among CACFP-participating childcare centers contributed to higher nutritional quality of meals and snacks offered. Snack quality would benefit most from greater compliance with nutrition standards. Providers outside of CACFP need additional supports in the implementation of licensing regulations to improve the food environment for young children.

Opportunities to Promote Healthy Weight Through Child Care Licensing Regulations: Trends in the United States, 2016-2020

BACKGROUND

Policies that support healthy nutrition and physical activity environments in early care and education (ECE) settings can help promote healthy weight in children. State child care licensing regulations are a critical mechanism for setting such policies.

OBJECTIVES

To develop a research instrument to evaluate the promotion of healthy child weight in state child care licensing regulations and assess the strength of the regulations over time.

DESIGN

For measure development, systematic reviews of evidence on the impact of healthy weight strategies relevant to the ECE environment were combined with expert stakeholder input to identify 15 healthy weight promotion policy standards and a coding tool to measure the strength and comprehensiveness of regulatory language matching these standards. For assessing the strength of regulations, the coding tool was applied to child care regulations nationwide in 2016 and again in 2020.

SUBJECTS/SETTING

Child care licensing regulations in 2016 and 2020 for all 50 US states plus Washington DC.

OUTCOME MEASURES

Strength and comprehensiveness scores for state licensing regulations.

STATISTICAL ANALYSES

Intraclass correlation coefficients were calculated to estimate interrater reliability of the coding tool. Paired t tests were used to compare scores within states from 2016 to 2020.

RESULTS

Interrater reliability for the coding tool had intraclass correlation coefficients of 0.81 for strength and 0.87 for comprehensiveness scores. Strength and comprehensiveness of states' healthy weight promotion policies increased significantly over time (P < .001). However, most states still lack important healthy weight policies in their licensing regulations, such as prohibiting serving sugary drinks.

CONCLUSIONS

This study presents a reliable research instrument for measuring the strength and comprehensiveness of healthy weight promotion standards in child care licensing regulations. States have increased their incorporation of strategies for healthy weight into state policy.

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

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

State Regulations to Support Children's Cultural and Religious Food Preferences in Early Care and Education

Objective

In July 2018 the Academy of Nutrition and Dietetics released a benchmark encouraging early care and education (ECE) programs, including child care centers and family child care homes, to incorporate cultural and religious food preferences of children into meals. We examined the extent to which states were already doing so through their ECE licensing and administrative regulations prior to the release of the benchmark. This review may serve as a baseline to assess future updates, if more states incorporate the benchmark into their regulations.

Methods

For this cross-sectional study, we reviewed ECE regulations for all 50 states and the District of Columbia (hereafter states) through June 2018. We assessed consistency with the benchmark for centers and homes. We conducted Spearman correlations to estimate associations between the year the regulations were updated and consistency with the benchmark.

Results

Among centers, eight states fully met the benchmark, 11 partially met the benchmark, and 32 did not meet the benchmark. Similarly for homes, four states fully met the benchmark, 13 partially met the benchmark, and 34 did not meet the benchmark. Meeting the benchmark was not correlated with the year of last update for centers (P = 0.54) or homes (P = 0.31).

Conclusions

Most states lacked regulations consistent with the benchmark. Health professionals can help encourage ECE programs to consider cultural and religious food preferences of children in meal planning. And, if feasible, states may consider additional regulations supporting cultural and religious preferences of children in future updates to regulations.

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.

Participation in the Child and Adult Care Food Program is associated with fewer barriers to serving healthier foods in early care and education

BACKGROUND

Early care and education (ECE) is an important setting for influencing young children's dietary intake. There are several factors associated with barriers to healthy eating in ECE, and recent evidence suggests that participation in the Child and Adult Care Food Program (CACFP), the primary national food assistance program in ECE, may be associated with fewer barriers to serving healthier foods. However, no prior studies have examined differences between CACFP participants and non-participants across a large, multi-state sample. This is the first study to examine the association between CACFP participation and barriers to serving healthier foods in ECE using a random sample of directors from two regions across the country.

METHODS

We conducted a cross-sectional survey among a random sample of child care center directors from four states (Massachusetts, North Carolina, Rhode Island, and South Carolina). We conducted logistic and Poisson regression to calculate the odds and incidence rate ratios of reporting 1) no barriers, 2) specific barriers (e.g., cost), and 3) the total number of barriers, by CACFP status, adjusting for covariates of interest.

RESULTS

We received 713 surveys (36% response rate). About half (55%) of centers participated in CACFP. The most prevalent reported barriers to serving healthier foods were cost (42%) and children's food preferences (19%). Directors from CACFP centers were twice as likely to report no barriers, compared to directors from non-CACFP centers (OR 2.03; 95% CI [1.36, 3.04]; p < 0.01). Directors from CACFP centers were less likely to report cost as a barrier (OR = 0.46; 95% [CI 0.31, 0.67]; p < 0.001), and reported fewer barriers overall (IRR = 0.77; 95% CI [0.64, 0.92]; p < 0.01), compared to directors from non-CACFP centers.

CONCLUSIONS

CACFP directors reported fewer barriers to serving healthier foods in child care centers. Still, cost and children's food preferences are persistent barriers to serving healthier foods in ECE. Future research should evaluate characteristics of CACFP participation that may alleviate these barriers, and whether barriers emerge or persist following 2017 rule changes to CACFP nutrition standards.

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.

A Menu to Evaluate Factors Influencing Implementation of Obesity Prevention Early Care and Education Regulations

CONTEXT

In recent years, several states have adopted new regulations concerning nutrition, physical activity, and screen time in early care and education (ECE) settings to help prevent childhood obesity.

OBJECTIVE

To disseminate a menu of factors that facilitate and/or impede implementation of obesity prevention regulations in ECE settings.

DESIGN

To create the menu, we condensed and categorized factors identified in the literature and through field work by placing them within domains. We applied the menu by conducting semistructured interviews during a pilot test assessing implementation of ECE regulations in Colorado.

SETTING AND PARTICIPANTS

We first interviewed state and local government agency leaders responsible for policy oversight, and state employees and contractors who acted as intermediaries to direct implementers. We then interviewed directors at ECE centers in the Denver, Colorado, area. We selected 21 ECE centers for a site visit on the basis of feasibility, percentage of low-income families, and diversity in race and ethnicity at each center. Seven centers participated.

MAIN OUTCOME MEASURES

Minor and major facilitators and impediments to implementation of childhood obesity prevention regulations in ECE settings.

RESULTS

The resulting menu includes 7 domains and 39 factors influential for implementation of ECE regulations. Of these 39 factors, interviewees identified 7 facilitating factors (4 major and 3 minor) and 2 impeding factors (both major). Major facilitating factors were buy-in from parents/caregivers, training and communication provided by governing authority and their contractors, and low level of change required by the regulations themselves. Major impeding factors were timing of implementation and balancing the demands of the regulations against other priorities.

CONCLUSIONS

The menu developed by our research team, combined with existing frameworks in dissemination and implementation research, can be used by researchers, practitioners, and policy makers to anticipate factors that facilitate and/or impede implementation of ECE policies to prevent childhood obesity.

Status of Beverages Served to Young Children in Child Care After Implementation of California Policy, 2012-2016

INTRODUCTION

Since 2012, licensed California child care centers and homes, per state policy, are required to serve only unflavored low-fat or nonfat milk to children aged 2 years or older, no more than one serving of 100% juice daily, and no beverages with added sweeteners, and they are required to ensure that drinking water is readily accessible throughout the day. We evaluated adherence to the policy after 4 years in comparison to the adherence evaluation conducted shortly after the policy went into effect.

METHODS

Licensed California child care sites were randomly selected in 2012 and 2016 and surveyed about beverage practices and provisions to children aged 1-5 years. We used logistic regression to analyze between-year differences for all sites combined and within-year differences by site type and participation in the federal Child and Adult Care Food Program (CACFP) in self-reported policy adherence and beverage provisions.

RESULTS

Respondents in 2016 (n = 680), compared with those in 2012 (n = 435), were more adherent to California's 2010 Healthy Beverages in Child Care Act overall (45.1% vs 27.2%, P < .001) and with individual provisions for milk (65.0% vs 41.4%, P < .001), 100% juice (91.2% vs 81.5%, P < .001), and sugar-sweetened beverages (97.4% vs 93.4%, P = .006). In 2016, centers compared with homes (48.5% vs 28.0%, P = .001) and CACFP sites compared with non-CACFP sites (51.6% vs 27.9%, P < .001) were more adherent to AB2084 overall.

DISCUSSION

Beverage policy adherence in California child care has improved since 2012 and is higher in CACFP sites and centers. Additional policy promotion and implementation support is encouraged for non-CACFP sites and homes. Other states should consider adopting such policies.

Provider reported implementation of nutrition-related practices in childcare centers and family childcare homes in rural and urban Nebraska

Approximately 15 million children under age 6 are in childcare settings, offering childcare providers an opportunity to influence children's dietary intake. Childcare settings vary in organizational structure - childcare centers (CCCs) vs. family childcare homes (FCCHs) - and in geographical location - urban vs. rural. Research on the nutrition-related best practices across these childcare settings is scarce. The objective of this study is to compare nutrition-related best practices of CCCs and FCCHs that participate in the Child and Adult Care Food Program (CACFP) in rural and urban Nebraska. Nebraska providers (urban n = 591; rural n = 579) reported implementation level, implementation difficulty and barriers to implementing evidence-informed food served and mealtime practices. Chi-square tests comparing CCCs and FCCHs in urban Nebraska and CCCs and FCCHs in rural Nebraska showed sub-optimal implementation for some practices across all groups, including limiting fried meats and high sugar/ high fat foods, using healthier foods or non-food treats for celebrations and serving meals family style. Significant differences (p < .05) between CCCs and FCCHs also emerged, especially with regard to perceived barriers to implementing best practices. For example, CCCs reported not having enough money to cover the cost of meals for providers, lack of control over foods served and storage problems, whereas FCCHs reported lack of time to prepare healthier foods and sit with children during mealtimes. Findings suggest that policy and public health interventions may need to be targeted to address the unique challenges of implementing evidence-informed practices within different organizational structures and geographic locations.

The impact of basic vs. enhanced Go NAPSACC on child care centers' healthy eating and physical activity practices: protocol for a type 3 hybrid effectiveness-implementation cluster-randomized trial

BACKGROUND

To prevent childhood obesity and promote healthy development, health authorities recommend that child care programs use the evidence-based practices that foster healthy eating and physical habits in children. Go NAPSACC is an intervention shown to improve use of these recommended practices, but it is known to encounter barriers that limit its impact and widespread use.

METHODS

This study will use a type 3 hybrid effectiveness-implementation cluster-randomized trial to compare effectiveness and implementation outcomes achieved from Go NAPSACC delivered with a basic or enhanced implementation approach. Participants will include approximately 25 coaches from Child Care Aware of Kentucky (serving four geographic regions), 97 child care centers with a director and teacher from each and two cross-sectional samples of 485 3-4-year-old children (one recruitment at baseline, another at follow-up). Coaches will be randomly assigned to deliver Go NAPSACC using either the basic or enhanced implementation approach. "Basic Go NAPSACC" represents the traditional way of delivering Go NAPSACC. "Enhanced Go NAPSACC" incorporates preparatory and support activities before and during their Go NAPSACC work, which are guided by the Quality Implementation Framework and the Consolidated Framework for Implementation Research. Data will be collected primarily at baseline and post-intervention, with select measures continuing through 6, 12, and 24 months post-intervention. Guided largely by RE-AIM, outcomes will assess change in centers' use of evidence-based nutrition and physical activity practices (primary, measured via observation); centers' adoption, implementation, and maintenance of the Go NAPSACC program (assessed via website use); center directors', teachers', and coaches' perceptions of contextual factors (assessed via self-report surveys); children's eating and physical activity behaviors at child care (measured via observation and accelerometers); and cost-effectiveness (assessed via logs and expense tracking). The hypotheses anticipate that "Enhanced Go NAPSACC" will have greater effects than "Basic Go NAPSACC."

DISCUSSION

This study incorporates many lessons gleaned from the growing implementation science field, but also offers opportunities to address the field's research priorities, including applying a systematic method to tailor implementation strategies, examining the processes and mechanisms through which implementation strategies produce their effects, and conducting an economic evaluation of implementation strategies.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03938103, Registered April 8, 2019.

Nutritional Quality of Meals and Snacks Served and Consumed in Family Child Care

BACKGROUND

Improving the nutritional quality of food, including beverages, served in early care and education settings should enhance children's diet quality. However, few studies have explored the relationship between what is served and consumed in family child-care homes (FCCHs).

OBJECTIVE

To describe the nutritional quality of food served to children in FCCHs and to assess the extent to which children eat what is served.

DESIGN

This study was a cross-sectional analysis using baseline data (n=166) from a cluster-randomized controlled trial (2013-2016).

PARTICIPANTS/SETTING

Eligible FCCHs in central North Carolina had to have at least two children between 18 months and 4 years, have been in business for at least 2 years, and serve at least one meal and one snack.

MAIN OUTCOME MEASURES

Food was captured using the Diet Observation at Child Care protocol.

STATISTICAL ANALYSES

Frequencies, means, and multivariate analysis were used to examine the relationship between food served and consumed by food groups and by Healthy Eating Index (HEI-2010).

RESULTS

Children consumed between 61% and 80% of what was served, with vegetables having the lowest percent consumed (61.0%). Total HEI-2010 score for food served was 63.6 (10.4) and for food consumed was 61.7 (11.5) out of a 100-point maximum. With regards to food served, FCCH providers came close to meeting HEI-2010 standards for dairy, whole fruit, total fruit, and empty calories. However, providers appeared to fall short when it came to greens and beans, seafood and plant proteins, total vegetables, whole grains, and fatty acids. They also exceeded recommended limits for sodium and refined grains.

CONCLUSIONS

Although FCCHs are serving some healthy food, mainly fruit, dairy, and few empty calories, there is room for improvement with regards to vegetables, grains, seafood and plant protein, fatty acids, and sodium. Future trainings should help providers find ways to increase the serving and consumption of these foods.

State Regulations Promoting Infant Physical Activity in Early Care and Education

BACKGROUND

State policies have the potential to improve early care and education (ECE) settings, but little is known about the extent to which states are updating their licensing and administrative regulations, especially in response to national calls to action. In 2013, we assessed state regulations promoting infant physical activity in ECE and compared them with national recommendations. To assess change over time, we conducted this review again in 2018.

METHODS

We reviewed regulations for all US states for child care centers (centers) and family child care homes (homes) and compared them with three national recommendations: (1) provide daily tummy time; (2) use cribs, car seats, and high chairs for their primary purpose; and (3) limit the use of restrictive equipment (e.g., strollers). We performed exact McNemar's tests to compare the number of states meeting recommendations from 2013 to 2018 to evaluate whether states had made changes over this period.

RESULTS

From 2013 to 2018, we observed significant improvement in one recommendation for homes-to use cribs, car seats, and high chairs for their primary purpose (odds ratio 11.0; 95% CI 1.6-47.3; p = 0.006). We did not observe any other significant difference between 2013 and 2018 regulations.

CONCLUSIONS

Despite increased awareness of the importance of early-life physical activity, we observed only modest improvement in the number of states meeting infant physical activity recommendations over the past 5 years. In practice, ECE programs may be promoting infant physical activity, but may not be required to do so through state regulations.

Barriers and Facilitators to Compliance with a State Healthy Eating Policy in Early Care and Education Centers

BACKGROUND

Early care and education (ECE) policies can improve childhood obesity risk factors. We evaluated barriers and facilitators to implementing mandatory nutrition standards for foods provided in South Carolina ECE centers serving low-income children, comparing centers participating in the Child and Adult Care Food Program (CACFP) with non-CACFP centers.

METHODS

We mailed 261 surveys (demographics, policies and practices, barriers and facilitators) to center directors after new state nutrition standards were implemented in South Carolina. We conducted univariate and bivariate analyses to explore relationships between barriers, facilitators, and center-level characteristics, by CACFP status.

RESULTS

We received 163 surveys (62% response rate). Centers had a median [interquartile range (IQR)] of 5 (4-7) classrooms and 59 (37.5-89) total children enrolled. More than half (60.1%) of directors reported they were moderately or fully informed about the standards. The most common barriers were food costs (17.8%) and children's food preferences (17.8%). More non-CACFP directors reported food costs as a barrier (28.6% vs. 6.5%, p < 0.001), having to spend additional money on healthier foods (48.8% vs. 28.6%, p = 0.01), and having to provide additional nutrition education to parents (28.6% vs. 11.7%, p = 0.01), compared with CACFP directors.

CONCLUSIONS

Center directors were generally well informed about the nutrition standards. The most common barriers to implementing the standards were food costs and children's food preferences. Centers participating in CACFP may be in a better position to adhere to new state nutrition standards, as they receive some federal reimbursement for serving healthy foods and may be more accustomed to regulation.

Feasibility of a Multicomponent Program to Promote Physical Activity and Nutrition in Georgia Low-Income Early Care and Education Settings

BACKGROUND

This article describes the process and intermediate outcomes from a program implemented in 65 Early Care and Education (ECE) centers serving low-income families throughout Georgia during the 2014-2017 school years.

METHODS

The HealthMPowers' Empowering Healthy Choices in Schools, Homes, and Communities ECE program was based on the organization's previously successful elementary school program and aligns with current early childhood nutrition and physical activity recommendations. Participating centers worked with HealthMPowers for up to 3 years. A team from each center led changes by conducting annual self-assessments, creating and implementing improvement plans, and implementing nutrition and physical activity programs using educational resources and environmental cues. A monitoring and evaluation plan provided ongoing feedback to HealthMPowers and centers. Family and staff surveys provided insights into behaviors of children, families, and staff. Process measures included specific benchmarks (e.g., center leadership team formation, improvement plan implementation). Annual self-assessment results served as intermediate outcome measures.

RESULTS

As of 2017, 65 centers had enrolled in the program. All centers formed a health team and completed the baseline self-assessment and most implemented an improvement plan (88%). At the 1-year follow-up self-assessment, centers reported improvements from baseline including never offering food incentives for good behavior (75%-86%), conducting taste testing at least once a month (61%-79%), and rarely/never serving sugar-sweetened beverages (93%-96%).

CONCLUSIONS

Initial process measures from a multicomponent health promotion program in ECE were promising. An integrated continuous improvement approach to working with child care settings is feasible and likely effective.

Multisector Approach to Improve Healthy Eating and Physical Activity Policies and Practices in Early Care and Education Programs: The National Early Care and Education Learning Collaboratives Project, 2013-2017

Purpose and Objectives

Embedding healthy eating and physical activity best practices in early care and education settings is important for instilling healthy behaviors early in life. A collaborative partnership between Nemours Children’s Health System and the Centers for Disease Control and Prevention was created to implement the National Early Care and Education Learning Collaboratives Project (ECELC) in childcare settings in 10 states. We measured improvement at the program level by the self-reported number of best practices implemented related to healthy eating and physical activity.

Intervention Approach

The ECELC implemented a collaborative model with state-level partners (eg, child care resource and referral networks) and early care and education programs. Intervention components received by program directors and lead teachers included 1) self-assessment, 2) in-person learning and training sessions, 3) action planning and implementation, 4) technical assistance, and 5) post-reassessment.

Evaluation Methods

A pre–post design assessed self-reported policies and practices related to breastfeeding and infant feeding, child nutrition, infant and child physical activity, screen time, and outdoor play and learning as measured by the validated Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) best practices instrument. The sample included 1,173 early care and education programs.

Results

The number of best practices met for each of the 5 NAP SACC areas increased from pre-assessment to post-assessment approximately 6 months later and ranged from 1.5 to 4.7 best practices (P < .001). Almost all increases occurred regardless of participation in the Child and Adult Care Food Program, Quality Rating Improvement System, Head Start/Early Head Start, and/or accreditation status.

Implications for Public Health

The innovative and collaborative partnerships led to broad implementation of healthy eating and physical activity–based practices in early care and education settings. Development, implementation, and evaluation of policy and practice-based partnerships to promote healthy eating and physical activity among children attending early care and education programs may contribute to obesity prevention in the United States.

Parental child feeding practices and their relationship with children's dietary intake and weight status in Nepal

Background: Small children have less control over their dietary intake and parents have a major role to play in it. The aim of our study was to determine parental child feeding practices and their association with the weight status and dietary intake of the child. Design and methods: A cross-sectional study was conducted among 138 parents and preschool children attending two private schools in Kathmandu Valley, Nepal using a structured questionnaire. Parents filled in a self-report questionnaire to assess child feeding practices, perceived activity level of the child, and dietary intake at home. Child's height and weight was measured using a standard height scale and a digital weighing scale. A digital food scale was used for measuring dietary intake. Results: Eight percent of the children were overweight and another 8% were obese. On bivariate analysis, the BMI of parents had weak, positive, and significant correlation (r=0.206, p=0.016 for fathers; r=0.307, p≤0.001 for mothers) with child's weight status. Similarly, concern about child's overweight had a significant, positive correlation (r=0.232, p=0.006) with the weight status of the child. Furthermore, these three independent variables were found to be significant predictors of a child's weight status on multivariate analysis. None of the studied independent variables was associated with dietary intake. Conclusion: The study concludes that parental BMI and parental concern about the child being overweight is significantly associated with the weight status of the child.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

NCT02452645.

The quality of nutrition and physical activity environments of child-care centers across three states in the southern U.S

This cross-sectional study assessed the quality of nutrition and physical activity environments of child-care centers in three southern states and examined differences by rural versus urban location, participation in the Child and Adult Care Food Program, and Head Start status. The sample included 354 centers that enroll children aged 2-5: 154 centers from Georgia, 103 from Kentucky, and 97 centers from Mississippi. Directors and 1-2 teachers per center completed the Environment and Policy Assessment and Observation Self-Report (EPAO-SR) tool that assesses nutrition and physical activity environments of child-care centers. The EPAO-SR items were scored to capture six nutrition domains and six physical activity domains that were averaged and then summed to create a combined nutrition and physical activity environment score (range = 0-36); higher scores indicated that centers met more best practices, which translated to higher-quality environments. Overall, the centers had an average combined nutrition and physical activity environment score of 20.2 out of 36. The scores did not differ between rural and urban centers (mean = 20.3 versus 20.2, p = 0.98). Centers in the Child and Adult Care Food Program had higher combined nutrition and physical activity environment scores than non-participating centers (mean = 20.6 versus 19.1, p < 0.01). Head Start centers also had higher combined environment scores than non-Head Start centers (mean = 22.3 versus 19.6, p < 0.01). Findings highlight the vital role of federal programs in supporting healthy child-care environments. Providing technical assistance and training to centers that are not enrolled in well-regulated, federally-funded programs might help to enhance the quality of their nutrition and physical activity environments.

Physical activity and sedentary behavior legislation in Canadian childcare facilities: an update

Background

Within the childcare sector, physical activity and sedentary behaviors are not legislated at a national level in Canada. Efforts have been undertaken to identify factors within childcare facilities which support and deter physical activity and sedentary behaviors. The purpose of this paper was to provide an amended review of the legislative landscape, at the provincial and territorial level, regarding physical activity and sedentary behaviors (via screen-viewing) in Canadian childcare centers.

Methods

Individual childcare acts and regulations for each province and territory were collected; documents were reviewed with a focus on sections devoted to child health, physical activity, screen time, play, and outdoor time. An extraction table was used to facilitate systematic data retrieval and comparisons across provinces and territories.

Results

Of the 13 provinces and territories, 8 (62%) have updated their childcare regulations in the past 5 years. All provinces provide general recommendations to afford gross motor movement; but the majority give no specific requirements for how much or at what intensity. Only 3 provinces (Northwest Territories, Nunavut, and Nova Scotia) explicitly mentioned daily physical activity while all provinces’ and territories’ required daily outdoor play. Only 1 province (New Brunswick) made mention of screen-viewing.

Conclusions

The variability in childcare regulations results in different physical activity requirements across the country. By providing high-level targets for physical activity recommendations, by way of provincial/territorial legislation, staff would have a baseline from which to begin supporting more active behaviors among the children in their care. Future research is needed to support translating physical activity policies into improved activity levels among young children in childcare and the role of screen-viewing in these venues.

Nutritional Assessment of Snacks and Beverages in Southeastern Virginia Daycare Centers

This study sought to determine the nutritional quality of snacks and beverages provided at licensed daycare centers of variable sizes in Southeastern Virginia. This cross-sectional study employed self-report surveys about snack offerings administered at each daycare site that agreed to participate. In addition, researchers completed an observation survey on the day of visit to observe and document the food and beverages actually served at snack time. Although many daycare directors reported serving fresh fruit and vegetables for snacks, there was a poor correlation on the offering of these healthy snacks between researchers and directors ( P < .05). Researchers observed salty, caloric dense foods for snack time more frequently than fresh fruits and vegetables. These findings demonstrate the importance of improving and perhaps regulating the quality and diversity of snacks and beverages offered in childcare, as dietary amendments may prevent the development of childhood obesity.

The family child care home environment and children's diet quality

BACKGROUND

Developing healthy eating behaviors and food preferences in early childhood may help establish future healthy diets. Large numbers of children spend time in child care, but little research has assessed the nutritional quality of meals and snacks in family child care homes. Therefore, it is important to assess foods and beverages provided, policies related to nutrition and feeding children, and interactions between providers and children during mealtimes. We examined associations between the nutrition environments of family child care homes and children's diet quality.

METHODS

We assessed the nutrition environments of 166 family child care homes using the Environment and Policy Assessment and Observation (EPAO) (scores range: 0-21). We also recorded foods and beverages consumed by 496 children in care and calculated healthy eating index (HEI) (scores range: 0-100). We used a mixed effects linear regression model to examine the association between the EPAO nutrition environment (and EPAO sub-scales) and child HEI, controlling for potential confounders.

RESULTS

Family child care homes had a mean (standard deviation, SD) of 7.2 (3.6) children in care, 74.1% of providers were black or African American, and children had a mean (SD) age of 35.7 (11.4) months. In adjusted multivariable models, higher EPAO nutrition score was associated with increased child HEI score (1.16; 95% CI: 0.34, 1.98; p = 0.006). Higher scores on EPAO sub-scales for foods provided (8.98; 95% CI: 3.94, 14.01; p = 0.0006), nutrition education (5.37; 95% CI: 0.80, 9.94; p = 0.02), and nutrition policy (2.36; 95% CI: 0.23, 4.49; p = 0.03) were all associated with greater child HEI score.

CONCLUSIONS

Foods and beverages served, in addition to nutrition education and nutrition policies in family child care homes, may be promising intervention targets for improving child diet quality.

Supporting Obesity Prevention in Statewide Quality Rating and Improvement Systems: A Review of State Standards

Introduction

A quality rating and improvement system (QRIS) is a fundamental component of most states’ early care and education infrastructures. States can use a QRIS to set standards that define high-quality care and award child care providers with a quality rating designation based on how well they meet these standards. The objective of this review was to describe the extent to which states’ QRIS standards include obesity prevention content.

Methods

We collected publicly available data on states’ QRIS standards. We compared states’ QRIS standards with 47 high-impact obesity prevention components in Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, 3rd Edition, and 6 additional topics based on the Centers for Disease Control and Prevention’s Spectrum of Opportunities for Obesity Prevention in the Early Care and Education Setting.

Results

Thirty-eight states operated a state-wide QRIS in early 2015. Of those, 27 states’ QRIS included obesity prevention standards; 20 states had at least one QRIS standard that aligned with the high-impact obesity prevention components, and 21 states had at least one QRIS standard that aligned with at least one of the 6 additional topics. QRIS standards related to the physical activity high-impact obesity prevention components were the most common, followed by components for screen time, nutrition, and infant feeding.

Conclusion

The high proportion of states operating a QRIS that included obesity prevention standards, combined with the widespread use of QRISs among states, suggests that a QRIS is a viable way to embed obesity prevention standards into state early care and education systems.

State Variations in Infant Feeding Regulations for Child Care

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of the Supporting Physical Activity in the Childcare Environment (SPACE) intervention on preschoolers' physical activity levels and sedentary time: a single-blind cluster randomized controlled trial

BACKGROUND

Physical activity levels among preschoolers in childcare are low and sedentary time high. The Supporting Physical Activity in the Childcare Environment (SPACE) intervention had three components: 1. portable play equipment; 2. staff training; and, 3. modified outdoor playtime (i.e., shorter, more frequent periods). This study aimed to examine the effectiveness of the SPACE intervention on preschoolers' physical activity levels and sedentary time during childcare hours (compared to standard care).

METHODS

Via a single-blind cluster randomized controlled trial, 338 preschoolers (39.86 ± 7.33 months; 52% boys) from 22 centre-based childcare facilities (11 experimental, 11 control) were enrolled. Preschoolers wore an Actical™ accelerometer for 5 days during childcare hours at baseline, post-intervention, and 6- and 12-month follow-up, and were included in the analyses if they had a minimum of two valid days (5 h each day) at baseline and one additional time point. Intervention effectiveness was tested using a linear mixed effects model for each of the four outcome variables (i.e., sedentary time, light physical activity [LPA], moderate-to-vigorous physical activity [MVPA], and total physical activity [TPA]). Fixed effects were further evaluated with t-tests, for which degrees of freedom were estimated using a Satterthwaite approximation.

RESULTS

One hundred and ninety-five preschoolers were retained for analyses. The intervention did not significantly impact LPA. MVPA was significantly greater among children in the experimental group when comparing post-intervention to pre-intervention, t(318) = 3.50, p = .0005, but no intervention effects were evident at 6- or 12-month follow-up. TPA was significantly greater for children in the intervention group at post-intervention when compared to pre-intervention, t(321) = 2.70, p = .007, with no intervention effects evident at later time periods. Finally, sedentary time was significantly lower among preschoolers in the experimental group when comparing post-intervention to pre-intervention, t(322) = 2.63, p = .009, with no significant effects at follow-up.

CONCLUSIONS

The SPACE intervention was effective at increasing MVPA and TPA among preschoolers, while simultaneously decreasing sedentary time. The ability of the SPACE intervention to target higher intensity activity is promising, as MVPA levels have been documented to be low in centre-based childcare. The changes in physical activity were not sustained long term (6- or 12-month follow-up).

TRIAL REGISTRATION

ISRCTN70604107 (October 8, 2014).

Improving Nutrition and Physical Activity Policies and Practices in Early Care and Education in Three States, 2014-2016

The National Early Care and Education Learning Collaboratives (ECELC) project aims to facilitate best practices in nutrition, physical activity, screen time, and breastfeeding support and infant feeding among early care and education (ECE) programs across multiple states. The project uses a train-the-trainer approach with 5, in-person learning-collaborative sessions, technical assistance, and action planning. We describe the longitudinal practice-based evaluation of the project and assess whether ECE programs evaluated (n = 104) sustained changes in policies and practices 1 year after completing the project. The number of best practices increased from pre-assessment to post-assessment (P < .01) but did not change significantly from post-assessment to follow-up assessment. ECELC shows promise as an approach to incorporate professional development and training focused on improving best practices for environment-level child nutrition and physical activity, which is one strategy among many that are warranted for obesity prevention in young children.

Assessment of nutrition and physical activity environments in family child care homes: modification and psychometric testing of the Environment and Policy Assessment and Observation

BACKGROUND

Early care and education (ECE) settings play an important role in shaping the nutrition and physical activity habits of young children. Increasing research attention is being directed toward family child care homes (FCCHs) specifically. However, existing measures of child care nutrition and physical activity environments are limited in that they have been created for use with center-based programs and require modification for studies involving FCCHs. This paper describes the modification of the Environment and Policy Assessment and Observation (EPAO) for use in FCCHs.

METHODS

The EPAO underwent a through modification process that incorporated an updated format for the data collection instrument, assessment of emerging best practices, tailoring to the FCCH environment, and creation of a new scoring rubric. The new instrument was implemented as part of a larger randomized control trial. To assess inter-rater reliability, observations on 61 different days were performed independently by two data collectors. To assess construct validity, associations between EPAO scores and measures of children's dietary intake (Healthy Eating Index (HEI) score) and physical activity (accelerometer-measured minutes per hour of moderate to vigorous physical activity, MVPA) were examined.

RESULTS

The modified EPAO assesses 38 nutrition and 27 physical activity best practices, which can be summarized into 7 nutrition-related and 10 physical activity-related environmental sub- scores as well as overall nutrition and overall physical activity scores. There was generally good agreement between data collectors (ICC > 0.60). Reliability was slightly lower for feeding practices and physical activity education and professional development (ICC = 0.56 and 0.22, respectively). Child HEI was significantly correlated with the overall nutrition score (r = 0.23), foods provided (r = 0.28), beverages provided (r = 0.15), nutrition education and professional development (r = 0.21), and nutrition policy (r = 0.18). Child MVPA was significantly associated with overall time provided for activity (r = 0.18) and outdoor playtime (r = 0.20). There was also an unexpected negative association between child MVPA and screen time (-0.16) and screen time practices (r = -0.21).

CONCLUSIONS

The EPAO for the FCCH instrument is a useful tool for researchers working with this unique type of ECE setting. It has undergone rigorous development and testing and appears to have good psychometric properties.

TRIAL REGISTRATION

NCT01814215 , March 15, 2013.

A mixed methods protocol for developing and testing implementation strategies for evidence-based obesity prevention in childcare: a cluster randomized hybrid type III trial

Background

Despite the potential to reach at-risk children in childcare, there is a significant gap between current practices and evidence-based obesity prevention in this setting. There are few investigations of the impact of implementation strategies on the uptake of evidence-based practices (EBPs) for obesity prevention and nutrition promotion. This study protocol describes a three-phase approach to developing and testing implementation strategies to support uptake of EBPs for obesity prevention practices in childcare (i.e., key components of the WISE intervention).

Methods

Informed by the i-PARIHS framework, we will use a stakeholder-driven evidence-based quality improvement (EBQI) process to apply information gathered in qualitative interviews on barriers and facilitators to practice to inform the design of implementation strategies. Then, a Hybrid Type III cluster randomized trial will compare a basic implementation strategy (i.e., intervention as usual) with an enhanced implementation strategy informed by stakeholders. All Head Start centers (N = 12) within one agency in an urban area in a southern state in the USA will be randomized to receive the basic or enhanced implementation with approximately 20 classrooms per group (40 educators, 400 children per group). The educators involved in the study, the data collectors, and the biostastician will be blinded to the study condition.

The basic and enhanced implementation strategies will be compared on outcomes specified by the RE-AIM model (e.g., Reach to families, Effectiveness of impact on child diet and health indicators, Adoption commitment of agency, Implementation fidelity and acceptability, and Maintenance after 6 months). Principles of formative evaluation will be used throughout the hybrid trial.

Discussion

This study will test a stakeholder-driven approach to improve implementation, fidelity, and maintenance of EBPs for obesity prevention in childcare. Further, this study provides an example of a systematic process to develop and test a tailored, enhanced implementation strategy.

Trial registration

ClinicalTrials.gov, NCT03075085

A review of early influences on physical activity and sedentary behaviors of preschool-age children in high-income countries

PURPOSE

Promoting physical activity (PA) is a key component of preventing and controlling childhood obesity. Despite well-documented benefits of PA, globally, rates of PA among young children have declined over the past decades, and most children are not accruing sufficient PA daily. Helping children develop the foundation for PA habits early in life is critical for the promotion of health in childhood and prevention of chronic diseases later in life, and will ultimately promote longer and healthier lives for individuals and the general population. The purpose of this review is to provide a synthesis of current evidence on influences on PA and sedentary behaviors of preschool-age children in high-income countries.

DESIGN AND METHODS

A systematic review of three databases was performed. Studies conducted in high-income countries and published from 2000 onward that addressed influences on PA and sedentary behaviors of preschool-age children were identified and reviewed. Additionally, reference lists of identified articles and relevant published reviews were reviewed. Studies that met the following inclusion criteria were considered: (a) sample included preschoolers (age ≤5 years); (b) PA and/or sedentary behaviors or factors associated with PA and/or sedentary behaviors was assessed; (c) published in English; (d) used either quantitative or qualitative methods; and (e) conducted in a high-income country. Data were extracted from selected studies to identify influences on PA and sedentary behaviors of preschool-age children and organized using the social-ecological model according to multiple levels of influence.

RESULTS

Results from included studies identify multiple factors that influence PA and sedentary behaviors of young children in high-income countries at the various levels of the social-ecological model including intrapersonal, interpersonal, environmental, organizational, and policy.

PRACTICE IMPLICATIONS

Given pediatric nurses' role as primary care providers, and their frequent and continued contact with parents and their children throughout childhood through well-child visits, immunization, and minor acute illnesses, they are well positioned to promote and support the development of early healthful PA habits of children starting in early childhood.

Alterations in physique among young children after the Great East Japan Earthquake: Results from a nationwide survey

Background

Data for earthquake-related alterations in physique among young children in developed countries is lacking. The Great East Japan Earthquake caused severe damage in Iwate, Miyagi, and Fukushima Prefectures in northeastern Japan.

Methods

We retrospectively obtained anthropometric measurements in nursery school from 40,046 (cohort 1, historical control) and 53,492 (cohort 2) children aged 3.5–4.5 years without overweight in October 2008, and in October 2010, respectively. At the time of the earthquake in March, 2011, children in cohort 1 had already graduated from nursery school; however, children in cohort 2 were still enrolled in nursery school at this time. We compared the onset of overweight at 1 year after the baseline between children enrolled in their school located in one of the three target prefectures versus those in other prefectures using a logistic regression model, with adjustment for sex, age, history of disease, and obesity index at baseline. Overweight was defined as an obesity index of >+15%, which was calculated as (weight minus sex- and height-specific standard weight)/sex- and height-specific standard weight.

Results

The odds ratio (OR) for the onset of overweight in the three target prefectures was significant in cohort 2 (OR 1.25; 95% confidence interval [CI], 1.01–1.55) but not in cohort 1. When the two cohort were pooled (n = 93,538), the OR of the interaction term for school location × cohort was significant (OR 1.56; 95% CI, 1.09–2.23).

Conclusions

Incident overweight in young children was significantly more common in the three prefectures affected by the Great East Japan Earthquake than in other prefectures after the disaster.

•

We obtained anthropometric data from 93,538 children aged 3.5–4.5 years.

•

Anthropometric data were measured before and after the Great East Japan Earthquake.

•

We compared the data in Iwate, Miyagi, and Fukushima vs. the other prefectures.

•

Incident overweight was higher in the three prefectures than the other prefectures.

Teacher Perceptions of Multilevel Policies and the Influence on Nutrition Education in North Carolina Head Start Preschools

OBJECTIVE

To develop a theory that explains the process of how teachers' perception of multilevel policies may influence nutrition education (NE) teaching strategies in Head Start preschools.

DESIGN

Semistructured telephone interviews.

SETTING

North Carolina Head Start preschools.

PARTICIPANTS

Thirty-two Head Start teachers.

PHENOMENON OF INTEREST

All interviews were transcribed verbatim. Following a grounded theory approach, authors coded interview data for emergent themes.

ANALYSIS

Two primary themes emerged during analysis, including teachers' policy perceptions and teacher-perceived influence of policy on NE.

RESULTS

A theoretical model was developed to explain how teachers' perceptions of policies influenced NE (eg, teaching strategies) in the classroom. Teachers discussed multiple policy areas governing their classrooms and limiting their ability to provide meaningful and consistent NE. How teachers perceived the level of regulation in the classroom (ie, high or low) influenced the frequency with which they used specific teaching strategies.

CONCLUSION AND IMPLICATIONS

Despite federal policies supporting the provision of NE, teachers face competing priorities in the classroom (eg, school readiness vs NE) and policies may conflict with standardized NE curricula. To understand how Head Start centers develop local policies, additional research should investigate how administrators interpret federal and state policies.

Assessment of nutrition and physical activity practices using self-report and observation in early care and education across multiple US states

OBJECTIVE

The National Early Care and Education Learning Collaboratives (ECELC) Project aims to promote healthy physical activity and nutrition environments, policies and practices in early care and education (ECE) programmes across multiple states. The present pilot study sought to assess changes to the physical activity and nutrition practices in a sub-sample of ECE programmes participating in the ECELC using the Environment and Policy Assessment and Observation (EPAO). Additionally, it sought to compare results with the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC).

DESIGN

Quasi-experimental pre-post pilot study where paired-sample t tests examined changes to physical activity and nutrition practices from pre-assessment to post-assessment (P<0·05). Pearson correlation coefficients examined change scores from EPAO compared with NAP SACC with statistical significance set at a two-sided α level of P<0·10 to account for sample size.

SETTING

The study occurred among ECE programmes.

SUBJECTS

Pre-school classrooms in nineteen ECE programmes across four US states were observed.

RESULTS

EPAO data demonstrated an increase in total score from pre-assessment to post-assessment (150 (sd 30) to 176 (sd 35)). NAP SACC change scores demonstrated little relationship with EPAO domain change scores, with exceptions in Nutrition Policy and Physical Activity Policy (r=-0·4 and -0·6, respectively).

CONCLUSIONS

The overall improvements reported through the EPAO suggest participation in the ECELC resulted in changes in critical nutrition- and physical activity-related practices. However, considerable differences in data reported using the NAP SACC compared with the EPAO suggest subjective data should be interpreted with caution and objective measurement should be used when feasible.

Appetite self-regulation: Environmental and policy influences on eating behaviors

OBJECTIVE

Appetite regulation is influenced by the environment, and the environment is shaped by food-related policies. This review summarizes the environment and policy research portion of an NIH Workshop (Bethesda, MD, 2015) titled "Self-Regulation of Appetite-It's Complicated."

METHODS

In this paper, we begin by making the case for why policy is an important tool in efforts to improve nutrition, and we introduce an ecological framework that illustrates the multiple layers that influence what people eat. We describe the state of the science on how policies influence behavior in several key areas: the federal food programs, schools, child care, food and beverage pricing, marketing to youth, behavioral economics, and changing defaults. Next, we propose novel approaches for multidisciplinary prevention and intervention strategies to promote breastfeeding, and examine interactions between psychology and the environment.

RESULTS

Policy and environmental change are the most distal influences on individual-level appetite regulation, yet these strategies can reach many people at once by changing the environment in which food choices are made. We note the need for more research to understand compensatory behavior, reactance, and how to effectively change social norms.

CONCLUSIONS

To move forward, we need a more sophisticated understanding of how individual psychological and biological factors interact with the environment and policy influences.

Evaluation of a Physical Activity Regulation for Child Care in Massachusetts

OBJECTIVES

A number of states have enacted regulations to increase physical activity in children attending child care, but most were not evaluated. In 2010, Massachusetts (MA) enacted a new regulation requiring 60 minutes of light, moderate, and vigorous physical activity (LMVPA) for children in child care; we conducted a prospective evaluation. We hypothesized that MA centers would comply with the regulation at follow-up, resulting in increases in children's LMVPA.

METHODS

We evaluated compliance with the regulation in MA using Rhode Island (RI) as the comparison. We measured physical activity in a longitudinal sample of 20 centers and cross-sectional samples of 180 children per state three times before and three times after the regulation took effect. We assessed physical activity using the Observation System for Recording Activity in Preschoolers. We conducted difference-in-differences tests to evaluate changes in LMVPA in MA compared with RI from baseline to follow-up.

RESULTS

Children were active for at least 60 minutes of LMVPA in over 80% of centers at baseline and follow-up in MA and RI. Nevertheless, LMVPA increased in both states. In multivariable adjusted regressions, LMVPA increased from baseline to follow-up [MA estimate 38.1 minutes; confidence interval (CI): 28.6, 47.5; p ≤ 0.0001; and RI estimate 42.7 minutes; CI: 35.2, 50.1; p ≤ 0.0001]. The average difference-in-differences estimate indicated no difference in MA compared with RI (estimate -4.6 minutes; CI: -16.6, 7.5; p = 0.46) since LMVPA increased comparably in both states.

CONCLUSIONS

Although LMVPA increased in MA, we observed similar changes in RI. Thus, other factors could have influenced children's physical activity.

Engaging Parents to Promote Children's Nutrition and Health

PURPOSE

Using the Academy of Nutrition and Dietetics benchmarks as a framework, this study examined childcare providers' (Head Start [HS], Child and Adult Care Food Program [CACFP] funded, and non-CACFP) perspectives regarding communicating with parents about nutrition to promote children's health.

DESIGN

Qualitative.

SETTING

State-licensed center-based childcare programs.

PARTICIPANTS

Full-time childcare providers (n = 18) caring for children 2 to 5 years old from varying childcare contexts (HS, CACFP funded, and non-CACFP), race, education, and years of experience.

METHODS

In-person interviews using semi-structured interview protocol until saturation were achieved. Thematic analysis was conducted.

RESULTS

Two overarching themes were barriers and strategies to communicate with parents about children's nutrition. Barriers to communication included-(a) parents are too busy to talk with providers, (b) parents offer unhealthy foods, (c) parents prioritize talking about child food issues over nutrition, (d) providers are unsure of how to communicate about nutrition without offending parents, and (e) providers are concerned if parents are receptive to nutrition education materials. Strategies for communication included-(a) recognize the benefits of communicating with parents about nutrition to support child health, (b) build a partnership with parents through education, (c) leverage policy (federal and state) to communicate positively and avoid conflict, (d) implement center-level practices to reinforce policy, and (e) foster a respectful relationship between providers and parents.

CONCLUSION

Policy and environmental changes were recommended for fostering a respectful relationship and building a bridge between providers and parents to improve communication about children's nutrition and health.

Family child care home providers as role models for children: Cause for concern?

Health behaviors associated with chronic disease, particularly healthy eating and regular physical activity, are important role modeling opportunities for individuals working in child care programs. Prior studies have not explored these risk factors in family child care home (FCCH) providers which care for vulnerable and at-risk populations. To address this gap, we describe the socio-demographic and health risk behavior profiles in a sample of providers (n = 166 FCCH) taken from baseline data of an ongoing cluster-randomized controlled intervention (2011-2016) in North Carolina. Data were collected during on-site visits where providers completed self-administered questionnaires (socio-demographics, physical activity, fruit and vegetable consumption, number of hours of sleep per night and perceived stress) and had their height and weight measured. A risk score (range: 0-6; 0 no risk to 6 high risk) was calculated based on how many of the following were present: not having health insurance, being overweight/obese, not meeting physical activity, fruit and vegetable, and sleep recommendations, and having high stress. Mean and frequency distributions of participant and FCCH characteristics were calculated. Close to one third (29.3%) of providers reported not having health insurance. Almost all providers (89.8%) were overweight or obese with approximately half not meeting guidelines for physical activity, fruit and vegetable consumption, and sleep. Over half reported a "high" stress score. The mean risk score was 3.39 (± 1.2), with close to half of the providers having a risk score of 4, 5 or 6 (45.7%). These results stress the need to promote the health of these important care providers.

Childcare arrangements and infant feeding practices by family structure and household income among US children aged 0 to 2 years

The primary objective of this study is to examine the disparities in childcare and infant feeding practices by family structure (single-mother vs. two-parent households) and whether household income level may modify the observed associations by family structure. The cross-sectional data analysis was conducted using a nationally representative sample of children aged 0 to 2 years enrolled in the 2007 National Survey of Children's Health. The analytic sample is children from single mothers (n = 1801, 16.0%) and children from two parents (n = 11 337, 84.0%). Children of single mothers used more non-parental childcare [adjusted odds ratios (AOR) = 2.67, 95% confidence intervals (CI) = 1.99-3.58], especially relative care and centre care, than children of two parents. Lower rates of any breastfeeding for 6 months (AOR = 0.57, 95% CI = 0.43-0.77) and ever breastfed (AOR = 0.66, 95% CI = 0.50-0.89) were reported among children of single mothers than those of two parents. The many observed differences in childcare arrangements and breastfeeding by family structure remained significant in both low- and high-income households. However, children of low-income single mothers had more last-minute changes of childcare arrangement (AOR = 2.34, 95% CI = 1.55-3.52) than children of low-income two-parent households and children of high-income single mothers had more early introduction of complementary foods (AOR = 1.92, 95% CI = 1.12-3.29) than children of high-income two-parent households. This study documented disparities in childcare arrangements and infant feeding practices by family structure, regardless of income level. These findings support the need to for comprehensive policies that address maternal employment leave, childcare support and workplace accommodations and support for breastfeeding for children 0 to 2 years, especially among single mothers, regardless of income.

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.

Influence of Teachers' Personal Health Behaviors on Operationalizing Obesity Prevention Policy in Head Start Preschools: A Project of the Children's Healthy Living Program (CHL)

OBJECTIVE

To quantify the Head Start (HS) teacher mediating and moderating influence on the effect of a wellness policy intervention.

DESIGN

Intervention trial within a larger randomized community trial.

SETTING

HS preschools in Hawaii.

PARTICIPANTS

Twenty-three HS classrooms located within 2 previously randomized communities.

INTERVENTION

Seven-month multi-component intervention with policy changes to food served and service style, initiatives for employee wellness, classroom activities for preschoolers promoting physical activity (PA) and healthy eating, and training and technical assistance.

MAIN OUTCOME MEASURES

The Environment and Policy Assessment and Observation (EPAO) classroom scores and teacher questionnaires assessing on knowledge, beliefs, priorities, and misconceptions around child nutrition and changes in personal health behaviors and status were the main outcome measures.

ANALYSIS

Paired t tests and linear regression analysis tested the intervention effects on the classroom and mediating and moderating effects of the teacher variables on the classroom environment.

RESULTS

General linear model test showed greater intervention effect on the EPAO score where teachers reported higher than average improvements in their own health status and behaviors (estimate [SE] = -2.47 (0.78), P < .05).

CONCLUSIONS AND IMPLICATIONS

Strategies to improve teacher health status and behaviors included in a multi-component policy intervention aimed at child obesity prevention may produce a greater effect on classroom environments.

Supporting Physical Activity in the Childcare Environment (SPACE): rationale and study protocol for a cluster randomized controlled trial

BACKGROUND

Young children are prone to low levels of physical activity in childcare. Researchers have identified that preschoolers tend to be more active outdoors than indoors, with higher activity levels occurring during the first 10 minutes of outdoor playtime. Additionally, interventions incorporating either staff training or the inclusion of play equipment have been effective at increasing children's activity in this setting. As such, the overarching objective of the Supporting Physical Activity in the Childcare Environment (SPACE) intervention is to improve the physical activity levels of preschoolers during childcare hours, utilizing a combination of the above components. The purpose of this manuscript is to provide a detailed account of the protocol, innovative methods, and evaluation plans used in the implementation of the SPACE study; in an effort to support the development of further research in this field.

METHODS/DESIGN

The SPACE study, a cluster randomized controlled trial, involves 22 childcare centres randomly allocated to either the experimental (n = 11) or the control (n = 11) group. Childcare centres receiving the intervention will adopt an 8-week physical activity intervention with the following components: 1. shorter, more frequent bouts of outdoor playtime (4 × 30 min periods rather than 2 × 60 min periods); 2. new portable play equipment (e.g., obstacle course, balls); and, 3. staff training (1 × 4 hr workshop). Actical accelerometers will be used to assess total physical activity with measurements taken at baseline (i.e., week 0), immediately post-intervention (i.e., week 8), and at 6- and 12-month follow-up. As secondary objectives, we aim to evaluate the effectiveness of the intervention on preschoolers': a) sedentary time; b) standardized body mass index scores (percentiles); c) health-related quality of life; and childcare providers' physical activity-related knowledge and self-efficacy to implement physical activity.

DISCUSSION

The SPACE study aims to increase the low levels of physical activity observed within childcare centres. The findings of this work may be useful to policy makers and childcare providers to consider modifications to the current childcare curriculum and associated outdoor play time.

TRIAL REGISTRATION

ISRCTN70604107 (October 8, 2014).

Head Start Wellness Policy Intervention in Hawaii: A Project of the Children's Healthy Living Program

BACKGROUND

The increased prevalence of childhood overweight and obesity across the United States and the Pacific has become a serious public health concern, with especially high prevalence among Native Hawaiian and Pacific Islander (NHPI) children. This study aimed to measure the effect of a Head Start (HS) policy intervention for childhood obesity prevention.

METHODS

Twenty-three HS classrooms located in Hawaii participated in the trial of a 7-month policy intervention with HS teachers. Classroom- and child-level outcome assessments were conducted, including: the Environment and Policy Assessment and Observations (EPAO) of the classroom environment; plate waste observations to assess child intake of fruit and vegetables; and child growth.

RESULTS

The intervention showed a positive and significant effect on classroom EPAO physical activity (PA) and EPAO total scores. Although mean BMI z-score (zBMI) increased at postintervention for both intervention (mean = 0.60; standard deviation [SD], 1.16; n = 114) and delayed-intervention groups (mean = 0.35; SD, 1.17; n = 132), change in zBMI was not significantly different between the groups (p = 0.50; p = 0.48).

CONCLUSIONS

These findings contribute evidence on the potential for HS wellness policy to improve the PA environment of HS classrooms. More research is needed to link these policy changes to other child outcomes.

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

OBJECTIVE

To assess and compare the nutrition environment and practices (as they relate to pre-schoolers) of centre- and home-based child-care facilities.

DESIGN

Using a cross-sectional study design, nineteen child-care facilities (ten centre-based, nine home-based) were assessed for one full day using the Environment and Policy Assessment and Observation (EPAO) tool (consisting of a day-long observation/review of the nutrition environment, practices and related documents). Specifically, eight nutrition-related subscales were considered.

SETTING

Child-care facilities in London, Ontario, Canada.

SUBJECTS

Child-care facilities were recruited through directors at centre-based programmes and the providers of home-based programmes.

RESULTS

The mean total nutrition environment EPAO scores for centre- and home-based facilities were 12·3 (sd 1·94) and 10·8 (sd 0·78) out of 20 (where a higher score indicates a more supportive environment with regard to nutrition), respectively. The difference between the total nutrition environment EPAO score for centre- and home-based facilities was approaching significance (P=0·055). For both types of facilities, the highest nutrition subscale score (out of 20) was achieved in the staff behaviours domain (centre mean=17·4; home mean=17·0) and the lowest was in the nutrition training and education domain (centre mean=3·6; home mean=2·0).

CONCLUSIONS

Additional research is needed to confirm these findings. In order to better support child-care staff and enhance the overall nutrition environment in child care, modifications to food practices could be adopted. Specifically, the nutritional quality of foods/beverages provided to pre-schoolers could be improved, nutrition-related training for child-care staff could be provided, and a nutrition curriculum could be created to educate pre-schoolers about healthy food choices.

Application of the Intervention Mapping protocol to develop Keys, a family child care home intervention to prevent early childhood obesity

Background

Many families rely on child care outside the home, making these settings important influences on child development. Nearly 1.5 million children in the U.S. spend time in family child care homes (FCCHs), where providers care for children in their own residences. There is some evidence that children in FCCHs are heavier than those cared for in centers. However, few interventions have targeted FCCHs for obesity prevention. This paper will describe the application of the Intervention Mapping (IM) framework to the development of a childhood obesity prevention intervention for FCCHs

Methods

Following the IM protocol, six steps were completed in the planning and development of an intervention targeting FCCHs: needs assessment, formulation of change objectives matrices, selection of theory-based methods and strategies, creation of intervention components and materials, adoption and implementation planning, and evaluation planning

Results

Application of the IM process resulted in the creation of the Keys to Healthy Family Child Care Homes program (Keys), which includes three modules: Healthy You, Healthy Home, and Healthy Business. Delivery of each module includes a workshop, educational binder and tool-kit resources, and four coaching contacts. Social Cognitive Theory and Self-Determination Theory helped guide development of change objective matrices, selection of behavior change strategies, and identification of outcome measures. The Keys program is currently being evaluated through a cluster-randomized controlled trial

Conclusions

The IM process, while time-consuming, enabled rigorous and systematic development of intervention components that are directly tied to behavior change theory and may increase the potential for behavior change within the FCCHs.

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

BACKGROUND

Preschoolers do not consume whole fruit and vegetables (FVs) in recommended quantities. Two strategies to increase FV intake were tested.

METHODS

One Head Start preschool participated. Two variations of family-style feeding were compared to usual practice: (1) Fruits, vegetables, and milk were served before the main meal (first course); and (2) fruits, vegetables, and milk were served before the main meal and meats and grains were removed from the table after the first serving (combination). A within-subject crossover design was used to test each condition for three meals. The amount of food served and consumed was weighed and converted to Child and Adult Care Feeding Program (CACFP) standard serving sizes for analysis.

RESULTS

Eighty-five children ages 3-5 participated. The sample was 81% Hispanic with diverse racial backgrounds. Thirty percent of the children were overweight. FV consumption was at CACFP recommended levels at baseline and remained consistent across conditions. The average amount served for each meal component was at or above CACFP recommendations for all foods except milk, which was consistently served in small portions. Meat and grains servings were frequently 2-3 times larger than CACFP recommendations. Milk consumption was significantly higher in the Combined intervention for two meals. Children ate significantly less meat during the Combined intervention for one meal.

CONCLUSIONS

The intervention led to significant increases in milk consumption, which was the only underconsumed meal component. These strategies should be tested with children who have lower baseline intake of FVs.

Evaluation of Nutrition and Physical Activity Policies and Practices in Child Care Centers within Rural Communities

BACKGROUND

Although some researchers have examined nutrition and physical activity policies within urban child care centers, little is known about the potentially unique needs of rural communities.

METHODS

Child care centers serving preschool children located within low-income rural communities (n = 29) from seven states (Indiana, Kansas, Michigan, North Dakota, Ohio, South Dakota, and Wisconsin) were assessed to determine current nutrition and physical activity (PA) practices and policies. As part of a large-scale childhood obesity prevention project, the Community Healthy Living Index's previously validated Early Childhood Program Assessment Tool was used to collect data. Descriptive statistical analysis was conducted to identify high-priority areas. Healthy People 2020 and the Academy of Nutrition and Dietetics' recommendations for nutrition and PA policies in child care centers were used as benchmarks.

RESULTS

Reports of not fully implementing (<80% of the time) recommended nutrition-related policies or practices within rural early child care centers were identified. Centers not consistently serving a variety of fruits (48%), vegetables (45%), whole grains (41%), limiting saturated fat intake (31%), implementing healthy celebration guidelines (41%), involving children in mealtime (62%), and referring families to nutrition assistance programs (24%) were identified. More than one third of centers also had limited structured PA opportunities. Although eligible, only 48% of the centers participated in the Child and Adult Care Food Program.

CONCLUSIONS

Overall, centers lacked parental outreach, staff training, and funding/resources to support nutrition and PA. These results provide insight into where child care centers within low-income, rural communities may need assistance to help prevent childhood obesity.

Comparison of Feeding Practices in Infants in the WIC Supplemental Nutrition Program Who Were Enrolled in Child Care as Opposed to Those with Parent Care Only

BACKGROUND

The environment or setting to which an infant is exposed is crucial to establishing healthy eating habits and to preventing obesity. This study aimed to compare infant feeding practices and complementary food type between parent care (PC) and childcare (CC) settings among infants receiving the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

MATERIALS AND METHODS

This study sampled 105 dyads of mothers and infants between 2 to 8 months of age from a WIC office in Central Illinois. Mothers completed a cross-sectional survey to assess their infant feeding practices and demographic characteristics. CC was defined as infants receiving 10 hours or more per week of care from a nonparental caregiver.

RESULTS

Almost half of the infants (44%) were enrolled in CC. Infants in CC had an average of 29 hours of care per week compared with 0.64 hours in the PC group (p<0.01). There were no differences between the two groups in age, sex, race/ethnicity, preterm birth, and birth weight. Overall, there were no significant differences in breastfeeding initiation and duration. The average age at formula introduction was earlier for PC infants (0.90 ± 1.16 months) than for CC infants (1.66 ± 1.64 months) (p = 0.03). PC infants stopped breastfeeding at 1.96 ± 1.15 months compared with 2.31 ± 1.64 months for CC infants (p = 0.080). Among complementary foods introduced to infants, the primary food type was infant cereal, followed by baby food of fruits and vegetables, 100% fruit juice, and meat-based baby food. The timing of introduction and the types of complementary foods were similar between study groups.

CONCLUSIONS

CC use is not a significant influence on breastfeeding rates, introduction of complementary foods, and types of complementary foods; however, it does influence when formula is introduced. The findings support the need for infant nutrition education and breastfeeding promotion targeting WIC mothers, regardless of their pattern of CC.