Introduction
From 2012 to 2014, a total of 17 family child care homes participated in a multisector, community-wide initiative to prevent obesity. Strategies included staff workshops, materials, site visits, and technical assistance regarding development and implementation of nutrition policies. The purpose of the evaluation was to examine the impact of the initiative on family child care home nutrition-related policies and practices and child dietary intake.
Study design
Pre- and post-intervention without control group. Measures taken at baseline and follow-up included structured observations and questionnaires regarding nutrition policies, practices, and environments; documentation of lunch foods served on 5 days; and lunch plate waste observations on 2 days. Paired t-tests were used to determine the significance of change over time.
Setting/participants
Seventeen family child care homes in a low-income diverse community in Northern California; children aged 2–5 years who attended the family child care homes.
Main outcome measures
Change in nutrition-related policies and practices, lunch foods served and consumed.
Results
Data was collected at 17 sites for an average of 5.2 children aged 2–5 years per site per day at baseline and 4.6 at follow-up for a total of 333 plate waste observations. There were significant increases in staff training, parental involvement, and several of the targeted nutrition-related practices; prevalence of most other practices either improved or was maintained over time. There were significant increases in the number of sites meeting Child and Adult Care Food Program meal guidelines, variety of fruit and frequency of vegetables offered, and reductions in frequency of juice and high-fat processed meats offered. Adequate portions of all food groups were consumed at both time points with no significant change over time.
Conclusions
A simple, policy-focused intervention by a child care resource and referral agency was successful at reinforcing and improving upon nutrition-related practices at family child care homes. Children consumed adequate, but not excessive, portions of the balanced meals served to them, suggesting there is no reason to offer unhealthy options.
Supplement information
This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.
Introduction
Prevalence of obesity among young children in the U.S. has decreased modestly in recent years but remains high and therefore continues to be of concern. Among children aged 2 to 5 years, the obesity rate was 14% in 2003–2004, 8% in 2011–2012, and 9% in 2013–2014.
1
, 2
Obesity among children is associated with the early-onset risk of developing type 2 diabetes and cardiovascular disease, and these conditions are likely to persist into adulthood.3
, 4
It is recommended that to reduce childhood obesity, conditions that support inactivity and the over-consumption of energy-dense, low-nutrient foods should be addressed.
5
, 6
, 7
Child care is the optimal setting for reaching preschool-aged children in the U.S. Sixty percent of children younger than age 6 years, and not yet in kindergarten, receive non-parental care at least once a week. On average, young children spend 36 hours a week in child care and consume large proportions of their calories in this setting.8
, 9
, 10
Improving nutrition policies and practices, such as limiting low-nutrient, high-energy density foods, and sweetened beverages, offering more fresh fruits and vegetables, improving feeding practices, and providing quality nutrition education have been shown to be effective and sustainable, yet many child care providers have not fully implemented these optimal policies and practices.11
, 12
, - Story M.
- Kaphingst K.M.
- Robinson-O’Brien R.
- Glanz K.
Creating healthy food and eating environments: policy and environmental approaches.
Annu Rev Public Health. 2008; 29: 253-272https://doi.org/10.1146/annurev.publhealth.29.020907.090926
13
, 14
Two recent reviews of obesity prevention interventions in early childhood education centers found positive changes in physical activity, diet, and weight status, especially multicomponent interventions with parent engagement components.
15
, 16
, 17
However, to the authors’ knowledge, there are no published studies in family child care homes (FCCs).The Kaiser Permanente Community Health Initiative funds and supports policy and environmental change to promote Healthy Eating and Active Living (HEAL) interventions in under-resourced neighborhoods in five Kaiser Permanente regions. More about the Community Health Initiative design and research principles, and HEAL interventions have been published elsewhere.
18
The Northern California Region of Kaiser Permanente funded four community-based collaboratives to work in neighborhoods called HEAL Zones. The primary goals are to reduce calorie consumption, increase fruit and vegetable intake, and increase physical activity. One of these Zones chose to address the HEAL goals in the child care setting. The authors hypothesize that participating child care sites will adopt policies and practices that will improve the food environment and support healthy eating as defined by CACFP (Child and Adult Care Food Program), local, and state guidelines for child care.Methods
Study Sample
The local child care resource and referral agency (Council) reached out to all CACFP FCCs in the HEAL Zone. Thirty providers were identified that showed interest in participating. Of these 30, 24 attended a Council event where intervention project and evaluation requirements were described and providers were encouraged to participate. Twenty-one FCCs that served children aged 2–5 years agreed to participate in the project. Four sites moved or closed for a final sample size of 17 sites. Data were collected in May and June of 2012 and 2014. Incentives included a $100 grocery store gift card at the beginning and a $50 gift certificate for nutrition promotion materials at the end of the project.
The nutrition-related project activities included two provider workshops; provision of materials such as newsletters, nutrition policy templates, and handouts for parents; site visits that included technical assistance on nutrition-related topics and development of nutrition-related organizational policies, practices, and implementation strategies.
According to the Council, all the providers adopted nutrition-related policies and practices. Parent engagement involved provider discussion with the parents about how the site values good nutrition and active play and how the parents can support these policies, for example, by not bringing donuts to share. Parents also received a revised parent handbook, handouts, and information by e-mail. All new parents received orientation to the policies upon enrollment.
Child care families may have been exposed to HEAL Zone efforts including a social marketing campaign. All the sites in the study sample were already participating in CACFP at baseline and may have received the standard Council support for nutrition best practices prior to the study.
Measures
Council staff collected basic program and demographic information and administered the Creating Healthy Opportunities in Childcare Environments (CHOICE) self-assessment questionnaire, which was designed by the Council to measure progress with regard to their priority nutrition and physical activity-related practices and policies (Table 1). Trained professionals, with experience working in child care settings, conducted observations of the food and activity environments and administered a separate policies and practices questionnaire. The policies and practices questionnaire and observation form were adapted from a validated tool, Nutrition and Physical Activity Self-Assessment for Child-Care.
19
The Nutrition and Physical Activity Self-Assessment for Child-Care constructs are based on national recommendations and standards and a review of the literature.20
They also conducted the plate waste observations and recorded all lunch foods offered for 2 days. They instructed the provider on how to record all lunch foods offered on an additional 3 days using a standardized form developed by the study authors.Table 1Data Collection Methods
| Method | Timing | Description |
|---|---|---|
| Background information form | 1 per site in 2012; updated in 2014 | Demographics, basic program information |
| CHOICE self-assessment questionnaire (SAQ) | 1 per site in 2012 and 2014 | Provider self-report (35 items): rating feeding practices, foods served, physical activity, and staff/parent training on Likert-type scales |
| Policies and practices questionnaire (PPQ) | 1 per site in 2012 and 2014 | Provider self-report of nutrition and physical activity policies and practices; combination of yes/no and Likert-type scale responses |
| Environmental observations (Obs) | 1 per site in 2012 and 2014 | Observations of food- and physical activity–related aspects of the child care site environment conducted by trained research staff |
| Plate waste observation (PW) | 1 per child aged 2–5 years present at lunch on 2 days in 2012 and 2014 | Observations of the amount of each food served to and eaten by children at lunch conducted by trained research staff |
| Lunch foods record (LFR) | 1 per site on each of 5 days in 2012 and 2014 | Recording of all lunch foods served and specifics regarding each food (e.g., whole-grain, low-fat) by trained research staff (2 days) and the provider (3 days) |
CHOICE, Creating Healthy Opportunities in Childcare Environments.
The plate waste protocol was based on the validated quarter waste method.
21
Portion sizes of all foods served were recorded as large, medium, small, or none based on the average amount served which was, according to observer recorded estimates, similar to, or somewhat larger than, standard serving sizes for age. Amounts left on the plate were observed and recorded by trained observers in quarter serving increments to determine the amount consumed by each child aged 2–5 years who was present at lunch on the chosen 2 days. The plate waste observations included an average of 4.6 children per site each day in 2012 and 5.2 per site each day in 2014 for a total of 156 observations in 2012 and 177 in 2014. A trainer accompanied each data collector on the first visit; both independently recorded their observations and compared the results, which in all cases were nearly identical.Statistical Analysis
Likert-type scale responses were converted to binary (yes/no) variables based on responses to one or a combination of categories at either extreme on the scale. Amounts consumed were converted to scores on a scale of 0 to 8, where 0=ate none of the item, 1=ate less than half of a small portion, and 8=ate all of a large portion.
Statistical analyses were conducted using SPSS, version 23.0. Frequencies and means were calculated at the site level for all variables, and paired t-tests were used to compare change in means (ordinal variables) or proportions (binary variables) from baseline to follow-up, with the significance level reported as p<0.05.
IRB approval was obtained from the University of California, Berkeley.
Results
All 17 FCCs offered full-day programs and participated in CACFP. All meals and snacks were provided by the child care provider. Lunch was served at all sites, and breakfast was served at most sites. In 2012 and 2014, an average of seven children (aged 2–5 years) regularly attended each site (range from two to 15 children in 2012 and two to 13 children in 2014). More than half of the children were white (64% in 2012 and 56% in 2014), followed by Hispanic/Latino (19% and 25%), with far fewer children represented by other ethnic groups. Some sites occasionally offered care to children aged <2 or >5 years, but only children aged 2–5 years were included in this study.
A major focus of this intervention was to engage parents. The number of sites that provided parents with nutrition policies upon enrollment increased from three to 13 (p<0.001), and the number of sites that provided parents with nutrition information increased from ten to 14 (p=0.096; Table 2). The number of sites that provided nutrition training for staff increased from seven to 13 sites (p=0.054). All but one of the other measures in this category improved but not significantly.
Table 2Nutrition-related Policies and Practices
| Tool | Practice (number of sites) | % of child care sites | p-value | |
|---|---|---|---|---|
| 2012 | 2014 | |||
| Parent and staff education and training | ||||
| SAQ | Parents are informed about what their children are eating (17) | 88 | 88 | 1.000 |
| SAQ | Parents are provided with info on child nutrition (16) | 63 | 88 | 0.096 |
| SAQ | Parents are provided guidelines for foods brought from home (13) | 54 | 62 | 0.584 |
| PPQ | Nutrition education for children monthly or more (14) | 50 | 64 | 0.339 |
| SAQ | Training opportunities are provided for staff on child nutrition (15) | 47 | 87 | 0.054 |
| PPQ | Provide nutrition education to families at least monthly (17) | 47 | 53 | 0.425 |
| SAQ | Menus are posted for parents to see (15) | 33 | 47 | 0.499 |
| SAQ | Parents receive nutrition policies upon enrollment (15) | 20 | 87 | 0.000 |
| PPQ | Staff training on nutrition monthly (16) | 6 | 25 | 0.388 |
| Feeding practices and mealtime environment | ||||
| SAQ | Meals and snacks are at scheduled times (17) | 94 | 100 | 0.332 |
| SAQ | Portion sizes are age-appropriate (17) | 94 | 94 | 1.0 |
| SAQ | Food is served in a form that young children can eat without choking (17) | 94 | 94 | 1.0 |
| Obs | Staff talk about table manners (16) | 94 | 88 | 0.333 |
| Obs | Staff provide encouragement to eat new/less-favorite foods (14) | 93 | 100 | 0.337 |
| Obs | TV not on during mealtime (16) | 94 | 94 | 1.0 |
| Obs | Mealtimes are relaxed, with shared conversation (17) | 88 | 88 | 1.0 |
| Obs | Plates are not removed prematurely (17) | 88 | 53 | 0.029 |
| Obs | Additional servings of foods/beverages allowed for any foods (16) | 81 | 100 | 0.083 |
| SAQ | Mealtimes are, relaxed, calm, with shared conversation (17) | 82 | 94 | 0.322 |
| SAQ | Children are not required to eat all of the foods on their plates (17) | 82 | 88 | 0.579 |
| SAQ | Children decide what foods to eat from offerings (15) | 73 | 80 | 0.582 |
| SAQ | Foods reflect ethnicity/culture of children served (16) | 69 | 75 | 0.669 |
| SAQ | Adults sit with children at meals (16) | 63 | 75 | 0.497 |
| Obs | Staff talk about trying/enjoying healthy foods (16) | 50 | 88 | 0.029 |
| SAQ | Adults eat the same foods (17) | 47 | 65 | 0.083 |
| Obs | Staff engage children to participate in clean-up of meal (14) | 43 | 36 | 0.586 |
| Obs | Staff sit and eat meals with children (16) | 31 | 38 | 0.669 |
| SAQ | Children serve themselves from serving dishes at mealtime (17) | 29 | 41 | 0.431 |
| Obs | Staff encourage children to serve themselves (17) | 24 | 24 | 1.0 |
| Obs | Staff encourage children to participate in prep/setup of meal (16) | 25 | 25 | 1.0 |
| Food rewards and celebrations | ||||
| PPQ | Food rarely/never withheld for misbehavior (16) | 100 | 100 | 0.333 |
| PPQ | Food is rarely/never used to reward desirable behavior (16) | 94 | 88 | 0.333 |
| SAQ | Special occasions with healthy foods/non-food items (16) | 75 | 75 | 1.0 |
| PPQ | Celebrations with party foods 1× per month or more (16) | 25 | 19 | 0.331 |
| PPQ | Celebrations with mostly healthy foods 1× per month or more (14) | 21 | 29 | 0.335 |
| Gardens | ||||
| Obs | Had a garden on site (17) | 35 | 59 | 0.163 |
| Obs | Used the garden for education (17) | 29 | 53 | 0.216 |
| Obs | Children tend the garden (17) | 24 | 47 | 0.104 |
| Obs | Use garden foods in meals (17) | 24 | 35 | 0.332 |
| Water | ||||
| Obs | Water is available, visible, and self-serve at all times indoors (17) | 18 | 41 | 0.104 |
| Obs | Water is available, visible, and self-serve at all times outdoors (17) | 24 | 41 | 0.188 |
Note: Boldface indicates statistical significance (p<0.10). Likert-type scale responses were converted to binary variables by defining the variable as yes/no to the highest-level response option.
a n varies depending on number of missing responses for any given time and question.
b p-values are for analyses comparing the mean of reported values on the Likert-type scale.Obs, observation by trained data collector; PPQ, policies and practices questionnaire; SAQ, self-assessment questionnaire.
The Council identified feeding practices and the mealtime environment as the most fundamental aspect of their intervention. Twelve of the 21 best practices listed in this category in Table 2 were already in place at ≥70% of the sites at baseline. The proportion of sites with these practices increased in some cases but not significantly. One practice, not removing plates prematurely, decreased significantly over time.
Improvement was seen in all of the nine best practices (related to feeding practices and mealtime environment) that were least commonly practiced (at ≤70% of sites) at baseline. The largest increases included an increase from eight to 14 in the number of sites where staff talked about enjoying or trying healthy foods (p=0.29) and from eight to 11 in the number of sites where adults ate the same foods as the children (p=0.083).
Three best practices were followed at <50% of sites at baseline, and therefore had much room for improvement, but did not increase over time (i.e., percentage of sites that engage children in meal clean-up, encourage children to serve themselves, and involve children in meal preparation).
There was not much room for improvement with regard to practices in the category of food rewards and celebrations. Use of foods for reward or punishment was rarely or never practiced at 94%–100% of sites at baseline and 88%–100% of sites at follow-up. The percentage of sites holding parties with traditional party foods (e.g., cupcakes, cookies, chips, pizza, soda) more than once per month decreased from 25% to 19% and those holding parties more than once per month with mostly healthy foods increased from 21% to 27% (Table 2).
All the sites reported that drinking water was available to the children at all times at baseline but in most cases it was only available on request. Only 18% and 24% of sites at baseline had visible self-serve water available at all times indoors and outdoors, respectively. This increased, but not significantly, to 41% indoors and 41% outdoors by follow-up (Table 2).
The number of sites with gardens increased from six to ten (p=0.163). Of the sites with gardens at endpoint, 90% used the garden for educational purposes, 80% involved children in tending the garden, and 60% used garden produce in the meals (Table 2).
The percentage of sites meeting all the CACFP guidelines at lunch on each of the 5 days increased significantly from 71% to 94% between 2012 and 2014; this was due to increases from 82% to 100% (p=0.083) of sites meeting the fruit and vegetable and milk guidelines (Table 3).
Table 3Lunch Foods Served Over a Consecutive 5-day Period
| Lunch practice | Mean % of sites or no. of foods | p-value | |
|---|---|---|---|
| 2012 | 2014 | ||
| Sites that met the following CACFP guidelines on all 5 days, % | |||
| All guidelines | 71 | 94 | 0.041 |
| Milk guidelines | 82 | 100 | 0.083 |
| Bread/grain guidelines | 94 | 94 | n/a |
| Meat/meat alternative guideline | 100 | 100 | n/a |
| Fruit and vegetable guideline | 82 | 100 | 0.083 |
| Average number of different vegetables served per day, n | 1.6 | 1.8 | 0.224 |
| Sites that served leafy greens on at least 1 day, % | 53 | 65 | 0.496 |
| Average number of different vegetables served over 5 days, n | 6.1 | 5.9 | 0.553 |
| Serve vegetables >1×/day (SAQ) (n=16), % | 56 | 81 | 0.041 |
| Average number of different fruits served per day, n | 1.2 | 1.4 | 0.115 |
| Average number of different fruits served over 5 days, n | 3.9 | 5.2 | 0.021 |
| Serve fruits ≥3 times/day (SAQ) (n=16), % | 63 | 88 | 0.104 |
| Sites that served juice on any day, % | 12 | 6 | 0.579 |
| Almost never serve fruit juices (SAQ) (n=15), % | 27 | 60 | 0.019 |
| Meals with legumes (n=85, 85), % | 6 | 6 | n/a |
| Grains that were whole grains (n=124, 92), % | 54 | 57 | 0.435 |
| Served whole grains at least 2×/week (SAQ) (n=15), % | 73 | 80 | 0.582 |
| Sites that served flavored milk on any day, % | 6 | 0 | 0.332 |
| Sites that served 2% or whole milk on any day, % | 6 | 6 | n/a |
| Serve lowfat 1% milk to children aged ≥2 years (SAQ) (n=15), % | 87 | 73 | 0.433 |
| Entrees that were fast food (n=85, 85), % | 11 | 14 | 0.487 |
| Average number of different entrees (not fast food) served over 5 days (n=85, 85), n | 3.8 | 4.2 | 0.269 |
| Meals that included high-fat, processed meats b (n=85, 85), %Defined by the local child care resource and referral agency (Council) as chicken nuggets, fish sticks, hotdogs, corndogs, bologna/lunch meat, pepperoni, sausage, or bacon. CACFP, Child and Adult Care Food Program; LFR, lunch food record; n/a, not applicable; no., number; SAQ, self-assessment questionnaire. | 4 | 6 | n/a |
| Almost never serve high-fat/processed meats/fish b (SAQ) (n=15), %Defined by the local child care resource and referral agency (Council) as chicken nuggets, fish sticks, hotdogs, corndogs, bologna/lunch meat, pepperoni, sausage, or bacon. CACFP, Child and Adult Care Food Program; LFR, lunch food record; n/a, not applicable; no., number; SAQ, self-assessment questionnaire. | 0 | 27 | 0.041 |
Source: LFR (n=17 sites) or SAQ (n=15–17 sites) where indicated.
Note: Boldface indicates statistical significance (p<0.10). Likert-type scale responses were converted to binary variables by defining the variable as yes/no to the highest-level response option.
a Fast food entrees included pizza, burgers, hot/corn dogs, chicken nuggets, fish sticks.
b Defined by the local child care resource and referral agency (Council) as chicken nuggets, fish sticks, hotdogs, corndogs, bologna/lunch meat, pepperoni, sausage, or bacon.CACFP, Child and Adult Care Food Program; LFR, lunch food record; n/a, not applicable; no., number; SAQ, self-assessment questionnaire.
At baseline, sites were offering an average of more than one type of fruit and one type of vegetable per day at lunch. Ninety percent of the fruit and 82% of the vegetables served were fresh at both time points. Legumes were served infrequently (6% of meals). A little more than half the grains were whole grains. Only 6% of sites offered flavored milk, 6% offered milk with >1% fat, and 12% served juice on any of the 5 recorded days. During lunch, no sugar-sweetened desserts were offered. The only sugar-sweetened beverages were sugar-sweetened juices offered with eight of the 85 meals at baseline and only one of the meals at follow-up. Typical fast food was offered in <15% of meals, and self-reports (from the self-assessment questionnaire) indicated that high-fat, processed foods were offered less than once per week at all sites. Although data on method of preparation were not systematically collected, many dishes were described as homemade or appeared to be homemade based on the ingredients.
Most of the changes over time in foods served were small improvements that were not significant. Significant improvements included an increase in the average number of different fruits served at lunch over 5 days (from 3.9 to 5.2) and the number of sites that served more than one vegetable per day (from 56% to 81%); almost never served juice (from 27% to 60%); and almost never served high-fat processed meats (from 0% to 27%).
At both time points, children on average ate the equivalent of more than half of an average-sized serving from all the food and beverage groups (Table 4). Grains/starches were consumed in the largest quantities, score=6.29, and vegetables were consumed in the smallest quantities, score=5.53, at follow-up on a scale of 0–8, where 5=ate all of a small serving or half of a large serving and 6=ate more than half of a medium serving. The largest changes from baseline to follow-up were an increase in fruit consumption from 4.78 to 6.13 (p=0.089) and a decrease in vegetable consumption from 6.8 to 5.53 (p=0.062) for a net increase in total fruit and vegetable consumption that was not significant.
Table 4Amounts of Food and Beverages Consumed at Lunch by Children Aged 2–5 Years (n=17 sites)
| Meal component | Mean consumed score | p-value | |
|---|---|---|---|
| 2012 | 2014 | ||
| 6.13 | 6.00 | 0.733 |
| 4.78 | 6.13 | 0.089 |
| 6.80 | 5.53 | 0.062 |
| 6.87 | 6.29 | 0.236 |
| 5.99 | 5.82 | 0.644 |
a Plate waste data were collected on 2 separate days for an average of 4.6 children per site each day in 2012 and 5.2 per site each day in 2014. Averages were generated for each site and data were analyzed at the site level.
b Scores are on a scale of 0 to 8, where 0=ate none of the item, 1=ate less than half of a small serving, 5=ate all of a small serving or half of a large serving, 6=ate more than half of a medium serving, 8=ate all of a large serving.
Discussion
Given the small setting, FCCs may easily lend themselves to the child-directed approach to feeding advocated by the Council. At baseline, providers in this study excelled in the basics, such as providing age-appropriate foods and portion sizes, a relaxed meal environment, no TV, and not requiring children to clean their plates. More intensive child and staff involvement, such as child help with food preparation and clean-up, or adults eating with the children, were much less common, and although these practices increased over time there remains considerable room for improvement. During the course of the study, the number of sites with optimal feeding practices and mealtime environments increased, but because of the small sample size, only a few of these increases reached statistical significance.
Food offered between meals was not a focus of this study. However, findings indicate that parties with typical party foods and use of food as reward were infrequent, and therefore the impact of these practices on the children’s diets overall is probably minimal at these sites.
The FCC setting may also lend itself to balanced, home-cooked meals. Few typical fast foods or high-fat processed foods were offered and many reported or described meals that appeared to be homemade. Meals were for the most part balanced and healthy from the onset and improved modestly over the course of the intervention. There were statistically significant improvements in meeting CACFP guidelines, increasing the variety of fruit, and decreasing juice and high-fat processed meats.
Children at the FCCs in this study were willing to consume a balanced variety of healthy foods. At both time points, children ate the majority of the foods served from all food groups. Given the favorable baseline values, it is not surprising that there were no statistically significant changes in the amount consumed of any food group. It is encouraging that the children did not eat excessively large portions from the grain or protein groups that might lead to excess calorie intake and they ate most of the fruits and vegetables served. As the healthfulness of the lunch foods improved modestly over time, children did not reduce their intake. This suggests that there may be no need to provide less-healthy alternatives in order to entice preschool children to eat.
The California Healthy Beverages in Child Care Act went into effect at the onset of this study (January 2012) and therefore may have contributed to the relatively favorable beverage practices at the sites in this study at baseline and the improvements seen with regard to water, juice, and milk. When Ritchie et al.
22
examined practices in child care (mostly centers, some FCCs) before and after the Act was implemented, whole milk and fruit juice consumption declined, but were still higher than at the FCCs in this study, but water availability was better at the sites examined by Ritchie and colleagues.All the FCCs were already participating in CACFP at the onset of the study and would have received the standard support offered by the Council including training on how to meet federal guidelines, administrative reviews, and technical assistance. This support, and possibly higher motivation of CACFP providers, may explain the relatively high performance at baseline on many of the reported measures and also attests to the effectiveness of CACFP. Other studies have found that nutrition practices are better at CACFP-participating sites.
23
No other studies in FCCs were identified but findings from studies in child care centers are generally consistent with this study’s findings, with some notable differences.
22
, 23
, 24
Studies have found that nutrition policies and practices at many child care centers are mixed. In some cases, baseline performance is quite high but in general there was more need for improvement in policies and practices than was the case with the FCCs in this study.22
, 23
, 25
, 26
As with this study, interventions to improve nutrition policies and practices in child care centers have had mixed results21
, 23
, 24
, 25
, 26
, 27
, 28
, 29
possibly because of high baseline performance in some cases or challenges encountered in making changes in larger center environments.In particular, several studies in child care centers have found considerable room for improvement in terms of the foods and beverages offered.
23
, 25
, 30
, 31
, 32
Improving these foods has not always been successful, and improvements, when made, have been modest in many cases.22
, 23
, 25
, 26
Finally, many studies in child care centers have demonstrated that multicomponent interventions that include improved nutrition policy/practices and nutrition education are effective at improving dietary intake.
15
, 16
, 33
, 34
, 35
This study shows that optimal practices can also support healthy eating in FCCs. As was the case with this study, where intervention policies support optimal institutional practices, studies have found that staff training and parent engagement are key aspects of successful programs.15
, 16
, 28
, 30
Limitations
The main limitation of the study is lack of a comparison group, thereby limiting the ability to attribute observed effects to the intervention. The small sample size may have limited the ability to achieve statistical significance for anything other than very large differences. The sites were self-selected and therefore may have been more motivated than sites that chose not to participate. Despite these limitations, given the paucity of data regarding FCCs, this study provides valuable descriptive information that can inform policy, practice, and research in this setting.
Conclusions
This study’s findings demonstrate that CACFP-participating FCCs that serve a diverse low-income community were willing and able to adopt policies and practices that support healthy eating. A simple intervention appears to have been successful in reinforcing and improving upon existing practices that may have been initially fostered by support offered through CACFP. The policy approach examined in this study could help other FCCs institutionalize these practices, thereby helping to ensure their sustainability over time. Applying this effort to other FCCs could be significant because these small centers provide care to a substantial number of children across the country. It is most encouraging that the children on average consumed adequate, but not excessive, portions of the balanced meals that were served to them. These findings suggest that it is not necessary to offer preschool children unhealthy options, and it is worthwhile for child care referral and resource agencies to provide support for FCCs to implement optimal nutrition-related policies and practices.
Acknowledgments
The content is solely the responsibility of the authors and does not necessarily represent the official views of Kaiser Permanente. Kaiser Permanente was the sole source of funding for this study, and Kaiser Permanente staff were involved to varying degrees in all aspects of the study. The authors acknowledge and thank Kaiser Permanente for financial support. GWL contributed to study design, provided overall study leadership, and drafted the manuscript. JK contributed to study design, data collection, analysis, and interpretation of findings. EK conducted data analyses and contributed to interpretation of findings. SR contributed to design and interpretation of findings. KL and PJ contributed to design, supervision of data collection, and interpretation of findings. KB and DW contributed to design and provided project leadership and guidance. CB assisted with data collection and analysis. All authors critically reviewed and approved the manuscript. The article contents in part have been presented at professional meetings.
No financial disclosures were reported by the authors of this paper.
Supplement Note
This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives: Evaluations from 10 Years of Kaiser Permanente's Community Health Initiative to Promote Healthy Eating and Active Living, which is sponsored by Kaiser Permanente, Community Health.
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