Nutrition Practices of Family Childcare Home Providers and Children’s Diet Quality

Abstract

Objective

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

Design

Cross-sectional analysis

Participants

FCCH 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 two days at each FCCH. The Environment and Policy Assessment and Observation tool was used to document whether providers exhibited a set of nutrition practices based on 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 (HEI-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 where a greater number of best practices were implemented had higher diet quality (B = 1.05, 95%CI = [0.12, 1.99], p = .03). Specifically, children whose providers promoted autonomous feeding (B = 27.52, 95%CI = [21.02, 34.02], p < .001) and provided nutrition education (B = 7.76, 95%CI = [3.29, 12.23], p = .001) had higher total HEI 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 as well as providing healthful foods and beverages.

Introduction

Childhood obesity is a serious public health problem in the United States,^1,2 with 12.7% of 2-5-year-old children categorized as obese between 2017 to 2020.³ Thus, it’s important to improve nutrition and activity environments where these children spend time such as Early Care and Education (ECE) settings.⁴ Currently in the United States, approximately 60% of preschool-aged children with working parents are in some form of ECE, with most in full-day care.⁵ Given the frequency and duration that children spend in ECE settings, childcare providers are important influencers in shaping the food preferences and other health behaviors of young children.^6-10

Compared to center-based ECE settings, fewer studies have been conducted in family childcare homes (FCCHs), a setting that serves 1.6 million US. children.¹¹ In this type of ECE setting, one provider cares for a small group of children in his/her home.¹² Depending on individual state regulations, providers in FCCHs may or may not be required to be licensed. FCCHs have different environments compared to ECE centers, such as having home-based environments, flexible hours, and smaller groups of children at multiple ages.¹³ In addition, many family childcare providers (FCCPs) care for ethnic/racial minority children and are often themselves low-income and ethnically diverse.^14,15

Social cognitive theory, which defines behavior as a dynamic and reciprocal interaction of personal factors, behavior and the environment can provide a framework for factors that impact children’s diet.¹⁶ Children’s dietary behaviors are influenced by the foods that ECE providers serve, and the nutrition related practices that providers implement both in center-based ECE settings,^8,17-30and FCCHs.^22,31-33Despite what we know about the importance of serving nutritious foods in ECE, several studies show that the diet quality of the foods being served in FCCH may need improvement and that providers may engage in nutrition related feeding practices that may interfere with the development of healthy eating habits in children .^6,31,33-37 It is important to assess FCCPs’ nutrition-related practices because the foods and beverages served and how they are served to children at FCCHs may contribute to unhealthy dietary habits for preschoolers, and increase the risk of childhood obesity.⁶ Responsive feeding practices (e.g., not pressuring children to eat, and encouraging self-feeding) have been found to help children develop eating self-regulation and accept new foods.³⁸ According to a recent study, pressuring a child to finish their food was observed more frequently in FCCHs compared to ECE centers.³⁹

Overall, 2-4-year-old children in the U.S. do not meet dietary recommendations, with an average Healthy Eating Index (HEI) score of 60 (maximum score 100).⁴⁰ Two studies found that the mean HEI score among children in FCCHs was well below the recommended score for diet quality,^31,41 although the average HEI score of the children in these studies (58 and 61) was close to the average score for children in this age group in the U.S.⁴⁰ Several studies have shown that children enrolled in FCCHs may be at higher risk for obesity compared to children in center-based care^42-44. While there is growing evidence that ECE providers’ nutrition related practices can influence children’s’ diets, ^18,30,31 few studies have been done in FCCH and no studies have included Hispanic FCCPs, who often care for Hispanic children that are at higher risk for obesity.^1,2

Therefore, the purpose of this study is to examine differences in children’s diet quality in FCCHs based on whether FCCPs met or did not meet best practice nutrition guidelines from the Nutrition and Physical Activity Self-Assessment for Child Care (NAPSACC). We hypothesized that children in FCCHs where the providers met more NAPSACC best practice nutrition guidelines would have higher diet quality while in their care than children in FCCHs where the providers met fewer best practices.

Methods and Procedures

Participants and Recruitment

The present study used baseline data from the Healthy Start study, an 8-month cluster randomized controlled trial examining the efficacy of a multicomponent intervention to improve nutrition and physical activity environments in English and Spanish-speaking FCCH. Details about study recruitment, intervention and evaluation have been described in full elsewhere,⁴⁵ but methods relevant to the current analyses are described below. The Institutional Review Boards of Brown university and the University of Connecticut approved all study procedures and materials (full board review).

To meet study eligibility requirements, FCCHs in Rhode Island and Massachusetts had to be within 60 miles of Providence, Rhode Island and in operation for at least 6 months. Providers had to read and speak Spanish or English, provide meals and snacks for children, and care for at least two 2-to-5-year-old children for at least 10 hours per week. We collected data from 120 FCCP’s from November 2015 to July 2018 (pre-COVID 19 restrictions). Eligible providers completed a baseline telephone survey and in-person survey at the FCCH. Once we received consent from at least one parent of an eligible 2-to-5-year-old child being cared for in the FCCH, a 2-day observation and measurement session was scheduled. All measures were administered by trained project staff. Providers received $25 for completing the baseline in-person survey and $50 for the 2-day observation. Children received a reusable water bottle as a thank you gift and parents received a $20 gift card.

Measures

Demographics and other provider characteristics.

Providers reported their sex (male, female, or refuse to answer), race (White, Black or African American, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, other races not mentioned above, unknown),⁴⁶ ethnicity (Hispanic/non-Hispanic),⁴⁶ and ethnic subgroups (Dominican, Puerto Rican, Colombian, Guatemalan, Mexican, Other) in a telephone survey and the following variables on an in-person survey: age, household income (less than 25k, 25k – 50k, 50k -75k, 75k-100k, more than 100k), marital status (single, married or living with a partner, divorced, separated, widowed), education (less than high school, high school or GED, associate’s degree, Bachelor’s degree, Master’s degree or higher), years in the U.S., country of origin (U.S./non-U.S.), years as a childcare professional, number of children currently in their care (and how many are their own children or grandchildren) and whether the FCCH was enrolled in the Child and Adult Care Food Program (CACFP).

FCCH Observation.

Field research staff used the Environment and Policy Assessment and Observation (EPAO), which was developed by the University of North Carolina (UNC) to observe ECE settings environments, policies, and providers’ practices, that influence children’s health related behaviors.^47-51 The EPAO for FCCH had good inter-rater reliability and validity for most nutrition measures.³⁷ EPAO variables calculated from the observations included the types and frequency of foods and beverages served; the feeding environment; feeding practices; and nutrition education. This tool was slightly adapted based on formative research to reflect cultural differences for our population.^52,53 For example, we added food items such as yautia, yucca, and plantains to the “starchy vegetables” section.

Meeting NAPSACC Guidelines.

The list of 26 nutrition best practices were from the NAPSACC ⁵⁴, which was designed to assess and improve nutrition and physical activity environments in early care and education settings.^47,55,56 NAPSACC’s recommended nutrition best practices were derived from a strong scientific evidence base.^47,55-59 To determine whether FCCPs met NAPSACC nutrition guidelines, we compared EPAO data collected for each nutrition practice to its associated NAPSACC guideline using simple algorithms (See Table 1).³⁵ If staff observed the specific behaviors outlined in Table 1, the algorithm coded the corresponding best practice was as “met” (1). If the behaviors were not observed, the best practice was coded as “not met” (0).³⁵ The count of nutrition practices met by each provider was calculated.

Table 1.

Best Practices from NAP SACC and Algorithm for Meeting Best Practices Based on EPAO¹ Observational Data.

DOMAIN	BEST PRACTICE	REQUIREMENT TO MEET BEST PRACTICE
Water	Make drinking water available for children at all times.	Observer indicates that children have self-service access to water in the FCCH (including from filled cups that are always accessible)
Water	Prompt children to drink water during each indoor and outdoor play time.	Observer indicates that provider reminds children to drink water at least once during every outdoor play time and every active indoor play time.
Juice	Limit 100% fruit juice to no more than two, 4-6oz servings per week.	Observer indicates that the total amount of 100% fruit juice served to a single child across the 2 days of observation does not exceed 12 ounces; AND the amount of 100% fruit juice that the provider reports serving the children does not exceed 12 ounces per week.
Juice	Only serve 100% fruit juice that has no sugar added.	Observer indicates that provider does not serve juice that is less than 100% fruit juice at any meal or snack time.
Milk	Children ages 2 and older should only be served skim or 1% milk.	Observer does NOT indicate that provider serves 2% or whole milk at any meal or snack time.
Milk	Never serve flavored milk (milk with chocolate or strawberry syrup, or with added sugar).	Observer does NOT indicate that provider serves flavored milk at any meal or snack time.
Sugary Drinks	Never serve sugary drinks.	Observer does NOT indicate that provider serves sugary drinks (e.g. fruit flavored drink, lemonade, sports drink, soda, sweetened tea, or homemade drink with added sugar) at any meal or snack time.
Vegetables	Offer children vegetables two or more times/day.	Observer indicates that provider offers vegetables at more than one meal or snack time on each observation day.
Vegetables	Don' prepare vegetables with added fat. A small amount of vegetable oil is the healthiest option.	Observer does NOT indicate that vegetables are fried or prepared with lard, butter, margarine, or cheese sauce at any meal or snack time.
Fruit	Offer children fruit two or more times/day.	Observer indicates that provider offers fruit at more than one meal or snack time on each observation day.
Fruit	Never serve fruit in syrup or with added sugar.	Observer does NOT indicate that fruit served at any meal or snack time was canned in syrup or sweetened with added sugar.
Whole Grains	Offer children high fiber, whole grain foods two or more times/day.	Observer indicates that FCCP2 offered a whole grain food (including whole grain breads, pastas, cereals, crackers, and granola bars) two or more times daily on both observation days (at any combination of morning meal, morning snack, lunch, and afternoon snack)
Snack Foods	Limit offering children sugary, salty, or fatty foods to less than 1 time per week or never.	Observer indicates that the provider does NOT serve crackers, pretzels, chips, dessert items, sugary cereal, granola bars, pastries, or Pop-Tarts at any meal or snack time; AND the provider reports serving such items less than once per week.
High-fat meats	Limit serving high-fat meats to less than 1 time per week or never.	Observer indicates that the provider does NOT serve bacon, ham, hot dogs, bologna, salami, regular sausage, or other high-fat meat at any meal or snack time; AND the provider reports serving such items less than once per week.
Fried and Pre-Fried Foods	Limit offering children fried or pre-fried foods to less than 1 time per week or never.	Observer indicates that the provider does NOT serve fried meat, fried potatoes, or other fried foods at any meal or snack time; AND the provider reports serving such items less than once per week.
Mealtime Environment	Always sit at the table and eat with the children.	Observer indicates that FCCP sat with the children “a lot” at every observed meal on both days (morning meal, morning snack, lunch, and afternoon snack)
Mealtime Environment	Teach children how to serve themselves or, in the case of older children, allow them to serve themselves.	Observer indicates that “children served themselves most or all foods and decided what size portions to take” at every observed meal and snack time.
Self-Regulation	Always ask children if they are full before removing an unfinished meal or snack plate.	Observer indicates that provider never removes an unfinished plate without asking a child if they are full at any observed meal and snack time.
Self-Regulation	Always ask children if they are hungry before serving more food.	Observer indicates that provider does the following behavior “a lot” at every observed meal and snack time where seconds are served - Serves seconds only after a child requests them and after asking if child is still hungry.
Self-Regulation	Never pressure children to eat more food than they want.	Observer indicates that provider never required a child who ate less than half of a meal or snack to sit at the table until they cleaned their plate at any observed meal or snack time.
Self-Regulation	Do not use food or sweets as a reward or reward children for finishing their plate.	Observer indicates that provider never uses food or sweets as a reward or rewards children for finishing their plate at any meal or snack time.
Role Modeling	Enthusiastically role model eating and drinking healthy foods	Observer indicates that provider enthusiastically role models eating and drinking healthy foods at least a little at 75% or more of observed meal and snack times.
Encouragement	Always prompt and praise children for trying new or less preferred foods.	Observer indicates that provider prompts and praises children for trying new, less preferred, or healthy foods at least a little at 50% or more of observed meal and snack times.
Nutrition Education	Lead a planned nutrition education lesson one or more times per week.	Provider reports leading a planned nutrition education lesson at least once per week.
Nutrition Education	Talk with children informally about nutrition and healthy eating as often as possible.	Observer indicates that provider talks with children informally about nutrition at least a little at every observed meal and snack time.
Parent Communication	Provide families with information on child nutrition to help them continue healthy practices at home.	Provider reports sharing information with families about child nutrition topics, including 1) types of foods and drinks children should eat, 2) recommended serving sizes, 3) the importance of serving a variety of foods, and 4) a healthy mealtime environment.

¹EPAO: Environment and Policy Assessment and Observation

²FCCP: family childcare home provider

Children’s Diet.

Children’s dietary quality was measured using the 2015 Healthy Eating Index (HEI) score,⁶⁰ which was calculated based on dietary intake data collected during the 2-day observation using the UNC developed Dietary Observation in Child Care (DOCC), a reliable, valid visual observation technique.^61,62 DOCC data was entered in to the Nutrition Data System for Research (NDSR),⁶³ a windows-based dietary analysis program. Each child’s daily averaged data among both observation days and the total HEI and component scores were calculated based on the HEI-2015 algorithm.⁶⁰ The total HEI score is a sum of 13 dietary components sub-scores, with higher scores indicating better diet quality (score range 0-100).⁶⁰ HEI component scores are calculated as intake per 1000 calories (except for fatty acids, which is scored as a ratio of unsaturated to saturated fatty acids) including total vegetables (5), greens/beans (5), total fruit (5), whole fruit (5), whole grains (10), dairy (10), total proteins (5), seafood and plant protein (5), fatty acids (10), sodium (10), refined grains (10), added sugars (10), and saturated fats (10).⁶⁰

Data Collector Training

The DOCC and EPAO observations were conducted by the same observers over the same 2 days. Field observers underwent an extensive DOCC and EPAO training and had to achieve 80% inter-rater reliability with a “gold standard” observer to be certified prior to field data collection.⁶⁴ Technical error of the measures was calculated quarterly, and data collectors were retrained as needed to maintain 80% agreement level throughout. One or two field observers (2 observers were required for FCCHs with more than three children) conducted the observations in each FCCH for 2 full childcare days. Each observation day began before children ate breakfast and ended when children left for the day and included at least 2 eating occasions (breakfast, morning snack, lunch, afternoon snack, and sometimes dinner).

Data Analysis

We used a multilevel linear regression model to assess the association between the count of nutrition practices, or each nutrition practice met by providers, and children’s total HEI scores. The Bonferroni correction was used to control the multiple comparisons, and the adjusted critical value was p = .002. The associations between meeting certain nutrition best practices and the related children’s HEI sub scores were also assessed by multilevel linear regression models. Each model accounted for the nesting of children in FCCHs, and included moderators (FCCP ethnicity and income level)⁴¹ to help reduce confounding and the risk of including variables that could increase bias. The multilevel linear regression results were presented as parameter estimates, 95% confidence intervals, and 2-sided p values. All analyses were conducted using Stata, version 16.0 (Stata Corp, College Station, Texas 77845 USA, 2019).⁶⁵

Results

Participants

The sample consisted of 120 female FCCPs (67.5% Hispanic, 75% married or living with a partner). Participants were on average 48.9 (SD = 9.0) years old and about 13.3% had yearly household income less than $25k; 43.3% had a high school degree/GED or less. The majority (82.5%) accepted CACFP subsidies. See Table 2.

Table 2.

Family Childcare Provider Demographics

Variable	Category	ALL (n=120) % (n)/ Mean (SD)
Gender
	Female	100 (120)
Ethnicity
	Hispanic	67.5 (81)
	Non-Hispanic	32.5 (39)
Ethnic subgroup
	Dominican	40.0 (48)
	Puerto Rican	7.5 (9)
	Colombian	9.2 (11)
	Guatemalan	1.7 (2)
	Mexican	0.8 (1)
	Other	40.8 (49)
Race
	White/ Caucasian	42.5 (51)
	Black or African American	15 (18)
	American Indiana or Alaska Native	3.3 (4)
	Native Hawaii or Other Pacific Islander	2.5 (3)
	Other	23.3 (28)
	Multi race	2.5 (3)
	Unknown	10.8 (13)
Country born in
	United States	29.2 (35)
	Non-United States	70.8 (85)
State
	Rhode Island	59.2 (71)
	Massachusetts	40.8 (49)
Marital status
	single	9.2 (11)
	Married or living with a partner	75 (90)
	divorced	8.3 (10)
	separated	4.2 (5)
	widowed	3.3 (4)
Yearly household Income ($)
	Less than 25k	13.3 (16)
	25k-50k	47.5 (57)
	50k-75k	20 (24)
	75k-100k	10 (12)
	More than 100k	5.8 (7)
Highest level of education
	Less than High school	10.8 (13)
	High school or GED1	32.5 (39)
	Associates degree	38.3 (46)
	Bachelor’s degree	15 (18)
	Master’s degree or higher	3.3 (4)
Age		48.9 (9.0)
Accept CACFP2 subsidies		82.5 (99)
Hours work per week as a provider		62.4 (13.8)
Number of Children in the care (include own children or grandchildren)		7.7 (3.1)
Number observed in the pre COVID-193		120 (100)
Years working in early childcare		12.8 (8.4)
Count of best practices met by providers		11.1 (2.3)

¹GED: General Equivalency Diploma

²CACFP: Child and Adult Care Food Program

³COVID-19: coronavirus disease 2019

The child sample consisted of 370 children with 51% girls, 58% Hispanic, 47% White, 10% Black. Children were on average 3.5 (SD = 1.0) years old. Most children ate breakfast (84%) and lunch (97%) at the FCCH. Overall, they spent 7.6 (SD = 0.9) hours per day at the FCCH. See Table 3.

Table 3.

Child Demographics

Variable	Category	ALL (n=370) % (n)/ Mean (SD)
Gender
	Male	48.6 (180)
	Female	51.4 (190)
Ethnicity
	Latinx	57.6 (208)
	Non-Latinx	42.4 (153)
Race
	White/ Caucasian	46.8 (168)
	Black	10.3 (37)
	American Indiana	0.8 (3)
	Native Hawaii	0.8 (3)
	Asian	0.8 (3)
	Other	30.1 (108)
	Multi Race	10.3 (37)
State
	Rhode Island	55.1 (204)
	Massachusetts	44.9 (166)
Age		3.5 (0.98)
Child Eats Breakfast at FCCH1		83.8 (310)
Child Eats Lunch at FCCH		96.8 (358)
Child Eats Dinner at FCCH		8.4 (31)
Hours per Day at FCCH		7.6 (0.86)

¹FCCH: family childcare homes

Associations between providers’ nutrition practices and children’s overall HEI scores

In general, providers implemented 11.0 (SD = 2.3) of 26 nutrition best practices. The mean HEI-2015 score was 62.2 (SD = 12.1). Providers who met more best practices cared for children with higher total HEI scores. Children cared for by providers who met best practices related to allowing children to self-serve food and providing nutrition education at least once per week had higher total HEI scores compared to children in FCCHs where these best practices were not met. See Table 4.

Table 4.

Associations between providers’ practices and children’s overall diet quality (N=370)

Providers’ practice	Total HEI score B	p value	95% CI
Total Score	1.05	.03	[.12, 1.99]
Making drinking water available for children at all times	2.29	.44	[−3.55, 8.13]
Prompt children to drink water during each indoor/outdoor play	4.56	.24	[−3.05, 12.18]
Limit 100% fruit juice to no more than two, 4-6 oz servings/ day	3.24	.10	[−.59, 7.06]
Only serve 100% fruit that has no sugar added	1.22	.85	[−11.90, 14.34]
Children ages two and older should only be served skim or 1% milk	1.02	.67	[−3.69, 5.74]
Never serve flavored milk	4.75	.03	[.40, 9.10]
Never serve sugar drinks	4.49	.46	[−7.56, 16.54]
Offer children vegetables 2 or more times/day	4.40	.08	[−.54, 9.34]
Don’t provide vegetables with added fat	1.52	.70	[−6.45, 9.39]
Offer children fruit 2 or more times/day	6.00	.007	[1.70, 10.31]
Never serve fruit in syrup or with added sugar	−2.66	.24	[−7.10, 1.77]
Offer children high fiber whole grain food 2 or more times/day	3.39	.18	[−1.53, 8.31]
Limit offering children sugary, salty or fatty foods to <1 times/day	−2.11	.18	[−5.20, .95]
Limit serving high fat meat to less than one time per week or never	2.61	.16	[−1.03, 6.24]
Limit serving fried/pre fried foods to <1 times/day	3.16	.14	[−1.06, 7.37]
Always sit at the table and eat with children	4.82	.09	[−.68, 10.46]
Teach children how to serve themselves or allow them to serve themselves	27.52	<.001	[21.02, 34.02]
Always ask children if they are full before moving an unfinished meal or snack plate	2.78	.18	[−1.26, 6.82]
Always ask children if they are hungry before serving more food	−2.25	.28	[−6.39, 1.89]
Never pressure children to eat more food than they want	2.49	.34	[−2.62, 7.61]
Do not use food or sweets as a reward or reward children for finishing their plate	−.05	.98	[−4.14, 4.03]
Lead a planned nutrition education lesson one or more time per week	−1.01	.62	[−4.99, 2.97]
Talk with children informally about nutrition	7.76	.001	[3.29, 12.23]
Enthusiastically role model eating and drinking healthy foods	2.65	.47	[−4.55, 9.85]
Always prompt and praise children for trying new food	.64	.76	[−3.42, 4.70]
Provide families with information on child nutrition to help them continue healthy practices at home	−2.89	.12	[−6.50, .72]

Note. All models were controlled for provider ethnicity, income and Bonferroni correction (except for the total practice score). The adjusted critical value was 0.002. The reference group for each practice is not implementing this best practice.

Associations between providers’ nutrition practices and children’s related HEI subcomponent scores

Children cared for by providers who offered fruits two or more times a day had higher total fruit and whole fruit HEI component scores compared to the children cared for by providers who did not engage in this practice. Children cared for by providers who offered high-fiber, whole-grain foods two or more times a day had higher (better) refined grain scores compared to the children of providers who did not engage in this practice. Children cared for by providers who met 4 best practices related to added sugar had a higher mean added sugar score (indicating less sugar intake). See Table 5. However, we did not find significant associations between providers’ feeding practices related to vegetables and saturated fat and children’s associated HEI component scores.

Table 5.

Associations between provider nutrition-related practices and related children’s Healthy Eating Index (HEI) subcomponent scores (N=370)

Providers’ practice	HEI sub score B	p value	95% CI
	Total vegetables
Offer children vegetables two or more times/day	.77	.37	[−.90, 2.43]
	Green beans
Offer children vegetables two or more times/day	−.59	.43	[−2.08, .89]
	Total fruit
Offer children fruit two or more times/day	.59	.03	[.05, 1.13]
	Whole fruit
Offer children fruit two or more times/day	.73	.007	[.20, 1.26]
	Whole grain
Offer children high fiber, whole grain foods two 2 or more times/day	2.40	.09	[−.39, 5.20]
	Fatty Acid
Limit serving high fat meat to less than one time per week or never	.70	.19	[−.35, 1.75]
	Refined grain
Offer children high fiber, whole grain foods 2 or more times/day	2.47	.01	[.52, 4.42]
	Added sugar
Never serve sugar drinks	3.24	.02	[.45, 6.02]
Make drinking water available for children at all times	.37	.35	[−.41, 1.16]
Prompt children to drink water during indoor and outdoor play time	.84	.003	[.29, 1.39]
Limit 100% fruit juice to no more than two, 4-6 oz servings/ day	.91	.01	[.18, 1.64]
Only serve 100% fruit that has no sugar added	2.42	.03	[.24, 4.59]
Never serve flavored milk	.41	.35	[−.46, 1.29]
	Saturated fat
Limit serving high fat meat to less than one time per week or never	.33	.41	[−.46, 1.13]
Children ages two and older should only be served skim or 1% milk	.93	.11	[−.21, 2.08]

Note. All models control for provider ethnicity and income. Refined grains, sodium, added sugars, and saturated fats components were reversed scored. The reference group for each practice is not implementing this best practice. Multilevel linear regression models were run separately by each best practice and HEI subscore. The critical value was 0.05.

Discussion

The current study examines the influences of providers’ nutrition practices on children’s diet quality in FCCHs with a high proportion of Hispanic providers. The findings of this study add to the growing literature that highlights the importance of ECE provider nutrition-related practices on child diet quality.

Overall, providers in the current study met less than half of the NAPSACC best practices for nutrition. Details about practices met and not met by FCCPs in the Healthy Start study have previously been published³⁵; many providers did not serve children enough vegetables and whole grains, and did not adequately limit salty, sugary, and fatty snacks. In addition, many providers did not role model eating healthy foods, sit at the table and eat with children, talk with children informally about healthy eating, and teach children how to serve themselves or allow them to serve themselves.³⁵ Other studies assessing foods served and feeding practices in FCCHs have found similar results.^{6,31,34,66,67} In the current study, we found that providers meeting best practices related to serving certain foods or beverages was associated with better related HEI sub-scores for total fruit, whole fruit, whole grains, refined grains, and added sugar.

We found that children cared for by providers who practiced having “children serve themselves most or all foods and deciding what size portions to take at every observed meal and snack time” had higher overall mean HEI diet quality scores in their FCCH. Findings from the Keys study, conducted in North Carolina FCCHs, which also collected 2-day EPAO observation and DOCC data, indicated that FCCPs who engaged in responsive feeding practices that were supportive to children’s self-regulation of eating had children with higher HEI diet quality scores.⁶⁸ Other research has found that children serving their own food is associated with less food waste, and more appropriate portion sizes, which may help in the self-regulation of hunger and satiety.²² Studies with parents have also shown that by engaging in more responsive feeding practices is associated with better diet quality of children.⁶⁹

In our study, we found that children cared for by providers who “talked with children informally about nutrition at least a little at every observed meal and snack time” had higher overall mean HEI scores. Although few studies have explored the association between providing children informal nutrition education and child diet in FCCHs, a 2-day observational study suggested that providing nutrition education for both children and parents in North Carolina FCCHs was associated with higher children’s overall HEI scores.³¹

Other responsive feeding practices such as asking children if they are hungry before serving more food, encouraging children to try new foods, and not using food as a reward were not significantly associated with children’s diet quality in our sample. Although limited research has examined the associations between specific responsive feeding practices and children’s diet quality in FCCHs, previous observational studies had inconsistent findings.^31,68 For example, one study conducted in North Carolina did not observe that more provider responsive feeding practices were associated with children’s diet quality.³¹ However, another observational study found that a collection of several feeding practices supporting children’s autonomy were the only feeding practices significantly associated with children’s HEI scores.⁶⁸ The inconsistent findings among these studies may be due to the fact that some responsive feeding practices are more promotive of children's diet quality relative to others. It may be more difficult to detect a significant association when examining these practices as a sub score, rather than examining them separately, or it is possible that each individual practice may be less meaningful than capturing an overall feeding style.

Providers in FCCHs may face various barriers such as financial and structural challenges, stress and overwork, parental conflict, and lack of storage and food preparation equipment when trying to follow nutrition best practice guidelines.^52,70-72 Improving the nutritional quality of foods often requires higher food spending. For example, a study in Washington that linked food receipt and childcare menu data found that higher daily food expenditures were associated with the number of whole grains and fresh fruits and vegetables served to children in FCCHs.⁷³

Because of the high proportion of Hispanic providers (67.5%) in our sample, we considered cultural factors that might account for some of our findings. Previous studies have reported differences in the feeding practices that are implemented between Hispanic and non-Hispanic providers.^35,53,74.70 Therefore, cultural norms may influence ECE providers’ implementation of nutrition best practices. Previous analyses from the Healthy Start study found that some nutrition best practices were more likely to be implemented by Hispanic FCCPs while others were more likely to be implemented by non-Hispanic FCCPs.⁷⁵ Furthermore, children cared for by Hispanic FCCPs had better total HEI scores than those cared for by non-Hispanic providers.⁴¹

The NAPSACC best practice nutrition guidelines are evidence-based,^47,55,56 but generally stricter than most national and state nutrition regulations for ECE. Thus, ECE providers are not required to follow NAPSACC guidelines to be licensed. Opportunities to use policy to improve the nutrition environment in FCCHs exist at many levels. At the federal level, there are opportunities to strengthen the nutrition environment through the CACFP,⁷⁶ which most of our providers utilized. Currently, CACFP requires ECE providers to follow national nutrition standards for meals and snacks served in their settings, which supports the service of a greater variety of vegetables and fruit, whole grains, lean meats, and low-fat and free dairy while limiting added sugar and saturated fat.⁷⁶ Major revisions to the CACFP guidelines went into effect in October 2017⁷⁷ strengthening requirements to serve more vegetables, whole grains, and lean meats while avoiding added sugars.⁷⁷ While this is a federal program, some states require that all licensed ECE settings must follow CACFP standards, even if they do not participate in the program. Other state regulations require or ban specific foods or beverages. For example, Arizona, Colorado, Illinois, Maryland, Mississippi, New Jersey, New York, North Carolina, Oklahoma, Rhode Island and California have laws prohibiting licensed ECE settings from serving beverages with added sweeteners.⁷⁸ Studies have shown that statewide nutrition policies for ECE can have an impact on children’s diet quality in childcare centers. ⁷⁹ Federal, state and facility level policies for ECE systems could all be leveraged to provide optimal nutrition early in life.⁸⁰

Our study has some limitations to consider as we examine this work. The study sample may not be representative of all FCCPs, as the current sample is only from RI and MA and has a higher proportion of Hispanic providers compared to other studies conducted in FCCHs. Therefore, the results may not be generalizable to FCCPs in other states. In addition, due to the cross-sectional design, causality cannot be inferred in the current study. Nonetheless, we did not find significant relationships for some nutrition-related provider practices and children’s diet quality, that does not mean that those practices are not important for children’s diets. Our results could be due to the cross-sectional nature of the current study as well as the small sample size and the specific study location. Binary scores in the current study may not capture the variability of nutrition practices in FCCHs. Further, the 2-day observation data may not be fully representative of usual nutrition practices. Providers may have altered their behaviors on the observation days to reflect their perceptions of desired practices. Further provider-reported data could be biased by social desirability and recall. However, the prevalence of meeting the best practice nutrition guidelines was generally quite low. Similarly, 2 days of children’s diet data may not be representative of their usual diet; however, it likely corresponds to the FCCPs’ practices on those days.

As mentioned earlier, CACFP nutrition guidelines changed during this study. Two-thirds of the enrolled FCCPs had baseline measurements before CACFP guidelines changed and one-third after. However, it is unlikely that the changes to the CACFP guidelines affected the relationship between children’s diets and FCCP’s practices in our study. In addition, two prior analyses of our data examined the relationship between CACFP status of the FCCHs and baseline children’s dietary quality⁴¹ and whether CACFP status was a moderator of intervention effects,⁸¹ and both studies found no association.

As the current study was conducted pre-COVID-19, our results may not represent the situation during or after the pandemic. FCCHs closed during the lockdown, which affected providers’ livelihoods. When they were allowed to reopen, providers that returned to work faced harsher working conditions and greater stressors including stricter hygiene guidelines, uncertainty about their business, higher food prices, and mental health issues of families.⁸² These issues might impact their ability to provide healthy food and activity environments for children cared for in FCCHs.^82,83

Implications for Research and Practice

Given the results of the current study, it is clear that foods served to children and the feeding practices of FCCPs are related to children’s dietary quality in the family childcare setting. Based on the results, some of the most important practices for providers to improve children’s diet quality may be autonomy feeding practices, talking informally to children about nutrition as well as providing healthful foods and beverages. Therefore, future research and intervention projects should focus on how to help providers to implement these best practices and more related training opportunities and resources should be provided to providers. Policy and intervention efforts need to focus directly on the foods and beverages served to children such as increasing the servings of healthy foods, decreasing the amount of unhealthy foods, as well as fostering positive feeding practices. Further, supporting FCCPs in providing nutrition education to children might be a promising intervention target for improving child diet quality in ECE settings. Future interventions could also include food or beverage-specific components to support adherence to the related guidelines, which could result in improvement in the comparable areas of a healthy child diet. Future studies with larger samples could further examine the relationship between provider ethnicity, their likelihood to meet best practice nutrition guidelines and how that is related to children’s dietary quality.

Policy changes at the federal or state level could strengthen nutrition guidelines and/or mandate that providers follow best practice nutrition guidelines, but must also recognize the barriers that may be involved and include more training opportunities, support and resources for FCCPs. Future research and intervention projects could focus on how to help providers to implement these best nutrition practices, including better understanding of what motivates or supports the needed changes.