Fruit and Vegetable Preparation Style in Family Child Care Homes in Oklahoma

Abstract

Background:

Children spend 33–35 hours per week in family child-care homes and may consume up to five meals and snacks there, making these settings important for understanding how food especially fruits and vegetables are prepared and served. The purpose was to examine frequency and variety, preparation styles by meal, and identify predictors of fresh and frozen fruit and vegetable service in Oklahoma family child care homes (FCCH).

Methods:

Ninety-six FCCHs participated in two cohorts (n = 51 in-person; n = 45 virtual). Frequency, variety, and preparation styles of fruits/vegetables were recorded for both in-person and virtual cohorts. The average frequency and variety of fruits and vegetables, and the frequency of their preparation styles were calculated. The association of FCCH characteristics with fresh/frozen fruits and vegetables service score was examined.

Results:

All FCCH providers identified as female (mean age 43.9 – 15.1 years). At breakfast, whole fruits and juice were served by 88.6% and 6.8% of providers, respectively. At lunch, whole fruits and juice were served by 86.6%–94.1% and 2.0%–4.4%, and vegetables by 94.1%–97.8%. At snack, fruits, fruit juice, and vegetables were served by 60%, 13.3%, and 11.1%, respectively. Bananas and apples/applesauce were the most common fruits, and carrots and green beans were the most common vegetables served. Fresh fruit was most common at breakfast (77.3%), lunch (53%–61%), and snack (63%). Fresh and frozen vegetables were equally prevalent (50%) at breakfast, canned vegetables (44–57%) at lunch, and fresh vegetables (100%) at snack. No provider/program characteristics were associated with fresh/frozen service scores.

Conclusions:

Opportunities exist to improve fruits/vegetables service in Oklahoma FCCHs by serving vegetables at breakfast and snacks and reducing juice and canned options.

Background

Young children are particularly at risk of developing unhealthy dietary patterns,^1–4 because early eating behaviors are shaped by multiple interacting influences. These patterns emerge from a complex combination of individual, family, social, and environmental factors including the school meal environment.³ Also, young children lack autonomy and depend on caregivers for what, when, and how they eat. Concerning dietary trends including a rising consumption of added sugar and sodium,⁵ and insufficient intake of fruits/vegetables.⁶ This is highly concerning because higher consumption of high-sugar and high-sodium foods, and low fruits/vegetables intake, are predictors of diet-related chronic diseases,^1,7,8 including childhood obe- sity.⁹ Canned fruits¹⁰ and sweetened beverages, including fruit-flavored drinks or juices are sources of added sugar.¹¹ Most US preschoolers exceed current sodium recommendations,¹² and do not meet the daily recommended intake of both fruits and vegetables.^13,14 In Oklahoma, preschoolers’ weekly consumption of sugar sweetened beverages (72.1%) even greatly exceeds national metrics of weekly consumption (US: 57.1%).^8,9 Increasing fruits/vegetables intake and reducing sugar and sodium consumption may improve young children’s diet and future health.

It is crucial to promote both the frequency and quality of fruits/vegetables served to young children. Although preparation and serving methods may impact the nutritional quality, evidence on common methods of preparing and serving fruits/vegetables remains limited. Common preparation methods include fresh, frozen, canned, dried, and juice, with fresh and frozen varieties having superior nutritional quality than canned and juice ones.^13,15 Further, peeling, cooking, canning, and processing can significantly decrease the nutrient content.^15–19 For example, canned options typically contain lower levels of fiber, vitamins, and minerals than their fresh or frozen counterparts.^15,19 Additionally, canned options tend to have higher sodium and sugar.¹⁹ Current recommendations suggest that at least half of daily fruit intake comes from whole fruits as opposed to 100% juice.^7,13,20

Early care and education settings are a critical setting for understanding children’s FV intake, as around 60%–65% of US preschoolers (ages 2–5 years) attend early care and education while parents may be working, at school, or in other obligations,^21,22 where they receive up to two-thirds of their meals.²³ Family Child Care Homes (FCCHs) are small early care and education programs in which providers care for children in their own homes and prepare and serve meals.²⁴ FCCHs are typically run by a single, nonrelative caregiver who takes on multiple roles while caring for a smaller group of mixed-age children—generally between 6 and 12.^25,26 Due to numerous responsibilities and minimal support, FCCHs often face difficulties in serving healthy meals,²⁴ especially fresh fruits/vegetables,⁶ compared with center-based facilities.²⁷ Children in FCCHs may also face a higher risk of overweight or obesity,²⁸ and these settings are often chosen by low-income families because they offer more flexible hours and tend to be more affordable.²⁹

FCCHs participating in the federal food program³⁰ often serve healthier foods compared to non-participating FCCHs.³¹ The food program reimburses FCCHs for healthy meals³² and requires at least 1/4 cup of fruits and 1/4 cup of vegetables in every meal.³³ Despite this support, some FCCHs find it difficult to serve fresh produce.⁶ Previous studies examining mealtime best practice in FCCHs have not differentiated fruits/vegetables preparation styles.^{6,24,27,31,34–36} Such information is critical for determining the meal quality, especially the fruits/vegetables service in child care settings. Therefore, this descriptive study, conducted in Oklahoma FCCHs, aimed to determine the: (1) frequency and variety, and (2) preparation of fruits/vegetables by meal; and (3) association of FCCH provider and program demographic characteristics with a lunchtime fresh/frozen service score.

Methods

Study Design and Participants

The present study examined baseline measures from the data collected in two cohorts of the Happy Healthy Homes, an intervention study aimed at improving FCCH nutritional quality and nutrition environments³⁷ and nutritional quality (ClinicalTrials.gov Identifier: NCT03560050; retrospectively registered on May 23, 2018). The first cohort, initiated in 2017 (before the COVID-19 pandemic), was in-person and included 51 providers located within 60 miles of Oklahoma City.³⁷ The second cohort, initiated in 2020 (during the COVID-19 pandemic), was virtual and included 48 providers located in predominantly rural areas of Oklahoma. Eligibility criteria for both cohorts included participation in the food program, serving at least one preschool child, planning to remain in business for at least 12 months, and preparing and serving meals for the children in care. Informed consent was obtained from all participants before data collection, in-person for the first cohort and virtually for the second cohort.

All study procedures were approved by the Institutional Review Board at the University of Oklahoma Health Campus for both cohorts (7551 and #10747, respectively). Both cohorts included collecting up to 2 days of meal observations, photographs, and recipe details from the providers (described in detail below). Remunerations of $30 for in-person and $50 for virtual baseline measures were provided.

Recruitment

For the in-person cohort, recruitment occurred between October 2017 and November 2018 (39) in 9 counties (of 77) through direct outreach via phone calls, meetings, training events, emails, flyers, and collaboration with food program sponsors. For the virtual cohort, recruitment occurred in the summer and fall of 2020 in 24 counties (of 77) through food program sponsors and extension educators distributing recruitment materials and direct phone calls to the providers using the Oklahoma Public Registry. In the in-person cohort, 370 eligible providers were contacted,74 consented to participate, and 51 (68.9%) completed at least 1 day of baseline data collection. In the virtual cohort, 230 eligible providers were contacted, 63 providers consented to participate, and 45 (71.4%) provided meal photographs and detailed recipes.

Measures

Provider/program characteristics.

In both cohorts, participants completed questionnaires about the program, personal demographics, distance to the grocery store, the number of children under their care, years in business, and an open response to describe their barriers to getting healthy foods. Open responses were classified into the following categories: food cost, time, knowledge of healthy food, healthy food availability, children’s food preferences, shelf life, and storage space.

In-person cohort: Fruits/vegetables service and preparation styles.

Lunch observations were conducted by trained research assistants at FCCHs on two nonconsecutive, unannounced days within 2 weeks. Observations were conducted to answer 12 specific questions about fruits/vegetables preparation styles (fresh, frozen, canned, dried, and fruit juice), frequency, and variety. For example, “Are fruits/vegetables served for lunch? (yes/no response options); and “If fruit/vegetable is served for lunch, what kind?” (Fresh/frozen/canned/dried/unspecified response options).

Virtual cohort: Fruits/vegetables service and preparation styles.

Providers were asked to take photographs and provide detailed recipes for foods that they served at breakfast, lunch, and afternoon snack for 1 day. Trained research assistants reviewed photos and recipes to answer 26 questions about preparation styles, frequency, and variety. For example, “Are fruits/vegetables served for breakfast/lunch/snack?” (yes/no response options).

Statistical Analyses

Central tendencies were calculated for the provider and program characteristics. All available data were used in analysis. Across aims, separate analyses were conducted for the in-person and virtual cohorts to account for differences in data collection methods.

For the frequency and variety of fruits/vegetable served, lunch values were calculated for each observation day in the in-person cohort. For the virtual cohort, frequencies and variety were calculated for breakfast, lunch, and snack based on the single day of data.

For frequency of preparation styles, only lunch values (in-person cohort) and breakfast, lunch and snack (virtual cohort) were calculated.

Association of FCCH provider/program demographic characteristics with a lunchtime fresh/frozen service score was calculated. Provider/program characteristics included in the analysis were provider’s self-reported general health status, age, number of years in business, number of additional part-time or full-time staff, number of children in care, distance to grocery store (miles), and number of self-reported barriers in getting healthy food. As lunch is the only meal requiring both vegetables and fruit (or a second vegetable) at each meal, only lunch was used to determine the association of provider/program demographic characteristics with a lunchtime fresh/frozen fruits/vegetables service. To determine associations between the program characteristics and fruits/vegetables variable, a fresh/frozen service score was developed. The fresh/frozen service score was determined by the number of fresh or frozen fruits/ vegetables served across 2 days (2 lunches) for the in-person cohort (range: 0–4) and 1 day lunch for the virtual cohort (range: 0–2), with a higher score indicating more fresh or frozen was served. A series of bivariate linear regression analyses were calculated for each characteristic and the fresh/frozen service score given the small sample size.

Data analyses were conducted using IBM SPSS Statistics for Windows, Version 29.0.1.0 (IBM Corp., Armonk, NY, USA). Statistical significance was set at p < 0.05.

Results

Descriptive characteristics of providers are displayed in Table 1. All providers in both cohorts identified as women (100%), were predominantly White (53.1%–55.6%), and with mean ages of 44.2 ± 14.1 and 43.6 ± 10.2 years for the in-person and virtual cohorts, respectively. Rural providers (virtual cohort) reported traveling 24.3 miles roundtrip to the grocery store, while those in metropolitan (in-person) cohort reported traveling 9.7 miles roundtrip. The mean number of children served in the in-person cohort was 9.5 ± 4.2 and 9.2 ± 3.5 in the virtual cohort with a range of 3–24 children. The mean fresh/frozen service score was 2.4 ± 1.3/4 possible and 1.1 ± 0.7/2 possible for the in-person and virtual cohorts, respectively. As for self-reported barriers, over half of providers in both cohorts reported having barriers to obtaining healthy food. The most reported barrier was the cost of food, followed by the availability of healthy food and children’s food preferences.

Table 1.

Descriptive Characteristics of Family Child Care Home Providers Participating in the Happy Healthy Home in Oklahoma (In-Person, 2017 and Virtual, 2020)

Variable	In-Person (n = 51)	Virtual (n = 45)
FCCH Provider Demographic Characteristics
	Mean ± SD or % (n)
Age, y	44.2 ± 14.2	43.6 ± 10.2
Race/Ethnicity (percent)
White	53.1% (26)	56.6% (25)
Black/African American	30.6% (15)	33.3% (14)
American Indian/Alaska Native	4.1% (2)	9.0% (4)
Hispanic	4.2% (2)	6.7% (3)
Other-specify	8.2% (4)	2.2% (1)
Do not wish to provide	4.1% (2)	0.0% (0)
Household income
≤$49,999	16.3% (8)	40.0% (18)
$50,000 to $99,999	34.7% (17)	44.4% (20)
≥$100,000	20.4% (10)	11.4% (5)
Do not wish to provide	10.2% (5)	4.4% (2)
Level of education
High school or less	8.2% (4)	4.4% (2)
More than high school	91.8% (45)	95.6% (43)
Self-reported health status
Poor, fair, good	42.8% (21)	40.0% (18)
Very good or excellent	57.1% (28)	60.0% (27)
Program characteristics
No. of years in business	10.8 ± 9.6	10.2 ± 9.1
No. of staff	1.4 ± 1.4	2.2 ± 1.4
No. of children in care	9.5 ± 4.2	9.2 ± 3.5
Distance to grocery store (miles)	9.7 ± 9.8	24.3 ± 31.2
Fresh/frozen fruit and vegetable score	2.3 ± 1.3	1.1 ± 0.7
No. of hours spent preparing meals for the children each day	1.9 ± 0.9	2.2 ± 3.6
Reported barriers to get healthy food	53.0% (27)	66.6% (30)
Self-reported barriers for getting healthy food in FCCH
Number of self-reported barriers	1.0 ± 0.3	0.7 ± 0.8
Food costs	25.2% (12)	23.1% (11)
Time	4.2% (2)	4.2% (2)
Knowledge	4.2% (2)	0% (0)
Healthy food availability	6.1% (3)	18.9% (9)
Children’s food preferences	12.2% (6)	6.3% (3)
Shelf life and storage space	4.2% (2)	6.3% (3)
COVID-19 healthy food availability	N/A	4.2% (2)

^aIn person, n = 6 missing age, n = 2 missing race, income, education, self-reported health; in virtual n = 0 missing demographic variables.

^bRace/ethnicity variable includes multiple races, therefore sums to >100%.

Frequency of Fruits/Vegetables Service and Variety, by Meal

Frequency of fruits/vegetables service at respective meals and the prevalence of specific FV (i.e., variety) by meal are shown in Table 2.

Table 2.

Frequency of Fruit and Vegetables Served by Meal and the Most Common Fruit and Vegetables Served in Oklahoma Family Child Care Homes in 2017 and 2020

Variable	Percent (n)
	In-Person day 1	In-Person day 2	Virtua
	(n = 51)	(n = 48)	(n = 45)
Breakfast includes whole fruits	N/A	N/A	88.6% (39)
Breakfast includes fruit juice	N/A	N/A	6.8% (3)
Breakfast includes vegetables	N/A	N/A	4.5% (2)
Lunch includes whole fruits	94.1% (48)	93.6% (44)	86.6% (39)
Lunch includes fruit juice	3.9% (2)	2.0% (1)	4.4% (2)
Lunch includes vegetables	94.1% (48)	95.8% (46)	97.8% (44)
Lunch includes second vegetable	0.0% (0)	0.0% (0)	13.3% (6)
Snack includes whole fruits	N/A	N/A	60.0% (27)
Snack includes fruit juice	N/A	N/A	13.3% (6)
Snack includes vegetables	N/A	N/A	11.1% (5)
			(n = 41)
Breakfasta
Fruits
Apples (including applesauce)	N/A	N/A	17.0% (7)
Bananas	N/A	N/A	36.5% (15)
Blueberries	N/A	N/A	2.4% (1)
Grapes	N/A	N/A	4.8% (2)
Oranges (including Mandarin oranges)	N/A	N/A	4.8% (2)
Peaches	N/A	N/A	4.8% (2)
Pears	N/A	N/A	4.8% (2)
Pineapples	N/A	N/A	2.4% (1)
Raisins	N/A	N/A	4.8% (2)
Strawberries	N/A	N/A	17.0% (7)
			(n = 2)
Vegetables
Potatoes (In form of hash brown)	N/A	N/A	50% (1)
Tomatoes	N/A	N/A	50% (1)
	(n = 48)	(n = 44)	(n = 39)a
Luncha
Fruits
Apples/applesauce	23.0% (10)	29.5% (13)	27.5% (10)
Bananas	10.41% (5)	16.0% (7)	15.0% (6)
Blueberries	0.0% (0)	4.5% (2)	0.0% (0)
Cantaloupe	8.3% (4)	2.3% (1)	0.0% (0)
Fruit cocktail and mixed fruits	0.0% (0)	11.3% (5)	10.0% (4)
Grapes	12.5% (6)	13.6% (6)	0.0% (0)
Oranges (Including Mandarin oranges)	8.3% (4)	20.4% (9)	15.4% (6)
Peaches	12.5% (6)	9.1% (4)	12.8% (5)
Pears	6.25% (3)	6.8% (3)	7.7% (3)
Pineapples (Including pineapple tidbits)	10.41% (5)	9.1% (4)	7.7% (3)
Raisins	0.0% (0)	0.0% (0)	2.5% (1)
Strawberries	12.0% (6)	0.0% (0)	5.1% (2)
Watermelons	0.0% (0)	4.5% (2)	0.0% (0)
	(n = 48)	(n = 46)	(n = 43)
Vegetablesa
Asparagus	2.0% (1)	0.0% (0)	0.0% (0)
Beans (Including lima, pinto, Black, chili, and White beans)	10.4% (5)	4.3% (2)	11.6% (5)
Bell Pepper	2.0% (1)	0.0% (0)	6.8% (3)
Broccoli	2.0% (1)	13.0% (6)	7.0% (3)
Carrots	29.2% (14)	34.7% (16)	20.6% (9)
Cauliflower	0.0% (0)	2.2% (1)	0.0% (0)
Celery	2.0% (1)	2.2% (1)	2.3% (1)
Corns	12.5% (6)	13.0% (6)	18.6% (8)
Cucumbers	4.2% (2)	0.0% (0)	4.6% (2)
Edamame	0.0% (0)	0.0% (0)	2.3% (1)
Green Beans (Not including other kinds of beans)	33.3% (16)	28.3% (13)	23.2% (10)
Lettuce (Including romaine and iceberg)	4.2% (2)	6.5% (3)	9.3% (4)
Mix Vegetables (Including spring mix salad and mix salad)	2.0% (1)	10.8% (5)	4.6% (2)
Onions	0.0% (0)	2.2% (1)	7.0% (3)
Peas (Including sweet peas)	18.7 (9)	15.2% (7)	13.8% (6)
Potatoes (Including mashed, dried mashed, hash brown, and tater tots)	14.6% (7)	6.5% (3)	4.6% (2)
Red Cabbage	2.0% (1)	0.0% (0)	0.0% (0)
Spinach	2.0% (1)	0.0% (0)	4.6% (2)
Squash (Including yellow and green)	2.0% (1)	2.2% (1)	0.0% (0)
Sweet Potatoes	0.0% (0)	2.2% (1)	2.2% (1)
Tomatoes (Including tomatoes, diced tomatoes, tomato sauce, soup, paste, and salsa)	25.0% (12)	21.7% (10)	25.6% (11)
Vegetable Soup	2.0% (1)	0.0% (0)	0.0% (0)
			(n = 27)
Snacka
Fruits
Apples (Including Applesauce)	N/A	N/A	51.8% (14)
Bananas	N/A	N/A	7.4% (2)
Berry mix	N/A	N/A	3.7% (1)
Grapes	N/A	N/A	11.1% (3)
Oranges	N/A	N/A	11.1% (3)
Pineapples	N/A	N/A	3.7% (1)
Raisins	N/A	N/A	7.4% (2)
			(n = 5)
Vegetables
Bell Peppers	N/A	N/A	20.0% (1)
Carrots	N/A	N/A	20.0% (1)
Celery	N/A	N/A	20.0% (1)
Cucumbers	N/A	N/A	40.0% (2)

^aThe reduced sample size reflects the missing data or only those providers serving that meal component at the respective meal.

For breakfast (in the virtual cohort), 88.6% of providers served whole fruit while 6.8% served 100% fruit juice. About 91% of the providers served fruits and of those, the most common fruits served included bananas (36.5%), apples/applesauce (17.0%), and strawberries (17.0%). Only two providers (4.5%) served vegetables (tomatoes and potatoes).

For lunch (both cohorts), most providers served whole fruits (>86.6%, Table 2). A small percentage reported that they served fruit juice (2.0%-4.4%). Apple/applesauce was the most served fruit at lunch (23%–29.5%), which was mainly applesauce rather than apples (36.4%–38.5% in-person and 27.3% virtual cohort). Most providers served at least one vegetable (94. 1%–97.8%), with only the virtual cohort (13.3%) serving a second vegetable. Variety across both cohorts was limited with one-fifth to one-third of all vegetables served being carrots (20.6%–34.7%), green beans (23.2%–33.3%), and/or tomatoes (21.7%–25.6%).

For snack (in the virtual cohort), 60.0% served whole fruit and 13.3% served 100% fruit juice. The most common fruit served was apple/apple sauce (51.8% including 37.5% apple sauce). Only 11.1% of providers served vegetables, and the variety was limited to four types (Table 2); cucumbers were the most common choice (40.0%).

Fruits/Vegetables Preparation Styles by Meal

The preparation styles by meal are presented in Figure 1 (breakfast), Figure 2 (lunch), and Figure 3 (snack). As shown in Figure 1, for breakfast, most providers served fresh fruits (80.5%) followed by canned, frozen, and dried fruit. Vegetables served were equally fresh (50.0%) and frozen (50.0%) (Fig. 1). During lunch (Fig. 2A and B), over half of the providers serving fruit served fresh fruits (52.4%–64.6%) and more than one-third (37.0%–40.5%) served canned fruit. About a third of providers who served a vegetable served fresh vegetables (31.3%–41.3%) and approximately half served canned vegetables (41.3%–60.4%). For snacks, among providers serving a fruit, 63.0% served fresh fruits, with canned fruits (22.2%) being a close second (Fig. 3). All vegetables served were fresh.

Figure 1.

Breakfast fruit and vegetable preparation style in Family Child Care Homes in Oklahoma 2020–2021 among providers serving whole fruit, vegetable, or fruit juice for breakfast (Fruits: n = 41, Vegetables: n = 2, Juice n = 3)*. *The reduced sample size reflects providers not serving fruit, vegetable, or fruit juice in lieu of fruit or breakfast (n = 3); dark bars indicate fruit and light bars indicate vegetables. **Percents may add to 100 as providers may serve multiple preparation styles of fruit and vegetables at the meal.

Figure 2.

Lunch fruit and vegetable preparation style in Family Child Care Homes in Oklahoma in 2017–2019 and 2020–2021 among providers serving whole fruit, vegetables, or fruit juice. (A) fruit preparation style (B) vegetable preparation style.*

Figure 3.

Snack fruit and vegetable preparation style in Family Child Care Homes in Oklahoma 2020–2021 among providers serving whole fruit, vegetable, or fruit juice for snack (Fruits: n = 27, Vegetables: n = 5, Juice n = 6)*. *The reduced sample size reflects providers not serving fruit, vegetable, fruit juice for snack n = 13); **Percents may add to 100 as providers may serve multiple preparation styles of fruit and vegetables at the meal; dark barks indicate fruit and light bars indicate vegetables.

Aim 3: Association of Demographic Characteristics and Lunchtime Fruits/Vegetables Preparation Styles

No statistically significant associations were observed between demographic characteristics and the fresh/frozen service score at lunch (Table 3).

Table 3.

Association of Provider and Program Demographic Variables with Fresh/Frozen Score among Family Child Care Homes Providers in In-Person Cohort, 2017 (n = 51) and Virtual Cohort, 2020 (n = 48)

Variables	In-Person (n = 51)			Virtual (n = 48)
	Beta	Std. Error	p-Value	Beta	Std. Error	p-Value
Provider’s self-reported general health status	0.652	0.430	0.138	0.920	0.791	0.252
Age	−0.003	0.018	0.850	−0.003	0.014	0.816
No. of years in business	0.007	0.025	0.779	−0.005	0.016	0.729
No. of additional part-time or full-time staff	−0.038	0.180	0.836	0.093	0.096	0.339
No. of children in care	−0.071	0.060	0.245	0.020	0.037	0.594
Distance to Grocery store (miles)	−0.001	0.022	0.974	−0.02	0.037	0.594
Number of self-reported Barriers in getting healthy food	0.281	0.330	0.399	−0.135	0.134	0.321

^aSeries of individual bivariate linear regression models each with a respective FCCH provider characteristic and the outcomes of Fresh/Frozen Score; Beta presented are unstandardized.

Discussion

Study findings indicate that most breakfasts and snacks served in Oklahoma FCCHs included some fruits, whereas vegetables were seldom served for breakfast or snack. Unsurprisingly, almost all lunches in this study included a vegetable and a fruit (a second vegetable can be served in lieu of fruit) since it is a required meal component. While providers served fresh, frozen, and canned options, fruit was mostly served fresh, and vegetables were mostly served canned for lunch in both cohorts. Providers reported barriers to serving healthy foods; however, no reported barriers or program/provider characteristics were associated with higher fresh/frozen service score.

Most providers served fruit for breakfast and over half served fruit for snacks. There is room, however, to promote inclusion of vegetables, especially at breakfast. Breakfast and snack time present opportunities to increase fruits/vegetables service, specifically frequency of vegetables and overall fruits/vegetables variety.^35,36,38 Including vegetables at breakfast supports early and repeated exposure to vegetables and positive associations with children’s vegetable intake.^39–42 Familiarization through repeated exposure is a fundamental form of learning, especially important during early development when most stimuli are unfamiliar.⁴³ Further, providing a variety of fruits/vegetables as snacks as well can increase consumption and foster healthy habits in children.^44,45 However, providers may be reluctant to serve vegetables at breakfast or as snacks given young children’s preferences for sweet and salty foods rather than more bitter vegetables,⁴⁶ due to food waste concerns⁴⁷ and perceived barriers to preparing vegetables.⁶ Additional strategies are needed to encourage inclusion of vegetables at breakfast and snack and help providers to overcome perceived barriers related to serving fruits/vegetables.^21,48,49

Our findings indicate opportunities to serve fresh or frozen options as canned fruits were served more frequently than frozen fruits across all mealtimes, and canned vegetables were served more often than both fresh and frozen vegetables during lunch. This change is especially important because canned varieties typically contain higher amounts of sodium⁵⁰ and added sugars, and often have lower nutrient density due to canning processing.¹⁹ For example, significant losses have been reported for vitamin C (carrots lose 88%, broccoli 84%, and green peas 73.0%), vitamin B,¹³ vitamins A, vitamin E, and carotenoids in certain fruits.⁵¹ Frozen produce retains most nutrients if handled properly¹³ and it is cost-effective to providers.⁵⁰

Fruit juice was served more frequently at breakfast and snacks compared with lunch. While 100% fruit juice is allowable as a fruit, fruit juice has a high amount of free sugars⁹ and a higher glycemic index and⁷ does not include the fiber^7,13,20 or many of the nutrients found in whole fruit.⁵² Four ounces of 100% apple juice contains 60 calories, 13 g sugar, and 0 g fiber while half a cup of sliced apples has 30 calories, 5.5 g sugar, and 1.5 g fiber.⁹ Considering the low fiber intake among children,^53,54 replacing juice with whole fruit could improve their fiber intake. This would help regulate slower calorie absorption and promote positive health outcomes such as lower visceral fat and childhood obesity.⁵⁵ By improving breakfast and snacks with whole fruit consumption,²¹ FCCHs could play a key role in preventing obesity and reducing obeso- genic environments.⁵⁶

Regarding program characteristics, while none of the provider/program characteristics were associated with fresh/frozen service scores, barriers to service of healthy foods were common including food costs, distance to access fruits/vegetables, children’s preferences, shelf life, storage, time constraints, and knowledge of healthy options. Cost and distance specifically are the most common challenges, consistent with previous research.^{47,51,57–60} Also, primary reasons for serving canned options over fresh are affordability, extended shelf-life,⁵⁸ and convenience.⁵³ Longer grocery trips reported by virtual cohort (rural) participants likely amplify financial and logistical challenges, restricting access to affordable, healthy foods, especially perishable fresh produce with shorter shelf-life. These findings were exemplified in their use of more frozen alternatives than in-person cohort. Promoting canned options with frozen alternatives could be a cost-effective strategy to enhance nutrient quality while ensuring a longer shelf-life, thereby addressing the barriers.

There are strengths and limitations to this study. A key strength of this study is its novel focus on preparation styles and variety in FCCHs. Detailed collection of food preparation in-person and virtually adds rigor to, and addresses a gap in, the existing literature on this topic, and within a U.S. state with high rates of childhood obesity (Oklahoma). However, there are limitations. Data on low-sugar or low-sodium options were not collected, so all canned fruits/vegetables were assumed to contain added sugar or sodium. Additionally, data collection methods differed between the cohorts, with virtual data relying on photographs and recipes, which may have impacted data quality. Furthermore, actual food consumed was not uniformly collected across cohorts and was not included, which limits our ability to address children’s fruit/vegetable intake. The study’s timing, spanning both before and during the COVID-19 pandemic, may also have influenced food availability and preparation styles. Lastly, missing data on certain meals in the in-person cohort may limit the completeness and generalizability of the findings. Moreover, these results present only one U.S. state and may not apply to other FCCHs elsewhere or to other early care and education settings.

Conclusions

This study describes current fruits/vegetables service practices in FCCHs across Oklahoma. It also highlights opportunities to improve fruits/vegetables service quality in FCCHs, particularly by serving vegetables for breakfast and snacks, reducing canned fruits/vegetables across all meals, and reducing the frequency of juice service. Future research can extend current understanding and examine food preparation styles, children’s preparation preferences, explore barriers such as cost and accessibility, especially in rural areas, and examine the role of the food program on promoting fresh and frozen alternatives. Further, interventions are needed to address identified barriers and make healthier options feasible and desirable for FCCHs. Inclusion of FCCH providers, especially in rural areas, in the development of these interventions would strengthen their relevance to the diverse environments and practices of this home-based care setting.