Dietary Intake of Children Attending Full-time Child Care: What are they eating away from the Child-Care Center?

Abstract

Background

The Academy of Nutrition and Dietetics recommends children attending full-time child care obtain 1/2 – 2/3 of daily nutrient needs, leaving 1/3-1/2 to be consumed away from the center. While there are guidelines to optimize dietary intake of children attending child care, little is known about what these children consume away from the center.

Objective

To describe the dietary intake away from the child care center for preschool-aged children relative to the expected 1/3-1/2 proportion of recommended intake, and to examine the relationships between energy intake away from the center with weight status, food group consumption and low-income status.

Design

Cross-sectional study conducted between November 2009 and January 2011.

Participants/Setting

Participants (n=339) attended 30 randomly selected, licensed, full-time child-care centers in Hamilton County, Ohio.

Main Outcome Measures

Child weight status and dietary intake (food/beverages consumed outside the child-care setting from the time of pickup from the center to the child’s bedtime) including energy and servings of fruits, vegetables, milk, 100% juice, sugar sweetened beverages and snack foods.

Statistical Analyses

Generalized linear mixed models were used to examine independent associations of food group servings and low income status to energy intake; and energy intake to child weight status.

Results

The mean energy intake consumed away from the center (685 ± 17 kcal) was more than the recommended target range (433–650 kcal). Intake of fruits, vegetables, and milk were less than recommended. Food group servings and overweight/obesity status were positively associated with energy intake while away from the center.

Conclusion

Preschool children consumed more energy and less fruits, vegetables, and milk outside of child-care center than recommended. Overweight status was associated with children’s dietary intake after leaving the child-care center. It may be beneficial to include parents in obesity prevention efforts targeting children attending child-care centers.

BACKGROUND

Recent evidence suggests that overweight and obesity established prior to kindergarten are difficult to reverse.¹ Currently 22.8% of 2–5 year olds are overweight or obese (body mass index [BMI] ≥85^th percentile for age and sex),² with racial and ethnic minorities^2,3 and lower socio-economic group^4,5 being disproportionately affected. Fifty-five percent of US preschoolers 3–5 years of age who are not yet in kindergarten are in child-care centers.^6,7 Some studies have found child-care center usage to be positively associated with an increased risk of obesity in later childhood,^8,9 while others have found no association.^10,11 An increased risk of obesity among children attending child-care centers compared to those in parental care suggests excess energy intake is either occurring in the child-care center, away from the child-care center, or both, among children attending child care.

Understanding where children’s excess energy intake is occurring can better help target obesity prevention efforts. The challenge is that little attention has focused on the dietary intake of children away from the center¹² due to the predominant focus in recent years on dietary intake at child-care centers.¹³ The few studies that have examined diets of preschool children away from child-care center have found a greater consumption of fat, oils, and sweets away from the center compared to dietary intake while at the child care center,^12,14–16 indicating the environment away from the center may play an important role in excess energy intake. The Academy of Nutrition and Dietetics (Academy) recommends that child-care centers provide an appropriate diet that meets one half to two thirds of children’s daily energy and nutrient requirements. This presumes the balance (1/3-1/2) of energy and nutrients will be provided outside the child-care center by parents and other caregivers.¹⁷

The objectives of this secondary data analyses were to: (1) describe the dietary intake of preschool-aged children while away from the child-care center relative to the Academy’s recommendations (i.e., 1/2–2/3 proportion of intake¹⁷ recommended by the Dietary Guidelines for Americans¹⁸; (2) how intake varies by Child and Adult Care Food Program (CACFP) eligibility, a proxy for low-income status; (3) identify contributors (food group servings, low-income status) to children’s energy intake away from the child-care center; and (4) evaluate the relationship between energy intake away from the child-care center and weight status.

METHODS

Participants and Setting

Participants in this study were enrolled in a larger observational study of diet and physical activity of children (n=447) who attended 30 randomly-selected, licensed, full-time child-care centers in Hamilton County, Ohio. Two classrooms per child-care center were randomly selected to participate for a total of 60 classrooms. As per state and federal recommendations, children attending these centers full-time were typically served breakfast and/or morning snack, lunch and an afternoon snack. The Academy recommends that menus at child-care centers should meet one-half to two-thirds of children’s energy and nutrient needs.¹⁷ Children that met the following eligibility criteria participated in the larger study: age 36 to 72 months, not enrolled in kindergarten, had attended the child-care center for at least one month, and had no chronic disability that prevented their participation in physical activity. Further, only one child per family was eligible to participate. Written informed consent was received from the directors at each child-care center and from a parent of the participating child. The Institutional Review Board at Cincinnati Children’s Hospital Medical Center approved the study protocol.

Measures

Dietary Intake

Data collection occurred on Tuesdays and Wednesdays, over 15 months between November 2009 and January 2011, to allow for data collection over all four seasons. On data collection days parents were asked to record all foods and beverages their child consumed from the time of pickup from the child-care center until the time of drop-off at the child-care center the following day, on a food record, which is a validated method¹⁹ of measuring dietary intake for this age group. On the food record parents indicated the time and type of meal (e.g., dinner or snack), brand names and quantity of foods consumed. Detailed instructions with pictures were provided to assist estimation of food quantities and recording of homemade recipes. Research staff reviewed the food records with parents when they were returned the following morning to clarify as necessary quantities consumed, type of preparation (e.g., fried or grilled meat), and potential omissions (e.g., cereal recorded without milk).

The following inclusion criteria were utilized for this secondary analysis: parents completed a food record; child attended the child-care center for a full day (≥ 5 hours) on the study day; and the child was picked up from the center after 3:30 pm and after afternoon snack was served. Although two centers also offered dinner for families working non-standard hours, children consuming dinner at the child-care center (n=12) were not included in this analysis. Dietary intake away from the child-care center was defined as all foods and beverages reported from the time of pickup from the child-care center to child’s bedtime, to standardize the consumption timeframe.

Dietary intake data were analyzed with Nutrition Data System for Research (NDS-R) software (versions 2009, 2010, 2011, Nutrition Coordinating Center, University of Minnesota, Minneapolis, MN) to compute energy intake and servings of whole fruits, whole vegetables, white milk, 100% juice, sugar-sweetened beverages including sweetened milk, and sweet and salty snack foods. Foods were entered as written on the dietary record. For sweet and salty snack foods, we included NDS-R codes for fruit-based savory snacks; vegetable-based savory snacks; all crackers; all cakes, cookies, pies, pastries, Danish, doughnuts, and cobblers; all snack bars; all snack chips; all popcorn; meat-based savory snacks; nuts and seeds; yogurt nondairy; frozen dairy and non-dairy dessert; all puddings; chocolate and non-chocolate candy; and miscellaneous desserts. Fried fruits and vegetables and fruit and vegetable juices were not counted toward servings of whole fruits and whole vegetables.

Dietary intake away from the center was evaluated relative to the Academy’s recommended 1/2–2/3 proportion of intake¹⁷ using the Dietary Guidelines for Americans,¹⁸ which recommends preschool-aged children consume approximately 1300 kilocalories (kcal) a day for a healthy growth, ^18,18,18 and that energy should come from a balanced diet across food groups (grains, fruits, vegetables, milk, meats and beans). Thus, energy intake away from the child-care center is expected to be one third to one half (433–650 kcal) of total energy intake. The dietary guidelines for foods groups were operationalized through the United States Department of Agriculture’s My Plate.²⁰ Similarly, using the Academy’s recommendations, target intakes away from the child-care center should be approximately 1–1.5 servings of fruits, 1–1.5 servings of vegetables and 2/3 to 1 serving of milk each day for a child attending full-time child care.

Anthropometrics

The participants’ weight and height were measured at the child-care center in triplicate by trained research staff using a portable scale and stadiometer. BMI (kg/m²) was compared to the Centers for Disease Control and Prevention’s 2000 growth reference for calculation of age-specific percentiles and z-scores.^21,22 Children were classified as overweight/obese if their sex-specific BMI-for-age was at or above the 85^th percentile.

Demographics

Parents completed a demographic questionnaire that included questions about child age, sex, race, ethnicity, and eligibility status for free/reduced-price lunch in the CACFP. To assess time elapsed between pick-up and child’s bed time, research staff recorded the time of the child’s pick-up from the center and the parents recorded the child’s bedtime that night.

Statistical Analyses

Data were initially checked for distribution and outlying values. To account for the clustered study design within child-care centers, all analyses were performed using generalized linear mixed models and included center as a random effect. Demographic and dietary intake data were reported as least square means with associated standard error and frequencies for continuous and categorical measures, respectively. To determine if CACFP-eligibility, a proxy for low-income status, was associated with consumption of specific food groups, the relationships between servings of each food group (whole fruits, whole vegetables, white milk, sugar-sweetened beverages, 100% juice, and sweet and salty snack foods) as the dependent variable and CACFP-eligibility, the independent variable, were examined using bivariate analyses. Next, significant contributors to energy intake away from the child-care center were identified using a multivariable generalized linear model. Independent contributors of interest were food groups (whole fruits, whole vegetables, white milk, sugar-sweetened beverages, 100% juice, and sweet and salty snack foods) and CACFP-eligibility. Time elapsed between pick-up and child’s bed time, child age, race, and child sex were included in the models to adjust for potential confounding. Last, the relationship between the binary dependent variable, child overweight/obesity status, and the independent variables, energy intake away from the child-care center and CACFP-eligibility, was examined with a generalized linear model with a logit link function. All analyses were conducted using SAS®, version 9.3(SAS Institute Cary, NC). An alpha level of <0.05 was considered statistically significant.

RESULTS

Child Demographics and Anthropometrics

Of the 447 children enrolled for the larger study, 339 met criteria for inclusion in this secondary analysis. The sample was diverse based on child and household demographics (Table 1). The majority (69.6%) of children were of healthy weight (BMI-for-age ≥5^th, but <85^th percentile), about quarter (25.6%) of children were overweight or obese (BMI-for-age ≥85^th percentile) and 4.7% underweight (BMI-for-age <5^th percentile).

Table 1.

Demographic, Anthropometric and Household Characteristics^a of Preschool Children from 30 Child-care Centers in Hamilton County, Ohio

	LSMb ± SEc or n (%)
Child Demographics
Age, years (n = 339)	4.4 ± 0.1
Sex (n = 339)
Female	171 (50)
Race (n = 337)
White	147 (44)
Black or African American	135 (40)
Otherd	55 (16)
Ethnicity (n = 335)
Hispanic or Latino	12 (4)
Child Anthropometrics
BMIe percentile (n = 324)	63.8 ± 1.7
BMIe z-score (n = 324)	0.48 ± 0.06
Household Characteristics
Education Level of Parentf (n = 335)
≤High School/GEDg	58 (17)
Some College/Associate’s, Technical, or Trade degree	136 (41)
Graduated College	79 (24)
Advanced Degree	62 (18)
Adults in household (n = 333)
Two adult household	180 (54)
Single adult household	153 (46)
Family Income (n = 319)
Less than $25,000	116 (36)
$25,000 to $50,000	75 (24)
$50,000 to $75,000	29 (9)
$75,000 to $100,000	23 (7)
$100,000 to $150,000	38 (12)
Greater than $150,000	38 (12)
CACFPh Eligibility (n = 334)
Eligible	186 (56)

^aThe numbers in the parentheses next to the variable name reflect the denominator in the response rate for each demographic characteristic. Response rates for each item differ due to missing responses on the parent demographic questionnaire.

^bLSM, least square means

^cSE, standard error

^dOther includes Asian, American Indian or Alaskan Native, Native Hawaiian or other Pacific Islander, other, unknown, or more than one race.

^eBMI, body mass index

^fThe education level represents that of the parent who completed the demographic questionnaire.

^gGED, general education development

^hCACFP, Child and Adult Care Food Program

Dietary Intake

The mean energy intake while away from the child-care center was 685 ± 17 kcal (Table 2). Half of the children (51%) consumed more than the upper limit of the recommended target range for energy (433–650 kcal) away from the child-care center; these 174 children consumed 908 ± 23 kcal away from the center after attending a full day of child care. Some children (30.4%) met the recommended range and consumed 532 ± 6 kcal, while 18.3% of children consumed less than the recommended range, with an intake of 310 ± 12 kcal away from the child-care center. Few children consumed the recommended servings of whole fruit (16.3%), whole vegetables (15.2%) and white milk (9.0%) away from the child-care center; on average children consumed a third to a half of recommended targets for servings of whole fruit, whole vegetables, and white milk when away from the child-care center (Table 2). Of the 138 children (41% of sample) who consumed milk after leaving school and before bedtime, the majority (63%) consumed reduced-fat (2%) milk, 22% consumed low-fat (1%) or fat-free milk, 14.5% consumed whole milk, and <1% consumed more than one type of milk. Additionally, children consumed means of 0.3 ± 0.04 servings of 100% juice, 0.4 ± 0.04 servings of sugar-sweetened beverages and 0.9 ± 0.06 servings of snack foods while away from the child-care center.

Table 2.

Daily Dietary Recommendations^a for Preschool Children Compared to Actual Intake Away from the Child-care Center

	Daily dietary intake recommendationsa (2–4 year-olds)	Recommended intake away from the child- care centerb	Actual intake away from the child-care center (LSMc ± SEd) n=339
Energy (kcals)	1300	433 – 650	685 ± 17
Fruits
cups	1.25 cups	0.4 cups – 0.62 cups	--
servings	≈2.5 servings	≈1–1.5 servings	0.6 ± 0.1 servingse
Vegetables
cups	1.5 cups	0.5 cups – 0.75 cups	--
servings	≈3 servings	≈1–1.5 servings	0.6 ± 0.04 servingf
Milk
cups	2 cups	0.67 cups – 1 cup	--
servings	≈2 servings	≈0.67–1 serving	0.4 ± 0.04 servingsg

^aDaily dietary recommendations are based on the 2010 US Dietary Guidelines for Americans.¹⁹

^bRecommended intake away from the child-care center was based on the Academy’s recommendations given to child-care centers for children receiving fulltime care. These recommendations state child care centers with full-time care provide 1/2–2/3 of children’s daily energy and nutrient requirements.¹⁷ Based off this recommendation, the recommended intake at home is 1/3-1/2 of children’s daily energy and nutrient requirements.

^cLSM, least square means

^dSE, standard error

^eOne fruit serving = ½ cup fresh or frozen, 1 medium piece, or ¼ cup dried

^fOne vegetable serving = ½ cup fresh or frozen, 1 cup leafy greens, or ¼ cup dried

^gOne milk serving = 1 cup fluid or dry, ½ cup evaporated

Bivariate analyses showed low-income status (CACFP eligibility) was significantly associated with higher consumption of only one food group, servings of sugar-sweetened beverages. Low income children eligible for CACFP consumed on average one quarter of a serving more of sugar-sweetened beverages than those who were ineligible (β = 0.24 ± 0.06, p = 0.0002). In a multivariable generalized linear model controlling for time elapsed between pickup and bed time, child age, child sex and child race, significant contributors to energy intake away from the child-care center were: servings of whole fruits, whole vegetables, white milk, sugar-sweetened beverages, 100% juice, and sweet and salty snack foods (Table 3). Based on the greatest contributors to energy intake away from the center, the multivariate model in Table 3 shows that a one serving increase in sugar-sweetened beverages contributed 141 kcal, sweet and salty snack foods contributed 137 kcal, and white milk contributed 126 kcal to the energy intake away from the center. CACFP-eligibility was not significantly associated with energy intake away from the center.

Table 3.

Contributors to Energy Intake (kcals) Away from the Child-care Center among Preschool Children from 30 Full-Day Child-care Centers in Hamilton County, Ohio^a

Independent Variable	β	SE	p-value
CACFP eligibility (not eligible)	0.5	27	0.99
Time elapsed from pick-up to bed time, hours	27	11	0.01
Age, years	38	18	0.04
Sex (female)	−52	24	0.03
Race (white)	19	18	0.29
Fruit, servings	48	13	0.0003
Vegetable, servings	95	16	<0.0001
Milk, servings	126	23	<0.0001
100% juice, servings	84	16	<0.0001
Sugar-sweetened beverage, servings	141	22	<0.0001
Sweet and salty snack food, servings	137	11	<0.0001

^aMultivariable generalized linear model includes all variables listed and child-care center included as a random effect. Confounding variables in the model include: time elapsed from pick-up to bed time, age, and sex.

^bβ, The beta coefficient is derived from the multivariable generalized linear regression model. The model predicted kilocalories (dependent variable), and a 1 unit increase in an independent variable was associated with an increase (or decrease) in the number of kilocalories represented by the beta coefficient. For example, each increased serving of sugar-sweetened beverages was associated with an average increase of 141 kilocalories.

^cSE, standard error

^dCACFP, Child and Adult Care Food Program

Child overweight/obesity status was significantly (p = 0.02) associated with energy intake away from the child-care center, but not with CACFP-eligibility (p=0.99). For a 200 kcal increase per day away from the child-care center, the odds of being overweight/obese increased by 20% (OR: 1.20, 95% CI 1.02, 1.41).

DISCUSSION

This study indicates that children who attend full-time child care may be consuming more energy than recommended when they leave child care, but less than recommended servings of whole fruits, whole vegetables, and white milk relative to the Academy’s recommended proportion of intake based on the Dietary Guidelines.

Half of the children consumed more than 900 kilocalories away from the child-care center, in addition to the calories consumed at the child-care center. If children consumed the expected 1/2–2/3 proportion of daily intake at child care, their intake may be above the daily recommended 1300 kcal for healthy growth. In spite of higher energy intake, children consumed low quantities of fruits, vegetables, and white milk away from the child-care center, which is consistent with previous findings.^23–25

While it has been hypothesized low-income status may reduce accessibility of healthier foods, and therefore consumption,^26,27 in this study there was no difference in fruit and vegetable intake away from the child-care center between children who were eligible versus ineligible for CACFP. CACFP-eligibility was however associated with higher sugar-sweetened beverage consumption away from the child-care center. These findings are in congruence with a study by Watowicz and colleagues²⁸ in which children 2 to 4 years-old from high income families consumed significantly less sugar-sweetened soda than children who participated in Special Supplemental Nutrition Program for Women, Infants, and Children participants (WIC) and lower-income non-WIC participants. Altogether, these findings suggest low-income status is most strongly associated with intake of energy-dense, nutrient-poor beverages (e.g., sugar-sweetened beverages), but not foods (e.g., snack foods, fruits, vegetables).

While it was expected that increased servings from all food groups would be associated with greater energy intake, understanding which food groups were the greatest contributors to intake away from the child-care center may help identify the most important food groups to target for obesity prevention in the environment outside the child-care center. Energy dense foods such as sweet and salty snack foods, sugar-sweetened beverages, and white milk had the greatest relative contribution to energy intake away from the center. As expected, white milk consumption was a significant contributor to energy intake. This finding is consistent with results from the 2003–2006 National Health and Nutrition Examination Survey where milk was found to be the greatest contributor to energy and nutrient intake in this age group.²⁹ While the consumption of adequate white milk is important for child growth,¹⁸ low-fat milk provides the necessary nutrients for child growth without the excess energy.

The significant association between energy intake while away from the child-care center and overweight/obesity status suggests that differences in weight status among children attending child care may be influenced by differences in what these children are consuming away from the child-care center.^8,9 Interestingly, despite a literature to support the significant association between overweight/obesity and low socio-economic status,^4,5 CACFP-eligibility was not associated with child BMI z-score (p = 0.27) or overweight/obesity status in this study (p = 0.99). Thus, results indicate a link between energy intake away from the child-care center and child overweight/obesity status, independent of socio-economic status.

Strengths of the study include a large, racially and socio-economically diverse sample. This is also one of few studies that has examined dietary intake away from the child-care center among children attending full day child care. Limitations of this study include the cross-sectional nature and use of a parent-reported dietary intake measure.³⁰ Since researchers did not collect dietary intake data for all study participants while in the child-care center, it was not possible to examine the relationship between the energy intake at home and the energy consumed at child care and it was assumed children were consuming one third to one half their needs at child-care. Menus were not reviewed for compliance to CACFP guidelines. Further, dietary data only included a one-day dietary record, limiting a more complete representation of an individual child’s usual diet. As data collection involved a random sample of centers within a single county in Ohio, findings may not be generalizable to other populations. Also, energy consumed from each food group could not be determined because the NDS-R software used does not provide energy intake from individual foods that make up combination foods such as a cheeseburger.

This study has potential research implications. First, this study should be repeated with dietary intake and daily physical activity measured over an entire day. Second, it would be informative to collect data on the settings where meals occur (restaurant, other home, child’s home) away from the child-care center.

This study’s findings also lend support to recently proposed changes to CACFP.³¹ These changes call for a greater variety of vegetables and fruits and less sugar and fat to be served in child-care settings to help curb the obesity epidemic; a specific proposed change is that grain-based desserts can no longer be credited for the grain component requirement of the program. As snack foods were a significant source of energy intake away from centers for children in this study, and children consumed more than recommended energy combined with less than recommended fruits and vegetables away from child-care centers, this study suggests the proposed changes are warranted to help children meet the daily dietary recommendation.

CONCLUSION

While the majority of children in this study reported consuming more than the recommended energy away from the child-care center, and less than recommended servings of whole fruits, whole vegetables and white milk, future research should assess the total dietary intake of preschool-aged children to better understand intake away from the center in the context of dietary intake at the center. In the study population low-income status was associated with higher consumption of sugar-sweetened beverages. Overweight/obesity status was not associated with income status, but overweight/obesity was associated with greater energy intake away from the child-care center. Children consumed more calories than recommended after a full day in child care and these extra calories appear to come from energy-dense, nutrient-poor foods, namely sweet and salty snack foods and sugar-sweetened beverages. While child-care centers are positioned to play a role in obesity prevention, interventions that engage parents and target dietary intake away from the child-care center may be needed to successfully prevent obesity in preschool children.