The preschool years are a critical period for obesity prevention, as both eating habits and growth trajectories are established during this time.
Data supports that children who become overweight/obese in early childhood have a five-fold increase of being overweight/obese adults¹.
A key environment for obesity prevention efforts is the child-care center. 61% of preschool age children (3 to 6 years)² are in child-care, where they spend an average of 33 hours per week³ and consume up to two-thirds of their daily caloric intake⁴.

Best practices for child-care mealtime environments that support obesity prevention are outlined by the Nutrition and Physical Activity Self-Assessment for Child Care program (NAP SACC)5. These best practices, listed below, were derived from experimental studies and expert opinion. Few studies prior to ours examined the use of these practices in real-world settings.

Study Design

We sought to describe adherence to child-care mealtime best practices and to evaluate the association between practices and children’s dietary intake. As such, we randomly chose 30 child-care centers in Hamilton County, Ohio to participate in an observational study of physical activity and nutrition environments in child care – the Preschool Eating and Activity Study (PEAS)6. Data collection occurred between November 2009 and January 2011. Eligible children were 36 to 72 months old. Two classrooms at each center were randomly chosen. Three observers were stationed in each classroom concurrently: two observers recorded the intake of three separate children during lunch while one observer recorded mealtime practices and teacher behaviors. General mixed linear models with child-care center as a random effect were used to evaluate the association between mealtime behaviors and children’s dietary intake.

Adherence with Mealtime Best Practices

We found variable adherence with individual mealtime best practice recommendations. Table 1 shows the frequency with which each best practice was observed in our study.

Dietary Outcomes Associated with Best Practices

Children consumed an average of 349 kcal, 0.4 servings of vegetables, and 0.5 servings of fruit at observed lunches.

• Energy (total caloric) consumption:
  Staff sitting with children at lunch was associated with lower energy consumption (313 kcal vs. 368 kcal, p=0.04). Staff eating some of the same foods was associated with higher energy consumption (375 kcal vs. 309 kcal, p=0.008).
• Fruit consumption:
  The best practice of staff encouraging children to try a new or less favorite food resulted in a mixed effect on fruit intake. Encouragement once led to a non-statistical increase in fruit consumption (0.5 to 0.7 servings). Repeat encouragement was associated with significantly lower fruit intake (0.7 to 0.4 servings; p trend = 0.008).
• Vegetable consumption:
  Two mealtime best practices were associated with increased vegetable consumption: staff sitting with children at lunch (0.5 servings vs. 0.3 servings, p = 0.03) and staff eating some of the same foods (0.4 servings vs. 0.3 servings, p = 0.04). Family style meal service and staff talking about healthy eating were not significantly associated with fruit, vegetable, or total energy intake.

Implications

Our study was the first direct observation of child-care mealtime environments and children’s associated dietary intake in the United States. We demonstrated that adherence with individual mealtime best practices varies considerably and that few guidelines are associated with actual dietary outcomes. Given the large amount of time many children spend in child-care, targeting these facilities as areas for prevention efforts is key. Further research is needed in order to identify modifiable practices and behaviors that lead to positive dietary outcomes for children. This research is essential to improving child-care mealtime environments and helping shift the course of the childhood obesity epidemic.