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Review ArticleExamining the Obesogenic Attributes of the Family Child CareHome Environment: A Literature Review

Lucine Francis ,1 Lara Shodeinde,1 Maureen M. Black,2,3 and Jerilyn Allen1,4,5

1Department of Acute and Chronic Care, Johns Hopkins University School of Nursing, Baltimore, MD 21205, USA2Division of Growth and Nutrition, Department of Pediatrics, University of Maryland School of Medicine, Baltimore,MD 21201, USA3RTI International, Research Triangle Park, NC 27709, USA4Division of Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA5Department of Health, Behavior, and Society, Johns Hopkins School of Public Health, Baltimore, MD 21205, USA

Correspondence should be addressed to Lucine Francis; [email protected]

Received 4 November 2017; Revised 3 April 2018; Accepted 19 April 2018; Published 10 June 2018

Academic Editor: Sharon Herring

Copyright © 2018 Lucine Francis et al.,is is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Childhood obesity is a major public health concern in the US. More than a third of young children 2–5 years old are placed innonrelative child care for the majority of the day, making the child care setting an important venue to spearhead obesityprevention. Much of the obesity research in child care has focused on center-based facilities, with emerging research on FamilyChild Care Homes (FCCHs)—child care operated in a home setting outside the child’s home. ,e purpose of this review was toassess the obesogenic attributes of the FCCH environment. A search of the PubMed, Embase, CINHAL, and PsycINFO electronicdatabases identified 3,281 citations; 35 eligible for full-text review, and 18 articles from 17 studies in the analysis.,is review founda lack of comprehensive written nutrition and physical activity policies within FCCHs, lack of FCCH providers trained innutrition and physical activity best practices, lack of adequate equipment and space for indoor and outdoor playtime activities inFCCHs, inaccurate nutrition-related beliefs and perceptions among FCCH providers, poor nutrition-related communication withfamilies, and poor feeding practices. Future research focusing on interventions aimed at addressing these problem areas cancontribute to obesity prevention.

1. Introduction

Although young children 2–5 years of age in the UnitedStates (US) have experienced a decline in obesity, from13.9% in 2004 to 8.4% in 2012, the prevalence of overweightor obesity continues to be alarmingly high, with 22.8% ofyoung children classified as overweight or obese [1]. Youngchildren from low-income and ethnic minority families areevenmore likely to be obese, compared to nonpoor and non-Hispanic White children [1, 2]. A total of 16.7% of Hispanicand 11.3% non-Hispanic Blacks are obese, compared to 3.5%non-Hispanic White and 3.4% Asian 2–5-year-olds. In 2014,data from the Centers for Disease Control and Preventionshowed that 14.5% of low-income 2- to 4-year-olds whoparticipated in the Special Supplemental Nutrition Programfor Women, Infants, and Children (WIC) were obese [2].

Obesity among young children increases the likelihood ofdeveloping high blood pressure, [3] glucose intolerance [4],and poor sleep [5], all of which influence the risk for heartdisease. Additionally, high hospital expenses related tocomplications of elevated body mass index (BMI) in youngchildren have contributed to increasing financial burdens [6].

Much attention has been given to energy balance-relatedcauses of obesity that are amenable to effective preventioninterventions [7]. To effect change in reducing childhoodobesity, a greater understanding of the environment in whichchildren spend the majority of their time is imperative.

Parents of young children aged 2–5 years rely on earlychild care on a regular basis [8]. Although most childrenare placed in center-based child care or are cared for byrelatives, nearly 2 million young children in the US areplaced in Family Child Care Homes (FCCH)s, which

HindawiJournal of ObesityVolume 2018, Article ID 3490651, 20 pageshttps://doi.org/10.1155/2018/3490651

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https://doi.org/10.1155/2018/3490651

provide nonrelative care in a home setting outside the child’shome [8]. Children in child care settings eat 2-3 meals in-cluding beverages each day and have opportunities forphysical activity. Young children in FCCHs are at increasedrisk for becoming overweight or obese, compared to childrenplaced in center-based facilities; however, little is knownabout how the FCCH environment relates to childhoodoverweight or obesity [9–11]. Although most research relatedto child care and obesity has concentrated on center-basedchild care, research on the obesogenic attributes of the FCCHenvironment is emerging. We identified no reviews that havesynthesized the literature on the FCCH environment. ,epurpose of this review was to examine the attributes of theobesogenic environment of US-based FCCHs.

2. Methods

2.1. Search Strategy and Eligibility Criteria. We searched thefollowing electronic databases for relevant articles publishedin English between 2006 and 2016: MEDLINE via PubMed,EMBASE via Elsevier, CINAHL via EBSCOhost, and Psy-cINFO via EBSCOhost. To identify candidate studies forreview, we used the keywords and controlled vocabularyterms in the following concept groups: (child care OR familychild care homes OR day care OR home-based day care ORchild care centers) AND (obesity OR overweight). ,ecomplete search strategy can be found in the online resourcefor this manuscript. We chose to review articles since 2006coinciding with a landmark commentary on the role of childcare settings in obesity prevention, highlighting the need tofocus on FCCHs [12]. ,e final search for each database wasconducted on August 8, 2016.

Studies were eligible for inclusion if they were US-based,child care studies in peer-reviewed journals that included anenvironmental assessment of FCCHs, and focused onFCCHs that cared for children aged 2–5 years. Nonpilotintervention studies that provided results for the assess-ment of the environment preintervention and studies thatcompared the environments of FCCHs and other types ofnonrelative child care settings, including center-based fa-cilities, were also included. ,e environmental assessmentcould have been conducted through various methods; forexample, through observations, surveys, interviews, or focusgroups. We excluded studies that focused on parental homesettings. All search terms regarding the type of child carewere used because FCCHs are described in many differentways (e.g., child care homes and home-based daycare). Wealso aimed to resolve any confusion of child care terms suchas preschools operating out of homes. Finally, we includedstudies that compared FCCHs to other types of nonrelativechild care settings.

2.2. Screening Process. ,e screening process occurred intwo waves. In the first wave, titles, abstracts, and occasionalfull-text were screened to determine eligibility regardingUS-based nonrelative child care studies in which the envi-ronment was assessed for children 2–5 years of age. In thesecond wave, titles and abstracts identified for inclusion

from the first wave were further screened to identify studiesthat included FCCHs and assessed the environment of theFCCH setting. ,ese studies included nonpilot interventionstudies that provided results for the assessment of the FCCHenvironment preintervention and studies that compared theenvironments of FCCHs to other types of nonrelative childcare settings. LF and LS independently screened the titles,abstracts, and occasional full-text. Any discordant reviewsconcerning eligibility were discussed and resolved. Articlesidentified from the second wave of screening were eligiblefor full-text review.

2.3. Data Abstraction. Articles identified for full-text reviewwere examined for eligibility for inclusion in this review.Data from full-text articles eligible for inclusion were ab-stracted and included information on authorship, year ofpublication, the location of study, and FCCH provider leveland child level demographic information (i.e., sample size,race/ethnicity, level of education, age, and BMI). Addi-tionally, we abstracted information on the status of FCCHsbased on their participation in the Child and Adult CareFood Program (CACFP), a subsidy program operatedthrough the US Department of Agriculture (USDA), whichprovides reimbursements to eligible providers for the pur-chase of nutritious foods. Finally, we recorded the assess-ment findings of the FCCH environment. LF and LSexamined the full-text articles for eligibility, abstracted thedata, and reviewed each others’ abstraction for any missingor incorrect information. We used Microsoft Excel forscreening titles and abstracts and for abstraction of data.Full-text articles were read in portable document formats.

2.4. Classification of Studies. ,e articles included in thereview were further classified using the EnvironmentalResearch framework for weight gain prevention (EnRG), aninnovative framework grounded in behavior change-ecological theory [13]. EnRG consists of 2 frameworks.,e first is the ANGELO-ANalysis Grid for EnvironmentsLinked to Obesity-framework, which we used to classify theobesogenic attributes within the physical (what’s available inand outside the FCCH, including education and trainingopportunities), sociocultural (i.e., culture around feedingpractices, mealtime environment), and policy (child carepolicies to ensure best practices and to prevent obesity in theFCCH) environment [14]. ,e second is the ,eory ofPlanned Behavior (TPB), which we used to classify articlesthat assessed the environment related to FCCH providerattitudes, beliefs, and perceptions [15]. ,ese articles wereorganized by matching the terms and definitions used in thearticles to the TPB concepts; Attitudes (behavioral beliefsabout consequences or expected outcomes), Subjective Norm(normative beliefs or perception of beliefs held by mostFCCH providers), Perceived Behavioral Control (perceivedlevel of control to engage in best practices or perceivedfactors that may serve as enablers or barriers to engaging inbest practices), and Behavioral Intent (strategies that are putin place to ensure that providers provide quality environ-ments for the children in their care) regarding energy

2 Journal of Obesity

balance-related behaviors (EBRBs). Since knowledge isclosely aligned to perceived control, provider knowledge wasalso classified under TPB. Demographic factors that werehighlighted in the articles and included in the data analyses(i.e., neighborhood, FCCH/facility level, provider, and childlevel information) were classified as potential moderators.EBRBs refer to any activity that may influence children’sweight in an FCCH setting. ,ese four categories (envi-ronment, TPB concepts, potential demographic moderators,and EBRBs), which represent major components of the EnRGframework, were chosen to organize the study findings. Usingthis framework to help identify obesogenic attributes of theFCCH environment and EBRBs can potentially serve asa model to help guide child care researchers on how to de-velop tailored interventions unique to the FCCH setting.

3. Results

3.1. Results of Search. ,e summary of the search andscreening results is shown in a flow diagram in Figure 1. Atotal of 3,281 records were identified from the four databasessearched: 687 duplicate records were removed, and the titles

of the remaining 2,594 records were screened in wave 1 foreligibility. A total of 103 records identified through wave 1were screened for further eligibility, and 35 studies wereidentified for full-text review. Seventeen articles were ex-cluded, and 18 articles were included in the review, reportingresults from 17 studies.

3.2. Study Population. ,e results abstracted from thestudies are summarized in Tables 1 and 2. Table 1 displaysthe policy, physical, and sociocultural FCCH environmentassessment results. Table 2 displays the results from studiesthat assessed the FCCH environment related to providers’attitudes, beliefs, and perceptions. Per eligibility criteria, allarticles included in this review involved FCCHs and assessedthe environment [16–33]. ,ere were eleven cross-sectionalstudies [16, 17, 19, 20, 22, 23, 25, 26, 29–32], one obser-vational study [27], one study used accelerometers [21], andfour studies used qualitative methods [18, 24, 28, 33]. Eightstudies focused solely on FCCHs or FCCH providers,meaning these studies did not include other types of childcare facilities [16, 18, 21, 24, 27–30]. Five studies examinedboth the nutrition and physical activity environment

Full-text articles excluded, withreasons (n = 17):

PA or nutrition environment notassessed (8); FCCH included but

not assessed separate from center-based assessment (1);

intervention study but no baselineassessment (1); not journal

articles, i.e., abstracts, dissertation,and poster (3); studies based on

infants (2); non-US basedstudy (1); not published within

time frame (1)

Articles included in review(n = 18 articles; 17 studies)

Records screened(n = 103) again(title, abstracts,

occasional full text toidentify studies thatincluded FCCHs)

Records excluded(n = 2,485):

non-US basedstudies, non-child caresettings (i.e., parental

home settings),school-aged children,

no assessment of environment,

intervention studieswithout baselineassessment data

Records a�er duplicatesremoved(n = 687)

Records identifiedthrough database

searching(n = 3,281)

Records screened(title, abstracts,

occasional full-text forclarity on existence of

baseline data forintervention studies)

(n = 2,594)Records excluded

(n = 68):FCCH setting not

included, no assessmentof FCCH environment,studies related only to

infants

Articles eligible for full-text review

(n = 35)

Iden

tifica

tion

Scre

enin

g(p

art I

)Sc

reen

ing

(par

t II)

Elig

ibili

tyIn

clude

d

Figure 1: Preferred reporting items for systematic and meta-analyses diagram depicting the flow of records.

Journal of Obesity 3

TA

BL

E1:

,epo

licy,

physical,and

socioculturale

nviron

mento

ffam

ilychild

care

homes.

Cita

tion/year/

state/metho

dSampledescription

Datasource/

measures

Policyenvironm

ent

Physical

environm

ent

Sociocultural

environm

ent

EBRB

sCovariatesin

analyses

(potentia

ldem

ograph

icmod

erators)

Nutritio

n

Freedm

anand

Alvarez

[17],Jou

rnal

oftheAmerican

Dietetic

Associatio

n/2010/CA/

Pre-po

sttest;cross-

sectionala

nalysesof

pre-test

phase

N�54%

(39)

FCCHs;

46%

center-based

a Provider

Race/ethnicity:7

6%of

FCCHsHisp

anic

Age:18years+

Mod

ified

SCFQ

andHCFS

Q

FCCH>Ce

nters

cook

ingfood

schild

renlik

ed(63versus

39%,n

s)allowed

child

rento

eatless

than

they

thinkthey

shou

ld(47versus

29%,n

s)Ra

rely/never

allowed

child

ren

toeatm

orethan

they

thou

ght

they

shou

ld(55versus

27%,n

s)

Ethn

icity

Hisp

anics

less

likelyto

eatm

eals

with

child

ren(diff:0

.24,

χ2�3.04;p<0.05);

morelik

elyto

force

child

rento

eatw

hatis

“goo

dforthem

”(χ

2�7.25

,p<0.05).

3xmorelik

elyto

cook

food

stheykn

ewchild

ren

liked

(χ2

�1.96

,p<0.001)

50%

insis

tedchild

ren

finish

food

before

leaving

thetable

Liuet

al.[19],

Materna

land

Child

Health

Journa

l/2016/OH/

cross-sectionalsurvey

N�185child

care

setting

s;44%FC

CHs;56%

centers

Mod

ified

NAPS

ACC

andEP

AO

FCCH

s<Ce

ntersre

policies

Beverages

only

milk

,water,a

nd100%

fruit

juiceserved;(47

versus

77%,

p�0.001)

<6oz

of100%

fruitjuice/day

served

to≥a

ge12

mon

ths(22

versus

43%,p

�0.003)

skim

,1or

2%milk

served>a

ge2

years(28versus

50%,p

�0.003)

Noeatin

g/drinking

outsidefood

s(12versus

31%,p

�0.003)

Useoffood

aspu

nishment/rew

ard

cann

otwith

hold/delay

food

/drink

sas

punishment;(44

versus

83%,p

�0.001)

cann

otgive

food

/drink

sas

arewardor

anincentive(30

versus

48%,p

�0.01)

Authoritarian/controlling

feeding

interactions

Noforcingchild

rento

eatcertain

food

sor

quantities;(33versus

55%,p

�0.004)

allowingchild

rento

decide

how

muchto

eat(25

versus

38%,

p�0.05)

Encouraged

(not

forced)to

eat/taste

food

(30versus

45%,

p�0.03)

FCCH

s>Ce

nters

teachabou

tfoo

d≥1

x/mos.(44

versus

27%,p

�0.01)

FCCH

s<Ce

nters

noto

ffering

fried

food

s(38%

versus

59%,p

�0.001)


Tabl

e1:

Con

tinued.

Cita

tion/year/

state/metho

dSampledescription

Datasource/

measures

Policyenvironm

ent

Physical

environm

ent

Sociocultural

environm

ent

EBRB

sCovariatesin

analyses

(potentia

ldem

ograph

icmod

erators)

Natalee

tal.[20],Early

Child

hood

Education

Journa

l/2014/FL

/cross-sectionalsurvey

ofbaselin

edata

N�298FC

CHs;842

center-based

Provider/hom

eb,c SES

:Facilities’zip

code

�18.1%>40%

ofho

useholdincome<2

5KChildren

Race/ethnicity

Enrollm

ent

8.3%

FCCHs

predom

inantly

black

45.8%

FCCHs

predom

inantly

Hisp

anic

Mod

ified

HSF

FQ

FCCH

s>Ce

nters

provided

morelessons

with

abasis

inhealth

andnu

trition

/week

(p�0.036)

FCCH

s<Ce

nters

provided

1%milk

>1x/day(45.2versus

55%,p

�0.015)

FCCH

s>Ce

nters

provided

morefresh

fruit(

p�0.001),

limitedservings

ofrolls/bread

(28.1

versus

18.6%,

p�0.001)

Incomezone

offacility

Adjustin

gforincome

zone:

(nsassociations

between

facilitytype

andallo

ther

nutrition

al/dietary

outcom

es(p>0.05)

Ritchieet

al.[22],

Child

hood

Obesity/2012/M

ulti-

state/cross-sectional

survey

N�65

Headstart

centers;68

preschoo

ls;104CACFP

centers;88

non-CACFP

centers;65

CACFP

FCCHs;38

non-

CACFP

FCCHs

Adapted

NAPS

ACC

FCCH

s<state

preschools,

centers

Useddietitian

inmenuplanning

(0%

versus

19.1%,4

.2%,

p<0.001)

CACFP

status

CACF

Pan

dno

n-CA

CFP

FCCH

s>Ce

nters

served

who

lemilk

(p<0.001).

non-CA

CFP

FCCH

s>CA

CFPFC

CHs

served

cand

ydaybefore

survey

(15.8%

versus

6.2,

p<0.001)

served

sweeteneddrinks

daybefore

thesurvey

(18.4%

versus

7.7%

,p<0.001)

Ritchieet

al.[23],

Preventin

gCh

ronic

Dise

ase/2015/CA/


in2008

and2012

N�429child

care

sites

(2008);435

child

care

sites

(2012);65CACFP

homes;

38no

n-CACFP

homes

Adapted

NAPS

ACC

FCCH

s<Ce

nters

madewater

easily

availableto

child

ren

forself-service

indo

orsandou

tside

(44.8%

versus

73.1%,

p<0.001)

provided

tapwater

(p�0.01)

Tand

onet

al.[26],

Journa

lofN

utrition

Educationan

dBeha

vior/2012/FL

,MA,M

I,WA/cross-

sectionalsurveys

N�94

FCCHs;74

center-based

Provider

Levelo

fedu

catio

n:28%

HSgrad,21%

some

college,51%

2or

4year

college

NAPS

ACC

FCCHs+

Centers

�follo

wbest

practice

recommendatio

nsforservingwater

atleastdaily

+sugar

sweetenedbeverages

66%

FCCHsand

centerso

ffered100%

juice3-4tim

esweekly


Tabl

e1:

Con

tinued.

Cita

tion/year/

state/metho

dSampledescription

Datasource/

measures

Policyenvironm

ent

Physical

environm

ent

Sociocultural

environm

ent

EBRB

sCovariatesin

analyses

(potentia

ldem

ograph

icmod

erators)

Tovaret

al.[27],

Appetite/2016/RI/

Observatio

nalstudy

N�48

FCCHs;214

observed

mealsandsnack

times;2

27child

-provider

interactions

captured

Provider

Race/ethnicity:

75%

African-A

merican

19%

white

Gender:100%

female

Levelo

fedu

catio

n:57%HSor

associates,40%

Bachelors

BMI:

77%

obese

18%

overweigh

tChildren

BMI

67%

norm

alweigh

t13%

overweigh

t20%

obese

Mod

ified

EPAO

Onlyplated

mealsserved

Respo

nseto

verbalrefuseso

ffood

55%

best

feedingpractices

inrespon

seto

verbal

refuses

45%

coercive

controlling

practices

Respo

nseto

nonv

erba

lrefusesof

food

both

best

practices

andcoercive

controlling

practices

equally

Respo

nseto

verbal

andno

n-verbal

acceptan

ceof

food

reactedto

food

acceptance

with

autono

mysupp

ortiv

epractices>coercive

controlling

practices

(43

versus

5interactions)

Respo

nseforsecond

s85%

respon

dedwith

coercive

controlling

practices,esp.

during

lunch

pressuredchild

rento

clean

theirp

latesfi

rsttogetsecon

dsof

certainfood

ssomesim

ply

complied/off

ered

bribes

Being“alldo

ne”

respon

dedequally

with

coercive

andbest

practices

Pressuring

child

rento

eat

morefrequently

observed

Attem

ptsforpraise

orattentionfrequently

praised

fortrying

new

food

sand

eatin

gcertainfood

s

Troste

tal.[30],

American

Journa

lof

Preventiv

eMedicine/2011/K

S/cross-sectionalsurvey

N�297FC

CHs;85.3%

CACFP

participation

Provider

Levelo

fedu

catio

n:40.8%

HSdiplom

aor

GED

,42.9%

somecollege

orAssociate’s,

14.3%

Bachelor

degree

d NAPS

ACC

M(sd)

Nutritio

npo

licy2.41±0.5

Menus

andvariety

2.50±0.6

Nutritio

neducation

2.60±0.7

Food

sserved

Fruits

and

vegetables

3.20±0.4

Friedfood

sand

high

-fat

meats

3.10±0.3

Beverages2.90±0.5

Mealsandsnacks

3.70±0.3

Food

sou

tsideof

regularmealsand

snacks

2.00±0.7

Supp

ortin

ghealthy

eatin

g3.00±0.5


Tabl

e1:

Con

tinued.

Cita

tion/year/

state/metho

dSampledescription

Datasource/

measures

Policyenvironm

ent

Physical

environm

ent

Sociocultural

environm

ent

EBRB

sCovariatesin

analyses

(potentia

ldem

ograph

icmod

erators)

Troste

tal.[29],

American

Journa

lof

Preventiv

eMedicine/2009/K


N�297FC

CHs

NAPS

ACC

Writte

nguidelines

concerning

type

offood

sbrou

ghtfor

celebrations

18.6%

(95%

CI:13.7,

23.4)

comprehensiv

ewritte

npo

licyon

nutrition

andfood

services

53.7%

(95%

CI:47.6,5

9.7)

Received

nutrition

training≥1

x/yr

47.5%

(95%

CI:41.2,5

3.8)

offered

nutrition

educationforc

hildren

46.9%

(95%

CI:40.6,

53.2)

offered

nutrition

educationto

parents

45.3%

(95%

CI:39.1,

51.5)

Family-style

meals23%

(95%

CI:17.7,2

8.4)

Served

lean

meats

>4x/wk41.7%

(95%

CI:35.4,4

8)served

100%

fruit

juice>1

x/day55.8%

(95%

CI:49.6,6

2)Served

1%milk

13.9%

(95%

CI9.7,

18.1)

Infrequent

useof

healthyfood

sfor

celebrations

43.9%

(95%

CI:37.6,5

0.2)

Physical

activ

ity

Liuet

al.[19],

Materna

land

Child

Health

Journa

l/2016/OH/


N�44%

FCCHs;56%

centers

Mod

ified

NAPS

ACC

andEP

AO

FCCH

s>Ce

nters

preschoo

lers

engagedin

60min

ofadult-ledph

ysical

activ

ity/day

(33

versus

18%,

p�0.02)

requ

ired

training

onho

wto

helpchild

ren

beph

ysically

activ

e(78versus

56%,

p�0.002).

Natalee

tal.[20],Early

Child

hood

Education

Journa

l/2014/FL

/cross-sectionalsurvey

ofbaselin

edata

N�298FC

CHs;842

center-based

child

care

Provider/hom

eb,c SES

:Facilities’zip

code

�18.1%>40%

ofho

useholdincome<2

5KChildren

Race/ethnicity:

Enrollm

ent:

8.3%

FCCHs

predom

inantly

black

45.8%

FCCHs

predom

inantly

Hisp

anic

e PAFQ

FCCH

s<Ce

nters

provided

outsidePA

for30

min+/3x/wk.

(92.9%

versus

96.5%,p

�0.022)

ratedexcellent

inam

ount

oflim

iting

TV/video

(39.2%

,59.5

%,p<0.001)

FCCH

s>Ce

nters

repo

rted

high

erlevelsof

limiting

compu

tertim

e(63.9

versus

51.8%,

p�0.003)

Incomezone

ofFa

cility

Adjustin

gforincome

zone:sig.D

ifferences

remainedb/tindo

orph

ysicalactiv

ity,o

utdo

orph

ysical

activ

ity,and

televisio

n-usepractices

(p≤0.05)


Tabl

e1:

Con

tinued.

Cita

tion/year/

state/metho

dSampledescription

Datasource/

measures

Policyenvironm

ent

Physical

environm

ent

Sociocultural

environm

ent

EBRB

sCovariatesin

analyses

(potentia

ldem

ograph

icmod

erators)

Rice

andTrost[21],

Journa

lofN

utrition

Educationan

dBeha

vior/2014/

OR/

accelerometer

readings

N�47

FCCHs,114

child

ren(60bo

ys,5

4girls),70%

CACFP

Provider

Age:

2%less

than

30,4

4%30–3

9,54%

greaterthan

40Provider

race

90%

white,M

eanyrs.of

operation:

10(IQR5–15)

Levelo

fedu

catio

n66%

HSdiplom

aor

GED

,20%

somecollege

orassociatedegree,1

5%Ba

chelor’sdegree

Children

Avg.B

MI

16.8±202%

overweighto

robese:

29%

ActiGraph

GT1

Maccelerometer

Avg.participationin

MVPA

andtotalP

A5.8±3.2and10.4±

4.4min/h,

respectiv

ely

BMI

overweigh

tand

obese

4-5yr

olds<healthy

4-5yr

olds

MVPA

andTP

A(p<0.5)

Gen

der

Girls<bo

ysexhibited

MVPA

andTP

A(p<0.5)

Tand

onet

al.[26],

Journa

lofN

utrition

Educationan

dBeha

vior/2012/FL

,MA,M

I,WA/cross-

sectionalsurveys

N�94

FCCHs;74

center-based

Provider

Levelo

fedu

catio

n:28%

HSgrad,21%

some

college,51%

2or

4year

college

NAPS

ACC

FCCH

s<Ce

nters

varietyof

fixed-play

equipm

ent(76

versus

89%,

χ2�5.3,

p�0.02)

varietyof

portable

play

equipm

ent(86

versus

95%,

χ2�4.4,

p�0.04)

rarely

ornever

show

edTV

(29versus

68%

χ2�25

,p<0.001)

50%

ofpreschoo

lers

inFC

CHs<1

hr/day

outdoo

rplay

time


Tabl

e1:

Con

tinued.

Cita

tion/year/

state/metho

dSampledescription

Datasource/

measures

Policyenvironm

ent

Physical

environm

ent

Sociocultural

environm

ent

EBRB

sCovariatesin

analyses

(potentia

ldem

ograph

icmod

erators)

Tand

onet

al.[25],

Academic

Pediatric

s/2012/cross-

sectionala

nalyseson

long

itudinald

ata

N�Overall(1900);

Non

relativ

ein

Child’s

home(n

�150);

Non

relativ

ein

another

home(n

�550)

Provider

(non

relativ

ein

child

’shome,no

nrelative

inan

otherhome)

Race:

85%,8

2%white,6

%,1

3%Black,26%,14%

Hisp

anic

Levelo

feducation

34,3

7%HSor

less

35,4

5%somecollege

26,

14%

college

graduate

6,4%

graduate

degree

ECLS

-B

50%

ofho

me-based

providerstake

the

child

outsidetowalk

orplay≥1

x/day

Non

relativ

esin

home-

based>relativ

esin

homes

Increasedod

dsof

goingou

tsidedaily

forchildren(O

R1.5,

95%

CI1.36–1.64).

Non

relativ

ecare

inanother

home≠

relativ

ecare

Odd

sof

outdoo

rplay

didno

tdiffer

Troste

tal.[30],

American

Journa

lof

Preventiv

eMedicine/2011/K


N�297FC

CHs:85.3%

CACFP

participation

Provider

Levelo

fedu

catio

n:40.8%

HSdiplom

aor

GED

,42.9%

somecollege

orAssociate’s,

14.3%

bachelor

degree

NAPS

ACC

M(sd)

PApo

licy

1.6±1.2

Play

environm

ent

3.10±0.6

Physical

activ

ityeducation

2.2±0.9

Supp

ortin

gph

ysical

activ

ity2.40±0.7

Activeplay

and

inactiv

etim

e3.20±

0.4

TVuseandTV

view

ing2.90±0.8

Troste

tal.[29],

American

Journa

lof

Preventiv

eMedicine/2009/K


N�297FC

CH

providers

NAPS

ACC

Existence

ofcomprehensiv

ewritte

npo

licyon

PA24.9%

(95%

CI:19.5,3

0.3)

Suita

blespaceindo

ors

whenweather

isbad

17.6%

(95%

CI:12.8,

22.3)

Disp

layedpo

sters,

pictures,o

rbo

oks

abou

tPA

21.9%

(95%

CI:16.5,2

7.2)

Received

training

onPA≥1

x/peryear

46.1%

(95%

CI:39.8,

52.3):

Provided

PAeducationto

parents

30.2%

(95%

CI:24.3,

36)

Restricted

activ

eplay

timefor

misb

ehavior62.7%

(95%

CI:

56.6,6

8.7)

TVturned

onevery

dayforat

leastp

art

oftheday64.6%

(95%

CI:58.7,7

0.5)

55.1%(95%

CI:48.7,

61.4)allowed

child

rento

watch

TV/videos≥1

x/day

a Includedresults

regardingethn

icity

since

agreatp

ercentageof

homes

wereHisp

anic;bsig

nificantly

different

from

center

based;

c FCCHsmorelik

elyto

care

forchild

renenrolledin

federalsub

sidyprograms;

d Scoring

guide:1

�marginally

meetin

gchild

carestandards,2

�meetin

gchild

carestandards,3

�exceedingchild

carestandards,and4

�farexceeding

child

care

standardsa

ndusingbestpractice;

e develop

edbased

onph

ysical

activ

itystandardsfrom

CaringforOur

ChildrenNationalH

ealth

andSafety

Performance

Standards;SC

FQ�Stanford

Child

FeedingQuestionn

aire;H

CFS

Q�HughesCaregiver

FeedingStyles

Questionn

aire;E

PAO

�En

vironm

entandPo

licyAssessm

entandObservatio

n;HSF

FQ�Harvard

ServiceFo

odFrequencyQuestionn

aire;P

AFQ

�Ph

ysical

Activity

FrequencyQuestionn

aire;E

CLS

-B�Ea

rlyChildho

odLo

ngitu

dinalS

tudy-Birth

Coh

ort;FC

CHs�

Family

Child

CareHom

es;N

APS

ACC

�Nutritio

nandPh

ysicalActivity

Self-Assessm

entfor

Child

Care;CACFP

�Child

andAdu

ltCareFo

odProgram;

PA�ph

ysical

activ

ity;M

VPA

�mod

erateto

vigorous

physical

activ

ity;T

PA�totalp

hysic

alactiv

ity;M

�mean;

SD�standard

deviation;

ns�no

tsignificant;mos.�

mon

ths.


Tabl

e2:

TPBCon

cepts_Attitudes,subjectiv

eno

rm,p

erceived

behavioral

control,intent

andpractices+kn

owledge.

Cita

tion/year/state/

metho

dSampledescription

Stud

yconcepts

(related

TPB

concepts)andarticle’s

defin

ition

Results

onTP

B-relatedconcepts

Associatio

nbetweenTP

Bconcepts

andchild

care

practices

Covariatesin

analyses

(potentia

ldem

ograph

icmod

erators)

Brann[16],Jou

rnal

ofPediatric

Health

Care/2010/Ono

ndaga

Cou

nty,

central

NY/Cross-sectio

nal

survey

N�123FC

CH

providers

Provider

a Race:

84%

white,1

1%black,

2%hispan

ic,0

.8%

nativ

eAmerican

Age:

45%

20–4

0,50%

41–6

0,5%

greaterthan

60years

Educationlevel:30%

college

graduate

orabove,66%

HS

graduate

orsomecollege,4

%someHS

Avg.B

MI:

27±7.7

Children

Avg.a

ge:

4.5years±

1.5

Avg.h

ousehold

Income:

42%<40K,5

2%40–8

0K,6

%>80K

Perceptio

nsof

child

hood

overweigh

t(subjectiv

enorm):

perceptio

nof

whatis

considered

overweigh

tby

identifying

draw

ings

ofbo

ysandgirls

rang

ingfrom

very

thin

tovery

heavythat

liein

agradient

from

thin

toheavy

Perceivedrespon

sibilityin

child

feeding

(perceived

beha

vioral

control)

Perceptio

nof

child

hood

overweigh

t(sub

jectiveno

rm)

Mostp

roviders

choseafig

urerepresentin

gan

above

average-siz

edbo

yandgirlas

acutoff

pointfor

overweigh

tPe

rceivedrespon

sibilityin

child

feeding

(perceived

beha

vioral

control)

Highlevelo

frespo

nsibility

forfeedingandmon

itoring

Perceptio

nof

child

hood

overweigh

t(sub

jectiveno

rm)

Providerswho

selected

smallers

ilhou

ettesfor

girls

asameasure

foroverweigh

trepo

rted

usingmorefood

restrictionon

girls

(U�257.5,

p�0.10).

Levelo

fEd

ucation

Providerswith

ahigh

erlevelo

fedu

catio

nwere

correlated

with

less

pressuring

ofchild

rento

eatm

orefood

(r�−0

.27,

p<0.01)

Con

cerned

abou

tchild

weigh

tRe

latio

nshipexist

betweenconcernabou

tweigh

tand

restrictionof

unhealthyfood

s(r

�0.27

,p<0.01)

Providersw

hoselected

smallersilho

uette

sfor

girls

weremorelik

elyto

have

moreconcernabou

tthechild

’sweigh

t(U

�235,

p<0.04)

Kim

etal.[32],Materna

lan

dCh

ildHealth

Journa

l/2012/Ea

stCentral

Illinois/Cross-sectio

nal

analysis

N�88

FCCH

providers;94

center-based

providers

Perceptio

ns(perceived

beha

vioral

control)

providers’perceptio

nsof

the

levelo

finfl

uenceon

child

ren’shealthybehaviors

andweigh

tstatus

Providers’perceptio

nsof

thelevelo

finflu

ence

onchild

ren’shealthybeha

viorsan

dweigh

tstatus

(perceived

beha

vioral

control)

Both

thefamily

andcenter-based

providersfeltthatthe

homeenvironm

enthadmoreinflu

ence

onhealthy

eatin

g/PA

habits

andweigh

tstatusof

thechild

ren

(pairedttests,allsignifican

tpvalues)

FCCHs>

centers

rank

edinflu

ence

onhealth

behaviorsandweigh

tstatus

with

theexceptionof

PA.

FCCH

providersfeltthat

homeandcenter-based

facilities

shared

similarinflu

ence

onph

ysical

activ

ityof

the

child

ren.

Levelo

ftraining

results

>55%

ofFC

CH

providers�

obesity

preventio

ntraining

with

inthepast

year,

which

isamarked

difference30%

ofcenter-

basedproviders

(χ2 ,

p�0.0005).

HighlytrainedFC

CH

providersmorelik

elyto

receivenu

trition

andPA

training

(χ2 ,

p�0.0009

,0.0024

respectiv

ely)

HighlytrainedFC

CH

providersmorelik

elyto

dissem

inatehealthy

nutrition

andPA

inform

ationto

child

ren

(PA

andob

esity

preventio

ninform

ation

toparents(allsig

nifican

tpvalues)


Tabl

e2:

Con

tinued.

Cita

tion/year/state/

metho

dSampledescription

Stud

yconcepts

(related

TPB


defin

ition

Results

onTP

B-relatedconcepts

Associatio

nbetweenTP

Bconcepts

andchild

care

practices

Covariatesin

analyses

(potentia

ldem

ograph

icmod

erators)

Lind

sayetal.[18],Journa

lof Obesity/2015/M

A/Focus

grou

ps

N�44

Latin

oFC

CH

providers;4focusgrou

psPr

ovider

Ethn

icity

100%

Latin

oEd

ucationlevel

−1/3

HSgraduate

orGED

,40%

somecollege

Yearsof

experie

nce

93%

upto

25yearsof

child

care

experience

Provider’sperceptio

ns,

attitud

esan

dpractic

esrelatedto

nutrition

and

physical

activ

ity(attitudes)

perceptio

nsof

theCACFP

andEE

C(attitudes)

attitud

esrelatedto

commun

icationwith

parents

(sub

jectiveno

rm)

perceptio

nof

child

weigh

tstatus

ofkids

incare

ofproviders

(sub

jectiveno

rm)

beliefsabou

tphysic

alactiv

ityandsedentarybehaviors

(perceived

beha

vioral

control)

provider

controlo

nwhata

ndho

wmuchchild

reneat

(perceived

beha

vioral

control)

perceivedbarriers

toPA

and

healthyeatin

g(perceived

beha

vioral

control)

provider’sbeliefrelated

totheirrole

(perceived

beha

vioral

control)

perceivedbarriers

toprovision

ofhealthyfood

s(BehavioralIntent)

Strategies

toincorporate

nutritiou

sfood

s

Attitu

destowards

CACFP

andEE

C(attitudes)

CACFP

policieshelpfula

ndmadeadifferencein

the

health

ofchild

ren.

Attitu

desrelatedto

commun

icationwith

parents

(attitudes)

commun

icationwith

parentsim

portantandcriticalin

understand

ingchild

’swell-b

eing

atho

me

didno

tfeel

comfortable

discussin

gchild

ren’sweigh

tstatus

with

parents.

Perceptio

nsof

child

weigh

tstatus

(sub

jectiveno

rm)

Fewprovidersrepo

rted

having

somechild

renat

risk

foroverweigh

torob

esity

Mostreportedthat

they

didno

thavemajor

concerns

abou

tweigh

tstatusof

child

rencurrently

undertheir

care.

Belie

fsab

outPA

andsedentarybeha

vior

(sub

jective

norm

)Mostb

elievedtheim

portance

forchild

rento

engage

inPA

througho

uttheday.How

ever,the

amou

ntof

time

providersbelievedchild

renshou

ldengage

inPA

varied

(from

30minutes

to2ho

urs)

Food

sserved

andpo

rtionsizes(perceived

beha

vioral

control)

perceive

parentsto

beabarrierto

healthyeatin

gin

FCCH

Belie

fsrelatedto

child

feeding(perceived

beha

vioral

control)

Perceivedrole

isto

nurtureandeducatechild

ren

Mostfeel

confi

dent

intheabilitiesto

servehealthy

food

sPe

rceptio

non

need

tocontrolfeeding

(perceived

beha

vioral

control)

Feltneed

tocontrolw

hata

ndho

wmuchchild

reneat

Perceivedba

rriers

toPA

(perceived

beha

vioral

control)

Mostb

elievedlack

ofspacea

ndcoldwhetherto

bemajor

obstaclesforPA

oppo

rtun

ities

Perceivedba

rriers

toprovisionof

healthyfood

s(perceived

beha

vioral

control)

Perceivedhigh

costof

freshfruitsandvegetables

does

note

nablethem

topu

rchase

andprovidethesefood

s.Perceivedthat

theCACFP

does

notp

ayenou

ghfor

purchase

offreshfruits

andvegetables

Strategies

toincorporatenu

trition

food

s(behavioral

intent)

Encouragingnew

food

sMealp

lann

ing

Participatingin

worksho

ps

Attitu

desrelatedto

commun

icationwith

parentsan

dcommun

icating

weigh

tconcerns

topa

rents

(attitudes)

Providersw

horepo

rted

being

uncomfortable

andreluctant

todiscusschild’sweigh

tfelt

that

parentscanbe

very

sensitive

tootherpeop

le’s

perceptio

nsof

theirchild

ren,

andbecauseof

that

they

preferredno

tto

talk

abou

tit

with

parents.

Food

sserved

andpo

rtion

sizes(sub

jectiveno

rm)

Providersrepo

rtserving

food

salignedwith

recommendatio

nsfrom

USD

AManyprovidersbase

portionsiz

eson

ageof

child

Perceptio

nsof

child

weigh

tstatus

anddeterm

ining

portionsizes(sub

jective

norm

)Few

providersrepo

rted

having

somechild

renat

risk

foroverweigh

torob

esity

and

that

thisinflu

encedtheir

feedingpractices,especially

indeterm

iningpo

rtionsiz

es

Providers’placeof

birth

Providerswho

had

form

ativey

earsou

tsideo

fUS,

inwarmer

clim

ates,

perceivedwinteras

abarriertoPA

morethan

US-bo

rnproviders


Tabl

e2:

Con

tinued.

Cita

tion/year/state/

metho

dSampledescription

Stud

yconcepts

(related

TPB


defin

ition

Results

onTP

B-relatedconcepts

Associatio

nbetweenTP

Bconcepts

andchild

care

practices

Covariatesin

analyses

(potentia

ldem

ograph

icmod

erators)

Rosenthale

tal.[24],

Journa

lofN

utrition

Educationan

dBeha

vior/2013/CT/in-

depthinterviews

N�17

FCCH

providers

Provider

Race/ethnicity

29%

African

American,5

3%white,2

4%Latin

aMeanage

43yrs

(31–

54)

Meanyrsw

orking

inchild

care

13(5–3

2)Hou

sehold

income

less

than

50K

(47%

),50–7

5K(29%

),75–100K

(18%

),more

than

100K

(6%)

Attitu

destowards

parents

(attitudes)

Perceivedrole

inob

esity

preven

tion(perceived

beha

vioral

control)

Strategies

used

toim

plem

entbest

practic

esin

nutrition

andPA

(behavioral

intent)

Attitu

destowards

parents(attitudes)

expressedbo

them

pathyandfrustrationwith

parents.

Perceivedrole

inob

esity

Preven

tion

(perceived

beha

vioral

control)

perceivedthey

hadaperson

alrespon

sibility

inob

esity

preventio

n.Disc

ussedtheimpo

rtance

oftheirroleinsharinghealthy

food

swith

parents.

ackn

owledged

thesupp

ortiv

erole

offood

guidelines,

unanno

uncedinspectio

nsfrom

thegovernment

spon

soredfood

program,and

thepeer

grou

p.

Strategies

used

toim

plem

entbest

practic

esin

nutrition

andPA

(behavioral

intent)

describedho

w,a

tthe

first

meetin

gwith

parents,they

try

tobe

clearw

ithparentsa

bout

food

guidelines.

Someh

avew

ritte

nrulesabo

utfood

guidelines

andall

describedhaving

aconv

ersatio

nwith

families

abou

tfoo

dguidelines.

describedusingtheirow

nkn

owledgeof

child

developm

entto

improve

nutrition

alintake

and

incorporatingdram

atic

play

tofacilitatetim

esof

high

PAdescribedho

wthey

incorporateanotheraspect

ofchild

developm

ent,

socialization,

toim

prove

achild

’snu

trition

.describedho

wthey

use

dram

aticplay

tofacilitatePA

describedsharingwith

parentsbo

ththeactual

food

andthetechn

iquestheyuseto

encouragechild

rento

eat

nutritiou

slydidno

tpressurekids

toeat

butw

erestill

concernedso

helped

thechild

toeat


Tabl

e2:

Con

tinued.

Cita

tion/year/state/

metho

dSampledescription

Stud

yconcepts

(related

TPB


defin

ition

Results

onTP

B-relatedconcepts

Associatio

nbetweenTP

Bconcepts

andchild

care

practices

Covariatesin

analyses

(potentia

ldem

ograph

icmod

erators)

Tovaret

al.[28],

Child

hood

Obesity/2015/RI/Fo

cus

grou

ps

N�30

FCCH

providers;4

focusgrou

psPr

ovider

Race/ethnicity

100%

female,Hisp

anic

(predo

minantly

Dom

inican,

77%),andSpanish

speaking

Levelo

fedu

catio

n50%

�somecollege+

Meanage

50years

Perceptio

nson

useof

TV

(sub

jectiveno

rm)

Perceptio

nsan

dbelie

fsregardingwhich

factors

influ

ence

child

ren’sPA

,screen

timeanddietary

behaviors(perceived

beha

vioral

control)

Perceivedstrategies

toim

provethenu

trition

and

PAen

vironm

entof

FCCHs

(behavioralintentio

n)

Provider

perceptio

nson

screen

timebeha

viors

(sub

jectiveno

rm)

Screen

timeshou

ldbe

limitedandrulesshou

ldbe

inplaceto

stop

parentsfrom

leavingchild

renat

FCCH

with

electron

icdevices

Perceivedwatchingeducationalp

rogram

ssuch

asDoratheEx

plorer

learning

andno

tscreen

time

Use

ofTV

forfood

prep

Othersfeltthat

watchingTV

didno

tbenefit

child

Provider’sperceptio

nson

how

preschoo

l-aged

child

rencanbe

physically

activ

e(perceived

beha

vioral

control)

Perceivedthat

child

renhave

manyop

portun

ities

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intheho

me

Perceivedthat

child

renaremoreactiv

ewhenou

tside

Perceivedthat

thereareop

portun

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indo

orbu

tneedsto

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howprovidersfeedor

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PAop

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ities

forpreschoo

l-agedchild

ren(perceived

beha

vioral

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Perceivedrespon

sibility

toprovidechild

renwith

nutritiou

sfood

sPerceivedneed

toabideby

program

regulatio

ns,

thou

ghsomedeem

regulatio

nsas

contribu

tingto

added

stress

Culture

influ

encedfood

sserved

Poor

parental

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influ

encesthechild

care

environm

ent

Providersp

erceiveparents’po

orbeliefsregardingPA

tobe

amajor

barrierto

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theFC

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ren’svaryingpreferencesto

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grou

pPA

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ofchild

rengetting

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inho

melim

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me

Winterweather

Provider

perceived50Fto

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ren

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Perceivedstrategies

toim

provethenu

trition

andPA

environm

entof

FCCHs(behavioralintent)

Moreprob

lem-based

solutio

nsoriented

training

s,programsandresources

Increasedreim

bursem

entfor

purchase

offruits

and

vegetables

Improvecommun

icationwith

parentsregarding

prop

ernu

trition

andPA

practices

Training

andfeeding

practic

esOfte

ndiscon

nect

between

providersbeliefo

nthe

impo

rtance

ofhealthyfood

sandwhattheyactually

serve

PerceivedtheCACFP

program

tohelp

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know

ledgeon

nutrition

food

s,yets

omestill

dono

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trition

guidelines

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dueto

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ralfeeding

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Providersreliedon

child

’sageandph

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statureto

determ

inepo

rtionsiz

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relyingon

age-

approp

riateguidelines

for

portionsiz

esDue

totraining

,providers

appreciatedtheimpo

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ofno

tforcefeedingandbeing

arole

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Tabl

e2:

Con

tinued.

Cita

tion/year/state/

metho

dSampledescription

Stud

yconcepts

(related

TPB


defin

ition

Results

onTP

B-relatedconcepts

Associatio

nbetweenTP

Bconcepts

andchild

care

practices

Covariatesin

analyses

(potentia

ldem

ograph

icmod

erators)

Vincietal.[33],Journa

lof

Obesity/2016/FL/Fo

cus

grou

ps

N�27

FCCHs(75.9%

ofsampleof

child

care

providers)

Subjectiv

ebelie

fsof

wha

tis

needed

toen

sure

PAin

homes

(perceived

beha

vioral

control)

Subjectiv

ebelie

fsof

wha

tis

needed

toen

sure

PAin

homes

(perceived

beha

vioral

control)

additio

nalspecific

factorsthatw

ereno

traisedby

center

staff

includ

ingtheneed

fora

ctivities

thatcanbe

adapted

forawiderang

eof

ages.

Hom

eproviderscautionedagainstp

roviding

PAthat

requ

ired

extensivespaceor

equipm

ent,sin

cespace

islim

itedin

FCCHs.

Van

Stan

etal.[31],

Child

hood

Obesity/2013/D

E/survey

N�62%

FCCHs;

5%center

owner;84%

CACFP

Kno

wledg

eof

nutrition

and

PArules

FCCHs>

Centerstaff

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wledgeof

DE’snu

trition

andPA

rules

(14.7versus

18ou

tof2

6,p<0.001)

a Miss

ingdataforfi

veproviders;FC

CH

�Family

Child

CareHom

es;E

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ucationandCare;BM

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ex;P

A�ph

ysicalactiv

ity;M

VPA

�mod

erateto

vigorous

physicalactiv

ity;T

PA�total

physical

activ

ity;U

�Mann–

Whitney

test.


[19, 20, 26, 29, 30]. Four studies focused only on the nu-trition environment [22, 23, 27, 31] while two focused solelyon the physical activity environment [21, 25]. Six studiesexamined TPB related beliefs [16, 18, 24, 28, 32, 33]. Four ofthese studies used qualitative methods such as focus groups[18, 28, 33] and in-depth interviews [24]. Five studies includedFCCHs participating in CACFP, [21–23, 30, 31] with 3 studieshaving majority (∼80%) CACFP FCCHs [21, 30, 31]. Of thestudies that reported the race or ethnicity of the providers orthe children, 50% (4/8) reported having majority Hispanicproviders and/or children [17, 18, 20, 28]. ,ree studies hadmajority white providers [16, 21, 24], and one study involvedproviders who were majority African American [27]. Of thestudies that reported educational level, all (7/7) reported thatthe majority of providers had a high school degree or GED orsome college [16, 18, 21, 25, 26, 30]. Two studies reportedproviders’ weight status; most were overweight or obese[16, 27]. Two studies reported children’s weight status; mostwere of normal weight with 20–30% obese [21, 27].

3.3. Policy Environment. FCCH providers have the oppor-tunity to have written nutrition and physical activity policies.,ree studies found that few FCCH providers had compre-hensive written policies on nutrition and physical activity[19, 29, 30]. Compared to center-based child care facilities, fewFCCH providers had written policies regarding best practicesrelated to beverages, the use of food as reward or punishment,and encouragement for consumption of healthy foods [19].Trost et al. showed that fewer than 20% of FCCHproviders hadpolicies regarding best practices related to foods purchased forcelebratory events [29]. Additionally, only about 25% of FCCHproviders had written physical activity policies [29, 30].

3.4.PhysicalEnvironment. Seven studies assessed the physicalenvironment in FCCHs [20, 22, 23, 25, 27, 29, 30]. Althoughmore FCCH providers provided nutrition education to chil-dren, compared to center-based providers (44 versus 27%,p � 0.01), [19, 20], few FCCH providers used books or gameswith nutrition themes in their delivery of nutrition education[29]. No FCCH providers reported using a dietitian to plantheir menus, [22] and 44.8% of FCCH providers made waterreadily accessible indoors and outdoors, compared to 73.1% ofcenters [23]. Less than half of FCCH providers received ad-equate nutrition and physical activity training one or moretimes a year [29]. Also, the FCCH’s physical activity envi-ronment was shown to be suboptimal for indoor and outdoorplaytime [25, 29]. For example, Tandon et al. found that 76%FCCHs had a variety of fixed play and 86% portable playequipment when compared to center-based centers, 89% and95%, respectively [25]. Additionally, 71% of FCCHs relied ontelevision for part ormost of the day [25]. Finally, about 22% ofFCCH providers had physical activity displays such as posters,pictures, or books about physical activity [29].

3.5. Sociocultural Environment. Only three studies exam-ined the sociocultural environment in the FCCH setting[17, 27, 29]. An observational study conducted in Rhode

Island showed that FCCH providers frequently praised thechildren for trying new foods and eating healthy foods.However, in response to children’s mealtime behaviors,providers used both best practices and coercive controllingpractices (i.e., insistence, pressuring, and threats) whenresponding to children’s verbal and nonverbal refusals offood, and the verbal and nonverbal acceptance of food [27].In 85 of the interactions observed related to the providers’response for seconds, providers responded with coercivecontrolling practices, especially during lunch times [27].Providers also pressured their children to “clean their plates”before offering seconds of certain foods [27]. Trost et al.showed that only 27% of FCCH providers provided family-style meals [29]. Additionally, 62.7% of FCCH providersrestricted play time for misbehavior [29].

3.6. ?eory of Planned Behavior (TBP) Concepts. ,ere wereseven articles that addressed beliefs related to knowledge,attitudes, subjective norms, perceived behavioral control,and behavioral intent [16, 18, 24, 28, 31–33]. ,e beliefsdescribed in the articles were closely matched with therelevant TPB concepts. ,e matching of concepts was doneby carefully reviewing the definitions of the concepts pro-vided in the articles and how they were measured andmatching the terms to the TPB-related concepts. Results aresummarized in Table 2.

3.6.1. Attitudes. Overall, two studies showed that there werepoor attitudes among providers regarding parents andparents’ role in fostering a healthy environment in theFCCH setting [18, 24]. For example, some providers believedthat although communication with parents is important toget a better understanding of the child’s well-being at home,they felt frustrated and reluctant to discuss a child’s weightstatus with parents for fear of offending parents [18]. FCCHproviders felt that the nutrition-related CACFP policies werehelpful and made a difference in the health of the childrenattending the FCCHs [18].

3.6.2. Subjective Norm. ,ree studies addressed subjectivenorms [16, 18, 28]. ,ere were inconsistent perceptions ofwhat was considered normal weight among FCCH providers[16, 18]. Lindsay et al. showed that despite Hispanic childrenbeing disproportionately overweight or obese, HispanicFCCH providers reported having few children at risk foroverweight or obesity or showed no concern about theweight status of the children under their care [18]. ,esebeliefs, in turn, influenced their belief that portion sizesshould be based on age and not on weight [18]. Providers,mostly white, who were presented with drawings of boys andgirls of differing sizes, selected smaller sized drawings forgirls as a measure for overweight, as compared to thedrawing of boys [16]. ,ese providers reported using morefood restriction with girls in the FCCH, than with boys(U � 257.5, p � 0.10) [16]. On the topic of physical activity,most providers believed in the importance of daily physicalactivity in FCCHs [18]; however, the amount of time


providers believed that children should engage in physicalactivity varied [18]. Additionally, Hispanic providers be-lieved that 50 degrees Fahrenheit was too cold for children toplay outside [28]. Although most providers perceived screentime should be limited, focus group discussions pointed tothe perception among Hispanic FCCH providers thatwatching TV was not considered screen time [28].

3.6.3. Perceived Behavioral Control. Perceived behavioralcontrol was assessed in all six articles. Lindsay et al. showedthat most providers were confident in their abilities toprovide a nutritious environment for the children in theircare [18]. Providers believed that they had a high level ofresponsibility to provide a healthy nutritional and physicalactivity environment and that their role was to nurture andeducate the children [16, 18, 24]. Providers also perceivedthat they had control over what and how much children eat[18]. Providers felt that they had more influence than center-based providers on eating habits of children. However,FCCH providers also believed that both the center-basedproviders and FCCH providers have an equal share of in-fluence on physical activity behavior [32]. Providers iden-tified several enablers or barriers to engaging in nutritionand physical activity best practices. Providers believed thatthe high cost of food prevented the purchase of quality freshfruits and vegetables for the children [18]. Lack of space forplay was identified as a major barrier to physical activityengagement [18, 33]. Additionally, the varying needs forphysical activities across ages could be challenging forproviders [28, 33]. Finally, providers perceived poor parentalbeliefs to be an obstacle to ensuring best nutrition andphysical activity practices in the FCCH [18, 28].

3.6.4. Behavioral Intent. ,ree studies addressed providers’perceived strategies to improve the FCCH environment[18, 24, 28]. Strategies mentioned by providers includedencouraging new foods, meal planning, and participatingin workshops [18], problem-based solutions-orientedtrainings, and programs and resources to address chal-lenging feeding behaviors among children [28], increasedreimbursement from CACFP for purchase of nutritiousfoods [28], improving communication with parents re-garding recommended nutrition and physical activitypractices [24, 28], use of dramatic play during active playtime, [24] and having written, comprehensive rules insidethe FCCH [24].

3.6.5. Knowledge. Provider knowledge was addressed inthree of the articles [24, 28, 31]. FCCH providers knew moreof the rules on best nutrition practices than center-basedproviders in the State of Delaware (18 versus 14.7, p< 0.001)[31]. Providers described using their own knowledge onchild development to improve what was offered to childrenin the FCCH [24]. Finally, providers perceived that theCACFP improved their nutrition knowledge [28]; however,this improved knowledge did not help in engaging in bestfeeding practices due to cultural feeding practices [28].

3.7. Covariates Included Analyses (Potential DemographicModerators). Although not directly tested for their mod-eration effects, this review suggests that there are certainneighborhood, FCCH/facility level, provider, and child-levelcharacteristics that may confound relationships between theenvironment and EBRBs within the FCCH context.

3.7.1. Neighborhood: Income Zone of Neighborhood. Whenadjusting for the income zone of the neighborhood in whichcenters and FCCHs are located, indoor and outdoor physicalactivity and television-use practices remained significantlydifferent between FCCHs and centers, with fewer FCCHproviders providing best practices in these areas (p≤ 0.05)[20]. For nutritional practices, however, the differencesbetween FCCHs’ and centers’ nutritional practices were nolonger significant when adjusting for the income zone of theneighborhood of the facilities (p � 0.05) [20].

3.7.2. FCCH/Facility Level. Four studies reported the numberof CACFP-participating FCCHs included in the study sample[22, 23, 30, 31]. Ritchie et al. was the only study that examinedthe differences in environment between CACFP and non-CACFP homes [22]. CACFP and non-CACFP FCCHs weresignificantly more likely to serve whole milk than centers(p< 0.001). More non-CACFP homes served candy andsweetened beverages compared to all other types of child caresettings including CACFP homes (15.8% non-CACFP homesversus 6.2% CACFP Homes, p< 0.001; 18.4% non-CACFPversus 7.7% CACFP homes, p< 0.001) [22].

3.7.3. Provider Level. Hispanic providers were more likely toengage in authoritarian and controlling feeding practices.Freedman et al. found that compared to White and Asianproviders, Hispanic providers (representing 76% of studypopulation) were more likely to force children to eat what theproviders perceived to be good for them (χ2 � 7.25, p< 0.05),to insist that the children clean their plates before leaving thetable, and to not allow children to eat less than they thoughtthey should and were least likely to sit at the table and eatmeals with the children (χ2 � 3.04, p< 0.05) [17]. Hispanicproviders were also three times more likely to cook foods thatthey knew children liked compared to Asian and Whiteproviders (χ2 � 1.96, p< 0.001) [17]. Brann et al. demon-strated that FCCH providers (84% White) who selectedsmaller silhouettes for girls as overweight were more likely tohave concern about the children’s weight, as compared toproviders who chose larger silhouettes as representing over-weight (U � 235, p< 0.04) [16]. Additionally, providers withhigher education had fewer instances of pressuring of childrento eat (r � −0.27, p< 0.01) [16]. Kim et al. demonstrated thathighly trained FCCH providers were more likely to dissem-inate healthy nutrition information to children and obesityprevention information to parents [32].

Hispanic providers who spent their formative years inwarmer climates outside the US perceived winter as a barrierto physical activity engagement more than US-born His-panic providers [18].


3.7.4. Child Level. Among 4- and 5-year-olds, overweightand obese children exhibited lower levels of moderate tovigorous physical activity and total physical activity thanhealthy weight 4- and 5-year-olds (p< 0.5). Relative to boys,girls exhibited lower levels of moderate to vigorous and totalphysical activity during the day (p< 0.5) [21].

3.8. Energy Balance-Related Behaviors (EBRBs). FCCHproviders reported offering more fresh fruit and vegetablesthan center-based child care providers (80.3% versus 51.2%,p< 0.001) and more frequently limiting rolls and breadcompared to center-based child care providers (28.1 versus18.6%, p � 0.001) [20]. However, Trost et al. showed thatonly 41.7% of FCCH providers served lean meats more thanfour times per week and less than half of the providersreported serving healthy foods for celebratory events [29]. Inthe study by Liu et al., fewer FCCH providers reported notoffering fried foods compared to center-based providers(38% versus 59%, p � 0.001) [19].

Although FCCH providers reported following bestpractice recommendations for serving water at least dailyand limiting sweetened beverages, 55.8% of the FCCHproviders offered 100% juice 3-4 times weekly in Tandonet al. and 66% of FCCH providers in Trost et al. [26, 29].Additionally, only 13.9% of FCCH providers offered 1%milkmore than once daily [29]. Natale et al. showed that whencompared to center-based child care, fewer FCCH providersprovided 1% milk more than once daily (45.2 versus 55%,p � 0.015) [20].

When compared to center-based child care, fewerFCCHs provided outside physical activity for 30min ormore three times a week (92.9% versus 96.5%, p � 0.022)[20]. Children in FCCHs spent on average 5.8min/hour ofmoderate to vigorous physical activity and 10.4min/hour oftotal physical activity [21]. Although a higher portion of FCCHproviders reported preschoolers engaged in 60min of adult-led play time compared to center-based child care (33 versus18%,p � 0.02), only a third of FCCHproviders engaged youngchildren in an hour of playtime [19]. Seventy-eight percent ofproviders reported that they needed training on how to helpchildren be physically active [19].

Nearly 65% of providers had the TV turned on every dayfor at least part of the day, and 55.1% of providers allowedchildren to watch TV or video at least once a day [29]. Nataleet al. showed that more FCCH providers reported higherlevels of limiting computer time than center-based child careproviders (63.9 FCCH versus 51.8% centers, p � 0.003);however, fewer FCCH providers rated excellent in limitingTV or video (39.2%, 59.5%, p< 0.001) [20].

4. Discussion

Research on obesity prevention involving FCCHs is accel-erating, illustrating that a review on the obesity promotingattributes of the FCCH environment can identify priorityareas for intervention development unique to the FCCHsetting. With the guidance of an innovative framework, thisliterature review examined the obesogenic attributes of the

FCCH policy, physical, and sociocultural environment. ,eexamination of the policy environment revealed that therewas lack of comprehensive written nutrition and physicalactivity policies within FCCHs. FCCHs are generally lessregulated than center-based child care and are not mandatedto have written nutrition and physical activity policies inplace. Nonetheless, encouraging FCCHs to provide writtennutrition and physical activity policies would provideguidance for engaging in nutrition and physical activity bestpractices. Children in many FCCHs have few opportunitiesto engage in quality physical activity due to inadequatespaces for physical activity and high television use. ManyFCCH providers are also inadequately trained in nutritionand physical activity and seldom provide nutrition in-formation to parents. ,ere is limited research on the as-sessment of the sociocultural environment in FCCHs withrespect to obesity and obesity prevention. In this review,there is some evidence that FCCH providers engage incontrolling feeding practices and restrict physical activity asa punitive strategy for misbehavior. Since controlling andrestrictive feeding styles are associated with overeating inyoung children, interventions aimed at reducing theseobesogenic interactions are warranted [34].

,e EnRG framework postulates that the environmentcan have an effect on EBRB through the mediating role ofcertain cognitive factors; the TPB concepts. In this review,six articles explored FCCH providers’ attitudes, normativebeliefs, and control beliefs as they pertain to the FCCHenvironment and obesity. Although mediation was notexamined, the evidence suggests that providers’ attitudesand beliefs influence their feeding and physical activitypractices as well as family communication practices. Furtherunderstanding of these concepts as they relate to the FCCHenvironment would be instrumental in developing trainingstrategies that can eliminate misconceptions and in-appropriate beliefs about nutrition and physical activitypractices and enhance self-efficacy, which would help withbetter communication with families concerning children’seating behaviors. Partnering with families is likely to beeffective since families engage with child care providers dailyand often share information on the child’s daily activities.

We abstracted information on the covariates that werecollected and/or included in the analyses. Although thecovariates were not tested for moderation, the evidencesuggests that many of the covariates may function as po-tential demographic moderators that should be tested infuture research. Within the EnRG framework, demographicmoderators may confound relations between the mediatedenvironment and EBRBs or relations between the un-mediated and automatic-lack of awareness or control-environment and EBRBs.

Although most studies did not examine neighborhooddifferences, one study adjusted for neighborhood charac-teristics in comparing FCCH with child care centers [20].,e finding that nutrition-related FCCH/center differenceswere eliminated after neighborhood adjustment suggeststhat FCCH and center nutritional practices may be related toneighborhood conditions, such as food availability. Incontrast, that finding that neighborhood adjustment did not


alter that finding that FCCHs had worse physical activitypractices than center-based child care suggests that FCCH/center differences may be more closely related to physicalactivity resource and practice differences within the sites,rather than the neighborhoods.

Only one study examined the differences in the foodenvironment by CACFP status [22]. ,e finding that non-CACFP homes served candy and sweetened beverages moreoften than CACFP homes is consistent with a study thatshowed that compared to non-CACFP providers, moreCACFP providers engaged in best nutrition practices [35].Since thirty percent of US children are enrolled in CACFP-participating FCCHs, more research is needed to examinethe impact that CACFP is making on the food environmentand feeding practices in FCCHs especially since the in-troduction of new CACFP guidelines on October 1, 2017, toincrease the consumption of fruits and vegetables and reducegrain-based deserts, such as donuts and pastries [36].

On the provider and child-level, FCCH interventions areneeded to address Hispanic providers’ propensity to usecontrolling and coercive feeding practices, along with theirinaccurate beliefs concerning physical activity and TV use.Provider nutrition training was effective in empoweringproviders to disseminate healthy nutrition-related infor-mation to parents and children [32]. Strategies to increasefunding and availability for nutrition training programsfor FCCH providers, through CACFP or independent ofCACFP, could be instrumental in helping to curb obesityamong young children.

Finally, FCCH providers engage in obesogenic EBRBs,providing fried foods, high-fat milk, sweetened beverages, andhaving limited opportunties for play both indoors and out-doors coupled with high TV use. A mixed-methods approachcan help rearchers to understand FCCHproviders’ knowledgein nutrition and physical activity best practices and barriers toproviding an optimal environment for the children in theircare. Developing social marketing campaigns tailored forFCCH providers can be an effective approach to influencebehavior change.

4.1. Limitations and Strengths. ,ere are several limitationsto this review that can affect the generalizability of thefindings. ,e few studies that examined the FCCH envi-ronment were limited to only several states, with no nationalrepresentation.We limited the search to published literature,not grey literature, meaning that unpublished studies orpublished studies in a noncommercial form were excluded.Since most studies did not report the licensure status and thesize of the FCCHs, we were unable to make inferencesconcerning the role of licensure and size on EBRBs. Half ofthe studies that reported race or ethnicity involved majorityHispanic providers and only one study had majority AfricanAmerican providers. Of the studies that examined the policy,physical, and sociocultural environment, only one studyrelied on observations to assess the environment [27]. Moststudies relied on self-report cross-sectional survey data,potentially introducing biases that could be minimized byobjectively observing the FCCH environment. Due to the

studies’ heterogeneity in design, we were unable to evaluatethe quality of the studies using one tool. Finally, none of thestudies examined the food environment in the neighbor-hoods outside of the FCCH. Expanding the child care re-search network to include FCCHs across the US, striving forequal representation in races/ethnicities of FCCH providersand children in their care, addressing neighborhood char-acteristics, including systematic and observational methodsthat examine policies and practices, and examining FCCHsover time, would improve generalizability in the process ofdefining the FCCH environment in the US.

,ere are also multiple strengths to the review. FCCHsare a primary resource for many families and are an idealvenue for the implementation of childhood obesity pre-vention efforts. With strong theoretical guidance, we are ableto show that making changes in the policy, physical, andsociocultural environment of FCCHs can provide optimalenvironments for young children. Enhancing nutritiontraining for providers and promoting healthy mealtimeinteractions may improve children’s dietary environment.Lastly, we show the need for more studies to understand theimpact CACFP has on the food environment of FCCHs.

5. Conclusion

In conclusion, this review of the obesogenic attributes ofthe Family Child Care Home highlights the priority areasin which to intervene within the FCCH environment.Interventions addressing child care policies and practicesregarding what food is served, how food is served, oppor-tunities provided to young children for physical activity, andthe quality of space available within FCCHs, are essential.With better opportunities for FCCH providers to be trainedin childhood obesity prevention and in best practices innutrition and physical activity, providers can be proactivein implementing written nutrition and physical activitypolicies. FCCH providers would benefit from innovativestrategies to implement physical activity and minimizescreen time, given space limitations. Finally, addressingmisconceptions and inappropriate attitudes and beliefs re-lated to food and physical activity can benefit the health ofthe FCCH environment. Ensuring that all child care optionsfor young children, including FCCHs, including the policies,practices, and resources to help children build healthynutrition and physical activity habits, can be instrumental inpreventing overweight and obesity.

Conflicts of Interest

,e authors have no conflicts of interest to declare.

Authors’ Contributions

All authors contributed to the design of the review. LucineFrancis and Lara Shodeinde conducted the article screening.Lucine Francis drafted the manuscript. Jerilyn Allen andMaureen M. Black critically reviewed the manuscript. Allauthors read and approved the final manuscript.


Acknowledgments

,e authors thank Stella Seal, Johns Hopkins informationist,for assisting with identifying key search terms and conductingthe database searches. ,is work was supported by the Na-tional Institutes of Health (NIH/NINR F31 NR015399), RuthL. Kirschstein National Research Service Award (NIH/NINRT32 NR012704), and Pre-Doctoral Fellowship in Interdisci-plinary Cardiovascular Health Research. Maureen M. Black’scontribution was supported by NIDDK R01DK107761.

Supplementary Materials

Complete search strategy for this review. Final searchconducted on August 8, 2016. (Supplementary Materials)

References

[1] C. L. Ogden, M. D. Carroll, B. K. Kit, and K. M. Flegal,“Prevalence of childhood and adult obesity in the UnitedStates, 2011-2012,” JAMA, vol. 311, no. 8, pp. 806–814, 2014.

[2] L. Pan, D. S. Freedman, A. J. Sharma et al., “Trends in obesityamong participants aged 2–4 years in the special supplementalnutrition program for women, infants, and children-UnitedStates, 2000–2014,” Morbidity and Mortality Weekly Report(MMWR), vol. 65, no. 45, pp. 1256–1260, 2016.

[3] R. Din-Dzietham, Y. Liu, M. V. Bielo, and F. Shamsa, “Highblood pressure trends in children and adolescents in nationalsurveys, 1963 to 2002,” Circulation, vol. 116, no. 13,pp. 1488–1496, 2007.

[4] D. S. Ludwig and C. B. Ebbeling, “Type 2 diabetes mellitus inchildren: primary care and public health considerations,”JAMA, vol. 286, no. 12, pp. 1427–1430, 2001.

[5] S. Redline, P. V. Tishler, M. Schluchter, J. Aylor, K. Clark, andG. Graham, “Risk factors for sleep-disordered breathing inchildren,” American Journal of Respiratory and Critical CareMedicine, vol. 159, no. 5, pp. 1527–1532, 1999.

[6] L. Trasande and B. Elbel, “,e economic burden placed onhealthcare systems by childhood obesity,” Expert Review ofPharmacoeconomics and Outcomes Research, vol. 12, no. 1,pp. 39–45, 2012.

[7] I. Romieu, L. Dossus, S. Barquera et al., “Energy balance andobesity: what are the main drivers?,” Cancer Causes andControl, vol. 28, no. 3, pp. 247–258, 2017.

[8] L. Laughlin, “Who’s minding the kids? Child care arrange-ments, Spring 2011,” in Household Economic Studies, pp.70–135, U.S. Department of Commerce, Bureau of theCensus, USA, 2013.

[9] S. E. Benjamin, S. L. Rifas-Shiman, E. M. Taveras et al., “Earlychild care and adiposity at ages 1 and 3 years,” Pediatrics,vol. 124, no. 2, pp. 555–562, 2009.

[10] E. J. Maher, G. Li, L. Carter, and D. B. Johnson, “Preschoolchild care participation and obesity at the start of kinder-garten,” Pediatrics, vol. 122, no. 2, pp. 322–330, 2008.

[11] L. McLaren, M. Zarrabi, D. J. Dutton, M. C. Auld, andJ. C. Emery, “Child care: implications for overweight/obesityin Canadian children?,” Chronic Diseases and Injuries inCanada, vol. 33, no. 1, pp. 1–11, 2012.

[12] M. Story, K. Kaphingst, and S. French, “,e role of child caresettings in obesity prevention,”?e Future of Children, vol. 16,no. 1, pp. 143–168, 2006.

[13] S. P. J. Kremers,G.-J. de Bruijn, T. L. S. Visscher,W. vanMechelen,N. K. de Vries, and J. Brug, “Environmental influences on

energy balance-related behaviors: a dual-process view,”International Journal of Behavioral Nutrition and PhysicalActivity, vol. 3, no. 1, p. 9, 2006.

[14] B. Swinburn, G. Egger, and F. Raza, “Dissecting obesogenicenvironments: the development and application of a frame-work for identifying and prioritizing environmental in-terventions for obesity,” Preventive Medicine, vol. 29, no. 6,pp. 563–570, 1999.

[15] I. Ajzen, “,e theory of planned behaviour is alive and well,and not ready to retire: a commentary on Sniehotta, Presseau,and Araujo-Soares,” Health Psychology Review, vol. 9, no. 2,pp. 131–137, 2014.

[16] L. S. Brann, “Child-feeding practices and child overweightperceptions of family day care providers caring for preschool-aged children,” Journal of Pediatric Health Care, vol. 24, no. 5,pp. 312–317, 2010.

[17] M. R. Freedman and K. P. Alvarez, “Early childhood feeding:assessing knowledge, attitude, and practices of multi-ethnicchild-care providers,” Journal of the American DieteticAssociation, vol. 110, no. 3, pp. 447–451, 2010.

[18] A. C. Lindsay, J. A. Salkeld, M. L. Greaney, and F. D. Sands,“Latino family childcare providers’ beliefs, attitudes, andpractices related to promotion of healthy behaviors amongpreschool children: a qualitative study,” Journal of Obesity,vol. 2015, Article ID 409742, 9 pages, 2015.

[19] S. T. Liu, C. L. Graffagino, K. A. Leser, A. L. Trombetta, andP. L. Pirie, “Obesity prevention practices and policies in childcare settings enrolled and not enrolled in the child and adultcare food program,” Maternal and Child Health Journal,vol. 20, no. 9, pp. 1933–1939, 2016.

[20] R. Natale, M. Page, and L. Sanders, “Nutrition and physicalactivity practices in childcare centers versus family childcarehomes,” Early Childhood Education Journal, vol. 42, no. 5,pp. 327–334, 2014.

[21] K. R. Rice and S. G. Trost, “Physical activity levels amongchildren attending family day care,” Journal of NutritionEducation and Behavior, vol. 46, no. 3, pp. 197–202, 2014.

[22] L. D. Ritchie, M. Boyle, K. Chandran et al., “Participation inthe child and adult care food program is associated with morenutritious foods and beverages in child care,” ChildhoodObesity, vol. 8, no. 3, pp. 224–229, 2012.

[23] L. D. Ritchie, S. Yoshida, S. Sharma, A. Patel, E. H. Vitale, andK. Hecht, “Drinking water in California child care sites beforeand after 2011-2012 beverage policy,” Preventing ChronicDisease, vol. 12, p. E89, 2015.

[24] M. S. Rosenthal, A. A. Crowley, and L. Curry, “Family childcare providers’ self-perceived role in obesity prevention:working with children, parents, and external influences,”Journal of Nutrition Education and Behavior, vol. 45, no. 6,pp. 595–601, 2013.

[25] P. S. Tandon, C. Zhou, and D. A. Christakis, “,e frequency ofoutdoor play for preschool age children cared for at home-based child care settings,” Academic Pediatrics, vol. 12, no. 6,pp. 475–480, 2012.

[26] P. S. Tandon, M. M. Garrison, and D. A. Christakis, “Physicalactivity and beverages in home- and center-based child careprograms,” Journal of Nutrition Education and Behavior,vol. 44, no. 4, pp. 355–359, 2012.

[27] A. Tovar, A. E. Vaughn, M. Fallon et al., “Providers’ responseto child eating behaviors: a direct observation study,”Appetite, vol. 105, pp. 534–541, 2016.

[28] A. Tovar, N. Z. Mena, P. Risica, G. Gorham, and K. M. Gans,“Nutrition, and physical activity, environments of home-


http://downloads.hindawi.com/journals/jobe/2018/3490651.f1.docx

based child care: what hispanic providers have to say,”Childhood Obesity, vol. 11, no. 5, pp. 521–529, 2015.

[29] S. G. Trost, L. Messner, K. Fitzgerald, and B. Roths, “Nutri-tion, and physical activity policies and practices in family childcare homes,”American Journal of PreventiveMedicine, vol. 37,no. 6, pp. 537–540, 2009.

[30] S. G. Trost, L. Messner, K. Fitzgerald, and B. Roths, “A nu-trition and physical activity intervention for family child carehomes,” American Journal of Preventive Medicine, vol. 41,no. 4, pp. 392–398, 2011.

[31] S. Van Stan, L. Lessard, and K. Dupont Phillips, “,e impactof a statewide training to increase child care providers’knowledge of nutrition and physical activity rules in Dela-ware,” Childhood Obesity, vol. 9, no. 1, pp. 43–50, 2013.

[32] J. Kim, J. E. Shim, A. R. Wiley, K. Kim, and B. A. McBride,“Is there a difference between center and home care providers’training, perceptions, and practices related to obesity pre-vention?,” Maternal and Child Health Journal, vol. 16, no. 8,pp. 1559–1566, 2012.

[33] D. M. Vinci, M. C. Whitt-Glover, C. K. Wirth, C. Kraus, andA. P. Venezia, “Let’s wiggle with 5-2-1-0: curriculum devel-opment for training childcare providers to promote activity inchildcare settings,” Journal of Obesity, vol. 2016, Article ID8967092, 10 pages, 2016.

[34] L. L. Birch, J. O. Fisher, and K. K. Davison, “Learning toovereat: Maternal use of restrictive feeding practices promotesgirls’ eating in the absence of hunger,” American Journal ofClinical Nutrition, vol. 78, no. 2, pp. 215–220, 2003.

[35] S. Korenman, K. S. Abner, R. Kaestner, and R. A. Gordon,“,e child and adult care food program and the nutrition ofpreschoolers,” Early Childhood Research Quarterly, vol. 28,no. 2, pp. 325–336, 2013.

[36] United States Department of Agriculture, January 2017, https://www.fns.usda.gov/cacfp/child-and-adult-care-food-program.


https://www.fns.usda.gov/cacfp/child-and-adult-care-food-program

https://www.fns.usda.gov/cacfp/child-and-adult-care-food-program

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