Research Article|Articles in Press

Nutrition Practices of Family Child Care Home Providers and Children's Diet Quality



      To examine the relationship between the diet quality of children aged 2–5 years cared for in family child care homes (FCCHs) with provider adherence to nutrition best practices.


      Cross-sectional analysis.


      Family child care home providers (n = 120, 100% female, 67.5% Latinx) and children (n = 370, 51% female, 58% Latinx) enrolled in a cluster-randomized trial.

      Main Outcome Measures

      Data were collected over 2 days at each FCCH. The Environment and Policy Assessment and Observation tool was used to document whether providers exhibited nutrition practices on the basis of the Nutrition and Physical Activity Self-Assessment for Child Care. Each practice was scored as either present or absent. Children's food intake was observed using Diet Observation at Child Care and analyzed with the Healthy Eating Index–2015.


      Multilevel linear regression models assessed the association between providers exhibiting best practices regarding nutrition and children's diet quality. The model accounted for clustering by FCCH and controlled for provider ethnicity, income level, and multiple comparisons.


      Children in FCCHs in which more of the best practices were implemented had higher diet quality (B = 1.05; 95% confidence interval [CI], 0.12–1.99; P = 0.03). Specifically, children whose providers promoted autonomous feeding (B = 27.52; 95% CI, 21.02–34.02; P < 0.001) and provided nutrition education (B = 7.76; 95% CI, 3.29–12.23; P = 0.001) had higher total Healthy Eating Index scores.

      Conclusions and Implications

      Future interventions and policies could support FCCH providers in implementing important practices such as autonomy feeding practices, talking informally to children about nutrition, and providing healthful foods and beverages.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access

      SNEB Member Login

      SNEB Members, full access to the journal is a member benefit. Login via the SNEB Website to access all journal content and features.


      Subscribe to Journal of Nutrition Education and Behavior
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ogden CL
        • Carroll MD
        • Lawman HG
        • et al.
        Trends in obesity prevalence among children and adolescents in the United States, 1988–1994 through 2013–2014.
        JAMA. 2016; 315: 2292-2299
        • Ogden CL
        • Fryar CD
        • Martin CB
        • et al.
        Trends in obesity prevalence by race and Hispanic origin-1999–2000 to 2017–2018.
        JAMA. 2020; 324: 1208-1210
      1. Stierman B, Afful J, Carroll MD, et al. National health and nutrition examination survey 2017–March 2020 prepandemic data files—development of files and prevalence estimates for selected health outcomes. Natl Health Stat Rep. Accessed May 1, 2023.

        • Sanchez-Flack JC
        • Herman A
        • Buscemi J
        • Kong A
        • Bains A
        • Fitzgibbon ML.
        A systematic review of the implementation of obesity prevention interventions in early childcare and education settings using the RE-AIM framework.
        Transl Behav Med. 2020; 10: 1168-1176
      2. Percentage of 3-, 4-, and 5-year-old children enrolled in preprimary programs, by level of program, attendance status, and selected child and family characteristics: 2017. National Center for Education Statistics. Accessed May 26, 2022.

        • Francis L
        • Shodeinde L
        • Black MM
        • Allen J.
        Examining the obesogenic attributes of the family child care home environment: a literature review.
        J Obes. 2018; 20183490651
        • Sisson SB
        • Krampe M
        • Anundson K
        • Castle S.
        Obesity prevention and obesogenic behavior interventions in child care: a systematic review.
        Prev Med. 2016; 87: 57-69
        • Story M
        • Kaphingst KM
        • French S.
        The role of child care settings in obesity prevention.
        Future Child. 2006; 16: 143-168
        • Nicklas TA
        • Baranowski T
        • Baranowski JC
        • Cullen K
        • Rittenberry L
        • Olvera N.
        Family and child-care provider influences on preschool children's fruit, juice, and vegetable consumption.
        Nutr Rev. 2001; 59: 224-235
        • Lindsay AC
        • Sussner KM
        • Greaney ML
        • Peterson KE.
        Influence of social context on eating, physical activity, and sedentary behaviors of Latina mothers and their preschool-age children.
        Health Educ Behav. 2009; 36: 81-96
      3. Mamedova S, Redford J. Early childhood program participation, from the national household education surveys program of 2012 (NCES 2013-029.REV2). National Center for Education Statistics, Institute of Education Sciences, US Department of Education. Accessed October 20, 2022.

      4. Leaving children to chance: NACCRRA's ranking of state standards and oversight of small family child care homes. 2012 Update. National Association of Child Care Resource and Referral Agencies. Accessed May 1, 2023.

        • Trost SG
        • Messner L
        • Fitzgerald K
        • Roths B.
        Nutrition and physical activity policies and practices in family child care homes.
        Am J Prev Med. 2009; 37: 537-540
      5. Office of Planning, Research and Evaluation. The Administration for Children and Families. Accessed November 27, 2022.

      6. Paschall K, Madill R, Halle T. Professional characteristics of the Early Care and Education workforce: descriptions by race, ethnicity, languages spoken, and nativity status. Office of Planning, Research, and Evaluation, Administration for Children and Families, US Department of Health and Human Services. Accessed May 1, 2023.

        • Bandura A.
        Human agency in Social Cognitive Theory.
        Am Psychol. 1989; 44: 1175-1184
        • Benjamin Neelon SE
        • Copeland KA
        • Ball SC
        • Bradley L
        • Ward DS.
        Comparison of menus to actual foods and beverages served in North Carolina child-care centers.
        J Am Diet Assoc. 2010; 110: 1890-1895
        • Kharofa RY
        • Kalkwarf HJ
        • Khoury JC
        • Copeland KA.
        Are mealtime best practice guidelines for child care centers associated with energy, vegetable, and fruit intake?.
        Child Obes. 2016; 12: 52-58
        • Larson N
        • Ward DS
        • Neelon SB
        • Story M.
        What role can child-care settings play in obesity prevention? A review of the evidence and call for research efforts.
        J Am Diet Assoc. 2011; 111: 1343-1362
        • Ward S
        • Bélanger M
        • Donovan D
        • Carrier N.
        Systematic review of the relationship between childcare educators’ practices and preschoolers’ physical activity and eating behaviours.
        Obes Rev. 2015; 16: 1055-1070
        • Ward S
        • Blanger M
        • Donovan D
        • et al.
        Association between childcare educators’ practices and preschoolers’ physical activity and dietary intake: A cross-sectional analysis.
        BMJ Open. 2017; 7e013657
        • Dev DA
        • Garcia AS
        • Dzewaltowski DA
        • et al.
        Provider reported implementation of nutrition-related practices in childcare centers and family childcare homes in rural and urban Nebraska.
        Prev Med Rep. 2020; 17101021
        • Breck A
        • Dixon LB
        • Kettel Khan L
        Comparison of planned menus and centre characteristics with foods and beverages served in New York City child-care centres.
        Public Health Nutr. 2016; 19: 2752-2759
        • Copeland KA
        • Benjamin Neelon SE
        • Howald AE
        • Wosje KS.
        Nutritional quality of meals compared to snacks in child care.
        Child Obes. 2013; 9: 223-232
        • Larson N
        • Ayers Looby A
        • Frost N
        • Nanney MS
        • Story M
        What can be learned from existing investigations of weight-related practices and policies with the potential to impact disparities in US child-care settings? A narrative review and call for surveillance and evaluation efforts.
        J Acad Nutr Diet. 2017; 117: 1554-1577
        • Oakley CB
        • Bomba AK
        • Knight KB
        • Byrd SH.
        Evaluation of menus planned in Mississippi child-care centers participating in the Child and Adult Care Food Program.
        J Am Diet Assoc. 1995; 95: 765-768
        • Anundson K
        • Sisson SB
        • Anderson M
        • Horm D
        • Soto J
        • Hoffman L.
        Staff food-related behaviors and children's tastes of food groups during lunch at child care in Oklahoma.
        J Acad Nutr Diet. 2018; 118: 1399-1407
        • Bagnall AM
        • South J
        • Hulme C
        • et al.
        A systematic review of the effectiveness and cost-effectiveness of peer education and peer support in prisons.
        BMC Public Health. 2015; 15: 290
        • Gubbels JS
        • Kremers SPJ
        • Stafleu A
        • Dagnelie PC
        • de Vries NK
        • Thijs C.
        Child-care environment and dietary intake of 2- and 3-year-old children.
        J Hum Nutr Diet. 2010; 23: 97-101
        • Gubbels JS
        • Gerards SM
        • Kremers SP.
        Use of food practices by childcare staff and the association with dietary intake of children at childcare.
        Nutrients. 2015; 7: 2161-2175
        • Benjamin-Neelon SE
        • Vaughn AE
        • Tovar A
        • Østbye T
        • Mazzucca S
        • Ward DS.
        The family child care home environment and children's diet quality.
        Appetite. 2018; 126: 108-113
        • Vaughn AE
        • Mazzucca S
        • Burney R
        • et al.
        Assessment of nutrition and physical activity environments in family child care homes: modification and psychometric testing of the Environment and Policy Assessment and Observation.
        BMC Public Health. 2017; 17: 680
        • Tovar A
        • Vaughn AE
        • Fisher JO
        • et al.
        Modifying the Environment and Policy Assessment and Observation (EPAO) to better capture feeding practices of family childcare home providers.
        Public Health Nutr. 2019; 22: 223-234
        • Erinosho T
        • Hales D
        • Vaughn A
        • Gizlice Z
        • Ward D.
        The quality of nutrition and physical activity environments of family child-care homes in a state in the Southern United States.
        J Acad Nutr Diet. 2019; 119: 991-998
        • Gans KM
        • Tovar A
        • Jiang Q
        • et al.
        Nutrition-related practices of family child care providers and differences by ethnicity.
        Child Obes. 2019; 15: 167-184
        • Martyniuk OJM
        • Vanderloo LM
        • Irwin JD
        • Burke SM
        • Tucker P.
        Comparing the nutrition environment and practices of home- and centre-based child-care facilities.
        Public Health Nutr. 2016; 19: 575-584
        • Pérez-Escamilla R
        • Jimenez EY
        • Dewey KG.
        Responsive feeding recommendations: harmonizing integration into dietary guidelines for infants and young children.
        Curr Dev Nutr. 2021; 5: nzab076
        • Risica PM
        • Karpowicz JM
        • von Ash T
        • Gans KM
        • Cooksey-Stowers K
        • Tovar A
        Feeding and activity environments for infants and toddlers in childcare centers and family childcare homes in Southeastern New England.
        Int J Environ Res Public Health. 2022; 19: 9702
      7. HEI Scores for Americans. US Department of Agriculture, Center for Nutrition Policy and Promotion. Accessed October 20, 2022.

        • Tovar A
        • Risica PM
        • Ramirez A
        • et al.
        Exploring the provider-level socio-demographic determinants of diet quality of preschool-aged children attending family childcare homes.
        Nutrients. 2020; 12: 1368
        • Benjamin SE
        • Rifas-Shiman SL
        • Taveras EM
        • et al.
        Early child care and adiposity at ages 1 and 3 years.
        Pediatrics. 2009; 124: 555-562
        • McLaren L
        • Zarrabi M
        • Dutton DJ
        • Auld MC
        • Emery JCH.
        Child care: implications for overweight /obesity in Canadian children?.
        Chronic Dis Inj Can. 2012; 33: 1-11
        • Maher EJ
        • Li G
        • Carter L
        • Johnson DB
        Preschool child care participation and obesity at the start of kindergarten.
        Pediatrics. 2008; 122: 322-330
        • Risica PM
        • Gorham G
        • Dionne L
        • et al.
        A multi-level intervention in worksites to increase fruit and vegetable access and intake: rationale, design and methods of the ‘Good to Go’ cluster randomized trial.
        Contemp Clin Trials. 2018; 65: 87-98
      8. NIH policy on reporting race and ethnicity data: subjects in clinical research. NOT-OD-01-053. National Institutes of Health. Accessed February 10, 2023.

        • Ammerman AS
        • Ward DS
        • Benjamin SE
        • et al.
        An intervention to promote healthy weight: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) theory and design.
        Prev Chronic Dis. 2007; 4: A67
        • Benjamin Neelon SE
        • Vaughn A
        • Ball SC
        • McWilliams C
        • Ward DS.
        Nutrition practices and mealtime environments of North Carolina child care centers.
        Child Obes. 2012; 8: 216-223
        • Erinosho T
        • Vaughn A
        • Hales D
        • Mazzucca S
        • Gizlice Z
        • Ward D.
        Participation in the Child and Adult Care Food Program is associated with healthier nutrition environments at family child care homes in Mississippi.
        J Nutr Educ Behav. 2018; 50: 441-450
        • McWilliams C
        • Ball SC
        • Benjamin SE
        • Hales D
        • Vaughn A
        • Ward DS.
        Best-practice guidelines for physical activity at child care.
        Pediatrics. 2009; 124: 1650-1659
        • Ward DS
        • Benjamin SE
        • Ammerman AS
        • Ball SC
        • Neelon BH
        • Bangdiwala SI.
        Nutrition and physical activity in child care: Results from an environmental intervention.
        Am J Prev Med. 2008; 35: 352-356
        • Tovar A
        • Mena NZ
        • Risica PM
        • Gorham G
        • Gans KM.
        Nutrition and physical activity environments of home-based child care: what Hispanic providers have to say.
        Child Obes. 2015; 11: 521-529
        • Tovar A
        • Risica PM
        • Mena N
        • Lawson E
        • Ankoma A
        • Gans KM.
        An assessment of nutrition practices and attitudes in family child-care homes: implications for policy implementation.
        Prev Chronic Dis. 2015; 12: E88
      9. Ward D, Morris E, McWilliams C, et al. Go NAPSACC: Nutrition and Physical Activity Self-Assessment for Child Care, 2nd ed. Center for Health Promotion and Disease Prevention and Department of Nutrition, University of North Carolina at Chapel Hill. Accessed August 27, 2022.

        • Benjamin SE
        • Ammerman A
        • Sommers J
        • Dodds J
        • Neelon B
        • Ward DS.
        Nutrition and Physical Activity Self-assessment for Child Care (NAP SACC): results from a pilot intervention.
        J Nutr Educ Behav. 2007; 39: 142-149
        • Benjamin SE
        • Neelon B
        • Ball SC
        • Bangdiwala SI
        • Ammerman AS
        • Ward DS.
        Reliability and validity of a nutrition and physical activity environmental self-assessment for child care.
        Int J Behav Nutr Phys Act. 2007; 4: 29
        • Benjamin Neelon SE
        • Briley ME
        American Dietetic Association. Position of the American Dietetic Association: benchmarks for nutrition in child care.
        J Am Diet Assoc. 2011; 111: 607-615
        • McGuire S.
        Institute of Medicine (IOM) early childhood obesity prevention policies.
        The National Academies Press, 2011: 56-57 (Adv Nutr. 2012;3)
      10. Caring for our children: national health and safety performance standards. Guidelines for Early Care and Education programs. American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Accessed May 1, 2023.

        • Krebs-Smith SM
        • Pannucci TE
        • Subar AF
        • et al.
        Update of the Healthy Eating Index: HEI-2015.
        J Acad Nutr Diet. 2018; 118: 1591-1602
        • Ball SC
        • Benjamin SE
        • Ward DS.
        Development and reliability of an observation method to assess food intake of young children in child care.
        J Am Diet Assoc. 2007; 107: 656-661
        • Erinosho TO
        • Ball SC
        • Hanson PP
        • Vaughn AE
        • Ward DS.
        Assessing foods offered to children at child-care centers using the Healthy Eating Index-2005.
        J Acad Nutr Diet. 2013; 113: 1084-1089
        • Risica PM
        • Tovar A
        • Palomo V
        • et al.
        Improving nutrition and physical activity environments of family child care homes: the rationale, design and study protocol of the ‘Healthy Start/Comienzos Sanos’ cluster randomized trial.
        BMC Public Health. 2019; 19: 419
        • Barnes TL
        • Lenk K
        • Caspi CE
        • Erickson DJ
        • Laska MN.
        Perceptions of a healthier neighborhood food environment linked to greater fruit and vegetable purchases at small and non-traditional food stores.
        J Hunger Environ Nutr. 2019; 14: 741-761
        • Williams BD
        • Sisson SB
        • Stinner EL
        • et al.
        Quality of nutrition environments, menus and foods served, and food program achievement in Oklahoma family child care homes.
        Nutrients. 2021; 13
        • Mennella JA
        • Ventura AK.
        Early feeding: setting the stage for healthy eating habits.
        Nestle Nutr Workshop Ser Pediatr Program. 2011; 68 (discussion 164-8): 153-168
        • Jiang Q
        • Tovar A
        • Risica PM
        • et al.
        Ethnic differences in family childcare providers’ nutrition- and activity-related attitudes and barriers.
        J Obes. 2021; 20216697006
        • Tovar A
        • Vaughn AE
        • Grummon A
        • et al.
        Family child care home providers as role models for children: cause for concern?.
        Prev Med Rep. 2017; 5: 308-313
        • Elharake JA
        • Shafiq M
        • Cobanoglu A
        • et al.
        Prevalence of chronic diseases, depression, and stress among US childcare professionals during the COVID-19 pandemic.
        Prev Chronic Dis. 2022; 19: E61
        • Monsivais P
        • Johnson DB.
        Improving nutrition in home child care: are food costs a barrier?.
        Public Health Nutr. 2012; 15: 370-376
      11. Porter T, Paulsell D, Grosso P Del, Avellar S, Hass R, Vuong L. A review of the literature on home-based child care: implications for future directions. Mathematica Policy Research. Accessed May 1, 2023.

      12. Early childhood and child care study. US Department of Agriculture, Food and Nutrition Service. Accessed May 3, 2022.

        • Food and Nutrition Service, USDA
        Child and Adult Care Food Program: meal pattern revisions related to the Healthy, Hunger-Free Kids Act of 2010. Final rule.
        Fed Regist. 2016; 81: 24347-24383
        • Benjamin SE
        • Cradock A
        • Walker EM
        • Slining M
        • Gillman MW.
        Obesity prevention in child care: a review of U.S. state regulations.
        BMC Public Health. 2008; 8: 188
        • Zaltz DA
        • Hecht AA
        • Neff RA
        • et al.
        Healthy eating policy improves children's diet quality in Early Care and Education in South Carolina.
        Nutrients. 2020; 12: 1-13
        • Dooyema CA
        • Hall K
        • Tovar A
        • Bauer KW
        • Lowry-Warnock A
        • Blanck HM.
        Leveraging federal, state, and facility-level Early Care and Education systems and providers toward optimal child nutrition in the first 1000 days.
        Am J Public Health. 2022; 112: S779-S784
        • Gans KM
        • Tovar A
        • Kang A
        • et al.
        A multi-component tailored intervention in family childcare homes improves diet quality and sedentary behavior of preschool children compared to an attention control: results from the Healthy Start-Comienzos Sanos cluster randomized trial.
        Int J Behav Nutr Phys Act. 2022; 19: 45
      13. Adams G, Ewen D, Luetmer G. Supporting the child care and early education workforce. A menu of policy options for the COVID-19 Pandemic and Recovery. Accessed November 27, 2022.

        • Hashikawa AN
        • Sells JM
        • DeJonge PM
        • Alkon A
        • Martin ET
        • Shope TR.
        Child care in the time of coronavirus Disease-19: A period of challenge and opportunity.
        J Pediatr. 2020; 225: 239-245