Evidence for Criterion-Related Validity of Pressure-Mediated Reflection Spectroscopy for Approximating Fruit and Vegetable Consumption among Preschool Children.

BACKGROUND: Skin carotenoids are a valid biomarker for approximating fruit and vegetable consumption (FVC). Veggie Meter® (VM®, Longevity Link Corp.) is a pressure-mediated reflection spectroscopy (RS)-based device that allows for noninvasive and rapid assessment of skin-carotenoid score (SCS) in adults and children. Although VM® is established as a valid tool to measure FVC in adults, there is limited research supporting the validity evidence of the VM® to approximate FVC among preschool children. OBJECTIVE: The current study aims to assess evidence supporting the criterion-related validity of RS-based SCS for approximating FVC among preschool children (3-5-y old). METHODS: We collected cross-sectional data from typically developing preschool children (n = 136) attending the Child and Adult Care Food Program-participating family child care home settings (FCCHs) (n = 46) in Nebraska. Research team members collected children's height and weight to calculate body mass index; and measured children's SCS using the VM®. Children's FVC in FCCHs were collected using dietary observation. In addition, parents (n = 89) completed a shortened food frequency questionnaire to report children's FVC at home. Kendall's Tau (τ) correlation tests were conducted to measure the association between children's SCS with FVC in FCCHs and with parent-reported total fruit and vegetable (FV) frequency scores. RESULTS: Children's SCS were significantly correlated with their mean FVC in FCCHs, τ = 0.14 (P = 0.02), total provitamin A carotenoids intake in FCCHs, τ = 0.19 (P < 0.001), and with parent-reported total FV frequency score, τ = 0.16 (P = 0.04). CONCLUSION: The correlation coefficients in this study are comparable with results from a meta-analysis examining associations between FVC and SCS in 7-10-y-old children (r = 0.20). Thus, evidence suggests that RS offers a potentially valid, objective, and feasible method to assess preschool children's total FVC in multiple settings, especially in conjunction with other dietary assessment tools.

Illuminating Child and Adult Care Food Program Partnerships That Improved Food Access and Waiver Utilization for Feeding Young Children in Early Care and Education Programs During COVID-19: A Qualitative Study.

BACKGROUND: Little is known about the partnerships formed between early care and education (ECE) programs and the Child and Adult Care Food Program (CACFP) and other organizations to continue to feed young children during the COVID-19 pandemic. Such information can provide important lessons to build ECE capacity for feeding children during future emergencies and has the potential strengthen the ECE food systems. OBJECTIVE: This study aimed to identify the unique partnerships that CACFP state agencies established to provide nutrition to young children during the COVID-19 pandemic DESIGN: Qualitative semi-structured interviews with 24 participants representing 21 states across the United States. PARTICIPANTS/SETTING: Virtual interviews with CACFP directors from December 2020 through May 2021. ANALYSIS: Following the realist method, transcripts were analyzed using thematic analysis. Codes were developed inductively and grouped to identify themes and subthemes. RESULTS: Four themes were identified: (1) CACFP partnerships that supported children and families directly; (2) CACFP partnerships that built the capacity of ECE providers to provide food to children in their own settings; (3) CACFP systems-level partnerships that improved coordination of efforts to continue to feed children in ECE; and (4) CACFP directors encouraged other CACFP state agencies to build nontraditional, diverse partnerships that can be leveraged during pandemics and other natural disasters. Within these themes (subthemes), the purpose of the partnerships focused on improving waiver utilization (eg, Department of Transportation, state health departments), improving food access (eg, Summer Food Service Program [SFSP], food banks, grocery stores, dairy councils), supporting ECE programs to participate in food reimbursement programs (eg, SFSP, CACFP sponsors), and resource sharing (eg, coalitions, CACFP sponsors). CONCLUSIONS: The CACFP state directors reported that existing and new partnerships between CACFP state agencies and external entities successfully facilitated feeding young children in ECE during the COVID-19 pandemic. States may consider developing a road map to proactively explore potential partners in their state to meet specific needs such as accessibility, availability, and affordability for feeding young children in ECE.

Accuracy of Parent-Measured Weight and Height of Preschool Children at Home With Increasing Levels of Instruction.

Background: The purpose of this study was to determine how accurately parents measure their preschool child's weight and height with increasing levels of instruction. Methods: Parents measured their child's (n = 30 dyads) weight (own weight scale) and height (soft tape measure) using three levels of instruction: instructional guide (level 1); guide, demonstration video (level 2); and guide, video, and virtual monitoring (level 3), which were compared to researcher measurements (electronic weight scale, Stadiometer). Paired t-tests were used to determine differences between researcher and parent measurements and between the three parent levels. Inaccurate classifications were calculated using parent-measured values for the four categories (underweight, healthy, overweight, obese). Results: Raw mean parent-measured weights (17.4 ± 2.3 kg) differed from researcher by 0.2 kg (level 1), 0.3 kg (level 2), and 0.1 kg (level 3). Raw mean parent-measured heights (104.0 ± 5.9 cm) differed from researcher by 0.9 cm (level 1, p = 0.005), 0.4 cm (level 2, NS), and 0.3 cm (level 3, NS). Across all levels, 48.9% and 65.5% parents overmeasured their children's weights and heights, respectively. Using parent-measured values, 29.4% of children were classified high while 70.5% were classified low. Parents were more likely to make errors if their children were on the borderline between any of the two weight categories. Conclusion: Findings indicate that an instructional guide with demonstration video is helpful in improving the parents' accuracy of their children's weights and heights. More research is needed to determine accuracy in population other than White parents with high education levels and children under overweight and obese category.

Integration of Food-based Learning With Science in the Preschool Classroom: Implementation Gaps and Opportunities.

OBJECTIVE: To explore Head Start teachers' use and integration of food-based learning (FBL) with science learning in the Head Start classroom. DESIGN: Phenomenological approach using in-depth semistructured telephone interviews. SETTING: North Carolina Head Start preschools. PARTICIPANTS: Thirty-five Head Start lead and assistant teachers. PHENOMENON OF INTEREST: All interviews were transcribed verbatim. Authors coded interview data for emergent themes. ANALYSIS: Eleven primary themes were identified during analysis and inductively organized using the Systems Thinking Iceberg Model. RESULTS: Teachers described most frequently using FBL during mealtimes. Teachers stated they felt successful when children were engaged and willing to try a new food. However, they struggled to connect food to science concepts. Teachers reported several motivators (eg, improving health) and barriers (eg, food waste) to integrating FBL. Teachers prioritized preparing children for kindergarten, but most teachers did not see how FBL could help them achieve this goal. CONCLUSIONS AND IMPLICATIONS: Head Start teacher professional development programs could impact all 4 levels of the Systems Thinking Model to improve teachers' perceptions, underlying structures, and mental models regarding integrative FBL. Additional research is warranted to investigate the adoption, implementation, and potential impact of FBL on academic outcomes.

Systematic Review of Reflection Spectroscopy-Based Skin Carotenoid Assessment in Children.

Assessing children's skin carotenoid score (SCS) using reflection spectroscopy (RS) is a non-invasive, widely used method to approximate fruit and vegetable consumption (FVC). The aims for the current review were to (1) identify distributions of SCS across demographic groups, (2) identify potential non-dietary correlates for RS-based SCS, (3) summarize the validity and reliability of RS-based SCS assessment, and (4) conduct meta-analyses of studies examining the correlation between RS-based SCS with FVC. A literature search in eight databases in June 2021 resulted in 4880 citations and peer-reviewed publications written in English that investigated children's (2-10 years old) SCS using RS. We included 11 studies (intervention = 3, observational = 8). Potential covariates included weight status, ethnicity, seasonal variation, age, sex, and income. Studies reported criterion validity with children's FVC but not with plasma carotenoid. Additionally, no studies reported the reliability of RS-based SCS in children. Among the 726 children included in the meta-analysis, the correlation between RS-based SCS and FVC was r = 0.2 (p < 0.0001). RS-based SCS is a valid method to quantify skin carotenoids for children's FVC estimation with the potential for evaluating nutrition policies and interventions. However, future research should use standardized protocol for using RS and establish how RS-based SCS can translate to the amount of daily FVC in children.

Implementation of Federal Waivers for Feeding Children in Early Care and Education During the COVID-19 Pandemic.

OBJECTIVE: To capture Child and Adult Care Food Program (CACFP) state directors' experiences implementing federal waivers for feeding children in early care and education (ECE) settings during coronavirus disease 2019. DESIGN: Qualitative semistructured interviews. SETTING: Virtual interviews with state CACFP directors. PARTICIPANTS: Child and Adult Care Food Program directors from 21 states from December 2020 to May 2021. PHENOMENON OF INTEREST: Implementation of state-level waivers. ANALYSIS: Qualitative thematic analysis. RESULTS: State directors reported that the coronavirus disease 2019 waivers allowed ECE programs to continue feeding children despite being closed or having limited enrollment. The meal pattern, noncongregate feeding, parent/guardian meal pick-up, and monitoring waivers were most frequently used by states. Challenges included maintaining integrity to CACFP meal pattern requirements, addressing the limited capacity of ECE to produce and distribute noncongregate meals, and adapting technology for virtual reviews. Suggested improvements included streamlined communication from the US Department of Agriculture, standing waivers for emergencies, ongoing flexibilities for feeding children, and strategies to increase CACFP enrollment and reduce financial viability requirements for ECE. CONCLUSIONS AND IMPLICATIONS: Results indicate the need for the US Department of Agriculture to consider issuing and extending waivers, increasing ECE participation in CACFP, and ensuring timely communication and guidance on waiver tracking.

Relationships between proximity to grocery stores and Oklahoma Early Care and Education classroom nutrition practices.

The study purpose was to determine associations between proximity to grocery stores and Early Care and Education programs' (i.e., ECEs) classroom nutrition practices and barriers, by ECE context (Head Start, community-based childcare [CBC], and family child care homes [FCCHs]). A statewide cross-sectional survey was implemented in Oklahoma ECEs. Directors reported classroom nutrition practices with the Nutrition and Physical Activity Self-Assessment tool, and barriers to implementation. Locations of 457 grocery stores statewide were determined by in-person audit. Geocoded ECEs were considered within a "low proximity" area if no grocery stores were available within a 0.25-mile radius for urban, or 10-mile radius for rural, ECEs. From November 2019 to February 2020, 54 Head Starts, 159 CBCs, and 160 FCCHs participated. 31.0 % were considered as low proximity. Head Starts demonstrated the highest classroom nutrition scores for mealtime practices, and nutrition education and policy. While proximity to grocery stores was not related to classroom nutrition practices for any ECE context (p > 0.05), FCCHs located within a low proximity area reported barriers to implementing those practices more often compared to FCCHs in an area within accessible proximity of grocery store. Thus, proximity to grocery stores was related to barriers in FCCHs only; those provider's experiences and perceptions may be most susceptible to influence of the community nutrition environment, compared to other ECE contexts. Contrary to studies in residential areas and schools, nutrition environments were not related to nutrition practices in ECEs. ECEs may serve as protective micro-environments supporting health for children residing in nearby low-access communities.

Ecological Approach to Family-Style, Multilevel Child Care Intervention: Formative Evaluation Using RE-AIM Framework.

OBJECTIVE: Conduct formative evaluation of Ecological Approach to Family-Style Dining (EAT) Intervention. DESIGN: Qualitative semistructured interviews and demographic surveys. SETTING: Early care and education (ECE) centers in Nebraska. PARTICIPANTS: Cooperative Extension coaches (n = 9), ECE administrators (n = 8), and teachers (n = 17) caring for children aged 3-5 years. INTERVENTION: The EAT intervention (a 16-week, 7-lesson, evidence-based online responsive feeding ECE model) uses a multilevel improvement system of 5 implementation strategies. Early care and education administrators and teachers completed 1 lesson/wk followed by a coaching session. MAIN OUTCOME MEASURES: The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework includes 5 evaluative dimensions. ANALYSIS: Thematic analysis. RESULTS: Overall, 77% of children aged 3-5 years (n = 216) participated from targeted Child and Adult Care Food Program ECEs (Reach). All perceived EAT improved children's nutritional and developmental outcomes and encouraged a positive mealtime environment (Effectiveness). Coaches found professional development incentives important, whereas administrators/teachers valued inservice hours (Adoption). Teachers reported successful implementation of responsive feeding, and administrators supported the teachers (Implementation). All reported they intended to continue using EAT, and administrators and teachers discussed incorporating EAT practices into the handbook/school policy (Maintenance). CONCLUSION AND IMPLICATIONS: The EAT was valued by all stakeholders for its perceived effectiveness to positively impact children's nutritional outcomes. Furthermore, stakeholders valued the provided incentives and multilevel design with coaching, ECE administrators, and teachers. Future research is needed on how to use Extension coaches in ECE interventions.

Correlates of children's dietary intake in childcare settings: A systematic review.

CONTEXT: Children consume up to two-thirds of their daily dietary requirements in full-time childcare, making the setting a critical vector for preventing childhood obesity. OBJECTIVE: To summarize the ecological correlates of children's dietary intake in childcare settings that were identified and categorized using the Six-Cs developmental ecological model of contributors to overweight and obesity in childhood. DATA SOURCES: A literature search was conducted in 4 electronic databases. STUDY SELECTION: English-language, peer-reviewed publications that investigated at least 1 correlate of children's (ages 2-6 years) dietary intake in childcare settings and measured children's actual consumption of foods and beverages from food groups were included. DATA EXTRACTION: Correlates were categorized into child, clan, community, and country groups. RESULTS: A total of 55 studies, which examined 29 correlates, were reviewed. Correlates identified included child's age, sex, characteristics of food provision (namely, food composition, foods and beverages served, portion sizes), repeated exposure, nutrition education, book reading, peer influence, meal service type, and childcare teachers' responsive feeding practices. Policies and participation in Head Start and the Child and Adult Care Food Program could not be determined as correlates of children's dietary intake, owing to a lack of evidence. CONCLUSION: This review produced a list of correlates to consider in designing interventions to improve children's dietary intake in childcare settings. The correlates could contribute to development of lifelong healthy eating habits, thereby preventing childhood obesity.

Food Waste, Preference, and Cost: Perceived Barriers and Self-Reported Food Service Best Practices in Family Child Care Homes.

Background: Family Child Care Homes (FCCHs) are a setting where providers care for children at their own residence. FCCHs face unique challenges and children may not always receive optimal nutrition and have higher risk of obesity compared to other programs. The objective of this study was to determine differences in food service best practices scores between FCCHs who did/did not perceive barriers to serving healthy meals. Methods: FCCHs (n = 167) self-reported demographics, and perceived barriers to serving healthy foods. Nutrition and Physical Activity Self-Assessment for Child Care was used to assess food served with 1 (indicating poor practice) to 4 (indicating best practice). Means, standard deviations, and t-tests were conducted to determine differences in scores between FCCHs with and without perceived barriers. Adjusted alpha was 0.013. Results: FCCHs perceiving food waste as a barrier had significantly lower scores for total food and beverage (p = 0.006, 3.2 ± 0.3 vs. 3.4 ± 0.3); fruits and vegetables (p = 0.003, 3.1 ± 0.5 vs. 3.3 ± 0.5), whole fruits (p = 0.048, 3.1 ± 1.2 vs. 3.4 ± 0.9), and nonstarchy vegetables (p = 0.007, 2.8 ± 0.9 vs. 3.2 ± 0.9). Providers perceiving food preferences as a barrier had significantly lower scores compared to those who did not (p = 0.008, 2.9 ± 0.9 vs. 3.3 ± 0.9). No significant differences found in best practices among providers with vs. without perceived barrier of food costs. Conclusion: Food waste is an understudied barrier in FCCHs to serve healthy meals. Research is needed to explore these perceived barriers in FCCHs to improve best practices around meals.

Examining correlates of feeding practices among parents of preschoolers.

Background: Parent feeding practices play a critical role in children's eating behaviors. Limited research has explored child-level correlates of parent feeding practices. Aim: To identify correlates of feeding practices (responsive and controlling) among parents of preschoolers US. Methods: Participants included parents (n = 273) of preschoolers (3-5 years), recruited from Early Care and Education settings (n = 24) located in a metropolitan city in the US. Analysis included descriptives, correlations, and multiple regression. Results: For responsive feeding practices, positive associations included child's weight with unintentional modeling (ß = .17, 95% CI [0.12, 0.53]), child vegetable consumption with behavioral role modeling (ß = 0.22, 95% CI [0.17, 0.44]), and parent monitoring with verbal modeling (ß = 0.21, 95% CI [0.12, 0.34]). For controlling feeding practices, parent restriction was positively associated with child weight concern (ß = 0.22, 95% CI [0.13, 0.39]) and parent monitoring (ß = 0.13, 95% CI [0.01, 0.19]), whereas child vegetable consumption was negatively associated (ß = -0.16, 95% CI [-0.27, -0.05]). Pressure to eat was negatively associated with child weight concern (ß = -0.18, 95% CI [-0.45, -0.09]), child fruit consumption (ß = -0.12, 95% CI [-0.37, -0.01]), household income (ß = -0.13, 95% CI [-0.30, -0.02]), and parent weight (ß = -0.14, 95% CI [-0.60, -0.05]), Conclusions: Findings highlight the importance of child characteristics when examining correlates of parent feeding practices, demonstrating bidirectional interactions between parent feeding practices and children's eating behaviors. Considering child-level correlates may improve the implementation of responsive feeding practices and reduce controlling feeding practices.

A qualitative comparison of parent and childcare provider perceptions of communication and family engagement in children's healthy eating and physical activity.

BACKGROUND: Parents and childcare providers play a substantial role in the development of health behaviours among the children they care for. In order to ensure the optimal growth and development of children, communication and family engagement in childcare is critical. Previous studies examining parent or provider perceptions about healthy eating or physical activity have explored these concepts individually and/or have only included only parents or providers. Therefore, the purpose of this study was to compare childcare provider and parent perceptions of communication regarding healthy eating and physical activity as well as use of best practice strategies on family engagement for these topics. METHODS: Childcare providers (n = 12) in childcare centres or a family childcare home and a parent (n = 12) of a child they provide care for participated in a semi-structured interview guided by the Social Ecological Model. Interviews were transcribed verbatim and uploaded to NVivo for data analysis. Data were analysed using a directed content analysis. Three trained qualitative researchers developed a codebook and then compared responses between parents and providers. RESULTS: Similarities in provider and parent responses included agreement on healthy eating; influences on child development; parents being the most influential on children's healthy eating; how they identified physical activity opportunities; and the use of family engagement principles. Differences that arose included parents' roles in promoting children's physical activity; challenges for parents in promoting healthy eating and physical activity; and providers' encouragement of physical activity. Importantly, few parents mentioned providers were top influences on their child's healthy eating or physical activity. Providers also mentioned having difficult conversations with parents was challenging. CONCLUSIONS: Future efforts are needed to (1) help parents understand the providers' role in the development of their child's health behaviours and (2) strengthen efforts to engage families in healthy behaviours outside of childcare facilities.

Mealtime emotional climate and child health: A systematic review.

BACKGROUND: Positive mealtime emotional climate (MEC) has been linked to better nutrition, psychosocial, literacy and academic outcomes, and fewer behavior problems. However, MEC has been defined in a variety of ways across studies, limiting the ability to synthesize findings and plan future research. OBJECTIVE: To identify which child characteristics are associated with MEC and to determine how previous studies have measured MEC. METHODS: We searched three databases (1980-2020) for peer-reviewed articles measuring MEC. Inclusion criteria required at least one child-level outcome related to physical, nutritional, or developmental health; children aged 0-18 years old; and quantitative data using cohort, case-control, intervention, or experimental designs. We used a previously published taxonomy to categorize child/adolescent characteristics as correlates, non-correlates, unclear, or as having insufficient evidence, according to the amount of evidence linking them to MEC. Additionally, we extracted data about the measures and definitions of MEC from each included article. RESULTS: Out of 668 unique studies identified in the initial search after duplicates removed, 14 met inclusion criteria, and only three used the same measure of MEC. Healthful dietary intake, disordered eating behaviors, and weight/BMI were categorized as correlates of MEC, but links to unhealthy dietary intake are unclear. Several characteristics (e.g. temperament, academic success) were examined in one study only. CONCLUSIONS: Future research should examine the relationship between MEC and child psychosocial child outcomes and utilize a preschool age group. These findings aid in conceptualizing how MEC has been defined and measured and illuminate the importance of MEC on children's health.

'Read for Nutrition' programme improves preschool children's liking and consumption of target vegetable.

OBJECTIVE: To determine whether the 'Read for Nutrition' programme would increase liking and consumption of broccoli (a target vegetable) in preschool children and test acceptability and practicality of the programme. DESIGN: Pilot pre-post intervention study, where childcare teachers received training and coaching followed by reading the book 'Monsters Don't Eat Broccoli' multiple times with the children during a three-week intervention. SETTING: Five classrooms of Educare, Lincoln, Nebraska in 2018. PARTICIPANTS: Sixty-nine (11 to 16 children per classroom) preschool-aged children and sixteen teachers (minimum, three per classroom). RESULTS: Average total consumption of broccoli increased 35 % (0·14 ounces or 0·05th cup) after the 'Read for Nutrition' programme (t = 2·66; P = 0·01; 95 % CIs (0·035, 0·246)) for all children. Proportional consumption increased for children who received ≥ five exposures to the book (t46 = 2·77; P = 0·008). Exposures to the book predicted proportional consumption (ß = 0·365; P = 0·002). Liking of broccoli increased (W69 = 2·2, P = 0·03) as well. Teachers rated the programme as acceptable, practical and enjoyable to children and to themselves. CONCLUSIONS: Programmes such as 'Read for Nutrition' have the potential to improve children's vegetable liking and consumption in early care and education settings with only book readings and no exposure to a real vegetable.

Associations between Community Built Environments with Early Care and Education Classroom Physical Activity Practices and Barriers.

The influence of community-built environments on physical activity (PA) support in Early Childhood Education settings (ECEs) is unknown. The purpose of this cross-sectional study was to determine associations between community PA environments and ECE classroom PA practices. We included licensed Oklahoma ECE directors serving 3-to-5-year-old children. Parks and playground locations were exported from Google Earth. National Walkability Index was derived from 2010 US Census data. ArcMap 10.6 was used to geocode ECE locations, which were within an Activity Desert if no parks/playgrounds were located within a 1-mile radius or if Walkability Index was 10.5 or below. Classroom PA practices were determined by using the Nutrition and PA Self-Assessment tool (NAP SACC). Barriers to implementing practices were reported. Most Head Starts (n = 41; 80.3%), center-based childcare settings (CBC; n = 135; 87.0%), and family childcare homes (FCCHs; n = 153; 96.4%) were in an Activity Desert. Parks/playgrounds within a 10-mile buffer were correlated with classroom PA practices in FCCHs only (p < 0.001). Activity Desert status was not related to classroom PA practices for any ECE context (p > 0.029). While FCCHs may be the most vulnerable to lack of park and playground access, overall findings suggest ECEs provide a healthful micro-environment protective of the typical influence of community-built environments.

Food Program Participation Influences Nutrition Practices in Early Care and Education Settings.

OBJECTIVE: To determine differences by Child and Adult Care Food Program (CACFP) participation on nutrition requirements and best practices and barriers to implementing both in early care and education programs (ECEs) stratified by context (centers vs home-based ECEs). DESIGN: Cross-sectional survey. SETTING: Three-thousand and fourteen licensed Nebraska ECEs in 2017. PARTICIPANTS: One-thousand three hundred forty-five ECEs. MAIN OUTCOME MEASURE(S): Director-reported nutrition practices in classrooms serving children aged 2-5 years (8 requirements for foods served, 5 best practices for foods served, and 14 best practices for mealtime behaviors). ANALYSIS: Chi-square analysis adjusted for multiple comparisons. RESULTS: Of the sample, 86.8% participated in CACFP, 21.7% were center-based, and 78.3% were home-based. Overall, CACFP participation was related to the higher implementation of CACFP requirements for foods served (P < 0.004 for all) and receiving professional development on nutrition (P < 0.012). In home-based ECEs only, CACFP participation was related to a higher prevalence of serving meals family-style (P = 0.002); however, these practices had low implementation overall. CONCLUSION AND IMPLICATIONS: Findings suggest strengthening of requirements to include staff mealtime behaviors beyond service of healthful foods. Improving CACFP enrollment and including CACFP standards in state licensing requirements may be key strategies for improving nutrition practices in ECEs.

Eastern North Carolina Head Start Teachers' personal and professional experiences with healthy eating and physical activity: a qualitative exploration.

OBJECTIVE: Explore the interrelationship between teachers' personal and professional socio-ecological structures while examining Head Start (HS) teachers' experiences with (1) trying to eat healthy and engage in physical activity (PA) and (2) promote healthy eating and PA in their classrooms. DESIGN: In-depth semi-structured interviews were collected from March through June 2017. Researchers designed the data collection and analysis methods using a phenomenological approach. All interviews were recorded using digital audio and transcribed verbatim. SETTING: Seven HS centres in two rural eastern North Carolina counties. PARTICIPANTS: Teachers (n 15) who had recently participated in a healthy eating and physical activity intervention. Participants were 100 % female, an average age of 43 years (sd 9·6) and primarily Black/African American (93·3 %). RESULTS: Eighteen primary themes were identified providing unique insight into individual, social and environmental determinants that may influence teachers' personal health behaviours and professional health promotion practices. Findings indicated that teachers want to improve health behaviours personally (individual/family health) and professionally (children/families served); however, barriers exist at all levels impacting their ability to improve their own health and facilitate positive behaviours among the children/families they serve. Many teachers observed connections between their personal and professional experiences, but not beyond the individual level. CONCLUSIONS: Study findings highlight the importance of considering and emphasising the potential relationship between personal and professional determinants of health when working with early childhood teachers. Findings from this study may be useful for informing the development, implementation and evaluation of future health promotion interventions using teachers as implementers.

Does context matter? A multilevel analysis of neighborhood disadvantage and children's sleep health.

OBJECTIVES: To determine how demographic, socioeconomic, and neighborhood characteristics are associated with bedtimes among US kindergarteners. DESIGN: Parents reported bedtimes of their children as well as personal, household, and residential characteristics via interviews in the Early Childhood Longitudinal Study-Kindergarten (ECLS-K) Class of 1998-1999. The ECLS-K links individual households to US Census tracts. SETTING: A random selection of 1,280 schools and surrounding communities in the US. PARTICIPANTS: A random selection of 16,936 kindergarteners and their parents. MEASUREMENTS: The 2 outcomes were regular and latest weekday bedtimes of kindergarteners. Through a series of nested multilevel regression models, these outcomes were regressed on individual- and neighborhood-level variables, including race/ethnicity, sex, family type, household income, mother's educational attainment, neighborhood disorder, and several additional neighborhood characteristics. RESULTS: Models showed significant (P < .05) bedtime disparities by race/ethnicity, sex, family income, and mother's educational attainment. Additionally, models tended to indicate that kindergarteners from disadvantaged neighborhoods experienced later bedtimes than children from more advantaged areas. Neighborhood characteristics accounted for a portion of racial/ethnic differences, suggesting that bedtime disparities are partly rooted in disparate environmental conditions. CONCLUSIONS: Reducing disparities in childhood sleep may require programs that target not only children and their parents, but also the communities in which they reside.

Participation in the CACFP Ensures Availability but not Intake of Nutritious Foods at Lunch in Preschool Children in Child-Care Centers.

BACKGROUND: The US Department of Agriculture Child and Adult Care Food program (CACFP) recently (October 2017) updated requirements for meal reimbursement and best practice recommendations for serving nutritious meals and beverages, and minimum age-specific serving sizes for five food groups. It is not known whether CACFP-funded child-care centers are meeting the updated meal pattern requirements and best practice recommendations, and whether children are meeting nutrition recommendations based on the current 2015-2020 Dietary Guidelines for Americans (DGA). OBJECTIVE: This study assessed whether the recruited CACFP-funded child-care centers in this study were meeting the updated (2017) CACFP requirements regarding foods served for lunch and whether children attending these child-care centers were meeting age- and sex-specific DGA recommendations regarding foods consumed. DESIGN: This was a cross-sectional study using the Dietary Observation for Child Care method.  PARTICIPANTS AND SETTINGS: Children aged 3 to 5 years (n=108) from 10 classrooms in three CACFP-funded child-care centers in Lincoln, NE, were recruited by convenience sampling during spring 2018. MEASURABLE OUTCOMES: Food served and consumed during observed lunches in comparison with updated CACFP requirements and DGA, respectively. STATISTICAL ANALYSIS: Adjusted mean amounts of foods served from each food group were compared with age specific minimum CACFP serving size requirements. Adjusted mean amounts of foods consumed from each food group were then compared with age- and sex-specific DGA recommendations. RESULTS: The recruited child-care centers were meeting the updated CACFP requirements regarding foods served but showed limited adherence to the best practice recommendations during the observed lunches. However, the overall mean intake for grains, fruits, and vegetables was significantly lower (P<0.01) than DGA recommendations. In addition, approximately 25% of the children did not consume any vegetables during their meal.      CONCLUSIONS: Although child-care centers were meeting the updated CACFP requirements by serving the recommended amounts of foods, children were not meeting DGA-recommended intakes. Future studies are needed to explore ways to improve adherence to best practice recommendations to improve children's consumption of healthy foods in child-care centers.

The Impact of Responsive Feeding Practice Training on Teacher Feeding Behaviors in Tribal Early Care and Education: The Food Resource Equity and Sustainability for Health (FRESH) Study.

BACKGROUND: Establishing healthy eating habits early affects lifelong dietary intake, which has implications for many health outcomes. With children spending time in early care and education (ECE) programs, teachers establish the daytime meal environment through their feeding practices. OBJECTIVE: We aimed to determine the effect of a teacher-focused intervention to increase responsive feeding practices in 2 interventions, 1 focused exclusively on the teacher's feeding practices and the other focused on both the teacher's feeding practices and a nutrition classroom curriculum, in ECE teachers in a Native American (NA) community in Oklahoma. METHODS: Nine tribally affiliated ECE programs were randomly assigned to 1 of 2 interventions: 1) a 1.5-h teacher-focused responsive feeding practice training (TEACHER; n = 4) and 2) TEACHER plus an additional 3-h training to implement a 15-wk classroom nutrition curriculum (TEACHER + CLASS; n = 5). Feeding practice observations were conducted during lunch at 1 table in 1 classroom for 2- to 5-y-olds at each program before and 1 mo after the intervention. The Mealtime Observation in Child Care (MOCC) organizes teacher behaviors into 8 subsections. Descriptive statistics and the Shapiro-Wilk test for normality were calculated. Paired t tests were calculated to determine change in each group. RESULTS: A mean ± SD of 5.2 ± 2.0 (total n = 47) children and 1.7 ± 0.5 (total n = 14) teachers/center were observed at baseline, and 5.6 ± 1.7 (total n = 50) children and 1.7 ± 0.7 teachers (total n = 14) were observed/center postintervention. Total MOCC scores (max possible = 10) improved for TEACHER (6.1 ± 0.9 compared with 7.5 ± 0.3, t = 4.12, P = 0.026) but not for TEACHER + CLASS (6.5 ± 0.8 compared with 6.4 ± 1.0, t = -0.11, P = 0.915). No other changes were observed. CONCLUSIONS: Teacher intervention-only programs demonstrated improvements in responsive feeding practices, whereas the programs receiving teacher and classroom training did not. Greater burden likely decreased capacity to make changes in multiple domains. We demonstrated the ability to implement interventions in NA ECE. Further research with larger communities is necessary. This trial was registered at clinicaltrials.gov as NCT03251950.