Mediation of the Association between Social Environmental Characteristics of Family Childcare Home and Weight Status in Children by Diet Quality

Background: The food and beverages served in family childcare homes (FCCHs) may play an important role in the development of childhood overweight and obesity. This analysis examines whether children’s diet quality mediates the relationship between foods and beverages served in FCCHs and preschool-aged children’s weight status. Methods: Trained and certified staff conducted observations for two days in each FCCH, using the Environment and Policy Assessment and Observation (EPAO) measure to determine the foods and beverages served to children (N=370) in FCCHs (N=120). They also used the Dietary Observation in Child Care (DOCC) protocol to assess children’s food and beverage intake during childcare, from which we calculated the Healthy Eating Index-2015 (HEI), a measure of diet quality. Height and weight were measured for each child with parent consent from which the child’s body mass index (BMI) z-scores were calculated from. A multilevel mediation analysis was conducted to indicate whether children’s diet quality mediates the relations between food and beverage served in FCCHs and preschool-aged children’s weight status. Results: Children’s total HEI scores significantly mediated the relationship between the EPAO subscale “Food provided” and children’s BMI z-scores (B=−.01, p<.05, 95% CI = [−.03, −.002]). Further, the EPAO subscale “Food provided” was positively associated with the total HEI score (B=.75, p<.01, 95% CI = [.32, 1.18]). Total HEI scores were negatively associated with BMI z-score (B=−.01, p<.05, 95% CI = [−.02, −.001]). Conclusion: Children’s diet quality did significantly mediate the relationship between the food served in FCCHs and children’s weight status. More longitudinal studies with longer follow-up periods need to be conducted to confirm these relationships. Further, future studies need to examine the relationships between a broader spectrum of FCCH environmental characteristics and home environment with children’s weight status, as well as other mediators including physical activity.


Introduction
The prevalence of obesity among preschool aged children has increased in the past 30 years, (1) with 13.7% of 2-5-year-old children who experience obesity in 2018. (2)2)(13) Childcare becomes an essential environment for the prevention of childhood obesity given that children who attend childcare spend an average of 35 hours per week in such settings. (14)A systematic review in 2018 concluded that the associations between the early childcare social environment and young children's weight status were likely mediated by the nutrition and physical activity behaviors that affect children's energy balance. (14)Speci cally, the calorically dense foods and beverages served in early childcare settings likely lead to excess energy intake, which in turn affects children's weight status. (14))(17)(18)(19)(20) One reason may be that the foods and beverages offered in FCCHs are less likely to meet nutrition standards set by the Child and Adult Care Food Program (CACFP) than center-based childcare settings. (12)However, to the author's knowledge, no study has explored whether the food and beverages served in FCCHs is related to children's weight status mediated through children's diet quality.
Thus, the aim of the present study is to examine whether the observed food and beverages served in FCCHs are associated with preschool-aged children's weight status mediated through children's diet quality.We hypothesized that food and beverage served in FCCH is related to children's diet quality which in turn is related to children's weight status.

Participants and FCCHs
The present study utilizes baseline data from Healthy Start/Comienzos Sanos study, an 8-month cluster randomized controlled trial examining the e cacy of a multicomponent intervention to improve nutrition and physical activity environments in English and Spanish-speaking FCCH. (21)Details about study recruitment, intervention, and evaluation as well as study results have been described in full elsewhere, (21,22) and the methods relevant to the current analyses are described below.The Institutional Review Boards of the University of Connecticut, Brown University, and University of Rhode Island approved all study procedures and materials.
To meet study eligibility requirements, FCCHs had to be within 60 miles of Providence, Rhode Island, and had to have been in operation for at least 6 months.FCCH providers had to read and speak Spanish or English, provide meals and snacks for children, and care for at least two 2-to-5-year-old children for at least 10 hours per week.Data was collected from November 2015 to July 2018.Eligible providers completed a baseline telephone survey and in-person survey at the FCCH.A two-day observation was scheduled when at least one parent of an eligible child consented for that child to participate.All measures were conducted or administered by trained project staff.Providers received $25 for completing the baseline in-person survey and $50 for the two-day observation.Children received a reusable water bottle as a thank you gift and parents received a $20 gift card.

Measures
Demographics and other provider characteristics.Providers were asked to provide information about their sex (male, female, or refuse to answer), race (White, Black or African American, American Indian or Alaska Native, Asian, Native Hawaiian or Other Paci c Islander, other races not mentioned above, unknown), (23) ethnicity (Hispanic/non-Hispanic) (23) in a telephone survey and the following variables on an in-person survey: age, household income (less than 25k, 25k -50k, 50k -75k, 75k-100k, more than 100k), marital status (single, married or living with a partner, divorced, separated, widowed), education (less than high school, high school or GED, associate's degree, Bachelor's degree, Master's degree or higher), years in the U.S., country of origin (U.S./non-U.S.), years as a childcare professional, number of children currently in their care (and how many are their own children or grandchildren) and whether the FCCH was enrolled in the CACFP.
Weight Status.Children's body weight and height were measured using an established research protocol. (24)The research staff member conducting measurements set up equipment in a space visible to, but located away from the main childcare activities.Children with parental consent who assented to the measurement came to the area to be measured one at a time.Height was measured using a SECA portable stadiometer to the nearest 8th of an inch.Weight was measured using a Tanita digital scale to one decimal place.Measurements were repeated three times and averaged for each child.Body mass index (BMI) was calculated as weight(kg)/height(m²) and BMI z-scores were calculated based on each child's sex, age and BMI according to the Centers for Disease Control (CDC) growth charts.Per CDC guidance, overweight was de ned as BMI > 85th percentile and obesity as BMI > 95th percentile. (25)od and Beverages Environment in FCCH.To assess the food and beverage environment, we used the validated Environment and Policy Assessment and Observation (EPAO) instrument. (26)The EPAO, originally developed for use in childcare centers, was modi ed to assess the FCCH environment. (27,28)e or two eld observers (two observers if FCCHs with more than three children) conducted the EPAO observation in each FCCH for two full childcare days, which included at least two eating occasions (breakfast, morning snack, lunch, afternoon snack, and/or dinner).Observations began before children ate breakfast and ended when children left for the day.The nutrition-related sections of the EPAO assess compliance with 38 nutrition best practices.Each practice is rated on a scale of 0-3, where higher scores indicate better compliance.The best practices are grouped and averaged into 7 sub-scale scores, each re ecting an aspect of the overall nutrition environment within FCCHs.In the current study, we used the rst two subscales: foods provided (amount, type, and quality of foods provided to children during meals and snacks), and beverages provided (amount, type, and quality of beverages provided to children during meals and snacks).The food provided subscale included serving of 12 types of food (i.e., whole fruit; fruit with syrup; total vegetables; dark green, orange, yellow vegetables; vegetables with added fat; fried potatoes; fried meat; high-fat meat; low-fat meat; high-ber whole grain foods; high-sugar high-fat foods; and high-salt high-fat snacks).Beverages provided subscale included serving 5 beverages (i.e., water; fruit juice; sugary drinks; milk; avored milk).Observations from the two days were combined to create a single, continuous set of subscores and an overall score.Detailed notes about the FCCH environment and providers' nutrition and physical activity practices were recorded by the observer during the home visit.Forms were reviewed for accuracy and completeness by eld staff.Additional review was conducted by data staff. (21)hildren's Diet.Children's dietary quality was measured by calculating the 2015 Healthy Eating Index (HEI) score (29) with two days of dietary data collected using the Dietary Observation in Child Care (DOCC).The DOCC is a reliable, valid visual observation technique for measuring children's dietary intake developed by Ward and her team. (30,31)During the DOCC certi cation process, eld staff need to accurately estimate at least 80% of 20 measured portions of food that a child would typically eat.Field staff must achieve 80% inter-rater reliability with a "gold standard" observer in the eld at a FCCH to pass the certi cation.The quality of observations was continually assessed throughout dietary data collection such that observers needed to pass the certi cation process annually, and participate in structured monthly practice, quarterly validity checks, and semi-annual inter-rater reliability checks.Trained and certi ed data collectors observed all meals/snacks over two days and estimated the amount of food and beverages served and consumed for each child.These data were entered into Nutrition Data System for Research (NDSR) (32) to calculate an average daily HEI score.The total HEI score is a sum of 13 dietary components sub-scores based on two-day averaged score, ranging from 0 to 100, with higher scores indicating better diet quality. (29)A score of 80 or higher re ects a high-quality diet among preschool aged children. (33)HEI component scores are calculated as intake per 1000 calories (except for fatty acids which is scored as a ratio of unsaturated to saturated fatty acids) including total vegetables (5), greens/beans (5), total fruit (5), whole fruit (5), whole grains (10), dairy (10), total proteins (5), seafood plant protein (5), fatty acids (10), sodium (10), re ned grains (10), added sugars (10), and saturated fats (10). (29)alysis A multilevel mediation analysis was conducted to examine two questions.First, are there any direct effects of the food and beverages provided in FCCHs (measured by the EPAO) on children's BMI z scores?Second, are these effects mediated by children's diet quality, as measured by HEI scores?(37) Many intervention programs are conducted in group settings such as schools and community groups. (38,39)As individuals within a cluster tend to be more similar than those selected from different clusters, the statistical assumption of independence of units is violated.Thus, statistical multilevel analysis are needed to account for clustering (40) or it may lead to invalid results. (41)The data collection of the current study occurs at two levels.Because multiple children were sampled within each FCCH, all models account for children clustered within FCCHs.In each model, data collected at the child level are called level-1 data, while data collected at the FCCH level are called level-2 data.In the current study, a 2-1-1 model was employed, which corresponds to measurement levels of the independent (i.e., FCCH food provided/beverage provided -level 2 data), mediator (i.e., child diet quality (HEI) -level 1 data) and outcome (i.e., weight status -level 1 data) variables, respectively (Fig. 1).This two-level model, which allows for grouping of child outcome within FCCHs included residuals at the child and FCCH level. (41)rameters for the models, including xed effects of independent variables and mediators as well as random effects of mediators (only random intercepts between mediators and the outcome were estimated), were estimated using restricted maximum likelihood estimation. (42)The FCCH level independent variables did not vary at the individual level; therefore, the within-group effects of the independent variables were omitted and the mediation effects are presented as between-group indirect effects (i.e., the effect of the group differences in independent variables on the outcome through the mediator). (42)The signi cance level was set at p < .05.A bootstrapping approach was used to determine if this mediation effect is statistically signi cant. (43)All analyses were conducted in Stata SE 16.

Participants
A total of 120 female FCCH providers (67.5% Latinx, 42.5% White, 15% Black, 75% married or living with a partner) were included in the current study.Participant providers averaged 48.9 (9.0) years old and about 60.8% had yearly household income less than $50K; 43.3% had a high school degree/GED or less.The majority (82.5%) accepted Child and Adult Care Food Program (CACFP) subsidies.We moved forward with the mediational analysis because we anticipated that the effect size would be small and we suspected possible suppression. (43)th The environmental subscale "Food provided" was positively associated with the total HEI score (B = .751,p < .01,95% CI = [.32,1.18]).This indicates that higher score on the food provided subscale was associated with better children's diet quality.(Fig. 2 and Table 3).However, the environmental subscale "Beverage Provided" was not signi cantly associated with the total HEI score, so no further analysis was conducted with beverage variables.(See Fig. 3 and Table 3).b).This suggests that better children's diet quality was associated with lower weight status when controlling for food provided in FCCHs.However, when diet quality was included in the model, there was no signi cant direct effect of food provided on BMI z-scores (path c'), suggesting the effect of food provided on BMI z-scores is mediated by children's diet quality.(Fig. 2 and Table 3).
There was a signi cant negative indirect effect of food provided scores on BMI z-scores through total HEI scores (B =-.009, p < .05,95% CI = [-.03,− .002]).There was no signi cant indirect effect of Beverage Provided on BMI z-scores through total HEI scores.(Table 3 and Figs. 2 and 3).

Discussion
The goal of this study was to examine whether preschool-aged children's diet quality mediates the relationship between FCCH food and beverage environments and children's weight status, using objective measures of FCCH environments (i.e., food and beverages provided) and children's diet quality.The study found there is room for improvement in the overall quality of food and beverage served, as well as children's diet quality.These ndings were similar to what others have found about the quality of food/beverage served (10) and children's diet quality in FCCHs (10,44) .Further, we found over a third (35%) of the children in the current study were classi ed in the overweight or obese categories, (45) which is higher than national estimates of 26% overweight/obese prevalence in this age group. (2)Thus, it is urgent to improve the quality of foods and beverages served in FCCHs to promote children's healthy eating, as well as their healthy weight status.We found children's total HEI scores signi cantly mediated the relationship between the EPAO subscale "Food provided" and children's BMI z-scores Though the majority (82.5%) of FCCHs in the current study enrolled in CACFP, many providers did not serve enough vegetables and whole grains, make drinking water available and prompt children to drink it, or limit salty/sugary/fatty snacks. (13)Other studies in FCCHs also found that many providers didn't implement best practices in serving whole grains and vegetables, and foods that are lower in fat and sugar. (12)However, most of the baseline data collection for the current study was done before October 2017 changes to the CACFP guidelines.The updated guidelines have addressed some of these issues (e.g., offering at least 1 serving of whole grain-rich foods daily, prohibiting homes from offering of foods fried/pre-fried food on-site). (46)These changes might help with promoting children to eat more whole grains and less high-fat food in FCCHs.
In mediation models, we found that a higher mean FCCH food-provided score was associated with higher child diet quality in our sample of FCCHs.Further, we found that the FCCH food environment (foods served) in FCCHs indirectly affected child weight status through child diet quality.Similar to previous studies assessing the association between the EPAO foods provided sub-scale and child diet quality in FCCHs, (10,44,47) we also found that better FCCH food environments were positively associated with child overall HEI scores.Together, these studies point out the value of improving the quality of the food served in FCCHs in order to promote children's healthy eating.Consistent with the ndings from Benjamin-Neelon et al (2018), (10) we didn't nd a signi cant association between the beverage served EPAO score and child diet quality.One possible reason might be that most FCCHs in the current study served healthier beverages and very few of them served sugar sweetened beverages or excessive juice, so very little variability was assessed in these models.For example, in a prior study conducted with the same sample, it was observed that over 95% of providers consistently offered 100% fruit juice without any add sugar, while refraining from serving sugary drinks. (48)Future studies might identify the associations of beverage-served subcomponent scores with the HEI score.
For young children who cannot make health-related choices for themselves, an obesogenic environment is likely to in uence young children's weight status (49,50) though in the current study, we did not nd a signi cant direct effect of food-served environments in FCCHs on child weight status.Similarly, previous research conducted in center-based childcare settings found that the overall nutrition environment was not signi cantly associated with preschooler weight status. (51)However, this study found that certain aspects of a healthier food environment such as a lower opportunity for high sugar and high fat foods were associated with lower BMI percentile in preschool-aged children. (51)According to Hayes (2017), mediation without evidence of a total effect of the independent variable means only that on the aggregate, when all paths of in uence between independent variable and outcome variable are added up, they are not linearly related. (42)It would be helpful for future studies to examine the associations between obesogenic environment and children's weight status.
Although previous research conducted in center-based early childcare settings has shown that the some aspects of food environment may affect the development of childhood overweight and obesity, (51) the indirect relationships between social environmental characteristics of early childcare settings and children's weight status has not been examined.In the current study, we found that the food-served environment in FCCHs indirectly affected child weight status through child diet quality, suggesting that interventions focusing on helping providers to increase healthy foods and decrease unhealthy foods served in FCCHs may play an important role in reducing the risk of childhood overweight and obesity through the improvement of child diet quality.However, the direct and indirect relationships between FCCHs social environmental characteristics and children's weight status need to be further assessed through longitudinal studies.In addition, other FCCH environmental characteristics which were not included could in uence weight status such as provider feeding practices, portion sizes , (13) exposure to opportunities to be physically active and screen time,RE.Individual level child characteristics such as temperament, appetite regulation and child preferences, which were not included, may also be associated with weight status.
The current study is the rst to examine the associations between food environmental characteristics of early childcare settings and children's weight status mediating through children's diet quality, in preschoolaged children.Our use of the observational measures allowed the objective assessment of both the quality of the FCCH food environment and the diet quality of children, which can be more accurate than the subjective self-reported measures used in previous studies.The use of multilevel analysis also allowed us to account for the clustered nature of our data.However, this study does have some limitations.First, the causality of the relationships in the current study cannot be inferred from the crosssectional design.Further, reverse causality might be possible as parents who value nutrition may choose FCCHs with better food environments, which could affect the associations above.Future analysis should analyze longitudinal datasets to examine whether the changes in FCCH environments cause changes in children's weight status.Second, our sample consisted of a majority of Latinx providers in certain geographic locations, so the results may not be generalizable to a broader population of family childcare providers.Further, only two-day observation data may not be representative of the usual food and beverage served more generally in FCCHs.Future studies should examine the variability in both food served in FCCH.Further, the truncation of EPAO scores within the range of 0-3 may not adequately capture the full spectrum of variability in the types of food and beverages served in FCCHs.However, expanding the score range would likely result in an impractical assessment process.Two days of diet quality data may also not be representative of a child's usual diet and may not capture the variability of children's dietary intake.In the current study, only foods and beverages served scores were included in the analysis, but other EPAO scales and scores such as feeding practices may in uence children's diet quality and weight status as well.In addition, we didn't measure children's food intake at home and children's weight could certainly be affected by that, not just in childcare.Given that children spend their time at home and FCCH, future studies could look at the cumulative impact of both food environments on weight status.

Conclusion
Overall, the food served in FCCHs has indirect effects on preschool-aged children's weight status through children's diet quality, although longitudinal studies need to con rm these relationships.It is crucial to prioritize the implementation of regulations and policies aimed at improving access to healthy foods within FCCHs.Ensuring that appropriate measures are in place will promote healthier dietary choices and prevent childhood obesity.

Figures
Figures

Table 1
The multilevel mediation analyses did not detect signi cant associations between the environmental scores (i.e., foods (B = .005,p > .05,95%CI=[-.03,.04]) and beverages (B = .013,p > .05,95%CI=[-.04,.07]))provided and children's BMI z-scores.Baron and Kenny suggest that if there is no relationship between independent variable and outcome variable, there is no need to test for mediation, however this interpretation is controversial.

Table 3
Multilevel mediation models of diet quality in associations between FCCHs environment and BMI zscores