Are Feeding Practices of Family Child Care Home Providers Related to Child Fruit & Vegetable Intake?

Objectives: To explore the relationship between three feeding practice constructs (role modeling, encouragement, and pressure to eat) of family child care home (FCCH) providers, and fruit and vegetable intake of the preschool-aged children in their care. Participants: Subjects were family child care home providers and the children in their care. Participants were recruited from Providence, Rhode Island and surrounding areas of Rhode Island and Massachusetts. Methods: Baseline data, collected during a two-day home visit from an ongoing clusterrandomized trial, Healthy Start/Comienzos Sanos, were used (n=61 FCCH). Feeding practice data was collected using the Environment and Policy Assessment and Observation (EPAO) tool. Child dietary intake was collected using the Dietary Observation in Child Care (DOCC) protocol. A score for each construct was created by summing the relevant feeding practice items (averaged across two days) for each and averaging across the number of items. Child whole fruit, total fruit (whole fruit plus fruit juice), and vegetable intake were averaged across both observation days and across all children observed within a home. Multiple linear regressions were used to examine the relationship between FCCH provider feeding practice constructs and diet variables. Results: The majority of providers identified as Hispanic/Latina (83%), all were female, and the mean age of providers was 50.8±8.3 years. The majority of children were Hispanic/Latino (69%), and about half were female (48%). The mean age of children was 3.4±1.0 years. Mean whole fruit intake was 1.02±1.03 cups/day, mean total fruit intake was 1.35±1.07 cups/day, and mean vegetable intake was 0.54±0.41 cups/day. In adjusted multivariate models, encouragement was significantly positively associated with child vegetable intake (β =0.51, p=0.007), total fruit intake (β =0.45, p=0.02), and whole fruit intake (β =0.55, p=0.002), and fruit and vegetable intake combined (β =0.64, p=0.0004). In the adjusted model, pressure to eat was also significantly negatively associated with whole fruit intake (β =-0.27, p=0.05). No other provider practices were significantly associated with child whole fruit, total fruit, or vegetable intake. Conclusions: FCCH provider encouragement was associated with a significant increase in child fruit and vegetable intake, and although the frequency of pressure to eat was low, it was associated with a significant decrease in child whole fruit intake. Future studies should further explore the relationship between provider feeding practices and child diet. With this information, interventions and training for FCCH providers can be better tailored to improve the diets of young children.

Although there are a variety of factors that influence a child's FVC, how adult caregivers interact with children, including the feeding practices they use during meals, is important. For example, among parents, more responsive feeding practices such as role modeling, reasoning, and encouraging have been associated with higher FVC. [6][7][8][9][10][11][12] Fewer studies have explored the impact of childcare provider feeding practices and FVC.
Although a large percent of children attend childcare centers, many disadvantaged children attend family child care homes (FCCH) 13 highlighting the importance of understanding provider feeding practices and their impact on FVC in this setting. It is especially important to understand the impact that provider feeding practices may have on child FVC given that 24% of children in child care in the US attend a FCCH. 14 In addition, FCCHs may also have regulations that are less stringent, including those that are related to promotion of food and nutrition. 13 However, no studies that I have found have explored the influence of provider feeding practices on FVC in FCCHs. Therefore, the purpose of this secondary data analysis is to explore the association between observed feeding practices of FCCH providers and fruit and vegetable intake in children.

Trends in fruit and vegetable consumption in children
Young children in the United States are not meeting recommendations for fruit and vegetable consumption. 15 The Dietary Guidelines for Americans, 2015-2020 (8 th edition) recommends 1 and 1.25 cup equivalent of fruits and vegetables, respectively, per 1000 daily calories consumed 3 and ChooseMyPlate.gov recommends that 2-3 year old children consume 1 cup equivalent each of fruits and vegetables per day, and that 4-8 year old children consume 1-1½ cups of fruit and 1½ cups of vegetables per day. 1,2 In 2008, 25% of preschoolers did not consume at least 1 cup of fruit and 30% did not consume at least 1 cup of vegetables per day. 16 FVC is linked to a reduced risk of chronic diseases, such as cardiovascular disease (CVD), and may help to prevent some cancers. 4,3 Fruits and vegetables are also important sources of several vitamins, minerals, antioxidants, and fiber, and contribute to the maintenance of a healthy body weight. 3 There is also evidence to suggest that dietary preferences and patterns that develop during infancy and early childhood track into later life. 4,17,18 Given that young children are not consuming the recommended amounts of fruits and vegetables it is important to explore possible contributors to these eating patterns and behaviors.

Feeding practices
Eating habits and attitudes about food that develop in early childhood often last a lifetime. 19 While there are other factors such as genetics and breastfeeding, 5 adult caregivers are also important in shaping children's food behaviors early in life; one way in which they do this is through their feeding practices. 10,[20][21][22] Feeding practices are the goal-oriented behaviors used by caregivers to influence their children's eating. 7 Although there are many inconsistencies in terminology and definitions when it comes to feeding practices, this study will include feeding practices that are considered responsive, and those that are considered non-responsive. It is important to include responsive practices since they are associated with the best outcomes in child dietary intake and weight status, such as higher fruit and vegetable intake, and less sweet and sugary snack intake. 7,10,[27][28][29][30][31] Responsive feeding practices are child-centered, and involve guiding and teaching children to listen to internal hunger and satiety cues. Responsive feeding practices include, nutrition education, child involvement, encouragement, praise, reasoning and negotiation, limited/guided choices, modeling, and monitoring. On the other hand, nonresponsive overly controlling practices, which have been studied more extensively, are associated with lower fruit and vegetable consumption and increased pickiness and resistance to eating. 7,31,32,[34][35][36][37][38][39][40][41] Controlling practices include restriction, pressure to eat, threats and bribes, and using food to control negative emotions. Parental feeding practices are clearly important within the home environment, but the home is not the only environment in which young children spend time. 34

Importance of understanding feeding practices of child care providers
According to parental self-reports in 2012, 60% of children under the age of 5 who were not enrolled in kindergarten had some sort of non-parental child care arrangement. 14 Of children cared for by someone else other than a parent, 56% attended center-based child care, such as a day care center, preschool, or prekindergarten, 42% were cared for by a family member, and 24% received child care in a non-relative's home, also called a family child care home (FCCH). 14 A family child care home is a form of licensed child care in which children are cared for in the provider's home, rather than a child care center or facility. 13 This setting is different from child care centers in that it offers a more home-like setting with fewer children. 13 Additionally, FCCH providers tend to have less formal education in early childhood education and fewer professional development opportunities, especially those pertaining to child food and nutrition. 13 FCCHs are also different from child care centers in that they tend to be more affordable and offer more flexible hours, characteristics that make them appealing to low-income families. 13 Young children spend 26 hours per week in child care on average and it is recommended that children enrolled in a full-time program consume up to two thirds of their daily energy intake while in this setting, and one third at home. 35 Given that children spend significant amounts of time and consume much of their daily energy in child care, child care providers are increasingly important in shaping children's eating behaviors. 20 Therefore, it is important to understand how child care providers are interacting with children during mealtimes; unfortunately, data exploring this are limited.
Organizations such as Caring for Our Children, 36 the Institute of Medicine's Early Childhood Obesity Preventions Policies, 37,38

and the Academy of Nutrition and Dietetics
Benchmarks for Nutrition in Child-care, 32 have made recommendations for nutrition practices in child care, and all are in line with responsive feeding practices. Both Caring for Our Children and the Academy of Nutrition and Dietetics (AND) recommends division of responsibility between caregiver and child, where the caregiver provides a variety of healthy foods and allows children to decide what and how much to eat. 32,39 The organizations recognize the importance of creating an eating environment that is responsive to the child's self-regulation, and therefore recommends family-style meals where children serve themselves. 6,29,37 Other recommended feeding practices include instruction on how to eat, conversation and education about food and nutrition, encouraging, and modeling healthy eating behaviors. 32,41 With regards to less responsive feeding practices, both organizations discourage overly controlling feeding practices, such as forcing children to eat or using food as a reward or punishment, as this can lead to higher levels of picky eating and increased resistance to eating. 32,42 Although these recommendations are evidence based, the literature which they are based are from studies done with parents and not child care providers; it is unclear if child care provider's feeding practices have a similar impact on child diet. There is a need to explore feeding practices of child care providers, however, of the few studies that have explored feeding practices in a child care setting, most of them have been completed in child care centers as opposed to FCCHs. 6,[40][41][42][43][44]

Feeding Practices of Child Care Providers
Of the studies that have looked at the feeding practices of providers in child care centers, most are consistent with the parenting literature. For example, feeding practices consistent with autonomy support have been associated with higher fruit and vegetable intake, as well as lower intake of sweet and salty snacks. 6,7,8,23,28,31,32,41,58 However, these studies have always looked at individual items rather than constructs, and there are inconsistencies regarding which individual practices are associated with these outcomes.
For example, three different studies that aimed to explore the association between observed feeding practices and child diet in child care centers had different outcomes.
One study found that responsive feeding practices such as role modeling and encouraging were associated with more FVC and less sweet and salty snack intake, 6 while another study found that only the practices of sitting with children during mealtimes and eating the same foods as children were associated with more vegetable intake. 49 A third study found that responsive feeding practices were only significantly associated with more dairy intake. 46 While parenting literature is more conclusive about the relationship between responsive feeding practices and higher FVC and lower sugary snack intake, findings from the child care setting are mixed. In addition to this research gap, there have also been no studies that explore the association between feeding practices and child diet in FCCHs; all studies done in a child care setting have been in a child care center. This is important because there are 482 FCCHs compared to 318 center-based facilities in Rhode Island, meaning that about 66% of child care facilities in Rhode Island are a FCCH.

Conclusion
Given that children spend significant amounts of time and consume much of their daily energy intake in child care, it is important to understand what practices child care providers are utilizing and how these are associated with fruit and vegetable intake of children. This information may help inform future programs and interventions to modify the feeding practices of child care providers in ways that increase fruit and vegetable consumption of children in FCCHs. Thus, the purpose of this study was to describe child fruit and vegetable consumption in Rhode Island FCCHs and determine if feeding practices of FCCH providers are related to fruit and vegetable consumption of the children in their care.

Study Design
This study was a secondary data analysis using baseline data from Brown

Participants
Subjects were 61 providers and 277 children. To be eligible for the study, participants must be a FCCH provider in RI or a surrounding area of Massachusetts (MA). In order to be a participant in the study, providers need to have been in operation for at least 6 months and plan to remain in operation for at least 1 year. FCCH providers must speak and read English or Spanish and have at least 1 child between the ages of 2-5 years old in their care, not including their own child, for a minimum of 10 hours per week, who consumes at least 1 meal and 1 snack prepared by the provider during their time at the FCCH each day. FCCH providers who closed their FCCH for more than 3 weeks during the study were excluded.

Recruitment
Providers were recruited through local community organizations that provide training and support for FCCH providers. These organizations provided informational recruitment sessions, flyers, and brochures to FCCH providers to help with recruitment.
Additional FCCH providers could be referred to participate from already participating providers. At recruitment sessions, the study and its eligibility requirements were explained to providers and those who were interested had the option to sign registration forms. Research staff then contacted the provider by phone to complete an eligibility survey.

Data Collection
Eligible providers then completed the first part of the baseline survey over the phone, which gathered demographic information. Further demographic information was collected during an in-person survey. There was only one provider per home. Eligible children were required to have consent forms signed by their parents to participate in the study. If participating, parents filled out a demographics survey about their child or children. Anthropometric data were then collected for children by research staff. As part of baseline data collection, trained observers went into the FCCH for two full days and collected relevant data. Of interest to this project, they observed feeding practices of providers for each meal and snack and collected data on child dietary consumption for each of these meals and snacks.

Measures
The measures used in this study were provider and child demographic information, provider feeding practices, and child fruit and vegetable intake.
Demographic information was collected using the provider phone survey, the provider inperson survey, and the child survey, filled out by parents. Provider feeding practices were collected using a modified version of the Environment and Policy Assessment and Observation (EPAO). 50 Child fruit and vegetable intake was collected using the Dietary Observation in Child Care (DOCC) protocol. 51 This study used a modified version of the EPAO, developed by Ward et al. 50 It has been validated in child care settings. The EPAO used in this study was modified to reflect cultural differences for the study sample based on formative research (focus groups), and was used to collect objective observation data about feeding practices during meal times in addition to the dietary data. 50 The EPAO contains 53 items that relate to the mealtime environment and feeding practices, as well as additional items relating to physical activity and screen time. Feeding practices captured are reflective of parenting literature, and include both responsive, and non-responsive practices. 52 Of the practices relating to meals and feeding, 26 were used in this study. Specifically, three constructs reported in the parenting literature, role modeling, encouragement, and pressure to eat, were used. 27 Based on the literature, the 26 feeding practices were grouped into three constructs: encouragement, role modeling, and pressure to eat. 27 The role modeling construct included 10 items, the encouragement construct included 5 items, and the pressure to eat construct included 11 items (Figure 1). Provider feeding practice construct scores had the potential to range from 0 to 3, where 0 means the practice did not occur, 1 means the practice occurred a little bit, 2 means the practice occurred sometimes, and 3 means the practice occurred a lot. Some individual practices in the role modeling construct only had the potential score of 0 to 1, where 0 means the practice did not occur and 1 means the practice did occur. However, negative role modeling practices such as consuming fast food, sweet salty snacks, sweet snacks, sugar sweetened beverages, coffee drinks, or nothing in front of the children were reverse scored so that 0 means the practice did occur, and 1 means the practice did not occur.
Children's food intake was recorded using the Dietary Observation in Child Care (DOCC), a valid and reliable instrument developed by Ball et al. 51 The gold standard for measuring child dietary intake is observation, because recall completed by the provider is less accurate. 53

Procedures
The data used in this study were collected by Healthy Start (Comienzos Sanos) staff. Only children who were eligible and had signed consent forms to participate in the study were observed and included in this study. The beginning of each observation period was determined by the arrival of the first eligible child and continued until the last eligible child has left. Data were not collected for the provider's own child or children.
According to the DOCC protocol, an observer can only accurately and reliably assess three children at one time; if more than three children were present, two observers collected data. 51 Another observer recorded information about the mealtime environment and feeding practices using the EPAO.

Statistical Analyses
Independent Variables: Each of the 3 feeding practice constructs, role modeling, encouragement, and pressure to eat, were summarized into weighted average scores at the provider level. A weighted score was used to account for the different number of meals and snacks offered during the day and for longer meals. This was done dividing the duration (minutes) of each meal and snack by the total duration for all meals and snacks that day. This weighting factor was then multiplied by the number of occurrences of each individual feeding practice item at each meal and snack. This was then summed over the entire day to create a weighted daily score for that item, which was then averaged across both days of observation. The average weighted score for each individual feeding practice within each construct can be seen in Table 2. An average of all the feeding practice item weighted scores within each construct was calculated to create an average weighted score for each construct (Table 2).
Dependent Variables: Fruit and vegetable intake were examined using cups as a continuous measure of the mean fruit and vegetable consumption in each home. NDSR generates outputs that group foods into food groups ( Figure 2). Fruits and vegetables were analyzed at the home level, not the child level, therefore it was necessary to create variables of average vegetables, whole fruit, and total fruit (fruit plus 100% fruit juice), and total whole fruits and vegetables per home. This was done by taking the average vegetable, whole fruit, and total fruit consumption across all children in a home. Since children each have two days of observation, and up to 4 meals per observation (breakfast, lunch, and 2 snacks), fruits and vegetables were averaged per day of meals, then across the two days, to create the average per home.
Prior to the main analysis, preliminary analyses and basic data visualization were conducted to generate summary statistics, basic tests of comparison, distribution evaluation for continuous variables, and examination of correlation structure. After preliminary analyses, Pearson's correlations tested for associations between each of the feeding practice constructs and fruit and vegetable consumption as continuous variables.
Cronbach's alpha was determined to assess the internal consistency of the constructs. To examine the association between each feeding practice construct and fruit and vegetable consumption, multiple linear regression models were developed. To adjust for covariates, potential covariates were chosen based on the literature, such as provider ethnicity, 55,56 provider income level, 13,56 provider education level, 13 and CACFP participation. 57 Potential covariates were added to the model one at a time to determine if the addition of the variable made at least a 10% difference in the β coefficient. 58 If a variable made at least a 10% difference in the β coefficient, it would be added to the model. A sample size of 76 providers is appropriate to fit a multiple regression model with up to 3 predictor variables (alpha at the 0.05 level and 80% power and an anticipated effect size of 0.15).
All statistical analysis was done using SAS 9.4.

Study Sample
The study had a final sample of 61 providers and 277 children. Descriptive statistics of the study sample are reported in Table 1

Feeding Practice Constructs
The alpha level for the role modeling construct was 0.55, signifying that the role modeling construct had a low internal consistency. The alpha level for the encouragement and pressure to eat constructs were 0.73 and 0.74, respectively. The mean score for role modeling was 0.78, encouragement was 0.50, and pressure to eat was 0.30. Mean scores for all 3 constructs were between 0 (did not occur) and 1 (occurred a little bit). In the role modeling construct, all item means ranged between 0.02 -1.50; providers almost never consumed fast food, salty snacks, sweet snacks, sugar sweetened beverages, or coffee drinks in front of the children. They also rarely ate anything in front of the children, or ate the same foods as children, and almost never consumed fruits and vegetables in front of the children. The mean score for enthusiastic role modeling eating healthy foods was also infrequent with a mean score of 0.64. The most frequent practice in this construct was sitting with the children during meals, however this was still infrequent with a mean score of 1.50 (between "a little bit" and "sometimes") ( Table 2).
Of the individual practices in the encouragement construct, the most common was encouraging children to try new or less preferred foods, with a mean score of 1.00 however this score is still infrequent. All other practices in this construct had a mean score of below 1.00. All individual practices in the pressure to eat construct had mean score of below 1.00 as well. Praising children for eating unhealthy foods, requiring children to clean their plates, using food as a reward or withholding food as punishment, and using food as a reward or bribe for eating a less-preferred food almost never occurred, all having scores of below 0.10 (Table 2).
Mean whole fruit intake per child was 1.02±1.03 cups/day, mean total fruit intake was 1.35±1.07 cups/day, and mean vegetable intake was 0.54±0.41 cups/day. The mean combined whole fruit and vegetable intake was 1.56±1.23 cups/day (Table 3).
The results of the unadjusted regression models indicated that provider encouragement explained 16.5% of the variance in child vegetable intake (R 2 =0. 16 Although no single covariate made greater than a 10% difference in the β coefficient when added to the model, the combination of covariates made a meaningful difference in the results. Based on the previous literature, covariates to be included in the adjusted models were provider age, ethnicity, CACFP participation, income, education, and the number of children in the home. 7,55,57,59 In the adjusted regression model, encouragement was significantly positively associated with child vegetable intake (β =0.51, p=0.007), total fruit intake (β =0.45, p=0.02), and whole fruit intake (β =0.55, p=0.002), and fruit and vegetable intake combined (β =0. 64, p=0.0004). In the adjusted model, pressure to eat was also significantly negatively associated with whole fruit intake (β =-0.27, p=0.05), and role modeling was no longer significantly negatively associated with vegetable intake (Table 5).

Discussion
This study assessed the association between feeding practices of family child care home providers and average child fruit and vegetable intake. This study found that children are consuming adequate amounts of fruit in this setting, but vegetable intake is still low. This study also found that although many of the feeding practices observed were not frequent, encouragement was positively associated with child vegetable intake, total fruit intake, whole fruit intake, and fruit and vegetable intake combined.
Furthermore, in the unadjusted model, role modeling was significantly associated with vegetable intake, but in an unexpected direction. In the adjusted model, pressure to eat was significantly associated with a decrease in whole fruit intake. This is consistent with parenting and some child care center literature regarding the positive association between responsive feeding practices (such as encouragement) and child fruit and vegetable intake, and the negative association between non-responsive feeding practices (such as pressure to eat) and child fruit and vegetable intake. Future studies should further explore the association between feeding practices and child diet in the child care setting, and ways to improve the feeding practices of FCCH providers.
This study found that on average, children are meeting recommendations for fruit intake in child care (two-thirds of a cup to one cup, depending on age), 1,2 with the mean whole fruit intake being about 1 cup. The mean total fruit intake was about one-third of a cup higher than mean whole fruit intake, suggesting that providers are serving 100% fruit juice, which is a source of sugar and calories. 60 Mean vegetable intake is only about onehalf of a cup, which is slightly below the recommended intake for child care (two-thirds of a cup to one cup, depending on age). However, from this study it is unknown if children are still meeting the daily recommendation for vegetables by consuming additional vegetables at home. This is consistent with the latest CDC report that fruit intake is increasing, and vegetable intake remains low. 15 However, two studies done in child care centers found that, on average, children consumed less fruits and vegetables than what was observed in this study. One study found that children consumed 0.25 cups of vegetables per day, and 0.32 cups of fruit (excluding juice) per day, on average. 61 Another study found similar results, with children consuming 0.2 cups of vegetables per day, and 0.4 cups of fruit (including juice), on average. 62 Children in these studies consumed about half the amount of vegetables, and less than half the amount of fruit compared to what was observed in this study.
Overall, frequency of provider role modeling, encouragement, and pressure to eat was low. In the role modeling construct, providers demonstrated infrequent use of negative role modeling (consuming unhealthy foods and beverages in front of children), but also demonstrated infrequent use of positive role modeling. FCCH providers rarely consumed the same foods as children, and almost never consumed fruits and vegetables in front of children. This is consistent with previous research which has found that center providers rarely consume unhealthy foods in front of children. 63 While another study done with 105 FCCH providers found that most providers (67.3%) reported sitting with children during mealtimes, 64 which is consistent with this study as we found that most (90.0%) providers were observed to sit with children at least a little bit throughout the day, however, the mean score for sitting with children during meals was below 2.00, meaning that most providers did not sit with children at all meals, or for the whole duration of the meal. Similar to role modeling, the mean score for all pressuring feeding practices was also low. A study done with FCCH providers found that most providers (74.4%) reported pressuring a child to clean their plate, 64 which is different from the current study, which found infrequent use of this practice. However, several other studies done with center providers reported low pressuring behaviors, similar to what was observed in this study. 11,65,66 Although pressuring feeding practices were infrequent, they were associated with a significant decrease in whole fruit consumption in the adjusted model. Training for providers should continue to educate providers on the potential long-term negative effects of pressuring children to eat, as these behaviors may lead to increased resistance to eat, such as what was seen with whole fruit intake, and interfere with children's internal hunger and satiety cues. 64 While overall provider encouragement was low, it still was significantly associated with an increase in child fruit and vegetable intake, with a one-unit increase in encouragement accounting for about one-half of a cup increase in child vegetable intake, and over one-half of a cup increase in child whole fruit intake. An example of a one-unit increase in encouragement could be moving from no encouragement to a little encouragement, or from a little encouragement to some encouragement. Even with low frequency of encouragement, the association with child fruit and vegetable intake can still be observed, emphasizing the importance of this construct. These findings are consistent with some of the literature exploring center provider feeding practices and child diet. One study found that children will increase food intake if encouraged by caregivers to eat more (based on a single item), regardless of what is being served, 46 while two other studies found that encouragement specifically increases child fruit and vegetable consumption. 6,67 However, these previous studies have looked at individual feeding practice items. Our results add to the literature by assessing a construct including multiple encouragement items, which is a more comprehensive view of the feeding practices occurring in the home. These findings highlight the importance of using responsive feeding practices to get children to consume more fruits and vegetables in a family child care home setting.
Unexpectedly, role modeling was significantly associated with a decrease in child vegetable intake in the unadjusted model. This may be due to overall low use of role modeling, as providers rarely consumed foods or beverages in front of the children. This also may be due to the low internal consistency of the construct. Other studies have also found that enthusiastic role modeling is effective in improving child diet, whereas silent role modeling is not. 67,68 Most of the items in this construct were passive role modeling (i.e. eating fruits and vegetables in front of children), which may explain why this construct was not positively associated with child diet.
This finding suggests exposure to fruits and vegetables and passive role modeling may not be enough to increase child intake of fruits and vegetables. Several studies have shown that CACFP participation is associated with providers serving more fruits and vegetables. [61][62][63][64] However, most of the providers in this study participated in CACFP, yet child vegetable intake was still low. This suggests that simply providing fruits and vegetables may not be enough, and children must be encouraged to eat them. Other studies show that early, repeated exposure to fruits and vegetables is the best way to increase child intake. 21,71,72 However, as infants become toddlers and neophobia sets in, encouraging a child to try a food is the first step towards repeated exposure, 72 further emphasizing the importance of encouraging children to eat the fruits and vegetables provided.

Limitations and Strengths
This study is not without limitations. First, sample size was relatively small, and the study was slightly underpowered with a final sample of 61 homes, whereas the study was powered at 76 homes. Additionally, the study was cross-sectional, so we were unable to assess the longitudinal impact of provider feeding practices on child diet. Although the study used observation and aimed to be minimally invasive, children and providers were still aware of the observers in the home. Therefore, social desirability bias may have influenced provider and child behavior. While observation was a limitation, it was also one of the strengths of this study, as observation is more accurate than self-report.
Another strength of this study is the sample of family child care homes, which have not been studied as much as center-based child care. The relatively homogenous sample of female, Latina, providers is both a strength and a limitation of this study; while the results of this study may not be generalizable to the general population of FCCH providers, it provides valuable information on the feeding practices of Latina providers.

CONCLUSION
This study found that FCCH provider encouragement may improve fruit and vegetable intake in children ages 2-5, which is important because low FVC is associated with increased risk of developing chronic diseases 3,4 and early childhood is a critical time for the development of food preferences and eating behaviors. 5 The findings of this study are consistent with parenting literature regarding the associations between responsive and non-responsive feeding practices of adult caregivers and child fruit and vegetable intake.
Future research should further explore the association between provider feeding practices and other aspects of child diet besides fruits and vegetables, such as sweet and salty snack foods, whole grains, and dairy. It should also explore ways to increase the use of encouraging feeding practices by FCCH providers. The literature suggests that that there is a need for more frequent nutrition-related training for FCCH providers. [66][67][68] While many trainings for providers have focused on which foods to serve children and which feeding practices to avoid, future trainings for FCCH providers should highlight the importance of practices that may improve child diet, such as encouragement. Scores range from 0-3, where 0 = did not occur, 1 = occurred a little, 2 = occurred sometimes, and 3 = occurred a lot a Scores range from 0-1, where 0 = did not occur and 1 = did occur b Negative practices were reverse scored so that the absence of the practice = 1 and the presence of the practice = 0 *N was less than 61 due to missing observations because the practice was "Not Applicable"   Pressure to Eat 1. Provider rushed child to eat 2. Provider praised child for eating unhealthy foods 3. Provider praised child for cleaning their plate 4. Provider pressured child to eat more than they seemed to want 5. Provider required child to clean their plate 6. Provider spoon-fed child 7. Provider insisted a child eat a certain food 8. Provider prompted a child to finish one food in order to receive another 9. Provider promised something other than food for eating a specific food 10. Provider used food a reward or withheld food as a punishment 11. Provider used food as a reward or bribe for eating a less preferred food

The consequences of low fruit and vegetable consumption
FVC is linked to a reduced risk of chronic diseases, such as cardiovascular disease (CVD), and may help to prevent some cancers. 4,3 Fruits and vegetables are also important sources of several vitamins, minerals, antioxidants, and fiber, and contribute to the maintenance of a healthy body weight. 3 There is also evidence to suggest that dietary preferences and patterns that develop during infancy and early childhood track into later life. 4,17,18 Given that young children are not consuming the recommended amounts of fruits and vegetables it is important to explore possible contributors to these eating patterns and behaviors.

Factors that influence child diet
Eating habits and attitudes about food that develop in early childhood often last a lifetime. 19 Research demonstrates that the development of child fruit and vegetable preferences is biological, developmental, and socioenvironmental, beginning in infancy. 71 While infants are genetically predisposed to liking sweet and salty flavors, and disliking bitter flavors, such as vegetables, infants who are breastfed are repeatedly exposed to a variety of flavors early on, leading to a better transition to solid foods. 21 The transition from breastmilk or formula to complementary foods is a narrow acceptance period, followed by the toddler years, which are typically characterized by increased neophobia and decreased intake of vegetables. 71 Research shows that a later introduction of vegetables is associated with decreased acceptance of them.
Parents are the main influencers of child diet, as parents typically make food choices for the family. 21 Sociodemographic factors such as parent education, nutrition knowledge, socioeconomic status, and food marketing to parents and children, as well as parent beliefs, availability of food, the home environment, and feeding practices all play a role in a child's acceptance of fruits and vegetables. 72 Feeding practices are the goaloriented behaviors used by caregivers to influence their children's eating. 7

Ways to classify feeding practices
Over the years, different terminology and definitions have been used surrounding feeding practices in the literature. This inconsistency in terminology and definitions have made research in this field more challenging. In 2016, experts in the field came together to create a clearly defined content map to guide future research. The content map outlines 3 higher-order constructs, each containing specific feeding practice subconstructs. The higher-order constructs are coercive control, structure, and autonomy support.
Coercive control is defined as attempts to dominate, pressure, or impose the parents' will upon the child. This construct includes subconstructs such as restriction, pressure to eat, bribes, and using food to control negative emotions. Structure involves the use on non-coercive practices and is defined as parents' organization of children's environment to facilitate children's competence. Subconstructs in this higher-order construct include rules and limits, role modeling, routines, guided choices, and food availability and accessibility. The final higher-order construct of autonomy support can be defined as promoting psychological autonomy and encouragement of independence, and includes subconstructs such as encouragement, praise, reasoning, and child involvement. 73 The following sections will use the terminology of specific feeding practice constructs to describe the literature regarding feeding practices and child diet.

Responsive feeding practices
The literature suggests that responsive feeding practices are associated with the best outcomes in child dietary intake and weight status, such as higher fruit and vegetable intake, and less sweet and sugary snack intake. 7,10,27-31 Responsive feeding practices are child-centered, and involve guiding and teaching children to listen to internal hunger and satiety cues. Responsive feeding practices include, nutrition education, child involvement, encouragement, praise, reasoning and negotiation, limited/guided choices, modeling, and monitoring. On the other hand, overly controlling practices are associated with lower fruit and vegetable consumption and increased pickiness and resistance to eating. 7,31,32,[34][35][36][37][38][39][40][41] Controlling practices include restriction, pressure to eat, threats and bribes, and using food to control negative emotions.

Feeding practices of parents
In general, parenting literature concludes that overly controlling feeding practices such as restriction, pressure to eat, and bribes, may be associated to greater aversion to the foods that children are being pressured to eat. 5,73 However, in one study, pressure was found to be associated with higher vegetable intake. Although higher vegetable intake is a positive thing, it is important to consider the long-term implication of pressure on a child's ability to self-regulate. On the other hand, many responsive practices such as encouragement to eat fruits and vegetables, reasoning, negotiating, and praise were associated with higher intake of fruits and vegetables. 12 Research also suggests that positive role modeling may be associated with child diet, 5 and encouragement can help children try new foods, therefore creating repeated exposure and increasing the likelihood that the child will like a certain food. 72 Parental feeding practices are clearly important within the home environment, but the home is not the only environment in which young children spend time. 34 With more mothers entering the workforce, more children are being cared for by someone other than their parents. Therefore, child feeding is a shared responsibility between parents and other child care providers.

Importance of understanding feeding practices of child care providers
According to parental self-reports in 2012, 60% of children under the age of 5 who were not enrolled in kindergarten had some sort of non-parental child care arrangement. 14 Of children cared for by someone else other than a parent, 56% attended center-based child care, such as a day care center, preschool, or prekindergarten, 42% were cared for by a family member, and 24% received child care in a non-relative's home, also called a family child care home (FCCH). 14 Young children spend 26 hours per week in child care on average and it is recommended that they consume up to two thirds of their daily energy intake while in this setting. 35 Given that children spend significant amounts of time and consume much of their daily energy in child care, child care providers are increasingly important in shaping children's eating behaviors. 20 While feeding practices literature has surrounded parents, feeding practices of other caregivers may be different from parent practices, and may not have the same impact on child diet.
Therefore, it is important to understand how child care providers are interacting with children during mealtimes; unfortunately, data exploring this is limited.

Recommendations for feeding practices in child care
Organizations such as Caring for Our Children, 36 the Institute of Medicine's Early Childhood Obesity Preventions Policies, 37,38

and the Academy of Nutrition and Dietetics
Benchmarks for Nutrition in Child-care, 32 have made recommendations for nutrition practices in child care, and all are in line with responsive feeding practices. Both Caring for Our Children and the Academy of Nutrition and Dietetics (AND) recommends division of responsibility between caregiver and child, where the caregiver provides a variety of healthy foods and allows children to decide what and how much to eat. 32,39 The organizations recognize the importance of creating an eating environment that is responsive to the child's self-regulation, and therefore recommends family-style meals where children serve themselves. 6,29,37 Other recommended feeding practices include instruction on how to eat, conversation and education about food and nutrition, encouraging, and modeling healthy eating behaviors. 32,41 With regards to less responsive feeding practices, both organizations discourage overly controlling feeding practices, such as forcing children to eat or using food as a reward or punishment, as this can lead to higher levels of picky eating and increased resistance to eating. 32,42 Although these recommendations are evidence based, the literature which they are based on are from studies done with parents and not child care providers; it is unclear if child care provider's feeding practices have a similar impact on child diet. There is a need to explore feeding practices of child care providers, however, of the few studies that have explored feeding practices in a child care setting, most of them have been completed in child care centers as opposed to FCCHs. 6,[40][41][42][43][44] Feeding practices of child care providers Several studies have been conducted to learn more about child care providers' use to feeding practices. For example, several studies found high use of overall responsive behavior, including encouragement and monitoring. 65,66,74 However, it is important to consider that some of these studies included self-report by providers, which may have led to social desirability bias and over-reporting of positive practices. Other studies found that providers do not often role model eating healthy foods in front of children. 32,75 While some studies generally found low use of restriction, bribes, and pressuring practices, 11,65,75 another study found high use of pressuring practices. 6 Literature has shown that overall, providers help to foster healthy eating in children. 76 Studies reporting what feeding practices providers are using vary in results. Results also vary regarding the association between provider feeding practices and child diet.

Impact of provider feeding practices on child diet
For example, feeding practices consistent with autonomy support have been associated with higher fruit and vegetable intake, as well as lower intake of sweet and salty snacks. 6,7,8,23,28,31,32,41,58 However, there are inconsistencies regarding which individual practices are associated with these outcomes. For example, three different studies that aimed to explore the association between observed feeding practices and child diet in child care centers had different outcomes. One study found that responsive feeding practices such as role modeling and encouraging were associated with more FVC and less sweet and salty snack intake, 6 while another study found that only the practices of sitting with children during mealtimes and eating the same foods as children were associated with more vegetable intake. 49 A third study found that responsive feeding practices were only significantly associated with more dairy intake. 46 While parenting literature is much more conclusive about responsive feeding practices and higher FVC, research in child care is not as certain.

Family child care homes
In addition to the research gap surrounding feeding practices in child care, there have also been few studies that explore the association between feeding practices and child diet in FCCHs; most studies done in a child care setting have been in a child care center. This is important because there are 552 FCCHs compared to 311 center-based facilities in Rhode Island, meaning about 64% of child care facilities in Rhode Island are a FCCH. Therefore, it is important to further explore these environments, including provider feeding practices and knowledge of feeding practices.
Studies have found that many FCCHs fail to meet child care standards for nutrition, with areas of concern being frequent servings of fruit juice, frequent unhealthy foods for celebrations, and little nutrition training. 65 Another study done with Latino FCCH providers found that that providers had low self-efficacy regarding healthy eating and physical activity, despite their positive beliefs and attitudes about healthy lifestyles, which may hinder their ability to be influential role models. 77 Lastly, another study done with Latino FCCH providers found that while some positive practices are occurring, such as sitting with children during meals, negative practices were also occurring, such as pressuring children to clean their plates. 59 Overall, this study found that providers were motivated to serve healthy foods to children, they also reported infrequent nutrition training. The literature demonstrates a lack of training for FCCH providers regarding nutrition topics, specifically feeding practices, which may be a cause for concern given the popularity of this form of child care.

Conclusion
Given that children spend significant amounts of time and consume much of their daily energy intake in child care, it is important to understand what practices child care providers are utilizing and how these are associated with fruit and vegetable intake. This information may help inform future programs and interventions to modify the feeding practices of child care providers and increase fruit and vegetable consumption of children in FCCHs. It also may justify increased training for family child care home providers.
Thus, the purpose of this study is to determine if feeding practices of FCCH providers are related to fruit and vegetable consumption of the children in their care.

Study Design
This study was a secondary data analysis using baseline data from Brown week, and consumes at least 1 meal and 1 snack prepared by the provider during their time at the FCCH each day. FCCH providers who close their FCCH for more than 3 weeks during the study were excluded.

Recruitment
Providers were recruited through local community organizations that provide training and support for FCCH providers. These organizations provided informational recruitment sessions, flyers, and brochures to FCCH providers to help with recruitment.
Additional FCCH providers could be referred to participate from already participating providers. At recruitment sessions, the study and its eligibility requirements were explained to providers and those who were interested had the option to sign registration forms. Research staff then contacted the provider by phone to complete an eligibility survey.

Data Collection
Eligible providers then completed the first part of the baseline survey over the phone, which gathered demographic information. Further demographics information was collected during an in-person survey. There is only one provider per home. Eligible children were required to have consent forms signed by their parents to participate in the study. If participating, parents filled out a demographics survey about their child or children. Anthropometric data was collected for children by research staff. As part of baseline data collection, observers go into the FCCH for two full days and collect relevant data. Of interest to this project, they observed feeding practices of providers for each meal and snack and collected data on child dietary consumption for each of these meals and snacks.

Measures
The measures used in this study were provider and child demographic information, provider feeding practices, and child fruit and vegetable intake.
Demographic information was collected using the provider phone survey, the provider inperson survey, and the child survey, filled out by parents. Provider feeding practices were collected using the Environment and Policy Assessment and Observation (EPAO). Child fruit and vegetable intake was collected using the Dietary Observation in Child Care (DOCC) protocol. All instruments used will be described in further detail.

Demographics Surveys
The baseline provider phone survey is 75 questions long, and the in-person survey is 108 questions long. Each contained demographics information that were of interest to this study, such as provider age, race, ethnicity, and gender, to be used as potential covariates in the analysis. The child demographics survey was 9 questions long, including child age, gender, race, ethnicity, time spent in child care, and meals typically consumed in child care. The child anthropometry form recorded child height and weight, which were used to calculate child BMI percentile and BMI z-score.

Environment and Policy Assessment and Observation (EPAO)
This study used a modified version of the EPAO, developed by Ward et al. 50 It has been validated in child care settings. The EPAO used in this study was modified to reflect cultural differences for the study sample based on formative research, and was used to collect objective observation data about feeding practices during meal times in addition to the dietary data. 50 Feeding practices captured are reflective of parenting literature, and include both responsive, and non-responsive practices. 52

Dietary Observation in Child Care (DOCC) Protocol
Children's food intake was recorded using the Dietary Observation in Child Care (DOCC), a valid and reliable instrument developed by Ball et al. 51 The gold standard for measuring child dietary intake is observation, because recall completed by the provider is less accurate. 53,54 The DOCC is minimally intrusive and aims to not make children hyperaware that they are being observed. Once the data from the DOCC was collected, it was entered into Microsoft Excel spreadsheets.

Procedures
The data used in this study were collected by Healthy Start (Comienzos Sanos) staff. Only children that were eligible and had signed consent forms to participate in the study were measured and included in this study. The beginning of each observation period was determined by the arrival of the first eligible child, and continued until the last eligible child has left. Data was not collected for the provider's own child or children.
Staff members asked for more details about foods served after the observation if needed, including brands, ingredients, and cooking methods. If possible, food packaging was photographed. According to the DOCC protocol, an observer can only accurately and reliably assess three children at one time; if more than three children are present, two observers collected data. 51 Another observer recorded information about the mealtime environment and feeding practices using the EPAO.

Statistical Analyses
Once all datasets are imported to SAS, they are merged to create one dataset. A score was created for each of the 3 feeding practice constructs that were chosen: role modeling, encouragement, and pressure to eat. On the EPAO, each feeding practicerelated item is scored by how often it occurred: never (0) a little (1) sometimes (2) a lot (3) or for some items, not applicable (4). Responses that were not applicable were coded as "missing", so as not to make the score artificially high when a feeding practice was not applicable. A score was created for each practice for each day by multiplying the score for how often the practice occurred at a particular meal by how long the meal occurred, and summing across all meals, creating a weighted score for the practice for the day. This was done for each practice for each day and the scores for each day were then averaged to create an average feeding practice score per day. Based on the literature, feeding practices were grouped into the constructs, role modeling, encouragement, and pressure to eat. Role modeling contained 10 items, encouragement contained 5 items, and pressure to eat contained 11 items. The feeding practices for that construct were summed to make a score for that construct. Some individual practices in the role modeling construct only had the potential score of 0 to 1, where 0 means the practice did not occur and 1 means the practice did occur. However, negative role modeling practices such as consuming fast food, sweet salty snacks, sweet snacks, sugar sweetened beverages, coffee drinks, or nothing in front of the children were reverse scored so that 0 means the practice did occur, and 1 means the practice did not occur. This became my independent variable.
Fruit and vegetable intake were examined using cups as a continuous measure of the mean fruit and vegetable consumption in each home. NDSR generates outputs that group foods into food groups. Dark green vegetables, deep yellow vegetables, tomato, white potatoes, other starchy vegetables, legumes, other vegetables, and vegetable juice were summed to create a vegetable variable, whole citrus fruit, non-citrus fruit, avocado, and fruit-based snacks were summed to create a whole fruit variable, and whole citrus fruit, non-citrus fruit, avocado, fruit-based snacks, citrus juice and other fruit juice were summed to create a total fruit variable (whole fruit plus 100% fruit juice). Fruits and vegetables were analyzed at the home level, not the child level, therefore it was necessary to create variables of average vegetables, whole fruit, and total fruit per home. This was done by taking the average vegetable, whole fruit, and total fruit consumption across all children in a home. Since children each have two days of observation, and up to 4 meals per observation (breakfast, lunch, and 2 snacks), fruits and vegetables were averaged per day of meals, then across the two days, to create the average per home. These became my dependent variables. I also created a variable of combined vegetables and whole fruit for a total fruit and vegetable variable.
Prior to the main analysis, preliminary analyses and basic data visualization were conducted to generate summary statistics, basic tests of comparison, distribution evaluation for continuous variables, and examination of correlation structure. After preliminary analyses, Pearson's correlation coefficient tested for associations between each of the feeding practice construct and fruit and vegetable consumption as continuous variables. Cronbach's alpha was determined to assess the internal consistency of the constructs. To examine the association between each feeding practice construct and fruit and vegetable consumption, multiple linear regression models were developed. To adjust for covariates, potential covariates were chosen based on the literature, such as provider ethnicity, provider income level, provider education level, and CACFP participation.      /*Merging Batches 1-4*/ /*sort data for merging by ID and date of intake*/ proc sort data=data.HSBLB109; by participant_ID date_of_intake; proc sort data=data.HSBLB209; by participant_ID date_of_intake; proc sort data=data.HSBLB309; by participant_ID date_of_intake; proc sort data=data.HSBLB409; by participant_ID date_of_intake; /*merging NDSR output files imported into SAS */ data data.