Perceived effective and feasible strategies to promote healthy eating in young children: focus groups with parents, family child care providers and daycare assistants

Specific feeding practices

Three behaviors – rewarding, verbally encouraging and imposing a taste-rule – could be categorized under “specific feeding practices”, since they addressed the child directly, with the intent to influence eating behaviors, such as tasting, eating and liking. The three groups of caregivers reported no problems concerning the feasibility of these behaviors in their specific setting. This can be explained by the nature of these specific feeding practices: they involve single and simple behaviors, independent of environmental constraints. The three practices have in common that they involve an instruction to perform a certain behavior and only differ in the sense of what follows after the behavior has been performed. In the case of rewarding, a reward is announced, which can be a non-tangible social reward or a tangible reward. We assume that verbal encouragement is in fact a kind of social reward since it implies that the caregiver will be proud if the behavior is carried out. In the case of imposing a taste-rule, the consequences were not specified by the caregivers.

Most of the caregivers used rewards or verbal encouragement to influence children’s eating behavior. However, they had different opinions concerning (a) the specific behavior they expect from the child (e.g. tasting behavior or clearing the plate) and (b) the type of reward (e.g. a dessert, a non-token reward). The use of rewards or verbal encouragement to facilitate desirable eating behavior can be conceptualized as operant or instrumental conditioning. This learning process implies that an individual's behavior is modified by its positive (i.e. reinforcement) or negative (i.e. punishment) consequences [25]. When a specific behavior has unpleasant consequences, the frequency of that behavior will decrease. Conversely, if a behavior is followed by a rewarding stimulus, this behavior will be repeated in the future. It has indeed been shown that rewards can have a positive influence on children’s eating behavior (for a review, see [26]), but only if used appropriately. For example, the type of behavior being encouraged plays an important part in whether or not positive effects will be shown. Encouraging children (verbally or with a reward) to clear their plate may undermine their internal regulation system and lead to overweight [27–29]. Conversely, encouraging children to taste a food item they dislike might eventually have positive effects on liking and consumption [30], but only if the child is not intrinsically motivated to taste. According to Social Determination Theory, an extrinsic motivator (i.e. a reward) undermines intrinsic motivation (for a review, see [31]). A second factor that determines the success of rewards is what type of reward is given. Offering sweets as a reward provokes negative effects, as it enhances children’s preference for sweets [32]. In contrast, various studies have demonstrated that both non-food tangible rewards (e.g. stickers) and non-tangible rewards (e.g. praise) enhance children’s liking and consumption of disliked food items [33–35]. These findings indicate that the effectiveness of rewards in the context of eating behavior is more complex than the general principle of operant conditioning, as formulated by Skinner [25]. Based on the different opinions and statements of all caregivers, we can infer that most of them are not aware of (a) what behavior to encourage (i.e. tasting vs how much a child ate) and (b) the importance of considering the type of reward.

The last specific feeding practice put forward was to impose a taste-rule. All three groups agreed that children had to taste at least once a meal. This rule can lead to familiarization and eventually liking and increased consumption of the vegetable [36]. However, it can also have counterproductive effects if accompanied by pressure and negativity [37]. Furthermore, the definition of “tasting” is often misunderstood among caregivers. Caregivers often expect their children to swallow the food item, which is usually the hardest part. The critical aspect of “tasting” in the process of liking a food item is familiarizing children with the taste by bringing the food item in contact with the taste buds. Obligating children to swallow may even decrease liking of the food item and increase a food neophobic reaction [38]. We could not infer from the focus group interviews that caregivers were aware of the specificity of the taste-rule or knew how to react when the child disobeyed the rule.

General behavior

This category contains five aspects (i.e. sensory sensations, involvement, variation, modeling, and repeated exposure) that are not immediately directed toward the child, but do have an influence on the child’s eating behavior. The importance of these five behaviors was acknowledged by all three groups of caregivers. However, in contrast to the specific feeding practices, these general behaviors seemed far less feasible, depending on the type of caregiver. As the menu is beyond the control of daycare assistants and some of the family child care providers, they cannot choose to repeatedly expose children to a certain food, make sure that there is enough variation, or determine how the food tastes or smells. Obviously, they can choose how they present the food and whether or not to impose a taste-rule (see above). Involvement is the least feasible for daycares, since they have rigid hygiene and safety rules: the food is not prepared in the daycare center, so children cannot observe the cooking or be involved in the cooking process. Family child care providers face a different kind of problem: children can observe them while they are cooking, but it is difficult for them to involve the children, because they are usually on their own and have more children to look after than daycare assistants. For the same reason, adult modeling during mealtime is the least feasible for family child care providers. Although there are more employees in daycares, adult modeling during mealtime also seems difficult for daycare assistants. In contrast to the United States, where federal standards help to ensure that caregivers in childcare settings (e.g. Head Start programs) model healthy eating behavior by sitting with children during mealtime [39–41], no such standards exist for Belgian childcare settings. As a consequence, the request to sit and eat with the children might be seen as an option instead of a necessity. Peer modeling is the least feasible for family child care providers, since they have children of different ages, with babies eating on their own rhythm and thus at different moments. This is less the case for daycares, where children of the same age eat together in small groups, and can act as a model.

Research has shown that these general behaviors have a positive influence on children’s eating behavior [20, 36, 42, 43]. First of all, providing enough food variety and continuing to offer children all kinds of food (even if they insist that they do not like it) is beneficial for taste development and the acceptance of food [44]. Second, repeatedly exposing children to the taste of food items (i.e. Repeated Exposure) is proven to be effective in increasing children’s liking and consumption of vegetables that they initially disliked [36, 45, 46]. Next, according to Social Cognitive Theory [47], modeling can also be very influential in establishing learning and behavioral change. Not only adults (familiar as well as unfamiliar ones) seem to be effective role models [48–50], but also peers [42, 51], and even cartoon characters have a positive influence on children’s eating behavior [52]. Furthermore, we assume that attractive sensory sensations and involvement create a positive context in which healthy eating behavior may be facilitated. This can be explained by flavor-context learning, which is a form of classical conditioning. According to the principle of classical conditioning, an individual's behavior is modified as a consequence of repeated pairings of two stimuli. A stimulus that initially provokes no reaction (i.e. neutral stimulus) is paired with a meaningful biologically relevant stimulus (i.e. unconditioned stimulus) that automatically provokes a reaction (i.e. unconditioned response). After repeated pairings, the initially neutral stimulus starts to elicit the same response as the biologically relevant stimulus (i.e. conditioned response) [53, 54]. In the case of flavor-context learning, children associate food (i.e. neutral stimulus) with the emotional valence of the social context (i.e. unconditioned stimulus). The preference of food will increase (i.e. conditioned response), if the food is accompanied by positive behaviors or aspects [27], for example by attractive sensory sensations or by involving children in a positive way. Conversely, providing food in a negative social context (e.g. by means of coercive feeding techniques) will lead to a decrease in food preferences [37]. We could not infer from the focus group interviews that caregivers were aware of the “long-term” character of these general behaviors; since these behaviors imply a learning process, caregivers cannot expect to detect any immediate changes in tasting or liking behavior. If they continue carrying out these behaviors, then changes will occur eventually.

Global influences

A peaceful, cozy atmosphere could be categorized under global influences, since it is a consequence of multiple behaviors and aspects (e.g. the above-mentioned general behaviors, the functioning of the group). Everybody agrees that a cozy, homelike situation is important, but it is challenging for the three groups of caregivers. A positive climate indeed facilitates healthy eating behavior [20], which can also be explained by flavor-context learning: the preference of food will increase, if the food is accompanied by a cozy atmosphere.

Strengths, limitations and future research

The main strength of this study is the inclusion of different groups of caregivers in a Flemish population. As many young Flemish children spend a significant amount of time in child care [19], family child care providers and daycare assistants have considerable impact on children’s eating behavior. To our knowledge, little research has focused on how children’s eating behavior can be improved in the Flemish childcare system. In the United States, more research has been conducted on obesity prevention in childcare settings [9, 55–57]. However, due to cultural and policy differences, these findings and conclusions are not necessarily valid for a Flemish population. Since childhood obesity as well as unhealthy eating behaviors are rising in Flanders too, there is an urgent need for studies in this population.

A few limitations of this study need to be considered. First, for daycare assistants and family child care providers, we only studied one focus group per type of caregiver. Therefore, thematic saturation might not have been reached and valuable information might have been missed. For example, we could not infer from the focus groups whether or not children serving themselves was perceived as an effective strategy to promote healthy eating behavior. Furthermore, we may also question whether overall themes can actually be derived from this limited population. However, as all daycare assistants and family child care providers in Flanders follow the policy guidelines of the national institute “Child and Family” (i.e. Kind&Gezin), it can be assumed that the current findings are not unique to the sites of the participants. Nevertheless, more groups per type of caregiver could have strengthened the generalizability of the overall themes. Second, since daycare assistants do not have a lot of control over policies, including the menu, future research should address the authorities or individuals responsible for the menu as well as daycare directors for their attitudes, beliefs and policy concerning healthy food. Third, as the current study dealt with events just before and during mealtime, we may have missed behaviors during other times of the day, for example, when children see that a caregiver is eating fruit in the afternoon (i.e. adult modeling). Fourth, the recruitment procedure may have introduced a selection bias. Caregivers interested in healthy food were probably more inclined to participate, which may have been why they all were very much aware of the importance of a lot of the health-improving behaviors. Fifth, promoting healthy eating behavior is a complex and difficult matter which depends on multiple factors. For example, the three levels of Rhee [20] interact, and depending on the global influences (i.e. a good or bad atmosphere), the individual practices will work better or worse [20]. To grasp the interaction between these levels, individual in-depth interviews would be more appropriate. Finally, previous research has shown that the effectiveness of some strategies might depend on individual differences in child characteristics, such as reward sensitivity [58] or food responsiveness [59]. Besides general guidelines on how to improve healthy eating behavior, caregivers should be aware that children are individuals and that some may benefit more from strategy X than from strategy Y. Whether caregivers take these individual differences into account does not emerge from our data, but this could simply be because we did not specifically ask for it. This limitation should be addressed by future research.

Implications

The current study provides first-hand information on caregivers’ perceived effectiveness and feasibility of strategies used at home, in daycare centers and in family child care homes to promote healthy eating in young children. We can infer from the focus group interviews that caregivers use various techniques to accomplish this. However, our findings also show that they often do not have any specific knowledge on how to apply a particular strategy. There is therefore a need for better training of caregivers [55], with specific evidence-based written or visualized material, in which clear and concrete guidelines clarify what strategies to apply, and how to apply them (e.g. when and how to reward behavior). A training program for child care providers could be based on existing evidence-based methods in the United States (i.e. Nutrition and Physical Activity Self-Assessment for Child Care, NAP SACC [60, 61]), which include facility-level interventions. The implementation of effective parent-led home-based interventions [62–64] could help parents to improve their children’s eating behavior. Research has shown that both a parent-led home-based intervention consisting of specific information on repeated daily tastings of a vegetable [64], and additional instructions on modeling and rewarding [62] effectively increased children’s liking and consumption of a disliked vegetable, while such effects were not obtained from nutritional advice or leaflets [64]. Furthermore, our results show that strategies vary in applicability. For example, caregivers expressed the difficulty of eating together with the children which could facilitate modeling. If this perceived difficulty is caused by policy-makers not attaching enough weight to this strategy, more efforts are needed to convince all stakeholders of the importance of modeling. If necessary, certain rules should be tightened to solve this problem (e.g. in daycares, the assistants should be obliged to sit and eat with the children). However, if it appears that more stringent rules do not produce the desired effect due to workload, a rotation system could be developed or, ideally, more staff should be hired. In other cases, reforms should be applied. For example, the problem of children eating on their own rhythm, which hinders peer and adult modeling, can be solved by grouping together children of the same age. Furthermore, the current restrictions imposed by the authorities (e.g. it is not allowed to prepare food in the daycare center) are justifiable for the sake of hygiene and safety, but interfere with many possibilities to pursue a policy promoting healthy eating behavior. A compromise should be reached to create a hygienic and safe environment in which healthy food is promoted as well. For example, the food should be prepared in a place that can be observed safely by all children at any time. On some days, older children should be allowed to help with simple and safe tasks, such as stirring the soup, washing vegetables or cutting vegetables with a blunt knife. Rules such as washing hands before entering the kitchen, storing food at the right temperature, and cleaning kitchen equipment may in turn contribute to hygiene. In the United States, the systematic QRIS approach (i.e. Quality Rating and Improvement Systems [65]) has been used to assess, improve and communicate the level of quality in early care and education programs [66]. Specific policy implementation strategies (i.e. professional development, assessment, technical assistance, and incentives) are recommended to improve eating, physical activity and breastfeeding practices and limit screen time in child care settings [67]. Examples of these recommendations that could also follow from the current results are including health as a mandatory policy element to reflect its importance in children’s development, or offering the advice of a consultant who could help address issues such as staff modeling behaviors [67].