**Dietary Intake by Dutch 1- to 3-Year-Old Children at Childcare and at Home**

**Jessica S. Gubbels, Lieke G. M. Raaijmakers \*, Sanne M. P. L. Gerards and Stef P. J. Kremers** 

Department of Health Promotion, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre, PO Box 616, Maastricht 6200 MD, The Netherlands; E-Mails: jessica.gubbels@maastrichtuniversity.nl (J.S.G.); sanne.gerards@maastrichtuniversity.nl (S.M.P.L.G.); s.kremers@maastrichtuniversity.nl (S.P.J.K.)

**\*** Author to whom correspondence should be addressed; E-Mail: lieke.raaijmakers@maastrichtuniversity.nl; Tel.: +31-43-388-2401; Fax: +31-43-367-1032.

*Received: 24 October 2013; in revised form: 10 December 2013 / Accepted: 24 December 2013 / Published: 8 January 2014* 

**Abstract:** The goal of the current study was to assess dietary intake in a large sample (*N* = 1016) of Dutch toddlers (1–3 years old), both at childcare and at home. Dietary intake during two weekdays was recorded using an observation format applied by childcare staff for intake at childcare, and partially pre-coded dietary journals filled out by parents for intake at home. Children's intake of energy, macronutrients and energy balance-related food groups (fruit, vegetables, sweet snacks, savoury snacks) were compared with Dutch dietary guidelines. In addition, differences between the dietary intake by various subgroups (based on gender, age, childcare attendance, socio-economic status of childcare centre) were explored using multilevel regression analyses, adjusting for nesting of children within centres. Energy intake was high relative to dietary guidelines, and children consumed more or less equal amounts of energy at home and at childcare. Dietary fibre, fruit and vegetable and snack intakes were low. Intake at childcare mainly consisted of carbohydrates, while intake at home contained more proteins and fat. The findings imply various opportunities for childcare centres to improve children's dietary intake, such as providing fruit and vegetables at snacking moments. In addition, the findings underline the importance of assessing dietary intake over a whole day, both at childcare and at home, to allow intake to be compared with dietary guidelines.

**Keywords:** childcare; day-care; dietary intake; dietary journal; nutrition; observation; overweight; parent; toddler

#### **1. Introduction**

Worldwide, at least 42 million children under the age of five were overweight in 2010, and these numbers are expected to continue to increase [1]. Childhood overweight is a major risk factor for several chronic conditions such as cardiovascular diseases and type 2 diabetes mellitus [2]. Moreover, childhood overweight is known to track into adulthood, in that overweight children often remain overweight or obese during later life [3]. Dietary intake plays a crucial role in the development of overweight [4]. Dietary habits are often established at a young age [5] and maintained throughout life [6–8], indicating the urgency of increasing our understanding of the origin and development of dietary habits in young children.

In Europe, over half of the toddlers (below primary school age) attend some form of childcare or educational facilities [9]. It has been recommended that a child in full-time childcare (*i.e.*, 8 h or more per day) should consume one half to two-thirds of his or her daily dietary intake at childcare [10], indicating the importance of childcare for the development of children's dietary habits. Childcare use has been found to be associated with an increased overweight risk throughout childhood (e.g., [11–13]). Furthermore, various studies have shown that children attending childcare often do not meet dietary intake recommendations: they may consume excess energy [14] and excessive amounts of total fat [14,15], saturated fat [15,16] and sweets [14]. In addition, they are not consuming sufficient amounts of fruit [16], vegetables [14,16,17] and dietary fibre [18]. However, several of these studies were limited to dietary intake at childcare [16,19,20], ignoring the intake at home. As such, they have to rely on the estimated proportion of the dietary intake that takes place at childcare. Since dietary intake at home is not known, these studies assume the composition of the meals to be stable throughout the day and do not take into account possible compensation behaviour at home. The studies that have taken account of both dietary intake at home and intake at childcare [14,15,17,18,21–23] mostly had small sample sizes (*N* < 200) [14,17,18,21,22], assessed dietary intake at childcare through the parents [18], or only examined specific meals instead of dietary intake during a whole day [18]. In addition, the majority of the studies examining dietary intake have been conducted in the United States [14–18,20,21], with only a few from Europe [19,22,23].

The current study aimed to assess dietary intake in terms of energy, macronutrients and the food groups of fruit, vegetables, sweet snacks and savoury snacks, both at childcare and at home, in a large sample (*N* = 1016) of Dutch toddlers (aged 1–3 years). In addition, it explored the dietary intake in various subgroups (according to gender, age, childcare attendance and socio-economic status (SES) of the childcare centre's neighbourhood).

#### **2. Methods**

#### *2.1. Respondents and Procedure*

Ethical approval for this study was not required according to Dutch law, since the current research did not involve invasive procedures, and thus did not fall under the Dutch Medical Research Involving Humans Act (Wet Medisch-Wetenschappelijk Onderzoek met Mensen) [24]. All childcare centres in the Netherlands were approached to participate in the study from March 2011 onwards. Several strategies were used to recruit childcare centres. A direct mailing of letters was sent to addresses acquired by purchasing commercially available addresses. In addition, a digital mailing was sent, and childcare centers were recruited at conferences and through appointments at the head offices of the childcare organizations to which the centres belonged. If the head office was interested, the recruitment was continued at the individual centres. All childcare centres were allowed to participate. Sometimes a centre decided not to participate citing reasons such as that it would be too much effort, the centre had been closed down, the parent committee did not agree or management had changed. The 112 childcare centres that responded before August 2013 were included in the study. Data collection started as soon as a childcare centre consented to participate. All parents of the children aged 1 to 3 years from these centres were invited to participate. A total of 2788 children participated. All parents of participating children provided informed consent. Children's dietary intake was recorded on two entire weekdays, randomly chosen during one week, both at home using food diaries and at childcare using observations.

#### *2.2. Assessment of Dietary Intake*

In the Netherlands, children attending childcare usually consume their breakfast at home. Subsequently, they consume a morning snack, lunch and afternoon snack at childcare, and their dinner again at home.

#### 2.2.1. Dietary Intake at Childcare

Staff at the childcare centre was instructed by a dietician to record the dietary intake of each of the participating children on a poster. The poster was a partially pre-coded dietary record, providing a list of the most common products that might consumed at each different eating moment. For instance, it showed a list of sweet snacks, beverages and fruits commonly consumed at snacking moments in the Netherlands. In addition, it provided space at each eating moment to record any other products consumed which were not on the standard list. There was a separate column on the poster for each participating child, where their intake could be recorded. Childcare staff was asked to specify the type of product (e.g., whether the milk product consumed was milk, chocolate milk, butter milk or yoghurt drink), the unit (e.g., whether it was a cup or a bottle), and the amount (*i.e.*, number of units).

The first eating moment (the snacking moment of the first observation day) was recorded together with the dietician, at which point the childcare staff received detailed instructions from the dietician on how to record the dietary intake. If the childcare staff were still uncertain about any aspects, these would also be explained by the dietician. During the rest of that day, and on the second observation day, the childcare staff filled in the poster for all eating moments at the centre (*i.e.*, morning snack, lunch and afternoon snack).

An additional questionnaire was filled in by the childcare staff together with the dietician to record further information regarding the meals and foods offered at the centre, such as the standard portion size used for certain products (e.g., how many mL were in the cups used) and the type and brand of particular products (e.g., whether regular or low-fat margarine was used and what brand).

#### 2.2.2. Dietary Intake at Home

Parents were also asked to record their child's dietary intake at different eating moments at home during the two measurement days (*i.e.*, breakfast, dinner including dessert, and anything consumed after dinner, including anything consumed during the night). The questionnaire consisted of a partially pre-coded food journal, providing a list of common products that might be consumed at each different eating moment. For instance, the food journal listed the bread and bread products, butters or margarines, sandwich toppings, fruit, porridges and beverages that are often consumed at breakfast in the Netherlands. In addition there was space to record any other products consumed at each eating moment that were not on the standard list. Parents were asked to specify the type of product (e.g., whether bread was white or brown), the unit (e.g., whether it was a slice of bread or a roll), the brand, and the amount (*i.e.*, number of units).
