*3.4. Dietary Intake in Subgroups*

Overall, there were few differences in total dietary intake between boys and girls. Boys consumed significantly more energy than girls (1304.8 *vs*. 1264.6 kcal, *p* < 0.01), as well as more dietary fibre (12.7 *vs*. 12.2 g, *p* < 0.02). There were no significant differences between boys and girls in intake specifically at childcare.

Intake of energy was significantly higher among older children, both specifically at childcare and for the day as a whole (see Table 4). Dietary fibre intake also increased with age, mainly at childcare. Sweet snacks intake increased with age, although at childcare, this increase was only significant between 2 and 3 years, while the increase in overall sweet snacks intake was only significant between 1 and 2 years. Total savoury snack intake increased between the ages of 1 and 2 years.

Children who attended childcare for 3 or more days a week had a higher total vegetables consumption (73.3 *vs*. 62.0 g, *p* < 0.02), and consumed more savoury snacks (1.1 *vs*. 0.6 g, *p* < 0.04; results not tabulated) than children attending childcare for 2 days or less. Childcare attendance was not significantly related to specific dietary intake at childcare.


**Table 3.** Dietary intake by toddlers at different eating moments. 




\* *p* < 0.05, \*\* *p* < 0.01, \*\*\* *p* < 0.001; f Including salty snacks and fried snacks.

**Table 4.** Dietary intake differences based on age.

There were no differences in overall intake between childcare centres with different SES. With regard to the specific intake at childcare, children at high-SES childcare centres consumed significantly less fruit (93.0 g) than children at medium- and low-SES centres (106.2 g and 101.2 g, respectively, *p* < 0.04). On the other hand, they consumed significantly more vegetables at childcare (14.9 g) compared to children from medium- and low-SES centres (7.2 g and 7.3 g, respectively, *p* < 0.01). Children at low-SES childcare centres consumed significantly lower amounts of energy (619.0 kcal) than those at medium- and high-SES centres (679.8 and 652.9 kcal, respectively, *p* < 0.04). Finally, children at low-SES centres consumed significantly less savoury snacks (0.4 g compared to 0.1 g and 0.3 g in medium- and high-SES centres, respectively, *p* < 0.05; results not tabulated).

#### **4. Discussion**

The current study assessed dietary intake at childcare and at home in a large sample (*N* = 1016) of Dutch toddlers (1–3 years) who attended childcare. Energy intake was high relative to dietary guidelines, while dietary fibre, fruit and vegetable intakes were low. Snack intake (both sweet and savoury) was low. In 2005 and 2006, a national food consumption survey was conducted among toddlers in the Netherlands including children who attended childcare as well as those who did not. The dietary intake among the 2- to 3-year-olds (*N* = 788) from that survey was very similar to the intake we found in the current sample, specifically as regards the intake of energy, all macronutrients, dietary fibre and fruit (differences all <5%) [30]. This indicates that the overall dietary intake by children attending childcare does not seem to be very different from that by children not using childcare. Compared to the national survey, however, children in the current sample appeared to consume far less snacks (13.5 g of sweet snacks *vs*. 47 g in the national survey; and <1 g of savoury snacks *vs*. 3 g in the national survey) and more vegetables (64.7 g compared to 40 g in the national survey) [30].

It is unclear why there were such considerable differences with regard to vegetable and snack intakes, but not with regard to any other dietary intake measures. Perhaps the fact that the current study included 1-year-olds can partly explain these differences, especially with regard to snacks, because the 1-year-olds in the current sample consumed significantly less snacks than the older children. Furthermore, it should be noted that the current study did not include days on which the children did not attend childcare. It is possible that the children from the current sample had different intake patterns during a full day at home. However, a previous study by Ziegler and colleagues [18], which compared lunch and snacking moments at childcare with the corresponding eating moments during a full day at home, found only slight differences in intake between these two locations, which were only significant for the afternoon snacking moment: at home, children seemed to consume a bit more protein and fat in the afternoon. Furthermore, Ziegler *et al*. [18] reported more frequent consumption of salty snacks in the afternoon at home than at childcare. A study by Lehtisalo [23] that compared the dietary intake of children cared for at childcare with that of children cared for at home found lower vegetable consumption and higher sweet pastry consumption by the children cared for at home. These findings are in line with the deviating vegetable and snack consumption in the current sample compared to the national survey [30]. A final explanation for the differences between the current study and the national survey may regard the fact that the current study did not include weekend days. Several studies have shown that children's dietary intake is generally less healthy on weekend days (e.g., [22,23,31]), possibly explaining the lower snack consumption and higher vegetable intake in the current study.

In line with previous research among young children (e.g., [30,32]), the children in the current sample skipped very few meals and snacking moments: 98.6%–99.8% of the children consumed food at each of the eating moments (except for an evening snack, consumed by 62.4%). As regards the quality of children's diets, the macronutrient content of their diets seemed to be very good, with 83.2% to 99.2% of the children meeting the guidelines for carbohydrates, proteins, total fat and saturated fat. Studies from the US found excess consumption of total and saturated fat in childcare [14–16], perhaps reflecting a cultural difference between the US and the Netherlands. However, in line with previous US studies [14,16–18], many children in the current sample did not consume sufficient dietary fibre, vegetables and fruit. Furthermore, almost half of the children consumed excess amounts of energy (*i.e.*, >1320 kcal), which is in line with previous research [14]. About equal amounts of energy were consumed at home and at childcare. Energy intake at the different eating moments in the current study was comparable to that found in US studies [18,20].

There were few differences in dietary intake between subgroups, both at childcare and in total. In line with previous research [19], boys consumed more energy than girls. In addition, boys consumed more dietary fibre. Concerns about children's diet seemed to change with age: while younger children were more likely to consume insufficient dietary fibre, the older children often consumed more snacks and energy. These differences were visible specifically at childcare as well as during a whole day, with the exception of savoury snack intake, whose increase was only significant as regards intake during a whole day. With regard to childcare attendance, children who attended three or more days a week consumed more vegetables and savoury snacks, though not at childcare, indicating that this increased vegetable and snack intake took place at home. Furthermore, we found older children to consume more energy, dietary fibre, sweets and snacks. Despite the fact that The Netherlands Nutrition Centre recommends the same intake for children aged 1–4 in their guidelines [29], our results show that children within this age group have different needs. Children in the age of 1 may for example still be nursed which influences their dietary intake.

Although the overall consumption of snacks seemed to be low (13.5 g of sweet snacks and less than one gram of savoury snacks per day on average), the majority of the sweet snacks were consumed at childcare, especially during the afternoon snacking moment. Fruit was consumed especially during the morning snack at childcare, and to a lesser extent in the afternoon. This indicates an opportunity for childcare centres to improve children's fruit consumption (which was too low for almost three quarters of the children), and at the same time even further lower snack consumption, by replacing the afternoon sweet snacks with fruit. Fruit consumption seemed to be especially low in high-SES childcare centres, while intake at home was not significantly different between childcare centres with different SES. Previous studies have repeatedly shown that children from low-SES families often consume less fruit (e.g., [33,34]). However, children from high-SES childcare centres in the current study also consumed more vegetables. It seems that high-SES childcare centres place more emphasis on vegetable intake, and less on fruit intake.

Various previous studies examining dietary intake at childcare have used the guidelines of the American Dietetic Association (that a child who spends a full day at childcare [*i.e.*, 8 h or more] should consume one half to two-thirds of his or her daily dietary intake at childcare [10]) to convert daily dietary intake guidelines into estimated guidelines for intake at childcare (e.g., [16,17,19]). However, such conversion into childcare-specific guidelines ignores the fact that the composition of meals and other eating moments is not stable throughout a day (e.g., the composition of a typical lunch is different from the composition of a typical dinner), as the current study shows. It therefore makes no sense to apply the same guidelines at home and at childcare. This underlines the importance of studies assessing dietary intake during a total day, both at home and at childcare, enabling comparison with daily intake guidelines.

The current study had several limitations. There was a relatively high percentage of incomplete cases (56.3%), although the final sample included in the study can still be considered very large (over 1000 children from over 100 different childcare centres) compared to previous studies. This large sample size also provided sufficient statistical power to correct the analyses for the multi-level structure of the data. Nonetheless, there was some selective drop-out with regard to longer childcare attendance. In addition, the data collection took place over a relatively long period (30 months), which could have influenced the results. A strength of the current study was that dietary intake was assessed both at childcare and at home, making it possible to compare the intake with dietary guidelines without having to estimate the proportion of intake taking place at childcare. However, dietary intake at childcare was observed and recorded by childcare staff, while dietary intake at home was self-reported by parents, possibly introducing bias. Moreover, the dietary intake assessment methodologies used in both settings (childcare and home) were not validated, and weekend days were not assessed in the current study. With regards the software used to recalculate intake, participants were not asked whether children consumed their entire plate/glass which may have biased the reported intake. However, the ability of the program to register amounts of half or a quarter of a portion helped accurate assessment of children's intake. Moreover, the dietary intake in the current sample was very similar to the intake in a previous national survey, indicating that the assessment methods in the current study were probably sufficiently reliable.

#### **5. Conclusions**

In terms of energy balance, the main concern of children's dietary intake in our study was their low fibre, vegetable and fruit consumption, and their high energy intake, putting them at risk for developing overweight. Childcare has a large potential to contribute to resolving these issues, for instance by offering fruit as a snack twice instead of once a day, and by providing vegetables during lunch and snacking moments. This could potentially also further lower snack consumption and thereby lower energy intake, thus also reducing the overweight risk. Previous studies have shown that childcare staff can have an important positive influence on children's dietary intake at childcare, for example by serving sufficient healthy foods [16,35], preferably using a family serving style (in which the child can take healthy foods him/herself and can decide how much to take) [19,36,37] or indulgent feeding style (giving and offering seconds for healthy foods) [37,38]; by being a positive role model and eating healthy foods together with the children [19]; and by talking about healthy foods with the children [19].

As regards research, the current findings underline the importance of future research assessing dietary intake during a total day, both at home and at childcare. This enables comparison with daily guidelines, instead of having to convert these guidelines to improvised childcare-specific guidelines. In addition, intake should be assessed during a full day at home as well, including weekend days, to be able to compare intake at home and at childcare and to check for variability in children's diets across locations.

#### **Acknowledgments**

The data collection for this study was financially supported by Nutricia, as part of the Eet Compleet Test. Nutricia had no influence on the analysis and reporting of this study. We are grateful to all childcare staff, children and parents who participated in the study.

#### **Conflicts of Interest**

The authors declare no conflict of interest.
