Examining the Obesogenic Attributes of the Family Child Care Home Environment: A Literature Review

Childhood obesity is a major public health concern in the US. More than a third of young children 2–5 years old are placed in nonrelative child care for the majority of the day, making the child care setting an important venue to spearhead obesity prevention. Much of the obesity research in child care has focused on center-based facilities, with emerging research on Family Child Care Homes (FCCHs)—child care operated in a home setting outside the child's home. The purpose of this review was to assess the obesogenic attributes of the FCCH environment. A search of the PubMed, Embase, CINHAL, and PsycINFO electronic databases identified 3,281 citations; 35 eligible for full-text review, and 18 articles from 17 studies in the analysis. This review found a lack of comprehensive written nutrition and physical activity policies within FCCHs, lack of FCCH providers trained in nutrition and physical activity best practices, lack of adequate equipment and space for indoor and outdoor playtime activities in FCCHs, inaccurate nutrition-related beliefs and perceptions among FCCH providers, poor nutrition-related communication with families, and poor feeding practices. Future research focusing on interventions aimed at addressing these problem areas can contribute to obesity prevention.


Introduction
Although young children 2-5 years of age in the United States (US) have experienced a decline in obesity, from 13.9% in 2004 to 8.4% in 2012, the prevalence of overweight or obesity continues to be alarmingly high, with 22.8% of young children classified as overweight or obese [1]. Young children from low-income and ethnic minority families are even more likely to be obese, compared to nonpoor and non-Hispanic White children [1,2]. A total of 16.7% of Hispanic and 11.3% non-Hispanic Blacks are obese, compared to 3.5% non-Hispanic White and 3.4% Asian 2-5-year-olds. In 2014, data from the Centers for Disease Control and Prevention showed that 14.5% of low-income 2-to 4-year-olds who participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were obese [2].
Obesity among young children increases the likelihood of developing high blood pressure, [3] glucose intolerance [4], and poor sleep [5], all of which influence the risk for heart disease. Additionally, high hospital expenses related to complications of elevated body mass index (BMI) in young children have contributed to increasing financial burdens [6].
Much attention has been given to energy balance-related causes of obesity that are amenable to effective prevention interventions [7]. To effect change in reducing childhood obesity, a greater understanding of the environment in which children spend the majority of their time is imperative.
Parents of young children aged 2-5 years rely on early child care on a regular basis [8]. Although most children are placed in center-based child care or are cared for by relatives, nearly 2 million young children in the US are placed in Family Child Care Homes (FCCH)s, which provide nonrelative care in a home setting outside the child's home [8]. Children in child care settings eat 2-3 meals including beverages each day and have opportunities for physical activity. Young children in FCCHs are at increased risk for becoming overweight or obese, compared to children placed in center-based facilities; however, little is known about how the FCCH environment relates to childhood overweight or obesity [9][10][11]. Although most research related to child care and obesity has concentrated on center-based child care, research on the obesogenic attributes of the FCCH environment is emerging. We identified no reviews that have synthesized the literature on the FCCH environment. e purpose of this review was to examine the attributes of the obesogenic environment of US-based FCCHs.

Search Strategy and Eligibility Criteria.
We searched the following electronic databases for relevant articles published in English between 2006 and 2016: MEDLINE via PubMed, EMBASE via Elsevier, CINAHL via EBSCOhost, and Psy-cINFO via EBSCOhost. To identify candidate studies for review, we used the keywords and controlled vocabulary terms in the following concept groups: (child care OR family child care homes OR day care OR home-based day care OR child care centers) AND (obesity OR overweight). e complete search strategy can be found in the online resource for this manuscript. We chose to review articles since 2006 coinciding with a landmark commentary on the role of child care settings in obesity prevention, highlighting the need to focus on FCCHs [12]. e final search for each database was conducted on August 8, 2016.
Studies were eligible for inclusion if they were US-based, child care studies in peer-reviewed journals that included an environmental assessment of FCCHs, and focused on FCCHs that cared for children aged 2-5 years. Nonpilot intervention studies that provided results for the assessment of the environment preintervention and studies that compared the environments of FCCHs and other types of nonrelative child care settings, including center-based facilities, were also included. e environmental assessment could have been conducted through various methods; for example, through observations, surveys, interviews, or focus groups. We excluded studies that focused on parental home settings. All search terms regarding the type of child care were used because FCCHs are described in many different ways (e.g., child care homes and home-based daycare). We also aimed to resolve any confusion of child care terms such as preschools operating out of homes. Finally, we included studies that compared FCCHs to other types of nonrelative child care settings.

Screening Process.
e screening process occurred in two waves. In the first wave, titles, abstracts, and occasional full-text were screened to determine eligibility regarding US-based nonrelative child care studies in which the environment was assessed for children 2-5 years of age. In the second wave, titles and abstracts identified for inclusion from the first wave were further screened to identify studies that included FCCHs and assessed the environment of the FCCH setting. ese studies included nonpilot intervention studies that provided results for the assessment of the FCCH environment preintervention and studies that compared the environments of FCCHs to other types of nonrelative child care settings. LF and LS independently screened the titles, abstracts, and occasional full-text. Any discordant reviews concerning eligibility were discussed and resolved. Articles identified from the second wave of screening were eligible for full-text review.

Data Abstraction.
Articles identified for full-text review were examined for eligibility for inclusion in this review. Data from full-text articles eligible for inclusion were abstracted and included information on authorship, year of publication, the location of study, and FCCH provider level and child level demographic information (i.e., sample size, race/ethnicity, level of education, age, and BMI). Additionally, we abstracted information on the status of FCCHs based on their participation in the Child and Adult Care Food Program (CACFP), a subsidy program operated through the US Department of Agriculture (USDA), which provides reimbursements to eligible providers for the purchase of nutritious foods. Finally, we recorded the assessment findings of the FCCH environment. LF and LS examined the full-text articles for eligibility, abstracted the data, and reviewed each others' abstraction for any missing or incorrect information. We used Microsoft Excel for screening titles and abstracts and for abstraction of data. Full-text articles were read in portable document formats.

Classification of Studies.
e articles included in the review were further classified using the Environmental Research framework for weight gain prevention (EnRG), an innovative framework grounded in behavior changeecological theory [13]. EnRG consists of 2 frameworks. e first is the ANGELO-ANalysis Grid for Environments Linked to Obesity-framework, which we used to classify the obesogenic attributes within the physical (what's available in and outside the FCCH, including education and training opportunities), sociocultural (i.e., culture around feeding practices, mealtime environment), and policy (child care policies to ensure best practices and to prevent obesity in the FCCH) environment [14]. e second is the eory of Planned Behavior (TPB), which we used to classify articles that assessed the environment related to FCCH provider attitudes, beliefs, and perceptions [15]. ese articles were organized by matching the terms and definitions used in the articles to the TPB concepts; Attitudes (behavioral beliefs about consequences or expected outcomes), Subjective Norm (normative beliefs or perception of beliefs held by most FCCH providers), Perceived Behavioral Control (perceived level of control to engage in best practices or perceived factors that may serve as enablers or barriers to engaging in best practices), and Behavioral Intent (strategies that are put in place to ensure that providers provide quality environments for the children in their care) regarding energy balance-related behaviors (EBRBs). Since knowledge is closely aligned to perceived control, provider knowledge was also classified under TPB. Demographic factors that were highlighted in the articles and included in the data analyses (i.e., neighborhood, FCCH/facility level, provider, and child level information) were classified as potential moderators. EBRBs refer to any activity that may influence children's weight in an FCCH setting. ese four categories (environment, TPB concepts, potential demographic moderators, and EBRBs), which represent major components of the EnRG framework, were chosen to organize the study findings. Using this framework to help identify obesogenic attributes of the FCCH environment and EBRBs can potentially serve as a model to help guide child care researchers on how to develop tailored interventions unique to the FCCH setting.

Results of Search.
e summary of the search and screening results is shown in a flow diagram in Figure 1. A total of 3,281 records were identified from the four databases searched: 687 duplicate records were removed, and the titles of the remaining 2,594 records were screened in wave 1 for eligibility. A total of 103 records identified through wave 1 were screened for further eligibility, and 35 studies were identified for full-text review. Seventeen articles were excluded, and 18 articles were included in the review, reporting results from 17 studies.

Policy Environment.
FCCH providers have the opportunity to have written nutrition and physical activity policies. ree studies found that few FCCH providers had comprehensive written policies on nutrition and physical activity [19,29,30]. Compared to center-based child care facilities, few FCCH providers had written policies regarding best practices related to beverages, the use of food as reward or punishment, and encouragement for consumption of healthy foods [19]. Trost et al. showed that fewer than 20% of FCCH providers had policies regarding best practices related to foods purchased for celebratory events [29]. Additionally, only about 25% of FCCH providers had written physical activity policies [29,30]. [20,22,23,25,27,29,30]. Although more FCCH providers provided nutrition education to children, compared to center-based providers (44 versus 27%, p � 0.01), [19,20], few FCCH providers used books or games with nutrition themes in their delivery of nutrition education [29]. No FCCH providers reported using a dietitian to plan their menus, [22] and 44.8% of FCCH providers made water readily accessible indoors and outdoors, compared to 73.1% of centers [23]. Less than half of FCCH providers received adequate nutrition and physical activity training one or more times a year [29]. Also, the FCCH's physical activity environment was shown to be suboptimal for indoor and outdoor playtime [25,29]. For example, Tandon et al. found that 76% FCCHs had a variety of fixed play and 86% portable play equipment when compared to center-based centers, 89% and 95%, respectively [25]. Additionally, 71% of FCCHs relied on television for part or most of the day [25]. Finally, about 22% of FCCH providers had physical activity displays such as posters, pictures, or books about physical activity [29].

Sociocultural Environment.
Only three studies examined the sociocultural environment in the FCCH setting [17,27,29]. An observational study conducted in Rhode Island showed that FCCH providers frequently praised the children for trying new foods and eating healthy foods. However, in response to children's mealtime behaviors, providers used both best practices and coercive controlling practices (i.e., insistence, pressuring, and threats) when responding to children's verbal and nonverbal refusals of food, and the verbal and nonverbal acceptance of food [27]. In 85 of the interactions observed related to the providers' response for seconds, providers responded with coercive controlling practices, especially during lunch times [27]. Providers also pressured their children to "clean their plates" before offering seconds of certain foods [27]. Trost et al. showed that only 27% of FCCH providers provided familystyle meals [29]. Additionally, 62.7% of FCCH providers restricted play time for misbehavior [29].

eory of Planned Behavior (TBP) Concepts.
ere were seven articles that addressed beliefs related to knowledge, attitudes, subjective norms, perceived behavioral control, and behavioral intent [16,18,24,28,[31][32][33]. e beliefs described in the articles were closely matched with the relevant TPB concepts. e matching of concepts was done by carefully reviewing the definitions of the concepts provided in the articles and how they were measured and matching the terms to the TPB-related concepts. Results are summarized in Table 2. 3.6.1. Attitudes. Overall, two studies showed that there were poor attitudes among providers regarding parents and parents' role in fostering a healthy environment in the FCCH setting [18,24]. For example, some providers believed that although communication with parents is important to get a better understanding of the child's well-being at home, they felt frustrated and reluctant to discuss a child's weight status with parents for fear of offending parents [18]. FCCH providers felt that the nutrition-related CACFP policies were helpful and made a difference in the health of the children attending the FCCHs [18].

Subjective Norm.
ree studies addressed subjective norms [16,18,28]. ere were inconsistent perceptions of what was considered normal weight among FCCH providers [16,18]. Lindsay et al. showed that despite Hispanic children being disproportionately overweight or obese, Hispanic FCCH providers reported having few children at risk for overweight or obesity or showed no concern about the weight status of the children under their care [18]. ese beliefs, in turn, influenced their belief that portion sizes should be based on age and not on weight [18]. Providers, mostly white, who were presented with drawings of boys and girls of differing sizes, selected smaller sized drawings for girls as a measure for overweight, as compared to the drawing of boys [16]. ese providers reported using more food restriction with girls in the FCCH, than with boys (U � 257.5, p � 0.10) [16]. On the topic of physical activity, most providers believed in the importance of daily physical activity in FCCHs [18]; however, the amount of time providers believed that children should engage in physical activity varied [18]. Additionally, Hispanic providers believed that 50 degrees Fahrenheit was too cold for children to play outside [28]. Although most providers perceived screen time should be limited, focus group discussions pointed to the perception among Hispanic FCCH providers that watching TV was not considered screen time [28].

Perceived Behavioral Control.
Perceived behavioral control was assessed in all six articles. Lindsay et al. showed that most providers were confident in their abilities to provide a nutritious environment for the children in their care [18]. Providers believed that they had a high level of responsibility to provide a healthy nutritional and physical activity environment and that their role was to nurture and educate the children [16,18,24]. Providers also perceived that they had control over what and how much children eat [18]. Providers felt that they had more influence than centerbased providers on eating habits of children. However, FCCH providers also believed that both the center-based providers and FCCH providers have an equal share of influence on physical activity behavior [32]. Providers identified several enablers or barriers to engaging in nutrition and physical activity best practices. Providers believed that the high cost of food prevented the purchase of quality fresh fruits and vegetables for the children [18]. Lack of space for play was identified as a major barrier to physical activity engagement [18,33]. Additionally, the varying needs for physical activities across ages could be challenging for providers [28,33]. Finally, providers perceived poor parental beliefs to be an obstacle to ensuring best nutrition and physical activity practices in the FCCH [18,28].

Behavioral Intent.
ree studies addressed providers' perceived strategies to improve the FCCH environment [18,24,28]. Strategies mentioned by providers included encouraging new foods, meal planning, and participating in workshops [18], problem-based solutions-oriented trainings, and programs and resources to address challenging feeding behaviors among children [28], increased reimbursement from CACFP for purchase of nutritious foods [28], improving communication with parents regarding recommended nutrition and physical activity practices [24,28], use of dramatic play during active play time, [24] and having written, comprehensive rules inside the FCCH [24].
3.6.5. Knowledge. Provider knowledge was addressed in three of the articles [24,28,31]. FCCH providers knew more of the rules on best nutrition practices than center-based providers in the State of Delaware (18 versus 14.7, p < 0.001) [31]. Providers described using their own knowledge on child development to improve what was offered to children in the FCCH [24]. Finally, providers perceived that the CACFP improved their nutrition knowledge [28]; however, this improved knowledge did not help in engaging in best feeding practices due to cultural feeding practices [28].

Covariates Included Analyses (Potential Demographic Moderators).
Although not directly tested for their moderation effects, this review suggests that there are certain neighborhood, FCCH/facility level, provider, and child-level characteristics that may confound relationships between the environment and EBRBs within the FCCH context. 3.7.1. Neighborhood: Income Zone of Neighborhood. When adjusting for the income zone of the neighborhood in which centers and FCCHs are located, indoor and outdoor physical activity and television-use practices remained significantly different between FCCHs and centers, with fewer FCCH providers providing best practices in these areas (p ≤ 0.05) [20]. For nutritional practices, however, the differences between FCCHs' and centers' nutritional practices were no longer significant when adjusting for the income zone of the neighborhood of the facilities (p � 0.05) [20].

FCCH/Facility Level.
Four studies reported the number of CACFP-participating FCCHs included in the study sample [22,23,30,31]. Ritchie et al. was the only study that examined the differences in environment between CACFP and non-CACFP homes [22]. CACFP and non-CACFP FCCHs were significantly more likely to serve whole milk than centers (p < 0.001). More non-CACFP homes served candy and sweetened beverages compared to all other types of child care settings including CACFP homes (15.8% non-CACFP homes versus 6.2% CACFP Homes, p < 0.001; 18.4% non-CACFP versus 7.7% CACFP homes, p < 0.001) [22].

Provider Level.
Hispanic providers were more likely to engage in authoritarian and controlling feeding practices. Freedman et al. found that compared to White and Asian providers, Hispanic providers (representing 76% of study population) were more likely to force children to eat what the providers perceived to be good for them (χ 2 � 7.25, p < 0.05), to insist that the children clean their plates before leaving the table, and to not allow children to eat less than they thought they should and were least likely to sit at the table and eat meals with the children (χ 2 � 3.04, p < 0.05) [17]. Hispanic providers were also three times more likely to cook foods that they knew children liked compared to Asian and White providers (χ 2 � 1.96, p < 0.001) [17]. Brann et al. demonstrated that FCCH providers (84% White) who selected smaller silhouettes for girls as overweight were more likely to have concern about the children's weight, as compared to providers who chose larger silhouettes as representing overweight (U � 235, p < 0.04) [16]. Additionally, providers with higher education had fewer instances of pressuring of children to eat (r � −0.27, p < 0.01) [16]. Kim et al. demonstrated that highly trained FCCH providers were more likely to disseminate healthy nutrition information to children and obesity prevention information to parents [32].
Hispanic providers who spent their formative years in warmer climates outside the US perceived winter as a barrier to physical activity engagement more than US-born Hispanic providers [18].

Child
Level. Among 4-and 5-year-olds, overweight and obese children exhibited lower levels of moderate to vigorous physical activity and total physical activity than healthy weight 4-and 5-year-olds (p < 0.5). Relative to boys, girls exhibited lower levels of moderate to vigorous and total physical activity during the day (p < 0.5) [21].

Energy Balance-Related Behaviors (EBRBs).
FCCH providers reported offering more fresh fruit and vegetables than center-based child care providers (80.3% versus 51.2%, p < 0.001) and more frequently limiting rolls and bread compared to center-based child care providers (28.1 versus 18.6%, p � 0.001) [20]. However, Trost et al. showed that only 41.7% of FCCH providers served lean meats more than four times per week and less than half of the providers reported serving healthy foods for celebratory events [29]. In the study by Liu et al., fewer FCCH providers reported not offering fried foods compared to center-based providers (38% versus 59%, p � 0.001) [19].
Although FCCH providers reported following best practice recommendations for serving water at least daily and limiting sweetened beverages, 55.8% of the FCCH providers offered 100% juice 3-4 times weekly in Tandon et al. and 66% of FCCH providers in Trost et al. [26,29]. Additionally, only 13.9% of FCCH providers offered 1% milk more than once daily [29]. Natale et al. showed that when compared to center-based child care, fewer FCCH providers provided 1% milk more than once daily (45.2 versus 55%, p � 0.015) [20].
When compared to center-based child care, fewer FCCHs provided outside physical activity for 30 min or more three times a week (92.9% versus 96.5%, p � 0.022) [20]. Children in FCCHs spent on average 5.8 min/hour of moderate to vigorous physical activity and 10.4 min/hour of total physical activity [21]. Although a higher portion of FCCH providers reported preschoolers engaged in 60 min of adultled play time compared to center-based child care (33 versus 18%, p � 0.02), only a third of FCCH providers engaged young children in an hour of playtime [19]. Seventy-eight percent of providers reported that they needed training on how to help children be physically active [19].
Nearly 65% of providers had the TV turned on every day for at least part of the day, and 55.1% of providers allowed children to watch TV or video at least once a day [29]. Natale et al. showed that more FCCH providers reported higher levels of limiting computer time than center-based child care providers (63.9 FCCH versus 51.8% centers, p � 0.003); however, fewer FCCH providers rated excellent in limiting TV or video (39.2%, 59.5%, p < 0.001) [20].

Discussion
Research on obesity prevention involving FCCHs is accelerating, illustrating that a review on the obesity promoting attributes of the FCCH environment can identify priority areas for intervention development unique to the FCCH setting. With the guidance of an innovative framework, this literature review examined the obesogenic attributes of the FCCH policy, physical, and sociocultural environment. e examination of the policy environment revealed that there was lack of comprehensive written nutrition and physical activity policies within FCCHs. FCCHs are generally less regulated than center-based child care and are not mandated to have written nutrition and physical activity policies in place. Nonetheless, encouraging FCCHs to provide written nutrition and physical activity policies would provide guidance for engaging in nutrition and physical activity best practices. Children in many FCCHs have few opportunities to engage in quality physical activity due to inadequate spaces for physical activity and high television use. Many FCCH providers are also inadequately trained in nutrition and physical activity and seldom provide nutrition information to parents. ere is limited research on the assessment of the sociocultural environment in FCCHs with respect to obesity and obesity prevention. In this review, there is some evidence that FCCH providers engage in controlling feeding practices and restrict physical activity as a punitive strategy for misbehavior. Since controlling and restrictive feeding styles are associated with overeating in young children, interventions aimed at reducing these obesogenic interactions are warranted [34].
e EnRG framework postulates that the environment can have an effect on EBRB through the mediating role of certain cognitive factors; the TPB concepts. In this review, six articles explored FCCH providers' attitudes, normative beliefs, and control beliefs as they pertain to the FCCH environment and obesity. Although mediation was not examined, the evidence suggests that providers' attitudes and beliefs influence their feeding and physical activity practices as well as family communication practices. Further understanding of these concepts as they relate to the FCCH environment would be instrumental in developing training strategies that can eliminate misconceptions and inappropriate beliefs about nutrition and physical activity practices and enhance self-efficacy, which would help with better communication with families concerning children's eating behaviors. Partnering with families is likely to be effective since families engage with child care providers daily and often share information on the child's daily activities.
We abstracted information on the covariates that were collected and/or included in the analyses. Although the covariates were not tested for moderation, the evidence suggests that many of the covariates may function as potential demographic moderators that should be tested in future research. Within the EnRG framework, demographic moderators may confound relations between the mediated environment and EBRBs or relations between the unmediated and automatic-lack of awareness or controlenvironment and EBRBs.
Although most studies did not examine neighborhood differences, one study adjusted for neighborhood characteristics in comparing FCCH with child care centers [20]. e finding that nutrition-related FCCH/center differences were eliminated after neighborhood adjustment suggests that FCCH and center nutritional practices may be related to neighborhood conditions, such as food availability. In contrast, that finding that neighborhood adjustment did not alter that finding that FCCHs had worse physical activity practices than center-based child care suggests that FCCH/ center differences may be more closely related to physical activity resource and practice differences within the sites, rather than the neighborhoods.
Only one study examined the differences in the food environment by CACFP status [22]. e finding that non-CACFP homes served candy and sweetened beverages more often than CACFP homes is consistent with a study that showed that compared to non-CACFP providers, more CACFP providers engaged in best nutrition practices [35]. Since thirty percent of US children are enrolled in CACFPparticipating FCCHs, more research is needed to examine the impact that CACFP is making on the food environment and feeding practices in FCCHs especially since the introduction of new CACFP guidelines on October 1, 2017, to increase the consumption of fruits and vegetables and reduce grain-based deserts, such as donuts and pastries [36].
On the provider and child-level, FCCH interventions are needed to address Hispanic providers' propensity to use controlling and coercive feeding practices, along with their inaccurate beliefs concerning physical activity and TV use. Provider nutrition training was effective in empowering providers to disseminate healthy nutrition-related information to parents and children [32]. Strategies to increase funding and availability for nutrition training programs for FCCH providers, through CACFP or independent of CACFP, could be instrumental in helping to curb obesity among young children.
Finally, FCCH providers engage in obesogenic EBRBs, providing fried foods, high-fat milk, sweetened beverages, and having limited opportunties for play both indoors and outdoors coupled with high TV use. A mixed-methods approach can help rearchers to understand FCCH providers' knowledge in nutrition and physical activity best practices and barriers to providing an optimal environment for the children in their care. Developing social marketing campaigns tailored for FCCH providers can be an effective approach to influence behavior change.

Limitations and Strengths.
ere are several limitations to this review that can affect the generalizability of the findings. e few studies that examined the FCCH environment were limited to only several states, with no national representation. We limited the search to published literature, not grey literature, meaning that unpublished studies or published studies in a noncommercial form were excluded. Since most studies did not report the licensure status and the size of the FCCHs, we were unable to make inferences concerning the role of licensure and size on EBRBs. Half of the studies that reported race or ethnicity involved majority Hispanic providers and only one study had majority African American providers. Of the studies that examined the policy, physical, and sociocultural environment, only one study relied on observations to assess the environment [27]. Most studies relied on self-report cross-sectional survey data, potentially introducing biases that could be minimized by objectively observing the FCCH environment. Due to the studies' heterogeneity in design, we were unable to evaluate the quality of the studies using one tool. Finally, none of the studies examined the food environment in the neighborhoods outside of the FCCH. Expanding the child care research network to include FCCHs across the US, striving for equal representation in races/ethnicities of FCCH providers and children in their care, addressing neighborhood characteristics, including systematic and observational methods that examine policies and practices, and examining FCCHs over time, would improve generalizability in the process of defining the FCCH environment in the US.
ere are also multiple strengths to the review. FCCHs are a primary resource for many families and are an ideal venue for the implementation of childhood obesity prevention efforts. With strong theoretical guidance, we are able to show that making changes in the policy, physical, and sociocultural environment of FCCHs can provide optimal environments for young children. Enhancing nutrition training for providers and promoting healthy mealtime interactions may improve children's dietary environment. Lastly, we show the need for more studies to understand the impact CACFP has on the food environment of FCCHs.

Conclusion
In conclusion, this review of the obesogenic attributes of the Family Child Care Home highlights the priority areas in which to intervene within the FCCH environment. Interventions addressing child care policies and practices regarding what food is served, how food is served, opportunities provided to young children for physical activity, and the quality of space available within FCCHs, are essential. With better opportunities for FCCH providers to be trained in childhood obesity prevention and in best practices in nutrition and physical activity, providers can be proactive in implementing written nutrition and physical activity policies. FCCH providers would benefit from innovative strategies to implement physical activity and minimize screen time, given space limitations. Finally, addressing misconceptions and inappropriate attitudes and beliefs related to food and physical activity can benefit the health of the FCCH environment. Ensuring that all child care options for young children, including FCCHs, including the policies, practices, and resources to help children build healthy nutrition and physical activity habits, can be instrumental in preventing overweight and obesity.