The accounts of the participants in this study provide nuanced insights which could help inform obesity prevention initiatives and highlight where caregivers many benefit from educational and practical support.
Rules and routines may influence feeding goals and behaviours
Rules and routines were positive in their intention and reflected both European and national-level anti-obesity and healthy-eating messages [5, 6] such as encouraging regular meals, increasing fruit and vegetable consumption, limiting, or completely avoiding SSB consumption, and providing water as a beverage of choice. The setting of limits in relation to foods perceived to be unhealthy is consistent with findings from qualitative studies with caregivers of young children in the U.S., U.K. and Australia [24–26]. Nonetheless, despite displaying knowledge about good dietary behaviours, studies indicate that dietary guidelines are poorly adhered to by both adults and children in Switzerland [27, 28]. Therefore the description of rules and routines may indicate feeding goals but may not reflect actual consumption behaviours. Further research is required to understand if actual food and beverage intake patterns reflect caregiver feeding goals.
As described in the theoretical framework, rules and routines may originate through caregivers attempts to standardise the recurrent situation of meals and snacks using a classification system that can be cultural, social, or personal [29, 30]. For example, eating in-between meals was perceived negatively, but the cultural practice of feeding children in Switzerland at 10 am and 4 pm was not perceived as snacking per se. Participants described snacking as involving certain salty snacks or sweet foods. This indicates that the conceptualisation of snacking by the researcher and the participant may be different, or have cultural specificities. This requires further understanding since it may impact how HCP advice is delivered along with impacting the collection of dietary intake data.
Portioning foods vs. beverages: the tacit and the explicit
Caregivers were unsure how to provide appropriate food-portion sizes and had difficulty to explain how they estimated the appropriate food-portion size. Participants exclaimed they did not need further support/education about portion sizes. Tacit knowledge is commonly defined as that which cannot be explicated, whereas explicit knowledge follows rules and steps, and can be written down and described [31]. The use of tacit knowledge in estimating preschool children’s food portion sizes has not been previously reported in Switzerland, but has been described in studies from the U.S. Johnson et al. [32] reported two key themes about how mothers portioned meals for their children in the home-setting; (1) portion sizes differ for children who are “good” eaters and “picky” eaters; (2) mothers know the “right amounts” to serve their child. The present study supports the findings in (1) and (2). This study also agrees with previous qualitative work from the UK amongst caregivers who reported that they fed their children the amount they thought the children could eat, based on their perception of the child’s individual appetite [10, 25].
A novel finding of this study is that contrary to the description of preparing food portions, participants were able to precisely describe beverage portions, even as far as providing volume estimates for the amounts of water, tea, juice and milk consumed. This attention to the volume of liquids consumed in the early years of the child’s life—along with the fact that drinking vessels contain a scale for the estimation of volume—may be a means in which the caregiver becomes more attuned to the quantities of liquids served and consumed. This may suggest that major life events, such as having a child, may impact expertise in relation to the portioning of liquids. This is also consistent with the theoretical framework whereby Sobal et al. [30] describe the impact of major life events on the feeding behaviours. This hypothesis would require further research and may have impact for the collection of dietary intake data.
Explicit knowledge about health effects of beverages
Despite milk being consumed morning and evening by all participants, and the health benefits of milk being widely described, caregivers perceived water to be the healthiest of all beverages. This would be in agreement with public health nutrition advice in Switzerland to offer water in preference to sweetened beverages, especially when feeding young children [6, 14]. Several participants’ subjectively integrated advice of HCPs in providing fruit juice—specifically orange juice—when their child experienced constipation. A search of the literature failed to find any studies which reference this notion, nor paediatric guideline, to support this recommendation [33]. If such a recommendation has no scientific basis, then there is scope to educate HCPs. Sweetened beverages were limited, by the caregiver, if they contained “fizz” (i.e. carbonated beverages) but fruit juice was not perceived as a sweetened beverage that should be limited. Rather, the “fizziness” itself was perceived as being unhealthy. This has been reported in a previous study in Switzerland in older children and adults [34] and indicates opportunity to educate caregivers about the nature and composition of sugar sweetened beverages and their moderation in the diets of toddlers and preschoolers.
Challenges in the provision of foods and beverages
Participants described three sub- themes which impacted their ability to manage the provision of foods and beverages of their choosing, in the manner of their choosing; 1) Time to cook 2) Homemade is better and 3) Budget.
Most participants expressed issues in finding time for planning and preparing meals. This is comparable to findings from the US in which families of employed mothers have less frequent family meals, more frequent fast food for family meals, and spend less time on food preparation [35]. There may be scope to include “available time” as a factor in the development of healthy eating guidelines and in advice from HCPs.
Several participants preferred homemade food and rejected commercially produced meals. Negative attitudes towards commercially prepared meals have been reported in previous European studies [36, 37]. Homemade food has been thought of as an authentic creation of the family, and a way for the family to create meaning and identity [38]. Therefore, regardless of the nutritional quality of a meal, homemade food may be linked to creation of family identity and meaning and be the preferred option for feeding young children. Caregivers may benefit from advice on how to prepare quick, healthy, age-appropriate, family meals.
With the exception of 3 participants, all caregivers described shopping according to a budget often buying lower quality items, for example meats, due to the cost constraints. Cost can be a barrier to a high-quality, nutrient-dense and varied diet [39]. As described by one low-income participant, households may experience periods whereby the acquisition of nutrient-dense foods may not be possible for the entire family. The extent to which periods of food insecurity may occur amongst low-income families in Switzerland is not known. Recent studies in Switzerland describe how low-cost food items are comparable in nutrient composition to more costly branded items [40] but available product choice of low-cost food items is sometimes limited. The feasibility of access to a healthy diet, for low-income families in Switzerland, remains under-researched.
A qualitative study, such as this, can help to improve understanding in a way that randomized controlled trials cannot. As usual, in qualitative research, the purposively selected participants are not expected to be representative of all caregivers in Switzerland. However, this study provides an explorative overview of the caregiver experiences when feeding very young children, and makes a novel contribution to Swiss and European qualitative research in nutrition. Future research is required to confirm the study findings herein.
