Obesity Prevention Practices and Policies in Child Care Settings Enrolled and Not Enrolled in the Child and Adult Care Food Program

Objectives The United States Department of Agriculture’s Child and Adult Care Food Program (CACFP) provides meals and snacks to low-income children in child care. This study compared nutrition and physical activity practices and policies as well as the overall nutrition and physical activity environments in a sample of CACFP and non-CACFP child care settings. Methods A random stratified sample of 350 child care settings in a large Midwestern city and its suburbs, was mailed a survey on obesity prevention practices and policies concerning menu offerings, feeding practices, nutrition and physical activity education, activity levels, training, and screen time. Completed surveys were obtained from 229 of 309 eligible child care settings (74.1 % response rate). Chi square tests were used to compare practices and policies in CACFP and non-CACFP sites. Poisson and negative binomial regression were used to examine associations between CACFP and total number of practices and policies. Results Sixty-nine percent of child care settings reported CACFP participation. A significantly higher proportion of CACFP sites reported offering whole grain foods daily and that providers always eat the same foods that are offered to the children. CACFP sites had 1.1 times as many supportive nutrition practices as non-CACFP sites. CACFP participation was not associated with written policies or physical activity practices. Conclusions for Practice There is room for improvement across nutrition and physical activity practices and policies. In addition to food reimbursement, CACFP participation may help promote child care environments that support healthy nutrition; however, additional training and education outreach activities may be needed.     

Updated Meal Patterns in the Child and Adult Care Food Program and Changes in Quality of Food and Beverages Served: A Natural Experimental Study

With diet-related chronic diseases being the largest contributors to U.S. morbidity and mortality, identifying population-level strategies to promote healthier diets is essential. Intervention during early childhood may be particularly important. The Child and Adult Care Food Program (CACFP), a federal nutrition assistance program in the U.S. that supports serving meals and snacks in child care settings, reaches millions of U.S. children. Recent 2017 updates to CACFP’s meal patterns were meant to improve the nutritional quality of food served through CACFP by providing more whole grains, fruit, and vegetables. In this study, we used a natural experimental, longitudinal study of child care centers participating in CACFP compared to nonparticipating centers to assess whether the quality of food and beverages served (per menu analysis) improved following the CACFP meal pattern changes. While we found that CACFP centers were more likely to meet several key nutrition standards in comparison to non-CACFP centers overall, there were no differences in menu quality from before to after the 2017 standards change between CACFP and non-CACFP centers. Nutrition standards for CACFP may need to be further strengthened with adequate financial and technical support given to child care programs for effective implementation.     

Foods Served in Child Care Programs Participating in the Child and Adult Care Food Program and Alignment with Program Meal Patterns

ObjectiveAssess Child and Adult Care Food Program (CACFP) program compliance with meal component requirements for children aged 3-5 years by program type, and describe foods and beverages most commonly served.DesignCross-sectional analysis of 1-week menu surveys during winter/spring 2017.SettingUS CACFP-participating child care programs.ParticipantsNationally representative multistage cluster sample of 664 programs: 222 child care centers, 247 Head Start programs, 195 family child care homes.Main Outcome Measure(s)Percentage of meals including required components; frequently served foods and beverages.AnalysisMean percentages; 2-tailed t tests; alpha = 0.05 significance level.ResultsMost breakfasts (97%), lunches (88%), and afternoon snacks (97%) included all required CACFP meal components. Most breakfasts included fruits (96%), but not vegetables; 16% included a meat/meat alternate. Most lunches (81%) included both fruits and vegetables. Afternoon snacks were mostly grains/breads (80%) and fruits (57%). Most frequently served foods included 1% unflavored milk and fresh fruits such as apples and bananas. Most menus limited juice, offered low-sugar cereal, and did not include flavored milk; very few menus included noncreditable foods with added sugar.Conclusions and ImplicationsMost CACFP meals provided required components, but there is room for improvement, particularly for increasing vegetables served and limiting foods high in added sugar and fat.     

Implementation of Minimum Nutrition Standards and Best Practices in Childcare Centers

BackgroundThe federal Child and Adult Care Food Program (CACFP) provides reimbursable meals to 4.6 million children annually and sets nutrition standards for foods served. Licensing regulations in many states extend these rules to nonparticipating programs.ObjectiveTo evaluate the quality of meals and snacks served in Connecticut licensed childcare centers in 2019 and assess implementation of a state licensing requirement to adhere to CACFP minimum nutrition standards in all centers.DesignCross-sectional survey.Participants/settingTwo hundred licensed childcare centers in Connecticut in 2019.Main outcome measuresMeal/snack quality was assessed based on menus. Foods/beverages listed were compared to the minimum CACFP nutrition standards and optional best practices. Surveys completed by center directors measured center characteristics.Statistical analysisLogistic and linear multivariable regression models tested differences in centers’ adherence to nutrition standards and best practices by CACFP participation status.ResultsCACFP centers complied with more required nutrition standards than non-CACFP centers (an adjusted mean of 4.7 vs 3.4 standards among programs serving meals, P < 0.001), with particularly large mean differences for whole grains and low-fat milk. Implementation of optional best practices, except for beverages, was relatively low among all centers, especially for snacks. Compliance (adjusted mean number of minimum nutrition standards met) was greater among centers accredited by the National Association for the Education of Young Children and those using a registered dietitian or a sponsoring agency to prepare menus and receiving food from a vendor. Recent completion of nutrition training was associated with greater mean implementation of best practices.Conclusions and implicationsBetter adherence to minimum nutrition standards and best practices among CACFP-participating childcare centers contributed to higher nutritional quality of meals and snacks offered. Snack quality would benefit most from greater compliance with nutrition standards. Providers outside of CACFP need additional supports in the implementation of licensing regulations to improve the food environment for young children.     

The Child and Adult Care Food Program: Barriers to Participation and Financial Implications of Underuse

ObjectiveTo assess facilitators and barriers to participation in the Child and Adult Care Food Program (CACFP) and estimate foregone federal funds because of CACFP underuse.MethodsAn online survey of food service practices and experiences with CACFP among Connecticut-based licensed child care centers (n = 231).ResultsServing meals and the center's nonprofit status predicted CACFP participation. The most common challenge among participants was collecting family income eligibility. Streamlining paperwork (mentioned by 44% of respondents) and funding for nonfood, administrative costs (40%) were recommended facilitators to increase CACFP uptake. Nonparticipating centers had limited knowledge about the program and its eligibility. Foregone federal funding due to CACFP underuse among eligible Connecticut centers was estimated at $30.7 million in 2019, suggesting that 20,300 young children from low-income areas missed out on CACFP-subsidized food.Conclusions and ImplicationsImproving knowledge about CACFP and reducing participation burdens through additional funding and technical assistance can help expand the program to support child nutrition.     

Connecting Families to Food Resources amid the COVID-19 Pandemic: A Cross-Sectional Survey of Early Care and Education Providers in Two U.S. States

Early care and education (ECE) settings are important avenues for reaching young children and their families with food and nutrition resources, including through the U.S. federally funded Child and Adult Care Food Program (CACFP). Researchers conducted a cross-sectional survey of ECE providers in two U.S. states in November 2020 to identify approaches used to connect families with food and nutrition resources amid the COVID-19 pandemic. Logistic regression models were used to estimate odds of sites reporting no approaches and adjusted Poisson models were used to estimate the incidence rate ratio of the mean number of approaches, comparing sites that participate in CACFP to those that did not. A total of 589 ECE sites provided responses. Of those, 43% (n = 255) participated in CACFP. CACFP participating sites were more likely to report using any approaches to connecting families to food resources and significantly more likely to report offering “grab and go” meals, providing meal delivery, distributing food boxes to families, and recommending community food resources than non-CACFP sites. This study suggests that CACFP sites may have greater capacity to connect families to food resources amid emergencies than non-CACFP participating sites.     

Predictors of Nutrition Quality in Early Child Education Settings in Connecticut

Objective

This study assessed the dietary quality of lunches and feeding practices (family-style service, teacher role modeling) in Connecticut child care centers and made comparisons by center participation in the federal Child and Adult Care Food Program (CACFP).

Implementation of Revised Nutrition Standards in US Department of Agriculture's Child and Adult Care Food Program

ObjectiveIn October 2017, substantial changes were made to improve the nutritional quality of meals served in the Child and Adult Care Food Program (CACFP). This study describes the experience of child care providers and sponsors during the first year of implementation.MethodsA 1-time survey was administered to CACFP sponsors in Delaware 1 year after implementation of the changes. Data analysis included frequencies and chi-square tests of independence.ResultsAmong respondents (n = 137), 21% faced moderate or significant challenges. Food cost (53.1%) and communicating with parents about changes (44.6%) were the most common challenges faced. The majority reported that parents supported the changes and that children and teachers generally ate the new food.Conclusions and ImplicationsA minority of providers in Delaware faced significant challenges, suggesting that broad changes to CACFP may be feasibly implemented across settings. Training focused on food cost and parent communication may be warranted.     

Foods Served in Child Care Facilities Participating in the Child and Adult Care Food Program: Menu Match and Agreement with the New Meal Patterns and Best Practices

Objective

To assess the agreement of posted menus with foods served to 3- to 5-year-old children attending federal Child and Adult Care Food Program (CACFP)-enrolled facilities, and the degree to which the facilities met the new meal patterns and best practices.

Academy of Nutrition and Dietetics Benchmarks for Nutrition in Child Care 2011: Are Child-Care Providers across Contexts Meeting Recommendations?

The Academy of Nutrition and Dietetics (Academy) recommends feeding practices for child-care providers to establish nutrition habits in early childhood to prevent obesity. With >12 million US children in child care, little is known about child-care providers’ feeding practices. The purpose of this study was to examine child-care providers’ feeding practices to assess whether providers met the Academy’s benchmarks and whether attainment of benchmarks varied across child-care contexts (Head Start, Child and Adult Care Food Program [CACFP], and non-CACFP). Cross-sectional data was collected in 2011 and 2012 from 118 child-care providers who completed self-administered surveys regarding their feeding practices for 2- to 5-year-old children. χ² tests and analysis of variance were used to determine variation across contexts. Head Start providers sat more frequently with children during meals (P=0.01), ate the same foods as children (P=0.001), and served meals family style (P<0.0001) more often compared with CACFP and non-CACFP providers. Head Start providers (P=0.002), parents (P=0.001), and children (P=0.01) received more nutrition-education opportunities compared with CACFP and non-CACFP. Head Start providers encouraged more balance and variety of foods (P<0.05), offered healthier foods (P<0.05), modeled healthy eating (P<0.001), and taught children about nutrition (P<0.001) compared with CACFP and non-CACFP providers. Providers across all three contexts used significantly more non-internal than internal mealtime verbal comments (P<0.0001). Head Start providers had greater compliance with the Academy’s benchmarks compared with CACFP and non-CACFP providers. Possible reasons for this compliance might be attributed to Head Start nutrition performance standards and increased nutrition-training opportunities for Head Start staff. Head Start programs can serve as a model in implementing the Academy’s benchmarks.     

Peer Reviewed: Child Care Provider Training and a Supportive Feeding Environment in Child Care Settings in 4 States, 2003

Introduction

Strategies to prevent adult chronic diseases, including obesity, must start in childhood. Because many preschool-aged children spend mealtimes in child care facilities, staff should be taught supportive feeding practices for childhood obesity prevention. Higher obesity rates among low-income children suggest that centers providing care to these children require special attention. We compared self-reported feeding practices at child care centers serving low-income children on the basis of whether they received funding and support from the Child and Adult Care Food Program (CACFP), which suggests supportive feeding practices. We also assessed training factors that could account for differences among centers.

Methods

Eligible licensed child care centers (n = 1600) from California, Colorado, Idaho, and Nevada received surveys. Of the 568 responding centers, 203 enrolled low-income families and served meals. We analyzed the responses of 93 directors and 278 staff for CACFP-funded centers and 110 directors and 289 staff from nonfunded centers. Chi square analyses, pairwise comparisons, t tests, and multiple linear regressions were used to compare CACFP-funded and nonfunded centers.

Results

Significant differences were noted in 10 of 26 feeding practices between CACFP-funded and nonfunded centers. In each case, CACFP-funded centers reported practices more consistent with a supportive feeding environment. Forty-one percent of the variance could be explained by training factors, including who was trained, the credentials of those providing training, and the type of training.

Conclusion

Our findings suggest that when trained by nutrition professionals, child care staff learn, adopt, and operationalize childhood obesity prevention feeding guidelines, thereby creating a supportive mealtime feeding environment.     

Dietary intake and health outcomes among young children attending 2 urban day-care centers

Objective To assess the impact of the Child and Adult Care Food Program (CACFP) on diet and 3 health outcomes—weight-for-height status, dental caries (tooth decay) score, and number of days of illness—among preschool children attending 2 urban day care centers.

Design Dietary intake and health outcome measures were assessed and compared for children attending 2 day-care centers in an urban community. Data were obtained for 14 days of dietary intake, which were analyzed for energy and 15 nutrients and 6 food groups; anthropometric measures, including weight-for-height; dental caries; and days of illness.

Subjects/setting Forty 3- to 5-year-old black children from 2 day-care centers participated. One center participates in the CACFP. At the other center, children bring all meals and snacks from home.

Statistical analyses performed Data from the 2 groups of children were compared using parametric and nonparametric t tests.

Results Children receiving CACFP meals at day care had significantly higher mean daily intakes of vitamin A (804±191 vs 595±268 retinol equivalents), riboflavin (1.45±0.32 vs 1.21±0.22 mg), and calcium (714±180 vs 503±143 mg) than the children who brought all of their meals and snacks from home. Children who received CACFP meals also consumed significantly more servings of milk (2.9±0.9 servings vs 1.5±0.7) and vegetables (1.8±0.5 vs 1.2±0.5 servings) and significantly fewer servings of fats/sweets (4.6±1.3 vs 5.4±1.1 servings) than children who brought their meals. Weight-for-height status and dental caries scores did not differ between the 2 groups. Children from the center participating in the CACFP have significantly fewer days of illness (median 6.5 vs 10.5 days) than children from the nonparticipating center.

Applications Nutritious meals provided by the CACFP can improve diets and may promote health among young, urban children. Registered dietitians can contribute to food assistance programs by intervening to enhance the quality of meals served and by examining the impact of participation on measures of diet quality and diet-related health outcomes. J Am Diet Assoc. 1999;99:1529–1535.     

Self-Paced Online Training on Healthy Beverage Policy for Child Care Providers

ObjectiveDetermine if online training for child care providers increases knowledge and awareness of and adherence to California's Healthy Beverages in Child Care Act (AB2084) policy.DesignCluster, randomized controlled trial with 2 intervention groups and 1 control group.SettingLicensed child care centers and family child care homes.ParticipantsChild care providers in 3 California regions.InterventionThirty-minute, self-paced online training in English or Spanish, with or without 6-months of ongoing technical assistance.Main outcomes measuredProviders’ self-reported knowledge and awareness of and adherence to AB2084 at baseline, after 1 and 6 months.AnalysisGeneralized estimating equations and generalized linear models, adjusted for the percentage of children on child care subsidies and region.ResultsOutcomes were similar between groups receiving and not receiving technical assistance. Providers receiving training (both intervention groups combined) experienced larger increases in knowledge (P = 0.002 and P = 0.003) and awareness (P = 0.004 and P = 0.001) of AB2084 compared with the control group after 1 and 6 months. All groups reported pre-post increases in adherence to AB2084.Conclusions and ImplicationsA brief online training supports increased knowledge and awareness of healthy beverage policy among child care providers. The training is available online and is free for California child care providers.     

Food Program Participation Influences Nutrition Practices in Early Care and Education Settings

ObjectiveTo determine differences by Child and Adult Care Food Program (CACFP) participation on nutrition requirements and best practices and barriers to implementing both in early care and education programs (ECEs) stratified by context (centers vs home-based ECEs).DesignCross-sectional survey.SettingThree-thousand and fourteen licensed Nebraska ECEs in 2017.ParticipantsOne-thousand three hundred forty-five ECEs.Main Outcome Measure(s)Director-reported nutrition practices in classrooms serving children aged 2-5 years (8 requirements for foods served, 5 best practices for foods served, and 14 best practices for mealtime behaviors).AnalysisChi-square analysis adjusted for multiple comparisons.ResultsOf the sample, 86.8% participated in CACFP, 21.7% were center-based, and 78.3% were home-based. Overall, CACFP participation was related to the higher implementation of CACFP requirements for foods served (P < 0.004 for all) and receiving professional development on nutrition (P < 0.012). In home-based ECEs only, CACFP participation was related to a higher prevalence of serving meals family-style (P = 0.002); however, these practices had low implementation overall.Conclusion and ImplicationsFindings suggest strengthening of requirements to include staff mealtime behaviors beyond service of healthful foods. Improving CACFP enrollment and including CACFP standards in state licensing requirements may be key strategies for improving nutrition practices in ECEs.     

More nutritious food is served in child-care homes receiving higher federal food subsidies

The US Department of Agriculture's Child and Adult Care Food Program (CACFP) serves 2.3 million children by providing monetary subsidies for food to participating child-care providers. This cross-sectional study tested the hypothesis that higher reimbursement rates for food result in higher food expenditures and higher nutritional quality of foods served in family child-care homes participating in CACFP. Sixty family home child-care providers were recruited in 2008-2009 from King County, Washington. Half the sample received higher reimbursements and the other half received the lower rates. Participants provided a 5-day menu of meals/snacks served and food shopping receipts. The nutritional quality of foods served was assessed from portion-standardized menus. Nutritional quality was quantified as the mean adequacy (mean percent of dietary reference intake) for seven nutrients of concern for child health. Food expenditures were calculated by linking menus with receipts. Student's t tests for independent samples and general linear models were used to test for between-group differences. The two groups of providers were socioeconomically and demographically similar with comparable professional backgrounds. However, higher reimbursement providers had significantly greater menu expenditures than the lower reimbursement group ($2.36 vs $1.96/child/day; P=0.031). Reimbursement level was not associated with a difference in calories, but menus of higher reimbursement providers showed a significantly higher mean nutritional adequacy (64.5% vs 56.3%; P=0.033). The finding that reimbursement rates were positively associated with food expenditures and the nutritional quality of foods served suggests that raising CACFP reimbursements can improve child nutrition.     

Implementation of Federal Waivers for Feeding Children in Early Care and Education During the COVID-19 Pandemic

ObjectiveTo capture Child and Adult Care Food Program (CACFP) state directors’ experiences implementing federal waivers for feeding children in early care and education (ECE) settings during coronavirus disease 2019.DesignQualitative semistructured interviews.SettingVirtual interviews with state CACFP directors.ParticipantsChild and Adult Care Food Program directors from 21 states from December 2020 to May 2021.Phenomenon of InterestImplementation of state-level waivers.AnalysisQualitative thematic analysis.ResultsState directors reported that the coronavirus disease 2019 waivers allowed ECE programs to continue feeding children despite being closed or having limited enrollment. The meal pattern, noncongregate feeding, parent/guardian meal pick-up, and monitoring waivers were most frequently used by states. Challenges included maintaining integrity to CACFP meal pattern requirements, addressing the limited capacity of ECE to produce and distribute noncongregate meals, and adapting technology for virtual reviews. Suggested improvements included streamlined communication from the US Department of Agriculture, standing waivers for emergencies, ongoing flexibilities for feeding children, and strategies to increase CACFP enrollment and reduce financial viability requirements for ECE.Conclusions and ImplicationsResults indicate the need for the US Department of Agriculture to consider issuing and extending waivers, increasing ECE participation in CACFP, and ensuring timely communication and guidance on waiver tracking.     

Opportunities to Promote Healthy Weight Through Child Care Licensing Regulations: Trends in the United States, 2016-2020

BackgroundPolicies that support healthy nutrition and physical activity environments in early care and education (ECE) settings can help promote healthy weight in children. State child care licensing regulations are a critical mechanism for setting such policies.ObjectivesTo develop a research instrument to evaluate the promotion of healthy child weight in state child care licensing regulations and assess the strength of the regulations over time.DesignFor measure development, systematic reviews of evidence on the impact of healthy weight strategies relevant to the ECE environment were combined with expert stakeholder input to identify 15 healthy weight promotion policy standards and a coding tool to measure the strength and comprehensiveness of regulatory language matching these standards. For assessing the strength of regulations, the coding tool was applied to child care regulations nationwide in 2016 and again in 2020.Subjects/settingChild care licensing regulations in 2016 and 2020 for all 50 US states plus Washington DC.Outcome measuresStrength and comprehensiveness scores for state licensing regulations.Statistical analysesIntraclass correlation coefficients were calculated to estimate interrater reliability of the coding tool. Paired t tests were used to compare scores within states from 2016 to 2020.ResultsInterrater reliability for the coding tool had intraclass correlation coefficients of 0.81 for strength and 0.87 for comprehensiveness scores. Strength and comprehensiveness of states’ healthy weight promotion policies increased significantly over time (P < .001). However, most states still lack important healthy weight policies in their licensing regulations, such as prohibiting serving sugary drinks.ConclusionsThis study presents a reliable research instrument for measuring the strength and comprehensiveness of healthy weight promotion standards in child care licensing regulations. States have increased their incorporation of strategies for healthy weight into state policy.