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.     

Participation in the CACFP Ensures Availability but not Intake of Nutritious Foods at Lunch in Preschool Children in Child-Care Centers

BackgroundThe US Department of Agriculture Child and Adult Care Food program (CACFP) recently (October 2017) updated requirements for meal reimbursement and best practice recommendations for serving nutritious meals and beverages, and minimum age-specific serving sizes for five food groups. It is not known whether CACFP-funded child-care centers are meeting the updated meal pattern requirements and best practice recommendations, and whether children are meeting nutrition recommendations based on the current 2015-2020 Dietary Guidelines for Americans (DGA).ObjectiveThis study assessed whether the recruited CACFP-funded child-care centers in this study were meeting the updated (2017) CACFP requirements regarding foods served for lunch and whether children attending these child-care centers were meeting age- and sex-specific DGA recommendations regarding foods consumed.DesignThis was a cross-sectional study using the Dietary Observation for Child Care method. Participants and settingsChildren aged 3 to 5 years (n=108) from 10 classrooms in three CACFP-funded child-care centers in Lincoln, NE, were recruited by convenience sampling during spring 2018.Measurable outcomesFood served and consumed during observed lunches in comparison with updated CACFP requirements and DGA, respectively.Statistical analysisAdjusted mean amounts of foods served from each food group were compared with age specific minimum CACFP serving size requirements. Adjusted mean amounts of foods consumed from each food group were then compared with age- and sex-specific DGA recommendations.ResultsThe recruited child-care centers were meeting the updated CACFP requirements regarding foods served but showed limited adherence to the best practice recommendations during the observed lunches. However, the overall mean intake for grains, fruits, and vegetables was significantly lower (P<0.01) than DGA recommendations. In addition, approximately 25% of the children did not consume any vegetables during their meal. ConclusionsAlthough child-care centers were meeting the updated CACFP requirements by serving the recommended amounts of foods, children were not meeting DGA-recommended intakes. Future studies are needed to explore ways to improve adherence to best practice recommendations to improve children’s consumption of healthy foods in child-care centers.     

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.     

What's in Children’s Backpacks: Foods Brought from Home

Forty-one percent of elementary schoolchildren bring lunch to school on any given day. Forty-five percent bring snacks. Surprisingly, little is known about the foods and beverages they bring. This cross-sectional analysis of baseline data from the GREEN (Growing Right: Eco-friendly Eating and Nutrition) Project Lunch Box Study sought to characterize foods and beverages brought from home to school by elementary schoolchildren and compare the quality of packed lunches with National School Lunch Program standards and packed snacks with Child and Adult Care Food Program requirements. Lunches and snacks from 626 elementary schoolchildren were assessed and evaluated using digital photography and a supplemental food checklist. Food and beverage types most likely to be provided for lunch were sandwiches (59%), snack foods (42%), fruit (34%), desserts (28%), water (28%), and sugar-sweetened beverages (24%). Twenty-seven percent of lunches met at least three of five National School Lunch Program standards. At snack, snack foods (62%), desserts (35%), and sugar-sweetened beverages (35%) were more common than fruits (30%), dairy foods (10%), and vegetables (3%). Only 4% of snacks met two of four Child and Adult Care Food Program standards. Future research is needed to understand the multiple determinants of food-packing behavior, including constraints faced by families. School wellness policies should consider initiatives that work collaboratively with parents to improve the quality of foods brought from home.     

Dietary Intakes of Children Enrolled in US Early Child-Care Programs During Child-Care and Non-Child-Care Days

BackgroundEarly-child-care (ECE) programs may substantially influence child diet quality.ObjectiveThe Study of Nutrition and Activity in Child Care Settings describes the usual food group intake of preschool-aged children attending ECE programs relative to Dietary Guidelines for Americans (DGA) recommendations, comparing intakes during child-care and non-child-care days.DesignMeal observations and parent-completed food diaries in a cross-sectional nationally representative multistage cluster sample of Child and Adult Care Food Program-participating ECE programs.Participants/settingOne thousand four hundred sixty-eight children aged 3 to 5 years attending 217 Child and Adult Care Food Program-participating ECE programs (eg, child-care centers and Head Start) during 2017.Main outcome measuresDaily energy intake, daily US Department of Agriculture Food Pattern Food Group intakes, and percentage of daily intakes meeting 2015-2020 DGA Food Pattern recommendations.Statistical analyses performedRegression-adjusted usual intakes and percentage of children meeting recommendations were estimated using the National Cancer Institute method. Single-day mean intakes were used to test for statistical differences between child-care and non-child-care days.ResultsMean usual energy intake was 1,524 ± 19.3 kcal during child-care days and exceeded the recommended range at 1,702 ± 30.2 kcal during non-child-care days; single-day means indicated significantly lower energy intake on child-care days (P < 0.001). The percent of children meeting DGA recommendations on a child-care day varied by DGA food group: fruits (51.4%), grains (50.1%), dairy (42.5%), vegetables (6.5%), whole grains (4.6%), and protein foods (0.1%). Recommended limits on calories from added sugar and solid fats were met by 28.2% and 14.6% of children, respectively. Compared with mean food group intakes during a single child-care day, non-child-care day intakes were similar for fruits and vegetables, lower for dairy and whole grains, and higher for total grains, protein foods, and calories from added sugars and solid fats.ConclusionsAlthough there is room to increase nutrient density inside and outside of child care, intakes on child-care days more closely align to DGAs.     

Child Care Sites Participating in the Federal Child and Adult Care Food Program Provide More Nutritious Foods and Beverages

ObjectiveTo compare food/beverage provisions between child care sites participating and not participating in the Child and Adult Care Food Program (CACFP).DesignCross-sectional survey administered in 2016.SettingLicensed child care centers and homes.ParticipantsChild care providers (n = 2,400) randomly selected from California databases (30% responded). Respondents (n = 680) were primarily site directors (89%) at child care centers (83%) participating in CACFP (70%).Main Outcome MeasuresMeals/snacks served, and food/beverage provisions provided to children of age 1–5 years on the day before the survey.AnalysisOdds ratios unadjusted and adjusted for the number of meals/snacks using logistic regression.ResultsCompared with CACFP sites, non-CACFP sites provided fewer meals/snacks; had lower odds of providing vegetables, meats/poultry/fish, eggs, whole grains, and milk; and had higher odds of providing candy, salty snacks, and sugary drinks. After adjusting for the number of meals/snacks, differences were attenuated but remained significant for meats/poultry/fish, milk, candy, salty snacks (centers only), and sugary drinks. Differences emerged in favor of CACFP for flavored/sugar-added yogurt, sweet cereals, frozen treats, and white grains.Conclusions and ImplicationsChild care sites participating in CACFP are more likely to provide nutritious foods/beverages compared with non-CACFP sites. Child care sites are encouraged to participate in or follow CACFP program guidelines.     

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.     

New Mexico Sponsors Identify Time and Money as Factors Affecting Home-Based Provider Child and Adult Care Food Program Engagement

ObjectiveDescribe Child and Adult Care Food Program (CACFP) sponsor perspectives on barriers and facilitators to home-based provider CACFP eligibility, enrollment, and participation and ways to improve provider support.MethodsSemistructured interviews were conducted with 11 New Mexico CACFP sponsor staff representing 9 out of 13 agencies (69% response rate) from August to September, 2020. Interviews were analyzed using thematic analysis with an essentialist/realist epistemological approach.ResultsSponsor-perceived barriers to provider CACFP: eligibility (costs, background checks, fear/stigma, and delays in becoming state-approved providers); enrollment (lack of translated/low-literacy materials and cumulative systems requirements); and participation (challenges maintaining qualifying menus and documentation and accessing qualifying food, inadequate reimbursements, and unannounced visits). Sponsors suggested systems changes to improve provider support (eg, more assistance with becoming state-approved and for start-up costs and accessible, progressive nutrition training opportunities).Conclusions and ImplicationsSponsors noted CACFP barriers for home-based providers and identified corresponding systems changes that could be tested.     

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.     

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.     

Go NAPSACC On-Demand Trainings for Early Care and Education Providers: Development and Dissemination

Twenty-two on-demand nutrition training sessions were developed for Early Care and Education providers and disseminated in 21 states using the Go Nutrition and Physical Activity Self-Assessment for Child Care (Go NAPSACC) platform. The training was developed using the DESIGN (decide target behavior, explore determinants, select theory-based model, indicate objectives, generate education plans, and nail down the evaluation) procedure framework, adult learning principles, and behavior change techniques purposively disseminated. More than 96% of the nearly 3,000 providers who completed training in year 1 reported anticipated application of what they learned. On-demand training integrated into existing systems can potentially increase training access for hard-to-reach groups. Strategic promotion may be needed to encourage engagement of non-Child and Adult Care Food Program participating programs and completion of targeted modules.     

Ecological Approach to Family-Style,Multilevel Child Care Intervention: Formative Evaluation Using RE-AIM Framework

ObjectiveConduct formative evaluation of Ecological Approach to Family-Style Dining (EAT) Intervention.DesignQualitative semistructured interviews and demographic surveys.SettingEarly care and education (ECE) centers in Nebraska.ParticipantsCooperative Extension coaches (n = 9), ECE administrators (n = 8), and teachers (n = 17) caring for children aged 3–5 years.InterventionThe EAT intervention (a 16-week, 7-lesson, evidence-based online responsive feeding ECE model) uses a multilevel improvement system of 5 implementation strategies. Early care and education administrators and teachers completed 1 lesson/wk followed by a coaching session.Main Outcome MeasuresThe Reach, Effectiveness, Adoption, Implementation, and Maintenance framework includes 5 evaluative dimensions.AnalysisThematic analysis.ResultsOverall, 77% of children aged 3-5 years (n = 216) participated from targeted Child and Adult Care Food Program ECEs (Reach). All perceived EAT improved children's nutritional and developmental outcomes and encouraged a positive mealtime environment (Effectiveness). Coaches found professional development incentives important, whereas administrators/teachers valued inservice hours (Adoption). Teachers reported successful implementation of responsive feeding, and administrators supported the teachers (Implementation). All reported they intended to continue using EAT, and administrators and teachers discussed incorporating EAT practices into the handbook/school policy (Maintenance).Conclusion and ImplicationsThe EAT was valued by all stakeholders for its perceived effectiveness to positively impact children's nutritional outcomes. Furthermore, stakeholders valued the provided incentives and multilevel design with coaching, ECE administrators, and teachers. Future research is needed on how to use Extension coaches in ECE interventions.     

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.

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).

Quality of Nutrition Environments,Menus and Foods Served,and Food Program Achievement in Oklahoma Family Child Care Homes

Child care environments foster children’s healthy eating habits by providing exposure to healthy foods and feeding practices. We assessed the healthfulness of nutrition environments, menu/meal quality, and the achievement of Child and Adult Care Food Program (CACFP) guidelines and best practices in Oklahoma CACFP-enrolled family child care homes (FCCHs) (n = 51). Two-day classroom observations were conducted. Healthfulness of classroom nutrition environments was assessed using the Environment and Policy Assessment and Observation (EPAO). Foods served to and consumed by children were quantified using the Dietary Observations in Child Care (DOCC) tool. Nutrient analysis was performed to determine total energy for foods listed on menus, served to, and consumed by children. Menu and meal food variety and CACFP Guideline Achievement Scores were determined. Average nutrition environment score was 11.7 ± 1.2 (61.5% of maximum possible score). Energy (kcals) from menus and consumed by children was insufficient to meet two-thirds of their daily reference intake. Children were exposed to 1.7 vegetables and 1.3 fruits per meal. CACFP Guideline Achievement Scores were 66.3% ± 7.8 for menus and 59.3% ± 7.6 for mealtimes. Similar to previous research, our findings indicate a need for improved FCCH nutrition practices. Tailored interventions for FCCHs are needed.     

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.