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Journal Issue: Childhood Obesity Volume 16 Number 1 Spring 2006

The Role of Child Care Settings in Obesity Prevention
Authors: Mary Story Karen M. Kaphingst Simone French

Nutrition

Obesity prevention involves maintaining energy balance at a healthy weight while achieving overall health and meeting nutritional needs. Technically, energy balance means that energy intake is equivalent to energy expenditure, resulting in no net weight gain or weight loss. But children must be in a slightly positive energy balance to get the energy necessary for normal growth. In children, the goal is to promote growth and development and prevent excess weight gain. A primary obesity-prevention approach emphasizes efforts that can help normal-weight children maintain that weight and help overweight children prevent further excess weight gain.19

Nutrition Recommendations for Young Children
A high-quality diet for young children provides sufficient energy and nutrients to promote normal growth and development, to achieve and maintain a healthy weight, and to attain immediate and long-term health. The Institute of Medicine Dietary Reference Intakes provide specific daily nutrient needs of children.20 The Dietary Guidelines for Americans provide science-based dietary advice to promote health and reduce the risk for obesity and other chronic diseases through diet and physical activity for Americans older than age two.21 The 2005 Dietary Guidelines make five key recommendations. At least half the grains consumed by children should be whole grains. Children aged two to eight should drink two cups a day of fat-free or low-fat milk or equivalent milk products. Children aged two and older should eat sufficient amounts of fruits and vegetables. Children aged two to three should limit their total fat intake to 30 to 35 percent of calories, and children aged four and older should consume between 25 to 35 percent of calories from fat, with most fats coming from sources of polyunsaturated and monounsaturated fatty acids. Finally, children should get at least sixty minutes of physical activity on most, preferably all, days of the week.

Poor diet is a major contributor, along with physical inactivity, to the obesity epidemic. To reverse the trend toward obesity, children must have access to and consume such healthful foods as fruits and vegetables, consume adequate portion sizes, limit intake of fats and added sugars, and get plenty of physical activity. The diets of most U.S. children do not meet the Dietary Guidelines.22 They tend to be low in fruits and vegetables, calcium- rich foods, and fiber and to be high in total fats, saturated and trans fats, salt, and added sugars. A recent study examined diet quality trends among a nationally representative sample of preschool children aged three to five between 1977 and 1998.23 Although dietary quality improved slightly over those years, total energy intake increased, as did added sugars and excess juice consumption. Consumption of grains, fruits, and vegetables improved but was still well below recommended levels.

Diets of infants and toddlers are also of concern. In the Feeding Infants and Toddlers Study, a national random sample of 3,022 infants and toddlers from four to twenty-four months old, energy intakes were higher than recommended, according to dietary recall data, suggesting that many caregivers may be overfeeding their children.24 Up to a third of children aged seven to twenty-four months ate no vegetables or fruits on the day of the dietary recall. For fifteen- to eighteen-month- olds, the vegetable most commonly eaten was french fries. More than 25 percent of nineteen- to twenty-four-month-olds ate french fries or fried potatoes on any day, and 44 percent consumed a sweetened beverage.25  Although these studies did not distinguish between foods and beverages consumed at home and at child care, they point to troubling aspects of young children's diets.

The overall diets of children must be improved. Early attention to diet would have immediate nutritional benefits, would help prevent obesity, and could reduce chronic disease risk if healthful habits are carried into adulthood. Clearly, establishing healthful dietary and physical activity behaviors needs to begin in childhood. Child care settings can lay the foundations for health and create an environment to ensure that young children are offered healthful foods and regular physical activity.

Child Care Meals and Snacks: The Child and Adult Care Food Program
The Child and Adult Care Food Program (CACFP) provides federal funds for meals and snacks served to children in licensed child care homes, child care centers, Head Start programs, after-school care programs, and homeless shelters (see table 1). The program, begun as a pilot program in 1968, became permanent in 1978 and is administered by the Department of Agriculture's Food and Nutrition Service through grants to the states. In most states, the state educational agency administers the program.26

Participation and reach. In 2004, CACFP reached almost 2 million children a day in child care centers and Head Start programs and more than 913,000 children in family child care homes. More than 44,000 child care centers and 157,000 family child care homes participated. On an average day, CACFP served meals and snacks to 2.8 million children in these settings.27

Eligibility. Programs that may participate in CACFP include eligible public or private nonprofit child care centers, for-profit child care centers serving 25 percent or more low-income children, after-school programs, Head Start programs, and other institutions that are licensed or approved to provide day care services. Because family child care homes tend to be very small businesses, they can participate in CACFP only if they have a recognized sponsor to serve as an intermediary between them and the responsible state agency. Sponsors are responsible for recruiting, for determining that homes meet the CACFP eligibility criteria, for providing training and other support to family child care providers, for monitoring homes to ensure they comply with federal and state regulations, for verifying the homes' claims for reimbursement, and for distributing the meal reimbursements to the homes.28

Funding reimbursement is provided for up to two meals and one snack, or one meal and two snacks, for each child. The Department of Agriculture also makes available donated agricultural commodities or cash in lieu of commodities. Subsidies for food served to children in child care centers are calculated differently than for those paid to family and group day care homes. Under CACFP regulations, meals and snacks served to children in child care centers, Head Start, and outside-of- school programs are reimbursed at rates based on a child's eligibility for free, reduced-price, or paid meals.29 Children in Head Start programs categorically receive free meals and snacks, thus qualifying the Head Start center for the highest reimbursement rate.

Reimbursement for meals served in day care homes is based on eligibility for Tier I rates (which targets higher levels of reimbursement to low-income areas, providers, or children) or lower Tier II rates (not located in a low-income area nor operated by a low-income provider).30 In 1996, welfare reform legislation changed the reimbursement structure for child care homes to target benefits more specifically to homes serving low-income children.31 As a result, the number of low-income children served in CACFP homes grew by 80 percent between 1995 and 1999, and the number of meal reimbursements for low-income children doubled.32 A family child care provider serving five low-income children can receive about $4,000 a year in CACFP funds.33 In fiscal year 2002, the program's total cost, including cash and commodity subsidies, administrative costs, and a payment to states for audits and oversight, was $1.8 billion—$100 million more than the previous year's expenditures.34

Meal pattern requirements. To be eligible for federal reimbursement, providers must serve meals and snacks that meet established meal pattern requirements modeled on the food-based menu planning guidelines in the National School Lunch Program and School Breakfast Program. The meal patterns specify foods to be offered at each meal and snack as well as minimum portion sizes, which vary by age.35 The four food categories are: milk; vegetables, fruit, or 100 percent juice; grains or breads; and meat and meat alternates. Fluid milk must be served at all meals and may also be served as part of a snack. No requirements govern whether children older than two should be served whole, 2 percent, 1 percent, or skim milk. Milk and 100 percent fruit or vegetable juices are the only beverages that are reimbursable through the program. CACFP regulations pertain only to foods and beverages for which the provider is seeking federal reimbursement. They do not preclude providers from offering additional low-nutrition, high-calorie foods.

Need for improved nutritional quality in CACFP. CACFP meals and snacks are not required to meet specific nutrient-based standards such as those implemented in the mid- 1990s for the school lunch and school breakfast meals.36 The Healthy Meals for Healthy Americans Act of 1995 required that these school meals be consistent with the Dietary Guidelines for Americans, including fat and saturated fat content. Moreover, as noted, the CACFP regulations do not prevent providers from offering additional low-nutrition, high-calorie foods or beverages for which they are not seeking reimbursement. As with schools, comprehensive nutrition policies for the total child care food environment are needed.

Many child care facilities depend on CACFP to defray expenses, and many parents, especially low-income working families, depend on these settings for a substantial portion of their children's nutritional intake.37 CACFP motivates a family child care home to become licensed, thus coming under applicable health, quality, and safety standards. It interacts regularly with family child care providers, providing monitoring, training, including nutrition education, and other assistance. Further, CACFP is an entitlement program, meaning that all eligible homes and centers must be allowed to participate and that all eligible children being cared for in the homes and centers must be served. Immigrant status does not affect eligibility status. CACFP provides a basic nutritional safety net for low-income children. Strengthening the regulations to make CACFP meals, snacks, and beverages comply with the Dietary Guidelines, including fat and saturated fat content, could further improve children's nutrition and help prevent child obesity. Increasing the number of licensed family child care homes to enable them to participate in CACFP could extend healthful eating and quality child care to many more at-risk children.38

Nutrition Quality of Foods in Child Care Settings
Surprisingly little research has been done to assess the nutritional quality of foods in child care settings. Most studies have focused on CACFP providers. A recent research review identified ten descriptive studies of CACFP in child care settings published between 1982 and 2004, four of which were national studies.39 Because CACFP does not have nutrient- based standards, almost all of the studies have used the recommendations of the American Dietetic Association (ADA) as evaluation benchmarks. The ADA recommends that food served to children in care for a full day (eight hours or more) meet at least one-half to two-thirds of their daily needs for energy and nutrients and that food served to children in part-time care (four to seven hours) provide at least one-third of their daily needs. These benchmarks are requirements for the Head Start nutrition program.40 The ADA also recommends that child care meals and snacks be consistent with the Dietary Guidelines.

The only comprehensive national study, done in 1995, collected meal and snack data on a nationally representative sample of 1,962 CACFP-participating child care sites (family child care homes and child care centers, including Head Start centers) and food intake data on children aged five and older at 372 centers or homes. Nutrient analysis showed that the most common combinations of meals and snacks offered (breakfast, lunch, and one to two snacks) provided 61 to 71 percent of children's daily energy needs and more than two-thirds of the recommended dietary allowance for key nutrients. Meals and snacks had an average of 13 percent of calories from saturated fat, exceeding the Dietary Guidelines of no more than 10 percent. Few providers offered lunches that met the Dietary Guidelines' goals for total fat or saturated fat; 50 percent served lunches with more than 35 percent of the calories from fat. Providers that met the dietary fat recommendation were more likely to serve 1 percent or skim milk and fruit, and they were less likely to serve french fries, fried meats, hot dogs, cold cuts, and high-fat condiments. On average 90 percent of the breakfasts and 87 percent of the lunches complied with the meal pattern requirements. The food component most often missing from meals was fruits and vegetables.41

A 1999 national study of CACFP meals and snacks conducted in 542 Tier II child care homes (not located in a low-income area nor operated by a low-income provider) found that meals and snacks offered to children aged two and older provided, on average, more than two-thirds of the recommended dietary allowance for calories and key nutrients.42  Mean saturated fat content exceeded national recommendations. Less than one-third of the morning snacks (31 percent) and afternoon snacks (28 percent) included fresh, canned, or dried fruit. Less than 25 percent of day care homes offered any fresh fruit as snacks. Only 3 percent of the afternoon snacks included vegetables.

The few smaller-scale studies that have evaluated the menus in child care settings, primarily CACFP sites, show cause for concern.43 One study collected data on 171 child care centers that participated in CACFP in seven states.44  It collected copies of menus and menu records for meals and snacks for ten consecutive days. Meal patterns were inconsistent with the Dietary Guidelines regarding fat, sodium, fruits and vegetables, and serving a variety of foods. Menus were high in fat and seldom provided recommended servings of vegetables. Cookies were frequently on the menus. Another study evaluated menus in nine Texas child care centers participating in CACFP and found that only about half the centers included fresh produce; among those that did, the amount was frequently minimal. Food service staff did not always understand the CACFP requirements and had limited nutrition knowledge. One staff member said he never served fresh fruit because he didn't “know how far an apple will go,” but he knew exactly how much applesauce to ladle from a can to make the minimum portion required by CACFP. Another staff member thought that bottled orange drink was “full-strength juice” because no water was added.45

A recent study compared the dietary intakes of fifty children aged three to nine who attended nine child care centers in Texas with the recommendations of the Food Guide Pyramid for Young Children.46 Researchers observed children's meals and snacks during child care for three consecutive days and took reports on dietary intakes of the children before and after child care from the parents. During child care, the three-year-olds ate enough fruit, but not enough grains, vegetables, or dairy to meet two-thirds of the Food Guide Pyramid for Young Children recommendations. The four- and five-year-old children consumed adequate dairy only. The vegetables and grains served most often were potatoes and refined flour products. Intakes at home did not compensate. These findings suggest that children attending child care centers are not getting adequate diets at child care centers or at home.

In summary, relatively little is known about the dietary quality and types of foods and beverages offered in child care facilities, especially those that are not licensed or regulated and do not participate in the CACFP program. The nutritional quality of meals and snacks may be poor. Increased attention should thus be paid to the nutritional adequacy of foods served in child care settings. More research is needed on the current food environment in child care, including what foods are served, their nutritional quality, and staff training on nutrition. It has been ten years since any national survey described the nutrient content of meals and snacks in child care centers and day care homes participating in CACFP, and that survey included only children older than five.47 Given the increased number and use of child care facilities over the past decade, an updated national survey is needed to assess nutrition quality and practices, including types and portion sizes of foods and beverages offered and consumed by children in child care settings.