Academy Comments re: The Childcare Survey of Activity and Wellness Pilot Study

May 24, 2019

Jeffrey M. Zirger
Information Collection Review Office
Centers for Disease Control and Prevention
1600 Clifton Road NE
Atlanta, Georgia 30329

RE: The Childcare Survey of Activity and Wellness (C-SAW) Pilot Study (CDC-2019-0013)

Dear Mr. Zirger:

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Centers for Disease Control and Prevention related to its request for feedback on the Childcare Survey of Activity and Wellness (C-SAW) Pilot Study (CDC-2019-0013), originally published in the Federal Register on April 2, 2019 (84 FR 1261). Representing more than 104,000 registered dietitian nutritionists (RDNs),1 nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States. We are committed to accelerating improvements in the nation’s health and well-being through food and nutrition.

The Academy supports efforts to study the current practices and policies of early care and education (ECE) providers in four states around nutrition, physical activity, and wellness to inform a potential national surveillance system.

A. Importance of Studying the Early Childhood Education Environment

Approximately 7.5 million children, from newborns to five-year-olds not yet in kindergarten, are enrolled in ECE centers as their primary care arrangement2 and children birth to three-years-old spend, on average, 32 hours a week at these centers.3 With such a wide reach, the ECE environment is an excellent place to promote nutrition, physical activity and wellness initiatives to children.

Policy based approaches to promoting healthy eating and physical activity in ECE are becoming more common in the United States. A number of states and cities have made licensing and administrative regulatory changes targeting child-care programs.4,5 Cross-sectional studies have evaluated the presence of healthy eating regulations targeting ECE through legal research methods and found wide variation among states.6 However, because causality cannot be determined in these regulatory reviews, additional studies are needed. By establishing a national surveillance system, it will help facilitate the measurement of impact for all interventions by collecting a baseline of practices and measuring change over time.

B. Estimate of the burden of the proposed collection

After examining the proposed study survey, the Academy notes some areas for consideration: 1) the time necessary to complete the survey may be too long and we suggest examining ways to reduce survey fatigue; 2) more explicit direction should be given to reviewers at the beginning of the instructions including: expected length of survey, the characteristics of an ideal respondent and the materials needed to answer the questions; and 3) survey questions should include an option for "not sure" or "I don't know," since many of the questions require a comprehensive understanding of the entire child care operation. By providing better expectations and instructions, the researchers can help ensure more reliable responses.

C. Suggestions for enhanced quality, utility and clarity of the information to be collected.

Upon review of the survey instrument, the following is a list of suggested changes that may enhance the quality, utility and clarity of the information being collected.

Table 1: Detailed Comments on the Childcare Survey of Activity and Wellness Instrument

Question Comment

Suggest change in wording to "administers childcare at a single site."


Consider including volunteer hours in this question to compare centers with more adult resources to those with fewer adult resources.


In many states, the subsidy program has a name that providers are more likely to recognize. Suggest rewording this question to ask what percentages of the children's parents are getting help from the government to pay for child care or specifically naming the program in the state where the survey is being administered.


Consider including registered dietitian or other credentialed nutrition expert to the list of responses.


Consider dividing responses into fresh and other.


Consider dividing responses into fresh and other.


Some of these foods are allowable under CACFP—what's the intent of question?

Section B

Consider including questions regarding drinking water.

Using the response options of always, often, sometimes, never and don't know, the following are suggested questions in priority order:

  • Water is available throughout the day
  • Water is available for self-serve throughout the day
  • At least 3 times/day, we proactively ask if child would like water
  • We provide water on the table at meals
  • We provide water on the table with snacks
  • Our tap water has been tested for lead in the past 3 years
Section C

Throughout the section on physical activity the word "provided" is confusing. Suggest changing to "how much time are children given the opportunity to participate in physical activity."


The category is too vague. Consider including examples such as menu planning and importance of nutrition in childhood.


The category is too vague. Consider providing examples to clarify intended responses.


Consider separating into two different questions: one about nutrition and the other about physical activity.


This could be easily misinterpreted by programs. Some state QRIS contain HEPA best practices and programs may confuse a QRIS recognition with a designation.


Suggest rewording question to: "In response to challenging behaviors (such as kicking, biting or hitting), which of the following actions has the child care center taken in the past 12 months." In the responses, consider rewording "behavior problems" to "challenging behaviors;" it currently sounds like a question for school aged programs, not ECE settings.

D. Conclusion

The Academy appreciates the opportunity to submit comments related to the request for feedback on the Childcare Survey of Activity and Wellness Study. We urge CDC to make adjustments to the survey in order to best solicit quality responses that support the intent of the data collection efforts. Please contact either Jeanne Blankenship at 312/899-1730 or, or Liz Campbell at 202/775-8277, ext. 6021 or with any questions or requests for additional information.


Jeanne Blankenship, MS, RDN
Vice President
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Liz Campbell, MA, RDN
Senior Director
Legislative & Government Affairs
Academy of Nutrition and Dietetics

1 The Academy approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.

2 Early Childhood Program Participation, Results from the National Household Education Surveys Program of 2016: First Look National Center for Education Statistics Web site External. Accessed April 2, 2019.

3 Early Care and Education Usage and Households’ Out-of-Pocket Costs: Tabulations from the National Survey of Early Care and Education (NSECE) OPRE Report #2016-09 | August 2016 [PDF-2.41MB]External Accessed April 2, 20.

4 Benjamin Neelon SE, Duncan DT, Burgoine T, Mayhew M, Platt A. Promoting breastfeeding in child care through state regulation. Matern Child Health J. 2015;19(4):745-754.

5 Kim J, Kaste LM, Fadavi S, Benjamin Neelon SE. Are state child care regulations meeting national oral health and nutritional standards? Pediatr Dent. 2012;34(4):317-324

6 Mersky RM, Dunn DJ. Fundamentals of Legal Research. 8th ed, revised. New York, NY: Foundation Press; 2002.