Academy Comments Study of Nutrition and Activity in Child Care Settings

April 22, 2016

Desk Officer for Agriculture
Office of Information and Regulatory Affairs
Office of Management and Budget
Mail Shop 7602
Washington, DC 20250-7602

RE: Study of Nutrition and Activity in Child Care Settings (OMB 0584-NEW)

Dear Sir or Madam,

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the United States Department of Agriculture (USDA) Food and Nutrition Service's (FNS's) information collection of March 23, 201 "Study of Nutrition and Activity in Child Care Settings" (the "Study"). Representing over 90,000 registered dietitian nutritionists (RDNs),1 nutrition dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States committed to improving the nation's health through food and nutrition across the lifecycle. The Academy's members demonstrate this commitment in part by designing nutrition education programs for the CACFP and conducting trainings to enhance its effectiveness.

The Academy enthusiastically supports the proposed Study of four broad topics in childcare centers and family day care homes: (1) Nutritional quality of foods offered, (2) physical activity, (3) sedentary activity, and (4) barriers to and facilitators of nutritional quality, physical activity, and participation by childcare centers and family day care homes in the Child and Adult Care Food Program (CACFP).

Mandated as part of the Healthy Hunger-Free Kids Act of 2010 (HHFKA),2 this Study has the potential to provide insight into needed updates and revisions of the CACFP nutrition standards and can help to improve dietary intake and long-term health of millions of children and older Americans. The Academy believes the Study has significant practical utility in strengthening the program's nutrition and physical activity standards, ensuring providers and programs can continue to afford participation in the CACFP, and enhancing program operations through greater alignment with the Dietary Guidelines for Americans (DGA or the "Guidelines") and other federal food assistance programs as appropriate.

I. CACFP's Charge and Challenges

It is the position of the Academy of Nutrition and Dietetics that children and adolescents should have access to an adequate supply of healthful and safe foods that promote optimal physical, cognitive, and social growth and development. Nutrition assistance programs, such as food assistance and meal service programs and nutrition education initiatives that also serve at-risk adults, play a vital role in meeting this critical need. CACFP creates a safety net that ensures that children and adolescents at risk for poor nutritional intakes have access to a safe, adequate, and nutritious food supply. In addition, federally funded nutrition assistance programs such as CACFP serve as a means to combat hunger and food insecurity and as a vehicle for nutrition education and promotion of physical activity designed to prevent or reduce obesity and chronic disease.3

Too many Americans, including millions of children, face significant challenges from their lack of consistent, dependable access to adequate food. According to a 2013 USDA Economic Research Service (ERS) report,4 households with children and adolescents were nearly twice as likely as households without children to report food insecurity (i.e., "these households were uncertain of having, or unable to acquire, enough food to meet the needs of all their members because they had insufficient money or other resources for food").5 Approximately 8.6 million children and adolescents (9.0%) live in households that were food insecure and just under 1% of children and adolescents experienced very low food security. Over one-third (34%) of children and adolescents living in female-headed households were food insecure, with 10.8% being classified as having very low food security.

Among the food secure and insecure alike, many of America's children and adolescents consume inadequate amounts of nutrient-rich foods such as fruits and vegetables. Infants and children consistently do not consume enough vegetables. In a sample of children ages 1 to 5 years participating in WIC, the children only consumed 17% of recommended dark green vegetable intakes, 64% of recommended starchy vegetable intakes, 48% of recommended red-orange vegetable intakes and 44% of total vegetable intakes.6 In contrast, children's total intake of fruit was 122% of recommendations. Similarly, NHANES 1999-2002 data analyzed by Lorson and associates indicates that higher percentages of all children 2-18 years of age meeting fruit recommendations than vegetable recommendations, especially among children 2-5 years of age.7 CACFP provides an important part of the solution to increase the variety and consumption of fruits and vegetables offered as part of the meal pattern.

Since its earliest iteration in the late 1960s, the CACFP has helped to meet these challenges by providing critically important financial assistance and trainings that simultaneously improves the quality of day care foods and makes it more affordable for many low-income families. Three million three hundred thousand children receive nutritious meals and snacks through CACFP every day, in addition to 120,000 older and severely disabled adults receiving care in nonresidential adult day care centers.8 CACFP also provides meals to children in homeless shelters and food to at-risk youths participating in certain eligible afterschool programs.9

II. Study Objectives

A. Nutritional Quality of Foods

The Academy supports collecting information regarding the nutritional quality of foods offered in facilities and homes participating in the CACFP program and those that are not.

1. Breastfeeding

One important element to study is the nutritional quality and type of foods served to infants. It is the position of the Academy of Nutrition and Dietetics that exclusive breastfeeding provides optimal nutrition and health protection for the first six months of life, and that breastfeeding with complementary foods from six months until at least 12 months of age is the ideal feeding pattern for infants.10 Understanding the extent to which childcare centers and family home day cares comport with this position and the updates to standards proposed in 2015 are critical to understanding nutritional quality of foods provided. Breastfeeding is an important public health strategy for improving infant and child morbidity and mortality, improving maternal morbidity, and helping to control health care costs. Research continues to support the positive effects of human milk on infant and maternal health, as it is a living biological fluid with many qualities not replicable by human milk substitutes. We also encourage FNS to study how expressed breastmilk can be integrated for infants beyond 12 months to identify whether and to what extent these infants would substitute breastmilk for cow's milk. Specifically, we encourage studying the prevalence and the timeline of infants' weaning to cow's milk.

The Academy thus supports initiatives that increase the acceptance of breastfeeding as the social norm and present feeding of human milk substitutes as subpar will continue to be needed to move the nation in a positive direction.11 Breastfeeding promotion by health care professionals, day care providers and programs, and policymakers is needed to educate families and increase awareness of the important role of breastfeeding in improving health and reducing health care costs. Families need support to reach their breastfeeding goals.  RDNs and NDTRs are well situated to promote and support breastfeeding.12

2. Fruits and Vegetables

The Academy supports studying whether and to what extent childcare centers and family daycare homes (a) require a fruit or vegetable serving in the snack meal pattern for the six through 11 month age group; (b) eliminate the service of fruit juice to infants of any age (except for medical exceptions); and (c) serve fruits and vegetables at each meal and snack and the servings of each. Requiring a fruit or vegetable serving in the snack meal pattern for the 6-11 month infant age group and eliminating fruit juice from the meal pattern for infants will create a healthier balance in infant diets. Evidence suggests that fruit juice is a top contributor to children's caloric intake13,14 and that people who eat whole fruits have a lower risk for type 2 diabetes compared to those who consume fruit juice.15 Juice intake has increased overall among children five years and younger compared to three decades ago,16 with the largest increases in Latino and African American children.17 At the same time, children and adolescents do not consume the recommended amounts or variety of fruits and vegetables: they consume more fruit juice and less whole fruit and more starchy vegetables and less dark green and orange vegetables and legumes than recommended.18

3. Availability and Servings of Milk

As part of the Academy's commitment to meeting nutrition needs across the lifecycle, we are supportive of efforts to improve calcium intake and bone health by increasing milk consumption as recommended in the Dietary Guidelines for Americans (DGA), in particular consumption by school-aged children. Milk provides nine essential nutrients that all Americans need, including three of the four nutrients of concern identified in the Dietary Guidelines: calcium, potassium and vitamin D. Milk is an excellent source of calcium that helps build strong and healthy bones. The 2015 DGA recognizes that "[r]esearch also has linked dairy intake to improved bone health, especially in children and adolescents."19 Unfortunately, as the 2010 DGA noted, "[i]ntake of milk and milk products, including fortified soy beverages, is less than recommended amounts for most adults, children and adolescents ages four to 18 years, and many children ages two to three years."20 The Academy encourages the study to include assessment of both the fat content of milk served to children of various age groups and whether milk served is flavored or not.

The Academy encourages the Study to examine when infants and children are introduced both to cow's milk and cow's milk byproducts, recognizing the possibility that consuming cow's milk would become a substitute for iron-fortified formula, thereby putting the infant at risk of iron deficiency anemia. Although the Academy supports delaying introduction of cow's milk itself until infants are 12 months old, we do not support delaying introduction of cow's milk byproducts, such as yogurt or cheese, on the same basis, given the unlikelihood that consumption of the byproducts would result in lowered consumption of formula.

We also encourage FNS to study the extent to which accommodations for children with medical or other special dietary needs for milk substitutes are made in childcare centers and family daycare homes (provided that the milk substitutes are nutritionally equivalent to milk, as outlined by the NSLP under 7 CFR 210.10(d)).

4. Grains

The Academy supports to improving the nutritional quality of grains served to children, and encourages FNS to study both serving and consumption of grains and specifically whole grains by children and adults present at childcare centers and family daycare homes. Grains are important sources of many nutrients, including dietary fiber, B vitamins (thiamin, riboflavin, niacin, and folate), and minerals (iron, magnesium, and selenium). Dietary fiber from whole grains may help reduce blood cholesterol levels and is associated with lower risk of heart disease, obesity, and type 2 diabetes.21 Whole grains are notably underconsumed among preschool children.22 According to research that evaluated NHANES 1999-2004 data, average consumption of whole grains in children 2 to 5 years of age was only 0.45 servings per day, and only 8.4% of study participants consumed the minimum recommended 1.5 servings per day.23 Assessment of adult consumption is important, because if parents and child care providers consumed more whole grains themselves, the grains would be more readily available as an option to serve children, and will also make whole grains more desirable as adults model healthy behaviors, making children more likely consume them as well.

5. Food Preparation

The Study should include review of food preparation techniques in childcare centers and family daycare homes, specifically the use of frying as an on-site food preparation technique. Such assessment should include a clear, verifiable definition of frying.  This definition may include specifying an "allowable % calories from fat" or "fat content amount" for prepared foods that are heated onsite or prepared offsite and served onsite. The definition should not simply be an on-site preparation test. It should include a "fat content" test, since the goal is to reduce the fat content of foods. Also, cooking food in a small amount of fat (sautéing, etc.) can be a cultural and organoleptic issue. Relatedly, the Study should identify the extent to which children are served foods from caterers, restaurants, or carry-out facilities.

6. Water

FNS should study the extent to which providers make drinking water available to children throughout the day. The Academy believes that safe, fresh drinking water should be available and accessible for children to serve themselves at all times, both indoors and outdoors. Children should not have to request water from the provider; water should be freely available and children should be encouraged to drink it and take water breaks. FNS should also study the extent to which providers serve as role models, drinking water throughout the day instead of drinking beverages such as soda, fruit drinks, and sports drinks that are high in added sugars in front of children.

B. Barriers to and Facilitators of Nutritional Quality

1. Cost and Funding

The Academy recognizes the unfortunate financial constraints under which these revisions had to be made and hope that when future iterations of the CACFP meal pattern are promulgated and implemented, the resources necessary to increase fruit and vegetable serving sizes and variety requirements will be made available. Unfortunately, food assistance programs are under constant threat of elimination or significant alteration of eligibility and service provision because of changing funding priorities by federal and state governments. To ensure continued availability of nutrition assistance programs for children and adolescents, permanent and adequate funding must be guaranteed.

It is appropriate and worthwhile to discuss the financial limitations imposed upon CACFP as it revises its nutrition standards that essentially required the program to improve without the resources necessary to make the improvements the IOM recommended. Operators, providers, and staff can share success stories for making reimbursement work as the new meal patterns are explained, with the overarching focus on the significant benefits received by the CACFP participants and the difference CACFP is making in their lives.

2. Training and Technical Assistance

The Academy encourages FNS to study the extent and effectiveness of technical assistance to be provided to participating CACFP centers and training or continuing education provided to non-CACFP providers. Particular areas worthy of study include foods that qualify for reimbursement under specific components (such as whole grain); food purchasing and preparation; menu planning and recipes; recordkeeping; and updates to the Food Buying Guide and the "Nutrition and Wellness Tips for Young Children: Provider Handbook for CACFP." In addition, FNS should study the availability and provision of technical assistance and training related to flavored milk, yogurt, frying, whole grains, physical activity, sugar-sweetened beverages, accessible drinking water, and family-style eating.

3. Use of Foods as a Reward or Punishment

FNS should study the extent to which childcare centers and family daycare homes use food as a punishment or reward. Many child care resources recommend not using food as a punishment or reward in the child care setting.24,25,26 A wide variety of alternative rewards can be used to provide positive reinforcement for children's behavior, including praise or encouragement, stickers, extra physical activity time, etc. Providing food based on performance or behavior links food to mood. This practice can encourage children to eat treats even when they are not hungry and can instill lifetime habits of rewarding or comforting themselves with food behaviors associated with unhealthy eating or obesity.  The Academy believes prohibition of using food as a punishment should extend to physical activity as well. Given the high rates of obesity and chronic diseases among Americans, we should not take away children's opportunities to be physically active. There are many more constructive ways to correct children's behavior.27

4. Family Style Eating and Offer v. Serve

The Academy requests that FNS study the manner in which childcare centers and family daycare homes provide food, specifically whether they "offer" or "serve," and drawing a clear distinction between this practice and family-style dining to alleviate provider conclusion.  We note that during family-style meal service, some providers are unclear whether they will still be reimbursed for placing foods that meet the meal pattern requirements into a serving bowl and offering children to serve themselves or if they must serve the required portion size and place it on the child's plate. This is a concern considering the changes this rule makes to offer vs. serve practices in school-based programs. We believe that family-style dining is a valuable and effective tool for teaching children under age five appropriate portion sizes, hunger and fullness cues, and self-serving skills and should be further encouraged with clarification to the difference between it and the offer versus serve requirements.

The Academy is supportive of family-style meal practices and their promotion in federal nutrition programs for preschool age children. We recommend USDA include a best practice around family-style dining. The benefits of family-style meal service include:

  • Improved self-feeding skills and recognition of hunger and fullness cues.
  • Cultivating understanding of appropriate portion sizes for different meal components.
  • Support of social, emotional, and motor skill development.
  • Learning about the foods children are eating and cultivating enjoyment from eating healthy food.
  • Language skills improve as adults and children talk with each other.
  • Providing an opportunity for positive role modeling.

We also encourage FNS to study whether and to what extent an adult is present at mealtimes (i.e., sitting with the children and eating the same foods as the children). This practice is important for adult modeling, safety for children, and support of social and physical development.

III. Conclusion

The Academy appreciates the opportunity to comment and serve as a resource to FNS as you finalize the proposed rule and develop resources to implement the revised standards for the CACFP. The revisions proposed are a significant step forward in improving nutrition and health of millions of Americans. We are happy to discuss these recommendations in greater detail in the near future. Please contact either Jeanne Blankenship at 202-775-8277 ext. 6004 or by email at jblankenship@eatright.org or Pepin Tuma at 202-775-8277 ext. 6001 or by email at ptuma@eatright.org with any questions or requests for additional information.

Sincerely,

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

Pepin Andrew Tuma, Esq.
Senior Director
Government and Regulatory Affairs
Academy of Nutrition and Dietetics


1 The Academy recently 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 Healthy, Hunger-Free Kids Act of 2010, 42 U.S.C. § 1751 et seq. (2010).

3 Stang J, Bayerl CT. Position of the American Dietetic Association: Child and Adolescent Nutrition Assistance Programs. J Am Diet Assoc. 2010;110(5):791-99.

4 Food Insecurity in Households With Children: Prevalence, Severity, and Household Characteristics, 2010-11.  Accessed April 10, 2015 at http://www.ers.usda.gov/media/1120651/eib-113.pdf.

5 Key Statistics and Graphs. United States Department of Agriculture Economic Research Service website. http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/key-statistics-graphics.aspx#children. Updated January 12, 2015. Accessed April 15, 2015.

6 Rasmussen K, Latulippe M, and Yaktine A. Review of WIC Food Packages: An Evaluation of White Potatoes in the Cash Value Voucher: Letter Report.  https://www.iom.edu/Reports/2015/Review-WIC-Food-Packages-Letter-Report.aspx.  February 3, 2015. Accessed April 15, 2015.

7 Lorson, B. A., Melgar-Quinonez, H. R., & Taylor, C. A. (2009). Correlates of fruit and vegetable intakes in US children. Journal of the American Dietetic Association109(3), 474-478.

8 Child and Adult Care Food Program. United States Department of Agriculture Food and Nutrition Service website.   http://www.fns.usda.gov/cacfp/child-and-adult-care-food-program.  Updated July 23, 2014.  Accessed April 15, 2015.

9 Child and Adult Care Food Program Afterschool Programs. United States Department of Agriculture Food and Nutrition Service website.   http://www.fns.usda.gov/cacfp/afterschool-programs. Updated August 25, 2014. Accesed April 15, 2015.

10 Lessen R, Kavanagh K. Position of the Academy of Nutrition and Dietetics: Promoting and Supporting Breastfeeding. J Acad Nutr Diet. 2015;115(3):444-9.

11 Lessen R, Kavanagh K. Position of the Academy of Nutrition and Dietetics: Promoting and Supporting Breastfeeding. J Acad Nutr Diet. 2015;115(3):444-9.

12 Academy of Nutrition and Dietetics. Practice Paper of the Academy of Nutrition and Dietetics: Promoting and Supporting Breastfeeding. Accessed February 2, 2014.

13 Rader RK, Mullen KB, Sterkel R, et al. (2014). Opportunities to Reduce Children's Excessive Consumption of Calories from Beverages. Clinical Pediatrics, 1047-54.

14 U.S. Department of Agriculture & U.S. Department of Health and Human Services. (2010). Dietary Guidelines for Americans, 2010. Washington, D.C.: U.S. Government Printing Office.

15 Muraki I, Imamura F, Manson JE, Hu FB, Willett WC, van Dam RM, & Sun Q. (2013). Fruit Consumption and Risk of Type 2 Diabetes: Results from Three Prospective Longitudinal Cohort Studies. British Medical Journal, 347, f5001.

16 Fulgoni III VL & Quann EE. (2012). National Trends in Beverage Consumption in Children from Birth to 5 Years: Analysis of NHANES across Three Decades. Nutrition Journal, 1-11.

17 Beck AL, Patel A, & Madsen K. (2013) Trends in Sugar-Sweetened Beverage and 100% Fruit Juice Consumption among California Children. Academic Pediatrics, 364-370.

18 ibid.

19 U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/. Accessed April 15, 2016.

20 Dietary Guidelines for Americans 2010 ("DGA 2010"), United States Departments of Agriculture and Health and Human Services, available at http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/ PolicyDoc/PolicyDoc.pdf, page 38, accessed April 15, 2015.

21 O'Neil, C. E., Nicklas, T. A., Zanovec, M., Cho, S. S., & Kleinman, R. (2011). Consumption of whole grains is associated with improved diet quality and nutrient intake in children and adolescents: the National Health and Nutrition Examination Survey 1999–2004. Public health nutrition, 14(02), 347-355.

22 Ball, S. C., Benjamin, S. E., & Ward, D. S. (2008). Dietary intakes in North Carolina child-care centers: Are children meeting current recommendations?.Journal of the American Dietetic Association, 108(4), 718-721.

23 Adams JF, Engstrom A. Helping consumers achieve recommended intakes of whole grain foods. J Am Coll Nutr 2000;19(3 Suppl):339S–344S.

24 American Academy of Pediatrics, American Public Health Association, & National Resource Center for Health and Safety in Child Care and Early Education. (2010). Preventing Childhood Obesity in Early Care and Education: Selected Standards from Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, 3rd Edition. Retrieved from: http://cfoc.nrckids.org/. Accessed on April 2, 2015.

25 National Resource Center for Health and Safety in Child Care and Early Education. (2011). National Resource Center for Health and Safety in Child Care and Early Education: Achieving a State of Healthy Weight: A National Assessment of Obesity Prevention Terminology in Child Care Regulations 2010. Retrieved from: http://nrckids.org/default/assets/file/products/ashw/regulations_report_2010.pdf. Accessed on April 2, 2015.

26 American Dietetic Association. (2011). Benchmarks for Nutrition in Child Care. Journal of the Academy of Nutrition and Dietetics, 607-615.

27 Alternative School Discipline Options to Withholding Recess.  Center for Science in the Public Interest website. http://cspinet.org/new/pdf/Alternatives_to_Withholding_Recess.pdf.  Accessed on April 6, 2015.