September 17, 2015
Director, Office of Head Start Policy and Planning Division
Administration for Children and Families
Department of Health and Human Services
1250 Maryland Avenue SW.
Washington, DC 20447
Re: Head Start Performance Standards (ACF-2015-0008)
Dear Ms. Rathgeb:
The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Administration for Children and Families ("ACF" or "the agency") regarding the proposed rule of June 19th, 2015, "Head Start Performance Standards". Representing over 90,000 registered dietitian nutritionists (RDNs),1 nutrition dietetic technicians, registered (NDTRs),2 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. Many of our members work in early child care settings and Head Start programs, and we recognize the importance of the early years (birth to age five) as crucial to a child's healthy development.
In addition, we recognize the importance of Head Start settings in providing numerous opportunities to promote healthy eating and physical activity behaviors in young children. Poor diet and lack of physical activity are major contributors to obesity. About 10% of infants from birth to age 2, and 23% of children aged two to five are overweight or have obesity.3 Children and adolescents with obesity are likely to have obesity as adults4 and are at increased risk for serious health problems in adulthood, including heart disease, Type 2 diabetes, asthma, and endometrial cancer in women.5 Increased physical activity and decreased sedentary behavior are associated with lower rates of obesity, and physical activity reduces the risk for many of the diseases associated with obesity, such as diabetes and heart disease.6
The Head Start performance standards offer an opportunity to ensure healthy development of the children within the programs, as well as influencing their families. Overall, the Academy supports the agency's proposed regulations for addressing the healthy development of children in Head Start/Early Head Start. While we support the enhanced emphasis on nutrition as part of healthy development, we offer suggestions on how to strengthen and enhance language around healthy eating in a variety of settings. In addition, we urge the agency to encourage Head Start programs and trainers to maximize the USDA Child and Adult Care Food Program ("CACFP") nutrition, physical activity, and breast feeding education materials that are available at no cost to all CACFP centers.7
We respectfully offer ACF the following comments on specific sections:
§ 1302.11 Determining community strength and needs. (b) Community assessment
It is the position of the Academy that children ages 2 to 11 years should achieve optimal physical and cognitive development, maintain healthy weights, enjoy food, and reduce the risk of chronic disease through appropriate eating habits and participation in regular physical activity.8 Given that close to 30 million Americans across the U.S. are in food deserts and those living in low-income areas lack sufficient access to supermarkets,9 the Academy support the proposed inclusion of "nutrition" as a component of the community assessment provision. Food insecurity is associated with adverse health, growth, and development outcomes among children from birth to age 18,10 with very low food security among children being associated with more frequent hospitalizations.11
In addition, we suggest that the community assessment include an evaluation of safe and available places where children and families can engage in active play. Families and children living in communities with higher levels of poverty and communities of color have significantly less access to parks, green spaces, and bike paths than those in higher-income or predominantly white communities.12 Active play is an important part of quality child care. Regular physical activity promotes a healthy weight, enhances motor skills, and improves cardiovascular function.13 The American Academy of Pediatrics recommends that children participate in a variety of activities, including unstructured play, and also engage in activities such as running, tumbling, throwing and catching, with adult attention to safety and supervision.14 To highlight the importance of physical activity as part of the community assessment, we suggest that the term "physical activity" be added after the word "nutrition" in the description of the community assessment required in § 1302.11(b)(vii), so that the section would state, "the education, health, nutrition, physical activity, and social service needs of eligible children and their families."
§ 1302.31 Teaching and the learning environment. (b) Effective teaching practices
While the Academy support the overall goal of streamlining the regulations and reducing bureaucratic demands on programs, we believe the standards regarding effective teaching practices should address the time spent in active play and in viewing media. We understand that both center and family-home based Head Start programs must be licensed and comply with state licensing regulations. However, most states' licensing schemes do not presently regulate the time allotted for active play, the viewing of media (i.e., television, video, DVDs or other visual recordings), or use of computers (including tablets, or related devices).15 Exposure to energy-dense, nutrient-poor food advertisements has been shown to have a negative effect on food requests made by children.16 A recent study indicated the elimination of advertising of unhealthy foods and beverages to children on television alone could reduce childhood obesity by 18%, or approximately 2.8 million children.17 High levels of screen time can also contribute to overweight or obesity by replacing more physically demanding activities. In 2009, American children spent an average of 7.4 hours per day watching media (television, computers, video games, movies, etc.), a figure even higher for minority children.18 The explosion of social media has led to excessive use by some to the point of becoming "problematic."19 Although there have been some variations by age and sex, numerous studies have linked sedentary or screen time and number of media resources in the household to overweight or obesity and detrimental impacts on physical fitness among children and youth.
The Head Start performance standards offer an opportunity to ensure healthy development of the children accessing their programs. In order to do so, the performance standards should also address screen time. On page 35534, second column, we recommend including two new paragraphs, subsections (v) and (vi), as follows:
(v) Include opportunities to engage in moderate to vigorous physical activity, of no fewer than 60 minutes in total for children in the Early Head Start program and no fewer than 90 minutes in total for children in the Head Start program. Physical activity should include opportunities for outdoor play and structured or staff-lead activities that promote movement.
(vi) Include limits on the time spent viewing media (television, video, DVD or other visual recordings), or using computers (including tablets, or related devices). Children in Early Head Start programs under the age of two should not spend any time viewing media. Viewing of media in Head Start programs should be limited to no more than thirty minutes per week—for educational or physical activity use only—that is free of advertising and brand placement. Computer use—for educational activities only—should be limited to no more than fifteen-minute increments, except for children with special health care needs who require and consistently use assistive and adaptive computer technology.
§ 1302.31 Teaching and the learning environment. (e) Promoting learning through approaches to rest, meals, and routines
The Academy strongly support the language allowing sufficient time to eat and not using food as reward or punishment, as well as not forcing children to finish their food. Many child care resources recommend not using food as a punishment or reward in the child care setting.20,21,22 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.23
Furthermore, the Academy urges the agency to include language encouraging the use of family-style meal service. Children learn about food and nutrition from messages conveyed by child-care providers, and these messages can be conveyed through instruction, in conversation, in guided practice, and through modeling.24 Family-style meal service also allows children to pay attention and respond appropriately to hunger and fullness cues, try new foods and help children develop gross motor skills related to scooping and selecting food and passing bowls and plates. The use of family style meal service is also included in the YMCA's Healthy Eating and Physical Activity Standards for Early Childcare and Afterschool Programs.25 Head Start staff practice family style meal service more frequently than non-Head Start staff16 elucidate its benefits and provide suggestions to overcome barriers related to its practical implementation.12 Therefore, retaining family style meal service in Head Start performance standards will encourage its implementation.
On page 35534, third column, (2), last sentence, we recommend revising the language as follows "This approach must also provide sufficient time to eat, encourage family style meal service, not use food as reward or punishment, and not force children to finish their food."
§ 1302.42 Child health status and care
We appreciate the addition of the child's nutritional health needs assessment to this section, especially the considerations around family and staff discussions on weight, body mass index, and information on major community nutritional issues. Given that over 30% of young children between 13 and 24 months consume fruit drinks, soda and sports drinks, and 1 to 2 year olds consume about 120 calories per day from sugar sweetened beverages,26 it is important to more specifically assess intake of sugary drinks, as well as other food and beverages. In addition, assessing activity levels is important to have a more comprehensive view of overall health.
We recommend strengthening language to better assess the food and beverage intake and activity status of children as follows: On page 35537, third column, (b)(4), after "body mass index" add "physical activity status," and after "nutrition-related assessment data," add "healthy eating, including eliminating sugar sweetened beverages, and encouraging the consumption of fruits, vegetables, whole grains and water."
On page 35537, third column, at the ending of § 1302.42(a)(4), we recommend adding: "If concerns continue to persist on these issues, then staff should encourage families to see their physician or primary care provider for further assessment." Discussions on body mass index and determining if a child has overweight or obesity can be challenging for program staff, and these discussions are more appropriate to be had with the child’s physician or primary care provider.
§ 1302.44 Child Nutrition. (a) Nutrition service requirements
The Academy supports the language outlined in § 1302.44(a)(1) regarding the need to accommodate the feeding requirements of each child and recommend the agency include the need to accommodate cultural and ethnic preferences of children. The Academy's Nutrition Care Manual27 promotes cultural competence and will assist facilities in meeting the proposed regulations proposed requirement for menus to reflect the cultural and ethnic needs of residents. We recommend that on page 35538, first column, the agency modify the sentence to read: "…and accommodate the feeding, cultural and ethnic requirements of each child…"
We also support the provision in § 1302.44(a)(2)(iii) that requires that programs serve 3 to 5 year-old children meals and snacks that conform to USDA requirements in 7 CFR parts 210 (National School Lunch Program), 220 (School Breakfast Program), and 226 (Child and Adult Care Food Program – CACFP). Meals and snacks should be offered to children every 2 to 3 hours in childcare programs, while children in care for 8 hours or less should be offered at least one meal and two snacks or two meals and one snack.28 Recommended patterns and portion sizes for providing well-balanced meals and snacks are available from a variety of sources, including CACFP.29
The Academy supports the emphasis on breastfeeding in § 1302.44 (a)(2)(viii). We support 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.30 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.31
The Academy also encourages stakeholders to engage with their communities' local breastfeeding coalitions. Members often share culturally appropriate materials and dissemination strategies. We recommend that the agency assure that appropriate Head Start staff complete a Certified Lactation Counselor training program to ensure evidence based breastfeeding support is the norm.
§ 1302.46 Family support services for health, nutrition, and mental health. (b)Parental Collaboration and Opportunities
We support the enhanced language requiring programs to collaborate with parents to promote children's health and wellbeing by providing medical, oral, nutrition, and mental health education support services. We strongly support the addition of subsection (b)(ii) ensuring that programs discuss with parents their child's nutritional status including the importance of physical activity. Early parental influence is associated with the development of a child's relationship with food later in life. For example, young adult eating habits, such as eating all food as an incentive or threat, eating dessert, and eating regularly scheduled meals were related to the same feeding practices reportedly used by their parents during their childhood.32 Regular physical activity plays an essential role in the prevention of obesity and related chronic conditions and engaging in active play is essential to healthy development.33 We also strongly support the focus on selecting and preparing nutritious foods that meet the family's nutrition and food budget needs.
Conclusion The Academy appreciates the opportunity to comment on the proposed rule and serve as a resource to the agency as you finalize the Head Start Performance Standards and develop resources to implement and encourage them nationwide. We are happy to discuss these recommendations in greater detail in the near future. Please contact either Mary Pat Raimondi at 312/899-1731, or by email at email@example.com, or Stefanie Winston Rinehart at 202/775-8277, or by email at firstname.lastname@example.org, with any questions or requests for additional information.
Mary Pat Raimondi, MS, RDN
Vice President, Strategic Policy and Partnerships
Academy of Nutrition and Dietetics
Stefanie Winston Rinehart, Esq.
Director HHS Legislation and Policy
Academy of Nutrition and Dietetics
1The 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.
2NDTRs are educated and trained at the technical level of nutrition and dietetics practice for the delivery of safe, culturally competent, quality food and nutrition services. They are nationally credentialed and are an integral part of health care and foodservice management teams. They work under the supervision of a registered dietitian nutritionist when in direct patient/client nutrition care; and often work independently in providing general nutrition education to healthy populations.
3 Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of High Body Mass Index in US Children and Adolescents, 2011-2012. JAMA. 2014;311(8), 806-814.
4 Freedman DS, Kettel L, Serdula MK, Dietz WH, Srinivasan SR, Berenson GS. The relation of childhood BMI to adult adiposity: the Bogalusa Heart Study. Pediatrics 2005; 115:22–27.
5 US Department of Health and Human Services, Office of the Surgeon General. 2001. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Accessible at: http://surgeongeneral.gov/topics/obesity/calltoaction/fact_adolescents.htm.
6 U.S. Department of Health and Human Services, Office of the Surgeon General. 2010. The Surgeon General’s Vision for a Fit and Healthy Nation. Accessible at: http://www.surgeongeneral.gov/priorities/healthy-fit-nation/obesityvision2010.pdf.
7 U.S. Department of Agriculture, Team Nutrition. CACFP Wellness Resources for Child Care Providers. Accessible at: http://healthymeals.nal.usda.gov/cacfp-wellness-resources-child-care-providers.
8 Position of the Academy of Nutrition and Dietetics: Nutrition Guidance for Healthy Children Ages 2 to 11 Years. J Acad Nutr Diet. 2014:114;1257-1276.
9 U.S. Department of Agriculture. Economic Research Service. Access to Affordable and Nutritious Food: Updated Estimates of Distance to Supermarkets Using 2010 Data. USDA, 2012. Web. 15 Oct. 2013. Accessible at: http://www.ers.usda.gov/publications/err-economic-research-report/err143.aspx>.
10 Position of the American Dietetic Association: Food Insecurity in the United States. J Am Diet Assoc. 2010;110: 1368-1377.
12 Powell L, Slater S, and Chaloupka F. The Relationship between Community Physical Activity Settings and Race, Ethnicity and Socioeconomic Status. Evidence-Based Preventive Medicine. 2004;1(2):135-144.
13 American Dietetic Association. (2011). Benchmarks for Nutrition in Child Care. J Am Diet Assoc. 2001;111:607-615.
15 Healthy Eating Research and Active Living Research. Preventing Obesity Among Preschool Children, How Can Childcare Settings Promote Healthy Eating and Physical Activity? Research Synthesis. October 2011, p.6. Accessible at: www.healthyeatingresearch.org/publications-mainmenu-111/research-briefs-and-syntheses-mainmenu-114.
16 Position of the Academy of Nutrition and Dietetics: The Role of Nutrition in Health Promotion and Chronic Disease Prevention. J Acad Nutr Diet. 2013;113(7):972-979.
17 Chou S, Rashad I, Grossman M. "Fast-food Restaurant Advertising on Television and Its Influence on Childhood Obesity." J. Law Econ. 2008; 51:599-617.
18 Position of the Academy of Nutrition and Dietetics: The Role of Nutrition in Health Promotion and Chronic Disease Prevention. J Acad Nutr Diet. 2013;113(7):972-979.
19 Meena PS, Mittal PK, Solanki RK. Problematic use of social networking sites among urban school going teenagers. Industrial Psychiatry Journal. 2012;21(2):94-97. doi:10.4103/0972-6748.119589.
20 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. Accessible at: http://cfoc.nrckids.org/.
21 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. Accessible at: http://nrckids.org/default/assets/file/products/ashw/regulations_report_2010.pdf.
22 American Dietetic Association. (2011). Benchmarks for Nutrition in Child Care. J Am Diet Assoc. 2011;111:607-615.
23 Center for Science in the Public Interest. Alternative School Discipline Options to Withholding Recess. Accessible at: http://cspinet.org/new/pdf/Alternatives_to_Withholding_Recess.pdf.
24 American Dietetic Association. (2011). Benchmarks for Nutrition in Child Care. J Am Diet Assoc. 2011;111:607-615.
25 YMCA Healthy Eating and Physical Activity Standards for Early Childcare and Afterschool Programs. Accessible at: http://www.ymcaeuc.org/content/promo/2013%2004%20HEPA%20Standards.pdf.
26 Bleich, S., Wolfson, J. Trends in SSBs and snack consumption among children by age, body weight, and race/ethnicity. Obesity. 2015;23(5): 1039-46.
27 Academy of Nutrition and Dietetics. Nutrition Care Manual. Accessible at: https://www.nutritioncaremanual.org/.
28 American Dietetic Association. (2011). Benchmarks for Nutrition in Child Care. J Am Diet Assoc. 2011;111:607-615.
30 Position of the Academy of Nutrition and Dietetics: Promoting and Supporting Breastfeeding. J Acad Nutr Diet. 2015;115(3):444-9.
31 Academy of Nutrition and Dietetics. Practice Paper of the Academy of Nutrition and Dietetics: Promoting and Supporting Breastfeeding. Accessible at: http://www.eatrightpro.org/ resources/practice/position-and-practicepapers/practice-papers.
32 Academy of Nutrition and Dietetics. Position Paper of the Academy of Nutrition and Dietetics: Nutrition Guidance for Healthy Children Ages 2 to 11 Years. J Acad Nutr Diet. 2014;114:1257-1276.
33 Healthy Eating Research and Active Living Research. Preventing Obesity Among Preschool Children, How Can Childcare Settings Promote Healthy Eating and Physical Activity? Research Synthesis. October 2011, p.6. Accessible at: www.healthyeatingresearch.org/publications-mainmenu-111/research-briefs-and-syntheses-mainmenu-114.