Comments to USDA re: Revised Nutrition Standards in the Child and Adult Care Food Program

April 15, 2015

Tina Namian, Branch Chief
Policy and Program Development Division
Food and Nutrition Service Department of Agriculture
PO Box 66874
St. Louis, MO 63166

RE: Child and Adult Care Food Program: Meal Pattern Revisions Related to the Healthy, Hunger-Free Kids Act of 2010 (FNS-2011-0029)

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) proposed rule of January 15, 2015 "Child and Adult Care Food Program [CACFP]: Meal Pattern Revisions Related to the Healthy, Hunger-Free Kids Act of 2010." 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 almost all of the proposed revisions to CACFP meal patterns and respectfully offers the below comments for FNS's consideration as it finalizes the rule. Mandated as part of the Healthy Hunger-Free Kids Act of 2010,2 these proposed revisions represent the first major update of the CACFP nutrition standards since the program's inception in 1968 and will help to improve dietary intake and long-term health of millions of children and older Americans. The proposed revisions strengthen the program's nutrition standards, ensures providers and programs can continue to afford participation in the CACFP, and enhances program operations through greater alignment with the Dietary Guidelines for Americans (DGA or the "Guidelines") and other federal food assistance programs as appropriate.

Our comments are organized in respective sections as (I) CACFP's Charge and Challenges; (II) Infant Meal Pattern; (III) Child and Adult Meal Pattern; (IV) Best Practices; (V) Administrative Implementation; and (VI) Conclusion.

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 percent) live in households that were food insecure and just under 1 percent of children and adolescents experienced very low food security. Over one-third (34 percent) of children and adolescents living in female-headed households were food insecure, with 10.8 percent 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 percent of recommended dark green vegetable intakes, 64 percent of recommended starchy vegetable intakes, 48 percent of recommended red-orange vegetable intakes and 44 percent of total vegetable intakes.6 In contrast, children's total intake of fruit was 122 percent 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

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.

II. Infant Meal Patterns

The Academy supports the revised infant meal patterns and proposed best practices for infant feeding and breastfeeding. The CACFP's proposed revisions closely align the infant meal pattern for breastfeeding with the Academy's positions on promoting and supporting breastfeeding and will advance important public health goals.

A. Promoting Breastfeeding

It is the position of the Academy of Nutrition and Dietetics that exclusive breastfeeding provides optimal nutrition and health protection for the first 6 months of life, and that breastfeeding with complementary foods from 6 months until at least 12 months of age is the ideal feeding pattern for infants, consistent with the proposed revision.10 The proposed revision will make the age groups consistent with the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). 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. Recent research advancements include a greater understanding of the human gut microbiome, the protective effect of human milk for premature infants and those born to women experiencing gestational diabetes mellitus, the relationship of breastfeeding with human immunodeficiency virus, and the increased ability to characterize cellular components of human milk.11

Human milk is considered the optimal form of infant nutrition for nearly all infants, as the risks of not receiving human milk include increased rates of infant and maternal morbidity and mortality, increased health care costs, and significant economic losses to families and employers.12 The relatively low protein content and high bioavailability of essential minerals are also optimally suited to the immature digestive system of the young infant. Although human milk is optimal in most situations, if infant iron stores are found to be inadequate, such as in situations of low birth weight or prematurity, in some less-developed countries, or when maternal prenatal iron status was low, it is recommended that the addition of iron drops begin before the introduction of iron-rich complementary foods (at approximately 6 months).13

In spite of the overwhelming evidence recommending breastfeeding, exclusive and partial breastfeeding rates have room for improvement in the United States; only 17 percent of infants being exclusively breastfed at 4-5.9 months of age and only 27 percent of infants 6-8 months of age breastfeeding at all.14 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.15 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.16

Thus, the Academy supports the proposal to reimburse infant meals when the mother comes to the child care facility to breastfeed, providing additional incentives for providers to promote breastfeeding. We encourage FNS to ensure continued reimbursement for breastmilk brought to the childcare facility by the infant’s family. We further recommend that FNS share these recommendations with WIC to encourage mothers to breastfeed longer. As this provision is implemented, we encourage USDA to make it least burdensome on providers while ensuring that regulations include instructions that providers respect a mother’s right to public accommodation for breastfeeding and that mothers are not directed to breastfeeding locations that are uncomfortable or unsanitary (e.g. a bathroom). We also encourage FNS to include a positive and affirmative statement that seeing other mothers breastfeed is healthy for children and consistent with the U.S. Surgeon General's Call to Action on removing barriers to breastfeeding.17

Finally, we encourage FNS to give consideration to the issue raised in the Food Research and Action Center's (FRAC's) comments on this proposed rule regarding the need for the infant meal pattern to include adequate breast milk and formula quantities to fulfill individual energy needs, specifically whether the amount for infant snacks is intended to be 2-4 ounces rather than 4-6 ounces, as the former amount would not meet certain USDA recommendations for calories an infant should consume per day.

B. Timing to Introduce Complementary Foods to Infants

As noted above, it is the position of the Academy that breastfeeding with complementary foods from 6 months until at least 12 months of age is the ideal feeding pattern for infants. Given research indicating that a significant percentage of infants may be introduced to complementary foods well before the recommended 4-6 months,18 we share concern that the current CACFP standards of 4-7 months may inadvertently encourage introduction too early for some infants. We do note, however, that the American Academy of Pediatrics (AAP's) recommends that solid foods should begin "around" 6 months of age, accounting for variances in children’s developmental readiness.19 We encourage CACFP to reconsider its proposed regulatory language implementing the revision, as it appears to remove any of the flexibility permitted under the AAP’s recommendations or currently allowed under CACFP rules.

C. Infant Fruits and Vegetables

The Academy supports both of the interrelated proposed revisions to the infant meal patterns regarding fruits and vegetables: (1) requiring a fruit or vegetable serving in the snack meal pattern for the 6 through 11 month age group and (2) eliminating the service of fruit juice to infants of any age (except for medical exceptions).

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 intake.20,21 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.22 These two proposed revisions will help ensure that infants are exposed to a variety of fruits and vegetables, providing a basis for increased consumption now and better acceptance later in life.23,24,25,26 The revised standard is consistent with current practices of many CACFP state agencies, including Rhode Island and Mississippi, which restrict the practice of providing juice to infants through child care regulations.27,28

III. Child and Adult Meal Pattern

A. Fruits and Vegetables

1. Separating the Current Fruit and Vegetable Component

The Academy supports the proposal to separate the current fruit and vegetable component into two separate components for lunch and supper meals and snacks, consistent with the National School Lunch Program (NSLP). We understand that to maintain consistency with the School Breakfast Program (SBP), the recommendation to separate the fruit and vegetable component for breakfast meals was not adopted, but hope that recommendation becomes a best practice.

Separating fruits and vegetables is another significant revision to the meal pattern that creates greater opportunities for fruit and vegetable consumption at snack and aligns with the Dietary Guidelines. We recommend strengthening the proposed change by allowing the option to serve two vegetables for lunch or supper rather than a fruit and a vegetable. This proposed change would help bring vegetable consumption closer to the Dietary Guidelines—quite simply, children generally do not consume enough vegetables.29 This change could help reduce the offering of juice as the fruit serving for meals; overconsumption of fruit juice is a common problem, as we outline below. It would also allow flexibility to take advantage of local and seasonal availability of vegetables. We encourage FNS to consider offering the different vegetable subgroups as described in NSLP.

Ideally, CACFP revisions would increase the quantity of fruit (1/4 cup) to equal that of vegetables (1/2 cup) for children ages 6-13 years old to better align with the Dietary Guidelines and the Institute of Medicine (IOM) recommendations.30,31 We recognize 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.

2. Juice Comprising the Entire Fruit/Vegetable Component

The Academy respectfully does not support the proposal to allow fruit juice or vegetable juice to comprise the entire fruit or vegetable component for all meals. Studies show that people who eat whole fruits have a lower risk for type 2 diabetes compared to those who consume fruit juice.32 Juice intake has increased overall among children 5 years and younger compared to three decades ago,33 with the largest increases in Latino and African American children.34 Evidence suggests that fruit juice is one of the top contributors to children's calorie intake.35,36 Further, fruit juice has several nutritional disadvantages compared to whole fruit: juice has little or no dietary fiber; prolonged, excessive, or frequent exposure could lead to dental caries.37,38 To ameliorate one of those disadvantages when juice is served, the Academy recommends specifying that juice should be served from a cup rather than a bottle to reduce caries and continuous exposure to high sugar content.

The Academy's fundamental concern with the proposal is that children need more exposure to and consumption of real fruits and vegetables. Another concern is the likelihood that children will consume the juice as a substitute for served milk. Should FNS elect to take an intermediate approach in the final rule that limits the allowable contribution juice may make to fruit and vegetable components, several options may be appropriate. FNS could specify that juice in the CACFP program will be treated similarly to juice in the NSLP (i.e., juice cannot comprise more than 50 percent of the fruit or vegetable servings per week), or alternatively, juice could be part of the snack program (in limited amounts).

B. Milk and Other Dairy

Milk provides nine essential nutrients that all Americans need, including three of the four nutrients of concern identified by the Dietary Guidelines: calcium, potassium and vitamin D. Milk is an excellent source of calcium that helps build strong and healthy bones. The DGA recognizes "that intake of milk and milk products is linked to improved bone health, especially in children and adolescents."39 The Institute of Medicine (IOM) notes that "[m]ilk and milk products provide more than 70 percent of the calcium consumed by Americans."40 Unfortunately, "[i]ntake of milk and milk products, including fortified soy beverages, is less than recommended amounts for most adults, children and adolescents ages 4 to 18 years, and many children ages 2 to 3 years."41

1. Regular Milk

The Academy generally supports requiring unflavored whole milk for children 12-23 months. However, we recognize the American Academy of Pediatrics' (AAP's) recommendation that children in this age range may have lowfat or reduced fat milk if they have a family history of heart disease or obesity. We encourage FNS to allow this medical exception to be considered on an individual basis.

The Academy generally supports the rationale for allowing only 1 percent or fat-free milk for children two years and older and for adults and also recognizes the statutory requirement to align the program with the Dietary Guidelines. Nonetheless, the requirement may be overly inflexible. First, it may be difficult to get children to switch from drinking whole milk one day before their second birthday to drinking skim or 1 percent milk the next day. A similar difficulty could arise when children currently in the program used to drinking 2 percent would now be required to drink skim milk. Concerns about childhood obesity are certainly well-founded, but some Academy Reviewers expressed concern that in this instance, the use of the Dietary Guidelines may be overly restrictive. Academy Reviewers additionally seek greater flexibility because of some of the challenges they see created by inflexible and untailored requirements at state WIC programs where they work, for example, with special needs children 5 and under. Many of these children are tagged as "failure to thrive," yet WIC simply cannot provide 2 percent or whole milk to meet their needs.

2. Flavored 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, in particular consumption by school-aged children. Flavored milk has been shown to be an effective tool in encouraging milk consumption by school--‐aged children; studies have demonstrated that school-aged children who drink flavored milk meet more of their nutrient needs, do not consume more added sugar, fat, or calories, and are similar in weight to non-milk drinkers.42 Flavored milk is not a major source of added sugars for children (major sources include soda, fruit drinks, grain desserts, candy, dairy desserts, and cold cereals).43

  • The Academy generally supports requiring that any flavored milk served must be fat-free, consistent with the NSLP, but respectfully requests that FNS reconsider this requirement in light of concerns raised by Academy members about burdens on programs and providers. Specifically, many members workingin the field thought that fat content should be consistent across all milk offerings within a program (except for the unflavored whole milk uniquely provided to children 12-23 months) and that sugar content should be regulated. This concern is particularly significant for operators flavoring their own milk in the facility).
  • Although Academy Reviewers saw merits to both options, the Academy supports option A2, limiting the sugar content of flavored milk served to children 2-4 years of age, because as noted above, evidence shows that flavoring milk can increase milk consumption and provide critical vitamins and minerals to children without adversely impacting their health. Should FNS consider a middle ground between options A1 and A2, Academy Reviewers would also support limiting the number of times that flavored milk is served to twice a week. We appreciate the reasons one might favor option A1 to prohibit flavored milk in CACFP, including an issue for small centers in which children of different ages will be at the same table, resulting in difficulties and misunderstandings as the operators attempt to manage serving flavored and unflavored milk at to different children.
  • The Academy strongly supports making mandatory those provisions limiting sugar in flavored milk (22g/8oz) served to children 5 years of age and older in the CACFP meal patterns (option B1), rather than option B2, merely a best practice that facilities may choose to adopt. We do however, recognize the additional burden on centers that mix their own flavored milks on site and encourage FNS to consider solutions for them.

3. Delaying Cow's Milk and Cow's Milk Byproducts until 12 Months

The Academy supports delaying introduction of cow's milk until infants are 12 months old, in accord with the AAP's recommendation, because of 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.

However, the Academy does 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 note that the American Academy of Pediatrics has not to our knowledge recommended delaying byproducts until 12 months of age and instead suggests introducing cheese and yogurt to infants between 9 and 12 months of age.44 The Academy recommends limiting CACFP reimbursement for cow's milk byproducts to plain, unsweetened yogurt (flavored with pureed fruit) and low-fat cheeses for infants between 9 and 12 months of age.

4. Non--‐Dairy Substitutions for Milk

The Academy fully supports the proposed accommodations for children with medical or other special dietary needs for milk substitutes, provided that the milk substitutes are nutritionally equivalent to milk, as outlined by the NSLP under 7 CFR 210.10(d) and required under this proposed rule. This proposed revision for accommodation ensures participants will continue to receive all the nutritional benefits of milk without the need to procure a note from a medical authority. WIC has been working to accommodate religious and other beliefs in the program, including in Texas, where Kosher and Cholov Yisroel milk and cheese will now be covered by the state.45 We recommend continued coordination between programs to ensure consistency in implementing and overseeing this reasonable and practical alternative.

5. Yogurt

The Academy supports allowing adults to be served yogurt as a fluid milk alternate a maximum of one time per day across all eating occasions if the yogurt contains added sugars or fats. In addition, the Academy strongly encourages FNS to revise regulations to allow adults to be served plain, unflavored yogurt as a fluid milk alternate for any and all eating occasions throughout the day.

The Academy at this time supports option C2, which would make the sugar limits for yogurt (set at 30g/6oz) merely a best practice that facilities are encouraged to choose to adopt. However, FNS should make clear that sugar limits will be specified for yogurts within this best practice, consistent with the WIC Program’s yogurt sugar requirement.

The Academy remains concerned about an apparent assumption in the proposed rule that centers will purchase individual 6-ounce containers rather than dispensing yogurt from larger containers. The use of individual containers is significantly more expensive, but it is the current marketplace standard. The large and increasing number of individuals with diabetes who are counseled to limit sugar could lead to broadly beneficial changes with packaging. To meet the sugar standard, make a healthy choice, and save money, plain yogurt flavored with fruits or vegetables would be a good alternative to sweetened yogurts.

C. Grains

The Academy supports CACFP's commitment to improving the nutritional quality of grains served to CACFP participants through multiple proposed revisions to the child and adult meal patterns and offer comments on the specific proposals below. 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.46 Whole grains are notably underconsumed among preschool children.47 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.48 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.

1. One Serving Per Day Must Be Whole Grain or Whole Grain-Rich

The Academy supports the proposed revision that at least one serving of grains per day, across all eating occasions, be whole grain or whole grain-rich as described in the new definition of "whole grains" under 7 CFR 226.2. This revision will help achieve the Dietary Guidelines recommendation to consume one-half of all grains as whole grains. In addition, the proposed requirement that a portion of the grains served be whole grain or whole grain-rich is consistent with requirements in the NSLP, SBP, and WIC.

The Academy believes this requirement should be applicable only when a grain is served during the day and we encourage FNS to clarify that limitation to the requirement in the final rule. For example, afterschool programs serving only a snack might not have a grain component each day and thus would not need to serve a whole grain product.

The Academy was pleased that the proposed rule recognized that the whole grain content of food products is not always easily identifiable on a product label, and noted that FNS intends to provide additional guidance on evaluation of grain products as needed. We agree that child and adult care centers need better guidelines to determine whether products meet these requirements, and although there are some NSLP guidelines on the FNS website,49 these can be difficult to apply. Quality training and resources have been shown to facilitate the identification and provision of whole grains.50

2. Breakfast Cereals and WIC Standards

The Academy supports elements of the proposed requirement that breakfast cereals in the CACFP conform to requirements as outlined by WIC, under Table 4 of 7 CFR 246.10(e)(12). Consistency among food assistance programs makes application of the standards easier and increases the likelihood of product availability at competitive prices, and we support many of the WIC requirements setting standards for healthfulness, including limiting eligible breakfast cereals to six grams of total sugars per serving. However, we have concerns about adopting the entirety of the WIC cereal standards.

We agree that technical assistance and training will be necessary to help providers understand and implement these new requirements, and share a concern raised by FRAC in their comments that adopting the entirety of WIC standards may create complications, such as inconsistent whole grain standards and requirements for additional fortification. The plan to default to the State WIC cereal lists is questionable, because the State WIC lists are incomplete. State WIC agencies limit the number of WIC eligible cereals listed to conserve space in their food guides and WIC cereal lists are often subject to state cost containment efforts that may limit CACFP cereal options. In short, there is likely too much variability in the content of the state WIC cereal lists to use them as de facto nutrition criteria for a federal food program. Lastly, the Academy asks that FNS confirm whether the WIC whole grain cereal standard requirement "whole grain food with moderate fat content': (1) Contain a minimum of 51 percent whole grains (using dietary fiber as the indicator);" may be used as a standard for all cereals, or whether that requirement would not be inappropriate for fiber, corn, and rice cereals.

3. Grain-based Desserts

The Academy supports the proposal to prohibit "grain-based desserts" from being used to meet the grain component requirement. Grain-based desserts are major sources of extra calories, added sugars, saturated, fat, and trans fat, and they are generally low in nutritional value. According to research that evaluated NHANES data, grain-based desserts contribute 12.9 percent of calories from total added sugars and 10.8 percent of calories from solid fat.51 Many other more healthful food choices are available for providers to use in meeting the grain component requirement.

The prohibition on grain-based desserts was a necessary result of the decision not to accept the Institute of Medicine’s (IOM’s) recommendation to implement weekly meal patterns (see recommendation for a weekly meal planning best practice in Section IV(F), below), although we encourage FNS to continue to think creatively for a way to allow more healthful grain-based dessert products that meet specified limits of sugars and fats to count for the grain component in a limited but fair way.

Given that a desire for consistency with the NSLP led to the prohibition on using grain based desserts to meet the grain component requirement, it seems appropriate to use consistent definitions among the programs as well. Unfortunately, "grain-based desserts" can be a confusing term without a commonly understood or universally applied meaning. More likely, "we know them when we see them." In suggesting a necessary definition, some have focused on simple elements, such as a product where "sugars or fats" are added to "grain based foods," but that definition overbroadly incorporates many relatively healthful food items. For example, is a slice of zucchini bread or a banana muffin a breakfast food, a snack, or a grain-based dessert? Are pancakes a grain-based dessert?

In developing a definition, it may be helpful to be clear about the specific intent of the prohibition, which is likely for the purpose of limiting products with high sugar and fat contents overall and/or in relation to the other ingredients. Ensuring the definition is narrowly tailored to the specific intent of the prohibition is necessary to enable its proper implementation and evaluation. It could be read that the desserts would not "count" and you would need another grain-based food, which is not the intent.

D. Meat and Meat Alternatives

Meat and meat alternates can be good sources of nutrients including many vitamins and minerals, such as B vitamins, vitamin E, zinc, magnesium, and iron.

  • The Academy supports allowing tofu be allowed to be counted as a meat alternate. Tofu is good source of protein, iron, magnesium, phosphorus, copper and selenium, and a very good source of calcium and manganese. Treating tofu as a meat alternate in CACFP is consistent with its treatment in the NSLP and is culturally important for a number of Americans. The Academy also strongly encourages FNS to develop nutrient-content definitions for any replacement foods recognized in the program.
  • FNS noted that the proposed rule did not adopt the IOM recommendation to limit processed meats because of the difficulty in clearly defining processed meats. In response to FNS's request for comment on how processed meats could be defined and the feasibility, practicality, and challenges associated with such a limitation, the Academy suggests that to the extent practicable, CACFP definitions should be consistent with NSLP standards at this time for program consistency. It is important to develop future standards for fat and sodium contents for processed meats that consider the needs of very young children. The Academy recognizes the difficulty in clearly defining processed meats in a short timeframe and is confident that FNS, working with stakeholders, will find a solution that seizes this opportunity to improve childcare nutrition.

E. Other; Miscellaneous Regulations

1. Food Preparation

The Academy supports the proposed disallowance of frying as an on-site food preparation technique, consistent with the NSLP. We recommend that FNS establish a clear, verifiable definition of frying in the final rule, as there could be confusion in the field about what constitutes "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.

The problem is that although the term "frying" seems intuitive, it is not. Frozen french fries are not cooked in a vat of hot fat. They are sprayed with oil while on a conveyer belt that goes through an oven. When you "bake" them you can watch them sizzle. If you turn them out onto paper towels, you can see the fat absorbed on the towels. If you cook vegetables in fat, the fat also coats the product, but this is not frying. A frying definition should include the fat content of the fried food in a uniform way. This question requires much more work to be useful and effective. The Academy also notes it is premature for us to provide an answer whether we "support the best practice to limit all fried and pre-fried foods (including vegetables) to no more than once per week across all eating occasions" before the term "fried" is defined.

Despite the difficulty in settling on a satisfactory definition, we should be able to reach some consensus on cheese products and pre-fried vegetables using their Nutrition Facts Panels for nutrient content information. For cheese, the WIC definition could be used for consistency across programs. We regret the decision to delay consideration on the reimbursability of cheese products, pre-fried vegetables, and processed meats may be a missed opportunity.

In the interim and in the future, FNS should recommend through training and assistance to providers alternative cooking methods as promoted, healthier techniques. These could include methods which use limited cooking fats such as baking, sautéing, broiling, searing, and stir-frying. Guidance also should recommend moving away from cooking with solid fats, high in saturated fat, and toward healthier vegetable oils. We further recommend that fried foods from caterers, restaurants, or carry-out facilities be disallowed in Early Childhood Education (ECE) programs. As currently written, it appears that fried foods would be allowable if brought in from an outside food service provider.

The integrated education and training surrounding fried foods best practices, as detailed in Section IV(G), below, should be integrated into the proposed improvement to ban on-site frying. Program administrators, center and home monitors, as well as providers should r ive training. For example, the North Carolina, Nutrition Services Branch (CACFP State agency) implemented a USDA Child Care Wellness Grant funded nutrition education initiative, which included training on cooking skills and healthy menu planning. The topic of limiting fried foods including commercially prepared fried foods was also featured in the new education options created for the initiative: an online self-study module on childhood obesity prevention, and a 20-hour nutrition and physical activity training for early care and education professionals offered through rural community colleges.52

2. Prohibition on Using Foods as a Reward or Punishment

We support FNS in prohibiting the use of food as a punishment or reward. Many child care resources recommend not using food as a punishment or reward in the child care setting.53,54,55 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.56

3. Water

The Academy supports the proposed requirement that providers make drinking water available to children throughout the day. FNS should, however, clarify 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. Providers also should be encouraged to 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.

4. Family Style Eating and Offer v. Serve

The Academy requests that FNS provide further clarification on offer vs. serve, particularly drawing a clear distinction between this practice and family-style dining to alleviate provider conclusion. In some cases, providers are interpreting these two distinct practices as the same. For example, during family-style meal service, ECE 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 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. One way FNS could help clarify this difference is to provide videos and other visual resources, such as those available through the Lets Move! Child Care (LMCC) website.57

IV. Best Practices

A. Infant Meal Pattern and Breastfeeding

The Academy offers several possible best practices for the infant meal pattern. One best practice would highlight the importance of regular communication between mother and provider regarding the timing of the last feed, which is key to making direct breastfeeding at the end of the day work for all parties. The Academy also suggests that CACFP should partner with WIC to share breastfeeding materials with a consistent, reinforceable message. WIC has excellent materials that are peer--‐reviewed, culturally appropriate, and locally available. This partnership would also encourage women in WIC to receive consistent messaging and food assistance meeting the Dietary Guidelines by participating in centers using CACFP. We are happy to highlight the NC Breastfeeding Friendly Child Care Designation Program for its work in helping recognize facilities understand what is needed to build an excellent breastfeeding friendly setting. The designation program recognizes child care facilities that have taken steps to promote, protect, and support breastfeeding using its rating system that awards child care facilities with a gold--‐starred building block for every two steps achieved in the Ten Steps to Breastfeeding--‐Friendly Child Care.58

We also want to call attention to a program in which government agencies can purchase state-of-the-art, long-lasting, multi-user breast pumps (quantity of 5 for $1,000) to further enhance breastfeeding support for mothers using Child Care. Each mother will also need her own individual "kit" that costs approximately $10 (if purchased through this government contract). The state WIC office in each state can be contacted for more information, and we encourage dissemination of this opportunity.

Lastly, the Academy encourages stakeholders to engage with their communities' local breastfeeding coalitions. Members often share culturally appropriate materials and dissemination strategies. We recommend that FNS assure that appropriate CACFP staff (state and local) complete a Certified Lactation Counselor training program to ensure evidence based breastfeeding support is the norm.

B. Fruits, Vegetables, and Juice

The Academy offers recommendations and support for a number of best practices related to the fruit, vegetable, and juice requirements.

  • The Academy supports a best practice to encourage serving a fruit or vegetable in the child snack pattern, but we encourage FNS to suggest a weekly allowance.
  • The Academy recommends separating the fruit and vegetable component for breakfast.
  • The Academy would support a best practice to limit consumption of fruit juice to no more than once per day for children. If FNS elects not to make that limitation a best practice, we suggest perhaps limiting juice to 4 ounces per day and alternating fruit and vegetable juices.

C. Milk and Other Dairy

In response to FNS's question whether we support the best practice to serve only unflavored milk to all children, regardless of age, we note that while this can be used as a best practice goal, research shows that children offered flavored milk drink more of it. This means that they get more of the nutrients they need from milk. Instead, we recommend limiting calories from sugar in flavored milk. The Academy at this time would make the sugar limits for yogurt (set at 30g/6oz) merely a best practice that facilities are encouraged to choose to adopt. However, FNS should make clear that sugar limits will be specified for yogurts within this best practice, consistent with the WIC Program's yogurt sugar requirement.

D. Meat

In response to FNS's question whether we support the best practice to limit processed meat to no more than once per week across all eating occasions, the Academy confirms that we do support such a recommended limit. However, before this can be a best practice that providers and operators can implement with assurance and consistency, the definition of processed meats will have to be developed and reviewed by producers and users.

E. Family Style Eating and Offer v. Serve

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.

ECE programs need support and guidance about how to successfully implement family dining in ways that align with CACFP requirements. For example, many providers have concerns about how to ensure adequate and appropriate portion sizes. Many of the providers we have worked with use measuring cups and spoons to encourage children to serve appropriate portion sizes. Guidance should also be given about having an adult present at mealtimes (this means 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. Many resources to successfully implement family-style dining are available on the Let's Move! Child Care website, including videos, tip sheets, testimony from programs, and more.

F. Weekly Planning of Meal and Snacks

The Academy strongly encourages FNS to make it a best practice to do weekly menu planning of both meals and snacks when it finalizes the proposed rule as the first step in obtaining its significant benefits. This would allow time for providers and sponsoring organizations to develop and share expertise and would also permit the development of a monitoring protocol for future implementation.

Adherence to suggested weekly meal and snack patterns might be implemented in stages, as the importance of serving a variety of foods becomes better appreciated and hopefully as additional CACFP funding is allocated. We suggest that serving a variety of fruits and vegetables might be the first priority. To reduce administrative burden and costs, meals could be patterned on those being implemented in the NSLP and SBP, both of which are planned on a weekly basis. Implementing a weekly plan for snacks should be even easier, since fewer items are offered.

We also encourage FNS to consider funding a pilot study of weekly planning in both larger centers and family homes to better determine the relative costs and complexity, as well as the difference in adherence to the Dietary Guidelines when compared to the proposed daily planning rules.

G. Food Preparation

We recommend integrating training and technical assistance on the best practice of limiting the service of commercially prepared fried foods to no more than once per week. State agencies and sponsoring organizations have successfully implemented best practices related to limiting the service of commercially prepared fried foods through:

  • Providing nutrition education emphasizing the importance of healthy choices and the negative health consequences of unhealthy choices;
  • Training on menu planning, healthy product identification and smart shopping; and Hosting food preparation and cooking skills development classes locally or regionally and through web-based videos.

V. Administration and Implementation

A. Clarity of the Proposed Rule

The Academy notes that the requirements section in the proposed rule was very helpful for our Academy Reviewers, although we suggest making a more explicit connection with the NSLP initiatives. The audience of CACFP program administrators is likely to be less organized than those from NSLP and may not be aware of how to read these regulations in depth. Several Academy Reviewers noted the difficulty in keeping track of unfamiliar acronyms, and we encourage FNS to ascertain whether those who work in and with these programs find the acronyms to be an issue. We also encourage FNS to be creative with group headings and other formatting opportunities that improve clarity.

The Academy believes that the current organization and sectional breakdown of the proposed rule generally appears adequate, although it would be helpful to have a separate area for CACFP on the FNS web site to make it easier for states to share resources; the childcare resources are buried deep within the web site. Having a separate area or a reference sections would make them more accessible. We also suggest that programs participating in CACFP should be encouraged to organize professionally, using a model developed by the School Nutrition Association.59

B. Explanation of the Final Rule, Meal Patterns, and Best Practices

1. CACFP and the Rationale for the Revisions

It is critical that FNS clearly communicate in a positive and inspiring way why the revised standards are structured in the manner in which they are, with mandatory standards and recommended best practices. 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.

It may be helpful to provide an overview of CACFP's transformation from its original focus on malnutrition to a new focus on the overconsumption of certain nutrients and the underconsumption of others in line with the Dietary Guidelines. Given the challenges facing the country and the CACFP population, the new focus is appropriate.

2. Ease of Understanding Meal Patterns

The proposed rule asserted that “CACFP wants to ensure meal patterns are easy to understand, implement, and monitor in a wide variety of settings,” which the Academy applauds and commits to supporting however possible. We suggest that meal patterns would be easier to develop, easier to validate and more consistent with other food assistance programs if operators were allowed to follow food group guidelines established for the National School Lunch Program (NSLP), such as the vegetable subgroup guidelines. We note throughout some opportunities to reap the benefits of collaboration with the NSLP and other programs. It would also be easier to plan and evaluate meals for meat alternates if operators were given nutrient guidelines that used information on Nutrition Fact Panels to determine equivalencies for protein and other key nutrients in meat alternates.

The Academy is concerned that the decision to decline to follow the IOM's recommendation for weekly meal patterns removes many of the anticipated benefits of revised standards, specifically the variety of meals and the likelihood that the daily meal patterns could result in nutrient inadequacy. We are unfamiliar with any research showing that weekly meal planning would be more burdensome than daily planning and suggest that, while the initial change to weekly meal planning may have a slight learning curve for some, the benefits in time, money, and improved nutrition for CACFP participants would make the commitment a worthy one. The Academy and our members are happy to work together with regional and federal agencies providing assistance to ensure success. Please note the related suggested "best practice" for weekly meal planning in Section IV(F), above.

3. Facilitating Understanding of Complex Requirements

Communication would be enhanced with (1) clear concrete rules when possible (e.g., no flavored milk products; only plain yogurt without added sugar for infants; (2) creating food art opportunities for enrolled children; (3) creating partnerships with culinary experts on the community level, including culinary arts programs and local chefs, to tweak current menus with more nutrient dense foods added to existing favorites.

The Academy believes that workshops are needed for effective implementation. “Train the Trainer” workshops are especially helpful. Webinars and phone conferences remain useful for identifying concerns and sharing successes. We note many individuals continue to use the resources of the National Food Service Management Institute at University of Mississippi for training and resource development and sharing.60

Should resources become available, there are two worthy initiatives the Academy wishes to highlight. We encourage FNS to offer funds to states and CACFP institutions to upgrade kitchen facilities and training similar to recent USA Awards Grants to Support Schools Serving Healthier Meals and Snacks.61 We also encourage FNS to add resources including breastfeeding support resources to the Healthy Meals web site at the Food and Nutrition Information Center (FNIC). The site appears to concentrate largely, if not entirely on school lunch at present. We respectfully request that FNS add resources specifically targeting childcare providers, and that information needs to be labeled in the links/tabs.62

C. Training and Technical Assistance

As part of the HHFKA, FNS is required to provide technical assistance to participating CACFP centers in complying with the new standards. We thank FNS for the time and resources the Agency has dedicated to CACFP technical assistance to date. We encourage FNS to release its final needs assessment research report, pertinent resources, and guidance materials to continue to educate centers in a meaningful way. FNS should develop resources that address issues such as 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 particular, there will need to be technical assistance and training related to flavored milk, yogurt, frying, whole grains, physical activity, sugar-sweetened beverages, accessible drinking water, and family-style eating. Materials should be easy to understand for a general lay audience and encourage solutions that promote provider and sponsor collaboration with grocers, parents, local farms, and others. The USDA's Farm to Child Care Programs and the Fresh Fruit and Vegetable Program are important resources that the USDA should continue to promote through CACFP to encourage experiential learning opportunities that reiterate healthy food choices.

Anecdotally, there are different challenges that home-based childcare sites face in comparison to center-based sites. However, we urge FNS to keep the standards consistent across sites to ensure children are receiving nutritious meals and snacks regardless of the early care and education setting. Home-based sites may require additional technical assistance and training to support their efforts. Sponsors, too, must be adequately prepared by FNS to answer concerns about the implementation timeline and state agency monitoring.

We recommend FNS include an appendix or chart comparing new meal component requirements, former meal component requirements, and recommended best practices in such a way that it visually encourages providers to be drawn to the best practices. This type of quick reference guide would help providers understand not only minimum requirements, but areas to strive for additional improvement.

On the state and local level, CACFP should connect to the expertise, materials and training capacity of the Academy of Nutrition and Dietetics including professionals currently assisting Head Start centers with their menus, SNAP--‐Ed programs and educators, Public Health Departments' obesity initiatives, WIC offices, the American Heart Association, and Nemours. We note that Head Start utilizes CACFP to feed children during the day. Sharing resources developed by Head Start Nutrition Coordinators to the larger CACFP network could be helpful to other providers. Implementation of the CACFP final rule will require ample lead time, phased-in changes, and grace periods.

Implementation and administration of this new rule will be resource-intensive. It is important to use strategies that will make implementation of these regulations as successful as possible. It is helpful to use strategies that take into account the time needed for providers to learn about and implement the new CACFP meal pattern and address the challenges that providers may encounter. Strategic implementation including strong technical assistance and training support will help sustain the participation of child care centers, family child care home providers, and afterschool programs in CACFP. We recommend that implementation occur in phases over the course of several years. This will help to ensure that there is enough time for providers to be trained and that providers will not be overburdened by the introduction of too many changes simultaneously. We recommend including a learning or grace period between training and enforcement of the regulations. This will help ensure that providers have time to thoroughly learn and implement the meal pattern standards before they are enforced.

VI. 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 24 Tuma at 202-775-8277 ext. 6001 or by email at ptuma@eatright.org with any questions or requests for additional information.

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

Pepin Andrew Tuma, Esq.
Director, 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.

5 Key Statistics and Graphs. United States Department of Agriculture Economic Research Service website. 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. 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 Association, 109(3), 474-478.

8 Child and Adult Care Food Program. United States Department of Agriculture Food and Nutrition Service website. 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. 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 See, American Dietetic Association. Position of the American Dietetic Association: Promoting and supporting breastfeeding. J Am Diet Assoc. 2009;109(11):1926-1942. Eidelman AI, Schanler RJ, Johnston M, et al. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):E827-E84. Bartick M. Mothers’ costs of suboptimal breastfeeding: Implications of the maternal disease cost analysis. Breastfeed Med. 2013;8(5):448-449. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: A pediatric cost analysis. Pediatrics. 2010;125(5):E1048-E1056. Bartick MC, Stuebe AM, Schwarz EB, Luongo C, Reinhold AG, Foster EM. Cost analysis of maternal disease associated with suboptimal breastfeeding. Obstet Gynecol. 2013;122(1):111-119.

13 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., citing Eidelman AI, Schanler RJ, Johnston M, et al. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):E827-E84.

14 Briefel, R. R., Reidy, K., Karwe, V., & Devaney, B. (2004). Feeding infants and toddlers study: Improvements needed in meeting infant feeding recommendations. Journal of the American Dietetic Association, 104, 31-37. Chicago.

15 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.

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

17 U.S. Department of Health and Human Services. (2011). The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General.

18 Briefel, R. R., Reidy, K., Karwe, V., & Devaney, B. (2004). Feeding infants and toddlers study: Improvements needed in meeting infant feeding recommendations. Journal of the American Dietetic Association, 104, 31-37. Chicago.

19 American Academy of Pediatrics (2013). In: Kleinman RE, ed. Pediatric Nutrition Handbook. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics.

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

21 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.

22 ibid.

23 Mennella, J. A., Nicklaus, S., Jagolino, A. L., & Yourshaw, L. M. (2008). Variety is the spice of life: strategies for promoting fruit and vegetable acceptance during infancy. Physiology & Behavior, 94(1), 29-38.

24 Forestell, C. A., & Mennella, J. A. (2007). Early determinants of fruit and vegetable acceptance. Pediatrics, 120(6), 1247-1254.

25 Sullivan, S. A., & Birch, L. L. (1994). Infant dietary experience and acceptance of solid foods. Pediatrics, 93(2), 271--‐277.

26 Gerrish, C. J., & Mennella, J. A. (2001). Flavor variety enhances food acceptance in formula-fed infants. The American Journal of Clinical Nutrition, 73(6), 1080-1085.

27 National Resource Center for Health and Safety in Child Care and Early Education (2015). Rhode Island Regulations. Retrieved from Improving the Quality of Out-Of-Home Child Care and Early Education. Accessed April 2, 2015.

28 National Resource Center for Health and Safety in Child Care and Early Education (2015). Mississippi Regulations. Retrieved from Improving the Quality of Out-Of-Home Child Care and Early Education. Accessed April 2, 2015.

29 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 14 May 2013.

30 Ibid.

31 Institute of Medicine. (2011). Child and Adult Care Food Program. Washington, DC: The National Academies Press.

32 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.

33 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.

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

35 Rader, see footnote #1.

36 Dietary Guidelines for Americans 2010 ("DGA 2010"), United States Departments of Agriculture and Health and Human Services, page 38, accessed April 15, 2015., see footnote #2.

37 American Academy of Pediatrics: Committee on Nutrition. (2001). The Use and Misuse of Fruit Juice in Pediatrics. Pediatrics, 1210--‐1213.

38 Evans EW, Hayes C, Palmer CA, et al. (2013). Dietary Intake and Severe Early Childhood Caries in Low--‐Income, Young Children. Journal of the Academy of Nutrition and Dietetics, 1057-1061.

39 Dietary Guidelines for Americans 2010 ("DGA 2010"), United States Departments of Agriculture and Health and Human Services, page 38, accessed April 15, 2015.

40 Dietary Guidelines for Americans 2005 ("DGA 2005"), United States Departments of Agriculture and Health and Human Services, page 56, accessed April 15, 2015.

41 DGA 2010 at 38.

42 Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth (“IOM Report”), Institute of Medicine, page 58, accessed 14 May 2013. See also, Mary M. Murphy et al., Drinking Flavored or Plain Milk is Positively Associated with Nutrient Intake and Is Not Associated with Adverse Effects on Weight Status in U.S. Children and Adolescents, 108 J. Am. Diet. Assoc. 631, 631 (2008).

43 Fitch, C., & Keim, K. S. (2012). Position of the Academy of Nutrition and Dietetics: use of nutritive and nonnutritive sweeteners. Journal of the Academy of Nutrition and Dietetics, 112(5), 739–758; 744.

44 Pediatrics AA. American Academy of Pediatrics Guide to Your Child's Nutrition, Making Peace at the Table and Building Healthy Eating Habits for Life. 1999.

45 Elisha Ferber. Texas Families to Benefit from Religious Accommodation. The Matzav Network website. March 24, 2009. Accessed April 15, 2015.

46 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.

47 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.

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

49 Whole Grain Resource for the National School Lunch and School Breakfast Programs: A Guide to Meeting the Whole Grain-Rich Criteria. United States Department of Agriculture website. http://www.fns.usda.gov/sites/default/files/WholeGrainResource.pdf. January 2014. Accessed April 15, 2015.

50 LaRowe, T. L. CACFP Child Care Wellness Grant: Evaluation Survey Reports. Wisconsin Department of Public Instruction website. March 8, 2013. Accessed April 15, 2015.

51 National Cancer Institute. (2015). Sources of Added Sugars in the Diets of the U.S. Population Ages 2 Years and Older, NHANES 2005–2006. Risk Factor Monitoring and Methods. Retrieved from: Cancer Control and Population Sciences. Accessed February 11, 2015.

52 Martin H, Hency G. CACFP Best Practice Case Study. Food Research and Action Center website. Accessed on April 6, 2015.

53 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. Accessed on April 2, 2015.

54 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. Accessed on April 2, 2015.

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

56 Alternative School Discipline Options to Withholding Recess. Center for Science in the Public Interest website. Accessed on April 6, 2015.

57 Nemours Children’s Health System & Let’s Move Child Care. (2015). Five Healthy Goals: Improve Food Choices. Retrieved from: https://healthykidshealthyfuture.org/5-healthy-goals/improve-food-choices/. Accessed on April 2, 2015.

58 North Carolina Breastfeeding-Friendly Child Care Designation Program. North Carolina Nutrition Services Branch website. March 5, 2015. Accessed April 15, 2015.

59 Keys to Excellence: Standards of Practice for Nutrition Integrity. School Nutrition Association website. April 2014. Accessed April 15, 2015.

60 National Food Service Management Institute website. http://www.nfsmi.org. Accessed April 15, 2015.

61 USDA Awards Grants to Support Schools Serving Healthier Meals and Snacks. United States Department of Agriculture website. Updated March 6. 2015. Accessed April 15, 2015.

62 Healthy Meals Team Nutrition. United States Department of Agriculture website. Updated April 15, 2015. Accessed April 15, 2015.