Guia_3954 Benchmarks for Nutrition in Child Care

8/3/2019 Guia_3954 Benchmarks for Nutrition in Child Care

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from the association

Position of the American Dietetic Association:

Benchmarks for Nutrition in Child Care

ABSTRACTIt is the position of the American Di-etetic Association that child-care pro-grams should achieve recommendedbenchmarks for meeting childrensnutrition needs in a safe, sanitary,and supportive environment that pro-motes optimal growth and develop-ment. Use of child care has becomeincreasingly common and is now the

norm for the majority of families inthe United States. Therefore, it is es-sential that registered dietitians; di-etetic technicians, registered; andother food and nutrition practitionerswork in partnership with child-careproviders and families of children inchild care to meet childrens nutritionneeds and provide them with modelsof healthful eating and active life-styles. This Position Paper providesguidance for food and nutrition prac-titioners, health professionals, andchild-care providers regarding recom-

mendations for nutritional quality offoods and beverages served; menus,meal patterns, and portion sizes; foodpreparation and service; physical andsocial environment; nutrition train-ing; nutrition consultation; physicalactivity and active play; and workingwith families. This Position Papertargets children aged 2 to 5 yearsattending child-care programs andhighlights opportunities for food andnutrition practitioners to promotehealthful eating in child care throughboth intervention and policy-basedinitiatives.

J Am Diet Assoc. 2011;111:607-615.

POSITION STATEMENT

It is the position of the American Di-etetic Association that child-care programs should achieve recommendedbenchmarks for meeting childrens

nutrition needs in a safe, sanitary,and supportive environment that pro-motes optimal growth and develop-ment.

Child-care providers play an im-portant role in shaping thehealth of our nations children.

Nearly three quarters of childrenaged 3 to 6 years in the United Statesspend time in organized child care (1),

with even more cared for in less-for-mal arrangements such as family,friend, or neighbor care. According toestimates, nearly 9 million childrenattend child care (2), and the majorityof them spend more than 15 hours perweek there (3). The number of child-care centers has increased from lessthan 5,000 in 1977 to roughly 119,000in 2007, with an estimated additional238,103 family child-care homes (4).To promote healthful eating in allchild-care settings, food and nutritionpractitioners need to work in partner-ship with child-care providers and

families to ensure that meals andsnacks served in child care meet chil-drens nutrition needs and that pro-

viders support and model healthfuleating to create a positive child-careenvironment.

Child-care programs often serve ashomes away from home, where chil-dren adopt early nutrition-related be-haviors. Young children appear morelikely than older children to be influ-enced by adults in an eating environ-ment (5), and food habits and pat-terns of nutrient intake acquired in

childhood track into adolescence andadulthood (6,7). In addition, youngchildren typically consume half tothree quarters of their daily energywhile in full-time child-care programs(8,9), making this an ideal setting forthe promotion of healthful eating.Thus, achieving recommended bench-marks for nutrition in child-care pro-grams is an important public healthpriority, and food and nutrition prac-titioners can play a key role in thatcharge. This Position Paper identifies

nutrition benchmarks for childrenaged 2 to 5 years attending child careand provides guidance for food andnutrition practitioners, health profes-sionals, and providers regarding rec-ommendations for: nutritional qual-ity of foods and beverages served;menus, meal patterns, and portionsizes; food preparation and service;physical and social environment; nu-

trition training; nutrition consulta-tion; physical activity and active play;and working with families.

BENCHMARKS FOR NUTRITION IN CHILDCARE

Nutritional Quality of Foods andBeverages Served

Foods and Beverages Served Should Be Nu-tritionally Adequate and Consistent with theDietary Guidelines for Americans (DGA).Foods and beverages served in child-

care programs should be consistentwith the DGA (10). Child-care provid-ers can help ensure that children eatnutritious foods that promote optimalgrowth and development in theirearly and formative years. The impor-tance of this benchmark is under-scored in the Healthy People objec-tives for the nation to increase theproportion of persons aged 2 yearsand older whose diets are consistentwith the DGA. The Dietary ReferenceIntakes (DRIs) also provide guida-nce on childrens nutrient needs (11).

Foods and beverages served to chil-dren in child care should provide aproportional share of daily nutrient re-quirements. Children in part-time pro-grams should receive foods and bever-ages that provide at least one thirdof the daily nutrient requirements,whereas those in full-time programsshould receive foods and beveragesthat meet at least one half to twothirds of daily nutrient needs (12).

A Variety of Healthful Foods, IncludingFruits, Vegetables, Whole Grains, and Low-

0002-8223/$36.00doi: 10.1016/j.jada.2011.02.016

2011 by the American Dietetic Association Journal of the AMERICAN DIETETIC ASSOCIATION 607


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Fat Dairy Products, Should Be Offered toChildren Daily. A key recommendationin the DGA is that children consumefive or more servings of fruits and

vegetables, especially dark-green andyellow vegetables and citrus fruits ev-ery day (10). Children should be

served fruits and vegetables high invitamin C daily and high in vitamin Aat least three times a week. Emphasisshould be placed on minimally pro-cessed fruits and vegetables whenavailable from a safe and cleansource. Choosing fresh fruits and veg-etables and serving them raw ratherthan cooked helps increase theamount of dietary fiber, minimize fatand sodium in the diet, and avoid theloss of nutrients, such as vitamin C,through cooking. Frozen fruits and

vegetables are also good options; how-

ever, canned fruits and vegetablesmay be more economical in the child-care setting. Fruits packed in waterrather than syrup and vegetables lowin sodium are good options whenfresh or frozen fruits and vegetablesare unavailable or costly. Providerscan rinse canned fruits and vegeta-bles to reduce added sugar and so-dium before serving them.

Juice is often served in lieu of wholefruits or vegetables in child-care pro-grams for convenience, cost, shelf life,and perceived health benefits. The

American Academy of Pediatrics rec-ommends limiting juice to 4 to 6 oz/day, but less should be served inchild-care programs because childrenmay consume juice at home (13).Juice provides less fiber and fewernutrients than whole fruits or vegeta-bles. Moreover, excessive juice con-sumption may contribute to the de-

velopment of obesity (14,15).In addition to consuming adequate

amounts of fruits and vegetables,children should consume at least sixservings of a combination of breads,cereals, and legumes daily, and at

least half of all grains consumedshould be whole grains. Whole-grainproducts such as whole-wheat bread,brown rice, and oatmeal help providedietary fiber, which may be lacking inmeals provided to children in childcare (16).

Dairy products are an importantsource of calcium and vitamin D forchildren. As young children age, theyshould consume less energy from fat,including fat in milk, and increasetheir consumption of 1% or fat-free

milk for children older than age 2years (10,17). Despite these recom-mendations, few children drink re-duced-fat or fat-free milk (17,18).

Foods and Beverages High in Energy,Sugar, and Sodium and Low in Vitaminsand Minerals Should Be Limited. Foods

high in nutrients and low in fat,sugar, and sodium may help preventthe development of chronic diseasessuch as obesity. Child-care programsare an important setting for the pro-motion of healthful eating and theprevention of obesity (19,20). Re-searchers have started to explore therelationship between child-care at-tendance and obesity, with one studylinking part-time child care with adecreased risk of obesity later inchildhood compared to children caredfor at home (21). Another study found

that full-day Head Start programsmay provide more protection againstobesity (22) than part-day Head Startprograms (9). A study examining thequality of foods and beverages servedin Head Start programs through a na-tional survey of directors and foundthat more than half of programs sur-

veyed did not allow flavored milk orvending machines, and nearly all didnot allow sugar-sweetened beverages(23). The Head Start program perfor-mance standards (24) can serve as amodel for other child-care programs.These standards require participat-ing child-care programs to focus onhealthful options and to limit foods ofminimal nutritional value. More re-cent studies have found that child-care attendance may actually contrib-ute to development of obesity (25,26).Despite mixed results on the relation-ship between child-care attendanceand obesity, promotion of healthfuleating in child care remains an im-portant issue when addressing long-term healthful behavior.

Menus, Meal Patterns, and Portion SizesFoods and Beverages Should Be Provided inQuantities and Meal Patterns Appropriateto Ensure Optimal Growth and Develop-ment. Children typically grow 2.5 inand gain 5 to 6 lb each year from age1 year through adolescence. Total en-ergy needs increase slightly with age,although energy needs per kilogramof body weight actually decline grad-ually during childhood.

Meals and snacks should be offeredto children every 2 to 3 hours in child-

care programs (27). Generally, chil-dren in care for 8 hours or less shouldbe offered at least one meal and twosnacks or two meals and one snack(27). Children in care more than 8hours should be offered at least twomeals and two snacks or three snacks

and one meal (27). Recommended pat-terns and portion sizes for providingwell-balanced meals and snacks areavailable from a variety of sources,including the US Department of Ag-ricultures Child and Adult CareFood Program (CACFP) (28,29). Por-tion sizes and frequency of meals andsnacks affect the energy intake ofchildren (30,31).

By ensuring that children receiveadequate amounts of foods and bever-ages, served at appropriate intervals,child-care programs can make sub-

stantial contributions to helping prevent hunger in children. Nearly 15%of families in the United States reportfood insecurity, and a number of thesefamilies include young children (32).Child-care providers should followcurrent portion size recommenda-tions but should also respond to chil-drens cues related to hunger andsatiety.

Child-Care Programs that Meet Require-ments Can Benefit from Participation in theCACFP. The CACFP (28) is a federalnutrition assistance program that

provides reimbursement for mealsand snacks served to children fromfamilies with low incomes and somechildren with disabilities and chronichealth conditions enrolled in child-care facilities. The program also de-livers nutrition education, regulatesmeal patterns and portion sizes, andoffers sample menus to help child-care providers comply with nutritionstandards. The program providesmeal-pattern and child-size-portionguides for feeding infants and chil-dren ages 1 through 2 years, 3

through 5 years, and 6 through 12years. Both child-care centers andfamily child-care homes are eligible toparticipate in the program, but homesmust work with a sponsoring agency.Child-care programs not eligible toparticipate in CACFP are encoura-ged to follow CACFP guidelines forhealthy meals and snacks. Centersthat participate in CACFP, includingHead Start programs (22) not partic-ipating in the National School Lunchand Breakfast Program (33), must

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provide copies of menus to ensurecompliance with CACFP meal pat-tern food group requirements.

Child-Care Programs Should Provide Me-nus that Reflect Actual Foods and Bevera-ges Served. Menus are an importantsource of information for families of

children in child care, state and fed-eral regulators, food and nutritionpractitioners, and researchers. Post-ing menus is an inexpensive way tokeep families informed about mealpatterns and foods and beverages pro-

vided. A review found that 39 states(76%) required child-care centers topost menus or make them available toparents, and 19 states (37%) requi-red family child-care homes to postmenus or make them available to par-ents through their state regulations(34). Roughly one quarter of states

also specify that menus match foodsserved to children and required child-care providers to note any deviationsfrom the menu in advance of the mealor snack (34). Previous studies havedemonstrated that child-care menusare only partially accurate sources ofinformation about foods and bever-ages served to children in child care(35). Child-care programs can en-hance the accuracy of their menus byaiming to serve foods and beverageslisted on menus and when necess-ary noting substitutions directly onmenus in advance of the meal orsnack.

State and federal regulators reviewmenus to ensure that child-care pro-

viders are serving foods and bever-ages that meet nutrient and dietaryrequirements. They also use menusas a cost-effective method to monitoradherence to program guidelines andstate regulations. Food and nutritionpractitioners and researchers reviewmenus to assess the dietary quality offoods and beverages served to chil-dren to identify opportunities for im-provement (36,37).

Food Preparation and Service

Food Preparation and Service Should BeConsistent with National Standards andRecommendations for Food Safety andSanitation. Children in child careshould be served food that is stored,prepared, and presented in a safe andsanitary manner. The challenges offoodborne illness have changed be-cause of newly identified pathogensand vehicles of transmission, changes

in food production and distribution,and decline in food-safety awarenessin child-care programs and society(38,39). The Centers for Disease Con-trol and Prevention reported 21,183cases of foodborne disease in 2007,with the majority of foodborne disease

caused by bacterial pathogens (38).Many more cases, however, are notreported and are therefore not docu-mented. In addition, new pathogenshave emerged and are transportedthrough the food chain (38). I t i simportant that proper institutionalfood-management practices be imple-mented to protect the health andsafety of children in child care. Food-service personnel in child-care pro-grams need to assess the safety andquality of their foodservice operationdaily using the recommendations of

Hazard Analysis and Critical ControlPoints for the handling, cooking, serv-ing, and storage of food and equip-ment (40). Moreover, providing sani-tary facilities for foodservice staff andenforcing sanitary practices, includ-ing thorough hand washing, is one ofthe most effective strategies for pre-

venting the spread of disease in childcare (40-43).

Materials for training foodservicepersonnel to avoid foodborne illnessand cross-contamination are abun-dant and accessible to child-care pro-

viders (40-43). Caring for Our Chil-drenNational Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Pro-grams (CFOC) provides detailed stan-dards (27). Chief among these arestandards that children and child-care providers wash their hands, thatchildrens food be served on plates orother disinfected holders and notplaced on a bare table, that foods beproperly refrigerated, that kitchenequipment be appropriately designedand maintained, and that single-ser-

vice articles such as paper napkins be

discarded after each use. Another re-source, Making Food Healthy and Safefor Children: How to Meet the National Health and Safety Performance Stan-dardsGuidelines for Out-of-HomeChild Care Programs (43), was de-signed to help child-care providers com-ply with CFOC standards.

Food allergies are an important is-sue related to food safety. Food aller-gies are common in children and prev-alence rates have increased in recentyears (44). Milk allergy is common,

especially in young children (45), butpeanut allergy has received consider-ably more attention because of somechildrens severe reactions (46). Anumber of child-care programs nolonger allow peanuts or peanut prod-ucts in the facility to help prevent

accidental exposure, although mostshould be considered peanut-res-tricted rather than peanut-free (47).Nonetheless, child-care providersshould provide a safe environment forchildren with peanut allergies andrecognize and treat a food allergy-based reaction (48). CFOC providesstandards for developing medicaltreatment plans, training staff, andadministering medication related tofood allergies in child care (27).

Physical and Social Eating Environment

Child-Care Providers Should Model andEncourage Healthful Eating for Children.Children mimic adults, and thuschild-care providers have the op-portunity to model and encouragehealthful eating. Children learnabout food and nutrition from mes-sages conveyed by child-care provid-ers (49). Messages can be conveyedthrough instruction, in conversation,in guided practice, and through mod-eling (50). Although modeling health-ful eating behaviors by providers isthought to be important, research to

date is inconclusive. One study foundthat provider modeling alone was noteffective at encouraging childrensconsumption of unfamiliar foods(49). When modeling was combinedwith encouraging comments, chil-dren were more likely to accept thenew foods (50).

Child-Care Providers Should Work withChildren to Understand Feelings of Hungerand Satiety and Should Respect ChildrensHunger and Satiety Cues, Once Expres-sed. Young children are aware of feel-ings of hunger and satiety, but by age

5 years, this ability begins to wane.Specifically, 3-year-olds consumedconsistent amounts of food, regard-less of portion size, whereas 5-year-olds increased consumption as thesize of the portion increased (51).Serving foods and beverages familystyle, where children select their ownportions and serve themselves, mayencourage better self-regulation of in-take in children (52,53). Division ofresponsibility is another approach tofeeding that may help children self-

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regulate food intake (54). Thismethod specifies that adults are re-sponsible for the what, when, andwhere of feeding, whereas childrenare responsible for the how much andwhether of eating. In theory, this ap-proach facilitates child self-regula-

tion, but there is no direct evidence tosupport this approach. The method is,however, consistent with other feed-ing practices that support healthfuleating in children, including adultmodeling, repeated exposure to novelfoods, and family-style meals.

There is also evidence that negativeaspects of the mealtime environmentmay facilitate unhealthful eating be-haviors in children. Pressuring chil-dren to eat may lead to higher levels ofpicky eating, greater resistance to eat-ing (55,56), and a dislike of certain

foods that can persist well into adult-hood (57).

Furniture and Eating Equipment Should BeAge-Appropriate and Developmentally Suit-able for Children. Chairs, tables, andeating equipment and utensils shouldbe comfortable and suitable in sizeand shape for children, with accom-modations made for children with de-

velopmental disabilities (27). It is im-portant that the eating environmentsupport childrens health and safety.Eating utensils should be appropriatein size and weight for the childrensmotor skills and protect them fromchoking. Children should be able tosit in chairs that allow them to resttheir feet on the floor or on a footrestto minimize the risk of falling. Post-ers, pictures, and decorations thatcommunicate nutrition messagescan help reinforce nutrition con-cepts taught by child-care providersand modeled during meals andsnacks (58).

Nutrition Training

Child-Care Providers Should Receive Ap-

propriate Training in Child Nutrition andShould Be Aware of the Benchmarks PutForth in this Position Paper. Child-careproviders should be knowledgeableabout the basic principles of child nu-trition, strategies for creating a posi-tive mealtime environment, develop-ment of healthful eating habits, andthe other benchmarks included inthis Position Paper. In addition, theyshould be offered training that pro-motes their own health and well-be-ing. Foodservice personnel, including

cooks and other providers who pre-pare food for children, should havetraining in how to plan, prepare, andserve nutritious, safe, and appealingmeals and snacks that are consistentwith the DGA and the DRI. Food andnutrition practitioners can provide

training to child-care programs onthese benchmarks. Having a regularschedule for training of providers isalso important owing to high turnoverrates. Half of providers and one thirdof center directors leave their centerswithin a 4-year period (59). Annualprogram-related training is requiredfor child-care programs that partici-pate in CACFP (28), and CFOC rec-ommends nutrition-related educationtailored to the level of involvementthat providers have with foodservicewithin the child-care program (27).

Nutrition Education for Children and Fami-lies Should Be a Component of the Child-Care Program. Child-care providershave the opportunity to incorporatenutrition education into their dailyroutines with children. Childrenshould develop a basic understandingof the origin of food through books,posters, hands-on experiences, andconversations with providers. Provid-ers can help teach children about foodby engaging their senses. Childrenwho taste, smell, and manipulate newfoods may be more likely to eat them,especially after repeated exposure(60). Nutrition education for childrencan be both formal (eg, circle timeactivity) and informal (eg, mealtimeconversations). Providers should talkwith families about nutrition educa-tion that takes place in the child-careprogram to help engage them in theprocess of communicating nutritioninformation to children. Child-careprograms may also provide nutritiontraining opportunities for families tohelp ensure that messages children re-ceive at the child-care program are con-sistent with those they receive at home.

CFOC recommends that child-care pro-grams partner with food and nutritionpractitioners to offer trainings to fami-lies at least twice per year (27).

Nutrition Consultation

Food and Nutrition Practitioners, IncludingRegistered Dietitians and Dietetic Techni-cians, Registered, Can Provide Consultationto Child-Care Programs on Nutrition forChildren. Food and nutrition practitio-ners can provide consultation to

child-care programs to assist withmenu planning and evaluation andnutrition information and training forfoodservice personnel, providers, andfamilies. Other important tasks thatensure high-quality nutrition inchild-care programs include screen-

ing and assessment, information andeducation activities, and counselingthat take into account physical, emo-tional, and financial considerations.Tools and assessments are availa-ble to help food and nutrition practi-tioners evaluate the achievement ofthese benchmarks in child-care pro-grams (61). In addition, a unique op-portunity exists in states requiringmenu review from a food and nutri-tion practitioner through state licens-ing regulations. Based on a 2008 re-

view, eight states require child-care

centers and three states require fam-ily child-care homes have their menusreviewed by a food and nutrition prac-titioner (34). In those states, food andnutrition practitioners may have sub-stantial influence over foods and bev-erages served to children in child-careprograms. In states without this reg-ulation, food and nutrition practitio-ners may encourage adoption of newpolicies related to nutrition in childcare, including menu review by a foodand nutrition practitioner.

Physical Activity and Active PlayFood and Nutrition Practitioners Can Workwith Child-Care Providers to Encourage Ac-tive Play in Children. Active play is animportant part of quality child care.Regular physical activity promotesa healthy weight, enhances motorskills, and improves cardiovascularfunction (62,63). Studies have alsolinked physical activity and childrensability to pay attention and focus(64,65). Some research suggests thatphysical activity and other weight-re-lated behaviors begin in early child-

hood and track over time (66,67).Thus, encouraging physical activityin early childhood may have long-term benefits. DGA recommendationsstate that children should accumulate60 minutes of physical activity dailyor on most days of the week (10). TheNational Association for Sport andPhysical Education recommends thatchildren accumulate at least 60 min-utes of structured physical activitydaily and up to several hours of daily,unstructured physical activity, and



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children should develop gross motorskills that serve as the foundation formore advanced movement (68). The

American Academy of Pediatrics rec-ommends that children participate ina variety of activities, including un-structured play, and also engage in

activities such as running, tumbling,throwing, and catching, with adult at-tention to safety and supervision (69).

Children are more active whenplaying outdoors (70,71) and engag-ing in moderate and vigorous physicalactivity in short bursts throughoutthe day (72). Evidence also suggeststhat childrens physical activity lev-els depend on their child-care pro-grams (73). Providers can helpachieve this benchmark by creatingopportunities for children to engagein both structured and unstructured

physical activity throughout the dayand facilitating outdoor time at leastonce per day and preferably more of-ten. Recent studies have found thatchildren in child care are largely in-active (74,75). In addition to provid-ing ample time for active play, it isimportant to limit sedentary time to30 to 60 minutes per full day of childcare for children while they are notsleeping or eating (58,68).

Working with Families

Child-Care Providers Should Work withFamilies to Ensure that Foods and Bever-ages Brought from Home Meet NutritionGuidelines. A number of child-care pro-grams require families to providemeals and snacks for their children.Child-care programs may provide cul-turally sensitive written guidelines orpolicies to families to help outline re-quirements and prohibited foods. Fewstudies have examined the nutri-tional quality of foods and beveragesbrought to child-care programs fromhome. A study found that lunchesbrought from home provided inade-

quate amounts of total kilocalories,vitamin A, iron, calcium, zinc, and fi-ber and that sodium was 114% of theDRI (76). In addition, foods and bev-erages provided did not meet CACFPstandards for fruits, vegetables, andmilk in the majority of lunches. Theauthors recommended communica-tion and education to help ensure thatmeals and snacks sent from homemeet childrens nutrition needs (76).Providers can work with families tohelp ensure that foods and beverages

meet the nutrition guidelines out-lined in this Position Paper. Child-care programs should have food avail-able to supplement meals and snacksbrought from home if the food pro-

vided does not meet childrens basicnutrition needs (27).

Families of Children in Child Care ShouldEncourage the Provision of Healthful Foodsand Beverages in Child-Care Programs. Asmore parents rely on providers toshare their role as caregiver, it is im-portant that food and nutrition prac-titioners help families communicatewith providers about foods and bever-ages served to their children. Onestudy found that parent suggestionsto improve healthful eating and phys-ical activity in their child-care pro-gram were consistent with nationalrecommendations (77), and interac-

tions between providers and familiesshould be encouraged. Food and nu-trition practitioners can help familiesadvocate for improved nutrition intheir child-care programs.

OPPORTUNITIES TO PROMOTE HEALTHFULEATING IN CHILD CARE THROUGHINTERVENTION

A primary way to achieve thesebenchmarks is through interventions,a number of which have been devel-oped by researchers and food andnutrition practitioners and dissemi-nated for use in states and communi-ties, or by child-care programs di-rectly. Three programs are includedin this Position Paper, two of whichwere highlighted in the nationalChildhood Obesity Task Force Action Plan: Solving the Problem of Child-hood Obesity Within a Generation(78). Other programs exist and maybe used to promote healthful eating inchild care (79).

Hip-Hop to Health Jr. is a class-room-based intervention designed topromote healthy weight in racially

and ethnically diverse children aged 3to 5 years. The intervention was suc-cessful in controlling excess weightgain in African-American children at-tending 12 Head Start centers at both1 and 2 years postintervention (80).In addition, saturated fat intake wassubstantially lower in children at-tending intervention centers at1-year follow-up, but not at 2-year fol-low-up. Researchers evaluated Hip-Hop to Health Jr. in 12 Head Startcenters serving predominately Latino

children, but did not find significantdifferences in weight or dietary in-take between children attending in-tervention centers compared to thoseattending control centers (81).

I Am Moving, I Am Learning (82) isanother program developed for use in

Head Start centers. The programaims to enhance both fine and grossmotor skills as well as to improve di-etary intake among children attend-ing Head Start programs. The goals ofthe program are to increase theamount of time children spend inmoderate to vigorous physical activityeach day, improve movement qualityof structured activities, and promotehealthful eating. The interventionmaterials are centered on a charactercalled Choosy that was developed tohelp children make good choices re-

lated to food and physical activity.Preliminary results from pilot testingare favorable and suggest that theprogram increased childrens physicalactivity levels, decreased sedentarytime, and enhanced family involve-ment in the child-care program (83).

The Nutrition and Physical Activ-ity Self-Assessment for Child Careprogram is an environmental inter-

vention designed to improve policiesand practices in child care that pro-mote healthy weight in children aged2 to 5 years. The intervention encour-ages child-care centers to self-assess

their nutrition and physical activityenvironments, select areas for im-provement from the self-assessmentinstrument (61), and make environ-mental changes with the help of ahealth professional (58). Pilot testingin 19 child-care centers and evalua-tion in 84 additional centers foundthat participating centers improvedtheir nutrition environments, butwere less likely to make substantialchanges related to physical activity(84,85).

OPPORTUNITIES TO PROMOTE HEALTHFULEATING IN CHILD CARE THROUGHPOLICY AND REGULATION

A second way to help achieve thesebenchmarks is through policy andregulation. Child care is regulatedprimarily at the state level, and eachstate establishes its own regulationsfor licensed child-care programs andsets minimum enforcement stan-dards to improve adherence. In somecases, cities and other municipalities



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have enacted regulations that aremore robust than those in their statesbut not all cities and municipalitieshave the authority to do so. New YorkCity, for example, enacted healthfuleating and physical activity regula-tions in 2006 revisions to the New

York City Health Code (86).Most states license a number of dif-

ferent classes of child-care facilities,but the majority of them include bothchild-care centers and family child-care homes (87,88). Generally, regu-lations related to nutrition are morecommon for centers. Two reviews ofstate regulations found that moststates lacked adequate regulationsrelated to healthful eating. In a 2007study, researchers examined stateregulations and recorded mention ofeight items, including water, sugar-

sweetened beverages, foods of low nu-tritional value, forcing children to eat,using food as a reward, supportingbreastfeeding, limiting screen time,and requiring physical activity daily(88). The study found substantial

variation among states. Tennesseehad six of the eight regulations forchild-care centers, whereas the Dis-trict of Columbia, Idaho, Nebraska,and Washington had none of them.For family child-care homes, Georgiaand Nevada had five of the eight reg-ulations, and California, the Districtof Columbia, Idaho, Iowa, Kansas,and Nebraska had none. A similar2006 review of state regulations alsofound substantial variability amongstates (20). Centers were the mostheavily regulated and had more spe-cific regulations, followed by largefamily and group child-care homes.Small family child-care homes hadthe fewest and most general regula-tions. The researchers found that 12states had regulations that limitedfoods of low nutritional value in cen-ters, seven states had regulations forlarge family and group child-care

homes, and four states had regula-tions for small family child-carehomes. It is important to note thatchild-care regulations represent min-imum standards, or the floor. Act-ual practice of child-care programsshould exceed standards put forth instate regulations.

States have the opportunity to en-hance regulations to help achievethese benchmarks. Food and nutri-tion practitioners can help by provid-ing their expertise and understand-

ing of how regulatory and policychanges happen in their states. Tomake changes in regulations, somestates must work through their legis-lature. In other cases, the legislaturehas empowered an agency to amendand enact new regulations for child

care. The existence of a regulationdoes not guarantee provider compli-ance or state enforcement of the reg-ulation, but child-care providers arelikely a compliant group, given thattheir livelihoods and the health of thechildren in their care depend on theiradherence. States can improve theirregulations by enacting more strin-gent CACFP policies. A number ofstate regulations require that allchild-care programs comply withtheir CACFP standards, and thus inmany states there are two potential

avenues for enhancing policies gov-erning child care. In 2006, roughly60% of states specified CACFP or sim-ilar meal pattern requirements forchild-care centers, approximately50% did for large family or grouphomes, and approximately 40% didfor small family child-care homes(20). A few states have made policychanges and revised their standardsfor CACFP. Delaware limited less-healthful foods, such as cheese foodproducts, fried vegetables such asfrench fries, and processed meats(89). New CACFP standards in Dela-

ware also limit juice served to chil-dren (no juice for infants aged 12months and younger) and promotewhole grains. Because Delaware statechild-care regulations defer to stateCACFP standards, this policy changeaffects all licensed child-care pro-grams. Efforts to enhance child-careenvironments through both stateregulations and CACFP are war-ranted. Policy and regulation, how-ever, rarely reach children in unreg-ulated child-care arrangements suchas family, friend, or neighbor care.

Additional efforts are needed to pro-mote the health of children in theseless-formal types of child care.

ROLES AND RESPONSIBILITIES OFREGISTERED DIETITIANS AND DIETETICTECHNICIANS, REGISTERED

Provide consultation to child-careprograms, including assessment ofchildrens nutritional status, assis-tance with menu planning and

evaluation, training for foodservicepersonnel, and nutrition informa-tion and education for providers.

Review the scientific literature,guidelines for federal nutritionassistance programs, state regula-tions for child care, dietary guide-

lines, and nutrition-education re-sources regularly to offer providerstimely and current information.

Encourage families to become ac-tive in their child-care nutritionprograms, and help facilitate effec-tive communication between fami-lies and programs.

Participate in research and dissem-ination of research findings regard-ing best practices for nutrition inchild-care programs.

Participate in policy developmentand implementation to promote and

support high-quality nutrition ser-vices in child-care programs.

The American Dietetic Associat-ion supports achievement of recom-mended benchmarks for nutrition inchild-care programs. The benchmarksoutlined in this Position Paper focuson meeting childrens nutrition needsand providing a safe and pleasant en-

vironment that promotes healthfuleating for optimal growth and devel-opment. Food and nutrition practitio-ners can play a powerful role in advo-cating for these nutrition benchmarks

and can include families, child-careproviders, foodservice personnel, hea-lth professionals, and policymakers topromote the overall health of childrenin child care.

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This American Dietetic Association (ADA) position was adopted by the

House of Delegates Leadership Team on October 26, 1986, and reaffirmed on

September 11, 1993; September 12, 1997; July 23, 2002; and May 17, 2007.

This position is in effect until December 31, 2015. ADA authorizes republi-

cation of the position, in its entirety, provided full and proper credit is given.

Readers may copy and distribute this paper, providing such distribution is

not used to indicate an endorsement of product or service. Commercial

distribution is not permitted without the permission of ADA. Requests to

use portions of the position must be directed to ADA headquarters at

800/877-1600, ext 4835, or [email protected] .

Authors: Sara E. Benjamin Neelon, PhD, MPH, RD (Duke UniversityMedical Center, Durham, NC); and Margaret E. Briley, PhD, RD, LD (The

University of Texas at Austin, Austin, TX).

Reviewers: Sarah C. Ball, MPH, RD (University of North Carolina atChapel Hill, NC); Pediatric Nutrition dietetic practice group (DPG) (Lynn S.

Brann, PhD, RD, Syracuse University, Syracuse, NY); Public Health/Com-

munity Nutrition DPG (Lisa S. Brown, PhD, RD, Simmons College, Boston,

MA); Sharon Denny, MS, RD (ADA Knowledge Center, IL); Hunger and

Environmental Nutrition DPG (Fern Gale Estrow, MS, RD, CDN, FGE Food

& Nutrition Team, New York City, NY); Mary A. Musil, MS, RD (Montana

Department of Public Health and Human Services, Helena, MT); Esther

Myers, PhD, RD, FADA (ADA Research & Strategic Business Development,

Chicago, IL); Mary Pat Raimondi, MS, RD (ADA Policy Initiative & Advo-

cacy, Washington, DC); Lisa Spence, PhD, RD (ADA Research & Strategic

Business Development, Chicago, IL); and Jennifer A. Weber, MPH, RD

(ADA Policy Initiative & Advocacy, Washington, DC).

Association Positions Committee Workgroup: Alana Cline, PhD, RD(chair); Katrina Holt, MPH, MS, RD; and Dayle Hayes, MS, RD (content

advisor).

The authors thank the reviewers for their many constructive comments

and suggestions. The reviewers were not asked to endorse this position or

the supporting paper.

mailto:[email protected]:[email protected]:[email protected]

Documents

Guia_3954 Benchmarks for Nutrition in Child Care