Margaret E. Briley

Position of the American Dietetic Association: Benchmarks for Nutrition in Child Care

It is the position of the American Dietetic Association that child-care programs should achieve recommended benchmarks for meeting childrens nutrition needs in a safe, sanitary, and supportive environment that promotes optimal growth and development. Use of child care has become increasingly common and is now the norm for the majority of families in the United States. Therefore, it is essential that registered dietitians; dietetic technicians, registered; and other food and nutrition practitioners work in partnership with child-care providers and families of children in child care to meet childrens nutrition needs and provide them with models of healthful eating and active lifestyles. This Position Paper provides guidance for food and nutrition practitioners, health professionals, and child-care providers regarding recommendations for nutritional quality of foods and beverages served; menus, meal patterns, and portion sizes; food preparation and service; physical and social environment; nutrition training; nutrition consultation; physical activity and active play; and working with families. This Position Paper targets children aged 2 to 5 years attending child-care programs and highlights opportunities for food and nutrition practitioners to promote healthful eating in child care through both intervention and policy-based initiatives.

Dietary Intake at Child-Care Centers and Away: Are Parents and Care Providers Working as Partners or at Cross-Purposes?

OBJECTIVE To examine how meals and snacks children consume before and after their time at a child-care facility complement the menu at the facility. DESIGN Dietary intake of children at and away from the child-care center was compared with recommended standards for child nutrition. Registered dietitians observed foods consumed at the center during 3 consecutive days. Parents reported foods consumed away from the center during the same 3 days. SUBJECTS/SETTING Six nonprofit child-care centers with strong menus (i.e., menus that come close to meeting dietary recommendations) and 6 with menus supplying less than 50% of the Recommended Dietary Allowance were selected for study. Five families at each center were invited to participate. Complete data sets were obtained for 51 children aged 3 to 6 years. STATISTICAL ANALYSES PERFORMED Descriptive and inferential statistics were calculated to compare the childrens dietary intake during center time and family time and over a full day with recommended standards. Energy and nutrient profiles and food frequencies were included in the analysis. RESULTS Children consumed plenty of foods at the center and away from the following groups: meat, poultry, fish, dry beans, eggs, nuts; milk, yogurt, cheese; and fruit, fruit juice. Most children failed to consume enough vegetables. Nearly all the children failed to consume enough bread, cereal, pasta, and rice, especially while at the center. The majority ate more than sparing amounts of fats, oils, and sweets, especially during family time. Average percentage of energy from fat was 33 +/- 4. Intakes of concern for the full day were energy, iron, sodium, and zinc. APPLICATIONS Child-care menus are an appropriate target for increasing iron and zinc by serving more cereal and whole grains. Families are an appropriate target for reducing young childrens consumption of fats, oils, and sweets. Nutrition education and advocacy are needed to strengthen the partnership between parents and caregivers.

Lunch Is In The Bag: Increasing Fruits, Vegetables, and Whole Grains in Sack Lunches of Preschool-Aged Children

Fruits, vegetables, and whole grains are important sources of nutrients for healthy growth and development of young children. Recent evidence suggests that sack lunches packed by parents for children to consume at child-care centers do not regularly meet the goal of one serving of fruit, vegetables, and whole grains. Lunch Is In The Bag is a child-care center-based nutrition education program targeted at parents of preschool-aged children to increase the number of servings of fruits, vegetables, and whole grains in sack lunches sent from home that was pilot tested in fall 2008. In a quasiexperimental design, six child-care centers were paired by size before being randomly assigned to intervention (n=3) and comparison (n=3) groups. The parents of caregivers with primary responsibility for preparing the sack lunches of the 3- to 5-year-old children attending the centers were enrolled as parent-child dyads. The intervention included parent handouts, classroom activities, education stations, and teacher training. The contents of the lunch sacks for both the intervention group and comparison group were recorded for 3 nonconsecutive days before and immediately after the intervention period to measure the number of servings of fruits, vegetables, and whole grains. A total of 132 parent-child dyads completed the study, 81 in the intervention group and 51 in the comparison group. Direct observation of childrens lunches from the intervention group showed an increase in predicted mean number of servings of vegetables, from 0.41 to 0.65 (P<0.001) and whole grains, from 0.54 to 1.06 (P<0.001). No significant difference was observed in the mean number of servings of fruit. Lunch Is In The Bag, which is designed to fit in the child-care environment and targets parents of 3- to 5-year-old children, is a feasible intervention for improving the nutritional quality of sack lunches.

Do Sack Lunches Provided by Parents Meet the Nutritional Needs of Young Children Who Attend Child Care

Recent changes in Texas state regulations of child-care foodservice have resulted in more centers halting meal and snack preparation and requiring parents to provide food from home for their children. In the spring of 2006, sack lunches prepared at home for children attending licensed child-care centers were evaluated based on Dietary Reference Intakes (DRIs) and Child and Adult Care Food Program (CACFP) standards. The study included 3- to 5-year-old children attending full-time child-care centers that required parents to provide lunches. Lunch contents were observed and recorded for 3 consecutive days. A 3-day mean nutrient content was used to determine whether the lunches provided a minimum of 33% of the DRI. The following nutrients were evaluated: energy, carbohydrates, protein, dietary fiber, thiamin, riboflavin, niacin, vitamin C, vitamin A, calcium, iron, zinc, and sodium. Food items were summarized and compared with CACFP standards. More than 50% of the 3-day means provided less than 33% of the DRIs for energy (n=58), carbohydrate (n=59), vitamin A (n=58), calcium (n=49), iron (n=44), and zinc (n=38). Seventy-one of the 74 children (96%) received less than 33% of the DRI for dietary fiber, yet the mean amount of sodium in observed lunches was 114% of the DRI. The observed lunches did not meet the CACFP standards for servings of fruits and vegetables for 157 (71%) or for servings of milk in 178 (80%). Sack lunches sent from home may not regularly provide adequate nutrients for the growth and development of young children. Nutrition education should be provided to parents to ensure that sack lunches sent from home meet childrens nutritional needs.

What can children learn from the menu at the child care center

As a result of studies in Texas that indicated menus in child care centers may be depriving children of nutrients, a study was conducted to determine the prevalence of similar problems in 7 states. Menus for breakfast or morning snack, lunch, and afternoon snack for 10 consecutive program days were obtained from 171 child care centers. Results of nutrient analysis of the menus were compared against the Recommended Dietary Allowances (RDA) for children aged 1 to 3 and 4 to 6. Menus typically provided at least 100 percent of the RDA for protein and the vitamins A, ascorbic acid, B12, and riboflavin. The menus offered an average of only 42 percent of the iron needed by both the younger and older children. In all 7 states the menus provided less than 56 percent of the kilocalories recommended and less than 64 percent of niacin for the 1 to 3 year olds. Mean value for kilocalories for the 3–5 year old averaged 40 percent of recommendation while niacin averaged 48 percent. These findings indicate that attention should be directed toward careful assessment of nutritional adequacy of meals and snacks actually served at child care centers, the childrens nutritional intake at the center, and the nutritional content of meals and snacks eaten away from the center.

Nutrition and the Child-Care Setting

In the past 20 years, America’s population of preschool children has increased by 3.5% (from 21.8 million to 25.3 million) (1). More than 52% of children age 3 to 5 years (4.4 million) were enrolled in center-based care in 1991, compared with 57% (5.2 million) in 2005 (2,3). Today, approximately 82% of all children younger than the age of 6 years are in care outside of the home (3). This is partially due to decreasing family incomes, resulting in parents entering the workforce. Subsequently, enrollment at child-care centers has increased. Center-based care facilities enroll the largest number of preschool children receiving care outside of the home and include child-care centers, preschools, and Head Start programs (4). A smaller percentage of parents enroll children in family child-care environments. The environment is critical to the development of food habits among preschool children. An amalgam of meal combinations can be served in the child-care center, but most commonly parents can expect that their children will be offered lunch and two snacks and sometimes breakfast. These meals are critically important for the development of children’s impressions and expectations about food and nutrition. The quantity and content of foods served to preschool children is considered a major public health matter because lifelong food habits are established in these early formative years. Today, approximately 21% of the US preschool population is characterized as overweight or obese (5). Overweight or obesity during childhood has been shown to be a strong predictor for comorbidities in adolescents and later in life, these include atherosclerosis, type 2 diabetes, sleep apnea, hypertension, hyperlipidemia, asthma, lower self-esteem, and psychological and social stress (6). The primary contributing factors to the development of overweight and obesity in preschool children is the quality of overall diet and a lack of physical activity. In this issue of the Journal of the American Dietetic Association,

Unbundling Outcomes of a Multilevel Intervention to Increase Fruit, Vegetables and Whole Grains Parents Pack for Their Preschool Children in Sack Lunches.

Abstract Background: Packing fruit, vegetables and whole grains in preschool childrens sack lunches is a powerful way for parents to teach their children eating habits and food preferences to support a lifetime of good health. A multilevel intervention pilot-tested in childcare settings increased servings of vegetables and whole grains, but the lunches still fell short of the intervention goals. Purpose: Secondary analyses were conducted to identify specific behavior changes underlying achieved increases in servings of vegetables and whole grains. Methods: Food records from direct observation of 769 parent-packed lunches were investigated to unbundle and measure multiple aspects of lunch packing behavior. Changes from baseline to six week follow-up for the intervention (N = 81) and comparison (N = 51) parent-child dyads were evaluated in multilevel modeling. Results: The increase for whole grains was explained by more parents packing whole grain items whereas increase for vegetables was explained by parents packing vegetables on more days. Discussion: Tailored options were identified for further strategies to increase vegetables and whole grains in parentpacked sack lunches. Translation to Health Education Practice: Linking achieved outcomes to specific behaviors can be an aid in assessing needs and designing interventions to maximize the chances for success.

Nutrition standards in child care programs: Technical support paper

ADA supports achievement of comprehensive nutrition standards in child care programs. The standards recommended here focus on meeting the childs nutrition needs and providing a safe and pleasant environment that promotes acquisition of habits that prevent disease and enable healthy growth and development. Nutrition and health professionals can play a powerful role in advocating and assisting the acceptance of child care nutrition standards by parents, caregivers, foodservice personnel, and directors and policy makers for child care programs.

How to help parents pack better preschool sack lunches: Advice from parents for educators

OBJECTIVES This exploratory study obtained parent suggestions about messages and activities to guide parents to pack healthful sack lunches for preschool-aged children. METHODS A facilitator conducted group interviews using a modified nominal group technique with a convenience sample of parents who pack daily lunches for their children. Interviews took place after hours at child care centers in group settings. Investigators reviewed written statements for common themes then calculated frequencies of references to identified themes. RESULTS In total, 31 parents participated in 3 group interviews held at 3 centers. Interest in receiving written information and in activities stimulating parent interaction were dominant themes in 29% of the comments. Workshops and activity stations were suggested in 20% of the comments. Finally, recommendations for support from local supermarkets were present in 10% of the comments. CONCLUSIONS AND IMPLICATIONS Parents provided helpful suggestions that can guide nutrition educators to implement effective program messages and strategies.

Development of a Method to Observe Preschoolers' Packed Lunches in Early Care and Education Centers.

BACKGROUND As early childhood education (ECE) centers become a more common setting for nutrition interventions, a variety of data collection methods are required, based on the center foodservice. ECE centers that require parents to send in meals and/or snacks from home present a unique challenge for accurate nutrition estimation and data collection. We present an observational methodology for recording the contents and temperature of preschool-aged childrens lunchboxes and data to support a 2-day vs a 3-day collection period. METHODS Lunchbox observers were trained in visual estimation of foods based on Child and Adult Care Food Program and MyPlate servings and household recommended measures. Trainees weighed and measured foods commonly found in preschool-aged childrens lunchboxes and practiced recording accurate descriptions and food temperatures. Training included test assessments of whole-grain bread products, mixed dishes such as macaroni and cheese, and a variety of sandwich preparations. Validity of the estimation method was tested by comparing estimated to actual amounts for several distinct food types. Reliability was assessed by computing the intraclass correlation coefficient for each observer as well as an interrater reliability coefficient across observers. To compare 2- and 3-day observations, 2 of the 3 days of observations were randomly selected for each child and analyzed as a separate dataset. Linear model estimated mean and standard error of whole grains, fruits and vegetables, and amounts of energy, carbohydrates, protein, total fat, saturated fat, dietary fiber, thiamin, riboflavin, niacin, vitamins A and C, calcium, iron, sodium, and dietary fiber per lunch were compared across the 2- and 3-day observation datasets. RESULTS The mean estimated amounts across 11 observers were statistically indistinguishable from the measured portion size for each of the 41 test foods, implying that the visual estimation measurement method was valid: intraobserver intraclass correlation coefficients ranged from 0.951 (95% CI 0.91 to 0.97) to 1.0. Across observers, the interrater reliability correlation coefficient was estimated at 0.979 (95% CI 0.957 to 0.993). Comparison of servings of fruits, vegetables, and whole grains showed no significant differences for serving size or mean energy and nutrient content between 2- and 3-day lunch observations. CONCLUSIONS The methodology is a valid and reliable option for use in research and practice that requires observing and assessing the contents and portion sizes of food items in preschool-aged childrens lunchboxes in an ECE setting. The use of visual observation and estimation with Child and Adult Care Food Program and MyPlate serving sizes and household measures over 2 random days of data collection enables food handling to be minimized while obtaining an accurate record of the variety and quantities of foods that young children are exposed to at lunch time.