The problem. Opportunities to prevent childhood obesity through child-care facilities have received little research and policy attention. Yet, the preschool years are very important in children's development of food habits, tastes and preferences. Also, little was known about the quality of food and beverages served to younger children in child-care facilities. One question needed an answer: What were preschoolers in child care eating and drinking?
The proposal. Kenneth Hecht, L.L.B., co-founded California Food Policy Advocates in Oakland, Calif., in 1992. The statewide public policy and advocacy organization is dedicated to improving the health and well-being of low-income Californians by increasing their access to nutritious, affordable food.
By 2006, Hecht had noticed that many children entering kindergarten were already overweight or obese. “ "Most of the focus of obesity prevention had been in K–12 schools, but it seemed that the more important age to intervene would be before that," said Hecht. "Rather than targeting the population that already had the problems, we could make a greater impact by getting there before the problems occurred."
In California, almost 2 million children regularly spend time in child-care facilities, varying from as little as one hour to over 50 hours per week for each child. California Food Policy Advocates wanted to assess the quality of food and beverages served in licensed child-care facilities in California.
The project. Since 2006, California Food Policy Advocates has received multiple awards from the Robert Wood Johnson Foundation (RWJF) national program Healthy Eating Research that supports research on environmental and policy strategies with strong potential to promote healthy eating among children to prevent childhood obesity, especially among low-income and racial and ethnic populations, which are at the highest risk for obesity.
With a grant from the program (RWJF grant ID# 063053), from September 2007 through February 2009, Hecht and researchers at California Food Policy Advocates assessed the quality of food and beverages served in licensed child-care facilities. They worked on this project in collaboration with research partners—the University of California, Berkeley, Center for Weight and Health and Samuels & Associates. Samuels & Associates is a consulting firm specializing in public health evaluation, research, policy analysis and advocacy, also located in Oakland.
To find out what children ages 2 to 5 in child care in California were eating and drinking, the project team mailed surveys to approximately 1,400 randomly selected child-care centers in California based on type of child-care setting and participation or nonparticipation in the federal Child and Adult Care Food Program (CACFP), which provides reimbursement for meals and snacks served to nearly 3 million children in child-care centers, emergency shelters and after-school programs, as well as nearly 86,000 adults. The child-care settings were:
- Child-care centers
- Sponsored day-care homes
- Infant centers
- Preschool centers
- Head Start centers
- Even Start centers
- Outside-school-hours care centers
"We went in without knowing what we would find, what they were serving, who they were," said Hecht.
Key findings. Hecht noted these key findings from the Healthy Eating Research study in Nutrition and Physical Activity Environments in Licensed Child Care: A Statewide Assessment of California:
- The nutrition and quality of the foods and beverages served in child-care sites that participated in the Child and Adult Care Food Program were superior to the nutrition and quality in the facilities that did not participate in the program.
- The Head Start programs provided the most nutritious meals and beverages.
- The food and beverages that parents packed at home were the least nutritious.
- When it came to beverages, about one in five or 20 percent of child-care facilities served whole milk instead of the reduced-fat or skim milk recommend by standard guidelines. Some 28 percent of the facilities noted that they regularly served water at the table during meals and snacks, but one-third said they did not have water easily available for self-serve.
- Child-care facilities identified high cost as the greatest challenge to providing nutritious food.
With support from other funders, California Food Policy Advocates used the findings of this study to advocate for legislation to improve nutrition in all licensed child-care facilities. In 2010, California was one of two states in the country to enact legislation designed to help improve nutrition in early childhood programs; California AB [Assembly Bill] 2084 requires licensed child day-care facilities to:
- Serve only low-fat (1 percent) or nonfat milk to children two years of age or older
- Limit juice to not more than one serving per day of 100 percent juice
- Serve no beverages with added sweeteners, either natural or artificial, except for infant formula or complete balanced nutritional products designed for children.
The law also requires child-care facilities to make clean, safe drinking water readily available throughout the day.
The legislative result was "exciting, partly because there is very little legislation in the child-care arena," said Hecht. "This draws attention to even younger kids and says, 'If we don't intervene, we are going to have problems that are not likely to be reversed.' They make people think about obesity—not just about making the right choices but providing the environment where people can make the right choices."
Grantee perspective. With a law degree from Yale Law School, Hecht has spent his entire career in the legal and advocacy professions, first as a public interest attorney at San Francisco Neighborhood Legal Assistance Foundation and then as executive director of the San Francisco Legal Aid Society. In the early 1980s, Hecht also became interested in anti-hunger issues and started volunteering at the Haight Ashbury Food Program, a San Francisco-based program that provides meals and referral services to those in need.
After leaving Legal Aid to serve as associate director of the San Francisco Foundation from 1981 to 1984, Hecht then became an independent consultant to public and private nonprofit nutrition projects until 1992. While a consultant, he pursued a postdoctoral fellowship in health policy at Johns Hopkins School of Public Health in Baltimore from 1986 to 1988. At Hopkins, Hecht "developed an interest in hunger prevention, and later obesity prevention, as an effective response to unfairness in the allocation of resources and opportunities in the United States. Nothing is more basic or pervasive than nutrition," he said.
After starting California Food Policy Advocates in 1992, Hecht focused on two segments of federal nutrition and food programs:
- The Food Stamp program, recently renamed the Supplemental Nutrition Assistance Program or SNAP and called CalFresh in California.
- Federally funded child nutrition programs, including school lunch and breakfast programs, child-care meals, after-school snacks, summer foods and the WIC (Women, Infants and Children) program.
Over time, California Food Policy Advocates began to examine the quality of the nutrition in the programs. "As the obesity epidemic began to surface, it was not enough simply to advocate for increased access and expanded participation in the programs. We needed to be attentive to the nutritional quality of the foods and beverages offered in the programs and to make sure that they responded both to people who are not getting enough calories and to those who are getting too many of the wrong calories," said Hecht.
Advocacy, said Hecht, "is a very slow push. I have to believe that information produces the right results, gradually. Sooner or later, the right information will prevail."
Hecht is quick to add that advocacy without research would never result in legislative changes. "We could not do it without research," Hecht said. "The Healthy Eating Research projects that are coming out of RWJF are fabulous. I give enormous credit to Mary Story, who runs the program. She has helped to identify and support key research that turns into effective policy. It is marvelous."
Staff from California Food Policy Advocates, the University of California, Berkeley, Center for Weight and Health and Samuels & Associates are currently working on another Healthy Eating Research grant (RWJF grant ID# 068244) to explore how processing foods provided to schools for school lunches by the U.S. Department of Agriculture's Child Nutrition Commodity Program—for heat-and-serve use in the schools—impacts the cost and nutritional quality of meals served in K–12 schools.
RWJF perspective. The Healthy Eating Research program is part of RWJF's efforts to reverse the childhood obesity epidemic by 2015. The Foundation's efforts include improving access to affordable, healthy foods and increasing opportunities for physical activity in schools and communities across the nation.
"The Healthy Eating Research program provides decision-makers and key policy-makers with evidence they can use to improve children's nutrition and access to healthy foods," says C. Tracy Orleans, Ph.D., Robert Wood Johnson Foundation senior scientist.
"In collaboration with other national research funders, Healthy Eating Research is working to build solid evidence for action—with a focus on understanding and changing the policy and environmental drivers of the childhood obesity epidemic on the lower-income and racial and ethnic communities at highest risk. Our goals are to fund rigorous, solution-oriented studies, to build a diverse and robust network of researchers and to communicate findings effectively to inform policy action. Mary Story, Ph.D., R.D., has provided pioneering vision and leadership that are critical to the program's success and national progress towards reversing the childhood obesity epidemic."