The following is a statement from Risa Lavizzo-Mourey, MD, president and CEO of the Robert Wood Johnson Foundation, to the Child Nutrition Programs of the Food and Nutrition Service, U.S. Department of Agriculture. It responds to the Child and Adult Care Food Program: Meal Pattern Revisions Related to the Healthy, Hunger-Free Kids Act of 2010.
The Robert Wood Johnson Foundation (RWJF) commends the U.S. Department of Agriculture (USDA) for updating the meal pattern and nutrition standards for the Child and Adult Care Food Program (CACFP).
This proposal represents the first major revisions to the CACFP meal patterns since the program was created in 1968 and reflects the interest in, and support for, promoting healthy habits at an early age, as well as the science-based recommendations put forth by the Institute of Medicine (IOM).[i]
Roughly three-quarters of children ages 2 to 5 spend time in some form of child-care arrangement such as child-care centers and family child-care homes, preschools, Head Start programs, and pre-kindergarten programs. These settings offer important opportunities to promote healthy eating at a young age, given that children consume a significant portion of their daily calories and spend many of their waking hours in such settings. Taste preferences and dietary habits are also formed early in life, making these settings and this developmental period critical in establishing healthy practices at an early age.
Earlier this year, RWJF committed $500 million over the next 10 years to expand our efforts to help all children grow up at a healthy weight. Building on a commitment we made in 2007, we will have dedicated more than $1 billion toward reversing the childhood obesity epidemic. We doubled our commitment because we are heartened by the progress this country has made in recent years, but we know there is a lot more to be done.
In recent years, the national childhood obesity rate has leveled off. The rate among children ages 2 to 5 may be decreasing,[ii] and 18 states and the U.S. Virgin Islands have recorded declines among preschool children from low-income families.[iii] But more than one in five children ages 2 to 5 in the United States remains overweight or obese, and significant racial, ethnic, and economic disparities persist. Young children starting out life with an unhealthy body weight face a higher risk for chronic disease, bone and joint problems, sleep apnea, and social and psychological problems such as stigmatization and poor self-esteem.[iv]
We must help kids get on the right path from the very start. One of RWJF’s priorities is to ensure that by 2025 all children enter kindergarten at a healthy weight. We know that children who start off at a healthy weight are more likely to maintain a healthy weight into adolescence and adulthood. Part of that effort will mean working more closely with preschools and child care providers to provide young children with healthy foods and drinks, and make sure they take part in active play, every day.
CACFP serves more than 3.3 million young children every day, so updating the meal patterns is essential to our goal. Healthier meals and snacks for our youngest children can help us build a national Culture of Health, one which ensures that all children, no matter who they are or where they live, can grow up at a healthy weight.
To ensure young children get the full value from the proposed changes, RWJF respectfully offers the following comments as the agency proceeds toward developing final regulations.
Proposed Changes to the Infant Meal Plan
Age Groups, Breastfeeding
RWJF supports the intention to alter the existing three infant age groups (0 to 3 months; 4 to 7 months; 8 to 11 months) to two groups (0 to 5 months; 6 to 11 months) as these ranges align with recommendations by the American Academy of Pediatrics (AAP) and are consistent with the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). AAP guidelines encourage mothers to breastfeed or formula feed infants through five months of age and introduce solids at six months of age as breastfeeding may serve as a protective agent against obesity later in life and should be encouraged and accommodated.[v] Additionally, we support the proposal to allow reimbursement of the meal component when a mother breastfeeds her child onsite.
Fruits and Vegetables
RWJF supports USDA’s proposal to require a fruit or vegetable serving in the snack meal pattern for the 6- through 11-month age group and eliminate fruit juice from the meal pattern for infants. Given that most children and adolescents consume more fruit juice and starchy vegetables and less whole fruit and dark green and orange vegetables and legumes than recommended, the proposed changes will help set the stage for greater acceptance of these healthy foods down the road.[vi]
Proposed Changes to the Meal Pattern for Children and Adults
Fruits and Vegetables
RWJF supports the proposal separating the current fruit and vegetable component into two components for lunch and supper meals and snacks. This change is consistent with the Dietary Guidelines for Americans and updated standards to the National School Lunch Program (NSLP) and allows child care providers more flexibility to offer a greater variety of fruits and vegetables at meals and snacks.
Juice
RWJF does not support allowing fruit or vegetable juice to comprise the entire fruit or vegetable component for all meals and snacks. Juice intake has increased overall among children 5 years and younger compared to three decades ago,[vii] with the largest increases among Latino and African American children.[viii] Evidence suggests that fruit juice is the top contributor to children’s excessive beverage calories.[ix]
If fruit or vegetable juice is creditable as an entire fruit or vegetable meal component, we recommend USDA limit reimbursement of 100 percent juice (no sugar added) to once a day in age-appropriate portion sizes. A panel of experts convened by Healthy Eating Research, a national program of the Robert Wood Johnson Foundation, recommended that if juice were provided to preschool and school-aged children, portion size should be limited to 0-4 ounces of 100 percent juice for children 2-4 years old, 0-6 ounces for children 5-10 years old, and 0-8 ounces for children 11-18 years old.[x]
Grains
We support the requirement to have at least one serving of whole grain-rich products per day across all eating occasions. This is consistent with the direction of the updated school meal patterns and Smart Snacks. We also applaud USDA for removing grain-based desserts as a reimbursable component, since these desserts are the top source of calories among children ages 2 through 18; moreover, about 13 percent of their total calories come from added sugars.[xi] Lastly, we support the proposal to align breakfast cereals with WIC cereal standards.
Milk and Yogurt
We support USDA’s proposal to require only unflavored whole milk for children 1 year of age, consistent with the most recent recommendations of the AAP and the IOM. We also support the requirements that only low-fat or fat-free milk be served to children 2 years of age and older and adults. In response to USDA’s request for input on flavored milk and yogurt, we recommend that any flavored milk should be required to be fat free, but USDA should prohibit the serving of flavored milk to children five and under in child care settings. For children in school who are 5 years and older, we recommend limiting sugar content of flavored milk to no more than 22 grams per 8 fluid ounces as part of the CACFP meal pattern requirement. Five-year-olds could be represented in either setting, depending on when they enter kindergarten. If mixed age groups are together in the same facility, we recommend the stronger standard be followed. These comments reflect the Healthier Beverage Recommendations noted earlier.[xii]
Regarding sugar content in yogurt, RWJF recommends that USDA require that yogurt available through CACFP meet a lower sugar standard – 23 grams of sugar per 6 ounces versus the 30 grams suggested by USDA. A 23 gram standard is consistent with where a number of large yogurt producers are heading. For example, Dannon has committed to reduce the amount of total sugar in 100 percent of their children’s products to 23 grams or less per 6 ounce serving by 2016.[xiii] Many yogurts on the market today meet the 23 grams per 6 ounce standard and by the time these CACFP updates are implemented, there will likely be many yogurt options available across the country that meet that standard.
Sugar-Sweetened Beverages
USDA should prohibit CACFP participants from serving sugar-sweetened beverages, such as juice drinks, sodas, and sports drinks to children ages 0 to 5 years, since consumption of sugar-sweetened beverages is associated with weight gain.[xiv] Sugary drinks have no place in toddlers’ diets, and RWJF has set a goal of eliminating the consumption of sugar-sweetened beverages among children younger than 5. Many states already require that healthier drinks, such as water, replace sugar-sweetened beverages in child-care settings, so this should be an achievable standard.[xv], [xvi]
Water
We support the proposal on the availability of water as it aligns with requirements for the school meals programs.
Prohibition on Using Food as a Reward or Punishment
We support USDA in prohibiting the use of food as a punishment or reward and recommend that this prohibition extend to physical activity as well. Given high rates of obesity and chronic diseases, we should not take away children’s opportunities to be physically active.
Best Practices
In response to the request for suggestions for implementing best practices, we recommend USDA create CACFP model wellness policies and a USDA recognition program (similar to HealthierUS School Challenge) that features best practices with respect to child care-wide policies, such as eliminating sugary beverages. Research on school wellness policies at the state and district level from Bridging the Gap, a nationally recognized research program supported by RWJF, found that schools in states and districts with strong wellness policies had healthier school environments.[xvii] Lessons learned from wellness policy implementation in schools should be considered as initiatives are expanded in the early care and education setting.
Summary
RWJF commends USDA for proposing much needed updates to CACFP meal patterns and nutrition standards. Once implemented, these updates will help our collective efforts to reverse the childhood obesity epidemic, and take us one step closer to creating a Culture of Health for every child in our nation. We appreciate the opportunity to comment on this proposal and encourage USDA to finalize the rule and begin full implementation in a timely manner.
Notes
[i] Institute of Medicine. 2010. Child and Adult Care Food Program: Aligning Dietary Guidance for All. Accessed April 6, 2015.
[ii] Ogden Cynthia, Carroll Margaret, Kit Brian, et al. 2014. “Prevalence of Childhood and Adult Obesity in the United States, 2011-2012.” JAMA. 311(8): 806-14.
[iii] Centers for Disease Control and Prevention. 2013. “Vital Signs: Obesity Among Low-Income, Preschool-Aged Children — United States, 2008–2011.” Morbidity and Mortality Weekly Report. 62(31);629-634.
[iv] Centers for Disease Control and Prevention. Childhood Obesity Facts. Accessed March 16, 2015. www.cdc.gov/HealthyYouth/obesity/facts.htm.
[v]Horta Bernardo, Victora Cesar. World Health Organization. 2013. “Long-term Effects of Breastfeeding: A Systematic Review.” Accessed April 6, 2015. http://apps.who.int/iris/bitstream/10665/79198/1/9789241505307_eng.pdf.
[vi] U.S. Department of Agriculture and U.S. Department of Health and Human Services. December 2010. Dietary Guidelines for Americans, 2010. 7 Edition, Washington: GPO.
[vii] Fulgoni Victor, Quann Erin. 2012. “National Trends in Beverage Consumption in Children From Birth to 5 Years: Analysis of NHANES Across Three Decades.” Nutrition Journal. 11(92).
[viii] Beck Amy, Patel Anisha, Madsen Kristine. 2013. “Trends in Sugar-Sweetened Beverage and 100% Fruit Juice Consumption Among California Children.” Academic Pediatrics. 13(4): 364-70.
[ix] Rader Ryan, Mullen Kathy, Sterkel Randall, et al. 2014. “Opportunities to Reduce Children’s Excessive Consumption of Calories from Beverages.” Clinical Pediatrics. 53(11): 1047-54.
[x] Healthy Eating Research. 2013. Recommendations for Healthier Beverages. Accessed April 6, 2015. www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf404852
[xi] Dietary Guidelines for Americans 2010.
[xii] Recommendations for Healthier Beverages.
[xiii] Dannon. 2014. “The Dannon Company Commits To Further Improve Nutrition Profile Of Its Yogurt With Partnership For A Healthier America.” Accessed April 6, 2015. www.dannon.com/partnership-for-healthy-america/.
[xiv] De Ruyter Janne, Olthof Margreet, Seidell Jacob, et al. 2012. “A Trial of Sugar-Free or Sugar-Sweetened Beverages and Body Weight in Children.” New England Journal of Medicine. 367: 1397-406.
[xv] Office of Child Care National Center on Child Care Quality Improvement. 2012. State Child Care Licensing Requirements to Promote Healthy Weight. Accessed March 30, 2015.
[xvi] Child Care Centers – Healthy Eating and Physical Activity Act, Maryland House Bill 1276. 2014.
[xvii] Taber, Daniel, Chriqui, Jamie, Perna, Frank, et al. “Weight Status Among Adolescents in States that Govern Competitive Food Nutrition Content.” Pediatrics 130(3): 437-44.