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7
Recommendations for Meal Requirements

This chapter presents recommendations for revised Meal Requirements for the Child and Adult Care Food Program (CACFP). As structured by the committee, the revised Meal Requirements encompass two distinct elements: meal patterns and food specifications. This chapter begins with three Meal Requirement recommendations, which cover (1) recommended meal patterns for infants up to 1 year of age, (2) recommended meal patterns for children ages 1 year or older and adults, and (3) an option for an enhanced afternoon snack. Then the chapter provides detailed information about recommended meal patterns for the different age groups and the proposed food specifications.

RECOMMENDED MEAL REQUIREMENTS

In order to bring the Meal Requirements into alignment with the best available dietary guidance and to improve consistency with the requirements of other U.S. Department of Agriculture (USDA) food programs, the committee developed the following three recommendations for the Food and Nutrition Service of USDA. The meal pattern tables that are identified as part of the recommendations appear in the section “Recommended Meal and Snack Patterns” and the table of food specifications appears in the section “Food Specifications.”



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7 Recommendations for Meal Requirements This chapter presents recommendations for revised Meal Require- ments for the Child and Adult Care Food Program (CACFP). As struc- tured by the committee, the revised Meal Requirements encompass two distinct elements: meal patterns and food specifications. This chapter begins with three Meal Requirement recommendations, which cover (1) recommended meal patterns for infants up to 1 year of age, (2) rec- ommended meal patterns for children ages 1 year or older and adults, and (3) an option for an enhanced afternoon snack. Then the chapter provides detailed information about recommended meal patterns for the different age groups and the proposed food specifications. RECOMMENDED MEAL REQUIREMENTS In order to bring the Meal Requirements into alignment with the best available dietary guidance and to improve consistency with the require- ments of other U.S. Department of Agriculture (USDA) food programs, the committee developed the following three recommendations for the Food and Nutrition Service of USDA. The meal pattern tables that are identi- fied as part of the recommendations appear in the section “Recommended Meal and Snack Patterns” and the table of food specifications appears in the section “Food Specifications.” 113

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114 CHILD AND ADULT CARE FOOD PROGRAM Improve Nutritional Quality of CACFP Meals and Snacks over Time and in Alignment with Dietary Guidance Meal Requirement Recommendation 1: USDA should adopt the recom- mended Meal Requirements for healthy infants up to 1 year of age (shown in Tables 7-1 and 7-8). Key elements of this recommendation are • the provision of only breast milk or formula for infants under 6 months of age; • the gradual introduction of baby meats, cereals, fruits, and veg- etables beginning at age 6 months; and • the omission of fruit juice of any type before the age of 1 year. In addition, for infants 6–11 months of age, when solid foods are intro- duced, it is recommended to introduce meat as the preferred first solid food to help ensure an iron source for breastfed infants (AAP, 2009; Krebs et al., 2006). Practices that promote breastfeeding should be encouraged. Meal Requirement Recommendation 2: For all children age 1 year and older and for adults, USDA should adopt Meal Requirements that increase the variety of fruits and vegetables, increase the proportion of whole grains, and decrease the content of solid fats, added sugars, trans fats, and sodium (shown in Tables 7-2 through 7-8). Key elements of this recommendation follow: • One fruit and two vegetables are to be served at each lunch and supper meal. Over the course of a 5-day week, different types of vegetables are to be served at each lunch and supper, as follows: dark green vegetables at least twice per week, orange vegetables at least twice/week,1 legumes at least once/week, starchy vegetables no more than twice per week, and other vegetables at least three times per week. Appendix Table H-1 lists vegetables in each veg- etable subgroup. Serving sizes are tailored to the age group’s nu- tritional needs. • Fruit rather than fruit juice is to be served at most meals; unsweet- ened 100 percent juice is allowed only once per day in a serving size tailored to the age group’s needs. • Over the course of the week and day, at least half of the grains/ 1 The 2010 Report from the Dietary Guidelines Advisory Committee (available at: http:// www.cnpp.usda.gov/DGAs2010-DGACReport.htm [accessed February 10, 2011]) recom - mends that tomatoes be moved from the other vegetables group to a new group, red/or- ange vegetables. If incorporated into the Dietary Guidelines for Americans, this change will require a minor adjustment to the CACFP weekly vegetable servings to match the new recommendations.

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115 RECOMMENDATIONS FOR MEAL REQUIREMENTS breads served in meals and snacks must be whole grain-rich, meet- ing the definition given in the table of proposed food specifications (Table 7-8). Other grain/bread must be enriched. Providers are en- couraged to gradually increase the proportion of grain foods that are whole grain-rich to well above half of the grain foods and to include 100 percent whole grain foods often. • Each morning and afternoon snack will provide two different food components in a serving size tailored to the age group’s needs; over the course of a 5-day week, the food components provided will include two servings of fruit, one serving of an orange vegetable, one serving of a non-starchy vegetable, two servings of grain/bread, two servings of lean meat or meat alternate, and two servings of low-fat or nonfat milk. • The amounts of solid fats, added sugars, trans fats, and sodium are to be limited in all meals and snacks. For example, milk and yogurt must be low-fat or nonfat for those ages 2 years or older (whole milk for 1-year-old children), meats must be lean, fruits and juices must be free of added sugars, foods with nutritional labels must be labeled as containing zero grams of trans fat, and foods high in added sugars and/or sodium are to be served infrequently, if at all. Table 7-8 provides guidance. Incorporating these elements into the Meal Requirements will help ensure the nutritional quality of the meals over time and improve their alignment with the Dietary Guidelines. Each of the vegetable subgroups makes different nutrient contribu- tions. Compared with the common practice of offering only a few kinds of vegetables over the course of weeks, offering varied selections from the combination of vegetable subgroups each week improves the nutritional quality of the diet and alignment with current dietary guidance. The snack pattern also calls for variety to help ensure nutritional quality over time. Similarly, increased variety was a key component of the Institute of Medicine’s recommended revisions of the WIC Food Packages (IOM, 2006) and of the Dietary Guidelines. For adults, the recommended meal patterns are more consistent with guidance in the publication Nutrition Service Providers Guide for Older Adults (HHS/AoA, 2006). In addition, the U.S. Department of Health and Human Services (HHS) Administration on Aging (AoA) (2006), in its Nutrition Services Providers Guide for Older Adults, aligns menus for the Older Americans Nutrition Program (commonly called Meals On Wheels) with the Dietary Guidelines, separates fruits and veg- etables and increases their servings per meal, and recommends averaging menus over a week. It also requires computer analysis of the weekly menus

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116 CHILD AND ADULT CARE FOOD PROGRAM to assess nutrient content in relation to the Dietary Reference Intakes (DRIs) for older adults (HHS/AoA, 2006). Provide an Enhanced Snack Option for Adults and Children over 5 Years of Age Meal Requirement Recommendation 3: USDA should give CACFP pro- viders the option of serving one enhanced snack in the afternoon in place of a smaller snack in both the morning and the afternoon (shown in Table 7-6). The enhanced snack option would be particularly appropriate for at-risk children in afterschool programs and for older adults because their access to nutritious foods may be limited at home. The enhanced snack would have the same requirements as two of the smaller snacks. Provid- ers would specify in advance which snack option they were choosing and would serve the same type of snack to all participants in their care. The current CACFP monitoring and reimbursement structure would need to be modified to allow for this new option. RECOMMENDED MEAL AND SNACK PATTERNS The meal and snack patterns developed by the committee are essen- tial parts of the recommended Meal Requirements. The tables that are presented below show, by eating occasion and age group, the types and amounts of food components that are to be offered. Footnotes in the tables refer the reader to the proposed food specifications. Those specifications are key elements of the Meal Requirements and appear later in this chapter. Infants The recommended meal and snack patterns for infants, shown in Table 7-1, increase the consistency of CACFP infant meals with recommenda- tions made by the American Academy of Pediatrics (AAP) (see Table 3-1 in Chapter 3) and also with the Institute of Medicine’s recommended revisions for the Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages for infants (IOM, 2006). Children and Adults For children and adults, the recommended weekly meal and snack pat- terns covered below align CACFP meals and snacks with dietary guidance. For 1-year-old children, the patterns are aligned with recommendations from the AAP and the DRIs. For those ages 2 years and older, the patterns are consistent with the Dietary Guidelines and the DRIs. For all the age

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117 RECOMMENDATIONS FOR MEAL REQUIREMENTS TABLE 7-1 Recommended Daily Meal and Snack Patterns for Infants Meats, Vegetables, Fruits, and Breast Milk/ Infant Cereals Infant Formulaa (Complementary Foods)a,b Infant Age Meal 0–5 months All feedings 4–6 oz breast milk No solid foods or infant formula per feedingc 6–11 months Breakfast 6–8 oz breast milk 1–4 T meat, fish, poultry, or or formulac (meal 1) egg yolk OR 1–4 T infant cereald PLUS 1–2 T vegetable OR 1–2 T fruitd Lunch/supper 6–8 oz breast milk 1–4 T meat, fish, poultry or egg or formulac (meals 2 and 3) yolk OR 1–4 T infant cereald PLUS 1–2 T vegetable OR 1–2 T fruite Snack 2–4 oz breast milk 1–2 T vegetable or formulac OR 1–2 T fruite PLUS ½ slice of bread OR 2 crackers NOTES: Do not serve any type of milk, foods mixed with milk (such as milk with cereal, milk in mashed potatoes), or milk-based products (yogurt, milk, cottage cheese) until 1 year of age. Begin transitioning to cow milk at 1 year of age. oz 5 ounce; T 5 tablespoon. aSee Table 7-8 for food specifications. Specifications address topics such as the added ingre- dients that are allowed in the infant foods. bAt 6 months, introduce these foods one at a time, starting with meat or infant cereal, followed by vegetables, fruits, and bread or crackers in amounts and types that are develop- mentally appropriate. cAs prescribed. dAs prepared. eNo fruit juice for infants under 12 months of age. groups, the patterns were designed by (1) basing the amounts of foods in each of the five meal components on guidance provided by MyPyramid (USDA, 2009), (2) specifying a wide variety of vegetables, (3) requiring at least half of the grain foods to be in the form of whole grain-rich products, and (4) controlling calories. The patterns are similar to those recommended

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118 CHILD AND ADULT CARE FOOD PROGRAM by the Institute of Medicine for the National School Lunch Program and the School Breakfast Program (IOM, 2010). Patterns for meals and snacks are addressed separately below. Patterns for Meals The meal patterns below are expressed as both weekly and daily pat- terns. Weekly patterns are especially useful for specifying the variety of vegetables to be offered at lunch and the amounts of grains and lean meats or meat alternates to be offered at breakfast. Daily patterns make it clear what amounts of each food group are consistent from day to day. As stated in Chapter 9, USDA will need to arrange for the development and testing of methods for presenting the meal patterns in easy-to-use formats for pro- viders. Regardless of the manner in which they are expressed, they must incorporate the essential elements that are presented under Meal Require- ment Recommendation #2. Weekly patterns Table 7-2 shows the recommended 5-day weekly patterns for breakfast and lunch/supper by age group. Attention to the footnotes is TABLE 7-2 Recommended Patterns for Breakfast and Lunch/Supper Covering a 5-Day Week: Amountsa of Food by Meal, Age Group, Food Group, and Vegetable Subgroup Breakfast 1 2–4 5–13 Food Groupb (Measure) Year Years Years 14–18 Years Adults Fruit (c)c 1¼c 2½c 2½c 2½c 2½c Vegetable (c) 0 0 0 0 0 Dark green 0 0 0 0 0 Orange 0 0 0 0 0 Legumes 0 0 0 0 0 Starchy 0 0 0 0 0 Other 0 0 0 0 0 Grain/bread (oz eq)d 3½ 7 9½ 12 12 1½e 3e 3e 6e 3e Lean meat or meat alternate (oz eq) Milk (c) 2½ 2½ 3¾ 5 3¾ NOTE: c 5 cup; oz eq 5 ounce equivalent. aThese amounts of food are to be distributed over 5 days of menus. See Table 7-9 and Ap- pendix K for sample menus planned using these patterns. bSee Appendix Table H-1 for a listing of foods by MyPyramid food group and subgroup. See Table 7-8 for applicable food specifications to control calories, reduce sodium, and en- sure diet quality. Specifications address topics such as the type of milk, forms of fruit, and fat content of meats.

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119 RECOMMENDATIONS FOR MEAL REQUIREMENTS essential for planning meals that meet the Meal Requirements. For example, the table of food specifications (referred to by footnote b) makes it clear that all milk and yogurt for those ages 2 years or older must be low-fat or nonfat. Although healthy fats (e.g., vegetable oil, olive oil, soft margarine, may- onnaise, many salad dressings) are not listed as part of the meal patterns, moderate amounts are to be included daily. Healthy fats provide essential fatty acids and vitamin E, and they improve the palatability of meals and aid satiety. The table of food specifications (Table 7-8) lists healthy fats. Daily patterns Table 7-3 shows the recommended daily amounts of food to be offered at breakfast and lunch/supper, by age group. Footnotes e and f are especially important because they link the daily meal pattern to the weekly pattern. Patterns for Snacks Regular snacks Regular snacks are small snacks. Most programs provide two meals and one regular snack under CACFP, but programs currently have the option of being reimbursed for one meal and two regular snacks. Each of the recommended regular snacks would provide approximately cNon-starchy vegetables may be substituted for fruit at breakfast. Non-starchy vegetables in- clude all vegetables in Appendix Table H-1 except those listed in the starchy vegetable subgroup. dAt least half of the grain/bread must be whole grain-rich (see specifications in Table 7-8). Other grains must be enriched. eLean meat or meat alternates are to be served 3 days per week at breakfast for all age groups. On each of the days without meat or meat alternates, serve an additional ½ oz eq of bread/ grain for 1-year-old children and an additional 1 oz eq of bread/grain for all other age groups.

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120 CHILD AND ADULT CARE FOOD PROGRAM TABLE 7-3 Recommended Daily Meal Patterns for Breakfast and Lunch/ Supper: Amounts of Food by Age Group, Meal, and Food Groupa 1 2–4 14–18 Food Groupb (Measure) Year Years 5–13 Years Years Adults Breakfast Fruit or non-starchy vegetables (cup)c ¼ ½ ½ ½ ½ Grain/bread (oz eq)d ½ 1 1½ 2 2 AND Lean meat or meat alternate (oz eq)e ½ 1 1 2 1 OR Grain/bread (oz eq)d 1 2 2½ 3 3 AND Lean meat or meat alternate (oz eq)e 0 0 0 0 0 (Amounts of grain/bread and meat or meat alternate vary across the week. See footnote e.) Milk (cup) ½ ½ ¾ 1 ¾ Lunch/Supper Fruit (cup) ¼ ½ ½ ½ ½ Vegetable (cup)f ¼ ½ 1 1 1 Grain/bread (oz eq)d ½ 1 2 2½ 2 Lean meat or meat alternate (oz eq)e ½ 1 2 2½ 2 Milk (cup) ½ ½ 1 1 1 NOTE: oz eq 5 ounce equivalent; svgs 5 servings; wk 5 week. aSee Table 7-9 and Appendix K for sample menus planned using these patterns. bSee Appendix Table H-1 for a listing of foods by food group and subgroup. See Table 7-8 for applicable food specifications to control calories, reduce sodium, and ensure diet qual- ity. Specifications address topics such as the type of milk, forms of fruit, and fat content of meats. cNon-starchy vegetables include all vegetables in Appendix Table H-1 except those listed in the starchy vegetable subgroup. dAt least half of the grain/bread must be whole grain-rich. Other grain/bread must be enriched. eMeat/meat alternates should be served 3 days per week at breakfast for all age groups. On each of the days without meat or meat alternates, serve an additional ½ oz eq of bread/ grain for children age 1 year and an additional 1 oz eq of bread/grain for all other age groups. fThe number of cups indicated represents the total amount of vegetables served at lunch/ supper. Offer two different vegetables per meal. With reference to either lunch or supper (or both), serve dark green vegetables at least twice per week, orange vegetables at least twice per week, legumes at least once per week, starchy vegetables no more than twice per week, and other vegetables at least three times per week. See Appendix Table H-1 for listings of vegetables in each subgroup. (emphasis added) one-half as many calories as the lunch meal. Table 7-4 shows the weekly pattern for the regular snack, by age group. The following three steps provide guidance for using the regular snack pattern:

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121 RECOMMENDATIONS FOR MEAL REQUIREMENTS TABLE 7-4 Weekly Meal Pattern for Regular Snacks: Number of Servings from Each Food Group per Week and Amount per Serving, by Age Groupa 1 Year 2–4 Years 5–13 Years 14–18 Years Adults Groupb (Amount/Serving)c Food Number of Servings per Week Fruit 2 (½ c) 2 (½ c) 2 (½ c) 2 (1 c) 2 (1 c) Orange vegetabled 1 (1⁄8 c) 1 (¼ c) 1 (½ c) 1 (½ c) 1 (½ c) Non-starchy 1 (1⁄8 c) 1 (¼ c) 1 (½ c) 1 (1 c) 1 (½ c) vegetablee Grain/breadf 2 (½ oz eq) 2 (1 oz eq) 2 (1 oz eq) 2 (2 oz eq) 2 (1 oz eq) Lean meat or meat 2 (½ oz eq) 2 (1 oz eq) 2 (1 oz eq) 2 (1 oz eq) 2 (1 oz eq) alternate Milk 2 (½ c) 2 (½ c) 2 (½ c) 2 (½ c) 2 (½ c) NOTE: c 5 cup; oz eq 5 ounce equivalent. aSee Table 7-9 and Appendix K for sample regular snack menus that follow these patterns. bSee Appendix Table H-1 for a listing of foods by MyPyramid food group and subgroup. See Table 7-8 for applicable food specifications to control calories, reduce sodium, and ensure diet quality. Specifications address topics such as the type of milk, forms of fruit, and fat content of meats. cThe patterns for each age group show number of servings and amount per serving for either a morning or afternoon snack. If both morning and afternoon snacks are provided daily, the same pattern is to be used for each. Over the course of a 5-day week, a total of 10 servings would be offered for the morning snack and the same number for the afternoon snack (if both were provided); 2 servings would be offered for each daily snack. dSee Appendix Table H-1 for a list of orange vegetables. eNon-starchy vegetables include all vegetables in Appendix Table H-1 except those listed in the starchy vegetable subgroup. fAt least half of the grain/bread must be whole grain-rich (see specifications in Table 7-8). Other grains must be enriched. 1. Plan regular snacks for a 5-day week so that they meet the require- ments shown in Table 7-4 for the age group being served. 2. For all age groups, each daily snack will include two servings, but the size of the servings will vary. 3. Use a snack template to simplify the process of meeting the daily and weekly snack requirements. A sample template is shown in Table 7-5 for children ages 5–13 years. Templates for children ages 1 and 2–4 years and for adults could show the same pattern of meal components, but some of the serving sizes would differ. Note that this is just one example of a template for the children. The food groups could be distributed in different ways over the week, but it is essential to make sure that each daily regular snack includes two servings of the size specified for the age group in Table 7-4 and that the total amounts for each food group are served over the week.

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122 CHILD AND ADULT CARE FOOD PROGRAM TABLE 7-5 Regular Snack Menu Sample Templatea: Children 5–13 Years Food Group b,c Monday Tuesday Wednesday Thursday Friday juiced Fruit or fruit 0 ½ c juice ½ c fruit 0 0 Vegetable 0 ½ c orange 0 0 ½ c non- starchy vege veg Cereals/grains/ 1 oz eq 0 0 1 oz eq 0 breadsf refined whole grain grain Lean meat or meat 0 0 1 oz eq 0 1 oz eq alternate Low-fat or nonfat ½c 0 0 ½c 0 milk NOTES: c 5 cup; oz eq 5 ounce equivalent; veg 5 vegetable. aThis is only one possible distribution of how the meal components may be served across the day and week. bProvide water as a beverage. cSee Appendix Table H-1 for a listing of foods by MyPyramid food group and subgroup. See Table 7-8 for applicable food specifications to control calories, reduce sodium, and ensure diet quality. Specifications address topics such as the type of milk, forms of fruit, and fat content of meats. dJuice is an option only if it is 100 percent fruit juice and has not been served at another meal or snack because juice is limited to one serving per day. “Fruit” refers to fresh, frozen, canned, or dried choices that meet specifications (see Table 7-8). eNon-starchy vegetables include all vegetables in Appendix Table H-1 except those listed in the starchy vegetable subgroup. fAt least half of the grains served across the week should be whole grain-rich (see specifica- tions in Table 7-8). Other grains must be enriched. Enhanced snack In the recommended snack patterns for children, the committee included an option for participants ages 5 years and older. In reviewing the pattern of snacks commonly served to CACFP participants, it was clear that the afternoon snacks were much more common than morning snacks. Furthermore, compared with the time between lunch and supper, the period between breakfast and lunch is typically shorter. Thus, for children at least 5 years of age and adults, the recommendation is for providers to have the option of providing an enhanced snack that would be available only as an afternoon snack. The amounts of meal components in the enhanced snack, shown in Table 7-6, are twice the amounts in the regular snack. The committee does not recommend an enhanced snack option for children under 5 years of age because these children typically consume smaller meals and require relatively smaller snacks in both the morning and the afternoon.

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123 RECOMMENDATIONS FOR MEAL REQUIREMENTS TABLE 7-6 Weekly Pattern for Enhanced Snacks, by Age Group: Number of Servings from Each Food Group per Week and Amount per Serving, by Age Groupa 5–13 Years 14–18 Years Adults Groupb Number of Servings per Week (Amount/Serving)c Food Fruit 4 (½ c) 4 (1 c) 4 (1 c) Orange vegetabled 2 (½ c) 2 (½ c) 2 (½ c) Non-starchy vegetablee 2 (½ c) 2 (1 c) 2 (½ c) Grain/breadf 4 (1 oz eq) 4 (2 oz eq) 4 (1 oz eq) Lean meat or meat 4 (1 oz eq) 4 (1 oz eq) 4 (1 oz eq) alternate Low-fat or nonfat milk 4 (½ c) 4 (½ c) 4 (½ c) NOTE: c 5 cup; oz eq 5 ounce equivalent. aSee Table 7-9 and Appendix K for sample regular snack menus that follow these patterns. bSee Appendix Table H-1 for a listing of foods by MyPyramid food group and subgroup. See Table 7-8 for applicable food specifications to control calories, reduce sodium, and ensure diet quality. Specifications address topics such as the type of milk, forms of fruit, and fat content of meats. cThe patterns for each age group show number of servings and amount per serving covering a 5-day week. Over the course of the 5-day week, a total of 20 servings would be offered. Each enhanced snack includes 4 servings. For children ages 14–18 years, some of the serv- ing sizes are large, and it may be desirable to offer two items within the same food group to equal the specified amount. The committee urges consideration of the enhanced snack option for adults. dSee Appendix Table H-1 for a list of orange vegetables. eNon-starchy vegetables include all vegetables in Appendix Table H-1 except those listed in the starchy vegetable subgroup. fAt least half of the grain/bread must be whole grain-rich (see specifications in Table 7-8). Other grains must be enriched. The following three steps provide guidance for using the enhanced snack pattern: 1. Plan enhanced snacks for a 5-day week so that they meet the re- quirements shown in Table 7-6 for the age group being served. 2. For all age groups, each daily snack will include four servings. For children ages 14–18 years, some of the serving sizes are large, and it may be desirable to offer more than one food within the same food group. 3. Use a snack template to simplify the process of meeting the daily and weekly snack requirements. A sample template is shown for children ages 14–18 years in Table 7-7. Note that the template is an example only. The meal components could be distributed in

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126 CHILD AND ADULT CARE FOOD PROGRAM TABLE 7-8 Continued Participant Specificationsa Food Group Group 1. The product includes the following FDA-approved whole grain health claim on its packaging: “Diets rich in whole grain foods and other plant foods and low in total fat, saturated fat, and cholesterol may reduce the risk of heart disease and some cancers” (FDA, 2008). 2. Product ingredient listing lists whole grain first, specifically: a. Nonmixed dishes (e.g., breads, cereals): Whole grains must be the primary ingredient by weight. b. Mixed dishes (e.g., pizza, corn dogs): Whole grains must be the primary grain ingredient by weight (a whole grain is the first grain ingredient in the list). Whole grain ingredients are those specified in the HealthierUS School Challenge Whole Grain Resource guide (USDA/FNS, 2009) and include whole wheat flour, rye flour, brown rice, bulgur, hulled and de- hulled barley, quinoa, oatmeal, and popcorn, among others. (Popcorn is not to be served to young children because of its choking hazard.) For foods prepared by the CACFP provider, the recipe is used as the basis for a calculation to determine whether the total weight of whole grain ingredients exceeds the total weight of non-whole grain ingredients. Detailed instructions for this method appear in the HealthierUS School Challenge Whole Grains Resource guide (USDA/FNS, 2009). Breakfast Ready-to-eat cereals and hot cereals (instant-, quick-, cereals and regular-cooking forms), whether whole grain- rich or enriched [must conform to FDA standard of identity], must contain less than or equal to 21.2 g sucrose and other sugars per 100 g dry cereal (less than or equal to 6 g per dry oz of cereal, as specified in WIC Food Packages [IOM, 2006]). Other baked Children and Baked or fried grain products that are high in solid or fried adults fats and added sugars are limited to one serving per grain week across all eating occasions. Examples of grain products foods that are high in solid fats and added sugars and that are commonly served in CACFP include pancakes and waffles served with syrup, muffins and quick breads, sweet rolls, croissants, toaster pastries, donuts, flour tortillas, granola/cereal bars, cookies, brownies, cake, and pie.

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127 RECOMMENDATIONS FOR MEAL REQUIREMENTS Participant Specificationsa Food Group Group Milk and alternatives Milk Infants, 0–11 No milk products (e.g., yogurt, cheese) allowed months Children Whole milk only (age 1 y) Children Nonfat (skim) and low-fat (1%), no higher fat milks (age $ 2 y) and adults Children Nonfat flavored milk containing no more than 22 g of (age $ 5 y) sugar per 8 fl oz is allowed only for children age 5 and older in at-risk afterschool programsc and for and adults adults. Yogurt Children Yogurt must conform to the FDA’s Standard of Identity (age $ 2 y) (21 C.F.R. 131.200) and any updates of these and adults regulations; low-fat yogurt, (21 C.F.R. 131.203); nonfat yogurt, (21 C.F.R. 131.206); plain or flavored; fortified with vitamin D to be comparable to milk; # 17 g of total sugars per 100 g yogurt (40 g/8 oz serving). Yogurt may not contain more than 1% milk fat. May be used as an alternative to either milk or meat no more than once per day. Soy beverages Children and Soy beverage must meet the standards set in the USDA/ and other adults FNS Interim Rule for the Special Supplemental milk Nutrition Program for Women, Infants, and Children substitutes (WIC): Revisions in the WIC Food Packages and provide a minimum 8 g of protein, 100 IU for vitamin D and 500 IU for vitamin A, and 276 mg calcium per 8 oz (USDA/FNS, 2007). Low-fat or nonfat unflavored soy beverages for children at least 2 years of age and adults. Flavored soy beverage must be nonfat and may contain no more than 22 g of sugar per 8 fl oz. Other milk substitutes must be fortified as stated for soy beverage above. For children, requests for soy beverage and other milk substitutes must be processed consistent with USDA procedures. Meatd and meat alternates Red meats Children and Fresh or plain frozen lean beef, pork, lamb, venison, and poultry adults chicken, turkey, other poultry: broiled, roasted, braised, stewed, stir fried in mixed dishes with nonstick spray or vegetable oil. Remove skin from poultry before serving. Limit higher fat meats (e.g., hamburger with $ 20% fat, fatty pork). Fish Children and Fresh, frozen, or canned fish or seafood. No more adults than 6 oz (or for children, age-appropriate servings) of albacore tuna per week. Avoid serving shark, swordfish, tilefish, or king mackerel. Choose low- sodium water-pack canned fish. continued

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128 CHILD AND ADULT CARE FOOD PROGRAM TABLE 7-8 Continued Participant Specificationsa Food Group Group Highly Children and Limit highly processed meat, poultry, and fish (including processed adults highly salted products and breaded fried products) to red meat, one time per week across all eating occasions. poultry, and fish Eggs Children and If fried or scrambled, cook in vegetable oil or soft adults margarine rather than in solid fat. Cheese Children and Natural cheese. Low-fat cheese is encouraged. No adults processed cheese, cheese food, or cheese spread because of their higher sodium content and lower content of other nutrients. Tofu Children and May not contain added fats, oils, or sodium. adults Dried peas, Children and Dried or canned. Limit those prepared with added beans, adults solid fat and high sodium content, such as pork and lentil beans and most types of refried beans. Choose nonfat versions. Nuts, peanut Children (age Nut butters if they do not pose a choking hazard; no butter 1–3 y) nuts Children (age Nut butters and unsalted nuts of any type; preferably $ 3 y) and with no added salt or sugars; only if measures are adults taken to avoid choking hazard Yogurt Children and See entry under “Milk and alternatives” above. adults Healthy fats and oils Oils Children and Moderate amounts of unsaturated vegetable oils such adults as canola oil, corn oil, olive oil, peanut oil, safflower, sunflower oil Soft Children and Moderate amounts of soft vegetable oil table spreads, margarine adults labeled as containing zero grams of trans fat NOTES: CACFP 5 Child and Adult Care Food Program; FDA 5 Food and Drug Admin- istration; FNS 5 Food and Nutrition Service; g 5 grams; IU 5 International Units; mg 5 milligrams; mo 5 months; oz 5 ounce; USDA 5 U.S. Department of Agriculture; y 5 years. aNutrition labels on all foods must state that the content of trans fat is zero. Foods that pres- ent a choking hazard (e.g., whole grapes, raisins, hot dogs, raw carrots) are not to be offered to young children unless the form of the food has been changed to make it safe for them to eat. See Altkorn et al. (2008) for further information about foods that pose choking hazards. bThe meal patterns for children and adults stipulate that at least half the grains served must meet the whole grain-rich food specifications, and an even higher proportion of whole grain- rich grain products is encouraged. All refined grain foods must be enriched. c“At-risk afterschool programs” refers to programs offered by at-risk afterschool care cen- ters: public or private nonprofit organizations that are participating in CACFP as an institution or as a sponsored facility and that provide nonresidential child care to children after school through an approved afterschool care program located in an eligible area. dWeights specified for meat, poultry, and fish in meal patterns refer to edible portion as served.

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129 RECOMMENDATIONS FOR MEAL REQUIREMENTS mended Meal Requirements. Their purpose is to indicate the types of infant foods and foods from the five meal components that will help achieve nutri- tional quality. In general, the foods are low in solid fats and added sugars (or the frequency of use of such foods is limited). The foods are low in trans fat, the use of high-sodium foods is discouraged or limited, some cooking methods are given, and acceptable ingredients are indicated. The committee anticipates that states will develop materials that provide concrete guidance to providers for meeting the specifications. For reasons of practicality and to limit unfavorable unintended con- sequences, it may be beneficial for USDA to phase in selected aspects of the food specifications and to have processes in place to test the effects of specific restrictions and for strengthening some of the specifications. A few possibilities follow: • With regard to grain foods that are high in added sugars (a type of food that the Minute Menu Systems, LLC [2008] data showed was offered frequently), consider setting the initial limit to be two per week rather than one, but set a final date for achieving the goal of no more than once per week. • Determine how the restriction on flavored milk for young children affects their intake of milk and other foods. • As acceptable products that are high in whole grain content be- come more available and affordable, change the specifications for whole grain-rich foods (or increase their proportion in the meal and snack patterns). • As acceptable products that are lower in sodium become available, increase the specificity for foods with added sodium. TRANSLATING MEAL REQUIREMENTS INTO MENUS The committee’s recommended Meal Requirements comprise the meal patterns in Tables 7-1 through 7-4 and Table 7-6 together with the proposed food specifications in Table 7-8. Table 7-3 provides one possible method for showing how a daily meal pattern can accurately reflect the weekly pattern. The committee recognizes that tools will need to be developed and tested to simplify the process of translating the Meal Requirements into menus; and, as an example, it provided guidelines for planning snacks for the week, including sample templates (see “Patterns for Snacks” above). To illustrate the result of basing menus on the Meal Requirements, the committee wrote sample menus for breakfast, lunch/supper, and snacks for each age group by calorie level. Table 7-9 shows a 1-week set of sample menus for children ages 5–13 years, and Appendix K presents 2 weeks of sample menus for all the age groups. Although mixed dishes such as stew or gumbo could

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130 CHILD AND ADULT CARE FOOD PROGRAM TABLE 7-9 Sample Menu for Children Ages 5–13 Years Monday Tuesday Food Group Menu Item Amt Menu Item Amt Breakfast Fruit/juice Tangerine ½c Peaches ½c Cereal/grain/ bread Toasted oats cereal c Oatmeal ¾c 3⁄8 Additional grain English muffin ½ WW toast 1 slice Meat/meat LF Canadian alternatea bacon 1 oz –— –— Fluid milk Milk 6 oz Milk 6 oz Other items –— –— Soft margarine 1 tsp Lunch/Supper Pears ½c Honey dew ½c Fruit/juice melon Vegetable Mixed vegetables ½c Green beans ½c Additional Sweet vegetable potatoes ½c Cream corn ½c Cereal/grain/ WW elbow bread WW bun 1.8 oz pasta 1c Meat/meat Chicken Beef and pasta alternate burger 2 oz casserole (beef) 2 oz Fluid milk Milk 8 oz Milk 8 oz Light mayo Other items & ketchup 1 T each –— –— NOTE: Amt 5 amount; c 5 cup; LF 5 low-fat; oz 5 ounce; RF 5 reduced fat; T 5 table- spoon; tsp 5 teaspoon; WW 5 whole wheat. aThe committee encourages use of meat alternates whenever possible as an alternative to processed high-sodium meats. Examples could include scrambled egg, natural peanut butter, low-fat yogurt, or low-fat cheese. be included in menus, the committee named the food items so that readers could easily see how the menus correspond to the menu pattern. COMPARISON BETWEEN CURRENT AND RECOMMENDED MEAL REQUIREMENTS The recommended Meal Requirements continue to contain valuable features of the current meal requirements, such as focusing on food groups, specifying minimum amounts of foods to be provided at meals and snacks, and not allowing foods such as soft drinks and candy to qualify for reimbursement. On the other hand, they differ in many important

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131 RECOMMENDATIONS FOR MEAL REQUIREMENTS Wednesday Thursday Friday Menu Item Amt Menu Item Amt Menu Item Amt Breakfast Strawberries ½c Diced pears ½c Tropical fruit ½c LF flour Choice of tortilla 1.1 oz dry cereal 1 1⁄8 c WW pancakes 1.7 oz –— –— WW bagel ½ –— –— Egg ½ –— –— LF turkey sausage 1 oz Milk 6 oz Milk 6 oz Milk 6 oz –— –— RF cream cheese 1T Syrup 1T Lunch/Supper Watermelon ½c Pineapple ½c Fresh orange slices ½c tidbits Pinto beans ½c Broccoli ½c Carrots ½c Cabbage ½c Cauliflower ½c Spinach salad 1c Corn tortilla 1.8 oz Brown rice 1c WW noodles 1c Chicken LF Salisbury taco (chicken) 2 oz steak 2 oz Tuna patties 2 oz Milk 8 oz Milk 8 oz Milk 8 oz Salsa 2T Soft margarine 2 tsp FF ranch dressing 1T ways from those in the current regulations, as shown in Table 7-10. The revisions bring the recommended Meal Requirements in closer alignment with (1) current dietary guidance, (2) regulations for the new WIC food packages, (3) recommendations for competitive foods offered or sold in schools, and (4) recommendations concerning the Meal Require- ments for the National School Lunch Program and the School Breakfast Program.

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132 CHILD AND ADULT CARE FOOD PROGRAM TABLE 7-10 Comparison of Current and Recommended Meal Requirements Current Age Groups Requirements Recommended Requirements and Specifications Infants 0–3, 4–7, 8–11 mo 0–5, 6–11 mo Children Patterns for 3 age Patterns for 4 age groups spanning 1 to 19 years groups spanning 1 to 12 years, older children “may be served larger portions” Eating Occasion All Must meet daily Must meet daily and weekly pattern to provide pattern more flexibility and better alignment with the Dietary Guidelines Breakfast 3 meal components 4 or 5 meal components Lunch or 4 meal components 5 meal components supper Snack Any 2 of 4 Variety specified for the week components Choice between 2 small snacks or 1 enhanced snack Meal Component Fruit Fruits and vegetables Fruits are a separate category, and servings are are combined as a increased; juice is not provided for infants and category is limited for children; fruits containing added sugars are limited. Vegetable Vegetables are a separate category from fruit, and servings are increased; must provide variety including dark green leafy, bright yellow/orange, legumes; sodium content is limited; starchy vegetables are limited. Grain/bread Enriched or whole At least half must be whole grain-rich, grain, proportions additional whole grains are encouraged, grain not specified products high in SoFAS are limited to control calories and saturated fat, high-sodium grains are also limited. Meat/meat None at breakfast Included in weekly breakfast pattern three alternate times a week to provide balance to meal but flexibility through the week; some types are limited to help control calories, solid fat, and sodium. Milk Any type of fluid Must be nonfat or low-fat (1% fat) for children milk over 2 years of age and adults. Flavored milk must be nonfat and is allowed only for at-risk afterschool programsa and adults. For children over 2 years of age and adults, nonfat or low-fat yogurt may be used as a substitute for milk or as a meat alternate no more than once per day.

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133 RECOMMENDATIONS FOR MEAL REQUIREMENTS Food Component Energy No requirement Calories are controlled by limiting foods high in SoFAS. Micronutrients No standard specified Meal patterns are designed to achieve, for by regulation protein and most micronutrients, DRI targets consistent with a low prevalence of inadequacy. Fats No restriction Label must state zero trans fat (if applicable); food specifications limit highly processed and high-fat meats and foods Sodium No restriction No salt at the table; encouragement to prepare foods with less salt. Food specifications limit some sources of sodium. NOTES: DRI 5 Dietary Reference Intake; mo 5 months; SoFAS 5 solid fats and added sugars. a“At-risk afterschool programs” refers to programs offered by at-risk afterschool care centers: public or private nonprofit organizations that are participating in the CACFP as an institution or as a sponsored facility and that provide nonresidential child care to children after school through an approved afterschool care program located in an eligible area. Practical Considerations The recommendations for revised Meal Requirements were influ- enced by practical considerations relating to the CACFP setting. For example, portion sizes often needed to be rounded up or down to com- mon fractions of 1 cup; and, except for meat and grain at breakfast, the amount to be offered from each major food group at meals was made the same from day to day. Because the committee considers variety from the five vegetable subgroups to be a key element of the Meal Require- ments, however, the types of vegetables to be offered must vary from day to day. The committee recognizes that some participants follow a vegetarian meal pattern, and provisions for meat and milk alternates are thus included. Guidance for Encouraging Breastfeeding The committee recommends that CACFP providers encourage and support breastfeeding by providing mothers access to breastfeeding educa- tion opportunities (such as printed materials, on-line breastfeeding support programs, or pre-recorded audio/visual materials), encouragement to bring a supply of breast milk to the day care site, assurances that the milk will be handled safely, and the opportunity to come to the site to breastfeed the baby when possible. Providers need appropriate storage space for the milk and training in the safe handling and preparation of breast milk for feed-

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134 CHILD AND ADULT CARE FOOD PROGRAM ings. (Resources for safe handling of milk include ADA [2004] and CDC [2010].) As an additional measure to support breastfeeding, the recom- mended meal pattern for infants does not provide juice for participants less than 1 year of age or complementary foods before 6 months of age. The committee encourages USDA to work together with other federal agencies as well as state- and local-level coalitions of WIC lactation consultants, and existing breastfeeding programs to consider ways to provide incentives for breastfeeding for both participants and providers. Options for breastfeeding incentives are provided in Appendix L. SUMMARY The recommended Meal Requirements encompass (1) daily and weekly meal patterns for breakfast, lunch and supper, and snacks appropriate for the age groups served by CACFP and (2) food specifications to help ensure the nutritional quality of the meals. Key elements of the Meal Requirements for children ages 1 year and older and for adults address (a) the amount of fruit and the amount and type of vegetables to be served; (b) the propor- tion of grain that is to be whole grain-rich; (c) fruit versus juice; (d) snack components over the course of the week; and (e) limitations on solid fats, added sugars, trans fat, and sodium. As described in Chapter 6, the recom- mendations were designed to align with the Dietary Guidelines for Ameri- cans and the DRIs with necessary adjustments to keep them practical and to limit cost increases. Encouragement for breastfeeding is strongly supported by the committee. Realistic options for supporting breastfeeding, however, were determined to be beyond the task of making recommendations for revised Meal Requirements. REFERENCES AAP (American Academy of Pediatrics). 2009. Pediatric Nutrition Handbook, 6th ed. Elk Grove Village, IL: American Academy of Pediatrics. ADA (American Dietetic Association). 2004. Infant Feedings: Guidelines for Preparation of Formula and Breastmilk in Health Care Facilities, edited by S. T. Robbins and L. T. Beker. Chicago, IL: ADA. Altkorn, R., X. Chen, S. Milkovich, D. Stool, G. Rider, C. M. Bailey, A. Haas, K. H. Riding, S. M. Pransky, and J. S. Reilly. 2008. Fatal and non-fatal food injuries among chil- dren (aged 0–14 years). International Journal of Pediatric Otorhinolaryngology 72(7):1041–1046. CDC (Centers for Disease Control and Prevention). 2010. Proper Handling and Storage of Human Milk. http://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk. htm (accessed October 21, 2010).

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135 RECOMMENDATIONS FOR MEAL REQUIREMENTS FDA (Food and Drug Administration). 2008. XI. Appendix C: Health Claims: Guidance for In- dustry, A Food Labeling Guide. http://www.fda.gov/Food/GuidanceComplianceRegulatory I nformation/GuidanceDocuments/FoodLabelingNutrition/FoodLabelingGuide/ ucm064919.htm (accessed November 2, 2010). HHS/AoA (U.S. Department of Health and Human Service/Administration on Aging). 2006. Nutrition Service Providers Guide for Older Adults. Washington, DC: HHS/AoA. http:// www.health.gov/dietaryguidelines/dga2005/toolkit/default.htm (accessed October 11, 2010). IOM (Institute of Medicine). 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. IOM. 2010. School Meals: Building Blocks for Healthy Children. Washington, DC: The Na- tional Academies Press. Krebs, N. F., J. E. Westcott, N. Butler, C. Robinson, M. Bell, and K. M. Hambidge. 2006. Meat as a first complementary food for breastfed infants: Feasibility and impact on zinc intake and status. Journal of Pediatric Gastroenterology and Nutrition 42(2):207–214. Minute Menu Systems, LLC. 2008. Minute Menu Systems. http://www.minutemenu.com/web/ index.html (accessed August 27, 2010). USDA (U.S. Department of Agriculture). 2009. Inside the Pyramid. http://www.mypyramid. gov/pyramid/index.html (accessed October 19, 2010). USDA/FNS (U.S. Department of Agriculture/Food and Nutrition Service). 2007. Special Sup- plemental Nutrition Program for Women, Infants and Children (WIC): Revisions in the WIC Food Packages. Interim Rule. Federal Register 72(234):68966–69032. USDA/FNS. 2008. Food Buying Guide for Child Nutrition Programs. Alexandria, VA: USDA/ FNS. http://teamnutrition.usda.gov/Resources/foodbuyingguide.html (accessed Novem- ber 2, 2010). USDA/FNS. 2009. HealthierUS School Challenge Whole Grains Resource. http://www.fns. usda.gov/TN/HealthierUS/wholegrainresource.pdf (accessed May 14, 2009).

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