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1
Introduction

The U.S. Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP) is a federally sponsored program designed to provide healthy meals and snacks to children and adults receiving day care at participating family day care homes, traditional child care centers, at-risk afterschool care facilities, outside school hours care facilities, adult care facilities, and emergency shelters. Figure 1-1 shows the relative proportion of different facilities that participate in CACFP. Participating sites receive federal reimbursement for the meals and snacks they serve if the CACFP standards are met. In fiscal year 2010, the program served more than 3 million children and 114,000 functionally impaired adults and other adults over the age of 60 years. The total costs for the program in 2010 were approximately $2.2 billion (USDA/FNS, 2010, Tables 11, 15c, and 15d).

CACFP plays a critical role in improving day care for children and elderly or disabled adults. The benefits of CACFP include the following:

  • Day care programs receive reimbursement for food served, which helps the programs to control their costs and offer more reasonable rates;

  • As a result, care is more affordable for those who need it—in many cases enabling the child’s or adult’s primary care provider to work outside the home;

  • CACFP regulations help ensure the nutritional quality and safety of the food served;



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1 Introduction The U.S. Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP) is a federally sponsored program designed to pro- vide healthy meals and snacks to children and adults receiving day care at participating family day care homes, traditional child care centers, at-risk afterschool care facilities, outside school hours care facilities, adult care facilities, and emergency shelters. Figure 1-1 shows the relative proportion of different facilities that participate in CACFP. Participating sites receive federal reimbursement for the meals and snacks they serve if the CACFP standards are met. In fiscal year 2010, the program served more than 3 million children and 114,000 functionally impaired adults and other adults over the age of 60 years. The total costs for the program in 2010 were approximately $2.2 billion (USDA/FNS, 2010, Tables 11, 15c, and 15d). CACFP plays a critical role in improving day care for children and elderly or disabled adults. The benefits of CACFP include the following: • Day care programs receive reimbursement for food served, which helps the programs to control their costs and offer more reason- able rates; • As a result, care is more affordable for those who need it—in many cases enabling the child’s or adult’s primary care provider to work outside the home; • CACFP regulations help ensure the nutritional quality and safety of the food served; 15

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16 CHILD AND ADULT CARE FOOD PROGRAM FIGURE 1 Percentage of various types of facilities participating in CACFP. SOURCE: USDA/FNS, 2009. F IG UR E 1-1 • CACFP helps make afterschool programs more appealing to at- risk youth by offering nutritious snacks1 in programs serving low- bitmapped income areas (USDA/FNS, 2000); and • Many CACFP participants also utilize other food programs; con- sistency in nutrition messages and nutritional benefits contribute to healthier outcomes for participants. THE COMMITTEE’S TASK Background This study is the latest of a series of Institute of Medicine (IOM) stud- ies that USDA has funded as a part of its multipronged effort to update regulations and guidance for several of its food programs. The updates are needed to bring the programs into better alignment with Dietary Guidelines for Americans (DGAs) (HHS/USDA, 2005) and with the nutrient reference standards called Dietary Reference Intakes (DRIs). In August 2008, the Food and Nutrition Service (FNS) of USDA asked the IOM’s Food and Nutrition Board to make recommendations for CACFP meal requirements. This study augments the work done by the IOM to provide recommenda- tions to revise the Nutrition Standards and Meal Requirements for the National School Lunch Program (NSLP) and the School Breakfast Program 1 Suppers also may be offered now in 14 states.

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17 INTRODUCTION (SBP), as covered in the report School Meals: Building Blocks for Healthy Children (IOM, 2010). Statement of Task Specifically, USDA requested that the IOM convene a panel of experts to • Review and assess the nutritional needs of the target populations based on the Dietary Guidelines for Americans and the Dietary Reference Intakes, and • Use that review as a basis for recommended revisions to the meal requirements for the Child and Adult Care Food Programs. As part of its task, the committee was asked to consider certain critical issues identified by the FNS of USDA (Appendix D). The committee’s goal was to develop well-conceived, practical, and economical recommendations that reflect current nutritional science; to increase the content of key food groups in the meals provided, as appropriate; and to allow the program to effectively meet the nutritional needs of the children and adults served. Approach to the Task To address its task, the committee reviewed published literature and other available evidence and drew information from public workshop pre- sentations (see Appendix C). In addition, the committee contracted for nutrient and cost analyses of data based on the National Health and Nutri- tion Examination Survey (NHANES) 2004–2005 and data collected from CACFP programs (Food Research and Action Center, Washington, DC, contributed by G. Henchy, February 23, 2010). The committee formulated a strategy to address the scope of work, conducted analyses, and deliber- ated on issues relevant to its charge. To guide its deliberations and evalu- ate possible recommendations, the committee developed a set of criteria, presented in Chapter 6. The process and findings are described in detail in Chapter 7. RATIONALE FOR REVISING THE MEAL REQUIREMENTS The three major reasons for revising the meal requirements for CACFP are to 1. Improve alignment with current dietary guidance; 2. Achieve satisfactory consistency with standards and regulations of

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18 CHILD AND ADULT CARE FOOD PROGRAM three other USDA nutrition programs (the Supplemental Nutrition Program for Women, Infants, and Children [WIC], the NSLP, and the SBP) and with recommendations for competitive foods offered or sold in schools proposed in the report Nutrition Standards for Foods in Schools (IOM, 2007); and 3. Address the high prevalence of [childhood] obesity and other health concerns that result from limited access to nutritious foods. These three topics are addressed on the following pages. Changes in Dietary Guidance The CACFP regulations were based in part on guidance in Diet and Health (NRC, 1989a) and on the 1989 Recommended Dietary Allow- ances (NRC, 1989b). Since the 1980s, many changes have been made in the three major sources of dietary guidance: (1) the Dietary Guidelines for Americans, source of federal nutrition policy; (2) the DRIs, intake recom- mendations that form the basis of U.S. dietary guidance; and (3) feeding recommendations from the American Academy of Pediatrics (AAP) for infants and children younger than 2 years of age. Dietary Guidelines for Americans Alignment with the Dietary Guidelines is essential because the guide- lines form the basis of U.S. federal nutrition policy. In particular P.L. 101- 445, Section 3 (7 U.S.C. 5341, the National Nutrition Monitoring and Related Research Act of 1990, Title III), directs the Secretaries of USDA and the Department of Health and Human Services (HHS) to issue jointly at least every 5 years a report entitled Dietary Guidelines for Americans. This law states that the DGA form the basis of federal food, nutrition edu- cation, and information programs. The most recent edition of the Dietary Guidelines was published in 2005 (HHS/USDA, 2005), and the release of the 2010 edition is expected in 2011. Compared with the 1985 Dietary Guidelines (HHS/USDA, 1985), which were in effect when CACFP regula- tions were established, the 2005 Dietary Guidelines are more quantitative and place stronger emphasis on the following: • adequate calories within energy needs; • controlling calorie intake to manage body weight; • daily physical activity; • increasing daily intake of fruits, vegetables, whole grains, and non- fat or low-fat milk and milk products;

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19 INTRODUCTION • choosing fats wisely for good health; • choosing carbohydrates wisely for good health; • choosing and preparing foods with little salt; • keeping alcohol intake moderate, if alcohol is consumed; and • keeping food safe to eat. Recommendations from the 2010 Dietary Guidelines Advisory Commit- tee (USDA/HHS, 2010) are similar to the above but include even stronger emphasis on weight management, limiting intake of foods that are high in solid fats and added sugars, and reducing salt (sodium) intake. Further information about the 2005 Dietary Guidelines is available at http://www. cnpp.usda.gov/DietaryGuidelines.htm (accessed December 31, 2009). De- tailed information about translating the Dietary Guidelines into meal pat- terns is provided by MyPyramid (HHS/USDA, 2005). Notably, both the Dietary Guidelines and MyPyramid apply to the general population ages 2 years and older but not to the younger children served by CACFP. Dietary Reference Intakes In 1994, the IOM developed a new paradigm for nutrient reference values that replaced the long established Recommended Dietary Allow- ances (RDAs) for the United States and the Recommended Nutrient Intakes (RNIs) for Canada. The new reference values, known as DRIs, differ from the RDAs and RNIs in several important ways. For example, the DRIs comprise a number of nutrient-based reference values, described in Chapter 3, that serve different purposes and are used in new ways. These reference values, along with descriptive text, are contained in six volumes published by the IOM between 1997 and 2005 (IOM, 1997, 1998, 2000, 2001, 2002/2005, 2005). American Academy of Pediatrics The American Academy of Pediatrics (AAP) Committee on Nutrition develops guidelines on the nutritional needs of infants, children, and ado- lescents. The AAP Committee works together with federal agencies includ- ing the HHS Food and Drug Administration, USDA, the HHS Centers for Disease Control and Prevention, the HHS National Institutes of Health, and the Canadian Paediatric Society to pursue advocacy opportunities that promote healthy dietary habits and provide technical assistance to facilitate relevant federal regulatory processes. The AAP Committee on Nutrition provides guidance on infant feeding, including breastfeeding, through its policy statements and its publication Pediatric Nutrition Handbook (AAP, 2009).

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20 CHILD AND ADULT CARE FOOD PROGRAM Consistency with Standards for WIC Food Packages and for Foods and Meals in Schools Recent changes in several types of standards related to USDA nutrition assistance programs have been made or proposed to align the standards with current dietary guidance. In particular, new standards have been developed for WIC, and the IOM has proposed standards for competitive foods offered or sold in schools (IOM, 2007) and for the two major school meal programs: the NSLP and the SBP (IOM, 2010). One of the intended outcomes of new recommendations for CACFP meal requirements is to achieve consistent nutrition messages across programs. Revised Regulations for WIC Food Packages New WIC regulations have revised the WIC food packages to supply a set of foods that should help reduce both inadequate and excessive nutri- ent intake and contribute to a dietary pattern consistent with the current Dietary Guidelines. The regulations are based largely on recommendations made in the IOM report WIC Food Packages: Time for a Change (IOM, 2006). The revised packages allow more flexibility in the selection of certain types of food and include changes designed to support and promote the breastfeeding of infants. Recommended Nutrition Standards for Foods in Schools The report Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth (IOM, 2007) presents IOM recommendations, us- ing a tiered approach, for nutrition standards for competitive foods offered or sold in schools. The standards were developed to encourage school-aged children and adolescents to consume foods and beverages that are healthful and to limit food components in competitive foods and beverages that are not healthful when consumed at levels that fall outside the current Dietary Guidelines. The proposed standards were developed for individual foods, not for meals. In addition, recommendations were made to limit the use of non-nutritive sweeteners and caffeine in foods offered in competition with school meal programs. Subsequent to the release of the IOM report, many school districts and several states have adopted new nutrition standards for competitive foods offered or sold in schools. Recommended Requirements for School Meals Currently, USDA is developing new meal requirements for the NSLP and SBP, using the IOM report School Meals: Building Blocks for Healthy

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21 INTRODUCTION Children (IOM, 2010) as a major resource. The recommendations con- tained in School Meals, like those in the above-mentioned IOM reports relating to WIC and foods offered or sold in schools, focus on providing standards that are aligned with the current Dietary Guidelines and the DRIs, but in this case the focus is on complete meals. Concern About Childhood Obesity As discussed in Chapter 4, the prevalence of childhood obesity is much higher than it was when the current regulations for CACFP were adopted. The availability of foods and beverages at home, in a care center, or in any other location affects the overall quality of a child’s diet and patterns of growth and weight gain. Thus, the type, nutritional quality, and amount of foods offered through CACFP are important factors that influence nu- tritional health. Over the past several years, considerable research has been conducted to evaluate the nutritional effects of the consumption of foods that are low in nutrients but high in energy content (often called low-nutrient, energy- dense foods). Two studies (Drewnowski and Specter, 2004; Miech et al., 2006) indicate that the consumption of low-nutrient, energy-dense foods and irregular meal consumption patterns are contributing factors to the high prevalence of childhood obesity. Another study examined the types and amounts of beverages consumed by preschool children (O’Connor et al., 2006). This study, based on NHANES 1999–2002 data, found that the average milk consumption for preschool children was less than amounts recommended by the Dietary Guidelines, and that increased consumption of all beverages, including fruit juice and other sweetened drinks and soda, was associated with increased energy intake. Clearly, it was important for the committee to consider the nutrient and energy content of foods and beverages in developing its recommendations for meal requirements and food specifications for CACFP. ORGANIZATION OF THE REPORT The report is organized into 11 chapters. This chapter briefly introduced CACFP and provided a description of the committee’s task and the ratio- nale for the study. Chapter 2 describes CACFP in more detail and provides an overview of how CACFP contributes to the food and nutrition safety net that is provided by USDA’s food assistance programs. Chapter 3 reviews and summarizes methods to examine food and nutrient intakes. Chapters 4 and 5 consider nutritional concerns for infants and children, and adults, respectively. Chapter 6 describes the process for developing recommenda- tions for meal requirements, and Chapter 7 presents the recommendations

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22 CHILD AND ADULT CARE FOOD PROGRAM for Meal Requirements. Chapter 8 contains an examination of cost implica- tions and market effects relevant to CACFP meal requirements. Chapter 9 discusses implementation, and Chapter 10 compares the recommendations to the committee’s working criteria. Chapter 11 presents recommendations for evaluation and future research. Additional material is provided in the appendixes. REFERENCES AAP (American Academy of Pediatrics). 2009. Pediatric Nutrition Handbook, 6th ed. Elk Grove Village, IL: AAP. Drewnowski, A., and S. E. Specter. 2004. Poverty and obesity: The role of energy density and energy costs. American Journal of Clinical Nutrition 79(1):6–16. HHS/USDA (U.S. Department of Health and Human Services/U.S. Department of Agricul- ture). 1985. Nutrition and Your Health: Dietary Guidelines for Americans, 2nd ed. Washington, DC: Government Printing Office. http://www.cnpp.usda.gov/Publications/ DietaryGuidelines/1985/DG1985pub.pdf (accessed June 29, 2010). HHS/USDA. 2005. Dietary Guidelines for Americans, 6th ed. Washington, DC: U.S. Gov- ernment Printing Office. http://www.health.gov/DietaryGuidelines/dga2005/document/ (accessed July 23, 2008). IOM (Institute of Medicine). 1997. Dietary Reference Intakes for Calcium, Phosphorus, Mag- nesium, Vitamin D, and Fluoride. Washington, DC: National Academy Press. IOM. 1998. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academy Press. IOM. 2000. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington, DC: National Academy Press. IOM. 2001. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academy Press. IOM. 2002/2005. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: The National Academies Press. IOM. 2005. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, DC: The National Academies Press. IOM. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Acad- emies Press. IOM. 2007. Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth. Washington, DC: The National Academies Press. IOM. 2010. School Meals: Building Blocks for Healthy Children. Washington, DC: The Na- tional Academies Press. Miech, R. A., S. K. Kumanyika, N. Stettler, B. G. Link, J. C. Phelan, and V. W. Chang. 2006. Trends in the association of poverty with overweight among US adolescents, 1971–2004. Journal of the American Medical Association 295(20):2385–2393. NRC (National Research Council). 1989a. Diet and Health: Implications for Reducing Chronic Disease Risk. Washington, DC: National Academy Press. NRC. 1989b. Recommended Dietary Allowances, 10th ed. Washington, DC: National Acad- emy Press. O’Connor, T. M., S. J. Yang, and T. A. Nicklas. 2006. Beverage intake among preschool chil- dren and its effect on weight status. Pediatrics 118(4):e1010–e1018.

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23 INTRODUCTION USDA/FNS (Food and Nutrition Service). 2000. Building for the Future in the Child and Adult Care Food Program (CACFP). http://www.fns.usda.gov/cnd/care/publications/ pdf/4Future.pdf (accessed June 29, 2010). USDA/FNS. 2010. Program Information Report (Key Data) U.S. Summary, FY 2009–FY 2010. http://www.fns.usda.gov/fns/key_data/july-2010.pdf (accessed October 19, 2010). USDA/HHS. 2010. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010. http://www.cnpp.usda.gov/DGAs2010-DGACReport. htm (accessed June 29, 2010).

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