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11
Evaluation and Research Recommendations

The current meal requirements for Child and Adult Care Food Program (CACFP) participants have been in place since 1989. Implementing the recommendations for revisions to the CACFP meal requirements contained in this report would align the meals served with the Dietary Guidelines for Americans (HHS/USDA, 2005) and improve consistency with the food package provided by the U.S. Department of Agriculture (USDA) Supplemental Food Program for Women, Infants, and Children (WIC) (USDA/FNS, 2009) and with recommendations for school meals (IOM, 2010). A major change in the Meal Requirements in CACFP will have an impact on participants and program operators in a broad array of settings including child care centers and homes, adult care centers, emergency shelters, and afterschool programs. The following recommendations focus on a plan of ongoing evaluation, targeted research, and periodic reassessment to determine the magnitude of impact and identification of the need for future revisions in the Meal Requirements.

RECOMMENDATIONS FOR EVALUATION

Program Evaluation Recommendation 1: USDA, in collaboration with relevant agencies, should provide support for research to evaluate the impact of the Meal Requirements on participants’ total and program-related dietary intake and consumption patterns, on the food and nutrient content of the meals and snacks served, on demand from eligible providers to participate in CACFP, and on program access by participants. This evaluation would determine (a) the food and nutrient content of meals and snacks as



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11 Evaluation and Research Recommendations The current meal requirements for Child and Adult Care Food Program (CACFP) participants have been in place since 1989. Implementing the recommendations for revisions to the CACFP meal requirements contained in this report would align the meals served with the Dietary Guidelines for Americans (HHS/USDA, 2005) and improve consistency with the food package provided by the U.S. Department of Agriculture (USDA) Supple- mental Food Program for Women, Infants, and Children (WIC) (USDA/ FNS, 2009) and with recommendations for school meals (IOM, 2010). A major change in the Meal Requirements in CACFP will have an impact on participants and program operators in a broad array of settings including child care centers and homes, adult care centers, emergency shelters, and afterschool programs. The following recommendations focus on a plan of ongoing evaluation, targeted research, and periodic reassessment to de- termine the magnitude of impact and identification of the need for future revisions in the Meal Requirements. RECOMMENDATIONS FOR EVALUATION Program Evaluation Recommendation 1: USDA, in collaboration with relevant agencies, should provide support for research to evaluate the im- pact of the Meal Requirements on participants’ total and program-related dietary intake and consumption patterns, on the food and nutrient content of the meals and snacks served, on demand from eligible providers to par- ticipate in CACFP, and on program access by participants. This evaluation would determine (a) the food and nutrient content of meals and snacks as 183

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184 CHILD AND ADULT CARE FOOD PROGRAM served, (b) participant’s overall food and nutrient intakes as related to cur- rent dietary guidance, and (c) the number of providers and participants in the CACFP program. Program Evaluation Recommendation 2: USDA should take appropri- ate actions to establish the current baselines prior to implementation of the new Meal Requirements for comparison purposes. Collection of a nation- ally representative baseline database of foods actually served is crucial. It will also be important to collect information on significant factors that might influence the impact of CACFP, including the number and types of meals served by age and setting, variations in state licensing requirements, and differences in the cost of living. Comparing CACFP child care to non- CACFP child care in the same geographic location could also contribute to fully understanding the impact of CACFP. Program Evaluation Recommendation 3: To the extent possible, USDA should take steps to ensure that the final rule for the new Meal Require- ments is informed by the results of evaluation of program impact (described in Recommendation 1 above). It will be critically important to evaluate the extent to which implementation of the revised Meal Requirements achieves the goal of promoting health and improving participants’ diets by reducing the prevalence of inadequate and excessive intakes of foods, nutrients, and calories, and contributing to an overall diet consistent with established di- etary recommendations including the Dietary Guidelines for Americans. To gain a comprehensive understanding of this dynamic, the evaluation should determine the impact of the Meal Requirements on • participants’ total and program-related dietary intakes and con- sumption patterns, • the food and nutrient content of the meals and snacks served, • demand by child care and other eligible providers for the program, and • access to the program by eligible participants. Key Evaluation Components Evaluate Impact of Meal Requirements Evaluating the impact of the Meal Requirements on participant’s total and program-related dietary intakes and consumption patterns requires consideration of the following components: 1. Consistency with the Dietary Guidelines for Americans: • What changes have occurred in the consumption by CACFP participants, through CACFP meals and snacks and overall,

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185 EVALUATION AND RESEARCH RECOMMENDATIONS of key food groups encouraged by the Dietary Guidelines for Americans, but often underconsumed, including fruits and vegetables, low-fat/fat-free milk products, and whole grain-rich foods? • Do diets conform more closely to the Dietary Guidelines? • How do participant’s food group intakes compare with the daily dietary patterns recommended in the MyPyramid food guidance system? 2. Nutrient Intakes: • What may be the effect of the recommended Meal Require- ments on participant’s nutrient intakes, both from meals and snacks served in care/program settings and across the day? • Has the prevalence of inadequate or excessive nutrient intakes been improved? • Do the Meal Requirement age-range categories function effectively? • Were the desired mean (or range of) calorie intakes for each age group achieved? • How did the distribution of energy intake per kilogram of body weight change? 3. Participant Acceptance of Meals and Snacks: • Have the Meal Requirements allowed program operators to offer nutritious foods and beverages that are readily accept- able, widely available, commonly consumed, and appealing to participants of diverse cultural backgrounds? • What is the feedback from participants regarding the desir- ability of the meals and snacks offered under the new Meal Requirements? • Have the Meal Requirements changed the percentage of plate waste overall and for foods commonly underconsumed relative to the Dietary Guidelines for Americans? Evaluating the impact of the Meal Requirements on the food and nu- trient content of the meals and snacks served requires consideration of the following components: 4. Food and Nutrient Content: • Do the meals and snacks served meet the Meal Requirements and the corresponding Target Median Intakes specified in this report? • Are the meals and snacks served in CACFP consistent with the Dietary Guidelines for Americans and the Dietary Reference Intakes?

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186 CHILD AND ADULT CARE FOOD PROGRAM • What changes have occurred in the availability, through CACFP meals and snacks, of key food groups encouraged by the Di- etary Guidelines for Americans but often underconsumed, in- cluding fruits and vegetables, low-fat/fat-free milk products, and whole grains? • How do the foods offered in CACFP meals and snacks com- pare with the dietary patterns recommended in the MyPyramid food guidance system? • What are the barriers and facilitators to providing meals and snacks to participants that meet the recommended Meal Requirements? 5. Food Procurement, Preparation, and Service Patterns: • Have the Meal Requirements been compatible with the devel- opment of menus that are practical to prepare and serve in a variety of different settings? If not, what aspect(s) of the Meal Requirements is/are incompatible, in what settings, and what adjustments are needed to address the issues identified? • Are the Meal Requirement age-range categories practical for program meal service operations? • What skills and technology do program operators need to op- erate within the new Meal Requirements effectively? • How do the changes in the Meal Requirements affect the time required by state agencies and sponsoring organizations moni- toring institutions and facilities? • Is the expanded variety of recommended foods available in food markets accessed by providers? Evaluating the impact of the Meal Requirements on the demand from eligible providers to participate in CACFP and on access by eligible partici- pants requires consideration of the following components: 6. Demand: • Have the new Meal Requirements affected the demand for CACFP by program operators in child care and other settings? • What are the program operators’ perceptions of participating in the program under the new Meal Requirements? Has this changed over time? Has this impacted word-of-mouth program endorsements? • Have the trends for CACFP participation rates of child care centers and homes, adult care centers, emergency shelters, and afterschool programs changed at the national, regional, and/ or state level?

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187 EVALUATION AND RESEARCH RECOMMENDATIONS • Have the trends in the number of participants (children, teens, and/ or elderly) overall and specifically in child care centers and homes, adult care centers, emergency shelters, and afterschool programs changed at the national, regional, and/or state level? Have the saturation rates for these programs changed over time? • Has the relative distribution of meal types changed within the range of program settings at the national, regional, and/ or state level? 7. Factors Potentially Influencing Demand: • How well have the projected costs compared to the actual costs of the recommended Meal Requirements, and how do costs vary by geographic location and setting? • What is the impact of the Meal Requirements on the reim- bursement levels? • Does CACFP align with other USDA Child Nutrition and WIC programs, allowing a smooth interface for program operators and a consistent nutrition message for program participants and their families? RECOMMENDATIONS FOR RESEARCH Targeted Research Research Recommendation 1: USDA, in collaboration with relevant agencies and foundations, should support research on topics related to the implementation of the Meal Requirements and to fill important gaps in knowledge of the role of CACFP in meeting the nutritional needs of pro- gram participants. This targeted research should including the following: • What are the best ways to maximize the value of the new Meal Requirements in providing good nutrition for children and adults in the various CACFP settings? How can meal-time environmen- tal factors be used in CACFP child care settings to help facilitate healthy eating? What are the best practices to educate and engage staff, par- ents, guardians, and caregivers to fully support the new Meal Requirements? How can CACFP play a more effective role in encouraging and supporting breastfeeding? • How do environmental disparities in access to healthy food at af- fordable prices affect both demand for CACFP and the ability of program operators to meet CACFP Meal Requirements? Does this affect the types and quality of foods offered through CACFP meals and snacks in food deserts?

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188 CHILD AND ADULT CARE FOOD PROGRAM Can CACFP participation under the new Meal Requirements increase the availability of affordable healthy foods in the gro- cery stores in a neighborhood? • How does participation in CACFP under the new Meal Require- ments affect children and adult weight status, including the dynam- ics of obesity and its consequences; food insecurity, including the consequences of chronic food insecurity the connection between hunger and obesity; children’s dietary intake and diet quality, in- cluding program impacts on household food expenditures, food purchases, food choices, and nutrient intake; and the trade-offs in balancing work, child care, and food preparation? • What nutrition and dietary guidelines are needed for infants and young children? How can the Dietary Guidelines be extended to a coordinated set of recommendations for infants and young children? Periodic Reassessment A revision of the Dietary Guidelines for Americans is expected to be released in 2011, and further revisions of the Dietary Guidelines are ex- pected at periodic intervals thereafter. Similarly, the DRIs for vitamin D and calcium currently are under review, and changes in the DRIs for various other nutrients may be published in the future. Furthermore, the American Academy of Pediatrics periodically updates its recommendations for infants and children. To keep the Meal Requirements aligned with these sources of dietary guidance, periodic review is necessary, followed by revisions if needed. The recent release of the report of the 2010 Dietary Guidelines Advisory Committee (USDA/HHS, 2010) provides an opportunity to sug- gest types of revision that might be needed. The committee’s reading of the advisory committee’s preliminary report revealed a few proposed changes in dietary guidance that might affect the Meal Requirements. Most notably, that report presents a somewhat dif- ferent set of vegetable subgroups, with changes in weekly recommended amounts of some subgroups. If adopted as policy, the change would call for the Meal Requirements to adopt the vegetable subgroup revisions and to make small adjustments in the recommended number of servings of vegetable subgroups over the week. The advisory committee’s proposed lowering of the values for maximum sodium and saturated fat intakes, if adopted, might eventually call for somewhat stricter food specifications. Research Recommendation 2: USDA should review and update, as appropriate, the CACFP Meal Requirements to maintain consistency with the Dietary Guidelines and other relevant science. Periodic reassessment

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189 EVALUATION AND RESEARCH RECOMMENDATIONS of the program meal requirements should be undertaken to ensure that the meals and snacks served • Are consistent with the goals of the most recent Dietary Guidelines for Americans and • Promote the health of the population served by the program as indicated by the most recent relevant nutrition science. This process should include a review of costs to program operators resulting from updated requirements for meals and snacks served under the program. SUMMARY The effect of the recommended Meal Requirements for CACFP should be examined through an initial short-term evaluation as well as through ongoing periodic evaluations. Targeted research is needed to fill important gaps in our knowledge of the nutritional needs of CACFP recipients. Peri- odic reassessment of the Meal Requirements is needed to ensure consistency with the latest dietary guidance. Funding will be needed to support these research and evaluation activities. REFERENCES HHS/USDA (U.S. Department of Health and Human Services/U.S. Department of Agriculture). 2005. Dietary Guidelines for Americans, 6th ed. Washington, DC: U.S. Government Printing Office. http://www.health.gov/DietaryGuidelines/dga2005/document/ (accessed July 23, 2008). IOM (Institute of Medicine). 2010. School Meals: Building Blocks for Healthy Children. Washington, DC: The National Academies Press. USDA/FNS (U.S. Department of Agriculture/Food and Nutrition Service). 2009. Women, Infants, and Children. http://www.fns.usda.gov/wic/ (accessed March 24, 2010). USDA/HHS (U.S. Department of Agriculture/U.S. Department of Health and Human Services). 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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