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D
Critical Issues for Consideration by the Committee to Review Child and Adult Care Food Program Meal Requirements, as Submitted by the U.S. Department of Agriculture1

There are a number of important issues on which USDA seeks recommendations. In the descriptions below, we have raised a number of questions and concerns, as well as tentative policy concepts for IOM’s critical review. These issues are intended to clarify the scope of the committee’s charge, but not to constrain or pre-determine its recommendations. When making recommendations in each of these areas, we also ask the committee to consider the varied operational factors of meal service in small group settings, impacts on participants’ acceptability of meals and the decision of child care providers to participate in the program.

Nutrition goals in the CACFP:

The purpose of the CACFP is to assist child and adult care institutions in providing nutritious meals to their enrolled participants. Unlike the National School Lunch Program (NSLP)/School Breakfast Program (SBP), there is no legislative or regulatory requirement that meals served in CACFP meet specific Recommended Dietary Allowance or Dietary Reference Intake levels. Instead, the program uses a food-based menu planning approach, which establishes minimum portions of food components according to the meal type (i.e. breakfast, lunch, or snack) and as appropriate for the age of the participant being served. Maintaining a simple, food-based menu planning approach is critical in CACFP. A significant portion of the meals are provided in small group settings, often in a residential home, by child

1

Provided by USDA to the committee.



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D Critical Issues for Consideration by the Committee to Review Child and Adult Care Food Program Meal Requirements, as Submitted by the U.S. Department of Agriculture1 There are a number of important issues on which USDA seeks recommen- dations. In the descriptions below, we have raised a number of questions and concerns, as well as tentative policy concepts for IOM’s critical review. These issues are intended to clarify the scope of the committee’s charge, but not to constrain or pre-determine its recommendations. When making recommendations in each of these areas, we also ask the committee to con- sider the varied operational factors of meal service in small group settings, impacts on participants’ acceptability of meals and the decision of child care providers to participate in the program. Nutrition goals in the CACFP: The purpose of the CACFP is to assist child and adult care institutions in providing nutritious meals to their enrolled participants. Unlike the National School Lunch Program (NSLP)/School Breakfast Program (SBP), there is no legislative or regulatory requirement that meals served in CACFP meet specific Recommended Dietary Allowance or Dietary Reference Intake levels. Instead, the program uses a food-based menu planning approach, which establishes minimum portions of food components according to the meal type (i.e. breakfast, lunch, or snack) and as appropriate for the age of the participant being served. Maintaining a simple, food-based menu planning approach is critical in CACFP. A significant portion of the meals are provided in small group settings, often in a residential home, by child 1 Provided by USDA to the committee. 207

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208 CHILD AND ADULT CARE FOOD PROGRAM care providers lacking the support or expertise to implement a more com- plicated, nutrient-based system. However, FNS would like the IOM committee to provide recommendations for nutrient goals or targets for each meal type and age group served. Nutri- ent content goals would include minimum and maximum calorie require- ments, as well as appropriate macro and key micronutrient levels. These goals would be useful in developing food-based meal requirements and for possible State and Federal oversight activities. The targets for intake at each meal, and the nutrient goals for meals planned at the offered and served level, would be necessary for evaluation studies and assessments. Attainable recommendations: The majority of CACFP meals are prepared and served on-site in small group environments. In day care homes, food purchasing, planning, prepa- ration, and service are often carried out by the same individuals; these indi- viduals, who also provide the child care service, frequently have no formal nutrition, food service, or management training. While FNS encourages the IOM to build upon the meal pattern work conducted for the NSLP and SBP when developing recommendations for CACFP, it is important to recognize that the scale and scope of meal services in CACFP are very different than those in NSLP and SBP. All recommendations must be realistic to imple- ment in a home-based setting and should be as economical as possible. To ensure that the recommendations are attainable, the Department re- quests that the final IOM report include a 4-week cycle menu for each of the recommended age groups. These menus should meet all recommenda- tions, remain relatively cost neutral and not be likely to have an adverse effect on program participation. Age groups: The CACFP provides meals primarily to children from birth to age 18. The number of meals served to disabled and elderly adults in the program is significantly increasing. The current CACFP meal pattern establishes minimum portion sizes for each food component in seven age groupings. We request that the committee recommend age groupings that can be suc- cessfully implemented via the various operational styles in CACFP and that also reflect the appropriate nutritional needs for relevant stages of growth and development in children and adolescents as well as among disabled and elderly adults. The following list includes particular areas of concern in the current meal pattern that we would like IOM to address:

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209 APPENDIX D • The existing infant and toddler groupings in the CACFP meal patterns may need careful review given current understanding of the nutritional needs and developmental readiness of children at various ages. • While it may be appropriate to mirror the age groupings developed for the NSLP and SBP (ages 5–18), the CACFP has a distinct op- erational cut-off at age12. Children 12 and under may be served up to two meals and a snack each day in centers, homes and outside school hours facilities in CACFP. After the age of 12, the program services become limited to those provided in emergency shelters or at-risk afterschool settings; however no additional age group- ings, between age 12 and adult, are included in the meal patterns. Currently, institutions must serve teens at least the minimum por- tions established for children aged 6 through 12 years but have the option of increasing the portion. This optional increase is not regulated and may not adequately address the nutritional needs of teens and creates the potential for under or over feeding teens in these facilities. • The CACFP includes adult care centers that provide non-residential day care services to functionally disabled adults and elderly adults over the age of 60. The nutritional needs of a 25-year-old disabled man are significantly different from that of an 85-year-old woman. However, the current CACFP meal pattern includes only one adult age grouping that may not be appropriate for unique needs of the varied population it serves. Additionally, the committee should take into consideration the common special dietary needs of the adult populations, such as limited sodium or fat consumption, when establishing recommendations for adult age groups. Developmental readiness for solid foods: Each infant develops at his or her own pace and the infant meal pattern must provide flexibility for parents and providers to be responsive to each infant’s abilities, while still providing sufficient nutrients and opportunity for feeding development. This is especially important when establishing component and portion size requirements for various age groupings in the infant meal pattern. FNS encourages the committee to consider factors such as the different ages at which infants begin eating solid foods, the pace and order of introducing various foods, the changing texture of foods as feeding skills develop, and potentially inappropriate food selections by providers. In addition, the current meal patterns for infants and toddlers include ranges for some food components. This should be evaluated to determine if ranges are the best way to accommodate the differences in development for portion

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210 CHILD AND ADULT CARE FOOD PROGRAM requirements in an age group. Additionally, FNS would like the commit- tee’s recommendation on the appropriate amount of time for transition of infants from formula or breastmilk to cow’s milk. Breastfeeding: The CACFP encourages breast-feeding by reimbursing for meals that in- clude breast milk. Additionally, CACFP policy allows providers to serve smaller portions of breastmilk than are required of infant formula to avoid the potential of waste, particularly for very young infants that eat several smaller portions over the course of a day. FNS encourages the committee to provide recommendations for other means of encouraging breastfeeding in CACFP, while ensuring that the provider continues to provide a reimburs- able service to the infant. Family-style meal service: Child care facilities have the option of providing meals in a family-style service. This approach ensures that enough food is available at the table to provide each child with the minimum portion of each required compo- nent, but allows children to select the foods in the quantities they want. Various operational models exist, but typically children are encouraged to select, serve, and regulate their own portions and components. Providers must encourage children to try foods they have not selected and allow the children to take additional amounts of any components in the meal. Head Start programs are required to use a family-style meal service; many other facilities use it as well. The realities of this operational option should be considered in the committee’s work. Fruit, vegetables, low-fat/fat-free milk products, and whole grains: FNS is requesting recommendations to increase the availability of the food groups encouraged by the most recent version of the Dietary Guidelines for Americans. FNS wishes to establish requirements to ensure that the participants served by CACFP have access to adequate amounts of these recommended food groups. Current CACFP regulations require that minimum servings of fruits and/or vegetables, fluid milk and whole grain or enriched sources of grains/breads be offered at each meal (breakfast, lunch and supper). Snacks may or may not include a vegetable or fruit, as any two of four possible components may be served. Fluid milk is required at each breakfast, lunch and/or supper served to participants aged 1 year or older. The current meal pattern makes

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211 APPENDIX D no reference to the appropriate fat content of milk for any age group. While bread and bread alternate products must be made with whole or enriched grains or flour, there is no requirement to offer whole grains. Milk alternates: Unlike NSLP and SBP, there is no legislative requirement that fluid milk be offered in meals. However, the CACFP regulations require fluid milk to be served in each breakfast, lunch and supper meal. Cheese and yogurt may be used in the meal as meat alternates, but are not allowed to count toward the milk requirement. Adult care facilities are allowed to implement Offer Versus Serve meal services; providers have indicated that some participants do not like fluid milk and would prefer cheese or yogurt as a source of the critical calcium, potassium and vitamin D required in their diets. FNS is requesting the committee’s recommendations as to whether other milk products should serve as an alternate to fluid milk in the meal pattern for adult participants. Aligning nutrition requirements between FNS programs: In many instances CACFP is administered in conjunction with other CN programs at the State, local and institutional level. For example, a central school kitchen may prepare meals for NSLP, SBP, CACFP, and SFSP. Yet, each program has some unique nutritional requirements based on the functional and operational distinctions as well as the population being served. FNS encourages the committee to consider opportunities to align meal require- ments for CACFP, as appropriate, with requirements for NSLP, SBP, and the Supplemental Nutrition Program for Women, Infants and Children.

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