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CHILD AND ADULT CARE FOOD PROGRAM

ALIGNING DIETARY GUIDANCE FOR ALL

Committee to Review Child and Adult Care Food Program Meal Requirements

Food and Nutrition Board

Suzanne P. Murphy, Ann L. Yaktine, Carol West Suitor, and Sheila Moats, Editors

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington D.C.
www.nap.edu



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ChilD and Adult Care FOOD PROGRAM A L I G N I N G D I E TA RY G U I D A N C E F OR A L L Committee to Review Child and Adult Care Food Program Meal Requirements Food and Nutrition Board Suzanne P. Murphy, Ann L. Yaktine, Carol West Suitor, and Sheila Moats, Editors

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropri- ate balance. This study was supported by Contract No. AG-3198-C-08-0001 between the Na- tional Academy of Sciences and the U.S. Department of Agriculture. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-15845-9 International Standard Book Number-10: 0-309-15845-1 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap. edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2011 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent ad- opted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2011. Child and Adult Care Food Program: Aligning Dietary Guidance for All. Washington, DC: The National Acad- emies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE TO REVIEW CHILD AND ADULT CARE FOOD PROGRAM MEAL REQUIREMENTS SUZANNE P. MURPHY (Chair), Cancer Research Center of Hawaii, University of Hawaii, Honolulu NORMA D. BIRCKHEAD, District of Columbia Office of the State Superintendent of Education, Washington, DC ALICIA L. CARRIQUIRY, Department of Statistics, Iowa State University, Ames RONNI CHERNOFF, Geriatric Research Education and Clinical Center, Central Arkansas Veterans Healthcare System; Arkansas Geriatric Education Center, University of Arkansas for Medical Sciences, Little Rock SONIA COTTO-MORENO, Teaching and Mentoring Communities, Laredo, TX KAREN WEBER CULLEN, Children’s Nutrition Research Center, Baylor College of Medicine, TX MARY KAY FOX, Mathematica Policy Research, Inc., Cambridge, MA GERALDINE HENCHY, Food Research and Action Center, Washington, DC HELEN H. JENSEN, Department of Economics, Iowa State University, Ames CHARLENE RUSSELL-TUCKER, Connecticut Department of Education, Middletown VIRGINIA A. STALLINGS, The Children’s Hospital of Philadelphia, University of Pennsylvania KATHERINE L. TUCKER, Department of Health Sciences, Northeastern University, Boston, MA Study Staff ANN YAKTINE, Study Director SHEILA MOATS, Associate Program Officer JULIA HOGLUND, Research Associate HEATHER BREINER, Program Associate ANTON BANDY, Financial Officer GERALDINE KENNEDO, Administrative Assistant, Food and Nutrition Board LINDA D. MEYERS, Director, Food and Nutrition Board v

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Denise M. Brown, Department of Nutrition and Food Systems, The University of Southern Mississippi, Hattiesburg Jean Charles-Azure, Indian Health Service, Rockville, MD Barbara L. Devaney, Mathematica Policy Research, Inc., Princeton, NJ Craig Gundersen, Department of Agriculture and Consumer Education, University of Illinois, Urbana James O. Hill, Center for Human Nutrition, Colorado Clinical Nutrition Research Unit, Denver Nancy F. Krebs, Department of Pediatrics, Section of Nutrition, University of Colorado, Denver Joanne R. Lupton, Department of Nutrition and Food Science, Texas A&M University, College Station vii

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viii REVIEWERS Sandra J. Rhoades, Division of Nutrition, New York State Department of Health, Albany Nancy S. Wellman, Department of Dietetics and Nutrition, Florida International University, Miami Walter C. Willett, Department of Nutrition, Harvard School of Public Health, Boston, MA Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Eileen Kennedy, Friedman School of Nutrition Science and Policy, Tufts University, and Jeanne Brooks-Gunn, Teachers College and College of Physicians and Sur- geons, Columbia University. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface The Child and Adult Care Food Program (CACFP) is a U.S. Depart- ment of Agriculture (USDA) food program that is not well-known to either the general public or nutrition professionals. I must admit that I knew little about this program before the Committee to Review CACFP Meal Require- ments began its work. I did not know that CACFP • Serves almost 3 million children and adults, • Has participants ranging in age from small infants to elderly adults, and • Can provide over half of the day’s calories for some participants through two meals and a snack, or two snacks and a meal. Over the past year, as the committee carried out its tasks, my knowledge and appreciation for CACFP have grown enormously. Several members of the committee, including me, had served as members of the authoring committees for two other recent reviews of USDA’s food programs: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the National School Lunch and Breakfast Programs. However, we still had much to understand about the uniqueness of CACFP. In this process, we were guided and informed by the expertise of committee members with many years of experience with the program. The resulting report was truly a team effort by experts from many disciplines: nutrition, epidemiology, statistics, economics, and food program implementation. I think I speak for the whole committee in saying it has been a very rewarding experience to participate in the review of the CACFP meal requirements. We hope that the ix

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x PREFACE resulting recommendations will help to make this excellent food program even better. Furthermore, given the broad scope of CACFP, these recom- mendations should be applicable across all age groups, and thus effectively align dietary guidance for all Americans. The committee could not have done its work without the tireless efforts of the Institute of Medicine study team. The Study Director, Ann Yaktine, kept us focused and on time, and contributed substantially to the writing effort. She was assisted by an able team, including Sheila Moats, Associate Program Officer, who assisted with food pattern analysis; Julia Hoglund, Research Associate, who assisted with the cost analysis and research sup- port; and Heather Breiner, Program Associate, who managed program logistics. Linda Meyers, the Director of the Food and Nutrition Board, provided us with wise advice at crucial points in our deliberations. Last, but certainly not least, Carol Suitor joined us as a consulting editor during the writing phase and made extensive contributions to the final report. I am grateful to all of them. Other people made important contributions to the many analyses that were necessary for the report. Todd Campbell from Iowa State University developed the software that was used to determine the costs and helped with assigning codes to foods for the purpose of nutrient analyses, and Janice Maras from Northeastern University assisted with the menu analy- ses. In addition, we held an open session at our second meeting, and we heard from both the CACFP program administrators at the Food and Nu- trition Service at USDA and from others with expertise relevant to the com- mittee’s task. Our thanks go to all who contributed to our deliberations. Finally, as chair, I would like to express my sincere appreciation to the committee members for their commitment to making the report scientifi- cally accurate as well as realistic and practical. The committee added this volunteer effort to their full-time jobs, and that often required working nights and weekends. I thank them for their time and many contributions. It was a pleasure working with each of them. Suzanne P. Murphy, Chair Committee to Review Child and Adult Care Food Program Meal Requirements

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Contents Summary 1 Task and Approach, 2 Recommendations, 4 Consistency of Recommendations with Criteria, 12 Conclusion,14 1 Introduction 15 The Committee’s Task, 16 Rationale for Revising the Meal Requirements, 17 Organization of the Report, 21 2 The Child and Adult Care Food Program 25 Program Overview, 25 Program Settings, 26 Client Characteristics, 29 History and Growth of the Program, 29 Administration and Regulations, 31 Monitoring the Quality of CACFP Meals, 37 CACFP as Part of the Food and Nutrition Safety Net, 38 Summary, 41 3 Methods for Examining Food and Nutrient Intakes 45 Food and Nutrient Data Sources, 45 Standards Used to Review Food Intakes, 48 xi

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xii CONTENTS The Determination of Age Groups, Body Weights and Heights, and Estimated Calorie Requirements, 48 Food Intake Evaluation, 52 Nutrient Intake Evaluation, 53 Summary, 57 4 Nutritional Considerations for Infants and Children 61 Food Intakes, 61 Nutrient Intakes, 65 Special Nutritional Considerations, 70 5 Nutritional Considerations for Adults 77 Food Intakes, 77 Energy and Nutrient Intakes, 78 Special Nutritional Considerations, 82 Food and Nutrients to Be Encouraged or Limited, 86 6 Process for Developing Recommendations for Meal Requirements 89 Criteria, 89 Overall Approach to Developing Recommendations, 89 Establishing Calorie and Nutrient Targets, 93 Developing Meal Requirements, 109 Summary, 111 7 Recommendations for Meal Requirements 113 Recommended Meal Requirements, 113 Recommended Meal and Snack Patterns, 116 Food Specifications, 124 Translating Meal Requirements into Menus, 129 Comparison Between Current and Recommended Meal Requirements, 130 Summary, 134 8 Meal Cost Implications 137 Projected Changes in Food Costs, 137 Non-Food Meal Costs, 149 Summary, 151

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xiii CONTENTS 9 Implementation 153 Promoting the Implementation of Key Elements of the Recommended Meal Requirements, 154 Recommendations to Support the Implementation of the Revised Meal Requirements, 163 Summary, 166 10 Consistency of Recommendations for Meal Requirements and Implementation Strategies with the Committee’s Criteria 169 Overview, 169 Recommendations for Meal Requirements Are Consistent with the Criteria, 169 Recommendations for Implementation Strategies Are Consistent with the Criteria, 181 Summary,182 11 Evaluation and Research Recommendations 183 Recommendations for Evaluation, 183 Recommendations for Research, 187 Summary, 189 Appendixes* A Acronyms, Abbreviations, and Glossary 191 B Biographical Sketches of Committee Members 197 C Workshop Agenda: February 2010 205 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 Agriculture 207 E Current CACFP Meal Patterns 213 F Selected Food Program Descriptions and Websites 223 G Data Sources and Analytical Methods 229 H MyPyramid Food Groups and Subgroups 235 I Food Cost Approach and Methods 239 *Appendixes D through M are not printed in this book but can be found on the CD at the back of the book or online at http://www.nap.edu.

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xiv CONTENTS J Nutrient Targets by Meal and Age Group and Comparison of MyPyramid Food Group and Nutrient Targets with Recommended Meal Patterns 251 K Sample Menus 269 L Options for Breastfeeding Incentives 281 M Potential Partnerships to Assist with Technical Training for CACFP 283 INDEX 285