1

Introduction

With over 16 million children living in food-insecure1 households in 2010 and an increasing number of children either overweight or obese, improving child nutrition has emerged as one of the nation’s most urgent public health challenges (ERS, 2011). The Child and Adult Care Food Program (CACFP), a U.S. Department of Agriculture (USDA) food program, is helping to meet this challenge. In fiscal year (FY) 2011, CACFP served about 3.3 million children, many living in food-insecure households, as well as over 124,000 adults who require daily supervision or assistance (FNS, 2012a, Tables 11 and 15c). Because many participants rely on CACFP for the majority of their food intake, the quality of foods provided has the potential to substantially improve the adequacy and healthfulness of their diets. To ensure that the meals and snacks provided by CACFP are consistent with national nutrition guidance, the USDA asked the Institute of Medicine (IOM) to review and recommend improvements, as necessary, to bring CACFP meal requirements into alignment with those of other federally funded food assistance programs and with the Dietary Guidelines for Americans (DGA) (USDA and HHS, 2010). The review and recommendations are described in detail in the 2011 IOM report Child and Adult Care Food Program: Aligning Dietary Guidance for All.2 The panel of experts who conducted the review encountered a considerable

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1The measure of food insecurity was based on respondents’ perceptions of whether the household was able to obtain enough food to meet their needs.

2Unless otherwise indicated, any reference to “the CACFP report” in this summary is a reference to this report.



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1 Introduction W ith over 16 million children living in food-insecure1 households in 2010 and an increasing number of children either overweight or obese, improving child nutrition has emerged as one of the nation’s most urgent public health challenges (ERS, 2011). The Child and Adult Care Food Program (CACFP), a U.S. Department of Agriculture (USDA) food program, is helping to meet this challenge. In fiscal year (FY) 2011, CACFP served about 3.3 million children, many living in food- insecure households, as well as over 124,000 adults who require daily supervision or assistance (FNS, 2012a, Tables 11 and 15c). Because many participants rely on CACFP for the majority of their food intake, the quality of foods provided has the potential to substantially improve the adequacy and healthfulness of their diets. To ensure that the meals and snacks pro- vided by CACFP are consistent with national nutrition guidance, the USDA asked the Institute of Medicine (IOM) to review and recommend improve- ments, as necessary, to bring CACFP meal requirements into alignment with those of other federally funded food assistance programs and with the Dietary Guidelines for Americans (DGA) (USDA and HHS, 2010). The re- view and recommendations are described in detail in the 2011 IOM report Child and Adult Care Food Program: Aligning Dietary Guidance for All.2 The panel of experts who conducted the review encountered a considerable 1 The measure of food insecurity was based on respondents’ perceptions of whether the household was able to obtain enough food to meet their needs. 2 Unless otherwise indicated, any reference to “the CACFP report” in this summary is a reference to this report. 1

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2 RESEARCH METHODS TO ASSESS DIETARY INTAKE BOX 1-1 Child and Adult Care Food Program: Aligning Dietary Guidance for All Recommendations for Program Evaluation and Research The IOM committee that reviewed and recommended improvements to the meal requirements for CACFP, as described in Child and Adult Care Food Pro- gram: Aligning Dietary Guidance for All (IOM, 2011), encountered a considerable lack of data relevant to CACFP, including food group and nutrient intake and par- ticipant characteristics. As described in detail in Chapter 11 of the 2011 report, the committee made the following recommendations: ongoing evaluation of CACFP; targeted research on nutrient intake, participant characteristics, and certain pro- gram outcomes; and periodic reassessment to determine the magnitude of impact of recommended changes in meal requirements. These research recommenda- tions parallel the research objectives identified in the Healthy, Hunger-Free Kids Act of 2010 (see Box 1-3). Program Evaluation Recommendation 1: USDA, in collaboration with rel- evant 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 nutrition content of the meals and snacks served, on demand from eligible providers to participate in CACFP, and on program access by participants. Program Evaluation Recommendation 2: USDA should take appropriate ac- tions to establish the current baselines prior to implementation of the new Meal Requirements for comparison purposes. Program Evaluation Recommendation 3: To the extent possible, USDA should take steps to ensure that the final rule for the new Meal Requirements is informed by the results of the evaluation of program impact (described in Recom- mendation 1 above). Research Recommendation 1: USDA, in collaboration with relevant agen- cies and foundations, should support research on topics related to the implemen- tation of the Meal Requirements and to fill important gaps in knowledge of the role of CACFP in meeting the nutritional needs of program participants. Research Recommendation 2: USDA should review and update, as appro- priate, the CACFP Meal Requirements to maintain consistency with the Dietary Guidelines for Americans and other relevant science. lack of up-to-date data relevant to CACFP and recommended that USDA support research to fill important gaps in knowledge. The committee also recommended that USDA support research to evaluate the impact of antici- pated changes in CACFP meal requirements (see Box 1-1). The IOM held an additional workshop in February 2012 to discuss the evaluation and research recommendations articulated in the 2011 report (see Appendix A

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3 INTRODUCTION BOX 1-2 Statement of Task Following release of the report Child and Adult Care Food Program: Align- ing Dietary Guidance for All, an ad hoc committee will plan and organize a 1-day public workshop that will discuss questions and indicators that could be used to carry out the evaluation and research recommendations as laid out in the report. The committee will define the specific topics to be addressed at the workshop, develop the agenda, and select and invite speakers and discussants. An unedited transcript of the workshop presentations will be provided to the sponsor and an individually authored summary of the workshop will be prepared and reviewed through National Academies procedures prior to release. for the workshop agenda). This report summarizes the presentations3 and discussions that occurred during the February 2012 workshop and has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. The planning committee’s role was limited to planning and convening the workshop (see Box 1-2 for the Statement of Task). Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the IOM, and they should not be construed as reflecting any group consensus. Workshop participants considered three general areas of research: (1) the dietary intake of children participating in CACFP, including methods for assessing foods and nutrients in meals and snacks offered and served, and how closely that intake aligns with recommendations of the 2010 DGA (USDA and HHS, 2010); (2) barriers and facilitators to providing meals and snacks that align with the current dietary guidance; and (3) program access and participation trends. As Suzanne Murphy, workshop moderator, stated, the intention was not to present data or to conduct any sort of evaluation of CACFP. Rather, the focus was directed toward methodology, specifically to discuss how to design and conduct a nationally representative study assess- ing children’s dietary intake and participation rates in child care4 facilities, including CACFP-sponsored child care centers and homes (see Appendix A for the workshop purpose). Much of the workshop discussion revolved 3 Slides are available at http://www.iom.edu/Activities/Nutrition/ChildAdultCareFood/2012- FEB-07.aspx. 4 Throughout this summary “child care” refers to child care centers and family or group day care homes.

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4 RESEARCH METHODS TO ASSESS DIETARY INTAKE around past studies, some of CACFP but mostly of other programs, and the adaptability of methods used in those studies for evaluating CACFP. In addition to exploring the evaluation and research recommendations laid out in the 2011 IOM report, workshop participants explored ways to answer the research mandate prescribed by the Healthy, Hunger-Free Kids Act of 2010 (P.L. 111-296). Considered a major step forward in U.S. efforts to provide all children with healthy foods, the 2010 act has been widely recognized for the significant improvements it requires of school meal programs. However, the legislation is more comprehensive than its requirements for school lunch programs. It also authorizes funding and sets policy for the other USDA core child nutrition programs, including CACFP. In addition to expanding CACFP, the act requires a study of nutri- tion and wellness quality in all child care settings, including but not limited to CACFP programs, and provides USDA with $5 million for conducting such research. The legislative language of the 2010 act very closely aligns with some of the evaluation and research recommendations of the CACFP report (see Box 1-3). ORGANIZATION OF THIS REPORT Organization of this report parallels organization of the workshop itself, with Chapter 1 summarizing introductory remarks made by Jay Hirschman and Julie Brewer, and the keynote address by Virginia Stallings, in addition to providing background information. Chapters 2, 3, and 4 summarize the presentations and discussion that took place during sessions 1, 2, and 3, respectively, and Chapter 5 summarizes the open discussion that took place at the end of the workshop. Appendix A contains the workshop agenda, Appendix B contains the biographical sketches of the moderators and speakers, Appendix C lists the workshop attendees and their affilia- tions, and Appendix D identifies acronyms and abbreviations. The workshop was designed to address three broad areas of research. Session 1 focused on methods for evaluating whether and how dietary intake in young children aligns with current dietary guidelines. Speakers and participants discussed and debated which specific research questions to address, the type of data needed to answer those questions and ways to collect those data, and existing methodologies used in previous studies. An overarching theme of the session was the importance of being very clear about the specific research question before deciding which method(s) to use. As Beth Dixon said, “Begin with the end in mind.” Choice of method should depend on the nature and level of detail of evidence sought. Another overarching theme was that there are plentiful lessons to be learned from past studies, including past studies on CACFP but mostly studies on other

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5 INTRODUCTION BOX 1-3 The Healthy, Hunger-Free Kids Act of 2010 The research and evaluation recommendations described in Child and Adult Care Food Program: Aligning Dietary Guidance for All (IOM, 2011) align with the legislative directive in the Healthy, Hunger-Free Kids Act of 2010 (P.L. 111- 296) to conduct a nationally representative study of child care settings. Thus, as Jay Hirschman explained during the workshop, even though the 2010 act is not specific to CACFP, but covers all child care centers and homes, USDA will none- theless use the presentations and discussion summarized in this report to help guide its preparation of a Request for Proposal (RFP) as mandated by Section 223(a) of the 2010 act (see below; research topics that were addressed during the workshop are in boldface italics). SEC. 223. STUDY ON NUTRITION AND WELLNESS QUALITY OF CHILD CARE SETTINGS. (a) IN GENERAL.—Not less than 3 years after the date of enactment of this Act, the Secretary, in consultation with the Secretary of Health and Human Services, shall enter into a contract for the conduct of a nationally representative study of child care centers and family or group day care homes that includes an assessment of— (1) the nutritional quality of all foods provided to children in child care settings as compared to the recommendations in most recent Dietary Guidelines for Americans published under section 301 of the National Nutrition Monitoring and Related Research Act of 1990 (7 U.S.C. 5341); (2) the quantity and type of opportunities for physical activity provided to children in child care settings; (3) the quantity of time spent by children in child care settings in sedentary activities; (4) an assessment of barriers and facilitators to— (A) providing foods to children in child care settings that meet the recommendations of the most recent Dietary Guidelines for Ameri- cans published under section 301 of the National Nutrition Monitoring and Related Research Act of 1990 (7 U.S.C. 5341); (B) providing the appropriate quantity and type of opportunities of physi- cal activity for children in child care settings; and (C) participation by child care centers and family or group day care homes in the child and adult care food program established under section 17 of the Richard B. Russell National School Lunch Act (42 U.S.C. 1766); and (5) such other assessment measures as the Secretary may determine to be necessary.

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6 RESEARCH METHODS TO ASSESS DIETARY INTAKE child nutrition programs, such as the School Nutrition Dietary Assessment (SNDA) study, and studies in the published literature. Session 2 focused on ways to evaluate barriers and facilitators to pro- viding meals and snacks in child care centers and homes that align with the current dietary guidelines. Speakers and participants discussed the types of barriers and facilitators to consider, survey and other tools for measuring barriers and facilitators, and methodological lessons learned from past studies. As with the first session, a common theme was that the best methods depend on the desired outcomes. Another common theme was the relevancy of past studies, not just studies in child care settings but also studies in the (non–child care) home environment that could be adapted to the home day care setting. Session 3 focused on how to evaluate CACFP program access and participation trends. Speakers and participants considered the type of data needed, potentially useful data that already exist in various databases, and methodological lessons learned from past research. Again, a common theme of the session was the importance of defining the outcome of interest first and then determining how to collect data based on that outcome. The open session at the end of the workshop centered around a set of prepared questions on baseline data (e.g., what type of data to collect), research priorities, survey design (e.g., whether there is an ideal design for a nationally representative study), the value of state-level data (i.e., in relation to national survey data), the use of survey tools in different settings (i.e., child care centers versus family day care homes), and other research topics to consider that were not addressed during the workshop. THE IMPORTANCE OF DATA IN SETTING POLICY5 Over the past decade, the IOM Food and Nutrition Board (FNB) has played a vital role in providing expert guidance to the USDA Food and Nutrition Service (FNS) on how to best use resources provided by Congress for managing FNS food and nutrition programs. FNS sponsored a series of IOM reports with the first addressing food package revisions to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (IOM, 2004, 2006). In 2009 USDA implemented revisions to WIC food packages based on recommendations in the 2006 IOM report. The IOM FNB carried out a similar study on revisions to nutrition standards for meals provided through the National School Lunch and School Breakfast 5 This section summarizes introductory remarks made by Jay Hirschman from the USDA Food and Nutrition Service, with some additional comments (where indicated) by Julie Brewer, Chief of the Policy and Program Branch in the Child Nutrition Division of the USDA Food and Nutrition Service.

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7 INTRODUCTION Program (IOM, 2008, 2010). School meal nutrition standard revisions based on recommendations in the 2010 report are in the process of imple- mentation based on a final rule published by FNS in January 2012. Most recently, the FNS commissioned the study that produced the 2011 CACFP report referenced above (IOM, 2011). Meal requirement revisions recom- mended in that report are under review by USDA. Jay Hirschman noted that recommendations in the 2010 IOM report, School Meals: Building Blocks for Healthy Children, were based partly on data compiled from a number of FNS-sponsored studies, including the School Nutrition Dietary Assessment studies (SNDA-I, II, III6) (FNS, 1993, 2001, 2007), the School Lunch and Breakfast Cost Studies (I and II) (FNS, 1994, 2008), and the School Food Purchase Studies (SFPS-I, II7) (FNS, 1987, 1998). The intention was to use the same analytical approach and compile the same type of dataset for use when deliberating recom- mendations for the 2011 CACFP report. But the expert committee that was convened to put together the 2011 report, some members of which had worked on the 2010 report, fell into what Hirschman described as a “black hole.” That is, comparable data on CACFP do not exist. There are many unanswered questions about what children are eating in child care and what needs to be done to improve nutrition in child care. Data on CACFP are sparse partly because USDA has invested so heavily in the much larger National School Lunch and School Breakfast Programs, with a majority of available child nutrition research money having gone to- ward studying school meals (see Table 1-1). But the USDA research agenda is shifting, according to Hirschman. While the school meal programs and program integrity issues will continue to draw research funds, the Healthy, Hunger-Free Kids Act of 2010 (P.L. 111-296) directs $5 million toward re- search on nutrition and wellness quality in child care settings (see Box 1-3). While not specific to CACFP, the legislatively required research will include CACFP child care centers and homes. The law requires the main focus of this research to be on the nutritional quality of foods provided to children, physical activity provided to the children, barriers and facilitators to meet- ing the 2010 DGA and to providing opportunities for physical activity, and barriers and facilitators to provider participation in CACFP. Hirschman remarked that, for many of components of the study, the question is, how do you actually obtain those data in a child care setting? Moreover, how does a study with finite resources address these questions not just in one child care setting but in a range of child care settings and nationwide? The standard procedure for FNS is to put out a Request for Proposals 6 The SNDA-IV report will be published in 2012. 7 TheSFPS-III was published in March 2012 (FNS, 2012c) and therefore was not available to the IOM committee that developed the recommendations in the 2010 report on school meals.

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8 RESEARCH METHODS TO ASSESS DIETARY INTAKE TABLE 1-1 FNS Food and Nutrition Programs Funding and Participation, Fiscal Year 2010 Cost Participation Program ($ million) (millions)* Supplemental Nutrition Assistance Program, or SNAP 68,180 40.3 (formerly the Food Stamp Program) National School Lunch Program 10,458 31.6 Special Supplemental Nutrition Program for Women, 6,756 9.2 Infants, and Children (WIC) School Breakfast Program 2,843 11.6 Child and Adult Care Food Program (CACFP) 2,641 3.4 Nutrition Assistance for Puerto Rico 2,048 1 The Emergency Food Assistance Program 700 746 million pounds Summer Food Service Program 357 2.3 Commodity Supplemental Food Program 161 0.519 Food Distribution Program on Indian Reservations 93 0.85 Fresh Fruit and Vegetable Program 73 n/a WIC Farmers’ Market Nutrition Program 22 2.4 Senior Farmers Market Nutrition Program 22 0.9 Special Milk Program 12 72 million 1/2-pints *Participation is listed as millions of people unless otherwise noted. SOURCE: FNS, 2010, 2012b. (RFP) and then fund contracts for research that will answer the questions and produce the necessary reports for Congress. The RFP in response to the child care research directive in the Healthy, Hunger-Free Kids Act of 2010 (P.L. 111-296) is currently being developed. The legislation provides fund- ing not less than 3 years from the date of enactment, which was December 13, 2010. So FNS will have access to the money on December 13, 2013. According to Hirschman, FNS would like to be in a position at that time to award contracts. Julie Brewer of FNS echoed Hirschman’s remarks about the important role that the IOM FNB plays in FNS efforts to improve nutrition services, as evident by the fact that IOM recommendations—and the science upon which they are based—really do inform policy decisions. Brewer remarked that it is “disheartening” when FNS is asked to make a decision about policy without having a strong scientific evidence base for making that decision. Personal experiences and anecdotal stories do not provide the nec-

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9 INTRODUCTION essary strength for moving forward. Data collected as part of a nationally representative study will provide a picture of the current state of nutrition in child care and play a vital role in future policy decisions around child nutrition. What Is the Child and Adult Care Food Program? CACFP is one of 15 domestic food and nutrition programs managed by FNS. The program provides reimbursement for nutritious meals and snacks served to children and adults receiving care at participating family child care homes, child care centers, at-risk after-school care facilities, outside- school-hours care facilities, adult care facilities, and emergency shelters. As shown in Table 1-1, CACFP is by no means the largest FNS program, nor is it the only program that provides services to children. CACFP serves more than 3.4 million participants. The program’s FY 2010 national budget was $2,641 billion. In FY 2011, there were approximately 186,000 CACFP- funded outlets, or service sites. The larger share was family day care homes (132,297), with the remainder being child care centers (53,572). While family day care homes make up about two-thirds of all service sites, they make up only about one-fourth of all participants. Most participants are in various types of child care centers (see Figure 1-1). DATA NEEDS FOR THE CHILD AND ADULT CARE FOOD PROGRAM8 Virginia Stallings agreed with Hirschman and Brewer that the IOM FNB has made a major contribution to child health and nutrition by examining existing data and thinking about how to move programs for- ward based on that evidence. She described the changes in the WIC food packages that occurred as a result of IOM work (IOM, 2002, 2006) as “amazing” and commented that the committee behind the report on the National School Lunch and School Breakfast Programs (IOM, 2010) is looking forward to seeing the new regulations based on recommendations in that report being implemented nationwide. While the committee behind the CACFP report (IOM, 2011) wanted to be as efficient and task oriented as possible, adapting lessons learned from previous work on WIC and the school meal programs to the child care setting, the committee faced several new challenges, not the least of which was the lack of data on CACFP providers and participants. In the Executive Summary of the report, the committee wrote, “While conducting this study, the committee encountered 8 Thissection summarizes the keynote address by Virginia A. Stallings, from the University of Pennsylvania and The Children’s Hospital of Philadelphia.

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10 RESEARCH METHODS TO ASSESS DIETARY INTAKE 186,000 Outlets Average Daily Participation 53,572 814,415 974,388 815,020 132,297 546,129 132,653 Day Care Homes Day Care Homes Child Care Centers Title XX Outside School Hours Head Start Other Centers FIGURE 1-1 Types of CACFP service sites and participation within each type, fiscal year 2011. NOTE: Day Care Homes refers to nonresidential day care in private homes that are licensed, registered, or approved to provide family child care. Child Care Centers refers to a variety of public or private nonprofit child care centers which are licensed or approved to provide day care services to children. Title XX refers to the Social Security Act Title XX—Block Grants to States for Social Services and Elder Justice. SOURCE: Hirschman, 2012. a considerable lack of up-to-date data relevant to CACFP.” They referred to “a need to improve data-gathering in all aspects of the program” (IOM, 2011). In her keynote address, Stallings identified two major challenges to collecting and interpreting CACFP data, that is, variation in ages of the par- ticipants and variation in child care settings. She urged that baseline data be collected before recommended meal requirement revisions are implemented or as soon as possible and emphasized the need for research on the impact of CACFP on participants, providers, and caregivers. Variation in Age: A Major Challenge One of the greatest challenges to collecting data on CACFP is the fact that CACFP covers a very broad age range relative to WIC and the National School Lunch and School Breakfast Programs. While the program covers many more children (3.3 million in 2010) than it does impaired or older (over 60 years) adults (114,000 in 2010), nonetheless it spans the entire

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11 INTRODUCTION human life cycle. Because some after-school and at-risk programs are sup- ported by CACFP, CACFP also covers the teenage years. Specifically, the IOM report recommends consideration of seven age groups that are cov- ered by CACFP: 0–5 months, 6–11 months, 1 year, 2–4 years, 5–13 years, 14–18 years, and 19 years and older. The fact that half of the age groups are below 4 years reflects varying nutrient requirements at different early developmental stages. Data on infants and young children are especially sparse. In fact, they are so sparse that there is a significant gap in child health policy for children from birth to 2 years. There are no national dietary guidelines for those age groups. Instead, guidance is sought from the American Academy of Pediatrics, which Stallings described as a very creditable organization, but one without resources to do the type of evidence-based review upon which the DGA are based. Evolving science indicates that nutrition in the birth- to-2-years age range is more important than was thought 30 years ago and may have major health implications. Evidence of its importance is coming from areas of research such as breastfeeding (e.g., effect of exclusivity of breastfeeding, effect of duration of breastfeeding), the introduction of complementary foods and beverages (i.e., the introduction into the infant’s diet of foods and beverages in addition to breast milk), and rate of growth (e.g., as an early indicator of obesity). Stallings urged collection of nutrient intake data among both breast-fed and formula-fed infants. Variation in Setting: Another Challenge In addition to variation in age, a second major challenge to CACFP data collection and interpretation is variation in setting. The range of CACFP child and adult day care settings includes family homes (73 percent), child care centers (20 percent), at-risk after-school facilities, Head Start pro- grams, and emergency shelters. Stallings emphasized the need to collect data from all CACFP settings (from different types of programs, such as child care home versus day care center; and from programs with varying numbers of participants), as well as all regions of the country. Moreover, in order to fully comprehend the impact of CACFP, she recommended that data also be collected from child care facilities not supported by CACFP. The Urgency of Collecting Baseline Data Stallings emphasized the urgency of collecting baseline data before the recommended meal requirement changes are implemented. Unlike the WIC and school meal settings, both of which have a history of routine surveil- lance, CACFP has very little baseline data upon which to build. If there is not enough time or money to collect baseline data before the changes are

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12 RESEARCH METHODS TO ASSESS DIETARY INTAKE initiated, she urged designing a study that allows for the collection of data as soon as changes are rolled out. The Need for Impact Research In addition to baseline data, another important need is for data that measure the impact of CACFP. Stallings identified three key impact research questions: 1. Does the program improve participants’ daily or weekly food in- take as compared to the DGA? 2. Does the program improve the intake of at-risk nutrients (i.e., nu- trients whose intakes were identified by the CACFP committee as being too low or too high)? 3. How does food intake and intake of at-risk nutrients in children participating in CACFP compare to similar intake in children who are not involved with CACFP? Other Data to Collect as Part of a Nationally Representative Study In addition to program impact data and nutrient intake data for infants and young children, Stallings listed several other general areas where more data are especially needed: participant characteristics; the types of foods be- ing served and their nutrient composition; and the impact of programmatic cost (e.g., the cost of food and the regulatory burden), which Stallings said can be more difficult to assess in CACFP settings than in other settings. Stallings encouraged consideration of collecting several other types of data as part of a nationally representative study to assess nutrition and physical activity in child care facilities: body mass index (BMI) data,9 biomarker data (specifically iron and vitamin D status), nutritional status data (e.g., obesity and undernutrition prevalence), nutrition-related health status data (e.g., obesity, hypertension, cardiovascular disease, diabetes, lactose intolerance or liquid milk refusal, celiac disease), and data on the use of supplements (i.e., vitamins, minerals, and other supplements). Fi- nally, Stallings remarked that while the CACFP report did not make any gender-specific recommendations, it may be interesting to collect the data necessary to compare findings for participants of both genders to gender- specific nutrient requirements. 9 While collecting height and weight data would be helpful for understanding the CACFP population, Stallings cautioned that those data need to be collected accurately, which may be beyond the scope of a nationally representative study. If collected, they need to be handled carefully so that any detected association between CACFP and either underweight or over- weight is not misinterpreted as causal.

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13 INTRODUCTION REFERENCES ERS (Economic Research Service). 2011. Household food security in the United States in 2010. Washington, DC: USDA. FNS (Food and Nutrition Service). 1987. School Food Purchase Study: Final report. Wash- ington, DC: USDA. FNS. 1993. The School Nutrition Dietary Assessment Study: School food service, meals of- fered, and dietary intakes. Alexandria, VA: USDA/FNS. http://www.fns.usda.gov/ora/ MENU/Published/CNP/FILES/SNDA-Sum.pdf (accessed April 30, 2012). FNS. 1994. School Lunch and Breakfast Cost Study, final report. Alexandria, VA: USDA/ FNS. http://www.fns.usda.gov/ora/MENU/Published/CNP/FILES/Lunch_BreakfastCost Sum.pdf (accessed April 30, 2012). FNS. 1998. School Food Purchase Study, final report. Alexandria, VA: USDA/FNS. http:// www.fns.usda.gov/ora/MENU/Published/CNP/FILES/SFPS-Execsum.pdf (accessed April 30, 2012). FNS. 2001. School Nutrition Dietary Assessment Study-II, final report. Alexandria, VA: USDA/FNS. http://www.fns.usda.gov/ora/MENU/Published/CNP/FILES/sndaII.pdf (ac- cessed April 30, 2012). FNS. 2007. School Nutrition Dietary Assessment Study-III. Alexandria, VA: USDA/FNS. http://www.fns.usda.gov/ora/MENU/Published/CNP/FILES/SNDAIII-Vol1ExecSum.pdf (accessed April 30, 2012). FNS. 2008. School Lunch and Breakfast Cost Study-II, final report. Alexandria, VA: USDA/ FNS. http://www.fns.usda.gov/ora/MENU/Published/CNP/FILES/MealCostStudy.pdf (ac- cessed April 30, 2012). FNS. 2010. National Data Bank. Alexandria, VA: USDA/FNS. www.fns.usda.gov/cga/press releases/2010/retailer/summary.docx (accessed April 30, 2012). FNS. 2012a. Program information report (KeyData) U.S. summary, FY 2011–FY 2012. http:// www.fns.usda.gov/fns/key_data/october-2011.pdf (accessed May 22, 2012). FNS. 2012b. Data and statistics. Alexandria, VA: USDA/FNS. http://www.fns.usda.gov/fns/ data.htm (accessed April 30, 2012). FNS. 2012c. School Food Purchase Study-III. Alexandria, VA: USDA/FNS. http://www.fns. usda.gov/ora/MENU/Published/CNP/FILES/SFSPIII_Final.pdf (accessed April 30, 2012). Hirschman, J. 2012. The importance of data in setting policy. Presented at the Institute of Medicine Workshop on Research Methods to Assess Dietary Intake and Program Par- ticipation in Child Day Care: Application to the Child and Adult Care Food Program. Washington, DC, February 7, 2012. IOM (Institute of Medicine). 2002. Dietary risk assessment in the WIC program. Washington, DC: National Academy Press. IOM. 2004. Proposed criteria for selecting the WIC food packages: A preliminary report of the Committee to Review the WIC Food Packages. Washington, DC: The National Academies Press. IOM. 2006. WIC food packages: Time for a change. Washington, DC: The National Acad- emies Press. IOM. 2008. Nutrition standards and meal requirements for National School Lunch and Breakfast Programs: Phase I. Proposed approach for recommending revisions. Washing- ton, DC: The National Academies Press. IOM. 2010. School meals: Building blocks for healthy children. Washington, DC: The Na- tional Academies Press. IOM. 2011. Child and Adult Care Food Program: Aligning dietary guidance for all. Washing- ton, DC: The National Academies Press.

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14 RESEARCH METHODS TO ASSESS DIETARY INTAKE USDA (U.S. Department of Agriculture) and HHS (U.S. Department of Health and Hu- man Services). 2010. Dietary guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office. http://www.cnpp.usda.gov/DGAs2010-Policy Document.htm (accessed April 2, 2012).