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Alignment of Young Children’s Dietary Intake with Current Dietary Guidance

There are very few data on the quality of meals and snacks served to children in the Child and Adult Care Food Program (CACFP) and the contributions of those meals and snacks to children’s overall dietary intakes. Thus, a major goal of future research identified in the CACFP report is to assess the food and nutrient content of meals and snacks served to and consumed by children and the impact of these meals and snacks on children’s overall diets. This chapter summarizes presentations and discussion on existing methodologies that might be useful in implementing a study that would address these and related issues.

Mary Kay Fox began the presentation by describing potentially relevant methodologies used in previous national studies of child nutrition. These included the School Nutrition Dietary Assessment (SNDA) studies, the Feeding Infants and Toddlers Study (FITS) studies, and two previous studies of CACFP. She explored ways that the methods used in these studies could provide “some starting ground” for thinking about optimal approaches to collecting data in a nationally representative study of child day care, including CACFP. She also pointed out how the child day care setting presents unique challenges that need to be addressed.

In addition to national surveys, smaller studies in the published literature serve as another source of information for potentially relevant methodologies. Dianne Ward presented an overview of the scientific literature on methods for assessing foods served in child care settings. She argued that, regardless of the method(s) chosen, researchers should consider using multiple methods to ensure accuracy. She also encouraged testing protocols before widespread implementation.



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2 Alignment of Young Children’s Dietary Intake with Current Dietary Guidance T here are very few data on the quality of meals and snacks served to children in the Child and Adult Care Food Program (CACFP) and the contributions of those meals and snacks to children’s overall di- etary intakes. Thus, a major goal of future research identified in the CACFP report is to assess the food and nutrient content of meals and snacks served to and consumed by children and the impact of these meals and snacks on children’s overall diets. This chapter summarizes presentations and discus- sion on existing methodologies that might be useful in implementing a study that would address these and related issues. Mary Kay Fox began the presentation by describing potentially relevant methodologies used in previous national studies of child nutrition. These included the School Nutrition Dietary Assessment (SNDA) studies, the Feeding Infants and Toddlers Study (FITS) studies, and two previous studies of CACFP. She explored ways that the methods used in these studies could provide “some starting ground” for thinking about optimal approaches to collecting data in a nationally representative study of child day care, includ- ing CACFP. She also pointed out how the child day care setting presents unique challenges that need to be addressed. In addition to national surveys, smaller studies in the published litera- ture serve as another source of information for potentially relevant meth- odologies. Dianne Ward presented an overview of the scientific literature on methods for assessing foods served in child care settings. She argued that, regardless of the method(s) chosen, researchers should consider using multiple methods to ensure accuracy. She also encouraged testing protocols before widespread implementation. 15

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16 RESEARCH METHODS TO ASSESS DIETARY INTAKE While Ward focused on foods served, Sara Benjamin Neelon focused on foods consumed. She explored the various methods that have been used in the past, as well as some potentially new methods, to assess food and nutrient intake both in and out of child care. Based on comments made at various times throughout the workshop, other speakers and participants seemed to generally agree with Benjamin Neelon’s assessment that the preferred method for collecting data to assess nutrient intake is direct ob- servation in the child care setting, coupled with 24-hour dietary recalls1 of intake both inside and outside the care facility. Finally, Beth Dixon considered the different types of dietary data that can be collected in child care settings and elaborated on the trade-off be- tween project scope and data detail (i.e., with fixed funding, the larger the scope of a study, the less detailed the dietary data collection). The more detailed the data, the greater the opportunity for accurate comparisons with recommended dietary intakes or meal pattern recommendations. While di- rect observation provides the greatest level of detail, it is an expensive data collection method, especially because of the labor involved in collecting the data on site by trained observers. A recurrent theme over the course of the 1-day workshop was the need to be very clear about the desired outcome(s) of a study before developing the methodology—addressing the “what” before the “how.” This is because the “best” method depends on the desired outcome(s). Different methods yield different types of information. This theme was especially prominent in the dialogue summarized in this chapter. For example, the preferred methodology for assessing what children are being served is not necessar- ily the same as the preferred methodology for assessing what children are actually consuming. Nor are the best methods in one setting necessarily the best methods for another setting. All of the speakers featured in this chap- ter emphasized the importance of formulating the research question(s) and desired outcome(s) before deciding on which methods, tools, or research design to use. ADAPTING METHODOLOGY FROM PREVIOUS NATIONAL STUDIES TO ASSESS THE CHILD AND ADULT CARE FOOD PROGRAM2 A useful starting point for considering how to move forward with a nationally representative study of child day care, including CACFP, is to 1 The 24-hour recall method involves collecting data on everything consumed by the partici- pant over the previous 24 hours. 2 This section summarizes the presentation Adapting Methodology from SNDA and FITS Studies to CACFP by Mary Kay Fox of Mathematica Policy Research.

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17 ALIGNMENT OF YOUNG CHILDREN’S DIETARY INTAKE examine methodologies used in similar large national studies. Mary Kay Fox identified two series of studies, conducted by Mathematica Policy Re- search, Inc. for the U.S. Department of Agriculture (USDA), which might be especially helpful: (1) the SNDA studies and (2) the FITS studies. USDA has been conducting the SNDA studies since the early 1990s to assess the food and nutrient content of meals offered and served to students in schools as well as the contribution of these meals to students’ total diets. The 2002 and 2008 FITS studies assessed the usual dietary intakes of infants and tod- dlers and included special procedures for collecting and processing dietary intake data for these age groups. In addition, the SNDA and FITS studies included national samples and provided data that informed previous Insti- tute of Medicine (IOM) Food and Nutrition Board committee work. While components of the SNDA and FITS studies data collection methodologies may be useful in designing the approach for a study of child care, includ- ing the CACFP, Fox emphasized that the methodologies would need to be tailored to the CACFP child care setting(s). She indicated that she would also discuss data collection approaches used in two previous studies of the CACFP, which were modeled on the approaches used in the SNDA studies. Relevance of the SNDA Studies USDA has relied on the SNDA studies since the early 1990s to monitor the quality of school meals and contributions of school meals to children’s overall dietary intakes. Ideally, a national study of child care would pro- vide “SNDA-like” data for the CACFP. The two most recent rounds of the SNDA studies, SNDA-III and SNDA-IV,3 were conducted in school years 2004–2005 (Gordon and Fox, 2007) and 2009–2010, respectively. Both studies included large national samples of school districts and schools— SNDA-III included 129 school districts and 398 schools in 36 states, and SNDA-IV included 578 school districts and 884 schools in 48 states—and collected data on meals offered and served in schools. SNDA-III also col- lected detailed information on students’ dietary intakes both in school and outside of school (2,314 students in 287 schools). Relevance of the FITS Studies The FITS studies, which were sponsored by the Nestlé Nutrition In- stitute in 2008 and Gerber Products Company in 2002, included a com- prehensive assessment of food and nutrient intakes of infants, toddlers, and preschoolers. FITS 2002 included 3,022 infants and toddlers 4 to 24 months of age. FITS 2008 had a slightly larger sample (3,273) and included 3 Data will be published in 2012.

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18 RESEARCH METHODS TO ASSESS DIETARY INTAKE infants, toddlers, and preschoolers from birth to 48 months of age. FITS researchers developed special procedures for collecting and processing di- etary intake data for infants and young toddlers. Given that CACFP feeds infants and toddlers and the unique challenges of collecting dietary intake data on those age groups, Fox suggested that some of the procedures de- veloped by FITS researchers may be useful in a national study of child care, including CACFP. Previous Food and Nutrition Service (FNS)-Sponsored Studies of CACFP Dating back to 1979, USDA has conducted at least three studies of meal quality in CACFP. Fox suggested that the data collection methodolo- gies used in the two most recent studies—the Early Childhood and Child- care Study (Fox et al., 1997) and the Family Child Care Homes Legislative Changes Study (Crepinsek et al., 2002)—should also be reviewed in plan- ning a national study. The Early Childhood and Childcare Study collected data on the foods included in meals and snacks offered by 1,962 CACFP providers, including both child care centers and family child care homes. To obtain information about the amounts of food served, the study included observations of 1,347 children. The CACFP Legislative Changes Study col- lected data on a smaller sample of Tier 24 CACFP family child care homes to see if changes in the way homes were categorized for reimbursement pur- poses (i.e., dividing homes into Tier 1 and Tier 2 categories) had any impact on the quality of meals provided. The study adapted and used most of the data collection methods used in the Early Childhood and Childcare Study. Modifying Existing Methodologies for Use in a National Study of CACFP When considering how existing methodologies might be useful for a nationally representative study of CACFP, Fox suggested that a good first step is to identify key research question(s). With the desired outcome(s) in mind, one can then evaluate whether and how the methodologies can be used or adjusted to accommodate the unique challenges that must be addressed when collecting data in child care settings. She identified two potential overarching research questions for the study. First, how do the meals and snacks offered in child day care centers and homes, including 4 Family child care homes that participate in the CACFP are categorized as either Tier 1 or Tier 2 for reimbursement purposes. Tier I homes are those that are located in low-income areas, or those in which the provider’s household income is at or below 185 percent of the federal income poverty guidelines. Tier II homes are those that do not meet the location or pro- vider income criteria for a Tier I home. However, Tier II providers may elect to have their spon- soring organizations identify income-eligible children, so that meals served to those children who qualify for free and reduced-price meals could be reimbursed at the higher Tier I rates.

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19 ALIGNMENT OF YOUNG CHILDREN’S DIETARY INTAKE those participating in CACFP, align with required meal patterns and the underlying requirements for calories and nutrients? Second, how do the meals and snacks consumed in these settings contribute to children’s overall dietary intakes, and how do children’s overall dietary intakes align with current dietary recommendations? To answer the first question, Fox pointed to the menu survey used in SNDA-IV as a potentially useful tool. She described the SNDA-IV menu survey as a sophisticated and well-organized data collection tool that has been continually tested, refined, and improved since the early 1990s. The original survey was a blank form on which participants simply recorded what they served at lunch and breakfast for a full school week. Over time, SNDA researchers found ways to decrease the burden on respondents while increasing the completeness and quality of the data they provided. The menu survey used in SNDA-IV is now precoded with foods and beverages commonly offered in school meals and includes check boxes and prompts to elicit descriptive information about the foods needed for nutrient analysis (for example, the fat content of milk and whether canned fruit was packed in heavy syrup, light syrup, juice, or water). Menu survey respondents re- ceive an instruction booklet that includes simple but detailed instructions about how to complete each form. In addition, respondents receive in-depth training (by telephone) before they start completing the menu survey, as well as assistance throughout the course of data collection. There is also a detailed editing process that occurs after the surveys are completed (e.g., if there is no mention of condiments, does that mean that no condiments were served or that the respondent forgot to record the condiments?). Finally, respondents in SNDA-IV were offered a $40 to $50 incentive to complete the menu survey. According to Fox, the menu survey methodology used in SNDA-IV could be used as a starting point in developing a menu survey for a study of CACFP, but the materials would need to be modified to accommodate important differences between schools and CACFP settings. Although the meals offered in CACFP settings are generally simpler than meals offered in schools (i.e., they tend to be “set” menus with few choices), CACFP providers typically have less technical food service skills than school food service operators. Additionally, they serve a broad range of age groups, from infants through school-age children, and may serve different foods and beverages to children of different ages. Finally, obtaining information about portion sizes is a particular challenge in CACFP settings. CACFP pro- viders do not typically serve standardized portions the way schools do (e.g., No. 8- or 4-ounce scoops). Many child care providers use family-style meal service at tables where one provider sits with multiple children; providers do not formally track how much food any individual child is receiving. The Early Childhood and Child Care Study used a menu survey that

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20 RESEARCH METHODS TO ASSESS DIETARY INTAKE was adapted from the tools used in the early SNDA studies. It included fewer forms and simpler step-by-step instructions. Fox suggested that this tool could be improved by incorporating precoded lists of foods and check boxes and prompts like those used in the SNDA-IV menu survey. These changes would make it easier for respondents to complete the survey and make it less likely that they would leave out valuable descriptive informa- tion about the foods offered. With respect to the second key research question, which pertains to children’s dietary intakes and contribution of CACFP meals and snacks, useful insights about potential data collection methodologies can be ob- tained from SNDA, FITS, and previous CACFP studies. SNDA-III and both rounds of FITS studies (2002 and 2008) collected data on dietary intakes using 24-hour recalls. Each study included a second 24-hour recall on a subset of the study population in order to estimate usual nutrient intake distributions (IOM, 2000). The FITS studies also collected data on vitamin and mineral supplements, which Fox noted would be important to include in a national study of CACFP if the goal is to assess total nutrient intake. She also emphasized the importance of incentives in gaining cooperation from parents and caregivers. Both SNDA-III and the FITS studies offered incentives, SNDA-III provided $5 to $10 for each recall, and the FITS stud- ies provided $20 for the first recall and $10 for the second. Fox identified two unique challenges that need to be considered in thinking about adapting SNDA-III and FITS methodologies to a study of child day care. The first is how to collect data on the foods consumed while the child is in care. In SNDA-III, data collectors interviewed children about their in-school food consumption shortly after meal times. But the CACFP serves younger children who cannot provide reliable information about their food intakes. In the FITS studies, data on what a child consumed while in care were communicated by the provider either to the parent or to study data collection staff. Theoretically, this approach could work in a child care setting. However, Fox questioned whether it would be realistic to expect a provider to report on multiple children. The second challenge identified by Fox was collecting data on out- of-care intakes for infants and toddlers. Portion sizes for infants and tod- dlers are a unique challenge because of spillage, under- or overestimating amounts, and other factors. For example, portion sizes were overreported in the 2002 FITS, primarily as a result of overreporting of beverage portion sizes. Before the 2008 FITS was initiated, great effort was spent on investi- gating and revising visual aids for estimating portion sizes (i.e., researchers developed visual aids that included age-appropriate measuring cups and bowls; see Figure 2-1). The data collection protocol also needs to include procedures for probing respondents about spillage and waste when estimat- ing the amounts that children actually consumed. Fox also commented that

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21 ALIGNMENT OF YOUNG CHILDREN’S DIETARY INTAKE FIGURE 2-1 Age-appropriate measuring cups used to measure portion size in the 2008 FITS. SOURCE: Nestlé, 2011. Figure 2-1 Bitmapped because of the number of different age groups served in the CACFP, total sample sizes for the dietary intake component of the study may need to be quite large if the goal is to assess usual nutrient intakes for each age group. HOW TO ASSESS FOOD SERVED IN CHILD CARE SETTINGS5 The published literature describes several methodologies for assessing foods served in child care or similar settings: plate waste, direct observa- tion, provider self-report, child care menu analysis, and food purchase receipts. Dianne Ward provided an overview of each methodology and discussed the strengths and limitations of each. To ensure accurate data collection, Ward urged the use of multiple methods (e.g., validating menu analysis with actual observation data; validating self-report with direct observation data; and using a combination of self-report, menu, and direct observation data to get a full picture of types and amounts of foods and beverages served). Regardless of the method(s), she urged that protocols be tested and results verified before large-scale implementation. 5 This section summarizes the presentation of Dianne Ward from the University of North Carolina.

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22 RESEARCH METHODS TO ASSESS DIETARY INTAKE Plate Waste Studies Plate waste studies involve weighing portions provided at a meal or snack prior to service; weighing waste after eating; and then, using a database and software program, translating specific foods and amounts consumed into macro- and micronutrients (e.g., Buzby and Guthrie, 2002; Graves and Shannon, 1983). Plate waste studies have two major strengths, according to Ward. First, they provide a precise estimate of food served and consumed. Second, foods served and consumed can easily be translated into nutrients using the appropriate database or software program. They are limited by the fact that they work better with plated meals (if not plated, the researcher must take self-served meals from the children, then weigh and return them); they require handling foods, which may not be permitted in some settings; and they are very labor intensive and costly. Diet (Direct) Observation Diet, or direct, observation is a visual estimation of the types and amounts of foods and beverages served. There is considerable variability in methodology among published studies with respect to specific proto- col, amount of training required, and precision obtained. Most published observational studies are based on relatively small numbers of centers or homes, with the number of days of intakes observed varying from half a day to multiple days (e.g., half-days at 40 centers, Erinosho et al., 2011; 2 consecutive days at 20 centers, Ball et al., 2008; 3 consecutive days at 12 centers, Briley et al., 1999; 14 days, 7 in the fall and 7 in the spring, at two centers, Bruening et al. 1999). Ball et al. (2007) developed the first published protocol for using direct observation to assess dietary intake among young children in child care. The goal was to train five observers to visually estimate at a predetermined level of precision the amount of food types being served. The training re- quired a total of 56 hours over the course of a month. During the training, after practicing with measuring cups and spoons, the observers were tested in a laboratory setting with 20 common child care foods (e.g., applesauce, animal crackers, spaghetti). The researchers found good agreement between the observer food-quantity estimates and the 20 measured portions of com- mon child care foods (with a mean intraclass correlation coefficient value, or ICC, of 0.99). However, there was considerable variability across foods, with portion sizes of spaghetti being more difficult to estimate than other foods. At the end of the training, the observers were tested again, but in a child care center setting. With foods that were not easy to discern with visual observation, observers were instructed to ask the classroom staff or cook about preparation of the food in question. The child care setting cer-

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23 ALIGNMENT OF YOUNG CHILDREN’S DIETARY INTAKE tification demonstrated good agreement between the observer food-quantity estimates and the 56 foods and beverages tested (ICC = 0.88). The strengths of direct observation are that it is less intrusive than food weighing and provides a replicable dietary observation approach that is po- tentially more usable by researchers. However, the methodology is limited by its requirement for extensive training to ensure interrater reliability, the small number of children that can be observed by one observer, and the need for observers to clarify with food service staff portions for foods that are not easy to decipher by vision. Provider Self-Report Provider self-report involves asking providers (e.g., directors, teachers, food staff) what foods were served to children and, sometimes, the amount of food served. As part of an effort to develop an effective self-report instrument for assessing comprehensive nutrition and physical activity en- vironments in child care, Ward discussed evaluating the reliability and va- lidity of self-report data collection in child care centers. In 2008 Ward and colleagues used an observational instrument known as the Environmental Policy and Assessment Observation tool, which had been developed for the Nutrition and Physical Activity Self Assessment for Child Care program. She described the methodology as being similar to 24-hour recall except that the assessment was conducted in real time (more like a food diary), with both trained observers and care providers recording food intake (Ward et al., 2008). More recently, trained observers visited 50 centers every day for 4 days and assessed the nutrition environment, including foods served (not portion size, except for juice) in target classrooms. Teachers of the target classrooms (i.e., the “providers”) were asked to report on foods and beverages served to the children on each of the same 4 days. The research- ers assessed both reliability (i.e., repeatability of the providers’ reported food lists from one day to the next) and validity of the provider reports (i.e., how closely the providers’ food lists matched the trained observers’ food lists). The researchers concluded that providers can report what was served, but multiple days of reporting might yield more accurate reporting of foods served. Provider self-report is typically used in combination with direct obser- vation on a subsample of centers or homes. For example, both provider self-report and direct observation were used in the two CACFP studies de- scribed by Mary Kay Fox, the Early Childhood and Child Care study (Fox et al., 1997) and the Effects of Lower Meal Reimbursement study (Crepin- sek et al., 2002) (see the previous section summarizing Fox’s presentation). In the 1997 study, which aimed to describe the food and nutrient content of meals and snacks offered by CACFP providers and consumed by par-

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24 RESEARCH METHODS TO ASSESS DIETARY INTAKE ticipating children, the researchers used a provider self-report menu survey of all foods and beverages in all meals and snacks served over a specified 5-day period. Because pretesting showed that most providers were unable to report sufficient detail on portion size, the researchers did not collect portion size data. In addition to provider self-report of the types of foods and beverages offered, trained field staff conducted meal observation in a subset of child care facilities on all meals and snacks consumed by children while in child care on 2 nonconsecutive days. Each observer was responsible for collecting data on six or fewer children. Prior to the meal or snack pro- vision, the observers weighed or measured five reference portions of each food that was going to be offered. During meal time, observers used visual methods to estimate the amount of food received and the amount of food left over by each child. The observation data were used to calculate aver- age portion sizes, which were then used to estimate the nutrient content of the foods offered. The strengths of provider self-report include its lower cost compared to direct observation and other methodologies; the potential to be imple- mented in large numbers of centers and homes; and that it can be supple- mented with observation. However, the methodology is limited by a risk of misreporting, possible inaccuracies, and the multiple days of reporting required. Child Care Menus Child care menu methodology involves assessing detailed lists of foods and beverages served to children for meals and snacks. Such lists are typi- cally offered as a service to parents and, in some states, as a mandate to ensure compliance with program requirements. Ward opined that child care menus could be used to monitor CACFP guidelines. However, foods actually served do not always match planned menus. Fleischhacker et al. (2006) observed and recorded foods served throughout the school day and then compared the food records against monthly menus for 77 days in one Head Start center and found very poor agreement. Of 269 meals and snacks observed, only three breakfast meals and one “ethnic day” matched the menu. Benjamin Neelon et al. (2010), on the other hand, compared 1 day of direct observation with menus at 84 child care centers and found good agreement, with 52 percent of 254 meals and snacks served matching the menu and 87 percent of 710 individual items served matching the menu. Other limitations of child care menus include their lack of detail regarding specific types of foods and beverages provided (e.g., fruit juice versus 100 percent fruit juice), lack of specification about how foods are prepared (e.g., no indication whether the chicken in a sandwich is baked or fried),

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25 ALIGNMENT OF YOUNG CHILDREN’S DIETARY INTAKE the absence of reported condiments used with foods, and difficulty in deci- phering specific ingredients in some dishes (e.g., casseroles). A key strength of child care menus is that they provide a quick and easy way of collecting information about foods served to children. Food Purchase Receipts Food purchase receipts have been used to evaluate associations between food cost and quality of food served. For example, Monsivais and Johnson (2012) collected receipts and detailed menus from 60 home child care pro- viders and found that greater cost was associated with a higher nutritional quality of foods (based on servings of whole grains, fresh whole fruits, and vegetables; energy density [kJ/g]; and mean nutrient adequacy for seven nutrients of concern for child health). Menu details were obtained from forms given to the providers by the research staff. Food purchase receipts provide a quick, easy, and cheap way to collect data about types of foods and beverages offered to children. The methodology places little to no burden on participants, especially if receipts are collected over only a short period of time. However, they are limited as a methodology by the impact of missing or lost receipts; social desirability bias (i.e., during the period of examination, the providers might change the foods they purchase); and that they provide information only about foods purchased, not foods prepared, served, or consumed. DIETARY ASSESSMENT IN YOUNG CHILDREN: TOTAL DAILY INTAKE OF FOOD AND NUTRIENTS6 Sara Benjamin Neelon described assessing dietary intake as a “daunt- ing task,” especially in young children (i.e., children under 5 years of age). She identified several methods for collecting dietary intake data: 24-hour recall (i.e., retrospectively asking someone about everything that the person ate or drank over the previous 24-hour period), food record or diary (i.e., prospectively asking participants to write down everything they consume in a day), food frequency questionnaire (i.e., measuring usual intake over a given amount of time), direct observation (i.e., visually observing what individuals eat), indirect observation (i.e., electronically documenting what individuals eat via videography or photography), and biomarkers (e.g., as- sessing iron status through a blood test, selenium with a toenail clipping, or 6 This section summarizes the presentation of Sara Benjamin Neelon from Duke University. It also describes the discussion that occurred at the end of the first session, when audience members asked questions about one of the methods that Benjamin Neelon described (indirect observation via videography or digital photography).

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26 RESEARCH METHODS TO ASSESS DIETARY INTAKE TABLE 2-1 Three Potential Methods for Assessing Dietary Intake of Children in Child Care Type of Assessment Assessment Method Respondents Direct observation Researcher observation of N/A child Food record or diary Self-administered by adult Parent and child care provider Indirect observation Photography or videography N/A of child SOURCE: Benjamin Neelon, 2012. carotenoid intake as a proxy for fruit and vegetable intake via a palm scan). She focused on three of these methods: direct observation, food record or diary, and indirect observation (see Table 2-1). According to Benjamin Neelon, direct observation is the most common method for assessing dietary intake in child care and is likely to provide the most specific information about foods and beverages consumed in child care. Regardless of the method employed, Benjamin Neelon emphasized the importance of consistency in the use of dietary assessment methodol- ogy to allow for comparison across studies. For example, Ball et al. (2008) assessed foods served to and consumed by children in 20 child care centers and compared both amounts to CACFP and MyPyramid recommended portion sizes for children. By using the same observation method in a recent study of dietary intake of children in child care in Mexico City, Benjamin Neelon et al. (unpublished) were able to compare the Ball dietary intake data to that of the Mexican children. Most researchers couple whichever method they use for in-care data collection with a second method for foods consumed outside of child care. Choices for at-home data collection include 24-hour recall by the parent, food record by the parent, direct observation, and indirect observation (e.g., setting up a video camera in the area of the home where meals are typically eaten). Direct observation in a home setting is usually not practical, and indirect observation is limited by the fact that people often eat in multiple areas of the home (e.g., while watching TV or while “grazing”), outside of the range of the video camera. In Benjamin Neelon’s opinion, 24-hour recall is likely to provide the most specific information about foods and beverages consumed outside of care. Direct Observation in Child Care With direct observation, trained observers are present in the classroom or family child care home for all meals and snacks. Observers document in

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27 ALIGNMENT OF YOUNG CHILDREN’S DIETARY INTAKE detail, often using prepopulated forms, all foods and beverages, including condiments, provided to and consumed by children. Data for both foods and beverages are usually reduced to food groups (e.g., milk) and nutrients (e.g., grams of fat). The preferred ratio is one observer to three children. Benjamin Neelon agreed with Dianne Ward and other workshop par- ticipants who emphasized the importance of using well-trained observers, given that effective direct observation requires practice and skill. She also emphasized the importance of collecting data over multiple days, typically 2 or 3. Limitations of direct observation data collection include the intensive training required of observers, the large amount of time required of observ- ers (both training and observation time), the need for target children to sit near each other (i.e., if an observer is watching multiple children), the small number of children that can be observed (i.e., three per observer in one classroom/area), and the need for some onsite interaction to record specific information about foods and beverages served (e.g., preparation method). Benefits of direct observation in child care include its appropriateness for documenting intake in children of all ages, including infants; its potential to be used in both child care centers and family child care homes; its rela- tively accurate portrayal of foods and beverages and nutrients consumed, with proper training of observers; and the opportunity to collect detailed information about foods and beverages. Many researchers have coupled direct observation in child care with a second method to assess dietary intake at home (i.e., in the morning before child care and in the evening after child care). For example, Bruening et al. (1999) combined direct observation in child care with 24-hour recall from parents (i.e., the 24-hour recall excluded time in child care). Briley et al. (1999) combined direct observation in child care with food records from parents (i.e., the food records excluded time in child care). Bollela et al. (1999) combined direct observation with both 24-hour recall and food records. Food Records in Child Care Food records in child care involve providers recording the amount of all foods and beverages consumed by children throughout the day. Data are often reduced only to food groups. Estimating nutrient content is more challenging (e.g., if a provider does not record condiment consumption, any estimate of fat or sodium consumption would be inaccurate). While it is possible for providers to record both foods provided and foods consumed, researchers typically ask providers to focus on one or the other. The method requires clear instructions and visual aids to help the provider determine portion sizes and other details (e.g., method of food preparation). Research-

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28 RESEARCH METHODS TO ASSESS DIETARY INTAKE ers have not had enough experience with food records to know how many children a single provider can account for at any given time. As an example of food record data collection, Hoyo et al. (2011) asked child care provid- ers to record foods consumed by specific children in child care and asked parents of those children to conduct a 24-hour recall for foods consumed outside of child care. Food record data collection is challenging. The method is limited by the small number of children that can be covered by a provider (one or two); its high risk for inaccuracy, which makes it difficult to calculate nutrient intake; the burden it imposes on providers, given that providers must pay attention to all children during meals and snacks; and limited opportunity to correct mistakes at a later time. Its strengths include its relatively low cost and little researcher time; its lesser invasiveness and disruption for both providers and children, compared to direct observation; its appropriateness for documenting intake in children of all ages, including infants (Benjamin Neelon remarked that food records are “probably one of the better ways to report usual intake” for infants); its potential to be used in multiple classrooms; and its appropriateness for both child care centers and homes. Indirect Observation in Child Care Benjamin Neelon described indirect observation as an “interesting al- ternative” to assessing dietary intake in child care. She was unable to find any published studies that rely on the method but described work that she and her colleagues have been conducting. The staff member places a video camera in the classroom to record all meals and snacks; the camera must be positioned properly; otherwise, some consumption can be missed (e.g., if children move around while eating or drinking). Once the data are collected, trained observers view the videotapes and, as with direct obser- vation, document all foods and beverages provided to and consumed by children. The data are then reduced to foods and beverages by food groups (e.g., milk) and nutrients (e.g., grams of fat). The limitations of indirect observation in child care include the need for target children to sit in a specified location and not move; the inability to adapt to changes in the setting unless the observer stays with the video camera; limited opportunity to correct mistakes; its requirement for some onsite interaction to record certain types of information about foods and beverages (e.g., preparation method); and its limitations for documenting intake in infants (unless the video camera scans the entire room). Benefits of the methodology are the ability to assess multiple children at once; its rela- tively low cost and little researcher time; its lesser invasiveness and disrup- tion compared to direct observation (i.e., children typically become adapted to the presence of video cameras and eventually ignore them); the potential

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29 ALIGNMENT OF YOUNG CHILDREN’S DIETARY INTAKE for multiple observers to review and record dietary intake at a later time, building some quality control into the method; the potential for data to be collected in multiple classrooms (i.e., using multiple video cameras); and its applicability in both child care centers and family child care homes. The question-and-answer period at the end of the first session included some discussion about indirect observation. First, Joanne Guthrie asked about the use of digital photography as a data collection method. Benjamin Neelon replied that food consumption in child care is a dynamic process, with children moving, trading food, throwing food, etc., which can be dif- ficult for a still photo to capture. Dixon mentioned a colleague who worked on a large school food project in New York City that involved photography. In addition to trying to capture what is a dynamic process, it was difficult to get detailed information about type and amount of food. For example, one may see juice but not know whether it is 100 percent juice. With respect to amounts, it was difficult to get the camera angled properly. The research- ers eventually abandoned the effort. Moderator Karen Cullen added that it would be very difficult to capture in a photograph the amount of trading that goes on with elementary children. Second, Jay Hirschman asked about the types of clearances and consents required for videography data collec- tion, as it is not a method that FNS has used in any of its studies. Benjamin Neelon responded that, in her work, she and colleagues ask parents to sign a video consent release form in addition to the standard consent form. So far, they have not received any resistance from parents. ANALYSIS OF DIETARY DATA COLLECTED FROM CHILD CARE SETTINGS7 Beth Dixon elaborated on what emerged as a major overarching theme of the workshop: the choice of method depends on the level of detailed information and outcome(s) desired. She said, “You have to begin with the end in mind.” She identified two sets of “big picture” questions: 1. What do you want to measure? Is the goal of the study to measure what is served, what the children are eating, or both? 2. How much detail do you want to measure? For example, do you want to know “generic” types of foods being served or consumed (e.g., that a child is drinking milk) or do you want to know “spe- cific” types and amounts of foods being served or consumed (e.g., that a child is drinking 1/2 cup of 1 percent milk)? 7 This section summarizes the presentation of Beth Dixon, from New York University.

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30 RESEARCH METHODS TO ASSESS DIETARY INTAKE TABLE 2-2 Suitability of Different Types of Data for Collecting Generic Versus Specific Information About Foods and Beverages, as Well as Amounts Generic Information Specific Information Data Collection Method (e.g., “milk”) (e.g., “1% milk”) Amounts Receipts Yes Yes No Menus Yes Possibly Possibly Staff reports Yes Possibly Likely Direct observation Yes Likely Yes SOURCE: Dixon, 2012. The more detailed the information, the greater the accuracy when comparing data to quantitative dietary recommendations and assessing overall quality of foods served or consumed. While there are a variety of sources of dietary data (see Table 2-2), Dixon said that direct observation provides the greatest level of detail about types and amounts of foods either served or consumed, with menu and staff-reported data being helpful for confirmation. The Challenge of Data Variability Regardless of the source of data, Dixon cautioned that there is consid- erable cross-center variability in the level of detail recorded. This is espe- cially true of menu data collection. For example, a menu from one center may simply list “milk” or “peaches,” while another may list “one-half cup of 1 percent milk” or “4 ounces of canned peaches in light syrup.” Some- times there is considerable cross-center variability in detail even with the more detailed data collection methods, including direct observation. Dixon described two “tiers” of variability in direct observation data collection. First is the actual visual estimate of the type and amount of food being served or consumed, with details varying not just from study to study (e.g., depending on how much instruction is provided), but also from ob- server to observer. With respect to amount, one of the challenges with direct observation is that most estimates of amounts of foods served or consumed are visual “guesstimates” based on observations or staff reports. Most observers are trained to look at foods from a distance and count pieces or mounds of something, which is very difficult given how much activity goes on around food (e.g., children drop food; they share food; sometimes they eat very quickly). The second source of variability in direct observation data collection is data entry into a dietary assessment software system. Researchers rely on

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31 ALIGNMENT OF YOUNG CHILDREN’S DIETARY INTAKE both public and private dietary assessment software systems for estimating food group and nutrient composition of foods served or consumed. Dixon mentioned the National Cancer Institute Automated Self-Administered 24- hour Dietary Recall, which is based on the USDA Automated Multiple Pass Method, the USDA Food and Nutrient Database for Dietary Studies, and the USDA MyPyramid Equivalents Database; the University of Minnesota’s Nutrition Data System for Research; and the Elizabeth Stewart Hands and Associates Food Processor. Irrespective of the software system used, when data are entered in real time, questions about types and amounts of foods recorded on forms can be clarified as necessary. But when entered later, and particularly if they are entered by someone other than the observer, it becomes more difficult to confirm the information. When information is not clear, data enterers have to use their best judgment, rely on defaults in the software system, and, when possible, confirm information with staff at the centers. Scope of the Study Versus Detail of the Data The best-quality data will be those that can be reduced to a level of detail that allows for comparison with both CACFP-recommended meal patterns and Dietary Reference Intakes (i.e., either Recommended Dietary Allowance or Adequate Intake, depending on nutrient). This is true regard- less of whether data are collected only while the child is in child care (and regardless of type of child care facility) or both in care and out of care (i.e., total dietary intake over the course of an entire day), and regardless of whether one is seeking information on what is being served or consumed. Additionally, it would be helpful to collect age-dependent data so that com- parisons can be made to age-based recommendations, as both meal pattern and nutrient intake recommendations are different for different age groups. One of the challenges for the child care setting is that children are often observed randomly and their exact ages are unknown. In addition to detail, an accurate comparison to CACFP-recommended meal patterns and Dietary Reference Intakes requires accurate collection of both types and amounts of foods. Reiterating what previous speakers said, Dixon emphasized the importance of observer training. Research staff members need to be trained to observe consistently, record consistently (e.g., “cookie” versus “chocolate chip cookie” versus “Chips Ahoy choco- late chip cookie”), accurately estimate common portion sizes, and enter data into the data assessment software system consistently. To improve identification of foods, observers can confirm with teachers or food service staff and check the kitchen. To improve estimation of amounts, researchers should provide observers with visual aids of portion sizes and list options for proportions of portion sizes on forms (e.g., 1/4 cup, 1/2 cup, 3/4 cup).

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32 RESEARCH METHODS TO ASSESS DIETARY INTAKE Which Method(s)? Importance in Study less more Number of Dietary Factors less more Distribution of Dietary Factors less more Time less more Money less more Food Menus, Direct Receipts Staff Reports Observation FIGURE 2-2 Different dietary data collection methods provide varying levels of detailed information and require varying amounts of time and money. SOURCE: Dixon, 2012. Because the collection of high-quality comprehensive dietary informa- tion takes time and money (see Figure 2-2), Dixon cautioned that a nation- Figure 2-2 ally representative survey will need to be either small(er) in scope and focus on detailed dietary data collection from all centers or large(r) in scope with a subsample that includes detailed dietary data collection. REFERENCES Ball, S. C., S. E. Benjamin, and D. S. Ward. 2007. Development and reliability of an observa- tion method to assess food intake of young children in child care. Journal of the Ameri- can Dietetic Association 107(4):656-661. Ball, S. C., S. E. Benjamin, and D. S. Ward. 2008. Dietary intakes in North Carolina child-care centers: Are children meeting current recommendations? Journal of the American Dietetic Association 108(4):718-721. Benjamin Neelon, S. E. 2012. Dietary assessment in young children: Total daily intake of food and nutrients. Presented at the Institute of Medicine Workshop on Review of the Child and Adult Care Food Program: Future Research Needs, Washington, DC, February 7.

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34 RESEARCH METHODS TO ASSESS DIETARY INTAKE Nestlé. 2011. FITS 2008 food measurement guide. http://medical.gerber.com/nestlescience/fits. aspx (accessed May 7, 2012). Ward, D. S., D. Hales, K. Haverly, J. Marks, S. Benjamin, S. Ball, and S. G. Trost. 2008. An instrument to assess the obesogenic environment of child care centers. American Journal of Health Behavior 32(4):380-386.