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Policy Improves What Beverages Are Served to Young Children in Child Care
RESEARCH
Original Research
Policy Improves What Beverages Are Served to Young Children in Child Care Lorrene D. Ritchie, PhD, RD; Sushma Sharma, PhD; Ginny Gildengorin, PhD; Sallie Yoshida, DrPH, RD; Ellen Braff-Guajardo, JD, MEd; Patricia Crawford, DrPH, RD ARTICLE INFORMATION Article history: Accepted 16 July 2014 Available online 11 September 2014
Keywords: Child care Nutrition policy Beverages Policy compliance Food assistance 2212-2672/Copyright ª 2015 by the Academy of Nutrition and Dietetics. http://dx.doi.org/10.1016/j.jand.2014.07.019
ABSTRACT Background During 2008, we conducted a statewide survey on beverages served to preschool-aged children in California child care that identified a need for beverage policy. During 2011, the US Department of Agriculture began requiring that sites participating in the Child and Adult Care Food Program (CACFP) make drinking water available throughout the day and serve only low-fat or nonfat milk to children aged 2 years and older. During 2012, the California Healthy Beverages in Childcare law additionally required that all child-care sites eliminate all beverages with added sweetener and limit 100% juice to once daily. Design To assess potential policy effects, we repeated the statewide survey in 2012. During 2008 and 2012, a cross-sectional sample of w1,400 licensed child-care sites was randomly selected after stratifying by category (ie, Head Start, state preschool, other CACFP center, non-CACFP center, CACFP home, and non-CACFP home). Results Responses were obtained from 429 sites in 2008 and 435 in 2012. After adjustment for child-care category, significant improvements in 2012 compared with 2008 were found; more sites served water with meals/snacks (47% vs 28%; P¼0.008) and made water available indoors for children to self-serve (77% vs 69%; P¼0.001), and fewer sites served whole milk usually (9% vs 22%; P¼0.006) and 100% juice more than once daily (20% vs 27%; P¼0.038). During 2012, 60% of sites were aware of beverage policies and 23% were judged fully compliant with the California law. Conclusions A positive effect occurred on beverages served after enactment of state and federal policies. Efforts should continue to promote beverage policies and support their implementation. J Acad Nutr Diet. 2015;115:724-730.
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EARLY TWO-THIRDS OF US CHILDREN YOUNGER than age 5 years attend child care, where they spend an average of 33 hours each week 1 and receive up to two-thirds of their daily nutrition.2 Compared with school settings, few obesity prevention efforts have focused on child-care settings.3 Because more than one quarter of children are overweight or obese when entering kindergarten,4 waiting until children attend school misses an early opportunity to establish healthy dietary behaviors. During the past 4 decades in which obesity prevalence has risen, children’s intake of sugar-sweetened beverages and 100% juice has increased, intake of milk has declined,5,6 and water intake has remained low.7,8 Nationally, preschool-aged children’s daily intakes average 12.3 oz milk (below the recommended 16 to 20 oz/day9), 4.7 oz 100% juice, 5.0 oz fruit drinks, and 3.3 oz soda.10 It is estimated that sugarsweetened beverages account for at least one fifth of the weight gained by the US population since the 1970s.11 As intake of caloric beverages increases, so does energy intake,10 consistent with clinical studies demonstrating incomplete physiologic compensation for calories consumed in liquid 724
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compared with solid forms.12 During 2008, we evaluated the beverages served in a statewide sample of child-care sites in California and identified need for improvement concerning the provision of water, serving lower-fat milk, and limiting juice.13 Child-care sites can elect to participate in the federal Child and Adult Care Food Program (CACFP), which provides reimbursement for meals and snacks served daily to more than 3 million children.14,15 More than one in nine children in CACFP reside in California.16 Meals and snacks provided through CACFP must follow a pattern of food groups (ie, milk, fruit/vegetables, grains/breads, and meats) in portions specified by age and eating occasion. Consistent with the Healthy, Hunger-Free Kids Act of 2010, as of October 2011 sites participating in CACFP must serve low-fat or nonfat milk to children aged 2 years and older, and drinking water must be made available throughout the day.17,18 There are no restrictions on 100% juice, flavored milk, or other sugarsweetened beverages. A number of states also have enacted legislation to improve beverage quality in child care,19 of which California’s Healthy Beverages in Childcare law (Assembly Bill 2084) is the most ª 2015 by the Academy of Nutrition and Dietetics.
RESEARCH comprehensive. It exceeds federal CACFP beverage requirements17,18 and Institute of Medicine recommendations for CACFP20 in scope, and applies to all licensed child-care sites, including non-CACFP sites. Passed in September 2010 and implemented in January 2012, the California law mandates that drinking water should be available at all times, all beverages with added sweetener, either artificial or natural and including flavored milk, are prohibited, no more than one age-appropriate serving of 100% juice is allowed daily, and only low-fat or nonfat milk should be served to children aged 2 years and older.21 Before this law, no state regulations existed in California on beverages in child care. The aim of this study was to evaluate changes in beverages served to children aged 2 to 5 years by comparing crosssectional statewide samples of child-care sites before (in 2008) and after (in 2012) the California and federal child care beverage policies were implemented. The primary hypothesis was that beverages would improve, as measured by more sites making drinking water available and serving only lowfat or nonfat milk, and fewer sites serving sugar-sweetened beverages and serving 100% juice more than once daily.
METHODS The study was an uncontrolled preepost assessment of childcare sites, with independent samples surveyed during 2008 and 2012. The methods used in 2012 were the same as those used in the 2008 study.13 The study was deemed exempt by the Committee for the Protection of Human Subjects at the University of California, Berkeley.
Sample Selection A stratified random sample of 1,484 child-care sites was selected in late 2011 from state databases of all licensed child-care centers and family homes in California (>50,000). To allow for comparisons over time within category, an equivalent number of sites was selected from each of six categories: Head Start centers (CACFP participation required), state preschools (required to follow CACFP standards by participating in either CACFP or the federal school meals program), other centers in CACFP, non-CACFP centers, family child-care homes in CACFP, and non-CACFP homes.
Survey Instrument Study-specific questions were adapted from a previous survey that had been validity tested by comparing provider selfreport to researcher observation.22 The same survey was used in 2008 and 2012, with minor modifications specific to the purpose of each study. Included was a frequency checklist of 21 foods and beverages that asked respondents to record what was served to children aged 2 to 5 years on the day preceding the survey. Respondents were instructed to include items provided by the site as well as by parents, and to indicate whether items were served at a meal (ie, breakfast, lunch, and dinner) or snack. Additional questions asked about type of milk served (usually and ever), provision of drinking water at the table with meals or snacks, availability of selfserve drinking water indoors and outside, and factors influencing beverages served. For each beverage category, a question was asked about what makes it hard to serve more (for water and lower-fat, unflavored milk) or less (for sugarsweetened drinks and juice) of a beverage. Respondents May 2015 Volume 115 Number 5
were asked to mark all that apply among up to 20 reasons provided, including “it is not hard” and a write-in option. Similar questions asked about what helps sites serve beverages. The survey was tested for comprehension and length with staff of child-care sites participating in another research project. The survey and accompanying materials were translated into Spanish and then reviewed by a second native Spanish-speaker of Mexican descent. Discrepancies in translation were discussed and resolved. The final survey took approximately 20 minutes to complete (available at http:// cwh.berkeley.edu/sites/default/files/primary_pdfs/CA_Child CareSurvey_English_Spanish_1.12.pdf).
Sample Recruitment and Survey Data Collection During early 2012, selected sites were mailed postcards, in English and Spanish, inviting one or more staff familiar with foods and beverages served to complete a single online survey (developed by Qualtrics). A reminder letter, paper copy of the survey, and return stamped envelope were mailed 2 months later to nonrespondents. Follow-up telephone calls were made to nonrespondents 1 month later. All respondents were sent a $5 gift card, and enrolled in a lottery for a $200 grocery store gift certificate.
Data Analysis Data from paper surveys (n¼335) were merged with data from online surveys (n¼121). Ten percent of paper surveys were double-entered to check for data entry errors. Of the total of 456 completed surveys in 2012 (for a 31% response rate), eight were excluded as sites caring only for children younger than age 2 years, and 13 were excluded as having incomplete data on site characteristics and beverages served. Fewer than 4% of responses were missing for any survey item; imputation of missing data was not performed and nonresponses were included in the denominator when appropriate. Because we were interested in comparing child-care categories rather than obtaining population estimates, sample weights were not used. In 2008 and 2012, 16% and 12%, respectively, of family child-care home providers elected to complete the survey in Spanish. The number of usable surveys (n¼435) and response rate in 2012 were similar to that observed in 2008 (n¼429; 31% response rate). Data were analyzed using the statistical analysis software SPSS version 19 (2010, SPSS Inc) and SAS version 9.3 (2011, SAS Institute Inc). Differences between survey responses in 2008 and 2012 were assessed using c2 tests or logistic regression for categorical variables and analysis of variance or linear regression models for continuous variables. Binary measures (whether or not a beverage was served) were created. Multivariate regression models used the maximum likelihood method to fit the logistic regression models for binary outcomes. All models included child-care category (ie, Head Start, state preschool, other CACFP center, nonCACFP center, CACFP home, or non-CACFP home) as a covariate to adjust for differences by category. If significant F statistics were found in the analysis of variance models, we then accounted for multiple comparisons using the TukeyKramer test. A significance level of 0.05 was used for all statistical tests. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
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RESEARCH RESULTS Site Characteristics
Beverage Practices
Between 2008 and 2012, there were differences in the numbers of sites in each category, the mean number of children in child care, and the proportion of sites serving snacks, and using an independent vendor for food preparation (Table 1). Characteristics that might influence foodservice also differed by the six child-care categories (eg, meals and snack served; data not shown).
Milk was served by a majority of sites on the day before the survey both before and after the beverage policies were instituted (Table 2). Significantly fewer sites reported usually serving whole milk and more sites usually served lower-fat (reduced-fat or low-fat) or nonfat milk during 2012 compared with 2008. When asked about all types of milk served, lower-fat milk was most commonly reported and significantly more sites ever served lower-fat and nonfat milk
Table 1. Characteristics of California child-care sites participating in 2008 and 2012 surveys on beverages served to children aged 2 to 5 years 2008a (n[429) Characteristic
n
2012 (n[435) %
n
%
Child-care categoryc
0.0001
Head Start centers
66
15
78
18
State preschools
68
16
93
21
d
CACFP centers
104
24
48
11
88
21
82
19
CACFP family homes
65
15
93
21
Non-CACFP family homes
38
9
41
10
Non-CACFP centers
P valueb
meanstandard deviation! No. of children (2-5 y) in care
72.6192.6
93.1317.2
0.027
% ! Site director/owner responded to survey
97.7
98.0
0.335
Full-day care provided
75.0
72.9
0.357
Meals and snacks served Breakfast
75.1
80.5
0.060
Morning snack
60.1
82.8
0.0001
Lunch
89.3
89.2
1.00
Afternoon snack
83.7
91.0
0.001
Dinner
17.7
19.5
0.497
Evening snack
21.4
12.2
0.034
Food source Site only
0.238 99.3
98.1
Site and home
0.2
0.2
Home only
0.5
1.7
Location of food preparation At local site
66.7
63.0
0.518
Central kitchen
13.3
16.1
0.169
School foodservice
17.7
20.5
0.773
3.5
6.7
0.022
Independent vendor a
Findings from the 2008 survey were previously published.13 Analyzed by logistic regression or linear regression models adjusted for child-care category (child-care category is unadjusted). c Head Start centers and state preschools are required to participate in CACFP or the federal school meals program. CACFP centers were other centers that also participated in CACFP. d CACFP¼Child and Adult Care Food Program. b
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May 2015 Volume 115 Number 5
RESEARCH Table 2. Beverages provided by California child-care sites before (in 2008) and after (in 2012) beverage policies for children aged 2 to 5 years were enacted Beverage
2008 (n[429)
2012 (n[435)
P valuea
% of sites! Milk Provided (any type) on day before survey
93.1
93.0
0.570
21.9
8.5
0.006
72.0
79.0
0.013
1.9
6.9
0.001
Type most often provided Whole Lower-fat (reduced-fat or low-fat)
b
Nonfat Rice or soy
0.9
0.5
0.909
Flavored or sweetened
1.6
0.5
0.056
32.2
26.9
0.099
All types of milk (ever) provided Whole Lower-fat (reduced-fat or low-fat)
b
81.2
98.0
0.008
5.1
13.1
<0.001
Rice or soy
25.2
28.0
0.072
Flavored or sweetened
10.5
7.4
0.088
Available for self-serve indoors
69.0
76.5
0.001
Available for self-serve outside
68.8
77.5
<0.001
Always provided with meals and snacks
28.0
46.7
0.008
Nonfat
Water
100% fruit or vegetable juicec Provided on day before survey
64.1
61.6
0.105
Provided more than once per day on day before survey
27.0
19.5
0.038
7.6
6.9
0.903
Sugar-sweetened beveragesd Provided on day before survey a
Analyzed by logistic regression models and adjusted for child-care categories. During 2008 response options for reduced-fat and low-fat milks were combined. During 2012, reduced-fat and low-fat milks were separate response options but are combined in this Table. c Excludes fruit-flavored drinks like Kool-Aid (Kraft Foods), Sunny Delight (Procter & Gamble), Hawaiian Punch (Dr Pepper Snapple Group), lemonade, and agua frescas. d Includes soda, sports drinks, Kool-aid, Sunny Delight, Capri Sun (Kraft Foods), Hawaiian Punch, lemonade, fruit drinks, agua frescas, and sweet teas. Does not include diet drinks sweetened with artificial sweeteners. b
during 2012 compared with 2008. Although the percentage of sites usually or ever serving flavored milk decreased from 2008 to 2012, the changes were not significant. Compared with 2008, during 2012 significantly more childcare sites made water available for self-serve, both indoors and outside, and served water with meals and snacks. The proportion of sites serving 100% juice more than once daily decreased significantly. Few sites served sugar-sweetened beverages during 2008, and this did not change significantly in 2012. Diet beverages were not queried in 2008; during 2012 they were served by 5.0% of sites the day before the survey.
Policy Compliance A total of 60.2% of survey respondents in 2012 reported being aware of new beverage policies. A significantly higher May 2015 Volume 115 Number 5
percentage of CACFP (67.3%) than non-CACFP (42.2%) sites were aware of the policies (P¼0.043). Full compliance with the state law was calculated for the 2012 sample based on having water easily available for self-serve both inside the child-care site and outside where children play, usually serving low-fat or nonfat milk, never serving whole or flavored milk, serving 100% juice not more than once, and serving no sugar-sweetened or diet beverages the day before the survey. We were unable to calculate full compliance during 2008 because provision of diet drinks was not queried and response options for low-fat and reduced-fat milk were combined. During 2012, 23.2% of sites (n¼101) were fully compliant; compliance rates differed significantly by childcare category (P¼0.0001). Forty-one percent of Head Start sites, 32.3% of state preschools, and 27.1% of CACFP centers were judged fully compliant. Lower rates of compliance were found in non-CACFP centers (15.9%), CACFP homes (9.3%), and JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
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RESEARCH Table 3. Factors that influence change in beverages served to children aged 2 to 5 years in California child-care sites during 2012 (N¼435)
Factor
More water
Lower-fat/ unflavored instead of higher-fat/flavored
Limit sugar-sweetened beverages
Limit 100% juice
Overalla (mean–SDb)
% of sites! Beverage policy
37.5
41.6
43.0
42.3
41.12.5y
Parent/family support
27.6
24.4
26.7
24.6
25.81.6z
Training for child-care providers
23.7
22.8
22.1
26.0
23.61.7z
Lessons for children
40.2
18.9
27.4
23.2
27.49.2z
Information for families
39.1
34.9
37.9
35.9
36.91.9y
P¼0.0001 for differences in facilitating factors for changing beverages based on analysis of variance model. SD¼standard deviation. yz Values not sharing a common superscript (y, z) are significantly different based on Tukey’s adjustment for multiple comparisons. a
b
non-CACFP homes (7.3%). Significantly more sites in CACFP (30.2%) were fully compliant compared with non-CACFP sites (12.4%) (P¼0.032). The provision that was not met by the most sites was type of milk served (48.7% of sites were noncompliant), 26.7% of sites served 100% juice more than once per day, 22.5% did not have water available inside and outside, and 13.3% served sugar-sweetened or diet beverages.
Factors Influencing Compliance Most sites reported no barriers to serving children lower-fat or unflavored milk (70.6%), more water (76.6%), and less juice (76.7%), and eliminating sugar-sweetened beverages (83.9%). Fewer than 10% reported issues that made serving healthy beverages difficult, which included:
self-identified government rule against serving water with meals and snacks (although there is no CACFP rule against serving water with meals and snacks); cost (associated with serving fresh fruit vs juice, and serving bottled water or needing water filters or cups); no CACFP reimbursement for water; receiving whole milk or >1 serving of juice from school foodservice; difficulty buying different types of milk for children of different ages; taste preferences of children for whole milk, sugarsweetened beverages, and juice; parent preferences for milk; and parents bringing sugar-sweetened beverages to childcare sites.
The two most frequently cited factors that facilitated serving healthy beverages were having beverage policy and information for families (Table 3). There was a significant correlation between awareness of beverage policies and full compliance with it (r¼0.37; P¼0.004). Other factors cited as helping with the provision of healthy beverages were: lessons for children, parent/family support, and training for child-care providers. 728
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IMPLICATIONS FOR PRACTICE We documented improvements in the serving of healthy beverages in California child-care sites between 2008 and 2012, several months after the California Healthy Beverages in Childcare law and federal CACFP requirements on water and milk went into effect. Significant improvements were noted in water available for self-service indoors and outside, water served with meals and snacks, providing lower-fat varieties of milk instead of whole or reduced-fat milk, and limiting 100% juice servings to once per day. Before these policies, nearly all sites were serving milk and did not serve sugar-sweetened beverages, and these practices did not change between the two survey time points. In contrast, during 2008-2009 more than 90% of US public elementary schools served flavored milk at lunch on most days.23 Despite notable improvements in beverage offerings, our results suggest the need for additional improvement. Overall, more than three quarters of sites did not meet all provisions of the California law. The California law was used as the standard for compliance because it is more comprehensive than the federal CACFP beverage requirements in that it includes provisions on sugar-sweetened beverages and juice in addition to water and milk and pertains to all licensed childcare sites, regardless of CACFP participation. Incomplete compliance may be attributable to the large proportion of sites (w40%) that were unaware of beverage policies, and insufficient time or knowledge on how to fully implement the provisions. The California law was implemented only 2 months before the start of survey data collection and the federal CACFP law only a couple months before the California law, although both laws passed during 2010, more than a year before the start of the 2012 survey. Few sites reported barriers to serving healthy beverages, but factors such as cost and parent and child preferences may have influenced some sites more than others. Systematic outreach and education with sites and parents may be needed to educate and support efforts to improve beverage offerings. Compliance was higher among sites participating in CACFP compared with non-CACFP sites. It is possible that CACFP sites were more likely than non-CACFP sites to receive May 2015 Volume 115 Number 5
RESEARCH communications about beverage policies because they were covered by both the California and federal policies. We and others have previously shown that CACFP sites may be better informed about nutrition and provide healthier options to children.13,24 During a 2008 national study, 59% of Head Start centers never served flavored milk, 99% never served other sugarsweetened beverages, and 70% served mostly low-fat or nonfat milk to children.25 Higher numbers for sugarsweetened beverages were reported by our sample, which included other categories of child care in addition to Head Start. Head Start sites have previously been shown to provide healthier options than other categories of child care,13 possibly because of more extensive federal regulations and support.2 In a recent study of 40 CACFP centers in Connecticut involving direct observation, 84% had water accessible in classrooms and one third had water accessible during physical activity periods from either adult-accessible or childaccessible sources; water was not available for general consumption during any of the lunch observations.26 In our study, child-accessible water both indoors and outside in addition to water provision with meals and snacks were examined, based on the assumption that child-care providers have limited time available to serve water to children individually upon request. The fact that we found a much higher proportion (47%) of sites that reported making water available at the table compared with the Connecticut study may be because we relied on self-reported practice and included sites not participating in CACFP. Anecdotally, numerous childcare providers have reported the misperception that the US Department of Agriculture prohibits CACFP sites from serving water with meals and snacks due to concern that water will compete with the intake of milk and other foods. Although there is little evidence to support this concern,27 more studies on this topic with young children are warranted and may be necessary before child-care providers widely adopt the practice of serving water with meals and snacks. To our knowledge this is the first comprehensive assessment of the influence of beverage policies in child care. Beverage policies in schools have been associated with reduced student access and consumption of sugary drinks during school time.28-30 However, less conclusive is whether school beverage policies influence students’ overall daily consumption.29,31 Studies are needed of the influence of child-care beverage policies on children’s intakes. Our study has limitations. Although similar to the response seen in other institutional survey studies,32 the response rate was relatively low (w30%), and it is possible that findings would have been different with a higher response. Generalizability may be further limited by the uneven response by category of child care, although category was controlled for in analyses. Because of high turnover in child care-settings likely to have occurred over 5 years, it was not possible to survey the same sites in 2012 as in 2008. In addition, study data were reliant on self-reported practices and several measures of compliance relied on what was served during a single day. It is possible that sites overreported their policy compliance or reported on a day that was not representative of usual practice, which cannot be verified without onsite observations. Also, with naturalistic experiments such as this, unidentified factors could have changed child-care beverages beyond the possible influence of the state and federal May 2015 Volume 115 Number 5
policies. The significant correlation observed between knowledge of and compliance with beverage policies and the fact that beverage policy was endorsed by more sites than other factors in helping to serve healthier beverages suggest that the laws played a role in the observed improvements. Nonetheless, contribution from other factors cannot be ruled out. Although the policies had been passed over a year before the 2012 survey, sites were only required to implement the laws several months before being assessed. It is possible that had we conducted the follow-up later, we may have found greater compliance. Finally, we did not assess the influence of the changes in beverages served on the intake of beverages— or other foods that may have changed in compensation—by children in child care.
CONCLUSIONS This study is the first to show a positive influence on beverages served at child-care sites after the introduction of healthy beverage policies. Having policy in place was reported to be the main factor in helping sites to provide healthy beverages. However, given that most sites were not judged fully compliant, efforts should continue to raise awareness and support child-care providers to achieve compliance with the letter and—more importantly for the health of children—the spirit of the law.
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Taber DR, Chriqui JF, Powell LM, Chaloupka FJ. Banning all sugarsweetened beverages in middle schools: Reduction of in-school access and purchasing but not overall consumption. Arch Pediatr Adolesc Med. 2012;166(3):256-262.
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Turner L, Chaloupka FJ. Wide availability of high-calorie beverages in US elementary schools. Arch Pediatr Adolesc Med. 2011;165(3): 223-228.
32.
Ragland E, Tropp J. USDA National Farmers Market Manager Survey, 2006. May 2009. http://dx.doi.org/10.9752/MS037.05-2009. Accessed December 3, 2013.
AUTHOR INFORMATION L. D. Ritchie is director of research, Atkins Center for Weight and Health, University of California, Berkeley, and director and cooperative extension specialist, Nutrition Policy Institute, Agriculture and Natural Resources, Office of the President, University of California, Oakland. S. Sharma is director of population and public health research, Dallas-Fort Worth Hospital Council Foundation, Irving, TX; at the time of the study, she was an assistant researcher, Atkins Center for Weight and Health, University of California, Berkeley. G. Gildengorin is a senior statistician and P. Crawford is director, Atkins Center for Weight and Health, University of California, Berkeley. S. Yoshida is executive director, Sarah Samuels Center for Public Health Research and Evaluation, Oakland, CA. E. Braff-Guajardo is program officer, W.K. Kellogg Foundation, Battle Creek, MI; at the time of the study, she was senior nutrition policy advocate, California Food Policy Advocates, Oakland. Address correspondence to: Lorrene D. Ritchie, PhD, RD, Nutrition Policy Institute, Agriculture and Natural Resources, Office of the President, University of California, 1111 Franklin St, 10th Fl, Oakland, CA. E-mail: [email protected]
STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT This research was supported by Robert Wood Johnson Foundation Healthy Eating Research Grant No. 69298.
ACKNOWLEDGEMENTS The authors thank Ken Hecht, JD, Kumar Chandran, MS, MPH, and the late Sarah Samuels, DrPH, for providing study conception and design; Paula James, Ed Mattson, and Anisha Patel, MD, MSPH, MSHS, for providing survey critique; Sally Smyth, MPP, Shelly Mandel, Sheila Stern, Lauren Goldstein, PhD, Temika Green, Shauna Pirotin, MPH, RD, Jessica Jew, Claudia Olague, and Nayeli Cerpas-Bernal, MPH, for providing assistance with conducting the study; and Karen Webb, PhD, and Elyse Homel Vitale, MPH, for providing manuscript review. The authors also thank the many busy child-care site staff members for responding to the surveys.
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JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
May 2015 Volume 115 Number 5
Original Research
Policy Improves What Beverages Are Served to Young Children in Child Care Lorrene D. Ritchie, PhD, RD; Sushma Sharma, PhD; Ginny Gildengorin, PhD; Sallie Yoshida, DrPH, RD; Ellen Braff-Guajardo, JD, MEd; Patricia Crawford, DrPH, RD ARTICLE INFORMATION Article history: Accepted 16 July 2014 Available online 11 September 2014
Keywords: Child care Nutrition policy Beverages Policy compliance Food assistance 2212-2672/Copyright ª 2015 by the Academy of Nutrition and Dietetics. http://dx.doi.org/10.1016/j.jand.2014.07.019
ABSTRACT Background During 2008, we conducted a statewide survey on beverages served to preschool-aged children in California child care that identified a need for beverage policy. During 2011, the US Department of Agriculture began requiring that sites participating in the Child and Adult Care Food Program (CACFP) make drinking water available throughout the day and serve only low-fat or nonfat milk to children aged 2 years and older. During 2012, the California Healthy Beverages in Childcare law additionally required that all child-care sites eliminate all beverages with added sweetener and limit 100% juice to once daily. Design To assess potential policy effects, we repeated the statewide survey in 2012. During 2008 and 2012, a cross-sectional sample of w1,400 licensed child-care sites was randomly selected after stratifying by category (ie, Head Start, state preschool, other CACFP center, non-CACFP center, CACFP home, and non-CACFP home). Results Responses were obtained from 429 sites in 2008 and 435 in 2012. After adjustment for child-care category, significant improvements in 2012 compared with 2008 were found; more sites served water with meals/snacks (47% vs 28%; P¼0.008) and made water available indoors for children to self-serve (77% vs 69%; P¼0.001), and fewer sites served whole milk usually (9% vs 22%; P¼0.006) and 100% juice more than once daily (20% vs 27%; P¼0.038). During 2012, 60% of sites were aware of beverage policies and 23% were judged fully compliant with the California law. Conclusions A positive effect occurred on beverages served after enactment of state and federal policies. Efforts should continue to promote beverage policies and support their implementation. J Acad Nutr Diet. 2015;115:724-730.
N
EARLY TWO-THIRDS OF US CHILDREN YOUNGER than age 5 years attend child care, where they spend an average of 33 hours each week 1 and receive up to two-thirds of their daily nutrition.2 Compared with school settings, few obesity prevention efforts have focused on child-care settings.3 Because more than one quarter of children are overweight or obese when entering kindergarten,4 waiting until children attend school misses an early opportunity to establish healthy dietary behaviors. During the past 4 decades in which obesity prevalence has risen, children’s intake of sugar-sweetened beverages and 100% juice has increased, intake of milk has declined,5,6 and water intake has remained low.7,8 Nationally, preschool-aged children’s daily intakes average 12.3 oz milk (below the recommended 16 to 20 oz/day9), 4.7 oz 100% juice, 5.0 oz fruit drinks, and 3.3 oz soda.10 It is estimated that sugarsweetened beverages account for at least one fifth of the weight gained by the US population since the 1970s.11 As intake of caloric beverages increases, so does energy intake,10 consistent with clinical studies demonstrating incomplete physiologic compensation for calories consumed in liquid 724
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
compared with solid forms.12 During 2008, we evaluated the beverages served in a statewide sample of child-care sites in California and identified need for improvement concerning the provision of water, serving lower-fat milk, and limiting juice.13 Child-care sites can elect to participate in the federal Child and Adult Care Food Program (CACFP), which provides reimbursement for meals and snacks served daily to more than 3 million children.14,15 More than one in nine children in CACFP reside in California.16 Meals and snacks provided through CACFP must follow a pattern of food groups (ie, milk, fruit/vegetables, grains/breads, and meats) in portions specified by age and eating occasion. Consistent with the Healthy, Hunger-Free Kids Act of 2010, as of October 2011 sites participating in CACFP must serve low-fat or nonfat milk to children aged 2 years and older, and drinking water must be made available throughout the day.17,18 There are no restrictions on 100% juice, flavored milk, or other sugarsweetened beverages. A number of states also have enacted legislation to improve beverage quality in child care,19 of which California’s Healthy Beverages in Childcare law (Assembly Bill 2084) is the most ª 2015 by the Academy of Nutrition and Dietetics.
RESEARCH comprehensive. It exceeds federal CACFP beverage requirements17,18 and Institute of Medicine recommendations for CACFP20 in scope, and applies to all licensed child-care sites, including non-CACFP sites. Passed in September 2010 and implemented in January 2012, the California law mandates that drinking water should be available at all times, all beverages with added sweetener, either artificial or natural and including flavored milk, are prohibited, no more than one age-appropriate serving of 100% juice is allowed daily, and only low-fat or nonfat milk should be served to children aged 2 years and older.21 Before this law, no state regulations existed in California on beverages in child care. The aim of this study was to evaluate changes in beverages served to children aged 2 to 5 years by comparing crosssectional statewide samples of child-care sites before (in 2008) and after (in 2012) the California and federal child care beverage policies were implemented. The primary hypothesis was that beverages would improve, as measured by more sites making drinking water available and serving only lowfat or nonfat milk, and fewer sites serving sugar-sweetened beverages and serving 100% juice more than once daily.
METHODS The study was an uncontrolled preepost assessment of childcare sites, with independent samples surveyed during 2008 and 2012. The methods used in 2012 were the same as those used in the 2008 study.13 The study was deemed exempt by the Committee for the Protection of Human Subjects at the University of California, Berkeley.
Sample Selection A stratified random sample of 1,484 child-care sites was selected in late 2011 from state databases of all licensed child-care centers and family homes in California (>50,000). To allow for comparisons over time within category, an equivalent number of sites was selected from each of six categories: Head Start centers (CACFP participation required), state preschools (required to follow CACFP standards by participating in either CACFP or the federal school meals program), other centers in CACFP, non-CACFP centers, family child-care homes in CACFP, and non-CACFP homes.
Survey Instrument Study-specific questions were adapted from a previous survey that had been validity tested by comparing provider selfreport to researcher observation.22 The same survey was used in 2008 and 2012, with minor modifications specific to the purpose of each study. Included was a frequency checklist of 21 foods and beverages that asked respondents to record what was served to children aged 2 to 5 years on the day preceding the survey. Respondents were instructed to include items provided by the site as well as by parents, and to indicate whether items were served at a meal (ie, breakfast, lunch, and dinner) or snack. Additional questions asked about type of milk served (usually and ever), provision of drinking water at the table with meals or snacks, availability of selfserve drinking water indoors and outside, and factors influencing beverages served. For each beverage category, a question was asked about what makes it hard to serve more (for water and lower-fat, unflavored milk) or less (for sugarsweetened drinks and juice) of a beverage. Respondents May 2015 Volume 115 Number 5
were asked to mark all that apply among up to 20 reasons provided, including “it is not hard” and a write-in option. Similar questions asked about what helps sites serve beverages. The survey was tested for comprehension and length with staff of child-care sites participating in another research project. The survey and accompanying materials were translated into Spanish and then reviewed by a second native Spanish-speaker of Mexican descent. Discrepancies in translation were discussed and resolved. The final survey took approximately 20 minutes to complete (available at http:// cwh.berkeley.edu/sites/default/files/primary_pdfs/CA_Child CareSurvey_English_Spanish_1.12.pdf).
Sample Recruitment and Survey Data Collection During early 2012, selected sites were mailed postcards, in English and Spanish, inviting one or more staff familiar with foods and beverages served to complete a single online survey (developed by Qualtrics). A reminder letter, paper copy of the survey, and return stamped envelope were mailed 2 months later to nonrespondents. Follow-up telephone calls were made to nonrespondents 1 month later. All respondents were sent a $5 gift card, and enrolled in a lottery for a $200 grocery store gift certificate.
Data Analysis Data from paper surveys (n¼335) were merged with data from online surveys (n¼121). Ten percent of paper surveys were double-entered to check for data entry errors. Of the total of 456 completed surveys in 2012 (for a 31% response rate), eight were excluded as sites caring only for children younger than age 2 years, and 13 were excluded as having incomplete data on site characteristics and beverages served. Fewer than 4% of responses were missing for any survey item; imputation of missing data was not performed and nonresponses were included in the denominator when appropriate. Because we were interested in comparing child-care categories rather than obtaining population estimates, sample weights were not used. In 2008 and 2012, 16% and 12%, respectively, of family child-care home providers elected to complete the survey in Spanish. The number of usable surveys (n¼435) and response rate in 2012 were similar to that observed in 2008 (n¼429; 31% response rate). Data were analyzed using the statistical analysis software SPSS version 19 (2010, SPSS Inc) and SAS version 9.3 (2011, SAS Institute Inc). Differences between survey responses in 2008 and 2012 were assessed using c2 tests or logistic regression for categorical variables and analysis of variance or linear regression models for continuous variables. Binary measures (whether or not a beverage was served) were created. Multivariate regression models used the maximum likelihood method to fit the logistic regression models for binary outcomes. All models included child-care category (ie, Head Start, state preschool, other CACFP center, nonCACFP center, CACFP home, or non-CACFP home) as a covariate to adjust for differences by category. If significant F statistics were found in the analysis of variance models, we then accounted for multiple comparisons using the TukeyKramer test. A significance level of 0.05 was used for all statistical tests. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
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RESEARCH RESULTS Site Characteristics
Beverage Practices
Between 2008 and 2012, there were differences in the numbers of sites in each category, the mean number of children in child care, and the proportion of sites serving snacks, and using an independent vendor for food preparation (Table 1). Characteristics that might influence foodservice also differed by the six child-care categories (eg, meals and snack served; data not shown).
Milk was served by a majority of sites on the day before the survey both before and after the beverage policies were instituted (Table 2). Significantly fewer sites reported usually serving whole milk and more sites usually served lower-fat (reduced-fat or low-fat) or nonfat milk during 2012 compared with 2008. When asked about all types of milk served, lower-fat milk was most commonly reported and significantly more sites ever served lower-fat and nonfat milk
Table 1. Characteristics of California child-care sites participating in 2008 and 2012 surveys on beverages served to children aged 2 to 5 years 2008a (n[429) Characteristic
n
2012 (n[435) %
n
%
Child-care categoryc
0.0001
Head Start centers
66
15
78
18
State preschools
68
16
93
21
d
CACFP centers
104
24
48
11
88
21
82
19
CACFP family homes
65
15
93
21
Non-CACFP family homes
38
9
41
10
Non-CACFP centers
P valueb
meanstandard deviation! No. of children (2-5 y) in care
72.6192.6
93.1317.2
0.027
% ! Site director/owner responded to survey
97.7
98.0
0.335
Full-day care provided
75.0
72.9
0.357
Meals and snacks served Breakfast
75.1
80.5
0.060
Morning snack
60.1
82.8
0.0001
Lunch
89.3
89.2
1.00
Afternoon snack
83.7
91.0
0.001
Dinner
17.7
19.5
0.497
Evening snack
21.4
12.2
0.034
Food source Site only
0.238 99.3
98.1
Site and home
0.2
0.2
Home only
0.5
1.7
Location of food preparation At local site
66.7
63.0
0.518
Central kitchen
13.3
16.1
0.169
School foodservice
17.7
20.5
0.773
3.5
6.7
0.022
Independent vendor a
Findings from the 2008 survey were previously published.13 Analyzed by logistic regression or linear regression models adjusted for child-care category (child-care category is unadjusted). c Head Start centers and state preschools are required to participate in CACFP or the federal school meals program. CACFP centers were other centers that also participated in CACFP. d CACFP¼Child and Adult Care Food Program. b
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RESEARCH Table 2. Beverages provided by California child-care sites before (in 2008) and after (in 2012) beverage policies for children aged 2 to 5 years were enacted Beverage
2008 (n[429)
2012 (n[435)
P valuea
% of sites! Milk Provided (any type) on day before survey
93.1
93.0
0.570
21.9
8.5
0.006
72.0
79.0
0.013
1.9
6.9
0.001
Type most often provided Whole Lower-fat (reduced-fat or low-fat)
b
Nonfat Rice or soy
0.9
0.5
0.909
Flavored or sweetened
1.6
0.5
0.056
32.2
26.9
0.099
All types of milk (ever) provided Whole Lower-fat (reduced-fat or low-fat)
b
81.2
98.0
0.008
5.1
13.1
<0.001
Rice or soy
25.2
28.0
0.072
Flavored or sweetened
10.5
7.4
0.088
Available for self-serve indoors
69.0
76.5
0.001
Available for self-serve outside
68.8
77.5
<0.001
Always provided with meals and snacks
28.0
46.7
0.008
Nonfat
Water
100% fruit or vegetable juicec Provided on day before survey
64.1
61.6
0.105
Provided more than once per day on day before survey
27.0
19.5
0.038
7.6
6.9
0.903
Sugar-sweetened beveragesd Provided on day before survey a
Analyzed by logistic regression models and adjusted for child-care categories. During 2008 response options for reduced-fat and low-fat milks were combined. During 2012, reduced-fat and low-fat milks were separate response options but are combined in this Table. c Excludes fruit-flavored drinks like Kool-Aid (Kraft Foods), Sunny Delight (Procter & Gamble), Hawaiian Punch (Dr Pepper Snapple Group), lemonade, and agua frescas. d Includes soda, sports drinks, Kool-aid, Sunny Delight, Capri Sun (Kraft Foods), Hawaiian Punch, lemonade, fruit drinks, agua frescas, and sweet teas. Does not include diet drinks sweetened with artificial sweeteners. b
during 2012 compared with 2008. Although the percentage of sites usually or ever serving flavored milk decreased from 2008 to 2012, the changes were not significant. Compared with 2008, during 2012 significantly more childcare sites made water available for self-serve, both indoors and outside, and served water with meals and snacks. The proportion of sites serving 100% juice more than once daily decreased significantly. Few sites served sugar-sweetened beverages during 2008, and this did not change significantly in 2012. Diet beverages were not queried in 2008; during 2012 they were served by 5.0% of sites the day before the survey.
Policy Compliance A total of 60.2% of survey respondents in 2012 reported being aware of new beverage policies. A significantly higher May 2015 Volume 115 Number 5
percentage of CACFP (67.3%) than non-CACFP (42.2%) sites were aware of the policies (P¼0.043). Full compliance with the state law was calculated for the 2012 sample based on having water easily available for self-serve both inside the child-care site and outside where children play, usually serving low-fat or nonfat milk, never serving whole or flavored milk, serving 100% juice not more than once, and serving no sugar-sweetened or diet beverages the day before the survey. We were unable to calculate full compliance during 2008 because provision of diet drinks was not queried and response options for low-fat and reduced-fat milk were combined. During 2012, 23.2% of sites (n¼101) were fully compliant; compliance rates differed significantly by childcare category (P¼0.0001). Forty-one percent of Head Start sites, 32.3% of state preschools, and 27.1% of CACFP centers were judged fully compliant. Lower rates of compliance were found in non-CACFP centers (15.9%), CACFP homes (9.3%), and JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
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RESEARCH Table 3. Factors that influence change in beverages served to children aged 2 to 5 years in California child-care sites during 2012 (N¼435)
Factor
More water
Lower-fat/ unflavored instead of higher-fat/flavored
Limit sugar-sweetened beverages
Limit 100% juice
Overalla (mean–SDb)
% of sites! Beverage policy
37.5
41.6
43.0
42.3
41.12.5y
Parent/family support
27.6
24.4
26.7
24.6
25.81.6z
Training for child-care providers
23.7
22.8
22.1
26.0
23.61.7z
Lessons for children
40.2
18.9
27.4
23.2
27.49.2z
Information for families
39.1
34.9
37.9
35.9
36.91.9y
P¼0.0001 for differences in facilitating factors for changing beverages based on analysis of variance model. SD¼standard deviation. yz Values not sharing a common superscript (y, z) are significantly different based on Tukey’s adjustment for multiple comparisons. a
b
non-CACFP homes (7.3%). Significantly more sites in CACFP (30.2%) were fully compliant compared with non-CACFP sites (12.4%) (P¼0.032). The provision that was not met by the most sites was type of milk served (48.7% of sites were noncompliant), 26.7% of sites served 100% juice more than once per day, 22.5% did not have water available inside and outside, and 13.3% served sugar-sweetened or diet beverages.
Factors Influencing Compliance Most sites reported no barriers to serving children lower-fat or unflavored milk (70.6%), more water (76.6%), and less juice (76.7%), and eliminating sugar-sweetened beverages (83.9%). Fewer than 10% reported issues that made serving healthy beverages difficult, which included:
self-identified government rule against serving water with meals and snacks (although there is no CACFP rule against serving water with meals and snacks); cost (associated with serving fresh fruit vs juice, and serving bottled water or needing water filters or cups); no CACFP reimbursement for water; receiving whole milk or >1 serving of juice from school foodservice; difficulty buying different types of milk for children of different ages; taste preferences of children for whole milk, sugarsweetened beverages, and juice; parent preferences for milk; and parents bringing sugar-sweetened beverages to childcare sites.
The two most frequently cited factors that facilitated serving healthy beverages were having beverage policy and information for families (Table 3). There was a significant correlation between awareness of beverage policies and full compliance with it (r¼0.37; P¼0.004). Other factors cited as helping with the provision of healthy beverages were: lessons for children, parent/family support, and training for child-care providers. 728
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IMPLICATIONS FOR PRACTICE We documented improvements in the serving of healthy beverages in California child-care sites between 2008 and 2012, several months after the California Healthy Beverages in Childcare law and federal CACFP requirements on water and milk went into effect. Significant improvements were noted in water available for self-service indoors and outside, water served with meals and snacks, providing lower-fat varieties of milk instead of whole or reduced-fat milk, and limiting 100% juice servings to once per day. Before these policies, nearly all sites were serving milk and did not serve sugar-sweetened beverages, and these practices did not change between the two survey time points. In contrast, during 2008-2009 more than 90% of US public elementary schools served flavored milk at lunch on most days.23 Despite notable improvements in beverage offerings, our results suggest the need for additional improvement. Overall, more than three quarters of sites did not meet all provisions of the California law. The California law was used as the standard for compliance because it is more comprehensive than the federal CACFP beverage requirements in that it includes provisions on sugar-sweetened beverages and juice in addition to water and milk and pertains to all licensed childcare sites, regardless of CACFP participation. Incomplete compliance may be attributable to the large proportion of sites (w40%) that were unaware of beverage policies, and insufficient time or knowledge on how to fully implement the provisions. The California law was implemented only 2 months before the start of survey data collection and the federal CACFP law only a couple months before the California law, although both laws passed during 2010, more than a year before the start of the 2012 survey. Few sites reported barriers to serving healthy beverages, but factors such as cost and parent and child preferences may have influenced some sites more than others. Systematic outreach and education with sites and parents may be needed to educate and support efforts to improve beverage offerings. Compliance was higher among sites participating in CACFP compared with non-CACFP sites. It is possible that CACFP sites were more likely than non-CACFP sites to receive May 2015 Volume 115 Number 5
RESEARCH communications about beverage policies because they were covered by both the California and federal policies. We and others have previously shown that CACFP sites may be better informed about nutrition and provide healthier options to children.13,24 During a 2008 national study, 59% of Head Start centers never served flavored milk, 99% never served other sugarsweetened beverages, and 70% served mostly low-fat or nonfat milk to children.25 Higher numbers for sugarsweetened beverages were reported by our sample, which included other categories of child care in addition to Head Start. Head Start sites have previously been shown to provide healthier options than other categories of child care,13 possibly because of more extensive federal regulations and support.2 In a recent study of 40 CACFP centers in Connecticut involving direct observation, 84% had water accessible in classrooms and one third had water accessible during physical activity periods from either adult-accessible or childaccessible sources; water was not available for general consumption during any of the lunch observations.26 In our study, child-accessible water both indoors and outside in addition to water provision with meals and snacks were examined, based on the assumption that child-care providers have limited time available to serve water to children individually upon request. The fact that we found a much higher proportion (47%) of sites that reported making water available at the table compared with the Connecticut study may be because we relied on self-reported practice and included sites not participating in CACFP. Anecdotally, numerous childcare providers have reported the misperception that the US Department of Agriculture prohibits CACFP sites from serving water with meals and snacks due to concern that water will compete with the intake of milk and other foods. Although there is little evidence to support this concern,27 more studies on this topic with young children are warranted and may be necessary before child-care providers widely adopt the practice of serving water with meals and snacks. To our knowledge this is the first comprehensive assessment of the influence of beverage policies in child care. Beverage policies in schools have been associated with reduced student access and consumption of sugary drinks during school time.28-30 However, less conclusive is whether school beverage policies influence students’ overall daily consumption.29,31 Studies are needed of the influence of child-care beverage policies on children’s intakes. Our study has limitations. Although similar to the response seen in other institutional survey studies,32 the response rate was relatively low (w30%), and it is possible that findings would have been different with a higher response. Generalizability may be further limited by the uneven response by category of child care, although category was controlled for in analyses. Because of high turnover in child care-settings likely to have occurred over 5 years, it was not possible to survey the same sites in 2012 as in 2008. In addition, study data were reliant on self-reported practices and several measures of compliance relied on what was served during a single day. It is possible that sites overreported their policy compliance or reported on a day that was not representative of usual practice, which cannot be verified without onsite observations. Also, with naturalistic experiments such as this, unidentified factors could have changed child-care beverages beyond the possible influence of the state and federal May 2015 Volume 115 Number 5
policies. The significant correlation observed between knowledge of and compliance with beverage policies and the fact that beverage policy was endorsed by more sites than other factors in helping to serve healthier beverages suggest that the laws played a role in the observed improvements. Nonetheless, contribution from other factors cannot be ruled out. Although the policies had been passed over a year before the 2012 survey, sites were only required to implement the laws several months before being assessed. It is possible that had we conducted the follow-up later, we may have found greater compliance. Finally, we did not assess the influence of the changes in beverages served on the intake of beverages— or other foods that may have changed in compensation—by children in child care.
CONCLUSIONS This study is the first to show a positive influence on beverages served at child-care sites after the introduction of healthy beverage policies. Having policy in place was reported to be the main factor in helping sites to provide healthy beverages. However, given that most sites were not judged fully compliant, efforts should continue to raise awareness and support child-care providers to achieve compliance with the letter and—more importantly for the health of children—the spirit of the law.
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US Department of Agriculture, Food and Nutrition Service. Child Nutrition Reauthorization 2010: Nutrition requirements for fluid milk and fluid milk substitutions in CACFP. Memo #21-2011. September 15, 2011. http://www.fns.usda.gov/cnd/care/regspolicy/policymemo/2011/CACFP-21-2011.pdf. Accessed July 29, 2013.
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AUTHOR INFORMATION L. D. Ritchie is director of research, Atkins Center for Weight and Health, University of California, Berkeley, and director and cooperative extension specialist, Nutrition Policy Institute, Agriculture and Natural Resources, Office of the President, University of California, Oakland. S. Sharma is director of population and public health research, Dallas-Fort Worth Hospital Council Foundation, Irving, TX; at the time of the study, she was an assistant researcher, Atkins Center for Weight and Health, University of California, Berkeley. G. Gildengorin is a senior statistician and P. Crawford is director, Atkins Center for Weight and Health, University of California, Berkeley. S. Yoshida is executive director, Sarah Samuels Center for Public Health Research and Evaluation, Oakland, CA. E. Braff-Guajardo is program officer, W.K. Kellogg Foundation, Battle Creek, MI; at the time of the study, she was senior nutrition policy advocate, California Food Policy Advocates, Oakland. Address correspondence to: Lorrene D. Ritchie, PhD, RD, Nutrition Policy Institute, Agriculture and Natural Resources, Office of the President, University of California, 1111 Franklin St, 10th Fl, Oakland, CA. E-mail: [email protected]
STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT This research was supported by Robert Wood Johnson Foundation Healthy Eating Research Grant No. 69298.
ACKNOWLEDGEMENTS The authors thank Ken Hecht, JD, Kumar Chandran, MS, MPH, and the late Sarah Samuels, DrPH, for providing study conception and design; Paula James, Ed Mattson, and Anisha Patel, MD, MSPH, MSHS, for providing survey critique; Sally Smyth, MPP, Shelly Mandel, Sheila Stern, Lauren Goldstein, PhD, Temika Green, Shauna Pirotin, MPH, RD, Jessica Jew, Claudia Olague, and Nayeli Cerpas-Bernal, MPH, for providing assistance with conducting the study; and Karen Webb, PhD, and Elyse Homel Vitale, MPH, for providing manuscript review. The authors also thank the many busy child-care site staff members for responding to the surveys.
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JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
May 2015 Volume 115 Number 5