Assessment of Mealtime Environments and Nutrition Practices in Child Care Centers in Georgia

Abstract

Background:

The amount of time children spend in child care each week has increased in recent years. The aim of this cross-sectional study was to describe the nutritional quality of foods served and the mealtime environment in 24 child care centers in Georgia.

Methods:

Data were collected between April 2010 and September 2010. Each child care center provided a sample 5-day menu (breakfast, lunch, and an afternoon snack) at baseline. Energy and nutrient contents of the menus were analyzed using NutriKids Menu Planning & Nutritional Analysis software (LunchByte Systems, Inc., Rochester, NY). Foods and beverages on the menus were compared to MyPlate food group standards for preschoolers. The child care environment was assessed in each center over 1 full day using the Environment and Policy Assessment and Observation instrument.

Results:

Menus met one half to two thirds of the recommended levels for energy, carbohydrate, protein, and vitamins A and C. However, the menus were high in saturated fat and sodium content and did not meet the recommendations for iron or fiber. The majority of the centers did not meet the recommendations for MyPlate food group standards for preschoolers. On the day of the observation, seven centers did not serve a vegetable and more than half of the centers (n=13) did not serve any whole grains. Nineteen centers served high-sugar and/or high-fat foods and 11 did not have visible water indoors.

Conclusions:

This study identified determinants of the child care environment and nutritional characteristics of the combined meals and snacks offered to children. Findings from this study could inform child care centers how to provide healthier nutrition environments to preschool children.

Introduction

The obesity rate for children 2–5 years of age has more than doubled since 1980, and more than 20% of the nation's preschool aged children are overweight or obese.¹ Georgia is ranked as having the second-highest population of overweight and obese children in the United States.² Overweight and obesity increase the risk for chronic diseases, including type 2 diabetes, heart disease, hypertension, and certain cancers.³ Early intervention is considered to be the most promising strategy for reducing obesity and the many chronic health conditions that may result as a consequence of excessive weight gain during childhood.⁴

This increase in overweight and obesity in preschoolers is paralleled by a concurrent increase in the use of child care facilities in the United States. Approximately 60% of preschool-aged children with employed mothers are in some form of nonparental care on a regular basis.⁵ Children consume a large proportion of their daily energy intake at child care facilities. The Academy of Nutrition and Dietetics recommends that children consume at least one third of their daily nutrition requirements at part-time child care programs (4–7 hours per day) and at least one half to two thirds of their daily nutrition requirements at full-time child care programs (i.e., 8 hours or more).⁶ Child care centers that serve low-income families may qualify to participate in the USDA Child and Adult Care Food Program (CACFP) and receive reimbursement for meals and snacks served.⁷ Currently, this federal program requires centers to include components from the milk, fruit, vegetable, grain or bread, and meat or meat alternate food groups on their menus, but does not require meals and snacks to meet nutrient-based standards.⁸ To ensure that the meals and snacks provided by CACFP are consistent with national nutrition guidance, the USDA asked the Institute of Medicine (IOM) to review and recommend improvements, as necessary, to bring CACFP meal requirements into alignment with those of other federally funded food assistance programs and with the 2010 Dietary Guidelines for Americans.^9,10 According to the IOM, the recommended meal requirements will likely increase children's and adults' consumption of fruits, vegetables, whole-grain–rich foods, and lean meats while decreasing their intake of solid fats, trans fats, added sugars, and sodium.¹⁰

Previous studies have assessed the nutritional quality of foods and beverages served to children in child care^11–19; however, few studies exist on mealtime environment and center policies, including monitoring and training staff.^17–21 The aim of this study was to assess, at baseline, the foods and beverages listed on the menus and describe the nutrition practices and mealtime environments in child care centers in southwest Georgia.

Methods

Study Design

This study is part of the Caregivers Promoting Healthy Habits project, a 1-year wellness policy implementation program in 24 child care centers in southwest Georgia.^22,23 The objectives of the project are to (1) introduce child care providers to the concept and benefits of wellness policy, (2) help child care providers develop and implement wellness policy in their child care centers, (3) support child care centers through training, technical assistance, and funding, and (4) evaluate the effect of a wellness policy on children and staff in a child care environment.

Centers were provided with technical assistance by a registered dietitian and up to $2000 to support implementation. Center directors and staff participated in four trainings on nutrition and physical activity, menu planning, food safety, and healthy habits consistent with the wellness policies. Trainings were conducted in group settings where participants could exchange ideas with other child care center staff.

Setting and Participants

The southwest region of Georgia was selected for program implementation based on many of the counties' low rankings on a number of health status indicators, including child poverty, adult obesity, and high school graduation rate. In winter 2010, the Georgia Department of Early Care and Learning issued an abbreviated request for applications (RFAs) to centers, held a preapplication conference to introduce centers to the program, and distributed previously developed nutrition and physical activity materials and curricula. Interested centers were asked to respond to RFAs by submitting a self-assessment to help identify areas related to nutrition and physical activity that needed improvement, six selected wellness policies, and proposed activities related to implementation of policies. At baseline, 24 child care centers applied and were enrolled in the program.

Participation criteria for the program included that centers were licensed by the state and were not considered a child care or Pre-K program in an elementary school. All centers were required to be enrolled in the CACFP.⁷ For-profit (n=14) and nonprofit (n=10) centers were included in the program, with four centers offering the Head Start program and only one accredited by the National Association for the Education of Young Children. All centers provided full-day programs.

Baseline data were collected between April 2010 and September 2010. The Georgia State University Institutional Review Board approved all study procedures and activities. All participants (child care centers' directors) provided written informed consent.

Assessment of Nutrition Environment and Practices

Assessment of child care centers' menus

All centers provided two meals and one snack each day to participating children while at the child care centers. Centers were asked to provide their 5-day menu during the initial visit, because it is a required document as part of the Environment and Policy Assessment and Observation instrument (EPAO; described later). A registered dietitian coded and standardized all the menu items. NutriKids Menu Planning & Nutritional Analysis software (Version 11.1, 2009; LunchByte Systems Inc., Rochester, NY) was used for menu analysis. Food service providers were asked for clarification regarding specific types of different foods when they were not listed on the menu (e.g., type of milk). Food items described in the menus were matched with the most appropriate food item in the database (e.g., the “assorted cereal” choice on NutriKids was matched for “cereal” on the menu). Information on portion sizes was also entered for every menu item. The centers were using the portion sizes required in the CACFP program for the meal pattern components for children 3–5 years of age.⁸ For quality control, each menu entered was compared with the submitted menu for errors.

Energy and nutrient contents of 120 menus across the 24 centers were analyzed quantitatively for energy and 11 main nutrients (carbohydrate, protein, total fat, saturated fat, cholesterol, fiber, sodium, calcium, iron, and vitamins A and C) based on the 2011 Position of the Academy of Nutrition and Dietetics⁶ and the 2010 Dietary Guidelines for Americans.⁹ Energy and nutrient content for breakfast, lunch, and snacks served each day were summed and averaged over the 5 days for each participating center. The mean and standard deviation (SD) of the 5-day mean nutrients were then calculated for the 24 participating centers.

The menus were also analyzed qualitatively using a menu rubric developed by the researchers and a registered dietitian. The rubric evaluated the frequency of food items listed on the menus from the different food groups from MyPlate for preschoolers²⁴: whole grains; vegetables; fruits; meats and meat alternatives; milk and milk alternatives; high-fat or high-sugar foods; and sugar-sweetened or artificially sweetened beverages. A registered dietitian filled the rubric based on the 5-day menus provided by the participating centers.

Observation of the nutrition environment

The child care environment was assessed using the EPAO. The EPAO has been shown to be a “reliable” tool for assessing nutrition and physical activity environments in child care centers.^25,26 The EPAO protocol consists of one full-day visit to each child care center and includes direct observation of the nutrition and physical environment and documented review of activities. Observations in 24 child care centers took place between May 2010 and September 2010. Center visits were unannounced, and observations were performed by one registered dietitian who completed training to conduct the EPAO. During the observation day, all activities of a randomly selected classroom of 3- to 5-year-old children were observed during breakfast, lunch, and afternoon snack. In some cases, the registered dietitian asked child care providers for clarification or additional information. The document review involves an evaluation of the teacher's lesson plan for that week, past or future fund-raising documents, menus for up to 1 month that include the week of the visit, parent handbook, staff handbook, nutrition training documents, nutrition curricula, and written nutrition policies.¹⁷ Observations began at breakfast and lasted until the conclusion of the child care program. For the purpose of this study, the domains related to the nutrition section of the EPAO were assessed: fruits and vegetables; whole grains; foods high in sugar or fat; beverages; food availability and service; staff behaviors; training and education; and policies.^25,26

Statistical Analysis

Descriptive statistics for energy, macronutrients, and micronutrients were determined. For the menu analysis, mean calorie and nutrient contents of the menus were compared against one half and two thirds of the IOM's Dietary Reference Intakes (DRI) for 3- to 5-year-old children²⁷ to determine the number (and percentage) of centers meeting recommendations. All statistical analyses were done using Statistical Package for the Social Sciences (version 18, 2010; PASW Statistics, Chicago, IL).

Results

Centers' Characteristics

A total of 24 child care centers serving a total of 2042 children participated in the study (mean number of children, 85; range, 20–245). All centers participated in the CACFP. Twenty-two centers had a kitchen in the same building as the classrooms for food preparation. The two centers that did not have an on-site kitchen received cooked food from the local hospital. Seventy percent of the centers (n=17) reported the cook as the person responsible for menu planning. The director of the center (n=5) and staff members (n=2) were also reported as the menu planner. Only 25% of the centers (n=6) reported consulting a dietitian for menu planning.

Nutrient and Food Group Content of Menus

A sample of 120 menus across the 24 participating centers was analyzed for energy and nutrient contents. When compared to the DRIs for the 3- to 5-year-old children,²⁴ it was found that the menus provided one half to two thirds of the DRI for energy, carbohydrate, protein, and vitamins A and C (Table 1). However, the menus were high in saturated fat and sodium. The average menus usually provided one half of the daily requirements for calcium and iron, but fell short of the two-thirds recommendation for iron in 10 centers. Additionally, the menus were low in fiber; none of the centers met one half or two thirds of the recommendations for fiber content (Table 1).

Table 1.

Mean Nutrient Contents of Baseline Menus at 24 Child Care Centers in Georgia and Number of Centers Meeting One Half and Two Thirds of Dietary Reference Intake and 2010 Dietary Guidelines Recommendations

				One-half rec.		Two-thirds rec.
Nutrient	Source^a	Recommendation	Mean±SD	n	%	n	%
Calories (kcal)	EER^b	1400^b	883±98	24	100	9	37
Carbohydrates (g)	RDA^c	130	122±13	24	100	24	100
% calories from carbohydrates	AMDR^d	45-65%	55.5±3.8	24	100	24	100
Protein (g)	RDA^c	19 g	37±4	24	100	24	100
% of calories from protein	AMDR^d	10–30%	17±2	24	100	24	100
Total Fat (g)		—	29±7	—	—	—	—
% calories from total fat	AMDR^d	25–35%	29.8±4.2	22	92	22	92
% calories from saturated fat	DG^e	<10%	12±2	7	30	7	30
Cholesterol (mg)	DG^e	<300 mg	91±31	24	100	24	100
Sodium (mg)	AI^f	1200 mg	1210±192	3	12.5	0	0
Fiber (g)	AI^f	20 g	7.5±0.7	0	0	0	0
Calcium (mg)	RDA^c	1000 mg	690±68	24	100	17	70
Iron (mg)	RDA^c	10 mg	6.3±1.0	21	87	14	58
Vitamin A (mcg)	RDA^c	400 mcg	870±422	24	100	24	100
Vitamin C (mg)	RDA^c	25 mg	46±14	24	100	24	100

Dashes indicate not calculated or not available.

2010 Dietary Guidelines recommendations⁹ are used when no quantitative Dietary Reference Intake²⁷ value is available.

Based on Estimated Energy Requirements (EER) equations, using reference heights (average) and reference weights (healthy) for each age-gender group; 1400 kcal/day is based on moderately active 4-year-old males.

Recommended Dietary Allowance.²⁷

Acceptable Macronutrient Distribution Range.²⁷

2010 Dietary Guidelines recommendations.⁹

Adequate Intake.²⁷

SD, standard deviation; rec., recommendations.

All the centers listed milk on their menus on a daily basis; however, 71% of the centers listed whole or 2% milk and only 29% of the centers (n=7) listed the recommended 1% or skim milk. Most centers (92%) had fried or high-fat proteins one to two times/week on the menu (Table 2). Vegetables, not including fried vegetables, were listed on the menu daily in only seven centers (29%). All centers listed fruits on a daily basis (Table 2). All centers listed a sweet snack on the menu (e.g., cookies, donut, pastries, cookies, or muffins), and 71% a high-sugar or high-fat condiment (e.g., butter, dressing, syrup, or jelly; Table 2).

Table 2.

Food Group Contents of Baseline Menus at 24 Child Care Centers in Georgia

Menu rubric	No. of centers	% of centers
Grain group
50% or more of total grains are whole grains.	3	12.5
Vegetable group
Vegetables, not including fried vegetables, are listed daily.	7	29.0
Dark green vegetables are listed (broccoli, spinach, collard greens, turnip greens, and mustard greens) at least once a week.	17	71.0
Orange vegetables are listed (carrots, sweet potatoes, and squash) at least once a week.	14	58.0
Fried vegetables are listed (French fries, hash browns, tater tots, fried okra, and fried zucchini) one to two times/week	16	67.0
Fruit group
Fruits, not including 100% juice, are listed daily.	24	100
100% fruit juice is listed three to four times/week.	7	29.0
Dairy group
1% or skim milk listed	7	29.0
Protein foods group
Yogurt or cheese is listed two times/week.	19	79.0
Beans or lentils are listed 1+times/week.	19	79.0
Lean proteins are listed (baked chicken and fish, tuna, deli turkey, eggs, nuts, beans, lentils, and low-fat yogurt) 5+times/week.	2	8.0
Fried or prefried meats are listed (chicken or steak nuggets, chicken patty, fish sticks, and corn dogs) one to two times/week.	22	92.0
High-fat meats are listed (sausage, bacon, bologna, salami, ham, hot dogs, and ground beef ) 3+times/week.	18	75.0
Empty calories
High-fat or high-sugar foods are listed (donuts, pastries, cookies, muffins, sugary cereals, and biscuits) 3+times per week.	20	83.0
High-sugar or high-fat condiment (butter, dressing, syrup, and jelly)	17	71.0
Beverages
Sugar-sweetened or artificially sweetened beverages are listed (flavored milk, sports drinks, soda, and sweet tea) 1+times/week.	0	100

Nutrition Practices and Mealtime Environments

On the day of the observation, lunch was served family style (children serve themselves from common bowls and platters) in one third of the centers (n=9), delivered in bulk and proportioned by staff in seven centers (29%), and delivered and served in prepared portions in eight centers (33%). In most of the centers (n=22), all foods served on the day of the observation matched what was on the menu.

Foods and beverages served on the day of observation

Seventeen of twenty-four centers served a vegetable on the day of the observation, but rarely were these servings dark green, red, orange, or yellow vegetables (Table 3). More than half of the centers (n=13) did not serve any whole grains. Only 13 centers did not serve any meats naturally high in fat (e.g., bacon or sausage), and the majority of the centers (80%) served high-sugar and/or high-fat foods. Drinking water was not visible indoors in 11 centers and not available outdoors in 16 (Table 3). Fruit juice (100% juice) was served one time per day in 14 centers and two times per day in three centers. All centers avoided sugar-sweetened beverages during the day of observation (Table 3).

Table 3.

Nutrition Practices and Mealtime Environments at 24 Child Care Centers

Nutrition domains	Response category	Number of centers (%)
Fruits and vegetables
Number of times fruit was served^a	1	5 (21)
	2	17 (71)
	3	2 (8)
Number of times fruit was served fresh, frozen, or canned in own juice^a	0	6 (25)
	1	11 (46)
	2	6 (25)
	3	1 (4)
Number of times vegetables (not including French fries or fried vegetables) were served^a	0	7 (29)
	1	14 (58)
	2	3 (13)
Number of times dark green, red, orange, or yellow vegetables were served^a	0	14 (58)
	1	10 (42)
Grains
Number of times beans/lentils were served^a	0	16 (67)
	1	8 (33)
Number of times whole grains were served^a	0	13 (54)
	1	9 (38)
	2	2 (8)
Number of times high-fiber whole-grain foods were planned to be served (on the menu) that week^b	0	13 (54)
	1	9 (38)
	2	2 (8)
Beverages
Drinking water visible in the classroom^a	Yes	13 (54)
	No	11 (46)
Drinking water was accessible/available to children in the classroom^a	Self-service	12 (50)
	By request only	1 (4)
	During water breaks	7 (29)
	No	4 (17)
Drinking water available outdoors^a	Yes	7 (29)
	No	16 (67)
	Did not observe any outdoor time	1 (4)
Number of times 100% fruit juice was served^a	0	7 (29)
	1	14 (58)
	2	3 (13)
Number of times sugar-sweetened beverages were served^a	0	24 (100)
Number of times milk was served^a	2	19 (79)
	3	5 (21)
High-sugar/high-fat foods
Number of times fried or prefried vegetables were served^a	0	21 (87)
	1	3 (13)
Number of times high-fat meats were served^a	0	13 (54)
	1	10 (42)
	2	1 (4)
Number of times high-sugar and/or high-fat foods were served^a	0	5 (21)
	1	10 (42)
	2	9 (37)
Staff behaviors
Staff encouraged children to drink water throughout the day.^a	Yes	17 (71)
	No	7 (29)
Staff encouraged children to try new or less familiar foods.^a	Yes	13 (54)
	No	1 (4)
	Did not observe picky eating	10 (42)
Staff asked children if they were still hungry before serving second helpings (one staff member asked at least one child).^a	Yes	1 (4)
	No	23 (96)
Staff used food to reward or control behavior.^a	Yes	1 (4)
	No	23 (96)
Staff sat with children during lunch (at least one staff member sat with children).^a	Yes	13 (54)
	No	11 (46)
Staff consumed less-healthy (e.g., high-sugar or high-fat) foods or beverages in front of children (at least one staff member).^a	Yes	4 (17)
	No	13 (54)
	Did not observe staff eating or drinking	7 (29)
Training and education
Staff talked with children about healthy foods.^a	Yes	17 (71)
	No	7 (29)
Nutrition curriculum for children available^c	Yes	12 (50)
	No	12 (50)
Nutrition training provided to staff in past year^c	Yes	11 (46)
	No	2 (8)
	No documents received from center	11 (46)
Nutrition education materials available for parents^c	Yes	3 (12)
	No	21 (88)
Policies
Written wellness policy is shared with parents.^c	Yes	15 (63)
	No	9 (37)
Written guidelines addressing foods served for holidays and celebrations^c	Yes	16 (67)
	No	8 (33)
Written guidelines addressing foods bought from home^c	Yes	17 (72)
	No	7 (28)

Measured by ^aobservation, ^bmenu review, or ^cdocument review.

Staff behaviors

In half of the centers (n=13), staff ate together with the children, and in only four centers, staff ate and/or drank less healthy food in front of the children (Table 3). In three centers, children were encouraged to eat more than they wanted to (e.g. “clean your plate” and “you won't get dessert until you finish”) for an average of two eating occasions (data not shown). In only one center, staff asked children whether they were still hungry before serving second helpings and staff used food to control behavior (Table 3).

Training and education

Half of the centers had a nutrition curriculum for children, but its use in the classroom was not evaluated in this study (Table 3). We observed informal nutrition education for children (e.g., staff talking with children about healthy foods) in most centers (n=17) for an average of two eating occasions.

Policies

All centers had a written policy on nutrition and food services. Sixteen centers (67%) had a written policy that addressed foods served during holidays and celebrations, and 17 had a written policy addressing food bought from home (Table 3).

Discussion

Analysis of the combined menus from the participating child care centers shows that the menus met the recommended levels for energy, carbohydrate, protein, and vitamins A and C. However, the percent of energy from saturated fat (12%) exceeds the 10% recommendation, findings similar to those reported by Oakley and colleagues¹³ and Bollella and colleagues.²⁸ The high sodium content of the menus is of concern, and this may be a result of the frequent use of commercially prepared food items (e.g., chicken nuggets and fish sticks) and canned vegetables. Another concern is that the menus served at participating centers failed to meet one half or two thirds of requirements for fiber. Additionally, the menus fell short on iron, which is a key nutrient essential for normal growth and development. Our findings are consistent with other research in child care centers that has demonstrated that the meals served for children were below the recommendations for fiber and iron.^11,12,29

Findings from the menu analyses were supported by the observation of the foods and beverages offered during the 1-day visit to the centers. Our data suggest that the meals offered at participating centers do not include the recommended amounts of whole grains, lean proteins, and fresh fruits or vegetables. Findings from this study are consistent with a recent study assessing nutrition practices and mealtime environment of North Carolina child care centers.²¹ Children are being offered excessive amounts of added sugars from sweet snacks, sodium, and saturated fat from whole milk and high-fat or fried meats. The 2010 Dietary Guidelines stress the importance of consuming fat-free and low-fat milk and milk products, especially during childhood and adolescence.⁹ Although children were offered adequate amounts of milk, 71% of the centers served whole or 2% milk and only 29% of the centers (n=7) served the recommended 1% or skim milk. Our findings are consistent with others that found that most children in child care drink full-fat milk.^12,19,21 White bread and ready-to-eat cereal, food sources that are often fortified with vitamins and minerals, were among the most frequently reported foods on the menus. Currently, no nutrition standards exist for the type of cereals allowed in child care meals. Requirements related to the whole-grain content of cereals may help centers substitute current cereal offerings with ones that may increase children's daily intake of whole grains. Although child care meals have frequent offerings of fruits and vegetables, improvements can be made to the type and variety of fruits and vegetables offered.^14,21 For example, very few daily menus provided colorful fresh fruits, and menus were more likely to include starchy vegetables (potatoes, corn, and peas) than dark green and orange vegetables.

There is an increasing body of work on the quality of meals and snacks served to children in the CACFP.^13,30 Because of the nonspecific nutrition guidelines set by the CACFP, it is possible for child care centers to be in compliance with all regulations without necessarily serving children appropriate food to meet their energy and nutrient requirements. Our findings were similar to the results of the study by Oakley and colleagues¹³; centers participating in CACFP had menus lower in energy, carbohydrate, and protein and some micronutrients and higher in fat and sodium, compared to nonparticipating centers.¹³ A major goal of future research identified in the CACFP report¹⁰ is to assess the food and nutrient content of meals and snacks served to, and consumed by, children and the effect of these meals and snacks on children's overall diets. Policy makers should utilize evidence from this study to support CACFP program revision, in addition to local standards in Georgia.

Beyond the foods and beverages listed on the menus, this study also assessed nutrition practices and mealtime environments at the day care centers. Child care providers could improve their interactions with children by sitting with them during mealtime. This situation enables adults to teach, serve as role models, and initiate socialization skills among children. Additionally, few centers served meals family style, although serving themselves allows children the experience of learning a self-help skill, as well as some measure of control over the type and amount of food on their plates.³¹ Centers had also room for improvement in regard to staff's nutrition education and training. Although limited, there is evidence linking training and education to improved health outcomes in child care.³² In addition, centers could provide more formal, informative nutrition education to children and parents.

To our knowledge, this is the first study to assess nutritional characteristics of the combined meals and snacks offered to children and other aspects of the nutrition environment in a sample of child care centers in Georgia. This study provides timely information because it follows the release of a 2010 report from the IOM on nutrition recommendations for the CACFP¹⁰ and a 2011 Academy of Nutrition and Dietetics updated position paper on benchmarks for nutrition in child care settings.⁶ This study contributes to the growing body of literature examining nutrition environments of child care centers, including staff behaviors during meal and snack time. Four previous studies have examined child care provider behaviors and found similar results^17–19,21; however, only two examined center environments through direct observation,^19,21 rather than self-report by survey.^17,18 This study, however, is not without limitations, and results should be interpreted with some caution. This study was limited to child care centers in rural areas and small cities, and this may not reflect the situation in other child care centers or in other urban locations. In addition, we chose only one classroom for observation, and, although no data exist stating that children are differentially served by classroom, future studies may want to assess multiple classrooms per facility. This study relied on menus to assess dietary intake in child care and might not accurately reflect the quantity of food consumed by children. However, a study by Ball and colleagues found that children consumed 50–100% of the foods and beverages served to them in child care centers.¹² Additionally, we analyzed the nutrient composition of foods and beverages listed on the menu, not what was actually served to children. Previous studies have shown that menus are somewhat accurate, when comparing them to actual foods and beverages served to children, and might provide some information on categories of food (e.g., fruits and vegetables) actually served in child care.^14,33 Results regarding specific nutrient information, such as vitamins and minerals, should be interpreted with caution when based on menu analysis. Finally, we made a number of assumptions regarding the specific foods and methods of preparation on the menus, and the Nutrition Data System for Research software, the gold standard for dietary analysis, was not used for nutrient analysis.

Conclusions

Overall, this and other studies lend evidence to the need for improving the nutritional quality of foods served to children as well as enhancing the overall mealtime and feeding environments to support healthy eating for preschool children. This study also speaks to the need for more nutrition education of child care staff and increased nutrition intervention in child care. Child care center menu planners need resources and support in providing healthier foods for children. Child care providers can share their menus with parents, as a medium of nutrition communication, which can help create healthier environments for preschool children.

Footnotes

Acknowledgments

The authors would like to thank the directors and staff of the child care centers that participated in the program, as well as those organizations that provided support for the Caregivers Promoting Healthy Habits program: Bright from the Start: Georgia Department of Early Care and Learning; Georgia Department of Public Health; Georgia State University; USDA, and CDC. At the time of the study, Joyce Maalouf was a research director and project manager at Georgia State University, Atlanta, GA.

Author Disclosure Statement

No competing financial interests exist.

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