Beverage Policy Implementation by Child and Adult Care Food Program Participation and Program Type: A Statewide Examination in Georgia

Abstract

Background:

The child care setting is a promising venue to establish healthy habits and promote obesity prevention. One major contributor to weight gain among young children is high intake of sugar-sweetened beverages (SSBs). Increasing access to water and other healthy beverages is a viable strategy to reduce childhood obesity. The goal of our study was to investigate implementation of the beverage policies in child care programs in Georgia (GA) by Child and Adult Care Food Program (CACFP) participation and program type.

Methods:

The study employed a cross-sectional design. A statewide survey was conducted using the GA Child Care Wellness Survey. A random sample of 3054 child care programs was obtained. Programs were stratified by six state regions to acquire a representative sample.

Results:

A total of 974 surveys were returned. Sixty-seven percent of the respondents were enrolled in CACFP. Programs participating in CACFP (96%) were less likely to serve SSBs (x²(2) = 15.309, p < 0.001), than non-CACFP programs (90%). CACFP programs were more likely to serve low-fat or fat-free milk to 2–5-year olds than non-CACFP programs (87% vs. 35%, p < 0.001). Family child care homes were significantly more likely to comply with serving only whole milk to 1 year olds (66%; p < 0.001) than other program types. All program types had low compliance with implementing water policies.

Conclusions:

Study outcomes provide vital information on the implementation of beverage policies that can inform beverage policy training, with the ultimate goal of reducing obesity risk and promoting healthier diets among preschool children in GA.

Background

Approximately 20% of American children are overweight or obese before they enter kindergarten.¹ Childhood obesity among preschool-aged children is higher for low-income children.² Geographic disparities also exist among overweight and obese children.³ Seven of the states with the highest rates of childhood obesity are located in the southern United States.³ More specifically, in Georgia (GA), 13% of low-income children ages 2–4 are obese.⁴ One major contributor to high rates of obesity among young children is intake of sugar-sweetened beverages (SSBs).⁵ SSBs are drinks that contain sucrose, fruit concentrate, high fructose corn syrup, or other caloric sweeteners.⁵ National Health and Nutrition Examination Survey (NHANES) data show 62% of children 2–5 years of age consume SSBs, contributing 127–130 kcal to daily caloric intake.⁶

To reduce childhood obesity, it is important to establish healthy habits early in life, when food and activity preferences are developing.⁷ Over 11 million children in the United States spend time in nonparental care each week,⁸ therefore, the child care setting provides opportunities for early obesity prevention.⁸ Increasing access to water and other healthy beverages and reducing consumption of SSBs are viable strategies to prevent childhood obesity.⁹ For many children, a substantial decrease in daily caloric intake could result from eliminating SSBs and reducing juice intake in the child care setting, thereby reducing weight gain.

Improving implementation of obesity prevention policies in the child care setting aids in promoting healthy behavior among young children, which may lead to a reduction in childhood weight gain. Studies conducted in North Carolina, GA, New York (NY), and Florida have shown significant improvement in the adoption of food and beverages policies, which promote healthy weight among preschool children.^10–13

Since SSBs are directly linked to weight gain among children 2–5 years of age,⁵ policy implementation to eliminate SSBs may decrease weight gain for children who spend a large amount of time in child care. For example, researchers examining nutrition practices at child care centers in NY found that child care centers were serving healthy foods and beverages to children, however, improvements could be made in water availability, decreasing whole and 2% milk, and eliminating SSBs.¹⁴ Findings were used to develop required nutrition policies for NY child care centers to promote healthy weight among young children.¹⁴

As childhood obesity rates have increased, national policy recommendations for healthy foods and beverages in child care have been created by national organizations and government agencies.^15–17 The Child and Adult Care Food Program (CACFP), revised in 2016, is a federal program that reimburses child care programs serving low-income children for healthy meals and snacks served.¹⁸ The new CACFP national policies include requirements for child care providers to: (1) make water available to children throughout the day; (2) serve milk that is unflavored and low fat (1%) or fat free for children 2–5 years old; (3) limit serving 100% juice to once per day; and (4) serve only breast milk and infant formula to infants 0–5 months old.¹⁷

CACFP regulations do not have limits on SSBs served, however, there is an optional best practice recommending that child care providers avoid serving SSBs.¹⁹ CACFP has the potential to impact the diets of millions of young children.¹⁸ Because of the new guidance in CACFP regulations, obtaining information on the extent to which these new policies are being implemented as well as barriers and facilitators to enhance compliance is a critical need.

Interventions that focus on implementation of nutrition and physical activity policies have been successful in promoting obesity prevention, especially among programs that participate in CACFP.^20,21 Findings from one study conducted in California (CA) showed that CACFP participation resulted in healthier foods and beverages being served in child care programs.²¹ The results of this study assisted with policy development and legislation for healthy beverages in child care in CA. A follow-up study, completed after the CA Healthy Beverage Act was passed, indicated that CACFP programs were significantly more likely to be fully compliant with beverage best practices than non-CACFP programs.²²

CACFP participation, state licensure, and voluntary quality rating may affect beverage policy implementation by child care facility type in GA. The Department of Early Care and Learning (DECAL) administers CACFP in GA child care programs. As of 2014, all licensed child care centers in GA are required to comply with CACFP rules whether or not they participate in the program.²³ However, GA state regulations do not have clear language on eliminating SSBs.²³ Furthermore, family child care homes that do not participate in CACFP are not required to follow any beverage standards. Many states have implemented voluntary programs with standards that go above and beyond CACFP rules.

Quality Rating Improvement Systems (QRIS) are voluntary improvement systems that assign a quality star rating to child care programs that meet a set of defined program standards.²⁴ QRISs have been successful in promoting obesity prevention standards in 29 states.²⁴ One example of a state QRIS is South Carolina's ABC Child Care Program, which includes nutrition and physical activity recommendations.²⁴ In GA, Quality Rated, which is overseen by DECAL, includes specific standards related to beverages served in child care centers and family child care homes.²⁵

State licensing regulations and Quality Rated standards do not apply to license-exempt programs, which legally operate without a license, despite the fact that they serve a large number of children. These programs are could potentially be key sites for health promotion and have not yet been included in nearly any research on food and beverage practices in the child care setting.²⁶ While GA has endorsed implementation of CACFP standards for centers and has created additional standards for beverages through Quality Rated, no known studies have examined how the policies are being implemented and translated into practice by child care programs on a statewide level.

The primary outcome of the study is the current status of beverage policy implementation in child care programs in GA based on CACFP participation. The beverage policies that were examined include: (1) making water available for self-serve both indoors and outdoors, (2) eliminating SSBs; (3) limiting juice to being served once per day; and (4) serving unflavored whole milk to 1 year olds and low fat or fat free milk to 2–5 year olds; and (5) serving only breast milk and infant formula to infants 0–5 months old. Barriers and facilitators related to the implementation of beverage policies were also identified. We hypothesized that child care programs participating in CACFP in GA would have higher compliance to the implementation of healthy beverage practices as compared with programs that do not participate in CACFP.

Methods

The University of Georgia (UGA) Institutional Review Board reviewed the project research protocol for approval to work with human subjects and classified the project as exempt. The research design was a cross-sectional 18-month study that investigated the current status of beverage policy implementation in child care programs in GA using a statewide survey.

Sample

A sample size analysis completed in G*Power 3.1 revealed that if there is a difference of 10% between centers and homes in terms of a yes/no question (e.g., “does the program, serve 100% juice”), 80% power can be achieved with a sample of size 404 each from center and home-based facilities. A sample of 68 of each type of facility was needed from each of the 6 geographic regions in GA. Because response rates for similar studies have been around 30%,^21,22 the sample size of 68 was multiplied by 1/0.3 for an initial random sample of 227 of each type of 3 types of facilities from each of the 6 regions in GA (North, Metro, Central, Southwest, Southeast, and East). The regions were created by the state Child Care Resource and Referral Agency. A comparable sample was drawn from the exempt facilities in each region, resulting in an initial sample of size (227 × 3) × 6 = 4086, divided evenly across regions and types of facilities.

Through our partnership with DECAL, we recruited child care programs for our study. A stratified, random sample of programs was selected from a database of over 10,000 child care programs in GA. After survey distribution, many programs were no longer in existence and other programs did not have working email addresses on file, which resulted in a total sample of 3054 child care programs.

Measures

Researchers conducted a statewide survey (Georgia Child Care Wellness Survey) using a modified version of the California (CA) Survey of Child Care Providers of 0–5 Year Old Children. The CA survey, first developed 2008 and refined in 2012 to focus on beverages by Ritchie et al., was used for a statewide assessment of foods and beverages served in licensed child care programs in CA.^21,22 The CA Survey of Child Care Providers of 0–5 Year Old Children measured CACFP participation, food and beverage practices, and barriers to implementing healthy beverage practices.

The tool contains a frequency checklist of 21 foods and beverages served in child care programs.²¹ Respondents were asked about prior day's provision of foods and beverages at breakfast, lunch, dinner, and snack. The survey also included questions about barriers to serving water and other healthy beverages and respondents were asked to check all barriers that applied. The instrument is based on the child care environment evaluation tool, the Nutrition and Physical Activity Self-Assessment for Child Care (NAPSACC) by Benjamin et al.²⁷ The NAPSACC obtains information on assessing the level of implementation of food, beverage, and physical activity best practices.²⁸

Survey Distribution

In March 2017, a letter from DECAL was emailed to the study sample to promote the statewide survey and request online participation. Participants completed an online version of the GA Child Care Wellness Survey using the Qualtrics survey platform (www.Qualtrics.com). Nonrespondents were sent email reminders about the survey over a period of four weeks. After the electronic survey response period (∼4 weeks; March–April 2017), nonrespondents were mailed a survey with a stamped and addressed envelope and a pencil included in the mailer.

Child care program directors or a designated appointee were asked to complete the survey to evaluate current implementation of beverage policies. The survey took ∼20–30 minutes to complete. To encourage participation, the first 34 respondents to complete the survey (electronic and paper) in each region in GA (204 in total) were mailed a Healthy Beverage Resource Kit. The kit included resources to implement beverage policies (e.g., a child-sized pitcher to provide water for self-serve throughout the day). In addition, the entire study sample was eligible to enter a drawing for a $250 local grocery store gift card.

Data Analysis

Researchers assessed the implementation of beverage policies as well as barriers and facilitators to implementing beverage policies in child care programs. To assess the implementation of beverage practices, the study team created dichotomous variables for whether or not programs were in compliance with beverage policies. The overall percentage of respondents meeting the policies, as well as percentage by CACFP participation and child care program type, were calculated. In all cases, this percentage is calculated out of the number who responded to the related item. Chi-square tests were used to compare CACFP vs. non-CACFP programs, as well as across the three child care program types.

In some cases, the expected counts for one or more groups were too low to meet the assumptions of the chi-square test, and in these cases a Fisher exact test (or the Freeman–Halton extension to the Fisher exact test) was calculated. Analyses were conducted using SPSS Version 24.0. A significance level of 0.05 was used to determine statistical significance.

Results

A total of 974 surveys were returned, resulting in an overall response rate of 32%. Sixty-three percent of surveys were completed online and four surveys were in Spanish. Responses were evenly distributed among the six geographic regions in GA. Forty-six percent of respondents were from family care homes, 39% from child care learning centers, and 15% from license-exempt programs. The majority of participants who completed the survey was site directors or owners. Sixty-seven percent of the respondents were enrolled in CACFP.

Healthy Beverage Policy Implementation by CACFP Status and Child Care Program Type

The current status of healthy beverage policy implementation in GA by CACFP status and child care program type is described in Table 1. A large majority of child care providers reported compliance with policies related to limiting juice, serving breast milk or formula only, and eliminating SSBs for 1–5-year olds and infants. Statistically significant relationships were noted for CACFP participation and program type for serving SSBs. Programs participating in CACFP were less likely to serve SSBs to 1–5-year olds. CACFP programs were also significantly more likely serve 2–5-year olds 1% or nonfat milk (87%) than non-CACFP programs (87% vs. 35%, p < 0.001).

Table 1.

Healthy Beverage Policies Implemented by Child Care Programs Serving 0–5-Year Olds in Georgia

	CACFP^b status					Child care program type
	CACFP	Non-CACFP			All	CCLC	FCCLH	Exempt^c
Healthy beverage policies^a	% (n)		χ² (1)	p	% ( n )				χ² (2)	p
Juice served once per day or less to 1–5-year olds	83.7 (637)	87.9 (298)	2.88	0.090	85.2 (974)	83.6 (379)	83.4 (445)	94.7 (150)	12.58	0.002^*
Juice not served to infants (0–12 months)	64.2 (438)	69.6 (148)	1.45	0.229	65.4 (593)	61.0 (287)	70.5 (271)	62.9 (35)	5.68	0.059
1 year olds served whole milk only	60.2 (548)	52.4 (206)	3.73	0.053	57.4 (767)	52.5 (341)	65.9 (358)	36.8 (68)	25.83	<0.001^*
2–5-year olds most often served 1%/nonfat/rice or soy milk	86.9 (559)	35 (203)	204.50	<0.001^*	72.6 (776)	74.7 (344)	75.7 (367)	43.1 (65)	31.05	<0.001^*
Breast milk or formula only provided to infants (0–6 months)	97.6 (371)	96.4 (110)	0.74	0.492	97.1 (488)	98.0 (254)	95.7 (209)	100.0 (25)	^d	0.299
Sugar sweetened beverages not served to 1–5-year olds	96.2 (637)	90.3 (298)	13.51	<0.001^*	94.6 (974)	97.4 (379)	93.7 (445)	90.0 (150)	12.47	0.002^*
Sugar-sweetened beverages not served to infants	97.9 (438)	98.6 (148)	0.30	0.586	98.1 (593)	99.7 (287)	96.3 (271)	100 (35)	^d	0.012^*
Water is available for self-serve outside for 1–5-year olds	42.5 (586)	37.0 (246)	2.17	0.141	41.0 (848)	55.7 (359)	40.4 (389)	32.0 (100)	5.02	0.081
Water is available for self-serve inside for 1–5-year olds	51.0 (584)	57.0 (249)	2.52	0.112	53.1 (849)	65.3 (354)	41.7 (391)	54.8 (104)	41.57	<0.001^*

Self-reported data from Statewide Georgia Child Care Wellness Survey. All survey respondents did not respond to every survey question and some programs did not serve infants.

Healthy Beverage Policies examined are based on guidelines of national policy recommendations for healthy beverages in child care (i.e., Centers for Disease Control and Prevention and National Academy of Medicine).

Child and Adult Care Food Program is a Federal reimbursement program for child care programs that serve healthy meals and snacks.

License-Exempt Program.

Indicates a Fisher Exact Test (or Freeman–Halton extension) was used.

p < 0.05.

CACFP, Child and Adult Care Food Program; CCLC, Child Care Learning Center; FCCLH, Family Child Care Learning Home.

When examining beverage policy implementation by child care program type, having water available for self-serve indoors and outdoors for self-serve showed the lowest level of compliance across all program types. Family child care homes were significantly more likely to comply with serving only whole milk to 1 year olds (66%; p < 0.001) than other program types (Table 1). All program types reported high compliance with eliminating SSBs for infants and 1–5-year olds. All exempt programs serving infants met this standard for infants (p = 0.012) as compared with other programs and nearly 100% of centers were meeting the guideline for 1–5-year olds (p = 0.002). License-exempt child care programs were more likely to limit juice (95%; p = 0.002) than centers (84%) and family child care homes (83%). Additionally, while no license-exempt child care programs reported serving SSBs to infants, these programs were more likely than other program types to serve SSBs to 1–5-year olds.

Barriers and Facilitators to Implementing Healthy Beverages by CACFP Status and Child Care Program Type

Limiting juice

Reported barriers for serving juice to 1–5-year olds once per day or less are highlighted in Table 2. CACFP participants find it less challenging than non-CACFP participants to meet guidelines related to limiting juice for 1–5-year olds, as the majority reported, “It is not hard” (p = 0.015). Another significant difference by CACFP status was related to parents bringing juice to child care (4% for CACFP sites vs. 12% for non-CACFP sites, p < 0.001).

Table 2.

Barriers to Limiting Juice Served to 1–5-Year Olds in Georgia

	CACFP^a status					Child care program type
Barriers to limiting juice served to 1–5-year olds	CACFP (n = 587), %	Non-CACFP (n = 242), %	χ²(1)	p	All (N = 846), %	CCLC (n = 358), %	FCCLH (n = 390), %	Exempt^b (n = 98), %	χ²(2)	p
Children like taste	12.9	12.4	0.05	0.829	13.2	9.8	15.6	16.3	6.51	0.039^*
Parents bring to child care	4.3	11.6	15.31	<0.001^*	6.6	5.0	5.1	18.4	24.75	<0.001^*
High cost of whole fruit	4.1	3.7	0.06	0.805	4.0	3.4	4.6	4.1	^c	0.681
Children do not like other drinks	3.9	2.9	0.52	0.472	3.9	2.8	5.1	3.1	^c	0.263
Serving less juice is not a priority	5.6	3.7	1.29	0.256	5.2	4.5	5.9	5.1	0.77	0.679
It is not hard to limit juice	76.3	68.2	5.89	0.015^*	73.5	78.2	72.3	61.2	11.95	0.003^*

Self-Reported data from Statewide Georgia Child Care Wellness Survey.

Child and Adult Care Food Program is a Federal reimbursement program for child care programs that serve healthy meals and snacks.

License-Exempt Program.

Indicates a Fisher Exact Test (or Freeman–Halton extension) was used.

p < 0.05.

License-exempt programs found it difficult to limit juice and were significantly more likely to report barriers, such as “children like the taste,” (p = 0.039) and “parents bring to child care” (p < 0.001), than other program types (Table 2). Major facilitators for limiting juice for 1–5-year olds regardless of CACFP participation and program type included: written juice guidelines (34%), support from families (26%), training for providers (21%), and information for families (21%).

Serving low-fat or fat-free milk to 2–5-year olds

Table 3 outline barriers to implementing recommended beverage policies related to serving milk. CACFP participating programs found it easier than non-CACFP program to serve 1% and fat-free milk (p = 0.004). In addition, some non-CACFP programs encountered parents bringing flavored milk, although most CACFP programs did not (5% vs. 2%, p = 0.047). Family child care homes (9%, p = 0.035) were more likely to report less consumption as a barrier to serving 1% or fat-free milk as compared with centers (7%) and exempt programs (1%). License-exempt programs significantly indicated parents bringing in flavored or whole milk to child care as a barrier (p = 0.010).

Table 3.

Barriers to Serving Low-Fat of Fat-Free Milk to 2–5-Year Olds in Georgia

	CACFP^a status					Child care type
Barriers to implementing milk policy barriers to providing unflavored low-fat or fat-free milk to 2–5-year olds	CACFP (n = 587), %	Non-CACFP (n = 237), %	χ²(1)	p	All (N = 838), %	CCLC (n = 356), %	FCCLH (n = 395), %	Exempt^b (n = 87), %	χ²(2)	p
Children do not like unflavored low-fat or fat-free milk	7.8	6.8	2.86	0.593	7.6	6.2	9.6	4.6	4.41	0.110
Children drink less milk if not flavored or low-fat/fat-free	8.0	5.1	2.20	0.138	7.4	7.0	9.1	1.1	6.73	0.035^*
Parents bring flavored or whole milk to child care	2.4	5.1	3.96	0.047^*	3.2	2.2	2.8	9.2	^c	0.010^*
High cost of unflavored low-fat or fat-free milk	0.7	0.4	^c	1.000	0.6	0.6	0.8	0.0	^c	1.000
Unflavored low-fat or fat-free milk not available where I shop for food	0.3	1.3	^c	0.146	0.6	0.6	0.8	0.0	^c	1.000
Serving unflavored low-fat or fat-free milk to children is not a priority	2.2	2.5	0.08	0.784	2.3	2.2	2.3	2.3	^c	1.000
It is not hard	80.4	71.3	8.09	0.004^*	77.4	79.8	78.5	63.2	11.43	0.003^*

Self-Reported data from Statewide Georgia Child Care Wellness Survey.

Child and Adult Care Food Program is a Federal reimbursement program for child care programs that serve healthy meals and snacks

License-Exempt Program.

Indicates a Fisher Exact Test (or Freeman–Halton extension) was used.

p < 0.05.

Providing breast milk

Barriers related to providing only breast milk to infants are shown in Table 4. While there were no significant differences in reported barriers by CACFP status, the greatest reported barrier was mothers not providing breast milk (70%). This is most challenging for exempt programs (82%) and least challenging for centers (76%) and family child care homes (62%, p = 0.001). Family child care homes were also most successful with providing all infants with breast milk (17%, p < 0.001).

Table 4.

Barriers to Providing Breast Milk to Infants in Georgia

	CACFP^a status					Child care type
Barriers to providing breast milk to infants	CACFP (n = 393), %	Non-CACFP (n = 127)	χ²(1)	p	All (N = 527)	CCLC (n = 269)	FCCLH (n = 230)	Exempt^{c b} (n = 28)	χ²(2)	p
Breast milk is not provided by mothers	7.2	68.5	0.35	0.555	70.4	76.2	62.2	82.1	13.68	0.001^*
Not enough refrigerator storage for breast milk	0.0	1.6	^c	0.059	0.4	0.4	0.0	3.6	^c	0.172
Not enough private space for mothers to breastfeed or express milk	2.5	2.4	^c	0.604	2.5	3.3	1.7	0.0	^c	0.546
Mothers are unable to take time from work to come breastfeed or express milk	22.1	24.4	0.28	0.595	22.6	24.5	19.1	32.1	3.62	0.164
Not enough training for staff on proper handling of breast milk	0.3	0.0	^c	0.756	0.2	0.0	0.4	0.0	^c	0.490
None of these because all are given breast milk	10.9	10.2	0.05	0.824	10.8	7.1	16.5	0.0	^c	<0.001^*

Self-Reported data from Statewide Georgia Child Care Wellness Survey. All survey respondents did not respond to every survey question and some programs did not serve infants.

Child and Adult Care Food Program is a Federal reimbursement program for child care programs that serve healthy meals and snacks.

License-Exempt Program.

Indicates a Fisher Exact Test (or Freeman–Halton extension) was used.

p < 0.05.

Reported facilitators included: training for providers (15%), written guidelines (16%), no help needed (41%), providing breastfeeding support to help mothers breastfeed when working or returning to school (34%), and support from a local breastfeeding coalition (9%).

Discussion

The GA Child Care Wellness Survey determined the current status of implementation of beverage policies among child care programs in GA by CACFP participation status and program type. We hypothesized that CACFP participating programs were more likely to comply with beverage policies. Findings provided some support for this hypothesis, although findings differed by type of beverage served. CACFP participating programs reported successful implementation of policies related to serving only breast milk or formula to infants, outdoor water availability, and serving 1% or fat-free milk, and had less success with the implementation of juice policies and indoor water availability. Many of these differences, while significant, were small in absolute magnitude. Overall results from survey data indicate that CACFP participating programs were more likely to comply with beverage policies compared with non-CACFP participating programs. The study findings are consistent with outcomes from similar studies.^20,21

The survey methodology and results are comparable to studies showing that CACFP participation is related to higher compliance with nutrition best practices among child care providers.^20,21 A recent study conducted in Mississippi showed that family child care home providers participating in CACFP reported serving healthier foods and beverages.²⁰ The current study supports findings that show CACFP participation encourages serving healthier beverages. This study further illustrates that differences exist in beverages served by program type.

A similar study in Minnesota and Wisconsin evaluated obesity prevention best practices and difficulty of implementation in licensed child care centers and homes.²⁶ Child care centers performed slightly better than family child care homes in the implementation of nutrition and physical activity best practices.²⁶ This study revealed that centers were more successful at implementing policies related to SSBs and water than family care homes, but this was not the case with other beverage policies.

Many states require child care providers to follow CACFP guidelines regardless of participation in the program. In GA, this is the case for child care centers only. In this study 67% of programs reported participation in CACFP. Child care centers were more likely to implement SSB and water polices, however, significant differences were only evident for eliminating SSBs for children and infants. Some CACFP beverage policies are not as stringent as the nationally recommended beverage best practices (e.g., Caring for Our Children standards) for child care. For example, eliminating SSBs is not a required CACFP beverage policy; however, it is a national recommendation.

Achieving policies that are not required by CACFP may be difficult for some child care programs. While overall study data show that many programs are moving in healthier direction to implement best practices (e.g., eliminating SSBs), further assistance to accomplish beverage policy implementation may be needed. This offers an opportunity for targeted training for all programs regardless of participation in CACFP.

As the study examined beverage policy implementation by child care program type, findings revealed the need for improvement in all program types. While centers reported the highest compliance with SSB policies, this study found that family child care homes comply with beverage policies as well as or better than centers on some policies. One example is that family child care homes had fewer barriers to providing breastfeeding support. Similarly, another study reported that family child care homes were more successful than centers with implementation of certain obesity prevention policies.²⁹

A novel feature of the study was the inclusion of license-exempt programs. Very few studies have evaluated license-exempt child care programs³⁰ and their role in obesity prevention. This may be due to a lack of regulation of license-exempt programs, which varies greatly from state to state.³⁰ As 15% of study respondents were from license-exempt child care programs, outcomes provide much needed insight into beverage policy implementation among license-exempt programs. For example, findings demonstrated that license-exempt programs are successfully implementing policies related to limiting juice and eliminating SSBs. Greater improvement is needed in the areas of serving 1% or fat-free milk, providing breast milk, and making water available for self-serve outside. To assist license-exempt programs with the implementation of beverage policies, efforts for training program staff and parents must be established.

Overall, survey results indicated that improvement in beverage policy compliance is needed among child care providers in GA. Although a majority of the statewide respondents were meeting SSB and breast milk policies, programs were not complying as well with juice, milk, and water policies. Less than 60% of providers were meeting the recommendation for serving whole milk to1 year olds, and about 70% of respondents were serving 1% or fat-free milk to 2–5-year olds.

Interestingly, findings show that many providers are not meeting the recommendation to have water available throughout the day for self-serve both indoors and outdoors. This suggests that providers may need to overcome barriers related to serving water such as mistrust of the water system or misinterpretation of CACFP rules regarding serving water with meals and snacks. Based on overall results, compliance with beverage policies in child care programs in GA can be improved among all beverage categories, indicating the need for the development of a beverage policy training.

Project findings provide evidence about current implementation of beverage policies which can inform policy makers in GA on how to improve implementation of existing policies. Results have identified pertinent beverage policy implementation barriers and opportunities that can be used by researchers to develop training and interventions targeting child care providers. In addition, data such as these may be of interest to parents seeking healthier environments for their children to assist in establishing healthy habits early in life.

Strengths and Limitations of Study

No known studies have investigated the beverage policy implementation among child care providers on a statewide level in GA. This study, therefore, adds to the dearth of knowledge about beverage policy implementation among child care programs in GA. Several strengths of our study include a random sampling process from regions across the state, the inclusion of license-exempt programs, and our partnership with DECAL to promote survey participation. The study also had a few limitations. Data collected from the survey were self-reported and there could be a degree of social desirability and/or fear of being punished for noncompliance with state regulations. To address this concern, programs were assigned a unique ID and informed that their answers are completely confidential. In addition, programs that were more likely to be in compliance with beverage policies, such as those who participate in CACFP, may have been more eager to return the survey. The response rate for this survey (32%) is consistent with previous studies (∼30%–40%)^21,22,26,31; however, this is a low response rate.

The majority of the respondents were from family child care homes and CACFP participating programs. Having a higher response rate may have showed different outcomes in the implementation of beverage practices in each program type. Another limitation is that the study only included child care programs in GA so the information may not be generalizable to other populations in other states; however, valuable insight was gained on beverage policy implementation in child care programs in the southeastern United States. In addition, our study was limited by the inability to control for socioeconomic differences between sites; however, an analysis of the impact of socioeconomic status on beverage quality will be reported in a future article.

Conclusion

Our results contribute to addressing the knowledge gap on how beverage policy implementation varies by CACFP participation among child care programs. Policies related to juice, milk, and water are in greater need of improvement than those related to SSBs and breast milk. Facilitators such as training and written guidelines assist providers in implementing policies. Further examination of barriers and facilitators of healthy beverage policy implementation were explored in a qualitative objective for the overall study, which provides further insight about challenges and supports.

Additionally, socioeconomic, geographic, and racial/ethnic disparities may exist in beverage compliance across the state. We will report on existence or lack of disparities in beverage compliance throughout GA in the forthcoming assessments. Future research should focus on the development of beverage policy training for child care providers, with the ultimate goal of reducing obesity risk and promoting healthier diets among preschool children.

Footnotes

Acknowledgments

The authors would like to thank the undergraduate and graduate students in the Childhood Obesity Prevention Laboratory at the University of Georgia for their assistance in data collection and data entry. The authors greatly appreciate the assistance provided by the Georgia Department of Early Care and Learning. They also sincerely thank the child care professionals that participated in their study. This research was supported by grant #74373 from the Robert Wood Johnson Foundation through its Healthy Eating Research program.

Author Disclosure Statement

No competing financial interests exist.

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