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Child and Adult Care Food Program: Aligning Dietary Guidance for All Summary The Child and Adult Care Food Program (CACFP) has the broadest scope of any of the U.S. Department of Agriculture (USDA) food programs. It supports the nutrition and health of our nation’s most vulnerable populations—infants and children (especially those in low-income households) and adults who require daily supervision or assistance. Many of these participants rely on CACFP for the majority of their food intake, so the quality of the foods provided has the potential to substantially improve the overall adequacy and healthfulness of their diets. Furthermore, the availability of affordable care that includes meals and snacks of high nutritional quality provides an invaluable form of support for parents, guardians, or caregivers who need to be employed. CACFP currently serves approximately 3.3 million children and 114,000 adults across the United States. Yet, in spite of the importance of this program to millions of American families, the key role of CACFP in the food assistance spectrum is under-appreciated by both nutrition professionals and the public. To ensure that the meals and snacks provided by this crucial food program are of the highest quality possible, the USDA asked the Institute of Medicine (IOM) to review and recommend improvements, as necessary, to the Meal Requirements for CACFP. Over the past decade, the federal government has sought the advice of the IOM to improve the nutrition and health opportunities for millions of Americans across a range of age, gender, and economic groups. In response, reports from the IOM have issued recommendations for
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Child and Adult Care Food Program: Aligning Dietary Guidance for All Improved food packages provided through the Supplemental Nutrition Program for Women, Infants, and Children (WIC), Nutrition standards for competitive foods offered or sold in the school setting, and Revised Meal Requirements for the National School Lunch Program and the School Breakfast Program. These recommendations are grounded in the sound nutritional guidance and nutrient standards of the current Dietary Guidelines for Americans and the Dietary Reference Intakes (DRIs). This study of CACFP is a follow-up of the study to recommend revised standards and requirements for school meals. Like WIC and the school meal programs, CACFP is a nutrition assistance program that is administered by the Food and Nutrition Service (FNS) of USDA. CACFP serves infants, preschool children, and children younger than 12 years in child care centers and homes, older children in at-risk afterschool programs and emergency shelters; and disabled and older adults in adult day care centers. CACFP is also broad in the types of meals provided, which may include breakfast, lunch, supper, and snacks. Finally, the settings for CACFP meals are diverse, ranging from small family day care homes to large day care centers and schools. TASK AND APPROACH USDA requested that the IOM convene a panel of experts to undertake a study to review and recommend revisions to the CACFP Meal Requirements. The major objective was to develop practical recommendations that would bring CACFP meals and snacks into alignment with current dietary guidance. Specifically, the committee was asked to Review and assess the nutritional needs of the target populations based on the Dietary Guidelines for Americans and the DRIs, and Use that review as a basis for recommended revisions to the Meal Requirements for CACFP. As part of its task, the committee was asked to consider certain critical issues identified by the FNS. The committee’s goal was to develop well-conceived, practical, and economical recommendations that reflect current nutritional science; to omit foods of low nutritional value; and to enhance the ability of the program to effectively meet the nutritional needs of the children and adults served. Considering the broad scope of CACFP, the committee took a broad view of its assignment by developing Meal Requirements that could be
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Child and Adult Care Food Program: Aligning Dietary Guidance for All used for specific meals and across a full day, that covered all age groups from infants through older adults, and that could be implemented both by providers in family homes and by those in large centers. The recommended Meal Requirements that are described in this report provide a framework that can be extended beyond CACFP and used to design and implement other food and nutrition recommendations in a variety of settings and programs as the need arises. To address its task, the committee formulated a strategy that included the review of published literature and other available evidence, consideration of information from public workshop presentations, analyses of relevant data, and deliberations on topics relevant to its charge. Prior to proposing revisions to the CACFP Meal Requirements, the committee developed criteria to guide its deliberations. Box S-1 presents the five criteria that guided the decision-making process used to generate the committee’s recommendations. BOX S-1 CACFP Criteria Criterion 1. The Meal Requirements will be consistent with current dietary guidance and nutrition recommendations to promote health with the ultimate goal of improving participants’ diets by reducing the prevalence of inadequate and excessive intakes of food, nutrients, and calories. For infants and children younger than 2 years of age, the Meal Requirements will contribute to an overall diet that is consistent with established dietary recommendations for this age group and encourage and support breastfeeding for infants. For participating adults and children ages 2 years and older, the Meal Requirements will be consistent with the Dietary Guidelines for Americans and the Dietary Reference Intakes. Criterion 2. The Meal Requirements will provide the basis for menus that are practical to plan, purchase, prepare, and serve in different settings. Criterion 3. The Meal Requirements will provide the basis for menus that incorporate healthful foods and beverages and are appealing to diverse age ranges and cultural backgrounds. Criterion 4. The Meal Requirements will facilitate the planning of menus that are compatible with the capabilities and resources for the variety of program providers. Criterion 5. The Meal Requirements will allow the planning of menus that are sensitive to considerations of cost.
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Child and Adult Care Food Program: Aligning Dietary Guidance for All TABLE S-1 Recommended Age Groups for CACFP Meal Patterns Age Group Age Rangea Infants 0–5 months 6–11 months Children 1 year 2–4 years 5–13 yearsb 14–18 yearsb Adults 19 years and older aAge ranges are inclusive; e.g., ages 0–5 months includes ages 0 through 5 months. bThe committee recognizes that children older than 12 years ordinarily are eligible only for the at-risk afterschool program, but migrant children are eligible through age 15 years, and youths in shelters are eligible to age 18 years. Process to Develop Recommendations An iterative process was used to develop recommendations for revised CACFP Meal Requirements. The first step was to set key parameters, including age groups and total daily calorie requirements. Then the current intakes of individuals in these age groups were evaluated by comparison to standards for food groups and nutrient intakes. This was done to identify food and nutrient intakes of concern. Next, nutrient and food group intake targets for CACFP were developed, taking into account the identified nutritional needs of the CACFP population. Finally, meal patterns and food specifications were developed to be used as the basis of the recommended Meal Requirements for CACFP. This last step was repeated until the new Meal Requirements aligned with the Dietary Guidelines for Americans and the DRIs. As a part of this process, the committee considered the five criteria in Box S-1 and the unique aspects of the program. Importantly, the committee gave consideration to the practicality and cost of implementing revisions to the program in the different types of settings in which CACFP operates. Age Groups The age groups for which patterns are recommended are similar to those currently used by CACFP, although some changes have been made for the younger children to correspond to recent dietary guidance. See Table S-1 for the recommended age groups. RECOMMENDATIONS As structured by the committee, the recommended Meal Requirements encompass two distinct elements: meal patterns and food specifications.
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Child and Adult Care Food Program: Aligning Dietary Guidance for All The Meal Requirements serve to (1) provide patterns and specifications for menus consistent with the Dietary Guidelines and nutrient targets and (2) allow the identification of meals that qualify for reimbursement. Recommendations for Meal Requirements, implementation strategies, and evaluation and research are addressed below. Recommendations for Revised Meal Requirements: Meal Patterns and Food Specifications In order to bring the Meal Requirements into alignment with the best available dietary guidance and to improve consistency with the requirements of other FNS programs, the committee recommends that the FNS of USDA take the following steps: Meal Requirement Recommendation 1: USDA should adopt the recommended Meal Requirements for healthy infants up to 1 year of age. Key elements of this recommendation are the provision of only breast milk or formula for infants under 6 months of age; the gradual introduction of baby meats, cereals, fruits, and vegetables beginning at age 6 months; and the omission of fruit juice of any type before the age of 1 year. Tables 7-1 and 7-8 in Chapter 7 provide the detailed specifications for the infant meal patterns. Meal Requirement Recommendation 2: For all children age 1 year and older and for adults, USDA should adopt Meal Requirements that increase the variety of fruits and vegetables, increase the proportion of whole grains, and decrease the content of solid fats, added sugars, trans fats, and sodium. The recommended Meal Requirements continue to contain valuable features of the current meal requirements, such as focusing on food groups, specifying minimum amounts of foods to be provided at meals and snacks, and not allowing foods such as soft drinks, fruit drinks, and candy to be included in reimbursable meals. Three types of meal patterns continue to be defined: breakfast, lunch and supper, and snacks. The major food groups in the meal patterns are also similar to those currently used: fruits and vegetables, grains/bread, meat/meat alternates, and milk (but fruits and vegetables are now separated in the pattern specifications). Although the foods contained in these groups continue to be like the MyPyramid food groups and cheese and yogurt still may be used as meat alternates, there is an emphasis on lean or low fat choices. The new recommended food specifications place limitations on a larger number of foods within each food group. As with the current meal patterns, differences in energy and nutrient needs across the age groups for children and adults are considered by adjusting the portion sizes within the food groups. The amount of food in the meal patterns increases across the four younger age groups (age 1 year, 2–4 years, 5–13 years, and 14–18 years), and then decreases for adults to
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Child and Adult Care Food Program: Aligning Dietary Guidance for All BOX S-2 Recommended Daily Meal Patterns for Breakfast, Lunch/Supper, and Snacks: Number of Servings and Range of Serving Sizesa Food Group Serving Number Range of Serving Size Breakfast Fruit or non-starchy vegetable 1 ¼ to ½ cup Grains/breads 1 ½ to 3 ounce equivalent Lean meat/meat alternate 1 ½ to 2 ounce equivalent (3 times weekly) Milk 1 ½ to 1 cup Lunch/Supper Fruit 1 ¼ to ½ cup Vegetable 2 ⅛ to ½ cup Grains/breads 1 ½ to 2-½ ounce equivalent Lean meat/meat alternate 1 ½ to 2-½ ounce equivalent Milk 1 ½ to 1 cup Snacks (Choose 2 Food Groups per Snack) Fruit 2 per week ½ to 1 cup Vegetable 2 per week ⅛ to 1 cup Grains/breads 2 per week ½ to 2 ounce equivalent Lean meat/meat alternate 2 per week ½ to 1 ounce equivalent Milk 2 per week ½ cup aServing sizes vary by age group approximately the same level as for children 5–13 years of age. In addition, for several of the food groups, the amounts of food within the group are similar to those specified for the current meal patterns. Box S-2 shows the basic format of the meal patterns and the ranges of portion sizes across age groups. Tables 7-2 through 7-8 provide more details on these patterns. However, within this framework for meal patterns and food specifications, several new elements are being recommended, as follows: One fruit and two different vegetables are to be served at each lunch and supper meal. Over the course of a 5-day week, different types of vegetables are to be served at each lunch and supper,
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Child and Adult Care Food Program: Aligning Dietary Guidance for All as follows: dark green vegetables at least twice per week, orange vegetables at least twice per week, legumes at least once per week, starchy vegetables no more than twice per week, and other vegetables at least three times per week. Fruit rather than fruit juice is to be served at most meals; juice must be unsweetened 100 percent juice and is allowed only once per day in a serving size tailored to the age group’s needs. At least half of the grains/breads served in meals and snacks must be whole grain-rich, meeting the definition given in the table of proposed food specifications (Table 7-8). Other grain/bread must be enriched. Providers are encouraged to gradually increase the proportion of grain foods that are whole grain-rich to well above half of the grain foods and to include 100 percent whole grain foods often. Each morning and afternoon snack will provide two different food components in a serving size tailored to the age group’s needs; over the course of a 5-day week, the food components provided will include two servings of fruit, one serving of an orange vegetable, one serving of a non-starchy vegetable, two servings of grain/bread, two servings of lean meat or meat alternate, and two servings of low-fat or nonfat milk. The amounts of solid fats, added sugars, trans fats, and sodium are to be limited in all meals and snacks. For example, milk and yogurt must be low fat or nonfat for those ages 2 years or older (whole milk for 1-year-old children), meats must be lean, fruits and juices must be free of added sugars, foods with nutritional labels must be labeled as containing zero grams of trans fat, and foods high in added sugars and/or sodium are to be served infrequently, if at all. Meat or meat alternates are to be served at breakfast three times a week. Table 7-8, in Chapter 7 gives the specifications for lean meat and low-fat cooking methods. Although the major food groups in each meal are served every day, specific selections within the food groups vary across the days of the week, as do the snack selections. As a result, the committee notes that weekly menu planning would help providers achieve the specified variety and adopt efficient new shopping patterns and ways to control costs. As shown in Table S-2, the recommended Meal Requirements differ in many important ways from those in the current regulations. They are much more consistent with current dietary guidance and nutrition recommendations to promote health. The committee’s recommendations create a comprehensive system of requirements focusing control on the specific food
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Child and Adult Care Food Program: Aligning Dietary Guidance for All TABLE S-2 Comparison of Current Requirements with Recommended Meal Requirements and Specifications Eating Occasion Current Requirements Recommended Requirements and Specifications All Must meet daily pattern Must meet daily and weekly patterns to provide more flexibility and better alignment with the Dietary Guidelines Breakfast 3 meal components 4 or 5 meal components Lunch or supper 4 meal components 5 meal components Snack Any 2 of 4 components Variety specified for the week Choice between 2 small snacks or 1 enhanced snack Meal Component Fruit Fruits and vegetables are combined as a category Fruits are a separate category, and servings are increased; juice is not provided for infants and is limited for children; fruits containing added sugars are limited Vegetable Vegetables are a separate category from fruit, and servings are increased; must provide variety including dark green leafy, bright yellow/orange, legumes; sodium content is limited; starchy vegetables are limited Grain Enriched or whole grain, proportions not specified At least half must be whole grain-rich; additional whole grains are encouraged; grain products high in solid fats and added sugars are limited to control calories and saturated fat; high-sodium grain products are also limited Meat/alternate None at breakfast No restrictions on high-fat, highly processed meats Included in weekly breakfast pattern Some types are limited to help control calories, solid fat, and sodium
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Child and Adult Care Food Program: Aligning Dietary Guidance for All Eating Occasion Current Requirements Recommended Requirements and Specifications Milk Any type of fluid milk Must be nonfat or low-fat (1% fat) for children over 2 years of age and adults, whole milk for 1-year-old children Flavored milk must be nonfat and is allowed only for at-risk and afterschool programs and adult programs A limited amount of nonfat or low-fat yogurt is allowed as a milk substitute for children over 2 years of age and adults, if not used as a meat substitute Food Component Energy No requirement Calories are controlled by limiting foods high in solid fats and added sugars Micronutrients No standard specified by regulation Meal patterns are designed to achieve, for protein and most micronutrients, DRI targets consistent with a low prevalence of inadequacy Fats No restriction on type of amount Label must state zero trans fat (if applicable); food specifications limit highly processed and high fat meats and foods; moderate use of healthy fats is encouraged Sodium No restriction No salt at the table Recommendations to choose commercial foods low in sodium and to prepare foods with less salt NOTE: DRI = Dietary Reference Intake.
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Child and Adult Care Food Program: Aligning Dietary Guidance for All groups and variety of key subgroups offered for all meals and snacks and on the nutrition quality of all foods served through food specifications. By convening a panel of expert CACFP sponsors, providers, state administrators, and CACFP associations (see Appendix M), and trainers, it is possible that USDA could identify a process for phasing in some of the more complex new elements with the goal of supporting the recommended Meal Requirements. Meal Requirement Recommendation 3: USDA should give CACFP providers the option of serving one enhanced snack in the afternoon in place of a smaller snack in both the morning and the afternoon. The enhanced snack option (shown in Table 7-6) would be particularly appropriate for at-risk children in afterschool programs and for older adults because their access to nutritious foods may be limited at home. The enhanced snack would have the same requirements as two of the smaller snacks. Providers would specify in advance which snack option they were choosing, and would serve the same type of snack to all participants in their care. Recommendations for Implementation Strategies In order to bring the Meal Requirements into alignment with the best available guidance and improve their consistency with the nutritional requirements of other programs of the FNS, the committee makes the following recommendations. Implementation Strategy Recommendation 1: USDA, working together with state agencies and health and professional organizations, should provide extensive technical assistance to CACFP providers to implement the recommended Meal Requirements. Key aspects of new technical assistance to providers include measures to continuously improve menu planning (including variety in vegetable servings and snack offerings across the week), purchasing, food preparation, and record keeping. Such assistance will be essential to enable providers to meet the Meal Requirements while controlling cost and maintaining quality. Many potential partners and resources are available that USDA could tap to assist with developing training materials and/or provide the training. Some of these are listed in Appendix M. Implementation Strategy Recommendation 2: USDA should work strategically with the CACFP administering state agencies, CACFP associations, and other stakeholders to reevaluate and streamline the system for monitoring and reimbursing CACFP meals and snacks. The CACFP National Professional Association and the Child and Adult Care Food Program Sponsor’s Association would be key partners. Several aspects of the existing monitoring and reimbursement processes will need to be revised to enable states to efficiently administer the CACFP program with the new recommended Meal Requirements in place. The procedures would be expected
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Child and Adult Care Food Program: Aligning Dietary Guidance for All to (1) focus on meeting relevant Dietary Guidelines and (2) provide information for continuous quality improvement and for mentoring program operators to assist in performance improvement. Among the challenges will be the development of practical methods for states to monitor for compliance with weekly requirements and for minimizing providers’ reporting requirements. Recommendations for Program Evaluation and Research While conducting this study, the committee encountered a considerable lack of up-to-date data relevant to CACFP, including participant characteristics, nutrient intake profiles, program costs, and certain program outcomes. The committee identified a need to improve data-gathering in all aspects of the program. In addition, a need was identified for ongoing evaluation of program standards and implementation efforts. Thus, the committee recommends that USDA take the following steps. Program Evaluation Recommendation 1: USDA, in collaboration with relevant agencies, should provide support for research to evaluate the impact of the Meal Requirements on participants’ total and program-related dietary intake and consumption patterns, on the food and nutrient content of the meals and snacks served, on demand from eligible providers to participate in CACFP, and on program access by participants. This evaluation would determine: (a) the food and nutrient content of meals and snacks as served, (b) participants’ overall food and nutrient intakes as related to current dietary guidance, and (c) the number of providers and participants in the CACFP program. Program Evaluation Recommendation 2: USDA should take appropriate actions to establish the current baselines prior to implementation of the new Meal Requirements for comparison purposes. Collection of a nationally representative baseline database of foods actually served is crucial. It will also be important to collect information on significant factors that might influence the impact of CACFP, including the number and types of meals served by age and setting, variations in state licensing requirements, and differences in the cost of living. Comparing CACFP child care to non-CACFP child care in the same geographic location could also contribute to fully understanding the impact of CACFP. Program Evaluation Recommendation 3: To the extent possible, USDA should take steps to ensure that the final rule for the new Meal Requirements is informed by the results of evaluation of program impact (described in Recommendation 1 above). It will be critically important to evaluate the extent to which implementation of the revised Meal Requirements achieves the goal of promoting health and improving participants’ diets by reducing the prevalence of inadequate and excessive intakes of foods, nutrients, and
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Child and Adult Care Food Program: Aligning Dietary Guidance for All calories and contributing to an overall diet consistent with established dietary recommendations, including the Dietary Guidelines for Americans. Research Recommendation 1: USDA, in collaboration with relevant agencies and foundations, should support research on topics related to the implementation of the Meal Requirements and to fill important gaps in knowledge of the role of CACFP in meeting the nutritional needs of program participants. Research Recommendation 2: USDA should review and update, as appropriate, the CACFP Meal Requirements to maintain consistency with the Dietary Guidelines and other relevant science. CONSISTENCY OF RECOMMENDATIONS WITH CRITERIA The recommendations for Meal Requirements for CACFP and for implementing and monitoring them were evaluated for consistency with the committee’s criteria, as summarized below. The committee worked to achieve an appropriate balance between competing aspects of the criteria, such as increased amounts of certain types of food, practicality, and cost. Criterion 1: Consistency with Dietary Guidance Recommendations for infants and children younger than 2 years of age reflect guidance from the American Academy of Pediatrics and result in feedings or meals that are in alignment with the DRIs. The Meal Requirements for those 2 years of age and older were designed to come as close as possible to Dietary Guidelines and to nutrient targets that were based on the DRIs while still being practical. Estimates of the nutrient content of the recommended sample menus indicated reasonable agreement with the nutrient targets, with the notable exception of sodium, vitamin E, and potassium. Review of the meal patterns and menus developed from the recommended Meal Requirements shows improved alignment with Dietary Guidelines (see Box S-3). The high nutrient quality of the meals contributes to the major role that CACFP plays in supporting the nutrition of those in day care and other CACFP settings. Criterion 2: Practicality in Terms of Planning, Purchasing, Preparing, and Serving Meals The committee acknowledges that the recommended Meal Requirements are more complex than the current requirements, especially with regard to meal planning, even though adjustments were made to keep them as simple as possible. An increase in complexity is absolutely essential to achieve greater consistency with the Dietary Guidelines. For example, the
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Child and Adult Care Food Program: Aligning Dietary Guidance for All BOX S-3 Recommended Meal Requirements Improve Alignment with the Dietary Guidelines Better control of calories More fruits and more vegetables A greater variety of vegetables More whole grain-rich foods, fewer refined grain foods Milk choices limited to nonfat and low fat; no flavored milk for younger children Increased emphasis on limiting foods high in solid fats and added sugars Minimized content of trans fat Stronger emphasis on gradual reduction of sodium recommended meal pattern was revised to cover a 5-day week as well as a single day. This increase in complexity is one of the reasons for the recommendations related to technical assistance and monitoring. Reduced use of pre-prepared foods and increased in-house food preparation would be helpful in reducing sodium, solid fats, added sugars, and cost; technical assistance would help develop the skills needed. Criterion 3: Appeal to Diverse Age Groups and Cultures The meal patterns allow broad flexibility in planning menus. This means, for example, that those providers who serve preschool children can meet the pattern with a selection of foods that are suitable for their stage of development and that providers who serve the elderly can meet the pattern with an entirely different selection of foods if appropriate to the circumstances. The meal patterns developed by the committee are intended to allow for the inclusion of foods enjoyed by different cultures. Criterion 4: Compatibility with the Capabilities and Resources of Program Providers The committee developed the standards for menu planning with the intent of making them adaptable to different provider venues: day care homes, centers, and other facilities such as Head Start. In the short term, program providers may face challenges in obtaining acceptable products, especially whole grain-rich foods and foods that are reduced in solid fats, added sugars, and sodium. This is a particular concern for day care settings with limited shopping options. Providers in all venues will need training
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Child and Adult Care Food Program: Aligning Dietary Guidance for All and other types of support to plan menus that meet the recommended Meal Requirements and that are realistic for their situation. Criterion 5: Sensitive to Cost The recommended Meal Requirements increase overall food costs in CACFP mainly because of increased amounts and variety of fruits and vegetables for many age groups at lunch/supper and snacks, the addition of meat/meat alternates at breakfast (balanced only in part by reductions of meat/meat alternates at lunch for the younger children), and increases in the amount of whole grain-rich foods for some age groups. For example, using 2003–2004 prices, the combined cost of breakfast, lunch, and a regular snack is estimated to increase by $0.30, or 31 percent, for children 1 year of age, and by $0.56, or 44 percent, for children 2–4 years of age. Non-food meal costs are expected to increase initially, to vary with the provider setting and with the extent to which the provider has already implemented changes similar to those recommended, and to be influenced substantially by the quality and extent of technical assistance provided. An increased need for training may persist but will be accompanied by improvements in food service and nutrition education, especially in larger centers. The expected increase in costs will likely exceed the amount that can be absorbed by CACFP providers under current federal reimbursement levels. If the recommended Meal Requirements are fully implemented, continued participation by most providers will require an increase in reimbursement. CONCLUSION The new recommended Meal Requirements (meal patterns and food specification standards) will result in menus that are more closely aligned with the Dietary Guidelines for Americans and the DRIs than are the menus based on the current regulations. Notably, the recommended Meal Requirements may increase the consumption of fruits, vegetables, whole grain-rich foods, and lean meats, while decreasing the intake of solid fats, added sugars, and sodium. Initially, however, most providers will need considerable technical assistance in order to implement the recommended Meal Requirements without undue difficulty. With appropriate reimbursement and implementation strategies, the committee anticipates that providers’ acceptance of the recommended changes in meals and snacks are achievable and that participation rates can be maintained or enhanced.