Sugary Drinks Research: Childcare Settings

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This is part of our Sugary Drinks & Latino Kids: A Research Review »

Early childcare settings are diverse

The National Household Education Survey reports that 60 percent of all U.S. children ages 5 and younger not yet enrolled in kindergarten were in some form of non-parental care at least once a week in.69

Among these children, 56 percent were cared for in a center such as a day care center, Head Start program, preschool, prekindergarten, or other early childhood programs.

Children in full-time child care programs obtain typically half to three-fourths of their daily energy in these settings.70

The types of child care facilities and programs available in the U.S. vary considerably, including large and small child care centers, family day care homes, Head Start facilities, and others.71

Regulations differ for different childcare settings

With the exception of the federal Health Start program, child care programs are regulated primarily at the state level, with states setting regulations and minimum enforcement standards for licensed programs.

Some facilities, such as faith-based centers and smaller family day care homes, are exempt from licensure and regulations.

Local regulations have been enacted in some municipalities, but not all states give muniticpalities this authority.

Some facilities participate in the Child and Adult Care Food Program (CACFP), a federal program of the U.S. Department of Agriculture that provides site training and reimbursement for meals and snacks served to income-eligible children.

Public and private nonprofit child care centers and for-profit centers receving title XX funds for at least 25 percent of the children in care are eligible to participate in CACFP and participating providers must ensure that meals and snacks met current food-based meal pattern standards.72

CACFP regulations pertain only to those foods and beverages for which providers seek reimbursement; therefore, they do no preclude providers from offering non-reimbursable items such as SSBs.71

Finally, the Head Start program is a federal program of the U.S. Department of Health and Human Services that provides health, eduation, and nutrition resources to low-income children.72

Unlike the CACFP, the Head Start program has federal performance standards for nutrition and must have a registered dietitian review and evaluate centers’ menus.71

Sugary drinks in early childcare settings

Limited research has documented the types of beverages available and served to children in such child care settings.

Studies have shown that some (but few) facilities do serve SSBs to children in this age group and that provision and promotion of water does not often meet recommended practices.

For example, in a 2005-06 survey of 40 New York City child-care center directors (38 of which participated in the CACFP), three directors (8.1%) reported that fruit drinks with less than 100 percent juice were available.

Half of the centers did not provide a source of drinking water, and only three provided drinking water to children at mealtimes.73

By comparison, a national survey of 1,810 Head Start program directors found that nearly all (99%) reported never serving sugary drinks such as Kool-Aid, sports drinks, punches, or soda, and 95 percent reported never serving juice drinks with less than 100 percent juice.74

An observational study conducted in 40 child care centers participating in the CACFP in Connecticut found that 16 percent and 68 percent of centers, respectively, did not have water available for students in the classroom or during physical activity.72

Further, staff verbal promotion of water was observed in less than a quarter of the centers in both the classroom and physical activity components.

In a 2008 statewide survey of 432 child care providers in California, provision of sweetened drinks (including soda or fruit drinks) to children ages 2-5 on the day preceding the survey varied by type of facility, with CACFP centers reporting the lowest frequency (2.9%) and non-CACFP homes reporting highest frequency (18.4%).75

Lastly, in a survey of nearly 300 home child care providers (caring for up to six children ages 12 and younger) in Kansas, 93.5 percent of respondents reported that sugary drinks (e.g., fruit drinks, punches, sports drinks, soda) were served fewer than twice weekly and 70 percent and 96 percent reported that drinking water was readily available outside and inside, respectively.76

State regulations on obesity-related practices in childcare

In 2007, a review of regulations in each of the 50 states and the District of Columbia was conducted to assess policies related to beverages and other obesity-related practices in child care.77

Just seven states (14%) had policies limiting SSBs in both licensed child care centers and family child care homes.

A number of these states’ regulations stated that these beverages could only be served occasionally or on special occasions.

Forty-one states (80%) had policies ensuring that water was available to all children in child care centers, while 34 states (67%) had policies requiring water be available to all children in family child care homes.

Even when policies were in place, the authors note that regulations often lack specificity and may be difficult to interpret by child care providers.77

In 2010, California passed Assembly Bill 2084, the Healthy Beverages in Childcare law, which among other things prohibited beverages with added sweetener (artificial or natural and including flavored milk), mandated that drinking water be available at all times, and limited 100 percent juice to no more than one age-appropriate serving per day.78

These regulations exceeded federal CACFP beverage requirements and applied to all licensed child-care sites in the state, including non-CACFP sites.

A study comparing beverage availability in California licensed child care facilities in 2008 and 2012 (before and after the new regulations took effect) surveyed approximately 1,400 sites and found that after the policy took effect, significantly more child care sites served water with meals and snacks (46.7% vs. 28.0%, p=0.008) and made self-service water available to children both indoors (76.5% vs. 69.0%, p=0.001) and outdoors (77.5% vs. 68.8%, p<0.001).78

Only 7.6 percent of sites reported providing SSBs in 2008 and 6.9 percent did so in 2012, representing a decrease but not a significant change. Compliance with the SSB and water provisions was higher among centers participating in the CACFP.78

In 2007, new regulations were set for early childhood centers in New York City, where the Board of Health has independent regulatory authority over child care centers.

Among other obesity-related practices, the regulations restricted SSBs for all children and required water to be made available and accessible at all times.79

In late 2009/early 2010, a study evaluating compliance with the regulations was conducted in 106 group child care centers (93% of which participated in CACFP and 73% of which participated in Head Start).80 Researchers found that most centers (67%) complied with the SSB regulations (i.e., had no SSBs in center’s kitchen facilities during two site visits and no SSBs served to any child with any meal or snack during two-day site visits).

A little more than half (52.8%) of sites made water available to children (i.e., teachers consistently reported that water was available to children throughout the day and drinking water was visible in the classroom or in a nearby hallway).80

Furthermore, this study demonstrated that compliance with the new regulations was associated with 86 percent lower odds of a child consuming SSBs with any meal or snack; compliance was not associated with the likelihood of a child consuming water during meals or snacks, however.80

Childcare centers and promotion of water

The Healthy, Hunger-Free Kids Act of 2010 requires that child care facilities participating in the CACFP make drinking water available throughout the day (as of October 2011); however, it does not place any restrictions on SSBs.

In January 2015 the USDA Food and Nutrition Service issued a proposed rule to amend the meal patterns for the CACFP to better align them with the Dietary Guidelines for Americans and Institue of Medicine recommendations.

The proposed rule includes the following language: “States and sponsors should encourage facilities to serve water with snacks when no other beverage is being served, and in lieu of other high calorie, sweetened beverages (juice drinks, soda, sports drinks, etc.) that are served outside of meal times.”81

As the revised guidelines were in review, states and localities (where they are given the authority) were given authority to go beyond the nutrition requirements in the federal CACFP regulations and influence beverages available not only in centers participating in CACFP, but non-CACFP centers and day care homes as well.

The revised CACFP rules were approved in April 2016.

The new guidelines “will improve access to healthy beverages, including low-fat and fat-free milk and water, and encourage breastfeeding for the youngest program participants,” according to the USDA.82

The revised rules also: limit service of juice to once per day; prohibit flavored milk for children ages 2-5; recommend as a best practice that flavored milk contain no more than 22 grams of sugar per 8 fluid ounces for children ages 6 and and older; and require potable drinking water to be offered to children throughout the day and available to children upon their request throughout the day.82,83

The revised rules also include some non-mandatory best practices, which cinlude “avoid serving non-creditable foods that are sources of added sugars, such as sweet toppings (e.g., honey, jam, syrup), mix-in ingredients sold with yogurt (e.g., honey, candy or cookie pieces), and sugar-sweetened beverages (e.g., fruit drinks or sodas).83

Also, in February 2016, the Colorado State Board of Human Services Office of Early Childhood approved a new obesity prevention rule took effect in child care centers within Colorado banning all centers on providing sugar-sweetened sodas, fruit drinks, energy and sports drinks and flavored milk.84

More from our Sugary Drinks & Latino Kids: A Research Review »

References for this section »

69. Mamedova, S. & Redford, J. Early Childhood Program Participation, from the National Household Education Surveys Program of 2012. (U.S. Department of Education, 2013).

70. Benjamin Neelon, S. E., Briley, M. E. & American Dietetic Association. Position of the American Dietetic Association: benchmarks for nutrition in child care. J Am Diet Assoc 111, 607–615 (2011).

71. Story, M., Kaphingst, K. M. & French, S. The role of child care settings in obesity prevention. Future Child 16, 143–168 (2006).

72. Middleton, A., Henderson, K. & Schwartz, M. From Policy to Practice: Implementation of Water Policies in Child Care Centers in Connecticut. (2013).

73. Erinosho, T., Dixon, L. B., Young, C., Brotman, L. M. & Hayman, L. L. Nutrition Practices and Children’s Dietary Intakes at 40 Child-Care Centers in New York City. 1391–1397 (American Dietetic Association, 2011).

74. Whitaker, R. C., Gooze, R. A., Hughes, C. C. & Finkelstein, D. M. A national survey of obesity prevention practices in Head Start. 1144–1150 (2009).

75. Ritchie, L. D. et al. Participation in the Child and Adult Care Food Program Is Associated with More Nutritious Foods and Beverages in Child Care. Childhood Obesity 8, 224–229 (2012).

76. Trost, S. G., Messner, L., Fitzgerald, K. & Roths, B. Nutrition and Physical Activity Policies and Practices in Family Child Care Homes. 537–540 (2009).

77. Benjamin, S. E., Cradock, A., Walker, E. M., Slining, M. & Gillman, M. W. Obesity prevention in child care: A review of U.S. state regulations. BMC Public Health 8, 188 (2008).

78. Ritchie, L. D. et al. Policy Improves What Beverages Are Served to Young Children in Child Care. 724–730 (2015).

79. Nonas, C., Silver, L. D., Kettel Khan, L. & Leviton, L. Rationale for New York City’s Regulations on Nutrition, Physical Activity, and Screen Time in Early Child Care Centers. Preventing Chronic Disease 11, (2014).

80. Kakietek, J., Osuji, T. A., O’Dell, S. A., Breck, A. & Kettel Khan, L. Compliance With New York City’s Beverage Regulations and Beverage Consumption Among Children in Early Child Care Centers. Preventing Chronic Disease 11, (2014).

81. Lee, T. A. S., Biing-Hwan Lin, Jonq-Ying. USDA Economic Research Service – ERR100. Available at: http://www.ers.usda.gov/publications/err-economic-research-report/err100.aspx. (Accessed: 9th September 2016)

82. United States Department of Agriculture (USDA). USDA Announces Effort to Strengthen Nutrition among Young Children, Create Healthy Habits Early | Food and Nutrition Service. Available at: http://www.fns.usda.gov/pressrelease/2016/fns-000616. (Accessed: 17th November 2016)

83. U.S. Department of Agriculture. Federal Register | Child and Adult Care Food Program: Meal Pattern Revisions Related to the Healthy, Hunger-Free Kids Act of 2010.

84. Amanda Merck. Colorado Steps Up Obesity Prevention Policies in Child Care Centers. Community Commons (2016). Available at: http://www.communitycommons.org/groups/salud-america/changes/colorado-steps-up-obesity-prevention-policies-in-child-care-centers/. (Accessed: 3rd October 2016)

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