The Child and Adult Care Food Program and young children's health: a systematic review

A Narrative Review of Public Health Interventions for Childhood Obesity

PURPOSE OF REVIEW

Public health interventions that intervene on macrolevel systems hold the promise of reducing childhood obesity at the population level through prevention. The purpose of this review is to highlight some of the recent and best scientific evidence related to public health interventions for the prevention of childhood obesity. We provide a narrative review of scientific evidence for six categories of public health interventions and their impact on childhood obesity: federal nutrition assistance programs, programs implemented in early care and education centers, interventions to support healthy nutrition and physical activity in schools, community-based programs and policies, labeling policies and marketing to children, and taxes on sugar sweetened beverages (SSB).

RECENT FINDINGS

Federal nutrition assistance programs have the strongest evidence to support reduction in childhood obesity and serve populations with the highest prevalence of childhood obesity. Other interventions including SSB taxes, community-wide interventions, and interventions at schools and early care and education centers also show significant improvements in child weight status. Overall public health interventions have strong evidence to support widespread implementation in service of reducing childhood obesity rates at the population level. To effectively address the recalcitrant childhood obesity epidemic, multi-pronged solutions are needed. The current evidence for public health obesity interventions is consistent with the paradigm that recognizes the importance of macrolevel systems influences on childhood obesity: interventions that are most effective intervene at macrolevels.

State Agency Perspectives on Successes and Challenges of Administering the Child and Adult Care Food Program

The federal Child and Adult Care Food Program (CACFP) improves nutrition and reduces food insecurity for young children while helping cover food costs for care providers and families. Despite its important benefits, the program is underutilized. This report uses qualitative interviews with state CACFP administrators representing 28 states to explore federal and state policies and practices that support or discourage CACFP participation among licensed child care centers. We report on successful approaches to program outreach and administration, barriers that make CACFP participation challenging, and recommendations to expand access to CACFP for eligible child care providers and the populations they serve.

Federal Nutrition Assistance for Young Children: Underutilized and Unequally Accessed

INTRODUCTION

The federal Child and Adult Care Food Program (CACFP) improves nutrition and reduces food insecurity among young children by helping cover the food costs for child care providers and families. This nationwide study evaluated the extent and predictors of the CACFP's utilization among licensed child care centers to identify opportunities for expanding CACFP nutrition support.

METHODS

Administrative data from the CACFP and child care licensing agencies in 47 states and District of Columbia were compiled and geocoded for 93,227 licensed child care centers. CACFP participation was predicted using a multivariable Bayesian spatial logistic regression model in the sample of low-income areas to target CACFP eligible child care centers. Data were collected in 2020-2021 and analyzed in 2022.

RESULTS

Of all licensed child care centers, 36.5% participated in the CACFP, ranging from 15.2% to 65.3% across states; when restricted to low-income areas, 57.5% participated (range, 15.7%-85.7%). Income differences did not explain the large variation in CACFP participation rates across states. Having at least three CACFP sponsoring agencies per state predicted a 38% higher probability of CACFP participation (OR=1.38; 95% Credible Interval=1.08-1.78).

CONCLUSIONS

Currently CACFP participation rates among licensed child care centers point to program underutilization and unequal access, particularly in some states and regions. Work at the federal and state levels is warranted to expand participation in the program, above all in low-income areas, so that more young children could eat healthfully with the CACFP.

Nutrition Interventions for Pediatric Obesity Prevention: An Umbrella Review of Systematic Reviews

Nutrition interventions to prevent pediatric obesity can help to establish healthy habits to improve current and future health. The objective of this umbrella review of systematic reviews (SRs) is to examine the impact of obesity prevention interventions with a nutrition component on body mass index measures, overweight/obesity prevalence, and cost-effectiveness in participants 2-17 years old. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods were used, and this umbrella review was registered on PROSPERO (CRD42023443033). Included SRs were required to search ≥2 databases and to assess the risk of bias (RoB) of primary studies, and they were published 2017-June 2023. Database searches identified 4776 articles, and 31 SRs were included. In all age groups combined, interventions with both nutrition and physical activity were effective and cost-effective in all settings combined, and in the community setting specifically. In children ≤5 years old, interventions in the home and family, community, and healthcare settings demonstrated some efficacy, whereas in children 6-12 years old, school interventions were most effective. Evidence with individuals 13-17 years was limited. The certainty of evidence was generally low due to RoB in included studies, inconsistency, and imprecision. Pediatric obesity prevention interventions with nutrition should be tailored to the developmental stage to ensure appropriateness and efficacy.

How policy implementation shapes the impact of U.S. food assistance policies: the case study of the Child and Adult Care Food Program

Much of the chronic disease burden in the U.S. population can be traced to poor diet. There has been a sustained focus on influencing children's diets and encouraging healthier eating habits by changing policies for what foods and beverages can be served to children through large federally-funded nutrition assistance programs. Yet without attention to how nutrition policies are implemented, and the surrounding context for these policies, these policy changes may not have the intended results. In this perspective, we used Bullock et al.'s (2021) Process Model of Implementation from a Policy Perspective to analyze how the complexities of the implementation process of large-scale nutrition policies can dilute potential health outcomes. We examine the Child and Adult Care Food Program (CACFP), a federal program focused on supporting the provision of nutritious meals to over 4 million children attending childcare, as a case study. We examine how the larger societal contexts of food insecurity, attitudes towards the social safety net, and a fragmented childcare system interact with CACFP. We review the "policy package" of CACFP itself, in terms of its regulatory requirements, and the various federal, state, and local implementation agencies that shape CACFP's on-the-ground implementation. We then review the evidence for how each component of the CACFP policy implementation process impacts uptake, costs, feasibility, equity, and effectiveness at improving children's nutrition. Our case study demonstrates how public health researchers and practitioners must consider the complexities of policy implementation processes to ensure effective implementation of nutrition policies intended to improve population health.

Child Care Feeding Programs Associated With Food Security and Health for Young Children From Families With Low Incomes

BACKGROUND

The Child and Adult Care Food Program is the primary national program that enables child-care settings to provide healthy meals for children. Associations between Child and Adult Care Food Program participation and child health and development and health care utilization are understudied.

OBJECTIVE

To assess associations between children's health, development, health care utilization and food security by meal source (child-care-provided vs parent-provided) among children from low-income families with a child care subsidy attending child-care in settings likely eligible to participate in Child and Adult Care Food Programs.

DESIGN

The study used repeat cross-sectional surveys (new sample at successive time points) conducted year-round.

PARTICIPANTS AND SETTING

Primary caregivers of 3,084 young children accessing emergency departments or primary care in Baltimore, MD; Boston, MA; Little Rock, AR; Minneapolis, MN; and Philadelphia, PA, were interviewed between 2010 and 2020. The sample was limited to children aged 13 to 48 months, receiving a child care subsidy and attending child-care centers or family child-care homes ≥20 hours per week.

MAIN OUTCOME MEASURES

Outcomes included household and child food security; child health, growth, and developmental risk; and admission to the hospital on the day of the emergency department visit.

STATISTICAL ANALYSES

Meal source and participant characteristics were analyzed using χ2 tests; associations of outcomes with parent-provided meals were analyzed with adjusted logistic regression.

RESULTS

The majority of children had child-care-provided meals (87.2% child-care-provided vs 12.8% parent-provided). Compared with children with parent-provided meals, children with child-care-provided meals had lower adjusted odds of living in a food-insecure household (adjusted odds ratio 0.70, 95% CI 0.55 to 0.88), being in fair or poor health (adjusted odds ratio 0.61, 95% CI 0.46 to 0.81), or hospital admission from the emergency department (adjusted odds ratio 0.59, 95% CI 0.41 to 0.83), with no differences in growth or developmental risk.

CONCLUSIONS

Compared with meals provided from home, child-care-provided meals likely supported by the Child and Adult Care Food Program are related to food security, early childhood health, and reduced hospital admissions from an emergency department among low-income families with young children.