CHILD AND ADOLESCENT FOOD AND NUTRITION
PROGRAMS
POSITION OF ADA
http://www.eatright.com/adaposchild.html
J Am Diet Assoc. 1996;96:913-917.
Our children are our future. In light of that, The American Dietetic Association
(ADA) recognizes the importance of nutrition, nutrition education, and physical
activity to the growth and development of the nation's children (1). Food and
nutrition programs for children and adolescents, whether school food programs or
programs targeting at-risk populations, are an important way to ensure that US
children will continue to have access to a healthful diet that follows the
recommendations of the Dietary Guidelines for Americans (2): eat a healthful,
varied diet, as outlined in the Food Guide Pyramid (3), and balance energy intake
with physical activity. Children who do not have access to an adequate diet are at
risk for a variety of conditions. For example, research has estab lished that
malnutrition in early life can limit long-term intel lectual development, and that
learning capabilities are af fected by how recently one has eaten (4).
Despite the demonstrated need for nutrition programs for children, historically,
local, state, and federal governments have had a controversial role in meeting the
food and nutrition needs of our children and adolescents (5). Furthermore, because
most child nutrition programs are federally funded, there is a constant threat of
elimination or alteration as the political climate changes. To ensure continued
access to food and nutrition programs we must have reliable funding and national
nutrition standards that ensure quality programs for all children and adolescents
(6).
Position Statement
It is the position of The American Dietetic Association that all children and
adolescents should have access to adequate food and nutrition programs, regardless
of economic status, special needs, and cultural diversity. Appropriate
child/adolescent food and nutrition programs include food assistance and feeding
programs and nutrition education, screening, assessment, and intervention.
Overview
Child food and nutrition programs contribute to the nutrient and energy needs of
children and adolescents and are of critical importance for reducing food insecurity
and improving their nutritional status (7). A broad scope of publicly supported
food and nutrition programs provides direct nutrition intervention through food
subsidies and/or supplements. Such programs must respond to emerging nutritional
concerns about the role of diet in health promotion, the role of nutrition and
cognitive development in the prevention of chronic degenerative disease, the extent
of program participation, and the level and quality of funding available (8).
Existing food assistance programs that help ensure adequate nutrient intake include
the Special Supplemental Nutrition Program for Women, Infants, and Children,
Head Start, Child and Adult Care Food Programs, the School Breakfast Program,
the National School Lunch Program, the Special Milk Program, the Summer Food
Service Program, and the Commodity Supplemental Food Program.
Rationale for Continuing Support of Child Nutrition Programs
In the past 25 years, major strides have been made in our understanding of child
nutrition. Table 1 summarizes important actions taken to provide adequate food
and nutrition for the nation's children and adolescents. Through nutrition research
specific to children and adolescents, improvements have been made in all child
nutrition programs. However, an examination of some of the key research studies
on children's diets shows that some concerns still remain about nutrition
deficiencies. Thus, there is a clear need for continued support for child nutrition
programs.
Milestones in the history of child nutrition programs. aMorris PM, US Dept of
Agriculture, Washington, DC. 1996. From a letter to all states on guidelines for
implementing Public Law 104-149, the Healthy Meals for Children Act.
1935
Federal legislation authorized surplus farm commodities for use in school lunch
programs. Other child nutrition programs were locally funded and operated.
1943 and 1944
Additional federal funds were designated for school lunch and milk programs for
school children and child care centers (42). Child nutrition programs as we know
them evolved at the end of World War II as a result of the armed forces physical
screening process.
1946
The National School Lunch Program was permanently authorized by Congress to
"safeguard the health and well-being of the nation's children and to encourage the
domestic consumption of nutritious agricultural commodities and other foods." A
meal pattern was designed to include 2 oz protein, 6 oz vegetables and/or fruits, a
portion of bread and butter, and a half pint of whole milk (42).
1962
Funding changed from enrollment based to participation based and funds were
added for low-income families (42).
1964
Head Start programs began as part of the Economic Opportunity Act. These
programs were designed for preschool children from differing cultural and
economic circumstances. They include nutrition education for children and parents
and supply meals for the participants (42).
1966
Child Nutrition Act established the School Breakfast Program as a pilot to provide
breakfast to children in low income areas and were children had to travel long
distances to school (42).
1968
Summer Food Service Program was authorized to provide foodservice to children
from needy areas during the time when schools are closed for vacation (35). A full
year of food assistance was funded to provide food for children in day care.
1972
Special Supplemental Nutrition Program for Women, Infants, and Children was
authorized by Congress to safe-guard the health of pregnant, postpartum, and
breast-feeding women, infants, and children under 5 years of age (42).
1975
Amendments to the Child Nutrition Act of 1966 made the School Breakfast
Program permanent, offer vs serve lunch provisions were first tested, and the
Child and Adult Care Food Program was created to provide for children in day
care (all day/year round) and for those in extended day school programs (35).
1977
Child Nutrition amendment to the School Lunch Act established the Nutrition
Education and Training program (42).
1980
US Department of Agriculture first issued competitive food guidelines. Later the
states and school districts assumed responsibility for regulation of competitive
food sales with stronger guidelines.
1986
Children in households receiving food stamps or Aid to Families with Dependent
Children could be directly certified for free or reduced-price meals. Offer vs serve
provision was extended to School Breakfast Program (42).
1987
Commodity Distribution and Reform Act directed the Secretary of Agriculture to
improve the nutritional quality and packaging of commodities (42).
1990
National Food Service Management Institute authorized by Congress as a resource
center for child nutrition and related programs through training, education to
school foodservice personnel, and as a clearing house for related information (37).
1994
Healthy Meals for Healthy Americans Act requires the National School Lunch
Program and School Breakfast Program to comply with the Dietary Guidelines for
Americans (43).
1995
School Meals Initiative for Healthy Children ensures that nutrition standards for
school meals meet the Dietary Guidelines for Americans by updating nutrition
standards for school meals, providing a variety of menu planning alternatives, and
streamlining program administration (43).
1996
Healthy Meals for Children Act grants additional flexibility to school food
authorities to meet the nutrition standardsestablished in the Dietary Guidelines for
Americans. Schools may thus continue to use the traditional meal pattern or any
reasonable approach to menu planning providing the menus meet the US Dietary
Guidelines.a
Excess fat in the American diet remains an area of dietary concern because of the
relationship of fat intake to heart disease and certain cancers. The Bogalusa Heart
Study (9), which has examined children and their eating patterns since 1973,
tracked a decline in fat consumption from 38% of energy to 34% of energy over a
20-year period. This change resulted from natural changes in food consumption
patterns and the influences of industry, mass communication, and commercial
advertising. Nevertheless, the amount of fat and sodium consumed is in excess of
amounts recommended by the American Heart Association and the American
Cancer Society.
A number of studies have shown the success of current child and adolescent
nutrition programs and interventions in improving children's diets. The Dietary
Intervention Study in Children (10,11), for example, looked at the implications of
feeding a modified-fat diet to 8- to 10-year-olds with moderately elevated levels of
plasma low-density lipoprotein cholesterol (LDL-C). Laboratory results after 3
years indicated that the children's LDL-C levels decreased; at the same time they
were able to maintain growth and an adequate nutrient intake.
The Child and Adolescent Trial for Cardiovascular Health (CATCH)--a large,
national, multisite, longitudinal research effort--is measuring the effects of schooland family-based interventions for promoting healthful behaviors in children and
adolescents that will reduce their risk for developing cardiovascular disease later in
life (12-16). Schools and families work together to help children lower their fat
intake to no more than 30% of energy, lower their saturated fatty acid intake to no
more than 10% of energy, and reduce their sodium intake. Participants are also
encouraged to increase their consumption of complex carbohydrates and the
amount of time spent in physical activity. The Eat Smart Program, which was
developed for CATCH, provides meals that are lower in fat and sodium without
decreasing intake of vitamins and minerals and that still meet all the requirements
for reimbursable meals as specified by the National School Lunch Program and
School Breakfast Program.
In 1992, the US Department of Agriculture (USDA) Food and Nutrition Service
analyzed school meals and students' 24-hour food and beverage consumption over
a 5-month period (17). This School Nutrition Dietary Assessment Study examined
whether students' diets and school meals met the Recommended Dietary
Allowances (RDA) (18) for nutrients. The study also measured fat and saturated fat
intake against recommendations of the Dietary Guidelines for Americans (2) and
sodium, cholesterol, and carbohydrate intake against National Research Council
recommendations (18). National School Lunch Program lunches provided one
third or more of the RDA for energy; protein; cholesterol; vitamins A, C, and B-6;
calcium; iron; and zinc. Students consumed 37% of energy from fat and 14% from
saturated fat and had a sodium intake of 1,500 mg--nearly two thirds of the
National Research Council recommendation. School lunch participants consumed
almost twice the amount of milk and milk products as nonparticipants. The source
of students' lunches influenced their intake. Those who purchased food from other
sources, such as vending machines and a la carte lines, consumed 23% of the RDA
for energy and less than 20% of the RDA for several key nutrients. Students who
brought lunch from home consumed 31% of the RDA for energy and less than one
third of the RDA for several key nutrients, and those who ate lunch off campus
consumed 34% of the RDA for energy but less than one third of the RDA for
several vitamins and minerals.
The School Nutrition Dietary Assessment Study also examined children's and
adolescents' breakfast habits. Although 59% of students ate breakfast at home and
19% participated in the School Breakfast Program, an alarming 12% ate no
breakfast. The School Breakfast Program has been shown to contribute
significantly to the total daily nutrient requirements of participating children and
adolescents (19). Those who skip breakfast are also documented as unable to
recoup nutrients lost at breakfast. In a study (20) in Lawrence, Mass, students who
participated in the School Breakfast Program achieved higher scores on the
Comprehensive Tests of Basic Skills while decreasing their rate of absences and
tardiness. Others have concluded that those who skip breakfast have delayed
cognition, particularly regarding the speed of information retrieval in working
memory (21). Another study indicates that a time-hunger correlation results when
breakfast is eaten after the school day starts (22).
Fiber is a part of a healthful diet and lifestyle for children and adolescents,
especially when included as part of a balanced diet high in complex carbohydrates
and low in fat (1,23). Currently, no fiber levels are established for child nutrition
programs. At the same time, these programs are mandated to increase dietary fiber.
As a rule, amounts of fiber recommended for children are their age plus 5 g/day up
to age 20 (eg, the fiber recommendations for a 7-year-old child is 12 g/day). After
age 20, levels of 25 to 35 g/day are recommended. Fiber is essential for children
and adolescents for the prevention and treatment of childhood obesity and elevated
blood cholesterol levels as well as for reducing the risk for chronic diseases such as
cancer, cardiovascular diseases, and non-insulin-dependent diabetes mellitus (24).
Food and Nutrition Programs
Foodservice programs should be available for all children and adolescents. Special
consideration must be given to cultural and environmental factors, children with
special needs (25), problems associated with émigrés' nutritional status, limited
communication skills, and food and environment adjustment.
Food and nutrition needs of multigenerational, often multicultural clientele may be
met through Child and Adult Care Food Programs. From the child in a family daycare home, day-care center, or after-school, extended day-care program to the adult
in a day-care center or for those with chronic impairments, assistance for meals
and snacks is available. Child day-care providers must be cognizant of the
children's ages and physiologic and emotional needs to ensure adequate food and
nutrition services (26).
The participants of the Summer Food Service Program are from needy areas. This
program provides foodservice to children when schools are closed for vacation.
Despite outreach projects in many areas, additional Summer Food Service
Programs are needed. Children do not stop needing nutrients when the school year
ends. The combination of the Summer Food Service Program and educational and
physical activities has many proven benefits (1,39).
Children and adolescents at risk for nutrition problems secondary to pregnancy,
physical handicaps, allergies, poor oral health, and eating disorders such as
bulimia, anorexia nervosa, and obesity require the services of a qualified dietetics
professional (27,28). Once the special needs of children or adolescents are
identified, qualified dietetics professionals may be called on to counsel the children
and their families regarding food, nutrition, and physical activity.
Food and nutrition programs should contribute to the nutrition needs of children
and adolescents, including those requiring medical nutrition therapy for special
needs (25). Programs should be offered in a manner and setting that provides
positive contributions to the emotional and social development of the child (29,30).
Meals should include a variety of foods and be planned to provide choices,
encourage consumption, increase participation, and serve as a laboratory for
applying nutrition information. It is imperative that barriers to full participation
such as competitive foods, inefficient scheduling, negative media advertising, and
excessive meal prices be identified and eliminated so the programs meet the needs
of all children and adolescents (31-33).
Training
Each agency responsible for child food and nutrition programs should adopt,
promote, and update standards for employment of federal, state, and local
foodservice personnel to develop, coordinate, and operate all child nutrition
programs (34). A basic understanding of the growth and development of children
and adolescents and current child feeding practices is also necessary. Special
multilingual training sessions in nutrition, menu planning, food purchasing and
preparation, sanitation, customer service, merchandising, and nutrition education
should be planned and provided to all employees in child food and nutrition
programs. To ensure continued effectiveness, it is essential that professional
technical assistance be available on a regular basis to child nutrition personnel at
the local and state level. Imperative to this assistance is distance learning and the
application of new technologies as they emerge. A certification and credentialing
program should be provided for employees at all levels.
The National Food Service Management Institute is a national resource center
designed to support administrators and providers of child food and nutrition
program (35). The institute uses applied research to improve the quality and
operation of child nutrition programs. The institute's activities include providing
scientific applications for the improvement of nutrition and cost-effectiveness of
child nutrition programs; developing education and training materials; providing
technical assistance to school foodservice professionals; offering a national
network of trained professionals who conduct workshops and training; and
scrutinizing and disseminating research and reports, including those developed by
the Nutrition Education and Training program.
Nutrition Education
Appropriate nutrition education to recipients of child and adolescent food and
nutrition programs is recognized as a key factor in health promotion/chronic
disease prevention. As part of any comprehensive health program, nutrition should
be integrated across the curriculum, in all subject areas. Delivery of nutrition
education should include experiences that use integrated education resources such
as the cafeteria dining area, health and physical education classes, and mathematic
and writing skills designed to enhance critical thinking processes (36).
One nutrition education program is Team Nutrition, a USDA program in which
schools join representatives of health and education organizations, the food
industry, and nutrition experts to actively involve children and their parents in
nutrition education. With Team Nutrition, teachers and school nutrition
professionals work together to provide scenarios, role playing, and demonstrations
to support critical thinking skills.
School-based nutrition education programs should be designed to include parental
and community involvement as well as physical activity. Qualified dietetics
professionals and those trained in nutrition should be involved in those areas where
schools are unable to provide effective nutrition education programs (36).
Qualified dietetics professionals are nutrition education experts and should act as
nutrition educators or reinforcers of nutrition education. Nutrition education should
be available for all children and adolescents, as well as parents, caregivers,
teachers, and coaches (36,37). Innovative use should be made of different settings
and outlets to deliver nutrition education.
Qualified dietetics professionals must also serve as interpreters of nutrition
information and misinformation for children and adolescents. This includes
supplying children and adolescents with knowledge and skills so they can interpret
nutrition information when they are outside the school environment and later in
life. Dietetics professionals must continue to recognize the role physical activity
and nutrition play in the prevention of chronic disease and obesity (38,39).
Nutrition Screening, Assessment, and Counseling
Nutrition screening can identify individual children, adolescents, or populations
that may be at risk (40). Screening should be performed by trained professionals
and based on reliable diagnostic procedures that have been carefully selected and
targeted appropriately to the population. Medical nutrition therapy supervised by
qualified dietetics professionals can help children, adolescents, families, and food
and nutrition programs adjust dietary intakes and identify resources to meet
specific health needs of children and adolescents.
Nutrition counseling is an individualized process that can help to manage personal
nutrition care effectively. It is an essential service, particularly for children at risk.
Counseling may be used to obtain more information, to review and strengthen
acquired knowledge or desirable habits, or to help the child or adolescent set
personal goals and make individualized decisions.
It is important that nutrition counseling be conducted or supervised by a qualified
dietetics professional. The dietitian should initiate collaboration with other
professionals, including physicians, parents, foodservice and nutrition
professionals, school nurses, coaches, health educators, and members of the school
and community who can assist with the nutritional management of the child or
adolescent. In turn, the qualified dietetics professional should design and maintain
a nutrition management record for each child or adolescent that identifies special
conditions and nutrition needs. The record enhances cooperation between home
and school, and ensures consistent support and reinforcement by all who assist in
meeting the needs of the child or adolescent.
Summary
To protect the nutritional health of children and adolescents and to promote their
optimal health and nutritional status, ADA recommends that the following basic
child food and nutrition services be available to all children and adolescents
regardless of economic status, race, special needs, or national origin:
Access for all children and adolescents to optimal amounts of health-promoting
food;
Food programs that provide nutritious, appealing, wholesome foods that reflect the
Dietary Guidelines for Americans (2) and the Food Guide Pyramid (3) and ensure
that meals are served in an environment that encourages their acceptance;
Meals that serve as a laboratory to apply critical thinking skills to food selection;
Nutrition screening to identify children and adolescents at risk; and
Nutrition assessment and counseling to meet special health needs.
Recommendations
To help ensure the availability and provision of such programs, ADA encourages
its membership to provide leadership to:
Promote and provide optimum food and nutrition programs to all children and
adolescents;
Provide technical assistance and training in nutrition and nutrition education to
providers of programs for children, adolescents, and their families;
Promote a dynamic exchange of information across all disciplines, agencies, and
programs that can affect the nutritional status of children and adolescents;
Stimulate, support, and participate in the transfer and application of
child/adolescent nutrition research findings to food and nutrition services;
Encourage planned and sequential programs in nutrition and health education, and
physical activity for children and adolescents;
Encourage major health care insurers to reimburse for comprehensive nutrition
services (medical nutrition therapy and wellness/prevention of chronic disease);
Support public policy, legislation, and a regulatory process that promotes uniform,
adequately funded programs to ensure optimum nutrition services without
fragmentation and duplication of effort;
Support local policies that encourage the promotion of nutrition programs and the
environments conducive to healthful eating behaviors; and
Support the development of separate dietary guidelines for healthy children and
adolescents to ensure adequate energy and nutrients for their growth and
development (41).
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ADA Position adopted by the House of Delegates on October 26, 1986, and
reaffirmed on October 24, 1991, and September 15, 1995. This position will be in
effect until December 31, 2001. The American Dietetic Association authorizes
republication of the position statement/support paper, in its entirety, provided full
and proper credit is given. Requests to use portions of the position must be directed
to ADA Headquarters at 800/877-1600, ext 4896 or ppapers@eatright.org.
Recognition is given to the following for their contributions:
Authors:
Penney E. McConnell, MS, RD, and Jean B. Shaw, MS, RD
Reviewers:
Connie L. Evers, MS, RD; Pediatric Nutrition dietetic practice group (Barbara E.
Gaffield, MS, RD; Peggy C. Papathakis, RD, CS); Pubic Health Nutrition dietetic
practice group (Julie Seiber, RD); Debra B. Reed, PhD, RD; School Nutrition
Services dietetic practice group (Dorothy Caldwell, MS, RD; Tami Cline, RD);
Jamie Stang, MPH, RD.