591887
research-article2015
CPJXXX10.1177/0009922815591887Clinical PediatricsLutzkanin et al
Original Article
Report of Sugar-Sweetened Beverages Offered in Pennsylvania Childcare Centers
Clinical Pediatrics 1–7 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815591887 cpj.sagepub.com
Kristen M. Lutzkanin, MD1, Abigail K. Myers, MD1, Eric W. Schaefer, MS2, and Deepa L. Sekhar, MD, MSc1
Abstract The study objective was to quantify sugar-sweetened beverage (SSB) offerings to children in Pennsylvania (PA) childcare centers and determine whether this information is communicated to parents. In October 2014, a SurveyMonkey link was sent to 4461 PA childcare centers. The 518 respondents represented 88% of PA counties. 279 centers (54%) serve SSBs. 330 (65%) of childcare centers provide parents a report of their child’s daily intake. Of 185 centers serving SSBs and providing a daily intake report, 91% include SSB consumption. In total, 38% of centers (103/272) offer but do not report SSB consumption. In 96% of centers, parents may request their child not receive SSBs. In conclusion, though more than half of PA childcare centers surveyed offer SSBs, those providing daily intake reports usually include SSB consumption. Requiring daily intake reports may be a strategy to increase parental awareness of items consumed outside the home. Keywords sugar-sweetened beverages, childcare centers, obesity Recent data demonstrate that children younger than 6 years receive close to 4.5% of energy intake (69 kcal/d) from sugar-sweetened beverages (SSBs).1,2 SSBs are drinks containing sucrose, high fructose corn syrup, fruit juice concentrates, or other added caloric sweeteners.3 The American Academy of Pediatrics recommends limiting SSB serving size to 4 to 6 oz per day for children 1 to 6 years old.4,5 Though data from the National Health and Nutrition Examination Survey 2009-2010 suggest that overall SSB intake is declining, average intakes still exceed the recommended amounts.1-3 Excessive SSB consumption is linked to weight gain and higher body mass index.5-10 Children who are overweight/obese are more likely to remain so into adulthood.11 With prevalence rates of 24% and 11% for overweight and obesity among children younger than 6 years, respectively, SSBs have been a target of obesity prevention efforts.6,12 Parents may closely monitor SSB consumption in the home, but national data suggest that approximately 11 million young children are in some form of out of home care.13 Nonmaternal care has been associated with an increased likelihood of juice consumption in infants and toddlers.14 Prior studies of childcare centers conducted in other states as well as federally regulated programs such
as Head Start suggest that SSBs are frequently offered to children.15 Similar to many states, Pennsylvania (PA) requires childcare centers to plan menus in advance and post menus for parents to view.16 The 2014 Child Care in America fact sheets report PA has 4601 childcare facilities and 3100 family childcare homes.13 While parents may receive daily reports regarding food consumption and toileting, it is unclear whether beverages are included in the report. Thus, the purpose of this study was to quantify SSB offerings to children enrolled in PA childcare centers and to determine whether such information is routinely communicated to parents. The results of this study may be used to inform policy changes in the beverage choices and reporting requirements for childcare facilities both in PA and nationally.
1
Pediatrics, Penn State College of Medicine, Hershey, PA, USA Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA 2
Corresponding Author: Deepa L. Sekhar, Department of Pediatrics, Penn State College of Medicine, 500 University Drive, HS83, Hershey, PA 17033, USA. Email: [email protected]
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Methods
your voluntary consent to participate in the research. You may exit the survey at any point and your responses will not be recorded . . .
Participants This was an electronic survey of PA childcare centers. The study was approved by the Penn State College of Medicine and Hershey Medical Center Institutional Review Board (study identification number: STUDY00000772). The email addresses of 4461 centers were obtained from a publicly available online listing maintained and updated by the Pennsylvania Department of Human Services.17 Duplicate listings were removed, and those childcare centers without an email address were not included.
A reminder was sent out 7 days into the 14-day survey period.
Data Analysis Descriptive statistics were calculated on all responses. Chi-square tests were subsequently used to evaluate whether childcare center demographic factors were associated with centers offering SSBs.
Instrumentation
Results
Survey questions were developed with the expertise and input of general pediatricians, parents, and childcare center providers. The survey instrument underwent 2 rounds of pilot testing with four parents and four childcare providers on each round. In addition, the electronic version of the survey was pilot tested by the authors for ease of administration and flow of the skip logic.
Demographics
Procedure
There were 518 surveys completed, a response rate of 12%, representing 59/67 (88%) PA counties (Figure 1). Most centers (51%) were in suburban locations. The majority of participating childcare centers served more than 50 children at their facility and had been in operation for more than 10 years (Table 1).
Offering Sugar-Sweetened Beverages
The survey could be completed by the childcare center director or another staff member in 10 to 15 minutes. Participants had the option to start the survey, save responses and return later. Only 1 response per center was requested. An electronic link to the survey in SurveyMonkey was sent out September 28, 2014 with an introductory message (excerpt below) and remained open until October 10, 2014. . . . With the growing epidemic of childhood obesity we are all struggling with how best to improve childhood nutritional habits. We advise parents to restrict consumption of juice and other sugar sweetened beverages. Yet, in speaking with the parents in my clinic, they report beverages given at home, but they fail to account for beverage options offered by their childcare centers. Thus, children may be getting more than the recommended amount of sugar sweetened beverages between home and child care. Included below is a link to a survey which has been approved by the Penn State Milton S. Hershey Medical Center Institutional Review Board (IRB) with a waiver of consent. This survey should be completed by the center director or a person designated by the center director to fill out this survey. If you choose to participate, please answer the questions to the best of your ability; your responses will remain anonymous. Your completion of the survey implies
Of those surveyed, 279 childcare centers (54%) reported serving SSBs with snacks or meals (Table 2). Among these centers, SSBs were most commonly introduced at 12 to 23 months (50%). The most common serving size reported was 4 ounces (53%) and most children were not permitted a second serving. SSBs were most likely to be served as a first option with afternoon snack (29%; Table 3). Among centers that offered SSBs, 96% indicated that parents could request their child not be given any SSBs and only receive plain milk or water.
Center Meal Plans The majority of centers had a scheduled meal plan (84%) which was set by the individual facility (85%) rather than a parent company (15%; Table 4). For those with a parent company setting the menu, 43% indicated they had limited ability to make alterations. There were 95% of centers that indicated parents were able to view a hard copy of the meal plan at the center. A majority of centers (330, 65%) provide parents a report of their child’s daily consumption in written form. Of these 330 centers, 185 offer SSBs and 169 (91%) include SSBs in the daily report. Overall, 38% of centers who offer SSBs do not report on SSB consumption.
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Figure 1. Statewide distribution of survey respondents.
Free Do It Yourself Color-Coded State, US, Canada and Mexico Maps; http://diymaps.net/.
Table 1. Demographics of Survey Participants. Characteristic Center location (N = 503) Urban Suburban Rural Number of enrollees (N = 511) 100 Years in operation (N = 508) ≤10 >10
% (n) 20.1 (101) 51.3 (258) 28.6 (144) 18.6 (95) 11.0 (56) 18.8 (96) 27.2 (139) 24.5 (125) 29.3 (149) 70.7 (359)
The number of years a center had been in operation (≤10 years vs >10 years) was not associated with provision of SSBs (56% vs 54%, respectively; P = .65). The
number of children enrolled (grouped as 100 children, with 50% to 59% providing SSBs; P = .77) and location of center (urban, suburban, rural, with 51% to 60% providing SSBs; P = .31) were also not associated with provision of SSBs.
Discussion The results of this analysis indicate that over half of responding PA childcare centers provide SSBs to children. While 38% of centers providing SSBs do not report this information, among those that have a daily intake report, 91% include SSBs. This information provides clear avenues for action by policy makers, providers, and parents to partner with childcare centers in improving the dietary habits of children. Excess calories from consumption of SSBs have repeatedly been linked to the obesity epidemic.5-10 Children receiving nonmaternal care have been shown to have a higher likelihood of juice consumption.14 Prior studies of the nutritional quality of meals offered at
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Table 2. Details of Sugar-Sweetened Beverage (SSB) Offerings in Pennsylvania Childcare Centers. Characteristic
% (n)
Are SSBs provided? (N = 518) Yes No At what age does your center start serving SSBs? (N = 279) Newborn to 5 months 6-11 months 12-23 months 2-5 years Other What is the typical serving size? (N = 279) 2 ounces 4 ounces 6 ounces 8 ounces 12 ounces Other Are children permitted a second serving? (N = 279) Yes No Depends on individual teacher Are children permitted SSBs outside of scheduled meal and snack time? (N = 279) Yes No Depends on individual teacher Can parents request their children not receive any SSBs? (N = 279) Yes No
53.9 (279) 46.1 (239) 0 (0) 3.2 (9) 49.8 (139) 34.1 (95) 12.9 (36) 22.9 (64) 52.7 (147) 13.3 (37) 5.0 (14) 1.1 (3) 5.0 (14) 15.8 (44) 71.3 (199) 12.9 (36) 3.6 (10) 95.3 (266) 1.1 (3) 96.4 (269) 3.6 (10)
Table 3. First Drink Option by Meal/Snack. % (n) Meal/Snack
Water
White Milk
Breakfast (n = 499) 5.0 (25) 67.7 (338) Lunch (n = 503) 14.3 (72) 69.0 (347) am Snack (n = 477) 37.3 (178) 18.7 (89) pm Snack (n = 513) 42.9 (220) 26.9 (138)
100% Fruit Diluted Fruit Juice Juice Fruit Juice (Not 100%)
Flavored Sports Milk Soda/Pop Drinks
4.4 (22) 2.8 (14) 10.1 (48) 17.2 (88)
0.4 (2) 2.0 (10) 0.8 (4) 2.1 (11)
2.2 (11) 0.99 (5) 6.3 (30) 7.8 (40)
0.4 (2) 0 (0) 0.8 (4) 1.4 (7)
0 (0) 0 (0) 0 (0) 0 (0)
0 (0) 0 (0) 0 (0) 0 (0)
N/Aa 19.8 (99) 10.9 (55) 26.0 (124) 1.8 (9)
a
N/A indicates not applicable as center does not provide this particular meal/snack.
childcare centers indicate SSBs are frequently given to children.15 Many PA childcare facilities participate in the Child and Adult Care Food Program, a US Department of Agriculture initiative to reimburse facilities for providing meals that meet requirements for milk, fruit, grains, and meat.18 In this program, the fruit requirement may be met by serving fruit or undiluted fruit juice.19 It is clear among those PA childcare centers reporting daily intake, in a majority of cases SSBs are included in their
report. Thus, a next step for policy makers may be to require daily intake reports for parents, as it is likely this will translate into increased reporting of SSB consumption. Policies to limit the allowance of SSBs to children enrolled in childcare centers are a valuable step. In New York City, a 2007 modification to regulations on beverage offerings in childcare facilities stated SSBs should not be provided, and a follow-up study indicated that
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Lutzkanin et al Table 4. Details of Childcare Center Meal Plans. Characteristic
% (n)
Is there a scheduled meal/snack plan (n = 518) Yes No Is the meal snack plan set by the individual center or a parent company? (n = 438) Parent company Individual center If set by a parent company, how flexible can your center be in terms of altering food/drinks offered? (n = 65) Inflexible Not very flexible Neutral Flexible Very flexible Is your center’s meal/snack plan readily available to review by parents? (n = 438) Yes No In what form is your center’s meal/snack plan available for review? (n = 408) Hard copy available on premises Hard copy provided to parents Virtual copy available on website Virtual copy emailed to parents Does your center provide parents a written report of what the child consumes during the day? (n = 509) Yes No Are sugar-sweetened beverages (SSBs) included in this report? (n = 272) Provide a written report including SSBs Provide a written report without SSBs Do not provide a written report
67% of centers were in compliance.20 The number of facilities serving SSBs is reduced compared with our findings in PA. However, policy alone is unlikely to be successful in reducing SSB intake among young children. In particular, though programs such as Head Start are subject to federal guidelines, individual childcare facilities and small family-based childcare centers fall under state regulations, which vary significantly across the country.15 Thus, including providers and parents will be a key component in changing beverage offerings and reporting of SSBs in childcare settings. Parents routinely receive anticipatory guidance on a variety of topics from their pediatric providers. This counseling frequently involves recommendations on nutrition, diet, and exercise.21,22 Providers inquiring about daily SSB intake should remind parents to include SSBs offered in their childcare center in the “total.” Parents should be made aware that if their child is enrolled in outside of home care, SSBs may be routinely offered with snacks or meals. Providers can explain to parents that this information may not be provided as part of a daily report on meals and toileting. However, most
84.4 (437) 15.6 (81) 14.8 (65) 85.2 (373) 21.5 (14) 21.5 (14) 10.8 (7) 36.9 (24) 9.2 (6) 94.3 (413) 5.7 (25) 94.9 (387) 45.3 (185) 15.4 (63) 18.9 (77) 64.8 (330) 35.2 (179) 62.1 (169) 5.9 (16) 32.0 (87)
important, parents should be aware of the option to request that SSBs not be given to their child. In addition to awareness of food consumed outside the home, parents themselves must model good dietary habits for their children. Studies of lunches packed by parents or provided at home indicate the meals are often of poor nutritional value and include SSBs.23,24 Thus, another valuable intervention might be to offer parents healthy, cost-conscious ideas for breakfast and lunch options for children.25,26 Such information could be provided at the physician’s office, via the Women, Infants and Children’s supplemental nutrition program, or even during registration at childcare facilities and might specifically include a statement that SSBs are not recommended as a beverage option. Finally, childcare centers must be included in the dialogue on SSB offerings. Those which have not complied with regulations in places such as New York City should be queried. Programs that reward childcare centers for removing SSBs from menus may provide further incentives. Addressing any underlying issues, which may include concerns separate from nutrition such as food
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storage, convenience and cost, may improve the appeal of new policies.
Limitations Although 59 of the 67 counties in Pennsylvania were represented in this survey, responses were not evenly distributed across counties. This may have created a reporting bias if certain areas of the state are more likely to include SSBs in the diet due to societal preferences or economic constraints. The low response rate, 12%, may mean the results are not representative of all childcare centers. Centers without an email address were not included. Surveys were sent out to childcare center directors. Center directors may have different responses than in-classroom teachers, the ones who actually distribute SSBs and report meal consumption to parents. Family childcare centers and less formal caretaking arrangements were also under represented in this survey, but they are an important area for policy makers, providers, and parents when addressing out of home meals/ snacks. Finally, bias may have been introduced by our introductory message to the survey, which speaks negatively of SSBs, thus possibly discouraging full candid disclosure of their use by respondents.
Conclusions Sugar-sweetened beverages are regularly offered at many PA childcare centers in the preschool years, and though 38% of centers serving SSBs do not report this information, in 91% of cases when a daily intake report is provided, SSBs are included. In considering interventions to curb the obesity epidemic, SSBs provided to children in out of home care is an underutilized area for policy makers, providers, and parents to make a difference. These results provide an opportunity to partner with childcare centers to improve the health of children by establishing healthy dietary habits and increasing parental awareness of food consumed outside the home. Authors’ Note Underlying research material related to this article may be accessed by contacting the corresponding author, Deepa L. Sekhar.
Author Contributions KML contributed to study conception and design; acquisition, analysis and interpretation of the data; drafting and crticially revising the manuscript; gave final approval of the mansucript and agreed to be accountable for all aspects of the accuracy and integrity of the published work. AKM contributed to; study conception; drafting of the manuscript; gave final
approval of the mansucript and agreed to be accountable for all aspects of the accuracy and integrity of the published work. EWS contributed to analysis and interpretation of the data; critically revised the manuscript; gave final approval of the mansucript and agreed to be accountable for all aspects of the accuracy and integrity of the published work. DLS contributed to the study conception and design; acquisition, analysis and interpretation of the data, and crticially revisied the manuscript; gave final approval of the mansucript and agreed to be accountable for all aspects of the accuracy and integrity of the published work.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Nickelson J, Lawrence JC, Parton JM, Knowlden AP, McDermott RJ. What proportion of preschool-aged children consume sweetened beverages? J Sch Health. 2014;84:185-194. 2. Kit BK, Fakhouri TH, Park S, Nielsen SJ, Ogden CL. Trends in sugar-sweetened beverage consumption among youth and adults in the United States: 1999-2010. Am J Clin Nutr. 2013;98:180-188. 3. Malik VS, Pan A, Willett WC, Hu FB. Intake of sugarsweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98:1084-1102. 4. American Academy of Pediatrics Committee on Nutrition. The use and misuse of fruit juice in pediatrics. Pediatrics. 2001;107:1210-1213. 5. Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 19882004. Pediatrics. 2008;121:e1604-e1614. 6. Sonneville KR, Long MW, Rifas-Shiman SL, Kleinman K, Gillman MW, Taveras EM. Juice and water intake in infancy and later beverage intake and adiposity: could juice be a gateway drink? Obesity. 2015;23:170-176. 7. Wang YC, Ludwig DS, Sonneville K, Gortmaker SL. Impact of change in sweetened caloric beverage consumption on energy intake among children and adolescents. Arch Pediatr Adolesc Med. 2009;163:336-343. 8. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001;357:505-508. 9. Harnack L, Stang J, Story M. Soft drink consumption among US children and adolescents: nutritional consequences. J Am Diet Assoc. 1999;99:436-441.
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Lutzkanin et al 10. Welsh JA, Cogswell ME, Rogers S, Rockett H, Mei Z, Grummer-Strawn LM. Overweight among low-income preschool children associated with the consumption of sweet drinks: Missouri, 1999-2002. Pediatrics. 2005;115:e223-e229. 11. Nader PR, O’Brien M, Houts R, et al. Identifying risk for obesity in early childhood. Pediatrics. 2006;118:e594-e601. 12. Skinner AC, Skelton JA. Prevalence and trends in obesity and severe obesity among children in the United States, 1999-2012. JAMA Pediatr. 2014;168:561-566. 13. Child Care Aware. Child care in America: 2014 state fact sheets. http://usa.childcareaware.org/sites/default/ files/19000000_state_fact_sheets_2014_v04.pdf. Published 2014. Accessed February 24, 2015. 14. Wasser HM, Thompson AL, Siega-Riz AM, Adair LS, Hodges EA, Bentley ME. Who’s feeding baby? Nonmaternal involvement in feeding and its association with dietary intakes among infants and toddlers. Appetite. 2013;71:7-15. 15. Larson N, Ward DS, Neelon SB, Story M. What role can child-care settings play in obesity prevention? A review of the evidence and call for research efforts. J Am Diet Assoc. 2011;111:1343-1362. 16. Benjamin SE, Copeland KA, Cradock A, et al. Menus in child care: a comparison of state regulations with national standards. J Am Diet Assoc. 2009;109:109-115. 17. Pennsylvania Department of Human Services. Office of Child Development and Early Learning. OCDEL Child care providers—December 2014. http://www.ocdelresearch.org/ Reports/Forms/AllItems.aspx?RootFolder=%2FReports% 2FOCDEL%20Public%20Data%20File&FolderCTID=0x 01200092EA27E29EEE3E4AAE2D4C5508AC9E5A&V iew={5EEC6855-F8A8-486E-B6E0-FE6B9FDEBE2E}. Published 2014. Accessed March 30, 2015.
18. US Department of Agriculture. Child and Adult Care Food Program (CACFP). http://www.fns.usda.gov/cacfp/childday-care-centers. Published January 27, 2014. Accessed March 23, 2015. 19. US Department of Agriculture. Child care meal pattern. http://www.fns.usda.gov/sites/default/files/Child_Meals. pdf. Accessed March 23, 2015. 20. Kakietek J, Osuji TA, O’Dell SA, Breck A, Kettel Khan L. Compliance with New York City’s beverage regulations and beverage consumption among children in early child care centers. Prev Chronic Dis. 2014;11:E180. doi:10.5888/pcd11.130430. 21. Sgrignoli NR, Lehman EB, Sekhar DL. Does trainee involvement affect anticipatory guidance in well-child care? Clin Pediatr (Phila). 2014;53:121-127. 22. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision for Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008. 23. Hubbard KL, Must A, Eliasziw M, Folta SC, Goldberg J. What’s in children’s backpacks: foods brought from home. J Acad Nutr Diet. 2014;114:1424-1431. 24. Ziegler P, Briefel R, Ponza M, Novak T, Hendricks K. Nutrient intakes and food patterns of toddlers’ lunches and snacks: influence of location. J Am Diet Assoc. 2006;106(1 suppl 1):S124-S134. 25. Sweitzer SJ, Briley ME, Roberts-Gray C, et al. Lunch is in the bag: increasing fruits, vegetables, and whole grains in sack lunches of preschool-aged children. J Am Diet Assoc. 2010;110:1058-1064. 26. Briley ME, Ranjit N, Hoelscher DM, Sweitzer SJ, Almansour F, Roberts-Gray C. Unbundling outcomes of a multilevel intervention to increase fruit, vegetables, and whole grains parents pack for their preschool children in sack lunches. Am J Health Educ. 2012;43:135-142.
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research-article2015
CPJXXX10.1177/0009922815591887Clinical PediatricsLutzkanin et al
Original Article
Report of Sugar-Sweetened Beverages Offered in Pennsylvania Childcare Centers
Clinical Pediatrics 1–7 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815591887 cpj.sagepub.com
Kristen M. Lutzkanin, MD1, Abigail K. Myers, MD1, Eric W. Schaefer, MS2, and Deepa L. Sekhar, MD, MSc1
Abstract The study objective was to quantify sugar-sweetened beverage (SSB) offerings to children in Pennsylvania (PA) childcare centers and determine whether this information is communicated to parents. In October 2014, a SurveyMonkey link was sent to 4461 PA childcare centers. The 518 respondents represented 88% of PA counties. 279 centers (54%) serve SSBs. 330 (65%) of childcare centers provide parents a report of their child’s daily intake. Of 185 centers serving SSBs and providing a daily intake report, 91% include SSB consumption. In total, 38% of centers (103/272) offer but do not report SSB consumption. In 96% of centers, parents may request their child not receive SSBs. In conclusion, though more than half of PA childcare centers surveyed offer SSBs, those providing daily intake reports usually include SSB consumption. Requiring daily intake reports may be a strategy to increase parental awareness of items consumed outside the home. Keywords sugar-sweetened beverages, childcare centers, obesity Recent data demonstrate that children younger than 6 years receive close to 4.5% of energy intake (69 kcal/d) from sugar-sweetened beverages (SSBs).1,2 SSBs are drinks containing sucrose, high fructose corn syrup, fruit juice concentrates, or other added caloric sweeteners.3 The American Academy of Pediatrics recommends limiting SSB serving size to 4 to 6 oz per day for children 1 to 6 years old.4,5 Though data from the National Health and Nutrition Examination Survey 2009-2010 suggest that overall SSB intake is declining, average intakes still exceed the recommended amounts.1-3 Excessive SSB consumption is linked to weight gain and higher body mass index.5-10 Children who are overweight/obese are more likely to remain so into adulthood.11 With prevalence rates of 24% and 11% for overweight and obesity among children younger than 6 years, respectively, SSBs have been a target of obesity prevention efforts.6,12 Parents may closely monitor SSB consumption in the home, but national data suggest that approximately 11 million young children are in some form of out of home care.13 Nonmaternal care has been associated with an increased likelihood of juice consumption in infants and toddlers.14 Prior studies of childcare centers conducted in other states as well as federally regulated programs such
as Head Start suggest that SSBs are frequently offered to children.15 Similar to many states, Pennsylvania (PA) requires childcare centers to plan menus in advance and post menus for parents to view.16 The 2014 Child Care in America fact sheets report PA has 4601 childcare facilities and 3100 family childcare homes.13 While parents may receive daily reports regarding food consumption and toileting, it is unclear whether beverages are included in the report. Thus, the purpose of this study was to quantify SSB offerings to children enrolled in PA childcare centers and to determine whether such information is routinely communicated to parents. The results of this study may be used to inform policy changes in the beverage choices and reporting requirements for childcare facilities both in PA and nationally.
1
Pediatrics, Penn State College of Medicine, Hershey, PA, USA Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA 2
Corresponding Author: Deepa L. Sekhar, Department of Pediatrics, Penn State College of Medicine, 500 University Drive, HS83, Hershey, PA 17033, USA. Email: [email protected]
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Methods
your voluntary consent to participate in the research. You may exit the survey at any point and your responses will not be recorded . . .
Participants This was an electronic survey of PA childcare centers. The study was approved by the Penn State College of Medicine and Hershey Medical Center Institutional Review Board (study identification number: STUDY00000772). The email addresses of 4461 centers were obtained from a publicly available online listing maintained and updated by the Pennsylvania Department of Human Services.17 Duplicate listings were removed, and those childcare centers without an email address were not included.
A reminder was sent out 7 days into the 14-day survey period.
Data Analysis Descriptive statistics were calculated on all responses. Chi-square tests were subsequently used to evaluate whether childcare center demographic factors were associated with centers offering SSBs.
Instrumentation
Results
Survey questions were developed with the expertise and input of general pediatricians, parents, and childcare center providers. The survey instrument underwent 2 rounds of pilot testing with four parents and four childcare providers on each round. In addition, the electronic version of the survey was pilot tested by the authors for ease of administration and flow of the skip logic.
Demographics
Procedure
There were 518 surveys completed, a response rate of 12%, representing 59/67 (88%) PA counties (Figure 1). Most centers (51%) were in suburban locations. The majority of participating childcare centers served more than 50 children at their facility and had been in operation for more than 10 years (Table 1).
Offering Sugar-Sweetened Beverages
The survey could be completed by the childcare center director or another staff member in 10 to 15 minutes. Participants had the option to start the survey, save responses and return later. Only 1 response per center was requested. An electronic link to the survey in SurveyMonkey was sent out September 28, 2014 with an introductory message (excerpt below) and remained open until October 10, 2014. . . . With the growing epidemic of childhood obesity we are all struggling with how best to improve childhood nutritional habits. We advise parents to restrict consumption of juice and other sugar sweetened beverages. Yet, in speaking with the parents in my clinic, they report beverages given at home, but they fail to account for beverage options offered by their childcare centers. Thus, children may be getting more than the recommended amount of sugar sweetened beverages between home and child care. Included below is a link to a survey which has been approved by the Penn State Milton S. Hershey Medical Center Institutional Review Board (IRB) with a waiver of consent. This survey should be completed by the center director or a person designated by the center director to fill out this survey. If you choose to participate, please answer the questions to the best of your ability; your responses will remain anonymous. Your completion of the survey implies
Of those surveyed, 279 childcare centers (54%) reported serving SSBs with snacks or meals (Table 2). Among these centers, SSBs were most commonly introduced at 12 to 23 months (50%). The most common serving size reported was 4 ounces (53%) and most children were not permitted a second serving. SSBs were most likely to be served as a first option with afternoon snack (29%; Table 3). Among centers that offered SSBs, 96% indicated that parents could request their child not be given any SSBs and only receive plain milk or water.
Center Meal Plans The majority of centers had a scheduled meal plan (84%) which was set by the individual facility (85%) rather than a parent company (15%; Table 4). For those with a parent company setting the menu, 43% indicated they had limited ability to make alterations. There were 95% of centers that indicated parents were able to view a hard copy of the meal plan at the center. A majority of centers (330, 65%) provide parents a report of their child’s daily consumption in written form. Of these 330 centers, 185 offer SSBs and 169 (91%) include SSBs in the daily report. Overall, 38% of centers who offer SSBs do not report on SSB consumption.
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Figure 1. Statewide distribution of survey respondents.
Free Do It Yourself Color-Coded State, US, Canada and Mexico Maps; http://diymaps.net/.
Table 1. Demographics of Survey Participants. Characteristic Center location (N = 503) Urban Suburban Rural Number of enrollees (N = 511) 100 Years in operation (N = 508) ≤10 >10
% (n) 20.1 (101) 51.3 (258) 28.6 (144) 18.6 (95) 11.0 (56) 18.8 (96) 27.2 (139) 24.5 (125) 29.3 (149) 70.7 (359)
The number of years a center had been in operation (≤10 years vs >10 years) was not associated with provision of SSBs (56% vs 54%, respectively; P = .65). The
number of children enrolled (grouped as 100 children, with 50% to 59% providing SSBs; P = .77) and location of center (urban, suburban, rural, with 51% to 60% providing SSBs; P = .31) were also not associated with provision of SSBs.
Discussion The results of this analysis indicate that over half of responding PA childcare centers provide SSBs to children. While 38% of centers providing SSBs do not report this information, among those that have a daily intake report, 91% include SSBs. This information provides clear avenues for action by policy makers, providers, and parents to partner with childcare centers in improving the dietary habits of children. Excess calories from consumption of SSBs have repeatedly been linked to the obesity epidemic.5-10 Children receiving nonmaternal care have been shown to have a higher likelihood of juice consumption.14 Prior studies of the nutritional quality of meals offered at
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Table 2. Details of Sugar-Sweetened Beverage (SSB) Offerings in Pennsylvania Childcare Centers. Characteristic
% (n)
Are SSBs provided? (N = 518) Yes No At what age does your center start serving SSBs? (N = 279) Newborn to 5 months 6-11 months 12-23 months 2-5 years Other What is the typical serving size? (N = 279) 2 ounces 4 ounces 6 ounces 8 ounces 12 ounces Other Are children permitted a second serving? (N = 279) Yes No Depends on individual teacher Are children permitted SSBs outside of scheduled meal and snack time? (N = 279) Yes No Depends on individual teacher Can parents request their children not receive any SSBs? (N = 279) Yes No
53.9 (279) 46.1 (239) 0 (0) 3.2 (9) 49.8 (139) 34.1 (95) 12.9 (36) 22.9 (64) 52.7 (147) 13.3 (37) 5.0 (14) 1.1 (3) 5.0 (14) 15.8 (44) 71.3 (199) 12.9 (36) 3.6 (10) 95.3 (266) 1.1 (3) 96.4 (269) 3.6 (10)
Table 3. First Drink Option by Meal/Snack. % (n) Meal/Snack
Water
White Milk
Breakfast (n = 499) 5.0 (25) 67.7 (338) Lunch (n = 503) 14.3 (72) 69.0 (347) am Snack (n = 477) 37.3 (178) 18.7 (89) pm Snack (n = 513) 42.9 (220) 26.9 (138)
100% Fruit Diluted Fruit Juice Juice Fruit Juice (Not 100%)
Flavored Sports Milk Soda/Pop Drinks
4.4 (22) 2.8 (14) 10.1 (48) 17.2 (88)
0.4 (2) 2.0 (10) 0.8 (4) 2.1 (11)
2.2 (11) 0.99 (5) 6.3 (30) 7.8 (40)
0.4 (2) 0 (0) 0.8 (4) 1.4 (7)
0 (0) 0 (0) 0 (0) 0 (0)
0 (0) 0 (0) 0 (0) 0 (0)
N/Aa 19.8 (99) 10.9 (55) 26.0 (124) 1.8 (9)
a
N/A indicates not applicable as center does not provide this particular meal/snack.
childcare centers indicate SSBs are frequently given to children.15 Many PA childcare facilities participate in the Child and Adult Care Food Program, a US Department of Agriculture initiative to reimburse facilities for providing meals that meet requirements for milk, fruit, grains, and meat.18 In this program, the fruit requirement may be met by serving fruit or undiluted fruit juice.19 It is clear among those PA childcare centers reporting daily intake, in a majority of cases SSBs are included in their
report. Thus, a next step for policy makers may be to require daily intake reports for parents, as it is likely this will translate into increased reporting of SSB consumption. Policies to limit the allowance of SSBs to children enrolled in childcare centers are a valuable step. In New York City, a 2007 modification to regulations on beverage offerings in childcare facilities stated SSBs should not be provided, and a follow-up study indicated that
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Lutzkanin et al Table 4. Details of Childcare Center Meal Plans. Characteristic
% (n)
Is there a scheduled meal/snack plan (n = 518) Yes No Is the meal snack plan set by the individual center or a parent company? (n = 438) Parent company Individual center If set by a parent company, how flexible can your center be in terms of altering food/drinks offered? (n = 65) Inflexible Not very flexible Neutral Flexible Very flexible Is your center’s meal/snack plan readily available to review by parents? (n = 438) Yes No In what form is your center’s meal/snack plan available for review? (n = 408) Hard copy available on premises Hard copy provided to parents Virtual copy available on website Virtual copy emailed to parents Does your center provide parents a written report of what the child consumes during the day? (n = 509) Yes No Are sugar-sweetened beverages (SSBs) included in this report? (n = 272) Provide a written report including SSBs Provide a written report without SSBs Do not provide a written report
67% of centers were in compliance.20 The number of facilities serving SSBs is reduced compared with our findings in PA. However, policy alone is unlikely to be successful in reducing SSB intake among young children. In particular, though programs such as Head Start are subject to federal guidelines, individual childcare facilities and small family-based childcare centers fall under state regulations, which vary significantly across the country.15 Thus, including providers and parents will be a key component in changing beverage offerings and reporting of SSBs in childcare settings. Parents routinely receive anticipatory guidance on a variety of topics from their pediatric providers. This counseling frequently involves recommendations on nutrition, diet, and exercise.21,22 Providers inquiring about daily SSB intake should remind parents to include SSBs offered in their childcare center in the “total.” Parents should be made aware that if their child is enrolled in outside of home care, SSBs may be routinely offered with snacks or meals. Providers can explain to parents that this information may not be provided as part of a daily report on meals and toileting. However, most
84.4 (437) 15.6 (81) 14.8 (65) 85.2 (373) 21.5 (14) 21.5 (14) 10.8 (7) 36.9 (24) 9.2 (6) 94.3 (413) 5.7 (25) 94.9 (387) 45.3 (185) 15.4 (63) 18.9 (77) 64.8 (330) 35.2 (179) 62.1 (169) 5.9 (16) 32.0 (87)
important, parents should be aware of the option to request that SSBs not be given to their child. In addition to awareness of food consumed outside the home, parents themselves must model good dietary habits for their children. Studies of lunches packed by parents or provided at home indicate the meals are often of poor nutritional value and include SSBs.23,24 Thus, another valuable intervention might be to offer parents healthy, cost-conscious ideas for breakfast and lunch options for children.25,26 Such information could be provided at the physician’s office, via the Women, Infants and Children’s supplemental nutrition program, or even during registration at childcare facilities and might specifically include a statement that SSBs are not recommended as a beverage option. Finally, childcare centers must be included in the dialogue on SSB offerings. Those which have not complied with regulations in places such as New York City should be queried. Programs that reward childcare centers for removing SSBs from menus may provide further incentives. Addressing any underlying issues, which may include concerns separate from nutrition such as food
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storage, convenience and cost, may improve the appeal of new policies.
Limitations Although 59 of the 67 counties in Pennsylvania were represented in this survey, responses were not evenly distributed across counties. This may have created a reporting bias if certain areas of the state are more likely to include SSBs in the diet due to societal preferences or economic constraints. The low response rate, 12%, may mean the results are not representative of all childcare centers. Centers without an email address were not included. Surveys were sent out to childcare center directors. Center directors may have different responses than in-classroom teachers, the ones who actually distribute SSBs and report meal consumption to parents. Family childcare centers and less formal caretaking arrangements were also under represented in this survey, but they are an important area for policy makers, providers, and parents when addressing out of home meals/ snacks. Finally, bias may have been introduced by our introductory message to the survey, which speaks negatively of SSBs, thus possibly discouraging full candid disclosure of their use by respondents.
Conclusions Sugar-sweetened beverages are regularly offered at many PA childcare centers in the preschool years, and though 38% of centers serving SSBs do not report this information, in 91% of cases when a daily intake report is provided, SSBs are included. In considering interventions to curb the obesity epidemic, SSBs provided to children in out of home care is an underutilized area for policy makers, providers, and parents to make a difference. These results provide an opportunity to partner with childcare centers to improve the health of children by establishing healthy dietary habits and increasing parental awareness of food consumed outside the home. Authors’ Note Underlying research material related to this article may be accessed by contacting the corresponding author, Deepa L. Sekhar.
Author Contributions KML contributed to study conception and design; acquisition, analysis and interpretation of the data; drafting and crticially revising the manuscript; gave final approval of the mansucript and agreed to be accountable for all aspects of the accuracy and integrity of the published work. AKM contributed to; study conception; drafting of the manuscript; gave final
approval of the mansucript and agreed to be accountable for all aspects of the accuracy and integrity of the published work. EWS contributed to analysis and interpretation of the data; critically revised the manuscript; gave final approval of the mansucript and agreed to be accountable for all aspects of the accuracy and integrity of the published work. DLS contributed to the study conception and design; acquisition, analysis and interpretation of the data, and crticially revisied the manuscript; gave final approval of the mansucript and agreed to be accountable for all aspects of the accuracy and integrity of the published work.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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