Journal of the American College of Nutrition, Vol. 18, No. 2, 108-114 (1999)
Published by the American College of Nutrition
Nutrient Intake of Head Start Children: Home vs. School
Marguerite C. Bollella, MS, RD, CDN,
Arlene Spark, EdD, RD, FACN,,
Laura A. Boccia, MS, RD,
Theresa A. Nicklas, DrPH, LDN,
Brian P. Pittman, MS and
Christine L. Williams, MD, MPH
The American Health Foundation, Child Health Center, Valhalla, New York, (M.C.B., L.A.B., A.S., C.L.W.)
Department of Food and Nutrition, College of Human Development and Education, North Dakota State University, Fargo, North Dakota, (T.A.N.)
Division of Epidemiology, American Health Foundation, New York, New York, (B.P.P.)
Nutrition and Food Science and Public Health Nutrition, Program in Urban Public Health, Hunter College School of Health Sciences, New York, New York, (A.S.)
Address reprint requests to: Marguerite C. Bollella, MS, RD, CDN, The American Health Foundation, Child Health Center, 1 Dana Road, Valhalla, New York 10595
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ABSTRACT
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Objective: To determine mean intake of energy and protein, total fat, saturated fat, percent energy from total and saturated fat, cholesterol, carbohydrate, calcium, iron, zinc, folate, vitamins A, C, E, B-6 and B-12, thiamin, niacin, riboflavin, magnesium, sodium and fiber of preschool Head Start children at school and away from school.
Design: Twenty-four-hour food intakes for 358 Head Start children were obtained by observing food intake at school and acquiring intake recalls from parents or guardians specifying food their children consumed for the balance of the day. After determining group estimates of energy and nutrient intake, mean intake was compared to standard nutrient recommendations for the entire 24-hour day, i.e., for the time the children were in school and for the remaining hours away from school ("home" intake).
Subjects: The 358 Head Start children attended school either half-day (2- to 3-hour AM and PM sessions) or all-day (5 to 6 hours).
Statistical analyses: Differences in nutrient intake among class times were analyzed using one-way analysis of variance (ANOVA) followed by Tukey’s multiple comparison test. Differences with a p-value <0.05 (two-tailed) were considered to be statistically significant. Total energy, protein, calcium, iron, zinc, vitamins A, C, E, B6, and B12, thiamin, niacin, riboflavin as well as folate and magnesium were compared to the Recommended Dietary Allowances for the 4- to 6-year-old age group. Other standards that were used for comparisons included the National Cholesterol Education Program (fat, saturated fat and cholesterol), the 1989 National Research Council’s Diet and Health Report (carbohydrate and sodium) and the recommendation for fiber proposed by the American Health Foundation.
Results: At school, half-day children consumed up to 25% of the daily recommendation for energy and nutrients, while all-day children achieved at least a third of the recommended intakes. When intakes at home and school were combined, all three groups of children (AM, PM and all-day) exceeded dietary recommendations for protein, vitamins and minerals. Energy intake remained below 100% of the recommendation, while intake of total fat, saturated fat and cholesterol exceeded recommendations.
Application: Further research is required to explore energy needs and determine nutritional status and nutrient needs of minority and low-income preschool children. Strategies are required to increase nutrient density, but not fat density, of meals and snacks served to children who attend day care for part of the day. Finally, school meals and nutrition education programs such as Team Nutrition should broaden their base to include healthful eating habits for all school children, including the very youngest children in preschool programs.
Key words: preschool diet, diet assessment, 24-hour recall, energy intake
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INTRODUCTION
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Nutrition of children in the school setting is a subject that receives broad attention. Comprehensive analyses are available of food that is offered to [1–3] and consumed by [4–7] school-age children in the elementary, middle and high school grades. Much less is known, however, about nutrition of preschool children. There have been a number of reports concerning the nutrient content of food offered to preschoolers at day care centers [8–13]. Deficiencies in energy and iron were found when Briley et al. [10] compared the nutrient content of the menus used at a child care center in Texas to the Recommended Dietary Allowances (RDA) for 4- to 6-year-old children. An analysis of lunch menus by Beckett Oakley et al. [11] demonstrate that child care centers in Mississippi provide less than one-third of the RDA for energy and key nutrients, such as vitamins B12 and E, as well as for calcium, iron and zinc. The Early Childhood and Child Care Study, released by the United States Department of Agriculture (USDA) [13], shows that menus offered to children who have participated in the Child and Adult Care Food Program (CACFP) provided one-half of the RDA for energy and greater than two-thirds of the RDA for key nutrients (protein, calcium, iron, as well as vitamins A and C). Total fat met or approximated the Department of Health and Human Services (DHHS)/USDA Dietary Guidelines for Americans [14] for percent of energy from fat, while saturated fat exceeded recommendations. Drake [15] analyzed the nutrient content of food and beverages consumed by children from four day care centers in Missouri and found that energy, zinc, iron, magnesium, as well as vitamins A, C and folate were consumed at less than 75% of the standard set for comparison (2/3 of the RDA for 4- to 6-year-old children). In a study of food consumption of Canadian preschool children, McNicol [16] reported that lunch intake met or exceeded recommended Canadian guidelines for children. We have found no reports to date that examine 24-hour intakes of children who attend preschool programs, especially reports which contrast intake at school with intake away from school. The purpose of this study is to compare the nutrients that preschool children receive at school to those obtained at home and to determine adequacy of nutrient intake when home and school intakes are combined. In this context, home consumption is defined as any food or beverage consumed outside the school setting.
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MATERIALS AND METHODS
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Overview of the Healthy Start Project
This study is part of the Healthy Start Project, a three-year demonstration and education research project designed to evaluate the effectiveness of a cardiovascular-risk reduction program in minority and low-income children and their parents. A detailed description of the study design of the project is reported elsewhere [17].
Subjects
Baseline participants (Fall, 1995) were 723 Head Start children who had consent to participate in the Healthy Start Project. Six hundred forty-one of the 723 children were present for direct meal observation on study days. Twenty-four-hour dietary intakes (home plus school meal consumption) were collected on 439 of the 641 children observed at the Head Start Centers. Of the 439 children, 358 attended Head Start at the participating Centers. The remaining 81 children attended day care at the Head Start Centers and were not included in the study sample. The subjects in this study, therefore, were 358 3- to 5-year-old Head Start children (mean age 48.7 months ± 6.2 months) who attended school either half-day (2- to 3-hour sessions subdivided into AM [n = 96] or PM [n = 95] groups) or all-day (5 to 6 hours [n = 167]). Forty-four percent of the children were African American and 53% were male. A full description of the study sample is found in Table 1. The children who attended school for 2
hours were referred to as AM or PM children, depending upon the time of day that they attended school. The children who attended school for 5 to 6 hours were referred to as all-day children. Approval for the use of human subjects in research was received from the Committee on Protection of Human Rights of the American Health Foundation, Valhalla, New York.
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Table 1. Classification of Children by Race, Gender and Age According to Time of Day in School. Baseline, Fall 1995
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Dietary Methodology
Baseline 24-hour dietary recalls (Fall, 1995) were collected on the Head Start children for the purpose of obtaining a group estimate of energy and selected nutrient intake prior to intervention. A combined child-observation/parent-recall method was employed by means of a methodology developed and tested prior to the main intervention [18]. Quality controls included use of a standardized protocol [19–23], a Product Identification Notebook for snack probing [19] and school and family recipe collection [24]. Meal observers (undergraduate students in nutrition) were trained to assess the food intake of the children at the participating Head Start Centers while parent-telephone instructors (also undergraduate students in nutrition) were trained to instruct the parents or guardians of the participating Head Start children on how to record their children’s food consumption outside of Head Start. Telephone interviewers were registered dietitians trained to interview the parents or guardians on their children’s food consumption outside the Head Start Center. They used the University of Minnesota Nutrient Data System (Version 2.8, Nutrition Coordinating Center, University of Minnesota, 1300 South Second Street, Minneapolis, MN) to enter the data obtained from the parents or guardians into a computer. The completed food records were used as a prompt for reviewing the children’s food intake [18]. By combining meal observation data with home intake data (data collected from the parents or guardians) 24-hour dietary intakes were collected on the Head Start children.
Statistical Analysis
Mean energy, macronutrient and selected micronutrient intakes were determined for meals consumed at home as well as at school. Menus served at the participating Head Start Centers were analyzed for total energy, fat, protein, carbohydrate, fiber, saturated fat, cholesterol and selected micronutrients (calcium, iron, zinc, vitamins A, C, D, E, B6, B12, as well as thiamin, niacin, riboflavin, and magnesium, folate and sodium). The same variables were used to analyze the nutrient intake of the Head Start children. Differences in nutrient intake among the three groups of children were analyzed using one-way analysis of variance (ANOVA) followed by Tukey’s multiple comparisons test [25]. Differences with a p-value <0.05 (two-tailed) were considered to be statistically significant. Total energy and micronutrient intakes of the children were compared to one-third of the RDA for the 4- to 6-year-old age group for foods consumed at school and two-thirds of the RDA for combined home and school intake for the same age group [26].
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RESULTS
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Analysis of Head Start Menus
Meals served at the participating Head Start Centers include breakfast, lunch and snack. Each child is served at least two meals. Morning children eat breakfast and lunch at school, afternoon children eat lunch and a snack, and all-day children receive breakfast, lunch and snack. Table 2 shows mean total energy, macronutrient and micronutrient values for the menus provided by the Head Start Centers. When compared to the RDA for the 4- to 6-year-old children, it was found that the meals served provided one-third or more of the RDA for energy, protein and micronutrients (vitamins A, D, E, C, B6, B12, thiamin, niacin, riboflavin, folate, calcium, phosphorus, magnesium, iron, zinc and selenium).
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Table 2. Energy and Nutrient Content of All-Day Head Start Menus Compared to One-third of Recommended Intakes (Baseline, 1995)
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Energy, Macronutrient and Selected Micronutrient Intake Derived from School Meals
Since no differences were observed with regard to Body Mass Index, age and total energy intake between males and females when home and school intake were combined, they were analyzed together, classified by group (AM, PM, or all-day). Table 3 shows energy, macronutrient and micronutrient intake of the children at school. Children in the AM and PM groups consumed one-fourth or less of their total daily intake for energy, protein, carbohydrate, fat, zinc, vitamins E and B12, folate and sodium compared to the all-day children. AM children consumed more cholesterol (17% vs. 9.4% of total daily intake), iron (26% vs. 16% of daily intake), calcium (28% vs. 24%), vitamin A (34% vs. 23% of daily intake) and magnesium (25% vs. 22% of daily intake) than the PM children. Both the AM and PM groups consumed 26% of their daily fiber intake at school. No significant difference was observed between energy intakes of the AM and PM groups. Both the AM and PM children achieved one-third of the RDA for protein, vitamins A, C, and B12, folate and magnesium. Compared to the AM and PM children, the children in the 5- to 6-hour day group consumed significantly greater amounts of all nutrients (p values ranged from <.01–<.0001) during the school hours. Additionally, they achieved one-third RDA for protein, calcium, iron, vitamins A, C, E, and B12, folate and magnesium and just over one-fourth of the RDA for zinc. Both AM and PM children met National Cholesterol Education Program (NCEP) [27] guidelines for consumption of total fat, saturated fat and cholesterol. All-day children met NCEP guidelines for cholesterol consumption, just met the guidelines for total fat intake (30.1%) and exceeded guidelines for saturated fat (12%).
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Table 3. Comparison of School Meal Consumption to Total Day’s Intake and One-Third Recommended Intake in 358 Head Start Children, Classified by Time in School. Baseline, Fall 1995
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Energy, Macronutrient and Selected Micronutrient Intake Derived from Home Meals
The all-day children consumed significantly less energy than the AM and PM children (954 kcal vs. 1154 [p < .01] and 1112 kcal [p < .05], respectively) at home. When compared to the AM children, the all-day children consumed significantly less total protein, carbohydrate, total fat, calcium and magnesium (p values ranged from <.05 to <.001). Significantly less sodium was consumed by the all-day children at home (1331 mg) compared to the AM children (1840 mg) and the PM children (1912 mg) with p-values ranging from <.001 to <.01, respectively. Saturated fat intake exceeded recommendations for all three groups of children. Percent energy from total fat and cholesterol exceeded recommendations in the AM and all-day groups, while the PM group just met total fat recommendation (30.6%) (table not shown).
Energy, Macronutrient and Selected Micronutrient Derived from Combined Home and School Intake (24-Hour Recall)
Total energy intakes, distribution of macronutrients as well as select micronutrient intake for the three groups of children, are shown in Table 4. Total energy intake did not differ among the three groups of children. Distribution of percent of energy from protein, carbohydrate and fat was similar for the three groups of children (15%, 54% and 31%, respectively). Total mean calcium intake was significantly greater (p < .05) among the all-day children when compared to that of the AM children. Mean total intakes of vitamin A, vitamin E and vitamin B12 were significantly greater for the all-day children when compared to those of the AM and the PM children (p values of <.001, <.01 and <.05 respectively). AM and all-day children exceeded recommendations for total fat intake, while the PM children just met (30.5%) the recommended intake. All three groups of children exceeded saturated fat recommendations and met cholesterol recommendations. All three groups did achieve the American Health Foundation recommendation for fiber intake in children [28].
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Table 4. Total Energy, % Macronutrient and Selected Micronutrient Intake in Head Start Children—Home Plus School Combined, Classified by Class Time with Comparison to Two-thirds Recommended Intake. Baseline, Fall 1995
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Nutrient Intake of the Head Start Children Stratified by Ethnicity
When the 24-hour intakes of the children in the three groups were stratified by ethnicity and class time (AM, PM or 5- to 6-hour day), no significant differences were found between the AM and PM groups with respect to total energy, macronutrient or selected micronutrient intakes (data not shown). However, several differences were observed among the all-day children when stratified by ethnicity alone. Mean 24-hour intake of total energy, protein, fat, carbohydrate, iron, calcium, vitamins A, E, and B12, magnesium and folic acid was significantly higher (P values range from p < .05 to p < .0001) in the Caucasian children when compared to that of the Hispanic children. Mean 24-hour intake of total protein, saturated fat, calcium, magnesium and vitamin B12 was significantly higher in the Caucasian children when compared to that of the African-American children (p values range from p < .05 to p < .0001). No significant difference in 24-hour intake was observed between the African-American and Hispanic children.
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DISCUSSION
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Head Start Program Performance Standards stipulate that children who attend Head Start in a part-day program receive one-third of their daily nutritional requirements from meals and snacks served and that children who attend Head Start in a full-day program receive one-half to two-thirds of their daily nutritional requirements from meals and snacks served [29]. The technical support paper of the American Dietetic Association [30] defines part-day as 4 to 7 hours’ and full-day as greater than eight hours’ attendance. Because all the children in our study attended Head Start fewer than eight hours a day, they were required by the Head Start Program Performance Standards to receive one-third of their daily nutritional requirements from the meals and snacks served at the Head Start Centers, regardless of the number of meals and snacks consumed. Analysis of the combined menus from each of the Head Start Centers shows that the menus, as served, provide at least one-third of the RDA for the 1- to 3- and the 4- to 6-year-old age group for energy and protein, as well as the micronutrient intake for most nutrients that have RDA values. These menus reflect breakfast, lunch and snack items served. The data in our study, reflecting actual food intake of the children, suggests that children who attend Head Start fewer than 5 to 6 hours a day do not obtain one-third RDA for energy, calcium, iron, zinc and Vitamin E, while children who attend for 5 to 6 hours a day achieve one-third RDA for all target nutrients, except zinc. Energy intake at school is below one-third the RDA for all three groups. The fact that the children serve themselves foods and beverages may result in smaller than optimal quantities of food consumed by the AM and PM groups. In addition, AM and PM children who attend school for fewer than three hours are not present for either one meal or snack; this results in decreased caloric and nutrient intake. When home plus school data are combined, however, all children achieve two-thirds RDA for all target nutrients. Energy intake remains below 100% of RDA for the three groups. Recent studies using the doubly labeled water technique to determine total energy expenditure in young children have shown recommended intakes to be above actual energy expenditure by as much as 25% [31,32]. Therefore, the total energy intake during the day for the children in our study (1482, 1393 and 1477 kcal for the AM, PM and all-day children, respectively) may be more representative of their actual needs. With respect to energy from total fat (31%), intakes exceed the 30% of energy recommendations established by the NCEP [27], yet are slightly lower than those reported in other national surveys [33,34]. Percent of energy from saturated fat (12%) exceeds the 10% recommendation of the NCEP, findings similar to those reported by both the Continuing Survey of Food Intake by Individuals (CSFII-95) and the third National Health and Nutrition Examination Survey (NHANES III) (12.3% and 12.6%, respectively).
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CONCLUSIONS AND RECOMMENDATIONS
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Although analysis of day care center menus indicates that adequate nutrients are available through the breakfast, lunch and snack served each day, only full-day children consume one-third of the RDA for micronutrients at school. However, when home and school consumption is combined, mean intakes are between two-thirds and 100% of the RDA. Our analysis shows that preschool menus contain more saturated fat than recommended and that children’s intake of saturated fat is in excess of recommendations. Their saturated fat intake also exceeds guidelines for the entire day.
Energy is another concern. Although day care center menus deliver one-third of a day’s recommendation for energy, children fail to consume enough food to meet the energy intake that is recommended. While our data would appear to indicate the need for an increase in energy provided to half-day children, this complex issue requires further study. The doubly labeled water technique of determining total energy expenditure suggests that current recommendations for energy are too high for children four to six years of age. Energy metabolism of children needs close examination in order to provide more accurate recommendations for energy intake among preschool children. Furthermore, there is substantial documentation of both the prevalence of overweight and obesity among minority children and of the relationship between obesity and poverty (35). These associations prevent us from recommending the development of strategies to increase the energy intake of half-day preschool children.
We recommend the development of education programs that foster healthy lifestyles and improved nutritional intake in this population of children. Our research indicates that preschool day care menu planners need technical assistance in reducing saturated fat without reducing the energy and nutrients provided to preschool children. Research is also needed to explain the ethnic differences in diets and nutrient intakes of minority and low-income preschoolers, which are shown in our study and reported elsewhere [36].
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ACKNOWLEDGMENTS
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This study was supported by Grant Number HL 50321 from the National Heart, Lung and Blood Institute.
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FOOTNOTES
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Supported by Grant Number HL 50321 from the National Heart, Lung and Blood Institute.
Received June 1, 1998.
Accepted December 1, 1998.
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ABSTRACT
INTRODUCTION
