April15,2015
ChildNutritionPrograms
FoodandNutritionService
U.S.DepartmentofAgriculture
3101ParkCenterDrive
Alexandria,VA22302
Re:FNS‐2011‐0029
DearSirorMadam:
On behalf of the American Heart Association (AHA), including the American
Stroke Association (ASA) and more than 22.5 million volunteers and
supporters, we appreciate the opportunity to provide comments on the
proposedrevisionstotheChildandAdultCareFoodProgram(CACFP).
AHA is extremely pleased that the U.S. Department of Agriculture (USDA) is
workingtoupdatethemealpatternrequirementsfortheCACFP.Theexisting
standards, which have not been altered significantly since the program’s
inception in 1968, are outdated and no longer reflect the needs of today’s
population.Updatingthestandardsislongoverdue.
Ingeneral,AHAstronglysupportstheproposedrevisionstothemealpattern
requirements.WearepleasedthattherulewouldrequireCACFPprovidersto
servemorewholegrains,fruitsandvegetables,aswellaslesssugarandfat.We
would,however,liketheUSDAtogofurtherandlimittheamountoffruitjuice
thatcanbeserved,eliminateflavoredmilkforchildrenbetweentwoandfive
years of age, and restrict the amount of sugar in yogurt and flavored milk
servedtoolderparticipants.WewouldalsoliketheAgencytochangeanumber
oftherecommended“bestpractices”intorequirements.
AHA’scommentsarebasedonourdietaryrecommendationsforchildrenand
adults, as well as our experience working with child care centers through
Healthy
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Healthy Way to Grow1, a program created by AHA and Nemours to help child care centers
createhealthierenvironmentsbyprovidingdirect,hands‐onassistance,customizedtraining,
resourcesandtoolsatnocost.
INFANTMEALPATTERN
InfantAgeGroups
AHAsupportstheUSDA’sproposaltodivideinfantsintotwoagegroups:0–5monthsand6–
11months.TheagegroupsareconsistentwithrecommendationsfromtheAmericanAcademy
of Pediatrics and will help reinforce that solid foods should not be introduced until
approximatelysixmonthsofage.
Breastfeeding
Wesupportallowingreimbursementforinfantmealswhenmothersdirectlybreastfeedtheir
childrenatthechildcarefacility.
Daycareprovidersshouldpromoteandsupportmotherswhowanttobreastfeedorpump
their breastmilk by having a quiet, private area with an outlet and comfortable seating,
includingaplacetowashtheirhands.Weagreethatthisisanappropriatebestpracticeand
notethatchildcareprovidersparticipatingintheHealthyWaytoGrowprogramarealready
familiarwithit.
FruitsandVegetables
Westronglysupporttheproposaltoeliminatefruitjuiceforinfantsofanyage.Thereisno
nutritionalneedforjuice,2juicetendstobehighinsugarandcalories,andjuiceconsumption
coulddisplacebreastmilkorformula.TheproposedchangeisalsoconsistentwiththeHealthy
WaytoGrowprogramwhichrecommendsnojuicebeforetheageofone.
Wealsosupportthenewrequirementthatafruitorvegetablebeservedaspartofthesnack
mealpatternforthesixthrough11monthagegroup.Fruitsandvegetablesprovidevaluable
nutrientswithouttheadditionalsugarcontentfoundinjuice.Childrenarealsomorelikelyto
acceptandenjoyfruitsandvegetablesiftheyareintroducedatayoungage.
MeatandMeatAlternatives
We agree that cheese, cottage cheese, and cheese food or spread should not be served to
infants.
1Seehttp://www.healthywaytogrow.org/HWTG/formoreinformation.
2TheUseandMisuseofJuiceinPediatrics.AmericanAcademyofPediatricsCommitteeonNutrition.
http://pediatrics.aappublications.org/content/107/5/1210.full
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CHILDANDADULTMEALPATTERNS
ChildAgeGroups
TheCACFPmealpatternscurrentlydividechildrenintothreeagegroups(1–2years;3–5
years;6–12years).AHAsupportstheadditionofafourthagegrouptoaddresschildrenolder
than12yearsofage.Weare,however,disappointedthatUSDAdidnotfollowtheInstituteof
Medicine’srecommendationtorevisetheagegroupstomakethemconsistentwiththeage
groups used in the National School Lunch Program (NSLP) and School Breakfast Program
(SBP).WhileweunderstandtheAgency’sconcernthatusingtheNSLPandSBPagegroups
wouldmovesomechildrenintothenextagegroup,therebyrequiringlargerquantitiesoffood
tobeservedandpossiblyincreasingcoststoCACFPproviders,webelievetheprimaryfocus
shouldbeonprovidingfoodsthatmeetthenutritionalneedsofaparticularagegroup.We
urgetheUSDAtoreconsiderandrevisetheagegroupstomatchtheNSLP/SBP.
FruitsandVegetables
Wesupporttheproposaltoseparatethecurrentfruit/vegetablecomponentintotwoseparate
categories with specific requirements for each. Creating two separate requirements will
ensurethatprovidersarenolongerabletomeetthefruit/vegetablecomponentbyservinga
singlefruitorvegetable.Providerswillnowberequiredtoservebothafruitandavegetable
atlunchandsupper,notjustoneortheother.Werecognize,however,thattheremaybesome
circumstanceswhereaproviderwouldprefertoservetwovegetablesratherthanonefruit
andonevegetable.Forexample,aprovidermaywishtoservechickenwithroastedcarrots
andgreenbeans.Wewouldsupportallowingproviderstoservetwovegetablesatlunchor
supperwhenitwouldmakeamoreappealingmenu.Vegetableintakeamongchildrenislow
withlessthan5%meetingrecommendedguidelinesofatleasttwo‐and‐a‐halfcupsperday,3
andeffortstoincreaseconsumptionshouldbeencouraged.Therefore,werequestthatthe
USDA consider modifying the rule to allow providers to meet the fruit and vegetable
requirements at lunch and supper by serving one fruit and one vegetable or serving two
differentvegetables.Atleastoneofthefoods,however,mustbeavegetable;twofruits,which
aregenerallyhigherincaloriesandsugarthanvegetables,shouldnotbecreditable.
Inaddition,weareconcernedthatthereisnorequirementthatprovidersvarythefruitsand
vegetablestheyserve;providerscouldservethesamefruitandthesamevegetableatevery
meal, every day. Providers should be required to serve a variety of fruits and vegetables.
Increasingconsumptionofawidevarietyoffruitsandvegetablesisakeyrecommendationin
the2010DietaryGuidelinesforAmericans,theMyPlateprogram,andAHA’sDietandLifestyle
Recommendations.TheUSDAhasalsorecognizedthisneed,requiringschoolsparticipating
intheNSLPtoserveavarietyofvegetablesduringtheschoolweek.Whileweappreciatethe
inclusion of a “best practice” that recommends at least one serving each of dark green
vegetables, red or orange vegetables, and legumes per week, we believe this should be a
requirement.
3NHANES2009–2010.
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Wearealsoconcernedthattheproposedmealpatternswouldallowproviderstousejuiceto
meettheentirefruitorvegetablecomponentatallmeals.Althoughfruitandvegetablejuice
couldnotbeservedatthesamemeal,thereisnolimitonthenumberoftimesjuicecouldbe
servedperday.Aprovidercouldservejuiceatbreakfast,lunch,supper,andforasnack.This
issimplytoomuchjuice.Fruitjuicesarenotequaltowholefruitsinfibercontent,tendtobe
highinsugarandcalories,andmaybeassociatedwithhigherbodyweightinchildrenand
adolescents.Vegetablejuicestendtobehighinsodium.Therefore,wewouldpreferifCACFP
providersusewholefruitsandvegetablestomeetthefruitandvegetablerequirements.Fruits
andvegetablesintheirnaturalformsarerichinnutrients,lowincalories,andhighinfiber;
and diets rich in fruits and vegetables have been shown to lower blood pressure, improve
other cardiovascular disease risk factors, and lower the risk of developing cardiovascular
disease. 4 To encourage providers to serve whole fruits and vegetables, the USDA should
establishjuicerestrictionsbyage.Werecommendthefollowinglimitswhicharesupported
bybothAHAandtheAmericanAcademyofPediatrics:
 Children1–6years=4to6ouncesperday
 Children7–18years=8to12ouncesperday
TheAgencyshouldalsoprovidetrainingandguidancetoprovidersonhowtopurchaseand
preparefruitsandvegetables.Providersshouldbeadvisedtousefreshorfrozenvegetables
whenever possible. Canned vegetables that are high in sodium should be limited. When
cannedvegetablesmustbeused,providersshouldbedirectedtochooselowsodiumversions.
Fruitcanbefresh,frozen,orcanned,butcannedfruitsshouldbelimitedtothosepackedin
100%juice,extralightsyrup,orlightsyrup.
Grains
The USDA has proposed requiring that at least one grain serving per day, across all eating
occasions,bewholegrainorwholegrain‐rich.Thisproposalisastepforwardovercurrent
requirements,butitdoesnotgofarenough.TheAgencyshouldrequirethatatleasthalfofall
grainsbewholegrainsorwholegrain‐rich.The2010DietaryGuidelinesforAmericans,the
2015DietaryGuidelinesAdvisoryCommitteeReport,andAHA’sdietaryrecommendationsall
recommendthatpeopleconsumeatleasthalfoftotalgrainsaswholegrains.Dietshighin
wholegrainsandfiberhavebeenassociatedwithincreaseddietqualityanddecreasedriskof
cardiovasculardisease.
To help providers select whole grain foods, the USDA should provide specific examples of
foodstoservesuchas100%wholewheatbread,brownrice,rolledorsteel‐cutoats,orfoods
labeled“100%wholegrain.”TheAgencyshouldalsoprovideguidanceonlabelreading,such
ashowtochoosewholegrainitemsthatarenothighinaddedsugars.Werecommendthe
followinglanguagecurrentlyusedonaUSDAwellnesstipsheet:“Checktheingredientlistof
whole‐grain‐richproductsforaddedsugars.Lookforsugar,honey,andingredientsendingin
4DietandLifestyleRecommendations:AScientificStatementfromtheAmericanHeartAssociationNutrition
Committee;2006.
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“‐ose.”Ifpresent,makesuretheyarenotoneofthefirstthreeingredientsontheingredient
list.”5
Providerswillalsoneedassistanceidentifyinggrain‐baseddesserts.Westronglyagreewith
theAgencythatgrain‐baseddessertsshouldnotcounttowardthegrainsrequirement,butit
isunclearwhatwouldqualifyasagrain‐baseddessertintheCACFP.AHArecommendsthat
the USDA provide a simple definition that will be easy for providers to understand and
implementsuchasthefollowing:
Grain‐baseddessertsincludegrain‐basedfoodswithaddedsugarssuchascakes,
cookies,pies,sweetrolls,pastries,donuts,candy,andready‐to‐eatbreakfastcereals
withmorethansixgramsofsugarperserving.
We caution the Agency against using the same definition for grain‐based desserts that is
currentlycontainedinaQuestionandAnswerdocumentontheSchoolMealsfinalrule.6That
definitionisdifficulttointerpretandapply.
MeatandMeatAlternatives
AHAsupportstheproposaltoallowameat/meatalternativeatbreakfastinlieuofuptoone‐
half of the grains requirement, and the proposal to add tofu as a credited meat/meat
alternative.
Cheeseisalsolistedasanacceptablemeatalternative,butunlikemeat,whichisdescribedas
“lean”,thereisnoindicationastowhattypeofcheesecanbeserved.Providersshouldbe
encouragedtousereduced‐fatorlowfatandlowersodiumcheeses.
FluidMilk
Intheproposedrule,theUSDArequestscommentonwhetheritshouldprohibitorlimitthe
servingofflavoredmilktochildrentwothroughfouryearsofage.AHAstronglyurgesthe
Agency to adopt “Alternative A1” and prohibit serving flavored milk to this age group.
Flavoredmilkcontainsaddedsugarsandisgenerallyhigherincaloriesthanitsunflavored
counterparts
5BuildaHealthyPlatewithWholeGrains:NutritionandWellnessTipsforYoungChildren:Provider
HandbookfortheChildandAdultCareFoodProgram.
http://www.fns.usda.gov/sites/default/files/whole_grains.pdf
6SP10‐2012(v.8).Questions&AnswersontheFinalRule,“NutritionStandardsintheNationalSchool
LunchandSchoolBreakfastPrograms”.April4,2014.http://www.fns.usda.gov/sites/default/files/SP10‐
2012v8os.pdf
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counterparts.Childrenwhodrinkflavoredmilkalsohavelowerintakesoffolate,vitaminA,
andvitaminC,andhigherintakesoftotalcaloriesandpercentofenergyfromsaturatedfat.7,8,9
Children should instead be served low‐fat or fat‐free unflavored milk or a nutritionally
equivalentnon‐dairybeverage.
We also recommend that the Agency extend the ban on flavored milk to include children
betweentheagesoftwoandfiveyearsold.Manyfiveyearoldsarestillinfulltimedaycare
becausetheirbirthdays–andeligibilitytostartkindergarten–occurlaterintheschoolyear.
Foreaseofimplementation,allpreschoolchildren,includingfiveyearolds,shouldhavethe
sameflavoredmilkstandard.
TheUSDAshouldalsolimittheamountofsugarallowedinflavoredmilkservedtoschool‐aged
children and adults. We strongly recommend adopting “Alternative B1” requiring that
flavoredmilkcontainnomorethan22gramsofsugarpereightfluidounceserving.Unlike
AlternativeA1above,wedonotrecommendmodifyingtheagegroup,butratherkeepingitat
five years of age and older. We recognize that five year olds will be represented in both
settingsdependingonthetimingofwhentheyenterkindergarten.Ifmixedagegroupsare
togetherinthesamefacility,werecommendthestrongerstandardbefollowed.
Yogurt
TheUSDAhasalsorequestedcommentsonwhetheritshouldlimittheamountofsugarsin
yogurt.Westronglysupport“AlternativeC1”whichwouldrequirethatyogurtmeetasugar
standard.However,weareconcernedthattheproposedsugarstandardofnomorethan30
gramsofsugarpersixounceservingistoohigh.Veryfewproductsonthemarket(eventhose
withcandyandcookiesinthem)wouldbedisallowedbya30gramstandard.Forcomparison,
30gramsofsugarismoresugarthananeightounceservingoffull‐caloriesoda,1018grams
(4.5teaspoonsor72calories)ofwhichareaddedsugars.Thisissignificantlymoreadded
sugarsthanwhatistypicallyaddedtootherallowabledairyproductssuchasflavoredmilk(2
or2.5teaspoons).TheAgencyshouldlowertheexemptiontonomorethan20gramspersix
ounces.Manyreasonably‐pricedyogurtsonthemarkettodaymeeta20grampersixounce
standard.
77KranzS,LinPJ,WagstaffDA.Children'sdairyintakeintheUnitedStates:toolittle,toofat?JPediatr.
2007;151:642‐6.
8NicklasTA,O’NeilCE,FulgoniVL.TheNutritionalRoleofFlavoredandWhiteMilkintheDietsofChildren.J
SchHealth.2013;83:728‐33.
9MurphyMM,DouglassJS,JohnsonRetal.Drinkingflavoredorplainmilkispositivelyassociatedwith
nutrientintakeandisnotassociatedwithadverseeffectsonweightstatusinUSchildrenandadolescents.J
AmDietAssoc.2008;108:631‐9.
108ounceservingofregularCokecontains27gramsofsugar.8ounceservingofregularPepsicontains28
gramsofsugar.
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WealsorecommendthattheAgencyclarifythatyoungerchildrenwhowillreceivesmaller
servingsofyogurtshouldbeservedyogurtwithproportionallylesssugar.Forexample,no
morethan14gramsofsugarperfourounceservingofyogurtandnomorethan7gramsof
sugarpertwoounceserving.
FoodPreparation
WeappreciatetheAgency’sattempttodecreasetheamountoffriedfoodservedbyCACFP
providers; we agree that it is an important goal. Fried foods are generally high in fat and
calories,andtendtobeheavilysalted.Friedfoodsarealsoassociatedwithanincreasedrisk
ofType2diabetes,highbloodpressure,heartattack,andobesity,andaccordingtoarecent
study,maybeassociatedwithahigherriskofheartfailure.11
We are concerned, however, that the Agency’s proposal to prohibit providers from frying
onsiteisunlikelytohaveasignificantimpactifprovidersarestillallowedtoservepurchased
foods that are pre‐fried, flash‐fried, or par‐fried by the manufacturer. Based on AHA’s
experience with CACFP providers, most do not fry foods onsite; they purchase and reheat
foodsthatwerealreadyfried.Becausefoodsfriedoffsitewouldstillbeallowed,theproposed
rulewillhavelittleimpactoncurrentpractice.
Todecreasetheuseoffriedfoods,theAgencyshouldlimithowoftenallfriedfoods,including
thosepre‐fried,flash‐fried,orpar‐friedbythemanufacturer,canbeserved.Werecommenda
limitofnomorethanoncepertwoweekmenucycle.IftheAgencyfeelsthiswouldbetoo
restrictive,alimitofnomorethanonceperweekshouldbeconsidered.Eitherstandardwould
stillbemoreliberalthantheHealthyWaytoGrowbestpracticewhichonlyallowsfriedorpre‐
friedvegetables(e.g.,frenchfries,tatortots,hashbrowns)andmeats(e.g.,chickennuggets,
fishsticks)lessthanoncepermonth.WhateverlimittheAgencyselectsshouldbeadoptedas
arequirement,notabestpracticeascurrentlyproposed.
Inaddition,theUSDAshouldprovideacleardefinitionsfor“frying”and“friedfoods”inthe
finalrule,asthereissomeconfusionamongproviders.Forexample,friedandpre‐friedfoods
suchaschickennuggetsarecommonlyservedbyCACFPproviders,yetmanyprovidersdonot
considerthemtobefriedfoods;insteadreferringtothemasbreadedproducts.Toalleviate
thisconfusion,theAgencyshouldclarifythat“frying”includesdeep‐fatfryingorimmersing
foodsintohotoiloranotherfat,andthat“friedfoods”includesbreadedproductsthatarefried
atanypointduringthemanufacturingorpreparationprocess.
TheAgencyshouldalsoprovidetechnicalassistancetohelpproviderslimittheuseoffried
foods. We recommend promoting healthier cooking techniques such as baking, sautéing,
broiling,searing,andstir‐frying.Guidanceshouldalsorecommendmovingawayfromcooking
withtropicaloilsorsolidfats,highinsaturatedfat,andtowardhealthiervegetableoils.
11L.Djousse,etal.AbstractP382:FriedFoodConsumptionisAssociatedwithaHigherRiskofHeartFailure
amongUSMalePhysicians.AmericanHeartAssociationEPI/LifestyleConference2015.See
http://circ.ahajournals.org/content/131/Suppl_1/AP382.
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Providers should also be encouraged to replace fried items with non‐fried alternatives or
revamp the menu to feature non‐breaded items such as serving refrigerated chicken strips
instead of frozen chicken nuggets. We have found that these tips help child care centers
participatingintheHealthyWaytoGrownprogramsuccessfullyreducethefrequencywith
whichfriedandpre‐friedfoodsareserved.
BestPractices
Accordingtotheproposedrule,theUSDAproposedlimitedchangestotheCACFPmealpattern
becauseofconcernaboutincreasedcoststoproviders.Consequently,theAgencyhasincluded
anumberof“bestpractices”orrecommendationsintheproposedrulethatproviderswould
beencouragedtoimplement,butwouldnotbepenalizedforfailingtomeet.
We understand the Agency’s concern about increasing costs for providers, however, we
believe that providers could implement some of the best practices with no or minimal
additional cost. For example, the Agency has included serving only unflavored milk to all
participants, regardless of age, as a best practice for CACFP providers. Purchasing only
unflavoredmilkwouldnotresultinacostincrease.Ortherecommendedbestpracticetomake
atleastoneofthetworequiredcomponentsofeverysnackafruitorvegetable.Acomparison
of20fruitsandvegetablesversus20commonsnackfoodssuchascookies,chips,pastries,and
crackersfoundthattheaveragepriceperportionoffruitsandvegetableswaslower(31cents)
andhadfeweraveragecalories(57calories)thansnackfoods(33centsand183calories).12
TheUSDAshouldconsiderchangingthesebestpracticesintorequirements.
The USDA should also, for the reasons discussed previously, change the following best
practicesintomandatoryrequirements:
 Limitingtheconsumptionoffruitjuicetonomorethanoneservingperday
 Providingatleastoneservingeachofdarkgreenvegetables,redororangevegetables,
andlegumesperweek
 Providingatleasttwoservings(orhalfofallservings)ofwholegrain‐richgrainsper
day
The Agency should also adopt the following sugar limits for fluid milk and yogurt as
requirements,notbestpractices:
 ModifiedAlternativeA1prohibitingservingflavoredmilktochildrentwotofiveyears
old
 Alternative B1 requiring flavored milk contain no more than 22 grams of sugar per
eightounceserving
 ModifiedAlternativeC1requiringthatyogurtcontainnomorethan20gramsofsugar
persixounceserving
12MozaffarianD,etal.AmericanHeartAssociationStatisticalUpdate:HeartDiseaseandStrokeStatistics–
2015Update.Circulation.2015;131:00‐00.
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MiscellaneousChanges
RewardsandPunishments
Wesupporttheproposaltoprohibittheuseoffoodasapunishmentorreward.Manychild
care resources recommend not using food as a punishment or reward in the child care
setting. 13 , 14 , 15 A wide variety of alternative rewards can be used to provide positive
reinforcement for children’s behavior such as praise or encouragement, stickers, extra
physicalactivitytime,etc.
Providing food based on performance or behavior links food to mood. This practice can
encouragechildrentoeattreatsevenwhentheyarenothungryandcaninstilllifetimehabits
ofrewardingorcomfortingthemselveswithfoodbehaviorsassociatedwithunhealthyeating
orobesity.
Theprohibitionofusingfoodasapunishmentshouldextendtophysicalactivityaswell.Given
the high rates of obesity and chronic diseases among Americans, we should not take away
children’sopportunitiestobephysicallyactive.
Water
We support the proposed requirement that providers make drinking water available to
childrenthroughouttheday.USDAshould,however,clarifythatsafe,freshdrinkingwater
shouldbeavailableandaccessibleforchildrentoservethemselvesatalltimes,bothindoors
andoutdoors.Childrenshouldnothavetorequestwaterfromtheprovider;watershouldbe
freelyavailableandchildrenshouldbeencouragedtodrinkit.Providersalsoshouldserveas
rolemodels,drinkingwaterthroughoutthedayinsteadofdrinkingbeveragessuchassoda,
fruitdrinks,andsportsdrinksthatarehighinaddedsugars.
Family‐StyleMeals
We are pleased that the proposed rule addresses family‐style meal practices. Family‐style
mealsallowchildrentoservethemselves,orservethemselveswithanadult’shelp,controlling
theamountoffoodontheirplate.Thishelpschildrentolearnaboutportionsize,hungerand
fullnesscues,andself‐servingskills.TheAgencyshouldencourageproviderstoincorporate
family‐stylemealpracticesintotheirprograms,includingpromotingtheresourcesontheLet’s
Move!ChildCarewebsite.
13AmericanAcademyofPediatrics,AmericanPublicHealthAssociation,andNationalResourceCenterfor
HealthandSafetyinChildCareandEarlyEducation.PreventingChildhoodObesityinEarlyCareand
Education:SelectedStandardsfromCaringforOurChildren:NationalHealthandSafetyPerformance
Standards;GuidelinesforEarlyCareandEducationPrograms,3rdEdition;2010.
14NationalResourceCenterforHealthandSafetyinChildCareandEarlyEducation,UniversityofColorado
Denver.NationalResourceCenterforHealthandSafetyinChildCareandEarlyEducation:AchievingaStateof
HealthyWeight:ANationalAssessmentofObesityPreventionTerminologyinChildCareRegulations2010.
Aurora,CO;2011.
15PositionoftheAmericanDieteticAssociation:BenchmarksforNutritioninChildCare.JAmDiet
Assoc.2011;111:607‐615.
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We are aware, however, that some providers are confused about the difference between
family‐stylemealpracticesandofferversusserverequirements.Insomecases,providersare
interpretingthesetwodistinctpracticesasthesamepractice.Forexample,duringfamily‐
stylemealservice,providersareuncleariftheywillstillbereimbursedforplacingfoodsthat
meet the meal pattern requirements into a serving bowl and offering for children to serve
themselvesoriftheymustservetherequiredportionsizeandplaceitonthechild’splate.This
isasignificantissuebecauseprovidersmayelectnottousefamily‐stylediningoutofconcern
thattheywillnotbereimbursed.TheUSDAshouldprovideclarificationonofferversusserve,
particularlydrawingacleardistinctionbetweenthispracticeandfamily‐styledining.
PromotingHealthandWellness
We applaud the USDA for encouraging CACFP providers to provide daily opportunities for
structured and unstructured age appropriate physical activity. Physical activity produces
overallphysical,psychological,andsocialbenefitsandshouldbeseenasacriticalcomponent
ofchildcareprograms.Tohelpprovidersincreasephysicalactivity,theAgencyshouldexplain
how physical activity can be integrated into normal daily activities and provide
recommendationsforphysicalactivityfrequencyanddurationbyage.Forexample,childcare
providersintheHealthyWaytoGrowprogramareencouragedtomeetthefollowinggoals:
InfantPhysicalActivity:
 Infantsareprovidedwithsuperviseddailytummytimewhenawake,beginningwith3‐
5minutesatatimeandincreasingasable,foratleast2timesperday,allowingthem
tomovefreelyandexploretheirsurroundings.
 Infantsareprovidedopportunitiestomovefreelythroughoutthedayandinthecontext
ofdailyroutinesinordertosupporttheirphysicaldevelopmentandmovementskills.
 Providersplayindoorswithinfantsonthefloorandoutsideonthegroundeachdayto
engageinadult‐infantinteractions.
 Outdoor play will be provided for infants at least two times daily in a safe, adult
supervisedsetting,weatherandairqualitypermitting.
 Whileawake,infantswillspendlessthan15minutesatatimeinconfiningequipment
suchasswings,bouncychairs,carseatsandstrollers.
ToddlersandPreschoolers:
 Fortoddlers:Atleast60–90minutesofactiveplaytimeareprovidedeachdayincluding
45minutesofstructured(teacher‐led)physicalactivityand45minutesofunstructured
(activeplay)time.
 For preschoolers: At least 120 minutes of active playtime are provided each day
including60minutesofstructured(teacher‐led)physicalactivityand60minutesof
unstructured(activeplay)time.
 Childrenhaveoutdooractiveplaytimeatleasttwotimesdaily,weatherandairquality
permitting.
 Providers incorporate short physical activities (10 – 15 minutes) into daily lesson
plans.
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Childrenarenotseatedforperiodslongerthan30minutesexceptwhensleepingor
eating.
Inadditiontoscheduledphysicalactivitytime,activeplayispartofstorytime,circle
time,centertime(activitystations)andmovingfromoneactivitytoanother.
Providers lead and participate in active play, such as games and activities, during
indoorandoutdoortimesetasideforphysicalactivity.
Providers encourage all children to participate in physical activity and avoid
eliminationgames.Childrenwithdisabilitiesregularlyjointheirnondisabledpeersin
physicalactivities.Structuredplayisdesignedtoaccommodatechildren’svariedskill
levels.
PlaySpaceandEquipment:
 Indoorandoutdoorplayareasmeetorexceedrecommendationsforequipmentand
space for large‐muscle activities that include running, jumping, climbing, marching,
dancing, hopping, kicking and skipping. There are fun and engaging activities for
childrenofallabilities.
 Providers interact with children and model fun ways to move and play in both
structured and unstructured physical activities, using available open space and
equipment.
WealsoappreciatetheUSDA’srecognitionthattheuseofelectronicmediashouldbelimited.
Werecommendthatchildrenundertwoyearsofagenotbeexposedtoscreentime.Among
childrentwoandolder,screentimeshouldbelimitedtonomorethan30minutesonceper
week, and only quality, educational or physical activity programming should be shown.
Providersshouldnotallowscreentimeduringmealtimesorsnacks,andscreentimeshould
notbeusedasareward.
TrainingandTechnicalAssistance
WethanktheUSDAforthetimeandresourcestheAgencyhasdedicatedtoCACFPtechnical
assistance to date. To help providers comply with the new standards, we encourage the
Agency to release its final needs assessment research report, pertinent resources, and
guidancematerialsinatimelymanner.TheAgencyshouldfocusonresourcesthataddress
foodpurchasingandpreparation,menuplanningandrecipes,andrecordkeeping.TheAgency
should also update its Food Buying Guide and the “Nutrition and Wellness Tips for Young
Children:ProviderHandbookforCACFP”.Providerswillalsoneedtechnicalassistanceand
trainingrelatedtowholegrains,flavoredmilk,yogurt,frying,family‐styleeating,andphysical
activity.Thematerialsshouldbeeasytounderstandforagenerallayaudience.
InworkingwithCACFPprovidersaspartofHealthyWaytoGrow,wehavefoundthatcenters
often benefit from interactive training and discussion around regulations, guidelines and
recommendations.USDAinvestmentincoordinatedandconsistentmessagingandtraining
for agencies, states, sponsors and CACFP providers is critical to ensuring equitable and
sustainableimplementationofthenewmealpatterns.
AmericanHeartAssociation
April15,2015
FNS‐2011‐0029
Page12
Conclusion
In closing, we reiterate our overall support for the proposed revisions to the CACFP meal
pattern requirements. The proposed standards are a much‐needed update and we look
forwardtoseeingthemfinalizedandimplementedasquicklyaspossible.
However, as discussed above, we recommend that the USDA make a number of specific
changestotheproposedstandardstofurtherimprovetheCACFPprogram.Specifically,the
Agencyshould:
 RevisethechildagegroupstomatchtheNSLP/SBP
 Establishjuicerestrictionsbyage(1‐6yearolds:4‐6oz;7‐18yearolds:8‐12oz)
 Requireatleastoneservingeachofdarkgreenvegetables,redororangevegetables,
andlegumesperweek
 Requireatleasthalfofallgrainstobewholegrain‐rich
 Provideadefinitionofgrain‐baseddesserts
 Prohibitservingflavoredmilktoyoungchildrenandexpandtheagegrouptoinclude
childrenbetweentwoandfiveyearsold
 Prohibitservingflavoredmilkwithmorethan22gramsofsugarpereightounces
 Reducethesugarlimitforyogurttonomorethan20gramspersixounces
 Expandthebanonfryingasanonsitepreparationmethodtoincludealimitonhow
oftenanyfriedfood,includingpre‐friedfoods,canbeserved
Thesechangeswillhelpbringthemealpatternrequirementsin linewithcurrentnutrition
science.
Ifyouhaveanyquestionsorneedanyadditionalinformation,pleasedonothesitatetocontact
Susan Bishop, AHA’s senior advisor for regulatory affairs, at (202) 785‐7908 or
[email protected].
Thankyouforyourconsideration.
ElliottM.Antman,MD,FAHA
President,AmericanHeartAssociation