Assessment Highlights Health Gains, State Opportunities in Child Care Nutrition

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Only about 5 percent of health impact assessments in the United States have examined federal policies, partly due to challenges in studying national programs. The Kids’ Safe and Healthful Foods Project, a collaboration between the Robert Wood Johnson Foundation and The Pew Charitable Trusts, broke ground with a report it released last month that analyzed the effects of proposed nutrition standards for the government’s Child and Adult Care Food Program (CACFP). Overseen by the U.S. Department of Agriculture, CACFP funds meals and snacks served to more than 4 million young children. The Health Impact Project spoke with Sallyann Bergh and Mimi Majumdar Narayan, two Pew researchers who led the assessment, about the lessons it offers the field.

Q. Why did you choose to examine the USDA’s proposal with a health impact assessment (HIA)?

Bergh: Past HIAs have demonstrated the value of this tool to inform federal policies and ensure that health is considered in decision-making. For example, in 2012, a USDA rule that updated nutrition standards for school snacks and beverages cited findings from an HIA.

The proposed CACFP changes presented a similar opportunity. The project team determined that an HIA could help to illuminate for the USDA the potential health benefits for kids; different perspectives among the families and providers participating in the program; and likely effects on various groups served by CACFP, such as children of color and those living in food-insecure households.

Q. When changes are made to a federal program, differences in state policies can shape the effects. Can you explain the challenges that this posed in evaluating the impact of the updated CACFP rule?

Narayan: Characterizing the impact of a federal policy change can be extremely difficult when you have to consider how it could interact with regulations and other decisions at the state level. Our analysis had to contend with these challenges because states typically have their own nutrition standards for licensed child care providers who serve food, which can be linked to CACFP’s.

We examined whether and how each state and the District of Columbia has aligned its policies with the CACFP. In states that automatically update their nutritional requirements to reflect higher CACFP standards, some child care providers who do not participate in the federal program will nonetheless serve healthier meals and snacks—extending the health benefits to more kids. Based on these findings, we assert that states have a tremendous opportunity to improve children’s nutrition by aligning nutrition requirements in licensing rules with CACFP standards. (For more details, see the “Effects on state early care licensing regulations” section of the report.)

Q. This research also analyzed how child care providers’ food costs could change under healthier nutrition standards. Did that part of the research yield lessons for future assessments that aim to quantify cost effects?

Narayan: Cost analyses are often a struggle for HIAs due to conflicting or scarce financial data, and we encountered those limitations with CACFP. Through our literature review and stakeholder interviews, we found that some CACFP providers were serving foods in line with or above the new standards prior to the USDA’s proposal. Therefore, we constructed a cost simulation to demonstrate how specific changes in the rule could influence a provider’s costs. The simulation offers a dollars-and-cents perspective that CACFP officials and other policymakers can easily grasp, though, as the report cautions, they should keep in mind that the costs are not representative of all providers’ experiences.

As HIA practitioners consider conducting cost analyses for future work, we encourage them to first understand the available data they have to work with and to consider the value the potential results will bring to the policy decision at hand.

Q. A central premise of the HIA process is to engage stakeholders at every step. When conducting an HIA that analyzes federal policy, are there specific challenges and opportunities that practitioners are likely to encounter or should consider in this regard?

Bergh: Although it can be challenging given the vast geographic scale that federal policies reach, stakeholder engagement can add tremendous value to the decision-making process by grounding the assessment in the lives of people directly affected by the proposed policy.

In this case, we wanted to better understand the views of participating programs and families in different parts of the county, the cultural diversity of foods that providers may choose to serve, the availability of healthy foods and barriers to accessing them, the economic status of providers and other variables. We used a range of data collection methods, including three in-depth case study visits, focus groups, and one-on-one key informant phone interviews to capture this information.

Through this mixed-methods approach, we communicated with stakeholders at all levels of the implementation process, including parents of children served by CACFP. Though not representative of all individuals who will be affected by the policy change, engaging these diverse groups provided important insights on the program and proposed rule, and informed our findings and recommendations. (For more details on our stakeholder engagement process, see the report’s methodological supplement.)

Q. Ideas for how to monitor and evaluate the reviewed policy or program are a core element of health impact assessments. What opportunities for further research were identified for CACFP?

Narayan: The evaluation component of any HIA typically has three elements: process, impact, and outcome. As described in our methodological supplement, our research offers opportunities for interested stakeholders and HIA practitioners to build on this study. These include tracking state policies that incorporate our recommendations and determining whether stakeholders identified in the report adopted any of the implementation recommendations.

Our analysis also shows the value that CACFP can have on the short- and long-term impacts on children’s health. We encourage the USDA or another organization to monitor the number of providers that participate in CACFP, the number of children they serve, and any changes directly or indirectly associated with improved nutrition standards. Additionally, continued research around state early care licensure is a ripe arena in need of monitoring that could lead to the development of an advocacy platform that encourages CACFP as the nutritional standard of choice as part of state licensure.