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Preschool lessons

With child obesity rates climbing, day-care centers help shape eating and exercise habits

By Nancy Reardon Stewart
Globe Correspondent / September 26, 2011

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Diana Alexander wants her 2-year-old to know that peaches aren’t plucked from the tree in light syrup and chicken isn’t always served in nugget form or wrapped in a tortilla with cheese.

But the Framingham mother of two boys, ages 2 and 5, also works full time. She sends her youngest to a local day-care center that serves breakfast, lunch, and two snacks and, like many programs, prohibits outside food.

That means at least two-thirds of his daily calories are eaten outside the home - and away from parental control.

“Sugar and syrup drive me insane,’’ said Alexander. “Maybe a plain old chicken breast instead of nuggets or bean burritos?’’

When parents work outside the home, caregivers often have a large role in forming young children’s eating habits and food preferences, as well as promoting exercise and healthy activity levels.

About 63 percent of the 21 million American children under age 5 are in some form of day care and spend about 29 hours a week there, according to the 2010 US Census. At the same time, the US Centers for Disease Control and Prevention estimates that one in seven low-income preschoolers is obese, as well as 17 percent of all children and adolescents.

While most anti-obesity campaigns are aimed at educating families on how to buy and prepare healthier foods, two recent studies have called for a secondary focus: early child-care providers.

A report published this month in the Journal of the American Dietetic Association found lax standards in place for nutrition and exercise in child-care settings across the country and huge differences among states, which set and enforce their own regulations.

Researchers from the Duke University Medical Center and the public health schools at the University of Minnesota and University of North Carolina assessed 42 studies on anti-obesity efforts, which included reviews of state regulations and child-care practices.

They found that in general, American children in child care are too sedentary and are not getting enough nutrients, even when served a variety of foods.

“Eating and activity behaviors formed during the preschool years have the potential to prevent obesity in the short term and, if carried into adulthood, to set the stage for a lifetime of better health,’’ the research team wrote.

In Massachusetts, licensed child-care providers - including private and nonprofit centers, in-home day cares and preschools - must follow two regulations aimed at obesity prevention: Provide one hour of physical activity every six hours, and follow US Department of Agriculture guidelines, which say meals should include fruits and vegetables, lean protein, whole grains, and low-fat dairy.

“Massachusetts generally ranks on top. That being said, the bar is pretty low on this issue,’’ said Linda Smith, executive director of the National Association of Child Care Resource and Referral Agencies, or NACCRRA, a Washington, D.C.-based advocacy group that published its own report earlier this year on obesity prevention in child care.

The state’s standards for children in day care, however, are not as stringent as those now in place for public school students, which are considered to be the strictest in the nation and ban fried foods, sugary beverages, and foods high in sodium and saturated fat.

That means toddlers can eat french fries for lunch, but high school freshmen cannot.

Sherri Killins, commissioner of the state Department of Early Education and Childcare, said there are no plans right now to extend those rules to day-care programs.

Early child-care providers, she said, “must meet USDA guidelines and be trained on them. That’s what we picked as our standard. . . . We don’t name foods in or out.’’

According to the Partnership for a Healthier America, a nonprofit aimed at obesity prevention, 12 other states explicitly limit unhealthy foods in day care.

Interviews with parents and day-care providers found the USDA guidelines are open to broad interpretation. Pancakes and French toast sticks counted as whole grains for breakfast. Some lunches recently served included hot dogs and french fries, pizza, fish sticks, and macaroni and cheese. Most included fruits or vegetables on the side.

Suzanne Rostler, a registered dietitian for the Optimal Weight for Life Program at Children’s Hospital Boston, said eating fruits and vegetables is important at a young age.

“Eating a diet that is high in sugar and refined starch can train the palate from a very young age to accept only these tastes,’’ Rostler said. “In these cases, vegetables become bitter and very unacceptable for children, and as they get older it’s harder and harder for them to eat healthy.’’

The clinic is seeing children as young as 2 who are morbidly obese and showing risk factors for developing type 2 diabetes, she said.

The challenge is balancing the need to serve healthy meals and offering foods that kids will actually eat.

Mildred Kelley, who runs a day-care program out of her Quincy home, said if she serves carrot sticks or celery, she ends up tossing them out.

“What toddler you know wants carrots and celery sticks for their snack?’’ she said.

Recent lunches she served included mini burgers one day and chicken nuggets another, with french fries and corn on the side both days.

KinderCare - which operates 65 day-care and preschool centers in Massachusetts - serves its meals family-style and encourages students to help themselves not only to the beefy mac and cheese, but also the green beans on the side, said Carly Dunn, national dietitian for the chain.

“The meals should be a whole experience,’’ Dunn said. “You sit down with your friends, with your classmates and your teacher. You slow down, look at the food, taste the food. . . . It’s meant to promote good eating habits.’’

Still, Dunn added, the side vegetable isn’t always the most popular dish on the table. And getting kids to eat fruits includes offering those peaches served in light syrup.

Many day-care providers said introducing fruits and vegetables to children in their care has become an uphill battle.

Siobhan McHugh, who runs a day care in her Brighton home, makes it a personal goal to introduce her children to eating four fruits and two vegetables every day as part of their regular overall diet.

“In the last six years, I have seen a lot of kids who have no idea what vegetables look like,’’ said McHugh. “I’ve put out celery and kids don’t know what it is.’’

Experts say promoting good eating habits must be a partnership, with parents and providers getting more education and, if they are low-income or serve low-income children, receiving more federal assistance. Smith, of the National Association of Child Care Resource and Referral Agencies, said federally subsidized programs like the Child and Adult Care Food Program, which reimburse some caregivers for serving nutritious food to low-income children, should be expanded. But the roadblock there is funding.

In Massachusetts, Killins said her department is working with the Department of Public Health to train child-care workers in better practices for physical activity and nutrition planning at programs with 50 percent or more low-income children. Since January 2010, 21 workers at 105 programs have been trained. The goal is to reach 226 in total over the next few years.

The state, however, has over 3,000 centers and more than 8,000 licensed in-home day cares.

In the end, Killins said, the problem boils down to two issues: access to high-quality food and the ability to prepare it in ways that children will eat.

“There’s a huge interest in the field,’’ Killins said. “Do we need to do more policy to encourage more of it? I’m not sure. We need to make it affordable.’’

Nancy Reardon Stewart can be reached at

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