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11.0 The Nutrition Domain
11.1 Overview
The link between health and nutrition is well recognized. Poor nutrition during childhood can have lifelong effects on the health and functioning of an individual. Nutrition problems (e.g., iron deficiency anemia) are often associated with poverty. Children from low-income families are generally found to have lower values than other children for height, weight, and triceps skinfold thickness (Rosenbaum, 1992). Poor nutrition contributes to childhood obesity in instances where low cost food, often high in fats and caloric content, is the obvious choice over no food at all. Studies of growth trends among low-income children have provided some mixed results and suggest the need for targeted research in this area.
The Second National Health and Nutrition Examination Survey (NHANES II) data indicated that low-income children (ages 6 months to 10 years) have a greater prevalence of low height for age; however, these children were not more likely to be overweight than children from middle-class families (Yip, Scanlon & Trowbridge, 1993). However, data on low-income, school-age children and adolescents included in the Center for Disease Control and Prevention's Pediatric Nutrition Surveillance System indicate that they had a greater prevalence of obesity than their counterparts in the middle-class population (Yip et al., 1993).
Head Start plays a significant role in working with families to ensure that children receive nutrition screenings and treatments when necessary. The Head Start program requirements for nutrition screenings and services are detailed in the Program Performance Standards (§1304.3-10). The Standards list the main nutrition objectives as the following:
- Promote physical, emotional, and social growth and development through the provision of food;
- Use feeding situations for educational purposes;
- Educate children, families, and staff on the relationship between nutrition and health, and on the development of sound nutritional habits;
- Demonstrate the impact of nutrition on other Head Start program activities and on overall child development; and
- Engage parents, staff, and the community in identifying the nutritional needs of Head Start children and their families.
These goals are met through nutrition assessments (height, weight, hemoglobin/hematocrit), the collection of information on individual child and family eating habits, and assessments of community nutrition needs.
In order to assure a degree of good nutrition for enrolled children, the Program Performance Standards also require that children in part-day programs receive meals and snacks which provide at least one third of the children's daily nutrition needs. For children attending full-day programs, the required proportion increases to between one half and two thirds of the daily nutritional needs. Meals are also expected to contribute to the overall socialization experience of the children. The Standards require that if the nutrition services are not overseen by a qualified nutritionist, that one be used to provide an ongoing review of the meals and nutrition services provided by the program.
The prevalence of each nutrition-related health condition noted among children in the study sample, both in the parents' reports and in the child health files, are presented in this chapter. Subsequent to the findings of the nutrition screenings, the Program Performance Standards require that Head Start programs provide or arrange for treatment where necessary (§1304.3-4), much as they do when conditions are noted within the other health domains.
11.2 Findings
In this chapter, percentages based on data from the parent interviews and the reviews of the child health files are presented as weighted estimates (see Chapter 3: Methodology), unless noted otherwise. Percentages using the Nutrition Coordinator's interviews are reported unweighted.
11.2.1 Screenings
Of the 39 Nutrition Coordinators who completed an interview, 87.2% reported that children enrolled in their Head Start Program received individual nutrition screenings, although such screenings are not required by the Program Performance Standards. It was not indicated whether all children served by these Nutrition Coordinators received such screenings.
Staff Reports. Exhibit 11-1 lists nutrition-related screening tests and whether or not they are included as part of each child's physical examination as reported by the Health Coordinators. Since it was possible for the Health Coordinators to answer that the screening tests were both part of the initial physical examination and provided separately, the categories in Exhibit 11-1 are not mutually exclusive. Virtually all the programs collect height and weight measurements and hemoglobin/hematocrit results.
11.2.2 Conditions
The nutrition conditions reported in this section are those which parents reported had been identified during the initial screenings or examinations required for entry into Head Start, and through subsequent tests that were not part of the initial screening or examination. The child health files were a second source of information on nutrition conditions.
| Percent | |||
|---|---|---|---|
| Test Is Part of the Physical Examination | Test Is Provided Separately From Physical Examination | Test Is Not Provided At All | |
| Height and Weight Measurement |
76.2 | 38.1 | 0.0 |
| Hemoglobin/Hematocrit Testing | 73.8 | 31.0 | 7.1 |
| Note: N=42 Health Coordinators. Health Coordinators could report tests being both part of the initial physical examination and as subsequent screening tests. | |||
Parent reports of medical problems included several health conditions related to nutrition. Obesity was mentioned for 1.3% of the children, being underweight was noted for 0.8%, and general nutrition concerns were reported by 3.7% of the parents. On the Head Start Child Health Record, the nutrition section includes a review of the child's status concerning nutrition. A summary of these status reports is included in Exhibit 11-2. The most reported nutrition concern in the health files was the suspicion of dietary problems or inadequate food intake, but this was noted in a relatively small percentage of records (5.3%).
While the percentages for these conditions were low (all criteria were noted for about 5% or less of the children), programs not using the updated Head Start health forms for data management often did not have space to specifically note nutrition conditions. Therefore, nutrition-based conditions may be under-reported in the child health files. However, note that these conditions, in contrast to medical and dental conditions, were reported more frequently in the health files than by the parents.
| Criteria for Referral | Unweighted n |
Weighted Percent |
|---|---|---|
| Suspicion of Dietary Problem or Inadequate Food Intake | 67 | 5.3 |
| Hemoglobin Less Than 11 Grams or Hematocrit Less Than 34% | 46 | 3.9 |
| Overweight | 35 | 3.0 |
| Weight for Height Greater or Less Than Typical | 31 | 2.6 |
| Underweight | 28 | 2.2 |
| Short for Age | 18 | 1.5 |
| N | 1,189 | |
| Note: The categories are not mutually exclusive | ||
11.2.3 General Status
Height and Weight. Height and weight measurements are often indicative of the physical and nutritional health status of children, and should be regularly assessed according to the health guidelines of the Program Performance Standards. Many programs maintained height and weight records on growth charts similar to those found in the Head Start Child Health Record (1992 version). Height charts were found for 65.0% of the children, weight charts for 64.5%, and height by weight charts in 54.2% of the files. The mean height for the children was 41.0 inches (standard deviation (sd) = 3.2 in), and the mean weight was 39.0 lbs (sd = 7.7 lbs). Comparisons with national standards indicate that 10.2% and 11.6% of the Head Start children were above the 95th percentile for height (by age) and weight (by age), respectively. Further comparisons show that 6.7% of the children were below the 5th percentile for height (by age) and that 5.3% were below for weight (by age). There were 11.2% children above the 95th percentile for weight by height, while 3.8% were below the 5th percentile.
Hematocrit/Hemoglobin Screenings. Hematocrit and hemoglobin screening test results are presented in Exhibit 11-3. According to the child health files, 44% of the children had a hematocrit and 36% had a hemoglobin test to screen for anemia. The remaining 19% either had no test or had a test that was not recorded in the child's health file. The mean hematocrit was 36.5%, with 11.5% of the children having a hematocrit less than 34%. For hemoglobin, the mean was 12.7 grams, and 8.4% of the children had a hemoglobin level less than 11 grams. Low levels are usually indicative of children requiring nutrition screenings and services. However, data were not typically available to determine whether the children with these low levels received nutrition screening and services.
| Children Who Had Test Performed |
Test Results | Tested Children with Undesirable Levels* | |||
|---|---|---|---|---|---|
| Type of Screening Test |
Unweighted n |
Weighted Percent |
Mean | Unweighted n |
Weighted Percent |
| Hematocrit | 506 | 44.0 | 36.54% | 58 | 11.5 |
| Hemoglobin | 447 | 36.0 | 12.68 grams | 37 | 8.4 |
| *Hematocrit less than 34%, Hemoglobin less than 11 grams. | |||||
11.2.4 Treatments
As noted, nutrition conditions and treatments were reported during the parent interviews as part of the questions asked about medical conditions and treatments. Parents were asked what treatments were recommended for identified health conditions and the status of these treatments (completed, in progress or ongoing, not stated, or did not seek treatment). Conditions and treatments also were available from the child health files, but there were no parallel questions between the parent reports and the health files that can be compared. Identified nutrition-related conditions reported by the parents included being underweight and having digestive problems or eating problems. It was not possible to identify treatments specific to these nutrition problems or to determine the status of these treatments, except for nutritional or dietary alterations. Such alterations were recommended for 10.9% of the treatments resulting from the initial examination, for 12.9% of the conditions identified during subsequent tests, and for 5.5% of the conditions reported in child health files. In reviewing the treatments mentioned by the parents, it was not clear which type of dietary alterations were for which specific nutrition conditions, therefore, adherence with these specific treatments could not be determined.
When children needed nutrition services, over half of the Nutrition Coordinators reported that they most frequently used cooking activities (69.3%), dietary restrictions (69.2%), diet management (53.8%), and parent education (51.3%) as methods for meeting these needs (see Chapter 6: Health Education).
11.2.5 Head Start Meals
The meals and snacks provided at Head Start serve a variety of purposes. Beyond meeting nutritional needs through the provision of healthful foods, the Program Performance Standards also direct staff to use meals to integrate education and socialization opportunities (§1304.3-10) into the classroom routine. Meals provided the research staff in this study with an opportunity to observe nutrition education across all of the study sites. The education activities associated with Head Start meals were discussed earlier in Chapter 6: Health Education.
It was observed that meals provided a great opportunity for exchanging nutrition information with the children, and that children took an active role in activities around the meals (e.g., washing hands, setting the tables).
Head Start staff were observed sitting with the children for 97.2% of the meals, and 87.6% of the time they ate with the children. This suggests an excellent opportunity for staff to offer nutrition information to the children. Usually through family style service, children had a hand in serving themselves 68.4% of the time. At 61.4% of the meals, staff were observed providing children with information about the foods on the table. Children were encouraged to take the available foods 74.6% of the time, and were encouraged by staff to taste specific foods at 77.7% of the meals. Classroom discussions about the meals were observed 36.4% of the time. While nutritional content is another important issue to be assessed, the measurement of this aspect of the meals was beyond the scope and resources of this study. Currently, the nutritional content of Head Start meals is being studied by Abt Associates under contract a with the United States Department of Agriculture (USDA) (The Early Childhood and Childcare Study, USDA, Contract Number 53-3198-3-018).
11.3 Summary
Activities related to the provision of nutrition screenings provided or arranged for by Head Start programs were reported. The highlights of responses are presented below.
- Almost 90% of the Nutrition Coordinators reported that all children enrolled in Head Start received individual nutrition screenings.
- Nutrition summaries were available in some of the child health files. Approximately 5% of the children were described as being in need of nutrition services. Very few parents (less than 5%) reported their child being obese or
- underweight as a health condition.
- Meals were observed to provide an excellent opportunity for teaching children
about nutrition. At least one hot meal is required each day
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