Supporting Statement A

This information collection is being conducted using the Generic Information Collection mechanism of the OSTLTS OMB Clearance Center (O2C2) – OMB No. 0920-0879. The respondent universe for this information collection aligns with that of the O2C2. Data will be collected from 51 Early Care and Education (ECE) state coordinators within each State Health Department across all states and the District of Columbia (see Attachment A — List of health departments by state). Data will also be collected from 51 State Child and Adult Care Food Program directors (CACFP) located within each state and the District of Columbia for a total of 102 respondents. The organizational affiliation of the 51 CACFP Directors vary by state. Directors are affiliated with the Department of Education, Department of Health and Human Services, Department of Agriculture, or Department of Early Learning or Children (see Attachments B and C — Map of CACFP administering agency by state and List of CACFP administering agency by state)

This information collection is authorized by Section 301 of the Public Health Service Act (42 U.S.C. 241). This information collection falls under the essential public health services⁹ of #5 the development of policies and plans that support individual and community health efforts and #9 evaluating effectiveness, accessibility, and quality of personal and population-based health services

1. Monitoring health status to identify community health problems

2. Diagnosing and investigating health problems and health hazards in the community

3. Informing, educating, and empowering people about health issues

4. Mobilizing community partnerships to identify and solve health problems

5. Development of policies and plans that support individual and community health efforts

6. Enforcement of laws and regulations that protect health and ensure safety

7. Linking people to needed personal health services and assure the provision of health care

when otherwise unavailable

8. Assuring a competent public health and personal health care workforce

9. Evaluating effectiveness, accessibility, and quality of personal and population-based health

services

10. Research for new insights and innovative solutions to health problems¹

Childhood obesity is a serious national problem that affects children of every age in communities across the United States. Approximately 23% of children aged 2-5 years are overweight or obese ². The health consequences of childhood obesity are serious and children who are obese are more likely to have dyslipidemia, impaired glucose tolerance/type 2 diabetes, fatty liver disease, breathing and joint problems ³. They can also experience social and psychological problems such as stigmatization and poor self-esteem ³. Studies indicate that those who are overweight or obese in childhood and adolescence are more likely to be overweight in adulthood⁴. For example, a recent study in the New England Journal of Medicine found that children who were overweight in kindergarten were four times as likely as their normal-weight peers to be obese in 8^th grade. ⁵ These statistics underscore the importance of obesity prevention efforts targeting our nation’s youngest children. CDC’s Division of Nutrition Physical Activity and Obesity (DNPAO) is committed to improving the health of all children through healthy eating, physical activity and obesity prevention. One area of focus for DNPAO is obesity prevention in child care, also known as the “early care and education” (ECE) setting. This information collection request is directly related to this critical period in early childhood.

ECE is an important setting for obesity prevention because an estimated 60% of U.S. children aged 0-5 years spend 30+ hours each week in non-parental care in places such as child care centers, family daycare homes, pre-kindergarten classrooms and Head Start programs. ⁶ Improving the ECE nutrition and physical activity environment and the practices of ECE providers can have a direct impact on what children consume and how active they are, as well as help children develop a foundation of healthy habits for life. The ECE setting has been identified as a priority setting for obesity prevention in several key documents including the Surgeon General’s Vision for a Healthy and Fit Nation,⁷ the White House Task Force on Childhood Obesity Report to the President ⁸and Institute of Medicine reports in 2010 and 2011.^9-10 Obesity prevention work in the ECE setting is guided by a national set of standards ¹¹ that focus on: 1) improving the foods and beverages served in ECE facilities; 2) providing opportunities for physical activity; 3) supporting breastfeeding; and 4) limiting screen time in ECE facilities. Several reports including the 2010 and 2011 IOM reports ^9-10 and the 2015 Dietary Guidelines Advisory Committee ¹² report state that governmental agencies should ensure access to affordable, nutritious foods through CACFP and maximize participation in the program. ¹²

For the past 20 years CDC’s DNPAO has funded state health departments though cooperative agreements to work towards improving nutrition, increasing physical activity, decreasing obesity, and promoting and supporting breastfeeding. The current 5 year (2013-2018) cooperative agreement is entitled “State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health/Funding Opportunity Announcement DP13-1305” (herein after referred to as 1305/State Public Health Actions). In the 1305/State Public Health Actions cooperative agreement, states are required to work in the ECE setting to promote physical activity through state level policy, systems, and environmental approaches. States are also required to promote nutrition standards in the setting of their choice (e.g. ECE, worksite, community); many have chosen to focus their efforts on ECE ¹³. Currently, all 50 states and the District of Columbia are grantees of CDC’s 1305/State Public Health Actions cooperative agreement.

To guide state health department work, CDC’s DNPAO developed a framework and set of guidance materials to assist states in supporting ECE facilities to meet the national obesity prevention standards. The framework, known as The Spectrum of Opportunities ,¹⁴ identifies prevention areas that states can draw upon to support obesity prevention in state ECE systems

(See Attachment D — CDC’s Spectrum of Opportunities). Although the framework outlines 11 areas, this information collection request will only focus on 7 key state-level obesity prevention areas. These 7 areas were chosen by CDC’s DNPAO staff because they are the highest priority areas and easiest to evaluate at the state level. The 7 spectrum areas assess how obesity prevention has been incorporated into a state’s systems and include: 1) State Quality Rating and Improvement System (QRIS), 2) State Professional Development activities, 3) State Facility Level Obesity Prevention Interventions, 4) Access to Healthy Environments: State Farm to Preschool Activities, 5) State Early Learning Standards 6) Emerging Opportunities: State level obesity initiatives, and 7) the State Child and Adult Care Food Program (CACFP). The 7 selected areas have a broad reach and can improve the nutrition and physical activity environments of ECE facilities statewide, thus benefiting large numbers of children. For example, if obesity prevention activities can be embedded into state’s Quality Rating and Improvement Systems and/or ECE provider continuing education systems they can reach many ECE programs and providers in a state. Additionally, if obesity prevention interventions or farm to preschool programs are present in a state this can also help increase children’s access to healthier ECE environments. Many states also have obesity prevention work occurring in state CACFP programs. Though linkages between public health and existing programs, such as CACFP, states can maximize obesity prevention efforts in a time of limited state resources and reach many of the state’s ECE providers.

The 1305 ECE state coordinators are funded through the Centers for Disease Control and Prevention (CDC) grant and oversee all of CDC’s 1305 grant activities related to obesity prevention in the ECE setting. The 1305 ECE coordinators have been selected as a respondent group because they are subject matter experts in their state responsible for the implementation of strategies to support obesity prevention in the ECE setting. Information collected from this respondent group will provide the most reliable and accurate information on 6 of the Spectrum of Opportunity areas described in the previous paragraph (spectrum of opportunities areas #1-6).

State CACFP directors oversee each state’s CACFP program. CACFP is a federal nutrition assistance entitlement program funded by the United States Department of Agriculture (USDA) that provides more than $2 billion in reimbursement for meals and snacks served to more than 3.3 million children daily in child care ¹⁵. There is state by state variation in the state agency that administers the federal CACFP program. In some states CACFP is administered by the Department of Education (n=35). In other states the CACFP program is administered by the Department of Health/Human/Social Services (n=11), Department of Agriculture (n=3) or Early Learning (n=2) (see Attachment B and C — Map/List of CACFP administering agency by state). Regardless of state administering agency many children rely on the federal CACFP for a substantial portion of their daily food intake and thus included in the respondent universe for the following reasons:

The provision of food to children through the federal CACFP program, irrespective or administrating agency, is part of Essential Public Health Services #9 Evaluating effectiveness, accessibility, and quality of personal and population-based health services. The overarching purpose of CACFP as a program is “that [it] provides aid to child and adult care institutions and family or group day care homes for the provision of nutritious foods that contribute to the wellness, healthy growth, and development of young children” ¹⁶. To achieve this goal CACFP provides nutritious meals and snacks to low-income children in child-care centers and family child-care homes. CACFP also encourages health and wellness by the provision of guidance and technical assistance in a number areas including nutrition, physical activity, and limiting electronic media use. ¹⁶Thus, state CACFP program efforts to increase access to healthy food for children and educate ECE providers on the pressing public health problem of childhood obesity is carrying out an essential public health function. Several studies indicate that children in ECE settings that comply with CACFP meal pattern standards consume more nutritious diets than those who do not ^17-20. This respondent group was targeted because they will be the person who will know the most about each state’s CACFP program standards and obesity prevention activities.
State sponsored CACFP obesity prevention work and training can be viewed as an extension or companion efforts to the ongoing work of state health departments to advance obesity prevention in ECE. State CACFP directors are considered the subject matter expert on their state’s CACFP program and its standards. State CACFP directors will provide the most reliable and accurate information for the 7^th spectrum area listed above; the State Child and Adult Care Food Program (CACFP).

State Public Health Departments vary widely in their level of experience working in the ECE setting and in partnering with the agencies and offices that operate the different components of their state’s ECE system. Few data exist to identify which of CDC’s Spectrum of Opportunities framework areas states are pursuing. Thus, the primary purpose of this information collection request is to collect information on 7 state level ECE obesity prevention areas to gather the critical information necessary to produce and publish CDC’s first ECE State Indicator Report (ECE SIR

The information collected from each of the respondent groups: state public health and state CACFP directors will be combined to create the ECE SIR.

The purpose of the ECE SIR is to describe state level ECE obesity prevention efforts. States will be able to identify how and where they align to CDC’s ECE obesity prevention framework: “Spectrum of Opportunities.” The ECE SIR will help inform and improve states’ work in obesity prevention in the ECE setting.

Overview of the Information Collection System

Data will be collected via a web-based data collection instrument. This questionnaire will allow respondents to complete and submit their responses electronically (see Attachment E—Instrument: Word version and Attachment F—Instrument: Web version). The online instrument will be used to gather information from 2 respondent types in each state: the 1305 ECE coordinators and the state CACFP directors, regarding state level obesity prevention efforts targeting the ECE setting to create CDC’s first ECE SIR. This method was chosen to reduce the overall burden on respondents. The data collection instrument was pilot tested by 6 state public health professionals. Feedback from this group was used to refine questions as needed, ensure accurate programming and skip patterns and establish the estimated time required to complete the data collection instrument.

Items of Information to be Collected

The online data collection instrument consists of 26 questions consisting predominantly of closed-ended, multiple response questions. An effort was made to limit questions requiring narrative responses from respondents whenever possible. Skip patterns based on the respondent type will also limit the number of questions for each respondent group. These questions collect information on state level ECE obesity prevention efforts in 7 distinct areas from CDC’s Spectrum of Opportunities framework and this information will be used to create CDC’s first ECE SIR. State 1305 ECE coordinators will receive a maximum of 19 questions and questions will include the following 6 Spectrum of Opportunity areas. Questions will assess:

If obesity prevention has been incorporated into state ECE Quality Rating and Improvement Systems (QRIS); [For reference, QRIS is a state-based systematic approach to assess, communicate, and improve the level of quality in ECE programs]
If the state supports professional development through continuing education opportunities for ECE providers focused on obesity prevention.
If the state provides a facility level obesity prevention intervention to ECE providers throughout the state.
If the state supports access to healthy environments through farm to preschool activities.
If the state has incorporated nutrition, physical activity, and obesity prevention into the state’s Early Learning Standards (ELSs). [For reference, ELSs are federally mandated to help prepare children for school entry. Every state sets its own ELSs, which specify the content areas that must be taught and assessed in children who attend ECE facilities]
If the state supports emerging opportunities to promote ECE obesity prevention such as: 1) an ECE obesity prevention task force or coalition 2) a voluntary statewide recognition program for ECE facilities that promote nutrition, physical activity, breastfeeding and 3) if ECE obesity prevention is included in the state’s chronic disease plan.

Information on the 7^th Spectrum of Opportunities framework area (CACFP) will be obtained from state CACFP directors. Five to seven (5-7) questions (depending on a skip pattern) will be asked of the second respondent type: State CACFP directors. The questions are directly related to their state’s CACFP program. The State CACFP directors will be asked about:

Their state’s meal pattern standards
Obesity prevention activities
Obesity prevention trainings offered to ECE providers carried out by state CACFP programs

The information gathered will inform CDC’s first ECE SIR.

Purpose and Use of the Information Collection

The purpose of this information collection request is to collect information on 7 state level ECE obesity prevention areas to gather the critical information necessary to produce CDC’s first ECE State Indicator Report (ECE SIR). The purpose of the ECE SIR is to describe state level ECE obesity prevention efforts and provide states with the visibility to see how they align to the CDC ECE obesity prevention framework: the Spectrum of Opportunities. As stated earlier, states have varying experience working in the ECE setting and many use CDC’s Spectrum of Opportunities to guide their work. However, previously, there had been no systematic way to document or share this information. The ECE SIR will fill this gap by documenting state information in each of the 7 spectrum areas allowing states to use this information to inform and advance ECE work at the state level.

Use of Improved Information Technology and Burden Reduction

Data will be collected primarily via a web-based data collection instrument allowing respondents to complete and submit their responses electronically. This method was chosen to reduce the overall burden on respondents. The data collection instrument was designed to collect the minimum information necessary for the purposes of this project. The assessment consists of 26 questions including dichotomous (yes/no) and multiple response question types. An effort was made to limit questions requiring narrative responses from respondents whenever possible. Skip patterns based on the respondent type will also limit the number of questions for each respondent group.

Efforts to Identify Duplication and Use of Similar Information:

Currently, states have varying levels of experience with obesity prevention efforts targeting the ECE setting. No data exist that describe the various components of state ECE systems.

There is one state level data source for the ECE setting collected annually by the National Resource Center for Health and Safety in Child Care, and this report is called “Achieving a State of A Healthy Weight” ²¹. However, these data are very limited in that they only provide information on a state’s child care licensing regulations and do not include any additional information on other parts of a state’s ECE system.

Specific efforts were made to ensure there is no duplication of effort between this proposed information collection and others:

When developing the information collection instrument, United States Department of Agriculture (USDA) colleagues were consulted to ensure the proposed questions were not duplicative of USDA information collections, specifically those the concerning Child and Adult Food Care Program (CACFP). Colleagues confirmed the proposed information collection was not duplicative.
When DNPAO developed the ECE SIR information collection request the objective of OMB package 0920-1059: Monitoring and Reporting System for the State Public Health Actions Cooperative Agreements Information Collection Request ²¹ was reviewed. The intent of 0920-1059 is broader and collects information from the administrators of the 1305 grant (such as principal investigators and key program administration staff) on the progress toward 1305 work plan objectives and 1305 performance measures. Colleagues confirmed the respondent groups are different and two different information collection requests are unique and not duplicative.

Impact on Small Businesses or Other Small Entities

No small businesses will be involved in this information collection.

Consequences of Collecting the Information Less Frequently

This request is for a one time information collection. There are no legal obstacles to reduce the burden. If no data are collected, CDC will be unable to:

Describe how states are including obesity prevention into their state ECE systems and programs such as CACFP, Quality Rating and Improvement systems (QRIS) or continuing education systems;
Highlight state’s success in ECE obesity prevention;
Produce the first ECE State Indicator Report to summarize what obesity prevention areas states are pursuing based on CDC’s Spectrum of Opportunities framework

Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

There are no special circumstances with this information collection package. This request fully complies with the regulation 5 CFR 1320.5 and will be voluntary.

Comments in Response to the Federal Register Notice and Efforts to Consult Outside the Agency

This information collection is being conducted using the Generic Information Collection mechanism of the OSTLTS OMB Clearance Center (O2C2) – OMB No. 0920-0879. A 60-day Federal Register Notice was published in the Federal Register on October 31, 2013, Vol. 78, No. 211; pp. 653 25-26. No comments were received.

CDC partners with professional STLT organizations, such as the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), and the National Association of Local Boards of Health (NALBOH) along with the National Center for Health Statistics (NCHS) to ensure that the collection requests under individual ICs are not in conflict with collections they have or will have in the field within the same timeframe.

Explanation of Any Payment or Gift to Respondents

CDC will not provide payments or gifts to respondents.

Protection of the Privacy and Confidentiality of Information Provided by Respondents.

The Privacy Act does not apply to this information collection. STLT governmental staff and / or delegates will be speaking from their official roles and will not be asked, nor will they provide individually identifiable information.

This information collection is not research involving human subjects.

Institutional Review Board (IRB) and Justification for Sensitive Questions

No information will be collected that are of personal or sensitive nature.

Estimates of Annualized Burden Hours and Costs

The estimate for burden hours is based on a pilot test of the information collection instrument by 6 state staff. In the pilot test, the average time to complete the instrument, including time for reviewing instructions, gathering needed information and completing the relevant questions in the instrument, varied widely between respondent groups. For example the State CACFP director portion only took an average of 4 minutes (range 3-5 minutes) because this respondent group received fewer questions. However, the ECE respondent groups took an average of 22 minutes (range 7-30 minutes). Based on these results, the estimated time range for actual respondents to complete the instrument is 3 to 30 minutes. Since the groups varied so widely, for the purposes of estimating burden hours, the upper limit for each respondent group is used:

5 minutes for CACFP state directors;
30 minutes for 1305 ECE coordinators

Estimates for the average hourly wage for respondents are based on the Department of Labor (DOL) National Compensation Survey estimate for each respondent type is as follows:

State health department staff in charge of ECE prevention (state health scientist category) was $27.52.
State CACFP director (state health service manager category) average hourly wage is $57.11 (http://www.bls.gov/ncs/ocs/sp/nctb1349.pdf).

Table A-12 shows estimated burden and cost information.

Table A-12: Estimated Annualized Burden Hours and Costs to Respondents

Information collection Instrument: Form Name	Type of Respondent	No. of Respondents	No. of Responses per Respondent	Average Burden per Response (in hours)	Total Burden Hours	Hourly Wage Rate	Total Respondent Costs
ECE SIR	State health staff for ECE	51	1	30/60	26	27.52	$716
ECE SIR	State CACFP director	51	1	5/60	4	57.11	$228
	TOTALS	102	1		30		$944

Estimates of Other Total Annual Cost Burden to Respondents or Record Keepers

There will be no direct costs to the respondents other than their time to participate in each information collection.

Annualized Cost to the Government

There are no equipment or overhead costs. The only cost to the federal government is the salary of CDC staff supporting the information collection activities and associated tasks. The primary CDC staff member for this project are a behavioral scientist (GS-13) in the Division of Nutrition, Physical Activity and Obesity, who consulted with the ECE Team Lead (Commissioned Corps O-6).

The primary CDC staff member will collect the data, code, enter and prepare the data for analysis; conduct data analysis; and prepare the ECE State Indicator with ongoing consultation from the ECE team lead. Hourly rates of $45.95 for the GS-13, and $44.00 for the Commissioned Corps O-6 Team lead were used to estimate staff costs. The total estimated cost to the federal government is $5,035.

Table A-14 describes how this cost estimate was calculated.

Table A-14: Estimated Annualized Cost to the Federal Government

Staff (FTE)	Average Hours per Collection	Average Hourly Rate	Average Cost
Behavioral Scientist GS-13	100	$45.95	$4,595
Team Lead (Captain in the Commissioned Corps level O-6)	10	$44.00	$440
Estimated Total Cost of Information Collection			$5,035

Explanation for Program Changes or Adjustments

This is a new information collection.

Plans for Tabulation and Publication and Project Time Schedule

Data will be exported from Survey Monkey into a Microsoft Excel file. Data will be reviewed for completion and simple descriptive statistics will be calculated to look at response frequencies. Data from this information collection will inform the development of the ECE SIR. The ECE SIR will be shared with state health department staff (who is the primary audience) and posted on the CDC website. The report will also be shared with key public and private ECE partners, such as HHS Agency for Children and Families (ACF) and others working in the ECE setting including the Robert Wood Johnson Foundation and Nemours Health Foundation. We are anticipating that the ECE SIR will be disseminated in early 2016.

Project Time Schedule

Design questionnaire (COMPLETE)

Develop protocol, instructions, and analysis plan (COMPLETE)

Pilot test questionnaire (COMPLETE)
Prepare OMB package (COMPLETE)
Submit OMB package (COMPLETE)

OMB approval (TBD)
Conduct online information collection (Collection open 4 weeks)
Code, quality control, and analyze data (4 weeks)
Prepare ECE SIR draft and obtain division clearance (8 weeks)
Disseminate results/reports (4 weeks)

Reason(s) Display of OMB Expiration Date is Inappropriate

We are requesting no exemption.

Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification. These activities comply with the requirements in 5 CFR 1320.9.

LIST OF ATTACHMENTS – Section A

Attachment A: List of state health departments by state
Attachment B: Map of CACFP administering agency by state
Attachment C: List of CACFP administering agency by state
Attachment D: Figure of CDC’s Spectrum of Opportunities for Obesity Prevention in ECE
Attachment E Instrument Word version
Attachment F: Instrument Web version

REFERENCE LIST

Disease Control and Prevention (CDC). "National Public Health Performance Standards Program (NPHPSP): 10 Essential Public Health Services." Available at http://www.cdc.gov/nphpsp/essentialservices.html. Accessed on 8/14/14.
Ogden CL, Kit BK, and Flegal KM., Prevalence of Obesity and Trends in Body Mass Index among US Children and Adolescents, 1333-2010. JAMA, 2012; 307 (5):483-490
CDC, Division of Nutrition, Physical Activity and Obesity Child Overweight and Obesity Webpage available at: http://www.cdc.gov/obesity/childhood/index.html. Accessed August 13, 2015
The NS, Suchindran C., North KE., Popkin BM., Gordon-Larsen P. (2010) Association of Adolescent Obesity with Risk of Sever Obesity in Adulthood. JAMA 2010;304(18):2042-2047
Cummingham, SA., Kramer, M.R., and Venkat Narayan, K.M. Incidence of Childhood Obesity in the United States. NEJM, 2014; 370 (5): 403-411.
U.S. Census Bureau (2013). Who’s minding the kids? Child Care Arrangements: Spring 2011 Data tables. Retrieved April 16, 2015 from http://www.census.gov/prod/2013pubs/pdf
U.S. Department of Health and Human Services. The Surgeon General's Vision for a Healthy and Fit Nation. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General, January 2010.
White House Task Force on Childhood Obesity, Report to the President (2010)
Institute of medicine (IOM) 2010 Child and Adult Care Food Program: Aligning Dietary USDA Food and Nutrition Services webpage. Available at: http://www.fns.usda.gov/cacfp/child-and-adult-care-food-program. Accessed August 13, 2015
Institute of Medicine (IOM). 2011. Early Childhood Obesity Prevention Policies. Washington, DC: The National Academies Press.
Academy of Pediatrics, American Public Health Association, and National Resource Center for Health and Safety in Child Care and Early Education. Preventing Childhood Obesity in Early Care and Education: Selected Standards from Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, 3rd Edition Elk Grove Village, IL: American Academy of Pediatrics; Washington, DC: American Public Health Association; 2012. Available at:
Dietary Guidelines Advisory Committee Scientific Report (2015) submitted to the Secretaries of the U.S. Department of Health and Human Services (HHS) and the U.S.
CDC State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health (1305) Early Care and Education work. Available at http://www.cdc.gov/obesity/strategies/childcareece.html. Accessed August 13, 2015
CDC, Spectrum of Opportunities for Obesity Prevention in Early Care and Education, available at: http://www.cdc.gov/obesity/downloads/spectrum-of-opportunities-obesity-prevention.pdf. Accessed August 13, 2015
USDA Food and Nutrition Services webpage. Available at: http://www.fns.usda.gov/cacfp/child-and-adult-food-care-program. Accessed August 13, 2015
USDA CACFP Federal Register Notice. Available at https://www.federalregister.gov/articles/2015/01/15/2015-00446/child-and-adult-care-food-program-meal-pattern-revisions-related-to-the-healthy-hunger-free-kids-act#h-9. Accessed August 13, 2015
Buscemi J, Kanwischer K, MS, Becker AB. Ward DS, Fitzgibbon ML. Early Care and Education (ECE) Policies Can Impact Obesity Prevention among Preschool Aged Children. Society of Behavioral Medicine Position Statement. September 2014
Crepinsek, M. K., and N. Burstein. Maternal Employment and Children’s Nutrition: Volume II, Other Nutrition-Related Outcomes 2004; U.S. Department of Agriculture, Economic Research Service
Whaley, S., Gomez, J., Mallo, N., James, P., Fredericks, D., Abascal, P., Sharp, M., Chandran, K., & Hecht, K. (2008). It’s 12 O’clock...What Are Our Preschoolers Eating for Lunch? An Assessment of Nutrition and the Nutrition Environment in Licensed Child Care in Los Angeles County. Irwindale, CA: Public Health Foundation Enterprises WIC Program, Child Care Food Program Roundtable and California Food Policy Advocates. Available at: http://www.cfpa.net/cacfp/gilbert_execsumm.pdf. Accessed July 11 2014.
Ritchie, L 2012 Participation in CACFP is Associated with More Nutritious Foods and Beverages in Child Care. Child Obesity
National Resource Center for Health and Safety in Child Care and Early Education (2014) Achieving a State of A Healthy Weight. Available at: http://nrckids.org/index.cfm/products/achieving-a-state-of-healthy-weight1/. Accessed Sept 16, 2015
United States Office of Management and Budget, Office of Information and Regulatory Affairs Webpage available at: http://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=201411-0920-001). Accessed August 13, 2015

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