ª 2014 by the Academy of Nutrition and Dietetics. J

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Transitioning to New Child-Care Nutrition Policies:Nutrient Content of Preschool Menus Differs byPresence of Vegetarian Main EntréeGabrielle M. Turner-McGrievy, PhD, MS, RD; Sarah B. Hales, MSW; Angela C. Baum, PhD

ARTICLE INFORMATION

Article history:Accepted 14 July 2013Available online 19 October 2013

Keywords:Child careNutrition policyVegetarianFoodserviceParental support

Copyright ª 2014 by the Academy of Nutritionand Dietetics.2212-2672/$36.00http://dx.doi.org/10.1016/j.jand.2013.07.036

ABSTRACTChildren who attend child care outside the home may be at increased risk for devel-oping obesity. In 2012, the South Carolina ABC Child Care program issued new standardsfor food and nutrition. The goal of our study (conducted June to December 2012) was toexamine changes that occurred at a large, Columbia, SC, preschool during the imple-mentation of the South Carolina ABC Child Care program standards using an observa-tional design, including a survey of parents and nutrient analysis of menus. Thenutrition content of menu items before (n¼15 days; six of which were vegetarian) andafter (n¼15 days; six of which were vegetarian) implementation of the new standardswas compared. In addition, parents (N¼75) were surveyed to examine opinions andsupport for the changes. Independent samples t tests were used to compare nutrientvalues before and after menu changes and analysis of variance was used to comparepre- and post-change vegetarian menus and pre- and post-change nonvegetarianmenus. There were no significant differences between before and after menus with theexception of a 0.3 cup/day increase in vegetables (P<0.05). Vegetarian menus after therevisions were significantly higher in fiber (13�3 g) than postrevision nonvegetarianmenus (11�3 g; P<0.05) and lower in sodium (1,068�207 mg) than postrevisionnonvegetarian menus (1,656�488 mg; P<0.05). Standards that received the mostparental support were serving at least two vegetables (score of 8.7 on a scale of one tonine) and two fruits per day (score of 8.6) and implementing policies against staff usingfood as a reward or punishment (score of 8.6). The center-specific policy of only bringinghealthy foods for celebrations received the lowest support (score of 5.8). Adding morevegetarian menu items has the potential to improve the nutrient content of menuswhile keeping energy intake, saturated fat, sodium, and cholesterol levels at a moreoptimum level.J Acad Nutr Diet. 2014;114:117-123.

OFTHE>20MILLION CHILDREN YOUNGER THANAGE5 years in the United States, 61% attend some form ofchild care.1 Children who attend child care outsidethe home may be at higher risk of developing

obesity2 thus improving foods served in child-care settingsmay be a target for childhood obesity prevention. Child-carevenues have demonstrated that they are an important settingfor introducing young children to healthy eating habits.3,4

With the introduction of the Healthy, Hungry-Free KidsAct,5 schools across the United States began implementingchanges in their breakfast and lunch menus. These changeshave also occurred within the preschool setting. Althoughthese new nutrition requirements can be set by regulatoryagencies, support is needed by key stakeholders to ensureregulations are followed and implemented effectively. Thereare numerous stakeholders involved in feeding preschoolchildren, including school administrators, parents, teachers,foodservice workers, and food companies.6,7 Parent support

and involvement may be particularly important in sustainingnew nutrition policies.8,9 Previous studies examining the in-fluence of nutrition policies on changes in food intake havereported no or minimal effects, with certain changes, such aswhole grains or water, being especially challenging.10-13

Few research studies have examined the transition thatoccurs within child-care centers as new policy changes un-fold. Therefore, the goal of our study was to examine changesthat occurred at a large, South Carolina child-care centerduring the implementation of new nutrition standards. Ouranalysis examined changes in the nutrition content of menusbefore and after implementation of the new standards as wellas the influence of vegetarian meals on the nutrient contentof menus. In addition, parent opinions and support for thesechanges were examined, as well as parent support for addingmore vegetarian entrées. We hypothesized that post-policymenus would have higher fiber and lower fat than pre-policy menus due to recommendations to increase fruit,

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StandardStandard metbefore changes Level A Level B Level C

Food- and menu-based nutrition standard

Only nonfat or reduced-fat milk is servedto children aged �2 y

Yes Must meet Must meet Must meet

Do not serve sugar-sweetened beverages Yes Must meet Must meet Must meet

Juice is allowed only once per day in a servingsize tailored to age group’s need

Yes Must meet Must meet

Offer fruit (not juice) at least 2 times per day Yes Must meet Must meet

Offer vegetables other than white potatoes No At least 2 timesper day

At least onceper day

Limit fried or pre-fried vegetables(including potatoes) to:

Yes No more than oncein a 2-wk period

No more thanonce a week

Limit high-fat meats (eg, sausage, bacon, hotdogs, bologna, and ground beef) to:

No No more than oncea week

No more than2 times/wk

Offer whole grains No At least2 times daily

At leastonce daily

Limit sweet food items to: No No more thanonce a week

No more than2 times/wk

Nutrition policy-related standards

Staff does not use food as reward orpunishment

Undetermined Must meet Must meet

Staff joins children when they eat Yes Must meet

Figure. The 2012 South Carolina ABC Grow Healthy Best Practices food- and menu-based and nutrition policy-related nutritionstandards by level of regulated care and whether or not standards were being met by the child-care center before implementingthe new regulations.

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vegetables, and whole grains and limit high-fat meats, witheven greater changes seen in post-policy vegetarian menus.

METHODSThe South Carolina ABC Child Care (SCABC) program wasestablished to assist families with finding and paying for childcare and defines quality standards exceeding current stateregulations for nutrition, physical activity, discipline, andother areas.14 Programs participating in the SCABC programare categorized into three levels: A (highest rated programsmeeting ratio and staff qualifications and receiving at least a5.0 on the Early Childhood Environment Rating Scale15), B(programs going beyond basic state standards with no vio-lations of staff to children ratios), and C (meeting basicstandards).14 In 2012, the SCABC program issued new orrevised standards for several of their rated areas, includingfood and nutrition.16 These standards go beyond current USDepartment of Agriculture (USDA) standards for reimburs-able meals.17 In addition, SCABC standards include nutritionpolicies that are not included in USDA standards. The Figureoutlines the food- and menu-based and nutrition policy-related standards required to receive an A, B, or C rating.Prior SCABC ratings required all snacks and lunches in Level A

118 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

and B schools to meet USDA standards but did not makerecommendations beyond those.Our study took place at a large, university-based child-care

center serving 200 children aged 6 weeks and older inColumbia, SC, between June and December 2012. In additionto infant classrooms, the center has nine classrooms forchildren aged 2 years through prekindergarten. The centerwas in the process of implementing the necessary changes tomaintain their current rating by SCABC. These changes weremandatory to maintain the highest rating by SCABC and weremonitored by SCABC regulatory staff. Menus were updated tomeet nutrition guidelines with the August 2012 menu cycle.Our observational study involved a survey to parents andanalysis of nutrient changes of menus before and after thenutrition policy change.Menus over a 7-month time frame (June to December 2012)

were collected for nutrient analysis. Items reported on themenus were analyzed for nutrient content. Due to budget andresearch staffing constraints, actual consumption of foodsserved was not measured. Menus did not follow a specificcycle or pattern but generally rotated through seven differentbreakfast meals (eg, French toast sticks, apricots, and milk), 14different lunch meals (eg, chicken nuggets, green peas, po-tatoes, whole-wheat rolls, and milk), and seven different snack

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meals (eg, mandarin oranges, cheese crackers, and water)varying throughout the month. Two consecutive weeks ofbreakfast, lunch, and snack menus in June and August wereanalyzed for nutrient content using the USDA Nutrient Data-base for Standard Reference (Release 25, 2012, Nutrient DataLaboratory) by a trained graduate research assistant. The leadkitchen supervisor provided a list of preparation methods forfood items and commonly served portion sizes for childrenaged 3 to 5 years, which was used for menu analysis. To obtaina sizable sample of vegetarian menu days, additional days thatfeatured a meatless main lunch entrée from the July andSeptember to December menus were included for analysis.Days analyzed were further divided into four categories: meat-containing lunch entrées before menu changes (meat-pre),meat-containing lunch entrées after menu changes (meat-post), vegetarian main lunch entrées before menu changes(veg-pre), and vegetarian main lunch entrées after menuchanges (veg-post).One of the goals of this research was to assess specific

opinions of the new SCABC regulations; because a validatedsurvey assessing these regulations was not available, ourresearch team developed the survey we used. The survey wasadministered to parents at the center and collected de-mographic information and examined parent support of thenew SCABC regulations (see the Figure). Parents were asked,for example: “Below are the proposed nutrition standards forcenters enrolled in South Carolina’s ABC program. Please rateyour support for this change on a scale of 1 to 9 (1 being notsupportive and 9 being supportive).” In addition, parentswere asked about their support for a center-specific policy(but a policy also suggested by SCABC14) of only bringinghealthy snacks for classroom celebrations. Because beansrepresent a low-cost protein option for child-care centers18,19

and the latest USDA MyPlate recommendations encourageincorporating more beans and peas into diets,20 the surveyalso contained items assessing support for the addition ofmore meatless entrée items to the menu cycle.Only one parent per household (with one or more child

aged 2 years or older) could complete the survey. Parentswere recruited through notes in children’s cubbies, e-mailmessages, and fliers. The survey was administered online andhad 38 questions, including additional sections to provideopen-ended feedback. Participants were eligible to win a $25gift card and the class with the most respondents received aset of healthy eating books. Surveys were conducted inSeptember and participants were asked to use the Augustmenu to answer the survey questions (the first month thatmenu changes were adopted). All participants providedinformed consent. The study was approved by The Universityof South Carolina Institutional Review Board.

Statistical MethodsIndependent samples t tests were used to compare nutrientvalues for before and after menu changes (which includedboth meatless entrées and entrées containing meat). Analysisof variance was used to compare the overall significance ofdifferences among the four menu groups. Post hoc analyseswere conducted using Turkey’s honestly significant differ-ence test. The software package SPSS for Windows (version20.0.0, 2011, IBM-SPSS Inc) was used for all analyses. A Pvalue of <0.05 was used to determine statistical significance.

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RESULTS AND DISCUSSIONMenu Analysis ResultsThe new SCABC menu requirements were mainly metthrough substitution or addition of foods. For substitution,whole grains replaced refined grains (eg, using whole-wheatbread to make toast), lower-fat protein sources were used inplace of higher-fat protein sources (eg, substituting legumesor low-fat ground turkey for ground beef used in tacos), andunsweetened snacks were used in place of sugar-sweetenedsnacks (eg, plain yogurt replaced pudding). For addition offoods, an additional fruit serving was added to the snack andan additional vegetable was served at lunch. All food andbeverage items on the examined menus were analyzed andincluded days before policy changes were made (n¼15; six ofwhich were vegetarian) and after (n¼15; six of which werevegetarian). Vegetarian main entrées appeared infrequentlyduring the 7 months of examined menus (an average of 2.9meatless meals per month). The Table presents samplemenus and the nutrient analyses of menus both before andafter changes as well as the four separate groups (meat-pre,meat-post, veg-pre, and veg-post). Energy content, macro-nutrients, or the examined micronutrients did not signifi-cantly differ from before to after the menu changes. Servingsof vegetables significantly increased (P<0.05). There was nochange in fruit servings. This lack of difference in macronu-trients could be because the menus already met five of thenine nutrition criteria before the changes, leaving less roomfor improvement.There were significant differences in the nutrition content

among the four menu groups. Both veg-pre and veg-postmeals contained significantly more fiber than meat-premenus. Veg-post meals also contained significantly less so-dium than meat-post meals. Meat-pre meals containedsignificantly fewer vegetable servings than the other threemenu groups. There was a significant difference in choles-terol among the four examined groups, although post hocanalyses were not significant to determine the direction ofthese differences. Well-planned vegetarian and vegan mealsare nutritionally adequate for all stages of the life cycle,including childhood.21 A study of children aged 6 to 12 yearsin two Belgian schools found that vegetarian meals (servedonce per week) were nutritionally adequate and acceptableto the children, with no differences in plate waste betweenvegetarian and nonvegetarian meals.22 In our study, vege-tarian meals only differed from nonvegetarian meals in themain lunch entrée served, which was generally a legume-based dish. This minor variation appeared to lead to signifi-cant differences in the nutrient profile of the vegetarian andnonvegetarian menus, such as improvements in fiber andsodium. Vegetarian menus also contained half the amount ofcholesterol found in the meat-based entrées. SCABC providesinformation on adding vegetarian entrées to the menus, suchas a recipe for bean spread on their website, as well as menutemplates that include several vegetarian protein sourcesunder the Meat or Meat Alternative category (eg, beans, peas,lentils, hummus, and tofu).14 Legumes may represent a wayfor child-care centers to keep costs low and to improve thenutrient content of their menus.23

The Table also shows the Dietary Reference Intakes (DRIs)for 3-year-olds and 4- to 5-year-olds for two thirds of the day(which would represent the portion of the DRI that should be

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Table. Nutrient content and servings of fruits and vegetables in pre- and post-changes menus, along with meat-based entrées and vegetarian entrées and two thirds ofthe Dietary Reference Intakes (DRI)a for each nutrient for menus examined between June and December 2012 at a large, South Carolina child-care center

Nutrientsper day

Pre-change(n[15)

Post-change(n[15)

Pre-changemeat entrées(n[9)

Post-changemeat entrées(n[9)

Pre-changevegetarianentrées(n[6)

Post-changevegetarianentrées(n[6)

P fordifferencesamong the4 menugroups

Two thirdsof the DRIfor age 3 y

Two thirdsof the DRIfor age 4-5 y

Examplebreakfast

— — Biscuits andturkey sausage,apricots, milk

Whole-wheatbagel withplain creamcheese,apricots, milk

English muffin,peaches,milk

Whole-wheatEnglish muffin,peaches, milk

— — —

Example lunch — — Barbequemeatball,peas and carrots,fresh fruit,rolls, milk

Barbeque chicken,corn and limabeans,whole-wheatrolls, milk

Black-eyedpeas,stewedtomatoes,yellow rice,applesauce, milk

Pinto beans,stewedtomatoes,brown rice,lettuce, milk

— — —

Example snack Mandarin oranges,fish-shapedcrackers, water

Mandarin oranges,fish-shapedcrackers, water

Kixb cereal, milk Kixb cereal, milk,sliced apples

— — —

Total energy(kcal)

830�146 863�193 875�176 929�89 764�186 763�169 0.15 700 kcalboys aged1-2 y; 665 kcalgirls age 1-2 yc

1,167 kcalboys age 3-8 y;1,100 kcal girlsage 3-8 yc

Protein(% energy)

20�3 20�3 21�4 21�4 19�0.2 19�2 0.42 5-20 10-30

Carbohydrate(% energy)

53�16 60�13 49�16 56�13 60�14 66�11 0.14 45-65 45-65

Dietary fiber (g) 11�3 12�3 9�3 11�3 13�1* 13�3* 0.013d 13 17

Fat (% energy) 28�13 28�16 32�13 34�16 23�13 18�11 0.12 30-40 25-35

Saturated fat(% energy)

14�8 12�6 15�8 14�6 13�8 9�6 0.46 As low as possible while consuminga nutritionally adequate diet

Cholesterol (mg) 96�69 83�64 125�71 111�66 52�37 48�44 0.04e As low as possible while consuminga nutritionally adequate diet

(continued on next page)

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Table. Nutrient content and servings of fruits and vegetables in pre- and post-changes menus, along with meat-based entrées and vegetarian entrées and two thirds ofthe Dietary Reference Intakes (DRI)a for each nutrient for menus examined between June and December 2012 at a large, South Carolina child-care center (continued)

Nutrientsper day

Pre-change(n[15)

Post-change(n[15)

Pre-changemeat entrées(n[9)

Post-changemeat entrées(n[9)

Pre-changevegetarianentrées(n[6)

Post-changevegetarianentrées(n[6)

P fordifferencesamong the4 menugroups

Two thirdsof the DRIfor age 3 y

Two thirdsof the DRIfor age 4-5 y

Calcium (mg) 975�258 956�237 1,004�311 932�221 932�167 992�277 0.91 469 670

Potassium (mg) 1,523�237 1,643�252 1,433�258 1,624�300 1,659�118 1,673�177 0.18 2,010 2,546

Sodium (mg) 1,468�437 1,421�490 1,637�485 1,656�488 1,212�163 1,068�207** 0.018f 670 804

Iron (mg) 7.9�2.5 7.7�2.1 7.8�2.5 7.7�2.4 8.0 �2.8 7.8�1.8 0.995 5 7

Zinc (mg) 6.6�1.8 6.8�1.4 7.1�2.1 7.2�1.5 5.8�1.0 6.2�1.2 0.28 2 3

Vitamin A(mg RAEg)

605�201 607�180 670�210 692�184 508�153 480�72 0.053 201 268

Vitamin B-6 (mg) 0.9�0.2 0.9�0.3 0.9�0.2 1.0�0.2 0.8�0.2 0.6�0.2 0.003h 0.3 0.4

Vitamin B-12 (mg) 3.5�1.2 3.7�1.2 3.9�1.3 3.9�1.3 2.9�0.5 3.4�0.9 0.32 0.6 0.8

Vitamin C (mg) 26�14 29�10 23�12 31�10 30�17 27�12 0.60 10 17

Vitamin D (mg) 6.1�1.6 6.0�1.5 6.3�1.8 5.8�1.6 5.8�1.3 6.3�1.2 0.83 10 10

Vitamin E (mg) 2.3�1.3 1.9�0.6 1.9�1.1 1.9�0.8 2.8�1.5 1.8�0.4 0.24 4 5

Vitamin K (mg) 22�14 31�17 25�16 36�18 17�9 24�13 0.13 20 37

Folate (mg) 291�119 275�101 277�124 262�122 312�119 294�62 0.86 101 134

Vegetables (c) 0.8�0.4 1.1�0.4*** 0.6�0.2 1.0�0.5* 1.1�0.3* 1.3�0.2* 0.003h 0.7i 1i

Fruit (c) 1.0�0.5 0.9�0.2 0.9�0.5 0.8�0.3 1.2�0.4 0.9�0.1 0.41 0.7i 1i

aTwo thirds of the DRI is used to represent the portion of the DRI that should be obtained from breakfast, lunch, and a snack.bKellogg Company.cBased on reference 24.dF(3,29)¼4.4.eF(3,29)¼3.2.fF(3,29)¼4.0.gRAE¼retinol activity equivalents.hF(3,29)¼5.9.iRecommended amount as detailed by MyPlate (http://www.choosemyplate.gov/).*P<0.05 for difference from pre-menu changes with meat-based entrée items.**P<0.05 for difference from post-menu changes with meat-based entrée items.***P<0.05 for difference from pre-menu changes.

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obtained from breakfast, lunch, and a snack). Both meat-preand meat-post menus exceeded energy recommendationsfor 3-year-olds. All menus were within range for energyrecommendations for 4- to 5-year-olds. Meat-pre and meat-post menus did not meet fiber DRIs for either age group,whereas veg-pre and veg-post menus met the DRIs for 3-year-olds, but was 4 g short of the DRI for 4- to 5-year-olds.The DRIs do not specify a level of saturated fat for children,but state that intake should be “as low as possible whileconsuming a nutritionally adequate diet.”24 Other sources,such as the American Heart Association and the Institute ofMedicine, recommended that adults and children maintain adiet with <10% of energy being derived from saturatedfat.25,26 Only the veg-post menu met this criterion. None ofthe menus met potassium recommendations and only theveg-post menu came close to meeting the sodium limits,although all menus exceeded 1,000 mg.Both vegetarian and meat-containing menus met iron, zinc,

and vitamin B-12 requirements. All menus failed to meetvitamins E and D requirements, veg-pre did not meet vitaminK requirements for any age group, and veg-post did not meetvitamin K goals for 4- to 5-year-olds. An increase in some ofthese nutrients could be accomplished through the additionof leafy greens to the menu each day. For example, 1/2 cupcooked spinach would add 287 mg potassium, 3.4 mgvitamin E, and 514 mg vitamin K to the menu. Finding ways tomake leafy green vegetables palatable to children, byblending them into foods27 or adding low-fat herb dips,28

may be needed to ensure adequate intake.

Survey ResultsThe Figure details the nutrition standards that the child-carecenter was already achieving before the required changes.Before the menu changes, the center was not meeting thenew required servings of vegetables and whole grains andwas not limiting high-fat meat and sweet food items to lessthan once per week each. At the time of the survey, therewere 134 families with at least one child aged 2 years or olderenrolled at the center. A total of 71 parents (one per family)completed part or all of the survey (response rate 53%). Par-ticipants were mainly women (n¼60; 85%) and white (n¼51;75%), with a reported yearly household income of$112,633�$69,137 and body mass index of 23.9�4.0.Parents were first asked about support for menu changes.

Standards that received the most parent support (using ascale of one to nine) were serving two or more fruits (mean8.7, range¼5 to 9) and vegetables (mean 8.6, range¼5 to 9)per day and implementing policies prohibiting using food asa reward or punishment (mean 8.6, range¼4 to 9). All newSCABC regulations received at least moderate support (sevenor higher). The center-specific policy of only bringing healthyfoods for classroom celebrations (eg, fruit instead of cup-cakes) received the lowest support (mean 5.8, range¼1 to 9),and of the 27 comments in the open-ended section, 37%(n¼10) were in reference to this recommendation, with eightparent comments opposing it. Classroom celebrations withsweets and beverages can contribute an average of 20% ofdaily energy needs.29 The center examined in this study has20 children per prekindergarten classroom. This would meanan average of 1.5 birthdays per month and six or more holi-day celebrations each year for an average of two celebrations

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per month. A study found that the mean energy values forthese celebrations was 444 kcal, which would be equivalentto an additional 888 kcal/month, mostly from lowenutrient-dense foods, for these prekindergarten classrooms.30

Lastly, parents were asked to rate their support for addingmore meatless entrées. They were provided with a list ofexample meatless entrées and asked which ones they wouldlike to see added/retained. On a scale of one to nine, withnine being very positive, parents reported a mean rating of6.9 (range¼2 to 9) when asked: “How would you feel aboutadding more meatless entrées (such as beans and rice, beanburritos, etc) to the menu offerings at the center.” More than50% of parents supported adding veggie pizza, bean burritos,pinto beans and rice, spaghetti with tomato sauce and lentils,and grilled cheese to the menu, but did not support addingveggie burgers, veggie nachos, tofu stir-fry, or vegetarian“chicken” nuggets. Only one parent said they would not wantany meatless entrées added to the menus.Our study has several limitations. The survey used was not

validated and only one center was observed. The parent pop-ulation surveyed was mostly normal weight, highly educated,and white. Therefore, the findings may not translate to otherchild-care settings. In addition, the center was alreadymeetingsome of the new nutrition standards, which may have limitedthe influence that would be seen in a center not meeting anyof the standards before the menu changes. In addition,whereas menus were analyzed for nutrient content, actualconsumption by the children was not measured. Measuringactual consumption of foods served during nutrition policychanges is an important next step for research in this area.Assessing cost differences of menu changes would have beenimportant, but this data was not available to the researchers.Future studies should also examine whether costs increasewhen these policy changes take place. Our study also hasseveral strengths. The design allowed for an examination ofmenus before and after implementation of new nutritionstandards, as well as assessing parent support for the newmenu standards. In addition, this study was able to examinevegetarian meals for preschoolers. To our knowledge, few re-searchers have examined all of these components in relationto nutrition policy changes.Adding vegetarian entrées to menus, which in our study

involved the substitution of legumes for a meat-based entrée,can have a significant effect on the nutrient content of menus,particularly around fiber and sodium, and can help menusmeet cholesterol and saturated fat recommendations. Le-gumes are one of the most inexpensive sources of fiber andpotassium19 and could represent a way for child-care food-service directors to enhance the nutrition quality of menuswhile keeping costs low. Parent support may be important forpolicy changes to move forward in the child-care setting. Inthe parent survey, parents had greater support for nutritionpolicy changes than for the addition of more meatless en-trées. Dietetics practitioners involved with child-care nutri-tion could enhance support for meatless entrées throughparent education, taste tests, and recipe distribution.

CONCLUSIONSThe results of our study suggest that within this populationthere is high parent support for meeting improved nutritionstandards for menus and school-related policies. In addition,

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adding more vegetarian menu items has the potential toimprove the nutrient content of menus while keeping energyintake, saturated fat, sodium, and cholesterol levels at a moreoptimum level. Future studies should examine actual con-sumption of the menu items during nutrition standardchanges and assess barriers to implementing changes fromthe point of view of foodservice managers and staff.

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10. Lessard L, Williams Leng S, Brennan R. Consistency of compliancewith nutrition-related regulations among Delaware child care cen-ters. Child Obes. 2013;9(3):233-239.

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14. South Carolina ABC Child Care Program. What is the ABC program?http://www.abcqualitycare.org/What_Is_ABC.pdf. Accessed June 8,2013.

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AUTHOR INFORMATIONG. M. Turner-McGrievy is an assistant professor and S. B. Hales is a licensed master social worker and a graduate research assistant, Department ofHealth Promotion, Education, and Behavior, Arnold School of Public Health, and A. C. Baum is an assistant professor of early childhood education,Department of Instruction and Teacher Education, College of Education, all at the University of South Carolina, Columbia.

Address correspondence to: Gabrielle M. Turner-McGrievy, PhD, MS, RD, Department of Health Promotion, Education, and Behavior, ArnoldSchool of Public Health, University of South Carolina, 921 Assembly St, Room 132, Columbia, SC 29208. E-mail: brie@sc.edu

STATEMENT OF POTENTIAL CONFLICT OF INTERESTNo potential conflict of interest was reported by the authors.

FUNDING/SUPPORTThere is no funding to disclose.

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