Current Developments in Nutrition 7 (2023) 100040

journal homepage: www.journals.elsevier.com/current-developments-in-nutrition

Original Research

Changes in Meal and Menu Quality at Early Care and Education

Programs after Training with Food Service Staff: the FRESH Study
Divya Patel 1, Susan B. Sisson 1, *, Kaysha Sleet 1, 2, Rachel Rickman 1, 3, Charlotte Love 4,
Tori Taniguchi 5, Margaret Sisk 6, Valarie Blue Bird Jernigan 5
1
Department of Nutritional Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; 2 University Medical Center,
Lubbock, TX, USA; 3 Department of Nutritional Sciences, College of Natural Sciences, University of Texas at Austin, Austin, TX, USA; 4 School of
Health Care Administration, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA; 5 Center for Indigenous Health Research and
Policy, Oklahoma State University, Tulsa, OK, USA; 6 Harvest Land, Osage Nation, Pawhuska, OK, USA

A B S T R A C T

Background: Prevalence of obesity in Native American (NA) children is disproportionately high, indicating a higher risk of health dis-
parities. Many children attend early care and education (ECE) programs, presenting an opportune environment to improve meal and menu
quality as the intake of healthy foods is associated with lowered risk of childhood obesity.
Objectives: We aimed to examine the effectiveness of food service staff training on meals and menu quality across NA ECEs.
Methods: Food service staff from 9 participating ECE programs attended a 3-h training focused on Child and Adult Care Food Program
(CACFP) best practices, and received a tailored, best-practice menu, and healthy recipes. Meals and menus prepared across 1 wk were
examined per CACFP serving size assumptions at baseline, 4 mos, 6 mos, and 12 mos for all 9 programs. Healthy Eating Index (HEI), CACFP
requirements and best practices achievement, and food substitutions quality (classified into superior, equivalent, and inferior based on the
nutritional quality) were calculated. A repeated measures ANOVA model was used to determine the differences across time points.
Results: The total meal HEI score increased significantly from baseline to 4 mos (71.1
2.1; 78.6
5.0; P ¼ 0.004), but did not differ from
baseline to 12 mos. Menu CACFP requirements and best practices achievement did not differ across time points, although achievement with
CACFP requirements was already high at baseline. Superior nutrition quality substitutions declined from baseline to 6 mos (32.4
8.9; 19.5

10.9; P ¼ 0.007); however, it did not differ from baseline to 12 mos. Equivalent and inferior quality substitutions did not differ across time
points.
Conclusions: Implementing a best-practice menu with healthy recipes showed immediate improvements in meal quality. Although the
change did not sustain, this study showed evidence of an opportunity to educate and train food service staff. Robust efforts are needed for
improving both meals and menus.
This trial was registered ClinicalTrials.gov as NCT03251950 (https://clinicaltrials.gov/ct2/show/NCT03251950?cond¼foodþresourc
eþequity&draw¼2&rank¼1).

Keywords: childcare, food service staff, intervention, best practices, food preparation, nutrition education, childhood obesity, Healthy Eating
Index, Head Start programs

Introduction
Oklahoma ranks 6th nationally for early childhood obesity
[1] and the prevalence of obesity among Native American (NA)
children aged 2–5 y is higher than the obesity prevalence among
US children nationally of the same age group (20.7% vs. 13%)
[2], putting them at a greater risk of developing diseases such as
type-2 diabetes, hypertension, cardiovascular disease, and can-
cer later in life [2, 3]. Obesity prevention programs, especially
those with dietary modifications, have shown positive effects on
BMI, dietary intake and quality, and obesogenic behaviors in the

Abbreviations: CACFP, Child and Adult Care Food Program; ECE, early care and education; HEI, Healthy Eating Index; NA, Native American.
* Corresponding author. E-mail address: susan-sisson@ouhsc.edu (S.B. Sisson).

https://doi.org/10.1016/j.cdnut.2023.100040
Received 5 July 2022; Received in revised form 20 January 2023; Accepted 25 January 2023; Available online 20 February 2023
2475-2991/© 2023 The Author(s). Published by Elsevier Inc. on behalf of American Society for Nutrition. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
D. Patel et al. Current Developments in Nutrition 7 (2023) 100040

past, which makes it imperative to develop interventions to personnel, which showed improvements in the intake of fruit,
improve the dietary quality of preschoolers to prevent risk of vegetables, and saturated fat children [17, 28–34]. To our
obesity and other chronic diseases in later life [4–6]. Around knowledge, this is the first study to incorporate a
60%-65% of preschool children attend some kind of early care community-based participatory research (CPBR) approach to
and education (ECE) [7] program in the US [8–10]. These chil- develop a nutrition training and an optimal nutrient menu in
dren receive a majority of their meals from ECE programs; collaboration with food service staff in NA ECE programs. The
therefore, it is crucial to ensure that these programs provide purpose of this study is to examine the effects of community and
nutritious meals [11]. Evaluation of ECE preschool menus is an ECE intervention, including nutrition training and optimal
inexpensive way to keep the families informed about their chil- nutrition menu implementation, with food service staff, on the
dren’s dietary intake at the ECE programs, examine the nutrient meal and menu quality in tribally affiliated ECE programs. We
quality of the foods served, and explore the opportunity for hypothesized that the meal and menu quality will improve and
enhancing nutrition quality through training and interventions sustain after the training with food service staff at these NA ECE
[12–14]. Evaluating menus is a time- and resource-efficient settings.
method to do because it does not require as much time or
commitment from the research staff to conduct site visits in the Methods
classroom and observe the foods consumed by children. It is also
less intrusive and burdensome for the participating ECE
Study design
programs.
This intervention study is part of a larger community-based
Many studies include evaluation of foods served to children;
participatory research (CBPR) study known as FRESH (Food
however, only a few studies have evaluated the menu quality in
Resource Equity and Sustainability for Health). CBPR is a
childcare settings [6, 15, 16]. A nationwide study reported a
research approach unifying education and social action to reduce
94%-100% agreement between the menu and actual foods
health disparities and improve overall health. CBPR focuses on
served [17]. Fruits, vegetables, and meat/beans are rarely listed
relationships between research partners and the goals of the
as a part of snack, and 100% fruit juice is listed more than 3 times
societal shift rather than specific research methods. In this study,
a week in menus [16]. Menus include foods high in sugar and salt
the Osage Nation community members guided all aspects of the
[6, 16], those that lack sufficient energy [6, 15], and those that
research study, from the development of the research focus and
are high in sodium and other micronutrients [15]. Further,
question to the design, implementation, and evaluation of the
evaluation of meals served in the ECE programs show that
intervention. Site directors, lead teachers, and food service staff
higher-fat milk and sugar-sweetened beverages are served [18].
worked collaboratively with the research team to address spe-
ECE programs can participate in the Child and Adult Care Food
cific community needs and goals. Food service staff reviewed
Program (CACFP) that reimburses the programs for providing
menus and revised them to address specific barriers and needs
healthy meals and snacks to children. Studies report that
within each school kitchen setting, including for example storage
CACFP-participating programs serve healthier foods and bever-
needs and food-preparation space needs. Menus were adapted in
ages than non-CACFP participating programs [19, 20]. However,
accordance with these needs and priorities. The training
there is variation in the fidelity with which programs implement
included key components needed and requested by the com-
the CACFP guidelines, meaning that achievement of CACFP re-
munity and was fit into busy schedules of the food service staff.
quirements is much higher whereas achievement of best prac-
The needs of the parents, students, teachers, and staff were dis-
tices is relatively low [21–23], and these variations may
cussed in participatory research meetings held within each
compromise the nutritional quality of menus and meals served.
community to develop all phases of the study.
These studies collectively indicate the need to improve the
The goals of FRESH were to enhance vegetable and fruit
menus and meals in ECE programs and to focus on improving the
intake and lower food insecurity, BMI, and blood pressure among
best practices.
NA families residing in Osage Nation. Intervention details have
Several factors influence food preparation and service de-
been described elsewhere [24, 35–38]. This paper focuses on the
cisions in ECE programs, including menus and food-service staff
effect of the intervention component with food service staff on
training [6, 17, 24]. Only 20% of food-service staff receive some
meal and menu quality. Nine food service staff personnel from
training on healthy eating [6] and food is prepared most often by
each of the 9 ECE programs participated in the intervention
a person who has not received any formal training or education
along with 9 program directors and 3 site administrators. The
in nutrition [17], identifying the need to collaborate with food
FRESH study implementation took place in the spring semester
service staff in education and training [24]. Food preparation
of 2018. This study was approved by the University of Oklahoma
staff have limited knowledge of optimal nutrition for young
Health Sciences Center Institutional Review Board, which acted
children, yet they have the responsibility to design menus, pro-
as the IRB of record for Osage Nation, as per request of the
cure and prepare foods, and provide optimal nutrition for
Nation at the time of the study.
growing children. Addressing this outlined lack of knowledge
and training through interventions is critical for ECE program
staff to enhance the nutritional quality of meals served. Previous Description of ECE programs
interventions conducted with ECE settings found an improve- Nine ECE programs in 4 communities in Oklahoma (Skiatook,
ment in the menu quality [25], nutrition-related practices [26], Fairfax, Hominy, and Pawhuska) are operated by the Osage
and nutrition knowledge and policy [27], and they did not Nation, including 4 Head Start programs, 4 Wah-Zha-Zhi Early
include food service staff in their trainings. A few ECE inter- Learning Academies (WELAs), and 1 Osage Language Immersion
vention studies involved training of the food-preparation school. The Head Start programs enroll between 19 and 95

2
D. Patel et al.
children per community and have been operational for ~4 de-
cades and all participate in the CACFP. The WELAs and Language
Immersion programs enroll between 12 and 34 children per
community and operation duration ranges between 3 and 8 y.
The WELAs participated in the CACFP and one Language Im-
mersion program did not participate in the CACFP at the time of
data collection. The ECE programs operate on a 6-wk menu cycle
and share one central menu planning team, with a registered
dietitian overseeing the menus. However, individual programs
have the liberty to alter menus based on vendor food availability,
spoilage, food preparation staffing/storage, and preference [24].
Intervention overview
The intervention with the food service staff is fully described
elsewhere [24] and took place in Hominy, Oklahoma. The
FRESH intervention was based on the ecological framework [39]
that conceptualizes the many food environments and conditions
that influence food choices, emphasizing the policy and envi-
ronmental and individual contributors to eating patterns. It
included 2 main components developed specifically for and
based on needs identified by the tribal community partners,
which were 1) collaborative development of a best-practice
menu for all programs and 2) training on meals and menu best
practices. A best-practice menu based on the CACFP best prac-
tices guidelines was designed with consideration for vendor
regularity and food procurement, refrigerated storage availabil-
ity, and food service staff’s burden and availability. Existing
recipes were modified to introduce healthy and new recipes.
Goals of the tailored best-practice menu were to increase offering
of whole fruit, vegetables, and grains; to reduce pre-fried and
processed foods; and to eliminate juice. The three-hour in-person
training included the following topics: 1) why meet best prac-
tices; 2) best practices in food preparation; 3) strategies for easier
menu planning; 4) understanding food labels; 5) easy recipe
modifications; and 6) explanation and discussion of the
best-practice menu.
Large group, small group, and individual activities were
included to facilitate trainee engagement. Examples of large
group activities included identifying which frozen foods were
fried or baked from the pictures and identifying quality of the
meal plates photos to assess visual appeal. Small group activities
included identifying recipes that could be prepared in bulk,
choosing 1–2 recipes from the menu and identifying healthy
alternatives for the same, and identifying healthy substitutes for
some recipes listed on the menu. Individual activities included
setting smart goals, identifying barriers and solutions to imple-
menting best practices, identifying recipes that could be pre-
pared in advance, and completing a healthy cooking quiz.
Best-practice menu implementation
The best-practice menu was developed for implementation
beginning January 2018. Process evaluation data assessing the
implementation of the menus at each of the 9 programs was
collected by research personnel. Information from the food ser-
vice staff at each program at 5 different time points was collected
for 1 y (from fall 2017 to fall 2018). Copies of the menus were
collected to assess menu quality and research personnel visited
each site to record what was served, ingredients used, quantity
served, and preparation methods for a 1-wk period (week 5 of
the menu cycle) to assess the meal quality. Food service staff was
3
Current Developments in Nutrition 7 (2023) 100040
aware that week 5 was going to be included in the data collec-
tion. Once the training on the implementation of the best-
practice menu was completed, all sites were instructed to
follow the menu for the rest of the data collection period; how-
ever, there were no additional follow-ups on the menu imple-
mentation post the intervention. After the intervention, the study
coordinator was in weekly communication with the food service
staff and the developer of this intervention was available as
needed. No additional support was provided after the interven-
tion unless requested.
Data collection and procedure
FRESH ECE program menus and actual meals (breakfast,
lunch, and snacks) served to FRESH study children attending 9
ECE programs were examined for 1 wk at 5 time points: 1) pre-
baseline (September 2017, before 2017 CACFP meal pattern
requirements were enforced); 2) baseline (October/November
2017, after CACFP meal patterns changed and before training on
best practices); 3) early intervention (February/March 2018,
after the training on best practices, early in FRESH intervention);
4) late intervention (May 2018, after the training on best prac-
tices, late in FRESH intervention); and 5) postintervention
(October 2018, after FRESH intervention). Evaluation of the first
2 time points describing changes in meals and menus before and
after the revised 2017 CACFP meal pattern has been previously
published [35]. The impact of the FRESH intervention from
baseline in October/November 2017 to postintervention in
October 2018 are described herein. Menus were collected from
each program for the 6-wk menu cycle across the duration of the
FRESH intervention, and foods served to children during week 5
of the menu cycle were evaluated. Food service staff from each
program provided recipes, food preparation style, quantity, and
brand of foods served during the week. Whenever possible,
mixed dishes were broken into their respective ingredients and
brands and food labels were photographed by research personnel
to assist in the record keeping. Meals and menus were evaluated
using multiple approaches, including Healthy Eating Index (HEI)
scores measuring quality of the meals, percentage indicating
menu achievement with the revised 2017 CACFP meal pattern
requirements and best practices, and percent and quality of
menu substitutions.
HEI
HEI-2015 is a standardized method to measure diet quality
[40]. All foods served at ECE programs during breakfast, lunch,
and snacks in week 5 of the 6-wk cycle menu were entered into
the ASA-24 [41] to estimate overall HEI scores as well as indi-
vidual components of HEI. Consistent with previous research
[15, 21, 35, 42–45], the minimum required serving size from the
revised 2017 CACFP meal pattern requirements for 3–5-y-old
children was used because serving size is not commonly reported
on menus. If brand names were unknown to the food service staff
or research personnel or unavailable in the ASA-24 database,
brand assumptions were made and applied consistently across all
instances. A detailed list of assumptions consistently used was
maintained by research personnel. HEI consists of 13 compo-
nents based on their nutrient quality and is divided into 2 groups:
1) adequacy components (9 items) and 2) moderation compo-
nents (4 items). The adequacy components refer to the food
groups or nutrients needed in adequate amounts and are healthy
D. Patel et al.
for the body whereas moderation components refer to food
groups or nutrients that are supposed to be consumed in
moderation and are unhealthy for the body if consumed in
excess. Both components have a range of minimum to maximum
points. Adequacy components for HEI include total vegetables in
cups (0–5 points), greens and beans in cups (0–5 points), total
fruits in cups (0–5 points), whole fruits in cups (0–5 points),
whole grains in ounces (0–10 points), dairy in cups (0–10
points), total protein foods in ounces (0–5 points), seafood and
plant proteins in cups (0–5 points), and fatty-acid ratio (0–10
points). Moderation components include sodium in grams,
refined grains in ounces, saturated fat in percent of total calories,
and added sugars in percent of total calories. Each moderation
component has a range of 0–10 points. Total HEI score ranges
from 0 to 100; higher total score correlates to higher diet quality.
Menu CACFP meal pattern requirement and best-
practice achievement
To assess menu achievement with the revised 2017 CACFP
meal pattern requirements and best practices and change over
time, a quantitative index was used to evaluate the actual foods
served and is described in detail elsewhere [35]. There were 51
items used to assess the CACFP achievement and each carried 1
point. Percentages were calculated by adding up the total score
divided by the maximum possible score (19) multiplied by 100 to
compute percentages (possible score of zero to 100 percent).
Two percentages are presented: 1) percentage of menu
achievement to meal pattern requirements and 2) percentage of
menu achievement to best practices.
Substitution quality
Substituting a meal component in place of what the menu
suggests is allowed on the CACFP. Although a substitution is not
inherently adverse, less nutrient-dense substitutions would be
undesirable. The percentage of weekly food components
substituted and their nutritional quality (nutritionally equiva-
lent, nutritionally superior (higher nutrient-density), or nutri-
tionally inferior (lower nutrient-density) were calculated [35].
For example, chicken nuggets are a nutritionally equivalent
substitution for fish sticks, whereas canned corn are a nutri-
tionally inferior substitution for fresh corn because of the addi-
tional sodium present in canned vegetables. Furthermore, fresh
fruit is a nutritionally superior substitution for canned fruit
because of the likelihood of greater nutrients and zero added
sugar. For calculating substitution quality percentage, the num-
ber of components served was the denominator, the number of
components that were substituted was the numerator and
multiplied by 100 to compute a percentage.
Data analyses
Means, standard deviation, medians, and interquartile ranges
were calculated for all variables. Total HEI scores and individual
component scores were calculated for each of the 4 time points.
Similarly, menu achievement percent was calculated for CACFP
requirements and best practices. Lastly, substitution quality
percent was calculated for each of the 9 programs at each time
point. Repeated measures ANOVA was used to determine dif-
ferences in total HEI score, percent menu CACFP achievement,
and percent menu substitution quality across the course of the
4
Current Developments in Nutrition 7 (2023) 100040
intervention. The α value was set at 0.05 and P values smaller
than α were considered statistically significant. All data analysis
was conducted in SAS 9.4.
Results
Nine ECE programs participated in this intervention study
(Table 1). Overall, there was a significant time effect observed
for HEI total score (P ¼ 0.0227; Table 2). Total HEI score
increased significantly (7.5 points) from baseline (71.1
2.1;
95% CI: 69.4, 72.7) to early intervention (78.6
5.0, 95%CI:
3.1, 11.9, P ¼ 0.0045) across all 9 programs. However, the total
HEI score was not significantly different from baseline to late
intervention or postintervention. Compared with baseline (88.1

4.5, 95%CI: 84.7, 91.6; Figure 1), achievement of CACFP menu
requirements decreased significantly (4.8%) at early interven-
tion (83.3
5.6, 95%CI: 2.3, 7.3, P ¼ 0.0022), and did not in-
crease through late intervention (85.4
5.0, 95%CI: 0.8, 6.1, P
¼ 0.1114), and postintervention (84.2
3.9, 95%CI: 1.1, 6.7, P
¼ 0.0123). Achievement of menu best practices did not differ
across the 5 time points (P ¼ 0.2516). Overall, menu substitution
percentage also did not differ across the 5 time points (P ¼
0.5959; Figure 2). There was a significant decline observed in the
superior quality substitutions from baseline to late intervention
(P ¼ 0.007) and an increase in equivalent and inferior quality
substitutions, although not statistically significant.
Discussion
The aim of this study was to evaluate the impact the FRESH
study on enhancement of meal and menu quality in 9 NA ECE
programs. The HEI score of meals to children at baseline was
71.1, which was higher than a previous study evaluating the diet
quality (59.1) in child care centers [46]; however, our study used
HEI for measuring quality of foods served to children in the ECE
programs. There was an immediate and statistically significant
improvement in the meal quality from baseline to early inter-
vention as determined by HEI; however, this increase did not
sustain. Adequate servings of dairy were served, and most
TABLE 1
Demographic characteristics of 9 Early Care and Education programs in
Osage Nation
Variable Frequency (%)
Type of ECE setting
Head start 4 (44)
WELA 4 (44)
Language immersion school 1 (12)
Years in operation
2 2 (22)
3 2 (22)
10 5 (56)
Minimum provider education requirements
High school 7 (78)
4-y college graduate 2 (22)
Continued education requirements
Yes 9 (100)
Written nutrition education policies
Staff training 7 (78)
Education for children 5 (56)
Education for parents 4 (44)
D. Patel et al. Current Developments in Nutrition 7 (2023) 100040

TABLE 2
Impact of food service staff training across the intervention on Healthy Eating Index, menu CACFP achievement, and menu substitution quality
(n ¼ 9)
Outcome Baseline Early intervention Late intervention Postintervention
Healthy Eating Index mean scores (SD)
Total HEI 71.1 (2.1) 78.6 (5.0)1 72.0 (7.0) 74.6 (5.6)
Adequacy components2
Total vegetables 2.4 (0.8) 2.5 (1.0) 2.3 (0.9) 2.7 (1.1)
Greens and beans 2.2 (1.4) 3.7 (1.5) 2.3 (1.2) 2.0 (1.8)
Total fruit 5.0 (0) 5.0 (0) 4.9 (0.3) 5.0 (0)
Whole fruit 5.0 (0) 5.0 (0) 5.0 (0) 5.0 (0)
Whole grains 5.6 (1.9) 7.0 (2.7) 4.8 (2.7) 6.8 (2.6)
Dairy 10.0 (0) 10.0 (0) 10.0 (0) 10.0 (0)
Total protein foods 3.1 (1.0) 4.1 (0.8) 3.8 (0.6) 3.3 (0.8)
Seafood and plant protein 1.9 (2.0) 2.8 (1.3) 1.8 (2.1) 1.1 (1.7)
Fatty-acid ratio 8.4 (2.8) 9.8 (0.5) 10.0 (0) 10.0 (0)
Moderation components2
Sodium 4.6 (1.0) 4.1 (2.2) 4.4 (1.1) 5.1 (1.6)
Refined grains 7.4 (2.4) 8.8 (1.1) 7.7 (1.6) 8.2 (1.4)
Saturated fat 5.9 (1.5) 5.9 (1.7) 5.4 (1.3) 5.9 (1.2)
Added sugars 9.7 (0.4) 9.7 (0.3) 9.5 (0.6) 9.5 (0.4)
1
Statistically significant change compared with baseline at α  0.05.
2
Only descriptive statistics were computed, and inferential statistics (ANOVA) were computed only for the total score and not on the individual
components because of power and small sample size.

FIGURE 1. Impact of food service staff training across the intervention on menu CACFP achievement with requirements and best practices
(n ¼ 9). *Statistically significant with baseline as the reference time point and α ¼ 0.05. CACFP, Child and Adult Care Food Program.

centers served 1% milk, which is recommended by the CACFP.
There was an increase in the servings of fruits, vegetables, and
whole grains immediately from baseline to early intervention,
partially accomplishing the goals of the intervention; however, it
is important to note that some of these changes did not sustain.
These findings are supported in previous studies demonstrating
improvements in fruits and dairy [25], menu quality [26],
reduced fat content in milk [29, 34], and nutrition practices
[27]. It is worth noting that these interventions ranged from a
1-d in-person training to 5 to 8 1-h in-person workshops sched-
uled across weeks [26, 27, 29, 34], except for one study where it
provided an interactive web-based application and food service
staff were trained to use it throughout the 1-y intervention
period [25]. These longer interventions also included regular
follow-ups and phone calls [34], newsletters [26], online re-
sources, and support [25]. Our training with food service staff
was a single session lasting 3 h and conducted in-person. Given
that the significant findings observed in our study were not
sustained over the duration of the follow-up, to promote sus-
tained changes, longer duration training and training on multiple
occasions over weeks or months to reinforce curriculum, perhaps
with the use of booster sessions to refresh content, may improve
the menus as well as meals. Collective findings from previous
studies and our study support inclusion of food service staff to
improve ECE meal quality.
Participation in the CACFP has been associated with healthier
foods and beverages served [20], fewer barriers reported by the
centers [47], and better nutrition outcomes [48]. In our study,

5
D. Patel et al.
FIGURE 2. Impact of food service staff training across the intervention on superior, equivalent, and inferior quality menu substitutions (n ¼ 9).
*Statistically significant with baseline as the reference time point and α ¼ 0.05.
achievement with menu CACFP requirements was high (83%–
88%), whereas the achievement with menu best practices was
low (62%–65%) throughout the intervention. Previous studies
reported 75%–100% and 53%–61% or partial agreement with
the CACFP requirements and best practices, respectively [23,
35]. We observed a significant 5.6% decrease in the CACFP re-
quirements achievement from baseline to early intervention,
specifically a decline in serving 1% milk in snacks, fruit as a
component of snack, serving at least one whole grain per day,
and increased serving of fruit juice during breakfast contributed
to the decrease in the CACFP requirements achievement. This
was an unexpected finding as our training was designed to
augment and enhance CACFP achievement and strive toward
best-practice. Best practices remained unchanged, which was a
surprising finding because the training focused on implementa-
tion of best practices. However, the newly introduced
best-practice menu may have taken some time for the food ser-
vice staff to get acclimated to, but no changes were observed
even with the 1-y follow-up
The ECE programs in this study resided in the Osage Nation in
rural Oklahoma. They have limited access to healthy foods,
grocery stores, and other resources, which affect their ability to
always serve the food items listed on the menu. As a result, foods
are often substituted in the absence of an item listed on the
menu. Studies consistently show that there are discrepancies
between the foods and beverages listed on the menus versus
what is actually served to children [13, 23, 19]. Hence, consid-
ering the number and food substitution quality is crucial to
accurately measure the meal and menu quality. Studies report
foods substitutions ranging between 5% and 25% [14, 23]. In
our sample, about 54% of the total foods served during breakfast,
lunch, and snack time were substituted, which is substantially
higher than some previous studies. Our study was the first, to our
knowledge, to assess the quality of the substitution and not just
the percent of the foods substituted, added, or omitted. There
were small, non-significant changes (both positive and negative)
observed in the quality of food substitution across the interven-
tion. Inferior quality substitutions increased from baseline to
early intervention, whereas both superior and equivalent quality
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Current Developments in Nutrition 7 (2023) 100040
substitutions decreased simultaneously. Although this could be
considered undesirable, they were consistent with trends
observed with other aspects of the menu quality (CACFP
achievement with requirements and best practices). There was a
larger variability observed among the programs for equivalent
and inferior quality substitutions, and this may be because of the
different ways of operation for each program; for instance, some
programs prepared food on-site, whereas a few sites had the
cooked lunch delivered to their site because of limited food
preparation and storage area. Future studies could consider this
limitation as a factor that may influence their decisions related to
food service and substitutions and make necessary accommo-
dations as part of the training.
There were many strengths in this study. To our knowledge,
this was the first CBPR study to observe a quick positive change
in the meal quality at ECE programs. It offered evidence of po-
tential opportunities to train the food service staff along with the
teachers and other caregivers involved with children’s nutrition.
This approach is also supported as the benchmarks for nutrition
in child care by the Academy of Nutrition and Dietetics [12].
This intervention also laid the foundation for future researchers
to develop similar trainings tailored to the community as a whole
and execute robust long-term interventions with more rigorous
follow-ups. This study collected data on both menus and meals,
which provided us the ability to measure the effectiveness of the
best practice on both meals and menu quality. Although the
training was short-term, there was an immediate significant ef-
fect observed specifically in the diet quality, indicating that
robust trainings may be successful in sustaining these positive
changes.
There were some limitations to this study. We had a small
sample of 9 ECE programs participating in the intervention, and
hence, the findings may not be generalizable and must be used
cautiously. The small sample size also limits the power to detect
actual changes that may be present. Future studies could include
a larger sample to achieve reliable findings that truly represents
the population. Research personnel traveled to each program
once during the evaluation week (week 5 of the cycle menu) to
assist with record keeping and recording. Research personnel
D. Patel et al.
again traveled to the program after the evaluation week to
collect the records for the week. This resource-intensive process
could not feasibly be maintained throughout the 6-wk cycle.
Timing was such that the programs were in their fifth week of the
cycle menu at the initial date of data collection. In addition, the
number of days the participating ECE programs operated varied,
because there were some facilities closed on certain days because
of bad weather. Therefore, data collected ranged from 3 to 5 days
a week and this may have skewed the findings. Future studies
should attempt to include a fixed number of days for all programs
for consistency during data analysis and interpretation. Finally,
the training was short-term and may have contributed to the lack
of sustainability in the positive improvements in this study.
Future studies could sustain this change by developing long-term
interventions tailored to address the needs of the food service
staff in the ECE settings.
There were several practical lessons learned from this CBPR
intervention focusing on ECE food service staff that warrants
discussion. During CBPR process and community meetings, often
site directors, lead teachers, and occasionally food service staff
were present. The training was short-term (3 h) and hands-on,
designed to include the key components needed and requested
by the community, and fit into busy schedules of the food service
staff. Although several iterative meetings were conducted with
site directors and some participating food service staff on the
barriers to food procurement, best-practice foods service, and the
suggested changes to the menu itself, these meetings occurred
before the menu launch rather than following. Not having
ongoing and follow-up conversations with the food service staff
prevented us from knowing emergent and unpredicted imple-
mentation barriers that arose. This limitation could be addressed
in future studies by designing a protocol that includes weekly or
monthly follow-ups with the participants based on the duration
of the intervention. Further, with the integration of remote
learning technology post pandemic, the ability to deliver the
interventions and follow-up to rural ECE programs has
enhanced. Given the lack of sustained impact of the training, it is
recommended that future trainings include more follow-up
communication and booster sessions. Balancing the community
partner needs for short interventions with the need for more
sustained intervention guide to smaller sections of nutrition and
best practice content delivered over weeks and/or months.
Community partnership would also be strengthened by more
buy-in of the food service staff and food-preparation staff in
addition to site directors and teachers. Food service staffs often
have different background than the site directors and teachers
who often have education and teaching backgrounds rather than
food service. In hindsight during the CBPR process, less effort
was given to ensure that the food service staff had lasting
contribution and buy-in to the entire project. Although several
meetings included these personnel, likely more relationship
building at the front end of the intervention would have been
beneficial. Ensuring the unique needs of these individuals within
the ECE context are heard will strengthen implementation and
sustainability.
In conclusion, the meal quality improved immediately from
baseline to early intervention, which provided evidence that
training food service staff and other food service staff may be
beneficial to improve meal quality in the ECE programs. How-
ever, it is important to note that the positive changes in the meal
7
Current Developments in Nutrition 7 (2023) 100040
quality did not sustain, indicating a need for longer and rigorous
trainings. Although the changes observed in the menu CACFP
achievement for best practices and the food substitution quality
were not statistically significant, our findings present an oppor-
tunity to work and train the food service staff to improve the
meal and menu quality as well as provide optimal nutrition en-
vironments for young children.
Funding
Supported by the National Institute of Minority Health and
Health Disparities (grant R01MD011266). The funding agency
had no role in the study design, data collection, analysis, decision
to publish, or preparation of the manuscript.
Author disclosures
The authors report no conflicts of interest.
Acknowledgments
The authors thank the leaders and citizens of the Osage
Nation for their participation and continued support of the Food
Resource Equity and Sustainability for Health (FRESH) Study.
The authors also thank the Osage Nation Executive Committee
who served as the guiding body throughout the duration of the
FRESH study and their commitment to address diet-related
chronic disease in the young families in their communities
through participation in the committee and numerous other
endeavors. The study was reviewed and approved by the Insti-
tutional Review Board of the University of Oklahoma Health
Sciences Center.
Author contributions
All authors’ responsibilities were as follows – DP: conducted
the current analyses including data processing and manuscript
preparation; SBS: supervised the current analyses, lead manu-
script preparation, supervised and designed the food preparer’s
training, performed data collection at ECE sites, and contributed
to site-level data security; KS and RR: conducted initial training
for food preparer’s, collected data, processed data, and contrib-
uted to manuscript preparation; CL: coordinated the FRESH
study, facilitated community engagement and partnerships,
ensured FRESH study data security, supported manuscript
preparation; TT: coordinated the FRESH study including com-
munity partnership meetings and data integrity, ensured FRESH
study data security, and contributed to data interpretations and
manuscript preparation; MS: is the Osage Nation site principal
investigator, co-developed the FRESH intervention, and
contributed to manuscript preparation; VBBJ: designed the
FRESH intervention, supervised all data collection and data se-
curity for the FRESH study, and contributed to data in-
terpretations and manuscript preparation; and all authors: have
read and approved the final manuscript.
Data Availability
This work has not been published elsewhere. We plan to
present this work through conferences, publication, and other
state-level agencies.
D. Patel et al.
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