GROWING THE NEXT GENERATION: STRATEGIES TO IMPROVE NUTRITION AND CHILD DEVELOPMENT IN LOS ANGELES COUNTY

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Growing the Next Generation: Strategies to Improve Nutrition and Child Development in Los Angeles County was prepared by Leslie Mikkelsen, Larry Cohen, Karen Harris, and Katherine Keir.

This report was originally commissioned by the County of Los Angeles, Department of Health Services. The information presented and the opinions expressed in this report are those of the authors. While some of the data are specific to Los Angeles County, the issues addressed, recommendations, and strategies within the paper are relevant and applicable to communities everywhere.

Funding was provided in part by a grant from The California Wellness Foundation (TCWF). Created in 1992 as an independent, private foundation, TCWF's mission is to improve the health of the people of California by making grants for health promotion, wellness education, and disease prevention programs.

Prevention Institute would like to thank the following individuals who agreed to be interviewed for this paper: Johanna Asarian-Anderson, Patricia Bowie, Andy Fisher, Doris Fredericks, Suzanne Heydu, Paula James, Michelle Mascarenhas, Ursula Ng, Matthew Sharp, and Frank Tamborello.

Suggested Citation:
Mikkelsen L, Cohen L, Harris K, Keir K. Growing the Next Generation: Strategies to Improve Nutrition and Child Development in Los Angeles County. Oakland, Calif: Prevention Institute; 2001.

Introduction

When women are undernourished during pregnancy, or children do not consume necessary nutrients in their early years, the future consequences for children's health can be severe and long lasting. Young children (from birth through age 5) have specific nutritional needs, which must be met for them to reach their full physical, mental, and social potential. Because they undergo periods of rapid growth, these children are particularly vulnerable to the detrimental effects of poor diet.

Government agencies, health organizations, and nutritionists have been disseminating nutrition information for decades, yet national and statewide dietary intake surveys indicate that most families in America, as well as in California, do not eat according to United States Department of Agriculture (USDA) dietary guidelines.¹ What prevents these families from consuming a healthy diet? Clearly, the problem is not simply that they lack information.

While nutrition education is important, environmental, cultural, socioeconomic, and political factors are also critical in influencing how families eat. For example, young children who watch television advertising for sugary cereals and high-fat foods may pressure their parents to buy these foods. Food is closely tied to cultural and social practices; if families are accustomed to buying and preparing foods high in fat, sugar, and salt, they are unlikely to alter these habits simply because they know these foods are unhealthy. Financial pressures can impact the quantity and variety of foods that families eat; for those who must choose between food and rent or medicine, food is often the most flexible item in the family budget. Finally, political issues, such as the availability of funding for supplemental nutrition programs, can have a dramatic impact on whether low-income families are able to ensure that their children have nutritious diets.

Why Is Adequate Nutrition Essential for Children Ages 0-5?

Good nutrition begins before conception, and continues when the child is in the womb. When women do not consume sufficient amounts of the B vitamin folic acid before conception and in early pregnancy, their babies are more likely to be born with neural tube defects.² (The neural tube is the hollow dorsal tube in the embryo that eventually gives rise to the brain and spinal cord.) In pregnant women, improved diet has been shown to result in higher birth weights, greater head circumference, and improved cognitive functioning for children after birth.³ Conversely, inadequate maternal weight gain and iron deficiency anemia is linked to retarded fetal growth, fetal and infant mortality, and behavioral and learning problems after birth.^{4, 5}

Young children, who grow rapidly between birth and five years of age, require good nutrition to achieve healthy development. Children require sufficient calories to meet their daily energy needs; they also must consume a variety of foods to obtain necessary vitamins and minerals. A healthy diet helps children achieve proper physical growth and protects them against illness and infection. Proper nutrition not only contributes to young children's physical development, but affects their cognitive development as well. Undernourished children can have trouble concentrating, become easily fatigued, listless, or irritable, and are likely to face difficulties in learning.⁶ These symptoms can lead children to develop behavioral and social problems. In addition, malnourished children are more likely to miss school due to illness⁷ and are more susceptible to lead poisoning,⁸ both of which can negatively impact a child's learning and development.

Promoting good eating habits in young children can also help to prevent chronic diseases later in life.⁹ Good nutrition is associated with lower risks of cancer, cardiovascular disease, stroke, and diabetes. Between the ages of 12 and 21 months, young children are inclined to put things in their mouths. Parents can take advantage of this "window of opportunity" by introducing a variety of foods so that children learn to enjoy a varied, nutritious diet.¹⁰

Food also plays a central role in social interaction. When young children's experiences of mealtimes are pleasant, meals can foster social bonds within the family. However, when parents react negatively to children's eating behaviors or use food as a way to discipline or reward their children, children's eating habits can become distorted.¹¹ The psychological and cultural elements that come into play during meals ultimately influence a child's attitudes toward certain foods and eating in general.

What Are the Nutritional Needs of Children Ages 0-5?

Young children's nutritional needs vary according to developmental stage, and differ from the dietary needs of adults. Thus, the definition of "good nutrition" for young children evolves and changes as they grow. This section briefly explores nutritional requirements before birth, during infancy, and in early childhood.

The American Academy of Pediatrics recommends breastfeeding as the best source of nutrients to promote infant health, growth, and development through 12 months of age.¹² For newborns, breastfeeding is especially beneficial because it provides immunological protection and resistance to allergies, reduces the risk of future obesity, and fosters bonding between mother and child. While mothers who choose to use formula should be supported in their decision, every effort should be made to support and promote breastfeeding. Between 1994 and 1999, the percentage of mothers in L.A. County that initiated breastfeeding was 79%, higher than the U.S. Department of Health and Human Services goal of 75%. By the time their infants were six months of age, 40% of L.A. County mothers were still breastfeeding. This figure is slightly lower than the national target figure of 50%, indicating efforts should continue to be made toward promoting sustained breastfeeding.^{13, 14}

Foods that are not likely to cause allergies can be introduced between four and six months of age, according to the child's level of readiness.¹⁵ Between six and twelve months of age, breast milk or formula intake can decrease gradually as the infant's intake of solid foods, such as fruit and vegetable purees and cereals, increases.¹⁶ Between one and two years of age, parents may also choose to introduce milk, eggs, meats, and other protein foods that may cause allergies if given earlier. At this young age, children have high calorie needs and therefore whole milk is recommended. Once children begin to consume solids, the healthiest diet is one that emphasizes high fiber plant foods, including fruits, vegetables, grains, and legumes, with smaller amounts of protein and dairy products.¹⁷ The USDA Food Guide Pyramid is a good resource for basic information on the dietary needs of children over the age of two.¹⁸

Are Our Children Well-Nourished?

Dietary intake surveys show that, across all income levels, children from birth to 5 years of age tend to consume less fiber and fewer servings of fruits and vegetables, but more fat and sodium than recommended.¹⁹ A recent study of middle- and upper-income preschool children found that the most frequently consumed foods were fruit drinks, carbonated beverages, milk, and French fries.²⁰ This dietary pattern is consistent with studies that find that young children generally consume lower than recommended amounts of calcium, iron, zinc, and vitamins A, C, and E.²¹

Rates of obesity in U.S. children have been rising steadily, with a 100% increase between 1980 and 1994.²² Obesity increases risk for heart disease, diabetes, stroke, and other chronic diseases. Childhood obesity also puts a child at risk for teasing and stigmatization.²³ A less active lifestyle combined with greater intake of high-calorie foods is responsible for rising obesity rates.²⁴ One study has concluded that for every hour of television that young people watch per week, their probability of obesity increases by 2%, both because they are less active and because television encourages overeating.²⁵ Increasing soda consumption has also been implicated; a study by Boston Children's Hospital found that one additional soft drink serving a day increases a child's risk of becoming obese by 60%.²⁶ Obesity is a significant problem in Los Angeles County. A 2000 L.A. County Department of Health Services report found that nearly half of adult Angelenos are overweight.²⁷ Promoting good nutrition and physical activity in young children may help reduce the increasing prevalence of obesity.

Children from low-income families are at greater risk of obesity due to factors such as parents' reliance on inexpensive fast foods and inadequate opportunities for exercise in dangerous neighborhoods that lack play facilities.²⁸ At the same time, low-income children are at higher risk for inadequate intake of nutrients.²⁹ Since one third of Los Angeles County's children live below the poverty line, this is a serious concern.³⁰ Iron deficiency is one manifestation of chronic micronutrient under-nutrition. An estimated 22% of preschool children screened by the California Children's Health and Disability Prevention Program are anemic; 6% are small for their age.³¹

What Are the Barriers to Adequate Nutrition for Children Ages 0-5?

Many cultures and ethnicities have traditions that emphasize high consumption of fruits, vegetables, and grains. But what families in this country choose to eat is influenced by many factors beyond these traditions. Some of the significant forces that shape dietary habits and nutrition are discussed below.

Lack of Knowledge, Skills, and Time

Children are not born with an innate ability to choose healthy diets.³² Parents' and other caretakers' nutrition knowledge, food preparation skills, cultural background, socioeconomic status, and attitudes toward food all influence how they select foods for their children, and ultimately shape their children's eating habits.³³ It can be difficult for parents to know what to serve, especially when nutrition information seems contradictory or inconsistent.³⁴ When parents lack knowledge of proper nutrition, or do not have the skills or inclination to cook healthy foods at home, they can instill poor eating habits in their children.

Long hours and work pressures often make it difficult for parents to shop for and prepare food. "Are crazy hours and takeout dinners the elixir of America's success?" asked a recent article in U.S. News and World Report.³⁵ The University of California, San Francisco's recent Work and Health Study found that 21% of parents with children work between 45 and 54 hours a week, while 17% work more than 55 hours.

These long hours contribute to American families' increased consumption of fast foods and pre-prepared "convenience foods." In a recent dietary survey, over 40% of California adults reported eating at least one meal from a restaurant or cafeteria on the previous day; almost half of those meals were purchased from a fast food restaurant.³⁶ Children are also eating more meals away from home.³⁷ Meals that are not prepared at home tend to be higher in fat, calories, and salt,³⁸ and people who eat at restaurants report consuming fewer fruits and vegetables than those who eat at home.³⁹

Financial Pressures/Poverty

Inadequate income makes it difficult for many parents to purchase enough nutritious food for their children. According to 1995 census data, 34% of children in Los Angeles County live below the federal poverty line (an annual income of $16,050 for a family of four),⁴⁰ and even families with incomes above the poverty line often struggle to survive. In California, recent data found that an estimated 11% of households are "food insecure," meaning that they do not have sufficient means to purchase food to meet their families' needs reliably. An estimated 5% of households experience moderate to severe hunger.⁴¹ In Los Angeles County, 36% of soup kitchen and food pantry clients are children.⁴² One neighborhood survey of residents in South Central Los Angeles found that 27% of households reported running out of money for food an average of five days a month.⁴³

The Influence of Marketing

Food manufacturers spent $7 billion on advertising in 1997 and the greatest expenditures tended to be for the most highly processed and highly packaged foods.⁴⁴ Food advertising influences adult buying patterns, as well as children's demands for particular foods.⁴⁵ As Dr. Milton Chen, an expert in the influence of television on children relates, "Ad execs should be especially thankful for small children, because [children] work so hard for them."⁴⁶ Young children between the ages of 2 and 5 spend approximately 27 hours per week watching television; on average, 3 of those 27 hours are commercials. Over half of advertisements targeting children are for food, especially foods high in fat and sugar and low in nutrients.⁴⁷

Food marketing also goes beyond advertising. Branding of products such as T-shirts, hats, and school supplies reinforce commercial messages. Some soft drink companies have even licensed their logos to baby bottle manufacturers and studies show that parents who buy these bottles are significantly more likely to give soft drinks to infants.⁴⁸

Lack of Access to Healthy Choices

Each year, thousands of new food products are introduced into grocery stores; the majority of them are highly-processed foods containing added fat, oil, sugar, and salt.⁴⁹ In the U.S., fast food chains, convenience stores, and cookie and ice cream shops have proliferated in recent decades.

Many large chain supermarkets have abandoned the inner city, leaving corner stores that feature snack and processed foods rather than a variety of groceries and fresh produce.⁵⁰ A 1995 analysis of 21 major U.S. metropolitan areas found there were 30% fewer supermarkets in low-income areas than in higher-income areas. Studies have consistently shown that prices at small grocery and convenience stores can exceed those at chain supermarkets by as much as 48%. Smaller stores are also unlikely to offer the variety of products or the high product quality offered by most major supermarkets.^{51, 52, 53} In a survey of food stamp recipients, USDA found that they were more likely to make just one major trip to the supermarket each month, usually after receiving their food stamps.⁵⁴ Thus they are more reliant on neighborhood stores for perishable items such as fresh fruits and vegetables.

Low-income households are less likely than more affluent households to have a car.⁵⁵ In a 1993 survey of South Central Los Angeles residents, 38% of households reported not having a car and 33% reported difficulty transporting groceries home from the store.⁵⁶ Neighborhood residents either get less for their money shopping at smaller neighborhood stores or they spend precious food dollars on transportation to obtain a better selection.^{57, 58}

The Need for Multi-Level Interventions

Given the many influences on early childhood nutrition described above, interventions to promote nutrition will have greater impact if they utilize multiple strategies. Frequently public health efforts to improve nutrition are directed towards educating individuals and communities. However, education is only one component of a successful strategy to change social norms and influence health behavior. Noting the failure of information and counseling initiatives to change people's dietary and smoking habits, Dr. Leonard Syme, Professor Emeritus at the University of California, Berkeley, stated that such programs have little impact on the distribution of disease because they "do not address the forces in society that caused the problem in the first place."⁵⁹ The surrounding environment is therefore an important focus for interventions. Glanz and Mullis have defined environmental approaches as those that "encourage positive nutrition behavior by creating opportunities for action and removing barriers to following a healthy diet. Environmental efforts... remove the emphasis on personal health behaviors and move it to factors in society or culture that generate or set the stage for unhealthy practices."⁶⁰

The Spectrum of Prevention is a tool for developing multifaceted solutions to complex health problems that include attention to environmental factors.⁶¹ The tool is comprised of six levels of increasing scope, beginning with a focus on the individual and family and moving towards institutional practices and policies. The Spectrum seeks to aid community coalitions, public health practitioners, and policy makers to improve health outcomes by identifying the need for a systems approach and encouraging an overall strategy that can result in "a whole that is greater than the sum of its parts." By using the Spectrum to develop and shape a comprehensive nutritional strategy, Los Angeles can more effectively support the health of its youngest residents. Local decision makers and issue specialists can use the Spectrum to prepare their own plan for meeting the nutritional needs of young children.

The Spectrum of Prevention

Level	Description	Recommendation
Influencing Policy and Legislation	Develop strategies to change laws and policies to influence health outcomes.	Improve food access of low-income families through federal nutrition programs and community food projects.
Changing Organizational Practices	Adopt regulations and norms to improve health and nutrition and create new models.	Integrate support for breastfeeding and healthy food choices into the practices of public, business, and nonprofit organizations.
Fostering Coalitions and Networks	Bring together groups and individuals for broader goals and greater impact.	Build strong community collaborations.
Educating Providers	Inform service and care providers who can transfer skills and knowledge to others.	Provide training to professionals and community residents working with young children and their families in disseminating accurate information on early childhood nutrition.
Promoting Community Education	Reach groups of people with information and resources to promote health and nutrition.	Support high-quality nutrition education and social marketing campaigns to provide consistent information and wide dissemination of positive messages at the community level.
Strengthening Individual Knowledge and Skills	Enhance an individual's capability to prevent nutrition-related diseases.	Ensure that pregnant women and parents are provided with accurate information about prenatal nutrition, breastfeeding, and child feeding.

The final section of this paper offers examples of current efforts, such as community-based nutrition programs, that are elements of an effective nutrition strategy for Los Angeles County. In addition, it offers strategies that L.A. County could employ to improve coordination of and access to the county's nutrition services. In developing their comprehensive plan, L.A. County leaders and early childhood nutrition experts may wish to bear in mind the following key recommendations.

Influence Policy: Improve food access of low-income families through federal nutrition programs and community food projects.

The safety net of federal nutrition programs is the primary resource available to low-income households to supplement shortfalls in the household food supply. The Food Stamp Program and the Supplemental Nutrition Program for Women, Infants and Children (WIC) provide direct assistance to families and have been demonstrated to have a positive impact on the nutrient intakes of young children.^{62, 63, 64}

Participation in the Food Stamp Program has dropped dramatically across the United States in recent years. In Los Angeles County, the program served more than 200,000 individuals in September 1994 but as of 1999 served just over 100,000 people monthly.⁶⁵ Many eligible households, including working families with young children, are not using the program. Barriers to participation include lack of knowledge about eligibility, administrative barriers, confusion over changes wrought by welfare reform, and stigma associated with using public assistance.⁶⁶ Many immigrant families fail to participate for fear that program use could affect immigration status.

The WIC program serves 68% of all babies born in Los Angeles County.⁶⁷ However, WIC is not an entitlement program and funding is insufficient to serve all eligible individuals. Prompted by a declining economy and threatened cutbacks at the federal level, current concern is that fewer families will receive benefits. Local efforts need to be directed to ensuring that the highest risk women, infants, and children are enrolled in WIC and to advocating for retaining adequate funding at the federal level.

Improving access to reasonably priced, nutritious food ensures that limited food dollars will stretch farther. Responding in part to Seeds of Change, a 1993 landmark analysis of the food access concerns faced by residents of South Central Los Angeles, a growing number of community food security projects have been established in Los Angeles designed to meet this goal. Strategies employed range from establishing new supermarkets and improving transportation to stores to promoting alternative food sources such as farmers' markets and community gardens to linking local institutions such as schools for direct purchases from local farmers.⁶⁸

Key Actions

• Work through community agencies that serve families with young children to ensure all families are aware of food stamps, WIC, and school lunch/breakfast programs and understand their eligibility requirements and how to apply for them.

• Create more outstations where households can be directly enrolled in food stamps, WIC, and school meals.

• Train nonprofit agency staff to pre-certify eligibility for food stamps and provide assistance with the application process.

• Engage neighborhood residents and community organizations in the mapping of food stores, restaurants (quality and quantity), and nutrition-related resources for families.

• Modify zoning, tax, and other county and city regulations to encourage food stores and farmers' markets in under-served areas.

• Provide small business loans and training to small store and restaurant owners in under-served areas to carry produce and improve the nutritional quality of prepared foods.

Change Organizational Practices: Integrate support for breastfeeding and healthy food choices into the practices of public, business, and non-profit organizations.

Through supporting and modeling healthy behaviors, institutional practices can have a direct impact on the food served to young children and can broadly influence social norms around breastfeeding and healthy eating. Helping a greater number of institutions adopt this role is a key element of positive norms change.

For example, the Child and Adult Care Food Program (CACFP) is a federally funded program that reimburses family and nonprofit daycare providers for meals and snacks they serve to children. To receive reimbursements, providers must receive training in nutrition and serve foods that meet nutritional standards established by the federal government. A USDA evaluation found that children enrolled in CACFP-reimbursed daycare facilities received meals that were nutritionally superior to those served to children in childcare without CACFP.⁶⁹

Worksite programs can also be instrumental in supporting breastfeeding mothers. Organizations as diverse as the Cigna Health Insurance Corporation and the Southern California-based Public Health Foundation WIC Program provide consultation for mothers with a professional lactation consultant before and after birth, and time and space for mothers to pump and properly store breast milk in the workplace. Both programs have demonstrated success, as more than 70% of enrolled women were still nursing their babies at 6 months of age, compared to the national average of about 20% of employed new mothers. Since breastfed babies require fewer prescriptions, CIGNA is also reporting an additional benefit in savings on pharmacy costs.^{70, 71}

Key Actions

• Target 100% enrollment of family childcare and nonprofit centers in the Child and Adult Care Food Program.

• Provide support to all settings with preschoolers (e.g., family daycare centers, childcare centers, and other related sites) to offer healthy, nutritious meals and snacks.

• Recognize, support, and encourage workplaces to promote breastfeeding practices by providing information, materials, and access to comfortable surroundings for feeding or breast pumping and milk storage.

• Recognize, support, and encourage public businesses, nonprofit organizations, faith-based organizations, and other influential neighborhood institutions to serve as models of good nutrition by ensuring healthy choices are always available.

Foster Coalitions and Networks: Build strong community collaborations.

The many benefits of good nutrition for young children warrant a coordinated approach across the county. Many public, business, and nonprofit organizations have a role to play in promoting good nutrition. Some of these organizations, such as WIC and Head Start, may already see themselves squarely in the role of promoting nutrition. Others, such as city and county planners, public transit agencies, or corner store owners, may not realize they have a valuable role to play in ensuring that children in Los Angeles County are well-nourished. Coalition building provides an opportunity to build a multifaceted strategy that no single organization could carry out alone.

Coordinating efforts that build on the mission of each organization will lead to a greater impact. A coordinated system can also help maximize resources, advancing complementary efforts rather than duplication among county departments and community agencies. Implementing a systematic approach to nutrition promotion can also provide a mechanism for ensuring that all potential state and federal funding is leveraged and positions the county to be an impressive applicant for new funds.

Key Actions

• Ensure collaborative efforts between early childhood development entities and nutrition programs, i.e., Los Angeles Child Care Council, Children and Families First (Proposition 10 Commission), Children's Planning Council, Project LEAN, and advocacy organizations.

• Link nutrition with other health-related issues (i.e., physical activity, tobacco, alcohol, and substance abuse) as part of a comprehensive approach to healthy childhood development.

• Foster collaborative planning between public health nutrition programs and other private and nonprofit entities such as the retail and food processing industries, public transportation, and city and county planning, all of which play a role in improving access to healthy foods.

• Develop a countywide action plan with broad community participation for delineating a comprehensive approach to improving nutrition in Los Angeles County.

• Establish a county monitoring system for key nutrition-related health indicators.

Educate Providers: Provide training to professionals and community residents working with young children and their families in disseminating accurate information on early childhood nutrition.

Parents rely on a variety of sources for information on the best ways to feed their children. Health care providers are one leading source, though nutrition may not be a central part of their training. Early childhood educators are also in an excellent position to provide information to parents. Peer educators are another option for assisting parents and they have been utilized successfully in a number of settings including the USDA Expanded Food and Nutrition Education Program.⁷² These educators, also known as promotoras or lay health workers, have employed and trained neighborhood residents to provide information and resources on a variety of health topics. Such an approach builds the capacity of community residents, especially in low-income neighborhoods, to learn and disseminate vital health information.

Key Actions

• Ensure that health care providers are well-trained or partnered with lactation counselors and nutritionists to provide support to parents.

• Ensure a fully integrated approach to child health and development by expanding training and certification in breastfeeding and childhood nutrition issues for early childhood educators.

• Provide training in the benefits of breastfeeding and nutrition for all individuals involved in home visits to families with young children.

• Expand programs utilizing community residents to be sources of information on early childhood nutrition for families in their neighborhoods.

Promote Community Education: Support high-quality nutrition education and social marketing campaigns to provide consistent information and wide dissemination of positive messages at the community level.

Most public nutrition education programs, such as Head Start and WIC, are targeted to families with low incomes. Activities may include mealtime experiences that model adherence to the USDA dietary guidelines, positive social interactions, and good eating behaviors. Lessons learned from programs targeted toward families with young children are that three key elements are needed for successful nutrition education. First, efforts must be appropriate to the cultural, educational, and socioeconomic needs of the audience. Second, program staff must be adequately trained and supported to ensure that they provide accurate information and utilize appropriate teaching and counseling techniques. Third, the organization that coordinates educational efforts should put into practice the messages it sends, i.e., staff should model healthy behavior.⁷³

In addition to group classes, nutrition education utilizes broader information dissemination strategies such as social marketing campaigns (the application of commercial marketing techniques to promote social good) and "point-of-purchase" displays (information posted in places where consumers make their purchasing decisions, such as grocery stores, restaurants, or cafeterias). Well-designed social marketing campaigns have been demonstrated to have a positive influence on increasing consumption of fruits and vegetables ("5 A Day"), lower-fat milk ("1% or Less"), and have been applied to breastfeeding promotion.^{74, 75} Given that individual health behaviors are also influenced by the media (both news stories and the entertainment industry), efforts have also been made to influence media content to model healthy behaviors and provide nutrition information.

Key Actions

• Promote inclusion of developmentally appropriate nutritional education and positive mealtime experiences with nutritious foods into all childcare and preschool settings.

• Integrate educational information regarding good food choices, food buying, and preparation into parenting classes.

• Utilize tested social marketing campaigns and coordinate with campaigns across the media region.

• Encourage news stories, public service announcements, and program story lines to promote healthy nutritional habits.

Strengthen Individual Knowledge and Skills: Ensure that pregnant women and parents are provided with accurate information about prenatal nutrition, breastfeeding, and child feeding.

Pregnant women and first-time parents are often open to child-rearing advice; it is therefore important to ensure that these individuals have access to accurate advice regarding nutrition for their children. Essential topics include education about prenatal nutrition, breastfeeding, and child feeding. This advice will be most useful if it goes beyond descriptions of the kinds of food children should eat to address the developmental and emotional issues related to feeding. Early on, breastfeeding can be challenging and lead to frustrations for the mother and baby. Skilled lactation counseling can help resolve difficulties. Later, with the introduction of solids, parents need to understand their role in the feeding relationship and how to cope with what they may consider inappropriate eating behavior on the part of their child.

Key Actions

• Ensure that individualized lactation and nutrition counseling, provided by appropriately training staff, is built into clinical services.

• Educate mothers on the benefits of breastfeeding their children; support and promote breastfeeding among new mothers.

• Link parents to nutrition education programs.

Conclusion

Given food's social role and relationship to physical and cognitive health, promoting good nutrition is one of the efforts that has great promise for improving children's health and contributing to broader community well-being. Through employing a comprehensive systems approach that focuses on the child, the family, institutions, and policies, communities can have a significant impact on improving childhood nutrition.

References

¹ California Dietary Practices Survey: Overall Trends in Healthy Eating Among Adults, 1989-1997, A Call to Action, Part 2. Sacramento, Calif: California Dept of Health Services; 1999.

² Centers for Disease Control. Recommendations for use of folic acid to reduce the number of spina bifida cases and other neural tube defects. JAMA. 1993;269:1233-1238.

³ Meyers A, Chawla N. Nutrition and the social, emotional, and cognitive development of infants and young children. Zero to Three. August/September 2000;21:5-12.

⁴ Institute of Medicine Committee on Nutritional Status During Pregnancy and Lactation. Nutrition During Pregnancy. Washington, DC: National Academy Press; 1990.

⁵ Institute of Medicine Committee on the Prevention, Detection, and Management of Iron Deficiency Anemia Among U.S. Children and Women of Childbearing Age. Earl R, Woteki CE, eds. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: National Academy Press; 1993.

⁶ Center on Hunger, Poverty and Nutrition Policy. Statement on the Link Between Nutrition and Cognitive Development in Children 1995. 2nd ed. Medford, Mass: Tufts University School of Nutrition; 1995.

⁷ Ibid.

⁸ The Health of Angelenos. Los Angeles, Calif: Office of Health Assessment and Epidemiology, Los Angeles County Department of Health Services; 2000.

⁹ National Research Council Committee on Diet and Health. Diet and Health: Implications for Reducing Chronic Disease Risk. Washington, DC: National Academy Press; 1989.

¹⁰ Meyers A, Chawla N. Nutrition and the social, emotional, and cognitive development of infants and young children. Zero to Three. August/September 2000;21:5-12.

¹¹ Sutter E. Child of Mine: Feeding with Love and Good Sense. Palo Alto, Calif: Bull Publishing Co; 1986.

¹² American Academy of Pediatrics Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 1994;100:1035-1039.

¹³ Breastfeeding Practices in L.A. County. Los Angeles, Calif: Office of Health Assessment and Epidemiology, Los Angeles County Department of Health Services; February 2001. L.A. Health Issue 3.

¹⁴ US Department of Health and Human Services. Healthy People 2010: Conference Edition. Vol 2. Washington, DC: US Dept of Health and Human Services; 2000:16-46.

¹⁵ Meyers A, Chawla N. Nutrition and the social, emotional, and cognitive development of infants and young children. Zero to Three. August/September 2000;21:5-12.

¹⁶ Ibid.

¹⁷ National Research Council Committee on Diet and Health. Diet and Health: Implications for Reducing Chronic Disease Risk. Washington, DC: National Academy Press; 1989.

¹⁸ The Food Guide Pyramid: A Guide to Daily Food Choices. Washington, DC: Human Nutrition Services, US Dept of Agriculture; 1992. Home and Garden Bulletin No. 252.

¹⁹ Kennedy E, Goldberg JP. What are American children eating? Implications for public policy. Nutrition Reviews. 1995;53:111-126.

²⁰ Skinner JD, Carruth BR, Houck KS, et al. Longitudinal study of nutrient and food intakes of white preschool children aged 24 to 60 months. J Am Diet Assoc. 1999;99:1514-1521.

²¹ Ibid.

²² Dietz WH. Battling obesity: notes from the front. Chronic Disease Notes and Reports. Winter 2000;13:2.

²³ Neumark-Sztainer D, Story M, Harris T. Beliefs and attitudes about obesity among teachers and school health care providers working with adolescents. Journal of Nutrition Education. 1999;31:3-9.

²⁴ Nestle M, Jacobsen MF. Halting the obesity epidemic: a public health policy approach. Public Health Reports. 2000;115:12-24.

²⁵ Dietz WH. Television, obesity, and eating disorders. Adolescent Medicine: State of the Art Reviews. 1993;4:543-549.

²⁶ Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. The Lancet. 2001;357:505-508.

²⁷ The Health of Angelenos. Los Angeles, Calif: Office of Health Assessment and Epidemiology, Los Angeles County Department of Health Services; 2000.

²⁸ Sherman A, Munoz C, True L, Radigan D, Cowell C. Barriers to adequate nutrition for very young children. Zero to Three. August/September 2000;21:37-42.

²⁹ Cook JT, Martin KS. Differences in Nutrient Adequacy Among Poor and Non-Poor Children. Medford, Mass: Center on Hunger, Poverty and Nutrition Policy, Tufts University School of Nutrition; 1995.

³⁰ US Census Bureau. Model-based income and poverty estimates for Los Angeles County, California in 1995. Available at: http://www.census.gov/hhes/www/saipe/estimate/cty/cty06037.htm. Accessed December 27, 1999.

³¹ Pediatric Nutrition Surveillance: 1996 Annual Summaries, California. El Monte, Calif: Los Angeles County Department of Health Services Child Health Disability and Prevention Program; 1997.

³² Swadener SS. Nutrition education for preschool children. Journal of Nutrition Education. 1995;27:291-297.

³³ Skinner JD, Carruth BR, Houck KS, et al. Longitudinal study of nutrient and food intakes of white preschool children aged 24 to 60 months. J Am Diet Assoc. 1999;99:1514-1521.

³⁴ Liebman B. Solving the diet-and-disease puzzle. Nutrition Action Healthletter. May 1999;26:1-7.

³⁵ Lardner J. World-class workaholics: are crazy hours and takeout dinners the elixir of America's success? US News and World Report. December 20th, 1999;127:42-53.

³⁶ California Dietary Practices Survey: Overall Trends in Healthy Eating Among Adults, 1989-1997, A Call to Action, Part 2. Sacramento, Calif: California Dept of Health Services; 1999.

³⁷ Kennedy E, Goldberg JP. What are American children eating? Implications for public policy. Nutrition Reviews. 1995;53:111-126.

³⁸ Kennedy E, Blaylock J, Kuhn B. Introduction: on the road to better nutrition. In: Frazao E, ed. America's Eating Habits: Changes and Consequences. Washington, DC: Economic Research Service, United States Dept of Agriculture; 1999. Agriculture Information Bulletin No. 750:1-4.

³⁹ California Dietary Practices Survey: Overall Trends in Healthy Eating Among Adults, 1989-1997, A Call to Action, Part 2. Sacramento, Calif: California Dept of Health Services; 1999.

⁴⁰ US Census Bureau. Model-based income and poverty estimates for Los Angeles County, California in 1995. Available at: http://www.census.gov/hhes/www/saipe/estimate/cty/cty06037.htm. Accessed December 27, 1999.

⁴¹ Hamilton WL, Cook JT, Thompson WW, et al. Household Food Security in the United States in 1995: Summary Report of the Food Security Measurement Project. Alexandria, Va: Food and Consumer Service, US Dept of Agriculture; September 1997.

⁴² America's Second Harvest. Hunger 1997: The Faces and Facts. Chicago, Ill: America's Second Harvest; March 1998.

⁴³ Ashman L, de La Vega J, Dohan M, Fisher A, Hippler R, Romain B. Seeds of Change: Strategies for Food Security for the Inner City. Los Angeles, Calif: Southern California Interfaith Hunger Coalition; 1993.

⁴⁴ Gallo AE. Food advertising in the United States. In: Frazao E, ed. America's Eating Habits: Changes and Consequences. Washington, DC: Economic Research Service, United States Dept of Agriculture; 1999. Agriculture Information Bulletin No. 750:173-180.

⁴⁵ Borzekowski DLG, Robinson TN. The 30-second effect: An experiment revealing the impact of television commercials on food preferences of preschoolers. J Am Diet Assoc. 2001;101:42-46.

⁴⁶ Chen M. The Smart Parent's Guide to Kids' TV. San Francisco, Calif: KQED Books; 1994.

⁴⁷ Kotz F, Story M. Food advertisements during children's Saturday morning television programming: are they consistent with dietary recommendations? J Am Diet Assoc. 1994;94:1296-1300.

⁴⁸ Nestle M. Soft drink pouring rights. Public Health Reports. 2000;115:308-319.

⁴⁹ Gussow JD. Chicken Little, Tomato Sauce and Agriculture: Who Will Produce Tomorrow's Food? New York, NY: Bootstrap Press; 1991.

⁵⁰ Ashman L, de La Vega J, Dohan M, Fisher A, Hippler R, Romain B. Seeds of Change: Strategies for Food Security for the Inner City. Los Angeles, Calif: Southern California Interfaith Hunger Coalition; 1993.

⁵¹ Weinberg Z. No place to shop: food access lacking in the inner city. Race, Poverty & the Environment. Winter 2000.

⁵² Hoats K. The Cost of Being Poor in the City: A Comparison of Cost and Availability of Food in the Lehigh Valley. Lehigh, Pa: Community Action Committee of the Lehigh Valley; 1993.

⁵³ Weinberg Z. No place to shop: food access lacking in the inner city. Race, Poverty & the Environment. Winter 2000.

⁵⁴ Ibid.

⁵⁵ Cotterill RW, Franklin AW. The Urban Grocery Store Gap. Storrs: Food Marketing Policy Center, University of Connecticut; 1995. Food Marketing Policy Issue Paper No. 8.

⁵⁶ Ashman L, de La Vega J, Dohan M, Fisher A, Hippler R, Romain B. Seeds of Change: Strategies for Food Security for the Inner City. Los Angeles, Calif: Southern California Interfaith Hunger Coalition; 1993.

⁵⁷ Ibid.

⁵⁸ California Food Policy Advocates. Improving Access to Food in Low-Income Communities: An Investigation of Three Bay Area Neighborhoods. San Francisco, Calif: California Food Policy Advocates; 1996.

⁵⁹ Syme LS. Community participation, empowerment, and health: development of a wellness guide for California. Lecture in: The California Wellness Foundation/University of California Wellness Lectures Program 1997 Wellness Lectures; Berkeley, Calif.

⁶⁰ Glanz K, Mullis RM. Environmental interventions to promote healthy eating: a review of models, programs, and evidence. Health Education Quarterly. 1988;15:395-415.

⁶¹ Cohen L, Swift S. The spectrum of prevention: developing a comprehensive approach to injury prevention. Injury Prevention. 1999;5:203-207.

⁶² Moss NE, Carver K. The effect of WIC and Medicaid on infant mortality in the United States. American Journal of Public Health. 1998;88:1354-1361.

⁶³ Rose D, Habicht JP, Devaney B. Household participation in the food stamp and WIC programs increases the nutrient intakes of preschool children. Journal of Nutrition. 1998;128:548-555.

⁶⁴ The Research Findings on WIC. Washington, DC: Center on Budget and Policy Priorities; 1994.

⁶⁵ Los Angeles County Department of Public Social Services. Persons aided - FSO/mixed food stamps, January 1990 to June 1999. Available at: http://dpss.co.la.ca.us/r_and_s/99_june/persons_aided-fso_pgg.gif. Accessed December 27, 1999.

⁶⁶ US Department of Agriculture. The Decline in Food Stamp Participation: A Report to Congress. Washington, DC: Office of Analysis, Nutrition and Evaluation, Food and Nutrition Service, US Dept of Agriculture; 2001. Nutrition Assistance Research Report Series. Report No. FSP-01-WEL.

⁶⁷ Whaley S, True L. California WIC and Proposition 10: Made for Each Other. Halfon N, Shulman E, Shannon M, Hochstein M, eds. Los Angeles: UCLA Center for Healthier Children, Families and Communities; 2000. Building Community Systems for Young Children Series.

⁶⁸ Gottlieb R. Environmentalism Unbound: Exploring New Pathways for Change. Cambridge, Mass: MIT Press; 2001.

⁶⁹ US Department of Agriculture. Evaluation of the Child and Adult Care Food Program. Washington, DC: US Dept of Agriculture.

⁷⁰ Personal communication, Karen Meehan, MPH, RD, Public Health Foundation Enterprise WIC Program; March and April, 2001.

⁷¹ Breastfeeding.com. Supporting moms is good business: CIGNA's corporate lactation program pays off. Available at: http://www.breastfeeding.com/workingmom/corp_lact.html. Accessed May 31, 2001.

⁷² Serrano E, Taylor T, Kendall P, Anderson J. Training program preparing abuelas as nutrition educators. Journal of Nutrition Education. 2000;32:225-232.

⁷³ Swadener SS. Nutrition education for preschool children. Journal of Nutrition Education. 1995;27:291-297.

⁷⁴ Reger B, Wootan MG, Booth-Butterfield S. Using mass media to promote healthy eating: a community-based demonstration project. Preventive Medicine. 1999;29:414-421.

⁷⁵ Potter JD, Finnegan JR, Guinard JX, et al. 5 A Day for Better Health Program Evaluation Report. Bethesda, Md: National Cancer Institute, National Institutes of Health; 2000.

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