Partnering with Head Start to Support Healthy Nutrition in Young Children

Partnering with Head Start to Support Healthy Nutrition in Young Children

Florence Rivera: Good afternoon. Welcome to our webinar Partnering with Head Start to Support Healthy Nutrition in Young Children. Marco Beltran is our officer from Office of Head Start and is having some technical issues. So, hopefully, he will be able to join us shortly.

Marco Beltran: Joining. Thank you. I'm joining shortly.

Florence: Wonderful.

Marco: Thank you so much. On behalf of the Office of Head Start and the Office of Child Care, as well as the Supplemental Nutrition and Safety program, and the Children Nutrition programs from the USDA, we want to welcome you to this webinar titled Partnering with Head Start to Support Healthy Nutrition in Young Children. This is our national effort, or our federal effort to help to support you as programs as you engage in local efforts to improve program coordination and service delivery for low-income children and their families who are eligible purchase stake in Head Start. And my name is, as Florence indicated, my name is Marco Beltran, and I'm the federal project officer for the National Center on Health and Wellness, as well as the health lead for the Office of Head Start. By way of housekeeping, we want to let you know one of the questions we usually get through the webinars is the presentation available to us. We want to let you know that under the Handouts Tab, you'll have the PowerPoint presentation available, as well as two handouts that are going to be referenced throughout the presentation. And now I want to turn it over to Florence Rivera.

Florence: Wonderful. Thank you, Marco, very much. Sorry about the technical issues. Let me introduce myself. One second. Sorry. I'm Florence Rivera. I actually work for the National Center on Early Childhood Health and Wellness, which is a large collaborative agreement under Office of Head Start and Office of Child Care. And I come to this collaborative agreement from developing Early Head Start programs in homeless shelters, where I was working as a health educator. So, part of that job obviously required implementing the CACFP meal pack. And before that, manage the women and children clinic.

So, I have some experience around the multiple sectors represented on the call today. And I hope to be able to offer some perspective. In addition, I constantly monitor the Chat Box, and I encourage you, I highly encourage you to use it throughout the presentation. I will try to answer your comments, your questions as we move forward so that they're relevant to the topic that we're discussing. And I'll be also leaning on some of you to hear about things that you're doing or challenges that you have around some of these nutrition standards that Head Start programs are asked to implement.

Okay. We thought it important to talk, to get the conversation started, just to provide a little bit about who we are. We recognize, and I won't spend a ton of time on this, but I recognize that many of you are probably very familiar with Head Start. We've been around since 1965. So, we're certainly not new. But it kind of helps set the tone of why and what we're trying to achieve within Head Start programs. Like I said, it was started in 1965 under President Johnson's administration for the War on Poverty as an 8-week program. And today, it's providing 300 -- 52 weeks a year. Excuse me. So, all year long. And serves over a million children. And we do it through various program options that I just want to briefly touch upon so that you can understand the scope and diversity of who Head Start reaches and how we do it.

So, we have Head Start programs that traditionally serve in either in center-based or home-based services to 3- to 5-year-olds. We have Early Head Start, which is, that enrolls pregnant women to, from birth to 3. And we have Migrant and Seasonal programs, which has been around since 1969, but they serve families who are often transient, harvesting some of our crops throughout the country. And these families typically work long hours, don't have access to quality early education services for their children, or child care options, and so, sometimes might be forced to take the children with them into the field. And so, these programs are actually open six to seven days a week for 12 to 14 hours a day. As long as that crop is in season, and then they close down until the next year. And so, their shorter term.

We serve American Indian Alaskan Native programs. We serve about 34,000 children of American Indian Alaska Native heritage, either through this program option or others. This particular program option offers traditional language and cultural practices within the education setting. And those of you who are from CACFP perspective, we get a lot of questions about how to implement, or integrate, excuse me, culturally, or traditional foods through the meal patterns. So, this comes up a lot in this program option. And last but certainly not least, our Early Head Start-Child Care Partnerships. And this is an effort to bridge the best practices and support structure that we offer through Early Head Start. We'll talk about here in a minute what that looks like, with Child Care options such as Child Care centers and Family Child Care homes. And offer those children the benefits that Early Head Start can offer such as home visits, health tracking, family support services.

So, when I talk about Head Start throughout the rest of this discussion, I'm really talking about all of these program options. What do we do? Well. Historically, we're, we're known as an educational program, that we're really trying to, our overall goal is to promote early learning and school readiness for young children, particularly young children in low-income families. But we recognize that this requires a whole-child approach. We can't simply provide educational service. We need to support the health and well-being of that individual child because a healthy child is ready to learn. An unhealthy child is unable to learn. And that the family structure is vital to that child's success. And so, we provide services, we want to dive into all of these services today to help you understand how health and nutrition is really integrated into Head Start as a means of supporting how well that child learns, how well that child grows. And we're guided through the Head Start Program Performance Standards, which define quality services or best practices for education, but in particular to our conversation, health and nutrition services.

So, they guide how programs set up the services that they provide to the community and their, their families. So, we will talk about these specific standards to nutrition today, and then, how programs implement them, and what are some possible partnership opportunities for other entities to work with Head Start. How can we work together? And what hopefully you take away from this conversation is not about all the nuanced things or methods that Head Start programs use to provide nutrition services, but how we're all really trying to achieve the same target behaviors for young children. We're all trying to achieve very specific things around healthy eating and movement for young kids. And I recognize I'll be throwing in some new words for those of you who may not be familiar with how Head Start programs are set up. So, I want to just briefly talk about the staff support that might be available to a Head Start program and who might be implementing some of these services. It's not all, it's not all the same or one staff person. So, here, at the top are the health managers.

This is is traditionally going to be the person who is tracking all of your health information and would be your first contact when you're looking at partnership opportunities because they would understand what nutrition standards are being implemented and how their program's doing it, and who's in charge of what. We also have -- I'm going to go down to the red and green box -- your family service workers and your home visitors. They're going to be the ones who are talking with families, and very often, conducting nutrition assessments or family education services. Back up to the top are cooks and educations are so intricately linked to how well we implement our nutrition services. Our cooks are the ones who are meeting those meal pattern standards. They're the ones preparing the foods on our menus, those healthy foods we offer to children. And educators are the ones who were eating it, and they are also the ones who are encouraging children to eat it and implementing a really positive eating environment, which we'll talk about later. And then, of course, the registered dietitian and nutritionist.

And they're unique, often nuanced role within various programs that I will talk about here in the next couple of slides. So, really take away that there's not one person who are supporting, who is supporting the nutrition services that Head Start programs provide. There's a myriad, and they all have different roles and strengths. And so, we will talk about this, and I'll use these words throughout the conversation. So, speaking of staff, we have certain qualifications. And I'm just talking about our health managers, our health- related staff. I really don't want to go into the qualifications of everyone. But, they are required at a minimum to have a bachelor's degree in a related feel, field. Excuse me. And specifically in this slide, I want to talk -- I'm not going to read all of the nutrition status to you, of course. But this last bullet point who talks about that they should have a registered dietician or nutritionist with appropriate conver -- qualifications. This looks very different program to program for various reasons. A small program may not be able to afford a registered dietitian as a full-time staff person.

So, they might have them as a consultant to review menus. Whereas larger programs can afford a full-time staff, register dietitian, who can be in charge of conducting nutrition assessments and implementing professional development with staff so that, so that they understand some of the nutrition needs of young children and working with families. So, it looks very different. And it's always a wonderful partnership opportunity to look at how we can link Head Start programs with registered dietitians as often as possible.

This is from a recent Head start health manager survey. And it tells you a little bit about those health manager roles. You know, your first point of contact when talking to a Head Start program, who they are. So, 66 percent of them have a bachelor degree. Twenty- three percent have a masters or some sort of postgraduate degree, and over half have a health-related license. This tends to be an RN of some sort. But again, it can also be a RD. And overall, about 86 percent has some sort of health-related associate's, or bachelor's, or credentials which tend to be in child health and health development. So, this is our -- this is where we are going to get started about child nutrition services, I want to call out some of the phrases in here, that there -- Programs are required to design their own nutrition services and they need to be culturally and developmentally appropriate, which we'll talk about what that means.

We have to know what cultures are represented in our communities. We have to understand what is developmentally appropriate for 0 to 5, from birth to 5. We have to meet the nutrition needs and accommodate the feeding requirements of each individual child, which requires that we know the feeding needs and the nutritional needs of each individual child. So, we conduct nutrition assessments. And then, we'll talk a little bit about family-style meals that was changed recently in our standards from being required to encourage, but we'll talk about then, why that is and the intent of encouraging family-style meals, moving it more from a checklist into implementing something more inline to responsive feeding. And how do we do this? Well, we do this through a host of different activities. We provide this community assessment. A nutrition assessment that I just talked about. We have ongoing professional development. If you have all of the staff -- I mentioned a couple of slides ago -- who are implementing these nutrition services, we have to make sure that they are familiar and comfortable with this topic. We provide nutrition education in the classroom. We hope children understand where food comes from, how they grow. We help encourage our picky eaters to try new foods. And we certainly introduce what healthy foods are. Our healthy menus. You know, it's interesting.

In 2016, when the new meal patterns came through or were revised under CACFP, a lot of our Head Start programs found that they had already made a very substantial commitment to providing healthy foods for their young children and that there weren't extensive changes that they needed to make. And many of them were already doing the things that these new healthier menu options were requiring. And then, we provide family education continuing education around what their child needs, and how to feed their child and help their baby grow. So, this is just our standard about community assessment, that they have to do it periodically. And as we dive into this, you'll see that -- I have some examples of particular information that community assessments, you know, collect, and how that may be applicable n helpful to other community providers. So, they collect information on education. So, where your school districts are, and we provide transition services when they turn 5, how are you going to enroll in school. Making sure that they, you know, get the physical.

That if they need an IEP, an Individualized Education Plan with the school system, then we're helping them with that. Social services. So, TANF. Housing supports. Adult education supports. And then, we'll talk a little bit more about the health and nutrition information that is collected. Hopefully, we're collecting some awareness of health care providers, community health centers in our general area. Those who accept Medicaid. For sure. How many families do we have without health insurance? Do we have dentists? Do we have dentists who take Medicaid? Do we understand any nutritional health needs who might be applicable to our community? Specifically, I am thinking of last year's few events. Do we have a community that has high lead levels in our water or soil? Those are -- that's information that is collected in our community assessment. These are just some examples.

So, this one, in particular, used school district boundaries and mapped where health care centers are. And as you can see here, we have school -- a very nice visual of school systems where children have great access to health care, and others where they have little to no access to health care. Which is really important if we're tracking health information and trying to make sure that they're receiving all of their EPSDT so that their regular immunizations, their regular check-ups, and so forth from the medical providers. We need to identify whether or not that's going to be a huge barrier for some of these families. We also collect other information such as BMIs and overweight or obese. And we're able to compare that to community data to recognize whether or not children in our Head Start program are seeing higher rates of overweight and obesity, which we traditionally are. Hopefully, this looks very familiar to you.

This is a list of nutrition-related resources that would be collected and probably very similar to things that would be in the resource list in your local WIC office that you offer to families. You know. Food pantries. Your Health and Human Services department. Faith-based initiatives that often operate food pantries and so forth. So, this is a wonderful opportunity to make sure that your resource list and their resource list match. And see if there are any other community partners that you should consider. I enjoy this example, as well, because we'll talk a little bit about food insecurity. And this community assessment collected the food insecurity rates for the towns that they represent in their Head Start communities, and then, outside of their communities. And they, of course, collected -- or conducted some surveys with some of those families, as well.

So, this is one of those opportunities. I'm going to ask you to use the Chat Box if I can.

I don't see any comments or questions at this point, so feel free to use the Chat Box. I'd love to hear from you. Specifically for my Head Start programs. What are ways that your program utilizes your community assessment to create program activities to inform how you provide program activities, or how do you build partnerships? And if you all wouldn't mind sharing that, that would be really helpful. And as you're doing it, I'm going to share an example of a program I met in Kansas. They were a very rural community that recognized a lot of food insecurity in the families that they served. They were experiencing behavior issues, specifically on Friday afternoons, you know, when children often recognize that they're going to go home to a food insecure environment. And they looked at their nutrition resources in the community assessment and really struggled with what was available. You know, they had the food pantry. They had the WIC office, but there were limitations. And they felt like they, they really wanted to dedicated to do more. So, they went back to the community assessment and realized they had a major employer in their community, which was actually a local prison.

And so, they partnered with them. And the incarcerated residents grew fruits and vegetables and donated them to the program. And so, from my CACFP folks who phoned in, they did not incorporate the donated food into the menu, but essentially created their own backpack program. If you've never heard of that, it's actually very simple. It's donated foods in backpacks that young children and families can take home, typically on the weekends, on Friday afternoons. So, that's an example of how programs utilize their community assessment data to inform where they're going to put their resources each year. And I didn't see anyone in the Chat Box offer any opportunities. But don't worry, feel free to add them as we go along. Hold on one second. Here we go. In addition, we collect health-related information.

 This is back to that nutrition assessment -- that we have to identify what each child nutritional health needs are, including their health records, family concerns, special dietary requirements, and use that to inform some of our menus and program services. Now we don't stipulate if you haven't noticed in here -- I'm going to go back. We don't stipulate what sort of questions they need to ask or how they need to ask them. And this is a wonderful partnership opportunity. It's -- Programs do this differently everywhere that I go and see it. They ask a lot of different questions and conducted by different staff. It's not as rigid as what a WIC certification appointment might look like with the VENA questions that are very evidence-based and designed to elicit certain information in a certain way. Nor are they always conducted by registered dietitians or nutritionists. And so, it would be wonderful to partner with a Head Start program and think through ways to support the nutrition assessment. Help them design questions or methods to get the information they really want to get.

So, in general, though, nutrition assessments are, collect the growth assessment, including a BMI or a growth -- weight for length measures. The hemoglobin [Inaudible] very simple, similar to what WIC and medical providers will collect. The lead screening, which can be a real challenge and concern for many programs. It can be difficult if we want to collect a blood sample or blood screening of lead versus the questionnaire. Sometimes a medical provider struggles with providing this, and WIC providers -- it's not consistent on whether or not we offer that, and so we have to send these families to a public health department, which can be a large barrier. So, we struggle a little bit with collecting blood lev -- lead levels beyond the questionnaire. And then, of course, the quality of the diet we're trying to incorporate in the nutrition assessment. Very similar to how a WIC would conduct their nutrition assessment, a WIC staff member, this is how I talk to Head Start Program Perform -- Head Start programs about the nutrition assessment. It's an opportunity to engage families. Learn about their goals for their child, how they want their child to eat. How they want their child to learn. Learn about what their needs are. Do they struggle with food and security? Provide nutrition education, which would look very different for nutrition assessment in a Head Start program, while a certification appointment would be very, very common. Nutrition education. This would be something -- I'm thinking of an example around if I'm collecting information on sugar-sweetened beverages, and I ask a question related to, you know, how many cups of juice do you serve your daughter every day. And I get one cup. And that's my opportunity to educate if that cup is four to six ounces or 14 to 16 ounces.

That's our opportunity to educate about what a serving size is. But again, this a wonderful opportunity to think about what staff member is conducting that nutrition assessment. Are they comfortable talking about it? Have they received the training from, you know, through their professional development activities to be able to do that? And then, we talk about this. Using your community assessment data. And we talked about the industrial urban area with higher levels of lead.

Okay. And so, I'd love to hear from some of you. If you feel like sharing. If you partner currently with anyone regarding nutrition, nutrition services, or anyone in your community if you won't mind sharing those in our Chat Box. Let's move on to services to pregnant women. And feel free to share any opportunities that you currently engage in in the Chat Box. But services to pregnant women. What sort of things do we provide? First up, we actually provide a whole host, usually, a curriculum-based education through home visits that tend to be every week for 90 minutes. And we talk with pregnant women and their families about very similar conver -- topics or target behaviors that many of our other sectors on this call intersect with, such as fetal development, prenatal nutrition, taking your multi-vitamin, making sure you have a medical home and are attending those prenatal visits. Eating right. Sleeping enough. Whether or not you're going to breastfeed. How you're going to feed this baby? Where's this baby going to sleep? How you're going to take care of them? How do you recover postpartum? All of those things are covered within these curriculum-based home visits with pregnant moms.

In addition, we offer a two -- a newborn visit two weeks after delivery. What's really striking about this is we ask almost identical questions. Almost, almost identical questions to the -- Sorry, apparently, I was looking in the wrong spot. Wonderful. Thank you so much for everyone giving us some great ideas on the previous chat questions. If you don't see them there in the Question Box, and I'll try to review them as we move through, forward. Sorry about that. I didn't notice those earlier. But I was saying that we offer a two- weeks visit. And we have almost identical questions at an early Head Start two-week visit as we do for the mom who's coming into the WIC office to certify her baby. Now, what the difference is an early Head Start that mom is no longer a participant, that the newborn now takes that slot. But in, whereas in WIC, that mom would be a participant for six months or a year afterward depending on how she is feeding her baby. But we ask similar questions in terms of are you taking your prenatal vitamin. Was the baby born at 38 weeks gestational period or before? How are you feeding the baby? If you're breastfeeding, how is it going? How can I help you? When to start solids? All of those things we talk about in that first visit.

And it's, like I said, really striking to that first infant certification appointment at WIC. So, how do we feed our young children? Well, of course, first and foremost, we promote breastfeeding. So, we provide education to moms and families about breastfeeding. But we also have some program structures. We refer obviously to the local WIC clinic, the women and children clinic, and lactation consultants. This is also a wonderful partnership opportunity. We struggle often to have access to lactation consultants in the program setting, that we have to use our community resources. We have to have partners.

And so, this is a wonderful opportunity to bridge the strengths of these two entities, of WIC and Head Start, because something we're very good at is promoting peer-to-peer learning, that we have constant access to families and follow. And we can support that peer-to-peer learning much easier than if we struggle to have local lactation consultants available to us. We encourage mothers to supply breastmilk. Were able to store it in center base, and feed it to their babies, of course. And now, or we're also able to seek reimbursement when we feed that child breastmilk as we would with formula-fed babies. And then, we offer a quiet, private area, or encourage to offer some sort of physical space that is sanitary and comfortable for the mom to feed their baby at the center. Now, this may look very different based on the physical space or organization of a program. So, what's really interesting at a local level is to work with a program to where the space could be, how this might work, work for their breastfeeding moms. And think about ways that their environment can be breastfeeding friendly, as in do you have pictures of children who are being breastfed versus bottle fed.

Do you have pictures of breastfeeding moms that look at every mom? You know, those sorts of questions, you have a formula out and about versus a particular location, not necessarily on site. And lactation consultants are wonderful in the local community to help programs think through some of this. In addition, and I forgot to mention earlier, this is not specific to only Early Head Start, or birth to three. We really try to encourage all of our program options to offer a quiet, quiet area because we recognize you might have an enrolled 3-, or 4-, or 5-year-old, but very likely, they have a younger sibling. So, we want to create this atmosphere that is breastfeeding friendly for everybody. Alright. Now that I'm reading the right Question Box, I want to ask you another question and I'll be able to see is what are your biggest challenges supporting breastfeeding. I think this might be extremely helpful across sectors to understand.

Okay. So, if you wouldn't mind sharing some of that. That would be helpful. I'm just making sure I"m looking at the right box now. In the Chat Box. Yes. Thank you, Joanne. And we see -- some of these options are fiscal support. Absolutely. I think a big funding issue having the right staff and the training. It's really hard to have, you know, those lactation consultants available all the time, especially for free. Or supporting some of the peer-to-peer learning takes money, as well. Staffing issue. Having a quiet area where mothers to breathe. Breastfeed. Excuse me. And the space. Yeah. It's a combination that has to be individualized to the program. And that's why it's so helpful to have those partnerships to really be able to help programs think about what works for them versus having a -- we might have a national standard that says we offer a quiet space. But what does that look like to you? That's a question that can only be answered by that person. I will say -- because I see space here a lot -- and in infants rooms for breastfeeding. And it comes as -- it's not necessarily its own room. It can very often be, you know, a chair in the corner with a provided cover-up. Mommies would like that, and even headphones so it's a nice quiet space. And Ruth is, made a good point. The challenges cultural. In West Virginia, most people believe that it's not important. And I think that it's true in many areas across the country, something that we all are working to make breastfeeding more culturally appropriate to all of our communities throughout the country. And that's why I brought up some of those environmental issues around having images depicting all mothers, you know, based on skin color, or religion, or whatever, breastfeeding. So, those are really important.

Okay. So, I want to just keep moving. Because these are some great comments. So, hopefully you can see them. If not, I'm sure we'll be able to share some as ideas after the webinar. Talk a little bit about child nutrition. So, we do use the CACFP where requires to participate in that so that we are providing some consistency in the quality of diet that we are offering to young children. For obvious reasons, our low-income families struggle the most, or at least more vulnerable to having lower-quality diets. So, we make a commitment in Head Start to providing healthy foods including at breakfast. You know, we recognize that the child, with breakfast, the role that it has to play in that child's ability to pay attention and participate in school.

So, all of our programs that are operating morning center-based setting are offering a nourishing breakfast. And then we start talking into daily nutritional needs based on how long our program is open each day. And I won't get into the, the percentages and so forth. But this is really a part where we lean on our registered dietitians or need them the most, just to make sure that we're providing those daily nutritional needs. So, our menu requirements from CACFP look at some of those specific nutrients that young children need. Vitamin C. Vitamin A. Enough calories, etcetera, that nice balance, balanced meal, that we're offering fruits and vegetables throughout the day as snacks and mealtimes. So, typically -- sorry. I just want to add it. Typically if you're using a registered dietitian as a consultant, this might be the only are that you're using them on, while others might benefit from much more expansive services from a registered dietitian or nutritionist. And I'd be remiss if I didn't touch on food insecurity. We hear about it a lot in the Head Start program. But recognize that all of our programs are designed to serve the same target audience. You know, about a third of our Head Start families have been shown to experience food insecurities. And this is just an infographic or a graphic that I like from this toolkit for pediatricians on food insecurity. There are numerous ones out there, but I'd like to talk about all the things on it.

So, I put this on here, which is a childhood food insecurity can lead to poor educational outcomes, health status, developmental risks, all things that we really worry about in all of our sectors. And that may present as developmental delays or behavior problems. A lot of questions that I get around from Head Start programs do start circulating around behavior problems before mealtime, or on the weekends, you know, on Friday before the weekend, or on Monday, after being in a dysregulated environment over the weekend can often be tied to food insecurity. We also see a lot of food behaviors such as hoarding, or pocketing food in their mouth, or negotiating for additional snacks, to take home food. Some of those issues are kind of the ones that come in the Head Start program setting that all center around food insecurity. Obesity is another issue. And we know that of those Head Start families that are experiencing food insecurity, about 10 percent of those are also overweight or obese.

And this manifests itself a lot. This is one of my, probably most common questions I receive is that what about the child who is already overweight or obese and wants to keep eating. They have four, five, six servings. How man can I get reimbursed for? How can I stop them? And a lot of that has to -- you know -- when you start digging into it, talks about that overweight or obese child who is also experiencing food insecurity, and some of those behavior issues that manifest due to that. And then, poor growth and inappropriate feeding practices. What I think is the most important to note here is that at the bottom here, these federal nutrition programs that are designed to improve food insecurity, four out of these five are on the call today, that we're really all built as a structure to support, to support food security. And so, having us look -- I want us to talk at least a little bit about it, and showcase how it's addressed or brought up in the Head Start program. I will also add, another issue that comes up that I like to tie back to food insecurity is staff anxiety. You know, when we have meal changes or registered dietitians are suggesting alternatives or healthier ways or strategies for their menus, staff often are resistant to that.

And the staff here I'm talking about are educators or cooks, those who are making these foods, and those who are eating the foods. And many of their reasons are, you know, the children aren't going to eat that. Or, that's not enough food for them are very common comments that I hear. And what's probably the most interesting about this, when you're talking with them, is that it's really tied to this acknowledgment either consciously or subconsciously that if the child doesn't eat during their program, or doesn't get enough during their program, that they're probably going home to a food insecure home, or hunger environment. And so helping staff work through some of those issues and understand how healthier foods support a child's early learning is really pivotal to making many menu changes within the program.

So, let me just check in to make sure there are no questions. Look really good. Thank you all for sharing. So, let's talk a little bit about this slide. Actually, this is a loaded, as in it's very heavy, Performance Standard that says we feed our infants and toddlers up to age 3 according to their individual developmental readiness. So, is that a 6-month-old really ready for solids? Can they move the food from the front of their mouth to the back of their mouth? Can they swallow without choking? Can they sit with support? Being able to recognize those milestones. And feeding skills. So, can they use a cup? Can they use a spoon? Do they have the pincher grasp? And aligning the services that we offer according to this progression of skill development and development, developmental readiness. And sure, they are fed on demand, so that practicing responsive feeding. And then, this last one. Ensuring bottle-fed infants -- you know, we don't craft the bottle. You know, what I really like about this one, in the context of our discussion today, is that if you recognize, these are all of the, your target behaviors we recommend to families that we're role modeling in the program setting, that we're showing families this is how we do it.

And that's why it's so important to us that all staff are implementing this well and understand why we're implementing it because then we can share that information with families, that we're doing this for a particular reason, for the health and well-being of your child. And so, we'll talk a little bit more because there are some more instances here that we're essentially role model -- role modeling the behaviors that we want families to adopt at home. This isn't saying much else. So, I want to call out the second bullet here. Introducing solids with a parent- approved food plan. So, we're not serving foods without parents' approval. But it's also our opportunity to talk about those milestones with their, with families such as, you know, is your baby ready to start foods, solids. Is she -- What sort of things is she telling you in terms of does she sit with support, all those milestones that I just mentioned? And helping families recognize their child's individual signs. And it gives us the opportunity to say, "No. We don't start solids at 2 months, 3 months, 4 months.

We try to wait later on, which is aligned very well with the CACFP meal pattern that we changed in 2016, as well. So, we're back to family-style meals that also role modeling that positive eating environment, the things that we want families to do at home. So, while programs aren't necessarily required to provide family-style meals, if you look through here, there, there asked to do all the things that are components of it. So, certain meal times must be structured, but use explain opportunities that support communication, conversations, contribute to a child's learning and socializations. All of these are components of the family-style meal and how you actually implement those well. The other types of behaviors here that are captured in this standard is that we provide sufficient time for children to eat, that 30 to 45 minutes. We don't use food as a reward or punishment.

We put all foods on the table, so we're not saying that one food is better than the other. We don't negotiate in terms of two more bites of this and you can have that. Or use it as a punishment. "Pick up all your toys or you can't have snack time." We don't use those things. All the things that we want parents to do at home, we have the opportunity to showcase in our, in our program. And we don't force children to finish their food. So, that whole mantra within responsive feeding of parents or caregiver provides and the child decides. The other thing I would like to note here is that on the left part of the screen, we're no longer in nutrition standards. We're actually in the teaching and learning environment, that we're recognizing that how we provide foods and how we interact during the mealtime actually supports how that child learns. And these are just some graphics of why we use family-style meals, and while you're -- which align very well to why you recommend that families are eating together as often as possible. We support responsive feeding. We're building that mealtime expectation.

So, we spend a lot of time talking to families about when you eat meals as a family, you're teaching that child how you want them to behave during mealtimes, and eventually it actually improves mealtime behavior. We're affecting that child's food preferences, that we're teaching them how to try new foods, that it's okay you don't like it, but we're going to try it again. And we support appropriate child servings. Very often, programs use measuring cups so the child, children if they're old enough, usually in the 3 to 5 age, are serving themselves with those measuring cups, which doesn't require the educator in the classroom to be able to visualize a half or quarter cup, depending on the age. Okay. So, we've moved, we move from nutrition services and the learning environment, and now we're talking about the family support services. How do we support families in this? We talk with families in many many different ways. Through common interactions such as pick-up and drop-off, through phone calls, through family education services such as socialization events or what we call family nights.

And we also have consistent home visits and family check- ups. And we talk about a myriad of nutritional topics, but specifically, we talk about physical activity, healthy eating, sugar-sweetened beverages, and food budgeting, which probably align very well with the activities that you talk about with the families that you work with. Okay. So, what are some common nutrition questions you receive from families? I'd love to hear from you all for a minute about some common nutrition concerns or questions. Healthy food on a budget. Yeah. That's a very hard one. Is breastmilk enough? There just seems to be quite a few common misconceptions about breastmilk still. When to stop breastfeeding and to feeding. Yeah. Yeah, I found that one interesting. I'm lost on the name, I'm sorry, but how to cook.

That was something that blew my mind, as well, working directly with families in homeless shelters, you have very common expectations of where families will be able to start when you talk about food. And I was working with families who had never lived by themselves, and they didn't have any pots and pans. And so, you know, bringing back those conceptions about where I should start was interesting. How do you keep kids on a meal schedule? That's an interesting one. The bottle rot. Okay. That oral health issue. Food allergies. Learning to eat healthy but your family doesn't. Yeah. Why can't WIC give me whole milk for my older child, for Maggie? And I got to say, I had a lot of comments. Why can't WIC give me whole milk for my infant? Right? A lot of ideas about what their child needs to eat. Yep. The infant water still comes up a lot, as well. That's an interesting one. Can I give my infant water from birth to 5 months? And Kim has a great nutrition question that comes up a lot, as well. Feeling that a child's weight is okay even though their child is overweight.

And I think, Kim, that comes up for everyone. And what's really interesting about that is how you talk to parents about that? Because you're right. They don't recognize that their baby is overweight. They might be able to recognize that someone else's child is overweight, but and we've seen this in studies, as well. When parents have been asked to identify whether or not their child is overweight or obese, they are not able to do that, but they are able to recognize someone else's child with the same BMI or similar BMI, which is fascinating but it also speaks to our strength as parents. So, how do we use that strength when talking about healthy foods for the baby? What type of milk does Head Start offer? So, BMI is not a proper measure of health. How do we change the communication around that? That's an interesting comment or question, and I talk a lot about that, too.

And I think Head Start programs in particular, in thinking about how to reach them, and I'm sure WIC is, as well, is how do we start talking about foods that support how your baby learns and how active play or playing supports how well your child can do in school, and so forth. Interesting. Okay. So, these are really great. And if you aren't able to see them, I see a couple of questions about that, we'll make sure that they're available because these are really great common nutrition questions, and what I noticed more than anything is that it doesn't seem to be dependent on an entity. You can work at any WIC, Head Start, local community partner office and you probably get all of these same questions. Okay. And Charlene says she can't see other people's responses. So, I'll make sure to answer these.

Okay. So, I'll make sure to do that. But let me move on, and then -- Because I want to get through all of our slides and have time to answer any questions that I see in the questions box. So, now we're talking about staff supports. So, we've moved on from family support, and we're talking about how we can support staff. So, staff in a Head Start program are required to clock about 15 hours of professional development every year. Because of all the staff roles that touch up on nutrition, often staff across all sectors within the Head Start program are provided some nutrition straining at some point during the year, and that usually it includes an in-service before the new program year. And this is another wonderful partnership opportunity, to have some outside experts provide nutrition concerns. But also, this whole list you all just generated about common nutrition questions and making sure that both of us in the community setting know answers to these, that we're answering in the same way, and that we understand where families' confusion is coming from. Could be a wonderful professional development opportunity. And I'd be remiss if I didn't talk about the power of educators. I spoke a lot today about what health managers do, and how they're really the conduit to the Head Start program. But the conduit or the gateway to the classroom and sometimes even families is through the educator. That, I talk about it as in, well, who do families trust. They're going to trust who feeds their babies, so cooks. They get a lot of questions around, you know, "My child eats your spaghetti, but not my spaghetti. How do you do that?" Sort of questions are wonderful times for our cooks to talk about picky eating, and responsive feeding, and etcetera. And families trust who teaches their baby.

This is the person they see the most. This is the person they have the most interactions with, that tell them funny stories about their child when they pick them up, and things silly they did that day. They're the ones that have these positive interactions, and they become very trusted sources of information for families. Now, these bullet points here I'm presenting are actually from studies we've done in school-aged children around health and education interventions. But what we found is that compared to an outside health educator, the teachers were actually more effective to influence behaviors, to create behavior-change because the kids knew them, and trusted what they were telling them. And so, when you're thinking about how to partner with a Head Start program, while your health manager will be the staff person as the main contact, it would be regrettable if we didn't also bring in the educators in terms of how do we implement this partnership. And so, I wanted to make sure that I touched upon the power of, of early childhood educators. And you guys have come up with some great ideas of how can we partner. I was able to briefly look at the Question Box and see some of the partnership opportunities that you're doing now. And you talked about your extension office, and food pantries, and WIC offices, and so forth.

So, hopefully, there are some wonderful opportunities that you been able to identify throughout the presentation today. There are a lot of nutrition services that Head Start programs provide to families. They have continual access to families, and they spend a lot of time building relationships. Instead of every three months, they see these families every day and have phone conversations with them regularly. So, it's, it's wonderful to think about how, you know, can areas of expertise be breached here to serve the same families.

And then, I also want to provide some resources. So, you have two handouts in addition to the slide set that we could attach to the webinar. And I'll be happy afterward to share a few more. But they can also all be found at this link here at the bottom of this slide. What I'm showcasing here in the middle of the screen is our Growing Healthy suite of services that we provide to Head Start to talk about some of these topics. So, on the right-hand of your screen where we have Feeding Your 9 Month Old. As you can see, the front of the page is actually a lot of white space, very few words, so it has a low literacy level. Mostly images that depict what we're trying to talk about. So, in this particular one, we're talking about what are appropriate serving sizes and giving visuals of what those servings are for your 9-month-old. And then on the back, we provide a little bit of the science behind it for staff. So, why is it important? Why did we make these recommendations? What are we hoping to achieve? And then, we provide conversation starters. How do you talk to families about this in a very respectful way? How do you try to ask open-ended questions to get more information, not less? And provide advice that's not directed. The left-hand side of your screen, we have Growing Healthy Worksheet around 5210.

So, just a brief introduction of what that is. Families can make their own goals and if you were able to see the back of the sheet, we have example, very actionable, small, achievable things that families can do when they make their own goals, examples, and then, they make their own goals and they can write it out. So, it just a little worksheet for us to work with families around nutrition goals. Very similar to the ones that would be built at a WIC certification appointment, where you're asking the family to create a nutrition goal. Essentially, very similar. And then we have tip sheets that we provide to families if programs want to hand things out. Again, we try to keep them low literacy level. Lot's of pictures. And we have some newsletters, which I'll be able to share after the webinar, as well, because I wasn't able to attach them to this webinar. I ran out of space, storage space, that talk to actual staff, Head Start staff.

But we talk about a lot of these nutrition standards, including our health service advisory committee, which I actually didn't touch on today, and how you can be a part of that. So, with that said, I want to provide some time for questions. We have about four minutes. But I'm happy to answer any questions that you might have, and, and I will certainly follow up with those that I don't get to, get to today, in the next few minutes. So, here's a question. Is there any national data that shows the number of centers being reimbursed for human milk feeding? And I'm not familiar, if that's the reimbursed req -- the reimbursement requests are being tracked nationally. I don't know if that's a question that I will be able to access. Marco, if you're still with us, and know the answer, by all means, chime in. If not, maybe we can even look into it.

Marco: We can look -- I don't know of anything that tracks it, but we can, we can try to find out. That's a good question.

Florence: Yeah. That's a good question. And Brittany has asked, "Where can I find the community assessment for my state and region?" So, I think you're talking about the Head Start Community Assessment which wouldn't necessarily be done on a state or a region. It's done by grantee, which is linked to the funding stream from Office of Head Start. But it's all developed in the public domain. So, you should be able to find, if you're looking for a particular region, find the Head Start or Head Starts, you know, multiple programs that would be conducting this. They might be if they're very close together, you know, conducting nutrition assessment together. Also, tell you your public health department should have access to this information, as well. So, if I were you, and I'm looking for a particular region, I would call the Head Start program and see if you can access that. A lot of them also post them online, too.

Okay. Jessica has a great question, as long as I don't lose it here. "When do the requirement for family-style meals changed to encouraging? And what prompted the change?" So, I'm going to take a first stab, and then Marco, if you want to chime in to anything I've forgot. I think that would be helpful. So, my understanding as a grantee myself in some regards. I'm not necessarily part of those conversations, but it was an effort to move from a checklist of, "Okay. Well, I've done all the things that I'm required to do with family-style meals," and really move into the intent about how to implement responsive feeding. So, moving more from a requirement so that programs can relax and actually understand what they're trying to achieve with family-style meals. So, am I engaging the child in a collaborative, positive eating environment? And Marco, I'll give you an opportunity to share anything additional to that.

Marco: Yeah. You're right. I think what we were trying to do was move away from individuals really struggling with the concept of family-style meals. And they would turn around and tell us, "Well, we can't do it because of our study. We're not allowed to do it." We really wanted to emphasize what actually happens with family-style meals as, instead of just the act of doing it. So, I think many people were focused on the act of it versus what we were trying, what the intent behind that standard really was, and that's why there was a shift in it. And that's why we moved it from where it was previously under the nutrition standards, over to the education piece, because a lot of those things that we were asking as it relates to family-style meals were happening in collaboration with teachers. So, we really wanted to get to those opportunities of having conversation, socialization, modeling, and doing some of those pieces to help the child-teacher interaction.

Florence: Great. Thank you. I have just one more, here and I realize we are at 2, or 3 if you're on Eastern Time. But we have a couple people looking or the resources. So, not all of the resources I could attach to the actual webinar. My slides are fairly large because of the images, so it takes up a lot of the storage space. The link at the bottom of that slide -- Let me actually go back to it so you can see the link. Or, it's in that slide set. We can also email that link out afterwards as follow up to the webinar. You can access all of those things. And someone else had a comment. These resources are all available in Spanish, as well. So, if you're looking for the Feeding Your 9 Month Old, if you go to this link, there's actually a Feeding Your 9 Month Old and Toddler. So, we have toddler serving sizes and preschooler serving sizes so we can talk to families about how those serving sizes change. Okay. Alright. Well, thank you so much. And if you have additional questions, feel free to post them here, or see them in follow-up. And thank you for participating. I'm glad that I found all your comments in the Question Box. It makes it a lot more interesting than me talking to myself for an hour. So, thank you very much. Marco, did you have anything you wanted to say at the end.

Marco: No. Just thank, thank you. There were plenty of participants who stayed through the whole [Inaudible]. So, we really appreciate that. Thank you.

Florence: Absolutely.