This is the first national study to describe practices in Head Start programs in 3 related areas: assessing BMI, addressing food insecurity, and determining children’s portion sizes. Nearly all programs allocated staff time to the assessment of children’s height and weight, but not all calculated BMI or discussed children’s growth with families. Many programs reported that their staff saw children who appeared to not be getting enough to eat at home, and the programs often addressed this situation in ways that used the programs’ food resources, such as keeping extra food on hand to feed children, giving food to families to take home, and feeding children more on Mondays and Fridays. During family-style meals, a setting in which childhood obesity and food insecurity are at the same table, differing strategies were reported for how Head Start programs determined portion sizes. Some programs reported that teachers determined portion sizes, and other programs allowed children to decide how much food to take at meals.
Assessing BMI in schools has received increasing attention as an obesity prevention measure, but the practice remains controversial. There is no professional consensus regarding the usefulness of BMI screening in schools (18
), and the practice has not been evaluated in early childhood education programs. Nearly all children attending Head Start are eligible for WIC, and the Program Performance Standards require programs to identify a source of primary health care for enrolled children. In addition to the practices of some Head Start programs, WIC program directors and other health care professionals also measure children’s height and weight and communicate the results to families.
For every child in a Head Start Program who does not appear to be getting enough food to eat at home, there is likely another child in the program who appears to be getting enough to eat at home but who is living in a food insecure household. Although obesity is often more visible than food insecurity, the latter has been associated with behavior and attention problems in preschool-aged children and with depressive symptoms and anxiety in mothers (19
), all of which may affect children’s learning. We did not ask whether programs routinely screen families for household food insecurity, but such screening could be implemented as a routine part of the family assessment that is required at Head Start enrollment (7
Evidence is increasing to support the role of serving appropriate portion sizes to prevent obesity in young children, but research is still needed to implement this practice in Head Start. For example, experimental studies show that mealtime energy intake of preschool-aged children increases when entree portion size is increased (20
) and that children tend to select and consume less food if allowed to serve themselves (21
). However, for children who are obese, food insecure, or both, more research is needed to determine what constitutes an appropriate portion size in any given meal or snack and how best to ensure that the child consumes that portion, especially at family-style meals. Therefore, we still lack evidence-based guidance for Head Start staff about how to determine children’s portion sizes and practice responsive feeding in circumstances where obesity and food insecurity are both present, sometimes in the same child (22
Qualitative studies with Head Start teachers indicate that teachers face practical and emotional dilemmas during family-style meals when children in their classrooms have competing health and nutrition problems (23
). Our finding that staff used several mechanisms to provide extra food to children who appeared hungry suggests that staff find the problem of perceived hunger emotionally compelling. However, 1 in 3 children entering a Head Start classroom each fall is overweight or obese (3
), and Head Start has made an effort with its staff to prevent childhood obesity (25
This study had several limitations. First, household food insecurity was not directly measured (26
); however, the study was not designed to provide an estimate of the prevalence of food insecurity in Head Start. Second, the survey data reflected the perceptions of program directors and not those of the classroom teachers. Particularly in larger programs with many centers, the directors may have lacked accurate knowledge about the specific practices in question, and we did not attempt to validate the survey responses with on-site observations or record reviews. Third, we did not collect data on the types of foods actually eaten by children or the physical activity levels of children. Finally, the survey did not include questions about more detailed aspects of the reported practices, such as how height and weight were measured by staff or the content of discussions with parents about their children’s BMI.
Much like a family does, a Head Start program must allocate its limited financial resources to meet the varied needs of its children. More applied research is needed to assist Head Start programs in the optimal allocation of resources across the related areas of assessing BMI, addressing food insecurity, and determining children’s portion sizes. Awaiting such research, programs may consider the recommendations that follow.
Programs should re-evaluate whether they should directly measure children’s heights and weights, because the practice is resource intensive, may be redundant, and does not have clear utility. The practice is common, although it is not explicitly required by Head Start Program Performance Standards. Many Head Start programs are already closely coordinated with WIC clinics and pediatric offices, where BMI is assessed longitudinally. Furthermore, effective interventions are lacking for the treatment of obesity in preschool-aged children (27
), and most approaches used to address obesity in Head Start are directed at all children, not just those who are obese (25
Head Start should consider systematically assessing household food security. In contrast to BMI assessment, assessing food security requires no equipment and little training, is not systemically conducted in other settings, and identifies a condition that Head Start has the capability to address with its limited resources. A short, validated instrument exists to identify food insecure households (26
), and this instrument is not regularly used in WIC or pediatric offices (28
). Participation in programs such as SNAP and WIC may help to address food insecurity (29
). Making referrals from Head Start to these food assistance programs may be important, because some families who are eligible for the programs may not be participating (3
). In addition, families in Head Start may benefit from a greater collaboration with SNAP-Ed, the educational component of SNAP (30
Finally, regardless of whether obesity and food insecurity are assessed in Head Start, these conditions will continue to exist at the same table and create challenges for staff during meals and snacks. Programs may wish to invest in more training and technical assistance to help their staff with managing children’s portion sizes at family-style meals, which would involve the use of such promising practices in this area (31
) as the following: 1) allowing children to serve their own portions, 2) using child-sized dishes and utensils, and 3) encouraging children to select small first portions, then allowing children to request second portions.