Maternal Risk of Cardiovascular Disease Is Associated With Higher BMI Among Preschool-Aged Children: A Cross-Sectional Study

Childhood obesity is an ongoing concern in the United States. Higher weight status in early childhood is associated with higher weight status at older ages. The Maternal Obesity Matters (MOMs) Study investigated associations between maternal risk of cardiovascular disease (CVD) and child BMI z-scores (BMIz) among preschool-aged children. This cross-sectional exploratory study included mothers and their 3- to 5-year-old children in Colorado, United States. Maternal nonfasting blood samples, blood pressure, and maternal and child anthropometrics were collected. Maternal CVD risk was assessed on a scale of 0-5 using five health measures. Multivariate regression tested associations between maternal CVD risk and child BMIz. Each 1-point increase in maternal CVD risk was associated with a 0.18 increase in child BMIz, controlling for maternal employment. Intervening upon maternal health may be an important strategy for addressing childhood obesity.

Using Plan, Do, Study, Act Cycles to Improve a Maternal Self-Care Intervention With Audience Input

Maternal self-care, including healthy eating, physical activity, and stress management behaviors, is influenced by environmental, social, and individual factors. Plan-Do-Study-Act (PDSA) Cycling is an effective quality improvement process using rapid cycling to refine interventions to fit audience-specific contexts and to address socioecological influences on behavior change. To refine components of the Healthy EnviROnmentS Self-Care intervention, a mindful self-care program for mothers of preschool-aged children in rural communities, PDSA cycles were used to examine: (A) acceptability of content, (B) suitability of implementation strategies, and (C) feasibility of digital supports across three stages of program development. Stage 1 included a group discussion with an expert panel (n = 8). Stage 2 used brief interviews and group discussion with a convenience sample (n = 5). Stage 3 included in-depth interviews with the focal population (n = 6). In-depth interviews were transcribed and analyzed using a directed approach, and data were compiled from group discussion notes and assessed for congruence and analyzed for emergent themes. PDSA cycles relating to content led to the addition of activities to introduce mindfulness and foster social support and the revision of handouts. Implementation strategies were refined with respect to workshop duration, activity order, and meeting type. Digital supports resulted in refinement to the study website and tablet applications. Utilization of PDSA cycles allowed for input from the focus population at every point of intervention design and considered socioecological factors that can influence behavior change.

A Narrative Review of Dietary Assessment Tools for Preschool-Aged Children in the Home Environment

Preschool-aged children in the U.S. have suboptimal diets. Interventions to improve child nutrition focus on parents and their role in shaping social and physical home environments, which influence children's eating behaviors. Dietary assessment tools selected to measure intervention objectives, and how results are interpreted in key findings, are essential when examining children's diets. The objectives of this review were to (1) describe dietary assessment tools used in intervention studies in young children focused within the home environment; and (2) examine how the application of these dietary assessment tools addressed intervention objectives. PubMed and Web of Science were searched for English-language nutrition intervention studies that included children aged 2-5 years, had a home environment component, used a dietary assessment tool, and reported on diet-related outcomes. Seventeen studies were included. Intervention objectives focused on overall diet, specific food groups, eating occasions, and obesity prevention/treatment. Concordance of key findings with intervention objectives, type of tool used, and multiple tools within the same study varied with 8 studies aligning in objective and tool, 1 discordant in both, and 8 partially concordant or too broad to determine. This review highlights current challenges in measuring dietary intake in preschoolers and provides recommendations for alternative applications and strategies.

Digital Intervention Strategies for Increasing Physical Activity Among Preschoolers: Systematic Review

Background

Digital interventions are increasingly used to improve health behaviors. Improved access and lower costs (relative to in-person interventions) make such interventions appealing. Specifically, digital platforms may be a promising approach for increasing physical activity (PA) in young children.

Objective

The goal of this systematic review was three-pronged: (1) to determine the quality of studies using digital PA intervention strategies with preschool-aged children (ie, 3 to 5 years old); (2) to assess the efficacy of digital interventions and approaches designed to improve PA in preschool-aged children; and (3) to examine theoretical application and implementation outcomes with current approaches to digital PA interventions.

Methods

This review identified and summarized studies on digitally supported interventions for promoting PA in preschool-aged children. We generated 3 lists of relevant search terms that included technology-related terms, PA-related terms, and weight-related terms. The search included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. Study selection was led by a single author and verified by a second; the same 2 authors assessed study quality using a standardized tool, and 3 authors completed data extraction on PA outcomes, theory application, and implementation outcomes.

Results

In total, 601 studies were identified; 8 met the inclusion criteria. For study quality, only 2 studies received an overall rating of strong quality and low risk of bias. All but 1 study had a small sample size (<100). Positive and significant changes in child PA outcomes were reported in only 2 studies with weak overall quality, both of which used child-directed approaches. In total, 5 studies applied a behavioral theory for designing the intervention; no patterns of effectiveness were identified based on the application of theory. Finally, no studies reported on the implementation outcomes of adoption, cost, penetration, or sustainability; 1 study did not assess any implementation outcomes, and no single study reported on more than 2 implementation outcomes. Studies measured the implementation outcome of acceptability most frequently (n=4), and researchers assessed fidelity in 3 studies.

Conclusions

The interventions with a significant effect on PA used child-centered activities; parent-directed digital interventions alone were ineffective for improving PA. Future research with rigorous designs, monitoring of implementation outcomes, and testing of the contributions of digital components will advance understanding of the effectiveness of digital interventions for increasing PA in children.

Strengthening Nutrition Education and Behavior Research for Academicians and Practitioners

Nutrition education and behavior research is essential for translating scientific nutrition-related evidence into actionable strategies at the individual, family, community, and policy levels. To enhance the impact of nutrition educators and researchers' efforts, there is a need for continued and directed support to sustain the rigor of research. It is the perspective of this paper that the field of nutrition education and behavior research address its inherent complexities to meet the diverse investigative strategies used by academicians as well as practitioners. Such strategies could ensure the role of nutrition education and behavior in ongoing nationwide efforts to address emerging and novel nutrition research.

Predictors of sustainment of two distinct nutrition and physical activity programs in early care and education

Introduction

The goal of the present study was to investigate factors associated with sustainment of two evidence-based programs for nutrition promotion in early care and education (ECE) settings - Food Friends (FF) and Together, We Inspire Smart Eating (WISE).

Materials and methods

In a cross-sectional study design, ECE directors (N = 55) from centers that had previously been trained in WISE or FF completed a survey. Program-specific measures included Steckler's Perception of Innovations, the Program Sustainability Assessment Tool (PSAT), and the Organizational Readiness for Change Assessment (ORCA). For our primary outcomes, two measures of sustainment were examined: Nutrition Continued Practice (i.e., the use of or general focus on nutrition programs) and Program Fidelity (i.e., how well centers used specific evidence-based practices of WISE or FF). Multiple regression was used to determine the association of these outcomes with program, years since last implementation, and overall scores on predictors. Follow-up correlation analyses were used to investigate outcome relationships with context submeasures due to high intercorrelations between predictor submeasures.

Results

Nutrition Continued Practice was significantly predicted by program and overall PSAT score. WISE programs had significantly higher Nutrition Continued Practice scores than FF program (p = 0.03). All subscales of the PSAT (e.g., environmental support, funding stability, organizational capacity, program adaptation, communications, and strategic planning) were significantly correlated with Nutrition Continued Practice (all rs > 0.30, all ps < 0.03). Program Fidelity was significantly predicted by PSAT and Steckler Perception of Innovation scores. All subscales of the PSAT were strongly positively correlated with Program Fidelity (all rs > 0.48, all ps < 0.001); relative advantage (r = 0.54, p < 0.001) and level of institutionalization (r = 0.61, p < 0.001) were positively correlated with Program Fidelity.

Conclusion

This study suggests that factors associated with the continued practice of program principles are partially distinct from those that are associated with the sustainment of specific practices driving program fidelity. Results suggest capacity building strategies may be important for both continued attention to nutrition and physical activity as well as sustaining fidelity to specific evidence-based practices.

Switching up sides: Using choice architecture to alter children's menus in restaurants

U.S. children's frequent consumption of restaurant foods has been associated with low vegetable consumption. Use of choice architecture in restaurants has been shown to increase children's orders of healthy sides, but what children consume when healthy sides are included is unknown. The purpose of the present study was to investigate whether altering the choice architecture of children's meals by restructuring the menu, using optimal defaults and vice-virtue bundles, would impact ordering of side dishes and consumption of a vegetable side dish during a restaurant meal. Families with a child between 4-8y attended three dinners at a university-based restaurant. Children's meals included choice of entree (macaroni-and-cheese or chicken tenders) and default side: all carrots (150 g; Menu-1), small fries (50 g)/large carrots (100 g; Menu-2), and small carrots (50 g)/large fries (100 g; Menu-3). Participants could opt-out of the default side for: only fries (Menu-1) or only fries or carrots (Menus-2/3). All foods were pre- and post-weighed to determine consumption. Descriptive statistics examined children's ordering behavior. Repeated measures ANOVA examined differences in consumption of study foods. A paired samples t-test examined differences in french fry consumption (Menus-2/3). Forty-eight children (6.2 ± 1.3 years; 25 male) participated. Most children remained with the default side (Meal-1: 90%; Meal-2: 88%; Meal-3: 85%). Significant differences were seen in children's consumption of french fries (t = -2.57, p = .014) where children ate more during meal 3 compared to meal 2. There were no significant differences in carrot consumption. Use of optimal defaults led to increased orders of healthy sides and steady consumption across the meal conditions. However, use of an optimal, vice-virtue bundle led to a decrease in consumption of french fries. Further investigation of optimal default use on children's menus is warranted.

Validation of a Home Food Environment Instrument Assessing Household Food Patterning and Quality

The home food environment (HFE) is associated with dietary intake; yet measuring HFE quality often requires burdensome collection of detailed inventories. This project evaluated the capacity of the Home Inventory to Describe Eating and Activity, version 2 (Home-IDEA2) to capture HFE quality by measuring the presence or absence of household foods. Validity was tested using a modified application of the Healthy Eating Index-2010 (HEI). Comparative data were drawn from the National Food Acquisition and Purchase Survey (FoodAPS) Food-at-Home Public Use File. HEI scores were calculated for 4202 households in FoodAPS using Home-IDEA2 inventories and full reported inventories. Paired t-tests compared: (1) estimated vs. total edible grams (EEG; TEG); (2) limited vs. all reported foods; and (3) EEG + limited foods vs. TEG + all reported foods. Sensitivity and range of scores were compared. Mean HEI scores for Home-IDEA2 were higher (p < 0.003) than FoodAPS: (1) 51.6 ± 16.1 vs. 49.6 ± 18.1 (food amounts); (2) 53.5 ± 15.8 vs. 49.8 ± 15.4 (food items); (3) 55.5 ± 15.7 vs. 49.8 ± 15.4 (full instrument); differences were small. Scores demonstrated comparable sensitivity and range. The study found that the Home-IDEA2 can capture HFE quality adequately with low data collection burden.

Picture Perfect: How Attaining the Ideal Meal is Not So Easy for Parents of Young Children

OBJECTIVE

To explore parental perspectives on the ideals and realities of family mealtimes.

DESIGN

Mini-focus groups (n = 7).

SETTING

Rural Colorado, US.

PARTICIPANTS

Parents (n = 30) were recruited at Head Start/preschool centers.

PHENOMENON OF INTEREST

Parent perspectives on mealtimes with preschool-aged children.

ANALYSIS

Transcripts were analyzed using thematic analysis.

RESULTS

Three categories of themes emerged: participant conceptions of ideal family meals, challenges to achieving their ideal family meal, and parental solutions. The theme of participant conceptions of ideal family meals composed family togetherness, children liking and eating the prepared food, healthfulness of food, and a nonchaotic mealtime. Challenges to achieving their ideal family meal included work schedules, disruptive child behaviors, child pickiness, snacking, and negative role-modeling. Finally, parental solutions to challenges incorporated having flexible meal timings, considering child preferences in premeal preparations, role-modeling, and numerous other parenting strategies.

CONCLUSIONS AND IMPLICATIONS

While parents valued many aspects of a version of the ideal meal rooted in historical standards, families faced many challenges in trying to attain that ideal. Although parents employed various strategies to combat mealtime challenges, parental expectations for preschool-aged children's mealtime behaviors may be unrealistic for the developmental stage of early childhood. Future interventions could help parents develop age-appropriate mealtime expectations.

What Do Mom and Dad Think? Examining Parent Preferences for the Use of Behavioral Economic Strategies on Children's Menus in Restaurants

BACKGROUND

A majority of children's restaurant meals are nutritionally deficient; use of behavioral economics may improve healthful menu selections. Parents play a role in children's restaurant meal selection, thus understanding parent preferences for potential behavioral economic strategies is warranted.

OBJECTIVE

To examine parent-derived and -stated preferences for selected attributes of children's restaurant menus, which included behavioral economic strategies (eg, optimal defaults and vice-virtue bundles).

DESIGN

A descriptive, cross-sectional, within-subjects survey integrating a conjoint design was developed along with 8 children's menus. Menus were manipulated by varying levels of attributes (meal price, healthful side dishes, number of side dish items, healthful entrées, and cost for sugar-sweetened beverages [SSB]). Parents rated menus and attributes using Likert scales.

PARTICIPANTS/SETTING

A national sample of US parents with children 4 to 10 years (n = 463) were recruited in August of 2019 via Amazon's Mechanical Turk.

ANALYSIS

A conjoint (regression) analysis was conducted to derive parent preference for each attribute and overall menu preference. Descriptive statistics (means) described overall stated parent menu preferences and ratings. Cluster analysis segmented parents into groups with similar preferences.

RESULTS

Derived preferences showed parents had the strongest preference for choice of side dishes (β = .73) and low-priced menus (β = .51), and weak preferences for inclusion of healthful entrées (β = .04) and added cost for SSB (β = .18). Parents stated preference was for a menu that included healthful entrées, was low priced, and featured choices for side dishes. Cluster analysis revealed half of parents preferred the low-cost children's menu with the other half of parents split evenly across preferences related to health, choice, and traditional menus.

CONCLUSION

Parents stated preference was for a socially desirable menu featuring healthful entrée options and added cost for SSB, which was contrary to the conjoint derived menu preferences. Understanding parent preferences may help guide nutrition professionals working to build a more healthful food environment through the use of behavioral economic strategies.

Examining Front-of-Package Product Names and Ingredient Lists of Infant and Toddler Food Containing Vegetables

OBJECTIVE

To investigate the alignment between vegetables and fruits listed in the ingredients of commercially produced infant and toddler food (ITF) and inclusion in front-of-package product names.

DESIGN

A database of commercial ITF containing vegetables (n = 548) was created. Inclusion of each vegetable or fruit in the product name (yes/no), form (ie, whole/puree, juice/juice concentrate, etc), and ingredient list position (ie, first, second) were recorded. Vegetables were classified per US Department of Agriculture categories; fruits were classified into 2 categories.

ANALYSIS

Chi-square tests of association tested associations between product name inclusion and (1) vegetable and fruit category, (2) form, and (3) form by category.

RESULTS

Associations were observed between vegetable and fruit categories and inclusion in product names [χ² (6, N = 1,462) = 70.3, P < 0.001]. Vegetables in the US Department of Agriculture dark green category were more likely to appear in product names (94%; standardized residual [SR] = 2.1), as were other vegetables (62%; SR = 4.9). Vegetable and fruit forms were associated with inclusion in product name [χ² (4, N = 1,462) = 206.6, P < 0.001]. Juice/juice concentrates were less likely to be included in names (32.4%; SR = -5.4).

CONCLUSIONS AND IMPLICATIONS

Substantial discrepancies exist between ITF ingredient lists and front-of-package product names. When only front-of-package information informs purchases, caregivers may not be purchasing products that facilitate children's building of vegetable preferences.

Food Photography as a Tool to Assess Type, Quantity, and Quality of Foods in Parent-Packed Lunches for Preschoolers

OBJECTIVE

Explore using food photography to assess packed lunches in a university-based Early Childhood Center and contextualize these photographs through parent interviews.

METHODS

An explanatory sequential design was used. Packed lunches were photographed to assess the type and quantity of foods offered and consumed by Child and Adult Food Care Program components (fruit, vegetable, grain, and protein) and quality of foods offered using the Healthy Meal Index. Parent interviews aimed to understand motivations and behaviors related to packing lunch.

RESULTS

Data were collected on 401 lunches. Only 16.2% of lunches met all Child and Adult Food Care Program requirements. Most lunches included fruit (84%) and grains (82%), whereas fewer included vegetables (44%). Portion sizes were large, especially for grains (2.7 ± 1.5 servings). In interviews (n = 24), parents expressed tension between offering healthful items and foods they knew their child would eat, as well as concern about children going hungry.

CONCLUSIONS AND IMPLICATIONS

Food photography is a feasible methodology to capture parent-packed lunches for preschoolers and may have utility in nutrition education, particularly related to age-appropriate portion sizes.

A mixed-methods protocol for identifying successful sustainability strategies for nutrition and physical activity interventions in childcare

BACKGROUND

Despite the importance of sustainability for nutrition and physical activity in public health interventions, limited studies have explored the factors that promote and inhibit evidence-based program sustainment in the childcare setting. This study protocol describes a mixed-methods approach to develop novel sustainability strategies based on real-world settings and stakeholder feedback, with the goal of providing support for future obesity prevention programs and related studies on intervention sustainability. Two interventions, Together, We Inspire Smart Eating (WISE) and The Food Friends' (FF) Fun with New Foods and Get Movin' with Might Moves, are studied to this end.

METHODS

The study will deploy an explanatory, sequential mixed-methods design. First, the research team will collect a quantitative survey to assess rates of sustainment among WISE and Food Friends sites. We expect to collect 150 surveys from WISE and FF sites combined. Data from these surveys will be used to purposively sample sites for 12 to 18 site visits. Specifically, we will purposively sample low, partial, and high sustaining sites where we will conduct key informant interviews and focus groups as well as validate self-reports on sustainability. Survey content, qualitative interviews, and coding will be based on the Dynamic Sustainability Framework. We will draw on findings from the quantitative survey on predictors of sustainment and the qualitative site visits to understand varying levels of program sustainment. Then, we will utilize evidence-based quality improvement sessions to engage stakeholders in developing a multi-component sustainability strategy.

DISCUSSION

This study will provide a stakeholder-informed sustainability strategy ready for testing in a full-scale trial examining effects on sustainment of evidence-based nutrition and physical activity practices in childcare. We expect this strategy to be relevant for educators and consistent with the views of administrators as a guide for future practice for the targeted nutrition and physical activity interventions and beyond.

Microgreens: Consumer sensory perception and acceptance of an emerging functional food crop

Microgreens are an emerging functional food crop with promise for sustainably diversifying global food systems, facilitating adaptations to urbanization and global climate change, and promoting human health. Previous work suggests microgreens have high nutritional quality, low environmental impacts, and broad consumer acceptance. For better reception into the global food system and increased per capita consumption, research is needed to elucidate consumer acceptance of various microgreens species, including factors contributing to their acceptance or lack thereof. Using a consumer panel (n = 99), this study evaluated consumer sensory perception and acceptability of six microgreens species (arugula, broccoli, bull's blood beet, red cabbage, red garnet amaranth, and tendril pea), and potential drivers and barriers to consumer acceptance. All microgreens species received high mean liking scores for acceptability by consumers (means ranged from highly acceptable to slightly acceptable), with more distinct differences across microgreens species for flavor and overall acceptability, which appeared to be driven by specific sensory properties. Data from principal component analysis demonstrated that high acceptability scores were associated with higher intent to purchase microgreens and negatively associated with food neophobia. Participants indicated that factors such as knowledge and familiarity of microgreens, cost, access/availability, freshness/shelf life, among other factors, influence their intention to purchase microgreens. These findings suggest that further integration of microgreens into the global food system will be met with high consumer acceptability, but needs to be aligned with enhanced consumer education regarding microgreens, as well as considerations of cost, availability/access, and freshness/shelf life. PRACTICAL APPLICATION: Researchers investigated consumer sensory perception and acceptability of six microgreens species (arugula, broccoli, bull's blood beet, red cabbage, red garnet amaranth, and tendril pea), and potential drivers and barriers to consumer acceptance. All microgreens tested had high consumer acceptability, but certain factors such as sensory perception and food neophobia impacted their acceptability. Additionally, participants indicated that factors such as knowledge, access and availability, cost, freshness, and shelf life may impact the purchasing of microgreens and thus are important factors to consider for further integration of this emerging functional food crop into the global food system.

Assessing dinner meals offered at home among preschoolers from low-income families with the Remote Food Photography Method

BACKGROUND

The high prevalence of obesity among preschoolers may be partially explained by the type and quantity of foods offered by parents and left unconsumed by preschoolers.

OBJECTIVES

(a) To compare foods offered and consumed at dinner to the Dietary Guidelines for Americans (DGAs) and the Child and Adult Care Food Program (CACFP) standards and (b) to examine the types, quantities, and nutrient composition of foods offered to and consumed by preschoolers and their plate waste.

METHODS

Participants were recruited from six Head Start/preschool centres. The Remote Food Photography Method was used to document dinner meals over 1 week (n = 153 meals). Energy and nutrients for foods offered, consumed, and plate waste were calculated. Foods offered and consumed were compared with the DGAs and CACFP standards.

RESULTS

Foods and beverages offered at dinner equaled 506 kcal, which is 36% of the DGA-recommended total daily energy intake. Meals offered and consumed were high in fat and sodium and low in fibre. Adherence to CACFP standards was low for fruits (25%) and milk (2%) and moderate for vegetables (63%). Mean plate waste (29%) was similar across food types.

CONCLUSIONS

Opportunities exist to improve preschoolers' adherence to the DGAs and CACFP standards by enhancing the quality of dinner meals offered to them.

Nutritional Content and Ingredients of Commercial Infant and Toddler Food Pouches Compared With Other Packages Available in the United States

The ingredients and nutrients of infant and toddler foods (ITFs) sold in pouches were compared with products available in other packages, such as jars/packs and other containers. Company websites (n = 21) and in-store shelf inventory (n = 3) were used to create a database of commercial ITFs containing vegetables (n = 548) sold in the United States. Results indicated that ITFs containing vegetables were most commonly packaged in pouches (50%), followed by "other" packages (25%) and jars/packs (25%). Infant and toddler food pouches contained significantly more sugars per serving and per Reference Amount Customarily Consumed, as well as a greater percentage of calories from sugars, compared with both jars/packs and "other" packages. Pouches were also more likely to contain vegetable/fruit blends, whereas jars/packs were more likely to contain single-vegetable or multivegetable blends, and "other" packages were more likely to contain vegetable/other ingredient combinations (eg, grains and/or dairy). Pouches are popular, widely available, and convenient but may not represent the vegetable profiles and nutritional qualities that parents believe they are buying for their children.

An Ecocultural Perspective on Eating-Related Routines Among Low-Income Families With Preschool-Aged Children

Eating-related routines, such as regular mealtimes, can protect against obesity. Little is known about eating-related routines among preschoolers or the factors that shape those routines. Ecocultural Theory and qualitative interviews with 30 caregivers of preschoolers in Colorado were used to describe eating-related routines at home and parents' perspectives on the factors that shape routines. Qualitative content analysis was used to analyze and interpret data. Consistent with clinical recommendations, parents' goals included dinner meals where adults and preschoolers eat the same food, in the same place, at the same time. However, parents' employment schedules and challenges in managing preschoolers' behavior prevented parents from consistently enacting recommended routines. Educating parents alone may not be sufficient to ensure optimal eating-related routines among preschoolers, and the household context needs to be considered. Families organized routines according to cultural values and available resources.

A longitudinal intervention to improve young children's liking and consumption of new foods: findings from the Colorado LEAP study

BACKGROUND

Many interventions have been conducted to improve young children's liking and consumption of new foods however their impacts on children's consumption have been limited. Consistent evidence supports the use of repeated exposure to improve liking for new foods however longitudinal effects lasting greater than 6 months often have not been demonstrated. Here we report the eating-related findings of the Colorado Longitudinal Eating And Physical Activity (LEAP) Study, a multi-component intervention, delivered primarily in the school setting, which aimed to improve children's liking and consumption of a target food via repeated exposure and positive experiential learning.

METHODS

Four sites in rural Colorado, each housing Head Start preschool programs, matched on state vital statistics for childhood obesity rates, (2 intervention and 2 control sites) took part in a quasi-experimental study design which included 4 time points (baseline, post-intervention, one-year [Y1] and two- year [Y2] follow ups). A total of 250 children and families were enrolled (n = 143 intervention and n = 107 control; 41% Hispanic and 69% low-income). A 12-week intervention, Food Friends - Fun With New Foods®, delivered by trained preschool teachers and which focuses on positive and repeated experiences with new foods, and a 5-month (1 unit/month) social marketing "booster program" was delivered in kindergarten (one-year follow up) and 1st grade (two-year follow up). Main outcome measures included change in children's liking for new foods, analyzed by ordinal regression using generalized estimating equations, and change in weighed consumption of new foods over time, analyzed using a hierarchical mixed effects model.

RESULTS

The intervention was delivered with good fidelity (87%). Both intervention and control groups demonstrated an increase in liking for the target food over time (p = 0.0001). The pattern of consumption of the target food was different, over time, for intervention and control groups (p < 0.005). In particular the change in intake between baseline and post-intervention was significantly greater in the intervention compared to the control group (p < 0.0001) though this pattern of change did not hold between baseline and Y2 follow up (p = 0.1144). Children in the intervention group who liked the target food consumed nearly double their baseline consumption at post-intervention (p < 0.0001;) and maintained this increase at Y2 follow up (p < 0.0001).

CONCLUSIONS

The Food Friends intervention, which utilized positive, repeated experiences with new foods, and was delivered with good fidelity by trained preschool teachers, found that larger improvements were observed in children's eating behaviors than would be expected with developmentally-based changes in eating behaviors.

TRIAL REGISTRATION NUMBER

This trial is registered at ClinicalTrials.gov : NCT01937481. Date registered: 09/09/2013; Retrospectively registered. Date first participant registered: 09/15/2010.

Beyond Nutrient Intake: Use of Digital Food Photography Methodology to Examine Family Dinnertime

OBJECTIVE

To explore the feasibility of using an image-based food photography methodology (Remote Food Photography Method) in a rural, low-resource audience and use the photos to examine the context of family dinner.

DESIGN

Parents used the SmartIntake app on study-issued tablets to take before and after photos of their and their child's dinner for about 7 nights and participated in a mini-focus group to discuss their experience with the Remote Food Photography Method.

SETTING

Six Head Start/preschool centers in rural Colorado.

PARTICIPANTS

Mother-child dyads (n = 31).

VARIABLES MEASURED

Number and quality of photos received, participant feedback, meal timing, concordance, location, preparation, and quality.

ANALYSIS

The researchers assessed feasibility via practicality (percent photos received) and acceptability (general inductive approach used to analyze mini-focus group transcripts for participant feedback); time stamps, meal quality, and food preparation scales were used to analyze dinner photos.

RESULTS

The majority of photographs (738 of 864) were received. Participants reacted favorably to the methodology; for some, it led to greater self-reflection about mealtime. Mother-child dyads usually ate dinner at the same time and often ate the same food. Children were frequently served protein and refined grains and were rarely served whole grains or fruit. Many families relied on convenience foods.

CONCLUSIONS AND IMPLICATIONS

Digital food photography was feasible in this audience. Photos yielded a holistic picture of family dinnertime: meal timing, location, concordance in parent-child meals, level of preparation, and meal quality.

Checklist to Capture Food, Physical Activity, and Sedentary Devices in the Home Environment: The Home Inventory Describing Eating and Activity (Home-IDEA2)

OBJECTIVE

To modify and test a self-report checklist for the home food and activity environment, Home-Inventory Describing Eating and Activity (IDEA2), psychometrically with families of young children.

DESIGN

A mixed-methods approach: (1) cognitive interviews informed instrument design (content validity), (2) parent and trained independent raters concurrently and independently completed the Home-IDEA2 during home visits (criterion validity); (3) the Home-IDEA2 was compared with a national sample via the Food Acquisition and Purchase Survey (FoodAPS) database (construct validity).

SETTING

Rural communities in Colorado.

PARTICIPANTS

Families of preschoolers: cognitive interviews (n = 20) and home visits (n = 26).

MAIN OUTCOME MEASURES AND ANALYSIS

Content validity: responses to each question were analyzed using a general inductive approach. Criterion validity: Cohen's kappa (κ) coefficient was calculated for each Home-IDEA2 item. Construct validity: frequencies were calculated to determine the proportion of Home-IDEA2 food items found in FoodAPS households.

RESULTS

Cognitive interviews identified the need for more food descriptions and the reduction of total items from 154 to 134. Testing resulted in acceptable agreement (κ = 0.6-1.0) for 82 items (58 food, 16 physical activity, and 8 electronics), moderate agreement for 36 (35 food and 1 physical activity; κ = 0.4-0.5), and poor agreement for 16 (15 food and 1 electronics; κ ≤ 0.3). Overall reliability improved from 55% to 65% for Home-IDEA2 items. Comparison of Home-IDEA2 items with FoodAPS demonstrated that 60% of foods found in US homes were covered by the Home-IDEA2.

CONCLUSIONS AND IMPLICATIONS

This study resulted in a valid, reliable, and low-burden self-report measure for food, activity, and electronic home environments by low-income, minority parents of preschoolers.

Social-ecological correlates of fundamental movement skills in young children

PURPOSE

To identify the social-ecological correlates associated with fundamental movement skills at the child, family, and environment levels in young children.

METHODS

Preschool children from 4 Colorado Head Start/preschool centers were recruited from 2010 to 2012. Two hundred twenty-eight children (128 girls; age = 56.08 ± 4.09 months; body mass index (BMI) z-score = 0.53 ± 1.12 (mean ± SD); 42.1% Hispanic/Latino) and 159 families were included in the final analysis. Children's perceived competence and fundamental movement skills were assessed via the Pictorial Scale of Perceived Competence and Social Acceptance and the Bruininks-Oseretsky Test of Motor Proficiency, 2nd edition. Data on the number of children in the family, parent age, BMI, education, employment status, family income, perception of child coordination, and home physical activity environment were collected via a questionnaire. Linear regressions adjusted for child BMI, age, sex, and school site were performed at each level.

RESULTS

Child perceived cognitive competence was positively associated with locomotor skills (p = 0.04; adjusted R ² = 0.035) and object-control skills (p = 0.003; adjusted R ² = 0.083) at the child level. Parent education, BMI, and perception of child coordination were positively associated with locomotor skills and explained 8.8% of variance, but only parent education was significant (p = 0.04) at the family level. In addition, physical environment was positively associated with locomotor skills (p = 0.02) and explained 5.5% of variance at the environment level.

CONCLUSION

Social-ecological correlates associated with young children's fundamental movement skills are multidimensional and differ according to skill category at the child, family, and environment levels.

Development of a Quality Score for the Home Food Environment Using the Home-IDEA2 and the Healthy Eating Index-2010

The home food environment (HFE) is an important factor in the development of food preferences and habits in young children, and the availability of foods within the home reflects dietary intake in both adults and children. Therefore, it is important to consider the holistic quality of the HFE. The purpose of this study was to apply the Healthy Eating Index (HEI; a measure of diet quality in conformance to the Dietary Guidelines for Americans) algorithm to the Home-IDEA2, a valid and reliable food inventory checklist, to develop a Home-IDEA2 HEI Score. After an initial score was developed, it was psychometrically tested for content, criterion, and construct validity. Content validity testing resulted in 104 foods being retained. Internal criterion testing demonstrated that 42 foods (40%) changed component scores by >5%; however, no single food changed a total Home-IDEA2 HEI score by >5%. Testing of hypothetical HFEs resulted in a range of scores in the expected directions, establishing sensitivity to varied HFEs. This study resulted in a validated methodology to assess the overall quality of the HFE, thus contributing a novel approach for examining home food environments. Future research can test interventions modifying the HFE quality to improve individual dietary intake.

Mobile Device Use Among Rural, Low-Income Families and the Feasibility of an App to Encourage Preschoolers' Physical Activity: Qualitative Study

BACKGROUND

As mobile devices are becoming ubiquitous, technology-based interventions provide a promising strategy to positively influence health behaviors of families with young children. However, questions remain about the feasibility and acceptability of intervention delivery via mobile apps in low-income, rural settings and among families with preschoolers.

OBJECTIVE

The aims of this study were to understand the content and context of mobile device use for preschoolers; explore parent beliefs on this topic, including the acceptability of intervention delivery via mobile devices; and test a prototype of an app to encourage preschoolers' physical activity with both parents and children.

METHODS

Parents (n=29) were recruited from 5 preschool centers in eastern, rural Colorado to complete a semistructured telephone interview regarding preschoolers' mobile device use. A second sample of parents (n=31) was recruited from the same preschool centers to view the app prototype independently and provide feedback. A third sample of preschool children (n=24) was videotaped using the app in small groups to measure engagement and record their responses to the app.

RESULTS

Five key content areas emerged from the telephone interviews: (1) mobile devices are an important part of families' everyday routines, and parents have parameters governing their use; (2) parents often use mobile devices as a tool for behavior management; (3) parents clearly distinguish between mobile device use for learning versus entertainment; (4) parents have an overarching desire for balance in regard to their child's mobile device use; and (5) parents were generally supportive of the idea of using mobile apps for intervention delivery. From the app prototype testing with parents, participants reacted positively to the app and felt that it would be useful in a variety of situations. Testing with preschoolers showed the children were highly engaged with the app and a majority remained standing and/or actively moving through the entire length of the app.

CONCLUSIONS

Mobile devices are already integrated into most families' daily routines and appear to be an acceptable method of intervention delivery in low-income families in rural Colorado. The physical activity app represents an innovative way to reach these families and, with further improvements based on participant feedback, will provide children with a unique opportunity to practice key movement skills.

HEROs: Design of a Mixed-Methods Formative Research Phase for an Ecocultural Intervention to Promote Healthy Eating and Activity Behaviors in Rural Families With Preschoolers

OBJECTIVE

To describe the mixed-methods formative research phase in the development of the Healthy Environments Study (HEROs), a technology-based, interactive family intervention to promote healthy eating and activity behaviors for young children in the home environment.

DESIGN

A mixed-method iterative approach, using ecocultural theory as a framework, will guide the development of both quantitative and qualitative formative research assessments.

SETTING

Rural eastern Colorado.

PARTICIPANTS

Low-income families (n = 200) with preschool-aged children enrolled at 6 Head Start/preschool centers.

MAIN OUTCOME MEASURES

Quantitative and qualitative methodologies will garner insights into 4 key topic areas: (1) food behaviors and environments (Remote Food Photography Method, parent focus group, and survey), (2) physical activity behaviors and environments (parent interview and survey), (3) mobile device use (parent survey and interview), and (4) daily life (ecocultural family interview and teacher/staff group discussions).

ANALYSIS

Results will be interpreted in combination to allow for a holistic understanding of participant behaviors, beliefs, attitudes and values related to each of the 4 topic areas. Collectively, outcomes will provide a comprehensive picture of preschoolers' daily life and inform intervention design and strategies to enhance preschoolers' eating and activity behaviors in the home environment.

Variety and content of commercial infant and toddler vegetable products manufactured and sold in the United States

Background

Exposure to vegetable flavors during infancy and toddlerhood is hypothesized to enhance vegetable acceptance when children transition to table foods.

Objective

We sought to examine the vegetable types, ingredients, and nutrient contents of vegetable-containing infant and toddler foods (ITFs) manufactured and sold in the United States.

Design

A database of ITFs that contain vegetables (n = 548) was compiled from websites of companies based in the United States (n = 24). Product information was recorded, including intended age or stage, ingredient lists, and selected nutrients from the Nutrition Facts label. Ingredient lists were used to categorize vegetables using the USDA vegetable categories: dark green (e.g., spinach), red and orange (e.g., carrots), starchy (e.g., green peas, corn), beans and peas (e.g., black beans), and other (e.g., green beans, beets). Furthermore, products were categorized as single-vegetable, multi-vegetable, vegetable and fruit, vegetable and meat, or vegetable and other combinations (e.g., grains and and or dairy). Nutrients were examined, including energy (kilocalories), carbohydrates, fiber, and total sugars [per serving, per 100 g, per reference amount customarily consumed (RACC), and percentage of kilocalories from sugars].

Results

Of the 548 vegetable products, only 52 single-vegetable products (9.5%) were identified, none of which contained dark green vegetables or beans and peas. Red and orange vegetables most often appeared as the first ingredient (23.7%) compared to other vegetable types, such as dark green vegetables, which were rarely listed first (1.1%). Fruits were listed as the first ingredient more commonly than all vegetables (37.8%). One-way ANOVA revealed that vegetable and fruit products contained more sugars on average than did vegetable products with other ingredients, such as dairy and/or grains (all P values < 0.001).

Conclusions

Current available products do not provide caregivers with a sufficient variety of single-vegetable products or products containing dark green vegetables to facilitate children's subsequent acceptance of these vegetables. Guidance should include making caregivers aware of the limitations of commercial ITFs manufactured and sold in the US market.

Parent Perceptions of Mobile Device Use Among Preschool-Aged Children in Rural Head Start Centers

OBJECTIVE

To describe child use and parents' beliefs and comfort with young children's use of mobile devices in low-income, rural communities.

METHODS

This was a descriptive, cross-sectional study. The survey, which consisted of 18 multiple-part questions, was distributed to families at 5 Head Start/preschool centers in Colorado.

RESULTS

In total, 192 surveys were returned (28.5% response rate). Most children (92%) used a smartphone or tablet at some frequency and most parents (90%) had downloaded apps specifically for their child. Education and ethnicity were related to parents' technology beliefs. Parent comfort with technology was positively associated with greater child use of technology (P < .001).

CONCLUSIONS AND IMPLICATIONS

Mobile device use was relatively high in this sample. Mobile devices appear to be a feasible platform to offer nutrition and physical activity education for this audience. Ensuring parent comfort with technology and apps will be important.

Motor skill development in low-income, at-risk preschoolers: A community-based longitudinal intervention study

OBJECTIVES

This study aimed to: (1) determine the status of fundamental movement skill (FMS) performance in low-income, at-risk preschoolers; and (2) evaluate the impact of the Food Friends Get Movin' with Mighty Moves (MM) program on improving children's FMS at two-year follow-up.

DESIGN

Longitudinal, quasi-experimental study with matched controls.

METHODS

The Colorado LEAP study was conducted in four Head Start/preschools (two intervention, two control) serving children aged 3-5 years. MM was delivered to the intervention group during preschool. The Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2) subtests for balance, running speed and agility, upper-limb coordination (object control (OC) skills) and strength were administered to children at baseline, post-intervention in preschool, one-year follow-up (kindergarten), and two-year follow-up (first grade).

RESULTS

Compared to the normative sample's mean, the mean scaled score for all participants at baseline was significantly lower for balance (p=0.016) and OC skills (p<0.001). At two-year follow-up, the means of balance for all participants and OC skills for just the control group were significantly lower than those of the normative sample (p≤0.001). Hierarchical linear regression analyses revealed a significant intervention effect for OC skills with the overall model accounting for 41% of variance at two-year follow-up, F_(6,165)=20.45, p<0.001. No intervention effects were found for the other three BOT-2 subtests.

CONCLUSIONS

Delivering the MM program in preschool confers a lasting impact on FMS, specifically OC skills, in at-risk elementary school children. Results suggest that at-risk preschoolers are already behind in FMS development and these delays will continue through first grade.

The Healthy Weight Disparity Index: Why We Need It to Solve the Obesity Crisis

OBJECTIVE

This study assessed the usefulness of the Healthy Weight Disparity Index (HWDI) to evaluate income disparities related to obesity. We compared state based body mass index (BMI) rankings with HWDI rankings.

METHODS

National data from the 2010 Behavioral Risk Factor Surveillance System were used to estimate mean BMI levels in each of the 50 states (plus Washington, D.C.) by income level. Income-related disparities were described with the HWDI. Kappa statistics analyzed the concordance between the two rankings.

RESULTS

State-based BMI and the HWDI rankings were not concordant. For example, Washington, D.C. was ninth for lowest mean BMI yet ranked 49th on the HWDI. West Virginia ranked 42nd and 5th, and Mississippi ranked 51st on both the BMI and HWDI, respectively.

DISCUSSION

State-based BMI and HWDI rankings present divergent perspectives on the obesity crisis. We recommend adding HWDI rankings to BMI rankings to reflect fully patterns of obesity and subgroup differences.

Young Children's Food Neophobia Characteristics and Sensory Behaviors Are Related to Their Food Intake

BACKGROUND

Food neophobia in children has been associated with poor dietary variety and nutrient intakes. Underlying characteristics that may predispose a child to neophobia have not been widely studied.

OBJECTIVE

We investigated the associations between children's food neophobia, sensory sensitivity, and dietary intake in a diverse sample of typically developing preschoolers.

METHODS

Caregiver reports of children's food neophobia and sensory behaviors (SBs) as measured by the Food Neophobia Scale and the Sensory Profile, children's observed weight outcome [body mass index z score (BMIz)], and children's food intake as estimated from the Block Kids Food Screener were collected at baseline in the Colorado LEAP (Longitudinal Eating and Physical Activity Study) study of childhood obesity. Preschool-aged children (n = 249; 136 girls, 113 boys; aged 55.6 ± 4.7 mo; BMIz = 0.54 ± 1.14) and caregivers [n = 180; 57 Hispanic, 119 non-Hispanic white (NHW), 4 unknown] participated. Data were analyzed by Pearson correlations and multivariate hierarchical linear regression analyses.

RESULTS

Lower scores for children's oral sensory characteristics (i.e., more atypical) were related to higher neophobia ratings (r = -0.53, P < 0.001), and neophobia was negatively associated with reported vegetable intake (r = -0.31, P = 0.001) and dietary variety (r = -0.22, P < 0.001). Hispanic caregivers reported more atypical child SB scores (46.2 ± 8.8) than did NHW caregivers (50.5 ± 7.6; P = 0.006); however, no differences were noted for neophobia and SB scores by parent income and education or child sex. Neophobia was negatively associated with vegetable intake and dietary variety (P < 0.001 for both). SBs were associated with children's energy intake from sugar-sweetened beverages in bivariate analyses (r = -0.18, P < 0.05); however, in regression models, only ethnicity was significantly associated with energy from sugar-sweetened beverages (P < 0.001). Hispanic ethnicity was positively associated with sugar-sweetened beverage consumption (P < 0.001).

CONCLUSIONS

Children's neophobia and sensory sensitivity may be important in understanding underlying issues related to limited food acceptance in typically developing young children and for helping caregivers facilitate healthy dietary intake patterns for their children. This trial was registered at clinicaltrials.gov as NCT01937481.

Obesity Prevention Study: A Physical Activity Program Improved Gross Motor Skills in Preschool Children

Date Presented 4/18/2015

A physical activity program, part of an obesity prevention study implemented by teachers in rural areas, improved the motor skills in children. This study demonstrates that programs developed by an interdisciplinary team, including occupational therapists (OTs), affected healthy outcomes in young children in underserved areas.

Report of an EU-US symposium on understanding nutrition-related consumer behavior: strategies to promote a lifetime of healthy food choices

This report summarizes an EU-US Task Force on Biotechnology Research symposium on healthy food choices and nutrition-related purchasing behaviors. This meeting was unique in its transdisciplinary approach to obesity and in bringing together scientists from academia, government, and industry. Discussion relevant to funders and researchers centered on (1) increased use of public-private partnerships, (2) the complexity of food behaviors and obesity risk and multilevel aspects that must be considered, and (3) the importance of transatlantic cooperation and collaboration that could accelerate advances in this field. A call to action stressed these points along with a commitment to enhanced communication strategies.

Home food and activity assessment. Development and validation of an instrument for diverse families of young children

The purpose of this study was to refine and psychometrically test an instrument measuring the home food and activity environment of geographically and economically diverse families of preschool aged children. Caregivers of preschool aged children (n = 83) completed a modified self-report questionnaire. Reliably trained researchers conducted independent observations on 25 randomly selected homes. Agreement statistics were conducted at the item level (154 total items) to determine reliability. Frequency counts were calculated to identify item availability. Results showed Kappa statistics were high (.67-1.00) between independent researchers but varied between researchers and parents resulting in 85 items achieving criterion validity (Kappa >.60). Analyses of reliable items revealed the presence in the home of a high frequency of unhealthy snack foods, high fat milk and low frequency of availability of fruits/vegetables and low fat milk. Fifty-two percent of the homes were arranged with a television in the preschool child's bedroom. Physical Activity devices also were found to have high frequency availability. Families reporting lower education reported higher levels of sugar sweetened beverages and less low-fat dairy (p < .05) compared with higher education families. Low-income families (<$27K per year) reported significantly fewer Physical Activity devices (p < .001) compared with higher income families. Hispanic families reported significantly higher numbers of Sedentary Devices (p < .05) compared with non-Hispanic families. There were no significant differences between demographic comparisons on available fruits/vegetables, meats, whole grains, and regular fat dairy. A modified home food and activity instrument was found to reliably identify foods and activity devices with geographically and economically diverse families.

The Colorado LEAP study: rationale and design of a study to assess the short term longitudinal effectiveness of a preschool nutrition and physical activity program

BACKGROUND

The preschool years are a critical window for obesity prevention efforts; representing a time when children establish healthy eating habits and physical activity patterns. Understanding the context in which these behaviors develop is critical to formulating a model to address childhood obesity. The Colorado LEAP Study, an intervention study designed to prevent early childhood obesity, utilizes a social ecological approach to explore individual, family and environmental factors and their relationship to child weight status over a 3 year timeframe.

METHODS

The study is located in 5 rural Colorado preschool centers and elementary schools (2 treatment and 3 control). Treatment sites receive The Food Friends nutrition (12 weeks) and physical activity (18 weeks) interventions during preschool. Observational measures assess 3 layers of the social ecological model including individual, family and organizational inputs. Children's food preferences, food intake, gross motor skills, physical activity (pedometers/accelerometers), cognitive, physical and social self-competence and height/weight are collected. Parents provide information on feeding and activity practices, child's diet, oral sensory characteristics, food neophobia, home food and activity environment, height/weight and physical activity (pedometers). School personnel complete a school environment and policy assessment. Measurements are conducted with 3 cohorts at 4 time points - baseline, post-intervention, 1- and 2-year follow-up.

DISCUSSION

The design of this study allows for longitudinal exploration of relationships among eating habits, physical activity patterns, and weight status within and across spheres of the social ecological model. These methods advance traditional study designs by allowing not only for interaction among spheres but predictively across time. Further, the recruitment strategy includes both boys and girls from ethnic minority populations in rural areas and will provide insights into obesity prevention effects on these at risk populations.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01937481.

Effectiveness of a physical activity intervention for Head Start preschoolers: a randomized intervention study

OBJECTIVES

The level of children's motor skill proficiency may be an important determinant of their physical activity behaviors. This study assessed the efficacy of an intervention on gross motor skill performance, physical activity, and weight status of preschoolers.

METHOD

The Food Friends: Get Movin' With Mighty Moves(®) program was conducted in four Head Start centers. Measurements included the Peabody Developmental Motor Scales, pedometer counts, and body mass index (BMI) z scores.

RESULTS

The intervention led to significant changes in gross motor skills in the treatment group (n = 98) compared with the control group (n = 103) and was a strong predictor of overall gross motor performance (gross motor quotient), locomotor, stability, and object manipulation skills. No intervention effect was found for physical activity levels or weight status.

CONCLUSION

The intervention dose was adequate for enhancing gross motor skill performance but not for increasing physical activity levels or reducing BMI.