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>> JILL PENTIMONTI: Good afternoon, everyone! We're going to get started. Feel free to get more pizza.
So, good afternoon! I'm Jill Pentimonti, and I am a research scientist at the Crane Center for Early Childhood
Research and Policy. That shortens to CCEC.
On behalf of CCEC, I'd like to welcome you all to the first of our Friday Colloquia series.
We're really excited about it.
Mostly we're excited because one of our key missions at the CCEC is to have a format
to share our expertise in child development, in early educational experiences, and to
really connect with our university community, and to have a spot where we can be
informal and collegial and have some great discussions.
So, we're hoping that this first Friday Colloquia series will do that for us.
So, we're really pleased to have you all here for our first discussion.
So please join us every first Friday of the month for pizza
and hopefully for some really great discussion.
So, for the first of these, we're very pleased to have Dr. Carolyn Gunther. She is an
assistant professor in the Department of Human Sciences, a clinical assistant
professor in Pediatrics and an Adjunct assistant professor in Animal Sciences.
Her research program focuses on developing and testing community based family
nutrition interventions to improve the food choices and eating behaviors of young
children, and then to ultimately reduce the incidence of childhood obesity.
So, without further ado I'll let Carolyn take the stage.
>>DR. GUNTHER: Do I need to turn this on? No?
Good to go, alright, we are ready to rock and roll.
Thank you for your warm introduction. It's my pleasure and honor to be here for the
inaugural meeting of the Crane Center's seminar series.
This is really exciting for me and you.
So, I'm here today to talk about the role of food choices and eating behaviors in a
kids diet, health and well-being. I know the common factor that binds all of us is our
interest in early childhood development, but I'm pretty sure there's only a small
group of nutritionists in that group.
That's the case, they're right over there, my team ends right over there [LAUGHS]
So I've tried my best to craft this discussion with that awareness, that you don't have
an obesity and nutrition background.
I did my training at Purdue University in adult obesity treatment and prevention
efforts through, primarily through diet interventions. Now in my career at Ohio
State, I'm interested in pediatric obesity prevention.
As I said, the tie that binds us is our interest in early childhood development and I'm
making the assumption because we're all living in the United States, even though
you don't have a nutrition background and you're not specifically studying
childhood obesity prevention, that you're all keenly aware of the problem of
childhood obesity in the U.S. today. You would have to really be living in a vacuum
not to be aware of what a serious problem it is.
So, in all the readings that I've done, I don't think there's any quote that really better
represents the seriousness of the problem of childhood obesity in the U.S. today
than the Surgeon General's recent quote regarding her vision for a fit and healthy nation.
She says here, "Today's epidemic of overweight and obesity threatens the historic
progress we have made in increasing American's quality and years of healthy life".
She says here that, "Two-thirds of adults", and one in three kids are overweight or
obese, and the "sobering impact of these numbers is reflected in the nation's
concurrent epidemics of diabetes, heart disease", all these chronic illnesses. So
they're occurring together; the incidence of obesity and chronic illnesses in the U.S.
She says here that if we don't put a stop to these trends that our kids, our most
precious resource, will be, "afflicted in early adulthood with these serious illnesses".
And she concludes by saying that, "This future is simply unacceptable". So this is just
a quote that I like to sort of put forward you know - right out front - to just put
some weight to the seriousness of the problem of childhood obesity.
Okay. So on this next slide here we're simply looking at the statistics that back the
surgeon general's warning, okay? So over the past three decades - or over the last
30 years - we've seen a significant rise in the rate of childhood obesity among all age
groups of kids. Even our youngest. So this disease - of obesity - does not
discriminate with regards to age. Even our youngest kids - our preschoolers, our
toddlers and some infants are being affected by the problem of carrying excess
weight, specifically adiposity or fat mass, okay? So again, we're looking at a near
tripling in the rate of obesity among young kids and adolescents over the past 30 years.
This disease does discriminate though in regards to race and ethnicity. And I don't
have that data here - but there's a disproportionate risk that's experienced by those
individuals from racial minority backgrounds. So - African American kids and
Hispanic kids are at a much higher risk for becoming obese then their white counterparts.
There's new data that's not shown here on this graph - but there has been a report
made by CDC in the last year that there's been a leveling off - or a plateau of these
numbers which is good news. It's indication that all of these efforts - these pro-
gramatic efforts and policy efforts that are being invested in to solving the problem
of childhood obesity are resulting in - at least - a leveling off of numbers.
But even at a rate of 30% okay. 30% of our kids - even at that rate, it's too high.
It's still a problem. There was a report in the last - literally within the last month that
preschoolers - and that's who our group studies - that in that age group, there's
been a drop in the rate of obesity among preschoolers. So that's age two or three to
five years old. That's - good news. The CDC - when they released this report - they
released it by state. Ohio did not make the list. So we still have this serious problem
in the state of Ohio. We have a lot of work to do.
Okay. So the next question that I like to pose to students and to myself is - why do
we care about this problem? Why does - does it really matter that people - our kids
- are carrying around excess weight. And when I talk about weight, I'm talking
specifically about body fat mass. Well - there are . . . it matters. The consequences of
excess weight - carrying around excess weight in childhood
and adulthood are serious and widespread.
So what I'm showing here is first the health risks. These are the health risks or
consequences that result from childhood obesity. The risks occur in childhood - we
see kids now in clinic who have high-blood pressure, high cholesterol, problems
with their glucose metabolism, insulin resistance - the list goes on. So that is
relatively new data - that kids are becoming clinically sick in childhood.
And we also know that kids that are overweight also have an increased risk for
becoming overweight and obese into adulthood. And that of course as we know
leads to all sorts of chronic illness such as heart-disease, diabetes and some cancers.
And this is really just you know - a snapshot. There's data indicating that there's a
multitude of other health risks that are consequences of childhood obesity.
There are negative social and psychological effects. Kids who carry excess weight in
childhood through adulthood experience low self-esteem, they're at a higher risk for
dealing with discrimination in the school setting, and kids who are overweight are
also at a much higher risk for depression and suicide and other related things.
This is of interest to many of you in the room, and you're probably aware of this
association that's been made: kids who carry excess weight are underperforming in
the classroom. There's been a relationship, at least in a correlational sense, that kids
who are overweight don't perform as well academically. So there's a real girth of
information in that particular area of scholarship,
which presents a real opportunity for us in this room to address.
And then there's also the economic burden that results from childhood obesity.
There's been a near tripling of obesity related healthcare costs just in kids alone in
the last three decades. So we're talking about a thirty percent increase in the rate of
obese kids in adolescence over the last three years.
We've seen healthcare costs in kids parallel that statistic.
So the bottom line take-home message from this slide is there are many reasons to
care why our kids today are overweight. The consequences are grave and they're
widespread. It's not just health that's affected, but all sorts of other aspects of
childhood health and development.
Next, I'd like to begin talking about what are the causes of obesity. So, we've known
for some time that it's a multi-factorial problem. So that's clear.
This framework here, this theoretical model that I'm showing here, the social
ecological framework is really the mechanism that's being most used at least in our
field of community nutrition and this really points to the complicated nature of the
problem and it's also for those of us in the field;
it presents a great tool for developing interventions.
Here we can see that a child's risk for becoming obese is effected by multiple factors.
Genetic factors and behavioral factors at the individual and family level, a child's
risk for obesity is also influenced by various behavioral, contextual settings, so the
home environment, the school environment, the community environment, the work
environment. All of these settings in which a child lives
effects his or her risk for becoming obese.
Policies at these various sectors of influence also influence a child's risk for
becoming obese, and then of course at the outer ring here we can see that societies'
rules that guide individuals and groups' attitudes,
beliefs and behaviors influence risk for obesity.
Simply put, it's a complicated problem. A child's risk for becoming obese is
influenced by multiple factors at these multiple layers of influence.
What I also, and like many things about this particular theoretical framework for
understanding the causes of obesity but it really, one thing I like about this is that it
really points the importance of conducting multi and cross disciplinary research.
If we're not communicating with each other in a real meaningful, active kind of way
we have no chance of solving this problem.
I want to sort of shift gears right now. I've hopefully really set the tone for the
problem of childhood obesity. Why do we care? What are the consequences? What
are the causes? And I want to shift now to talk about what my research group is
really interested in, specifically interested in.
In our group we're really interested in studying the individual and family factors
related to diet and a little bit of exercise. But we're nutritionists and we're
interested in dietary behaviors.
We're interested in studying those factors and how they influence a child's risk for
becoming overweight and or obese and we do our work in a couple of behavioral
settings so we're interested in intervening in the daycare. Most kids these days as you
know are enrolled in some sort of childcare program and so there's real
intentionality to why we've decided to make that our site of intervention.
I've listed home here because we're really interested in if we use the daycare setting
as our site of intervention, how do those intervention effects carry over into the
home food environment, so that's an area of research that we're also interested in.
Okay. So let's talk a little bit about - I've mentioned that there are dietary behaviors .
. . other lifestyle behaviors that influence a child's risk for becoming obese.
So what are those behaviors?
Well, we know what they are. This is a really wonderful article that came out in
2009 that clearly delineates what those modifiable dietary behaviors are that
relate to key dietary determinants and in affect influence a child's weight status. And
part of the reason I'm going to kind of walk you through each of these is because
these - each of these behaviors are incorporated into our intervention.
So at the child level, it's been clearly identified that a child who has had . . . you
know, meets the recommendation for fruit and vegetable intake, who eats ready to
eat cereals, has a nutrient-dense low-fat diet, has regular breakfast, drinks milk, eats
beans, limits eating out at fast food restaurants, is a picky eater but that's a negative
determinant - I've moved now from positive to negative determinants.
A child who drinks soda is at an increased risk, a child who skips breakfast is at an
increased risk for obesity and a child that has poor snacking behaviors is at an
increased risk for developing or acquiring excess weight.
So all of these behaviors are on the child level.
On the parent or family level they've - we've identified that parents who model
healthy eating behaviors have a better chance of having a child that is at a healthy
weight. Availability of healthy foods at the home and in the meals is another
determinant - positive determinant of healthy weight status. Preparing healthy
foods in the home, planning meals and family meals. Okay so again - these are
based on the current literature. These are the modifiable dietary behaviors that
have been associated with determining a child's weight status.
And these are points of interest in the work that we do.
Okay so around the same time - and this was not coincidental - the American
Academy of Pediatrics Expert Committee for the Prevention and Treatment of
Childhood Obesity came out with a short-list of evidence-based dietary
recommendations that clinicians could use in their practice. So these included
things like: encouraging consumption of fruits and vegetables, limiting sugar-
sweetened beverages, eating breakfast daily, limiting eating out at restaurants,
encouraging family meals, and limiting portion sizes. So these recommendations -
again that were established by the American Academy of Pediatrics Expert
Committee for the Prevention and Treatment of Childhood Obesity came out right
around the same time that this article came out. So this was great - news for us in
the nutrition field because it really gave us a guide in our intervention work.
Okay so let's talk about - we've talked about the dietary behaviors that we know
relate to a child's weight status. We've talked about what those are at the child level
and at the parent level and at the family level, okay. Let's talk now a little bit about
how - when and how eating behaviors are laid down in life. And we know from the
literature that it's during those early years that kids develop their food choices and
eating behaviors. And our group is particularly interested in the preschool age time
in life because it's during that time that a child moves away from a primarily milk-
based diet to adopting the eating behaviors of the family. Simply put - moving away
from the breast to the table. So that - that in essence makes it nutritionally a critical
window of time. And so that's why in particular - why we're interested in the
preschooler age child. And we know that those eating behaviors that are laid down
during that period persist through a lifetime.
So how are they laid down? We also know that parents play a major role in the foods
that a child eats and the type of eating behaviors that they engage in. There have
been key parents practices that have been identified. And those include things like
making healthy food available, setting expectations for intake of healthy foods and
I've listed here role modeling. So when you're talking about a child whose three to
five years old, they are - for intuitive reasons - they are really dependent in large
part and in the most part on the adults around them. So parents play a major role as
the nutritional gatekeepers of the home.
Okay so we also know that - so we know that eating behaviors are laid down early
in life, we know that parents play a major role - we also know that parents face
multiple barriers to establishing these healthy eating behaviors for their families.
And I've listed here what we know from the literature. First - a lack of nutrition
knowledge. So they don't know that the recommendations are - what is a healthy
diet for a child, and for a family? We also know that parents lack food preparation
and cooking skills. So this is something - this is an art. Cooking as an art and a skill is
something that's been lost in the 21st century. Parents deal with food acceptance
issues. So preschoolers - by nature - deal with issues such as neophobia or fear of
new foods. They're also classified - and this is really just a developmental artifact -
but they're classified as picky eaters. So preschoolers by nature deal with food
acceptance issues -of new foods and then also commonly consumed foods. Time and
budget limitations is another major barrier that parents face in establishing healthy
eating behaviors for their families and also lack of social support. So we know this
based on literature - that these are the barriers that parents face in establishing a
healthy food and eating environment for their kids.
So we also know that there are some real commonalities among the successful
efforts. So there have been plenty of efforts - programmatic efforts - as they relate
to nutrition - to solve the problem of childhood obesity. So there's no limit to the
number of efforts that have been made. But if we look at the commonality among
the successful efforts we know that all successful efforts have relied on some
theoretical framework in their intervention.
We also know that there has to be at least either direct or indirect engagement of
parents in order to get kids diet better and get them on a healthy weight gain
trajectory. We also know that multi-component strategies work better than singular
component strategies. And that can sort of play out in a variety of different ways.
For example interventions that combine education efforts with skill-building efforts
tend to be more successful than education efforts alone. Okay - documentation of
behavior change is another commonality among the few successful efforts, and then
follow-up in a clinical or daycare kind of setting. So you need to get kids and families
into some sort of community setting in order
to interact with them and document the behavior changes.
Okay - so I wanted to present to you one example of a successful intervention
targeted to kids. These were older kids, but this was a study conducted by Jane
Fulkerson who's at University of Minnesota and she's a nursing faculty there. And in
2010 - she had been working on this project for a while - but in 2010 her paper
came out and I've presented that to you here. So the title of her intervention was the
Healthy Home Offerings via the Mealtime Environment Study (HOME). Okay - this
was a randomized control trial - it was a pilot childhood obesity prevention
intervention - community-based. They relied on the social-cognitive theory of
behavioral change for their theoretical framework. This was a community-based
intervention as I mentioned that involved both parents and kids. She was interested
in the pre-adolescent period of life - eight to ten years old. The educational sessions
were - she delivered five of those and they were 90-minute sessions and delivered
over a three-month period of time. The sessions included nutrition education,
testing, cooking and parent discussion groups. This was a pre-post test design and
they not only did pre-post testing but they also did a 6-month follow-up test to
determine retention of changed behavior. Okay so this is again one - one example of
a successful effort that incorporated all of those
commonalities that we talked about in the previous slide.
So what they found was that - in kids that were enrolled in the intervention group
that they had a significantly higher intake of fruits and vegetables. They also had a
significantly lower intake of sugar-sweetened beverages, they also saw an increased level of
dietary fiber as compared to the control group. And that of course would be in
correlation with the consumption of fruits and vegetables intake. And they also saw
an increase in calcium intake. So kids enrolled randomized to the intervention group
had a significantly higher calcium intake versus the control group. Okay so Jane's
study really pointed to - was another piece of evidence - pointing to the importance
of including all of these components to . . . in interventions - childhood obesity
prevention intervention. So that's theoretical framework to the intervention direct.
In her case they engaged directly and found that that was successful. They found the
multi-component strategy was important. Documentation of behavioral change and
again follow-up and delivery in a clinical or daycare kind of setting.
So I just wanted to refresh your memory: these are the commonalities among
successful efforts. And I would argue you know - based on the literature that we
need to add to this list "early intervention". Knowing that kids lay down those eating
behaviors early in life that persist through a lifetime that our best bet is to intervene
early - particularly during those preschool years when kids are establishing their
food choices and eating behaviors that will persist through a lifetime.
Okay - so this . . . that was all the work you know - setting the framework for why it
is that we're here today. So here comes the fun part! So this leads me to study
hypothesis. So based on what we know - based on the gaps in literature - this is
what we hypothesized: That participation in a daycare-based nutrition education
and cooking program aimed at parents and their preschool kids - aimed to teach
them positive eating behaviors - will lead to these improvements.
On the child level we hypothesized that participation in this program would lead to
improvements in food preparation skills and also an improvement in diet quality.
We were particularly interested in - based on the evidence - fruit and vegetable
intake, high-fat foods, high-sugar foods and also high-sugar beverages. We're also
interested in parents' self-efficacy or confidence in establishing healthy foods and
eating behaviors for their families and frequency of family meals prepared at home.
Okay so - based on those hypotheses, our objective was to develop and test
feasibility, acceptability and potential efficacy of a blended nutrition education and
cooking program aimed at teaching parents and
their preschool age kids positive eating behaviors.
Okay our aims were - number one: to develop and implement a nutrition, education
and food preparation cooking program targeted to parents and young kids. And
number two: to evaluate potential efficacy of participation in this program on
improvements in child and parent food choices and eating behaviors. And we
outline those on the previous slide - those
particular eating behaviors that we were interested in.
So before we set out to design and implement our intervention, the first thing we did
was conduct a needs assessment study. So we're really interested in knowing - we
asked a lot of different questions - but here I'm just going to focus on the family
meals data. But the aim of the needs assessment essentially was to understand the
value that families place on family meals, the challenges that they face in
establishing regular family mealtime and topics of interest. So we asked parents you
know, "If we were to come to your daycare and offer a nutrition education and
cooking program for families, what sort of topics would you be interested in seeing?
So our sample here was parents with young kids who were enrolled at the
Schoenbaum Family Center. We had a sample size of sixteen - so this was a 17%
response rate. The survey on this quick survey - we asked several questions related
to our aims. The first was - we asked parents to rate their level of importance of
preparing and sharing family meals. We asked them in an open-ended question
about challenges that they face in establishing regular family mealtime. And next we
again asked them in an open-ended question what
sort of topics that they'd like to see in such a program.
Okay so here's some data from the needs assessment study. So - interestingly - we
found that the large majority of parents placed a high value on family meals, okay.
So it's something that they identified as being important
to them, an important routine or ritual of the family.
Almost all parents-15 out of 16-reported at least one barrier to regular family
meal time. Time barrier was the biggest barrier of all, followed by having a lack of
recipe ideas, and then meeting the different preferences of the family, with one kid
asking for this and one kid asking for that.
Parents were very quick to share ideas that they would like to see in a potential
program like this, and I've listed those here. They included ideas for preparing quick
and healthy meals that are also affordable, how to involve their child in meal
preparation, and recipes that are not only quick, healthy, and affordable,
but also appealing to a child.
So, the bottom line finding from this needs-assessment study
was that parents place a high value on family meals number one,
and number two they're having a trouble getting it done.
They're not able to establish that routine with their family
on a regular basis due to these multiple barriers, and they provided
really excellent feedback on what topics they would like to see.
Results from this needs-assessment survey, in part,
inform the design of the curriculum itself.
On this next slide here I'm showing you a little bit of information
that went into the design of the curriculum.
So, again, we used data from the needs-assessment survey.
We also relied heavily on National Dietary Guidelines.
So, the 2010 U.S. Dietary Guidelines.
The messaging that's incorporated in those guidelines
really heavily informed the design of our curriculum.
We also included the behavioral targets that are included in
The American Academy of Pediatrics Expert Committee Guidelines-we looked at those previously.
We also worked from two existing curricula and took "lessons learned" from those curricula.
These are curricula that have been tested in the community--
not just in Columbus but nationally.
The first of these is the Happy Healthy Preschoolers Program.
The brainchild for that curriculum is sitting here in the room-Dr. Murray,
and actually Kelly was a part of that as well.
So the two of them are here today.
So, that was a previously tested curriculum for parents of preschoolers.
It was a community-based nutrition and physical activity program
for parents of preschoolers, particularly low-income preschoolers.
So, we worked from that curriculum in the design of our new curriculum,
and we also worked from the expanded Food and Nutrition Education Program,
which is essentially a Federal Nutrition Education Program for families with kids of all ages.
So, there were a lot of various inputs into the design of our curriculum.
So, the theoretical framework for our intervention, like Jane Fadewkfes,
and most other community-based nutrition interventions going on was
the Social Cognitive Theory of Behavior Change.
This theoretical model asserts that behavior, an individual's behavior
or behavior change is really the result of a reciprocal relationship
between various personal factors and external or environmental factors.
So some personal factors include knowledge and skills-these are the resources
that an individual needs in order to make a behavioral change.
Self-efficacy, or confidence in one's ability to make behavior change
is another important personal factor that influences behavior change.
And then outcome expectancies, which is essentially the value or benefit
an individual expects to receive by engaging in that target behavior
is another personal factor that influences behavior change.
External or environmental factors, when you're talking about parents as
the proxy child or the two critical external factors are role modeling
and availability meaning-making healthy foods available.
So again this is the theoretical framework for intervention and one important note
here is that all these factors I've listed here, the personal and external factors, are
dependent on an individuals ability to self control or self regulate ones behavior and
we know that there is a lot of literature pointing to the fact that when an individual
engages in the act of goal setting and goal monitoring that that is sort of mechanism
for increasing their, at least their perception of self control.
Okay so this again was the theoretical framework of our intervention.
So our intervention was a multi component intervention, we involved nutrition,
education, and activities those were developed as apart of the program.
These occurred separately for kids and parents.
We also had skill building and food preparation, cooking.
Goal setting was part of the program for the parents.
Of course kids are too young cognitively to engage in that activity.
Family meal preparation, our program occurred over the dinner hour,
which gave parents and kids the opportunity to prepare a meal and partake in the meal.
We had take home educational materials and then session evaluations.
So these were all of the components that were apart of each program session.
We developed and implemented ten programs, each were 90 minutes in length.
These occurred on a monthly basis over the academic year from September to June,
and again as I mentioned the program was delivered over the dinner hour,
and there was real intentionality in designing the intervention in that way.
This is probably familiar to most of you in the room, but we've done all of our pilot
testing over the last three years at the Schoenbaum Family Center,
which, as you know, is an EHE affiliated lab school.
The Center is located in Weinland Park, which is juxtaposed to the University.
It's an extraordinarily low-income area within the Columbus area,
and the center itself draws a mixed population.
So, at the time of the data that I'm presenting now,
there was an equal mix of individuals or families from low-income
and non-low-income backgrounds.
Which in a research sense that does present some logistical problems.
So, our staffing structure, let's talk a little bit about that.
We relied on two Schoebaum family preschool teachers.
Those individuals were responsible for the
activities involving the child alone, separate from the parents.
We had honors undergraduate students helping out
with teaching and program preparations.
As part of our staffing structure, we rely heavily on the dietetic interns.
At Ohio State, there are two dietetic internship programs,
and one of those is housed in the Department of Human Sciences.
Those individuals, who have their B.S., are in a
yearlong training program in our department.
As part of that internship, they're required to gain real-life practical field experiences.
So, this has ended up being a really wonderful provision in our programming,
and also a provision in their training.
So, our target audience was families with young kids enrolled at
the Schoenbaum Family Center, and we had both low and non-low income households.
Here I'm showing you a listing of our process outcomes to assess program feasibility.
We measured attendance to assess program acceptability-
we measured that via a parent and child satisfaction tool.
And then we developed a program-
specific tool that assessed intervention fidelity.
So these were our three process outcomes.
On the next slide I'm showing you our study outcomes, our behavioral outcomes.
So I'll just mention before we go into those that this was a pre-posed test design.
We collected data at baseline, midway through the project, and at the project end.
On the child level, we collected data on their food preparation and cooking skills.
We also collected dietary data on kids that were enrolled in this project.
On the parent level, we measured their self-efficacy
for making healthful changes in the home, and
then we also measured with a validated tool the frequency of family meals.
So we're moving into results here.
In this next slide I'm showing you the ten lessons
that were developed as part of our intervention.
You can see the titles for each of
these here and the behavioral targets for each of these.
Our topics ranged from helping parents understand the value of family meals,
and then in the next portion of our program we focused essentially on food groups,
from fruits and vegetables to whole grains, calcium,
protein, and fat, and we finished off with special topics.
One included a focus on having regular breakfast, decreasing salt intake,
which is a new-old message that is coming out in the national dietary guidelines.
We had a whole session dedicated to healthy snacks,
and then we had another session that was focused on pleasing picky eaters.
So this gives you a sort of flavor for the program topics and the behavioral topics.
Here I'm showing you greater detail from one of the lessons.
This one in particular was focused on building strong bones.
From a dietary perspective, we were interested in helping parents and kids
increase their intake of calcium-rich foods
and beverages, particularly from dairy sources.
I've listed here the specific aims, and these look similar for each of the lessons.
We start out by introducing the benefits of calcium-rich food and beverages,
or whatever the topic is that we were talking about that night.
And then we essentially help them gain knowledge on good
non-dairy and dairy sources of calcium,
and what the recommendations are for them.
We help the kids learn those recommendations specific for preschoolers,
and then we move into a section where we work with parents
to develop effective ways for establishing the target behaviors,
find easy ways to incorporate calcium-rich foods and beverages in kids diets,
and then we finish off by working with parents to help
them set goals to reach the recommendation.
Here, I've also included a menu for that night, which was spinach salad,
whole-wheat pizza, and banana pudding with wafers.
Now, I'm a calcium researcher by training, so there was real intentionality.
We were very careful about synchronizing the
menus and recipes with the topic for the night.
So, for a vegetable food source, spinach has a high calcium level.
The pizza had cheese, and the pudding was made with milk.
So that was something that was taken into consideration in the design of our program.
So we had experienced high program feasibility with this study,
and I think that's one of the main selling points of the work that we do.
We consented eleven families, ten completed,
and that translated into a 91% retention rate,
which is very high for community-based programming.
We can talk later about why that might be, and this was intentional in the design of
our program too, but this is an incredibly difficult population to reach.
The families, parents, and preschoolers have every kind of demand on them.
Throughout the program, incentive-ization was a real consideration.
Having a meal, and giving families bags of groceries with ingredients
for the food we made that night-all of thee incentives that were woven
into the program may explain the high retention rate.
Our average attendance rate, of the consented families, over the year's time was
45%. And that ranged from 45% to 100%. We actually had, if you look at total
attendance for each program over the year's time, we had an average attendance of
10 to 15 families, it's just that not all of them were consented to participate in the
So here we're looking at program satisfaction. Remember that the primary aim of
this project was feasibility and acceptability-to test those two factors in this pilot
test. We experienced high feasibility-we saw that on the last slide. And here we're
looking at the satisfaction data. So all of our parents reported high or very high
satisfaction with the program, and all reported that their parents enjoyed the
program. So that's a flavor of the satisfaction data.
Here we're looking at our participant characteristics by income status. I mentioned
to you that we recruited families that had children enrolled at the Schoenbaum
Family Center, which is by nature a mixed-income population. We had 11 families
consented, and they were split equally. This was unintentional. We opened up
invitation to participate in this study to everyone who had children enrolled in the
Center, but we ended up with an equally mixed-income group.
The majority of our low-income parents were younger, they were less educated, and
were primarily African-American as compared to their non-low-income
counterparts. The majority of our kids were in the 3-4 year age group. We did have
some kids below the technical preschool age definition. We had a handful-4-in
the 1-2 year age group.
This is a bit messed up here. The sex of the children was equal between groups, and
we also had an equal proportion of male and female children participants.
I'm just going to zoom out for a second. You remember that we had behavioral
targets or outcome measures on multiple levels: on the child level, on the family
level, and also on the home level. So, on the child level we were interested in a
couple of things. First of all, we were interested in food preparation and cooking
skills in kids, and we were also interested in their diet itself. So here we're looking at
results of food preparation skills. You'll see here that when adjusted for potential
confounders, which included baseline age of child, baseline BMI of child, and family
economic status, we saw a significant increase in children's ability to rinse fruits and
vegetables and an increase in children's ability to help assemble foods.
We'll talk about this later, but these are pretty weak, modest findings. But
regardless, we did see couple positive outcomes of the intervention itself as it
related to food preparation skills of kids.
So here we're looking at the dietary data. Again adjusted for potential confounders,
which in this study included baseline age of child, baseline BMI of child, and family
economic status. We saw a significant increase in fruit and vegetable intake in kids,
and that was from midway through the project to the end of the project. We also
saw a significant reduction in sugar and sweet beverage intake, although this
positive change did not persist to the end of the study. It washed out in the end,
when we looked at baseline to final levels.
There was some trend data with intake of fat in kids, but that did not reach significance.
So let's look at the parent data. We were interested in a couple of outcomes related
to parents. The first was self-efficacy, or the confidence of parents in their ability to
establish healthy behaviors for their families. This was where our strength in
findings was in the parent data. Again, adjusting for potential confounders, we saw a
significant increase in all these outcomes or parent practices, their self-efficacy in
these practices. Participating parents were more confident, for example, that they
would plan to include one vegetable at lunch and supper.
They were more confident that they could cut up vegetables and put them in the
refrigerator for their families. They were more confident that they could introduce
low-fat foods to their families in meals and snacks, and they were more confident in
their ability to engage their children in meal preparation. They were also more
confident that they could introduce a new vegetable on a monthly basis.
So, one thing to mention here is that all of these parent practices that we identified,
that were incorporated in our intervention and that we measured as outcomes, have
direct implications for a child's diet. So that's sort of the weight of our findings.
This was really our strongest finding, which was encouraging, because one of the
main emphases of our program was to encourage family meals. Again, adjusting for
potential confounders, we saw a significant increase in the frequency of family
meals from baseline to the end of the project. So, again, I'm working on revisions to
this paper and they're due Tuesday, but really our strongest findings relating to the
efficacy of the program were in the parent population, and that sort of trickles down
to the kids.
So, the summary of results. Our needs-assessment study, our formative research,
showed that parents value family meals and also that they face multiple barriers.
This was really consistent with what we already know and see in the literature. We
also demonstrated that our program, our innovative and evidence-based program,
successfully engaged parents and their pre-school age kids. So this again points to
the high feasibility and acceptability of the program that we designed and tested.
There were hints of potential efficacy regarding certain child food preparation skills
and diet outcomes, and also parent self-efficacy regarding healthy food and eating
practices, and then family meals as a singular outcome.
So, where are we going from here? This research is really in its infancy. We've been
testing it over the last 2-3 years, and we have a long way to go. We're excited about
our paper that's coming out, but there's a lot of work that needs to be done in this
line of research. So, at a curricular or programmatic level, there's work that needs to
be done in terms of the content of the curriculum itself and also the sequencing.
Think back, for example, to the dietary data. At the midway point we saw a
significant decrease in the sugar and sweetened beverages, but that changed and
that positive change did not persist. When you go back and look at the curriculum
itself, you'll remember that we did not have a singular lesson dedicated to that topic
and the messaging relating to that behavior really came towards the beginning
of the intervention. It's things like that that we really need to think through.
Perhaps we should actually have a whole entire lesson dedicated to sugar and
sweetened beverage intake, or perhaps we should weave that message more heavily
throughout the entire curriculum.
Program dose is an issue that we're considering. We're actually just finishing up
testing program dose. So for feasibility of a community-based project, a monthly
program dose is acceptable. It worked for us, and it gives you plenty of downtime
between programming to go back to the curriculum, make revisions, and then come
back up. We just finished a trial where we delivered the program on a bi-weekly
basis, so once every two weeks, three months, and then we delivered monthly
booster programs for three months thereafter. So that's really the dosage, based on
what we know in the literature, that works with regards to changing people's
behavior in a community kind of program like this.
I talked about the need for a booster program, and we're considering that now.
Another thing that we're thinking about is, in order to affect the problem of
childhood obesity in a significant and lasting way, we've talked about the value or
wisdom in linking a program for preschoolers with other programs in the
community that precede ours and come after ours.
So, as part of this dosage trial that we just finished this past spring, we linked our
program with the Moms-To-Be program. The PI of that project is (unheard name).
It's a similar program-the mechanism is the same with nutrition education and
cooking, but their target population is different. They're interested in pregnant
moms, and we're interested in young kids. So there was a natural point of
collaboration there. That's something else we're thinking through.
Staffing structure. When you're doing community-based work, something that's
always in the back of your mind is program sustainability, and not just sustainability
but also how easily your program or efforts could be scaled up, naturally.
So we're now working so you'll recall that this particular project that our staffing
structure included preschool teachers, students and dietetic interns, and there is
sustainability, some sustainability in that staffing structure as preschool teachers
and all daycares and there are dietetic internship programs all over the country, not
just affiliated with universities.
So in moving forward, we were talking about and actually, in an active sense, relying
on the extension network so that the extension network becomes university
employees, individuals who are nutrition educators working in communities - and
so we're now weaving in the extension network into our staffing structure.
Program efficacy - I mean this data that I showed today - I'm not fooling any of you,
you're all researchers. You know we - this was great data generated from this study
here that will support the design of a larger randomized control trial. But we really
need to establish program efficacy moving forward - and that will require a group
randomized control trial.
So - we're revising a grant right now to work on that - and scale-up is always on our
mind. Unfortunately - or fortunately - so there's a real need . . . as we've developed
this program over the past three years, we've learned from the community - not just
locally but also nationally - that there's a real need of daycare administrators and
staff for a program like this. A program that combines parent-child learning together
that includes an education in nutrition and also skill-building and food and
preparation skills. And so this program - "Simple Suppers" is the name of the
program - has already begun to be replicated within a couple communities within
Ohio. And you know - just got off the phone last week with Kansas State and North
Dakota State University who also knows what we're talking about - scaling up in
other states as well. So it's encouraging when - as a researcher we're really . . . I
mean I'm not - we're not ready to go there yet. But - here we are.
We've also talked about - in our future research - expanding health outcomes. I
didn't show you the BMI data but we did collect heights and weights of these kids.
Which - from those two pieces of information - you can calculate a child's BMI.
Which is essentially you know an indicator of - it a height for weight outcome - but
it's an indicator possibly as well. So we did measure heights and weights as part of
this program here and we're measuring it in our current and future efforts.
But we've talked about expanding our health outcomes beyond heights and weights
and looking at measurers - non-invasive bio-markers or measurers - of outcomes
that precede excess weight. So we've talked about potentially collecting data on the
gut microbiota- there's a lot of research in that area that an individuals gut and
their microbiota is related to their weight status and risk for other chronic illnesses.
That data can be collected pretty easily with fecal samples. I won't go into the
details, but this is another line of research.
So-it takes a village to do this kind of work. I'm a young assistant professor and I'm
just getting my feet on the ground. I've been really fortunate to have such a great
team of students and collaborators. This is my collaborator Dr. Julie Kennel. She's
the dietetic internship program director. We've worked closely in the design and
implementation and evaluation of this program. Again, these are her interns and
some of my students as well. Julie is not my only collaborator. Dr. Thelma Patrick,
who's a faculty member in Nursing, has been a close collaborator of mine, and she
also does community-based nutrition work with pregnant moms. Dr , whose name I
mentioned, Dr. Murray who's here as well, and the Schoenbaum family center has
been really critical in helping us get our work done.
I've listed all of my team members here: research associate Angela Rose, my two
undergrads Allen Wagner and Priya Patel, and I have a whole new team over
here this year. So Collin McGinnis is an honors undergraduate student here at Ohio
State, (Rowenberger?) is here as well, Allana is another honors undergrad student.
Lana Brown is a new M.S. student, and then Katie Rogers is a new doctoral
student of mine. I've also included our new extension educator, who we've worked
with this past year. She's been really instrumental in helping us and providing
overall direction to the program itself.
So that was way over the limit! Thank you.