ERIC EJ917438: Pilot-Testing CATCH Early Childhood: A Preschool-Based Healthy Nutrition and Physical Activity Program

2011·0.16 MB·English

by  ERIC

Research Article
pilot-testing CATCH Early Childhood: A preschool-based
Healthy Nutrition and physical Activity program
Shreela Sharma, Ru-Jye Chuang, and Ann Marie Hedberg
AbstrAct
Background: The literature on theoretically-based programs targeting healthy nutrition and physical activity in
preschools is scarce. Purpose: To pilot test CATCH Early Childhood (CEC), a preschool-based nutrition and physical
activity program among children ages three to five in Head Start. Methods: The study was conducted in two Head
Start centers (N=75 children, their parents; 9 teachers). CEC was implemented by trained teachers over six weeks in
fall 2008. Qualitative data on feasibility and acceptability was collected using post-intervention parent and teacher
focus groups and lesson plan evaluation forms. Pre-to-post intervention changes in children’s fruit and vegetable
intake and physical activity at school were evaluated. Results: Results showed good feasibility and acceptability for
the classroom curriculum, activity box and parent tip-sheets. There was a trend towards an increase in children’s
fruit, 100% fruit juice and vegetable intake and mean minutes of physical activity at school pre-to-post intervention.
However, this increase was not significant. Discussion: The CEC program showed good feasibility and acceptability
in the study population. Further evaluation of behavioral outcomes using a larger sample and a prospective design is
needed. Translation to Health Education Practice: These results provide information important for developing and
implementing evidence-based programs in preschools.
Sharma S, Chuang R-J, Hedberg AM. Pilot-testing CATCH early childhood: a preschool-based healthy nutrition and physical activity pro-
gram. Am J Health Educ. 2011;42(1):12-23. This paper was submitted to the Journal on April 9, 2010, revised and accepted for publication
on October 9, 2010.
BACKgRoUND or a second rise in body mass index (bMI), obesity-prevention behaviors such as healthy
The prevalence of overweight and are at high risk for later obesity.3 because nutrition and physical activity to reach large
obesity among young children aged 2-5 in current bMI status is strongly predictive of numbers of children, their parents and teach-
the United States is 24.4%.1,2 The rates are future obesity, 4 intervening at a young age is ers. Currently there are few guidelines for
disproportionately higher for minority chil- important in curbing the epidemic. nutrition and physical activity in preschools
dren with 24.8% of African American and Obesity is a consequence of individual
29.9% of Hispanic children categorized as factors as well as social, cultural and environ-
overweight or obese. From a lifetime physi- mental factors surrounding an individual.5 Shreela Sharma is an assistant professor in
cal development perspective, early child- Modifiable behavioral determinants of the Division of Epidemiology, University of
hood experiences can set an important life obesity include diet, physical activity and Texas-Houston School of Public Health, RAS
trajectory with regard to ideal weight status. sedentary behaviors.6 These behaviors de- E603, University of Texas, Houston,TX 77030;
Adiposity or body fatness typically increases velop in childhood, making it a critical time E-mail: [email protected]. Ru-Jye
in the first year of life and then decreases. to establish healthy behaviors.7 Chuang is a research assistant in the Division of
A renewed rise is then seen again at 5.5 to Approximately 13 million of 21 million Epidemiology, E RAS 611, University of Texas,
6 years of age. This increase is termed as preschool-age children in the U.S. spend Houston, TX 77030. Ann Marie Hedberg is an
adipose tissue rebound. Adipose tissue is the a large amount of their day in child care.8 assistant professor in the Health Science Center
part of the body where fat is stored. Children, Thus, preschools may be an optimal setting at Houston School of Public Health, W RAS 908,
who experience early adipose tissue rebound for implementing interventions targeting University of Texas, Houston, TX 77030.
12 American Journal of Health Education — January/February 2011, Volume 42, No. 1
Shreela Sharma, Ru-Jye Chuang, and Ann Marie Hedberg
and those that do exist vary considerably by physical activity at school were evaluated us- for Women, Infants and Children (WIC),23
state.9 Literature on interventions aimed to ing a one-group, pre-post evaluation design National Association for Sport and Physi-
promote healthy dietary and physical activ- to determine if the program had any effect cal Education (NASPE) guidelines for
ity behaviors in preschool-age children is on these behaviors. preschoolers,24 Caring for our Children25
limited. Several interventions in preschool- and documents from the National Head
Sample
age children have been implemented,8, 10-16 Start Association.
A convenience sample of children en-
but only a few conducted have targeted
rolled in four classrooms in the two par- Theoretical Model
nutrition and physical activity for obesity
ticipating Head Start centers as well as The Social Cognitive Theory (SCT) 26,27
prevention using preschools.14, 15 Evidence-
their parents and teachers were recruited was utilized to guide the development of
based programs in preschool settings are
to participate in the study. Each classroom program objectives. Intervention strate-
needed to guide policies and practices for
had no more than 23 children for a total of gies were chosen based on the formative
nutrition and physical activity.
92 children enrolled in the two centers. The research described above. The four major
response rate was 81%, resulting in a final components of CEC include (see Table 1
pURpoSE
sample of 75 children and their parents who for a detailed description of each of the
The purpose of this study was to pilot test consented to participate in the study. All components and Table 2 for objectives for
the CATCH Early Childhood (Coordinated enrolled children in the two centers received each component):
Approach to Child Health for Early Child- the CEC intervention (since activities were 1. Teacher-led, nutrition-based class-
hood) program. CATCH Early Childhood all preschool-based). However, only those room curriculum It’s Fun to Be Healthy!
(CEC) is a preschool-based program aimed children whose parents provided informed consisting of nine nutrition-based lessons
at promoting healthy nutrition and increas- consent were measured. All teachers from aimed at promoting healthful eating habits
ing physical activity among 3 to 5 year old the two centers, which included nine teach- such as increased intake of fruit, vegetables,
children (refer to http://catchinfo.org/pdf/ ers and teaching aides (N = 5 from center whole grains, low-fat dairy and decreased
cec%20flier.pdf for program description). 1; N = 4 from center 2), consented to par- intake of energy-dense foods and sugar-
ticipate in the study. Each classroom had sweetened beverages.
METHoDS at least one teacher and one teaching aide. 2. Teacher-led Physical Activity Box de-
The CEC program was piloted in two Prior to starting, all parents of children signed to promote gross motor skills, im-
Harris County Department of Educa- enrolled in the two participating centers prove classroom management and increase
tion (HCDE) Head Start centers over six were provided with a recruitment packet overall physical activity including moderate-
weeks in fall 2008. HCDE Head Start cur- including the consent forms in English and to-vigorous physical activity (MVPA) during
rently has 16 centers located across Harris Spanish for themselves and their children to preschool hours.
County, Texas, enrolling up to 1200 low participate in the study. Parents and teachers 3. Parent education consisting of nine
income children, predominantly Hispanic who participated received $20 gift cards for parent tip-sheets designed to modify the
and African American. Typically, children their time. home nutrition and physical activity envi-
enrolled in Head Start spend on average 7 Formative phase for program development ronment.
hours per day at school (7:30 A.M. to 2:30 The CEC program was modeled after the 4. Teacher training for participating
P.M.) and receive free breakfast, lunch and original Coordinated Approach to Child preschool teachers by CATCH trainers
one afternoon snack. The day is structured Health (CATCH) program5, 17, 18 to include a on implementing all the CEC program
in segments of 20-30 minutes each to include preschool-based nutrition, physical activity components.
various activities such as circle time, music and family component. CEC was developed Training for teachers in the participating
and movement time, outdoor free play, meal by a team consisting of CATCH curriculum centers was conducted in August 2008 by
times and nap times. Typically, in each Head experts, master trainers and national and CATCH master trainers prior to program
Start classroom, all children are grouped local preschool experts. Initial program implementation. All classrooms were pro-
such that all 3 to 5 year old children are development involved a review of nutrition vided with a six-week schedule for imple-
together through the day. and physical activity recommendations menting program components, a CEC ‘kit’
The CEC pilot included qualitative evalu- for preschoolers. The guidelines reviewed consisting of the classroom curriculum,
ation of the feasibility and acceptability of included the 2005 Dietary Guidelines for activity box, parent tip sheets and related
the CEC program using post-intervention Americans,19 Dietary Approaches to Stop equipment. The classroom lessons were
parent and teacher focus groups and, les- Hypertension (DASH) Eating Plan,20 Food to be implemented two lessons per week.
son plan evaluation forms. Additionally, Guide Pyramid for preschoolers,21 the Child The physical activities were to be imple-
quantitative changes in children’s intake of and Adult Care Food Program (CACFP),22 mented every day. Parent tip-sheets were
fruits, 100% fruit juice and vegetables and Special Supplemental Nutrition Program sent home twice a week. All the classroom
American Journal of Health Education — January/February 2011, Volume 42, No. 1 13
Shreela Sharma, Ru-Jye Chuang, and Ann Marie Hedberg
Table 1. Social Cognitive Theory (SCT) Constructs operationalized by the CEC program Components
CEC Component Title Description & Highlights SCTa Constructs Operationalized
Classroom It’s Fun • Nine nutrition lesson plans • Knowledge
Curriculum to be • Three-dimensional including use of col- • Skills
Healthy! ored pictures and hand puppets • Self-Efficacy
• Role playing in classroom • Environment
• Extension activities and curriculum con- • Self-control of Performance
nectors • Reinforcement
• Hands-on healthy snack activities
• Teacher’s Resource Manual
• Key Vocabulary Words in English, Spanish
& French
Physical Activity CEC • Over 120 activities designed to promote • Knowledge
Activity gross motor skills, classroom management • Skills
Box and increase physical activity • Self-Efficacy
• Adapted ideas for children with physical • Environment
disabilities • Observational Learning
• Music CD with age-appropriate music • Reinforcement
• Activities can be done either indoor or
outdoor
Parent Education Parent • Tip-sheets complementing the CEC class- • Knowledge
tip-sheets room lesson plans and PE activities • Skills
• Designed to be sent home to the parents • Self-Efficacy
• Tailored to 4th grade reading level • Outcome Expectation
• Interactive with child coloring activities, • Environment
tips for healthy living, parent resources • Reinforcement
and recipe ideas
• Bilingual in English and Spanish
Teacher Training • Conducted by CATCH trainers • Knowledge
• Interactive role-plays and activities for • Skills
implementing CEC program components • Self-efficacy
• In-depth review of recommendations for • Observational Learning
nutrition and physical activity • Outcome Expectation
• Active learning and feedback from teach- • Environment
ers to enhance the training experience • Reinforcement
a Social Cognitive Theory
lessons were in English and included key language and parent perception of their project staff. Thirty parents participated in
vocabulary words translated in Spanish to child’s weight status collected. the focus groups (center1: N = 6; center 2:
accommodate Spanish speaking children. All Parent and teacher qualitative data: N = 24). For parents, all focus groups were
parent tip-sheets were bilingual in English qualitative data was collected from parents conducted in their respective Head Start
and Spanish. and teachers using focus groups to assess centers during school hours on predeter-
Data collection feasibility and acceptability of CEC. Six mined days after the parents had dropped
Parent demographic data: question- structured focus groups were conducted off their children in the morning. The focus
naires requesting demographic data were with parents and teachers from the two cen- groups took approximately 60 minutes to
given to all participating parents/guardians ters (4 parent and 2 teacher focus groups). complete, and were led by a bilingual (Eng-
during the consent process. Data on parent All parent and teacher focus groups were lish and Spanish) moderator who asked
and child gender, race/ethnicity, household recorded and transcribed by bilingual open-ended questions. Parent focus group
14 American Journal of Health Education — January/February 2011, Volume 42, No. 1
Shreela Sharma, Ru-Jye Chuang, and Ann Marie Hedberg
Table 2. Description of CATCH Early Childhood program Components
Classroom curriculum
Lesson Title Objectives
Lesson 1 Hearty Heart Helps a • To introduce healthy eating behaviors
Friend • To identify healthy eating behaviors
Lesson 2 All Aboard the Veggie • To identify a variety of vegetables
Train! • To understand the importance of vegetables in a healthy diet
• To eat more vegetables of different colors
Lesson 3 Singing About Milk, • To identify milk and dairy foods
Yogurt and Cheese • To understand the importance of milk and dairy foods in a healthy diet
• To eat cheese and yogurt
• To drink plain white milk instead of flavored milk
Lesson 4 Let’s Eat Some Every- • To taste-test a vegetable and cheese as an example of a healthy snack
day Foods
Lesson 5 Singing About Fruits • To identify a variety of fruits
• To introduce fruits as part of a healthy daily diet
• To eat more fruits
Lesson 6 Rabbit, turtle and • To identify a variety of healthy snack foods
Everyday Snacks • To understand the importance of eating healthy snacks foods
Lesson 7 Everyday Drinks • To identify water, 100% fruit juices, and milk as healthy beverages
• To understand the importance of drinking healthy beverages
Lesson 8 Let’s Eat an Everyday • To taste-test low-fat crackers, fruit, and water as an example of a healthy
Snack snack
• To eat more Everyday snacks
Lesson 9 Singing for Everyday • To review the concepts presented in It’s Fun to Be Healthy!
Foods • To set a goal to eat an Everyday Food
Parent Tip-Sheets
Tip-sheet # Title Objectives
#1 Food and Your Family • To promote eating together as a family.
#2 Make Veggies Fun • To increase knowledge of recommendations for vegetables in children
ages 3 to 5.
• To understand the benefits of vegetables in a child’s diet.
• To try easy recipe ideas to increase vegetable intake in children ages
3 to 5.
#3 Milk Group Foods are • To increase knowledge of recommendations for milk and dairy foods and
Very Nutritious! types of milk and dairy foods for children ages 3 to 5.
• To try easy and healthy recipe ideas containing milk and dairy foods.
#4 Snack to Health • To understand healthy snacking habits.
• To try snack recipes containing fruits, vegetables and whole grains.
#5 Fruit-alicious • To increase knowledge of recommendations fruits for children ages 3 to 5.
• To understand the benefits of fruits in a child’s diet.
• To try recipes containing fruit.
Continued on next page
American Journal of Health Education — January/February 2011, Volume 42, No. 1 15
Shreela Sharma, Ru-Jye Chuang, and Ann Marie Hedberg
Table 2. Description of CATCH Early Childhood program Components (Con’t)
Tip-sheet # Title Objectives
#6 Eating Out: taking • To increase nutrition knowledge of various types of foods when eating
an inside look at the out.
nutrition • To increase knowledge of how to eat healthy when eating out.
#7 Let’s Get Moving • To increase knowledge of recommendations for physical activity for chil-
dren ages 3 to 5.
• To increase opportunities for various types of physical activities inside and
outside for children.
#8 Try to cut down on • To increase knowledge of recommendations for screen time for children
Screen Time ages 3 to 5.
• To increase knowledge for alternatives to screen time for children.
#9 Don’t Know Where to • To increase knowledge of reliable sources of information for parents in-
Go cluding books and websites for information regarding child nutrition and
physical activity.
Physical Activity Box
Activity
Time Period Objectives
sectiona
Classroom 5-7 minutes • Introductory lesson plan to help establishing the rules and behaviors
Manage- expected from children
ment • To learn and practice how to move safely in a group
Warm-up 3-5 minutes • To prepare students for more vigorous movements
Go activi- 5-7 minutes • To promote muscular strength, muscular endurance and cardiovascular
ties endurance
• To provide developmentally appropriate and enjoyable activities and
games for children
Cool Down 3-5 minutes • To provide closure, cool down the students’ bodies and help with the
transition back to the classroom
Limber 3-5 minutes • To promote gross motor skills, flexibility and coordination
Limbs
a Teachers were instructed to select at least one activity from the various sections which include classroom management, warm up, go activity, limber
limbs and cool down for each physical activity session.
questions included: (1) if they were aware For teachers, all focus groups took ap- (i.e., did they enjoy it?); (5) how teachers
of the CEC program being implemented in proximately 60 minutes and were conducted felt about teaching nutrition concepts; (6)
their child’s Head Start center; (2) if parents by moderators in English in their respective feasibility of implementing the physical
perceive such programs as beneficial for Head Start centers after school hours on activity box as planned; (7) which were
their children; (3) if they received the CEC predetermined days. Specifically, questions the children’s most and least favorite activ-
tip-sheets and how many; (4) if parents included: (1) feasibility of implementing ity from the physical activity box; (8) how
read the tip-sheets they received; (5) which the classroom curriculum as planned; (2) teachers felt about teaching physical activ-
tip-sheet the parents liked the most or least discussing each lesson and what the teach- ity using the box format; (9) feasibility of
and why and; (6) what changes, if any, did ers liked most or least about each lesson; (3) sending tip-sheets home to the parents as
they implement in their preschooler’s eating if they were able to implement the lesson planned; (10) did the training fully prepare
and physical activity habits after reading the activities in the classroom; (4) which were them for implementing CEC in their class-
tip-sheets. the children’s most and least favorite lesson rooms; and (11) suggestions for program
16 American Journal of Health Education — January/February 2011, Volume 42, No. 1
Shreela Sharma, Ru-Jye Chuang, and Ann Marie Hedberg
improvement. recess and afternoon movement time. Total to take second servings. For our study, fruit,
Evaluation of classroom lessons: Feasi- minutes of active time, physical activity level 100% fruit juice and vegetable (FJV) intake
bility and acceptability assessments of the and physical activity type were recorded. of the children was measured at baseline
classroom lesson plans were conducted us- Physical activity level (i.e., lying, sitting, and end of six weeks using direct observa-
ing teacher-reported lesson plan evaluation standing, walking and fast/very active) and tion of participating children during meal
forms for each of the nine lessons. This has type (i.e., type of activity the child is en- times (breakfast, lunch and snack) while
been used in previous CATCH-based studies gaged in such as pushing, pulling, throwing, at school. This included trained project
successfully.17, 18, 28 The form provided teacher jumping, dancing, etc.) were coded every 30 staff directly observing (on the spot) and
feedback on feasibility of implementing each seconds using momentary time sampling recording on coding sheets the food plates
of the lesson plans during a class period (i.e., (20 second observation; 10 second record- of all participating children before, during
were all the lesson components completed?) ing). An iPod provided the observing and and after eating meals during school hours.
as well as its acceptability by the children recording prompts which were used by the The number of servings of food that was
(i.e., did they enjoy it?). observer to guide the recording of the physi- initially served as well as second servings
Child anthropometrics: Height and cal activity level and physical activity type on were recorded. Plate waste was recorded
weight were assessed using digital platform a separate coding sheet. The observer prese- using measuring cups after each child had
scales with portable stadiometers (Perspec- lected one student at a time randomly to a finished eating the meal. Finally, the number
tive Enterprises Portable Adult Measuring total of four children to represent the group of servings of FJV left on the plate was sub-
Unit PE-AIM-101) and digital scales (Tanita and documented their level and activity type tracted from that initially served (including
Professional Digital Scales with Remote Dis- throughout the class time. After finishing second servings if applicable) to obtain the
play, bWb-800S) respectively. body mass the fourth student, if the activity was still in number of servings of FJV consumed by the
index (bMI) was calculated from the mea- session, the observer started with the first children during these meal times. This type
surements using the following equation: student again. These four children were con- of measurement of dietary intake has been
bMI = (weight in kg)/ (height in m)2 where sidered representative of the physical activity previously validated and used successfully
kg = kilograms, and m = meters. Age and for their entire class. Thus, group, and not in other studies in children.33-35 Our study
gender specific bMI percentiles were used to individual data was reported. Activity codes showed inter-observer reliability of >0.90
categorize weight status of the children. bMI were assigned for each activity level that the at baseline and post-intervention measure-
>85th and <95th percentile was categorized as child participated in. Overall, the instrument ments. This was done by two trained ob-
overweight and >95th percentile was catego- showed inter-observer agreement of >0.60 servers observing and recording the dietary
rized as obese.29, 30 This provided an estimate for physical activity level and physical activ- intake of the same participant at the same
of the prevalence of overweight and obesity ity type indicating good agreement. Also, time. Inter-observer reliability data was col-
in this study population. the mean kappa scores ranged from 0.66 to lected on 15% of the participants. There was
Child physical activity: Child physical 0.86 indicating good agreement of observed no change in the Head Start menu during
activity levels were measured at baseline from expected. the six week intervention period.
and post-intervention during outdoor Child dietary intake: Dietary intake Data analysis
and indoor active/movement times during of participating children was measured at For focus group data, transcripts were
preschool hours using SOFIT-P (System baseline and post-intervention using direct reviewed by two study investigators sepa-
for Observing Fitness Instruction Time for observation by trained observers. At HCDE rately to identify themes in the parent and
Preschoolers), SOFIT-P, a modified version Head Start, the children are not allowed to teacher comments. Subsequently, the themes
of the validated SOFIT instrument31,32 was bring food from outside and typically con- that were common were then organized into
developed by the investigative team and used sume their breakfast, lunch and afternoon categories which the investigators reviewed,
to measure physical activity levels, indoor snack at school. The menus are developed refined and summarized.
and outdoor activity contexts and type of by Head Start dietitians and meet the Child SAS 9.1 statistical software (SAS Institute
physical activity through direct observation and Adult Food Care program (CACFP) Inc., Cary, NC) was used to conduct statisti-
of preschool children. Details regarding guidelines. The meals are prepared in the cal analyses to describe participant demo-
development, reliability and validity test- kitchens of each Head Start center and the graphics and analysis of physical activity and
ing of SOFIT-P are presented elsewhere (S. children and teacher sit around the table and dietary data. All demographic variables were
Sharma, unpublished data, 2010). For our eat the meals family-style, i.e. the foods are examined for their means ±SD or frequency
study, children from each classroom were placed on the table and the teacher serves the distributions. The diet and physical activity
observed by trained observers only at active children the foods and/or the children serve data was not normally distributed. Hence
time points during the school day: morning themselves. Four ounce scoops are used to subsequent analysis used non-parametric
recess, morning movement time, afternoon serve each food item. Children are allowed tests. The pre-to-post intervention change
American Journal of Health Education — January/February 2011, Volume 42, No. 1 17
Shreela Sharma, Ru-Jye Chuang, and Ann Marie Hedberg
in the proportion of FJV consumed dur-
ing meal times at school were calculated Table 3. Baseline Characteristics of Study participants
from the direct observation measures using from HCDE Head Start, 2008
the Wilcoxon matched pairs test. The data
Frequency Percent
for all the meals (i.e. breakfast, lunch and Demographic variables
(N) (%)
snack) was collapsed to determine the FJV
consumption pre and post intervention. Child gender (N=75)
Mann-Whitney U test was used to evaluate Male 31 41.3
pre-to-post intervention changes in physical Female 44 58.7
activity as measured using the SOFIT-P. The Center (N=74)
mean minutes of active movement at base- Center 1 33 44.6
line and post-intervention were calculated. Center 2 41 55.4
For physical activity level, activity codes were Household language (N=62)
assigned to describe the body position of the English 38 61.3
student (lying, sitting, standing, walking and Spanish 24 38.7
fast/very active). The mean percent time Child’s Ethnicity (n=73)
spent in each physical activity level was African-American 25 34.3
calculated using the activity codes at baseline Hispanic 47 64.4
and post-intervention. Light physical activity Native American 1 1.4
was calculated by collapsing percent time Parents’ perception of children’s weight (N=65)
spent at lying, sitting and standing. Moderate Under-weight 3 4.6
physical activity was calculated by percent Normal weight 61 93.9
time spent walking. Vigorous physical activity Over-weight 1 1.5
was calculated by percent time spent in fast/ Children’s BMI percentile (n=61)
very active movements. Moderate-vigorous Normal (BMI <85th percentile) 37 60.6
physical activity (MVPA) was calculated by Over-weight (BMI ≥85th percentile) 12 19.7
collapsing percent time spent at walking Obese ( BMI ≥95th percentile) 12 19.7
and fast/very active movements.31 Statistical
significance was set at P<0.05. This study was
12 Hispanic, 3 Caucasian, 11 African Ameri- school day. Teachers said that the children
approved by the University of Texas-Houston,
can). The primary theme for parent focus responded positively to the activities in-
Committee for Protection of Human Subjects
groups was that all reported having received cluded in the CEC lessons and were able to
(HSC-SPH-08-0414). Additionally, the study
the tip sheets and reported that using CEC distinguish which foods are “everyday food”
protocols and measurements were approved
to introduce healthy eating in their children and which ones are not (i.e., “sometimes
by the HCDE Institutional Review board.
was beneficial. For example: foods”). For example:
RESUlTS “Yes, it was helpful to learn about the “Sometimes they’ll pick up food and
Table 3 shows the baseline characteristics snacks, to get some ideas.” say this is ‘sometimes’ food, or this is a
of the children participating in the study. healthy food. So, they enjoyed it.”
“Yes, telling them that vegetables are
58.7% of the participants were female and
“I think it’s important teaching the kids
healthy for them and not just that we
64.4% were Hispanic; furthermore, 39.4%
about everyday foods because they’ll go
want them to eat them.”
of the children were overweight or obese
home and talk about everyday food and
based on anthropometric measurement.
“She used to drink a lot more Cokes and that’s a good food. One student talked
When asked about their children’s weight
we minimized that.” about French fries and how it’s a vegetable
status, only 1.5% of the participating parents
but not an everyday food. So, I think it’s
perceived their children to be overweight Nine teachers participated in the focus
a good thing.”
or obese. groups conducted at center 1 (N=5 ) and
Thirty-three parents participated in the center 2 (N=4). All participating teachers “We colored the pictures to make things
post-intervention focus groups from the two were female. The primary theme for the colorful, like the veggie train. And I made
centers; center 1 (N=7; 1 Male, 6 Females post-intervention focus groups was that different games to go along with it. Like
and; 5 Hispanic, 2 African American) and the teachers were able to incorporate the coloring the vegetables so they knew what
center 2 (N=26; 2 Males, 24 Females and; lessons and activities successfully into their the vegetables really were.”
18 American Journal of Health Education — January/February 2011, Volume 42, No. 1
Shreela Sharma, Ru-Jye Chuang, and Ann Marie Hedberg
Suggestions for improvements included Results of the nutrition lesson plan length of the lessons by breaking them down
shortening the length of the classroom les- evaluation forms showed an overall good into segments and reducing the length of
sons. Teachers considered the activities as feasibility and acceptability of the classroom the stories.
simple enough for the children in that age curriculum. Table 4 shows that a total of For dietary intake, the mean proportion
group to follow, interesting for them to par- 21 evaluation forms out of a possible 36 of servings of FJV consumed by the partici-
ticipate and easy for the teachers to prepare. (9 forms from each of the 4 participating pating children for all the meals at school
For example: classrooms at the two centers) were obtained were calculated (Table 5). Overall, children
indicating a 58% response rate. Results indi- were consuming a greater proportion of
“The stories need to be shortened some
cate that the mean time to teach the lessons fruits and 100% fruit juice as compared to
because of the attention span of the kids.
was 23 minutes. Teachers reported having vegetables at baseline and post-intervention.
I do mine (story telling) during snack
taught most, if not all parts of each lesson. On an average, children were consuming
time. because the story is kind of lengthy,
Teacher comments, provided at the end of <20% of the vegetables and >60% of the
if you could narrow it down and have
each lesson plan evaluation form, indicated fruits and juice served. Pre-to-post-interven-
some puppets or something to keep the
that the children were enthusiastic and en- tion showed an increase in the proportion of
children’s attention. The activities, I really
gaged in the lessons and especially liked the FJV consumed by the children. However, this
enjoyed the activities and the kids like
songs and stories in the lessons. Suggestions trend was not statistically significant.
them. They’re good for transition.”
for improvements included reducing overall For physical activity measurement using
The focus group data on the activity
box indicated that the teachers did not
Table 4. Results of Classroom lesson plan Evaluation Form
implement the physical activities every day
(N = 21 forms)
as intended. However, the primary theme
was that, when implemented, the activities Variable Mean ±SD (Range)
were feasible and enjoyed by the children.
To what extent did you teach the following parts of
For example: the lesson? (1=Not at all to 4=Completely)
Introduction 3.71 ±0.46 (3-4)
“We did the activities. They liked the
Story or Songs 3.80 ±0.51 (2-4)
activities. Didn’t have any least favorites
Interviews/Discussion 3.60 ±0.75 (2-4)
or any activities that did not work with
Session summary 3.59 ±0.61 (2-4)
the kids.”
“They were simple enough for them to How long did the lesson last (minutes)? 23.19 ±7.50 (10-30)
do and it was something new so they
N (%)
were interested in it, like the yoga poses.
They’ve never done that before. And it To what extent did you teach the following parts of
follows along with the discipline, like lin- the lesson? (1=Not at all to 4=Completely)
ing up and asking them to follow. That’s
Introduction
what I like about that.” Mostly (score=3) 6 (28.5)
Completely (score=4) 15 (71.4)
“I like that they were on cards. A lot of
time when you try to come up with a Stories
movement activity, you kind of go blank. Somewhat (score=2) 1 (4.8)
So, you can just grab a card real quick and Mostly (score=3) 2 (9.5)
Completely (score=4) 18 (85.7)
I liked that. It had exactly what you were
supposed to do.” Activities
Somewhat (score=2) 3 (15.0)
Suggestions for improvements on the
Mostly (score=3) 2 (10.0)
activity box included a more in-depth
Completely (score=4) 15 (75.0)
training on implementation of the activity
box in an indoor and outdoor setting and Session summary
changing the music on the CD included in Somewhat (score=2) 1 (5.9)
the physical activity box because it was found Mostly (score=3) 5 (29.4)
Completely (score=4) 11(64.7)
to be too slow.
American Journal of Health Education — January/February 2011, Volume 42, No. 1 19
Shreela Sharma, Ru-Jye Chuang, and Ann Marie Hedberg
Table 5. pre-to-post intervention Changes in Mean proportion of Servings of Fruits, vegetables
and Juice Consumed by the Children during Meal Times at the Two Centers (N = 61)
Fruits Vegetables 100% Fruit Juice
Variable Servings eaten/Servings Servings eaten/Servings Servings eaten/Servings
provideda provideda provideda
Baseline Posttest Baseline Posttest Baseline Posttest
Mean 0.61 0.81 0.13 0.16 0.71 0.75
(SD) (0.44) (0.39) (0.18) (0.31) (0.45) (0.34)
Note: Wilcoxon matched pairs test used to determine pre-to-post intervention changes.
aServings provided= number of servings at the start of the meal plus second servings minus servings given away. Serving size of FJV was set using the USDA
Food Guide Pyramid definitions. For example, one serving of fruit is equal to one medium whole fruit or one half cup of cut fruit or ¾ cup (6 ounces) of
100% fruit juice; one serving of vegetable is equal to 1 cup (8 ounces) of raw or ½ cup of cooked vegetables.
direct observation, a total of 23 baseline weight or obese. This indicates the need for the CEC program more integrated with the
and 11 post-intervention observations on obesity prevention programs in this cohort current typical preschool structure.
the four classrooms were conducted using of preschoolers. Parent involvement and communication
SOFIT-P (Table 6). The smaller number Results of the post-intervention teacher were found to be very important in this
of observations post-intervention was due focus groups and the lesson plan evaluation preschool setting. The parents indicated that
to fewer scheduled activity times provided forms indicate that the nutrition-based they enjoyed the recipe ideas, coloring activi-
to the children at the centers during this classroom curriculum was well received ties and being informed about the CEC pro-
period. Results of baseline data showed that by the children and feasible to teach in a gram via the tip-sheets. Another interesting
children spent on an average 39.8 (+/-14.3 preschool setting. The trend towards an result was the parental perception of their
SD) minutes in active movement which increase in the children’s FJV intake pre-to- child’s weight. While measured height and
increased to 47.3 (+/-13.5 SD) minutes post intervention also supports these results. weight showed that 39% of the participating
post-intervention. This increase, however, It is important to note that overall, children children were overweight or obese, only 1.5%
was not statistically significant. At baseline, were consuming < 20% of the vegetables of the parents perceived their children to be
of the total time spent in active movement, served during meal times while at school. in these categories indicating a significant
72.1% was spent in light physical activity Vegetables were typically served every day at discrepancy between the magnitude of the
and only 27.9% in moderate-to-vigorous lunch and some days at snack time to meet prevalence of overweight and obesity in this
physical activity (MVPA). At post-inter- the CACFP guidelines. While these results population and parent perceptions related to
vention, 84.9% of the active time was spent are exploratory in nature, given that food the same. These results emphasize the need
in light physical activity and only 15.1% in preferences develop in early childhood, it for early childhood programs to be inclusive
MVPA. Thus, there was a decrease pre-to- is important to further evaluate vegetable of parents. Parents are responsible for setting
post intervention in the percent time spent intake in preschoolers. Suggestions for im- guidelines for screen time and determining
in MVPA. However, this decrease was not provements of the classroom curriculum by family meal times, all of which are envi-
statistically significant. the teachers included shortening the length ronmental factors related to the adoption
of the nutrition lessons. In response to this, of dietary and physical activity behaviors.
DiSCUSSioN the investigative team has subsequently Research has indicated that preschooler’s
Overall, the CEC pilot testing showed modified the lessons such that it can be food preferences are largely dependent on
good feasibility and acceptability in the divided into segments with each no more their parents/caregivers.36-38 These results are
study population of low-income, predomi- than 5-7 minutes long. Each segment can further emphasized in studies which have
nantly Hispanic and African American pre- be introduced separately to the children shown that if parents constantly expose their
schoolers, their parents and teachers. The at different times through the day or the children to fatty food choices, their child’s fat
prevalence of obesity was higher than the week. The inclusion of ‘extension activities’ intake and preferences for fat will be greater
national average in the study population and ‘curriculum connectors’ which includes than those not exposed.39,40 Spurrier et al.41
with 39% of the participants being over- activities for various learning centers make recently reported that the home environ-
20 American Journal of Health Education — January/February 2011, Volume 42, No. 1
Shreela Sharma, Ru-Jye Chuang, and Ann Marie Hedberg
Table 6. pre-to-post intervention Changes in percent Time Spent at Each of Four
physical Activity levels during Active Times at the Head Start Centers
Pretest (23 observations)a Posttest (11 observations)a
Light Moderate Vigorous MVPA Light Moderate Vigorous MVPA
(%) (%) (%) (%) (%) (%) (%) (%)
Total 72.13 19.43 8.44 27.87 84.86 11.73 3.41 15.14
Center 1 69.90 17.75 12.35 30.10 83.16 12.75 4.09 16.84
Center 2 73.67 20.59 5.94 26.33 91.65 7.65 0.70 8.35
Note: Mann-Whitney U test used to determine pre-to-post intervention changes
anumber of observations excludes double observations conducted for reliability check.
MVPA – Moderate-to-Vigorous Physical Activity
ment and parental behaviors are associated dren at the centers during the post-interven- programs for children in a preschool setting.
with preschool children’s physical activity, tion period when these measurements were As next steps the CEC program has been
sedentary behavior and dietary patterns. carried out. Thus, even though the children modified to: (1) strengthen teacher training
For those children who attend preschools/ were provided with more minutes of physi- towards implementation of program com-
daycares, studies have shown that, in addi- cal activity during the day, the number of ponents; (2) include planning notes for each
tion to parents, teacher characteristics and these opportunities was fewer during the classroom nutrition lesson including exten-
preschool resources play a significant role post-intervention period. Several reasons sion activities and curriculum connectors so
in promoting healthy behaviors.42 Thus, were cited by teachers, such as cold weather, that it can be taught at one time or divided
interventions targeting both, preschools and since the intervention was carried out from up into segments through the various HCDE
families are needed. October to December during which time Head Start learning times in the day or week;
The physical activity component of the it got progressively colder, preventing the (3) include colorful hand puppets, plastic
CEC program showed mixed results. While children from receiving outdoor physical fruits and vegetables and colored illustra-
teacher focus groups indicated that the ac- activity time every day. Secondly, teachers tions with the nutrition lessons; (4) include
tivities were feasible and enjoyed by the chil- reported that the Head Start centers did not information in the physical activity box on
dren, implementation of the activities did have a scheduled physical education time or implementation of the activities indoors or
not take place as planned. Overall, high levels a gym area for the children to perform the outdoors; and (5) include a new music CD.
of light activity and low levels of MVPA were CEC activities indoors. Teachers reported The impact of this newly modified CEC pro-
observed in the study population. These being unaware that the activities could also gram is being evaluated over the 2009-2010
results concur with other research in the be implemented in a classroom setting even school year in a larger sample of preschoolers
preschool population43-45indicating a strong though this was indicated during the teacher enrolled in HCDE Head Start centers using a
need for programs promoting physical activ- training conducted prior to implementation group-randomized controlled trial design.
ity while at preschool. There was an increase of CEC. Teachers suggested that the training Limitations
in the mean minutes of active movement session needs to emphasize the flexibility The sample size for this pilot test was
from baseline to post-intervention which is of the activities to be implemented in any small and the study was not powered to de-
provides positive feedback on the feasibility setting, whether indoors or outdoors. The tect significant changes in dietary habits and
and acceptability of CEC. However, unex- investigative team has now modified the physical activity. The analysis of the dietary
pectedly, the percent time spent in MVPA teacher training component to include in- intake and physical activity is exploratory
during this active movement decreased from structions on how to conduct these activities and provides preliminary information on
baseline to post-intervention which could be indoors or outdoors and has included this the potential effect of the program on these
due to several reasons. There were a signifi- information on the activity cards as well as behaviors and effect sizes for sample size
cantly fewer number of post-intervention in the activity box instruction section. calculations in future studies. Additionally,
SOFIT-P measurements as compared to In conclusion, this study provides in- the lack of a control group does not allow
baseline (23 pretest vs. 11 posttest). This was formation on important factors to take for attribution of the results of diet and
primarily due to fewer scheduled physical into consideration when developing and physical activity to the intervention. Another
activity opportunities provided to the chil- implementing nutrition and physical activity limitation of the study is associated with the
American Journal of Health Education — January/February 2011, Volume 42, No. 1 21