Parent packs, child eats: Surprising results of Lunch is in the Bag's efficacy trial.

Early care and education (ECE) centers that require lunch brought from home provide an uncluttered view of parent-child dietary interactions in early childhood. Children's eating from parent-provided bag lunches was observed at 30 ECE centers in Texas, with 15 randomly assigned to the Lunch is in the Bag intervention to improve the lunch meal and 15 to a wait-list control condition. Study participants were parent and child aged 3-5 years (N = 633 dyads). Data were collected at baseline (pre-intervention) and follow-ups at weeks 6 (post-intervention), 22 (pre-booster), and 28 (post-booster). Changes effected in the children's lunch eating-e.g., increase of 14 percent in prevalence of children eating vegetables (SE = 5, P = 0.0063)-reciprocated changes in parent lunch-packing. Irrespective of intervention, however, the children consumed one-half to two-thirds of the amounts of whatever foods the parents packed, and the eat-to-pack ratio did not change across time. Thus, children's lunch eating at the ECE centers appeared to be regulated by perceptual cues of food availability rather than food preferences or internal cues of hunger and satiety.

Adequacy of Parent-Packed Lunches and Preschooler's Consumption Compared to Dietary Reference Intake Recommendations.

BACKGROUND: U.S. preschool children consume inadequate amounts of key nutrients. Understanding the contents of lunches packed by parents and consumed by their children can help identify areas of opportunity for the development of healthy food preferences. OBJECTIVE: To evaluate the nutrient adequacy of lunches packed by parents and consumed by children attending early care and education (ECE) centers. METHODS: Baseline data from 607 parent-child dyads in the "Lunch Is in the Bag" cluster-randomized controlled trial in Central Texas were examined. Foods packed by parents and consumed by children in sack lunches were observed at 30 ECE centers on 2 nonconsecutive days. Mean levels of energy, macronutrients, vitamins, and minerals were estimated with covariate-adjusted multilevel regression models that accounted for center-level clustering and repeated within-child measures. RESULTS: Energy (kilocalories) was 602.48 for packed lunches compared to 374.40 for consumed lunches. In packed lunches, percentage of energy as macronutrients for protein (14.8%), carbohydrate (55.9%), and total fat (31.2%) were within the acceptable macronutrient distribution range (AMDR) for the children's ages. Sugar (28.9% of energy) was above the AMDR recommendation. Only a quarter of parents packed 33% or more of the child's dietary reference intake (DRI) for dietary fiber. Over half the parents packed 33% or more of the DRI for vitamin A and calcium, and less than one in 8 packed 33% of the DRI for potassium. Children consistently consumed between 60 and 80% of the nutrients that were packed. CONCLUSIONS: Preschool children rely on parents to present them with healthy food choices, but lunches packed by parents for their preschool children do not consistently provide adequate nutrients. These data and the relationships between the dietary quality of packed and consumed lunches can be useful information to guide nutrition behavior change through targeted interventions.

Contribution of Beverage Selection to the Dietary Quality of the Packed Lunches Eaten by Preschool-Aged Children.

BACKGROUND: Sweet drinks early in life could predispose to lifelong consumption, and the beverage industry does not clearly define fruit drinks as part of the sweet drink category. OBJECTIVES: To ascertain the relationship between beverage selection and dietary quality of the lunches packed for preschool-aged children evaluated using the Healthy Eating Index-2010. METHODS: Foods packed by parents (n=607) were observed at 30 early care and education centers on two nonconsecutive days. Three-level regression models were used to examine the dietary quality of lunches by beverage selection and the dietary quality of the lunch controlling for the nutrient composition of the beverage by removing it from the analysis. RESULTS: Fruit drinks were included in 25% of parent-packed lunches, followed by 100% fruit juice (14%), milk (14%), and flavored milk (3.7%). Lunches with plain milk had the highest Healthy Eating Index-2010 scores (59.3) followed by lunches with 100% fruit juice (56.9) and flavored milk (53.2). Lunches with fruit drinks had the lowest Healthy Eating Index-2010 scores at 48.6. After excluding the nutrient content of the beverage, the significant difference between lunches containing milk and flavored milk persisted (+5.5), whereas the difference between fruit drinks and 100% fruit juice did not. CONCLUSIONS: Dietary quality is associated with the type of beverage packed and these differences hold when the lunch is analyzed without the nutrient content of the beverage included.

Structuring Process Evaluation to Forecast Use and Sustainability of an Intervention: Theory and Data From the Efficacy Trial for Lunch Is in the Bag.

BACKGROUND: A cluster-randomized trial at 30 early care and education centers (Intervention = 15, waitlist Control = 15) showed the Lunch Is in the Bag intervention increased parents' packing of fruits, vegetables, and whole grains in their preschool children's bag lunches (parent-child dyads = 351 Intervention, 282 Control). PURPOSE: To examine the utility of structuring the trial's process evaluation to forecast use, sustainability, and readiness of the intervention for wider dissemination and implementation. METHOD: Pretrial, the research team simulated user experience to forecast use of the intervention. Multiattribute evaluation of user experience measured during the trial assessed use and sustainability of the intervention. Thematic analysis of posttrial interviews with users evaluated sustained use and readiness for wider dissemination. RESULTS: Moderate use was forecast by the research team. Multiattribute evaluation of activity logs, surveys, and observations during the trial indicated use consistent with the forecast except that prevalence of parents reading the newsletters was greater (83% vs. 50%) and hearing their children talk about the classroom was less (4% vs. 50%) than forecast. Early care and education center-level likelihood of sustained use was projected to be near zero. Posttrial interviews indicated use was sustained at zero centers. DISCUSSION: Structuring the efficacy trial's process evaluation as a progression of assessments of user experience produced generally accurate forecasts of use and sustainability of the intervention at the trial sites. CONCLUSION: This approach can assist interpretation of trial outcomes, aid decisions about dissemination of the intervention, and contribute to translational science for improving health.

Dietary Quality of Preschoolers' Sack Lunches as Measured by the Healthy Eating Index.

BACKGROUND: Eating habits are developed during the preschool years and track into adulthood, but few studies have quantified dietary quality of meals packed by parents for preschool children enrolled in early care and education centers. OBJECTIVE: Our aim was to evaluate the dietary quality of preschoolers' sack lunches using the Healthy Eating Index (HEI) 2010 to provide parents of preschool children with guidance to increase the healthfulness of their child's lunch. DESIGN: This study is a cross-sectional analysis of baseline dietary data from the Lunch Is in the Bag trial. PARTICIPANTS: A total of 607 parent-child dyads from 30 early care and education centers in Central and South Texas were included. MAIN OUTCOME MEASURES: Total and component scores of the HEI were computed using data obtained from direct observations of packed lunches and of children's consumption. STATISTICAL ANALYSIS: Three-level regression models with random intercepts at the early care and education center and child level were used; all models were adjusted for child sex, age, and body mass index (calculated as kg/m(2)). RESULTS: Mean HEI-2010 total scores were 58 for lunches packed and 52 for lunches consumed, out of 100 possible points. Mean HEI component scores for packed and consumed lunches were lowest for greens and beans (6% and 8% of possible points), total vegetables (33% and 28%), seafood and plant proteins (33% and 29%), and whole grains (38% and 34%); and highest for empty calories (85% and 68% of possible points), total fruit (80% and 70%), whole fruit (79% and 64%), and total protein foods (76% and 69%). CONCLUSIONS: Parents of preschool children pack lunches with low dietary quality that lack vegetables, plant proteins, and whole grains, as measured by the HEI. Education of parents and care providers in early care and education centers is vital to ensure that preschoolers receive high dietary-quality meals that promote their preference for and knowledge of a healthy diet.

Development of a Method to Observe Preschoolers' Packed Lunches in Early Care and Education Centers.

BACKGROUND: As early childhood education (ECE) centers become a more common setting for nutrition interventions, a variety of data collection methods are required, based on the center foodservice. ECE centers that require parents to send in meals and/or snacks from home present a unique challenge for accurate nutrition estimation and data collection. We present an observational methodology for recording the contents and temperature of preschool-aged children's lunchboxes and data to support a 2-day vs a 3-day collection period. METHODS: Lunchbox observers were trained in visual estimation of foods based on Child and Adult Care Food Program and MyPlate servings and household recommended measures. Trainees weighed and measured foods commonly found in preschool-aged children's lunchboxes and practiced recording accurate descriptions and food temperatures. Training included test assessments of whole-grain bread products, mixed dishes such as macaroni and cheese, and a variety of sandwich preparations. Validity of the estimation method was tested by comparing estimated to actual amounts for several distinct food types. Reliability was assessed by computing the intraclass correlation coefficient for each observer as well as an interrater reliability coefficient across observers. To compare 2- and 3-day observations, 2 of the 3 days of observations were randomly selected for each child and analyzed as a separate dataset. Linear model estimated mean and standard error of whole grains, fruits and vegetables, and amounts of energy, carbohydrates, protein, total fat, saturated fat, dietary fiber, thiamin, riboflavin, niacin, vitamins A and C, calcium, iron, sodium, and dietary fiber per lunch were compared across the 2- and 3-day observation datasets. RESULTS: The mean estimated amounts across 11 observers were statistically indistinguishable from the measured portion size for each of the 41 test foods, implying that the visual estimation measurement method was valid: intraobserver intraclass correlation coefficients ranged from 0.951 (95% CI 0.91 to 0.97) to 1.0. Across observers, the interrater reliability correlation coefficient was estimated at 0.979 (95% CI 0.957 to 0.993). Comparison of servings of fruits, vegetables, and whole grains showed no significant differences for serving size or mean energy and nutrient content between 2- and 3-day lunch observations. CONCLUSIONS: The methodology is a valid and reliable option for use in research and practice that requires observing and assessing the contents and portion sizes of food items in preschool-aged children's lunchboxes in an ECE setting. The use of visual observation and estimation with Child and Adult Care Food Program and MyPlate serving sizes and household measures over 2 random days of data collection enables food handling to be minimized while obtaining an accurate record of the variety and quantities of foods that young children are exposed to at lunch time.