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.

Efficacy of the Lunch is in the Bag intervention to increase parents' packing of healthy bag lunches for young children: a cluster-randomized trial in early care and education centers.

BACKGROUND: Lunches that parents pack for their young children to eat at school or the Early Care and Education (ECE) center fall short of recommended standards. Lunch is in the Bag is a multi-level behavioral nutrition intervention to increase parents' packing of fruit, vegetables, and whole grains in their children's lunches. Designed for implementation in ECE centers, the five-week long intervention is followed three months later with a one-week booster. METHODS: Efficacy of Lunch is in the Bag was tested in cluster randomized trial. Participants were 633 families from 30 ECE centers (15 intervention, 15 control) across Austin, San Antonio, and Houston, Texas, USA. Primary outcomes were servings of fruit, vegetables, and whole grains observed in the children's parent-packed bag lunches. Servings of refined grains, meats/beans/eggs/nuts, dairy, chips, and sweets also were observed. Data were collected at baseline, post-intervention (6-week follow-up), pre-booster (22-weeks follow-up), and post-booster (28-week follow-up). Time-by-treatment interactions were analyzed separately for each of the food groups using multi-level models to compare changes from baseline. Analyses were adjusted for relevant demographic variables and clustering within centers and parents. RESULTS: The intervention effected increases from baseline to 6-week follow-up in vegetables (0.17 servings, SE = 0.04, P < 0.001) and whole grains (0.30 servings, SE = 0.13, P = 0.018). The increase in whole grains was maintained through the 28-week follow-up (0.34 servings, SE = 0.13, P = 0.009). Fruit averaged more than 1.40 servings with no differences between groups or across time. The intervention prevented increase in sweets (-0.43 servings, SE = 0.11, P < .001, at the 22-week follow-up). Parents persisted, however, in packing small amounts of vegetables (averages of 0.41 to 0.52 servings) and large amounts of sweets and chips (averages of 1.75 to 1.99 servings). CONCLUSIONS: The need for and positive effects of the Lunch is in the Bag intervention at ECE centers where parents send bag lunch for their preschool-aged children was confirmed. An important direction for future research is discovery of more options for leveraging the partnership of ECE centers and families to help young children learn to eat and enjoy vegetables and other healthy foods in preference to less healthy choices such as chips and sweets. TRIAL REGISTRATION: The Clinical Trials Number is NCT01292434 .

Exploratory Cross-Sectional Study of Factors Associated with the Healthfulness of Parental Responses to Child Food Purchasing Requests.

Objective The main objective of this study was to investigate the relationship between various factors (e.g., sociodemographic, child, and parental factors) and the healthfulness of parental responses to child in-store food purchasing requests. Additionally, a secondary objective is to describe "resist strategies" used by parents to respond to child food-purchasing requests and their efficacy in avoiding conflict. Methods Parent-child dyads (children aged 2-6 years) completed an audio-/visual-recoded food shopping trip at their usual grocery store and time. Recordings of trips were coded for behavioral and environmental factors. Parental healthful response rate (i.e., percent of responses that were healthful) was the primary outcome variable. A healthful response occurred when a parent yielded to a healthful child request, or resisted a non-healthful request. Parents also completed a questionnaire. Kruskal-Wallis tests were used to assess the relationship between the main outcome variable and sociodemographic, child, and parent factors. Results Parents (n = 39) responded healthfully to 62.9 % (±26.7 %) of child food purchasing requests. Low- and middle-income parents, and black and white parents, had significantly higher healthful response rates compared to high-income parents (p = 0.03) and Hispanic/Indian-descent parents (p = 0.02), respectively. Using the "ignore" strategy proved an effective resist strategy in this study, leading to no parent-child conflicts. Conclusions Programming that seeks to improve the healthfulness of food purchasing in families with young children should address unhealthful response behaviors in Hispanic/Indian-descent parents and high-income parents; although, the needs of these groups are different. Further research is needed to confirm and expand on these findings.

Method of assessing parent-child grocery store purchasing interactions using a micro-camcorder.

The purpose of this study was to assess the validity of using participant worn micro-camcorders (PWMC) to collect data on parent-child food and beverage purchasing interactions in the grocery store. Parent-child dyads (n = 32) were met at their usual grocery store and shopping time. Parents were mostly Caucasian (n = 27, 84.4%), mothers (n = 30, 93.8%). Children were 2-6 years old with 15 girls and 17 boys. A micro-camcorder was affixed to a baseball style hat worn by the child. The dyad proceeded to shop while being shadowed by an in-person observer. Video/audio data were coded for behavioral and environmental variables. The PWMC method was compared to in-person observation to assess sensitivity and relative validity for measuring parent-child interactions, and compared to receipt data to assess criterion validity for evaluating purchasing decisions. Inter-rater reliability for coding video/audio data collected using the PWMC method was also assessed. The PWMC method proved to be more sensitive than in-person observation revealing on average 1.4 (p < 0.01) more parent-child food and beverage purchasing interactions per shopping trip. Inter-rater reliability for coding PWMC data showed moderate to almost perfect agreement (Cohen's kappa = 0.461-0.937). The PWMC method was significantly correlated with in-person observation for measuring occurrences of parent-child food purchasing interactions (rho = 0.911, p < 0.01) and characteristics of those interactions (rho = 0.345-0.850, p < 0.01). Additionally, there was substantial agreement between the PWMC method and receipt data for measuring purchasing decisions (Cohen's kappa = 0.787). The PWMC method proved to be well suited to assess parent-child food and beverage purchasing interactions in the grocery store.

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.

How to help parents pack better preschool sack lunches: advice from parents for educators.

OBJECTIVES: This exploratory study obtained parent suggestions about messages and activities to guide parents to pack healthful sack lunches for preschool-aged children. METHODS: A facilitator conducted group interviews using a modified nominal group technique with a convenience sample of parents who pack daily lunches for their children. Interviews took place after hours at child care centers in group settings. Investigators reviewed written statements for common themes then calculated frequencies of references to identified themes. RESULTS: In total, 31 parents participated in 3 group interviews held at 3 centers. Interest in receiving written information and in activities stimulating parent interaction were dominant themes in 29% of the comments. Workshops and activity stations were suggested in 20% of the comments. Finally, recommendations for support from local supermarkets were present in 10% of the comments. CONCLUSIONS AND IMPLICATIONS: Parents provided helpful suggestions that can guide nutrition educators to implement effective program messages and strategies.

Psychosocial outcomes of Lunch is in the Bag, a parent program for packing healthful lunches for preschool children.

OBJECTIVE: This pilot study evaluated effects of Lunch is in the Bag on behavioral constructs and their predictive relationship to lunch-packing behaviors of parents of young children. METHODS: Six child care centers were pair-matched and randomly assigned to intervention (n = 3) and comparison (n = 3) groups. Parent/child dyads participated. Constructs of knowledge, outcome expectations, perceived control, subjective norms, and intentions were measured by a pre/post questionnaire. Hierarchical linear regression was used, and P < .05 was considered significant. RESULTS: There were significant increases in knowledge (P = .01); outcome expectations for whole grains (P < .001); and subjective norms for fruit (P = .002), vegetables (P = .046), and whole grains (P = .02). Perceived control, outcome expectations, and intentions significantly predicted packing vegetables and knowledge predicted whole grains. CONCLUSIONS AND IMPLICATIONS: Lunch is in the Bag is a feasible intervention to improve the lunch-packing behaviors of parents of preschool-aged children.

Lunch is in the bag: increasing fruits, vegetables, and whole grains in sack lunches of preschool-aged children.

Fruits, vegetables, and whole grains are important sources of nutrients for healthy growth and development of young children. Recent evidence suggests that sack lunches packed by parents for children to consume at child-care centers do not regularly meet the goal of one serving of fruit, vegetables, and whole grains. Lunch Is In The Bag is a child-care center-based nutrition education program targeted at parents of preschool-aged children to increase the number of servings of fruits, vegetables, and whole grains in sack lunches sent from home that was pilot tested in fall 2008. In a quasiexperimental design, six child-care centers were paired by size before being randomly assigned to intervention (n=3) and comparison (n=3) groups. The parents of caregivers with primary responsibility for preparing the sack lunches of the 3- to 5-year-old children attending the centers were enrolled as parent-child dyads. The intervention included parent handouts, classroom activities, education stations, and teacher training. The contents of the lunch sacks for both the intervention group and comparison group were recorded for 3 nonconsecutive days before and immediately after the intervention period to measure the number of servings of fruits, vegetables, and whole grains. A total of 132 parent-child dyads completed the study, 81 in the intervention group and 51 in the comparison group. Direct observation of children's lunches from the intervention group showed an increase in predicted mean number of servings of vegetables, from 0.41 to 0.65 (P<0.001) and whole grains, from 0.54 to 1.06 (P<0.001). No significant difference was observed in the mean number of servings of fruit. Lunch Is In The Bag, which is designed to fit in the child-care environment and targets parents of 3- to 5-year-old children, is a feasible intervention for improving the nutritional quality of sack lunches.