Hands-on childcare garden intervention: A randomized controlled trial to assess effects on fruit and vegetable identification, liking, and consumption among children aged 3-5 years in North Carolina.

Gardening at childcare centers may have a potent influence on young children's learning about fruits and vegetables and their development of healthy dietary behaviors. This randomized controlled trial examined the effect of a garden intervention on fruit and vegetable (FV) identification, FV liking, and FV consumption among 3-5-year-old children enrolled in childcare centers in Wake County, North Carolina, USA. Eligible childcare centers (serving primarily low-income families) were randomly selected and then randomly assigned to one of three groups: (1) intervention; (2) waitlist-control that served as a control in year 1 and received the intervention in year 2; or (3) no-intervention control. From the 15 participating childcare centers, 285 children aged 3-5 years were consented by their parents or guardians to participate. The intervention comprised six standardized, raised, mulched garden beds, planted with warm-season annual vegetables and fruits, and perennial fruits. A Gardening Activity Guide describing 12 age-appropriate, sequential gardening activities was distributed for teachers to lead hands-on gardening activities during the growing season. Data were gathered between Spring 2018 and Fall 2019. FV identification and liking were measured using an age-appropriate tablet-enabled protocol. FV consumption was measured by weighing each child's fruit and vegetable snack tray before and after tasting sessions. Compared to children receiving no-intervention, children who received the garden intervention showed a greater increase in accurate identification of both fruits and vegetables as well as consumption of both fruit and vegetables during the tasting sessions. Consistent with prior research, the effects on fruit consumption were greater than on vegetable consumption. There was no significant effect of the garden intervention on children's FV liking. Garden interventions implemented early in life foster learning about FV and promote healthy eating. Early exposure to gardening may yield a return on investment throughout the lifecourse, impacting healthy diet and associated health outcomes, which are particularly important within disadvantaged communities where children's health is challenged by a host of risk factors. Clinical Trials Registration #NCT04864574 (clinicaltrials.gov).

A qualitative study exploring teachers' beliefs regarding breastfeeding education in family and consumer sciences classrooms.

BACKGROUND: Research shows that elementary and secondary school children have considered infant feeding choices for when they become parents and are interested in learning about breastfeeding in school. Despite recommendations to include infant feeding education in secondary school classrooms, teachers' practices and attitudes regarding this topic have been the subject of minimal research. The purpose of this study was to explore North Carolina, USA, family and consumer sciences teachers' infant feeding education practices and their views on incorporating breastfeeding education in the curricula of family and consumer sciences classes that cover topics related to parenting and nutrition. METHODS: The study used a purposive sample of 19 teachers who participated in semi-structured qualitative telephone interviews exploring their attitudes and practices relating to infant feeding education. We transcribed and analyzed the interviews using the constant comparative method through the lens of the Theory of Planned Behavior by examining the participants' attitudes, subjective norms, and perceived behavioral controls. RESULTS: Teachers had predominantly positive attitudes towards the inclusion of breastfeeding education in high school parenting, child development, and nutrition courses, citing the need to normalize breastfeeding and support students' ability to make informed choices when they become parents. Teachers' subjective norms included concerns about parents' and administrators' views on the appropriateness of the content and apprehension about negative student responses. Perceived behavioral controls included student maturity, teachers' own experiences and comfort with infant feeding, and the view that curriculum guidelines limit content selection. CONCLUSIONS: The results of this study can be used in the development and implementation of secondary school education programs that increase knowledge about infant feeding and positive attitudes towards breastfeeding for all members of the community. Teachers' concerns need to be addressed in the implementation of these programs.

Twelve-Month Efficacy of an Obesity Prevention Program Targeting Hispanic Families With Preschoolers From Low-Income Backgrounds.

OBJECTIVE: Assess effects of an obesity prevention program promoting eating self-regulation and healthy preferences in Hispanic preschool children. DESIGN: Randomized controlled trial with pretest, posttest, 6- and 12-month assessments. Fourteen waves, each lasting 7 weeks. SETTING: Families recruited from Head Start across 2 sites. PARTICIPANTS: Two hundred fifty-five families randomized into prevention (n = 136) or control (n = 119). INTERVENTION: Prevention received curriculum; control received no curriculum. MAIN OUTCOME MEASURE(S): Feeding knowledge/practices/styles (parent); body mass index percentile, eating self-regulation, trying new foods, and fruit/vegetable consumption (child). ANALYSIS: Multilevel analyses for nested data (time points within families; families within waves) and multinomial regression. RESULTS: Program increased mothers' repeated presentation of new foods (P < 0.05), measured portion sizes (P < 0.05), child involvement in food preparation (P < 0.001), feeding responsiveness (P < 0.001), knowledge of best feeding practices (P < 0.001), and feeding efficacy (P < 0.05); reduced feeding misconceptions (P < 0.01) and uninvolved feeding (P < 0.01). Effects on child eating behavior were minimal. At 12 months, children in the prevention group were less likely to have overweight (P < 0.05) or obesity (P < 0.05). CONCLUSIONS AND IMPLICATIONS: Program effects emphasize the importance of feeding approaches in reducing childhood obesity.

Food-Based Science, Technology, Engineering, Arts, and Mathematics (STEAM) Learning Activities May Reduce Decline in Preschoolers' Skin Carotenoid Status.

OBJECTIVE: To assess the effectiveness of food-based science, technology, engineering, arts, and mathematics (STEAM) learning activities on preschoolers' liking of 9 target vegetables and objectively-assessed fruit and vegetable (FV) intake. METHODS: Seven hands-on, food-based STEAM learning activities were implemented to expose children to 9 target vegetables in 3 Head Start preschools (11 classrooms) across North Carolina. Child-reported vegetable liking scores and skin carotenoid status (SCS) were dependent variables collected at baseline, midpoint, and posttest. Adjusted repeated-measures ANOVA was used to examine intervention impact. RESULTS: A total of 113 children (intervention = 49; comparison = 64) participated. Children were an average age of 3.7 ± 0.57 years at baseline. Mean target vegetable liking scores for the intervention and comparison groups, respectively, were 3.2 ± 0.19 and 3.2 ± 0.17 at baseline, 2.9 ± 0.17 and 3.1 ± 0.15 at midpoint, and 2.8 ± 0.15 and 3.1 ± 0.13 at posttest. A time × group interaction was not significant for target vegetable liking scores. Mean SCS were 268.6 ± 13.24 and 270.9 ± 12.13 at baseline, 271.3 ± 12.50 and 275.6 ± 11.46 at midpoint, and 267.8 ± 11.26 and 229.6 ± 10.32 at posttest for the intervention and comparison groups, respectively. A time × group interaction was significant for SCS (F1,77 = 3.98; P = 0.02; r = 0.10). Both groups declined from baseline to posttest (intervention = 0.06%; comparison = 15.09%), which occurred after winter break, with a smaller decline observed in the intervention group (P = 0.02). CONCLUSIONS AND IMPLICATIONS: Food-based STEAM learning activities may present a unique opportunity to affect FV intake while meeting academic standards. More research is needed to understand how liking for familiar FV changes over time and its relationship with consumption. In addition, more implementation research featuring larger sample sizes, teachers as the interventionist, and a longer study duration is needed to confirm the outcomes of food-based STEAM learning observed in the current study and the long-term impact this approach may have on children's' dietary quality.

Understanding Preschoolers' Anticipation of Trying A New Food and Past Food Experiences.

OBJECTIVE: The primary objectives of the study were to explore (1) preschoolers' anticipation when trying a new food and (2) preschoolers' past experiences with the food they like and do not like. METHODS: Two semistructured interviews were conducted 3-7 days apart with each participant. Through thematic analysis, themes and subthemes related to children's food-related perspectives were identified. RESULTS: A total of 34 preschoolers (4-5 years old) from low-income families in North Carolina participated in the study. Three major themes were found: preschoolers' avoidance techniques, predictors behind preschoolers' food-related emotions, and preschoolers' description of their food preferences. CONCLUSIONS AND IMPLICATIONS: Preschoolers were able to discuss both their positive and negative food-related emotions and perspectives. Thus, strategies allowing children to discuss their perspectives of food could provide new insights into children's food preferences and improve dietary quality.

Eastern North Carolina Head Start Teachers' personal and professional experiences with healthy eating and physical activity: a qualitative exploration.

OBJECTIVE: Explore the interrelationship between teachers' personal and professional socio-ecological structures while examining Head Start (HS) teachers' experiences with (1) trying to eat healthy and engage in physical activity (PA) and (2) promote healthy eating and PA in their classrooms. DESIGN: In-depth semi-structured interviews were collected from March through June 2017. Researchers designed the data collection and analysis methods using a phenomenological approach. All interviews were recorded using digital audio and transcribed verbatim. SETTING: Seven HS centres in two rural eastern North Carolina counties. PARTICIPANTS: Teachers (n 15) who had recently participated in a healthy eating and physical activity intervention. Participants were 100 % female, an average age of 43 years (sd 9·6) and primarily Black/African American (93·3 %). RESULTS: Eighteen primary themes were identified providing unique insight into individual, social and environmental determinants that may influence teachers' personal health behaviours and professional health promotion practices. Findings indicated that teachers want to improve health behaviours personally (individual/family health) and professionally (children/families served); however, barriers exist at all levels impacting their ability to improve their own health and facilitate positive behaviours among the children/families they serve. Many teachers observed connections between their personal and professional experiences, but not beyond the individual level. CONCLUSIONS: Study findings highlight the importance of considering and emphasising the potential relationship between personal and professional determinants of health when working with early childhood teachers. Findings from this study may be useful for informing the development, implementation and evaluation of future health promotion interventions using teachers as implementers.

Short-Term Effects of an Obesity Prevention Program Among Low-Income Hispanic Families With Preschoolers.

OBJECTIVE: To assess the short-term effects of an obesity prevention program promoting eating self-regulation and healthy food preferences in low-income Hispanic children. DESIGN: Randomized controlled trial with pretest, posttest, and 6- and 12-month assessments. SETTING AND PARTICIPANTS: Head Start and similar early learning institutions in Houston, TX, and Pasco, WA. A total of 255 families with preschoolers randomized into prevention (n = 136) and control (n = 119) groups. INTERVENTION: Multicomponent family-based prevention program. Fourteen waves lasted 7 weeks each with 8-10 mother-child dyads in each group. MAIN OUTCOME MEASURES: Parent assessments included feeding practices, styles, and knowledge. Child assessments included child eating self-regulation, willingness to try new foods, and parent report of child fruit and vegetable preferences. Parent and child heights and weights were measured. ANALYSIS: Multilevel analyses were employed to consider the nested nature of the data: time points within families within waves. RESULTS: The program had predicted effects on parental feeding practices, styles, and knowledge in the pre- to post-comparisons. Effects on child eating behavior were minimal; only the number of different vegetables tried showed significant pre-post differences. CONCLUSIONS AND IMPLICATIONS: Short-term effects of this prevention program highlight the importance of family-focused feeding approaches to combating child overweight and obesity.

Exploring North Carolina Family and Consumer Sciences Teachers' Attitudes Towards Breastfeeding and Infant Feeding Education Practices.

BACKGROUND: The World Health Organization (WHO) and the United Kingdom Committee for UNICEF recommend that secondary schools include infant feeding education in the curriculum. However, little attention has been given to the study of educators' views and practices regarding infant feeding education. AIMS: The aims of this research were to (1) explore North Carolina Family and Consumer Sciences teachers' attitudes towards infant feeding education in secondary schools and (2) describe North Carolina Family and Consumer Sciences teachers' infant feeding education practices. METHODS: Researchers conducted interviews (N = 19) and a survey (N = 137) using a sequential mixed methods design. The constant comparative method was used to analyze interview transcripts. Subsequently, a 33-item survey was developed to assess teachers' attitudes and practices, and this survey was tested for validity and reliability. RESULTS: The majority of participants supported including infant feeding (n = 119, 86.9%) and breastfeeding (n = 116, 84.7%) education in high school. Approximately half of the participants supported including infant feeding (n = 71, 51.9%) and breastfeeding (n = 64, 46.7%) education in middle school. Participants reported that they taught infant feeding at both levels; topics taught included complementary foods, patterns of infant feeding, and the safe preparation of infant formula. Breastfeeding content was covered primarily in the high school Parenting and Child Development course. CONCLUSIONS: North Carolina Family and Consumer Sciences teachers have positive attitudes towards teaching about breastfeeding at the secondary school level. Content about infant nutrition and breastfeeding is currently included in courses that cover child development and human nutrition.

Comparison of Parent and Child Ratings of Fruit and Vegetable Liking to Assess Parent Accuracy as Proxy Reporters.

This study examined the accuracy of parent-report child fruit/vegetable (FV) liking. Child/parent dyads (n = 24) were recruited from six Head Start preschools in North Carolina. Liking for 10 FVs was assessed using a validated pictorial tool for children; a similar scale was used for parents. Negative relationships were observed between parent/child for one fruit (grapes) and one vegetable (broccoli). Positive relationships were observed among oranges, grapes, and overall fruit rankings. Parents tended to rank children's liking of fruits higher than their children, while children ranked liking vegetables higher. Findings suggest parents may not be accurate respondents for preschool children's FV liking.

Observed and self-reported assessments of caregivers' feeding styles: Variable- and person-centered approaches for examining relationships with children's eating behaviors.

BACKGROUND: Demandingness and responsiveness are dimensions used in general parenting as well as the feeding literature to measure parent attitudes and behaviors. These dimensions can be treated as continuous variables (variable-centered) or used to form groups of parents based on scores on each dimension (person-centered). Research focusing on these dimensions in the feeding domain has relied exclusively on maternal self-reports; observational studies of feeding styles have yet to be conducted. OBJECTIVES: The purpose of this study was to investigate the effectiveness of variable-centered versus person-centered analyses in examining relationships between maternal feeding styles, child eating behaviors, and child weight status using both self-reported and observational methods for assessing parental feeding style. METHODS: Participants included 137 low-income Head Start mothers and their preschoolers. Mothers completed the Caregiver's Feeding Styles Questionnaire and the Children's Eating Behavior Questionnaire. Parent/child interactions were observed during dinner meals at home and were coded using a previously developed coding system. RESULTS: Maternal demandingness during feeding was negatively associated with child BMI z-scores and positively associated with slowness in eating and satiety responsiveness. Maternal responsiveness was associated positively with enjoyment of food and associated negatively with food fussiness. Significant demandingness by responsiveness interactions showed that children of authoritarian mothers showed the highest levels of food fussiness and the lowest enjoyment of food. Overall, the findings were stronger for the self-report than for the observational measures and the variable-centered approach was clearly superior to the person-centered approach. CONCLUSIONS: The current results indicate that for research purposes the variable-centered approach may be the most powerful for examining relationships between maternal feeding and child eating. However, for clinical purposes, the person-centered approach might be most informative.

Stability in the feeding practices and styles of low-income mothers: questionnaire and observational analyses.

BACKGROUND: During the last two decades, researchers have devoted considerable attention to the role of maternal feeding behaviors, practices, and styles in the development of obesity in young children. Little is known, however, about the consistency of maternal feeding across settings and time. The purpose of this paper was to provide data on this issue by examining the consistency of observed maternal feeding behavior across multiple eating occasions, as well as examine the consistency of observed and self-reported maternal feeding behavior across 18 months. METHODS: Videotapes from two studies of low-income mothers and their preschool children were coded for feeding practices, dimensions, and styles: a study of 137 low-income, African American and Latina mothers and their children observed during three meals in their homes over a two to three week period, and a study of 138 low-income, Latina mothers observed during a buffet meal in a laboratory setting on two separate occasions 18 months apart. Videotapes from both studies were coded for a wide range of maternal feeding behaviors and strategies. Mothers in the second study also completed three validated, self-report questionnaires on their feeding practices and styles. RESULTS: Overall, both observed and self-reported feeding practices and styles showed only moderate levels of stability across meals and over time. Maternal attempts to regulate children's eating showed more stability across meals and over time than the content of general mealtime conversation. Also, greater stability was found in what mothers were trying to get their children to do during the meals than in the strategies they used to influence child behavior. Self-reports of feeding showed greater stability over time than observational measures. Across meals and across 18 months, the stability of general feeding styles was between 40% and 50%. CONCLUSIONS: The findings demonstrate that maternal feeding behavior was only moderately stable across meals and over time-that is, feeding behavior varied considerably across situations. The lack of high levels of consistency in feeding behavior suggests that situational factors may play a major role in influencing maternal behavior as well. Family-focused childhood obesity programs should focus not only on helping parents change their feeding practices and styles, but also focus on increasing parents' sensitivity to situational factors that affect their approach to feeding their children.

Medical students' perceived educational needs to prevent and treat childhood obesity.

BACKGROUND: Medical schools are challenged to incorporate more prevention-based education into curricula, offering an opportunity to revisit approaches to nutrition education. The objective of this study was to explore United States (US) medical students' understanding of childhood obesity, specifically barriers to childhood obesity prevention and treatment and students' perceived educational deficits. METHODS: The research team conducted phone interviews with 78 3rd- and 4th-year medical students, representing 25 different medical schools across the US. Using a semi-structured interview guide, researchers asked students to describe the etiology of childhood obesity and reflect on where they acquired knowledge of the etiology and what additional resources they would need to treat obese children. Using a phenomenological approach to analysis, researchers identified five dominant emergent themes. RESULTS: Student-perceived barriers to childhood obesity prevention and treatment in clinical care included student-centered (e.g., lack of knowledge), patient-centered (e.g., lack of access), and healthcare system-centered barriers (e.g., limited time). Students requested more applicable nutrition information and counseling skills relevant to preventing and treating childhood obesity; however, they tended to identify others (e.g., parents, schools), rather than themselves, when asked to describe how childhood obesity should be prevented or treated. DISCUSSION: To provide students with an understanding of their role in preventing and treating childhood obesity, US medical schools need to provide students with childhood obesity-specific and general nutrition education. To build their self-efficacy in nutrition counseling, schools can use a combination of observation and practice led by skilled physicians and other healthcare providers. Increasing students' self-efficacy through training may help them overcome perceived barriers to childhood obesity prevention and treatment.

Teacher Perceptions of Multilevel Policies and the Influence on Nutrition Education in North Carolina Head Start Preschools.

OBJECTIVE: To develop a theory that explains the process of how teachers' perception of multilevel policies may influence nutrition education (NE) teaching strategies in Head Start preschools. DESIGN: Semistructured telephone interviews. SETTING: North Carolina Head Start preschools. PARTICIPANTS: Thirty-two Head Start teachers. PHENOMENON OF INTEREST: All interviews were transcribed verbatim. Following a grounded theory approach, authors coded interview data for emergent themes. ANALYSIS: Two primary themes emerged during analysis, including teachers' policy perceptions and teacher-perceived influence of policy on NE. RESULTS: A theoretical model was developed to explain how teachers' perceptions of policies influenced NE (eg, teaching strategies) in the classroom. Teachers discussed multiple policy areas governing their classrooms and limiting their ability to provide meaningful and consistent NE. How teachers perceived the level of regulation in the classroom (ie, high or low) influenced the frequency with which they used specific teaching strategies. CONCLUSION AND IMPLICATIONS: Despite federal policies supporting the provision of NE, teachers face competing priorities in the classroom (eg, school readiness vs NE) and policies may conflict with standardized NE curricula. To understand how Head Start centers develop local policies, additional research should investigate how administrators interpret federal and state policies.

Strategies Low-Income Parents Use to Overcome Their Children's Food Refusal.

Introduction Parents play a key role in the development of eating habits in preschool children, as they are the food "gatekeepers." Repeated exposure to new foods can improve child food preferences and consumption. The objective of this study was to determine parent feeding strategies used to influence child acceptance of previously rejected foods (PRF). Methods We conducted eighteen focus groups (total participants = 111) with low-income African American and Hispanic parents of preschool children (3- to 5-year-olds) in Texas, Colorado, and Washington. Through thematic analysis, we coded transcripts and analyzed coded quotes to develop dominant emergent themes related to strategies used to overcome children's food refusal. Results We found three major themes in the data: parents most often do not serve PRF; parents value their child eating over liking a food; and parents rarely use the same feeding strategy more than once for a PRF. Desiring to reduce waste and save time, parents said they most often intentionally decided not to purchase or serve PRF to their children. Discussion Because parents' primary goal in child feeding is getting children to eat (over acceptance of a variety of foods), strategies to help parents promote consumption of less easily accepted foods could help parents with child feeding struggles and improve children's dietary quality.

Nutrition Education Resources in North Carolina-Based Head Start Preschool Programs: Administrator and Teacher Perceptions of Availability and Use.

OBJECTIVE: The purpose of this study was to provide new insight into common barriers to the availability and use of nutrition education (NE) resources in Head Start preschool programs based on administrator and teacher perceptions. METHODS: In-depth, semistructured phone interviews (n = 63) were conducted with administrators (n = 31) and teachers (n = 32) from North Carolina-based Head Start programs. Interviews were audio-recorded and transcribed verbatim. Data were analyzed qualitatively using content analysis to identify common themes. RESULTS: Five emergent themes were identified within the areas of NE resource availability and use and barriers to NE resource availability and use. Participants expressed desire for greater organization of existing NE material resources, increased community support, and professional development opportunities for teachers specific to NE. Funding and time constraints were reported as affecting NE resources. CONCLUSIONS AND IMPLICATIONS: Creative strategies for addressing NE resource availability and use and barriers (eg, NE integration with educational standards) in Head Start are needed.

Depressive Symptoms and Perceptions of Child Difficulty Are Associated with Less Responsive Feeding Behaviors in an Observational Study of Low-Income Mothers.

BACKGROUND: Maternal depressive symptoms and perceptions of child difficulty are associated with negative effects on general development and cognitive functioning in children. The study examined associations between maternal depressive symptoms, perceptions of child difficulty, and maternal feeding behaviors in a population at elevated risk for childhood obesity. METHODS: Participants were 138 low-income black and Hispanic mothers and their children (ages 3-5) participating in an observational study of mealtimes among Head Start families. Three dinnertime observations were conducted over 2 weeks on each family and audio/videotaped for coding. Coding included eating influence attempts and other food- and nonfood-related interactions exhibited by the mother during dinner. Mothers completed questionnaires on depressive symptoms and perceptions of child difficulty. Linear regressions were conducted, examining associations between maternal depressive symptoms, perceptions of child difficulty, and coded parent feeding behaviors. RESULTS: Mothers reporting higher levels of depressive symptoms used more verbal pressure to get their child to eat during meals, were more likely to discourage child independence, and less likely to enforce table manners. Mothers reporting higher perceptions of child difficulty were less likely to have nonfood-related discussions during meals and to try to get the child to eat a different food. CONCLUSIONS: This study is one of the first to investigate associations between maternal depression, perceptions of child difficulty, and mother's feeding behaviors during meals using observational methodology. These results may help researchers identify specific parental characteristics and feeding practices on which to intervene when developing tailored intervention programs for reducing childhood obesity.

Practical Qualitative Research Strategies: Training Interviewers and Coders.

The increased emphasis on incorporating qualitative methodologies into nutrition education development and evaluation underscores the importance of using rigorous protocols to enhance the trustworthiness of the findings. A 5-phase protocol for training qualitative research assistants (data collectors and coders) was developed as an approach to increase the consistency of the data produced. This training provides exposure to the core principles of qualitative research and then asks the research assistant to apply those principles through practice in a setting structured on critical reflection.

Strategies for Effective Eating Development-SEEDS: Design of an Obesity Prevention Program to Promote Healthy Food Preferences and Eating Self-Regulation in Children From Low-Income Families.

OBJECTIVE: To develop a scientifically based childhood obesity prevention program supporting child eating self-regulation and taste preferences. This article describes the research methods for the Strategies for Effective Eating Development program. A logic model is provided that depicts a visual presentation of the activities that will be used to guide the development of the prevention program. DESIGN: Randomized, controlled prevention program, pretest, posttest, 6 months, and 12 months. SETTING: Two sites: Houston, TX and Pasco, WA. Each trial will last 7 weeks with 8-10 mother-child dyads in each arm (prevention and control). PARTICIPANTS: Recruitment at Head Start districts (Texas; n = 160) and Inspire Child Development Center including Early Childhood Education and Head Start (Washington; n = 160). Sixteen trials with 16-20 parent-child dyads per trial will provide adequate power to detect moderate effects. INTERVENTION: Multicomponent family-based prevention program incorporating a dialogue approach to adult learning and self-determination theory. MAIN OUTCOME MEASURES: Child assessments will include observed taste preferences, caloric compensation, and eating in the absence of hunger. Parent assessments will include parent-reported feeding, feeding emotions, acculturation, child eating behaviors, child food preferences, and child dietary intake. Heights and weights will be measured for parent and child. ANALYSIS: A multilevel growth modeling analysis will be employed to consider the nested nature of the data: time points (level 1) within families (level 2) within trials (level 3).