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Journal of Prevention & Intervention in the Community Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wpic20
A University–School Collaboration to Enhance Healthy Choices Among Children a
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Yolanda Suarez-Balcazar , Joanne Kouba , Lindsay M. Jones & Valentina V. Lukyanova
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Department of Occupational Therapy , University of Illinois at Chicago , Chicago , Illinois , USA b
Department of Nutrition , Loyola University Chicago , Chicago , Illinois , USA c
RehabCare , Chicago , Illinois , USA Published online: 04 Apr 2014.
To cite this article: Yolanda Suarez-Balcazar , Joanne Kouba , Lindsay M. Jones & Valentina V. Lukyanova (2014) A University–School Collaboration to Enhance Healthy Choices Among Children, Journal of Prevention & Intervention in the Community, 42:2, 140-151, DOI: 10.1080/10852352.2014.881193 To link to this article: http://dx.doi.org/10.1080/10852352.2014.881193
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Journal of Prevention & Intervention in the Community, 42:140–151, 2014 Copyright # Taylor & Francis Group, LLC ISSN: 1085-2352 print=1540-7330 online DOI: 10.1080/10852352.2014.881193
A University–School Collaboration to Enhance Healthy Choices Among Children YOLANDA SUAREZ-BALCAZAR Downloaded by [Kungliga Tekniska Hogskola] at 09:41 10 October 2014
Department of Occupational Therapy, University of Illinois at Chicago, Chicago, Illinois, USA
JOANNE KOUBA Department of Nutrition, Loyola University Chicago, Chicago, Illinois, USA
LINDSAY M. JONES RehabCare, Chicago, Illinois, USA
VALENTINA V. LUKYANOVA Department of Occupational Therapy, University of Illinois at Chicago, Chicago, Illinois, USA
One factor contributing to the childhood obesity epidemic is easy access to foods with high fat content available in public schools. After several years of advocacy efforts conducted by a city-wide coalition, the public schools system in an urban Midwestern city introduced fresh salad bars for lunch in three schools. Researchers have argued, however, that the introduction of salad bars in schools, without nutrition education, is not enough to produce changes in eating patterns. In this study, researchers used a target and control school to evaluate the impact of a 5-month nutrition education program. The results indicated that once the nutrition education program was implemented, the number of children consuming salad entrees and salad items doubled and quadrupled respectively, and knowledge about fruits and vegetables increased. Implications for community researchers interested in addressing childhood obesity are discussed. KEYWORDS children, Ecological Model
nutrition
education,
obesity,
Social
Address correspondence to Yolanda Suarez-Balcazar, Ph.D., Department of Occupational Therapy, University of Illinois at Chicago, 1919 West Taylor Street, Suite 307, Chicago, IL 60612, USA. E-mail: [email protected] 140
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A public health crisis facing America’s children and youth is the high rate of obesity, reaching over 17% of our young population (CDC, 2010; Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). One of the issues that impact this rate is the lack of access to fruits and vegetables available to kids. The relationship of dietary patterns and nutrient intake with normal growth and development in children is well recognized by the scientific and lay communities alike. In recent decades, the link between diet and health has been vigorously examined in relation to chronic disease risk in adults. The concern about this relationship was the topic of the U.S. Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity in Americans in 2001. However, by 2007, no state met the 15% adult obesity reduction benchmark set forth by the U.S. Department of Health and Human Services in the Healthy People objectives (CDC, 2010; USDHHS, 2001). Considering the emergence of obesity as a common intermediary for adult health problems and the increased prevalence of overweight children and youth, the quality of children’s eating patterns should be addressed in relation to obesity prevention (CDC, 2011; Wyatt, Winters, & Dubbert, 2006; Stovitz et al., 2010). Researchers have demonstrated that American children are not eating the necessary servings of fruits and vegetables (Adams, Pelletier, Zive, & Sallis, 2005; CDC, 2011; Pieper & Whaley, 2011; Raynor, Jelalian, Vivier, Hart, & Wing, 2009; Morland & Filomena, 2007; Nicklas, Yang, Baranowski, Zakeri, & Berenson, 2003). In addition, evidence suggests that children who are eligible for free or reduced fee lunches in public schools are more likely to be exposed to fried foods and foods with high caloric and high fat content than children who are not (Suarez-Balcazar et al., 2007). To address the lack of access to fruits and vegetables in many communities, experts are recommending the introduction of salad bars in the schools. The state of California was the first one to introduce salad bars in the luncheon menu followed by many other states. Evaluation of a salad bar initiative in urban elementary schools in a Los Angeles school district confirmed a significant increase in fruit and vegetable consumption in elementary school children (Slusser, Cumberland, Browdy, Lange, & Neumann, 2007). Since then, the Let’s Move Salad Bars to Schools Initiative has supplied over 1,000 salad bars and has committed to providing 6,000 salad bars to schools nationwide (Seymour, 2012). However, the presence of the salad bars is no guarantee that kids will consume healthy produce and more research is needed to evaluate the impact of access to healthy foods (Slusser et al., 2007). Studies support nutrition education and access to fruits and vegetables as essential variables to increase the consumption of healthy meals and snacks (Blanchette & Brugg, 2005; USDHHS, 2011; Mason et al., 2006). Few studies, however, have examined the combined impact of nutrition education and salad bar access in schools on children’s eating patterns. Effective health promotion programs have been grounded on the Social Ecological Model (SEM) developed by Lewin in 1951 (see McLeroy, Bibeau,
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Steckler, & Glanz, 1988; Valenzuela et al., 2011). The SEM emphasizes the importance of integrating the person and environment to promote healthy behaviors (Economos et al., 2001; Sigman-Grant, 2002; Stokols, 1992; Suarez-Balcazar et al., 2007). Within the context of this article, the first level of influence is the student. The sphere immediately surrounding the student includes the peers, family members, and teachers who interact with the student and serve as role models. The third level of influence refers to institutions and systems in the community, one of which is the school system which formally or informally affects access and exposure to healthy foods. The fourth level includes the vendors who obtain the food and contract with the schools. The outer-most levels include the agencies or institutions that develop or administer regulations related to food supply and dietary choices and formulate food policies. Examples of these include the U.S. Department of Agriculture’s National School Lunch Program or the Food and Drug Administration, which establishes nutrition guidelines on food labels. The study described in this article was designed to impact children’s behaviors, which is the first level of influence in the SEM and the school system, which is the third level. Based on McLeroy’s framework, a system— school system in this case—is a complex set of interactions between different spheres of influence and stakeholders. The environmental context of school systems includes an intricate set of relationships between parents, teachers, students, principals, superintendents, and the community at-large regulating health actions and practices. Given this, the purpose of this study is to examine the impact of nutrition education on children’s eating habits in a target school compared to a school that did not receive the nutrition education program. Both schools were chosen by the local schools to be part of the new initiative to open salad bars in the public school system.
METHODS Background and Context A community coalition concerned with the high rates of obesity in an urban school system, serving over 430,000 children, 85% of them receiving free or reduced fee lunch, had long advocated for changes in food offerings to children (see coalition efforts, Suarez-Balcazar et al., 2007). The coalition was composed of food experts, food advocates, nutritionists and dieticians, public policy and public health experts, psychologists, and other researchers and practitioners from a variety of related fields, who brought their knowledge together to advocate for the removal of vending machines in the public schools and the introduction of healthy food choices. Typical lunch choices in many of the schools in the system included pizza, nachos and chips, cheese burgers, and hot dogs. A successful outcome of the advocacy efforts was the implementation of a salad bar in three of the public schools (1-year goal of 10 schools), two of
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which were chosen for this study by the coalition. They were selected, in part, due to their readiness to collaborate in the evaluation with the university partners. However, based on existing evidence suggesting that access to healthy foods is not a sufficient condition to change eating habits, a nutrition education program was implemented in the target school and not in a comparison school. The first two authors of this article were provided with an opportunity to evaluate the impact of the nutrition education program on children’s eating choices during the lunch hour and knowledge about fruits and vegetables.
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Setting and Participants The salad bar intervention was initially introduced into three public schools in a large urban metropolitan city. The coalition members selected the two schools whose principals wanted to participate in the evaluation and were willing to allow the evaluation team to come to the school. Based on their willingness to work with the team, and the fact that one school had recently implemented a healthy lifestyles curriculum, one school was selected to be the target school and a second one was selected as the comparison school. The team delivered the same nutrition education initiative to the comparison school once this project was completed, except for a visit from the farmers co-op. Participants in this study were young children from two urban area multicultural schools. The target school had a total of 90 children in the kindergarten and first grade classrooms and the comparison school had 120 children also in kindergarten and first grade. Children in the target school were mostly Hispanic, while children in the comparison school were mostly African American. Both schools were similar in that they offered no access to vending machines, the children were from similar socioeconomic levels and neighborhoods, and both schools had access to a kitchen. There were two reasons for selecting the younger elementary classes: firstly, the target school selected had only those two grade levels. Secondly, and more importantly, researchers have stated that the earlier the intervention to change eating habits, the better the outcomes (CLOCC, 2010; Dietz, 1998; Ernst & Obarzanek, 1994).
Procedure Researchers came into each school once or twice a week for 5 months. This strategy yielded 30 days of data collection from lunch time observations at each school. Specifically, the following procedure was used. First, researchers conducted an inventory based on foods offered during the lunch periods. All available foods were recorded on a foods checklist. Second, during the days of data collection in the schools, researchers recorded the number of both girls and boys choosing the salad bar as an entre´e and those choosing a salad bar item as a side dish. These observations were conducted in a non-intrusive manner. During this procedure researchers made no eye, verbal or physical contact with the students. Third, twice a month for 5 months the team came
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into the kindergarten and first grade classroom to deliver an education session about specific fruits and vegetables. These sessions lasted about 30 to 45 minutes and covered the following: (a) identification of fruits and vegetables (F=V), (b) importance of F=V to health by highlighting one food item each month in an age-appropriate manner, and (c) a container gardening project in the classroom in which the students learned how to plan tomatoes which were placed by a large sunny window in the classroom. At one of the sessions, researchers partnered with an African American rural community farmers co-op to visit with the students and demonstrate farming skills and vegetable crops. Team members used handouts with large and colorful pictures, actual fruits and vegetables, and mostly visual material to introduce the F=V.
Measures and Design The team used a pre and post design to assess the impact of nutrition education in children’s knowledge of F=V in addition to repeated time-series across the target and comparison schools to measure food choices during the lunch hour. The intervention consisted of a salad bar option and a nutrition education component. The intervention was designed to provide continuity between what was available in the cafeteria for lunch (changing the school system environment) and what was talked about in the classroom (nutrition education). In this project the independent variable was nutrition education and the salad bar, and the dependent variable was the salad bar selection and consumption, as well as scores on nutritional assessments to evaluate nutrition knowledge. A 12-item nutrition survey was conducted in the classroom before the educational sessions began and the measure was repeated at the end of the school year 5 months later. The same short survey was also completed by students at the comparison school. Due to the young age of the students, surveys were read individually to each student. An adapted version of the Head Start instrument and the Kansas State University food and nutrition programs, Bright Futures materials were used (see www.oznet.ksu.edu/fnp/ Evaluation/programact.htm) as well as materials available through Head Start. All materials were available in Spanish and English. This tool included very simple language and large colorful pictures. The 12-item survey included a variety of questions examining nutrition knowledge and attitudes. Examples of questions included: ‘‘circle the foods from the fruit group’’ (children are presented with six large colorful pictures of which three are fruits); ‘‘circle the foods from the vegetable group’’; and ‘‘circle the foods that you like the most.’’ Children were presented with no more than 10 questions of this type. Prior to observations, the school sent letters to the parents or guardians of all children in both the target and comparison schools to announce the project and seek participation. Materials sent home included the consent form, a letter explaining the study, and a self-addressed stamped envelope.
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A passive consent was used in this study. Families were asked to sign a form and send it to the school if they did not want their children to participate in the pre and post fruits and vegetables survey. Each participating family was provided with a $10 gift certificate at the beginning of the study and another one at the end of the study. All except two families in the comparison school participated. Consent forms were not sought for the observations in the cafeteria, as these were non-obtrusive observations. The Human Subjects Institutional Review Boards for the University of Illinois at Chicago and Loyola University approved the study. In order to determine the availability of F=V, researchers used the food inventory, which was completed at the beginning of each observation session during the lunch hour. At the target school the fruits available were canned pineapple, canned peaches, pears, oranges, tangerines, and raisins, whereas the other school had pears and tangerines in the salad bar. In addition, the target school offered 1 or 2 whole fruits (bananas, apples and=or pears) to students. These same fruits were available at the comparison school on most days. Aside from the food inventory, researchers identified a random number of children in the lunch line and recorded the types of foods and quantities served by the child. Quantities were pre-determined based on plate size and serving spoon sizes. A variety of vegetables were available on the salad bar at both the target and comparison schools. These included broccoli, baby carrots, carrot sticks, celery, cucumbers, corn, greens, green beans, green peas, green peppers, lettuce, mushrooms, tomatoes, bean sprouts, and pickles. Vegetables were served at both schools in similar quantities, mainly, a half cup of cooked or fresh vegetables. Foods common in the cultural background of the children were also commonly found in their respective schools. For instance, in the target school nachos and chips and guacamole and beans were more common than at the comparison school, while fried chicken and okra were common at the comparison school.
RESULTS A pre–post survey was used to evaluate first graders’ and kindergarteners’ knowledge of fruits and vegetables introduced during the nutrition education sessions. At the target school 75 children took the pre-survey and 82 took the post-survey; while at the comparison school 116 and 108, respectively. These numbers changed as a result of absentees at the time the data were collected. The surveys were confidential and no personal information or student names were tracked, therefore all surveys were included in the analysis.
Salad Bar Impact: Pre and Post Nutrition Education An examination of mean differences comparing before (M ¼ 10.21, SD ¼ 2.40) and after (M ¼ 13.33, SD ¼ 2.83) nutritional education and t-test for pre and
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post survey ratings revealed statistically significant changes in the number of children choosing the salad bar or salad items before and after nutrition education at the target school (t ¼ 9.54, p < .10). Significant differences were also noted for the post data between the target and the comparison schools (t ¼ 9.38, p < .01). This increase was observed for both boys and girls with girls showing a slightly higher increase. Figure 1 illustrates data for the target school while Table 1 illustrates the t values for both target and comparison schools. Boys’ and girls’ salad bar choices at the comparison school stayed at a low level. A slight increase in the number of children choosing the salad entrees was noted while the selection of a salad bar side item decreased. At both schools, it was observed that children were more likely to choose the salad bar on days when fish and pasta were offered and were less likely to choose the salad bar when burgers and pizza were offered. Unfortunately, these later food items were offered often, in particular at the comparison school. These data were gathered by examining the date of the observation and comparison across observation dates. It was also observed that the number of children selecting a fresh fruit also increased in the target school and decreased in the comparison school. In the target school 25% of the children selected a whole fruit before nutrition education while 29% did after nutrition education. In the comparison school 38% of children selected a whole fruit at the beginning of the observation period and 31% did during the last 2 weeks of observation. These percentages were calculated based on the average percent for the days of observation.
Changes in Knowledge Pre and Post Nutrition Education A comparison between pre and post applications of the 12-item nutrition survey showed that children’s knowledge of fruits and vegetables significantly
FIGURE 1 Total salad bar chosen at the target school for boys and girls. (Color figure available online.)
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TABLE 1 Differences in Nutrition Knowledge Between the Target and Comparison School at Pre- and Posttest Pretest
Target school Comparison school
Posttest
Mean
SD
t
Mean
SD
t
10.21 9.65
2.40 2.57
1.53 1.55
13.33 9.63
2.83 2.50
9.54 9.38
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Note. Significant differences between the pre- and posttest for the target school (p < .10). Significant differences between the target and comparison school at posttest (p < .01).
increased in the target school, while children in the comparison school showed no change. At post test most students had difficulty discerning the function of essential nutrients and their functions in the body. For example, most children had difficulty determining what vegetables have vitamin C and defining and describing the function of fiber. Most students were able to identify fruits and veggies and recall general facts like carrots are good for your eyes and apples grow on trees. All the knowledge topics asked on the surveys were introduced during the nutrition education classes. See Table 1 for t-test results of the pre and post survey.
Community Partnerships and Student Satisfaction Based on narrative notes taken throughout the study and multiple visits to the schools, we observed that the target school had developed strong partnerships with the local food growers and organic food producers. In addition, the school collaborated with a well-known university in the area to strengthen their areas of research and nutrition education. The school provided community residents with opportunities to visit and provide input. Parents were often present during the morning light and healthy breakfast provided to the kids giving them an opportunity to interact with the teachers. In addition, parents were volunteering during the lunch hour and during recesses to help supervise kids. Overall, the students seem very pleased with the nutrition education program. They were observed actively engaged, asking questions, and participating in the hands-on activities. The children expressed high levels of satisfaction with the visit from the farmers.
DISCUSSION Overall, findings from this study suggest that nutrition education has an impact on children’s behavior of choosing healthy items from the salad bar during the lunch period. Data indicated that number of children eating salad and=or salad items increased significantly in the target school, while it did not
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significantly change in the comparison school. In the target school, the number of children selecting salad bar as an entre´e doubled while number of children selecting a salad bar side item quadrupled. Overall, knowledge about fruits and vegetables increased significantly at the post assessment in the target school. This study indicated that nutrition education sessions are an important component for increasing the consumption of fresh fruits and vegetables among kindergarten and first grade students, however, continuity might be necessary to allow for a larger impact. When this study was conducted the target school was implementing a healthy lifestyles curriculum which also included several opportunities for physical exercises. Students were gathering in a large room in the luncheon area to play and stretch in-between classes and before lunch. The collaboration with each school’s principal was critical in this study. School administrations have to be committed to providing children with healthy food choices and need to be cognizant of the quality of food brought in by food vendors and contractors. Although the two schools participating in this study did have a kitchen to warm and prepare food, most schools in this district contract food from outside and do not have the capacity to cook and prepare food in their own facilities. Schools need to be willing to work with food vendors and food suppliers to advocate for the implementation of a salad bar, as well as the inclusion of more fruits and vegetables in the school menu. It is important to note that although in the target school the number of children choosing salad bar entre´e or a salad bar item increased, not all children were placing fruits and veggies on their plates. Future studies may examine the role of teachers and other adults as role models. Teachers can become great role models for the students in terms of eating healthy foods and can play a role reinforcing healthy food choices and consumption. An important observation was that the salad bar wagon was placed at the end of the lunch line cafeteria of the comparison school. With this arrangement, the first things that kids see are hot lunch items, which often include fried foods. If the kids are very hungry, then they may be likely to choose the first things they see. The presentation of foods in the physical environment and the variables of the social environment have been shown in the evidence to influence food choice and amount of food consumption (Staiano, Baker, & Calvert, 2011). Children are more likely to have a full plate before recognizing that salad is available and are less likely to select an item from the salad bar. As observed in many research studies, large amounts of food were wasted by the students (Adams et al., 2005). This happened, in part, because of a timing factor. We observed a higher likelihood of food waste from children who are at the end of the food service line. Children at the end of the line had limited time to eat (about 5 minutes) and therefore were more likely to leave food on their plates at the end of the lunch period. Future studies might examine food waste in public schools.
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Limitations The study has several limitations, including the fact that although the two schools were similar they were different in some dimensions including ethnic background, size, and curriculum focus. We also need to be mindful of cultural and contextual variables that exist and must be considered when attempting to generalize findings from this study. A related limitation is that the schools and students participating in this study were not randomly selected. It would have been unethical to offer a salad bar to one group of students and not others at the same time in the same school. In order to have a comparison group, two different schools with different extraneous variables were included in the study. Because of the innate contextual differences between schools, it is not certain how comparable the target and comparison groups truly are.
Implications for Policy In general, based on the results and observations gathered in this study we yielded the following recommendations for community practice regarding food access in the schools. Specifically, schools and their partners should: (a) develop partnerships with organizations advocating for healthy food choices; (b) collaborate with institutions of higher education to help establish evidence of the impact of healthy foods and healthy lifestyles curriculum in the lives of children; (c) make a commitment to contract with food venders who can provide fresh and healthy products into the schools; (d) obtain feedback from students and parents about preferred food choices and recommendations; (e) incorporate parents=family cooking demonstrations and nutrition education; and (f) adopt nutrition education throughout the school’s curriculum. Additional research on obesity prevention outcomes and the long-term effectiveness of these implications will add to the existing evidence of the critical role of nutrition education and access to healthy food products. Most importantly, providing American children with healthy lifestyles has become a social justice issue that needs a commitment from a variety of disciplines and society at large. Given the national concern about the increase in childhood obesity, there is a need to place pressure on schools to provide kids with healthy choices. National movements to address the obesity epidemic have ranged from the First Lady Michelle Obama’s ‘‘Let’s Move!’’ campaign and promotion of growing local F=V, to hundreds of programs implemented at the schools and community levels nation-wide. Given that low-income American children are likely to eat two or three meals in our public schools, policy and social systems change efforts need to develop accountability measures and enforcement of the U.S. food guidelines implementation in the schools. Fines should be charged to schools not meeting food and nutrition guidelines.
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We need to advocate for schools and communities to provide children and families with affordable and easy access to healthy foods in school cafeterias and provide nutrition education programs in a culturally appropriate and respectful manner. Placement of a salad bar in the cafeteria does not guarantee consumption. Furthermore, teachers, parents, and students need to be educated about the importance of F=V in the diet. To address the social epidemic of obesity we need to begin examining more systematically what our children are offered and how we can best promote healthy choices in the school cafeteria.
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Ogden, C. L., Carroll, M. D., Curtin, L. R., Lamb, M. M., & Flegal, K. M. (2010). Prevalence of high body mass index in US children and adolescents, 2007–2008. Journal of the American Medical Association, 303(3), 242–249. Pieper, J. R., & Whaley, S. E. (2011). Healthy eating behaviors and the cognitive environment are positively associated in low-income households with young children. Appetite, 57, 59–64. Raynor, H. A., Jelalian, E., Vivier, P. M., Hart, C. N., & Wing, R. R. (2009). Parentreported eating and leisure-time activity selection patterns related to energy balance in preschool- and school-aged children. Journal of Nutrition Education and Behavior, 41(1), 19–26. Seymour, J. (2012). Let’s Move Salad Bars to Schools and the second anniversary of Let’s Move. Retrieved from http://www.letsmove.gov/blog/2012/02/15/let%E2% 80%99s-move-salad-bars-schools-and-second-anniversary-let%E2%80%99s-move Sigman-Grant, M. (2002). Strategies for counseling adolescents. Journal of the American Dietetic Association, 102(3), 32–39. Slusser, W. M., Cumberland, W. G., Browdy, B. L., Lange, L., & Neumann, C. (2007). A school salad bar increases frequency of fruit and vegetable consumption among children living in low-income households. Public Health Nutrition, 10, 1490–1496. Staiano, A. E., Baker, C. M., & Calvert, S. L. (2011). Dietary digital diaries: Documenting adolescents’ obesogenic environment. Environment & Behavior. Retrieved from http://eab.sagepub.com/content/early/2011/03/29/0013916511403623 Stokols, D. (1992). Establishing and maintaining healthy environments. American Psychologist, 47(1), 6–22. Stovitz, S. D., Hannan, P. J., Lytle, L. A., Demerath, E. W., Pereira, M. A., & Himes, J. H. (2010). Child height and the risk of young-adult obesity. American Journal of Preventative Medicine, 38, 74–77. Suarez-Balcazar, Y., Hellwig, M., Kouba, J., Redmond, L., Martinez, L., Block, D., Kohlman, C., & Peterman, W. (2006). The making of an interdisciplinary partnership: The case of the Chicago Food System Collaborative. American Journal of Community Psychology, 38, 113–123. Suarez-Balcazar, Y., Redmond, L., Kouba, J., Hellwig, M., Davis, R., Martinez, L., Jones, L. (2007). Introducing systems change in the schools: The case of school luncheons and vending machines. American Journal of Community Psychology, 39, 335–345. U.S. Department of Health and Human Services. (2011). Healthy People 2020: Nutrition and status. Retrieved from http://www.healthypeople.gov/2020/ topicsobjectives2020/ overview.aspx?topicid=29 U.S. Department of Health and Human Services. (2001). The Surgeon General’s call to action to prevent and decrease overweight and obesity. Rockville, MD: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General. Valenzuela, J. M., Jacquez, F., Pendery, R., Niemes, L., Huddleston, D., & Mitchell, M. J. (2011). The impact of a community-based activity and nutrition program for children. Journal of Prevention & Intervention in the Community, 39(3), 182–193. Wyatt, S. B., Winters, K. P., & Dubbert, P. M. (2006). Overweight and obesity: Prevalence, consequences, and causes of a growing public health problem. The American Journal of the Medical Sciences, 331(4), 166–174.
Journal of Prevention & Intervention in the Community Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wpic20
A University–School Collaboration to Enhance Healthy Choices Among Children a
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Yolanda Suarez-Balcazar , Joanne Kouba , Lindsay M. Jones & Valentina V. Lukyanova
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Department of Occupational Therapy , University of Illinois at Chicago , Chicago , Illinois , USA b
Department of Nutrition , Loyola University Chicago , Chicago , Illinois , USA c
RehabCare , Chicago , Illinois , USA Published online: 04 Apr 2014.
To cite this article: Yolanda Suarez-Balcazar , Joanne Kouba , Lindsay M. Jones & Valentina V. Lukyanova (2014) A University–School Collaboration to Enhance Healthy Choices Among Children, Journal of Prevention & Intervention in the Community, 42:2, 140-151, DOI: 10.1080/10852352.2014.881193 To link to this article: http://dx.doi.org/10.1080/10852352.2014.881193
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Journal of Prevention & Intervention in the Community, 42:140–151, 2014 Copyright # Taylor & Francis Group, LLC ISSN: 1085-2352 print=1540-7330 online DOI: 10.1080/10852352.2014.881193
A University–School Collaboration to Enhance Healthy Choices Among Children YOLANDA SUAREZ-BALCAZAR Downloaded by [Kungliga Tekniska Hogskola] at 09:41 10 October 2014
Department of Occupational Therapy, University of Illinois at Chicago, Chicago, Illinois, USA
JOANNE KOUBA Department of Nutrition, Loyola University Chicago, Chicago, Illinois, USA
LINDSAY M. JONES RehabCare, Chicago, Illinois, USA
VALENTINA V. LUKYANOVA Department of Occupational Therapy, University of Illinois at Chicago, Chicago, Illinois, USA
One factor contributing to the childhood obesity epidemic is easy access to foods with high fat content available in public schools. After several years of advocacy efforts conducted by a city-wide coalition, the public schools system in an urban Midwestern city introduced fresh salad bars for lunch in three schools. Researchers have argued, however, that the introduction of salad bars in schools, without nutrition education, is not enough to produce changes in eating patterns. In this study, researchers used a target and control school to evaluate the impact of a 5-month nutrition education program. The results indicated that once the nutrition education program was implemented, the number of children consuming salad entrees and salad items doubled and quadrupled respectively, and knowledge about fruits and vegetables increased. Implications for community researchers interested in addressing childhood obesity are discussed. KEYWORDS children, Ecological Model
nutrition
education,
obesity,
Social
Address correspondence to Yolanda Suarez-Balcazar, Ph.D., Department of Occupational Therapy, University of Illinois at Chicago, 1919 West Taylor Street, Suite 307, Chicago, IL 60612, USA. E-mail: [email protected] 140
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A public health crisis facing America’s children and youth is the high rate of obesity, reaching over 17% of our young population (CDC, 2010; Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). One of the issues that impact this rate is the lack of access to fruits and vegetables available to kids. The relationship of dietary patterns and nutrient intake with normal growth and development in children is well recognized by the scientific and lay communities alike. In recent decades, the link between diet and health has been vigorously examined in relation to chronic disease risk in adults. The concern about this relationship was the topic of the U.S. Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity in Americans in 2001. However, by 2007, no state met the 15% adult obesity reduction benchmark set forth by the U.S. Department of Health and Human Services in the Healthy People objectives (CDC, 2010; USDHHS, 2001). Considering the emergence of obesity as a common intermediary for adult health problems and the increased prevalence of overweight children and youth, the quality of children’s eating patterns should be addressed in relation to obesity prevention (CDC, 2011; Wyatt, Winters, & Dubbert, 2006; Stovitz et al., 2010). Researchers have demonstrated that American children are not eating the necessary servings of fruits and vegetables (Adams, Pelletier, Zive, & Sallis, 2005; CDC, 2011; Pieper & Whaley, 2011; Raynor, Jelalian, Vivier, Hart, & Wing, 2009; Morland & Filomena, 2007; Nicklas, Yang, Baranowski, Zakeri, & Berenson, 2003). In addition, evidence suggests that children who are eligible for free or reduced fee lunches in public schools are more likely to be exposed to fried foods and foods with high caloric and high fat content than children who are not (Suarez-Balcazar et al., 2007). To address the lack of access to fruits and vegetables in many communities, experts are recommending the introduction of salad bars in the schools. The state of California was the first one to introduce salad bars in the luncheon menu followed by many other states. Evaluation of a salad bar initiative in urban elementary schools in a Los Angeles school district confirmed a significant increase in fruit and vegetable consumption in elementary school children (Slusser, Cumberland, Browdy, Lange, & Neumann, 2007). Since then, the Let’s Move Salad Bars to Schools Initiative has supplied over 1,000 salad bars and has committed to providing 6,000 salad bars to schools nationwide (Seymour, 2012). However, the presence of the salad bars is no guarantee that kids will consume healthy produce and more research is needed to evaluate the impact of access to healthy foods (Slusser et al., 2007). Studies support nutrition education and access to fruits and vegetables as essential variables to increase the consumption of healthy meals and snacks (Blanchette & Brugg, 2005; USDHHS, 2011; Mason et al., 2006). Few studies, however, have examined the combined impact of nutrition education and salad bar access in schools on children’s eating patterns. Effective health promotion programs have been grounded on the Social Ecological Model (SEM) developed by Lewin in 1951 (see McLeroy, Bibeau,
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Steckler, & Glanz, 1988; Valenzuela et al., 2011). The SEM emphasizes the importance of integrating the person and environment to promote healthy behaviors (Economos et al., 2001; Sigman-Grant, 2002; Stokols, 1992; Suarez-Balcazar et al., 2007). Within the context of this article, the first level of influence is the student. The sphere immediately surrounding the student includes the peers, family members, and teachers who interact with the student and serve as role models. The third level of influence refers to institutions and systems in the community, one of which is the school system which formally or informally affects access and exposure to healthy foods. The fourth level includes the vendors who obtain the food and contract with the schools. The outer-most levels include the agencies or institutions that develop or administer regulations related to food supply and dietary choices and formulate food policies. Examples of these include the U.S. Department of Agriculture’s National School Lunch Program or the Food and Drug Administration, which establishes nutrition guidelines on food labels. The study described in this article was designed to impact children’s behaviors, which is the first level of influence in the SEM and the school system, which is the third level. Based on McLeroy’s framework, a system— school system in this case—is a complex set of interactions between different spheres of influence and stakeholders. The environmental context of school systems includes an intricate set of relationships between parents, teachers, students, principals, superintendents, and the community at-large regulating health actions and practices. Given this, the purpose of this study is to examine the impact of nutrition education on children’s eating habits in a target school compared to a school that did not receive the nutrition education program. Both schools were chosen by the local schools to be part of the new initiative to open salad bars in the public school system.
METHODS Background and Context A community coalition concerned with the high rates of obesity in an urban school system, serving over 430,000 children, 85% of them receiving free or reduced fee lunch, had long advocated for changes in food offerings to children (see coalition efforts, Suarez-Balcazar et al., 2007). The coalition was composed of food experts, food advocates, nutritionists and dieticians, public policy and public health experts, psychologists, and other researchers and practitioners from a variety of related fields, who brought their knowledge together to advocate for the removal of vending machines in the public schools and the introduction of healthy food choices. Typical lunch choices in many of the schools in the system included pizza, nachos and chips, cheese burgers, and hot dogs. A successful outcome of the advocacy efforts was the implementation of a salad bar in three of the public schools (1-year goal of 10 schools), two of
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which were chosen for this study by the coalition. They were selected, in part, due to their readiness to collaborate in the evaluation with the university partners. However, based on existing evidence suggesting that access to healthy foods is not a sufficient condition to change eating habits, a nutrition education program was implemented in the target school and not in a comparison school. The first two authors of this article were provided with an opportunity to evaluate the impact of the nutrition education program on children’s eating choices during the lunch hour and knowledge about fruits and vegetables.
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Setting and Participants The salad bar intervention was initially introduced into three public schools in a large urban metropolitan city. The coalition members selected the two schools whose principals wanted to participate in the evaluation and were willing to allow the evaluation team to come to the school. Based on their willingness to work with the team, and the fact that one school had recently implemented a healthy lifestyles curriculum, one school was selected to be the target school and a second one was selected as the comparison school. The team delivered the same nutrition education initiative to the comparison school once this project was completed, except for a visit from the farmers co-op. Participants in this study were young children from two urban area multicultural schools. The target school had a total of 90 children in the kindergarten and first grade classrooms and the comparison school had 120 children also in kindergarten and first grade. Children in the target school were mostly Hispanic, while children in the comparison school were mostly African American. Both schools were similar in that they offered no access to vending machines, the children were from similar socioeconomic levels and neighborhoods, and both schools had access to a kitchen. There were two reasons for selecting the younger elementary classes: firstly, the target school selected had only those two grade levels. Secondly, and more importantly, researchers have stated that the earlier the intervention to change eating habits, the better the outcomes (CLOCC, 2010; Dietz, 1998; Ernst & Obarzanek, 1994).
Procedure Researchers came into each school once or twice a week for 5 months. This strategy yielded 30 days of data collection from lunch time observations at each school. Specifically, the following procedure was used. First, researchers conducted an inventory based on foods offered during the lunch periods. All available foods were recorded on a foods checklist. Second, during the days of data collection in the schools, researchers recorded the number of both girls and boys choosing the salad bar as an entre´e and those choosing a salad bar item as a side dish. These observations were conducted in a non-intrusive manner. During this procedure researchers made no eye, verbal or physical contact with the students. Third, twice a month for 5 months the team came
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into the kindergarten and first grade classroom to deliver an education session about specific fruits and vegetables. These sessions lasted about 30 to 45 minutes and covered the following: (a) identification of fruits and vegetables (F=V), (b) importance of F=V to health by highlighting one food item each month in an age-appropriate manner, and (c) a container gardening project in the classroom in which the students learned how to plan tomatoes which were placed by a large sunny window in the classroom. At one of the sessions, researchers partnered with an African American rural community farmers co-op to visit with the students and demonstrate farming skills and vegetable crops. Team members used handouts with large and colorful pictures, actual fruits and vegetables, and mostly visual material to introduce the F=V.
Measures and Design The team used a pre and post design to assess the impact of nutrition education in children’s knowledge of F=V in addition to repeated time-series across the target and comparison schools to measure food choices during the lunch hour. The intervention consisted of a salad bar option and a nutrition education component. The intervention was designed to provide continuity between what was available in the cafeteria for lunch (changing the school system environment) and what was talked about in the classroom (nutrition education). In this project the independent variable was nutrition education and the salad bar, and the dependent variable was the salad bar selection and consumption, as well as scores on nutritional assessments to evaluate nutrition knowledge. A 12-item nutrition survey was conducted in the classroom before the educational sessions began and the measure was repeated at the end of the school year 5 months later. The same short survey was also completed by students at the comparison school. Due to the young age of the students, surveys were read individually to each student. An adapted version of the Head Start instrument and the Kansas State University food and nutrition programs, Bright Futures materials were used (see www.oznet.ksu.edu/fnp/ Evaluation/programact.htm) as well as materials available through Head Start. All materials were available in Spanish and English. This tool included very simple language and large colorful pictures. The 12-item survey included a variety of questions examining nutrition knowledge and attitudes. Examples of questions included: ‘‘circle the foods from the fruit group’’ (children are presented with six large colorful pictures of which three are fruits); ‘‘circle the foods from the vegetable group’’; and ‘‘circle the foods that you like the most.’’ Children were presented with no more than 10 questions of this type. Prior to observations, the school sent letters to the parents or guardians of all children in both the target and comparison schools to announce the project and seek participation. Materials sent home included the consent form, a letter explaining the study, and a self-addressed stamped envelope.
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A passive consent was used in this study. Families were asked to sign a form and send it to the school if they did not want their children to participate in the pre and post fruits and vegetables survey. Each participating family was provided with a $10 gift certificate at the beginning of the study and another one at the end of the study. All except two families in the comparison school participated. Consent forms were not sought for the observations in the cafeteria, as these were non-obtrusive observations. The Human Subjects Institutional Review Boards for the University of Illinois at Chicago and Loyola University approved the study. In order to determine the availability of F=V, researchers used the food inventory, which was completed at the beginning of each observation session during the lunch hour. At the target school the fruits available were canned pineapple, canned peaches, pears, oranges, tangerines, and raisins, whereas the other school had pears and tangerines in the salad bar. In addition, the target school offered 1 or 2 whole fruits (bananas, apples and=or pears) to students. These same fruits were available at the comparison school on most days. Aside from the food inventory, researchers identified a random number of children in the lunch line and recorded the types of foods and quantities served by the child. Quantities were pre-determined based on plate size and serving spoon sizes. A variety of vegetables were available on the salad bar at both the target and comparison schools. These included broccoli, baby carrots, carrot sticks, celery, cucumbers, corn, greens, green beans, green peas, green peppers, lettuce, mushrooms, tomatoes, bean sprouts, and pickles. Vegetables were served at both schools in similar quantities, mainly, a half cup of cooked or fresh vegetables. Foods common in the cultural background of the children were also commonly found in their respective schools. For instance, in the target school nachos and chips and guacamole and beans were more common than at the comparison school, while fried chicken and okra were common at the comparison school.
RESULTS A pre–post survey was used to evaluate first graders’ and kindergarteners’ knowledge of fruits and vegetables introduced during the nutrition education sessions. At the target school 75 children took the pre-survey and 82 took the post-survey; while at the comparison school 116 and 108, respectively. These numbers changed as a result of absentees at the time the data were collected. The surveys were confidential and no personal information or student names were tracked, therefore all surveys were included in the analysis.
Salad Bar Impact: Pre and Post Nutrition Education An examination of mean differences comparing before (M ¼ 10.21, SD ¼ 2.40) and after (M ¼ 13.33, SD ¼ 2.83) nutritional education and t-test for pre and
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post survey ratings revealed statistically significant changes in the number of children choosing the salad bar or salad items before and after nutrition education at the target school (t ¼ 9.54, p < .10). Significant differences were also noted for the post data between the target and the comparison schools (t ¼ 9.38, p < .01). This increase was observed for both boys and girls with girls showing a slightly higher increase. Figure 1 illustrates data for the target school while Table 1 illustrates the t values for both target and comparison schools. Boys’ and girls’ salad bar choices at the comparison school stayed at a low level. A slight increase in the number of children choosing the salad entrees was noted while the selection of a salad bar side item decreased. At both schools, it was observed that children were more likely to choose the salad bar on days when fish and pasta were offered and were less likely to choose the salad bar when burgers and pizza were offered. Unfortunately, these later food items were offered often, in particular at the comparison school. These data were gathered by examining the date of the observation and comparison across observation dates. It was also observed that the number of children selecting a fresh fruit also increased in the target school and decreased in the comparison school. In the target school 25% of the children selected a whole fruit before nutrition education while 29% did after nutrition education. In the comparison school 38% of children selected a whole fruit at the beginning of the observation period and 31% did during the last 2 weeks of observation. These percentages were calculated based on the average percent for the days of observation.
Changes in Knowledge Pre and Post Nutrition Education A comparison between pre and post applications of the 12-item nutrition survey showed that children’s knowledge of fruits and vegetables significantly
FIGURE 1 Total salad bar chosen at the target school for boys and girls. (Color figure available online.)
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TABLE 1 Differences in Nutrition Knowledge Between the Target and Comparison School at Pre- and Posttest Pretest
Target school Comparison school
Posttest
Mean
SD
t
Mean
SD
t
10.21 9.65
2.40 2.57
1.53 1.55
13.33 9.63
2.83 2.50
9.54 9.38
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Note. Significant differences between the pre- and posttest for the target school (p < .10). Significant differences between the target and comparison school at posttest (p < .01).
increased in the target school, while children in the comparison school showed no change. At post test most students had difficulty discerning the function of essential nutrients and their functions in the body. For example, most children had difficulty determining what vegetables have vitamin C and defining and describing the function of fiber. Most students were able to identify fruits and veggies and recall general facts like carrots are good for your eyes and apples grow on trees. All the knowledge topics asked on the surveys were introduced during the nutrition education classes. See Table 1 for t-test results of the pre and post survey.
Community Partnerships and Student Satisfaction Based on narrative notes taken throughout the study and multiple visits to the schools, we observed that the target school had developed strong partnerships with the local food growers and organic food producers. In addition, the school collaborated with a well-known university in the area to strengthen their areas of research and nutrition education. The school provided community residents with opportunities to visit and provide input. Parents were often present during the morning light and healthy breakfast provided to the kids giving them an opportunity to interact with the teachers. In addition, parents were volunteering during the lunch hour and during recesses to help supervise kids. Overall, the students seem very pleased with the nutrition education program. They were observed actively engaged, asking questions, and participating in the hands-on activities. The children expressed high levels of satisfaction with the visit from the farmers.
DISCUSSION Overall, findings from this study suggest that nutrition education has an impact on children’s behavior of choosing healthy items from the salad bar during the lunch period. Data indicated that number of children eating salad and=or salad items increased significantly in the target school, while it did not
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significantly change in the comparison school. In the target school, the number of children selecting salad bar as an entre´e doubled while number of children selecting a salad bar side item quadrupled. Overall, knowledge about fruits and vegetables increased significantly at the post assessment in the target school. This study indicated that nutrition education sessions are an important component for increasing the consumption of fresh fruits and vegetables among kindergarten and first grade students, however, continuity might be necessary to allow for a larger impact. When this study was conducted the target school was implementing a healthy lifestyles curriculum which also included several opportunities for physical exercises. Students were gathering in a large room in the luncheon area to play and stretch in-between classes and before lunch. The collaboration with each school’s principal was critical in this study. School administrations have to be committed to providing children with healthy food choices and need to be cognizant of the quality of food brought in by food vendors and contractors. Although the two schools participating in this study did have a kitchen to warm and prepare food, most schools in this district contract food from outside and do not have the capacity to cook and prepare food in their own facilities. Schools need to be willing to work with food vendors and food suppliers to advocate for the implementation of a salad bar, as well as the inclusion of more fruits and vegetables in the school menu. It is important to note that although in the target school the number of children choosing salad bar entre´e or a salad bar item increased, not all children were placing fruits and veggies on their plates. Future studies may examine the role of teachers and other adults as role models. Teachers can become great role models for the students in terms of eating healthy foods and can play a role reinforcing healthy food choices and consumption. An important observation was that the salad bar wagon was placed at the end of the lunch line cafeteria of the comparison school. With this arrangement, the first things that kids see are hot lunch items, which often include fried foods. If the kids are very hungry, then they may be likely to choose the first things they see. The presentation of foods in the physical environment and the variables of the social environment have been shown in the evidence to influence food choice and amount of food consumption (Staiano, Baker, & Calvert, 2011). Children are more likely to have a full plate before recognizing that salad is available and are less likely to select an item from the salad bar. As observed in many research studies, large amounts of food were wasted by the students (Adams et al., 2005). This happened, in part, because of a timing factor. We observed a higher likelihood of food waste from children who are at the end of the food service line. Children at the end of the line had limited time to eat (about 5 minutes) and therefore were more likely to leave food on their plates at the end of the lunch period. Future studies might examine food waste in public schools.
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Limitations The study has several limitations, including the fact that although the two schools were similar they were different in some dimensions including ethnic background, size, and curriculum focus. We also need to be mindful of cultural and contextual variables that exist and must be considered when attempting to generalize findings from this study. A related limitation is that the schools and students participating in this study were not randomly selected. It would have been unethical to offer a salad bar to one group of students and not others at the same time in the same school. In order to have a comparison group, two different schools with different extraneous variables were included in the study. Because of the innate contextual differences between schools, it is not certain how comparable the target and comparison groups truly are.
Implications for Policy In general, based on the results and observations gathered in this study we yielded the following recommendations for community practice regarding food access in the schools. Specifically, schools and their partners should: (a) develop partnerships with organizations advocating for healthy food choices; (b) collaborate with institutions of higher education to help establish evidence of the impact of healthy foods and healthy lifestyles curriculum in the lives of children; (c) make a commitment to contract with food venders who can provide fresh and healthy products into the schools; (d) obtain feedback from students and parents about preferred food choices and recommendations; (e) incorporate parents=family cooking demonstrations and nutrition education; and (f) adopt nutrition education throughout the school’s curriculum. Additional research on obesity prevention outcomes and the long-term effectiveness of these implications will add to the existing evidence of the critical role of nutrition education and access to healthy food products. Most importantly, providing American children with healthy lifestyles has become a social justice issue that needs a commitment from a variety of disciplines and society at large. Given the national concern about the increase in childhood obesity, there is a need to place pressure on schools to provide kids with healthy choices. National movements to address the obesity epidemic have ranged from the First Lady Michelle Obama’s ‘‘Let’s Move!’’ campaign and promotion of growing local F=V, to hundreds of programs implemented at the schools and community levels nation-wide. Given that low-income American children are likely to eat two or three meals in our public schools, policy and social systems change efforts need to develop accountability measures and enforcement of the U.S. food guidelines implementation in the schools. Fines should be charged to schools not meeting food and nutrition guidelines.
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We need to advocate for schools and communities to provide children and families with affordable and easy access to healthy foods in school cafeterias and provide nutrition education programs in a culturally appropriate and respectful manner. Placement of a salad bar in the cafeteria does not guarantee consumption. Furthermore, teachers, parents, and students need to be educated about the importance of F=V in the diet. To address the social epidemic of obesity we need to begin examining more systematically what our children are offered and how we can best promote healthy choices in the school cafeteria.
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