Eat better feel better t t minor elementary school
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Eat Better, Feel Better T.T. Minor Elementary School. A program evaluation by University of Washington Nutritional Sciences 531 students. Intervention at T.T. Minor. Part of national initiative: Healthy Eating by Design (HEBD) HEBD funded by Robert Wood Johnson Foundation

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Eat Better, Feel Better T.T. Minor Elementary School

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Eat better feel better t t minor elementary school

Eat Better, Feel Better T.T. Minor Elementary School

A program evaluation by University of Washington Nutritional Sciences 531 students

Presentation by Laura Fanning and Celia Framson

Intervention at t t minor

Intervention at T.T. Minor

  • Part of national initiative: Healthy Eating by Design (HEBD)

  • HEBD funded by Robert Wood Johnson Foundation

  • Goal to increase fruit and vegetable consumption among students and their families

  • T.T. Minor also recipient of USDA Fresh Fruits and Vegetables Program (provided mid-morning snack)

Why the need

Why the Need?

  • 15% of U.S. children overweight

  • Prevalence has doubled in past 3 decades

  • Overweight children have more health complications; more likely to become obese adults

  • In 2002, estimated costs of treating obesity-related conditions = $92 - $117 billion

Still not convinced

Still Not Convinced?

  • World Health Report shows that adequate fruit and vegetable consumption can decrease obesity risk

  • According to 2001 Youth Risk Behavior Survey only 21% of high school students reported eating at least five servings of fruits and vegetables per day

Why intervene in schools

Why Intervene in Schools?

  • Schools have most continuous contact with young children

  • Many children eat 2 meals a day at school

  • Children eat more than half their daily calories at school

  • Thus school-based interventions have powerful potential to influence dietary behavior

Key project elements

Key Project Elements

  • Goal: Positively impact food environment for students and their families

  • Multi-component approach, comprising:

    • Dietitian

    • Salad bar

    • Nutrition education

    • Family nights

    • Cooking demonstrations

    • School garden

    • Mid-morning snack (USDA Fruit and Vegetable Program)

Evaluation methods

Evaluation Methods

Methods study design

Methods: Study Design

  • Quasi- experimental design with no baseline data available and no randomization or blinding

  • MLK chosen as comparison school

    • Similar demographics

    • No nutrition intervention

  • Study only included 5th graders at T.T. Minor and 4th and 5th grade combined class at MLK

Methods evaluation tools

Methods: Evaluation Tools

  • Lunchroom observations

  • Student surveys

  • Faculty/staff interviews

  • Parent/guardian interviews

Methods lunchroom observations

Methods: Lunchroom Observations

  • Trained study staff observed fruit and vegetable intake of participating students during lunchtime

  • Observations conducted at both schools over a 3 day period

  • Each observer assigned 1-4 children



TT Minor


Methods student survey

Methods: Student Survey

  • Self-administered

  • Assessed intake

  • Assessed self-efficacy for choosing fruits and vegetables

  • Rated on five-category Likert scale from “I disagree very much” to “I agree very much”

  • Example question:

    • “For a snack, I think I can choose my favorite fruit instead of my favorite candy bar.”

Methods key informant interviews

Methods: Key Informant Interviews

  • Goal to evaluate the perceived effectiveness of the program

  • Trained study staff interviewed T.T. Minor personnel

    • n=19

  • Also interviewed parents and guardians of T.T. Minor 5th graders

    • n=11

Methods key informant interviews1

Methods: Key Informant Interviews

  • Teachers and staff asked about:

    • Experiences with the program

    • Eating behavior of the students

    • Own eating behavior

  • Parents and guardians asked about:

    • Foods their families eat

    • Experiences with T.T. Minor intervention programs

Statistical and qualitative analysis

Statistical and Qualitative Analysis

Statistical analysis lunchroom observations

Statistical Analysis: Lunchroom Observations

  • Calculated mean consumption per lunch period per school

  • Compared means at each school using generalized estimating equation

  • Two-sided p-value < 0.05 considered significant

Statistical analysis self efficacy

Statistical Analysis: Self-Efficacy

  • Five Likert categories grouped into two: Disagree or Agree

  • Between school difference analyzed using:

    • chi-square test

    • Fisher’s exact when expected values < 5

  • Two-sided p-value < 0.05 considered significant

Analysis qualitative data

Analysis: Qualitative Data

  • Answers to interview questions compiled in a spreadsheet

  • Yes/No responses summarized numerically

  • For open-ended questions, recurrent issues and emergent themes highlighted and grouped

  • Results compared between analysis team members to verify interpretation of responses



Results participation rates

Results: Participation Rates

  • T.T. Minor

    • 17/21 participated, rate = 81%

    • Student decline primary reason for nonparticipation

  • MLK

    • 15/20 participated, rate = 75%

    • Student decline primary reason for nonparticipation

Results specific self efficacy and intake questions

Results: Specific Self-Efficacy and Intake Questions

  • 57% of T.T. Minor students agreed they could eat a vegetable served for lunch at school vs. 20% from MLK (p = 0.04)

  • 63% of students from T.T. Minor reported eating 3 or more fruits vs. 27% from MLK (p = 0.05)

  • 36% of students from T.T. Minor reported eating 3 or more vegetables vs. 7% from MLK (p = 0.08)

Results self efficacy questions

Results: Self-Efficacy Questions

Results lunchroom observations summary statistics

Results: Lunchroom Observations, Summary Statistics

  • Over the 3 days, T.T. Minor 5th graders consumed:

    • 0.07 cups (95% CI: -0.31 - 0.16) fewer fruits than MLK 4th and 5th graders

    • 0.09 (95% CI: 0.03 - 0.22) cups more vegetables than MLK 4th and 5th graders

    • 0.01 (95% CI: -0.27 – 0.26) cups fewer total fruits and vegetables than MLK 4th and 5th graders

Results lunchroom observations

Results: Lunchroom Observations

Results parent guardian interviews

Results: Parent/Guardian Interviews

  • Participation rate = 55%

  • Incorrect telephone number primary reason for nonparticipation

  • Majority of respondents aware of new salad bar and indicated their child/children used it

  • Majority aware that fresh f/v available for snack and indicated their child/children ate them

Results parent guardian interviews1

Results: Parent/Guardian Interviews

  • Most respondents indicated awareness of nutritionist in school and thought she positively impacted students’ eating patterns

  • “They have been introduced to food at the food fair. It’s neat! Now they watch for the signs for the farmers’ market because they want to go.”

Results parent guardian interviews2

Results: Parent/Guardian Interviews

  • Almost all respondents indicated their children asked them to buy more fruits and vegetables

  • Almost all respondents indicated that their child/children are eating more f/v than they did in the previous year

  • Over half of respondents indicated their family is eating more f/v than they did in the previous year

Results teacher and staff interviews

Results: Teacher and Staff Interviews

  • Participation rate = 59%

  • Scheduling challenges due to limited time frame main reason for nonparticipation

  • Most respondents indicated they would like to see the salad bar and morning snacks continue

Results teacher and staff interviews1

Results: Teacher and Staff Interviews

Teacher and staff recommendations

Teacher and Staff Recommendations

  • Increase variety and accessibility of salad bar items and snacks:

    • “[I would like to see] more variety of food on the salad bar. It got repetitive after a while.”

    • “I would like to see the salad bar lowered in height so all kids can reach it.”

  • Suggestions for the classes and activities:

    • “Include more in-depth health information at family nights. Set up booth or health fair.”

    • “Offer more staff education.”

  • Other suggestions:

    • “More time with staff. Katie is only here one time per week.”





  • Fruit and vegetable consumption during the lunchroom observations for 5th graders at T.T. Minor and 4th and 5th graders at MLK was quantitatively similar

  • Qualitative data does suggest positive changes in dietary behavior among students and their families, and school personnel



  • Data from self-administered surveys reported:

    • 63% of students from T.T. Minor ate 3 or more fruits vs. 27% from MLK (p = 0.05)

    • 36% of students from T.T. Minor ate 3 or more vegetables vs. 7% from MLK (p = 0.08)

  • Perhaps here we are seeing the effects of the multi-component approach to the EFBB program



  • Faculty/ Staff and Parent/Guardian responses overwhelmingly positive:

    • All teachers indicated students increased f/v intake over the year

    • 82% of P/G said their children ate more f/v than in the previous year

    • P/G also indicated their children asked them to buy more f/v than in the past



  • Staff also reported making many positive changes for themselves:

    • 100% indicated they eat more f/v than before EBFB program

    • 89% said the salad bar at T.T. Minor caused them to eat more f/v than last year

    • 79% indicated they tried a new f/v during the program

    • “I work out more because I feel better about what I am eating.”



  • Data suggest that T.T. Minor 5th graders exhibited greater self-efficacy

    • 57% of T.T. Minor 5th graders agreed they could eat a vegetable served for lunch at school vs. 20% of 4th and 5th graders from MLK (p = 0.04)

  • Literature suggests that increased self-efficacy may play a role in improving fruit and vegetable consumption in children



  • Salad bar use declined over the three-day observation period:

    • Wed = 69%, Thurs = 35%, Fri = 7%

  • UW student observers reported decreasing variety of f/v offered over the three days

  • Previous studies found a significant positive association between variety and consumption





  • Difficult to detect small differences with very small sample sizes

    • Previous evaluations of school-based interventions reporting significant results had sample sizes ranging from 319 - 2684



  • Discrepancy between lunch observation data and student, F/S, P/G reports could be due to mid-morning snacks provided by USDA f/v program

  • Accessibility of f/v may have been a barrier to consumption

    • Height of salad bar

    • Whole fruit rather than pre-cut (e.g., oranges)



  • Ideal study design is RCT with baseline data and blinding

  • Our study design assumed control and intervention schools were identical

  • Limited timeframe for:

    • Training lunchroom observers

    • Lunchroom observations

    • Key informant interviews



  • Sources of error:

    • Observers not blinded to intervention status

      • Tend to bias toward finding associations

    • Students aware of being observed – may have altered behavior

      • Could introduce random error attenuating any association

    • Self-selection bias among P/G, F/S, and students that agreed to participate

      • Tend to bias toward finding associations

Recommendations and conclusions

Recommendations and Conclusions



  • Improvements for future evaluations:

    • Larger sample size

    • Capture influence of mid-morning snack

    • Include 24-hr dietary recall

    • Rigorous training of observers

    • Collect base-line data

    • Longer timeframe for data collection



  • Improvements for Eat Better, Feel Better program:

    • Lower height on salad bar (or install ramp)

    • Increase variety of f/v

    • Modify practices to ensure consistent variety throughout the week

    • Increase availability of pre-cut fruit

    • Extend lunch period



  • Although lunchtime observation data suggest that students at T.T. Minor did not consume significantly more f/v than students at MLK, important limitations may mitigate ability to detect differences

  • Qualitative findings suggest that the Eat Better, Feel Better program positively impacts students’ self-efficacy, self-reported f/v intake, and attitudes towards f/v



  • Faculty, staff, and students at T.T. Minor and MLK elementary schools

    • Drew Gagne at T.T. Minor

    • Rae Richardson at MLK

    • Dr. Gloria Mitchell at T.T. Minor

    • Barry Dorsey at MLK

  • Parents and guardians of T.T. Minor 5th graders

  • Center for Public Health Nutrition

    • Donna Johnson, Molly Shaw, Lynne Smith

  • ECOR

    • Laura Streichert

  • Katie Busby, Kirsten Frandsen, Wendy Weyer of Seattle Schools



  • Centers for Disease Control and Prevention. Overweight and Obesity: Health Consequences. Retrieved 5/15/2006.

  • Haskins R, Paxson C, Donahue E. Fighting Obesity in the Public Schools. The Future of Children Policy Brief. Spring 2006.

  • Daniels SR. The Consequences of Childhood Overweight and Obesity. The Future of Children. Vol 16; No.1, Spring 2006.

  • Koplan JP, Liverman CT, Kraak VI. Preventing childhood obesity: Health in the balance: Executive summary. Journal of the American Dietetic Association, 2005. 105(1): p. 131-138.

  • Ogden, CL, et al., Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA, 2002. 288(14): p. 1728-32.

  • Whitaker RC et al., Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med, 1997. 337(13): p. 869-73.

  • Sallis JF, Glanz K. The Role of Built Environments in Physical Activity, Eating, and Obesity in Childhood. The Future of Children. Vol 16; No.1, Spring 2006.

  • Gleason P, Suitor C, U.S. Food and Nutrition Service. Children’s Diets in the Mid-1990s: Dietary Intake and Its Relationship with School Meal Participation. Special Nutrition Programs. 2001. No. CN-01-CD1.

  • The World Health Report 2003: Shaping the Future. Accessed at

  • Grumbaum J, Kann L, Kinchen SA, et al: Youth risk behavior surveillance—United States, 2001. MMWR 51(SS04):1-64. 2002.

  • French SA, Wechsler H. School-based research and initiatives: fruit and vegetable environment, policy, and pricing workshop. Prev Med: 39 S101–S107. 2004.



  • Robert Wood Johnson Foundation. Active Grants: Childhood Obesity. Accessed at

  • Washington State Department of Agriculture News Release. 25 schools set to receive free fresh fruits and vegetables: State is one of four chosen by USDA to offer free, healthy snacks. Oct. 26, 2004. Accessed at

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Thank you

Thank You

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