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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

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)

http://seattletimes.nwsource.com/html/pacificnw10092005/coverstory.html



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


Lunchrooms
Lunchrooms

TT Minor

MLK


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 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

http://seattletimes.nwsource.com/html/pacificnw10092005/coverstory.html


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 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 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.”

http://depts.washington.edu/uwecor/projects/eatbetter_feelbetter.htm


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



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.”



Discussion1
Discussion

  • 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


Discussion2
Discussion

  • 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


Discussion3
Discussion

  • 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


Discussion4
Discussion

  • 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.”


Discussion5
Discussion

  • 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


Discussion6
Discussion

  • 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



Limitations1
Limitations

  • 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


Limitations2
Limitations

  • 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)


Limitations3
Limitations

  • 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


Limitations4
Limitations

  • 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
Recommendations

  • 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


Recommendations1
Recommendations

  • 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


Conclusions
Conclusions

  • 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


Acknowledgments
Acknowledgments

  • 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


References
References

  • Centers for Disease Control and Prevention. Overweight and Obesity: Health Consequences. Retrieved 5/15/2006. http://www.cdc.gov/nccdphp/dnpa/obesity/consequences.htm

  • 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 http://www.who.int/whr/2003/en/whr03_en.pdf.

  • 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.


References1
References

  • Robert Wood Johnson Foundation. Active Grants: Childhood Obesity. Accessed at www.rwjf.org/portfolios/resources/grant.jsp?id=53324&iaid=138&gsa=1

  • 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 http://agr.wa.gov/News/2004/25%20schools%20set%20to%20receive%20free%20fruits%20&%20vegetables.htm.

  • Glasgow RE, Lichtenstein E, Marcus AC. Why don’t we see more translation of health promotion research to practice (Rethinking the efficacy-to-effectiveness transition). Am J Public Health. 2003;93:1261–1267.

  • Stables GJ, Young EM, Howerton MW, Yaroch AL, Kuester S, Solera MK, Cobb K, Nebeling L. Small school-based effectiveness trials increase vegetable and fruit consumption among youth. J Am Diet Assoc. 2005 Feb;105(2):252-6.

  • Economic Research Service (ERS). Evaluation of the USDA Fruit and Vegetable Pilot Program: Report to Congress. USDA, May 2003. Retrieved from http://www.uffva.org/pdf/FVPP.pdf

  • Eriksen K, Haraldsdottir J, Pederson R, Flyger H. Effect of a 688 fruit and vegetable subscription in Danish schools. Public Health Nutr 2003;6:57-63.

  • Resnicow K, Davis-Hearn M, Smith M, Baranowski T, Lin LS, Baranowski J, Doyle C, Wang DT. Social-cognitive predictors of fruit and vegetable intake in children. Health Psychol. 1997 May;16(3):272-6.

  • Blanchette L, Brug J. Determinants of fruit and vegetable consumption among 6-12-year-old children and effective interventions to increase consumption. J Hum Nutr Diet. 2005 Dec;18(6):431-43.

  • Reynolds, K.D., Hinton, A.W., Schewchuk, R.M. & Hickey, C.A. (1999) Social coginitive model of fruit and vegetable consumption in elementary school children. J. Nutr. Educ. 31, 23–30.

  • 21. Adams MA, Pelletier RL, Zive MM, Sallis JF. Salad bars and fruit and vegetable consumption in elementary schools: a plate waste study. J Am Diet Assoc. 2005 Nov;105(11):1789-92.


Thank you
Thank You

http://seattletimes.nwsource.com/html/pacificnw10092005/coverstory.html


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