- Email: [email protected]
Impact of a Nutrition Education Curriculum on Snack Choices of Children Ages Six and Seven Years
RESEARCH BRIEF
Impact of a Nutrition Education Curriculum on Snack Choices of Children Ages Six and Seven Years Oksana Matvienko, PhD ABSTRACT Objective: To report the impact of nutrition education on snack choices of children ages 6 and 7 years. Design: In this quasi-experimental study, students at 2 intervention schools participated in a 4-week after-school program, NutriActive Healthy Experience, that included nutrition lessons, healthy snacks, and parent education. Students at 2 comparison schools did not receive any intervention but participated in the assessment of snack choices. Intervention and comparison students were offered the choice of 3 out of 10 snack items at baseline, at the end of the 4-week program, and 4 months later. Setting: An after-school program in the school setting. Participants: 36 intervention and 23 comparison kindergarten and first-grade students. Main Outcome Measures: Students’ snack choices were coded and analyzed. Analysis: t test, repeated-measures analysis of variance (ANOVA). Results: Immediately after the program, the intervention group showed a 25.7% improvement in choosing more healthful snacks, and the comparison group showed an 18.2% decline. At 4 months, the intervention group’s score was 33.3% higher than baseline and the comparison group’s score remained 18.2% lower than baseline (time by treatment interaction, P⫽ .023). Conclusions and Implications: Intervention students were significantly more likely than comparison students to choose more healthful snacks when given the opportunity. The snack test may be a useful alternative for assessing snack choices of children ages six to seven years. Key Words: nutrition education, food choices, children, dietary behavior assessment (J Nutr Educ Behav. 2007;39:281-285)
INTRODUCTION The effect of nutrition interventions on dietary intakes of children is frequently assessed using various questionnaires and recalls.1,2 However, some studies have questioned the usefulness of these instruments because of the children’s limited ability to accurately recall information and estimate portion size.3-5 Dietary intakes of young children are sometimes estimated using assessment instruments completed by adults including trained investigators, parents, and guardians. This kind of assessment also has some limitations. Hammon et al6 validated a food frequency questionnaire designed to assess dietary intakes of 5-11 year old children against 14 daily recalls. Both assessment instruments were completed by parents. The researchers determined that the percentage agree-
School of Health, Physical Education, and Leisure Services, University of Northern Iowa, Cedar Falls, Iowa Address for correspondence: Oksana Matvienko, PhD, Assistant Professor of Nutrition, School of Health, Physical Education, and Leisure Services, University of Northern Iowa, 147 Wellness/Recreation Center, Cedar Falls, IA 50614-0241; Phone: (319) 273-3613; Fax: (319) 273-5958; E-mail: [email protected]
©2007 SOCIETY FOR NUTRITION EDUCATION doi: 10.1016/j.jneb.2007.01.004
ment between food consumption frequencies reported in the 2 methods ranged from 99.8% to 46.5% depending on the food item. Similarly, Stein et al7 reported a moderately low consistency between the results of the Willett semiquantitative food questionnaire and dietary recalls completed by parents of preschool children. In some instances, quantitative assessment of children’s dietary intakes is neither necessary nor feasible. In recent years, the number of nutrition education programs for children has increased substantially. Some programs may have insufficient time and resources to conduct detailed assessment of children’s dietary intakes. At the same time, professionals implementing such programs may be interested in using some form of dietary assessment to establish the effectiveness of their nutrition education curricula. The purpose of this study was to determine the impact of a nutrition education curriculum on snack choices of children ages 6 and 7 years. The children’s snack choices were assessed using a novel snack selection test.
DESCRIPTION OF THE INTERVENTION This study was approved by the University of Northern Iowa Institutional Review Board. The participants included
282
Matvienko/A NUTRITION EDUCATION CURRICULUM AND SNACK CHOICES OF YOUNG CHILDREN
a convenience sample of 70 rural kindergarten and firstgrade students (53.5% boys, 82% Caucasian) from 4 schools (2 intervention and 2 comparison) within the same district. Random assignment was not possible because 2 of the 4 participating schools sublet their gymnasiums to outside parties, such as sports teams. Since the intervention included a strong physical activity component, the 2 schools that had their gymnasiums available in the afternoon automatically became the intervention sites. The intervention students participated in the NutriActive Healthy Experience program that lasted 4 weeks and was designed to improve participants’ nutrition and health knowledge, food choices, fitness, and motor skill levels. The program consisted of a 15-minute walk before school and a 90-minute after-school session that included a daily 50-60 minute physical activity component, a 20-minute classroom lesson (nutrition or body awareness and injury prevention), and snack. As part of this multicomponent program, the intervention students received 20-minute nutrition education lessons twice a week during the month of April. The topics covered included the basics of energy balance, food composition, and health benefits of different food groups and specific nutrients. The nutrition component of the program also included a daily after-school snack. The intervention students were served snacks of high nutritional value, including skim milk, vanilla yogurt, a variety of fruits and vegetables, whole-grain food items, cheese, and 100% juices. The same snacks were served every 2 weeks. The students were encouraged to taste each item. The snack time was used as a food education session to increase the students’ familiarity with a variety of healthy snacks, as well as to help them develop preferences (liking) for nutritious snacks and overcome food neophobias. In addition, parents at the intervention sites received 4 weekly newsletters containing an overview of major nutrition concepts covered each week. The parents were instructed to spend a few minutes a day reinforcing the concepts with their children. Students and parents at the comparison sites did not receive any nutrition education or snack. Their involvement was limited to participation in assessment sessions. Each participant in the intervention and comparison group received a small gift item (a jump rope, a t-shirt, or a backpack) at the end of each assessment session. Snack choices of the intervention and comparison students were assessed at baseline (end of March), immediately after the 4-week program (early May), and at the 4-month follow-up (early September). With 1 exception, assessment sessions were conducted after school. In 1 comparison school, the assessment was conducted mid-morning owing to schedule conflicts in the afternoon. Neither intervention nor comparison students had contact with the investigators over summer break (ie, between the 4-week and 4-month assessment sessions). Although 70 students (42 intervention and 28 comparison) participated in baseline and 4-week assessments, only 59 students (36 intervention and 23 comparison) returned for the 4-month follow-up. The remaining 11 students were unable to return because of
relocation to another area (n ⫽ 5) and schedule conflicts (n ⫽ 6). Snack choices were assessed using a test designed by the investigators. Each student was offered ten food items (7 snacks and 3 beverages): fruit chews (gummy fruit-flavored candies), apples, refined flour crackers, whole-grain crackers, cheese, potato chips, baby carrots, water, skim milk, and fruit drink. Snack items included common food items of low and high nutritional value matched by food group, whenever possible (eg, fruit chews vs. fresh fruit, white crackers vs. whole-grain crackers, and potato chips vs. carrots). Skim milk, fresh fruit, whole-grain crackers, baby carrots, water, and cheese were coded as items of high nutritional value, whereas white crackers, potato chips, fruit chews, and fruit drink were coded as nutritionally poor items. Cheese, although high in fat, is a calcium-rich food and, in moderate amounts, can be a part of a healthful diet. Water does not provide nutrients. However, it is a healthful substitute for sugary beverages, such as fruit drinks and soda. In addition to the snack test, each assessment session included a series of motor skill and fitness tests and an interviewer-administered nutrition and health knowledge questionnaire, the results of which are not reported here. The students who completed physical activity tests and an interview were sent to the last station—the snack test. The duration of an interview varied. Thus, students arrived at the snack station 1 at a time and thereby were unable to see snack choices made by others. Students were instructed to come to the snack table, look at all items, and choose any 2 snack items and 1 beverage: “Please take a look at all food items and drinks on the table and choose any 2 food items and 1 drink for your snack.” After the student made his or her selection, he or she was asked to proceed to an area designated for snack consumption. If more than 1 student came to the table at the same time, 1 of them was asked to wait aside. Items removed by 1 student were immediately replaced to ensure that the next student’s choice would not be influenced by the number of items on the table. All snacks were offered in single-size servings. A sign was placed next to each item indicating what that item was. However, many of the children did not pay attention to the signs (some of them could not read well). The snack test was administered by 2 trained research assistants (graduate and undergraduate students). One assistant was in charge of instructing children as they arrived at the snack station and recording their choices (using a checklist). The other assistant was in charge of replacing removed items. The actual intake and waste of items selected by students were not measured.
OUTCOME EVALUATION Students’ choices were recorded and coded. Total scores ranged from 0 to 3. A score of 0 was assigned if all 3 items a student selected were of low nutritional value, and a score of 3 was assigned if all three items a student selected were of high nutritional value. The snack test was administered
Journal of Nutrition Education and Behavior ● Volume 39, Number 5, September/October 2007
283
mained 18.2% lower (1.17 ⫾ 0.9) than baseline. Repeatedmeasures ANOVA determined that a time-by-treatment interaction was significant for the total score (P⫽ .023, Figure 1), approaching significance for the beverage score (P⫽ .054, Figure 2), and not significant for the snack score (P⫽ .16, Figure 3). Significant between-group effects were found for the total score (P⫽ .014) and snack score (P⬍ .001).
DISCUSSION
Figure 1. Change in the mean total score (snack ⫹ beverage) in the intervention and comparison groups. Time of Assessment: 1 ⫽ baseline, 2 ⫽ 4-week follow-up (end of intervention), 3 ⫽ 4-month follow-up. Time ⫻ treatment interaction, P ⫽ 0.023, repeated measures ANOVA.
by trained college students not involved in the delivery of the nutrition curriculum. Repeated-measures analysis of variance (ANOVA) was used to determine the effect of the NutriActive program on the participants’ snack choices. Separate analyses were performed for the snack scores (score range 0-2), beverage scores (0-1), and total score (the sum of 2 snacks and 1 beverage, 0-3). Only those participants who were present at all 3 assessment sessions were included in the analysis (36 intervention and 23 comparison students). An independent sample t test was used to compare baseline snack scores and participants’ characteristics.
This study tested a hypothesis that nutrition education would have an impact on children’s snack choices. The impact of the intervention was determined using a novel snack selection test. Previously, Bannon and Schwartz8 investigated the effect of nutrition message framing on snack choices of kindergarten students. The students were shown a 60-second video about apples. Immediately after watching the video, they were offered a choice of animal crackers or an apple. The authors reported that following a single nutrition education message, significantly more intervention than control students chose apples rather than animal crackers as their snack (56% vs. 33%). The results of the snack test used in this study showed that the NutriActive program had a significant and relatively long-lasting (at least 4 months) impact on snack choices of kindergarten and first-grade students. In addition to nutrition lessons, the intervention group was provided with a daily healthful snack with the intent to increase the students’ familiarity with nutritious foods and to help them develop preferences for those food items using verbal encouragement. The rationale behind this approach was based on previous reports that taste preferences are one of the strongest predictors of food intake in childhood.9-10 In adults, self-reported food
DESCRIPTION OF THE OUTCOMES At baseline, students in the intervention and comparison groups did not differ significantly in age, sex, and socioeconomic status based on combined family annual income (all P⬎ .21). The intervention group was more ethnically diverse and included 75% Caucasian, 5.6% African American, 8.3% Asian, and 11.1% mixed-race students. The comparison group included 95.7% Caucasian and 4.3% mixed-race students. The groups did not differ significantly in their baseline snack scores, beverage scores, or total scores (all P⬎ .22). Means for the total scores were 1.44 ⫾ 0.8 (mean ⫾ SD) for the intervention group and 1.43 ⫾ 1.1 for the comparison group. Immediately after the 4-week program, the intervention group showed a 25.7% increase in their total score (mean ⫾ SD, 1.81 ⫾ 0.9), whereas the comparison group showed an 18.2% decrease (1.17 ⫾ 1.0). At the 4-month follow-up, the intervention group’s score was 33.3% higher (1.92 ⫾ 0.9) than baseline, and the comparison group’s score re-
Figure 2. Change in the mean beverage score in the intervention and comparison groups. Time of assessment: 1 ⫽ baseline, 2 ⫽ 4-week follow-up (end of intervention), 3 ⫽ 4-month follow-up. Time ⫻ treatment interaction, P ⫽ 0.054, repeated measures ANOVA.
284
Matvienko/A NUTRITION EDUCATION CURRICULUM AND SNACK CHOICES OF YOUNG CHILDREN
Figure 3. Change in the mean snack score in the intervention and comparison groups. Time of assessment: 1 ⫽ baseline, 2 ⫽ 4-week follow-up (end of intervention), 3 ⫽ 4-month follow-up. Time ⫻ treatment interaction, P ⫽ 0.165, repeated measures ANOVA.
preferences are associated with food choices and dietary intakes.11 Limited research findings suggest a similar association in early elementary children. In one randomized trial, cafeteria programs were implemented at the intervention sites to encourage fruit and vegetable consumption among first- and third-grade students.12 The authors determined that verbal encouragement by the food service staff was a significant predictor of increased fruit intake. Anderson et al13 reported that a school-based nutrition education intervention that included increased availability of fruit and vegetables at school, newsletters for children and parents, information for teachers, and nutrition curriculum for 6-7 and 10-11 year olds resulted in significantly higher fruit consumption in the intervention schools compared with the control schools. It should be noted that children’s vegetable consumption was not affected in either study despite the efforts to increase the consumption of both fruit and vegetables. Reinaerts et al14 stated that the intakes of fruits and vegetables among 4- to 12-year-old children are 2 different behaviors, which should be targeted individually. Clearly, further research is needed to ascertain the impact of various nutrition education approaches on children’s food choices and dietary intakes. It is generally thought that young children do not make many food choices because they usually eat what is served to them in school or at home. The results of this study suggest that 6- and 7-year-old children can be empowered to make more healthful food choices in response to an intervention that combines nutrition education (classroom lessons) and food education (snack consumption). Following the intervention, the students in this study were significantly more likely to choose more healthful snacks when given the opportunity. Thus, it appears to be beneficial to include lessons on healthful food choices in a nutrition curriculum for 6- and 7-year-olds.
A novel snack test was used to assess students’ food choices. The test was quick and easy to administer, as well as functional in detecting changes in children’s snack choices. In addition, the test determined children’s actual rather than reported food choices. The test can be modified and tested as a tool to assess children’s choices of any food items specifically targeted by the intervention. However, the snack test may not be useful in assessing overall food choices. The results of this study should be interpreted with caution. Major limitations include a nonrandomized design; small, uneven groups; and that children’s snack choices were assessed, but not their actual intake of the selected snacks. Additional work is needed to validate that when more healthful choices are selected, they are also consumed. With respect to the snack selection test, future investigations may consider conducting the test more than once at each assessment time (for example, on 2 consecutive days) and providing a greater variety of snack items.
IMPLICATIONS FOR RESEARCH AND PRACTICE The impact of a nutrition education curriculum on selected food choices of 6- and 7-year-olds can be assessed using a snack selection test, as described in this article. The test is simple and quick and provides insight into children’s selfselected food choices that may be reflective of actual behavior. The snack test may be useful to researchers and practitioners who are interested in evaluating the impact of nutrition education on food choices but lack sufficient time or resources for using sophisticated assessment methods. The snack test may be more appropriate for evaluating selection of specific foods rather than overall food choices.
REFERENCES 1. Melnik TA, Rhoades SJ, Wales KR, Cowell C, Wolfe WS. Food consumption patterns of elementary schoolchildren in New York City. J Am Diet Assoc. 1998;98:159-164. 2. Cullen KW, Eagan J, Baranowski T, Owens E, de Moor C. Effect of a la carte and snack bar foods at school on children’s lunchtime intake of fruits and vegetables. J Am Diet Assoc. 2000;100:1482-1486. 3. Baxter SD, Thompson WO, Litaker MS, Frye FH, Guinn CH. Low accuracy and low consistency of fourth-graders’ school breakfast and school lunch recalls. J Am Diet Assoc. 2002;102:386-395. 4. Baxter SD, Smith AF, Litaker MS, et al. Recency affects reporting accuracy of children’s dietary recalls. Ann Epidemiol. 2004;14:385-390. 5. Warren JM, Henry CJ, Livingstone MB, Lightowler HJ, Bradshaw SM, Perwaiz S. How well do children aged 5-7 years recall food eaten at school lunch? Public Health Nutr. 2003;6:41-47. 6. Hammond J, Nelson M, Chin S, Ronal RJ. Validation of a food frequency questionnaire for assessing dietary intake in a study of coronary heart disease risk factors in children. Eur J Clin Nutr. 1993;47:242-250. 7. Stein AD, Shea S, Basch CE, Contento IR, Zybert P. Consistency of the Willett semiquantitative food frequency questionnaire and 24hour dietary recalls in estimating nutrient intakes of preschool children. Am J Epidemiol. 1992;135:667-677.
Journal of Nutrition Education and Behavior ● Volume 39, Number 5, September/October 2007
8. Bannon K, Schwartz MB. Impact of nutrition messages on children’s food choices: pilot study. Appetite. 2006;46:124-129. 9. Domel SB, Thompson WO, Davis H, Baranowski T, Leonard SB, Baranowski J. Psychosocial predictors of fruit and vegetable consumption among elementary school children. Health Educ Res.1996;11:299-308. 10. Blanchette L, Brug J. Determinants of fruit and vegetable consumption among 6-12-year-old children and effective interventions to increase consumption. Hum Nutr Diet. 2005;18:431-443. 11. Drewnowski A, Hann C. Food preferences and reported frequencies of food consumption as predictors of current diet in young women. Am J Clin Nutr. 1999;70:28-36. 12. Perry CL, Bishop DB, Taylor GL, et al. A randomized school
285
trial of environmental strategies to encourage fruit and vegetable consumption among children. Health Educ Behav. 2004;31: 65-76. 13. Anderson AS, Porteous LEG, Foster E, et al. The impact of a schoolbased nutrition education intervention on dietary intake and cognitive and attitudinal variables relating to fruits and vegetables. Pub Health Nutr. 2005;8:650-656. 14. Reinaerts E, de Nooijer J, Candel M, de Vries N. Explaining school children’s fruit and vegetable consumption: the contributions of availability, accessibility, exposure, parental consumption and habit in addition to psychosocial factors. Appetite. 2007;48:248258.
Erratum The May/June issue of The Journal of Nutrition Education and Behavior carried an article by Suzanne Domel Baxter, PhD, RD, FADA, entitled Fourth-grade Children are Less Accurate in Reporting School Breakfast than School Lunch during 24-Hour Dietary Recalls (J Nutr Educ Behav. 2007;39:
126-133). Current affiliations for Dr. Baxter and 2 of her co-authors, Julie A. Royer, MSPH, and Caroline H. Guinn, RD, should have all been listed as “The Institute for Families in Society, University of South Carolina, Columbia, SC.” The Journal regrets the error.
Impact of a Nutrition Education Curriculum on Snack Choices of Children Ages Six and Seven Years Oksana Matvienko, PhD ABSTRACT Objective: To report the impact of nutrition education on snack choices of children ages 6 and 7 years. Design: In this quasi-experimental study, students at 2 intervention schools participated in a 4-week after-school program, NutriActive Healthy Experience, that included nutrition lessons, healthy snacks, and parent education. Students at 2 comparison schools did not receive any intervention but participated in the assessment of snack choices. Intervention and comparison students were offered the choice of 3 out of 10 snack items at baseline, at the end of the 4-week program, and 4 months later. Setting: An after-school program in the school setting. Participants: 36 intervention and 23 comparison kindergarten and first-grade students. Main Outcome Measures: Students’ snack choices were coded and analyzed. Analysis: t test, repeated-measures analysis of variance (ANOVA). Results: Immediately after the program, the intervention group showed a 25.7% improvement in choosing more healthful snacks, and the comparison group showed an 18.2% decline. At 4 months, the intervention group’s score was 33.3% higher than baseline and the comparison group’s score remained 18.2% lower than baseline (time by treatment interaction, P⫽ .023). Conclusions and Implications: Intervention students were significantly more likely than comparison students to choose more healthful snacks when given the opportunity. The snack test may be a useful alternative for assessing snack choices of children ages six to seven years. Key Words: nutrition education, food choices, children, dietary behavior assessment (J Nutr Educ Behav. 2007;39:281-285)
INTRODUCTION The effect of nutrition interventions on dietary intakes of children is frequently assessed using various questionnaires and recalls.1,2 However, some studies have questioned the usefulness of these instruments because of the children’s limited ability to accurately recall information and estimate portion size.3-5 Dietary intakes of young children are sometimes estimated using assessment instruments completed by adults including trained investigators, parents, and guardians. This kind of assessment also has some limitations. Hammon et al6 validated a food frequency questionnaire designed to assess dietary intakes of 5-11 year old children against 14 daily recalls. Both assessment instruments were completed by parents. The researchers determined that the percentage agree-
School of Health, Physical Education, and Leisure Services, University of Northern Iowa, Cedar Falls, Iowa Address for correspondence: Oksana Matvienko, PhD, Assistant Professor of Nutrition, School of Health, Physical Education, and Leisure Services, University of Northern Iowa, 147 Wellness/Recreation Center, Cedar Falls, IA 50614-0241; Phone: (319) 273-3613; Fax: (319) 273-5958; E-mail: [email protected]
©2007 SOCIETY FOR NUTRITION EDUCATION doi: 10.1016/j.jneb.2007.01.004
ment between food consumption frequencies reported in the 2 methods ranged from 99.8% to 46.5% depending on the food item. Similarly, Stein et al7 reported a moderately low consistency between the results of the Willett semiquantitative food questionnaire and dietary recalls completed by parents of preschool children. In some instances, quantitative assessment of children’s dietary intakes is neither necessary nor feasible. In recent years, the number of nutrition education programs for children has increased substantially. Some programs may have insufficient time and resources to conduct detailed assessment of children’s dietary intakes. At the same time, professionals implementing such programs may be interested in using some form of dietary assessment to establish the effectiveness of their nutrition education curricula. The purpose of this study was to determine the impact of a nutrition education curriculum on snack choices of children ages 6 and 7 years. The children’s snack choices were assessed using a novel snack selection test.
DESCRIPTION OF THE INTERVENTION This study was approved by the University of Northern Iowa Institutional Review Board. The participants included
282
Matvienko/A NUTRITION EDUCATION CURRICULUM AND SNACK CHOICES OF YOUNG CHILDREN
a convenience sample of 70 rural kindergarten and firstgrade students (53.5% boys, 82% Caucasian) from 4 schools (2 intervention and 2 comparison) within the same district. Random assignment was not possible because 2 of the 4 participating schools sublet their gymnasiums to outside parties, such as sports teams. Since the intervention included a strong physical activity component, the 2 schools that had their gymnasiums available in the afternoon automatically became the intervention sites. The intervention students participated in the NutriActive Healthy Experience program that lasted 4 weeks and was designed to improve participants’ nutrition and health knowledge, food choices, fitness, and motor skill levels. The program consisted of a 15-minute walk before school and a 90-minute after-school session that included a daily 50-60 minute physical activity component, a 20-minute classroom lesson (nutrition or body awareness and injury prevention), and snack. As part of this multicomponent program, the intervention students received 20-minute nutrition education lessons twice a week during the month of April. The topics covered included the basics of energy balance, food composition, and health benefits of different food groups and specific nutrients. The nutrition component of the program also included a daily after-school snack. The intervention students were served snacks of high nutritional value, including skim milk, vanilla yogurt, a variety of fruits and vegetables, whole-grain food items, cheese, and 100% juices. The same snacks were served every 2 weeks. The students were encouraged to taste each item. The snack time was used as a food education session to increase the students’ familiarity with a variety of healthy snacks, as well as to help them develop preferences (liking) for nutritious snacks and overcome food neophobias. In addition, parents at the intervention sites received 4 weekly newsletters containing an overview of major nutrition concepts covered each week. The parents were instructed to spend a few minutes a day reinforcing the concepts with their children. Students and parents at the comparison sites did not receive any nutrition education or snack. Their involvement was limited to participation in assessment sessions. Each participant in the intervention and comparison group received a small gift item (a jump rope, a t-shirt, or a backpack) at the end of each assessment session. Snack choices of the intervention and comparison students were assessed at baseline (end of March), immediately after the 4-week program (early May), and at the 4-month follow-up (early September). With 1 exception, assessment sessions were conducted after school. In 1 comparison school, the assessment was conducted mid-morning owing to schedule conflicts in the afternoon. Neither intervention nor comparison students had contact with the investigators over summer break (ie, between the 4-week and 4-month assessment sessions). Although 70 students (42 intervention and 28 comparison) participated in baseline and 4-week assessments, only 59 students (36 intervention and 23 comparison) returned for the 4-month follow-up. The remaining 11 students were unable to return because of
relocation to another area (n ⫽ 5) and schedule conflicts (n ⫽ 6). Snack choices were assessed using a test designed by the investigators. Each student was offered ten food items (7 snacks and 3 beverages): fruit chews (gummy fruit-flavored candies), apples, refined flour crackers, whole-grain crackers, cheese, potato chips, baby carrots, water, skim milk, and fruit drink. Snack items included common food items of low and high nutritional value matched by food group, whenever possible (eg, fruit chews vs. fresh fruit, white crackers vs. whole-grain crackers, and potato chips vs. carrots). Skim milk, fresh fruit, whole-grain crackers, baby carrots, water, and cheese were coded as items of high nutritional value, whereas white crackers, potato chips, fruit chews, and fruit drink were coded as nutritionally poor items. Cheese, although high in fat, is a calcium-rich food and, in moderate amounts, can be a part of a healthful diet. Water does not provide nutrients. However, it is a healthful substitute for sugary beverages, such as fruit drinks and soda. In addition to the snack test, each assessment session included a series of motor skill and fitness tests and an interviewer-administered nutrition and health knowledge questionnaire, the results of which are not reported here. The students who completed physical activity tests and an interview were sent to the last station—the snack test. The duration of an interview varied. Thus, students arrived at the snack station 1 at a time and thereby were unable to see snack choices made by others. Students were instructed to come to the snack table, look at all items, and choose any 2 snack items and 1 beverage: “Please take a look at all food items and drinks on the table and choose any 2 food items and 1 drink for your snack.” After the student made his or her selection, he or she was asked to proceed to an area designated for snack consumption. If more than 1 student came to the table at the same time, 1 of them was asked to wait aside. Items removed by 1 student were immediately replaced to ensure that the next student’s choice would not be influenced by the number of items on the table. All snacks were offered in single-size servings. A sign was placed next to each item indicating what that item was. However, many of the children did not pay attention to the signs (some of them could not read well). The snack test was administered by 2 trained research assistants (graduate and undergraduate students). One assistant was in charge of instructing children as they arrived at the snack station and recording their choices (using a checklist). The other assistant was in charge of replacing removed items. The actual intake and waste of items selected by students were not measured.
OUTCOME EVALUATION Students’ choices were recorded and coded. Total scores ranged from 0 to 3. A score of 0 was assigned if all 3 items a student selected were of low nutritional value, and a score of 3 was assigned if all three items a student selected were of high nutritional value. The snack test was administered
Journal of Nutrition Education and Behavior ● Volume 39, Number 5, September/October 2007
283
mained 18.2% lower (1.17 ⫾ 0.9) than baseline. Repeatedmeasures ANOVA determined that a time-by-treatment interaction was significant for the total score (P⫽ .023, Figure 1), approaching significance for the beverage score (P⫽ .054, Figure 2), and not significant for the snack score (P⫽ .16, Figure 3). Significant between-group effects were found for the total score (P⫽ .014) and snack score (P⬍ .001).
DISCUSSION
Figure 1. Change in the mean total score (snack ⫹ beverage) in the intervention and comparison groups. Time of Assessment: 1 ⫽ baseline, 2 ⫽ 4-week follow-up (end of intervention), 3 ⫽ 4-month follow-up. Time ⫻ treatment interaction, P ⫽ 0.023, repeated measures ANOVA.
by trained college students not involved in the delivery of the nutrition curriculum. Repeated-measures analysis of variance (ANOVA) was used to determine the effect of the NutriActive program on the participants’ snack choices. Separate analyses were performed for the snack scores (score range 0-2), beverage scores (0-1), and total score (the sum of 2 snacks and 1 beverage, 0-3). Only those participants who were present at all 3 assessment sessions were included in the analysis (36 intervention and 23 comparison students). An independent sample t test was used to compare baseline snack scores and participants’ characteristics.
This study tested a hypothesis that nutrition education would have an impact on children’s snack choices. The impact of the intervention was determined using a novel snack selection test. Previously, Bannon and Schwartz8 investigated the effect of nutrition message framing on snack choices of kindergarten students. The students were shown a 60-second video about apples. Immediately after watching the video, they were offered a choice of animal crackers or an apple. The authors reported that following a single nutrition education message, significantly more intervention than control students chose apples rather than animal crackers as their snack (56% vs. 33%). The results of the snack test used in this study showed that the NutriActive program had a significant and relatively long-lasting (at least 4 months) impact on snack choices of kindergarten and first-grade students. In addition to nutrition lessons, the intervention group was provided with a daily healthful snack with the intent to increase the students’ familiarity with nutritious foods and to help them develop preferences for those food items using verbal encouragement. The rationale behind this approach was based on previous reports that taste preferences are one of the strongest predictors of food intake in childhood.9-10 In adults, self-reported food
DESCRIPTION OF THE OUTCOMES At baseline, students in the intervention and comparison groups did not differ significantly in age, sex, and socioeconomic status based on combined family annual income (all P⬎ .21). The intervention group was more ethnically diverse and included 75% Caucasian, 5.6% African American, 8.3% Asian, and 11.1% mixed-race students. The comparison group included 95.7% Caucasian and 4.3% mixed-race students. The groups did not differ significantly in their baseline snack scores, beverage scores, or total scores (all P⬎ .22). Means for the total scores were 1.44 ⫾ 0.8 (mean ⫾ SD) for the intervention group and 1.43 ⫾ 1.1 for the comparison group. Immediately after the 4-week program, the intervention group showed a 25.7% increase in their total score (mean ⫾ SD, 1.81 ⫾ 0.9), whereas the comparison group showed an 18.2% decrease (1.17 ⫾ 1.0). At the 4-month follow-up, the intervention group’s score was 33.3% higher (1.92 ⫾ 0.9) than baseline, and the comparison group’s score re-
Figure 2. Change in the mean beverage score in the intervention and comparison groups. Time of assessment: 1 ⫽ baseline, 2 ⫽ 4-week follow-up (end of intervention), 3 ⫽ 4-month follow-up. Time ⫻ treatment interaction, P ⫽ 0.054, repeated measures ANOVA.
284
Matvienko/A NUTRITION EDUCATION CURRICULUM AND SNACK CHOICES OF YOUNG CHILDREN
Figure 3. Change in the mean snack score in the intervention and comparison groups. Time of assessment: 1 ⫽ baseline, 2 ⫽ 4-week follow-up (end of intervention), 3 ⫽ 4-month follow-up. Time ⫻ treatment interaction, P ⫽ 0.165, repeated measures ANOVA.
preferences are associated with food choices and dietary intakes.11 Limited research findings suggest a similar association in early elementary children. In one randomized trial, cafeteria programs were implemented at the intervention sites to encourage fruit and vegetable consumption among first- and third-grade students.12 The authors determined that verbal encouragement by the food service staff was a significant predictor of increased fruit intake. Anderson et al13 reported that a school-based nutrition education intervention that included increased availability of fruit and vegetables at school, newsletters for children and parents, information for teachers, and nutrition curriculum for 6-7 and 10-11 year olds resulted in significantly higher fruit consumption in the intervention schools compared with the control schools. It should be noted that children’s vegetable consumption was not affected in either study despite the efforts to increase the consumption of both fruit and vegetables. Reinaerts et al14 stated that the intakes of fruits and vegetables among 4- to 12-year-old children are 2 different behaviors, which should be targeted individually. Clearly, further research is needed to ascertain the impact of various nutrition education approaches on children’s food choices and dietary intakes. It is generally thought that young children do not make many food choices because they usually eat what is served to them in school or at home. The results of this study suggest that 6- and 7-year-old children can be empowered to make more healthful food choices in response to an intervention that combines nutrition education (classroom lessons) and food education (snack consumption). Following the intervention, the students in this study were significantly more likely to choose more healthful snacks when given the opportunity. Thus, it appears to be beneficial to include lessons on healthful food choices in a nutrition curriculum for 6- and 7-year-olds.
A novel snack test was used to assess students’ food choices. The test was quick and easy to administer, as well as functional in detecting changes in children’s snack choices. In addition, the test determined children’s actual rather than reported food choices. The test can be modified and tested as a tool to assess children’s choices of any food items specifically targeted by the intervention. However, the snack test may not be useful in assessing overall food choices. The results of this study should be interpreted with caution. Major limitations include a nonrandomized design; small, uneven groups; and that children’s snack choices were assessed, but not their actual intake of the selected snacks. Additional work is needed to validate that when more healthful choices are selected, they are also consumed. With respect to the snack selection test, future investigations may consider conducting the test more than once at each assessment time (for example, on 2 consecutive days) and providing a greater variety of snack items.
IMPLICATIONS FOR RESEARCH AND PRACTICE The impact of a nutrition education curriculum on selected food choices of 6- and 7-year-olds can be assessed using a snack selection test, as described in this article. The test is simple and quick and provides insight into children’s selfselected food choices that may be reflective of actual behavior. The snack test may be useful to researchers and practitioners who are interested in evaluating the impact of nutrition education on food choices but lack sufficient time or resources for using sophisticated assessment methods. The snack test may be more appropriate for evaluating selection of specific foods rather than overall food choices.
REFERENCES 1. Melnik TA, Rhoades SJ, Wales KR, Cowell C, Wolfe WS. Food consumption patterns of elementary schoolchildren in New York City. J Am Diet Assoc. 1998;98:159-164. 2. Cullen KW, Eagan J, Baranowski T, Owens E, de Moor C. Effect of a la carte and snack bar foods at school on children’s lunchtime intake of fruits and vegetables. J Am Diet Assoc. 2000;100:1482-1486. 3. Baxter SD, Thompson WO, Litaker MS, Frye FH, Guinn CH. Low accuracy and low consistency of fourth-graders’ school breakfast and school lunch recalls. J Am Diet Assoc. 2002;102:386-395. 4. Baxter SD, Smith AF, Litaker MS, et al. Recency affects reporting accuracy of children’s dietary recalls. Ann Epidemiol. 2004;14:385-390. 5. Warren JM, Henry CJ, Livingstone MB, Lightowler HJ, Bradshaw SM, Perwaiz S. How well do children aged 5-7 years recall food eaten at school lunch? Public Health Nutr. 2003;6:41-47. 6. Hammond J, Nelson M, Chin S, Ronal RJ. Validation of a food frequency questionnaire for assessing dietary intake in a study of coronary heart disease risk factors in children. Eur J Clin Nutr. 1993;47:242-250. 7. Stein AD, Shea S, Basch CE, Contento IR, Zybert P. Consistency of the Willett semiquantitative food frequency questionnaire and 24hour dietary recalls in estimating nutrient intakes of preschool children. Am J Epidemiol. 1992;135:667-677.
Journal of Nutrition Education and Behavior ● Volume 39, Number 5, September/October 2007
8. Bannon K, Schwartz MB. Impact of nutrition messages on children’s food choices: pilot study. Appetite. 2006;46:124-129. 9. Domel SB, Thompson WO, Davis H, Baranowski T, Leonard SB, Baranowski J. Psychosocial predictors of fruit and vegetable consumption among elementary school children. Health Educ Res.1996;11:299-308. 10. Blanchette L, Brug J. Determinants of fruit and vegetable consumption among 6-12-year-old children and effective interventions to increase consumption. Hum Nutr Diet. 2005;18:431-443. 11. Drewnowski A, Hann C. Food preferences and reported frequencies of food consumption as predictors of current diet in young women. Am J Clin Nutr. 1999;70:28-36. 12. Perry CL, Bishop DB, Taylor GL, et al. A randomized school
285
trial of environmental strategies to encourage fruit and vegetable consumption among children. Health Educ Behav. 2004;31: 65-76. 13. Anderson AS, Porteous LEG, Foster E, et al. The impact of a schoolbased nutrition education intervention on dietary intake and cognitive and attitudinal variables relating to fruits and vegetables. Pub Health Nutr. 2005;8:650-656. 14. Reinaerts E, de Nooijer J, Candel M, de Vries N. Explaining school children’s fruit and vegetable consumption: the contributions of availability, accessibility, exposure, parental consumption and habit in addition to psychosocial factors. Appetite. 2007;48:248258.
Erratum The May/June issue of The Journal of Nutrition Education and Behavior carried an article by Suzanne Domel Baxter, PhD, RD, FADA, entitled Fourth-grade Children are Less Accurate in Reporting School Breakfast than School Lunch during 24-Hour Dietary Recalls (J Nutr Educ Behav. 2007;39:
126-133). Current affiliations for Dr. Baxter and 2 of her co-authors, Julie A. Royer, MSPH, and Caroline H. Guinn, RD, should have all been listed as “The Institute for Families in Society, University of South Carolina, Columbia, SC.” The Journal regrets the error.