Kid's Choice Program improves weight management behaviors and weight status in school children

Appetite 56 (2011) 484–494

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Research report

Kid’s Choice Program improves weight management behaviors and weight status in school children§ Helen M. Hendy a,*, Keith E. Williams b, Thomas S. Camise c a

Psychology Program, Penn State University, Schuylkill Campus, 200 University Drive, Schuylkill Haven, PA, 17972, United States Feeding Program, Department of Pediatrics, Penn State Hershey Medical Center, United States c Schuylkill Haven Area School District, United States b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 31 July 2010 Received in revised form 17 January 2011 Accepted 19 January 2011 Available online 26 January 2011

The present study examined the effectiveness of the Kid’s Choice Program (KCP) for increasing children’s weight management behaviors, and decreasing body mass index percentile (BMI%) for overweight and average-weight children. It also evaluated KCP characteristics relevant to long-term application in schools. Participants included 382 children assigned to two groups: a KCP group that received token rewards for three ‘‘Good Health Behaviors’’ including eating fruits or vegetables first at meals (FVFIRST), choosing lowfat and low-sugar healthy drinks (HDRINK), and showing 5000 exercise steps recorded on pedometers (EXERCISE), or a control group that received token rewards for three ‘‘Good Citizenship Behaviors.’’ School lunch observations and pedometer records were completed for one month under baseline and three months under reward conditions. The school nurse calculated children’s BMI% one year before baseline, at baseline, at the end of KCP application, and six months later. The KCP increased FVFIRST, HDRINK, and EXERCISE from baseline through reward conditions, with ANCOVAs demonstrating that these increases were associated with both the offer of reward and nearby peer models. Overweight (n = 112) and averageweight (n = 200) children showed drops in BMI% after the three-month KCP, but overweight children regained weight six months later, suggesting the need for more ongoing KCP application. HDRINK choice was the behavior most associated with BMI% drops for overweight children. Small teams of parent volunteers effectively delivered the KCP, and school staff endorsed parent volunteers as the best personnel to deliver the KCP, which costs approximately two U.S. dollars per child per month of application. ß 2011 Elsevier Ltd. All rights reserved.

Keywords: Child obesity School lunch Child nutrition Child exercise

Introduction School-based programs for child obesity prevention Over 30% of American school-aged children are now overweight or obese (Wang & Beydown, 2007) and they face a number of health, social, and psychological problems. These problems include diabetes, high blood pressure, gallstones, sleep apnea, orthopedic abnormalities, menstrual irregularities, peer teasing, fewer friends, poor body image, and depression (Davison & Birch, 2001; Latner & Stunkard, 2003; Must & Strauss, 1999; Turnbull, Heaslip, & McLeod, 2000; Williams, Bulli, & Deckelbaum, 2001). To avoid

§ This research was supported by grants from Penn State University. We thank the student research team members from Psychology 494 of Penn State Schuylkill for supply preparation, data collection, and data processing. For their support, we also express appreciation to the school board, superintendent, school staff, and parent volunteers of Schuylkill Haven Area Elementary Center, with special thanks to Rene Reese, Nurse Cheryl Wagner, Melanie Wade, Wally Haus, and Alberta Hudson. * Corresponding author. E-mail address: [email protected] (H.M. Hendy).

0195-6663/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.appet.2011.01.024

problems associated with child obesity, the Centers for Disease Control and Prevention (CDCP, 2000) have recommended that children maintain a body mass index percentile (BMI%) between the 10th and 85th percentile for their age and gender (with values above the 85th percentile considered at risk for overweight and values over the 95th percentile considered obese). The CDCP (2000) recommends that to maintain a healthy weight, children should be encouraged to exercise daily (EXERCISE), to choose lowfat and low-sugar foods and healthy drinks (HDRINK), and to eat more fruits and vegetables (FV) because they are high in nutrients and relatively low in calories. Eating FV first during meals (FVFIRST) may be especially valuable because it may reduce the total mealtime calories consumed (Rolls, Roe, & Meengs, 2004), increase the percentage of mealtime calories contributed by the nutrient-rich FV, and enhance the palatability of FV for children because they would be eaten at the beginning of the meal when children are most hungry (Hendy et al., 2008; Rolls, Rolls, Rowe, & Sweeney, 1981; Spill, Birch, Roe, & Rolls, 2010). The healthy behaviors recommended by the CDCP are often the focus of clinical programs available in hospitals or special camps for overweight children. However, any new behaviors learned in these special settings may not always generalize to children’s everyday

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environments, and children may feel singled out from their peers when required to participate in these special programs. Because most American children eat lunch at school five days a week (James, Rienzo, & Franzee, 1996), with the school-provided lunch often providing their most frequent exposure to fruits and vegetables (Baranowski et al., 1997; Burchett, 2003), school-based programs for child obesity prevention offer a unique opportunity to encourage many children at the same time to develop healthy behaviors while in their everyday environment, and while in the company of their peers. Unfortunately, although most schools include health education in their curriculum, research suggests that education alone may improve children’s knowledge about healthy behaviors, but it has little impact on their actual behavior or weight status (Burchett, 2003; Contento, Balch, & Bronner, 1995). In addition, reviews of the available school-based programs (Blanchette & Brug, 2005; Budd & Volpe, 2006; Howerton et al., 2007; Knai, Pomerlau, Lock, & McKee, 2006) suggest that very few of them produce well-documented improvements in children’s food consumption, exercise, or BMI%. For example, many of these programs rely on self-report by children, parents, or teachers, rather than direct measurement of the outcome variables. Also, most improvements produced by school programs tend to last only as long as the program is in place, and the programs often include many complex components that reduce their acceptability for long-term application by busy parents and school staff (Bauer, Yang, & Austin, 2004; Burchett, 2003; Contento et al., 1995). Finally, no available school program documents the costs per child per month of application. The Kid’s Choice Program The Kid’s Choice Program (KCP) was developed as an easy-to-use and relatively inexpensive school-based intervention to improve well-documented changes in children’s weight management behaviors. The KCP shows promise for long-term adoption by schools because it improves weight management behaviors in children (such as eating FV and choosing low-fat and low-sugar healthy drinks) for 1st–4th grade children, for boys and girls, for fussy-eating children, and for both average-weight and overweight children (Hendy, Williams, and Camise, 2005; Hendy, Williams, and Camise, 2011; Hendy et al., 2007, 2008). It also increases children’s self-reported preference ratings for these healthy behaviors, it is simple in design, it is relatively low-cost (at approximately two U.S. dollars per child per month of application), and it is well-accepted by children and parents (Hendy et al., 2005, 2007, 2008). The KCP includes three simple school procedures: (1) children wear nametags during school lunch and recess, (2) star-shaped holes are punched into the nametags when children exhibit small amounts of specific weight management behaviors, with at least two choices being available for each behavior, and (3) Reward Days are presented once each week when children can trade their stars for small prizes. Each component of the KCP was chosen based on theory and past research results in support of theory. For example, Social Cognitive Theory (Bandura, 1997) suggests that children’s development of any behavior (including weight management behaviors such as FVFIRST, HDRINK, and EXERCISE) would be increased by offering them rewards as an incentive to try the new behaviors, and many studies have documented that offers of small rewards can increase children’s FV consumption (Baranowski et al., 2000; Davis et al., 2000; Hendy, 1999; Horne, Fergus-Lowe, Fleming, & Dowey, 1995; Perry et al., 1998; Reynolds et al., 2000). Social Cognitive Theory also suggests that children’s confidence to perform behaviors (including weight management behaviors) would increase if they are provided with many small experiences with these behaviors, and past research demonstrates that children require approximately 8–10 taste experiences over time to learn to enjoy new foods (Birch, McPhee, Shoba, Pirok, &

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Stineberg, 1987; Wardle, Herrera, Cooke, & Gibson, 2003). However, to avoid the aversive effects of satiation, these repeated tastes may need to be relatively small in the amount of food consumed, with some choices available (Rolls et al., 1981). Self Determination Theory (Deci & Ryan, 1985) also suggests that a child’s intrinsic motivation for any behavior (including weight management behaviors) would be enhanced by perceived choices surrounding the behavior, and past research has documented that the availability of FV choices increases children’s consumption of these healthy foods (Hendy, 1999; Perry et al., 2004). Finally, both Social Cognitive Theory (Bandura, 1997) and Group Socialization Theory (Harris, 1995) emphasize the importance of peer models for the development of any new behavior in children, and past research consistently demonstrates the effectiveness of peer models for increasing children’s FV consumption (Hendy, 2002; Hendy & Raudenbush, 2000; Horne et al., 1995). Purpose of the present study The purpose of the present study was to strengthen the KCP application with a number of new components that allow additional evaluations of the program as a possible weight management program for long-term adoption by schools. (1) To strengthen the KCP application and its possibility of improving children’s weight status, we extended it from a one-month application as in our previous research (Hendy et al., 2005, 2007, 2008, 2011) to a three-month application, as well as extending the number of weight management behaviors targeted from two behaviors (FVFIRST and HDRINK) to three behaviors (FVFIRST, HDRINK, and EXERCISE). (2) To make the KCP more of a school–home partnership for child obesity prevention and healthy children, we added an optional component of parent participation for which parents could use a weekly Parent Record to report children’s weight management behaviors (FVFIRST, HDRINK, and EXERCISE) in the home environment. (3) To understand more about which components of the KCP were most associated with changes in the three weight management behaviors, we added an analysis of covariance to examine separate effects for the offer of token reward and the presence of peer models. (4) Most importantly, because the present KCP application targeted more weight management behaviors and for a longer duration than previous KCP applications, we added an examination of whether the KCP could improve BMI% scores for overweight and averageweight embedded within the sample. (6) In addition, we added an analysis to determine which of the three weight management behaviors (FVFIRST, HDRINK, and EXERCISE) explained the most variance in any significant BMI% changes seen for the overweight and average-weight children. Besides the new procedures used to examine the effectiveness of the KCP for improving weight management behaviors and BMI% in school children, the present study added analyses to provide school administrators with information to guide decisions about adopting the KCP for long-term application. (1) We included an examination of whether the KCP could be validly and effectively delivered by small teams of two to four parent volunteers. (2) We added a brief questionnaire for school staff to determine their acceptability ratings for various KCP procedures. (3) We provided estimations of the dollar costs per child per month of KCP application, with suggestions for additional cost reductions. Methods Participants The present application of the Kid’s Choice Program was conducted in an elementary school in a small town in eastern

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Pennsylvania, with children who had not participated in earlier KCP applications (Hendy et al., 2005, 2007, 2008, 2011). Of the 457 children who attended the 1st–4th grades at some time during the KCP application, data from 382 (83.6%) children were included in statistical analyses of the present report only if they had been a student at the school throughout the program, and only if they did not have severe disabilities that would make it difficult for them to understand the program (211 boys and 171 girls; 97 1st graders, 94 2nd graders, 100 3rd graders, and 91 4th graders; over 95% Caucasian). However, so that children with these circumstances would not feel left out, they also received all KCP supplies and opportunities as those received by their classmates. Children were given nametags necklaces to wear at school three days each week, pedometers to wear five days each week at school and home, and Parent Record cards to report children’s home behaviors during five dinner meals each week. Each child’s nametag, pedometer, and Parent Records used a code number it to represent the child’s identity throughout the present study, with subsets of the total 382 children available for the study phases used for each of the procedures described below to evaluate the KCP effectiveness. Procedures for lunch observer training Children were habituated to the presence of lunch observers for one month before baseline conditions, during which time observer training and inter-observer reliability trials were completed. Children were told that ‘‘the Penn State Team has come to your school to see what children do during lunchtime.’’ During each grade’s 30 min lunch period, the usual school procedure was that children with home-packed lunches entered the lunchroom first and sat together at one end of the table, separate from children eating the school-provided lunch, who lined up for their lunch trays, then sat next to classmates of their choosing. The schoolprovided lunch always included two or more choices of FV and HDRINK (with the FV choices including one or more fresh foods presented in small paper cups). Ten psychology juniors and seniors from Penn State University served as lunch observers who stood quietly at the side of the lunch tables with a clipboard and a prepared datasheet. Each observer was assigned to a region of the lunchroom where they recorded the behaviors of up to 24 children. First, observers recorded the timesensitive FVFIRST, defined as eating 1/8 cup or more of FV before any other food, and then they recorded HDRINK, defined as choosing a low-fat and low-sugar healthy drink (such as skim milk, 1% or 2% low-fat white milk, 100% fruit juice, or water, but not whole milk, any flavored sweetened milks, artificial ‘‘fruit’’ drinks, or soda). To avoid inflated FVFIRST scores, the high-fat and highsalt potato foods served with the school lunch were not considered vegetables for the present study. Also, because the opaque beverage cartons made it difficult to determine the exact amount of fluid consumed, HDRINK was measured only as the type of drink chosen. However, we have observed that nearly 100% of children open and drink from their chosen cartons. Inter-observer reliability trials were conducted having the 10 trained lunch observers simultaneously record (NO/YES) for the FVFIRST and HDRINK behaviors of 24 children. For each behavior, agreement scores for each observer pair were calculated as the number of agreements divided by the number of children observed, with the mean agreement scores found to be 91% for FVFIRST and 97% for HDRINK. Children bringing home-packed lunches have rarely been included in past research, even though they often include the most fussy-eaters in the sample, and even though such homepacked lunches often include fewer FV and more high-fat, highsugar, high-salt foods than the school-provided lunches (Douglass, 1999; Horne, Hardman, Lowe, & Rowlands, 2009; Simons-Morton et al., 1992). To see if the KCP could improve home-packed lunches

(with more FV included) and children’s consumption of healthy foods (with more FVFIRST and HDRINK), we conducted three lunch observations of home-packed lunches during the second month of reward conditions to compare the behavior of children in the control and KCP groups. Two trained lunch observers served as ‘‘packer observers’’ for the children present for these three observations, with inter-observer reliability measured by having them simultaneously observe 24 children with home-packed lunches to record (NO/YES) whether the parent had packed FV, and to record (NO/YES) whether the child showed FVFIRST and HDRINK behaviors. The ‘‘packer observers’’ demonstrated 100% agreement for all three measures. School lunch observations to measure FVFIRST and HDRINK After the month of observer training and habituation of the children, lunch observations of FVFIRST and HDRINK behaviors were made three days each week (Tuesday, Thursday, and Friday) across two study phases: one month under baseline conditions, three months under token reward conditions. Of the total 382 children, 252 (66.0%) were observed eating the school-provided lunch under both baseline and reward conditions (139 boys and 113 girls; 62 1st graders, 65 2nd graders, 64 3rd graders, and 61 4th graders), with these children randomly assigned to either a control group or a KCP intervention group (as described below). Also, 75 children were observed eating a home-packed meal under reward conditions, with a random half assigned to control and KCP groups (41 boys and 34 girls; 18 1st graders, 16 2nd graders, 19 3rd graders, and 22 4th graders). (NOTE: Of the 382 children, 55 children ate both home-packed and school-provided lunches, but not enough of either to be included in the separate lunch analyses.) After one month of baseline records, children were randomly assigned to one of the two study groups for three months of reward conditions. (1) The KCP group (called the ‘LIONS’’) received stars punched into their nametags for each of three ‘‘Good Health Behaviors’’ that included eating 1/8 cup FV (‘‘the size of a ping pong ball’’) first during their meal (FVFIRST), choosing a low-fat and lowsugar healthy drink (HDRINK), and having 5000 exercise steps recorded on their pedometers (EXERCISE). (2) The control group (called the ‘‘TIGERS’’) received stars punched into their nametags for each of three ‘‘Good Citizenship Behaviors’’ that included talking quietly during meals, keeping their meal area clean, and respecting others by not touching them or their things. Children were told that the purpose of these new procedures was to help them learn Good Health Behaviors or Good Citizenship Behaviors by giving them stars and prizes for their good choices, with one star-shaped hole punched into their nametag for each behavior in their group, and then with a Reward Day each week when they could trade 10 stars for one small prize. Lunch observers used the prepared datasheets used during baseline conditions to record FVFIRST and HDRINK behaviors, while also noting any reprimands children received from lunch staff for talking too loudly, making a mess, or showing disrespect to others. Lunch observers were kept blind as to children’s group assignments as they completed their lunchtime datasheets, which were then handed over to other research assistants who walked down the lunch tables, flipped over each child’s nametag to read the small print showing each child’s group assignment, and punched stars into the child’s nametag according to how many of the ‘‘Good Citizenship Behaviors’’ or ‘‘Good Health Behaviors’’ were recorded on the datasheet. Children were also told that they could earn extra stars if their parents reported their behaviors during five dinner meals at home, with children dropping Parent Records in their classroom’s weekly Collection Box (with one star given for each dinner and for each mealtime behavior reported, according to their group assignment

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to ‘‘LIONS’’ or ‘‘TIGERS’’). Collection Boxes were used to gather children’s nametags, pedometers, and Parent Records during baseline and reward conditions. During the reward phase, research assistants totaled children’s stars according to their group assignments, so that on Reward Day children could trade 10 stars for one prize. Pedometer records to measure EXERCISE Pedometers were used to record EXERCISE steps each week for all 382 children across two study phases: one month of baseline conditions, three months of reward conditions. Pedometers were chosen to record EXERCISE because we believed they would serve as a cue or prompt to remind children to exercise, and they allowed children more individualized exercise choices than procedures using compulsory group exercise as often used in past research (Robinson, 1999). In addition, pedometers have been used successfully as part of the FOOD DUDES program to increase children’s exercise steps by 1500 per day (Horne, Hardman, Lowe, & Rowlands, 2009). Pedometers were gathered each week using the Collection Boxes, the number of steps was recorded for each child, pedometers were reset to zero, and then they were returned to children in Collection Box. If children failed to turn in their pedometers, they were scored as having zero EXERCISE steps for that week. Procedures for Reward Day Reward Days were offered each week so children could trade 10 stars for one small prize (pens, fancy pencils, notebooks, modeling clay, puzzles, banks, toy gliders, stickers, water bottles, playing cards, jump ropes, stuffed animals, balls, silly hats, etc.). A large table was set up in the corner of the lunch room with large plastic bins containing a selection of five or six prizes. During the last 10 min of the lunch period for each grade, children were called by classroom to line up along the edge of the lunchroom to approach the table and trade their 10 stars for a prize of their choice. Children were given new nametags each week, but allowed to keep leftover stars toward the next week’s Reward Day. Procedures to measure BMI% changes in overweight and averageweight children The school nurse measured children’s height and weight at four points in time: one year before the present study, at baseline conditions, during follow-up conditions two weeks after KCP application, and during follow-up conditions six months later. She had over 10 years of experience taking such measurements for children in the school district, and she remained blind to children’s group assignments. Children were measured on days with similar temperatures, and children were asked to remove their shoes, coats, and heavy sweaters. Measurements were taken with standardized scales during 2 h before lunch, or at least 1 h after lunch so that children’s weight would not be altered significantly by foods consumed at lunch. The nurse calculated children’s body mass index (BMI = lb/in.2  704.5), then used standard charts provided by the Centers for Disease Control and Prevention to determine each child’s z-score or body mass index percentile (BMI%) in comparison to children of the same age and gender. Of the total 382 children in the present study, 341 (89.3%) had BMI% scores available, with 11 (3.2%) being underweight with BMI% scores less than the 10th percentile, with 210 (61.6%) being average-weight with BMI% scores between the 10th and 85th percentile, and with 120 (35.2%) being at risk for overweight or obesity with BMI% scores above the 85th percentile. Of the 120 children with overweight BMI% scores, 112 (93.3%) children had BMI% scores for the first three study phases that

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included the year before baseline, baseline, and the end of the three-month KCP application (68 boys and 44 girls; 29 1st graders, 28 2nd graders, 27 3rd graders, and 28 4th graders), with 98 (87.5%) of these 112 overweight children also present for the six month follow-up BMI% measurements (57 boys and 41 girls; 21 2st graders, 25 2nd graders, 26 3rd graders, and 26 4th graders). Of these 112 overweight children, 89 (79.5%) had complete records for their FVFIRST, HDRINK, and EXERCISE changes from baseline to reward conditions so that multiple regression could examine which behavior change explained the most variance in BMI% changes for overweight children (54 boys and 35 girls; 18 1st graders, 24 2nd graders, 26 3rd graders, and 21 4th graders). Of the 210 children with average-weight BMI% scores, 200 (95.2%) had BMI% scores for the first three study phases that included the year before baseline, baseline, and the end of the three-month KCP application (99 boys and 101 girls; 38 1st graders, 53 2nd graders, 57 3rd graders, and 52 4th graders), with 186 (93.0%) of these 200 average-weight children also present for the six month follow-up measurements (90 boys and 96 girls; 32 2st graders, 50 2nd graders, 55 3rd graders, and 49 4th graders). Of these 200 average-weight children, 129 (64.5%) had complete records for their FVFIRST, HDRINK, and EXERCISE changes from baseline to reward conditions so that multiple regression could examine which behavior change explained the most variance in BMI% changes for average-weight children (65 boys and 72 girls; 24 1st graders, 34 2nd graders, 36 3rd graders, and 35 4th graders). Procedures to evaluate the KCP when delivered by parent volunteers To examine whether small teams of parent volunteers could validly and effectively deliver the KCP to increase children’s FVFIRST, HDRINK, and EXERCISE behaviors, we used two brief study phases six months after the KCP application at the school: one week of baseline conditions (three days per week), one week of reward conditions (three days per week). We focused only on children in the 2nd and 3rd grades because they had back-to-back lunch periods, which reduced the total time we asked the parent volunteers to contribute. All 182 children in the 2nd and 3rd grades were given nametags and pedometers to wear at school for two weeks (98 boys and 84 girls; 97 2nd graders and 85 3rd graders). Of the 182 children, 111 (61.0%) children were observed eating the school-provided lunch for at least two of the three meals in both baseline and reward conditions (66 boys and 45 girls; 56 2nd graders and 55 3rd graders). For measures of FVFIRST, HDRINK, and EXERCISE under one week of baseline conditions, four trained observers from the previous study waited until children had been seated for the first 10 min of their 30 min lunch period, then walked along the lunch tables to record children’s behaviors. The three behaviors were defined as before, except that the very time-sensitive behavior of FVFIRST was now defined as eating 1/8 cup or more of FV sometime in the first 10 min, rather than eating FV as the very first food during the meal. (NOTE: This slight change in the definition of FVFIRST made it less time sensitive and easier for the parent volunteers to use, while still encouraging children to eat FV early in the meal when they were most hungry.) Children had been told that the Penn State Team had no more prizes, but they had returned to see what a normal, everyday lunch was like at their school. For measures of FVFIRST, HDRINK, and EXERCISE under one week of reward conditions delivered by parent volunteers, children were told that some new prizes had been found and they could now earn one star punched into their nametags for each of three healthy behaviors: (1) eating FV during the first 10 min of lunch, (2) choosing a low-fat and low-sugar healthy drink, and (3)

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Procedures to evaluate KCP acceptability and costs To measure acceptability of KCP components and options according to school staff, a brief and anonymous questionnaire was distributed at the end of the three-month KCP application to 31 school staff members (such as the principal, school secretary, school nurse, cafeteria staff, custodians, and 1st–4th grade teachers). School staff were asked to rate the acceptability of various program features using a five-point scale (from 1 = not at all to 5 = very much). To estimate costs of the Kid’s Choice Program in U.S. dollars per child per month of application, we recorded expenses for the primary supplies needed, which included the nametag necklaces, the pedometers, and the small prizes used for Reward Day. Results Changes in children’s FVFIRST and HDRINK

large sample sizes and power of these ANOVAs, we used a conservative criterion of p < .01. ANOVA results found significant study-phase main effects for both FVFIRST and HDRINK (F(4, 976) = 86.62, p = .000, partial Eta2 effect size = .262; F(4, 976) = 150.77, p = .000, partial Eta2 effect size = .382; respectively), indicating that both the KCP group and the control group increased these healthy food choices from baseline conditions through reward conditions (see Fig. 1a and b). ANOVA results also found significant study phase  study group interaction effects for FVFIRST and HDRINK (F(4, 976) = 23.33, p = .000, partial Eta2 = .087; F(4, 976) = 69.51, p = .000, partial Eta2 = .222; respectively). [()TD$FIG] From baseline to the end of reward conditions, the KCP group

FVFIRST (# MEALS)

a

6 5 4 3 KCP

2

control

1 0 baseline

reward (block 1)

reward (block 3)

reward (block 4)

b

6 5 4 3 KCP

2

control

1 0 baseline

reward (block 1)

reward (block 2)

reward (block 3)

reward (block 4)

STUDY PHASE

c

40000 30000 20000 KCP control

10000 0 baseline

To examine the KCP effectiveness for increasing children’s FVFIRST and HDRINK during school lunch, 2  4  5 repeatedmeasures ANOVAs were conducted with two study groups (KCP and control) and four grades (1st–4th) serving as between-subjects variables, and with five study phases serving as the within-subjects variable (one six-meal block under baseline conditions, four sixmeal blocks under reward conditions). FVFIRST was measured as the number of six meals for which children ate 1/8 cup FV first during the meal. HDRINK was measured as the number of six meals for which children chose a low-fat and low-sugar healthy drink. (NOTE: To keep sample sizes as large as possible, we included in these analyses all children observed eating school-provided lunches for at least 6 of the 12 meals in baseline conditions, and for at least 24 of the 34 meals in reward conditions. These observed meals extended across the full three-month KCP application, but interspersed with home-packed lunches.) Because of the relatively

reward (block 2)

STUDY PHASE

HDRINK (# MEALS)

having 5000 exercise steps recorded on their pedometers (with additional stars for additional sets of 5000 steps). At the end of the week, a Reward Day was presented, with five stars earning one small prize. The parent volunteers had been recruited through the Parent Teacher Organization (PTO) and eight female parents responded, with two to four parents coming to school lunch on each of the three days of KCP application (for a ratio of approximately 1 parent volunteer needed for every 50 children). Training of the parent volunteers required only 5 min, during which they were given a one-page description of KCP goals and procedures, a star-shaped hole-puncher, and a ping-pong ball as a visual reminder of the 1/8 cup of FV children were required to eat to earn one star. To check the validity of the parent volunteer’s behavior definitions, trained observers walked along the lunch tables ahead of the volunteers to record FVFIRST, HDRINK, and EXERCISE, then the parent volunteer verbalized her decision for each child’s star delivery, and the observer noted whether their decisions agreed. For 25 children simultaneously observed in this manner, mean agreement scores were 100% for FVFIRST, 95% for HDRINK, and 90% for EXERCISE. To include as large a sample as possible for analyses, FVFIRST and HDRINK were defined as the number of the first two observed meals for which these behaviors occurred, and EXERCISE was defined as the number of pedometer steps recorded on the first day in each study phase. Of 182 children in 2nd and 3rd grades, 111 (61.0%) children completed these observations of the school-provided lunch (66 boys and 45 girls; 56 2nd graders and 55 3rd graders), and 124 (68.1%) children completed these observations of pedometer steps (70 boys and 54 girls; 74 2nd graders and 50 3rd graders).

EXERCISE (# STEPS)

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reward (month 1)

reward (month 2)

reward (month 3)

STUDY PHASE Fig. 1. Changes in children’s three weight management behaviors: (a) FVFIRST = the number of six meals in which children ate 1/8 cup FV first during the meal across four study phases: one six-meal block under baseline conditions, four six-meal blocks under reward conditions (120 KCP and 132 control). ANOVA revealed a study group  study phase interaction in which the KCP group increased FVFIRST from baseline through reward conditions more than did the control group (p = .000). (b) HDRINK = the number of six meals during which children chose a low-fat and lowsugar healthy drink across four study phases: one six-meal block under baseline conditions, four six-meal blocks under reward conditions (120 KCP and 132 control). ANOVA revealed a study group  study phase interaction in which the KCP group increased HDRINK from baseline through reward conditions more than did the control group (p = .000). (c) EXERCISE = the number of steps recorded on pedometers across four study phases: one month in baseline, three months in reward conditions (193 KCP and 189 control). ANOVA revealed a study group  study phase interaction in which the KCP group increased EXERCISE steps more from baseline through reward conditions than did the control group (p = .000).

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increased their FVFIRST behavior by 2.31 meals (of six meals observed), while the control group increased it by only .72 meals. From baseline to the end of reward conditions, the KCP group increased their HDRINK behavior by 3.46 meals, while the control group increased it by only .52 meals. No study phase  study group  grade interactions were significant for either FVFIRST or HDRINK (F(12, 976) = 1.81, p = .043; F(12, 976) = 1.07, p = .380; respectively). Only 20% of parents returned Parent Records that reported children’s behaviors in the home environment. However, t-tests to compare the 48 KCP and 27 control children (randomly assigned to their groups) who regularly brought home-packed lunches found that parents of KCP children PACKED FV in these lunches significantly more than parents of control children (t(73) = 2.48, p = .016), with a mean of 1.73 meals (of three meals) that FV were packed for KCP children in comparison to 1.00 meals for control children. KCP children also ate FVFIRST from their home-packed meals more than did control children (t(73) = 5.07, p = .000), with a mean of 1.17 meals for KCP children in comparison to .07 meals for control children. In addition, KCP children chose HDRINK more than did control children (t(73) = 2.01, p = .048), with a mean of 1.90 meals for KCP children in comparison to 1.30 meals for control children.

children in the present study, 278 (72.8%) had complete records (131 KCP and 147 control; 155 boys and 123 girls, 73 1st graders, 70 2nd graders, 68 3rd graders, and 67 4th graders). For EXERCISE, a secondary data file was created from pedometer records, with the dependent variable being the total pedometer steps during the second month of reward conditions, with the independent variable of reward being the child’s group assignment (KCP and control), and with the covariate of peer modeling being the mean pedometer steps that month for children in the same classroom. All 382 children in the present study had complete records available (192 KCP and 189 control; 211 boys and 171 girls, 97 1st graders, 94 2nd graders, 100 3rd graders, and 91 4th graders). ANCOVA results revealed that the offer of reward was significantly associated with all three behaviors (for FVFIRST, F(1, 275) = 55.67, p = .000; partial Eta2 = .168; for HDRINK, F(1, 275) = 146.37, p = .000; partial Eta2 = .347; for EXERCISE, F(1, 379) = 7.96, p = .005; partial Eta2 = .021). ANCOVA results also revealed that the peer modeling covariate was significantly associated with all three behaviors (for FVFIRST, F(1, 275) = 25.23, p = .000; partial Eta2 = .084; for HDRINK, F(1, 275) = 36.11, p = .000; partial Eta2 = .116; for EXERCISE, F(1, 379) = 32.11, p = .000; partial Eta2 = .078).

Changes in children’s EXERCISE

Changes in BMI% for overweight and average-weight children

To examine effectiveness of the KCP for increasing children’s EXERCISE behavior as recorded on pedometers, a 2  4  4 repeated-measures ANOVA was conducted with two study groups (KCP and control), four grades (1st–4th), and four study phases (one month block of pedometer records under baseline conditions, three one-month blocks of pedometer records under reward conditions). EXERCISE was measured as the number of pedometer steps recorded in each month block. Because of the relatively large sample size, we again used a conservative criterion value of p < .01. ANOVA results found a significant study-phase main effect for EXERCISE (F(3, 1122) = 7.33, p = .000; partial Eta2 = .019), indicating that both the KCP and control groups increased EXERCISE steps from baseline through reward conditions (see Fig. 1c). ANOVA results also found a study phase  study group interaction effect (F(3, 1122) = 3.99, p = .008; partial Eta2 = .011). From baseline to the end of reward conditions, the KCP group increased EXERCISE by 11,971 per month, while the control group increased it by only 758 steps. No study-phase  study-group  grade interaction effects were found.

To see if the KCP application had immediate effects on BMI% scores for overweight children within the sample, a 2  3 repeatedmeasures ANOVA was conducted with two study groups (KCP and control) and with three study phases (one year before, baseline, and end of three-month KCP application). The dependent variable was the BMI% score for the 112 children with BMI% values above the 85th percentile the year before, with a low degree of skewness ( .4) found for this distribution of BMI% scores. ANOVA results found only a study phase main effect (F(2, 220) = 10.05, p = .000; partial Eta2 = .084) showing that overweight children from both KCP and control groups decreased their BMI% across the three study phases. Post hoc comparisons revealed no change in BMI% scores for overweight children from the year before to baseline conditions (tcorr(111) = .85, p = .398), but with a significant decrease in BMI% only after the three-month KCP application (tcorr(111) = 3.49, p = .001; with a mean drop of 2.6 in their BMI%) (see Fig. 2a). To see if these BMI% decreases for overweight children lasted until six months later, a 2  2 repeated-measures ANOVA was conducted with two study groups (KCP and control) and two study phases (end of KCP and six months later). Of 112 overweight children, 98 (87.5%) were present for BMI% measurements at both study phases. ANOVA results found only a study phase main effect (F(1, 96) = 14.54, p = .000; partial Eta2 = .132) showing that overweight children from both KCP and control groups had increases in BMI% scores from the end of the KCP application to six months later (with a mean increase of 1.5 in BMI%) (see Fig. 2b). To see if the KCP application had immediate effects on BMI% scores of average-weight children within the sample, another 2  3 repeated-measures ANOVA was conducted with two study groups (KCP and control) and three study phases (one year before, baseline, end of KCP). The dependent variable was the BMI% score for the 200 children with BMI% values between the 10th and 85th percentile the year before, with a low degree of skewness ( .5) found for this distribution of BMI% scores. ANOVA results found only a significant study phase main effect (F(2, 396) = 3.55, p = .030; partial Eta2 = .018) showing that average-weight children from both KCP and control groups decreased BMI% across the three study phases. Post hoc comparisons revealed no change in BMI% for average-weight children from the year before to baseline (tcorr(199) = .79, p = .428), but with significant decreases in BMI% only after the three-month KCP application (tcorr(199) = 2.16, p = .032; with a mean

Examination of reward and peer modeling as effective KCP components To examine the separate effects of the two KCP components we believe most associated with children’s display of FVFIRST, HDRINK, and EXERCISE, we conducted one-way ANCOVAs for each of these outcome behaviors with the offer of reward serving as an independent variable (YES = KCP group, NO = control group), and with a measure of peer modeling serving as a covariate. For FVFIRST and HDRINK, we created a secondary data file from school lunch observation records for the second month of reward conditions when children were likely to be very familiar with the school program. Dependent variables for these ANCOVAs were the number meals children ate FVFIRST and chose HDRINK. The independent variable of reward was the child’s group assignment (KCP and control), and the covariate of peer modeling was the number of adjacent peers at the lunch table who displayed FVFIRST and HDRINK behaviors for each of the six observed meals. For example, a child could have 0–2 adjacent peers who modeled FVFIRST during each observed meal, with a possible range of 0–12 adjacent peer models for FVFIRST across all six observed meals. Of the total 382

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STUDY PHASE Fig. 2. (a) Changes in BMI% for 112 overweight children (53 KCP and 59 control) across three study phases: the year before, baseline conditions, after a three-month KCP application. ANOVA revealed a significant main effect for study phase, with both KCP and control groups showing no change in BMI% from the year before to baseline conditions, with significant decreases in BMI% only after the KCP application (with a mean drop of 2.6 in BMI%). (b) Changes in BMI% for 98 overweight children (45 KCP and 53 control) across two study phases: after the KCP application, six months later. ANOVA revealed a significant main effect for study phase, with both KCP and control groups showing significant increases in BMI% from the end of the KCP application to six months later (with a mean increase of 1.5 in BMI%).

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drop of 2.4 in their BMI%) (see Fig. 3a). To see if these BMI% decreases for average-weight children lasted until six months later, a 2  2 repeated-measures ANOVA was done with two study groups (KCP and control) and two study phases (end of KCP, six months later). Of 200 average-weight children, 186 (93.0%) had BMI% measurements at both study phases. ANOVA results found no significant effects for study phase (p = .158), study group (p = .910), or study group  study phase (p = .396) (see Fig. 3b).

65

To examine which of the three weight management behaviors (FVFIRST, HDRINK, and EXERCISE) best explained the improvements seen in BMI% scores for overweight children, multiple regression was conducted with the outcome variable measured as BMI% change from baseline to the end of the three-month KCP application (end-of-KCP BMI% baseline BMI%), and with the change in children’s FVFIRST, HDRINK, and EXERCISE behaviors from baseline to reward conditions serving as predictor variables. For FVFIRST and HDRINK, behavior change was calculated as the mean number of six meals the behavior occurred in reward conditions, minus the number of six meals the behavior occurred in baseline conditions. For EXERCISE, behavior change was calculated as the mean number of pedometer steps per month in reward conditions, minus the number of steps per month of baseline conditions. Results revealed an R2 value of .10 (F(3, 85) = 3.00, p = .035), meaning that the set of three behaviors explained 10% of BMI% changes for overweight children. More specifically, changes in the overweight children’s EXERCISE (measured with pedometers) was unrelated to the changes in their BMI% scores (beta = .034, p = .743). Also surprising was the finding that the more overweight children increased their FVFIRST behavior, the more their BMI% increased from baseline to the end of the KCP application (beta = .316, p = .006). In contrast, the more overweight children increased their HDRINK choices, the more their BMI% decreased from baseline to the end of the KCP application. To examine which of the three behaviors (FVFIRST, HDRINK, and EXERCISE) best explained the improvements seen in BMI% scores for average-weight children, multiple regression was conducted with BMI% change from baseline to the end of KCP serving as the outcome variable, and with changes in FVFIRST, HDRINK, and EXERCISE serving as the predictor variables (and measured as above for the analysis with overweight children). Results revealed that changes in the three behaviors were not significantly associated with changes in BMI% for average-weight children (F(3, 125) = 1.83, p = .146). Effectiveness of KCP when delivered by parent volunteers

60 KCP

55

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STUDY PHASE Fig. 3. (a) Changes in BMI% for 200 average-weight children (102 KCP and 98 control) across three study phases: the year before, baseline conditions, after a three-month KCP application. ANOVA revealed a significant main effect for study phase, with both KCP and control groups showing no change in BMI% from the year before to baseline conditions, with significant decreases in BMI% only after KCP application (with a mean drop of 2.4 in BMI%). (b) Changes in BMI% for 186 average-weight children (94 KCP and 92 control) across two study phases: after the KCP application, six months later. ANOVA revealed no significant effects, suggesting the improved BMI% scores lasted until six months after the KCP application for average-weight children.

To examine whether small teams of parent volunteers could effectively deliver the KCP to increase children’s FVFIRST, HDRINK, and EXERCISE behaviors, 2  2 repeated-measures ANOVAs were conducted with the two grades (2nd and 3rd) and three study phases (one week of baseline conditions, one week of KCP conditions). FVFIRST was defined as the child eating 1/8 cup or more of FV (‘‘the size of a ping pong ball’’) during the first 10 min of school lunch. HDRINK was defined as the child choosing a low-fat and low-sugar healthy drink. EXERCISE was defined as the number of steps per day recorded on pedometers (see Fig. 4). Results found a significant study phase main effect for all three behaviors, indicating that the brief KCP delivered by parent volunteers significantly increased children’s FVFIRST (F(1, 109) = 57.18, p = .000; partial Eta2 = .344), HDRINK choices (F(1, 109) = 53.23, p = .000; partial Eta2 = .328), and EXERCISE steps (F(1, 122) = 12.64, p = .001; partial Eta2 = .094).

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(1) Nametag necklaces were worn by the children to individualize delivery of token rewards for their healthy behavior choices with holes punched into nametags. Because nametags and hole-punchers could be provided from supplies typically available at school, these KCP materials were virtually costfree. For greater durability, nametags could also be laminated using equipment found in many schools. (2) Pedometers used in the present KCP application to record children’s EXERCISE were a costly but unnecessary option (at approximately five U.S. dollars per child per month). For example, in other KCP applications, we have used the first 10 min of recess to observe whether or not children were actively moving, with each observer scanning a section of approximately 25 children, then delivering some type of token reward to them (such as holes punched into their nametags, stickers, and soft rubber bracelets). (3) Small prizes for which children traded their stars on weekly Reward Days were the primary expense of the Kid’s Choice Program (at approximately two U.S. dollars per child per month). The inexpensive items used as prizes were available in bulk from a variety of venders, with some prizes donated by local community businesses. Discussion

0 baseline

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c

8000

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7000 6000 5000 4000 3000 2000 1000 0 baseline

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STUDY PHASE Fig. 4. Changes in weight management behaviors when the KCP is delivered by parent volunteers. (a) FVFIRST = significant increases in the meals that 111 children ate 1/8 cup FV first from baseline to KCP conditions (p = .000). (b) HDRINK = significant increases in the meals that 111 children chose low-fat and low-sugar healthy drinks from baseline to KCP conditions (p = .000). (c) EXERCISE = significant increases in pedometer steps per day for 124 children from baseline to KCP conditions (p = .001).

KCP acceptability and costs To measure KCP acceptability according to the 31 school staff, we calculated their mean five-point ratings for various KCP components ‘‘for long-term application throughout the school year’’ (see Fig. 5). Highest acceptability ratings were given to the program options of the three weight management behaviors as targets (FVFIRST, HDRINK, and EXERCISE), children wearing nametags, star-shaped holes punched into nametags as token rewards, weekly Reward Days, inclusion of Parent Records to report children’s behaviors in the home environment, and parent volunteers delivering the program. Least acceptable program options were pedometers (which children forgot, lost, or broke), and the use of busy school staff themselves to deliver the program. Finally, when asked to report the overall acceptability of the KCP ‘‘for long-term application,’’ the school staff have a mean rating of 3.8 (SD = .9). Costs of the KCP application described in the present study were divided into three categories:

One purpose of the present study was to extend the number of targeted weight management behaviors and the length of application of the Kid’s Choice Program (KCP) to examine if improvements in children’s weight management behaviors would last throughout the three-month application, and to see if decreases in BMI% could be produced for overweight children (as ‘‘intervention’’ for child obesity) and for average-weight children (as ‘‘prevention’’ of child obesity). As in previous onemonth KCP applications (Hendy et al., 2005, 2007, 2008), the present study found that the KCP-targeted behaviors (FVFIRST, HDRINK, and EXERCISE) showed improvements lasting throughout the three-month application, both for children who received the program directly (the KCP group), and for children who only observed it being applied to their classmates (the control group). The present study also revealed that by the second month of KCP application, the frequency of all three behaviors could be explained both by the offer of reward (received by the KCP group) and by incidental peer modeling (experienced by KCP and control groups). These findings suggest that for schools that wish to ‘‘thin’’ the schedule of rewards (both to reduce costs for prizes and to move children closer to ‘‘intrinsic’’ motivation to continue the healthy behaviors they have learned), the second month may be a good time to attempt it because peer modeling effects are present. Most importantly, the present study found that the threemonth KCP application significantly decreased BMI% scores both for overweight children (with mean drops of 2.6 in BMI%) and for average-weight children (with a mean drop of 2.4 in BMI%). These drops in BMI% occurred both for children to whom the program was applied directly (the KCP group) and for those who observed it applied to classmates (the control group), which again supports the effectiveness of both reward and peer modeling components of the KCP application. Present results also documented that averageweight children tend to maintain their drops in BMI% for six months after the KCP application, but overweight children regain some of their lost weight after six months without the program (with a mean increase of 1.5 in BMI%). These results suggest that a more on-going presentation of the KCP may help maintain obesity intervention for overweight children and obesity prevention for average-weight children.

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MEAN ACCEPTANCE RATING

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KCP PROCEDURES Fig. 5. Acceptability ratings given by 31 school staff for KCP procedures at the end of a three-month KCP application at their school. School staff used five-point ratings (from 1 = not at all to 5 = very much) to report their acceptance of each procedure ‘‘for long-term application throughout the school year.’’

Another new feature of the present study was the comparison of three weight management behaviors (FVFIRST, HDRINK, and EXERCISE) for their ability to explain changes in BMI% scores for overweight and average-weight children. For average-weight children, no specific behavior stood out as the best explanation of BMI% drops. For overweight children, EXERCISE was found unrelated to the drops in BMI% scores, suggesting that the low EXERCISE expectation used in the present KCP application (i.e., 5000 steps per week required to earn one ‘‘star’’) was insufficient to produce weight loss. Other researchers have found pedometers can be effective for increasing children’s exercise by 1500 steps per day (Horne, Hardman, Lowe, Tapper, et al., 2009), so perhaps EXERCISE expected by children in the KCP could be raised to 10,000 steps per week. However, even if pedometers can increase children’s EXERCISE to levels that produce weight loss, pedometers have practical problems because they increase KCP costs (from $2 to $7 per child per month) and managing them is not well accepted by school staff. Surprisingly, eating FVFIRST more often was associated with increases in BMI% for overweight children, perhaps because unlike adults who consume fewer mealtime calories when they eat FVFIRST (Rolls et al., 2004), school-aged children usually fail to adjust their mealtime calories after being given a ‘‘preload’’ of FV or other sources of calories (Spill et al., 2010), with overweight children actually more likely to over-eat after receiving such ‘‘preloads’’ (Cecil et al., 2005). In contrast, when overweight children of the present study increased their low-fat and low-sugar HDRINK choices, they showed decreases in BMI%, perhaps because such ‘‘liquid calories’’ tend to produce no adjustments in other mealtime calories consumed (DiMeglio & Mattes, 2000), for a net reduction in calories when a low-fat and low-sugar liquid is chosen, with a gradual reduction in BMI%. For example, if a child switched from his/her usual drink of one pint of 2%-fat sweetened chocolate milk (195 kcal) to one pint of skim milk (86 kcal), that child would consume 545 fewer calories per week. Advantages of the Kid’s Choice Program for long-term school adoption Based on the results from the present study and other KCP evaluations (Hendy et al., 2005, 2007, 2008, 2011), we believe the KCP shows promise for long-term adoption by schools seeking an evidence-based, cost-effective, and easy-to-deliver program to

promote children’s healthy behaviors and to reduce the risk of child obesity. The KCP has been documented to improve CDCPrecommended weight management behaviors for 1st–4th grade children, for boys and girls, for average-weight and overweight children, for fussy eaters, and for children eating the schoolprovided lunch or those bringing a home-packed lunch. The KCP also improves children’s self-reported preference ratings for such healthy behaviors (Hendy et al., 2005, 2007). Most importantly, the present study documents that the KCP can reduce BMI% scores of overweight children (for intervention of child obesity) and of average-weight children (for prevention of child obesity) without singling them out and while children are in their everyday school environment. For schools wishing for more of a ‘‘school–home partnership’’ to reduce child obesity, the KCP includes an optional Parent Report that may be used to encourage children’s healthy behaviors in the home environment. Parents may also participate by serving as one of the parent volunteers who deliver the KCP three days each week, and the present study documents that the KCP can be validly and effectively delivered by small teams of two to four such parent volunteers (with approximately one parent volunteer needed for every 50 children being observed at the same time). The KCP is relatively low in cost at two U.S. dollars per child per month of application (with an additional five U.S. dollars per child per month if pedometers are used to record EXERCISE rather than recess observations). Most of the required supplies are typically found at school and home (e.g., heavy paper or index cards, string or shoelaces, and hole-punchers), and the small prizes used for Reward Day are readily available in bulk from a variety of vendors. These program costs may be reduced further by communitydonated prizes, school fund-drives, and state or federal wellness grants. The program has received high acceptability ratings from children and parents in past research, with a mean rating of 2.9 on a three-point scale for children, and a mean rating of 4.4 on a fivepoint scale for parents (Hendy et al., 2008), and the present study documented a mean rating of 3.8 on a five-point scale for school staff. Limitations and directions for future research One limitation of the present study was that, in order to include as large a sample of children as possible, the analyses excluded

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data from a number of observed meals (including 10 of 34 meals under reward conditions). Although patterns seen in Fig. 1a and b suggest that the KCP-produced increases in children’s healthy food choices (FVFIRST and HDRINK) remained steady across 24 meals, it remains possible that the KCP effectiveness might decrease beyond this point. Another limitation of the present study was that only 20% of parents returned the Parent Records to encourage children’s healthy behaviors in the home environment. Perhaps parent participation would be enhanced if parents were offered more input as to the KCP procedural options included such as the healthy behaviors that would be targeted at school and home (e.g., FVFIRST, HDRINK, and EXERCISE), the volunteers who would deliver the program (e.g., parents, grandparents, high school students, or college students), and the type of small prizes made available on Reward Days. With such parent input, the Kid’s Choice Program might become more of a school/home partnership to encourage children to develop weight management habits in their everyday environments. Finally, the present KCP was conducted with a sample of school-aged children from a small-town in eastern Pennsylvania and with mostly Caucasian children. Future KCP applications could be examined in schools with more regional and ethnic diversity, and they could evaluate the ideal age for which the KCP would have the most lasting impact on healthy behavior choices in children. Past research has documented that preschool-aged children respond well to many KCP components, especially the offer of small rewards and the availability of peer models (Hendy, 1999, 2002; Hendy & Raudenbush, 2000), and some authors believe that two to five years of age may be the most sensitive period in the development of children’s food acceptance patterns (Cashdan, 1994). Vegetables tend to be rejected more than fruits throughout childhood (Carruth, Ziegler, Gordon, & Barr, 2004), but a previous KCP application has documented the program’s effectiveness for increasing consumption of both fruits and vegetables (Hendy et al., 2005). In conclusion, we believe that widespread use of the Kid’s Choice Program in schools has the potential to reduce child obesity and improve public health in the United States. Based on results of the present study, the Kid’s Choice Program is easy to implement, low in cost, and it can serve both as primary prevention to increase healthy behaviors in average-weight children, and as secondary prevention to promote weight loss in overweight children. References Bandura, A. (1997). Self-efficacy: The exercise of control. New York: Freeman and Company. Baranowski, T., Davis, M., Resnicow, K., Baranowski, J., Doyle, C., Lin, L. S., et al. (2000). Gimme 5 fruit, juice and vegetables for fun and health. Outcome evaluation. Health Education and Behavior, 27, 96–111. Baranowski, T., Smith, M., Hearn, M. D., Lin, L. S., Baranowski, J., Doyle, C., et al. (1997). Patterns in children’s fruit and vegetable consumption by meal and day of the week. Journal of American College Nutrition, 16, 216–223. Bauer, K. W., Yang, Y. W., & Austin, S. B. (2004). How can we stay healthy when you’re throwing all of this in front of use? Findings from focus groups and interviews in middle schools on environmental influences on nutrition and physical activity. Health Education and Behavior, 31, 34–36. Birch, L. L., McPhee, L., Shoba, B. C., Pirok, E., & Stineberg, L. (1987). What kind of exposure reduces children’s food neophobia. Looking vs. tasting? Appetite, 9, 171– 178. Blanchette, L., & Brug, J. (2005). Determinants of fruit and vegetable consumption among 6–12-year old children and effective interventions to increase consumption. Journal of Human Nutrition and Diet, 18, 431–443. Budd, G. M., & Volpe, S. L. (2006). School-based obesity prevention. Research, challenges, and recommendations. Journal of School Health, 76, 485–496. Burchett, H. (2003). Increasing fruit and vegetable consumption among British primary schoolchildren. A review. Health Education, 103, 99–109. Carruth, B. R., Ziegler, P. J., Gordon, A., & Barr, S. I. (2004). Prevalence of ‘‘picky/fussy’’ eaters among infants and toddlers and their caregivers’ decision about offering new food. Journal of the American Dietetic Association, 104, S57– S64.

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