- Email: [email protected]
Promotion of healthy eating habits in children
850
Editorial correspondence
The Journal of Pediatrics May 1995
Reply To the Editor: Our article focused on the association between Helicobacterpylori and a diverse group of symptoms in neurologically impaired patients; we did not devote significant attention to the variable nature of clinical presentations. One of our patients who had refusal to feed had been thought to have predominantly a behavioral disorder. Only after documentation of H. pylori infection and a prompt increase in appetite with effective therapy did it become clear that this was not a behavioral disorder. It is our belief that the usual symptoms of H. pylori infection such as nausea, vomiting, dyspeptic symptoms, or anorexia could potentially lead to a number of behavioral responses in the neurologically impaired patient. It will be interesting to observe, as this diagnosis is pursued more aggressively in this group of patients, the full spectrum of clinical manifestations. At the same time, for some of our patients H. pylori infection was coexistent with other gastrointestinal problems, particularly gastroesophageal reflux. Thus attributing a specific behavior or symptom to the presence of H. pylori infection in a specific patient requires demonstration of improvement of this symptom with effective therapy for Helicobacter infection, and documentation of resolution of the infectious process.
Roy Proujansky, MD Stephen Shaffer, MD Nancy Vinton, MD Steven Bachraeh, MD AlJ?ed L duPont Institute Wilmington, DE 19899 9/35/63157
Promotion of healthy eating habits in children To the Editor: I enjoyed the article by Whitaker et al., ~ but was disappointed that the results were only modest. During the study intervention, the selection of low-fat food items by students in the school cafeterias increased by 4% compared with baseline. The intervention involved modifying elementary school lunch menus to emphasize the low-fat entrees. The parents of the students were mailed a package that included a modified menu, an educational pamphlet on healthy diets, and a letter explaining the availability of low-fat diets in the menu. No component of the intervention directly educated the children on the significance of low-fat diets in disease prevention. This specific component is essential for promoting positive behavior change. Behavior change can result from the modification of three types of factors that influence health behaviors--predisposing factors, enabling factors, and reinforcing factorsfl Predisposing factors include individuals' knowledge, attitudes, and beliefs surrounding a particular health issue. Enabling factors provide access to resources or teach particular skills to assist in the modification of the behavior. Reinforcing factors either positively or negatively influence a particular behavior to encourage and maintain behavior change. In
this study, the predisposing factors were not specifically addressed. Encouraging changes in the dietary habits of children for health promotion and disease prevention can be a challenging and difficult task. Effective change can be achieved by multiple and integrative strategies that target all three types of factors that influence the behavior.
Sherry R. Crump, AID Morehouse School of Medicine Department of Community Health and Preventive Medicine 720 Westview Dr. S.W. Atlanta, GA 30310 9/35/63154
REFERENCES 1. Whitaker RC, Wright JA, Koepsell TD, Finch A J, Psaty BM. Randomized intervention to increase children's selection of low-fat foods in school lunches. J PEmATR 1994;125:535-40. 2. Green LW. Prevention and health education. In: Last JM, Wallace RB, eds. Public health and preventive medicine. 13th edt. Norwalk, Connecticut: Appleton & Lange, 1992:787-802.
Reply To the Editor: We agree, in principle, with an approach to dietary interventions that integrates different strategies for behavior change, 1 but we deliberately omitted a direct educational component targeting the students. In choosing among intervention strategies, we considered their potential efficacy, cost, ease of implementation, and generalizability. Failure to consider these factors may lead to designing interventions that cannot be maintained in the study setting after the formal research has ended, or cannot be transferred to other settings where resources are more modest. Our approach, therefore, was to find a minimal, rather than maximal, intervention that would result in changing a specific observed dietary behavior--selection of low-fat foods in school lunches. Unfortunately, there is little evidence that changes in nutrition knowledge, attitudes, or beliefs in children (predisposing factors) are related to changes in observed (as distinct from reported) dietary behavior. 2 The beneficial effects, if any, of classroom nutrition education on eating behavior have been hard to detect. Nutrition education curricula are difficult to implement evenly across units of intervention (schools, classes, or students). School foodservice departments may not have adequate resources, and teachers may already be burdened by competing curriculum demands (e.g., drug use and violence prevention). We also believe that the simultaneous application of different strategies (for example, classroom nutrition education and altered food choice availability) may leave the investigator unable to determine the relative efficacy of each strategy. Those who wish to go on and implement components of a studied, multifaceted intervention may be unable to assess which components of the intervention were most potent. Given these considerations, we decided on two interventions (in-
Editorial correspondence
The Journal of Pediatrics May 1995
Reply To the Editor: Our article focused on the association between Helicobacterpylori and a diverse group of symptoms in neurologically impaired patients; we did not devote significant attention to the variable nature of clinical presentations. One of our patients who had refusal to feed had been thought to have predominantly a behavioral disorder. Only after documentation of H. pylori infection and a prompt increase in appetite with effective therapy did it become clear that this was not a behavioral disorder. It is our belief that the usual symptoms of H. pylori infection such as nausea, vomiting, dyspeptic symptoms, or anorexia could potentially lead to a number of behavioral responses in the neurologically impaired patient. It will be interesting to observe, as this diagnosis is pursued more aggressively in this group of patients, the full spectrum of clinical manifestations. At the same time, for some of our patients H. pylori infection was coexistent with other gastrointestinal problems, particularly gastroesophageal reflux. Thus attributing a specific behavior or symptom to the presence of H. pylori infection in a specific patient requires demonstration of improvement of this symptom with effective therapy for Helicobacter infection, and documentation of resolution of the infectious process.
Roy Proujansky, MD Stephen Shaffer, MD Nancy Vinton, MD Steven Bachraeh, MD AlJ?ed L duPont Institute Wilmington, DE 19899 9/35/63157
Promotion of healthy eating habits in children To the Editor: I enjoyed the article by Whitaker et al., ~ but was disappointed that the results were only modest. During the study intervention, the selection of low-fat food items by students in the school cafeterias increased by 4% compared with baseline. The intervention involved modifying elementary school lunch menus to emphasize the low-fat entrees. The parents of the students were mailed a package that included a modified menu, an educational pamphlet on healthy diets, and a letter explaining the availability of low-fat diets in the menu. No component of the intervention directly educated the children on the significance of low-fat diets in disease prevention. This specific component is essential for promoting positive behavior change. Behavior change can result from the modification of three types of factors that influence health behaviors--predisposing factors, enabling factors, and reinforcing factorsfl Predisposing factors include individuals' knowledge, attitudes, and beliefs surrounding a particular health issue. Enabling factors provide access to resources or teach particular skills to assist in the modification of the behavior. Reinforcing factors either positively or negatively influence a particular behavior to encourage and maintain behavior change. In
this study, the predisposing factors were not specifically addressed. Encouraging changes in the dietary habits of children for health promotion and disease prevention can be a challenging and difficult task. Effective change can be achieved by multiple and integrative strategies that target all three types of factors that influence the behavior.
Sherry R. Crump, AID Morehouse School of Medicine Department of Community Health and Preventive Medicine 720 Westview Dr. S.W. Atlanta, GA 30310 9/35/63154
REFERENCES 1. Whitaker RC, Wright JA, Koepsell TD, Finch A J, Psaty BM. Randomized intervention to increase children's selection of low-fat foods in school lunches. J PEmATR 1994;125:535-40. 2. Green LW. Prevention and health education. In: Last JM, Wallace RB, eds. Public health and preventive medicine. 13th edt. Norwalk, Connecticut: Appleton & Lange, 1992:787-802.
Reply To the Editor: We agree, in principle, with an approach to dietary interventions that integrates different strategies for behavior change, 1 but we deliberately omitted a direct educational component targeting the students. In choosing among intervention strategies, we considered their potential efficacy, cost, ease of implementation, and generalizability. Failure to consider these factors may lead to designing interventions that cannot be maintained in the study setting after the formal research has ended, or cannot be transferred to other settings where resources are more modest. Our approach, therefore, was to find a minimal, rather than maximal, intervention that would result in changing a specific observed dietary behavior--selection of low-fat foods in school lunches. Unfortunately, there is little evidence that changes in nutrition knowledge, attitudes, or beliefs in children (predisposing factors) are related to changes in observed (as distinct from reported) dietary behavior. 2 The beneficial effects, if any, of classroom nutrition education on eating behavior have been hard to detect. Nutrition education curricula are difficult to implement evenly across units of intervention (schools, classes, or students). School foodservice departments may not have adequate resources, and teachers may already be burdened by competing curriculum demands (e.g., drug use and violence prevention). We also believe that the simultaneous application of different strategies (for example, classroom nutrition education and altered food choice availability) may leave the investigator unable to determine the relative efficacy of each strategy. Those who wish to go on and implement components of a studied, multifaceted intervention may be unable to assess which components of the intervention were most potent. Given these considerations, we decided on two interventions (in-