Principal Investigator Mildred A. Horodynski, Ph.D., R.N.C. 1 Co-Investigators

1. EARLY HEAD START – MICHIGAN STATE UNIVERSITY Final PARTNERSHIP MEETINGCulturally Sensitive Measurement of Toddler – Parent Mealtime Behaviors Funded By: The Office of Planning, Research and Evaluation of the Administration of Children and Families (OPRE/ACF), Grant Number: 90-YF0046

2. Research Team Principal Investigator Mildred A. Horodynski, Ph.D., R.N.C.1 Co-Investigators Manfred Strommel, Ph.D.1 Holly Brophy-Herb, Ph.D.2 Lorraine Weatherspoon, Ph.D., R.D. 3 1 College of Nursing 2 Department of Family and Child Ecology 3 Department of Food Science and Human Nutrition Funded By: The Office of Planning, Research and Evaluation of the Administration of Children and Families (OPRE/ACF), Grant Number: 90-YF0046

3. Acknowledgment To Our Early Head Start Partners • Capital Area Community Services (CACS-Lansing) Early Head Start, Jump Start, Early Childhood Programs • Carman-Ainsworth (Flint) Early Head Start • City of Detroit Early Head Start • Eight CAP Early Head Start Site • Genesee County Community Action Resource Development (GCCARD) Early Head Start • Jackson County Community Action Agency Early Head Start • Mid-Michigan Community Action Agency (MMCAA) Early Head Start Sites • Northeast Michigan Community Service Agency (NEMCSA) Early Head Start Sites

4. Acknowledgment To Our Data Collectors

5. Special Recognition of our Participants 199 African American Mother-Toddler Dyads & 200 Non-Hispanic White Mother-Toddler Dyads Who Participated in this Research Study

6. Outline of the Presentation • Celebration of the Project • Summary of the Key Findings • Nutrition Assessment for Toddlers--- Assessment Tools

7. Celebration of the Project

8. Purpose • Collaborative research study designed to develop culturally sensitive measures for assessing parent – toddler mealtime feeding behaviors.

9. Specific Aims • Develop culturally appropriate measures (Phase I) • Test the psychometric properties of the tailored instruments (Phase II) • Provide evidence of validity of self-report mealtime behavior with direct mealtime observation (Phase II) • Develop a training manual and provide training and technical support to Early Head Start Programs (Phase III)

10. Study Design • 3 Phases: • Phase I = Focus Groups • Phase II = Survey & Instrument Validation • Phase III = Nutrition Assessment

11. Phase I: Focus Groups • Two focus groups with 27 African American mothers with toddlers, 12 to 36 months of age. • Goal: Assess cultural appropriateness of the Toddler-Parent Mealtime Behavior Questionnaire.

12. Phase II: Survey • Instrument validation with 399 EHS mother-toddler dyads -199 African American Mother-Toddler Dyads -200 Non-Hispanic White Mother-Toddler Dyads

13. Phase III: Nutrition Assessment • Development of NEAT Toolkit (NEATT) for EHS staff to assess toddler: • Current dietary intake • Eating/feeding behaviors • Eating/feeding concerns/problems • Food safety • Physical activity level

14. Key Findings

15. Participant Characteristics • 399 mother-toddler dyads: 199 African American and 200 Non-Hispanic White • Mean Age: 27 years for mothers (15-66 years) and 25 months for toddlers (11-47 months). • 96% were mothers, 2% grandmothers, 2% other relatives • 71% were single • 58% had no education beyond high school • 46% did not work outside of the home, 20% worked full-time, 16% were employed part-time, and 18% were students • 66% of the families had annual income lower than $20,000.

16. Characteristics of Study Participants (* p<0.05)

17. Mothers’ Body Mass Index (BMI) • <18.5 = Underweight • 18.5 --- 24.9 = Average Weight • 25 --- 29.9 = Overweight • > 30 = Obese

18. Toddlers’ Body Mass Index (BMI) • < 5% = Underweight • 5th --- 84th % = Average Weight • 85th --- 94th % = At Risk of Overweight • > 95% = Overweight

19. Key Findings--- Nutrition Patterns

20. Comparison of African American and Non-Hispanic White Mothers’ Food Consumption

21. Comparison of African American and Non-Hispanic White Toddlers’ Food Consumption

22. Key Findings--- Factors Predicting Quality of Toddlers’ Food Consumption

23. Factors Predicting Quality of Toddlers’ Food Consumption • Mothers’ healthy food consumption predicted in toddlers’ healthy food consumption. -When mothers consumed more healthy foods, toddlers consumed more healthy foods. • Healthy Foods include: • Vegetables • Fruits • Unsweetened cereal • Plain water

24. Factors Predicting Quality of Toddlers’ Food Consumption • Race, toddler’s age, whether more than one child was living in the family, and mother’s unhealthy food consumption predicted toddlers’ unhealthy food eating. -African American families, older toddlers, and households with more than one child consumed unhealthy foods more frequently. -Race predicted both mothers’ and toddlers’ unhealthy food consumption as well as TV watching during family mealtimes. • Unhealthy Foods include: • Canned, packaged or frozen dinners • Sweetened baked goods • Cookies, pastries • Snacks • Fried foods • Sweetened cereal • Sweetened drinks

25. Key Findings--- Family Television Watching During Mealtime

26. Maternal factors (depression, lower education, and minority status) predict TV watching during mealtime. • Race, education, and depression predicted TV watching during mealtime. • African American mothers watched TV more frequently during mealtime. • Mothers with less education watched TV more frequently during mealtime. • Depressed mothers watched TV more frequently during mealtime.

27. The more TV is watched during mealtime, the poorer the quality of maternal food intake • Maternal Quality of Food Intake • Maternal Healthy Food intake: • Mothers with higher education, less depression, and less TV watching during mealtime consumed healthy foods more frequently. • Maternal Unhealthy Food Intake: • African American mothers, younger mothers, and mothers who watched more TV during mealtime consumed unhealthy foods more frequently.

28. The quality of maternal food intake predicts the quality of toddlers’ food intake • Toddler Quality of Food Intake: • Toddler Healthy Food Intake: • Toddlers whose mothers consumed more healthy food consumed more healthy food. • Toddler Unhealthy Food Intake: • Older toddlers, and toddlers whose mothers consumed more unhealthy food consumed more unhealthy foods.

29. Key Findings--- Toddler Food Portion Sizes

30. Toddlers’ Food Portion Sizes • The mothers were asked to provide their toddlers’ usual meal portion as follows:

31. Toddlers’ Food Portions • Food portion Sizes : - (A) Appropriate Portion Size - (B) Slightly Large Portion - (C+D) Oversized Portion • Findings showed that toddlers’ food portion was influenced by two variables • Race • Gender

34. Key Findings--- Mothers’ Perception and Toddlers’ Food Portion Size

36. Mothers’ Perception of their Toddlers’ Weight Compared to their Real Weight Yellow: Mothers “overestimate” weight Purple: Mothers “underestimates” weight Lavender: Mothers “realistic” estimate weight

38. Mothers’ Perception of their Toddlers’ Weight by Race

39. Mothers’ Perception and Food Portion Size

40. Nutrition Assessment for Toddlers • Mealtime Behavior Assessment • Toddler Parent Mealtime Behavior Questionnaire (TPMBQ) • Mealtime Behavior Observation (MO) • Nutrition Education and Assessment for Toddlers Toolkit

41. Mealtime Behavior Assessment • Toddler Parent Mealtime Behavior Questionnaire (TPMBQ) • Mealtime Behavior Observation (MO)

42. Mealtime Behavior Assessment--- TPMBQ • Toddler Parent Mealtime Behavior Questionnaire (TPMBQ) • 35 items • Measure of parents’ self-report of toddler eating and mealtime behaviors. • Approximately 15 minutes to complete. • 5-point Likert response scale how often the behavior occurs (i.e., never, rarely, sometimes, often, always).

43. Mealtime Behavior Assessment--- TPMBO • Parent-Toddler Mealtime Behavior Observation (TPMBO) • The Mealtime Observation (MO) was developed as a companion to the TPMBQ. • 29 items • Measure of the observed toddler eating and mealtime behaviors. • Approximately 20 minutes to observe and complete depending on the family mealtime duration. • A trained observer indicates on a 4-point Likert response scale how often the behavior occurs (i.e., “never/not at all”, “at times/occasionally”, “often”, and “throughout the entire meal”).

44. Instrument Validation • Test-Retest Reliability of TPMBQ & MO • Both self-report and observational measures contain three scales, the Mealtime Television Watching, the Mother Mealtime Socialization, and the Mother Mealtime distress. • These three scales were tested for its test-retest reliability. • Cross Validation of TPMBQ & MO • Mealtime Television watching had “high” consistency • Mother Socialization during mealtime had “moderate” consistency. • Mother Distress during mealtime had “low” consistency.

45. NEATT Nutrition Education and Assessment For Toddlers Toolkit (NEATT)

46. NEATT Toolkit • The NEATT includes three components: • a questionnaire with three different versions, a short version, a long version and a long version with action message; • 26 folders with 37 handouts; and • and a box (toolkit) with materials symbolizing a toddler’s stomach size and appropriate portion sizes for toddler’s food consumption.

47. NEATT Toolkit Update • CDI Question 1-Fruit and Vegetable Consumption • CDI Question 2 and 3-Tips for Lowering Dietary Sugar • CDI Question 2-Tips for Lowering Dietary Fat • CDI Question 3-Sugar in Beverages • CDI Question 4-Choking Hazards • CDI Question 6C-How To Cook • CDI Question 6C-Sample Menu recipes • CDI Question 6E - Food Labels • CDI Question 6E-Food Shopping • FS Extra Handout - Kitchen Safety • PF Question 1-Physical Fitness for all Seasons • PF Question 1 - Physical Activity for 2&3-year olds

48. Nutrition Assessment for Toddlers • Comparison of TPMBQ, MO and NEATT • Purposes • TPMBQ is a self-report measure completed by parents. • Participants might report what they “should have” done, not what they “have” done. • MO is an observationalmeasure completed by a trained observer, such as a home visitor/data collector. • Observers usually make references based on a one-time observation. It may not be the “usual” family behaviors. • The NEATT is designed for assessment and educational purposes. • Risk Score ( Appendix 8)> 10  a referral should be made to a nutritionist.

49. Reminder of Using Assessment Tools • It is important to remember that toddlers’ growth changes rapidly. • It is important to pay attention to the “pattern” of family mealtime, feeding, and/or eating behaviors. • Caution must be used to not make any conclusions based on a single observation or assessment. • Assessment provides educators the tools to educate the family about toddler feeding strategies and nutrition information.