Abela, Benjamin III; De Castro, Ricardo; Hernandez, Luisa

1. Evaluation of a Kindergarten-based Nutrition Education Intervention for Pre-school Children in China Abela, Benjamin III; De Castro, Ricardo; Hernandez, Luisa

2. Introduction • Unhealthy behaviours • Develop in early childhood • Parental influences • Education of both children and parents • Pre-school period is an essential time • Formation of behaviors

3. Introduction • Chinese nutrition • Color, smell, taste, apperance, etc. > balance of nutrition • Serve as rewards • Nutritional status improved, but morbidity and mortality haven’t (2002 China National Nutrition and Health Survey) • Morbidity rate malnutrition • High in indigent areas • Morbidity rate excess nutrition • High in urban and rural areas

4. Methods • Sampling • Hefei (capital of Anhui province, Eastern China) • 2 kidgergartens (East and West) • 3 kindergartens (Central) • Stratified randomization • Intervention (1 east – 1 west – 2 central = 4 kindergartens) • 1252 child-parent pairs • Control (1 east – 1 west – 1 central = 3 kindergartens) • 850 child-parents pairs

5. Methods • Sampling • Total children = 2102 • 4-6 years old (2nd to 3rd grade) • Final division • Intervention = 1237 • Control = 831 • Informed consent

6. Intervention Design • 4 intervention kindergartens • Monthly nutrition education sessions over 2 semesters • Interventions • Monthly nutrition curriculums • Nutrition graduate students • Basic nutrition information (National Dietary Guidelines for China) • Skill for food arranging and cooking • Benefits of physical activity • At least 8 lectures or activities per semester during the 1 year period

7. Intervention Design • Interventions • Illustrated book • IG: Nutritional theme • CG: General picture stories • Pamphlets • Nutritional information • IG: Healthy lifestyle behaviors (parents concerns were addressed) • 2 promotional pictures • Providing information about nutrition • Unhealthy behaviors & good lifestyle behaviors

8. Data Collection • Collection • Pre-test (baseline) • Baseline, social and demographic • Age • Gender • Parental education • Family income • Mid-term (6 months) • Post-test (1 year) • Self-administered questionnaires

9. Measures • Self-administered questionnaire • 14 items w/ a 3-point scale (frequently, occasionally and no) • Parental nutritional knowledge scale • 20 items • Correct = 1 • Incorrect = 0 • Cronbach’s a coefficient = 0.771

10. Measures • Parents attitudes • Child’s preferences • Nutritional value of foods • Nutritional needs of the child • Own eating habits • Cost of food • Frequency of consumption (preceding study)

11. Measures • Body weight and body height • Pre-term, midline and post-term • BMI • Nutritional status • Z-scores for height-for-age and weight-for-age (WHO child growth standards)

12. Results: Demographics • No statistically significant differences between Intervention Group (IG) & Control Group (CG) children in age, gender, parents’ education or family income as seen in Table 1

14. Results: Child and Diet-related Behaviours • Changes in unhealthy lifestyle behaviours in IG & CG children between pre-test and post-test are shown in Table 2 • Results suggested that: • Unhealthy snacks, monotonous diet, adult assistance during meals, playing during dinner and watching television during dinner were significantly different between the IG and CG children following the intervention(P<0.05)

15. Results: Child and Diet-related Behaviours • Western-style high-energy food, preference for salty foods, eating candy before meals and eating candy before going to bed were not significantly different • Healthy lifestyle behaviours, such as eating breakfast, taking part in outdoor activities and helping with household duties, improved markedly in IG children (P<0.05) • However, variables such as eating at the table and eating a fixed quantity at a particular time did not change statistically

17. Results: Anthropometry of Children • Height and weight data are shown in Table 3 • Repeated measures ANOVA indicated that height, weight, HAZ and WAZ varied significantly with time for both IG and CG children • No statistically significant differences between IG and CG children in any of the above indices in pre-test, mid-term and post-test assessments

18. Results: Nutritional Knowledge of Parents • Data on parents’ nutritional knowledge are shown in Table 4 • Nutritional knowledge among IG parents increased significantly during the follow-up period • Repeated-measures analysis indicated that the mean scores for nutritional knowledge among IG parents rose significantly from pre-test to post-test (F=13.51, P<0.0001)

19. Results: Nutritional knowledge of parents • However, the nutritional knowledge of CG parents varied little during the same period of time, and there were no significant differences in the mean scores of CG parents’ nutritional knowledge between pre-test, mid-term and post-test evaluations (F=0.27, P=0.7604) • Comparison of nutritional knowledge between IG and CG parents indicated that IG parents performed better than CG parents, especially at mid-term and post-test

21. Results: Parents’ Attitudes to Diet • Parents’ attitudes to managing their children’s diet and eating behaviours at baseline, mid-term and post-test are shown in Table 5 • Attitudes regarding management of the diet changed in some aspects during the intervention

22. Results: Parents’ Attitudes to Diet • In the IG, parents paid more attention to the nutritional value of foods and less to their children’s taste • However, items concerning children’s nutritional needs, parents’ own eating habits and money spent on food were not significantly different between the two groups • Parents appeared to improve their lifestyle behaviours during the intervention

23. Results: Parents’ Attitudes to Diet • Frequency of eating milk, meat, seafood and laver increased significantly in IG while miscellaneous grain crops did not change significantly • Frequency of consuming fast foods and Western-style high-energy foods increased from 24.6% and 13.1% at pre-test to 30.5% and 24.7% at post-test, respectively

25. Discussion • Both genetic and environmental factors play significant roles in growth and development • Adequate nutrition promotes children’s physical development and learning abilities • Critical period of childhood • Eating habits and behaviours are established • Nutrition education improves children’s dietary habits and behaviours

26. Discussion • Kindergarten-based education is a popular method for conducting nutrition intervention for pre-schoolers, and parental involvement influences the effects of any intervention in a positive manner. • Parental influence is especially crucial in developing nutritional behaviours in children.

27. Discussion • The results indicate that a one-year intervention programme produces beneficial behavioural changes among children • Decreasing unhealthy dietary behaviours • Increasing healthy lifestyle behaviours • No significant effect on height and weight

28. Discussion • All parents in the intervention group showed a statistically significant improvement in their general nutrition-related knowledge • Nutrition education and promotion of child growth and development should be the focus of pre-school education to encourage children to develop good dietary habits.

29. Conclusion