Eat Better, Feel Better T.T. Minor Elementary School

1. Eat Better, Feel Better T.T. Minor Elementary School A program evaluation by University of Washington Nutritional Sciences 531 students Presentation by Laura Fanning and Celia Framson

2. Intervention at T.T. Minor • Part of national initiative: Healthy Eating by Design (HEBD) • HEBD funded by Robert Wood Johnson Foundation • Goal to increase fruit and vegetable consumption among students and their families • T.T. Minor also recipient of USDA Fresh Fruits and Vegetables Program (provided mid-morning snack)

3. Why the Need? • 15% of U.S. children overweight • Prevalence has doubled in past 3 decades • Overweight children have more health complications; more likely to become obese adults • In 2002, estimated costs of treating obesity-related conditions = $92 - $117 billion

4. Still Not Convinced? • World Health Report shows that adequate fruit and vegetable consumption can decrease obesity risk • According to 2001 Youth Risk Behavior Survey only 21% of high school students reported eating at least five servings of fruits and vegetables per day

5. Why Intervene in Schools? • Schools have most continuous contact with young children • Many children eat 2 meals a day at school • Children eat more than half their daily calories at school • Thus school-based interventions have powerful potential to influence dietary behavior

6. Key Project Elements • Goal: Positively impact food environment for students and their families • Multi-component approach, comprising: • Dietitian • Salad bar • Nutrition education • Family nights • Cooking demonstrations • School garden • Mid-morning snack (USDA Fruit and Vegetable Program) http://seattletimes.nwsource.com/html/pacificnw10092005/coverstory.html

7. Evaluation Methods

8. Methods: Study Design • Quasi- experimental design with no baseline data available and no randomization or blinding • MLK chosen as comparison school • Similar demographics • No nutrition intervention • Study only included 5th graders at T.T. Minor and 4th and 5th grade combined class at MLK

9. Methods: Evaluation Tools • Lunchroom observations • Student surveys • Faculty/staff interviews • Parent/guardian interviews

10. Methods: Lunchroom Observations • Trained study staff observed fruit and vegetable intake of participating students during lunchtime • Observations conducted at both schools over a 3 day period • Each observer assigned 1-4 children

11. Lunchrooms TT Minor MLK

12. Methods: Student Survey • Self-administered • Assessed intake • Assessed self-efficacy for choosing fruits and vegetables • Rated on five-category Likert scale from “I disagree very much” to “I agree very much” • Example question: • “For a snack, I think I can choose my favorite fruit instead of my favorite candy bar.”

13. Methods: Key Informant Interviews • Goal to evaluate the perceived effectiveness of the program • Trained study staff interviewed T.T. Minor personnel • n=19 • Also interviewed parents and guardians of T.T. Minor 5th graders • n=11

14. Methods: Key Informant Interviews • Teachers and staff asked about: • Experiences with the program • Eating behavior of the students • Own eating behavior • Parents and guardians asked about: • Foods their families eat • Experiences with T.T. Minor intervention programs

15. Statistical and Qualitative Analysis

16. Statistical Analysis: Lunchroom Observations • Calculated mean consumption per lunch period per school • Compared means at each school using generalized estimating equation • Two-sided p-value < 0.05 considered significant

17. Statistical Analysis: Self-Efficacy • Five Likert categories grouped into two: Disagree or Agree • Between school difference analyzed using: • chi-square test • Fisher’s exact when expected values < 5 • Two-sided p-value < 0.05 considered significant

18. Analysis: Qualitative Data • Answers to interview questions compiled in a spreadsheet • Yes/No responses summarized numerically • For open-ended questions, recurrent issues and emergent themes highlighted and grouped • Results compared between analysis team members to verify interpretation of responses

19. Results!

20. Results: Participation Rates • T.T. Minor • 17/21 participated, rate = 81% • Student decline primary reason for nonparticipation • MLK • 15/20 participated, rate = 75% • Student decline primary reason for nonparticipation http://seattletimes.nwsource.com/html/pacificnw10092005/coverstory.html

21. Results: Specific Self-Efficacy and Intake Questions • 57% of T.T. Minor students agreed they could eat a vegetable served for lunch at school vs. 20% from MLK (p = 0.04) • 63% of students from T.T. Minor reported eating 3 or more fruits vs. 27% from MLK (p = 0.05) • 36% of students from T.T. Minor reported eating 3 or more vegetables vs. 7% from MLK (p = 0.08)

22. Results: Self-Efficacy Questions

23. Results: Lunchroom Observations, Summary Statistics • Over the 3 days, T.T. Minor 5th graders consumed: • 0.07 cups (95% CI: -0.31 - 0.16) fewer fruits than MLK 4th and 5th graders • 0.09 (95% CI: 0.03 - 0.22) cups more vegetables than MLK 4th and 5th graders • 0.01 (95% CI: -0.27 – 0.26) cups fewer total fruits and vegetables than MLK 4th and 5th graders

24. Results: Lunchroom Observations

25. Results: Parent/Guardian Interviews • Participation rate = 55% • Incorrect telephone number primary reason for nonparticipation • Majority of respondents aware of new salad bar and indicated their child/children used it • Majority aware that fresh f/v available for snack and indicated their child/children ate them

26. Results: Parent/Guardian Interviews • Most respondents indicated awareness of nutritionist in school and thought she positively impacted students’ eating patterns • “They have been introduced to food at the food fair. It’s neat! Now they watch for the signs for the farmers’ market because they want to go.” http://depts.washington.edu/uwecor/projects/eatbetter_feelbetter.htm

27. Results: Parent/Guardian Interviews • Almost all respondents indicated their children asked them to buy more fruits and vegetables • Almost all respondents indicated that their child/children are eating more f/v than they did in the previous year • Over half of respondents indicated their family is eating more f/v than they did in the previous year

28. Results: Teacher and Staff Interviews • Participation rate = 59% • Scheduling challenges due to limited time frame main reason for nonparticipation • Most respondents indicated they would like to see the salad bar and morning snacks continue

29. Results: Teacher and Staff Interviews

30. Teacher and Staff Recommendations • Increase variety and accessibility of salad bar items and snacks: • “[I would like to see] more variety of food on the salad bar. It got repetitive after a while.” • “I would like to see the salad bar lowered in height so all kids can reach it.” • Suggestions for the classes and activities: • “Include more in-depth health information at family nights. Set up booth or health fair.” • “Offer more staff education.” • Other suggestions: • “More time with staff. Katie is only here one time per week.”

31. Discussion

32. Discussion • Fruit and vegetable consumption during the lunchroom observations for 5th graders at T.T. Minor and 4th and 5th graders at MLK was quantitatively similar • Qualitative data does suggest positive changes in dietary behavior among students and their families, and school personnel

33. Discussion • Data from self-administered surveys reported: • 63% of students from T.T. Minor ate 3 or more fruits vs. 27% from MLK (p = 0.05) • 36% of students from T.T. Minor ate 3 or more vegetables vs. 7% from MLK (p = 0.08) • Perhaps here we are seeing the effects of the multi-component approach to the EFBB program

34. Discussion • Faculty/ Staff and Parent/Guardian responses overwhelmingly positive: • All teachers indicated students increased f/v intake over the year • 82% of P/G said their children ate more f/v than in the previous year • P/G also indicated their children asked them to buy more f/v than in the past

35. Discussion • Staff also reported making many positive changes for themselves: • 100% indicated they eat more f/v than before EBFB program • 89% said the salad bar at T.T. Minor caused them to eat more f/v than last year • 79% indicated they tried a new f/v during the program • “I work out more because I feel better about what I am eating.”

36. Discussion • Data suggest that T.T. Minor 5th graders exhibited greater self-efficacy • 57% of T.T. Minor 5th graders agreed they could eat a vegetable served for lunch at school vs. 20% of 4th and 5th graders from MLK (p = 0.04) • Literature suggests that increased self-efficacy may play a role in improving fruit and vegetable consumption in children

37. Discussion • Salad bar use declined over the three-day observation period: • Wed = 69%, Thurs = 35%, Fri = 7% • UW student observers reported decreasing variety of f/v offered over the three days • Previous studies found a significant positive association between variety and consumption

38. Limitations

39. Limitations • Difficult to detect small differences with very small sample sizes • Previous evaluations of school-based interventions reporting significant results had sample sizes ranging from 319 - 2684

40. Limitations • Discrepancy between lunch observation data and student, F/S, P/G reports could be due to mid-morning snacks provided by USDA f/v program • Accessibility of f/v may have been a barrier to consumption • Height of salad bar • Whole fruit rather than pre-cut (e.g., oranges)

41. Limitations • Ideal study design is RCT with baseline data and blinding • Our study design assumed control and intervention schools were identical • Limited timeframe for: • Training lunchroom observers • Lunchroom observations • Key informant interviews

42. Limitations • Sources of error: • Observers not blinded to intervention status • Tend to bias toward finding associations • Students aware of being observed – may have altered behavior • Could introduce random error attenuating any association • Self-selection bias among P/G, F/S, and students that agreed to participate • Tend to bias toward finding associations

43. Recommendations and Conclusions

44. Recommendations • Improvements for future evaluations: • Larger sample size • Capture influence of mid-morning snack • Include 24-hr dietary recall • Rigorous training of observers • Collect base-line data • Longer timeframe for data collection

45. Recommendations • Improvements for Eat Better, Feel Better program: • Lower height on salad bar (or install ramp) • Increase variety of f/v • Modify practices to ensure consistent variety throughout the week • Increase availability of pre-cut fruit • Extend lunch period

46. Conclusions • Although lunchtime observation data suggest that students at T.T. Minor did not consume significantly more f/v than students at MLK, important limitations may mitigate ability to detect differences • Qualitative findings suggest that the Eat Better, Feel Better program positively impacts students’ self-efficacy, self-reported f/v intake, and attitudes towards f/v

47. Acknowledgments • Faculty, staff, and students at T.T. Minor and MLK elementary schools • Drew Gagne at T.T. Minor • Rae Richardson at MLK • Dr. Gloria Mitchell at T.T. Minor • Barry Dorsey at MLK • Parents and guardians of T.T. Minor 5th graders • Center for Public Health Nutrition • Donna Johnson, Molly Shaw, Lynne Smith • ECOR • Laura Streichert • Katie Busby, Kirsten Frandsen, Wendy Weyer of Seattle Schools

48. References • Centers for Disease Control and Prevention. Overweight and Obesity: Health Consequences. Retrieved 5/15/2006. http://www.cdc.gov/nccdphp/dnpa/obesity/consequences.htm • Haskins R, Paxson C, Donahue E. Fighting Obesity in the Public Schools. The Future of Children Policy Brief. Spring 2006. • Daniels SR. The Consequences of Childhood Overweight and Obesity. The Future of Children. Vol 16; No.1, Spring 2006. • Koplan JP, Liverman CT, Kraak VI. Preventing childhood obesity: Health in the balance: Executive summary. Journal of the American Dietetic Association, 2005. 105(1): p. 131-138. • Ogden, CL, et al., Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA, 2002. 288(14): p. 1728-32. • Whitaker RC et al., Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med, 1997. 337(13): p. 869-73. • Sallis JF, Glanz K. The Role of Built Environments in Physical Activity, Eating, and Obesity in Childhood. The Future of Children. Vol 16; No.1, Spring 2006. • Gleason P, Suitor C, U.S. Food and Nutrition Service. Children’s Diets in the Mid-1990s: Dietary Intake and Its Relationship with School Meal Participation. Special Nutrition Programs. 2001. No. CN-01-CD1. • The World Health Report 2003: Shaping the Future. Accessed at http://www.who.int/whr/2003/en/whr03_en.pdf. • Grumbaum J, Kann L, Kinchen SA, et al: Youth risk behavior surveillance—United States, 2001. MMWR 51(SS04):1-64. 2002. • French SA, Wechsler H. School-based research and initiatives: fruit and vegetable environment, policy, and pricing workshop. Prev Med: 39 S101–S107. 2004.

49. References • Robert Wood Johnson Foundation. Active Grants: Childhood Obesity. Accessed at www.rwjf.org/portfolios/resources/grant.jsp?id=53324&iaid=138&gsa=1 • Washington State Department of Agriculture News Release. 25 schools set to receive free fresh fruits and vegetables: State is one of four chosen by USDA to offer free, healthy snacks. Oct. 26, 2004. Accessed at http://agr.wa.gov/News/2004/25%20schools%20set%20to%20receive%20free%20fruits%20&%20vegetables.htm. • Glasgow RE, Lichtenstein E, Marcus AC. Why don’t we see more translation of health promotion research to practice (Rethinking the efficacy-to-effectiveness transition). Am J Public Health. 2003;93:1261–1267. • Stables GJ, Young EM, Howerton MW, Yaroch AL, Kuester S, Solera MK, Cobb K, Nebeling L. Small school-based effectiveness trials increase vegetable and fruit consumption among youth. J Am Diet Assoc. 2005 Feb;105(2):252-6. • Economic Research Service (ERS). Evaluation of the USDA Fruit and Vegetable Pilot Program: Report to Congress. USDA, May 2003. Retrieved from http://www.uffva.org/pdf/FVPP.pdf • Eriksen K, Haraldsdottir J, Pederson R, Flyger H. Effect of a 688 fruit and vegetable subscription in Danish schools. Public Health Nutr 2003;6:57-63. • Resnicow K, Davis-Hearn M, Smith M, Baranowski T, Lin LS, Baranowski J, Doyle C, Wang DT. Social-cognitive predictors of fruit and vegetable intake in children. Health Psychol. 1997 May;16(3):272-6. • Blanchette L, Brug J. Determinants of fruit and vegetable consumption among 6-12-year-old children and effective interventions to increase consumption. J Hum Nutr Diet. 2005 Dec;18(6):431-43. • Reynolds, K.D., Hinton, A.W., Schewchuk, R.M. & Hickey, C.A. (1999) Social coginitive model of fruit and vegetable consumption in elementary school children. J. Nutr. Educ. 31, 23–30. • 21. Adams MA, Pelletier RL, Zive MM, Sallis JF. Salad bars and fruit and vegetable consumption in elementary schools: a plate waste study. J Am Diet Assoc. 2005 Nov;105(11):1789-92.

50. Thank You http://seattletimes.nwsource.com/html/pacificnw10092005/coverstory.html