Reducing Solid Fat and Added Sugar Intakes in Low-income Preschoolers through Environmental and Behavioral Portion Size Strategies

<p>NON-TECHNICAL SUMMARY:<br/> The overarching goal of this project is to prevent obesity among low-income preschoolers by reducing excessive energy intakes from foods high in solid fats and added sugars (SFAS). To achieve this goal, the proposed project will systematically translate basic behavioral science around child portion sizes to clinic-based and then community-level nutrition education programming for low-income mothers of young children. We propose to enhance Families Eating Smart and Moving More (FESMM), a widely used Cooperative Extension nutrition education program, with environmental and behavioral parenting strategies targeting SFAS portions. This program will be developed with careful consideration of the ecological context surrounding portion sizes in low-income urban families and will then be rigorously evaluated and ultimately launched in the "real world"
setting of Supplemental Nutrition Assistance Program Education (SNAP-Ed). Phase I will use a two-stage qualitative design to identify contextual issues (i.e. psychosocial, economic) that may influence mothers' acceptance of portion size strategies. Phase II will use these findings to develop, pilot, and then evaluate the efficacy of an intensive, portion size enhanced version of FESMM (PSE-FESMM) in a two-arm RCT. Phase III will adapt the "best" of the intensive PSE-FESMM with input from SNAP-Ed stakeholders and evaluate its translation into practice by training SNAP-Ed educators to teach the curriculum. The project addresses child obesity prevention within the US agricultural priority area of food safety, nutrition and health and aids long-term improvement in US food systems through efforts to bring low-income children's discretionary calories in line with Dietary Guidelines.
<p>APPROACH:<br/> The proposed project will consist of three Phases designed to reach the ultimate endpoint of implementing a nutrition education program emphasizing portion sizes and high SFAS foods with SNAP-Ed mothers of young children. Phase I will use a two-stage qualitative design to identify socio-cultural and economic influences on urban low-income mothers' acceptance of environmental and behavioral portion size strategies. Focus group discussions and ethnographic interviews will be used to obtain information to help tailor the portion size intervention so that it is appropriate and acceptable to the target population. A total of 3 hours of qualitative interview data from each of 30 mothers will be collected. Phase I outputs, focus groups and interviews with low-income mothers, will be evaluated using qualitative data analysis. Phase II will use these findings to
pilot and then evaluate the efficacy of an intensive portion size-enhanced version of the FESMM nutrition education program in a two-arm RCT with 100 mother-child dyads. Authoritative portion size strategies will be shaped, using the findings of Phase I, to target the family food environment, mothers' own eating behaviors, and their child feeding practices. Environmental and behavioral strategies will be emphasized. The clinical RCT setting will provide a high degree of experimental control and allow the collection of secondary behavioral outcomes that would otherwise be difficult to obtain in "usual" SNAP-Ed settings. The main Phase II output, implementation of authoritative portion size strategies by low-income mothers in the PSE-FESMM program, will be evaluated using extensive process and outcome data including child dietary analyses, with child discretionary calories as the main
outcome. Phase III will use the RCT findings to adapt the "best" of the intensive PSE-FESMM for SNAP-Ed and evaluate its translation into practice by training urban SNAP-Ed educators to teach the curriculum. Focus groups with Virginia SNAP-Ed educators will be used to tailor the intervention to SNAP-Ed state and participant needs. Phase III outputs, focus group data on PSE-FESMM materials from SNAP-Ed educators, will be evaluated using qualitative analyses. A single group pre/post-test design will then be employed to evaluate its effectiveness, consistent with SNAP-Ed evaluation methods in 200 mother-child dyads. The main Phase III output, implementation of the PSE-FESMM in Virginia SNAP ED mothers, will be evaluated using process data and analyses of children's diets, with child discretionary calories as the main outcome. Findings and materials will be disseminated through SNAP-Ed and
EFNEP coordinator list-serves, eXtension Families, Food, and Fitness community of practice, and scholarly writing and presentations at annual scientific and SNAP-Ed conferences.
<p>PROGRESS: 2012/03 TO 2013/02<br/>OUTPUTS: The long term goal of the project is to prevent child obesity in preschool aged children by teaching low-income mothers simple behavioral and environmental strategies to promote healthful portion sizes and decreased intake of solid fats and added sugars. This integrated project is being carried out in low-income mothers of preschoolers participating in the educational programs of the U.S. Department of Agricultures Supplemental Nutrition Assistance Program (SNAP). The project commenced in August of 2011. Work undertaken in this project period addressed the second aim of developing an obesity prevention nutrition education program for low-income mothers of preschoolers emphasizing behavioral and environmental parenting strategies around portion size in a clinic-based setting. Activities included developing and pilot testing a
12 week child feeding intervention with 9 low-income mothers of preschoolers who were recruited from WIC programs in Philadelphia. Events included a meeting of the PDs with SNAP-Ed educators in VA who will deliver the final feeding intervention in the last phase of the research. The purpose of the event was to introduce the project and discuss initial ideas for reaching the target population. Other activities included providing education to 1 graduate student who received training in scientific writing as part of writing up the findings from Phase 1 as well as 1 post-doctoral student, 1 graduate student, and 2 undergraduate students who received training in intervention research methods and data collection. Dissemination included a presentation of Phase I findings to nutrition clinical managers at N.O.R.T.H. Inc. which manages WIC in Philadelphia where mothers are being recruited. The
main product produced during the project period was the development of 12 educational modules, including supporting materials and activities, which comprise the child feeding intervention. PARTICIPANTS: Individuals who worked on the project include the project directors (Fisher and Serrano) and co-investigators (Whitaker, Foster, Davey, Harnack). All investigators contributed meaningfully during the reporting period. Whitaker took a lead role in developing manuscripts, Foster and Fisher took a lead role in developing the intervention modules, Serrano took a lead role in setting up connections with SNAP Educators in VA, and Harnack took a lead role in the methods for the main outcome. Collaborators who are supporting the dissemination and evaluation of the feeding intervention in Virginia SNAP-Ed include Dr. Mary McFerrin, Director of the Virginia Family Nutrition Program (FNP), as well
as Gina Kindred and Johanna Hahn who are area coordinators for VA FNP. Training and professional development was obtained by a project coordinator who has a background in Public Health, two graduate students in Public Health, two undergraduate students, and post-doctoral student who has led the group intervention sessions. Partner organizations include N.O.R.T.H. Inc., directed by Dr. Linda Kilby, that has acted as a major community partner by supporting recruitment efforts at WIC for the intervention. TARGET AUDIENCES: One target audience reached during the project period was students and included 1 graduate student who received training in scientific writing as part of writing up the findings from Phase 1 as well as 1 post-doctoral student, 1 graduate student, and 2 undergraduate students who received training in intervention research methods and data collection. A second target
audience reached during the project period was low-income mothers who participated in the 12 intervention and gave high acceptability ratings. A final target audience included Virginia SNAP-Ed administrators and educators who met to discuss initial plans to disseminate and evaluate the intervention in the final phase of this project. PROJECT MODIFICATIONS: Nothing significant to report during this reporting period.
<p>PROGRESS: 2011/03/01 TO 2012/02/28<br/>OUTPUTS: The long term goal of the project is to prevent child obesity in preschool aged children by teaching low-income mothers simple behavioral and environmental strategies to promote healthful portion sizes and decreased intake of solid fats and added sugars. This integrated project will be carried out in low-income mothers of preschoolers participating in the educational programs of the U.S. Department of Agriculture's Supplemental Nutrition Assistance Program. The project commenced in August of 2011, beginning with a full meeting of the investigative team to discuss project goals and timelines. Work undertaken in this project period addressed the first aim of this project which is to understand the contextual factors (i.e. socio-cultural, economic, structural) that will support mothers' acceptance and implementation of the
proposed nutrition education program. To address this aim, the project has conducted a series of focus groups with low-income mothers of preschoolers who are enrolled WIC programs in Philadelphia. To date, 88 mothers have been screened for inclusion, 71 have been eligible to participate. A total of 9 focus groups have been conducted with 39 primarily African American mothers, 16 of whom have participated in more than one group discussion. Weekly meetings have been used to discuss focus group discussions and transcripts as well as emerging themes. Formal analysis of the qualitative data commenced in January of 2012. Other events of note include a meeting with N.O.R.T.H. Inc. which manages WIC in Philadelphia to discuss recruitment of mothers at local WIC clinics for focus group discussions. The investigative team presented the project and recruitment plans at a meeting of WIC clinic
managers in northern Philadelphia. Development activities include a qualitative data analysis seminar attended by the project director (Fisher) and Co-I (Whitaker) as well as project staff. PARTICIPANTS: The main investigative team includes the project directors (Fisher and Serrano) and co-investigators (Whitaker, Foster, Davey, Harnack). Drs. Whitaker and Fisher have led the scientific activities undertaken during the reporting period. They have developed and revised interview guides, led focus group discussion, developed recruitment strategies, supervised project staff, and developed the approach to data analyses. The project staff includes a project coordinator who has a background in Public Health, two graduate students in Public Health, an undergraduate student worker who is majoring in Psychology, and a part-time focus group moderator with extensive sociological training. The
qualitative research conducted during the project period provided research training for all project staff and contributed to degree requirements for two Public Health graduate students. N.O.R.T.H. Inc. which manages WIC in Philadelphia has supported recruitment efforts during the project period and has been a major community partner. Linda Kilby is the Executive Director of N.O.R.T.H. Inc. and has been a major collaborator during the project period. TARGET AUDIENCES: One target audience reached during the project period were the two graduate and undergradate students who have received training in qualitative research methods and data collection. Another target audience reached during the project period were low-income mothers who participated in focus group discussions. Though no formal efforts were made to provide education, a number of mothers commented that the group discussions of
child feeding experiences were interesting, motivating, and provided support. PROJECT MODIFICATIONS: One modification to the Phase I methods was a decision not to conduct one-on-one interviews of low-income mothers in the home setting, in favor of addressing the interview topics in additional focus groups. Specifically, instead of conducting 4-5 focus groups and 40 individual interviews to explore contextual issues around portion sizes in young children we have opted to convene 10 focus groups. This decision was made because the investigators realized in the course of data collection that focus group dynamics were powerful for generating contextual themes around portion size and also yielded important information regarding the group format of the delivery of the nutrition education program.