Jessica D. Linnell

The Shaping Healthy Choices Program: Design and Implementation Methodologies for a Multicomponent, School-Based Nutrition Education Intervention

OBJECTIVE To provide a framework for implementation of multicomponent, school-based nutrition interventions. This article describes the research methods for the Shaping Healthy Choices Program, a model to improve nutrition and health-related knowledge and behaviors among school-aged children. DESIGN Longitudinal, pretest/posttest, randomized, controlled intervention. SETTING Four elementary schools in California. PARTICIPANTS Fourth-grade students at intervention (n = 252) and control (n = 238) schools and their parents and teachers. Power analyses demonstrate that a minimum of 159 students per group will be needed to achieve sufficient power. The sample size was determined using the variables of nutrition knowledge, vegetable preference score, and body mass index percentile. INTERVENTION A multicomponent school-based nutrition education intervention over 1 academic year, followed by activities to support sustainability of the program. MAIN OUTCOME MEASURES Dietary and nutrition knowledge and behavior, critical thinking skills, healthy food preferences and consumption, and physical activity will be measured using a nutrition knowledge questionnaire, a food frequency questionnaire, a vegetable preferences assessment tool, the Test of Basic Science Process Skills, digital photography of plate waste, PolarActive accelerometers, anthropometrics, a parent questionnaire, and the School and Community Actions for Nutrition survey. ANALYSIS Evaluation will include quantitative and qualitative measures. Quantitative data will use paired t, chi-square, and Mann-Whitney U tests and regression modeling using P = .05 to determine statistical significance.

Evaluating the relationship between plasma and skin carotenoids and reported dietary intake in elementary school children to assess fruit and vegetable intake.

Accurate assessment of dietary intake of children can be challenging due to the limited reliability of current dietary assessment methods. Plasma carotenoid concentration has been used to assess fruit and vegetable intake, but this testing is rarely conducted in school settings in children. Resonance Raman spectroscopy (RRS) is emerging as a useful method to objectively assess fruit and vegetable intake. This methodology has been validated in adults, but limited work has been done in children, particularly in the school setting. The purpose of this research is to further validate the RRS methodology in children. Children (9-12 year) participating in a school-based intervention were recruited. Plasma carotenoids were quantified using HPLC, skin carotenoid status was measured using RRS, and dietary intake of carotenoids was measured with the Block Food Frequency Questionnaire Ages 8-17. Total plasma carotenoid concentrations and skin carotenoid intensities were strongly correlated (r=0.62, p<0.001, n=38). Reported total carotenoid intake correlated with skin carotenoids (r=0.40, p<0.0001, n=128). Skin carotenoid status as measured by RRS can be a strong predictor of plasma carotenoid status and dietary intake of carotenoids in children. RRS may be used as a valid, non-invasive, and useful method to assess fruit and vegetable intakes in this population.

A Multicomponent, School-Based Intervention, the Shaping Healthy Choices Program, Improves Nutrition-Related Outcomes

Objective: To evaluate the effectiveness of the Shaping Healthy Choices Program (SHCP). Design: A clustered, randomized, controlled intervention lasting 1 school year. Setting: Schools in northern and central California. Participants: Fourth‐graders (aged 9–10 years) at 2 control schools (n = 179) and 2 intervention schools (n = 230). Intervention: Garden‐enhanced education, family, and community partnerships; increased regionally procured produce in the lunchroom; and school‐site wellness committees. Main Outcome Measures: Changes in body mass index (BMI) percentiles/Z‐scores; nutrition knowledge, science process skills, and vegetable identification and preferences; and reported fruit and vegetable intake. Analysis: Student t test, chi‐square, ANOVA of change, and multilevel regression mixed model to evaluate change in outcomes with school as a random effect to account for cluster design effects. Statistical significance was set at P < .05. Results: There was a greater improvement in BMI percentile (−6.08; P < 0.01), BMI Z‐score (−0.28; P < .001), and waist‐to‐height ratio (−0.02; P < .001) in the intervention compared with the control schools. Conclusions and Implications: The SHCP resulted in improvements in nutrition knowledge, vegetable identification, and a significant decrease in BMI percentiles. This supports the concept that the SHCP can be used to improve the health of upper elementary school students.

Using a Systematic Approach and Theoretical Framework to Design a Curriculum for the Shaping Healthy Choices Program

OBJECTIVE To examine the use of a systematic approach and theoretical framework to develop an inquiry-based, garden-enhanced nutrition curriculum for the Shaping Healthy Choices Program. METHODS Curriculum development occurred in 3 steps: identification of learning objectives, determination of evidence of learning, and activity development. Curriculum activities were further refined through pilot-testing, which was conducted in 2 phases. Formative data collected during pilot-testing resulted in improvements to activities. RESULTS Using a systematic, iterative process resulted in a curriculum called Discovering Healthy Choices, which has a strong foundation in Social Cognitive Theory and constructivist learning theory. Furthermore, the Backward Design method provided the design team with a systematic approach to ensure activities addressed targeted learning objectives and overall Shaping Healthy Choices Program goals. CONCLUSIONS AND IMPLICATIONS The process by which a nutrition curriculum is developed may have a direct effect on student outcomes. Processes by which nutrition curricula are designed and learning objectives are selected, and how theory and pedagogy are applied should be further investigated so that effective approaches to developing garden-enhanced nutrition interventions can be determined and replicated.

Using Skin Carotenoids to Assess Dietary Changes in Students After 1 Academic Year of Participating in the Shaping Healthy Choices Program

Objective: To determine whether fourth‐grade students participating in the Shaping Healthy Choices Program (SHCP), a school‐based nutrition intervention, would change vegetable and carotenoid intake measured by skin carotenoids and dietary intake. Methods: Single‐group pretest–posttest with a self‐selected, convenience sample of students (n = 30) participating in the SHCP, which lasted 1 academic year (9 months). Dietary intake of vegetables and carotenoids as measured by Block food frequency questionnaire and skin carotenoids as measured by Raman spectroscopy were collected at the school preintervention and postintervention. Results: Reported carotenoid intake decreased by 1.5 mg (P = .05) and skin carotenoids decreased by 2,247.9 RRS intensity units (P = .04). Change in reported intake correlated with change in skin carotenoids (r = .43; P = .02). Conclusions and Implications: The reported decrease in vegetable and carotenoid intake was unanticipated; nevertheless, the RRS measurements confirmed this. RRS data can help evaluate changes in fruit and vegetable intake.

Effect of the Shaping Healthy Choices Program, a Multicomponent, School-Based Nutrition Intervention, on Physical Activity Intensity

ABSTRACT Objective: Physical activity has been shown to have a wide range of beneficial health effects, yet few youth meet the United States physical activity recommendation of 60 minutes of moderate-to-vigorous physical activity (MVPA) everyday. The objective of this study was to determine whether physical activity patterns improved in a subsample of fourth-graders participating in the multicomponent intervention, the Shaping Healthy Choices Program (SHCP). Methods: At pre- and post-intervention assessments, youth at the control and intervention schools wore a Polar Active monitor on their nondominant wrist 24 h/d for at least 2 consecutive days. Multiple linear regression was used to evaluate change in physical activity by adjusting for covariates and other potential confounders, including ethnicity/race, household income, and sex. Statistical significance was set at p < 0.05. Results: Mean minutes of MVPA significantly increased at the intervention school (22.3 + 37.8; p = 0.01) and at the control school (29.1 + 49.5; p = 0.01). There were no significant differences in the change in MVPA between the schools. Youth at the intervention school significantly decreased mean minutes in sedentary activity compared to the controls (p = 0.02). Conclusions: Youth who participated in the SHCP decreased time spent in sedentary activity and increased very vigorous physical activity from pre- to post-intervention, while these changes were not observed at the control school. The overall small physical activity intensity pattern shift supports that physical activity is an important area to target within a multicomponent nutrition intervention aimed at preventing childhood obesity.

Associations Among Fatty Acids, Desaturase and Elongase, and Insulin Resistance in Children

ABSTRACT Objectives: Fatty acid profiles and desaturase (SCD-16, SCD018, D5D, D6D) and elongase (ELOVL6) enzyme activity have been associated with adiposity and metabolic disease. While this has been studied in adults, few studies have included children. The objective of this study was to evaluate these markers in children and identify relationships with markers of metabolic health. It was hypothesized that these lipid markers would be correlated to adiposity and metabolic disease. Methods: This study was a cross-sectional analysis of fourth- and fifth-grade children (n = 86, aged 9–12) participating in a comprehensive nutrition program. Any student enrolled in the program was eligible for inclusion in this study. Fasting plasma was collected and analyzed for total fatty acids, glucose, insulin, and full lipid panels. Insulin resistance was estimated using calculated homeostatic model assessment for insulin resistance (HOMA-IR) values. Results: There were no differences in lipid markers, glucose, insulin, or HOMA-IR among children classified as normal weight, overweight, or obese. SCD-16, D5D, and ELOVL6 activity was significantly correlated to HOMA-IR values (r = 0.39, p = 0.001; r = −0.33, p = 0.006; r = −0.37, p = 0.005, respectively). In regression analysis, body mass index for age percentile, D6D activity, ELOVL6 activity, and systolic blood pressure were the most significant predictors of HOMA-IR values (adjusted r2 = 0.39, p ≤ 0.001). Conclusions: There was no relationship between these lipid markers and adiposity in this population; however, there were correlations with HOMA-IR. Regardless of adiposity, there may be underlying changes in fatty acid and lipid metabolism associated with the development of metabolic diseases.

Impact of a multicomponent, school-based nutrition intervention on students’ lunchtime fruit and vegetable availability and intake: A pilot study evaluating the Shaping Healthy Choices Program

ABSTRACT This pilot study evaluated the impact of a school-based intervention integrating garden-enhanced nutrition education, family and community partnerships, and improvements to school fruit and vegetable availability. Two elementary schools in Northern California were randomly assigned to control and intervention. Changes in lunchtime fruit and vegetable intake as well as changes in fruit and vegetable availability were compared between schools, with dietary outcomes assessed among fourth-grade students having complete fruit (n = 111) and vegetable (n = 112) intake data. There were greater increases in vegetable consumption, produce expenditures, and vegetable variety at the intervention than control school (p < 0.01) but no differences for fruit outcomes. The complementary nature of program components illustrates how the promotion of vegetables available at school meals can be connected to garden-enhanced nutrition education.

Evaluating the Relationships Among Teacher Characteristics, Implementation Factors, and Student Outcomes of Children Participating in an Experiential School-Based Nutrition Program

The purpose of this study was to examine whether teacher characteristics and implementation factors influenced the effectiveness of a multicomponent nutrition education program to improve nutrition-related knowledge and behavior among fourth-grade children. Schools implemented the Shaping Healthy Choices Program (SHCP), a multicomponent nutrition intervention, during 2013-2014. Fourth-grade teachers (n = 8) at two schools facilitated nutrition education using an experiential, garden-enhanced nutrition curriculum among students (n = 173) in their classrooms. Teacher characteristics of teaching experience, self-efficacy in teaching nutrition, and knowledge about nutrition were collected at baseline. Implementation factors of fidelity and completion were measured using self-reports and qualitative observations. Student outcomes included body mass index percentile-for-age, nutrition knowledge, critical thinking skills, and identification of vegetables and were measured pre/post. Relationships were analyzed using multivariate mixed-model regression with classroom as a random effect. Pre/post changes were analyzed using t tests. Students improved body mass index percentile-for-age (−1.99 ± 7.95) and increased nutrition knowledge (2.28 ± 3.40), critical thinking skills (1.98 ± 3.28), and the ability to identify vegetables (0.87 ± 1.09). Teachers’ characteristics of teaching experience, experience teaching nutrition, attendance in a college nutrition course, self-efficacy, and nutrition knowledge were significantly related to fidelity and completeness of program implementation. This study demonstrated implementation of SHCP by teachers can positively influence student outcomes, though program implementation depends on teacher characteristics.