S.J. Sweitzer

Lunch Is In The Bag: Increasing Fruits, Vegetables, and Whole Grains in Sack Lunches of Preschool-Aged Children

Fruits, vegetables, and whole grains are important sources of nutrients for healthy growth and development of young children. Recent evidence suggests that sack lunches packed by parents for children to consume at child-care centers do not regularly meet the goal of one serving of fruit, vegetables, and whole grains. Lunch Is In The Bag is a child-care center-based nutrition education program targeted at parents of preschool-aged children to increase the number of servings of fruits, vegetables, and whole grains in sack lunches sent from home that was pilot tested in fall 2008. In a quasiexperimental design, six child-care centers were paired by size before being randomly assigned to intervention (n=3) and comparison (n=3) groups. The parents of caregivers with primary responsibility for preparing the sack lunches of the 3- to 5-year-old children attending the centers were enrolled as parent-child dyads. The intervention included parent handouts, classroom activities, education stations, and teacher training. The contents of the lunch sacks for both the intervention group and comparison group were recorded for 3 nonconsecutive days before and immediately after the intervention period to measure the number of servings of fruits, vegetables, and whole grains. A total of 132 parent-child dyads completed the study, 81 in the intervention group and 51 in the comparison group. Direct observation of childrens lunches from the intervention group showed an increase in predicted mean number of servings of vegetables, from 0.41 to 0.65 (P<0.001) and whole grains, from 0.54 to 1.06 (P<0.001). No significant difference was observed in the mean number of servings of fruit. Lunch Is In The Bag, which is designed to fit in the child-care environment and targets parents of 3- to 5-year-old children, is a feasible intervention for improving the nutritional quality of sack lunches.

Do Sack Lunches Provided by Parents Meet the Nutritional Needs of Young Children Who Attend Child Care

Recent changes in Texas state regulations of child-care foodservice have resulted in more centers halting meal and snack preparation and requiring parents to provide food from home for their children. In the spring of 2006, sack lunches prepared at home for children attending licensed child-care centers were evaluated based on Dietary Reference Intakes (DRIs) and Child and Adult Care Food Program (CACFP) standards. The study included 3- to 5-year-old children attending full-time child-care centers that required parents to provide lunches. Lunch contents were observed and recorded for 3 consecutive days. A 3-day mean nutrient content was used to determine whether the lunches provided a minimum of 33% of the DRI. The following nutrients were evaluated: energy, carbohydrates, protein, dietary fiber, thiamin, riboflavin, niacin, vitamin C, vitamin A, calcium, iron, zinc, and sodium. Food items were summarized and compared with CACFP standards. More than 50% of the 3-day means provided less than 33% of the DRIs for energy (n=58), carbohydrate (n=59), vitamin A (n=58), calcium (n=49), iron (n=44), and zinc (n=38). Seventy-one of the 74 children (96%) received less than 33% of the DRI for dietary fiber, yet the mean amount of sodium in observed lunches was 114% of the DRI. The observed lunches did not meet the CACFP standards for servings of fruits and vegetables for 157 (71%) or for servings of milk in 178 (80%). Sack lunches sent from home may not regularly provide adequate nutrients for the growth and development of young children. Nutrition education should be provided to parents to ensure that sack lunches sent from home meet childrens nutritional needs.

Unbundling Outcomes of a Multilevel Intervention to Increase Fruit, Vegetables and Whole Grains Parents Pack for Their Preschool Children in Sack Lunches.

Abstract Background: Packing fruit, vegetables and whole grains in preschool childrens sack lunches is a powerful way for parents to teach their children eating habits and food preferences to support a lifetime of good health. A multilevel intervention pilot-tested in childcare settings increased servings of vegetables and whole grains, but the lunches still fell short of the intervention goals. Purpose: Secondary analyses were conducted to identify specific behavior changes underlying achieved increases in servings of vegetables and whole grains. Methods: Food records from direct observation of 769 parent-packed lunches were investigated to unbundle and measure multiple aspects of lunch packing behavior. Changes from baseline to six week follow-up for the intervention (N = 81) and comparison (N = 51) parent-child dyads were evaluated in multilevel modeling. Results: The increase for whole grains was explained by more parents packing whole grain items whereas increase for vegetables was explained by parents packing vegetables on more days. Discussion: Tailored options were identified for further strategies to increase vegetables and whole grains in parentpacked sack lunches. Translation to Health Education Practice: Linking achieved outcomes to specific behaviors can be an aid in assessing needs and designing interventions to maximize the chances for success.

How to help parents pack better preschool sack lunches: Advice from parents for educators

OBJECTIVES This exploratory study obtained parent suggestions about messages and activities to guide parents to pack healthful sack lunches for preschool-aged children. METHODS A facilitator conducted group interviews using a modified nominal group technique with a convenience sample of parents who pack daily lunches for their children. Interviews took place after hours at child care centers in group settings. Investigators reviewed written statements for common themes then calculated frequencies of references to identified themes. RESULTS In total, 31 parents participated in 3 group interviews held at 3 centers. Interest in receiving written information and in activities stimulating parent interaction were dominant themes in 29% of the comments. Workshops and activity stations were suggested in 20% of the comments. Finally, recommendations for support from local supermarkets were present in 10% of the comments. CONCLUSIONS AND IMPLICATIONS Parents provided helpful suggestions that can guide nutrition educators to implement effective program messages and strategies.

Development of a Method to Observe Preschoolers' Packed Lunches in Early Care and Education Centers.

BACKGROUND As early childhood education (ECE) centers become a more common setting for nutrition interventions, a variety of data collection methods are required, based on the center foodservice. ECE centers that require parents to send in meals and/or snacks from home present a unique challenge for accurate nutrition estimation and data collection. We present an observational methodology for recording the contents and temperature of preschool-aged childrens lunchboxes and data to support a 2-day vs a 3-day collection period. METHODS Lunchbox observers were trained in visual estimation of foods based on Child and Adult Care Food Program and MyPlate servings and household recommended measures. Trainees weighed and measured foods commonly found in preschool-aged childrens lunchboxes and practiced recording accurate descriptions and food temperatures. Training included test assessments of whole-grain bread products, mixed dishes such as macaroni and cheese, and a variety of sandwich preparations. Validity of the estimation method was tested by comparing estimated to actual amounts for several distinct food types. Reliability was assessed by computing the intraclass correlation coefficient for each observer as well as an interrater reliability coefficient across observers. To compare 2- and 3-day observations, 2 of the 3 days of observations were randomly selected for each child and analyzed as a separate dataset. Linear model estimated mean and standard error of whole grains, fruits and vegetables, and amounts of energy, carbohydrates, protein, total fat, saturated fat, dietary fiber, thiamin, riboflavin, niacin, vitamins A and C, calcium, iron, sodium, and dietary fiber per lunch were compared across the 2- and 3-day observation datasets. RESULTS The mean estimated amounts across 11 observers were statistically indistinguishable from the measured portion size for each of the 41 test foods, implying that the visual estimation measurement method was valid: intraobserver intraclass correlation coefficients ranged from 0.951 (95% CI 0.91 to 0.97) to 1.0. Across observers, the interrater reliability correlation coefficient was estimated at 0.979 (95% CI 0.957 to 0.993). Comparison of servings of fruits, vegetables, and whole grains showed no significant differences for serving size or mean energy and nutrient content between 2- and 3-day lunch observations. CONCLUSIONS The methodology is a valid and reliable option for use in research and practice that requires observing and assessing the contents and portion sizes of food items in preschool-aged childrens lunchboxes in an ECE setting. The use of visual observation and estimation with Child and Adult Care Food Program and MyPlate serving sizes and household measures over 2 random days of data collection enables food handling to be minimized while obtaining an accurate record of the variety and quantities of foods that young children are exposed to at lunch time.

Psychosocial outcomes of Lunch is in the Bag, a parent program for packing healthful lunches for preschool children.

OBJECTIVE This pilot study evaluated effects of Lunch is in the Bag on behavioral constructs and their predictive relationship to lunch-packing behaviors of parents of young children. METHODS Six child care centers were pair-matched and randomly assigned to intervention (n = 3) and comparison (n = 3) groups. Parent/child dyads participated. Constructs of knowledge, outcome expectations, perceived control, subjective norms, and intentions were measured by a pre/post questionnaire. Hierarchical linear regression was used, and P < .05 was considered significant. RESULTS There were significant increases in knowledge (P = .01); outcome expectations for whole grains (P < .001); and subjective norms for fruit (P = .002), vegetables (P = .046), and whole grains (P = .02). Perceived control, outcome expectations, and intentions significantly predicted packing vegetables and knowledge predicted whole grains. CONCLUSIONS AND IMPLICATIONS Lunch is in the Bag is a feasible intervention to improve the lunch-packing behaviors of parents of preschool-aged children.

Efficacy of the Lunch is in the Bag intervention to increase parents’ packing of healthy bag lunches for young children: a cluster-randomized trial in early care and education centers

BackgroundLunches that parents pack for their young children to eat at school or the Early Care and Education (ECE) center fall short of recommended standards. Lunch is in the Bag is a multi-level behavioral nutrition intervention to increase parents’ packing of fruit, vegetables, and whole grains in their children’s lunches. Designed for implementation in ECE centers, the five-week long intervention is followed three months later with a one-week booster.MethodsEfficacy of Lunch is in the Bag was tested in cluster randomized trial. Participants were 633 families from 30 ECE centers (15 intervention, 15 control) across Austin, San Antonio, and Houston, Texas, USA. Primary outcomes were servings of fruit, vegetables, and whole grains observed in the children’s parent-packed bag lunches. Servings of refined grains, meats/beans/eggs/nuts, dairy, chips, and sweets also were observed. Data were collected at baseline, post-intervention (6-week follow-up), pre-booster (22-weeks follow-up), and post-booster (28-week follow-up). Time-by-treatment interactions were analyzed separately for each of the food groups using multi-level models to compare changes from baseline. Analyses were adjusted for relevant demographic variables and clustering within centers and parents.ResultsThe intervention effected increases from baseline to 6-week follow-up in vegetables (0.17 servings, SE = 0.04, P < 0.001) and whole grains (0.30 servings, SE = 0.13, P = 0.018). The increase in whole grains was maintained through the 28-week follow-up (0.34 servings, SE = 0.13, P = 0.009). Fruit averaged more than 1.40 servings with no differences between groups or across time. The intervention prevented increase in sweets (-0.43 servings, SE = 0.11, P < .001, at the 22-week follow-up). Parents persisted, however, in packing small amounts of vegetables (averages of 0.41 to 0.52 servings) and large amounts of sweets and chips (averages of 1.75 to 1.99 servings).ConclusionsThe need for and positive effects of the Lunch is in the Bag intervention at ECE centers where parents send bag lunch for their preschool-aged children was confirmed. An important direction for future research is discovery of more options for leveraging the partnership of ECE centers and families to help young children learn to eat and enjoy vegetables and other healthy foods in preference to less healthy choices such as chips and sweets.Trial registrationThe Clinical Trials Number is NCT01292434.

Temperature of Foods Sent by Parents of Preschool-Aged Children

OBJECTIVE: To measure the temperatures of foods in sack lunches of preschool-aged children before consumption at child care centers. METHODS: All parents of 3- to 5-year-old children in full-time child care at 9 central Texas centers were invited to participate in the study. Foods packed by the parents for lunch were individually removed from the sack and immediately measured with noncontact temperature guns 1.5 hours before food was served to the children. Type of food and number of ice packs in the lunch sack were also recorded. Descriptive analyses were conducted by using SPSS 13.0 for Windows. RESULTS: Lunches, with at least 1 perishable item in each, were assessed from 235 parent-child dyads. Approximately 39% (n = 276) of the 705 lunches analyzed had no ice packs, 45.1% (n = 318) had 1 ice pack, and 88.2% (n = 622) of lunches were at ambient temperatures. Only 1.6% (n = 22) of perishable items (n = 1361) were in the safe temperature zone. Even with multiple ice packs, the majority of lunch items (>90%) were at unsafe temperatures. CONCLUSIONS: These results provide initial data on how frequently sack lunches sent by parents of preschool-aged children are kept at unsafe temperatures. Education of parents and the public must be focused on methods of packing lunches that allow the food to remain in the safe temperature zone to prevent foodborne illness.

Examining How Adding a Booster to a Behavioral Nutrition Intervention Prompts Parents to Pack More Vegetables and Whole Gains in Their Preschool Children's Sack Lunches

Data from a five-week intervention to increase parents’ packing of vegetables and whole grains in their preschool childrens sack lunches showed that, although changes occurred, habit strength was weak. To determine the effects of adding a one-week booster three months post-intervention, childrens (N = 59 intervention and 48 control) lunches were observed at baseline (week 0), post-intervention (week 6), pre-booster (week 20), and post-booster (week 26). Servings of vegetables and whole grains were evaluated in repeated measures models and results inspected relative to patterns projected from different explanatory models of behavior change processes. Observed changes aligned with projections from the simple associative model of behavior change. Attention in future studies should focus on behavioral intervention elements that leverage stimulus-response associations to increase gratification parents receive from providing their children with healthy lunches.

Effectiveness of the Lunch is in the Bag program on communication between the parent, child and child-care provider around fruits, vegetables and whole grain foods: A group-randomized controlled trial

OBJECTIVE To evaluate the effectiveness of the parent- and early care education (ECE) center-based Lunch is in the Bag program on communication between parent, child, and their ECE center providers around fruits, vegetables and whole grain foods (FVWG). METHOD A total of n=30 ECE center; 577 parent-child dyads participated in this group-randomized controlled trial conducted from 2011 to 2013 in Texas (n=15 ECE center, 327 dyads intervention group; n=15 ECE center, 250 dyads comparison group). Parent-child and parent-ECE center provider communication was measured using a parent-reported survey administered at baseline and end of the five-week intervention period. Multilevel linear regression analysis was used to compare the pre-to-post intervention changes in the parent-child and parent-ECE center provider communication scales. Significance was set at p<0.05. RESULTS At baseline, parent-child and parent-ECE center provider communication scores were low. There was a significant increase post-intervention in the parent-ECE center provider communication around vegetables (Adjusted β=0.78, 95%CI: 0.13, 1.43, p=0.002), and around fruit (Adjusted β=0.62, 95%CI: 0.04, 0.20, p=0.04) among the parents in the intervention group as compared to those in the comparison group. There were no significant intervention effects on parent-child communication. CONCLUSION Lunch is in the Bag had significant positive effects on improving communication between the parents and ECE center providers around FVWG.