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

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

• A program evaluation by University of Washington
  Nutritional Sciences 531 students

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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)

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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

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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

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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

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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)

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Evaluation Methods
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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

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Methods Evaluation Tools

• Lunchroom observations
• Student surveys
• Faculty/staff interviews
• Parent/guardian interviews

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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

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Lunchrooms
TT Minor
MLK
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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.

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Methods Key Informant Interviews

• Goal to evaluate the perceived effectiveness of
  the program
• Trained study staff interviewed T.T. Minor
  personnel
• n19
• Also interviewed parents and guardians of T.T.
  Minor 5th graders
• n11

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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

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Statistical and Qualitative Analysis
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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 lt 0.05 considered significant

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Statistical Analysis Self-Efficacy

• Five Likert categories grouped into two Disagree
  or Agree
• Between school difference analyzed using
• chi-square test
• Fishers exact when expected values lt 5
• Two-sided p-value lt 0.05 considered significant

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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

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Results!
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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

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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)

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Results Self-Efficacy Questions
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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

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Results Lunchroom Observations
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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

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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. Its neat! Now they watch for the signs
  for the farmers market because they want to go.

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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

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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

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Results Teacher and Staff Interviews
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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.

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Discussion
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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

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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

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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

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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.

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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

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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

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Limitations
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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

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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)

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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

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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

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Recommendations and Conclusions
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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

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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

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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

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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

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Thank You
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