A parent-directed portion education intervention for young children: Be Beary Healthy
Version of Record online: 26 SEP 2012
© 2012, Wiley Periodicals, Inc
Journal for Specialists in Pediatric Nursing
Volume 17, Issue 4, pages 312–320, October 2012
How to Cite
Small, L., Bonds-McClain, D., Vaughan, L., Melnyk, B., Gannon, A. and Thompson, S. (2012), A parent-directed portion education intervention for young children: Be Beary Healthy. Journal for Specialists in Pediatric Nursing, 17: 312–320. doi: 10.1111/j.1744-6155.2012.00340.x
We wish to acknowledge the funding support to the first author by the Center for Improving Health Outcomes in Children, Teens, and Families for completion of this project. We would also like to acknowledge the editorial support provided by Nancy Moore.
Disclosure: The authors report no actual or potential conflicts of interest.
- Issue online: 26 SEP 2012
- Version of Record online: 26 SEP 2012
- Manuscript Accepted: 23 JUN 2012
- Manuscript Revised: 20 MAR 2012
- Manuscript Received: 11 JAN 2012
- Center for Improving Health Outcomes in Children, Teens, and Families
- preschool child
This pilot study aimed to determine the effects of an intervention on nutrition knowledge, food parents serve, and children's dietary intake.
Design and Methods.
A single-group pre-/posttest design was used with 45 mothers and their 4- to 6-year-old children. After pretesting, parents received child nutrition information and portion-related activities.
Paired samples t-tests revealed that from pre- to posttest the average calories mothers served and the average calories children ate significantly decreased (medium effect size). Medium effects also were recognized from pre- to posttest for the carbohydrates served and carbohydrates consumed. No significant change was found in parents' nutrition knowledge.
Interventions focusing on skill building rather than on increasing knowledge may more effectively lead to changed child intake.
Portion sizes in the United States have greatly increased over the last 20 years, which some researchers believe is contributing to the rising prevalence of overweight/obesity in children (Colapinto, Fitzgerald, Taper, & Veugelers, 2007; Young & Nestle, 2003). Parents are uniquely positioned to influence young children, who have little control over the amount of food they are offered and the way in which food is served. Therefore, parent-focused education programs that aim to “rightsize” portions for their preschool children may be effective in helping children improve their eating patterns (e.g., caloric intake), which may in turn contribute to a healthy weight gain trajectory.
Although portion size information has been a component of many interventions, the specific content of effective, parent-focused dietary interventions for young children is not clear. A recently conducted review and synthesis of the research evidence resulted in the following findings: (a) children older than 3 years of age appear to be at a critical juncture, becoming less sensitive to innate satiety signals and eating more food when offered larger portion sizes (Fisher, 2007; Fisher, Arreola, Birch, & Rolls, 2007; Fisher, Liu, Birch, & Rolls, 2007; Fisher, Rolls, & Birch, 2003; Rolls, Engell, & Birch, 2000; Spill, Birch, Roe, & Rolls, 2010); (b) the specific portion guidelines for feeding children 5 through 8 years are not clear (American Dietetic Association, 2004; McConahy, Smiciklas-Wright, Birch, Mitchell, & Piccano 2002; U.S. Department of Agriculture [USDA] & U.S. Department of Health and Human Services [DHHS], 2010); (c) little research has been conducted with preschool children and their parents to understand the effects of offering age-appropriate portion sizes (Small, Lane, Vaughan, Melnyk, & McBurnett, 2012); (d) all portion-related studies conducted with preschool children have occurred in a laboratory or other well-controlled settings (e.g., childcare facilities; Fisher, 2007; Fisher et al., 2003; Fisher, Arreola, et al., 2007; Fisher, Liu, et al., 2007; Rolls et al., 2000; Spill et al., 2010); and (e) there have been few theory-guided research studies conducted; thus, researchers are often unable to determine what may have led to particular outcomes (Small, Melnyk, & Anderson, 2007; 2012). The purpose of this pilot study was to implement and evaluate the Be Beary Healthy program, a parent-focused, educational intervention that strengthens feeding skills for preschool children.
The information, motivation, and behavior skills model represents the conceptualization of the psychological determinants of health behavior and provides a general framework for understanding and promoting health-related behaviors (Fisher & Fisher, 1992, 2002). The model focuses on the informational, motivational, and behavioral skill factors that are conceptually and empirically associated with the prevention of deleterious behaviors. In essence, effects of information and motivation are expressed mainly as a result of developing and deploying behavioral skills that are directly applied to initiating and maintaining preventive behavior. This partially mediating theoretical model guided us to provide motivational support to parents and general information regarding the nutritional requirements of preschool children; however, the focus of the intervention was to offer practical, skill-building information to participating parents. While the sample size included in this study is not large enough to conduct meditational analyses, the direction and size of preliminary effects (effect sizes) can be calculated.
A single-group pilot study with a pre-/posttest design was conducted to determine the preliminary efficacy and acceptability of this intervention. The research questions were: Can this parental intervention influence parents' knowledge and ability to “rightsize” their child's portions? Can a parent-focused portion intervention result in changes in a child's dietary intake? Will parents find this intervention to be acceptable to use with their preschool-age child? The effect sizes generated from this preliminary study will be used to calculate power and estimate the sample size for a future, randomized controlled trial.
After the participating parents completed the formal consenting process and pretesting, the research assistant gave them general age-appropriate child nutrition information (e.g., examples of food groups), skill-building recommendations (e.g., suggested portion sizes), and practical tips to serve appropriate portion sizes for their preschool children (Ayala, 2006; Kleinman, 2009; Riley, Beasley, Sowell, & Behar, 2007). We standardized the information for parents by providing it in both audiotaped (25 min in length) and written forms, and encouraged the parents to ask any questions they had after they reviewed the information. In addition, we offered the research office phone number to the parents and encouraged them to call and speak with a research assistant if they had any questions; however, we received no phone calls.
To facilitate practicing the provision of right-sized portions with their preschool children, we provided parents with child-friendly, 10-inch “Beary Healthy Plates” (see Figure 1). The unique design visually reminds parents of age-appropriate portion sizes of different food groups (i.e., protein, carbohydrate, fruit, vegetable) for preschool children. Empirical evidence has shown that this type of intervention enhances adults' ability to estimate portion sizes (Byrd-Bredbenner & Schwartz, 2004).
The design of the plate allows it to be used in two ways, both of which were detailed in the audiotaped/written information provided. Using the “plate model,” parents serve portions of different food groups (see Figure 1; Camelon et al., 1998). Many nutritional professionals have adopted this visual method of teaching healthful eating habits. Parents choosing this method were to place an unspecified amount of fruits and vegetables on half of the plate, carbohydrates on one quarter of the plate, and a protein-rich food on the remaining quarter; this method is similar to the use of the plate depicted in the ChooseMyPlate.gov example (USDA, 2011). Using the “portion model,” parents place food on specific items drawn on the plate (e.g., a bag of grain, fruit tree, basket of vegetables; see Figure 1). In this model, parents were instructed to use an illustrated and laminated portion counter, provided to facilitate parents serving their children food in the recommended portion sizes and number of portions throughout the day. Parents were told to accommodate any request by their children for more food if they were hungry after consuming the food initially served but to provide one additional portion of each food group to maintain the balance of the plate. Parents were given 2–4 weeks before posttesting to practice and integrate this method of serving food to their young children.
Before they received the intervention information, parents completed a 33-item demographic questionnaire and a nutrition knowledge questionnaire, and then received the items necessary to complete a photographic diet diary to collect preintervention information on the child's dietary intake (pretest). After we provided the intervention information and parents completed a 2- to 4-week implementation period to use their newly taught skills in portion control, we asked parents to complete a second nutrition knowledge questionnaire and photographic diet diary (posttest), and provide feedback regarding their experience using the plate with their child. Pre- and posttest nutrition knowledge questionnaires and diet diaries were analyzed to determine the effects of the intervention.
The nutrition knowledge questionnaire
This questionnaire consisted of 16 nutrition knowledge questions to which parents were asked to respond No, Yes, or Don't Know (0, 1, or 2, respectively). The nutrition knowledge questionnaire included questions adapted from a variety of published instruments (Hartline-Grafton, Nyman, Briefel, & Cohen, 2004; Macro & Frazao, 2005; Melnyk et al., 2007; Parmenter & Wardle, 1999) and covered a range of nutritional topics. Parents were asked to read a series of statements and indicate the response they felt was most correct (e.g., Whole milk has more saturated fat [“unhealthy fat”] than skim milk). Recoding and scoring this tool resulted in a summed score that ranged from 0 to 16, with greater scores indicating greater nutrition knowledge. This measure was used in prior pilot work; a panel of eight pediatric and nutritional experts and 15 parents found it to have face validity, and prior Cronbach's alphas ranged from.75 to.84. In this study the Cronbach's alphas at pre- and posttesting were.70 and.72, respectively.
The 2-day photographic diet diary
The photographic diet diary is an accepted method for assessing dietary intake (Bird & Elwood, 1983; Elwood & Bird, 1983; Ovaskainen et al., 2008; Robson & Livingstone, 2000; Wang, Kogashiwa, Ohta, & Kira, 2002; Williamson, Allen, Martin, Gerald, & Hunt, 2003) and requires a two-step process to estimate caloric and macronutrient data. In preparation for step 1 (documenting food served and consumed), parents were provided with a disposable flash camera and asked to attend a short session presenting a standardized approach (Small et al., 2009) for the completion of pre- and postmeal photographs for a 2-day period at each measurement time point. They were also given the Beary Healthy Plate and a clear 4-oz cup, which assisted researchers with subsequent visual estimations of food and beverage amounts. A simple spreadsheet was provided to parents to record general dietary information such as the type of food consumed (e.g., bread), an approximation of the amount eaten (e.g., 1/2 slice), and any food brand names or restaurant information. After the parents completed taking the pre- and postmeal photos and recording general dietary information for 2 full days, they gave these materials to the research assistants.
Research assistants completed the second step of the photographic diet diary assessment after photographs were developed and converted to electronic pictures. The electronic picture files and the accompanying spreadsheets were submitted to a trained research assistant for the estimation of pre- and postmeal food weights (this process has been outlined in a previously published manuscript [Small et al., 2009]). By subtracting postmeal food weights from premeal weights, the amount of each food eaten was estimated. The estimated weight of each food component (e.g., beans, cheese, bread), both served by the parent and eaten by the child, was entered into Diet Analysis Plus, Version 9.0 (Wadsworth Cengage Learning, 2008) to determine the caloric and macronutrient value of the food (e.g., grams of carbohydrates, fat, saturated fat, and protein) for both 24-hr periods. A second trained research assistant repeated this process to verify the results and inconsistencies were resolved. The average daily caloric and macronutrient distribution of foods served by parents and consumed by the children were calculated.
The participating parents were all mothers 23–53 years of age (M = 34.6 years, SD = 6.4). The target children ranged from 4 to 6 years of age (M = 4.5 years, SD =.6). A majority of the mothers self-identified as White (84.4%) and disclosed their body mass indexes as ranging from 18 to 42 kg/m2 (M = 25 kg/m2, defined as “overweight”). The other 15.6% of participant mothers identified themselves as Black (2.2%), Hispanic (11.1%), or other (2.2%), and none of the mothers indicated that they were American Indian, Alaskan Native, Asian, or Pacific Islander. Most (62%) of the mothers had a college degree; 24% had “some college education”; 4% had a high school diploma; and 9% did not have a high school diploma. Approximately 77% reported an annual household income greater than $40,000.
Following Institutional Review Board approval, 45 mothers and their preschool children, 4–6 years old, were recruited, consented, and enrolled from childcare centers and primary healthcare offices. Recruitment for this study involved the use of posters and flyers distributed in the different settings. Thirty mother–child dyads completed the posttest assessment; thus, the attrition rate was 33%. There was no significant difference in the attrition rate between those mothers who did not have a college education and those who did. A multiple imputation method in SPSS 17 was used to account for the missing data, which requires a less stringent missing at random assumption and produces more robust parameter estimates than traditional approaches such as listwise deletion or mean imputation (Enders, 2010). In the imputation phase, all study variables were used in an iterative regression-based procedure to create 20 data sets with different imputed values. Next, analyses were conducted on each imputed data set, and the estimates and standard errors were pooled into a single set of results. Lastly, results of the analyses using the original data were compared with the results gained using the imputed data set.
To examine the preliminary efficacy of the intervention, paired samples t tests were computed to compare the average calories and macronutrients served by mothers and consumed by children from pre- to posttest (see Table 1). The average total daily calories served by mothers significantly decreased from pre- to posttest (t = 3.92, p <.01). The average total daily calories eaten by the children also significantly decreased over this time period (t = 3.35, p <.01). There were significant reductions in the average served and consumed amounts of several macronutrients. The average total fat (g) consumed by children significantly declined from pre- to posttesting (t = 1.96, p =.05), whereas the average amount of fat (g) served by mothers pretest versus posttest showed a nonsignificant decline (t = 1.94, p =.06). Saturated fat (g), both served and eaten, decreased significantly from pre- to posttest (t = 1.96, p =.05 and t = 2.14, p =.03, respectively). Mean carbohydrates (g) served was also found to be significantly lower at posttest compared with pretest (t = 3.98, p <.01), as was total carbohydrates (g) eaten (t = 4.64, p <.01). There were no significant pre- versus posttest differences in the amount of protein (g) served or consumed.
|Pretest||Posttest||t-test results for pre- vs. posttest|
|M (SD)||t-value||M (SD)||t value||t value||Sig||Effect size|
|Calories served||1,528 (247)||1,369 (251)||3.92*||<.01||.58|
|Calories consumed||1,418 (252)||1,267 (259)||3.35*||<.01||.50|
|t-test results for calories served vs. consumed||5.94***||7.22***|
|Protein served (g)||57.1 (12.6)||54.8 (15.5)||.91||.36||.14|
|Protein consumed (g)||51.9 (12.4)||50.2 (14.6)||.69||.49||.10|
|t-test results for protein served vs. consumed||4.65***||4.41***|
|Fat served (g)||54.9 (15.6)||50.8 (13.4)||1.94†||.06||.23|
|Fat consumed (g)||51.1 (16.4)||45.9 (12.8)||1.96*||.05||.29|
|t-test results for fat served vs. consumed||2.90**||5.51***|
|Saturated fat served (g)||19.8 (7.1)||17.4 (6.4)||1.96*||.05||.30|
|Saturated fat consumed (g)||18.3 (6.89)||15.87 (5.54)||2.14*||.03||.33|
|t-test results for saturated fat served vs. consumed||3.89***||2.52**|
|Carbohydrates served (g)||208.7 (40.5)||179.3 (38.6)||3.98*||<.01||.60|
|Carbohydrates consumed (g)||193.7 (40.8)||167.5 (38.5)||3.64*||<.01||.54|
|t-test results for carbohydrates served vs. consumed||5.78***||5.89***|
|Fiber served (g)||13 (5)||11 (5)||1.29||.20||.20|
|Fiber consumed (g)||11 (5)||11 (5)||.77||.44||.12|
|t-test results for fiber served vs. consumed||3.86***||1.97*|
We also calculated effect sizes using dz, which measures the magnitude of the intervention effects from pre- to posttest (Faul, Erdfelder, Georg-Lang, & Buchner, 2007). Faul and colleagues defined the effect size index dz as
where μx and μy denote the population means, σx and σy denote the standard deviation in either population, and ρxy denotes the correlation between the two random variables. According to Cohen's (1988) interpretation of effect sizes, small effects range from.20 to.49, medium effects range from.50 to.79, and large effects are greater than or equal to.80. Effect sizes for each of the macronutrient weights ranged from.10 to.60, with medium effects from pre- to posttest for the total daily calories served, total daily calories consumed, carbohydrates served, and carbohydrates consumed (see Table 1; Cohen, 1988).
One-sample t tests were conducted to compare the average calories served by parents and consumed by the children at pre- and posttest to the recommended daily amount of calories (1,400–1,600 kcal per 24 hr) needed to maintain energy balance for moderately active children ages 4–8 years (USDA & DHHS, 2010). For the purposes of these analyses, the value at the lower end of the range was used (1,400 calories). The average number of calories served at pretest (M = 1,528) was significantly greater than 1,400 calories (t = 3.49, p <.01) but within the recommended range. The average calories the children consumed at pretest (M = 1,418) and the average calories parents served at posttest (M = 1,369) were not significantly different from 1,400 calories (t =.50, p =.62 and t = −.84, p =.42, respectively). The average calories eaten by the children at posttest (M = 1,267) were significantly less than 1,400 calories (t = −3.45, p <.01), which is the low end of the recommended range of calories for a moderately active preschool child.
Paired samples t tests were calculated to examine the difference between macronutrients served by mothers and consumed by children at pre- and posttesting to determine if the children were eating significantly less than what was served before or after the intervention. The average macronutrients consumed were significantly less than the average macronutrients served for fat, saturated fat, protein, carbohydrates, and calories at both pre- and posttest (see Table 1).
Lastly, paired samples t tests were conducted to compare pre- and posttest means on parents' knowledge of healthy nutrition. No significant difference was found when pre- (M = 14.8) and posttest (M = 15.3) scores were compared (t = −1.12, p =.26).
We obtained qualitative data on acceptability from the extensive positive feedback parents gave us regarding their experience of using the plate and their child's response to seeing and eating from the plate. One example of parental feedback about the experience of using the plate to provide age-appropriate portion sizes was, “The Beary Healthy Portion Plate became an essential part of our mealtime. The plate allowed me to gauge portion size along with right nutrients.” One mother stated, “The plate is great! All my kids love it and ask to use it.” A few parents struggled with using the plate. One mother remarked that she could not remember where the portion guide was and how to use the plate. Another common request was to have more than one plate because other siblings wanted to use it.
This intervention pilot study was developed and tested with parents of preschool children. It was guided by theory, focused on providing skill-based information (Amico, Toro-Alfonso, & Fisher, 2005; Fisher, Fisher, Bryan, & Misovich, 2002; Fisher, Fisher, & Harman, 2003; Small, Melnyk, & Strasser, 2007), and involved the use of the Beary Healthy Plate as a visual way of assisting parents to provide age-appropriate food portions for their children. Parents provided a wealth of positive feedback regarding their experiences using the plate with their children, suggesting acceptability of the intervention in this pilot study. Following the intervention, the mothers served their children significantly fewer calories, less saturated fat, and fewer carbohydrates, and their children consumed significantly fewer calories and less fat, saturated fat, and carbohydrates. These changes resulted in a medium effect size with regard to the rightsizing of portions by parents and reduced caloric intake by the children. The effects we recognized following the intervention occurred while the macronutrient distribution (i.e., percentage of total calories from protein, fat, saturated fat, and carbohydrates) remained stable and within the recommended ranges for preschool children, with the exception of saturated fat. Thus, the outcome achieved (reduced caloric consumption) was most likely related to the parents reducing food portions served, not to a change in the types of foods served or in parents' knowledge of healthy nutrition.
The findings from this study are similar to those of other studies conducted in tightly controlled environments, especially the finding that smaller portion sizes served resulted in smaller dietary intakes by young children. However, in this pilot study, we did not instruct the parent regarding how much food to place on the plate (i.e., half the amount of food) and then monitor the child's intake as other researchers have done in portion-related intervention studies conducted with young children. Instead, we provided general nutrition information and simple instructions regarding how to use the Beary Healthy Plate. If the parents used the plate as we designed it, the child would be served an age-appropriate serving size, but upon request, the child could receive more food. Because of the differing methodologies, results of the different portion studies are not comparable.
Although the average daily caloric intake of the children fell below the lower end (1,400–1,600 kcals) of the range recommended for moderately active children, the majority of preschool children, regardless of their weight status, are not moderately active, as evidenced by the research literature (Brown et al., 2009; Pate, McIver, Dowda, Brown, & Addy, 2008; Pate, Pfeiffer, Trost, Ziegler, & Dowda, 2004; Reilly, 2010; Trost, Sirard, Dowda, Pfeiffer, & Pate, 2003) and our concurrent physical activity studies using accelerometry (Small et al., 2012). Furthermore, the caloric intake of these children following the intervention remained within the recommended range (1,200–1,400 kcal/day) for sedentary children (4–8 years; USDA & DHHS, 2010). Our physical activity study findings (Small et al., 2012) indicated that preschool children have been found to spend up to 85% of their waking hours in sedentary time and are only moderately to vigorously active one-half hour a day, findings that are similar to those of other researchers (Brown et al., 2009; Pate et al., 2004, 2008; Reilly, 2010; Trost et al., 2003). Therefore, a lower-calorie diet may allow preschool children to be more energy neutral and thus have a less obesogenic profile.
There are several limitations inherent with a single-group study that uses immediate posttesting only. Without the inclusion of a control group and random assignment to experimental groups, it is difficult to know if the changes that occurred following the intervention resulted from some other confounding factor(s) or if the rightsizing of portions and reduced calories the children ate truly resulted from the intervention. Additionally, without longitudinal data, it is difficult to know how long the effects of the intervention might be sustained. The attrition rate for this pilot study (33%) adds to the information needed to plan and appropriately power the sample size of a full-scale study. While this attrition rate may seem high, research regarding attrition from studies that employ diaries have demonstrated a precipitous drop (36%) in participation when going from a prediary phase to a diary-keeping phase, and so the attrition rate in our study was not excessive (Lee, Hu, & Toh, 2004). Lastly, the sample size of this study was small, which increases the threat of a type II error (failing to find a statistical difference when a difference does exist).
Some researchers assert that results obtained by imputing data are questionable; however, others have determined that this is an acceptable method that enables researchers to utilize all the data provided from all study participants and guard against a type II error. To address this concern, we ran all the analyses prior to data imputation, and the results were the same as those from the data set with imputed data, except that a few of the effect sizes had a smaller magnitude after the imputation. Despite the limitations, this preliminary efficacy study produced medium effects of the intervention on the reduction of the amount of food that parents served and children consumed following the delivery of the Be Beary Healthy intervention.
This study may be an important step toward the behavioral change of rightsizing portions by parents for preschool children, a strategy recommended by the American Academy of Pediatrics Childhood Overweight and Obesity Expert Committee (Barlow & Expert Committee, 2007) and the Dietary Guidelines for Americans (Institute of Medicine, 2002; USDA & DHHS, 2010). A strength of this study is that a specific process for parents to provide age-appropriate portions has been developed and preliminary efficacy has been demonstrated. The next step will be to conduct a full-scale study in which a large, diverse sample of parents and their preschool children are randomly assigned to one of two groups (i.e., intervention and control), and immediate and longitudinal outcomes are assessed. Additionally, more controls can be put into place to strengthen the rigor of the methodology (e.g., same intervention period, categorization of different carbohydrates, inclusion of child demographic and activity data). By empowering parents to moderate calorie consumption, the Be Beary Healthy intervention has the potential to help preschool children who need to reach calorie neutrality.
How might this information affect nursing practice?
Many interventions designed to change child behaviors have focused on providing information to parents; however, increasing knowledge does not necessarily result in changed parent behaviors or altered child behaviors. Significant evidence suggests that effective parenting interventions include offering parents skill-building activities that can be practiced with their child(ren). The results of this small pilot study offer support to this premise. Parents changed their feeding behaviors (e.g., portion sizes offered to children) when they were offered practical, skill-based guidance regarding how to provide a child with an age-appropriate portion of different foods.
Nurses interact with parents in unique and personal ways regarding child health. Encouraging parents to engage their children in new ways by offering practical, skill-building activities to practice with their child may be an effective intervention strategy that nurses can use when they personally interact with parents. Developing innovative ways to facilitate parental skill building may be seen as an exciting new challenge for nurses. Because of the interpersonal interaction nurses have with parents and children, translation of research evidence and the development of practical skill-building interventions may foster new and effective parent–child interactions that lead to changed behavior.
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