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

By Briley, Margaret E.; Ranjit, Nalini et al. | American Journal of Health Education, May-June 2012 | Go to article overview

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


Briley, Margaret E., Ranjit, Nalini, Holescher, Deanna M., Sweitzer, Sara J., Almansour, Fawaz, Roberts-Gray, Cynthia, American Journal of Health Education


ABSTRACT

Background: Packing fruit, vegetables and whole grains in preschool children's 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 parent- packed 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.

Am J Health Educ. 2012;43(2):135-142. Submitted December 20, 2010. Accepted August 12, 2011.

BACKGROUND

Packing fruit, vegetables and whole grains in preschool children's sack lunches is a powerful way for parents to teach their children eating habits and food preferences to support a lifetime of good health. Diets rich in fruits, vegetables and whole grains provide nutrients children need for healthy growth and development, protect against certain cancers (1,2) and reduce risks for diabetes and other chronic diseases. (3) But the majority of preschool-aged children eat much less than the recommended amounts of these foods. (4-7) Early introduction and frequent exposure have been shown to be strongly related to children's later acceptance and intake of fruits and vegetables. (8,9) When parents pack a daily serving of fruit, vegetables and whole grains in their preschool children's sack lunches, they provide frequent early exposure and tacitly communicate to their child their own belief that these are the appropriate foods to eat and enjoy in the middle of a busy day.

Observation of preschoolers' sack lunches indicates, however, that packing safe, nutritious lunches that teach healthful eating habits is challenging. A study of parent-packed sack lunches at childcare centers in Texas showed the majority were deficient in servings of fruits and vegetables compared to meal patterns recommended in guidelines for the U.S. Department of Agriculture's Child and Adult Care Food Program (CACFP) (10) and failed to supply one-third of recommended Dietary Reference Intake (DRI) (11) for energy, calcium, iron, and other essential nutrients. (12) An earlier evaluation of parent-packed sack lunches at childcare centers in California showed only 16% contained a vegetable whereas more than 80% contained low-nutrient foods such as chips, cookies, and sweetened beverages. (13)

Parents cite lack of knowledge, (14) time and resources, (15) along with family and child preferences, (16) as barriers to providing children with recommended amounts of fruits, vegetables and whole grains. When parents were asked in group interviews what can be done to help them pack better lunches for their preschool children, they expressed interest in receiving nutrition information presented in handouts from their children's childcare centers and recommended recipe exchanges and other methods that facilitate parents' talking to and learning from each other. (17)

In response to parent-identified levers and barriers, Lunch is in the Bag was developed to help parents to pack healthy sack lunches for their preschool children. …

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