June 6, 2006 Presentation by Laura Fanning and Celia Framson Eat Better, Feel Better T.T. Minor Elementary School A program evaluation by University of

June 6, 2006June 6, 2006 Presentation by Laura Fanning and Celia Presentation by Laura Fanning and Celia FramsonFramson

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

SchoolSchool

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

studentsstudents

Intervention at T.T. MinorIntervention at T.T. Minor

Part of national initiative: Healthy Eating Part of national initiative: Healthy Eating by Design (HEBD)by Design (HEBD)

HEBD funded by Robert Wood Johnson HEBD funded by Robert Wood Johnson FoundationFoundation

Goal to increase fruit and vegetable Goal to increase fruit and vegetable consumption among students and their consumption among students and their familiesfamilies

T.T. Minor also recipient of USDA Fresh T.T. Minor also recipient of USDA Fresh Fruits and Vegetables Program (provided Fruits and Vegetables Program (provided mid-morning snack)mid-morning snack)

Why the Need?Why the Need?

15% of U.S. children overweight15% of U.S. children overweightPrevalence has doubled in past 3 Prevalence has doubled in past 3

decadesdecadesOverweight children have more health Overweight children have more health

complications; more likely to become complications; more likely to become obese adultsobese adults

In 2002, estimated costs of treating In 2002, estimated costs of treating obesity-related conditions = $92 - obesity-related conditions = $92 - $117 billion$117 billion

Still Not Convinced?Still Not Convinced?

World Health Report shows that World Health Report shows that adequate fruit and vegetable adequate fruit and vegetable consumption can decrease obesity consumption can decrease obesity riskrisk

According to 2001 Youth Risk According to 2001 Youth Risk Behavior Survey only 21% of high Behavior Survey only 21% of high school students reported eating at school students reported eating at least five servings of fruits and least five servings of fruits and vegetables per dayvegetables per day

Why Intervene in Schools?Why Intervene in Schools?

Schools have most continuous contact Schools have most continuous contact with young childrenwith young children

Many children eat 2 meals a day at Many children eat 2 meals a day at schoolschool

Children eat more than half their daily Children eat more than half their daily calories at schoolcalories at school

Thus school-based interventions have Thus school-based interventions have powerful potential to influence dietary powerful potential to influence dietary behaviorbehavior

Key Project ElementsKey Project Elements Goal: Positively impact Goal: Positively impact

food environment for food environment for students and their students and their familiesfamilies

Multi-component Multi-component approach, comprising:approach, comprising: DietitianDietitian Salad barSalad bar Nutrition educationNutrition education Family nightsFamily nights Cooking demonstrationsCooking demonstrations School gardenSchool garden Mid-morning snack (USDA Mid-morning snack (USDA

Fruit and Vegetable Fruit and Vegetable Program)Program)

http://seattletimes.nwsource.com/html/pacificnw10092005/coverstory.html

Evaluation MethodsEvaluation Methods

Methods: Study DesignMethods: Study Design

Quasi- experimental design with no Quasi- experimental design with no baseline data available and no baseline data available and no randomization or blindingrandomization or blinding

MLK chosen as comparison schoolMLK chosen as comparison schoolSimilar demographicsSimilar demographicsNo nutrition interventionNo nutrition intervention

Study only included 5Study only included 5thth graders at graders at T.T. Minor and 4T.T. Minor and 4thth and 5 and 5thth grade grade combined class at MLK combined class at MLK

Methods: Evaluation ToolsMethods: Evaluation Tools

Lunchroom observationsLunchroom observationsStudent surveysStudent surveysFaculty/staff interviewsFaculty/staff interviewsParent/guardian interviewsParent/guardian interviews

Methods: Lunchroom Methods: Lunchroom ObservationsObservations

Trained study staff observed fruit Trained study staff observed fruit and vegetable intake of participating and vegetable intake of participating students during lunchtimestudents during lunchtime

Observations conducted at both Observations conducted at both schools over a 3 day period schools over a 3 day period

Each observer assigned 1-4 children Each observer assigned 1-4 children

LunchroomsLunchrooms

TT Minor MLK

Methods: Student SurveyMethods: Student Survey

Self-administeredSelf-administered Assessed intake Assessed intake Assessed self-efficacy for choosing fruits Assessed self-efficacy for choosing fruits

and vegetablesand vegetables Rated on five-category Likert scale from “I Rated on five-category Likert scale from “I

disagree very much” to “I agree very disagree very much” to “I agree very much”much”

Example question:Example question: ““For a snack, I think I can choose my favorite For a snack, I think I can choose my favorite

fruit instead of my favorite candy bar.”fruit instead of my favorite candy bar.”

Methods: Key Informant Methods: Key Informant InterviewsInterviews

Goal to evaluate the perceived Goal to evaluate the perceived effectiveness of the programeffectiveness of the program

Trained study staff interviewed T.T. Trained study staff interviewed T.T. Minor personnel Minor personnel n=19 n=19

Also interviewed parents and Also interviewed parents and guardians of T.T. Minor 5guardians of T.T. Minor 5thth graders gradersn=11n=11

Methods: Key Informant Methods: Key Informant InterviewsInterviews

Teachers and staff asked about:Teachers and staff asked about:Experiences with the programExperiences with the programEating behavior of the studentsEating behavior of the studentsOwn eating behaviorOwn eating behavior

Parents and guardians asked about:Parents and guardians asked about:Foods their families eatFoods their families eatExperiences with T.T. Minor intervention Experiences with T.T. Minor intervention

programsprograms

Statistical and Statistical and Qualitative AnalysisQualitative Analysis

Statistical Analysis: Lunchroom Statistical Analysis: Lunchroom ObservationsObservations

Calculated mean consumption per Calculated mean consumption per lunch period per schoollunch period per school

Compared means at each school Compared means at each school using generalized estimating using generalized estimating equation equation

Two-sided p-value Two-sided p-value << 0.05 considered 0.05 considered significantsignificant

Statistical Analysis: Self-Statistical Analysis: Self-EfficacyEfficacy

Five Likert categories grouped into Five Likert categories grouped into two: Disagree or Agreetwo: Disagree or Agree

Between school difference analyzed Between school difference analyzed using:using: chi-square testchi-square testFisher’s exact when expected values < Fisher’s exact when expected values <

55Two-sided p-value Two-sided p-value << 0.05 considered 0.05 considered

significantsignificant

Analysis: Qualitative DataAnalysis: Qualitative Data

Answers to interview questions Answers to interview questions compiled in a spreadsheetcompiled in a spreadsheet

Yes/No responses summarized Yes/No responses summarized numericallynumerically

For open-ended questions, recurrent For open-ended questions, recurrent issues and emergent themes issues and emergent themes highlighted and groupedhighlighted and grouped

Results compared between analysis Results compared between analysis team members to verify interpretation team members to verify interpretation of responsesof responses

Results!Results!

Results: Participation RatesResults: Participation Rates

T.T. MinorT.T. Minor 17/21 participated, rate 17/21 participated, rate

= 81%= 81% Student decline primary Student decline primary

reason for reason for nonparticipationnonparticipation

MLKMLK 15/20 participated, rate 15/20 participated, rate

= 75%= 75% Student decline primary Student decline primary

reason for reason for nonparticipationnonparticipation


Results: Specific Self-Efficacy Results: Specific Self-Efficacy and Intake Questionsand Intake Questions

57% of T.T. Minor students agreed 57% of T.T. Minor students agreed they could eat a vegetable served for they could eat a vegetable served for lunch at school vs. 20% from MLK (p lunch at school vs. 20% from MLK (p = 0.04)= 0.04)

63% of students from T.T. Minor 63% of students from T.T. Minor reported eating 3 or more fruits vs. reported eating 3 or more fruits vs. 27% from MLK (p = 0.05)27% from MLK (p = 0.05)

36% of students from T.T. Minor 36% of students from T.T. Minor reported eating 3 or more vegetables reported eating 3 or more vegetables vs. 7% from MLK (p = 0.08)vs. 7% from MLK (p = 0.08)

Results: Self-Efficacy Results: Self-Efficacy QuestionsQuestions

Table 2: Self Efficacy Questions for students at T.T. Minor vs. MLK

Survey questions (Self-efficacy) P for χ2 test

I think I can eat a vegetable that is served for lunch at school 0.04

I think I can eat a fruit that is served for lunch at school 0.21

I think I can choose my favorite fruit instead of my favorite cookie for a snack 0.71

I think I can choose my favorite fruit instead of my favorite candy bar for a snack 0.27

I think I can choose my favorite raw vegetable with dip instead of my favorite cookie for a snack

0.70

I think I can choose my favorite raw vegetable with dip instead of my favorite candy bar for a snack

0.25

I think I can choose my favorite raw vegetable instead of chips for a snack 0.10

I think I can eat a serving of vegetables for dinner 0.34

I think I can eat my favorite fruit instead of my usual dessert for dinner 0.71

Results: Lunchroom Results: Lunchroom Observations, Summary Observations, Summary

StatisticsStatisticsOver the 3 days, T.T. Minor 5Over the 3 days, T.T. Minor 5thth

graders consumed:graders consumed: 0.07 cups (95% CI: -0.31 - 0.16) fewer 0.07 cups (95% CI: -0.31 - 0.16) fewer

fruits than MLK 4fruits than MLK 4thth and 5 and 5thth graders graders0.09 (95% CI: 0.03 - 0.22) cups more 0.09 (95% CI: 0.03 - 0.22) cups more

vegetables than MLK 4vegetables than MLK 4thth and 5 and 5thth graders graders0.01 (95% CI: -0.27 – 0.26) cups fewer 0.01 (95% CI: -0.27 – 0.26) cups fewer

total fruits and vegetables than MLK 4total fruits and vegetables than MLK 4thth and 5and 5thth graders graders

Results: Lunchroom Results: Lunchroom ObservationsObservations

Table 4: Summary of Daily Lunchroom Data

Item T.T. Minor MLK

Used Salad Bar Day 1 1 9/13 (69%) NA



Fruit Intake on Day 1 0.50 cups 0.32 cups



Vegetable Intake on Day 1 0.15 cups 0.14 cups



Total Fruits and Vegetables Intake on Day 1 0.58 cups 0.45 cups



Results: Parent/Guardian Results: Parent/Guardian InterviewsInterviews

Participation rate = 55%Participation rate = 55% Incorrect telephone number primary Incorrect telephone number primary

reason for nonparticipationreason for nonparticipationMajority of respondents aware of new Majority of respondents aware of new

salad bar and indicated their salad bar and indicated their child/children used itchild/children used it

Majority aware that fresh f/v Majority aware that fresh f/v available for snack and indicated available for snack and indicated their child/children ate themtheir child/children ate them


Most respondents Most respondents indicated awareness of indicated awareness of nutritionist in school nutritionist in school and thought she and thought she positively impacted positively impacted students’ eating students’ eating patternspatterns

““They have been They have been introduced to food at introduced to food at the food fair. It’s neat! the food fair. It’s neat! Now they watch for the Now they watch for the signs for the farmers’ signs for the farmers’ market because they market because they want to go.”want to go.”

http://depts.washington.edu/uwecor/projects/eatbetter_feelbetter.htm


Almost all respondents indicated Almost all respondents indicated their children asked them to buy their children asked them to buy more fruits and vegetablesmore fruits and vegetables

Almost all respondents indicated that Almost all respondents indicated that their child/children are eating more their child/children are eating more f/v than they did in the previous yearf/v than they did in the previous year

Over half of respondents indicated Over half of respondents indicated their family is eating more f/v than their family is eating more f/v than they did in the previous yearthey did in the previous year

Results: Teacher and Staff Results: Teacher and Staff InterviewsInterviews

Participation rate = 59%Participation rate = 59%Scheduling challenges due to limited Scheduling challenges due to limited

time frame main reason for time frame main reason for nonparticipationnonparticipation

Most respondents indicated they Most respondents indicated they would like to see the salad bar and would like to see the salad bar and morning snacks continuemorning snacks continue

Results: Teacher and Staff Results: Teacher and Staff InterviewsInterviews

Table 6: Teacher and Staff Interview Responses (n=19)

“Yes/No” Questions Yes No

Were the programs a burden to you? 0 (0%) 19 (100%)

Was it worth the extra effort? 17 (89%) 2 (11%)

Have you noticed a change in the eating behaviors for the students?19 (100%) 0 (0%)

Have you tasted any fruit or vegetable that was new to you since the beginning of the year? 15 (79%) 4 (21%)

Are you eating more fruits and vegetables now than you did last year?19 (100%) 0 (0%)

Has having a salad bar caused you to eat more fruits and vegetables than last year? 17 (89%) 2 (11%)

Has having a nutritionist on staff led you to change your eating behavior? 10 (53%) 9 (47%)

Teacher and Staff Teacher and Staff RecommendationsRecommendations

Increase variety and accessibility of salad bar Increase variety and accessibility of salad bar items and snacks:items and snacks: ““[I would like to see] more variety of food on the salad [I would like to see] more variety of food on the salad

bar. It got repetitive after a while.”bar. It got repetitive after a while.” ““I would like to see the salad bar lowered in height so all I would like to see the salad bar lowered in height so all

kids can reach it.” kids can reach it.” Suggestions for the classes and activities:Suggestions for the classes and activities:

““Include more in-depth health information at family Include more in-depth health information at family nights. Set up booth or health fair.” nights. Set up booth or health fair.”

““Offer more staff education.” Offer more staff education.” Other suggestions:Other suggestions:

““More time with staff. Katie is only here one time per More time with staff. Katie is only here one time per week.”week.”

DiscussionDiscussion


Fruit and vegetable consumption Fruit and vegetable consumption during the lunchroom observations during the lunchroom observations for 5for 5thth graders at T.T. Minor and 4 graders at T.T. Minor and 4thth and 5and 5thth graders at MLK was graders at MLK was quantitatively similarquantitatively similar

Qualitative data does suggest Qualitative data does suggest positive changes in dietary behavior positive changes in dietary behavior among students and their families, among students and their families, and school personneland school personnel


Data from self-administered surveys Data from self-administered surveys reported:reported:63% of students from T.T. Minor ate 3 or 63% of students from T.T. Minor ate 3 or

more fruits vs. 27% from MLK (p = 0.05)more fruits vs. 27% from MLK (p = 0.05)36% of students from T.T. Minor ate 3 or 36% of students from T.T. Minor ate 3 or

more vegetables vs. 7% from MLK (p = more vegetables vs. 7% from MLK (p = 0.08)0.08)

Perhaps here we are seeing the effects Perhaps here we are seeing the effects of the multi-component approach to the of the multi-component approach to the EFBB programEFBB program


Faculty/ Staff and Parent/Guardian Faculty/ Staff and Parent/Guardian responses overwhelmingly positive:responses overwhelmingly positive:All teachers indicated students All teachers indicated students

increased f/v intake over the yearincreased f/v intake over the year82% of P/G said their children ate more 82% of P/G said their children ate more

f/v than in the previous yearf/v than in the previous yearP/G also indicated their children asked P/G also indicated their children asked

them to buy more f/v than in the pastthem to buy more f/v than in the past


Staff also reported making many Staff also reported making many positive changes for themselves:positive changes for themselves:100% indicated they eat more f/v than 100% indicated they eat more f/v than

before EBFB program before EBFB program 89% said the salad bar at T.T. Minor 89% said the salad bar at T.T. Minor

caused them to eat more f/v than last caused them to eat more f/v than last yearyear

79% indicated they tried a new f/v during 79% indicated they tried a new f/v during the programthe program

““I work out more because I feel better I work out more because I feel better about what I am eating.”about what I am eating.”


Data suggest that T.T. Minor 5Data suggest that T.T. Minor 5thth graders graders exhibited greater self-efficacyexhibited greater self-efficacy57% of T.T. Minor 557% of T.T. Minor 5thth graders agreed they graders agreed they

could eat a vegetable served for lunch at could eat a vegetable served for lunch at school vs. 20% of 4school vs. 20% of 4thth and 5 and 5thth graders from graders from MLK (p = 0.04)MLK (p = 0.04)

Literature suggests that increased self-Literature suggests that increased self-efficacy may play a role in improving efficacy may play a role in improving fruit and vegetable consumption in fruit and vegetable consumption in childrenchildren


Salad bar use declined over the three-Salad bar use declined over the three-day observation period:day observation period:Wed = 69%, Thurs = 35%, Fri = 7%Wed = 69%, Thurs = 35%, Fri = 7%

UW student observers reported UW student observers reported decreasing variety of f/v offered over decreasing variety of f/v offered over the three daysthe three days

Previous studies found a significant Previous studies found a significant positive association between variety positive association between variety and consumptionand consumption

LimitationsLimitations


Difficult to detect small differences Difficult to detect small differences with very small sample sizeswith very small sample sizesPrevious evaluations of school-based Previous evaluations of school-based

interventions reporting significant interventions reporting significant results had sample sizes ranging from results had sample sizes ranging from 319 - 2684319 - 2684


Discrepancy between lunch Discrepancy between lunch observation data and student, F/S, P/G observation data and student, F/S, P/G reports could be due to mid-morning reports could be due to mid-morning snacks provided by USDA f/v programsnacks provided by USDA f/v program

Accessibility of f/v may have been a Accessibility of f/v may have been a barrier to consumptionbarrier to consumptionHeight of salad barHeight of salad barWhole fruit rather than pre-cut (e.g., Whole fruit rather than pre-cut (e.g.,

oranges)oranges)


Ideal study design is RCT with Ideal study design is RCT with baseline data and blinding baseline data and blinding

Our study design assumed control and Our study design assumed control and intervention schools were identicalintervention schools were identical

Limited timeframe for:Limited timeframe for:Training lunchroom observersTraining lunchroom observersLunchroom observationsLunchroom observationsKey informant interviewsKey informant interviews


Sources of error:Sources of error:Observers not blinded to intervention Observers not blinded to intervention

statusstatusTend to bias toward finding associationsTend to bias toward finding associations

Students aware of being observed – may Students aware of being observed – may have altered behaviorhave altered behaviorCould introduce random error attenuating Could introduce random error attenuating

any associationany associationSelf-selection bias among P/G, F/S, and Self-selection bias among P/G, F/S, and

students that agreed to participatestudents that agreed to participateTend to bias toward finding associationsTend to bias toward finding associations

Recommendations Recommendations and Conclusionsand Conclusions

RecommendationsRecommendations

Improvements for future evaluations:Improvements for future evaluations:Larger sample sizeLarger sample sizeCapture influence of mid-morning snackCapture influence of mid-morning snackInclude 24-hr dietary recallInclude 24-hr dietary recallRigorous training of observersRigorous training of observersCollect base-line dataCollect base-line dataLonger timeframe for data collectionLonger timeframe for data collection

RecommendationsRecommendations

Improvements for Eat Better, Feel Improvements for Eat Better, Feel Better program:Better program:Lower height on salad bar (or install Lower height on salad bar (or install

ramp)ramp)Increase variety of f/v Increase variety of f/v Modify practices to ensure consistent Modify practices to ensure consistent

variety throughout the weekvariety throughout the weekIncrease availability of pre-cut fruitIncrease availability of pre-cut fruitExtend lunch periodExtend lunch period

ConclusionsConclusions

Although lunchtime observation data Although lunchtime observation data suggest that students at T.T. Minor did not suggest that students at T.T. Minor did not consume significantly more f/v than consume significantly more f/v than students at MLK, important limitations students at MLK, important limitations may mitigate ability to detect differencesmay mitigate ability to detect differences

Qualitative findings suggest that the Eat Qualitative findings suggest that the Eat Better, Feel Better program positively Better, Feel Better program positively impacts students’ self-efficacy, self-impacts students’ self-efficacy, self-reported f/v intake, and attitudes towards reported f/v intake, and attitudes towards f/vf/v

AcknowledgmentsAcknowledgments Faculty, staff, and students at T.T. Minor and MLK Faculty, staff, and students at T.T. Minor and MLK

elementary schoolselementary schools Drew Gagne at T.T. MinorDrew Gagne at T.T. Minor Rae Richardson at MLKRae Richardson at MLK Dr. Gloria Mitchell at T.T. MinorDr. Gloria Mitchell at T.T. Minor Barry Dorsey at MLKBarry Dorsey at MLK

Parents and guardians of T.T. Minor 5Parents and guardians of T.T. Minor 5thth graders graders Center for Public Health NutritionCenter for Public Health Nutrition

Donna Johnson, Molly Shaw, Lynne SmithDonna Johnson, Molly Shaw, Lynne Smith ECORECOR

Laura StreichertLaura Streichert Katie Busby, Kirsten Frandsen, Wendy Weyer of Katie Busby, Kirsten Frandsen, Wendy Weyer of

Seattle SchoolsSeattle Schools

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Documents

June 6, 2006 Presentation by Laura Fanning and Celia Framson Eat Better, Feel Better T.T. Minor Elementary School A program evaluation by University of