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DEVELOPING AN INSTRUMENT FOR ASSESSING FOOD PATTERNS OF PRESCHOOL CHILDREN by Dana Marie Torisky Thesis submitted to the Faculty of the Virginia Polytechnic Institute and State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE in Human Nutrition and Foods APPROVED: A. A. Hertzler, Chairman L. J. Taper D. E. Hinkle July, 1983 Blacksburg, Virginia DEVELOPING AN INSTRUMENT FOR ASSESSING FOOD PATTERNS OF PRESCHOOL CHILDREN by Dana Marie Torisky (ABSTRACT) A 60-item food sort patterned after a game used in anthropological studies was developed to measure food intake of 19 preschool children attending a day care center in Southwest Virginia. Response agreement was determined by administering the game twice to children one month apart, followed by phone interviews with parents, school menu reveiw and teacher interview to confirm child response. Most three-year-olds completed only 20 out of 60 items; nine four- to five-year-olds were able to complete all 60. Children were fairly consistent in response over a month's time, with rough agreements 80 percent or higher for al- most half the group; rough parent-child agreements were also reasonably good, with more than half scoring 75 percent or higher and none scoring below 60 percent. Dietary assessment was only possible to a limited degree, but food group frequency scores revealed children's estimates of their own intake to be considerably higher than those of parents. While reliability of children as primary sources of dietary data is suggested, further study is needed before true validity and reliability of the instrument can be established. ACKNOWLEDGEMENTS Sincere thanks is extended to Ann Hertzler, Dennis Hinkle, Janette Taper and Julein Axelson for their guidance and encouragement throughout this project, and whose doors were never closed. Elizabeth Aydlett, Mona Sutnick, Thomas Fitzgerald, Harriet Talmage, Joanne Pearson and James Moran III all deserve recognition for their ideas and professional ex- pertise from the project's beginning. Two of my colleagues, Miew Leng Mark Teo and Carolyn Raab, deserve special credit for their suggestions and peer support. A special thanks goes to Sherry Saville for her in- valuable typing and technical assistance. This project would not have been possible without the support and cooperation of Pastor Jesse Woodward, Susan Dille, Deborah Cromer and the entire day care center staff. The children were wonderful and all parents are to be applauded for their time and participation, as well as suggestions offered. My parents, Constance and Daniel Torisky, receive my deepest respect and appreciation for their professional advice along the way. Much love and support has been given by all family members throughout this venture. iii TABLE OF CONTENTS TITLE PAGE/APPROVALS •••••..•••••••••.•••••••• . .. i ABSTRACT • ••..•••••.•••••••••.•••.•••....•...•.•••••.••.••.•••.••••••.• ii ACK.NOWLEDGE~NTS ••••••••••••.••.••.••••••.•••.•..•.••.•.••.•.•••••••• iii TABLE OF CONTENTS • •••••••..••.••••..••.••••••••••.••.••••••••••••.•••• iv LIST OF TABI..ES • •••.•••••••.•.•••.•••••••..•...•.••••••••.•••.••.•.•.• vii LIST OF FIGURES • ...••...••.••.....•......................•.....•.... viii INTRODUCTION •••••••••••••.•••••.•••• ................................ 1 Background ••••••• • • • • ,. • • • • • • • • • • • • • • • • e • • • • • • • • • • • • • • 1 Purpose of Study •• .................. 2 REVIEW OF LITERATURE . .......•......................•...........•...•... 4 Basis for Instrument Development ••••.•.••••.•••..•..••..••...•••.• 4 Grade School and Kindergarten Children as Primary Sources of Dietary Data .. .................................... 7 Ennnons and Ha-:y·es . ............. ,, .. ., ................ e •••••••• e • 7 Fanslow, Pease, Njus and Brun ••.•••.•.•••••.•.•..•.•.••.•.••. 8 Burt and Hertzler ... .....•................................. 10 Preschool Children as Primary Sources of Dietary Data .•.•.••••••. 10 Birch . .......... ..........•...... ., ....... 11 Need for Improved Methodology .•••••.•••.••.•••••....•••...•••..•• 13 ~THODOLOGY • •.•..•.•••.••••.•.•..•••...••••••.•••.•.• II •• ... 14 Instrument Development •••• . 14 Preliminary Work ••••••.••• .14 Choice of sample •••.• .14 Food survey ••••••••••• " ...... 15 Instrument Construction •.••..• ..16 Selection of food items •• • • 16 Construction of food sort cards •• . .19 iv Collection of Data .....••...............•..........•.•...•..•..• 21 The Food Sort Game •.•..•..••..••.•...•........•....•....•.. 21 Interviews with Parents •..•.......•.•...•...•......•..••.•• 28 Menu Review and Teacher Interview as Aid in Food Group Scoring . ............................................. 2 9 Data Analysis, ...•..••.• .......................... 30 Acceptance of Game . .••••.•........•..••...••.•.••.......••. 30 Item Recognition ... ...................... 30 Reducing Bias in Analysis .••.••• I 31 Response Agreement - Children ••••.••••.....•..•••.••.•.•••• 31 Response Agreement - Parents with Children •..••••.•.•••..•• 33 Response Levels . ........................................... 33 Food Group Scoring . ................... II •••••••••••• , ••••••• 36 How menu review and teacher interview information was used in scoring . ............................ 9 ••••• 38 RES~TS • •.••••••••••••••••••••••••••••••••.••••••••••.••.••••• • •••.•• 39 Acceptance of Food Sort Game. ............. 39 Number of Items Completed •.••....••... ............ 40 Time Required to Complete Food Sort •.•••.......•..••.••..•...•.. 42 Item Recognition •.. ••• 43 Response Agreement - Children .•.. • •• 48 Response Agreement - Parents with Children ..••..•.•....••....••. 51 Food Group Scores .. .................... 53 DISCUSSION ........................................................... 57 Instrument Reliability ...•....••..•..••....•....••....••..••...• 57 Food Group Scores . .............................................. 5 7 V Instrument Validity ••••••••••••••••.•••••••.••••••••.•••••.••••• 58 Implications for Future Use •••••••• , .••••••.•••••.••• , •••••••••. 59 Single Nutrient Index •••••••••••••••••.••••••••••••.•••.••• 60 Specific Food Identification •••••••••..•••••••••••••••••.•• 60 Nutrition Education Tool •••••••••••••••••••••.•.•••••.••••• 61 Food Preference Research ••••••••••.•••••••••••.•••••••••••• 61 SUMMARY AND RECOMMENDATIONS •••••••••••••••••••••••••••••••••••••••••• 63 LITERATURE CITED ••••••••••••••••••••••••••••••••••••••••••••.•.• , ••.• 65 APPENDIX 1 - FOOD SURVEY AND COVER LETTER ••••••••••..•.•••••••••••••• 69 APPENDIX 2 - DATA COLLECTION FORM •••••••••••••••••••••••••••••••••••• 7 4 APPENDIX 3 - DATA SUMMARY SHEET •••••••• •••••••••••••••••••••••••••.. 78 APPENDIX 4 - FOOD GROUP SCORE SHEETS ••••••••••••••.••.••.•••••.• , •.•• 82 VITA ...................................................... .......... 91 vi LIST OF TABLES PAGE Table 1. Summary of criteria for selection of foods for sort ......................•........... , ........•.......... 18 Table 2. Food items composing sort, classified by food group and numbered according to order of pre- sentation ...................................... 9." •••••••• 20 Table 3. Criteria used in scoring agreement between first and second food- sort trials ....• • ........... •. • • •. • 32 Table 4. Criteria used in scoring agreement between parent and child ...••......••....••.....•......•.....•... 34 Table 5. Number of items completed and time taken by child for both trials of food sort ....•......••................ 41 Table 6. Recognition of first_ twenty items of food sort by children on first trial .•....•..............•......... 44 Table 7. Closely estimated and unrecognized items••···············45 Table 8. Response agreement for children between Trials I and II ........•.•........... ; ............•..•.......... 49 Table 9. Parents' definitions of frequency categories ............. 52 Table 10. Response agreement between children (Trial I) and parents .•...............••••..•...................... 54 Table 11. Food group scores of eight children completing 60 items of food sort game ..•......................•..... 56 vii LIST OF FIGURES PAGES Figure 1. Food sort game board .••.••.••.•• ·•...••..••...••.••.••..•. 22 Figure 2. Food sort game· arrangements •.••.••••...•..•..•...•••...•• 24 viii INTRODUCTION Background The need for developing more valid and reliable instruments for collecting dietary information has been expressed widely in nutrition literature (Talmage and Rasher, 1982; Fanslow, Pease, Njus and Brun, 1982; Talmage and Rasher, 1981; Stunkard and Waxman, 1981; Karvetti and Knuts, 1981; Carter, Sharbaugh and Stapell, 1981; Keys, 1979; Frank, Berenson, Schilling and Moore, 1977; Emmons and Hayes, 1973; Pekkarinen, 1970). In the interest of beginning early in establishing health- promoting dietary habits for life, nutritionists and other health pro- fessionals are concerned with the measurement of food intake of pre- school children, Instruments must be chosen which are capable of re- liably and accurately assessing nutritional status of young children (Morgan, 1980; Christakis, 1979), as well as evaluating nutrition educa- tion efforts aimed at changing or maintaining various dietary patterns. While recall methods and food records kept by parents have common- ly been used for obtaining dietary information from children (Morgan, 1980), these data do not necessarily reflect usual food intake for a given individual (Morgan, 1980; Garn, 1978; Pekkarinen, 1970; Beal, 1967; Burke, 1947), Food recall, food record