Adaptation of the Simple Suppers Family Meals Intervention to a Head Start Setting: Feasibility and Health Behavior Outcomes Thesis

Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in the Graduate School of The Ohio State University

Allison Labyk, B.S.

Graduate Program in Human Nutrition

The Ohio State University

2018

Master’s Examination Committee:

Carolyn Gunther, Ph.D., Advisor

Irene Hatsu, Ph.D., R.D.

Sanja Ilic, Ph.D.

Julie Kennel, Ph.D., R.D.

Abstract

Background: Fourteen percent of all U.S. preschool-aged children are obese and the prevalence is even greater among racial/ethnic minorities. Obese children are at an increased risk for short- and long-term health consequences. Healthy family mealtime routines offer a protective effect.

Objective: Assess feasibility, child and caregiver health behavior outcomes of the Simple

Suppers (SS) family meals intervention designed for underserved, racially diverse school- aged children and caregivers adapted to a Head Start (HS) population and setting.

Methods: Programmatic modifications included: age-appropriateness of food preparation skills, frequency and timing of programming, and staffing structure. This was a single group pre- to post-test study design. The intervention was delivered over two years. In year one, SS was delivered over five monthly lessons to one site. In year two, SS was delivered over seven monthly lessons to two sites. Retention, attendance, fidelity and acceptability served as main feasibility outcomes. Main child outcomes were child food preparation skill ability and frequency, diet (fruit (cups/day) (c/d)), vegetables (c/d), frequency of consumption of sugar sweetened beverages (SSB) and BMI z-score. Main caregiver outcomes were parent self-efficacy for preparing family meals, frequency of shared family breakfast, dinner, frequency of meals in the dining area, frequency of

ii television viewing during dinner, and BMI. Paired t-test was used to determine pre- to post-test changes in these outcomes.

Results: In year one, 18 caregiver-child dyads enrolled in the study and 12 completed

(66.7% retention). There were no significant changes in zBMI or dietary outcomes.

Frequency of child food preparation in the home increased and trended towards significance (p=0.09). There were no significant differences in caregiver level outcomes.

In year two, 39 caregiver-child dyads enrolled and 34 completed (87.2% retention).

Significant positive changes were seen in child food preparation skill ability (p=0.000) and frequency (p=0.0001). No significant changes were observed in dietary outcomes. zBMI increased significantly but stayed within normal zBMI range (p=0.0004).

Significant positive changes were observed in caregiver self-efficacy (p=0.03). No significant differences were observed in home food environment outcomes. Caregiver

BMI increased significantly (p=0.01). Focus group data in both years revealed high acceptability, an increase in child food preparation in the home, and encouraged many programmatic modifications to increase program feasibility.

Conclusions: The SS intervention demonstrated high feasibility at HS in both years.

Significant outcomes were observed at both the child and caregiver level. These preliminary findings suggest that HS is a suitable venue for this childhood obesity prevention family meals intervention.

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Acknowledgements

First and foremost, I would like to thank my graduate school advisor Dr. Carolyn

Gunther. I would not be writing this had it not been for your unwavering support, encouragement, flexibility, and willingness to take me on as a graduate student. I would also like to thank my lab members, both past and present. Specifically, I would like to thank Dr. Laura Hopkins who served as an incredible peer mentor for me throughout this journey.

I would like to extend an enormous thank you to my graduate committee Dr. Julie

Kennel, Dr. Sanja Ilic, and Dr. Irene Hatsu for your continuous support and dedication to this project. I would also like to thank Dr. Julie Kennel for encouraging me to pursue graduate work after the completion of my undergraduate degree and for her support throughout. In addition, I would like to thank Dr. Rich Bruno for providing me my first research opportunity in this department, giving me the confidence to pursue graduate degree work in community nutrition.

I would next like to thank all of the undergraduate students and dietetic interns that worked tirelessly to make this work possible. In addition, I would like to thank the

Columbus Urban League Head Start for their dedication to this program as we conducted this study in their facilities.

Finally, I would like to thank my friends, family, and boyfriend for their support and patience over the past two and a half years. This simply would not have been possible without you all.

Vita

Brecksville Broadview Heights High School ...... June 20ll B.S. Human Nutrition – Dietetics, The Ohio State University ...... December 2015 Research Assistant, Dr. Rich Bruno, The Ohio State University ..... January 2016 – August 2016 Graduate Teaching Associate, The Ohio State University ...... August 2016 – Present Dietetic Internship, The Ohio State University...... August 2017 – Present

Publications Jinhui Li, Geoffrey Y. Sasaki, Priyankar Dey, Chureeporn Chitchumroonchokchai, Allison N. Labyk, Joshua D. McDonald, Joshua B. Kim, Richard S. Bruno. “Green tea extract protects against hepatic NFκB activation along the gut-liver axis in diet-induced obese mice with nonalcoholic steatohepatitis by reducing endotoxin and TLR4/MyD88 signaling.” J Nutr Biochem. doi:10.1016/j.jnutbio.2017.10.016.

Joshua D. McDonald, Chureeporn Chitchumroonchokchai, Jinhui Li, Eunice Mah, Allison N. Labyk, Elizabeth J. Reverri, Kevin D. Ballard, Jeff S. Volek, Richard S. Bruno. “Replacing carbohydrate during a glucose challenge with the egg white portion of whole eggs protects against postprandial impairments in vascular endothelial function in prediabetic men by limiting increases in glycemia and lipid peroxidation.” British Journal of Nutrition. doi:10.1017/S0007114517003610.

Field of Study Major Field: Human Nutrition

Table of Contents

Abstract ...... ii Acknowledgements ...... iv Vita ...... v Table of Figures ...... ix List of Tables ...... x Chapter 1: Introduction ...... 1 Chapter 2: Review of the Literature ...... 10 Chapter 3: Simple Suppers at Head Start 2016/2017...... 24 3.1 Background ...... 24 3.2 Methods ...... 27 3.21 Intervention and Adaptations for the Head Start Population and Setting ...... 27 3.22 Data Collection ...... 32 3.23 Recruitment and Incentives ...... 37 3.24 Data Analysis ...... 38 3.3 Results ...... 40 3.31 Objective 1: Feasibility Outcomes ...... 40 3.32 Objective 2: Child Level Outcomes ...... 43 3.33 Objective 3: Caregiver Level Outcomes ...... 45 3.4 Discussion ...... 48 3.41 Objective 1: Feasibility Outcomes ...... 49 3.42 Objective 2: Child Level Outcomes ...... 50 3.43 Objective 3: Caregiver Level Outcomes ...... 52 3.44 Limitations ...... 53 3.45 Conclusions ...... 55 Chapter 4: Simple Suppers at Head Start 2017/2018...... 57 4.1 Background ...... 57 4.2 Methods ...... 61 4.21 Intervention and Adaptations for the Head Start Population and Setting ...... 62

4.23 Recruitment ...... 66 4.22 Data Collection ...... 66 4.24 Data Analysis ...... 72 4.3 Results ...... 74 4.31 Objective 1: Feasibility Outcomes ...... 74 4.32 Objective 2: Child Outcomes ...... 84 4.23 Objective 3: Caregiver Outcomes ...... 86 4.4 Discussion ...... 90 4.41 Objective 1: Feasibility Outcomes ...... 91 4.42 Objective 2: Child Outcomes ...... 93 4.43 Objective 3: Caregiver Outcomes ...... 95 4.44 Limitations ...... 97 4.45 Conclusions ...... 99 Chapter 5: Epilogue ...... 103 References ...... 105 Appendix A: Recruitment Materials ...... 112 A1. Moler Elementary School Head Start Recruitment Flyer ...... 112 A2. Southside Head Start Recruitment Flyer ...... 113 Appendix B: Consent, Parental Permission, Assent and Photograph Release Forms .... 114 B1. Consent Form ...... 114 B2. Parental Permission Form ...... 120 B3. Child Assent Form ...... 126 B4. Photograph Release Form ...... 127 Appendix C: Questionnaire Data Collection Forms ...... 128 C1. Demographic Questionnaire ...... 128 C2. Household Food Security Screener ...... 136 C3. Home Food Environment Questionnaire ...... 137 C4. Parent Family Meals Self-Efficacy...... 140 C5. Child Food Preparation Skills ...... 145 C6. Parent Anthropometric Form ...... 150 C7. Child Anthropometric Form ...... 151 C8: Block Screener...... 152 vii

Appendix D: Acceptability Data Collection Forms ...... 154 D1. Focus Group Consent Forms ...... 154 D2. Focus Group Scripts ...... 160 D3. Acceptability Questionnaire ...... 166 D4. Fidelity Checklist ...... 167 D5: Lesson Sign-In Sheet ...... 169

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Table of Figures

Figure 1. Consort Flow Diagram Simple Suppers at Head Start 2016/2017 ...... 43 Figure 2. Consort Flow Diagram Simple Suppers at Head Start 2017/2018 ...... 79

List of Tables

Table 1. Simple Suppers Curriculum- Topics and Meals ...... 5 Table 2. Simple Suppers Child Food Preparation Skills for 4-5 Year Olds ...... 6 Table 3. Simple Suppers 2016/2017 Programming Dates ...... 30 Table 4. Simple Suppers 2016/2017 Topics and Meals ...... 31 Table 5. Child Food Preparation Skills ...... 31 Table 6. Child Baseline Characteristicsa ...... 44 Table 7. Child Level Outcomes a,b ...... 44 Table 8. Caregiver Baseline Characteristics ...... 46 Table 9. Caregiver Outcomes a,b ...... 47 Table 10. Simple Suppers 2017/2018 Programming Dates ...... 64 Table 11. Simple Suppers 2017/2018 Topics and Meals ...... 64 Table 12. Child Food Preparation Skills ...... 65 Table 13. Simple Suppers Feasibility and Fidelity Process Evaluation Outcomes ...... 79 Table 14. Child Baseline Characteristics (n=39) ...... 85 Table 15. Child Level Outcomes (n=34)a ...... 85 Table 16. Caregiver Characteristics ...... 88 Table 17. Caregiver Outcomesa,b ...... 90

Chapter 1: Introduction

Data from the 2015-2016 National Health and Nutrition Examination Survey

(NHANES) show that 18.5% of youth aged 2-19 are obese.1 Within this age group,

13.9% of children between the ages 2-5 are obese.1 The overall rate of childhood obesity

(18.5%) is higher than the Healthy People 2020 goal of 14.5%.2 In addition, the current prevalence of obesity among 2-5 year olds is higher than the Healthy People 2020 goal of

9.4%, making obesity among this age group of high public health concern.2

The same NHANES survey data show disparities in racial/ethnic minority groups such that the highest prevalence of obesity among 2-19 year olds was Hispanic youths at

25.8% with the next highest prevalence of non-Hispanic black at 22.0%1. These numbers are significantly different from the prevalence for non-Hispanic white youth, which falls at 14.1%.1 The lowest prevalence of obesity was amongst non-Hispanic Asian youth at

8.9%.1

Disparities in childhood obesity also exist among socioeconomically disadvantaged children as data show that children living below the federal poverty level have an obesity rate 2.7 times higher than children living in home at or above 400% of the poverty level.3

In addition, children from low-income communities are 20-60% more likely to be obese in their lifetimes.3 A 2016 report from the Center for Disease Control and Prevention’s

(CDC) Pediatric Nutrition Surveillance System (PNSS) shows an increase in the prevalence of obesity among low-income, preschool-aged children enrolled in Women

Infants and Children (WIC), from 14.0% in 2000 to 15.5% in 2004.4 This number grew to

15.9% in 2010 and the most recent data from 2014 showed a decrease to 14.6%.4 While this number has decreased in recent years, it remains higher than both the national average for all children of this age range, as well as higher than the prevalence 14 years prior, making the prevalence of obesity among this age and income level of high public health concern.

The state of Ohio is not immune to the childhood obesity epidemic. As of 2016, Ohio children enrolled in WIC are experiencing obesity at 13.1%, putting Ohio 35th out of the

50 states.5 Data collected in 2014 from the Ohio Head Start BMI surveillance program demonstrated that 17% of children enrolled in Head Start in the state of Ohio are overweight and 19% are obese, higher than the most recent national rates of childhood obesity documented from 2015-2016.1,6 Thus, low-income, minority children are currently at an excessive risk for developing obesity.1,3,4,5,6

These rates of obesity are of public health concern because overweight and obese children are at an increased risk for developing short-term health consequences, as well as tracking obesity into adolescence and adulthood.7,8 Childhood obesity is associated with multiple comorbidities such as hypertension, atherosclerosis, insulin resistance, type two diabetes, metabolic syndrome, asthma, obstructive sleep apnea, nonalcoholic fatty liver disease, and polycystic ovary syndrome.9 Not only do these children suffer short- term comorbidities, but they are also at risk for tracking obesity into adulthood and for serious long-term complications such as stroke, cancer of the breast, colon and kidney, musculoskeletal disorders, and gall bladder disease.10

Obesity in early childhood is of particular concern given that these children are creating lasting nutrition habits and developing food perceptions that will track throughout the lifetime.11,12 In addition, they are developmentally dependent on their caregivers as “nutritional gatekeepers,” as children are dependent on their caregivers for food.13 Considering the importance of nutritional habits formed at this age as well as the risk of tracking obesity throughout the lifetime, focusing obesity intervention efforts on this age group is of upmost public health importance. More so, involving the caregivers in these interventions is integral to their success.

The American Academy of Pediatrics Expert Committee released a statement on recommendations for the prevention and treatment of childhood obesity. The following health behaviors were recommended: limiting the consumption of sugar sweetened beverages, encouraging the consumption of the recommended quantities of fruits and vegetables, limiting screen time, eating breakfast daily, limiting eating out at restaurants and fast foods, encouraging regular family meals, and limiting portion size.14 More recently, the 2015 Dietary Guidelines Advisory Report called for public health professionals to assess the frequency and quality of family meals in diverse populations and to conduct randomized control trials in order to isolate the effect that family meal interventions have on weight status.15 The literature shows that the frequency of shared family meals is positively related to nutritional health in children as children who share three or more family meals per week are more likely to be of a normal weight and to have healthier dietary patterns than those who share fewer than three family meals.16 In addition, it has been demonstrated that involving children in food preparation for family meals is related to improved dietary quality and eating patterns among children.17 For

3 these reasons, the incorporation of public health programming centered on family meals has become a popular practice. However, much of these interventions occur with older children and adolescents and do not represent families from diverse racial or ethnic and socioeconomic backgrounds or preschool aged children.

Simple Suppers (SS) is a nutrition education, family meals intervention developed to address the epidemic of childhood obesity through family meals.18 The goal of this intervention is to increase the frequency of family meals among racially diverse, underserved families to positively impact child diet quality and weight status. SS includes

10, 90-minute program lessons delivered weekly for 10 weeks over the dinnertime hour.

Each 90-minute lesson is separated into three components. These include a caregiver lesson, child lesson, and family lesson and meal. The first 45 minutes include a separate but simultaneous lesson for the children and caregivers. The caregivers learn skills to help in planning and executing a family meal while the children learn an age appropriate kitchen preparation skill. In the following 45 minutes the children and caregivers come together to complete a family lesson and eat a meal together. Each lesson and meal correspond to a specific theme. The lesson themes and meals are included in Table 1. The child food preparation skills associated with each theme are located in

Table 2.

The Social Cognitive Theory (SCT) functions as the theoretical framework for the

SS intervention.19 The SCT has been shown as an effective theoretical framework to promote behavior change among this population and describes human behavior as an interaction between personal, behavioral, and environmental factors. It works towards the

4 goal of improving child weight status and dietary outcomes by targeting the personal, socio-environmental, and behavioral factors that are associated with improved diet quality in children. In addition to the SCT, the Intervention Mapping protocol was used in the development of SS. This protocol provides tools and guidelines for selecting theoretical foundations of health promotion programs as well as for the application of and translation of these theories into tangible program materials and activities. 18,20

Table 1. Simple Suppers Curriculum- Topics and Meals

Lesson Themes Meal 1 Making family mealtime fun! Fruit and yogurt-topped whole wheat pancakes with veggie scrambled eggs 2 Planning family meals on a budget Fiesta skillet with fresh fruits and vegetables 3 Timesaving strategies for family Breakfast burrito and salsa with meals baked apple wedges 4 Connecting with children through Quick skillet lasagna with veggies & meals dip with crunchy frozen bananas 5 Planning well-balanced family meals Baked potato bar, chicken tortilla soup, and orange fluff salad 6 Rethink your drink Meatloaf muffins, twice-as-nice mashed potatoes, and fruit pudding 7 Making healthy cooking tasty & easy Garden sloppy joes and easy fruit salad 8 Serving & eating healthy portions Scrambled egg muffins, roasted potatoes, and crunchy berry parfait 9 Eating healthy away from home Cheesy crunchy chicken tenders, applesauce, and glazed carrots

10 Planning fun & healthy snacks Whole grain pizza, side salad, berry good banana splits

Table 2. Simple Suppers Child Food Preparation Skills for 4-5 Year Olds

Lesson Child Food Preparation Skill 1 Setting the table 2 Wash and prepare fresh produce 3 Cut soft foods with a blunt knife 4 Measure dry ingredients 5 Measure liquid ingredients 6 Grease or spray baking pans 7 Cut soft foods with a blunt knife 8 Measure liquid ingredient, cut soft foods with a blunt knife 9 Measure dry ingredients 10 Measure dry ingredients and portion food

The SS intervention was implemented by Rogers et al as a quasi-experimental trial with a staggered cohort design.21 It was delivered at a faith-based community center for underserved families with 4-10-year-old children from racially diverse backgrounds.18

Data were collected at baseline, post-test, and at a 10-week follow up period. Diet quality, body mass index z-score (zBMI), and blood pressure served as the main child outcomes measures while diet quality, BMI, caregiver self-efficacy for healthy dietary patterns, and frequency of family meals served as the main caregiver and family outcome measures. One hundred and twenty-six children from 95 families enrolled in the SS intervention. Intervention children attended 71% of SS lessons on average. Ninety-five percent of lessons were delivered as intended and child participants were engaged in the

6 program 96% of the time. At program completion, 100% of the participating caregivers reported their child enjoyed participating in the program. Generalized Linear Mixed

Models (GLMMs) that included group assignment, baseline values, and confounders as independent variables demonstrated an intervention effect on food preparation skills, with intervention children having higher skill ability (p<0.001) and frequency (p=0.003) at post-test, maintained at 10-week follow-up. In GLMMs that included attendance, baseline values, and confounders as independent variables, each additional lesson attended was associated with lower BMI (p=0.04) and systolic BP (p=0.03) z scores, and higher child food preparation skill ability (p<0.001) and frequency (p=0.01) at post-test.

Caregivers who participated in the intervention had a significant decrease in BMI

(p=0.028), which was maintained at follow-up. In addition, caregiver self-efficacy for healthy dietary behaviors significantly increased among intervention caregivers relative to control at post-test (p=0.012), which was maintained at 10-week follow up. SS was demonstrated to be highly feasible and significant child and caregiver outcomes were observed.

While SS addressed the gap in literature regarding racially diverse, underserved populations, the intervention did not address preschool-aged children from families at or below the poverty line. With such large disparities among racially diverse, low-income families, specifically in the state of Ohio, it became ethically relevant to deliver this intervention in such a high-risk population when a community leader involved with the local Columbus, Ohio Head Start reached out to bring this intervention to their students.

Head Start is a federal program through the U.S. Department of Health and

Human Sciences that aims to promote school readiness for children below the age of five from families at or below the poverty line. Thus, delivering SS at Head Start leads to a change in the population enrolled in the SS nutrition education intervention. Families at

Head Start are of a lower-income level than those who have been previously enrolled in the SS program. In addition, these children are between the ages of 3-5, younger than the

4-10 year olds previously enrolled. These changes bring about the need for a feasibility trial of SS adapted for the Head Start population and setting.

The aim of the current study is to assess the feasibility of the SS intervention in the Head Start population and setting. To address this aim, the following three objectives were assessed.

Objective 1: Assess feasibility outcomes (retention, attendance, acceptability, and fidelity) of the SS intervention in the Head Start population.

It was hypothesized that the SS intervention would have a high retention rate, attendance, acceptability, and fidelity in the Head Start population and setting.

Objective 2: Assess the effects of the SS intervention on child outcomes related to behavior (food preparation skills and frequency), diet (fruit/fruit juice (cups), vegetables excluding potatoes (cups), and sugar sweetened beverages (SSB) per day), and weight status (zBMI).

It was hypothesized that when compared to baseline, children would have improved behavioral (increased food preparation skills and frequency), diet (increased

8 consumption of fruits and beverages and decreased intake of SSB), and weight status

(prevention of inappropriate increase in zBMI) outcomes at post-test.

Objective 3: Assess the effects of the SS intervention on caregiver outcomes related to cognition (self-efficacy for healthy dietary practices), the home food environment

(frequency of eating dinner together, eating breakfast together, consuming meals in the dining area, and viewing of television during mealtimes), and weight status (BMI).

It was hypothesized that when compared to baseline, caregivers would have improved cognition (increased self-efficacy for healthy dietary practices), positive changes in the home food environment (increased frequency of eating dinner together, eating breakfast together, and eating meals in the dining area and a decrease in the viewing of television during mealtimes), and weight status (decreased or prevention of increase in BMI) outcomes at post-test.

Chapter 2: Review of the Literature

Childhood obesity data from the 2015-2016 National Health and Nutrition

Examination Survey (NHANES) show that 18.5% of youth aged 2-19 are obese and

13.9% of children between the ages 2-5 are obese.1 While obesity rates are lower among preschool aged children, this is of public health concern as this obesity is likely to track throughout the child’s lifetime.7,8

Disparities in childhood obesity exist among racial/ethnic minorities and socioeconomically disadvantaged children. Hispanic youths have the highest prevalence of obesity (25.8%), followed non-Hispanic blacks (22.0%).1 These numbers are significantly different from the prevalence among non-Hispanic white youth (14.1%).1

Children from low-income households experience obesity at 2.7 times the rate than children from households at 400% of the poverty level and these children are 20-60% more likely to be obese.3

Preschool is an important age to intervene because preschool-age children are creating dietary habits affecting their intake that will persist throughout their lifetime. A study conducted by Singer et al demonstrated that the nutrient intakes of children aged 3-

4 track into their early school years.11 One hundred six, 2-parent families with children aged 3-5 enrolled in the Framingham Children’s Study. Intake of 10 nutrients were estimated using four sets of 3-day food diaries in the first year (one set for each season); two sets in years 2,3 and 5 and one set was requested in years 4 and 6. Food diaries were

10 classified into three age groups (3-4, 5-6, and 7-8). Nutrient intakes were compared at each of these age classifications. Data from 95 children were included in analyses.

Children aged 3-4 in the highest quintile of intake for each nutrient remained in the highest quintile at age 5-6 and at age 7-8. Results from this study demonstrated that children who had an extreme intake of calories compared to their needs during preschool years maintained that extreme intake through 8 years of age.

Not only are children developing such dietary habits but their environment and experiences at this age are shaping their health related behaviors regarding food.

Matheson et al conducted structured open-ended interviews and observed children in their play environments in public preschools and elementary schools in Midwest

Michigan.12 They found that children are aware of food-related scenarios and often mimicked activities in play that they likely saw at home. These activities included cultural food practices, meal patterns, and food safety behaviors. The home environment serves as an important environment for the development of these habits and it is likely that caregivers play a key role in shaping these habits among their children.

Caregivers influence their child’s food preferences in three different ways: setting rules/expectations in the home, making healthy foods available to their children, and through setting an example or role modeling healthy eating practices.22 Thus, childhood obesity interventions must also address caregiver dietary habits, including their barriers and facilitators to healthy eating. Natale et al examined the effect of parent role modeling on preschool-aged child behavior within an ethnically diverse population.23 Results showed that parents who consumed more fruits and vegetables also had children who

11 consumed more fruits and vegetables. This finding is supported by the SCT that suggests the importance of parent role modeling in teaching children positive habits. This role modeling is an external factor that influences child behaviors and diet.24 Knowing the significance of role modeling in child behavior, it is important to examine parent’s knowledge, barriers, and strategies to overcome barriers of role modeling this healthy behavior.

One setting that allows parents to role model healthy eating is during family meals.

Due to this, the American Academy of Pediatrics Expert Committee released a statement on recommendations for the prevention and treatment of childhood obesity that included encouraging regular family meals.14 More recently, the 2015 Dietary Guidelines

Advisory Report called for public health professionals to assess the frequency and quality of family meals in diverse populations and to conduct randomized control trials in order to isolate the effect that family meal interventions have on weight status.15

The frequency of family meals in the home has been shown to be significantly associated with positive dietary outcomes in children.16 A meta-analysis was conducted reviewing 17 studies that examined overweight and obese children and their food consumption and eating patterns.16 When pooled, the meta-analysis included 182,836 children in the age range of 2.8-17.3 years. A family meals occasion was defined as a meal where at least one parent or caregiver was present. The authors found that children who shared three or more family meals per week were more likely to have healthier dietary outcomes than those who shared less than three family meals per week. More specifically, they saw a 20% reduction in eating unhealthy foods, and a 24% increase in

12 eating healthy foods among the children who shared three or more family meals, compared to those who shared less than three. They also demonstrated a 12% reduction in overweight. This study illustrated the importance of shared family meals in the reduction of childhood obesity and improved child dietary intake.

The impact of family meals on child dietary intake was further elucidated in 2014, when a cross-sectional study of 1992 children from birth-17 years of age that assessed child dietary quality and family meals frequency was conducted.25 It was found that participation in greater than or equal to five family meals per week was associated with lower sugar sweetened beverage intake in younger children aged birth to 6 (p<0.05) and increased consumption of vegetables (p<0.05) in older children aged 6-11. Similar trends, including an increased frequency of consumption of fruits were seen by older children and adolescents aged 11-17. These data help to explain how family meals may decrease childhood obesity as increased family meals lead to healthier dietary patterns.

It is evident that family meals positively affect child health through improved dietary patterns. Caregivers serve as “nutritional gatekeepers” thus their self-efficacy in provided these healthy meals is important in their success. Researchers from Temple University conducted focus groups with parents of preschool-aged children from low-income families regarding their perceptions and feelings on family meals.26 Three themes emerged from these focus groups. These were the mother’s childhood experiences with family meals, that mothers enjoyed family meals and felt they established a connection with their children through family meals, and that family meals are hard work. More specifically, mothers stated that family meals were tiring and time-consuming to complete and that it was challenging to maintain a calm and orderly atmosphere. This

13 suggests that while mothers within this population feel the desire to have family meals, there are barriers that may keep them from doing so. Thus, it is important to address these barriers when conducting intervention work.

Martin-Biggers et al used a mixed method approach to further examine the cognitions, barriers, supports, and role modeling of key obesogenic behaviors such as consumption of breakfast, fruit and vegetables, and sugar sweetened beverages, as well as portion sizes and feeding practices of parents to their preschool aged children.27 It was found that cognitively, parents understand the importance of eating healthfully, however; they experience many barriers in doing so. These barriers included lack of time, neighborhood safety, limited knowledge of portion sizes, cooking methods and ways to prepare healthy foods or play active indoor games, the perceived cost of healthy options, and family members who were picky eaters. Focus group data also illustrated the importance of parents sharing their experiences with their peers (other parents of preschool aged children) in increasing self-efficacy or confidence in their ability to role model positive behaviors in their own home. These findings not only suggest the importance of involving the entire family in obesity prevention efforts with preschool aged children, but also suggest the importance of connecting caregivers with one another in these interventions.

In 2010, Campbell et al conducted a cross-sectional study that aimed to conduct a more in depth examination of how caregiver self-efficacy influences their children’s eating behaviors.28 Data were collected at two time points, when children were one year of age and again when children were five years of age. Mother’s reported child dietary

14 intake and maternal self-efficacy for children’s eating behaviors were recorded. The results showed a decline in maternal self-efficacy regarding limiting non-core food and drink during the first few years of life. Higher maternal self-efficacy was associated with the 5-year-old children’s water (p<0.05) and fruit and vegetable consumption (p<0.005), and 1-year-old children’s vegetable consumption (p<0.05). Mother self-efficacy was inversely associated with cordial and cake consumption (p<0.05) in both age groups. This study suggests the importance of targeting the maternal self-efficacy when intervening with children in this stage of life and illustrate the importance of increasing caregiver self-efficacy in promoting positive health outcomes in children.

Knowing the importance of intervening early in childhood, a pre-post cohort family- centered intervention was developed and pilot tested for low-income families with preschool-aged children enrolled in Head Start.29 In this community-based participatory research (CBPR) approach, the parents and the research team worked together to plan and conduct a community assessment in order to design a family-centered childhood obesity intervention. Upon completion of the community assessment, the parents and research team worked to implement this intervention and evaluate its impact. Four intervention components were included: “1) revisions of letters sent home to families reporting child body mass index; 2) a communication campaign to raise parents’ awareness of their child’s weight status; 3) the integration of nutrition counseling into Head Start family engagement activities; and 4) a 6-week parent-led program to strengthen parents’ communication skills, conflict resolution, resource related empowerment for healthy lifestyles, social networks, and media literacy.” Four hundred and twenty-three children from five Head Start centers in upstate New York and their families were involved in the

15 intervention. Of these families, 154 participated in the evaluation of the intervention.

Child BMI z-scores were calculated and dietary data was collected on children with the use of 24-hour recalls. Parents completed questionnaires on parenting practices and attitudes specific to children’s diet. Children had marginally lower BMI z-scores (p<0.10) and significantly lower rates of obesity (p<0.01) at post-intervention when compared to pre-intervention. In addition, children had significantly lower total energy intake (p<0.01) and macronutrient intake (p<0.05) at post-test when compared to pre-intervention. At the parent level, there was a significant increase in parental self-efficacy to provide healthy foods (p<0.01) and marginally greater frequency of offering fruits and vegetables

(p<0.10) to children at post-intervention when compared to pre-intervention. These data help to determine intervention factors that may increase caregiver self-efficacy. In addition, they further suggest that increased caregiver self-efficacy may have positive effects on child dietary patterns.

While caregiver self-efficacy is important in promoting family meals, examining the home food environment in which they are being held is important as well. Family Meals,

LIVE! was a mixed-methods, cross-sectional study designed to identify factors relating to the home food environment that increase or minimize the risk for childhood obesity.30

Both healthy weight and overweight children aged 6-12 were recruited from primary care clinics from low-income, minority neighborhoods. Interviews were conducted with families in order to better understand the parents’ perspectives of potential risk or protective factors for child obesity in the home environment. Findings showed that parents of normal weight children “had family meals because they promoted connection and communication among family members and did not pressure their children to eat

16 food served at meals.” This suggests that the promotion of communication and connection during family meals and utilizing feeding practices that are less controlling may create an atmosphere at family meals that leads to healthier eating and thus a more normal weight status. Findings also showed that parents of overweight/obese children had family meals because it was tradition, tended to use pressure-to-eat feeding practices with children, allowed electronic devices at meals, reported behavior problems at meals and reported having trouble getting children to help with clean up when compared to parents of normal weight children. These differences suggest that the consumption of a family meal alone may not be enough to change child weight status, emphasizing the importance of the interpersonal dynamics during family meals. Similarities existed between families with and without overweight or obese children including having family meals to feed people, wanting to feed children more healthfully, and involving children in meal preparation. Berge et al suggested that these similarities should be considered and emphasized when developing interventions in order to gain buy in from parents.

Another factor that effects the success of family meals in the involvement of children.

It is well-established that involving preschool-aged children in food preparation activities is associated with a higher nutritional awareness and better dietary intake.31 A cross- sectional study among 3,398 fifth graders in Alberta, Canada was conducted to assess the association between frequency of food preparation and healthy food preference and self- efficacy of making healthy food choices. It was found that fruit and vegetable preference along with self-efficacy of choosing healthy foods increased with increasing frequency of home meal preparation. 32 This suggests that frequent involvement in food-related

17 activities such as meal preparation, may be important in developing healthy eating behaviors in children.

Clemson Cooperative Extension created a resource using peer-reviewed literature to outlines both the benefits of involving children in meal preparation, as well as the age appropriate meal preparation activities in which they are capable of participating.33

There are short-term and long-term benefits of child involvement in food preparation. In the short term, children will feel encouraged to try new and healthy foods, will feel a sense of accomplishment, are more likely to engage in a family meal they helped to prepare, are spending quality time with their family, and are spending that time in the kitchen rather that in front of a screen. In the long term, children are learning skills for the rest of their lives, they are more likely to eat healthfully as adults, and they can gain self-confidence through their cooking experiences. At age 3, children are able to pour liquids, mix ingredients, spread soft spread, knead dough, and throw away trash. By the age of 4 and 5 children are capable of setting the table, mashing soft fruit, forming round shapes, measuring dry and liquid ingredients, peeling fruit, and cutting with a blunt knife.

Researchers from the University of Minneapolis sought to measure the effects of the

Cooking Matters for Families Program developed by a national nonprofit organization

Share Our Strength on family’s ability to procure, prepare, and serve vegetables to children at mealtime.34 Families that qualified for public assistance with children aged 9-

12 were invited to participate in this program. The program consisted of six 2-hour cooking skills and nutrition education sessions. These sessions included four parts: “(1) a professional chef demonstrated a vegetable-focused recipe, (2) parent–child pairs prepared the recipe under the guidance of the chef and nutrition educator, (3) a nutrition

18 educator delivered a nutrition education lesson, and (4) participants ate the meal they prepared together.” This program was originally delivered to two intervention groups and data from these two groups were combined for this analysis. Data was collected at baseline and post-test to assess changes in psychosocial measures, vegetable liking, variety of vegetables eaten, and home vegetable availability. One hundred three parent- child dyads enrolled in the study and 89 families completed post-test data collection.

Parent self-confidence (P<0.001) and healthy food preparation improved (P<0.001) from baseline to post-test. Child self-efficacy improved (P<0.001) from baseline to post-test but no improvement for child attitudes towards cooking were observed (P=0.277). Mean number of vegetables for which parents felt confident preparing increased from baseline to post-test from 16.5 – 19.6 (P<0.001) and confidence in using four cooking methods

(roasting, poaching stir-frying, strewing/braising) increased from 51%-73% (P<0.049).

This study showed positive impact on psychosocial measures, vegetables liking, vegetable variety, and home availability of vegetables for participants. The authors concluded that the hands-on participation in food preparation ultimately led to increased confidence in preparing these vegetables. In addition, it is believed that positive role modeling of consumption of vegetables lead to eventual positive effects on child intake of these vegetables. Results from this study may inform future family-focused nutrition education programs.

A wealth of literature exists showing positive associations between children and adolescents involvement in home food preparation and positive dietary and health outcomes. However, this research is currently limited to children over the age of 5 years.

The benefits of involving children in meal preparation, the positive associations of food

19 preparation and health outcomes, along with this gap in the literature suggests the need for intervention work involving food preparation with preschool-aged children.

As a result of the positive findings surrounding family meals and childhood health, family meals-based nutrition education interventions have become an increasingly common. The HOME Plus program was an intervention developed to increase the frequency of family meals and thus improve child diet and weight status.35,36 This randomized control trial included 160 families each with a child aged 8-12. Rooted in the

SCT, this intervention had three overreaching behavioral messages; ‘Plan healthy meals and snack with your family more often, have meals with your family at home more often, and improve the healthfulness of food available at home.’ The program was met with high participant satisfaction as well as high fidelity. While not statistically significant, modest decreases in excess weight gain post-intervention were observed. These decreases were seen specifically in the prepubescent children (8-10 years old) enrolled in the study, suggesting that association between weight or BMI and family meal frequency may be stronger in younger children. Thus, providing evidence that such interventions should occur earlier in development in children.

Successful pilot studies of childhood obesity prevention interventions have been conducted in the low-income, preschool setting. Rose et al conducted a feasibility trial of a nutrition education and cooking program for low-income children and their families in the day care setting.37 Ten, 90-minute lessons were delivered to families once per month.

Data were collected at three time points, baseline, midpoint, and post-test. The program demonstrated high feasibility with 91% retention of families from baseline to post-test. In

20 addition, average attendance was 74% and families reported high satisfaction with the program. While no changes in child food preparation skills were observed, consumption of fruits and vegetables (excluding potatoes) increased from the mid-study to post-test

(p<0.05). Child consumption of sugar-sweetened beverages decreased from baseline to mid-study (p<0.05). No gain in child BMI percentile was observed. In addition, caregivers reported greater confidence in planning and promoting healthy food choices in their home and an overall increase in the frequency with which the families prepared meals at home and ate together (p<0.05). This obesity prevention intervention implemented in a childcare center with preschool aged children demonstrates the efficacy of not only conducting research among this age group, but of delivering such programs within this type of community setting.

While these interventions were successful, a gap in the literature remains regarding family meals interventions in a low-income, preschool-age population in subsidized childcare centers. Therefore, assessing the effectiveness of alternative nutrition education interventions in preschool-age children helps to justify the incorporation of the SS intervention within this age group. Natale et al conducted a group randomized control trial to examine the effects of an obesity prevention program on preschool-age children.38

The Healthy Inside - Healthy Outside (HI-HO) nutrition education intervention was conducted was a six-month nutrition education intervention delivered to four of eight childcare centers in Miami, Florida. The intervention was developed using the socio- ecological model framework and included three educational components. The first component was an education module geared towards the teachers at each childcare

21 center. The teachers learned the rationale of the intervention (HI-HO) and taught implementation strategies. The second component included parent education in the form of monthly group educational dinners, newsletters, and at home activities. Finally, modifications to the childcare environments were made in the form of policy change.

These policy changes were made to increase physical activity and healthy eating at the centers and included modification of menus to include less saturated fat, a drink policy making water the primary beverage, switching from whole to 1% milk, including healthy snacks (fruits and vegetables), and the inclusion of at least one hour per day of physical activity. Child food intake, physical activity, and anthropometric measurements were taken. Ninety-seven percent of children who were normal weight at baseline had maintained a healthy weight 12 months later. Of those children who were overweight at baseline, 4% were of normal weight by 12 months post intervention. Two of the children who were obese at baseline were overweight by 12 months post intervention. Strong correlations between parent involvement and child dietary outcomes were observed. It was found that children consumed less soft drinks at home in families whose parents felt satisfied with the at-home activities and parent lessons (r=−0.44, p<0.001). Furthermore, of the parents who read more of the newsletters, their children consumed fewer fruit drinks (r=−0.34, p<0.05) and participated in more minutes of physical activity per day

(r=−0.24, p<0.01). The strong relationship between parent involvement and child dietary outcomes suggests the need for family involvement in interventions with young children.

The authors of this study concluded that intervention programs based in childcare centers are feasible and that such settings are important in promoting healthy eating behaviors

22 and physical activity. This intervention worked to change the child’s environment, but did not directly educate the children on nutrition or physical activity.

Evidence exists to show that family meals are an effective childhood obesity intervention and that such interventions can be successfully implemented in the preschool-age population. While the importance of family meals has been elucidated, data from the 2007-2008 NHANES survey on the prevalence and patterns of cooking dinner at home in the US found disparities in frequency of family meals among various socioeconomic statuses and racial/ethnic minorities. Results showed that Black households cooked the fewest dinners at home. In addition, it was found that families with lower household wealth and educational attainment were more likely to never cook dinner at home, while wealthier, more educated households were more likely to sometimes cook dinner at home (p<0.05).39 This is significant as children from these families are also at the highest risk for developing obesity and family meals may have a protective effect.1,4

Overall, family meals play an important role in childhood obesity prevention.

Caregiver self-efficacy, role modeling (home food environment), and child involvement in food preparation play a large role in the efficacy of family meals interventions and should be considered when constructing them. While family meals interventions currently exist, they fail to address low-income, preschool-age children. However, successful nutrition education interventions in such settings, along with data showing a lack of family meals in low-income households suggest that family meals interventions are suitable to conduct in this population.

Chapter 3: Simple Suppers at Head Start 2016/2017

3.1 Background

In the United States today, one in three children are overweight or obese.40 From

2011-2016 rates of childhood obesity rose in all age groups spanning 2-18 years.1,7

Preschool-aged children are experiencing obesity at a rate of 13.9%, an increase of 4% over the past five years. These statistics are of public health concern as children are experiencing multiple comorbidities as well as tracking this obesity along with its associated comorbidities into adulthood.9 This may be in part because children in this age group are creating lasting habits and developing preferences regarding foods and nutrition that will span their lifetime.11,12

For children of preschool age, caregivers serve as an important gatekeeper in nutrition and food availability.13,41 Caregivers also play an influential role, serving as role models for many health behaviors.41 Family mealtimes serve as an important opportunity for role modeling this behavior. For this reasons, the American Academy of Pediatrics as well as the Dietary Guidelines for Americans recommend family meals as an obesity prevention strategy. A family meal is defined as … one consumed with at least one child and caregiver present.16 The literature show that children who share three or more family meals per week are more likely to be of a healthy weight and to have healthier dietary patterns.16 Many of these interventions fail to intervene within low-income, racially diverse populations. In order to address this gap in literature, Rogers et al developed the

Simple Suppers (SS) family meals nutrition education, obesity prevention intervention,

24 aiming to increase the frequency of family meals shared in the home to improve the dietary intake and weight gain trajectory of children.18

This intervention was developed for underserved families from racially diverse backgrounds with children aged 4-10 and was implemented as a quasi-experimental trial with a staggered cohort design. Ten, 90 minute lessons were delivered weekly over the dinnertime hour at a faith-based community center (SS@VCC).18

Data were collected at baseline, post-test, and at 10-week follow up. Diet quality, body mass index z-score (zBMI), and blood pressure served as the main child level outcomes measures while diet quality, BMI, caregiver self-efficacy for healthy dietary patterns, and frequency of family meals served as the main caregiver and family level outcomes. GLMMs that included group assignment, baseline values, and confounders as independent variables demonstrated an intervention effect on food preparation skills, with intervention children having higher skill ability (p<0.001) and frequency (p=0.003) at post-test, maintained at 10-week follow-up. In GLMMs that included attendance, baseline values, and confounders as independent variables, each additional lesson attended was associated with lower BMI (p=0.04) and systolic BP (p=0.03) z scores, and higher child food preparation skill ability (p<0.001) and frequency (p=0.01) at post-test.

Caregivers who participated in the intervention had a significant decrease in BMI

The SS intervention addressed a racially diverse, underserved population, but not one that was truly low-income (at or below the poverty line). In addition, their age range did not span the entire preschool-age years (3-5 years). For this reason, the current study sought to investigate the feasibility of the SS intervention within a low-income, preschool-age population. In order to serve this population, the intervention was delivered at Head Start (SS@HS). Head Start is federally funded early childhood development program servicing preschool-aged children from low-income families. In the state of Ohio, Head Start children are experiencing obesity at 19%, much higher than the current national rate of 13.9%.6 This rate mirrors data showing disparities in socioeconomically disadvantaged children. Delivering this intervention at Head Start involves a change in both the setting and population. Specifically, children are of a younger age (3-5 years) and a lower income level (at or below the poverty level). Thus, the SS intervention must be adapted through programmatic modifications in order to best serve this population in this setting.

The aim of the current study was to assess the feasibility of the SS intervention adapted to the Head Start population and setting.

Objective 1: Assess feasibility outcomes (retention, attendance, and acceptability) of the

SS intervention in the Head Start population.

It was hypothesized that the SS intervention would have a high retention rate, attendance, and acceptability in the Head Start population and setting.

Objective 2: Assess the effects of the SS intervention on child outcomes related to behavior (food preparation skills and frequency), diet (fruit/fruit juice (cups), vegetables

26 excluding potatoes (cups), and sugar sweetened beverages (SSB) per day), and weight status (zBMI).

It was hypothesized that compared to baseline, children would have improved behavioral (increased food preparation skills and frequency), diet (increased consumption of fruits and beverages and decreased intake of SSB), and weight status (prevention of inappropriate increase in zBMI) outcomes at post-test.

Objective 3: Assess the effects of the SS intervention on caregiver outcomes related to cognition (self-efficacy for healthy dietary practices), the home food environment

(frequency of eating dinner together, eating breakfast together, consuming meals in the dining area, and viewing of television during mealtimes), and weight status (BMI).

It was hypothesized that compared to baseline, caregivers would have improved cognition (increased self-efficacy for healthy dietary practices), positive changes in the home food environment (increased frequency of eating dinner together, eating breakfast together, and eating meals in the dining area and a decrease in the viewing of television during mealtimes), and weight status (decreased or prevention of increase in BMI) outcomes at post-test.

3.2 Methods

3.21 Intervention and Adaptations for the Head Start Population and Setting

SS is a nutrition education, obesity prevention intervention focused on the promotion of family mealtimes. The SS curriculum includes ten, 90-minute lessons intended for delivery over the dinnertime hour. Each 90-minute lesson is divided into three components. These include a caregiver lesson, child lesson, and family lesson and meal.

The first 45 minutes include a separate but simultaneous lesson for the children and caregivers. The caregivers learn skills to overcome barriers in planning and executing family meals while the children learn age appropriate kitchen preparation skills. In the following 45 minutes, the children and caregivers come together to complete a family lesson regarding the nutrition of the meal served and to eat a meal together.

In order to deliver the SS curriculum in the Head Start setting, it was necessary to modify the timing and delivery of the intervention. The Head Start director invited the research team to complete programming during “Family Friday.” This is a mandatory event where parents are required to attend and receive Head Start updates and participate in various Head Start programming activities. This once per month schedule dictated when SS could be offered. Thus, five of the 10 SS lessons were delivered during the

2016/2017 school year. These lessons were chosen in collaboration with the Head Start director and staff and based on alignment with parents interests and the child food preparation skills taught. Additional considerations were made to deliver lessons with accompanying meals that Head Start’s kitchen could accommodate (i.e. meals not requiring an oven). In addition, timing was modified to fit the needs of Head Start. To this end, the lessons were delivered over the lunch time hour (rather than the dinner hour), as Family Friday occurred during the school day.

Modifications were also made to the child lesson. At Head Start, the child lesson was not limited to only children enrolled in SS. While data were only collected on caregivers and children that had consented and provided parental permission to enroll in the study, all children in the Head Start classroom were invited to participate in the SS

28 lesson. This meant that roughly 30 thirty children were involved at each lesson all within the same 3-5 year old age group. Previously, the child lesson was separated into 4-5 year olds, 6-8 year olds, and 9-10 year olds. Each age group completed an age appropriate food preparation skill was added to the meal being served that evening. For the purposes of SS at Head Start, the same food preparation skills used by the 4-5 year olds in the SS curriculum was used in this feasibility study with 3-5 year olds, as it was determined that these activities were age appropriate for the newly included age of three years.33 In addition, due to the lack of food preparation from older age groups, most of the food was prepared off-site in a university kitchen. The food was then transported and the remainder of the cooking process was completed on-site.

With an increase in the number of children in the same age group, another adaptation was made to the staffing structure of SS@HS. One parent educator, four child educators, and one cook were involved in program delivery. Head Start staff were actively involved in the delivery of the child lesson therefore; less child educators were involved in program delivery (when compared to SS@VCC). In addition, SS@VCC included a peer educator for the parent education. The research team attempted to secure a peer educator for SS@HS but was unsuccessful.

The final adaptation was made to the family meal and lesson. Due to the nature of

SS@HS, not all children who attended the lesson were enrolled in the study or had a caregiver in attendance. This is because all children and caregivers were invited to participate if they attended that day. Not all enrolled caregivers attended each lesson and likewise, not all participants in attendance had enrolled in the study. For this reason, at

29 the conclusion of programming all children who had caregivers in attendance joined the caregivers for the family lesson at the conclusion of the separate but simultaneous child and caregiver lessons. At this time, the caregiver educator delivered the family meals education to families and the child educators worked to serve the family meal. The children in the opposite classroom completed an activity with Head Start staff and were then served the same meal.

Table 3 outlines the study timeline and Table 4 and Table 5 outline the 10 original curriculum lessons and the corresponding food preparations skills, respectively. The five lessons that were delivered in at Head Start are highlighted in yellow.

Table 3. Simple Suppers 2016/2017 Programming Dates Simple Suppers 2016/2017 Programming Moler Elementary School Head Dates Start: Friday’s 10:00a – 11:30a Baseline Data Collection November 2016

Lesson 1 December 13

Lesson 2 January 27

Lesson 4 February 24

Lesson 5 March 31 Lesson 7 April 28

Post-Test Data Collection April 2017

Focus Groups June 2017

Table 4. Simple Suppers 2016/2017 Topics and Meals Lesson Themes Meal 1 Making family mealtime fun! Fruit and yogurt-topped whole wheat pancakes with veggie scrambled eggs 2 Planning family meals on a Fiesta skillet with fresh fruits and budget vegetables 3 Timesaving strategies for Breakfast burrito and salsa with baked family meals apple wedges 4 Connecting with children Quick skillet lasagna with veggies & through meals dip with crunchy frozen bananas 5 Planning well-balanced family Baked potato bar, chicken tortilla soup, meals and orange fluff salad 6 Rethink your drink Meatloaf muffins, twice-as-nice mashed potatoes, and fruit pudding 7 Making healthy cooking tasty Garden sloppy joes and easy fruit salad & easy 8 Serving & eating healthy Scrambled egg muffins, roasted portions potatoes, and crunchy berry parfait 9 Eating healthy away from home Cheesy crunchy chicken tenders, applesauce, and glazed carrots 10 Planning fun & healthy snacks Whole grain pizza, side salad, berry good banana splits

Table 5. Child Food Preparation Skills Lesson Child Food Preparation Skill 1 Setting the table 2 Wash and prepare fresh produce 3 Cut soft foods with a blunt knife

4 Measure dry ingredients 5 Measure liquid ingredients 6 Grease or spray baking pans 7 Cut soft foods with a blunt knife 8 Measure liquid ingredient, cut soft foods with a blunt knife 9 Measure dry ingredients 10 Measure dry ingredients and portion food

3.22 Data Collection

Objective 1: Assess the feasibility of the SS intervention adapted to the Head Start population and setting.

In order to assess the feasibility of Simple Suppers in this setting data on retention, attendance, and acceptability were collected.

The number of families that consented to participate at baseline and completed data collection at post-test determined retention rate.

Attendance was assessed using a sign-in sheet at each program lesson.

Acceptability of the program was assessed through separate focus groups with both the caregivers and the Head Start staff.

Focus group questions asked to caregivers included the following: 1. To begin, we will go around the table and name our favorite lesson from the

program, feel free to introduce yourself at this time as well?

2. How did you feel about the program overall?

3. What was your favorite part of the…parent education? Family meals education?

4. What was your least favorite part of the… parent education? Family meals

education?

5. From your point of view, how did your child feel about the program? Child

education? Family meal?

6. In what ways, if any, have family meals in your home changed since you and your

family participated in SS?

a. Do you feel any other changes in your child’s or your own health have

happened since you and your family began participating in the program?

7. How did SS compare to other programming you and your family have done

during Family Friday?

8. What suggestions do you have to help us make this program more useful in the

future?

Focus group questions asked to Head Start Staff included the following:

1. To begin, if you could all go around and share how long you have been working

with Head Start.

2. What was your overall impression of the Simple Suppers program? Parent

education? Family meal? Child education?

3. What do you believe the families overall impressions of the program were? How

do you think the parents felt about the parent education and family meal? How do

you think the children felt about the child education and family meal?

4. How would you describe your experience in delivering the program? What did

you think about the format (day, time, and length)? What did you think about the

curriculum (lesson, topics)?

5. Did you find this program to be an effective use of Head Start’s time during

Family Fridays? Please explain why or why not?

6. What suggestions do you have to help us make this program more effective for

families in the future? Parent education? Child education? Family meal?

7. What suggestions do you have to help make this program more effective for the

purposes of Head Start Family Friday Programming? i.e delivery, timing, etc…

8. Is this a program something you would enjoy bringing to Family Fridays in the

coming years?

The tools used to assess feasibility (focus group scripts and sign-in sheet) are located in

Appendix D.

To address objective two, both survey data and direct measures were collected at baseline and post-test. Behavioral outcomes were measured using the 17-item ‘Child

Food Preparation Skills (Ages 3-5 Years)’ adapted from the original SS data collection for 4-5 year olds. The questionnaire uses a 5-point scale (strongly agree to strongly disagree) to assess a child’s ability to participate in eight age-appropriate food preparation skills. In addition, the questionnaire assesses frequency of child participation in the eight age-appropriate food preparation skills during the past 30 days (5-point scale;

0 times to 7+ times).42 This questionnaire demonstrated internal consistency for both skill

34 and frequency outcomes respectively (Cronbach’s alpha= 0.7960 and 0.8291). Caregivers completed this questionnaire on behalf of their children.

Dietary outcomes of the children were assessed using the ‘Block Kids Food

Screener-Last Week (age 2-17), Parent Version.’43 This screener assesses the type and amount of food consumed the week before data collection and was completed by caregivers on behalf of their children.

Finally, weight status outcomes were assessed through the measurement of zBMI.

The research team followed procedures outlined in the NHANES Anthropometry

Procedural Manual44 to collect these measurements. Height and weight of the children were taken to determine zBMI.

Two height measurements were taken in centimeters using a stadiometer with shoes and outerwear removed. If the two measurements differed by more than one centimeter a third measurement was taken.

Two weight measurements were taken in kilograms using a digital weight scale with shoes and outerwear removed. If the two measurements differed by more than 0.1 kilogram, a third measurement was taken.

The average was taken for each height and weight and these measurements along with change age in months and gender were used to calculate zBMI in Stata. Data collection forms regarding anthropometrics and behavioral outcomes are located in

Appendix C.

Objective 3: Assess the effects of the SS intervention on caregiver outcomes related to cognition (self-efficacy for healthy dietary practices), the home food environment

(frequency of eating dinner together, eating breakfast together, consuming meals in the dining area, and viewing of television during mealtimes), and weight status (BMI).

Objective three was addressed using survey data and direct measures at both baseline and post-test. A demographics questionnaire was completed by caregivers at baseline. This questionnaire assessed child and caregiver race, gender, and age. It was also assessed caregiver relationship to child, income level, and reliance on food assistance programs (WIC, SNAP, and Free or Reduced Lunch).

The US Household Food Security Survey: Six-Item Short Form was completed by caregivers at baseline to assess food security status of this sample.45

Caregiver cognition was measured using the ‘Parent Family Meals Self-Efficacy

Questionnaire.’ This 12-item questionnaire assesses parent self-efficacy regarding family meals and child dietary habits. Each question is ranked on a scale of 0-10, 0 being not confident at all and 10 being extremely confident.46 This questionnaire demonstrated good internal consistency (Cronbach’s Alpha=0.9430).

The home food environment was assessed through the use the ‘Home Food

Environment Questionnaire.’ This 10-item questionnaire assesses the frequency of various home food activities ranking each on a scale of never to seven times per week.

The Home Hood Environment Questionnaire was developed for the SS intervention from constructs/items from three previously validated home food environment questionnaires.

This questionnaire assesses frequency of family mealtimes at dinner and breakfast times

36 using a 5-point scalar (1=never; 5=7 times per week) question. It also assessed the location of family meals using a 5-point scalar (1=never; 5=7 times) question that asks frequency of eating family meals in the dining area (not living room or family room). The questionnaire also assessed frequency of television viewing during family meals over the past 7 days using a 5-point scale (1=never; 5=7 times). 42,47,48

Weight status outcomes were measured using height and weight to assess BMI.

All height and weight measurements followed the procedures outlined in the NHANES

Anthropometry Procedural Manual.44

Height was measured twice in centimeters with shoes and outerwear removed using a stadiometer. Measurements that differed more than 1 centimeter were taken a third time.

Weight was measured twice in kilograms with shoes and outerwear removed using a digital scale. Measurements that differed more than 0.1 kg were measured a third time. Average height and weight were taken for each participant and BMI calculated.

Data collection forms regarding anthropometrics and behavioral outcomes are located in

Appendix C.

3.23 Recruitment and Incentives

Recruitment began in October of 2016. Research staff joined the October Family

Friday event with the caregivers and children. Families were introduced to the program and interested families completed consent, parental permission, and child assent forms on site. Upon completion of these forms, families were invited to complete the baseline data collection including questionnaires and anthropometric measurements. A complete list of

37 questionnaires is included in Appendix C. Families that completed baseline data collection received a $25 Kroger gift card and were informed of the upcoming SS dates.

Upon the completion of programming, post-test data collection occurred. Families received a $25 Kroger gift card for their participation. The following month, caregivers that had completed post-test data collection were invited to participate in a focus group regarding the SS program. The focus groups were held at a Columbus Metropolitan

Library location and those involved received a $25 Kroger gift card. A second focus group was conducted with the Head Start staff in order to order to assess the feasibility of continuing this program in the future. Head Start staff also received a $25 Kroger gift card for their participation. The consent forms and scripts for both focus groups are located in

Appendix D: Acceptability Data Collection Forms.

3.24 Data Analysis

Objective 1: Feasibility Outcomes

Retention rate was calculated from the number of participants that completed post-test data collection divided by the number of participants that enrolled in SS at baseline.

Attendance from all enrolled participants was summed for each lesson and the average attendance across all five lessons was averaged and recorded.

Focus groups were recorded and transcribed verbatim. From these transcriptions, two separate researchers coded each focus group and reconciled to determine themes.

Objective 2: Child Outcomes

Summary statistics were calculated for the demographics questionnaire for child age, gender, and race.

The Child Food Preparation Skills (Ages 3-5 Years) questionnaire was scored for both the skill and frequency at baseline and post-test. Food preparation skill ability was measured on a scale of 0-32 with a higher score representing increased skill ability. Food preparation skill frequency was measured on a scale of 0-40 with a higher score presenting increased skill frequency. A paired t-test was conducted assessing the changes between scores at baseline and post-test.

Dietary data collected via the Block Kids Food Screener-Last Week (age 2-17),

Parent Version were analyzed by NutritionQuest.43 A paired t-test was used to assess pre- to post-test changes.

Child zBMI was calculated in STATA using child height, weight, gender, and age and a paired t-test was used to assess pre- to post-test changes.

In the instance that a caregiver had more than one child enrolled, one child was randomly selected from each family for data analysis due to potential clustering effect.

Objective 3: Caregiver Outcomes

Summary statistics were calculated for caregiver age, gender, race, income level, relationship to child, and reliance on food assistance programs.

The US Household Food Security Survey: Six-Item Short Form was coded and scored according to USDA guidelines and results recorded.45

The Parent Family Meals Self-Efficacy and Home Food Environment questionnaires were coded and scored at baseline and post-test. Self-efficacy was scored on a 0-120 point scale with higher score representing increased skills. A paired t-test was used to assess pre- to post-test changes.

The Home Food Environment Questionnaire was scored and used to assess the four desired outcomes, family dinner frequency, family breakfast frequency, family meals in the dining area, and family meals with television all in meals per week. A paired t-test was used to assess pre- to post-test changes.

BMI was calculated using average recorded heights and weights and a paired t- test was conducted assessing pre- to post-test change.

3.3 Results

3.31 Objective 1: Feasibility Outcomes

Eighteen families enrolled in the SS intervention and 12 families completed post-test data collection, resulting in a 66.7% retention rate (Figure 1). On average, 44.7% of enrolled child/caregiver dyads attended each of the five SS lessons.

Five caregivers participated in the participant focus group. All of the participants were female and four of the five participants were primary caregivers that had enrolled in the SS intervention. One participant was a family member of an enrolled participant that had accompanied them to SS throughout the duration of the program.

Focus group data with participants resulted in three main themes. The first theme was

40 overcoming feeding challenges in the home. The following quotes reflect this finding.

“… is a picky eater, but when I duplicate the things at are in the cookbook you gave

us, she tears it up.”

“He also impulse eats, but when I cook things that are in the cookbook, he get full

quicker … for some reason. It really helped me a lot.”

The second theme was greater child involvement in the kitchen at home. The following quotes reflect this finding.

“… now he’ll try to actually help.”

“… wants to help all the time in the kitchen, especially if she see me with that book.”

“… getting the kids involved, so they feel like a part of it.”

The final theme revealed in the participant focus group was improvement in food choices in the home at both the child and caregiver level. The following quotes reflect this theme.

“He will definitely eat more fruit and vegetables now, I definitely had a problem with

that, now he’ll choose strawberries over donuts…” – and also at the caregiver level -

“for me … make wise food choices …. Because I’m diabetic.”

Six staff members participated in the Head Start staff focus group. All of the staff members involved in the focus groups had been present at each of the five SS lessons.

Focus groups revealed three main themes. The first theme was that children and caregivers were highly engaged and enjoyed the program. The following quotes reflect this theme.

“I couldn’t believe how much they [caregivers] were participating in the program.”

“I could see that the children really enjoyed themselves, like getting to cut stuff and

like mix stuff…”

“You can tell like they [children] were really engaged in, especially like the

measuring or the cutting, like the got to do it for themselves…”

The second theme observed was that the Head Start staff enjoyed hosting the SS program at their center. The following quotes reflect this theme.

“I really enjoyed the program. It just, it showed the parents, it even showed me that

there’s a – cause you know for the most part you think healthy food’s expensive so it

showed us a way to make something healthy and less expensive and so I liked that

part of the program.”

“I would have to say too that, your group of students, I’m assuming they’re all your

students that come out and work this session … are phenomenal. I mean, they, they

are very good with the children and um, the way they talk with the children and the

words that they use with them.”

“The food was also good, sometimes, I had to go back, go get me some more.”

The third theme involved changes that would help to improve the feasibility of SS at

Head Start in future years. The following quotes reflect this theme.

“After they were done cutting and then we would just kinda be waiting for the parents…”

“we may this year decide to separate it out from Family Friday to have a special, to

have its own special day.”

Figure 1. Consort Flow Diagram Simple Suppers at Head Start 2016/2017 Screened for enrollment n= 18 families

Did not meet inclusion criteria n=0

Enrolled in Simple Suppers n=18

Lost to follow up n=6

Completed post-test data collection n=12

3.32 Objective 2: Child Level Outcomes

Table 6 outlines the demographic and baseline participant characteristics of the sample. Mean (SD) child age was 3.6 (1.2) years with gender evenly split, 58.3% male and 41.7% female. The majority of our sample was Black at 75.0%. Twenty-five percent of children were underweight, 41.7% of children were of a normal weight and 33.33% of children were overweight or obese. Overall, mean (SD) zBMI fell into the normal range at 0.25 (0.4).

There was no significant change in child food preparation skills from pre- to post-test

(p=0.87) (Table 7). Frequency of child food preparation in the home increased but not significantly (p=0.09). There was no significant change in dietary outcomes regarding fruit/fruit juice (p=0.11), vegetables excluding potatoes (p=0.43), or estimated average

43 daily frequency of consumption of sugary beverages (p=0.86) nor were there any significant changes in zBMI (p=0.98).

Table 6. Child Baseline Characteristicsa Baseline Characteristics

Ageb 3.6 ± 0.6 Gender Malec 58.3 (7) Femalec 41.7 (5)

Race

Blackc 75.0 (9) Non-Blackc 25.0 (3)

Anthropometrics zBMIb 0.25 ± 1.2 Underweight c 25.0 (3)

Normal Weightc 41.4 (5) c Overweight/Obese 33.3 (4) a n=12 b Values are mean ± standard deviation c Values are % (n)

Table 7. Child Level Outcomes a,b Child Level Outcomes Baselinec Post-testc Changec P-value Health Behavior Outcomes Child Food Preparation 21.8 ± 4.9 21.6 ± 5.5 -0.2 ± 3.8 0.88 Skillsd Child Food Preparation 16.6 ± 6.0 20.2 ± 9.0 3.6 ± 6.4 0.09 Frequencye Dietary Outcomes

Fruit/Fruit Juicef 1.6 ± 1.02 2.2 ± 0.1.23 0.6 ± 1.20 0.11 Vegetables Excluding 0.7 ± 0.51 0.8 ± 0.36 0.1 ± 0.42 0.43 Potatoesf Estimated Average Daily Frequency of 0.15 ± 0.23 0.16 ± 0.21 0.01 ± 0.26 0.86 Consumption of Sugary Beveragesg Anthropometrics -0.0075 ± zBMI 0.25 ± 0.35 0.24 ± 0.32 0.98 0.27 a n=12 b Paired t-test c Values are mean ± standard deviation d Values on a scale of 0-32 d Values on a scale of 0-40 f Values are cups/day g Values are number of beverages per day

3.33 Objective 3: Caregiver Level Outcomes

Baseline data are reported on 12 caregivers that completed pre-and post-test data collection (Table 8). Mean (SD) age was 38.6 (15.1) years. The majority of caregivers were female (90.9%) as well as Black (90.0%). Household income levels were all below

$50,000 with the majority below $25,000 (54.6%). The majority of caregivers were parents (75.0%) with the remainder of caregiver’s as grandparents (16.7%) or an aunt or uncle (8.3%). The majority of caregivers were receiving some sort of food assistance including WIC, SNAP, Free or Reduced Lunch, or a combination of the three (72.7%).

The majority of caregivers reported experiencing marginal to high food security (83.3%), while the remaining caregivers (16.7%) reported experiencing low food security. All caregivers but one had received a high school diploma/GED or higher education. Four caregivers (18.2%) had received some college education while two caregivers (18.2%) received a four-year college degree. Mean (SD) BMI fell into the obese category at 33.1

(10.5) kg/m2.

No change was observed in caregiver self-efficacy (p=0.98) nor the home food environment outcomes. Frequency of eating dinner together (p=0.22), eating breakfast together (p=0.72), and eating meals in the dining area decreased but not significantly.

Frequency of television viewing during mealtimes also decreased but not significantly

(p=0.76). Caregiver BMI increased and trended towards significance (p=0.08). These data are presented in Table 9.

Table 8. Caregiver Baseline Characteristics Baseline Characteristics Agea 38.6 ± 15.1 Gender (n=11) Maleb 9.1 (1) Femaleb 90.9 (10) Race (n=10) Blackb 90.0 (9) Non-Blackb 10.0 (1) Income (n=11) <$25,000b 54.6 (6) $25,000 - $44,999b 36.4 (4) Prefer not to answerb 9.1 (1)

Relationship to Child (n=12) Parentb 75.0 (9) Grandparentb 16.7 (2) Aunt or Uncleb 8.3 (1) Food Assistance (n=11) WICb 18.2 (2) SNAPb 9.1 (1) Reduced Lunchb 9.1 (1) Noneb 27.3 (3) More than Oneb 36.4 (4) Food Security (n=12) Marginal to High Food Securityb 83.3 (10) Low Food Securityb 16.7 (2) Education Level (n=11) No High Schoolb 9.1 (1) High School Diploma/GEDb 36.4 (4) Some Collegeb 36.4 (4) Four Year Degreeb 18.2 (2) Anthropometrics (n=10) BMIa,c 33.1 ± 10.5 a Values are mean ± standard deviation b Values are % (n) c kg/m2

Table 9. Caregiver Outcomes a,b Outcome Baselinec Post-testc Changec P-value Caregiver Cognition Caregiver Self-Efficacyd 94.2 ± 23.7 94.0 ± 24.5 -0.17 ± 21.6 0.98

Home Food Environment Eat Dinner Togethere 3.9 ± 0.9 3.6 ± 0.9 -0.33 ± 0.9 0.22 Eat Breakfast Togethere 3.3 ± 1.2 3.1 ± 0.9 -0.17 ± 1.5 0.72 Eat Meal in Dining Areae 3.3 ± 1.0 3.17 ± 0.8 -0.17 ± 1.3 0.66 Watch TV During Meale 2.5 ± 1.4 2.4 ± 1.3 -0.09 ± 0.9 0.76 Anthropometrics BMIf 32.0 ± 7.9 32.6 ± 7.6 0.59 ± 0.8 0.08 a n=12 b Data analyzed using a paired t-test c Values are mean ± standard deviation d Values on a scale of 0-120 e Values on a scale of 1-5, 1=never, 5=7 days f kg/m2

3.4 Discussion

The Simple Suppers intervention was developed to address the epidemic of childhood obesity through the incorporation of family mealtimes. With its success in a racially diverse, underserved population along with the rising rates of obesity in low- income, preschool aged children, the present study sought to assess the feasibility of the

SS intervention in the Head Start setting and population. We hypothesized that SS@HS would be feasible in this setting and produce positive changes in health behavior outcomes at both the child and caregiver level. Focus group data showed high acceptability and feasibility of the intervention in this setting. No significant differences were found in outcomes at the child or caregiver level; however, children experienced an increase in frequency of food preparation in the home that trended towards significance,

48 which was corroborated by focus group findings. SS@HS displayed feasibility in this setting and warrants further investigation of the SS intervention within this population and setting.

3.41 Objective 1: Feasibility Outcomes

Eighteen families enrolled in the SS intervention and 12 families completed post- test data collection. The families lost to follow up had left Head Start before the end of the school year. These families were contacted and either uninterested in completing the post-test evaluation or no longer had reliable contact information. The retention rate of a similar study delivering nutrition education monthly to low-income preschool-age children and their families conducted by Rose et al was 90.9% and the retention rate of the original SS intervention (SS@VCC) was 87.5%.37,21 Thus, our retention rate may be considered low. This low retention rate may be related to poor recruitment during programming throughout the school year. Head Start staff worked to remind caregivers of upcoming lessons at drop off and pick up times, but our staff did not have any contact with caregivers prior to each lesson. In future years, it may be best to make reminder calls to families before each lesson date to encourage attendance.

Less than half of enrolled caregivers attended the SS lessons despite pairing the intervention with a mandatory attendance day for caregivers. It is noteworthy that caregiver attendance is the only attendance rate reported, as many children attended the lessons without a caregiver present. When comparing our attendance rates to similar interventions our attendance rate of caregivers may be considered low. Attendance rate for Rose et al was 74.0% and 68% of participants in the HOME Plus family meals study

49 attended seven out of 10 lessons.37,35 The SS intervention delivered by Rogers et al had an attendance rate of 70.0%.21 These interventions were delivered over the dinner time hour; but income level of participants, setting, and frequency of delivery (weekly or monthly) varied between them. It is possible this timing of programming (dinnertime hour) was more suitable for this population, thus resulting in a higher attendance rate.

Our intervention was delivered over the lunch time hour at the request of Head Start; therefore, we were unable to mirror this timing. Program delivery in the evenings would be an ideal next step; however, researchers are limited by Head Start’s preferences and availability.

Focus groups served as the main acceptability outcome for this study. Focus group data revealed strong program acceptability from both caregivers and Head Start staff. Head Start asking us to return the following school year and to deliver the intervention at two sites corroborated our positive focus group findings from Head Start staff. They stated that not only they enjoyed the program, but they perceived the families to enjoy the program as well. Acceptability measures would have been strengthened had a satisfaction survey been administered to all participants.

3.42 Objective 2: Child Level Outcomes

The mean (SD) child age was 3.6 (0.6) years and the majority of children (75.0%) were Black. This is representative of the population we proposed to study: low-income, racially diverse, preschool-aged children. Mean (SD) zBMI was normal at 0.25 (1.2).

When zBMI was categorized, it was found that the majority of children were in the normal BMI range, 41.7% while 25.0% of children were underweight and 33.3% of children were overweight or obese. A mean zBMI in the normal range is expected, as the

50 majority of children in this age range both nationally and within this population (Ohio

Head Start) are of a normal weight.1,6 We observed similar obesity rates experienced by

Head Start children in the state of Ohio (35.0%); however, our sample had a higher number of underweight children when compared to all Head Start children in the state of

Ohio (33.00%).6

No significant differences were observed in any of the child level outcomes, but child food preparation frequency increased and trended towards significance. This measure of child food preparation demonstrates the frequency with which children are completing the learned food preparation skills in the home per month. This modest increase in frequency is relevant to child health, as child involvement in food preparation has been shown to increase consumption of vegetables.49 Focus groups conducted with caregivers corroborate this data, as an increase in child food preparation in the home was a theme discovered from this focus group. The small sample size combined with the low- dose intervention (five out of 10 lessons delivered monthly) may explain the nonsignificant findings in the remainder of the child level outcomes.

The majority of children maintained a healthy weight throughout the duration of program with no significant differences in zBMI. This matched our hypothesis that the intervention would result in the prevention of inappropriate weight gain. The majority of children were not overweight or obese. Our goal is not to lower weight of healthy children, but to keep these children on a healthy weight gain trajectory as they age.

Our modest increase in the frequency of food preparation may be a result of a higher child attendance rate than caregiver attendance rate as it is possible children began to help more in the kitchen despite their caregiver’s absence.

3.43 Objective 3: Caregiver Level Outcomes

The mean (SD) caregiver age was 38.6 (15.1). This large standard deviation may be explained by the relationship caregivers had to children, as this ranged from parent to grandparent. The majority of caregivers were female (90.9%), which was also seen in the

SS intervention delivered by Rogers et al.21 The majority of caregivers were Black

(90.0%) and had an income level below $25,000. 16.7% of caregivers experienced low food security while the remaining 83.3% experienced marginal to high food security. A similar number of participants also were using one or more type of food assistance program, which may have contributed to their food security status. The mean (SD) BMI fell into the obese category at 33.1 (10.5) kg/m2. This average BMI is not surprising considering national rates of obesity among Black women aged 20-39 are currently at

54.8%.1

No significant differences were observed in the caregiver outcomes; however, caregiver BMI increased and trended towards significance. This may be explained by the low attendance rate and low-dose intervention.

Home food environment outcomes were not significantly different; however, it is interesting to note the frequency with which this population is participating in family meals. Roughly half of families nationally are consuming seven or more family meals together each week.50 Our data show that on average our families are consuming at least seven meals per week (when combining breakfast and dinner data). The same study noted that families who consumed meals together also generally had healthier food options in the home. However, health outcomes collected from children and caregivers showed that obesity is still an issue within this population. While low-income families may consume

52 family meals more frequently, they may not be consuming healthier foods. Further research on the quality of food served at family meals along with the environment in which they are shared is warranted for this population.

3.44 Limitations

The following limitations were noted in this work. Due to time constraints with

Head Start, only five of the 10 SS lessons were delivered. Child and caregiver level outcomes were collected despite this low dose. Ideally, all 10 of these lessons would be delivered in order to measure the intended effects of the intervention on child and caregiver outcomes. In addition, the intervention was delivered monthly rather than weekly. Data from Head Start staff focus groups indicated that the monthly schedule worked best for them and they believed it worked best for their families as well. In addition, previous family meal interventions showed efficacy of a monthly delivery of programming.37,35 The intervention was delivered during traditional working hours, thus, many families took off work in order to attend the event. Delivering the intervention weekly may have further decreased attendance rates, as families may not have been able to get time off weekly.

Sample size was another limitation in this study. Delivering the intervention at one site limited the number of families that we could recruit. In future years, delivering the program at multiple sites would help to increase sample size. Due to this small sample size, only a paired t-test could be used to assess differences in outcomes. A paired t-test does not control for variables that may have influenced our results such as age, race, and gender.

Another limitation was the possibility of social desirability bias in survey

53 answers. Caregivers answered surveys for caregiver level outcomes and served as a proxy for the child level survey outcomes. Social desirability bias may have been introduced as caregivers may have answered these surveys in a manner that was more socially desirable than what was actually true.

Another limitation of this work was the lack of feasibility outcomes collected.

Feasibility may have been better assessed if we had collected fidelity data and assessed program satisfaction through the use of questionnaire. Without fidelity data, we are unaware of the number of lessons delivered as intended. In addition, while focus group data showed a positive caregiver response to the intervention, not all caregivers chose to participate in focus groups and our data may not be representative of the entire cohort of families enrolled in the intervention.

Study design was another limitation of this work. The lack of a control group limited the rigor of study design and statistical analyses that could be performed. The aim of this study was to assess the feasibility of SS in the Head Start setting thus, a control group may not have been necessary, as child and caregiver level outcomes were secondary. In addition, only five of 10 lessons were delivered and it is unlikely group differences would have been observed in such a small sample size with this low-dose intervention.

Throughout the duration of the school year, Head Start also had additional nutrition education interventions delivered to the children. These included programming from Local Matters and the Supplemental Nutrition Assistance Program Education

(SNAP-Ed). These programs were delivered only to the children and did not focus on the importance of family meals, nor did they include a hands-on child food preparation skill.

However, the presence of these programs does limit the conclusions that can be drawn from data collection on child BMI z-scores, as these additional in-class programs may have influenced this.

3.45 Conclusions

The Simple Suppers intervention was successfully adapted and delivered to the

Head Start population and setting. Focus group data indicated high acceptability from both caregivers and Head Start staff regarding the SS intervention. There were no significant differences in the child and parent level outcomes; however, this was a feasibility trial, not powered to detect changes, and participants were only exposed to half of the lessons in the SS curriculum, thus a lack of changes is not unforeseen. Child zBMI did not change from baseline to post-test therefore children remained on a healthy weight gain trajectory throughout the duration of programming. Based on these outcomes, we believe that the SS intervention is feasible in the Head Start setting and that these preliminary findings warrant further feasibility testing of this intervention in this setting.

Focus groups revealed that participants made positive changes in the home. Not only did the intervention transcend the classroom and into the home, but it did in fact increase child food preparation in the home for these families, corroborating the near significant increase observed for child food preparation frequency.

To our knowledge, this intervention was the first time a family meals intervention has been delivered to a racially diverse, low-income, preschool-age population attending a subsidized childcare center.

From notes taken during programming along with focus group feedback from

Head Start staff, the following changes should be considered for the delivery of the SS

55 intervention in the Head Start setting in future years to address the noted limitations and to further improve the feasibility and effectiveness of SS in the Head Start setting:

1. Inclusion of a secondary activity for the children’s education. The child education

was shorter than the caregiver education at every lesson. The addition of a

secondary nutrition related lesson to better match the length of the caregiver

education is suggested.

2. To conduct the SS programming on days outside of Family Friday. This

suggestion was made by the Head Start director as they felt there was not enough

time on these days to complete the necessary Family Friday programming as well

as the SS intervention.

3. To collect more feasibility outcomes. We propose the inclusion of a fidelity

checklist to assure lessons are being delivered as intended. In addition, a

satisfaction survey should be included for caregiver completion to directly address

both child and caregiver perceptions of the program.

4. In order to increase attendance, we suggest the use of reminder phone calls to

families before each lesson date.

5. In order to increase sample size, we suggest both the inclusion of another Head

Start site as well as beginning recruitment earlier in the school year.

6. We suggest incorporating all ten of the SS lessons into programming to better

assess the impact the program has on child and caregiver level outcomes.

Chapter 4: Simple Suppers at Head Start 2017/2018

4.1 Background

In the United States today, one in three children are overweight or obese.40 From

2011-2016 rates of childhood obesity rose in all age groups spanning 2-18 years.1,7

Preschool-aged children are experiencing obesity at a rate of 13.9%, an increase of 4% over the past 5 years. These statistics are of public health concern as children are experiencing multiple comorbidities as well as tracking this obesity along with its associated comorbidities into adulthood.9 This may be in part because children in this age group are creating lasting habits and developing preferences regarding foods and nutrition that will span their lifetime.11,12

For children of preschool age, caregivers serve as an important gatekeeper in nutrition and food availability.13,41 Caregivers also play an influential role, serving as role models for many health behaviors.41 Family mealtimes serve as an important opportunity for role modeling this behavior. For this reasons, the American Academy of Pediatrics as well as the Dietary Guidelines for Americans recommend family meals as an obesity prevention strategy. A family meal is defined as one consumed with at least one child and caregiver present.16 The literature show that children who share three or more family meals per week are more likely to be of a healthy weight and to have healthier dietary patterns.16 Many of these interventions fail to intervene within low-income, racially diverse populations. In order to address this gap in literature, Rogers et al developed the

Simple Suppers (SS) family meals nutrition education, obesity prevention intervention, aiming to increase the frequency of family meals shared in the home to improve the dietary intake and weight gain trajectory of children.18

Caregivers who participated in the intervention had a significant decrease in BMI

58 observed.21

The SS intervention addressed a racially diverse, underserved population, but not one that was truly low-income (at or below the poverty line). In addition, the age range did not span the entire preschool-age years (3-5). For this reason, the research team sought to investigate the feasibility of the SS intervention in a low-income, preschool-age population. In order to serve this population, the intervention was delivered at Head Start

(SS@HS) over the 2016/2017 school year (year 1). Head Start is a federally funded early childhood development program servicing preschool aged children from low-income families. In the state of Ohio, Head start children are experiencing obesity at a rate of

19%, much higher than the current national rate of 13.9%.16 Delivering this intervention at Head Start involved a change in both setting and population. Specifically, children are of a younger age (3-5 years) and of a lower income level (at or below the poverty level).

Thus, the SS intervention was adapted through programmatic modifications in order to best serve this population in this setting.

During 2016/2017 year of SS@HS, five of the 10 SS lessons were delivered monthly over the lunchtime hour. Feasibility and health behavior outcomes were collected from both caregivers and children at baseline and post-test. Retention rate, attendance, and focus groups served as the main feasibility outcomes. Child outcomes observed were change in zBMI, child food preparation skills and frequency with which they were completed, consumption of fruit/fruit juice (cups/day), vegetables (cups/day), and estimated average daily frequency of consumption of sugary beverages. Caregiver outcomes included BMI, self-efficacy for preparing family meals, and the home food environment.

Eighteen families enrolled in the SS intervention and 12 families completed post- test data collection. Attendance rate was 44.67% of enrolled families per lesson. No significant differences were found in the child or caregiver outcomes; however, child food preparation skills increased and trended towards significance (p= 0.09). Focus group data revealed positive program perceptions from both participants and Head Start staff.

Themes included overcoming feeding challenges in the home, greater child involvement in the kitchen at home, and making better food choices. These data were not reflected in the questionnaire outcomes; however, the small sample size along with the low-dose intervention (five of 10 lessons delivered monthly rather than weekly) may explain this.

From these data, it was concluded that SS is feasible in the Head Start setting and that further testing of the SS program in the Head Start setting is warranted.

Focus group and observational data collected during programming revealed multiple programmatic modifications necessary to effectively deliver this intervention in the Head Start setting in future years. From this data, the research team chose adapt these modifications and deliver SS during the 2017/2018 year to better assess its feasibility in the Head Start setting.

The aim of the current study was to further assess the feasibility of Simple

Suppers adapted to the Head Start population and setting. In order to assess this aim, the following objectives were assessed.

Objective 1: Assess feasibility outcomes (retention, attendance, acceptability, and fidelity) of the SS intervention in the Head Start population and setting.

It was hypothesized that the SS intervention would have a high retention rate, attendance, acceptability, and fidelity in the Head Start population and setting.

Objective 2: Assess the effects of the SS intervention on child outcomes related to behavior (food preparation skills and frequency), diet (fruit/fruit juice (cups), vegetables excluding potatoes (cups) and sugar sweetened beverages (SSB) per day), and weight status (zBMI).

Objective 3: Assess the effects of the SS intervention on caregiver outcomes related to cognition (self-efficacy for healthy dietary practices), the home food environment

(frequency of eating dinner together, eating breakfast together, consuming meals in the dining area, and viewing of television during mealtimes), and weight status (BMI).

4.2 Methods

4.21 Intervention and Adaptations for the Head Start Population and Setting

SS is a nutrition education, obesity prevention program focused on the promotion family mealtimes. The SS curriculum includes ten, 90-minute lessons intended for delivery over the dinnertime hour. Each 90-minute lesson is divided into three components. These include a caregiver lesson, child lesson, and family meal. The first 45 minutes include a separate but simultaneous lesson for the children and caregivers. The caregivers learn skills to help in planning and executing a family meal while the children learn age appropriate kitchen preparation skills. In the following 45 minutes the children and caregivers come together to complete a family lesson and eat a meal together.

In year one, SS was adapted and delivered monthly through five, 90-minute monthly lessons during the lunch hour at one Head Start locations on the south side of Columbus,

Ohio. In the current study, SS was adapted further based on data from year one and delivered monthly through 7, 90-minute monthly lessons during the lunch hour, at two

Head Start locations on the south side of Columbus, Ohio. These sites include Moler

Elementary School Head Start and Southside Head Start.

Utilizing data from year one, the following adaptations were made to the curriculum to better adapt the SS curriculum to the Head Start setting and population.

1. An additional site was added to the intervention. With the success of year one,

the Head Start director asked our research team to expand to a second Head Start

location under the same management and in the same zip code. The research

team accepted this offer in order to expand the reach of the intervention and

increase sample size for a more thorough analysis of the intervention.

2. Staffing structure changed to better accommodate the intervention. Two dietetic

interns delivered the caregiver education, while four to five undergraduate

nutrition students delivered the children’s lesson. Finally, two cooks

(undergraduate students and dietetic interns) worked on cooking each meal. Two

groups of undergraduate students and researchers delivered the intervention at

each site.

3. Two additional lessons were added to the curriculum of SS at Head Start. These

lessons were chosen in collaboration with Head Start staff to best meet the needs

of the caregivers involved. Additional considerations were made regarding the

cooking facilities available at each site to accommodate the family meal.

4. The SS intervention was no longer delivered on Family Friday per Head Start

request. The intervention continued to be delivered over the lunch hour, but with

its own programming time slot.

5. An additional child activity was added to each of the child lessons. This was done

to better match the timing of the child lesson with the caregiver lesson. At the

completion of each food preparation activity, children gathered for story time or a

coloring activity related to nutrition. The books utilized for this portion of the

lesson were from Head Start’s collection of children’s books on nutrition.

6. A Hazard Analysis and Critical Control Point (HACCP) plan was developed for

one lesson of this intervention. This is used to identify and control specific

hazards in the food production process to ensure food safety. Considerations were

made for transportation, cooking and holding temperatures, procedures used

when cooking the meal, and meal service.

Table 10 outlines the study timeline. Table 11 includes the SS lessons and Table 12 includes child food preparation skills completed. Tables 11 and 12 include the 10 original curriculum lessons with the seven lessons delivered in this study highlighted in yellow.

Table 10. Simple Suppers 2017/2018 Programming Dates Simple Suppers 2017/2018 South Side Head Moler Elementary School Programming Dates Start: Friday’s Head Start: Wednesday’s 10:00a – 11:30a 10:00a – 11:30a Baseline Data Collection September 2017 September 2017

Lesson 1 October 6 October 11

Lesson 2 November 3 November 8

Lesson 3 December 1 December 6

Lesson 4 January 12 January 10

Lesson 5 February 2 February 7 Lesson 6 March 2 March 7 Leeson 7 April 13 April 11 Post Test Data Collection April 2018 April 2018

Table 11. Simple Suppers 2017/2018 Topics and Meals Lesson Themes Meal 1 Making family mealtime Fruit and yogurt-topped whole wheat fun! pancakes with veggie scrambled eggs 2 Planning family meals on Fiesta skillet with fresh fruits and a budget vegetables 3 Timesaving strategies for Breakfast burrito and salsa with baked apple family meals wedges

4 Connecting with children Quick skillet lasagna with veggies & dip through meals with crunchy frozen bananas 5 Planning well-balanced Baked potato bar, chicken tortilla soup, and family meals orange fluff salad 6 Rethink your drink Meatloaf muffins, twice-as-nice mashed potatoes, and fruit pudding 7 Making healthy cooking Garden sloppy joes and easy fruit salad tasty & easy 8 Serving & eating healthy Scrambled egg muffins, roasted potatoes, portions and crunchy berry parfait 9 Eating healthy away from Cheesy crunchy chicken tenders, home applesauce, and glazed carrots 10 Planning fun & healthy Whole grain pizza, side salad, berry good snacks banana splits

Table 12. Child Food Preparation Skills Lesson Child Food Preparation Skill 1 Setting the table 2 Wash and prepare fresh produce 3 Cut soft foods with a blunt knife 4 Measure dry ingredients 5 Measure liquid ingredients 6 Grease or spray baking pans 7 Cut soft foods with a blunt knife 8 Measure liquid ingredient, cut soft foods with a blunt knife 9 Measure dry ingredients 10 Measure dry ingredients and portion food

4.23 Recruitment

Families were recruited to participate in SS using fliers and in-class announcements during the first month of the academic school year. During this month, fliers were posted in the classrooms, and a recruitment flyer (Appendix A) was shared with families during child pick-up and drop-off times. Name and contact information of all interested participants were collected and families were called, screened, and informed of the data collection dates. Families were eligible to participate if they are the legal guardian and primary caregiver of the child enrolled in the Head Start program.

4.22 Data Collection

During September of 2017, baseline data collection of all eligible families was completed. Data collection staff attended one pick-up and one drop-off time at each site.

During this time consent, parental permission, child assent, and a photography release form were completed with families (Appendix B). In April of 2018, post-test data collection occurred. After the completion of the final Simple Suppers lesson, research staff attended one drop off and one pick up time at teach site to collect data. Families received a $25 Kroger Gift Card at baseline and second $25 Kroger Gift Card at post-test.

Data was collected using questionnaires at the child, caregiver, and family level to address the three specific aims.

Four focus groups took place after the completion of the intervention in April of

2018 representing the staff and participants at each of the two intervention sites. All families that had attended at least one Simple Suppers lesson were invited to participate

66 as well as all Head Start staff at each site. All participants received a $25 Kroger Gift

Card for the participation.

Objective 1: Assess the feasibility of the SS intervention adapted to the Head Start population and setting.

The number of families that consented to participate at baseline and completed data collection at post-test determined retention rate.

Attendance was assessed using a sign-in sheet at each program lesson.

Program fidelity was assessed using a fidelity checklist completed by a non- interventionist.

In order to assess acceptability of the program, focus groups were conducted with both the caregivers and the Head Start staff at both intervention sites (four focus groups total).

Questions asked to caregivers included the following: 1. To begin, we will go around the table and name our favorite lesson from the

program, feel free to introduce yourself at this time as well?

2. How did you feel about the program overall?

3. What was your favorite part of the…parent education? Family meals education?

4. What was your least favorite part of the… parent education? Family meals

education?

5. From your point of view, how did your child feel about the program? Child

education? Family meal?

6. In what ways, if any, have family meals in your home changed since you and your

family participated in SS?

a. Do you feel any other changes in your child’s or your own health have

happened since you and your family began participating in the program?

7. How did SS compare to other programming you and your family have done

during Family Friday?

8. What suggestions do you have to help us make this program more useful in the

future?

Focus group questions asked to Head Start Staff included the following:

9. To begin, if you could all go around and share how long you have been working

with Head Start.

10. What was your overall impression of the Simple Suppers program? Parent

education? Family meal? Child education?

11. What do you believe the families overall impressions of the program were? How

do you think the parents felt about the parent education and family meal? How do

you think the children felt about the child education and family meal?

12. How would you describe your experience in delivering the program? What did

you think about the format (day, time, and length)? What did you think about the

curriculum (lesson, topics)?

13. Did you find this program to be an effective use of Head Start’s time during

Family Fridays? Please explain why or why not?

14. What suggestions do you have to help us make this program more effective for

families in the future? Parent education? Child education? Family meal?

15. What suggestions do you have to help make this program more effective for the

purposes of Head Start Family Friday Programming? i.e delivery, timing, etc…

16. Is this a program something you would enjoy bringing to Family Fridays in the

coming years?

Caregivers also completed a satisfaction survey at post-test. The tools used to assess feasibility (sign-in sheets, fidelity checklist, focus group scripts and satisfaction survey) are located in Appendix D.

Objective 2: Assess the effects of the SS intervention on child outcomes related to behavioral outcomes (food preparation skills and frequency), diet (food frequency questionnaire), and weight status (zBMI).

To address objective two, both questionnaire and direct measures were taken at baseline and post-test. Behavioral outcomes were measured using a 17-item ‘Child Food

Preparation Skills (Ages 3-5 Years)’ questionnaire adapted from the original SS data collection for 4-5 year olds. The questionnaire uses a 5-point scale (strongly agree to strongly disagree) to assess a child’s ability to participate in eight age-appropriate food preparation skills. In addition, the questionnaire assesses frequency of child participation in the eight age-appropriate food preparation skills during the past 30 days (5-point scale;

0 times to 7+ times).42 Caregivers completed this questionnaire on behalf of their children. This questionnaire demonstrated good internal consistency both at the skill and frequency level respectively (Cronbach’s alpha=0.6268 and 0.8035).

Child dietary outcomes were assessed using the ‘Block Kids Food Screener-Last

Week (age 2-17), Parent Version.’43 This screener assesses the type and amount of food consumed the week before data collection and was completed by caregivers on behalf of their children.

Finally, weight status was assessed through zBMI. Height, weight, age, and gender were used to calculate zBMI. All height and weight measurements followed the procedures outlined in the NHANES Anthropometry Procedural Manual.44

Two height measurements were taken in centimeters using a stadiometer with shoes and outerwear removed. If the two measurements differed by more than one centimeter a third measurement was taken.

The average measurement was calculated for both height and weight and these measurements were used in addition to child age and gender to calculate zBMI using

Stata. Data collection forms regarding behavioral outcomes and direct measures are located in Appendix C.

Objective 3: Assess the effects of the SS intervention on caregiver and family outcomes related to cognition (self-efficacy for healthy dietary practices), the home food environment (frequency of family meals), and weight status (BMI).

Objective three was addressed using questionnaires and direct measures at both baseline and post-test. Caregivers completed a demographics questionnaire at baseline.

This questionnaire assessed child and caregiver ethnicity, gender, and age. It was also used to collect data on caregiver relationship to child, education level, dependence of food assistance programs (WIC, SNAP, and Free or Reduced Lunch), and income level.

The US Household Food Security Survey: Six-Item Short Form was completed by caregivers at baseline to assess food security status.

Caregiver cognition was measured using the ‘Parent Family Meals Self-Efficacy

Questionnaire.’ This 12-item questionnaire assesses caregiver self-efficacy regarding family meals and child dietary habits. Each question is ranked on a scale of 0-10, 0 being not confident at all and 10 being extremely confident.46 This questionnaire demonstrated adequate internal consistency (Cronbach’s alpha=0.7765).

The home food environment was assessed through the use of the 10-item ‘Home

Food Environment’ questionnaire assessing the frequency of various home food activities ranking each on a scale of never to seven times per week. This questionnaire was developed for the SS intervention from constructs/items from three previously validated home food environment questionnaires. The Home Food Environment questionnaire assesses frequency of family mealtimes at breakfast and dinner times using a 5-point scalar (1=never; 5=7 times per week) question. It also assessed the location of family meals using a 5-point scalar (1=never; 5=7 times) question that asks frequency of eating family meals in the dining area (not living room or family room). The questionnaire also assessed frequency of television viewing during family meals over the past 7 days using a

5-point scale (1=never; 5=7 times). 42,47,48

Weight status was measured through BMI. All height and weight measurements followed the procedures outlined in the NHANES Anthropometry Procedural Manual.44

Height was measured twice in centimeters with shoes and outerwear removed using a stadiometer. Measurements that differ more than one centimeter were taken a third time.

Weight was measured twice in kilograms with shoes and outerwear removed using a digital scale. Measurements that differ more than 0.1 kg were measured a third time. Average height and weight were taken for each participant and BMI calculated.

Data collection forms regarding behavioral outcomes and direct measures are located in

Appendix C.

4.24 Data Analysis

Objective 1: Feasibility Outcomes

Retention was calculated from the number of participants that enrolled at baseline divided by the number of participants that completed post-test data collection and reported as a percentage both overall and for each site.

Attendance of enrolled participants at each lesson was averaged and reported both overall and at each site.

The fidelity checklists were coded and percentage of the program delivered as intended was calculated for each question and reported as a percentage for each site.

Focus groups were recorded and transcribed verbatim. From these transcriptions, two separate researchers coded each focus group and reconciled to determine themes.

Objective 2: Child Outcomes

Summary statistics were calculated for the demographics questionnaire for child age, gender, and race. Chi-square tests were completed to determine if there were any significant demographic differences between sites.

The Child Food Preparation Skills (Ages 3-5 Years) questionnaire was scored for both the skill and frequency score at baseline and post-test. Food preparation skill ability was measured on a scale of 0-32 with a higher score representing increased skill ability.

Food preparation skill frequency was measured on a scale of 0-40 with a higher score presenting increased skill frequency. A paired t-test was conducted to assess pre- to post- test changes.

Dietary data collected via the Block Kids Food Screener-Last Week (age 2-17),

Parent Version were analyzed by NutritionQuest.43 A paired t-test was used to assess pre- to post-test changes.

Child zBMI were calculated in Stata using child height, weight, gender, and age and a paired t-test was used to assess pre- to post-test changes.

Outcome data from both sites were combined to increase sample size for the purposes of these analyses.

Objective 3: Caregiver Outcomes

Summary statistics were calculated for caregiver age, gender, race, income level, relationship to child, and reliance on food assistance programs. Chi-square tests were

73 completed to determine if there were any significant demographic differences between sites.

The US Household Food Security Survey: Six-Item Short Form was coded and scored according to USDA guidelines and results recorded.45 Chi-square tests were completed to determine if there were any significant differences between sites.

The Parent Family Meals Self-Efficacy and the Home Food Environment questionnaires were coded and scored at baseline and post-test. Self-efficacy was scored on a 0-120 point scale with higher score representing increased skills. A paired t-test was used to assess pre- to post-test changes.

The Home Food Environment questionnaire was scored and used to assess the four desired outcomes, family dinner frequency, family breakfast frequency, family meals in the dining area, and family meals with television all in meals per week. A paired t-test was used to assess pre- to post-test changes.

BMI was calculated using average recorded heights and weights and a paired t- test was conducted assessing pre- to post-test change.

Outcome data from both sites were combined to increase sample size for the purposes of these analyses.

4.3 Results

4.31 Objective 1: Feasibility Outcomes

Twenty child-caregiver dyads enrolled in SS at Southside Head Start (Southside) while 14 child-caregiver dyads enrolled in SS at Moler Elementary School Head Start

(Moler) equaling 34 child-caregiver dyads total. Sixteen of the dyads at Southside and 13 of the dyads at Moler completed post-test data collection leading to a retention rate of

80.00% at Southside and 92.86% at Moler. The overall retention rate across schools was

85.29% (Figure 2).

Attendance was taken at each lesson. Overall, Moler had an attendance rate of

30.93% of enrolled caregivers at each lesson, while Southside had an attendance rate of

28.57% of all enrolled caregivers (Table 13).

Fidelity data were collected at each lesson to determine to what extent each lesson was delivered as intended. Fidelity data was not collected at the first lesson at Southside

Head Start due to a lack of research staff. Fidelity data was not collected at the fifth lesson at Moler Elementary, as the school experienced a snow day and the lesson was cancelled and not made up. Overall, 87.69% of the lessons at Moler Elementary School and 91.67% of the lessons at Southside were delivered as intended. Fidelity data for each question at each school are presented in Table 13.

Twenty-nine participants at post-test completed a satisfaction survey regarding the SS intervention. The overall mean (SD) caregiver satisfaction score was 3.67 (0.15) out of four possible points. Moler had a mean (SD) satisfaction score of 3.75 (0.25), while Southside’s mean (SD) satisfaction score was 3.61 (0.18). When asked about perceived child satisfaction, 28 of the families recorded their child being satisfied with the program while one caregiver reported that they were unsure. When asked if they would like to see anything changed about the SS intervention, most caregivers reported having no suggestions, while one responded that more activities could be included. When

75 asked about the child’s favorite part of the lesson the following responses were recorded: eating different foods; trying new foods; helping to prepare foods; learning; learning about different food groups; learning to use a knife; learning about healthy snacks; learning MyPlate; being hands on; being with the SS help (staff); the cook book. When asked about suggestions for SS in future years, the following responses were recorded: nothing; offer the program later in the day; more kid friendly meals; better organized; hand out ingredient list with meal. When asked about barriers regarding attendance, the following responses were recorded: work; class; appointment; sick child. When asked about facilitators to attendance, the following responses were recorded: requested time off from work; did not have class; free (no conflicting appointments, work, or class); had a sitter; want to learn something new; want to share experiences with child; want to learn how to feed child better. The questions and responses are included in Table 13.

Four focus groups were conducted with Head Start staff and caregivers at both

Moler and Southside. Eight staff members participated in the focus group at Southside and seven staff members participated in the focus group at Moler. Each focus group was coded separately for themes.

Focus groups were conducted with caregiver participants at both sites. Six caregivers participated in focus groups at Southside and five caregivers participated in the focus group at Moler. Themes were determined separately for each focus group. The themes presented are representative of results from both caregiver focus groups.

The first theme was that the intervention led to caregivers making healthy changes within their home. The following quotes reflect this theme.

“Healthier cooking, a lot healthier.”

“So instead of buying ice cream, we started eating yogurt, and now we eat

yogurt.”

“Yes, I've started cooking vegetables, all of them now.”

The second theme was that children were more involved in the kitchen at home as a result of the programming. The following quotes reflect this theme.

“Like they help more. They, they, did the tables and everything beforehand, but I

let them like help me with like the cooking and prepping.”

“He likes being involved more now in the kitchen than before.”

“My granddaughter is actually helping and wanting to be in the kitchen and help

with the dinners.”

“My daughter loves it, she wants to help cook every day all day all the time, no

matter what it is.”

The third theme was that children became more open to trying new foods as a result of the program. The following quotes reflect this theme.

“So I liked that one cause now he's eating vegetables.”

“She wants more of um, well fruits, well fruits more so than vegetables, but um

fruits and she tries to try more and instead of asking for chips and fruit snacks and

crackers.”

“My son got to eat peppers, which he never did.”

Two focus groups were conducted with Head Start staff, one at each site. The themes presented are representative of results from both Head Start staff focus groups.

Three themes were observed in the Head Start staff focus groups.

The first theme was that staff felt it was challenging to increase caregiver attendance. The following quotes reflect this theme.

“I think this year, it was hard capturing parents, trying to get them to come in.”

“And I know it was, we were, you know, er, collaborating with family day, um,

um last year, so families were here automatically to come to family day that we’re

telling them that they have to come to, so they would be, like, a captive audience

too. So when we moved it off, we wondered how it was going to work and so, it,

it was a struggle to get families, and not only at this location, at the other one too

is to get people to come an extra day of the month. So, I think that was a struggle

for parents.”

The second theme was that despite low attendance, Head Start staff perceived that caregivers enjoyed the program. The following quotes reflect this theme.

“I think they enjoyed it.”

“I do get a lot of positive feedback.”

“The parents really liked it, They enjoyed the food.”

The third theme that emerged was that the child lesson could have been improved upon to make programming run more smoothly. The following quotes reflect this theme.

“I think sometimes there was a little bit of lag time and it was kind of hard to keep

the kids engaged.”

“they would get distracted too, cause then, like the ones that would be doing

something else would be watching the other group, cutting and stuff, and like, I

mean, the kids wanna work with the foods the most.”

“This year was rough. I think it was just hard trying to keep up with the lag time,

or the transitions was kind of hard.”

Figure 2. Consort Flow Diagram Simple Suppers at Head Start 2017/2018

Expressed interest n=50 families

No longer interested n=16

Screened for enrollment n=34

Enrolled n=34

Enrolled at Moler Head Start Enrolled at Southside Head Start n=14 n=22

Lost to follow Up Lost to follow Up n=4 n=1

Table 13. Simple Suppers Feasibility and Fidelity Process Evaluation Outcomes

Moler Elementary Southside Head Total School Head Start Start Retentiona 92.9 (13) 80.0 (16) 85.3 (29)

Attendanceb, Mean Lessons 1.9 ± 0.5 1.9 ± 0.5 1.9 ± 0.3 Parent education: review goal from 75% 100% 88% previous week (lessons 3-10)c Parent education: Educator anchored 100% 100% 100% topic with an open discussionc Parent education: Educator added new information on the 100% 100% 100% topic (provide handouts when applicable)c Parent education: Educator applied new 100% 100% 100% information with interactive activityc Parent education: Parents planned a family meal for the 100% 100% 100% upcoming week (lessons 3-10)c Child education: each child age group 83% 83% 83% completed a specific food prep skillc

Group family meal: Educator leads nutrition discussion by 50% 83% 67% identifying foods groups in upcoming family mealc Group family meal: Educator leads food safety discussion 50% 67% 58% related to upcoming family mealc Group family meal: Families complete 50% 50% 50% family meal food preparationc Group family meal: Educator guides parents in establishing 67% 67% 67% family meal behavior expectationsc Child participants are engaged & involved in 83% 100% 92% the programc

Adult participants are engaged & involved in 100% 100% 100% the programc Child Educators create a positive, interactive 100% 100% 100% environmentc

Adult Educators creates a positive, 100% 100% 100% interactive environmentc Child Educators exhibit a caring 100% 100% 100% attitudec Adult Educators allow 100% 100% 100% time for questionsc Adult Educators answer questions 100% 100% 100% adequatelyc SS = Simple Suppers a Values are % (n) b Values are mean ± standard deviation c Values are % yes

Summary of SS Caregiver Satisfaction Survey Responses Caregiver Satisfactiona,b Overall (n=30) 3.7 ± 0.2 Moler (n=12) 3.8 ± 0.3 Southside (n=18) 3.6 ± 0.2 Perceived Child Satisfactionc Yes 96.4 (29) No 0.0 (0) I don’t know 3.6 (1) a Values on a scale of 1-4 b Values are mean ± standard deviation c Values are % (n) Question Responses

Would you like to see anything  No changed about SS?  More activities for children

What was your child's favorite part  Eating different foods; Trying new about SS? foods  Helping to prepare foods  Learning; learning about different food groups; Learning to use a knife; Learning about healthy snacks; Learning MyPlate  Being hands on  Being with the SS help  The cook book

Please include any suggestions to  Nothing improve SS for future families.  Offer the program later in the day  More kid friendly meals  Better organized  Hand out ingredient list with meal When you were not able to attend SS  Work programming, what were the  Class reasons?  Appointment  Sick child When you were able to attend SS  Requested time off from work programming, what were the  Did not have class reasons?  Free (no conflicting appts, work, class, etc…)  Sitter  To learn something new

 Share experiences with my child  Want to learn how to feed my children better

4.32 Objective 2: Child Outcomes

Thirty-nine children were enrolled in the SS intervention at baseline with 17 children at Moler and 22 children at Southside. The overall mean (SD) child age was 3.7

(0.5) with the mean (SD) age at Moler of 3.9 (0.5) and of 3.6 (0.5) at Southside. Overall,

53.9% of children were male with 58.8% at Moler and 50.0% at Southside. The majority of the children were Black at 71.8% with 82.4% children that were Black at Moler and

63.6% at Southside. The mean (SD) zBMI was in the normal range at 0.3 (1.5). Children at Moler were underweight with a mean (SD) zBMI of -0.3 (0.4) and children at

Southside were normal weight with a mean (SD) zBMI of 0.8 (0.3). When broken down categorically, 14.3% of children were underweight (25.0% at Moler and 5.3% at

Southside), 51.4% of children were of a normal weight (50.0% at Moler and 53.6% at

Southside) and 34.3% of children were overweight or obese (25.0% at Moler and 42% at

Southside). zBMI was the only baseline characteristic significantly different between schools (p=0.0234). Baseline characteristics are presented in Table 14.

Child level outcomes were first assessed using a paired t-test to assess differences from pre- to post-test. Child food preparation skills significantly increased from pre- to post-test (p=0.00). Child food preparation frequency significantly increased from pre- to post-test (p=0.0001). Child zBMI significantly increased from pre- to post-test

(p=0.0004), but remained in the normal range. No significant changes were observed in

84 dietary outcomes regarding fruit/fruit juice (cups/day) (p=0.8190), vegetables (cups/day)

(p=0.4255) or estimated average daily frequency of consumption of sugary beverages

(p=0.9118). These data are presented in Table 15.

Table 14. Child Baseline Characteristics (n=39) Baseline Total Moler n=17 Southside P-value Characteristics n=22

Agea 3.7 ± 0.5 3.9 ± 0.5 3.6 ± 0.5 0.08

Gender (n=38)

Male b,c 53.9 (21) 58.8 (10) 50.0 (11) Female bc 46.2 (18) 41.2 (7) 50.0 (11) 0.58

Race (n=38)

Blackb,c 71.8 (28) 82.4 (14) 63.6 (14) Non-Blackb,c 28.2 (11) 17.7 (3) 36.4 (8) 0.32

Anthropometrics (n=35) zBMIa 0.3 ± 1.5 -0.3 ± 0.4 0. 8± 0.3 0.02

Underweightb,c 14.3 (5) 25.0 (4) 5.3 (1) Normal Weightb,c 51.4 (18) 50.0 (8) 53.6 (10) 0.21 Overweightb,c 34.3 (12) 25.0 (4) 42.1 (8) a Values are mean ± standard deviation b Chi-squared c Values are % (n)

Table 15. Child Level Outcomes (n=34)a Child Level Outcomes Baselineb Post-testb Changeb P-value Health Behaviors

Child Food Preparation 20.8 ± 4.3 25.7 ± 4.2 4.9 ± 4.4 0.0000 Skillsc Child Food Preparation 21.7 ± 5.6 26.0 ± 6.1 4.3 ± 5.6 0.0001 Frequencyd Dietary Outcomes Fruit/Fruit Juicee 1.7 ± 1.2 1.8 ± 1.0 0.05 ± 1.2 0.82 Vegetables Excluding 0.8 ± 0.6 0.8 ± 0.7 0.09 ± 0.6 0.43 Potatoese Estimated Average Daily Frequency of 0.2 ± 0.2 0.2 ± 0.2 -0.005 ± 0.2 0.91 Consumption of Sugary Beveragesf Anthropometrics zBMI 0.28 ± 1.5 0.34 ± 1.4 0.06 ± .08 0.0004 a Paired t-test b Values are mean ± standard error c Values are on a scale of 8-32 d Values are on a scale of 0-40 e Values are cups/day f Values are number of sugary beverages consumed per day

4.23 Objective 3: Caregiver Outcomes

Thirty-four caregivers enrolled in the intervention at baseline. Fourteen caregivers enrolled at Moler and 20 caregivers at Southside. The overall mean (SD) age was 33.6

(12.7) years. The mean (SD) age at Moler was 36.0 (15.5) years while the mean (SD) age at Southside was 31.9 (10.5). The majority of caregivers were female with 82.4%. At

Moler 100.0% of caregivers were female, while at Southside only 70.0% of caregivers

86 were female. Overall, 73.5% of caregivers were Black, with 85.7% at Moler and 65.00% caregivers identifying as Black at Southside. The majority of caregivers reported an income level below $25,000 (47.1%) with 64.3% reporting this income level at Moler and 35.0% reporting this at Southside. 82.4% of enrolled caregivers were parents to the enrolled children while 17.7% were grandparents. A higher percentage of caregivers were parents at Southside (85.0%) than at Moler (78.6%). The majority of caregivers received some type of food assistance including WIC, SNAP, Free or Reduced Lunch, or a combination of the three (70.6%). 78.6% of families were receiving some type of assistance at Moler and 65.0% at Southside. 47.1% of caregivers had received their high school diploma or GED with 57.1% at Moler and 40.0% at Southside. 29.4% of caregivers had received some college education with 35.7% at Moler and 25.0% at

Southside, and 11.8% had received a four year degree with none at Moler and 20.0% at

Southside. The majority of caregivers reported experiencing marginal to high food security 70.6% while 20.6% reported low food security and 8.8% reported very-low food security. At Moler, 64.3% caregivers reported marginal to high food security, 28.6% reported low food security and 7.1% reported very-low food security. At Southside,

75.0% reported marginal to high food security while 15.0% reported low food security, and 10.0% reporting very low food security. Mean (SD) BMI fell into the obese category at 33.0 (8.9) kg/m2. Mean (SD) BMI was 30.3 (7.2) kg/m2 at Moler and 35.0 (9.7) kg/m2 at Southside. Caregiver gender was the only variable significantly different between sites

(p=0.02).These data are presented in Table 16.

Caregiver outcomes were assessed using paired t-test to assess differences from pre- to post-test. Caregiver self-efficacy increased significantly from pre- to post-test

(p=0.03). No significant differences were observed in the family meals outcomes.

Frequency of eating dinner together increased (p=0.86), frequency of eating breakfast together decreased (p=0.16), frequency of meals consumed in the dining area did not change (p=1.00), and frequency of TV viewing during mealtime decreased (p=0.15); however none of these changes were significant. Caregiver BMI increased significantly from baseline to post-test (p=0.01). These data are presented in Table 17.

Table 16. Caregiver Characteristics Baseline Characteristics Total (n=34) Moler (n=14) Southside P-Value (n=20)

Agea 33.6 ± 12.7 36.0 ± 15.5 31.9 ± 10.5 0.32

Genderb,c

Male 17.7 (6) 0.0 (0) 30.0 (6) 0.02 Female 82.4 (28) 100.0 (14) 70.0 (14)

Raceb,c

Black 73.5 (25) 85.7 (12) 65.0 (13) 0.33 Non-Black 26.5 (9) 14.3 (2) 35.0 (7)

Incomeb,c <$25,000 47.1 (16) 64.3 (9) 35.0 (7) 0.39 $25,000-44,999 32.4 (11) 28.6 (4) 35.0 (7) $45,000-64,999 11.8 (4) 7.1 (1) 15.0 (3) $65,000-84,999 5.88 (2) 0.00 (0) 10.00 (2) Prefer Not to Answer 2.94 (1) 0.00 (0) 5.00 (1)

Relationship to Childb,c Parent 82.4 (28) 78.6 (11) 85.0 (17) 0.23 Grandparent 17.7 (6) 21.4 (3) 15.0 (3) Food Assistanceb,c None 29.4 (10) 21.4 (3) 35.0 (7) 0.68 WIC 23.5 (8) 14.3 (2) 30.0 (6) SNAP 0.0 (0) 0.0 (0) 0.0 (0) Free/Reduced Lunch 11.8 (4) 14.3 (2) 10.0 (2) (Lunch) WIC & SNAP 17.7 (6) 21.4 (3) 15.0 (3) SNAP and Lunch 5.9 (2) 7.1 (1) 5.0 (1) WIC and Lunch 2.9 (1) 7.1 (1) 0.0 (0) All Three 8.8 (3) 14.3 (2) 5.0 (1) Education Levelb,c No High School 11.8 (4) 7.1 (1) 15.0 (3) 0.25 High School/GED 47.1 (16) 57.1 (8) 40.0 (8) Some College 29.4 (10) 35.7 (5) 25.0 (5) 4-Year Degree 11.8 (4) 0.0 (0) 20.0 (4) Food Securityb,c

Marginal to High Food 70.6 (24) 64.3 (9) 75.0 (15) 0.21 Security Low Food Security 20.6 (7) 28.6 (4) 15.0 (3) Very-Low Food Security 8.8 (3) 7.1 (1) 10.0 (2)

Anthropometrics BMIa,d 33.0 ± 8.9 30.3 ± 7.2 35.0 ± 9.7 0.12 a Values are mean ± standard deviation b Chi-squared c % (n)

89 d Values are kg/m2

Table 17. Caregiver Outcomesa,b Outcome Baselinec Post-testc Changec P-value Caregiver Self-Efficacyd 98.0 ± 20.1 103.1 ± 17.5 5.1 ± 13.4 0.03 (0-120) Home Food Environment Eat Dinner Togethere 4.09 ± 0.2 4.1 ± 0.2 0.03 ± 0.2 0.86

Eat Breakfast Togethere 3.4 ± 0.3 3.0 ± 0.2 -0.4 ± 0.3 0.16

Meal in Dining Areae 4.0 ± 0.2 4.0 ± 0.2 0.0 ± 0.2 1.00

TV During Meal Timee 2.1 ± 0.2 1.9 ± 0.1 -0.3 ± 0.2 0.15 Anthropometrics BMIf 33.4 ± 9.7 34.3 ± 9.4 0.9 ± 1.9 0.01 a n=34 b Paired t-test c Values are mean ± standard deviation d Values on a scale of 0-120 e Values on a scale of 0-5, 0=never 5=7 days f Values are kg/m2

4.4 Discussion

SS intervention in the Head Start setting and population. After the successful completion

90 of a feasibility study in one Head Start site, our team was invited to deliver the intervention at two Head Starts sites in Columbus, Ohio. This led to an increased sample size and allowed our research team to address various limitations experienced in year one of the intervention. We hypothesized that SS@HS would be feasible in this setting and produce positive changes in health behavior outcomes at both the child and caregiver level. Feasibility data showed high retention and acceptability of the intervention in this setting. Positive, significant differences were found in outcomes at both the child and caregiver level that were corroborated in participant focus group themes. SS@HS displayed high feasibility in this setting and warrants further investigation of the SS intervention within this population and setting.

4.41 Objective 1: Feasibility Outcomes

Retention rate of families in this program was 88.2%. The families lost to follow up were all families that had dropped out of Head Start during the school year and were uninterested in completing post-test data collection when contacted. Data from a family meals nutrition intervention delivered in the low-income, preschool age population had a similar retention rate of 91%, with 11 child-caregiver dyads enrolled at baseline and 10 dyads that completed post-test data collection. In the intervention conducted by Rogers et al the retention rate of child-caregiver dyads was 87.5%. The retention rate of 88.2% is also higher than the retention rate in year one of SS@HS which was 66.7%. Thus, 88.2% is a high retention rate for this intervention.

Attendance rates were low throughout the duration of this intervention. One major change that was made during year two was that SS was delivered on a day separate from

Family Friday (a day where caregiver attendance is mandatory). This change in day may have decreased caregiver attendance because not only were caregivers now being asked into the classroom two times per month, but also the SS program was not paired with a day where attendance was mandatory. In addition, the satisfaction survey revealed that many parents did not attend due to work, class, childcare duties in the home, or a doctor’s appointment. Thus, parents may be willing to take off work or find a babysitter for the one mandatory day during the school year, but not for a second day of in class programming. Focus groups with caregivers and Head Start staff revealed a preference for the time of day programming was delivered, despite the low attendance rates. Thus, pairing programming with a day where attendance is mandatory may help to increase attendance at Head Start.

The fidelity questionnaire revealed that 87.7% of the lessons were delivered as intended at Moler, while 91.7% of lessons were delivered as intended at Southside

(average of 89.7% across sites). The lowest scores recorded were for questions regarding the family lesson. With roughly 30 children participating in the child food preparation skill and an average of two caregivers in attendance, the transition from the separate but simultaneous lessons to the family lesson was often arduous. This may have led to a decrease in fidelity of the family lesson. At the conclusion of the separate caregiver and child lessons, children with caregivers in attendance were sent to the room where caregiver education occurred to complete the family lesson. At this time, not all caregivers chose to stay for the family lesson and meal. The family lesson did not occur until after the meal had been served. Many of the families however split up and ate the meal with their families rather than as a group. Therefore, the educators delivering the

92 family lesson had to go from family to family to review the lesson with each. This made delivery of the lesson challenging leading to a low fidelity score in this section. Fidelity may have been improved if more structure was given to the family lesson. Bringing together child and caregiver at the beginning of the lesson before families had a chance to leave, or split into smaller groups may help this. Outside of the family lesson, the remainder of the SS intervention (caregiver lesson and child lesson) was delivered as intended. Ninety-five percent of the lessons delivered in SS conducted by Rogers et al were delivered as intended. Thus, our overall fidelity rate of 89.68% may be considered high.

Caregiver BMI increased significantly from baseline to post-test in this intervention. This may have occurred for a variety of reasons. First, our intervention was delivered monthly rather than weekly, only seven of 10 lessons were delivered and our attendance rates were low. There may not have been appropriate exposure to the intervention to elicit this change. In addition, the curriculum emphasized the addition of fruits and vegetables and various healthy modifications to foods. It is possible that families simply added these food items to their regular diet rather than swapping them for less healthy options. Including an emphasis on swapping healthy foods for less healthful options in the curriculum may be necessary.

4.42 Objective 2: Child Outcomes

Baseline data revealed a normal zBMI for children enrolled in the program. When broken down categorically, data revealed that 30.8% of all children were overweight or obese. This number is slightly lower than, but near the rates of overweight/obesity experienced at Head Start in the state of Ohio.6

The mean (SD) age was 3.7 (0.5) years and the majority of the children enrolled at both sites were Black at 71.8%. In addition, families must be at or below 100% of the poverty line to enroll in Head Start. Therefore, we were assessing the proposed population of racially diverse, low-income, preschool-aged children.

Child outcomes assessed using a paired t-test revealed positive and significant changes in child food preparation skills (p<0.00) and child food preparation frequency

(p=0.0001). While alternative nutrition programming was ongoing at these sites through

Local Matters, SS was the only program at Head Start that addressed child food preparation skills and that allowed hands on learning of these skills in the classroom.

These data are corroborated by focus group themes that reveal an increase in child food preparation in the home. It is worth noting that our attendance rate is representative of caregiver attendance rather than child. Thus, while our attendance rate was low it is likely that the children had a much higher attendance rate than their caregivers because children did not need their caregiver present in order to participate in the lesson. Therefore, children likely has more exposure to the lessons, explaining our significant food preparation skills and frequency finding.

Mean zBMI increased significantly (p=0.0004) from baseline to post-test. While an increase was observed, the mean zBMI remained in the normal range at baseline and at post-test. Natale et al presented similar results where BMI remained in the normal range throughout the duration of programming.51 When broken down categorically, the percentage of children in each category (underweight, normal weight, and overweight/obese) remained the same. Children may have gained weight, but without it

94 shifting them from their respective weight category. Therefore, we believe our second hypothesis was correct and that the intervention prevented inappropriate weight gain in children.

Fruit and vegetable consumption improved modestly but overall no significant changes were seen in the dietary outcomes observed. This may be for a number of reasons. Caregivers filled out the food frequency questionnaire as a proxy for children, potentially introducing desirability bias. In addition, the measures presented were a result of a secondary analysis and not a primary result of the food frequency questionnaire administered. Caregivers serve as nutritional gatekeepers for children in the home51, thus with such low caregiver attendance it is not surprising that child consumption in the home was not changed as a result of programming.

4.43 Objective 3: Caregiver Outcomes

Mean (SD) caregiver age was 33.6 (12.7) years, which mirrors the average age observed in year one. The majority of caregivers were female (82.4%) with significantly more male caregivers at Southside than Moler (p=0.02). Six of the caregivers at

Southside were male while Moler had no male caregivers enrolled in the program. The majority of caregivers were Black, mirroring the race of enrolled children. Mean BMI of adults was 33.0 kg/m2, which falls in the obese category. This is not surprising considering the high rates of obesity in socioeconomically disadvantaged, racial minority adults in the United States today. Specifically, Black women are experiencing obesity at

54.8%.1 The majority of participants (70.6%) experienced marginal to high food security at baseline while 20.6% experienced low food security and 8.8% experienced very low

95 food security. 70.6% of caregivers were receiving some sort of food assistance, which may have helped contribute to those who experienced marginal to high food security.

When caregiver outcomes were assessed using a paired-test, caregiver self- efficacy increased significantly from baseline to post-test (p=0.03). This change was not observed in year one of SS at Head Start, but was observed in the iteration of SS implemented by Rogers et al.21 This finding is surprising, as caregiver attendance was so low. At baseline, our self-efficacy scores were lower than the score of Rogers et al (98.0 and 102.7 points respectively). Our intervention raised self-efficacy score to 103.1 points, meaning that our post-test score were close to the baseline scores of the participants in

Rogers et al’s study and that their participants had higher self-efficacy to begin with. This may be explained by the difference in income levels and suggests that families with higher incomes at baseline may experience higher self-efficacy than those with lower income levels.

No changes were observed in the four home food environment outcomes. When frequency of breakfast and dinner shared were combined, the frequency of family meals matched national rates. Roughly 50% of families in the United States share seven or more meals together per week.50 Similar results were found in year one of SS at Head Start.

Data from this year are from a larger sample size and are more representative of Head

Start families, thus corroborating that low-income families may share a higher rate of family meals. Rates of childhood overweight and obesity as well as adult obesity remained high in this population despite this fact and the fact that children who share three or more family meals together per week are more likely to be of a healthier weight

96 and have healthier dietary habits.16 This calls into importance the family meal environment and the quality of the foods served at these meals. Further research is warranted investigating these topics.

4.44 Limitations

The pre-posttest study design with a lack of control group was a limitation of this work. However, a randomized control trial of this intervention is not yet warranted, as we remain in the feasibility testing stages of this work. Program dose was another limitation.

Only seven of the 10 SS lessons were delivered in this intervention and these lessons were delivered monthly rather than weekly as intended in the original study design. In addition, one lesson at Moler Elementary school was cancelled due to a school snow day.

We were unable to make up this lesson, therefore Moler Elementary only received six of

10 lessons. Both the timing of delivery as well as the number of lessons delivered were at the discretion of the Head Start staff. In order to fit programming within the school year, there was only time for seven lessons. In addition, the timing and frequency of the intervention was carried over from SS at Head Start in 2016/2017 as both Head Start staff and participants from this year believed it to be the best time to deliver the program.

The inclusion of a second site helped to increase sample size, however this sample size is relatively small when compared to similar interventions. Due to this small sample size, a paired t-test was chosen to assess child and caregiver level outcomes. A paired t- test does not control for confounding variables, nor does it control for differences between sites, or the nesting effect that occurs when families have more than one child enrolled in the intervention. A mixed-effects linear regression model was considered,

97 however was not chosen. This decision was made because our intervention was not designed to detect such differences in outcomes. We had a small sample size and all 10

SS lessons were not delivered. In addition, our aim was to assess feasibility of the study, making child and caregiver level outcomes secondary. With that, the significant results observed from the paired t-test help to corroborate our feasibility data and warrant continued intervention in the Head Start setting.

Another limitation was that caregivers served as the proxy for child outcomes, possibly introducing desirability bias.

Throughout the duration of the school year, Head Start also had another nutrition education intervention delivered to the children, called Local Matters. This program was only delivered to the children and did not focus on the importance of family meals, nor did it include a hands-on child food preparation skill. However, the presence of this program does limit the conclusions that can be drawn from the child level outcomes.

While caregiver attendance was taken at each lesson, child attendance was not.

Therefore, there were likely more children in attendance than caregivers. Collecting data on child attendance may help to explain the positive child outcome findings.

Our intervention was adapted in many ways to the Head Start population; however, our caregiver education was not modified. A review of the literature to better assess the barriers that families of this income level, and in this community face regarding family meals may be necessary to better adapt this intervention for future years.

Finally, while we had two dietetic interns conducting the caregiver education, we lacked a peer educator in this role. In SS@VCC peer educators were used to deliver the caregiver education. Despite our efforts, we were unable to recruit a peer educator for this intervention.

4.45 Conclusions

The high retention rate, positive acceptability outcomes from both focus groups and the satisfaction questionnaire, and significant changes in both caregiver and child level outcomes have led us to conclude that SS demonstrated high feasibility in the Head

Start setting. Significant and positive changes in child food preparation frequency and skills as well as caregiver self-efficacy were observed. It was found that families in this population are consuming a high number of family meals; however, health outcomes were not impacted. We believe these outcomes warrant further testing of this intervention in the Head Start setting specifically investigating the environment and diet quality of meals shared among these families.

Focus group and observational data collected during this study have led to several suggestions for the delivery of SS@HS in future years. These changes may work to better assess the effects of the intervention and to better incorporate the SS intervention into the

Head Start curriculum.

1. Completing all 10 of the SS lessons with the children and caregivers.

2. Increase sample size to better assess the effects of the intervention on child and

caregiver level outcomes.

3. Inclusion of a follow up data collection point to assess whether the positive

changes in child level outcomes are associated with prevention of inappropriate

weight gain in future years.

4. Introducing the SS educators to the parents and children at a time before the

programming begins for the school year. This was a suggestion by Head Start

staff so that educators have a chance to build better rapport with the participants

before beginning the actual lessons begin.

5. Sharing the curriculum with Head Start staff before the lessons so that they are

familiar with the curriculum and are able to better support our staff during

programming. Head Start staff expressed interest in being involved with the child

education, however were not provided with adequate knowledge regarding the

curriculum to successfully help the SS staff in delivering the child education.

Thus, the Head Start staff has requested we share the lessons with them and

provide an outline of their responsibilities. While our child educators are well

versed in nutrition, they are not necessarily experts in education, particularly at

the preschool age. The willingness of the Head Start staff (experts in pre-school

age education) to assist in the delivery of the SS programming allows for the best

utilization of available resources – advanced level nutrition students plus expert

child educators.

6. Better incorporation of the child education with Head Start’s curriculum. Head

Start has a certain amount of time they must engage children in gross motor skills

each day. Because of this, they have suggested that we use the extra time when

the child education ends early to incorporate their need for these gross motor

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skills. Head Start staff expressed that there were days when our programming

went too long and they struggled to have enough time to include their own

necessary programming. This suggestion can contribute to Head Start’s

curriculum as well as SS’s curriculum.

7. The incorporation of a HACCP plan for each meal served at each location to

ensure food safety of all meals.

8. Changing some meal items served to be more culturally acceptable to the

population. Focus group data revealed a dislike of food options because they were

too “healthy.” Modifying meals to be more culturally appropriate may help with

acceptability. In addition, this serves as a learning opportunity for families to

observe healthier ways of preparing commonly consumed foods.

9. A more efficient system of incorporating families that enrolled in Head Start in

the middle of the school year. A few families that enrolled at Head Start after SS

enrollment had occurred missed incentives for participation. In addition, this

valuable data was not collected during the duration of programming.

10. Moving the parent education to a separate location so that the child education

could occur in two separate classrooms. More specifically, on some occasions,

children were split into two groups, one completing the food preparation activity

and one completing story time or coloring. This often led to distractions when

they occurred in the same room. Splitting the children into two separate rooms

may lead to a more focused and informative lesson.

11. The SS meals sometimes coincided with the Head Start snacks and meals.

Meaning that children sometimes had carrots as a side dish with the SS meal and

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then carrots at snack time. This could have been avoided by sharing the

curriculum with Head Start staff ahead of time and planning meals to better

coincide with Head Start’s meals.

12. Handwashing was done by Head Start staff before our programming began,

however this could be incorporated into programming and account for some of the

lag time between parent education and child education.

13. Incorporating a more culturally sensitive menu. Focus groups showed that many

families preferred learning how to make the types of food they are already eating

healthier rather than changing their diet entirely. Input from families and Head

Start staff may help to develop this menu.

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Chapter 5: Epilogue

The present study sought to assess the feasibility of the SS intervention in the

Head Start setting and population. In order to deliver this intervention in this setting, many programmatic modifications were made. Data collected from year one was used to help increase the feasibility of the program in year two. Our data show that not only was the intervention feasible in this setting, but significant and positive changes in both child and caregiver level (child food preparation skills and frequency and parent self-efficacy) outcomes were observed.

The data collected in these two years have led to many suggested program modifications that may work to increase program feasibility and potentially prevent childhood obesity within this population. Overall, these changes work to better incorporate the SS curriculum into Head Start’s curriculum and lead to a more cohesive experience for the Head Start staff, SS staff, and the participants. With a large-scale community nutrition intervention it is important that the needs of the partnering agencies be accounted for and that the intervention not only contributes to the literature, but also meets the needs of the partnering agency, in this case Head Start. The ultimate goal of such an intervention is for it to become self-sustaining in its desired setting. These suggestions are the first steps in incorporating the SS programming into Head Start’s curriculum.

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We believe our findings warrant further testing of the SS intervention within the

Head Start setting. Next steps would be to incorporate all ten lessons and to pair the intervention with a mandatory attendance day for Head Start caregivers. In addition, the noted changes in section 4.45 Conclusions should be considered when delivering the intervention in future years.

Our observation of a high frequency of shared family meals combined with negative weight status outcomes in both child and caregiver zBMI and BMI suggest that a poor environment and unhealthy food choices may contribute to the lack of change in these outcomes in this population. Future studies in the field of family meals and childhood obesity prevention should consider the environment with which family meals are consumed as well as quality of foods served at these meals.

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37. Rose AM, Wagner AK, Kennel JA, et al. Determining the feasibility and acceptability of a nutrition education and cooking program for preschoolers and their families delivered over the dinner hour in a low-income day care setting. Infant, Child, Adolesc Nutr. 2014;6(3):144-151. doi:10.1177/1941406414524274.

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39. Virudachalam S, Long JA, Harhay MO, Polsky DE, Feudtner C. Prevalence and patterns of cooking dinner at home in the USA: National Health and Nutrition Examination Survey (NHANES) 2007-2008. Public Health Nutr. 2014;17(5):1022-1030. doi:10.1017/S1368980013002589.

40. Centers for Disease Control and Prevention. Obesity Among Low-Income Preschool Children. Children. 2014:4. http://www.cdc.gov/obesity/downloads/PedNSSFactSheet.pdf%5Cn %5Ct http://www.cdc.gov/obesity/downloads/pednssfactsheet.pdf.

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46. Bohman B, Nyberg G, Sundblom E, Sch??fer Elinder L. Validity and Reliability of a Parental Self-Efficacy Instrument in the Healthy School Start Prevention Trial of Childhood Obesity. Heal Educ Behav. 2014;41(4):392-396. doi:10.1177/1090198113515243.

47. Gattshall ML, Shoup JA, Marshall JA, Crane LA, Estabrooks PA. Validation of a survey instrument to assess home environments for physical activity and healthy eating in overweight children. 2008;13:1-13. doi:10.1186/1479-Received.

48. Berlin KS, Davies WH, Silverman AH, Rudolph CD. Assessing Family-based Feeding Strategies , Strengths , and Mealtime Structure with the Feeding Strategies Questionnaire. 2018;36(5):586-595.

49. van der Horst K, Ferrage A, Rytz A. Involving children in meal preparation. Effects on food intake. Appetite. 2014;79:18-24. doi:10.1016/j.appet.2014.03.030.

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51. Natale RA, Lopez-Mitnik G, Uhlhorn SB, Asfour L, Messiah SE. Effect of a Child Care Center-Based Obesity Prevention Program on Body Mass Index and Nutrition Practices Among Preschool-Aged Children. Health Promot Pract. 2014;15(5):695-705. doi:10.1177/1524839914523429.

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Appendix A: Recruitment Materials

A1. Moler Elementary School Head Start Recruitment Flyer

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A2. Southside Head Start Recruitment Flyer

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Appendix B: Consent, Parental Permission, Assent and Photograph Release Forms

B1. Consent Form The Ohio State University Consent to Participate in Research

Simple Suppers: a novel approach to childhood Study obesity prevention Title: Resear Dr. Carolyn Gunther cher: Sponso Cardinal Health Foundation; OSU Seed grant r: 7 This is a consent form for research participation. It contains important information about 8 this study and what to expect if you decide to participate. Your participation is voluntary.

9 Please consider the information carefully. Feel free to ask questions before making your 10 decision whether or not to participate. If you decide to participate, you will be asked to sign 11 this form and will receive a copy of the form. Purpose:

12 The purpose of the Simple Suppers (SS) program is to equip you with healthy cooking skills 13 and nutrition knowledge to use in preparing family meals and have a better overall diet. 16

Procedures/Tasks:

17 The program will occur monthly for 10 months. Each SS session will include separate parent 18 and child nutrition education lessons, a cooking lesson, and a group meal. You will be asked 19 to complete multiple questionnaires at 2 time points throughout the 10 month study. We will

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20 collect height/weight data on your participating child(ren) at 2 time points during the study. 21 You will have the opportunity to have your height and weight measured at 2 time points 22 during the study as well. All identifying information will be removed from the surveys and 23 the results will be published in aggregate only. 25

Duration:

26 You may leave the study at any time. If you decide to stop participating in the study, there 27 will be no penalty to you, and you will not lose any benefits to which you are otherwise 28 entitled. Your decision will not affect your future relationship with The Ohio State 29 University. The program will occur monthly for 10 months and each session will last 90 30 minutes. 32

Risks and Benefits:

33 The risks of this study are minimal. The benefits are that you may gain healthy cooking skills 34 and nutrition knowledge. 36

Confidentiality:

40 Efforts will be made to keep your study-related information confidential. However, there may 41 be circumstances where this information must be released. For example, personal information 42 regarding your participation in this study may be disclosed if required by state law. Also, 43 your records may be reviewed by the following groups (as applicable to the research): 44  Office for Human Research Protections or other federal, state, or international

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45 regulatory agencies; 46  The Ohio State University Institutional Review Board or Office of Responsible 47 Research Practices; 48  The sponsor, if any, or agency (including the Food and Drug Administration for FDA- 49 regulated research) supporting the study. 51

Incentives:

52 You will be asked to complete a packet of surveys and participate in 3 diet-recall interviews at 53 2 time points: 1 week before the start of the program, 1 week after the end of the program. For 54 participating with your family at each time point, you will receive a $25 retail gift card for a 55 total of $50. 57

58 Participant Rights:

60 You may refuse to participate in this study without penalty or loss of benefits to which you 61 are otherwise entitled. If you are a student or employee at Ohio State, your decision will not 62 affect your grades or employment status. 63

64 If you choose to participate in the study, you may discontinue participation at any time 65 without penalty or loss of benefits. By signing this form, you do not give up any personal 66 legal rights you may have as a participant in this study. 67

68 An Institutional Review Board responsible for human subjects research at The Ohio State 69 University reviewed this research project and found it to be acceptable, according to 70 applicable state and federal regulations and University policies designed to protect the rights 71 and welfare of participants in research.

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Contacts and Questions:

73 For questions, concerns, or complaints about the study, or you feel you have been harmed as a 74 result of study participation, you may contact Dr. Carolyn Gunther (614) 292-5125 75 [email protected]. 77

78 For questions about your rights as a participant in this study or to discuss other study-related 79 concerns or complaints with someone who is not part of the research team, you may contact 80 Ms. Sandra Meadows in the Office of Responsible Research Practices at 1-800-678-6251.

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82 Signing the consent form

84 I have read (or someone has read to me) this form and I am aware that I am being asked to 85 participate in a research study. I have had the opportunity to ask questions and have had them 86 answered to my satisfaction. I voluntarily agree to participate in this study. 87

88 I am not giving up any legal rights by signing this form. I will be given a copy of this form. 89

Printed name of subject Signature of subject

AM/PM

Date and time

Printed name of person authorized to consent for Signature of person authorized to consent for subject subject (when applicable) (when applicable)

AM/PM

Relationship to the subject Date and time

93 Investigator/Research Staff

95 I have explained the research to the participant or his/her representative before requesting the 96 signature(s) above. There are no blanks in this document. A copy of this form has been given 97 to the participant or his/her representative. 98

118

Printed name of person obtaining consent Signature of person obtaining consent

AM/PM

Date and time

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B2. Parental Permission Form 1

The Ohio State University Parental Permission

2 For Child’s Participation in Research 4

Simple Suppers Scale-Up (S3): An expanded pilot study to Study Title: determine the effectiveness of participation in an

innovative nutrition education and cooking program for

families with young children Researcher: Dr. Carolyn Gunther Sponsor: Cardinal Health Foundation; OSU Seed grant 6

7 This is a parental permission form for research participation. It contains important 8 information about this study and what to expect if you permit your child to participate. Your child’s participation is voluntary.

9 Please consider the information carefully. Feel free to discuss the study with your friends and 10 family and to ask questions before making your decision whether or not to permit your child 11 to participate. If you permit your child to participate, you will be asked to sign this form and 12 will receive a copy of the form. Purpose:

13 The purpose of the Simple Suppers (SS) program is to equip parents and their children with 14 healthy cooking skills and nutrition knowledge to use in preparing family meals and have a 15 better overall diet. 18

Procedures/Tasks:

19 The program will occur monthly for 10 months. Each SS session will include separate parent 120

20 and child nutrition education lessons, a cooking lesson, and a group meal. During the child 21 nutrition education lessons, your child will learn several age-appropriate food preparation 22 skills. We will collect height/weight data on your participating child at 2 time points during 23 the study. Your child will be asked to complete a food preference survey at 2 time points 24 during the study. All identifying information will be removed from data and the results will be 25 published in aggregate only. 27

Duration:

28 Your child may leave the study at any time. If you or your child decides to stop participation 29 in the study, there will be no penalty and neither you nor your child will lose any benefits to 30 which you are otherwise entitled. Your decision will not affect your future relationship with 31 The Ohio State University. Simple Suppers will occur monthly for 10 months and each 32 session will last 90 minutes. 34

Risks and Benefits:

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35 The risks of this study are minimal. The benefits are that your child may gain healthy cooking 36 skills and nutrition knowledge. Confidentiality:

37 Efforts will be made to keep your child’s study-related information confidential. However, 38 there may be circumstances where this information must be released. For example, personal 39 information regarding your child’s participation in this study may be disclosed if required by 40 state law. Also, your child’s records may be reviewed by the following groups (as applicable 41 to the research): 42  Office for Human Research Protections or other federal, state, or international 43 regulatory agencies; 44  The Ohio State University Institutional Review Board or Office of Responsible 45 Research Practices; 46  The sponsor, if any, or agency (including the Food and Drug Administration for FDA- 47 regulated research) supporting the study. 50

Incentives:

51 Children will not be directly incentivized. Families will be asked to complete a packet of 52 surveys at the beginning and end of the program. For completing the surveys and participating 53 in the interviews at each time point, your family will receive a $25 retail gift card, for a total 55 of $50.

57 Participant Rights:

59 You or your child may refuse to participate in this study without penalty or loss of benefits to 60 which you are otherwise entitled. If you or your child is a student or employee at Ohio State,

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61 your decision will not affect your grades or employment status. 62

63 If you and your child choose to participate in the study, you may discontinue participation at 64 any time without penalty or loss of benefits. By signing this form, you do not give up any 65 personal legal rights your child may have as a participant in this study. 66

67 An Institutional Review Board responsible for human subjects research at The Ohio State 68 University reviewed this research project and found it to be acceptable, according to 69 applicable state and federal regulations and University policies designed to protect the rights 70 and welfare of participants in research.

Contacts and Questions:

72 For questions, concerns, or complaints about the study, or you feel your child has been 73 harmed as a result of study participation, you may contact Dr. Carolyn Gunther (614) 292- 74 5125 [email protected]. 76

77 For questions about your child’s rights as a participant in this study or to discuss other study- 78 related concerns or complaints with someone who is not part of the research team, you may 79 contact Ms. Sandra Meadows in the Office of Responsible Research Practices at 1-800-678- 80 6251.

82 Signing the parental permission form

84 I have read (or someone has read to me) this form and I am aware that I am being asked to 85 provide permission for my child to participate in a research study. I have had the opportunity

123

86 to ask questions and have had them answered to my satisfaction. I voluntarily agree to permit 87 my child to participate in this study. 88

89 I am not giving up any legal rights by signing this form. I will be given a copy of this form. 90

Printed name of subject

Printed name of person authorized to Signature of person authorized to provide permission for provide permission for subject subject

AM/PM

Relationship to the subject Date and time

93 Investigator/Research Staff

Printed name of person obtaining consent Signature of person obtaining consent

AM/PM

D a t 124

e a n d t i m e

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B3. Child Assent Form Simple Suppers Child Assent Script

You are being asked to be in a research study called Simple Suppers. It is okay to say “No” if you don’t want to be in the study. If you say “Yes” you can change your mind and quit being in the study at any time without getting in trouble.

If you decide you want to be in the study, an adult (usually a parent) will also need to give permission for you to be in the study.

In Simple Suppers you will learn how to help your family make dinner and learn about healthy eating. Over 10 months you’ll come with your family to Simple Suppers for 90 minutes once a month. Each session will include sharing a healthy dinner with your family that you helped to make. We will measure your height and weight, and, with the help of a parent, you will tell us about what you eat and drink. Everything you tell us will be kept private. You can stop being in the study at any time.

Would you like to be in Simple Suppers?

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B4. Photograph Release Form IRB No.: 2014B0494 Simple Suppers Date of IRB Release Form for Use of Approval: Photograph/Videotape 1/27/15

Please print:

Name of Participants:

Address:

I am 18 years of age or older and hereby give my permission to Simple Suppers to use any photos or videotape material taken of myself and my children during the Simple Suppers program. The photos and videotape material will only be used for research purposes and for the presentation of the research. My name and names of my children members will not be used in any publication. I will make no monetary or other claim against OSU for the use of the photograph(s)/video. As with all research consent, I may at any time withdraw permission for photos or video footage of me and my children to be used in this research project.

Signature:

Date:

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Appendix C: Questionnaire Data Collection Forms

C1. Demographic Questionnaire Questions 1-6 will ask questions about YOUR CHILD(REN)

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Child Name: 1. How old is your child?  4 years old  5 years old  6 years old  7 years old  8 years old  9 years old  10 years old

2. Is this child a boy or girl?  Boy  Girl

3. Please check () only one box about your child.

ETHNICITY OF THIS CHILD Please check () only one box. Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or  Central American, or other Spanish culture or origin, regardless of race. Not Hispanic or Latino.

4. How would you best describe this child with respect to race?

RACE OF THIS CHILD You may check () more than one box. Black or African American. A person having origins in any of the Black  racial groups of Africa. White. A person having origins in any of the original peoples of Europe,  the Middle East, or North Africa. Alaska native or American Indian. A person having origins in any of the  original peoples of North, Central and South America, and who maintains tribal affiliation or community attachment. Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including for example,  Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. Native Hawaiian or other Pacific Islander. A person having origins in any  of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.  Other. A group not mentioned above. If Other is checked, please describe:

5. What is your relationship to this child? Parent (includes step parent/foster) Grandparent Aunt or uncle Sibling Other, please specify 

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6. On average, how many days of the week does this child live in your home? 1-3 days 4 or more day 7. How many children are under the age of 18 in your home? 1 2 3 4 5 6 or more children

Questions 8-9 are about YOUR SPOUSE

8. Please check () only one box about your spouse.

ETHNICITY OF YOUR SPOUSE Please check () only one box. I do not have a spouse. Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or  Central American, or other Spanish culture or origin, regardless of race. Not Hispanic or Latino.

9. How would you best describe your spouse with respect to race?

RACE OF YOUR SPOUSE You may check () more than one box.  I do not have a spouse. Black or African American. A person having origins in any of the Black  racial groups of Africa. White. A person having origins in any of the original peoples of Europe,  the Middle East, or North Africa. Alaska native or American Indian. A person having origins in any of the  original peoples of North, Central and South America, and who maintains tribal affiliation or community attachment. Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including for example,  Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. Native Hawaiian or other Pacific Islander. A person having origins in any  of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.  Other. A group not mentioned above.

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If Other is checked, please describe:

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Questions 10-22 are about YOU.

10. Please check () only one box about yourself.

YOUR ETHNICITY Please check () only one box. Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South  or Central American, or other Spanish culture or origin, regardless of race. Not Hispanic or Latino.

11. How would you best describe yourself with respect to race?

YOUR RACE You may check () more than one box. Black or African American. A person having origins in any of the Black  racial groups of Africa. White. A person having origins in any of the original peoples of Europe,  the Middle East, or North Africa. Alaska native or American Indian. A person having origins in any of the  original peoples of North, Central and South America, and who maintains tribal affiliation or community attachment. Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including for example,  Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. Native Hawaiian or other Pacific Islander. A person having origins  in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.  Other. A group not mentioned above. If Other is checked, please describe:

12. How old are you? years old 13. Are you a man or a woman? Man Woman

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14. How many adults over the age of 18, counting yourself, live in your home? 1 2 3 or more

15. What is your highest level of formal education? Have not completed high school

133

Received high school diploma or GED Some college or technical school 4-year college, university degree or advanced degree

16. Which of the following best describes your employment status? Homemaker/househusband Not employed Employed part-time Employed full-time Retired

17. Are you a student (either full or part time)? Yes No

18. Are you or your family members participating in the following programs? (Mark all that apply) WIC SNAP (Supplemental Nutrition Assistance Program) or formerly called Food stamps Free/reduced priced school lunch None

19.) What is your annual household income range?

a. Below $25,000 b. $25,000-$44,999 c. $45,000-$64,999 d. $65,000-$84,999 e. $85,000 or more f. Prefer not to answer

20. Where were you born? Ο In the USA Ο Outside of the USA

21. What language do you speak at home? Ο Only English Ο Mostly English Ο English and another language about the same Ο Mostly another language Ο Only another language

22. How long have you lived in the U.S.? Ο 1-5 years Ο 6-10 years

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Ο More than 10 years

135

C2. Household Food Security Screener

Household Food Questionnaire

How often were the following true for your family in the past 30 days:

1. The food we bought just didn’t Sometime Never Often Don’t last, and we didn’t have money s true true true know to get more.     2. We couldn’t afford to eat Sometime Never Often Don’t balanced meals. s true true true know    

In the past 30 days:

3. Did you or other adults in your household ever cut the size of your Yes No Don’t know meals or skip meals because there    wasn’t enough money for food?

If YES, in the past 30 days, how many days did this happen?

______days In the past 30 days:

4. Did you ever eat less than you felt you Yes No Don’t know    should because there wasn’t enough

money for food?

5. Were you ever hungry but didn’t eat Yes No Don’t know

because there wasn’t enough   

money for food?

136

C3. Home Food Environment Questionnaire

Home Food Environment Questionnaire

For each of the items below, please place an “X” in the box that best represents your thoughts or actions.

Over the past 7 days, home many times….. 1. …did all or most, of your family eat dinner together? Never 1-2 3-4 5-6 7 ☐ ☐ ☐ ☐ ☐

2. …did all or most, of your family eat breakfast together? Never 1-2 3-4 5-6 7 ☐ ☐ ☐ ☐ ☐

3. …was at least one parent present when you child(ren) ate dinner? Never 1-2 3-4 5-6 7 ☐ ☐ ☐ ☐ ☐

4. …was dinner prepared at home and eaten together as a family? Never 1-2 3-4 5-6 7 ☐ ☐ ☐ ☐ ☐

5. …was your child(ren) involved in meal preparation? Never 1-2 3-4 5-6 7 ☐ ☐ ☐ ☐ ☐

6. …was a family meal eaten at the table in the dining area? Never 1-2 3-4 5-6 7 ☐ ☐ ☐ ☐ ☐

137

7. …was a separate meal made for your child(ren) because he/she did not like the foods prepared for the rest of the family? Never 1-2 3-4 5-6 7 ☐ ☐ ☐ ☐ ☐

8. …was dinner for the family purchased from a fast- food restaurant, and eaten either at the restaurant or at home? Never 1-2 3-4 5-6 7 ☐ ☐ ☐ ☐ ☐

138

9. …has your child(ren) watched TV while eating meals? N 1-2 3-4 5-6 7 e v e r ☐ ☐ ☐ ☐ ☐

10. …has your child(ren) requested to watch TV while eating meals? N 1- 3- 5- 7 e 2 4 6 v e r ☐ ☐ ☐ ☐ ☐

139

C4. Parent Family Meals Self-Efficacy

Parent Family Meals Self-Efficacy Questionnaire

Date:

On a scale from 0 (not confident at all) to 10 (extremely confident), indicate your confidence in managing the following situations with your child (4-10 years old) concerning dietary habits? Mark an X in the appropriate box to indicate your confidence level.

1. I can make sure my child has healthy dietary habits. 0 1 2 3 4 5 6 7 8 9 10 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Not at all Extremel confident y confiden t

2. I can have pleasant meals with my child. 0 1 2 3 4 5 6 7 8 9 10 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Not at all Extremel confident y confiden t

3. I can plan regular family meals at home. 0 1 2 3 4 5 6 7 8 9 10 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Not at all Extremel confident y confiden t

4. I can make sure that my family has meals together. 0 1 2 3 4 5 6 7 8 9 10

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☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Not at all Extremel confident y confident

5. I can offer my child meals that include fruits and vegetables. 0 1 2 3 4 5 6 7 8 9 10 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Not at all Extremel confident y confident

141

6. I can limit the number of times my family eats away- from-home to once a week. 0 1 2 3 4 5 6 7 8 9 10 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Not at all Extremel confident y confident

7. I can remain calm even when confronted with difficulties at meals. 0 1 2 3 4 5 6 7 8 9 10 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Not at all Extremel confident y confident

8. I can set mealtime expectations at the beginning of family meals. 0 1 2 3 4 5 6 7 8 9 10 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Not at all Extremel confident y confident

9. I can role model healthy dietary habits to my child. 0 1 2 3 4 5 6 7 8 9 10 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Not at all Extremel confident y confident

10. I can keep the TV off during mealtime. 0 1 2 3 4 5 6 7 8 9 10 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Not at all Extremel confident y

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confident

11. I can involve my child in family meal food preparation at least 3 times a week. 0 1 2 3 4 5 6 7 8 9 10 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Not at all Extremel confident y confident

143

12. I can serve well-balanced family meals that include at least 3 food groups. 0 1 2 3 4 5 6 7 8 9 10 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Not at Extrem all ely confide confide nt nt

144

C5. Child Food Preparation Skills

Child Food Preparation Skills (Ages 3-5 years)

Date: Please answer the following questions based on your 3-5 year old child by putting an X in the appropriate box.

1a. When we prepare food at home, my 3-5 year old child is able to set the table Strongly Disagree Agree Strongly Do not Disagree Agree know ☐ ☐ ☐ ☐ ☐ b. Over the past 30 days, my 3-5 year old child set the table… 0 1-2 times 3-4 5-6 7 or more times times times times ☐ ☐ ☐ ☐ ☐

2a. When we prepare food at home, my 3-5 year old child is able to wipe table after mealtime Strongly Disagree Agree Strongly Do not Disagree Agree know ☐ ☐ ☐ ☐ ☐ b. Over the past 30 days, my 3-5 year old child wiped the table after mealtime… 0 1-2 times 3-4 5-6 7 or more times times times times ☐ ☐ ☐ ☐ ☐

3a. When we prepare food at home, my 3-5 year old child is able to grease or spray baking pans Strongly Disagree Agree Strongly Do not Disagree Agree know ☐ ☐ ☐ ☐ ☐ b. Over the past 30 days, my 3-5 year old child greased or sprayed a baking pan… 0 1-2 times 3-4 5-6 7 or more times times times times ☐ ☐ ☐ ☐ ☐

4a. When we prepare food at home, my 3-5 year old child is able to

145

peel fruit (e.g., orange, banana) Strongly Disagree Agree Strongly Do not Disagree Agree know ☐ ☐ ☐ ☐ ☐ b. Over the past 30 days, my 3-5 year old child peeled fruit (e.g., orange, banana)… 0 1-2 times 3-4 5-6 7 or more times times times times ☐ ☐ ☐ ☐ ☐

146

5a. When we prepare food at home, my 3-5 year old child is able to measure dry ingredients Strongly Disagree Agree Strongly Do not Disagree Agree know ☐ ☐ ☐ ☐ ☐ b. Over the past 30 days, my 3-5 year old child measured dry ingredients… 0 1-2 times 3-4 5-6 7 or more times times times times ☐ ☐ ☐ ☐ ☐

6a. When we prepare food at home, my 3-5 year old child is able to measure liquid ingredients Strongly Disagree Agree Strongly Do not Disagree Agree know ☐ ☐ ☐ ☐ ☐ b. Over the past 30 days, my 3-5 year old child measured liquid ingredients… 0 1-2 times 3-4 5-6 7 or more times times times times ☐ ☐ ☐ ☐ ☐

7a. When we prepare food at home, my 3-5 year old child is able to cut soft foods with a blunt knife Strongly Disagree Agree Strongly Do not Disagree Agree know ☐ ☐ ☐ ☐ ☐ b. Over the past 30 days, my 3-5 year old child cut soft foods with a blunt knife… 0 1-2 times 3-4 5-6 7 or more times times times times ☐ ☐ ☐ ☐ ☐

8a. When we prepare food at home, my 3-5 year old child knows when to wash their hands, utensils and cooking surfaces during food prep/cleanup Strongly Disagree Agree Strongly Do not Disagree Agree know ☐ ☐ ☐ ☐ ☐

147

b. Over the past 30 days, my 3-5 year old child independently washed their hands, a utensil or a cooking surface for food safety during food prep/cleanup… 0 1-2 times 3-4 5-6 7 or more times times times times ☐ ☐ ☐ ☐ ☐

148

9. Over the past 30 days, my 3-5 year old child asked to help with food prep activities… 0 1-2 times 3-4 5-6 7 or more times times times times ☐ ☐ ☐ ☐ ☐

149

C6. Parent Anthropometric Form

Parent/Guardian Anthropometric Data Collection Sheet

Weight and Height Assess weight with participants wearing only light clothing and no shoes. Please take two measurements for weight and height.

Weight #1: kg Height

#1: cm Weight #2: kg Height #2:

Waist Circumference Assess waist circumference at the upper crest of the right iliac, with the tape measure parallel to the floor. Please take 2 measurements of waist circumference.

Waist Circumference #1: cm

Waist Circumference #2: cm

FOR OFFICE USE ONLY (not to be completed by

data collection staff) BMI: kg/m2

150

C7. Child Anthropometric Form

Child Anthropometric Data Collection Sheet

Height and Weight Assess weight with participants wearing only light clothing and no shoes. Please take two measurements for height and weight

Weight #1: kg Height #1: cm Weight

#2: kg Height #2: cm

Waist Circumference

Assess waist circumference at the upper crest of the right iliac, with the tape measure parallel to the floor. Please take 2 measurements for waist circumference.

Waist Circumference #1: cm

Waist Circumference #2: cm

FOR OFFICE USE ONLY (not to be completed by

data collection staff) BMI: kg/m2

BMI %:

BMI-Z-score _

151

C8: Block Screener

152

153

Appendix D: Acceptability Data Collection Forms

D1. Focus Group Consent Forms

Focus Group Consent Form- Head Start Staff

The Ohio State University Consent to Participate in Research

Simple Suppers: a novel approach to childhood obesity Study Title: prevention Researcher: Dr. Carolyn Gunther

Sponsor: Cardinal Health Foundation; OSU Seed grant

This is a consent form for research participation. It contains important information about this study and what to expect if you decide to participate. Your participation is voluntary. Please consider the information carefully. Feel free to ask questions before making your decision whether or not to participate. If you decide to participate, you will be asked to sign this form and will receive a copy of the form.

Purpose: Learn about your experiences implementing the Simple Suppers (SS) program to identify program strengths and weaknesses. This information will be used to modify the SS program to make it a more effective and positive program for participants and volunteers.

Procedures/Tasks: You will be asked to participate in a 1 hour focus group interview (in-person) with a SS research staff. During the group interview, you will be asked to answer questions about your experience volunteering with the SS program. Your responses will be audio recorded and transcribed. All identifying information will be removed from the data (audio recording) and the results will be published in aggregate only.

Duration:

154

You may leave the study at any time. If you decide to stop participating in the study, there will be no penalty to you, and you will not lose any benefits to which you are otherwise entitled. Your decision will not affect your future relationship with The Ohio State University. Your participation in this study will consist of a single, 1 hour focus group interview.

Risks and Benefits: The risks of this study are minimal. The benefit is that you will be contributing to improving the SS program to make it a more effective and positive program for participants and volunteers. Confidentiality:

Efforts will be made to keep your study-related information confidential. However, there may be circumstances where this information must be released. For example, personal information regarding your participation in this study may be disclosed if required by state law. Also, your records may be reviewed by the following groups (as applicable to the research):  Office for Human Research Protections or other federal, state, or international regulatory agencies;  The Ohio State University Institutional Review Board or Office of Responsible Research Practices;  The sponsor, if any, or agency (including the Food and Drug Administration for FDA-regulated research) supporting the study.

Please also note that while we ask other group participants to keep the discussion in the group confidential, we cannot guarantee this. Please keep this in mind when choosing what to share in the group setting.

Incentives: You will be compensated with a $25 gift card for your participation in this study.

Participant Rights:

You may refuse to participate in this study without penalty or loss of benefits to which you are otherwise entitled. If you are a student or employee at Ohio State, your decision will not affect your grades or employment status.

If you choose to participate in the study, you may discontinue participation at any time without penalty or loss of benefits. By signing this form, you do not give up any personal legal rights you may have as a participant in this study.

155

An Institutional Review Board responsible for human subjects research at The Ohio State University reviewed this research project and found it to be acceptable, according to applicable state and federal regulations and University policies designed to protect the rights and welfare of participants in research.

Contacts and Questions: For questions, concerns, or complaints about the study, or you feel you have been harmed as a result of study participation, you may contact Dr. Carolyn Gunther at 614-292-5125.

For questions about your rights as a participant in this study or to discuss other study- related concerns or complaints with someone who is not part of the research team, you may contact Ms. Sandra Meadows in the Office of Responsible Research Practices at 1- 800-678-6251. Signing the consent form

I have read (or someone has read to me) this form and I am aware that I am being asked to participate in a research study. I have had the opportunity to ask questions and have had them answered to my satisfaction. I voluntarily agree to participate in this study.

I am not giving up any legal rights by signing this form. I will be given a copy of this form.

Printed name of subject Signature of subject

AM/PM Date and time

Printed name of person authorized to consent for Signature of person authorized to consent for subject subject (when applicable) (when applicable)

AM/PM Relationship to the subject Date and time

Investigator/Research Staff

I have explained the research to the participant or his/her representative before requesting the signature(s) above. There are no blanks in this document. A copy of this form has been given to the participant or his/her representative.

Printed name of person obtaining consent Signature of person obtaining consent

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AM/PM Date and time Focus Group Consent Form- Participants The Ohio State University Consent to Participate in Research

Simple Suppers: a novel approach to childhood obesity Study Title: prevention Researcher: Dr. Carolyn Gunther

Sponsor: Cardinal Health Foundation; OSU Seed grant

This is a consent form for research participation. It contains important information about this study and what to expect if you decide to participate.

Your participation is voluntary. Please consider the information carefully. Feel free to ask questions before making your decision whether or not to participate. If you decide to participate, you will be asked to sign this form and will receive a copy of the form.

Purpose: Learn about your experiences in the Simple Suppers (SS) program to identify program strengths and weaknesses. This information will be used to modify the SS program to make it a more effective and positive program for future participants.

Procedures/Tasks: You will be asked to participate in a 1 hour focus group interview (in-person) with a SS research staff. During the group interview, you will be asked to answer questions about your experience with the SS program. Your responses will be audio recorded and transcribed. All identifying information will be removed from the data (audio recording) and the results will be published in aggregate only.

Duration: You may leave the study at any time. If you decide to stop participating in the study, there will be no penalty to you, and you will not lose any benefits to which you are otherwise entitled. Your decision will not affect your future relationship with The Ohio State University. Your participation in this study will consist only of the single, 1 hour focus group interview.

Risks and Benefits:

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The risks of this study are minimal. The benefit is that you will be contributing to improving the SS program to make it a more effective and positive program for participants and volunteers.

Confidentiality:

Incentives: You will be compensated with a $25 gift card for your participation in this study.

Participant Rights: You may refuse to participate in this study without penalty or loss of benefits to which you are otherwise entitled. If you are a student or employee at Ohio State, your decision will not affect your grades or employment status.

Contacts and Questions:

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For questions, concerns, or complaints about the study, or you feel you have been harmed as a result of study participation, you may contact Dr. Carolyn Gunther at 614-292-5125.

Signing the consent form

I am not giving up any legal rights by signing this form. I will be given a copy of this form.

Printed name of subject Signature of subject

AM/PM Date and time

Printed name of person authorized to consent for Signature of person authorized to consent for subject subject (when applicable) (when applicable)

AM/PM Relationship to the subject Date and time

Investigator/Research Staff

Printed name of person obtaining consent Signature of person obtaining consent

AM/PM Date and time

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D2. Focus Group Scripts

Focus Group Script 1 – Participants **Allow participants to grab food and to fill out a nametag before taking their seats**

PREAMBLE: Good evening and welcome to our session. Thanks for taking the time to join us to talk about the Simple Suppers Program you participated this past school year. My name is Allison Labyk and assisting me is Katie Van Fossen. We are both with The Ohio State University. Katie will be leading today’s session and I will be assisting her and taking notes. Today we will be taking part in a focus group. We will be having a guided discussion to learn more about your thoughts on the Simple Suppers Program.

Before we start, we will begin with the consent forms that I will pass out now. The purpose of the consent form is to explain your rights as a participant in this focus group. It is The Ohio State University’s way of protecting you and your interests. I’m going to briefly go over the form with you, section by section, and answer any questions that you may have. When we are finished, if you are not interested in participating in the project, just let me know. You can keep a copy for your records.

The first part of the form states that your participation is voluntary. Meaning you have made the decision to come here and participate on your own. We ask that you consider the following information carefully. Feel free to ask any questions before making your decision as to whether you’d like to participate. If you do decide to participate, you will be asked to sign this form and will receive a copy of the form.

In the next part of the form, we explain the purpose of this study. We have asked you all to join us today so that we can learn what you thought of the Simple Suppers program we delivered during Family Fridays. We would like to know what you liked, did not like, and how we can improve this program if delivered at Head Start in the future.

Under the Procedures/Tasks section, we explain what we will ask you to do. Today you will be participating in a focus group discussion. We will ask questions to better understand your thoughts and impressions of the Simple Suppers Program. Your responses will be audio recorded. All identifying information will be removed from the data.

The duration section informs that you are able to leave this study at any time. There will be no penalty to you if you decide to stop participating in the study and you will not lose any of the benefits for participation. Your decision will not affect your future relationship with OSU. Your participation, as mentioned above will consist of a single, 1 hour focus group interview here today.

The risks and benefits section states that risks of this study are minimal. The benefit is that you will be contributing to the improvement of our SS program to make it a more effective program for future participants.

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The confidentiality section of the form lets you know that the records of the study are private, no one will be able to identify you from any report we might publish. Only the researchers will have access to the records. We are taping the discussion today and only the researchers will have access to the tapes. To maintain confidentiality we will just refer to you by your first name. It also states that in some rare situations, we may need to release your name as a participant in this group if required by state law.

Under incentives you will see that you will be given a $25 Kroger gift card for your participation today.

Participant Rights outlines the rights you have a participant of this focus group. I will ask you to read this section to yourself, as it summarizes most of what we have read here this evening. Finally, before you begin you will see contact information at the bottom of this form. If you have any questions after you leave today please contact us at the number listed. If you have any questions now we are happy to answer them.

Once you have finished reading the remainder of this form please turn to the final page. We ask for your printed name, signature, and the date and time (June 1st, 4:00p). Only worry about the top 3 lines. The bottom are for participants under the age of 18. We ask that you sign both. They are identical copies so that we may keep one for our records and you may keep one for yours.

FOCUS GROUP QUESTIONS:

9. INTRO: To begin, we will go around the table and name our favorite lesson from the program, feel free to introduce yourself at this time as well? 10. How did you feel about the program overall? 11. What was your favorite part of the… a. parent education b. family meals education 12. What was your least favorite part of the… a. parent education b. family meals education 13. From your point of view, how did your child feel about the program? a. child education b. family meal 14. In what ways, if any, have family meals in your home changed since you and your family participated in SS? a. Do you feel any other changes in your child’s or your own health have happened since you and your family began participating in the program? 15. How did SS compare to other programming you and your family have done during Family Friday? 16. What suggestions do you have to help us make this program more useful in the future?

CONCLUSION:

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We want to thank you all for taking time out of your day to join us for this discussion. Your thoughts on and suggestions for this program are important and will allow us to change and grow this program for future years. Thank you for working with us this past school year, we hope you enjoyed this time as much as we have.

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Focus Group Script 2- Head Start Staff **Allow participants to grab food and to fill out a nametag before taking their seats**

PREAMBLE: Good morning and welcome to our session. Thanks for taking the time to join us to talk about the Simple Suppers Program you helped us run this past school year. My name is Allison Labyk and assisting me is Katie Van Fossen. We are both with The Ohio State University. Katie will be leading the focus group and I will be taking notes.

Before we start, we will begin with the consent forms. The purpose of the consent form is to explain your rights as a participant in this research study. It is The Ohio State University’s way of protecting you and your interests. I am going to briefly go over the form with you, section by section, and answer any questions that you may have. When we are finished, if you are not interested in participating in the project, just let me know. You can keep a copy for your records.

The first part of the form states that your participation is voluntary. We ask that you consider the following information carefully. Feel free to ask any questions before making your decision as to whether you’d like to participate. If you do decide to participate, you will be asked to sign this form and will receive a copy of the form.

Under the Procedures/Tasks section, we explain what we will ask you to do. Today you will be participating in a focus group discussion. We will ask questions to better understand your thoughts and impressions of the Simple Suppers Program. Your responses will be audio recorded and transcribed. All identifying information will be removed from the data.

The confidentiality section of the form lets you know that the records of the study are private, no one will be able to identify a subject from any report we might publish. Only the researchers will have access to the records. We are taping the discussion today and only the researchers will have access to the tapes. To maintain confidentiality we will just refer to you by your first name. It also states that in some rare situations, we may need to release your name as a participant in this group if required by state law.

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Under incentives, you will see that you will be compensated with a $25 Kroger gift card for your participation today.

Once you have finished reading the remainder of this form please turn to the final page. We ask for your printed name, signature, and the date and time (June 2nd, 7:30a). Only be concerned with the top 3 lines. The bottom are for participants under the age of 18. We ask that you sign both copies, they are identical so that we may keep one for our records and you may keep one for yours.

FOCUS GROUP QUESTIONS:

1. INTRO: To begin, if you could all go around and share how long you have been working with Head Start. 2. What was your overall impression of the Simple Suppers program? a. Parent education? b. Family meal? c. Child education? 3. What do you believe the families overall impressions of the program were? a. How do you think the parents felt about the parent education and family meal? b. How do you think the children felt about the child education and family meal? 4. How would you describe your experience in delivering the program? a. What did you think about the format (day, time, and length) b. What did you think about the curriculum (lesson, topics) 5. Did you find this program to be an effective use of Head Start’s time during Family Fridays? Please explain why or why not? 6. What suggestions do you have to help us make this program more effective for families in the future? a. Parent education b. Child education c. Family meal 7. What suggestions do you have to help make this program more effective for the purposes of Head Start Family Friday Programming? i.e delivery, timing, etc… 8. Is this a program something you would enjoy bringing to Family Fridays in the coming years?

CONCLUSION:

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We want to thank you all for taking time out of your day to talk with us about Simple Suppers. Your input will be very important as we move forward in helping us to change and grow this program. We would also like to thank you for allowing us to work with you this past school year; we hope you have enjoyed it as much as we have.

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D3. Acceptability Questionnaire

Simple Suppers Evaluation

Please tell us what you think of Simple Suppers.

1. How would you rate your satisfaction with the Simple Suppers program you just completed?

 Very Unsatisfied  Somewhat Unsatisfied  Somewhat Satisfied  Very Satisfied

2. What would you like to see changed about the Simple Suppers Program? ______

3. Did your child enjoy the Simple Suppers program?

 Yes  No  I am not sure

4. What was your child’s favorite part about the Simple Suppers program? ______

5. In the space below, please include any comments, critiques, questions, or suggestions you have for the Simple Suppers staff. ______

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D4. Fidelity Checklist

Leader (ADULT) ______Leader (CHILD) ______Date ______Session Number ______

Simple Suppers Fidelity Checklist

Core Component Yes No Comment 1. Parent education: review goal from previous week (lessons 3-10) 2. Parent education: Educator anchored topic with an open discussion 3. Parent education: Educator added new information on the topic (provide handouts when applicable) 4. Parent education: Educator applied new information with interactive activity 5. Parent education: Parents planned a family meal for the upcoming week (lessons 3-10) 6. Child education: each child age group completed a specific food prep skill 7. Group family meal: Educator leads nutrition discussion by identifying foods groups in upcoming family meal 8. Group family meal: Educator leads food safety discussion related to upcoming family meal 9. Group family meal: Families complete family meal food preparation 10. Group family meal: Educator guides parents in establishing family meal behavior expectations 11. Group family meal: Families receive take-home bags

12. Child participants are engaged & involved in the program

13. Adult participants are engaged & involved in the program

14. Child Educators create a positive, interactive environment

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15. Adult Educators creates a positive, interactive environment 16. Child Educators exhibit a caring attitude

17. Adult Educators allow time for questions

18. Adult Educators answer questions adequately

Unusual events during the session:

Overall comments:

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D5: Lesson Sign-In Sheet

Simple Suppers Sign-In Sheet Date: ______Lesson: ______Location: ______Parent Educators: ______Child Educators: ______Cooks: ______Name Child Name Child Age

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