April 2011 // Volume 49 // Number 2 // Tools of the Trade // v49-2tt5
Program Review: Raising Healthy Eaters
The prevalence of overweight children and adults has been increasing steadily over the past three decades. Behaviors related to diet and nutrition are often established in early childhood. Toddlers most often develop healthy eating habits through parent modeling. Due to the steady increase in obesity in children, there is a clear need for nutrition and parenting programming that helps parents gain a better understanding of nutrition and feeding habits of children. In this article we review the curriculum Raising Healthy Eaters, a program that integrates parenting and nutrition.
Need for Integrated Parenting and Nutrition Programs
The prevalence of obese or overweight children and adults has been a steadily increasing problem in the U.S. over the last three decades. In 2002, 16.5% of children were considered overweight (Hedley et al., 2004). Although the development of obesity is complex, a major component is poor eating habits. Children tend to have diets low in vegetables, fruits, and milk, and high in sweetened beverages (Lin, 2005). Because behaviors related to diet develop early in life and are modeled by family members, it is critical to begin setting limits and boundaries on eating habits during early childhood (Horodynski & Stommel, 2005).
Parents of overweight or obese children have identified barriers that affect their ability to model healthy eating behaviors for their children. Perhaps the greatest barrier to developing healthy eating behaviors is lack of knowledge, training, and experience. Parents reported that lacking knowledge about nutrition limits their ability to buy, prepare, or introduce their children to healthier foods (Birkett, Johnson, Thompson, & Oberg, 2004). Parents who understand both feeding and nutrition are more likely to help children make healthy food choices (Horodynski & Stommel, 2005). Parents also reported lacking knowledge of normal child development and using food as a parenting tool to calm, reward, and nurture children (Chamberlin, Sherman, Jain, Powers, & Whitaker, 2002). Similarly, parents who have difficulty setting limits with children and who lack knowledge or ability to discipline children tend to give in to their children rather than set limits with their children's diets (Chamberlin et al.).
There is a need for a client-centered program that addresses both nutrition and parenting issues together. Client-centered programs focus on recognizing the client's issues and helping them to explore their feelings and attitudes related to their problem areas (Rogers, 1965). There is a lack of support for low-income parents in basic knowledge of healthy eating habits and parenting skills, including age-appropriate development, discipline, and limit setting (Horodynski & Stommel, 2005). There is a gap in the literature regarding the impacts of using parenting education in nutrition programming. This article is reviews a client-centered program that addresses these problems—Raising Healthy Eaters.
Raising Healthy Eaters was developed by Gayle Coleman, Nutrition Education Program Specialist, University of Wisconsin Extension, and Heather Harvey, Windsor-Essex County Health Unit. The goals of the program are to help parents gain knowledge, skills, and confidence to promote the development of healthy eating habits within their families. The objectives of the program are to reduce sweetened beverage consumption and increase fruit and vegetable intake in children (Harvey & Coleman, 2008). Raising Healthy Eaters emphasizes facilitating group discussions with parents that focus on nutrition, eating behaviors, and parenting.
The Raising Healthy Eaters curriculum is based on the Social Cognitive Theory (SCT), a theoretical framework used frequently with research on dietary determinates. SCT emphasizes the importance of interrelationship among cognitive, socioenvironmental, and behavioral factors (Ball et al., 2009). The SCT constructs of reciprocal determinism, behavioral capability, expectations, self-efficacy, observational learning, and reinforcements were combined with child development, parenting skills, nutrition, and age-appropriate feeding practices.
The Raising Healthy Eaters curriculum is learner-centered and is intended to serve low-income families with children age two to five. Parents in the program learn about helping children develop healthy eating habits, introducing new foods to children, handling choosy eaters, managing mealtime, and preparing quick and easy meals. The curriculum is provided to parents via eight weekly small group lessons.
Evaluation of Pilot Study
Only one study was found that tested the effectiveness of Raising Healthy Eaters (Harvey & Coleman, 2008). The program evaluation targeted low-income parents with children between the ages of two and five. Participants included 29 parents: 27 mothers, one father, and one grandmother (28 females and one male). Participants included 74% white non-Hispanic, 22% Hispanic, and 4% Native American. Eighty percent of participants were in one or more programs for low-income audiences, such as WIC, Head Start, food stamps, and free or reduced-price school meals. Similarly, in a study that focused on the Family Nutrition Program, the majority of participants were female, never married, unemployed, and reasonably educated (Steinhaus, Brunt, Pankow, Garden-Robinson, & Terbizan, 2009).
In the pilot study, University of Wisconsin-Extension Family and Consumer Science educators taught Raising Healthy Eaters in eight weekly 60- to 90-minutes lessons. Participants completed the Feeding Self-Efficacy Questionnaire and the Child-Parent Mealtime Behavior Questionnaire before the first and after the last lessons. Parents were asked to self-report to trained non-facilitator paraprofessionals what their child ate over the last 24 hours. The paraprofessionals used a "three-pass method" to obtain dietary recalls. In a "three-pass method" an interviewer asks a respondent several times over the course of a day to search their memory in order to increase the retrieval of the requested information (Jonnalagadda et al., 2000).
Due to the small sample size, significant changes were not evident in the results; however, participants reported increased knowledge of age-appropriate feeding practices (p<. 05). Participants reported increasing their confidence in offering their child healthy choices and in getting their child to try vegetables and new foods (p< .05). There was an increase in the number of meals when the television was turned off (p<. 01). Participants reported trying new foods with their children, serving smaller portions, and making more healthful choices (Harvey & Coleman, 2008).
Raising Healthy Eaters has been empirically studied once with 29 parents. The curriculum shows some strengths that encourage implementation by Extension faculty. The curriculum is based on Social Cognitive Theory. A pilot study shows promise in reaching the goals of the program, namely to help parents gain knowledge, skills, and confidence to promote the development of healthy eating habits within their families, as seen in the change in age-appropriate feeding practices and increased confidence in providing healthy eating habits. Further research is needed to test its effectiveness with experimental and wait-list control groups and with larger samples of mothers and fathers with different economic classes and cultural backgrounds.
Ball, K., MacFarlane, A., Crawford, D., Savige, G., Andrianopoulos, N., & Worsley, A. (2009). Can social cognitive theory constructs explain socio-economic variations in adolescent eating behaviours? A mediation analysis. Health Education Research, 24(3), 496-506.
Birkett, D., Johnson, D., Thompson, J., & Oberg, D. (2004). Reaching low-income families: Focus group results provide direction for a behavioral approach to WIC services. Journal of the American Dietetic Association, 104(8), 1277-1280.
Chamberlin, L., Sherman, S., Jain, A., Powers, S., & Whitaker, R. (2002). The challenge of preventing and treating obesity in low-income, preschool children: Perceptions of WIC health care professionals. Archives of Pediatrics & Adolescent Medicine, 156(7), 662-668.
Harvey, H., & Coleman, G. (2008). Raising Healthy Eaters: A parenting and nutrition curriculum. Journal of Nutrition Education & Behavior, 40(1), 52-53.
Hedley, A., Ogden, C., Johnson, C., Carroll, M., Curtin L., & Flegal, K. (2004). Prevalence of overweight and obesity among U.S. children, adolescents, and adults, 1999-2002. Journal of the American Medical Association 291(23), 2847-2850.
Horodynski, M., & Stommel, M. (2005). Nutrition education aimed at toddlers: An intervention study. Pediatric Nursing, 31(5), 364.
Lin, B.W. (2005). Nutrition and health characteristics of
low-income populations—healthy eating index. Economic Research Service, USDA. Retrieved from http://www.ers.usda.gov/publications/aib796/aib796-1/aib796-1.pdf.
Jonnalagadda, S., Mitchell, D., Smiciklas-Wright, H., Meaker, K., Van Heel, N., Karmally, W., et al. (2000). Accuracy of energy intake data estimated by a multiple-pass, 24-hour dietary recall technique. Journal of the American Dietetic Association, 100(3), 303-311.
Rogers, C. (1965). Client-centered therapy: Its current practice, implications and theory. Boston, MA: Houghton Mifflin.
Steinhouse, J., Brunt, A., Pankow, D., Garden-Robinson, J., Terbizan, D. (2009). Who attends the Extension Family Nutrition Program in a rural state, and what are the preferences of its diverse clientele? Journal of Extension [On-line], 47(4) Article 4RIB3. Available at http://www.joe.org/joe/2009august/rb3.php