August 2017 Issue

Nutrition Education for Preschoolers
By Christen Cupples Cooper, EdD, RDN
Today's Dietitian
Vol. 19, No. 8, P. 20

Research shows that targeting the overall nutrition environment seems to be most effective for encouraging healthful eating habits among this young age group.

In a preschool classroom in suburban New York, the walls are lined with drawings of fruits and vegetables as well as lists of the children in the class who have tasted each of the foods. The school is Mt. Kisco Child Care Center (MKCCC) in Mt. Kisco, New York, which, like an increasing number of preschools across the United States, has chosen to emphasize healthful eating as a key to learning. MKCCC makes trying new foods a badge of honor. In addition to offering exclusively healthful food and disallowing any branded foods or beverages from the outside, the school boasts a garden and its own in-house chef. Lunches include pasta with a variety of legumes, broccoli, and peppers, and pizza with whole grain crust loaded with fresh veggies. The children eat family style in their classrooms, and most consume the mixed dishes without hesitation. During the meal, teachers engage the students in conversation about how colorful the foods are, how and where the vegetables and legumes are grown, and why each is good for their health.

The importance of good nutrition at preschool is perhaps more important than ever in history. According to the Bureau of Labor Statistics, in 2014, 64% of mothers with children under age 6 are in the workforce. Childcare has become a "home away from home" for more than three-quarters of American children aged 3 to 5. Other sources note that following the recession of 2008, many women with young children took jobs in the low-wage service economy, working for hourly pay and unpredictable, nontraditional work hours. These circumstances created the need to place children in day care more hours during the day on more days of the week. The Institute of Medicine (IOM) reports that for such children, preschool meals can represent the bulk of their weekday nourishment.

In 2010, acknowledging the importance of preschool nutrition, former President Barack Obama signed into law the Healthy, Hunger-Free Kids Act, which revamped meals provided to preschool children under the Child and Adult Care Food Program (CACFP). Similar to the National School Lunch Program, CACFP is a federal food assistance program that subsidizes meals for low-income preschools, including most Head Start programs. The new regulations brought CACFP meals in line with the Dietary Guidelines for Americans so children would receive more servings of nutrient-dense foods such as fruits, vegetables, and whole grains. While some standards of the National School Lunch Program have been delayed under the Trump Administration (eg, schools can now serve 1% flavored milk vs only fat-free flavored milk; schools no longer have to serve 100% whole wheat; and sodium targets have been relaxed), at this writing none of the nutrition standards for the CACFP have changed.

These standards may be just the beginning of what's necessary to get kids eating more of the healthful foods served at preschool. A study by Ball and colleagues in the Journal of the American Dietetic Association in April 2008 found that children consumed only one-third of a serving of fruit and one-quarter of a serving of vegetables per day while in childcare. It seems that bringing more servings of healthful foods to the preschool meal table may not be enough. Research suggests that other factors can help to encourage children to partake of these nutrient-rich foods.

Pam Koch, EdD, RD, executive director of the Laurie M. Tisch Center for Food, Education & Policy at Columbia University in New York City and a research associate professor at Teachers College, Columbia University, states that "Getting good food on the table is crucial to getting young children to eat well. Yet, it's only the first step. Research has shown that other necessary ingredients are adults modeling healthful eating and encouraging students to try new foods as they eat with them, a calm atmosphere and a positive reinforcement approach to discipline during meals and snacks, and nutrition education such as hands-on activities, gardening, and cooking that are creatively designed to motivate and inspire students to eat school meals."

Importance of Guidelines
At the most basic level, there's evidence that teachers' adherence to preschool nutrition guidelines can increase children's intake of healthful foods.1 The Academy of Nutrition and Dietetics, CACFP, the Head Start program, and many local governments across the United States provide recommendations to preschool teachers for creating a positive mealtime environment—one that's conducive to exploring new foods and that allows children to eat according to their own internal cues for hunger and fullness. The recommendations encourage teachers to sit with and eat the same foods as the children, generating conversation about the foods served and acting as positive nutrition role models.

Rachel Blaine, DSc, MPH, RD, director and an assistant professor of nutrition and dietetics at California State University in Long Beach, stresses the importance of role modeling: "Eating is social, and kids are always watching and mimicking what adults in their lives are doing. I would encourage preschool directors and teachers to make meals and snacks fun, low-pressure, and an opportunity to explore, rather than coerce or pressure children to consume foods."

The Head Start program has, from its beginnings in the 1970s, taken a holistic approach to education, ranking good health, good nutrition, and ample physical activity as integral to learning. This health-minded culture and the leadership of Head Start directors may help to reinforce positive nutrition messages and foster a comfortable eating environment in Head Start preschools.

Haley Anderson, RD, CSP, LD, nutrition services coordinator at Reach-Up Head Start in the Minneapolis/St. Paul region agrees that she has learned from experience with her students that it isn't one component but a blend of efforts that make children willing to try new foods and aim for healthful eating.

She believes that as we introduce novel foods, especially vegetables, to children, "we give up too soon before children develop these tastes." She notes that it's important to "take it slow and introduce one new or unfamiliar food at a time along with familiar foods." Role modeling, she notes, also is key to helping children to continue enjoying a variety of foods.

Blaine agrees that multiple opportunities for preschoolers to try new foods is key. "It's developmentally normal for young kids to be picky, but this is often interpreted as a permanent phenomenon. Anyone feeding a preschooler needs to understand that while all of us have likes and dislikes, many of the ones we see in early childhood can naturally be overcome with repeated exposure to foods."

Importance of Professional Development
Professional development on nutrition and feeding young children seems to make a difference in preschool children's food choices. CACFP systematically offers food preparation and service training to kitchen staff. The program doesn't require any formal nutrition training for teachers, but many states have used some of their public nutrition funding sources to develop nutrition training for childcare providers. In some states, Head Start offers nutrition-focused professional development for its childcare providers.2

In a study published in Preventing Chronic Disease in September 2011, Sigman-Grant and colleagues looked at factors that contributed to a supportive nutrition environment. They defined this as "one that offers children adequate nutritious food in a physical and social setting that enhances their development, establishes routines, and maintains trust" and "one in which adults use feeding practices that help children to eat according to their hunger and fullness cues."

In the study, 41% of the variance in teachers' reported practices could be explained by the extent of their nutrition training. "Training" included receiving materials or training provided by CACFP, state food programs, or cooperative extension; reading popular books and magazines; having information provided by a nutritionist; having onsite trainings; having the director or a dietitian deliver the training; and having a director that's proactive about nutrition-related professional development.

However, there's some evidence suggesting that despite training, teachers regularly face barriers to carrying out recommended practices. While most teachers believe good nutrition is key to children's well-being, many report they lack the knowledge and skills to help children make healthful choices.3 Teachers also report that promoting the fruits and vegetables served in CACFP preschools is difficult because these foods may be of low quality or prepared in unappealing ways. A study of 660 preschool teachers in New York City found that many teachers believed that the foods served at their preschool weren't enjoyable and that the children at their preschools also didn't enjoy the foods served; the author has been published on this subject.4

Interventions: What Works in Preschool Nutrition
Several studies suggest that nutrition interventions in preschool and childcare improve children's diets.5-7 A systematic review of the preschool nutrition intervention literature by Mikkelsen and colleagues in the June 2014 issue of Nutrition Journal suggested that most studies on preschool nutrition have targeted children's food preferences, willingness to try new foods, and in-school nutrient intakes.1 Studies that involved educational interventions mainly measured knowledge and attitudes, as well as the intake of some highly nutritious target foods. None of the educational interventions resulted in significant decreases in BMI. Only one study resulted in a significant change in school-day fruit and vegetable consumption, and one study resulted in parent-reported at-home consumption of these foods. Multicomponent interventions, those that involved multiple activities or exposures, tended to have greater impacts.

A study by Williams and colleagues, published in the February 2002 issue of the Journal of the American College of Nutrition, presented the results of the Healthy Start project, which targeted heart health risks among preschool age children. The study evaluated the effects of an intervention that included foodservice modification, especially with the aim of decreasing total and saturated fat in meals, as well as food safety education and a nutrition education curriculum. The intervention targeted a primarily black and Latino group of 787 foodservice workers.

Results were derived from at-school food intake observations and parent reports of children's intake. There was strong evidence of a decreased relative risk of elevated blood cholesterol levels among children with elevated blood cholesterol and strong evidence of a decrease in total blood cholesterol in the two foodservice modification groups compared with the control group.

Research conducted in the home environment with parents and preschool-age children can give some insights into what techniques can effectively encourage children to eat more fruits and vegetables. Some useful techniques include taking a nonintrusive feeding approach, using role modeling, providing choices, taking advantage of teachable moments, and offering warm, responsive comments that can help encourage higher consumption of healthful foods including fruits and vegetables.8 Rewarding children with items like stickers for their agreement to try a new food9 and using negotiation, monitoring, and involvement at mealtimes also are useful.4

One notable study, "Color Me Healthy," published in the March–April 2012 issue of the Journal of Education and Behavior by Witt and colleagues is a preschool curriculum that targets raising fruit and vegetable intake. Witt and colleagues studied 17 preschool sites (10 received the intervention; seven didn't). In all, 263 preschool children participated. The program was implemented for six weeks and included two circle-time lessons of 15 to 30 minutes each, and a food-related imaginary trip per week. A process evaluation assessed the delivery of lessons to the children and the completion of take-home activities. Children were given vegetable snacks at baseline and then after the intervention to determine the amount of fresh fruit and vegetable snacks they consumed. Children in the intervention group increased their consumption of fruit snacks by approximately 31.2% and vegetable snacks by approximately 24.2% between baseline and an assessment performed one week after the close of the study. In addition, children assessed three months after the intervention continued to display an increase in their fruit and vegetable consumption. More research that examines longitudinal effects of such interventions is needed to determine what works best for long-lasting impacts on young children's food intake.

"Eat Well, Play Hard" is an intervention that takes a multilevel approach to increasing young children's consumption of fruits, vegetables, and low-fat and nonfat dairy, and to decrease their time watching TV. The program is offered at CACFP-eligible preschools in 15 municipalities across New York State, including four boroughs of New York City. The preschool-based program consists of 10 lessons for preschool children, 10 lessons for preschoolers' parents, and five lessons for preschool teachers. Dietitians conduct all of the lessons. The lessons for preschool children involve hands-on food experiences and focus on recipes and cooking, mealtime behavior, and physical activity. A USDA evaluation of the program conducted in 2013, which relied on parent reports, resulted in statistically significant increases in children's daily at-home consumption of vegetables, at-home use of 1% or fat-free milk, an increase in reports of the rate of child-initiated vegetable snacking, and a trend towards increased parental offerings of vegetables.

According to a study by Cooke and Wardle, published in the May 2005 issue of the British Journal of Nutrition, exposing children to a variety of fruits and vegetables in early childhood and allowing them to grow their own produce may increase consumption throughout life. A study by Nanney and colleagues, published in the April 2007 issue of the Journal of the American Dietetic Association, suggests that preschool-age children eat more fruits and vegetables when they have experience with gardens. A recent review by Robinson-O'Brien and colleagues in the February 2009 issue of the Journal of the American Dietetic Association suggests that garden-based programs are a promising avenue for increasing fruit and vegetable consumption in school-age children. However, less is known about this approach for younger children, and few interventions have targeted childcare environments, where large numbers of children spend time.

A garden-based intervention by Brouwer and Neelon, "Watch Me Grow," appearing in the April 2013 issue of BMC Public Health, studied the impact of preschool children's exposure to a fruit and vegetable garden, monthly curriculum, and incorporation of the garden's produce into preschool meals. They found that children in the intervention preschools, on average, increased their vegetable intake by one-quarter of a serving, while those in the control group decreased their intake by one-fifth of a serving. And although the intervention schools served smaller quantities of vegetables, their students consumed greater quantities than did control school students. The authors note that there may have been increased acceptance of vegetables exposed to the Watch Me Grow intervention.

Preschools that seek to address nutrition on a multilevel basis and target the overall nutrition environment—providing training to providers, communicating positive nutrition messages to parents, allowing children hands-on experiences with food and growing food, rewarding children for trying new foods, and creating an atmosphere safe for children to explore healthful foods—seem to be the most effective for encouraging healthful eating among this important age group.

— Christen Cupples Cooper, EdD, RDN, is founding director of nutrition programs at Pace University in Pleasantville, New York.

References
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2. Dev DA, Speirs KE, McBride BA, Donovan SM, Chapman-Novakofski K. Head Start and child care providers' motivators, barriers and facilitators to practicing family-style meal service. Early Child Res Q. 2014;29(4):649-659.

3. Gable S, Lutz S. Nutrition socialization experiences of children in the Head Start program. J Am Diet Assoc. 2001;101(5):572-577.

4. Cooper CC. Creating a Home Away From Home: Examining Preschool Teachers' Beliefs, Practices and Feeding Styles, and Associations With Training [dissertation]. New York: Columbia University; 2017.

5. Grantham-McGregor SM, Fernald LC, Kagawa RM, Walker S. Effects of integrated child development and nutrition interventions on child development and nutritional status. Ann N Y Acad Sci. 2014;1308:11-32.

6. Larson N, Ward DS, Neelon SB, Story M. What role can child-care settings play in obesity prevention? A review of the evidence and call for research efforts. J Am Diet Assoc. 2011;111(9):1343-1362.

7. Ward DS, Vaughn A, McWilliams C, Hales D. Interventions for increasing physical activity at child care. Med Sci Sports Exerc. 2010;42(3):526-534.

8. O'Connor TM, Hughes SO, Watson KB, et al. Parenting practices are associated with fruit and vegetable consumption in pre-school children. Public Health Nutr. 2010;13(1):91-101.

9. Shim JE, Kim J, Lee Y; STRONG Kids Team. Fruit and vegetable intakes of preschool children are associated with feeding practices facilitating internalization of extrinsic motivation. J Nutr Educ Behav. 2016;48(5):311-317.e1.