Effects of Healthy Eating Promotion on Food Preference of Head Start Preschoolers

Objective: The healthy eating promotion strategies within the “Míranos” (Look at US, We Are Healthy) program aimed to increase fruit and vegetables (FV) intake, decrease sugary drinks while increase water consumption; as well as decrease energydense foods intake among preschoolers in Head Start Centers. Design: “Míranos!” was a one-school year intervention using a quasi-experimental pre-test/post-test design with two treatment groups and a comparison group. Two centers received a centerbased intervention (T1), one center received a combined centerand home-based intervention (T2), and one center served as comparison. Healthy eating was promoted through classroom nutrition education, fruits and vegetable (FV) tasting, healthy eating contest and peer-parental nutrition education. Children’s food preference was measured. GLM Univariate procedure was used to determine intervention effect. Setting: Head Start Centers Subjects: Study subjects were predominantly MexicanAmerican preschoolers (n = 356; mean age = 4.1; 62% in normal weight range) enrolled in the participating Head Start Centers Results: Compared to the comparison group, T1 had significantly higher preference scores for FV (p<0.05), while T2 had significantly higher preference scores for FV and water (p<0.05). Conclusions: The “Míranos!” Program effectively improved preschoolers’ preference in healthful foods. The combined center-based and home-based approach appears more promising than the center-based intervention alone. Word count: 205

Larson et al. 2011) In the USA, Head Start is a federally funded early childhood education program for nearly one million low-income preschool children with one third being overweight and obesity.Head Start programs provide comprehensive services to enrolled children and their families including health, nutrition, and social services. (The Office of Head Start (OHS) 2014) Head Start Programs present a promising venue for obesity prevention interventions among high risk Hispanic preschoolers.Birch and Ventura 2009) As such, a comprehensive primary obesity prevention program "MIRANOS!" (Look at US, We Are Healthy) was implemented in Head Start Centers in San Antonio, Texas from September 2010 to April 2011.The effectiveness of the program on primary outcomes including BMI, physical activity level and food intake during lunch was reported by Yin et al. (Yin et al. 2012) The present paper specifically reports the healthy eating intervention strategies and their effects on Head Start preschoolers' food preference.

Overview of "Míranos!" Study Design
"Míranos!" was a one school-year culturally tailored, multicomponent prevention intervention to promote healthy weight gain and gross motor development in low-income preschoolers. (

Descriptions of Healthy Eating Promotion Intervention Strategies
Hesketh and Campbell 2010)   2012) The following is a specific description of the healthy eating intervention behavioral goals and strategies.
The healthy eating behavioral goals included increasing fruit and vegetables (FV), decreasing sugary drinks consumption while increasing water consumption; as well as decreasing energy-dense foods.Healthy eating was promoted through multiple strategies including Head Start staff development, classroom teaching, food tasting, and healthy eating contest in both the center-based (T1) and combined intervention groups (T2).Peer parental nutrition education was only implemented in the combined intervention group (T2).

• Food tasting
In an effort to repeatedly expose preschoolers to healthy foods that they learned in the classroom, fresh fruit and vegetables were served as snacks during afternoon snack time.Food tasting activities were implemented once per week for four consecutive weeks.The food items served were coincidently with the teaching topics of the Sesame Workshop's Healthy Habits for Life curriculum.For instant, a colorful rainbow FV tray was served when children explored the "wonderful and colorful foods" in Chapter 1.The FV items selected were based on their availability in local grocery stores, while not commonly served to Hispanic preschoolers such as broccoli, Kiwi, blueberries etc.One serving of either colorful fruits or vegetables was served at each food tasting events.
Teachers were encouraged to serve as a role model by eating healthy foods, using water bottles for water, and avoiding soda in front of preschoolers.Teachers also reminded preschoolers of what they have learned from the Sesame Workshop curriculum.

Parental Nutrition Education
Míranos! aimed to create a home environment conducive for healthy eating and physical activity by providing a homebased intervention at one center-the combined center-and home-based intervention.The objective was to increase health literacy on obesity, nutrition, physical activity among parents and family members and providing at-home activities.A peer-led model was used to promote healthy eating among parents in the combined intervention group.Head Start centers require parents/guardians to physically sign their child in and out of class.Seizing on this opportunity to engage parents, seven parents were trained as peer educators to deliver an educational series on obesity prevention to other parents/guardians during dismissal time.Specifically, peer educators received nutrition education training prior to delivering the messages to their peer parents through a weekly "health fair" style education in the hallway during child pick up time.Three hallway "health fairs" were designated to cover key nutrition messages including the MyPlate food groups and serving size, "water instead of soda", and ways to encourage FV consumption among preschoolers.
Peer educators approached parents as they arrived to pick up their child and invited them to view the posters.When parents agreed, they were escorted to the area inside the center where the posters were set up.Parents visited posters, interacted with parent peer educators, completed an information scavenger hunt worksheet and received a Take-Home Bag with a story book from class, healthy eating tips and family activities (e.g., making a healthy snack, using the water bottle for drinking water).Parents also received a different healthy snack (a piece of fresh fruit or a whole grain granola bar) after viewing the posters.It took 5 to 10 minutes for parents to complete these activities.

Outcome Measures Related Healthy Eating Promotion
Jaramillo et al. 2006) This is an animated computer program measuring preschoolers' preference of fruits, vegetables and juices by asking them if the food item tasted "yummy," "yucky," or just "okay."The instrument show adequate testretest reliability (r = .70;p < .01)Jaramillo, Yang, Hughes, Fisher, Morales, & Nicklas 2006) For the purpose of the current study, two additional questions regarding water and milk were added into the testing process.Jaramillo, Yang, Hughes, Fisher, Morales, & Nicklas 2006) The measure can be used to yield an overall food preference score or to yield separate preference scores for fruits, fruit juices, vegetables, water and milk.Jaramillo, Yang, Hughes, Fisher, Morales, & Nicklas 2006) Due to limited availability of touch-screen computers, food preference data were only collected from a sub-sample.Each center designated one class (the one with the highest enrollment) to take part in the food preference assessment at baseline and endpoint.

Data analysis
Food preference scores were summed up to generate sub-food group scores (water, milk, fruits, vegetables, juices, French fries etc.).Data were analyzed using SPSS Statistics 21.0 (Armonk, NY: IBM Corp, 2012).GLM Univariate procedure was used to determine intervention effects on food preference scores between the two treatment group preschoolers and comparison preschoolers from post-test controlling for gender and pre-test measure.Significance level was set at p < .05 with two-tailed test.

Results
Among the 356 preschoolers in the participating Head Start Centers, 91% of parents gave informed consent at baseline (n=323) and 88% remained at endpoint (n=284).A sub-sample of 120 preschoolers were assessed for Food Preference, with 106 completed both pre-and post-test (88% retention).
Table 2 shows that preschoolers in the center-based intervention group (T1) had a marginally higher water and milk preference score than those in the comparison group (Table 2).
The combined intervention group (T2) also had a marginal higher milk preference score and a significantly higher water preference score than the control group.Schindler, Corbett, & Forestell 2013) In the current context, we used healthful food tasting events coinciding with topics in the Sesame Street Healthy Eating Lessons, along with healthy eating contests and parental nutrition education to promote healthier eating behaviors.These strategies may all contribute to the favorable changes in healthful food preference, but not healthy foods, as children's preference toward French Fries in the current study remains relatively high, i.e., 1.7 out 2 ("Yummy").De Lira-Garcia et al. 2012) Preschoolers' preference toward healthful foods in the current study was further reflected by the lunch food intake patterns.Noradilah & Zahara 2012b) It is also important to explore if the combined center-and home-based intervention (T2) results in a greater impact on preschoolers' eating preference and behaviors than the center-based alone intervention (TI).The magnitude of changes appears greater in the center-and home based intervention group than the centerbased alone group, showing the importance of parental and family influences on children's preferences toward healthful foods.Yin, Parra-Medina, Cordova, He, Trummer, Sosa, Gallion, Sintes-Yallen, Huang, Wu, Acosta, Kibbe, & Ramirez 2012) Given the fact that preschoolers' eating patterns are largely under the influence of their parents, (Klesges et al. 1986) combining center-and home-based intervention is more likely to sustain children's healthy eating behaviors.The peer parental nutrition education in the current study certainly may have contributed in increasing parental health literacy and skills, resulting in a healthier home food environment which is conducive for preschoolers' growth and development.
There were a number of limitations associated with this study.First, the study used a quasi-experimental design which may compromise internal validity.Second, due to a limited availability of touch screen computers, only a sub-sample of study subjects was assessed for food preference.The relative small sub-sample size limited statistical power in detecting intervention effect on food preference scores.Third, preschoolers' dietary intake at home was not assessed.

Conclusions
The "Míranos!" Program effectively improved preschoolers' preference in healthful foods.The combined center-based and home-based approach appears more promising than the center-based intervention alone.Future research should further develop intervention means to undo children's preference toward unhealthy foods.

Table 1 : Sesame Workshop's Healthy Habits for Life Healthy Eating Topics Chapter Topics Chapter 1: Nutritious and Delicious!
Children explore wonderful and colorful foods.