L. Suzanne Goodell, PhD, RD
Department of Food, Bioprocessing, Nutrition Sciences
North Carolina State University

Eugenia T. Goh, MS, RD
The Heart Center,
Children’s Medical Center Dallas

Sheryl O. Hughes, PhD, MA
USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics
Baylor College of Medicine

Theresa A. Nicklas, DrPH
USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics
Baylor College of Medicine

Abstract

Head Start caregivers are responsible for educating and feeding preschoolers enrolled in the Head Start program. Amongst pre-school aged children, portion size served is positively associated with intake of those foods. Researchers conducted eight focus groups with Hispanic and African American Head Start caregivers to identify their attitudes regarding amounts and types of foods served to Head Start preschoolers. Twenty-nine Hispanic and thirty-three African American caregivers participated in the study. Caregivers identified child preference, exposure, and pickiness, child age and size, and hunger and the home environment as key influencers on the amounts and types of foods served to Head Start children. Extension agents should be aware of caregivers’ attitudes regarding their influence on child food consumption and teach these caregivers appropriate behavior modeling and affirmation techniques.

Keywords: preschool, Head Start, focus group, nutrition

Introduction

Childhood obesity is one of the greatest health crises the US faces today. Over twelve percent of preschool-aged children (2 to 5 years of age) are obese (greater than or equal to the 95th percentile of BMI-for-age) (Ogden, Carroll, and Flegal 2008). The prevalence of obesity increases as age increases (Ogden, Carroll, and Flegal 2008), signifying that prevention of childhood obesity should begin at an early age. While the prevalence of childhood obesity is increasing among all demographic groups, low-income populations and Hispanics and African-Americans are at greater risk (Hedley et al. 2004). Among 2 to 5 year olds, 26.7% of Hispanic boys and 25.6% of African-American girls are overweight (greater than or equal to the 85th percentile of BMI-for-age) or obese (Hedley et al. 2004). Cooperative extension faculty and staff will likely encounter childhood obesity in their communities and need to be aware of the many different factors impacting this health concern. One factor contributing to childhood obesity is food intake and eating patterns.

Children’s eating patterns are initiated early in life (i.e., 2 to 5 years of age) (Cashdan 1994; Birch 1992; Birch et al. 1990), indicating that the pre-school age represents a sensitive period in development during which healthful eating patterns may be fostered. Evidence suggests that by the time children are 3 or 4 years old, eating is no longer hunger-driven but is influenced by children’s increased responsiveness to environmental cues regarding food intake (Blundell and Stubbs 1998). Exposure to larger portion sizes is one strong environmental cue that is positively associated with increased intake of those foods (Roe, Morris, and Rolls 2001; Rolls, Engell, and Birch 2000; Fisher et al. 2007). While USDA’s Child and Adult Care Food Program dictates minimum standard portions sizes to be served to children, little is known about other factors that may determine the portion sizes to which young children are routinely exposed.

Traditionally, the family was the primary influence on the eating behavior of the pre-school aged child (Wardle 1995; Hursti 1999; Burroughs and Terry 1992; Skinner et al. 1998). However, as the number of young children who eat outside of their parents’ care continues to grow,childcare settings constitute an increasingly important social environment in which food-related behaviors of young children develop (Burroughs and Terry 1992; Wright and Radcliffe 1992). Childcare feeding practices have important implications for the development of eating patterns, particularly those practices involving portion size. While the Child and Adult Care Food Program and healthcare professional organizations like the American Dietetic Association (Nicklas and Johnson 2004) provide child feeding guidelines for childcare professionals to follow, educators cannot assume that caregivers strictly adhere to these protocols. For the purpose of this study, researchers focused on understanding caregivers’ attitudes and behaviors regarding feeding practices, including portion sizes served to children at Head Start. Researchers defined “caregiver” as an individual employed by the Head Start facility to take care of the 3-to-5 year old children; this includes both primary and assistant teachers.

Methods

Sampling

The research team conducted eight focus groups with a convenience sample of 62 caregivers employed by Head Start to identify attitudes regarding feeding practices, including portion sizes served to pre-school aged children. From the team’s previous work and others’ (Morgan 1998), researchers determined that eight focus groups were sufficient to reach the point at which the researchers do not hear anything new from additional caregivers. Prior to implementing the study, Baylor College of Medicine Institutional Review Board approved the protocols, informed consent forms, recruitment materials and evaluation procedures.

The research team conducted eight focus groups, four conducted with African American (AA) and four with Hispanic caregivers employed by Head Start. The research team recruited caregivers at their place of employment in Houston, TX. Each focus group was conducted at a different site. In order to participate in a focus group, each participant had to be a caregiver employed by Head Start and identify themselves as belonging to the target ethnicity. The Hispanic caregiver focus groups were conducted in Spanish; the four AA focus groups were conducted in English. Group size ranged from six to 13 caregivers with an average group size of eight. A total of thirty-three AA and twenty-nine Hispanic caregivers participated in the study.

To better understand caregiver responses, it is important to know that all Head Start centers included in this study followed the USDA’s Child and Adult Care Feeding Program standards and that these Head Start centers also encouraged children of all ages to self-serve. While children were encouraged to self-serve, caregivers, against the Child and Adult Care Feeding Program recommendations, added food to children’s plate and encouraged others to remove what they believe is excess food from their plate before eating. Additionally, center cooks prepared what they estimated to be adequate amounts of food for at least one serving each. The amount of excess available for additional servings varied from meal to meal and center to center.

Qualitative Methodology

Standard focus group protocols were followed (Krueger 1994). A trained moderator and assistant conducted each 90-minute, audio-tape recorded focus group. Since a moderator of the same ethnicity as the participants usually increases the willingness of participants to respond, the ethnicity of the focus group moderators and participants were matched (Krueger 1994). The assistant took notes and recorded body language and other potentially relevant information not possible to collect with a tape recorder.

Moderator Guide

The research team developed a moderator script containing open-ended questions with probes to help guide the discussions and to ensure consistency across groups. Researchers generated questions that addressed caregiver’s attitudes about feeding practices and portion sizes served to pre-school aged children at Head Start. Moderator guide questions were cognitively tested with the target audience before the full research design was implemented. Below we have included the moderator guide questions relevant to this research:

• What is your opinion of the serving sizes on the menus? Is it too little or too much?
• The amount of food a child gets might differ from child to child. What about the kid individually that affects the amount of food he/she gets?
• Think about a child who gets less food than other children, why do you think this happens?
• Think about a child who gets more food than other children, why do you think this happens?
• What are some things that you have done or said that might have influenced a child to get more or less food?
• How much food should overweight children in your class get for lunch?
• How much food should underweight children in your class get for lunch?
• If you have some concern about the amount of food a child in your class has available at home, how might you treat this child differently at lunchtime?

Analytic Strategy

A certified professional transcription agency transcribed and translated the focus group audio-recordings verbatim, and the moderator or assistant from each group reviewed the transcripts for accuracy. Researchers sent the transcripts to a reputable qualitative research consultant group, DataSense, to code and summarize the data. To facilitate data coding, retrieval, and analysis, the consultant group utilized the qualitative software analysis program NVivo 2.0 (Morgan 1998). A research analyst not involved in project development or data collection (primary research analyst) and the moderator for the Hispanic focus groups independently coded and analyzed all data using directed content analysis (Hsieh and Shannon 2005).

Findings

Researchers found similarities in themes between the two ethnicities; therefore, findings from Hispanic and AA caregiver focus groups will be reported together unless otherwise stated. While some caregivers believed that the portion sizes served at the Head Start centers were adequate, most caregivers felt that what they believed to be mandated portion sizes were too small because most children were still hungry after eating the first serving. Caregivers reported that child preference, exposure and pickiness, size, and hunger and the home environment influenced the amount of food the child received on their plate and consequently ate. Caregivers believed they greatly affected what and how much a child ate during lunch.

Child Preference, Exposure and Pickiness

Caregivers reported that preference, previous exposure, and pickiness impacted how much of a particular food was served to a child or that a child served themselves. Caregivers based their portion size on history of how much they think the child will eat and food preference impacted how much a child ate, thus food preference impacted portion sizes served. The caregivers stated that in general the children preferred main dishes, fruits, and breads or starches over vegetables.

The caregivers at Head Start told the moderator that presentation and preparation of the food impacted how much of a food was put on a child’s plate. “Appearance has to do a lot with what they’ll eat, and some of the vegetables that we serve aren’t the best looking.” Caregivers stated that appearance, smell, and taste discouraged serving or consumption of many types of vegetables. While students were required to put each food item on their plate, caregivers did not encourage the children to eat foods that appeared unappetizing to the caregivers.

Caregivers used the term “picky eaters” to describe children who did not eat as much as the other children or who would only eat certain types of foods, limiting the variety in their diet. Caregivers said they served these children less food than their peers, because “they are picky eaters; it’s going to go to waste.” Knowing that the amount of food available to a whole class was limited and not wanting any child to go hungry, one Head Start caregiver said, “I [serve] the ones I know that eat a lot, I start with them first. And those who don’t eat a whole lot or those who are the picky ones they get served last.”

Size

The portion sizes caregivers served to underweight children varied among caregivers. Some caregivers reported they fed underweight children more than the other children. One caregiver said, “If I see a kid that I think is underweight…if I see them eating something, I’m really going to put some more [of that food] on [the plate] for them.” On the other hand, others stated they served underweight children smaller portions, because they ate less. A third group of caregivers believed they served the underweight child the same amount of food as all other children.

When asked, most caregivers said that childhood overweight was a serious concern for them. However, portion sizes served to overweight children differed greatly between caregivers. Some said they served overweight children more, because the caregivers believed the children eat more food than their normal weight peers. “In all honesty, I would give them a little more [than the normal weight kids].” Others reported serving overweight children smaller portions, because the caregivers believed the children did not need the food or because they were instructed by the parents to restrict intake. For example, one caregiver stated, “Well, I have one child, she’s overweight, and the mom say, okay, don’t give her any more food because the doctor says she needs to go on a diet.” A few caregivers reported they tried to restrict or limit certain types of foods (main dishes and starches) and encouraged overweight children to eat other foods (fruits and vegetables). Still, others said they served these children the same portion sizes as their normal weight peers.

Hunger and the Home Environment

Pervasive throughout all focus groups, the caregivers voiced concern about child hunger due to lack of food availability at home. One caregiver worried, “Maybe they didn’t eat dinner at home, so they come in hungry.” Caregivers stated they gave children more food at lunch if they suspected the child did not have enough to eat at home. One concerned caregiver explained, “Some children don’t eat well at home. Sometimes [Head Start lunch] is the only food they eat.” The caregivers recounted stories of going to the kitchen to get more food for those who were still hungry, allowing the children to put extra food in their pockets to take home, and putting extra food on the children’s plates before they asked for more. Caregivers felt it was their obligation to provide extra food to those children whose parents could not or did not provide enough food at home.

Caregiver Influence on What and How Much a Child Eats

Caregivers believed they had great sway over what and how much a child ate. With a few exceptions, the caregivers employed by Head Start viewed modeling good eating behaviors as an obligation no matter how they really felt about the foods being served. “You have to make certain sacrifices in order to model for them, to show them it’s okay.” However, some put limits on their role modeling capabilities. One caregiver stated, “I can’t make someone eat something that I don’t like. I don’t think that is fair, it is not comfortable for me.” Caregivers said they modeled eating vegetables, “because [the children] are actually waiting to see what you do before they start eating, unless it’s something they really like.” The caregivers said the children ate more types and amounts of these foods, because caregivers modeled eating fruits and vegetables:

“A lot of our kids in the beginning, like zucchini and squash, they wouldn’t try, but it was like, oh we ate it and then they was like, okay, well, let’s try. Oh it is good, it is good. So you being the caregiver you do have to model behavior you want them to exhibit later on which is good nutrition and trying different things.”

Not only did the caregivers model healthy eating behaviors, they also verbally encouraged their students to eat fruits and vegetables, explaining the benefits of eating fruits and vegetables to children. One caregiver explained, “Repeat to them to eat carrots because they are going to be healthy and strong and that they are going to have beautiful sight, and broccoli to have beautiful faces and so on.” Playing on the power of media, the caregivers also provided the students with examples of how cartoon characters ate fruits, vegetables and milk.

“In my class the majority of kids, they like Spiderman a lot. So I tell them that Spiderman likes to eat spinach and Spiderman told me that he drinks his milk and so on. So they start because Spiderman drinks it and they start showing their muscles.”

Trying to make vegetables more appealing, caregivers said they would say positive things about the taste of the foods, including comments like “yum”, “this tastes good”, and “oh, I like this!” Although one caregiver said she told the children to eat all the food on their plate and “make a happy plate”, most caregivers stated they “encourage kids to eat a little bit of everything that is on the plate. At least to taste it.”

Discussion

The purpose of the current research was to determine caregivers’ attitudes and behaviors about feeding practices, including portion sizes served to children at Head Start. During the focus groups, the caregivers employed by Head Start revealed that they varied portion sizes served to the children based on their perception of individual child preferences and pickiness, child size, child hunger and the home environment. If a caregiver believed a child would eat more or less, the caregiver would vary their serving sizes accordingly. Caregiver assumptions about child food consumption were based on prior experiences with the child along with external factors, including the child’s hunger cues. Both the AA and Hispanic caregivers reported the same attitudes about the influences of portion sizes they served to the children in their care. Believing in the importance of setting a positive example, caregivers repeatedly discussed their influence on child consumption through behavior modeling and verbal encouragement.

When designing professional development training for Head Start caregivers, educators should be aware of caregiver beliefs and attitudes toward feeding preschool-aged children and adapt their messages accordingly. The caregivers in this study reported serving children larger portions or smaller portions based on experience of what individual children ate at previous meals. Caregivers believed several factors impacted what the children would eat, including child food preferences. They reported that if a child liked a food a lot, the child would eat more of that food; therefore, the caregiver served the child more of that food initially. Confirming caregiver beliefs, Rollins and Birch found quantitatively that young children eat more when they like the food than when they express a dislike or no preference for the food (2007).

Coupled with this, caregivers also reported serving children they designated as picky eaters smaller portions than their peers, because they believed the children would eat less and they did not want to waste food. Food neophobia, or fear of new foods, is common among preschool aged children. Some people might equate food neophobia to picky eating. In preschool-aged children, food neophobia can result in a decreased preference for foods, particularly vegetables, meats, and fruit (Russell and Worsley 2008). This decreased preference for a certain food group might then lead to a decreased intake of that food group (Rollins and Birch 2007). Based on this evidence, Head Start caregivers’ evaluation of child food consumption patterns appears to be correct and thus serving smaller or no portions of certain foods to children with food neophobia would be justified. However, one crucial piece of information is missing from this understanding of child food preferences and food intake. Children may need multiple exposures to a novel food before they learn even accept the food as part of their diet (Williams et al. 2008; Birch 1998).

A handful of studies have investigated the impact of teacher modeling on child food consumption. Similar to the caregivers from this study, Hendy and Raudenbush found that out of five behaviors, pre-school teachers rate modeling as the most effective teacher action in influencing children’s food acceptance (2000). Yet, silent teacher modeling alone is ineffective in promoting acceptance of novel foods (Hendy 1999; Hendy and Raudenbush 2000); enthusiastic teacher modeling (Hendy and Raudenbush 2000) and reward (Hendy 1999) improve children’s food acceptance.

Limitations

The qualitative results from this study may not be generalizable beyond the attitudes of AA and Hispanic caregivers employed by Houston Head Start. Additional studies should be conducted to compare this study’s findings with outcomes from other populations. While the results of this study may not represent the attitudes of those caregivers employed by Head Start who chose not to participate in the focus group discussions, the investigators believe the results reflect the majority opinion of AA and Hispanic caregivers in this setting.

Conclusions

According to their own accounts, the caregivers varied portion sizes served to the children based on their perception of individual child preferences and pickiness, child size, child hunger and the home environment. Applying the information presented, the researchers plan to establish how caregivers’ knowledge, attitudes, and behaviors impact portion sizes through additional studies. Continuing the logical flow of research, investigators will also determine how these portion sizes influence child food consumption. When discussing childhood obesity with caregivers of children from low-income families, county extension educators should be aware of the factors that impact caregivers’ feeding decisions. To be sensitive to the cultural and socio-economic needs of the community, county extension educators could tailor their nutrition educational approaches by applying these research findings.

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