EARLY HEAD START – MICHIGAN STATE UNIVERSITY

Final PARTNERSHIP MEETING

Culturally Sensitive Measurement of Toddler – Parent Mealtime

Behaviors

Funded By: The Office of Planning, Research and Evaluation of the Administration of Children and Families (OPRE/ACF), Grant Number: 90-YF0046

Principal InvestigatorMildred A. Horodynski, Ph.D., R.N.C.1

Co-InvestigatorsManfred Strommel, Ph.D.1

Holly Brophy-Herb, Ph.D.2 Lorraine Weatherspoon, Ph.D., R.D. 3

1 College of Nursing2 Department of Family and Child Ecology3 Department of Food Science and Human Nutrition

Research Team

Funded By: The Office of Planning, Research and Evaluation of the Administration of Children and Families (OPRE/ACF), Grant Number: 90-YF0046

• Capital Area Community Services (CACS-Lansing) Early Head Start, Jump Start, Early Childhood Programs

• Carman-Ainsworth (Flint) Early Head Start• City of Detroit Early Head Start• Eight CAP Early Head Start Site • Genesee County Community Action Resource Development (GCCARD)

Early Head Start • Jackson County Community Action Agency Early Head Start • Mid-Michigan Community Action Agency (MMCAA) Early Head Start

Sites • Northeast Michigan Community Service Agency (NEMCSA) Early Head

Start Sites

Acknowledgment To Our Early Head Start Partners

Acknowledgment To Our Data Collectors

County/Site Data Collectors

Capital Area Asha Barber; Michelle Henry

Eight-CapLinda Smith; Valecia Bryner; Shelley Edlinger; Megan Smith; Sarah Stockton

Flint Linda Campbell

JacksonNichole McColley; Evon Beavers; Priscilla Birch; Nichole McColley

Mid-Michigan

Renee Bisel; Shawna Kennedy; Brandi McClenathen; Lori Rosenberger; Sarah Stockton; Leah Doyle; Brandi McClenathen

NEMCSAMarion Eagling; Maureen Liden; Heather Reed; Angie Burkey; Shelley Edlinger

Wayne Patricia Barnes; Maya Callowa

Other Deb Jones; Latesha Thomas

Special Recognition of our Participants

199 African American Mother-Toddler Dyads

&

200 Non-Hispanic White Mother-Toddler Dyads

Who Participated in this Research Study

Outline of the Presentation

• Celebration of the Project

• Summary of the Key Findings

• Nutrition Assessment for Toddlers--- Assessment Tools

Celebration of the Project

• Collaborative research study designed to develop culturally sensitive measures for assessing parent – toddler mealtime feeding behaviors.

Purpose

• Develop culturally appropriate measures (Phase I)

• Test the psychometric properties of the tailored instruments (Phase II)

• Provide evidence of validity of self-report mealtime behavior with direct mealtime observation (Phase II)

• Develop a training manual and provide training and technical support to Early Head Start Programs (Phase III)

Specific Aims

• 3 Phases:– Phase I = Focus Groups– Phase II = Survey & Instrument Validation– Phase III = Nutrition Assessment

Study Design

• Two focus groups with 27 African American mothers with toddlers, 12 to 36 months of age.

• Goal: Assess cultural appropriateness of the Toddler-Parent Mealtime Behavior Questionnaire.

Phase I: Focus Groups

• Instrument validation with 399 EHS mother-toddler dyads

-199 African American Mother-Toddler Dyads

-200 Non-Hispanic White Mother-Toddler Dyads

Phase II: Survey

• Development of NEAT Toolkit (NEATT) for EHS staff to assess toddler:

1) Current dietary intake

2) Eating/feeding behaviors

3) Eating/feeding concerns/problems

4) Food safety

5) Physical activity level

Phase III: Nutrition Assessment

Key Findings

• 399 mother-toddler dyads: 199 African American and 200 Non-Hispanic White

• Mean Age: 27 years for mothers (15-66 years) and 25 months for toddlers (11-47 months).

• 96% were mothers, 2% grandmothers, 2% other relatives• 71% were single• 58% had no education beyond high school • 46% did not work outside of the home, 20% worked full-time,

16% were employed part-time, and 18% were students• 66% of the families had annual income lower than $20,000.

Participant Characteristics

X

X X

X

  African American (N= 199)

Non-Hispanic White(N=200)

Mother’s Age 

= 27 (±8.3) (yrs) = 28 (±7.5) yrs

Range = 15 – 62 Range = 17 – 66

Toddler’s Age 

= 25 (±8.7) (mths) = 25 (±7.9) (mths)

Range = 12 – 48 Range = 12 – 48

High School 53 (27%) 89 (45%)

Unemployed 81 (46%) 102 (54%)

Toddler CDC Percentile >85

94 (47%) 82 (41%)

Mother’s CESD > 16 62 (27%) 54 (31%)

Adult Cohabitation 165 (83%) 190 (96%)

Additional Child(ren) 146 (73%) 146 (73%)

Characteristics of Study Participants (* p<0.05)

Mothers’ Body Mass Index (BMI)

•<18.5 = Underweight

•18.5 --- 24.9 = Average Weight

•25 --- 29.9 = Overweight

•> 30 = ObeseBMI: Mothers

1

14

25

50

1

12

26

60

0

10

20

30

40

50

60

70

Underweight Average Weight Overweight Obese

Pe

rce

nta

ge

s

African American

Non-Hispanic White

Toddlers’ Body Mass Index (BMI)•< 5% = Underweight

•5th --- 84th % = Average Weight

•85th --- 94th % = At Risk of Overweight

•> 95% = Overweight

CDC-Weight-Height-Percentile: Toddlers

5

21

10

14

2

27

8

13

0

5

10

15

20

25

30

Underweight Healthy Weight At Risk of Overweight Overweight

Pe

rce

nta

ge

African American

Non-Hispanic White

Key Findings--- Nutrition Patterns

Comparison of African American and Non-Hispanic White Mothers’ Food Consumption

Frequency of Type of Food Consumption by Race: Maternal

1.3

3.6

2.5

2.8

2.5

2.1

1.6

1.8

1.5

0 1 2 3 4# if Times More Frequently Food was Consumed

NonHispanic White

African American

Comparison of African American and Non-Hispanic White Toddlers’ Food Consumption

Frewuency of Type of Food Consumption by Race: Toddler

2.1

2.2

1.5

1.5

2.3

1.9

1

1.7

1.1

0 0.5 1 1.5 2 2.5

Typ

e o

f F

oo

d C

ateg

ory

# of Times More Frequently Food was Consumed

NonHispanic White

African American

Key Findings--- Factors Predicting Quality of Toddlers’

Food Consumption

• Mothers’ healthy food consumption predicted in toddlers’ healthy food consumption.

-When mothers consumed more healthy foods, toddlers consumed more healthy foods.

Factors Predicting Quality of Toddlers’ Food Consumption

Healthy Foods include:• Vegetables• Fruits• Unsweetened cereal• Plain water

• Race, toddler’s age, whether more than one child was living in the family, and mother’s unhealthy food consumption predicted toddlers’ unhealthy food eating.

-African American families, older toddlers, and households with more than one child consumed unhealthy foods more frequently.

-Race predicted both mothers’ and toddlers’ unhealthy food consumption as well as TV watching during family mealtimes.

Factors Predicting Quality of Toddlers’ Food Consumption

Unhealthy Foods include:•Canned, packaged or frozen dinners •Sweetened baked goods •Cookies, pastries

•Snacks •Fried foods•Sweetened cereal•Sweetened drinks

Key Findings--- Family Television Watching During Mealtime

• Race, education, and depression predicted TV watching during mealtime. African American mothers watched TV more

frequently during mealtime. Mothers with less education watched TV more

frequently during mealtime. Depressed mothers watched TV more frequently during

mealtime.

Maternal factors (depression, lower education, and minority status) predict TV watching during mealtime.

• Maternal Quality of Food Intake

• Maternal Healthy Food intake: Mothers with higher education, less depression,

and less TV watching during mealtime consumed healthy foods more frequently.

• Maternal Unhealthy Food Intake: African American mothers, younger mothers,

and mothers who watched more TV during mealtime consumed unhealthy foods more frequently.

The more TV is watched during mealtime, the poorer the quality of maternal food intake

• Toddler Quality of Food Intake:

• Toddler Healthy Food Intake: Toddlers whose mothers consumed more healthy

food consumed more healthy food.

• Toddler Unhealthy Food Intake: Older toddlers, and toddlers whose mothers

consumed more unhealthy food consumed more unhealthy foods.

The quality of maternal food intake predicts the quality of toddlers’ food intake

Key Findings--- Toddler Food Portion Sizes

• The mothers were asked to provide their toddlers’ usual meal portion as follows:

Toddlers’ Food Portion Sizes

• Food portion Sizes :

- (A) Appropriate Portion Size

- (B) Slightly Large Portion

- (C+D) Oversized Portion• Findings showed that toddlers’ food portion was

influenced by two variables– Race

– Gender

Toddlers’ Food Portions

Toddler Food Portion Size By Race

11

21

181719

14

0

5

10

15

20

25

Appropriate Slightly Large Oversized

Perc

enta

ge

African American

Non-Hispanic White

Toddler Food Portion Size By Gender

13

171515

23

17

0

5

10

15

20

25

Appropriate Slightly Large Oversized

Perc

entag

e

Male

Female

Key Findings--- Mothers’ Perception and

Toddlers’ Food Portion Size

Mothers' Perception of Toddlers' Weight by Race

14

67

1915

68

18

0

10

20

30

40

50

60

70

80

Underweght Average Weight Overweight

Perc

enta

ge

African American

Non-Hispanic White

Mothers’ Perception of their Toddlers’ Weight Compared to their Real Weight

Yellow: Mothers “overestimate” weight Purple: Mothers “underestimates” weightLavender: Mothers “realistic” estimate weight

Weight Rating of Toddler by Mother

CDC Weight Centiles:

Under Weight:

12

Average:3 4

Over Weight:

5

Total

0-9 ‘Low’

5 12%

8 19%

25 59%

2 5%

2 5%

42 100%

10-89 ‘Average’

10 5%

24 11%

158 73%

22 10%

22 1%1%

216 100%

90-100 ‘High’

4 3%

7 5%

85 60%

34 24%

11 8%

141 100%

Total 19 5%

39 10%

268 67%

58 14%

15 4%

399 100%

How Realistic of Mothers' Perception about Their Toddlers' Weight

1219

59

5 5511

74

10

13 5

60

24

8

0

10

20

30

40

50

60

70

80

1 2 3 4 5

Underweight Average Weight Overweight

Mothers' Perception of Their Toddlers' Weight compared to other Toddlers at the same age

Perc

enta

ge

<10

10--89

>90

Mothers’ Perception of their Toddlers’ Weight by Race

Mothers' "Realistic" Perception about Their Toddlers' Weight by Race

14

31

5

13

35

2

0

5

10

15

20

25

30

35

40

Underestimate Realistic Overestimate

Perc

enta

ge

African American

Non-Hispanic White

Mothers’ Perception and Food Portion Size

Mothers' Perception and Food Portion Size

4 46

18

28

21

68

5

0

5

10

15

20

25

30

Appropriate Slightly Larger Oversize

Food Portion

Perc

enta

ges

Underweight

Average Weight

Overweight

Nutrition Assessment for Toddlers―Mealtime Behavior Assessment

―Toddler Parent Mealtime Behavior Questionnaire (TPMBQ)

―Mealtime Behavior Observation (MO)

―Nutrition Education and Assessment for Toddlers Toolkit

Mealtime Behavior Assessment― Toddler Parent Mealtime Behavior Questionnaire

(TPMBQ)

― Mealtime Behavior Observation (MO)

• Toddler Parent Mealtime Behavior Questionnaire (TPMBQ)– 35 items – Measure of parents’ self-report of toddler eating and

mealtime behaviors.– Approximately 15 minutes to complete. – 5-point Likert response scale how often the behavior

occurs (i.e., never, rarely, sometimes, often, always).

Mealtime Behavior Assessment--- TPMBQ

• Parent-Toddler Mealtime Behavior Observation (TPMBO)– The Mealtime Observation (MO) was developed as

a companion to the TPMBQ. – 29 items – Measure of the observed toddler eating and

mealtime behaviors.– Approximately 20 minutes to observe and complete

depending on the family mealtime duration.– A trained observer indicates on a 4-point Likert

response scale how often the behavior occurs (i.e., “never/not at all”, “at times/occasionally”, “often”, and “throughout the entire meal”).

Mealtime Behavior Assessment--- TPMBO

• Test-Retest Reliability of TPMBQ & MO– Both self-report and observational measures contain three

scales, the Mealtime Television Watching, the Mother Mealtime Socialization, and the Mother Mealtime distress.

– These three scales were tested for its test-retest reliability.

• Cross Validation of TPMBQ & MO– Mealtime Television watching had “high” consistency

– Mother Socialization during mealtime had “moderate” consistency.

– Mother Distress during mealtime had “low” consistency.

Instrument Validation

Nutrition Education and Assessment For Toddlers Toolkit (NEATT)

• The NEATT includes three components: – a questionnaire with three different versions, a short

version, a long version and a long version with action message;

– 26 folders with 37 handouts; and – and a box (toolkit) with materials symbolizing a

toddler’s stomach size and appropriate portion sizes for toddler’s food consumption.

NEATT Toolkit

• CDI Question 1-Fruit and Vegetable Consumption• CDI Question 2 and 3-Tips for Lowering Dietary Sugar• CDI Question 2-Tips for Lowering Dietary Fat• CDI Question 3-Sugar in Beverages• CDI Question 4-Choking Hazards• CDI Question 6C-How To Cook• CDI Question 6C-Sample Menu recipes• CDI Question 6E - Food Labels• CDI Question 6E-Food Shopping• FS Extra Handout - Kitchen Safety• PF Question 1-Physical Fitness for all Seasons• PF Question 1 - Physical Activity for 2&3-year olds

NEATT Toolkit Update

• Comparison of TPMBQ, MO and NEATT

– Purposes

• TPMBQ is a self-report measure completed by parents. – Participants might report what they “should have” done, not

what they “have” done.

• MO is an observational measure completed by a trained observer, such as a home visitor/data collector.

– Observers usually make references based on a one-time observation. It may not be the “usual” family behaviors.

• The NEATT is designed for assessment and educational purposes.

– Risk Score ( Appendix 8)> 10 a referral should be made to a nutritionist.

Nutrition Assessment for Toddlers

• It is important to remember that toddlers’ growth changes rapidly.

• It is important to pay attention to the “pattern” of family mealtime, feeding, and/or eating behaviors.

• Caution must be used to not make any conclusions based on a single observation or assessment.

• Assessment provides educators the tools to educate the family about toddler feeding strategies and nutrition information.

Reminder of Using Assessment Tools