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