Nutritional Assessment of Children Enrolled in Head Start/Preschool

Introduction to the problem

 Obesity is the leading cause of preventable death in the United States and nearly two-thirds of Americans are overweight or obese. Nutrition plays an important role in the etiology and management many medical conditions. Being overweight or obese as a child has its own set of challenges, but it also puts the child at risk for being overweight or obese as an adult, along with putting them at risk for other diseases associated with being overweight or obese; such as diabetes, cardiovascular disease, hypertension, sleep apnea, and many more. Adequate nutrition is important for children because it affects their growth and development. Determining nutritional status can lead to early detection of nutritional deficiencies that can lead to increased morbidity and mortality. It is important to identify these nutritional problems early so they can be addressed before they become too serious.

 Enrolling young children in Head Start and/or preschool settings has become a common practice in the United States. Due to employment trends, more families are having to place their child in a preschool setting while they work. Parents are relying on these programs to meet their child’s nutritional needs and also teach their children about eating healthy. Most children are in these settings for at least two out of three meals per day, not including snacks.

Purpose of study

Determining the nutritional status of children will reflect their health status. Children who have proper nutritional status are generally in better health and have a decreased risk for developing disease in the future. A nutrition assessment can detect any nutritional abnormalities at an early age so that lifestyle changes can be implemented before it becomes something more serious. The purpose of this study is to provide a nutritional status profile of children enrolled in a Head Start program to determine whether children enrolled in Head Start programs are more or less likely to be overweight or obese.

Research Question

Are children who are enrolled in a Head Start/preschool program at greater risk for being overweight/obese?

Objectives

 Possible objectives for my study are to:

1)     Complete a nutrition assessment on every child enrolled in the Head Start program

2)     Compare fruit, vegetable, carbohydrate, fat, and sugar intakes consumed by the enrolled children to the recommended dietary intakes using the Food Guide Pyramid/MyPlate

3)     Determine family income for enrolled children and whether income is a factor in enrolled children being overweight or obese

4)     Determine if enrolled families participate in Women, Infants and Children (WIC) Food and Nutrition Service or Supplemental Nutrition Assistance Program (SNAP), that provide nutrition education to families.

Definition of terms/concepts

 The Center for Disease Control (CDC) growth charts “consist of a series of percentile curves that illustrate the distribution of selected body measurements in U.S. children. The growth charts were developed in 1977 by the National Center for Health Statistics as a clinical tool for health professionals to determine if the growth of a child is adequate” (CDC, 2009).  Overweight is defined as having a BMI at or above the 85^th percentile and below the 95^th percentile for children and teens of the same age and sex. Obesity is defined as having a BMI at or above the 95^th percentile for children and teens of the same age and sex (CDC, 2016). Body mass index (BMI) is a person’s weight in kilograms divided by his/her height in meters, squared. BMI is a measurement of your weight relative to your height. It gives an approximation of total body fat, which increases the risk of diseases that are associated with being overweight or obese. Women, Infants and Children (WIC) is a supplemental nutrition program that serves low-income pregnant, postpartum, and breastfeeding women, infants, and children up to the age of 5 who are at nutritional risk, by providing nutritious foods to supplement diets, information on healthy eating including breastfeeding promotion and support, and referrals to health care (USDA, 2018). Supplemental Nutrition Assistance Program (SNAP) offers nutrition assistance to low-income individuals and families and provides economic benefits to communities. SNAP works with state agencies, nutrition educators, and neighborhood and faith-based organizations to ensure that those eligible for nutrition assistance can make informed decisions about applying for the program and can access benefits (USDA, 2018).

Significance of the study

Adequate nutrition is especially important for children because it affects their growth and development. To determine if children who participate in a structured childcare setting are getting proper nutrition, a nutrition assessment reviewing anthropometric measurements and dietary intakes is needed. Important anthropometric measurements include: height, weight, body mass index (height-for-age and weight-for-age according to the Center for Disease Control growth charts). Food Frequency Questionnaires or nutrition assessments can be used to assess the dietary component of this study. The results from the FFQ or nutrition assessments will help characterize nutritional status of each child individually, but also give an insight into the dietary and nutrition habits of the child’s family.

Literature Review

Adequate nutrition is an important aspect for children because if affects their growth and development, but can also have an effect on their response to illness. Because of the rising rates of childhood obesity and the importance of adequate nutrition during childhood, researchers are beginning to assess nutritional offerings for children in various settings, like Head Start/preschool programs. In order to determine whether children who participate in a structured childcare setting are receiving proper nutrition, researchers must use nutrition assessments, anthropometric measurements, nutrient blood levels, and dietary intakes. A thorough search of the current and past literature on the nutritional status of preschool-aged children identified a minimal number of studies that focused on using a full nutrition assessment to assess the nutrition of preschool-aged children.

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Alberdi et al. (2016), conducted a systematic review from the databases PubMed, MEDLINE, Cochrane Library and EMBASE to review the published evidence on the relationship between the type of childcare and risk of childhood overweight or obesity. Fifteen publications were included in their review. Alberdi et al. found the two most commonly reported childcare arrangements were center-based and information care (e.g. relatives, neighbors, friends). Studies they reviewed showed that hours spent in any time of childcare were associated with increased risk of childhood overweight/obesity. However, other studies they reviewed found no association between hours spent, or years spent, in childcare and weight status. Three studies found an association with overweight/obesity regarding center-based childcare, but other studies conducted found center-based childcare to be more protective than informal childcare.

Interestingly, Alberdi et al. found the most commonly reported factor was maternal overweight/obesity status, as well as father’s body mass index (BMI). Other factors that were assessed in this systematic review were: maternal education, maternal employment, and socioeconomically disadvantaged households. In conclusion, their review found evidence for an association between childcare and childhood overweight and obesity. The childcare environment may promote excessive weight gain in early childhood, because childcare providers may be less likely than parents to encourage healthful nutrition and physical activity behaviors. Informal caregivers lack childcare qualifications and are less likely to encourage healthful eating habits and even physical activity. Most informal caregivers are grandparents and are more likely to want to “spoil” their grandchild while they are with them; leading to possible bad eating habits in the future if they are not developed or corrected at an early age. Center-based programs are more regulated and also have more qualified staff compared to informal childcare settings. These settings most often also have guidelines that have to be followed that allow for a certain about of nutrition education and physical activity. Alberdi et al. concluded that the following factors all have an effect on childhood obesity in any kind of childcare setting: initiation to care, type of care, hours spent in care, mother’s education and occupation and parental overweight/obesity and breastfeeding were all positively associated with weight gain in young children. They noted further research is needed to determine if some of these relationships in more detail.

According to McGrady et al. (2009), it is estimated that 63% of children in the United States under the age of five attend some type of childcare located outside of their home. Given the large number of children enrolled in childcare outside the home and the fact that the preschool environment can influence food intake and physical activity levels, it is important to examine the relationship between the preschool environment and weight status. While research is limited and studies examining the link between enrollment in a childcare setting and childhood obesity, the results of a study of 1,244 grade school children showed that limited attendance (defined as 0-15 hours per week for children three to five years), was related to a decreased risk of being overweight in grade school (six to twelve years old). Researchers in this study found no significant association between extensive childcare attendance (greater than 15 hours per week) and weight status in grade school. McGrady et al. studied children who were just entering Kindergarten. They assessed height, weight and BMI and compared them to CDC norms. Their conclusion had two possible explanations; first, their research concluded that children who attended public preschool for at least one year were at an increased risk for being overweight or obese at Kindergarten entry. Their explanation for this finding was that children who are enrolled in a public preschool setting may be less active than those children in other childcare settings. The second possible explanation for the association between preschool attendance and overweight/obesity as a child is due to schools providing more calories than necessary to children. School lunches are required to meet dietary guidelines for protein, Vitamin A, Vitamin C, calcium and iron. McGrady et al. concluded that a majority of schools are exceeding recommendations for saturated fat and offering high-fat meal options to children.

Shoeps et al. (2011), evaluated the growth and nutrition status of preschool children, ages two to six years old, from low income families who were enrolled in daycare centers. Height, weight and BMI measurements were collected from preschool age children and compared to the 2000 National Center for Health Statistics (CDC/NCHS) for reference points. Their study included 1639 children between the ages of two and six years old, all from low income families. To determine “low income” status, the researchers observed average monthly income, taking into consideration how many people were in the household, median years of schooling for both mother and father, and occupation. Through their research Shoeps et al. concluded that low income preschool children are more likely to be overweight based on height, weight and BMI were all above the reference values of the CDC/NCHS. While this study shows a relationship between income and prevalence of overweight/obesity in preschool children, the study was carried out in Brazil. I believe the demographics of American children compared to those in this study, would be drastically different. This study focused on a different aspect of childhood obesity that other studies have not looked at, income. Income can have a huge effect on the nutrition of a family by determining what foods they can afford and even having the knowledge or education on how to prepare meals.

Another study by Jurkowski et al. (2012) also looked at engaging low income parents in childhood obesity prevention. The case study completed by Jurkowski et al., looked at engaging parents’ as co-researchers in the design, implementation and evaluation of an intervention program that was put into place for low income families with a child enrolled in a Head Start program. There were 4 parent engagement mechanisms they utilized: targeted partnership development, developing a Community Advisory Board for decision making, the Community Advisory Board was made up of parents, and addressing structural barriers to parent participation in childhood obesity intervention programs. In a vast majority of the studies the parents of enrolled children are not involved in the intervention. Children enrolled in Head Start are young, and while teaching them healthy eating habits at a young age is important, it is also extremely important to get the parents on board with the program so behaviors can be continued at home with the children as well. This case study was funded by the National Institute of Minority Health and Health Disparities of NIH, and was constrained to a rapid 2-year timeline to develop and pilot test the intervention. The goal was to develop and pilot test a childhood obesity prevention program for low income families, utilizing three phases; phase 1: partnership development, phase 2: community assessment and intervention development, and phase 3: intervention implementation and evaluation. Participating in this case study were 500 children, ages six weeks to five years old, who were enrolled in a Head Start program in NY. It was determined by Jurowski et al. that 28% of the families with children under five years old were living below the poverty level.

Koleilat et al. (2011), aimed to examine the relationship between childhood obesity and preschool enrollment and the number of hours in childcare among low-income, preschool-aged children who participated in WIC. They conducted a case-control study including 556 3- to 4- year old children, who were either classified as obese (BMI greater than 95^th percentile) or normal weight (BMI 25^th to 75^th percentile). Data from the case-control study was designed to examine the role of the WIC program in early childhood obesity. Koleilat et al., found the most commonly used preschool programs in LA county are Head Start programs, which have a regulated nutrition and physical activity component. Parents participating in this study were interviewed over a 14-month period in 2006 and 2007. Their case-control study had an equal number of obese children (BMI greater than 95^th percentile) and normal weight children (BMI 25^th to 75^th percentile). Through this study, Koleilat et al., determined that enrollment in a preschool program was actually a protective factor for the development of childhood obesity. They contributed this finding to the fact that most preschool/Head Start programs have regulated nutrition and physical activity components to their programs.

After reviewing past and current literature on childhood obesity in preschool children, studies are inconsistent in whether preschool/Head Start programs are a protective factor against childhood obesity, or possibly a factor leading to children enrolled in these structured setting programs to be overweight or obese. Most studies reviewed, viewed structured preschool program as a protective factor again childhood obesity. These structured programs often have regulated nutrition and physical activity components to their programs, unlike other informal childcare programs (friends, family, neighbors, grandparents, etc.) Further studies looking at nutrition assessments on enrolled children and families will help determine whether or not structured preschool/Head Start programs are an effective tool for preventing childhood obesity in children under the age of five years old. It would also be beneficial to have further studies completed using nutrition assessments along with anthropometric measurements, nutrient blood levels, and also dietary intakes of the enrolled child and family. In addition to these factors, further studies on whether or not income is a factor would be beneficial. Income plays a huge role in what foods families can afford and even the education of the parents to know how to prepare meals. Only a few of the studies reviewed have taken income into consideration when it comes to childhood obesity.

Purpose

The purpose of this study is to provide a nutrition profile and determine the nutritional status of children enrolled in Head Start through Bradford-Tioga Head Start, Inc. Determining the nutritional status of children will reflect their health status. Children who have proper nutritional status are generally in better health and have a decreased risk for developing disease in the future. A nutrition assessment can detect any nutritional abnormalities at an early age so that lifestyle changes can be implemented before it becomes something more serious.

Design/Methodology

For this study, I would use a cross-sectional design, descriptive in nature, to construct a profile of the nutritional status of preschool-aged children enrolled in a structured preschool/Head Start setting. This study will represent the nutritional status of children enrolled in the Bradford-Tioga Head Start program located in classrooms throughout Bradford and Tioga counties. This study will focus on anthropometric measures, dietary and socioeconomic demographics of children enrolled in Head Start. Using these measures, we will be able to develop a nutritional profile for each enrolled child.

Protection of human subjects

 Numerous measures will be taken to maximize the children’s and families’ safety and protection during this study. Approval from the Institutional Review Board (IRB) may be needed to conduct this study, the researcher will need to determine if IRB approval is needed and take the steps to get approval before the study begins. The researcher will also need to get consent from parents in order for children to participate in this study.  In order to ensure the children and families feel safe and comfortable, the researcher will spend time with the preschool children and their families before the study begins to get acquainted with the children and answer any questions their families may have. The researcher also plans to utilize the other Head Start staff while interacting with children and families. Teachers, teacher aides, classroom aides and Family Advocates have all built up a relationship with enrolled families and will provide a wealth of knowledge about eating habits/behaviors at school as well as bridge any communication gaps between the researcher and families.

Sampling

 The sample size for this study will include 306 children enrolled in Head Start and their families. The parents of enrolled children may have access to their child’s BMI and nutritional status profile, if they are interested. The subjects for this study were selected by the researcher due to interest in childhood obesity and also convenience. An informational letter will be sent home to parents prior to the start of the study.

Instrumentation

 The data needed to fulfill the objective of developing a nutrition profile/nutrition status of preschool-aged children attending Head Start derived from a nutrition assessment. Bradford-Tioga Head Start, Inc. (BTHS) has developed their own nutrition assessment form which is completed by the parents of an enrolled child, with help from the center’s Family Advocate. This nutrition assessment is completed twice a year; the first being at time of enrollment (August) and the second is completed just before the end of the school year (February/March). Since BTHS already has a nutrition assessment in place and the parents are familiar with the assessment, the researcher plans to utilize the nutrition assessment already in place. If there is any additional information the researcher needs it can be added to the nutrition assessment or asked on a separate form. The nutrition assessment form will also measure the fruit, vegetable, grain, sweets and other dietary intakes/eating patterns of enrolled children and their families.

 Anthropometric data that will be used for this study will be height, weight and BMI (body mass index). These measurements were chosen because they allowed the objectives of the study to be met and also because the researchers’ interest in childhood obesity.

 Socioeconomic demographics of enrolled families will also be taken into consideration for this study. Income for enrolled families is verified prior to enrollment and is kept on file. The researcher will use this economic information to determine if income is also another factor to consider.

 Instruments needed for this study will include a Balance-Beam scale and food frequency questionnaire/nutrition assessment form.

Procedure for collecting data

 Nutrition assessments are completed by Family Advocates with the parents at their Head Start enrollment visit. These nutrition assessments are then uploaded to ChildPlus, where the researcher can access the nutrition assessments and review them. If there are any additional questions about the assessments the researcher can contact the parents by phone and can set up an in-person meeting with the parents, if needed. The children’s heights and weights are also taken and entered into ChildPlus three times a year, where the Health Coordinator then reviews them and determines the children’s BMI. The researcher will also have access to review the heights and weights and determine BMI. To determine a nutritional profile for each child the researcher will review the completed nutrition assessments and height/weight/BMI information. Due to the timing of the study, two nutrition assessments will have already been completed as well as two measurements of height/weight/BMI.

Limitations

 A big limitation for this study will be dealing with the timeframe. Children enrolled in Bradford-Tioga Head Start are enrolled from August to the end of May. The children enrolled now will be completing their school year on May 31^st and will not return until the 2^nd week in August. For the purposes of this study the researcher may have to review nutrition assessments of those children who were enrolled from August 2017 to May of 2018. Another limitation for this study is the sample size. There are currently only 306 children enrolled in the Head Start program through Bradford-Tioga Head Start, Inc. There are also 66 children/families enrolled in the Early Head Start program. The sample size for this study is relatively small compared to other studies that have been conducted. Another possible limitation for this study will be the willingness of the children and families to participate.

References

• Alberdi, G., Mcnamara, A. E., Lindsay, K. L., Scully, H. A., Horan, M. H., Gibney, E. R., & Mcauliffe, F. M. (2016). The association between childcare and risk of childhood overweight and obesity in children aged 5 years and under: a systematic review. European Journal of Pediatrics,175(10), 1277-1294. doi:10.1007/s00431-016-2768-9
• Jurkowski, J. M., Mills, L. L., Lawson, H. A., Bovenzi, M. C., Quartimon, R., & Davison, K. K. (2012). Engaging Low-Income Parents in Childhood Obesity Prevention from Start to Finish: A Case Study. Journal of Community Health,38(1), 1-11. doi:10.1007/s10900-012-9573-9
• Koleilat, M., Harrison, G. G., Whaley, S., Mcgregor, S., Jenks, E., & Afifi, A. (2011). Preschool Enrollment is Associated with Lower Odds of Childhood Obesity Among WIC Participants in LA County. Maternal and Child Health Journal,16(3), 706-712. doi:10.1007/s10995-011-0774-0
• McGrady, M. E., Mitchell, M. J., Theodore, S. N., Sersion, B., & Holtzapple, E. (2010). Preschool Participation and BMI at Kindergarten Entry: The Case for Early Behavioral Intervention. Journal of Obesity,2010, 1-6. doi:10.1155/2010/360407
• National Center for Health Statistics. (2009, August 04). Retrieved from https://www.cdc.gov/growthcharts/background.htm
• Overweight & Obesity. (2016, October 20). Retrieved March, from https://www.cdc.gov/obesity/childhood/defining.html
• Supplemental Nutrition Assistance Program (SNAP). (2018, February 5). Retrieved from https://www.fns.usda.gov/snap/supplemental-nutrition-assistance-program-snap
• Women, Infants and Children (WIC). (2018, February 14). Retrieved from https://www.fns.usda.gov/wic/about-wic