Assessment of Weight, Dietary Intake, and Screen Time Patterns in Mississippi Head Start Children: Baseline Findings from the Impact of the Preschool Obesity Prevention Intervention

Introduction

An estimated 13.7% of children in the United States aged 2-5-years are obese.¹ Higher than the national average, it is estimated that 14% of preschool children in Mississippi are obese.² Children who are overweight or obese throughout childhood are more likely to remain obese throughout adulthood, resulting in an increased risk for developing physical and mental chronic conditions.³ Therefore, early childhood is a critical period for developing optimal, sustainable nutrition and activity behaviors.⁴

Since a systematic review was published a decade ago indicating that increased screen time led to decreased fruit, vegetable, and fiber consumption with increased fast food and sugar-sweetened beverage intake in 2-6 year old children,⁵ more evidence has mounted. More recently, significant relationships were found in multiple studies between television and/or total screen time viewing and dietary outcomes including fewer fruits and vegetables, and greater consumption of unhealthy foods.⁶

The Head Start Program for low-income preschool children is designed to bolster school readiness through the enhancement of social and cognitive development. In the realm of health and nutrition services, Head Start was originally concerned with addressing undernutrition, but since the onset of the child obesity epidemic, focus has shifted to the development of healthy eating and activity habits.⁷ Resolution of unhealthy weight at a young age is highly desirable, since early correction lessens long-term exposure to chronic weight-related illness and may instill healthy eating and activity habits that extend to later child- and adulthood. Therefore, the purpose of this paper is to describe the baseline dietary intake patterns and screen time activity of preschoolers before participating in an obesity prevention intervention in Mississippi Head Start centers.

Methods

The Impact of a Preschool Obesity Prevention (I-POP) intervention, described elsewhere in detail,⁸ was a multi-component intervention across 9 Head Start Centers. Heart Start Centers were randomly assigned to the immediate intervention group or a delayed intervention group. Recruitment included 177 parent-child dyads. Participants were excluded if they were missing baseline assessment information, yielding a final sample size of 172 (n=82 in the intervention group). Hip Hop to Health Jr. (HH2H) was selected for the child intervention curriculum.⁹ This curriculum focused on food groups (fruits, vegetables, whole grains, etc.) and physical activity (increasing activity and decreasing screen time). The interactive lessons were reviewed and piloted by a segment of the population to ensure suitability for the study sample. The study was approved by the University of Southern Mississippi and the Mississippi State Department of Health Institutional Review Boards. Parental informed consent and child assent were obtained before data were collected.

Baseline assessments were completed by the participating adult and children. All questionnaires, including demographic information, were completed by the participating adult. Child body weight (kilograms) and height (meters) were collected using a Seca digital scale and portable stadiometer in duplicate, and averages were used to calculate Body Mass Index (BMI) in kilograms/meters² (kg/m²).

Screen time assessment and dietary data are typically collected from parent-reported data using food frequency questionnaires and 24-hour recalls.⁶ Therefore, the Youth Risk Behavior Survey (YRBS), Middle School Content¹⁰ was used to assess dietary intake and screen time patterns of Head Start children. While this survey is not validated for this age group, the funding agency recommended using it as a common dietary intake measure across projects supported under the program announcement. Prior to study implementation, the YRBS was assessed for face validity and clarity by the I-POP community advisory board.

Participating adults were asked to respond to 15 items regarding the frequency of consumption of fruit, fruit juice, sugary foods and beverages, soda, milk, as well as participation in screen time activities over the past 7 days for their child. To align with common coding for the Youth Risk Behavior Survey¹¹ as well as dietary guidelines for 2-to-4-year-olds,¹² all 13 dietary variables were dichotomized into “<1 glass/time per day” versus “≥1 glass/time per day,” and the 2 screen time variables were collapsed and dichotomized into “<1 hour per day” versus “≥1 hour per day” to be consistent with screen time recommendations for 2-5-year olds.¹³

Data Analysis

Analyses were completed using Stata 15.1 (Stata Corporation, College Station, TX). Baseline data are presented in the overall sample, as well as by intervention and delayed intervention. BMI percentiles were evaluated using the Children’s Hospital of Philadelphia pediatric Z-score calculator based on Centers for Disease Control (CDC) and Prevention growth charts.¹⁴

Results

Sample characteristics for 172 participating adult-child dyads are presented in Table 1. The majority (71.4%, n=128) were non-Hispanic black or African American. The average age of participating adults was 32.2 ± 10.2 years of which 89% were female and 73% were the child’s mother. For children, 53% were female, with an average age of 3.2 ± 0.4 years. Almost 40% of participants participated in the Women Infants and Children and 28% of families participated in the Supplemental Nutrition Assistance Program.

Anthropometric data are shown in Table 2. Mean BMI was 16.7 ± 2.5 kg/m². Using CDC classifications for weight status, 60% of the sample was classified as healthy weight, 11% classified as overweight, and 20% classified as obese. Mean BMI percentile was 63.5 ± 30.0.

Descriptive statistics for the dietary intake patterns in the overall sample and by intervention group are shown in Table 2. At baseline, nearly half of the sample reported consuming fruits ≥1 time/day and 58% consumed 100% fruit juice ≥1 time/day. Fewer consumed vegetables >1 time/day with only 17% consuming green salad and 20% consuming potatoes; 30% of children consumed other vegetables ≥1 time/day. In terms of soda consumption, approximately 20% of the sample consumed regular soda ≥1 time/day. Fifty-eight percent of the sample consumed white milk ≥1 glass/day, and 31% of the sample consumed chocolate milk ≥1 glass/day. More than a third of the sample reported consumption of sugar-sweetened beverages and foods >1 glass/time/day (38%, 36%, respectively).

Descriptive statistics for screen time are also shown in Table 2. At baseline, approximately 91% of the sample engaged in screen time (watching television, playing video or computer games or using a computer for something that is not schoolwork) for ≥1 hour/day.

Discussion

Preschool-aged children are in their formative years when health behaviors begin to take root.³ Establishing healthy behaviors in early childhood such as recommended fruit and vegetable intake and physical activity is important for decreasing risk of childhood overweight and chronic disease in adulthood.^15,16 Early childhood education centers like Head Start offer opportunities for improving healthy eating and decreasing screen time through nutrition education and teacher modeling. Head Start is a government-funded program and is required to adhere to dietary and physical activity guidelines.¹⁷

In our study, most children consumed fruit and 100% fruit juice daily, but vegetables were consumed less than 1 time/day over the last 7 days, if at all. Recommendations for children ages 2 to 4 are between 1 cup of fruit per day and 1.5 cups of vegetables per day.¹² Fruit consumption results were similar to the baseline results of the HH2H effectiveness trial¹⁸ in which children consumed an average of .97 and 1.4 servings of fruit and fruit juice, respectively, in a 24-hour period; however, average vegetable consumption was 1.35 servings per day compared to the majority of children in our study who consumed vegetables <1 time/day. Similarly, results of the 2015-2016 National Health and Nutrition Examination Survey, What We Eat in America, indicated children 2 to 4 years did not meet recommendations for vegetables and milk and exceeded recommendations for added sugars.¹⁹ Foods with added sugars should be limited to <30 grams per day. In our study, approximately 31% of the sample were consuming sugar-sweetened beverages and sweetened foods more than 1 time per day.

With regards to screen time, 1 hour of screen time per day is recommended for this age group.¹¹ Most children (91.3%) in our study played video and computer games or watched television >1 hour per day, exceeding the recommendations. More precisely, almost three quarters of our sample engaged in more than 2 hours per day of screen time. Similarly, children in the HH2H effectiveness trial did not meet screen time recommendations with an average total screen time of 5 hours per day. Nevertheless, the HH2H effectiveness trial resulted in improved diet quality in Black/African American preschool children from low-income households at 1-year post-intervention.¹⁸ Although the two studies differ regionally, implementing the HH2H curriculum in Mississippi Head Start centers may result in positive outcomes.

Strengths of this intervention include 1) the early intervention in a highly at-risk population in Mississippi, and 2) the implementation of the validated HH2H curriculum in low-income Black/African American children with documented success after 1 year. However, several limitations should be noted. First, the participating adult may not have reported or considered food consumption at the Head Start center, which could have resulted in inaccurate intake frequencies of food groups such as vegetables. This was not a concern for screen time assessment, as video- or computer-related activities are not included in educational programming at Head Start centers.²⁰ Second, using the YRBS, which measures frequency of intake of a particular food group, does not give an indication of portion size and does not directly correlate with MyPlate recommendations.²¹ Third, the amount of screen time does not equate to the amount or level of physical activity the child is engaging in. Lastly, the data were self-reported by participating adults in Mississippi and findings may not be generalizable for other populations.

Despite these limitations, this study makes a valuable contribution to the successful future development of early interventions in a low-income, primarily Black/African American population in the deep south. Although most children participating in the I-POP intervention were a healthy weight, almost a third were overweight/obese and were not consuming a variety of vegetables daily, and over a third of the sample consumed sweets more than one time per day. The evidence based HH2H curriculum has the potential to improve dietary and physical activity habits and prevent weight gain in children. Further data from follow-up measurement points will give insights into the effectiveness of this intervention in this population.