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
Research Team
Principal Investigator
Mildred A. Horodynski, Ph.D., R.N.C.1
Co-Investigators
Manfred Strommel, Ph.D.1
Holly Brophy-Herb, Ph.D.2
Lorraine Weatherspoon, Ph.D., R.D. 3
1
College of Nursing
2 Department of Family and Child Ecology
3 Department of Food Science and Human Nutrition
Funded By: The Office of Planning, Research and Evaluation of the Administration
of Children and Families (OPRE/ACF), Grant Number: 90-YF0046
Acknowledgment To Our Early Head Start
Partners
•
•
•
•
•
•
•
•
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 Data Collectors
County/Site
Data Collectors
Capital Area Asha Barber; Michelle Henry
Eight-Cap
Linda Smith; Valecia Bryner; Shelley Edlinger; Megan Smith;
Sarah Stockton
Flint
Linda Campbell
Jackson
Nichole McColley; Evon Beavers; Priscilla Birch; Nichole
McColley
MidMichigan
Renee Bisel; Shawna Kennedy; Brandi McClenathen; Lori
Rosenberger; Sarah Stockton; Leah Doyle; Brandi McClenathen
NEMCSA
Marion 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
Purpose
• Collaborative research study designed
to develop culturally sensitive
measures for assessing parent – toddler
mealtime feeding behaviors.
Specific Aims
• 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)
Study Design
• 3 Phases:
– Phase I = Focus Groups
– Phase II = Survey & Instrument Validation
– Phase III = Nutrition Assessment
Phase I: Focus Groups
• 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 II: Survey
• Instrument validation with 399 EHS mother-toddler
dyads
-199 African American Mother-Toddler Dyads
-200 Non-Hispanic White Mother-Toddler Dyads
Phase III: Nutrition Assessment
•
Development of NEAT Toolkit (NEATT) for EHS
staff to assess toddler:
1)
2)
3)
4)
Current dietary intake
Eating/feeding behaviors
Eating/feeding concerns/problems
Food safety
5) Physical activity level
Key Findings
Participant Characteristics
• 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.
Characteristics of Study Participants (* p<0.05)
African American
(N= 199)
Mother’s Age
X = 27 (±8.3) (yrs)
Range = 15 – 62
Toddler’s Age
X
= 25 (±8.7) (mths)
Range = 12 – 48
Non-Hispanic White
(N=200)
X
= 28 (±7.5) yrs
Range = 17 – 66
X
= 25 (±7.9) (mths)
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%)
Mothers’ Body Mass Index (BMI)
• <18.5 = Underweight
• 18.5 --- 24.9 = Average Weight
• 25 --- 29.9 = Overweight
• > 30 = Obese
BMI: Mothers
70
60
60
Percentages
50
50
40
30
25
20
14
African American
Non-Hispanic White
26
12
10
1
1
0
Underweight
Average Weight
Overweight
Obese
Toddlers’ Body Mass Index (BMI)
• < 5% = Underweight
• 5th --- 84th % = Average Weight
• 85th --- 94th % = At Risk of Overweight
• > 95% = Overweight
CDC-Weight-Height-Percentile: Toddlers
30
27
25
21
Percentage
20
14
15
African American
13
10
10
8
5
5
2
0
Underweight
Healthy Weight
At Risk of Overweight
Overweight
Non-Hispanic White
Key Findings--Nutrition Patterns
Comparison of African American and Non-Hispanic
White Mothers’ Food Consumption
Comparison of African American and NonHispanic White Toddlers’ Food Consumption
Frewuency of Type of Food Consumption by Race: Toddler
M
ea
t
1.7
P
ot
at
p
1
2.3
ta
1.5
tF
oo
d/
R
B
F
as
re
a
1.5
d
ol
s
/R
is
e
S
/P
as
w
ee
te
n
ed
C
er
ea
l
Type of Food Category
F
is
h
1.9
F
rie
d
F
oo
d
2.2
D
rin
ks
2.1
eg
et
ab
le
s
NonHispanic White
Af rican American
0
0.5
1
1.5
2
V
S
w
ee
te
n
ed
1.1
# of Tim e s M or e Fr e que ntly Food w as Cons um e d
2.5
Key Findings--- Factors
Predicting Quality of Toddlers’
Food Consumption
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.
Healthy Foods include:
• Vegetables
• Fruits
• Unsweetened cereal
• Plain water
Factors Predicting Quality of Toddlers’ Food
Consumption
•
•
•
•
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.
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
Maternal factors (depression, lower education, and
minority status) predict TV 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.
The more TV is watched during mealtime, the poorer
the quality of maternal food intake
• 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 quality of maternal food intake predicts the quality
of toddlers’ 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.
Key Findings--Toddler Food Portion Sizes
Toddlers’ Food Portion Sizes
• The mothers were asked to provide their toddlers’
usual meal portion as follows:
Toddlers’ Food Portions
• 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
Toddler Food Portion Size By Race
25
21
19
Percentage
20
15
17
18
14
11
10
5
0
Appropriate
Slightly Large
Oversized
African American
Non-Hispanic White
Toddler Food Portion Size By Gender
23
25
Percentage
20
17
15
15
17
15
13
10
5
Male
0
Appropriate
Slightly Large
Oversized
Female
Key Findings--Mothers’ Perception and
Toddlers’ Food Portion Size
Mothers' Perception of Toddlers' Weight by Race
80
67
70
68
Percentage
60
50
40
30
20
19
14
15
18
10
African American
Non-Hispanic White
0
Underweght
Average Weight
Overweight
Mothers’ Perception of their Toddlers’ Weight
Compared to their Real Weight
Weight Rating of Toddler by Mother
CDC
Weight
Centiles:
Total
Under
Weight:
1
2
Average:
3
4
Over
Weight:
5
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%
2
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%
Yellow: Mothers “overestimate” weight
Purple: Mothers “underestimates” weight
Lavender: Mothers “realistic” estimate weight
How Realistic of Mothers' Perception about Their Toddlers' Weight
74
80
70
60
Percentage
60
59
50
40
30
20
10
24
19
12
5 3
11
5
5
10
5
8
1
0
1
2
Underweight
3
Average Weight
4
5
Overweight
Mothers' Perception of Their Toddlers' Weight compared to other Toddlers at
the same age
<10
10--89
>90
Mothers’ Perception of their Toddlers’ Weight by Race
Mothers' "Realistic" Perception about Their Toddlers' Weight by Race
40
35
35
31
Percentage
30
25
20
15
14
13
10
5
5
2
African American
0
Underestimate
Realistic
Overestimate
Non-Hispanic White
Mothers’ Perception and Food Portion Size
Percentages
Mothers' Perception and Food Portion Size
30
25
20
15
10
5
0
28
21
18
4
6
Appropriate
8
4
Slightly Larger
Food Portion
6
5
Oversize
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)
Mealtime Behavior Assessment--TPMBQ
• 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--- TPMBO
• 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”).
Instrument Validation
• 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.
Nutrition Education and Assessment
For Toddlers Toolkit (NEATT)
NEATT Toolkit
• 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 Update
•
•
•
•
•
•
•
•
•
•
•
•
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
Nutrition Assessment for Toddlers
• 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.
Reminder of Using Assessment Tools
• 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.