Researcharticle.pdf

R E S E A R C H A R T I C L E
Parent‐directed intervention in promoting knowledge ofpediatric nutrition and healthy lifestyle among low‐SES familieswith toddlers: A randomized controlled trial
Danielle LoRe1 | Christy Y. Y. Leung2 | Louisa Brenner2 | Dana L. Suskind2
1 Department of Pediatrics, Morgan Stanley
Children’s Hospital of NewYork‐Presbyterian,Columbia University Medical Center, New
York, NY
2 TMW Center for Early Learning and Public
Health, Department of Surgery, The University
of Chicago Medicine, Chicago, Illinois
Correspondence
Danielle LoRe, TMW Center for Early Learning
and Public Health, The University of Chicago
Medicine, Maryland Ave, MC 1035, Chicago, IL
60637.
Email: del9082@nyp.org
Funding information
Hemera Foundation; PNC Foundation
Abstract
Objective: The objective of this study is to determine the efficacy of an interactive,
home visiting curriculum tailored to low socio‐economic status families in improving
parental knowledge of paediatric nutrition and healthy lifestyle.
Methods: Parents of toddlers aged 13–16 months living with a household income
below 200% of the federal poverty line were randomized into healthy lifestyle inter-
vention and control home visiting curriculum groups. Each curriculum consisted of 12
one‐on‐one educational sessions with parents facilitated by a trained home‐visitor
that were administered over a 6‐month intervention period. Knowledge assessments
were administered before and after the intervention period.
Results: Results of a one‐way analysis of covariance (ANCOVA) analysis showed
that parents in the intervention group (M = 26.05, SD = 4.24) scored significantly
higher than control parents (M = 23.84, SD = 4.26) post‐intervention, controlling for
parent education level, F (1, 102) = 7.494 (95% confidence interval [−3.68, −0.59]).
One‐way ANCOVA analysis showed no significant mean difference between the par-
ents in the intervention group (M = 24.13, SD = 4.37) and the control group
(M = 23.93, SD = 4.16) at baseline, controlling for parent education level, F (1,
163) = 0.002 (95% confidence interval [−1.28, 1.22]).
Conclusions: An interactive healthy lifestyle intervention focused on low‐SES fam-
ilies significantly improved parental knowledge of paediatric healthy lifestyle.
Changes in parental knowledge is a key preliminary step in behaviour change to ulti-
mately affect behaviour. Informing and encouraging parents of toddlers to guide
healthy lifestyle development early remains a promising point of intervention for pre-
vention, rather than remediation, of childhood obesity.
KEYWORDS
child development, child public health, obesity
1 | INTRODUCTION
Childhood obesity remains a serious public health issue in the United
States that develops early in life, with 7.0% of infants and toddlers
ages 6–23 months having high weight‐for‐length based on Center
for Disease Control growth charts (Akinbami, Kit, Carroll, Fakhouri, &
Ogden, 2017). Infants and toddlers from low‐income families have a
higher prevalence of high weight‐for‐length than their higher income
Received: 17 January 2019 Revised: 24 April 2019 Accepted: 25 April 2019
DOI: 10.1111/cch.12682
518 © 2019 John Wiley & Sons Ltd Child Care Health Dev. 2019;45:518–522.wileyonlinelibrary.com/journal/cch

counterparts (Freedman et al., 2017). High weight‐for‐length in
infancy has been linked to an increased risk of obesity in adulthood
(Baird et al., 2005). Consequently, weight disparities during childhood
persist into adulthood, leading to increased risk of developing diabe-
tes, hypertension, and heart disease among low‐SES populations
(Paeratakul, Lovejoy, Ryan, & Bray, 2002).
Weight disparities can be attributed to a multitude of factors
affecting dietary and lifestyle choices. Low‐SES populations encounter
particular barriers to healthy eating, with inequalities including high
cost of healthy eating, lack of time due to work commitments, and
influence of family and friends (Inglis, Ball, & Crawford, 2005). Food
shopping habits also differ between low‐SES populations and higher‐
SES populations, as transportation and store accessibility affect shop-
ping frequency (Wiig & Smith, 2009). Low‐income families more fre-
quently shop at convenience stores and mid‐sized grocery stores,
rather than supermarkets (Shannon, 2014). In analysing promoters
and barriers to healthy lifestyles among low‐income, urban popula-
tions, cost and finances were identified as barriers to healthy food
consumption, whereas convenience and availability promoted fast
food consumption (Lucan, Barg, & Long, 2010). These factors may
contribute to consumption of an overall poorer quality diet; research
shows low‐SES populations consume more refined grains and added
fats and consume less lean protein, low‐fat dairy products, fresh veg-
etables, and fruit than higher SES populations (Darmon &
Drewnowski, 2008). Additionally, low‐SES children are less physically
active than high‐SES children (Humbert et al., 2006). Neighbourhood
safety, proximity to facilities, and cost of facilities limit physical activity
among low‐SES children (Humbert et al., 2006; Molnar, Gortmaker,
Bull, & Buka, 2004). Nutrition education is particularly important
among the low‐SES population, as studies have shown that low‐SES
parents have demonstrated significantly lower levels of nutritional
knowledge than more affluent parents (Morton & Guthrie, 1997;
Parmenter, Waller, & Wardle, 2000). Understanding of health impacts
can be key to shifting behaviour, as health concerns were identified as
a key promoter of fruit and vegetable consumption among low‐income
populations (Lucan et al., 2010).
Shifting the focus of obesity prevention interventions to early edu-
cation of parents has the potential to greatly affect child dietary habits
but has not been studied extensively to date in low‐SES populations.
The majority of childhood obesity interventions target school‐aged
children when unhealthy habits are already established and produce
minimal effects (Stice, Shaw, & Marti, 2006). Conversely, parenting
interventions as young as infancy have impacted infant dietary pat-
terns (Hohman, Savage, Paul, & Birch, 2016). However, research
regarding when or how to best target parent knowledge and behav-
iour is limited (Skouteris et al., 2011).
We designed an interactive healthy lifestyle development curricu-
lum to educate parents of toddlers about child healthy nutritional
and physical activity behaviours and strategies to best promote these
behaviours. This curriculum is unique in its tailored approach to low‐
SES parents by extending beyond knowledge of the general principles
of healthy eating and physical activity to also focus on knowledge of
strategies to address barriers affecting this population. These topics
included meal planning, grocery shopping on a budget, and increasing
physical activity with limited facilities. Additionally, the curriculum
emphasizes parent knowledge of child healthy habit development
and their influence on this development.
The curriculum is a 6‐month intervention being tested in a 5‐year
ongoing longitudinal study. Consistent with theory of behaviour
change, we expect changes in knowledge to be a key first step in
behaviour change. Therefore, preliminary testing of programme effi-
cacy and the aim of this paper is focused on changes in parent knowl-
edge following the 6‐month intervention period. We hypothesize that
this curriculum will significantly increase parent knowledge about pae-
diatric healthy eating and knowledge of healthy behavioural strategies.
2 | METHODS
2.1 | Participant recruitment
Sample size was determined by power calculations performed using
estimated effect size and standard deviation from existing research
on home interventions seeking to improve parent knowledge.
Research assistants recruited parent–child dyads through postings at
day care centres, libraries, health clinics, local stores, public transporta-
tion, and community organizations serving low‐income populations
around the Chicagoland area. Inclusion criteria required parents to
be at least 18 years old, have a child aged 13–16 months without sig-
nificant cognitive or physical impairments, and have a household
income level below 200% of the federal poverty line. Parents were
excluded if they had earned a graduate or professional degree, did
not have legal custody of their child, did not live with their child, or
did not spend at least two full days per week with their child. Written
informed consent was obtained from each parent.
2.2 | Study design
A trained research assistant who was blinded to the assigned condi-
tion of the parent–child dyad collected data from each parent–child
Key messages
• Obesity, particularly in low‐SES young children, remains a
public health epidemic.
• The majority of interventions focus on school‐aged
children, after eating habits are already formed.
• An intervention focused on parent knowledge and
promotion of paediatric nutritional needs significantly
improved parental understanding of these needs.
• Improvements in knowledge is a key first step in creation
of early interventions to ultimately target parental
behaviour.
LORE ET AL. 519

dyad during a visit at their home at baseline, and again post‐
intervention. The parent also reported demographics and completed
a knowledge questionnaire.
A matched‐pair randomization procedure was used, following the
baseline data collection, to ensure the two conditions are equivalent
on child age at baseline. All parent–child dyads were paired by child
age (in months). The first parent–child dyad in each age pair was ran-
domly assigned to either the healthy lifestyle intervention condition or
the language development control condition using coin flip. The sec-
ond parent–child dyad in the same age pair was then assigned to the
alternative condition. The project manager generated the matched‐
pair randomization sequence and assigned parent–child dyads to inter-
ventions. Both intervention and control curriculum started within
2 weeks following the baseline data collection. Participant recruitment
began in May 2014, and the trial was ended in March 2017 after
parent–child dyads had completed the 6‐month curriculum and the
post‐intervention knowledge assessment. Participants received $125
compensation in total for their time.
2.3 | Healthy lifestyle intervention condition
Parents in the intervention condition received a 6‐month computer‐
based curriculum designed to promote healthy eating and physical
activity. This curriculum consisted of 12 modules that were imple-
mented in sequence over 12 weekly home visits and facilitated by a
trained research assistant in one‐on‐one educational sessions with
parents. The content of all 12 modules was built upon the recommen-
dations by the American Academy of Pediatrics Bright Futures on pae-
diatric nutritional needs, healthy dietary behaviours, and physical
activities for obesity prevention (see Table 1 for an overview of the
content of each module) (Hagan, Shaw, & Dunca, 2007). In each of
the 12 modules, the home visitor and the parent discussed a specific
topic promoting a healthy lifestyle, reviewed certain practices and/or
activities that could be easily implemented in everyday life, and collab-
oratively developed goals for diet and activity. Moreover, three key
behavioural strategies, referred to as the “3Ms”: Make, Model, and
Mind, were interwoven throughout the curriculum to emphasize the
importance of making healthy meals, modelling healthy behaviours,
and minding healthy dietary decisions. The 3Ms were designed to pro-
vide parents with easy‐to‐understand and easy‐to‐remember strate-
gies to reinforce important concepts.
2.4 | Language development control condition
The control group also received 12 one‐on‐one biweekly home visits,
during which they received a child language intervention.
2.5 | Knowledge questionnaire
At baseline and post‐intervention, each parent completed a 38‐item
questionnaire designed to assess knowledge of paediatric nutrition
and physical activity needs, as well as behaviours and strategies to
promote healthy habits. Questions testing knowledge of paediatric
healthy nutrition included topics such as appropriate serving sizes,
vitamins, and healthy and unhealthy fats. Questions testing knowledge
of healthy behaviours and strategies included topics such as reading
nutrition labels, grocery shopping on a budget, and incorporating
physical activity into daily routine. The 38‐item knowledge question-
naire had an overall Flesch Reading Ease score of 78.6 (ranging 0–
100, with higher scores represent easier reading levels) and typically
read at a 5.2 Flesch Kincaid Grade level (a readability test of the
comprehension difficulty of a standard English passage, scored as
the normative reading level for U.S. school grades) (Williamson &
Martin, 2010). Cronbach’s α in the current sample was .76.
2.6 | Data analysis
Preliminary t tests and χ2 tests were first conducted to examine
whether parents in the intervention and the control conditions were
significantly different in terms of their demographic characteristics
including parent race/ethnicity, education level, and employment sta-
tus as well as their knowledge about healthy lifestyle at baseline.
Moreover, one‐way ANOVA and correlation analyses were conducted
to examine demographic characteristics in relation to their knowledge
at baseline. Two one‐way ANCOVAs were conducted to compare
knowledge between the two conditions (intervention vs. control) at
baseline as well as post‐intervention. Demographic characteristics that
were significantly associated with knowledge would be examined as
covariate. All analyses were performed using IBM SPSS Statistics 24.
TABLE 1 Twelve modules of healthy lifestyle curriculum
Modules Description
1. Introduction Empowering parent as role model for healthy
lifestyle development
2. Mind Reading nutrition labels and incorporating
5 food groups into diet
3. Make Cooking fresh food at home and avoiding
processed foods
4. Model Positive food socialization behaviours while
introducing new foods
5. Nutrients Maximizing healthy and minimizing unhealthy
nutrients in diet
6. Cooking on a
budget
Strategies to save money while food shopping
7. Cooking quickly Strategies to plan and prepare meals amid busy
schedule
8. Eating healthy
while out
Selecting healthy options from fast food and
restaurant menus
9. Hidden dangers Food preparation safety, allergies, and choking
hazards
10. Beverages
matter
Limiting intake of sugary drinks and drinking
more water
11. Exercise Ways to incorporate and promote physical
activity with child
12. Dental health Promoting appropriate dental health hygiene
520 LORE ET AL.

3 | RESULTS
3.1 | Cross‐sectional analyses
The demographic characteristics of parents and the control conditions
and their knowledge about healthy lifestyle at baseline are shown in
Table 2. One‐way ANOVA showed that parent race/ethnicity and
employment status were not significantly associated with their knowl-
edge at baseline. However, correlation analyses indicated that parents
who were more educated had higher levels of knowledge, r = .32,
p < .001. Thus, education level was examined as a covariate in the mixed model analysis. Results of two one‐way ANCOVAs testing knowledge across con- dition at baseline and post‐intervention, controlling for parent educa- tion level, are shown in Table 3. There was no significant mean difference found between the parents in the intervention group (M = 24.13, SD = 4.37) and the control group (M = 23.93, SD = 4.16) at baseline, controlling for parent education level, F (1, 163) = 0.002, (95% confidence interval [−1.28, 1.22]). However, parents in the inter- vention group (M = 26.05, SD = 4.24) scored significantly higher than control parents (M = 23.84, SD = 4.26) post‐intervention, controlling for parent education level, F (1, 102) = 7.494 (95% confidence interval [−3.68, −0.59]). 4 | DISCUSSION Despite significant national efforts, childhood obesity is a critical pub- lic health issue that disproportionately affects the low‐SES population. Our study adds to the literature by using this early education approach to specifically target the low SES population and address the barriers to development of a healthy lifestyle that this population faces. Consistent with our hypothesis, our preliminary findings demon- strate that the healthy lifestyle curriculum significantly increased par- ent nutritional knowledge and knowledge of healthy dietary behaviours, as compared with the control group. This improvement in parent knowledge is similar to that seen from other home visiting interventions targeting parents (Haire‐Joshu et al., 2008). Our multisession, long duration, and interactive intervention design is consistent with other obesity prevention or healthy lifestyle inter- ventions effective in increasing knowledge (Stice et al., 2006). This change in knowledge is an important preliminary step towards behaviour change. The study has a few limitations. This study has shown improve- ment in knowledge in the short term, but sustainability of this improvement in the long term is unknown. The curriculum is tailored to an urban, low‐SES study population, so generalizability to rural low‐SES populations may be limited. Additionally, the study popula- tion is predominantly African American, which could limit generaliz- ability to other racial groups. The strengths of our study include tailoring of an early parent edu- cation intervention to the needs of the high‐risk low‐SES population. The video‐based modules could feasibly be reliably scaled for wider dissemination. The longitudinal follow up in this 5‐year trial will pro- vide key information on sustainability of effects, as well as long‐term parent and child outcomes. Follow‐up studies are necessary to further investigate how increases in parental knowledge translate into behav- ioural changes for both parent and child. Future research may examine parental knowledge in relation to behavioural outcomes, such as par- ent and child food intake, activity logs, and parent–child mealtime behaviours. In conclusion, this study has shown that an intervention focused on low‐SES parent knowledge of paediatric healthy eating TABLE 2 Baseline characteristics of the health lifestyle (interven-tion) and the language development (control) participants Control (49) Intervention (55) Parent characteristics Age (year) 28.8, 6.51 28.5, 7.75 Race and Ethnicity African American 40 (81.6%) 47 (85.5%) Non‐Hispanic White 2 (4.1%) 2 (3.6%) Education level Some high school 5 (10.2%) 4 (7.3%) High school graduate or GED equivalent 10 (20.4%) 14 (25.4%) Some post‐secondary courses 23 (46.9%) 22 (40.0%) Associate's Degree 4 (8.2%) 8 (14.5%) Bachelor's Degree 7 (14.3%) 7 (12.7%) Married or Civil Union 8 (16.3%) 9 (16.4%) Employed 23 (46.9%) 28 (50.9%) WIC and/or LINK 40 (81.6%) 50 (90.9%) Age (month) 12.0, 2.52 11.4, 3.19 Male 26 (53.1%) 27 (49.1%) Note. Frequency and percentage are reported in Table 2 except as other- wise noted. TABLE 3 Results of two one‐way ANCOVAs testing knowledge across condition at baseline and post‐intervention, controlling for parent edu-cation level Control Intervention One‐way ANCOVA M (SD) M (SD) F df 95% Confidence interval Baseline 23.92 4.16 24.13 4.37 0.002 (1, 163) [−1.28, 1.22] Post‐Intervention 23.84 4.26 26.05 4.24 7.494 (1, 102) [−3.68, −0.59] Abbreviation: ANCOVA, analysis of covariance. LORE ET AL. 521 and behavioural strategies to promote development of healthy behav- iours significantly improved parental knowledge. This study shows the feasibility of reaching and targeting low‐SES parents early on to pro- mote healthy behaviours and modelling. Informing and encouraging parents of toddlers to guide healthy eating remains a promising point of intervention for prevention, rather than remediation, of childhood obesity. 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