Nutrition Content in a National Nutrition Education Program for Low-Income Adults: Content Analysis and Comparison With the 2010 Dietary Guidelines for Americans

Short-Term Efficacy of a Childhood Obesity Prevention Program Designed to Pair Feeding Content with Nutrition Education

Background: Family-based programs show considerable promise in preventing overweight and obesity in young children. However, dissemination is difficult because significant participant and staff involvement is required. This study examined the short-term efficacy of adding parental feeding content to a widely-used nutrition education curriculum for families in low-resourced communities comparing the influence of two delivery methods (in-class and online) on parents' feeding knowledge, practices, and styles. Methods: In this cluster randomized controlled trial, parents of 2- to 8-year-old children enrolled in the EFNEP (Expanded Food and Nutrition Education Program) in Colorado and Washington were randomly assigned to: in-class nutrition education only, in-class nutrition education with in-class feeding content, or in-class nutrition education with online feeding content. Data from the 382 participants who completed both pretest and posttest assessments are reported in this study. Results: Multilevel analyses showed empirical support for the influence of the program on parents' feeding knowledge, practices, and styles. Online and in-class methods were equally effective in delivering feeding content in low-resourced communities. Consistent effects were seen across the two delivery methods for encouraging children to try new foods (p < 0.05), use of child-centered feeding practices (i.e., greater responsiveness, p < 0.05), child involvement in food preparation (p < 0.05), and understanding the number of presentations often necessary for child acceptance of a new food (p < 0.001). Location and language differences were seen across some constructs. Conclusions: This study demonstrates the efficacy of in-class and online approaches to feeding highlighting the program's positive effects on promoting healthy feeding behaviors for parents of children in low-resourced families. ClinicalTrials.gov Identifier: NCT03170700.

Development of Reliable and Valid Questions to Assess Food Resource Management Behaviors in Adults With Limited Income

OBJECTIVE

Develop reliable, valid questions to assess changes in food resource management (FRM) behaviors in adults with limited incomes.

DESIGN

Questionnaire development using a mixed-methods approach: content validity (subject matter and curricula), face validity, temporal reliability (test-retest), sensitivity to change, and exploratory factor analysis (EFA).

SETTING

Community settings in 12 states.

PARTICIPANTS

Convenience samples of English-speaking Expanded Food and Nutrition Education Program (EFNEP) or EFNEP-eligible adults: 105 (cognitive interviews), 181 (test-retest), 185 (sensitivity), and 389 (EFA) adults.

VARIABLES MEASURED

Behaviors related to FRM skills: planning, shopping, and budgeting.

ANALYSIS

Consistency and agreement in cognitive interviews and temporal reliability; sensitivity at posttest (paired t tests, Wilcoxon signed-rank tests); internal consistency of scales identified in EFA (Cronbach α). P < 0.5.

RESULTS

All questions had acceptable temporal reliability ranges for the intraclass correlation coefficient (0.48-0.74) and Spearman rank-order correlation (0.48-0.73). All questions were sensitive to change at posttest (P < 0.001). Planning and saving scales, revealed by EFA, demonstrated internal consistency (> 0.80 Cronbach α).

CONCLUSIONS AND IMPLICATIONS

The 9 FRM behavior questions have acceptable temporal reliability and content and face validity and can be used nationally by EFNEP to assess participants' self-reported behavior changes. Other nutrition programs with similar audiences and content could use these questions to measure changes in FRM behaviors.

Implementation Science Strategies Promote Fidelity in the Food, Feeding, and Your Family Study

OBJECTIVE

Use of implementation science strategies to promote fidelity in the Food, Feeding, and Your Family study.

DESIGN

Cluster randomized controlled trial with 3 conditions: control, in-class, or online, delivered in English or Spanish. Observations of 20% of classes.

SETTING

Expanded Food and Nutrition Education Program (EFNEP) in 2 states.

PARTICIPANTS

EFNEP peer educators (n = 11).

INTERVENTION

Parental feeding content incorporated into EFNEP lessons (in-class) or through text with links to videos/activities (online). Extensive educator training, scripted curriculum, frequent feedback.

ANALYSIS

Assessment of fidelity compliance. Qualitative analysis of verbatim educator interviews and classroom observer comments.

RESULTS

During 128 class observations (40-45 per condition), peer educators followed scripted lesson plan 78% to 89% of the time. There was no evidence of cross-contamination of parental feeding content in control and only minor sharing in online conditions. Variations with fidelity were primarily tied to the EFNEP curriculum, not the parent feeding content. Educators (n = 7) expressed favorable opinions about the Food, Feeding, and Your Family study, thought it provided valuable information, and appreciated support from EFNEP leadership.

CONCLUSIONS AND IMPLICATIONS

Incorporating implementation science strategies can help ensure successful adherence to research protocols. With proper training and support, EFNEP peer educators can deliver an evidence-based curriculum as part of a complex research study.

Effectiveness of Expanded Food and Nutrition Education Program in Changing Nutrition-Related Outcomes Among Adults With Low Income: A Systematic Review

OBJECTIVE

To review the effect of the Expanded Food and Nutrition Education Program (EFNEP) in changing nutrition-related outcomes.

METHODS

Relevant research conducted before December 2020 was identified using PubMed, Web of Science, Google Scholar, and the EFNEP Research Database. The methodological quality of each eligible study was assessed.

RESULTS

Of the 406 studies found, 30 were eligible; 26 studies were on EFNEP, and 4 included both EFNEP and Supplemental Nutrition Assistance Program Nutrition Education (SNAP-Ed). The sample sizes ranged from 35 to 122,961. Outcome measures included consumption of food groups, nutrients, other nutrition-related behaviors, and food security. At least 1 immediate behavior change (P < 0.05) was reported in each study, but long-term maintenance of behavior change was not evident.

DISCUSSION

This review found a consistent, immediate improvement in nutrition behaviors after program participation but poor retention over time. Overall, variation in programming and outcome measures, incomplete reporting, and generally low study quality by modern standards precluded strong conclusions.

IMPLICATIONS FOR RESEARCH AND PRACTICE

This review identified the need for control groups, improved reporting of program protocols, theory-based curriculum, and measurement of long-term outcomes.

Positive Change in Healthy Eating Scores Among Adults With Low Income After Expanded Food and Nutrition Education Program Participation

OBJECTIVE

Using 24-hour dietary recalls, compare Healthy Eating Index (HEI)-2005 scores of Expanded Food and Nutrition Education Program participants before and after 8-12 weekly lessons.

DESIGN

Analysis of preexisting 24-hour dietary recalls information collected from October, 2012 through September, 2014.

PARTICIPANTS

Participants with complete pre-post dietary data (n = 122,961); subset of those with complete demographic data (n = 97,522).

MAIN OUTCOME MEASURES

Change in HEI-2005 scores (total and components).

STATISTICAL ANALYSIS

Linear regression model fit separately for total HEI and 12 components. The response variable was changed in the HEI-2005 score; predictor variables included age, education, sex, and race/ethnicity.

RESULTS

The mean total HEI scores were 51.1 (SD, 13.7) at entry and 56.5 (SD, 13.7) at exit, with a change of 5.4 (SD, 16.2). Nine of 12 component scores increased. Changes were greater as age increased, with increasing education, and in women. Hispanics had the greatest improvement (mean ± SE) in total HEI score (8.3 ± 0.1).

CONCLUSIONS AND IMPLICATIONS

Although diet quality remained poor, participation in the Expanded Food and Nutrition Education Program resulted in improvement in dietary quality. The degree of improvements varied among demographic groups, but all groups improved.

Development of a National Dietary Behaviors Questionnaire for EFNEP Adult Participants

OBJECTIVE

Develop and establish the reliability and validity of dietary behavior evaluation questions for the Expanded Food and Nutrition Education Program (EFNEP).

DESIGN

A mixed-methods study using cognitive interviews, expert panels, test/retest reliability, and pretests/posttests.

SETTING

14 states across the US.

PARTICIPANTS

A convenience sample of low-income EFNEP or EFNEP-eligible participants for cognitive interviews (n = 111), reliability testing (n = 181), and sensitivity to change testing (n = 382).

MAIN OUTCOMES MEASURES

Indicators of face and content validity, temporal reliability, and sensitivity to change.

ANALYSIS

Questions interpreted as intended in cognitive interviews, intraclass correlation coefficient and Spearman rank-order correlation for reliability testing; paired t tests or Wilcoxon signed-rank tests for sensitivity to change; and exploratory factor analyses to identify possible scales.

RESULTS

Cognitive interviews resulted in 3 rounds of question revisions; reliability value ranges were 0.48-0.77 for intraclass correlation coefficient and 0.43-0.77 for Spearman rank-order correlation. For sensitivity to change, 9 items had evidence of change (P < 0.05) between pretests and posttests, whereas 5 items had evidence for change after removing those with little room to change. Two scales were identified: diet quality and non-cheese dairy.

CONCLUSIONS AND IMPLICATIONS

The EFNEP's new dietary behavior evaluation questions demonstrated face and content validity, moderate to strong reliability, and sensitivity to detect self-reported behavior changes among low-income, diverse populations (culturally, racially/ethnically, and level of education) across 14 states. Nutrition education programs targeting similar behaviors with English speaking clients could consider this dietary behavior questionnaire.

Pairing Feeding Content With a Nutrition Education Curriculum: A Comparison of Online and In-Class Delivery

OBJECTIVE

To develop a childhood obesity prevention program, Food, Feeding and Your Family (FFYF), which encourages eating self-regulation in young children. This article describes the research methods for FFYF. Activities that will be used to guide the development of the program are illustrated in a logic model.

DESIGN

A randomized control trial will be conducted with participant groups randomized into 1 of 3 conditions: (1) in-class delivery of feeding content and nutrition education, (2) online delivery of feeding content and in-class delivery of nutrition education, and (3) nutrition education only. Assessments will be collected at baseline, program completion, and 6 and 12 months after completion of the program.

SETTING

Study will be conducted through the Expanded Food and Nutrition Education Program in Colorado and Washington State.

PARTICIPANTS

Parents with 2- to 8-year-old children will be recruited from affiliated community agencies, 540 participants across both states.

INTERVENTIONS

FFYF derives content from an empirically validated parental feeding program, Strategies for Effective Eating Development, and will be administered with Eating Smart • Being Active, an evidence-based, nutrition education curriculum.

MAIN OUTCOME MEASURES

Parents will report on feeding practices, child eating behaviors, feeding styles, and acculturation.

ANALYSIS

Because of the nested nature of the data, multilevel analyses will be used: time points, within parents, and within groups.

Using Sensory Science to Evaluate Consumer Acceptance of Recipes in a Nutrition Education Intervention for Limited Resource Populations

OBJECTIVE

This study evaluated consumer acceptance of recipes in a nutrition education intervention and assessed participants' intentions to change dietary behaviors.

DESIGN

Study participants tasted and evaluated 16 recipes in the University of Georgia Food Talk curriculum using the 9-point hedonic scale and indicated their likelihood of engaging in behaviors to improve diet quality on a similar, ordinal scale.

SETTING AND PARTICIPANTS

Convenience samples of 89 to 122 adult participants in the Expanded Food and Nutrition Education Program in Georgia evaluated each recipe.

INTERVENTION

Eight interactive nutrition education sessions in which study participants sampled and evaluated 2 recipes per session.

MAIN OUTCOME MEASURES

Mean scores for overall liking of each recipe and likelihood of engaging in promoted behaviors to improve diet quality were outcomes of interest.

ANALYSIS

Descriptive statistics were generated. Relationships between overall liking of recipes and intention to engage in promoted behaviors were assessed with Spearman correlation coefficients.

RESULTS

Results showed that 13 of the 16 recipes in the curriculum met criteria for acceptable sensory quality. Overall liking was significantly correlated with participants' intentions to engage in behaviors to improve diet quality. Notable age- and sex-related differences were identified.

CONCLUSIONS AND IMPLICATIONS

Evaluations of consumer acceptance may be useful in interventions designed to improve diet quality through the introduction of new recipes as improving consumer acceptance of recipes may improve program outcomes.

Evaluation and Lessons Learned From the Development and Implementation of an Online Prenatal Nutrition Training for EFNEP Paraprofessionals

OBJECTIVE

Design, implement, and evaluate the effectiveness of a video-based online training addressing prenatal nutrition for paraprofessional peer educators.

METHODS

Quasi-experimental pre-posttest study with 2 groups of paraprofessionals working for the Expanded Food and Nutrition Education Program in 17 states and US territories: intervention (n = 67) and delayed intervention comparison group (n = 64). An online training was systematically developed using Smith and Ragan's instructional design model, the Cognitive Theory of Multimedia Learning, principles of adult learning, and selected constructs of the Social Cognitive Theory. Changes in knowledge, identification of inappropriate teaching practices, and self-efficacy, were assessed. Within- and between-group comparisons were done using ANCOVA.

RESULTS

The intervention group scored significantly higher (P < .05) in all evaluations compared with preassessments and the comparison group. After delayed intervention, the comparison group scored significantly higher (P < .05) than in preassessments. Paraprofessionals reacted positively to future online trainings and were interested in them.

CONCLUSIONS AND IMPLICATIONS

A video-based online training is an effective method to complement in-person trainings to prepare paraprofessionals to teach nutrition lessons.