Tooty Fruity Vegie: An obesity prevention intervention evaluation in Australian preschools

Abstract

This paper presents the findings from a cluster randomised controlled evaluation of a preschool-based intervention (children aged 3-6 years), on the North Coast of NSW, which aimed to decrease overweight and obesity prevalence among children by improving fundamental movement skills (FMS), increasing fruit and vegetable intake and decreasing unhealthy food consumption.
The Tooty Fruity Vegie in Preschools program was implemented in 18 preschools for 10 months during 2006 and 2007. It included nutrition and physical activity strategies. Pre and post intervention evaluation compared intervention and control children and was conducted at the beginning and end of each year. It included FMS testing, lunch box audits and anthropometric measures of children as well as parents' surveys regarding children's food intake, physical activity and sedentary behaviours.
In comparison to controls, children in intervention preschools significantly improved movement skills (14.79 units, p<0.001), had more fruit and vegetable serves (0.63 serves, p=0.001) and were less likely to have unhealthy food items (p<0.001) in their lunch boxes following the intervention. There was also a significant difference in waist circumference growth (-0.80 cm, p=0.002) and a reduction of BMI Z scores (-0.15, p=0.022).
The 10-month intervention in preschools produced significant changes in children's food intake, movement skills and indicators of weight status.

Full text

Health Promotion Journal of Australia 2012: 23(1)
10
Program Evaluation
Introduction
Many of the precursors for chronic preventable diseases, including
type 2 diabetes and cardiovascular disease, already exist in overweight
and obese children and some of these may be irreversible.
1,2
Lifestyle
behaviours linked to unhealthy weight gain are formed in early
childhood, making this age group an important target for the
prevention of obesity.
2
One of the most effective ways to reach
young children and their parents is through early childcare facilities.
2
There is some evidence that programs that include a range of healthy
eating and active play strategies, including supportive environments,
formal curricula and parental education, offer promising benefits.
The authors had experience in implementing strategies in primary
schools which resulted in increased fruit and vegetable consumption
3
and improved Fundamental Movement Skills (FMS).
4,5
However,
only a few programs have published results and even fewer have
sought to evaluate outcomes in terms of weight-related variables.
2
Increasing preschoolers’ FMS is likely to increase energy output
6
and replacing energy-dense snacks with fruit and vegetables is a
promising strategy for reducing energy intake.
2
Childcare staff have
reported a lack of confidence, ideas and competence as barriers to
providing opportunities for teaching children FMS and have identified
the need for comprehensive developmentally-appropriate resources
on nutrition and physical activity.
7,8
Children’s food and drink intakes are influenced by dietary exposure,
parental food preferences, role modelling, child-parent interactions
around food, parenting style, food security, genetic factors, perinatal
effects and television viewing habits.
9
In childcare, potential influences
include nutrition policies, formal curriculum, food exposure, physical
education and the knowledge attitudes and practices of staff.
9
Based on the authors’ previous experience
5,10
and the literature
described above, the team devised, implemented and evaluated
a 10-month intervention in community preschools (children aged
3-6 years) in 2006 and 2007 in northern NSW. This paper reports the
evaluation results. The intervention aimed to improve Fundamental
Movement Skills, increase the amount of fruit and vegetable serves,
and reduce the amount of unhealthy snack items, brought to and
consumed in preschools. The evaluation aimed to assess whether the
above aims have been achieved and whether these changes were
associated with children’s weight status.
Methods
Intervention design
A detailed methods paper covering the intervention strategies,
intervention intensity and evaluation methods and instruments
has been published elsewhere.
11,12
A brief summary of strategies is
outlined in Table 1.
Abstract
Issues addressed: This paper presents the findings from a cluster randomised controlled evaluation of a preschool-based intervention
(children aged 3-6 years), on the North Coast of NSW, which aimed to decrease overweight and obesity prevalence among children by
improving fundamental movement skills (FMS), increasing fruit and vegetable intake and decreasing unhealthy food consumption.
Methods: The Tooty Fruity Vegie in Preschools program was implemented in 18 preschools for 10 months during 2006 and 2007. It
included nutrition and physical activity strategies. Pre and post intervention evaluation compared intervention and control children
and was conducted at the beginning and end of each year. It included FMS testing, lunch box audits and anthropometric measures of
children as well as parents’ surveys regarding children’s food intake, physical activity and sedentary behaviours.
Results: In comparison to controls, children in intervention preschools significantly improved movement skills (14.79 units, p<0.001), had
more fruit and vegetable serves (0.63 serves, p=0.001) and were less likely to have unhealthy food items (p<0.001) in their lunch boxes
following the intervention. There was also a significant difference in waist circumference growth (-0.80 cm, p=0.002) and a reduction of
BMI Z scores (-0.15, p=0.022).
Conclusions: The 10-month intervention in preschools produced significant changes in children’s food intake, movement skills and
indicators of weight status.
Key words: program evaluation, obesity, child care, fruit and vegetables, physical activity.
Health Promotion Journal of Australia 2012; 23: 10-15
So what?
More widespread implementation of similar programs is warranted as the findings indicate such programs could have an impact on
childhood obesity prevention. More research regarding the long-term effects of the program is needed.
Tooty Fruity Vegie: an obesity prevention intervention
evaluation in Australian preschools
Avigdor Zask, Jillian Kaye Adams, Lyndon Owen Brooks and Denise Frances Hughes

Health Promotion Journal of Australia 2012: 23(1)
11
Study design and sample
Preschools in the NSW North Coast area (n=40) were asked to
submit an expression of interest to participate in the program. Thirty
preschools volunteered and the team determined that it would
have the capacity and resources to provide the intervention to 18
of them, and that there would be enough power to detect changes
if more than 12 acted as controls, i.e. a random allocation in a ratio
of approximately 1.4:1.
Within the above framework, preschools were randomly allocated
to intervention or control groups. Preschools that acted as control
schools in one year, were on a waiting list for an intervention and
were offered the full program in subsequent years (the program
continued beyond 2007). After random allocation to either
intervention or control arms of the study, we compared preschool
localities’ socioeconomic status to ensure the groups were matched.
No change in allocation was required. Six intervention and one
control preschool participated in the pilot stage in 2006 to test the
intervention’s feasibility. The 2006 control preschool became an
intervention preschool in 2007 with additional 11 intervention and
12 control preschools. Overall, there were 18 intervention and 13
control preschools.
Dumville et al. argue that unequal randomisation is under-utilised
and that it should be used more often to reduce costs and increase
efficiency.
13
Avins contends that ethical considerations can often
justify a larger experimental group with minimal loss of power.
14
In
the context of childhood obesity prevention programs in a regional
health promotion unit, team members felt the imperative to deliver
an intervention to as many preschool students as possible while
evaluating this intervention rigorously.
Ethical approval or the study was provided by the North Coast Area
Health Service Human Research Ethics Committee in January 2006
(NCAHS HREC approval 321).
Measurements
Data collection occurred in the same preschools pre and post
intervention within one school year. However, while most children
were measured both pre and post intervention (85.2% of children
and 74.2% of records), data from all students, including students for
whom there was only pre or post data, were used in the analysis, in
line with multi-level modelling literature.
15,16
Pre and post intervention data were collected in February/March and
November/December respectively during 2006 and 2007. A team of
researchers visited each preschool in the morning. Children moved
between ‘stations’ of anthropometric measurement and FMS testing.
Anthropometric measures were described in detail by Adams et al.
11
Weight status was determined using these measures, following Cole
et al.’s recommendations.
17
FMS were measured using the validated
Test of Gross Motor Skills Development (TGMD)
18
and the testing
procedure is described in detail by Adams et al.
11
Paired observations
were conducted to assess inter-rater reliability. Additionally, to
maximise reliability the same tester assessed the same children’s FMS
pre and post intervention whenever possible. All lunch boxes were
inspected by two researchers who recorded their contents and these
contents were later coded as described elsewhere.
11
Written surveys,
with questions on children’s nutrition and physical activity behaviours
during the preceding day, and family rules and behaviours related
to those, were distributed to parents.
11
Parents either filled out the
survey at the preschool or took it home and sent it back. Testing and
data collection took one to three hours.
Analysis
Data from both 2006 and 2007 preschools were used in the final
analyses. Data were entered into a Microsoft Access database,
19
and
descriptive statistics were calculated using SAS.
20
Data were further
analysed by fitting multi-level regression models in MLwiN to account
for the clustered nature of the data (pre/post within students within
preschools).
21
To test intervention effect and adjust for baseline levels,
all models fitted included the variables pre/post, intervention/control
and an interaction variable pre/post by intervention/control (yielding
the intervention effect). Intra-class correlation coefficients (ICCs) and
proportion of variance explained by linear models were calculated
using Snijders and Boskers’ formulas.
15
Details of the models’ random
effects, including ICCs and proportion of variance explained (R
2
) are
not included in this manuscript but can be obtained by contacting
the corresponding author.
Age, gender, and their interaction with the intervention effect were
added to all models and were retained only if they were significant
predictors. To clarify factors influencing the significant gender
differences found in the FMS quotient results, further investigation
of raw locomotor and object control scores among boys and girls
was conducted.
Both random intercept and random slopes models were fitted.
Significant co-variance of the residuals in random slopes models
Table 1: Summary of intervention strategies undertaken
in pre-schools.
Physical activity
interventions
Healthy eating interventions
• Structured twice-weekly
fundamental movement
skill development through
prescribed games suitable for
a wide age range.
• Playground environment
review and alterations to
encourage more active
movement and better access
to sports equipment during
free play times.
• Small grants for sports
equipment.
• Workshop for parents on
limiting sedentary time,
promoting physical activity
and FMS.
• A monthlyfour page
newsletter contains tips of
healthy eating and active
playing ideas was provided to
each parent.
• Review and adjustment of food and
nutrition policies to explicitly identify
appropriate and inappropriate foods in
lunchboxes.
• Communication of new policy to parents
along with lunchbox displays.
• Colourful posters on “better foods” and
“foods better left out” on display all year.
• Distribution of the Family Feud/ Food
DVD which models practical ways to
improve childrens eating habits, for their
parent library.
• Parents workshops on positive parenting
in relation to healthy eating and feeding
‘fussy’ eaters.
• Simple consistent messages for children
about ‘sometimes’ and ‘everyday’ foods;
puppets, staff in fruit and vegetable
costumes, stories, role-play, growing,
cooking, and taste testing fruit and
vegetables were all used to reinforce this
message.
• Staff acting as role models and giving
positive reinforcement to children about
eating healthy food and drinking water.
• Drinking water made more accessible.
Program Evaluation Evaluation of obesity prevention intervention in Australian preschools

Health Promotion Journal of Australia 2012: 23(1)
12
indicated whether the effect of the program was larger for
preschools or children with higher or lower baseline levels of the
outcome variable (estimates of residual co-variance were converted
to a correlation scale for ease of interpretation). Significance of
independent variables was tested using Wald tests on one degree
of freedom.
Intra class correlation (ICC) was used to assess inter-rater reliability of
paired FMS observations. It is a widely used reliability measure and it
corrects for chance-expected agreement.
22
Results
Records from 560 children (yielding a total of 1005 records with 537
and 468 records at pre and post intervention) in 18 intervention
and 13 control preschools were used in the study. Data were
collected from 80.7% and 67.2% of all children enrolled pre and
post intervention respectively. Most of the missing data were due
to children being absent on the day of testing or having left the
preschool between consent and testing. Only 6.9% and 5.7% of
enrolled children’s parents did not consent to participate at pre and
post intervention.
Of the 1005 records collected, there were 966 complete records of
lunch box audits (96.1%), 952 complete records for anthropometric
measures (94.7%), 789 complete records of FMS testing (78.5%), and
699 returned parent surveys (69.6%). Waist circumference data were
only available in 498 cases in 18 preschools (10 intervention and 8
control) as records in other preschools were deemed unreliable. See
more details in Adams et al. (2009).
11
There were 520 (51.7%) and 485 (48.3%) boys’ and girls’ records
respectively. Age ranged from 29 to 73 months, with mean ages of
50.5 (SD 6.7) and 58.8 (SD6.8) months. About 5% of the FMS tests were
conducted as paired observations to ascertain inter-rater reliability.
Table 2 shows the values of outcome variables for intervention and
control preschools/children at baseline and follow-up. The student
and preschool variances have been accounted for in all models.
Table 3 shows the size and significance of the intervention effects.
Changes in fundamental movement skills
Both control and intervention preschools improved their movement
Table 2: Baseline and follow-up values of FMS, dietary indicators and anthropometric measures in control and intervention groups.
Variable/time Control at pre Control at post Intervention at pre Intervention at post
Movement skills quotient score
1, 2
n=73 n=65 n=133 n=123
Girls – Mean (SE)
109.91 (1.84) 114.54 (1.89) 104.30 (1.48) 123.87 (1.73)
Boys – Mean (SE)
n=69 n=68 n=140 n=118
107.26 (1.84)) 111.90 (1.94) 101.66 (1.48) 116.18 (1.73)
Number of fruit and vegetables serves
3
Mean (SE) 1.95 (0.17) 1.73 (0.12) 1.91 (0.13) 2.31 (0.11)
Proportion of children with 0, 1, or 2+ EDNP items in lunch box 4
% with 0 EDNP items (SE) n=75 n=63 n=114 n=166
47.2% (5.7) 44.0% (5.7) 33.1% (3.8) 59.0% (4.6)
% 1 EDNP item (SE) n=44 n=33 n=88 n=55
27.7% (2.8) 24.3% (2.2) 27.2% (1.3) 19.1% (2.1)
% 2+ EDNP items (SE) n=53 n=57 n=146 n=72
25.1% (3.0) 31.8% (3.8) 39.7% (3.0) 21.9% (2.2)
BMI Z scores
3, 5
n=163 n=152 n=335 n=286
Mean (SE) 0.11 (0.08) 0.24 (0.09) 0.14 (0.06) 0.11 (0.06)
Mean waist circumference in cm n=108 n=99 n=149 n=114
Mean (SE) 52.33 (0.29) 53.49 (0.28) 52.54 (0.23) 52.89 (0.29)
1 The only model where gender was a significant predictor. Reference group was girls.
2 The model was run with the age variable centered.
3 Age and gender were not significant.
4 Reference group is children who had 2+ items in control preschools at pre. The first part of the ordered multinomial model computes the probability of having 1 EDNP item with having none. The second part
of the model computes the probability of being having any number of EDNP items with having none.
5 BMI Z scores calculated against the 2000 CDC growth reference.
Table 3: Adjusted dierences in FMS, dietary indicators and
anthropometric measures between control and intervention
children at follow-up.
Variable Dierence Standard
Error
P
Movement Skills Quotient 14.79 2.07 <0.0001
Fruit and vegetable serves in
lunch box
0.61 0.14 0.0013
% children with 0 EDNP items in
lunch box
29.1% * <0.0001
% children with 2+ EDNP items
in lunch box
-24.5% * <0.0001
BMI Z scores -0.15 0.07 0.022
Waist circumference -0.80 0.35 0.020
* Standard errors for size of difference (relative change) could not be derived from the multinomial
model. See Table 2 for standard errors of baseline and follow-up values.
Zask et al. Article

Health Promotion Journal of Australia 2012: 23(1)
13
skills. However, on average, children in intervention preschools
improved their movement skills significantly more than those
in controls (p<0.001) with a relative improvement of 14.79 units
(13.45%) of the Quotient above baseline levels. The pre to post
change was significantly larger among children who had lower
scores pre intervention (r= -0.54, p<0.001). When adjusted for the
intervention effects and baseline values, girls had overall significantly
better quotient scores (2.88 Quotient units, p=0.022). Girls improved
their quotient scores significantly more than boys in intervention
preschools (4.76 Quotient units, p=0.017). ICC of FMS paired
observations (reliability) was 0.94.
Both raw locomotor and object control scores improved significantly
more among intervention children (by an average of 4.54 and 6.33
units respectively, p<0.001 for both). Girls had a better average
locomotor raw scores than boys (1.69 units of a 48-units scale,
p=0.005), but the magnitude of the intervention effect between
boys and girls was the same (model adjusted for baseline values
and overall intervention effect). While overall object control scores
were significantly higher among boys (3.28 units of a 48-unit scale,
p<0.001), the magnitude of the intervention effect was significantly
greater among girls in intervention preschools (2.01, p=0.036).
Foods in children’s lunch boxes
There was a significant increase (p<0.001) in the mean number of fruit
and vegetable serves in the lunch boxes of children in intervention
preschools compared to the control preschool children. The mean
improvement was 0.63 serves of fruit and vegetables, which is a
32.7% improvement in relation to baseline levels. The increase was
significantly larger among children and preschools with lower levels
of fruit and vegetables in the lunch boxes at baseline (preschool level
r and p value were -0.83 & 0.034 respectively, student level r and p
value were -0.57 and <0.001 respectively).
There was no interaction effect between fruit and vegetables
consumed on previous day and the intervention effect, i.e. an
increased number of fruit and vegetables serves in lunch boxes
was not compensated for by eating less outside preschool hours.
The significance, direction and magnitude of intervention effect
were retained when the number of fruit serves eaten and occasions
when child ate vegetables during the day preceding the survey were
included in the model.
To more easily interpret Energy Dense Nutrient Poor (EDNP) findings,
data were collapsed into three categories: no EDNP items, 1 item, 2
or more items. The percentage of children who had no EDNP items
in their lunch boxes significantly increased in intervention preschools
from pre to post and decreased (not significantly) in controls. The
percentage of children who had two or more EDNP items in their
lunch boxes significantly decreased in intervention preschools from
pre to post and increased (non significantly) in controls.
Weight status indicators
A very small number of children were obese when Cole et al.
17
cut-
off points were applied and the changes following the intervention
were not significant. While changes in overweight prevalence were in
the desired direction, there was no significant intervention effect on
overweight prevalence (11.7% and 12.5% among controls at pre and
post intervention respectively; 12.2% and 11.5% among intervention
children). However, there was a significant reduction in BMI Z scores
of intervention children in comparison to controls (-0.15, p=0.022).
Children’s mean waist circumference increased in both groups, but
children in control preschools increased significantly more than
children in intervention schools. This represented a significant relative
improvement of 0.80 cm (p=0.020).
The model was adjusted for the effect of age (in months) as children’s
waist circumference increases with age.
Discussion
The findings regarding FMS were encouraging. The significant
improvement of FMS among intervention children when compared
to controls was consistent with improvements found in other
preschool and primary school studies.
10,23,24
It is interesting to note
that the improvement was much larger than in the ‘Munch & Move’
study, which used an intervention based on our program.
24
It is
possible that the state roll-out of our program was less intensive and
an investigation and discussion of cost benefit comparing the two
programs may be useful. The significant gender differences between
FMS quotient scores were somewhat surprising and led to further
investigation of locomotor and object control scores as described
in the results section.
Previous studies, most of which tested primary school children,
found that boys had better object control skills,
4,25-27
so our findings
of a larger intervention effect on object control skills among girls is
encouraging. In addition to this finding, it is worth noting that the Test
of Gross Motor Development instrument assumes boys have better
object control skills and adjusts for gender in the standardisation
process which creates the movement skills quotient. This process and
the fact that the girls in our intervention preschools improved more
than boys, translated to a significant gender effect on FMS quotient
improvement as per tables 2 and 3.
Some non-Australian studies found no difference between boys and
girls,
23,27
or that boys had better locomotor skills.
28-30
However, two
Australian studies found that girls had better locomotor skills.
4,25
One
study was conducted by two of the authors and other colleagues in
the same geographical area measuring primary school students’ FMS
using another instrument,
4
and the second study measured preschool
children’s FMS in the same state using the same instrument.
25
The findings regarding food intake were also encouraging. The
program significantly decreased unhealthy food and drink intake
and increased fruit and vegetable intake. Importantly, the increase in
healthy food in intervention children’s lunch boxes occurred without
a decrease in reported fruit and vegetable consumption on the day
preceding the survey. In fact, there was a significant association
between increased healthy food consumption outside preschool
hours and lunch boxes’ healthy food contents. The nutrition findings
are consistent with other studies.
24,31
The program’s significant effects on BMI Z scores and waist
circumference were promising. The program did not have a significant
effect on overweight and obesity prevalence, which may be due to
the lower prevalence baseline in the sample. However, the trend was
in the desired direction of decreasing likelihood of being overweight.
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Health Promotion Journal of Australia 2012: 23(1)
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The difference in significance for different indicators of overweight
and obesity status may be related to the complexity inherent in its
assessment among preschool age children due to the adiposity
rebound process.
32
However, changes in all indicators were in the
same direction of reducing overweight rates among intervention
children, regardless of their magnitude and significance.
Changes in nutrition and physical activity behaviours take time
before they manifest as changes in body weight, so the short time
lapse between the intervention and follow-up evaluation could have
made such changes harder to detect.
A number of limitations should be noted. There were reliability issues
with waist circumference measurement so only data in which the
same tester measured waist circumference pre and post intervention
were included.
FMS inter-rater reliability was high, but was only measured in the
training and pilot stages. To minimise error, each child’s pre and post
FMS testing was conducted by the same tester whenever possible.
Even if there was a drift between testers, since most testing was done
by the same researchers the difference between intervention and
control baseline and follow-up scores should not have been affected
by inter-rater differences.
The use of a number of instruments allowed for triangulation of
findings, e.g., indicators of overweight and obesity moved in the same
direction. Measuring children’s food intake via the parent surveys, as
well as recording their lunch box contents, ensured that the positive
results achieved following the intervention − increasing healthier
food consumption during preschool hours − were not at the expense
of decreased healthy food consumption at home.
The parents’ survey may have had limitations typical of self-reported
instruments such as biasing responses towards the perceived desired
effect.
33
However, using baseline parent surveys for the above analysis
minimised potential differences between intervention and control
parents regarding this bias.
The instruments used in the study were comprehensive and covered
a number of variables of interest, e.g. healthy as well as unhealthy
foods and drinks were assessed. This allowed for an exploration of
a ‘big picture’ of the children’s behaviours as well as intervention
effects. Further analyses of the relationships and associations between
variables within and between instruments might be conducted and
published in future papers.
Overall, the results found in this study are very positive. It was
encouraging to find that the intervention had a significant effect
on BMI Z scores and waist circumference in such a short period. The
findings in this study are consistent with that of ‘Romp & Chomp’, a
whole-of-community intervention targeting similarly aged Australian
children, which showed that the implementation and enforcement
of effective policy, cultural changes and capacity building with early
childhood staff and caregivers can successfully reduce obesity in early
childhood.
31
The key difference is that the Tooty Fruity Vegie program
focused solely on preschools and is therefore unique in Australia. This
evaluation shows the utility of this type of intervention in preschools
and will add to the limited literature regarding early childhood obesity
prevention interventions. The TFV project has been adapted and
scaled up for all childcare centres in NSW by NSW Health under the
name Munch and Move.
Further research is warranted, particularly in relation to the association
between early FMS and later physical activity engagement. Findings
are inconsistent with one study finding no association,
34
another
study finding association only between locomotor skills and physical
activity,
35
and yet another study finding association between object
control skills and physical activity.
36
A follow-up study when children
are in primary school might add to and clarify the existing evidence
regarding this relationship. It could also examine the relationship
between early and late FMS levels as well as the relationship of both to
physical activity engagement. A follow-up study might also examine
whether the intervention had any long-term impact on motor skill
ability and/or physical activity.
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Authors
Avigdor Zask and Jillian Kaye Adams, Health Promotion, Northern New
South Wales Local Health District
Lyndon Owen Brooks, Division of Research, Southern Cross University,
New South Wales
Denise Frances Hughes, Health Promotion, Northern New South Wales
Local Health District
Correspondence
Dr Avigdor Zask, Health Promotion, Northern New South Wales Local
Health District, PO Box 498, Lismore, NSW 2480;
e-mail: avigdor.zask@ncahs.health.nsw.gov.au
Program Evaluation Evaluation of obesity prevention intervention in Australian preschools

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