Development of a Family-Based Nutrition Program Rooted in Food Parenting Literature

Abstract

Family-based nutrition programs have been used to support healthy eating; however, few programs emphasize parental roles in regard to food. The purpose of this study was to develop and test a family-based curriculum with a parenting focus aimed at influencing child obesity risk. Qualitative data in the pilot implementation (cohort 1, n = 6 families with elementary-aged children) suggested parent value for: positive messages, hands-on learning, and group sharing. However, Family Nutrition and Physical Activity (FNPA) scores for cohorts 2-6 (n = 18 families) did not change significantly from pre- to post-program. Future implementations will consider more robust ways of assessing change and recruiting participants at various stages of change.

Eating habits and nutrition status during childhood have been a significant focus of recent study, in response to increased obesity risk among U.S. children (Ogden et al., 2018). Food preferences developed in childhood are influenced by availability and accessibility of foods, familiarity to foods, and modeling by parents and caregivers, as important gatekeepers of early food experiences (Birch, Savage, & Ventura, 2007). Thus, parents and caregivers are important targets for interventions to improve children’s diet quality (Birch et al., 2007). While research supports the use of community and family-based interventions in improving eating habits and nutrition status of children, few programs have emphasized food-related parenting practices. The purpose of this study was to develop and pilot test a family-based curriculum with a parenting focus aimed at influencing child obesity risk.

REVIEW OF LITERATURE

Researchers have used diet quality measures to estimate the degree to which food intake aligns with nutrition recommendations. The Healthy Eating Index (HEI) is a diet quality measure used commonly with national data sets in the U.S. and is measured on a scale of 0-100. While mean HEI scores among 2-18 year old children improved from 44.6 in 1999-2000 to 49.6 in 2015-16 (HEI-2015), continued improvement is needed. Mean HEI sub-component scores during 2015-16 suggest areas to target. Children’s diet scores were particularly low in total vegetables (mean score 2.3 out of 5), greens and beans (1.2 out of 5), whole fruits (2.7 out of 5), seafood and plant proteins (2.0 out of 5), whole grains (3.2 out of 10), and fatty acids (3.6 out of 10). These scores indicate low consumption of foods with higher nutrient density and moderate to high consumption of refined grains, sodium, and saturated fats. Children’s diets came close to meeting the maximum scores for dairy and total protein foods (Liu, Rehm, Onopa, & Mozafarrian, 2020).

Parents and caregivers exert a key influence in the development of food intake patterns in children. One way parents influence this development is through the foods they make available to their children. Not surprisingly, research supports an association between a healthy home food environment and food intake measures, such as higher diet quality (Couch, Glanz, Zhou, Sallis, & Saelens, 2014), higher fruit and vegetable intake (Ding et al., 2012), and lower fast food intake (Ferris, Babskie, & Metzger, 2017). In addition to home food availability, a recent body of research has investigated parenting styles and practices related to food provisioning, leading to the development of the term “food parenting.” The food parenting literature describes feeding styles (such as authoritarian or indulgent styles) and parenting practices around child feeding (such as foods parents offer their children and parent modeling). This literature investigates the relationship between these constructs and child health outcomes.

Feeding Styles

Parent feeding styles characterize the emotional environment of the meal (Vollmer, 2019). Studies have investigated links between general parenting styles, feeding styles, and child weight status, suggesting an association between an indulgent feeding style and higher child weight, and between an authoritarian feeding style and healthy child weight (Shloim, Edelson, Martin, & Hetherington, 2015; Vollmer & Mobley, 2013). Evidence also suggests a relationship between the authoritarian feeding style and healthier food intake patterns (Vaughn et al., 2016; Vollmer & Mobley, 2013) and between the indulgent feeding style and higher intake of low nutrient-density foods (Hennessy, Hughes, Goldberg, Hyatt, & Economos, 2012). Relationships between food parenting and child eating behaviors are thought to be bidirectional. Thus, the child’s behavior and/or weight can influence the food parenting and vice versa, adding to the complexity of understanding these relationships (Vaughn et al., 2016). For example, parents who prioritize providing healthy snacks may use restrictive practices if they have a child who enjoys healthy foods but is overweight and tends to overeat all types of foods. In turn, the restrictive practices may contribute to the child overeating when food is available. Therefore, the child’s behavior influences the food parenting practices and vice versa, and the relationship between food parenting and child eating becomes bidirectional.

Parenting Practices

Food-related parenting practices have been found to influence children's dietary behaviors (such as foods parents make available, modeling of eating habits, and communication about food/health) (Dickin, Hill, & Dollahite, 2014; Gerards & Kremers, 2015; Vaughn et al., 2016; Vollmer & Baietto, 2017). Three main categories of food parenting practices have been described in the literature: coercive control, structure, and autonomy support (Musher-Eizenman et al., 2018; Vaughn et al., 2016). Coercive food-related parenting practices (such as using food as a reward, using food to regulate emotions, and pressuring children to eat) have been associated with child preference for higher sugar and/or fat foods (Vollmer & Baietto, 2017). Children whose parents make healthy food available at home, model healthy eating, and talk about the importance of eating healthy food may have lower preference for high sugar and high fat foods (Vollmer & Baietto, 2017). While more research is needed to better understand directionality of these associations, food-related parenting practices may be an important component of interventions aiming to improve eating habits within families. Additional research is needed to better understand long-term impacts of food-related parenting practices and styles on health (Vaughn et al., 2016; Vollmer & Mobley, 2013), and how to modify each to best support child health. Furthermore, interactions between practices and styles suggest addressing both of these constructs when providing nutrition education to parents (Vollmer, 2019).

Interventions

Research supports the use of community and family-based interventions in improving eating habits and nutrition status of children. Some family-based intervention studies have shown improvement in key health behaviors (e.g., increased consumption of fruits and vegetables, reduced consumption of sugar sweetened beverages, and increased physical activity) (Anderson, Newby, Kehm, Barland, & Hearst, 2015; Dollahite, Pijai, Scott-Pierce, Parker, & Trochim, 2014), while others have shown reductions in weight gain and risk for metabolic syndrome (Anderson et al., 2015; Dollahite et al., 2014). Family-based nutrition interventions with aims to improve the health of children under the age of 12 are mostly delivered in schools and are limited in assessing intervention impacts on parents (Black, D'Onise, McDermott, Vally, & O'Dea, 2017).

Few family-based nutrition programs have emphasized food-related parenting practices. An example that incorporates this perspective is the Healthy Children, Healthy Families: Parents Making a Difference (HCHF) curriculum, aimed at low-income parents and caregivers of elementary-aged children (Lent, Hill, Dollahite, Wolfe, & Dickin, 2012). The HCHF curriculum is an eight-workshop series delivered in various settings (e.g., child care, schools, and worksites) and promotes parenting practices to influence nutrition and physical activity behaviors associated with healthy weight in children. The parenting practices known as “Keys to Success” include: 1) showing healthy behaviors through role-modeling; 2) supporting the child’s self-regard; 3) guiding food choices and setting limits; and 4) shaping home environments.

A similar program (the Healthy, Happy Families (HHF) curriculum) also prioritized parent involvement to promote healthy eating for pre-school aged children (Ontai, Lipscomb, Sitnick, Bowers, & Lamp, 2013). In the program, parents were randomly assigned to three groups with different lesson formats and materials: 1) in-class mini lessons using HHF materials and parent brochures; 2) regular nutrition lessons and parent brochures; and 3) regular nutrition lessons only. The HHF lessons focused on parenting practices similar to HCHF’s “Keys to Success,” such as setting limits and supporting the child’s appropriate development, but also encouraged concepts such as play, eating routines, and positive communication with the child.

The lessons in both programs emphasized skills parents can use to influence healthy eating habits in their children. An evaluation of the HCHF curriculum reported positive behavior changes related to diet, physical activity, and media use in both parents and children (Dickin, Hill, & Dollahite, 2014). In the HHF program, parents who participated in groups that used HHF materials compared to those who participated in only regular nutrition lessons reported significant improvements in study measures of general parenting and attitudes about child feeding (Ontai et al., 2013).

As the food parenting literature is nascent, additional research in a variety of settings and audiences on family-based programs with a parenting focus to improve family habits known to influence child obesity risk is needed. The purpose of this article is to: 1) present a summary of the development of a family-based, food-parenting focused nutrition curriculum designed using theory and research; 2) describe formative assessment findings collected to guide future modifications of the program; and 3) highlight implications for practice and future directions of the program.

METHODOLOGY

Development of the Program

In 2017, a pediatric practice in Long Beach, California contacted California State University Long Beach requesting to form a collaboration with a local recreational facility (the Young Mens’ Christian Association [YMCA]) to provide a nutrition and fitness program for families. The pediatric practice desired a program to support healthy eating and activity among families with children experiencing obesity. A team of faculty and students at California State University Long Beach developed a nutrition curriculum, the Step UP, Eat Right Kids (SUPERKids) program, for implementation with families of elementary school children in a community setting. The program consisted of six lessons delivered once a week based on the food parenting literature and social cognitive theory. The program goal was to promote family habits known to influence child obesity risk.

A literature review focused on child nutrition, food parenting, and theory-based nutrition interventions was conducted for program development. Six weekly lessons were developed to include a nutrition topic, a parenting topic/strategy, and an application activity. A leading model for effective nutrition education suggests developing programs based on evidence and theory, while integrating: 1) a motivational component that addresses beliefs and attitudes; 2) an action phase focused on goal-setting and skills; and 3) an environmental component focused on enhancing support for healthy behaviors (Contento, 2008). To that end, the program integrated group discussions, application activities, goal setting, and social support in addition to teaching key concepts, with a base in Bandura’s social cognitive theory (SCT) (Bandura, 1986). In the context of nutrition, SCT emphasizes that food and diet-related behavior change is influenced by personal, behavioral, and environmental factors and interactions. Table 1 describes a general outline of each lesson including nutrition and parenting topics, lesson objectives, selected application activities, the connection between lesson components and SCT elements.

TABLE 1.

Topics, Selected Lesson Objectives and Activities, and Related Social Cognitive Theory Constructs in the SUPERKids Program

	Lesson 1	Lesson 2	Lesson 3	Lesson 4	Lesson 5	Lesson 6
Nutrition Topic	Nutrition Basics	Nutrition Label Reading	Portion Sizes & Paying Attention to Hunger & Fullness	Healthy Hydration & Carbohydrates	Snacking & Social Settings & Protein	Healthy Food Together & Fat
Selected Objectives (“Parents and children will be able to…”)	List at least two contributors to food choice & physical activity. Use MyPlate to plan a meal that includes all five food groups.	Use nutrition labels to select healthy foods.	Compare recommended portion sizes (MyPlate) to typical intakes. Use a Hunger and Fullness scale to guide mindful eating.	Differentiate between refined and whole grains. Use the Nutrition Facts label to calculate the amount of sugar (in tsp.) when given grams of sugar in a product.	Use nutrition labels to assess nutrient density of various snacks. Discuss parental roles in modeling healthy snacks in children’s social settings. (Parents Only)	List examples of sources of healthy fats. List at least two functions of fat in the body.
Parenting Topic	Basic Food Parenting Styles	Modeling Health	Mealtime and Family Communications	Food Routines	Body Image	Involving Children in Selecting and Preparing Food
Selected Objectives (Parents will be able to…)	List three food parenting styles.	Evaluate ways to improve modeling healthy eating and activity habits.	Assess feasibility of family meals. Develop a tool for facilitating conversation around meals.	Evaluate current food routines to identify one area of potential improvement.	Discuss strategies for promoting a healthy body image among children.	Assess current practices for involving children in food selection and preparation.
Selected Lesson Activities	Parents and children evaluated types of food available in their home as a take-home activity; incentives were used to promote home activities.	Parents reflected on their influence on children’s eating behaviors and discussed changes they could make in their home food environments, actions, and conversations about food and eating.	Children used the Hunger and Fullness (HF) Scale to evaluate sample scenarios.	Parents made a meal planning tool to use with their children and received a handout with meal ideas.	Parents collaborated to write a sample dialogue between a parent and child to illustrate body image concepts.	Parents reviewed age-appropriate kitchen tasks for children and identified tasks their children could perform. Parents and children worked together to make a Greek salad.
Theoretical Relevance	Reinforcements Providing incentives encouraged participants to apply lesson concepts at home and in social contexts. Observational learning A group format allowed parents to learn from one another.	Outcome expectancies Discussions stimulated parents to reflect on their values and goals and reiterated program values (e.g., parent modeling).	Behavioral capability Immediate opportunities to practice, such as the HF scale activity, allowed participants to practice skills. Families were encouraged to repeat what they learned at home.	Self-control The meal planning tool promoted self-regulation and allowed participants to consider values, preferences, and feasibility to meal plan as a family.	Self-efficacy Repetition of concepts and activities (e.g., label reading) promoted confidence in performing behaviors. Observational learning A group format allowed parents to learn from one another.	Outcome expectations Reflection-based discussions on topics such as child involvement in food preparation helped parents consider the potential impacts behaviors.

Nutrition topics.

Aimed to both parents and children, nutrition topics and activities were chosen to align with major messages of MyPlate (e.g., making half of the plate consist of fruits and vegetables and choosing whole grains), while integrating evidence-based strategies suggested in the research literature (e.g., teaching label reading, attunement to portion sizes and hunger/fullness cues, healthy hydration and snacking habits, and enjoying healthy food together in families) (Allirot, da Quinta, Chokupermal, & Urdaneta, 2016; Berge, MacLehose, Larson, Laska, & Neumark-Sztainer, 2016; Birch, Williams, & Fisher, 2015; Leung, DiMatteo, Gosliner, & Ritchie, 2018; Liang et al., 2016; Smith et al., 2015).

For example, in Lesson 5 participants evaluated facilitators and barriers to healthy snacking and used nutrition labels to assess common snacks. The activity for this lesson stimulated participants to evaluate nutrition labels of snack foods, combining concepts related to nutrient density (introduced in Lesson 1), label reading (Lesson 2), and sugar recommendations (Lesson 4). The intention of the repeated practice was to build self-efficacy in evaluating nutritional value of foods. Throughout the curriculum, group discussions were used to promote peer interaction and observational learning, an application of the SCT. Also, families discussed how they had applied lesson content at the beginning of each subsequent lesson.

Parenting topics.

Lessons related to parenting strategies were delivered while children participated in physical activity led by YMCA staff, and focused on food parenting behaviors related to: food availability/accessibility, modeling of healthy habits, and positive conversations about food, health, and bodies (Couch et al., 2014; Knol et al., 2016; Lucas-Thompson, Graham, Ullrich, & MacPhee, 2017; Roach et al., 2017; Robson et al., 2016; Sleddens et al., 2014). In Lesson 1, the concept of “food parenting” was introduced to participants.

Parents were prompted to evaluate their food parenting styles, while discussing three scenarios representing controlling, permissive, and structure/guidance food parenting styles. In this same lesson, strategies to support healthy eating were presented, focused on availability/accessibility, modeling, and communication around food. Subsequent weeks built upon this foundation. Discussions emphasized non-judgment, kindness, and support among parents, while acknowledging the difficulty of parenting. Parents were encouraged to draw upon past experiences (family, living environment, etc.) that have shaped their practices. Discussions allowed parents to learn from others’ thoughts and experiences. See Table 1 for examples of activities used to reinforce food parenting messages.

Application and practice.

At the conclusion of the parent discussion, the children returned from their physical activity session. Application activities aimed towards both parents and children were included at the end of each lesson, and ended with a family challenge to pursue. For example, participants prepared and tasted infused water after learning about sugar content of common beverages. They were challenged to try making infused water at home; participants shared their applications on a program social media site and were recognized and given a prize at the subsequent program meeting. Furthermore, the social media site was integrated in the program to foster communication between parent participants and instructors and to provide brief lesson reviews and reminders. The use of the social media site was voluntary, and parents who chose to opt out of the site were able to submit SUPERKids challenges through email. Social cognitive theory was used in designing application and challenge activities to support self-efficacy, behavioral capability, and to reinforce positive outcomes of healthy food and activity habits (Knol et al., 2016; Spears-Lanoix et al., 2015).

Implementation and Evaluation of the Program

Participants.

Parent and child participants for the program pilot were recruited using convenience sampling methods. Flyers describing the SUPERKids program were distributed at the collaborating pediatric practice to parents of elementary-aged children and at the collaborating YMCA. Interested participants were asked to contact the director of the YMCA facility to sign up.

Procedures.

A series of six lessons was presented to six cohorts of families between fall 2017 and spring 2019. Lessons were instructed by a dietetic intern and curriculum writers (a registered dietitian and an undergraduate research student in nutrition). The registered dietitian primarily covered the parenting topic, while the dietetic intern and undergraduate student alternated in presenting the nutrition topic and application. Instructors were provided with a detailed curriculum, script, and lesson handouts and slides to review and practice prior to each lesson. All study procedures were approved by the California State University Long Beach Institutional Review Board, and informed consent was collected among parents at the beginning of each series.

In Cohort 1, a qualitative design was used to collect formative evaluation data to assess fit between the program and the audience and to guide future modifications of the program. Qualitative methods are useful for gaining insight into how and why specific program elements operate well or need adjustment, and have been used in similar studies (Andrews, Gray, Galvan, & Donlin, 2017; Besnilian, Johnson, & Plunkett, 2018). Following each lesson, parent participants completed a survey with three open-ended questions assessing what they liked about the lesson, what they found helpful, and suggestions for improvement. After the final lesson, parents were invited to participate in a focus group led by a trained moderator to share motivations for participating, knowledge or skills gained, and successes and challenges in applying lesson concepts outside of the classroom. Amendments were made to the program based on findings from Cohort 1. For Cohorts 2-6, parent participants completed a demographic survey at the first lesson and a 20-item survey in the first and last lesson to assess changes in family habits known to impact obesity risk.

Instruments.

The focus group guide used in Cohort 1 included open ended questions to elicit program feedback and was developed by researchers with expertise in nutrition and child development/family studies. In Cohorts 2-6, program impacts on family behaviors were assessed using the validated 20-item Family Nutrition and Physical Activity (FNPA) assessment tool (Ihmels, Welk, Eisenmann, Nusser, & Myers, 2009), administered on the first and last days of the program. The FNPA tool was selected since scores have shown to predict change in BMI in children, and SUPERKids leaders desired to emphasize habit formation as a goal within the six-week class rather than focusing on immediate weight change as an outcome.

The tool includes 10 subscales that assess changes in practices related to family meals, family eating practices, food and beverage choices, food restriction and rewards, screen time practices, healthy food environments, child and family activity, and family schedule and sleep routines. Examples of FNPA questions include: “How often does your child eat at least one meal a day with at least one other family member?” (subscale: Family Meals); “How often does your family use candy, ice cream, or other foods as a reward for good behavior?” (subscale: Food Restriction and Reward); and “How often does your child do physical activities with at least one other family member?” (subscale: Family Activity). Question responses included never/almost never, sometimes, often, and very often/always. See Table 2.

TABLE 2.

Survey and Focus Group Questions from Cohort 1

	Questions
Survey (administered after every lesson)	What three things did you like about today’s lesson? What three things did you find most helpful about today’s lesson? What do you suggest changing about today’s lesson?
Focus Group (administered at the end of the program)	Statement of Confidentiality – Do you agree to keep the discussion in the room confidential? How did you hear about SUPERKids? What motivated you to participate? What did you think the program would be about? What have you learned in the SUPERKids Program? Next, I’d like you to reflect on the successes and challenges you have experienced in practicing what you have learned at home. What helped you to be able to apply what you learned? What makes it hard to make changes? What suggestions do you have for the SUPERKids lessons in the future?

Data analysis.

The focus group recording in Cohort 1 was transcribed and coded by two independent researchers using thematic analysis (Braun & Clarke, 2006). A codebook was developed based on the codes that were identified from the focus group data. This codebook was also used to assess the open-ended questions in the survey data, as themes that arose from the focus group data were consistent with survey data. These themes were used to suggest program modifications. For Cohorts 2-6, changes in overall FNPA score and subscales were assessed using related-samples sign tests. This is a non-parametric difference test for related samples used due to the small sample size.

RESULTS

Cohort 1

On average, families (n = 6) attended four of six classes, with an average attendance of four families per lesson of the pilot. Most commonly, one parent and one or two children attended. Most families identified as Hispanic (n = 4), and most were married (n = 4), with one family not submitting a demographic survey. Four parents (three mothers and one father) participated in a focus group at the end of session six, and 23 surveys were submitted, with an average of four surveys per lesson. See Table 3 for demographic data for all cohorts. Themes from the focus group included motivation, barriers, positive mindset, making changes, habits, and sharing (see Table 4 for selected quotes from focus groups related to each of these themes).

TABLE 3.

Demographic Data for Cohorts 1 to 6 (n=23)

	Group	n	%
Age (years)	Less than 25
	26-36	5	21.7
	36-45	12	52.2
	46-55	6	26.1
Race/Origin	White	7	30.4
	Black or African American	1	4.3
	Hispanic, Latino, or Spanish origin	9	39.1
	American Indian or Alaska Native	2	8.7
	Hawaiian or other Pacific Islander	2	8.7
	Multiple Groups (identified as >2)	2	8.7
Gender	Male	5	21.7
	Female	18	78.3
Marital Status	Single (never married)	1	4.3
	Married/Domestic Partner	21	91.3
	Divorced	1	4.3
Household Income Level	<$40k	2	8.7
	$40k-$69,999	5	21.7
	$70k-$99,999	5	21.7
	$100k-$150,000	8	34.8
	>$150k	3	13.0

TABLE 4.

Themes and Selected Quotes from Focus Group with Parents in Cohort 1 (n=4)

Themes	Selected Quotes
Motivations Family, health, and interactions with a nutrition professional as motivations to seek healthy habits.	Family: “Oh this feels good like I need to, I can do more with my child.” Health: “I want them to have a good health. My family has suffered from diabetes (and) high blood pressure…and I don’t want that future for my kids.” “For me it’s the fear… for all of us in a way but you know, my children, it’s like wait a second. (There are) things that are showing up in your bloodwork I don’t even have.” Professional: “This came as a perfect opportunity so that it can be someone else speaking to her about nutrition instead of me being the bad guy…” “Hearing someone else that’s not mom or dad or … it wasn’t taken as a like, are you nagging me? … you know what I mean; it’s a health professional.”
Barriers Time, cost, and habits as barriers to personal and family health goals.	Time: “Time’s always an issue.” “I’m a full time student and I work. And then I have the boys and it’s just I study so much.” Cost: “I’m gonna say it’s a little more expensive to eat healthier.” Habits: “We’re at restaurants we have been doing that a little bit too much so then because of time and everything but it’s really made us focus on eating at home.”
Positive Mindset Positive perspectives about food conversations, especially with their child.	Conversations with their child: “I had never heard anyone say ‘don’t call it junk food’… ‘don’t give it a shameful name.’ … I’d never heard that before so that was that was really helpful.” “But what is your body telling you: Are you hungry? Should you have that, or are you okay? You know, listen to it, give it a couple minutes.”
Making Changes Applications of program messages outside of the lesson setting.	In their child: “But after few weeks that she’s been here … we come home and she makes a little bit healthy cause we always fried food. That’s why now a little bit through her staying away from frying and little bit of salad here and there.” “We’ve all become aware and I notice especially for him, ‘Oh wait, what is our veggie today?’” “Whatever she’s learning here she’s trying to carry it over at home.” As a family: “We’ve been eating together more as a family, which I told you we hardly ever sat down to eat.” “I’ll come home and make with the girls the side dishes so their little salad or veggies and the fruits and veggies, and that’s been working really well. Personal change: “I have been losing weight since I started this program because I really am determined, like you said making sure that I’m getting my steps in, you know moving at work when I’m at work so I’m not sitting all day.”
Habits Impacts of lessons on developing healthier habits.	Breaking perceptions: “You kept saying this food should taste good, and that for me (is) so important because a lot of times when you think health food, oh it’s not gonna have…that flavor you know.” Food preparation: “We’ve done that infused water at home … so that was really nice to see it in action.”
Sharing Usefulness and enjoyability of discussions among parents.	“I liked our sharing ‘cause I got ideas off of everyone else… and realize like okay I’m not so bad it’s the same struggle we all have it.” “It was so great being able to talk to people.”

Motivation.

Participants shared they were motivated to attend by family health concerns and desire to establish healthy family eating and exercise habits.

Barriers.

Parents shared similar challenges that hindered them from achieving healthy eating goals, such as difficulty of planning meals, time, cost, and habits.

Positive mindset.

Parent learned the importance of being a positive role model for their children and were encouraged by the program emphasis on positive conversations to encourage healthy eating (e.g., not calling particular foods “bad”).

Making changes.

Parents believed that their children were more inclined to take action towards healthy eating habits when a professional spoke of its value and gave examples of changes they were making as a family.

Habits.

Parents found the program’s hands-on food preparation activities to be helpful in encouraging development of healthy eating habits. They noticed changes occurring in their family such as more time spent eating together, using their hunger cues, and increased communication about healthy eating.

Sharing.

Parents indicated in the focus group that they enjoyed interacting and sharing ideas with other parents, especially when common struggles were shared. In addition, parents mentioned the discussion of specific topics and information as helpful (e.g., learning to use the hunger and fullness scale, evaluating food labels, reviewing MyPlate, etc.).

Surveys elicited feedback on perceived value of each lesson; responses reinforced many focus group themes. Parents valued strategies for overcoming barriers. One parent shared, “I liked that we talked about real life and how to eat healthy even when we are busy.” Parents shared examples of valuing a positive mindset around food in the program. For example, one parent appreciated “opening up dialogue with my child about nutrition in a positive manner.” Parents mentioned gaining skills that support making changes and habits, such as learning about food parenting styles and modeling (Lesson 1), “evaluating food labels” (Lesson 2), “how to calculate how much sugar in a drink” (Lesson 4), and “how to teach positive change to my kids” (Lesson 5).

Survey respondents consistently noted for each lesson that class materials such as handouts and hands-on activities around food were also appreciated and helpful. Parents appreciated time for sharing in class discussions and suggested more time for collaborative dialogue and problem solving. In the words of one parent: “I really enjoyed talking about food ideas, ways to work on our daily challenges. I am really learning so much about health for me and my family.” Another parent valued “talking about our issues with our kids” and “sharing challenges.”

Cohorts 2-6

Pre- and post-data were obtained from 18 participants (one parent per family) in Cohorts 2-6. Most commonly, one parent and one or two children attended, with an average attendance of approximately four of six classes. Most participants identified as Hispanic (n = 6) and/or White (n = 9), and most were married (n = 17). Most (n = 14) participants were female.

While subscale and overall mean scores trended upward for all but two subscales, there were no statistically significant changes in overall or sub-scale FNPA scores. High scores on the pre-test (e.g., mean overall score of 62.1 out of 80 and mean family meals sub-scale score of 7.78 out of 8) may have limited change. See Table 5.

TABLE 5.

Family Nutrition and Physical Activity (FNPA)^a Sub-Component and Overall Scores at Pre- and Post-Intervention for Cohorts 2 to 6 in a Family-based Nutrition and Fitness Class (n=18)

FNPA Scale b	Pre-test (mean ± SD)	Post-test (mean ± SD)	p c
Family Meals (FM)	7.78 ± 0.55	7.61 ± 0.84	.08
Family Eating Practices (FEP)	5.83 ± 0.99	6.11 ± 0.96	.32
Food Choices (FC)	6.03 ± 0.88	6.39 ± 1.09	.18
Beverage Choices (BC)	5.78 ± 1.11	5.83 ± 1.62	.91
Restriction/Reward (RR)	6.28 ± 1.13	6.00 ± 1.33	.42
Screen Time (ST)	5.67 ± 1.37	5.92 ± 1.25	.40
Healthy Environment (HE)	6.36 ± 1.13	6.78 ± 0.94	.26
Family Activity (FA)	6.19 ± 1.32	6.67 ± 1.08	.19
Child Activity (CA)	5.32 ± 1.53	6.00 ± 1.77	.07
Family Schedule/Sleep Routine (FSSR)	6.83 ± 1.28	6.92 ± 1.09	.78
Overall FNPA Score d	62.1 ± 6.41	64.6 ± 6.49	.09

^a(Ihmels, Welk, Eisenmann, Nusser, & Myers, 2009)

^bEach sub-component score has a potential range of 2-8.

^cP-values from related samples sign tests.

^dOverall FNPA score has a potential range of 20-80.

CONCLUSION AND IMPLICATIONS

As the food parenting literature has expanded in recent years, applications to develop skills for promoting healthy eating that are relevant to family life may help parents find nutrition messages more achievable. The SUPERKids program strives to portray healthy family eating as enjoyable and attainable while empowering families to make small changes in family habits within the context of busy lives. For example, the program promotes a variety of ways to increase family meal sharing (breakfast, after school snack time, evening snacks after extracurricular activities, and weekend meals) rather than suggesting that daily, weekday evening meals are the best approach for family meals. While recognizing that many families entered the program with concern about their children’s eating habits and weight, participant feedback suggests value for focusing on healthy family habits as an outcome.

These findings align with a recent position paper with recommendations of the Nurturing Children’s Healthy Eating Collaboration for encouraging and supporting healthy eating in children living in the Western world. The paper makes recommendations around four key ideas: 1) positive parental feeding; 2) sharing food together in families; 3) healthy home food environments (including food availability, accessibility, and modeling); and 4) the pleasure of eating (Besnilian et al., 2018; Haines et al., 2019).

Feedback provided from Cohort 1 of the pilot intervention supports use of social-cognitive theory as a base for program activities. The Healthy Children, Healthy Families: Parents Making a Difference (HCHF) curriculum was also based on social cognitive theory and utilized behavior-focused activities and dialogue in its lessons. Similar to the feedback of SUPERKids participants, self-reports of HCHF participants noted positive changes in nutrition and physical activity behaviors (Lent et al., 2012). Additionally, feedback from Cohort 1 suggested enhancing ways for families to engage in hands-on learning (increasing behavioral capability and self-efficacy), to support each other and problem solve together in class through discussions (enhancing observational learning and outcome expectancies), and to engage with one another between classes (reinforcing class content).

This highlights the potential influence of group engagement in nutrition education interventions, not just between parents and children but between each family unit as a cohort. The curriculum was thus adapted for successive cohorts 2-6 (e.g., more hands-on and collaborative activities, inclusion of parents in the physical activity component, enhanced group discussions and problem solving around common barriers to family nutrition and physical activity habits, and enhanced use of the program social media site, which allowed participants to share program applications between sessions). Positive food messages and eating habits remained an emphasis of the curriculum.

While Cohorts 2-6 of this pilot intervention did not show evidence of significant changes in FNPA scores from pre- to post-intervention, family habits may take longer than six weeks to see notable changes; longer term follow up may improve capturing of program impacts. In addition, many participants started the program with relatively high pre-test scores. Therefore, targeted recruitment efforts to attract families with lower initial FNPA scores are needed.

Nutrition education programs like SUPERKids require environmental support to achieve long-term behavioral change. Policymakers in the community and at institutions that promote physical activity, such as the YMCA, can invest resources that support families in complementary health behaviors, such as healthy eating and physical activity. Resources may include additional funding, assistance with recruitment of participants and instruction of nutrition classes, and providing incentives for continued participation.

LIMITATIONS AND FUTURE RESEARCH

Formative evaluation of this program used a convenience sample of 24 families in Southern California, which limits generalizability of findings. Due to the small size of participants in each lesson and in the overall study, results between families across different sociodemographic variables such as race and income level were not compared. Future interventions with larger and diverse samples could provide additional insight on how to cater curricula to specific family needs by comparing results across various levels of sociodemographic variables.

Although parent education level was not measured in this study, other family-based interventions may benefit from collecting these data, as links between parent education level and children’s consumption of unhealthy foods have been noted (Fernández-Alvira et al., 2013). Self-selection bias may have limited change from pre- to post program, as participating families may have already been familiar with program recommendations and entered the program with high motivation.

For diverse audiences with a range of motivations and skills, complementing validated tools such as the FNPA tool with self-reported evaluations linked to lesson objectives may improve evaluations of program impacts. Examples may include collecting data on observable behaviors discussed in lessons or evaluating participant intake of specific foods mentioned in the program (Contento, Randell, & Basch, 2002). Intake can be feasibly measured through short dietary assessments, such as the Block Screener for Fruits, Vegetables, and Fiber used in the Loving Your Family nutrition education program (Schultz & Litchfield, 2016).

While nutrition and obesity prevention messages are common in U.S. culture, practitioners may find that programs like SUPERKids that emphasize enjoyment of healthy foods, positive health messages, parenting skills, and hands-on applications empower families to work together towards healthy habits. Additional research among diverse audiences, across geographical locations, and with longer term follow up is needed to improve understanding of how to use the emerging food parenting literature to best promote family nutrition.