Assessing food selection in a health promotion program: validation of a brief instrument for American Indian children in the southwest United States.

OBJECTIVE: Brief dietary assessment instruments are needed to evaluate behavior changes of participants in dietary intervention programs. The purpose of this project was to design and validate an instrument for children participating in Pathways to Health, a culturally appropriate, cancer prevention curriculum. DESIGN: Validation of a brief food selection instrument, Yesterday's Food Choices (YFC), which contained 33 questions about foods eaten the previous day with response choices of yes, no, or not sure. Reference data for validation were 24-hour dietary recalls administered individually to 120 students selected randomly. SUBJECTS: The YFC and 24-hour dietary recalls were administered to American Indian children in fifth- and seventh-grade classes in the Southwest United States. STATISTICAL ANALYSES PERFORMED: Dietary recalls were coded for food items in the YFC and results were compared for each item using percentage agreement and the kappa statistic. RESULTS: Percentage agreement for all items was greater than 60%; for most items it was greater than 70%, and for several items it was greater than 80%. The amount of agreement beyond that explained by chance (kappa statistic) was generally small. Three items showed substantial agreement beyond chance (kappa > or = 0.6); 2 items showed moderate agreement (kappa = 0.40 to 0.59) most items showed fair agreement (kappa = 0.20 to 0.39). The food items showing substantial agreement were hot or cold cereal, low-fat milk, and mutton or chile stew. Fried or scrambled eggs and deep-fried foods showed moderate agreement beyond chances. CONCLUSIONS: Previous development and validation of brief food selection instruments for children participating in health promotion programs has had limited success. In this study, instrument-related factors that apparently contributed to poor agreement between data from the YFC and 24-hour dietary recall were inclusion of categories of foods vs specific foods; food knowledge, preparation, and vocabulary, item length, and overreporting of attractive foods. Collecting and scoring the 24-hour recall data may also have contributed to poor agreement. Further development of brief instruments for evaluating changes in children's behavior in dietary programs is necessary. Factors related to the YFC that need further development may be issues that are also important in the development of effective, brief dietary assessments for children as individual clients or patients.

Portion-size estimation training in second- and third-grade American Indian children.

Training in portion-size estimation is known to improve the accuracy of dietary self-reporting in adults, but there is no comparable evidence for children. To obtain this information, we studied 110 second- and third-grade American Indian schoolchildren (34 control subjects were not trained), testing the hypotheses that a 45-min portion-size estimation training session would reduce children's food quantity estimation error, and that the improvement would be dependent on food type, measurement type, or both. Training was a hands-on, 4-step estimation and measurement skill-building process. Mixed linear models (using logarithmic-transformed data) were used to evaluate within- and between-group differences from pre- to posttest. Test scores were calculated as percentage estimation errors by difference and absolute value methods. Mean within-group estimation error decreased significantly (P<0.05) from pre- to posttest for 7 of 12 foods (trained group) by both calculation methods, plus 3 additional foods by the difference method and one additional food by the absolute value method. Significant (P<0.05) between-group differences occurred for 3 foods, reflecting a greater decrease in estimation error for the trained group. Improvement was greatest for solid foods estimated by dimensions (P>0.05) or in cups (P<0.05), for liquids estimated by volume or by label reading (P<0.001), and for one amorphous food estimated in cups (P<0.01). Despite these significant improvements in estimation ability, the error for several foods remained >100% of the true quantity, indicating that more than one training session would be necessary to further increase dietary reporting accuracy.

The Pathways study: a model for lowering the fat in school meals.

We describe the development and implementation of the Pathways school food service intervention during the feasibility phase of the Pathways study. The purpose of the intervention was to lower the amount of fat in school meals to 30% of energy to promote obesity prevention in third- through fifth-grade students. The Pathways nutrition staff and the food service intervention staff worked together to develop 5 interrelated components to implement the intervention. These components were nutrient guidelines, 8 skill-building behavioral guidelines, hands-on materials, twice yearly trainings, and monthly visits to the kitchens by the Pathways nutrition staff. The components were developed and implemented over 18 mo in a pilot intervention in 4 schools. The results of an initial process evaluation showed that 3 of the 4 schools had implemented 6 of the 8 behavioral guidelines. In an analysis of 5 d of school menus from 3 control schools, the lunch menus averaged from 34% to 40% of energy from fat; when the menus were analyzed by using the food preparation and serving methods in the behavioral guidelines, they averaged 31% of energy from total fat. This unique approach of 5 interrelated food service intervention components was accepted in the schools and is now being implemented in the full-scale phase of the Pathways study in 40 schools for 5 y.

Food preferences, practices, and cancer-related food and nutrition knowledge of southwestern American Indian youth.

BACKGROUND: Pathways to Health is a cancer prevention and health promotion curriculum for fifth- and seventh-grade Navajo and Pueblo students living in New Mexico. METHODS: A diet and nutrition questionnaire was administered to 1007 fifth- and seventh-grade students before beginning the Pathways to Health intervention. Sections of the questionnaire included listing favorite foods, frequency of intake of selected foods (e.g., "How often do you eat vegetables?"), targeted food practices (e.g., "When you eat chicken, do you eat the skin?"), and applied dietary fat and fiber knowledge questions. Descriptive analyses were generated by grade, gender, and tribe. RESULTS: Students' favorite foods were pizza, hamburgers, and tacos. Only 35.7% of students reported consuming the U.S. Dietary Guidelines recommendation of two or more daily servings of fruit, with only 19.3% reporting more than once-a-day intake of vegetables. The mean score (percent correct responses) to questions identifying common food sources of dietary fat and fiber, and other cancer-related nutrition knowledge questions, was 45.2% and 57.9% for fifth- and seventh-grade students, respectively. CONCLUSIONS: These and related data support the need for nutrition education interventions in this population that target essential cancer prevention skills and motivational information required to make positive dietary choices.

Tobacco use: baseline results from pathways to health, a school-based project for southwestern American Indian youth.

BACKGROUND: This paper describes a school-based cancer prevention project for fifth- and seventh-grade Navajo and Pueblo Indian children living in the Southwest. Baseline data are presented from 714 students who completed questionnaires on smoking and smokeless tobacco. METHODS: Questionnaires were administered in the fifth- and seventh-grade classrooms prior to students receiving the Pathways to Health cancer prevention curriculum. RESULTS: In our sample there were increases from fifth to seventh grade in self-reported current cigarette use and intention to use. Also, boys were more likely to use and intend to use cigarettes than girls. The use of smokeless tobacco also increased with increasing grade level, though this trend was less pronounced for girls. A significant gender difference was found in the use of smokeless tobacco with boys reporting higher use. However, reported use by girls was higher than is typically noted for non-Hispanic white girls. CONCLUSIONS: There is evidence of experimentation and regular use of tobacco products by both Navajo and Pueblo boys and girls. Even more students indicate intention to use tobacco products in the future. These data confirm the need for primary prevention programs designed for this population of American Indians.