Children from a low socioeconomic background are at increased risk for becoming obese, which underscores the importance of encouraging healthful behaviors such as vegetable consumption. Several factors influence child vegetable intake, including whether children like vegetables and if vegetables are available for consumption. Researchers have attempted to improve child vegetable intake in the school setting through the use of behavioral economics-informed changes in the cafeteria, where the social and physical environment is manipulated in a way to "nudge" children to make healthier choices. Interventions grounded in behavioral economics have been shown to improve vegetable intake in the school setting but have not been thoroughly explored in the home food environment. The latter is an ideal setting in which to improve vegetable consumption because children consume the majority of their daily calories at home. This dissertation investigated the feasibility and effectiveness of behavioral economics strategies to improve vegetable intake at dinner meals among children aged 9-12 residing in households receiving food assistance. Included in this dissertation were three studies which determined the feasibility of implementing behavioral economics strategies (Phase 1), measured the effectiveness of behavioral economics strategies to increase child vegetable intake (Phase 2), and explored adolescent involvement in home food preparation. Exploring the Feasibility of Implementing Behavioral Economics Strategies to Increase Vegetable Intake, Liking, and Variety Among Children Aged 9 to 12 Residing in Food Assistance Households (Phase 1). Phase 1 was a formative study that aimed to identify facilitators and barriers caregivers may experience when implementing strategies during dinner preparation and mealtime. One-time, in-home observations of dinner preparation and mealtime were conducted with caregiver/child dyads (n = 20). Survey data to assess vegetable availability, parent and child vegetable liking, and household food security were collected. Facilitators included liking of most vegetables by caregivers and children, and home vegetable availability (most families had 7-21 different types of vegetables available in the home). Barriers included perceived time constraints, lack of appropriate vegetable types or utensils/dishware, and concerns about child involvement in food preparation. Based on Phase 1 data, nine behavioral economics strategies were selected for further evaluation in a randomized controlled trial (Phase 2). Testing the Effectiveness of In-Home Behavioral Economics Strategies to Increase Vegetable Intake and Liking Among Children Residing in Households that Receive Food Assistance (Phase 2). The objectives for Phase 2 were to 1) to determine the 6 of 9 most effective and feasible behavioral economics strategies, and 2) to evaluate if 9 behavioral economics strategies increase vegetable intake, liking, and availability during a randomized controlled trial. Over the course of six weeks, caregivers in the intervention group (n = 39) incorporated one new strategy/week. Caregivers in the control group (n = 10) were not assigned strategies. For Objective 1, parent-reported food records (3 days/week) were used to assess child vegetable consumption at dinner meals on the days that strategies were implemented. Caregivers in the intervention group rated the level of difficulty for assigned strategies (1 - not difficult to 10 - very difficult) during weekly phone calls. They also reported facilitators and barriers to implementing the strategies. No differences were observed between intervention and control group for mean child dinner meal vegetable intake for any of the nine strategies. However, pairwise comparisons for the intervention group showed that vegetable intake for the strategy of serving at least two vegetables for the dinner meal was greater than intake for two other strategies: 'Pair vegetables with other foods child likes" "Eat dinner together with an adult(s) modeling vegetable consumption". Caregivers indicated that the strategies were generally not difficult to implement. For Objective 2, three 24-hour dietary recalls were collected at baseline and study conclusion from children to assess changes in overall vegetable intake. Also, at baseline and study conclusion, children and caregivers provided liking scores for 36 different vegetable types on a10-point labeled hedonic scale (1-Hate it to 10-Like it a lot, or "Never tried"). For the same 36 different vegetable types, home vegetable availability data were collected at baseline and study conclusion. Change in total daily vegetable intake (baseline to study conclusion) was not different between intervention and control group. No differences were noted in changes (pre-post differences) in caregiver and child mean vegetable liking ratings when mean liking was assessed across all vegetables. There were also no changes in home vegetable availability from baseline to study conclusion between intervention and control group. Adolescent Involvement in Food Preparation. In the final study, the objective was to understand how low-income adolescents are involved in home food preparation. At the conclusion of Phase 2, if an adolescent (13-18 years) was present in the home, he or she was invited to participate in a semi-structured interview. Interview questions inquired about how adolescents were involved in food preparation. Interviews (n = 19) were analyzed using grounded theory methodology. Three levels of involvement in food preparation were described. Eight adolescents were highly involved with responsibility for cooking for others in the household. When deciding what to prepare at mealtimes, they considered preferences of others, variety, nutrition, and time. Some adolescents were highly involved in food preparation out of family obligation and cultural expectations. Those highly involved in food preparation indicated that the additional responsibilities produced stress. They also indicated that they were confident in their ability to cook without the assistance of an adult. Adolescents who were moderately involved in food preparation (n = 7) assisted with cooking. They reported that they enjoyed cooking. Four adolescents had low levels of involvement in food preparation and rarely, if ever, helped their caregiver with cooking. They were not expected or encouraged to be involved in food preparation by parents.
Behavioral Economics Strategies and Vegetable Consumption Among Low-Income Children.
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