Early promotion of healthy dietary habits: Targeting kindergarten and home environments in a three-armed intervention study.

The overall aim of the project was to develop, implement and evaluate a theory- and evidence based intervention to promote healthy eating among 3-5 year olds through changing the environment in the kindergarten and at home in a group-randomized controlled trial. After the results are published in 2019, a best-practice report will be published along the toolbox with those components that work. Vegetable intake was chosen as the behavior to promote due to the great public health potential if children establish the habit of eating according to the national recommendations for vegetables. The primary aim in this study was to increase the frequency, variation and amount of vegetables the children ate, and the secondary aim was to availability and practices around serving vegetables in the kindergartens and homes. The study was conducted in public and private kindergartens in the counties of Vestfold and Buskerud using questionnaires to staff and parents to measure factors important for the children's vegetable intake and the child?s vegetables intake reported by parents. In addition, the kindergartens had to weight the vegetables they served for a week and a subsample of the children was observed with during meals in the kindergarten in 2015 and 2016. There were 73, 73 and 69 kindergartens, and 633, 592 and 559 parents participating in the spring of 2015, 2016 and 2017. Tips were developed on how to increase the availability and accessability of vegetables both in the kindergarten and at home. Furthermore, tips on how to be a good role model and how to encourage children to taste/eat vegetables were developed. These tips were tested among employees and parents in 2 kindergartens. A written material and practical cooking session was bought from "Geitmyra matkultursenter for barn". For the parents an inspirational brochure was developed in collaboration with "Opplysningskontoret for frukt og grønnsaker". A closed web-site and a Facebook group were also made. In September 2015, there were 5 inspirational day courses for the 37 intervention kindergartens with a total of 79 participants. The evaluation of these days and the material were positive. A process evaluation using internet-based questionnaires to unit leaders in the kindergartens and parents was conducted in January 2016. The questionnaires assessed changes in practices, what of the training/material had been in particularly useful, and what barriers they had experienced. Twelve units that either reported many or few changes, were invited to a telephone-interview. One of the main findings was that kindergartens that had made more changes had been involved in food projects previously. Among the parents, there were only 1/3 that responded, and many of these did not feel a need to change their practices. In the home, the baseline data showed that higher availability of vegetables was associated with higher intake of vegetables intake among the children. Furthermore, the more barriers for serving vegetables and the more negative parental attitudes, the lower the vegetable intake of the children. Both positive and negative associations were found for encouragement, which might indicate that how the encouragement is done matters for the vegetable intake. Including children in preparations of vegetables and a mild pressure to taste/eat were positively associated with vegetable intake for some of the children. Thus, modifiable factors in the home which could both promote or hinder vegetable intake were found. In the kindergarten, the baseline data showed that in kindergartens where parents paid an additional fee of 251,- NOK per month for food and beverages, a significantly higher frequency of vegetables was served per week, and a significantly larger amount of vegetables was eaten per day. In kindergartens where employees paid a monthly fee to eat in the kindergarten a significantly larger amount of vegetables was eaten. In kindergartens with written guidelines for food and beverages provided by the kindergarten, a significantly larger amount of vegetables was eaten. In January 2017, a one day workshop "Guidelines, food and pedagogics in the kindergarten" were organized together with Norwegian Directorate of Health and the Norwegian National Centre for Food, Health and Physical Activity. The workshop addressed various aspects for how to promote healthy eating through kindergartens. The results have been used in the Directorates revision of the guidelines for food and meals in the kindergarten and in the Centre's work on disseminating good practice. Furthermore, these results have been included in discussion with "Opplysningskontoret for frukt og grønnsaker" and the vegetable wholesale companies during winter 2017/spring 2018 about how to further use the results and the material from the study.

Early childhood is important for establishing healthy dietary habits. The importance of early prevention of social inequalities in health and promotion of a healthy diet early in life is highlighted in strategic document from health authorities at all lev els. Despite the recognition of early prevention as important, reviews show that there so far has been much more studies targeting school-aged children than pre-school children. The reason may be that schools until now have been the best place to reach al l children, but in Norway the attendance in kindergartens is now 90% of the age group 1-5 years, making it a highly relevant setting for interventions. Moreover, national dietary surveys among Norwegian pre-schoolers have identified several dietary challe nges which may be important to target in an intervention. The overall objective for the proposed project is to develop, implement and evaluate a theory and evidence-based intervention targeting healthy eating of 3-5 year olds through environmental chang es in the kindergarten and the home in a three-armed, group-randomized controlled study design. The intervention development will follow the Intervention Mapping approach. The intervention will be implemented for 1 year with one immediate evaluation and one follow-up evaluation one year after. The two intervention arms of the study will consist of one targeting the kindergarten personnel only and one targeting both kindergarten personnel and parents. The project will contribute with important knowledge and experience related to adoption, implementation, effects and sustainability of a kindergarten intervention within the existing educational and health promoting system in Norway. This knowledge will result in a "best-practice" document. The study will b ring the research field forward assessing the role of kindergarten personnel and parents in the promotion of healthy dietary habits - aiming for early prevention of social inequalities in health.