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**■ The Story ot Team Nutrition:
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Executive Summary
of the Pilot Study
Final Report
If ^-oftfctS^
United Sates Department ot Agriculture . iS»C
Food tad Nutnooo Semce "
Office of AmlyfcS, Nutnooo and ErmJuauoo »»•»•
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HAVE YOU HEARD THE LATEST ABOUT THE SCHOOL MEAL PROGRAMS?
TEAM NUTRITION MAKES A DIFFERENCE!!
TEAM NUTRITION IS A UNIQUE INITIATIVE TO PROMOTE HEALTHFUL EATING AMONG
CHILDREN.
Team Nutrition (TN) aims to change our children's behavior by using hands-on activities to build skills and
motivation, linking classroom lessons to the dining room, and engaging family, community and media to
reach children where they learn, play and live. It is a good example of how effective social markeung can
lead to changes in complex behaviors, like food choices and consumption.
HOW DO YOU KNOW TEAM NUTRITION WORKS?
USDA recendy completed a pilot test with seven, competitively chosen, school districts from across the
country. Participating schools agreed to deliver TN through multiple, reinforcing communication channels
- classroom, cafeteria, school-wide setting, home, community and media This comprehensive package of
positive nutrition messages was delivered in the spring semester of 1996 and again during the Fall.
All of the pilot schools provided details on what it takes to make TN happen, as well as teacher and staff
opinions about their students' response; schools from four districts also participated in a rigorous
evaluation. In this part of the study, matched schools were randomly assigned to a group that delivered the
multi-channel form of TN or to a control group that did not provide nutrition education. The food choices,
eating behavior, nutrition skills and motivation of 1.500 fourth graders were assessed at the beginning and
end of each semester.
CAN SCHOOLS ACTUALLY DELIVER A COMPREHENSIVE FORM OF TEAM NUTRITION!?
Yes! Despite a very tight project schedule and competing demands on teachers and food service staff, all of
the pilot schools succeeded in delivering most of the intended TN activities. For example, during each 8-10
week phase, TN schools provided an average of 1S hours of classroom lessons and activities, along with a
variety of school-wide and community events. Ail of the districts obtained some media coverage to
promote TN events and reinforce healthy food choice messages. TN schools aiso trained their food service
staff and took steps to provide more healthful and appealing meals.
This success did not come without lots of hard work and some frustration, especially among teachers who
had very limited preparation and implementation time. Nevertheless, both teachers and school food service
staff consistently reported that students found TN appealing and became actively engaged in learning.
Typical of the comments made is one teacher's observation: "Kids are really excited about learning this
stuff and seem to like talking about Team Nutrition."
7
BUT DOES THE KIND OF NUTRITION EDUCATION TEAM NUTRITION PROVIDES ACTUALLY
CHANGE BEHAVIOR?
Yes, again! We measured behavior changes by fourth graders' self-reports, observations of their school
lunch choices and consumption, and parents' opinions. TN resulted in several modest, but statistically
significant, gains. The typical size of these impacts is illustrated by the following:
r.v I sual Food Crwices Reported in Phase I
i maximum healthy wore =11) ( omtni Saalna
Pie-Test Poat-Tea Follow-Up Pre-Te* Poat-Te Follow-Up
While positive TN impacts were found across ail three measurement approaches, they were most consistent
for student descriptions of their usual, recent and very recent eating behavior. For each of these self-report
scales, the impact declines over time. That is. six months later. TN students were reporting smaller
improvements than immediately after their classroom exposure.
In addition, students' scores on the three self-report scales increased consistently with the number of TN
channels in which they participated. This finding is illustrated below:
Food Choices ui die Last Two Weeks - Phase II Reports
i maximum healthy score = 9)
AUSimiems mini 4 5 6
NMbcr •< TN Chaaaels
'Even students from control schools may have seen media message- and participated in commuaity events
WHAT DOES ALL THIS MEAN?
TN resulted in statistically significant improvement on. at least, some measures of eating behavior. This is
striking given the short time frame associated with each study phase. The data suggest this success is due
to implementing TN in a way that includes a wide range of promotional activities in addition to classroom
lessons and improvements in school meals. It is also clear that one-time efforts are not enough to maintain
improvements. Repeated reinforcement is necessary. In fact, TN is designed for delivery from pre-school
through the middle school years. USDA is working with schools and communities to help make
comprehensive Team Nutrition a reality!
*r-
^" file Story of Team Nutrition,
#^
Executive Summary
of the Pilot Study
Final Report
/ / 0 H ^■fc
&
United Stues Department of Agriculture . ,* M Food and Nutrition Serrice -
Office of Analysis. Nuintioo >nd Evaluation
TIT,
CONTENTS
What is Team Nutrition 1
Making School Lunches Healthier 1
The "Team" Approach 2
The Team Nutrition Pilot Project 4
Who Participated in the Pilot Implementation? 5
Components of the Pilot Implementation 7
How Was the Pilot Implementation Assessed? 8
Key Findings 10
Successes and Challenges with the Introduction of Team Nutrition 10
Team Nutrition Had Positive Impacts on Students 14
Multiple Channels Strengthened Team Nutrition Effects 19
What Does It All Mean? 20
References
s/
This executive summary describes Team Nutrition (TN) and findings from a pilot evaluation of
the initiative. Detailed research findings are contained in two separate repr rts. The Story of
Team Nutrition: Case Studies of the Pilot Implementation Communities, provides a
comprehensive report of how the initiative was implemented in each of the seven participating
school districts. The case studies include assessments of satisfaction with the matenals and
activities among teachers and staff, and participation by parents and community partners in
Team Nutrition activities. The second document, Team Nutrition: Pilot Study Outcome Report,
presents findings from an outcome evaluation conducted in four of the pilot districts. The basic
question guiding the evaluation is whether or not Team Nutrition has a positive impact on
students' nutrition skills, motivation and, most importantly, food choices. An overview of Team
Nutrition and highlights from both reports are presented below.
WHAT IS TEAM NUTRITION?
Team Nutrition is an USOA initiative launched in 1995. The mission of Team Nutrition is:
To improve the health and education of children by creating innovative
public and private partnerships that promote food choices for a healthful
diet through the media, schools, families, and the community
Team Nutrition has already been adopted by more than 30,000 local schools throughout the
country These TN schools demonstrate their commitment to meeting the Dietary Guidelines for
Americans by distributing TN materials to teachers, children, and parents; by involving school
food service, teachers, students, families, and administrators in livery and entertaining nutrition
acu.ities by sharing successful strategies and projects with other schools; and by engaging
private and public partners in the community to support TN activities.
Making School Lunches Healthier
The story of Team Nutrition begins with an initiative to provide students with healthy meals at
school. The USDA School Meals Initiative for Healthy Children, published in 1995. is a
comprehensive plan that aims to ensure that children have healthy meals at school. A major
part of this plan is an update of nutrition standards that requires school meals to meet the
Dietary Guidelines for Americans Recognizing that simply publishing a regulation is not likely
to change children's diets. USDA established Team Nutrition to ensure that schools are able to
implement the plan, and that students avail themselves of the healthier meals offered The
goals of Team Nutrition include:
• Eating less fat:
• Eating more fruits, vegetables, and grains and
• Eating a variety of foods
Team Nutrition supports the School Meals Initiatrv? through t*o interrelated components:
Training and Technical Assistance is designed to ensure that school nutrition and food
service personnel have the education, motivation, training, and skills necessary to provide
healthy meals that appeal to children and meet the Dietary Guidelines for Amencans It also
provides personnel with a clear vision of their roles in the school community; that is as integral
team members of a comprehensive and ongoing school nutrition initiative. This training and
technical assistance includes the dissemination of training standards and matehals, grants to
States to develop self-sustaining training projects, and an electronic resource system available
on the Internet and designed to foster communication among interested professionals
Multrfaceted Nutrition Education is delivered through the media, in schools, and at home to
build skills and motivate children to make food choices for a healthful diet. The educational
component emphasizes the school setting to reinforce and support nutrition policy changes in
school meals. In-school education is provided through the use of flexible cumculum modules
designed by Scholastic. Inc. in partnership with the USDA. The materials bring focused,
science-based nutrition messages to children in a language that they understand while
strengthening social support for healthy food choices among parents, educators, and food
service professionals.
77M Team" Approach
Team Nutrition operates through a vanety of public and pnvate partnerships to reach children
with information and activities at schools, in their homes, and in the community. The school-based
curriculum involves teachers, food service, and administrative staff Parents are
encouraged to participate in school- or community-based activities and to continue classroom
activities with take-home matenals Team Nutrition schools are encouraged to leverage
resources by developing partnerships with public and private sector organizations in tha
community, and to promote the TN messages and activities through the media. Media also
reinforces TN messages through PSAs produced by Disney and featuring characters from the
Lion King.
The use of multiple channels to reach children is a tenet of Social Learning Theory (SLT)—a
theoretical framework that provides an explanation of how individuals make behavior choices
(Bandura, 1986; Perry et al., 1990). SLT is the underlying theory for Team Nutrition, and has
been used for many research studies focused on changing eating behaviors (Contento et al.,
1995).
The premise of SLT is that personal characteristics, environmental factors and behaviors
interact dynamically In other words, behavior both affects and is affected by individual and
environmental factors. Further, each of these dimensions has multiple comDonents, including:
Personal Charactenstics: expected outcomes, relevant skills and knowledge, values
and attitudes, self-efficacy;
Environmental Factors: availability of role models, opportunities to engage in pertinent
behaviors, social group norms and expectations, incentives and rewards; and
Behaviors: intentions to act. specific behavior choices, and typical behavior.
Nutrition education projects grounded in SLT rely on multiple personal and environmental
factors to influence behavior. As seen in Figure 1, the Team Nutrition approach reflects this
concept. Also in concordance with SLT, individual characteristics, like skills and motivation, are
both objects of and vehicles for change.
Figure 1. Team Nutrition Approach to Effective Nutrition Education
THE TEAM NUTRITION PILOT PROJECT
USDA launched a pilot implementation of Team Nutrition with two purposes: to systematically
document the implementation process, and to evaluate whether the project results in healthier
food choices by students.
The Team Nutrition Pilot project was implemented in two phases—once in the Spring of 1996
and again in the Fall of 1996. The Fall implementation was essentially a replication of Spring
with a new set of students. However, participating districts made changes in the activities
conducted in Phase II based on their initial experiences.
Since the pilot project was designed to fit the evaluation schedule, it differs from the intended
TN effort in several ways The most important distinction is that, for evaluation purposes, the
outcome evaluation focused on only one grade level (the fourth grade) for one semester. This
is a small slice of the intended initiative Overall TN activities are to be implemented from pre-school
through the middle-school years During this time students are continually exposed to
TN messages through curricula, school-based activities, cafeteria-based activities, community
events, and the mass media.
Because of the evaluation, variations from more usual implementation procedures occurred
For example, teachers in the pilot project received in-person training on how to use nutrition
lesson materials In addition, project coordinators were designated for each pilot district and
had regular contact with both USDA and evaluation contractor staff. More typically, TN schools
and staff receive start-up kits containing a variety of materials Dut they do not have the personal
contacts and support provided tc pilot districts.
While the pilot communities benefited from some unique resources, they also operated under
special constraints imposed by the research schedule. These included limited preparation time
in Phase I and limited implementation time during both phases (roughly 8 to 10 weeks). In
Phase II, the time constraints were heightened by the demands associated with beginning a
new school year.
Although distinguished by these supports and constraints, the TN pilot schools operated in real
world settings—not a laboratory environment. Pilot schools faced implementation obstacles that
many schools might encounter. These included keen competition from other subjects and
standardized test preparation for scarce class time, changes in food service contracts, and
upheaval associated with a potential teacher strike in one district. Thus, the lessons learned
from this pilot study should prove valuable to schools around the country as they consider
pursuing Team Nutrition.
Who Participated in the Pilot Implementation?
In July 1995, the USDA issued announcements through its regional offices to recruit school
districts to participate in the TN Pilot Implementation Project.
The application for becoming a TN pilot community required answers to a set of questions about
the district's ability to carry out the project. In addition, districts were asked to nominate M least
two pairs of elementary schools. Each pair of schools was to be equivalent with respect to the
number of students, the percentage of students eligible for free or reduced-price lunches, the
racial/ethnic composition of the school student body, the extert of existing nutrition education
efforts, and the type of cafeteria service provided (e.g., menu choices available and type of
kitchen).
Seven TN pilot districts were chosen competitively from the applications received. The
selection criteria included the district's ability to carry out the project, I desire to hove a district in
k*j
each USDA region, and the need to have cost-efficient access to the communities for evaluation
purposes. Applications were approved from one district in each of the seven USDA regions, as
seen in Figure 2.
Figure 2. Districts Participating in the Team Nutrition Pilot Implementation
All of the districts were expected to implement a comprehensive TN initiative. However, four of
the seven school districts (Des Moines, Hamblen County, Tulsa, and Vacaville) were selected to
participate in an intensive process and outcome evaluation of the TN Pilot Implementation
Project. The remaining three (Lawrence, Passaic, and Cleveland) were subject only to a more
limited process evaluation.
In the four outcome evaluation districts, one-half of the matched school pairs were randomly
assigned to the treatment condition (i.e., to implement Team Nutrition). The others became
comparison sites and agreed to suspend existing nutrition education lessons until after the
evaluation. In the remaining three pilot districts, all of the nominated schools implemented
Team Nutrition.
Altogether, Team Nutrition was implemented at 19 schools in Phase I and 18 schools in Phase
II and in over 140 classrooms at three different grade levels.
Components of (he Pilot Implementation
All of the TN schools agreed to conduct the full set of grade-specific lessons available at the
time. These lessons are organized into three modules, one for each of the following sets of
grades:
• Module 1: Pre-Kindergarten and Kindergarten (Pre-K and K).
• Module 2: First- and Second Grades (1 and 2).
• Module 3: Third- through Fifth Grades (3 through 5).
Implementation schools in the seven pilot districts delivered each moudel to a single grade
Module 3 was targeted to fourth grade in all the implementation schools
The three modules share some distinguishing charactehstics. Although based on classroom
delivery, they are designed to involve other students in the school, as well as cafeteria staff and
parents. That is, the lessons include a variety of activities and materials that extend the lessons
to people and places outside of class Lessons are also designed to actively engage students
in the learning process by applying what is learned to choices and decisions they make. Finally
the lesson content offers flexibility. Teachers may use the materials either as a separate
nutrition curriculum or integrate them into other more tradition subjects, such as math and
science
Team Nutrition schools also agreed to have teachers participate in two half-day training
sessions, to offer at least ten hours of training to food service staff, and to implement a variety of
school-wide and community nutrition activities With respect to the latter activities, every
implementation school was expected to conduct at least:
• Two school-wide cafeteha events;
• Three parent contacts;
• Two chef events;
• One district-wide community event; and
• One media event.
While some of the activities could overlap, all TN-pilot schools committed to conducting a
minimum of five core activities dunng each project phase
To manage this comprehensive nutrition education inrt.at.ve, as well as to support evaluation
requirements, each pilot distnct provided one or more people to serve in a coordinating
capacity. More specifically, the role involved planning school-wide and community events,
coordinating the efforts of teachers and cafeteria staff, developing partnerships with community
organizations, ensuring media coverage, and facilitating the evaluation data collection
The approach to this coordination vaned across distncts. In some cases two or three persons
shared the role and divided responsibilities while In one district the coord.nator's }M MM a
single full time position The food service manager acted in a coordinating capacity in every
district, but there was more variation across distncts with respect to the involvement of
curriculum specialists. Coordinators also varied in terms of how much direct support and
communication they had with teachers, the extent to tf k* they delegated responsibilities, and
the degree to which they used established school and e.mmunity events as the foundation for
TN activities.
How Was the fWof Implementation Assessed?
The process evaluation was designed to systematically describe the nature and magnitude of
the Team Nutrition effort in all seven pilot districts Information was collected from a variety of
sources on a wide range of relevant topics.
• School and district features such as student enrollment and demographic
characteristics, came from routine erfant records
• Team Nutrition implementation plan; project diaries and progress reports were
submitted by project coordinators in each distnct to track events and document
strategies for involving others. These materials were supplemented by regular
interviews with coordinators. y '«»»«-
• Details about school lunches, including menus, preparation methods and number
served came rrom a combination of extant records kitchen observations and
interviews with food service staff
• Classroom Kssons school-wide events and community activities were described bv
implementing teachers. TNOs. and community partners respectveK
Information about teachers training interest and experience with nutrition education generally
and Team Nutrition specifically (implementation teachers om> | was obtained from sjrvevs
before and after the intervention
The primary objective of the outcome evaluation was to determine whether or not Team
Nutrition changes studente state motivations and behavior as they relate tc food choices
Survey items and observational measures were chosen tc assess changes associated with the
more speafic TN messages to eat more frurts vegetables and grains less fat and more variety
Given that TN activities expose all students m a school to at least some components o' the
intervention, it was not feasfcte to randomly assign classrooms o- students to treatment and
control conditions Instead, random assignment occurred for matched pairs o' schools and
student outcomes were measured for treatment and comparison students both before and ater
TN implementation This 'double difference' design provides considerable confidence that
outcomes can be attributed to the treatment
TTvs basic design was applied twice The replication offers a chance tc assess the reliability of
TN effects and to evaluate the impacts of a somewhat more -nature" project when it s
implemented a second time 1 In addition students who participated in the first pilot phase *<ere
surveyed again at the end of Phase ll to determine whether the initial impacts were sustained
over time—i e six months
The outcome evaluation focused on fourth grade students This grade was chosen because *
represents the youngest age group (8 to 10 years) who are able tc complete survey instruments
and food frequencies reliably (Dome! et al. 1994\ Such capabt'rh was P'e-reouiste tc this
evaluation
Although teachers ana staff «wi more evoenrxea dunng r» second phase or Team Mjirihon stjaerts wen m i
****** >*v* devctapmentatv Ths « because f»fias# II takes wace m the stan m the school wear
The primary data used for trie outcome analysis included:
• Fourth grader responses to a serf-administered questionnaire;
• Observations of fourth graders' food choices and consumption in the cafeteria; and
• Parent responses to a telephone survey that included questions about their fourth
grader's nutrition-related behavior at home.
Across the four distncts in the outcome evaluation, approximately 1,650 fourth-graders were
eligible to participate in each study phase. Students were divided about evenly between
implementation and comparison schools. Response rates for the student survey ranged
between 86 and 91 percent. Somewhat fewer students ate meals from their school's cafeteria
so participation in the observations ranged from 79 to 85 percent.
Parent phone interviews were conducted with the family adult who is most knowledgeable about
their fourth grader's nutrition behavior. Not surprisingly, this was typically the mother or female
guardian. The parents' response rates ranged from 72 to 87 percent with tower rates in the
second pilot phase. This decline is attributable to the challenge schools face to complete
accurate family rosters at the start of a new school year.
KEY FINDINGS
Successes and Challenges with the Introduction of Teem Nutrition
While four of the seven pilot districts had a formal nutrition education component in their
curricula prior to the implementation of Team Nutrition, there was broad latitude across schools
and teachers with respect to what was actually taught. Nevertheless, from 90 to 100 percent of
pilot study teachers indicated on the baseline survey that they were very interested in teaching
nutrition and believed the classroom was an appropriate place to do so. In general, there was
widespread support among teachers and administrators that nutrition education is an important
part of the classroom agenda. The prevailing view is perhaps best reflected by the one of the
Tulsa pnnapars who said. "It is as important to teach nutrition as it is the basic academics in
order to help children form good habits that will last them the rest of their lives. Nutrition is a
basic life skill.'
10
With this level of interest, one would expect successful TN implementation despite the short
start-up period and a squeeze to complete each phase within 8-10 weeks. In fact, all seven
districts completed most of the required TN activities. Most lessons were introduced in each
class. There were also a variety of school-wide and community nutrition events that reinforced
the classroom messages. These activities included taste tests, cooking demonstrations from
visiting chefs, plays written and/or performed by students, and community nutrition fairs. In
addition, ail districts obtained at least some media coverage to promote events and support the
heahhy food choice messages. Finally, the pilot project included training for school food service
staff and changes to menus and meal preparation that were objectively intended to result in
healthier cafeteria meal items.
Nevertheless, student exposure varied widely across teachers, schools and districts. While
most lessons were introduced in each class, teachers used different numbers of the available
lesson components. Thus, on average, students received between 12 and 33 hours of
classroom education. Similarly, students had an opportunity to participate in four to ten school-wide
or community nutrition events. This v a nation provided an evaluation opportunity to
examine the relationship between implementation features and student impacts.
First, however, here are the highlights of what TN stakeholders had to say about participating in
this initiative:
As expected. Team Nutrition Coordinators began the project with considerable enthusiasm
and commitment. They also brought to the study some goals specific to their individual districts.
These included an interest in using Team Nutrition as a vehicle to involve the many new
immigrant families from the community in school activities, as well as a desire to develop the
professionalism of food service staff and involve them in the educational process.
The continued commitment of coordinators is reflected in the variety of TN activities that were
completed in each district Coordinators repeatedly mentioned duhng evaluation interviews,
however, that the compressed schedule for planning and implementation added significantly to
the challenge of generating support and organizing others. For some, the task of building
community partnerships was new, and the job of getting media coverage for Team Nutrition was
a first for most coordinators. While they each offered lessons to share in these areas, they also
recommended more guidance up front.
11
When asked about the future of Team Nutrition at the end of the pilot, coordinators were
similarly committed and realistic. Without exception there were plans to continue activities in
the pilot schools and expand the initiative to additional schools. At the same time, it was clear
that the schedule and intensity of activities would probably be relaxed. The challenge of
obtaining enough time and dollars to implement a comprehensive version of Team Nutrition was
mentioned by all the coordinators. At the same time, at least some coordinators reported steps
to help institutionalize the initiative. These included lobbying school boards and state
legislatures to require nutrition education, in addition to applying for grants to support key
activities.
School principals from implementation schools were interviewed at the beginning of Phase II
to get their reactions to the initial T. i experience. All expressed a high degree of satisfaction
with the project, and some observed that students were eating things that they weren't
previously
Reactions to their schools cafeteria menus were more varied. Some expressed dissatisfaction
with the quality and/or limited choices of food items. Others noted improvements, such as the
introduction of salad bars, which they attributed to participation in the pilot project The variation
in responses is explained at least in part by the relative emphasis that districts placed on this TN
channel dunng the first phase.
In contrast to school principals who generally viewed their role as one of support and
encouragement, teachers were actively engaged in planning and carrying out TN activities.
The amount of time required for classroom education imposed some strain. Thirty-three percent
to 100 percent of all TN teachers reported that preparation time was reasonable and 33 percent
to 88 percent judged the amount of teaching time was reasonable. Along the same lines, the
percentage of teachers who reported satisfaction with TN classroom materials ranged from 41
to 100 percent.
There are several explanations for the negative reactions. Some are specific to a particular
school or district, such as the one where teachers were faced with introducing a new math
curriculum during the pilot study Other explanations are generic. For example, teachers stated
that the short time frame in which the cumculunri had to be Delivered was a key factor in the
feeling of time compression and that this would be resolveo if lessons were spread out over the
entire school year Similarly, teachers objected to the prescriptive nature of the study protocol.
12
which required all ieesons and most components to be delivered. Based on their experience
and given a future choice, they indicated that they would be more selective in which lesson
components to pursue.
Nevertheless, teachers repeatedly said that the TN materials engaged their students and made
a difference. Typical of the comments offered is the statement. "Kids are realty excited about
learning this stuff and seem to like talking about Team Nutrition.* One fourth-grade teacher
noted," a lot of kids have become label readers and bring in labels from snacks." Another
teacher passed along comments received at a recent parent conference, "both of our children
are involved in Team Nutrition, and at dinner they discuss what food groups are in the meal."
Food service managers and staff were also active participants in Team Nutrition. In addition
to their participation in training workshops and efforts to make lunch choices more healthful and
appealing, the cafetena staff became partners in the student education process. For example,
classroom lessons include a component known as the "Lunchroom Link." These typically
involve a connection with the cafeteria such as a kitchen tour or preparing a student-created
menu. The goal is to reinforce educational messages from the classroom. In addition,
cafetena staff played a significant role in supporting classroom, school-wide, and community
activities—very often by obtaining and/or preparing foods for taste testing which was mentioned
by the staff when int viewed at the end of each pilot phase.
While only a fe. scioots directly involved the food service staff as classroom teachers, the
Team Nutrition approach generally calls for a dynamic and synergistic relationship between the
classroom and cafetena. One of the important lessons came as a wish expressed by many
food service staff—that is a desire to have been more involved in the up-front planning and
curriculum training. We should note that food service staff involvement did increase as the
districts expanded Team Nutrition following the pilot project.
Even though Team Nutrition increased the workload of food service staff, there was a uniformly
high level of satisfaction expressed. As one manager put it. "When I first found out about Team
Nutrition. I thought. Oh, no. I don't want to do this.' But afterwards, my attitude changed a lot
I'm very positive about the project now."
It makes sense that at least some of this positive attitude is tied to the changes which cafetena
staff noted among students. Among the behaviors more frequently mentioned are—
conversations in the cafeteria line about the nutritional quality of different menu items.
13
references to the Food Guide Pyramid when making food choices, choosing skim or milk with
one percent fat, and eating more of the fruits and vegetables that are served.
Parents are another important channel for children's nutrition education. In the TN
environment, parents have a number of opportunities to become aware and involved. Although
teachers and pilot coordinators reported some dissatisfaction with the degree of parent
participation, the numbers suggest cause for some optimism.
During the telephone interviews with the parents of fourth graders' in TN schools, 47 percent
reported hearing about the initiative through the media. Twenty-three percent reported
participating in a school or community event. The most frequently attended activities typically
took place before or after usual work hours, such as a chef breakfast at school, or events in
which their children participated, like the nutrition skit performed during a meeting of the
Parent/Teacher Organization.
When asked if they had participated in any nutrition activities at home, the number is much
higher. Seventy-seven percent reported involvement; a majority (71 percent) of these described
using Team Nutrition materials sent home with students for use with parents.
In general, then, the pilot schools engaged a variety of partners and successfully delivered
nutrition education through multiple channels. While time was a constraint for ell the partners,
the schedule demands of the study were most challenging for teachers and food sorvice staff-
However, the same project participants reported that TN students were enthusiastically
engaged in learning and applying what they had learned.
Teem Nutrition Had Positive Impacts on Students
The results of the outcome evaluation show that Team Nutrition modestly increased the skill-based
knowledge and motivation to eat healthier among fourth graders According to the
theoretical foundation of Team Nutrition, such changes are prerequisites, but not sufficient in
and of themselves, to shifts in voluntary behavior.
The regression coefficients reported in Table 1 show that Team Nutrition produced statistically
significant increases in the number of correct responses even after controlling for other potential
explanations, such as general changes over time. The only exception occurs in Phase I with
respect to items, which ask students how the balanced diet concept applies to behavior.
14
Table 1. Overall Team Nutritic/»Impact on Number of Correct Answers to Nutrition
Skill Questions (Regression Coefficients)
Students' Ability to:
Immediate Impact by
Phase
Impact at
6-Month
Followup
Phaael Phase II Phase 1
Identify Healthier Choice 0.31" 0.33" 0.16*
Apply Food Guide Pyramid Knowledge 0.68" 0.83" 0.49"
Apply Balanced Diet Concept 0.02 0.09 0.10
*p<0.05. ~p<0.01
NOTE: Regression coefficients reflect the Team Nutrition-related increase in the number of correct answers relative
to scores received m the pretest.
Overall, the impact is small, an increase of less than one additional item answered correctly
The largest improvement occurs for questions that ask students to apply their knowledge of the
Food Guide Pyramid to behavior—for example, "from which food group should you eat the most
servings each day?" Results are, however, generally consistent in their direction across
different measures, for each phase, and over time for the Phase I students.
Similarly, the data in Table 2 indicate positive and statistically significant impacts of Team
Nutrition on motivation to make healthier food choices. The pattern is consistent across all
three impact measures, including the "cognitive rules" scale items which asks students to
indicate both their willingness to make the healthier food choice and an understanding of what
that requires.
15
Table 2. Overall Team Nutrition Impact on Nutrition Motivation (Regression
Coefficients)
Students' Motivation
Immediate Impact by
Phase
Impact at
6-Month
Followup
Phase I Phased Phase 1
General Attitudes 0.48" 0.50" 0.49"
Perceived Consequences of More Fruits,
Vegetables, and Grains
0.28" 0.41" 0.53"
Cognitive Rules for Healthy Choices 0.71" 0.64" 0.50"
*p<0.05. -p<0.01.
NOTE: Regression coefficients reftert the Team Nutrition-related increase in the number of answers that indicate
positive nutrition mouvation, relative to scores received in the pretest.
Positive impacts are on the order of an additional one-half of a healthier response Again the
pattern holds for both groups of fourth graders and over time for Phase I students.
One of the strengths of the evaluation is its incorporation of three different approaches to
measuring eating behavior. They include fourth graders' self-reports on the classroom survey,
parents' perceptions of their children's behavior, and observations of student food choices and
consumption in the cafeteria. Each of these approaches has particular strengths and
limitations. Collectively *hey provide a more comprehensive assessment of TN impacts.
In general, there were some, but not consistently, positive impacts across the different
measures of eating behavior The results from analyses of student self-reports are the most
uniform (see Table 3). Team Nutrition students were significantly more likely than comparison
school students to improve the quality of their responses when asked about usual food choices,
food choices in the last two weeks, and yesterday's choices
16
Table 3. Overall Team Nutrition Impact on Self-Reported Eating Behavior (Univariate
Regression Coefficients)
Students' Behavior
Immediate Impact by
Phase
Impact at
6-Month
Followup
Phase 1 Phasell Phase 1
Usual Food Choices 0.53** 0.96- 0.11
Choices in Last 2 Weeks 0.43" 0.53- 0.17
Variety of Food Choices Yesterday 0.38- 0.34- 0.07
-p<0.01.
NOTE: Regression coefficients reflect the Team Nutrition-related increase in the number of answers that indicate
healthy eating behavior, in comparison with the scores received in the pretest.
The degree of change is modest and comparable to that observed for nutrition skills and
motivation. In contrast, however, the serf-reported behavior changes were not statistically
significant at the 6-month followup for Phase I students.
Table 4 summarizes the results from the cafeteria observations. Here fourth graders' food
choices and consumption were measured for up to *^ree matched pairs of days before and after
Team Nutrition. The focus of the e observations was on behaviors that Team Nutrition is
expected to affect, e.g., increased grain consumption and selection of 'ower-fat milk.
Table 4. Summary Effect Size Statistics for Team Nutrition Implementations
Food Group Measure
Mean
Effect Size
Homogeneity Across
Districts & Phases
Grains Number Selected 0.13* No
Amount Consumed 0.13* Yes
Fruits Number Selected -0.01 No
Amount Consumed 0.01 No
Vegetables Number Selected 0.04 No
Amount Consumed 0.09 No
% Fat, Milk % Fat. Milk Selected 0.01 Yes
% Fat, Milk Consumed 0.04 Yes
Diversity Group/Day, Tasted 0.22* Yes
Item/Day, Tasted 0.22* Yes
*p<0.05.
17
Established techniques for meta-analysis were used for averaging the results across districts
whose menus differed from one another (Cooper and Hedges, 1994; Hunter and Schmidt,
1990). An unambiguous and positive TN impact requires that the mean effect is in the predicted
direction, statistically significant, and passes the homogeneity test (i.e., has essentially the
same value across distnu* tnd phases).
Tcs.n Nutrition produced such impacts in the amount of grains consumed from school lunches,
as well as in the diversity of food Herns and food groups tasted. The size of such changes is
again relatively small. The mean effect sizes are not equivalent to amounts selected or
consumed, rather they ccr *spond to modest shifts in the proportion of students who chose
foods in a more healthful manner. Team Nutrition effects on the selection and consumption of
fruits, vegetables and low fat milk were in the expected direction when averaged across districts
but neither statistically significant nor the same across different districts.
The third approach to assessing TN impacts on students involved asking parents to describe
the degree of any change in their children's nutrition awareness and eating behaviors. Based
on parents' perceptions, Team Nutrition produced statistically significant increases in nutrition
awareness and interest (Table 5). More specifically, parents of students from TN schools
perceived that their fourth graders talked more about nutrition at home and showed a greater
interest in food shopping. However perceived changes in eating behaviors were not
significantly different compared to reports from parents of comparison students.
Table 5. Parents' Perception of Changes in Students
Phase 1 Phase II
Increase in Student Nutrition Awareness and
Behavior Attributable to Team Nutrition 0.72" 0.49"
p<0.01
This pattern of results is similar to the one associated with more direct outcome measures. That
is, statistically significant TN impacts are more consistently observed for knowledge and
motivation than for behavior changes.
18
Multiple Channels Strengthened Team Nutrition Effects
The evaluation also includes a preliminary analysis of what particular student, family and
intervention characteristics either amplify or reduce the impacts of Team Nutrition. Student self-reports,
i.e., usual food choices, choices in the last two weeks, and variety eaten yesterday,
were the focus of this part of the analysis.
As a first step, multi-vanate analyses examined the interaction of a variety of student and family
variables t ith Te- m Nutrition on impacts. These variables included basic demographic
characteristics such as, gender and household income, as well as social environment features
that were hypothesized to be relevant to eating behavior. While several of these v« riables have
statistically significant correlations with self-reported eating behavior at the posttest, there were
no significant interactions with participation in Team Nutrition.
Tf-e second step compared TN impacts across different intervention experiences. The "uniform
treatment" model defines Team Nutrition as a whole—that is, students either participated OT did
not. "i his is in contrast to the "discrete components" model, which considers the relative
effectiveness of exposure to specific intervention elements:
• Student exposure to at least one TN public service message,
• Student receipt of TN classroom instruction,
• Student participation in TN cafeteria events,
• Student participation in TN community activities,
• Parent participation in Team Nutrition or any other nutrition events at school, and
• Parent participation in Team Nutrition or any otner nutrition activities at home.
Finally, impacts were assessed by defining Team Nutrition in terms of the cumulative number of
foments a student experienced; this is the "level of exposure" model.
In all three analyses, Team Nutrition had a small, but statistically significant and positive impact
on fourth graders' self-reported eating behaviors. This holds only for impacts measured
immediately after the intervention but not at the 6-month followup for Phase I students
19
Comparatively, tlie level of exposure model offers the strongest impact predictions. As shown
in Table 6, students' mean scores on the self-report scales increase fairly consistently with the
number of TN channels in which they participated. Note that students from comparison schools
may have seen the TN public service announcements, and may have also participated in TN
community events.
Table 6. Level of Exposure Model: Mean Scores for All Students'Self-Reported
Number of Channels
Of Participation
Usual Food
Choices
Choices in Last
2 Weeks
Variety of Food
Choices Yesterday
Phase 1 Phase II Phase 1 Phase II Phase 1 Phase II
0 4.3 4.0 44 3.9 3.1 3.0
1 4.5 4.5 4.8 4.7 3.3 3.3
2 4.7 46 5.3 5.3 3.4 3.0
3 48 47 5.5 5.5 3.5 3.3
4 54 5.5 5.4 56 3.7 3.7
5 5.6 59 5.6 6.4 4.0 3.9
6 51 6.6 5.9 6.7 4.3 3.8
This pattern of results fits the SLT and social marketing approach that underlie the design of
Team Nutrition. Both perspectives view eating behavior as a complex activity that is most
effectively influenced by reacning students through multiple channels and broad environmental
changes. Thus, it makes sense that the analytic model that captures the collective impact of
multiple channels is the one with the best predictive capacity.
What Does It All Mean?
Like some studies oi nutrition education targeted tc specific behavior changes (Perry, Mullis and
Maile, '385; Perry et al., 1998; Auld et al„ 1998; Coates et al., 1981), Team Nutrition resulted in
statistically significant improvements on at least selected measures of eating behavior. This is
particularly striking given the relatively short time frame associated with the intervention. Other
projects involving comparable strategies have had less successful behavioral outcomes (Parcel
et al., 1989; and Domel et al., 1993).
20
The data suggest this success is due to the comprehensive nature of the intervention Team
Nutrition encompasses not just classroom instruction but a wide range of other promotional
activities, along with changes to the School Lunch Program.
While this experience validates the nutrition education initiatives based on SLT and social
marketing strategies, important questions remain. For example, how can improvements be
increased in size? Equally important, how can we produce longer term effects? While the
current data are not sufficient to answer such questk* is, they underscore the need to begin
future research with broad, multiple channel nutrition education efforts.
21
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dandura. A. (1986). Social Foundations of Thought and Action: A °->cial Cognitive
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Sage Foundation
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MM S. B.. Baranowski. T.. Davis. H . Thompson, W O., Leonard, S. B.. Riley, P..
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intervention to increase fruit and vegetable consumption among 4th and 5m grade students.
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Hunter. J. E , & Schmidt. F. L (1990). Methods of meta-analysis: Correcting error and
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23
Home Economics and Household Collection
