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Snack Time at UBC : A Nutrition Assessment of the The Acadia’s Snack Program Wong, Kaelan; Schwab, Natasha; Tung, Angela; Andriani, Raisa Aulia Dec 14, 2016

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 UBC Social Ecological Economic Development Studies (SEEDS) Student ReportAngela Tung, Kaelan Wong, Natasha Schwab, Raisa Aulia AndrianiSnack Time at UBC: A Nutrition Assessment of the The Acadia’s Snack ProgramFNH 370December 14, 201615562199University of British Columbia Disclaimer: “UBC SEEDS Program provides students with the opportunity to share the findings of their studies, as well as their opinions, conclusions and recommendations with the UBC community. The reader should bear in mind that this is a student project/report and is not an official document of UBC. Furthermore readers should bear in mind that these reports may not reflect the current status of activities at UBC. We urge you to contact the research persons mentioned in a report or a SEEDS team representative about the current status of the subject matter of a project/report”.1          Snack Time at UBC:  A Nutrition Assessment of the The Acadia’s Snack Program  Kaelan Wong  Natasha Schwab  Angela Tung  Raisa Aulia Andriani  FNH370 - 001 University of British Columbia      2  Executive Summary: Acadia Child Care Centre The Acadia is one of twenty-five Childcare Centres situated on the Point Grey campus currently operated by University of British Columbia. There are a total of 5 staff members (4 early childhood educators; 1 senior supervisor) and 25 children (3-5 years of age) at this location. The objective of this case study was to determine the overall nutritional adequacy of the snacks provided by the daycare centre and the impact of daycare staff knowledge and behaviors through the use of both dietary (two direct observations sessions of snack time) and ecological assessment methods (self-reported questionnaire for daycare staff). Questionnaire results indicated that staff placed a great emphasis on nutritional value when choosing snacks for children. However, observations revealed inconsistencies regarding portion control. In addition, the children were served processed snacks alongside healthier options (vegetables), leading to a perceived reduction in interest towards the healthier options, as the children needed to be coaxed to eat the vegetables. Through the questionnaire result, time allocation for preparing the snack is not an issue as staffs usually take approximately 15-30 minutes each day. There is a general awareness of providing healthier snacks to the children by the staff; however, budget is a factor when making snack purchases.  The children at Acadia come from relatively educated and affluent families with adequate access to safe and sufficient amounts of food. The children are generally healthy and did not exhibit any signs of undernutrition. Based on these observations, we concluded that no nutrient deficiencies were present in the children. However, we have suggestions for how the snack program could be improved.  Our first proposed intervention is based on improving the nutritional value of the snacks. Staff indicated that they already avoid providing high sugar and fat snacks. Thus, we suggest 3  choosing low sodium and whole grain options when available. A diet low in sodium and high in whole grains have been associated with a reduced risk of chronic diet-related diseases.  Our second proposed intervention would involve altering staff behavior. As communal snacks were served, staff did not have complete control over each child’s intake, creating the possibility of over- and under-consumption. We suggest snacks be pre-portioned to avoid this. Furthermore, processed snacks and healthier options were served at the same time, and children exhibited less interest in the healthier options as a result. In the future, healthier options could be served first to encourage their consumption.  Introduction and Background The University of British Columbia (UBC) Childcare Centre currently operates 25 locations on the Point Grey Campus (The University of British Columbia, n.d.). Based on the requests of the children’s program manager, the objective of this case study was to determine the overall nutritional adequacy of the snacks provided by the daycare centre and the impact of daycare staff knowledge and behaviors. Assessment of child care nutrition is important because children may consume up to two-thirds of their total food intake at childcare facilities (Martyniuk et al., 2016). Based on our assessment, interventions will be provided to improve the snack program if necessary. The population examined in this study was a group of 25 3-5 year old children (males and females) who currently attend the Acadia daycare centre. Due to its location, majority of the parents are either students, staff, or faculty members of UBC. There are a total of 5 staff members (4 early childhood educators; 1 senior supervisor) at this location. Key stakeholders include the children, their parents and the daycare staff. The snacks provided to the children are completely determined by the staff. 4  Nutrition assessments were conducted through dietary (direct observations) and ecological methods (self-reported questionnaire for daycare staff). There are two snack sessions during daycare hours (8am-5:30pm); observations were conducted during the afternoon session (3-4pm). Two assessments were made approximately one week apart. The first assessment, made on a Wednesday, was a flexible snack day, meaning the snack items were not predetermined and the children participated in snack preparation. The second assessment was made on the following Thursday, which was a non-flexible day. Nutrition Care Process Nutrition Assessment Dietary Assessment A weekly snack menu is created by staff and used for 4 months at a time (Figure 1). With the exception of the flex day snacks, the same snacks are served each week. The menu reflected the recommendations made by Canada’s Food Guide to “serve small nutritious meals and snacks each day” (Health Canada, 2011).   Figure 1: Photo of Acadia snack menu. 5   Wednesday observations: Staff first served Goldfish crackers and carrot sticks to the children on communal plates. Consequently, each child consumed a different amount of each type of snack. Children exhibited greater preference for the Goldfish crackers; they finished the Goldfish very quickly and had to be coaxed to eat the carrots. Applesauce was prepared by staff and children, but not all the children consumed the applesauce as they left the daycare before it was served. Remaining children were given approximately 90mL of applesauce, and additional servings were provided when asked. The children were also given an average of 6 Premium Plus salted crackers each. However, the crackers were distributed on demand by the three different staff members present (each staff served 2 crackers each time). The children appeared to have enjoyed the snacks; they were smiling, eating eagerly and only a small subset did not finish their applesauce. Children had individual water bottles, but very few children were observed drinking from them and staff did not encourage this behavior. None of the snacks provided were organic. Thursday observations: Each child was first given a Quaker Crispy Minis White Cheddar rice cake and 2 small cubes of Armstrong medium cheddar cheese, apple, orange, and banana. Most children asked for and received additional servings. Similar to our previous observations, the children appeared to have enjoyed the snacks, consuming the snacks quickly and happily. More children were observed to be drinking water during this observation session compared to the previous session and staff were observed to encourage this behavior. The snacks for this session did not reflect the set weekly menu shown in Figure 1. None of the provided snacks were organic. Ecological Assessment To assess the nutritional knowledge and behavior of the daycare staff, a self-reported questionnaire was administered (Appendix A); 4 out of 5 staff completed the questionnaire. 6  Questionnaire results indicated that all staff had completed a nutrition course at the postsecondary level but only one had received Food Safe certification. Staff plan the snack menu ahead of time collectively and take turns to prepare the snacks each day (approximately 15-30 minutes per day). Nutrition was found to be greater factor in snack selection and preparation for the children rather than for staff themselves. Some staff reported that their ethnic background and daily eating patterns influenced the snacks prepared. Moreover, staff indicated that while there is no set budget for snacks, they did not want to spend too much on food purchases. Staff avoided providing snacks high in sugar and fat and indicated that they believed the snacks to be nutritionally adequate. Fruit and vegetables were incorporated into the menu everyday. Aside from water, beverages included milk or juice, and all staff also reported that they encouraged children to drink water throughout the day. However, staff reported that less than 33% of the snacks were organic and no emphasis was placed on providing whole grain snacks.  Nutrition Diagnosis The children at the Acadia are from relatively affluent, educated families with adequate access to safe and sufficient food. Children were generally healthy; they did not exhibit any physical difficulties eating or signs that an underlying illnesses may be causing undernourishment by impeding absorption or increasing nutrient needs. Thus, it is unlikely that any of the children are suffering from a nutrient deficiency. The children are completely reliant on staff to select and provide snacks, highlighting the important role of staff knowledge and behavior in ensuring children are adequately nourished. That being said, the selected snacks and inconsistencies in staff behavior, which includes lack of portion control and times snacks were given, indicate that improvements could be made in the Acadia’s snack program to increase the children’s nutrient status. 7  PES Statement: Sub-optimal child nutrition related to daycare staff nutrition knowledge and behavior as evidenced by the selection of snacks with low nutritional value, lack of portion control, and order in which snacks were served1. Nutrition Intervention Based upon our assessment, we have identified two possible nutrition interventions to address sub-optimal child nutrition.  The first intervention would be to improve the nutritional quality of the snacks being served. Questionnaire results indicate that staff are already making a conscious effort to avoid high sugar and fat snacks (Appendix B). Thus, we suggest that staff could also serve low sodium or whole grain options when possible. For instance, the children were served an average of 6 Premium Plus Salted Top Crackers. Whilst low in saturated fat and cholesterol, this serving size provides 180mg of sodium (Appendix C). This is 18% and 15% of the daily recommended intake value of sodium for children ages 1-3 and 4-8, respectively (Otten et al., 2006). Combined with other snacks served, such as Goldfish crackers, it is possible that the children have a high sodium intake, as processed foods have been identified as a major source of sodium (Samuel et al., 2014). High sodium intakes have been linked to an increased risk for hypertension, cardiovascular disease, stroke and renal disease (Mulder, Zibrik & Innis, 2011). By serving Premium Plus Unsalted Crackers instead, sodium intake will be reduced by approximately 81mg (MyFitnessPal, n.d.). Premium Plus Unsalted Crackers are available for the same price at both Save on Foods and Real Canadian Superstore, the supermarkets of choice for the childcare centre (Appendix D). Thus, switching to the low sodium option will not have a significant impact upon food budget or inconvenience to the day care.                                                  1 Due to the nature of our case study, there is no true nutrition problem observed. Thus, our problem is the fact the provided snacks could be of better nutritional value.  8  The second intervention involves altering staff behaviors to ensure portion control and to encourage healthy eating habits among children. It was observed that there were no set portion sizes for communal snacks; some children grabbed fistfuls of Goldfish crackers, whilst others only had one or two crackers. Thus, we suggest that snacks be portioned out equally to ensure children have consistent nutrient intakes and avoid over- and under-consumption. The communal snacks were served at the same time and the children showed a strong preference for the crackers. We recommend that the carrots (or any vegetable) be served first to encourage consumption. Studies have indicated that repeated exposure to healthy foods may increase one’s preference for such foods, and childcare meals and snacks are one of the best times to develop these food preferences (Martyniuk et al., 2016).  The expected outcomes of the interventions would be improved child nutrient status through the consumption of snacks of higher nutritional value and consistent serving sizes. A positive change in the children’s attitudes towards healthy foods may also be observed. Better childhood nutrient status will positively affect physical and cognitive development (Kurpad, Edward & Aeberli, 2013).  Nutrition Monitoring and Evaluation To monitor the progress of the interventions, a second round of observations and questionnaires would be administered. To determine if the intervention was effective, we would specifically observe for any changes in the snacks provided (are low sodium and whole grain options being provided?) and how the snacks are being served (are vegetables being served first? Are snacks being served in individual portions?). Our second questionnaire would contain similar questions to the first questionnaire to allow for comparisons in staff behavior and attitudes pre- and post-intervention. Specifically, we would observe if more staff responded 9  ‘Always’ or ‘Most of the time’ when asked if whole grains are incorporated into the snacks. We would also include new questions regarding 1) whether low sodium options chosen when possible, 2) how snacks are portioned and served, 3) if staff believe that the children receive equal amounts of snacks, and 4) if staff observe any children over- or under-consuming snacks. If no or little changes in behavior are observed, different interventions must be proposed to achieve the desired health outcomes. For instance, a list of healthy, nutrient-dense snacks could be compiled and given to the staff to use for menu planning and shopping. Furthermore, the staff could purchase pre-portioned snacks instead of bulk snacks to ensure equal portion sizes. However, pre-portioned products are typically more expensive and consequently may not fit into the daycare food budget.  Summary Based upon our assessment, whilst there are no nutrient deficiencies in the children attending the Acadia, there are areas in which the snack program could be improved to ensure better nutrient statuses in children. A strength of our study lies in the fact that we were able to directly observe snack sessions and not solely rely on self-reported questionnaires, eliminating the possibility of phantom or missing foods, and allowing for identification of any inconsistencies between staff behavior and questionnaire responses. This increases the validity of our results. However, due to time constraints, we were only able to assess two afternoon snack sessions. In addition, we did not have the means to do a complete assessment of the energy and nutrient profile of the snacks provided. Therefore, our observations may not be an accurate representation of Acadia's snack program. Future research could include more extensive assessments of both the morning and afternoon snack sessions to increase accuracy. Furthermore, we observed inconsistencies between staff behavior and questionnaire results. Despite the staff 10  reporting that they frequently encouraged children to drink water, we rarely observed such behaviors. Due to the negative health consequences associated with insufficient water consumption, it would be worthwhile to conduct future research analyzing the children’s water intake and related staff behavior (Kant, Graubard & Atchison, 2009). Recommendation to Stakeholders Whilst staff indicated that there is no set budget, they did not want to spend too much on snacks. Thus, we acknowledge that budget may be a limiting factor. One of the ways that UBC Childcare can overcome this barrier is through intra-departmental collaboration within the UBC community. We recommend researching a possible liaison with the UBC farm to increase access to more seasonal/affordable fruits and vegetables. In addition, because UBC Farm is on campus, it will also serve as an excellent place for the children to learn where their snacks come from.    11  Critical Questions 1. What are other possible assessment methods that can be used to more accurately assess the Acadia’s snack program? To more accurately determine the nutrient adequacy of the Acadia’s snack program, a weighed food record could be used. As exact measurements are known, this assessment method would allow for us to accurately determine the total energy (kilocalories) and nutrient profile (macronutrient and micronutrient breakdown) of the snacks provided. In addition, if a multiple-day food record is used, the data would be more representative of usual intake than the data we collected through direct observation of two snack sessions. 2. Research bias occurs when a “systematic error [is] introduced into sampling or testing by selecting or encouraging one outcome or answer over others”(Panucci & Wilkins, 2010). What are ways of preventing and/or reducing observer bias within the context of observation research of daycare afternoon snacks? One of the methods that can be employed to prevent or reduce observer bias is to utilize an impartial third party to conduct the observations. Because this third person is does not have any vested interest in the study, they would simply be recording what they saw. Another method that can be used is to ensure that the survey questions are worded in a neutral manner. Thus, guiding questions should be avoided as these may prompt staff to respond in a certain way. For example instead of asking staff “are whole grains incorporated into the snacks?” and “does the daycare make a conscious effort to avoid snacks high in sugar and fat?”, we could simply ask the staff to list all criteria they consider when choosing snacks for the children.  12  Bibliography American Diabetic Association. (2007). Nutrition diagnosis and intervention: Standardized language for the nutrition care process. Chicago, IL: American Dietetic Association. Kant, A., Graubard, B., & Atchison, E. (2009). Intakes of plain water, moisture in foods and beverages, and total water in the adult US population-nutritional, meal pattern, and body weight correlates: National health and nutrition examination surveys 1999-2006. American Journal of Clinical Nutrition, 90(3), 655-663. doi:10.3945/ajcn.2009.27749 Kurpad, A. V., Edward, B. S., & Aeberli, I. (2013). Micronutrient supply and health outcomes in children. Current Opinion in Clinical Nutrition and Metabolic Care, 16(3), 328-338. doi:10.1097/MCO.0b013e32835e8d0b Martyniuk, O. J., Vanderloo, L. M., Irwin, J. D., Burke, S. M., & Tucker, P. (2016). Comparing the nutrition environment and practices of home- and centre-based child-care facilities. Public Health Nutrition, 19(4), 575–584. doi:10.1017/S1368980015003535 Mininster of Health Canada. (2011). Eating Well with Canada’s food guide (8th ed.).Ottawa, ON: Minister of Health Canada.  Mulder, K., Zibrik, L., & Innis, S. (2011). High dietary sodium intake among young children in Vancouver, British Columbia. Journal of the American College of Nutrition, 30(1), 73-78. MyFitnessPal - Premium Plus Unsalted Crackers. (n.d.). MyFitnessPal. Retrieved from http://www.myfitnesspal.com/food/update_nutrition_facts/188824086?date=2016-11-16&show_controls=true 13  Otten, J. J., Hellwig, J. P., Meyers, L. D., & National Academies Press Free eBooks. (2006). Dietary reference intakes: The essential guide to nutrient requirements. Washington: National Academies Press. Pannucci, C. J., & Wilkins, E. G. (2010). Identifying and Avoiding Bias in Research. Plastic and Reconstructive Surgery, 126(2), 619–625. http://doi.org/10.1097/PRS.0b013e3181de24bc Samuel, L., Basch, C., Ethan, D., Hammond, R., & Chiazzese, K. (2014). The need for consumer nutrition education to identify high-sodium processed foods advertised in Bronx-based supermarket circulars. Journal of Nutrition Education and Behavior, 46(4), S185. doi:10.1016/j.jneb.2014.04.281 The University of British Columbia. (n.d.). Child Care Services: About us. Retrieved from http://www.childcare.ubc.ca/about/introduction/     14  Appendix A: Questionnaire  Nutrition Questionnaire for Child Care Staff Circle one answer or fill in the blanks or check all that apply. Please answer all questions to the best of your ability; if a question is not applicable, write N/A. 1. Have you received any education in nutrition?     Yes     /     No 2. If yes, please indicate the type of education you received. a. High school course b. Continuing education/workshop/certification c. Undergraduate i. Individual course(s): ___________________ ii. Degree: ____________________ d. Professional degree: ________________________ e. Other: ___________________ 3. What is your job title/role at the daycare centre? ________________________ 4. Do you hold a current Food Safety Certification?     Yes     /     No 5. On a scale of 1-10 (10 being important), how important is nutrition when making food for yourself? _____ 6. On a scale of 1-10 (10 being important), how important is nutrition when making food for children? _____ 7. On a scale of 1-10 (10 being always), how often do you encourage children to drink water? _____  15   8. What beverages are provided to the children? Check all that apply.  ___water ___milk ___juice  ___pop ___other (please specify below) _______________________ 9. Are snacks prepared on the day of, day before or earlier? _________________________ 10. Approximately how long does it usually take to prepare a snack? <15 mins     /     15-30 mins     /     >30 mins 11. What do you do with any leftover food? _______________________________________ 12. Who usually prepares the snacks? ____________________________________________ 13. If you play a role in preparing the snacks, on a scale of 1-10 (10 equal to having very big influence), how much does your ethnic background and dietary patterns influence what kind of snacks you decide to prepare? ______ 14. Is there a budget for food?     Yes     /     No     If yes, what is it? _______________________  Who determines this budget? _______________________ 15. Where does the food for the snacks come from? Please check all that apply.  ___local grocery store ___wholesale (ex. Costco) ___designated food supplier (ex. Sysco) ___other (please specify) __________________ 16  16. Who usually buys this food? ___________________________________ 17. Who usually plans the snacks? ____________________________________ 18. On a scale of 1-10 (10 being very nutritious), how nutritious do you think the provided snacks are? _____ 19. Are whole grains incorporated into the snacks?     Always     /     Sometimes     /     Never 20. Roughly what percentage of the snacks are organic?     <33%     /     33-67%     /     >67% 21. Does the daycare make a conscious effort to avoid snacks high in sugar?  Yes     /    No 22. Does the daycare make a conscious effort to avoid snacks high in fat?     Yes     /    No 23. How often are fruits and vegetables served as part of a snack?      Once per week     /        2-3 times per week     /     3-5 times per week     /     More than 5 times per week Appendix B: Questionnaire results Nutrition for Questionnaire for Child Care Staff Summary (n=4) (*denotes side notes/comments made on questionnaire)  17    18   Appendix C: Premium Plus Salted Tops Crackers Nutrition Facts Table       19   Appendix D: Premium Plus Salted and Unsalted Tops Cracker Prices   

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