From menu to plate:
One doctoral student’s mission to improve nutrition in childcare centers
By Kimberly Eaton
Elizabeth “Lizzy” Kroeger had always loved children, so when it came time to pick a major, it made sense to choose elementary education. She wanted to be a kindergarten teacher.
She took her first semester of classes, and things were going great, but then a friend told her about this nutrition program she was in and Kroeger started wondering if she was on the right path.
“I had always loved reading nutrition magazines and learning about health and nutrition,” said the 29-year-old North Carolina native. “I would get so frustrated that one day you would hear something was good for you, like eggs, but then the next day you’d hear it wasn’t good for you. I always wondered why researchers couldn’t get the message right.”
It was this annoyance with the conflicting nutrition messages being shared with the public that caused Kroeger to not only change her career path, but also instill in her a desire to dive into research.
Her research team did lunch observations where they observed three children at each center while they were eating lunch. Kroeger“I wanted to be able to answer some of these questions,” said Kroeger, a recent graduate of UAB’s Doctoral Nutrition Science program. “Now that I’m here, I realize it’s a little harder than I thought. I get why researchers have conflicting messages now.”
Kroeger chose UAB for her graduate studies because her mentor, Dr. Brenda Bertrand, had become UAB faculty about a year before. By the time Kroeger arrived, her mentor had established some funding to disseminate an existing curriculum that focused on infant and preschooler nutrition in an underserved community.
However, no one would show up to the educational sessions; the community was just not interested. It was Kroeger’s job to help identify next steps in order to make this project successful, and to make a positive impact on this community.
The decision was made to work directly with childcare centers, since the curriculum met the continuing education needs of the teachers and directors. It was through these conversations that Kroeger identified her research problem. Many childcare centers wanted help improving the nutrition at their center. Going this route would also be a little tricky. Kroeger quickly realized that each center had different reasons that contributed to the nutrition status of the center. Not every center was the same, so a one-size-fits-all approach to improve the nutrition at childcare centers was not going to work.
“A lot of interventions being done to improve the diet quality of children in centers were being done at the individual center level,” Kroeger said. “Researchers would go into one, try to improve diet quality and see if it worked, then go into the next one. That’s not the most effective strategy because it takes a lot of time. I wanted to look at all of the different characteristics that could influence diet quality in a childcare center and then create something similar to a Turbo Tax system. Each center fills out information about their center and then it spits out a guideline for improving diet quality in that particular center.”
Kroeger and her team of undergraduate honors students worked with 53 centers in eight Alabama counties. This did not include home-based centers. The centers also had to be within 50 miles of UAB and had to serve lunch to the children. These visits were completed between summer 2016 and fall 2018. Each center filled out a questionnaire that included information about the number of staff employed, the kind of kitchen equipment they had, general demographics about the center, as well as median income, food policies and more. The questions were selected based off current research, handbooks and guidelines and best practices from different academies, Kroeger said.
The team also did lunch observations where they observed three children at each center while they were eating lunch. The team recorded what the children were served and the amount, as well as what the children ate and the amount. Essentially, Kroeger was measuring diet quality in the centers in three different ways -- an analysis of what the children were served, what they actually consumed and what was actually on the lunch menu for that day – and comparing the three.
“When referring to diet quality we mean are the centers meeting the dietary guidelines set forth by the U.S. government,” Kroeger said. “The Healthy Eating Index just says how well you’re meeting the My Plate standards. A higher score means you’re eating better.”
Many times the diet quality on a childcare center’s menu was higher than what was actually served and what was consumed by the children, Kroeger said. This means that what was listed on the menu had a higher score, but what was being served had a lower score. Kroeger was not sure why there was a discrepancy but speculated it could be the center was worried the children would not eat what was listed on the menu, so they made substitutions.
However, what they found was that children were generally consuming what was served.
“We think children aren’t going to eat what we consider better diet quality, like vegetables, but what we’re seeing is if they’re served it, they’re consuming it” she said. “We just have this gap from what is on the menu to what is being served and that’s where we want to focus our interventions. Overall, diet quality is just poor in childcare centers, but the first step is making sure that what the children are served is what’s on the menu.”
There are also things childcare centers can do to improve diet quality that are fairly easy.
“Just sitting down during a meal and talking to them about new foods -- what does it look like, what color is it, how does it feel if you touch it,” she said. “Seeing the teachers and everyone else trying it as a group has been shown to help children try it themselves. Also, just expose them to a new food. If children are exposed to new food a certain amount of times then they are more likely to eat it later. Even if they hate it and throw it, at least you’re exposing them to it.”
Since this project specifically looks at diet quality in the childcare center, it doesn’t address diet quality once the child is at home. However, Kroeger said she is working with undergraduate honors students who want to develop a pilot nutrition curriculum that connects the home and childcare center so the children are hearing consistent messages in both places.
“When I first started this, I thought if I could help children improve their diet quality for the majority of what they’re eating, then that’s a start,” she said. “They’re usually at the center for eight hours and, during that time, they typically have breakfast, lunch and two snacks. Even if the center doesn’t serve breakfast, the children are still eating lunch and two snacks. They are consuming 75 percent of their daily caloric intake. That’s a majority of what they’re eating during the day. That’s my focus right now.”
Results from Kroeger’s study were published in the Journal of Nutrition Education and Behavior. She defended her dissertation in February of 2020 and is working on publishing the remaining findings. Kroeger is now an assistant professor in the department of nutrition sciences and the director of the Dietitian Education Program in the department.