PRESCHOOL FOOD WASTE AND NUTRITION BEHAVIOR by Allison Marie Milodragovich A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Health and Human Development MONTANA STATE UNIVERSITY Bozeman, Montana April 2017 ©COPYRIGHT by Allison Marie Milodragovich 2017 All Rights Reserved ii DEDICATION I would like to thank my first and most important support in all aspects of my life, my husband, Steven Milodragovich. Secondly, I want to thank my sons, Malcolm and Merrick for inspiring me every single day to enjoy life. iii ACKNOWLEDGEMENTS I would like to acknowledge the great contributions, assistance, and support of my committee: Dr. Ahmed, Dr. Shanks, and Dr. Lux. Dr. Selena Ahmed is an intelligent and impactful advisor who helped me reach for the moon with my research ideas. She always encourages creativity and rigor in the scientific process. Without her, my work would be less interesting and meaningful. Dr. Carmen Byker Shanks was extremely critical in all aspects of research design, analysis, and is an expert in the field. Dr. Christine Lux is one of the most enthusiastic and supportive people I have met. After one meeting, she was on board with my project and helped immensely in implementation and development of the nutrition education. I would also like to acknowledge the Child Development Center at Montana State University, all the teachers, and especially the CDC center director, Miranda Wheeler. The Center’s willingness to partner for this project made it possible. Finally, I could not have collected data without the support of all my fellow graduate students: Erin Smith, Madeline Kelly, Leah Smutko, Candace Moyer, and Candace Wollert. I would also like to acknowledge support of undergraduate students at the Food and Health Lab at Montana State University: Emilia Hitchcock and Debra Kraner. iv TABLE OF CONTENTS 1. INTRODUCTION ..........................................................................................................1 Food Waste and School Nutrition Programs in the Context of Sustainability ................1 Sustainable Food System Research Framework ......................................................1 Environmental ..........................................................................................................2 Social........................................................................................................................3 Economic .................................................................................................................3 Food Waste ..............................................................................................................4 Sustainability and Food Waste.................................................................................4 Food Waste in the United States ..............................................................................5 School Nutrition Programs ......................................................................................6 Preschool Children and Nutrition Programs ............................................................6 Preschool Children and Waste .................................................................................7 Sustainability and Preschool Food Waste ................................................................8 Food Waste and Nutrition Education .......................................................................8 Research Gap and Need ...........................................................................................9 Aim and Scope .......................................................................................................10 Research Questions and Hypotheses .........................................................10 Sampling and Recruitment .....................................................................................11 Sampling ....................................................................................................11 Recruitment ................................................................................................12 Consent and Institutional Review Board Approval ...............................................13 Conclusion .............................................................................................................13 2. REVIEW OF RELATED LITERATURE ...................................................................14 Food Waste in School Nutrition Programs ....................................................................14 Food Waste in K-12 Schools ................................................................................16 Food Waste in Preschools ......................................................................................17 Behavioral Theory for Education Review ............................................................17 Theory of Planned Behavior ......................................................................18 Triandis Model ...........................................................................................19 Theory of Triadic Influence .......................................................................19 Social Cognitive Theory ...........................................................................20 Intra-Personal Factors ..........................................................................................20 Self-efficacy ...............................................................................................20 Social Cognitive Theory ...........................................................................20 Attitude .....................................................................................................21 Social Norms .........................................................................................................22 Peer Influence ...........................................................................................22 Parental & Role Model Influence .............................................................23 v TABLE OF CONTENTS — CONTINUED Environment ...........................................................................................................24 Food Preference ....................................................................................................24 Education for Preschool .......................................................................................25 Conclusion ...........................................................................................................26 3. MIXED METHODS ANALYSIS OF PRESCHOOL PLATE WASTE AND FOOD PREFERENCES Contribution of Authors and Co-Authors ......................................................................27 Manuscript Information Page................................................................ ........................28 Background ....................................................................................................................29 Behavioral and Environmental Impact of Food Waste in the School Setting ...............30 Food Preferences ....................................................................................................30 Environment ...........................................................................................................31 Objectives, Research Questions, and Hypotheses .................................................32 Purpose .......................................................................................................32 Research Question and Hypotheses ...............................................................................32 Methodology ..................................................................................................................34 Ethics Statement.....................................................................................................34 Site and Participant Selection ...............................................................................34 Site Mealtime Service ............................................................................................35 Nutrition Education Description ...........................................................................35 Implementation ......................................................................................................37 Food Waste Measurements ....................................................................................38 Background ................................................................................................39 Prior to Lunch ............................................................................................39 Lunchtime ..................................................................................................40 After Lunch ...............................................................................................40 Food Preference Survey ........................................................................................41 Statistical Analysis .................................................................................................42 Results ............................................................................................................................43 Participants .............................................................................................................43 Food Waste ............................................................................................................43 Overall Total Waste ..................................................................................43 Overall Serving Waste ..............................................................................44 Overall Plate Waste ...................................................................................44 Vegetable Food Waste ..............................................................................45 Fruit Food Waste .......................................................................................47 Time Spent Eating .................................................................................................48 Food Preference Data .............................................................................................49 Time Spent Eating and Food Waste.......................................................................50 vi TABLE OF CONTENTS — CONTINUED Food Preference and Food Waste ..........................................................................51 Discussion ..........................................................................................................................52 Conclusion .......................................................................................................................54 Implications for Nutrition and Sustainability .......................................................54 CACFP Policy Recommendations .........................................................................55 4. ANALYSIS OF PRESCHOOL NUTRITION BEHAVIORS Contribution of Authors and Co-Authors ......................................................................56 Manuscript Information Page................................................................ ........................57 Introduction ...................................................................................................................58 Methods of Assessing Nutrition Behavior ............................................................59 Aim and Scope ..............................................................................................................60 Methodology ..................................................................................................................61 Ethics Statement ............................................................................................................61 Site and Participant Selection ...............................................................................61 Site Mealtime Service ...........................................................................................61 Methods of Assessing Nutrition Behavior ............................................................61 Observational Measurement .................................................................................62 Background ................................................................................................62 Validation ...................................................................................................63 Mealtime Protocol ......................................................................................63 Statistical Analysis .........................................................................................................65 Results ...........................................................................................................................65 Observational Data.................................................................................................65 Behaviors Related to Vegetables ..............................................................65 Behaviors Related to Fruit ........................................................................66 Comparison of Behavior towards FV to other Items .................................67 Analysis of Food Waste and Observations ................................................69 Discussion ......................................................................................................................70 Conclusion ....................................................................................................................72 Limits .....................................................................................................................73 5. CONCLUSION Recommendations for Further Research .......................................................................76 Implications for Policy Makers ......................................................................................77 Overall............................................................................................................................79 vii TABLE OF CONTENTS — CONTINUED REFERENCES CITED ...................................................................................................80 APPENDICIES ...............................................................................................................90 APPENDIX A: Preschool Plate Waste Protocol ............................................91 APPENDIX B: Preschool Lunch Observation Protocol .................................99 viii LIST OF TABLES Table Page 3.1 Description of Overall Education Timeline in a Preschool Nutrition Education.........................................................................36 3.2 Individual Lunch Menu Items and Time Period for Preschool Food Waste............................................................39 3.3 Total Waste Percentages and Standard Deviations for a Preschool Program Utilizing CACFP...........................................................43 3.4 Mean Serving Waste Percentages and Standard Deviations in a Preschool Program Utilizing CACFP...........................................................44 3.5 Mean Plate Waste Percentages and Standard Deviations in a Preschool Program Utilizing CACFP...........................................................44 3.6 Means and Standard Deviations of Total Vegetable Waste over the course Fruit and Vegetable Education........................................................................46 3.7 Means and Standard Deviations of Plate Waste for Vegetables over the course of a Fruit and Vegetable Education.........................................46 3.8 Means and Standard Deviations of Serving Waste for Vegetables over the course of a Fruit and Vegetable Education..........................................46 3.9 Means and Standard Deviations of Total Waste for Fruit over the course of a Fruit and Vegetable Education..........................................47 3.10 Means and Standard Deviations of Serving Waste for Fruit over the course of a Fruit and Vegetable Education.........................................47 3.11 Selected Food Preference Survey Results in a Preschool Using CACFP over the course of a Fruit and Vegetable Education........................49 3.12 Average Time Spent eating in a Preschool Program using CACFP..................................................................................50 4.1 Report of Behaviors as a Percentage of the Total Number of Potential Observations for the Behavior in a Preschool Nutrition Program.....................66 ix LIST OF TABLES – CONTINUED Table Page 4.2 Report of Fruit Behaviors as a Percentage of the Total Number of Potential Observations for the Behavior in a in a Preschool Nutrition Program...................................................................67 x LIST OF FIGURES Figure Page 3.1. Example of Food Preference Survey for Preschool Children Participating In CACFP..................................................................42 3.2. One Way Analysis of Variance of Total Plate Waste by Nutrition Education Phase in A Preschool Using CACFP...........................................................................48 3.3. One Way Analysis of Variance of Fruit Plate Waste by Nutrition Education Phase in A Preschool Using CACFP.............................................................................48 3.4. One Way Analysis of Variance of Time Spent Eating by Nutrition Education Phase in a Preschool Using CACFP.........................49 3.6. Trend of Food waste and Food Preferences during a Nutrition Education a Nutrition Education Phase in a Preschool Using CACFP...........................51 4.1 Example of Standardized Method to Number Children For Observation..............................................................................................65 4.2. One Way Analysis of Percent Occurrence of Taking Food Behavior by Food Category.............................................................................69 4.3. One Way Analysis of Percent Occurrence of Eating Food by Food Category............................................................................................69 4.4. One Way Analysis of Percent Occurrence of Please Pass Food Food Behavior Food Category.......................................................................70 xi ABSTRACT While fruit and vegetable (FV) consumption is a key component of healthy diets, evidence demonstrates that preschool-aged children in the USA do not meet dietary recommendations for FVs. Preliminary research has shown children that children receive fifty to sixty-five percent of nutrients during the school day through child nutrition programs. Concurrently, children are not eating enough FVs at the same time. The primary objective is to quantify the amount of food waste that occurs in the CACFP utilized in a preschool setting. The secondary objective is to examine the effectiveness of a FV nutrition education program on decreasing the amount of food wasted. A cross- sectional and quasi-experimental research project was implemented to collect food waste and observational measurements at the following three-day intervals corresponding to a nutrition education intervention: (1) pre-education phase, (2) behavioral education phase, (3) personal education phase, and (4) post-education phase. Quantitative food waste measurements were conducted through direct weighing. A unique observational tool was developed, piloted, and implemented. Food preference data was collected through a commonly implemented child preference survey. Findings from the plate waste data indicate that 43.6% total waste occurred across all data collection time periods with vegetables being the most wasted food category with an average of 66% waste across all data collection periods. Compared to vegetables, fruit is wasted at a lower rate of 18.2% across all data collection periods. Serving waste is the primary source of waste for all food categories representing 80% of total waste, while plate waste represents 16 % of total waste. Plate waste across the nutrition education periods found significant (p < 0.05) differences between the pre-education phase amount of 10.8% and post-education phase amount of 4.6%. No significant differences were found between means of total and serving waste across the four data collection periods of the nutrition education. Observational measurements showed greater incidence of positive fruit behavior. Preference data found that children prefer fruits over vegetables. Findings have the potential to inform the CACFP as well as other food and nutrition programs that seek to support healthy eating habits among pre-school children while supporting sustainability. 1 CHAPTER ONE – INTRODUCTION Food Waste and School Nutrition Programs in the Context of Sustainability The food system has a greater impact on environmental wellbeing including water, soil, biodiversity, and greenhouse gasses than any other human activity (Kummu et al., 2012). A food system includes the inputs, activities, people, products, and outcomes associated with progressing food from seed to consumption all the way through waste (Shannon, Kim, McKenzie, & Lawrence, 2015). Consumption of certain food categories is higher and lower for others (Munesue, Masui, & Fushima, 2015). Consumption rates impact the amount of waste that occurs for these food categories. Fruits and vegetables are the highest wasted food items in the world (Food and Agriculture Organization of the United Nations, 2011). Inadequate consumption of fruit and vegetable (FVs) to meet healthy dietary patterns and food waste is a key sustainability challenge of the food system. This introduction will first present a sustainable food system research framework that underpins this research including the three key pillars of sustainability. Following this context, the objectives and research questions of this study will be presented. The goal of the research presented here is to contribute to the literature regarding food waste and nutrition behaviors among preschool-aged children. 2 Sustainable Food System Research Framework The global food system has been recognized to compromise the environment through negative environmental externalities including air and water pollution, soil depletion, loss of biodiversity, and pressures on limited fossil fuels through agricultural production (Gliessman, 2015). The food system compromises the integrity of human health through the supply of foods that rely on agricultural chemicals and those that are linked to diet-related chronic diseases (Horrigan, Lawrence, & Walker, 2002). Economic, cultural, and socio-political factors have further locked-in our food system to widespread unsustainable modes of production and heightened consumption. In recognition of the challenges of the food system, food systems based on the three pillars of sustainability are increasingly being promoted. The three pillars of sustainability include environmental factors, economic factors, and social / human health factors (Brklacich, Bryant, & Smit, 1991). This study draws on the concept of sustainable food systems as a research framework. Sustainable food systems maintain or improve the resource base for future generations as well as associated factors of social justice, economic viability, and the environment (Brklacich, Bryant, & Smit, 1991). There are three main components of a sustainable food system: maintenance or improvement of social, economic, and environmental aspects of the food system (Shannon et al., 2015). Environmental The environmental impacts of agricultural production in the United States are well researched. Crop and animal production require the use of natural resources: fossil fuel, cropland acres, fertilizers, and freshwater (Kummu et al., 2012). The water 3 requirements for agriculture are vast. Agriculture accounts for 70 to 80% of freshwater use. There are regional water supply issues increasing in importance and will become critical in the future (Coleman-Jensen, Rabbitt, Gregory, & Singh, 2015; Zamora, Kirchner, & Lustgarten, 2015). Agricultural production requires three kcal of fossil fuel energy to produce one kcal of food energy (Kummu et al., 2012). Land requirements for the current type and rate at which agricultural production occurs is enormous. Agricultural land in the United States in 2012 accounted for over fifty percent of land use in the lower 48 states; and over seventy-five percent of this land is used for animal production (Farmland Information Center, 2017). Social One principal goal for a food system is to provide food security for the population (Shannon et al., 2015). Food security is the consistent, dependable, and culturally acceptable access to enough food for active, healthy living (Coleman-Jensen et al., 2015). Globally 10.9% of people suffer from undernourishment (FAO, IFAD, & WFP, 2015) and in the United States 19.9% of households with children suffer from food insecurity (Coleman-Jensen et al., 2015). There will be nearly 2 billion more mouths to feed in the world by 2050. Global population increases will require a nearly 70% increase in food production and reductions in food waste will decrease pressure on agriculture to produce more food (Searchinger et al., 2013). The way food is produced currently does not provide food security for the population globally or regionally. The rate at which the population is growing will require a change in food production or waste. 4 Economic Economic vitality is a critical function of the food system. In the United States, one percent of the total gross domestic product (GDP) is directly related to agriculture (Economic Reserach Service, 2017). The percent that agriculture contributes to the GDP has fallen over time and the distribution of income is concentrated in only six states (Economic Reserach Service, 2017). The economic vitality of producers of agricultural products can be debated and concurrently consumers are impacted. Retail value of food is over 500 billion dollars a year in the United States (Buzby & Hyman, 2012). Food Waste Waste is a critical part of the food system globally, regionally, and locally. Roughly 30-40% of the global food supply is wasted each year (Buzby & Hyman, 2012; Food and Agriculture Organization of the United Nations, 2011). Food waste is defined as food fit for human consumption that is thrown away in some segment of the food chain (Food and Agriculture Organization of the United Nations, 2011). A vast majority of food waste occurs at the consumer level in middle to high income countries, including the United States (Food and Agriculture Organization of the United Nations, 2011). In 2008, United States’ consumers threw away 126 billion pounds, or 29% of their food supply, which equated to nearly 1400 kilocalories (kcal, equal to one food Calorie) per capita of food thrown away (Buzby, Hyman, Stewart, & Wells, 2011; Hall, Guo, Dore, & Chow, 2009; Kummu et al., 2012). The amount of food waste varies by food category. Fruits and vegetables are wasted at the highest percent at the consumer level; up to 30% of fruits and vegetables are thrown away (Gunders, 2012). 5 Sustainability and Food Waste The quantity of food that is wasted globally, regionally, and locally is unsustainable (Kummu et al., 2012). When food is wasted, the environmental resources which went into that food are wasted as well. The rate of food waste currently accounts for 25% of the freshwater use and 4% of United States oil consumption (Hall, Guo, Dore, & Chow, 2009; Kummu et al., 2012). The amount of land that is used to produce food that is ultimately wasted is nearly 25% (Kummu et al., 2012). Global climate change and increasing populations compel changes in the amount of food and resources that are wasted. Socially, individuals suffer from food insecurity (Coleman-Jensen et al., 2015; FAO et al., 2015). Decreasing food waste is one low-cost solution to the multifaceted problem of food insecurity (Munesue, Masui, & Fushima, 2015). Munesue et al. state one mechanism of how this would work is a decrease in food waste will decrease food demand in developed regions in the world, thus decreasing global commodity prices due to the lower demand. Economically, the cost of the food that is wasted is astounding. Estimates conclude that each consumer in the United States wastes two-thirds of a pound of food per day; approximately $1.07 worth of food per day in 2008 (Buzby & Hyman, 2012; Food and Agriculture Organization of the United Nations, 2011). Therefore, nearly 300 million dollars of food are thrown away by consumers every day in the United States (Buzby & Hyman, 2012; Buzby, Hyman, Stewart, & Wells, 2011). The amount of food 6 being thrown away, the environmental impact of this food, and food security issues globally and in the United States make decreasing food waste an important issue. Food Waste in the United States Developed countries contribute most of their food waste at the consumer level of the food system (Food and Agriculture Organization of the United Nations, 2011). The United States is a developed country and this study is situated in the United States and therefore focuses on the topic of consumer level food waste. North America, including the United States, has the highest rates of total food waste per capita and highest proportion of that waste coming from consumers (Food and Agriculture Organization of the United Nations, 2011). United States consumers discard 95-115 kilograms of food per capita per year compared to only 6-11 kilograms per capita per year in sub-Saharan Africa (Food and Agriculture Organization of the United Nations, 2011). The vast percentage of food waste occurring at the consumer level, indicate to reduce overall levels of waste in the United States, policies and research must focus on consumers. School Nutrition Programs One population of consumers to consider for reduction in food waste is children that participate in child nutrition programs. The National School Lunch Program (NSLP). NSLP is a federally funded program that supports K-12 schools by reimbursing for meals that are nutritionally adequate (Food and Nutrition Service, 2014). Research of food waste by direct measures have found that approximately 45% of meals served in public schools are wasted (Byker, Farris, Marcenelle, Davis, & Serrano, 2014; Davidson, 1979; 7 Green & Munroe, 1987; Reger, O'Neil, Nicklas, Myers, & Berenson, 1996). A significant amount of food waste is occurring in K-12 schools, but there are limited studies about food waste among preschool children. Preschool Children and Nutrition Programs A large segment of children aged three to six (61%) attend some type of center based care or preschool before they attend kindergarten (Federal Interagency Forum on Child and Family Statistics, 2013). Child care centers and preschools can participate in Child and Adult Care Food Program. Child and Adult Care Food Program (CACFP) is the federally funded nutrition program aimed at improving nutrition in younger children (Food and Nutrition Service, 2014). CACFP is designed to provide nutritious snacks and lunches throughout the day (Food and Nutrition Service, 2014). CACFP can provide up to ½ to 2/3 of a child’s caloric needs for the day (Neelon & Briley, 2011). The guiding policy documents for CACFP are the Hunger-Free Kids Act of 2010, Public Law 111- 296 and the Dietary Guidelines for Americans (Food and Nutrition Service, 2014). A recommended practice under CACFP is family style meal service. Family style meal service is when all the meal pattern requirements are placed in serving plates or bowls on a table and children serve themselves or serve themselves with some help from site staff (Food and Nutrition Service, 2014). Starting October 1, 2017, CACFP meal patterns required for lunch will include: Fruit, Vegetable, Meat or Meat Alternative, Dairy or Dairy Alternative, and Grain (Food and Nutrition Service, 2014). The updated meal requirements encompass the most recent updates to healthy meal patterns from the Dietary Guidelines for Americans. 8 Preschool Children and Food Waste Preschools and child care centers are likely contributing to consumer level food waste, and younger children tend to waste more food than older children (Carver & Patton, 1958; Dillon & Lane, 1989; Jansen & Harper, 1978). There is limited research exploring waste in CACFP at preschools. One cross-sectional research study conducted in a preschool enrolled in CACFP found waste of up to 60% for vegetables and nearly 45% for total plate waste (Nicklas et al., 2013). Required serving amounts under CACFP regulation particularly for vegetables are likely contributing to waste amounts in CACFP. Sustainability and Preschool Food Waste The economic, social, and environmental sustainability of child nutrition programs will be a critical factor for future funding. Economically, quantifying plate waste in CACFP is important, because nearly 3.3 million meals are served daily to children through CACFP, accounting for 2.9 billion federal dollars spent per year (Food and Nutrition Service, 2014). Socially, the goal of child nutrition programs is to provide adequate nutrition. If preschool-aged children are throwing away nearly 60% of the vegetables served to them, then those children are missing out on key nutrients and long- term health habits. Fruit and vegetable consumption is one of the best indicators for long- term health outcomes (United States Department of Health Human Services & United States Department of Agriculture, 2010). And only seven percent of preschool age children eat the recommended amount of vegetables (National Cancer Institute, 2015). 9 Environmentally, food waste in child nutrition programs impacts resources such as land, water, and greenhouse gas emissions (Kummu et al., 2012). Food Waste and Nutrition Education Research in child nutrition programs largely focuses on increasing consumption of healthful foods (Mikkelsen, Husby, Skov, & Perez-Cueto, 2014). Although not a direct objective or question in most child nutrition research, waste reduction is a by-product of increasing consumption. If a nutrition education focuses and succeeds in increasing consumption a by-product should be a reduction in waste. Nutrition education in preschools show that education can positively change nutrition behaviors in the following ways: increased FV consumption, decreased saturated fat intake, and decreased energy intake (Alaimo et al., 2015; Auld, Romaniello, Heimendinger, Hambidge, & Hambidge, 1999; Caton et al., 2013; Farfan-Ramirez, Diemoz, Gong, & Lagura, 2011; Izumi, Eckhardt, Hallman, Herro, & Barberis, 2015; Witt & Dunn, 2012). A large portion of the literature on preschool-aged children focuses on FV consumption. The focus on FV consumption be attributed to the importance of FV consumption for long-term health outcomes (United States Department of Health Human Services & United States Department of Agriculture, 2010) and the fact that fruits and vegetables are the highest wasted food category in food waste studies (Byker et al., 2014; Nicklas et al., 2013). 10 Research Gap and Need The gap in food waste research as stated above is quantitative research studies on food waste in preschool using CACFP. The need comes from the large portion of children that participate in this program (Federal Interagency Forum on Child and Family Statistics, 2013), the low consumption of vegetables (National Cancer Institute, 2015), and high waste amount of vegetables (Nicklas et al., 2013). The logic behind the research conducted here is rooted in existing research on nutrition education. If researchers can increase consumption of FV, then a nutrition education should decrease the amount of food waste as well. Aim and Scope The primary objective of this research is to quantify the amount of food waste that occurs in CACFP utilized in a preschool setting. The secondary objective of the research presented here is to examine the effectiveness of a FV education program on decreasing the amount of food wasted. Research Questions and Hypotheses The three primary research questions addressed by this study and associated hypotheses are as follows: Research Question 1: How much food is wasted in childcare centers (CCCs) participating in CACFP? Hypothesis One: 45% waste will occur in this study at the baseline Research Question Two: What effect will a nutrition education aimed at increasing fruit and vegetable consumption have on food waste in CCCs? 11 Hypothesis Two: If children are exposed to a nutrition education focused on FV consumption, then their intake of those items will increase and waste will decrease. Research Question 3: How are food preferences and food waste correlated? Hypothesis 3: If children have more positive food preferences then waste will be lower. Waste will be negatively correlated with food waste. Each of the main research questions consist of the following sub-questions: Research Question 1a: Which food categories have the highest percentage of waste? Hypothesis One a: Fruits and vegetables will have the highest percentage wasted Research Question 1b: Is food waste in a preschool primarily from serving waste or plate waste? Hypothesis One b: Food waste in a preschool setting utilizing CACFP will be from serving waste not plate waste. Research Question One c: Does the amount of time children eat correlate to food waste? Hypothesis One c: The longer children eat, the less total waste there will be. (Cason, 2001; Lowe, Horne, Tapper, Bowdery, & Egerton, 2004; Amanda E Staiano, Arwen M Marker, Johannah M Frelier, Daniel S Hsia, & Corby K Martin, 2016). Research Question 2a: What behaviors do preschool children exhibit towards fruits and vegetables? Hypothesis Two a: Children will be less likely to display positive behaviors (defined in methodology) towards fruits and vegetables than for other food groups. 12 Research Question Two b: Are observations of lunchtime behavior related to food waste? Hypothesis Two b: Lunch time behaviors will be negatively correlated to food waste. For example, if the children display more positive behaviors then there will be less waste. Sampling and Recruitment Sampling The target samples for this project were children aged four to six in child care centers. Child care centers accommodate younger children, however due to recommendations from early childhood education professionals, only the older children’s plates were sampled. The plates will be observed at child care centers and therefore the basis for inclusion and exclusion is on the center enrollment criteria. Child care centers teaching three to six year old children participating in CACFP were included. Children younger than four were excluded due to differences in developmental ability. Childcare centers with populations of younger than three years old, older than six years old, or not participating in CACFP are excluded. Target number of students were 30 to 50. Recruitment Recruitment of childcare centers occurred through a non-probability purposive sample obtained through Montana State University early childhood education contacts. This study utilized established departmental contacts because relationships exist and that allows for more cohesive research. Purposive sampling occurred at the Child Development Center (CDC) on campus because this center often participates in research. No individual level socio-economic or demographic information was collected. However, center level demographic and socio-economic information was collected. The proxy indicator for socio-economic status will be percent of children in free, reduced, and 13 full price lunch categories as categorized with CACFP regulations. Lunchtime reimbursement rates are higher for children that are eligible for free-lunch. Free, reduced, and full priced lunch categories are based on gross income of the child’s home and levels are determined by the USDA (Food and Nutrition Service, 2014). For example, child care centers are reimbursed for a student eligible for free lunch at a rate of $3.16 versus only $.30 for a paid lunch student (Food and Nutrition Service, 2014) Consent and Institutional Review Board Approval Adult participants (teachers) had active, voluntary consent and student consent was passive through parental assent. Parents will be informed through daily folder pickups that occur regularly as part of daily routine at preschools. This study was approved by the Montana State University Institutional Review Board. Conclusion This thesis work will contribute to the growing body of food waste and nutritional behavior research. The food waste problem has been determined by the United States Department of Agriculture (USDA) and Environmental Protection Agency (EPA) as a critical problem in the United States contributing the highest proportion of solid municipal waste and a significant contributor to US methane emissions (Kummu et al., 2012). Waste amounts should be reduced to protect future funding ability. It is expected that findings will add to the body of food waste literature by filling a critical gap in the knowledge base. Most research on food waste in child nutrition programs focuses on the NSLP, whereas this research will focus on the child nutrition program used in preschools, 14 Child and Adult Care Food Program (CACFP). The knowledge gained in this research will assist practitioners and educators in positively changing waste and nutrition behaviors towards enhancing the sustainability of food systems. 15 CHAPTER TWO — REVIEW OF RELEVANT LITERATURE Food Waste in School Nutrition Programs Introduction Child nutrition research includes these areas: childhood obesity, childhood eating behaviors, origins of cardiovascular disease, phytonutrient biochemistry, and many more (Baylor School of Medicine, 2017). One area of research focuses on understanding childhood eating patterns through food waste measures in school nutrition programs. Quantitative measurements of the food wasted, give researchers the amount that children are wasting and consuming. Sustainability of child nutrition programs is critical. Understanding the quantity and behavior behind food waste in child nutrition programs can reveal key recommendations to improve sustainability of child nutrition programs. Economically, United States tax payers invest over 100 billion dollars annually into child nutrition programs (Food and Nutrition Service, 2016). Socially, many health behaviors are established and persistent from childhood into adulthood (Lloyd, Langley-Evans, & McMullen, 2012). Environmentally, any reduction in food waste will improve environmental quality (Kummu et al., 2012). One school nutrition program that has been studied extensively is the National School Lunch program (NSLP). NSLP is a federally funded program that supports K-12 schools for nutritionally adequate meals served to children at a free or low cost rate (Food and Nutrition Service, 2016). In 2013, the National School Lunch Program was funded at 106.8 billion (Atlas, 2015; National Confrence of State Legislatures, 2015). The amount 16 of money invested in NSLP means that continuing research for food waste amounts in NSLP is important. Child nutrition programs cost money and if children are throwing away food, they are throwing away the money invested. The goal of NSLP is to provide nutritionally acceptable meals based on current recommendations under the Dietary Guidelines for Americans (Food and Nutrition Service, 2016). When children throw away the food that is recommended for nutrition purposes, students are not receiving all the nutrients they need. For example, vegetables are the highest wasted food categories in NSLP direct waste studies (Buzby & Guthrie, 2002a; Byker et al., 2014). Concurrently, children do not consume adequate amounts of FV (Kim et al., 2014). Only 7% of children consume enough vegetables and 40% consume adequate amounts of fruits (National Cancer Institute, 2015). Concurrently, FV is the highest wasted food category in NSLP direct waste studies (Buzby & Guthrie, 2002a; Byker et al., 2014). The importance of FV for long-term health outcomes cannot be understated. Population-wide in the United States, diet-related chronic diseases such as: obesity, heart diseases, type 2 diabetes, and some cancers, have increased dramatically over the last two decades (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2015). Preventing chronic diseases through healthy dietary patterns over a lifetime, which include consuming a wide variety of fresh FV, could save billions of dollars a year in direct medical costs (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2015). Quantifying, categorizing, and understand FV food waste that occurs in child nutrition programs is an important first 17 step in reversing un-healthy food patterns in the United States. Understanding FV consumption and waste patterns can provide critical information to educators and practitioners to develop effective nutrition education. Food Waste in Pre- K-12 Schools Food waste in K-12 schools is an emerging and changing area of literature. This literature review focused on studies that included quantitative, direct measurement of waste methods. Most studies show a high amount of overall waste across all food categories (Buzby & Guthrie, 2002b; Byker et al., 2014). Studies that investigated total percentages of waste indicate that 45% of all food and beverages served were wasted (Byker et al., 2014). Studies also focus on strictly FV waste or include an analysis of FV with total waste (Amin, Yon, Taylor, & Johnson, 2015; Byker et al., 2014; Schwartz, Henderson, Read, Danna, & Ickovics, 2015; Yoder, Foecke, & Schoeller, 2015). All studies found indicated vastly different waste percentages and reported FV waste in different ways including: FV reported separately so individual percentages can be determined or FV reported together. Two studies indicated fruit-only waste in percentages ranging from 24.6 (Schwartz et al., 2015) to 33 (Byker et al., 2014) Vegetable-only waste was reported in ranges from 51.4% to as low as 36.4% (Byker et al., 2014; Schwartz et al., 2015). Two studies reported FV waste together ranging from 43.8% to 27% (Amin et al., 2015; Yoder et al., 2015). The relatively wide range of percentages reported and the different methods of reporting indicate that further research must be done to determine accurate amounts of fruit and vegetable waste that is occurring. 18 Food Waste in Preschools A large segment of children aged three to six (61%) attend some type of center based care or preschool before they attend kindergarten (Federal Interagency Forum on Child and Family Statistics, 2013). Preschools and care centers are likely contributing to consumer level food waste and younger children tend to waste more food than older children (Carver & Patton, 1958; Dillon & Lane, 1989; Jansen & Harper, 1978; Niaki, Moore, Chen, & Weber Cullen, 2017). Child and Adult Care Food Program (CACFP) is the federally funded nutrition program that childcare centers and preschools use (Food and Nutrition Service, 2014). Scientific literature demonstrates that a significant amount of waste occurs with NSLP, but very few studies explore waste in CACFP at preschools. Quantifying plate waste in CACFP is important because nearly 3.3 million meals are served daily to children through CACFP accounting for 2.9 billion federal dollars spent per year (Food and Nutrition Service, 2014). Behavioral Theory for Education Review Behavioral theory has a long and evolving history over the last forty years. Behavioral theories took a leap forward with the publication of a Theory of Reasoned Action (TRA) and continued to improve when TRA was improved and re-published as Theory of Planned Behavior (TPB) (Ajzen, 1991). The TPB is the parent of a vast majority of other behavioral theories and much of the literature on behavioral theory cites TPB as being adjusted to create the new theory currently being published (Flay & Petraitis, 1994). Initially, most studies implementing TPB were focused on smoking behavior as that was a major public health concern at the time (A. Bandura, 1986). More 19 current literature is using and adapting TPB to implement nutrition education (Appleton et al., 2016; Mikkelsen et al., 2014). Behavioral Theory and Practice The current research, “Preschool Nutrition and Waste Behaviors” integrates behavioral theory with practitioner recommendations to reduce food waste in lunch programs sponsored by the USDA, including CACFP. The researchers will emphasize effective methods to reduce waste of fruits and vegetables. One method to decrease waste is to increase consumption. Fruit and vegetable (F&V) FV consumption is not only critical to decrease waste in school lunches, but has historically been linked to health benefits (Van Duyn & Pivonka, 2000). Behavioral theory must be integrated to design an effective nutrition education that enforces the behavior of F&VFV consumption (Appleton et al., 2016; Mikkelsen, Husby, Skov, & Perez-Cueto, 2014; Wolfenden et al., 2012). Health education, s, including fruit and vegetable consumption, are commonly implemented in school settings for a number of reasons: hours participants spend in school, broad impact range, ease and cost of access (Klepp et al., 2005). Many studies have found that school education s have more impact than similar education s implemented at home (Brug et al., 2010; Klepp et al., 2005). TR programs sponsored by the United States Department of Agriculture, researchers should emphasize effective methods to reduce waste of fruits and vegetables. One method to decrease waste is to increase consumption. FV consumption is not only critical to decrease waste in school lunches, but has historically been linked to health benefits (Van Duyn & Pivonka, 2000). Behavioral theory must be integrated to design an effective nutrition education that 20 enforces the behavior of FV consumption (Appleton et al., 2016; Mikkelsen, Husby, Skov, & Perez-Cueto, 2014; Wolfenden et al., 2012). Health education, including fruit and vegetable consumption, are commonly implemented in school settings for a number of reasons: hours participants spend in school, broad impact range, ease and cost of access (Klepp et al., 2005). Many studies have found that school education have more impact than similar education implemented at home (Brug et al., 2010; Klepp et al., 2005). The above is a brief rationale as to why the project, “Preschool Nutrition and Waste Behaviors” was selected. Theory of Planned Behavior The main tenant of TPB is that behavior is determined by intention (Ajzen, 1991; Manstead & Parker, 1995). If the participant intends to perform or not perform a particular behavior then that determines if the behavior is executed. Three broad categories affect participants’ intentions to perform a behavior: attitude, self-efficacy, and perceived social norms (Ajzen, 1991). Attitude refers to how the participants view the behavior in a positive or negative light (Bogers, Brug, van Assema, & Dagnelie, 2004). Social (or subjective) norms refers to how the participants view peer pressure to perform or not perform a certain behavior. Social norms is all about how the participant perceives the pressure not whether or not that pressure is real or not (Bogers et al., 2004). Self-efficacy could also be referred to as behavioral control and refers to the amount that a participant feels that they have control over the behavior (Bogers et al., 2004). The above three factors interact with each other to predict behavioral intention. Behavioral prediction and most research related to it point 21 to the transient nature of human intention and behavior (S. B. Domel et al., 1996; Manstead & Parker, 1995). Triandis Model the Triandis model combines habit, intention, and environmental influences on the behavior (Valois, Desharnais, & Godin, 1988). Triandis models differ from TPB by including habit and environmental factors. Environment is a particularly important factor in eating behaviors, and the food environment has been shown in many different types of research to be an important determinant in eating behavior (Herforth & Ahmed, 2015; Valois et al., 1988; Wind et al., 2006). Habit is also an important determinant of health behaviors that is not accounted for in TPB (Valois et al., 1988). Fruit and vegetable consumption education have shown that habit can be one of the most important predictors of consumption (Brug, Lechner, & De Vries, 1995; Krebs-Smith et al., 1995). Theory of Triadic Influence Theory of Triadic Influence (TTI) combines the Triandis Models and TPB (Flay & Petraitis, 1994). The major components of TTI include: cultural/environmental influences, social-contextual influences, and intra- personal influences (Flay & Petraitis, 1994). TTI unlike TPB factors in the broad social and environmental context not in how those factors directly influence health behaviors, but in how they influence intra-personal influences such as attitude and self-efficacy (Flay & Petraitis, 1994). Similarly to the TPB, the TTI directly links perceived social norms to health related behaviors (Flay & Petraitis, 1994). 22 Social Cognitive Theory Social Cognitive Theory (SCT) states that three broad factors: behavior, personal factors, and environmental factors all interact and combine to predict the likelihood of health related behaviors being performed (A. Bandura, 1986). SCT has been used to design broad-based and extensive nutrition education (Reynolds, Hinton, Shewchuk, & Hickey, 1999). Intra-Personal factors Intra-personal factors that are involved in determining health behaviors include self-efficacy and attitude. A vast majority of health behavior models include intra- personal factors as a large contributor to predicting the outcome of health behavior (Ajzen, 1985; Flay & Petraitis, 1994; Resnicow et al., 1997). Self-efficacy is the belief in an individual that he or she can execute a health behavior (Albert Bandura, 1977; de Vries, Dijkstra, & Kuhlman, 1988). Behavioral theories suggest that health behaviors will only change if the individual in question feels that they have a high self-efficacy for the behavior (Albert Bandura, 1977). For FV consumption, actions that relate to self-efficacy include: shopping for fruit and vegetables, picking out fruit and vegetables, preparing, cooking, and growing fruits and vegetables (Brug et al., 1995; Davis, Martinez, Spruijt-Metz, & Gatto, 2015; Thomson & Ravia, 2011). Systematic reviews covering adult and child education show that nearly one-third of education aims to increase self-efficacy of FV consumption (Appleton et al., 2016; Thomson & Ravia, 2011; Wolfenden et al., 2012). Self-efficacy is commonly evaluated through questionnaires (Brug et al., 1995; Davis et al., 2015; S.B. Domel et al., 23 1996). Examples of questions on a scale answer basis that relate to self-efficacy include: I independently shop for fruits and vegetables, my parents or I cut fruits and vegetables for a snack, or I pack a fruit or vegetable in my lunch (S.B. Domel et al., 1996). Self-efficacy is an important behavioral determinant and should be assessed in nutrition education. Common activities related to increasing self-efficacy that are implemented in education include: cooking demonstrations with hands-on student activity, gardening activates, food shopping with children, and health and nutrition education (Mikkelsen et al., 2014). “Preschool Food Waste and Nutrition Behavior” will involve components aimed at increasing self-efficacy. The preliminary questionnaire will include items aimed at establishing a baseline self-efficacy score and activities during the education will include cooking demonstrations and fruit and vegetable education. Attitude in behavioral theory is defined as an individual’s positive or negative evaluation of a health behavior (Ajzen, 1985). For eating behaviors, such as fruit and vegetable consumption, attitude is also commonly referred to as “liking” or in research articles, hedonic factors. Whether an individual positively views or likes a food is strongly correlated to the consumption of that food (Mikkelsen et al., 2014; Woodward, 1986). An important hedonic factor in children is familiarity as nomophobia is a common issue in small children. One systematic review of nutrition education aimed at improving fruit and vegetable consumption among young children found that nearly half of all education involved an aspect of improving attitude, familiarity, and liking of fruits and vegetables among children (Appleton et al., 2016). Attitude and liking of fruits and vegetables is a critical component of any nutrition education. Common strategies to 24 increase attitude for fruits and vegetables among children include: gamification, repeated exposure, stories, and education (Appleton et al., 2016; Mikkelsen et al., 2014). Preschool plate waste in Bozeman, MT, will include questionnaire items in the pre and posttest to that asses the participants attitude and liking of fruits and vegetables before and after and will include repeated exposure at snacks and cooking demonstrations to vegetables especially. Social Norms Peer Influence Foods consumed or perceived as consumed by peers often have an increased intake compared to food that is not consumer or perceived as consumed (Woodward et al., 1996). Eating is an inherently social act and therefore this act is impacted by those eating around us (Leann Lipps Birch, 1980). Researchers have shown over a short period of time, the ability of peer influence to alter child taste preferences and consumption patterns (Leann Lipps Birch, 1980). Training peer models in a preschool classroom is a somewhat novel idea that has been used in a handful of studies (Hendy, 2002; Mikkelsen et al., 2014). Studies that use trained peer models often chose peer models based on their consumption of non-preferred foods or researchers use positive reinforcement to encourage peer models to consume non-preferred foods (Leann Lipps Birch, 1980; Hendy, 2002; Mikkelsen et al., 2014). One study shows that gender of the peer model significantly impacts the change in consumption patterns of the target children. Female peer models are found to be more effective peer-models (Hendy, 2002). Younger children’s fruit and vegetable consumption is more influenced by peer modeling than older children (Leann Lipps Birch, 1980). Peer normative beliefs effect fruit and 25 vegetable consumption (Karen Weber Cullen et al., 2001).The small amount of research on peer influence on preschooler’s FV consumption shows that it can be effective in changing fruit and vegetable consumption patterns. Peer modeling should be utilized more in preschool nutrition curriculum. Parental & Role Model Influence Parental usage and influence on nutrition impacts children’ liking and intake of foods (Woodward et al., 1996) at a very early age (Leann Lipps Birch, 1980). Parental modeling of FV consumption is positively correlated with children’s fruit and vegetable consumption (Karen Weber Cullen et al., 2001). The social context in which parents present FV has been shown to be important; if parent present FV in a positive light (i.e. they make you strong and smart) versus negative (i.e. you can’t leave the table until you finish your peas), their children can have a higher FV consumption (Anliker, Laus, Samonds, & Beal, 1990). In conclusion, the more people surrounding children that consume FV and accept them socially, the more children will consume FV. Therefore, multi-component FV consumption education should encourage parental participation. Environment Fruits and vegetables need to be available, affordable, and desirable in conjunction with all of the above discussed factors (personal factors). Eating behavior is highly complex and is influenced by the interaction of all of the above personal factors and environmental factors (A. Bandura, 1986). Availability and accessibility of fruit and vegetable accounts for up to 25% of the variance of fruit and vegetable consumption 26 among children (K. W. Cullen et al., 2003). Other similar research has shown that altering fruit and vegetable availability in the home can increase fruit and vegetable consumption by 15% (Bere, 2004). Fruit and vegetable availability and accessibility has been shown in scores of research, beyond what is cited above, to effect consumption of fruit and vegetables. Multi-component nutrition education aimed at increasing fruit and vegetable consumption should consider increasing availability and accessibility. Food Preferences Food preferences and food neophobia are widely researched topics in child nutrition literature. Food preferences in this research will be defined as self-reported through a widely utilized food preference survey in schools (FoodCorps, 2017). Food neophobia is defined as the rejection of new or novel foods to the child (Dovey, Staples, Gibson, & Halford, 2008). There is a level of genetic predisposition in food preferences, children are born to prefer sweet and salty and reject bitter and sour flavors(L. L. Birch, 1999) Some research exists on increasing exposure to novel vegetables to effectively decrease neophobia, which in turn decreases the amount of waste (Ahern, Caton, Blundell, & Hetherington, 2014; Dovey et al., 2008). The goal of this study is to relate self-reported fruit and vegetable preferences from a widely used survey to food waste. Education for Preschool Any nutrition education program must be focused around developmentally appropriate learning . An overarching principle in early childhood education and development is the learning and experiences that happen at this young age influence the 27 child’s future social and educational ability (Montana Office of Public Instruction, 2014). Modeling by caregivers and guardians, play, and open-ended materials and questions are all effective and appropriate means to educate preschool aged children (Montana Office of Public Instruction, 2014). Specific early learning standards associated with nutrition are to learn: eating to satisfaction, exploring foods with fingers, consuming a variety of healthy options from all five food groups, consuming appropriate amounts of healthy beverages, participating in meals, and identifying healthy options. Nutrition education programs that focus on FV consumption often show that knowledge and attitudes towards FV change during the education program (Jaimie N Davis, Martinez, Spruijt-Metz, & Gatto, 2015; Hutchinson et al., 2015; Mikkelsen et al., 2014; Parmer, Salisbury-Glennon, Shannon, & Struempler, 2009). However, just as often the increase in knowledge and attitude is not shown to be associated with a change in FV consumption behavior (Jaimie N Davis et al., 2015; Hutchinson et al., 2015; Parmer et al., 2009). Variable positive results of FV education programs show a lack of understanding in young children’s behavioral determinants. (J. N. Davis, Spaniol, & Somerset, 2015) Conclusion Preschools are an ideal place to implement nutrition education due to the age of the students and setting (Appleton et al., 2016; Mikkelsen et al., 2014). Education that aims to impact more than one fruit and vegetable consumption determinant are more effective (Mikkelsen et al., 2014). As reviewed above, FV determinants can be broadly categorized into personal and environmental factors. Personal factors include: attitude, 28 self-efficacy, and social norms (A. Bandura, 1986). Environmental factors are broad and many are not factors that can be changed (age, gender, SES, culture), but there are many the researcher can impact: accessibility, affordability, availability, and acceptability.. “ Preschool Food Waste and Nutrition Behavior” will impact attitude and self-efficacy through education and hands on experience in the curriculum. Social norms will be effected through peer leader modeling. Food waste amounts that occur in child nutrition programs are not well understood or quantified. Children spend a large majority of their day at school and consuming food at school (Federal Interagency Forum on Child and Family Statistics, 2013). The amount of time spent and nutrients consumed at school indicate a huge opportunity for researchers to effectively characterize, quantify, and effect change on food waste and consumption behaviors in children. 29 CHAPTER – THREE MIXED METHODS ANALYSIS OF PRESCHOOL PLATE WASTE AND FOOD PREFERENCES Contribution of Authors and Co-Authors Manuscript in Chapter 3 Author: Milodragovich, A. Contributions: Conceived and Implemented the study design. Collected and analyzed data. Wrote first draft of manuscript. Co-Author: Dr. Byker-Shanks, C. Contributions: Conceived study design. Provided framework and feedback for statistical analysis, assisted with data collection, and edited manuscripts. Co-Author: Dr. Ahmed, S. Contributions: Conceived study design. Provided framework and feedback for statistical analysis, assisted with data collection, and edited manuscripts. Co-Author: Dr. Lux, C. Contributions: Conceived study design. Provided framework and feedback for statistical analysis, assisted with data collection, and edited manuscripts. Co-Author: Barbour, Christopher. Contributions: Aggregation of data and statistical analysis. 30 Manuscript Information Page Author and Co-authors: Allison Milodragovich, Dr. Byker-Shanks, Dr. Selena Ahmed, Dr. Christine Lux, and Chris Barbour Journal of Nutrition Education and Behavior Status of Manuscript: ___x_ Prepared for submission to a peer-reviewed journal ____ Officially submitted to a peer-review journal ____ Accepted by a peer-reviewed journal ____ Published in a peer-reviewed journal Journal of Nutrition Education and Behavior 31 Background United States consumers discard at least 30% of their available food supply every year (Buzby et al., 2011; Hall et al., 2009; Kummu et al., 2012). One population of consumers that contribute significantly to food waste are children who participate in child nutrition programs at school such as the National School Lunch Program (NSLP). NSLP is a federally funded program that supports K-12 schools by reimbursing for meals that are nutritionally adequate (Food and Nutrition Service, 2014). Research of food waste by direct measures have found that approximately 45% of meals served in public schools are wasted (Byker et al., 2014; Davidson, 1979; Green & Munroe, 1987; Reger et al., 1996). A significant amount of food waste is occurring in K-12 schools, but little is known about food waste among pre-kindergarten children. The limited research on pre-kindergarten shows that preschool aged children waste at least as much as their K-12 counterparts and often times more (Buzby & Guthrie, 2002a; Byker et al., 2014; Niaki et al., 2017; Nicklas et al., 2013). A large segment of children aged three to six (61%) attend some type of center based care or preschool before they attend kindergarten (Federal Interagency Forum on Child and Family Statistics, 2013). Preschools and care centers are contributing to consumer level food waste and younger children tend to waste more food than older children (Carver & Patton, 1958; Dillon & Lane, 1989; Jansen & Harper, 1978). Child and Adult Care Food Program (CACFP) is the federally funded nutrition program for designed childcare centers and preschools (Food and Nutrition Service, 2014). There is limited research exploring food waste in CACFP at preschools. One 32 cross-sectional research study conducted in a preschool enrolled in CACFP found food waste of up to 60% for vegetables and nearly 45% for total waste (Nicklas et al., 2013). This is the one recent study of food waste in a preschool, but was framed in a highly specific situation: Head Start classrooms in Texas. Quantifying food waste in CACFP further is important because nearly 3.3 million meals are served daily to children through CACFP, accounting for 2.9 billion federal dollars spent per year (Food and Nutrition Service, 2014). Quantifying food waste is also important for long-term health outcomes. If preschool-aged children are throwing away nearly 60% of the vegetables served to them, then those children are missing out on key nutrients and long-term health habits. FV consumption is one of the best indicators for long-term health outcomes (United States Department of Health Human Services & United States Department of Agriculture, 2010). Adolescents self-report that nearly 40% of the time, they eat fruits and vegetables less than one time per day (Centers for Disease Control & Prevention, 2013). Behavioral and Environmental Impacts on Food Waste in the School Setting Behavior A complex food-related behavior is food preferences. Food preferences are an important health behavior determined both at birth and through environment (Birch & Fisher, 1998). Food preferences and food neophobia are widely researched topics in child nutrition literature. Food preferences in this research will be defined as self-reported through a widely utilized food preference survey in schools (FoodCorps, 2017). Food 33 neophobia is defined as the rejection of new or novel foods to the child (Dovey, Staples, Gibson, & Halford, 2008). Some research exists on increasing exposure to novel vegetables to effectively decrease neophobia, which in turn decreases the amount of waste (Ahern, Caton, Blundell, & Hetherington, 2014; Dovey et al., 2008). The goal of this study is to relate self-reported fruit and vegetable preferences from a widely used survey to food waste. Environment Socio-ecological environmental conditions that impact food waste in schools are widely varied and complex. One simple and researched condition is time spent eating. The amount of time spent eating is a simple, but profound indicator of food consumption that occurs in schools. There has been literature in elementary schools that show the more time children have to eat the less overall waste occurs (Cohen et al., 2016; Gosliner, 2014). The more time children have to eat or the quicker that FV option are available, the more likely students are to choose and eat FV components (Cohen et al., 2016; Gosliner, 2014; Kessler, 2016). To the authors’ knowledge, there are no studies that quantify the amount of time preschool children spend eating and how that correlates to waste or intake. The research conducted here focused on observing time spent eating and if there is a relationship between times spent eating and waste in preschool children. The research study presented here addresses the research gaps identified above by measuring food waste in a pre-kindergarten child care center that participates in CACFP in the rural state of Montana in the United States. Following are the objectives, research questions, and hypotheses of this study. It is expected that findings will contribute to the 34 literature on food waste and child behavior regarding preference and consumption of fruits and vegetables. It is further anticipated that findings can be used to inform CACFPs as well as other school food and nutrition programs. Objectives, Research Questions, and Hypotheses Purpose: The overall objectives for this research are to: (1) quantify food waste in pre-kindergarten child care centers that participate in CACFP before, during, and following a nutrition education intervention, (2) quantify the amount of time children spend eating, (3) measure child food preferences, (4) examine relationships between food waste and time spend eating and, (5) examine relationships between food waste and food preferences. Research Questions and Hypotheses The following research questions were addressed accompanied by the testing of the following hypotheses: Research Question One: How much food is wasted in childcare centers (CCCs) participating in CACFP before, during, and after a nutrition education intervention? a. Which Child and Adult Care Food Program (CACFP) food categories are the highest percentage wasted? b. Is food waste in a preschool primarily from serving waste or plate waste? 35 Hypothesis One: Based on existing literature in CACFP and NSLP, it is hypothesized there will be 45% food waste at the baseline for this research et al., 2014; Nicklas et al., 2013). a. Fruit and vegetable will have the highest percentage food waste. b. Food waste in a preschool will be primarily from serving waste not plate waste (Byker, Farris, Marcenelle, Davis, & Serrano, 2014) Research Question Two: How much time do children spend eating lunch before, during, and after a nutrition education intervention? Hypothesis Two: Children will spend on average twenty minutes eating long, it is not hypothesized that the nutrition education will impact average time spent eating. Research Question Three: What CACFP food categories do children prefer? Do these preferences vary before, during, and after a nutrition education intervention? Hypothesis Three: Fruits and vegetables will have the lowest positive responses for fruit and vegetable food categories. If the children are exposed to a nutrition education, then food preferences will increase. Research Question Four: Is there a relationship between food waste and time spend eating? Does this vary before, during, and after a nutrition education intervention? 36 Hypothesis Four: If children eat for longer, then food waste will be lower. It is not predicted that time spent eating will change with this specific intervention. Research Question Five: Is there a relationship between food waste and food preferences? Does this vary before, during, and after a nutrition education intervention? Hypothesis Five: Food preferences will be negatively correlated to food waste. If food preference are higher, then food waste will be lower. If children are exposed to nutrition education, then their food preferences will increase. Methodology Food waste data and lunchtime observations were conducted according to human subject’s protocol approved by the Intuitional Review Board at Blinded University. Participants were under the age of consent and therefore, written consent was obtained from all parents before children were observed. Site and Participant Selection Selection of the childcare center occurred through a purposive, non-random convenience sample. Children in the center were then purposively selected to participate if they were aged four and five and their parents consented to the child’s participation. The child center selected also serves children younger than age 4. However, these children were excluded. Children under four years old were excluded due to: advice from childcare center, staffing issues for certain lessons (such as field trips), and 37 implementation time. A total of 23 children participated in this study out of the total 51 of children in the childcare center. All enrolled four and five year old children participated. Site Mealtime Service Preschool mealtimes are a combination of routine and adherence to CACFP requirements. CACFP is a United States Department of Agriculture program that reimburses childcare centers for nutritionally acceptable meals (Food and Nutrition Service, 2014). CACFP sets amounts and kinds of foods to be served at mealtimes. Lunches must include: milk, meat and meat alternatives, fruit, vegetable, and grain (Food and Nutrition Service, 2014). Family style serving is a recommended practice under CACFP (Food and Nutrition Service, 2014). Family style serving is a child nutrition method in which all food is served in bowls on the table and children self-select portion sizes (Food and Nutrition Service, 2014). Empirical research has demonstrated that family style serving allows children to listen to internal satiation cues and does not waste more food over served portions in cafeteria-style meal service (Branen & Fletcher, 1994). Nutrition Education Description This research was quasi- experimental (one group pretest-posttest), cross- sectional design. The research had four distinct phases, see Table 3.1 for description. The objectives of the study were to: establish food waste amounts in the Child and Adult Care Food Program (described below) in a preschool setting, design a curriculum based on existing lesson plans in a Social Cognitive Theory framework, and determine the effectiveness of the curriculum in reducing overall food waste. FV consumption were the 38 focus of the curriculum for the following reasons: vegetables are the highest food category wasted in any population (Buzby & Guthrie, 2002b; Byker et al., 2014) and FV consumption is one of the most important behaviors for long-term health (United States Department of Health Human Services & United States Department of Agriculture, 2010). Before the education began, food waste measurements and observation data collection occurred to establish baseline behaviors around food and food waste amounts. The second phase of the education focused on increasing positive attitudes towards FV consumption through introduction of foods, discussion of foods, and activities. The third phase of the education focused on increasing intra-personal aspects of FV consumption by focusing on self-efficacy. The lessons involved in this segment focused on recipe cards, making grocery lists, and a field trip to the grocery store. The last phase of the education was seven weeks after the curriculum ended to determine the decay of the intervention, which is commonly found in nutrition interventions (Appleton et al., 2016; Mikkelsen et al., 2014; Wolfenden et al., 2012). Table 3.1 Description of Overall Education Timeline in a Preschool Nutrition Education Phase Research Action Curriculum Implementation Pre-Nutrition Education Food waste measurements and observation collection none Nutrition Education (Behavior Phase) During last week food waste measurements and observation collection Week 1-4 General nutrition introduction, then lessons focused on increasing positive attitude of FV 39 Nutrition Education (Personal Phase) During last week food waste measurements and observation collection Week 5-8 Lessons focused on increasing self-efficacy of FV consumption and then conclusion Post-Nutrition-Education Food waste measurements and observation collection None Implementation Lessons were implemented by an experienced early childhood education professional that had past interaction and established relationships with the four- and five-year-old children. Preschool teaching staff assisted with lesson implementation. Lessons were introduced weekly on Monday mornings for a duration of 45 minutes as part of the children’s preschool schedule. Follow up lessons were planned either on Wednesday or Friday mornings to maximize children’s engagement. Lessons for the nutrition education were selected or created using a Social Cognitive Theory lens, using The Food Trust’s The Preschool Initiative and the USDA’s Discover My Plate kindergarten curriculum as guides. The curriculum implemented in this study included both a general nutrition introduction week and a wrap-up week. The first set of lessons (Weeks 1 – 4) were aimed to influence individual and group behavior through changing attitudes of fruit and vegetable consumption. Children were introduced to MyPlate, recognizing different food groups, then engaged in taste testing apples, beets, and carrots. The researchers choose to emphasize fruit and vegetable consumption in the curriculum due to these food categories being the highest wasted categories in most food waste research (Buzby & Guthrie, 2002b; Byker et al., 2014). The second set of lessons (Weeks 5 – 8), were focused to influence personal aspects of nutrition and food 40 consumption mainly through self-efficacy. Children planned a meal using UDSA sorting cards, created and followed a recipe incorporating fruits and vegetables, and prepared a grocery list to take on a field trip to the store. Lesson implementation began one week after baseline food waste and children’s food preference data were collected, spanning the behavior and personal phases of the research design. In the behavior-focused lessons, children were encouraged to taste different varieties of local apples, including ginger gold, gala, and granny smith. Next, children examined the roots and stems of local beets and, after tasting raw beets, helped write a poem. The third behavior-focused lesson encouraged children to compare the appearance and taste of different varieties of local carrots. Children gained an understanding that FVs grow either above or below ground, and that stems can be edible. The lessons focused on self-efficacy and changing personal behavior began with meal planning and identifying favorite fruits and vegetables. Next, the children wrote and followed a recipe using beets, blueberries, and bananas. Using the same recipe format, the children created a grocery list and prepared to take a trip to the supermarket to purchase ingredients. The lessons culminated in the field trip and preparation of an afternoon snack, incorporating favorite FVs. Consistent focus to FVs throughout the lessons aimed to change children’s preferences, increase consumption, leading to less food waste at mealtimes. Food Waste Measurements Background The principal researcher and trained research assistants conducted the food waste measurements. Food waste measurements were conducted for three days, 41 once at baseline, twice during the educational curriculum, and once post-education See Table 3.2 for the menu served during the four data collection periods. Table 3.2. Individual Lunch Menu Items and Time Period for Preschool Food Waste PHASE Day Menu Items Pre- Education 1 Oranges, Spinach, Carrots, Turkey, Cheese, and Bread 2 Apples, peas, Meatballs or Veggie Burger, Whole Wheat Pita, and Yogurt Taki sauce 3 Pears, Beets, Turkey or Vegetable Burger, Wheat Bun, and Ketchup Behavior 1 Apples, peas, Meatballs or Veggie Burger, Whole Wheat Pita, and Yogurt Taki sauce 2 Pears, Beets, Turkey or Vegetable Burger, Wheat Bun, and Ketchup 3 Apples, Mixed Vegetables in Sauce, Chopped Chicken Breast, and Brown Rice Personal 1 Apples, peas, Meatballs or Veggie Burger, Whole Wheat Pita, and Yogurt Tzaki sauce 2 Pears, Beets, Turkey or Vegetable Burger, Wheat Bun, and Ketchup 3 Apples, Mixed Vegetables in Sauce, Chopped Chicken Breast, and Brown Rice Post- Education 1 Apples, peas, Meatballs or Veggie Burger, Whole Wheat Pita, and Yogurt Tzaki sauce 2 Pears, Beets, Turkey or Vegetable Burger, Wheat Bun, and Ketchup 3 Apples, Mixed Vegetables in Sauce, Chopped Chicken Breast, and Brown Rice 42 Prior to Lunch Plate waste measurements occurred through direct weighing (Byker et al., 2014). All meal components (fruit, vegetable, grain, meat and meat alternatives, and milk) were weighed in grams prior to placement in family-style serving bowls. All serving bowls were weighed in grams, labelled with the CACFP food category and table number, and recorded prior to food being placed inside. Weights for each recorded item were taken three times until the same number was read. Food was then covered for food safety and brought to lunch tables for service. Collection bins were used to collect food waste after lunch. Collection bins were labelled by CACFP food category (milk, meat and meat alternative, fruit, vegetable, grain and other), a trash bag placed inside, weighed in grams, and weights recorded prior to the beginning of lunch. Lunchtime On study days, children were told by teachers, “We are playing restaurant today,” to prevent children from clearing their own plates as usual. Teachers typically share in the family style meal with children as per CACFP standard practices. The research study altered this protocol by pre-plating all teacher and any special guest plates to ensure food consumed out of family bowls was child consumption only. Standard lunchtime procedure also includes sharing between tables, which was precluded by primary researcher to control the food waste measurements for children only participating in study. After Lunch After the children were finished eating, the research team collected all plates and serving dishes. All plates and serving dishes were placed on a cart which was labeled by table. The cart was removed from the classroom and brought to another room for measurement to decrease disruption of classroom procedure. Bins were placed 43 on scale, and by food item category plate waste was added to bin from table one, then table two, and finally table three. This procedure was repeated for all food item categories. Plate waste was measured for any food item that remained on child plates. The procedure began again with serving waste. Serving waste was measured from any items left in the family-style serving bowls. A bin was placed on the scale and table one serving waste for a food category placed inside, then table two, and finally table three. This procedure was repeated for all six food item categories. Food Preference Survey The survey utilized in this research was adapted from an existing method widely used in K-12 schools in the United States (FoodCorps, 2017). A similar food preference survey was validated and showed an inverse relationship between food preferences and food waste for FVs (Byker-Shanks et al., 2017 Forthcoming). An experienced early childhood education professional interviewed all participants at three different time phases throughout the educational curriculum to get survey responses. Individual level food preferences were collected. However, individual level waste was not collected, which altered analysis from validated study (Byker-Shanks et al., 2017 Forthcoming). See Figure 3.1 for survey. 44 Figure 3.1. Example of Food Preference Survey for Preschool Children Participating in CACFP Statistical Analysis Data was entered initial into three separate excel spreadsheets: food waste, observational data, and preference data. After preliminary data analysis, the two spreadsheets were merged into one to complete further analysis. A Fit Model using a Standard Least Square Means personality function and Analysis of Variance was performed using JMP 10.0 (SAS Institute Inc.) to determine how food waste quantities changed over the curriculum and whether that data corresponded with a change in observed behaviors. A multiple comparison using the Least Square Means Tukey HSD method was applied to examine if food waste significantly increased or decreased through the specific phases of the curriculum (before, behavior, personal, and post). 45 Results Participants A total of 23 out of 23 students that met inclusion criteria participated in the study. As requested by the center and the Institutional Review Board, no individual level data was collected on participants. Center enrollment data show 51 students enrolled in the year the study was completed with the following breakdown for free, reduced, and paid lunch: 2% free, 4% reduced, and 94% paid. Food Waste Overall Total Waste Analyzing food waste by proportion of waste and amount served is a commonly employed method in food waste research (Byker et al., 2014) this method accounts for non-standardized serving proportions over time. The results of total food waste percentages ( 𝑠𝑒𝑟𝑣𝑖𝑛𝑔 𝑓𝑜𝑜𝑑 𝑤𝑎𝑠𝑡𝑒+𝑝𝑙𝑎𝑡𝑒 𝑤𝑎𝑠𝑡𝑒 𝑡𝑜𝑡𝑎𝑙 𝑎𝑚𝑜𝑢𝑛𝑡 𝑠𝑒𝑟𝑣𝑒𝑑 ) are reported in Table 3.3. Table 3.3 Total Food Waste Percentages and Standard Deviations for a Preschool Program Utilizing CACFP Phase Mean Percentage Wasted St. Dev Pre-Nutrition Education 48.4% 29.0% Behavior Phase 33.6% 34.0% Personal Phase 49.7% 31.8% Post-Nutrition Education 42.5% 34.1% A one way analysis of variance of percentage of total food waste by education phase pre- education (48.4%) to post-education (42.5%) showed that total waste amounts were not significantly different. 46 Overall Serving Food Waste Serving food waste amounts at the baseline measurements conducted during the pre-education phase were 37.6 (+/- 31.3%) ( 𝑆𝑒𝑟𝑣𝑖𝑛𝑔 𝑊𝑎𝑠𝑡𝑒 𝑡𝑜𝑡𝑎𝑙 𝑎𝑚𝑜𝑢𝑛𝑡 𝑠𝑒𝑟𝑣𝑒𝑑 ) per table per day. Post-education data showed average serving waste per table per day were 38.0% (+/- 33.5%). Serving food waste amounts did not differ significantly when analyzed by education phase, See Table 3.4 for all serving waste percentages means and standard deviations. Table 3.4 Mean Serving Waste Percentages and Standard Deviations in a Preschool Program utilizing CACFP Mean Percentage St. Dev Pre- Nutrition Education 37.6% 31.3% Behavior Phase 28.1% 33.6% Personal Phase 42.4% 30.3% Post- Nutrition Education 37.9% 33.3% Overall Plate Waste Plate waste amounts at the baseline measurements conducted during the pre-education phase were 10.8% (+/- 8.6%) ( 𝑝𝑙𝑎𝑡𝑒 𝑤𝑎𝑠𝑡𝑒 𝑡𝑜𝑡𝑎𝑙 𝑎𝑚𝑜𝑢𝑛𝑡 𝑠𝑒𝑟𝑣𝑒𝑑 ) per table per day. Post-education data showed average plate waste per table per day were 4.6% (+/- 5.0%). See Table 3.5 for all plate waste percentages means and standard deviation Table 3.5 Mean Plate Waste Percentages and Standard Deviations in a Preschool Program utilizing CACFP Mean Percentage St. Dev Pre-Nutrition Education 10.8% 8.6% Behavior Phase 5.1% 5.1% Personal Phase 7.3% 8.4% Post-Nutrition Education 4.6% 5.0% 47 A one way analysis of variance of plate waste percentage by education phase showed plate waste percentages decreased significantly from the baseline measurements to the post- measurements (P<.001). There was also a significant decrease between the pre-education period and behavior phase (P<.001). Plate waste measurements were statistically the same during the behavior phase and post education phase, 5.4% and 4.6% respectively. See Figure 3.2 for One Way Analysis of Variance of Total Plate Waste over the course of the nutrition education Figure 3.2. One Way Analysis of Variance of Total Plate Waste by Nutrition Education Phase in a Preschool Using CACFP Vegetable Food Waste Analysis of food waste by food category showed there was no significant change in total waste, plate waste, or serving waste for the vegetable food category during the nutrition education. Proportions of total amount wasted versus what was served were high for vegetables averaging 66.5% pre-education and 66.0% post nutrition education. See Table 3.6 for all means and standard deviations of vegetable waste percentages. A B AB B 48 Table 3.6 Means and Standard Deviations of Total Vegetable Waste over the course of a Fruit and Vegetable Education Mean Percentage St. Dev Pre-Nutrition Education 66.5% 19.9% Behavior Phase 68.0% 33.5% Personal Phase 64.1% 33.5% Post-Nutrition Education 66.0% 32.9% Plate waste percentages for vegetables show no significant change from pre-education to post nutrition education. See Table 3.7 for all means and standard deviations of plate waste percentages. Table 3.7 Means and Standard Deviations of Plate Waste for Vegetables over the course of a Fruit and Vegetable Education Mean Percentage St. Dev Pre-Nutrition Education 4.6% 5.0% Behavior Phase 4.6% 6.6% Personal Phase 3.8% 4.3% Post-Nutrition Education 3.8% 5.6% Serving waste percentages for vegetables show no significant change from pre-education post nutrition education . See Table 3.8 for all means and standard deviations of serving waste percentages. Table 3.8 Means and Standard Deviations of Serving Waste for Vegetables over the course of a Fruit and Vegetable Education Mean Percentage St. Dev Pre-Nutrition Education 62.0% 20.4% Behavior Phase 63.4% 32.1% Personal Phase 60.4% 31.5% Post-Nutrition Education 62.2% 34.1% 49 Fruit Food Waste Total waste of the fruit category did not change significantly pre-education to post nutrition education. Percentage of total fruit waste at the beginning of the pre-education phase was 32.9% (+/-31.8%) compared to 10.6% (+/- 11.4%) post- nutrition education, see Table 3.9 for report of all percentages. Table 3.9 Means and Standard Deviations of Total Fruit Waste over the course of a Fruit and Vegetable Education Mean Percentage St. Dev Pre-Nutrition Education 32.90% 31.80% Behavior Phase 9.60% 13.30% Personal Phase 19.70% 19.70% Post-Nutrition Education 10.60% 11.40% Serving waste did not change from pre-education to post-education see Table 3.10 for report of average plate waste percentages and standard deviations. Table 3.10 Means and Standard Deviations of Fruit Serving Waste over the course of a Fruit and Vegetable Education Mean Percentage St. Dev Pre-Nutrition Education 20.5% 25.5% Behavior Phase 5.7% 11.8% Personal Phase 11.8% 12.0% Post-Nutrition Education 8.4% 12.0% Plate waste did significantly change from pre-education to post-nutrition education. The average percentage of fruit plate waste was 12.4% (+/- 8.5%) versus 2.2 % (+/- 2.6%) post-nutrition education. See figure 3.3 for a One Way Analysis of fruit plate waste. 50 Figure 3.3 One Way Analysis of Variance of Fruit Plate Waste Percent by Education Phase for a Preschool Program Time Spent Eating Average time for each nutritional curriculum period was analyzed. Average time spent eating over the first three portions of the educational curriculum were statistically the same and the post-education time spent eating was significantly higher than only the behavior phase (p<.01) See Figure 3.4 for a One Way Analysis of Variance. Figure 3.4 One Way Analysis of Variance of Time Spent Eating by Nutrition Education Phases in a Preschool Program using CACFP . A AB AB B AB B AB A 51 Food Preference Data Food preferences were collected for all children (n=23) four separate times. Aggregated responses are listed below as a percentage of total responses, Table 3.11 Table 3.11 Selected Food Preference Survey Results in a Preschool Using CACFP Food Item Time Period % of Respo nses Do Not Know % of Responses Did Not Try % of Response s Do Not Like % of Responses Like % of Responses Love apple Pre-Nutrition Education 0.0% 0.0% 8.7% 34.8% 56.5% apple Personal Phase 0.0% 0.0% 4.3% 30.4% 65.2% apple Post-Nutrition Education 0.0% 0.0% 0.0% 17.4% 82.6% beets Pre-Nutrition Education 17.4% 34.8% 13.0% 4.3% 30.4% beets Personal Phase 4.3% 34.8% 4.4% 30.4% 26.1% beets Post-Nutrition Education 8.7% 21.7% 9.0% 30.4% 30.4% carrots Pre-Nutrition Education 0.0% 0.0% 8.7% 52.2% 39.1% carrots Personal Phase 0.0% 0.0% 21.7% 43.5% 34.8% carrots Post-Nutrition Education 0.0% 0.0% 26.1% 39.1% 34.8% There were ten FV on the food preference survey, but the selected ones above were specifically introduced and spoken about during the nutrition education. Food preferences were analyzed through one way analysis of variance and no changes occurred in food preference by the nutrition education phase. Overall, there is a pattern of higher preference for FV. 52 Time Spent Eating and Food Waste There were no significant relationships between time spent eating and the amount of waste which occurred. See Table 3.12 for report of average time eating for each day. Table 3.12 Average Time Spent eating in a Preschool Program using CACFP Date Average Time Eating St DEV 10/17/2016 19.45 5.13 10/18/2016 22.31 3.69 10/19/2016 19.01 8.52 11/15/2016 21.41 1.88 11/16/2016 18.57 5.93 11/17/2016 13.11 3.35 12/13/2016 19.57 1.68 12/14/2016 23.53 2.28 12/15/2016 18.75 1.16 1/24/2017 29.65 7.66 1/25/2017 26.38 2.16 1/26/2017 23.17 2.35 Food Preferences and Food Waste Food preferences for nine out of ten of the fruits and vegetables did not correlate to food waste in any discernable way. One fruit did match the pattern researchers hypothesized. See Figure 3.5 for graph. 53 Figure 3.5 Trends of Food Waste and Food Preferences during a nutrition education in a Preschool using CACFP The above graphs show a generalized pattern that when food preferences go up, food waste goes down. However, this graph does not include the variation in the sample. Discussion One of the primary objectives of the research conducted was to quantify the amounts of waste that occur in a preschool program utilizing CACFP. This objective was reached and the waste amounts reported in Table 3.3 above. Overall total waste (includes plate waste and serving waste) averaged 43.6% over the course of four months. The total waste amount is similar to other quantitative, cross-section research on food waste in preschools (Byker et al., 2014; Nicklas et al., 2013). The amount of waste contributed by serving waste versus the amount of plate waste is not typically reported in quantitative, cross-sectional food waste research (Byker et al., 2014; Nicklas et al., 2013). The results of separating food waste amounts by serving and plate waste resulted in interesting 54 findings. Primarily, waste came from what was left in serving dishes, see Table 3.4 & 3.5. Plate waste amount were relatively low compared to serving waste. Overall, these results can be interpreted that preschool children are eating what is put on their plates, but not everything in the serving dishes. Also, total waste and serving waste did not go down with introduction of the nutrition education. However, plate waste did significantly decrease (p<.001) from 10.8 at pre-nutrition education to 4.6 % post-nutrition education. The nutrition education was effective in getting students to eat more of what they had put on their plates, but not in changing the amount of food the children put on their plates. There could be several reasons behind this behavior including: continued neophobia (Dovey et al., 2008) lack of sufficient exposure (Schindler, Corbett, & Forestell, 2013), peer influence (Amanda E. Staiano, Arwen M. Marker, Johannah M. Frelier, Daniel S. Hsia, & Corby K. Martin, 2016), and lack of environmental changes (Perry et al., 2004). Comparing food waste by CACFP food category was another primary goal of this research. The results indicated that by far vegetables are the highest wasted food category in total waste, serving waste, and plate waste, see table 3.6. Vegetable total waste averaged 66.2% over the course of the research, which is similar to amounts founds in other quantitative, cross-sectional food waste research in preschools (Byker et al., 2014; Nicklas et al., 2013). Total vegetable waste averaged 66.2% whereas total fruit waste averaged 18.2%. Often in food waste and nutrition education research, fruits and vegetables are lumped into one category. However, the results from this research indicate that any further research on child nutrition, consumption, or waste behaviors, must separately analyze fruits and vegetables. Fruits and vegetables are wasted at much 55 different rates and have much different nutrient and flavor profiles (Leann L. Birch, 1990). Neophobia towards vegetables is much more difficult to overcome due to the bitter flavor and low fat and sugar content of most vegetables (Leann L. Birch, 1999). Interpreting the food waste results of the vegetables indicate that in this preschool neophobia towards vegetables was high. Plate waste amounts for vegetables averaged 4.2% and serving waste amounts are 62%. Children are just not trying to eat the vegetables or placing them on their plates from the family-style serving dishes. The third research question focused on the amount of time spent eating and the amount of waste that occurred. There was no correlation among this population of time spent eating to the amount of waste that occurred. The results found in this research is counter to other research focused on time spent eating and the amount of waste (Cohen et al., 2016; Gosliner, 2014). There was no focus on the amount of time spent eating in the education nor were any lunchtime procedures changed to increase the amount of time spent eating. The researchers wanted to observe baseline behaviors for preschool children. With no nutrition education, there is not an association among preschool children with time spent eating and the amount of food they waste. Food preferences and food waste association was the final objective of this research. The results found indicate that generalized food preferences are not associated with lower or higher food waste. The methods these researchers used were different than other similar research with the same food preference survey (Byker et al., 2017 Forthcoming). The different methods could be why this research found no correlation between food preference and food waste. The generalized preferences utilized the 56 standard list of fruits and vegetables and not specifically to what the children were being served. The food categories used could have been too broad for a young child to answer. Conclusion Implications for Nutrition and Sustainability Child nutrition programs contribute food waste at the consumer level. Rates at which food waste is occurring in child nutrition programs and nationally in the United States are unsustainable. Food waste is unsustainable for environmental, social, and economic reasons. Economically, nutrition programs need to reduce waste to maintain political support. The particularly interesting result for this research is that 80% of waste in CACFP lunches is from serving waste. CACFP requires minimum serving amounts and this regulation results in waste. However, there must be regulation regarding serving size per food group to meet nutritional standards for the meal program. The conflict resulting between reducing waste and meeting regulations is a particularly complex issue for sustainability. CACFP Policy Recommendations CACFP currently has no requirement for FVs to be served at any other time than lunch. Exposure to novel fruits and vegetables during additional meals and snack times to decrease neophobia could result in increased consumption of FVs and therefore, less waste. CACFP should require a minimum number of times that FVs, in particular vegetables, are served during the week. CACFP should also require a minimum diversity in FVs per week similar to the National School Lunch Program requirements for multiple colors of vegetables offered in the meal pattern. 57 Modeling healthy eating behaviors is a key method in early childhood education. Therefore, CACFP should require any adult eating with children at a family style serving lunch to be trained to model healthy eating behavior. Teachers should model tasting all foods and serving themselves second helpings of FVs in preference to the other food groups. Overall, the research and results in this study added significant knowledge to the area of food waste research and child nutrition behavior. The research conducted informed researchers on how much waste is occurring, the source of the food waste, and which food categories are being wasted in CACFP in preschools. Further research should focus on how to influence how much food preschool children take from family-style serving bowls, how to decrease neophobia towards vegetables, and further investigate the relationship between food preferences and food waste among preschool children. 58 CHAPTER – FOUR ANALYSIS OF PRESCHOOL NUTRITON BEHAVIORS Contribution of Authors and Co-Authors Manuscript in Chapter 4 Author: Milodragovich, A. Contributions: Conceived and implemented the study design. Collected and analyzed data. Wrote first draft of manuscript. Co-Author: Dr. Byker-Shanks, C. Contributions: Conceived study design. Provided framework and feedback for statistical analysis, assisted with data collection, and edited manuscripts. Co-Author: Dr. Ahmed, S. Contributions: Conceived study design. Provided framework and feedback for statistical analysis, assisted with data collection, and edited manuscripts. Co-Author: Dr. Lux, C. Contributions: Conceived study design. Provided framework and feedback for statistical analysis, assisted with data collection, and edited manuscripts. Co-Author: Barbour, Christopher. Contributions: Aggregation of data and statistical analysis. 59 Manuscript Information Page Author and Co-authors Names: Allison Milodragovich, Dr. Byker-Shanks, Dr. Selena Ahmed, Dr. Christine Lux, and Chris Barbour Journal of Nutrition Education and Behavior Status of Manuscript: ___x_ Prepared for submission to a peer-reviewed journal ____ Officially submitted to a peer-review journal ____ Accepted by a peer-reviewed journal ____ Published in a peer-reviewed journal Journal of Nutrition Education and Behavior 60 Introduction Fruit and vegetable (FV) consumption is a key part of high dietary quality (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2015), yet FV consumption overall has been shown to decline in the USA (Produce for Better Health Foundation, 2015). However, a majority of preschool-aged children in the USA do not consume enough FVs (Kim et al., 2014). Consumption of FVs has been shown to contribute to lifelong dietary weight management strategies for preventing obesity (USDA & USDHHS 2011). Management of obesity is particularly relevant in the United States where childhood obesity rates are high with an average rate of obesity among all populations of children being 17% (Centers for Disease Control and Prevention, 2016). Obesity rates among preschool aged children (two to five years old) is lower at 8.9% (Centers for Disease Control and Prevention, 2016). Childhood obesity is highly associated with future health risks including: higher rates of cardiovascular diseases, increased insulin resistance, type 2 diabetes, fatty liver disease, and breathing problems (Lloyd, Langley-Evans, & McMullen, 2012). Strategies are needed to prevent future development and address current obesity rates among children. Childcare centers use a child nutrition program similar to National School Lunch Program (NSLP) titled the Child and Adult Care Food Program (CACFP). Child and Adult Care Food Program (CACFP) is the federally funded nutrition program for childcare centers and preschools (Food and Nutrition Service, 2014). A recommended practice under CACFP is family-style eating. Family-style eating is where food is served 61 in dishes on the table and shared with adults (Food and Nutrition Service, 2014) and provides for important teaching opportunities for young children. Food waste in CACFP is an understudied aspect of food waste research. One quantitative study of CACFP food waste showed an overall waste rate of 45% and up to 60% for the vegetable food category. Childcare centers use a child nutrition program similar to National School Lunch Program titled the Child and Adult Care Food Program (CACFP). Child and Adult Care Food Program (CACFP) is the federally funded nutrition program for childcare centers and preschools (Food and Nutrition Service, 2014). A recommended practice under CACFP is family-style eating. Family-style eating is where food is served in dishes on the table and shared with adults (Food and Nutrition Service, 2014) and provides for important teaching opportunities for young children. Food waste in CACFP is an understudied aspect of food waste research. One quantitative study of CACFP food waste showed an overall waste rate of 45% and up to 60% for the vegetable food category. Methods of Assessing Nutrition Behavior There are a myriad of methods for assessing nutrition behavior most of which focus on consumption of foods these include: food frequency questionnaires (FFQ), dietary recalls, and observations of intake (McPherson, Hoelscher, Alexander, Scanlon, & Serdula, 2000). Typically, these methods are utilized to assess dietary intake in lieu of direct measurements of consumption and waste. These methods have varying reliability and have been shown to be ineffective in younger children (Lim, Gold, Gaillard, Wey, & Reicks, 2015). The lack of validity in these methods among younger children led the 62 author’s to develop a different methodology, which focused on behaviors rather than consumption. Aim and Scope The overall research objectives of this study were to: (1) quantitatively describe preschool-aged children’s behaviors towards food during lunchtime at a family-style CACFP including prevalence of taking food items (fruit, vegetable, meat and alternative, grain, milk, and other); eating food; speaking positively, neutrally, or negatively about food on plate; and to request peers to pass food items; (2) examine the relationship of lunchtime behaviors to food waste. The following two research questions and associated hypothesis were examined in this study: Research Question 1: What behaviors do preschool children exhibit towards fruits and vegetables and other food items during lunchtime at a family-style CACFP? How do these behaviors vary during a nutrition education intervention? Hypothesis One: Preschool-aged children will display positive behaviors towards fruits and vegetables less than other food groups (grain, meat and meat alternative, and other). If children are exposed to a FV nutrition education program, then their positive behaviors towards FVs will increase. Research Questions 2: Are observations of lunchtime behavior related to food waste? Hypothesis 2: The more positive behaviors displayed toward a food group during lunch are associated with less waste of that food group. 63 Methodology Ethics Statement Lunchtime observations were conducted according to human subject’s protocol approved by the Intuitional Review Board at Blinded University. Participants were under the age of consent and therefore, written consent was obtained from all parents before children were observed. Site and Participant Selection Selection of the childcare center occurred through a purposive, non-random convenience sample. Children in the center were then purposively selected to participate if they were aged four and five and their parents consented to the child’s participation. The child center selected also serves children younger than age 4. However, these children were excluded. Children under four years old were excluded due to: advice from childcare center, staffing issues for certain lessons (such as field trips), and implementation time. A total of 23 children participated in this study out of the total 23 children eligible in thechildcare center. All enrolled four and five year old children participated. Site Mealtime Service Preschool mealtimes are a combination of routine and adherence to Child and Adult Care Food Program (CACFP) requirements. CACFP is a United States Department of Agriculture program that reimburses childcare centers for nutritionally acceptable meals (Food and Nutrition Service, 2014). CACFP sets amounts and kinds of foods to be 64 served at mealtimes. Lunches must include: milk, meat and meat alternatives, fruit, vegetable, and grain (Food and Nutrition Service, 2014). Family style serving is a recommended practice under CACFP (Food and Nutrition Service, 2014). Family style serving is a child nutrition method in which all food is served in bowls on the table and children self-select portion sizes (Food and Nutrition Service, 2014). Empirical research has demonstrated that family style serving allows children to listen to internal satiation cues and does not waste more food over served portions in cafeteria-style meal service (Branen & Fletcher, 1994). Observational Measurements Background Observation of lunchtime behaviors through the nutrition education was chosen to supplement and explain the quantitative food waste data, see appendix B for copy of “Preschool Lunchtime Observation Protocol.” The authors chose behaviors to observe based on the Social Cognitive Theory areas of influence the concurrent nutrition education was teaching. For example, during the behavior phase of the nutrition education, the curriculum was trying to positively influence children’s attitudes towards fruits and vegetables. Thus, the observation tool, included categories such as: taking food (fruit, vegetable, meat and alternative, grain, milk, and other), eating food, speaking positively, neutrally, or negatively about food on plate, and please pass (fruit, vegetable, meat and meat alternative, milk, grain, or other). During the personal phase of the nutrition education, the curriculum was attempting to increase self-efficacy of fruit and vegetable consumption. Therefore, the tool included: children speaking about food or 65 nutrition generally. The tool was collaboratively developed, but finalized by Dr. Shanks and Dr. Ahmed. Time sample intervals of predetermined behaviors were observed during lunchtime on days when food waste collection occurred by the principal investigator and three trained research assistants that served as observers. Training of observers proceeded by providing the standardized protocol and data collection form for observation. Observers were given an overview and opportunity to clarify questions prior to the observation. Observers were randomly assigned a table number and given a timer. Observers recorded all background information. Background information included: date, name of observer, meal items served, and duration of observation. Validation The tool was tested several different times to create the final iteration used during the nutrition education. Also before the nutrition education, the tool was tested twice to ensure inter-rater reliability. Each of the two test days, three tables were observed. Each table had two observers and the same protocol, listed below, was followed. Values were entered for each observer and then compared in statistical software. Mealtime Protocol Children aged 4-5 with signed consent forms were seated together at the same table. A total of three tables were used to accommodate as many as 20 children at one meal service. Other children enrolled in the preschool, but not participating in the mealtime observation were seated at other tables and not observed as part of the study. An experienced teacher, as per recommendations of the center director, was seated at the head of each of the three observation tables to ensure consistency of the 66 meal service. Children were served a family style meal as usual with small differences in procedure as listed in above section. One observer carried out observational measurements for one table included in the study for each mealtime service. Observers sat behind the teacher before children entered the classroom at all observation tables to avoid interruption and disruption of the meal service. The observers minimized their interaction with the children. When a child asked the observer what they are doing, the observer replied, “I am curious about the food the food you are eating.” The observational period for each child at a table started when a child sat down at the table. The observer started a stopwatch and recorded the time for the start of the observation period once the first child was seated at the table. The observer continued to record the start time for each child at the table as they were seated. To keep track of observations of each participating child, participants were assigned a number at the table based on their seating arrangement (Figure 4.1). Figure 4.1: Example of Standardized Method to Number Childs for Observation OBSERVER IS STANDING HERE (behind children) Observers recorded the time each child started and stopped eating. Mealtimes at the study site proceed by children serving themselves and then waiting to eat until all children have served themselves their first helping. As this study focuses on child-initiated food 67 behaviors, teachers were discouraged from initiating any food-related discussion at the table. Once all the children have food, the teacher states, “Now you may eat.” One minute after this statement or after all the children began eating, observers recorded behaviors on the protocol sheet at the predetermined intervals until all children were done eating. After the lunch period is over, children were asked to leave their plate on the table. Following this, the observer turned in their data collection forms to the lead investigator. Statistical Analysis Inter-rater reliability was analyzed using JMP 12.0 (SAS Institute Inc.). Statistics analyzed were for inter-rater reliability of the tool were: agreement percentages and kappa analysis. Data was entered initial into three separate excel spreadsheets: food waste, observational data, and preference data. After preliminary data analysis, food waste and observational data were merged into one to complete further analysis. A Fit Model using a Standard Least Square Means personality function and Analysis of Variance was performed using JMP 12.0 (SAS Institute Inc.) to determine how food waste amounts correlated to behaviors. A multiple comparison using the Least Square Means Tukey HSD method was applied to examine if food waste significantly increased or decreased through the specific phases of the curriculum (before, behavior, personal, and post). Statistical analysis assistance was provided by Dr. Ahmed. 68 Results Observational Data Behaviors Related to Vegetables Behaviors in the “Preschool Lunchtime Protocol” (see appendix B) related to the consumption of vegetables are: Taking Food (V), Eating Food (V), and Please Pass (V). These behaviors over the course of the nutrition education did not change according to Chi Square analysis. See table 4.1 for a report of percentages of total observations for presence of vegetable-related behaviors. Table 4.1 Report of Behavior as a Percentage of Total Number of Observations in a Preschool Program Behavior % of total observations for Time Period: Pre- Education % of total observations for Time Period Behavior % of total observations for Time Period: Personal % of total observations for Time Period: Post- Education Taking Vegetable1 4 6 6 4 Eating Vegetable2 11 10 9 10 Please Pass Vegetable 3 1 0 1 1 Note: * indicates p<.05 indicates significant difference from pre-nutrition education to post-nutrition education 1row indicates the percentage of the total times a child was observed taking vegetables out of family-style serving containers over a lunch period, default is absent if not observed. 2row indicates the percentage of the total times a child was observed eating vegetables over a lunch period, default is absent if not observed. 3row indicates the percentage of the total times a child was observed asking for more vegetables by saying “Please pass x vegetable “over a lunch period, default is absent if not observed. The above table indicates that children are seldom observed eating, taking from a serving bowl, or asking for more vegetables. 69 Behaviors Related to Fruit Behaviors in the “Preschool Lunchtime Protocol” related to the consumption of vegetables are: Taking Food (F), Eating Food (F), and Please Pass (F). Taking (F) and Please Pass (F) did not change significantly over the course of the nutrition education according to Chi Square Analysis. However, Eating (F) did change significantly. See Table 4.2 for a report of percentages of total observations of fruit-related behaviors. Table 4.2 Report of Fruit Behaviors as a Percentage of the Total Number of Potential Observations for the Behavior in a Preschool Nutrition Program Behavior % of total observation for Time Period: Pre-Nutrition education % of total observation for Time Period Behavior % of total observation for Time Period: Personal % of total observation for Time Period: Post- Nutrition education Taking Fruit Present1 9 11 15 12 Eating Fruit Present2 23* 29* 31* 30* Please Pass Fruit Present3 3 5 5 6 Note: * indicates p<.05 indicates significant difference from pre-nutrition education to post-nutrition education 1row indicates the percentage of the total times a child was observed taking Fruit out of family-style serving containers over a lunch period, default is absent if not observed. 2row indicates the percentage of the total times a child was observed eating over a lunch period, default is absent if not observed. 3row indicates the percentage of the total times a child was observed asking for more fruit by saying “Please Pass x fruit “over a lunch period, default is absent if not observed. Comparison of Behavior towards FV to Other Items Comparing the differences between children’s behavior towards FVs compared to other food categories (grain, meat 70 and meat alternative, and other) was an important goal of the research. The total number of observations over the 12 days were used to calculate percentages of each behavior (Taking, Eating, and Please Pass) for each food category (fruit (F), vegetable (V), meat and meat alternative (Me), Grain (G), and Other (O)). The percentages calculated from the entire data set were entered into an Excel spreadsheet and analyzed for significance (Microsoft, 2016). Taking Food showed significant differences between several food categories (p<.05). Taking fruit was significantly higher than all other food categories (p<.001) with an average of 11.8% occurrence, see figure 4.2. Figure 4.2 One Way Analysis of Percent Occurrence of Taking Food Behavior by Food Category. Eating Food showed significant differences between several food categories Eating fruit was significantly higher than Eating: Meat, Vegetable, and Other food categories (p<.001) with an average of 27.2% occurrence, see figure 4.3 for ANOVA. A B BC C BC 71 Fruit was not significantly different than grain. Vegetable and Other had the lowest incidence of observation (9.1% and 2.3%, respectively). Figure 4.3 One Way Analysis of Percent Occurrence of Eating Food Behavior by Food Category. Please Pass showed significant differences between several food categories Please Pass fruit was significantly higher than Please Pass: Vegetable, and Other food categories (p<.001) with an average of 4.9% occurrence, see figure 4.4 for ANOVA. Fruit was not significantly different than grain or meat. Vegetable and Other had the lowest incidence of observation (.85% and 1.9%, respectively). Figure 4.4 One Way Analysis of Percent Occurrence of Please Pass Food Behavior by Food Category. A AB B C C 72 Analysis of Food Waste and Observations Data for observations and plate waste were merged into a single spreadsheet to run a bivariate analysis. No significant relationships were found between positive fruit and vegetable behaviors (Taking, Eating, and Please Pass) and the amount of waste which occurred. Discussion Findings demonstrate behaviors and consumption of fruits and vegetables are vastly different and require separate analysis. The tool used in the study provides a quick and effective mechanism to evaluate child nutrition behaviors. To the author’s knowledge, there are no other tools similar to this one that determine behaviors towards fruits and vegetables. Only one other study showed a quasi- similar method to determine changes in fruit and vegetable preferences, but only analyzed one behavior (Farfan- Ramirez et al., 2011). However, most studies that are observational are based on estimating consumption and not strictly determining behaviors, which this study does. There are preferential behaviors towards fruits compared to other food categories, A AB AB B B 73 especially vegetables. Current available research shows that waste rates are higher for vegetables than for fruit (Byker et al., 2014; Nicklas et al., 2013) Understanding behaviors towards vegetables will help researchers and educators shift consumption of these foods. The corresponding food waste data for this research showed an average of waste of 66% for vegetables over the course of 12 days (Forthcoming??). Although none of the positive vegetables behaviors explained waste, there is a pattern of low rates of positive vegetable behaviors and a high amount of waste. Children displayed a higher rate of positive behaviors towards fruit and had a lower waste rate (18%) (Forthcoming??). Fruits and vegetables are consumed at different rates, have different levels of positive behaviors, and have greatly different nutritional quality. Dietary guidelines have been updated and all child nutrition program requirements updated to separately require a serving of fruit and vegetable versus servings of fruits and vegetables (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2015). This is an important distinction nutritionally, but waste, behavioral, and observational research are behind in understanding these behaviors in children separately for fruits and vegetables. The other main finding of this research is counter to existing research. There was no correlation in this population of preschool aged children between time eating and amount of waste which occurred. There are several cross-sectional research studies in elementary schools that show a negative association between time spent eating and amount of food waste (Cohen et al., 2016). There are many reasons why this could be different in a preschool using CACFP versus an elementary school using National School Lunch Program including: younger children tend to waste more overall (Niaki et al., 74 2017), younger children have less control over dietary behaviors (Ha et al., 2016), younger children are more unwilling to try novel food and are more resistant in their neophobic behaviors than older children (Loewen & Pliner, 1999), and other potentially confounding factors. It is important for practitioners and researchers to understand that increasing the amount of time available to eat in a preschool will not change waste behaviors in a way similar to the way it can in elementary schools. Conclusion Ultimately, this research contributes to the understanding critical behaviors pertaining to FV consumption in children that influence for long-term dietary patterns and health (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2015). Patterns of observed behavior, preferences, and waste indicate that vegetable consumption is limited in preschool-aged children. Vegetables are a critical component of a diverse diet, which can lead to positive health outcomes (National Cancer Institute, 2015). Broadly, nutrition education and waste research focus on fruit and vegetable consumption and waste. However, the results above indicate that vegetables must be the focus of future research. Waste rates were far higher for vegetables than for fruit, while observed positive behaviors and food preferences were lower. The results found above indicate that neophobia towards vegetables is high and exposure to vegetables in CACFP is not enough to decrease neophobic behavior. In the future, a multi-component vegetable consumption intervention, including materials or training in the home environment, should be implemented. Multi-component interventions are more effective in the long- term in changing dietary behavior (Appleton et al., 2016; Mikkelsen et al., 2014). 75 Beginning in October of 2017, CACFP will require a minimum serving of vegetables. The change in requirements has the potential to increase overall waste for this child nutrition program. CACFP should implement more exposure and train teachers on modeling to decrease waste of vegetables. Limitations There are several limitations in this study that will need to be addressed in future research: the research was conducted in one childcare center with high socio-economic status, research was conducted in the pacific northwest with in a specific socio-cultural context, and no control group was utilized. Further research is needed to determine behaviors towards fruits and vegetables and the amount of waste that occurs across a broader socio-ecological context. 76 CHAPTER FIVE — CONCLUSION In 2015, The United States Departement of Agriculture and Environmental Protection Agency set a food waste reduction goal for the United States: reduce food waste by 50% by the year 2030 (Environmental Protection Agency, 2015). One source of food waste is from institutions, such as elementary schools (Environmental Protection Agency, 2015). There are several studies that exist measuring the amount of waste that occurs in the National School Lunch Program implemented in elementary school. As discussed in the literature review, all studies do not agree on total amounts of waste or waste amounts for specific food categoreies. Serveral quantitative, cross-sectional research studies agree on total waste amounts near 45% and vegetable waste up to 60% (Amin et al., 2015; Buzby & Guthrie, 2002b; Byker et al., 2014). If policy makers and governments strictly cared about direct costs of food waste, this amount is significant and in the author’s opinion unaccpetable. Nearly 12 billion dollars a year are spent from the Farm Bill on National School Lunch Program (Food and Nutrition Service, 2016). From estimated percentages of total food waste and the cost of NSLP, roughly 6 billion dollars of food are thrown away in NSLP. If one takes the percentage wasted (45%) multiplied by the cost of the program that gives a monetary value of the food waste. The monetary impact of food waste in NSLP is significant alone, but food waste impact several other aspects of food system sustainability. Besides monetary value, nutrients lost must be considered. NSLP is designed to give children variety of foods and nutrients (Food and Nutrition Service, 2016). When children throw away 60% of the vegetables they are served, there are signfinicant nutritional and long-term health 77 implications. Vegetable consumpiton is associated with lower rates of chronic diseases, cardiovasuclar diesease, type 2 diabetes, and certain types of cancers (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2015). Only 7% of children consume recommended amounts of vegetables (National Cancer Institute, 2015) and nearly 60% of vegetables served to children in nutrition programs are being thrown away. Both of these facts and rising rates of obesity indicate at a popluation level, vegetable consumption could be considered a public health crisis. Waste amounts can be roughly estimated for NSLP because of the variety of research studies that have been completed. Child and Adult Care Food Program (CACFP) food waste studies are far more limited. To the author’s knowledge, before this research there existed only one study that quantified the amount of waste in CACFP (Nicklas et al., 2013). This study adds to the knowledge base of the greater issue of food waste. Understanding how much waste is occuring and the behaviors surronding food waste in preschool-aged children. Waste amounts found in this study mirror closely the amounts found in the above CACFP food waste study (Nicklas et al., 2013) and the most recent NSLP quantitative food waste studies (Amin et al., 2015; Byker et al., 2014). One interesting descrpencacy found is the reporting of fruits and vegetables as a single category or seperately. Fruits and vegeteables need to be analyzed seperately in waste and beavior studies for several reasons: fruits and vegetables have different nutritional content (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2015), children have more neophobia towards vegetables than fruit due to flavor profiles (Dovey et al., 2008), and vegetables are wasted at nearly double the rate 78 that fruit is in studies that analyzed them seperately (Amin et al., 2015; Byker et al., 2014; Nicklas et al., 2013). The research conducted in this study displays the potential for a nutrition education to impact waste and consumpiton patterns among yougner children. The resarch showed no change in serving waste, but a siginifcant reducaiton in plate waste. Reserachers concluded that these results show children are eating more of the food they put on their plates. However, one further question is how do educators and reseracher get children to put more food on their plates? Recommendations for Further Research There is a need for further research in child nutrition programs especially CACFP. The limitations of this study were: socio-economic status of participants as estimated by eligibiltiy for free and reduced lunch, limited demographic variation due to location in pacific northwest, small sample size, purposive sampling, and quasi-experimental. Further research should be conducted with a larger sample size with randomly assigned groups exposed to the nutrition education or not. Further, this research should be conducted in a different socio-ecological context, which could be achieved by researching in a different area of the United States. Further recommendations for research are to determine in what way a nutrition educaiton or other nutrition education can impact waste behavior among preschool-aged children should include the following questions: what is minimum exposure to a novel vegetable to increase consumption, what is the most effective way to increase dietary diversity and decrease neophobia among young children without increasing food waste, 79 could a fruit and vegetable snack program decrease waste at lunch, and what are long- term impacts of food waste in preschool children? For example if we reduce waste among a group of children, how long are those reductions maintained or do they waste less food as adolescents and young adults? Future research must focus on vegetable consumption and any data collected on nutrition beahvior must separate fruits and vegetables. Food waste is higher for vegetables than other food categories for complex reasons; however principal mechanisms in preschool children include: neophobia, inherent taste preferences against sour or bitter foods, and the environment (L. L. Birch, 1999; Leann L Birch & Fisher, 1995; Brug, Tak, te Velde, Bere, & de Bourdeaudhuij, 2008). Implications for Policy Makers Policy makers have recognized the importance of fruit and vegetable consumption by recently changing guidelines for CACFP (Food and Nutrition Service, 2014, 2016). The changes for CACFP are now ¼ cup fruit and ¼ cup vegetables for lunch compared with ½ of fruits and vegetables (Food and Nutrition Service, 2014). This requires the serving of vegetables at lunch whereas it was not specifically required before. Snacks are aalso a regulated meal under CACFP. Snack time is a excellent oppurtunity for children to be exposed to novel food and vegetables. However, under CACFP regulations, it is not required to serve fruits or vegetables at snack. It is unknown through the literature an overall analysis of food categories that are served at snack (only 2 of the 5 categories are required to be served), but from the author’s general knowledge it is very unlikely that vegetables are served more than once a week at snack. New CACFP regulations should 80 require snacks to contain vegteables at least two times per week.Exposure is one of the most important factors in reducing neophobia and increasing dietary quality among young children (Johnson, Davies, Boles, Gavin, & Bellows, 2015). This recommended requirement would need to be piloted in a large sample of schools over a period of time to determine if the waste that occurs in acceptable. Another specific recommendation under CACFP requirements is the lunch period in family-style meal service is nearly one hour a day that nutrition education can be taught. Early learning standards state that one of the most appropriate ways for preschool- aged children to be taught is through modeling (Montana Office of Public Instruction, 2014). Teachers or adults particpating in family-style meal service should always be trained in how important modeling and FV consumption are. The level of effort and time that went into the education in this research is not reasonable to expect a broad implementation. However, most preschool and child care centers have adults eat with the children and this is a critical time to implement education. The time spent on education during lunch is not extra and these adults would only need brief nutrition training. Policy makers at the EPA and USDA have set a goal to reduce food waste by 50% by 2030 (Environmental Protection Agency, 2015). If the goal is reached, food waste in the United States would be approximately 20%. There needs to be a level of food waste set for child nutrition programs as well. Is 20% food waste a reasonable and attainable goal for food waste in a child nutrition program? There is no research or recommendations out there for schools to look to and this needs to change. 81 Overall This research added to the understanding of food waste and nutrition behaviors among preschool aged children. Specifically, there are three essentital conclusions that practitiners and researchers must focus on. One, fruits and vegetables should no longer be grouped in any aspect of food waste or nutrition behavior research. Vegetables are wasted at a higher rate and have lower observed postive beahviors and lower food prefernce responses than fruit. Vegetable intake is critically low in the United States and behaviors must change. Secondly, the rates at which food waste occur in child nutrition programs is not sustainable. In the author’s opinion, child nutrition programs should follow food waste guidelines put out by the USDA and EPA; meaning child nutrition programs should reduce waste by 50% by 2030. The reduction in food waste should be completed equally across all food categories, indicating by 2030 vegetable waste in child nutrition programs should be no more than 35%. The third primary conclusion, is most food waste in a child nutrition program is from serving waste, not plate waste. The high amount of serving waste indicates at an institutional and policy level, preschools are serving too much food. It is the hope of the author that the knowledge gained in the study is used to frame further research or inform policy makers. Food waste, water and food scarcity are pressing issues gloabally that can be mitigated with smart, localized solutions. 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Purpose The purpose of this preschool lunch plate waste data collection is to obtain quantitative data about fruit and vegetable consumption during a family style preschool meal service. This protocol can be used alone or in conjunction with the Preschool Lunchtime Observation Tool, described elsewhere. 2. Data Collection One lead investigator with plate waste experience should be present and accompanied by research assistants whom have procedural training. For this study, Allison Milodragovich or Dr. Byker Shanks will oversee data collection. 3. Sites of data collection The lunch observations should be held during a preschool meal service. This study will occur at the MSU Child Development Center, Herrick Hall in Bozeman, MT. 4. Logistics Mealtime plate waste collected during at least three lunch periods. For this study, mealtime observations will occur during lunch (arrive at 1100am and depart by 1pm) in four separate weeks, for a total of 12 observation days. For data collected, all observers need to wear a Food and Health Lab shirt and a nametag. The first week is 10/17-10/19, second is 11/15-11/17, third week is 12/13-12/15, and the final observation will occur 1/24- 1/26. 5. Materials needed Observers will need: scale, five separate bins to collect data by food item category (fruit, vegetable, meat or meat alternative, grain, dairy), pen, paper, and data collection sheet (see Appendix A), tape, and a permanent marker. 6. Advance preparation  Consent for the child to participate should be obtained from parents prior to the study. For this study, consent forms will be distributed to four-year old children’s parents at the MSU CDC. Notes will be recorded only on children whose parents sign and return the consent forms.  A training session for observers should occur prior to the study. During the training session, a lead researcher will explain study protocol to observers, provide protocol to observers, and practice plate waste collection prior to research data being collected. 7. Plate Waste Measurements. Plate waste and pre-consumer kitchen waste will be measured for lunch served family-style with Child and Adult Care Food Program (CACFP) minimum meal components for three consecutive days. Family-style refers to the method of child feeding that allows the children to self-select from bowls with food items on the table instead of a pre-portioned serving cafeteria style. Family style serving is a recommended practice under CACFP (Food and Nutrition Service, 2014). 95 BACKGROUND INFORMATION 1. The lead researcher will complete the: date of observation, name of researchers, time at beginning of lunch, time at end of lunch, number of tables observed, number of preschool lunches observed, and name of meal components (F= fruit, V= vegetable, Me= meat and meat alternatives, Mi=milk, G= grain). SET UP 2. Work with preschool staff to set up a plate waste research station that is not disruptive to the preschool day. Students should not see the research station. 3. Plug in a scale at the plate waste research station. Prepare clipboards with pens and Plate Waste Collection Tool. BUCKETS 4. Prepare food waste collection bucket with one trash bag and a tape label for the type of food (F= fruit, V= vegetable, Me= meat and meat alternatives, Mi=milk, G= grain) on the front of the bucket. 5. Measure the weight (grams) of each food waste collection bucket. Record the weight on the Plate Waste Collection Tool in the BUCKETS portion when you have obtained three equivalent readings. 6. Write the weight of the bucket on the corresponding bucket label tape. 7. Line up the buckets. BOWLS AND SERVING CONTAINERS 8. Place tape on the bottom of all bowls and serving containers. 9. With a permanent marker, mark the bottom of all bowls and serving containers with: (1) type of food (F= fruit, V= vegetable, Me= meat and meat alternatives, Mi=milk, G= grain) and (2) table number (1, 2, or 3) that the food will be placed. 10. Measure the weight (grams) of each bowl or serving container empty. Record the weight on the Plate Waste Collection Tool in the BOWLS AND SERVING CONTAINERS – EMPTY portion when you have obtained three equivalent readings. Write the weight of the bowl or serving container on the tape on the bottom of the bowls or serving containers. 11. Notify preschool staff that the bowl or serving container are ready to be filled with food. 12. Weigh (in grams) the food filled bowl or serving container. Record the pre weight (grams) of food items in the category and table number designated on the bottom of the bowl. Record the weight in Plate Waste Collection Tool in the BOWLS AND SERVING CONTAINERS – FULL when you have obtained three equivalent readings. 13. Once food is placed on tables, researchers should photograph each table before students are seated. Photograph Table 1 first, then Table 2, and finally Table 3. 14. Children will eat and be observed according to the Preschool Lunchtime Observation Tool, described elsewhere. 96 PLATE WASTE 15. Children will be instructed to leave plates on table as they are finished eating and leave the table. a. If children ask questions about the plate waste collection to teachers or researchers the standard response will be: “We are curious about the food you eat.” 16. Researchers will collect plates from each table and bring to research station. Researchers should scrape the plate waste of table 1 into buckets with corresponding food types (F= fruit, V= vegetable, Me= meat and meat alternatives, Mi=milk, G= grain) labels on them. Record the weight on the Plate Waste Collection Tool in the PLATE WASTE portion under “Table 1” when you have obtained three equivalent readings. Continue with the same process for Table 2 and Table 3. Recorded weights should be cumulative. SERVING WASTE 17. When lunchtime is completely finished, researchers will collect any food left in the bowls or serving containers and bring to research station. Researchers should scrape the bowls or serving container waste of table 1 into buckets with corresponding food types (F= fruit, V= vegetable, Me= meat and meat alternatives, Mi=milk, G= grain) labels on them. Record the weight on the Plate Waste Collection Tool in the SERVING WASTE portion under “Table 1” when you have obtained three equivalent readings. Continue with the same process for Table 2 and Table 3. Recorded weights should be cumulative, including plate waste from step LEFTOVER WASTE 18. Finally, researchers will collect any leftovers from food preparation. Researchers should scrape the containers of leftover waste into buckets with corresponding food types (F= fruit, V= vegetable, Me= meat and meat alternatives, Mi=milk, G= grain) labels on them. Record the weight on the Plate Waste Collection Tool under “Leftovers” when you have obtained three equivalent readings. Continue with other food types. Recorded weights should be cumulative, including waste from steps 15 and 16. CLEAN UP 19. The lead researcher is responsible for collecting all data sheets and storing in a safe place that is not accessible by anyone except the research team. 20. Throw away all trash bags that contain waste. 21. Clean buckets and scale thoroughly. 22. Store research station materials in a safe place that is secure and not accessible by the public. 97 PRESCHOOL LUNCHTIME OBSERVATION TOOL BACKGROUND INFORMATION Date of plate waste data collection: Name of researchers: Time of start of lunch: Time of end of lunch: Number of tables observed: Number of preschool lunches observed: Name of meal components: Fruit = Vegetable = Meat or meat alternate = Grain = Milk = BUCKETS BUCKET NAME Weight (grams) Fruit Vegetable 98 Meat and meat alternative Milk Grain BOWLS AND SERVING CONTAINERS - EMPTY BOWL OR SERVING CONTAINER Weight (grams) for Table 1 Bowl or Serving Container Weight (grams) for Table 2 Bowl or Serving Container Weight (grams) for Table 3 Bowl or Serving Container Fruit Vegetable Meat and meat alternative Milk Grain BOWLS AND SERVING CONTAINERS – FULL (Pre weight) BOWL OR SERVING CONTAINER Weight (grams) for Table 1 Bowl or Serving Container Weight (grams) for Table 2 Bowl or Serving Container Weight (grams) for Table 3 Bowl or Serving Container Fruit Vegetable 99 Meat and meat alternative Milk Grain PLATE WASTE PLATE INGREDIENT Weight (grams) for Table 1 Plate Waste Weight (grams) for Table 2 Plate Waste Weight (grams) for Table 3 Plate Waste Fruit Vegetable Meat and meat alternative Milk Grain SERVING WASTE SERVING INGREDIENT Weight (grams) for Table 1 Serving Waste Weight (grams) for Table 2 Serving Waste Weight (grams) for Table 3 Serving Waste Fruit Vegetable Meat and meat alternative Milk Grain 100 LEFTOVER WASTE LEFTOVER INGREDIENT Weight (grams) for Table 1 Leftover Waste Weight (grams) for Table 2 Leftover Waste Weight (grams) for Table 3 Leftover Waste Fruit Vegetable Meat and meat alternative Milk Grain APPENDIX B 101 PRESCHOOL LUNCH OBSERVATION PROTOCOL 102 103 104 105 106 107 108 109 110