TARGETING OBESOGENIC BEHAVIORS: PILOT TESTING A MODIFIED RHODE ISLAND EFNEP CURRICULUM

....................................................................................................................... ii ACKNOWLEDGEMENTS ............................................................................................. iii PREFACE .......................................................................................................................... iv TABLE OF CONTENTS ................................................................................................... v LIST OF TABLES ............................................................................................................ vi LIST OF FIGURES ......................................................................................................... vii MANUSCRIPT ...................................................................................................................


Introduction
Given the high prevalence of childhood obesity among low-income and minority populations finding ways to intervene is critical. 1 In 2011-2012 over one third of children and adolescents (ages 2-19) were overweight or obese. 1 In addition, ethnic disparities in the prevalence of obesity are evident, whereby 17% of Hispanic children ages 2-5 are obese compared to 3.5% of non-Hispanic white children. 1 In Rhode Island, the prevalence of obesity among Hispanic children ages 2-5 is even higher at 25% compared to the national average of 17%. 1,2 This is of concern given that Hispanics are the largest and fastest growing minority population in the United States (US). 3 In addition, children who are overweight or obese are at an increased risk of becoming overweight or obese as an adult 4,5 and suffering from the associated comorbidities such as type two diabetes and cardiovascular disease. 6 Therefore, obesity prevention early in life among these disadvantaged populations is important.
Exploring ways to engage hard to reach low-income parents in prevention efforts is critical because parents help shape a child's healthy eating and lifestyle behaviors early in life. 5,[7][8][9][10][11] In an effort to engage parents in obesity prevention, several government initiatives have been put into place to promote healthful behaviors among low-income parents and children. 4,12 For example, "Let's Move" 1,4 provides parents with information that supports healthy lifestyles, more nutritious foods in schools, and ensures that families have access to healthy and affordable foods. 4 In addition to government programs, several interventions with an educational components related to healthy eating for low-income populations have found significant improvements in fruit and vegetable consumption 13 and decreases in BMI percentile. 14,15 Although some of these interventions have been successful in improving health behaviors among parents and children 13,15 , many did not include ethnically diverse parents participating in federal nutrition education programs and they did not discuss details on their process evaluation.
Intervention process evaluation techniques and components are critical to nutrition education interventions and programs. [16][17][18] Sustaining successful interventions requires identifying what is beneficial and what needs improvement also known as the "black box" of intervention effectiveness. 17 Quantitative observations or feedback can expose how behavior changes occurred and the attributes of the curriculum that are associated with these changes.
The Expanded Food Nutrition Education Program is a federal nutrition assistance program designed to assist low-income adults gain nutritional knowledge and skills to improve food-related attitudes and ultimately overall diet. 12 In Rhode Island, approximately 50% of participants are Hispanic. Although there have been several interventions to prevent obesity among low-income children and their families 21,22 few have done so through the federal EFNEP program. 13,15 A pilot intervention in New York State with parents of 3-11 year old children, Healthy Children Healthy Families: Parents Making a Difference (HCHF), tested an integrated nutrition and parenting education intervention using the EFNEP program structure. The study found overall improvements in home environment, physical activity (PA), screen time (ST) behaviors, fruit, vegetable, snack, and soda intake for the parent and child. Federal nutrition community programs, like EFNEP, can serve as an important vehicle to reach a vulnerable parent population and educate them not only on improving their dietary behaviors but also helping them to create a healthy home environment for their children.
The RI-EFNEP office recognized the need to address non-nutrition related obesogenic behaviors because although the current RI-EFNEP focuses on nutrition education, it does not incorporate education on other obesity-related behaviors. 13,23,24 Participants and their families who complete a curriculum, which addresses these behaviors, are more likely to improve health behaviors associated with obesity. 13 As part of program improvement, it is important to continue to assess participant satisfaction and their practices and incorporate them in to future nutrition education interventions. 25 Van Asch et al. 26 conducted semi-structured interviews with primarily Hispanic (73%) RI-EFNEP participants. Participants reported wanting more information on how to incorporate healthy habits around ST, PA, and parenting skills/education on household routines to decrease obesity risk. 26 These content areas were used to modify the EFNEP curriculum.
Although other curriculums, like the HCHF curriculum, can increase knowledge and motivate parental attempts for behavior change 13 , the needs of RI-EFNEP were to slightly modify the existing curriculum by creating additional modules that can be incorporated into the current curriculum without having to have paraprofessional go through an entire new training. Given that few studies have captured process evaluation among low-income parents, and obesity rates among RI Hispanic children are higher than the national average 1,2 , the goal of this study was to pilot test a newly modified RI-EFNEP curriculum that incorporates other behavior such as parental feeding, PA, and ST behaviors for children. As part of this pilot, we expect that collecting detailed process evaluation data will help inform future modifications of the new lessons. The first objective of the study is to assess participant satisfaction with regards to the implementation of the modified modules. The second objective of the study is to assess areas in need of change via participant feedback and investigator observations. Our hypothesis is that the newly modified RI-EFNEP curriculum will improve parental healthy eating behaviors and children's healthy eating pre to post intervention. Finally, we will explore behavior change in the areas of parental feeding, PA, ST, fruit and vegetable intake, and energy dense snack food intake.

Methodology Study Design
This non-experimental pilot study assessed a modified version of the RI-EFNEP curriculum for parents utilizing a pre-post design. Areas in need of improvement within RI-EFNEP were explored utilizing a prior formative study,

Participants
Participants for this study were recruited through traditional programmatic EFNEP methods. Eligible participants for this study were parents and caregivers over the age of 18 with a child ages 2-12 years who were enrolled in EFNEP.
Rhode Island EFNEP participants are at or below 185% of the federal poverty level income. Participants were either English or Spanish speaking. There was a translator present for groups with Spanish speaking participants. The RI-EFNEP supervisor utilized community agencies throughout the state of RI, such as adult education and workforce development agencies and parent groups to recruit participants. Working with the director of RI-EFNEP to coordinate recruitment we recruited a convenience sample of five classes with 42 participants. During the first session of EFNEP, eligible participants were informed about the study, asked if they were interested in participating and if so, signed informed consents at that time. No eligible participants declined being part of the study. The EFNEP classes took place in community centers in Rhode Island.

Creating a Modified Curriculum
The modified curriculum and materials were created the summer prior to initiation of this pilot study. The current RI-EFNEP curriculum teaches six main lessons: 1) MyPlate and Go-Slow-Whoa foods, 2) Fruits and Vegetables, 3) Grains, 4) Dairy and Think Your Drink, 5) Fats and Oils, and 6) Protein. Three new lesson modules on PA, ST, and parental feeding practices were created by means of EFNEP directors, paraprofessionals, previous findings, and best practices and evidence, 13,15,26,28 In order to help guide lesson modules, previous interventions have utilized the Four Steps of Learning that Lasts (The 4-A Model). 29 This model is used to ensure that appropriate content is included within each lesson, that participants can relate to it, apply it and be able to take the information with them. With this structure, participants are able to truly learn the material and be able to utilize it to exhibit behavior change. "Anchor" focuses the content specific to the participants from personal experiences. 30 "Add" takes the new information and incorporates it to the participants knowledge. 30 "Apply" allows the participant to relate to the new content in a new way. 30 "Away" asks the participant to take the new content and use it in the future. 30 Each of the three new lessons followed the 4 A's model.
After the new information "Add" was taught in the lesson the "Apply" component was then covered. Each new lesson had an activity that participants engaged in, these activities were poster and card matching, charades, food advertisement model (cereal boxes, "fruit" gummies) discussion. Goal setting was addressed in the "Away" component, a goal setting handout was to be filled out and taken home by the participants. Further explanation of the activities can be viewed in the lesson plan provided in appendix C.
We ensured that the modified curriculum was appropriate for the audience with regards to literacy, and layout using methods from the Suitability Assessment of Materials (SAM). 31 This assessment of materials is a widely used and accepted tool for modifying and improving education materials. 32 In order to ensure this process, the lessons and content were reviewed in detail with RI-EFNEP staff and paraprofessionals.

Process Evaluation:
Process evaluation is an integral part of this pilot. The steps to develop the process evaluation for this study can be viewed in further detail in Figure 1. These steps have been documented in the past and can be used for public health community programs to deliver more effective interventions. 20 Process evaluation measures included 1) fidelity of the intervention, 2) observations written by the graduate student researcher during the lessons, 3) short surveys completed by participants at the end of each session and, 4) audio-recorded focus group conducted for each group after the last RI-EFNEP lesson (Table 1).

i. Fidelity and Observations
Fidelity and observational checklists were developed and utilized while observing the new lessons in order to assess if the modules were being delivered as intended. 33 Because the fidelity checklist was thorough and matched practices from previous research we formulated the fidelity criteria and acceptable ranges accordingly. 15,17 Each area of the lesson plans (Anchor, Add, Apply, Away) had quantitative observations and at the end of the lessons these areas were summed and averaged to quantify the fidelity scoring.
The observational portion of the checklist was modeled after previous research observational checklists. 17   All outcomes were assessed pre and post. Parental feeding, child ST, parent and child PA, and fruit and vegetable intake were assessed using questions from a validated 16-item checklist from the HCHF study. 13,27 Example questions from the checklist include: "In a typical week, how often do you let your children decide how much food to eat?" and the response range is 1)"almost never" 2) "less than half the time", 3) "half the time", 4) "'more than half the time", 5) "almost always". 27 "How much time do your children spend watching TV, using the computer or playing video games?" the response range is 5) "less than 1 hour each day", 4) "1-2 hours each day", 3) "3-4 days each day", 2) "5-6 hours each day", 1)" 7 or more hours each day". 27 For this question higher scores on the likert scale representing the healthier behavior.
Physical activity is defined as breathing a little harder or heart beating a little faster than normal. The questions were scored using a 5-point Likert type scale of increasing frequency (per day, per week) and coded 1-5 using the increasing frequency. Five behaviors included "less" which reduced frequency is recommended and the checklist item is reverse coded. 13,27 Fruit intake is defined as fresh, dried, frozen, or canned with vegetables defined similarly without the "dried" criteria. Additional questions from the 16-item checklist used in the pre and post surveys for this study can be found in appendix E. Attendance data was collected and added as an additional variable.

a. Curriculum Implementation and evaluation procedures
Paraprofessionals attended a 3-hour hands on training on the new lesson modules (Table 2). Instructions were provided and paraprofessionals had an opportunity to teach back and role-play to ensure that they mastered the material.
A total of five RI-EFENP groups participated in six to eight classes, which lasted sixty minutes. Classes were conducted in English, if needed, a Spanish speaking interpreter was present to translate. The short surveys, observations, and fidelity data were collected at each of the new lessons. Pre-post tests were collected during the first and final lessons.

Process evaluation
For fidelity, frequency counts of the averaged module component were used to summarize the data. All observations, and post lesson short surveys were reviewed and themes highlighted by the student investigator. The student investigator reviewed the focus group audio tapes and data was analyzed according to the moderator guide. 34 Thematic coding and frequency counts were used in analyzing observations, post lesson short surveys, and focus group data. In the final phase, themes were again reviewed and modified as needed. The instruments used to analyze the new modules are further explained in Table 3.

Outcome evaluation
A coding manual was created to define variable names and missing values as necessary. Normality was assessed using the test of normality Kilmogoroc-Smirnov statistic. Participant demographics (i.e. age, gender, child ages in household, education etc.) and the participant behavior questions were analyzed descriptively. Chi-square tests for goodness of fit was used to investigate differences in demographic characteristics between participants who were present for the post-survey and excluded due to missing data, and the participants who completed the pre and post survey.
The quantitative data collected via pre and post surveys was analyzed using SPSS version 22 (IBM, Armonk, New York, 2013). The magnitude of change scores pre-post was not normally distributed, therefore paired t-tests was not appropriate and the Wilcoxon signed rank test, a nonparametric test of differences was utilized instead. Coefficient alpha of 0.05 was used. Modeled after a prior study utilizing the 16-item checklist, participants were also classified by whether or not their score improved by at least 1 point or by at least 2 points. 13,27

Results Overview
A description of the sample is provided followed by the process evaluation results (fidelity, observations, post lesson surveys and participant focus groups) and outcome evaluation results (pre-post 16-item checklist).

Sample Characteristics
Five groups and 24 out of 42 participants completed the pre-post surveys (57% of participants). Participants who did not attend post data measurements were less educated, spoke Spanish and participated in Head Start (p > 0.05) as compared to the participants that were present during pre and post. Demographic results from the 24 participants with pre-post data are presented (Table 4).   (Table 5). Participants were respectful to one another and were attentive to paraprofessionals throughout all of the observations (100%).
Researcher observations reported participants stating they wanted more information about healthy food advertisements that exist in the media and how to promote those healthy advertisements to their children. Additionally, based on the researcher observations lessons that were first taught in English and then translated into Spanish ran longer than usual and participants were more likely to appear board. Observations also showed that in over half of the lessons the participants did not articulate alternative strategies to problems presented to them. This is consistent with the observation that there was a lack of goal setting.
The quantitative results for the post lesson participant survey showed that all of the participants plan or might plan to do something new after participating in the new lessons. Furthermore, on average 95.5% of participants felt they learned new information ( Figure 2). The qualitative results from the three open ended questions showed that participants found charades, and the example food advertisements (i.e. cereal boxes, yogurt cups, "fruit" gummies) discussions to be the most helpful learning activities. Moreover, through these three process evaluation components participants wanted more food preparation techniques, indoor activities and recipes, information on activities for different child age groups, and information on healthy food advertisements. and… "…(we would) like to get cooking the food". ii.

Physical Activity
Participants had mostly positive feedback with regards to the question "What did you like most about the lesson on being active with your children? What didn't you like?" One of themes was spending time and being active with family.
Participants found the charades game (that was used as an activity in this lesson) was a fun way to show how to be active. One participant stated: "doesn't have to be running around chasing a ball, it can be something as small as something like charades (referring to physical activity)" Another theme that emerged was information on limiting screen time was enlightening. One participant stated: "I thought that was a good one because it's hard to get your child away from the video games".
Participants expressed multiple areas of behavior change around ST.
"I started limiting screen-time… they're not happy with me",

iii. Food Advertisements
Based on information discussed from the question "What did you like most about the lesson on how food is marketed to kids? What didn't you like?" two themes emerged. Participants felt that a lot of the information learned during this lesson was new and eye opening information. Participants said; "there were a lot of things I didn't know" and… "the visual stuff ("kids"cereal boxes, child directed yogurt cups, "fruit"gummies) was always my favorite because it was very eye opening".
Participants also stated how they will apply the information on how food advertisements affects their children.
For example: "it's our job to kinda see through the (food advertisements)" and another said; "… I worked on it with my kids".

iv. Overall
Based on the moderator guide question, "In what way were the classes most helpful to you and your family?" there were multiple areas where participants found age specific information would have been beneficial. This introduced the last theme to include age specific information in future lessons.

Some responses were:
"when kids get older…(incorporate ways) to still have (healthy behaviors)" and… "(kids)10 and up is lazy…include older (kids) tips".
Overall, paraprofessional and participant comments were very positive.
For example, one participant stated "…I really liked it!", and… "(the paraprofessional) was awesome… you made them all fun!"

Outcome Evaluation
There were significant with-in person improvements for 1 of 16 of the individual items on the checklist. As shown in Table 7 week", eating take out with their family "1-2 days each week", "more than half the time" fruit is available in their homes "and about half the time" did participants have energy dense snacks available to their children and did they let their child decide how much to eat about.
Although non-significant, the largest magnitude of change was in parents letting a child's decide on how much to eat (change = -0.540, p=0.15) and having energy dense snack foods less available (change = -0.458, p=0.068). Of the participants 37.5% had at least 1-point for parent physical activity (37.5%).
Furthermore, 33.3% of participants had at least a 1-point change for availability of energy dense foods and home fruit availability and 25% had a 2-point change.

Discussion
The overall goal of this study was to pilot test a newly modified RI-EFNEP curriculum that incorporates other behavior such as parental feeding, PA, and ST reported the modified curriculum was informative and that the paraprofessionals made the overall experience enjoyable. Four areas of improvement were identified: 1) need for more effective goal setting strategy 2) lack of age specific information within the new modules, 3) absence of hands on activities (specifically for the feeding module), and 4) necessity of a new approach to explain food advertisements. Although behavior change was not evident, probably due to the lack of power, future modifications within the new EFNEP curriculum can be made.
Through collecting this type of data in our study, we found that although fidelity and participant satisfaction was high for the newly added modules, goal setting strategies could be more effectively implemented. This is of particular importance given that studies have found that the execution of effective goal setting techniques are critical to behavior change. 23,35,36 A previous study, successful in modifying parental behaviors, utilized discussion of healthy goals to identify behavioral barriers and solutions to overcome them. 23 Although the lesson plans include an "Away" component that incorporates goal setting into the lesson, we hypothesize that participants are not fully engaging in this task. It is possible that paraprofessionals did not get enough direction and training on how to discuss participant barriers and to include enough time to discuss goal setting.
It is also possible that because the community classes often do not start "on-time" and goal setting is covered at the end of the lesson, that there is not enough time to discuss this component. Goal setting should be integral part of future paraprofessional training and it should be included throughout the lesson in order to ensure that participants engage in this activity.
Our finding that more age specific information is needed is similar to what others have found. 37 For example, most of the literature exploring feeding, child eating patterns, and diet quality groups all child ages together. Interventions should provide age-appropriate information to parents, specifically about portion sizes, to target this problem area. 37 It is possible that incorporating more age specific information into the curriculum (i.e. through tips for picky eaters in a school age child vs. toddler), might have lead to behavioral improvements in feeding and PA behaviors. This is true with regards to PA, whereby prominent differences exist between preschool to school aged children. Timmons et al. 38 provides four recommendations for children 2-5 years of age including a focus on gross motor play that children find fun and PA for children should be enhanced by adult facilitation and modeling. The recommendations are based on scientific evidence and can be used to for strategies on improving PA in children 2-5 years of age. Including these recommendations in to the new modules is appropriate and consistent with the literature on "how to make preschool children more active". 38 We also found that participants wanted more hands on activities around feeding their children. Involving children in meal preparation has shown to increase fruit and vegetable intake and 39,40 including meal preparation in nutrition intervention has shown to be successful in previous studies. 40 It is possible that including meal preparation demonstrations within the feeding your child lesson will help parents and children engage in meal preparation together and therefore improve the quality of their diet. Based on our findings, changes will be made to better target this area. Using meal preparation involvement as a model for demonstration may prove to be successful for behavior change. 39,40 Lastly, we found that participants were unaware of how the media targets unhealthy products for children. Specifically they were interested in how fruit and vegetable advertisement might be used in the media and wanted to learn more on this subject. However, there is an absence of sufficient fruit and vegetable food advertisement in the media. Most of the literature today is focused on child media exposure to unhealthy foods, and is severely lacking in child media exposure to fruit and vegetables 40 . The next iteration of the modified RI-EFNEP curriculum will include information on how unhealthy food advertisements are used to target children (i.e. fast food TV commercials). Additionally, an activity demonstrating how the overwhelming majority of child directed food advertisements with poor nutritional content occur on TV commercials will be incorporated.
Eight out of the 16-items in the checklist are targeted in the new modules.
Subsequently, significant improvements occurred for one of the HCHF 16-item behaviors. 13 We found that adult soda consumption was significant. While we did not find statistically significant improvements in parental feeding, PA, and ST behaviors these findings warrant careful consideration as at least two hypothesis may explain these findings: 1) The modified curriculum was ineffective and these areas were not appropriately targeted within the curriculum and 2) the outcome evaluation failed to measure an effect where one existed, keeping in mind the small sample (n=24). Future studies should consider working with larger sample sizes that utilize an experimental design.
Previous studies have found that EFNEP positively impacts family dietary behaviors and obesity prevention. 15,41 However, ongoing research is necessary to determine the most effective and efficient ways to deliver nutrition education to at-risk populations. 41 The added modules of the RI-EFNEP curriculum mirror similar successful interventions added to the other state EFNEP programs, including the HCHF curriculum. 13,15 Family based interventions targeting home food environment are needed in order to improve healthy family practices. 42 Dickin et al. 13 documented positive behavior changes in parenting skills and home food environment styles for parents receiving the HCHF curriculum using the validated HCHF 16-item checklist in regards to feeding, PA, ST, fruit and vegetable intake, and high calorie snack intake. However, it is worth noting that the HCHF curriculum is training intensive for the paraprofessionals with up to 40 hours of training. Given that detailed process evaluation data was omitted in this study due to space limitations it is unclear what aspects of the program were effective in measured behavior change. 13 Rhode Island EFNEP has the potential to address parental feeding practices, PA, and ST in order to establish healthy habits. Strengths of this study include the thorough process and outcome evaluation measures. Collecting data on both process and outcome evaluation helps us understand the mechanism by which behavior changes is achieved. [43][44][45] The use of both methods to evaluate the curriculum allows for important insights and could be critical in improving and refining future interventions. 21 The mixed methods analysis of this pilot study allows the investigator to examine multiple aspects of the curriculum thus uncovering strengths and weaknesses of the modified curriculum. Although other measures of feeding could have been included, participant burden was a concern, therefore a validated 16-item checklist which has low response burden was used. 13 This study adds to the growing literature on the importance of evaluating federal nutrition programs, which can impact chronic disease prevention among lowincome populations. 13,15 Some limitations of our findings should also be noted. First, we did not incorporate a control group and measured participant behavior change was selfreported. The study could have benefited from incorporating a pre-post parental feeding questionnaire to further assess parental feeding behavior change but as previously mentioned we wanted to reduce participant burden. Although we used extensive process evaluation in the new lessons there was no in depth evaluation of the entire curriculum. Our sample size was small and we may have not seen significant changed due to lack of power. In addition, with the pre-post tests on certain behaviors, there were multiple comparisons and our significant findings However, given that low-income populations are hard to reach, and Spanishspeaking participant numbers were low it was decided by EFNEP staff that combining the group would be best in order to reach all participants.

Implications
The findings from this study help inform the future of the EFNEP curriculum and highlight the importance of utilizing EFNEP as a vehicle to reach low-income populations that are risk for childhood obesity. Based on these results, lessons will be modified to incorporate age specific information for parents, create a more effective goal setting strategy, add an interactive activity in the feeding your child The Expanded Food Nutrition and Education Program (EFNEP) is designed to assist low-income adults gain nutritional knowledge and skills, while improving food-related attitudes to ultimately enhance their overall diet. 9 Educating parents can not only improve their overall diet but the knowledge can help create a home environment to foster healthy diet and behavioral changes in their children.
Although the current RI-EFNEP focuses on nutrition education, it does not incorporate education on other obesity-related behaviors, such as parental feeding, sleep, excess screen time (ST), and lack of physical activity (PA). Results from previous studies show strong evidence for an association between knowledge and healthy eating 17,18 and behaviors. 19 It is possible that parents and their families who complete a curriculum, which addresses these behaviors, would be more likely to improve health behaviors associated with obesity. The modified RI-EFNEP curriculum will be discussed in further detail later.
To better understand the scope of childhood obesity and the intervention and prevention efforts needed early in life among this high-risk population, this literature will describe the following areas: 1) The prevalence of childhood obesity and its consequences, 2) obesity-related (or obesogenic) behaviors (i.e, diet, ST and electronic media, PA, sleep, and parental behaviors), 3) the importance of effective nutrition education programs and, 4) current childhood obesity prevention and intervention efforts.

II. Prevalence of Childhood Obesity and its Consequences:
In the US, obesity has increased over the past three decades. 20 Obesity is a risk factor for many chronic diseases. 2,3 Data obtained from 2011-2012 suggests that about 20% of children and adolescents in the United States are overweight or obese. 10 This is of concern because overweight and obese children and adolescents can develop long-term and immediate health consequences related to obesity such as heart disease, high blood pressure, cancer, and asthma. 3 As a result, childhood obesity in the United States is considered a public health threat and there is a need for more community intervention. 3 Although prevention efforts appear to be successful, prevalence of obesity was high in children and adolescents 10  Diet quality is a major factor contributing to obesity. 46 About 85% of children ages 2-3 years consume at least one type of sugar sweetened beverage (SSB) or sweet or salty snack per day. 36 Sugar sweetened beverage intake has shown to be related to diet quality and BMI increases in school aged children. 45 Briefel et al. 47 found that the diet consumed at home provided the most "empty calories" during a 24-hour period in a population of children grades 1-12. Due to the major influence parents have on a child's diet parental involvement is crucial in the preventative efforts toward childhood obesity. 48,49 Diet quality among low-SES Hispanic children has shown to fail to adhere to The Dietary Guidelines for Americans. 50 Results from a study by Wilson et al. 50 show low-SES Hispanic children often exceed guidelines for fat and added sugar. Another study found that the dietary patterns described in Mexican Americans were high risk for chronic diseases due to the lack of "healthy" dietary patterns. 51 The findings of these studies highlight the importance of targeting dietary patterns in populations that are high risk for obesity and chronic diseases.

Screen Time and Electronic Media
For There is no recent evidence suggesting that ST has decreased significantly among US children and adolescents. 53,54 Moreover, multiple studies show that an increase in ST is positively associated with childhood obesity. 32,55-57 ST has also been associated with adverse dietary outcomes. 58 A positive association has been found between ST and snacking frequency. 59,60 While watching television children are more likely to consume more sweet snacks 61 , energy-dense drinks 62 , SSB, fruit juice, fast foods 63 , and higher energy dense snack foods. 62,64,65 Research has also indicated that Hispanic children tend to engage in greater ST than do White children 66 , thus targeting this high-risk population is critical.

i. Television viewing
High incidences of television viewing can contribute to the development of overweight and obesity during childhood and may be an indicator of unhealthy behaviors and health status in adulthood. 56,67 Bauer et al. 40 found the number of cable televisions and DVD players in the home to be positively associated with BMI and percent body fat in adolescent girls. Another study found that children consume a significant amount of their daily energy (weekend 25%, weekday 20%) while watching TV. 68 Consumption of high-fat foods while watching television has been positively associated with BMI in young children. 68 With these detrimental findings the current recommendations of the American Association of Pediatrics is to remove television sets from children bedrooms. 52 Removing the television from the bedroom can also have beneficial effects on sleep, 69 which will be discussed in more detail later.
To address ST and its relationship with childhood obesity many longitudinal studies have explored the relationship of ST and overweight and obesity from early childhood and adolescents to later in life. 56,65,67,70 In The Raine Study, a 14-year longitudinal cohort study conducted in Australian children ages 1-14 years, ST had a direct influence on BMI at 6 years and 10 years and reported a lag time effect from 8 to 10 years. 56 The study found that of the obese adolescents, 45.9% were already obese and 33.3% were high ST users at 6 years of age. 56

ii. Media and Advertising
ST is also a problem for children and adolescents due to the exposure of unhealthy food advertisements. 69 The Annual Review of Public Health explains the exposure to food marketing ads increases children's unhealthy food consumption. 74 In 2007, The Kaiser Family Foundation reported out of all advertisements seen by children, food was the largest product category. 75 Of the food products in advertisements targeting children and adolescents 34% were for candy and snacks, 28% were for cereal, 10% were for fast food, 4% were for dairy products and none were for fruits and vegetables. 75 Advertising and electronic media, among other environmental influences, can influence a child's food preferences. 40 Studies have shown advertising is targeted toward and may contribute to obesogenic behaviors specifically in low income children and adolescents. 76,77 The reported advertisements targeting to children 75  Results also showed a significantly lower increase in BMI when parental support was incorporated in the intervention compared to the intervention alone and control group. 82 There was a clear difference in BMI and BMI z-score in girls after the 2-year intervention, thus inferring with parental support, this intervention could be effective at preventing overweight and obesity over a longer period of time. 82 In addition to increasing parental support 81,82 Increased parental PA has shown to positively impact children and adolescent health. 40

,79 A review by Van
Der Horst et al. 79 found evidence of a positive association between parental PA and PA in boys. Promoting increased PA through parents decreases obesogenic behaviors in children and adolescents and serves as a valuable method for obesity prevention. _

Sleep
Sleep duration and Obstructive Sleep Apnea (OSA) has been linked to incidence of obesity in children. 39,83 Specifically, sleep duration has shown to have an inverse association with childhood obesity. 39 Children and adults differ in sleep by quantity and nature but sleep is similar to that of adults by age ten. 39 A meta-analysis by Cappuccio et al. 39 explored the relationship between sleep duration and child BMI. They found increased odds of having shorter sleep with higher BMI in childhood and adulthood. 39 Additionally, a reduction in sleep by 1 hour per day was associated with an increased BMI of 0.35kg/m 2 (i.e., with a person who is 70 inches it would be equivalent to 3.08lbs). 39 This association was consistent across different populations. 39 Another study by Gupta et al. 84 found that for each hour of sleep lost, the odds of obesity increased by 80%.
It has been hypothesized that the incidence of OSA is linked to metabolic alterations in glucose and insulin, which are known factors associated with and also increase the risk of obesity. 83 It is important for children to receive adequate sleep and as discussed previously, sleep can be negatively impacted by TV's in the bedroom. 69

Parental behaviors
Parental behaviors influence their children's behaviors. 85,86 Parents have the ability to modify their children's diet 48 , ST 52 , and PA 79 through their behaviors.
The parental behaviors that will be discussed in this review are: parental role modeling, controlling feeding practices, home food environment, and family meals.

i. Role Modeling
Parental modeling of unhealthy eating behaviors has been shown to be associated with increased child BMI z-scores. 87 (TFEQ). 87 Children whose parents scored high in both parent dietary restraint and disinhibiting had the greatest gains in sum of skinfolds (61.4mm). 87 The findings suggest that parental disinhibited eating, together with dietary restraint, may be associated with increased risk of obesity in their children. 87 These findings are consistent with the literature that parental role modeling is important for the prevention of unhealthy eating behaviors in children. 85,92 ii.

Feeding Practices and Styles
Parental feeding practices and styles are important in promoting healthy food choices and behavior in children 93 Four parenting styles centered around responsiveness how demands/requests are carried out by the parent which are either child or parent centered and demandingness is the number of demands that parents place on children to get them to eat. 94 The four parental feeding styles authoritarian high (demandingness low responsiveness), permissive (low demandingness high responsiveness), neglectful (low demandingness low responsiveness), and authoritative (high demandingness, high responsiveness) 95 have shown to associated with child health outcomes. 93 Controlling feeding practices have shown to have a negative impact on child BMI 96 and diet quality 85,97 . A longitudinal, observational cohort study of parents and their children aged 6-11 years (n=699) was conducted as part of the Neighborhood Impact on Kids (NIK) Study. 96 NIK evaluated the association of home environment factors with child and parent weight and weight related behaviors. 96 The study surveyed the participants on home food environment factors including a pressure to eat, restrictive food practices, and a permissive food practices scale. 96 Child BMI z-scores were negatively associated with parental pressure to eat and positively associated with parental use of food restriction. 96 Educating parents on how to be less controlling around child feeding can be an effective method of childhood obesity prevention. Ethnicity and income may have an influence on how mothers feed their children. 98 One study found Hispanic mothers exhibited more restriction and pressure to eat when compared to White mothers. 98 Thus highlighting the importance of targeting mothers who are at higher risk of controlling feeding practices in efforts to prevent obesogenic home environments.

iii. Home food environment
Home food environment plays an important role in the diet quality of children. 49,99,100 The home food environment includes parental controlling feeding practices but, for the purposes of this literature review, it will be discussed as healthy food availability (i.e., fruits and vegetables).
Availability of fruits and vegetables at home can positively impact intake in children. 49 Neumark-Sztainer et al. 49 explored factors associated with fruit and vegetable intake among adolescents through the administration of surveys in Project Eating Among Teens (EAT). Adolescents from 31 middle and high schools (n=3,957) were included in the study. 49 The Project EAT surveys encompassed 221-items assessing 13 factors which were grouped into categories; socio-environmental personal factors and behavioral factors, associated with fruit and vegetable intake among adolescents. 49 Of the 13 factors availability of fruits and vegetables and taste preferences were considered to have a possible direct effect on fruit and vegetable intake (p<0.01). 49 In contrast to fruits and vegetables, availability of energy dense snacks and SSB can have negative impact on diet quality in children. 99 Consumption of energy dense, low-nutrient foods such as high-fat snacks, and SSB are major dietary factors that influence risk for overweight and obesity. 46,101 A significant source of added sugars come from SSB, which may lead to weight gain as they contribute to excess energy intake. One study found that SSB contributed almost 50% of added sugars in the diet of children and adolescents from all racial, ethnic, and income groups. 102 Sugar sweetened beverages include fruit juices, sodas, and energy drinks, and are the primary sources of added sugars in the diet across all racial and ethnic groups 102 , however, they are consumed in excess among Hispanic children. 103 Income and education also appear to be associated with the amount of added sugar consumed, with lower intakes in children among more educated parents. 104 Santiago-Torres et al. 99 evaluated the diet quality of Hispanic children to explore the influences of home food availability on children's overall diet quality.
This cross sectional study reported dietary intake through The Healthy Eating Index (HEI), a food frequency questionnaire given to students (n=187) at a charter school in Wisconsin. 99 SSB availability had a significant (p<0.05) association with reduction in children's HEI scores. 99 Parental intake of fruits and vegetables was positively associated with children's HEI total score. 99 Therefore, changing the home food environment has the ability to aid in effective intervention approaches. 49,96,99 iv.

Family meals
Family meal frequency has been shown to be inversely associated with BMI 40 and preventative toward childhood obesity. 105 Positive family and parental-interpersonal dynamics have been found to be associated with reduced risk of childhood obesity. 86 Berge et al. 86 explored the relationship between families with interpersonal dynamics during family meals and overweight and obesity in children. This 2-year mixed methods, cross-sectional study collected video recordings of family meals, qualitative interviews with the parents, and three 24hour dietary recalls of children and parents (n=120) from low-income and minority communities. 86 Results showed more positive measures (i.e., group enjoyment and warmth/nurture) were associated with reduced prevalence of childhood overweight and obesity whereas negative measures (i.e., hostility and inconsistent discipline) were associated with increased prevalence of childhood overweight and obesity. 86 Research has shown frequent family meals are associated with increased fruit and vegetable intake and healthy eating. 106,107 Using data obtained in Project EAT Neumark-Sztainer et al. 107 examined the association between family meal patterns and dietary intake during family meals in adolescents. Project EAT is previously described under obesogenic behaviors, parental behaviors and home food environment. 107 Frequency of family meals was measured using a questionnaire and dietary intake was assessed with the 149-item Youth and Adolescent Food Frequency Questionnaire. 107 Results showed that frequency of family meals was positively associated with fruit and vegetables, grains, and calcium-rich foods intake and negatively associated with soft drink intake. 107 These studies support that family meals are an essential component of childhood obesity prevention efforts. 86,107

III. Childhood Obesity Prevention Interventions
Although there have been several interventions to prevent obesity among low-income children and their families 108 The checklist asked parents to report frequency of 16-key behaviors on a 5-point Likert-type scale. 19 The study found significant within participant improvements in the overall behavior checklist score when comparing entry and exit data from the program. 19 The largest magnitude changes were seen in 1) improvement in child and adult low-fat dairy intake (P<0.001), 2) improvement in adult fruit and vegetable intake, 3) allowing children to decide on quantity of food to eat, and 4) reduction in availability of energy-dense snacks and fast food. 19  other. 115 The intervention led to improvements in BMI in addition to increases in knowledge score. Weight changes in parents were associated with weight changes in children (R 2 = 0.32 P = 0.01, highlighting the importance of addressing behavior change in parents to promote healthy behaviors in the children). 115 The study also found that 14.4% of adult participants were classified as obese at baseline, but were no longer obese at follow-up (p<0.001); of children participants 38.2% of children were considered obese at baseline, but were not obese at follow-up (p<0.001). 115

Effective Nutrition Education (process evaluation?)
Effective nutrition education is important to aid in childhood obesity prevention. One key aspect within nutrition programs is the appropriate use of educational materials, which may enhance or hinder a participants' understanding and learning experience. Growing Right Into Wellness (GROW) was an intervention designed to reduce childhood obesity through parent education materials. 116 This study conducted quality assessments for the modules of the GROW study. 116 Their systematic process was 1) expert review of core content and core materials, 2) material assessment that were graded using Suitability

Gathering Feedback from Target Population Prior to Intervention
Given the different ethnic populations which federal nutrition programs serve it is important that the curriculum used is appropriately tailored. 117 Most children outgrow their weight problems; 5) If I do not give my children the food they want they will refuse to eat therefore it is appropriate to give them any food they will eat; 6) It is difficult to get children to eat breakfast so it is appropriate to give them any food they will eat; and 7) Cordial (a beverage made from juice, sugar and water) is an appropriate way to encourage children to drink more instead of consuming soft drinks. 117 This information can be used when addressing sub-optimal parental beliefs about nutrition. 117 Although there may be common themes across different populations, it is important to gather information from the target population through interviews, introspections or focus groups.
With this information appropriate modifications can be made to existing programs. 117,118 In RI, EFNEP serves low-income families who are at risk for obesity.
Given the potential to tailor existing programs such as EFNEP, it is important to According to the participants, the RI-EFNEP curriculum may also benefit from including parenting skills and education on household routines to decrease obesity risk. 119 Therefore the goal of this project will be to pilot test a modified RI-EFNEP curriculum that incorporates education related to these behaviors. To better understand the scope of childhood obesity and the intervention and prevention efforts needed early in life among this high-risk population, this literature will describe the following areas: 1) The prevalence of childhood obesity and its consequences, 2) obesity-related (or obesogenic) behaviors (diet, ST and electronic media, PA, sleep, and parental behaviors), 3) the importance of effective nutrition education programs and, 4) current childhood obesity prevention and intervention efforts

V. Conclusion
Findings from this literature review emphasize the need to prevent childhood obesity through programs like RI-EFNEP given the high-risk population they serve. It is important to include the target population as part of formative research and include the appropriate findings from this work into nutrition education interventions. 118 Most intervention studies to date that include education components targeted at low-income populations found significant improvements in fruit and vegetable consumption 19 and decreases in BMI percentile. 113,115 Although some of these interventions have been successful in improving health behaviors among parents and children 19,113 , many did not include ethnically diverse parents participating in federal nutrition education programs in the New England area and they did not discuss details on their formative or process evaluation. As previously stated, the purpose of this study will be to explore the impact of a modified RI-EFNEP curriculum to improve parent and child health behaviors that have been associated with obesity. This mixed methods, quasi-experimental, pilot study will assess the modified RI-EFNEP curriculum in decreasing ST and increasing PA, fruit and vegetable intake, and improving feeding practices among parents and children. As part of implementing this pilot, detailed process evaluation measures will be collected in order to capture intervention fidelity and to explore individual sessions.

Consent for Participation THE UNIVERSITY OF RHODE ISLAND A Research Study Observing and Testing Rhode Island EFNEP Curriculum
You have been invited to take part in a research project described below. The researcher will explain the project to you in detail. You should feel free to ask questions. If you have more questions later, Alison Tovar, PhD, the person mainly responsible for this study, (401) 874-9855, will discuss them with you. You must be at least 18 years old to be in this research project.

Description of this project:
This curriculum has been designed to inform and gather feedback from parents/caretakers of young children. We are asking you to participate in lessons, fill out a pre and post survey, and questions after each lesson. Your input will help develop future EFNEP programs.

What will happen if I decide to participate in the study?
If you agree to participate in this study, the following will happen: 1. You will participate eight EFNEP lessons that equal one EFNEP curriculum. Each lesson is about an hour. Five to ten parents/caretakers will be asked to participate. 2. Your group discussions and activities will be observed and notes will be taken. Any information gathered will be stored securely at the University of Rhode Island in Ranger Hall room 305. 3. In order to maintain confidentiality, please do not discuss what you hear in this group with people outside this group in any way that might identify the people you met here.

4.
To further gather feedback about the curriculum you asked to participate in an informal focus group during the last class session.

What will happen if I decide to participate in a focus group?
If you agree to participate in this focus group, the following will happen: 1. You will participate in one focus group (a small informal group discussion) for about 15 minutes at the end of the last EFNEP class. You will be in a focus group with the other people in your class who wished to participate. You will discuss how you felt about the additional lessons about feeding your child, being active with your child, and how food advertisements affect your child.
2. Your group discussion will be audiotaped with a digital tape recorder. Notes also will be taken. The tapes will be used to provide additional detail to the notes.
Identifiers will be removed, so no one will be able to identify you personally or anything that you have said. Tapes will be retained for three years following the completion of the project and then destroyed. The tapes will be stored securely at the University of Rhode Island in Ranger Hall room 305.

Benefits or risks:
If you do decide to participate in this study, you will be helping research project staff to help develop programs to allow you to be a part of future nutrition education programs. There is minimal risk in participating.

Confidentiality:
Any information that is gathered from this study will be kept confidential-that is, no one else will know what was discussed or gathered. Notes will be retained for three years following the completion of the project and then destroyed. The notes will be stored at the University of Rhode Island in Ranger Hall room 305.

Right to quit at any time:
The decision to participate in this study is voluntary and is up to you. You can quit the study or focus group at any time, simply by telling us that you no longer want to participate. If you decide not to participate in this study or leave during the focus group, nothing will happen and you will still be eligible for any services to which you are entitled.

APPENDIX C: LESSON PLANS AND HANDOUTS
Included in this section are the feeding your child, physical activity and screen time, and media literacy/food advertisements lessons, the corresponding handouts (screen shots) and background information, goal setting handouts (screen shots) and background information, and lesson materials and posters (screen shots).

Feeding Your Child Text in italics is what you explain to participants
Goals: Parents will improve their confidence when feeding their child around mealtimes.
Objectives: Parents will discuss why feeding their child may be difficult. Parents will identify possible ways to help make feeding their children easier.
Key Messages 1) Be a role model 2) Patience works better than pressure 3) Eat together 4) Create a healthy food home Handouts 1) Child feeding tips INTRODUCTION (30 seconds-1 minute) Introduce the lesson to the class. An example of what to say: "Hello class! In today's lesson we will be learning and discussing the topic feeding your children."

ANCHOR (5 minutes)
Family mealtimes are a great place to bond with your children. It's a place that you get to comfortably speak with your children and spend quality time with them.

Find a partner and discuss some of your favorite moments when feeding your children. Would anyone like to share with the class?
ADD (6 minutes) Reference the 4 feeding practices posters: 1) Create a healthy food home, 2) You are a role model, 3) Eat together, and 4) Patience works better than pressure.
How parents feed their children can help keep them healthy. Sometimes parents think that by restricting or controlling certain foods that they are helping their children be healthy but we know that this does not really work because children end up wanting to eat the "forbidden" foods more, and meal times become a battleground instead of a place to enjoy food and time together. Children are really good at knowing when they are hungry and when they are full. As a parent, it is important to let them decide how much to eat; let them listen to their tummies. As a parent you should decide WHAT is going to be served and your child can decide HOW MUCH to eat. Remember that parents are the ones who do the grocery shopping, so it is their responsibility to provide the healthy options. Keeping this in mind, we will now discuss some things you can do to help provide healthy food for your children.

Feeding Your Children Background Information
Parents have a strong influence on children's food intake because they control the availability of foods, family meal routines, and household rules. They determine when eating occurs, the extent to which feeding occurs in response to hunger, the context in which eating occurs, and the foods and portions that are available. Key strategies for effective parenting around mealtimes focuses on being a role model, not pressuring children to eat, creating a healthy food environment, and offering healthy choices.
When feeding children, new healthy foods should be encouraged, and parents may have to offer them many times. For example: children may refuse new healthy foods, act out about the taste of new healthy foods, etc. Parents will have to offer new healthy foods many times. Getting kids involved in food is a way to get them excited about eating healthfully. Parents can have their kids help them in the kitchen or have them help shop for groceries. Children can help select fruit or vegetables for the week. Children can help in the kitchen by wiping down counters, cleaning fruit or vegetables, opening jars, etc.
Children tend to be very good at determining how much food to eat. Let the child decide when and how much food to eat. Offer healthy choices, and then let your child determine what he/she would like to eat. Remember that parents control what is going to be served, but the child should determine how much to eat. When children act out or refuse to eat, it may be a sign of the child wanting attention. It is important for parents to respect their child and make them feel good about themselves. To get kids to try new fruit or vegetables, have them pick a new fruit or vegetable in the grocery store to try. Remember, meals shouldn't be a struggle. Make mealtimes positive. Meals can be a great time for you to enjoy your time with your family.
Trust the child's appetite. Parents can help preserve their children's innate ability to self-regulate or restore it if has diminished already. The dinner table can become the happiest spot in your house, children will to be there and are happy to be included in family meals. Meals can also be a time for parents to ask their children about things that happened during the day; non-meal related.
To get kids to eat more fruit and vegetables, parents can offer them as snacks. Kids may be afraid to eat whole fruit or vegetables. One solution is to cut them up ahead of time and serve them with dip. Have them ready when the children come home from school or childcare. Children like C.A.N. foods (Convenient, Attractive, and Normal). Fruit and vegetables that are cut up and ready to eat are Convenient. Colorful fruit and vegetables are Attractive. If parents act as role models and eat their fruit and veggies too, the children will see that it is Normal.
Childhood is a critical age for feeding. Children will develop habits that may follow them throughout their lifetime, so it is important for parents to help guide their children to make healthy choices at a young age.

Physical Activity and Screen-time Text in italics is what you explain to participants
Goals -Increase weekly hours of family physical activity.
-Decrease daily family screen-time.
Objectives -Parents will suggest an activity that can be used in place of screen-time.
-Parents will set one goal in order to increase family physical activity.
Key Messages 1) Be active every day 2) Limit screen time Handouts 1) Ideas for activities to do as a family Other Materials 1) Charades cards 2) Physical activity and screen time poster 3) Which one of these benefits of being active is important to you?
INTRODUCTION (30 seconds-1 minute) Introduce the lesson to the class. An example of what to say: "Hello class! In today's lesson we will be learning and discussing the topic being active with your children." ANCHOR (4 minutes) Being active is something that helps keep us healthy and maintain our weight. It helps you feel better, makes you smarter, sleep better, and can help make you happier. Children that are active get better grades in school.

Find a partner and discuss some daily activities you like to do to stay active. Discuss some things your kids do to stay active too! Remember, being active is any type of movement. Would anyone like to share with the group?
Write them down on the board.

ADD (5 minutes)
Refer to the poster about physical activity and screen time. Now we will discuss some ways to help you and your children stay and play actively. 1 1) I will make sure the TV is off during mealtimes.
2) I will encourage my child to play rather than watch TV after school.
3) I will play a game outside with my children at least once this week. 4) I will make a rule to limit screen time for my child

Physical Activity and Screen Time Background Information
Being active every day is good for your health and can protect against many diseases, such as diabetes, heart disease, and cancer. It is recommended that children and adults be active every day. Being active doesn't just include exercise, it can include outdoor play and recreational activities too.
Screen time goes along with physical activity because time spent watching TV, playing video games, or playing on the computer, tablet, and phone can be better spent being active. It is recommended that children do some type of physical activity for 1 hour each day.
Physical activity helps control weight, builds lean muscle, reduces fat, promotes strong bone and joint development, improves academic performance, and decreases the risk of obesity. Children need 1 hour of play or physical activity every day to grow up to a healthy weight. Only about a third of children are meeting the recommendations. Parents can help their child stay active. Below are some examples: -Be a role model by leading an active lifestyle yourself.
-Make physical activity part of your family's daily routine by taking family walks or playing active games together. -Take young people to places where they can be active, such as public parks, community baseball fields or basketball courts. -Be positive about the physical activities in which your child participates and encourage them to be interested in new activities. -Make physical activity fun. Fun activities can be anything your child enjoys, either structured or non-structured. Activities can range from team sports or individual sports to recreational activities such as walking, running, skating, bicycling, swimming, playground activities or free-time play. -Instead of watching television after dinner, encourage your child to find fun activities to do on their own or with friends and family, such as walking, playing tag or riding bikes. Because screen time and physical activity are related, it's important to discuss how to reduce screen time. Too much screen time can make it difficult for your child to sleep at night, can raise your child's risk of attention problems, anxiety, and depression, and can cause weight gain due to a lack of physical activity. Incredibly, children are spending upwards of 7 hours a day using some type of screen. It is recommended that parents limit children's screen time to 2 hours or less per day except for homework.
Some ways to limit screen time are • Remove the TV from bedrooms • Shut of the TV during meals • Set rules around screen time (and enforce them).
Parents are role models and can help reduce their child's screen time by also reducing theirs.

Food Advertisements and Media Literacy Text in italics is what you explain to participants
Goal -Improve parents' media awareness around unhealthy food advertisements.
Objectives -Parents' will discuss ways in which food is advertised in order for them to become aware of unhealthy food marketing.

Handout 1) Facts about TV
Other Materials: 1) 2 media literacy posters 2) Bag of food advertisements INTRODUCTION (30 seconds-1 minute) Introduce the lesson to the class. An example of what to say: "Hello class! In today's lesson we will be learning and discussing the topic how food advertisements influence your children's health." ANCHOR (5 minutes) Advertisements try and get people to buy certain products. Billions of dollars are spent on food advertising and consumers help pay for this by buying those foods. Famous brands cost more than store brands that are not advertised. Most people are likely to buy foods in fancy, eye-catching packages. Find a partner and discuss the following questions.

ADD I (5 minutes)
Food advertising is very important when thinking about your children because most children under the age of 6 cannot tell the difference between TV shows and TV commercials. Children can recognize brands after just a single food advertisement. Most ads targeted to children are for unhealthy foods. Think about what we discussed a few minutes ago; who noticed that the food your child requests is because of a TV commercial? Companies often use popular cartoon characters to advertise foods to children, which makes it even more difficult for children to tell the difference between a TV show and commercial.
During a single hour of TV, children see an average of 11 food commercials. All these commercials make children choose and ask for more unhealthy foods. Children who watch more TV drink more soda and more fast food. This is one reason why the more time children spend watching TV, the more weight they might put on.

APPLY I (8 minutes)
Companies are not allowed to advertise tobacco to kids. Some people think that food companies should not be allowed to advertise junk foods to kids.
With a partner, discuss your thoughts on this. Do you think food companies should be allowed to advertise unhealthy foods to kids? Why or why not? Would anyone like to share?
Keep the group in pairs and give each group a couple of food ads. Have them discuss how the ad makes them feel and if they are interested in the product. Ask the following questions: (Use the poster with the 5 questions as a visual aid for participants.) 5  After some time has passed and the groups seem to be finished discussing amongst themselves, ask

Let's highlight two ads. Who would like to share?
Facilitator will lead the group through discussing both ads, one at a time.

Does any group have an ad for fruits or vegetables?
Fruit and vegetable growers do not have as much money to advertise as big foods companies, that's why we don't see ads for fresh fruit and vegetables.

ADD II (2 minutes)
It is important to help your children understand food advertisements. To do this, parents can talk to their children about food advertisements. Letting your child know why something was advertised may help him/her make healthy choices easier. Use your goal setting form to write down a goal. You can make up your own or use one of the ones provided.

With a partner discuss what you would do when your child asks for
1) I will pay more attention to the way foods are advertised in the supermarket. 2) During TV commercials, I will mute the television.
3) I will pay more attention to what foods are advertised on TV.

Media Literacy Background Information
Television food advertising is one of the most influential factors affecting children's food choices and patterns. Children under the age of 6 cannot tell the difference between the TV show and advertisements. Children can even begin to recognize brands after a single advertisement. Children ages 2 -17 see many advertisements on television each day ranging from an average of 38 ads to 79 ads per day. On average, children ages 2 -17 years see between 12 -21 food advertisements per day. Children do not always understand the intent of food advertising, therefore, they easily believe the information provided in advertisements. Interestingly, half of all TV advertisements children see are for food and most advertisements are for unhealthy food. Provided is the breakdown of food advertisements: -34% for candy and snacks -29% for sugary cereal -10% for fast-food -4% for dairy products -1% for fruit juices/juice cocktails -NONE for fresh fruit or vegetables The way foods are marketed to children should be noted. Most food ads target children using appeals of taste or fun. Only 2% of food ads to children use the appeal of health or nutrition. In addition, children see little about nutrition or physical activity on TV. Children see, on average, only 1 ad regarding nutrition or physical activity every 2 -7 days. Advertising using cartoon characters or celebrities is a strategy used by many companies to market to children. In addition, many companies use toys to market to children (e.g. prizes in cereal boxes, a toy included with children's meals). Children frequently request that their parents buy specific foods that they remembered from certain advertisements. On top of this, when children see more food advertisements, they request specific foods more often.
Exposure to food advertisements affects the amount children eat. Children who watch more TV, drink more soft drinks and eat more fastfood than children who watch less TV.
On a typical day, a child between 2 -8 years will see: -5 ads for candy and snacks

Goal Setting Background Information
Goal setting is a key part of behavior change. It is important to actually write down goals and track progress. When developing goals, remember that they should always be SMART.
Specific: goals must identify exactly what you want to accomplish (I will walk for 15 minutes for 5 days this week). Measurable: you should be able to objectively measure the goal (e.g. I will walk for 15 minutes for 5 days this week).
Achievable/Attainable: goals need to be realistic. Keep them simple.
Relevant: make sure that the goal matters to the person making the goal. This can best be done by letting them choose their own goals.
Time-bound/Timely: the goal should indicate when you want the goal to be accomplished (e.g. I will walk for 15 minutes for 5 days this week).
Each week, there will be example goals that participants can choose from; they can also make their own. Remember, if they make their own goal, please help them create a goal that is SMART.
Each goal should focus on ONE behavior. For example: "This week, I will have my children select two new fresh fruits to try." A goal with two behaviors would look like this "This week, I will have my children select two new fresh fruits to try and I will walk for 15 minutes each day." Goals with two behaviors become challenging. It is much easier when you focus on one.
Because participants are goal setting each week, it would be helpful to ask them how they are doing with their goals. Give positive feedback and encourage participants. If they are struggling with a goal, help them through it; possibly give them some ideas to overcome the challenges they may be having.

Media Literacy/Food Advertisement lesson materials
Also used in this lesson but not included in the appendix are the child geared advertisement examples on yogurt cups, macaroni and cheese boxes, cereal boxes, gummy snacks, and soup cans.

2.
______Discussed how restricting foods is not a good feeding strategy. 3.
______Discussed children's ability to know when they are full, and how much to eat. 4. ______Discussed that parents are in charge of what is brought into the home 5.
_______Discussed how parents can provide healthy options for their children. Create a healthy food home 5.
______Discussed that children often like having convenient foods. 6.
______Provided examples of having fruits and vegetables in reach within their homes. 7.
______Discussed ways to make fruits and vegetables easier to eat like having veggies and fruit already cut up ready 8.
______Reiterated that parents are in-charge of what food comes into the home. 9.
______Discussed the importance of involving children in food preparation (i.e-cooking) You are a role model 10.
______ Introduced the concept that children learn from their parents. (Parents are a role model). 11.
______ Emphasized that showing healthy behaviors and not telling children has more impact Eat together 12.
______Discussed how to enjoy family meals with their children. 13.
______Discussed that they should try and eat together as often as they can 14.
______Discussed allowing little ones to select foods to put on their plates. 16.
______Reiterated allowing children to choose how much of healthy foods to eat. 17. ______Emphasized making meal time family time. 18. ______Facilitated a show of hands on how many participants already have regular family meals? Patience works better then pressure 19.
______Discussed that children should choose how much to eat. 20.
______Discussed that children are more likely to choose healthy foods when it is their choice. 21.
______Discussed that being patient is important because sometimes learning to like a new foods take time. 22.
______Provided the example that sometimes you must offer new fruits and vegetables many times and in different ways before they start liking it. 23.
______Discussed the importance of offering healthy choices so children feel they are making their own decision. Additional observations about fidelity and participant observation: