Digital Repository Doctoral Projects Fall 2021 Implementation of an Elementary School-Based Nutrition and Healthy Eating Curriculum Justin Robbins Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Robbins, J. (2021) Implementation of an Elementary School-Based Nutrition and Healthy Eating Curriculum Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Implementation of an Elementary School-Based Nutrition and Healthy Eating Curriculum by Justin Robbins A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 12, 2021 Mary Anne Hales Reynolds PhD, ARN, ACNS-BC_(signature) Faculty Advisor/Committee Chair Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director Running head: EDUCATION AND HEALTHY EATING 1 Implementation of an Elementary School-Based Nutrition and Healthy Eating Curriculum Justin Robbins Annie Taylor Dee School of Nursing Weber State University November 29, 2021 EDUCATION AND HEALTHY EATING 2 Abstract Proper nutrition is a key component that can significantly improve children's overall health. Many elementary schools do not include adequate nutrition education in their curricula. This Doctor of Nursing Practice (DNP) project implemented a nutritional curriculum for fifth graders to develop foundational knowledge and gain experience in choosing essential nutrition options to promote healthy eating behaviors and improve well-being. Fourteen nutrition lessons focusing on nutrition core standards from the Utah Education Network were delivered to 93 5th-grade elementary school students. Lessons taught the importance of consuming fruits and vegetables, avoiding sugar-sweetened beverages, avoiding nutrient-poor energy-dense foods, and applying practical healthy eating strategies. Project assessment included student attendance and participation in each lesson, pre-and post-test questionnaires, weekly interactive quizzes, and comments gathered from students and educators. Lessons had a 94% attendance rate, with an average post-lesson completion rate of 97%. Pre- and post-assessment quiz mean scores improved by 27%. 89% of students liked the nutrition lessons and 91% answered they would improve their food choices because of the lessons. Students’ comments on what they learned included statements about choosing healthier food options, MyPlate, and Utah agriculture. A nutritional curriculum specific to elementary-aged school children leads to increased knowledge and gained experience in choosing essential nutrition to promote well-being and the prevention of diseases. A DNP-FNP is crucial at promoting health and wellness and can serve as a resource for nutrition education that may improve community health outcomes. Keywords: elementary school nutrition, childhood obesity, MyPlate, education EDUCATION AND HEALTHY EATING 3 Implementation of an Elementary School-Based Nutrition and Healthy Eating Curriculum According to the World Health Organization (2020a), a healthy child can be defined as a child in a state of physical, mental, intellectual, social, and emotional well-being. The Centers for Disease Control (CDC, 2019a) approximates that 18.5% of children ages 2-19 are obese in the United States. Childhood obesity is closely linked to poor nutrition and unhealthy eating habits (Styne et al., 2017). Additionally, poor nutrition impacts the overall well-being and normal development and growth of children. The number of schools that provide education regarding healthy eating is declining, which increases the risk of developing health complications, such as obesity (CDC, 2019b). The Utah Department of Health (2018) states that the prevalence of obese children in Southern Utah is at 10%. The presence of obesity reflects a need for education about nutrition and healthy eating. Furthermore, the prevalence of adult obesity in Utah is 28.4% demonstrating that there continues to be a large gap of care between childhood and adult health interventions, with nutrition education being a vital component (Utah Department of Health, 2019). This DNP project implemented a nutritional curriculum at Iron Springs Elementary to improve healthy eating habits and decrease adverse health complications, such as childhood obesity. Childhood obesity is an important concern and can reflect a poor understanding of nutrition and healthy eating, especially in elementary school-age children in Cedar City, Utah. In addition to poor growth and development, unhealthy eating is associated with other health consequences, such as an increased risk of developing heart disease, stroke, iron deficiency, osteoporosis, certain cancers, brain function deficits, and obesity (CDC, 2020b; Styne et al., 2017). Furthermore, pediatric obesity specifically can lead to multiple health-related complications as a child, such as elevated blood pressure, high cholesterol, type 2 diabetes, EDUCATION AND HEALTHY EATING 4 asthma, sleep apnea, osteoarthritis, fatty liver disease, and gallstones (CDC, 2016). These complications persist into adulthood if left untreated. By implementing a nutrition education program at Iron Springs Elementary, fifth-grade students learned proper nutrition and healthy eating behaviors leading to improved health outcomes. Search A web search was conducted using several internet databases that included PUBMED; MEDLINE; the Cochrane Central Register of Controlled Trials (CENTRAL); PsycINFO; ERIC; ScienceDirect; A + education: and Google Scholar. Using Boolean operator and applying keywords such as "pediatric", "obesity", "overweight children", "pediatric nutrition", "healthy eating", "pediatric diet", "exercise", "elementary-aged children", "nutritional curricula", "pediatric education", and "child learning" guided the search and were limited to peer-reviewed articles only. The research surrounding childhood obesity provided the most comprehensive information related to healthy eating. Literature Review: Nutrition and Health Outcomes in Children Definition of Children A child is a young person between infancy and puberty (Child, n.d.). The United States Department of Health and Human Services (2003) defines infancy as between birth and two years of age; childhood as 2 to 12 years of age; and adolescence 12 to 21 years of age. For the context of this DNP project, the elementary school-aged child is between the ages of 6 to 12 years old. School-aged children demonstrate a variety of physical, socioemotional, and cognitive milestones based on different age groups. Physical development in school-age children includes smooth and strong motor skills with various coordination, endurance, balance, and physical EDUCATION AND HEALTHY EATING 5 abilities per age (National Institutes of Health, 2020). Gross motor skills for a kindergartner include starting to move in coordinated ways, such as walking on their tiptoes, hopping on each foot, and beginning to jump rope (Hagan et al., 2017; Morin, 2020a). The fifth grader's physical development includes fine motor skills with advanced and coordinated movements like dribbling and shooting a basketball and signs of puberty beginning (Hagan et al., 2017; Morin, 2020b). Social and emotional milestones for kindergartners include wanting to act like their friends, beginning to understand sharing, and seeking attention that may result in tantrums if they are not listened to (Hagan et al., 2017; Morin, 2020a). Fifth graders are often insecure about their bodies due to the effects of puberty, want to become more independent, value friends' opinions and struggle with peer pressure and self-esteem, and may try out new styles (Hagan et al., 2017; Morin, 2020b). In kindergarten, cognitive milestones include understanding right and wrong, naming colors, shapes, letters, beginning to read, and can dedicate 15 minutes to a project (Hagan et al., 2017; Morin, 2020a). Fifth graders' cognitive milestones include abstract thinking, predicting the consequences of an action, forming a plan, relying on friends and other sources for information, developing a sense of responsibility and understanding how things are connected (Hagan et al., 2017; Morin, 2020b). For children to meet critical developmental milestones, it is important to have proper nutrition. Healthy Eating Adequate nutrition is vital for life processes, especially for the school-aged child, and depends not only on how much is eaten but also on the quality of nutrients (Hagan et al., 2017). Energy comes through three main macronutrients and various micronutrients. Macronutrients include proteins, fats, and carbohydrates, while micronutrients include vitamins, minerals, and EDUCATION AND HEALTHY EATING 6 trace elements. Furthermore, there is a recommended percentage of each macronutrient and micronutrient that children should consume. For example, for children between the ages of nine to thirteen, the daily portion of proteins should be 10-30%, fats at 25-30%, and carbohydrates at 45-65% (Dietary Guidelines Advisory Committee, 2015). Childhood diets must consist of healthy foods, and eating calorie-dense nutrient-void food is a detrimental habit (Hagan et al., 2017). According to the Dietary Guidelines Advisory Committee (2015), the total calories per day for children ages five to twelve are 1200-1800. Meals should consist of fruits and vegetables, whole grains, dairy products that are fat-free or low-fat, certain oils, and various protein-rich food for caloric intake. Furthermore, there must also be an emphasis on avoiding calories from solid fats, added sugars, and sodium reduction. There are recommendations on how many calories children should consume per their activity level. The Dietary Guidelines Advisory Committee (2015) recommends that moderately active six-year-olds daily caloric need ranges from 1,400-1,600. However, for thirteen-year-olds, the daily caloric need increases to 2,000-2,200. Therefore, caloric intake must be assessed to determine if a child exceeds the recommended daily caloric intake based on their age and activity level. It is essential to balance caloric intake and energy expenditure with consideration of what foods children consume. Poor Nutrition According to the Council on School Health and Committee on Nutrition (2015), nutrient-poor, energy-dense food and drinks make up 30% to 40% of children and adolescents' daily caloric intake. Likewise, a cross-sectional survey by Reedy and Krebs-Smith (2010) found that added sugars and solid fats accounted for 40% of daily calories in children under the age of 18. The main contributors to high-calorie, low-nutrient food and beverages included soda, fruit EDUCATION AND HEALTHY EATING 7 drinks, dairy and grain desserts, pizza, and whole milk. Over one-third of children consume fast food on a given day, accounting for 12.4% of their daily caloric consumption (CDC, 2015a). Though fast-food consumption may contribute to increased caloric intake and weight gain, it may also signal unhealthy behaviors and poor diets at home (Potti, Duffey, & Popkin, 2014; Rosenheck, 2008). Excessive caloric intake without proper expenditure is thought to be a leading cause of obesity in children (Sahoo et al., 2015). A reduction in fast foods, sugar-sweetened beverages, high-fat, high-sodium food, and portion control can help improve a child's well-being (Styne et al., 2017). During a one-year trial among obese children who exercised and followed a diet with appropriate caloric intake, there was a reduction in body mass index (BMI), triglycerides, decreased insulin resistance, and an increase in HDL cholesterol (Verduci et al., 2015). In a study among children ages eight to twelve years old, increasing fruits and vegetables and consuming low-fat dairy products were associated with improved outcomes than the intervention of reducing high energy-dense foods alone (Epstein, Paluch, Beecher, & Roemmich, 2018). Healthy eating interventions reduce high-calorie nutrient-poor food and beverages to be replaced with nutrient-rich alternatives. Additionally, learning healthy eating patterns while in childhood will result in healthy eating patterns throughout the lifespan (Movassagh et al., 2017). Assessment Related Nutritional Status Nutritional status and eating behaviors can be evaluated in multiple ways to assess poor nutrition or excessive caloric intake. Obesity in childhood is often used as an indicator of poor nutrition and unhealthy eating. For children over the age of two until adulthood, obesity is defined by an excess body mass index (BMI) to other children's age and sex (CDC, 2018). BMI is calculated using the child's weight in kilograms and dividing by their height in meters squared EDUCATION AND HEALTHY EATING 8 (kg/m2). A normal or healthy BMI for children is between the 5th percentile to less than the 85th percentile (CDC, 2018). Children in the 85th to 95th percentile are considered overweight, while those above the 95th percentile are considered obese (CDC, 2018). Many online tools are available to calculate BMI and are useful for the clinician to determine when a child is classified as overweight or obese (Grossman et al., 2017). Datar, Shier, and Sturm (2011) found that the most substantial BMI gains, even among children with healthy BMI, were between the first and third grades. However, influencing behavioral patterns after the sixth grade is met with increased resistance, making it hard to perform interventions targeting a BMI reduction (Kandiah & Jones, 2010). Therefore, educating children before age 12 about proper nutrition and healthy eating may lead to improved outcomes, such as lower BMI. The development of obesity, especially in childhood, is complex, and it is important to evaluate nutrition, activity levels, socioeconomic factors, and genetic disposition (Styne et al., 2017). Asking about dietary habits through comprehensive history taking, which often is assessed through self-reported questionnaires and direct visual observation of what foods are consumed, may also be performed (Braet et al., 2014; Murphy et al., 2019). Other self-reported histories include familial obesity, inadequate physical activity levels, insufficient sleep patterns, low family income levels, and ethnic status (O'Connor et al., 2017). These screenings are meant to identify malnutrition, which can have many definitions. For example, malnutrition can signify undernutrition, the inadequate intake of vitamins and minerals, or excessive caloric intake, leading to obesity (WHO, 2020b). Other assessment tools include looking for growth stunting, overweight/underweight status, and the presence of dental caries (Rezaeian et al., 2014). Social inequities contribute to poor nutrition. Poverty is one socioeconomic factor that influences nutrition, and healthy foods are often associated with higher costs and decreased EDUCATION AND HEALTHY EATING 9 availability (Adamkiewicz et al., 2014; Maillot, Darmon, Vieux, & Drewnowski, 2007). Living below the poverty threshold is associated with eating an increased energy-dense diet due to the lower cost (Alkerwi et al., 2015; Drewnowski & Darmon, 2005). Conversely, higher-quality diets are associated with increased socioeconomic status (Darmon & Drewnowski, 2008). Because energy-dense nutrient-void foods are inexpensive, they are bought frequently. However, energy-dense nutrient-void food has less satiety, which leads to overeating displacing the chances of children consuming healthier food alternatives. Furthermore, a longitudinal study by Min, Xue, and Wang (2018) examined 16,800 children for eight years and found that recurrently poor households had the highest portion of excessive soda/fast food consumption. Therefore, special consideration should be given to children who live below the poverty threshold. Physical activity can involve different exercises, such as aerobic activity, muscle-strengthening, and bone-strengthening movements. Regular physical activity in children has many immediate benefits and can reduce the risk of developing heart disease, type 2 diabetes, cancer, osteoporosis, and obesity (Physical Activity Guidelines Advisory Committee, 2018). High levels of inactivity are negatively associated with decreased healthy eating and poor health outcomes such as obesity (Hong et al., 2016). Increased screen time is associated with reduced movement, increased consumption of high-calorie low-nutrient foods and beverages, and reduced sleep duration (Robinson et al., 2017). Children should be encouraged to be active, avoid a sedentary lifestyle, and replace negative habits with healthy alternatives. Consequences There are physical, psychological, academic, and financial consequences of poor nutrition. The most significant complications of poor nutrition are in conjunction with those who become overweight or obese. Obese children are at increased risk of developing elevated blood EDUCATION AND HEALTHY EATING 10 pressure, elevated cholesterol, type 2 diabetes, respiratory problems such as asthma and sleep apnea, musculoskeletal issues such as osteoarthritis, fatty liver disease, and gallstones (CDC, 2016; CDC, 2020b). When childhood obesity is left untreated, there are increased disparities that persist into adulthood. Simmonds et al. (2016) performed a meta-analysis analyzing obese children into adulthood. Among the 128,121 participants studied, 80% of obese adolescents were still obese in adulthood, and 70% were still obese after age 30. Obesity in adulthood further raises the risk of many cardiovascular diseases, diabetes, musculoskeletal problems, and even some cancers (World Health Organization, 2020b). In schoolchildren, the cardiometabolic risk factors increased with overweight or obese status (Wheelock et al., 2017). Specifically, as BMI increased, so did impaired fasting glucose tolerance, impaired glucose tolerance, and type 2 diabetes, which continues into adulthood. Among adolescent females, anxiety and depression symptoms were associated with higher BMI and body fat (Hillman, Dorn, & Huang, 2010). Obese children were more likely to internalize and externalize problems (Halfon, Larson, & Slusser, 2013). Among 182 second-grade students, those who were obese were teased three times more than their peers (Halasi et al., 2018). Weight-based victimization was also a shared concern among parents, especially those who have children who are obese or overweight (Puhl, Luedicke, & DePierre, 2013). These psychological consequences can lead to lower quality of life, increased anxiety, social isolation, and depression into adulthood (Rankin et al., 2016). Aside from physical and psychological effects, there may be academic repercussions of poor nutrition. Poor nutrition is linked to less fitness and worse academic performance (Powell & Greenberg, 2019). Fitness among children has been linked to more significant academic EDUCATION AND HEALTHY EATING 11 achievements, increased cognition, and parents' behavioral ratings (Davis & Cooper, 2011). These outcomes included test scores, internalizing behavior problems, school absences, and grade repetition. However, when considering other socioeconomic factors, weight may not be the causal factor (Datar, Sturm, & Magnabosco, 2004). Conversely, healthy dietary and nutritional status is positively associated with improved academic performance (Al-Saadi, Ali, Waly, & Al-Zuhaibi, 2020). In a longitudinal study analyzing educational success and adult health, educational attainment in grades as early as preschool had positive health-related outcomes in early adulthood (Topitzes et al., 2009). Therefore, healthy eating may lead to improved academic performance. Obesity contributes to healthcare costs. When accounting for annual prescriptions, emergency room visits, and outpatient costs, obese children's direct costs are estimated to be $14.1 billion annually (Trasande & Chatterjee, 2009). The financial cost of obesity and its associated diseases are substantial if obesity continues into adulthood, costing the United States healthcare system $147 billion annually (CDC, 2020b). Waters and Graf (2018) give a higher estimate of the cost of chronic conditions associated with obesity. In 2016, they stated diseases related to obesity and being overweight accounted for $480.7 billion in direct health care costs, plus $1.24 trillion in indirect costs. In a retrospective longitudinal cohort study by Ramasamy et al. (2019), those with obesity had 1.40 to 5.26-times higher odds of being among the 20% paying the highest amount in healthcare costs. These direct and indirect costs are for the adult population, and when proper steps are taken to improve healthy eating and decrease obesity in children, they may be significantly reduced. There are many barriers to addressing healthy eating for primary care providers. Informational learning about nutrition and healthy eating for children not only can come from EDUCATION AND HEALTHY EATING 12 healthcare providers, but it can also be taught from the home, and in school. The single most significant factor in healthy eating is the lack of education. Learning about good nutrition and healthy heating behaviors begins in the home. In a cross-sectional survey, barriers common to parents of obese children included inadequate information about healthy eating, insufficient knowledge on promoting physical activity in their children, and lack of access to healthy food options or appropriate locations for physical activity (Shahsanai et al., 2019). Nepper and Chai (2016) explored barriers that parents experienced in developing a healthy diet at home. Parents of obese children and parents of healthy-weight children shared similarities, such as time constraints, cost of healthy food, children who were 'picky' eaters, and exposure to unhealthy food. However, if a child did not have two supportive parents, there was an increase in weight gain. Implementing a healthy diet in children involves a team effort, and without appropriate support, it is difficult for parents to increase the healthy eating behaviors of their children. A primary source of nutrition information is healthcare providers. Healthcare providers recognize the importance of providing nutrition advice but often do not deliver material-specific to their patients (Adamski, Gibson, Leech, & Truby 2018). Many providers express inadequacies in providing nutrition care to their patients (Mogre, Aryee, Stevens, & Scherpbier, 2017). A meta-synthesis by Bradbury et al. (2018) examined the barriers healthcare providers faced when discussing the obese weight of their pediatric patients. Topics included issues relating to their knowledge deficit of nutrition as a provider, the sense of futility, complicated family situations, fear of parent reactions, few contact opportunities, limited resources, the normalization of overweight, and a poor economic environment. These themes reflect the complexity of treating pediatric patients, often involving many components rather than just the disease itself. Healthcare EDUCATION AND HEALTHY EATING 13 providers should be aware of all factors that influence pediatric obesity, especially healthy eating. Nutrition Education Nutrition education is addressed at national and local levels. The Healthy, Hunger-Free Kids Act (HHFKA) of 2010 was one policy implemented to improve the quality of food and drinks provided to school-aged children in the United States by providing federal assistance to those who qualify (U.S. Department of Agriculture, 2013). While giving kids healthy food is one step, kids must learn healthy eating habits and proper food choices, especially in an educational setting. Although the Department of Education recommends nutritional education in schools, a specific curriculum cannot be mandated (Moats & Olson, 2013). Elementary schools provide an environment where children can learn essential nutritional development topics, but it requires proactive educators. In 2014, only 68.9% of elementary schools received instruction on nutrition and dietary behavior (CDC, 2015b). Those students who received nutrition education received less than eight hours each year (CDC, 2019b). According to an ethnographic study involving elementary-aged children, children wanted to practice more nutritional awareness by developing health skills; however, they relied on teachers and parents to guide them (Velardo & Drummond, 2019). Furthermore, they viewed educators as models for healthy habits. Without proper instruction and role modeling, children may be at more risk for developing unhealthy habits. The school environment provides children with many learning opportunities and can incorporate nutritional concepts that would otherwise be impossible in a primary clinic due to time constraints. Implementing a school nutritional curriculum can improve knowledge about proper dietary guidelines. Fifth graders, who received just nine hours of nutrition education EDUCATION AND HEALTHY EATING 14 program while in school, improved nutritional expertise compared to their peers who received no curriculum (Kandiah & Jones, 2010). Likewise, fourth-graders, who received a nutritional curriculum in school, reported improved healthy eating behaviors than those with no curriculum (Qian, Newman, Yuen, Du, & Shell, 2019). Children that were actively engaged in a nutritional curriculum at school and included their parents with educational content demonstrated increased healthy behaviors (Murimi et al., 2018). Herbert et al. (2013) performed a quasi-experimental study using kinesthetic learning that increased vegetable intake and decreased French fries and potato chips' consumption in third and fourth graders. Interventions that improved school curricula involved components of educating students, parents, and teachers about increasing healthy food consumption and incorporation of a variety of learning activities, such as games, puzzles, and other hands-on activities (Herbert et al., 2013; Kandiah & Jones, 2010; Murimi et al., 2018; Qian et al., 2019). A curriculum focusing on nutrition should engage elementary-aged children and parents and educators to become empowered and active learners in healthy behaviors. As children are in school anywhere from four to six hours a day, this time can incorporate foundational dietary principles. Wang et al. (2015 found that obesity prevention measures had moderate success at improving diet and physical activity. A nutritional curriculum must be presented in a certain way to be successful. Murimi et al. (2018) found that interventions that were less than six months in duration, or had more than two-week intervals between sessions, or interventions delivered through a single educational method were less likely to succeed. Elementary school teachers face many challenges relating to educating children about good nutrition and healthy eating. While it is expected to provide nutritional curricula to students, many have expressed limited nutrition education (Perera et al., 2015). The lack of knowledge in EDUCATION AND HEALTHY EATING 15 nutrition can lead to uncertainty in preparing a proper curriculum to meet students' needs and achieve desired outcomes (Murimi et al., 2018). Another barrier identified was the lack of classroom time. After surveying 102 teachers, Jones and Zidenberg-Cherr (2015) found that 54% of respondents stated a significant reason nutrition education did not happen was because of insufficient time. Other barriers identified included completing academic expectations and a lack of suitable curricula (Perera et al., 2015; Stage et al., 2016). These barriers present real problems that educators face in implementing a successful nutritional curriculum in elementary school-aged children. It is critical that there be a crossover of the information learned at school into application at home, and parental involvement is vital for continuing learning. A cross-sectional study by Hildebrand, Betts, and Gates (2019) studied parents' familiarity and perceptions of school wellness programs in elementary grade schools. Although almost 63% of those surveyed knew there was a school wellness program, only half had actual knowledge of policy content. There must be interventions that promote a nutritional curriculum in elementary education and application in the home setting. Nutrition education interventions that used a multi-component multilevel approach are more likely to achieve objectives. Comparing lecture and experienced-based learning in a nutritional curriculum implemented in elementary school students, Jung, Choi, Bang, Shin, and Heo (2015) concluded that experience-based methods demonstrated alterations in dietary behaviors while lecturing only improved dietary knowledge. Therefore, a nutritional curriculum frequently presented throughout the school year, using various teaching strategies, may improve the children's healthy behaviors. EDUCATION AND HEALTHY EATING 16 There are numerous teaching strategies to improve knowledge of nutritional concepts to elementary-age school children. Dudley, Cotton, and Peralta (2015) found that enhanced curricula, cross-curricula, and experiential learning approaches were the most effective teaching strategies for primary school children and improved outcomes in nutritional knowledge. For the retention of lessons learned, there must be a continuum between school and home learning. Summary Although pediatric well-being has many components, healthy eating and good nutrition are paramount for well-being. While there are numerous mechanisms to improve pediatric wellness, improving nutrition is essential. The perceived complexity of pediatric nutrition creates frequent gaps in educating children while they are in school. This gap can lead elementary school educators not to implement nutritional curricula or lead to the belief that pediatric nutrition is not important for elementary-aged school children. Poor nutritional knowledge can lead to many health disparities, and early education interventions will promote healthy eating while children are young. The role of the DNP is to educate all members of the community about proper health promotion. Healthy eating is one component of increased health that the DNP should promote. The DNP leader serves as a role model to teach children important nutrition concepts that will benefit them in childhood and adulthood. Conceptual Model: PDSA cycle The Plan, Do, Study, Act (PDSA) cycle served as a conceptual model for project implementation. According to Finkelman (2018), to influence change, the PDSA model asks three questions: What is trying to be accomplished, how will the change be identified as an improvement, and what changes can be made? These questions are addressed by applying all four steps of the PDSA cycle. The PDSA cycle is action-oriented learning and applies the EDUCATION AND HEALTHY EATING 17 scientific method (Institute for Healthcare Improvement, 2020). Incorporating a nutritional curriculum for students at Iron Springs Elementary in Cedar City, Utah, required a scientific approach because it is a new process. Because the nutrition lessons require constant fine-tuning, using the PDSA cycle was ideal. The 'plan' step of the PDSA cycle consisted of identifying the who, what, when, where, and why. Fifth graders (who) at Iron Springs Elementary (where) received a nutritional curriculum (what) during Spring 2021 (when) to increase healthy eating (why). A nutritional curriculum was presented to students in the fifth grade using a multi-component approach to accomplish the 'do’ step of the PDSA cycle. The ‘study’ portion of the PDSA cycle was substituted to ‘check’ to evaluate the impact of change. This step involved collecting and analyzing data to understand if outcomes were being met (Finkelman, 2018). Lastly, the ‘act’ step consisted of acting on the previous step’s data and making changes accordingly to adjust future lessons. Practice Change Plan Goals and Objectives The DNP project’s overall goal was to improve the dietary habits of children at Iron Springs Elementary. Objectives included increasing students’ nutrition knowledge by implementing a nutritional curriculum, thereby improving healthy eating habits. Additionally, improving educators’ confidence in teaching elementary school nutrition occurred through an online teaching session highlighting key points of elementary school nutrition. Setting Iron Springs Elementary school is located in the suburbs of Cedar City, Utah, with 33,055 residents. Iron Springs Elementary enrolls students from kindergarten through fifth grade. EDUCATION AND HEALTHY EATING 18 The student-teacher ratio is 24.76, and it is one of six public elementary schools within 30 miles (NCES, 2018a). Significant persons for project implementation included the school principal, the school nurse, the food service team, and the 5th-grade educators. Children are in school between the hours of 8:15-3:00 pm, with varying class times based on grade level. However, on average, two hours of that time is not in the home classroom. This time consists of physical education, drama, music, and library time. There is also an additional 30-minute lunch period year-round. Population There were 676 students at Iron Springs Elementary (NCES, 2018a). Children at Iron Springs Elementary are between the ages of five to eleven, with 89.1% of the 676 students identifying as White (NCES, 2018b). Other ethnicities enrolled at Iron Springs Elementary include Hispanic, American Indian, Asian, and Black. Approximately 188 students were eligible for free lunch and 70 for reduced-price lunch. The number of 5th-grade students at Iron Springs Elementary was 93. Currently, no formal nutritional curriculum is presented to students at Iron Springs Elementary during school hours. No nutrition education contributes to a gap in learning foundational concepts and healthy habits early in development. Children will inevitability learn unhealthy habits that increase health complications if left uncorrected. 5th graders were chosen to implement a nutritional curriculum due to the willingness of four educators to have lessons presented to their students. Role of a DNP as a Leader and a Family Nurse Practitioner The DNP leader may serve many functions. According to the American Association of Colleges of Nursing (2020), some DNP roles include being a public health advocate and EDUCATION AND HEALTHY EATING 19 educator. The DNP leader advocates for positive health changes. A family nurse practitioner (FNP) serves to impact health at all ages. By influencing healthy habits in children, many burdens of chronic diseases could be lessened. A FNP may serve as a resource to children and educators to influence health in a community setting. During this project, the DNP-FNP role was accomplished by influencing healthy habits through educating and role-modeling healthy eating strategies that students implemented into practice. Children are considered a vulnerable population, and ethical considerations had to be taken into account. The Weber State University Institutional Review Board reviewed the project for approval before project implementation. As recommended by the CDC (2019b), nutrition education at school promotes healthy eating patterns, and curricula should be implemented as stand-alone health education classes or in combination with other subjects. This DNP project implemented a modified nutritional curriculum provided by the Utah Education Network in partnership with the Utah State Board of Education and the Utah System of Higher Education. Additionally, fifth-grade teachers were educated regarding pediatric nutrition to increase confidence in teaching future nutrition curricula and serving as nutrition education champions. The project plan was divided into two phases: pre-implementation and implementation phase. Pre-Implementation. During fall 2020, after having received project approval, an evaluation of 5th-grade educators’ beliefs of elementary school nutrition occurred. A brief survey that consisted of Likert-like questions and open-ended questions was prepared to identify educators’ attitudes and confidence in implementing a nutritional curriculum in their classrooms. During the pre-implementation phase, nutrition education lesson plans were compiled from the Utah Education Network and modified to fit class schedules. The Utah Education Network partners with the Utah State Board of Education and the Utah System of Higher Education to EDUCATION AND HEALTHY EATING 20 provide age-appropriate lesson content that meets the state’s health education core standards (Utah Education Network, n.d.). As a result, lessons were age-appropriate with functional learning outcomes defined by the Utah Education Network and were adjusted to fit classroom needs. Unfortunately, no readily available evidence-based nutrition curricula were readily available to fit the needs of the DNP project but were cross-referenced for accuracy and based on evidence-based nutritional principles. Implementation. After the initial survey and before the post-assessment survey, education was provided to 5th-grade educators at Iron Springs Elementary in the Fall of 2020. Specific teaching methods included delivering nutrition lessons in front of educators and students and providing a PowerPoint presentation highlighting key aspects of nutritional lessons. The goal of educating faculty members was to improve their knowledge of nutrition education, thereby increasing their confidence leading to the implementation of a personalized nutritional curriculum in their classroom (Rosario et al., 2012). In spring 2021, thirteen weekly nutrition lessons were presented in four different fifth-grade classrooms. Each lesson lasted 30 minutes and had an assessment plan that evaluated the learning and participation of the class. Lessons correlated with Utah core nutrition standards (see Appendix A). Project Evaluation and Analysis Data Collection To assess the implementation and impact of a nutritional curriculum on 5th-grade students and educators at Iron Spring Elementary, formative and summative methods were used. Formative assessments were collected through a pre-and post-assessment nutrition questionnaire (see Appendix B) and a post-lesson quiz delivered to students at the end of each lesson, with 14 lessons being delivered from January to May. Quizzes were either paper or electronic format and were EDUCATION AND HEALTHY EATING 21 used to verify if lesson objectives were met. Narrative data were taken during the post-implementation nutrition questionnaire and included questions on what subject was their favorite or one thing they learned. Comments were put into keywords and divided into groups for analysis. For the last nutrition post-assessment quiz Kahoot, two questions used Likert-type questions evaluating how well students liked the nutrition lessons and how well the nutrition lessons might influence them to make better food choices. Summative assessments included the number of students who attended each lesson and their participation in each lesson. Participation was evaluated by the number of students who took the post-lesson quiz, which was optional to each student. The class composite scores were calculated for each lesson using descriptive statistics Educators’ confidence in teaching 5th-grade nutrition was evaluated using a pre-and post-test survey administered through SurveyMonkey. The survey used Likert-type questions administered electronically to 5th-grade educators. Also included in the pre-implementation survey were questions to facilitate an educational PowerPoint presentation to address barriers educators might feel at implementing a nutritional curriculum. At the end of the post-implementation survey, 5th-grade educators were asked to leave comments and feedback about the nutrition lessons. Results Attendance to the nutrition lessons was high, with a 94% attendance rate with the average number of students taught for each lesson being 85 out of 91 students. The post-lesson quiz completion rate was also high, with an average completion rate of 97%. The nutrition lessons did not contain a pre-test due to time constraints of delivering the lessons in the allotted time. The correct response rate for the 14 post-assessment quizzes varied, with an average correct response rate at 69% (see Figure 1). Although the correct response rate to post-assessment learning may seem low at 69%, there were substantial increases across all six EDUCATION AND HEALTHY EATING 22 nutrition standards between the pre-and post-test nutrition questionnaire with the average rate of response rate improving by 27% (see Figure 2). Participation in the pre-and post-survey for 5th-grade educators was 100%, with all four educators taking the pre-and post-survey. After taking the pre-project implementation survey when assessing the educators’ views on whether implementing a nutritional curriculum in elementary school could positively impact students’ eating habits, all 5th-grade educators thought that outcomes could influence short- and long-term results. After being asked about barriers to implementing a nutritional curriculum in classrooms, all respondents stated that competing academic expectations, a lack of time, and no suitable curriculum were obstacles. Barriers identified by 5th-grade educators to implementing a nutritional curriculum included time management, feelings of inadequacy, and not knowing where to start. When educators were asked what a successful nutrition curriculum would look like, responses included answers of a curriculum that integrated nutrition topics into other curricula such as math, science, and English. Other factors identified were a curriculum that included parents and a school cafeteria component. When asked who was responsible for providing nutrition education to children, all responded that teachers and parents were responsible. One additional educator indicated that food service also had a responsibility to promote healthy eating. After project implementation, 5th-grade educators reported increased knowledge of elementary school nutrition when compared to the pre-implementation survey (see Figure 3). Educators rated their confidence in teaching pediatric nutrition on a 5-point Likert scale, zero (not confident) to five (completely confident). three out of four educators rated their confidence at a level four, with one educator rating their confidence at a five. Pre-and post-survey EDUCATION AND HEALTHY EATING 23 evaluations of educators’ opinions of the importance of providing nutrition education in elementary schools were higher after the DNP project implementation (see Figure 4). Students were asked what their favorite part of the nutrition lessons or something they learned was, their responses were categorized into eight categories: Utah agriculture, healthy eating, Kahoots, food groups/MyPlate, balancing meals, nutrition jokes, appetite vs. hunger, and no response received (see Figure 5). Comments from the survey included phrases such as: “ I loved how we got to learn if we are hungry or just having an appetite.”, “I learned that if you do not have a balanced meal, then it is not good for your body.”, “I learned that Utah is the second largest place that grows tart cherries.”, “I learned what food goes in what food group and what vitamins do.”, “I enjoyed the nutrition jokes.”, “My favorite part of the lessons were the Kahoots.” and “I learned how to make good and healthy choices.” Students were asked if they liked the nutrition lessons, responses were generally positive, with 89% of students answering the question (see Figure 6). Students were asked if they would make better food choices because of the nutrition lessons, responses were generally positive, with 91% of students answering the question (see Figure 7). Discussion Overall, this evidence-based DNP project demonstrated an increased interest and knowledge of 5th-grade students and educators about 5th-grade nutrition. Comments from 5th-grade educators post-DNP project implementation included expressing their enjoyment in having lessons provided to their classrooms and how proper nutrition can positively affect children. Participation in each nutrition lesson was well achieved, as displayed by student engagement and interest in each lesson, along with the post-lesson quiz participation. Overall, students and EDUCATION AND HEALTHY EATING 24 educators enjoyed having a presenter outside of faculty present the nutrition lessons during school hours as evidenced by comments given in the post-project survey. The largest increase in knowledge was in MyPlate, which correlates with standard 5.N.2 on creating a healthy meal. Although no direct observation took place to evaluate children’s eating habits, throughout the project implementation, students made statements on how they would change their meals to include all food groups and what to limit. One 5th-grade educator stated she overheard two of her students discussing lunch on arranging their meal to include more fruits and vegetables to be considered balanced in conjunction with MyPlate. Another educator viewed students actively stating while eating their lunch what food was part of which food group. Comments from educators indicated positive feelings toward having nutrition lessons presented in their classrooms and wished for continuing nutrition lessons in their classrooms. Through survey responses and personal comments, they expressed gratitude that their students learned foundational concepts that would benefit them throughout their lives. One educator stated her students reprimanded her for drinking multiple sodas a day and stated that her students encouraged healthier alternatives and used the nutrition lessons to support their concern. Likewise, students seemed to enjoy the nutrition lessons with excitement. The average correct response rate was 69% for post-assessment quizzes, these nutrition concepts were new to many students. Furthermore, lessons were only 30 minutes in length due to time constraints and possibly not allowing students to evaluate the information presented properly. However, when comparing the pre-and post-assessment nutrition questionnaires, knowledge of all six nutrition standards increased. EDUCATION AND HEALTHY EATING 25 Implementing an elementary school-based nutritional curriculum included Covid-19, adapting a curriculum due to instructional time, updated readily available educational material, and project sustainability. During the Covid-19 pandemic, there was uncertainty about whether students would remain in the classroom for instruction. However, the majority of 5th-grade students at Iron Springs Elementary chose to stay in person for classes. Students who chose remote learning did not receive nutrition lessons as there was no available accommodation. Some lesson plans were available through the Utah Education Network. However, the material needed to be adapted to fit individual classes and did not always cover appropriate learning objectives. Some curricula content had outdated nutrition information not conducive to current learning objectives. Other resources were available through the United States Department of Agriculture and other government agencies. A challenge was taking information from various credible sources and forming a cohesive lesson plan for certain learning outcomes. Time was another factor that influenced project implementation. In Utah, elementary school teachers have eleven different core standards to apply and only three to six hours of classroom time to do so (Utah Education Network, n.d.; NCES, 2018b). Therefore, the nutrition curriculum was presented during a 30-minute English, Science, and Language (ESL) prep once a week. The first five lessons were administered through traditional means consisting of a pen and paper. While students actively participated in the post-assessment through traditional means, there was less excitement. Therefore, midway through the lesson implementation, the post-lesson quiz was administered through Kahoot. Kahoot is a game-based learning application that was utilized through students taking questions through the use of Chromebooks. Chromebooks were readily available through their home classroom. After each question, a leader is displayed with EDUCATION AND HEALTHY EATING 26 points awarded if they answered the question right and how fast they answered. Scores are tallied, and at the end, the top three are displayed on a podium. Many students enjoyed this method; therefore, the post-lesson assessment was changed to Kahoot rather than pen and paper. This assessment change was done to ensure nutrition post-assessments were a favorable addition to the nutrition lessons rather than something students dreaded. Having shorter lessons and a post-assessment quiz delivered through a game-like system helped students pay attention to curricula content. This evidence-based DNP project adds to nursing practice that having a nutrition curriculum in elementary schools can positively impact students' knowledge of healthy eating principles. Students and educators who gain this knowledge can improve healthy habits that lead to positive health outcomes. Knowledge of core nutrition principles serves not only students but also educators. An elementary school nutrition curriculum should engage students and use game-based applications to improve participation. Lessons should cover various health-nutrition topics that are age-appropriate and allow students to practice what is taught. Conclusion Pediatric wellness involves a variety of measurements. There are interactions between nutrition, physical activity levels, genetic influences, and socioeconomic factors. Because diet plays an integral part in preventing diseases, interventions beginning in childhood to increase healthy eating are vital. A DNP-FNP is an important community resource that can influence health across all age spectrums. By serving as a community partner in health the DNP-FNP can limit childhood illness and decrease chronic healthcare conditions. This DNP project developed a nutritional curriculum specific to elementary-aged school children that improved healthy eating EDUCATION AND HEALTHY EATING 27 and improved pediatric wellness. 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Retrieved from https://assets1c.milkeninstitute.org/assets/Publication/ResearchReport/PDF/Mi-Americas-Obesity-Crisis-WEB.pdf Wheelock, K. M., Fufaa, G. D., Nelson, R. G., Hanson, R. L., Knowler, W. C., & Sinha, M. (2017). Cardiometabolic risk profile based on body mass index in American Indian children and adolescents. Pediatric Obesity, 12(4), 295-303. https://doi.org/10.1111/ijpo.12142 World Health Organization. (2020a). Constitution. Retrieved from https://www.who.int/about/who-we-are/constitution World Health Organization. (2020b). Obesity and overweight. Retrieved from https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight#:~:text=In%202016%2C%2039%25%20of%20adults,tripled%20between%201975%20and%202016. EDUCATION AND HEALTHY EATING 40 Appendix A Students will identify the basics of nutrition, healthy eating habits that support a healthy body, and how to recognize eating behaviors. Students will also recognize nationwide food resources. Standard 5.N.1: Use a food label to calculate how caloric intake can change depending on the number of servings consumed. Standard 5.N.2: Create a healthy meal, including beverages, using current dietary guidelines. Standard 5.N.3: Differentiate between appetite and hunger. Standard 5.N.4: Explain the role of healthy eating and physical activity in maintaining health. Standard 5.N.5: Analyze the influence of media and technology, including social media, on personal and family nutrition and body image. Standard 5.N.6: Explain why different foods are produced in various regions of the United States and how this may affect consumer practices and local diets. Lesson Focus Nutrition Standard 1 MyPlate + Nutrition Pre-assessment Standard 5.N.2 2 Nutrition Label Standard 5.N.1 3 Nutrition Label (continued) Standard 5. N.1 4 Drinks Standard 5.N.1 Standard 5.N.2 Standard 5.N.5 5 Breakfast Builder Standard 5.N.2 Standard 5.N.4 6 Balanced Meals Standard 5.N.2 Standard 5.N.4 7 Appetite vs Hunger Standard 5.N.3 8 Appetite vs Hunger (continued) + Mid-Semester Review Standard 5.N.1 Standard 5.N.2 Standard 5.N.3 Standard 5.N.4 Standard 5.N.5 9 Food and Activity Standard 5.N.4 10 Snacks Standard 5.N.2 11 Exercise vs Healthy Eating Standard 5.N.4 12 Advertisements/Commercials Standard 5.N.5 13 Food Culture Standard 5.N. 6 14 Nutrition Curricula Feedback + Nutrition Post-Assessment Standard 5.N.1 Standard 5.N.2 Standard 5.N.3 Standard 5.N.4 Standard 5.N.5 Standard 5.N.6 EDUCATION AND HEALTHY EATING 41 Appendix B EDUCATION AND HEALTHY EATING 42 EDUCATION AND HEALTHY EATING 43 Figure 1: Average Correct Response Rate for each Nutrition Lesson 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Lesson 1 Lesson 2 Lesson 3 Lesson 4 Lesson 5 Lesson 6 Lesson 7 Lesson 8 Lesson 9 Lesson 10 Lesson 11 Lesson 12 Lesson 13 Lesson 14EDUCATION AND HEALTHY EATING 44 Figure 2: Pre and Post-Test Scores Across Nutrition Standards 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Standard 5.N.1 Standard 5.N.2 Standard 5.N.3 Standard 5.N.4 Standard 5.N.5 Standard 5.N.6 Pre-Test Average Correct Response Post-Test Average Correct ResponseEDUCATION AND HEALTHY EATING 45 Figure 3: Change in 5th Grade Educators Knowledge in Elementary School Nutrition 0 1 2 3 4 No Knowledge Little Knowledge Average Knowledge High Knowledge Proficient Pre-DNP Project Implementation Post-DNP Project ImplementationEDUCATION AND HEALTHY EATING 46 Figure 4: Educators Opinion of Teaching Nutrition in Elementary Schools 0 1 2 3 4 Not Important Little Importance Somewhat Important Important Very Important Pre-DNP Project Implementation Post-DNP Project ImplementationEDUCATION AND HEALTHY EATING 47 Figure 5: Students’ Favorite Part of Nutrition Lessons 0 2 4 6 8 10 12 14 16 18 20EDUCATION AND HEALTHY EATING 48 Figure 6: Number of Students Who liked the Nutrition Lessons 0 10 20 30 40 50 60 Always Very Often Sometimes Rarely No AnswerEDUCATION AND HEALTHY EATING 49 Figure 7: 5th-Graders Self Rating of Choosing Better Food Choices 0 10 20 30 40 50 60 Most of the time Some of the time Not often Never No answer