Digital Repository Doctoral Projects Fall 2021 Introducing an After-School Healthy Eating Curriculum for Elementary School Children Gabriela Ramirez Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Ramirez, G. (2021) Introducing an After-School Healthy Eating Curriculum for Elementary School Children 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. Introducing an After-School Healthy Eating Curriculum for Elementary School Children by Gabriela Ramirez 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: HEALTHY EATING 1 Introducing an After-School Healthy Eating Curriculum for Elementary School Children Gabriela Ramirez Weber State University HEALTHY EATING 2 Abstract Healthy eating is pivotal for the adequate growth and development of school-age children. Unhealthy eating correlates to poor health outcomes, poor academic performance, and negative psychological consequences over time. The purpose of this Doctor of Nursing Practice (DNP) project was to implement an after-school healthy eating curriculum at an elementary school in the Ogden School District. The curriculum was designed to improve the healthy eating knowledge and behaviors at an elementary school in a low-income area. This program was guided by the USDA 2015-2020 nutritional guidelines and the social cognitive theory framework. The after-school program included teaching ten age-appropriate classes for K - 5th-grade students covering topics such as using MyPlate food groups, making healthy choices, and reading nutritional labels. The program's success was evaluated using pre-quiz and post-quiz results and in-class participation. Approximately 38 students participated in the program. In the curriculum evaluation, 70% of the students reported enjoying the healthy eating classes, and 80% reported wanting to continue with more nutrition projects. The post-curriculum surveys showed that, on average, students had a 35% increase in their understanding of healthy eating behaviors and the ability to recognize healthy food groups. The project findings demonstrated a significant increase in elementary students' learning of healthy eating concepts. These types of programs have the potential to lead to healthy eating self-efficacy, promote lifelong healthy behaviors, and ultimately prevent long-term health problems. Keywords: behavior, healthy eating, social cognitive theory HEALTHY EATING 3 Introducing a Healthy Eating Curriculum for Elementary School Children Healthy nutrition in elementary school-age children is essential for adequate growth and development (USDA, 2010). Poor nutrition can result from multiple factors such as unhealthy diets, low socioeconomic backgrounds, and low health literacy (World Health Organization [WHO], 2014). Unhealthy eating can lead to detrimental physical and psychological consequences over time, such as obesity, diabetes, cardiovascular disease, and low self-esteem, among other emotional hardships. According to the Center for Disease Control and Prevention (CDC), the obesity prevalence rate among children and adolescents from low socioeconomic groups is 8% higher than their counterparts in higher socioeconomic groups (2020). Ogden, Utah's poverty rate (19.6%) is 10% higher than the rest of the state (9.6%) (United States Census Bureau, n.d.). Learning good nutritional principles can help students improve their self-efficacy that will help to prevent the detrimental effects of unhealthy eating. This Doctor of Nursing Practice (DNP) project implemented a healthy eating curriculum at Odyssey Elementary school and evaluated its effectiveness. Define the Search An extensive literature review was conducted, and pertinent articles were retrieved from electronic databases such as CINAHL, Ovid, EBSCOhost, MEDLINE (Ebscohost) and PubMed.gov. The evidence-based information was recent and dated from 2002 through June 2020. The key search words included healthy eating, nutrition, childhood obesity, poverty, low socioeconomic status, school-based programs, healthy eating, self-efficacy, and health literacy. HEALTHY EATING 4 Literature Review Healthy Eating The National Prevention Council recognizes healthy eating as one of the main priorities for improving health, maintaining wellbeing, and preventing disease. The council defines healthy eating as: Consuming a variety of nutritious foods and beverages, especially vegetables, fruits, low and fat-free dairy products, and whole grains; limiting the intake of saturated fats, added sugars, and sodium; keeping trans-fat intake as low as possible, and balancing caloric intake with calories burned to manage body weight (2011, p. 34). Current USDA Dietary Guidelines describe a nutritionally dense diet as "foods and beverages that provide vitamins, minerals, and other substances that contribute to adequate nutrient intakes or may have positive health effects" (2015, p. xiv). The major nutrient-dense sources include protein, fruits, vegetables, dairy, and grains (Myplate.gov, 2020). These food groups provide the nutritional requirements needed for disease prevention, optimum growth, and development (USDA, 2015). Healthy eating intake is strongly influenced by ones' self-management behavior in which eating healthy fits the individual's diet preferences while also having a variety of nutritious foods and beverages (ADCES, 2020). The current Dietary Guidelines describe an eating pattern as a "customary way of eating, or a combination of foods recommended for consumption" (USDA, 2015, p. xiv). Among the key recommendations for improving healthy eating patterns include limiting the intake of saturated fats, trans fats, sodium, and added sugars (Sahoo et al., 2015). Adopting a healthy eating pattern should include a variety of nutrient-dense foods such as vegetables from all subgroups, whole fruits, fat-free or low-fat dairy products, and variety of HEALTHY EATING 5 proteins such as lean meats, seafood, poultry, eggs, legumes, nuts, and soy products (ADCES, 2020). For school-age children (ages 6 to 12) optimal nutrition is critical for their healthy growth and development (CDC, 2019). School-age children's nutritional energy (calories) vary depending upon their sex, activity level, and age (AHA, 2020). During the school-age years, children go through critical phases of their growth and development. Children experience substantial muscle and bone growth, their permanent teeth start to erupt, and their immune system reaches its developmental maturity level. Their motor skill milestones include moving in a strong and coordinated manner, engaging in sports activities, running, and learning to ride a bike. Cognitively, school-age children can use complex sentences, read and write stories, and focus their attention for longer periods (National Library of Medicine, 2020; Stanford Children's Health, 2020). As school-age children continue growing, they start participating in social activities and develop a sense of accomplishment. Their social network increases beyond family members. During this stage, children also increase their ability to understand concept definitions, such as cause and effect, and build self-control (Betz, 2007). At the end of the school-age years, children may start the onset of sexual and pubertal changes (Barners, 2003). Thus, it is advised that school-age children maintain an adequate nutritional and caloric balance to support their adequate growth and development. When children have healthy eating habits, vitamin and mineral supplementation for normal growth and cognitive development is not necessary. A varied and well-balanced diet can provide children the recommended nutritional requirements (Duryea, 2020). Furthermore, anthropometric data such as Body Mass Index (BMI) which looks at weight and height are useful measures for the examination of health and nutritional status during childhood (CDC, 2018). The value in measuring growth "resides in helping to determine the HEALTHY EATING 6 degree to which physiological needs for growth and development are being met during the important childhood period" (De Onis, 2009, p. 463). School-age children and adolescents recommended BMI is between the 5th and 85th percentile. When children have a healthy eating pattern this is reflected in a healthy range BMI (USDA, 2015). Healthy eating is essential for children to have adequate growth and development, maintain a healthy BMI, enable better academic performance, psychosocial health outcomes, and prevent a wide range of adverse outcomes resulting from unhealthy eating (Sahoo et al., 2015). Effects of Unhealthy Eating Healthy eating involves multiple interacting healthy patterns and their relationship to positive health outcomes. Conversely, unhealthy eating among students can lead to detrimental health outcomes such as negative psychological consequences over time, including deficient academic performance and low self-esteem, among other emotional hardships. Unhealthy eating also plays a critical role in the lifetime risk for obesity and chronic diseases such as cardiovascular disease and type 2 diabetes (Sahoo et al., 2015; WHO, 2020). Unhealthy diets can negatively influence children's academic performance. Sahoo et al. (2015) explain that children with unhealthy diets are likely to have a lower quality of life and poor academic performance. Moreover, these children are four times likely to be affected in their academic performance compared with their counterparts that have access to healthy diets. Correa-Burrows et al. (2016) looked at the associations of nutritional quality provided by healthy eating and its effects on the student's academic performance. They concluded that students who had energy-dense diets with poor nutritional content performed poorly academically. An unhealthy diet was associated with low academic outcomes, specifically in subjects such as foreign languages and mathematics. Unhealthy foods associated with lower GPA scores were HEALTHY EATING 7 identified as diets with saturated fat, highly processed carbohydrates, low protein, low vitamin, and mineral content. The adverse effects of unhealthy eating, such as obesity, are strongly associated with negative psychological impacts involving low self-esteem, anxiety, and depression (CDC, 2016). A study by Sahoo et al. (2015) found that emotional distress and low self-esteem predominates among children with poor eating patterns. Children who suffer the harmful effects of unhealthy eating, face various hardships such as social marginalization, discrimination, poor self-image, and low confidence. These adverse effects are connected to poor school performance, less social interaction, and missed school due to emotional and physical conditions due to obesity. Furthermore, the evidence has shown that there is a "relationship between unhealthy dietary patterns and poorer mental health in children and adolescents" (O'Neil et al., 2014, p.e31). Poor eating behaviors such as consuming sugary beverages, large food portion sizes, snacks, and fast-food eating can lead to childhood obesity, malnutrition among various health problems as these foods are energy-dense with high fat and sugar and low in minerals, vitamins, and other essential micronutrients (Sahoo et al., 2015). Poor nutrition due to unhealthy eating can affect children's optimal physical growth, cause tooth decay, lead to constipation or affect bowel function, as well as affect children's weight by being underweight, overweight, or obese (The Royal Children's Hospital Melbourne [RCH]. n.d.). Childhood obesity is strongly associated with unhealthy eating and poor nutrition. The World Health Organization defines obesity as the excessive accumulation of fatty tissue, which can lead to adverse health outcomes (2020). Obesity specifically has become a serious global health problem and is more prominent among children from low socioeconomic households (WHO, 2020). Childhood obesity is complex, as children go through many physiological HEALTHY EATING 8 changes during their elementary school years. The CDC has classified anthropometric measurements, and characteristics for the identification of unhealthy eating. Children with a BMI above the 85th percentile are considered overweight, and children with BMI above the 95th percentile are identified as having obesity (CDC, 2020). Unhealthy eating is recognized as contributing to less-than-ideal bone mass and thus negatively affecting bone health (Woo & Robinson, 2020). The American Academy of Orthopedic Surgery has emphasized that excess weight can severely impact bone, muscle, and joint health, leading to osteoarthritis, delayed bone plate growth, and even bone fractures among obese children (AAOS, 2020). Among other health problems identified are dyslipidemias, insulin resistance, metabolic syndrome, and non-alcoholic fatty liver ([NAFLD] Isasi et al., 2017). Substantial evidence has concluded that if childhood obesity remains unchanged, it can lead to further health problems over time and into adulthood, such as type 2 diabetes, osteoporosis, coronary artery disease, among other cardiometabolic disorders (Isasi et al., 2017). Contributors to Poor Nutrition in School-Age Children Nutritional intake of the school-age children is positively or negatively influenced by eating patterns, family and cultural influences, socioeconomic factors and health literacy. Unhealthy eating patterns involve poor diet choices that vary depending upon the children's appetite, food taste, and access to healthy food (Duryea, 2020). Poor nutritional diets are more prevalent in family environments with lower socioeconomic status and lower health literacy (Sahoo et al., 2015). Behaviors towards food choices and eating are influenced by various factors, including family, friends, social media, and marketing (Duryea, 2020). Poor Behaviors are associated with detrimental effects on one's mental or physical health (McGraw-Hill Concise Dictionary of Modern Medicine, 2002). Children with unhealthy eating behaviors do not eat HEALTHY EATING 9 enough fruits and vegetables and have a high tendency toward junk food, binging, and overeating (SA.gov, 2020). Children with unhealthy behaviors also tend to have prolonged time watching television, which also correlates with their consumption of unhealthy foods such as salty snacks and sweetened beverages. The lack of rules around junk food and screen time can strongly influence children's attitudes towards food, leading to unhealthy behaviors. (Sahoo et al., 2015). Family dynamics play a critical role in the development of healthy eating behaviors. Among the factors that influence healthy eating of school-age children are family background, parental education, and parenting style (Lieb, Snow, & DeBoer, 2009; Sahoo et al., 2015). Family culture strongly influences children's food choices. School-age children have had enough exposure to understand what food is available to them and learned their food preferences according to their culture (Birch & Ventura, 2009). Parenting style impacts children's eating behaviors by fostering food selection autonomy and fast-food leniency. Children eat at least five times a week at home (Duryea, 2020). Therefore, the home environment and food and snacks available at home can have a significant impact on the child's nutrition. Moreover, children tend to model parents’ behaviors, and preferences research studies have shown that besides socio-cultural factors, the parents’ lack of time to provide healthy choices due to long working hours. Parents' cultural perceptions towards healthy eating and obesity can strongly influence a child's health and food choices (Garcia et al., 2019). Children from low socioeconomic households below the poverty level are 2.7 times more likely to have unhealthy diets and childhood obesity than children from higher socioeconomic status (Luybli, Schmillen, &Sotos-Prieto, 2019). Children from poverty-level households are significantly more affected due to families have difficulty accessing healthy foods. Consequently, they are more likely to buy inexpensive food with low nutritional and high-calorie value (Teling, HEALTHY EATING 10 Appel, Roberts, Flores & Morris 2012). Food science technology and food-price inflation have led to cheaper calorie-dense food products making them more accessible and affordable to those from low socioeconomic status (Lieb, Snow, & DeBoer, 2017). Families living in rural and underserved areas are affected by less access to grocery stores that offer affordable nutritious and healthy foods (Luybli, Schmillen, &Sotos-Prieto, 2019). Children's exposure to socioeconomic and geographical discrepancies significantly affects the quality and quantity of healthy food availability. Dunaway et al. (2017) explain that low socioeconomic neighborhoods are affected with lower availability of accessible and affordable healthy and nutritious food compared with communities from higher socioeconomic status. Parents’ deficit knowledge of the positive effects of healthy eating and adequate nutrition are associated with their children's health outcomes. Those from minority groups and low socioeconomic status are particularly affected by the adverse effects of poor health literacy due to socio-cultural and language difficulties, which placed them at a disadvantage for increasing their knowledge and thus improving their health outcomes (Tsai, Lee, & Yu, 2018). Nevertheless, it is assumed that children's health outcomes are under the surveillance of their parents. However, children have the ability to make unsupervised decisions such as consuming fewer fruits and vegetables and eating vending machine foods with high-calorie density. Moreover, children with low health literacy are more likely to show poor health behaviors and are more likely to request unhealthy and calorie-dense foods to their parents (Sharif & Blank, 2010). Solutions to a Healthy Eating The National Prevention Strategy (2011) calls for providing people the knowledge that can improve their healthy eating patterns that helps them to achieve their optimal health and healthy weight. Providing people with knowledge for healthy eating fosters the consumption of HEALTHY EATING 11 adequate energy and nutritional requirements that are crucial to maintaining healthy outcomes through life span. Specifically, children require healthy eating that provides the necessary nutrient-dense foods for optimal growth and development (CDC, 2019). There are many healthy eating resources and programs, such as ChoseMyPlate; which is a guide that explains the recommended food requirements for specific age groups and dietary needs according to the current Dietary Guidelines for Americans 2010-2015. These guidelines also provide health professionals the tools based on evidence-based information for educating Americans to make healthier choices. The USDA (2015) emphasized the importance of nutritional education on whole grains, lean protein, and a variety of fruits and vegetables. It also stresses to limit the intake of beverages and foods with added sugars, solid fats, or sodium. Similarly, the American Heart Association (AHA) recommends the consumption of whole grains rather than refined grain products and limiting foods high in saturated fat, trans fat, cholesterol, sodium, and added sweeteners (2018). Additionally, children's calorie intake should be based on their lifestyle behaviors. With higher physical activity, higher calorie intake is necessary for their healthy development with an increase of "0-200 kilocalories per day if moderately physically active, and by 200–400 kilocalories per day if very physically active" (AHA, 2018). Children who consume the necessary foods and drinks according to individual nutritional and calorie requirements are building the foundation of having healthy eating patterns and maintaining a healthy weight across their lifespan (HHS, 2020; USDA, 2015). The Dietary Guidelines for Americans recommend following healthy eating patterns throughout the lifespan of individuals; nevertheless, they emphasized that maintaining a "healthy eating pattern is not a rigid prescription, but rather, an adaptable framework in which individuals HEALTHY EATING 12 can enjoy foods that meet their personal, cultural, and traditional preferences and fit within their budget" (USDA, 2015, p. xi). Similarly, the 2018 Cholesterol Management Guidelines recommends a healthy, nutrient adequate diet pattern. The dietary patterns should be appropriate to the nutritional and caloric demands as well as of the cultural food preferences of the children (Grundy et al., 2019). The USDA (2015) expounds on the importance of education to improve food choices and healthy attitudes. The Dietary Guidelines for Americans 2010-2015 also explain that healthy eating education can take place in a wide variety of settings and through diverse professional multidisciplinary teams. The focus of educational programs should include information about nutrition and food choices and good eating behaviors. Educational programs should include a culturally sensitive and school-age-appropriate healthy eating curriculum. A childhood healthy eating educational program should be adapted with fun and interactive activities. Thus, the presentation of the healthy eating curriculum must contain activities and colors that boost students' attention and that addresses students' interest and with logical sequence (CDC, 2019). There are various healthy eating and nutrition curriculums, including Choose MyPlate, adapted from the Dietary Guidelines for Americans 2010-2015, and the education standards according to school-age groups. This curriculum can be implemented in a variety of settings. However, the school settings render many opportunities to help children to improve their health outcomes and support their academic performance. School-based program Healthy eating practices begin early in life. During this time, children start becoming aware of their body shape and weight. School-age children begin to understand nutrition and meal planning concepts and thus start making their own choices. Children are often influenced HEALTHY EATING 13 by peers, teachers, and other non-family member figures in the school settings (Duryea, 2020). Kelishadi and Azizi-Soleiman (2013) suggested that school-based programs which provide in-classroom nutrition and healthy behavior education can promote not only lifelong healthy behaviors and prevent long term health problems but are also feasible and effective because children spend a significant amount of their time at school. Johnston et al. (2010) looked at the impact of a school-based program on children's behaviors. The program's interventions focused on increasing healthy behaviors such as healthy eating and physical activity. Throughout the program, the participants received consistent positive feedback. These students showed increases in positive behavior, class attendance, and when surveyed two years later, remained engaged in healthy eating. In addition, the program participants had positive results including lower cholesterol and triglycerides levels and maintained BMI values even at the two-year post-intervention follow up. Therefore, the findings of this study confirms that school-based programs can successfully educate students about the importance of adequate nutrition and healthy eating. Summary Substantial research has supported that healthy eating patterns play a critical role in the school-age children's growth and development and for the prevention of long-term problems including obesity, cardiovascular disease and type 2 diabetes. Moreover, emergent research has concluded that children from lower socioeconomic households have a higher incidence of obesity and lack knowledge regarding the benefits of healthy eating and obesity prevention. Despite this research, there are many schools that do not have healthy eating programs. Schools provide the perfect setting for healthy eating programs as school-age children spend much of their time in the classroom and are just starting to make their own health choices. Furthermore, HEALTHY EATING 14 school-based interventions have been proven successful in promoting students' lifelong healthy behaviors. Introducing an after-school healthy eating curriculum to elementary schools can promote students learning about nutritional principles and healthy eating behaviors which can positively impact student lifelong healthy outcomes and prevent the physical and emotional ailments associated with unhealthy eating. Social Cognitive Theory Social cognitive theory (SCT) has evolved from the Social Learning Theory developed by Bandura and Walters in 1963. The Social Learning theory is rooted in learning behaviors by observation of others. This was known as Observational Learning or Social Learning Theory. In 1986 Bandura advanced his views to focus on human functioning and cognitive components, which led to the creation of the SCT. The SCT has an emphasis on human functioning and suggests that human functioning results from the dynamic interaction of personal, behavioral, and environmental influences. Bandura describes personal factors as the form of cognition, affects, and biological events. This interaction of personal factors, behaviors, and environmental influences result in triadic reciprocality. This reciprocal interaction is known as the determinants of human functioning (Pajares, n.d) and all the components keep interacting with each other, one component is as important as the other, and one component can influence the other (Pennstate, 2016). Environment and social systems are important in influencing one's behavior. Issues such as "socioeconomic status, and educational and familial structures do not affect human behavior directly. Instead, they affect it to the degree that they influence people's aspirations, [and] self-efficacy beliefs" (Pajares, n.d). Self-efficacy is an essential construct and is the core of human motivation and confidence in their ability to perform a behavior. (Pajares, n.d; Boston University School of Public Health, 2019). HEALTHY EATING 15 The SCT constructs guided the implementation of the healthy eating curriculum in school-age children at Odyssey Elementary School. The SCT explains how children adopt and sustain behaviors by taking into consideration the social environment in which they implement the behavior. As per social environment factors to consider for the healthy eating program, interventions were informed by the home and family environment factors such as socioeconomic status, food security, food access, and types of food the children consume based on their socio-cultural environment. The interventions, such as meal planning and cooking, were adapted based on children's socio-cultural environment and food accessibility. Personal factors were addressed by improving students' healthy eating with the education provided during the program. These interventions of improving the knowledge of the participants about healthy eating aimed to positively improve students' attitudes towards nutritional diets. Consequently, the interventions impact the student's behavior by improving participants' self-efficacy, which will reflect in the participant's healthy weight management and healthy eating lifestyles. The Problem 1.Setting and Population Ogden, Utah is the largest city in Weber County, with a population of 87,773 (U.S. Census Bureau, 2019). Recent CDC statistics show that over 10,000 children living in Ogden live below the federal poverty level (Salud-America.org, 2020). The 2018 American Survey estimated that Ogden's poverty level is 10% higher than the state of Utah's average. Ogden has a larger uninsured population (16.4 %) compared to the rest of the state (10.8%) and the national average (9.5%) (U.S. Census Bureau, 2019). Many Ogden residents live in areas that are considered food deserts with only 1.25 grocery stores per 100,000 people as compared to the 2.10 rate in the rest of the United States (Salud-America.org, 2020). HEALTHY EATING 16 2.Population The Ogden School District (OSD) serves approximately 11,500 students. The district includes 13 elementary schools, three junior high schools, two high schools, and one alternative secondary school. The healthy eating curriculum was implemented at Odyssey Elementary School. Odyssey Elementary school serves 552 students from kindergarten to 6th grade from ages 4-13 years old. This elementary school has a diverse student population with 415 Hispanic- Latino students, 20 African American students, 89 White students and 25 students from diverse ethnicities. One hundred percent of Odyssey's student population receive free lunch and 23.3% of those families are identified intergenerational poverty (Intergenerational Welfare Reform Commission, 2020). The specific target population for this DNP project only included children enrolled in the after-school program at Odyssey elementary school which corresponded to around 38 total students from kindergarten to 5th grade. 3.Gap One hundred percent of Odyssey Elementary School children receive federal assistance lunch programs; these children are also affected by food insecurity and intergenerational poverty. Unhealthy eating often correlates with children from low socioeconomic status and leads to negative physical and psychological health consequences as well as poor school performance. Ogden City Schools recognized the need to educate children about good nutrition and healthy eating, which prompted them to reach out to the Weber-Morgan Health Department (WMHD) and Weber State University College of Education. This led to two students from the Master of Education program at Weber State University creating an evidenced-based nutrition curriculum aimed to help elementary school students gain nutritional knowledge. The curriculum addresses HEALTHY EATING 17 food insecurity with positive deviance approaches and follows the USDA nutritional guidelines and the Utah Health Education Standards (2020). 4.Expected Outcomes/Goals The overall goal of the DNP project was to improve knowledge of healthy eating behaviors at an elementary school in a low-income area. This goal was accomplished by introducing a healthy eating curriculum modified to be age-appropriate for kindergarten through 2nd grade and 3rd through 5th grade students in an after-school program. The curriculum addressed healthy eating education which promotes healthy eating behaviors. In addition, the curriculum was evaluated, and recommendations provided for future healthy eating programs to the school district stakeholders. Implementation The DNP student's role consisted of implementing a healthy eating curriculum and evaluating the school nutrition curriculum written by students from the master's in education program at Weber State University. This project was developed as a response to a curriculum project created by Ogden Civic Action Network (CAN), Weber-Morgan Public Health Department, Weber State University, and Ogden School District due to the emerging need for a healthy eating curriculum manifested by Ogden students' higher obesity rate, food insecurity, and poverty level. The DNP student worked collaboratively with the Ogden School District stakeholders coordinating meetings to finalize the project logistics and timeline. Project planning was initiated in August 2020. During the first meeting, the Ogden School District stakeholders identified the target population to be a group with specific determinants including lower socioeconomic status and food insecurity. The Odyssey Elementary School met all criteria and planning with the after- HEALTHY EATING 18 school program educators began. The evidence-based curriculum was provided by the Ogden School District. The curriculum was adapted to a short after-school program for school-age children from 4 to 10 years old. Ten succinct and systematic classes were planned to follow the USDA nutritional guidelines using the MyPlate recommendations and activities as a reference for specific age groups and dietary needs. Using MyPlate.gov and other healthy eating reputable sites for resource. The lessons aimed to guide students in developing positive life-long health-related attitudes and behaviors. This DNP project was funded in collaboration with the Sigma Theta Project fund and the Ogden School District Intergenerational Poverty Grant. The funds were used to buy class supplies and healthy food for students. Because this project was implemented with a vulnerable population, the project proposal had to go through review by the Weber State University Institutional Review Board before implementation. The class implementation phase was initiated over sixteen weeks with a total of 10 classes with one day used for evaluations and certificate of completion ceremony. The one-hour classes comprised of nine themes designed to teach students the basic concepts of healthy eating habits and healthy nutrition choices. School-age nutritional requirements were reinforced through workbook activities. The activities aimed to boost student engagement and persuade adopting healthy behaviors. In order to implement the curriculum based on children's age and cognitive level, the classes were organized into three different age groups, from kindergarten to first grade, second to third grade, and fourth to fifth grade, respectively. The curriculum classes included fun videos and activities with bright colors that promoted student engagement and learning, including food selection, and sharing food samples of the food group explored that week. For instance, if the class was related to the grain food groups a quinoa salad was cooked HEALTHY EATING 19 and shared with the students. Students also had the opportunity to participate in cooking, singing, and dancing activities related to the food groups explained during the class. Students' engagement was pivotal during the implementation of the project. Activities and videos aimed to promote engagement and positive reinforcement were used. Students were engaged in cooking demonstrations and excitedly volunteered to help. They were also interested in any competitive activities with the content like quizzes and games. Positive reinforcement was implemented with empowering notes written on snacks and fruit (one day for example, "You are strong!" was written on the students' banana peels before class) and encouraging language in discussions. Notes about student engagement were collected and provided important feedback for future classes. On the last day of class, water bottles and a certificate of project completion were distributed to all the participating students. Evaluation and Data Analysis Data Collection The data collection process took place over the period of sixteen weeks. During this period a pre and post-test were implemented and used as evaluation tools for this project. The pre and post-test were adapted from Health World Inc. (see Appendix.1). This test consisted of multiple-choice questions and aimed to evaluate elementary school students' understanding regarding healthy eating and its importance for children's adequate growth and development. A three-question true or false quiz and a MyPlate drawing were added to the final test to evaluate students' understanding and application of the concepts of MyPlate, a guide that explains the recommended food requirements for specific age groups and dietary needs according to the current Dietary Guidelines for Americans 2010-2015. An evaluation survey using an emoji-based Likert scale was given to students, which aimed to evaluate the project and students' perspectives HEALTHY EATING 20 on future participation in healthy eating projects. Students from second grade to 5th grade completed pre-tests on the first day of the curriculum and the post-test and final evaluation activities, were conducted on the last day along with the completion of the healthy eating curriculum project. For the kindergarten and first grade group, no pre-test was implemented because students were at different writing and reading levels. With the assistance of the Boys and Girls Coordinator, who instructed them verbally, the post-test was completed by having the students draw MyPlate elements instead of writing their answers. Data Analysis The results of the tests were analyzed by calculating percentage scores and mean scores for each student group. The mean scores are denoted in the result section as (x̄ ), and the standard deviation values are indicated as "SD." The mean scores were obtained from the questions answered correctly on the pre-and post-test. To determine if there were any changes in students' healthy eating learning outcomes, the pre and post-test used the same questions, which helped evaluate the students' knowledge and understanding of nutrition and healthy eating behaviors prior to and after completing the curriculum. Data were analyzed to compare the mean score of each test to determine if knowledge increased for the participating students. In the true/false portion of the final assessment, the scores were taken and analyzed to obtain mean scores of student test results. The MyPlate activities and final assessment included providing written or drawing examples of the MyPlate components; a perfect score reflected ability to identify all of the five MyPlate components and a partial score was assigned to students who provided 1 to 4 elements only. HEALTHY EATING 21 Results The emoji-based Likert scale satisfaction survey revealed that 70% of the students reported enjoying the healthy eating classes, and 80% reported wanting to continue with more nutrition projects. In the post-test knowledge application evaluation on the final day of the program, the kindergarten and 1st grade students (n = 12) were instructed to write or draw examples of all the elements of MyPlate. This student group had a 67% (n = 8) perfect score by providing examples of each of the components of MyPlate. However, 33% (n = 4) of the students were unable to provide examples of all the food groups. The 2nd and 3rd grade students completed a knowledge-based multiple choice pre- and post-test. This test aimed to evaluate the understanding of nutrition and healthy eating behaviors. Students present on the first day (n = 10) had a pre-test mean score of 85% (x̄ = 5.1, SD=2.1). During the final day of the program the students (n = 10) had a post-test mean score of 91% (x̄ = 5.5, SD=0.7). In addition to the post-test, on the last day 60% of the students completed a knowledge application test, in which they provided all the components of MyPlate and accurate examples of each of food group; 40% (n = 4) partially provided or not completed examples. In the true/false portion of the post-test, the group had a mean score of 93% (x̄ =2.8, SD=0.4). The 4th and 5th grade students completed a knowledge-based multiple choice pre- and post-test. This group of students who were present on the first day of the project (n = 10) had a healthy eating curriculum pre-test score of 70% (x̄ = 4.2, SD=1.1). The student post-test (n = 8) had a score 93% (x̄ = 5.6, SD=0.7). On the last day the students (n = 9) completed the post-test. 89% of students (n = 7) provided all the components of MyPlate section of the test and provided accurate examples of each of MyPlate groups; 22% (n = 2) partially provided or not completed HEALTHY EATING 22 examples in this evaluation. In the true/false portion of the post-test, the students had a mean percentage score of 92% (x̄ = 2.7, SD=0.5). A T test was conducted using the students' scores who completed the pre-test and post-test The results of all the participating students’ pre-test (M= 3.6, SD= 1.9) and post-test (M=5.7, SD=0.7) indicate that there is a significant increase of healthy eating awareness among the students who participated in the project t (17) = 4.6, p<0.001. This positive increase in students' scores reflects that the curriculum was effective by helping students understand healthy eating behaviors and being able to recognize the nutrient-dense food groups recommended by MyPlate. Table 1. t-test using descriptive statistics Grade n Diff x̄ Sd df t p 2nd-3rd grade 10 1.1 0.69 9 1.6 0.07 4th-5thgrade 8 3.125 0.43 7 7.25 <0.001 Combined data 18 2.12 0.46 17 4.59 <0.001 The process of evaluating the curriculum for stakeholders revealed that in order to obtain reliable data during pre and post-test evaluations, it is necessary to approach the lower-level literacy during pre-test and post-test evaluations of the kindergarten and first grade students differently. This can be addressed by implementing picture-based evaluations and tailor classes based on students cognitive and literacy level. Discussion The goal of the DNP project was to improve the knowledge of healthy eating behaviors among students from low socioeconomic status in Ogden, Utah. This was achieved by implementing an after-school healthy eating curriculum. The project findings demonstrated the positive impact the curriculum had on students' learning by having positive scores on the healthy HEALTHY EATING 23 eating application activities and post-test scores. Furthermore, throughout the project the students of all ages were engaged and showed eagerness to learn which then manifested in the increase of test's scores. The fifth graders showed reluctance to learn on the first day, but during the remaining classes they were eager to learn and participate in activities such as cooking. Some of the most popular activities where MyPlate examples, dancing to songs that taught food groups, and cooking demonstrations. Students enjoyed and appreciated positive reinforcement approaches such as fruits with positive messages and were willing to try new foods and drinks that haven't tried before including rice cakes, Greek yogurt, quinoa and infusion water. Limitations This project was impacted by COVID-19 restrictions. The Ogden School District practiced strict CDC-recommended COVID-19 precautions. As a guest to the school and a representative of the health care community, the safety of the children and teachers was paramount to the project. Other activities such as the market tour had to be canceled in order to follow the pandemic precautions. The number of classes originally planned had to be reduced to accommodate the lower teacher to staff ratio required by the office of Child Care Licensing, Lower-level literacy was an important factor in the data collection among the kindergarten and first grade group. The study did not anticipate the kindergarten students' literacy proficiency compared to the rest of the participating student groups. Because of the discrepancy in literacy levels, the study was not able to obtain consistent pre or post-test values. During the evaluation it was decided that kindergarten and first grade students would be removed from in the pre and post-test evaluation process. HEALTHY EATING 24 Practice Implications This project revolved around the importance of promoting self-efficacy, by using positive deviance and positive reinforcement approaches. The project findings demonstrated a positive statistical significance in student learning by being able to apply healthy eating concepts and recognize the nutrient-dense food groups recommended by MyPlate. Children who have healthy eating knowledge attain behaviors that promote healthy eating choices rich in nutrient-dense foods which are optimal for school-age children's adequate growth and development. As DNP-FNP graduate it is critical to understand healthy nutrition concepts and use this knowledge to promote the importance of maintaining healthy eating patterns as they play a critical role in helping children, especially for those in vulnerable populations, achieve their optimal health and healthy weight Furthermore, a major healthcare implication includes to continue working collaboratively by lobbying legislation and promoting further curriculums that can help prevent at an earlier age the lifetime risk of obesity and other chronic ailments. Since the Affordable Care Act in 2010 an ever-rising awareness of promoting healthy eating has occurred. This policy calls on the importance of healthy eating early in life. There is a need for creating myriad ways to improve healthy eating and healthy behaviors that help children to attain a healthy start in life. Therefore, it is necessary to continue supporting these projects as they are demonstrating to be effective and that have the potential to improve the health outcomes of Ogden's children. Recommendations Recommendations from this project implementation include the expansion of this project throughout other schools that are affected with the same social determinants as the group from this project. The positive-deviance and food insecurity curriculum used in this project can be HEALTHY EATING 25 optimized by providing a curriculum with lesson and activities tailored to f’ cognitive and literacy levels. Another recommendation includes the creating of a family-oriented program which can impact not only the students but also their families. During the project, students related to the DNP student as a local nurse, non-native speaker, and member of their community. Shared social determinants helped the classes feel like finding solutions together. It is important to engage and educate elementary school teachers and principals for project sustainability. Their collaborative support provides excellent opportunities to incorporate strategies for classroom nutrition and healthy eating education. Educators can reinforce nutrition and healthy eating principles if they are knowledgeable about it. Conclusion Children from low socioeconomic status are disproportionally affected by the negative effects of having unhealthy eating habits. Research correlates unhealthy eating to poor health outcomes, poor academic performance, and negative psychological consequences over time, including depression. Ogden School District provides nutritionally balanced meals to their elementary school students. However, limited healthy eating education is incorporated into elementary schools’ curriculum. This DNP project evolved from the ongoing work from Ogden's local community groups, Weber-Morgan Health Department and OSD stakeholders to improve the health outcome of Ogden's children and address this problem. The project implementation consisted of an after-school healthy eating curriculum developed from a positive-deviance and food insecurity curriculum and used the social cognitive theory framework. The post-curriculum surveys showed that students had a 35% increase in their understanding of healthy eating behaviors and recognizing healthy food groups. Children who HEALTHY EATING 26 have healthy eating knowledge can attain behaviors that promote healthy eating choices, which ultimately help them achieve their optimal health and healthy weight. It is important to continue optimizing and promoting this project's expansion throughout other schools that are affected with the same social determinants as the population group. It is also essential to include elementary school teachers and principals and promote their involvement and collaboration in helping elementary school students attain healthy eating literacy. These projects are proving not only to be effective in promoting students' self-efficacy but also have the potential to improve the health outcomes of children and help them attain a healthy start in life. HEALTHY EATING 27 Reference Association of Diabetes Care and Education Specialist ([ACDES], 2020). Healthy eating. Retrieved from https://www.diabeteseducator.org/living-with-diabetes/aade7-self-care-behaviors/ healthy-eating American Academy of Orthopedic Surgeons. (2020). How childhood obesity impacts bone and muscle health. Retrieved from https://orthoinfo.aaos.org/en/staying-healthy/the-impact-of- childhood-obesity-on-bone-joint-and-muscle-health/ Action for Healthy Kids. (2019). Nutrition education. 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Retrieved from:https://www.census.gov/quickfacts/fact/table/UT,webercountyutah,ogdencityutah/P ST045219 United States Census Bureau. (2018). U.S. Census Bureau Quick Facts: Utah; Ogden City, Utah. Retrieved from https://www.census.gov/quickfacts/fact/table/UT,ogdencityutah/PST045219 U.S. Department of Agriculture and U.S. Department of Health and Human Services (2010). Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office. U.S. Department of Agriculture and U.S. Department of Health and Human Services (2015) 2015–2020 Dietary Guidelines for Americans. 8th Edition. Retrieved from: https://health.gov/sites/default/files9-09/2015-2020_Dietary_Guidelines.pdf U.S. Department of Agriculture. (2020). MyPlate, MyWins | ChooseMyPlate. Retrieved from https://www.choosemyplate.gov/eathealthy/myplate-mywins World Health Organization. (2014). What is overweight and obesity? Retrieved from https://www.who.int/dietphysicalactivity/childhood_what/en/ Woo, T., & Robinson, M. (2020). Pharmacotherapeutics for advanced practice nurse Prescribers (5th ed.). Philadelphia, PA: F. A. Davis Company. HEALTHY EATING 33 Appendix A.Lesson plan example Week 1: My Plate/ Food Groups Objectives: Theme Objectives: 1. Students will develop an understanding of the different areas of MyPlate. 2. Students will design healthy meals based on MyPlate. 3. Students will begin to identify healthy food options for the different areas of MyPlate. Sub-Theme Objectives: ● Students will grasp the objectives behind the MyPlate model. ● Students will define where, and how much, grains/carbohydrates, as well as fruits and vegetables, are suggested per meal for their plates. ● Students will define where, and how much, protein and dairy are suggested per meal for their plates. ● Students will demonstrate their knowledge by building MyPlate approved meals. Materials: Time Teacher Activity Materials 01-01:05 Ice breaker ●Name ●Grade ●Favorite food ●Whiteboard ●Markers ●Flipchart Prompt "Introduce yourself! Tell us your name, your grade, and your favorite food" 01:05- 01: 25 Introduction to Healthy Eating Introduction to MyPlate principles. What is MyPlate? Why do we use MyPlate? Brief intro. to what the different disciplines of MyPlate are. Complete Pre-test Watch My Plate My Body Video. Break 01:25 – 01:30 ● Play song ● Pass out lyrics with the group highlighted ● Play and sing along Stand up and move around (practice a choreography) https://fns-prod. azureedge.net/sites/default/files/tn/ali vewithfive.mp3 HEALTHY EATING 34 THEN ● Each kid makes up their own dance moves ● Share your moves and pick the best ones! Alive with Five!! https://www.youtube.com/watch?v=9U2h uJTVzjc https://www.youtube.com/watch?v=iSheg ZyzXm8 some steps? https://www.youtube.com/watch?v=Ojblh vzvjsk 01:30-01:35 Visit each individual area of a MyPlate plate. Give specific food examples for each that are culturally appropriate to the audience. As you teach each section, instruct students to color in that section with their favorite foods that apply. MyPlate Placemat worksheet Puzzle Board kids_food_plate_printable.pdf Shopping list Magnets to the Placemat Extras Activities Visit each individual area of a MyPlate plate. Give specific food examples for each that are culturally appropriate to the audience. As you teach each section, instruct students to color in that section with their favorite foods that apply. MyPlate Placemat worksheet, markers, colored pencils, or crayons MyPlate Placemat Activities ● Coloring sheet of Utah with my plate ● Activity sheet ● Games Materials: MyPlate Placemat roulette, markers, colored pencils, or crayons, scissors. HEALTHY EATING 35 01:40-01:45 Wrap up. Test student comprehension of lesson by asking appropriate questions related to MyPlate. Ask them to share one or two sentences that they completed while in their group activity. Review what healthy eating is Review what are the elements of my plate? Review what are the colors of my plate? Review what do the colors present in my plate represent? Thank the children for their participation and ask for suggestions! Materials: Whiteboard, dry-erase marker(s) Exit Tickets Week 2: My Plate/Food Groups Time Teacher Activity Materials 12-12:05 Ice breaker "I’m so glad to see you all here again! Today we’re going to talk about the food groups. Turn to the person to your right and tell them the five food groups!” Check to see if they are focused. When they’re not, pull the group back together. “Awesome! We’re going to learn a little more today about the food groups. First, let’s watch a video. The woman in the video talks pretty fast because she’s so excited about the food groups! Don’t worry about understanding everything she says.” MyPlate on the screen or poster or handouts. Share how they applied what they learned with a partner or small group (person to your right). https://fit.sanfordhealth.org/resources/u1l 1-k2-what-choices-do-you-make-each-day- slideshow HEALTHY EATING 36 01:05- 01: 12 Introduction to Healthy Eating “Wow! She talked so fast! Don’t worry if you didn’t understand everything in the video. We’re going to review and keep talking about the food groups for the rest of the day and keep talking about it throughout the program!” the five food groups 01:12- 01:27 Choreography time Each group a food group Remember only your move/food group for next week Put it all together later Stand up and move around https://fns-prod. azureedge.net/sites/default/files/tn/a livewithfive.mp3 https://www.youtube.com/watch?v=9U2h uJTVzjc https://www.youtube.com/watch?v=iShe gZyzXm8 Extra? Who wants to play Bingo? (Bingo instructions are included on the link) Bingo Time!! 01:20 01:35 Visit each individual area of a MyPlate plate. Give specific food examples for each that are culturally appropriate to the audience. As you teach each section, instruct students to color in that section with their favorite foods that apply. MyPlate Placemat Activities ● My Plate game 01:35- 01:40 Visit each individual area of a MyPlate plate. MyPlate Placemat worksheet, markers, colored pencils, or crayons ● Activity sheet ● Coloring plate ● Placemat coloring page ● Games HEALTHY EATING 37 All MyPlate Activities ● Print p. 10 x1 ● Print p. 11 x10 Materials: MyPlate Placemat roulette, markers, colored pencils, or crayons, scissors. 01:40-01:45 Wrap up. Test student comprehension of lesson by asking appropriate questions related to MyPlate. Ask them to share one or two sentences that they completed while in their group activity. Review what healthy eating is Review what are the elements of my plate? Review what are the colors of my plate? Review what does the colors present in my plate represent? Thank the children for their participation and ask suggestions! Materials: White board, dry-erase marker(s) HEALTHY EATING 38 B. Data collection tools satisfaction Survey HEALTHY EATING 39 C. Data Collection Pre and Post-test.