Original Article

Role Modeling as an Early Childhood Obesity Prevention

Strategy: Effect of Parents and Teachers on Preschool
Children’s Healthy Lifestyle Habits
Ruby A. Natale, PsyD, PhD,*† Sarah E. Messiah, PhD, MPH,†‡ Lila Asfour, MS, MA,‡
Susan B. Uhlhorn, PhD,* Alan Delamater, PhD,* Kris L. Arheart, EdD†‡

ABSTRACT: Objective: To assess the effectiveness of a child care center-based parent and teacher healthy
lifestyle role-modeling program on child nutrition and physical activity outcomes. Methods: Child care cen-
ters (N 5 28) serving low-income families were randomized to intervention or control arms. Intervention
centers (N 5 12) implemented (1) menu modifications, (2) a child’s healthy lifestyle curriculum, and (3) an
adult (teacher- and parent-focused) healthy lifestyle role-modeling curriculum. Control centers (N 5 16)
received an attention control safety curriculum. Nutrition and physical activity data were collected at the
beginning (T1) and at the end (T2) of the school year. Exploratory factor analysis identified positive and
negative nutrition and physical activity practices by children, parents, and teachers. Results: Intervention
parents’ baseline (b 5 .52, p < .0001) and school year consumption (b 5 .47, p < .0001) of fruits/vegetables
significantly increased their children’s consumption of fruits/vegetables from T1 to T2. Intervention parents
significantly influenced a decrease in children’s junk food consumption (b 5 2.04, p < .05), whereas control
parents significantly influenced an increase in their children’s junk food consumption (b 5 .60, p < .001) from
T1 to T2. Control children showed a significant increase in junk food consumption (b 5 .11, p 5 .01) and
sedentary behavior (b 5 .09, p < .005) from T1 to T2. Teachers did not significantly influence preschool-age
children’s nutrition or physical activity patterns from T1 to T2. Conclusions: Parent nutrition and physical
activity patterns significantly influence their preschool-age children’s consumption of fruits/vegetables, junk
food, and level of sedentary behavior. Future obesity prevention intervention efforts targeting this age group
should include parents as healthy lifestyle role models for their children.
(J Dev Behav Pediatr 35:378–387, 2014) Index terms: obesity, preschool, childcare, prevention, early childhood.

H ealthy People 20201 identifies “Nutrition and

Weight Status” as one of the major objectives to “pro-
mote health and reduce chronic disease risk through the
consumption of healthful diets and achievement and
maintenance of healthy body weights.” This objective
emphasizes that efforts to change diet and weight should
address the policies and environments that support these
behaviors in settings such as schools.1 This objective is
particularly relevant in our nation’s preschools and early
childhood/child care environments (or “child care cen-
From the *Division of Clinical Psychology, Department of Pediatrics, University
of Miami Miller School of Medicine, Miami, FL; †Division of Pediatric Clinical
Research, Department of Pediatrics, University of Miami Miller School of Med-
icine, Miami, FL; ‡Department of Epidemiology and Public Health, University of
Miami Miller School of Medicine, Miami, FL.
Received February 2014; accepted May 2014.
Supported by the US Department of Agriculture (Grant number: AFRI/NRI-2009–
0506, RCT, registration number: NCT017220321).
Disclosure: The authors declare no conflict of interest.
Address for reprints: Ruby A. Natale, PsyD, PhD, Division of Clinical Psychology,
Department of Pediatrics, University of Miami Miller School of Medicine, Mailman
Center for Child Development, Miami, FL 33136; e-mail: rnatale@med.miami.edu.
Copyright Ó 2014 Lippincott Williams & Wilkins
ters”), given that 1 in 4 US children under age 5 years are
either overweight ($85th to ,95th percentile of body
mass index [BMI] for age and sex) or obese ($95th
percentile BMI for age and sex)1 with ethnic-minority
children being disproportionately affected.2,3
These statistics are of particular concern because
preschool-aged children with obesity are 5 times more
likely to be overweight during adolescence4 and 4 times
more likely to be adults with obesity when compared
with their normal weight counterparts.5 These results
show that, contrary to popular belief, children do not
“grow out of” their “baby fat.” In fact, evidence indicates
that excessive weight gain in the first years of life can
alter developing neural, metabolic, and behavioral sys-
tems in ways that increase the risk for obesity and
chronic disease later in life such as type 2 diabetes,
cardiovascular disease, hypertension, stroke, osteoar-
thritis, asthma, and certain cancers.6–8
Although few attempts have been made to prevent
excess weight gain during the first years of life, this pe-
riod may represent the best opportunity for obesity
prevention. During early childhood, lifestyle behaviors
that promote obesity are just being learned, and it is
easier to establish new behaviors than to change existing

378 | www.jdbp.org Journal of Developmental & Behavioral Pediatrics

ones. Child care settings offer a potentially powerful in-
frastructure to implement such efforts because: (1) 70%
of US preschool-aged children are enrolled in daily, out-
of-home child care,9 (2) children from low-income
backgrounds consume 50% to 100% of their Recom-
mended Dietary Allowances (standards established by
the Child Care Food Program) in the child care setting,10
(3) many children spend the majority of their waking
hours out-of-home and in the child care setting,11 and (4)
access to high-quality food is a health disparity.12
Previous studies in preschool settings have been suc-
cessful in increasing child physical activities, reducing
television viewing, reducing the consumption of sweet-
ened beverages, and increasing healthy weight among
participants.11,13–17 These studies suggest that quality
nutrition and adequate physical activity are essential to
growth and development, underscoring the importance
of focusing healthy lifestyle choices in the early child-
hood years.11,13–17
Young children are particularly at risk for obesity
because they are fully dependent on adults for their nu-
tritional needs in both the home18 and child care envi-
ronment.19 However, this provides a unique opportunity
to intervene by assigning parents and teachers to the role
of nutritional gatekeepers or healthy lifestyle role models
for the young children in their care. The concept of the
nutritional gatekeeper suggests that empowering parents
and teachers in the home and the child care center will
potentiate a lasting and effective impact on the health
and nutrition of future adults by intervening when they
are young. Moreover, these adults make food choices
couched in attitudes and beliefs toward food and nutri-
tion, which in turn will influence the child’s beliefs,
attitudes, and behaviors surrounding food.20,21
The first school year (2010–2011) results of a ran-
domized controlled trial to prevent obesity by instilling
healthy lifestyle habits among preschool-aged children
are reported here. It was hypothesized that children
randomized to the obesity prevention intervention,
“Healthy Caregivers-Healthy Children (HC2),” would
show better quality nutrition intake and physical activity
patterns versus children in an attention control arm that
received a safety curriculum. The HC2 program focused
on parents/caregivers and teachers as healthy lifestyle
role models/nutritional gatekeepers.
METHODS
A detailed description of the Healthy Caregivers-
Healthy Children (HC2) methods is available else-
where.22 In summary, a total of 28 child care centers
were randomly assigned (through a random number ta-
ble) to 1 of 2 arms: (1) Intervention Arm (n 5 12 centers)
that received HC2, which consisted of an environmental/
center modifications (i.e., menu changes), a Child Cur-
riculum, and a USDA Role Modeling/Gatekeeper Curric-
ulum for parents and teachers or (2) Control Arm (n 5
16 centers) that received an attention control safety
curriculum. An additional 4 centers were added to the
Vol. 35, No. 6, July/August 2014
control arm due to low enrollment at the centers. Both
arms were followed and/or received treatment for 1
school year. This study was approved by the University
of Miami Institutional Review Board (Clinical Trial num-
ber, NCT01722032).
To be included in the randomization process, centers
met the following inclusion criteria: (1) have .30 chil-
dren ages 2 to 5 years enrolled, (2) serve low-income
families, (3) be part of the USDA food program and
SNAP-eligible, (4) reflect the ethnic distribution of the
Miami-Dade County Public School System (63% Hispanic,
19% African-American, and 18% white), and (5) center
directors agree to participate and sign a letter of com-
mitment as evidence of such.
HC2 Content Description
Policy/Environmental Component
HC2 implemented the following best-practice policies
(critical to intervention maintenance and an effective
mediator of change) in all intervention child care cen-
ters: (1) Drink Policy: water promoted as the primary
beverage for staff and children, all cow’s milk provided
will contain #1% milk fat, and juice limited to 1 time per
week, (2) Snack Policy: snack and meal time incorporate
fresh fruits and/or vegetables daily, (3) Physical Activity
Policy: physical activity will be encouraged for
$60 minute/day, and (4) Screen Time Policy: TV/video-
tape/computer viewing will be logged and limited to
,30 minute/week.
Parent and Teacher HC2 Role-Modeling
Curriculum
The HC2 role modeling curriculum (available in both
English and Spanish, with culturally sensitive language
and activities) is the only one of its kind developed
through USDA funding, including components of Project
MOM23 and Team Nutrition24 messaging regarding the
importance of nutritional gatekeepers. The inter-
vention’s substantive nutrition and lifestyle education
covers key behavior-focused topics, grouped by mediat-
ing factors related to perceived benefits, perceived
control, and self-efficacy. Six trainings occurred on
a monthly basis during the 2010 to 2011 school year.
They were delivered to parents and teachers and oc-
curred at times agreed on by each center (child pickup
time has been the most used).
HC2 program staff conducted joint parent-teacher
meetings (providing a substitute so that teachers can at-
tend during parent pickup times) that focused on an
evidence-based nutrition and physical activity curriculum.
Parents and teachers were taught about (1) choosing
healthy foods with an emphasis on fruits and vegetables,
(2) making healthy food choices for child development,
(3) preparing nutritious snacks, (4) preparing new rec-
ipes, (5) tasting new foods, (6) learning about food safety
and storage, (7) planning meals, (8) making grocery lists,
(9) shopping wisely for groceries, (10) budgeting food
dollars and food stamps, and (11) using food labels to
choose best buys. By means of role modeling, parents and
© 2014 Lippincott Williams & Wilkins 379
teachers were encouraged to implement change at the
family/home and child care center level. Additionally,
nutritional professionals served as role models for the
teachers and parents and assisted them as nutritional
gatekeepers and positive models for the children.
HC2 Child Curriculum
Lesson plans were designed to incorporate and re-
inforce the policy standards; half focused on beverage/
snack policies and half focused on physical activity/
screen time policies. To increase ease of use, the lesson
plans outline includes cognitive, fine motor, and self-help
instructional components required for teachers as they
apply to the policy objective. The curriculum has lesson
plans for teachers based on Caring for Children, 3rd
Edition25 standards and messaging from the Let’s Move
Child Care campaign.26 The teachers received weekly
technical assistance instruction on how to promote
wellness within a group’s child care setting. During these
weekly visits, curriculum specialists targeted the cogni-
tive, cultural, and environmental barriers to a low fat,
high fiber diet that include more fruits and vegetables.
These weekly visits are designed to increase self-efficacy
for implementing change in nutrition and physical ac-
tivity. The child curriculum was conducted weekly from
November 2010 to April 2011.
Control Group
Schools randomized to the control arm received an
attention control safety curriculum delivered by charac-
ter “Safety Sam,” which provided parents and teachers
with home, car, and child seat safety information. They
received all the same pre-post measures as the in-
tervention arms. They also received the same incentives
as the intervention arms to foster involvement and en-
sure retention/reduce loss to follow up. The safety cur-
riculum was conducted 3 times during the 2010–2011
school year.
Child Measures
Child measures included Consumption of Fruit/
Vegetables, Consumption of Junk Food, and Sedentary
Behavior. These measures were based on questions
from the Healthy Kids Checklist,27 a 32-item rating
scale targeted at children in preschool through pa-
rental responses on their behalf. The Consumption of
Fruit/Vegetables was measured using 5 survey ques-
tions, such as “my child eats fruit” and “my child eats __
vegetables at his main meal.” The Consumption of Junk
Food was measured using 8 survey questions, such as
“my child eats fast food __ times a week,” “my child
drinks soda or sugared drinks with meals,” and “my
child eats chips for snacks __ times a day.” Sedentary
Behavior was measured using 4 survey questions, such
as “my child watches TV __ hours a day” and “my child
plays video or computer games __ hours a day.” The
Healthy Kids Checklist uses representative visuals with
text at a second grade reading level and has been vali-
dated for our population.28
380 Parent-Teacher Healthy Lifestyle Role Modeling
Parent and Teacher Measures
Parents’ and teachers’ measures include Consumption
of Fruits/Vegetables, Consumption of Junk Food, and
Physical Activity. Consumption of Fruits/Vegetables and
Consumption of Junk Food were based on questions
from the Food Behavior Checklist,29 a short, culturally-
neutral, valid, and reliable measure.30 With a sample
of low-income clients from 8 counties participating,
authors reported a criterion validity coefficient (r 5 .43)
with a biomarker, serum carotenoids, for the fruit and
vegetable subscale.30 Convergent validity was reported
for 10 selected nutrients and the Healthy Eating Index for
the 16-item tool. Responses to 19 food behavior items
were significantly correlated with hypothesized 24-hour
recall data (with a maximum correlation of .44 for
drinking milk and calcium) or the USDA Household Food
Security Survey Module (.42 with the food security item).
Coefficients for test-retest reliability ranged from .35 to
.79. Cronbach’s a ranged from .49 for the diet quality
subscale to .80 for the fruit and vegetable subscale.31
Consumption of Fruits/Vegetables was based on 5 survey
questions, such as “fruit—how much do you eat each
day” and “do you eat more than 1 kind of vegetable each
day.” Consumption of Junk Food was based on 4 survey
questions, such as “do you drink regular soda” and “do
you drink fruit drinks, sport drinks, or punch.” Physical
Activity was based on a calculation from the following 2
survey questions: “how many days a week are you
physically active” and “how many minute/hour are you
physically active per day.”
Data Analysis
A principal components factor analysis created factor
scores for children, parents, and teachers based on
responses to food and physical activity behavior survey
questions. Responses of parents and teacher were ana-
lyzed together and separated from children. Using
MPLUS Version 7. (Computer Software. Los Angeles, CA:
Muthén & Muthén.), 3 factor scores were created for
children: Consumption of Fruits/Vegetables, Consump-
tion of Junk Food, and Sedentary Behavior. Two factor
scores were created for the parent-teacher group: Con-
sumption of Fruits/Vegetables and Consumption of Junk
Food. Factor loadings (correlation of the item with the
factor) were positive indicating that a higher response
on that item was positively correlated with a higher
factor value. The factor loadings, Comparative Fit Index
(CFI) and composite reliability for each factor are pre-
sented in Table 1. The resulting factor scores have
a standard normal distribution (mean 5 0; SD 5 1).
To analyze the impact of the intervention on changes
in child food and physical activity behavior, 3 general
linear mixed models were run, with the outcome vari-
able for each model being one of the 3 child factor
scores. Data from T1 (baseline or beginning of the 2010–
2011 school year) and T2 (end of 2010–2011 school
year) were included in the models. Predictors of interest
Journal of Developmental & Behavioral Pediatrics
Table 1. Demographic Characteristics of Children, Parents and included Arm (intervention or control), Visit (T1 or T2),
Teachers, Healthy Caregivers, and Healthy Children and the interaction between Arm and Visit. Model-
Children Parents Teachers estimated means were calculated for baseline differ-
(N 5 1211), (N 5 1211), (N 5 179), ences between the treatment and control group, the
n (%) n (%) n (%) difference in the treatment group from T1 to T2, and the
Sex difference in the control group from T1 to T2.
Two additional general linear mixed models with
Female 607 (50.12) 972 (90) 120 (98.36)
child Consumption of Fruits/Vegetables and Consump-
Male 604 (49.88) 108 (10) 2 (1.64)
tion of Junk Food as the outcome variable were run.
Race Corresponding parent factor scores nested within treat-
Hispanic (Cubans) 163 (15.35) 163 (15.35) 59 (32.96) ment group were added into the model to assess the
Other Hispanics 435 (40.96) 435 (40.96) 63 (35.2) impact of parent factor scores on child factor scores.
Non-Hispanic 150 (14.12) 150 (14.12) 22 (12.29) Two further models were run to assess the impact of
blacks (Haitians) both parent and teacher factor scores on child factor
Other non-Hispanic 202 (19.02) 202 (19.02) 21 (11.73) scores. These models included the outcome and pre-
blacks dictors of the previous 2 models, but added in corre-
Non-Hispanic 71 (6.69) 71 (6.69) 6 (3.35) sponding teacher factor scores nested within
whites treatment group.
Other 41 (3.86) 41 (3.86) 8 (4.47) For the Consumption of Fruit/Vegetables, the model-
estimated means for both the treatment and control
Children age (mean), 46.72 (11.18)
mo group significantly increased from T1 to T2. However,
there were significant baseline differences between the
Parent/teacher age
categories, yr treatment and control groups, where the treatment
group started at a higher consumption of fruits and
18–24 151 (15.05) 11 (6.29)
vegetables, making interpretation of these changes dif-
25–30 373 (37.19) 23 (13.14)
ficult. Therefore, models with the child Consumption of
31–40 381 (37.99) 44 (25.14) Fruit/Vegetables used the change of child Consumption
41–50 86 (8.57) 52 (29.71) of Fruit/Vegetables from T1 to T2 as the outcome mea-
511 12 (1.2) 45 (25.71) sure, and baseline Consumption of Fruit/Vegetables was
Relationship to child included as a covariate.
In all the mixed models, gender (reference group
Mother 958 (88.38)
females), child ethnicity (reference group non-Hispanic
Father 104 (9.59)
whites), and age in months were included as covariates.
Other 22 (2.02) Also, random effects were used to account for the dif-
Languages spoken in ferent sources of variation in the multilevel group ran-
the home domized research design. A random effect was included
English only 226 (18.62) to measure the variation of schools nested in treatment
Spanish only 368 (30.31) groups. In the models including teacher factor scores,
Creole only 35 (2.88) another random term was included for the clustering
effect of teachers (classrooms) nested within schools.
English and Spanish 303 (24.96)
The p value of .05 was used to determine statistical sig-
English and Creole 120 (9.88)
nificance. All mixed models were analyzed using SAS 9.3
Other 162 (13.34) (SAS Institute, Inc., Cary, NC).
Level of education
,12th grade 366 (35.19) RESULTS
Completed high 541 (52.02) A total of 1211 children, 1080 parents, and 122
school or teachers participated in baseline data collection and
equivalency were eligible for follow-up evaluations. Gender was
Completed 133 (12.79) evenly split between boys (n 5 604) and girls (n 5 607),
education with a mean age of 47 months for both. A total of 56% of
beyond high the sample’s children were Hispanic; 41% identified as
school
“other Hispanic” for example, Dominican, Columbian,
Birthplace of caregiver Nicaraguan, etc., and 15% identified as Cuban. Other
US born 330 (30.75) ethnicities included were Haitian (14%), non-Hispanic
Foreign born 743 (69.25) black (19%) and non-Hispanic white (7%). Respondents
were predominantly mothers (88%), and born outside of
the United States (69%). The majority of caregivers
completed high school or GED (52%). Languages other

Vol. 35, No. 6, July/August 2014 © 2014 Lippincott Williams & Wilkins 381
than English were common in the children’s homes, with Table 2. Factor Analysis Loading Scores for Nutrition and Physical
30% speaking only Spanish, whereas 25% spoke Spanish Activity Items
and English. Creole with and without English was also Child Factor Parent/Teacher
spoken in approximately 13% of homes (Table 2). Loadinga Factor Loadinga
Consumption of fruits/
Child Consumption of Fruits/Vegetables Factor Score vegetables
as Outcome
Eat vegetables 0.799 0.774
Results of Only Child Factors Included in Model
Results show that after controlling for baseline con- Eat multiple 0.818 0.861
vegetables/day
sumption, the treatment group did not significantly
change their consumption of fruits and vegetables, Eat fruits 0.786 0.711
whereas the control group significantly decreased their Eat vegetables with 0.702 0.749
consumption (b 6 SE: 2.32 6 .08, p , .001), and this main meal
between-group difference was statistically significant Eat fruit for snacks 0.684 0.781
(p , .05) (Table 3, Column 1). Gender, age, and race/ Model fit—CFI 0.967 0.949
ethnicity had no significant effects on the outcome, Composite reliability 0.872 0.872
whereas the child’s baseline factor score was signifi-
Consumption of junk
cantly negatively associated (the less the child ate fruits food
and vegetables at baseline, the less likely they were to
Eat fried foods/times 0.573
consume them after 1 school year) with the factor score per week
change (b 6 SE: 2.53 6 .04; p , .001).
Drink sports drinks/ 0.602 0.498
Results of Parent Factors Included in Model times per day
For both the treatment and control groups, greater
Eat fast food/times per 0.607
parent Consumption of Fruits/Vegetables corresponded week
to greater child Consumption of Fruits/Vegetables
Eat chips for snack/ 0.713
(Table 3, Column 2). When the parents baseline factor times per day
score and change were added to the model, a slight de-
Drink soda/times per 0.736 0.437
crease in fruit/vegetable consumption in the intervention day
group became significant (20.10 6 0.04; p 5 .01), and
Eat junk food (candy, 0.718
the decrease in the control group remained significant cookies, etc)
(.21 6 0.05; p , .001). Gender, age, and race/ethnicity
Eat snacks/per day 0.711 0.655
had no significant effects on the outcome, whereas the that are junk food
child’s baseline factor score was significantly negatively
Drink soda with 0.712
associated with the factor score change (b 6 SE: 2.68 6 meals/times per day
.04; p , .001).
Drinks citrus or fruit 0.690
Results of Parent and Teacher Factors Included juice
in Model
Model fit—CFI 0.953 0.917
Adding teacher factor scores into the model signifi-
Composite reliability 0.869 0.662
cantly reduced the number of units for analysis (Table 3,
Column 3). Parent Consumption of Fruits/Vegetables Sedentary behavior
was significantly associated with child consumption for Watch TV/hours per 0.757
the treatment group but not the control group. The day
teacher factor scores were not significant. Both non- Videogames/hours 0.614
Hispanic blacks and Haitians consumed significantly per day
less fruits and vegetables versus their non-Hispanic white Watch TV during 0.576
peers. There were no significant changes in any of the meals
groups in either treatment or control nor was there Have TV in bedroom 0.559
a significant difference between treatment and control Model fit—CFI 0.994
when teachers were included in the model. Composite reliability 0.723
aReported value represents the correlation between the item and the factor score.
Child Consumption of Junk Food Factor Score
as Outcome
Results of Only Child Factors Included in Model Results of Parent Factors Included in Model
Over the school year, the control group significantly Intervention group parents significantly influenced
increased their consumption of junk food (p 5 .01), their children to decrease their junk food consumption
whereas the treatment group slightly decreased their (b 6 SE: 2.12 6 .06; p , .05), whereas control group
consumption, (NS) and this between-group difference parents influenced their children to consume more junk
was significant (p 5 .01). (Table 4, Column 1). food (b 6 SE: .60 6 .07; p , .001) over the school year

382 Parent-Teacher Healthy Lifestyle Role Modeling Journal of Developmental & Behavioral Pediatrics
Table 3. Child Consumption of Fruits/Vegetables Factor Score as Outcomea
Only Child Factors Including Parent Factors Including Parent and Teacher
(n 5 650) (n 5 650) Factors (n 5 97)
Variable b Coefficient SE p b Coefficient SE p b Coefficient SE p
Arm (intervention) .22 .10 .04 .07 .06 .28 2.22 .21 .33
Baseline child factor score 2.53 .04 ,.001 2.68 .04 ,.001 2.75 .11 ,.001
Baseline parent factor score — — — .52 .05 ,.001 .56 .13 ,.001
Parent factor (intervention arm) — — — .47 .05 ,.001 .64 .12 ,.001
Parent factor (control arm) — — — .79 .05 ,.001 .29 .20 .16
Baseline teacher factor score — — — — — — .37 .19 .06
Teacher factor (intervention arm) — — — — — — 2.06 .13 .66
Teacher factor (control arm) — — — — — — .25 .20 .21

Adjusted Mean SE p Adjusted Mean SE p Adjusted Mean SE p

Intervention change 20.10 0.07 .17 20.10 0.04 .01 0.04 0.11 .71
Control change 20.32 0.08 ,.001 20.21 0.05 ,.001 0.25 0.17 .17
Intervention vs control change 0.22 0.10 .04 0.11 0.06 .07 20.21 0.21 .34
aAll models controlled for gender, age, and race/ethnicity.

(Table 4, Column 2). Compared with non-Hispanic
white children, other black children were more signif-
icantly likely to consume junk food over the school year
(b 6 SE: .34 6 .08; p , .001). Age was positively sig-
nificantly associated with the consumption of junk food
(b 6 SE: .05 6 .002; p , .005). Parental effects did not
change the junk food consumption of the intervention
group (mean 6 SE: time 1, 0.05 6 0.04; time 2, 0.03 6
0.04; change, 20.02 6 0.03; p 5 .44). However, pa-
rental influence blunted the consumption in the control
group (mean 6 SE: time 1, 0.02 6 0.05; time 2, 0.08 6
0.05; change, 0.06 6 0.04; p 5 .19). The amount of
change was not significantly different between the
groups (p 5 .13).
Results of Parent and Teacher Factors Included
in Model
When teachers were included in the model, no sig-
nificant changes were found (Table 4, Column 3).
Child Sedentary Behavior Score as Outcome
Results of Only Child Factors Included in Model
The control group experienced a significant increase
in sedentary behavior from T1 to T2, whereas the treat-
ment group slightly decreased sedentary behavior (NS)
(Table 5, Column 1). These between-treatment group
changes were significant (p , .004). Compared with
white children, other black children (b 6 SE: .26 6 .08;
p , .001) and Haitian children (b 6 SE: .15 6 .06; p 5 .01)

Table 4. Child Consumption of Junk Food Factor Score as Outcome

Only Child Factors Including Parent Factors Including Parent and Teacher
(n 5 650) (n 5 650) Factors (n 5 97)
Variable b Coefficient SE p b Coefficient SE p b Coefficient SE p
Arm (intervention) .06 .06 .32 .04 .06 .49 2.09 .14 .52
Visit (Time 2) .11 .04 .01 .06 .04 .19 .13 .10 .18
Arm visita 2.13 .05 .01 2.08 .05 .13 2.13 .12 .26
Parent factor (intervention arm) 2.12 .06 .04 2.07 .14 .64
Parent factor (control arm) .60 .07 ,.001 .07 .20 .72
Teacher factor (intervention arm) — — 2.18 .15 .22
Teacher factor (control arm) — — .12 .20 .56

Adjusted Mean SE p Adjusted Mean SE p Adjusted Mean SE p

Intervention change 20.02 0.03 .38 20.02 0.03 .44 20.002 0.07 .98
Control change 0.11 0.04 .01 0.06 0.04 .19 0.13 0.10 .18
Intervention vs control change 20.13 0.05 .01 20.08 0.05 .13 20.13 0.12 .26
aAll models controlled for gender, age, and race/ethnicity.

Vol. 35, No. 6, July/August 2014 © 2014 Lippincott Williams & Wilkins 383
Table 5. Child Sedentary Behavior as Outcome
Child Sedentary Behavior Including Parent Activity Including Parent and
Factor Score (n 5 821) (n 5 772) Teacher Activity (n 5 75)
Variable b Coefficient SE p b Coefficient SE p b Coefficient SE p
Arm (intervention) .06 .04 .166 .05 .04 .24 .08 .17 .64
Visit (time 2) .09 .03 .003 .02 .03 .57 .15 .08 .07
Arm visit a
2.11 .04 .004 2.03 .03 .30 2.26 .17 .13
Parent activity (intervention arm) — — 2.005 .002 .053 2.002 .01 .80
Parent activity (control arm) — — .004 .003 .19 2.001 .01 .89
Teacher activity (intervention arm) — — — — .03 .02 .07
Teacher activity (control arm) — — — — .001 .01 .90

Adjusted Mean SE p Adjusted Mean SE p Adjusted Mean SE p

Intervention change 20.02 0.02 .43 20.02 0.02 .30 20.11 0.15 .47
Control change 0.09 0.03 .003 0.02 0.03 .57 0.15 0.08 .07
Intervention vs control change 20.11 0.04 .004 20.03 0.03 .30 20.26 0.17 .13
aAll models controlled for gender, age, and race/ethnicity.

were more likely to exhibit sedentary behavior over the
school year.
Results of Parent Factors Included in Model
When parents were included in the model, (1) no
changes in sedentary behavior were noted between non-
Hispanic blacks and Haitians versus non-Hispanic whites
and (2) no significant changes in the children’s sedentary
behavior were found (Table 5, Column 2).
Results of Parent and Teacher Factors Included
in Model
When teachers were added to the model, non-
Hispanic black children became more sedentary versus
non-Hispanic white children (Table 5, Column 3).
DISCUSSION
Results here show that multiethnic parents are sig-
nificant role models for their children in context of fresh
produce consumption: parents who eat more fruits and
vegetables also have children who consume more fruits
and vegetables. The intervention group children did not
increase their intake of junk food or sedentary behaviors
over the school year, whereas the control group did.
Teachers were not found to be significant role models
for fruit and vegetable, junk food consumption, or sed-
entary activity among preschool children.
Overall, these findings have direct implications for the
Nutrition and Weight Status objectives for Healthy Peo-
ple 2020 that reflect strong science supporting the
health benefits of eating a healthful diet and maintaining
a healthy body weight. The objectives also emphasize
that efforts to change diet and weight should address
individual behaviors, as well as the policies and envi-
ronments that support these behaviors in settings such as
schools. These objectives are especially relevant to
maximize young children’s growth and development,
particularly those from low socioeconomic backgrounds.
In general, the diet quality of most children ages 2 to 9
years in the United States is less than optimal.32 This is of
concern because poor eating habits in young children
may not only impair their growth and development, but
also serve as the foundation for poor eating behaviors in
adolescence and adulthood. Such eating behaviors and
inactivity are key factors in the prevalence of overweight
or the maintenance of healthy weight in healthy growth
trajectories.1
The findings reported here support the crucial role
parents from diverse ethnic backgrounds play in making
sound nutritional choices and being positive role models
for their families. Although the family and home envi-
ronment are important in shaping the dietary patterns of
children, research among low-income minority groups
has been limited, particularly among subgroups of major
ethnic groups. In general, our treatment group results
corroborate with other studies that have reported in-
creased parent consumption of fruits and vegetables is
significantly associated with the child’s increased con-
sumption of fruits and vegetables. Others have shown
that parental food involvement was strongly correlated
with consumption of fruits and vegetables (amount and
diversity) for both parents and children.33 Another study
examining the relationship between parent role model-
ing on the consumption of unhealthy snack foods
reported significant correlations between parent and
child snack intake and eating motivations.34 Other
groups focused specifically on parents of preschool-age
children reported that mothers’ intake of unhealthy
foods parallels consumption by their children.35 Simi-
larly, results here showed that junk food consumption
increased for the control group, whereas decreased for
the intervention group over the study period, with
parents having a significant impact on these consump-
tion patterns. In context of ethnic group differences,

384 Parent-Teacher Healthy Lifestyle Role Modeling Journal of Developmental & Behavioral Pediatrics
Skala et al36 reported that Hispanic families were more
likely to have fresh fruits and vegetables available com-
pared with African-Americans.
Our analysis also found ethnic group differences in
the intake of junk food. Specifically, junk food intake
significantly increased over the study period among
non-Hispanic black children but not among other eth-
nic groups. This finding is supported by other studies
that have shown after controlling for socioeconomic
and demographic variables; increased fast-food con-
sumption was independently associated with non-
Hispanic black race/ethnicity.37 Similarly, our group
has reported previously that 78% of ethnic-minority
children attending federally subsidized child care cen-
ters in Miami, FL, ate dinner from a fast-food restaurant
at least once per week,38 which may help explain this
finding here in the same sample population. Skala
et al36 reported that African-Americans’ families were
more likely to restrict and reward their preschool-age
children with dessert than Hispanic families, but His-
panic families were more likely to have soda available
in the home.
Similar ethnic group differences were shown for
physical activity patterns. Overall, sedentary behavior
increased significantly in the control group, whereas
decreased in the intervention group when only the child
was included in the model over the school year. How-
ever, non-Hispanic black children were more likely to
exhibit sedentary behavior versus their non-Hispanic
white counterparts. This supports previous findings of
black children watching more television than other
ethnic groups.39 However, when parents were included
in the model, ethnic group differences in sedentary be-
havior were no longer observed, suggesting that parent
influence can override ethnic disparities through positive
role-modeling behaviors. Interestingly, when teachers
were included in the model, non-Hispanic black children
became more sedentary.
Previous studies have documented that a variety of
demographic, psychological, social, and physical envi-
ronmental variables correlate with older youth physical
activity.40–42 Parent support, through providing both
social relationships (e.g., directly supportive words), in-
terpersonal transactions (e.g., actions), and active role
modeling have all been suggested as having a significant
impact on child activity patterns. The Framingham
Children’s Study showed that children with 2 active
parents were almost 6 times as likely to be active than
children of sedentary parents.43 Others have reported
similar results using a comparable protocol in their ex-
amination of familial aggregation in physical activity for
young children and their parents.44 Several studies of
older aged children have also found positive correlations
between physical activity within families45 and in
African-American families in particular.46 However, to
our knowledge, there are no studies in the literature
reporting on the influence of parent physical activity role
modeling in preschool non-Hispanic black (of various
Vol. 35, No. 6, July/August 2014
origins including the West Indies) and Haitian children as
reported here.
Although the positive impact of parent role modeling
was consistently found for both nutrition and physical
activity outcomes, teachers were found to have no ef-
fect, and in some cases, even a negative impact. Given
that children enrolled in the study spend the majority of
their day (8AM–4PM) at school, more robust results were
expected about teacher role-modeling outcomes. One
possible explanation is that children look up to parents
in all areas of their life, but look to teachers as more of an
educational capacity. One study examined the role of
parents and teachers related to adolescents and found
that parent support was significantly related to the ado-
lescent self-determination in all life domains, but teach-
ers only added significantly to the domain of school.47
The only statistically significant impact teachers had
were with non-Hispanic black and Haitian children, and
the influence was negative. One possible explanation
may be that black and Haitian teachers do not see
physical activity as critically important during these
years, especially given limited health literacy with these
populations. Studies have documented limited health
literacy as a contributing factor to racial disparities in
health care with African-Americans.48,49 In addition,
immigrant women often experience more mortality
than women born in the United States because of be-
lief systems incongruent with preventive screening
behaviors,50–52 which has been noted in Haitian
populations.53,54
Study Limitations
The use of self-report nutrition and physical activity
measures remains a historic challenge to collecting ac-
curate information but in a community-based study, such
as this one, is a realistic option. Social desirability is al-
ways a concern in self-report data. However, because
social desirability and social approval are considered
traits, it was reasonable to assume that a randomized
controlled trial should address this limitation in that so-
cial desirability would be equal across both arms of the
study. In addition, literature suggests that reporting bia-
ses may be minimized through survey and questionnaire
design. In particular, with dietary data, biases may be
more concentrated in response to questionnaires that are
more structured and quantifiable.55,56 Our study that had
a mixture of questionnaires were structured and less
specific to further address this issue. Another limitation
was differences in the number of times the intervention
curriculum and the control curriculum were imple-
mented during the year. The control condition received
3 monthly injury prevention sessions, whereas the in-
tervention received 6 monthly obesity prevention ses-
sions. Finally, the low-literacy level of the population was
a limitation. To address these limitations, measures were
chosen to be simple, at a fifth grade reading level and
with frequent use of graphics to maximize parent com-
prehension. Furthermore, the data were collected in an
© 2014 Lippincott Williams & Wilkins 385
interview format with seasoned researchers who were
able to quickly gather the needed information to assist
with accuracy and in the parent’s native language
(English, Spanish, and Creole).
CONCLUSIONS
The results reported here support a role-modeling
theory of parental influence and indicate that parents’
behaviors closely correspond to those of their children.
Clinicians should encourage parents to be mindful of
their behaviors because they influence the development
of eating behaviors in the critical developmental years.
For obesity to be prevented, it is recommended that
clinicians and educators start with preschool-age children
and their families so the only habits they learn are healthy
ones. The findings here indicate that parents in non-
Hispanic black children in particular have a strong in-
fluence on their children’s healthy lifestyle behaviors,
suggesting cultural components should be included in
obesity prevention programs. Investigators should con-
sider addressing literacy barriers in health care as part of
obesity interventions to reduce racial disparities.
ACKNOWLEDGMENTS
The authors would like to acknowledge all center directors,
parents, teachers, and children who participated in the study to make
it a success.
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© 2014 Lippincott Williams & Wilkins 387