Sustainability via Active Garden Education (SAGE): results from two feasibility pilot studies

SAGE was implemented in the US by trained research staff in four ECEC in Houston, Texas (SAGE 1) and in two ECEC in Phoenix, Arizona (SAGE 2). All centers were licensed and accredited offering full and half day care to preschool aged children. All students between the ages of 3–5 who were enrolled in the preschool class at each participating center were eligible to participate. A sub-sample of parents (N = 20) from SAGE 2 completed a demographic survey, parenting PA practices questionnaire, and a satisfaction survey following the intervention; specific sample sizes by instrument are presented in Table 1. Unique among previous, nutrition-based curricula, SAGE was designed to source concepts from the plant life cycle as metaphors for humans growing into healthy and strong adults. This creative approach to garden-based ECEC curricula emanated from community partners and purposed to increase interest and engagement among teachers and learners. SAGE promoted, and offered opportunities for, increasing PA, reducing sedentary time, and improving knowledge of, appreciation for, and consumption of F&V. Feedback from implementers, our CAB and ECEC directors in SAGE 1 helped to fine-tune SAGE 2; thus, results are presented separately for each of the pilot studies. Detailed description of the development of the SAGE intervention protocol has been presented previously [46].

SAGE Pilots 1 and 2 were conducted using identical recruitment methods. ECEC within a five-mile radius of the University campus were identified. In both cases, the neighborhoods surrounding the campuses were lower to middle SES and had higher proportions of ethnic minorities residing there. In collaboration with our Partnership and CAB, a colorful and inviting postcard was developed and sent to ECEC directors. Using a standardized script, research assistants followed up with directors within 1 week with a phone call and email to describe the project. Four out of five centers contacted in Houston SAGE Pilot 1 enrolled. The director of the fifth center decided not to participate, owing to scheduling conflicts, such as field trips and teacher in-service days. Two ECEC were invited in Phoenix and agreed to participate. After sites were identified, parents were asked to participate in a parents’ night event which was used for promotional and recruitment purposes. At parents’ night, parents of children between the ages of 3 and 5 years were provided with a consent document that explained their and their child’s participation in the study. A research assistant was present to explain the informed consent form and answer any questions. Parents who were unable to attend parent’s night were informed of the study by research assistants as they dropped off or picked up their child. Once the parents understood the informed consent and their role in the study, they had the opportunity to enroll their child in the intervention.

The SAGE curriculum was implemented in participating centers twice a week in 1 hour sessions. Children participated in 12 one-hour sessions that included songs, games, and interactive learning activities involving garden maintenance and taste tests. Research assistants (i.e. undergraduate and graduate students) were paired and trained to deliver the intervention and were taught classroom management skills. All research assistants attended weekly meetings with the project director and principal investigator in order to give a report on program delivery and to discuss any challenges and potential barriers. Weekly newsletters developed in consort with our CAB were sent home with the children and used to engage parents in the program. Newsletters were available in English and Spanish and included information about what was going on in the classroom that week, to keep parents engaged and knowledgeable about SAGE. Newsletters also offered easy ideas for culturally tailored home activities and recipes, along with highlighting community resources that promoted PA and F&V consumption such as farmer’s markets or local gardening activities. Figure 1 presents a sample newsletter.

Reach of the population was measured as the sample representativeness of the population of the Census tract in which the ECEC were located. Using a written survey, parents from SAGE 2 reported on child age, gender, ethnicity and language spoken at home as well as family income (See Table 2). The decision to employ the demographic survey was made following SAGE 1; therefore, demographic data from parents whose children participated in SAGE 1  were unavailable. From the American Community Survey, 2009–2013 5-year estimates were used to indicate neighborhood sociodemographic variables at the Census tract level for each ECEC and to determine how representative the participants whom we enrolled were of the surrounding area [47].

Child physical activity, including light, moderate, and vigorous PA, was measured using ActiGraph GT3X accelerometers. Accelerometers were worn around the waist, centered over the right hip. During the intervention, children wore the accelerometer for 1 hour twice a week during the SAGE sessions only. SAGE staff fitted participating children with their designated devices upon arriving at ECEC for lessons, monitored device positioning throughout lessons, assisted children with realigning them as necessary, and collected devices after each lesson for data downloading and processing. Devices were initialized to collect activity at 60Hz, and light, moderate, and vigorous PA were processed in 15-second epochs according to validated cut-points for preschool aged children [48]. Specifically, light activity was defined as 800-1679 counts per minute (CPM), moderate activity as 1680-3367 CPM, and vigorous activity as at least 3368 CPM [48]. Accelerometers were initialized to start recording activity 10 min before and to continue recording activity 10 min after lessons (80 min total) to account for slight variations in lesson start and stop times. For each lesson, SAGE staff recorded the exact time at which lessons started, and, for purposes of accelerometer data processing, SAGE lessons were assumed to end 60 min after this time. Therefore, only 60 min of accelerometer-measured PA were possible for each SAGE lesson. Minutes of PA in each of the three intensities were combined, so that PA during SAGE lessons could be compared to the IOM recommendation of 15 min of total PA per hour, and sedentary (non-PA) time was calculated as the result of 60 min minus the total of light, moderate, and vigorous PA minutes. The same procedure was repeated for each of the SAGE lessons (12 in Houston, ten in Phoenix), and average minutes of activity and sedentary time per lesson attended were calculated for each child at each intervention site. Children also wore accelerometers in their ECEC for one hour the week prior to the SAGE program, during the same time at which SAGE lessons were scheduled. For example, if SAGE were due to be delivered on Tuesday at 9 am, then the pre-test would be done during the Tuesday at 9 am during the week preceding the intervention commencement. These data, processed in the same manner described above, were used to compare PA during SAGE lessons to the PA children may perform during a similar, non-SAGE hour in their ECEC.

Child vegetable and fruit consumption was measured with non-consecutive 3-day food records from parents, which are validated and preferred methods of dietary assessment among preschoolers [49‐51]. Parents were trained to complete the food records, taught portion sizes using food models, and provided with phone support. The United States Department of Agriculture’s super tracker software was used to assess food records [52]. Research assistants inputted the data from the food records onto the software. Super tracker then generated nutrient intake reports which provided the total cups of fruits and vegetables consumed on each day that data was available. Totals were averaged across the 3 days to provide the average number of cups of fruit and vegetables consumed per day.

Child recognition of hunger and fullness cues was measured by adapting the laboratory Eating in the Absence of Hunger test [53] to the classroom setting to determine the degree to which children ate in the absence of physiologic hunger [2, 54]. In the adapted protocol, trained research assistants conducted the assessment following a center provided meal. Tests were done during regular SAGE sessions which varied by ECEC. At the beginning of the assessment, pretend play was used to teach concepts of hunger and fullness using three tummy dolls, one doll with a full tummy, one doll with a tummy that was just right, and one doll with an empty tummy. Children were asked to identify their level of satiety using the tummy dolls to reinforce that the full tummy doll had eaten too much, the empty tummy doll had not eaten enough, and the just right tummy doll had eaten just enough to feel energetic for play time. Children were then given two palatable, center approved snacks in pre-weighed snack bags. In SAGE 1, one snack bag contained a salty snack of pretzels (20 g, 71 kcals) and the other snack bag contained a sweet snack of unwrapped M&Ms (28 g, 136 kcals). In SAGE 2, one snack bag contained Cheezit crackers (30 g, 136.8 kcals) and the other snack bag contained animal crackers (30 g, 150 kcals).

The children were instructed to taste one piece of each snack and were asked to rate their preference for the snack using a yummy, yucky, or just okay face to ensure that each snack was considered acceptable by the children. The children were then told that they could play with the toys in the classroom or continue snacking. After 10 min, instructors collected the snack bags and brought them back to the lab for weighing.

The Preschooler PA Parenting Practices survey is a 17 item instrument that measures the degree to which parents encourage their child to be physically active. Responses from all items are summed with a higher score indicating parenting practices that are more supportive of physical activity. This instrument has been validated for use among parents of preschoolers, including Latino parents, and has shown moderate to excellent test-retest reliability (0.56–0.85) [55].

The F&V Home Availability questionnaire was used to measure F&V items in the home. This self-report questionnaire has strong internal consistency α = 0.79 among parents of preschoolers and validity with home-inventory checks with parents of 4th and 6th graders [56].

Potential for maintenance was measured by a parent satisfaction survey. Parents completed a survey of 9 items measuring their level of satisfaction with their participation in the SAGE program and their interaction with the research team. The survey also asked parents about physical activity and nutrition knowledge gained through SAGE and the extent to which children engaged in SAGE activities in the home. Responses were recorded using a 5 point Likert scale where 1 = not satisfied and 5 = completed satisfied. See Table 3.