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“Healthy-Start”: Outcome of an Intervention to
Promote a Heart Healthy Diet in Preschool Children
Christine L. Williams MD, MPHa, Marguerite C. Bollella MS, RD, CDNa, Barbara A. Strobino
MPH, PhDa, Arlene Spark EdD, RD, FACNb, Theresa A. Nicklas DrPH, LDNd, Laura B. Tolosi
MS, RDc & Brian P. Pittman MSc
a Columbia University, Institute of Human Nutrition and Department of Pediatrics,
(C.I.W., M.C.B., B.A.S.) City University of New York, New York
b School of Health Sciences, Hunter College, City University of New York, New York (A.S.)
c American Health Foundation, (L.B.T., B.P.P.), Valhalla, New York
d Baylor College of Medicine (T.A.N.), Houston, Texas
Published online: 21 Jun 2013.
To cite this article: Christine L. Williams MD, MPH, Marguerite C. Bollella MS, RD, CDN, Barbara A. Strobino MPH, PhD,
Arlene Spark EdD, RD, FACN, Theresa A. Nicklas DrPH, LDN, Laura B. Tolosi MS, RD & Brian P. Pittman MS (2002) “Healthy-
Start”: Outcome of an Intervention to Promote a Heart Healthy Diet in Preschool Children, Journal of the American
College of Nutrition, 21:1, 62-71, DOI: 10.1080/07315724.2002.10719195
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Original Research
“Healthy-Start”: Outcome of an Intervention to Promote
a Heart Healthy Diet in Preschool Children
Christine L. Williams, MD, MPH, Marguerite C. Bollella, MS, RD, CDN, Barbara A. Strobino, MPH, PhD, Arlene
Spark, EdD, RD, FACN, Theresa A. Nicklas, DrPH, LDN, Laura B. Tolosi, MS, RD, and Brian P. Pittman, MS
Columbia University, Institute of Human Nutrition and Department of Pediatrics (C.L.W., M.C.B., B.A.S.), School of Health
Sciences, Hunter College, City University of New York (A.S.), New York, American Health Foundation (L.B.T., B.P.P.), Valhalla,
New York, Baylor College of Medicine (T.A.N.), Houston, Texas
Key words: preschool children, dietary fat, school health, food service modification, heart health, CVD prevention,
comprehensive school health education
Objective: We evaluated the effects of a preschool nutrition education and food service intervention
“Healthy Start,” on two-to-five-year-old children in nine Head Start Centers in upstate NY. The primary
objective was to reduce the saturated fat (sat-fat) content of preschool meals to Ͻ10% daily energy (E) and to
reduce consumption of sat-fat by preschoolers to Ͻ10% E.
Methods: Six centers were assigned to the food service intervention and three to control condition. Food
service intervention included training workshops for cooks and monthly site visits to review progress towards
goals. Child dietary intake at preschool was assessed by direct observation and plate waste measurement. Dietary
intake at home was assessed by parental food record and telephone interviews. Dietary data were collected each
Fall/Spring over two years, including five days of menus and recipes from each center. Dietary data were
analyzed with the Minnesota NDS software.
Results: Consumption of saturated fat from school meals decreased significantly from 11.0%E to 10.4%E
after one year of intervention and to 8.0%E after the second year, compared with an increase of 10.2% to 13.0%
to 11.4%E, respectively, for control schools (p Ͻ 0.001). Total caloric intake was adequately maintained for both
groups. Analysis of preschool menus and recipes over the two-year period of intervention showed a significant
decrease in sat-fat content in intervention preschools (from 12.5 at baseline to 8.0%E compared with a change
of 12.1%E to Ͼ11.6%E in control preschools (p Ͻ 0.001)). Total fat content of menus also decreased
significantly in intervention schools (31.0% to Ͼ25.0%E) compared with controls (29.9% to Ͼ28.4%E).
Conclusions: The Healthy Start food service intervention was effective in reducing the fat and saturated fat
content of preschool meals and reducing children’s consumption of saturated fat at preschool without compro-
mising energy intake or intake of essential nutrients. These goals are consistent with current U.S. Dietary
Guidelines for children older than two years of age.
have shown that anatomic changes in the aorta and coronary
arteries of young adults are related to antecedent risk factors
INTRODUCTION
Promoting a healthful diet among young children is a na-
tional public health objective since dietary factors contribute
substantially to the burden of preventable illness and death,
especially premature cardiovascular disease [1,2]. Promotion of
healthful behaviors should begin early in life, since it has been
established that atherosclerosis begins in childhood [3]. Studies
developed during childhood [4–7]. Moreover, evidence exists
that cardiovascular risk factors, such as blood pressure, obesity
and serum lipids and lipoproteins track from childhood to
young adulthood [8–13]. Toward this goal, the National Insti-
tutes of Health, the United States Department of Agriculture
(USDA), the American Academy of Pediatrics, the American
Supported by a grant from the National Heart, Lung and Blood Institute, National Institutes of Health (HL 50321). Presented at the Annual Meeting of the Council on
Epidemiology and Prevention, American Heart Association, March 3–5, 2000, San Diego, CA.
Address reprint requests to: Christine L. Williams, MD, MPH, Director, Children’s Cardiovascular Health Center, Columbia University, Institute of Human Nutrition,
Babies and Children’s Hospital, BHN7-702, 3959 Broadway, New York, NY 10032. E-mail: chrisw@pol.net
Journal of the American College of Nutrition, Vol. 21, No. 1, 62–71 (2002)
Published by the American College of Nutrition
62

Heart Healthy Diet in Preschool Children
Heart Association, the Centers for Disease Control and other
national organizations have initiated and supported new re-
search, programs and policies in the past decade aimed at
promoting health-enhancing changes in school food services
and nutrition education [1,14–21]. Several initiatives require
schools to serve meals that comply with the Dietary Guidelines
for Americans and offer technical support to schools that need
assistance in making the desired changes [22]. USDA also
urges that “nutrition education be a major educational compo-
nent of all child nutrition programs and offered in all the
schools, child care facilities, and summer sites” by the year
2000 [22]. The Healthy People 2010 national health objectives
have also specifically recommended provision of “nutrition
education from preschool through 12th grade” [1]. The syner-
gism of nutrition education in the classroom combined with a
school-food service offering healthy foods consistent with Di-
etary Guideline objectives provides the greatest likelihood that
efforts will translate into sustained healthy eating habits among
children and adolescents.
The majority of comprehensive health education programs,
school-based nutrition education initiatives and school food
service interventions have focused primarily on older children
and adolescents, of elementary, middle and high school age.
Very few studies and interventions have targeted younger chil-
dren, even though virtually all of our national dietary guidelines
include the two-to-five year-old preschool group. This includes
recommendations from Healthy People 2000, the American
Academy of Pediatrics, the National Cholesterol Education
Program, the American Heart Association, and the United
States Department of Agriculture [1,15–17,20]. The U.S. Di-
etary Guidelines apply to all Americans over two years of age.
With the growing consensus that children over two should
consume a diet with 30% or fewer of calories from total fat and
fewer than 10% from saturated fat, there is a need for popula-
tion-based studies to implement the guidelines among children,
including those of preschool age. This study was designed as a
preschool cardiovascular risk reduction and comprehensive
health education program designed to modify the preschool
environment with respect to the fat content (particularly satu-
rated fat) of preschool meals and snacks. We report the effects
of the program on preschool menus and children’s dietary
intake during a two year period of time.
food service component of the program were randomly as-
signed to one of two study conditions: food service modifica-
tion plus classroom education (A group), or school food service
modification plus classroom safety education (B group). The
food service modifications were exactly the same in the A and
B groups. Three other centers with food service operations not
amenable to modification served as controls C group). The
schools in group C all received their food from the school
district and could not make any changes in their acquisitions.
Schools in all groups had in common the fact that they had to
meet specific federal nutritional guidelines. All three groups
received one of two research versions of the Healthy Start
Comprehensive Preschool Health Education Curriculum, de-
veloped for this project. Group A received the core curriculum
plus nutrition-related units, while Groups B and C received the
core curriculum plus safety-related units. All preschoolers, as
required by federal Head Start guidelines, received the nutrition
education program already in place at each center prior to
initiation of this study. The primary goal of the supplemental
Healthy Start Preschool Health Education Curriculum was to
increase children’s health awareness and knowledge and to
provide children with ample opportunity to practice positive
health behaviors through stories and poems, games, crafts and
creative play, hands-on demonstrations, interactive discussions,
and investigative observations. Nutrition interventions were
designed to create an environment in which predisposing, en-
abling, and reinforcing factors could be targeted to facilitate a
decrease in consumption of total and saturated fat to AAP-
recommended levels of Յ30%E for total fat and Ͻ10% energy
for saturated fat.
Study Population
Children participating in the Healthy Start study were en-
rolled in nine Head Start preschool programs in upstate New
York with similar enrollments of low-income, predominately
minority preschool children. Subjects included in this report
consisted of 1,296 children who attended the Head Start school
either in Year 1 (Fall 1995 to Spring 1996) or in Year 2 (Fall
1996 to Spring 1997) or in both years. At baseline, children
were two to five years of age at their last birthday (mean 3.4 Ϯ
0.6 years). Ninety-eight percent of the children were three or
four years of age, and males and females were equally repre-
sented. Three-fourths of the children enrolled in the project
were minority, primarily African American (41%) and Latino
(33%). The majority of children lived in families with annual
income below poverty level (Ͻ$15,100 for a family of four).
METHODS
Study Design
Dietary Interventions
Healthy Start is a three-year intervention trial of preschool
children enrolled in nine New York State Head Start Centers.
The overall goal of the project was to evaluate the effects of a
food service modification and nutrition education intervention
on CVD risk reduction in preschool children. After baseline
measurements, six centers that were able to participate in the
The primary dietary intervention was a preschool Food
Service Modification plan designed to help preschools meet the
requirements for a USDA-reimbursable meal pattern [23] while
achieving a five-day meal/snack plan that provided no more
than 30% of energy from total fat and no more than 10% of
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
63

Heart Healthy Diet in Preschool Children
energy from saturated fat. Special emphasis was given to main-
taining adequate caloric intake.
methodology, preschool curriculum content, nutrition knowl-
edge assessment and other measures and outcomes has been
published elsewhere [24,25,31–36].
By design, after the five-day baseline menu assessment,
cooks in the intervention preschools participated in a one day
training program which covered the major food service inter-
vention areas: menu planning, recipe development, food pur-
chasing and food preparation. A list of objectives was devel-
oped which when implemented would gradually result in
increased offering and selection of fruit, vegetables, breads and
grains in meals, decreased total and saturated fat content of
foods purchased for the center and decreased total and saturated
fat due to alterations in food preparation techniques. These
objectives were developed together with the cooks, who then
selected initial objectives to target for their center. As the
initials objectives were met and incorporated into the daily
regimen, the cook selected others. In this manner, the food
modification program was a gradual process in which the cooks
played an active role. Once all the guidelines were selected, the
focus was on maintenance of change throughout the interven-
tion. An in-depth description of Healthy Start food service
intervention has been published [24].
Statistical Analysis
All preschools assigned to the food service intervention arm
of the study were grouped together, as were the preschools
assigned to the control condition. For all children with home
dietary recall data, school dietary intake data was added to
arrive at 24-hour dietary intake. Preschool menus were ana-
lyzed for nutrient content by obtaining menus, recipes, and
food labels for five days each Fall and Spring during the
intervention following a protocol modified from the CATCH
study [41]. The menu data was analyzed at the Nutrition Co-
ordinating Center, University of Minnesota using the Minne-
sota NDS software, Version 4.93 [42]. The five-day mean for
each school was used to compare baseline and follow-up nu-
trient values in the six intervention and three control schools
using a matched pair analysis (baseline versus end Year 1 and
baseline versus end of Year 2) p Ͻ 0.05 level, 2-tailed test. For
those children with complete one-year data or complete two-
year data, an independent samples t test procedure (SPSS
Version 10.1) was used to compare the differences in the
amount of change from baseline to follow-up in the interven-
tion and control groups [37].
Dietary Assessment
Since preschool children have not yet acquired the verbal or
written language skills to report on their own dietary intake and
since parents are not with their preschoolers while they are in
day-care centers, an innovative combination methodology was
employed to assess child dietary intake. The goal was to collect
24-hour dietary recalls on participating preschool children at
baseline in Fall 1995 and at follow-up at the end of Year 1
(Spring 1996) and at the end of Year 2 (Spring 1997) through
a combination of direct observation during school and parental
reports from home [25]. Data were also collected at the begin-
ning of Year 2 (Fall 1996). Total intake for the day was
obtained by (1) direct observation of the children as they ate
their meals and snacks at the centers with plate waste measure-
ment to determine amounts of foods and beverages consumed
combined with (2) telephone interviews with the primary adult
food providers to determine types and amounts of foods/bev-
erages consumed outside the Head Start setting on the same day
as the meal observation. The latter approach was assisted by
completion of a food record by the primary food provider to
give the telephone interviewer a more accurate record of the
child’s food intake. The complete dietary intake assessment
protocol was adapted from existing protocols proven to be
reliable and valid [26–30].
All micronutrients were compared to the current Recom-
mended Dietary Allowances (RDA) and for the four-to-eight
year-old age group [38]. Folic acid was compared to the Dietary
Reference Intakes (DRI) for the four-to-eight year-old group [39].
Fiber intake was compared to the “Age ϩ 5” guidelines [40],
while percent energy from total and saturated fat were com-
pared to the National Cholesterol Education Program (NCEP)
guidelines for children ages two to nineteen years [16].
RESULTS
School Menus: Changes in Fat Content of Menus
There were no significant differences between the interven-
tion and control preschools with respect to kcal or per cent of
calories from total fat or saturated fat at baseline. All menus, as
served, both pre- and post-intervention, satisfied federal guide-
lines for energy and nutrient content appropriate for preschool
children in a part-day Head Start program [23].
The percent of kcal in the menus from fat and saturated fat
decreased significantly over time in the intervention group
(Table 1). Percent of kcal from fat decreased 3.4% at the end of
Year 1 and an additional 2.6% by the end of Year 2. Percent of
kcal from saturated fat decreased 2.2% at the end of Year 1 and
an additional 2.3% by the end of Year 2. There were no
significant changes in the total fat or saturated fat content of
control menus from baseline to the end of Year 1 or the end of
Year 2.
Measurements
Dietary, anthropometric and physiologic measurements
were obtained in the Fall of 1995, and Fall of 1996. Follow-up
measures were obtained in the late Spring of 1996 and 1997. A
detailed description of the study design, dietary assessment
64
VOL. 21, NO. 1

Heart Healthy Diet in Preschool Children
Table 1. Changes in Preschool Menus from Baseline to Follow-up
Intervention Schools (x៮ Ϯ SD)
Control Schools (x៮ Ϯ SD)
Baseline
End of Year 1
End of Year 2
Baseline
End of Year 1
End of Year 2
KCal
Total Fat (g)
Sat Fat (g)
%Kcal from Total Fat
%Kcal from Sat. Fat
Cholesterol (mg)
Protein (g)
811.5 Ϯ 53.3
28.1 Ϯ 1.9
11.3 Ϯ 1.9
31.0 Ϯ 2.6
12.5 Ϯ 1.4
94.3 Ϯ 34.7
32.4 Ϯ 3.4
6.9 Ϯ 0.5
787.9 Ϯ 66.1
24.1 Ϯ 3.0
9.0 Ϯ 1.3
27.6* Ϯ 2.8
10.3 Ϯ 1.4
80.9 Ϯ 33.4
34.6 Ϯ 4.1
6.6 Ϯ 0.8
852.2 Ϯ 95.3
23.8 Ϯ 4.8
7.6* Ϯ 1.7
25.0** Ϯ 2.6
8.0* Ϯ 1.2
80.5 Ϯ 20.1
34.4 Ϯ 3.3
6.6 Ϯ 0.7
916.4 Ϯ 97.3
30.8 Ϯ 8.4
12.5 Ϯ 4.2
29.9 Ϯ 5.0
12.1 Ϯ 3.3
88.7 Ϯ 40.9
36.2 Ϯ 2.8
7.7 Ϯ 1.1
866.2 Ϯ 129.3
29.0 Ϯ 9.3
12.5 Ϯ 4.8
29.7 Ϯ 5.0
12.7 Ϯ 2.8
105.6 Ϯ 50.4
37.0 Ϯ 5.4
7.2 Ϯ 0.5
938.2 Ϯ 178.0
30.2 Ϯ 10.2
12.5 Ϯ 4.9
28.4 Ϯ 5.5
11.6 Ϯ 2.9
81.6 Ϯ 31.3
36.1 Ϯ 5.7
6.9 Ϯ 1.0
Fiber (g)
Calcium (mg)
Iron (mg)
627.9 Ϯ 33.5
5.6 Ϯ 0.8
682.1 Ϯ 87.3
5.9 Ϯ 1.0
642.7 Ϯ 80.6
5.2 Ϯ 0.6
675.2 Ϯ 83.1
8.2 Ϯ 2.3
643.1 Ϯ 72.0
6.7 Ϯ 2.1
688.6 Ϯ 95.3
7.6 Ϯ 2.5
Zinc (mg)
4.4 Ϯ 0.9
4.4 Ϯ 0.7
3.9 Ϯ 0.4
4.8 Ϯ 0.6
4.9 Ϯ 1.0
4.6 Ϯ 0.7
Magnesium (mg)
Vitamin A (␮g)
Vitamin C (mg)
Vitamin E (mg)
Folic Acid (␮g)
Riboflavin (mg)
Vitamin B12 (␮g)
128.7 Ϯ 6.9
3896 Ϯ 1098
55.1 Ϯ 11.1
3.0 Ϯ 0.8
115.5 Ϯ 20.4
1.2 Ϯ 0.1
132.2 Ϯ 19.0
2817 Ϯ 1388
47.7 Ϯ 11.9
2.1* Ϯ 0.3
116.7 Ϯ 28.5
1.2 Ϯ 0.1
129.0 Ϯ 12.5
2702 Ϯ 728
68.2 Ϯ 9.7
2.5 Ϯ 0.4
112.8 Ϯ 12.6
1.2 Ϯ 0.1
143.3 Ϯ 10.3
2370 Ϯ 520
58.2 Ϯ 6.8
2.5 Ϯ 0.2
143.32 Ϯ 3.1
1.2 Ϯ 0.2
134.0 Ϯ 13.1
2552 Ϯ 1151
66.8 Ϯ 10.5
2.2 Ϯ 0.5
158.6 Ϯ 6.4
1.3 Ϯ 0.1
140.3 Ϯ 5.4
2308 Ϯ 1167
71.1 Ϯ 21.2
2.2 Ϯ 0.4
148.4 Ϯ 20.1
1.3 Ϯ 0.1
2.2 Ϯ 0.3
2.4 Ϯ 0.5
2.1 Ϯ 0.2
2.4 Ϯ 0.3
2.2 Ϯ 0.5
2.2 Ϯ 0.1
* p Ͻ 0.05; ** p Ͻ 0.01 (Baseline 1 vs. end of Year 1, baseline vs. end Year 2); N ϭ 6 Intervention schools, 3 Control schools.
At baseline, menus in intervention and control schools were
similar in micronutrient content except for magnesium and iron
content, which were significantly (p Ͻ 0.05) lower in interven-
tion menus than in control menus. Based on recommendations
for four-to-eight year-old children(Table 2), there were small
increases for some nutrients (calcium, magnesium and Vitamin
C) from baseline to the end of the second year of intervention.
There were also small decreases in some nutrients (iron, zinc,
vitamins A, E, B12 and folic acid). Of note, however, menu
contributions for vitamins A, C, and B12 still exceeded 100%
of recommended daily values. Control school menus showed a
similar pattern of change from baseline to follow-up, with the
exception of an increase in folic acid and a decrease in mag-
nesium from baseline to the end of Year 2.
The contribution of preschool menus to daily requirements
for zinc was within approximately 40% of the recommended
intake, both pre- and post-intervention, which is adequate for
half-day children having a meal and snack at preschool, but
insufficient for full-day children who spend eight or more hours
at preschool. The latter should receive one-half to two-thirds of
their daily requirement in order to satisfy CACFP requirements.
Dietary Intake at School Meals
Healthy Start food service intervention efforts were aimed
primarily at decreasing saturated fat intake at preschool meals.
Less effort was aimed at decreasing total fat intake, since
baseline total fat intake at preschool meals (27.4%E) already
Table 2. Percent of Recommended Nutrients Provided by Head Start Menus at Baseline and Follow-up: Intervention (Int) and
Control (Con) Schools
Contributed
End of Year 1
RDA/DRI
Values*
Nutrient
Baseline
End of Year 2
Int
Con
Int
Con
Int
Con
Fiber (g)¶
Calcium (mg)
Iron (mg)
8.4
800
10
82%
78%
56%
92%
84%
82%
79%
85%
59%
86%
80%
67%
79%
80%
52%
82%
86%
76%
Zinc (mg)
10
44%
48%
44%
49%
39%
46%
Magnesium (mg)
Vitamin A (␮g)
Vitamin C (mg)
Vitamin E (mg)
Vitamin B12 (␮g)
Folic acid (␮g)
Riboflavin (mg)
130
700
45
90%
110%
339%
129%
36%
200%
72%
102%
402%
106%
30%
200%
58%
103%
365%
148%
31%
183%
79%
99%
108%
330%
159%
31%
183%
74%
557%
122%
43%
183%
58%
386%
152%
36%
175%
56%
7
1.2
200
0.6
200%
200%
200%
217%
200%
217%
* [39].
¶ Reference value ϭ mean age of population ϩ 5 g/day [40].
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
65

Heart Healthy Diet in Preschool Children
met the recommended NCEP and American Heart Association
guidelines of Յ30%E, and was within the American Academy
of Pediatrics guideline (total fat intake goal of 20% to 30%E for
children two years of age and older) [15].
Overall, there was a trend towards an increase in micronu-
trient intake at preschool meals from baseline to follow-up
which probably is likely the result of increased caloric intake.
Most children participate in Head Start for one year (at age
four), while fewer children participate for two years (ages three
and four). In the present study there were 567 children who
were evaluated at both baseline (Fall 1995) and at the end of
Year 1 (Spring 1996). An additional 144 children were evalu-
ated at baseline and at the end of Year 2 (Spring 1997). The
differences in nutrient intake from baseline to follow-up were
compared between children in the intervention schools and
control children (Table 4). From baseline to the end of Year 1,
there were significant differences in the amount of change
between the groups with respect to total caloric intake, most
nutrients and the %E from total fat and saturated fat. For those
children enrolled in the program for two years, the differences
between the intervention and control children in the amount of
change were not significant for total caloric intake and most
nutrients with the exception of grams of saturated fat (p Ͻ 0.01)
and %E from total fat (p Ͻ 0.001), %E from saturated fat (p Ͻ
0.001), iron (p Ͻ 0.05) and magnesium (p Ͻ 0.05), with all
changes favoring the intervention group.
Total caloric intake for intervention and control preschool
children was monitored throughout the Healthy Start food
service intervention, and data indicated that energy intake was
maintained even though saturated fat intake decreased. At the
end of Year 1 after one school-year of food service modifica-
tion, there was an increase in total energy intake in both
intervention and control schools (Table 3). Energy intake from
saturated fat at school meals, however, decreased by 5.5% in
intervention schools (11.0% to 10.4%E), compared with a
27.5% increase among control preschool children (10.2% to
13.0%E). At the end of Year 2 of the intervention, caloric
consumption continued to increase in the intervention schools
but decreased among control children. In the intervention
schools, %E from saturated fat intake showed an additional
decline at the end of Year 2 (27% decrease from baseline).
Energy intake from saturated fat decreased in the control
schools from the end of Year 1 to the end of Year 2 but did not
reach the baseline level.
Total fat intake from preschool meals and snacks met di-
etary guidelines at baseline (Ͻ30%E) in both intervention and
control schools. In the intervention schools energy intake from
total fat decreased further at the end of Year 1 (from 29.2% to
27.5%) and Year 2 (to 26.4%). Among children in control
schools, dietary intake of total fat at school increased from
24.8% to 30.2%E at the end of Year 1 and decreased slightly at
the end of Year 2.
24-Hour Dietary Intake (Home ؉ School)
Children consumed about one-third of daily energy at pre-
school and two-thirds at home. Therefore, it was not expected
that a food service intervention aimed at the preschool center
itself would be sufficient to make an impact on 24-hour dietary
Table 3. School Meal Dietary Intake: Changes in Fat and Other Nutrient Intake from Baseline to the Follow-up by Year:
Children in Intervention versus Control Preschools
Intervention
Controls
Baseline
(N ϭ 374)
x៮(SD)
End Year 1
(N ϭ 407)
x៮(SD)
End Year 2
(N ϭ 390)
x៮(SD)
Baseline
(N ϭ 254)
x៮(SD)
End Year 1
(N ϭ 298)
x៮(SD)
End Year 2
(N ϭ 318)
x៮(SD)
Nutrient
Kcal
Fat (g)
Sat Fat (g)
486 (226)
16.1 (9.6)
6.1 (4.2)
515 (234)
16.5 (11.2)
6.1 (3.9)
560 (258)
16.9 (10.0)
5.0 (3.2)
330 (193)
10.0 (7.9)
4.1 (3.6)
436 (238)
14.4 (8.0)
6.2 (3.9)
362 (211)
12.4 (9.0)
5.1 (4.6)
Fat, %KCal
Sat Fat %KCal
Cholesterol (mg)
Protein, (g)
Fiber (g)
29.2 (8.9)
11.0 (4.7)
46.0 (43.6)
18.2 (10.2)
3.8 (2.0)
27.5 (9.7)
10.4 (4.6)
51.6 (56.2)
21.8 (11.1)
3.9 (1.9)
26.4 (7.9)
8.0 (2.8)
51.4 (46.8)
22.7 (11.7)
3.9 (2.1)
24.8 (11.1)
10.2 (5.3)
25.6 (26.2)
11.8 (7.1)
3.2 (2.2)
30.2 (9.5)
13.0 (5.2)
51.1 (52.6)
17.5 (11.0)
3.5 (2.5)
29.1 (9.7)
11.4 (5.7)
34.4 (31.8)
14.2 (10.2)
2.7 (1.8)
Calcium (mg)
Iron (mg)
318 (192)
3.7 (3.3)
374 (212)
4.1 (3.3)
357 (188)
3.6 (2.1)
211 (155)
3.5 (4.0)
263 (184)
3.7 (4.5)
206 (188)
2.7 (2.7)
Zinc (mg)
2.5 (2.6)
2.7 (1.6)
2.4 (1.2)
1.7 (1.3)
2.2 (1.6)
1.7 (1.3)
Magnesium (mg)
Vit A (␮g)
Vit C (mg)
72.3 (31.1)
892 (1863)
34.9 (32.7)
2.4 (3.1)
80.0 (35.9)
595 (1010)
35.7 (31.0)
1.7 (1.3)
75.9 (31.8)
540 (679)
42.5 (33.5)
2.4 (1.4)
48.6 (30.1)
250 (214)
20.7 (25.7)
1.0 (0.8)
57.2 (33.6)
408 (396)
35.9 (33.7)
1.2 (0.9)
46.8 (26.7)
382 (1054)
30.7 (26.0)
1.1 (0.8)
Vit E (mg)
Folic acid (␮g)
Riboflavin (mg)
Vit B12 (␮g)
69.6 (68.9)
0.6 (0.4)
1.1 (1.2)
71.1 (44.6)
0.7 (0.4)
1.5 (1.0)
67.3 (48.6)
0.7 (0.3)
1.2 (0.7)
52.7 (45.1)
0.4 (0.3)
0.7 (0.7)
74.9 (54.4)
0.6 (0.4)
0.8 (0.7)
55.4 (41.4)
0.4 (0.3)
0.7 (0.6)
¶ BGD ϭ Between Group Differences-Intervention vs. Control.
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Heart Healthy Diet in Preschool Children
Table 4. Differences between Baseline and Follow-up by Year of Study: Children in Intervention Schools and Controls
Mean Change Baseline to End of Year 1
Mean Change Baseline to End of Year 2
Intervention
Control
N ϭ 234
p
Intervention
N ϭ 103
Control
N ϭ 41
p
N¶ ϭ 333
Int vs. Con
Int vs. Con
Kcal
Fat (g)
34.67
0.73
.001
Ϫ1.51
Ϫ0.71
7.02
116.0
4.33
1.86
4.97
2.16
25.66
6.14
0.41
Ͻ0.001
Ͻ0.001
Ͻ0.001
Ͻ0.001
Ͻ0.001
Ͻ0.001
Ͻ0.05
188.74
3.47
0.26
Ϫ4.45
Ϫ3.14
18.50
9.02
124.05
6.73
2.82
6.47
2.01
18.02
5.37
0.12
Sat. Fat (g)
Fat, %KCal
Sat Fat %KCal
Cholesterol (mg)
Protein, (g)
Fiber (g)
Ͻ0.01
Ͻ0.001
Ͻ0.001
3.60
0.09
0.90
Calcium (mg)
Iron (mg)
Zinc (mg)
Magnesium (mg)
Vit A (␮g)
Vit C (mg)
Vit E (mg)
Folic acid (␮g)
Riboflavin (mg)
Vit B12 (␮g)
52.46
0.51
0.20
57.04
0.27
0.58
130.63
0.77
0.46
18.73
Ϫ137.94
15.83
0.34
72.94
Ϫ0.76
0.24
Ͻ0.05
Ͻ0.05
7.57
9.11
6.44
Ϫ291.24
Ϫ0.94
Ϫ0.60
1.07
152.90
15.23
0.27
22.24
0.18
Ͻ0.001
Ͻ0.001
Ͻ0.001
Ͻ0.001
Ͻ0.01
406.88
19.29
0.40
9.69
0.10
17.51
0.24
0.29
0.09
0.40
0.08
Ͻ0.01
0.001
¶ N’s reflect the number of children attending at baseline and follow-up period.
intake. For the intervention group, %E from saturated fat did
decrease somewhat from 12% at baseline to 11.6% at the end
of Year 1 and 10.9% at the end of Year 2. For the Control
group, there was little difference between the three time periods
(Table 5).
At baseline, on the day the diet was assessed, 28.4% of
Healthy Start preschool children met AAP dietary guidelines
[15] for saturated fat intake (Ͻ10%E) and 42.8% met the
guideline for total fat intake (Յ30%E) based on the 24-hour
dietary intake. More children (89%) met dietary goals for
cholesterol intake (Ͻ300 mg/day). For fiber intake, 64.5% of
the children achieved the ‘Age ϩ 5’ goal for two-to-five
year-old children [40]. Micronutrient intake varied from over
80% meeting the RDA or DRI guidelines for riboflavin, mag-
nesium and vitamins C and B12 to less than 50% meeting the
requirements for calcium, vitamin E and zinc (Fig. 1).
Table 5. 24 Hour Energy, Macro and Micronutrient Intake of Children: Baseline to Follow-up
Intervention
Controls
Baseline
(N ϭ 267)
x៮(SD)
End Year 1
(N ϭ 241)
x៮(SD)
End Year 2
(N ϭ 248)
x៮(SD)
Baseline
(N ϭ 170)
x៮(SD)
End Year 1
(N ϭ 203)
x៮(SD)
End Year 2
(N ϭ 201)
x៮(SD)
Nutrient
Kcal
Fat (g)
Sat. Fat (g)
Fat, %KCal
Sat Fat %KCal
Cholesterol (mg)
Protein, (g)
Fiber (g)
Calcium (mg)
Iron (mg)
1491 (491)
51.3 (21.0)
19.9 (9.2)
30.9 (6.8)
12.0 (3.7)
166 (112)
55.0 (20.7)
10.8 (5.2)
806 (374)
13.5 (9.1)
8.8 (5.5)
1467 (517)
50.1 (25.5)
19.5 (11.0)
29.9 (7.5)
11.6 (3.5)
165 (119)
57.3 (24.0)
10.3 (5.1)
837 (510)
13.5 (8.8)
9.4 (6.0)
1559 (657)
53.8 (29.7)
19.3 (11.3)
30.2 (6.9)
10.9 (3.1)
170 (118)
59.0 (25.3)
10.8 (5.8)
843 (386)
12.1 (7.9)
8.2 (5.0)
1387 (439)
48.1 (20.0)
19.0 (7.1)
31.0 (6.8)
12.4 (3.2)
173 (111)
53.9 (18.0)
10.7 (5.2)
743 (308)
12.4 (7.5)
8.5 (4.7)
1498 (541)
51.8 (24.3)
20.9 (10.6)
30.7 (7.1)
12.4 (3.6)
200 (137)
58.9 (24.9)
11.2 (5.9)
782 (387)
14.0 (9.3)
9.4 (5.8)
1259 (474)
44.1 (21.0)
17.7 (9.1)
31.1 (6.4)
12.4 (3.5)
166 (127)
48.7 (21.5)
8.7 (4.3)
683 (369)
10.5 (6.6)
7.2 (4.7)
Zinc (mg)
Magnesium (mg)
Vit A (mcg)
Vit C (mg)
205 (75)
1566 (2061)
118 (85)
202 (78)
1236 (1318)
119 (83)
203 (84)
1121 (868)
111 (72)
190 (72)
903 (664)
112 (91)
197 (74)
1027 (657)
127 (83)
163 (65)
951 (1346)
99.7 (68.2)
6.3 (7.3)
Vit E (mg)
9.3 (7.4)
8.1 (7.6)
8.0 (6.5)
7.6 (7.8)
7.7 (6.8)
Folic acid (mcg)
Riboflavin (mg)
Vit B12 (mcg)
287 (188)
2.1 (0.9)
4.5 (3.1)
269 (185)
2.1 (1.0)
4.6 (3.1)
250 (167)
2.0 (0.9)
4.2 (2.9)
277 (195)
1.9 (0.9)
4.1 (2.7)
303 (191)
2.0 (0.9)
4.2 (3.2)
237 (159)
2.1 (7.1)
3.8 (7.4)
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67

Heart Healthy Diet in Preschool Children
the fact that the RDA for energy for four-to-six year-olds is
1800 Kcal/day, a 12% to 23% overestimate of energy require-
ments.
Recently the United States Department of Agriculture
(USDA) compared the macro- and micronutrient content of
menus of young children who participate in the Child and Adult
Care Food Program (CACFP) to nutrient standards [51]. An
analysis of these menus from the preschool day care programs
indicates that the total fat and saturated fat content of their
lunches exceed levels recommended in the Dietary Guidelines
for Americans [21].
Promoting heart healthier behaviors during childhood has
become the focus of school-based programs aimed at the pri-
mary prevention of atherosclerosis and CHD [54–61]. The
majority of school-based programs have targeted elementary
school children and include dietary intervention studies target-
ing both food service and individual dietary behavior change.
In general, these studies demonstrate that the total and saturated
fat content of school meals can be improved without compro-
mising physical growth or micronutrient intake.
The Healthy Start food service intervention was modeled
after methods developed by the Child and Adolescent Trial for
Cardiovascular Health, CATCH, [51,54,57], and similar mag-
nitudes of change in fat content of school menus were achieved
by both projects. The CATCH intervention decreased the sat-
urated fat content of school lunch menus by 18.9% compared to
9.3% among control schools. The Healthy Start intervention
decreased the saturated fat content of preschool menus by 36%
at the end of Year 2 of the intervention, while control schools
decreased saturated fat content by 4%.
While a number of strategies were used in the present study
to reduce the saturated fat content of preschool meals and
snacks, reducing the fat content of milk and other dairy prod-
ucts used in the preschool centers was commonly employed.
This is consistent with the findings of Sigman-Grant [62], who
suggested that, although a number of strategies could be effec-
tive in lowering the saturated fat content of children’s diets, use
of skim milk only as a minimum strategy could be effective in
achieving saturated fat goals in young children while maintain-
ing adequate intake of other essential macro and micronutri-
ents. Implementation of a few key strategies, such as switching
from whole or 2% fat milk to 1% fat milk, draining and rinsing
cooked ground meat, as well as removing skin and all other
visible forms of fat from poultry and meats, respectively, all
contributed to the overall reduction of saturated fat content of
school meals and dietary intake by children.
The present study demonstrates that in the preschool pop-
ulation it is possible to decrease the saturated fat content of
children’s diets, without compromising energy intake or the
overall nutritional value of the diet. Except for a significant
decrease in Vitamin E at the end of Year 1 of the intervention,
there were no significant differences in mean micronutrient
values from baseline to Year 1 or Year 2 of follow-up. Vitamin
E increased at the end of Year 2. The mean levels of most
Fig. 1. Percent of children at Head Start schools meeting dietary
guidelines.
DISCUSSION
Dietary guidelines endorsed by more than 26 U.S. health
organizations recommend that a fat-modified diet begin after
two years of age [16]. As recently as 1995, however, 77% of
U.S. preschool children, two-to-five years of age, still exceeded
the dietary recommendation for saturated fat [43]. This is of
particular concern with respect to the primary prevention of
atherosclerosis and coronary artery disease, since saturated fat
raises blood cholesterol levels and therefore contributes to
increased risk of atherosclerosis. Although there is recently
more debate regarding optimal levels of total fat in the diet, the
vast majority of health professionals agree that saturated fat
intake should not exceed 10% of energy intake after two years
of age.
In the past, concern has been voiced that fat-controlled diets
in early childhood might fail to provide adequate energy for
normal growth and development. Reports from the STRIP
study in Finland, however, suggest that a diet low in saturated
fat and cholesterol, even when started at seven months of age,
can be compatible with normal growth and development as
long as caloric and essential nutrient intake is adequate [44]. In
a recent report, neurological development was similar in inter-
vention and control groups at five years of age, providing
further evidence of the safety of the “heart-healthy” diet in
early childhood [45].
The dietary intake of the “Healthy Start” preschool children
reported at baseline was similar to two U.S. studies: a survey of
three-year-olds surveyed in the 1995 Continuing Survey of
Food intake by Individuals, CSFII [46], and the 1987–88
Nationwide Food Consumption Survey, NFCS, [47]. Baseline
saturated fat intake was 12% to 13%E in all surveys. Baseline
total fat intake was 31%, 32% and 35%E in the Healthy Start
sample, CSFII 1995 survey and NFCS surveys, respectively.
Total energy intake in the Healthy Start survey and the other
U.S. surveys varied between 1305 and 1576 Kcal per day.
These values are more consistent with measured TEE (total
energy expenditure) of four-to-six year-olds [48–50], despite
68
VOL. 21, NO. 1

Heart Healthy Diet in Preschool Children
nutrients were at or above recommended levels at baseline, but
the proportion of children meeting the recommended daily
levels based on a 24 hour dietary intake was less than 100% for
almost all nutrients. This disparity would indicate that although
some children are adequately nourished, many are not. This is
not unexpected since most of the children’s intake came from
home, where incomes are at the poverty level.
the administrators, nurses, cooks, teachers, parents, and chil-
dren in each of the Head Start Centers who participated in the
Healthy Start project, and without whose enthusiastic support
this project could not have been conducted. We also thank
Doris Gabari for her able administrative assistance throughout
the project.
National surveys conducted over the past two decades have
shown a decreasing secular trend in dietary intake of both total
and saturated fat by children [46,47,63–66]. The Bogalusa
Heart Study [67,68] has also reported the same secular trend
downward in total and saturated fat intake by children between
1973–1988. In the present study, total fat in the diet was
already close to goal at baseline, similar to national trends,
since preschool children in the 1995 CSFII survey had similar
total fat intakes. In addition, there are regional differences, with
dietary intake of preschoolers in the Northeastern part of the
U.S. somewhat lower in total and saturated fat than that of
preschool children in other parts of the U.S. [66]. Dietary intake
for the preschool children in the present Healthy Start popula-
tion appears to reflect this Northeastern pattern of intake.
There are certain limitations of this study. Assignment to
intervention or control schools could not be randomly carried
out. However, this is believed to have a minimal effect on the
outcome since we are looking at change from one point in time
to another point in time within each group, rather than a
difference between the groups at one endpoint in time. Indi-
vidual variation is therefore controlled within the group and
confounding is minimized. Although we monitored menus at
control preschools over time, we made no recommendations
regarding meal or snack content or food intake by children.
These schools could have instituted changes over time that
would influence the fat content of the diets. Changes made,
however, appear to be minimal, based on an analysis of menus
and interviews with food service personnel at baseline and at
the end of Year 1 and Year 2.
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