The prevalence of overweight and obesity among preschool children has been increasing world wide for over 40 years [1,2,3]. Mexican-American children have a higher prevalence than Caucasian children [4]. Preschool children from low income families are particularly affected with 1 in 7 children noted to be obese in 2009 [5]. The health consequences of obesity such as diabetes, previously limited to adults, are seen in younger age groups [6]. Obesity and ethnicity in Mexican American children markedly increases the risk of early onset Type 2 diabetes and early metabolic syndrome. Recent evidence suggests that obese children also have lower bone mineral density [7].

Many factors lead to increased weight in high risk preschool children but recent evidence suggests that dietary changes particularly increased consumption of sugar sweetened beverages [8], decreased consumption of high fiber foods such as vegetables and increased fat consumption are implicated [9]. Increased screen time as TV watching and computer time leads to decreased exercise. In addition, TV advertising on programming targeted toward children is heavily weighted toward food that is not nutritious and has been shown to influence food choices by children [10]. Targeting nutritional education in preschool children is essential to establish long term eating habits, but the challenges are substantial. The Head Start setting is an important opportunity for nutrition educational activities that are participatory and culturally relevant. This population is also at high risk for obesity because of ethnic and economic composition.

In the border state of Texas the poverty level is high, particularly in the Mexican-American population, and many of the families qualify for Head Start. The prevalence of obesity in the Head Start population surveyed is 20%, far above the national average [11]. In the Head Start Centers of Texas, many children speak Spanish or are bilingual, and reading skills are low at this age. Limited funding can also be a problem. In addition, access to dietary education for families is suboptimal. Studies of dietary habits of the population showed excess calories, fat, concentrated carbohydrates and sodium were taken and insufficient amounts of fiber, potassium, and vitamin A were eaten [12].

The purpose of this study was to test the effectiveness of a bilingual nutrition game to increase the servings of healthful foods particularly vegetables, fruit, and water offered to children and decrease the servings of sugar sweetened beverages in the Head Start population.

Results are shown in Table 1. The mean value for any given parameter was the mean servings of a given food per day for the entire population for the specified time period (Monday – Friday outside of Head Start or on weekends). The difference in the “means” was the difference between the mean value before and after the game was used. Before the intervention 38 parents reported no vegetable served on weekends and 16 reported no vegetable served at all. At the end of the study only 12 families reported no vegetable served on weekends and only 4 reported no vegetable served at any time. There was a statistically significant increase in vegetable served outside of Head Start both after school during the week and on the weekends. There was no change in the amount of exercise in the group over the school year. The study was unable to demonstrate any other statistically significant changes in dietary habits. However, feedback from a focus group of teachers demonstrated that the game was important in promoting recognition of a variety of foods by the children. The repetition of the rhymes could be used to promote the importance of increased water intake and reinforce the desirable decrease in drinking of sugar sweetened beverages and the routine intake of foods with high sugar content which is the policy of Head Start. The teachers felt that they would like to continue to use the game.

Recently, multiple initiatives have been directed toward changing the eating and exercise habits of the preschool population to attempt to decrease obesity and thus prevent the early onset of hypertension, diabetes and metabolic syndrome [14]. A structured education program for preschool children and parents has resulted in an increase in fruit and vegetable consumption [15]. Head Start particularly has made excellent progress in instituting education programs for parents and children [16]. The findings from this pilot study in cooperation with a Texas county Head Start show that vegetable servings may also be improved in the age group by using a simple pictorial nutrition education game that may be played in either English or Spanish and incorporates elements of the Mexican American culture familiar to the majority of the students and their parents. This familiarity simplifies instruction of the teachers and parents. The game is also inexpensive to reproduce helping to control costs. This study only encompasses one of the 5 counties and the data from the total population is still being analyzed. In the future the parents will be asked to play the game with the children and incentives will be provided to families who participate. An exercise initiative using cartoon characters leading the children in age appropriate exercise routines and counseling about healthy foods has been tested and accepted by the teachers and will be studied in the pilot county as well.