Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
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  • 1. Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children Living in Appalachian Ohio A thesis presented to the faculty of the College of Health and Human Services of Ohio University In partial fulfillment of the requirements for the degree Master of Science Ashley B. Zurmehly August 2009 © 2009 Ashley B. Zurmehly. All Rights Reserved.
  • 2. 2 This thesis titledUse of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children Living in Appalachian Ohio by ASHLEY B. ZURMEHLY has been approved for the School of Human and Consumer Sciences and the College of Health and Human Services by David H. Holben Professor of Human and Consumer Sciences Gary S. Neiman Dean, College of Health and Human Services
  • 3. 3 ABSTRACTZURMEHLY, ASHLEY B., M.S., August 2009, Food and NutritionUse of a Gardening and Nutrition Education Program to Improve the Produce Intake ofSchool Age Children Living in Appalachian Ohio (228 pp.)Director of Thesis: David H. Holben This study: (a) measured the effect of a nutrition and gardening educationprogram on Appalachian children’s fruit and vegetable intakes and preferences; and (b)examined the relationship of food security status to gardening habits and perceptions,produce intake, and personal characteristics of children and their adult female caregivers.In this study, participants were: (a) 91 children who completed a pre-test, nutritioneducation and gardening program (intervention), and a post-test over a six-week period;and (b) 99 female caregivers who completed a 79-item survey prior to the six-weekintervention period about themselves, their household, and their 157 children. Resultsindicated that the six-week nutrition education and gardening intervention did notsignificantly impact produce intake variety or produce preference variety among thechildren participating in the program. Overall, household food security was not related tothe variety of produce eaten or preferred reported by children; however, it was related tovegetable intake, education, diet quality, food assistance program participation, and bodymass index of the female caregivers. On the other hand, household food security wasrelated to the children’s estimated produce intake and preferences reported by the femalecaregivers prior to the intervention. It was also found that children’s gardening habitsreflected that of their female caregivers, but children’s self-reported produce intake
  • 4. 4variety was not related to their gardening habits. However, household food security wasnot related to gardening habits or produce readiness of female caregivers. Dietetic andnutrition professionals can use these findings to develop other interventions includinggardening and nutrition education with both children and their families.Approved: _____________________________________________________________ David H. Holben Professor of Human and Consumer Sciences
  • 5. 5 ACKNOWLEDGMENTS Thank you to my advisor Dr. David Holben, and other faculty members, whomade this possible: Ms. Deborah Murray and Dr. Jennifer Chabot. Also thanks to all ofmy family and friends for supporting me, especially Todd who helped me through theentire process.
  • 6. 6 TABLE OF CONTENTS PageABSTRACT ........................................................................................................................ 3 ACKNOWLEDGMENTS .................................................................................................. 5 LIST OF TABLES ............................................................................................................ 10 LIST OF FIGURES .......................................................................................................... 12 CHAPTER 1: INTRODUCTION ..................................................................................... 13  Overview and Background ........................................................................................... 13  Statement of the Problem .............................................................................................. 17  Purposes of the Study ................................................................................................... 17  Research Questions and Hypotheses ............................................................................ 18  Significance of the Study .............................................................................................. 20  Potential Delimitations and Limitations ....................................................................... 21  Definition of Terms ...................................................................................................... 22 CHAPTER 2: REVIEW OF LITERATURE .................................................................... 23  Food Security ................................................................................................................ 24  Definitions ................................................................................................................. 24  Measurement of Food Security ................................................................................. 25  Food Security in the United States............................................................................ 31  Risk Factors for Food Insecurity .............................................................................. 36  Outcomes of Food Insecurity in Adults ..................................................................... 38  Food insecurity and chronic disease risk among adults. ....................................... 39  Food insecurity and overweight/obesity among adults. ........................................ 39 
  • 7. 7 Food insecurity and overall health among adults. ................................................ 41  Food insecurity and diet among adults. ................................................................ 42  Outcomes of food insecurity in children ................................................................... 48  Food insecurity and overweight among children. ................................................. 48  Food insecurity and overall health status among children. ................................... 50  Food insecurity and diet and hunger among children. .......................................... 51 Federal and Non-Federal Food Assistance Programs ................................................... 53  The Special Supplemental Nutrition Program for Women, Infant, and Children (WIC)......................................................................................................................... 54  FNS Supplemental Nutrition Assistance Program (SNAP) ...................................... 55  School Meals Programs ............................................................................................ 57  The school lunch program. ................................................................................... 57  The special milk program. .................................................................................... 60  Summer Food Service Program ................................................................................ 60  Community Garden-Based Programs ....................................................................... 61  The America Community Gardening Association. ............................................... 61  Farm-to-School. .................................................................................................... 61  School gardening. ................................................................................................. 62  Community Food Initiatives. ................................................................................ 63 Appalachia .................................................................................................................... 63  Health ........................................................................................................................ 68  Obesity. ................................................................................................................. 69 
  • 8. 8 Cancer and chronic disease. .................................................................................. 70  Mental health. ....................................................................................................... 72  Food Security ............................................................................................................ 72  Produce Intake in the United States .............................................................................. 73  Produce and Gardening Interventions........................................................................... 75  Conclusion .................................................................................................................... 79 CHAPTER 3: METHODOLOGY .................................................................................... 81  Subjects ......................................................................................................................... 82  Setting ........................................................................................................................... 82  Project Description ....................................................................................................... 83  The Nutrition Education and Gardening Program ........................................................ 85  Data Scoring and Statistical Analysis ........................................................................... 85 CHAPTER 4: RESULTS .................................................................................................. 89  Child Participant Data ................................................................................................... 89  Female Caregiver Participant Data ............................................................................... 93 CHAPTER 5: DISCUSSION, CONCLUSIONS, AND RECOMMENDATIONS ....... 113  Children Participants’ Produce Preference and Intake Variety .................................. 114  Food Security .............................................................................................................. 116  Household Food Security Status ............................................................................. 116  Food Security, Body Weight, Diet, and Health ....................................................... 120  Food Security, Gardening, and Diet ....................................................................... 123  Food security and female caregiver’s gardening and diet. ................................. 123 
  • 9. 9 Food security and children’s diet. ....................................................................... 125  Female Caregiver Gardening and Produce Habits ...................................................... 128  Conclusions and Recommendations ........................................................................... 130  Conclusions ............................................................................................................. 130  Recommendations ................................................................................................... 133 References ....................................................................................................................... 136 APPENDIX A: FOOD SECURITY SURVEY MODULE SCORING FOOD SECURITYSURVEY MODULE 18 AND 6 ITEM SCORING ....................................................... 165 APPENDIX B: KIDS ON CAMPUS SURVEY SCORING .......................................... 170 APPENDIX C: IRB APPROVAL .................................................................................. 175 APPENDIX D: KIDS ON CAMPUS SURVEY ............................................................ 176 APPENDIX E: KIDS ON CAMPUS LESSON PLANS BIG TOP GARDEN 2008 ..... 193  WEEK 1: GARDENING IS GREAT ........................................................................ 193  WEEK 2: GARDENING IS COLORFUL ................................................................ 198  WEEK 3: FRUIT + VEGETABLES = FIBER......................................................... 204  WEEK 4: TEAMWORK........................................................................................... 210  WEEK 5: DYNAMIC DUO ..................................................................................... 215  WEEK 6: SCRAPS TO SOIL ................................................................................... 221 APPENDIX F: CHILD FRUIT AND VEGETABLE SURVEYS ................................. 227 
  • 10. 10 LIST OF TABLES PageTable 1: Research Questions and Hypotheses ................................................................19Table 2: 18-item Food Security Survey Module, 2008...................................................27Table 3: Food Security Categories Defined by the USDA .............................................29Table 4: Six-item Food Security Questionnaire, 2008....................................................31Table 5: SNAP 2009 Income and Resource Cut-off Levels ...........................................56Table 6: School Meal Income Qualifications .................................................................58Table 7: Region Economic and Educational Level Comparison ....................................66Table 8: Research Questions and Associated Statistical Test .........................................87Table 9: Child Participants’ Produce Preferences and Intakes .......................................91Table 10: Characteristics of Female Participants and Their Households .......................94Table 11: Female Caregiver Body Mass Index and Perceived Diet Quality and HealthStatus ...............................................................................................................................96Table 12: Female Participant Readiness for Eating Produce ..........................................98Table 13: Female Participant Gardening Habits and Readiness for Gardening Produce ............................................................................................................................................99Table 14: Relationship of Food Security Status to Gardening- and Produce-RelatedBehaviors and Intakes ...................................................................................................101Table 15: Relationship of Female Caregivers’ Habits to Gardening- and Produce-RelatedBehaviors and Intakes ...................................................................................................102
  • 11. 11Table 16: Female Caregiver and Household Characteristics Stratified by Food SecurityStatus .............................................................................................................................104Table 17: Female Caregiver Weight and Diet Characteristics Stratified by Food SecurityStatus……………………………………………………………………………….....106Table 18: Female Caregiver Produce Readiness Stratified by Food SecurityStatus……………………………………………………………………………….....108Table 19: Gardening Readiness and Habits of Female Caregivers Stratified by FoodSecurity Status ..............................................................................................................109Table 20: Female Caregiver’s Perception of Children’s Produce Intake Stratified by FoodSecurity Status ..............................................................................................................110Table 21: Female Caregiver’s Perception of Children’s Habits ...................................111
  • 12. 12 LIST OF FIGURES PageFigure 1: Food security status of U.S. households in 2007 ............................................33Figure 2: Food security and food insecurity trends in the U.S. from 1999-2007 ...........35Figure 3: Weekly household food spending per person..................................................43Figure 4: Food-insecure household food assistance participation ..................................46Figure 5: The Appalachian Region .................................................................................64Figure 6: Appalachian Ohio Counties.............................................................................67Figure 7. Child participants’ produce preference and intake variety ..............................92Figure 8. Female caregiver participants weight classification ........................................97Figure 9. Female caregiver produce and gardening readiness………………………...100Figure 10. Female caregiver body mass index and produce intake by food securitystatus…………………………………………………………………………………..107
  • 13. 13 CHAPTER 1: INTRODUCTION Overview and Background Appalachia is an area of the United States that is characterized by low educationalattainment, high poverty, and poor health. The area is made up of parts of 12 states andall of West Virginia, with almost half of the area being rural (Smith & Grant, 2008).Some studies also support that its rates of food insecurity, overweight and obesity,diabetes, and chronic disease are above those of the rest of the nation (Crooks, 1999;Demerath et al., 2003; Denham, Meyer, Toborg, & Mande, 2004; Holben, McClincy,Holcomb, Dean, & Walker, 2004; Holben & Pheley, 2006; Kropf, Holben, Holcomb, &Anderson, 2007; Pheley, Holben, Graham, & Simpson, 2002; Rappaport & Robbins,2005; Tulkki et al., 2006; Walker, Holben, Kropf, Holcomb, & Anderson, 2007; Wewers,Katz, Fickle, & Paskett, 2006). More specifically, and in relation to poverty and foodaccess, food insecurity has been found to be a concern to Appalachian residents (Holben,Barnett, & Holcomb, 2006; Holben et al., 2004; Holben & Pheley, 2006; Hutson, Dorgan,Phillips, & Behringer, 2007; Kendall, Olson, & Frongillo, 1996; Kropf et al., 2007;Pheley et al., 2002; Tessaro, Mangone, Parkar, & Pawar, 2006; Walker et al., 2007;Wewers et al., 2006). In fact, in the proposed study region of Appalachian Ohio, foodinsecurity was found to be three times the level of the rest of the state, as well as almostdouble the rate of the nation (Holben et al., 2004; Holben & Pheley, 2006; Kropf et al.,2007; Meek, 2005; Pheley et al., 2002; Walker et al., 2007). Food insecurity has been associated with many health problems among householdmembers across the lifespan (Alaimo, Olson, & Frongillo, 2002; Bronte-Tinkew, Zaslow,
  • 14. 14Capps, Horowitz, & McNamara, 2007; Casey et al., 2005; Cook et al., 2004; Cook et al.,2008; Hamelin, Habicht, & Beaudry, 1999; Pheley et al., 2002; Seligman, Bindman,Vittinghoff, Kanaya, & Kushel, 2007; Stuff et al., 2004; Tarasuk & Beaton, 1999;Vozoris & Tarasuk, 2003; Walker et al., 2007). Obesity rates, diabetes, and HemoglobinA1C levels have all been found to be greater in food-insecure households as compared totheir counterparts in Appalachian Ohio (Holben & Pheley, 2006). Overall, poorer self-reported physical and mental health was associated with food insecurity in Appalachian,even in households with minimal food insecurity (Pheley et al., 2002). Physical health isnot only in jeopardy when households are food insecure; mental and overall health canalso be affected in both adults and children (Alaimo et al., 2002; Bronte-Tinkew et al.,2007; Casey et al., 2004; Casey et al., 2005; Casey et al., 2006; Cook et al., 2006; Cooket al., 2008; Holben et al., 2006; Holben et al., 2006; Pheley et al., 2002; Rose & Bodor,2006; Skalicky et al., 2006; Wilde & Peterman, 2006) Food insecurity negatively impacts multiple aspects of the diet, including bothquality and quantity of food consumed (Chang, Nitzke, Guilford, Adair, & Hazard, 2008;Condrasky & Marsh, 2005; Langevin et al., 2007; McIntyre et al., 2003; Vozoris &Tarasuk, 2003). Such households have been found to have below the recommendedintakes of kilocalories, calcium, vitamin B-6, magnesium, iron, and zinc, compared tothose in food-secure households (Dixon, Winkleby, & Radimer, 2001; Matheson,Varady, Varady, & Killen, 2002; Olson, 1999; Rose & Oliveira, 1997). Studies haveshown food-insecure households to be of particular concern in relation to decreasedproduce intake, leading potentially to increased risk for certain cancers, cardiovascular
  • 15. 15disease, and lower overall wellness (Ahn et al., 2005; Cartmel, Bowen, Ross, Johnson, &Mayne, 2005; Dixon et al., 2001; Genkinger, Platz, Hoffman, Comstock, & Helzlsouer,2004; Guenther, Dodd, Reedy, & Krebs-Smith, 2006; Kendall et al., 1996; Kirsh et al.,2007; Larsson, Hakansson, Naslund, Bergkvist, & Wolk, 2006; Lee et al., 2006; Pierce etal., 2007; Pierce, Stefanick et al., 2007). For children, food insecurity can negativelyimpact diet, including decreased produce intake, which may negatively affect health(Casey et al., 2005; Casey et al., 2006; Cook et al., 2006; Dixon et al., 2001; Fu, Cheng,Tu, & Pan, 2007; Lakkakula, Zanovec, Silverman, Murphy, & Tuuri, 2008; Langevin etal., 2007; Riediger, Shooshtari, & Moghadasian, 2007). Federal food assistance programs have been developed to improve nutritionalstatus of Americans, including Supplemental Nutrition Assistance Program (SNAP), theSpecial Supplemental Nutrition Program for Women, Infant, and Children (WIC), SchoolMeals Programs, and local programs (e.g., Community Food Initiatives), all of whichstrive to increase the produce intake among participants (Food and Nutrition Service,2008; U.S. Department of Health and Human Services, 2008; U.S. Department of Healthand Human Services, 2009a, 2009b, 2009c; Zerbian, 2007). In order to further increaseproduce intake in food-insecure families and decrease their risk for such chronicproblems, a variety of community-based programs and interventions have beendeveloped, including produce distribution and gardening programs (Hazen, Holben,Holcomb, & Struble, 2008; Kropf et al., 2007; Nanney, Johnson, Elliott, & Haire-Joshu,2007; Struble, Holben, Hazen, & Holcomb, 2008). Gardening, in particular, has beenshown to increase access to fruits and vegetables in the face of food insecurity, and is a
  • 16. 16relatively inexpensive way to grow fresh produce (Holben et al., 2004; McAleese &Rankin, 2007; Nanney, Johnson et al., 2007; Rose & Richards, 2004). Further, gardeninginterventions have been shown to positively impact produce intake of children and theirhouseholds, which may also increase their food security (Graham & Zidenberg-Cherr,2005; Hermann et al., 2006; Holben et al., 2004; McAleese & Rankin, 2007; Morris &Zidenberg-Cherr, 2002). A variety of methods have been used by these programs,including varying time frames, lessons, and venues across the United States (Robinson-OBrien, Story, & Heim, 2009). However, none have been done in Appalachian Ohio,other than the federal and non-federal programs offered. Gardening may be a particularly effective strategy for a variety of reasons.Nanney et al. (2007) found that those families in rural areas who ate homegrown producehad an increase in produce availability, along with an increase in their child’s preferencefor new fruits and vegetables. In fact, gardening projects have been done to improve thehealth and fruit and vegetable intake of the participants, with most having positiveimpacts on their participants’ produce intake and gardening and nutrition knowledge(Graham & Zidenberg-Cherr, 2005; Hermann et al., 2006; McAleese & Rankin, 2007;Morris & Zidenberg-Cherr, 2002; Nanney, Johnson et al., 2007; Stables et al., 2005; VanDuyn & Pivonka, 2000). Compared to other interventions, gardening is an inexpensiveway to increase produce intake as well as physical activity in households (Graham &Zidenberg-Cherr, 2005; McAleese & Rankin, 2007; Nanney, Johnson et al., 2007).
  • 17. 17 Statement of the Problem Produce intake is inadequate among children, which negatively impacts diet (Ball,Benjamin, & Ward, 2008; Gao, Wilde, Lichtenstein, & Tucker, 2006; Langevin et al.,2007; Lorson, Melgar-Quinonez, & Taylor, 2009). It was recently reported that fruits andvegetables can reduce cardiovascular problems in adolescents (Holt et al., 2009).However, children do not typically meet the required intakes for fruits and vegetables,and most servings come from potatoes and fruit juices (Lorson et al., 2009). In the studyregion, multiple studies have indicated the need for intervention in the Southeastern OhioAppalachian region in relation to promoting fruit and vegetable intake (Ball et al., 2008;Cassady, Jetter, & Culp, 2007; Holben et al., 2004; Kropf et al., 2007; Luszczynska,Tryburcy, & Schwarzer, 2007; Walker et al., 2007; Wewers et al., 2006). One potentialsolution is to introduce gardening to children, who may, in turn, influence the entirehousehold’s habits surrounding gardening and produce. Through the introduction ofgardening, study area children will not only be involved directly in their own foodproduction, but will potentially improve food security in their households. Purposes of the Study Fruit and vegetable intake has been found to be related to household food security(Bhattacharya, Currie, & Haider, 2004; Dixon et al., 2001; Kendall et al., 1996; Kropf etal., 2007). For adult females and children living in food-insecure households, fruits andvegetables are typically the first groups reduced from the diet, due to their higher priceand shorter shelf life, compared to other foods (Cassady et al., 2007; Dixon et al., 2001;
  • 18. 18Kendall et al., 1996; Kropf et al., 2007). Therefore, through the practice of gardening, afamily may be able to grow fruits and vegetables at a lower cost than purchasing them,while increasing both physical activity and produce intake. Given the paucity of data surrounding this area of nutrition and relatedeffectiveness of gardening programs in improving both food security and produce intake,the purposes of this study were to: (a) measured the effect of a nutrition and gardeningeducation program on Appalachian children’s fruit and vegetable intakes and preferences;and (b) examined the relationship of food security status to gardening habits andperceptions, produce intake, and personal characteristics of children and their adultfemale caregivers. Research Questions and Hypotheses This study answered the research questions summarized in Table 1. Hypothesesfor the questions are also summarized in Table 1.
  • 19. 19Table 1Research Questions and Hypotheses Research Questions Hypotheses 1. Does a six-week nutrition and A six-week nutrition and gardening gardening education program education program positively impacts improve children’s preference for children’s fruit and vegetable intakes and and intake of fruits and vegetables? preferences. 2. At the onset of the study, is Food insecurity is associated with fewer household food security status gardening habits of the children as related to the female caregiver’s perceived by the female caregiver. perception of the gardening habits of the children? 3. At the onset of the study, is Food insecurity is associated with household food security status decreased gardening readiness of the related to the female caregiver’s female caregiver. gardening readiness? 4. At the onset of the study, is Food security is inversely associated with household food security status female caregiver’s produce intakes. related to produce intake of female caregiver? 5. At the onset of the study, are the Child’s gardening habits are positively female caregiver’s gardening habits associated with their female caregiver’s related to their perceptions of the gardening habits. child’s gardening habits? 6. At the onset of the study, is Food insecurity is associated with household food security status decreased produce preferences and intakes related to produce preferences and of child participants. intakes of child participants? 7. At the onset of the study, are the Child’s produce intake and perceptions are child’s produce intake and positively associated with their female preferences related to their female caregiver’s produce intake. caregiver’s produce intakes? 8. At the onset of the study, are the Child’s produce intake and perceptions are child’s produce intake and positively associated with their female preferences related to their female caregiver’s gardening habits. caregiver’s gardening habits?
  • 20. 20 9. Do body mass index (BMI), Body mass index (BMI) will be greater vegetable intake, and fruit intake and both vegetable and fruit intakes will differ between female caregivers lower in female caregivers from food- from food-secure versus food- insecure households compared to food- insecure households? secure households. 10. Do marital status, education level, Food-insecure female caregivers will be transportation, hunting, fishing, food single and have lower education, diet assistance program participation, quality, and health status while having perceived health level, diet quality, higher body mass index and food body mass index category, and assistance program participation than produce and gardening readiness food-secure females. Food-insecure differ between female caregivers females will also have lower produce and from food-secure versus food- gardening readiness than those from food- insecure households? secure households. Significance of the Study As previously discussed, food insecurity is associated with decreased produceintake. This may be especially prevalent in distressed areas such as Athens County,Ohio, where access to and availability of produce are concerns for food-insecure homes.Through the implementation of this program, the child participants became more awareof basic nutrition concepts, as well as gardening skills, that they can share with theirfamilies in order to increase their fruit and vegetable intake, as well as food security. Multiple groups have the potential of benefiting from this program and research,especially the children involved and their families. They not only received the directbenefit of the education and produce distribution, but they were also able to use theknowledge and skills after the program’s completion through the development of theirown garden. Other groups that may benefit included the Kids on Campus Program
  • 21. 21(university-based summer camp), where this program was initially piloted. Finally, thedietetics and nutrition profession may benefit from this research by using the findings asa basis for further research and program development. Practical outcomes of this project, other than its benefits to future research,include stimulation of similar programs developing in the future. Since this was a pilotstudy, improvements could be made in order to re-evaluate its effectiveness in theoriginal age group studied, or target other ages or populations in different regions of thecountry for evaluation. The unique aspect of this program, compared to previous studies, is that it focusedin the region of Appalachian Ohio. Based upon the literature related to food security inand the culture of the Appalachian region, as well as pediatric nutrition studies andsurveillance data, the program was developed. Potential Delimitations and Limitations Potential limitations of this pilot study include the pilot nature of program andstudy, potential for children to be absent for parts of the program or to discontinueparticipation in the study, limited participation of the family members/caregivers, literacylevel of all participants, and use of children and families participating in the camp ratherthan a randomly selected sample. These limitations could hinder participant selection andrecruitment, as well as the effectiveness of the program. Potential delimitations, or those factors out of our control that could hinder ourstudy, include summer camp practices (participant selection, daily schedule), climate of
  • 22. 22the study region during the study period, and the availability of produce from farmers fordistribution during the study. In addition, since this study utilized convenience sampling,we were unable to randomly sample the children living in the area or select for particulardemographics. To overcome these limitations and delimitations, we closely collaborated with thesummer camp program staff and utilized local farmers for produce who typically aresuccessful. Definition of Terms Food security: Access by all people at all times to enough food for an active,healthy life and includes at a minimum: a) the ready availability of nutritionally adequateand safe foods, and b) the assured ability to acquire acceptable foods in sociallyacceptable ways (e.g., without resorting to emergency food supplies, scavenging,stealing, and other coping strategies; Anderson, 1990, p. 1560). Food insecurity: Whenever the availability of nutritionally adequate and safefoods or the ability to acquire acceptable foods in socially acceptable ways is limited oruncertain (Anderson, 1990, p. 1560). Community food security: Prevention-oriented concept that supports thedevelopment and enhancement of sustainable, community-based strategies: to improveaccess of low-income households to healthful nutritious food supplies; to increase theself-reliance of communities in providing for their own food needs; and to promotecomprehensive responses to local food, farm, and nutrition issues (Andrews, 2008).
  • 23. 23 CHAPTER 2: REVIEW OF LITERATURE In the United States, food insecurity can lead to an increased risk for healthproblems, poor diet, and lack of fruit and vegetable intake (Bhattacharya et al., 2004;Bronte-Tinkew et al., 2007; Carmichael, Yang, Herring, Abrams, & Shaw, 2007; Caseyet al., 2005; Cook et al., 2004; Cook et al., 2006; Cook et al., 2008; Gundersen, Lohman,Garasky, Stewart, & Eisenmann, 2008; Hazen et al., 2008; Holben et al., 2006; Holben etal., 2004; Holben & Pheley, 2006; Jyoti, Frongillo, & Jones, 2005; Kropf et al., 2007;Lee & Frongillo, 2001; Lyons, Park, & Nelson, 2008; Matheson et al., 2002; C. M.Olson, Bove, & Miller, 2007; Rose & Bodor, 2006; Skalicky et al., 2006; Struble et al.,2008; Stuff et al., 2004; Tanumihardjo et al., 2007; Walker et al., 2007; Weinreb et al.,2002). These effects are particularly important for children in food-insecure householdsbecause such health problems and diet habits could follow them and exacerbatethroughout life (Connell, Lofton, Yadrick, & Rehner, 2005; Olson et al., 2007). Appalachia has been shown to be at higher risk for food insecurity and itsassociated outcomes than the rest of the nation (Hazen et al., 2008; Holben et al., 2006;Holben et al., 2004; Holben & Pheley, 2006; Kendall et al., 1996; Kropf et al., 2007;Meek, 2005; Pheley et al., 2002; Struble et al., 2008; Walker et al., 2007). Therefore, anintervention focusing on nutrition, gardening, and produce intake may alleviate some ofthese problems for children in Appalachian Ohio. This study was conducted to: (a)measure the effect of a nutrition and gardening education program on Appalachianchildren’s fruit and vegetable intakes and preferences; and (b) examine the relationship offood security status to gardening habits and perceptions, produce intake, and personal
  • 24. 24characteristics of children and their adult female caregivers. In this literature review,findings related to food security, Appalachia, produce intake, and gardening arereviewed. Food SecurityDefinitions Food security is defined as “access by all people at all times to enough food for anactive, healthy life and includes at a minimum: (a) the ready availability of nutritionallyadequate and safe foods, and (b) the assured ability to acquire acceptable foods insocially acceptable ways (e.g., without resorting to emergency food supplies, scavenging,stealing, and other coping strategies)” (Anderson, 1990, p. 1560). Food insecurity isdefined as “whenever the availability of nutritionally adequate and safe foods or theability to acquire acceptable foods in socially acceptable ways is limited or uncertain”(Anderson, 1990, p. 1560). Hunger is a condition that is not always associated with foodinsecurity, however is defined as an individual physiological condition due to prolongedlack of food causing weakness, illness, and pain (Anderson, 1990). Both individuals andoverall households can experience hunger (Radimer, Olson, & Campbell, 1990).Household hunger can be composed of one or more of the following: food depletion;food unsuitability; and food anxiety (Radimer et al., 1990). Individual hunger consists ofintake insufficiency, diet inadequacy, and disrupted eating patterns (Radimer et al.,1990). Since there are so many aspects to it, hunger is difficult to define for eachindividual which leads to multiple definitions. The Food Research and Action Center
  • 25. 25(FRAC) defined hunger as the physiological and psychological state that comes from nothaving enough food, while Harvard School of Public Health defined it as chronic underconsumption of food and nutrients (Radimer & Radimer, 2002). Community food security is difficult to assess. However, it is basically defined asthe attempt to increase the food security of a community through the use of education andprograms. The U.S Department of Agriculture defines it as a prevention-oriented conceptthat supports the development and enhancement of sustainable, community-basedstrategies which improve access of low-income households to healthful nutritious foodsupplies; increase the self-reliance of communities in providing for their own food needs;and promote comprehensive responses to local food, farm, and nutrition issues (Andrews,2008). As far as the community food security of Athens County, it has been found to becompromised and in need of such food, farm, and nutrition interventions (Bletzacker,Holben, & Holcomb, 2007).Measurement of Food Security The Food Security Measurement Project is a collaboration between federalagencies, researchers, and non-profit organizations developed in response to the NationalNutrition Monitoring and Related Research Act (NNMRR) in 1990 with the objective todevelop a methodology to assess the food security status nationwide (Nord, 2008b). Theidea for food security measurement began in the 1980s when hunger emerged as agrowing concern in the United States (Nord, Andrews, & Carlson, 2008). The HarvardSchool of Public Health and FRAC provided evidence to President Reagan’s Task Forceon Food Assistance urging for an investigation into the allegations of increasing hunger
  • 26. 26(Carlson, Andrews, & Bickel, 1999; Olson, 1999). After developing the definitions offood security, the team focused on the development of the instrument for measurement.Through the team work of the United States Department of Agriculture (USDA) and theCommunity Childhood Hunger Identification Project (CCHIP), an 18-item questionnairewas developed to determine the multiple levels of food security occurring in Americanhouseholds which was first administered as a supplement to the Current PopulationSurvey (CPS) in 1995 (Nord et al., 2008; Nord, 2008b). The questions for the FoodSecurity Survey Module (FSSM) were developed through extensive research by a team ofexperts in the field, along with field testing and validation (Nord, 2008b). The FSSM hassince been used by governmental and other researchers. For example, the instrument hasbeen used in the Continuing Survey of Food Intakes by Individuals (CSFII), the NationalHealth and Nutrition Examination Survey (NHANES), the Early Childhood LongitudinalStudy (ECLS), the Panel Survey of Income Dynamics (PSID), and the Survey of ProgramDynamics (SPD; Bickel, Nord, Price, Hamilton, & Cook, 2000; Nord et al., 2008). The FSSM is an 18-item survey with questions listed in order of severity, fromleast to most which aids in the categorization of the participant (Carlson et al., 1999;Radimer & Radimer, 2002). Each question uses key phrasing, including “because wecould not afford it” and “because there was not enough money”, in order to assess foodsecurity based on financial reasons over the past 12 months (Bickel et al., 2000). Some ofthe wording varied from 1995 to 1998, however the core questions have remainedunchanged (Bickel et al., 2000). The questions for the 18-item survey are shown in Table2, while the scoring is found in Appendix A.
  • 27. 27Table 218-item Food Security Survey Module, 2008Item Number QuestionQ1 “We worried whether our food would run out before we got money to buy more.” Was that often, sometimes, or never true for you in the last 12 months?Q2 “The food that we bought just didn’t last and we didn’t have money to get more.” Was that often, sometimes, or never true for you in the last 12 months?Q3 “We couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for you in the last 12 months?Q4 In the last 12 months, did you or other adults in the household ever cut the size of your meals or skip meals because there wasn’t enough money for food? (Yes/No)Q5 (If yes to Question 4) How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months?Q6 In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food? (Yes/No)Q7 In the last 12 months, were you ever hungry, but didn’t eat, because there wasn’t enough money for food? (Yes/No)Q8 In the last 12 months, did you lose weight because there wasn’t enough money for food? (Yes/No)Q9 In the last 12 months did you or other adults in your household ever not eat for a whole day because there wasn’t enough money for food? (Yes/No)Q10 (If yes to Question 9) How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months? Questions 11-18 are asked only if the household included children ages 0-18
  • 28. 28Q11 “We relied on only a few kinds of low-cost food to feed our children because we were running out of money to buy food.” Was that often, sometimes, or never true for you in the last 12 months?Q12 “We couldn’t feed our children a balanced meal, because we couldn’t afford that.” Was that often, sometimes, or never true for you in the last 12 months?Q13 “The children were not eating enough because we just couldn’t afford enough food.” Was that often, sometimes, or never true for you in the last 12 months?Q14 In the last 12 months, did you ever cut the size of any of the children’s meals because there wasn’t enough money for food? (Yes/No)Q15 In the last 12 months, were the children ever hungry but you just couldn’t afford more food? (Yes/No)Q16 In the last 12 months, did any of the children ever skip a meal because there wasn’t enough money for food? (Yes/No)Q17 (If yes to Question 16) How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months?Q18 In the last 12 months, did any of the children ever not eat for a whole day because there wasn’t enough money for food? (Yes/No)Note. From “Guide to Measuring Household Food Security, Revised 2000,” by G. Bickel,2000, Department of Agriculture, Food and Nutrition Service, 6, p. 22. Copyright 2000by USDA. Reprinted with permission. Per Appendix A, households are considered food-secure if they report only one ortwo food-insecure conditions. Food-insecure households are defined by having three ormore food-insecure conditions (Nord et al., 2008). Food insecurity is broken down intomultiple categories depending on the number of affirmative answers. Low food securityis classified as having multiple indications of food access, but few reduced intakepatterns. Very low food security, which is typically the situation where children are
  • 29. 29affected, is when the household reported to being hungry at some point due to lack ofmoney for food (Nord et al., 2008). This category breakdown is shown below in Table 3with both the old categories and new categories represented.Table 3Food Security Categories Defined by the USDA Old New Scale Scores Associated Conditions Categories Categories (18-item) (1995-2005) (2006- present)Food- Food-secure High food 0 affirmative No reported indications ofsecure security responses food-access problems or limitations Marginal 1-2 One or two reported food security affirmative indications—typically of responses anxiety over food security or shortage of food in the house. Little or no indication of changes in diets or food intakeFood- Food- Low food 3-5 Reports of reduced quality,insecure insecure security affirmative variety, or desirability of diet. without responses Little or no indication of hunger reduced food intake Food- Very low 6 or more Reports of multiple indications insecure food security affirmative of disrupted eating patterns and with hunger responses reduced food intakeNote. Adapted from “Food Security in the United States: Definitions of Hunger and FoodSecurity,” by M. Nord, 2008, Department of Agriculture, Food and Nutrition Service.Copyright 2006 by the USDA. Reprinted with permission.
  • 30. 30 Over the years, the 18-item survey has been adjusted to fit multiple situations,populations, and households. A shortened form of the Food Security Scale was developedin 1995 for research projects with less funding and time (Blumberg, Bialostosky,Hamilton, & Briefel, 1999). Researchers narrowed the original 18-item survey down tosix questions, which still accurately assessed the food security status of the household,but are not specific to children (Blumberg et al., 1999). In order to validate the survey formost households and remain time effective, the researchers removed the eight questionswhich are asked solely for households with children (Blumberg et al., 1999). This wasfound to have little effect on the validity of the tool, and so the survey was furthershortened from ten remaining questions down to six, leaving the original questions 2, 3,5, 7, 8, and 10 (Blumberg et al., 1999). The now 6-item, shortened form was tested withboth households with and without children resulting in 82.8% and 92.3 % accuracyrespectively. Both tools have been used in multiple research projects and validated formultiple population groups ( Frongillo Jr, 1999; Opsomer, Jensen, & Pan, 2003; Swindale& Bilinsky, 2006). The questions for the six-item survey are in Table 4, with the scoringfound in Appendix A.
  • 31. 31Table 4Six-item Food Security Questionnaire, 2008Item Number QuestionThe first four questions are in relation to the family’s food intakeQ5 In the last 12 months, did you or other adults in your household, ever cut the size of your meals or skip meals because there wasn’t enough money for food?Q8 (Ask only if Yes to Q5) How often did this happen- almost every month, some months but not every month, or in only 1 or 2 months?Q7 In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money to buy food?Q10 In the last 12 months, were you ever hungry but didn’t eat because you couldn’t afford enough food?The last two questions are in relation to the family’s food situationQ2 “The food that I/we bought just didn’t last and I/we didn’t have money to get more.” Was that often, sometimes, or never trough for you in the last 12 months?Q3 “I/we couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for you in the last 12 months?Note. From “The Effectiveness of a Short Form of the Household Food Security Scale,”S. Blumberg, 1999, American Journal of Public Health, 89, p. 1234. Copyright 1999 bythe USDA. Reprinted with permission.Food Security in the United States Estimates of food security in the United States are calculated from the annualCurrent Population Survey (CPS). The CPS is a monthly survey of 50,000 householdswhich includes an assessment of the food security of the nation through the use of the 18-
  • 32. 32item Food Security Survey Module, which asks households about their behaviors andconditions over the past 12 months (U.S. Census Bureau, 2008). The FSSM is included inthe December distribution of the CPS. The questions are finance- related as to excludethose who are purposely dieting or cutting back for other reasons. For example,approximately 45,600 households made of civilian, non-institutionalized citizens of thenation were utilized in 2007 (Nord et al., 2008). Statistics on the food security of the United States have been collected since 1995.In 2007, 88.9% of households were found to be food-secure while the other 11.1%, or 13million, were food-insecure (Nord et al., 2008). Of those who were food-insecure, 7.0%were households with low food security and 4.1% were found to have very low foodsecurity. Figure 1 below illustrates the 2007 estimates.
  • 33. 33 Low Food Secure Households Very Low Food 7% Secure Households 4% Food Secure Households 89%Figure 1. Food security status of U.S. households in 2007.Note. Adapted from “Household Food Security in the United States, 2007,” by M. Nord,2008, Economic Research Service/USDA , ERR-66, p. 4. Copyright 2008 by the USDA.Adapted with permission. Of the 4.7 million households who were determined to have very low foodsecurity in 2007, there were several conditions reported as a part of this phenomenon:98 % worried that their food would run out before they got money to buy more; 97 %reported that the food they bought just did not last and they did not have money to getmore; 94 % reported that they could not afford to eat balanced meals; 96 % reported thatan adult had cut the size of meals or skipped meals because there was not enough moneyfor food; and 93 % reported that they had eaten less than they felt they should because
  • 34. 34there was not enough money for food (Nord et al., 2008). When food insecurity didoccur, about one-fourth of those households had problems chronically for at least sevenmonths out of the year (Nord et al., 2008). The rates of both food security and food insecurity have not changed drastically inthe past ten years. The prevalence has changed less than one percent since 1999according to the data collected from the CPS surveys (Nord et al., 2008). The data from1999 on is based on the consistent FSSM after adjustments and changes were made from1995 through 1998 (Bickel et al., 2000). Figure 2 below shows further detail of the trendsin food security over the past ten years.
  • 35. 35 100% 98% 96% Percentage of Households 94% 92% 90% 88% 86% 84% 82% 1999 2000 2001 2002 2003 2004 2005 2006 2007 Food Insecurity 10% 10% 11% 11% 11% 12% 11% 11% 11% Food Security 90% 90% 89% 89% 89% 88% 89% 89% 89%Figure 2. Food security and food insecurity trends in the U.S. from 1999-2007.Note. Adapted from “Household Food Security in the United States, 2007,” by M. Nord,2008, Economic Research Service/USDA , ERR-66, p. 6. Copyright 2008 by the USDA.Adapted with permission. Even though the FSSM is distributed through the CPS annually in December, ithas not always been that way. Originally, the FSSM was included in the April 1995 CPS,and then changed from September, August, and back to April from 1996 through 1998(Bickel et al., 2000; Nord et al., 2008). December was finally chosen as the month for theFSSM distribution in 2001, which in turn keeps the data consistent from year to yearwithout seasonal influence (Nord et al., 2008). Between 1988 and 1994, before the official measurement of food security began,4.1% lived in families that reported food insecurity, which was due to lack of money,
  • 36. 36food stamps, or vouchers from WIC (Alaimo, Briefel, Frongillo, & Olson, 1998). A littleover 2% of these families had children under 17 who cut the size or skipped meals due tolack of money (Alaimo et al., 1998).Risk Factors for Food Insecurity Risk factors for food insecurity include lower education, lower income, beingfrom an ethnic minority, living in a non-suburban residence, and participation ingovernment assistance programs (Adams, Grummer-Strawn, & Chavez, 2003; Alaimo etal., 1998; Alaimo, Olson, & Frongillo, 2001b; Bhattacharya et al., 2004; Cutts, Pheley, &Geppert, 1998; Gundersen et al., 2008; Herman, Harrison, Afifi, & Jenks, 2004; Holben& Myles, 2004; Jones & Frongillo, 2006; Nord et al., 2008; Oberholser & Tuttle, 2004;Quandt et al., 2004; Quandt, Arcury, Early, Tapia, & Davis, 2004; Rose, 1999).Characteristics associated with being food-insecure in 2007 included households: (a) withincomes below the poverty line; (b) with children; (c) headed by a single person; and (d)headed by African-American or Hispanic individuals (Nord et al., 2008). Of thepopulation surveyed in 2007, 37.7% of those households were below the poverty line of$21,027 in income for a family of four (Nord et al., 2008). Those households withchildren headed by a single parent made up 48.2% of the food-insecure population (Nordet al., 2008). Both single male or female headed households were at greater risk for foodinsecurity, compared to other households (Nord et al., 2008). In another study, in fact,both divorced men and women were found to have lower food security status than whenthey were in a relationship (Hanson, Sobal, & Frongillo, 2007). African-American andHispanic based households made up 42.3% of the food-insecure group in 2007, with all
  • 37. 37of these groups having the most occurrence of very low food security (Nord et al., 2008).Below are facts from the literature discussing the risk factors, outcomes, and furtherdevelopments found. Overall, it has been found that those living in householdscharacterized by food insecurity tend to be in households with children, headed by asingle adult, being an African-American or Hispanic, with income below the poverty line,and located in metropolitan areas (Nord et al., 2008). Poverty is a key component of food insecurity. One-fifth of study participantsnationwide under the poverty level in 1998 were food-insecure (Nelson, Cunningham,Andersen, Harrison, & Gelberg, 2001). A study done in 2006 found many differencesbetween food-secure and insecure women in particular. Food-insecure women wereyounger, less educated, single, with lower incomes than their counterparts and 61% ofthem were overweight (Jones & Frongillo, 2006). Food assistance program participationhas also been associated with food insecurity and poverty. A household must meetspecific financial and resource requirements in order to be eligible for food assistanceprograms, which are between 185% and 130% of the poverty level (Food and NutritionService, 2008; U.S. Department of Health and Human Services, 2009b, 2009c). It wasfound that 34% of Supplemental Nutrition Assistance Program (SNAP) participants in aMaryland study sometimes did not have enough food to eat, or to provide adequate foodconsistently (Oberholser & Tuttle, 2004). A study done with SNAP Participants foundthat 66% of participants had some level of food insecurity with 7% being food-insecurewith hunger (Oberholser & Tuttle, 2004). In addition to food insecurity, lack of incomemay also compromise the ability to properly heat and cool the home. Another study
  • 38. 38found that energy security was strongly and positively associated with both householdand child food insecurity (Cook et al., 2008). All of these factors narrow down to mainly single, poor, low-educated womenwho are having trouble providing consistent access to nutritious for their families. Theserisks combined affect household diet, chronic disease risk, and weight of both childrenand female adults. Even with participation in government assistance programs, such asthe Special Supplemental Nutrition Program for Women, Infant, and Children (WIC) andSNAP, additional help may be needed due to the self-selection effect (Holben &American Dietetic Association (ADA), 2006). This self-selection phenomenon explainsthe higher occurrence of food-insecure participants in food assistance programs by sayingthese households seek assistance due to social perception that it is needed (Holben &ADA, 2006). Therefore any type of intervention that can teach self sufficiency or provideassistance to both these mothers and their children could help offset strugglinghouseholds.Outcomes of Food Insecurity in Adults Food insecurity has multiple household consequences and/or associations,including poor health, restricted activity, multiple chronic conditions, depression,physical impairment, psychological suffering, and family disturbances (Hamelin et al.,1999; Holben & ADA, 2006; Vozoris & Tarasuk, 2003). More specifically, foodinsecurity has been associated with higher chronic disease risk including obesity,diabetes, as well as mental and overall health (Hamelin et al., 1999; Hanson et al., 2007;Holben & Pheley, 2006; Pheley et al., 2002; Stuff et al., 2004). Physical and dietary
  • 39. 39implications also occur in food-insecure households including hunger, depletion, illness,stress, modification of eating habits, and disrupted household food management (Hamelinet al., 1999; Holben & ADA, 2006; Kendall et al., 1996; Olson, 2005). Food insecurity and chronic disease risk among adults. Food insecurity is associated with increased risk for chronic disease and poormanagement of the conditions. It has been found that food-insecure participants weretwice as likely to have diabetes as food-secure participants (Seligman et al., 2007). In astudy done in 2006, individuals with diabetes were more likely to live in food-insecurehouseholds (Holben & Pheley, 2006). The study also found that individuals living infood-insecure households were more likely to have HbA1c levels higher than therecommended level of seven (Holben & Pheley, 2006). Poor management of diabetes canlead to future health consequences for these individuals that they may not be able toafford or manage. Food insecurity and financial restraints were also related to diabetes(Nelson et al., 2001). Six percent of diabetic participants reported problems with foodinsecurity and finances related to their diabetes management (Nelson et al., 2001). Food-insecure individuals were more likely to report having heart disease, diabetes, high bloodpressure, and allergies in 2003 (Vozoris & Tarasuk, 2003). Food insecurity and overweight/obesity among adults. Adult individuals living in a food-insecure household, especially females, aremore likely to be obese than those in food-secure households (Lyons et al., 2008; Martin& Ferris, 2007). One study done in Canada found that the rates of obesity coincided withthe rates of food insecurity (Lyons et al., 2008). In national surveys, researchers found
  • 40. 40that obesity was lowest for fully food-secure women, while those who were food-insecure had the most weight gain over time (Hanson et al., 2007; Wilde & Peterman,2006). Women in California were also found to have an increased risk for obesity whenclassified as food-insecure, with almost one-fifth of food-insecure subjects being obese(Adams et al., 2003). Those women in food-insecure households were almost twice aslikely to be overweight or obese as those in food-secure households (Adams et al., 2003). As discussed above, obesity has been linked as a consequence of food insecurityeven though it seems to be counter intuitive. Food-insecurity is associated with lack offood for a nutritious, healthy life. However, high calorie, high fat, low nutrient densefoods tend to be less expensive than low calorie, low fat, and high nutrient dense items(Mendoza, Drewnowski, Cheadle, & Christakis, 2006). Therefore, these empty caloriefoods replace the more nutritious options leading to weight gain. Women especially have been directly affected by this obesity trend (Adams et al.,2003; Holben & Pheley, 2006; Jones & Frongillo, 2006; Lyons et al., 2008; Olson, 1999;Townsend, Peerson, Love, Achterberg, & Murphy, 2001; Wilde & Peterman, 2006).Women in food-insecure households have been found to have an overall higher bodymass than those in food-secure households (Olson, 2005). Nationwide data collected in1999 found a strong association between food-insecurity and overweight status,especially in women who were initially normal weight (Jones & Frongillo, 2007). In ruralNew York, it was found that obesity in early-pregnancy was positively associated withfood-insecurity in post-partum women (Olson & Strawderman, 2008). It was reportedthat 19.3% of women changed food insecurity category from the beginning of pregnancy
  • 41. 41to 2 years postpartum, whereas only 5.1% changed category for obesity (Olson &Strawderman, 2008). This infers that obesity may have a stronger correlation to foodinsecurity, rather than food insecurity to obesity. There have been nationwide please forfederal support of research that focuses on the causes, mechanisms, practices, therapies,and interventions in relation to overweight and obesity in all populations (Lyznicki,Young, Riggs, Davis, & Council on Scientific Affairs, American Medical Association,2001). Conflicting findings exist with regard to food insecurity and overweight andobesity in households. Food security was not related to overweight or obesity in low-income Massachusetts study participants; however food assistance participation wascorrelated (Webb, Schiff, Currivan, & Villamor, 2008). Another study done over multiplecities in the U.S. found that a participant’s change of food security status was notsignificantly associated with their change in weight (Whitaker & Sarin, 2007). In fact,those participants who began the study as food-secure and changed over the course oftwo years did not change in weight any more than participants whose food security statusremained unchanged (Whitaker & Sarin, 2007). Food insecurity and overall health among adults. Food insecurity has been associated with many other health problems besideschronic disease, including increased risk for birth defects, maternal depression, suicideattempts, depression, and overall poor health (Alaimo et al., 2002; Carmichael et al.,2007). It was found that 53% of mothers who reported food insecurity in their family alsohad depression (Casey et al., 2004). One study found as food insecurity rises, overall
  • 42. 42health status falls (Bronte-Tinkew et al., 2007). The elderly are a group whose health isheavily affected by food insecurity. Those who reported food insecurity also reportedpoor overall health more often than those who were food-secure (Lee & Frongillo, 2001).All of these health problems could be alleviated with more consistent access to healthyfood and education for these families. Food insecurity and diet among adults. Food insecurity negatively impacts multiple aspects of the diet, includingdecreased quality and quantity of food intake and diet (Chang et al., 2008; Condrasky &Marsh, 2005; Kendall et al., 1996; Langevin et al., 2007; McIntyre et al., 2003; Olson,2005; Vozoris & Tarasuk, 2003). Diets of individuals living in households characterizedby food insecurity have been found to have below the recommended intake ofkilocalories, protein, calcium, vitamins B-6 and B-12, riboflavin, niacin, magnesium,iron, and zinc, compared to those living in food-secure households (Dixon et al., 2001;Lee & Frongillo, 2001; Matheson et al., 2002; Olson, 1999; Rose & Oliveira, 1997).Studies have shown food-insecure households to be of particular concern in relation todecreased produce intake, as this can lead to increased risk for certain cancers,cardiovascular disease, and lower overall wellness (Ahn et al., 2005; Cartmel et al., 2005;Dixon et al., 2001; Genkinger et al., 2004; Guenther et al., 2006; Kendall et al., 1996;Kirsh et al., 2007; Larsson et al., 2006; Lee et al., 2006; Pierce et al., 2007; Pierce,Stefanick et al., 2007). While diet inadequacy is related to food insecurity, eating habits of householdmembers may also suffer. Women in food-insecure households have been found to
  • 43. 43decrease their intake in order to allow other members of the family to eat (Kendall et al.,1996; Olson, 2005). Low-income families who are found to be food-insufficient spendsignificantly less money per household member on food in 2001 (Casey, Szeto, Lensing,Bogle, & Weber, 2001). Food-insecure households spend on average ten dollars less perperson on food per week (Nord et al., 2008). The amounts are shown in Figure 3 below. Weekly Household Food Spending Per Person $45.00 $32.50 $33.33 $31.00 Food Secure Food Insecure Households with low Households with very Households Households food security low food securityFigure 3. Weekly household food spending per person.Note. Adapted from “Household Food Security in the United States, 2007,” by M. Nord,2008, Economic Research Service/USDA , ERR-66, p. 26. Copyright 2008 by the USDA.Adapted with permission. Over half of the women in a Toronto study living in food-insecure householdsreported to having some hunger in the 30 days preceding the study (Tarasuk & Beaton,1999). Hunger is typically a managed process with some women using coping tactics,
  • 44. 44which typically include reducing their own intake to avoid or delay such insufficiency inchildren (Olson, 2005; Radimer et al., 1990). In fact, women in food-insecure homeshave lower energy, protein, carbohydrate, fat, and essential nutrients, while theirchildren’s intake seem to be more adequate (McIntyre et al., 2003). It was also foundthat the women’s average food and calcium intakes were positively associated with theirfood security status, with those in more food-insecure homes having decreased intakes(Tarasuk & Beaton, 1999). Both disordered eating (binge-like eating) and reliance onothers for food can cause disturbed eating patterns (Drewnowski & Specter, 2004;Kendall et al., 1996; Olson, 2005), and lead to weight gain and poor health, which canonly heighten the health care burden on their family. Prices and incomes greatly affect food choices, dietary habits, and dietary quality(Drewnowski & Specter, 2004). Typically, more expensive, shorter shelf-life items, suchas fresh produce, dairy, and meat products, are substituted with cheaper items likeconvenience foods and snacks (Dixon et al., 2001). As previously noted, adults in food-insecure homes have lower intakes of energy, vitamin B-6, magnesium, iron, zinc, andcereals (Dixon et al., 2001). While food insecurity also may lead to hunger, it is notalways the result (Nelson, Brown, & Lurie, 1998). In addition to what has already been discussed, food insecurity also leads todecreased produce intake, which may be improved by gardening. Eating fewer servingsof produce can have negative outcomes. For example, subjects in food-insecurehouseholds were more likely to have lower vitamin C, fruit, and vegetable intake(Kendall et al., 1996). Almost 75% of food-insecure subjects consumed two or fewer
  • 45. 45fruits and vegetables per day, compared to 54.6% of food-secure participants (Kendall etal., 1996). The rural population of America in a 1993 study decreased their fruit, salad,carrots, and vegetable intake as their food insecurity status worsened, which cannegatively impact their health (Kendall et al., 1996). Another study found that thosefamilies with preschool children living in rural areas who ate homegrown produce had anincrease in home availability of produce (Nanney, Johnson et al., 2007). Gardening projects have been done in order to increase participants’ fruit andvegetable intake and subsequently improve health (Robinson-OBrien et al., 2009). Suchinterventions are an inexpensive way to increase produce intake, since price is typicallyseen as a barrier, as well as physical activity in households (Cassady et al., 2007). Food insecurity and food assistance programs. Many food-insecure familiesparticipate in food assistance programs, including SNAP, WIC, and the Summer FoodService Program (Condrasky & Marsh, 2005; Nord et al., 2008; Oberholser & Tuttle,2004). In 2007, more than half (53.9%) of food-insecure families studied participated ina food assistance program in the 30 days previous to data collection (Nord et al., 2008).The percentages of participants in the three main national programs are shown in Figure4.
  • 46. 46 60.0% 50.0% Percentage of Households 40.0% 30.0% 20.0% 10.0% 0.0% Any of the School SNAP WIC three Lunch programs Percentage of food insecure households participating 33.0% 33.6% 12.5% 53.9% Percentage of very-low food security households 34.9% 28.1% 9.1% 50.9% participatingFigure 4. Food-insecure household food assistance participation.Note. Adapted from “Household Food Security in the United States, 2007,” by M. Nord,2008, Economic Research Service/USDA , ERR-66, p. 33. Copyright 2008 by the USDA.Adapted with permission. A study of SNAP participants in South Carolina found that 25% were food-insecure with hunger, with more SNAP participants being food-insecure than non-participants (Condrasky & Marsh, 2005). They also determined that participants ate lessat the end of the food cycle than at the beginning. Both weight and BMI also increased
  • 47. 47over the two year period (Condrasky & Marsh, 2005). This appears to indicate that, thecyclical nature of SNAP may lead to disordered eating patterns, leading to weight gain. In order to improve the food security of these families, a study was done withSNAP participants that aimed to increase their access to produce in order to increaseproduce intake. Researchers found increased supermarket access was associated withincreased fruit consumption but not significantly increased intake for vegetables (Rose &Richards, 2004). Some federal programs have attempted to include produce into their householdprovisions. The WIC program recently changed their food packages to include moreallowance for purchase of fresh fruits and vegetables, along with fruit and vegetableequivalents for all ages (Food and Nutrition Service, 2008). The WIC program alsocreated the Farmers Market Nutrition Program which allowed participating families touse vouchers at the local farmers markets in order to increase their fresh produce intake.It was found that this significantly improved the participant’s vegetable intake, but didnot make a great impact on their fruit intake (Kropf et al., 2007; Walker et al., 2007).Another study focused on the transportation aspect of produce access by distributingproduce packages to low-income households (Hazen et al., 2008). The study foundpositive results in increased produce intake with participants (Hazen et al., 2008). Thisshows that if fresh vegetable access is increased, it might be less of a barrier to food-insecure families and further aid them in bettering their diet. When families lack food they may utilize socially unacceptable means of foodacquisition. A study done on low-income mothers in Canada found that 80% of them had
  • 48. 48received free food over the past year from mostly food banks and relatives, and 75% ofthe women were food-insecure (McIntyre et al., 2003). In a Canadian study done withfood bank participants, 69.9% of households were supported by welfare while 5.9%relied on a combination of unemployment, loans, or other sources (Tarasuk & Beaton,1999). A local study done with Ohio food pantry users found increased usage from food-insecure households (OConnell & Holben, 2005).Outcomes of food insecurity in children As previously mentioned, adults in the household are not the only householdmembers affected by lack of food, but when food insecurity is at its worst, children alsosuffer. In most cases, children are protected from the harms of food insecurity; howeverin 2007, 323,000 households had one or more children directly affected by foodinsecurity (Nord et al., 2008). In 1998, there were 2.4 to 3.2 million children living infood-insecure households, and the numbers are similar today (Alaimo et al., 1998; Nordet al., 2008). Data collected in 1994 to 1996 from 3,837 households indicated that 7.5%of the low-income families with children reported food insecurity, due to lack of money,SNAPs, or WIC vouchers (Alaimo, Olson, Frongillo, & Briefel, 2001; Casey et al.,2001). Lacking financial resources is a key feature of food insecurity. A 2006 studyfound that 85% of the food-insecure children lived in houses below the 185% povertylevel (Rose & Bodor, 2006). Food insecurity and overweight among children. Overweight and obesity trends are not only seen in adults, but may also occur inchildren. A 2006 nationwide household survey found that 17% of households with
  • 49. 49children were food-insecure, with 15% of those children having a BMI in the overweightor at risk for overweight categories (Casey et al., 2006). The same study determined thatchildren living in poverty-stricken and/or food-insecure households, independent ofdemographic data, were more likely to be at risk for overweight (Casey et al., 2006). Anationwide study using NHANES data collected from 1988 through 1994 found anincreased prevalence of food insecurity and overweight coexisting among low-income,older white children in the United States (Alaimo et al., 2001b). Another nationwidesurvey using USDA data found the energy density of the diet was related to both obesityand food insecurity in children, with those living in the Midwest having the highestenergy density (Mendoza et al., 2006). It has also been found that the prevalence ofoverweight in children is indirectly related to the family income. As a family’s incomeincreased their overweight status has been shown to decrease (Gordon-Larsen, Adair, &Popkin, 2003). Children from families with both lower parental education and income have beenfound to be more at risk for being overweight (Haas et al., 2003). This not only affectsthem during childhood, but may exacerbate health risks in adulthood. A study in 2007found that if a child grew up in a low-income household, they had an increased likelihoodof being overweight later in life, as well as have poor eating habits (Olson et al., 2007).Lack of insurance was also associated with being overweight, which could be related toless health care visits for both parents and children. When low-income families who were food insufficient were compared to low-income families who were food sufficient, households with children were more likely to
  • 50. 50be overweight and were less educated (Casey et al., 2001). However, not all studies offood-insecure children have found an association between food insecurity and overweightor obesity. In fact, one study reported that children who were classified as food-insecurewere in the intermediate BMI ranges and most reported as “trying to gain weight”(Gulliford, Nunes, & Rocke, 2006). Food insecurity and overall health status among children. There are multiple associations between food insecurity, low income, overweight,and health in children. A study done in the Mississippi Delta region in 2005 had similarresults as those done in the Appalachian region. Children in food-insecure householdshad significantly lower physical and psychosocial functions as well as health relatedquality of life (Casey et al., 2005). A study done in Texas using poor families found thechildren had increased blood glucose, overweight, along with decreased fitness, calcium,magnesium, phosphorus, potassium, and folate levels (Trevino et al., 2008). Children living in food-insecure households are nearly twice as likely to report afair/poor health status as children in food-secure households (Cook et al., 2004). Thosefood-insecure children also had tripled the chance of being hospitalized than food-securechildren (Cook et al., 2004). A nationwide study found that 85% of the food-insecurechildren were from households that were below 185% of the poverty threshold; andmothers with less than a college education were more likely to be overweight (Rose &Bodor, 2006). One Appalachian Kentucky study found that children coming frompoverty-stricken, low-educated households were more likely to have stunted growth andbe obese than their counterparts, while another found similar results in Appalachian
  • 51. 51Pennsylvania (Crooks, 1999; Haas et al., 2003; Rappaport & Robbins, 2005). Health ofthe child is also been found to be negatively impacted by the lowered household income.Therefore, it has been suggested that interventions aiming to increase health and foodsecurity of children should focus on increasing fruits and vegetables, along with wholegrains in their diets (Tanumihardjo et al., 2007). Food insecurity has also been shown to impact a child’s mental and cognitivehealth (Alaimo, Olson, & Frongillo, 2001a; Alaimo et al., 2002; Casey et al., 2005;Connell et al., 2005; Kleinman et al., 1998; Murphy et al., 1998). When children’s diet isnegatively impacted by food insecurity causing hunger, they have been found to havelower physical functioning along with behavioral and psychosocial problems (Alaimo etal., 2001; Casey et al., 2005; Kleinman et al., 1998; Murphy et al., 1998). Otherconsequences on food-insecure children include counseling, school disciplinaryproblems, increased suicide risk, and difficulty interacting with others (Alaimo et al.,2001; Alaimo et al., 2002). The longer a child is exposed to food-insecure conditions, themore likely their academic performance is to suffer, including arithmetic and gradecompletion (Alaimo et al., 2001), which can simply be improved through a healthy diet. Food insecurity and diet and hunger among children. Chronic food insecurity and hunger can lead to physical impairment, reducedlearning, and family disturbances (Hamelin et al., 1999). One study conducted inMassachusetts with homeless and low-income households focused on children’s healthand well-being and the impact of hunger. This study found that half of the preschoolchildren had been homeless and moved an average of twice in the past year, while their
  • 52. 52mothers also reported the family as having moderate hunger (Weinreb et al., 2002). Thechildren who showed more hunger signs were more likely to be white, and those who hadsevere hunger were more likely to have low birth weights and more chronic healthproblems (Weinreb et al., 2002). A national sample of kindergarteners found that 22.2%of the children’s households experienced food insecurity, which was also found to beassociated with increased weight gain, poor academic performance, and decline in socialskills (Jyoti et al., 2005). Those with higher incomes had better health, less need forhealth care, lower parental depression, and lower levels of food insecurity, while theopposite was true of poorer households (Ashiabi & ONeal, 2007). Even though children are typically protected from hunger, their diets can still beimpacted (Rose, 1999). Children in food-insecure households have lower intakes offruits, vegetables, and milk products, which directly impacts their calcium, vitamins Aand C intake (Dixon et al., 2001). Children typically consume the types of food suppliesprovided by their caretakers, so when household food supplies are depleted, due to foodinsecurity, children’s diets suffer, particularly intake of produce and meat (Matheson etal., 2002). A sample of households reported 10.4% child food insecurity, 7.8% reduceddiet quality, and 2.6% child hunger (Skalicky et al., 2006). This same study also foundthat food-insecure children were twice as likely to have iron-deficient anemia (Skalickyet al., 2006). It was even found that food insecurity at any level is linked to poor healthoutcomes in children, even without hunger or very low food security (Cook et al., 2006). Not having enough food alone caused poor health in children regardless ofincome level (Alaimo et al., 2001). It was also found that family food insecurity was
  • 53. 53linked to negative academic and psychosocial development in children (Alaimo et al.,2001a). An in-depth qualitative study asked children in rural Mississippi open-endedquestions to assess their experiences with food insecurity. Some of the childrenmentioned being ashamed or fearful of being labeled as “poor” and many copingstrategies were also discussed. Some of these strategies included eating less (quantity andfrequency), eating more or fast when food is available, use of cheap foods, feeling thatthere was no choice, and limiting participation in social activities (Connell et al., 2005).However, SNAP Program participation has been associated with better learning in food-insecure children (Frongillo, Jyoti, & Jones, 2006). These occurrences typically onlyhappen when food insecurity is at its worst level, food-insecure with hunger, yet negativeeffects on the children of these households appear to occur regardless of food securitycategorization. Federal and Non-Federal Food Assistance Programs Federal and non-federal food assistance programs have a common objective, toimprove the nutritional status of underprivileged families. Federal programs, such as theWIC program, SNAP, the School Meals Program, and the Summer Food ServiceProgram, aim to increase food security and reduce hunger of low-income familiesthrough increased access to healthy nutritious food (Food and Nutrition Service, 2008;U.S. Department of Health and Human Services, 2008; U.S. Department of Health andHuman Services, 2009a, 2009b, 2009c). Non-federal programs, such as Community Food
  • 54. 54Initiatives (CFI) and community gardens, share the same goals; however, their focus is ona smaller population within a particular community.The Special Supplemental Nutrition Program for Women, Infant, and Children (WIC) The Special Supplemental Nutrition Program for Women, Infant, and Children,better known as WIC, is a federal program started in 1974 which provides assistance tolow-income mothers with children under the age of 5 in order to assist with theirnutritional needs (Food and Nutrition Service, 2008). Services provided by WIC includefood vouchers, nutrition education, and health care referrals, which are all overseen bythe Food and Nutrition Service Department in conjunction with the USDA (Food andNutrition Service, 2008). In order to receive these benefits, women participants mustmeet the income guidelines of 185% poverty level, or $35,798 per year (2008information; Food and Nutrition Service, 2008). WIC foods include iron-fortified infantformula and infant cereal, iron-fortified adult cereal, vitamin C-rich fruit or vegetablejuice, eggs, milk, cheese, peanut butter, legumes, tuna, and carrots (Food and NutritionService, 2008). Special therapeutic infant formulas and medical foods may also beprovided if needed (Food and Nutrition Service, 2008). The program provides thesespecific foods due to research showing participants are typically lacking in protein,calcium, iron, and/or vitamins A and C (Food and Nutrition Service, 2008). A recentrevision of the WIC packages determined the need for more produce for all age groups.In order to accommodate for this change, the packages now include more allowance forthe purchase of fresh fruits and vegetables, along with fruit and vegetable equivalents foryounger ages such as juice and baby foods (Food and Nutrition Service, 2008). WIC has
  • 55. 55been shown to improve the food security and produce intake of households; especially insingle parent households, through programs such as the WIC farmers’ market nutritionprogram as well as participating in research studies that include produce distribution(Kropf et al., 2007; Walker et al., 2007).FNS Supplemental Nutrition Assistance Program (SNAP) The Supplemental Nutrition Assistance Program (SNAP) is formerly known asthe Food Stamp Program, which began in 1943 as a project created by the Secretary ofAgriculture, Henry Wallace and Milo Perkins (U.S. Department of Health and HumanServices, 2009c). After many trials and adjustments to the original program of usingorange and blue stamps to purchase certain commodities, President Johnson proposed tomake the program permanent, which was then confirmed by the Food Stamp Act of 1964(U.S. Department of Health and Human Services, 2009c). Since its beginning, SNAP haschanged to fit the needs of the consumers, including the switch from paper stamp usageto an updated electronic card system (U.S. Department of Health and Human Services,2009c). SNAP helps low-income families purchase food for their families through the useof an electronic debit card which provides discounts on items at grocery or conveniencestores (U.S. Department of Health and Human Services, 2009c). The program alsoprovides nutrition education to its participants in order to improve their overall diet,however not just anyone can qualify for SNAP (U.S. Department of Health and HumanServices, 2009c). In order to be eligible for the program, you must meet strict guidelines
  • 56. 56including income level and acquired resources. Table 5 summarizes the 2009 incomeguidelines for SNAP.Table 5SNAP 2009 Income and Resource Cut-off Levels Household Size Gross Monthly Net Monthly Maximum Monthly Income Income Benefits (130% poverty) (100% poverty)1 1,127 867 1762 1,517 1,167 3233 1,907 1,467 4634 2,297 1,767 5885 2,687 2,067 6986 3,077 2,367 8387 3,467 2,667 9268 3,857 2,967 1,058Each additionalmember + 390 + 300 + 132Member’s Age Range Resource Amount Allotted18-60 yrs $2,00060+ yrs or disabled $3,000Note. Adapted from “Supplemental Nutrition Assistance Program,” by USDA Food andNutrition Services, 2008, United States Department of Agriculture. Copyright 2008 bythe USDA. Adapted with permission. In conjunction with the SNAP assistance, the program also provides aneducational component called SNAP-Ed. SNAP-Ed’s objective is to educate low-incomeparticipants of the SNAP program so that they may make healthier choices and increasetheir physical activity (U.S. Department of Health and Human Services, 2009c). The
  • 57. 57SNAP-Ed Connection is an online resource center that provides local programs withnutritional education, financial tips, recipes, and health information (U.S. Department ofHealth and Human Services, 2009c). Children in participating households have beenfound to have better academic learning than those low-income non-participants (E. A.Frongillo et al., 2006). Food-insecure families who participate in the SNAP program have been found tohave higher mean energy intakes at the end of the month than non-participants, whichmeans the program is effective in keeping a steady amount of food for the familythroughout the month (Condrasky & Marsh, 2005). However, this cycle nature has alsobeen shown to increase the weight of female participants as opposed to non-participants(Jones & Frongillo, 2006).School Meals Programs The school lunch program. The school meals programs are made up of three separate entities: the schoollunch program, the school breakfast program, and the special milk program. The schoollunch program is a nationally funded program which provides nutritionally balanced,low-cost or free lunches to children in public and non-profit private schools, as well asresidential child care facilities each school day (U.S. Department of Health and HumanServices, 2009b). The program was established under the National School Lunch Act,signed by President Harry Truman in 1946 (U.S. Department of Health and HumanServices, 2009b). In 1999, it was found that children who participated in the SchoolLunch program had heights related to their income status, which is that those children
  • 58. 58who were the shortest received free lunch while those who paid for their lunch were taller(Crooks, 1999). In order for a child to be eligible for this program along with schoolbreakfast, they must be in a household which makes no more than 185% of the povertylevel (U.S. Department of Health and Human Services, 2009b). If they are between the185% and 130% they are eligible for reduced- meals, and if they are at 130% or belowthey qualify for free- meals (U.S. Department of Health and Human Services, 2009b).Table 6 shows income guidelines for all school meal programs.Table 6School Meal Income QualificationsProgram Income Guidelines Qualified CategorySchool Lunch > 185% Full Price Lunch 185%- 130% Reduced Price Lunch < 130% Free LunchSchool Breakfast > 185% Full Price Breakfast 185%- 130% Reduced Price Breakfast < 130% Free BreakfastSpecial Milk Program N/A Free MilkNote. Adapted from “School Meals,” by USDA Food and Nutrition Service, 2008, UnitedStates Department of Agriculture. Copyright 2008 by the USDA. Adapted withpermission. School lunches must meet the applicable recommendations of the 1995 DietaryGuidelines for Americans, which recommend that no more than 30 percent of anindividuals calories come from fat, and less than 10 percent from saturated fat (U.S.
  • 59. 59Department of Health and Human Services, 2009b). Regulations also establish a standardfor school lunches to provide one-third of the Recommended Dietary Allowances (RDA)of protein, vitamin A, vitamin C, iron, calcium, and calories (U.S. Department of Healthand Human Services, 2009b). A new program now being offered in conjunction with the school lunch programis the Fresh Fruit and Vegetable Program, which started in 2002, and is now in selectschools nationwide (U.S. Department of Health and Human Services, 2009b). Thisrequires the participating school to provide fresh fruits and vegetables to students for freethroughout the day (U.S. Department of Health and Human Services, 2009b). There aremany stipulations that go along with this program, including: program may not be offeredat the same time as lunch and breakfast; only fresh fruits and vegetables may be used, notcanned or jarred; and no dips may be served with the fruits, only serving size poucheswith vegetables (U.S. Department of Health and Human Services, 2009b). Since theprogram is fairly new, no evaluation on the overall success is scheduled until 2011; (U.S.Department of Health and Human Services, 2009b) however, the program does focus onlower-income schools which could lead to a change in the food security of participants. The school breakfast program. The school breakfast program is very similar tothe lunch program in that it has the same eligibility requirements and is provided by thesame agency for the same locations (U.S. Department of Health and Human Services,2009b). This program, however, did not start until 1966, when it was introduced as apilot study. It was made permanent in 1975 (U.S. Department of Health and HumanServices, 2009b). The nutritional requirements are also the same for the breakfast
  • 60. 60program as they are the lunch. Both must meet one-third RDA for protein, vitamin A,vitamin C, iron, calcium, and calories (U.S. Department of Health and Human Services,2009b). An intervention done with nutrition education and the School Breakfast Programfound an increase in healthy eating habits and reduced weight gain with high schoolparticipants (Ask, Hernes, Aarek, Johannessen, & Haugen, 2006). The special milk program. The special milk program is unique to the school meal program, since it is offeredat facilities that do not necessarily participate in the other two programs (U.S.Department of Health and Human Services, 2009b). However, those facilities thatparticipate in the school lunch and breakfast programs may also receive the special milkprogram, as long as they also have half-a-day kindergarten programs, since those childrenare not eligible for the lunch and breakfast programs (U.S. Department of Health andHuman Services, 2009b). Another unique feature of this program is that there are noincome guidelines in order for a child to receive the benefits. The school is reimbursedfor every half pint of milk that they sell, as long as they agree to reduce the overall cost ofthe milk to children (U.S. Department of Health and Human Services, 2009b).Summer Food Service Program The Summer Food Service Program is a program that fills the summer gap forthose children who do not have consistent access to meals on a daily basis. Through theUSDA, summer camps or other similar programs can receive the same benefit schools dothrough the School Lunch and Breakfast programs (U.S. Department of Health andHuman Services, 2008). The program started in 1968 as a pilot study, which was put in
  • 61. 61place permanently in 1975 for low-income families participating in community summerprogramming (U.S. Department of Health and Human Services, 2008).Community Garden-Based Programs The America Community Gardening Association. The American Community Gardening Association (ACGA) is a bi-nationalnonprofit membership organization of professionals, volunteers and supporters ofcommunity greening in urban and rural communities (Agriculture and Natural Resources,University of California, 2009). This association is based out of Columbus, Ohio, andfocuses on increasing the community’s access to produce, nutrition knowledge, andimproving their diet through the development of a community garden (Agriculture andNatural Resources, University of California, 2009). The ACGA started in 1979 and hassince been associated with over 400 gardening programs in the state (Agriculture andNatural Resources, University of California, 2009). Farm-to-School. The Farm-to-School series, which started in 2000, is a national organization thathas state-based programs which connect schools to local farms in order to increasenutrition education, healthy eating, and local farm support (Agriculture and NaturalResources, University of California, 2009). The National Farm to School Network beganwith the goal of supporting community-based food systems, strengthening family farms,and improving student health by reducing childhood obesity (Agriculture and NaturalResources, University of California, 2009). The program includes produce basedpractices such as farm fresh salad bars and local foods in the cafeteria, waste
  • 62. 62management programs like composting, and experiential education opportunities such asplanting school gardens, cooking demonstrations and farm tours (Agriculture and NaturalResources, University of California, 2009). The goals of these approaches are to helpchildren understand where their food comes from and how their food choices impact theirbodies, the environment and their communities at large (Agriculture and NaturalResources, University of California, 2009). In Ohio there are three existing programs,two of which are based in schools located in urban areas (Agriculture and NaturalResources, University of California, 2009). Due to the nationwide interest in theorganization, more Ohio agencies are starting their own farm-to-school based programs,which should increase in the future. School gardening. School gardens have been around since the 19th century as a way to educate,increase physical activity, and feed students (Agriculture and Natural Resources,University of California, 2009). School gardens are still included in curricula in order tomaintain physical activity of students and introduce a new way to learn the requiredsubjects math, science, and English. Many studies have used school gardens to improveproduce intake and nutrition education with mostly positive results in both physical andacademic areas (Graham & Zidenberg-Cherr, 2005; Hermann et al., 2006; McAleese &Rankin, 2007; Morris & Zidenberg-Cherr, 2002; Robinson-OBrien et al., 2009). In 2005,the Community Food Initiatives partnered with a local Athens County School District toplant a school garden of pumpkin, sunflowers, squash, corn, tomatoes, potatoes, and
  • 63. 63herbs which included over 300 students, faculty, and parents (Ohio Action for HealthyKids). Community Food Initiatives. The Community Food Initiatives (CFI) is a non-profit organization that started in1992 as a part of the Appalachian Center for Economic Networks, ACE-net, in Athens,Ohio (Zerbian, 2007). This program plays a role in providing food to low-incomefamilies in the Athens area. Some of CFI’s projects include school gardens, gardeningand produce education seminars, composting projects, community gardens, and producedonation (Zerbian, 2007). The programs that most directly impact the low-incomecommunity are the school gardens, which provide education and produce to the children;community gardens, which allow anyone the opportunity to plant and tend to their owngarden and reap the benefits, also require a produce donation, which is a program thatdonates the excess produce from the community gardens to local individuals, shelters,and community programs in need (Zerbian, 2007). This program, along with the others,provides inexpensive opportunities to provide nutritious food to those who cannot alwaysafford it on their own. Appalachia Appalachia is a 205,000-square-mile region that follows the AppalachianMountains from southern New York to northern Mississippi. It includes all of WestVirginia and parts of 12 other states: Alabama, Georgia, Kentucky, Maryland,
  • 64. 64Mississippi, New York, NM N North Carolina, Ohio, Pe ennsylvania, South Carolina, Tennes ssee,an Virginia. Figure 5 is a map of the region. nd eFigure 5. The Appalachia Region.F e anNote. From “T AppalacN The chian Region by D. Sm n,” mith, 2008, A Appalachian RegionalCommission. Copyright 2C 2008 by the Appalachian Regional C n Commission. Reprinted w withpermission of the author. f About 23.6 millio people liv in the 420 counties of Appalachia with 42 perc t on ve centof the populat tion being ru ural, compar with 20 p red percent of th rest of the nation (Smi & he e ith
  • 65. 65Grant, 2008). Most of the area’s economy is based upon natural resources, such as coal,and other manufacturing businesses (Smith & Grant, 2008). Appalachia has been thefocus of many studies, as it is known for low education, high unemployment, highpoverty, and lower access to health care (Smith & Grant, 2008). Athens County, Ohio, isin the northern region of Appalachia and is situated in the Southeast region ofAppalachian Ohio (see Figure 6; Smith & Grant, 2008). Table 7 compares the study area(Athens County, Ohio) to Appalachian Ohio, Ohio, the Appalachian region, and theentire United States for several characteristics.
  • 66. 66Table 7Region Economic and Educational Level Comparison Athens Appalachian Ohio Appalachian United Co., OH OH Region StatesPopulation, 2000 62,223 1,455,313 11,353,140 22,894,017 281,421,906Income, 2002 $19,885 $23,057 $29,195 $25,470 $30,906Income % of U.S., 64.3% 74.6% 94.5% 82.4% 100.0%2002Unemployment 4.8% 7.1% 6.1% 5.8% 6.0%Rate, 2003People Below 14,728 191,502 1,170,698 3,030,896 33,899,812Poverty Level,2000Poverty Rate, 2000 27.4% 13.6% 10.6% 13.6% 12.4%High School 82.9% 78.2% 83% 76.8% 80.4%GraduatePercentageAdults with 25.7% 12.3% 21.1% 17.7% 24.4%College Degree,PercentageEconomic Status, Distressed - - - -2009Note. Adapted from “The Appalachian Region,” by D. Smith, 2008, AppalachianRegional Commission. http://www.arc.gov. Copyright 2008 by the Appalachian RegionalCommission. Adapted with permission of the author. In 2008, Athens County, Ohio, was considered distressed according to theAppalachian Regional Commission (Smith & Grant, 2008), which means it is one of thepoorest in the area based upon income and poverty levels. It is classified as in persistent
  • 67. 67poverty by th USDA (Ec he conomic Res search Servi 2008). T ice, These classifi fications are allbased on an average of th county’s u a he unemployme poverty level, and in ent, ncome rate fo forth fiscal year (Smith & G he r Grant, 2008) ).Figure 6. AppF palachian Oh Counties hio s.Note. From “2N 2007 County Profiles,” b Ohio Job and Family Services, 20 Ohio y by b y 009,Government. http://www.ohio.gov. CG Copyright 20 by Ohio Job and Fam Services 009 mily s.Reprinted wit permissioR th on. Accor rding to the O Ohio Depart tment of Hea alth, Athens County is a partiallymedically undm derserved ar with a sh rea hortage of pri imary care, d dental, and m mental health h
  • 68. 68care providers (Ohio Department of Health, 2009). There are two hospitals in the countyemploying 124 physicians for the 62,223 residents. However, only 52.9% of thoseresidents have health insurance (Ohio Universitys Voinovich School for Leadership andPublic Affairs, 2008; Smith & Grant, 2008). Athens County is 93.4% Caucasian ethnicity (Smith & Grant, 2008; U.S. CensusBureau, 2009). The median age is 25.7 years, and 34% have only 12 years of education(Smith & Grant, 2008; U.S. Census Bureau, 2009). Regarding unemployment andfinancial resources, 8.4% families have both parents in work force, and 37.3% live below150% poverty level (Smith & Grant, 2008; U.S. Census Bureau, 2009). The top fiveemployers in Athens County are area high schools, Ohio University, the Athens citygovernment, Hocking College, and the Athens’s Wal-Mart (Ohio Universitys VoinovichSchool for Leadership and Public Affairs, 2008).Health Health is a large concern in Appalachia due to the level of poverty and overallrural landscape (Behringer & Friedell, 2006). Diabetes, Chronic Obstructive PulmonaryDisease (COPD), infant, stroke, accident, motor vehicle, suicide, heart disease, andcancer death rates and hospitalizations are all high in the Appalachian region(Appalachian Regional Commission, 2008). As mentioned previously, Athens County,which is located in Appalachia, is known as a partially medically underserved area,which can involve limited access to and availability of health care related resources (OhioDepartment of Health, 2009). Concerns with rural areas in relation to health care includethe increased distance to facilities, increased poverty in relation to ability to pay, and
  • 69. 69education level in relation to understanding conditions and associated treatments (Quandtet al., 2005). In fact, education can play a role in residents’ health and diet knowledge andexperiences (Behringer & Friedell, 2006). A large Appalachian study, which includeddata collected from Athens, Ohio, found that subjects typically based their healthknowledge on events that occurred to other family members, including theirunderstanding of personal disease and risk prevention (Denham et al., 2004). Theinformation also typically came from the elder members of the family, and most of thefamily’s focus was put on the children’s health before others (Denham et al., 2004).Obesity, cancer, chronic disease, and mental health are all concerns in the Appalachianregion and are discussed in more detail below. Obesity. Appalachian counties overall have been found to have a higher obesityprevalence, with the exception of African-American men (Appalachian RegionalCommission, 2008). Obesity rates have been found to be greater in food-insecurehouseholds as compared to their counterparts in Appalachian Ohio ( Holben & Pheley,2006; Holben & Pheley, 2006; Pheley et al., 2002). One study done with older adults inrural North Carolina found that 80% of their participants were overweight or obese(Quandt et al., 2005). It has also been suggested that rural residents are at a disadvantagewhen it comes to eating healthy, which cannot only impact their overall health, but alsotheir risk for chronic disease such as obesity and cancer. One study found only a quarterof the grocery stores in rural areas supported healthy eating guidelines by providing
  • 70. 70recommended foods while most offered only cheaper convenience foods (Liese, Weis,Pluto, Smith, & Lawson, 2007). Appalachian children have been found to have a higher overweight prevalencethan the rest of the nation (Demerath et al., 2003). A study done in Athens, Ohio, found46.2% of children were classified according to BMI criteria as overweight or obese(Tulkki et al., 2006). Half of the children found to be overweight while another 45% hadbody fat levels ranging from moderately high to very high (Tulkki et al., 2006). However,these trends were not related to food insecurity (Meek, 2005). A study in AppalachianPennsylvania found 36% of child participants were overweight or at risk for overweight,and another 23% were overweight while researchers in Kentucky found 33% of thechildren were above the 85th percentile for BMI (Crooks, 1999; Rappaport & Robbins,2005). A study done in West Virginia in 2003 had similar findings, with 45% of theirchildren subjects being either overweight or at risk for overweight (Demerath et al.,2003). This disturbing trend in children suggests that if not dealt with, this could lead to alarger increase in adult obesity in Appalachia in the future. Cancer and chronic disease. Appalachia has been found to have increased rates of premature mortality than therest of the nation. Heart disease, all-site cancers, lung cancer, and chronic obstructivepulmonary disease (COPD) are the primary health problems contributing to thisphenomenon (Appalachian Regional Commission, 2008). Central and SouthwesternAppalachia were found to be comparably disadvantaged in relation to socioeconomicstatus, while also having higher incidence of premature mortality (Appalachian Regional
  • 71. 71Commission, 2008). Overall, regions in Appalachia with the lowest rates of healthinsurance and the highest rates of poverty are the areas with the highest rates ofpremature mortality (Appalachian Regional Commission, 2008). In relation to heartdisease and cancer death rates, Appalachia has higher rates than the rest of the nation,especially the Southeastern Ohio region (Appalachian Regional Commission, 2008). Theliterature has suggested that due to Appalachia’s limited access to health care and highpoverty levels, future interventions should address these issues while focusing on ways toreduce these cancer rates (Wewers et al., 2006). For diabetes mellitus, it was found that older adults living with diabetes in ruralareas of Appalachia had achieved less gylcemic control than those living in urban areas,due to the distance between their homes and health care facilities, related to the region’slack of access to health care (Quandt et al., 2005). This could lead to many complicationsfrom their diabetic condition, including neuropathy, retinopathy, nephropathy, andneurological complications. These complications can lead to increased health costsrelated to the complications, which these rural citizens may not be able to care for. As mentioned previously, food insecurity has been associated with increased withincreased risk for chronic disease, while obesity also has a strong correlation. It has beenfound that those who have healthy, balanced diets had a lower risk of major chronicdisease, with the strongest reduction in cardiovascular disease (McCullough et al., 2002).However, these findings relate to mostly well-educated, middle class participants, whomay not be representative of the Appalachian population. It was found that women withhigher nutrition knowledge and healthy eating behaviors had lower risk of type 2 diabetes
  • 72. 72in a long-term research study, which suggests those who eat the recommended amountsof produce and have a healthy weight have less risk for chronic disease (Fung,McCullough, van Dam, & Hu, 2007). These studies suggest that with nutrition education,and increased access to healthy foods, the Appalachian population’s risk for chronicdisease may decrease. Mental health. Appalachia has been found to have higher rates of mental illness, regardless ofsubstance abuse, than the rest of the nation (Zhang, Infante, Meit, & English, 2008).Central Appalachia especially saw increases in mental health incidence 2008, whichincludes Kentucky, West Virginia, Virginia, and Tennessee (Zhang et al., 2008). Evenwith this increase in mental health treatment need, there is still a lack of inpatienttreatment centers (Zhang et al., 2008). This lack of treatment can be associated with food-insecurity as well, since it has also been found to be related to mental illness anddepression (Alaimo et al., 2002; Bronte-Tinkew et al., 2007; Casey et al., 2004; Olson,2005; Siefert, Heflin, Corcoran, & Williams, 2001).Food Security In relation to poverty and food access, food insecurity has been found to be aconcern to Appalachian residents (Holben et al., 2006; Holben et al., 2004; Holben &Pheley, 2006; Hutson et al., 2007; Kendall et al., 1996; Kropf et al., 2007; Pheley et al.,2002; Tessaro et al., 2006; Walker et al., 2007; Wewers et al., 2006). In fact, in theproposed study region of Appalachian Ohio, food insecurity was found to be three timesthe level of the rest of the state, as well as almost double the rate of the nation (Holben et
  • 73. 73al., 2004; Holben & Pheley, 2006; Kropf et al., 2007; Meek, 2005; Pheley et al., 2002;Walker et al., 2007). The entire state of Ohio from 2005 to 2007 had an average of 12.2%of households categorized as food-insecure, with 4.5% of all households being classifiedas very low food security (Nord et al., 2008). This can lead to many problems throughoutthe household, including adverse effects on the children’s health (Bronte-Tinkew et al.,2007; Casey et al., 2004; Casey et al., 2005; Casey et al., 2006; Connell et al., 2005;Cook et al., 2006; Kaiser & Townsend, 2005). As has been discussed in the previous foodsecurity section, food security has been associated with obesity, depression, increasedrisk for chronic disease, stunted growth, and poor diet quality (Bhattacharya et al., 2004;Bronte-Tinkew et al., 2007; Cook et al., 2004; Cook et al., 2008; Hamelin et al., 1999;Holben et al., 2006; Holben & Pheley, 2006; Lyons et al., 2008; Rose & Bodor, 2006;Seligman et al., 2007; Tanumihardjo et al., 2007; Townsend et al., 2001; Vozoris &Tarasuk, 2003; Walker et al., 2007; Weinreb et al., 2002). In addition, food insecurity isrelated to low-income and low-educated households, which is prevalent in theAppalachian region (Smith & Grant, 2008). This underscores the need to address thisproblem in the region. Produce Intake in the United States Produce intake has been linked to decreased risk of chronic diseases incidence,including cardiovascular disease, some types of cancers, and obesity (Dalton, 2006; Holtet al., 2009; Van Duyn & Pivonka, 2000). Produce intake has been shown to declinesignificantly as food insecurity worsens in women and children (Kendall et al., 1996).
  • 74. 74Childhood obesity has an even greater impact on health than adult obesity, since childrenare still developing when the consequences can occur. Nearly one million adolescentswere diagnosed with metabolic syndrome, posing an increased risk for chronic disease(Pan & Pratt, 2008). However, that same study reported that better diet quality, includingincreased produce intake and increased physical activity alleviated the risk for metabolicsyndrome (Pan & Pratt, 2008). Children in food-insecure households have been found to have lower intakes ofdark green vegetables and fruits than those in food-secure households ( Casey et al.,2001; Lorson et al., 2009). In a sample with 10.9% of participants from food-insecurehouseholds, participants’ mean intake of fruits and vegetables was 1 cup per day, muchless than the recommended amounts of five servings per day for most people (Lorson etal., 2009). A study focusing on fruit and vegetable intake of rural mothers and childrenfound that most produce intake was inadequate, but those who ate from all five colors ofproduce (red, orange/yellow, green, white, and purple/blue) consumed 1 ½ more servingsthan those who did not (Nanney, Schermbeck, & Haire-Joshu, 2007) . The studyparticipants were very similar in demographics to those in the Athens County, Ohio, area,which may indicate that an intervention focusing on fruits and vegetables of youngfamilies with children in a school-like setting could be beneficial. More than half of theadolescents in a Canadian study did not meet the 5-a-day fruit and vegetablerecommendations; however, intake did increase with increased family income, education,and two parent households (Riediger et al., 2007).
  • 75. 75 Decreased fruit and vegetable preference in children was found to lead to anincreased risk for overweight or obesity, which may indicate that produce intake isessential for a healthy body weight (Lakkakula et al., 2008). A study that focused on dietadequacy found that most participants did not have much variety in a one day recall oftheir dietary intake, but of those who did, they were more likely to meet nutrientadequacy as suggested by the Dietary Reference Intakes (DRIs; Foote, Murphy, Wilkens,Basiotis, & Carlson, 2004). This suggests that with higher produce intake, an adequatenutrient intake is more likely, which may lead to better health. A study conducted in ruralNorth Carolina found children who consumed excessive amounts of sweets did not meetthe recommendations for fruits, vegetables, dairy, or grains (Ball et al., 2008). Produce, gardening, and nutrition education interventions with children mayimprove their overall diet quality and health by improving their physical activity levelsand produce intake. Fruit and vegetable availability is particularly important for childrennot only to sustain adequate nutrition but to instill sound dietary practices early on. Therehas been some evidence to indicate that gardening programs could positively impact achild’s produce intake along with nutrition education (Hermann et al., 2006; Nanney,Johnson et al., 2007; Stables et al., 2005), which will be discussed further in the nextsection. Produce and Gardening Interventions Children in low income families have low calcium, iron, vitamins A and C, andfolate levels, along with increased body weight and health concerns (Ball et al., 2008;
  • 76. 76Casey et al., 2006; Dixon et al., 2001; Gao et al., 2006; Langevin et al., 2007; Rose &Oliveira, 1997; Skalicky et al., 2006). Therefore, it has been suggested that interventionsshould focus on increasing their produce and nutrient intake in school or similar settings(Langevin et al., 2007). Most studies using gardening and nutrition education forumshave found a positive change in produce intake (Hermann et al., 2006; Robinson-OBrienet al., 2009). The school setting does not have to be the only location for suchinterventions. Other programs have been done at community locations, summer or daycamps, and after-school programs. Multiple intervention avenues have also been tried with gardening and nutritionprograms, of variable lengths, foci, and populations, with mostly positive results (Graham& Zidenberg-Cherr, 2005; Hermann et al., 2006; McAleese & Rankin, 2007; Nanney,Johnson et al., 2007; Robinson-OBrien et al., 2009). An intervention focusing on a “5-a-day” fruit and vegetable intervention in low-income population used Project FRESHvouchers for use at the farmers market with WIC participants, along with educationsessions for some groups (Anderson et al., 2001). The study did not significantly improveproduce, which may be due to the original groups beginning with a high produce intake(Anderson et al., 2001). However, a similar project done with South Carolina SeniorFarmers’ Market Nutrition Education Program participants found that increasingavailability of produce and education of subjects resulted in an increased intake ofproduce (Kunkel, Luccia, & Moore, 2003). A study in 2005 had one-hour interventionsfor several weeks with seven to nine year old children in a school-based program focusedon specific fruit and vegetables that could be increased in the diet (Nanney, Haire-Joshu,
  • 77. 77Elliott, Hessler, & Brownson, 2005). Another type of six-week program focused on fruitand vegetable intake in Boston, but they provided information through an internetintervention. Even though most of the study focused on the development and use of thewebsite, it was found that those who had higher fruit and vegetable intakes used thewebsite more, suggesting that they had a higher interest in healthy eating (McNeill,Viswanath, Bennett, Puleo, & Emmons, 2007). This may indicate that regardless of theintervention method, those who are already interested in healthy practices may be morecompliant with an intervention than others. Behavior change is the central goal in suchinterventions, and therefore those who focus on the behavior change theory and stages ofchange seem to have more success. A very similar, but more extensive, gardening program was implemented inCalifornia. Three different schools were provided with nine nutrition lessons focused onplant structure, nutrients, Food Guide Pyramid, serving sizes, reading food labels,increasing physical activity, goal setting, consumerism, and snack preparation. Theprogram positively impacted both children’s nutrition knowledge and vegetablepreferences (Morris & Zidenberg-Cherr, 2002). An additional survey done in Californiaobtained the teachers opinions about the effectiveness of the school gardening andnutrition education programs. Researchers found that the teachers were using the gardenfor teaching nutrition, science, language arts, and math, but they indicated more resourcesto link the gardening to their curriculum were needed (Graham & Zidenberg-Cherr,2005). Another school gardening and nutrition education program was created for threeschools in Idaho, with the inclusion of a control school. The groups were divided into
  • 78. 78solely nutrition education, nutrition education plus gardening, and a control group whichreceived no treatment (McAleese & Rankin, 2007). Researchers found that the gardeningplus nutrition education group significantly improved their produce and nutrient intake,more specifically vitamins A and C, and fiber (McAleese & Rankin, 2007). In Canada, researchers created a school-based program to enhance the knowledgeand psychosocial factors related to healthy eating and its impact on the dietary fiber andfat intake of the children. They used a pre-test/post-test with elementary school children.The program was significantly associated with increased knowledge, dietary self-efficacy, and improved overall diet (Saksvig et al., 2005). A study done in 2005 focused on the Dietary Intervention Study in Children,consisting of a randomized controlled trial originally designed to test a three-yearintervention intended to lower blood cholesterol by focusing on reducing fat, cholesterol,while increasing fiber, fruits, and vegetables (Van Horn, Obarzanek, Friedman,Gernhofer, & Barton, 2005). Their message was based on a whoa/go foods system. Foodswere chosen through their fat content with “go” foods being lower fat, including fruitsand vegetables, and “whoa” foods having more fat (Van Horn et al., 2005). Theyencouraged “go” foods in each food group while suggesting less, but not none, of the“whoa” foods (Van Horn et al., 2005). It was found that the children had positive resultsto the intervention, and therefore the study was extended (Van Horn et al., 2005). Use ofelectronic communication in interventions was found to be associated with increased fruitand vegetable intake; however, the study focused on the self efficacy of the participantsprimarily (Luszczynska et al., 2007). Interventions typically work better when
  • 79. 79customized to the specific population. One study developed an interactive multimediaintervention for participants to decrease their fat consumption with positive results(Irvine, Ary, Grove, & Gilfillan-Morton, 2004). Since this intervention was specificallydesigned for this population, it may have gotten better results than if it had been a genericprogram developed for wide spread use. Overall, it seems that interventions that include gardening along with nutritioneducation have a more successful impact on produce preference and intake than thosethat only focus on nutrition education. Length of the intervention also seems to play arole with more time spent equaling greater results. Parental reporting of children’s dietary intake has been utilized in researchprojects. Therefore, researchers have asked how accurate these parents are when recallingtheir child’s fruit and vegetable intake. Overall it was found that parents accuratelyreported their child’s intake, with only some discrepancy on juices and combinationfoods that included fruits and vegetables (Linneman et al., 2004). Thus, it should be safeto include questions about their child’s perceptions and intake if necessary on oursurveys. However, another similar study done in the Netherlands found poor correlationbetween parent and child responses to the child’s vegetable intake, but better correlationwith their fruit intake (Reinaerts, de Nooijer, & de Vries, 2007). Conclusion The literature shows that food insecurity is a serious health-related problemaffecting both adults and children, while also associated with decreased produce intake. It
  • 80. 80has been suggested that interventions done by nutrition professionals should incorporateproduce options that relate to the culture, region, and status of that area (Nanney, Haire-Joshu, Hessler, & Brownson, 2004). Even though many studies have attempted to targetinterventions toward the younger population to combat this problem through use of fruitand vegetable and gardening programs, none have done so in Appalachian Ohio.Therefore, this study: (a) measured the effect of a nutrition and gardening educationprogram on Appalachian children’s fruit and vegetable intakes and preferences; and (b)examined the relationship of food security status to gardening habits and perceptions,produce intake, and personal characteristics of children and their adult female caregivers.
  • 81. 81 CHAPTER 3: METHODOLOGY Produce intake in the United States typically does not meet the recommendedlevels, especially in women and children (Anderson et al., 2001; Ball et al., 2008;Cassady et al., 2007; Foote et al., 2004; Fu et al., 2007; Fung et al., 2007; Guenther et al.,2006; Hazen et al., 2008; Holben & Pheley, 2006; Kropf et al., 2007; Lorson et al., 2009;McCullough et al., 2002; Nanney et al., 2005; Olson, 1999; Pierce, Stefanick et al., 2007;Potischman et al., 1998; Struble et al., 2008; Tarasuk & Beaton, 1999; Walker et al.,2007). Fruit and vegetable intake has been found to be inversely related to householdfood security (Bhattacharya et al., 2004; Dixon et al., 2001; Kendall et al., 1996; Kropf etal., 2007). For adult females and children living in food-insecure households, fruits andvegetables are typically the first groups reduced from the diet, due to their higher priceand shorter shelf life, compared to other foods (Cassady et al., 2007; Dixon et al., 2001;Kendall et al., 1996; Kropf et al., 2007). Through the practice of gardening, a family maybe able to grow fruits and vegetables at a lower cost than purchasing them, whileincreasing both physical activity and produce intake. This study: (a) measured the effectof a nutrition and gardening education program on Appalachian children’s fruit andvegetable intakes and preferences; and (b) examined the relationship of food securitystatus to gardening habits and perceptions, produce intake, and personal characteristics ofchildren and their adult female caregivers.
  • 82. 82 Subjects The Institutional Review Board at Ohio University approved of this quasi-experimental research study prior to the collection of any data (Appendix C). Potentialchild participants were children enrolled in Kids on Campus in the 1st through 4th gradeprograms. Potential caregiver participants were adult females 18 years and older living inAthens County, Ohio, with children enrolled in a university-based summer day camp,Kids on Campus, in 1st through 6th grade programs. Kids on Campus is a six-week,College of Health and Human Services program which serves households in AthensCounty, Ohio, through summer educational and recreational activities. Even though childparticipants were only in grades 1st through 4th for Kids on Campus scheduling reasons,female caregiver participants were those with any child participating in Kids on Campus(grades 1st through 6th). Male caregivers were ineligible, since the focus of this study wason characteristics of female caregivers. Participants were recruited using conveniencesampling through the summer day camp. Setting This study took place in Athens County, Ohio, which is classified as a distressedcounty in Appalachia by the Appalachian Regional Commission based upon income andpoverty levels (Smith & Grant, 2008), and as having persistent poverty by the UnitedStates Department of Agriculture (USDA; Economic Research Service, 2008). Accordingto the Ohio Department of Health, Athens County is a partially medically underservedarea with a shortage of primary care, dental, and mental health care providers (Ohio
  • 83. 83Department of Health, 2009). There are two hospitals in the county employing 124physicians for the 62,223 residents. However, only 52.9% of those residents have healthinsurance (Ohio Universitys Voinovich School for Leadership and Public Affairs, 2008;Smith & Grant, 2008). Project Description Adult female participants were surveyed only at the onset of the study,approximately one month prior to the start of the summer camp. Informed consent wasincluded on the first page of the survey (see Appendix D), with consent of the participantbeing assumed with the return of the survey. A 79-item survey (see Appendix D) wasdistributed in May 2008 through Kids on Campus with other programmatic recruitmentmaterials to assess the food security, health, and produce intakes and behaviors, as wellas their perception of the produce intakes and gardening behaviors of their children.Surveys included previously validated items [SF-12 health questionnaire (Ware &Sherbourne, 1992), Psychosocial Indicators of Fruit and Vegetable Intake in Low IncomeCommunities questionnaire and Food Behavior Checklist for a Limited ResourceAudience (Townsend & Kaiser, 2005; Townsend & Kaiser, 2007), U.S. household 6-itemfood security survey module (Bickel et al., 2000)]. There were also questions related toparticipant characteristics, including gender, age, and self-identified weight, height, anddiabetes mellitus status, as well as perception of self and family gardening habits andproduce. Only the food security, female fruit and vegetable intake, gardening, anddemographic data were used for this thesis.
  • 84. 84 Children were surveyed prior to and after the nutrition and gardening educationintervention. On the first day of the gardening program, each child participant completedboth an 18-item fruit and an 18-item vegetable preference and intake checklist (seeAppendix F). The questionnaires, adapted from the Saint Louis University School ofPublic Health’s SLU 4 Kids FFQ, itemized the produce names and included an image ofeach. Children circled foods that were liked and noted foods eaten in the past week bychecking a corresponding box. This instrument was developed for this study and has notbeen previously validated, but was based on the previously validated Saint LouisUniversity 4 Kids Food Frequency Questionnaire (SLU 4 Kids FFQ; Haire-Joshu et al.,2003). After completing the initial surveys, the first nutrition education and gardeningprogram was delivered. Five additional weekly lessons were delivered over the six-weekprogram. Overall, the nutrition education and gardening program included informationon gardening, plant growth and maintenance, composting, vitamins, minerals, fiber, andMyPyramid.gov. The next section details the entire program. The children were provided with educational materials, gardening information,and locally-grown produce with corresponding recipes to take home to the adult femalecaregiver participants weekly. All educational materials sent home included informationfrom the weekly lesson, as well as gardening tips and ways to increase produce intake athome with different recipes. During week six, at the conclusion of the program, eachchild completed the produce checklist to assess for changes in preferences and intake ofproduce.
  • 85. 85 The Nutrition Education and Gardening Program Overall, the nutrition education and gardening program included information ongardening, plant growth and maintenance, composting, and basic nutrition concepts.Based upon a needs assessment of US children, weekly lessons were developed andfocused on food groups and nutrients shown to be lacking (Ashiabi & ONeal, 2007; Ballet al., 2008; Casey et al., 2001; Gao et al., 2006; Lorson et al., 2009; Nanney et al., 2005;Skalicky et al., 2006; Trevino et al., 2008). The program included six, one-hour lessons: 1. Week 1: Gardening is Great! Gardening basics. 2. Week 2: Gardening is Colorful! Mypyramid basics. 3. Week 3: Fruit + Vegetables = Fiber. Fiber content in produce and its benefits. 4. Week 4: Teamwork. Functions and food sources of vitamin C and iron. 5. Week 5: Dynamic Duo. Functions and food sources of vitamin A and calcium. 6. Week 6: Scraps to Soil! Composting basics.Weekly lessons were developed for the 1st through 4th grade levels through a combinationof EarthBox®-suggested activities and original activities. The lessons were deliveredweekly to groups of campers (six groups of 25), according to grade level (3 groups 1st-2ndgraders, 3 groups 3rd-4th graders). The lesson plans are in Appendix E. Data Scoring and Statistical Analysis All data was tabulated and analyzed using the Statistical Program for the SocialSciences (SPSS) version 16.0. A p-value less than 0.05 was considered statisticallysignificant. Female caregiver’s weight was assed using body mass index (BMI)categories through self-reported heights and weights (kg/m2) and then categorized using
  • 86. 86the Center for Disease Control (CDC) guidelines. Household Food Security Status wasscored according to the standardized methods for the six-item survey scoring (Bickel etal. 2000), while produce readiness of the female caregiver’s were scored using themethods of Townsend and Kaiser ( Townsend & Kaiser, 2005; Townsend & Kaiser,2007). Gardening readiness was measured using two items modeled after the methods ofTownsend and Kaiser ( Townsend & Kaiser, 2005; Townsend & Kaiser, 2007). Scoringfor these instruments is summarized in Appendix A. Table 8 summarizes the statisticalanalyses completed by research question.
  • 87. 87Table 8Research Questions and Associated Statistical TestResearch Questions Statistical Test 1. Does a six-week nutrition and gardening T-test education program improve children’s preference for and intake of fruits and vegetables? 2. At the onset of the study, is household food Kendall tau-b Correlation security status related to the female caregiver’s perception of the gardening habits of the children? 3. At the onset of the study, is household food Kendall tau-b Correlation security status related to the female caregiver’s gardening readiness? 4. At the onset of the study, is household food Kendall tau-b Correlation security status related to produce intake of female caregiver? 5. At the onset of the study, are the female Kendall tau-b Correlation caregiver’s gardening habits related to their perceptions of the child’s gardening habits? 6. At the onset of the study, is household food Kendall tau-b Correlation security status related to produce preferences and intakes of child participants? 7. At the onset of the study, are the child’s produce Kendall tau-b Correlation intake and preferences related to their female caregiver’s produce intakes? 8. At the onset of the study, are the child’s produce Kendall tau-b Correlation intake and preferences related to their female caregiver’s gardening habits? 9. Do body mass index (BMI), vegetable intake, and Mann-Whitney U fruit intake differ between female caregivers from food-secure versus food-insecure households? 10. Do marital status, education level, transportation, Pearson Chi Square hunting, fishing, food assistance program participation, perceived health level, diet quality, body mass index category, and produce and
  • 88. 88gardening readiness differ between femalecaregivers from food-secure versus food-insecurehouseholds?
  • 89. 89 CHAPTER 4: RESULTS Fruit and vegetable intake has been found to be related to household food securitystatus (Bhattacharya et al., 2004; Dixon et al., 2001; Kendall et al., 1996; Kropf et al.,2007). For adult females and children living in food-insecure households, fruits andvegetables are typically the first groups reduced from the diet, due to their higher priceand shorter shelf life, compared to other foods (Cassady et al., 2007; Dixon et al., 2001;Kendall et al., 1996; Kropf et al., 2007). Through the practice of gardening, however, afamily may be able to grow fruits and vegetables at a lower cost than purchasing them,while increasing both physical activity and produce intake. This study: (a) measured theeffect of a nutrition and gardening education program on Appalachian children’s fruit andvegetable intakes and preferences; and (b) examined the relationship of food securitystatus to gardening habits and perceptions, produce intake, and personal characteristics ofchildren and their adult female caregivers. Child Participant Data Of the 150 children in grades 1st through 4th participating in Kids on Campusduring the summer of 2008, 91 completed both pre- and post-intervention surveys (60.7%completion rate). Of the 91 participants who completed both surveys, 49 (54.0%) wereentering grades 1st or 2nd grade, while 42 (46.0%) were entering 3rd or 4th grade.According to Kids on Campus records, child participants ranged in age from 5 to 9 yearsand were entering grades 1 through 4. Participating households had a median income of$22,000 per year. The child participants were Caucasian (93%), African American (2%),
  • 90. 90Asian, (2%), Hispanic (2%), and American Indian (1%). (Note: Due to Kids on Campusregulations, we were not able to obtain individual demographic information on thechildren.) Table 9 and Figure 7 describe the child participants’ variety of produce eatenand preferred. “Preferred” fruits and vegetables were those that the child liked(preference variety), while “eaten” fruits and vegetables were those items consumed inthe past week (intake variety).
  • 91. 91Table 9Child Participants’ Produce Preferences and Intakes Pre-Intervention Post-Intervention p-value Preferences & Intakes Preferences & Intakes (n = 91) (n = 91) Mean ± Standard Mean ± Standard Deviation DeviationVariety of Fruit Preferred 6.9 ± 6.6 7.3 ± 6.9 .554(Number of FruitsPreferred)Fruit Intake Variety 9.6 ± 6.1 9.1 ± 6.9 .563(Number of DifferentFruits Eaten in the PastWeek)Variety of Vegetables 6.2 ± 5.5 5.6 ± 5.9 .341Preferred (Number ofVegetables Preferred)Vegetable Intake Variety 7.3 ± 5.3 8.4 ± 6.0 .106(Number of DifferentVegetables Eaten in thePast Week)Variety of Produce 13.1 ± 10.9 13.0 ± 11.9 .977Preferred (Total Numberof Produce Preferred)Produce Intake Variety 16.9 ± 10.1 17.3 ± 11.4 .751(Total Number ofDifferent Produce ItemsEaten in the Past Week)Note. Paired t-test was used to calculate differences between groups.
  • 92. 92 Pre-intervention Post-intervention 16.9 17.3 13.1 13.0 9.6 9.1 8.4 7.3 7.3 6.9 6.2 5.6 Fruit Preference Fruit Intake Vegetable Vegetable Intake Total Produce Total Produce Preference Preference IntakeFigure 7. Child participants’ produce preference and intake variety. The nutrition education and gardening program was evaluated as part of the Kidson Campus evaluation process. Seventy-two children (48.0% response rate) completedthe Kids on Campus programmatic survey. Of those 72, 59 (81.9%) of the 150 1st through4th graders were 1st and 2nd graders, and 13 (18.1%) were 3rd and 4th graders. Of the 1stand 2nd graders, 43 (72.9%) liked, 9 (15.3%) sometimes liked, and 4 (6.8%) did not likethe nutrition education and gardening program. Among the 3rd and 4th graders, 3 (23.1%)liked, 3 (23.1%) sometimes liked, and 7 (53.8%) did not like the nutrition education andgardening program. Overall, 58 of the 72 students (80.6%) liked or sometimes liked thenutrition education and gardening program.
  • 93. 93 Female Caregiver Participant Data Of the 250 surveys sent to female caregivers of children participating in the 2008summer Kids on Campus Program, 99 (39.6% response rate) were returned. Table 10describes the female caregiver participants, who were 34.7 ± 7.2 years and living inhouseholds composed of 3.8 ± 1.2 members. Body mass index (BMI) classification andperceived diet and health status for the female participants are shown in Table 11. Figure8 also shows female caregiver’s BMI classification. Table 12 and Figure 9 describe thereadiness for produce intake among the female caregivers. Produce gardening habits andreadiness for gardening of female caregivers are summarized in Table 13 and Figure 9.As noted in Table 13, 23 and 37 reported having fruit and vegetable gardens,respectively. This mirrored the gardening readiness of female caregivers, with the samenumber of caregivers being in the action and maintenance stages for fruit and vegetablegardening.
  • 94. 94Table 10Characteristics of Female Participants and Their Households Number of Female Percentage of Female Caregivers CaregiversRACE (n = 98)American Indian or Native 4 4.1%AlaskanAsian 5 5.1%African American 7 7.1%Caucasian 82 83.7%MARITAL STATUS (n = 98)Married 45 45.9%Divorced 26 26.5%Separated 4 4.1%Single/Never Married 23 23.5%LEVEL OF EDUCATION (n = 99)Less than High School 3 3.0%High School: Diploma or 26 26.3%General EducationalDevelopment (GED)Some College or Higher 70 70.7%HOUSEHOLD FOOD SECURITY STATUS (n = 99)Fully Food Secure 36 36.4%Marginal Food Security 14 14.1%Low Food Security 24 24.2%Very Low Food Security 25 25.3%HOUSEHOLD FOOD ASSISTANCE PROGRAM PARTICIPATIONNational School Lunch 73 73.7%Program (Free or ReducedPrice; n = 99)School Breakfast Program 66 66.7%(Free or Reduced Price; n =99)
  • 95. 95Table 10: continued 19 19.6%Head Start Program (n =97)Special Supplemental 23 23.2%Nutrition Program forWomen, Infants, andChildren (WIC; n = 99)Supplemental Nutrition 53 53.5%Assistance Program (SNAP;n = 99)WIC Farmers Market 9 9.1%Nutrition Program (n = 99)Community Food Pantry 36 36.4%(n = 99)HOUSEHOLD HAD TRANSPORTATION FOR FOOD AQUISITION (n = 98)Yes 90 91.8%No 8 8.2%HOUSEHOLD HUNTED FOR FOOD (n = 97)Yes 20 20.6%No 77 79.4%HOUSEHOLD FISHED FOR FOOD (n = 97)Yes 14 14.4%No 83 85.6%
  • 96. 96Table 11Female Caregiver Body Mass Index and Perceived Diet Quality and Health Status Number of Female Percentage of Female Caregivers CaregiversBODY MASS INDEX (BMI) CLASSIFICATION (n = 93)Obese (BMI >30) 43 46%Overweight (BMI 25- 27 29%29.9)Normal (BMI 18.5-24.9) 20 22%Underweight (BMI < 3 3%18.5)PERCEIVED DIET QUALITY (n = 98)Excellent 2 2%Very Good 10 10%Good 45 46%Fair 28 29%Poor 13 13%PERCEIVED HEALTH STATUS (n = 98)Excellent 4 4%Very Good 39 40%Good 38 39%Fair 14 14%Poor 3 3%Note. Body mass index was calculated from self-reported height and weight data andwere classified using CDC guidelines.
  • 97. 97 U Underweight 3% Normal 20% Obese 44% Overw weight 27 7%Figure 8. Fem caregiver participants’ weight cF male v n classification n.
  • 98. 98Table 12Female Participant Readiness for Eating Produce Number of Female Percentage of Female Caregivers CaregiversREADINESS FOR EATING FRUIT (n = 98)Precontemplation 9 9.2%Contemplation 9 9.2%Preparation 9 9.2%Action 60 61.2%Maintenance 11 11.2%READINESS FOR EATING VEGETABLES (n = 97)Precontemplation 7 7.2%Contemplation 8 8.2%Preparation 10 10.3%Action 58 59.8%Maintenance 14 14.4%
  • 99. 99Table 13Female Participant Gardening Habits and Readiness for Gardening Produce Number of Female Percentage of Female Caregivers CaregiversHOUSEHOLD VEGETABLE GARDEN (n = 97)Yes 37 38.1%No 60 61.8%HOUSEHOLD FRUIT GARDEN (n = 96)Yes 23 23.9%No 73 76.1%READINESS FOR GARDENING VEGETABLES (n = 97)Precontemplation 36 37.1%Contemplation 16 16.5%Preparation 8 8.2%Action 14 14.4%Maintenance 23 23.7%READINESS FOR GARDENING FRUIT (n = 96)Precontemplation 52 54.2%Contemplation 16 16.7%Preparation 5 5.2%Action 15 15.6%Maintenance 8 8.3%
  • 100. 100 70.0% 60.0% Garden Percentage of Participants 50.0% Vegetables Garden Fruit 40.0% Eat Vegetables 30.0% 20.0% Eat Fruit 10.0% 0.0% Readiness Stage of ChangeFigure 9. Female caregiver produce and gardening readiness. Table 14 summarizes the relationship of food security status (scale score) toparameters measured, and Table 15 summarizes the relationship of female caregiverhabits to select parameters.
  • 101. 101Table 14Relationship of Food Security Status to Gardening- and Produce-Related Behaviors andIntakesCharacteristic Correlation Coefficient p-valueChild Vegetable Gardening .010 .888HabitsChild Variety of Produce -.112 .378PreferredChild Variety of Produce -.017 .893EatenFemale Caregiver Vegetable .051 .417Gardening ReadinessFemale Caregiver Fruit .088 .176Gardening ReadinessFemale Caregiver Fruit -.170 .009IntakeFemale Caregiver Vegetable -.224 .001IntakeFemale Caregiver Total -.205 .001Produce IntakeNote. Kendall’s tau was utilized to measure the relationship of food security to otherfactors.
  • 102. 102Table 15Relationship of Female Caregiver’s Habits to Gardening- and Produce-RelatedBehaviors and IntakesCharacteristic Correlation Coefficient p-valueFEMALE CAREGIVER’S VEGETABLE GARDEN READINESS bChild Vegetable Gardening Habits b -.163 .021Child Variety of Fruits Preferred b -.059 .659Child Variety of Vegetables Preferred b -.084 .518Child Variety of Produce Preferred b -.028 .826Child Variety of Fruits Eaten b -.170 .188Child Variety of Vegetables Eaten b -.103 .420Child Variety of Produce Eaten b -.142 .263Female Caregiver’s Readiness to .607 <.001Garden Fruit bFemale Caregiver’s Vegetable Intake b .150 .036FEMALE CAREGIVER’S FRUIT GARDEN READINESS cChild Vegetable Gardening Habits c -.119 .100Child Variety of Fruits Preferred c -.064 .638Child Variety of Vegetables Preferred c -.017 .899Child Variety of Produce Preferred c -.009 .944Child Variety of Fruits Eaten c -.234 .075Child Variety of Vegetables Eaten c -.073 .573Child Variety of Produce Eaten c -.195 .129Female Caregiver’s Fruit Intake c .275 .840FEMALE CAREGIVER’S FRUIT INTAKE dChild Variety of Fruits Preferred d -.370 .010Child Variety of Vegetables Preferred d -.153 .271Child Variety of Produce Preferred d -.275 .046Child Variety of Fruits Eaten d .320 .021Child Variety of Vegetables Eaten d .049 .723Child Variety of Produce Eaten d .232 .087FEMALE CAREGIVER’S VEGETABLE INTAKE eChild Variety of Fruits Preferred e .045 .755Child Variety of Vegetables Preferred e .042 .764
  • 103. 103Table 15: continuedChild Variety of Produce Preferred e .053 .704Child Variety of Fruits Eaten e .287 .040Child Variety of Vegetables Eaten e .261 .058Child Variety of Produce Eaten e .293 .031FEMALE CAREGIVER’S PRODUCE INTAKE fChild Variety of Fruits Preferred f -.117 .397Child Variety of Vegetables Preferred f -.016 .905Child Variety of Produce Preferred f -.069 .604Child Variety of Fruits Eaten f .384 .004Child Variety of Vegetables Eaten f .172 .193Child Variety of Produce Eaten f .313 .016Note. Kendall’s tau was utilized to measure the relationship the factors.b-f Factors with like superscripts indicate that the correlations of the characteristic inupper case were computed for its relationship to those in lower case. Data were also stratified by food security status. Table 16 shows female caregiverand household characteristics stratified by food security status, while Table 17 and Figure10 summarize the differences in female caregivers’ BMI and fruit and vegetable intakesby food security status. Table 18 shows female produce readiness in relation to foodsecurity status, while Table 19 displays female produce gardening readiness in relation tofood security status.
  • 104. 104Table 16Female Caregiver and Household Characteristics Stratified by Food Security StatusCharacteristic Number of Female Caregivers (%) p-value Food Secure Food InsecureMARITAL STATUS (n = 98)Married 21 (21.4%) 24 (24.5%) .427Not-married 29 (29.6%) 24 (24.5%)LEVEL OF EDUCATION (n = 99)No College 8 (8.1%) 21 (21.2%) .003Some College or Higher 42 (42.4%) 28 (28.3%)AVAILABILITY OF TRANSPORTATION FOR FOOD AQUISITION (n = 98)Reliable Transportation 47 (47.9%) 43 (43.9%) .425Unreliable Transportation 3 (3.1%) 5 (5.1%)PARTICIPATION IN HUNTING FOR FOOD ACQUISITION (n = 97)Hunt for Food 9 (9.3%) 11 (11.3%) .511Do not Hunt for Food 41 (42.3%) 36 (37.1%)PARTICIPATION IN FISHING FOR FOOD ACQUISITION (n = 97)Fish for Food 6 (6.2%) 8 (8.2%) .482Do not Fish for Food 44 (45.4%) 39 (40.2%)FOOD ASSISTANCE PROGRAM PARTICIPATIONSupplemental Nutrition 21 (21.2%) 32 (32.3%) .020Assistance Program(SNAP; n = 99)National School Lunch 30 (30.3%) 43 (43.4%) .002Program (Free- orReduced- Price; n = 99)
  • 105. 105Table 16: continuedSchool Breakfast Program 26 (26.3%) 40 (40.4%) .002(Free- or Reduced- Price; n= 99)Head Start Program 7 (7.2%) 12 (12.4%) .219(n = 97)Special Supplemental 8 (8.1%) 15 (15.2%) .085Nutrition Program forWomen, Infants, andChildren (WIC; n = 99)WIC Farmers Market 1 (1.0%) 8 (8.1%) .013Nutrition Program (n = 99)Community Food Pantry 9 (9.1%) 27 (27.3%) <.001(n = 99)PERCEIVED HEALTH (n = 98)Poor or Fair 6 (6.1%) 11 (11.2%) .182Good or Better 43 (43.9%) 38 (38.8%)PERCEIVED DIET (n = 98)Poor or Fair 15 (15.3%) 26 (26.5%) .015Good or Better 35 (35.7%) 22 (22.5%)BODY MASS INDEX (BMI) CLASSIFICATION (n = 93)Normal or Underweight 16 (17.2%) 7 (7.5%) .035Overweight or Obese 31 (33.3%) 39 (41.9%)Note. Pearson Chi-Square test was used to stratify household characteristics by foodsecurity status.
  • 106. 106Table 17Female Caregiver Weight and Diet Characteristics Stratified by Food Security Status Mean ± Standard Deviation (n, %) p-value Food Secure Food InsecureBMI (kg/m²) 28.3 ± 6.8 (47, 50.5%) 31.9 ± 10.3 (46, 49.5%) .075(n = 93)Female Caregiver 2.1 ± 1.2 (48, 50.5%) 1.5 ± 0.7 (47, 49.5%) .016Daily VegetableServing (n = 95)Female Caregiver 1.6 ± 0.8 (48, 50%) 1.3 ± 0.8 (48, 50%) .070Daily FruitServing(n = 96)Note. Mann-Whitney test was utilized to calculate differences between groups.
  • 107. 107 50 40 31.9 28.3 30 20 Food Secure Food Insecure 10 2.1 1.5 1.6 1.3 0 Average BMI Average Vegetable Serving Average Fruit Serving ‐10 ‐20Figure 10. Female caregiver body mass index and produce intake by food security status.
  • 108. 108Table 18Female Caregiver Produce Readiness Stratified by Food Security Status Number of Female Caregivers p- value Food Secure Food Insecure (%) (%)READINESS TO EAT FRUIT (n = 98)Precontemplation, Contemplation, 11(11.2%) 16 (16.3%) .258or Preparation StageAction or Maintenance Stage 38 (38.8%) 33 (33.7%)READINESS TO EAT VEGETABLES (n = 97)Precontemplation, Contemplation, 9 (9.3%) 16 (16.5%) .092or Preparation StageAction or Maintenance Stage 40 (41.2%) 32 (32.9%)Note. Pearson Chi-Square test was used to stratify parameters by food security status.
  • 109. 109Table 19Gardening Readiness and Habits of Female Caregivers Stratified by Food SecurityStatus Number of Female Caregivers (%) p-value Food Secure Food InsecureGARDENING FRUIT (n = 96)Gardens Fruit 12 (12.5%) 11 (11.5%) .811Does Not Garden Fruit 36 (37.5%) 37 (38.6%)GARDENING VEGETABLES (n = 97)Gardens Vegetables 20 (20.6%) 17 (17.5%) .480Does Not Garden Vegetables 28 (28.9%) 32 (32.9%)READINESS TO GARDEN FRUIT (n = 98)Precontemplation, Contemplation, 11 (11.2%) 16 (16.3%) .258or Preparation StageAction or Maintenance Stage 38 (38.8%) 33 (33.7%)READINESS TO GARDEN VEGETABLES (n = 97)Precontemplation, Contemplation, 9 (9.3%) 16 (16.5%) .092or Preparation StageAction or Maintenance Stage 40 (41.2%) 32 (32.9%)Note. Pearson Chi-Square test was used to stratify parameters by food security status. As previously noted in chapter 3, before the intervention, surveys were sent to allfemale caregivers (n = 250) of children participating in Kids on Campus. Tables 20 and21 show female caregiver’s perception of their children’s produce and gardening habits
  • 110. 110for all children stratified by food security, grades 1st through 6th who participated in thesummer of 2008.Table 20Female Caregiver’s Perception of Children’s Produce Intake Stratified by Food SecurityStatus Mean ± Standard Deviation (n, %) p-value Food Secure Food InsecureDaily Vegetable 2.1 ± 1.0 (78, 50%) 1.7 ± 1.0 (78, 50%) .017Servings (n = 156)Daily Fruit Servings 2.0 ± 1.2 (78, 50%) 1.7 ± .9 (78, 50%) .072(n = 156)ª Mann-Whitney test was utilized to calculate differences between groups.
  • 111. 111Table 21Female Caregiver’s Perception of Children’s Habits Number of Child Participants (%) p- value Food Secure Food InsecureCHILD EATS MORE THAN ONE TYPE OF FRUIT PER DAY (n = 156)Never or Sometimes 36 (23.1%) 56 (35.9%) .007Often or Always 39 (25.0%) 25 (16.0%)CHILD EATS MORE THAN ONE TYPE OF VEGETABLE PER DAY (n = 155)Never or Sometimes 24 (15.5%) 53 (34.2%) < .001Often or Always 50 (32.3%) 28 (18.1%)CHILD EATS TWO OR MORE VEGETABLE SERVINGS AT A MEAL (n = 152)Never or Sometimes 44 (28.9%) 67 (44.1%) .004Often or Always 27 (17.8%) 14 (9.2%)CHILD EATS CITRUS FRUIT OR JUICE (n = 160)Yes 54 (33.8%) 43 (26.9%) .010No 22 (13.8%) 41 (25.6%)CHILD EATS FRUITS OR VEGETABLES AS SNACKS (n = 156)Yes 67 (42.9%) 66 (42.3%) .077No 7 (4.5%) 16 (10.3%)CHILD IS INTERESTED IN EATING 3+ FRUIT PER DAY (n = 157)Strongly Agree or 57 (36.3%) 71 (45.2%) .041AgreeDisagree or Strongly 19 (12.1%) 10 (6.4%)DisagreeCHILD IS INTERESTED IN EATING 3+ VEGETABLES PER DAY (n = 155)Strongly Agree or 44 (28.4%) 56 (36.1%) .209AgreeDisagree or Strongly 30 (19.4%) 25 (16.1%)Disagree
  • 112. 112CHILD IS INTERESTED IN GARDENING VEGETABLES (n = 150)Strongly Agree or 56 (37.3%) 70 (46.7%) .046AgreeDisagree or Strongly 16 (10.7%) 8 (5.3%)DisagreeNote. Pearson Chi-Square test was used to stratify children’s characteristics by foodsecurity status.
  • 113. 113 CHAPTER 5: DISCUSSION, CONCLUSIONS, AND RECOMMENDATIONS Fruit and vegetable intakes have been found to be related to household foodsecurity status (Bhattacharya et al., 2004; Dixon et al., 2001; Kendall et al., 1996; Kropfet al., 2007). For adult females and children living in food-insecure households, fruits andvegetables are typically the first groups reduced from the diet, due to their higher priceand shorter shelf life, compared to other foods (Cassady et al., 2007; Dixon et al., 2001;Kendall et al., 1996; Kropf et al., 2007). Through the practice of gardening, a family cangrow fruits and vegetables at a lower cost than purchasing them, while increasing bothproduce intake and physical activity. This study: (a) measured the effect of a nutritionand gardening education program on Appalachian children’s fruit and vegetable intakesand preferences; and (b) examined the relationship of food security status to gardeninghabits and perceptions, produce intake, and personal characteristics of children and theiradult female caregivers. In this study, participants were: (a) 91 children who completed a pre-test, nutritioneducation and gardening program (intervention), and a post-test over a six-week period;and (b) 99 female caregivers who completed a 79-item survey prior to the six-weekintervention period about themselves, their household, and their 157 children. Resultsindicated that the six-week nutrition education and gardening intervention did notsignificantly impact produce intake variety or produce preference variety among thechildren participating in the program. Overall, household food security was not related tothe variety of produce eaten or preferred reported by children; however, it was related tovegetable intake, education, diet quality, food assistance program participation, and body
  • 114. 114mass index of the female caregivers. On the other hand, household food security wasrelated to the estimated children’s produce intake and preferences reported by the femalecaregivers prior to the intervention. It was also found that children’s gardening habitsreflected that of their female caregiver’s, but children’s self-reported produce intakevariety was not related to their gardening habits. However, household food security wasnot related to gardening habits or produce readiness of female caregivers. Children Participants’ Produce Preference and Intake Variety Produce intake is inadequate among children, which negatively impacts diet (Ballet al., 2008; Gao et al., 2006; Langevin et al., 2007; Lorson et al., 2009). In the studyregion, multiple studies have indicated the need for intervention in the Southeastern OhioAppalachian region in relation to promoting fruit and vegetable intake (Ball et al., 2008;Cassady et al., 2007; Holben et al., 2004; Kropf et al., 2007; Luszczynska et al., 2007;Walker et al., 2007; Wewers et al., 2006). One potential solution is to introducegardening to children, who may, in turn, influence the entire household’s habitssurrounding gardening and produce. Therefore, this research studied the effectiveness ofa six-week nutrition and gardening education program improve children’s preference forand intake of fruits and vegetables. In this study, produce intake variety did not significantly change after theintervention (p = .751). Overall, children reported consuming 16.9 ± 10.1 differentproduce items during the week prior to the intervention and 17.3 ± 11.4 during the lastweek of the intervention. Similarly, neither fruit intake variety (p = .563) nor vegetable
  • 115. 115intake variety (p = .106) changed after the intervention. More specifically, fruit andvegetable intake variety were 9.6 ± 6.1 and 7.3 ± 5.3 different items during the weekprior to the intervention, respectively, and were 9.1 ± 6.9 and 8.4 ± 6.0 during the lastweek of the intervention, respectively. As with intake variety, produce (p = .977), fruit (p = .554), and vegetable (p =.341) preference varieties did not significantly change after the intervention. Fruitpreference variety was 6.9 ± 6.6 pre-intervention and 7.3 ± 6.9 post-intervention.Vegetable preferences were 6.2 ± 5.5 and 5.6 ± 5.9 at the pre- and post-intervention timeframes, respectively. Total produce preferences of the children, at pre- and post-intervention were 13.1 ± 10.9 and 13.0 ± 11.9 (p = .977), respectively. When consideringthese intakes and preferences, it is important to underscore that these values do not equateto servings consumed. They relate, however, to the variety of produce eaten or preferredin the previous week. In subsequent sections of this chapter, the relationship of thesemeasures will be related to food security and caretaker qualities. While the variety measures did not significantly change through the course of theintervention, it may be that the children began at a high level. Studies typically usechildren’s produce intakes and preferences (Ball et al., 2008; Haire-Joshu et al., 2003;Lakkakula et al., 2008; Lorson et al., 2009; Nanney et al., 2005; Nanney, Johnson et al.,2007; Nanney, Schermbeck et al., 2007) rather than varieties, which were used in thisstudy. This could also be explained in multiple ways, including a lack of understandingby the children participants during survey completion, or an overestimation by thechildren on weekly produce intake. The modification of the Saint Louis University 4 Kids
  • 116. 116Food Frequency Questionnaire (Haire-Joshu et al., 2003) could have lead tomisinterpretation of the intakes and preferences options for the children. Therefore, futurestudies should use the Saint Louis University 4 Kids Food Frequency Questionnaireproduce intake and preference variety tool when using the recommended methods (Haire-Joshu et al., 2003). This may enable a total recall from both caregiver and child in orderto get a more complete idea of the child’s diet both at home and at school. It could alsoprovide insight on what type of produce variety the household provides, along withpossible limitations and cultural behaviors. The pictorial tool designed for this studycould be used in an in-person interview with both caregiver and child and be validated inconjunction with the Saint Louis University tool and dietary record information. Food SecurityHousehold Food Security Status The overall household food insecurity rate in this study (49.5%) was more thanfour times that of the nation and the state of Ohio in 2007, which was consistent withother research from the study region (Bletzacker et al., 2007; Hazen et al., 2008; Holbenet al., 2004; Holben & Pheley, 2006; Kendall et al., 1996; Kropf et al., 2007; Meek, 2005;Nord et al., 2008; Pheley et al., 2002; Walker et al., 2007). Low and very low householdfood security was 24.2% and 25.3%, respectively, more than twice that of the nation. In2007, the estimate of food insecurity was 11%, while in Ohio from 2005 to 2007; it wasestimated to be 12.2% of households (Nord et al., 2008). Estimates of low and very lowfood security nationwide were 7.0% and 4.1%, respectively, while in Ohio it was
  • 117. 117estimated that 7.7% of households and 4.5% of households were classified as low foodsecurity and very low food security, respectively (Nord et al., 2008). With half of thehouseholds in our study classified as food-insecure, and one-fourth of the householdsclassified as low or very low food security, our convenience sample may not accuratelyrepresent the study region, state, or nation. However, it gives insight into the familiesparticipating in Kids on Campus, and it may indicate the need to address not only thisissue among families in Kids on Campus, but also families living in Athens County,Ohio, and the region. Food insecurity has been associated with lower education, lower income, being anethnic minority, living in a non-suburban residence, and participation in governmentassistance programs (Adams et al., 2003; Alaimo et al., 1998; Alaimo et al., 2001b;Bhattacharya et al., 2004; Cutts et al., 1998; Gundersen et al., 2008; Herman et al., 2004;Holben & Myles, 2004; Jones & Frongillo, 2006; Nord et al., 2008; Oberholser & Tuttle,2004; Quandt et al., 2004; Quandt et al., 2004; Rose, 1999). In this study, however, theeducation level of the females was higher than what is typically seen with food-insecurehouseholds (Jones & Frongillo, 2006), with 70.7% (p = .003), almost three-fourths offemale caregivers, reporting to have some college education or higher. Although this rateis not implying college completion, it is much higher than recent rates of college degreesin Ohio (21.1%), Appalachia (17.7%), and the nation (24.4%). Similar results have beenfound in the area (Kropf et al., 2007; Walker et al., 2007) and could be explained by thecommunity from where our sample was drawn. Ohio University is located in AthensCounty, possibly leading to the higher level of education in the county, as compared to
  • 118. 118the rest of the state. There is also an adult career center and community college, whichmay also be contributing to this trend. More specifically, compared to caregivers fromfood-insecure households, a greater proportion of caregivers from food-securehouseholds had some college or higher (p = .003). While other characteristics besideseducation have been associated with food insecurity, in this study, marital status,availability of transportation for food, hunting for food, and fishing for food were notsignificantly different between caregivers from food-secure and food-insecurehouseholds. Participation in food assistance programs has also been associated with foodinsecurity. Many food-insecure families participate in food assistance programs,including SNAP, WIC, and the National School Meals Program (Condrasky & Marsh,2005; Nord et al., 2008; Oberholser & Tuttle, 2004). In 2007, more than half (53.9%) offood-insecure families living in the United States studied participated in a food assistanceprogram in the 30 days previous to data collection for the national estimates (Nord et al.,2008). Food assistance program participation by households in this study varied. Morethan half of our sample participated in the National School Lunch Program (73.7%), theSchool Breakfast Program (66.7%), or the SNAP (53.5%). However, participation waslower in the Head Start Program (19.6%) and WIC (23.2%) most likely due toqualification requirements. To illustrate, if children are over the age of five, families donot qualify for WIC benefits unless there is a female who is pregnant or breastfeeding,and families cannot participate in Head Start if their children are of school-age. Alongwith WIC, WIC Farmers Market Nutrition Participation was also low (8.1%). However,
  • 119. 119community food pantry usage (36.4%) was greater than what was found in 2007 (21.0%)nationwide (Nord et al., 2008). Participation in several of these programs differed between those from food-secure and food-insecure households, indicating participants were utilizing opportunitiesoffered in the Athens community, possibly as a coping strategy of being food insecure.Participation in SNAP (p = .020), National School Lunch Program (p = .002), SchoolBreakfast Program (p = .002), WIC Farmers Market Nutrition Program (p = .013), andCommunity Food Pantry (p = <..001) was significantly greater among food-insecurehouseholds compared to food-secure ones. The self-selection principle could explainthese findings. In the United States, individuals choose or “self-select” whether or not toparticipate in food assistance programs. The higher participation of food-insecureparticipants in food assistance programs supports that these insecure households seekassistance due to their perception that it is needed (Holben & ADA, 2006; Nord et al.,2008). This participation may also be a proxy for a higher income among food-securehouseholds, as the Federal Programs all have income guidelines. Participation in Kids onCampus may also lead to higher food assistance participation rates in female caregiversin Athens County. Such programs can assist female caregivers in connecting with othersin the area in similar situations, exposing them to other programs they otherwise may nothave been aware of. These practices can also benefit the households through increasedsocial capital while increasing their food security. Finally, Kids on Campus may itself beviewed as an assistance program, further explaining the increased rate of food insecurityamong participants.
  • 120. 120Food Security, Body Weight, Diet, and Health Adult individuals living in a food-insecure households, especially females, aremore likely to be overweight or obese than those in food-secure households (Lyons et al.,2008; Martin & Ferris, 2007). In this study, BMIs did not differ between food-insecurewomen (31.9 ± 10.3), compared to their food-insecure (28.3 ± 6.8) counterparts (p =.075). However, when stratified by weight classification, food-insecure women weremore likely to be overweight or obese, compared to those from food-secure households (p= .035). In fact, among the food insecure, 27% of female caregivers self reported weightclassified as overweight and 44% classified as obese. Binge eating in relation to food-insecurity has been associated with weight gain in women due to the cyclical nature offood assistance programs (Olson, 2005; Webb et al., 2008). This, along with decreaseddiet quality, leads to the counterintuitive finding of overweight and obesity in food-insecure women. Food-insecurity is associated with lack of nutritious food for an active,healthy life. However, high calorie, high fat, low nutrient-dense foods tend to be lessexpensive than low calorie, low fat, and high nutrient dense items (Mendoza et al., 2006).Therefore, the less nutrient-dense, empty calorie foods replace the more nutritiousoptions leading to weight gain, especially when coupled with binge eating when food isplentiful. Future research should measure the impact that gardening interventions have onthe diet quality and eating behaviors of female caregivers. Due to the high food assistanceprogram participation rates of this study, research should also attempt to compare groupsin such interventions to determine how much of an impact food assistance programparticipation has on female caregiver’s weight status. National studies using the National
  • 121. 121Health and Nutrition Examination Survey (NHANES) data could also be utilized toexplore these trends nationally. Poor diet quality and health have also been associated with food-insecurity(Chang et al., 2008; Condrasky & Marsh, 2005; Kendall et al., 1996; Langevin et al.,2007; McIntyre et al., 2003; Olson, 2005; Pheley et al., 2002; Vozoris & Tarasuk, 2003).Studies have found as food insecurity worsens, overall health status also worsens(Bronte-Tinkew et al., 2007; Holben et al., 2006; Holben & Pheley, 2006; Pheley et al.,2002; Tarasuk & Beaton, 1999). Those who report food insecurity also report pooroverall health more often than those who were food-secure (Lee & Frongillo, 2001;Pheley et al., 2002). This is a logical relationship due to diet quality’s impact on healthstatus. In 2003, a report found that those with incomes below the poverty line purchasedfewer fruits and vegetables due to taste and convenience issues (Stewart & Blisard,2008). However, when household income increased as little as 10%, fruit and vegetablepurchases increased (Stewart & Blisard, 2008). These findings reinforce the need forincreased produce intake in low-income families in order to increase diet quality andhealth status. Food insecurity negatively impacts multiple aspects of the diet, includingdecreased quality and quantity of food intake and diet (Chang et al., 2008; Condrasky &Marsh, 2005; Hazen et al., 2008; Holben et al., 2006; Holben et al., 2004; Holben &Pheley, 2006; Kendall et al., 1996; Kropf et al., 2007; Langevin et al., 2007; McIntyre etal., 2003; Olson, 2005; Vozoris & Tarasuk, 2003; Walker et al., 2007). In this study,more than half of respondents (58%) reported their diet as good, very good, or excellent.
  • 122. 122However, diet quality significantly differed between caregivers from food-secure homes,versus food-insecure homes (p = .015), with a greater proportion of food-securecaregivers perceiving their diet to be of higher quality. Over half of the females were inthe “action” stage of eating fruits and vegetables, while almost half reported“precontemplation” for gardening fruits and vegetables; however, neither of thesesignificantly differed between food-secure and insecure groups. Female caregiverreadiness to eat fruits (p = .258) and vegetables (p = .092) were mostly reported as“action or maintenance” stage for both food-secure and insecure participants, howeverthere was not a significant difference between these groups. Female caregiver fruit (tau = -.170, p = .009), vegetable (tau = -.224, p = .001),and produce (tau = -.205, p = .001) intakes were significantly related to food security,consistent with other studies (Kendall et al., 1996; Kropf et al., 2007; Olson, 2005). Bothfruit and vegetable intake significantly decreased as food insecurity worsened. Theaverage daily vegetable (1.5 ± 0.7) and fruit (1.3 ± 0.8) intake of food-insecure womenwas lower than recommended. Similarly, food-secure women also had low intakes ofboth vegetables and fruit (2.1 ±1.2; 1.6 ± 0.8). However, only vegetable intake of food-insecure women was significantly lower, compared to their food-secure counterparts (p =.016). This could indicate an overall need to improve produce intake in women, not onlythose in food-insecure households. It also supports, however, that food insecurity furthercompromises vegetable intake. Diets of individuals living in households characterized by food insecurity havebeen found to have below the recommended intake of kilocalories, protein, calcium,
  • 123. 123vitamins B-6 and B-12, riboflavin, niacin, magnesium, iron, and zinc, compared to thoseliving in food-secure households (Dixon et al., 2001; Lee & Frongillo, 2001; Mathesonet al., 2002; Olson, 1999; Rose & Oliveira, 1997). Studies have shown food-insecurehouseholds to be of particular concern in relation to decreased produce intake, as this canlead to increased risk for certain cancers, cardiovascular disease, and lower overallwellness (Ahn et al., 2005; Cartmel et al., 2005; Dixon et al., 2001; Genkinger et al.,2004; Guenther et al., 2006; Kendall et al., 1996; Kirsh et al., 2007; Larsson et al., 2006;Lee et al., 2006; Pierce et al., 2007; Pierce, Stefanick et al., 2007). Unlike diet, health status did not significantly differ (p = .182). The self-reportedhealth status of the female caregivers in this study ranged from excellent to poor, with83% of respondents reporting to have good, very good, or excellent health status. Healthproblems and status could be alleviated with more consistent access to healthy food andeducation for these families. Future studies should explore the relationship between dietquality and health status in food-insecure females to determine what role poor diet qualityplays in food-insecure families’ quality of life.Food Security, Gardening, and Diet Food security and female caregiver’s gardening and diet. Women living in food-insecure households have been shown to consume less thanthe recommended amounts of produce (Ahn et al., 2005; Cartmel et al., 2005; Dixon etal., 2001; Genkinger et al., 2004; Guenther et al., 2006; Kendall et al., 1996; Kirsh et al.,2007; Larsson et al., 2006; Lee et al., 2006; Pierce et al., 2007; Pierce, Stefanick et al.,2007), which gardening may be able to alleviate. In this study, household food security
  • 124. 124and gardening habits were not found to be significantly related in the female caregivers orthe children (p > .05). Similarly, having a fruit (p = .811) or vegetable (p = .480) gardendid not significantly differ between food-secure and food-insecure homes. Finally, femalereadiness for gardening vegetables (p = .092), gardening fruit (p =.258), eating vegetables(p = .092), and eating fruit (p = .258) did not significantly differ either. When comparing food-secure households to food-insecure households, gardeningreadiness did not significantly differ between groups. Gardening readiness followed asimilar trend to readiness to eat produce, with most reporting “precontemplation;”however, more food-secure households reported “action or maintenance” than food -insecure for gardening fruit (38.8%) and vegetables (41.2%). Considering the number offemale caregivers in the “action” stage for eating produce but “precontemplation” stagefor gardening, this may indicate that many of them are eating produce but not growing it.Precontemplation means that an individual is not considering the behavior in question,while action indicates the behavior is already occurring. Female vegetable intake wassignificantly related to gardening vegetables (p = .036), however fruit intake was notsignificantly related to gardening fruit (p = .840). This indicates that those females whogarden vegetables are more likely to have higher vegetable intake, where as gardeningfruit has no impact. In order to better assess this behavior change, future studies shouldmeasure garden usage of participants along with produce intake. Gardening readiness is anew measure developed for this study; therefore, more research is needed on theconstruct to further evaluate its validity.
  • 125. 125 As noted in the previous section, food insecurity significantly impacted produceintake and diet quality of female caregiver’s in this study, which follows trends ofprevious research. However, gardening was not related to either food security status ofthe household nor produce intake of the female caregivers. This raises the question ofwhy female caregivers are not choosing to garden in times of food-insecurity? What arethe barriers or limitations to gardening in this population? Future research shouldinvestigate this, focusing on both food-secure and food-insecure households to determinewhom the specific barriers impact most or if the gardening trend is decreasing inpopularity. Programs similar to the one used in this study with children participants couldbe developed for families in conjunction to food assistance programs in order to increasegardening habits. Food security and children’s diet. This study also examined if, at the onset of the study, whether household foodsecurity status was related to produce preferences and intakes of child participants. It wasfound that household food security was not related to the produce preferences (tau = -.112, p = .378) and intakes (tau = -.017, p = .893) of the child participants. Prior to the nutrition education and gardening intervention, female caregiversreported their perception of children’s produce and gardening habits. It was found thatfood security was significantly related to female caregiver’s perception of children’svegetable gardening habits, produce variety, and produce intake. Child daily vegetableservings were significantly different per household, according to their female caregivers,with children living in food-secure households eating 2.1 ± 1.0 servings a day and those
  • 126. 126in food-insecure households reporting 1.7 ± 1.0 servings a day (p = .017). Femalecaregiver’s perception of children’s fruit intake did not significantly differ amonghouseholds. Their perception of their children’s produce variety was impacted, however,with children from food-secure households consuming more than one type of vegetable(p < .001) and fruit (p = .007), more often than those from food-insecure households.While intakes varied between groups, children from food-insecure households were notless likely to consume citrus fruit or juice, compared to those from food-securehouseholds. However, children from food-insecure households were less likely toconsume two or more vegetable servings at a meal, with 44.1% caretakers reporting theirchild would never or sometimes meet this recommendation (p = .004). However, food-insecure children were not less likely to be interested in consuming three or more fruit orvegetable servings daily. Similarly, fruit or vegetables as snacks, or interest in gardeningvegetables were not different by food security status in children (p > .05). Produce intake has been found to be deficient in children, in both food-secure andinsecure homes. A study focusing on fruit and vegetable intake of rural mothers andchildren found that most produce intake was inadequate (Nanney, Schermbeck et al.,2007). More than half of the adolescents in a Canadian study did not meet the 5-a-dayfruit and vegetable recommendations; however, intake did increase with increased familyincome, education, and two parent households (Riediger et al., 2007). A study conductedin rural North Carolina found children who consumed excessive amounts of sweets didnot meet the recommendations for fruits, vegetables, dairy, or grains (Ball et al., 2008).Children in food-insecure households have lower intakes of fruits, vegetables, and milk
  • 127. 127products, which directly impacts their calcium, vitamins A and C intake (Dixon et al.,2001). These findings were consistent with what was found with female caregiver’sperception of their children’s produce intake, however, inconsistent with children’sperception of their own diet. Previous work found that children in food-insecure households had lower intakesof dark green vegetables and fruits than those in food-secure households (Casey et al.,2001; Lorson et al., 2009). Yet, our study did not actually measure the children’s produceintake. Rather, it measured produce variety consumed and preferred and the femalecaregiver’s perception of their children’s intake. Even though children are typicallyprotected from hunger, their diets can still be impacted (Rose, 1999). Children in food-insecure households have lower intakes of fruits, vegetables, and milk products, whichdirectly impacts their calcium, vitamins A and C intake (Dixon et al., 2001). Childrentypically consume the types of food provided by their caretakers. When household foodsupplies are depleted, due to food insecurity, children’s diets suffer, particularly intake ofproduce (Matheson et al., 2002). This could explain the differences in produce intakesfound in this study. Female caregiver’s responses could reflect their own diminishedproduce variety when responding for their children. The variety of produce reported bythe children in the intervention portion of the study may be due to intake of produceoutside the home, such as during school meals, or it may be explained by children notcorrectly reporting their intake. In addition, the caregivers were asked about theirchildren’s daily intake, while children were asked about the past week. Future studiesshould survey and measure children’s produce intake and preference variety in
  • 128. 128conjunction to female caregiver’s perceptions differently than this study due toconflicting reports from caregivers and children on produce variety. This can be achievedthrough combined interviews and surveying of children and caregivers together, whichenables discussion between the two parties on dietary intake leading to a more completereport. Even though our sample had a high level of household food-insecurity, it was notrelated to child participant’s perception of their produce intake variety or preferencevariety. While post-intervention food security status of the children was not measured,future interventions should do so. Anecdotally, the researchers observed throughout thestudy that many children, when provided with the weekly produce, ate the food rightaway, and some discussed ways they would share it with their families. When harvestingthe vegetables grown in the education program gardens, children were willing to tastewhatever products were available (radishes, greens, herbs), which may reflect an interestin trying new foods. Future studies should include questions pertaining to child foodsecurity and produce to further asses their relationship. Female Caregiver Gardening and Produce Habits At its onset, this study explored whether female caregiver’s gardening habits wererelated to their perceptions of the child’s gardening habits and their child’s produceintake and preferences. Less than half of female caregiver’s reported having a fruit(23.9%) or vegetable (38.1%) garden in this study. However, they reported 84% of theirchildren were interested in gardening vegetables, which was significantly related to
  • 129. 129female caregiver gardening habits (tau = -.163, p = .021). Female caregiver gardeninghabits were not related to produce intakes of the child (tau = -.142, p = .263) orpreferences (tau = -.028, p = .826). Fruit intake of female caregivers was significantlyrelated to child variety of fruits preferred (tau = -.370, p = .010), child variety of producepreferred (tau = -.275, p = .046), and child variety of fruits eaten (tau = .320, p = .021).Female caregiver vegetable intake, however, was only significantly related to childvariety of produce eaten (tau = .293, p = .031). Understandably, female caregiver produceintake was also related to child variety of produce eaten (tau = .313, p = .016). Nanney and others (Nanney, Johnson et al., 2007) found that those families inrural areas who ate homegrown produce had an increase in produce availability, alongwith an increase in their child’s preference for new fruits and vegetables. In fact,gardening projects have been done to improve the health and fruit and vegetable intake ofthe participants, with most having positive impacts on their participants’ produce intakeand gardening and nutrition knowledge (Graham & Zidenberg-Cherr, 2005; Hermann etal., 2006; McAleese & Rankin, 2007; Morris & Zidenberg-Cherr, 2002; Nanney, Johnsonet al., 2007; Stables et al., 2005; Van Duyn & Pivonka, 2000). Compared to otherinterventions, gardening is an inexpensive way to increase produce intake as well asphysical activity in households (Graham & Zidenberg-Cherr, 2005; McAleese & Rankin,2007; Nanney, Johnson et al., 2007). Future studies should assess this through follow-uptesting of both children female caregivers to assess the total impact of gardening on theirlifestyle.
  • 130. 130 Conclusions and RecommendationsConclusions Gardening has been shown to be positively related to access to fruits andvegetables, and is a relatively inexpensive way to grow fresh produce (Holben et al.,2004; McAleese & Rankin, 2007; Nanney, Johnson et al., 2007; Rose & Richards, 2004).Further, gardening interventions have been shown to positively impact produce intake ofchildren and their households, which may also increase their food security (Graham &Zidenberg-Cherr, 2005; Hermann et al., 2006; Holben et al., 2004; McAleese & Rankin,2007; Morris & Zidenberg-Cherr, 2002). Gardening projects have been conducted toimprove the health and fruit and vegetable intake of the participants, with most havingpositive impacts on their participants’ produce intake and gardening and nutritionknowledge (Graham & Zidenberg-Cherr, 2005; Hermann et al., 2006; McAleese &Rankin, 2007; Morris & Zidenberg-Cherr, 2002; Nanney, Johnson et al., 2007; Stables etal., 2005; Van Duyn & Pivonka, 2000). However, variables measured in this study as partof the gardening intervention and produce variety were not found to be significantlydifferent after the intervention, which could be for a variety of reasons including lengthof study, survey tool used, and population studied. Previous studies have found mixed results (Robinson-OBrien et al., 2009) inrelation to gardening and produce intake, and no program has been developed toconsistently improve produce intake in children. However, had our study population notstarted at such a high level of produce intake and preference, more significant results mayhave been achieved. A study in 2005 had one-hour interventions for several weeks with
  • 131. 131seven to nine year old children in a school-based program focused on specific fruit andvegetables that could be increased in the diet (Nanney et al., 2005). Another type of six-week program focused on fruit and vegetable intake in Boston found that those who hadhigher fruit and vegetable intakes had a higher interest in healthy eating (McNeill et al.,2007). Both studies indicate that length of study could increase produce intake inchildren, however, those who are currently eating high levels of produce may be the mostinvolved participants. Future studies should assess participants’ readiness levels pre-intervention in order to cater the program to all participants needs for more significantresults. The size of the population used could have limited the results through limitedcompetition of child surveys (60.7%). The high initial produce intake and preference alsoinhibited the potential of significant results in the post-testing. Children’s pre-intervention average weekly produce intake was 16.91 ± 10.1, which is almost half of themaximum 36 items surveyed. These results could also have been impacted by the surveytool used. Parental reporting of children’s dietary intake has been utilized in other previousresearch projects. One study found that parents accurately reported their child’s intake,with only some discrepancy on juices and combination foods that included fruits andvegetables (Linneman et al., 2004). However, another similar study done in theNetherlands found poor correlation between parent and child responses to the child’svegetable intake, but better correlation with their fruit intake (Reinaerts et al., 2007). Theresults of this study support that caregiver input on children’s produce intake may be
  • 132. 132essential in order to collect valid results. When assessing children’s produce intake,future studies should use combined methodology to get complete results. Food security was shown to impact a number of variables in female caregiversincluding vegetable intake, weight status, and perceived diet quality. These findings werefairly consistent with previous literature (Drewnowski & Specter, 2004; Hazen et al.,2008; Holben et al., 2004; Holben & Pheley, 2006; Kropf et al., 2007; Olson, 1999;Olson & Strawderman, 2008; Pheley et al., 2002; Rose & Oliveira, 1997; Rose, 1999;Tarasuk & Beaton, 1999; Townsend et al., 2001; Walker et al., 2007; Wilde & Peterman,2006). Gardening and health status have both been found to be related to food securitystatus ( Holben et al., 2006; Holben et al., 2004; Lee & Frongillo, 2001; Pheley et al.,2002; Stuff et al., 2004; Walker et al., 2007), however, this study did not agree with thosefindings. Food insecurity would have a similar impact on diet quality and vegetableintake, but weight status seems counterintuitive. Both diet quality and vegetable intakedecreased in food-insecure female caregivers, however overweight and obesity rates rose.These results, in fact, do relate to the literature due to the poor nutritional status offemales in food-insecure homes who have been found to have higher intakes of lowernutrient-dense foods with higher calories rather than fresh produce due to cost and shelf-life issues. This poor diet quality and possible binge eating then leads to overweight andobesity in these women, which needs to be addressed through nutrition education andcounseling. Gardening habits of the female caregivers were found to significantly relate tofemale vegetable intake and children’s gardening habits. These findings were consistent
  • 133. 133with previous studies (Graham & Zidenberg-Cherr, 2005; Nanney, Johnson et al., 2007)which found that family influence can increase children’s interest in both produce andgardening. It also shows that when produce is available, intake increases in females,which in turn may influence children’s intake in the future. Therefore, gardening can bean inexpensive way to not only increase produce availability, but also variety and intakein both women and children.Recommendations Suggestions for future studies and programming by nutrition professionals includelonger interventions with more in-depth information, post-testing the female caregiverparticipants, along with a follow-up of the child participants in order to assess the impacton their long-term diet and gardening. Some factors that could have impacted this studyinclude intervention length, population size, and produce habits of female caregivers andchildren. A longer, more in-depth study focusing on both family and child nutrition andgardening education may be needed to have more of an impact on produce intake andpreference variety of children. This would also allow for a cohesive interview processwith both caregiver and child leading to a more reliable survey tool. Length of study has been varied in such nutrition education and gardeningprograms with inconsistent results (Agriculture and Natural Resources, University ofCalifornia, 2009; Hermann et al., 2006; McAleese & Rankin, 2007; Morris & Zidenberg-Cherr, 2002; Nanney, Johnson et al., 2007; Robinson-OBrien et al., 2009). Therefore, alonger time frame than the six-weeks of this program may have led to a positive effect on
  • 134. 134children’s produce intake and preference while allowing for more information to bediscussed. The survey instrument used had not been previously validated; however, it wasbased on the previously validated Saint Louis University 4 Kids Food FrequencyQuestionnaire. The Saint Louis University 4 Kids Food Frequency Questionnaire wasintended to be read allowed to parents in order for them to respond for their children. Ourstudy did not have this option since we did not have one-on-one contact with the parentspre- and post- intervention, and so the children were given the surveys on the first day ofthe program. This could have lead to some confusion on the child’s part since each groupof 25 children were allotted three to four teaching assistants to assist in the completion ofthe survey. Reading and comprehension could have become an issue, even though allchildren involved were given picture surveys and detailed directions on how to completethe survey both pre and post intervention. With this limitation, results from the child’spreference and intakes could have been affected. Dietetic and nutrition professionals can use these findings to develop otherinterventions including gardening and nutrition education with both children and theirfamilies. For more significant results, future studies should focus on more nutritioneducation including the benefits of gardening. By introducing the benefits of gardeningand how families can use it as an opportunity to increase physical activity and produceintake, dietetic professionals can improve overall health of low-income families who maynot have done so otherwise. Future research should address the complex issue ofoverweight and obesity in food-insecure women through assessment of women’s
  • 135. 135nutritional education levels and diet habits. These findings could then be used for thedevelopment of nationwide nutrition education programs which could be used inconjunction with food-assistance programs. Even though this nutrition education and gardening intervention did notsignificantly impact children’s produce intake or preference variety, it did find that food-insecurity impacts both female and children’s diets. Although gardening was notassociated with produce intake or food security, nutrition professionals and researchersshould continue to include it as a way to increase produce and physical activity incommunities, whether regardless of food security status.
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  • 160. 160Stables, G. J., Young, E. M., Howerton, M. W., Yaroch, A. L., Kuester, S., Solera, M. K., et al. (2005). Small school-based effectiveness trials increase vegetable and fruit consumption among youth. Journal of the American Dietetic Association, 105(2), 252-256.Stewart, H., & Blisard, N. (2008). Are lower income households willing and able to budget for fruits and vegetables? (No. 54). Washington, DC: U.S. Dept. of Agriculture.Struble, C., Holben, D. H., Hazen, C., & Holcomb, J. P. (2008). Adult food insecurity is associated with poorer perceived health of rural impoverished women participating in a produce pilot study in Appalachian Ohio [Abstract]. Journal of the American Dietetic Association, 108(9), A108.Stuff, J. E., Casey, P. H., Szeto, K. L., Gossett, J. M., Robbins, J. M., Simpson, P. M., et al. (2004). Household food insecurity is associated with adult health status. The Journal of Nutrition, 134(9), 2330-2335.Swindale, A., & Bilinsky, P. (2006). Development of a universally applicable household food insecurity measurement tool: Process, current status, and outstanding issues. The Journal of Nutrition, 136(5), 1449S-1452S.Tanumihardjo, S. A., Anderson, C., Kaufer-Horwitz, M., Bode, L., Emenaker, N. J., Haqq, A. M., et al. (2007). Poverty, obesity, and malnutrition: An international
  • 161. 161 perspective recognizing the paradox. Journal of the American Dietetic Association, 107(11), 1966-1972.Tarasuk, V. S., & Beaton, G. H. (1999). Womens dietary intakes in the context of household food insecurity. The Journal of Nutrition, 129(3), 672-679.Tessaro, I., Mangone, C., Parkar, I., & Pawar, V. (2006). Knowledge, barriers, and predictors of colorectal cancer screening in an Appalachian church population. Preventing Chronic Disease, 3(4), 123-134.Townsend, M. S., & Kaiser, L. L. (2005). Development of a tool to assess psychosocial indicators of fruit and vegetable intake for 2 federal programs. Journal of Nutrition Education & Behavior, 37(4), 170-184.Townsend, M. S., & Kaiser, L. L. (2007). Brief psychosocial fruit and vegetable tool is sensitive for the US Department of Agriculture’s nutrition education programs. Journal of the American Dietetic Association, 107(12), 2120-2124.Townsend, M. S., Peerson, J., Love, B., Achterberg, C., & Murphy, S. P. (2001). Food insecurity is positively related to overweight in women. The Journal of Nutrition, 131(6), 1738-1745.Trevino, R. P., Fogt, D. L., Wyatt, T. J., Leal-Vasquez, L., Sosa, E., & Woods, C. (2008). Diabetes risk, low fitness, and energy insufficiency levels among children from poor families. Journal of the American Dietetic Association, 108(11), 1846-1853.
  • 162. 162Tulkki, L. A., Berryman, D. E., Rana, S., Denham, S. A., Holben, D. H., & Nisbett, N. (2006). Elevated body image dissatisfaction relates to body size of Appalachian children. Topics in Clinical Nutrition, 21(2), 101-107.U.S. Census Bureau. (2008). Current population survey (CPS). Retrieved March 4, 2009, from http://www.census.gov/cps/U.S. Census Bureau. (2009). Athens County, Ohio. Retrieved March 4, 2009, from http://quickfacts.census.gov/qfd/states/39/39009.htmlU.S. Department of Health and Human Services. (2008). Summer food service program. Retrieved February 24, 2009, from http://www.fns.usda.gov/cnd/summer/U.S. Department of Health and Human Services. (2009a). School breakfast program. Retrieved February 24, 2009, from http://www.fns.usda.gov/cnd/Breakfast/Default.htmU.S. Department of Health and Human Services. (2009b). School meals. Retrieved February 24, 2009, from http://www.fns.usda.gov/cnd/U.S. Department of Health and Human Services. (2009c). Supplemental nutrition assistance program (SNAP). Retrieved February 24, 2009, from http://www.fns.usda.gov/snap/
  • 163. 163Van Duyn, M. A., & Pivonka, E. (2000). Overview of the health benefits of fruit and vegetable consumption for the dietetics professional: Selected literature. Journal of the American Dietetic Association, 100(12), 1511-1521.Van Horn, L., Obarzanek, E., Friedman, L. A., Gernhofer, N., & Barton, B. (2005). Childrens adaptations to a fat-reduced diet: The dietary intervention study in children (DISC). Pediatrics, 115(6), 1723-1733.Vozoris, N. T., & Tarasuk, V. S. (2003). Household food insufficiency is associated with poorer health. The Journal of Nutrition, 133(1), 120-126.Walker, J. L., Holben, D. H., Kropf, M. L., Holcomb, J. P., Jr, & Anderson, H. (2007). Household food insecurity is inversely associated with social capital and health in females from special supplemental nutrition program for women, infants, and children households in Appalachian Ohio. Journal of the American Dietetic Association, 107(11), 1989-1993.Ware, J. E., Jr, & Sherbourne, C. D. (1992). The MOS 36-item short-form health survey (SF-36). I. conceptual framework and item selection. Medical Care, 30(6), 473- 483.Webb, A. L., Schiff, A., Currivan, D., & Villamor, E. (2008). Food stamp program participation but not food insecurity is associated with higher adult BMI in Massachusetts residents living in low-income neighborhoods. Public Health Nutrition, 11(12), 1248-1255.
  • 164. 164Weinreb, L., Wehler, C., Perloff, J., Scott, R., Hosmer, D., Sagor, L., et al. (2002). Hunger: Its impact on childrens health and mental health. Pediatrics, 110(4), 41- 52.Wewers, M. E., Katz, M., Fickle, D., & Paskett, E. D. (2006). Risky behaviors among Ohio Appalachian adults. Preventing Chronic Disease, 3(4), 127-135.Whitaker, R. C., & Sarin, A. (2007). Change in food security status and change in weight are not associated in urban women with preschool children. The Journal of Nutrition, 137(9), 2134-2139.Wilde, P. E., & Peterman, J. N. (2006). Individual weight change is associated with household food security status. The Journal of Nutrition, 136(5), 1395-1400.Zerbian, C. (2007). Community food initiatives. Retrieved February 24, 2009, from http://www.communityfoodinitiatives.com/index.htmlZhang, Z., Infante, A., Meit, M., & English, N. (2008). An analysis of mental health and substance abuse disparities & access to treatment services in the Appalachian region. Washington, DC: Appalachian Regional Commission.
  • 165. 165APPENDIX A: FOOD SECURITY SURVEY MODULE SCORING FOOD SECURITY SURVEY MODULE 18 AND 6 ITEM SCORING The following is a brief overview of how to code responses and assess householdfood security status in 2008 for the current categories based on various standard scales.For detailed information on these procedures, refer to the Guide to Measuring HouseholdFood Security, Revised 2000, and Measuring Children’s Food Security in U.S.Households, 1995-1999. Both publications are available through the ERS Food Securityin the United States Briefing Room. Responses of “yes,” “often,” “sometimes,” “almost every month,” and “some monthsbut not every month” are coded as affirmative. The sum of affirmative responses to aspecified set of items is referred to as the household’s raw score on the scale comprisingthose items.Item Number QuestionQ1 “We worried whether our food would run out before we got money to buy more.” Was that often, sometimes, or never true for you in the last 12 months? “The food that we bought just didn’t last and we didn’t haveQ2 money to get more.” Was that often, sometimes, or never true for you in the last 12 months?Q3 “We couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for you in the last 12 months?Q4 In the last 12 months, did you or other adults in the household ever cut the size of your meals or skip meals because there wasn’t enough money for food? (Yes/No)
  • 166. 166Q5 (If yes to Question 4) How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months?Q6 In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food? (Yes/No)Q7 In the last 12 months, were you ever hungry, but didn’t eat, because there wasn’t enough money for food? (Yes/No)Q8 In the last 12 months, did you lose weight because there wasn’t enough money for food? (Yes/No)Q9 In the last 12 months did you or other adults in your household ever not eat for a whole day because there wasn’t enough money for food? (Yes/No)Q10 (If yes to Question 9) How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months? Questions 11-18 are asked only if the household included children ages 0-18Q11 “We relied on only a few kinds of low-cost food to feed our children because we were running out of money to buy food.” Was that often, sometimes, or never true for you in the last 12 months?Q12 “We couldn’t feed our children a balanced meal, because we couldn’t afford that.” Was that often, sometimes, or never true for you in the last 12 months?Q13 “The children were not eating enough because we just couldn’t afford enough food.” Was that often, sometimes, or never true for you in the last 12 months?Q14 In the last 12 months, did you ever cut the size of any of the children’s meals because there wasn’t enough money for food? (Yes/No)Q15 In the last 12 months, were the children ever hungry but you just couldn’t afford more food? (Yes/No)Q16 In the last 12 months, did any of the children ever skip a meal because there wasn’t enough money for food? (Yes/No)
  • 167. 167Q17 (If yes to Question 16) How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months?Q18 In the last 12 months, did any of the children ever not eat for a whole day because there wasn’t enough money for food? (Yes/No)Note. Adapted from “Guide to Measuring Household Food Security, Revised 2000”, byG. Bickel, 2000, Department of Agriculture, Food and Nutrition Service, p.22. Copyright2000 by the USDA. Reprinted with permission.• Specification of food security status depends on raw score and whether there are children in the household (i.e., whether responses to child-referenced questions are included in the raw score). o For households with one or more children: Raw score zero—High food security Raw score 1-2—Marginal food security Raw score 3-7—Low food security Raw score 8-18—Very low food security o For households with no child present: Raw score zero—High food security Raw score 1-2—Marginal food security Raw score 3-5—Low food security Raw score 6-10—Very low food security Households with high or marginal food security are classified as food-secure. Those with low or very low food security are classified as food-insecure.• Questions 2 through 10 comprise the U.S. Adult Food Security Scale. Raw score zero—High food security among adults
  • 168. 168 Raw score 1-2—Marginal food security among adults Raw score 3-5—Low food security among adults Raw score 6-10—Very low food security among adults• Questions 2, 3, 5, 7, 8, and 10 comprise the six-item Short Module from which the Six-Item Food Security Scale can be calculated. Raw score 0-1—High or marginal food security (raw score 1 may be considered marginal food security, but a large proportion of households that would be measured as having marginal food security using the household or adult scale will have raw score zero on the six- item scale) Raw score 2-4—Low food security Raw score 5-6—Very low food securityQuestions 11 through 18 comprise the U.S. Children’s Food Security Scale. Raw score 0-1—High or marginal food security among children (raw score 1 may be considered marginal food security, but it is not certain that all households with raw score zero have high food security among children because the scale does not include an assessment of the anxiety component of food insecurity) Raw score 2-4—Low food security among children Raw score 5-8—Very low food security among children(2) Response Options: For interviewer-administered surveys, DK (“do not know”) and“Refused” are blind responses—that is, they are not presented as response options, but
  • 169. 169marked if volunteered. For self-administered surveys, “do not know” is presented as aresponse option.(3) Screening: The two levels of screening for adult-referenced questions and one levelfor child-referenced questions are provided for surveys in which it is consideredimportant to reduce respondent burden. In pilot surveys intended to validate the modulein a new cultural, linguistic, or survey context, screening should be avoided if possibleand all questions should be administered to all respondents. To further reduce burden for higher income respondents, a preliminary screenermay be constructed using question 1 along with a household income measure.Households with income above twice the poverty threshold, AND who respond <1> toquestion 1 may be skipped to the end of the module and classified as food-secure. Use ofthis preliminary screener reduces total burden in a survey with many higher-incomehouseholds, and the cost, in terms of accuracy in identifying food-insecure households, isnot great. However, research has shown that a small proportion of the higher incomehouseholds screened out by this procedure will register food insecurity if administeredthe full module. If question 1 is not needed for research purposes, a preferred strategy isto omit 1 and administer Adult Stage 1 of the module to all households and Child Stage 1of the module to all households with children.
  • 170. 170 APPENDIX B: KIDS ON CAMPUS SURVEY SCORINGItem Number QuestionThe first four questions are in relation to the family’s food intakeQ5 In the last 12 months, did you or other adults in your household, ever cut the size of your meals or skip meals because there wasn’t enough money for food?Q8 (Ask only if Yes to Q5) How often did this happen- almost every month, some months but not every month, or in only 1 or 2 months?Q7 In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money to buy food?Q10 In the last 12 months, were you ever hungry but didn’t eat because you couldn’t afford enough food?The last two questions are in relation to the family’s food situationQ2 “The food that I/we bought just didn’t last and I/we didn’t have money to get more.” Was that often, sometimes, or never trough for you in the last 12 months?Q3 “I/we couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for you in the last 12 months?Note. Adapted from “The Effectiveness of a Short Form of the Household Food SecurityScale,” by S. Blumberg, 1999, American Journal of Public Health, 89; 1231-1234.Copyright 1999 by the USDA. Adapted with permission.• Questions 2, 3, 5, 7, 8, and 10 comprise the six-item Short Module from which the Six-Item Food Security Scale can be calculated. Raw score 0-1—High or marginal food security (raw score 1 may be considered marginal food security, but a large proportion of households that would be measured as having marginal food security
  • 171. 171 using the household or adult scale will have raw score zero on the six- item scale) Raw score 2-4—Low food security Raw score 5-6—Very low food security(Bickel et al., 2000)Constructs/Domain Number of Items Points (Min, Max)Predisposing: 4 0-2Perceived benefits for eating fruits and Agree = 1vegetables Either agree or • I feel that I am helping my body by disagree = 0.5 eating more fruits and vegetables • I may develop health problems if I Disagree = 0 do not eat fruits and vegetables Other = 0Perceived control for eating fruits andvegetables Shared decision = 0.5 • In your household, who is in charge of what foods to buy? I am = 1 • In your household, who is in charge of how to prepare the food?Enabling: Agree = 1Self-efficacy for eating fruits and Either agree orvegetables disagree = 0.5 • I feel that I can plan meals or Disagree = 0 snacks with more fruit during the next week. • I feel that I can buy more vegetables the next time I shop. • I feel that I can plan meals with
  • 172. 172 more vegetables during the next week. • I feel that I can eat fruits or vegetables as snacks. • I feel that I can add extra vegetables to casseroles and stews. • I feel that I can eat 2 or more servings of vegetables at dinner.Intention: 3 0-3Readiness to eat more fruit • I am not thinking about eating more fruit. (pre-contemplation) • I am planning to start within 6 months. (contemplation) • I am definitely planning to eat more fruit in the next month. (preparation) • I am trying to eat more fruit now. (action) • I am already eating 2 or more servings of fruit a day. (maintenance)Readiness to eat more vegetables • I am not thinking about eating more vegetables.(pre- contemplation) • I am planning to start within 6 months. (contemplation) • I am definitely planning to eat more vegetables in the next month. (preparation) • I am trying to eat more vegetables now. (action) • I am already eating 2 or more servings of vegetables a day. (maintenance)Perceived diet quality Excellent = 5
  • 173. 173 • How would you describe your Very good = 4 diet? Good = 3 Fair = 2 Poor = 1TOTAL SCALE (6 pts) 13 0-6Note. From “Development of a tool to assess psychosocial indicators of fruit andvegetable intake for 2 federal programs,” by M. Townsend, 2005, Journal of NutritionEducational Behavior, (4) 37; 170-184. Copyright 2005 by Townsend and Kaiser.Reprinted with permission.Question ScoringI am not thinking about gardening to grow Affirmative = pre-contemplationvegetables for my householdI am thinking about gardening to grow vegetables Affirmative = contemplationfor my household, planning to start within sixmonthsI am definitely planning to garden to grow Affirmative = preparationvegetables for my household in the next monthI am trying to garden to grow vegetables for my Affirmative = actionhouseholdI am already gardening to grow vegetables for my Affirmative = maintenancehouseholdI am not thinking about gardening to grow fruit Affirmative = pre-contemplationfor my householdI am thinking about gardening to grow fruit for Affirmative = contemplationmy household, planning to start within six monthsI am definitely planning to garden to grow fruit Affirmative = preparationfor my household in the next month
  • 174. 174I am trying to garden to grow fruit for my Affirmative = actionhouseholdI am already gardening to grow fruit for my Affirmative = maintenancehousehold
  • 175. 175APPENDIX C: IRB APPROVAL
  • 176. 176 APPENDIX D: KIDS ON CAMPUS SURVEYTHIS SURVEY IS FOR THE MOTHER OR PRIMARY CARETAKER OF THECHILDREN IN KIDS ON CAMPUS.My name is:My child/children participating in Kids on Campus Grades 1 – 4 are:Child 1Child 2Child 3Child 4If you decide to complete this survey, this sheet will be detached. It is attached so thatwe can give you an identification number for the survey.Office Use Only – Subject Number:
  • 177. 177Kids on Campus Food and Nutrition SurveyCompletion and return of this survey is completely voluntary and implies yourconsent to use this information for research purposes. No one will be able toidentify you in any report resulting from this survey.This survey should be completed by the mother or primary female caretaker of thechild/children participating in Kids on Campus. The survey will take about 15 minutes tocomplete. The purpose of this survey is to ask about your food habits and yoursatisfaction with the food and gardening aspects of the Kids on Campus program thissummer. With this information, we are hoping to learn how to better serve you and otherfamilies in Kids on Campus. In no way will your answers affect your child’s/children’sparticipation in Kids on Campus. Please complete and return the survey with your Kidson Campus materials. Thank you very much for your time and assistance.*If you have questions about this survey please contact:David H. Holben, PhD, RD, LD/ Ashley ZurmehlySchool of Human and Consumer SciencesW324 Grover CenterAthens, Ohio 45701740-593-2875*If you have any questions regarding your rights as a research participant, pleasecontact:Ellen SherowDirector of Research ComplianceOhio University740-593-0664
  • 178. 178 Please write in or circle your answer to each.How old are you? ________What is your race? (circle all that apply)American Asian African- Hispanic Native WhiteIndian or American or Hawaiian orNative African OtherAlaskan American Pacific IslanderOther (Please specify.)What is your current marital status? (circle one answer) Single/NeverMarried Widowed Divorced Separated MarriedIf not married, do you have a live-in partner? Yes NoIncluding you, how many people live in your household?
  • 179. 179Including the incomes of the other members of your household, what is your pre-taxaverage monthly household income including child support (not including SNAP that youmay receive)?$______________________What is your highest level of education completed? (check one box only)Less than High SchoolHIGH SCHOOL GRADUATE – high school DIPLOMA or the equivalent (GED)Some College or Higher These questions are about your weight and height. How tall are you (inches)? How much do you weigh (pounds)? BMI (Do not complete this box - office use only) The rest of this survey deals with various aspects of your health. By health, we mean not only the absence of disease or injury but also physical, mental, and social well-being. (check one box)The following questions are about your health. Yes No
  • 180. 180Have you lost or gained 10 lbs. in the past 6 months without wanting to?Are you now drinking or have you ever drunk alcohol?Do you have vision problems that cannot be corrected by glasses?Do you consider yourself overweight?Have you ever been told that you are at risk for diabetes?Have you been told by your doctor that you have diabetes?When you cut yourself, does it take longer to heal?Are you aware of any family members with diabetes?Are you aware of any family members at risk for diabetes?Do you have a dark ring or darkened skin around your neck? The following are questions about your general well-being. In general my health is _____. (circle one answer) Excellent Very Good Good Fair Poor The following two questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (circle one answer for each) Moderate Yes, Limited A Lot Yes, Limited A No, Not Limited At activities Little All such as moving a table, pushing a vacuum cleaner, bowling, or playing golf:
  • 181. 181Climbing several Yes, Limited A Lot Yes, Limited A No, Not Limited Atflights of stairs: Little AllDuring the past 4 weeks have you had any of the following problems with your workor other regular activities as a result of your physical health?(circle one answer for each)Accomplished less than Yes Noyou would like:Were limited in the kind of Yes Nowork or other activities:During the past 4 weeks, were you limited in the kind of work you do or otherregular activities as a result of any emotional problems (such as feeling depressed oranxious)?(circle one answer for each)Accomplished less than Yes Noyou would like:Didn’t do work or other Yes Noactivities as carefully asusual:During the past 4 weeks, how much did pain interfere with your normal work(including both work outside the home and housework)?(circle one answer)Not At All A Little Bit Moderately Quite A Bit ExtremelyThe next three questions are about how you feel and how things have been during
  • 182. 182the past 4 weeks. For each question, please give the one answer that comes closest tothe way you have been feeling. How much of the time during the past 4 weeks:(circle one answer for each)Have you felt All of the Most of A Good Some of A Little None ofcalm and Time the Time Bit of the the Time of the the Timepeaceful? Time TimeDid you have All of the Most of A Good Some of A Little None ofa lot of Time the Time Bit of the the Time of the the Timeenergy? Time TimeHave you felt All of the Most of A Good Some of A Little None ofdownhearted Time the Time Bit of the the Time of the the Timeand blue? Time TimeDuring the past 4 weeks, how much has your physical health or emotional problemsinterfered with your social activities (like visiting friends, relatives, etc.)? (circle one answer)All of the time Most of the Some of the A little of the None of the time time time timeThe following questions are about the food situation for your household in thepast 12 months.During the past 12 months, the food that you (and others) bought just didn’t last and therewasn’t any money to get more. (circle one answer)Often True Sometimes True Never True
  • 183. 183During the past 12 months, you (and others) couldn’t afford to eat balanced meals.(circle one answer)Often True Sometimes True Never TrueThe following questions are about the food situation in the past 12 months for youor any other adults in your household.During the past 12 months, did you or other adults in your household ever cut the size ofyour meals or skip meals because there wasn’t enough money for food?(circle one answer)Yes. Almost every Yes. Some months Yes. Only one or two Nomonth. but not every month. months.During the past 12 months, did you Yes(personally) ever eat less than you felt youshould because there wasn’t enough money Noto buy food? (circle one answer)During the past 12 months, were you Yes(personally) ever hungry but didn’t eatbecause you couldn’t afford enough food? No (circle one answer)Please answer the following questions about you and your household. (Circle one answer in each row.)Do you have reliable transportation to get food? Yes No
  • 184. 184Do you or someone in your household hunt during the Yes Noyear for food?Do you or someone in your household fish during the Yes Noyear for food?Please answer the following questions about food program participation.(Circle one answer in each row.)In the past 12 months, did (you/anyone in your Yes Nohousehold) get SNAP benefits that is, either SNAP or aSNAP benefit card?During the past 12 months, did (your child/any Yes Nochildren in the household between 5 and 18 years old)receive free or reduced-cost lunches at school?During the past 12 months, did (your child/any Yes Nochildren in the household) receive free or reduced-costbreakfasts at school?During the past 12 months, did (your child/any Yes Nochildren in the household) receive free or reduced-costfood at a day-care or Head Start program?In the past 12 months, did (you/anyone in your Yes Nohousehold) receive benefits from the WIC program?In the past 12 months, did (you/anyone in yourhousehold) receive benefits from the WIC Farmers Yes NoMarket Nutrition Program?In the past 12 months, did (you/anyone in yourhousehold) receive benefits from the Senior Farmers Yes NoMarket Nutrition Program?
  • 185. 185In the last 12 months, did (you/you or other adults inyour household) ever get food from a church, a food Yes Nopantry, or food bank?Please answer the following about fruits and vegetables: (Circle one in each row.)I feel that I am helping my body by Agree Agree or Disagreeeating more fruits and vegetables. (Yes) Disagree (No) (Maybe)I may develop health problems if I do Agree Agree or Disagreenot eat fruit and vegetables. (Yes) Disagree (No) (Maybe)I feel that I can eat fruit or vegetables Agree Agree or Disagreeas snacks. (Yes) Disagree (No) (Maybe)I feel that I can buy more vegetables Agree Agree or Disagreethe next time I shop. (Yes) Disagree (No) (Maybe)I feel that I can plan meals or snack Agree Agree or Disagreewith more fruit during the next week. (Yes) Disagree (No) (Maybe)I feel that I can eat two or more Agree or Agreeservings of vegetables at dinner. Disagree Disagree (Yes) (Maybe) (No)I feel that I can plan meals with more Agree Agree or Disagreevegetables during the next week. (Yes) Disagree (No) (Maybe)
  • 186. 186I feel that I can add extra vegetables to Agree Agree or Disagreecasseroles and stews. (Yes) Disagree (No) (Maybe)In your household who is in charge of Shared I Am Other Personwhat foods to buy? DecisionIn your household who is in charge of Shared I Am Other Personhow to prepare the food? DecisionHow would you best describe your diet? (Circle one only.)Excellent Very Good Good Fair PoorChoose the one best statement that fits you. (Check one box only.)I am not thinking about eating more fruit.I am thinking about eating more fruit…planning to start within sixmonths.I am definitely planning to eat more fruit in the next month.I am trying to eat more fruit now.I am already eating 3 or more servings of fruit a day.Choose the one best statement that fits you. (Check one box only.)I am not thinking about eating more vegetables.
  • 187. 187I am thinking about eating more vegetables…planning to start withinsix months.I am definitely planning to eat more vegetables in the next month.I am trying to eat more vegetables now.I am already eating 3 or more servings of vegetables a day.Do you eat more than one kind of fruit daily? (Circle only one.)Never Sometimes Often AlwaysDo you eat more than 1 kind of vegetable in a day? (Circle only one.)Never Sometimes Often AlwaysDuring the past week, did you have citrus fruit (such as orange or grapefruit) orcitrus juice? (Circle one.)Yes NoHow many servings of vegetables do you eat each day? Number___________
  • 188. 188Do you eat 2 or more servings of vegetables at your main meal? (Circle one.)Sometimes Often Always NeverDo you eat fruit or vegetables as snacks? (Circle one.)Yes NoHow many servings of fruit do you eat each day? Number___________Choose the one best statement that fits you. (Check one box only.)I am not thinking about gardening to grow vegetables for myhousehold.I am thinking about gardening to grow vegetables for my household.…planning to start within six months.I am definitely planning to garden to grow vegetables for my householdin the next month.I am trying to garden to grow vegetables for my household. .I am already gardening to grow vegetables for my household.Choose the one best statement that fits you. (Check one box only.)
  • 189. 189I am not thinking about gardening to grow fruit for my household.I am thinking about gardening to grow fruit for my household.…planning to start within six months.I am definitely planning to garden to grow fruit for my household inthe next month.I am trying to garden to grow fruit for my household. .I am already gardening to grow fruit for my household.The following questions are about your child/children.How would you best describe your child’s diet? (Circle one only.)Child Excellent Very Good Good Fair Poor1Child Excellent Very Good Good Fair Poor2Child Excellent Very Good Good Fair Poor3Child Excellent Very Good Good Fair Poor4
  • 190. 190 How many servings of vegetables How many servings of fruit does does your child eat each day? your child eat each day?Child1Child2Child3Child4 Does your child eat Does your child eat Does your child eat 2 or more than one kind of more than 1 kind of more servings of fruit daily? vegetable in a day? vegetables at their main (Circle only one for each (Circle only one for each meal? (Circle only one child.) child.) for each child.) Never Never NeverChild Sometimes Sometimes Sometimes1 Often Often Often Always Always Always Never Never NeverChild Sometimes Sometimes Sometimes2 Often Often Often Always Always Always Never Never NeverChild Sometimes Sometimes Sometimes3 Often Often Often Always Always Always
  • 191. 191 Never Never NeverChild Sometimes Sometimes Sometimes4 Often Often Often Always Always AlwaysDuring the past week, did your child have citrus fruit (such as orange or grapefruit)or citrus juice? (Circle one for each child.)Child 1 Yes No Yes NoChild 2 Yes NoChild 3 Yes NoChild 4Does your child eat fruit or vegetables as snacks? (Circle one for each child.)Child 1 Yes No Yes NoChild 2 Yes NoChild 3 Yes NoChild 4 My child is interested My child is interested My child is interested in eating 3 or more in eating 3 or more in gardening servings of fruit each servings of vegetables vegetables. (Circle only day. (Circle only one for each day. (Circle only one for each child.)
  • 192. 192 each child.) one for each child.) Strongly Agree Strongly Agree Strongly AgreeChild Agree Agree Agree1 Disagree Disagree Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Agree Strongly Agree Strongly AgreeChild Agree Agree Agree2 Disagree Disagree Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Agree Strongly Agree Strongly AgreeChild Agree Agree Agree3 Disagree Disagree Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Agree Strongly Agree Strongly AgreeChild Agree Agree Agree4 Disagree Disagree Disagree Strongly Disagree Strongly Disagree Strongly Disagree
  • 193. 193 APPENDIX E: KIDS ON CAMPUS LESSON PLANS BIG TOP GARDEN 2008 WEEK 1: GARDENING IS GREATOhio Standards Connections:English Language Arts1) Acquisition of Vocabulary a) Know the meaning of specialized vocabulary by applying knowledge of word parts, relationship and meanings i) Classify words into categories(e.g., colors, fruits, vegetables)2) Reading Applications: Informational, Technical and Persuasive Text Standard a) Use visual aids as sources to gain additional information from text i) Identify information in diagrams, charts, graphs, and mapsMathematics1) Measurement Standard a) Develop common referents for units of measure for length, weight, volume and time to make comparisons and estimates i) Order a sequence of events with respect to time2) Patterns, Functions and Algebra Standard a) Sort, classify and order objects by size, number and other properties, and describe the attributes used i) Sort, classify and order objects by two or more attributes, such as color and shape and explain how objects were sortedScience1) Life Sciences Standard a) Discover that there are living things, non-living things and pretend things, and describe the basic needs of living things (organisms)Explore that organisms, including people, have basic needs which include air, water,food, living space and shelterLesson Summary:Students in grades 1-4 attending the Kids on Campus 2008Gardening Program: Big Top Garden, will participate inweekly sessions. During Week One:1) Children will participate in the multiple stages of planting different types of seeds.2) Students will be able to discuss the stages of plant growth and what the importance of each stage is.3) Students will have the opportunity to determine what fruits and vegetables they enjoy, what types they eat on a
  • 194. 194 regular basis, and what types they should try.Estimated Duration:Students will participate in the Kids on Campus 2008Gardening Program over a 6 week period, attending a weeklysession.The one hour weekly session is broken into 4 blocks of time:1) Introduction (5 minutes)2) Message (20 minutes)3) Pre-assignment (20 minutes)4) Activity (15 minutes)“Fit-tip” message of the week:Gardening can keep me fit while I grow food with my family!Pre-Assessment:Students engage in a discussion about the objectives of the program and how it alignswith the broader Kids on Campus Circus Fit theme. Students complete a checklist of thefoods they have eaten in the past week and identify those they prefer.Scoring Guidelines:The teacher uses the fruit and vegetable checklist completed by each student to identifyability to identify types of fruit and vegetable and vocabulary.Post-Assessment:The teacher uses the observational data and work samples of students to note their use ofvocabulary, sorting of seed into groups and sequencing the stages of plant growth.
  • 195. 195Instructional Procedures:Introduction (5 minutes)- • Introduce instructors and helpers as well as explain how the Big Top Garden fit in with the Kids on Campus Circus Fit theme.Message (20 minutes)- • Gardening is great! Handouts are given to children and read aloud by group after reading fit-tip message together. • Plant stages of growth are explained and the group discusses why each stage was important for the plant.Folder assignment (20 minutes)- • Each child is given a folder with their group name on top that they are to write their name on and keep handouts in for the duration of the program. • In the folder for this week are the fruit and vegetable check lists children fill out by marking a check in the box if they’ve eaten the food in the past week and circling the food if they like it.Activity: Planting of seeds (15 minutes)- • Children are divided up into 5 groups: o 2 soil groups o 2 seed groups o 1 watering group • The soil groups are in charge of filling the two containers (one EarthBox and one small container) full of soil. • The seed groups are randomly given one of three seed types: radish, lettuce mix, or an herb which they are instructed to place in the soil. • The water group then waters the top of the soil that has just been planted. • All groups then return inside to wash their hands and gather their bags to move to the next KOC activity making sure to take their Gardening is great handouts home with them.Differentiated Instructional SupportMaterial will be presented in written and visual forms to accommodate emergent readers.Instructions will be given verbally and in pictorial form to accommodate variations inlearning styles, strengths, and ability levels. Equipment and concrete materials will bemade accessible to all students to facilitate autonomy and promote success for each child.ExtensionStudents are encouraged to communicate their experiences with family and engage thefamily unit in continuation of the project beyond the scope of the Kids on CampusProgram. Materials are provided to promote communication with family in a reciprocalmanner, with the student incorporating their knowledge of food and nutrition in theirpersonal and classroom experience.
  • 196. 196Homework Options and Home ConnectionsStudents are provided materials and products introduced in the Big Top Garden programwith the objective they will be incorporated into the student’s diet and food choiceknowledge.Interdisciplinary Connections The content of the weekly session promote scientific understanding in makingconnections between the life sciences, collecting observational data, conducting simpleexperiments, and gaining knowledge of health and nutrition. Integrated within this studyis opportunity for students to write, discuss, classify, measure, compare, contrast,collaborate, cooperate, and problem solve.Materials and Resources:For teachers • copies of all handout materials • seeds • soil • watering can • Earthbox and additional containers • collection bags • checklists of vegetables • folders • pencils • visuals for plant growth stages • visual for planting seed processKey Vocabulary • fruit • vegetable • radish • lettuce • herb • soil • plant • seed • seedling
  • 197. 197
  • 198. 198 WEEK 2: GARDENING IS COLORFULOhio Standards Connections:English Language Arts3) Acquisition of Vocabulary a) Know the meaning of specialized vocabulary by applying knowledge of word parts, relationship and meanings i) Classify words into categories(e.g., colors, fruits, vegetables)4) Reading Applications: Informational, Technical and Persuasive Text Standard a) Use visual aids as sources to gain additional information from text i) Identify information in diagrams, charts, graphs, and mapsMathematics3) Measurement Standard a) Develop common referents for units of measure for length, weight, volume and time to make comparisons and estimates i) Order a sequence of events with respect to time4) Patterns, Functions and Algebra Standard a) Sort, classify and order objects by size, number and other properties, and describe the attributes used i) Recognize and explain how objects can be classified in more than one way ii) Identify what attribute was used to sort groups of objects that have already been sortedScience2) Life Sciences Standard a) Discover that there are living things, non-living things and pretend things, and describe the basic needs of living things (organisms) i) Explore that organisms, including people, have basic needs which include air, water, food, living space and shelter b) Explain how organisms function and interact with their physical environments i) Compare Ohio plants by describing changes in their appearance over timeSocial Studies1) Social Studies Skills and Methods Standard a) Obtain information from oral, visual, print and electronic sources i) Obtain information about a topic using a variety of oral and visual sources
  • 199. 199Lesson Summary:Students in grades 1-4 attending the Kids on Campus 2008Gardening Program: Big Top Garden, participate in weeklysessions. During Week Two:1) Children will observe the stages of plant growth through thegarden.2) Children will study the Food Guide Pyramid, throughdiscussion, handouts, and an activity, focusing on: a) how it is made up into groups b) what those groups mean c) how they can use it to eat healthyEstimated Duration:Students will participate in the Kids on Campus 2008 GardeningProgram over a 6 week period, attending a weekly session.The one hour weekly session is broken into 3 blocks of time: 1) Gardening Observation (15 minutes) 2) Message (20 minutes) 3) Activity (25 minutes)“Fit-tip” message of the week:MyPyramid can help me choose a variety of foods for healthy living!Pre-Assessment:Students will engage in a discussion about the structure of the food pyramid and itscontents, the focus being on identification of the groups and their content. The teacherwill collect observational data to assess children’s understanding of the manner in whichgroups are formed, similarities and differences within each group.Scoring Guidelines: Students’ ability to identify common feature of foods in various categories will serve asan assessment tool for directing the discussion and exploration.
  • 200. 200Post-Assessment:The teacher uses the observational data and work samples of students to note their use ofvocabulary, ability to place various foods into proper groups on food pyramid andidentifying changes in their plants’ growth.Instructional Procedures: Gardening observation (15 minutes)- • Children are able to go out to the pool deck and observe the changes in their garden through drawings.Message (20 minutes)- • Gardening is colorful! Handouts are distributed through their folders and the fit-tip is read aloud as a group. • A brief explanation of the food pyramid is given including its purpose and examples of each food groups’ contents and their role in keeping us healthy. • Children are then shown a poster of the food guide pyramid to explain how different groups have different portion sizes recommended and the group discusses what groups the foods we are growing would be in.Activity: Food Pyramid Challenge (25 minutes)- • Different color papers are handed out to the children in colors representing the pyramid colors in order to represent what group the child will be in: o Orange= grains (6 children) o Green= vegetables (5 children) o Red= fruits (4 children) o Blue= milk (3 children) o Purple= meat/beans (2 children) o Yellow= oils (1 child) • The number of children in each group is meant to represent the average number of servings they should have from each group per day so they can see the difference between the groups visually. • When the children have assembled outside in their groups food models will be presented one at a time and the groups have to decide what food group it belongs to. Once it has been correctly identified the group gets to collect their food. Try to have a variety of foods represented so that every child can hold a model.
  • 201. 201 • After all the models have been distributed the children should return them to the instructor and collect their Gardening is colorful and other handouts to take home.Differentiated Instructional SupportMaterial will be presented in written and visual forms to accommodate emergent readers.Instructions will be given verbally and in pictorial form to accommodate variations inlearning styles, strengths, and ability levels. Equipment and concrete materials will bemade accessible to all students to facilitate autonomy and promote success for each child.ExtensionStudents are encouraged to communicate their experiences with family and engage thefamily unit in continuation of the project beyond the scope of the Kids on CampusProgram. Materials are provided to promote communication with family in a reciprocalmanner, with the student incorporating their knowledge of food and nutrition in theirpersonal and classroom experience.Homework Options and Home ConnectionsStudents are provided materials and products introduced in the Big Top Garden programwith the objective they will be incorporated into the student’s diet and food choiceknowledge.Interdisciplinary ConnectionsThe content of the weekly session promote scientific understanding in makingconnections between the life sciences, collecting observational data, conducting simpleexperiments, and gaining knowledge of health and nutrition. Integrated within this studyis opportunity for students to write, discuss, classify, measure, compare, contrast,collaborate, cooperate, and problem solve.Materials and Resources:For teachers • copies of all handout materials • folders • pencils • paper for observational sketches • clipboards for sketching plant growth • visual for food pyramid • food props for sorting into groups • color paper for activity (6 sheets orange, 5 sheets green, 4 sheets red, 3 sheets blue, 2 sheets purple, one sheet yellow) • food pyramid model
  • 202. 202Key Vocabulary • fruit • vegetable • grains • milk • dairy • meat • beans • oil • servings • pyramid • food group • portion size
  • 203. 203
  • 204. 204 WEEK 3: FRUIT + VEGETABLES = FIBEROhio Standards Connections:English Language Arts5) Acquisition of Vocabulary a) Use resources to determine the meanings and pronunciations of unknown words i) Determine the meaning of unknown words using a beginner’s dictionary6) Reading Process: Contents of Print, Comprehension Strategies and Self-Monitoring Strategies Standard a) Apply reading skills and strategies to summarize and compare and contrast information in text, between text and across subject areas i) Compare and contrast information in texts with prior knowledge and experienceMathematics1) Patterns, Functions and Algebra Standard b) Describe and compare qualitative and quantitative change i) Describe qualitative and quantitative changes, especially those involving addition and subtraction; e.g., a student growing taller versus a student growing two inches in one year5) Geometry and Spatial Sense Standard a) Describe location, using comparative, directional, and positional words i) Name and demonstrate the relative position of objects, extending the use of location words to include distance (near, far, close to) and directional words (left, right)Science3) Life Sciences Standard a) Discover that there are living things, non-living things and pretend things, and describe the basic needs of living things (organisms) i) Explore that organisms, including people, have basic needs which include air, water, food, living space and shelter b) Explain how organisms function and interact with their physical environments i) Explain that food comes from sources other than grocery stores ii) Investigate the different structures of plants and animals that help them live in different environments (e.g., lungs, gills, leaves and roots) c) Describe similarities and differences that exist among individuals of the same kind of plants and animals i) Compare similarities and differences among individuals of the same kind of plants and animals, including peopleSocial Studies2) Social Studies Skills and Methods Standard a) Obtain information from oral, visual, print and electronic sources i) Obtain information about a topic using a variety of oral and visual sources
  • 205. 205Lesson Summary:Students in grades 1-4 attending the Kids on Campus 2008Gardening Program: Big Top Garden, will participate in weeklysessions. During Week Three: 1) Introduce the concept of fiber to the children and give a brief explanation of why it is important to have in the diet as well as food sources. 2) Through the use of handouts children will learn the parts of the plant and how each produces an edible part that can provide fiber to our diet. 3) Provide children with sprouts to take home in order to introduce a possible new source of fiber to their diet.Estimated Duration:Students participate in the Kids on Campus 2008 GardeningProgram over a 6 week period, attending a weekly session.The one hour weekly session is broken into 3 blocks of time: 1) Garden Observation (15 minutes) 2) Message (20 minutes) 3) Activity (25 minutes)“Fit-tip” message of the week:Getting fiber from eating fruits and vegetables keeps me healthy!Pre-Assessment:Students will engage in a discussion about fiber and its purpose and role in humans’ diets,the focus being on identification of why the substance is important and how to include itin our diet. The teacher will collect observational data to assess children’s understandingof the discussion of the term. Discussion about students’ sketches of the growing plantsin their Big Top Garden will serve as baseline information of students understanding ofthe parts of the plant.Scoring Guidelines:
  • 206. 206Students’ ability to identify part of the plant and use of the terminology from the foodpyramid will serve as an assessment tool for directing the discussion and exploration.Post-Assessment:The teacher uses the observational data and work samples of students to note their use ofvocabulary, ability to identify changes in their plants’ growth, parts of the plants, andsources of fiber to include in their diet.Instructional Procedures:Garden observation (15 minutes)- • Children are able to go out to the pool deck and observe the changes in their garden through drawings.Message (20 minutes)- • Distribute Fruit + Vegetables = Fiber handout as well as additional EarthBox handouts through folders. • Fit-tip message is read aloud as is F+V=F handout by children. Benefits and purpose of fiber is explained and then children are asked to provide some suggestions of foods we could eat to get our fiber. • Tied in with fiber, another handout that is provided discusses the parts of the plant and how each produce an edible result: o Roots= carrots, potatoes, radishes o Stem= celery o Leaves= lettuce o Flower= cauliflower, broccoli o Seed= corn, peas • Message is then finished with handout children complete by drawing different fruits or vegetables and then labeling the part of the plant they come from.Activity: Growing Sprouts (25 minutes)- • Each child is given a glass jelly jar and removes the lid. • The instructor then gives each child a tablespoon or two of mung bean sprout seeds in their jars. • The children then go fill the jars to about an inch above the seeds and replace the lid. • After checking to make sure all lids are on securely, the group then takes the jars and shakes them to “help them grow”.
  • 207. 207 • The children then take jars home and are instructed to place them in a dark area rinsing the seeds daily until they grow and then can be eaten. • Further instructions are provided on the F+V=F handout for the family. • Children then take their jar and handouts home.Differentiated Instructional SupportMaterial will be presented in written and visual forms to accommodate emergent readers.Instructions will be given verbally and in pictorial form to accommodate variations inlearning styles, strengths, and ability levels. Equipment and concrete materials will bemade accessible to all students to facilitate autonomy and promote success for each child.ExtensionStudents are encouraged to communicate their experiences with family and engage thefamily unit in continuation of the project beyond the scope of the Kids on CampusProgram. Materials are provided to promote communication with family in a reciprocalmanner, with the student incorporating their knowledge of food and nutrition in theirpersonal and classroom experience.Homework Options and Home ConnectionsStudents are provided materials and products introduced in the Big Top Garden programwith the objective they will be incorporated into the student’s diet and food choiceknowledge.Interdisciplinary ConnectionsThe content of the weekly session promote scientific understanding in makingconnections between the life sciences, collecting observational data, conducting simpleexperiments, and gaining knowledge of health and nutrition. Integrated within this studyis opportunity for students to write, discuss, classify, measure, compare, contrast,collaborate, cooperate, and problem solve.Materials and Resources:For teachers • copies of all handout materials (Fruit + Vegetable = Fiber, and EarthBox) • folders • pencils • paper for observational sketches • clipboards for sketching plant growth • visuals for parts of plants • beginner’s dictionary • glass jelly jar for each child • mung bean sprout seeds • soil • jar lids
  • 208. 208Key Vocabulary • fiber • fruit • vegetable • beans • roots • carrots • potatoes • radishes • stem • celery • leaves • lettuce • flower • cauliflower • broccoli • seed • corn • peas • sprout
  • 209. 209
  • 210. 210 WEEK 4: TEAMWORKOhio Standards Connections:English Language Arts7) Research Standard a) Retell important details and findings i) Recall information about a topic with teacher assistance8) Communication: Oral and Visual Standard a) Use active listening strategies to identify the main idea and to gain information from oral presentation i) Identify the main idea of oral presentations and visual media ii) Use active listening strategies, such as making eye contact and asking for clarification and explanation b) Follow multi-step directions i) Follow two- and three-step oral directionsMathematics6) Geometry and Spatial Sense Standard a) Describe location, using comparative, directional, and positional words i) Name and demonstrate the relative position of objects, extending the use of location words to include distance (near, far, close to) and directional words (left, right)Science4) Life Sciences Standard a) Discover that there are living things, non-living things and pretend things, and describe the basic needs of living things (organisms) i) Explore that organisms, including people, have basic needs which include air, water, food, living space and shelterSocial Studies1) Geography Standard a) Identify the location of Ohio, the United States, the continents and oceans on maps, globes, and other geographic representations i) Identify and correctly use terms related to location, direction and distance including: left/right; near/far3) Social Studies Skills and Methods Standard a) Obtain information from oral, visual, print and electronic sources i) Obtain information about a topic using a variety of oral and visual sources4) Citizenship Rights and Responsibilities Standard a) Describe the results of cooperation in group settings and demonstrate the necessary skills i) Demonstrate skills and explain the benefits of cooperation when working in a group setting
  • 211. 211Lesson Summary:Students in grades 1-4 attending the Kids on Campus 2008Gardening Program: Big Top Garden, will participate in weeklysessions. During Week Four: a. Children will learn the basic concepts of vitamins and minerals and how they help the body to stay healthy. b. They will also be able to identify multiple examples of foods high in Vitamin C and/or iron. c. The concept of Vitamin C and iron working together in the body will also be explained through the use of an activity.Estimated Duration:Students participate in the Kids on Campus 2008 GardeningProgram over a 6 week period, attending a weekly session.The one hour weekly session is broken into 3 blocks of time: 1) Garden Observation (15 minutes) 2) Message (20 minutes) 3) Activity (25 minutes)“Fit-tip” message of the week:Vitamins and minerals in food work together to keep me healthy!Pre-Assessment:Students will be engaged in a discussion of working together, sharing personalexperience related to the concept. The teacher will use the prompt of asking for studentsto name famous teammates that worked in pairs; e.g., Batman and Robin, Bert and Ernie,etc. Incidence of helping behaviors will be noted by the teacher to focus students’attention of the concept of team work and its benefits.Scoring Guidelines:
  • 212. 212 Using guided writing experience, the teacher will record children’s stories emphasizingterms used that align with concept of team work.Post-Assessment:The teacher uses the observational data and work samples of students to note their use ofvocabulary, ability to successfully navigate the maze with a partner, and use directionalwords, terminology, and nutritional terms.Instructional Procedures:Garden observation (15 minutes)- • Children are able to go out to the pool deck and observe the changes in their garden through drawings.Message (15 minutes)- • Children’s folders are distributed with handouts for the week and the “fit- tip” message is read aloud by the group. • Instructor gives brief explanation on the purpose of vitamins and minerals and examples of what foods Vitamin C and iron are specifically found in. • Vitamin C and iron are then explained further and their purpose and function in the body are discussed with the group in order to emphasize their importance to our health. • The teamwork aspect of Vitamin C and iron is then explained in the sense that Vitamin C and iron can both help the body in their own way but when used together they work much better and faster. This concept will come in to play during the activity.Activity (30 minutes)- • Children are taken outside and paired up by their choosing. One child decides to be Vitamin C while the other is iron. • The child playing Vitamin C must close their eyes and/or cover them while the child playing iron leads them through a maze. This reinforces the concept that on its own, Vitamin C could make it through on its own but it will be a lot faster and more efficient if iron helps. • Once through the maze the children switch roles and go again so each can experience both sides. The children may go through as many times as they like as long as they do not harm each other. • After the completion of the activity the children collect their handouts from this week and take them home.
  • 213. 213Differentiated Instructional SupportMaterial will be presented in written and visual forms to accommodate emergent readers.Instructions will be given verbally and in pictorial form to accommodate variations inlearning styles, strengths, and ability levels. Equipment and concrete materials will bemade accessible to all students to facilitate autonomy and promote success for each child.ExtensionStudents are encouraged to communicate their experiences with family and engage thefamily unit in continuation of the project beyond the scope of the Kids on CampusProgram. Materials are provided to promote communication with family in a reciprocalmanner, with the student incorporating their knowledge of food and nutrition in theirpersonal and classroom experience.Homework Options and Home ConnectionsStudents are provided materials and products introduced in the Big Top Garden programwith the objective they will be incorporated into the student’s diet and food choiceknowledge.Interdisciplinary ConnectionsThe content of the weekly session promote scientific understanding in makingconnections between the life sciences, collecting observational data, conducting simpleexperiments, and gaining knowledge of health and nutrition. Integrated within this studyis opportunity for students to write, discuss, classify, measure, compare, contrast,collaborate, cooperate, and problem solve.Materials and Resources:For teachers • copies of all handout materials • folders • pencils • paper for observational sketches • clipboards for sketching plant growth • easel paper to record dictation of students’ discussion of teamwork • marker • chairs and desks to create maze • scarf for blindfoldKey Vocabulary • Vitamin • Vitamin C • iron • team work
  • 214. 214
  • 215. 215 WEEK 5: DYNAMIC DUOOhio Standards Connections:English Language Arts9) Communication: Oral and Visual Standard a) Follow multi-step directions i) Follow two- and three-step oral directions10) Phonemic Awareness, Work Recognition and Fluency Standard a) Demonstrate fluent oral reading using sight words and decoding skills, varying intonation and timing as appropriate for text i) Demonstrate growing stock of sight words11) Acquisition of Vocabulary Standard a) Use context clues to determine the meaning of new vocabulary i) Use knowledge of word order and in-sentence context clues to support word identification and to define unknown words while reading Science5) Life Sciences Standard a) Describe similarities and differences that exist among individuals of the same kind of plant and animals i) Compare similarities and differences among individuals of the same kind of plants and animals, including people6) Scientific Inquiry Standard a) Ask a testable question i) Ask “what happens when” questions Social Studies2) Geography Standard a) Identify the location of Ohio, the United States, the continents and oceans on maps, globes, and other geographic representations i) Identify and correctly use terms related to location, direction and distance including: left/right; near/far5) Social Studies Skills and Methods Standard a) Obtain information from oral, visual, print and electronic sources i) Obtain information about a topic using a variety of oral and visual sources
  • 216. 216Lesson Summary:Students in grades 1-4 attending the Kids on Campus 2008Gardening Program: Big Top Garden, will participate in weeklysessions. During Week Five: a. Children will build on their knowledge of vitamins and minerals from last week by learning more in depth on two others- Vitamin A and calcium. b. Vitamin A and calcium’s purpose, food sources, and function in the body will all be discussed. c. Handouts will be provided in order to emphasize the different areas affected by various vitamins and minerals.Estimated Duration:Students participate in the Kids on Campus 2008 GardeningProgram over a 6 week period, attending a weekly session.The one hour weekly session is broken into 3 blocks of time: 1) Garden Observation (15 minutes) 2) Message (20 minutes) 3) Activity (25 minutes)“Fit-tip” message of the week:Vitamin A and calcium are key nutrients for health!Pre-Assessment:Students will be engaged in a review of the previous week’s discussion of workingtogether, sharing personal experience related to the concept. The teacher will use theprompt of asking for students to name famous teammates that worked in pairs; e.g.,Batman and Robin, Bert and Ernie, etc. Incidence of helping behaviors will be noted bythe teacher to focus students’ attention of the concept of team work and its benefits.Scoring Guidelines:
  • 217. 217 Using guided writing experience, the teacher will record children’s stories emphasizingterms used that align with concept of team work.Post-Assessment:The teacher uses the observational data and work samples of students to note their use ofvocabulary, ability to successfully navigate the maze with a partner, and use directionalwords, terminology, and nutritional terms.Instructional Procedures:Garden observation (15 minutes)- • Children are able to go out to the pool deck and observe the changes in their garden through drawings.Message (20 minutes)- • Once folders are distributed with handouts for that week, children read fit tip aloud as a group. • Instructor then provides brief explanation of Vitamin A and calcium including their benefits, food sources, and what roles they play in the body. • A vegetable pizza recipe provided on the handout is then used as an example of how to get both Vitamin A and calcium in the same meal.Activity (25 minutes)- • Children are provided with two handouts in their folders: o Map of the body indicating where each vitamin and mineral plays a role o Fruit and vegetable alphabet list • The group discusses the body handout while the children draw their own bodies around the skeleton provided on the handout. This allows for the children to relate to how each would help them. • The next handout begins once children are finished drawing on the first. • Five to ten minutes are given for the children to start on the fruit and vegetable alphabet on their own by trying to fill in letters A-E on their own. • After they seem stumped, food models are brought out to attempt to jog their memories and give them visual cues. This can also be tied in with week 4 and 5’s lessons by quizzing the children on what vitamins and minerals each of the foods have.
  • 218. 218 • After the handouts are complete the children may take them home to share with their families.Differentiated Instructional SupportMaterial will be presented in written and visual forms to accommodate emergent readers.Instructions will be given verbally and in pictorial form to accommodate variations inlearning styles, strengths, and ability levels. Equipment and concrete materials will bemade accessible to all students to facilitate autonomy and promote success for each child.ExtensionStudents are encouraged to communicate their experiences with family and engage thefamily unit in continuation of the project beyond the scope of the Kids on CampusProgram. Materials are provided to promote communication with family in a reciprocalmanner, with the student incorporating their knowledge of food and nutrition in theirpersonal and classroom experience.Homework Options and Home ConnectionsStudents are provided materials and products introduced in the Big Top Garden programwith the objective they will be incorporated into the student’s diet and food choiceknowledge.Interdisciplinary ConnectionsThe content of the weekly session promote scientific understanding in makingconnections between the life sciences, collecting observational data, conducting simpleexperiments, and gaining knowledge of health and nutrition. Integrated within this studyis opportunity for students to write, discuss, classify, measure, compare, contrast,collaborate, cooperate, and problem solve.Materials and Resources:For teachers • copies of all handout materials • folders • pencils • paper for observational sketches • clipboards for sketching plant growth • easel paper to record dictation of students’ discussion of teamwork • marker • map of body handout and visual • fruit and vegetable alphabet list • food models • recipe visual for vegetable pizza
  • 219. 219Key Vocabulary • Vitamin • Vitamin A • calcium • skeleton • body • mineral • vegetable pizza • recipe
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  • 221. 221 WEEK 6: SCRAPS TO SOILOhio Standards Connections:English Language Arts12) Communication: Oral and Visual Standard a) Follow multi-step directions i) Follow two- and three-step oral directions13) Phonemic Awareness, Work Recognition and Fluency Standard a) Demonstrate fluent oral reading using sight words and decoding skills, varying intonation and timing as appropriate for text i) Demonstrate growing stock of sight words14) Acquisition of Vocabulary Standard a) Use context clues to determine the meaning of new vocabulary i) Use knowledge of word order and in-sentence context clues to support word identification and to define unknown words while readingMath1) Number, Number Sense and Operations Standard a) Recognize, classify, compare and order whole numbers i) Recognize and generate equivalent forms for the same number using physical models Science1) Earth and Space Science Standard a) Explain that living things cause changes on Earth i) Explain that all organisms cause changes in the environment where they live; the changes can be very noticeable or slightly noticeable, fast or slow b) Describe what resources are and recognize some are limited but can be extended through recycling or decreased use i) Identify that resources are things that we get from the living and nonliving environment and that resources are necessary to meet the needs and wants of a population ii) Explain that the supply of many resources is limited but the supply can be extended through careful use, decreased use, reusing and/or recyclingSocial Studies6) Social Studies Skills and Methods Standard a) Obtain information from oral, visual, print and electronic sources i) Obtain information about a topic using a variety of oral and visual sources
  • 222. 222Lesson Summary:Students in grades 1-4 attending the Kids on Campus 2008Gardening Program: Big Top Garden, will participate in weeklysessions. During Week Six: a. All previous lesson objectives should still be able to be discussed by the group. b. The benefits of composting and gardening will be explained and able to take home to the families. c. The results of the garden will be observed by the children and provide a visual to the stages of the plant discussed in the first lesson.Estimated Duration:Students participate in the Kids on Campus 2008 GardeningProgram over a 6 week period, attending a weekly session.The one hour weekly session is broken into 3 blocks of time: 1) Garden Observation (15 minutes) 2) Message (30 minutes) 3) Activity (15 minutes)“Fit-tip” message of the week:Making compost reduces waste and helps the garden!Pre-Assessment:Students will be engaged in a review of the previous week’s discussions with completionof a K-W-L chart at the beginning of the session.Scoring Guidelines: The teacher will note the students’ recall and connections of previous knowledge.Post-Assessment:
  • 223. 223The teacher uses the observational data and work samples of students to note their use ofvocabulary, terminology, and nutritional terms.Instructional Procedures: Garden observation (15 minutes)- • Children are able to go out to the pool deck and observe the changes in their garden through drawings.Message (30 minutes)- • Once again the children will fill out fruit and vegetable check lists by marking a check in the box if they’ve eaten the food in the past week and circling the food if they like it. These will be used to compare to their first check lists for differences. • After the completion of the checklists the group will read the “fit-tip” aloud together. • Instructor will give a brief explanation of the benefits of composting, what it is, as well as what is put in a compost pile and what is left out.Activity (15 minutes)- • After the discussion with the group covering what goes in a compost pile and what does not each child receives an item and gets in a line. Items include: o Food models o Paper o “grass” o News paper o Plastic bottles o Plastic toys o Glass bottles o Duct tape o Shoes o Plants o Dirt • Once in line the instructor stands in front with a bin (compost box) and asks each child if their item goes in the bin or not and why. The group can help if the child is not sure about their item. • After the compost pile has been made the group discusses its benefits to the garden and how they could do the activity at home.
  • 224. 224 • At the end of the session the children take all remaining handouts home to share with their families while the instructor keeps the folders with their drawings and checklists from each week.Differentiated Instructional SupportMaterial will be presented in written and visual forms to accommodate emergent readers.Instructions will be given verbally and in pictorial form to accommodate variations inlearning styles, strengths, and ability levels. Equipment and concrete materials will bemade accessible to all students to facilitate autonomy and promote success for each child.ExtensionStudents are encouraged to communicate their experiences with family and engage thefamily unit in continuation of the project beyond the scope of the Kids on CampusProgram. Materials are provided to promote communication with family in a reciprocalmanner, with the student incorporating their knowledge of food and nutrition in theirpersonal and classroom experience.Homework Options and Home ConnectionsStudents are provided materials and products introduced in the Big Top Garden programwith the objective they will be incorporated into the student’s diet and food choiceknowledge.Interdisciplinary ConnectionsThe content of the weekly session promote scientific understanding in makingconnections between the life sciences, collecting observational data, conducting simpleexperiments, and gaining knowledge of health and nutrition. Integrated within this studyis opportunity for students to write, discuss, classify, measure, compare, contrast,collaborate, cooperate, and problem solve.Materials and • copies of all handout materialsResources: • foldersFor teachers • pencils • paper for observational sketches • clipboards for sketching plant growth • easel paper to record K-W-L • marker • Food models • Paper • “grass” • News paper • Plastic bottles • Plastic toys • Glass bottles • Duct tape • Shoes • Plants
  • 225. 225 • DirtKey Vocabulary• composting• compost pile• waste• recycle• reduce• reuse• Food models• Paper• “grass”• News paper• Plastic bottles• Plastic toys• Glass bottles• Duct tape• Shoes• Plants• Dirt
  • 226. 226 KIDS ON CAMPUS SCRAPS TO SOIL Indoor Composting with WORMS! Put moist shredded brown leaves and papers into a bin with several holes in the side. Add one cup of dirt to the paper mixture and place red worms on top. Composting is when you turn old food scraps, dead plants, and paper into yummy Bury green stuff (old food) soil for your garden! under the paper.Compost helps: Within six weeks theMake soil better for growing worms will help make greatPrevent pollution and landfillsSave money soil for other plants toMake a compost bin grow.in your own backyard!Have your family help you make a bin (3ft high and square) out ofwood scraps, plastic, or metal fencing.Make sure there are holes to allow air to go in and out.Mix green stuff (food scraps and grass) brown stuff (dead plants)and water.Soil will form at the bottom of the bin for your garden.
  • 227. 227APPENDIX F: CHILD FRUIT AND VEGETABLE SURVEYS
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