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Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of                 School Age Children Li...
2                                 This thesis titledUse of a Gardening and Nutrition Education Program to Improve the Prod...
3                                       ABSTRACTZURMEHLY, ASHLEY B., M.S., August 2009, Food and NutritionUse of a Gardeni...
4variety was not related to their gardening habits. However, household food security wasnot related to gardening habits or...
5                               ACKNOWLEDGMENTS       Thank you to my advisor Dr. David Holben, and other faculty members,...
6                                                TABLE OF CONTENTS                                                        ...
7       Food insecurity and overall health among adults. ................................................ 41        Food i...
8          Cancer and chronic disease. .................................................................................. ...
9           Food security and children’s diet. ....................................................................... 125...
10                                                       LIST OF TABLES                                                   ...
11Table 16: Female Caregiver and Household Characteristics Stratified by Food SecurityStatus ................................
12                                             LIST OF FIGURES                                                            ...
13                             CHAPTER 1: INTRODUCTION                                 Overview and Background       Appal...
14Capps, Horowitz, & McNamara, 2007; Casey et al., 2005; Cook et al., 2004; Cook et al.,2008; Hamelin, Habicht, & Beaudry,...
15disease, and lower overall wellness (Ahn et al., 2005; Cartmel, Bowen, Ross, Johnson, &Mayne, 2005; Dixon et al., 2001; ...
16relatively inexpensive way to grow fresh produce (Holben et al., 2004; McAleese &Rankin, 2007; Nanney, Johnson et al., 2...
17                                 Statement of the Problem       Produce intake is inadequate among children, which negat...
18Kendall et al., 1996; Kropf et al., 2007). Therefore, through the practice of gardening, afamily may be able to grow fru...
19Table 1Research Questions and Hypotheses   Research Questions                         Hypotheses   1. Does a six-week nu...
20   9. Do body mass index (BMI),                  Body mass index (BMI) will be greater      vegetable intake, and fruit ...
21(university-based summer camp), where this program was initially piloted. Finally, thedietetics and nutrition profession...
22the study region during the study period, and the availability of produce from farmers fordistribution during the study....
23                       CHAPTER 2: REVIEW OF LITERATURE       In the United States, food insecurity can lead to an increa...
24characteristics of children and their adult female caregivers. In this literature review,findings related to food securi...
25(FRAC) defined hunger as the physiological and psychological state that comes from nothaving enough food, while Harvard ...
26(Carlson, Andrews, & Bickel, 1999; Olson, 1999). After developing the definitions offood security, the team focused on t...
27Table 218-item Food Security Survey Module, 2008Item Number          QuestionQ1                   “We worried whether ou...
28Q11                    “We relied on only a few kinds of low-cost food to feed our                       children becaus...
29affected, is when the household reported to being hungry at some point due to lack ofmoney for food (Nord et al., 2008)....
30       Over the years, the 18-item survey has been adjusted to fit multiple situations,populations, and households. A sh...
31Table 4Six-item Food Security Questionnaire, 2008Item Number         QuestionThe first four questions are in relation to...
32item Food Security Survey Module, which asks households about their behaviors andconditions over the past 12 months (U.S...
33                    Low Food Secure                      Households                                              Very Lo...
34there was not enough money for food (Nord et al., 2008). When food insecurity didoccur, about one-fourth of those househ...
35                                     100%                                       98%                                     ...
36food stamps, or vouchers from WIC (Alaimo, Briefel, Frongillo, & Olson, 1998). A littleover 2% of these families had chi...
37of these groups having the most occurrence of very low food security (Nord et al., 2008).Below are facts from the litera...
38found that energy security was strongly and positively associated with both householdand child food insecurity (Cook et ...
39implications also occur in food-insecure households including hunger, depletion, illness,stress, modification of eating ...
40that obesity was lowest for fully food-secure women, while those who were food-insecure had the most weight gain over ti...
41to 2 years postpartum, whereas only 5.1% changed category for obesity (Olson &Strawderman, 2008). This infers that obesi...
42health status falls (Bronte-Tinkew et al., 2007). The elderly are a group whose health isheavily affected by food insecu...
43decrease their intake in order to allow other members of the family to eat (Kendall et al.,1996; Olson, 2005). Low-incom...
44which typically include reducing their own intake to avoid or delay such insufficiency inchildren (Olson, 2005; Radimer ...
45fruits and vegetables per day, compared to 54.6% of food-secure participants (Kendall etal., 1996). The rural population...
46                                                    60.0%                                                    50.0%      ...
47over the two year period (Condrasky & Marsh, 2005). This appears to indicate that, thecyclical nature of SNAP may lead t...
48received free food over the past year from mostly food banks and relatives, and 75% ofthe women were food-insecure (McIn...
49children were food-insecure, with 15% of those children having a BMI in the overweightor at risk for overweight categori...
50be overweight and were less educated (Casey et al., 2001). However, not all studies offood-insecure children have found ...
51Pennsylvania (Crooks, 1999; Haas et al., 2003; Rappaport & Robbins, 2005). Health ofthe child is also been found to be n...
52mothers also reported the family as having moderate hunger (Weinreb et al., 2002). Thechildren who showed more hunger si...
53linked to negative academic and psychosocial development in children (Alaimo et al.,2001a). An in-depth qualitative stud...
54Initiatives (CFI) and community gardens, share the same goals; however, their focus is ona smaller population within a p...
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children
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Transcript of "Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children"

  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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