1. Running Head: SCHOOL-BASED NUTRITION INTERVENTION PROGRAMS
School-Based Nutrition Intervention Programs: Does Knowledge Change Behavior?
Jordyn Wheeler
California State University, San Bernardino
Author Note
Jordyn C. Wheeler, California State University San Bernardino.
Correspondence regarding this paper should be addressed to: Jordyn Wheeler, Email:
wheej301@coyote.csusb.edu

2. SCHOOL-BASED NUTRITION INTERVENTION PROGRAMS 2
The Centers for Disease Control and Prevention reports that over one-third of children
and adolescence are considered overweight or obese as of 2010 (CDC, Childhood Obesity Facts).
These high prevalence rates indicate an epidemic in the United States; unfortunately, these trends
are occurring in other countries (e. g. UK, China, Germany, Australia) as well (Gonzalez-Suarez,
Worley, Grimmer-Somers, & Dones, 2009). Furthermore, these young people are likely to live
as obese adults (Lueke, 2011; Sbruzzi et al., 2013; Seo & Lee, 2011). Obesity is associated with
the incidence of other health conditions, such as cardiovascular disease, hypertension, diabetes,
and liver disease (Lueke, 2011; Seo & Lee, 2011). Sadly, Lueke (2011) notes that the younger
generations are expected to live shorter lives than their parents. These added health concerns
also create an economic burden; in 2005, obesity-related expenditures in the U.S. reached $190
billion (“Economic Costs,” n.d.). It follows that there is great concern over the obesity epidemic.
Many intervention programs aim to combat this epidemic by targeting children to
establish healthy behaviors at a young age. Childhood is the opportune time to create persisting
healthy practices (Forneris, 2010; Prelip et al., 2012; Wall, Least, Gromis, & Lohse, 2012). Such
interventions have the opportunity to tackle childhood obesity prevalence as well as prevent
future incidence. Accordingly, schools are often used as intervention platforms; several studies
suggest that because schools have concentrated exposure to the 95% of all enrolled youth, it
provides the necessary context for intervention (Lueke, 2011; Prelip et al., 2012). Many school-
based intervention programs focus on the elements of nutrition knowledge, attitudes toward
fruits and vegetables (FVs), increasing FV intake, and self-efficacy to eat FVs. However, several
studies cite a lack of rigorous experimental analysis on the intervention programs (Martin, Chater,
& Lorencatto, 2013; Prelip et al., 2012).
Intervention Components

3. SCHOOL-BASED NUTRITION INTERVENTION PROGRAMS 3
Nutrition interventions commonly focus on increasing FV intake. FVs are low-calorie,
nutrient dense foods with the potential to lower the risk of becoming obese (Prelip et al., 2012).
Ratcliffe et al. (2011) notes that the recommendations for FV intake are not being met in the
United States. With this in mind, Ratcliffe et al. (2011) indicates that consumption will not
increase from simply increasing the presence of FVs. Therefore, there is interest in intervention
approaches that can effectively increase FV consumption (Ratcliffe et al., 2011). Wall et al.
(2012) suggested that interventions should impact preference, a known predictor of FV intake.
Their research showed that greater FV preference is associated with higher daily FV intake, and
preference may even be the most influential personal factor (Reinaerts, de Nooijer, Candel, & de
Vries, 2007). Likewise, Tak, Velde, and Brug (2008) found increased FV intake to be influenced
by liking, parental facilitation, and availability at home. Furthermore, Parmer, Salisbury-
Glennon, Shannon, and Struempler, (2009) found involving students in nutrition education
reinforced preference. Additionally, Hernández-Garbanzo et al. (2013) suggests effective
interventions will include components on knowledge, self-efficacy, motivation, intention, and
initiating behavior change.
The targets of such nutrition intervention programs (i.e. young children) usually have low
levels of nutrition knowledge. Despite the research on other indicators increasing FV intake,
various nutrition interventions attempt to impact FV consumption with knowledge (Wall et al.,
2012). The goal of such interventions is to increase knowledge about healthy choices and
nutritious foods as a means to challenge childhood obesity. Nevertheless, research on nutrition
intervention programs is inconclusive on whether increasing knowledge promotes behavior
change (Lakshman et al., 2010; Sbruzzi et al., 2013). Lueke (2011), for example, argues that
providing youth with nutrition education will enable them to make healthier choices, while

4. SCHOOL-BASED NUTRITION INTERVENTION PROGRAMS 4
Lakshman et al. (2010) suggests increasing knowledge alone is not significant in changing
behavior. Wall et al. (2012) adds that knowledge is not single predictor of behavior change.
Similarly, Sbruzzi et al. (2013) found educational interventions were not useful in preventing
childhood obesity, but were beneficial for treatment. Moreover, their meta-analysis on
randomized control trials revealed that interventions focused on nutrition knowledge did not
have better outcomes. Because many nutrition interventions are based on increasing knowledge,
it is worth exploring whether this is an effective means of attaining behavior change. Perhaps
nutrition knowledge is best utilized as a component of an overall approach (Lakshman et al.,
2010).
School-based nutrition interventions often try to assess attitudes related to FVs and eating
healthy nutritious foods. Theoretically, it is understandable that increasing positive attitudes
would also increase consumption. However, according to Prelip et al. (2011; 2012), positive
attitudes related to eating FVs did not have an effect on behavior. In fact, attitudes toward FVs
at baseline were already high, yet those attitudes did not lead children to consume significantly
more FVs (Prelip et al., 2011). Hoffman et al. (2011) also found that preferences were steady
throughout the intervention, and even though fruit preferences were high, consumption of fruits
stayed low. Interestingly, the nutrition intervention Harvest of the Month (HOTM), which
routinely exposes students to different produce, anticipates increased intake post-exposure
(Prelip et al., 2011). Because there is a poor impact on behavior stemming from attitudes, it may
be necessary for interventions to adopt different strategies than improving attitudes. It may also
be that there is more of an effect when considering the interaction of variables. For example,
Reinaerts et al. (2007) found that children consume more FVs when they are available if they

5. SCHOOL-BASED NUTRITION INTERVENTION PROGRAMS 5
indicate a positive preference, but children who did not show preferences only consume more
FVs when they are available in an easy-to-eat form.
Self-efficacy, or assurance a person feels in completing a behavior, is another common
component of intervention programs (Molaison, 2002). Wall et al. (2012) asserts that self-
efficacy acts as a mediator of FV consumption, that is children will consume more FVs the
higher self-efficacy they have. In her description of the Transtheoretical model of behavior
change, Molaison (2002) signifies increased self-confidence as a fundamental element in
facilitating change. However, Reinaerts et al., (2007) cites inconsistent reports on the effect of
self-efficacy in relation to changing FV consumption in children. Self-efficacy may have
different impacts on children from different ethnic backgrounds; for example, self-efficacy was
shown to be a more influential factor for consumption of FV for non-native children in a study
conducted in the Netherlands (Reinaerts et al., 2007).
Outcomes
For those intervention strategies that are effective, duration is a crucial component. For a
nutrition intervention to be truly successful, there must be sustainable change. Prelip et al.
(2012) asserts that monitoring the intervention participants for longer than one school year may
be necessary to understand the influence on behavior change. Similarly, Gonzalez-Suarez’s
(2009) meta-analysis and Lakshman et al. (2010) concluded that interventions are more likely to
reduce the prevalence of obesity if long-term (i.e. more than two years). Conversely, some
longitudinal studies show that the effects of intervention programs tend to drop off over time.
Hoffman et al. (2011) longitudinal study found an intervention aimed at increasing FV intake to
show differences between the intervention and control group’s consumption diminished after 15
months, and after two years, the differences were nonexistent. With this in mind, it is essential

6. SCHOOL-BASED NUTRITION INTERVENTION PROGRAMS 6
to determine which intervention strategies have a long lasting impact, or modify the existing
strategies to achieve endurance.
Harvest of the Month
With these efficacious program qualifications in mind, we can examine the intervention
strategies used in HOTM, a nationally popular program. HOTM is a nutrition curriculum from
the Network for a Healthy California aimed at increasing FV consumption and physical activity
among K-12 students. The HOTM program provides low-resource schools with tools to increase
access and intake of FVs encompassing four strategies: the classroom, cafeteria, home, and
community. Drawing on the Socio-Ecological model, HOTM incorporates knowledge and skill
based approaches (“Program Overview,” 2007). HOTM curriculum is used in various school
districts across the nation. While HOTM has been implemented alone, it is also often used in
conjunction with other intervention programs. According to the literature, HOTM has
demonstrated effectiveness in improving FV knowledge, self-efficacy, and consumption.
However, there have not been many controlled evaluations published on HOTM.
Overview
The purpose of this study is to address inconsistencies in the literature regarding nutrition
intervention programs, and examine outcomes on nutrition behavior related to interventions to
increase knowledge. Specifically, we will examine the effectiveness of HOTM nutrition
intervention implemented in San Bernardino County. We expect that increasing knowledge will
not creating lasting change on nutrition behaviors.

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References
Centers for Disease Control and Prevention. Retrieved from:
http://www.cdc.gov/healthyyouth/obesity/facts.htm
Economic Costs. Retrieved from http://www.hsph.harvard.edu/obesity-prevention-
source/obesity-consequences/economic/
Forneris, T., Fries, E., Meyer, A., Buzzard, M., Uguy, S., Ramakrishnan, R., & ... Danish, S.
(2010). Results of a rural school-based peer-led intervention for youth: Goals for health.
Journal of School Health, 80(2), 57-65. doi:10.1111/j.1746-1561.2009.00466.x
Gonzalez-Suarez, C., Worley, A., Grimmer-Somers, K., & Dones, V. (2009). School-based
interventions on childhood obesity: A meta-analysis. American Journal of Preventive
Medicine, 37(5), 418-427. doi:10.1016/j.amepre.2009.07.012
Hernández-Garbanzo, Y., Griffin, S., Cason, K. L., Loberger, G., Williams, J., Baker, S., & ...
Hayden, V. (2013). A content analysis of nutrition education curricula used with low-
income audiences: Implications for questionnaire development. Health Promotion
Practice, 14(4), 534-542. doi:10.1177/1524839912461355
Hoffman, J. A., Thompson, D. R., Franko, D. L., Power, T. J., Leff, S. S., & Stallings, V. A.
(2011). Decaying behavioral effects in a randomized, multi-year fruit and vegetable
intake intervention. Preventive Medicine, 52(5), 370-375.
doi:10.1016/j.ypmed.2011.02.013
Lakshman, R. R., Sharp, S. J., Ong, K. K., & Forouhi, N. G. (2010). A novel school-based
intervention to improve nutrition knowledge in children: Cluster randomised controlled
trial. BMC Public Health, 10, 123-131.

8. SCHOOL-BASED NUTRITION INTERVENTION PROGRAMS 8
Lueke, L. (2011). Devouring childhood obesity by helping children help themselves. Journal of
Legal Medicine, 32(2), 205-220. doi:10.1080/01947648.2011.576621
Martin, J., Chater, A., & Lorencatto, F. (2013). Effective behaviour change techniques in the
prevention and management of childhood obesity. International Journal of Obesity,
37(10), 1287-1294. doi:10.1038/ijo.2013.107
Molaison, E. (2002). Stages of change in clinical nutrition practice. Nutrition In Clinical Care,
5(5), 251-257. doi:10.1046/j.1523-5408.2002.05507.x
Parmer, S. M., Salisbury-Glennon, J., Shannon, D., & Struempler, B. (2009). School Gardens:
An Experiential Learning Approach for a Nutrition Education Program to Increase Fruit
and Vegetable Knowledge, Preference, and Consumption among Second-grade Students.
Journal Of Nutrition Education & Behavior, 41(3), 212-217.
Prelip, M., Kinsler, J., Chan Le, T., Erausquin, J., & Slusser, W. (2012). Evaluation of a school-
based multicomponent nutrition education program to improve young children's fruit and
vegetable consumption. Journal of Nutrition Education & Behavior, 44(4), 310-318.
doi:10.1016/j.jneb.2011.10.005
Prelip, M., Slusser, W., Thai, C. L., Kinsler, J., & Erausquin, T. (2011). Effects of a school-based
nutrition program diffused throughout a large urban community on attitudes, beliefs, and
behaviors related to fruit and vegetable consumption. Journal of School Health, 81(9),
520-529. doi:10.1111/j.1746-1561.2011.00622.x
Program Overview. Retrieved from http://www.harvestofthemonth.cdph.ca.gov/program-
overview.asp
Ratcliffe, M. M., Merrigan, K. A., Rogers, B. L., & Goldberg, J. P. (2011). The effects of school
garden experiences on middle school-aged students’ knowledge, attitudes, and behaviors

9. SCHOOL-BASED NUTRITION INTERVENTION PROGRAMS 9
associated with vegetable consumption. Health Promotion Practice, 12(1), 36-43.
doi:10.1177/1524839909349182
Reinaerts, E., de Nooijer, J., Candel, M., & de Vries, N. (2007). Explaining school children's
fruit and vegetable consumption: The contributions of availability, accessibility, exposure,
parental consumption and habit in addition to psychosocial factors. Appetite, 48(2), 248-
258. doi:10.1016/j.appet.2006.09.007
Sbruzzi, G., Eibel, B., Barbiero, S. M., Petkowicz, R. O., Ribeiro, R. A., Cesa, C. C., & ...
Pellanda, L. C. (2013). Educational interventions in childhood obesity: A systematic
review with meta-analysis of randomized clinical trials. Preventive Medicine, 56(5), 254-
264. doi:10.1016/j.ypmed.2013.02.024
Seo, D., & Lee, C. (2012). Association of school nutrition policy and parental control with
childhood overweight. Journal of School Health, 82(6), 285-293. doi:10.1111/j.1746-
1561.2012.00699.x
Tak, N. I., Te Velde, S. J., & Brug, J. (2008). Are positive changes in potential determinants
associated with increased fruit and vegetable intakes among primary schoolchildren?
Results of two intervention studies in the Netherlands: The schoolgruiten project and the
pro children study. International Journal of Behavioral Nutrition & Physical Activity, 51-
11. doi:10.1186/1479-5868-5-21
Wall, D. E., Least, C., Gromis, J., & Lohse, B. (2012). Nutrition education intervention improves
vegetable-related attitude, self-efficacy, preference, and knowledge of fourth-grade
students. Journal of School Health, 82(1), 37-43. doi:10.1111/j.1746-1561.2011.00665.x