UReCA

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Nutrition Education in a Low-Income Middle School Setting Increases Students’ Smart Beverage Choices

Abstract

Soft drink consumption is increasing among adolescents, and the intake of fruits and vegetables by children is insufficient in America. Furthermore, children in low-income environments are even less likely than the average child to consume the recommended fruits and vegetables each day. Decreased fruit and vegetable and increased sugar-sweetened beverage consumption is linked to obesity which leads to other detrimental diseases such as cardiovascular disease and type II diabetes mellitus. The purpose of this intervention was to evaluate the effects of an afterschool nutrition education in a low-income middle school setting. A pre-survey and post- survey were given to evaluate how the intervention impacted the participants’ general nutrition knowledge, open-mindedness to taste unfamiliar fruits and vegetables, and intake of FVs and common beverages. Paired-sample t-tests were used to assess differences between the pre-survey and post-survey data. The results indicated a significant increase in the quality of smart beverage choices from baseline (12.40+3.50 score) to the end of the 16-week intervention (13.73+2.28 score), (t=2.256(14), p=0.041). There was a significant decrease in nutrition knowledge from baseline (7.40+1.40 score) to the end of the 16-week intervention (6.47+ 2.17 score), (t=-2.226 (14), p=0.043). No other significant differences were observed. This unique intervention indicates that nutrition education intervention in a low-income middle school can influence the beverage choices of the students positively.

Introduction

I worked for a nonprofit agency for the three years that provides free, healthy meals to children in low-income settings. We visited the neighborhood playgrounds and recreation centers of over two-thousand children, ready to provide a safe play environment and friendship. One day while working, I snacked on a fresh peach from home, and a middle school boy asked me if I was eating an apple. Although his question was simple, I slowly began to realize the complexity of his curiosity.

First, the boy was unable to recognize the vast differences in sensory characteristics between a peach and an apple – the varying colors, textures, and consistencies. A bite into a furry peach releases a burst of juices whereas an apple creates a subtle crunch. Furthermore, he was unfamiliar with the common fruit despite this fruit’s popularity in his geographic region. I explained the difference between the two fruits and enthusiastically offered to bring the boy a taste of a peach the next day. We also discussed the health benefits of consuming a diet rich in fruits and vegetables. Unsurprisingly, the boy loved the novel fruit and continuously asked for more throughout the summer.

This minor interaction left a small impact on the boy and a tremendous impact on me. I considered how this boy was willing to eat fruit, even though many children in our nation do not consume the recommended fruits and vegetables (FVs) per day (CDC, 2014). Unfortunately, he did not have access to nutritious food or the proper knowledge to choose it. Since the United States Department of Agriculture (USDA) subsidized the meals served to children in the summer food program, all meals were required to contain 1% milk. Many of the children complained about the milk and ask for sugar-sweetened beverages (SSBs). My observations at work led me to consider how proper nutrition education might influence FV intake, smart beverage choices, and the children’s open-mindedness to taste novel fruits and vegetables.

Background

Historically the consumption of FVs have been low in children but improvements have been made (CDC, 2014). According to the CDC, between 2003 and 2010, the amount of vegetables consumed by children aged 2-18 years old was unaltered while whole fruit consumption increased by 67 percent. Despite the increased consumption of fruit, the individual daily recommendation for fruit was not met by sixty-percent of children between 2007 and 2010. Likewise, SSB consumption among children has escalated in the past forty years (Harvard T.H. Chan School of Public Health, 2012). Between the years 1989 and 2004, calories consumed from SSBs by children between of the age of 6 and 11 increased by 60-percent. Similarly, each additional SSB consumed by a child is correlated with a 1.6% increase in the child’s likelihood of becoming obese (Harrington, 2008). Fortunately, national efforts such as Let’s Move! are devoted to increasing FV intake and improving beverage choices among children (CDC, 2014). Public officials realize that 60 million US children spend a large percentage of their time during the day at school and in daycare, so these institutions should be at the center of efforts to improve the dietary intake of children.

Regrettably, low-income children, like my friend from work, are even less likely to consume an adequate diet than the average American child. In regards to FV intake, income has repeatedly been shown to be positively correlated with intake, suggesting that low-income youth are at a disadvantage, because they have a lack of access, monetary support, and nutrition knowledge to purchase and consume fruits and vegetables (Di Noia, 2014). Other studies have found that the consumption of SSBs is the greatest among minority and impoverished children

(Bleich, Herring, Flagg, & Gary-Webb, 2012; Pinard, Davy, & Estabrooks, 2011). The lack of consumption of FVs and the elevated intake of SSB is associated with adolescent obesity which leads to other complications. (Bleich et al., 2012; Produce for Better Health Foundation, 2016). These complications may include: high blood pressure, high cholesterol, sleep apnea, asthma, joint problems, and increased risk of developing cardiovascular disease (CVD) and type 2 diabetes mellitus (Bariatric and Metabolic Institute; CDC, 2012). According to the CDC (2012), a study of obese children demonstrated that 70 percent had one CVD risk factor and 39 percent had at least two risk factors. Furthermore, research has shown that obese children and teens are likely to become obese adults, because lifestyle behavior habits are formed during childhood (Freedman et al., 2005). Educating children on the importance of consuming FVs and limiting the intake of SSBs is a feasible action which could prevent childhood obesity. In the low-income setting, afterschool nutrition education is a favorable option, because it limits the burden of parent participation. Kevin Concannon, the USDA Under Secretary for Food, Nutrition and Consumer Services, declared, “Schools are essential to early exposure to good nutrition and provide a blueprint for healthy eating that can last a lifetime” (CDC, 2014). Public officials are beginning to recognize the power that schools have on the obesity epidemic in America, but further research is needed to understand the most efficient way for schools to influence lifelong health habits.

Hypotheses

To further investigate the association between nutrition education and the consumption of FVs and SSBs in a low-income middle school setting, a weekly afterschool nutrition program was implemented at East Lake Academy of Fine Arts in Chattanooga, Tennessee. The current study investigated the following hypotheses:

Students who regularly attend the afterschool program will indicate on the 24- hour food recall questions that they made smarter beverage choices and consumed more FVs on the post-test compared to the pre-test.

Students who participate consistently in the nutrition afterschool program will demonstrate increased general nutrition knowledge between the pre- and post-test.

Students who regularly attend the afterschool program will demonstrate increased open-mindedness to sample FVs between the pre- and post-test.

The present study is important, because the pre- and post-test measures open-mindedness to taste FVs through unique methods. Likewise, the intervention was implemented by volunteer university students which is uncommon, and there is limited literature available regarding the effectiveness of nutrition education on middle school students in a low-income setting.

Methods

Setting and Population

The intervention took place at East Lake Academy of Fine Arts (ELA), a middle school located in a low-income area of Chattanooga, Tennessee. All students were invited and given equal opportunity to participate in the nutrition afterschool program. They were not obligated to participate in any activity that made them feel uncomfortable. ELA is considered a Title-1 middle school, indicating that the school receives extra financial assistance from the government to ensure that at-risk and low-income students have a fair opportunity to receive a high-quality education (Hamilton County Department of Education, 2016). The students at ELA are approximately60% African American, 32% Hispanic, and 8% Caucasian (National Center for Education Statistics, 2015; Start Class, n.d.). The demographics of ELA do not reflect the state-wide demographics of Tennessee which are about 23% African American, 9% Hispanic, and 65% Caucasian. ELA’s academic performance based on state testing is ranked in the lowest 20% in Tennessee (Start Class, n.d.). Ninety-nine percent of students at ELA are eligible for free or reduced lunch (Hamilton County School District, n.d.).

Participants

Fifteen participants, 12 girls and 3 boys, met the requirements of signed parental consent and completion of the pre- and post-tests. Their ages at the start of the intervention ranged from 11 to 15 years of age. The mean age was 12 years and 3 months old. Attendance of participants included in the sample ranged from 1 to 16 sessions. The average attendance was 5.25 sessions. Low attendance was often the result of conflicts in schedules resulting from other involvements such as sports teams and student council.

Intervention Description

The afterschool program, entitled Kids Interacting with Nutrition and Growth at School (KINGS) club, began September 15, 2015 and finished April 12, 2016. It was part of a larger grant entitled Combatting Obesity’s Multiple chronic conditions through Preparation Activities Shared among Students (COMPASS). COMPASS is a Health Resources and Services Administration (HRSA) grant with the School of Nursing and Department of Health and Human Performance at the University of Tennessee at Chattanooga (UTC). The present project received institutional review board (IRB) approval through an addendum to the COMPASS’s IRB. There were 16 total sessions throughout the school year. KINGS Club met on Tuesdays from 4 to 5:30 p.m.

The intervention followed a nonrandomized, pre- and post- comparison study design, and there were no control groups in the sample. It was implemented by the principal researcher and volunteers from UTC. All participants were given the same educational experience based on the days they attended KINGS Club. Participants completed a pre-test and baseline height/weight measurements on their first day which was not necessarily the first day of club meetings. Post-tests and final height/weight measurements were completed during the last two weeks of the intervention. All measurements and pre- and post- tests were implemented by volunteers.

There were 6 general nutrition education lessons that were offered during the intervention: (1) The health benefits of consuming whole, unprocessed foods; (2) How to choose nutritious snacks; (3) The benefits of consuming FVs that are a variety of colors; (4) The sugar content of common beverages; (5) How to choose nutritious fast food options; and (6) The proper portion sizes for the 5 food groups. A description of the 16 sessions is provided in Appendix 1. Typically, when a new lesson was taught, it was followed by physical activity games during the remaining time. The next week was devoted to reviewing previous concepts and more physical activity games. All concepts were reviewed periodically throughout the intervention.

Data Collection

Nutritional intake and nutrition knowledge data was assessed by a written survey. Data regarding attitudes was collected using a 4-point Likert-type scale. Open-mindedness to taste unfamiliar FVs was obtained using a ratio (# of FVs the students indicated that they would like to try/ # of FVs the student indicated that he or she had never tasted). All questions related to smart beverage choices, FV intake, nutrition knowledge, or open-mindedness to taste novel FVs were grouped together into separate categories. Smart beverages are defined as increased consumption of water and milk and decreased consumption of soda, 100% fruit juice, Kool-aid, sports drinks, and other fruit flavored drinks. On the survey, the participants indicated how many servings of these drinks that they had in the past 24 hours. Likewise, they indicated how many servings of FVs they had in the past 24 hours. Serving sizes were determined based on visual food models. The survey questions included fresh, frozen, canned, or dried fruits and vegetables. The answer choices for questions about beverages and FVs were 0-1 servings, 2-3 servings, 4-5 servings, and more than 5 servings. The participants’ knowledge about nutrition was the final construct assessed. Five factual questions about nutrition were included in the survey. The information used to formulate the questions was based on the lessons taught throughout the year. The ordinal or nominal values in each category were summed creating a scale, thereby treating the combination of nutritional intake or nutrition knowledge variables as a continuous variable. Statistical Analysis

Paired-sample t-tests were used to assess differences between the pre-survey and post- survey data. All analyses were performed using SPSS version 22.0.00, and the priori significance level was set to alpha <0.05.

Results

Descriptive characteristics are displayed in Table 1. A paired sample t-test indicated a significant increase in the quality of smart beverage choices from baseline (12.40+3.50 score) to the end of the 16-week intervention (13.73+2.28 score), (t=2.256(14), p=0.041). There was a significant decrease in nutrition knowledge from baseline (7.40+1.40 score) to the end of the 16- week intervention (6.47+ 2.17 score), (t=-2.226 (14), p=0.043). No other significant differences were observed. Results of the paired sample t-test for all constructs are displayed in Table 2.

Discussion

The weekly afterschool nutrition intervention implemented by volunteer university students was a unique way to investigate how nutrition intervention can influence middle school students’ nutrition knowledge, open-mindedness to taste novel foods, and intake of smart beverages and FVs. It did not create a burden on parents or teachers, making it ideal for the Title- I school setting. The survey results of the current study indicated that this type of intervention may be an effective method to positively influence the beverage choices of middle school increased consumption of water and milk and decreased students, although changes in FV intake were insignificant. The students had access to nutritious beverages and FVs because 99% of ELA students are eligible for free or reduced lunch (Hamilton County School District, n.d.). In addition, about 87% of participants indicated on the survey that they had access to FVs at the beginning and end of the 16-week intervention. The USDA’s National School Lunch and School Breakfast Programs standards require that cafeterias serve a minimum of 1 cup of milk and 1.25 cups of FVs per day (USDA, n.d.). Although the students had access to both nutritious beverages and FVs at school and home, the study results indicated that the students were more willing to eliminate sugary beverages and to increase water and milk consumption than to increase their FV intake.

Furthermore, the survey results demonstrated that the intervention did not impact the students’ open-mindedness to taste unfamiliar FVs, and there was a significant decrease in nutrition knowledge. The unexpected decrease in nutrition knowledge may be characteristic of the small sample size of 15 participants and the low-level of attendance. Increased advertisement prior to the intervention may have increased the sample size and improved the attendance. Absences from session(s) hindered the participants’ exposure to all nutrition topics that were tested. Also, a curriculum that focuses on one or two specific nutrition topics instead of many general nutrition topics may have allowed the students to better retain the information provided. Lastly, the construct of the survey may not have accurately depicted the students’ nutrition knowledge due to the small sample of questions. Including more questions to test the participants’ nutrition knowledge would have reduced the impact one student’s answer had on the overall statistical results. Amidst disappointing outcomes, observations from the intervention suggest that students were engaged and excited to learn about nutrition and physical activity while attending the sessions.

Conclusion

In summary, the results of this research reveal that nutrition education intervention in a low-income middle school can influence the beverage choices of the students positively. Further research on this type of nutrition education intervention will help support the promotion of child- nutrition in America. Limitations of the study include: (1) the self-report methods of beverage and FV intake, (2) the relatively short length of the intervention, (3) the limited access to teaching resources, (4) the small sample size, (5) the lack of nutrition education reinforcement from teachers and parents, and (6) the lack of a control group. Future studies should refine the curriculum to emphasize more specific nutrition topics, so the information can be reinforced more frequency which will support the retention of knowledge. They should also consider including samples of nutritious foods with the purpose of progressing the participants’ confidence of trying novel foods. To enhance attendance and boost the sample size, future researchers should consider offering incentives. For instance, participants who attend could receive a bag of groceries to take home. Finally, educating parents on how they can positively impact their child’s nutritional status and providing parents with resources such as cooking materials, nutrition activity ideas, and access to nutritious foods may make the intervention more effective.

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by Liana Rodrigues

University of Tennessee at Chattanooga

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