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 This thesis titled Use 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 ABSTRACT ZURMEHLY, ASHLEY B., M.S., August 2009, Food and Nutrition Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School 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 education program on Appalachian childrens 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, nutrition education 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-week intervention period about themselves, their household, and their 157 children. Results indicated that the six-week nutrition education and gardening intervention did not significantly impact produce intake variety or produce preference variety among the children participating in the program. Overall, household food security was not related to the variety of produce eaten or preferred reported by children; however, it was related to vegetable intake, education, diet quality, food assistance program participation, and body mass index of the female caregivers. On the other hand, household food security was related to the childrens estimated produce intake and preferences reported by the female caregivers prior to the intervention. It was also found that childrens gardening habits reflected that of their female caregivers, but childrens self-reported produce intake

4 variety was not related to their gardening habits. However, household food security was not related to gardening habits or produce readiness of female caregivers. Dietetic and nutrition professionals can use these findings to develop other interventions including gardening and nutrition education with both children and their families.

Approved: _____________________________________________________________ David H. Holben Professor of Human and Consumer Sciences

5 ACKNOWLEDGMENTS Thank you to my advisor Dr. David Holben, and other faculty members, who made this possible: Ms. Deborah Murray and Dr. Jennifer Chabot. Also thanks to all of my family and friends for supporting me, especially Todd who helped me through the entire process.

6 TABLE OF CONTENTS Page ABSTRACT ........................................................................................................................ 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 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 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 caregivers gardening and diet. ................................. 123

9 Food security and childrens 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 SECURITY SURVEY 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 LIST OF TABLES Page Table 1: Research Questions and Hypotheses ................................................................19 Table 2: 18-item Food Security Survey Module, 2008...................................................27 Table 3: Food Security Categories Defined by the USDA .............................................29 Table 4: Six-item Food Security Questionnaire, 2008....................................................31 Table 5: SNAP 2009 Income and Resource Cut-off Levels ...........................................56 Table 6: School Meal Income Qualifications .................................................................58 Table 7: Region Economic and Educational Level Comparison ....................................66 Table 8: Research Questions and Associated Statistical Test .........................................87 Table 9: Child Participants Produce Preferences and Intakes .......................................91 Table 10: Characteristics of Female Participants and Their Households .......................94 Table 11: Female Caregiver Body Mass Index and Perceived Diet Quality and Health Status ...............................................................................................................................96 Table 12: Female Participant Readiness for Eating Produce ..........................................98 Table 13: Female Participant Gardening Habits and Readiness for Gardening Produce ... .........................................................................................................................................99 Table 14: Relationship of Food Security Status to Gardening- and Produce-Related Behaviors and Intakes ...................................................................................................101 Table 15: Relationship of Female Caregivers Habits to Gardening- and Produce-Related Behaviors and Intakes ...................................................................................................102

11 Table 16: Female Caregiver and Household Characteristics Stratified by Food Security Status .............................................................................................................................104 Table 17: Female Caregiver Weight and Diet Characteristics Stratified by Food Security Status.....106 Table 18: Female Caregiver Produce Readiness Stratified by Food Security Status.....108 Table 19: Gardening Readiness and Habits of Female Caregivers Stratified by Food Security Status ..............................................................................................................109 Table 20: Female Caregivers Perception of Childrens Produce Intake Stratified by Food Security Status ..............................................................................................................110 Table 21: Female Caregivers Perception of Childrens Habits ...................................111

12 LIST OF FIGURES Page Figure 1: Food security status of U.S. households in 2007 ............................................33 Figure 2: Food security and food insecurity trends in the U.S. from 1999-2007 ...........35 Figure 3: Weekly household food spending per person..................................................43 Figure 4: Food-insecure household food assistance participation ..................................46 Figure 5: The Appalachian Region .................................................................................64 Figure 6: Appalachian Ohio Counties.............................................................................67 Figure 7. Child participants produce preference and intake variety ..............................92 Figure 8. Female caregiver participants weight classification ........................................97 Figure 9. Female caregiver produce and gardening readiness...100 Figure 10. Female caregiver body mass index and produce intake by food security status..107

13 CHAPTER 1: INTRODUCTION Overview and Background Appalachia is an area of the United States that is characterized by low educational attainment, high poverty, and poor health. The area is made up of parts of 12 states and all 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 food access, 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, food insecurity was found to be three times the level of the rest of the state, as well as almost double 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 household members across the lifespan (Alaimo, Olson, & Frongillo, 2002; Bronte-Tinkew, Zaslow,

14 Capps, 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 Hemoglobin A1C levels have all been found to be greater in food-insecure households as compared to their counterparts in Appalachian Ohio (Holben & Pheley, 2006). Overall, poorer selfreported physical and mental health was associated with food insecurity in Appalachian, even in households with minimal food insecurity (Pheley et al., 2002). Physical health is not only in jeopardy when households are food insecure; mental and overall health can also 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; Cook et 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 both quality 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 recommended intakes of kilocalories, calcium, vitamin B-6, magnesium, iron, and zinc, compared to those in food-secure households (Dixon, Winkleby, & Radimer, 2001; Matheson, Varady, Varady, & Killen, 2002; Olson, 1999; Rose & Oliveira, 1997). Studies have shown food-insecure households to be of particular concern in relation to decreased produce intake, leading potentially to increased risk for certain cancers, cardiovascular

15 disease, 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 et al., 2007; Pierce, Stefanick et al., 2007). For children, food insecurity can negatively impact 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 et al., 2007; Riediger, Shooshtari, & Moghadasian, 2007). Federal food assistance programs have been developed to improve nutritional status of Americans, including Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infant, and Children (WIC), School Meals Programs, and local programs (e.g., Community Food Initiatives), all of which strive 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 Health and Human Services, 2009a, 2009b, 2009c; Zerbian, 2007). In order to further increase produce intake in food-insecure families and decrease their risk for such chronic problems, a variety of community-based programs and interventions have been developed, 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 been shown to increase access to fruits and vegetables in the face of food insecurity, and is a

16 relatively inexpensive way to grow fresh produce (Holben et al., 2004; McAleese & Rankin, 2007; Nanney, Johnson et al., 2007; Rose & Richards, 2004). Further, gardening interventions have been shown to positively impact produce intake of children and their households, which may also increase their food security (Graham & Zidenberg-Cherr, 2005; Hermann et al., 2006; Holben et al., 2004; McAleese & Rankin, 2007; Morris & Zidenberg-Cherr, 2002). A variety of methods have been used by these programs, including varying time frames, lessons, and venues across the United States (RobinsonO'Brien, 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 produce had an increase in produce availability, along with an increase in their childs preference for new fruits and vegetables. In fact, gardening projects have been done to improve the health and fruit and vegetable intake of the participants, with most having positive impacts 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; Van Duyn & Pivonka, 2000). Compared to other interventions, gardening is an inexpensive way to increase produce intake as well as physical activity in households (Graham & Zidenberg-Cherr, 2005; McAleese & Rankin, 2007; Nanney, Johnson et al., 2007).

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 and vegetables 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 study region, multiple studies have indicated the need for intervention in the Southeastern Ohio Appalachian 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 potential solution is to introduce gardening to children, who may, in turn, influence the entire households habits surrounding gardening and produce. Through the introduction of gardening, study area children will not only be involved directly in their own food production, 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 et al., 2007). For adult females and children living in food-insecure households, fruits and vegetables are typically the first groups reduced from the diet, due to their higher price and shorter shelf life, compared to other foods (Cassady et al., 2007; Dixon et al., 2001;

18 Kendall et al., 1996; Kropf et al., 2007). Therefore, through the practice of gardening, a family 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 related effectiveness 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 gardening education program on Appalachian childrens 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.

Research Questions and Hypotheses This study answered the research questions summarized in Table 1. Hypotheses for the questions are also summarized in Table 1.

19 Table 1 Research Questions and Hypotheses Research Questions 1. Does a six-week nutrition and gardening education program improve childrens preference for and intake of fruits and vegetables? 2. At the onset of the study, is household food security status related to the female caregivers perception of the gardening habits of the children? 3. At the onset of the study, is household food security status related to the female caregivers gardening readiness? 4. At the onset of the study, is household food security status related to produce intake of female caregiver? 5. At the onset of the study, are the female caregivers gardening habits related to their perceptions of the childs gardening habits? 6. At the onset of the study, is household food security status related to produce preferences and intakes of child participants? 7. At the onset of the study, are the childs produce intake and preferences related to their female caregivers produce intakes? 8. At the onset of the study, are the childs produce intake and preferences related to their female caregivers gardening habits? Hypotheses A six-week nutrition and gardening education program positively impacts childrens fruit and vegetable intakes and preferences. Food insecurity is associated with fewer gardening habits of the children as perceived by the female caregiver.

Food insecurity is associated with decreased gardening readiness of the female caregiver. Food security is inversely associated with female caregivers produce intakes.

Childs gardening habits are positively associated with their female caregivers gardening habits. Food insecurity is associated with decreased produce preferences and intakes of child participants. Childs produce intake and perceptions are positively associated with their female caregivers produce intake. Childs produce intake and perceptions are positively associated with their female caregivers gardening habits.

20 9. Do body mass index (BMI), vegetable intake, and fruit intake differ between female caregivers from food-secure versus foodinsecure households? 10. Do marital status, education level, transportation, hunting, fishing, food assistance program participation, perceived health level, diet quality, body mass index category, and produce and gardening readiness differ between female caregivers from food-secure versus foodinsecure households? Body mass index (BMI) will be greater and both vegetable and fruit intakes will lower in female caregivers from foodinsecure households compared to foodsecure households. Food-insecure female caregivers will be single and have lower education, diet quality, and health status while having higher body mass index and food assistance program participation than food-secure females. Food-insecure females will also have lower produce and gardening readiness than those from foodsecure households.

Significance of the Study As previously discussed, food insecurity is associated with decreased produce intake. 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 aware of basic nutrition concepts, as well as gardening skills, that they can share with their families 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 direct benefit of the education and produce distribution, but they were also able to use the knowledge and skills after the programs completion through the development of their own garden. Other groups that may benefit included the Kids on Campus Program

21 (university-based summer camp), where this program was initially piloted. Finally, the dietetics and nutrition profession may benefit from this research by using the findings as a 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 pilot study, improvements could be made in order to re-evaluate its effectiveness in the original age group studied, or target other ages or populations in different regions of the country for evaluation. The unique aspect of this program, compared to previous studies, is that it focused in the region of Appalachian Ohio. Based upon the literature related to food security in and the culture of the Appalachian region, as well as pediatric nutrition studies and surveillance data, the program was developed.

Potential Delimitations and Limitations Potential limitations of this pilot study include the pilot nature of program and study, potential for children to be absent for parts of the program or to discontinue participation in the study, limited participation of the family members/caregivers, literacy level of all participants, and use of children and families participating in the camp rather than a randomly selected sample. These limitations could hinder participant selection and recruitment, as well as the effectiveness of the program. Potential delimitations, or those factors out of our control that could hinder our study, include summer camp practices (participant selection, daily schedule), climate of

22 the study region during the study period, and the availability of produce from farmers for distribution 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 particular demographics. To overcome these limitations and delimitations, we closely collaborated with the summer camp program staff and utilized local farmers for produce who typically are successful.

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 adequate and safe foods, and b) the assured ability to acquire acceptable foods in socially acceptable 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 safe foods or the ability to acquire acceptable foods in socially acceptable ways is limited or uncertain (Anderson, 1990, p. 1560). Community food security: Prevention-oriented concept that supports the development and enhancement of sustainable, community-based strategies: to improve access of low-income households to healthful nutritious food supplies; to increase the self-reliance of communities in providing for their own food needs; and to promote comprehensive responses to local food, farm, and nutrition issues (Andrews, 2008).

23 CHAPTER 2: REVIEW OF LITERATURE In the United States, food insecurity can lead to an increased risk for health problems, poor diet, and lack of fruit and vegetable intake (Bhattacharya et al., 2004; Bronte-Tinkew et al., 2007; Carmichael, Yang, Herring, Abrams, & Shaw, 2007; Casey et 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 et al., 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 households because such health problems and diet habits could follow them and exacerbate throughout life (Connell, Lofton, Yadrick, & Rehner, 2005; Olson et al., 2007). Appalachia has been shown to be at higher risk for food insecurity and its associated 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, an intervention focusing on nutrition, gardening, and produce intake may alleviate some of these problems for children in Appalachian Ohio. This study was conducted to: (a) measure the effect of a nutrition and gardening education program on Appalachian childrens fruit and vegetable intakes and preferences; and (b) examine the relationship of food security status to gardening habits and perceptions, produce intake, and personal

24 characteristics of children and their adult female caregivers. In this literature review, findings related to food security, Appalachia, produce intake, and gardening are reviewed.

Food Security Definitions Food security is defined as 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 adequate and safe foods, and (b) the assured ability to acquire acceptable foods in socially acceptable ways (e.g., without resorting to emergency food supplies, scavenging, stealing, and other coping strategies) (Anderson, 1990, p. 1560). Food insecurity is defined as whenever the availability of nutritionally adequate and safe foods or the ability 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 food insecurity, however is defined as an individual physiological condition due to prolonged lack of food causing weakness, illness, and pain (Anderson, 1990). Both individuals and overall 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 of intake 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 each individual which leads to multiple definitions. The Food Research and Action Center

25 (FRAC) defined hunger as the physiological and psychological state that comes from not having enough food, while Harvard School of Public Health defined it as chronic under consumption of food and nutrients (Radimer & Radimer, 2002). Community food security is difficult to assess. However, it is basically defined as the attempt to increase the food security of a community through the use of education and programs. The U.S Department of Agriculture defines it as a prevention-oriented concept that supports the development and enhancement of sustainable, community-based strategies which improve access of low-income households to healthful nutritious food supplies; 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 be compromised 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 federal agencies, researchers, and non-profit organizations developed in response to the National Nutrition Monitoring and Related Research Act (NNMRR) in 1990 with the objective to develop a methodology to assess the food security status nationwide (Nord, 2008b). The idea for food security measurement began in the 1980s when hunger emerged as a growing concern in the United States (Nord, Andrews, & Carlson, 2008). The Harvard School of Public Health and FRAC provided evidence to President Reagans Task Force on Food Assistance urging for an investigation into the allegations of increasing hunger

26 (Carlson, Andrews, & Bickel, 1999; Olson, 1999). After developing the definitions of food 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 the Community Childhood Hunger Identification Project (CCHIP), an 18-item questionnaire was developed to determine the multiple levels of food security occurring in American households which was first administered as a supplement to the Current Population Survey (CPS) in 1995 (Nord et al., 2008; Nord, 2008b). The questions for the Food Security Survey Module (FSSM) were developed through extensive research by a team of experts in the field, along with field testing and validation (Nord, 2008b). The FSSM has since been used by governmental and other researchers. For example, the instrument has been used in the Continuing Survey of Food Intakes by Individuals (CSFII), the National Health and Nutrition Examination Survey (NHANES), the Early Childhood Longitudinal Study (ECLS), the Panel Survey of Income Dynamics (PSID), and the Survey of Program Dynamics (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, from least to most which aids in the categorization of the participant (Carlson et al., 1999; Radimer & Radimer, 2002). Each question uses key phrasing, including because we could not afford it and because there was not enough money, in order to assess food security based on financial reasons over the past 12 months (Bickel et al., 2000). Some of the wording varied from 1995 to 1998, however the core questions have remained unchanged (Bickel et al., 2000). The questions for the 18-item survey are shown in Table 2, while the scoring is found in Appendix A.

27 Table 2 18-item Food Security Survey Module, 2008 Item Number Q1 Question We worried whether our food would run out before we got money to buy more. Was that often, sometimes, or never true for you in the last 12 months? The food that we bought just didnt last and we didnt have money to get more. Was that often, sometimes, or never true for you in the last 12 months? We couldnt afford to eat balanced meals. Was that often, sometimes, or never true for you in the last 12 months? 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 wasnt enough money for food? (Yes/No) (If yes to Question 4) How often did this happenalmost every month, some months but not every month, or in only 1 or 2 months? In the last 12 months, did you ever eat less than you felt you should because there wasnt enough money for food? (Yes/No) In the last 12 months, were you ever hungry, but didnt eat, because there wasnt enough money for food? (Yes/No) In the last 12 months, did you lose weight because there wasnt enough money for food? (Yes/No) In the last 12 months did you or other adults in your household ever not eat for a whole day because there wasnt enough money for food? (Yes/No) (If yes to Question 9) How often did this happenalmost 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

Q2

Q3 Q4

Q5

Q6

Q7

Q8 Q9

Q10

28 Q11 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? We couldnt feed our children a balanced meal, because we couldnt afford that. Was that often, sometimes, or never true for you in the last 12 months? The children were not eating enough because we just couldnt afford enough food. Was that often, sometimes, or never true for you in the last 12 months? In the last 12 months, did you ever cut the size of any of the childrens meals because there wasnt enough money for food? (Yes/No) In the last 12 months, were the children ever hungry but you just couldnt afford more food? (Yes/No) In the last 12 months, did any of the children ever skip a meal because there wasnt enough money for food? (Yes/No) (If yes to Question 16) How often did this happenalmost every month, some months but not every month, or in only 1 or 2 months? In the last 12 months, did any of the children ever not eat for a whole day because there wasnt enough money for food? (Yes/No)

Q12

Q13

Q14

Q15 Q16 Q17

Q18

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 2000 by USDA. Reprinted with permission.

Per Appendix A, households are considered food-secure if they report only one or two food-insecure conditions. Food-insecure households are defined by having three or more food-insecure conditions (Nord et al., 2008). Food insecurity is broken down into multiple categories depending on the number of affirmative answers. Low food security is classified as having multiple indications of food access, but few reduced intake patterns. Very low food security, which is typically the situation where children are

29 affected, is when the household reported to being hungry at some point due to lack of money for food (Nord et al., 2008). This category breakdown is shown below in Table 3 with both the old categories and new categories represented.

Table 3 Food Security Categories Defined by the USDA Old Categories (1995-2005) Foodsecure Food-secure New Categories (2006present) High food security Scale Scores (18-item) Associated Conditions

0 affirmative responses

No reported indications of food-access problems or limitations One or two reported indicationstypically of anxiety over food security or shortage of food in the house. Little or no indication of changes in diets or food intake Reports of reduced quality, variety, or desirability of diet. Little or no indication of reduced food intake Reports of multiple indications of disrupted eating patterns and reduced food intake

Marginal 1-2 food security affirmative responses

Foodinsecure

Foodinsecure without hunger Foodinsecure with hunger

Low food security

3-5 affirmative responses

Very low 6 or more food security affirmative responses

Note. Adapted from Food Security in the United States: Definitions of Hunger and Food Security, by M. Nord, 2008, Department of Agriculture, Food and Nutrition Service. Copyright 2006 by the USDA. Reprinted with permission.

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 developed in 1995 for research projects with less funding and time (Blumberg, Bialostosky, Hamilton, & Briefel, 1999). Researchers narrowed the original 18-item survey down to six 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 for most households and remain time effective, the researchers removed the eight questions which are asked solely for households with children (Blumberg et al., 1999). This was found to have little effect on the validity of the tool, and so the survey was further shortened 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 with both households with and without children resulting in 82.8% and 92.3 % accuracy respectively. Both tools have been used in multiple research projects and validated for multiple 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 scoring found in Appendix A.

31 Table 4 Six-item Food Security Questionnaire, 2008 Item Number Question

The first four questions are in relation to the familys food intake Q5 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 wasnt enough money for food? (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 Q10 In the last 12 months, did you ever eat less than you felt you should because there wasnt enough money to buy food? In the last 12 months, were you ever hungry but didnt eat because you couldnt afford enough food?

Q8

The last two questions are in relation to the familys food situation Q2 The food that I/we bought just didnt last and I/we didnt have money to get more. Was that often, sometimes, or never trough for you in the last 12 months? I/we couldnt afford to eat balanced meals. Was that often, sometimes, or never true for you in the last 12 months?

Q3

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 by the USDA. Reprinted with permission.

Food Security in the United States Estimates of food security in the United States are calculated from the annual Current Population Survey (CPS). The CPS is a monthly survey of 50,000 households which includes an assessment of the food security of the nation through the use of the 18-

32 item Food Security Survey Module, which asks households about their behaviors and conditions over the past 12 months (U.S. Census Bureau, 2008). The FSSM is included in the December distribution of the CPS. The questions are finance- related as to exclude those who are purposely dieting or cutting back for other reasons. For example, approximately 45,600 households made of civilian, non-institutionalized citizens of the nation 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 13 million, 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 food security. Figure 1 below illustrates the 2007 estimates.

33

Low Food Secure Households 7%

Very Low Food 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 food security 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 get more; 94 % reported that they could not afford to eat balanced meals; 96 % reported that an adult had cut the size of meals or skipped meals because there was not enough money for food; and 93 % reported that they had eaten less than they felt they should because

34 there was not enough money for food (Nord et al., 2008). When food insecurity did occur, about one-fourth of those households had problems chronically for at least seven months out of the year (Nord et al., 2008). The rates of both food security and food insecurity have not changed drastically in the past ten years. The prevalence has changed less than one percent since 1999 according to the data collected from the CPS surveys (Nord et al., 2008). The data from 1999 on is based on the consistent FSSM after adjustments and changes were made from 1995 through 1998 (Bickel et al., 2000). Figure 2 below shows further detail of the trends in food security over the past ten years.

35
100% 98% Percentage of Households 96% 94% 92% 90% 88% 86% 84% 82% Food Insecurity Food Security 1999 10% 90% 2000 10% 90% 2001 11% 89% 2002 11% 89% 2003 11% 89% 2004 12% 88% 2005 11% 89% 2006 11% 89% 2007 11% 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, it has 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 the FSSM distribution in 2001, which in turn keeps the data consistent from year to year without 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 food stamps, or vouchers from WIC (Alaimo, Briefel, Frongillo, & Olson, 1998). A little over 2% of these families had children under 17 who cut the size or skipped meals due to lack of money (Alaimo et al., 1998). Risk Factors for Food Insecurity Risk factors for food insecurity include lower education, lower income, being from an ethnic minority, living in a non-suburban residence, and participation in government assistance programs (Adams, Grummer-Strawn, & Chavez, 2003; Alaimo et al., 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) with incomes 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 the population 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 with children headed by a single parent made up 48.2% of the food-insecure population (Nord et al., 2008). Both single male or female headed households were at greater risk for food insecurity, 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 when they were in a relationship (Hanson, Sobal, & Frongillo, 2007). African-American and Hispanic based households made up 42.3% of the food-insecure group in 2007, with all

37 of 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 further developments found. Overall, it has been found that those living in households characterized by food insecurity tend to be in households with children, headed by a single 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 participants nationwide under the poverty level in 1998 were food-insecure (Nelson, Cunningham, Andersen, Harrison, & Gelberg, 2001). A study done in 2006 found many differences between food-secure and insecure women in particular. Food-insecure women were younger, less educated, single, with lower incomes than their counterparts and 61% of them were overweight (Jones & Frongillo, 2006). Food assistance program participation has also been associated with food insecurity and poverty. A household must meet specific financial and resource requirements in order to be eligible for food assistance programs, which are between 185% and 130% of the poverty level (Food and Nutrition Service, 2008; U.S. Department of Health and Human Services, 2009b, 2009c). It was found that 34% of Supplemental Nutrition Assistance Program (SNAP) participants in a Maryland study sometimes did not have enough food to eat, or to provide adequate food consistently (Oberholser & Tuttle, 2004). A study done with SNAP Participants found that 66% of participants had some level of food insecurity with 7% being food-insecure with hunger (Oberholser & Tuttle, 2004). In addition to food insecurity, lack of income may also compromise the ability to properly heat and cool the home. Another study

38 found that energy security was strongly and positively associated with both household and child food insecurity (Cook et al., 2008). All of these factors narrow down to mainly single, poor, low-educated women who are having trouble providing consistent access to nutritious for their families. These risks combined affect household diet, chronic disease risk, and weight of both children and female adults. Even with participation in government assistance programs, such as the Special Supplemental Nutrition Program for Women, Infant, and Children (WIC) and SNAP, additional help may be needed due to the self-selection effect (Holben & American Dietetic Association (ADA), 2006). This self-selection phenomenon explains the higher occurrence of food-insecure participants in food assistance programs by saying these 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 provide assistance to both these mothers and their children could help offset struggling households. 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, food insecurity 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 implications also occur in food-insecure households including hunger, depletion, illness, stress, modification of eating habits, and disrupted household food management (Hamelin et 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 poor management of the conditions. It has been found that food-insecure participants were twice as likely to have diabetes as food-secure participants (Seligman et al., 2007). In a study done in 2006, individuals with diabetes were more likely to live in food-insecure households (Holben & Pheley, 2006). The study also found that individuals living in food-insecure households were more likely to have HbA1c levels higher than the recommended level of seven (Holben & Pheley, 2006). Poor management of diabetes can lead to future health consequences for these individuals that they may not be able to afford or manage. Food insecurity and financial restraints were also related to diabetes (Nelson et al., 2001). Six percent of diabetic participants reported problems with food insecurity and finances related to their diabetes management (Nelson et al., 2001). Foodinsecure individuals were more likely to report having heart disease, diabetes, high blood pressure, and allergies in 2003 (Vozoris & Tarasuk, 2003). Food insecurity and overweight/obesity among adults. Adult individuals living in a food-insecure household, especially females, are more 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 with the rates of food insecurity (Lyons et al., 2008). In national surveys, researchers found

40 that obesity was lowest for fully food-secure women, while those who were foodinsecure 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 when classified 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 as likely 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 insecurity even though it seems to be counter intuitive. Food-insecurity is associated with lack of food for a nutritious, healthy life. However, high calorie, high fat, low nutrient dense foods tend to be less expensive than low calorie, low fat, and high nutrient dense items (Mendoza, Drewnowski, Cheadle, & Christakis, 2006). Therefore, these empty calorie foods 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 body mass than those in food-secure households (Olson, 2005). Nationwide data collected in 1999 found a strong association between food-insecurity and overweight status, especially in women who were initially normal weight (Jones & Frongillo, 2007). In rural New York, it was found that obesity in early-pregnancy was positively associated with food-insecurity in post-partum women (Olson & Strawderman, 2008). It was reported that 19.3% of women changed food insecurity category from the beginning of pregnancy

41 to 2 years postpartum, whereas only 5.1% changed category for obesity (Olson & Strawderman, 2008). This infers that obesity may have a stronger correlation to food insecurity, rather than food insecurity to obesity. There have been nationwide please for federal 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 and obesity in households. Food security was not related to overweight or obesity in lowincome Massachusetts study participants; however food assistance participation was correlated (Webb, Schiff, Currivan, & Villamor, 2008). Another study done over multiple cities in the U.S. found that a participants change of food security status was not significantly 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 of two years did not change in weight any more than participants whose food security status remained unchanged (Whitaker & Sarin, 2007). Food insecurity and overall health among adults. Food insecurity has been associated with many other health problems besides chronic disease, including increased risk for birth defects, maternal depression, suicide attempts, 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 also had depression (Casey et al., 2004). One study found as food insecurity rises, overall

42 health status falls (Bronte-Tinkew et al., 2007). The elderly are a group whose health is heavily affected by food insecurity. Those who reported food insecurity also reported poor 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 healthy food and education for these families. Food insecurity and diet among adults. Food insecurity negatively impacts multiple aspects of the diet, including decreased 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 characterized by food insecurity have been found to have below the recommended intake of kilocalories, 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 to decreased 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 household members may also suffer. Women in food-insecure households have been found to

43 decrease 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 spend significantly less money per household member on food in 2001 (Casey, Szeto, Lensing, Bogle, & Weber, 2001). Food-insecure households spend on average ten dollars less per person 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 Households

Food Insecure Households

Households with low Households with very food security low food security

Figure 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 households reported 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 which typically include reducing their own intake to avoid or delay such insufficiency in children (Olson, 2005; Radimer et al., 1990). In fact, women in food-insecure homes have lower energy, protein, carbohydrate, fat, and essential nutrients, while their childrens intake seem to be more adequate (McIntyre et al., 2003). It was also found that the womens average food and calcium intakes were positively associated with their food security status, with those in more food-insecure homes having decreased intakes (Tarasuk & Beaton, 1999). Both disordered eating (binge-like eating) and reliance on others 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 can only 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, such as fresh produce, dairy, and meat products, are substituted with cheaper items like convenience foods and snacks (Dixon et al., 2001). As previously noted, adults in foodinsecure homes have lower intakes of energy, vitamin B-6, magnesium, iron, zinc, and cereals (Dixon et al., 2001). While food insecurity also may lead to hunger, it is not always the result (Nelson, Brown, & Lurie, 1998). In addition to what has already been discussed, food insecurity also leads to decreased produce intake, which may be improved by gardening. Eating fewer servings of produce can have negative outcomes. For example, subjects in food-insecure households 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 fruits and vegetables per day, compared to 54.6% of food-secure participants (Kendall et al., 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 can negatively impact their health (Kendall et al., 1996). Another study found that those families with preschool children living in rural areas who ate homegrown produce had an increase in home availability of produce (Nanney, Johnson et al., 2007). Gardening projects have been done in order to increase participants fruit and vegetable intake and subsequently improve health (Robinson-O'Brien et al., 2009). Such interventions are an inexpensive way to increase produce intake, since price is typically seen as a barrier, as well as physical activity in households (Cassady et al., 2007). Food insecurity and food assistance programs. Many food-insecure families participate in food assistance programs, including SNAP, WIC, and the Summer Food Service Program (Condrasky & Marsh, 2005; Nord et al., 2008; Oberholser & Tuttle, 2004). In 2007, more than half (53.9%) of food-insecure families studied participated in a 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 Figure 4.

46
60.0%

50.0%

Percentage of Households

40.0%

30.0%

20.0%

10.0%

0.0% SNAP Percentage of food insecure households participating Percentage of very-low food security households participating 33.0% 34.9% School Lunch 33.6% 28.1% WIC 12.5% 9.1%

Any of the three programs 53.9% 50.9%

Figure 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 foodinsecure with hunger, with more SNAP participants being food-insecure than nonparticipants (Condrasky & Marsh, 2005). They also determined that participants ate less at the end of the food cycle than at the beginning. Both weight and BMI also increased

47 over the two year period (Condrasky & Marsh, 2005). This appears to indicate that, the cyclical 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 with SNAP participants that aimed to increase their access to produce in order to increase produce intake. Researchers found increased supermarket access was associated with increased fruit consumption but not significantly increased intake for vegetables (Rose & Richards, 2004). Some federal programs have attempted to include produce into their household provisions. The WIC program recently changed their food packages to include more allowance for purchase of fresh fruits and vegetables, along with fruit and vegetable equivalents for all ages (Food and Nutrition Service, 2008). The WIC program also created the Farmers Market Nutrition Program which allowed participating families to use vouchers at the local farmers markets in order to increase their fresh produce intake. It was found that this significantly improved the participants vegetable intake, but did not 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 distributing produce packages to low-income households (Hazen et al., 2008). The study found positive results in increased produce intake with participants (Hazen et al., 2008). This shows that if fresh vegetable access is increased, it might be less of a barrier to foodinsecure families and further aid them in bettering their diet. When families lack food they may utilize socially unacceptable means of food acquisition. A study done on low-income mothers in Canada found that 80% of them had

48 received free food over the past year from mostly food banks and relatives, and 75% of the women were food-insecure (McIntyre et al., 2003). In a Canadian study done with food 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 foodinsecure households (O'Connell & Holben, 2005). Outcomes of food insecurity in children As previously mentioned, adults in the household are not the only household members affected by lack of food, but when food insecurity is at its worst, children also suffer. In most cases, children are protected from the harms of food insecurity; however in 2007, 323,000 households had one or more children directly affected by food insecurity (Nord et al., 2008). In 1998, there were 2.4 to 3.2 million children living in food-insecure households, and the numbers are similar today (Alaimo et al., 1998; Nord et 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 study found that 85% of the food-insecure children lived in houses below the 185% poverty level (Rose & Bodor, 2006). Food insecurity and overweight among children. Overweight and obesity trends are not only seen in adults, but may also occur in children. A 2006 nationwide household survey found that 17% of households with

49 children were food-insecure, with 15% of those children having a BMI in the overweight or at risk for overweight categories (Casey et al., 2006). The same study determined that children living in poverty-stricken and/or food-insecure households, independent of demographic data, were more likely to be at risk for overweight (Casey et al., 2006). A nationwide study using NHANES data collected from 1988 through 1994 found an increased prevalence of food insecurity and overweight coexisting among low-income, older white children in the United States (Alaimo et al., 2001b). Another nationwide survey using USDA data found the energy density of the diet was related to both obesity and food insecurity in children, with those living in the Midwest having the highest energy density (Mendoza et al., 2006). It has also been found that the prevalence of overweight in children is indirectly related to the family income. As a familys income increased their overweight status has been shown to decrease (Gordon-Larsen, Adair, & Popkin, 2003). Children from families with both lower parental education and income have been found to be more at risk for being overweight (Haas et al., 2003). This not only affects them during childhood, but may exacerbate health risks in adulthood. A study in 2007 found that if a child grew up in a low-income household, they had an increased likelihood of 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 to less health care visits for both parents and children. When low-income families who were food insufficient were compared to lowincome families who were food sufficient, households with children were more likely to

50 be overweight and were less educated (Casey et al., 2001). However, not all studies of food-insecure children have found an association between food insecurity and overweight or obesity. In fact, one study reported that children who were classified as food-insecure were 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 similar results as those done in the Appalachian region. Children in food-insecure households had significantly lower physical and psychosocial functions as well as health related quality of life (Casey et al., 2005). A study done in Texas using poor families found the children 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 a fair/poor health status as children in food-secure households (Cook et al., 2004). Those food-insecure children also had tripled the chance of being hospitalized than food-secure children (Cook et al., 2004). A nationwide study found that 85% of the food-insecure children were from households that were below 185% of the poverty threshold; and mothers with less than a college education were more likely to be overweight (Rose & Bodor, 2006). One Appalachian Kentucky study found that children coming from poverty-stricken, low-educated households were more likely to have stunted growth and be obese than their counterparts, while another found similar results in Appalachian

51 Pennsylvania (Crooks, 1999; Haas et al., 2003; Rappaport & Robbins, 2005). Health of the 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 food security of children should focus on increasing fruits and vegetables, along with whole grains in their diets (Tanumihardjo et al., 2007). Food insecurity has also been shown to impact a childs mental and cognitive health (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 childrens diet is negatively impacted by food insecurity causing hunger, they have been found to have lower physical functioning along with behavioral and psychosocial problems (Alaimo et al., 2001; Casey et al., 2005; Kleinman et al., 1998; Murphy et al., 1998). Other consequences on food-insecure children include counseling, school disciplinary problems, 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, the more likely their academic performance is to suffer, including arithmetic and grade completion (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, reduced learning, and family disturbances (Hamelin et al., 1999). One study conducted in Massachusetts with homeless and low-income households focused on childrens health and well-being and the impact of hunger. This study found that half of the preschool children had been homeless and moved an average of twice in the past year, while their

52 mothers also reported the family as having moderate hunger (Weinreb et al., 2002). The children who showed more hunger signs were more likely to be white, and those who had severe hunger were more likely to have low birth weights and more chronic health problems (Weinreb et al., 2002). A national sample of kindergarteners found that 22.2% of the childrens households experienced food insecurity, which was also found to be associated with increased weight gain, poor academic performance, and decline in social skills (Jyoti et al., 2005). Those with higher incomes had better health, less need for health care, lower parental depression, and lower levels of food insecurity, while the opposite was true of poorer households (Ashiabi & O'Neal, 2007). Even though children are typically protected from hunger, their diets can still be impacted (Rose, 1999). Children in food-insecure households have lower intakes of fruits, vegetables, and milk products, which directly impacts their calcium, vitamins A and C intake (Dixon et al., 2001). Children typically consume the types of food supplies provided by their caretakers, so when household food supplies are depleted, due to food insecurity, childrens diets suffer, particularly intake of produce and meat (Matheson et al., 2002). A sample of households reported 10.4% child food insecurity, 7.8% reduced diet quality, and 2.6% child hunger (Skalicky et al., 2006). This same study also found that food-insecure children were twice as likely to have iron-deficient anemia (Skalicky et al., 2006). It was even found that food insecurity at any level is linked to poor health outcomes 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 of income level (Alaimo et al., 2001). It was also found that family food insecurity was

53 linked to negative academic and psychosocial development in children (Alaimo et al., 2001a). An in-depth qualitative study asked children in rural Mississippi open-ended questions to assess their experiences with food insecurity. Some of the children mentioned being ashamed or fearful of being labeled as poor and many coping strategies were also discussed. Some of these strategies included eating less (quantity and frequency), eating more or fast when food is available, use of cheap foods, feeling that there was no choice, and limiting participation in social activities (Connell et al., 2005). However, SNAP Program participation has been associated with better learning in foodinsecure children (Frongillo, Jyoti, & Jones, 2006). These occurrences typically only happen when food insecurity is at its worst level, food-insecure with hunger, yet negative effects on the children of these households appear to occur regardless of food security categorization.

Federal and Non-Federal Food Assistance Programs Federal and non-federal food assistance programs have a common objective, to improve the nutritional status of underprivileged families. Federal programs, such as the WIC program, SNAP, the School Meals Program, and the Summer Food Service Program, aim to increase food security and reduce hunger of low-income families through 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 and Human Services, 2009a, 2009b, 2009c). Non-federal programs, such as Community Food

54 Initiatives (CFI) and community gardens, share the same goals; however, their focus is on a 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 to low-income mothers with children under the age of 5 in order to assist with their nutritional needs (Food and Nutrition Service, 2008). Services provided by WIC include food vouchers, nutrition education, and health care referrals, which are all overseen by the Food and Nutrition Service Department in conjunction with the USDA (Food and Nutrition Service, 2008). In order to receive these benefits, women participants must meet the income guidelines of 185% poverty level, or $35,798 per year (2008 information; Food and Nutrition Service, 2008). WIC foods include iron-fortified infant formula and infant cereal, iron-fortified adult cereal, vitamin C-rich fruit or vegetable juice, eggs, milk, cheese, peanut butter, legumes, tuna, and carrots (Food and Nutrition Service, 2008). Special therapeutic infant formulas and medical foods may also be provided if needed (Food and Nutrition Service, 2008). The program provides these specific 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 recent revision 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 for the purchase of fresh fruits and vegetables, along with fruit and vegetable equivalents for younger ages such as juice and baby foods (Food and Nutrition Service, 2008). WIC has

55 been shown to improve the food security and produce intake of households; especially in single parent households, through programs such as the WIC farmers market nutrition program as well as participating in research studies that include produce distribution (Kropf et al., 2007; Walker et al., 2007). FNS Supplemental Nutrition Assistance Program (SNAP) The Supplemental Nutrition Assistance Program (SNAP) is formerly known as the Food Stamp Program, which began in 1943 as a project created by the Secretary of Agriculture, Henry Wallace and Milo Perkins (U.S. Department of Health and Human Services, 2009c). After many trials and adjustments to the original program of using orange and blue stamps to purchase certain commodities, President Johnson proposed to make the program permanent, which was then confirmed by the Food Stamp Act of 1964 (U.S. Department of Health and Human Services, 2009c). Since its beginning, SNAP has changed to fit the needs of the consumers, including the switch from paper stamp usage to an updated electronic card system (U.S. Department of Health and Human Services, 2009c). SNAP helps low-income families purchase food for their families through the use of an electronic debit card which provides discounts on items at grocery or convenience stores (U.S. Department of Health and Human Services, 2009c). The program also provides nutrition education to its participants in order to improve their overall diet, however not just anyone can qualify for SNAP (U.S. Department of Health and Human Services, 2009c). In order to be eligible for the program, you must meet strict guidelines

56 including income level and acquired resources. Table 5 summarizes the 2009 income guidelines for SNAP.

Table 5 SNAP 2009 Income and Resource Cut-off Levels Household Size Gross Monthly Income (130% poverty) 1 2 3 4 5 6 7 8 Each additional member Members Age Range 18-60 yrs 60+ yrs or disabled 1,127 1,517 1,907 2,297 2,687 3,077 3,467 3,857 + 390 Net Monthly Income (100% poverty) 867 1,167 1,467 1,767 2,067 2,367 2,667 2,967 + 300 Resource Amount Allotted $2,000 $3,000 176 323 463 588 698 838 926 1,058 + 132 Maximum Monthly Benefits

Note. Adapted from Supplemental Nutrition Assistance Program, by USDA Food and Nutrition Services, 2008, United States Department of Agriculture. Copyright 2008 by the USDA. Adapted with permission.

In conjunction with the SNAP assistance, the program also provides an educational component called SNAP-Ed. SNAP-Eds objective is to educate low-income participants of the SNAP program so that they may make healthier choices and increase their physical activity (U.S. Department of Health and Human Services, 2009c). The

57 SNAP-Ed Connection is an online resource center that provides local programs with nutritional education, financial tips, recipes, and health information (U.S. Department of Health and Human Services, 2009c). Children in participating households have been found to have better academic learning than those low-income non-participants (E. A. Frongillo et al., 2006). Food-insecure families who participate in the SNAP program have been found to have higher mean energy intakes at the end of the month than non-participants, which means the program is effective in keeping a steady amount of food for the family throughout the month (Condrasky & Marsh, 2005). However, this cycle nature has also been shown to increase the weight of female participants as opposed to non-participants (Jones & Frongillo, 2006). School Meals Programs The school lunch program. The school meals programs are made up of three separate entities: the school lunch program, the school breakfast program, and the special milk program. The school lunch program is a nationally funded program which provides nutritionally balanced, low-cost or free lunches to children in public and non-profit private schools, as well as residential child care facilities each school day (U.S. Department of Health and Human Services, 2009b). The program was established under the National School Lunch Act, signed by President Harry Truman in 1946 (U.S. Department of Health and Human Services, 2009b). In 1999, it was found that children who participated in the School Lunch program had heights related to their income status, which is that those children

58 who were the shortest received free lunch while those who paid for their lunch were taller (Crooks, 1999). In order for a child to be eligible for this program along with school breakfast, they must be in a household which makes no more than 185% of the poverty level (U.S. Department of Health and Human Services, 2009b). If they are between the 185% and 130% they are eligible for reduced- meals, and if they are at 130% or below they qualify for free- meals (U.S. Department of Health and Human Services, 2009b). Table 6 shows income guidelines for all school meal programs.

Table 6 School Meal Income Qualifications Program School Lunch Income Guidelines > 185% 185%- 130% < 130% > 185% 185%- 130% < 130% N/A Qualified Category Full Price Lunch Reduced Price Lunch Free Lunch Full Price Breakfast Reduced Price Breakfast Free Breakfast Free Milk

School Breakfast

Special Milk Program

Note. Adapted from School Meals, by USDA Food and Nutrition Service, 2008, United States Department of Agriculture. Copyright 2008 by the USDA. Adapted with permission.

School lunches must meet the applicable recommendations of the 1995 Dietary Guidelines for Americans, which recommend that no more than 30 percent of an individual's calories come from fat, and less than 10 percent from saturated fat (U.S.

59 Department of Health and Human Services, 2009b). Regulations also establish a standard for school lunches to provide one-third of the Recommended Dietary Allowances (RDA) of protein, vitamin A, vitamin C, iron, calcium, and calories (U.S. Department of Health and Human Services, 2009b). A new program now being offered in conjunction with the school lunch program is the Fresh Fruit and Vegetable Program, which started in 2002, and is now in select schools nationwide (U.S. Department of Health and Human Services, 2009b). This requires the participating school to provide fresh fruits and vegetables to students for free throughout the day (U.S. Department of Health and Human Services, 2009b). There are many stipulations that go along with this program, including: program may not be offered at the same time as lunch and breakfast; only fresh fruits and vegetables may be used, not canned or jarred; and no dips may be served with the fruits, only serving size pouches with vegetables (U.S. Department of Health and Human Services, 2009b). Since the program is fairly new, no evaluation on the overall success is scheduled until 2011; (U.S. Department of Health and Human Services, 2009b) however, the program does focus on lower-income schools which could lead to a change in the food security of participants. The school breakfast program. The school breakfast program is very similar to the lunch program in that it has the same eligibility requirements and is provided by the same agency for the same locations (U.S. Department of Health and Human Services, 2009b). This program, however, did not start until 1966, when it was introduced as a pilot study. It was made permanent in 1975 (U.S. Department of Health and Human Services, 2009b). The nutritional requirements are also the same for the breakfast

60 program as they are the lunch. Both must meet one-third RDA for protein, vitamin A, vitamin C, iron, calcium, and calories (U.S. Department of Health and Human Services, 2009b). An intervention done with nutrition education and the School Breakfast Program found an increase in healthy eating habits and reduced weight gain with high school participants (Ask, Hernes, Aarek, Johannessen, & Haugen, 2006). The special milk program. The special milk program is unique to the school meal program, since it is offered at facilities that do not necessarily participate in the other two programs (U.S. Department of Health and Human Services, 2009b). However, those facilities that participate in the school lunch and breakfast programs may also receive the special milk program, as long as they also have half-a-day kindergarten programs, since those children are not eligible for the lunch and breakfast programs (U.S. Department of Health and Human Services, 2009b). Another unique feature of this program is that there are no income guidelines in order for a child to receive the benefits. The school is reimbursed for every half pint of milk that they sell, as long as they agree to reduce the overall cost of the milk to children (U.S. Department of Health and Human Services, 2009b). Summer Food Service Program The Summer Food Service Program is a program that fills the summer gap for those children who do not have consistent access to meals on a daily basis. Through the USDA, summer camps or other similar programs can receive the same benefit schools do through the School Lunch and Breakfast programs (U.S. Department of Health and Human Services, 2008). The program started in 1968 as a pilot study, which was put in

61 place permanently in 1975 for low-income families participating in community summer programming (U.S. Department of Health and Human Services, 2008). Community Garden-Based Programs The America Community Gardening Association. The American Community Gardening Association (ACGA) is a bi-national nonprofit membership organization of professionals, volunteers and supporters of community greening in urban and rural communities (Agriculture and Natural Resources, University of California, 2009). This association is based out of Columbus, Ohio, and focuses on increasing the communitys access to produce, nutrition knowledge, and improving their diet through the development of a community garden (Agriculture and Natural Resources, University of California, 2009). The ACGA started in 1979 and has since been associated with over 400 gardening programs in the state (Agriculture and Natural Resources, University of California, 2009). Farm-to-School. The Farm-to-School series, which started in 2000, is a national organization that has state-based programs which connect schools to local farms in order to increase nutrition education, healthy eating, and local farm support (Agriculture and Natural Resources, University of California, 2009). The National Farm to School Network began with the goal of supporting community-based food systems, strengthening family farms, and improving student health by reducing childhood obesity (Agriculture and Natural Resources, University of California, 2009). The program includes produce based practices such as farm fresh salad bars and local foods in the cafeteria, waste

62 management programs like composting, and experiential education opportunities such as planting school gardens, cooking demonstrations and farm tours (Agriculture and Natural Resources, University of California, 2009). The goals of these approaches are to help children understand where their food comes from and how their food choices impact their bodies, the environment and their communities at large (Agriculture and Natural Resources, University of California, 2009). In Ohio there are three existing programs, two of which are based in schools located in urban areas (Agriculture and Natural Resources, University of California, 2009). Due to the nationwide interest in the organization, more Ohio agencies are starting their own farm-to-school based programs, which should increase in the future. School gardening. School gardens have been around since the 19th century as a way to educate, increase physical activity, and feed students (Agriculture and Natural Resources, University of California, 2009). School gardens are still included in curricula in order to maintain physical activity of students and introduce a new way to learn the required subjects math, science, and English. Many studies have used school gardens to improve produce intake and nutrition education with mostly positive results in both physical and academic areas (Graham & Zidenberg-Cherr, 2005; Hermann et al., 2006; McAleese & Rankin, 2007; Morris & Zidenberg-Cherr, 2002; Robinson-O'Brien et al., 2009). In 2005, the Community Food Initiatives partnered with a local Athens County School District to plant a school garden of pumpkin, sunflowers, squash, corn, tomatoes, potatoes, and

63 herbs which included over 300 students, faculty, and parents (Ohio Action for Healthy Kids). Community Food Initiatives. The Community Food Initiatives (CFI) is a non-profit organization that started in 1992 as a part of the Appalachian Center for Economic Networks, ACE-net, in Athens, Ohio (Zerbian, 2007). This program plays a role in providing food to low-income families in the Athens area. Some of CFIs projects include school gardens, gardening and produce education seminars, composting projects, community gardens, and produce donation (Zerbian, 2007). The programs that most directly impact the low-income community are the school gardens, which provide education and produce to the children; community gardens, which allow anyone the opportunity to plant and tend to their own garden and reap the benefits, also require a produce donation, which is a program that donates the excess produce from the community gardens to local individuals, shelters, and community programs in need (Zerbian, 2007). This program, along with the others, provides inexpensive opportunities to provide nutritious food to those who cannot always afford it on their own.

Appalachia Appalachia is a 205,000-square-mile region that follows the Appalachian Mountains from southern New York to northern Mississippi. It includes all of West Virginia and parts of 12 other states: Alabama, Georgia, Kentucky, Maryland,

64 Mississippi, New York, N M N North Carolina, Ohio, Pe ennsylvania, South Carolina, Tennes ssee, an Virginia. Figure 5 is a map of the region. nd e

Figure 5. The Appalachia Region. F e an Note. From T Appalac N The chian Region by D. Sm n, mith, 2008, A Appalachian Regional Commission. Copyright 2 C 2008 by the Appalachian Regional C n Commission. Reprinted w with permission of the author. f

About 23.6 millio people liv in the 420 counties of Appalachia with 42 perc t on ve cent of the populat tion being ru ural, compar with 20 p red percent of th rest of the nation (Smi & he e ith

65 Grant, 2008). Most of the areas economy is based upon natural resources, such as coal, and other manufacturing businesses (Smith & Grant, 2008). Appalachia has been the focus of many studies, as it is known for low education, high unemployment, high poverty, and lower access to health care (Smith & Grant, 2008). Athens County, Ohio, is in the northern region of Appalachia and is situated in the Southeast region of Appalachian Ohio (see Figure 6; Smith & Grant, 2008). Table 7 compares the study area (Athens County, Ohio) to Appalachian Ohio, Ohio, the Appalachian region, and the entire United States for several characteristics.

66 Table 7 Region Economic and Educational Level Comparison Athens Co., OH Population, 2000 Income, 2002 Income % of U.S., 2002 Unemployment Rate, 2003 People Below Poverty Level, 2000 Poverty Rate, 2000 High School Graduate Percentage Adults with College Degree, Percentage Economic Status, 2009 62,223 $19,885 64.3% 4.8% 14,728 Appalachian OH Ohio Appalachian Region United States

1,455,313 11,353,140 $23,057 74.6% 7.1% 191,502 $29,195 94.5% 6.1% 1,170,698

22,894,017 281,421,906 $25,470 82.4% 5.8% 3,030,896 $30,906 100.0% 6.0% 33,899,812

27.4% 82.9%

13.6% 78.2%

10.6% 83%

13.6% 76.8%

12.4% 80.4%

25.7%

12.3%

21.1%

17.7%

24.4%

Distressed

Note. Adapted from The Appalachian Region, by D. Smith, 2008, Appalachian Regional Commission. http://www.arc.gov. Copyright 2008 by the Appalachian Regional Commission. Adapted with permission of the author.

In 2008, Athens County, Ohio, was considered distressed according to the Appalachian Regional Commission (Smith & Grant, 2008), which means it is one of the poorest in the area based upon income and poverty levels. It is classified as in persistent

67 poverty by th USDA (Ec he conomic Res search Servi 2008). T ice, These classifi fications are all based on an average of th countys u a he unemployme poverty level, and in ent, ncome rate fo for th fiscal year (Smith & G he r Grant, 2008) ).

Figure 6. App F palachian Oh Counties hio s. Note. From 2 N 2007 County Profiles, b Ohio Job and Family Services, 20 Ohio y by b y 009, Government. http://www.ohio.gov. C G Copyright 20 by Ohio Job and Fam Services 009 mily s. Reprinted wit permissio R th on.

Accor rding to the O Ohio Depart tment of Hea alth, Athens County is a partially medically und m derserved ar with a sh rea hortage of pri imary care, d dental, and m mental health h

68 care providers (Ohio Department of Health, 2009). There are two hospitals in the county employing 124 physicians for the 62,223 residents. However, only 52.9% of those residents have health insurance (Ohio University's Voinovich School for Leadership and Public Affairs, 2008; Smith & Grant, 2008). Athens County is 93.4% Caucasian ethnicity (Smith & Grant, 2008; U.S. Census Bureau, 2009). The median age is 25.7 years, and 34% have only 12 years of education (Smith & Grant, 2008; U.S. Census Bureau, 2009). Regarding unemployment and financial resources, 8.4% families have both parents in work force, and 37.3% live below 150% poverty level (Smith & Grant, 2008; U.S. Census Bureau, 2009). The top five employers in Athens County are area high schools, Ohio University, the Athens city government, Hocking College, and the Athenss Wal-Mart (Ohio University's Voinovich School for Leadership and Public Affairs, 2008). Health Health is a large concern in Appalachia due to the level of poverty and overall rural landscape (Behringer & Friedell, 2006). Diabetes, Chronic Obstructive Pulmonary Disease (COPD), infant, stroke, accident, motor vehicle, suicide, heart disease, and cancer death rates and hospitalizations are all high in the Appalachian region (Appalachian Regional Commission, 2008). As mentioned previously, Athens County, which is located in Appalachia, is known as a partially medically underserved area, which can involve limited access to and availability of health care related resources (Ohio Department of Health, 2009). Concerns with rural areas in relation to health care include the increased distance to facilities, increased poverty in relation to ability to pay, and

69 education level in relation to understanding conditions and associated treatments (Quandt et al., 2005). In fact, education can play a role in residents health and diet knowledge and experiences (Behringer & Friedell, 2006). A large Appalachian study, which included data collected from Athens, Ohio, found that subjects typically based their health knowledge on events that occurred to other family members, including their understanding of personal disease and risk prevention (Denham et al., 2004). The information also typically came from the elder members of the family, and most of the familys focus was put on the childrens health before others (Denham et al., 2004). Obesity, cancer, chronic disease, and mental health are all concerns in the Appalachian region and are discussed in more detail below. Obesity. Appalachian counties overall have been found to have a higher obesity prevalence, with the exception of African-American men (Appalachian Regional Commission, 2008). Obesity rates have been found to be greater in food-insecure households as compared to their counterparts in Appalachian Ohio ( Holben & Pheley, 2006; Holben & Pheley, 2006; Pheley et al., 2002). One study done with older adults in rural North Carolina found that 80% of their participants were overweight or obese (Quandt et al., 2005). It has also been suggested that rural residents are at a disadvantage when it comes to eating healthy, which cannot only impact their overall health, but also their risk for chronic disease such as obesity and cancer. One study found only a quarter of the grocery stores in rural areas supported healthy eating guidelines by providing

70 recommended foods while most offered only cheaper convenience foods (Liese, Weis, Pluto, Smith, & Lawson, 2007). Appalachian children have been found to have a higher overweight prevalence than the rest of the nation (Demerath et al., 2003). A study done in Athens, Ohio, found 46.2% of children were classified according to BMI criteria as overweight or obese (Tulkki et al., 2006). Half of the children found to be overweight while another 45% had body fat levels ranging from moderately high to very high (Tulkki et al., 2006). However, these trends were not related to food insecurity (Meek, 2005). A study in Appalachian Pennsylvania found 36% of child participants were overweight or at risk for overweight, and another 23% were overweight while researchers in Kentucky found 33% of the children were above the 85th percentile for BMI (Crooks, 1999; Rappaport & Robbins, 2005). A study done in West Virginia in 2003 had similar findings, with 45% of their children subjects being either overweight or at risk for overweight (Demerath et al., 2003). This disturbing trend in children suggests that if not dealt with, this could lead to a larger increase in adult obesity in Appalachia in the future. Cancer and chronic disease. Appalachia has been found to have increased rates of premature mortality than the rest of the nation. Heart disease, all-site cancers, lung cancer, and chronic obstructive pulmonary disease (COPD) are the primary health problems contributing to this phenomenon (Appalachian Regional Commission, 2008). Central and Southwestern Appalachia were found to be comparably disadvantaged in relation to socioeconomic status, while also having higher incidence of premature mortality (Appalachian Regional

71 Commission, 2008). Overall, regions in Appalachia with the lowest rates of health insurance and the highest rates of poverty are the areas with the highest rates of premature mortality (Appalachian Regional Commission, 2008). In relation to heart disease and cancer death rates, Appalachia has higher rates than the rest of the nation, especially the Southeastern Ohio region (Appalachian Regional Commission, 2008). The literature has suggested that due to Appalachias limited access to health care and high poverty levels, future interventions should address these issues while focusing on ways to reduce these cancer rates (Wewers et al., 2006). For diabetes mellitus, it was found that older adults living with diabetes in rural areas of Appalachia had achieved less gylcemic control than those living in urban areas, due to the distance between their homes and health care facilities, related to the regions lack of access to health care (Quandt et al., 2005). This could lead to many complications from their diabetic condition, including neuropathy, retinopathy, nephropathy, and neurological complications. These complications can lead to increased health costs related to the complications, which these rural citizens may not be able to care for. As mentioned previously, food insecurity has been associated with increased with increased risk for chronic disease, while obesity also has a strong correlation. It has been found that those who have healthy, balanced diets had a lower risk of major chronic disease, with the strongest reduction in cardiovascular disease (McCullough et al., 2002). However, these findings relate to mostly well-educated, middle class participants, who may not be representative of the Appalachian population. It was found that women with higher nutrition knowledge and healthy eating behaviors had lower risk of type 2 diabetes

72 in a long-term research study, which suggests those who eat the recommended amounts of produce and have a healthy weight have less risk for chronic disease (Fung, McCullough, van Dam, & Hu, 2007). These studies suggest that with nutrition education, and increased access to healthy foods, the Appalachian populations risk for chronic disease may decrease. Mental health. Appalachia has been found to have higher rates of mental illness, regardless of substance abuse, than the rest of the nation (Zhang, Infante, Meit, & English, 2008). Central Appalachia especially saw increases in mental health incidence 2008, which includes Kentucky, West Virginia, Virginia, and Tennessee (Zhang et al., 2008). Even with this increase in mental health treatment need, there is still a lack of inpatient treatment centers (Zhang et al., 2008). This lack of treatment can be associated with foodinsecurity as well, since it has also been found to be related to mental illness and depression (Alaimo et al., 2002; Bronte-Tinkew et al., 2007; Casey et al., 2004; Olson, 2005; Siefert, Heflin, Corcoran, & Williams, 2001). Food Security In relation to poverty and food access, food insecurity has been found to be a concern to Appalachian residents (Holben et al., 2006; Holben et al., 2004; Holben & Pheley, 2006; Hutson et al., 2007; Kendall et al., 1996; Kropf et al., 2007; Pheley et al., 2002; Tessaro et al., 2006; Walker et al., 2007; Wewers et al., 2006). In fact, in the proposed study region of Appalachian Ohio, food insecurity was found to be three times the level of the rest of the state, as well as almost double the rate of the nation (Holben et

73 al., 2004; Holben & Pheley, 2006; Kropf et al., 2007; Meek, 2005; Pheley et al., 2002; Walker et al., 2007). The entire state of Ohio from 2005 to 2007 had an average of 12.2% of households categorized as food-insecure, with 4.5% of all households being classified as very low food security (Nord et al., 2008). This can lead to many problems throughout the household, including adverse effects on the childrens health (Bronte-Tinkew et al., 2007; Casey et al., 2004; Casey et al., 2005; Casey et al., 2006; Connell et al., 2005; Cook et al., 2006; Kaiser & Townsend, 2005). As has been discussed in the previous food security section, food security has been associated with obesity, depression, increased risk for chronic disease, stunted growth, and poor diet quality (Bhattacharya et al., 2004; Bronte-Tinkew et al., 2007; Cook et al., 2004; Cook et al., 2008; Hamelin et al., 1999; Holben et al., 2006; Holben & Pheley, 2006; Lyons et al., 2008; Rose & Bodor, 2006; Seligman et al., 2007; Tanumihardjo et al., 2007; Townsend et al., 2001; Vozoris & Tarasuk, 2003; Walker et al., 2007; Weinreb et al., 2002). In addition, food insecurity is related to low-income and low-educated households, which is prevalent in the Appalachian region (Smith & Grant, 2008). This underscores the need to address this problem in the region.

Produce Intake in the United States Produce intake has been linked to decreased risk of chronic diseases incidence, including cardiovascular disease, some types of cancers, and obesity (Dalton, 2006; Holt et al., 2009; Van Duyn & Pivonka, 2000). Produce intake has been shown to decline significantly as food insecurity worsens in women and children (Kendall et al., 1996).

74 Childhood obesity has an even greater impact on health than adult obesity, since children are still developing when the consequences can occur. Nearly one million adolescents were diagnosed with metabolic syndrome, posing an increased risk for chronic disease (Pan & Pratt, 2008). However, that same study reported that better diet quality, including increased produce intake and increased physical activity alleviated the risk for metabolic syndrome (Pan & Pratt, 2008). Children in food-insecure households have been found to have lower intakes of dark green vegetables and fruits than those in food-secure households ( Casey et al., 2001; Lorson et al., 2009). In a sample with 10.9% of participants from food-insecure households, participants mean intake of fruits and vegetables was 1 cup per day, much less than the recommended amounts of five servings per day for most people (Lorson et al., 2009). A study focusing on fruit and vegetable intake of rural mothers and children found that most produce intake was inadequate, but those who ate from all five colors of produce (red, orange/yellow, green, white, and purple/blue) consumed 1 more servings than those who did not (Nanney, Schermbeck, & Haire-Joshu, 2007) . The study participants were very similar in demographics to those in the Athens County, Ohio, area, which may indicate that an intervention focusing on fruits and vegetables of young families with children in a school-like setting could be beneficial. More than half of the adolescents in a Canadian study did not meet the 5-a-day fruit and vegetable recommendations; however, intake did increase with increased family income, education, and two parent households (Riediger et al., 2007).

75 Decreased fruit and vegetable preference in children was found to lead to an increased risk for overweight or obesity, which may indicate that produce intake is essential for a healthy body weight (Lakkakula et al., 2008). A study that focused on diet adequacy found that most participants did not have much variety in a one day recall of their dietary intake, but of those who did, they were more likely to meet nutrient adequacy as suggested by the Dietary Reference Intakes (DRIs; Foote, Murphy, Wilkens, Basiotis, & Carlson, 2004). This suggests that with higher produce intake, an adequate nutrient intake is more likely, which may lead to better health. A study conducted in rural North Carolina found children who consumed excessive amounts of sweets did not meet the recommendations for fruits, vegetables, dairy, or grains (Ball et al., 2008). Produce, gardening, and nutrition education interventions with children may improve their overall diet quality and health by improving their physical activity levels and produce intake. Fruit and vegetable availability is particularly important for children not only to sustain adequate nutrition but to instill sound dietary practices early on. There has been some evidence to indicate that gardening programs could positively impact a childs produce intake along with nutrition education (Hermann et al., 2006; Nanney, Johnson et al., 2007; Stables et al., 2005), which will be discussed further in the next section.

Produce and Gardening Interventions Children in low income families have low calcium, iron, vitamins A and C, and folate levels, along with increased body weight and health concerns (Ball et al., 2008;

76 Casey et al., 2006; Dixon et al., 2001; Gao et al., 2006; Langevin et al., 2007; Rose & Oliveira, 1997; Skalicky et al., 2006). Therefore, it has been suggested that interventions should focus on increasing their produce and nutrient intake in school or similar settings (Langevin et al., 2007). Most studies using gardening and nutrition education forums have found a positive change in produce intake (Hermann et al., 2006; Robinson-O'Brien et al., 2009). The school setting does not have to be the only location for such interventions. Other programs have been done at community locations, summer or day camps, and after-school programs. Multiple intervention avenues have also been tried with gardening and nutrition programs, of variable lengths, foci, and populations, with mostly positive results (Graham & Zidenberg-Cherr, 2005; Hermann et al., 2006; McAleese & Rankin, 2007; Nanney, Johnson et al., 2007; Robinson-O'Brien et al., 2009). An intervention focusing on a 5-aday fruit and vegetable intervention in low-income population used Project FRESH vouchers for use at the farmers market with WIC participants, along with education sessions for some groups (Anderson et al., 2001). The study did not significantly improve produce, which may be due to the original groups beginning with a high produce intake (Anderson et al., 2001). However, a similar project done with South Carolina Senior Farmers Market Nutrition Education Program participants found that increasing availability of produce and education of subjects resulted in an increased intake of produce (Kunkel, Luccia, & Moore, 2003). A study in 2005 had one-hour interventions for several weeks with seven to nine year old children in a school-based program focused on specific fruit and vegetables that could be increased in the diet (Nanney, Haire-Joshu,

77 Elliott, Hessler, & Brownson, 2005). Another type of six-week program focused on fruit and vegetable intake in Boston, but they provided information through an internet intervention. Even though most of the study focused on the development and use of the website, it was found that those who had higher fruit and vegetable intakes used the website more, suggesting that they had a higher interest in healthy eating (McNeill, Viswanath, Bennett, Puleo, & Emmons, 2007). This may indicate that regardless of the intervention method, those who are already interested in healthy practices may be more compliant with an intervention than others. Behavior change is the central goal in such interventions, and therefore those who focus on the behavior change theory and stages of change seem to have more success. A very similar, but more extensive, gardening program was implemented in California. Three different schools were provided with nine nutrition lessons focused on plant structure, nutrients, Food Guide Pyramid, serving sizes, reading food labels, increasing physical activity, goal setting, consumerism, and snack preparation. The program positively impacted both childrens nutrition knowledge and vegetable preferences (Morris & Zidenberg-Cherr, 2002). An additional survey done in California obtained the teachers opinions about the effectiveness of the school gardening and nutrition education programs. Researchers found that the teachers were using the garden for teaching nutrition, science, language arts, and math, but they indicated more resources to link the gardening to their curriculum were needed (Graham & Zidenberg-Cherr, 2005). Another school gardening and nutrition education program was created for three schools in Idaho, with the inclusion of a control school. The groups were divided into

78 solely nutrition education, nutrition education plus gardening, and a control group which received no treatment (McAleese & Rankin, 2007). Researchers found that the gardening plus nutrition education group significantly improved their produce and nutrient intake, more specifically vitamins A and C, and fiber (McAleese & Rankin, 2007). In Canada, researchers created a school-based program to enhance the knowledge and psychosocial factors related to healthy eating and its impact on the dietary fiber and fat intake of the children. They used a pre-test/post-test with elementary school children. The program was significantly associated with increased knowledge, dietary selfefficacy, and improved overall diet (Saksvig et al., 2005). A study done in 2005 focused on the Dietary Intervention Study in Children, consisting of a randomized controlled trial originally designed to test a three-year intervention intended to lower blood cholesterol by focusing on reducing fat, cholesterol, while increasing fiber, fruits, and vegetables (Van Horn, Obarzanek, Friedman, Gernhofer, & Barton, 2005). Their message was based on a whoa/go foods system. Foods were chosen through their fat content with go foods being lower fat, including fruits and vegetables, and whoa foods having more fat (Van Horn et al., 2005). They encouraged go foods in each food group while suggesting less, but not none, of the whoa foods (Van Horn et al., 2005). It was found that the children had positive results to the intervention, and therefore the study was extended (Van Horn et al., 2005). Use of electronic communication in interventions was found to be associated with increased fruit and vegetable intake; however, the study focused on the self efficacy of the participants primarily (Luszczynska et al., 2007). Interventions typically work better when

79 customized to the specific population. One study developed an interactive multimedia intervention for participants to decrease their fat consumption with positive results (Irvine, Ary, Grove, & Gilfillan-Morton, 2004). Since this intervention was specifically designed for this population, it may have gotten better results than if it had been a generic program developed for wide spread use. Overall, it seems that interventions that include gardening along with nutrition education have a more successful impact on produce preference and intake than those that only focus on nutrition education. Length of the intervention also seems to play a role with more time spent equaling greater results. Parental reporting of childrens dietary intake has been utilized in research projects. Therefore, researchers have asked how accurate these parents are when recalling their childs fruit and vegetable intake. Overall it was found that parents accurately reported their childs intake, with only some discrepancy on juices and combination foods that included fruits and vegetables (Linneman et al., 2004). Thus, it should be safe to include questions about their childs perceptions and intake if necessary on our surveys. However, another similar study done in the Netherlands found poor correlation between parent and child responses to the childs vegetable intake, but better correlation with their fruit intake (Reinaerts, de Nooijer, & de Vries, 2007).

Conclusion The literature shows that food insecurity is a serious health-related problem affecting both adults and children, while also associated with decreased produce intake. It

80 has been suggested that interventions done by nutrition professionals should incorporate produce options that relate to the culture, region, and status of that area (Nanney, HaireJoshu, Hessler, & Brownson, 2004). Even though many studies have attempted to target interventions toward the younger population to combat this problem through use of fruit and vegetable and gardening programs, none have done so in Appalachian Ohio. Therefore, this study: (a) measured the effect of a nutrition and gardening education program on Appalachian childrens fruit and vegetable intakes and preferences; and (b) examined the relationship of food security status to gardening habits and perceptions, produce intake, and personal characteristics of children and their adult female caregivers.

81 CHAPTER 3: METHODOLOGY Produce intake in the United States typically does not meet the recommended levels, especially in women and children (Anderson et al., 2001; Ball et al., 2008; Cassady et al., 2007; Foote et al., 2004; Fu et al., 2007; Fung et al., 2007; Guenther et al., 2006; Hazen et al., 2008; Holben & Pheley, 2006; Kropf et al., 2007; Lorson et al., 2009; McCullough et al., 2002; Nanney et al., 2005; Olson, 1999; Pierce, Stefanick et al., 2007; Potischman et al., 1998; Struble et al., 2008; Tarasuk & Beaton, 1999; Walker et al., 2007). Fruit and vegetable intake has been found to be inversely related to household food security (Bhattacharya et al., 2004; Dixon et al., 2001; Kendall et al., 1996; Kropf et al., 2007). For adult females and children living in food-insecure households, fruits and vegetables are typically the first groups reduced from the diet, due to their higher price and shorter shelf life, compared to other foods (Cassady et al., 2007; Dixon et al., 2001; Kendall et al., 1996; Kropf et al., 2007). Through the practice of gardening, a family may be able to grow fruits and vegetables at a lower cost than purchasing them, while increasing both physical activity and produce intake. This study: (a) measured the effect of a nutrition and gardening education program on Appalachian childrens 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.

82 Subjects The Institutional Review Board at Ohio University approved of this quasiexperimental research study prior to the collection of any data (Appendix C). Potential child participants were children enrolled in Kids on Campus in the 1st through 4th grade programs. Potential caregiver participants were adult females 18 years and older living in Athens County, Ohio, with children enrolled in a university-based summer day camp, Kids on Campus, in 1st through 6th grade programs. Kids on Campus is a six-week, College of Health and Human Services program which serves households in Athens County, Ohio, through summer educational and recreational activities. Even though child participants were only in grades 1st through 4th for Kids on Campus scheduling reasons, female caregiver participants were those with any child participating in Kids on Campus (grades 1st through 6th). Male caregivers were ineligible, since the focus of this study was on characteristics of female caregivers. Participants were recruited using convenience sampling through the summer day camp.

Setting This study took place in Athens County, Ohio, which is classified as a distressed county in Appalachia by the Appalachian Regional Commission based upon income and poverty levels (Smith & Grant, 2008), and as having persistent poverty by the United States Department of Agriculture (USDA; Economic Research Service, 2008). According to the Ohio Department of Health, Athens County is a partially medically underserved area with a shortage of primary care, dental, and mental health care providers (Ohio

83 Department of Health, 2009). There are two hospitals in the county employing 124 physicians for the 62,223 residents. However, only 52.9% of those residents have health insurance (Ohio University's Voinovich School for Leadership and Public Affairs, 2008; Smith & Grant, 2008).

Project Description Adult female participants were surveyed only at the onset of the study, approximately one month prior to the start of the summer camp. Informed consent was included on the first page of the survey (see Appendix D), with consent of the participant being assumed with the return of the survey. A 79-item survey (see Appendix D) was distributed in May 2008 through Kids on Campus with other programmatic recruitment materials to assess the food security, health, and produce intakes and behaviors, as well as their perception of the produce intakes and gardening behaviors of their children. Surveys included previously validated items [SF-12 health questionnaire (Ware & Sherbourne, 1992), Psychosocial Indicators of Fruit and Vegetable Intake in Low Income Communities questionnaire and Food Behavior Checklist for a Limited Resource Audience (Townsend & Kaiser, 2005; Townsend & Kaiser, 2007), U.S. household 6-item food security survey module (Bickel et al., 2000)]. There were also questions related to participant characteristics, including gender, age, and self-identified weight, height, and diabetes mellitus status, as well as perception of self and family gardening habits and produce. Only the food security, female fruit and vegetable intake, gardening, and demographic data were used for this thesis.

84 Children were surveyed prior to and after the nutrition and gardening education intervention. On the first day of the gardening program, each child participant completed both an 18-item fruit and an 18-item vegetable preference and intake checklist (see Appendix F). The questionnaires, adapted from the Saint Louis University School of Public Healths SLU 4 Kids FFQ, itemized the produce names and included an image of each. Children circled foods that were liked and noted foods eaten in the past week by checking a corresponding box. This instrument was developed for this study and has not been previously validated, but was based on the previously validated Saint Louis University 4 Kids Food Frequency Questionnaire (SLU 4 Kids FFQ; Haire-Joshu et al., 2003). After completing the initial surveys, the first nutrition education and gardening program was delivered. Five additional weekly lessons were delivered over the six-week program. Overall, the nutrition education and gardening program included information on gardening, plant growth and maintenance, composting, vitamins, minerals, fiber, and MyPyramid.gov. The next section details the entire program. The children were provided with educational materials, gardening information, and locally-grown produce with corresponding recipes to take home to the adult female caregiver participants weekly. All educational materials sent home included information from the weekly lesson, as well as gardening tips and ways to increase produce intake at home with different recipes. During week six, at the conclusion of the program, each child completed the produce checklist to assess for changes in preferences and intake of produce.

85 The Nutrition Education and Gardening Program Overall, the nutrition education and gardening program included information on gardening, plant growth and maintenance, composting, and basic nutrition concepts. Based upon a needs assessment of US children, weekly lessons were developed and focused on food groups and nutrients shown to be lacking (Ashiabi & O'Neal, 2007; Ball et al., 2008; Casey et al., 2001; Gao et al., 2006; Lorson et al., 2009; Nanney et al., 2005; Skalicky et al., 2006; Trevino et al., 2008). The program included six, one-hour lessons: 1. Week 1: Gardening is Great! Gardening basics. 2. Week 2: Gardening is Colorful! Mypyramid basics. 3. Week 3: Fruit + Vegetables = Fiber. Fiber content in produce and its benefits. 4. Week 4: Teamwork. Functions and food sources of vitamin C and iron. 5. Week 5: Dynamic Duo. Functions and food sources of vitamin A and calcium. 6. Week 6: Scraps to Soil! Composting basics. Weekly lessons were developed for the 1st through 4th grade levels through a combination of EarthBox-suggested activities and original activities. The lessons were delivered weekly to groups of campers (six groups of 25), according to grade level (3 groups 1st-2nd graders, 3 groups 3rd-4th graders). The lesson plans are in Appendix E.

Data Scoring and Statistical Analysis All data was tabulated and analyzed using the Statistical Program for the Social Sciences (SPSS) version 16.0. A p-value less than 0.05 was considered statistically significant. Female caregivers weight was assed using body mass index (BMI) categories through self-reported heights and weights (kg/m2) and then categorized using

86 the Center for Disease Control (CDC) guidelines. Household Food Security Status was scored according to the standardized methods for the six-item survey scoring (Bickel et al. 2000), while produce readiness of the female caregivers were scored using the methods of Townsend and Kaiser ( Townsend & Kaiser, 2005; Townsend & Kaiser, 2007). Gardening readiness was measured using two items modeled after the methods of Townsend and Kaiser ( Townsend & Kaiser, 2005; Townsend & Kaiser, 2007). Scoring for these instruments is summarized in Appendix A. Table 8 summarizes the statistical analyses completed by research question.

87 Table 8 Research Questions and Associated Statistical Test Research Questions 1. Does a six-week nutrition and gardening education program improve childrens preference for and intake of fruits and vegetables? 2. At the onset of the study, is household food security status related to the female caregivers perception of the gardening habits of the children? 3. At the onset of the study, is household food security status related to the female caregivers gardening readiness? 4. At the onset of the study, is household food security status related to produce intake of female caregiver? 5. At the onset of the study, are the female caregivers gardening habits related to their perceptions of the childs gardening habits? 6. At the onset of the study, is household food security status related to produce preferences and intakes of child participants? 7. At the onset of the study, are the childs produce intake and preferences related to their female caregivers produce intakes? 8. At the onset of the study, are the childs produce intake and preferences related to their female caregivers gardening habits? 9. Do body mass index (BMI), vegetable intake, and fruit intake differ between female caregivers from food-secure versus food-insecure households? 10. Do marital status, education level, transportation, hunting, fishing, food assistance program participation, perceived health level, diet quality, body mass index category, and produce and Statistical Test T-test

Kendall tau-b Correlation

Kendall tau-b Correlation

Kendall tau-b Correlation

Kendall tau-b Correlation

Kendall tau-b Correlation

Kendall tau-b Correlation

Kendall tau-b Correlation

Mann-Whitney U

Pearson Chi Square

88 gardening readiness differ between female caregivers from food-secure versus food-insecure households?

89 CHAPTER 4: RESULTS Fruit and vegetable intake has been found to be related to household food security status (Bhattacharya et al., 2004; Dixon et al., 2001; Kendall et al., 1996; Kropf et al., 2007). For adult females and children living in food-insecure households, fruits and vegetables are typically the first groups reduced from the diet, due to their higher price and shorter shelf life, compared to other foods (Cassady et al., 2007; Dixon et al., 2001; Kendall et al., 1996; Kropf et al., 2007). Through the practice of gardening, however, a family may be able to grow fruits and vegetables at a lower cost than purchasing them, while increasing both physical activity and produce intake. This study: (a) measured the effect of a nutrition and gardening education program on Appalachian childrens 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.

Child Participant Data Of the 150 children in grades 1st through 4th participating in Kids on Campus during the summer of 2008, 91 completed both pre- and post-intervention surveys (60.7% completion rate). Of the 91 participants who completed both surveys, 49 (54.0%) were entering grades 1st or 2nd grade, while 42 (46.0%) were entering 3rd or 4th grade. According to Kids on Campus records, child participants ranged in age from 5 to 9 years and were entering grades 1 through 4. Participating households had a median income of $22,000 per year. The child participants were Caucasian (93%), African American (2%),

90 Asian, (2%), Hispanic (2%), and American Indian (1%). (Note: Due to Kids on Campus regulations, we were not able to obtain individual demographic information on the children.) Table 9 and Figure 7 describe the child participants variety of produce eaten and preferred. Preferred fruits and vegetables were those that the child liked (preference variety), while eaten fruits and vegetables were those items consumed in the past week (intake variety).

91 Table 9 Child Participants Produce Preferences and Intakes Pre-Intervention Preferences & Intakes (n = 91) Mean Standard Deviation Variety of Fruit Preferred (Number of Fruits Preferred) Fruit Intake Variety (Number of Different Fruits Eaten in the Past Week) Variety of Vegetables Preferred (Number of Vegetables Preferred) Vegetable Intake Variety (Number of Different Vegetables Eaten in the Past Week) Variety of Produce Preferred (Total Number of Produce Preferred) Produce Intake Variety (Total Number of Different Produce Items Eaten in the Past Week) 6.9 6.6 Post-Intervention Preferences & Intakes (n = 91) Mean Standard Deviation 7.3 6.9 .554 p-value

9.6 6.1

9.1 6.9

.563

6.2 5.5

5.6 5.9

.341

7.3 5.3

8.4 6.0

.106

13.1 10.9

13.0 11.9

.977

16.9 10.1

17.3 11.4

.751

Note. Paired t-test was used to calculate differences between groups.

92
Pre-intervention Post-intervention

16.9 17.3 13.1 13.0 9.6 6.9 7.3 6.2 5.6 9.1 7.3

8.4

Fruit Preference

Fruit Intake

Vegetable Preference

Vegetable Intake Total Produce Preference

Total Produce Intake

Figure 7. Child participants produce preference and intake variety.

The nutrition education and gardening program was evaluated as part of the Kids on Campus evaluation process. Seventy-two children (48.0% response rate) completed the Kids on Campus programmatic survey. Of those 72, 59 (81.9%) of the 150 1st through 4th graders were 1st and 2nd graders, and 13 (18.1%) were 3rd and 4th graders. Of the 1st and 2nd graders, 43 (72.9%) liked, 9 (15.3%) sometimes liked, and 4 (6.8%) did not like the nutrition education and gardening program. Among the 3rd and 4th graders, 3 (23.1%) liked, 3 (23.1%) sometimes liked, and 7 (53.8%) did not like the nutrition education and gardening program. Overall, 58 of the 72 students (80.6%) liked or sometimes liked the nutrition education and gardening program.

93 Female Caregiver Participant Data Of the 250 surveys sent to female caregivers of children participating in the 2008 summer Kids on Campus Program, 99 (39.6% response rate) were returned. Table 10 describes the female caregiver participants, who were 34.7 7.2 years and living in households composed of 3.8 1.2 members. Body mass index (BMI) classification and perceived diet and health status for the female participants are shown in Table 11. Figure 8 also shows female caregivers BMI classification. Table 12 and Figure 9 describe the readiness for produce intake among the female caregivers. Produce gardening habits and readiness for gardening of female caregivers are summarized in Table 13 and Figure 9. As noted in Table 13, 23 and 37 reported having fruit and vegetable gardens, respectively. This mirrored the gardening readiness of female caregivers, with the same number of caregivers being in the action and maintenance stages for fruit and vegetable gardening.

94 Table 10 Characteristics of Female Participants and Their Households Number of Female Caregivers RACE (n = 98) American Indian or Native Alaskan Asian African American Caucasian MARITAL STATUS (n = 98) Married Divorced Separated Single/Never Married 45 26 4 23 45.9% 26.5% 4.1% 23.5% 4 5 7 82 4.1% 5.1% 7.1% 83.7% Percentage of Female Caregivers

LEVEL OF EDUCATION (n = 99) Less than High School High School: Diploma or General Educational Development (GED) Some College or Higher 3 26 3.0% 26.3%

70

70.7%

HOUSEHOLD FOOD SECURITY STATUS (n = 99) Fully Food Secure Marginal Food Security Low Food Security Very Low Food Security 36 14 24 25 36.4% 14.1% 24.2% 25.3%

HOUSEHOLD FOOD ASSISTANCE PROGRAM PARTICIPATION National School Lunch Program (Free or Reduced Price; n = 99) School Breakfast Program (Free or Reduced Price; n = 99) 73 73.7%

66

66.7%

95 Table 10: continued 19 Head Start Program (n = 97) Special Supplemental 23 Nutrition Program for Women, Infants, and Children (WIC; n = 99) Supplemental Nutrition 53 Assistance Program (SNAP; n = 99) WIC Farmers Market 9 Nutrition Program (n = 99) Community Food Pantry 36 (n = 99) 19.6%

23.2%

53.5%

9.1% 36.4%

HOUSEHOLD HAD TRANSPORTATION FOR FOOD AQUISITION (n = 98) Yes No 90 8 91.8% 8.2%

HOUSEHOLD HUNTED FOR FOOD (n = 97) Yes No 20 77 20.6% 79.4%

HOUSEHOLD FISHED FOR FOOD (n = 97) Yes No 14 83 14.4% 85.6%

96 Table 11 Female Caregiver Body Mass Index and Perceived Diet Quality and Health Status Number of Female Caregivers Percentage of Female Caregivers

BODY MASS INDEX (BMI) CLASSIFICATION (n = 93) Obese (BMI >30) 43 46% Overweight (BMI 2527 29% 29.9) Normal (BMI 18.5-24.9) 20 22% Underweight (BMI < 3 3% 18.5) PERCEIVED DIET QUALITY (n = 98) Excellent Very Good Good Fair Poor 2 10 45 28 13 2% 10% 46% 29% 13%

PERCEIVED HEALTH STATUS (n = 98) Excellent Very Good Good Fair Poor 4 39 38 14 3 4% 40% 39% 14% 3%

Note. Body mass index was calculated from self-reported height and weight data and were classified using CDC guidelines.

97

U Underweight 3%

Normal 20%

Obese 44% Overw weight 27 7%

Figure 8. Fem caregiver participants weight c F male v n classification n.

98 Table 12 Female Participant Readiness for Eating Produce Number of Female Caregivers READINESS FOR EATING FRUIT (n = 98) Precontemplation Contemplation Preparation Action Maintenance 9 9 9 60 11 9.2% 9.2% 9.2% 61.2% 11.2% Percentage of Female Caregivers

READINESS FOR EATING VEGETABLES (n = 97) Precontemplation Contemplation Preparation Action Maintenance 7 8 10 58 14 7.2% 8.2% 10.3% 59.8% 14.4%

99 Table 13 Female Participant Gardening Habits and Readiness for Gardening Produce Number of Female Caregivers HOUSEHOLD VEGETABLE GARDEN (n = 97) Yes No 37 60 38.1% 61.8% Percentage of Female Caregivers

HOUSEHOLD FRUIT GARDEN (n = 96) Yes No 23 73 23.9% 76.1%

READINESS FOR GARDENING VEGETABLES (n = 97) Precontemplation Contemplation Preparation Action Maintenance 36 16 8 14 23 37.1% 16.5% 8.2% 14.4% 23.7%

READINESS FOR GARDENING FRUIT (n = 96) Precontemplation Contemplation Preparation Action Maintenance 52 16 5 15 8 54.2% 16.7% 5.2% 15.6% 8.3%

100

70.0% 60.0%
Percentage of Participants

50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

Garden Vegetables Garden Fruit Eat Vegetables Eat Fruit

Readiness Stage of Change

Figure 9. Female caregiver produce and gardening readiness.

Table 14 summarizes the relationship of food security status (scale score) to parameters measured, and Table 15 summarizes the relationship of female caregiver habits to select parameters.

101 Table 14 Relationship of Food Security Status to Gardening- and Produce-Related Behaviors and Intakes Characteristic Child Vegetable Gardening Habits Child Variety of Produce Preferred Child Variety of Produce Eaten Female Caregiver Vegetable Gardening Readiness Female Caregiver Fruit Gardening Readiness Female Caregiver Fruit Intake Female Caregiver Vegetable Intake Female Caregiver Total Produce Intake Correlation Coefficient .010 -.112 -.017 .051 .088 -.170 -.224 -.205 p-value .888 .378 .893 .417 .176 .009 .001 .001

Note. Kendalls tau was utilized to measure the relationship of food security to other factors.

102

Table 15 Relationship of Female Caregivers Habits to Gardening- and Produce-Related Behaviors and Intakes Characteristic Correlation Coefficient p-value

FEMALE CAREGIVERS VEGETABLE GARDEN READINESS b Child Vegetable Gardening Habits b Child Variety of Fruits Preferred b Child Variety of Vegetables Preferred b Child Variety of Produce Preferred b Child Variety of Fruits Eaten b Child Variety of Vegetables Eaten b Child Variety of Produce Eaten b Female Caregivers Readiness to Garden Fruit b Female Caregivers Vegetable Intake b -.163 -.059 -.084 -.028 -.170 -.103 -.142 .607 .150 .021 .659 .518 .826 .188 .420 .263 <.001 .036

FEMALE CAREGIVERS FRUIT GARDEN READINESS c Child Vegetable Gardening Habits c Child Variety of Fruits Preferred c Child Variety of Vegetables Preferred c Child Variety of Produce Preferred c Child Variety of Fruits Eaten c Child Variety of Vegetables Eaten c Child Variety of Produce Eaten c Female Caregivers Fruit Intake c -.119 -.064 -.017 -.009 -.234 -.073 -.195 .275 .100 .638 .899 .944 .075 .573 .129 .840

FEMALE CAREGIVERS FRUIT INTAKE d Child Variety of Fruits Preferred d Child Variety of Vegetables Preferred d Child Variety of Produce Preferred d Child Variety of Fruits Eaten d Child Variety of Vegetables Eaten d Child Variety of Produce Eaten d -.370 -.153 -.275 .320 .049 .232 .010 .271 .046 .021 .723 .087

FEMALE CAREGIVERS VEGETABLE INTAKE e Child Variety of Fruits Preferred e Child Variety of Vegetables Preferred e .045 .042 .755 .764

103 Table 15: continued Child Variety of Produce Preferred e Child Variety of Fruits Eaten e Child Variety of Vegetables Eaten e Child Variety of Produce Eaten e .053 .287 .261 .293 .704 .040 .058 .031

FEMALE CAREGIVERS PRODUCE INTAKE f Child Variety of Fruits Preferred f Child Variety of Vegetables Preferred f Child Variety of Produce Preferred f Child Variety of Fruits Eaten f Child Variety of Vegetables Eaten f Child Variety of Produce Eaten f -.117 -.016 -.069 .384 .172 .313 .397 .905 .604 .004 .193 .016

Note. Kendalls tau was utilized to measure the relationship the factors. b-f Factors with like superscripts indicate that the correlations of the characteristic in upper case were computed for its relationship to those in lower case.

Data were also stratified by food security status. Table 16 shows female caregiver and household characteristics stratified by food security status, while Table 17 and Figure 10 summarize the differences in female caregivers BMI and fruit and vegetable intakes by food security status. Table 18 shows female produce readiness in relation to food security status, while Table 19 displays female produce gardening readiness in relation to food security status.

104

Table 16 Female Caregiver and Household Characteristics Stratified by Food Security Status Characteristic Number of Female Caregivers (%) Food Secure MARITAL STATUS (n = 98) Married Not-married 21 (21.4%) 29 (29.6%) 24 (24.5%) 24 (24.5%) .427 Food Insecure p-value

LEVEL OF EDUCATION (n = 99) No College Some College or Higher 8 (8.1%) 42 (42.4%) 21 (21.2%) 28 (28.3%) .003

AVAILABILITY OF TRANSPORTATION FOR FOOD AQUISITION (n = 98) Reliable Transportation Unreliable Transportation 47 (47.9%) 3 (3.1%) 43 (43.9%) 5 (5.1%) .425

PARTICIPATION IN HUNTING FOR FOOD ACQUISITION (n = 97) Hunt for Food Do not Hunt for Food 9 (9.3%) 41 (42.3%) 11 (11.3%) 36 (37.1%) .511

PARTICIPATION IN FISHING FOR FOOD ACQUISITION (n = 97) Fish for Food Do not Fish for Food 6 (6.2%) 44 (45.4%) 8 (8.2%) 39 (40.2%) .482

FOOD ASSISTANCE PROGRAM PARTICIPATION Supplemental Nutrition Assistance Program (SNAP; n = 99) National School Lunch Program (Free- or Reduced- Price; n = 99) 21 (21.2%) 32 (32.3%) .020

30 (30.3%)

43 (43.4%)

.002

105 Table 16: continued School Breakfast Program (Free- or Reduced- Price; n = 99) Head Start Program (n = 97) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC; n = 99) WIC Farmers Market Nutrition Program (n = 99) Community Food Pantry (n = 99) 26 (26.3%) 40 (40.4%) .002

7 (7.2%) 8 (8.1%)

12 (12.4%) 15 (15.2%)

.219 .085

1 (1.0%) 9 (9.1%)

8 (8.1%) 27 (27.3%)

.013 <.001

PERCEIVED HEALTH (n = 98) Poor or Fair Good or Better PERCEIVED DIET (n = 98) Poor or Fair Good or Better 15 (15.3%) 35 (35.7%) 26 (26.5%) 22 (22.5%) .015 6 (6.1%) 43 (43.9%) 11 (11.2%) 38 (38.8%) .182

BODY MASS INDEX (BMI) CLASSIFICATION (n = 93) Normal or Underweight Overweight or Obese 16 (17.2%) 31 (33.3%) 7 (7.5%) 39 (41.9%) .035

Note. Pearson Chi-Square test was used to stratify household characteristics by food security status.

106 Table 17 Female Caregiver Weight and Diet Characteristics Stratified by Food Security Status Mean Standard Deviation (n, %) Food Secure BMI (kg/m) (n = 93) Female Caregiver Daily Vegetable Serving (n = 95) Female Caregiver Daily Fruit Serving (n = 96) 28.3 6.8 (47, 50.5%) 2.1 1.2 (48, 50.5%) Food Insecure 31.9 10.3 (46, 49.5%) .075 1.5 0.7 (47, 49.5%) .016 p-value

1.6 0.8 (48, 50%)

1.3 0.8 (48, 50%)

.070

Note. Mann-Whitney test was utilized to calculate differences between groups.

107

50 40 31.9 30 20 10 2.1 0 Average BMI 10 20 Average Vegetable Serving Average Fruit Serving 1.5 1.6 1.3 28.3 Food Secure Food Insecure

Figure 10. Female caregiver body mass index and produce intake by food security status.

108 Table 18 Female Caregiver Produce Readiness Stratified by Food Security Status Number of Female Caregivers Food Secure (%) READINESS TO EAT FRUIT (n = 98) Precontemplation, Contemplation, or Preparation Stage Action or Maintenance Stage 11(11.2%) 38 (38.8%) 16 (16.3%) 33 (33.7%) .258 Food Insecure (%) p- value

READINESS TO EAT VEGETABLES (n = 97) Precontemplation, Contemplation, or Preparation Stage Action or Maintenance Stage 9 (9.3%) 40 (41.2%) 16 (16.5%) 32 (32.9%) .092

Note. Pearson Chi-Square test was used to stratify parameters by food security status.

109 Table 19 Gardening Readiness and Habits of Female Caregivers Stratified by Food Security Status Number of Female Caregivers (%) Food Secure GARDENING FRUIT (n = 96) Gardens Fruit Does Not Garden Fruit 12 (12.5%) 36 (37.5%) 11 (11.5%) 37 (38.6%) .811 Food Insecure p-value

GARDENING VEGETABLES (n = 97) Gardens Vegetables Does Not Garden Vegetables 20 (20.6%) 28 (28.9%) 17 (17.5%) 32 (32.9%) .480

READINESS TO GARDEN FRUIT (n = 98) Precontemplation, Contemplation, or Preparation Stage Action or Maintenance Stage 11 (11.2%) 38 (38.8%) 16 (16.3%) 33 (33.7%) .258

READINESS TO GARDEN VEGETABLES (n = 97) Precontemplation, Contemplation, or Preparation Stage Action or Maintenance Stage 9 (9.3%) 40 (41.2%) 16 (16.5%) 32 (32.9%) .092

Note. Pearson Chi-Square test was used to stratify parameters by food security status.

As previously noted in chapter 3, before the intervention, surveys were sent to all female caregivers (n = 250) of children participating in Kids on Campus. Tables 20 and 21 show female caregivers perception of their childrens produce and gardening habits

110 for all children stratified by food security, grades 1st through 6th who participated in the summer of 2008.

Table 20 Female Caregivers Perception of Childrens Produce Intake Stratified by Food Security Status Mean Standard Deviation (n, %) Food Secure Daily Vegetable Servings (n = 156) Daily Fruit Servings (n = 156) 2.1 1.0 (78, 50%) 2.0 1.2 (78, 50%) Food Insecure 1.7 1.0 (78, 50%) 1.7 .9 (78, 50%) .017 .072 p-value

Mann-Whitney test was utilized to calculate differences between groups.

111 Table 21 Female Caregivers Perception of Childrens Habits Number of Child Participants (%) Food Secure Food Insecure p- value

CHILD EATS MORE THAN ONE TYPE OF FRUIT PER DAY (n = 156) Never or Sometimes Often or Always 36 (23.1%) 39 (25.0%) 56 (35.9%) 25 (16.0%) .007

CHILD EATS MORE THAN ONE TYPE OF VEGETABLE PER DAY (n = 155) Never or Sometimes Often or Always 24 (15.5%) 50 (32.3%) 53 (34.2%) 28 (18.1%) < .001

CHILD EATS TWO OR MORE VEGETABLE SERVINGS AT A MEAL (n = 152) Never or Sometimes Often or Always 44 (28.9%) 27 (17.8%) 67 (44.1%) 14 (9.2%) .004

CHILD EATS CITRUS FRUIT OR JUICE (n = 160) Yes No 54 (33.8%) 22 (13.8%) 43 (26.9%) 41 (25.6%) .010

CHILD EATS FRUITS OR VEGETABLES AS SNACKS (n = 156) Yes No 67 (42.9%) 7 (4.5%) 66 (42.3%) 16 (10.3%) .077

CHILD IS INTERESTED IN EATING 3+ FRUIT PER DAY (n = 157) Strongly Agree or 57 (36.3%) Agree Disagree or Strongly 19 (12.1%) Disagree 71 (45.2%) 10 (6.4%) .041

CHILD IS INTERESTED IN EATING 3+ VEGETABLES PER DAY (n = 155) Strongly Agree or 44 (28.4%) Agree Disagree or Strongly 30 (19.4%) Disagree 56 (36.1%) 25 (16.1%) .209

112 CHILD IS INTERESTED IN GARDENING VEGETABLES (n = 150) Strongly Agree or 56 (37.3%) Agree Disagree or Strongly 16 (10.7%) Disagree 70 (46.7%) 8 (5.3%) .046

Note. Pearson Chi-Square test was used to stratify childrens characteristics by food security status.

113 CHAPTER 5: DISCUSSION, CONCLUSIONS, AND RECOMMENDATIONS Fruit and vegetable intakes have been found to be related to household food security status (Bhattacharya et al., 2004; Dixon et al., 2001; Kendall et al., 1996; Kropf et al., 2007). For adult females and children living in food-insecure households, fruits and vegetables are typically the first groups reduced from the diet, due to their higher price and shorter shelf life, compared to other foods (Cassady et al., 2007; Dixon et al., 2001; Kendall et al., 1996; Kropf et al., 2007). Through the practice of gardening, a family can grow fruits and vegetables at a lower cost than purchasing them, while increasing both produce intake and physical activity. This study: (a) measured the effect of a nutrition and gardening education program on Appalachian childrens 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, nutrition education 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-week intervention period about themselves, their household, and their 157 children. Results indicated that the six-week nutrition education and gardening intervention did not significantly impact produce intake variety or produce preference variety among the children participating in the program. Overall, household food security was not related to the variety of produce eaten or preferred reported by children; however, it was related to vegetable intake, education, diet quality, food assistance program participation, and body

114 mass index of the female caregivers. On the other hand, household food security was related to the estimated childrens produce intake and preferences reported by the female caregivers prior to the intervention. It was also found that childrens gardening habits reflected that of their female caregivers, but childrens self-reported produce intake variety was not related to their gardening habits. However, household food security was not related to gardening habits or produce readiness of female caregivers.

Children Participants Produce Preference and Intake Variety Produce intake is inadequate among children, which negatively impacts diet (Ball et al., 2008; Gao et al., 2006; Langevin et al., 2007; Lorson et al., 2009). In the study region, multiple studies have indicated the need for intervention in the Southeastern Ohio Appalachian region in relation to promoting fruit and vegetable intake (Ball et al., 2008; Cassady et al., 2007; Holben et al., 2004; Kropf et al., 2007; Luszczynska et al., 2007; Walker et al., 2007; Wewers et al., 2006). One potential solution is to introduce gardening to children, who may, in turn, influence the entire households habits surrounding gardening and produce. Therefore, this research studied the effectiveness of a six-week nutrition and gardening education program improve childrens preference for and intake of fruits and vegetables. In this study, produce intake variety did not significantly change after the intervention (p = .751). Overall, children reported consuming 16.9 10.1 different produce items during the week prior to the intervention and 17.3 11.4 during the last week of the intervention. Similarly, neither fruit intake variety (p = .563) nor vegetable

115 intake variety (p = .106) changed after the intervention. More specifically, fruit and vegetable intake variety were 9.6 6.1 and 7.3 5.3 different items during the week prior to the intervention, respectively, and were 9.1 6.9 and 8.4 6.0 during the last week of the intervention, respectively. As with intake variety, produce (p = .977), fruit (p = .554), and vegetable (p = .341) preference varieties did not significantly change after the intervention. Fruit preference variety was 6.9 6.6 pre-intervention and 7.3 6.9 post-intervention. Vegetable preferences were 6.2 5.5 and 5.6 5.9 at the pre- and post-intervention time frames, respectively. Total produce preferences of the children, at pre- and postintervention were 13.1 10.9 and 13.0 11.9 (p = .977), respectively. When considering these intakes and preferences, it is important to underscore that these values do not equate to servings consumed. They relate, however, to the variety of produce eaten or preferred in the previous week. In subsequent sections of this chapter, the relationship of these measures will be related to food security and caretaker qualities. While the variety measures did not significantly change through the course of the intervention, it may be that the children began at a high level. Studies typically use childrens produce intakes and preferences (Ball et al., 2008; Haire-Joshu et al., 2003; Lakkakula et al., 2008; Lorson et al., 2009; Nanney et al., 2005; Nanney, Johnson et al., 2007; Nanney, Schermbeck et al., 2007) rather than varieties, which were used in this study. This could also be explained in multiple ways, including a lack of understanding by the children participants during survey completion, or an overestimation by the children on weekly produce intake. The modification of the Saint Louis University 4 Kids

116 Food Frequency Questionnaire (Haire-Joshu et al., 2003) could have lead to misinterpretation of the intakes and preferences options for the children. Therefore, future studies should use the Saint Louis University 4 Kids Food Frequency Questionnaire produce intake and preference variety tool when using the recommended methods (HaireJoshu et al., 2003). This may enable a total recall from both caregiver and child in order to get a more complete idea of the childs diet both at home and at school. It could also provide insight on what type of produce variety the household provides, along with possible limitations and cultural behaviors. The pictorial tool designed for this study could be used in an in-person interview with both caregiver and child and be validated in conjunction with the Saint Louis University tool and dietary record information.

Food Security Household Food Security Status The overall household food insecurity rate in this study (49.5%) was more than four times that of the nation and the state of Ohio in 2007, which was consistent with other research from the study region (Bletzacker et al., 2007; Hazen et al., 2008; Holben et al., 2004; Holben & Pheley, 2006; Kendall et al., 1996; Kropf et al., 2007; Meek, 2005; Nord et al., 2008; Pheley et al., 2002; Walker et al., 2007). Low and very low household food security was 24.2% and 25.3%, respectively, more than twice that of the nation. In 2007, the estimate of food insecurity was 11%, while in Ohio from 2005 to 2007; it was estimated to be 12.2% of households (Nord et al., 2008). Estimates of low and very low food security nationwide were 7.0% and 4.1%, respectively, while in Ohio it was

117 estimated that 7.7% of households and 4.5% of households were classified as low food security and very low food security, respectively (Nord et al., 2008). With half of the households in our study classified as food-insecure, and one-fourth of the households classified as low or very low food security, our convenience sample may not accurately represent the study region, state, or nation. However, it gives insight into the families participating in Kids on Campus, and it may indicate the need to address not only this issue among families in Kids on Campus, but also families living in Athens County, Ohio, and the region. Food insecurity has been associated with lower education, lower income, being an ethnic minority, living in a non-suburban residence, and participation in government assistance programs (Adams et al., 2003; Alaimo et al., 1998; Alaimo et al., 2001b; Bhattacharya et al., 2004; Cutts et al., 1998; Gundersen et al., 2008; Herman et al., 2004; Holben & Myles, 2004; Jones & Frongillo, 2006; Nord et al., 2008; Oberholser & Tuttle, 2004; Quandt et al., 2004; Quandt et al., 2004; Rose, 1999). In this study, however, the education level of the females was higher than what is typically seen with food-insecure households (Jones & Frongillo, 2006), with 70.7% (p = .003), almost three-fourths of female caregivers, reporting to have some college education or higher. Although this rate is not implying college completion, it is much higher than recent rates of college degrees in Ohio (21.1%), Appalachia (17.7%), and the nation (24.4%). Similar results have been found in the area (Kropf et al., 2007; Walker et al., 2007) and could be explained by the community from where our sample was drawn. Ohio University is located in Athens County, possibly leading to the higher level of education in the county, as compared to

118 the rest of the state. There is also an adult career center and community college, which may also be contributing to this trend. More specifically, compared to caregivers from food-insecure households, a greater proportion of caregivers from food-secure households had some college or higher (p = .003). While other characteristics besides education have been associated with food insecurity, in this study, marital status, availability of transportation for food, hunting for food, and fishing for food were not significantly different between caregivers from food-secure and food-insecure households. Participation in food assistance programs has also been associated with food insecurity. Many food-insecure families participate in food assistance programs, including SNAP, WIC, and the National School Meals Program (Condrasky & Marsh, 2005; Nord et al., 2008; Oberholser & Tuttle, 2004). In 2007, more than half (53.9%) of food-insecure families living in the United States studied participated in a food assistance program in the 30 days previous to data collection for the national estimates (Nord et al., 2008). Food assistance program participation by households in this study varied. More than half of our sample participated in the National School Lunch Program (73.7%), the School Breakfast Program (66.7%), or the SNAP (53.5%). However, participation was lower in the Head Start Program (19.6%) and WIC (23.2%) most likely due to qualification requirements. To illustrate, if children are over the age of five, families do not qualify for WIC benefits unless there is a female who is pregnant or breastfeeding, and families cannot participate in Head Start if their children are of school-age. Along with WIC, WIC Farmers Market Nutrition Participation was also low (8.1%). However,

119 community food pantry usage (36.4%) was greater than what was found in 2007 (21.0%) nationwide (Nord et al., 2008). Participation in several of these programs differed between those from foodsecure and food-insecure households, indicating participants were utilizing opportunities offered in the Athens community, possibly as a coping strategy of being food insecure. Participation in SNAP (p = .020), National School Lunch Program (p = .002), School Breakfast Program (p = .002), WIC Farmers Market Nutrition Program (p = .013), and Community Food Pantry (p = <..001) was significantly greater among food-insecure households compared to food-secure ones. The self-selection principle could explain these findings. In the United States, individuals choose or self-select whether or not to participate in food assistance programs. The higher participation of food-insecure participants in food assistance programs supports that these insecure households seek assistance due to their perception that it is needed (Holben & ADA, 2006; Nord et al., 2008). This participation may also be a proxy for a higher income among food-secure households, as the Federal Programs all have income guidelines. Participation in Kids on Campus may also lead to higher food assistance participation rates in female caregivers in Athens County. Such programs can assist female caregivers in connecting with others in the area in similar situations, exposing them to other programs they otherwise may not have been aware of. These practices can also benefit the households through increased social capital while increasing their food security. Finally, Kids on Campus may itself be viewed as an assistance program, further explaining the increased rate of food insecurity among participants.

120 Food Security, Body Weight, Diet, and Health Adult individuals living in a food-insecure households, especially females, are more likely to be overweight or obese than those in food-secure households (Lyons et al., 2008; Martin & Ferris, 2007). In this study, BMIs did not differ between food-insecure women (31.9 10.3), compared to their food-insecure (28.3 6.8) counterparts (p = .075). However, when stratified by weight classification, food-insecure women were more likely to be overweight or obese, compared to those from food-secure households (p = .035). In fact, among the food insecure, 27% of female caregivers self reported weight classified as overweight and 44% classified as obese. Binge eating in relation to foodinsecurity has been associated with weight gain in women due to the cyclical nature of food assistance programs (Olson, 2005; Webb et al., 2008). This, along with decreased diet quality, leads to the counterintuitive finding of overweight and obesity in foodinsecure women. Food-insecurity is associated with lack of nutritious food for an active, healthy life. However, high calorie, high fat, low nutrient-dense foods tend to be less expensive than low calorie, low fat, and high nutrient dense items (Mendoza et al., 2006). Therefore, the less nutrient-dense, empty calorie foods replace the more nutritious options leading to weight gain, especially when coupled with binge eating when food is plentiful. Future research should measure the impact that gardening interventions have on the diet quality and eating behaviors of female caregivers. Due to the high food assistance program participation rates of this study, research should also attempt to compare groups in such interventions to determine how much of an impact food assistance program participation has on female caregivers weight status. National studies using the National

121 Health and Nutrition Examination Survey (NHANES) data could also be utilized to explore these trends nationally. Poor diet quality and health have also been associated with food-insecurity (Chang et al., 2008; Condrasky & Marsh, 2005; Kendall et al., 1996; Langevin et al., 2007; McIntyre et al., 2003; Olson, 2005; Pheley et al., 2002; Vozoris & Tarasuk, 2003). Studies have found as food insecurity worsens, overall health status also worsens (Bronte-Tinkew et al., 2007; Holben et al., 2006; Holben & Pheley, 2006; Pheley et al., 2002; Tarasuk & Beaton, 1999). Those who report food insecurity also report poor overall health more often than those who were food-secure (Lee & Frongillo, 2001; Pheley et al., 2002). This is a logical relationship due to diet qualitys impact on health status. In 2003, a report found that those with incomes below the poverty line purchased fewer fruits and vegetables due to taste and convenience issues (Stewart & Blisard, 2008). However, when household income increased as little as 10%, fruit and vegetable purchases increased (Stewart & Blisard, 2008). These findings reinforce the need for increased produce intake in low-income families in order to increase diet quality and health status. Food insecurity negatively impacts multiple aspects of the diet, including decreased quality and quantity of food intake and diet (Chang et al., 2008; Condrasky & Marsh, 2005; Hazen et al., 2008; Holben et al., 2006; Holben et al., 2004; Holben & Pheley, 2006; Kendall et al., 1996; Kropf et al., 2007; Langevin et al., 2007; McIntyre et al., 2003; Olson, 2005; Vozoris & Tarasuk, 2003; Walker et al., 2007). In this study, more than half of respondents (58%) reported their diet as good, very good, or excellent.

122 However, diet quality significantly differed between caregivers from food-secure homes, versus food-insecure homes (p = .015), with a greater proportion of food-secure caregivers perceiving their diet to be of higher quality. Over half of the females were in the action stage of eating fruits and vegetables, while almost half reported precontemplation for gardening fruits and vegetables; however, neither of these significantly differed between food-secure and insecure groups. Female caregiver readiness to eat fruits (p = .258) and vegetables (p = .092) were mostly reported as action or maintenance stage for both food-secure and insecure participants, however there was not a significant difference between these groups. Female caregiver fruit (tau = -.170, p = .009), vegetable (tau = -.224, p = .001), and produce (tau = -.205, p = .001) intakes were significantly related to food security, consistent with other studies (Kendall et al., 1996; Kropf et al., 2007; Olson, 2005). Both fruit and vegetable intake significantly decreased as food insecurity worsened. The average daily vegetable (1.5 0.7) and fruit (1.3 0.8) intake of food-insecure women was lower than recommended. Similarly, food-secure women also had low intakes of both vegetables and fruit (2.1 1.2; 1.6 0.8). However, only vegetable intake of foodinsecure women was significantly lower, compared to their food-secure counterparts (p = .016). This could indicate an overall need to improve produce intake in women, not only those in food-insecure households. It also supports, however, that food insecurity further compromises vegetable intake. Diets of individuals living in households characterized by food insecurity have been found to have below the recommended intake of kilocalories, protein, calcium,

123 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 to decreased 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). Unlike diet, health status did not significantly differ (p = .182). The self-reported health status of the female caregivers in this study ranged from excellent to poor, with 83% of respondents reporting to have good, very good, or excellent health status. Health problems and status could be alleviated with more consistent access to healthy food and education for these families. Future studies should explore the relationship between diet quality and health status in food-insecure females to determine what role poor diet quality plays in food-insecure families quality of life. Food Security, Gardening, and Diet Food security and female caregivers gardening and diet. Women living in food-insecure households have been shown to consume less than the recommended amounts of produce (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), which gardening may be able to alleviate. In this study, household food security

124 and gardening habits were not found to be significantly related in the female caregivers or the children (p > .05). Similarly, having a fruit (p = .811) or vegetable (p = .480) garden did not significantly differ between food-secure and food-insecure homes. Finally, female readiness for gardening vegetables (p = .092), gardening fruit (p =.258), eating vegetables (p = .092), and eating fruit (p = .258) did not significantly differ either. When comparing food-secure households to food-insecure households, gardening readiness did not significantly differ between groups. Gardening readiness followed a similar trend to readiness to eat produce, with most reporting precontemplation; however, more food-secure households reported action or maintenance than food insecure for gardening fruit (38.8%) and vegetables (41.2%). Considering the number of female caregivers in the action stage for eating produce but precontemplation stage for gardening, this may indicate that many of them are eating produce but not growing it. Precontemplation means that an individual is not considering the behavior in question, while action indicates the behavior is already occurring. Female vegetable intake was significantly related to gardening vegetables (p = .036), however fruit intake was not significantly related to gardening fruit (p = .840). This indicates that those females who garden vegetables are more likely to have higher vegetable intake, where as gardening fruit has no impact. In order to better assess this behavior change, future studies should measure garden usage of participants along with produce intake. Gardening readiness is a new measure developed for this study; therefore, more research is needed on the construct to further evaluate its validity.

125 As noted in the previous section, food insecurity significantly impacted produce intake and diet quality of female caregivers in this study, which follows trends of previous research. However, gardening was not related to either food security status of the household nor produce intake of the female caregivers. This raises the question of why female caregivers are not choosing to garden in times of food-insecurity? What are the barriers or limitations to gardening in this population? Future research should investigate this, focusing on both food-secure and food-insecure households to determine whom the specific barriers impact most or if the gardening trend is decreasing in popularity. Programs similar to the one used in this study with children participants could be developed for families in conjunction to food assistance programs in order to increase gardening habits. Food security and childrens diet. This study also examined if, at the onset of the study, whether household food security status was related to produce preferences and intakes of child participants. It was found that household food security was not related to the produce preferences (tau = .112, p = .378) and intakes (tau = -.017, p = .893) of the child participants. Prior to the nutrition education and gardening intervention, female caregivers reported their perception of childrens produce and gardening habits. It was found that food security was significantly related to female caregivers perception of childrens vegetable gardening habits, produce variety, and produce intake. Child daily vegetable servings were significantly different per household, according to their female caregivers, with children living in food-secure households eating 2.1 1.0 servings a day and those

126 in food-insecure households reporting 1.7 1.0 servings a day (p = .017). Female caregivers perception of childrens fruit intake did not significantly differ among households. Their perception of their childrens produce variety was impacted, however, with children from food-secure households consuming more than one type of vegetable (p < .001) and fruit (p = .007), more often than those from food-insecure households. While intakes varied between groups, children from food-insecure households were not less likely to consume citrus fruit or juice, compared to those from food-secure households. However, children from food-insecure households were less likely to consume two or more vegetable servings at a meal, with 44.1% caretakers reporting their child would never or sometimes meet this recommendation (p = .004). However, foodinsecure children were not less likely to be interested in consuming three or more fruit or vegetable servings daily. Similarly, fruit or vegetables as snacks, or interest in gardening vegetables were not different by food security status in children (p > .05). Produce intake has been found to be deficient in children, in both food-secure and insecure homes. A study focusing on fruit and vegetable intake of rural mothers and children found that most produce intake was inadequate (Nanney, Schermbeck et al., 2007). More than half of the adolescents in a Canadian study did not meet the 5-a-day fruit and vegetable recommendations; however, intake did increase with increased family income, education, and two parent households (Riediger et al., 2007). A study conducted in rural North Carolina found children who consumed excessive amounts of sweets did not meet the recommendations for fruits, vegetables, dairy, or grains (Ball et al., 2008). Children in food-insecure households have lower intakes of fruits, vegetables, and milk

127 products, which directly impacts their calcium, vitamins A and C intake (Dixon et al., 2001). These findings were consistent with what was found with female caregivers perception of their childrens produce intake, however, inconsistent with childrens perception of their own diet. Previous work found that children in food-insecure households had lower intakes of dark green vegetables and fruits than those in food-secure households (Casey et al., 2001; Lorson et al., 2009). Yet, our study did not actually measure the childrens produce intake. Rather, it measured produce variety consumed and preferred and the female caregivers perception of their childrens intake. Even though children are typically protected from hunger, their diets can still be impacted (Rose, 1999). Children in foodinsecure households have lower intakes of fruits, vegetables, and milk products, which directly impacts their calcium, vitamins A and C intake (Dixon et al., 2001). Children typically consume the types of food provided by their caretakers. When household food supplies are depleted, due to food insecurity, childrens diets suffer, particularly intake of produce (Matheson et al., 2002). This could explain the differences in produce intakes found in this study. Female caregivers responses could reflect their own diminished produce variety when responding for their children. The variety of produce reported by the children in the intervention portion of the study may be due to intake of produce outside the home, such as during school meals, or it may be explained by children not correctly reporting their intake. In addition, the caregivers were asked about their childrens daily intake, while children were asked about the past week. Future studies should survey and measure childrens produce intake and preference variety in

128 conjunction to female caregivers perceptions differently than this study due to conflicting reports from caregivers and children on produce variety. This can be achieved through combined interviews and surveying of children and caregivers together, which enables discussion between the two parties on dietary intake leading to a more complete report. Even though our sample had a high level of household food-insecurity, it was not related to child participants perception of their produce intake variety or preference variety. While post-intervention food security status of the children was not measured, future interventions should do so. Anecdotally, the researchers observed throughout the study that many children, when provided with the weekly produce, ate the food right away, and some discussed ways they would share it with their families. When harvesting the vegetables grown in the education program gardens, children were willing to taste whatever products were available (radishes, greens, herbs), which may reflect an interest in trying new foods. Future studies should include questions pertaining to child food security and produce to further asses their relationship.

Female Caregiver Gardening and Produce Habits At its onset, this study explored whether female caregivers gardening habits were related to their perceptions of the childs gardening habits and their childs produce intake and preferences. Less than half of female caregivers reported having a fruit (23.9%) or vegetable (38.1%) garden in this study. However, they reported 84% of their children were interested in gardening vegetables, which was significantly related to

129 female caregiver gardening habits (tau = -.163, p = .021). Female caregiver gardening habits were not related to produce intakes of the child (tau = -.142, p = .263) or preferences (tau = -.028, p = .826). Fruit intake of female caregivers was significantly related to child variety of fruits preferred (tau = -.370, p = .010), child variety of produce preferred (tau = -.275, p = .046), and child variety of fruits eaten (tau = .320, p = .021). Female caregiver vegetable intake, however, was only significantly related to child variety of produce eaten (tau = .293, p = .031). Understandably, female caregiver produce intake was also related to child variety of produce eaten (tau = .313, p = .016). Nanney and others (Nanney, Johnson et al., 2007) found that those families in rural areas who ate homegrown produce had an increase in produce availability, along with an increase in their childs preference for new fruits and vegetables. In fact, gardening projects have been done to improve the health and fruit and vegetable intake of the participants, with most having positive impacts 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; Van Duyn & Pivonka, 2000). Compared to other interventions, gardening is an inexpensive way to increase produce intake as well as physical activity in households (Graham & Zidenberg-Cherr, 2005; McAleese & Rankin, 2007; Nanney, Johnson et al., 2007). Future studies should assess this through follow-up testing of both children female caregivers to assess the total impact of gardening on their lifestyle.

130 Conclusions and Recommendations Conclusions Gardening has been shown to be positively related to access to fruits and vegetables, and is a relatively inexpensive way to grow fresh produce (Holben et al., 2004; McAleese & Rankin, 2007; Nanney, Johnson et al., 2007; Rose & Richards, 2004). Further, gardening interventions have been shown to positively impact produce intake of children and their households, which may also increase their food security (Graham & Zidenberg-Cherr, 2005; Hermann et al., 2006; Holben et al., 2004; McAleese & Rankin, 2007; Morris & Zidenberg-Cherr, 2002). Gardening projects have been conducted to improve the health and fruit and vegetable intake of the participants, with most having positive impacts 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; Van Duyn & Pivonka, 2000). However, variables measured in this study as part of the gardening intervention and produce variety were not found to be significantly different after the intervention, which could be for a variety of reasons including length of study, survey tool used, and population studied. Previous studies have found mixed results (Robinson-O'Brien et al., 2009) in relation to gardening and produce intake, and no program has been developed to consistently improve produce intake in children. However, had our study population not started at such a high level of produce intake and preference, more significant results may have been achieved. A study in 2005 had one-hour interventions for several weeks with

131 seven to nine year old children in a school-based program focused on specific fruit and vegetables that could be increased in the diet (Nanney et al., 2005). Another type of sixweek program focused on fruit and vegetable intake in Boston found that those who had higher fruit and vegetable intakes had a higher interest in healthy eating (McNeill et al., 2007). Both studies indicate that length of study could increase produce intake in children, however, those who are currently eating high levels of produce may be the most involved participants. Future studies should assess participants readiness levels preintervention in order to cater the program to all participants needs for more significant results. The size of the population used could have limited the results through limited competition of child surveys (60.7%). The high initial produce intake and preference also inhibited the potential of significant results in the post-testing. Childrens preintervention average weekly produce intake was 16.91 10.1, which is almost half of the maximum 36 items surveyed. These results could also have been impacted by the survey tool used. Parental reporting of childrens dietary intake has been utilized in other previous research projects. One study found that parents accurately reported their childs intake, with only some discrepancy on juices and combination foods that included fruits and vegetables (Linneman et al., 2004). However, another similar study done in the Netherlands found poor correlation between parent and child responses to the childs vegetable intake, but better correlation with their fruit intake (Reinaerts et al., 2007). The results of this study support that caregiver input on childrens produce intake may be

132 essential in order to collect valid results. When assessing childrens produce intake, future studies should use combined methodology to get complete results. Food security was shown to impact a number of variables in female caregivers including vegetable intake, weight status, and perceived diet quality. These findings were fairly consistent with previous literature (Drewnowski & Specter, 2004; Hazen et al., 2008; Holben et al., 2004; Holben & Pheley, 2006; Kropf et al., 2007; Olson, 1999; Olson & Strawderman, 2008; Pheley et al., 2002; Rose & Oliveira, 1997; Rose, 1999; Tarasuk & Beaton, 1999; Townsend et al., 2001; Walker et al., 2007; Wilde & Peterman, 2006). Gardening and health status have both been found to be related to food security status ( Holben et al., 2006; Holben et al., 2004; Lee & Frongillo, 2001; Pheley et al., 2002; Stuff et al., 2004; Walker et al., 2007), however, this study did not agree with those findings. Food insecurity would have a similar impact on diet quality and vegetable intake, but weight status seems counterintuitive. Both diet quality and vegetable intake decreased in food-insecure female caregivers, however overweight and obesity rates rose. These results, in fact, do relate to the literature due to the poor nutritional status of females in food-insecure homes who have been found to have higher intakes of lower nutrient-dense foods with higher calories rather than fresh produce due to cost and shelflife issues. This poor diet quality and possible binge eating then leads to overweight and obesity in these women, which needs to be addressed through nutrition education and counseling. Gardening habits of the female caregivers were found to significantly relate to female vegetable intake and childrens gardening habits. These findings were consistent

133 with previous studies (Graham & Zidenberg-Cherr, 2005; Nanney, Johnson et al., 2007) which found that family influence can increase childrens interest in both produce and gardening. It also shows that when produce is available, intake increases in females, which in turn may influence childrens intake in the future. Therefore, gardening can be an inexpensive way to not only increase produce availability, but also variety and intake in both women and children. Recommendations Suggestions for future studies and programming by nutrition professionals include longer interventions with more in-depth information, post-testing the female caregiver participants, along with a follow-up of the child participants in order to assess the impact on their long-term diet and gardening. Some factors that could have impacted this study include intervention length, population size, and produce habits of female caregivers and children. A longer, more in-depth study focusing on both family and child nutrition and gardening education may be needed to have more of an impact on produce intake and preference variety of children. This would also allow for a cohesive interview process with both caregiver and child leading to a more reliable survey tool. Length of study has been varied in such nutrition education and gardening programs with inconsistent results (Agriculture and Natural Resources, University of California, 2009; Hermann et al., 2006; McAleese & Rankin, 2007; Morris & ZidenbergCherr, 2002; Nanney, Johnson et al., 2007; Robinson-O'Brien et al., 2009). Therefore, a longer time frame than the six-weeks of this program may have led to a positive effect on

134 childrens produce intake and preference while allowing for more information to be discussed. The survey instrument used had not been previously validated; however, it was based on the previously validated Saint Louis University 4 Kids Food Frequency Questionnaire. The Saint Louis University 4 Kids Food Frequency Questionnaire was intended to be read allowed to parents in order for them to respond for their children. Our study did not have this option since we did not have one-on-one contact with the parents pre- and post- intervention, and so the children were given the surveys on the first day of the program. This could have lead to some confusion on the childs part since each group of 25 children were allotted three to four teaching assistants to assist in the completion of the survey. Reading and comprehension could have become an issue, even though all children involved were given picture surveys and detailed directions on how to complete the survey both pre and post intervention. With this limitation, results from the childs preference and intakes could have been affected. Dietetic and nutrition professionals can use these findings to develop other interventions including gardening and nutrition education with both children and their families. For more significant results, future studies should focus on more nutrition education including the benefits of gardening. By introducing the benefits of gardening and how families can use it as an opportunity to increase physical activity and produce intake, dietetic professionals can improve overall health of low-income families who may not have done so otherwise. Future research should address the complex issue of overweight and obesity in food-insecure women through assessment of womens

135 nutritional education levels and diet habits. These findings could then be used for the development of nationwide nutrition education programs which could be used in conjunction with food-assistance programs. Even though this nutrition education and gardening intervention did not significantly impact childrens produce intake or preference variety, it did find that foodinsecurity impacts both female and childrens diets. Although gardening was not associated with produce intake or food security, nutrition professionals and researchers should continue to include it as a way to increase produce and physical activity in communities, whether regardless of food security status.

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165 APPENDIX A: FOOD SECURITY SURVEY MODULE SCORING FOOD SECURITY SURVEY MODULE 18 AND 6 ITEM SCORING The following is a brief overview of how to code responses and assess household food security status in 2008 for the current categories based on various standard scales. For detailed information on these procedures, refer to the Guide to Measuring Household Food Security, Revised 2000, and Measuring Childrens Food Security in U.S. Households, 1995-1999. Both publications are available through the ERS Food Security in the United States Briefing Room. Responses of yes, often, sometimes, almost every month, and some months but not every month are coded as affirmative. The sum of affirmative responses to a specified set of items is referred to as the households raw score on the scale comprising those items.

Item Number Q1

Question We worried whether our food would run out before we got money to buy more. Was that often, sometimes, or never true for you in the last 12 months? The food that we bought just didnt last and we didnt have money to get more. Was that often, sometimes, or never true for you in the last 12 months? We couldnt afford to eat balanced meals. Was that often, sometimes, or never true for you in the last 12 months? 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 wasnt enough money for food? (Yes/No)

Q2

Q3 Q4

166 Q5 (If yes to Question 4) How often did this happenalmost every month, some months but not every month, or in only 1 or 2 months? In the last 12 months, did you ever eat less than you felt you should because there wasnt enough money for food? (Yes/No) In the last 12 months, were you ever hungry, but didnt eat, because there wasnt enough money for food? (Yes/No) In the last 12 months, did you lose weight because there wasnt enough money for food? (Yes/No) In the last 12 months did you or other adults in your household ever not eat for a whole day because there wasnt enough money for food? (Yes/No) (If yes to Question 9) How often did this happenalmost 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 Q11 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? We couldnt feed our children a balanced meal, because we couldnt afford that. Was that often, sometimes, or never true for you in the last 12 months? The children were not eating enough because we just couldnt afford enough food. Was that often, sometimes, or never true for you in the last 12 months? In the last 12 months, did you ever cut the size of any of the childrens meals because there wasnt enough money for food? (Yes/No) In the last 12 months, were the children ever hungry but you just couldnt afford more food? (Yes/No) In the last 12 months, did any of the children ever skip a meal because there wasnt enough money for food? (Yes/No)

Q6 Q7 Q8 Q9

Q10

Q12

Q13

Q14

Q15 Q16

167 Q17 (If yes to Question 16) How often did this happenalmost every month, some months but not every month, or in only 1 or 2 months? In the last 12 months, did any of the children ever not eat for a whole day because there wasnt enough money for food? (Yes/No)

Q18

Note. Adapted from Guide to Measuring Household Food Security, Revised 2000, by G. Bickel, 2000, Department of Agriculture, Food and Nutrition Service, p.22. Copyright 2000 by the USDA. Reprinted with permission.

Specification of food security status depends on raw score and whether there are children in the household (i.e., whether responses to child-referenced questions are included in the raw score). o For households with one or more children: Raw score zeroHigh food security Raw score 1-2Marginal food security Raw score 3-7Low food security Raw score 8-18Very low food security o For households with no child present: Raw score zeroHigh food security Raw score 1-2Marginal food security Raw score 3-5Low food security Raw score 6-10Very low food security Households with high or marginal food security are classified as food-secure. Those with low or very low food security are classified as food-insecure.

Questions 2 through 10 comprise the U.S. Adult Food Security Scale. Raw score zeroHigh food security among adults

168 Raw score 1-2Marginal food security among adults Raw score 3-5Low food security among adults Raw score 6-10Very low food security among adults Questions 2, 3, 5, 7, 8, and 10 comprise the six-item Short Module from which the Six-Item Food Security Scale can be calculated. Raw score 0-1High or marginal food security (raw score 1 may be considered marginal food security, but a large proportion of households that would be measured as having marginal food security using the household or adult scale will have raw score zero on the sixitem scale) Raw score 2-4Low food security Raw score 5-6Very low food security Questions 11 through 18 comprise the U.S. Childrens Food Security Scale. Raw score 0-1High or marginal food security among children (raw score 1 may be considered marginal food security, but it is not certain that all households with raw score zero have high food security among children because the scale does not include an assessment of the anxiety component of food insecurity) Raw score 2-4Low food security among children Raw score 5-8Very low food security among children (2) Response Options: For interviewer-administered surveys, DK (do not know) and Refused are blind responsesthat is, they are not presented as response options, but

169 marked if volunteered. For self-administered surveys, do not know is presented as a response option. (3) Screening: The two levels of screening for adult-referenced questions and one level for child-referenced questions are provided for surveys in which it is considered important to reduce respondent burden. In pilot surveys intended to validate the module in a new cultural, linguistic, or survey context, screening should be avoided if possible and all questions should be administered to all respondents. To further reduce burden for higher income respondents, a preliminary screener may be constructed using question 1 along with a household income measure. Households with income above twice the poverty threshold, AND who respond <1> to question 1 may be skipped to the end of the module and classified as food-secure. Use of this preliminary screener reduces total burden in a survey with many higher-income households, and the cost, in terms of accuracy in identifying food-insecure households, is not great. However, research has shown that a small proportion of the higher income households screened out by this procedure will register food insecurity if administered the full module. If question 1 is not needed for research purposes, a preferred strategy is to omit 1 and administer Adult Stage 1 of the module to all households and Child Stage 1 of the module to all households with children.

170 APPENDIX B: KIDS ON CAMPUS SURVEY SCORING

Item Number

Question

The first four questions are in relation to the familys food intake Q5 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 wasnt enough money for food? (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? In the last 12 months, did you ever eat less than you felt you should because there wasnt enough money to buy food? In the last 12 months, were you ever hungry but didnt eat because you couldnt afford enough food?

Q8

Q7

Q10

The last two questions are in relation to the familys food situation Q2 The food that I/we bought just didnt last and I/we didnt have money to get more. Was that often, sometimes, or never trough for you in the last 12 months? I/we couldnt afford to eat balanced meals. Was that often, sometimes, or never true for you in the last 12 months?

Q3

Note. Adapted from The Effectiveness of a Short Form of the Household Food Security Scale, by S. Blumberg, 1999, American Journal of Public Health, 89; 1231-1234. Copyright 1999 by the USDA. Adapted with permission.

Questions 2, 3, 5, 7, 8, and 10 comprise the six-item Short Module from which the Six-Item Food Security Scale can be calculated. Raw score 0-1High or marginal food security (raw score 1 may be considered marginal food security, but a large proportion of households that would be measured as having marginal food security

171 using the household or adult scale will have raw score zero on the sixitem scale) Raw score 2-4Low food security Raw score 5-6Very low food security (Bickel et al., 2000)

Constructs/Domain Predisposing: Perceived benefits for eating fruits and vegetables I feel that I am helping my body by eating more fruits and vegetables I may develop health problems if I do not eat fruits and vegetables

Number of Items 4

Points (Min, Max) 0-2 Agree = 1 Either agree or disagree = 0.5 Disagree = 0

Other = 0 Perceived control for eating fruits and vegetables In your household, who is in charge of what foods to buy? In your household, who is in charge of how to prepare the food? Shared decision = 0.5 I am = 1

Enabling: Self-efficacy for eating fruits and vegetables I feel that I can plan meals or snacks with more fruit during the next week. I feel that I can buy more vegetables the next time I shop. I feel that I can plan meals with

Agree = 1 Either agree or disagree = 0.5 Disagree = 0

172 more vegetables during the next week. I feel that I can eat fruits or vegetables as snacks. I feel that I can add extra vegetables to casseroles and stews. I feel that I can eat 2 or more servings of vegetables at dinner. 3 0-3

Intention: Readiness to eat more fruit I am not thinking about eating more fruit. (pre-contemplation) I am planning to start within 6 months. (contemplation) I am definitely planning to eat more fruit in the next month. (preparation) I am trying to eat more fruit now. (action) I am already eating 2 or more servings of fruit a day. (maintenance)

Readiness to eat more vegetables I am not thinking about eating more vegetables.(precontemplation) I am planning to start within 6 months. (contemplation) I am definitely planning to eat more vegetables in the next month. (preparation) I am trying to eat more vegetables now. (action) I am already eating 2 or more servings of vegetables a day. (maintenance) Excellent = 5

Perceived diet quality

173 How would you describe your diet? Very good = 4 Good = 3 Fair = 2 Poor = 1 TOTAL SCALE (6 pts) 13 0-6

Note. From Development of a tool to assess psychosocial indicators of fruit and vegetable intake for 2 federal programs, by M. Townsend, 2005, Journal of Nutrition Educational Behavior, (4) 37; 170-184. Copyright 2005 by Townsend and Kaiser. Reprinted with permission.

Question I am not thinking about gardening to grow vegetables for my household I am thinking about gardening to grow vegetables for my household, planning to start within six months I am definitely planning to garden to grow vegetables for my household in the next month I am trying to garden to grow vegetables for my household I am already gardening to grow vegetables for my household I am not thinking about gardening to grow fruit for my household I am thinking about gardening to grow fruit for my household, planning to start within six months I am definitely planning to garden to grow fruit for my household in the next month

Scoring Affirmative = pre-contemplation Affirmative = contemplation

Affirmative = preparation Affirmative = action Affirmative = maintenance Affirmative = pre-contemplation Affirmative = contemplation Affirmative = preparation

174 I am trying to garden to grow fruit for my household I am already gardening to grow fruit for my household Affirmative = action Affirmative = maintenance

175 APPENDIX C: IRB APPROVAL

176 APPENDIX D: KIDS ON CAMPUS SURVEY THIS SURVEY IS FOR THE MOTHER OR PRIMARY CARETAKER OF THE CHILDREN IN KIDS ON CAMPUS. My name is: My child/children participating in Kids on Campus Grades 1 4 are: Child 1

Child 2

Child 3

Child 4

If you decide to complete this survey, this sheet will be detached. It is attached so that we can give you an identification number for the survey. Office Use Only Subject Number:

177

Kids on Campus Food and Nutrition Survey

Completion and return of this survey is completely voluntary and implies your consent to use this information for research purposes. No one will be able to identify you in any report resulting from this survey.

This survey should be completed by the mother or primary female caretaker of the child/children participating in Kids on Campus. The survey will take about 15 minutes to complete. The purpose of this survey is to ask about your food habits and your satisfaction with the food and gardening aspects of the Kids on Campus program this summer. With this information, we are hoping to learn how to better serve you and other families in Kids on Campus. In no way will your answers affect your childs/childrens participation in Kids on Campus. Please complete and return the survey with your Kids on Campus materials. Thank you very much for your time and assistance.

*If you have questions about this survey please contact: David H. Holben, PhD, RD, LD/ Ashley Zurmehly School of Human and Consumer Sciences W324 Grover Center Athens, Ohio 45701 740-593-2875 *If you have any questions regarding your rights as a research participant, please contact: Ellen Sherow Director of Research Compliance Ohio University 740-593-0664

178

Please write in or circle your answer to each.

How old are you? ________

What is your race? (circle all that apply)

American Indian or Native Alaskan

Asian

AfricanAmerican or African American

Hispanic

Native Hawaiian or Other Pacific Islander

White

Other (Please specify.)

What is your current marital status? (circle one answer) Married Widowed Divorced Separated Single/Never Married

If not married, do you have a live-in partner?

Yes

No

Including you, how many people live in your household?

179

Including the incomes of the other members of your household, what is your pre-tax average monthly household income including child support (not including SNAP that you may receive)?

$______________________

What is your highest level of education completed? (check one box only) Less than High School HIGH SCHOOL GRADUATE high school DIPLOMA or the equivalent (GED) Some College or Higher

These questions are about your weight and height.

How tall are you (inches)?

How much do you weigh (pounds)?

BMI

(Do not complete this box - office use only)

The rest of this survey deals with various aspects of your health. By health, we mean not only the absence of disease or injury but also physical, mental, and social well-being. The following questions are about your health. (check one box) Yes No

180 Have you lost or gained 10 lbs. in the past 6 months without wanting to? Are you now drinking or have you ever drunk alcohol? Do you have vision problems that cannot be corrected by glasses? Do you consider yourself overweight? Have you ever been told that you are at risk for diabetes? Have you been told by your doctor that you have diabetes? When you cut yourself, does it take longer to heal? Are you aware of any family members with diabetes? Are you aware of any family members at risk for diabetes? Do you have a dark ring or darkened skin around your neck?

The following are questions about your general well-being.

In general my health is _____. (circle one answer) Excellent Very Good Good Fair Poor

The following two questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (circle one answer for each) Moderate activities such as moving a table, pushing a vacuum cleaner, bowling, or playing golf: Yes, Limited A Lot Yes, Limited A Little No, Not Limited At All

181 Climbing several flights of stairs: Yes, Limited A Lot Yes, Limited A Little No, Not Limited At All

During the past 4 weeks have you had any of the following problems with your work or other regular activities as a result of your physical health? (circle one answer for each) Accomplished less than you would like: Yes No

Were limited in the kind of work or other activities:

Yes

No

During the past 4 weeks, were you limited in the kind of work you do or other regular activities as a result of any emotional problems (such as feeling depressed or anxious)? (circle one answer for each) Accomplished less than you would like: Didnt do work or other activities as carefully as usual: Yes No Yes No

During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? (circle one answer) Not At All A Little Bit Moderately Quite A Bit Extremely

The next three questions are about how you feel and how things have been during

182 the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks: (circle one answer for each) Have you felt calm and peaceful? All of the Time Most of the Time A Good Bit of the Time Some of A Little None of the Time

the Time of the Time

Did you have a lot of energy?

All of the Time

Most of the Time

A Good Bit of the Time

Some of

A Little

None of the Time

the Time of the Time

Have you felt downhearted and blue?

All of the Time

Most of the Time

A Good Bit of the Time

Some of

A Little

None of the Time

the Time of the Time

During the past 4 weeks, how much has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)? (circle one answer) All of the time Most of the time Some of the time A little of the time None of the time

The following questions are about the food situation for your household in the past 12 months. During the past 12 months, the food that you (and others) bought just didnt last and there wasnt any money to get more. Often True (circle one answer) Never True

Sometimes True

183 During the past 12 months, you (and others) couldnt afford to eat balanced meals. (circle one answer) Often True Sometimes True Never True

The following questions are about the food situation in the past 12 months for you or any other adults in your household. During the past 12 months, did you or other adults in your household ever cut the size of your meals or skip meals because there wasnt enough money for food? (circle one answer) Yes. Almost every month. Yes. Some months but not every month. Yes. Only one or two months. No

During the past 12 months, did you (personally) ever eat less than you felt you should because there wasnt enough money to buy food? (circle one answer)

Yes

No

During the past 12 months, were you (personally) ever hungry but didnt eat because you couldnt afford enough food? (circle one answer)

Yes

No

Please answer the following questions about you and your household. (Circle one answer in each row.) Do you have reliable transportation to get food? Yes No

184 Do you or someone in your household hunt during the year for food? Do you or someone in your household fish during the year for food? Yes No Yes No

Please answer the following questions about food program participation. (Circle one answer in each row.) In the past 12 months, did (you/anyone in your household) get SNAP benefits that is, either SNAP or a SNAP benefit card? During the past 12 months, did (your child/any children in the household between 5 and 18 years old) receive free or reduced-cost lunches at school? During the past 12 months, did (your child/any children in the household) receive free or reduced-cost breakfasts at school? During the past 12 months, did (your child/any children in the household) receive free or reduced-cost food at a day-care or Head Start program? In the past 12 months, did (you/anyone in your household) receive benefits from the WIC program? In the past 12 months, did (you/anyone in your household) receive benefits from the WIC Farmers Market Nutrition Program? Yes No Yes No Yes No Yes No Yes No Yes No

In the past 12 months, did (you/anyone in your household) receive benefits from the Senior Farmers Market Nutrition Program? Yes No

185 In the last 12 months, did (you/you or other adults in your household) ever get food from a church, a food pantry, or food bank? Yes No

Please answer the following about fruits and vegetables: (Circle one in each row.) I feel that I am helping my body by eating more fruits and vegetables. Agree (Yes) Agree or Disagree (Maybe) I may develop health problems if I do not eat fruit and vegetables. Agree (Yes) Agree or Disagree (Maybe) I feel that I can eat fruit or vegetables as snacks. Agree (Yes) Agree or Disagree (Maybe) I feel that I can buy more vegetables the next time I shop. Agree (Yes) Agree or Disagree (Maybe) I feel that I can plan meals or snack with more fruit during the next week. Agree (Yes) Agree or Disagree (Maybe) I feel that I can eat two or more servings of vegetables at dinner. Agree (Yes) Agree (Yes) Agree or Disagree (Maybe) Agree or Disagree (Maybe) Disagree (No) Disagree (No) Disagree (No) Disagree (No) Disagree (No) Disagree (No) Disagree (No)

I feel that I can plan meals with more vegetables during the next week.

186 I feel that I can add extra vegetables to casseroles and stews. Agree (Yes) Agree or Disagree (Maybe) In your household who is in charge of what foods to buy? I Am Shared Decision Other Person Disagree (No)

In your household who is in charge of how to prepare the food?

I Am

Shared Decision

Other Person

How would you best describe your diet?

(Circle one only.)

Excellent

Very Good

Good

Fair

Poor

Choose the one best statement that fits you. I am not thinking about eating more fruit.

(Check one box only.)

I am thinking about eating more fruitplanning to start within six months. I am definitely planning to eat more fruit in the next month.

I am trying to eat more fruit now. I am already eating 3 or more servings of fruit a day.

Choose the one best statement that fits you.

(Check one box only.)

I am not thinking about eating more vegetables.

187 I am thinking about eating more vegetablesplanning to start within six months. I am definitely planning to eat more vegetables in the next month.

I am trying to eat more vegetables now.

I am already eating 3 or more servings of vegetables a day.

Do you eat more than one kind of fruit daily?

(Circle only one.)

Never

Sometimes

Often

Always

Do you eat more than 1 kind of vegetable in a day?

(Circle only one.)

Never

Sometimes

Often

Always

During the past week, did you have citrus fruit (such as orange or grapefruit) or citrus juice? (Circle one.) Yes No

How many servings of vegetables do you eat each day? Number___________

188

Do you eat 2 or more servings of vegetables at your main meal? (Circle one.)

Sometimes

Often

Always

Never

Do you eat fruit or vegetables as snacks? (Circle one.)

Yes

No

How many servings of fruit do you eat each day? Number___________

Choose the one best statement that fits you.

(Check one box only.)

I am not thinking about gardening to grow vegetables for my household. I am thinking about gardening to grow vegetables for my household. planning to start within six months. I am definitely planning to garden to grow vegetables for my household in the next month.

I am trying to garden to grow vegetables for my household. .

I am already gardening to grow vegetables for my household.

Choose the one best statement that fits you.

(Check one box only.)

189 I am not thinking about gardening to grow fruit for my household.

I am thinking about gardening to grow fruit for my household. planning to start within six months. I am definitely planning to garden to grow fruit for my household in the next month.

I am trying to garden to grow fruit for my household. .

I am already gardening to grow fruit for my household.

The following questions are about your child/children.

How would you best describe your childs diet? Child 1

(Circle one only.)

Excellent

Very Good

Good

Fair

Poor

Child 2

Excellent

Very Good

Good

Fair

Poor

Child 3

Excellent

Very Good

Good

Fair

Poor

Child 4

Excellent

Very Good

Good

Fair

Poor

190

How many servings of vegetables does your child eat each day? Child 1 Child 2 Child 3 Child 4

How many servings of fruit does your child eat each day?

Does your child eat more than one kind of fruit daily? (Circle only one for each child.) Never Child 1 Sometimes Often Always Never Child 2 Sometimes Often Always Never Child 3 Sometimes Often Always

Does your child eat more than 1 kind of vegetable in a day? (Circle only one for each child.) Never Sometimes Often Always Never Sometimes Often Always Never Sometimes Often Always

Does your child eat 2 or more servings of vegetables at their main meal? (Circle only one for each child.) Never Sometimes Often Always Never Sometimes Often Always Never Sometimes Often Always

191 Never Child 4 Sometimes Often Always Never Sometimes Often Always Never Sometimes Often Always

During the past week, did your child have citrus fruit (such as orange or grapefruit) or citrus juice? Child 1 Yes (Circle one for each child.) No

Child 2

Yes

No

Child 3

Yes

No

Child 4 Does your child eat fruit or vegetables as snacks? Child 1

Yes

No

(Circle one for each child.) Yes No

Child 2

Yes

No

Child 3

Yes

No

Child 4

Yes

No

My child is interested in eating 3 or more servings of fruit each

My child is interested in eating 3 or more servings of vegetables

My child is interested in gardening vegetables. (Circle only one for each child.)

day. (Circle only one for each day. (Circle only

192 each child.) Strongly Agree Child 1 Agree Disagree Strongly Disagree Strongly Agree Child 2 Agree Disagree Strongly Disagree Strongly Agree Child 3 Agree Disagree Strongly Disagree Strongly Agree Child 4 Agree Disagree Strongly Disagree one for each child.) Strongly Agree Agree Disagree Strongly Disagree Strongly Agree Agree Disagree Strongly Disagree Strongly Agree Agree Disagree Strongly Disagree Strongly Agree Agree Disagree Strongly Disagree Strongly Agree Agree Disagree Strongly Disagree Strongly Agree Agree Disagree Strongly Disagree Strongly Agree Agree Disagree Strongly Disagree Strongly Agree Agree Disagree Strongly Disagree

193 APPENDIX E: KIDS ON CAMPUS LESSON PLANS BIG TOP GARDEN 2008 WEEK 1: GARDENING IS GREAT Ohio Standards Connections: English Language Arts 1) Acquisition of Vocabulary a) Know the meaning of specialized vocabulary by applying knowledge of word parts, relationship and meanings i) Classify words into categories(e.g., colors, fruits, vegetables) 2) Reading Applications: Informational, Technical and Persuasive Text Standard a) Use visual aids as sources to gain additional information from text i) Identify information in diagrams, charts, graphs, and maps Mathematics 1) Measurement Standard a) Develop common referents for units of measure for length, weight, volume and time to make comparisons and estimates i) Order a sequence of events with respect to time 2) Patterns, Functions and Algebra Standard a) Sort, classify and order objects by size, number and other properties, and describe the attributes used i) Sort, classify and order objects by two or more attributes, such as color and shape and explain how objects were sorted Science 1) Life Sciences Standard a) Discover that there are living things, non-living things and pretend things, and describe the basic needs of living things (organisms) Explore that organisms, including people, have basic needs which include air, water, food, living space and shelter Lesson Summary: Students in grades 1-4 attending the Kids on Campus 2008 Gardening Program: Big Top Garden, will participate in weekly sessions. During Week One: 1) Children will participate in the multiple stages of planting different types of seeds. 2) Students will be able to discuss the stages of plant growth and what the importance of each stage is. 3) Students will have the opportunity to determine what fruits and vegetables they enjoy, what types they eat on a

194 regular basis, and what types they should try. Estimated Duration: Students will participate in the Kids on Campus 2008 Gardening Program over a 6 week period, attending a weekly session. The one hour weekly session is broken into 4 blocks of time: 1) 2) 3) 4) Introduction (5 minutes) Message (20 minutes) Pre-assignment (20 minutes) Activity (15 minutes)

Fit-tip message of the week: Gardening can keep me fit while I grow food with my family! Pre-Assessment: Students engage in a discussion about the objectives of the program and how it aligns with the broader Kids on Campus Circus Fit theme. Students complete a checklist of the foods they have eaten in the past week and identify those they prefer.

Scoring Guidelines: The teacher uses the fruit and vegetable checklist completed by each student to identify ability to identify types of fruit and vegetable and vocabulary. Post-Assessment: The teacher uses the observational data and work samples of students to note their use of vocabulary, sorting of seed into groups and sequencing the stages of plant growth.

195 Instructional Procedures: Introduction (5 minutes) Introduce instructors and helpers as well as explain how the Big Top Garden fit in with the Kids on Campus Circus Fit theme. Message (20 minutes) Gardening is great! Handouts are given to children and read aloud by group after reading fit-tip message together. Plant stages of growth are explained and the group discusses why each stage was important for the plant. Folder assignment (20 minutes) Each child is given a folder with their group name on top that they are to write their name on and keep handouts in for the duration of the program. In the folder for this week are the fruit and vegetable check lists children fill out by marking a check in the box if theyve eaten the food in the past week and circling the food if they like it. Activity: Planting of seeds (15 minutes) Children are divided up into 5 groups: o 2 soil groups o 2 seed groups o 1 watering group The soil groups are in charge of filling the two containers (one EarthBox and one small container) full of soil. The seed groups are randomly given one of three seed types: radish, lettuce mix, or an herb which they are instructed to place in the soil. The water group then waters the top of the soil that has just been planted. All groups then return inside to wash their hands and gather their bags to move to the next KOC activity making sure to take their Gardening is great handouts home with them. Differentiated Instructional Support Material will be presented in written and visual forms to accommodate emergent readers. Instructions will be given verbally and in pictorial form to accommodate variations in learning styles, strengths, and ability levels. Equipment and concrete materials will be made accessible to all students to facilitate autonomy and promote success for each child. Extension Students are encouraged to communicate their experiences with family and engage the family unit in continuation of the project beyond the scope of the Kids on Campus Program. Materials are provided to promote communication with family in a reciprocal manner, with the student incorporating their knowledge of food and nutrition in their personal and classroom experience.

196

Homework Options and Home Connections Students are provided materials and products introduced in the Big Top Garden program with the objective they will be incorporated into the students diet and food choice knowledge.

Interdisciplinary Connections The content of the weekly session promote scientific understanding in making connections between the life sciences, collecting observational data, conducting simple experiments, and gaining knowledge of health and nutrition. Integrated within this study is opportunity for students to write, discuss, classify, measure, compare, contrast, collaborate, cooperate, and problem solve. Materials and Resources: For teachers copies of all handout materials seeds soil watering can Earthbox and additional containers collection bags checklists of vegetables folders pencils visuals for plant growth stages visual for planting seed process

Key Vocabulary fruit vegetable radish lettuce herb soil plant seed seedling

197

198 WEEK 2: GARDENING IS COLORFUL Ohio Standards Connections: English Language Arts 3) Acquisition of Vocabulary a) Know the meaning of specialized vocabulary by applying knowledge of word parts, relationship and meanings i) Classify words into categories(e.g., colors, fruits, vegetables) 4) Reading Applications: Informational, Technical and Persuasive Text Standard a) Use visual aids as sources to gain additional information from text i) Identify information in diagrams, charts, graphs, and maps Mathematics 3) Measurement Standard a) Develop common referents for units of measure for length, weight, volume and time to make comparisons and estimates i) Order a sequence of events with respect to time 4) Patterns, Functions and Algebra Standard a) Sort, classify and order objects by size, number and other properties, and describe the attributes used i) Recognize and explain how objects can be classified in more than one way ii) Identify what attribute was used to sort groups of objects that have already been sorted Science 2) Life Sciences Standard a) Discover that there are living things, non-living things and pretend things, and describe the basic needs of living things (organisms) i) Explore that organisms, including people, have basic needs which include air, water, food, living space and shelter b) Explain how organisms function and interact with their physical environments i) Compare Ohio plants by describing changes in their appearance over time

Social Studies 1) Social Studies Skills and Methods Standard a) Obtain information from oral, visual, print and electronic sources i) Obtain information about a topic using a variety of oral and visual sources

199 Lesson Summary: Students in grades 1-4 attending the Kids on Campus 2008 Gardening Program: Big Top Garden, participate in weekly sessions. During Week Two: 1) Children will observe the stages of plant growth through the garden. 2) Children will study the Food Guide Pyramid, through discussion, handouts, and an activity, focusing on: a) how it is made up into groups b) what those groups mean c) how they can use it to eat healthy Estimated Duration: Students will participate in the Kids on Campus 2008 Gardening Program over a 6 week period, attending a weekly session. The one hour weekly session is broken into 3 blocks of time: 1) Gardening Observation (15 minutes) 2) Message (20 minutes) 3) Activity (25 minutes)

Fit-tip message of the week: MyPyramid can help me choose a variety of foods for healthy living! Pre-Assessment: Students will engage in a discussion about the structure of the food pyramid and its contents, the focus being on identification of the groups and their content. The teacher will collect observational data to assess childrens understanding of the manner in which groups are formed, similarities and differences within each group. Scoring Guidelines: Students ability to identify common feature of foods in various categories will serve as an assessment tool for directing the discussion and exploration.

200 Post-Assessment: The teacher uses the observational data and work samples of students to note their use of vocabulary, ability to place various foods into proper groups on food pyramid and identifying changes in their plants growth. Instructional Procedures: Gardening observation (15 minutes) Children are able to go out to the pool deck and observe the changes in their garden through drawings.

Message (20 minutes) Gardening is colorful! Handouts are distributed through their folders and the fit-tip is read aloud as a group. A brief explanation of the food pyramid is given including its purpose and examples of each food groups contents and their role in keeping us healthy. Children are then shown a poster of the food guide pyramid to explain how different groups have different portion sizes recommended and the group discusses what groups the foods we are growing would be in.

Activity: Food Pyramid Challenge (25 minutes) Different color papers are handed out to the children in colors representing the pyramid colors in order to represent what group the child will be in: o Orange= grains (6 children) o Green= vegetables (5 children) o Red= fruits (4 children) o Blue= milk (3 children) o Purple= meat/beans (2 children) o Yellow= oils (1 child) The number of children in each group is meant to represent the average number of servings they should have from each group per day so they can see the difference between the groups visually. When the children have assembled outside in their groups food models will be presented one at a time and the groups have to decide what food group it belongs to. Once it has been correctly identified the group gets to collect their food. Try to have a variety of foods represented so that every child can hold a model.

201 After all the models have been distributed the children should return them to the instructor and collect their Gardening is colorful and other handouts to take home.

Differentiated Instructional Support Material will be presented in written and visual forms to accommodate emergent readers. Instructions will be given verbally and in pictorial form to accommodate variations in learning styles, strengths, and ability levels. Equipment and concrete materials will be made accessible to all students to facilitate autonomy and promote success for each child. Extension Students are encouraged to communicate their experiences with family and engage the family unit in continuation of the project beyond the scope of the Kids on Campus Program. Materials are provided to promote communication with family in a reciprocal manner, with the student incorporating their knowledge of food and nutrition in their personal and classroom experience. Homework Options and Home Connections Students are provided materials and products introduced in the Big Top Garden program with the objective they will be incorporated into the students diet and food choice knowledge. Interdisciplinary Connections The content of the weekly session promote scientific understanding in making connections between the life sciences, collecting observational data, conducting simple experiments, and gaining knowledge of health and nutrition. Integrated within this study is opportunity for students to write, discuss, classify, measure, compare, contrast, collaborate, cooperate, and problem solve. Materials and Resources: For teachers copies of all handout materials folders pencils paper for observational sketches clipboards for sketching plant growth visual for food pyramid food props for sorting into groups color paper for activity (6 sheets orange, 5 sheets green, 4 sheets red, 3 sheets blue, 2 sheets purple, one sheet yellow) food pyramid model

202 Key Vocabulary fruit vegetable grains milk dairy meat beans oil servings pyramid food group portion size

203

204 WEEK 3: FRUIT + VEGETABLES = FIBER Ohio Standards Connections: English Language Arts 5) Acquisition of Vocabulary a) Use resources to determine the meanings and pronunciations of unknown words i) Determine the meaning of unknown words using a beginners dictionary 6) Reading Process: Contents of Print, Comprehension Strategies and Self-Monitoring Strategies Standard a) Apply reading skills and strategies to summarize and compare and contrast information in text, between text and across subject areas i) Compare and contrast information in texts with prior knowledge and experience Mathematics 1) Patterns, Functions and Algebra Standard b) Describe and compare qualitative and quantitative change i) Describe qualitative and quantitative changes, especially those involving addition and subtraction; e.g., a student growing taller versus a student growing two inches in one year 5) Geometry and Spatial Sense Standard a) Describe location, using comparative, directional, and positional words i) Name and demonstrate the relative position of objects, extending the use of location words to include distance (near, far, close to) and directional words (left, right) Science 3) Life Sciences Standard a) Discover that there are living things, non-living things and pretend things, and describe the basic needs of living things (organisms) i) Explore that organisms, including people, have basic needs which include air, water, food, living space and shelter b) Explain how organisms function and interact with their physical environments i) Explain that food comes from sources other than grocery stores ii) Investigate the different structures of plants and animals that help them live in different environments (e.g., lungs, gills, leaves and roots) c) Describe similarities and differences that exist among individuals of the same kind of plants and animals i) Compare similarities and differences among individuals of the same kind of plants and animals, including people Social Studies 2) Social Studies Skills and Methods Standard a) Obtain information from oral, visual, print and electronic sources i) Obtain information about a topic using a variety of oral and visual sources

205 Lesson Summary: Students in grades 1-4 attending the Kids on Campus 2008 Gardening Program: Big Top Garden, will participate in weekly sessions. During Week Three: 1) Introduce the concept of fiber to the children and give a brief explanation of why it is important to have in the diet as well as food sources. 2) Through the use of handouts children will learn the parts of the plant and how each produces an edible part that can provide fiber to our diet. 3) Provide children with sprouts to take home in order to introduce a possible new source of fiber to their diet. Estimated Duration: Students participate in the Kids on Campus 2008 Gardening Program over a 6 week period, attending a weekly session. The one hour weekly session is broken into 3 blocks of time: 1) Garden Observation (15 minutes) 2) Message (20 minutes) 3) Activity (25 minutes)

Fit-tip message of the week: Getting fiber from eating fruits and vegetables keeps me healthy! Pre-Assessment: Students will engage in a discussion about fiber and its purpose and role in humans diets, the focus being on identification of why the substance is important and how to include it in our diet. The teacher will collect observational data to assess childrens understanding of the discussion of the term. Discussion about students sketches of the growing plants in their Big Top Garden will serve as baseline information of students understanding of the parts of the plant. Scoring Guidelines:

206 Students ability to identify part of the plant and use of the terminology from the food pyramid will serve as an assessment tool for directing the discussion and exploration. Post-Assessment: The teacher uses the observational data and work samples of students to note their use of vocabulary, ability to identify changes in their plants growth, parts of the plants, and sources of fiber to include in their diet. Instructional Procedures: Garden observation (15 minutes) Children are able to go out to the pool deck and observe the changes in their garden through drawings.

Message (20 minutes) Distribute Fruit + Vegetables = Fiber handout as well as additional EarthBox handouts through folders. Fit-tip message is read aloud as is F+V=F handout by children. Benefits and purpose of fiber is explained and then children are asked to provide some suggestions of foods we could eat to get our fiber. Tied in with fiber, another handout that is provided discusses the parts of the plant and how each produce an edible result: o Roots= carrots, potatoes, radishes o Stem= celery o Leaves= lettuce o Flower= cauliflower, broccoli o Seed= corn, peas Message is then finished with handout children complete by drawing different fruits or vegetables and then labeling the part of the plant they come from.

Activity: Growing Sprouts (25 minutes) Each child is given a glass jelly jar and removes the lid. The instructor then gives each child a tablespoon or two of mung bean sprout seeds in their jars. The children then go fill the jars to about an inch above the seeds and replace the lid. After checking to make sure all lids are on securely, the group then takes the jars and shakes them to help them grow.

207 The children then take jars home and are instructed to place them in a dark area rinsing the seeds daily until they grow and then can be eaten. Further instructions are provided on the F+V=F handout for the family. Children then take their jar and handouts home.

Differentiated Instructional Support Material will be presented in written and visual forms to accommodate emergent readers. Instructions will be given verbally and in pictorial form to accommodate variations in learning styles, strengths, and ability levels. Equipment and concrete materials will be made accessible to all students to facilitate autonomy and promote success for each child. Extension Students are encouraged to communicate their experiences with family and engage the family unit in continuation of the project beyond the scope of the Kids on Campus Program. Materials are provided to promote communication with family in a reciprocal manner, with the student incorporating their knowledge of food and nutrition in their personal and classroom experience. Homework Options and Home Connections Students are provided materials and products introduced in the Big Top Garden program with the objective they will be incorporated into the students diet and food choice knowledge. Interdisciplinary Connections The content of the weekly session promote scientific understanding in making connections between the life sciences, collecting observational data, conducting simple experiments, and gaining knowledge of health and nutrition. Integrated within this study is opportunity for students to write, discuss, classify, measure, compare, contrast, collaborate, cooperate, and problem solve. Materials and Resources: For teachers copies of all handout materials (Fruit + Vegetable = Fiber, and EarthBox) folders pencils paper for observational sketches clipboards for sketching plant growth visuals for parts of plants beginners dictionary glass jelly jar for each child mung bean sprout seeds soil jar lids

208

Key Vocabulary fiber fruit vegetable beans roots carrots potatoes radishes stem celery leaves lettuce flower cauliflower broccoli seed corn peas sprout

209

210 WEEK 4: TEAMWORK Ohio Standards Connections: English Language Arts 7) Research Standard a) Retell important details and findings i) Recall information about a topic with teacher assistance 8) Communication: Oral and Visual Standard a) Use active listening strategies to identify the main idea and to gain information from oral presentation i) Identify the main idea of oral presentations and visual media ii) Use active listening strategies, such as making eye contact and asking for clarification and explanation b) Follow multi-step directions i) Follow two- and three-step oral directions Mathematics 6) Geometry and Spatial Sense Standard a) Describe location, using comparative, directional, and positional words i) Name and demonstrate the relative position of objects, extending the use of location words to include distance (near, far, close to) and directional words (left, right) Science 4) Life Sciences Standard a) Discover that there are living things, non-living things and pretend things, and describe the basic needs of living things (organisms) i) Explore that organisms, including people, have basic needs which include air, water, food, living space and shelter Social Studies 1) Geography Standard a) Identify the location of Ohio, the United States, the continents and oceans on maps, globes, and other geographic representations i) Identify and correctly use terms related to location, direction and distance including: left/right; near/far 3) Social Studies Skills and Methods Standard a) Obtain information from oral, visual, print and electronic sources i) Obtain information about a topic using a variety of oral and visual sources 4) Citizenship Rights and Responsibilities Standard a) Describe the results of cooperation in group settings and demonstrate the necessary skills i) Demonstrate skills and explain the benefits of cooperation when working in a group setting

211 Lesson Summary: Students in grades 1-4 attending the Kids on Campus 2008 Gardening Program: Big Top Garden, will participate in weekly sessions. During Week Four: a. Children will learn the basic concepts of vitamins and minerals and how they help the body to stay healthy. b. They will also be able to identify multiple examples of foods high in Vitamin C and/or iron. c. The concept of Vitamin C and iron working together in the body will also be explained through the use of an activity. Estimated Duration: Students participate in the Kids on Campus 2008 Gardening Program over a 6 week period, attending a weekly session. The one hour weekly session is broken into 3 blocks of time: 1) Garden Observation (15 minutes)

2) Message (20 minutes) 3) Activity (25 minutes)

Fit-tip message of the week: Vitamins and minerals in food work together to keep me healthy! Pre-Assessment: Students will be engaged in a discussion of working together, sharing personal experience related to the concept. The teacher will use the prompt of asking for students to name famous teammates that worked in pairs; e.g., Batman and Robin, Bert and Ernie, etc. Incidence of helping behaviors will be noted by the teacher to focus students attention of the concept of team work and its benefits. Scoring Guidelines:

212 Using guided writing experience, the teacher will record childrens stories emphasizing terms used that align with concept of team work. Post-Assessment: The teacher uses the observational data and work samples of students to note their use of vocabulary, ability to successfully navigate the maze with a partner, and use directional words, terminology, and nutritional terms. Instructional Procedures: Garden observation (15 minutes) Children are able to go out to the pool deck and observe the changes in their garden through drawings.

Message (15 minutes) Childrens folders are distributed with handouts for the week and the fittip message is read aloud by the group. Instructor gives brief explanation on the purpose of vitamins and minerals and examples of what foods Vitamin C and iron are specifically found in. Vitamin C and iron are then explained further and their purpose and function in the body are discussed with the group in order to emphasize their importance to our health. The teamwork aspect of Vitamin C and iron is then explained in the sense that Vitamin C and iron can both help the body in their own way but when used together they work much better and faster. This concept will come in to play during the activity.

Activity (30 minutes) Children are taken outside and paired up by their choosing. One child decides to be Vitamin C while the other is iron. The child playing Vitamin C must close their eyes and/or cover them while the child playing iron leads them through a maze. This reinforces the concept that on its own, Vitamin C could make it through on its own but it will be a lot faster and more efficient if iron helps. Once through the maze the children switch roles and go again so each can experience both sides. The children may go through as many times as they like as long as they do not harm each other. After the completion of the activity the children collect their handouts from this week and take them home.

213 Differentiated Instructional Support Material will be presented in written and visual forms to accommodate emergent readers. Instructions will be given verbally and in pictorial form to accommodate variations in learning styles, strengths, and ability levels. Equipment and concrete materials will be made accessible to all students to facilitate autonomy and promote success for each child. Extension Students are encouraged to communicate their experiences with family and engage the family unit in continuation of the project beyond the scope of the Kids on Campus Program. Materials are provided to promote communication with family in a reciprocal manner, with the student incorporating their knowledge of food and nutrition in their personal and classroom experience. Homework Options and Home Connections Students are provided materials and products introduced in the Big Top Garden program with the objective they will be incorporated into the students diet and food choice knowledge. Interdisciplinary Connections The content of the weekly session promote scientific understanding in making connections between the life sciences, collecting observational data, conducting simple experiments, and gaining knowledge of health and nutrition. Integrated within this study is opportunity for students to write, discuss, classify, measure, compare, contrast, collaborate, cooperate, and problem solve. Materials and Resources: For teachers copies of all handout materials folders pencils paper for observational sketches clipboards for sketching plant growth easel paper to record dictation of students discussion of teamwork marker chairs and desks to create maze scarf for blindfold

Key Vocabulary Vitamin Vitamin C iron team work

214

215 WEEK 5: DYNAMIC DUO Ohio Standards Connections: English Language Arts 9) Communication: Oral and Visual Standard a) Follow multi-step directions i) Follow two- and three-step oral directions 10) Phonemic Awareness, Work Recognition and Fluency Standard a) Demonstrate fluent oral reading using sight words and decoding skills, varying intonation and timing as appropriate for text i) Demonstrate growing stock of sight words 11) Acquisition of Vocabulary Standard a) Use context clues to determine the meaning of new vocabulary i) Use knowledge of word order and in-sentence context clues to support word identification and to define unknown words while reading Science 5) Life Sciences Standard a) Describe similarities and differences that exist among individuals of the same kind of plant and animals i) Compare similarities and differences among individuals of the same kind of plants and animals, including people 6) Scientific Inquiry Standard a) Ask a testable question i) Ask what happens when questions Social Studies 2) Geography Standard a) Identify the location of Ohio, the United States, the continents and oceans on maps, globes, and other geographic representations i) Identify and correctly use terms related to location, direction and distance including: left/right; near/far 5) Social Studies Skills and Methods Standard a) Obtain information from oral, visual, print and electronic sources i) Obtain information about a topic using a variety of oral and visual sources

216 Lesson Summary: Students in grades 1-4 attending the Kids on Campus 2008 Gardening Program: Big Top Garden, will participate in weekly sessions. During Week Five: a. Children will build on their knowledge of vitamins and minerals from last week by learning more in depth on two others- Vitamin A and calcium. b. Vitamin A and calciums purpose, food sources, and function in the body will all be discussed. c. Handouts will be provided in order to emphasize the different areas affected by various vitamins and minerals. Estimated Duration: Students participate in the Kids on Campus 2008 Gardening Program over a 6 week period, attending a weekly session. The one hour weekly session is broken into 3 blocks of time: 1) Garden Observation (15 minutes) 2) Message (20 minutes) 3) Activity (25 minutes)

Fit-tip message of the week: Vitamin A and calcium are key nutrients for health! Pre-Assessment: Students will be engaged in a review of the previous weeks discussion of working together, sharing personal experience related to the concept. The teacher will use the prompt of asking for students to name famous teammates that worked in pairs; e.g., Batman and Robin, Bert and Ernie, etc. Incidence of helping behaviors will be noted by the teacher to focus students attention of the concept of team work and its benefits. Scoring Guidelines:

217 Using guided writing experience, the teacher will record childrens stories emphasizing terms used that align with concept of team work. Post-Assessment: The teacher uses the observational data and work samples of students to note their use of vocabulary, ability to successfully navigate the maze with a partner, and use directional words, terminology, and nutritional terms. Instructional Procedures: Garden observation (15 minutes) Children are able to go out to the pool deck and observe the changes in their garden through drawings.

Message (20 minutes) Once folders are distributed with handouts for that week, children read fit tip aloud as a group. Instructor then provides brief explanation of Vitamin A and calcium including their benefits, food sources, and what roles they play in the body. A vegetable pizza recipe provided on the handout is then used as an example of how to get both Vitamin A and calcium in the same meal.

Activity (25 minutes) Children are provided with two handouts in their folders: o Map of the body indicating where each vitamin and mineral plays a role o Fruit and vegetable alphabet list The group discusses the body handout while the children draw their own bodies around the skeleton provided on the handout. This allows for the children to relate to how each would help them. The next handout begins once children are finished drawing on the first. Five to ten minutes are given for the children to start on the fruit and vegetable alphabet on their own by trying to fill in letters A-E on their own. After they seem stumped, food models are brought out to attempt to jog their memories and give them visual cues. This can also be tied in with week 4 and 5s lessons by quizzing the children on what vitamins and minerals each of the foods have.

218 After the handouts are complete the children may take them home to share with their families.

Differentiated Instructional Support Material will be presented in written and visual forms to accommodate emergent readers. Instructions will be given verbally and in pictorial form to accommodate variations in learning styles, strengths, and ability levels. Equipment and concrete materials will be made accessible to all students to facilitate autonomy and promote success for each child. Extension Students are encouraged to communicate their experiences with family and engage the family unit in continuation of the project beyond the scope of the Kids on Campus Program. Materials are provided to promote communication with family in a reciprocal manner, with the student incorporating their knowledge of food and nutrition in their personal and classroom experience. Homework Options and Home Connections Students are provided materials and products introduced in the Big Top Garden program with the objective they will be incorporated into the students diet and food choice knowledge. Interdisciplinary Connections The content of the weekly session promote scientific understanding in making connections between the life sciences, collecting observational data, conducting simple experiments, and gaining knowledge of health and nutrition. Integrated within this study is opportunity for students to write, discuss, classify, measure, compare, contrast, collaborate, cooperate, and problem solve. Materials and Resources: For teachers copies of all handout materials folders pencils paper for observational sketches clipboards for sketching plant growth easel paper to record dictation of students discussion of teamwork marker map of body handout and visual fruit and vegetable alphabet list food models recipe visual for vegetable pizza

219 Key Vocabulary Vitamin Vitamin A calcium skeleton body mineral vegetable pizza recipe

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221 WEEK 6: SCRAPS TO SOIL Ohio Standards Connections: English Language Arts 12) Communication: Oral and Visual Standard a) Follow multi-step directions i) Follow two- and three-step oral directions 13) Phonemic Awareness, Work Recognition and Fluency Standard a) Demonstrate fluent oral reading using sight words and decoding skills, varying intonation and timing as appropriate for text i) Demonstrate growing stock of sight words 14) Acquisition of Vocabulary Standard a) Use context clues to determine the meaning of new vocabulary i) Use knowledge of word order and in-sentence context clues to support word identification and to define unknown words while reading Math 1) Number, Number Sense and Operations Standard a) Recognize, classify, compare and order whole numbers i) Recognize and generate equivalent forms for the same number using physical models Science 1) Earth and Space Science Standard a) Explain that living things cause changes on Earth i) Explain that all organisms cause changes in the environment where they live; the changes can be very noticeable or slightly noticeable, fast or slow b) Describe what resources are and recognize some are limited but can be extended through recycling or decreased use i) Identify that resources are things that we get from the living and nonliving environment and that resources are necessary to meet the needs and wants of a population ii) Explain that the supply of many resources is limited but the supply can be extended through careful use, decreased use, reusing and/or recycling Social Studies 6) Social Studies Skills and Methods Standard a) Obtain information from oral, visual, print and electronic sources i) Obtain information about a topic using a variety of oral and visual sources

222 Lesson Summary: Students in grades 1-4 attending the Kids on Campus 2008 Gardening Program: Big Top Garden, will participate in weekly sessions. During Week Six: a. All previous lesson objectives should still be able to be discussed by the group. b. The benefits of composting and gardening will be explained and able to take home to the families. c. The results of the garden will be observed by the children and provide a visual to the stages of the plant discussed in the first lesson.

Estimated Duration: Students participate in the Kids on Campus 2008 Gardening Program over a 6 week period, attending a weekly session. The one hour weekly session is broken into 3 blocks of time: 1) Garden Observation (15 minutes) 2) Message (30 minutes) 3) Activity (15 minutes)

Fit-tip message of the week: Making compost reduces waste and helps the garden! Pre-Assessment: Students will be engaged in a review of the previous weeks discussions with completion of a K-W-L chart at the beginning of the session. Scoring Guidelines: The teacher will note the students recall and connections of previous knowledge. Post-Assessment:

223 The teacher uses the observational data and work samples of students to note their use of vocabulary, terminology, and nutritional terms. Instructional Procedures: Garden observation (15 minutes) Children are able to go out to the pool deck and observe the changes in their garden through drawings.

Message (30 minutes) Once again the children will fill out fruit and vegetable check lists by marking a check in the box if theyve eaten the food in the past week and circling the food if they like it. These will be used to compare to their first check lists for differences. After the completion of the checklists the group will read the fit-tip aloud together. Instructor will give a brief explanation of the benefits of composting, what it is, as well as what is put in a compost pile and what is left out.

Activity (15 minutes) After the discussion with the group covering what goes in a compost pile and what does not each child receives an item and gets in a line. Items include: o Food models o Paper o grass o News paper o Plastic bottles o Plastic toys o Glass bottles o Duct tape o Shoes o Plants o Dirt Once in line the instructor stands in front with a bin (compost box) and asks each child if their item goes in the bin or not and why. The group can help if the child is not sure about their item. After the compost pile has been made the group discusses its benefits to the garden and how they could do the activity at home.

224 At the end of the session the children take all remaining handouts home to share with their families while the instructor keeps the folders with their drawings and checklists from each week.

Differentiated Instructional Support Material will be presented in written and visual forms to accommodate emergent readers. Instructions will be given verbally and in pictorial form to accommodate variations in learning styles, strengths, and ability levels. Equipment and concrete materials will be made accessible to all students to facilitate autonomy and promote success for each child. Extension Students are encouraged to communicate their experiences with family and engage the family unit in continuation of the project beyond the scope of the Kids on Campus Program. Materials are provided to promote communication with family in a reciprocal manner, with the student incorporating their knowledge of food and nutrition in their personal and classroom experience. Homework Options and Home Connections Students are provided materials and products introduced in the Big Top Garden program with the objective they will be incorporated into the students diet and food choice knowledge. Interdisciplinary Connections The content of the weekly session promote scientific understanding in making connections between the life sciences, collecting observational data, conducting simple experiments, and gaining knowledge of health and nutrition. Integrated within this study is opportunity for students to write, discuss, classify, measure, compare, contrast, collaborate, cooperate, and problem solve. Materials and copies of all handout materials Resources: folders For teachers pencils paper for observational sketches clipboards for sketching plant growth easel paper to record K-W-L marker Food models Paper grass News paper Plastic bottles Plastic toys Glass bottles Duct tape Shoes Plants

225 Dirt

Key Vocabulary composting compost pile waste recycle reduce reuse Food models Paper grass News paper Plastic bottles Plastic toys Glass bottles Duct tape Shoes Plants Dirt

226
KIDS ON CAMPUS

SCRAPS TO SOIL
Indoor Composting with WORMS!
Put moist shredded brown leaves and papers into a bin with several holes in the side. Add one cup of dirt to the paper mixture and place

Composting is when you turn old food scraps, dead plants, and paper into yummy soil for your garden!
Compost helps:
Make soil better for growing Prevent pollution and landfills Save money

red worms on top. Bury green stuff (old food) under the paper. Within six weeks the worms will help make great soil for other plants to grow.

Make a compost bin in your own backyard!

Have your family help you make a bin (3ft high and square) out of wood scraps, plastic, or metal fencing. Make sure there are holes to allow air to go in and out. Mix green stuff (food scraps and grass) brown stuff (dead plants) and water. Soil will form at the bottom of the bin for your garden.

227 APPENDIX F: CHILD FRUIT AND VEGETABLE SURVEYS

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