Impact of Garden-Based Youth Nutrition Intervention Programs: A Review

A Growing Opportunity: Community Gardens Affiliated with US Hospitals and Academic Health Centers

Background

Community gardens can reduce public health disparities through promoting physical activity and healthy eating, growing food for underserved populations, and accelerating healing from injury or disease. Despite their potential to contribute to comprehensive patient care, no prior studies have investigated the prevalence of community gardens affiliated with US healthcare institutions, and the demographic characteristics of communities served by these gardens.

Methods

In 2013, national community garden databases, scientific abstracts, and public search engines (e.g., Google Scholar) were used to identify gardens. Outcomes included the prevalence of hospital-based community gardens by US regions, and demographic characteristics (age, race/ethnicity, education, household income, and obesity rates) of communities served by gardens.

Results

There were 110 healthcare-based gardens, with 39 in the Midwest, 25 in the South, 24 in the Northeast, and 22 in the West. Compared to US population averages, communities served by healthcare-based gardens had similar demographic characteristics, but significantly lower rates of obesity (27% versus 34%, P < .001).

Conclusions

Healthcare-based gardens are located in regions that are demographically representative of the US population, and are associated with lower rates of obesity in communities they serve.

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Community gardens may offer diverse public health benefits.

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We identified 110 gardens that are operating in partnership with hospitals.

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Communities served by hospital gardens may have lower obesity than US average.

School gardens and physical activity: a randomized controlled trial of low-income elementary schools

OBJECTIVE

This study examines effects of a school garden intervention on elementary school children's physical activity (PA).

METHOD

Twelve schools in New York were randomly assigned to receive the school garden intervention (n=6) or to the waitlist control group that later received gardens (n=6). PA was measured by self-report survey (Girls Health Enrichment Multi-site Study Activity Questionnaire) (N=227) and accelerometry (N=124, 8 schools) at baseline (Fall 2011) and follow-up (Spring 2012, Fall 2012, Spring 2013). Direct observation (N=117, 4 schools) was employed to compare indoor (classroom) and outdoor (garden) PA. Analysis was by general linear mixed models.

RESULTS

Survey data indicate garden intervention children's reports of usual sedentary activity decreased from pre-garden baseline to post-garden more than the control group children's (Δ=-.19, p=.001). Accelerometry data reveal that during the school day, children in the garden intervention showed a greater increase in percent of time spent in moderate and moderate-to-vigorous PA from baseline to follow-up than the control group children (Δ=+.58, p=.010; Δ=+1.0, p=.044). Direct observation within-group comparison of children at schools with gardens revealed that children move more and sit less during an outdoor garden-based lesson than during an indoor, classroom-based lesson.

CONCLUSION

School gardens show some promise to promote children's PA.

CLINICAL TRIALS REGISTRATION

clinicaltrials.gov # NCT02148315.

Evaluation of the impact of a school gardening intervention on children's fruit and vegetable intake: a randomised controlled trial

BACKGROUND

Current academic literature suggests that school gardening programmes can provide an interactive environment with the potential to change children's fruit and vegetable intake. This is the first cluster randomised controlled trial (RCT) designed to evaluate whether a school gardening programme can have an effect on children's fruit and vegetable intake.

METHODS

The trial included children from 23 schools; these schools were randomised into two groups, one to receive the Royal Horticultural Society (RHS)-led intervention and the other to receive the less involved Teacher-led intervention. A 24-hour food diary (CADET) was used to collect baseline and follow-up dietary intake 18 months apart. Questionnaires were also administered to evaluate the intervention implementation.

RESULTS

A total of 641 children completed the trial with a mean age of 8.1 years (95% CI: 8.0, 8.4). The unadjusted results from multilevel regression analysis revealed that for combined daily fruit and vegetable intake the Teacher-led group had a higher daily mean change of 8 g (95% CI: -19, 36) compared to the RHS-led group -32 g (95% CI: -60, -3). However, after adjusting for possible confounders this difference was not significant (intervention effect: -40 g, 95% CI: -88, 1; p = 0.06). The adjusted analysis of process measures identified that if schools improved their gardening score by 3 levels (a measure of school gardening involvement - the scale has 6 levels from 0 'no garden' to 5 'community involvement'), irrespective of group allocation, children had, on average, a daily increase of 81 g of fruit and vegetable intake (95% CI: 0, 163; p = 0.05) compared to schools that had no change in gardening score.

CONCLUSIONS

This study is the first cluster randomised controlled trial designed to evaluate a school gardening intervention. The results have found very little evidence to support the claims that school gardening alone can improve children's daily fruit and vegetable intake. However, when a gardening intervention is implemented at a high level within the school it may improve children's daily fruit and vegetable intake by a portion. Improving children's fruit and vegetable intake remains a challenging task.

TRIAL REGISTRATION

ISRCTN11396528.

Does the Royal Horticultural Society Campaign for School Gardening increase intake of fruit and vegetables in children? Results from two randomised controlled trials

Background

Children’s fruit and vegetable intake in the UK is low. Changing intake is challenging. Gardening in schools might be a vehicle for facilitating fruit and vegetable intake.

Objectives

To undertake the first clustered randomised controlled trials (RCTs) of a gardening intervention. To evaluate the impact of a school gardening programme, the Royal Horticultural Society (RHS) Campaign for School Gardening, on children’s fruit and vegetable intake.

Methods

Primary school children aged 8–11 years from eight London boroughs were included in one of two related RCTs. Trial 1 consisted of 23 schools, randomised to receive either a RHS-led or teacher-led intervention. Trial 2 consisted of 31 schools, randomised to either the teacher-led intervention or a comparison group. A 24-hour food diary [the Child And Diet Evaluation Tool (CADET)] collected baseline and follow-up dietary intake. Questionnaires measured children’s knowledge and attitudes towards fruit and vegetables and assessed intervention implementation. Data were collected by fieldworkers who were blind to the original allocation of the school. The primary outcome was change in fruit and vegetable intake analysed using a random effects model, based on intention to treat.

Results

Total sample size at baseline for both trials (2529 children) was lower than the original aim of 2900 children. The final sample size was 1557, with 641 children completing trial 1 (RHS-led,n = 312; teacher-led,n = 329) and 916 children completing trial 2 (teacher-led,n = 488; control,n = 428). The response rate at follow-up for the two combined was 62%.

Baseline analysis of children’s fruit and vegetable intake showed that eating a family meal together, cutting up fruit and vegetables, and parental modelling of fruit and vegetable intakes were all associated with higher intakes of fruit and vegetables in children.

The primary trial outcome, combined fruit and vegetable intake, showed that in trial 1 the teacher-led group had a mean change in intake of 8 g [95% confidence interval (CI) –19 to 36 g], compared with a mean of –32 g (95% CI –60 to –3 g) in the RHS-led group. However, this difference was not significant (intervention effect –43 g, 95% CI –88 to 1 g;p = 0.06). In trial 2, the teacher-led group consumed 15 g (95% CI –36 to 148 g) more fruit and vegetables than the comparison group; this difference was not significant. No change was found in children’s knowledge and attitudes. However, if schools improved their RHS gardening score by three levels, children had a higher intake of 81 g of fruit and vegetables (95% CI 0 to 163 g;p = 0.05) compared with schools with no change in gardening score.

Conclusion

Results from these trials provide little evidence that school gardening alone can improve children’s fruit and vegetable intake. In both trials, gardening levels increased across all groups from baseline to follow-up, with no statistically significant difference between groups in terms of improvement in gardening level. This lack of differentiation between groups is likely to have influenced the primary outcome. However, when the gardening intervention was implemented at the highest intensities there was a suggestion that it could improve children’s fruit and vegetable intake by a portion. Analysis of the baseline data showed that family support for fruit and vegetable intakes was associated with higher intakes of fruit and vegetables in children. This study highlights the need for more sophisticated and accurate tools to evaluate diet in children. Future intervention designs should include a greater level of parental involvement in school interventions, along with related components such as cooking, to substantially improve children’s fruit and vegetable intake. In addition, the home environment has been demonstrated to be an important focus for intervention.

Trial registration

Current Controlled Trials ISRCTN11396528.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 2, No. 4. See the NIHR Journals Library website for further project information.

Evaluating return on investment in a school based health promotion and prevention program: the investment multiplier for the Stephanie Alexander Kitchen Garden National Program

Successful health promotion and disease prevention strategies in complex community settings such as primary schools rely on acceptance and ownership across community networks. Assessing multiplier impacts from investment on related community activity over time are suggested as key alongside evidence of program health effects on targeted groups of individuals in gauging community network engagement and ownership, dynamic impacts, and program long term success and return on investment. An Australian primary school based health promotion and prevention strategy, the Stephanie Alexander Kitchen Garden National Program (SAKGNP), which has been providing garden and kitchen classes for year 3-6 students since 2008, was evaluated between 2011 and 2012. Returns on Australian Federal Government investment for school infrastructure grants up to $60,000 are assessed up to and beyond a two year mutual obligation period with: (i) Impacts on student lifestyle behaviours, food choices and eating habits surveyed across students (n = 491 versus 260) and parents (n = 300 versus 234) in 28 SAKGNP and 14 matched schools, controlling for school and parent level confounders and triangulated with SAKGNP pre-post analysis; (ii) Multiplier impacts of investment on related school and wider community activity up to two years; and (iii) Evidence of continuation and program evolution in schools observed beyond two years. SAKGNP schools showed improved student food choices (p = 0.024) and kitchen lifestyle behaviour (p = 0.019) domains compared to controls and in pre-post analysis where 20.0% (58/290) reported eating fruit and vegetables more often and 18.6% (54/290) preparing food at home more often. No significant differences were found in case control analysis for eating habits or garden lifestyle behaviour domains, although 32.3% of children helped more in the garden (91/278) and 15.6% (45/289) ate meals together more often in pre-post analysis. The multiplier impact on total community activity up to two years was 5.07 ($226,737/$44,758); 1.60 attributable to school, and 2.47 to wider community, activity. All 8 schools observed beyond two years continued garden and kitchen classes, with an average 17% scaling up and one school fully integrating staff into the curriculum. In conclusion evidence supports the SAKGNP to be a successful health promotion program with high community network impacts and return on investment in practice.

School Gardens in the Distrito Federal, Brazil

OBJECTIVE: The aim of the present study was to identify experiences with gardens in public schools in the Distrito Federal, Brazil, and to analyze factors involved in their use to promote healthy eating habits. METHODS: This is an analytical cross-sectional study with data collection in two phases: (1) telephone contact with all public schools in the Distrito Federal; (2) interviews conducted with a sample of schools with a garden (n=105). RESULTS: Of the 582 schools in the Distrito Federal, 453 (77.8%) participated in phase 1 and 37.7% of these had a garden. Rural schools had a higher prevalence of gardens (p=0.003). Among the schools which had no garden, 75.2% (n=212) had interest in creating one. The main reason for the deactivation of gardens was a lack of manpower to maintain them. The main reason for creating a garden was to supplement school food (56.2%). The garden was used as an educational space to promote healthy eating habits by 60.8% of the schools. CONCLUSION: An expressive percentage of schools with gardens (37.7%) was identified in the Distrito Federal. A number of factors were associated with the presence of a garden, including the location and size of the school, as well as the level of education. A significant percentage of schools reported using the garden as a space to promote healthy eating habits. This result must be refined by assessing the use and impact of gardens as a tool to promote healthy eating habits in the school community.

Behavioral contributions to the pathogenesis of type 2 diabetes

Behavioral contributions to the pathogenesis of prediabetes and Type 2 diabetes (T2D) include lifestyle behaviors including dietary intake, exercise, sedentariness, sleep, and stress. The purpose of this paper is to review evidence for the metabolic pathways by which the behavior is linked to T2D. Evidence for interventions, which change each of the lifestyle behaviors, is discussed. The article will close with a brief discussion on how new technologies may provide opportunities to better understand relationships between moment-to-moment fluctuations in behaviors and diabetes pathogenesis, as well as provide opportunities to personalize and adapt interventions to achieve successful behavior change and maintenance of that change. Especially promising are new technologies, which assist in tracking lifestyle behaviors along with clinical and metabolic outcomes.

Green schoolyards as havens from stress and resources for resilience in childhood and adolescence

This paper investigates how green schoolyards can reduce stress and promote protective factors for resilience in students. It documents student responses to green schoolyards in Maryland and Colorado in the United States under three conditions: young elementary school children׳s play in wooded areas during recess; older elementary school children׳s use of a naturalized habitat for science and writing lessons; and high school students׳ involvement in gardening. Drawing on ethnographic observations and interviews, it describes how the natural areas enabled students to escape stress, focus, build competence, and form supportive social groups. These findings have implications for theories of resilience and restoration and school interventions for stress management.

Position of the Academy of Nutrition and Dietetics: interventions for the prevention and treatment of pediatric overweight and obesity

It is the position of the Academy of Nutrition and Dietetics that prevention and treatment of pediatric overweight and obesity require systems-level approaches that include the skills of registered dietitians, as well as consistent and integrated messages and environmental support across all sectors of society to achieve sustained dietary and physical-activity behavior change. This position paper provides guidance and recommendations for levels of intervention targeting overweight and obesity prevention and treatment from preschool age through adolescence. Methods included a review of the literature from 2009 to April 2012, including the Academy's 2009 evidence analysis school-based reviews. Multicomponent interventions show the greatest impact for primary prevention; thus, early childhood and school-based interventions should integrate behavioral and environmental approaches that focus on dietary intake and physical activity using a systems-level approach targeting the multilevel structure of the socioecological model as well as interactions and relationships between levels. Secondary prevention and tertiary prevention/treatment should emphasize sustained family-based, developmentally appropriate approaches that include nutrition education, dietary counseling, parenting skills, behavioral strategies, and physical-activity promotion. For obese youth with concomitant serious comorbidities, structured dietary approaches and pharmacologic agents should be considered, and weight-loss surgery can be considered for severely obese adolescents. Policy and environmental interventions are recommended as feasible and sustainable ways to support healthful lifestyles for children and families. The Academy supports commitment of resources for interventions, policies, and research that promote healthful eating and physical-activity behaviors to ensure that all youth have the opportunity to achieve and maintain a weight that is optimal for health.

Methodology for the evaluation of the Stephanie Alexander Kitchen Garden program

ISSUES ADDRESSED

Community and school cooking and gardening programs have recently increased internationally. However, despite promising indications, there is limited evidence of their effectiveness. This paper presents the evaluation framework and methods negotiated and developed to meet the information needs of all stakeholders for the Stephanie Alexander Kitchen Garden (SAKG) program, a combined cooking and gardening program implemented in selectively funded primary schools across Australia.

METHODS

The evaluation used multiple aligned theoretical frameworks and models, including a public health ecological approach, principles of effective health promotion and models of experiential learning. The evaluation is a non-randomised comparison of six schools receiving the program (intervention) and six comparison schools (all government-funded primary schools) in urban and rural areas of Victoria, Australia. A mixed-methods approach was used, relying on qualitative measures to understand changes in school cultures and the experiential impacts on children, families, teachers, parents and volunteers, and quantitative measures at baseline and 1 year follow up to provide supporting information regarding patterns of change.

RESULTS

The evaluation study design addressed the limitations of many existing evaluation studies of cooking or garden programs. The multistrand approach to the mixed methodology maintained the rigour of the respective methods and provided an opportunity to explore complexity in the findings. Limited sensitivity of some of the quantitative measures was identified, as well as the potential for bias in the coding of the open-ended questions.

CONCLUSION

The SAKG evaluation methodology will address the need for appropriate evaluation approaches for school-based kitchen garden programs. It demonstrates the feasibility of a meaningful, comprehensive evaluation of school-based programs and also demonstrates the central role qualitative methods can have in a mixed-method evaluation. So what? This paper contributes to debate about appropriate evaluation approaches to meet the information needs of all stakeholders and will support the sharing of measures and potential comparisons between program outcomes for comparable population groups and settings.

The role of social cognitive theory in farm-to-school-related activities: implications for child nutrition

BACKGROUND

Farm-to-school (FTS) programs are gaining attention for many reasons, one of which is the recognition that they could help stem the increase in childhood overweight and obesity. Most FTS programs that have been evaluated have increased students' selection or intake of fruits and vegetables following the incorporation of FTS components. However, the wide range of activities that are typically part of FTS programs make it difficult to pinpoint which components have the greatest potential to improve students' health behaviors. Within the field of nutrition education, theory-based interventions that target the key underlying factors influencing health behavior offer the most promise.

METHODS

We review existing research on dietary health impacts and implications of 3 key FTS-related activities and explore the component activities of FTS in terms of their potential to address the key constructs of social cognitive theory (SCT)--which is a current best practice in the field of nutrition--suggesting that FTS programs incorporating a diverse set of activities appear to be most promising.

RESULTS

We find that components of FTS programs incorporate many of the key theoretical constructs in SCT, and show that FTS programs have great potential to facilitate movement toward desired dietary changes. However, it is unlikely that a set of activities in any one current FTS program addresses multiple constructs of the theory in a systematic manner.

CONCLUSION

More intentional inclusion of diverse activities would likely be beneficial. Future research can test these assertions.

Default options, incentives and food choices: evidence from elementary-school children

OBJECTIVE

To examine whether requiring children to place fruits and vegetables on their lunch trays increases consumption of these items.

DESIGN

Observational study that exploited naturally occurring variation between two school districts and a pre–post observational study at schools that changed their lunch policy mid-year.

SETTING

Fifteen elementary schools from two school districts, one requiring students to place a fruit or vegetable on their tray and one that does not. In addition, three schools that implemented a default option part way through the school year.

SUBJECTS

Students at eighteen elementary schools (41 374 child-day observations) across the two experiments.

RESULTS

Requiring that fruits and vegetables be placed on each child's tray increased the fraction of children who ate a serving of fruits or vegetables by 8 percentage points (P < 0·01) but led to an extra 0·7 servings being thrown away per lunch served (P < 0·01). The default option approach cost $US 1·72 to get one additional child to eat one serving of fruits and vegetables for 1 d. However, when default options were combined with a small rewards programme the efficacy of both interventions increased.

CONCLUSIONS

A default option, as a stand-alone programme, had only a limited impact on fruit and vegetable consumption but was much less cost-effective than other approaches. Schools requiring children to take fruits and vegetables with their lunch might consider adopting additional interventions to ensure that the additional items served do not end up being thrown away.

Watch me grow: a garden-based pilot intervention to increase vegetable and fruit intake in preschoolers

Background

Americans, including children, consume fewer fruit and vegetable servings than is recommended. Given that young children spend large amounts of time in child care centers, this may be an ideal venue for increasing consumption of and enthusiasm for fruits and vegetables. This pilot study aimed to assess the feasibility of a gardening intervention to promote vegetable and fruit intake among preschoolers.

Methods

We enrolled two intervention centers and two control centers. The intervention included a fruit and vegetable garden, monthly curriculum, gardening support, and technical assistance. We measured mean (SD) servings of fruits and vegetables served to and consumed by three children per center before and after the intervention.

Results

Post intervention, intervention and control centers served fewer vegetables (mean (standard deviation) difference of -0.18 (0.63) in intervention, -0.37 (0.36) in control), but intervention children consumed more than control children (+0.25 (1.11) vs. -0.18 (0.52). The number of fruits served decreased in all centers (intervention -0.62 (0.58) vs. control -0.10 (0.52)) but consumption was higher in controls (intervention -0.32 (0.58) vs. control 0.15 (0.26)).

Conclusions

The garden-based feasibility study shows promise, but additional testing is needed to assess its ability to increase vegetable and fruit intake in children.

Expanding children's food experiences: the impact of a school-based kitchen garden program

OBJECTIVE

Evaluate achievement of the Stephanie Alexander Kitchen Garden Program in increasing child appreciation of diverse, healthy foods.

DESIGN

Comparative 2-year study.

SETTING

Six program and 6 comparison primary schools in rural and metropolitan Victoria, Australia, matched for socioeconomic status and size.

PARTICIPANTS

A total of 764 children in grades 3 to 6 (8-12 years of age) and 562 parents recruited. Retention rates at follow-up included 85% children and 75% parents.

INTERVENTION

Each week of the school year, children spent 45 to 60 minutes in a garden class and 90 minutes in a kitchen class.

PHENOMENON OF INTEREST

Program impact on children's willingness to try new foods, capacity to describe foods, and healthy eating.

ANALYSIS

Qualitative data analyzed using inductive thematic analysis. Quantitative data analyzed using random-effects linear regressions adjusted for school clustering.

RESULTS

Child and parent qualitative and quantitative measures (if never tried before, odds ratio 2.0; confidence interval, 1.06-3.58) showed increases in children's reported willingness to try new foods. No differences in articulation of food descriptions (program vs comparison groups). Qualitative evidence showed that the program extended its influence to healthy eating, but this was not reflected in the quantitative evidence.

CONCLUSIONS AND IMPLICATIONS

Findings indicate program success in achieving its primary objective, meriting further program research.

Systematic review and meta-analysis of school-based interventions to improve daily fruit and vegetable intake in children aged 5 to 12 y

BACKGROUND

To our knowledge, no reviews have assessed the impact of a range of multi- and single-component school-based programs on daily fruit and vegetable intake by using a meta-analysis.

OBJECTIVE

The aim of this study was to quantify the impact of school-based interventions on fruit and vegetable intake in children aged 5-12 y.

DESIGN

A systematic literature review was carried out to identify randomized and nonrandomized controlled trials that were based in primary schools and designed to increase portions of daily fruit and vegetable intake. MEDLINE, Cochrane libraries, EMBASE, PsycINFO, and Educational Information Centre were searched from 1985 to 2009. Data were extracted, and mean effect sizes were calculated by using random effects models.

RESULTS

A total of 27 school-based programs involving 26,361 children were identified that met the inclusion criteria and assessed the daily weight of fruit and vegetable intake combined, fruit intake only, or vegetable intake only, and 21 studies were used in meta-analyses. The results of the meta-analyses indicated an improvement of 0.25 portions (95% CI: 0.06, 0.43 portions) of fruit and vegetable daily intake if fruit juice was excluded and an improvement of 0.32 portions (95% CI: 0.14, 0.50 portions) if fruit juice was included. Improvement was mainly due to increases in fruit consumption but not in vegetable consumption. The results of the meta-analyses for fruit (excluding juice) and vegetables separately indicated an improvement of 0.24 portions (95% CI: 0.05, 0.43 portions) and 0.07 portions (95% CI: -0.03, 0.16 portions), respectively.

CONCLUSIONS

School-based interventions moderately improve fruit intake but have minimal impact on vegetable intake. Additional studies are needed to address the barriers for success in changing dietary behavior, particularly in relation to vegetables.

Community-based interventions for enhancing access to or consumption of fruit and vegetables among five to 18-year olds: a scoping review

BACKGROUND

Low fruit and vegetable ( FV) consumption is a key risk factor for morbidity and mortality. Consumption of FV is limited by a lack of access to FV. Enhanced understanding of interventions and their impact on both access to and consumption of FV can provide guidance to public health decision-makers. The purpose of this scoping review is to identify and map literature that has evaluated effects of community-based interventions designed to increase FV access or consumption among five to 18-year olds.

METHODS

The search included 21 electronic bibliographic databases, grey literature, targeted organization websites, and 15 key journals for relevant studies published up to May 2011. Retrieved citations were screened in duplicate for relevance. Data extracted from included studies covered: year, country, study design, target audience, intervention setting, intervention strategies, interventionists, and reported outcomes.

RESULTS

The search located 19,607 unique citations. Full text relevance screening was conducted on 1,908 studies. The final 289 unique studies included 30 knowledge syntheses, 27 randomized controlled trials, 55 quasi-experimental studies, 113 cluster controlled studies, 60 before-after studies, one mixed method study, and three controlled time series studies. Of these studies, 46 included access outcomes and 278 included consumption outcomes. In terms of target population, 110 studies focused on five to seven year olds, 175 targeted eight to 10 year olds, 192 targeted 11 to 14 year olds, 73 targeted 15 to 18 year olds, 55 targeted parents, and 30 targeted teachers, other service providers, or the general public. The most common intervention locations included schools, communities or community centres, and homes. Most studies implemented multi-faceted intervention strategies to increase FV access or consumption.

CONCLUSIONS

While consumption measures were commonly reported, this review identified a small yet important subset of literature examining access to FV. This is a critically important issue since consumption is contingent upon access. Future research should examine the impact of interventions on direct outcome measures of FV access and a focused systematic review that examines these interventions is also needed. In addition, research on interventions in low- and middle-income countries is warranted based on a limited existing knowledge base.

Population-level intervention strategies and examples for obesity prevention in children

With obesity affecting approximately 12.5 million American youth, population-level interventions are indicated to help support healthy behaviors. The purpose of this review is to provide a summary of population-level intervention strategies and specific intervention examples that illustrate ways to help prevent and control obesity in children through improving nutrition and physical activity behaviors. Information is summarized within the settings where children live, learn, and play (early care and education, school, community, health care, home). Intervention strategies are activities or changes intended to promote healthful behaviors in children. They were identified from (a) systematic reviews; (b) evidence- and expert consensus-based recommendations, guidelines, or standards from nongovernmental or federal agencies; and finally (c) peer-reviewed synthesis reviews. Intervention examples illustrate how at least one of the strategies was used in a particular setting. To identify interventions examples, we considered (a) peer-reviewed literature as well as (b) additional sources with research-tested and practice-based initiatives. Researchers and practitioners may use this review as they set priorities and promote integration across settings and to find research- and practice-tested intervention examples that can be replicated in their communities for childhood obesity prevention.

Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association

BACKGROUND

Poor lifestyle behaviors, including suboptimal diet, physical inactivity, and tobacco use, are leading causes of preventable diseases globally. Although even modest population shifts in risk substantially alter health outcomes, the optimal population-level approaches to improve lifestyle are not well established.

METHODS AND RESULTS

For this American Heart Association scientific statement, the writing group systematically reviewed and graded the current scientific evidence for effective population approaches to improve dietary habits, increase physical activity, and reduce tobacco use. Strategies were considered in 6 broad domains: (1) Media and educational campaigns; (2) labeling and consumer information; (3) taxation, subsidies, and other economic incentives; (4) school and workplace approaches; (5) local environmental changes; and (6) direct restrictions and mandates. The writing group also reviewed the potential contributions of healthcare systems and surveillance systems to behavior change efforts. Several specific population interventions that achieved a Class I or IIa recommendation with grade A or B evidence were identified, providing a set of specific evidence-based strategies that deserve close attention and prioritization for wider implementation. Effective interventions included specific approaches in all 6 domains evaluated for improving diet, increasing activity, and reducing tobacco use. The writing group also identified several specific interventions in each of these domains for which current evidence was less robust, as well as other inconsistencies and evidence gaps, informing the need for further rigorous and interdisciplinary approaches to evaluate population programs and policies.

CONCLUSIONS

This systematic review identified and graded the evidence for a range of population-based strategies to promote lifestyle change. The findings provide a framework for policy makers, advocacy groups, researchers, clinicians, communities, and other stakeholders to understand and implement the most effective approaches. New strategic initiatives and partnerships are needed to translate this evidence into action.

Causal pathways linking Farm to School to childhood obesity prevention

Farm to School programs are rapidly gaining attention as a potential strategy for preventing childhood obesity; however, the causal linkages between Farm to School activities and health outcomes are not well documented. To capitalize on the increased interest in and momentum for Farm to School, researchers and practitioners need to move from developing and implementing evidence informed programs and policies to ones that are evidence-based. The purpose of this article is to outline a framework for facilitating an evidence base for Farm to School programs and policies through a systematic and coordinated approach. Employing the concepts of causal pathways, the authors introduce a proposed framework for organizing and systematically testing out multiple hypotheses (or potential causal links) for how, why, and under what conditions Farm to School Inputs and Activities may result in what Outputs, Effects, and Impacts. Using the causal pathways framework may help develop and test competing hypotheses, identify multicausality, strength, and interactions of causes, and discern the difference between catalysts and causes. In this article, we introduce causal pathways, present menus of potential independent and dependent variables from which to create and test causal pathways linking Farm to School interventions and their role in preventing childhood obesity, discuss their applicability to Farm to School research and practice, and outline proposed next steps for developing a coordinated research framework for Farm to School programs.

Social cognitive theory as a framework for considering Farm to School programming

BACKGROUND

Farm to School (FTS) programs are designed, in part, to improve childhood health and nutrition and may be implemented as a strategy to prevent childhood obesity. FTS programs have largely emerged out of grassroots efforts, and theory has not explicitly guided program development or implementation. This research considers the effectiveness of social cognitive theory (SCT) as a framework for FTS programming.

METHODS

In 2010, a survey was administered to 632 elementary schoolchildren in Vermont. Six indices were developed from 46 variables that measured personal characteristics and experiences with regard to fruits and vegetables, as described in the SCT.

RESULTS

These indices were the basis for cluster analysis, which identified three distinct clusters. Bivariate analysis showed significant differences among the clusters in the children’s likelihood of meeting the Dietary Guidelines for Americans (DGA). The significant differences observed among the clusters suggest that SCT is an appropriate framework within which FTS interventions may be considered.

CONCLUSIONS

The findings show that there are distinct food-related attitudes and behaviors that differ widely by the SCT informed clusters and that can be used to inform FTS programs.

Factors contributing to a school's decision to apply for the California Instructional School Garden Program

OBJECTIVE

To compare the applicant schools (AS) to non-applicant schools (NAS) residing in the same school districts for the California Instructional School Garden Program and identify barriers to the application process.

METHODS

A case-control, cross-sectional study design was used to compare resources and school environments. Pearson chi-square and logistic regression were conducted.

RESULTS

Public schools throughout California participated (n = 1,662). The response rates for AS and NAS were 43.2% and 48.2%, respectively. Applicant schools had greater access to garden coordinators and parent/community volunteers dedicated to school gardens, and they had other sources of funds/grants to support school gardens compared to NAS (P < .001).

CONCLUSIONS AND IMPLICATIONS

Access to certain garden resources played a significant role in predicting whether schools would decide to participate in the California Instructional School Garden Program.

Food sustainability education as a route to healthier eating: evaluation of a multi-component school programme in English primary schools

Promising approaches to the promotion of healthier eating among children in primary school settings include the opportunity to practise practical cooking and growing, promoting the take up of healthier school meals and nutritional education. However, less is known about the potential for strategies that integrate approaches through a focus on food sustainability issues--such as the promotion of awareness about local, seasonal, organic, fair trade and higher animal welfare foods. This paper presents an evaluation of the Food for Life Partnership, a multi-component programme that sought to address both the health and sustainability aspects of food. The study consisted of a two-stage cross-sectional survey of Years 5 and 6 students (ages 9-11) in 30 primary schools at enrolment and after 18-24 months, combined with an analysis of programme delivery. Higher self-reported fruit and vegetable consumption in the second stage survey was associated with a range of indicators of school participation in the programme. These included the reform of school meal procurement and preparation; experiential food growing, cooking and farm-based education and improved opportunities for stakeholder engagement. The study therefore develops a case for multilevel programmes that incorporate sustainability issues alongside experiential food education in primary school settings.

Exposure to multiple components of a garden-based intervention for middle school students increases fruit and vegetable consumption

OBJECTIVES

(1) To measure the effects of different levels of exposure to a multiple-component garden-based intervention on middle school students' fruit and vegetable (F&V) consumption and related variables and (2) to determine the separate effects of each of the intervention components on F&V consumption.

DESIGN

Unequal treatment-control posttest only.

SETTING

Five middle schools in ethnically diverse communities.

PARTICIPANTS

Two hundred and forty-six adolescents (59% Hispanic; 70% low-income). Intervention. The Sprouting Healthy Kids intervention consists of six components: (1) in-class lessons, (2) after-school gardening program, (3) farm-to-school, (4) farmers' visits to schools, (5) taste testing, (6) field trips to farms.

OUTCOME MEASURES

F&V consumption; motivation for eating F&V; self-efficacy for eating F&V; F&V preference; preference for unhealthy foods; knowledge.

ANALYSIS

Linear regression models controlling for gender, ethnicity/race, and income.

RESULTS

Compared with students who were exposed to less than two intervention components, students who were exposed to two or more components scored significantly higher on F&V intake, self-efficacy, and knowledge and lower on preference for unhealthy foods (p < .05). The farmers' visits, taste testing, and cafeteria components had the largest effect sizes but were not significant.

CONCLUSIONS AND IMPLICATIONS

Interventions targeting adolescent F&V behavior change should include multiple components such as farmers' visits to the school and taste testing.

Overcoming picky eating. Eating enjoyment as a central aspect of children's eating behaviors

Picky eating is a relatively common problem during childhood, and parents lack clear strategies with which to decrease picky eating. This study examined whether increasing eating enjoyment and cooking enjoyment might give opportunities to decrease picky eating. Parents (n=305), mainly mothers with children between 6 and 12 years of age (53.8% boys; 46.2% girls), completed a questionnaire on pressure and restriction, eating enjoyment, and picky eating, and cooking enjoyment. Path analyses were performed to examine the mediating role of eating enjoyment. The final model provided a good fit to the data and explained 33% variance in picky eating. A strong inverse association between eating enjoyment and picky eating was found (β=-.44). Significant direct effects were found between cooking enjoyment and picky eating (β=-.16) and restriction and picky eating (β=.18). Eating enjoyment partly mediated the association between cooking enjoyment and picky eating. Results showed pressure had only an indirect effect on picky eating through eating enjoyment. Eating enjoyment serves as an important and central factor in children's picky-eating behavior. High controlling practices might create a negative environment around food and healthy eating and so decrease eating enjoyment and increase picky eating.

Growing Community

This article presents results from a mixed-method evaluation of a structured cooking and gardening program in Australian primary schools, focusing on program impacts on the social and learning environment of the school. In particular, we address the Stephanie Alexander Kitchen Garden Program objective of providing a pleasurable experience that has a positive impact on student engagement, social connections, and confidence within and beyond the school gates. Primary evidence for the research question came from qualitative data collected from students, parents, teachers, volunteers, school principals, and specialist staff through interviews, focus groups, and participant observations. This was supported by analyses of quantitative data on child quality of life, cooperative behaviors, teacher perceptions of the school environment, and school-level educational outcome and absenteeism data. Results showed that some of the program attributes valued most highly by study participants included increased student engagement and confidence, opportunities for experiential and integrated learning, teamwork, building social skills, and connections and links between schools and their communities. In this analysis, quantitative findings failed to support findings from the primary analysis. Limitations as well as benefits of a mixed-methods approach to evaluation of complex community interventions are discussed.

Strategies for pediatric practitioners to increase fruit and vegetable consumption in children

High intake of fruits and vegetables (FV) is associated with a decreased risk for many chronic diseases and may assist in weight management, but few children and adolescents consume the recommended amounts of FV. The pediatric practitioner can positively influence FV consumption of children through patient-level interventions (eg, counseling, connecting families to community resources), community-level interventions (eg, advocacy, community involvement), and health care facility-level interventions (eg, creating a healthy food environment in the clinical setting). This article reviews the importance of FV consumption, recommended intakes for children, and strategies by which pediatric practitioners can influence FV consumption of children.

The impact of a school garden and cooking program on boys' and girls' fruit and vegetable preferences, taste rating, and intake

The aim of this study was to examine gender differences in the impact of a school garden and nutrition curriculum on fruit and vegetable intake, willingness to taste, and taste ratings in 127 children (11 to 12 years, 54% boys) in regional New South Wales, Australia. Classes were assigned to wait-list control, nutrition education only (NE), or nutrition education plus garden (NE + G) groups. Carrot taste rating was the only vegetable for which there was a significant gender difference, with girls rating it more highly (p = .04). There were no significant gender differences in fruit and vegetable consumption or willingness to taste scores for any other vegetables. There was a group effect (p < .001) for overall willingness to taste, overall taste rating, and the taste rating of pea and broccoli (p < .001), tomato (p = .03), and lettuce (p = .02). In the post hoc analysis by gender, both boys and girls in NE + G and NE groups were more willing to taste vegetables compared with control boys and girls postintervention (p < .001, p = .02). Boys in the NE + G group were more willing to taste all vegetables overall compared with NE boys at posttest (p = .05) and this approached significance for girls (p = .07). For overall tasting scores, a group effect was seen in girls only (p = .05). No significant treatment-time effect was found for vegetable intake in either gender. Further research is needed to examine whether a school garden, with or without school curriculum components, can be used to optimize fruit and vegetable intakes, particularly in boys.

School meals in French secondary state schools: Do national recommendations lead to healthier nutrition on offer?

To improve the dietary offering in schools, the French authorities published recommendations on nutrition in 1999, which were then revised in 2007. The aim of the present study was to assess the nutritional offering in secondary school meals and the extent to which the recommendations promote balanced nutritional offerings. In 2005, a national survey was conducted on a representative sample of secondary schools, either administrated by the Ministry of Education (ES) or the Ministry of Agriculture (AS). Information on school-catering organisation and twenty consecutive meals was collected from each of the 707 secondary schools surveyed. Nutritional composition was estimated according to the French food composition database. Univariate and multivariate analyses were used to investigate the impact of food-group frequency guidelines (FFG) on nutritional offering. It was found that 15 and 26 % of ES and AS schools, respectively, had high compliance with the FFG, at lunch. Macronutrient content was unbalanced in ES school lunches in which 42·8 % lipids, 21·5 % proteins and 35·7 % carbohydrates contributed to the energy. Nevertheless, proper offerings in Fe, Ca and vitamin C content were observed. In addition, a lower offering in lipids and a higher offering in proteins, Ca, vitamin C and Fe were found when the FFG were applied (P < 0·001). Similar results were found for AS schools. This paper confirms the effectiveness of FFG in providing nutritionally balanced school meals. However, others measures such as nutrition promotion and actions to improve children's food habits have to be introduced to make the recommendations more effective and easier to understand.

Primary school interventions to promote fruit and vegetable consumption: a systematic review and meta-analysis

OBJECTIVE

The consumption of fruits and vegetables (FV) may contribute to the prevention of many diseases. However, children at school age do not eat an enough amount of those foods. We have systematically reviewed the literature to assess the effectiveness of school interventions for promoting the consumption of FV.

METHODS

We performed a search in MEDLINE, EMBASE, CINAHL and CENTRAL. We pooled results and stratified the analysis according to type of intervention and study design.

RESULTS

Nineteen cluster studies were included. Most studies did not describe randomization method and did not take the cluster's effect into account. Pooled results of two randomized controlled trials (RCTs) of computer-based interventions showed effectiveness in improving consumption of FV [Standardized Mean Difference (SMD) 0.33 (95% CI 0.16, 0.50)]. No significant differences were found in pooled analysis of seven RCTs of multicomponent interventions or pooling results of two RCTs evaluating free/subsidized FV interventions.

CONCLUSIONS

Meta-analysis shows that computer-based interventions were effective in increasing FV consumption. Multicomponent interventions and free/subsidized FV interventions were not effective. Improvements in methodology are needed in future cluster studies. Although these results are preliminary, computer-based interventions could be considered in schools, given that they are effective and cheaper than other alternatives.

Healthy outcomes for teens project: diabetes prevention through distributed interactive learning

AIM AND METHODS

This study assessed whether distributed interactive learning via web-based modules and grounded in schema and social cognitive theory (treatment group, n = 101) would increase knowledge about diabetes prevention in adolescents from three middle schools to a greater extent than the control group (n = 80) and examined whether the school environment used to convey the education had an effect.

RESULTS

The treatment group showed substantially greater increases in overall and individual modular content knowledge, with 72 voluntarily choosing to retake evaluations that significantly improved their scores. The treatment (t[3.8], β ≥ 0.30, P < 0.001) and format of delivery (after school, pull out from physical education, or health education curriculum) (t[3.41], β ≥ 0.24, P < 0.001) influenced knowledge.

CONCLUSIONS

Thus, distributed interactive learning was more effective than its passive counterpart, and a more structured delivery enhanced knowledge, as did opportunities to self-regulate learning. Attention to these process components will facilitate effective interventions by educators in schools.

Valid and reliable measures of cognitive behaviors toward fruits and vegetables for children aged 9 to 11 years

OBJECTIVE

To examine reliability of validity-tested instruments measuring fruit and vegetable (FV) preference and self-efficacy (SE) for and attitude (AT) toward cooking.

METHODS

In Santa Fe, New Mexico, following cognitive interviews with 123 fourth- and fifth-graders, surveys were administered twice, less than 2 weeks apart, to students in 16 classrooms without intervening nutrition education. Results were assessed using Pearson correlation coefficient, Cronbach α, marginal homogeneity, Wilcoxon, and paired t tests.

RESULTS

Individual test-retest scores were significantly (P < .001) correlated (n = 344; 72.9% Hispanic); r = 0.80 (SE), 0.82 (AT), and 0.88 (FV). Cronbach α was ≥ 0.74 for all survey administrations. Classroom test-retest scores were significantly correlated (SE r = 0.66, AT r = 0.88, and FV r = 0.92). Self-efficacy and AT toward cooking were higher in girls (P < .001).

CONCLUSIONS AND IMPLICATIONS

Validity-tested 8-item SE, 6-item AT, and 16-item FV surveys showed internal consistency and test-retest reliability and are suitable for impact assessment of cooking-based education interventions, specifically Cooking with Kids.

Position of the American Dietetic Association, School Nutrition Association, and Society for Nutrition Education: comprehensive school nutrition services

It is the position of the American Dietetic Association (ADA), School Nutrition Association (SNA), and Society for Nutrition Education (SNE) that comprehensive, integrated nutrition services in schools, kindergarten through grade 12, are an essential component of coordinated school health programs and will improve the nutritional status, health, and academic performance of our nation's children. Local school wellness policies may strengthen comprehensive nutrition services by encouraging multidisciplinary wellness teams, composed of school and community members, to work together in identifying local school needs, developing feasible strategies to address priority areas, and integrating comprehensive nutrition services with a coordinated school health program. This joint position paper affirms schools as an important partner in health promotion. To maximize the impact of school wellness policies on strengthening comprehensive, integrated nutrition services in schools nationwide, ADA, SNA, and SNE recommend specific strategies in the following key areas: nutrition education and promotion, food and nutrition programs available on the school campus, school-home-community partnerships, and nutrition-related health services.

Exposure to a comprehensive school intervention increases vegetable consumption

PURPOSE

The current epidemic of childhood overweight has launched a variety of school-based efforts to address the issue. This study reports on the first 2 years of a 3-year evaluation of one school district's comprehensive intervention to transform school foodservices and dining experiences, offer cooking and gardening programs, and integrate nutrition and food systems concepts into the academic curriculum.

METHODS

This 3-year prospective study enrolled 327 4th and 5th graders in a mid-sized school district in California, and followed them into middle school. Intervention exposure was determined through interviews with school staff and student surveys. Student knowledge and attitudes were assessed annually by questionnaire, and student behavior was assessed annually by 3-day food diary. Household information was gathered by parent questionnaire. Changes in knowledge, attitudes, and behavior were compared by level of intervention exposure using analysis of covariance; pairwise differences were evaluated using Bonferroni's test at a procedure-wise error rate of 5%.

RESULTS

After controlling for family sociodemographic background, students most exposed to the intervention increased their consumption of fruits and vegetables by nearly 0.5 cups (one standard serving), whereas students least exposed decreased their consumption by 0.3 cups (p < .05). Students most exposed to the programming also showed a significantly greater increase in preference for fruit and green leafy vegetables, compared to students least exposed to the programming (p < .05).

CONCLUSIONS

Future research is needed to better understand the relative importance of the different components of such a program, and their cost-benefits as well as health impacts.

The impact of nutrition education with and without a school garden on knowledge, vegetable intake and preferences and quality of school life among primary-school students

OBJECTIVE

To investigate the impact of school garden-enhanced nutrition education (NE) on children's fruit and vegetable consumption, vegetable preferences, fruit and vegetable knowledge and quality of school life.

DESIGN

Quasi-experimental 10-week intervention with nutrition education and garden (NE&G), NE only and control groups. Fruit and vegetable knowledge, vegetable preferences (willingness to taste and taste ratings), fruit and vegetable consumption (24 h recall × 2) and quality of school life (QoSL) were measured at baseline and 4-month follow-up.

SETTING

Two primary schools in the Hunter Region, New South Wales, Australia.

SUBJECTS

A total of 127 students in Grades 5 and 6 (11-12 years old; 54 % boys).

RESULTS

Relative to controls, significant between-group differences were found for NE&G and NE students for overall willingness to taste vegetables (P < 0·001) and overall taste ratings of vegetables (P < 0·001). A treatment effect was found for the NE&G group for: ability to identify vegetables (P < 0·001); willingness to taste capsicum (P = 0·04), broccoli (P = 0·01), tomato (P < 0·001) and pea (P = 0·02); and student preference to eat broccoli (P < 0·001) and pea (P < 0·001) as a snack. No group-by-time differences were found for vegetable intake (P = 0·22), fruit intake (P = 0·23) or QoSL (P = 0·98).

CONCLUSIONS

School gardens can impact positively on primary-school students' willingness to taste vegetables and their vegetable taste ratings, but given the complexity of dietary behaviour change, more comprehensive strategies are required to increase vegetable intake.

Review of the nutritional implications of farmers' markets and community gardens: a call for evaluation and research efforts

The development and promotion of farmers' markets and community gardens is growing in popularity as a strategy to increase community-wide fruit and vegetable consumption. Despite large numbers of farmers' markets and community gardens in the United States, as well as widespread enthusiasm for their use as a health promotion tool, little is known about their influence on dietary intake. This review examines the current scientific literature on the implications of farmers' market programs and community gardens on nutrition-related outcomes in adults. Studies published between January 1980 and January 2009 were identified via PubMed and Agricola database searches and by examining reference lists from relevant studies. Studies were included in this review if they took place in the United States and qualitatively or quantitatively examined nutrition-related outcomes, including dietary intake; attitudes and beliefs regarding buying, preparing, or eating fruits and vegetables; and behaviors and perceptions related to obtaining produce from a farmers' market or community garden. Studies focusing on garden-based youth programs were excluded. In total, 16 studies were identified for inclusion in this review. Seven studies focused on the impact of farmers' market nutrition programs for Special Supplemental Nutrition Program for Women, Infants, and Children participants, five focused on the influence of farmers' market programs for seniors, and four focused on community gardens. Findings from this review reveal that few well-designed research studies (eg, those incorporating control groups) utilizing valid and reliable dietary assessment methods to evaluate the influence of farmers' markets and community gardens on nutrition-related outcomes have been completed. Recommendations for future research on the dietary influences of farmers' markets and community gardens are provided.

The Effects of School Garden Experiences on Middle School-Aged Students’ Knowledge, Attitudes, and Behaviors Associated With Vegetable Consumption

This study describes the effects of garden-based education on children’s vegetable consumption. As part of a pre—post panel study, 236 students complete the Garden Vegetable Frequency Questionnaire and 161 complete a taste test. Results indicate that school gardening may affect children’s vegetable consumption, including improved recognition of, attitudes toward, preferences for, and willingness to taste vegetables. Gardening also increases the variety of vegetables eaten. Future research should explore whether effects persist over time and if and how changes in children’s behavior affect the behavior of their caregivers. Implications of study findings for policy and practice are discussed. Suggestions for applying results to future health promotions are provided.

Food Systems and Public Health Disparities

The United States has set a national goal to eliminate health disparities. This article emphasizes the importance of food systems in generating and exacerbating health disparities in the United States and suggests avenues for reducing them. It presents a conceptual model showing how broad food system conditions interplay with community food environments-and how these relationships are filtered and refracted through prisms of social disparities to generate and exacerbate health disparities. Interactions with demand factors in the social environment are described. The article also highlights the separate food systems pathway to health disparities via environmental and occupational health effects of agriculture.