The Effect of Nutrition Education on Improving Fruit and Vegetable Consumption of Youth

The high rate of cancer deaths in two rural towns in northeast Colorado prompted community action and Extension intervention. Further investigation confirmed that these Colorado communities did have an increased incidence of cancer above the state norm. Further investigation revealed an increased cancer incidence (14% above the state norm) in their county (American Cancer Society, 1993). Citizens, aware that nutrition and eating practices could lower cancer risk, contacted their Colorado State University Cooperative Extension agent for program possibilities. A team was formed to work in these remote small towns to improve nutrition, diet, and health using the 5 A Day message. The 5 A Day campaign was developed by NCI (National Cancer Institute) and PBHF (Produce for Better Health Foundation) in 1991 (Staff, 1991). The 5 A Day program is designed to increase consumption of fruits and vegetables to at least five servings a day to improve the health of Americans. A small initiative grant from Colorado Cooperative Extension was awarded for this nutrition education intervention program. The nutrition study focused on grade schools, targeting children aged 5-11. The program was designed to be a hands-on education program and included: nutrition education materials on 5 A Day, skill sheets, fruit and vegetable demonstrations, related activities, experiments, puppet shows, and behavior simulation on good nutrition.

Also included was nutrition education for the residents of the community. Nutrition information was provided through local newspapers, grocery stores, and county fairs. Of the two towns in the county, Holyoke received the education program and Haxtun served as the control town. The 40-mile separation between towns isolated the control and intervention group.

This article outlines the nutrition education program implemented by a team of Colorado State University Cooperative Extension faculty and students. An evaluation was conducted to test the effectiveness of the intervention.

On April 1992 a community-wide meeting was held in the implementation town of Holyoke. Fifteen concerned residents attended the meeting. A set of open-ended questions was used to guide the discussion. It was the consensus that nutrition education should be delivered in the schools targeting the grade school children. Community information would be disseminated through local newspapers, the grocery store, and health fairs.

School Program

A teacher's workshop was held with University Continuing Education credit available for teacher re-certification. The workshop took place in February 1993. At this workshop, the teachers were educated on the 5 A Day nutrition education program and details were presented on the role of nutrition in cancer prevention. Specific nutrition education materials were developed by Colorado State University Cooperative Extension for use in the classroom. These materials, activities, and intervention plans were presented at the day-long workshop. For children in the implementation town of Holyoke, the nutrition education intervention included skill sheets, experimentation, games, and activities. The intervention also included unique fruit and vegetable demonstrations, activities, discussions, and taste testing. For grades K-3, a fruit and vegetable puppet show explaining 5 A Day and the importance of fruits and vegetables was presented.

Permission slips for children participating in the program were obtained from parents. Pre- and post-questionnaires to assess fruit and vegetable consumption were developed, evaluated, and determined to be both valid and reliable. All children in K-6 in both intervention and control towns completed a 24 hour food recall and a pre- and post- food habit questionnaire to assess the amounts and types of fruits and vegetables consumed.

During the intervention, the extension agent attended a PTA meeting in the intervention town of Holyoke to present a workshop for parents on nutrition and cancer. Also included were highlights of their children's involvement in the school program. At the end of the school year and completion of the nutrition education program, a meeting was held with the teachers to gather their opinions, judge the student's posters and class projects and plan for the next school year.

Community Program

A randomized community telephone survey was conducted in both rural towns by the Colorado State University Cooperative Extension agent and staff. A telephone directory for the towns of Holyoke and Haxtun was used. Every fifth head of household was contacted by the Extension office staff under the direction of the agent. The result was 10% of the population was surveyed. The survey measured fruit and vegetable consumption of the heads of household. After this pre-survey, materials on 5 A Day were distributed in the town of Holyoke through the newspaper, the mail, the grocery store, and local health fair. Four months after the intervention, at the end of the summer and before school started, a post-telephone survey to the same heads of household was completed. A follow-up town meeting was held in the community to solicit their opinions.

School Program

Results from the children's pre- and post-questionnaires and 24 hour food recall were gathered and a chi-square test for association was performed. Analysis was conducted using the totals as proportions. A total of 193 children participated (n = 158 for Holyoke intervention and n = 35 for Haxtun control). Due to the difference in numbers, analysis was performed based on the proportions.

Analysis of the 24 hour food recall for the Holyoke children showed: pre-24 hour food recall 2.9 servings of fruits and vegetables per day and at the post-assessment 3.7 servings. This is an increase of 0.77 servings of fruits and vegetables per day. The analysis of the children questionnaire determined consumption for the intervention to be: pre-questionnaire 4.5 servings of fruits and vegetables per day and post-questionnaire 5.0 servings. This is an increase of 0.5 servings of fruits and vegetables per day after intervention. The chi-square test showed that the intervention had a significant effect on fruit and vegetable consumption with a chi-square of 26.481 for the 24 hour food recall and a chi-square of 26.54 for the pre- and post- questionnaire.

For the control school, 2.5 servings of fruits and vegetables were reported for the pre-test and 2.5 servings of fruits and vegetables were reported for the post-test, showing no significant difference with a chi-square of 18.8.

Telephone Survey Analysis

A total of 168 heads of household responded to the survey: n = 122 from Holyoke and n = 46 from Haxtun. A chi-square and Multiple Response Permutation Procedure (MRPP; Mielke, 1976) was performed on the telephone survey of the two towns. An analysis of the Telephone Survey showed the average number of fruits and vegetables eaten in Holyoke prior to the intervention was 2.46 servings a day. Post-intervention showed 2.90 servings, which is an increase of 0.44 servings of fruits and vegetables per day.

For Haxtun, the control town, the average number of fruits and vegetables pre- was 2.05 and post-study 2.07--an increase of 0.02 servings per day. The increase in the number of servings in the intervention school and the control school showed no significant difference at the 0.05 level with a chi-square of 1.6 and MRPP of 0.03.

The statistical analysis comparing children pre- and post- 24 hour food recalls and adults/children pre- and post- questionnaires showed that the number of servings of fruits and vegetables consumed per day increased from one half to three fourths, after the intervention. This increase is within the national norm of 1/2 a serving following a nutrition education intervention (Public Health Service, 1994). It was interesting to note that while the Telephone Survey results showed no significant difference statistically, a difference can be seen. There was a .44 serving increase in fruits and vegetables consumed in the intervention town of Holyoke. In addition, after the intervention, the teacher and community members, expressed that the nutrition education program was well received and, in their view, effective.

Teachers indicated that the students enjoyed the class room material, activities, and demonstrations. Teachers also indicated they would like to continue using the 5 A Day nutrition education material in their classrooms. It was felt that the children had an increased awareness of fruits and vegetables in their diet. The residents of Holyoke stated they liked the newspaper articles, pamphlet, and demonstrations and would like the 5 A Day nutrition and cancer prevention program to continue. The parents of the school children felt there was an increased awareness of fruits and vegetables in their diet. As a result they wanted the nutrition intervention in the school to continue and additional information provided for the family.

The study did determine an increase in the amount of fruits and vegetables consumed. In addition, this program provided a unique opportunity for Cooperative Extension agents to become involved in national nutrition education campaigns. The response to this effort, especially in rural areas is encouraging. As a result of this study, there was a request for additional nutrition education for school food service personnel. This provides continuing opportunities for Cooperative Extension to become more involved with the schools and the education of students, teachers, and food service personnel.

American Cancer Society. (1993). Cancer facts and figures. Atlanta, GA: Author.

Mielke, P. W. (1976). Multi-response permutation procedures for a priori classifications. Communications in Statistics - Theory and Methods, 5, 790-794.

Public Health Service. (1994). Healthy people 2000: Progress report for nutrition objectives. Washington, DC: U.S. Department of Health and Human Services.

Staff. (1991, December). 5 a day is underway: President Bush's principal advisor on consumer affairs helps launch 5 a day. The 5 A Day News, p. 7.