The Effect of Nutrition Education on Children's Healthy Food Choices

Currently, a third of children in the United States are classified as overweight or obese, and the prevalence of obesity has doubled for children between the ages of six and eleven over the past thirty years. In order to address this serious public health problem, a variety of nutrition programs are being implemented across the country. The present research aims to analyze the effectiveness of one such program, the School Health Initiative Program, in two local Williamsburg-James City County Schools. Children at one school (n=28) received information about healthy eating and exposure to a variety of healthy foods, while children at the other school (n=30) received the health information, but not the healthy food exposure. Assessment of children’s knowledge about healthy eating and their willingness to try eight different fruits and vegetables before and after the program indicated that health knowledge increased as a result of the program at both schools regardless of the food exposure component. However, children at the school with the food exposure were more likely to try fruits after the program than were children who did not have the exposure. These results suggest that while providing children with nutritional information may increase their knowledge about healthy eating, their willingness to consume healthy foods is enhanced by exposure to fruits and vegetables. Effect of Nutrition Education 4 The Effect of Nutrition Education on Children’s Healthy Food Choices The growing obesity epidemic is profoundly impacting the nation’s health (Dietz, Benken, & Hunter, 2009). Currently, obesity is considered to be the leading lifestylerelated cause of disease and death in the United States after smoking (Mokdad, Stroup & Gerberding, 2004). The high prevalence of obesity, among children in particular, has recently risen to startling proportions (Vonzie, 2009). Approximately 33% of children in the United States are currently classified as overweight or obese (US Department of Health and Human Services, 2009), and the prevalence of obesity has doubled for children between six to eleven years of age in the past thirty years (Institute of Medicine, 2009). This is a grave public health concern because overweight and obese children are at an increased risk for a number of serious health complications that were previously considered rare in children, such as Type 2 diabetes, gallbladder disease, high blood pressure, and sleep apnea (Lee, Herman, McPheeters & Gurney, 2006). Fruits and vegetables provide many necessary nutrients (vitamin E, calcium, magnesium, potassium, and fiber), including those that the USDA claims are currently the most under-consumed (USDA, 2005). Nutritional experts believe that improving fruit and vegetable consumption can effectively promote a healthy diet. Consuming between five and thirteen servings (or the equivalent of 2.5-6.5 cups a day) of fruits and vegetables daily is correlated with a decreased risk of disease and healthier body weight (USDA, 2005). Currently, only 9.8% of girls and 13.8% of boys aged 4-8 consume the recommended levels of fruits and vegetables (Jan, Bellman, Barone, Jessen, & Arnold, 2009). Research has shown that children’s eating habits are influenced by their biological Effect of Nutrition Education 5 preferences for energy dense foods, which are often sweet and salty, as opposed to healthier foods, which may be bitter or sour tasting (Desor, Malor & Greene, 1977). This evolutionary predisposition for energy dense foods is suspected to have arisen to protect children from consuming toxins. In addition to these innate preferences, children also often demonstrate “neophobia,” defined by Rozin (1976) as the reluctance to try novel foods, which may have evolved from a fear of being harmed or poisoned (also known as the “learned fear hypothesis”). Rigal (2000), concluded that about two-thirds of children between the ages of three and ten exhibit varying amounts of neophobia (as cited in Bellisle, 2009). This is significant because neophobic children consume fewer fruits and vegetables than non-neophobic children (Cooke, Haworth & Wardle, 2007). Even though neophobia may have a genetic component, it can be modified through environmental exposure (Cooke et al., 2007). Despite their innate predispositions, children can learn to like many foods they initially reject if exposed to the proper food environment. Just as a child’s unhealthy eating habits are heightened by media popularity and advertising, similar positive exposure to healthy foods could increase fruit and vegetable appeal and consumption (Birch & Marlin, 1982). Research indicates that children’s preferences for healthy foods will increase if they are repeatedly exposed to these foods, and if they experience a variety of flavors in their diets (Forestell & Mennella, 2007; Pliner, 1982; Wardle, Herrara, Cooke & Gibson, 2003). By adding familiar ingredients to new or disliked foods, parents can further encourage the consumption of healthy foods (Stallberg-White & Pliner, 1999). Although taste exposures appear to be more effective than visual exposures in reducing food neophobia (Birch, McPhee, Shoba, Pirok, & Steinberg, 1987), Pelchat and Pliner (1995) Effect of Nutrition Education 6 also found that emphasizing a novel food’s pleasant taste increased the likelihood that children would it. In this study, when children were presented with familiar and novel foods, the statement, “Would you like to try it? It tastes good. ” was considerably more effective in increasing their willingness to try a food then asking, “Would you like to try it? ” This strategy could therefore serve as an effective tool for encouraging children to try fruits and vegetables. The Role of Nutrition Education In an effort to effectively respond to the childhood obesity epidemic, government agencies and community groups have begun to develop strategies that encourage healthy eating (CDC, 2009). In January of 2010, Michelle Obama announced her childhood obesity initiative to decrease the early onset of obesity by having the federal government partner with local communities (Hellmich, 2010). Consistent with this, a primary goal of the government objective “Healthy People 2010” (USHHS, 2000) is to decrease the prevalence of obesity among children by promoting physical activity and healthy eating. Research by the Robert Wood Johnson Foundation and two national programs, “Active Living Research” and “Healthy Eating Research,” have found that increasing access to healthy foods, encouraging physical activity, and decreasing sedentary behavior can help curb childhood obesity (Lavizzo-Mourey, 2009). Because children spend a large amount of time in educational environments, schools have been identified as key venues for the implementation of nutrition intervention programs (Mullen & Shield, 2004). There is some evidence that nutrition education programs that contain only school-based components can be effective in Effect of Nutrition Education 7 improving health knowledge. For example, The Shape It Up program, which promotes healthy eating and exercise at school, has been presented to almost 90,000 elementary students in over 257 New Jersey schools. This program teaches children about the food pyramid, the importance of eating fruits and vegetables, the benefits of drinking milk and water, and how to keep a healthy heart. These workshops significantly improved children’s responses to a health knowledge questionnaire (Jan et al., 2009). This suggests that targeting the school-based setting may be sufficient to increase nutrition knowledge; however, this type of program is not always successful at increasing consumption of healthy foods. Because not all nutrition programs are equally effective, and their success in encouraging healthy eating behaviors depends on many different factors, it is important to determine which aspects of these programs are most effective at modifying behavior over the long term. By comparing outcomes of specific programs that vary in home, school and community components, we can acquire a better understanding of how these components work together to produce effective behavioral change. One aspect of nutrition education that may be important is the length of the program. Although there is some evidence that some shorter programs can be effective in increasing children’s knowledge about healthy eating, they have not all been as successful in encouraging behavioral change. For example, a seven-week program addressing healthy food choices and the importance of physical activity through informational handouts and motivational posters resulted in a significant improvement in nutrition knowledge, compared to a no intervention control group (Minnerath, 2009). However, based on food diaries, it was not clear that participants actually changed their patterns of eating. As illustrated, short-term nutrition education may be an effective Effect of Nutrition Education 8 strategy for increasing nutrition knowledge, but may not be as effective in producing significant behavioral changes. In contrast, children who participated in a three-year school-based nutrition education program that encouraged healthy eating through increased awareness of healthy food choices in multiple settings (home, school, etc.), made healthier food choices (Ellis, 2008). In addition, Ellis (2008) reported that the children who took part in this nutrition program had an overall decrease in body mass indices. The effectiveness of changing eating behavior over time raises the possibility that longer nutrition education programs may produce better behavioral outcomes. In addition to the length of the program, the types of messages communicated to children appeared to affect their willingness to try healthful foods. For example, Wardle and Huon (2000) found that while nutrition education encouraged consumers to make healthier choices in general, children di