22 annotated bibliographies AMA style

Research Article

Effect of Nutrition Intervention Using a General Nutrition Course for Promoting Fruit and Vegetable Consumption among College Students Eun-Jeong Ha, PhD; Natalie Caine-Bish, PhD, RD, LD

ABSTRACT

Objective: To evaluate the effectiveness of implementing nutrition intervention using a general nutrition class to promote consumption of fruits and vegetables in college students. Design: 3-day food records were collected, verified, and analyzed before and after the intervention. Setting: A midwestern university. Participants: 80 college students, ages 18 to 24, participated in the study. Intervention: The intervention focused on nutrition knowledge related to prevention of chronic diseases, healthful dietary choices increasing fruit and vegetable consumption, dietary feedback, and interactive hands-on activities. Main Outcome Measures: Consumption of: total vegetable, fresh vegetable, starchy vegetable, french fries, vegetable juice, total fruit, fresh fruit, canned fruit, and fruit juice. Analysis: Dependent t test was used to analyze the differences in pre- and posttest. Analysis of variance was used to determine differences in dietary changes between groups. Results: Participants significantly increased consumption of not only total fruits and vegetables (P< .005), but also fresh fruits and vegetables (P< .005). Intake of french fries decreased significantly (P< .05). Females responded better to the intervention than males in increasing vegetable consumption (P < .05). Conclusions and Implications: Class-based nutrition intervention focusing on prevention of chronic diseases is a cost-effective approach to increasing fruit and vegetable consumption among college students. Key Words: college students, fruit, vegetable, nutrition class, nutrition intervention (J Nutr Educ Behav. 2009;41:103-109.)

INTRODUCTION

The college years are a period of signif- icant change in the lifestyles of young adults. Food patterns established dur- ing college are likely to be maintained for life and may have long-lasting in- fluences on college students’ future health and the health of their future families.1 Furthermore, an inadequate diet during the college years could re- sult in unfavorable physiological con- sequences that could lead to diet- related chronic diseases.2 The dietary patterns of college students should be a concern to health professionals. It is well documented that college students have unhealthful eating be-

haviors, including skipping meals,3

frequent snacking on energy-dense food,4 and engaging in unhealthful weight-loss methods.5,6 In addition, dietary intakes of college students ap- pear to be high in fat, saturated fat, cholesterol, and sodium,7,8 whereas they are low in fiber; vitamins A, C, and E; folate; iron; and calcium.9-12

An extensive body of research reveals that a diet high in fruits and vegeta- bles is associated with a reduced risk of cancer and heart disease13-18 and may aid in weight management.19

Fruit and vegetable consumption in college students is between 2.1 and 5.5 servings,20-22 which is below the current recommendation of 9 servings

or 41⁄2 cups. 23 Furthermore, college

students have less awareness than older adults of the health benefits of fruits and vegetables and the effects of poor dietary practices.24

Although numerous nutrition edu- cation programs promote fruit and vegetable consumption, relatively few efforts have targeted college students in these nutrition interventions.20

Traditionally, the most successful programs for diet modifications have involved individual contact with a registered dietitian or other primary health care provider.25 However, these methods may not fit with the busy life- styles and unpredictable schedules of most college students,4 causing poten- tial for high attrition. Recently, alterna- tive cost-effective interventions have been introduced to specifically target college students. For example, newslet- ters were used to promote fruit and veg- etable intake in college students, and their participation in this intervention was found to increase fruit and vegeta- ble intake by 1 serving.20 Investigators

103

Family and Consumer Studies, Kent State University, Kent, OH Address for correspondence: Eun-Jeong Ha, PhD, 130 Nixson Hall, Family and Consumer Studies, Kent State University, Kent, OH 44242; Phone: (330) 672-2701; Fax: (330) 672- 2194; E-mail: [email protected] �2009 SOCIETY FOR NUTRITION EDUCATION doi:10.1016/j.jneb.2008.07.001

Journal of Nutrition Education and Behavior � Volume 41, Number 2, 2009

104 Ha and Caine-Bish Journal of Nutrition Education and Behavior � Volume 41, Number 2, 2009

in this study combined newsletters with a motivational interview and e-mail follow-up to increase the inter- vention’s impact on dietary behavior change. Shive and Morris also found that a social marketing campaign im- proved fruit consumption among college students by offering a fruit fair on campus that included distribution of fruit samples and brochures.26

Similarly, college nutrition courses have been used to enhance nutritional knowledge in college students with the goal to encourage dietary change.27,28

However, results of these investiga- tions indicate that this type of inter- vention appears to be successful only in increasing nutrition knowledge and not in changing dietary intake. In contrast, Matvienko et al reported that participation in a college nutrition science course prevented weight gain in freshmen, suggesting that class- based nutrition education may help college students translate nutrition knowledge into dietary changes.29

Overall, prior research on interven- tions targeting college students’ die- tary behaviors suggests a need to develop curricula targeting specific nu- trition behaviors in college students.

The purpose of this study was two- fold: (1) to assess the current intake of fruits and vegetables in a sample of college students; and (2) to evaluate the effectiveness of participation in a 15-week basic nutrition class in in- creasing consumption of fruits and vegetables in college students. The present intervention is unique in combining the use of conventional education materials with interactive feedback and ‘‘hands-on’’ activities in promotion of increased fruit and vegetable intake.

METHODS

During the spring of 2006, 90 healthy college students between the ages of 19 and 35 years who were enrolled in a basic sophomore-level nutrition class at a midwestern university par- ticipated in the study. Among them, 10 participants were excluded from the final analysis. Exclusions included students who were older than 25 years, preexisting medical conditions limiting dietary intake (ie, celiac dis- ease), illnesses affecting food intake during the data collection period (ie,

flu), or incomplete or unreliable data. The study population consisted of undergraduate students from various majors including Nutrition and Die- tetics (35%), Human Development (28%), other (30%) (ie, Hospitality Management, Audiology, Exercise Sci- ence), and undeclared (7%) majors. Participants were told that the pur- pose of the study was to obtain data to develop a nutrition education in- tervention program for college stu- dents. This research was approved by the Kent State University Institutional Review Board, and informed consent was obtained from each participant before enrollment in the project.

A pretest–posttest design was used to assess effectiveness of nutrition educa- tion on changes in vegetable and fruit consumption of college students. Data were collected during the first 2 weeks and the last week of spring semester 2006. At the time of both pre- and post- testing, a 50-minute interview was conducted with each participant to gather anthropometric data, as well as to verify completion and accuracy of each participant’s food record. Body weight was measured in kilograms to the nearest � 0.1 kg using an electronic scale (Body Fat Monitor/Scale [TBF 551], Tanita, Arlington Heights, IL), with the student in light clothing and without shoes. Standing height with- out shoes was recorded on a portable stadiometer (The Portable Adult/Infant Measuring Unit [PE-AIM-101], Perspec- tive Enterprises, Kalamazoo, MI) to the nearest � 0.1 cm with mandible plane parallel to the floor. Each subject’s body mass index (BMI) was calculated as weight/height2 (kg/m2).

Dietary intake was assessed using 3-day dietary records. Subjects were instructed to record their food intake over 2 weekdays and 1 weekend day while adhering to their usual eating practices. They were told to avoid days with special events or exam days for reporting dietary intake. A va- riety of tools and procedures was used to obtain reliable data:

1. Food models, measuring cups and spoons, household utensils, and ta- bleware were used to illustrate proper portion sizes.

2. Participants were asked to collect and bring all the food labels of the products they consumed during the data collection period.

3. To obtain the most accurate infor- mation about ingredients and portion sizes, research associates visited the local restaurants and campus cafeterias where a majority of the participants ate.

4. Food items were also purchased by the researchers to estimate portion sizes when students were not able to provide accurate information.

Dietary analyses were performed by the trained researcher using Nutri- Base IV Clinical software (Cyber Soft, Inc., Phoenix, AZ, 2002).

Fruit and vegetable intake was re- ported in cups so results could be compared to the MyPyramid food guidance system.23 The guidelines provided by the Centers for Disease Control and Prevention are based on daily calorie needs estimated by con- sidering age, gender, and activity level.30 These guidelines are given in cups of fruits and vegetables.

The class met 3 times a week for 50 minutes per session over a 15-week period. To minimize the effect of class materials on eating behavior and physical activity patterns, lectures during the baseline data collection focused on topics not directly related to dietary intake and health, such as ‘‘How the Body Uses Food,’’ ‘‘Food Insecurity,’’ and ‘‘Food Safety.’’

Class lectures covered topics that addressed overall dietary quality, in- cluding: (1) the importance of nutri- tion related to prevention of chronic diseases; (2) increasing consumption of fruits, vegetables, and whole-grain products; (3) encouraging low-fat dairy product consumption; (4) dis- couraging over-reliance on dietary supplements; and (5) promoting an active lifestyle. In addition to the tra- ditional approach of lectures, video- tape watching and various class activities were introduced. The pres- ent educational investigation is unique because of its combination of conventional education materials and ‘‘hands-on’’ activities that were goal oriented. By focusing not only on increasing academic knowledge, educational materials and activities that were goal oriented, reinforced, and focused on students’ current envi- ronment and social constructs were developed.31 Many of the activities and class lectures were tied to the Social Cognitive Theory (SCT), whereby

Journal of Nutrition Education and Behavior � Volume 41, Number 2, 2009 Ha and Caine-Bish 105

Table 1. Class Activities for Basic Nutrition Course

Activity Description Social Cognitive Theory Conceptsa

1. Food label hunt Students bring the food label of a frequently used product

Behavioral capability; Environment

2. May I take your order? – Fiber-rich food

Pretending to go out for lunch, students select fiber-rich/ low-fat food from the menu. Answers are given in the order of fiber/fat contents.

Behavioral capability; Environment

3. Whole-grain product sampling Whole-grain products are introduced, and opinions are shared.

Situation; Expectancies

4. What changes do I want to make? Students list simple behavioral changes they want to make in a couple of weeks.

Self-control

5. Happy body log Students list up to three good things that they do for their body in a daily log.

Self-control; Expectations

6. How much risk do I have? - Osteoporosis and cardiovascular disease

Using risk assessment forms and food frequency form developed for calcium intake, students assess their risk of osteoporosis and cardiovascular diseases.

Behavioral capability

7. Calcium-rich food contest Students are asked to bring their favorite recipes high in calcium. Best 5 recipes are selected and shared with class.

Behavioral capability

8. New food challenge Students are asked to try any new dish containing vegetables and submit written report.

Reinforcements

9. What about my parent’s diet? Students perform dietary intake interview with their parent using the same packet they used at the beginning of the semester for themselves.

Reciprocal determination

aThe following are the definitions of each of the Social Cognitive Theory concepts used for the in-class projects: Behavioral capability: Knowledge and skills to perform behavior used to demonstrate skills training Environment: Factors physically external to the person Expectations: Model positive outcomes of a behavior Expectancies: Value placed on an outcome Reciprocal determination: Interaction of the person, environment, and behavior to demonstrate skill and personal change Reinforcements: Responses to a person’s behavior Self-control: Personal regulation of goal-directed behavior Situation: Perceptions of the environment

students were using their own dietary behaviors and lifestyle choices as a framework to learn course materials. Table 1 lists course activities, as well as the constructs from the SCT that each activity meets.32 The SCT is based on interaction of environment (ie, fac- tors that affect a person’s behavior), personal factors (cognitive, affective, and biological events), and behaviors that an individual performs. This the- ory is typically used in health educa- tion and behavior programs and can be used as a framework for developing intervention strategies. SCT has been successfully used in previous interven- tions to increase fruit and vegetable consumption.33,34

Statistical Analysis

Means and standard deviations were calculated for all the variables ana- lyzed. The statistical program and pro- cedures of SPSS for Windows (version 14.0, SPSS, Inc., Chicago, Ill, 2005) were used for all analyses. Consump- tion variables for the current investiga- tion included the following: total vegetable, fresh vegetable, starchy veg- etable, french fries, vegetable juice, to- tal fruit, fresh fruit, canned fruit, and fruit juice. Pre–post differences were assessed using analysis of variance (ANOVA). Differences in consumption were not significantly different accord- ing to gender, residency, and years in

college; therefore, data were pooled and paired t tests determined overall differences in fruit and vegetable vari- ables. Significance was set a priori at P # .05.

RESULTS

Eighty students enrolled in a sopho- more level general nutrition course participated in this investigation. Av- erage BMI of the participants was 26.3 � 5.6 kg/m2. Average age of the participants was 20.2 � 1.4 years. The majority of the participants were female (88%). The residence status of the participants was: 16% lived at

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Table 2. Pre- and Posttest Variable Means þ Standard Deviations for Vegetable And Fruit Consumption

Consumption (cups per day) Pretest Posttest P Value Vegetables 0.77 � 0.62 1.52 � 1.03 < .001 Fresh vegetables 0.46 � 0.50 1.2 � 0.93 < .001 Starchy vegetables 0.30 � 0.33 0.29 � 0.40 .47 French fries 0.15 � 0.28 0.07 � 0.15 .01 Vegetable juice 0.01 � 0.07 0.02 � 0.15 .75 Fruit 0.94 � 0.92 1.33 � 0.99 .002 Fresh fruit 0.43 � 0.61 0.99 � 0.85 < .001 Canned fruit 0.06 � 0.15 0.05 � 0.15 .473 Fruit juice 0.45 � 0.64 0.32 � 0.47 .107

home, 40% lived in the dorm, 35% lived off campus, and 6% reported an- other living arrangement.

Pre- and posttest means and stan- dard deviations are reported in Table 2. Since no differences in fruit and vegetable consumption between genders (P ¼ .13 and P ¼ .83, respec- tively), place of residence (P ¼ .49 and P ¼ .49, respectively), and years in college (P ¼ .27, P ¼ .79, respec- tively) were found between pre- and posttest measures, the data were pooled (ie, all participants included). Paired t tests revealed overall differ- ences in fruit and vegetable consump- tion from pre- to posttest regardless of grouping variables (ie, gender, resi- dency, year in school). Statistically sig- nificant increases in consumption of total vegetable, fresh vegetable, total fruit, and fresh fruit were demon- strated between pre- and posttest mea- sures (Table 2). A significant decrease in french fry consumption was also noted between pre- and posttest mea- sures (P ¼ .01). Fruit and vegetable consumption data at posttest between males and females did show a signifi- cant difference in vegetable consump- tion (P ¼ .036) at posttest whereby females consumed more vegetables than males. No differences (P ¼ .806) in fruit consumption at posttest were demonstrated.

Overall, vegetable consumption and fresh vegetable consumption were low at the beginning of the study. Seventy-two percent of partici- pants consumed 1 cup or less of total vegetables, and 90% of participants consumed 1 cup or less of fresh vege- tables at the onset of the investiga- tion. Both total vegetable and fresh vegetable consumption increased by

the end of the investigation. Sixty- five percent of the participants were consuming more than 1 cup of vege- tables, and over 50% of the partici- pants were consuming more than 1 cup of fresh vegetables by the conclu- sion of the class. The consumption of starchy vegetables did not change from pre- to posttest (P ¼ .47).

Overall, students participating in this study demonstrated an increase in fruit consumption (Table 2). Ninety-two percent of participants consumed 2 cups or less of fruit per day. By the conclusion of the semes- ter, 22% of the participants were con- suming more than 2 cups of fruit per day. Increases in fresh fruit consump- tion were also shown whereby at the time of the pretest, 90% of partici- pants were consuming 1 cup or less of fresh fruit, but at posttest, 39% of participants were consuming greater than 1 cup of fresh fruit per day. There was only a 10% decrease in fruit juice consumption over the semester, which was found to be nonsignificant between pre- and posttest measures (P ¼.147). No change in the consump- tion of canned fruit was demonstrated (P ¼ .473).

DISCUSSION

The present investigation assessed the intake of fruits and vegetables of col- lege-age students and examined the effectiveness of a 15-week interven- tion in fruit and vegetable consump- tion as part of a general nutrition course. Numerous researchers have re- ported that college students display unhealthful eating patterns3,4 and are engaged in unsound dieting prac-

tices.5,6 The typical diet of college students is often low in fruits and veg- etables and high in fat, simple sugar, and sodium content.7,8 This type of diet can be characterized by a lack of certain vitamins and minerals and fi- ber.9-12

The present study confirmed that college students do not consume fruits and vegetables at the recommended dietary intake. This research also found that exposure to a class-based nutrition education intervention driven by SCT for 18- to 24-year-old college students may help this age group meet the recommended serv- ings of fruits and vegetables (ie, 4.5 cups for women and 5 cups for men). This finding is important because in- creasing fruit and vegetable consump- tion would increase intake of dietary fiber, folate, and vitamins A and C, all of which are known to be lacking in the typical diet of college students.9-12

Furthermore, research literature that has shown that increases in nutrition knowledge or general nutrition knowl- edge does not necessarily predict dietary change.27,28 The present inves- tigation resulted in statistically signifi- cant increases in the intake of both fruits and vegetables. This finding is consistent with previous research that showed positive changes in dietary behaviors after nutrition edu- cation interventions with college stu- dents.20,35

Limited research exists on nutri- tion education interventions promot- ing fruit and vegetable consumption by college students. Mitchell reported that basic nutrition classes changed college students’ food choices but failed to show increases in fruit and vegetable consumption.36 More re- cently, Richards et al demonstrated that use of stage-based newsletters in college students increased fruit and vegetable consumption by 1 serving a day, which is equivalent to a 0.5- cup increase and is similar to the re- sults in the current investigation that nutrition education increased the consumption of fruits and vegeta- bles.20 However, the magnitude of in- crease in fruit and vegetable intake observed in this study was much higher. A general nutrition course may be more effective in increasing consumption because students are more frequently exposed to education materials.

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At the beginning of the investiga- tion, participants’ consumption of both fruits and vegetables did not meet the recommended intake. Consumption of both fruits and veg- etables by the current study’s partici- pants was lower than the intake by college students participating in sim- ilar studies.22,37 These differences may be owing to varying methodolo- gies such as method and timing of data collection. At the conclusion of the intervention, however, partici- pants consumed 2.85 cups of fruits and vegetables, which is less than current recommendation in MyPyra- mid of 41⁄2 cups a day, but this find- ing demonstrated an improvement over baseline intake.38 Furthermore, the number of servings of vegetables more than doubled, indicating the current intervention may have had a greater effect on increasing vegeta- ble intake than increasing fruit in- take. This result is inconsistent with other research showing more of an increase in fruit intake than vegetable consumption39 or similar increases in both fruits and vegetables.20 This in- consistency may be because fruit intake at baseline was closer to the recommended dietary intake and vegetable intake was below the rec- ommended servings. Although in- creases in fruit consumption were smaller compared to the increases in vegetable intake, it is notable that fresh fruit intake significantly in- creased, whereas fruit juice consump- tion remained the same.

In the current study, fruit and veg- etable consumption at baseline or be- tween pre- and posttest did not differ between genders. Other researchers have found that females consume more servings of fruits and vegetables than males,37,40 indicating the result of the current investigation might be specific to this study population or be- cause males’ caloric intake is higher, inadvertently explaining their con- sumption of vegetables to be higher. Another possible explanation is that the number of males in this study was not large enough to result in a statistically significant difference. Furthermore, males enrolled in the basic nutrition course may already be more interested in and practice healthful eating compared to typical male students. However, posttest re- sults showed that vegetable consump-

tion by female students was higher than that of their male counterparts, implying that female students may be more receptive than male students to interventions focused on increas- ing vegetable consumption. The difference in fruit and vegetable consumption patterns at the conclu- sion of the study is not surprising in light of previous research. Several re- searchers have demonstrated that fe- males hold a more positive attitude toward healthful eating and fruit con- sumption, more social pressure to consume fruit, and are more health conscious than their male counter- parts.41,42 This result suggests that future nutrition education interven- tion requires effective and specific tools focused on motivating male stu- dents to increase fruit and vegetable consumption.

The results of this research also in- dicated that, both at baseline and after the intervention, housing status did not appear to influence fruit and veg- etable consumption. Chung et al found that students living on campus ate more fruits and vegetables.21 One possible explanation for the inconsis- tent findings with Chung et al21 is that dining rooms for dorm residents on campus for this study population were open to nonresidents as well, which provided the same food choice opportunities for both residents and nonresidents. In addition, this inves- tigation found that fruit and vegetable intake did not differ according to years in college. This is not a surprising result, because all students are ex- posed to the same environment that affects their food intake, such as busy schedules both for work and class, limited funds, and lack of cook- ing facilities and skills.

There are several reasons why a prom- ising outcome was seen in this particular study population. Throughout the se- mester, during lectures, class activities, and projects, the importance of fruit and vegetable consumption was ad- dressed as well as its association with health-related topics (ie, cardiovascular diseases, cancer, diabetes, obesity, osteo- porosis, and hypertension). Lectures were also expanded to discuss mecha- nisms by which diet can prevent the de- velopment of certain chronic diseases. This knowledge may have been espe- cially interesting to the students, since more than half of the students in class

had more than 1 family member suffer- ing from at least 1 chronic disease, which might be an intrinsic factor to motivate students to change their eating habits. In addition, class lectures not only encouraged students to increase fruit and vegetable consumption, but also motivated them to change overall eating behavior and their lifestyle by us- ing a variety of class activities and assign- ments. Examples include: introducing simple recipes of fruits and vegetables; assigning home cooking, tasting health- ful snacks, and writing a healthful activ- ity log; providing tips for healthful eating when dining out; and using the guiding principles of SCT. These activi- ties and assignments provided students with opportunities throughout the course to assess their personal behaviors and environmental factors that affected those behaviors. Two key learning op- portunities were dietary record analysis and goal setting. This approach may have helped students relate the class ma- terial more directly to their own dietary habits, thereby giving them more aware- ness and motivation to change their own dietary behaviors. Another factor may be that the class met more fre- quently (ie, 3 times a week) than tradi- tional nutrition education intervention programs of only once a week. This find- ing is supported by research reporting that when the frequency of meeting was greater, dietary changes were higher.43 Finally, students received their baseline dietary analysis as feedback dur- ing the first month of the class and used it to compare their intake with recom- mended servings for each food group and nutrient recommendation covered during lectures. This activity helped stu- dents recognize their nutrient intakes in high and low values and identify food sources, which in turn motivated them to be engaged in overall healthful eat- ing, which included increasing fruit and vegetable consumption.

Overall, this research showed the possibility that using a class-based nutrition education intervention in a general nutrition course may be an effective approach that has the poten- tial to change eating behaviors with minimum additional manpower and financial resources in a college setting. Incorporation of messages to the stu- dents to increase fruit and vegetable consumption blended well with cur- rent general nutrition course material. It allowed for class learning to move

108 Ha and Caine-Bish Journal of Nutrition Education and Behavior � Volume 41, Number 2, 2009

from knowledge to application. To further strengthen the goal of the class to increase fruit and vegetable consumption, additional ‘‘hands-on’’ projects (Table 1) grounded in SCT allowed for students to use the knowl- edge that they gained in class and use it toward understanding their own di- etary behaviors. The class projects not only made the students aware of their dietary habits, but it also created op- portunities to address weaknesses in their diets, which then increased awareness and need for dietary modi- fication. Class activities in turn may have had a positive impact on stu- dents’ breadth of knowledge gained in the course and may as well have provided a forum necessary to create a behavior change.

This study has several limitations. A convenience sample rather than a random sample was used. As a result, the study population may not repre- sent traditional college students through oversampling of females and nutrition and dietetics students. In addition, a control group was not used to control for possible confound- ing factors such as seasonal variation in intake. Students who were already more interested in healthful eating may be more likely to choose to take a nutrition course. Long-term effect of the intervention over time was not included in the study design. Fu- ture research should be directed to- ward longitudinal studies to examine long-term effect of class-based nutri- tion education on changes in dietary behavior.

A major strength of the present study is that this study was focused on obtaining accurate dietary data us- ing various methods (ie, interviewing campus cafeteria managers; purchas- ing actual food from local restaurants; having participants to bring food la- bels, utensils, and cups used most at home; and having only one nutrition- ist analyze the dietary record).

IMPLICATIONS FOR RESEARCH AND PRACTICE

In conclusion, class-based nutrition education intervention focused on prevention of chronic diseases has po- tential to increase fruit and vegetable consumption among college students.

Furthermore, effectiveness of class- based nutrition education in increas- ing fruit and vegetable consumption among college students regardless of their major, housing status, gender, and year in college was demonstrated. Using a class-based nutrition educa- tion intervention in a general nutri- tion course may be an effective approach that has the potential to change eating behaviors with mini- mum manpower and financial re- sources in a college setting.

Male students responded differ- ently to this nutrition education inter- vention, indicting future research should focus on gender-tailored nutri- tion intervention.

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