farm fresh food for healthy kids - journal of nutrition advance... · poor access to fresh...
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Objective: To develop and implement a community-based, randomized intervention trial targeting childhood
obesity prevention. The intervention includes cost-offset community supported agriculture (CO-CSA) coupled
with tailored education for low-income families. We will examine the intervention’s effect on fruit and
vegetable intake as well as foods high in sugar and/or (solid) fat. A secondary objective is to examine
whether the CO-CSA mechanism can help support small farms and local agricultural economies.
Description: Formative, observational, and experimental methods are used to examine the impact of CO-
CSA on diet and other health behaviors as well as the economic impacts on local economies. Evaluation:
Formative interviews were conducted with 24 farmers; 42 adults and 20 children from low-income
households; 20 full-paying CSA members; and 20 cooperative extension educators. Additionally, three
quarterly longitudinal surveys examining factors such as fruit and vegetable consumption among children
were conducted with current members and new applicants to an established CO-CSA (n=50). Formative and
longitudinal data as well as Adult Learning Theory informed the development of a skill-based curriculum to
improve knowledge, ability, and self-efficacy to support intervention-relevant behavior change. Partnerships
were established with 12 farms across four states that will implement the CO-CSA intervention; 7 nutrition
educators will deliver the curriculum. Recruitment and enrollment began March 2016. Conclusions and
Implications: This study examines whether increased financial access using the CO-CSA mechanism plus
tailored education positively affects dietary behaviors and obesity prevention among low-income families.
Preliminary findings from the intervention will be available in 2017.
• Low intake of fruits and vegetables (FV) is a risk factor for obesity and chronic disease.
• FV consumption is lower for individuals with low socioeconomic status and food insecurity in part due to
poor access to fresh affordable foods.
• Community Supported Agriculture (CSA) can improve access to and consumption of fruits and vegetables
but low-income families may be less likely to participate due to the upfront payment structure, logistical
barriers, and unfamiliarity with produce items.
• Some evidence suggests that low-income customers who participate in financial incentive programs for
farmers’ markets or CO-CSAs consume more fruits and vegetables.
1. To develop and implement a community-based, randomized intervention focused on cost-offset
community supported agriculture (CO-CSA) coupled with a tailored curriculum for low-income families.
2. To examine the intervention’s effects on intake of fruits and vegetables as well as foods high in sugar
and/or (solid) fat as a pathway to childhood obesity prevention.
Formative Interviews with Stakeholder Groups
Themes from Farmer Interviews • All farms had mechanisms in place to accommodate difficulty paying the full cost of a CSA share.
• All offered a smaller share for a lower price and most had working shares for free or a lower price.
• All farms accepted payment in installments even when no installment plan was advertised.
• Seven of farms interviewed accepted SNAP/EBT at the farmers’ market; six of the farms interviewed
accepted SNAP/EBT for CSA payment.
• Financial strategies used by CO-CSA Farmers included grants (50%), sliding scale (50%), donations by
the farm (33%), fundraising by the farm (33%), and donations to the farm (17%).
Themes from Cooperative Extension Educator Interviews
Partner Farms We are partnering with 12 farms across four states to offer CO-CSA shares to study participants.
• CSA shares typically last 20 weeks (range 15-24 weeks).
• Most CSAs (73%) offer more than one size.
• CSA pick-up occurs at the farm (55%), farmers’ markets (54%), and other
community locations (64%).
• All farms accept cash; most also accept checks (73%) and credit or
debit cards (73%).
• All farms will accept SNAP benefits as payment, and 7 are newly enrolling
in SNAP because of the research partnership.
CO-CSA Curriculum
Intervention recruitment began in March 2016.
*Target is 240; enrollment period for 2016 season not yet closed.
Funding: This project was supported by Agriculture and Food Research Initiative Competitive
Grant number 2015-68001-23230 from the USDA National Institute of Food and Agriculture.
Farm Fresh Food for Healthy Kids Innovative Community Supported Agriculture Cost-Offset Intervention to Prevent Childhood Obesity and Strengthen Local Agricultural Economies
Rebecca A. Seguin1, Alice S. Ammerman2, Karla L. Hanson1, Stephanie B. Jilcott Pitts3, Jane Kolodinsky4, Marilyn H. Sitaker5
1Cornell University, Ithaca NY; 2University of North Carolina at Chapel Hill, Chapel Hill, NC; 3East Carolina University, Greenville, NC; 4University of Vermont, Burlington, VT; 5Battelle Memorial Institute, Seattle, WA
Share Size Typical # of Items CO-CSA Price/week
(range)
Small 5-7 $7.75 - $15
Regular 8-10 $10 - $16.25
Large 12-14 $14 – $21.43
Research
Design
2016 2017 2018
Group 1 –
Intervention
CO-CSA +
Education
CO-CSA Sustainability
Group 2 –
Control
Data collection
only
CO-CSA +
Education
CO-CSA
Group 3 –
Attrition
Replacements
– Intervention
CO-CSA +
Education
Sustainability
Group 4 –
Attrition
Replacements
– Control
Data collection
only
CO-CSA +
Education
Participant
Recruitment
as of 5-30-16 Nu
mb
er
scre
en
ed
Number of individuals screened that are:
Eligible Completed
enrollment
Group I -
Intervention
Group 2 -
Control
TOTAL 458 370 184* 93 91
New York 216 152 61 29 32
North Carolina 115 108 61 31 30
Vermont 74 59 29 14 15
Washington 53 51 33 19 14
Kitchen Tools
(14 total)
Need
(%)
Own
(%)
Among those who own the tool…
How often
used (%)
Quality of
tool (%)
Everyday Sometimes Adequate Poor
Salad Spinner 26% 53% 32% 56% 52% 16%
Food Processor 11% 89% 32% 59% 27% 18%
Storage Container 6% 83% 85% 13% 53% 0%
Chef Knife 2% 98% 83% 17% 38% 24%
Paring Knife 2% 96% 80% 16% 57% 19%
Slow Cooker or
Crock Pot 2% 89% 21% 60% 49% 15%
Cooking Spoons 2% 94% 95% 5% 54% 2%
Vegetable Peeler 0% 96% 47% 47% 57% 12%
Cutting Board 0% 100% 96% 4% 55% 11%
Mixing Bowl 0% 100% 72% 28% 43% 9%
Frying Pan or Sauté
Pan 0% 100% 87% 13% 27% 9%
Colander 0% 98% 65% 33% 49% 9%
Sauce Pan 0% 100% 72% 26% 45% 7%
Spatula 0% 100% 72% 28% 64% 5%
Reusable Grocery
Bag Formative data suggest they may be needed for CSA
produce preparation. Stock Pot
Longitudinal Examination of Fruit and Vegetable Intake Among Participants in an Established CO-CSA To date, three quarterly longitudinal surveys examining factors such as fruit and vegetable consumption among children and
adults were conducted with participants in an established CO-CSA (n=41 at baseline).
Research Design • Participants are 1:1 randomly assigned to two groups
(intervention and delayed intervention control group)
within farm community.
• Our estimated sample size of 240 across 12 clusters
(farms) will yield power to detect change over time in
total FV intake of 1/3 cup equivalent.
• If attrition from baseline to post-season (2016)
exceeds 25%, additional participants will be randomly
assigned to groups 3 and 4, also within farm
community.
• Eligible and interested participants are enrolled and
complete most baseline data collection activities
before being randomly assigned within each of the
communities served by our partner farms (clusters).
Stakeholder
Group
Farmers Individuals from Low-
income Households Full-paying
CSA
Member
Cooperative
Extension
Educators With
CO-CSA
Without
CO-CSA Adults Children
Number 12 12 42 20 20 20
Integration Approach:
Recruitment CSA
Intervention Curriculum
General lack of familiarity with CSA model Educate residents on CSAs as part of recruitment protocol
Perceptions of CSAs
Expensive CSA Intervention subsidizes 50% of cost through CO-CSA
Produce is ‘dirty’ Cleaning produce is built into each lesson
Can’t predict contents of share Recipes are flexible with interchangeable vegetables
Fear of getting unfamiliar produce Curriculum introduces unfamiliar produce via preparation/tasting
Fear of getting too much produce Participants select share size when multiple exist in their CSA
Lesson on freezing and preserving excess produce
Location might not be convenient
Recruitment occurred at or near most pick-up locations
Pick-up sites located convenient to low-income housing, Headstart, etc.
Don’t understand or use ‘local’ descriptor De-emphasized ‘local’ descriptor during recruitment
Perceptions of successful nutrition education integrated into curriculum
Involves children Lesson activities designed to accommodate children
Uses MyPlate because it is visual MyPlate concept introduced and revisited in lessons
Challenges the belief that a healthy meal is built around meat protein
Lessons encourage building a meal around vegetables and vegetable-based dishes
Adapts to participants’ varying levels of knowledge and skill
Curriculum uses ‘Anchor-Add-Apply-Away’ model that starts with a discussion of current knowledge and builds from that base
Data Collection Plan: Measures and Timeline
Ba
se
line
09
/20
16
03
/20
17
09
/20
17
03
/20
18
09
/20
18
Household Measures
Household composition and demographics X X X X X X
Kitchen equipment inventory X
Time and money spent on shopping, cooking and eating X X X
Home fruit and vegetable availability & accessibility X X X X
Receipt of food assistance X X X X X X
Household food security survey module X X X X X X
CSA participation measures X X X X X
Parent Measures
Knowledge, attitudes and beliefs about cooking and eating X X X X
Quantity of fruit and vegetables consumed X X X X X X
Sugar-sweetened beverages & processed snacks X X X X X X
Dermal scan of carotenoid levels X X X X
Ability to:
select, store, and prepare CSA produce
prepare food to minimize solid fat and sugar
substitute fruits/vegetables for energy-dense foods
X X X X
Child Measures
Quantity of fruit and vegetables consumed X X X X X X
Sugar-sweetened beverages & processed snacks X X X X X X
Reported physical activity X X X X X X
Measured height and body weight X X X X
Dermal scan of carotenoid levels X X X X
Three-day 24-hour dietary recall X X X X
Abstract
Background
Objectives
Evaluation
Intervention Trial Evaluation
Intervention Trial
Acknowledgements
Intervention participants
will select 2-4 kitchen
items at enrollment
(shaded grey).
Small kitchen tools will be
offered as educational
enhancements during
intervention curriculum
classes (shaded orange).
Fruit and vegetable intake (FVI) among for adults and children in a CO-CSA compared to recommendations
MyPyramid Cup Equivalents Reported Intakea Age/Sex-specific
Recommendationb Mean Differencec
Mean (SD) Mean (SD) p-value
Adults (n=38)
Total FVI 6.88 (3.64) 4.07 (0.33) 2.81 <.001
Fruit Only 1.31 (1.24) 1.55 (0.15) - 0.24 .216
Vegetable Only 5.57 (3.28) 2.53 (0.19) 3.04 <.001
Children (n=41)
Total FVI 5.05 (2.37) 2.83 (0.47) 2.22 <.001
Fruit Only 1.44 (0.82) 1.29 (0.25) 0.15 .242
Vegetable Only 3.61 (2.13) 1.54 (0.28) 2.07 <.001
Fruit and vegetable Intake (FVI) for adults and children in a CO-CSA by agricultural season
Agricultural Season
MyPyramid Cup Equivalents August February Mean Difference
Mean (SD) Mean (SD) p-value
Adults (n=20)
Total FVI 6.59 (3.25) 7.13 (4.02) 0.54 .562
Fruit Only 1.09 (1.19) 1.19 (0.99) 0.10 .368
Vegetable Only 5.50 (3.04) 5.94 (3.60) 0.45 .631
Children (n=20)
Total FVI 5.29 (2.40) 4.67 (2.58) - 0.63 .186
Fruit Only 1.43 (0.92) 1.39 (0.91) - 0.04 .885
Vegetable Only 3.86 (2.23) 3.28 (2.28) - 0.59 .100 a. National Cancer Institute Fruit and Vegetable Intake Screener
b. Estimated from the 2015 Dietary Guidelines for Americans
c. Differences were tested using paired t-tests.
Objectives
Skills and self-efficacy
• Storing, preparing, and
consuming CSA produce
• Strategies to substitute energy-
dense foods and beverages with FV
• Strategies to be more active in
daily life and reduce sedentary
time
Attitudes and Beliefs
• Value of consuming FV
• Reduce Barriers to CSA Produce
Acceptance
Behavioral Aims ↑ Intake of FV
↑ Nutrient density of
meals & snacks
↓ Intake of saturated
and trans fats
↓ Intake of SSB
↓ Intake of sodium
from packaged foods
↓ Sedentary time
• Informed by formative
and longitudinal data &
Adult Learning Theory
• Nine one-hour sessions
• Delivered by 7 educators
• Provide opportunities for
peer-to-peer modeling
and group discussion