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Locally Grown Fruit and VegetablePurchasing Habits and the AssociationWith Children’s DietMolly De Marcoa, Alison A. Gustafsonb, Ziya Gizlicea, Robin Crowdera

& Alice S. Ammermanac

a University of North Carolina at Chapel Hill, Center for HealthPromotion & Disease Prevention, Chapel Hill, North Carolina, USAb Department of Nutrition & Food Sciences, University of KentuckySchool of Human Environmental Sciences, Lexington, Kentucky, USAc University of North Carolina at Chapel Hill, Gillings School ofGlobal Public Health Department of Nutrition, Chapel Hill, NorthCarolina, USAPublished online: 25 Aug 2014.

To cite this article: Molly De Marco, Alison A. Gustafson, Ziya Gizlice, Robin Crowder & AliceS. Ammerman (2014) Locally Grown Fruit and Vegetable Purchasing Habits and the AssociationWith Children’s Diet, Journal of Hunger & Environmental Nutrition, 9:3, 372-387, DOI:10.1080/19320248.2014.929545

To link to this article: http://dx.doi.org/10.1080/19320248.2014.929545

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Journal of Hunger & Environmental Nutrition, 9:372–387, 2014Copyright © Taylor & Francis Group, LLCISSN: 1932-0248 print/1932-0256 onlineDOI: 10.1080/19320248.2014.929545

Locally Grown Fruit and Vegetable PurchasingHabits and the Association With Children’s Diet

MOLLY DE MARCO,1 ALISON A. GUSTAFSON,2 ZIYA GIZLICE,1

ROBIN CROWDER,1* and ALICE S. AMMERMAN1,3

1University of North Carolina at Chapel Hill, Center for Health Promotion & DiseasePrevention, Chapel Hill, North Carolina, USA

2Department of Nutrition & Food Sciences, University of Kentucky School of HumanEnvironmental Sciences, Lexington, Kentucky, USA

3University of North Carolina at Chapel Hill, Gillings School of Global Public HealthDepartment of Nutrition, Chapel Hill, North Carolina, USA

This study explores whether the frequency of parents’ local fruitsand vegetables (F&V) purchasing is associated with children’s F&Vintake. Questions from the 2008 Child Health Assessment andMonitoring Program survey assessed parental habits and perceivedbarriers to purchasing and preparing local food. Multivariablelogistic regression was used to assess the independent associationbetween frequency of purchasing local food and children’s F&Vconsumption. The study showed that 43.3% of parents report thattheir child consumes 5 or more servings of F&V/day. In addition,49.7% of those who purchase locally grown F&V regularly had achild who consumed 5 or more servings of F&V/day. Compared tothose parents who purchased locally grown F&V regularly, those inthe less frequent purchasing categories were less likely to report thattheir child consumed 5 or more servings of F&V/day, pointing tothe potential role that purchasing locally grown F&V may have ininfluencing children’s intake.

KEYWORDS local, food, environment, fruit, vegetable

∗Current affiliation: 21 Acres Center for Local Food and Sustainable Living, Woodinville,Washington, USA

Address correspondence to Molly De Marco, University of North Carolina at Chapel Hill,Center for Health Promotion & Disease Prevention, 1700 Martin Luther King Jr. Blvd., ChapelHill, NC 27599-7426, USA. E-mail: molly_demarco@unc.edu

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Local Fruit and Vegetable Purchasing 373

INTRODUCTION

Poor diet quality and obesity have been associated with environments thatpromote consumption of energy dense foods and limited fruit and vegetable(F&V) intake.1−3 The growing availability of locally produced food in thefood environment raises the question of whether local food purchasingbehaviors are associated with greater F&V intake. This may be becauselocally produced foods are perceived to be fresher,4 reduce environmentalimpacts through reduced transportation,4,5 and support the local economyand local farmers.4 Evidence exists for a preference for local foods given thetaste, freshness, connections with farmers, and desire to “buy local.”4,5 Ofparticular interest is whether the purchase of locally grown food influencesintake in children. This is of interest because of children’s relatively lowconsumption of F&V and the importance of early exposure to the develop-ment of life long healthy food habits.6 Many communities have environmentsthat facilitate the purchasing of local foods such as at farmers’ markets andthrough community-supported agriculture (CSA). These venues may provideopportunities to improve accessibility, availability, and affordability of F&V.Little is known, however, about whether purchasing locally grown foods willlead to meaningful improvement in F&V consumption among children.

A review of the literature suggests that establishment of additional farm-ers’ markets and other outlets for locally grown foods as one strategy forimproving access to healthy food among adults.7−9 Though there is lessinformation about youth dietary behaviors linked to local foods, one studyfound that adolescents who reported support for local and organic foodpractices had more healthful diets and consumed more F&V.10 Based on thisresearch, there is reason to believe that children exposed to more locallyproduced F&V through the purchasing decisions of their parents may con-sume more F&V than children with less exposure. Hence, we hypothesizethat children of parents who frequently purchase locally grown F&V willconsume more F&V. If true, achieving broad health benefits would requirepolicies supporting both access to and availability of locally grown food.The aims of this study are to (1) describe the population of people whopurchase locally grown fruit and vegetables from a statewide cross-sectionalsurvey and (2) determine the association between parental reporting of pur-chasing locally grown fruit and vegetables and children’s intake of fruits andvegetables.

METHODS

Study Sample

The Behavioral Risk Factor Surveillance System (BRFSS) is a state-level datacollection system administered in all 50 states using a random telephone

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374 M. De Marco et al.

survey of noninstitutionalized adults 18 years and older. The BRFSS assesseshealth status, health behaviors, and use of health services. The North CarolinaBRFSS uses stratified sampling to collect local level data in 23 regions,providing estimates for nationally tracked health indicators. Interviews areconducted in English and Spanish.11 The North Carolina Child HealthAssessment and Monitoring Program (CHAMP) survey is a follow-back sur-vey to the NC-BRFSS. Eligible children (aged 0 to 17) for the CHAMP surveyare drawn monthly from the adults, ages 18 and older, interviewed via tele-phone for the NC-BRFSS and with children in their household. We paid foradditional questions to be added to the 2008 CHAMP survey to measurelocally grown F&V purchasing among parents and barriers to serving moreF&V. In 2008, 2987 adults completed CHAMP telephone interviews abouttheir children.12

Overcoming Barriers to Serving More Fruits and Vegetables

To assess strategies to overcoming barriers to serving more F&V, the follow-ing question was asked of parents: “What would help you to serve yourfamily more fruits and vegetables than you do right now?” Answer choices:lower cost; more convenient packaging; easy access to affordable locallygrown F&V; greater willingness of family members to eat F&V; more skill infood preparation techniques; already serve plenty; and some other reasonspecified. The “some other reason” answers were collapsed into one cate-gory due to small numbers of cases. A dichotomous (yes–no) variable wascreated for each strategy.

Key Exposure Variable

Parental frequency of purchasing locally grown F&V was captured with thefollowing question: “How often in the past 12 months did you buy fruitsor vegetables locally grown such as from a farmer’s market, CSA, roadsidestand, or pick-your-own produce farm?” Frequency of locally grown F&Vpurchasing was categorized, due to the skewed distribution of the data andlarge frequencies of some response choices, as (1) never, (2) less than onceper month, (3) at least once per month, and (4) at least once per week.

Outcome Variable

On the CHAMP survey, fruit intake was captured with: “On a typical dayhow many servings of fruit does [child’s name] consume?” Vegetable intakewas captured with the question “On a typical day, how many servings ofvegetables does [child’s name] eat, not including French fries?” To providea standard serving size, parents where told: “A serving of fruit is a 1/2 cupor a medium piece of fruit” and “A serving of vegetables is 1/2 cup of

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Local Fruit and Vegetable Purchasing 375

cooked or raw vegetables or 1 cup of raw leafy salad greens.”13 The fruitand vegetable intake items were combined to obtain the total number ofservings of F&V consumed per day. Given the non-normal distribution andto be consistent across similar studies, the variable was dichotomized intomeeting Healthy People 2000 Guidelines for 5 or more servings of F&V perday or not meeting the Guidelines14 (since this study was conducted theGuidelines have changed; the Healthy People 2000 Guidelines are no longerin use).

Statistical Analysis

All analyses used the weighted data (North Carolina State Center for HealthStatistics) from both NC-BRFSS and CHAMP and were conducted usingSTATA 11.0 (College Station, TX) and SAS 9.2 (Cary, NC). Survey procedureswere used in all analyses to account for the complex sampling designs suchas stratification, disproportionate stratified sampling, and nonsampling error(poststratification adjustment). Sample characteristics were summarized usingdescriptive statistics such as means, proportions, standard errors, and/or 95%confidence intervals. Bivariate associations between frequency of purchasinglocally grown F&V and a set of sample characteristics, F&V consumption, andkey behaviors were assessed either using t tests (for continuous variables)or Rao-Scott chi-square tests (for categorical variables). Bivariate associationsbetween children’s F&V consumption and key behaviors and characteristicswere assessed. A multivariate logistic regression model was fitted to exam-ine the independent association between frequency of purchasing locallygrown F&V and children’s consumption of 5 or more F&V servings per day,controlling for demographics including household educational attainment;child’s race, age, and gender; household size; health insurance status; andSupplemental Nutrition Assistance Program (SNAP)/Food Stamp use. Controlvariables were chosen as they were associated with either purchasing localF&V or child’s F&V consumption at the P ≤ .1 level.

RESULTS

Sample Characteristics

The sample included 2845 parents or caregivers; 142 cases were droppedwhere the incident child was less than one year of age because parentswere not asked about servings of F&V for these children. Mothers were mostlikely to be the caregivers who completed the survey (71.1%; see Table 1).Household educational attainment in this sample was high, with 40% report-ing a college degree or more. This high educational attainment is in part dueto the fact that respondents were asked to identify the education level ofthe person with the highest attainment in the household, leading to 40% of

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TABLE 1 Demographics and Food-Related Behaviors of Sample (Weighted) and Those WhoWere Frequent (at Least Once per Week) Locally Grown F&V Purchasers, CHAMP, NorthCarolina 2008a

Demographics or behaviors N % (CI) or Mean (SE)

Subsample of thosewho frequently buy

local (%) (SE)

Parent–child relationshipBiological mother 2000 71.1% (69.0% − 73.2%) 71.0% (2.2)Biological father 487 17.4% (15.6% − 19.1%) 15.7% (1.7)Other 358 11.6% (10.2% − 13.0%) 13.4% (1.6)

Highest householdeducational attainmentLess than high school 285 10.5% (9.1% − 12.0%) 19.2% (2.0)High school grad/GED 677 22.6% (20.7% − 24.5% 20.4% (1.8)Some college 772 26.9% (24.9% − 29.0%) 26.6% (2.2)College grad or more 1110 40.0% (37.9% − 42.2%) 33.9% (2.3)

Child’s raceNon-Hispanic white 1924 61.1% (58.9% − 63.4%) 56.8% (2.4)Non-Hispanic black 413 21.6% (19.5% − 23.6%) 15.2% (1.9)Hispanic 287 11.3% (9.8% − 12.8%) 22.0% (2.1)Other 221 6.0% (5.0% − 7.0%) 6.0% (1.0)Child’s age 2845 9.0 (0.12) 9.1

Child’s genderFemale 1379 48.4% (46.1% − 50.7%) 47.2% (2.4)Male 1466 51.6% (49.3% − 53.9%) 52.9% (2.4)Household size 2845 4.3 (0.03)

Type of health insurance forchildPrivate 1856 63.0% (60.8% − 65.1%) 52.9% (2.4)Public 734 28.6% (26.5% − 30.7%) 36.0% (2.4)Other/none 255 8.4% (7.2% − 9.7%) 11.1% (1.5)

Enrolled in foodstamps/SNAP

Yes 317 13.9% (12.2% − 15.5%) 15.7% (1.9)No 2524 86.1% (84.5% − 87.8%) 84.3% (1.9)

Consumes 3+ meals athome with family/week

Yes 2224 78.6% (77.1% − 80.1%) 83.2% (1.7)No 605 21.4% (19.9% − 22.9%) 16.8% (1.7)

Child consumes 5 or moreF&V servings/day

Yes 1231 43.3% (41.5% − 45.1%) 49.7% (0.02)No 1613 56.7% (54.9% − 58.5%) 50.3% (0.02)

Frequency of locally grownF&V purchases

Never 744 26.6% (25.0% − 28.3%) −−Less than once per month 723 25.9% (24.2% − 27.5%) −−

At least once per month 635 22.7% (21.2% − 24.3%) −−At least once per week 693 24.8% (23.2% − 26.4%) −−

In the last 12 months, didyou ever rely on low-costfoods?

Yes 1851 65.2% (63.5% − 67.0%) 61.1% (2.4)No 987 34.8% (33.0% − 36.5%) 38.9% (2.4)

(Continued)

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Local Fruit and Vegetable Purchasing 377

TABLE 1 (Continued)

Demographics or behaviors N % (CI) or Mean (SE)

Subsample of thosewho frequently buy

local (%) (SE)

Did family cut size of child’smeals due to cost?

Yes 172 6.1% (5.2% − 6.9%) 9.1% (1.4)No 2669 94.0% (93.1% − 94.8%) 90.9% (1.4)

aF&V indicates fruits and vegetables; CHAMP, Child Health Assessment and Monitoring Program; CI,confidence interval; SNAP, Supplemental Nutrition Assistance Program.

respondents reporting that someone in their household had a college degreeor more; only 22.5% of North Carolinians have a college degree or more.15

The majority of respondents were Non-Hispanic white (61.1%), with 21.6%African American and 11.3% Hispanic. Table 1 also shows the characteristicsof those who reported frequently (at least once per week) purchasing locallygrown F&V.

Diet-Related Behaviors

The majority of respondents reported eating at least 3 meals at home perweek, but less than half reported that their child consumed the recom-mended number of servings of F&V per day (see Table 1). Table 1 alsoshows the food-related behaviors of those respondents who reported beingfrequent (at least once per week) purchasers of locally grown F&V.

Strategies for Overcoming Barriers to Serving More F&V

CHAMP respondents suggested strategies that might help them serve moreF&V at home. Of those strategies given, the most common strategy for facili-tating the increased serving of F&V was reducing the cost (38.6%), followedby willingness of family members to eat F&V (23.2%) and easier access tolocal food (13.5%). Respondents also suggested more convenient packag-ing (5.9%) and being more skilled in food preparation (4.9%) but much lessfrequently.

Associations

Results of the bivariate analysis are shown in Table 2. In our multivariatelogistic regression, fathers were consistently less likely to report that theirchild consumed 5 or more servings of F&V per day than were mothers(interviews were completed by either the mother or the father; see Table 2).Younger children and those who ate more meals in the home were morelikely to consume 5 or more servings of F&V per day. Finally, we found that

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tionsh

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58)

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Child

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0.96

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o25

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Ref

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-cost

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0.36

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—

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26.5

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23.1

%23

.6%

42.7

%—

No

28.8

%24

.2%

21.2

%25

.8%

45.6

%—

Did

fam

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lsdue

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29.3

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%32

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%0.

66(0

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Ref

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t

(Con

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)

379

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TAB

LE2

(Contin

ued

)

Freq

uen

cyofpurc

has

ing

loca

llygr

ow

nF&

V

Dem

ogr

aphic

sN

ever

<1/

Month

Atle

ast

1/m

onth

Atle

ast

1/w

eek

P

Child

consu

med

≥5se

rvin

gsof

F&V

per

day

P

Adju

sted

odds

ratio

(95%

confiden

cein

terv

al)

Ove

rall

adju

sted

P

Child

consu

med

≥5se

rvin

gsofF&

Vper

day

.04

——

Yes

26.0

%24

.7%

21.6

%27

.7%

——

No

28.4

%26

.7%

23.0

%21

.8%

——

Num

ber

ofm

eals

eate

nat

hom

e5.

25.

35.

76.

00.

0003

6.0

(vs.

5.1

for

those

who

did

not)

<.0

001

1.10

(1.0

6–1.

14)

<.0

001∗

Typ

eofhea

lthin

sura

nce

for

child

<.0

001

.002

.07

Priva

te24

.1%

30.6

%24

.9%

20.5

%41

.4%

Ref

eren

tPublic

34.0

%17

.6%

17.6

%30

.8%

50.3

%1.

40(1

.03–

1.89

)O

ther

/none

29.6

%18

.3%

20.0

%32

.1%

39.7

%1.

02(0

.71–

1.46

)Fr

equen

cyofpurc

has

ing

loca

llygr

ow

nF&

V.0

4∗

Nev

er—

——

——

——

0.70

(0.5

4–0.

92)

Less

than

once

per

month

——

——

—0.

74(0

.56–

0.97

)A

tle

astonce

per

month

——

——

—0.

73(0

.55–

0.98

)A

tle

astonce

per

wee

k—

——

——

Ref

eren

t

aF&

Vin

dic

ates

fruits

and

vege

table

s;SN

AP,

Supple

men

talN

utriti

on

Ass

ista

nce

Pro

gram

.

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Local Fruit and Vegetable Purchasing 381

when compared to frequent purchasers of locally grown F&V (purchasinglocally grown F&V at least once per week), less frequent purchasers wereless likely to report that their child consumed 5 or more servings of F&V perday.

DISCUSSION

We found that parents suggested easier access to locally grown F&V as oneof the top 3 strategies, among the 5 offered, that would help them to servemore F&V to their families than they do now. In addition, we found thatparents who are frequent (at least once per week) purchasers of locallygrown F&V were more likely to report that their children consumed at leastthe recommended number of servings of F&V per day, a relationship notseen in those who purchased locally grown F&V less frequently. Our findingssupports those of other studies.8,16 These findings suggest that a commitmentto purchasing locally grown F&V has a positive effect on children’s diet.

We found that the older the child was, the less likely the parent wasto report that the child consumed 5 or more servings of F&V. It may bethat the parent has less control over what a child eats as the child ages andis eating meals at school and obtaining her or his own snacks and mealsat home.17−19 We also found that fathers were less likely than mothers toreport that their children ate 5 or more servings of F&V per day. This findingsupports previous research suggesting that fathers underreport a variety oftheir children’s behaviors when compared to mothers.20−22

We assessed what strategies might assist respondents to serve more F&Vat home. These findings provide direction for which policies should be devel-oped to improve diet quality.23,24 We found that lower cost, willingness offamily members to eat F&V, and having easier access to local food were themost often endorsed strategies to facilitate serving more F&V consumptionat home. Given studies suggesting that consumers believe local food to bemore expensive,25−27 perceived access to local food may be confounded byperceived cost. Almost one quarter of respondents reported that they wouldserve more F&V if their family members were more willing to eat them.Studies have found a link between exposure to gardening and trying locallygrown F&V among elementary-aged children and increased consumption ofF&V, willingness to eat F&V, and choosing F&V as snacks suggesting a pos-sible place for intervention and policy creation.28−32 Schools have startedto offer more local food in their cafeterias.5 Potential Farm to School inter-ventions and policies could include facilitating gardening at schools, easingregulations for the use of school garden grown produce in school cafeteriasand allowing for vendor selection that gives preference to local sources ofproduce in school cafeterias. Policies supporting these efforts include theChild Nutrition Reauthorization Bill, which helps communities establish local

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farm to school networks, create school gardens, and ensures that more localfoods are used in the school setting.33

Increasingly, policies are being implemented that institute governmentalsupports to improve access to locally grown F&V among low-income pop-ulations, such as through the Special Supplemental Nutrition Program forWomen, Infants and Children and Senior Farmer’s Market Nutrition programs.There is promising evidence from studies conducted on these programs sug-gesting that access to locally grown produce is associated with improvedF&V intake among adults,34−37 and our study suggests that purchasing locallygrown produce may be associated with higher F&V intake among children.

Such evidence could fortify efforts to promote local food venues andincreased access to them via the use of Electronic Benefits Transfer for theSNAP and programs that provide matching funds for SNAP purchases atfarmers’ market.38−40 Federal policies are in place to increase access to localfood including the competitive Farmer’s Market Promotion Program grants,which assist in establishing, expanding, and promoting farmers’ markets andother farm-to-fork market opportunities.41

Study Limitations

The BRFSS and the CHAMP are cross-sectional surveys so direction of causal-ity cannot be determined. Compared with multiple 24-hour recall or foodrecords, there is the possibility that CHAMP and BRFSS, which derive theirestimates using a short food frequency questionnaire, underestimate theproportion of children consuming 5 or more servings of F&V.42,43 Previousresearch, however, suggests that this tool is a valid measure of F&V consump-tion.43 Despite this potential for underestimation, the F&V intake reportedhere (43.3% of parents reported that their child consumed at least 5 servingsof F&V per day) exceeds that reported for children in other studies.44−46 Thismay be due to the way the questions were asked. Parents were asked thequestions for their children instead of the youth providing their own answers.In addition, these data were collected through self-report instead of observa-tions or dietary recalls. Parents may have overestimated the number of F&Vservings because they know how many servings their children should be eat-ing. The interviewers who collected these data, however, received extensivetraining and were regularly monitored at random by a supervisor to ensureconsistency in questionnaire administration and to solicit answers as accurateas possible.

Most existing research has looked at willingness to and/or reasons forpurchasing locally grown F&V47,48 and not at frequency of purchasing locallygrown F&V, providing little basis for comparison. However, the reportedfrequency of local food purchases here appears high, and it is somewhatcounterintuitive that the rates are generally higher among lower income andminority consumers. Because the response options to the question about

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frequency of purchasing local foods include “roadside stand” and “pick-your-own,” it could be that more rural and underserved populations answered yesthan to usual questions asking about farmers’ market and CSA options morecommon in urban areas. Our data, however, do not allow us to correlateconsumer purchases with local produce outlets. BRFSS and CHAMP surveyshave some inherent threats to internal validity and generalizability becausethey do not include persons who do not have landlines, a telephone at all,or those residing in US institutions, households that are, on average, of lowerincome. Additionally, BRFSS and CHAMP have low response rates and dataare self-reported.

Despite these limitations, there are some significant advantages to theBRFSS/CHAMP surveys. The telephone survey methodology provides forquality control and relatively low cost and speeds data collection. The F&Vmeasures have been validated in various populations.49 The survey questionsand design, procedures, and interviewing techniques have been developedto improve data quality and reduce bias. Last, given the large sample size andthat the data are from a state-based population survey, findings can at least begeneralized to North Carolina and the American South. Additionally, accessand availability of the food environment and related responses may onlyreflect conditions within North Carolina. Therefore, when making conclu-sions only statements regarding correlations between access and availabilitywith key outcomes can be made.

This is the first known study addressing the role of the local foodenvironment as it relates to diet quality among children using a largecross-sectional data set. This study suggests a link between being a regu-lar purchaser of locally grown F&V and having a child who consumes therecommended number of servings of F&V. This evidence can be used bypolicy-makers to support policies linking children with F&V by decreasingbarriers to access such as through the policies mentioned above includingexpanding the Special Supplemental Nutrition Program for Women, Infantsand Children cash-value voucher benefits for fruits and vegetables to beused at farmers’ markets and with CSAs, using locally grown F&V in schoollunch programs, and expanding the farm-to-school program. In addition,state food policy councils can recommend policies to encourage school gar-dens, the use of school garden produce in classrooms and cafeterias, and theengagement of parents in those gardens including allowing families to takeproduce home.

ACKNOWLEDGEMENTS

We thank Melissa Cunningham-Kay and Meredith Robbins for their help inediting and providing background literature.

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FUNDING

This study is supported by a Gillings Innovation Laboratory award from theUniversity of North Carolina at Chapel Hill Gillings School of Global PublicHealth.

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