Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs

Assessment and Intervention 1

Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community

Needs Assessment and Intervention

January 2018

Elizabeth Joa

Queens College Dietetic Internship

 Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
Assessment and Intervention 2
Overview

Nutrition and Weight status is one of the objectives of the Healthy People 2020.1 The goal of

this objective is to “Promote health and reduce chronic disease risk through the consumption of

healthful diets and achievement and maintenance of healthy body weights.”1 This community

needs assessment and intervention is based on the following two specific objectives under

Nutrition and Weight1:

1. NWS-14 Increase the contribution of fruits to the diets of the population aged 2 years and

older

2. NWS-15.1 Increase the contribution of total vegetables to the diets of the population aged

2 years and older

The nutrition assessment and intervention were completed at a middle school in Bronx, NY.

The assessment revealed that the students knew that healthy food or snacks consisted of fruits

and vegetables. However, when asked what they actually eat, they stated chips and cookies. The

students who were part of this assessment and intervention have been a part of a after school

nutrition education program for a few months prior. Therefore, the students either had the correct

information but did not know how to apply that nutrition information into their own life or they

did not comprehend the nutrition education from the previous lessons. More specifically, the

students didn’t actually realize or know how much fruits and vegetables they needed to consume

in a day. It was also discovered that students chose chips and cookies because of its easy

accessibility at the school’s vending machine. Therefore, there is no support from the

environment they are in to be able to make the choice to eat fruits and vegetables before

choosing chips and cookies. Therefore, a nutrition education was implemented to intervene in

this nutrition problem to address how much of fruits and vegetables should be eaten per day and
 Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
Assessment and Intervention 3
how consuming more fruits and vegetables have many benefits to our health. An easy and

friendly recipe that displays how accessible it is to incorporate fruits and vegetables in our diet

was also done. The nutrition education was shown to be effective in reaching the goals and

objectives as changes were seen from the pre-surveys and post-surveys.

Nutrition Care Process (NCP): Assessment

Client History

The after school program is an organization that serves the underserved students of New

York City by providing various afterschool programs. The students who participate in the after

school program range from elementary to middle school age (CH-1.1.1).2 Both female and male

students are included in this program (CH-1.1.2).2 The predominant race/ethnicities of the

students who are a part of the programs are Hispanic and African American (CH-1.1.4 & CH-

1.1.5).2 Majority of students speak the English language but are also bilingual (CH-1.1.6).2

The nutrition assessment and intervention that took place was at a middle school. The

students are all in middle school and are dependent on their primary care givers and school for

their food (CH-1.1.8 & CH-1.1.9).2 There is a total of 560 students.3 484 of the 560 students are

of Hispanic ethnicity and 59 of the total school population is of Black ethnicity (CH-1.1.4 & CH-

1.1.5).2,3189 of the total school population are English Language Learners (CH-1.1.6). 2,3

According to Isasi, obesity in Hispanic youth in the United States still remains high.5 This

study also stated that Hispanic children have a higher level of abdominal adiposity than non-

Hispanic Caucasian children.5 In a 2012 Surveillance Report, it was noted that Hispanics had the

highest percentages of poor to fair health in comparison to other races or ethnic communities.6
 Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
Assessment and Intervention 4
In the Bronx, the Hispanic community is the most prevalent population that lives below

the poverty line.7 The African American population of the Bronx follows.7 The median household

income of the Bronx is $35,176.7

Food/Nutrition-Related History

Many students expressed that they like to eat fruit (FH-1.2.1.1) (FH-1.2.2.3).2 However,

when they were asked what food they actually eat, they state chips and cookies (FH-1.2.1.1)

(FH-1.2.2.3).2 One student expressed how she ate cake, chocolate, tacos, a mango, sandwich, and

smoothie in one day (FH-1.2.2.2).2 Another student stated that her lunch consisted of Takis,

cookies and water (FH-1.2.2.4).2 Another student said that she eats fruit 5 times a week (FH-

1.2.2.1).2 Many students do not enjoy eating vegetables. Not only did they vocally say that but it

was also seen in their lack of intake during the nutrition education class. Two lessons that

incorporated vegetables in the recipe were not liked by the students and they didn’t eat much of

it.

A study that reviewed food group intakes of Hispanics and African Americans showed

that Hispanics have a high consumption of whole fruits and fruit juice.8 This study also suggests

that higher fruit intake and decreasing excessive intake of protein foods should be encouraged for

African Americans as this study states that African Americans have high consumptions of

protein.8 This study also shows that both groups need to increase their vegetable intake, decrease

the amount of sweets, and increase intake of nutrient dense snacks (FH-1.2.2.2).2 This study also

reports that both population groups have been shown to have low physical activity levels.8

One study of Hispanic parents addressing their children’s obesity reported that parents

underestimate the severity of their child’s weight status.9 However, this same study also reported

that parents rely on what the doctors say.9 One source states that diabetes, heart disease, obesity
 Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
Assessment and Intervention 5
and cancer are more prevalent in the African American population.10 African Americans are

more content with their bodies and body size.10 This same study also found that African

Americans had higher consumptions of high-caloric beverages.10 This report also states that

participants in the study do believe food intake, weight, and physical activity are all important to

their health and wellness.10 Many participants were also able to share and recognize what it

means to be healthy.10

African American children who are overweight have a high chance of staying overweight

as they get older, which increases the rate of obesity.11 This implies that changes are not made

throughout their life to change their weight status. One study that reviewed the strategies of low-

income parents in feeding their children food that they refused before, states that to avoid

wasting food, parents wouldn’t buy the refused food to their children.12 Moreover, food that is

disliked, even if they are fruits and vegetables, are not provided to their children when they have

refused them in the past. This therefore reinforces the importance of having nutrition education

in schools and after school programs to provide children the opportunity to try new foods or retry

foods that they may enjoy now and that are healthy as well.

Nutrient Needs

Adolescent students’ estimated energy requirements are calculated using their gender,

age, height, weight and physical activity level.13 Female students ages 12-14 years old who are

living a sedentary lifestyle should have about 1700 kcal to 1800 kcal per day (FH-1.1.1.1).2, 13

Male students ages 12-14 years old, who are living a sedentary lifestyle, should consume about

1800 to 2000 kcals per day (FH-1.2.2.2).2, 13

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Nutrition Care Process (NCP): Diagnosis

1. Food- and Nutrition- Related Knowledge Deficit (NB-1.1) related to lack of

understanding of nutrition-related education as evidenced by incorrect reports of

perceived healthy snacks and the amount of fruit and vegetable consumption per day.

2. Not Ready for Diet/Lifestyle Change (NB-1.3) related to lack of social support for

implementing changes as evidenced by reports of the accessibility of chips and cookies

available at school and diminished availability of fruit and vegetables for snacks.

Nutrition Care Process (NCP): Intervention

Intervention #1:

Students were given Nutrition Education (E-1.4) The amount of fruits and vegetables intake per

day, the use of MyPlate, and the importance of eating more fruits and vegetables to decrease risk

of chronic disease such as hypertension, to address students’ lack of understanding of what

healthy foods are, and how much fruits and vegetables should be eaten per day.

Intervention #2:

Students were given Nutrition Education- making a healthy recipe (E-2) by making a simple

guacamole, to make students aware that it is easy to incorporate vegetables and fruit in their

daily life, and to bring healthy snacks to school to avoid choosing chips and cookies that are

made available at school.

Students were given Nutrition Education- importance of eating more fruit and vegetables (E-1)

through a discussion on the benefits of fruits and vegetables and how eating more fruits and

vegetables can help decrease the risk of developing chronic disease such as hypertension.
 Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
Assessment and Intervention 7
Healthy People 20201

1. NWS-14 Increase the contribution of fruits to the diets of the population aged 2 years and

older

Specific: People 2 years or older to eat about 1 cup of fruit per 1,000 calories.

Measurable: Record amount of fruit intake every day.

Attainable: Yes, incorporate more fruits in their diet.

Realistic: The focus to increase fruit consumption within this time frame.

Timely: To reach this goal by 2020.

2. NWS-15.1 Increase the contribution of total vegetables to the diets of the population aged

2 years and older

Specific: People 2 years or older to eat a little over 1 cup of vegetables per 1,000 calories.

Measurable: Record how much vegetables are consumed each day.

Attainable: Yes, consume more vegetables daily.

Realistic: The focus to increase vegetable consumption within this time frame.

Timely: To reach this goal by 2020.

Lesson Plan

The lesson plan (Appendix 1 & Appendix 2) incorporated discussions and activities that

were geared towards the overarching Healthy People 2020 goal of promoting health and

reducing the risk of chronic disease, but also towards the specific objectives that will help work

towards that bigger goal. A discussion on how much fruits and vegetables should be eaten per

day, and the use of MyPlate was conducted. A MyPlate activity was done where students list 10

different fruits and 10 different vegetables they want to eat and try (Appendix 3). A discussion

on the benefits of fruits and vegetables and how they decrease the risk of chronic diseases such
 Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
Assessment and Intervention 8
as hypertension was conducted. Lastly, a healthy recipe incorporating vegetables and fruit was

made with the class. A pre-survey and post-survey was conducted to evaluate the effectiveness

of the intervention (Appendix 4).

Marketing

This nutrition education did not need to be promoted heavily as the students that

participated are a part of the afterschool program. However, the students did choose to be in this

class.

Product: After School Nutrition Education program. This class exposes the students to different

foods that are not only tasty but healthy. In addition, the program provides students the

opportunity to learn how to cook and to prepare food. The students have the opportunity to do

tastings, to learn how to properly cut with a knife, and make various recipes. Students love to eat,

so the tasting and cooking portion of the class is appealing to students and keep them engaged in

the program.

Price: The after school program is free for the students. Therefore, this extracurricular activity is

that much more appealing and desired to attend.

Place: The nutrition education takes place at the school location and is a convenient location for

the students to attend to. The nutrition education would be easily accessible for students as they

would be in a safe environment after school and for parents to be comfortable for their children

to be a part of.

Promotion: The after-school nutrition education program is liked by students not only because

food is involved, but also because hands-on activities are done by the students. This program is

also appealing not only for the students, but also for the administration of the schools. The

schools are the ones who reach out to the after-school program to have the nutrition education
 Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
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program at their school. The after-school organization emphasizes the importance of how these

programs will help students to do better in their academics, and develop a healthy mind and

body. They also emphasize how they serve the underserved schools of New York City, where

public school don’t provide programs like this.14

Resources

Providing additional education to students during afterschool programs are priceless.

Students who participate in afterschool programs are more likely to be high school graduates

(63%).15 Whereas students who don’t participate have a 42% chance of graduating. 15Afterschool

programs also have shown to improve students’ performance with higher attendance, and better

grades.15

Each nutrition education program costs about $30 to $50 for each week, for about 15 to

30 students each week. The food and kitchen supplies were made available for the class to

happen. Food was delivered by Fresh Direct. There were two other adults in the class to help

with the program. Each school site is responsible for purchasing the food for the week but the

organization provides the training and the supply bin for the class.

Level 1 and Level 2 curriculum run about 10 weeks each. If a school runs the nutrition

education for two curriculums, it would be a total of 20 weeks, which is about $600 to $1000

spent on the program for 20 weeks. Looking only at obesity alone in 2008, $147 billion were

spent on national health care costs.16 With this information, approximately $56 billion is spent on

healthcare costs for obesity for only 20 weeks out of the year. Nutrition Education done in

schools are shown to significantly decrease students’ BMI, and overweight status, and increase

fruits and vegetable intake.16 Therefore, with obesity alone, the cost of the program of $600 to

$1000 and the benefits of nutrition education, outweighs the cost that would go into treating
 Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
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obesity. The amount of money going into the program is minuscule compared to the cost of

treating obesity. Therefore, school-based nutrition programs are cost-effective not only for

preventing obesity, but preventing other chronic diseases too.17

Emerging Trend and Innovative Delivery

According to the Academy of Nutrition and Dietetics, an emerging trend of the dietetics

profession is to incorporate interdisciplinary teams to drive innovation.18 Specifically in this

nutrition assessment and intervention, collaborative teams are implemented to provide

community-based health care.18 This intervention follows this emerging trend, as this nutrition

education engaged with the community in the middle school, to encourage behavior change

regarding their health. The collaboration between clinicians like dietitians/nutritionists and

leaders in schools can help promote nutrition education in school communities and thus promote

living a healthier lifestyle to make changes towards good health. This therefore helps to decrease

the risk of chronic diseases in the long run.

A systematic review of the impact of cooking classes on food preferences were

conducted.19 This review showed that cooking programs that children were a part of may make a

positive impact on their food behaviors and attitudes.19 This review stated that children were

more open to trying new foods when they had a part in preparing and cooking the food.19

Another study showed how the intervention groups had a significant increase in their preference

for 5 vegetables than the control group.19 Cooking with children is an innovative way to engage

children in learning about healthy eating. Not only that, but cooking with children may have an

impact on their food preferences, attitudes and behaviors towards food.19 The nutrition

intervention delivered had a cooking portion by making guacamole, which delivered this

innovative nutrition education at a school community.

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Nutrition Care Process (NCP): Monitoring & Evaluation

The effectiveness of the nutrition intervention was evaluated through the pre-survey and

post-survey. The results were compared and analyzed. Below is the analysis of the outcomes

from the nutrition education.

Although many students were still confused as to what snacks are the healthiest, the

students did recognize the importance of eating more fruits and vegetables. Therefore, they also

understood that eating more fruits and vegetables are important to help decrease the risk of

developing chronic diseases, which is a Healthy People 2020 goal. When comparing the pre-

survey and the post-survey, it shows also how some students may be ready for lifestyle change as

they recognized the importance of choosing fruits and vegetables over chips. Many students

knew what hypertension was and even mentioned how they know loved ones who have high

blood pressure.

The students’ understanding of the lesson is shown as students said that they would eat

half a plate of fruits and vegetables at every meal in the pre-survey and post-survey. However,

the post-survey showed that more students decided yes, which showed a change since when they

took the pre-survey. Therefore, the education made an impact on some of the kids’ decisions and

shows that the students had a better understanding of food and nutrition-related knowledge.

Many students chose to eat fruit instead of chips at school in the pre-survey and post-

survey. The number increased in the post-survey, which means that after the nutrition education,

majority of the students would rather choose fruit over chips. Therefore, just one education

lesson can influence a child in their food choices to choose healthier options. Therefore, nutrition

education programs should continue to make an impact in young students’ lives now so that they

can grow up and make healthy decisions in what they eat.

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Students have a misconception of what is healthy. Many students believe that protein bars

are healthier than fruits. Protein bars were not the focus of the lesson, and were not mentioned in

the lesson, but some still believed they are healthier than fruits and vegetables even in the post-

survey. Post-survey showed that students were more likely to pick a fruit over potato chips;

therefore, they realized the importance of fruits and vegetables since the pre-survey. Post-survey

showed that students were more likely to eat half a plate of fruits and vegetables; therefore, they

realized the importance of fruits and vegetables since the pre-survey. The differences in the pre-

survey and the post-survey showed that the nutrition education intervention was effective to

teach the students the importance of increasing our consumption of fruits and vegetables and the

benefits of it such as preventing chronic diseases (Appendix 5). These results show success of

the intervention toward the diagnosis of “food-and nutrition-related knowledge deficit” and also

“not ready for diet/lifestyle change.”

There were a few hindrances that took place during the education that influenced the

results of the pre-survey and post-survey, and the actual effectiveness of the intervention. There

were side conversations that took place during the education that more than likely affected how

much the students paid attention to the lesson. There was also a language barrier as some of the

students’ primary language is Spanish. Some students did not understand the wording of the

surveys and asked for translation. Some of the bilingual students were able to help with

translation. Moreover, due to the language barrier and disruptions, communication to the class

was sometimes a challenge, which affected the outcome of the intervention.

The goal after this intervention is to continue the nutrition education at the middle school

and provide nutrition education to the students to help promote eating healthful; and therefore,
 Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
Assessment and Intervention 13
decrease the risk of developing chronic diseases, by the time students graduate from middle

school.

Students should be monitored for their meal/snack pattern (FH-1.2.2.3)2 and see if they

actually made the decisions to eat fruits and vegetables over chips, cookies, or protein bars. They

should also be monitored for the amount (FH-1.2.2.1)2 of fruits and vegetables they eat in a day

to see if they increased their intake of fruits and vegetables. This monitoring will show whether

the intervention did actually cause students to change their attitudes and behaviors towards fruits

and vegetables; and therefore, decrease the risk of chronic diseases. Further study would be

needed as this study doesn’t represent the entire middle school population in the Bronx.
 Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
Assessment and Intervention 14
Appendix

Appendix 1. Lesson Plan

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Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
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 Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
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Appendix 2. Lesson Plan Template

Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
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 Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
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Appendix 3. 20, 21
 Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
Assessment and Intervention 20
Appendix 4. Pre-Survey and Post-Survey
Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
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 Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
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Appendix 5. Pre and Post Survey Outcomes (3 questions)

Which is the Healthiest Snack?

10
Number of Students

8
6
4
2
0
A large bag of potato A small bag of potato An apple with peanut 2 large cookies Protein Bar
chips chips butter

Snack Choices
Pre-Survey Post-Survey

Would you eat a piece of fruit for snack instead of a bag of

potato chips at school?
15
Number of Students

10
5
0
Yes No
Answer

Pre-Survey Post-Survey

Do You Think You Will Eat a Half of a Plate, Full of Vegetables or

Fruit in Every Meal This Week?
20
Number of Students

10
0
Yes No
Answer

Pre-Survey Post-Survey
Fruit and Vegetable Consumption of Middle School Students in the Bronx: Community Needs
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