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