Fruit and Vegetable Consumption of Rural Middle School

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Author: Weinrich, Alyssa, A Title: Fruit and Vegetable Consumption of Rural Middle School Children

Participating in the National School Lunch Program

The accompanying research report is submitted to the University of Wisconsin-Stout,

Graduate School in partial completion of the requirements for the

Graduate Degree/ Major: MS Food and Nutritional Sciences

Research Advisor: Karen Ostenso, MS, RD, CD

Submission Term/Year: Spring, 2013

Number of Pages: 58

Style Manual Used: American Psychological Association, 6th edition

I understand that this research report must be officially approved by the Graduate School and that an electronic copy of the approved version will be made available through the University Library website

I attest that the research report is my original work (that any copyrightable materials have been used with the permission of the original authors), and as such, it is automatically protected by the laws, rules, and regulations of the U.S. Copyright Office.

My research advisor has approved the content and quality of this paper.

STUDENT: Alyssa Weinrich ____________________________________ DATE: ADVISOR: Karen Ostenso, MS, RD, CD ____________________________________ DATE: This section to be completed by the Graduate School This final research report has been approved by the Graduate School.

Director, Office of Graduate Studies: DATE:

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Weinrich, Alyssa, A. Fruit and Vegetable Consumption of Rural Middle School Children

Participating in the National School Lunch Program

Abstract

Childhood obesity is a growing problem across the United States. Obese children are

more likely to become obese adults. Eating a balanced diet is believed to play a role in the

prevention of obesity; therefore, the nutritional content of school lunches is important for

children’s health. The 2012 revisions to the National School Lunch Program increased the

overall servings of fruit and vegetables offered. Now children must purchase either a fruit and/or

vegetable. At this time it is not known whether children consume the fruits and vegetables that

they purchase. The purpose of this research was to determine fruit and vegetable purchases and

consumption of rural middle school students participating in the National School Lunch

Program. Food production lists were examined to calculate total servings of fruits and

vegetables purchased under the previous school lunch guidelines in 2012 to the revised

guidelines in 2013. Children’s plates were examined to determine the percentage of fruits and

vegetables consumed. Though not significant, fruit and vegetable purchases increased from 2012

to 2013. Fruit consumption was significantly different between grades. Purchasing and

consumption of fruits and vegetables remain below the program’s nutritional goals; therefore,

continued focus on improving their intake is important.

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Acknowledgements

The successful completion of this thesis project would not be possible without the

assistance of several people. First off, I would like to extend my deepest gratitude to my

research adviser, Karen Ostenso for her endless support, encouragement, patience and dedication

to success of my project. I cannot thank you enough for all of your assistance!

Thank you to the staff in the UW-Stout Research Services Office for all of your help

with the IRB approval of the project. Thank you also to Jennifer Mans for all of your assistance

with the statistical analysis of my data. I would also like to genuinely thank Dr. Carol Seaborn

and Judy Kennedy for the mentorship and guidance throughout my time at UW-Stout.

I would like to sincerely thank the principal and foodservice staff at Twin Bluff Middle

School in Red Wing, Minnesota for generously welcoming me into your school to observe the

students during the lunch period. Thank you also for taking the time to provide me with the food

production summaries and for your willingness to answer all of my questions. Without your

assistance this project would not have been possible.

Lastly, I would like to thank my parents for their continued support and teaching me to

never give up. I also would like to thank my husband for all of the encouragement and patience

with me during the completion of this project.

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Table of Contents

Abstract ................................................................................................................................2

List of Tables .......................................................................................................................7

Chapter I: Introduction .........................................................................................................8

Statement of the Problem .......................................................................................11

Purpose of the Study ..............................................................................................12

Research Objectives ...............................................................................................13

Definition of Terms................................................................................................13

Assumptions of Study ............................................................................................14

Methodoloy ............................................................................................................14

Chapter II: Literature Review ............................................................................................15

National School Lunch Program Guidelines .........................................................15

Food Groups...............................................................................................15

Consumption ..............................................................................................17

Recommended Daily Intakes .....................................................................17

Benefits ......................................................................................................18

Fruit and Vegetable Consumption in Children ......................................................18

Consequences of Inadequate Fruit and Vegetable Consumption ..........................20

Health Consequences .................................................................................20

Psychosocial Consequences .......................................................................21

Determinants of Fruit and Vegetable Intake at School ..........................................22

A la Carte Services.....................................................................................23

Vending Machines .....................................................................................23

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Salad Bar ....................................................................................................23

Time …. .....................................................................................................24

Gender Differences in Fruit and Vegetable Consumption .....................................24

Food Waste in Middle Schools ..............................................................................26

Chapter III: Methodology ..................................................................................................29

Sample Selection and Description .........................................................................29

Instrumentation ......................................................................................................29

Data Collection Procedures ....................................................................................30

Data and Statistical Analysis Procedures ...............................................................30

Limitations .............................................................................................................31

Chapter IV: Results ............................................................................................................32

Demographic Information ......................................................................................32

Compliance of National School Lunch Guidelines ...............................................33

Comparison of Fruits and Vegetables Purchased from 2012 to 2013 ...................33

Comparison of Servings of Fruit Purchased to Servings of Vegetables

Purchased.. .......................................................................................................34

Gender Comparison of Fruits and Vegetables Purchased .....................................35

Breakdown of Fruits and Vegetables Purchased ...................................................36

Servings of Fruits and Vegetables Consumed .......................................................38

Chapter V: Discussion .......................................................................................................42

Limitations .............................................................................................................42

Conclusions ............................................................................................................43

Compliance with National School Lunch Program Guidelines .................43

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Fruit and Vegetable Consumption from 2012 to 2013 ..............................43

Comparison of Servings of Fruits and Vegetables Puchased ....................44

Specific Fruits and Vegetables Most Commonly Purchased .....................45

Grade and Gender Differences in Fruit and Vegetable Consumption .......46

Recommendations ..................................................................................................48

References ..........................................................................................................................50

Appendix A: UW-Stout IRB Approval..............................................................................56

Appendix B: Informational Letter to Parents.....................................................................57

Appendix C: Data Collection Chart ...................................................................................58

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List of Tables

Table 1. Comparison of Servings of Fruits and Vegetables Purchased in

February 2012 to February 2013 ............................................................................... 34

Table 2. Comparison of Servings of Fruits and Vegetables Purchased in

February 2013 .............................................................................................. ……….34

Table 3. Comparison of Boys’ and Girls’ Servings Fruits and Vegetables Purchased .... 35

Table 4. Grade Differences in Total Servings of Fruits and Vegetables Purchased ......... 36

Table 5. Breakdown of Fruits Purchased .......................................................................... 37

Table 6. Breakdown of Vegetables Purchased ................................................................ 38

Table 7. Comparison of Servings of Fruits and Vegetables Consumed by Gender ......... 39

Table 8. Comparison of Servings of Fruits and Vegetables Consumed by Grade ........... 41

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Chapter I: Introduction

Children who are obese are more likely to become obese adults. In a study by Freedman

et al. (2005), children’s weights were recorded and they were followed into adulthood to

determine adult body weight. Children’s weights were found to be positively correlated with the

amount of body fat as an adult. According to the Centers for Disease Control and Prevention

(CDC, 2013a), rates of obesity in children have tripled over the past thirty years, increasing from

7% in 1980 to 20% in 2008. The increasing rates of obesity are alarming and can be due to

several different factors. Eating a balanced diet is believed to play a significant role in

maintaining a healthy weight and consuming a poor diet can increase likelihood of being obese.

Children who are obese have been found to consume a poor diet (Nicklas, Yang, Baranowski,

Zakeri, & Berenson, 2003). High consumption of sweetened beverages and foods has been

found to be correlated with obesity (Nicklas et al., 2003). Therefore, a child’s eating patterns can

impact their weight later on in life. It is important for children to develop healthy eating habits at

a young age as their diet can affect their health further down the road.

There are several potential consequences associated with being obese. Some of these

consequences include high blood pressure and cholesterol which can in turn increase a child’s

risk of developing cardiovascular disease (CDC, 2013a). Freedman, Zuguo, Srinivasan,

Berenson, & Dietz (2007), determined that 70% of obese children between the ages of 5-17 have

at least one risk factor for developing cardiovascular disease. In addition to cardiovascular

disease, being obese increases the likelihood of developing other diseases as well. Children who

are obese are more likely to develop insulin resistance and type 2-diabetes (CDC, 2013a). Obese

children are also at increased risk for developing breathing problems such as asthma and sleep

apnea (CDC, 2013a). In addition to the physical effects of obesity there are also potential

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psychological problems that can result. Children and adolescents who are obese can suffer from

discrimination and poor self-esteem due to their weight (CDC, 2013a).

Eating a balanced diet can have many positive effects for children and can reduce their

likelihood of becoming obese. Adequate nutrition helps support proper development and growth

in children and can reduce the likelihood of several diseases including heart disease, cancer,

stroke and diabetes (CDC, 2013b). Children spend a large portion of their day at school, and the

nutritional value of the food offered is crucial for their overall health. According to Let’s Move!

(n.d.), children consume at least half of their daily calories at school and for some children, the

food they receive at school might be the only food that they eat each day. Therefore, it is

important for children to receive quality and nutritious food at schools as it can have a positive

effect on their health.

The National School Lunch Program has a longstanding history in the United States.

President Truman signed the National School Lunch Act in 1946 which provides nutritionally

balanced, affordable lunches to children at school each day (United States Department of

Agriculture, [USDA], 2012b). The National School Lunch Program serves many children all

across the United States. The program is federally funded and is offered in public, private and

residential child care facilities. Any child attending a participating school is able to purchase

lunch through the National School Lunch Program. Children may qualify to receive reduced-cost

or free lunches (USDA, 2012b). Children from families with an income either at or below

130% of the poverty level are eligible for free meals, and those from incomes between 130-185%

of the poverty level are eligible for reduced price meals. Today the program is offered in over

100,000 public and non-profit schools and child care institutions. In 2011, the program served

over 31 million children across the country (USDA, 2012b).

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Due to the rigorous nutritional guidelines of the National School Lunch Program,

participation can have several positive effects on a child’s health. Research has found the

program to increase fruit and vegetable consumption in schools (Robinson-O’Brien, Burgee-

Chamoux, Haines, Hannah, & Neumark-Sztainer, 2010). Children consuming school lunch were

found to consume more than 50% of their daily fruit and vegetable intake at school. Participants

in the program are more likely to consume at least one vegetable at lunch in comparison to

children who do not purchase lunch at school. In a study by Condon, Crepinsek, and Fox (2009),

school lunch participants were more likely than non-participants to consume milk, fruit and

vegetables. Students participating in the school lunch program were also less likely to consume

desserts, snack items and drinks other than milk and 100% juice (Condon et al., 2009).

Participation in the National School Lunch Program can ultimately impact the child to make

better diet choices.

Recently, the National School Lunch Program has experienced several modifications. In

2010, President Obama signed the Healthy, Hunger-Free Kids Act of 2010 which required the

United States Department of Agriculture (USDA) to create new school nutrition standards that

were consistent with the Dietary Guidelines for America (Food Research and Action Center,

2012). The goal of the new standards was to improve the quality of school lunches and to

decrease rates of obesity in the United States (The White House, 2010). The New National

School Lunch and School Breakfast Guidelines were issued by the USDA in 2012 and went into

effect for the 2012-2013 school year (Food Research and Action Center, 2012). The revisions to

the program contained several modifications to the previous standards. The new guidelines

increased the amount of fruits and vegetables which are served, emphasize whole-grain foods,

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required only low-fat and nonfat milk to be offered, limits calories and reduces saturated fat and

sodium (Food Research and Action Center, 2012).

The new guidelines increased the requirement for the servings of fruits and vegetables

that children must take each day. Previously, fruits and vegetables were together in the National

School Lunch Program, but have now been split into separate components. Children now must

take at least one serving of fruits or a serving of vegetables each day (Schilling, 2012).

However, simply having the fruit or vegetable on their lunch tray does not guarantee that the

child will choose to eat it.

Children are not benefiting nutritionally from the food served to them if it is being

thrown away. A large percentage of food purchased in the National School Lunch Program is

wasted each day. Adolescents in grades 6-8 have been found to discard 19% of their entrée, 47%

of their fruit, 73% of their vegetables and 25% of their milk each day in schools (Cohen,

Richardson, Austin, Economos, & Rimm, 2013). Because of the positive effect fruit and

vegetable consumption can have on a child’s health, it would be important to know whether

students are purchasing and consuming more fruits and vegetables under the revised guidelines.

Statement of the Problem

Obesity continues to be a growing problem across the United States. Research from

Ogden, Carroll, Kit, and Flegal (2012), found that more than one-third of children and

adolescents in the United States were found to be overweight or obese. The rates of obesity

increase as children get older. Specifically, 18.4% of adolescents between the ages of 12-19 are

obese (Ogden et al., 2012). Eating adequate servings of fruits and vegetables is believed to

decrease rates of obesity in children (Geller & Dzewaltowski, 2009). However, most children are

not meeting their nutritional needs for fruit and vegetable intakes. Fruit and vegetable

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consumption decreases as children become adolescents. Only 1.2% of boys and 3.6% of girls

between the ages of 9-13 years have been found to consume the recommended servings of fruit

and vegetables (Geller & Dzewaltowski, 2009). These data indicate that fruit and vegetable

consumption in adolescents is a cause of concern. Since children spend a large portion of their

day at school and the National School Lunch Program serves many children across the United

States, the program can have a positive impact on participants. According to the USDA (2013b),

in the 2012 fiscal year over 31.6 million children participated in the program. Due to the recent

changes to the National School Lunch Program, the fruit and vegetable purchases and

consumption of children under the revised guidelines is unknown. The topic needs to be

researched in order to determine if children are meeting their nutritional needs.

Purpose of the Study

The purpose of this study was to examine fruit and vegetable purchasing habits and

consumption in middle school students in Red Wing, Minnesota under the revised National

School Lunch Program guidelines and also examine if the school is complying with the

guidelines. More specifically, the goal of this research was to determine if students are

purchasing more fruits or more vegetables and also to determine which specific fruits and

vegetables they are purchasing most frequently. Higher fruit and vegetable intakes are

associated with better overall health and decreased rates of obesity (CDC, 2013a). However, just

because a child purchases a fruit or vegetable at lunch does not mean that they will eat it. The

study also attempted to determine the number of servings of fruits and vegetables that students

are actually eating in comparison to what they are throwing away each day.

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Research Objectives

The objectives of this study were to determine the purchases and consumption of fruit

and vegetables since the implementation of the updated National School Lunch Program

guidelines in comparison to the number of servings purchased under the previous guidelines in

2012. Trays were observed prior to disposing of waste to determine the proportion of servings of

fruits and vegetables that are consumed and how many are disposed of each day. The servings of

fruits and vegetables disposed of between boys and girls was compared for gender differences

and the differences between each grade was also examined. The servings of fruits and

vegetables purchased was compared to determine if students are purchasing more fruits or more

vegetables. More specifically, the types of fruits and vegetables being purchased most frequently

was determined.

Definition of Terms

The following terms are defined for clarification:

Body Mass Index (BMI). “A measure used to determine childhood overweight and

obesity calculated using a child’s weight and height. BMI does not measure body fat directly,

but it is a reasonable indicator of body fatness for most children and teens” (CDC, 2013a, para.

1).

National school lunch program. “Federally assisted meal program operating in public,

private, and non-profit schools and child care institutions to provide nutritionally balanced, low-

cost or free lunches to children each day” (USDA, 2012b, para. 1).

Overweight. “A BMI at or above the 85th percentile and lower than the 95th percentile

for children of the same age and sex” (CDC, 2013a, para. 3).

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Obesity. “A BMI at or above the 95th percentile for children of the same age and sex”

(CDC, 2013a, para. 3).

Assumptions of the Study

There were a number of assumptions that this study was based on. First, it was assumed

that each student threw away their own food and that they did not share their food with another

student. Secondly, the difference between the school food production records’ number of

portions prepared and the leftover list was assumed to provide an accurate percentage of the

number of portions of fruits and vegetables purchased by the students. Thirdly, it was assumed

that the children participating did not consume more or less fruits and vegetables because they

knew that their intake was going to be observed. Lastly, the servings of fruits and vegetables

thrown away on the days observed was assumed to be comparable to the amount of fruit and

vegetable waste on any given day.

Methodology

After the approval of this study from the Institutional Review Board at UW-Stout, the

study was conducted in April, 2013. A letter was sent home to parents informing them of the

study and since there was no communication with students during this study, implied consent

was given. A random sample of students in fifth, sixth and seventh grade were observed for two

days during the lunch period. The servings of fruits and vegetables purchased and consumed

were recorded. Food production lists were provided by the school and the servings of fruit and

vegetables purchased during one month in 2012 and 2013 were calculated. Statistical analysis

was computed using Statistical Program for Social Sciences, version 21.0.

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Chapter II: Literature Review

This chapter will examine pertinent literature necessary for this study. The chapter will

review the current guidelines of the National School Lunch Program followed by the incentives

for schools to participate in the program. Next, typical fruit and vegetable consumption patterns

will be discussed along with the negative consequences of inadequate fruit and vegetable

consumption. Then, possible factors affecting intake of fruits and vegetables in schools will be

reviewed. Lastly, the chapter will conclude with literature on the comparison of fruit and

vegetable intakes between boys and girls.

The National School Lunch Program Guidelines

In 2010, The Healthy, Hunger-Free Kids Act directed the USDA to update the school

nutrition standards to align with the updated Dietary Guidelines for Americans and help improve

children’s diets in an attempt to reduce rates of childhood obesity (USDA, 2012b & 2012c). The

recent guidelines have had several ramifications to the previous standards.

Food groups. The revised guidelines, which went into effect for the 2012-2013 school

year, made changes to each of the school lunch components to align with the dietary guidelines.

The revised guidelines increased the amount of fruits, vegetables and whole grains which are

offered on the menu (USDA, 2012b). Milk requirements were also changed to offer only fat-free

or low-fat milk. Age-appropriate calorie intakes were also set with the new guidelines and a new

requirement was set for trans-fats to have zero grams of trans-fat per serving. Although the

School Lunch Program does have rigorous standards, there is some flexibility in the menu

development. School lunches participating in the National School Lunch Program must meet the

Federal requirements in order to be reimbursed but ultimately what specific foods they serve and

how those foods are prepared is up to the school to decide (USDA, 2012b).

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To further align with the dietary guidelines, the servings of fruits and vegetables children

must purchase increased from the previous guidelines that required offering ½ to ¾ cup of fruit

and vegetables combined each day (USDA, 2012a). Under the revised National School Lunch

Program Meal Pattern schools must offer between ¾ to 1 cup of vegetables and ½ to 1 cup of

fruit each day and children must select at minimum one serving of fruits and/or vegetables.

Previously there were no set requirements for the five vegetable subgroups. Now each week

participating schools must offer vegetables within each of the subgroups which include: dark

green, red/orange, beans/peas, starchy, and other vegetables as defined in the 2010 Dietary

Guidelines (USDA, 2012b). A variety of fruits can be served to students participating in the

National School Lunch Program. Fruits offered can be fresh, canned in fruit juice, water or light

syrup, frozen without sugar added or dried (USDA, 2012b). One-hundred percent (100%) fruit

juice can be offered to students as well; however, no more than 50% of the fruit components

offered on that day can be juice (USDA, 2012b).

Other meal components to the National School Lunch Program are broken down by

specific age groups. The requirements for meat/meat alternative servings offered changed from a

minimum 1.5. to 2 ounces (oz) offered to include both daily minimum and weekly amounts

being offered based on age group (USDA, 2012a). The kindergarten through fifth grade

requirement is to offer a 1 ounce minimum of meat each day, with 8-10 ounces total offered per

week. The requirement for sixth grade to eighth grade is also a 1 ounce total minimum, with 9-10

ounces total offered each week and students in grades nine through twelve must have 2 ounces

minimum each day, with 10-12 ounces total offered each week. Previously the requirements for

grains was to include 8 total servings per week with a minimum of 1 serving per day and has

changed to a 1 ounce minimum each day with 8-9 ounces total each week. Sixth to eighth grades

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also have a 1 ounce total grain minimum each day and offer 8-10 ounces total each week.

Students in grades nine through twelve have 2 ounce minimum servings offered each day, with

10-12 ounces total offered each week. A requirement for whole grains has been incorporated in

to the National School Lunch Program as well. Previously, grains served in the National School

Lunch Program were simply encouraged to be whole grains, now at least half of the grains

offered must be whole grain. In the past, 1 cup servings of any type of milk was allowed to be

offered, and there were no flavor restrictions; however, the revised guidelines include either

flavored or unflavored fat-free milk or unflavored 1% milk (USDA, 2012a).

Consumption. The National School Lunch Program standards do not require children to

consume all of the food on their lunch tray. One potential downfall to the National School

Lunch Program guidelines is that it assumes that all of the foods served to students are consumed

and if the children are throwing away foods they might not be meeting their recommended

nutrient needs (Cohen et al., 2013). In an effort to reduce waste, the “offer vs. serve” component

was added to the school lunch program which allows students to select their meal components

rather than to be required to take everything that is offered. However, children are not

benefitting when the food is thrown away. Research by Cohen et al. (2013), determined that

children in grades 6-8 participating in the National School Lunch Program discarded almost all

of the vegetables purchased and half of their fruits.

Recommended daily intakes. Other than meeting the recommended intakes for the food

groups, participating schools must provide one-third of the recommended dietary allowances for

protein, calcium, iron, and vitamins A and C for lunches over a one week period (USDA, 2012c).

The nutrient allowances; however, only benefit students when they consume the food that they

purchase. Cohen et al. (2013), determined that although the iron, calcium, vitamin A and

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vitamin C levels for the food offered on the menu exceeded the amount necessary to be served

each week, the actual consumption of those nutrients fell well below ⅓ of the recommended

daily allowances due to the high percentage of fruit and vegetable waste. When children do not

consume adequate fruits and vegetables they are missing out on key nutrients for proper growth

and development.

Benefits. There are financial benefits for schools who participate in the National School

Lunch Program. The National School Lunch Program provides money to assist schools in

serving healthy lunches (USDA, 2013a). In order for schools to be reimbursed they must meet

the program requirements. Schools participating in the National School Lunch Program must

keep production and menu records which include the food components and quantities served

(United States Government Printing Office, n.d.). The forms are then sent into the state on a

regular basis to ensure the guidelines are being met. There are different rates of reimbursement

depending on if the student is on free lunch, reduced-price or paid lunch. The reimbursement for

students receiving free lunches is the highest rate at $2.86, whereas $2.46 is given for every

reduced-price lunch and schools receive $0.27 for every paid lunch (USDA, 2012b). Other

incentives are also provided outside of the cash reimbursement. Schools participating in the

National School Lunch Program also receive commodity foods from the USDA (USDA, 2012b).

Fruit and Vegetable Consumption in Children

Unfortunately, children today are not consuming enough fruits or vegetables. The

recommended intake in 9-13 year old children for fruits is 1½ cups per day (USDA, n.d.). The

requirement for vegetables differs between boys and girls. The recommended intake for

vegetables is 2 cups per day for girls, while it is 2½ cups per day for boys. The intake of fruits

and vegetables in schools is heavily researched. Research by Kubik, Lytle, Hannan, Perry and

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Story (2003), determined that for every 100 school lunches served to children, on average 49

servings of fruit are purchased and 30 servings of vegetables. Therefore, there is room for

improvement of fruit and vegetable consumption in children. This study; however, was done

prior to the implementation of the modified guidelines where children are required to purchase at

least one serving of fruit or a vegetable.

Not only are children not consuming enough fruits and vegetables, they are not selecting,

nutritionally, the best choices. Data from 2003-2004 National Health and Nutrition Examination

Survey examines two-day, 24-hour recalls from American adolescents (Kimmons, Gillespie,

Seymour, Serdula, & Blanck, 2009). Only 6.2% of adolescents were found to consume adequate

amounts of fruit, while 8% were consuming adequate vegetables. The median fruit intake was ½

cup per day and the median vegetable intake was 1¼ cups of vegetables. Of the vegetables

consumed, the majority were fried potatoes and tomato products. When removing fried potatoes

from vegetable intake, the median decreased by more than 50%. Therefore, adolescents are not

selecting the most nutrient dense vegetables. Dark green and orange vegetables have been found

to be only 8% of vegetables consumed by children ages 2-19 (Lorson, Melgar-Quinonez, &

Taylor, 2009). The highest percentage of fruits consumed was found to be 100% orange juice,

apples, apple juice and bananas (Lorson et al., 2009). Therefore, although adolescents are

consuming fruits and vegetables, most are not meeting the daily recommended intakes for their

age group and are not consuming the most nutrient dense foods.

Fruit and vegetable consumption decreases as children become adolescents. Fruit and

vegetable consumption declines starting in middle-childhood into early-adolescence and then

continues to decline throughout adolescence (Lytle, Seifert, Greenstein, & McGovern, 2000).

Research by Lytle et al., (2000) found that fruit consumption decreased from 41% between the

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third grade and eighth grade while vegetable consumption decreased by 25%. During the

adolescent period, fruit and vegetable consumption has been found to decrease further.

Adolescents have been found to decrease their intake of fruits by an average of 0.7 servings from

early to middle adolescence and decrease again by 0.6 servings from middle to late adolescence

(Larson, Neumark-Sztainer, Hannan, & Story, 2007). These data indicate that there is room for

improvement in adolescent fruit and vegetable consumption.

Consequences from Inadequate Fruit and Vegetable Intake in Children

Consuming adequate amounts of fruits and vegetables has proven to have many positive

health benefits for children such as healthy growth and body development (Geller &

Dzewaltowski, 2009). Children who eat a healthy diet are also at a decreased risk of developing

vitamin and mineral deficiencies. They are also more likely to consume less fat and sugar, which

may in turn help with the prevention of obesity. However, when children are not consuming

enough fruits and vegetables they are at risk for several health problems. Improving fruit and

vegetable intake can have a positive impact on reducing rates of obesity (Let’s Move!, n.d.). In

children (6-11 years), the obesity rates more than doubled over the past 20 years and in

adolescents (12-19 years), the obesity rates have tripled. Today, nearly one in three children in

the United States is either overweight or obese (Let’s Move!, n.d.). This increase in obesity rates

is a cause of concern as being obese can have several negative health and psychosocial

consequences.

Health consequences. Childhood obesity can have life-long effects and can ultimately

lead to a shorter life. Today’s children have a shorter life expectancy than their parents (Daniels,

2006). The decrease in life expectancy is due to several consequences of being overweight or

obese. Cardiovascular disease can begin to develop in childhood and is influenced by several

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genetic and modifiable risk factors such as being obese (Raj, 2012). Obesity in childhood is one

of the highest predictors of developing heart disease as an adult. Being obese also puts a child at

a higher risk of developing hypertension (high blood pressure) (Urrutia-Rojas et al., 2006).

Although rates of hypertension are lower in children then adults, children are not immune from

high blood pressure. Urrutia-Rojas et al. examined 1066 school children in Texas between the

ages of 8-13 for high blood pressure. In the study, 21% of the participants were found to have

hypertension. The likelihood of having high blood pressure was found to be three times higher

among the overweight and obese children in comparison to those of a healthy weight (Urrutia-

Rojas et al., 2006). Other than hypertension, obese children are at risk for several other

preventable diseases due to their weight.

As the rates of childhood obesity continue to climb, so do the rates of type 2 diabetes in

children and adolescents in the United States. There is a strong correlation between childhood

obesity and development of insulin resistance in adolescents (Steinberger, Moran, Hong, Jacobs,

& Sinaiko, 2001). In a study by Sinha et al. (2002), 165 obese children and adolescents took part

in a two hour oral glucose tolerance test. Impaired glucose tolerance was noted in 25% of the 55

obese children and 21% of the 112 obese adolescents. Another study in 13 year old children

determined that childhood BMI is inversely correlated with glucose utilization (Steinberger et al.,

2001). Being overweight and obese puts a child at risk for development of insulin resistance

which in turn can develop into type 2 diabetes.

Psychosocial consequences. Besides the physical problems associated with being obese,

children also can suffer emotionally from low self-esteem. In research from Latner and Stunkard

(2003), fifth and sixth graders evaluated drawings of healthy-weight, children with disabilities

and obese child in order to determine how they liked each child. The picture of the obese child

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was consistently ranked lowest out of all of the pictures examined. Children were biased

towards pictures of other children just because they were obese. Self-esteem has been reported

to be lower in obese children (Latner & Shunkard, 2003). One thousand one hundred and fifty-

seven (1157) children between the ages of 5-10 had height and weight recorded and also

completed a child health questionnaire and then completed the same assessment three years later.

Overweight and obese children were found to have lower self-esteem scores in comparison to

healthy-weight children at both points in the study; however, a lower self-esteem was found in

obese children at the three year follow-up (Latner & Stunkard, 2003). Low self-esteem is

another potential consequence of being an obese child.

Determinants of Children’s Fruit and Vegetable Intake at School

There are a variety of factors that determine whether children purchase and consume fruit

and vegetables at school. It is important children develop healthy eating habits which include

adequate fruit and vegetable intake at a young age as these habits can in turn carry over into

adulthood. Improving fruit and vegetable consumption in children may help to reduce the risk of

chronic disease later on in life (Blanchette & Brug, 2005). Both environmental and behavioral

factors are believed to play a role in the consumption of fruits and vegetables. Environmental

factors such as availability and accessibility, parental consumption, peer influences,

advertisements on television, and access to school snack bars may all play a role (Blanchette &

Brug, 2005). Personal factors such as taste preferences, outcome expectations, self-efficacy and

knowledge of the fruits and vegetables can determine whether or not a child chooses to eat fruits

and vegetables. Several factors can play a role in whether or not a child chooses to eat fruits and

vegetables.

23

A la carte services. The components of a school cafeteria can also impact the

consumption of fruits and vegetables in children. According to Kubik et al. (2003), in schools

that offer a la carte programs, the majority of the foods offered and sold were both considered

foods to limit, including high-fat snacks and sweetened drinks. In comparison to schools that do

offer a la carte services, students not exposed to a la carte programs consumed on average one

more serving of fruits and vegetables at school each (Kubik et al., 2003). In addition to offering

a la carte services in schools, other factors in the school cafeteria can impact fruit and vegetable

intakes.

Vending machines. Snack vending machines in schools have also been found to

negatively impact fruit and vegetable consumption in children (Kubik et al., 2003). Differences

were noted; however, between snack and drink vending machines. Each snack vending machine

available correlated with a decrease in the average fruit and vegetable consumption in seventh

graders by 11%. Beverage-only vending machines on the other hand were not found to correlate

fruit and vegetable consumption (Kubik et al., 2003). These data suggest that the presence of

snack vending machines in school cafeterias correlates with lower fruit and vegetable

consumption in children.

Salad bar. Another factor in the school cafeteria that can influence children’s fruit and

vegetable consumption is the presence of a salad bar. Fruit and vegetable consumption of

elementary-school children in three schools was evaluated for one week both before and after

implementing a salad bar at school (Slusser, Cumberland, Browdy, Lange, & Neumann, 2006).

The salad bars contained at least four different fruit and vegetable choices each day. Fruit and

vegetable consumption increased significantly in the school-age children after the

implementation of a salad bar. Both boys and girls consumed the salad bar; however, a higher

24

percentage of girls reported to eat from the salad bar more frequently than the boys (Slusser et

al., 2006). The presence of a salad bar in the school cafeteria can have a positive impact on the

amount of fruits and vegetables that children are consuming.

Time. Time constraints can also impact the fruit and vegetable consumption patterns of

children in schools. A portion of the lunch period may be spent waiting in line for their food.

According to Sharma, Bailey-Davis and Conklin (2012), students participating in the National

School Lunch program could take between 6-15 minutes, or between 20-50% of their lunch

period going through the lunch line. Middle school students participating in the study indicated

that the amount of time spent in the lunch line plays a factor in their food choices (Sharma et al.,

2012). The time spent in line can in turn impact the food choices that students make. Due to

lack of time, children may be less likely to consume fruits and vegetables because they consume

their other food items first. Having a longer lunch period can improve a child’s food

consumption. Students given a 30 minute lunch period have been found to consume more food

and nutrients compared to those given only 20 minutes (Bergman, Buergel, Englund & Femrite,

2004). The longer lunch period was found to decrease total plate waste from 43.5% to 27.25%.

Increasing the length of lunch periods can improve the amount and nutritional quality of food

consumed.

Gender Differences in Fruit and Vegetable Consumption

Research is conflicting on whether gender influences fruit and vegetable consumption

between adolescent boys and girls. According to Bere, Brug and Klepp (2007), girls are believed

to consume more fruits and vegetables in comparison to boys. Their study consisted of

surveying adolescent children on their frequency of fruit and vegetable consumption. Girls

reported eating more servings of fruit (14.5 per week) in comparison to boys (11.9 per week).

25

One possible reason for this difference is that girls like eating fruits and vegetables more than

boys, and also girls have higher self-efficacy and knowledge of the benefits of consumption,

which play a role in their probability of eating fruits and vegetables (Bere et al., 2007). In a

study by Pedersen, Mellstrup, Holstein and Rasmussen (2012), the percentage of boys receiving

inadequate fruit and vegetables was significantly higher than that of girls. Of boys, 73.8% were

found to not consume adequate fruits compared to 61.8% of girls. The same results were found

in vegetables where, 73.2% of boys were not consuming enough vegetables and 68.0% of girls.

Contrary to the findings by Pedersen et al. (2012) and Bere et al. (2007), that girls

consume more fruits and vegetables than girls, research from the National Health and Nutrition

Examination Survey (NHANES) on fruit and vegetable consumption in children and adolescents

between the ages of 2-18 years determined that boys consumed on average 1.07 cups of fruit per

day compared to 0.98 cups per day in girls (Lorson et al., 2009). The results were found to be

comparable, however, for vegetable consumption in boys and girls. Boys reported consuming on

average 1.06 cups per day and girls consumed 1.04. Although boys were consuming more fruits

than girls, neither group was found to be consuming adequate portions of fruits and vegetables

each day (Lorson et al., 2009). Both boys and girls can both improve on their daily fruit and

vegetable intakes.

On the other hand, research by Field, Gillman, Rosner, Rocket and Colditz (2003), did

not find significant differences in fruit and vegetable consumption between adolescent boys and

girls. A self-administered food frequency questionnaire given to 7843 adolescents between the

ages of 9-14 determined that the fruit and vegetable intakes were similar between both genders

(Field et al., 2003). Both genders on average consumed less than two servings of fruit (1.9

servings per day for girls and 1.8 servings per day for boys) and almost one-half of the fruit

26

reported was found to be juice. Participants reported consuming fewer servings of vegetables

than they did of fruits. The average number of vegetables consumed per day was 1.6 servings

for girls and 1.5 servings for females (Field et al., 2003).

Food Waste in Middle Schools

Food waste impacts whether children are receiving adequate nutrition. In an attempt to

decrease food waste, the offer vs. serve provision of the National School Lunch Program allows

children to choose what they put on their lunch plate (Guthrie & Buzby, 2002). Children;

however, are required to purchase at least one serving of fruits and/or vegetables each day

(Schilling, 2012). Children can choose whether or not to consume the fruits and vegetables that

they purchase for lunch. Girls participating in the National School Lunch Program have been

found to waste more food than boys (Guthrie & Buzby, 2002). Girls on average waste 16.9% of

their lunch items purchased while boys waste approximately 9%. Fortunately, the trends of food

waste have found to decrease with age. According to Guthrie & Buzby (2002), children less than

age 11 wastes on average 14.8% of their food, children ages 11-14 waste 11.9% and children

older than 14 waste 6.5%. Cooked vegetables and lettuce salads have been found to be the

highest reported items of food wasted (Guthrie & Buzby, 2002).

Several factors are believed to influence food waste in schools. In a comparison study of

sixth graders in three middle schools in Kentucky, leftover food was collected and weighed for

20 days (Marlette, Templeton, & Panemangalore, 2005). Out of all the different fruits offered,

Applesauce was found to be the most frequent fruit consumed by 37% of participants and 23% of

applesauce was wasted. The consumption of applesauce was higher than that of fresh apples

where 23% of students consumed apples and 62% wasted the apples that they purchased.

Oranges were found to only have 8% acceptability and 54% of oranges were wasted. For the

27

vegetables, mashed potatoes and French fries had the highest acceptability for students (70% and

68% respectively) while boiled potatoes, salad greens, and green beans had the lowest

acceptability (Marlette et al., 2005).

The lunch items on a child’s tray can impact which foods a child chooses to eat. Students

who purchased competitive foods (i.e., sweet and salty snacks) wasted significantly more fruits

compared to the students who did not purchase competitive foods (Marlette et al., 2005). The

total plate waste for fruit in students who did not purchase competitive foods was 35.8%, and

those who did purchase competitive foods for lunch wasted 52.3%. Differences in vegetable

consumption were not found to be significant with the purchases of competitive foods. Twenty-

nine percent of vegetables were wasted by those who did not purchase competitive items and

31.7% of those who purchased competitive items, with lunch, wasted vegetables (Marlette et al.,

2005). The results indicate that certain fruits and vegetables have been found to have the highest

acceptability among students including applesauce, French fries and mashed potatoes. Also,

students who purchase competitive foods may be more likely to waste more fruits and

vegetables.

Differences in fruit and vegetable acceptability in middle school students has not been

found to differ significantly (Gray et al., 2002). Gray et al. examined servings of fruits and

vegetables consumed by fifth-graders in Minnesota by observing students’ trays at the end of the

lunch line and recording the specific items and number of portions taken. The number of

portions thrown away at the end of the lunch period was observed and recorded. Of the 350

students that were observed, the average number of servings taken for fruit was 0.69 and the

number of servings consumed were 0.53 servings. For vegetables, students took 0.86 servings of

vegetables and consumed 0.76 servings (Gray et al., 2002). Students in the study by Gray et al.

28

were found to purchase less than one serving of fruits and vegetables; however, they were

consuming a majority of the fruits and vegetables that they purchased.

29

Chapter III: Methodology

This chapter will contain the methodology for conducting this research. The description

of independent variables and selection of the sample will be included. Instrumentation methods,

data collection and data analysis procedures will also be discussed. The chapter will conclude

with limitations of the method, sample and procedures.

Subject Selection and Description

The population for the study was a convenient sample of students in the fifth, sixth and

seventh grades at a small rural middle school in Red Wing, Minnesota. The school food service

director and principal were contacted and informed of the study and gave permission for the

research to be conducted at the school. After receiving approval from the Institutional Review

Board (Appendix A), a letter was sent home to parents (Appendix B) informing them of the

study and allowing them to contact the investigator, adviser or IRB administrator from the

University of Wisconsin-Stout with any questions or concerns. Since the students were not

spoken to during the observations for the study, implied consent was given. On April 11 and

April 12, the investigator observed the plate trays of selected students based on the ability to

distinguish them by clothing when purchasing their lunch and disposing of waste. Total servings

of fruits and vegetables on the students’ lunch tray when exiting the lunch line and disposing of

waste were recorded. The observer attempted to alternate between male and female students as

best as possible to get an equal sample of males and females.

Instrumentation

A chart was created by the investigator (Appendix C) to record the number of portions of

fruits and vegetables purchased and then thrown away. Children were observed when exiting the

lunch line and again when throwing away food waste. The grade and gender of child were

30

recorded. The grade of the child was determined from the lunch period attending. Clothing or

other noticeable features of the child were recorded to ensure that the same child was observed

when throwing away food waste. No other identifiable features were recorded as part of the

study.

Data Collection Procedures

The food production and leftover lists were provided by the school district for February

2012 and February 2013. The total servings of fruits and vegetables purchased were determined

by calculating the difference between the two lists. On two different days, the lunches of the

fifth, sixth and seventh graders were observed to record the type and amount of fruits and

vegetables being disposed of from the selected sample of students participating in the National

School Lunch Program. The students were randomly selected when exiting the lunch line and a

description of the child’s clothing was recorded. The same students were observed again when

disposing of waste. The sample of students observed differed each day.

Data and Statistical Analysis Procedures

Statistical analysis was performed using the Statistical Program for Social Sciences

(SPSS), version 21.0. Chi-square tests were done to determine if significant differences in the

consumption of fruits and vegetables were noted between gender and grade of students.

Independent samples t-tests were done to determine if students were purchasing more fruits and

vegetables under the revised National School Lunch Program guidelines. Paired samples t-tests

were conducted to examine the servings of fruits and vegetables purchased in February, 2013,

along with the male and female servings of fruits and vegetables purchased. Analysis of

Variance (ANOVA) was conducted between the fifth, sixth and seventh graders in the number of

servings of fruits and vegetables purchased. Lastly, frequency tests were conducted for both

31

fruits and vegetables purchased to determine which specific fruits and vegetables were purchased

most frequently. A standard of p < 0.05 was used as the significance level for all of the tests

performed.

Limitations

There were several potential limitations to this research. One limitation was that the fruit

and vegetables purchased and thrown away from one day is not necessarily the typical amount

being disposed of on other days. A second limitation is that the plate waste in this study was not

weighed and was only examined on tray by the observer. A third limitation was that there was

no verbal communication with the students in this study; therefore, it is not known if there was

sharing of lunch items between students. A fourth limitation was that students who purchased

lunch from the salad bar were not observed for this study; therefore, the total number of fruits

and vegetables purchased for all students in the school is unknown, and data was only researched

on those who went through the lunch line. Another limitation would be that the observer did not

use a random sample method when selecting students.

32

Chapter IV: Results

The purpose of this research was to determine the fruit and vegetable purchases and

consumption of middle school children under the revised National School Lunch Program

guidelines in comparison to the previous guidelines and also to determine if students are eating

the fruits and vegetables that they are purchasing. The students were observed on two different

occasions to determine the amount of fruits and vegetables purchased and the amount of fruits

and vegetables thrown away was also examined. The food production and leftover lists were

also examined to calculate the total servings of fruits and vegetables purchased in February 2012

and also in February 2013. The results were calculated using SPSS software. This chapter will

include the demographic information of participants in this study along with the findings from

the research objectives in this study including:

1. Determine whether the school complied with the revised National School Lunch Program

guidelines.

2. Determine whether students were purchasing more fruits and vegetables under the

revised guidelines.

3. Determine whether the students were purchasing more fruits or more vegetables.

4. Determine which specific fruits and vegetables were purchased most frequently.

5. Determine what percentage of the fruits and vegetables students purchased were

consumed.

Demographic Information

On Thursday, April 11 and Friday, April 12, a total of 68 (n = 68) middle school students

were observed when purchasing their lunch and also while disposing of their food waste to

determine the number of servings of fruits and vegetables consumed. Thirty-eight percent of the

33

sample was fifth graders (n = 26), 26% were sixth graders (n = 18) and 36% were seventh

graders (n = 24). The sixth graders were on a field trip the second day of observation; therefore,

there were fewer sixth graders observed and the data was only collected on April 11. Fifty-one

percent of the observed students were boys and 49% were girls.

Compliance with National School Lunch Guidelines

Under the current National School Lunch Program guidelines, students are required to

purchase either one serving of fruit or one serving of vegetables, but can take a combination of

up to three servings of fruits and/or vegetables. From observation it was noted by the observer

that all 68 students participating in this study took either a serving of fruit or a serving of

vegetable which was used as an indicator of compliance.

Comparison of Fruits and Vegetables Purchased from 2012 to 2013

Independent samples t-tests were done to compare the total servings of fruits purchased

in February 2012 to February 2013 and another t-test test was done to compare the total servings

of vegetables purchased in February 2012 to February 2013. Table 1 shows the comparison of

fruits and vegetables purchased in February 2012 compared to February 2013. Table 1 shows

that students purchased on average 501.05 servings of fruit per day in 2012 and in 2013 they

purchased 613.88 servings, with a mean difference of 112.8 servings which was a 19% increase.

Although the students are purchasing more fruits in 2013 in comparison to 2012, the difference

was not noted to be significant (p = 0.08). Table 1 also shows the comparison of vegetables

purchased from 2012 to 2013. In February 2012, students were purchasing an average of 215.11

servings of vegetables per day and in February 2013 they purchased 279.77 servings, with a

mean difference of 64.66 servings which was a 23% increase. Although the students purchased

34

more vegetables in 2013 in comparison to 2012, the results were not found to be significant (p =

0.120).

Table 1

Results of Independent Sample t-test Comparing the Number of Servings of Fruits and

Vegetables Purchased in February 2012 to February 2013

** Statistically significant at a level of p < 0.05

Comparison of Servings of Fruits Purchased to Servings of Vegetables Purchased

Table 2 contains the comparison of the number of servings of fruits purchased in

February, 2013, to the number of servings of vegetables purchased in February, 2013. On

average, 557.47 servings of fruits were purchased each day and 247.44 servings of vegetables.

Table 2 shows that the middle school students were purchasing significantly more fruits

compared to vegetables (p = 0.000).

Table 2

Results of the Paired-Samples t-test Comparing the Total Number of Fruit Servings Purchased in

February 2013 to the Total Number of Vegetable Servings Purchased in February 2013

Item Mean SD t df p Servings of Fruits 557.47 131.50 9.68 35 0.000**

Servings of Vegetables 247.44 124.33


Item Year Mean SD t df p Fruits: 2012 501.05 115.45 -2.18 34 0.08**

2013 613.88 124.64

Vegetables: 2012 215.11 118.66 -1.59 34 0.120**

2013 279.77 124.64

35

Gender Comparison of Servings of Fruits and Vegetables Purchased

Table 3 shows that boys are purchasing on average 1.73 servings of fruit each day and

0.37 servings of vegetables. The results were found to be significant, as boys are purchasing

significantly more fruits compared to vegetables each day (p = 0.000). Table 3 also shows that

girls are purchasing on average 1.43 servings of fruits each day and 0.40 servings of vegetables.

The same results were found for girls, that they are purchasing significantly more fruits each day

compared to vegetables (p = 0.000). There was a mean difference of 0.30 in the servings of fruit

purchased between boys and girls; however, the difference was not found to be significant. For

the comparison of servings of vegetables purchased between the boys and girls, there was a mean

difference of 0.03 servings, which is roughly the same amount. Therefore, no significant

differences were noted for fruit and vegetable purchases between boys and girls.

Table 3

Results of the Paired-Samples t-test Comparing the Boys’ and Girls’ Total Number of Servings

of Fruits Purchased to the Total Number of Servings of Vegetables Purchased

Item Mean SD t df p

Boys: Servings of Fruits 1.73 0.77 6.94 36 0.000**


Girls: Servings of Fruits 1.43 0.65 5.54 34 0.000**



The ANOVA test determined that the differences in the number of servings of fruits (p =

0.195) and vegetables (p = 0.236) purchased between the fifth, sixth and seventh graders were

not found to be significant.

36

Table 4

Results of ANOVA Determining Grade Differences in Total Servings of Fruits and Vegetables

Purchased

Sum of Squares df Mean

Square F p

Fruits: Between Groups 1.74 2 0.87 1.67 0.195**

Within Groups 35.77 69 0.52

Total 37.50 71

Vegetables: Between Groups 0.87 2 0.43 1.48 0.236**

Within Groups 20.24 69 0.29

Total 21.11 71


Breakdown of Fruits and Vegetables Purchased

Frequency tests were done to determine the number of servings of specific fruits and

vegetables purchased in February 2013. Tables 5 and 6 display the frequency of servings of

fruits and vegetables purchased, respectively. Table 5 shows that the most frequent fruits

purchased were fruit juice, applesauce, mixed fruit, apples and mandarin oranges Table 6 shows

that the most frequent vegetables purchased were Romaine salad, waffle fries, French fries,

scalloped potatoes and tator tots.

37

Table 5

Results of Frequency Test Examining Breakdown of Fruits Purchased

Fruits Total Servings Purchased Number of Days Offered

Fruit Juice 4933 18 Applesauce 692 2 Mixed Fruit 472 3 Apple 416 9 Mandarin Oranges 409 2 Orange 405 12 Kiwi 403 5 Pineapple Tidbits 398 2 Banana 359 6 Strawberries 347 3 Fruit Slushie 335 1 Pear 294 5 Baked Apples 257 2 Apple Crisp 210 1 Peaches 200 2 Melon Chunks 184 1 Pear Slices 184 1 Tropical Fruit 176 1 Apricot 138 3 Raspberries 136 1

38

Table 6

Results of Frequency Test Examining Breakdown of Vegetables Purchased

Vegetables Total Servings Purchased Number of Days Offered

Romaine Salad 1239 9 Waffle Fries 392 1 French Fries 380 1 Scalloped Potatoes 360 1 Tator Tots 354 1 Green Beans 350 3 Carrots 342 4 Whipped Potatoes 285 1 Corn 236 2 Broccoli 232 3 Peas 146 1 Sweet Potatoes 138 2 Refried Beans 98 1 Mixed Vegetables 96 1 California Vegetables 74 1 Monte Carlo Vegetables 72 1 Summer Blend Vegetables 62 1 Calico Beans 60 1 Tomato Soup 59 1 Tomatoes 32 2 Black Beans 29 1

Servings of Fruits and Vegetables Consumed

The Chi-square analysis in Table 7 found that fruit consumption between boys and girls

was not significantly different between groups, X² (2, N = 68) = 0.235, p = .889. There were 35

boys who purchased fruits in the study. Twelve percent (n = 4) consumed no fruits, whereas 34%

(n = 12) consumed a portion of the fruit purchased and 54% (n = 19) consumed all servings of

fruit purchased. There were 33 girls in the study who purchased fruits. Nine percent (n = 3)

consumed no fruits, whereas 39% (n =13) consumed part of the fruits purchased and 52% (n

=17) consumed all servings of fruit purchased. Table 7 also shows the vegetable consumption

between boys and girls was not significantly different between groups, X² (2, N = 22) = 1.70, p =

39

.427. There were 11 boys who purchased vegetables in the study. Twenty-seven percent of the

boys (n = 3) consumed no vegetables, whereas 55% (n = 6) consumed a portion of the vegetables

purchased, and18% (n = 2) consumed all servings of vegetables purchased. There were also 11

girls who purchased vegetables in this study. Forty-six percent (n = 5) consumed no vegetables,

whereas 27% (n = 3) consumed a portion of the vegetables purchased and 27% (n = 3) consumed

all of the vegetables purchased.

Table 7

Chi-Square Distribution of the Fruit and Vegetable Consumption Separated by Gender

Gender

Item Amount Consumed Boys Girls X²

Fruit: Consumed no fruits 4 (12%) 3 (9%) 0.889**

* ** Consumed a partial serving of

fruits 12 (34%) 13 (39%)

Consumed all fruits 19 (54%) 17 (52%)

Total 35 33

Vegetable: Consumed no vegetables 3 (27%) 5 (46%) 0.427**

Consumed a partial serving of vegetables

6 (55%) 3 (27%)

Consumed all vegetables 2 (18%) 3 (27%)

Total 11 11


40

Table 8 shows the fruit consumption between the fifth, sixth and seventh graders was

significantly different between groups, X² (4, N = 68) = 16.86, p = .002. There were 26 fifth

graders in the study who purchased fruits. Twelve percent (n = 3) consumed no fruits, whereas

23% (n = 6) consumed part of the fruits purchased and 65% (n = 17) consumed all servings of

fruit purchased. Eighteen sixth graders purchased fruits in this study. Twenty-two percent (n =

4) consumed no fruits, whereas 17% (n = 3) consumed part of the fruits purchased and 61% (n =

11) consumed all servings of fruit purchased. Twenty-four seventh graders purchased fruits in

this study. All seventh graders consumed at least a portion of their fruits. Sixty-seven percent (n

= 16) consumed part of the fruits purchased and 33% (n = 8) consumed all servings of fruits

purchased.

Table 8 also shows the vegetable consumption between the fifth, sixth and seventh

graders was not significantly different between groups, X² (4, N = 22) = 3.009, p = .556. There

were ten fifth graders in this study who purchased vegetables. Forty percent (n = 4) consumed no

vegetables, whereas 30% (n = 3) consumed part of the vegetables purchased and 30% (n = 3)

consumed all servings of vegetables purchased. Three sixth graders purchased vegetables. Sixty

seven percent (n = 2) consumed no vegetables, whereas 33% (n = 1) consumed part of the

vegetables purchased and none of the students (n = 0) consumed all servings of vegetables

purchased. There were nine seventh graders in the study who purchased vegetables. Twenty-two

percent (n = 2) consumed no vegetables, whereas 56% (n = 5) consumed part of the vegetables

purchased and 22% (n = 2) consumed all servings of vegetables purchased.

41

Table 8

Chi-Square Distribution of the Fruit and Vegetable Consumption Separated by Grade

Grade

Item Amount Consumed 5th 6th 7th X²

Fruits: Consumed no fruits 3 (12%) 4 (22%) 0 (0%) 0.02**

Consumed a partial serving of fruits

6 (23%) 3 (17%) 16 (67%)

Consumed all fruits 17 (65%) 11 (61%) 8 (33%)

Total 26 18 24

Vegetables: Consumed no vegetables 4 (40%) 2 (67%) 2 (22%) .556**

Consumed a partial serving of vegetables

3 (30%) 1 (33%) 5 (56%)

Consumed all vegetables 3 (30%) 0 (0%) 2 (22%)

Total 10 3 9


42

Chapter V: Discussion

The study was conducted to determine the fruit and vegetable purchasing and

consumption patterns of rural middle school students participating in the National School Lunch

Program. This chapter will provide a thorough discussion of the study. The chapter will begin

with potential limitations to this study. This chapter will also include a discussion of the results

and conclusions drawn from the data. Lastly, the chapter will be concluded with

recommendations for future research.

Limitations

There are several limitations in this research. The first limitation is the lack of

knowledge on the fruit and vegetable consumption of children in the National School Lunch

Program due to the recent transition to the new guidelines across the United States. Another

limitation was that not all students participating in the lunch program were observed; therefore,

the data from this study may not be an accurate depiction of actual plate waste. The sample of

this study included only one school and therefore the results may not be representative of other

populations. Also, there were only two days of observation in this study which may not be

representative of typical fruit and vegetable practices. Another limitation is the small sample size

of this study (n = 68) and the students were not randomly selected. The number of servings of

fruits and vegetables purchased from the food production summaries was calculated by

determining the difference between the number of portions made and the number of portions

leftover; therefore, there may be some error in recording and calculating the number of servings

purchased and was a limitation in this study.

43

Conclusions

There are several conclusions that can be drawn from this study. The conclusions will be

broken down based on the objective questions including: compliance with the National School

Lunch Program Guidelines, comparison of fruit and vegetable purchases from 2012 to 2013,

breakdown of specific fruits and vegetables purchased along with grade and gender differences

in fruit and vegetable consumption.

Compliance with National School Lunch Program guidelines. There are several

incentives for schools that participate and abide by the rules of the National School Lunch

Program. Schools keep track of the quantity of portions for each item that are purchased and

those records are sent in to the state to verify (United States Government Printing Office, n.d.)

and schools are reimbursed accordingly depending on if the student pays full price or if they

receive reduced-price or free-lunch (CDC, 2012b). Under the revised guidelines, students must

purchase either a serving of fruit or a serving of vegetables each day, but they can take up to

three servings of fruits and vegetables combined. From, observation it was determined the

middle school was found to comply with the standards as all students participating in the study

had either a fruit or a vegetable on their lunch tray. However, only two days were observed and

those days may not be representative of typical days.

Fruit and vegetable consumption from 2012 to 2013. In an attempt to improve fruit

and vegetable consumption in children and reduce rates of obesity, the National School Lunch

Program made fruits and vegetables separate lunch components (USDA, 2012c). Prior to

implementation of the new guidelines, fruits and vegetables were considered one component of

the National School Lunch Program (Schilling, 2012). Now, students must take either a serving

of fruit or a serving of vegetables each day with their lunch. This research examined if students

44

were taking more servings of fruits and vegetables in 2013, under the revised guidelines, in

comparison to in 2012. The results indicate that on average 112.8 more servings of fruits and

64.66 more servings of vegetables were purchased in February 2013 in comparison to February

2012; however, the difference was not noted to be significant. Previous research by Kubik et al.

(2003), determined that under the previous school lunch guidelines, not every student was

purchasing a fruit or a vegetable. Therefore, although students were not found to purchase

significantly more fruits and vegetables under the revised guidelines, there has been an increase

in fruit and vegetable purchases.

Comparison of servings of fruit purchased to servings of vegetables purchased.

Differences in the number of total servings of fruits and vegetables purchased in 2013 were

compared and the results indicate that significantly more fruits were purchased compared to

vegetables. The school was found to purchase on average, over 300 more servings of fruit per

day compared to vegetables. The average number of servings of fruit and vegetables purchased

for each student was 1.73 servings of fruit and 0.37 servings of vegetables for boys and 1.43

servings of fruit and 0.40 servings of vegetables for girls. The results were roughly equal for the

purchases of fruits and vegetables by gender and no significant difference was noted.

In comparison to other research, the students in this study took more servings of fruit but

comparable number of servings of vegetables. Research by Gray et al. (2002), determined that

middle school students participating in the National School Lunch Program took 0.69 servings of

fruit and 0.86 servings of vegetables. The students in this study took about one more serving of

fruits in comparison to the study by Gray et al. (2002), and almost ½ servings fewer of

vegetables. The difference in findings may be due to the fact that the study by Gray et al. was

done prior to the implementation of the revised guidelines.

45

Specific fruits and vegetables most commonly purchased. The five most frequently

purchased fruits in this study were found to be fruit juice, applesauce, mixed fruit, apples and

mandarin oranges. Fruit juice was offered each day of the month, applesauce was served on two

days, mixed fruit on three days, apples on nine days and mandarin oranges on two days. There

were 7948 total servings of fruit purchased for the month of February 2013. The type of fruit

appeared to play a role in the frequency of purchase. Although fruit was offered on every day of

the month, 62% of the total servings of fruit purchased were fruit juice, indicating a high

preference for fruit juice. Thirty-one percent of the servings of fruits purchased in this study were

canned fruits. These data suggest that students have a high preference for fruit juice and canned

fruit.

Although students were purchasing on average almost 1½ servings of fruit, which

exceeds the minimum purchase required of one serving, the majority of fruits consumed were

found to be in the form of fruit juice. Fruit juices have energy densities similar to sugar-

sweetened beverages and may contribute to excess caloric intake and weight gain (Monsivais &

Rehm, 2012). Currently fruit juice is able to be offered each day; however no more than 50% of

the fruit components offered on that day can be juice (USDA, 2012b). Perhaps limiting the days

that fruit juice is served could reduce intake of excess calories in children

The five most frequent vegetables were Romaine salad, waffle fries, French fries,

scalloped potatoes and tator tots. Out of the most frequent vegetables purchased, Romaine salad

was offered on nine days, and the French fries, waffle fries, scalloped potatoes and tator tots

were each only offered on one day of the month. Out of the 5036 total servings of vegetables

purchased in February 2013, almost 38% (n = 1909) were potato products. Another 25% (n =

1239) servings of the vegetables purchased were Romaine salad. The results indicate the students

46

have a high preference for potato products as they were popular items on the days that they were

served. Middle school students were also found to have a high preference for Romaine salad.

These results are comparable to other studies in adolescent children’s fruit and vegetable

intake. In a study by Lorson et al. (2009), which examined the consumption patterns of fruits

and vegetables in adolescents the highest percentage of vegetables consumed were fried potatoes

and the highest vegetables were 100% juice, apples and bananas. The results indicate a need to

promote consumption of fresh fruits and vegetables in adolescent children.

Grade and gender differences in fruit and vegetable consumption. Although the

research on the comparison of fruit and vegetable intake between boys and girls is conflicting,

the results of this study are comparable to other research articles where no significant differences

in consumption were noted. Research by Field et al. (2003), determined that adolescents

between the ages of 9-14 were consuming less than two servings of fruit (1.9 servings per day for

girls and 1.8 servings per day for boys). The average intake of vegetables was found to be 1.6

servings per day for girls and 1.5 servings for boys. The children in this study were found to

consume fewer servings of vegetables in comparison to the study by Field et al. However, Field

et al. determined the total daily fruit and vegetable intake for children and in this study the fruit

and vegetable consumption was only recorded for one meal; however, the results were similar

due to the fact that no significant differences were noted between boys and girls.

Fruit and vegetable consumption has been found to decrease as children get older (Lytle,

Seifert, Greenstein & McGovern, 2000). Research by Lytle et al. (2000), determined that fruit

consumption decreased by 41% between the third grade and eighth grade while vegetable

consumption decreased by 25%. In this study, no significant differences were noted in vegetable

consumption between the fifth, sixth and seventh graders; however, significant differences were

47

noted in fruit consumption. A majority of the seventh graders were found to only consume a

portion of the fruit purchased; whereas a majority of the students in fifth and sixth grade

consumed all of their fruit purchased. The results of the fruit consumption in this study trend

towards the results of Lytle et al. (2000), where fruit consumption was found to decrease as

children get older. The results indicate a need for nutrition education on the importance of fruit

and vegetable consumption to adolescent children.

Although there were not significant differences noted in the number of servings of fruits

and vegetables purchased between the fifth, sixth and seventh graders, significant differences

were noted in fruit consumption between the fifth, sixth and seventh graders with a majority of

seventh graders only consuming a partial serving of the fruits purchased. Therefore, a high

percentage of seventh graders were wasting a portion of the fruits that they purchased. Another

possible revision to the National School Lunch Program Guidelines would be to have minimum

weekly ranges servings of fruits and vegetables offered, with higher ranges for older children in

an attempt to improve fruit and vegetable consumption.

A positive finding of the study was that middle school students were found to consume a

majority of the fruits and vegetables that they purchased. However, fruits were found to be

purchased more frequently than vegetables; therefore, another possible revision to the National

School Lunch Program would be to require students to take both a serving of fruit and a serving

of vegetables each day. As the data from this study indicates, when children have a choice

between a fruit and a vegetable, a majority of students select a fruit.

48

Recommendations

Consumption of fresh fruits and vegetables should be encouraged in the adolescent

population. The students in the study were not consuming all of the fruits and vegetable

purchased; therefore, there is room for improving intakes. Inadequate fruit and vegetable

consumption also increases the likelihood that a child is deficient in essential nutrients (Lorson et

al., 2009). Nutrient dense vegetables should be promoted more than fruits as this sample was

found to consume fewer servings of vegetables compared to fruits. In particular, vegetables from

the dark green, red and orange, beans and peas, and other vegetable category should be promoted

in children as the most frequent vegetables consumed were starchy vegetables.

Efforts should be focused on encouraging nutrient dense fresh fruits and vegetables as

this study found adolescents were not meeting their nutritional needs. Eating nutrient dense fruits

and vegetables including leafy green and yellow/orange vegetables and citrus fruits can decrease

risk for multiple diseases (Lorson et al. 2009). Examining methods for increasing fruit and

vegetable intake is important as it can reduce rates of obesity and chronic disease. Although

students were found to consume fruits and vegetables, they are not the most nutrient dense

choices. Research on how to increase nutrient dense fruits and vegetables in the adolescent

population should be examined.

Barriers in adolescent fruit and vegetable consumption need to be examined to determine

possible strategies to increase consumption. Currently, students are not meeting their nutrient

needs due to inadequate fruit and vegetable consumption. It will be important for future studies

should include a larger sample and a broader age range of students to determine differences in

fruit and vegetable consumption between different age groups. The current study was also done

in a rural area with a high Caucasian sample, and future research should include larger schools

49

and other populations to gain more diversity. It would be helpful for future research to use a

random sample to weigh the plate waste of students rather than rely on observation. Talking to

the participants in the study would aid in knowing the children’s perception on their fruit and

vegetable intake. Nutrition education programs in schools should develop strategies to promote

fresh fruit and vegetable consumption as it could have a positive effect on intakes. Future

research of the National School Lunch Program may help determine the benefits to the program

on improving children’s diets and decreasing rates of obesity across the United States.

50

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Appendix A: UW- Stout IRB Approval February 7, 2013 Alyssa Weinrich Food & Nutrition UW-Stout RE: “Impact of new school lunch guidelines on improving fruit and vegetable consumption in children” Dear Alyssa, In accordance with Federal Regulations, your project, “Impact of new school lunch guidelines on improving fruit and vegetable consumption in children” was reviewed on 2/6/2013, by a member of the Institutional Review Board and was approved under Expedited Review through 2/5/2014. If your project involves administration of a survey or interview, please copy and paste the following message to the top of your survey/interview form before dissemination: If you are conducting an online survey/interview, please copy and paste the following message to the top of the form: “This research has been approved by the UW-Stout IRB as required by the Code of Federal regulations Title 45 Part 46.” Responsibilities for Principal Investigators of IRB-approved research:

1. No subjects may be involved in any study procedure prior to the IRB approval date or after the expiration date. (Principal Investigators and Sponsors are responsible for initiating Continuing Review proceedings.)

2. All unanticipated or serious adverse events must be reported to the IRB. 3. All protocol modifications must be IRB approved prior to implementation, unless they

are intended to reduce risk. 4. All protocol deviations must be reported to the IRB. 5. All recruitment materials and methods must be approved by the IRB prior to being used. 6. Federal regulations require IRB review of ongoing projects on an annual basis.

Thank you for your cooperation with the IRB and best wishes with your project. Should you have any questions regarding this letter or need further assistance, please contact the IRB office at 715-232-1126 or email [email protected]. Sincerely,

Susan Foxwell Research Administrator and Human Protections Administrator, UW-Stout Institutional Review Board for the Protection of Human Subjects in Research (IRB)

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Appendix B: Informational Letter to Parents

Dear Parents, My name is Alyssa Weinrich and I am a graduate student at the University of Wisconsin-Stout in the Human Nutritional Sciences Program. For my thesis project, I am examining the Impact of National School Lunch Program on Improving Fruit and Vegetable Consumption in Children. If your child participates in the National School Lunch Program at school, your child’s tray may be examined prior to throwing away waste to determine the number of servings of fruits and vegetables that they are disposing of. A benefit from this study is that the Red Wing School District will have data on the fruit and vegetable consumption of students. Your child’s name will not be included on any documents. We do not believe that he/she will be identified from any of the information collected. Thank you for your time. The study has been reviewed and approved by the University of Wisconsin-Stout’s Institutional Review Board (IRB). The IRB has determined that this study meets the ethical obligations required by federal law and University policies. If you have any questions or concerns regarding this study, please contact the Investigator or Advisor. If you have any questions, concerns, or reports regarding your child’s rights as a research subject, please contact the IRB Administrator. Investigator: Alyssa Weinrich, [email protected] Advisor: Ms. Karen Ostenso, MS, RD, CD, (715) 232-2394, [email protected] IRB Administrator: Sue Foxwell, Research Services

152 Vocational Rehabilitation Bldg. UW-Stout Menomonie, WI 54751 (715) 232-2477 [email protected]

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Appendix C: Data Collection Chart

Grade Gender Clothing Description Fruits and Vegetables Purchased

Fruits and Vegetables

Thrown away

Documents

Fruit and Vegetable Consumption of Rural Middle School