GEM No. 499Strategies to Promote High School Students’ HealthfulFood ChoicesAli Bukhari, MS1; Lynn Fredericks, BA2; Judith Wylie-Rosett, EdD, RD3

INTRODUCTION

The purpose of this study was to eval-uate the efficacy of a nutrition educa-tion curriculum that was developed toinspire new, more healthful dietaryhabits among adolescents, in orderto address the growing public healthproblem of overweight in youth. Pre-vious garden-based interventions im-proved attitudes or behaviors relatedto increased fruit and vegetable intakein pre-adolescent student popula-tions.1-3 In the present garden-to-table curriculum pilot, the authorsfocus on improving adolescent die-tary behavior and attitudes towardhealthful food choices by promotingcooking with fresh ingredients andenjoying meals with friends andfamily.

PROGRAM DESIGN,SETTING, ANDTHEORETICALFRAMEWORK

The Diet for a Healthy Planet withTeen Battle Chefs curriculum wasbased on Social Cognitive Theory4

and the social ecological model,5

both of which emphasize how behav-ior, personal factors, and environ-mental influences interact.6

FamilyCook Productions developeda daily, 19-week, ninth-grade curricu-lum to address nutrition-related atti-tudinal and behavior changes. Thecurriculum addresses New York state

1Institute of Human Nutrition, Columbia Univ2FamilyCook Productions, New York, NY3Department of Epidemiology and Population HBronx, NYAddress for correspondence: Lynn Fredericks43rd St, Suite 704, New York, NY 10017familycookproductions.comJ Nutr Educ Behav. 2011;43:414-418�2011 SOCIETY FOR NUTRITION EDUCdoi:10.1016/j.jneb.2011.01.008

414

educational standards for high schooland intermediate school. State Learn-ing Standards addressed for interme-diate school are Youth Development;Nutrition; Skills Empowerment; Ca-reer Exploration; Life Skills; Life &Environmental Science; Cultural Tol-erance. For high school, they are thesame as above, plus Food Systems;Civic Empowerment.7

Details of curriculum themes andcourse activities can be found in theTable. The program aims to buildhigh school students’ skills related tocooking and growing food while pre-senting opportunities for students togain insight into food productionand marketing, as well as how envi-ronmental and personal factors cancreate barriers to or opportunities forgood nutrition. The present interven-tion strategies included: skill develop-ment, experiential learning activities(eg, photovoice,8 video, neighbor-hood food assessments) and personalnutrition challenges (students’ reflec-tive diaries of changes made andhow the changes affected theirmood). FamilyCook trains classroomteachers to teach the program to en-hance its sustainability potential.

The authors applied Social Cogni-tive Theory in the curriculum design(Table). In-class activities—classroomlecture, inquiry-based problem-solving activities, and weekly develop-ment of gardening and/or cookingskills—are designed to increase stu-dents’ knowledge, build skills, andraise students’ self-efficacy for prepar-

ersity, New York, NY

ealth, Albert Einstein College of Medicine,

, BA, FamilyCook Productions, 330 East; Phone: (212) 867-3929; E-mail: lynn@

ATION

Journal of Nutrition Education and Beh

ing healthful snacks and meals andidentifying good food choices (eg,freshly grown fruits and vegetables,whole grains, and minimally pro-cessed foods) over processed and pre-packaged food. Students are asked toreflect on how to improve healthfulfood options in their school and com-munity environment via menuchanges and use of community gar-dens and farmers markets.

Evaluation Design

The Reach, Efficacy, Adoption, Imple-mentation and Maintenance (RE-AIM)model served as the evaluation frame-work for the project.9 This study’sReach focused on the penetration bygrade level and the demographiccharacteristics of the participatingstudents.

Program Efficacy was evaluatedusing both quantitative (pre- andposttests) and qualitative measures(culinary skills assessments, focusgroups, reflective exercises, etc.). Pre-and post-intervention dietary behav-iors were evaluated using 15 selecteditems from the Centers for DiseaseControl and Prevention’s Youth RiskBehavior Survey.10 These items in-clude: fruit juice, fruit, green salad, po-tatoes, carrots, other vegetables,hamburger, hot dog, fried chicken,sausage, green leafy vegetables, sodaor pop, milk, and sweet and saltysnacks. The score for each item rangedfrom 0 (not consumed in the pastweek) to 6 (consumed 4 times perday), with a total potential score of72. Food of low nutritional quality(eg, soda, sweet and salty snacks)were reverse scored. Also included inthe student pre- and post- surveyswere items related to attitudes aboutsnacking, cooking, meal preparation,and frequency of meals enjoyed withfriends and family. Additionally, stu-dent evaluation included assessmentof culinary skills and culinary perfor-mance based on observation of the

avior � Volume 43, Number 5, 2011

Table. Diet for a Healthy Planet with Teen Battle Chefs: Weekly Theme Descriptions

Theme Key Topics CoveredComponent of the Theory the

Theme Addresses Anticipated Outcome-Students will:1. What Influences My Diet? Body image; general nutrition

information; recipe: quesadillasKnowledge � Express awareness of body image

� Increase ability to discern foodchoices and behaviors

2. Where to Find ReliableInformation on Nutrition

Nutrition information resources; eatingby color; recipe: Caribbean salsa

Self-reflection: students realizethere are multiple ways to obtainhealthful food and are motivatedto try new options

� Identify perceived barriers toobtaining and cooking healthful food

� Develop awareness of where to findnutrition information

� Develop strategies for obtaininghealthful food choices

� Identify new sources and typesof fresh fruits and vegetables

3. Becoming a Smart Consumer Health claims; healthful snack:edamame

Intentionality: intentionally buyingcertain products over others

� Evaluate the validity of healthclaims in packaged food products

� Increase knowledge and skills tomake food choices

4. Food is Personal Food and mood; recipe:greens with quinoa

Knowledge and reflectiveness � Increase awareness of the associationsbetween mood and food behaviors

� Strengthen self-efficacy for monitoringsuch behaviors

5. Neighborhood FoodAssessment – Part 1

Survey of local stores and markets,school and local foodassessment development

Outcome expectations � Become more aware of which healthfulfood items are accessible in theirschool and neighborhood

� Develop strategies developed forplanning and finding other avenuesto healthful food choices

6. Neighborhood FoodAssessment – Part 2

Mapping activity: healthful vsnonhealthful neighborhoodfood sources; presentations

Self-reflections: students realizetheir local stores are not the onlyoption, but that they may venture outto stores with more healthful options

� Locate the more healthful choiceswithin their neighborhood andschool food using a community map

� Increase self-efficacy for obtaininghealthful food in their school andlocal community

7. What is Food? Production Effectson Human/Environmental Health

Ecosystem effects; food webevaluation; recipe: broccoliand ginger stir fry

Knowledge and intentionality: beingaware of the food products bought,keeping the environment in mind

� Develop awareness of the environmentalcosts of factory food production

� Increase self-efficacy for making foodchoices that promote environmentaland human health

8. Meet the Farmer Alternative food resources:community supported agriculture,farmers’ markets; food co-ops;recipe: veggie wrap

Knowledge, intentionality and skillbuilding, being aware of the foodproducts bought, keeping theenvironment in mind, learning recipes

� Increase awareness of regionalresources for sustainably produced food

� Gain knowledge and self-efficacy forchanging choices about food

(continued)

JournalofNutritio

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Table. Continued

Theme Key Topics CoveredComponent of the Theory the

Theme Addresses Anticipated Outcome-Students will:

9. Food Politics Food policy; areas forchange; recipe: fricassee

Knowledge and skill building � Develop knowledge of food policyimplications that influence food supply

� Increase awareness that food choicesare linked to political decisions

10. Seed Germination Garden visit; planting seedlings;climate considerations

Knowledge � Learn fundamentals of growing food� Increase awareness of food production� Increase self-efficacy for self-productionof food as alternative to commerciallyproduced food choices

11. Compost What is compost? Makea compost bin; dig for wormsand garden exploration

Self-reflection: studentsmotivated to become an activepart of supporting a healthyecosystem

� Develop understanding of the full cycleof food, from production, to consumption,to waste disposal/recycling anddecomposition

� Increase awareness about makingecological food choices

� Increase skills for making food choicesthat are consonant with theindividual’s personal values

12. Soil Study – Garden Planning Analyze soil samples; vegetableorigins; herb tasting with potatoes;selection for garden

Skill building � Explore how to grow a wide variety of herbs� Develop ability to add flavor ina healthful way

� Increase self-efficacy related to usingherbs and seasonings to reducereliance on salt for flavoring

13. Planting and Plant Life Cycle Planting; insects: beneficialsvs pests; perennials vs annuals

Skill building � Enhance gardening skills andself-efficacy by raising along the full cycleof the food system similar to #11 above

14. Plant Growth Comparisons Garden stewarding; studentvideo production

Skill building � Develop skill to successfully raisefood crops

� Enhance self-efficacy for choosing togrow food outside of school environment,even a simple window box of herbs

15. Garden-Fresh Snacking Early harvest garden recipes:edible flower; nut butter andherb crunch

Skill building � Develop gardening skills by completingthe growing cycle for garden-freshsnacking options

� Increase self-efficacy for more creation ofsnacks from scratch over processed food

416Bukhari

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Table.Continued

Theme

KeyTopicsCovered

ComponentoftheTheory

the

ThemeAddresses

AnticipatedOutcome-S

tudents

will:

16.GardenCelebratio

nPlanning

Planmenu;designgardenasevent

venue;assignresp

onsibilities

Skillbuilding:students

planandmake

goalsfortheyear-endcelebratio

napplyingwhattheyhave

learned

�Developskillsforskillsforplanninga

celebratio

nthatinvo

lvescookingownfood

ratherthanrelyingonstore-boughtfood

�Enhanceself-efficacyforso

cial

enjoym

entofhealth

ful,self-preparedfood

17.GardenCelebratio

nSemesterculm

inatio

nandpresentatio

ns,

student-preparedlunchin

garden

Self-reflectio

n:students

reflectonwhat

theyhave

learnedandhow

itwill

affectfuture

decisions

�Increase

self-esteem/prid

ebypreparin

gfoodforothers

inacelebratory

fash

ion

�Developself-efficacyforsh

arin

ghealth

fulfoodwith

others

Journal of Nutrition Education and Behavior � Volume 43, Number 5, 2011 Bukhari et al 417

students’ proficiency in using a knifefor chopping, following recipe direc-tions, and so on. Qualitative measuresincluded focus group data, journal en-tries, and writing activities about eat-ing, cooking, and beliefs about food.

Program Adoption was assessed bymonitoring the number of teachingstaff from each school who received2 days of program training (focusedon skills needed to teach the pro-gram’s comprehensive lesson plans)and the number of teachers who actu-ally taught the lessons. Program Im-plementation was measured byteachers’ completion of a weekly on-line lesson feedback survey to gatherinformation on lesson feasibility andfidelity. This feedback included sug-gestions to enhance student engage-ment, improve handouts, and betteraccommodate the daily 1-hour classlessons.

Program Maintenance was ad-dressed by creating an ongoing mech-anism for teacher training, as teacherattrition presents a problem for pro-gram sustainability in most inner-city schools. Additionally, the authorsdeveloped relationships with schoolfoodservice personnel to increase thepotential for maintaining positivechanges, as participating studentswere invited to join a school foodser-vice nutrition advisory committee.

STUDY FINDINGS

The study sample included the entireninth-grade class (n ¼ 98) at a Brook-lyn, New York, high school wherenearly one third of students are fromhouseholds with annual incomes be-low the poverty level and the schoolreports that 99% are from minoritygroups.11 Using a randomized pretestposttest control-group design, half(n ¼ 49) of the ninth-grade class wasrandomly assigned to the interven-tion and the other half (n ¼ 49) tothe comparison condition, whichconsisted of an art class.

Analysis of variance and t tests us-ing SPSS (version 14.0, SPSS, Inc., Chi-cago, IL, 2005) demonstratedimprovements in food intake basedon the 15 nutrition items selectedfrom the Youth Risk Behavior Surveyfor this survey. There was an overallincrease in score of 4.9 points, or20.4% (P < .01), in the intervention

classes compared with 1.6 points, or5.7%, in control classes (NS). Im-proved scores correlated with report-ing increases in eating vegetables assnacks (r ¼ 0.64, P < .001), preparinghealthful snacks for self (r ¼ 0.48, P< .01), and having sit-down mealswith family (r ¼ 0.55, P < .004).

The qualitative data (eg, focusgroup transcripts and student writingfrom reflective exercises) were re-viewed for common themes. Thesedata suggested that students im-proved their nutrition knowledgeand attitudes about healthful eating.Typical comments included: ‘‘I usedto think eating healthy was eatinga fruit a day and taking your vitamin.Now I see it is more than that. I love toeat fruits and vegetables to keephealthy’’ and ‘‘I used to think I shouldtry new foods; now I do it!’’ In anotherdevelopment, students became peereducators by conducting cookingdemonstrations in school and at com-munity events and farmers’ markets.

The Diet for a Healthy Planet withTeen Battle Chefs curriculum hasbeen further integrated into theschool’s curriculum offerings as 1 ofseveral electives. It is offered in 2-hour blocks with smaller class sizes(up to 12 students) each semester forstudents in grades 9-12 in over 85schools in 16 states. Depending onschool preference, it can be conductedin school or after school. This struc-ture is enhanced through peer learn-ing, in which students with priorexperience in the class assist studentswho are new to culinary arts and nu-trition. The schools also institutefoodservice changes to provide morehealthful menu choices.

CONCLUSIONS

Participants in Diet for a HealthyPlanet with Teen Battle Chefs re-ported behavioral changes and greaterawareness of opportunities for and in-terest in healthful eating at home andat school. These changes and the peerlearning suggest the value of studentssharing and using knowledge devel-oped in the course. Such lessonslearned can be applied to other highschool settings to encourage a combi-nation of skill building in cooking andgardening, experiential learning, andself-reflective techniques to improvedietary behavior and attitudes. The

418 Bukhari et al Journal of Nutrition Education and Behavior � Volume 43, Number 5, 2011

school foodservice linkage resulted inimproving both the ratio of freshfruits and vegetables offered and stu-dent participation in the school’slunch service.

NOTES

The Institutional Review Board of theNew York City Department of Educa-tion approved the project protocol.The Gateway Institute for Pre-CollegeEducation provided funding for thisproject.

REFERENCES

1. McAleese JD, Rankin LL. Garden-based nutrition education affects fruitand vegetable consumption in sixth-grade adolescents. J Am Diet Assoc.2007;107:662-665.

2. Morris JL, Zidenberg-Cherr S. Garden-enhanced nutrition curriculum im-proves fourth-grade school children’sknowledge of nutrition and preferences

for some vegetables. J Am Diet Assoc.2002;102:91-93.

3. Lineberger SE, Zajicek JM. School gar-dens: can a hands-on teaching tool affectstudents’ attitudes and behaviors re-garding fruit and vegetables. Horticul-ture Technology. 2000;10:593-597.

4. Bandura A. Self-efficacy: The Exercise ofControl. New York, NY: W.H. Free-man; 1997.

5. Gregson J, Foerster SB,OrrR, et al. Sys-tem, environmental, and policy changes:using the social-ecological model asa framework for evaluating nutrition ed-ucation and social marketing programswith low-income audiences. J NutrEduc. 2001;33(suppl 1):S4-S15.

6. Hoelscher DM, Evans A, Parcel GS,Kelder SH. Designing effective nutri-tion interventions for adolescents.J Am Diet Assoc. 2002;102(suppl 3):S52-S63.

7. New York State Department ofEducation. Curriculum and Instruction:Learning Standards of New YorkState. http://www.p12.nysed.gov/ciai/

standards.html. Accessed March 30,2011.

8. Photovoice Web site. http://www.photovoice.org. Accessed February 28,2011.

9. Glasgow RE, Vogt TM, Boles SM.Evaluating the public health impact ofhealth promotion interventions: theRE-AIM framework. Am J PublicHealth. 1999;89:1322-1327.

10. National Center for Chronic DiseasePrevention and Health Promotion.YRBSS: YouthRisk Behavior Surveil-lance System. http://www.cdc.gov/HealthyYouth/yrbs/index.htm. AccessedFebruary 28, 2011.

11. USCensusBureau.AmericanFactFinder:Kings County, New York - PovertyStatus in the Past 12 Months. http://factfinder.census.gov/servlet/STTable?_bm¼y&-context¼st&-qr_name¼ACS_2006_EST_G00_S1701&-ds_name¼ACS_2006_EST_G00_&-tree_id¼306&-redoLog¼true&-_caller¼geoselect&-geo_id¼05000US36047&-format¼&-_lang¼en. Accessed March 30, 2011.