Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of School Age Children

1. Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of
School Age Children Living in Appalachian Ohio
A thesis presented to
the faculty of
the College of Health and Human Services of Ohio University
In partial fulfillment
of the requirements for the degree
Master of Science
Ashley B. Zurmehly
August 2009
© 2009 Ashley B. Zurmehly. All Rights Reserved.

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This thesis titled
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of
School Age Children Living in Appalachian Ohio
by
ASHLEY B. ZURMEHLY
has been approved for
the School of Human and Consumer Sciences
and the College of Health and Human Services by
David H. Holben
Professor of Human and Consumer Sciences
Gary S. Neiman
Dean, College of Health and Human Services

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ABSTRACT
ZURMEHLY, ASHLEY B., M.S., August 2009, Food and Nutrition
Use of a Gardening and Nutrition Education Program to Improve the Produce Intake of
School Age Children Living in Appalachian Ohio (228 pp.)
Director of Thesis: David H. Holben
This study: (a) measured the effect of a nutrition and gardening education
program on Appalachian children’s fruit and vegetable intakes and preferences; and (b)
examined the relationship of food security status to gardening habits and perceptions,
produce intake, and personal characteristics of children and their adult female caregivers.
In this study, participants were: (a) 91 children who completed a pre-test, nutrition
education and gardening program (intervention), and a post-test over a six-week period;
and (b) 99 female caregivers who completed a 79-item survey prior to the six-week
intervention period about themselves, their household, and their 157 children. Results
indicated that the six-week nutrition education and gardening intervention did not
significantly impact produce intake variety or produce preference variety among the
children participating in the program. Overall, household food security was not related to
the variety of produce eaten or preferred reported by children; however, it was related to
vegetable intake, education, diet quality, food assistance program participation, and body
mass index of the female caregivers. On the other hand, household food security was
related to the children’s estimated produce intake and preferences reported by the female
caregivers prior to the intervention. It was also found that children’s gardening habits
reflected that of their female caregivers, but children’s self-reported produce intake

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variety was not related to their gardening habits. However, household food security was
not related to gardening habits or produce readiness of female caregivers. Dietetic and
nutrition professionals can use these findings to develop other interventions including
gardening and nutrition education with both children and their families.
Approved: _____________________________________________________________
David H. Holben
Professor of Human and Consumer Sciences

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ACKNOWLEDGMENTS
Thank you to my advisor Dr. David Holben, and other faculty members, who
made this possible: Ms. Deborah Murray and Dr. Jennifer Chabot. Also thanks to all of
my family and friends for supporting me, especially Todd who helped me through the
entire process.

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TABLE OF CONTENTS
Page
ABSTRACT ........................................................................................................................ 3
ACKNOWLEDGMENTS .................................................................................................. 5
LIST OF TABLES ............................................................................................................ 10
LIST OF FIGURES .......................................................................................................... 12
CHAPTER 1: INTRODUCTION ..................................................................................... 13
Overview and Background ........................................................................................... 13
Statement of the Problem .............................................................................................. 17
Purposes of the Study ................................................................................................... 17
Research Questions and Hypotheses ............................................................................ 18
Significance of the Study .............................................................................................. 20
Potential Delimitations and Limitations ....................................................................... 21
Definition of Terms ...................................................................................................... 22
CHAPTER 2: REVIEW OF LITERATURE .................................................................... 23
Food Security ................................................................................................................ 24
Definitions ................................................................................................................. 24
Measurement of Food Security ................................................................................. 25
Food Security in the United States............................................................................ 31
Risk Factors for Food Insecurity .............................................................................. 36
Outcomes of Food Insecurity in Adults ..................................................................... 38
Food insecurity and chronic disease risk among adults. ....................................... 39
Food insecurity and overweight/obesity among adults. ........................................ 39

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Food insecurity and overall health among adults. ................................................ 41
Food insecurity and diet among adults. ................................................................ 42
Outcomes of food insecurity in children ................................................................... 48
Food insecurity and overweight among children. ................................................. 48
Food insecurity and overall health status among children. ................................... 50
Food insecurity and diet and hunger among children. .......................................... 51
Federal and Non-Federal Food Assistance Programs ................................................... 53
The Special Supplemental Nutrition Program for Women, Infant, and Children
(WIC)......................................................................................................................... 54
FNS Supplemental Nutrition Assistance Program (SNAP) ...................................... 55
School Meals Programs ............................................................................................ 57
The school lunch program. ................................................................................... 57
The special milk program. .................................................................................... 60
Summer Food Service Program ................................................................................ 60
Community Garden-Based Programs ....................................................................... 61
The America Community Gardening Association. ............................................... 61
Farm-to-School. .................................................................................................... 61
School gardening. ................................................................................................. 62
Community Food Initiatives. ................................................................................ 63
Appalachia .................................................................................................................... 63
Health ........................................................................................................................ 68
Obesity. ................................................................................................................. 69

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Cancer and chronic disease. .................................................................................. 70
Mental health. ....................................................................................................... 72
Food Security ............................................................................................................ 72
Produce Intake in the United States .............................................................................. 73
Produce and Gardening Interventions........................................................................... 75
Conclusion .................................................................................................................... 79
CHAPTER 3: METHODOLOGY .................................................................................... 81
Subjects ......................................................................................................................... 82
Setting ........................................................................................................................... 82
Project Description ....................................................................................................... 83
The Nutrition Education and Gardening Program ........................................................ 85
Data Scoring and Statistical Analysis ........................................................................... 85
CHAPTER 4: RESULTS .................................................................................................. 89
Child Participant Data ................................................................................................... 89
Female Caregiver Participant Data ............................................................................... 93
CHAPTER 5: DISCUSSION, CONCLUSIONS, AND RECOMMENDATIONS ....... 113
Children Participants’ Produce Preference and Intake Variety .................................. 114
Food Security .............................................................................................................. 116
Household Food Security Status ............................................................................. 116
Food Security, Body Weight, Diet, and Health ....................................................... 120
Food Security, Gardening, and Diet ....................................................................... 123
Food security and female caregiver’s gardening and diet. ................................. 123

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Food security and children’s diet. ....................................................................... 125
Female Caregiver Gardening and Produce Habits ...................................................... 128
Conclusions and Recommendations ........................................................................... 130
Conclusions ............................................................................................................. 130
Recommendations ................................................................................................... 133
References ....................................................................................................................... 136
APPENDIX A: FOOD SECURITY SURVEY MODULE SCORING FOOD SECURITY
SURVEY MODULE 18 AND 6 ITEM SCORING ....................................................... 165
APPENDIX B: KIDS ON CAMPUS SURVEY SCORING .......................................... 170
APPENDIX C: IRB APPROVAL .................................................................................. 175
APPENDIX D: KIDS ON CAMPUS SURVEY ............................................................ 176
APPENDIX E: KIDS ON CAMPUS LESSON PLANS BIG TOP GARDEN 2008 ..... 193
WEEK 1: GARDENING IS GREAT ........................................................................ 193
WEEK 2: GARDENING IS COLORFUL ................................................................ 198
WEEK 3: FRUIT + VEGETABLES = FIBER......................................................... 204
WEEK 4: TEAMWORK........................................................................................... 210
WEEK 5: DYNAMIC DUO ..................................................................................... 215
WEEK 6: SCRAPS TO SOIL ................................................................................... 221
APPENDIX F: CHILD FRUIT AND VEGETABLE SURVEYS ................................. 227

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LIST OF TABLES
Page
Table 1: Research Questions and Hypotheses ................................................................19
Table 2: 18-item Food Security Survey Module, 2008...................................................27
Table 3: Food Security Categories Defined by the USDA .............................................29
Table 4: Six-item Food Security Questionnaire, 2008....................................................31
Table 5: SNAP 2009 Income and Resource Cut-off Levels ...........................................56
Table 6: School Meal Income Qualifications .................................................................58
Table 7: Region Economic and Educational Level Comparison ....................................66
Table 8: Research Questions and Associated Statistical Test .........................................87
Table 9: Child Participants’ Produce Preferences and Intakes .......................................91
Table 10: Characteristics of Female Participants and Their Households .......................94
Table 11: Female Caregiver Body Mass Index and Perceived Diet Quality and Health
Status ...............................................................................................................................96
Table 12: Female Participant Readiness for Eating Produce ..........................................98
Table 13: Female Participant Gardening Habits and Readiness for Gardening Produce ...
.........................................................................................................................................99
Table 14: Relationship of Food Security Status to Gardening- and Produce-Related
Behaviors and Intakes ...................................................................................................101
Table 15: Relationship of Female Caregivers’ Habits to Gardening- and Produce-Related
Behaviors and Intakes ...................................................................................................102

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Table 16: Female Caregiver and Household Characteristics Stratified by Food Security
Status .............................................................................................................................104
Table 17: Female Caregiver Weight and Diet Characteristics Stratified by Food Security
Status……………………………………………………………………………….....106
Table 18: Female Caregiver Produce Readiness Stratified by Food Security
Status……………………………………………………………………………….....108
Table 19: Gardening Readiness and Habits of Female Caregivers Stratified by Food
Security Status ..............................................................................................................109
Table 20: Female Caregiver’s Perception of Children’s Produce Intake Stratified by Food
Security Status ..............................................................................................................110
Table 21: Female Caregiver’s Perception of Children’s Habits ...................................111

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LIST OF FIGURES
Page
Figure 1: Food security status of U.S. households in 2007 ............................................33
Figure 2: Food security and food insecurity trends in the U.S. from 1999-2007 ...........35
Figure 3: Weekly household food spending per person..................................................43
Figure 4: Food-insecure household food assistance participation ..................................46
Figure 5: The Appalachian Region .................................................................................64
Figure 6: Appalachian Ohio Counties.............................................................................67
Figure 7. Child participants’ produce preference and intake variety ..............................92
Figure 8. Female caregiver participants weight classification ........................................97
Figure 9. Female caregiver produce and gardening readiness………………………...100
Figure 10. Female caregiver body mass index and produce intake by food security
status…………………………………………………………………………………..107

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CHAPTER 1: INTRODUCTION
Overview and Background
Appalachia is an area of the United States that is characterized by low educational
attainment, high poverty, and poor health. The area is made up of parts of 12 states and
all of West Virginia, with almost half of the area being rural (Smith & Grant, 2008).
Some studies also support that its rates of food insecurity, overweight and obesity,
diabetes, and chronic disease are above those of the rest of the nation (Crooks, 1999;
Demerath et al., 2003; Denham, Meyer, Toborg, & Mande, 2004; Holben, McClincy,
Holcomb, Dean, & Walker, 2004; Holben & Pheley, 2006; Kropf, Holben, Holcomb, &
Anderson, 2007; Pheley, Holben, Graham, & Simpson, 2002; Rappaport & Robbins,
2005; Tulkki et al., 2006; Walker, Holben, Kropf, Holcomb, & Anderson, 2007; Wewers,
Katz, Fickle, & Paskett, 2006). More specifically, and in relation to poverty and food
access, food insecurity has been found to be a concern to Appalachian residents (Holben,
Barnett, & Holcomb, 2006; Holben et al., 2004; Holben & Pheley, 2006; Hutson, Dorgan,
Phillips, & Behringer, 2007; Kendall, Olson, & Frongillo, 1996; Kropf et al., 2007;
Pheley et al., 2002; Tessaro, Mangone, Parkar, & Pawar, 2006; Walker et al., 2007;
Wewers et al., 2006). In fact, in the proposed study region of Appalachian Ohio, food
insecurity was found to be three times the level of the rest of the state, as well as almost
double the rate of the nation (Holben et al., 2004; Holben & Pheley, 2006; Kropf et al.,
2007; Meek, 2005; Pheley et al., 2002; Walker et al., 2007).
Food insecurity has been associated with many health problems among household
members across the lifespan (Alaimo, Olson, & Frongillo, 2002; Bronte-Tinkew, Zaslow,

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Capps, Horowitz, & McNamara, 2007; Casey et al., 2005; Cook et al., 2004; Cook et al.,
2008; Hamelin, Habicht, & Beaudry, 1999; Pheley et al., 2002; Seligman, Bindman,
Vittinghoff, Kanaya, & Kushel, 2007; Stuff et al., 2004; Tarasuk & Beaton, 1999;
Vozoris & Tarasuk, 2003; Walker et al., 2007). Obesity rates, diabetes, and Hemoglobin
A1C levels have all been found to be greater in food-insecure households as compared to
their counterparts in Appalachian Ohio (Holben & Pheley, 2006). Overall, poorer self-
reported physical and mental health was associated with food insecurity in Appalachian,
even in households with minimal food insecurity (Pheley et al., 2002). Physical health is
not only in jeopardy when households are food insecure; mental and overall health can
also be affected in both adults and children (Alaimo et al., 2002; Bronte-Tinkew et al.,
2007; Casey et al., 2004; Casey et al., 2005; Casey et al., 2006; Cook et al., 2006; Cook
et al., 2008; Holben et al., 2006; Holben et al., 2006; Pheley et al., 2002; Rose & Bodor,
2006; Skalicky et al., 2006; Wilde & Peterman, 2006)
Food insecurity negatively impacts multiple aspects of the diet, including both
quality and quantity of food consumed (Chang, Nitzke, Guilford, Adair, & Hazard, 2008;
Condrasky & Marsh, 2005; Langevin et al., 2007; McIntyre et al., 2003; Vozoris &
Tarasuk, 2003). Such households have been found to have below the recommended
intakes of kilocalories, calcium, vitamin B-6, magnesium, iron, and zinc, compared to
those in food-secure households (Dixon, Winkleby, & Radimer, 2001; Matheson,
Varady, Varady, & Killen, 2002; Olson, 1999; Rose & Oliveira, 1997). Studies have
shown food-insecure households to be of particular concern in relation to decreased
produce intake, leading potentially to increased risk for certain cancers, cardiovascular

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disease, and lower overall wellness (Ahn et al., 2005; Cartmel, Bowen, Ross, Johnson, &
Mayne, 2005; Dixon et al., 2001; Genkinger, Platz, Hoffman, Comstock, & Helzlsouer,
2004; Guenther, Dodd, Reedy, & Krebs-Smith, 2006; Kendall et al., 1996; Kirsh et al.,
2007; Larsson, Hakansson, Naslund, Bergkvist, & Wolk, 2006; Lee et al., 2006; Pierce et
al., 2007; Pierce, Stefanick et al., 2007). For children, food insecurity can negatively
impact diet, including decreased produce intake, which may negatively affect health
(Casey et al., 2005; Casey et al., 2006; Cook et al., 2006; Dixon et al., 2001; Fu, Cheng,
Tu, & Pan, 2007; Lakkakula, Zanovec, Silverman, Murphy, & Tuuri, 2008; Langevin et
al., 2007; Riediger, Shooshtari, & Moghadasian, 2007).
Federal food assistance programs have been developed to improve nutritional
status of Americans, including Supplemental Nutrition Assistance Program (SNAP), the
Special Supplemental Nutrition Program for Women, Infant, and Children (WIC), School
Meals Programs, and local programs (e.g., Community Food Initiatives), all of which
strive to increase the produce intake among participants (Food and Nutrition Service,
2008; U.S. Department of Health and Human Services, 2008; U.S. Department of Health
and Human Services, 2009a, 2009b, 2009c; Zerbian, 2007). In order to further increase
produce intake in food-insecure families and decrease their risk for such chronic
problems, a variety of community-based programs and interventions have been
developed, including produce distribution and gardening programs (Hazen, Holben,
Holcomb, & Struble, 2008; Kropf et al., 2007; Nanney, Johnson, Elliott, & Haire-Joshu,
2007; Struble, Holben, Hazen, & Holcomb, 2008). Gardening, in particular, has been
shown to increase access to fruits and vegetables in the face of food insecurity, and is a

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relatively inexpensive way to grow fresh produce (Holben et al., 2004; McAleese &
Rankin, 2007; Nanney, Johnson et al., 2007; Rose & Richards, 2004). Further, gardening
interventions have been shown to positively impact produce intake of children and their
households, which may also increase their food security (Graham & Zidenberg-Cherr,
2005; Hermann et al., 2006; Holben et al., 2004; McAleese & Rankin, 2007; Morris &
Zidenberg-Cherr, 2002). A variety of methods have been used by these programs,
including varying time frames, lessons, and venues across the United States (Robinson-
O'Brien, Story, & Heim, 2009). However, none have been done in Appalachian Ohio,
other than the federal and non-federal programs offered.
Gardening may be a particularly effective strategy for a variety of reasons.
Nanney et al. (2007) found that those families in rural areas who ate homegrown produce
had an increase in produce availability, along with an increase in their child’s preference
for new fruits and vegetables. In fact, gardening projects have been done to improve the
health and fruit and vegetable intake of the participants, with most having positive
impacts on their participants’ produce intake and gardening and nutrition knowledge
(Graham & Zidenberg-Cherr, 2005; Hermann et al., 2006; McAleese & Rankin, 2007;
Morris & Zidenberg-Cherr, 2002; Nanney, Johnson et al., 2007; Stables et al., 2005; Van
Duyn & Pivonka, 2000). Compared to other interventions, gardening is an inexpensive
way to increase produce intake as well as physical activity in households (Graham &
Zidenberg-Cherr, 2005; McAleese & Rankin, 2007; Nanney, Johnson et al., 2007).

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Statement of the Problem
Produce intake is inadequate among children, which negatively impacts diet (Ball,
Benjamin, & Ward, 2008; Gao, Wilde, Lichtenstein, & Tucker, 2006; Langevin et al.,
2007; Lorson, Melgar-Quinonez, & Taylor, 2009). It was recently reported that fruits and
vegetables can reduce cardiovascular problems in adolescents (Holt et al., 2009).
However, children do not typically meet the required intakes for fruits and vegetables,
and most servings come from potatoes and fruit juices (Lorson et al., 2009). In the study
region, multiple studies have indicated the need for intervention in the Southeastern Ohio
Appalachian region in relation to promoting fruit and vegetable intake (Ball et al., 2008;
Cassady, Jetter, & Culp, 2007; Holben et al., 2004; Kropf et al., 2007; Luszczynska,
Tryburcy, & Schwarzer, 2007; Walker et al., 2007; Wewers et al., 2006). One potential
solution is to introduce gardening to children, who may, in turn, influence the entire
household’s habits surrounding gardening and produce. Through the introduction of
gardening, study area children will not only be involved directly in their own food
production, but will potentially improve food security in their households.
Purposes of the Study
Fruit and vegetable intake has been found to be related to household food security
(Bhattacharya, Currie, & Haider, 2004; Dixon et al., 2001; Kendall et al., 1996; Kropf et
al., 2007). For adult females and children living in food-insecure households, fruits and
vegetables are typically the first groups reduced from the diet, due to their higher price
and shorter shelf life, compared to other foods (Cassady et al., 2007; Dixon et al., 2001;

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Kendall et al., 1996; Kropf et al., 2007). Therefore, through the practice of gardening, a
family may be able to grow fruits and vegetables at a lower cost than purchasing them,
while increasing both physical activity and produce intake.
Given the paucity of data surrounding this area of nutrition and related
effectiveness of gardening programs in improving both food security and produce intake,
the purposes of this study were to: (a) measured the effect of a nutrition and gardening
education program on Appalachian children’s fruit and vegetable intakes and preferences;
and (b) examined the relationship of food security status to gardening habits and
perceptions, produce intake, and personal characteristics of children and their adult
female caregivers.
Research Questions and Hypotheses
This study answered the research questions summarized in Table 1. Hypotheses
for the questions are also summarized in Table 1.

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Table 1
Research Questions and Hypotheses
Research Questions Hypotheses
1. Does a six-week nutrition and A six-week nutrition and gardening
gardening education program education program positively impacts
improve children’s preference for children’s fruit and vegetable intakes and
and intake of fruits and vegetables? preferences.
2. At the onset of the study, is Food insecurity is associated with fewer
household food security status gardening habits of the children as
related to the female caregiver’s perceived by the female caregiver.
perception of the gardening habits of
the children?
3. At the onset of the study, is Food insecurity is associated with
household food security status decreased gardening readiness of the
related to the female caregiver’s female caregiver.
gardening readiness?
4. At the onset of the study, is Food security is inversely associated with
household food security status female caregiver’s produce intakes.
related to produce intake of female
caregiver?
5. At the onset of the study, are the Child’s gardening habits are positively
female caregiver’s gardening habits associated with their female caregiver’s
related to their perceptions of the gardening habits.
child’s gardening habits?
6. At the onset of the study, is Food insecurity is associated with
household food security status decreased produce preferences and intakes
related to produce preferences and of child participants.
intakes of child participants?
7. At the onset of the study, are the Child’s produce intake and perceptions are
child’s produce intake and positively associated with their female
preferences related to their female caregiver’s produce intake.
caregiver’s produce intakes?
8. At the onset of the study, are the Child’s produce intake and perceptions are
child’s produce intake and positively associated with their female
preferences related to their female caregiver’s gardening habits.
caregiver’s gardening habits?

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9. Do body mass index (BMI), Body mass index (BMI) will be greater
vegetable intake, and fruit intake and both vegetable and fruit intakes will
differ between female caregivers lower in female caregivers from food-
from food-secure versus food- insecure households compared to food-
insecure households? secure households.
10. Do marital status, education level, Food-insecure female caregivers will be
transportation, hunting, fishing, food single and have lower education, diet
assistance program participation, quality, and health status while having
perceived health level, diet quality, higher body mass index and food
body mass index category, and assistance program participation than
produce and gardening readiness food-secure females. Food-insecure
differ between female caregivers females will also have lower produce and
from food-secure versus food- gardening readiness than those from food-
insecure households? secure households.
Significance of the Study
As previously discussed, food insecurity is associated with decreased produce
intake. This may be especially prevalent in distressed areas such as Athens County,
Ohio, where access to and availability of produce are concerns for food-insecure homes.
Through the implementation of this program, the child participants became more aware
of basic nutrition concepts, as well as gardening skills, that they can share with their
families in order to increase their fruit and vegetable intake, as well as food security.
Multiple groups have the potential of benefiting from this program and research,
especially the children involved and their families. They not only received the direct
benefit of the education and produce distribution, but they were also able to use the
knowledge and skills after the program’s completion through the development of their
own garden. Other groups that may benefit included the Kids on Campus Program

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(university-based summer camp), where this program was initially piloted. Finally, the
dietetics and nutrition profession may benefit from this research by using the findings as
a basis for further research and program development.
Practical outcomes of this project, other than its benefits to future research,
include stimulation of similar programs developing in the future. Since this was a pilot
study, improvements could be made in order to re-evaluate its effectiveness in the
original age group studied, or target other ages or populations in different regions of the
country for evaluation.
The unique aspect of this program, compared to previous studies, is that it focused
in the region of Appalachian Ohio. Based upon the literature related to food security in
and the culture of the Appalachian region, as well as pediatric nutrition studies and
surveillance data, the program was developed.
Potential Delimitations and Limitations
Potential limitations of this pilot study include the pilot nature of program and
study, potential for children to be absent for parts of the program or to discontinue
participation in the study, limited participation of the family members/caregivers, literacy
level of all participants, and use of children and families participating in the camp rather
than a randomly selected sample. These limitations could hinder participant selection and
recruitment, as well as the effectiveness of the program.
Potential delimitations, or those factors out of our control that could hinder our
study, include summer camp practices (participant selection, daily schedule), climate of

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the study region during the study period, and the availability of produce from farmers for
distribution during the study. In addition, since this study utilized convenience sampling,
we were unable to randomly sample the children living in the area or select for particular
demographics.
To overcome these limitations and delimitations, we closely collaborated with the
summer camp program staff and utilized local farmers for produce who typically are
successful.
Definition of Terms
Food security: Access by all people at all times to enough food for an active,
healthy life and includes at a minimum: a) the ready availability of nutritionally adequate
and safe foods, and b) the assured ability to acquire acceptable foods in socially
acceptable ways (e.g., without resorting to emergency food supplies, scavenging,
stealing, and other coping strategies; Anderson, 1990, p. 1560).
Food insecurity: Whenever the availability of nutritionally adequate and safe
foods or the ability to acquire acceptable foods in socially acceptable ways is limited or
uncertain (Anderson, 1990, p. 1560).
Community food security: Prevention-oriented concept that supports the
development and enhancement of sustainable, community-based strategies: to improve
access of low-income households to healthful nutritious food supplies; to increase the
self-reliance of communities in providing for their own food needs; and to promote
comprehensive responses to local food, farm, and nutrition issues (Andrews, 2008).

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CHAPTER 2: REVIEW OF LITERATURE
In the United States, food insecurity can lead to an increased risk for health
problems, poor diet, and lack of fruit and vegetable intake (Bhattacharya et al., 2004;
Bronte-Tinkew et al., 2007; Carmichael, Yang, Herring, Abrams, & Shaw, 2007; Casey
et al., 2005; Cook et al., 2004; Cook et al., 2006; Cook et al., 2008; Gundersen, Lohman,
Garasky, Stewart, & Eisenmann, 2008; Hazen et al., 2008; Holben et al., 2006; Holben et
al., 2004; Holben & Pheley, 2006; Jyoti, Frongillo, & Jones, 2005; Kropf et al., 2007;
Lee & Frongillo, 2001; Lyons, Park, & Nelson, 2008; Matheson et al., 2002; C. M.
Olson, Bove, & Miller, 2007; Rose & Bodor, 2006; Skalicky et al., 2006; Struble et al.,
2008; Stuff et al., 2004; Tanumihardjo et al., 2007; Walker et al., 2007; Weinreb et al.,
2002). These effects are particularly important for children in food-insecure households
because such health problems and diet habits could follow them and exacerbate
throughout life (Connell, Lofton, Yadrick, & Rehner, 2005; Olson et al., 2007).
Appalachia has been shown to be at higher risk for food insecurity and its
associated outcomes than the rest of the nation (Hazen et al., 2008; Holben et al., 2006;
Holben et al., 2004; Holben & Pheley, 2006; Kendall et al., 1996; Kropf et al., 2007;
Meek, 2005; Pheley et al., 2002; Struble et al., 2008; Walker et al., 2007). Therefore, an
intervention focusing on nutrition, gardening, and produce intake may alleviate some of
these problems for children in Appalachian Ohio. This study was conducted to: (a)
measure the effect of a nutrition and gardening education program on Appalachian
children’s fruit and vegetable intakes and preferences; and (b) examine the relationship of
food security status to gardening habits and perceptions, produce intake, and personal

24. 24
characteristics of children and their adult female caregivers. In this literature review,
findings related to food security, Appalachia, produce intake, and gardening are
reviewed.
Food Security
Definitions
Food security is defined as “access by all people at all times to enough food for an
active, healthy life and includes at a minimum: (a) the ready availability of nutritionally
adequate and safe foods, and (b) the assured ability to acquire acceptable foods in
socially acceptable ways (e.g., without resorting to emergency food supplies, scavenging,
stealing, and other coping strategies)” (Anderson, 1990, p. 1560). Food insecurity is
defined as “whenever the availability of nutritionally adequate and safe foods or the
ability to acquire acceptable foods in socially acceptable ways is limited or uncertain”
(Anderson, 1990, p. 1560). Hunger is a condition that is not always associated with food
insecurity, however is defined as an individual physiological condition due to prolonged
lack of food causing weakness, illness, and pain (Anderson, 1990). Both individuals and
overall households can experience hunger (Radimer, Olson, & Campbell, 1990).
Household hunger can be composed of one or more of the following: food depletion;
food unsuitability; and food anxiety (Radimer et al., 1990). Individual hunger consists of
intake insufficiency, diet inadequacy, and disrupted eating patterns (Radimer et al.,
1990). Since there are so many aspects to it, hunger is difficult to define for each
individual which leads to multiple definitions. The Food Research and Action Center

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(FRAC) defined hunger as the physiological and psychological state that comes from not
having enough food, while Harvard School of Public Health defined it as chronic under
consumption of food and nutrients (Radimer & Radimer, 2002).
Community food security is difficult to assess. However, it is basically defined as
the attempt to increase the food security of a community through the use of education and
programs. The U.S Department of Agriculture defines it as a prevention-oriented concept
that supports the development and enhancement of sustainable, community-based
strategies which improve access of low-income households to healthful nutritious food
supplies; increase the self-reliance of communities in providing for their own food needs;
and promote comprehensive responses to local food, farm, and nutrition issues (Andrews,
2008). As far as the community food security of Athens County, it has been found to be
compromised and in need of such food, farm, and nutrition interventions (Bletzacker,
Holben, & Holcomb, 2007).
Measurement of Food Security
The Food Security Measurement Project is a collaboration between federal
agencies, researchers, and non-profit organizations developed in response to the National
Nutrition Monitoring and Related Research Act (NNMRR) in 1990 with the objective to
develop a methodology to assess the food security status nationwide (Nord, 2008b). The
idea for food security measurement began in the 1980s when hunger emerged as a
growing concern in the United States (Nord, Andrews, & Carlson, 2008). The Harvard
School of Public Health and FRAC provided evidence to President Reagan’s Task Force
on Food Assistance urging for an investigation into the allegations of increasing hunger

26. 26
(Carlson, Andrews, & Bickel, 1999; Olson, 1999). After developing the definitions of
food security, the team focused on the development of the instrument for measurement.
Through the team work of the United States Department of Agriculture (USDA) and the
Community Childhood Hunger Identification Project (CCHIP), an 18-item questionnaire
was developed to determine the multiple levels of food security occurring in American
households which was first administered as a supplement to the Current Population
Survey (CPS) in 1995 (Nord et al., 2008; Nord, 2008b). The questions for the Food
Security Survey Module (FSSM) were developed through extensive research by a team of
experts in the field, along with field testing and validation (Nord, 2008b). The FSSM has
since been used by governmental and other researchers. For example, the instrument has
been used in the Continuing Survey of Food Intakes by Individuals (CSFII), the National
Health and Nutrition Examination Survey (NHANES), the Early Childhood Longitudinal
Study (ECLS), the Panel Survey of Income Dynamics (PSID), and the Survey of Program
Dynamics (SPD; Bickel, Nord, Price, Hamilton, & Cook, 2000; Nord et al., 2008).
The FSSM is an 18-item survey with questions listed in order of severity, from
least to most which aids in the categorization of the participant (Carlson et al., 1999;
Radimer & Radimer, 2002). Each question uses key phrasing, including “because we
could not afford it” and “because there was not enough money”, in order to assess food
security based on financial reasons over the past 12 months (Bickel et al., 2000). Some of
the wording varied from 1995 to 1998, however the core questions have remained
unchanged (Bickel et al., 2000). The questions for the 18-item survey are shown in Table
2, while the scoring is found in Appendix A.

27. 27
Table 2
18-item Food Security Survey Module, 2008
Item Number Question
Q1 “We worried whether our food would run out before we got money
to buy more.” Was that often, sometimes, or never true for you in
the last 12 months?
Q2 “The food that we bought just didn’t last and we didn’t have
money to get more.” Was that often, sometimes, or never true for
you in the last 12 months?
Q3 “We couldn’t afford to eat balanced meals.” Was that often,
sometimes, or never true for you in the last 12 months?
Q4 In the last 12 months, did you or other adults in the household ever
cut the size of your meals or skip meals because there wasn’t
enough money for food? (Yes/No)
Q5 (If yes to Question 4) How often did this happen—almost every
month, some months but not every month, or in only 1 or 2
months?
Q6 In the last 12 months, did you ever eat less than you felt you
should because there wasn’t enough money for food? (Yes/No)
Q7 In the last 12 months, were you ever hungry, but didn’t eat,
because there wasn’t enough money for food? (Yes/No)
Q8 In the last 12 months, did you lose weight because there wasn’t
enough money for food? (Yes/No)
Q9 In the last 12 months did you or other adults in your household
ever not eat for a whole day because there wasn’t enough money
for food? (Yes/No)
Q10 (If yes to Question 9) How often did this happen—almost every
month, some months but not every month, or in only 1 or 2
months?
Questions 11-18 are asked only if the household included children ages 0-18

28. 28
Q11 “We relied on only a few kinds of low-cost food to feed our
children because we were running out of money to buy food.” Was
that often, sometimes, or never true for you in the last 12 months?
Q12 “We couldn’t feed our children a balanced meal, because we
couldn’t afford that.” Was that often, sometimes, or never true for
you in the last 12 months?
Q13 “The children were not eating enough because we just couldn’t
afford enough food.” Was that often, sometimes, or never true for
you in the last 12 months?
Q14 In the last 12 months, did you ever cut the size of any of the
children’s meals because there wasn’t enough money for food?
(Yes/No)
Q15 In the last 12 months, were the children ever hungry but you just
couldn’t afford more food? (Yes/No)
Q16 In the last 12 months, did any of the children ever skip a meal
because there wasn’t enough money for food? (Yes/No)
Q17 (If yes to Question 16) How often did this happen—almost every
month, some months but not every month, or in only 1 or 2
months?
Q18 In the last 12 months, did any of the children ever not eat for a
whole day because there wasn’t enough money for food? (Yes/No)
Note. From “Guide to Measuring Household Food Security, Revised 2000,” by G. Bickel,
2000, Department of Agriculture, Food and Nutrition Service, 6, p. 22. Copyright 2000
by USDA. Reprinted with permission.
Per Appendix A, households are considered food-secure if they report only one or
two food-insecure conditions. Food-insecure households are defined by having three or
more food-insecure conditions (Nord et al., 2008). Food insecurity is broken down into
multiple categories depending on the number of affirmative answers. Low food security
is classified as having multiple indications of food access, but few reduced intake
patterns. Very low food security, which is typically the situation where children are

29. 29
affected, is when the household reported to being hungry at some point due to lack of
money for food (Nord et al., 2008). This category breakdown is shown below in Table 3
with both the old categories and new categories represented.
Table 3
Food Security Categories Defined by the USDA
Old New Scale Scores Associated Conditions
Categories Categories (18-item)
(1995-2005) (2006-
present)
Food- Food-secure High food 0 affirmative No reported indications of
secure security responses food-access problems or
limitations
Marginal 1-2 One or two reported
food security affirmative indications—typically of
responses anxiety over food security or
shortage of food in the house.
Little or no indication of
changes in diets or food intake
Food- Food- Low food 3-5 Reports of reduced quality,
insecure insecure security affirmative variety, or desirability of diet.
without responses Little or no indication of
hunger reduced food intake
Food- Very low 6 or more Reports of multiple indications
insecure food security affirmative of disrupted eating patterns and
with hunger responses reduced food intake
Note. Adapted from “Food Security in the United States: Definitions of Hunger and Food
Security,” by M. Nord, 2008, Department of Agriculture, Food and Nutrition Service.
Copyright 2006 by the USDA. Reprinted with permission.

30. 30
Over the years, the 18-item survey has been adjusted to fit multiple situations,
populations, and households. A shortened form of the Food Security Scale was developed
in 1995 for research projects with less funding and time (Blumberg, Bialostosky,
Hamilton, & Briefel, 1999). Researchers narrowed the original 18-item survey down to
six questions, which still accurately assessed the food security status of the household,
but are not specific to children (Blumberg et al., 1999). In order to validate the survey for
most households and remain time effective, the researchers removed the eight questions
which are asked solely for households with children (Blumberg et al., 1999). This was
found to have little effect on the validity of the tool, and so the survey was further
shortened from ten remaining questions down to six, leaving the original questions 2, 3,
5, 7, 8, and 10 (Blumberg et al., 1999). The now 6-item, shortened form was tested with
both households with and without children resulting in 82.8% and 92.3 % accuracy
respectively. Both tools have been used in multiple research projects and validated for
multiple population groups ( Frongillo Jr, 1999; Opsomer, Jensen, & Pan, 2003; Swindale
& Bilinsky, 2006). The questions for the six-item survey are in Table 4, with the scoring
found in Appendix A.

31. 31
Table 4
Six-item Food Security Questionnaire, 2008
Item Number Question
The first four questions are in relation to the family’s food intake
Q5 In the last 12 months, did you or other adults in your household, ever
cut the size of your meals or skip meals because there wasn’t enough
money for food?
Q8 (Ask only if Yes to Q5)
How often did this happen- almost every month, some months but not
every month, or in only 1 or 2 months?
Q7 In the last 12 months, did you ever eat less than you felt you should
because there wasn’t enough money to buy food?
Q10 In the last 12 months, were you ever hungry but didn’t eat because
you couldn’t afford enough food?
The last two questions are in relation to the family’s food situation
Q2 “The food that I/we bought just didn’t last and I/we didn’t have
money to get more.” Was that often, sometimes, or never trough for
you in the last 12 months?
Q3 “I/we couldn’t afford to eat balanced meals.” Was that often,
sometimes, or never true for you in the last 12 months?
Note. From “The Effectiveness of a Short Form of the Household Food Security Scale,”
S. Blumberg, 1999, American Journal of Public Health, 89, p. 1234. Copyright 1999 by
the USDA. Reprinted with permission.
Food Security in the United States
Estimates of food security in the United States are calculated from the annual
Current Population Survey (CPS). The CPS is a monthly survey of 50,000 households
which includes an assessment of the food security of the nation through the use of the 18-

32. 32
item Food Security Survey Module, which asks households about their behaviors and
conditions over the past 12 months (U.S. Census Bureau, 2008). The FSSM is included in
the December distribution of the CPS. The questions are finance- related as to exclude
those who are purposely dieting or cutting back for other reasons. For example,
approximately 45,600 households made of civilian, non-institutionalized citizens of the
nation were utilized in 2007 (Nord et al., 2008).
Statistics on the food security of the United States have been collected since 1995.
In 2007, 88.9% of households were found to be food-secure while the other 11.1%, or 13
million, were food-insecure (Nord et al., 2008). Of those who were food-insecure, 7.0%
were households with low food security and 4.1% were found to have very low food
security. Figure 1 below illustrates the 2007 estimates.

33. 33
Low Food Secure
Households
Very Low Food
7%
Secure Households
4%
Food Secure
Households
89%
Figure 1. Food security status of U.S. households in 2007.
Note. Adapted from “Household Food Security in the United States, 2007,” by M. Nord,
2008, Economic Research Service/USDA , ERR-66, p. 4. Copyright 2008 by the USDA.
Adapted with permission.
Of the 4.7 million households who were determined to have very low food
security in 2007, there were several conditions reported as a part of this phenomenon:
98 % worried that their food would run out before they got money to buy more; 97 %
reported that the food they bought just did not last and they did not have money to get
more; 94 % reported that they could not afford to eat balanced meals; 96 % reported that
an adult had cut the size of meals or skipped meals because there was not enough money
for food; and 93 % reported that they had eaten less than they felt they should because

34. 34
there was not enough money for food (Nord et al., 2008). When food insecurity did
occur, about one-fourth of those households had problems chronically for at least seven
months out of the year (Nord et al., 2008).
The rates of both food security and food insecurity have not changed drastically in
the past ten years. The prevalence has changed less than one percent since 1999
according to the data collected from the CPS surveys (Nord et al., 2008). The data from
1999 on is based on the consistent FSSM after adjustments and changes were made from
1995 through 1998 (Bickel et al., 2000). Figure 2 below shows further detail of the trends
in food security over the past ten years.

35. 35
100%
98%
96%
Percentage of Households
94%
92%
90%
88%
86%
84%
82%
1999 2000 2001 2002 2003 2004 2005 2006 2007
Food Insecurity 10% 10% 11% 11% 11% 12% 11% 11% 11%
Food Security 90% 90% 89% 89% 89% 88% 89% 89% 89%
Figure 2. Food security and food insecurity trends in the U.S. from 1999-2007.
Note. Adapted from “Household Food Security in the United States, 2007,” by M. Nord,
2008, Economic Research Service/USDA , ERR-66, p. 6. Copyright 2008 by the USDA.
Adapted with permission.
Even though the FSSM is distributed through the CPS annually in December, it
has not always been that way. Originally, the FSSM was included in the April 1995 CPS,
and then changed from September, August, and back to April from 1996 through 1998
(Bickel et al., 2000; Nord et al., 2008). December was finally chosen as the month for the
FSSM distribution in 2001, which in turn keeps the data consistent from year to year
without seasonal influence (Nord et al., 2008).
Between 1988 and 1994, before the official measurement of food security began,
4.1% lived in families that reported food insecurity, which was due to lack of money,

36. 36
food stamps, or vouchers from WIC (Alaimo, Briefel, Frongillo, & Olson, 1998). A little
over 2% of these families had children under 17 who cut the size or skipped meals due to
lack of money (Alaimo et al., 1998).
Risk Factors for Food Insecurity
Risk factors for food insecurity include lower education, lower income, being
from an ethnic minority, living in a non-suburban residence, and participation in
government assistance programs (Adams, Grummer-Strawn, & Chavez, 2003; Alaimo et
al., 1998; Alaimo, Olson, & Frongillo, 2001b; Bhattacharya et al., 2004; Cutts, Pheley, &
Geppert, 1998; Gundersen et al., 2008; Herman, Harrison, Afifi, & Jenks, 2004; Holben
& Myles, 2004; Jones & Frongillo, 2006; Nord et al., 2008; Oberholser & Tuttle, 2004;
Quandt et al., 2004; Quandt, Arcury, Early, Tapia, & Davis, 2004; Rose, 1999).
Characteristics associated with being food-insecure in 2007 included households: (a) with
incomes below the poverty line; (b) with children; (c) headed by a single person; and (d)
headed by African-American or Hispanic individuals (Nord et al., 2008). Of the
population surveyed in 2007, 37.7% of those households were below the poverty line of
$21,027 in income for a family of four (Nord et al., 2008). Those households with
children headed by a single parent made up 48.2% of the food-insecure population (Nord
et al., 2008). Both single male or female headed households were at greater risk for food
insecurity, compared to other households (Nord et al., 2008). In another study, in fact,
both divorced men and women were found to have lower food security status than when
they were in a relationship (Hanson, Sobal, & Frongillo, 2007). African-American and
Hispanic based households made up 42.3% of the food-insecure group in 2007, with all

37. 37
of these groups having the most occurrence of very low food security (Nord et al., 2008).
Below are facts from the literature discussing the risk factors, outcomes, and further
developments found. Overall, it has been found that those living in households
characterized by food insecurity tend to be in households with children, headed by a
single adult, being an African-American or Hispanic, with income below the poverty line,
and located in metropolitan areas (Nord et al., 2008).
Poverty is a key component of food insecurity. One-fifth of study participants
nationwide under the poverty level in 1998 were food-insecure (Nelson, Cunningham,
Andersen, Harrison, & Gelberg, 2001). A study done in 2006 found many differences
between food-secure and insecure women in particular. Food-insecure women were
younger, less educated, single, with lower incomes than their counterparts and 61% of
them were overweight (Jones & Frongillo, 2006). Food assistance program participation
has also been associated with food insecurity and poverty. A household must meet
specific financial and resource requirements in order to be eligible for food assistance
programs, which are between 185% and 130% of the poverty level (Food and Nutrition
Service, 2008; U.S. Department of Health and Human Services, 2009b, 2009c). It was
found that 34% of Supplemental Nutrition Assistance Program (SNAP) participants in a
Maryland study sometimes did not have enough food to eat, or to provide adequate food
consistently (Oberholser & Tuttle, 2004). A study done with SNAP Participants found
that 66% of participants had some level of food insecurity with 7% being food-insecure
with hunger (Oberholser & Tuttle, 2004). In addition to food insecurity, lack of income
may also compromise the ability to properly heat and cool the home. Another study

38. 38
found that energy security was strongly and positively associated with both household
and child food insecurity (Cook et al., 2008).
All of these factors narrow down to mainly single, poor, low-educated women
who are having trouble providing consistent access to nutritious for their families. These
risks combined affect household diet, chronic disease risk, and weight of both children
and female adults. Even with participation in government assistance programs, such as
the Special Supplemental Nutrition Program for Women, Infant, and Children (WIC) and
SNAP, additional help may be needed due to the self-selection effect (Holben &
American Dietetic Association (ADA), 2006). This self-selection phenomenon explains
the higher occurrence of food-insecure participants in food assistance programs by saying
these households seek assistance due to social perception that it is needed (Holben &
ADA, 2006). Therefore any type of intervention that can teach self sufficiency or provide
assistance to both these mothers and their children could help offset struggling
households.
Outcomes of Food Insecurity in Adults
Food insecurity has multiple household consequences and/or associations,
including poor health, restricted activity, multiple chronic conditions, depression,
physical impairment, psychological suffering, and family disturbances (Hamelin et al.,
1999; Holben & ADA, 2006; Vozoris & Tarasuk, 2003). More specifically, food
insecurity has been associated with higher chronic disease risk including obesity,
diabetes, as well as mental and overall health (Hamelin et al., 1999; Hanson et al., 2007;
Holben & Pheley, 2006; Pheley et al., 2002; Stuff et al., 2004). Physical and dietary

39. 39
implications also occur in food-insecure households including hunger, depletion, illness,
stress, modification of eating habits, and disrupted household food management (Hamelin
et al., 1999; Holben & ADA, 2006; Kendall et al., 1996; Olson, 2005).
Food insecurity and chronic disease risk among adults.
Food insecurity is associated with increased risk for chronic disease and poor
management of the conditions. It has been found that food-insecure participants were
twice as likely to have diabetes as food-secure participants (Seligman et al., 2007). In a
study done in 2006, individuals with diabetes were more likely to live in food-insecure
households (Holben & Pheley, 2006). The study also found that individuals living in
food-insecure households were more likely to have HbA1c levels higher than the
recommended level of seven (Holben & Pheley, 2006). Poor management of diabetes can
lead to future health consequences for these individuals that they may not be able to
afford or manage. Food insecurity and financial restraints were also related to diabetes
(Nelson et al., 2001). Six percent of diabetic participants reported problems with food
insecurity and finances related to their diabetes management (Nelson et al., 2001). Food-
insecure individuals were more likely to report having heart disease, diabetes, high blood
pressure, and allergies in 2003 (Vozoris & Tarasuk, 2003).
Food insecurity and overweight/obesity among adults.
Adult individuals living in a food-insecure household, especially females, are
more likely to be obese than those in food-secure households (Lyons et al., 2008; Martin
& Ferris, 2007). One study done in Canada found that the rates of obesity coincided with
the rates of food insecurity (Lyons et al., 2008). In national surveys, researchers found

40. 40
that obesity was lowest for fully food-secure women, while those who were food-
insecure had the most weight gain over time (Hanson et al., 2007; Wilde & Peterman,
2006). Women in California were also found to have an increased risk for obesity when
classified as food-insecure, with almost one-fifth of food-insecure subjects being obese
(Adams et al., 2003). Those women in food-insecure households were almost twice as
likely to be overweight or obese as those in food-secure households (Adams et al., 2003).
As discussed above, obesity has been linked as a consequence of food insecurity
even though it seems to be counter intuitive. Food-insecurity is associated with lack of
food for a nutritious, healthy life. However, high calorie, high fat, low nutrient dense
foods tend to be less expensive than low calorie, low fat, and high nutrient dense items
(Mendoza, Drewnowski, Cheadle, & Christakis, 2006). Therefore, these empty calorie
foods replace the more nutritious options leading to weight gain.
Women especially have been directly affected by this obesity trend (Adams et al.,
2003; Holben & Pheley, 2006; Jones & Frongillo, 2006; Lyons et al., 2008; Olson, 1999;
Townsend, Peerson, Love, Achterberg, & Murphy, 2001; Wilde & Peterman, 2006).
Women in food-insecure households have been found to have an overall higher body
mass than those in food-secure households (Olson, 2005). Nationwide data collected in
1999 found a strong association between food-insecurity and overweight status,
especially in women who were initially normal weight (Jones & Frongillo, 2007). In rural
New York, it was found that obesity in early-pregnancy was positively associated with
food-insecurity in post-partum women (Olson & Strawderman, 2008). It was reported
that 19.3% of women changed food insecurity category from the beginning of pregnancy

41. 41
to 2 years postpartum, whereas only 5.1% changed category for obesity (Olson &
Strawderman, 2008). This infers that obesity may have a stronger correlation to food
insecurity, rather than food insecurity to obesity. There have been nationwide please for
federal support of research that focuses on the causes, mechanisms, practices, therapies,
and interventions in relation to overweight and obesity in all populations (Lyznicki,
Young, Riggs, Davis, & Council on Scientific Affairs, American Medical Association,
2001).
Conflicting findings exist with regard to food insecurity and overweight and
obesity in households. Food security was not related to overweight or obesity in low-
income Massachusetts study participants; however food assistance participation was
correlated (Webb, Schiff, Currivan, & Villamor, 2008). Another study done over multiple
cities in the U.S. found that a participant’s change of food security status was not
significantly associated with their change in weight (Whitaker & Sarin, 2007). In fact,
those participants who began the study as food-secure and changed over the course of
two years did not change in weight any more than participants whose food security status
remained unchanged (Whitaker & Sarin, 2007).
Food insecurity and overall health among adults.
Food insecurity has been associated with many other health problems besides
chronic disease, including increased risk for birth defects, maternal depression, suicide
attempts, depression, and overall poor health (Alaimo et al., 2002; Carmichael et al.,
2007). It was found that 53% of mothers who reported food insecurity in their family also
had depression (Casey et al., 2004). One study found as food insecurity rises, overall

42. 42
health status falls (Bronte-Tinkew et al., 2007). The elderly are a group whose health is
heavily affected by food insecurity. Those who reported food insecurity also reported
poor overall health more often than those who were food-secure (Lee & Frongillo, 2001).
All of these health problems could be alleviated with more consistent access to healthy
food and education for these families.
Food insecurity and diet among adults.
Food insecurity negatively impacts multiple aspects of the diet, including
decreased quality and quantity of food intake and diet (Chang et al., 2008; Condrasky &
Marsh, 2005; Kendall et al., 1996; Langevin et al., 2007; McIntyre et al., 2003; Olson,
2005; Vozoris & Tarasuk, 2003). Diets of individuals living in households characterized
by food insecurity have been found to have below the recommended intake of
kilocalories, protein, calcium, vitamins B-6 and B-12, riboflavin, niacin, magnesium,
iron, and zinc, compared to those living in food-secure households (Dixon et al., 2001;
Lee & Frongillo, 2001; Matheson et al., 2002; Olson, 1999; Rose & Oliveira, 1997).
Studies have shown food-insecure households to be of particular concern in relation to
decreased produce intake, as this can lead to increased risk for certain cancers,
cardiovascular disease, and lower overall wellness (Ahn et al., 2005; Cartmel et al., 2005;
Dixon et al., 2001; Genkinger et al., 2004; Guenther et al., 2006; Kendall et al., 1996;
Kirsh et al., 2007; Larsson et al., 2006; Lee et al., 2006; Pierce et al., 2007; Pierce,
Stefanick et al., 2007).
While diet inadequacy is related to food insecurity, eating habits of household
members may also suffer. Women in food-insecure households have been found to

43. 43
decrease their intake in order to allow other members of the family to eat (Kendall et al.,
1996; Olson, 2005). Low-income families who are found to be food-insufficient spend
significantly less money per household member on food in 2001 (Casey, Szeto, Lensing,
Bogle, & Weber, 2001). Food-insecure households spend on average ten dollars less per
person on food per week (Nord et al., 2008). The amounts are shown in Figure 3 below.
Weekly Household Food Spending Per Person
$45.00
$32.50 $33.33
$31.00
Food Secure Food Insecure Households with low Households with very
Households Households food security low food security
Figure 3. Weekly household food spending per person.
Note. Adapted from “Household Food Security in the United States, 2007,” by M. Nord,
2008, Economic Research Service/USDA , ERR-66, p. 26. Copyright 2008 by the USDA.
Adapted with permission.
Over half of the women in a Toronto study living in food-insecure households
reported to having some hunger in the 30 days preceding the study (Tarasuk & Beaton,
1999). Hunger is typically a managed process with some women using coping tactics,

44. 44
which typically include reducing their own intake to avoid or delay such insufficiency in
children (Olson, 2005; Radimer et al., 1990). In fact, women in food-insecure homes
have lower energy, protein, carbohydrate, fat, and essential nutrients, while their
children’s intake seem to be more adequate (McIntyre et al., 2003). It was also found
that the women’s average food and calcium intakes were positively associated with their
food security status, with those in more food-insecure homes having decreased intakes
(Tarasuk & Beaton, 1999). Both disordered eating (binge-like eating) and reliance on
others for food can cause disturbed eating patterns (Drewnowski & Specter, 2004;
Kendall et al., 1996; Olson, 2005), and lead to weight gain and poor health, which can
only heighten the health care burden on their family.
Prices and incomes greatly affect food choices, dietary habits, and dietary quality
(Drewnowski & Specter, 2004). Typically, more expensive, shorter shelf-life items, such
as fresh produce, dairy, and meat products, are substituted with cheaper items like
convenience foods and snacks (Dixon et al., 2001). As previously noted, adults in food-
insecure homes have lower intakes of energy, vitamin B-6, magnesium, iron, zinc, and
cereals (Dixon et al., 2001). While food insecurity also may lead to hunger, it is not
always the result (Nelson, Brown, & Lurie, 1998).
In addition to what has already been discussed, food insecurity also leads to
decreased produce intake, which may be improved by gardening. Eating fewer servings
of produce can have negative outcomes. For example, subjects in food-insecure
households were more likely to have lower vitamin C, fruit, and vegetable intake
(Kendall et al., 1996). Almost 75% of food-insecure subjects consumed two or fewer

45. 45
fruits and vegetables per day, compared to 54.6% of food-secure participants (Kendall et
al., 1996). The rural population of America in a 1993 study decreased their fruit, salad,
carrots, and vegetable intake as their food insecurity status worsened, which can
negatively impact their health (Kendall et al., 1996). Another study found that those
families with preschool children living in rural areas who ate homegrown produce had an
increase in home availability of produce (Nanney, Johnson et al., 2007).
Gardening projects have been done in order to increase participants’ fruit and
vegetable intake and subsequently improve health (Robinson-O'Brien et al., 2009). Such
interventions are an inexpensive way to increase produce intake, since price is typically
seen as a barrier, as well as physical activity in households (Cassady et al., 2007).
Food insecurity and food assistance programs. Many food-insecure families
participate in food assistance programs, including SNAP, WIC, and the Summer Food
Service Program (Condrasky & Marsh, 2005; Nord et al., 2008; Oberholser & Tuttle,
2004). In 2007, more than half (53.9%) of food-insecure families studied participated in
a food assistance program in the 30 days previous to data collection (Nord et al., 2008).
The percentages of participants in the three main national programs are shown in Figure
4.

46. 46
60.0%
50.0%
Percentage of Households
40.0%
30.0%
20.0%
10.0%
0.0%
Any of the
School
SNAP WIC three
Lunch
programs
Percentage of food insecure
households participating 33.0% 33.6% 12.5% 53.9%
Percentage of very-low food
security households 34.9% 28.1% 9.1% 50.9%
participating
Figure 4. Food-insecure household food assistance participation.
Note. Adapted from “Household Food Security in the United States, 2007,” by M. Nord,
2008, Economic Research Service/USDA , ERR-66, p. 33. Copyright 2008 by the USDA.
Adapted with permission.
A study of SNAP participants in South Carolina found that 25% were food-
insecure with hunger, with more SNAP participants being food-insecure than non-
participants (Condrasky & Marsh, 2005). They also determined that participants ate less
at the end of the food cycle than at the beginning. Both weight and BMI also increased

47. 47
over the two year period (Condrasky & Marsh, 2005). This appears to indicate that, the
cyclical nature of SNAP may lead to disordered eating patterns, leading to weight gain.
In order to improve the food security of these families, a study was done with
SNAP participants that aimed to increase their access to produce in order to increase
produce intake. Researchers found increased supermarket access was associated with
increased fruit consumption but not significantly increased intake for vegetables (Rose &
Richards, 2004).
Some federal programs have attempted to include produce into their household
provisions. The WIC program recently changed their food packages to include more
allowance for purchase of fresh fruits and vegetables, along with fruit and vegetable
equivalents for all ages (Food and Nutrition Service, 2008). The WIC program also
created the Farmers Market Nutrition Program which allowed participating families to
use vouchers at the local farmers markets in order to increase their fresh produce intake.
It was found that this significantly improved the participant’s vegetable intake, but did
not make a great impact on their fruit intake (Kropf et al., 2007; Walker et al., 2007).
Another study focused on the transportation aspect of produce access by distributing
produce packages to low-income households (Hazen et al., 2008). The study found
positive results in increased produce intake with participants (Hazen et al., 2008). This
shows that if fresh vegetable access is increased, it might be less of a barrier to food-
insecure families and further aid them in bettering their diet.
When families lack food they may utilize socially unacceptable means of food
acquisition. A study done on low-income mothers in Canada found that 80% of them had

48. 48
received free food over the past year from mostly food banks and relatives, and 75% of
the women were food-insecure (McIntyre et al., 2003). In a Canadian study done with
food bank participants, 69.9% of households were supported by welfare while 5.9%
relied on a combination of unemployment, loans, or other sources (Tarasuk & Beaton,
1999). A local study done with Ohio food pantry users found increased usage from food-
insecure households (O'Connell & Holben, 2005).
Outcomes of food insecurity in children
As previously mentioned, adults in the household are not the only household
members affected by lack of food, but when food insecurity is at its worst, children also
suffer. In most cases, children are protected from the harms of food insecurity; however
in 2007, 323,000 households had one or more children directly affected by food
insecurity (Nord et al., 2008). In 1998, there were 2.4 to 3.2 million children living in
food-insecure households, and the numbers are similar today (Alaimo et al., 1998; Nord
et al., 2008). Data collected in 1994 to 1996 from 3,837 households indicated that 7.5%
of the low-income families with children reported food insecurity, due to lack of money,
SNAPs, or WIC vouchers (Alaimo, Olson, Frongillo, & Briefel, 2001; Casey et al.,
2001). Lacking financial resources is a key feature of food insecurity. A 2006 study
found that 85% of the food-insecure children lived in houses below the 185% poverty
level (Rose & Bodor, 2006).
Food insecurity and overweight among children.
Overweight and obesity trends are not only seen in adults, but may also occur in
children. A 2006 nationwide household survey found that 17% of households with

49. 49
children were food-insecure, with 15% of those children having a BMI in the overweight
or at risk for overweight categories (Casey et al., 2006). The same study determined that
children living in poverty-stricken and/or food-insecure households, independent of
demographic data, were more likely to be at risk for overweight (Casey et al., 2006). A
nationwide study using NHANES data collected from 1988 through 1994 found an
increased prevalence of food insecurity and overweight coexisting among low-income,
older white children in the United States (Alaimo et al., 2001b). Another nationwide
survey using USDA data found the energy density of the diet was related to both obesity
and food insecurity in children, with those living in the Midwest having the highest
energy density (Mendoza et al., 2006). It has also been found that the prevalence of
overweight in children is indirectly related to the family income. As a family’s income
increased their overweight status has been shown to decrease (Gordon-Larsen, Adair, &
Popkin, 2003).
Children from families with both lower parental education and income have been
found to be more at risk for being overweight (Haas et al., 2003). This not only affects
them during childhood, but may exacerbate health risks in adulthood. A study in 2007
found that if a child grew up in a low-income household, they had an increased likelihood
of being overweight later in life, as well as have poor eating habits (Olson et al., 2007).
Lack of insurance was also associated with being overweight, which could be related to
less health care visits for both parents and children.
When low-income families who were food insufficient were compared to low-
income families who were food sufficient, households with children were more likely to

50. 50
be overweight and were less educated (Casey et al., 2001). However, not all studies of
food-insecure children have found an association between food insecurity and overweight
or obesity. In fact, one study reported that children who were classified as food-insecure
were in the intermediate BMI ranges and most reported as “trying to gain weight”
(Gulliford, Nunes, & Rocke, 2006).
Food insecurity and overall health status among children.
There are multiple associations between food insecurity, low income, overweight,
and health in children. A study done in the Mississippi Delta region in 2005 had similar
results as those done in the Appalachian region. Children in food-insecure households
had significantly lower physical and psychosocial functions as well as health related
quality of life (Casey et al., 2005). A study done in Texas using poor families found the
children had increased blood glucose, overweight, along with decreased fitness, calcium,
magnesium, phosphorus, potassium, and folate levels (Trevino et al., 2008).
Children living in food-insecure households are nearly twice as likely to report a
fair/poor health status as children in food-secure households (Cook et al., 2004). Those
food-insecure children also had tripled the chance of being hospitalized than food-secure
children (Cook et al., 2004). A nationwide study found that 85% of the food-insecure
children were from households that were below 185% of the poverty threshold; and
mothers with less than a college education were more likely to be overweight (Rose &
Bodor, 2006). One Appalachian Kentucky study found that children coming from
poverty-stricken, low-educated households were more likely to have stunted growth and
be obese than their counterparts, while another found similar results in Appalachian

51. 51
Pennsylvania (Crooks, 1999; Haas et al., 2003; Rappaport & Robbins, 2005). Health of
the child is also been found to be negatively impacted by the lowered household income.
Therefore, it has been suggested that interventions aiming to increase health and food
security of children should focus on increasing fruits and vegetables, along with whole
grains in their diets (Tanumihardjo et al., 2007).
Food insecurity has also been shown to impact a child’s mental and cognitive
health (Alaimo, Olson, & Frongillo, 2001a; Alaimo et al., 2002; Casey et al., 2005;
Connell et al., 2005; Kleinman et al., 1998; Murphy et al., 1998). When children’s diet is
negatively impacted by food insecurity causing hunger, they have been found to have
lower physical functioning along with behavioral and psychosocial problems (Alaimo et
al., 2001; Casey et al., 2005; Kleinman et al., 1998; Murphy et al., 1998). Other
consequences on food-insecure children include counseling, school disciplinary
problems, increased suicide risk, and difficulty interacting with others (Alaimo et al.,
2001; Alaimo et al., 2002). The longer a child is exposed to food-insecure conditions, the
more likely their academic performance is to suffer, including arithmetic and grade
completion (Alaimo et al., 2001), which can simply be improved through a healthy diet.
Food insecurity and diet and hunger among children.
Chronic food insecurity and hunger can lead to physical impairment, reduced
learning, and family disturbances (Hamelin et al., 1999). One study conducted in
Massachusetts with homeless and low-income households focused on children’s health
and well-being and the impact of hunger. This study found that half of the preschool
children had been homeless and moved an average of twice in the past year, while their

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mothers also reported the family as having moderate hunger (Weinreb et al., 2002). The
children who showed more hunger signs were more likely to be white, and those who had
severe hunger were more likely to have low birth weights and more chronic health
problems (Weinreb et al., 2002). A national sample of kindergarteners found that 22.2%
of the children’s households experienced food insecurity, which was also found to be
associated with increased weight gain, poor academic performance, and decline in social
skills (Jyoti et al., 2005). Those with higher incomes had better health, less need for
health care, lower parental depression, and lower levels of food insecurity, while the
opposite was true of poorer households (Ashiabi & O'Neal, 2007).
Even though children are typically protected from hunger, their diets can still be
impacted (Rose, 1999). Children in food-insecure households have lower intakes of
fruits, vegetables, and milk products, which directly impacts their calcium, vitamins A
and C intake (Dixon et al., 2001). Children typically consume the types of food supplies
provided by their caretakers, so when household food supplies are depleted, due to food
insecurity, children’s diets suffer, particularly intake of produce and meat (Matheson et
al., 2002). A sample of households reported 10.4% child food insecurity, 7.8% reduced
diet quality, and 2.6% child hunger (Skalicky et al., 2006). This same study also found
that food-insecure children were twice as likely to have iron-deficient anemia (Skalicky
et al., 2006). It was even found that food insecurity at any level is linked to poor health
outcomes in children, even without hunger or very low food security (Cook et al., 2006).
Not having enough food alone caused poor health in children regardless of
income level (Alaimo et al., 2001). It was also found that family food insecurity was

53. 53
linked to negative academic and psychosocial development in children (Alaimo et al.,
2001a). An in-depth qualitative study asked children in rural Mississippi open-ended
questions to assess their experiences with food insecurity. Some of the children
mentioned being ashamed or fearful of being labeled as “poor” and many coping
strategies were also discussed. Some of these strategies included eating less (quantity and
frequency), eating more or fast when food is available, use of cheap foods, feeling that
there was no choice, and limiting participation in social activities (Connell et al., 2005).
However, SNAP Program participation has been associated with better learning in food-
insecure children (Frongillo, Jyoti, & Jones, 2006). These occurrences typically only
happen when food insecurity is at its worst level, food-insecure with hunger, yet negative
effects on the children of these households appear to occur regardless of food security
categorization.
Federal and Non-Federal Food Assistance Programs
Federal and non-federal food assistance programs have a common objective, to
improve the nutritional status of underprivileged families. Federal programs, such as the
WIC program, SNAP, the School Meals Program, and the Summer Food Service
Program, aim to increase food security and reduce hunger of low-income families
through increased access to healthy nutritious food (Food and Nutrition Service, 2008;
U.S. Department of Health and Human Services, 2008; U.S. Department of Health and
Human Services, 2009a, 2009b, 2009c). Non-federal programs, such as Community Food

54. 54
Initiatives (CFI) and community gardens, share the same goals; however, their focus is on
a smaller population within a particular community.
The Special Supplemental Nutrition Program for Women, Infant, and Children (WIC)
The Special Supplemental Nutrition Program for Women, Infant, and Children,
better known as WIC, is a federal program started in 1974 which provides assistance to
low-income mothers with children under the age of 5 in order to assist with their
nutritional needs (Food and Nutrition Service, 2008). Services provided by WIC include
food vouchers, nutrition education, and health care referrals, which are all overseen by
the Food and Nutrition Service Department in conjunction with the USDA (Food and
Nutrition Service, 2008). In order to receive these benefits, women participants must
meet the income guidelines of 185% poverty level, or $35,798 per year (2008
information; Food and Nutrition Service, 2008). WIC foods include iron-fortified infant
formula and infant cereal, iron-fortified adult cereal, vitamin C-rich fruit or vegetable
juice, eggs, milk, cheese, peanut butter, legumes, tuna, and carrots (Food and Nutrition
Service, 2008). Special therapeutic infant formulas and medical foods may also be
provided if needed (Food and Nutrition Service, 2008). The program provides these
specific foods due to research showing participants are typically lacking in protein,
calcium, iron, and/or vitamins A and C (Food and Nutrition Service, 2008). A recent
revision of the WIC packages determined the need for more produce for all age groups.
In order to accommodate for this change, the packages now include more allowance for
the purchase of fresh fruits and vegetables, along with fruit and vegetable equivalents for
younger ages such as juice and baby foods (Food and Nutrition Service, 2008). WIC has

55. 55
been shown to improve the food security and produce intake of households; especially in
single parent households, through programs such as the WIC farmers’ market nutrition
program as well as participating in research studies that include produce distribution
(Kropf et al., 2007; Walker et al., 2007).
FNS Supplemental Nutrition Assistance Program (SNAP)
The Supplemental Nutrition Assistance Program (SNAP) is formerly known as
the Food Stamp Program, which began in 1943 as a project created by the Secretary of
Agriculture, Henry Wallace and Milo Perkins (U.S. Department of Health and Human
Services, 2009c). After many trials and adjustments to the original program of using
orange and blue stamps to purchase certain commodities, President Johnson proposed to
make the program permanent, which was then confirmed by the Food Stamp Act of 1964
(U.S. Department of Health and Human Services, 2009c). Since its beginning, SNAP has
changed to fit the needs of the consumers, including the switch from paper stamp usage
to an updated electronic card system (U.S. Department of Health and Human Services,
2009c).
SNAP helps low-income families purchase food for their families through the use
of an electronic debit card which provides discounts on items at grocery or convenience
stores (U.S. Department of Health and Human Services, 2009c). The program also
provides nutrition education to its participants in order to improve their overall diet,
however not just anyone can qualify for SNAP (U.S. Department of Health and Human
Services, 2009c). In order to be eligible for the program, you must meet strict guidelines