Nutrition Program for Seventh Grade Students in Duval County

Program Portfolio

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Rebecca Barnes, Paige Davis, Jamie Herndon, Elizabeth Ashley Lewis,

Sarah Napolitano, Kristen Schroeder Assessing Need Triggers & Rationale: The obesity epidemic in the United States has, in recent years, been gaining widespread concern. With that concern has come many efforts to rally support for the development of obesity intervention programs and preventative strategies. With one third of Americans overweight and another one third classified as obese, something needs to be done to better the quality of life for Americans. People develop lifelong habits at an early age and it is known that it is easier to change poor habits and develop good habits at a younger age; it is this reason why we have chosen to develop a nutrition program targeted at children ages 11-14. At this age children are old enough to understand the importance of eating right and are cognitively developed to a point at which they can take what they have learned and apply it to their everyday lives. Targeting children at this age will allow them to feel more in control because we will be providing them with information they can use to better themselves. At this young age, children given the knowledge needed to sustain a healthy lifestyle can develop the habits necessary to live and maintain a higher quality way of life throughout adulthood. Providing students with quality health programs should improve their knowledge, attitudes, and skills needed to encourage healthy behaviors, with the ultimate goal of reducing their risk for obesity and other chronic diseases. The increased prevalence of type 2 diabetes, also known as adult-onset diabetes, in children is a disturbing trend that signifies that our nation is in dire need of a health make over. Children should not have to succumb to the chronic ailments that are most often experienced in adulthood. By increasing the nutritional knowledge of our younger generation we are paving the way for a healthier America in later years; we will be decreasing the widespread presence of obesity in adulthood, as well as decrease the commonness of other disease including but not limited to heart disease, type 2 diabetes, cancer and chronic kidney failure. Improving the health of young Americans will also aid in bettering students’ self-image and confidence which provides students with the foundation to develop healthier relationships among family members and peers. It is imperative to design a program for the younger generation because these children are our future and as they grow older they can then pass on the knowledge they’ve received to even younger generations and family members in order to establish a healthier community. Area of Need:

The area of need we will address is the lack of nutrition education among the middle school aged population.

Available Data: Dr. Debby Demory-Luce and Dr. Craig Jensen stated that the “nutritional needs during adolescence are increased because of the increased growth rate and changes in body composition associated with puberty. The dramatic increase in energy and nutrient requirements coincides with other factors that may affect adolescents’ food choices and nutrient intake, and thus nutritional status. These factors, including the quest for independence and acceptance by peers, increased mobility, and greater time spent at school and/or work activities, and preoccupation with self-image, contribute to the erratic and unhealthy eating behaviors that are common during adolescence. Sound nutrition can play a role in prevention of several chronic diseases, including obesity, coronary heart disease, and certain types of cancer, stroke, and type 2 diabetes. National and population-based surveys have found that adolescents often fail to meet dietary recommendations for overall nutritional status and for specific nutrient intakes. Many adolescents receive a higher proportion of energy from fat and/or added sugar and have a lower intake of vitamin A, folic acid, fiber, iron, calcium, and zinc than is recommended.”

There is a multitude of information about the dietary behaviors of the adolescents in the United States. The Centers for Disease Control and Prevention (also known as the CDC), an article in the Journal of the American Dietetic Association, and the School Health Policies and Programs Study (also known as SHHPS) can help understand the problem from a national standpoint. When examining the problem from a state level it is important to look at the Youth Risk Behavior Survey (also known as YRBS), the School Health Profiles (also known as Profiles), an article in the Journal of School Health, and the Youth Physical Activity and Nutrition Survey. Lastly, the YRBS can also help understand the problem from a county standpoint. With these resources combined we can accurately evaluate the magnitude of the problem from a national level, state level, and county level. National Level: The CDC provides key nutrition facts, consequences of a poor diet, eating behaviors of young people, and diet and academic performance information for the United States. Some of the key nutrition facts they provide are, “healthy eating is associated with reduced risk of many diseases, including several of the leading causes of death: heart disease, cancer, stroke, and diabetes. Healthy eating in childhood and adolescence is important for proper growth and development and can prevent health problems such as obesity, dental cavities, iron deficiency, and osteoporosis. The Dietary Guidelines for Americans recommend a diet rich in fruits and vegetables, whole grains, and fat-free and low-fat dairy products for persons aged 2 years and older. The guidelines also recommend that children, adolescents, and adults limit intake of solid fats (major sources of saturated and trans fatty acids), cholesterol, sodium, added sugars, and refined grains. Unfortunately, most young people are not following the recommendations set forth in the Dietary Guidelines for Americans. Schools are in a unique position to promote healthy eating and help ensure appropriate food and nutrient intake among students. Schools provide students with opportunities to consume an array of foods and beverages throughout the school day and enable students to learn about and practice healthy eating behaviors. Schools should ensure that only nutritious and appealing foods and beverages are provided in school cafeterias, vending machines, snack bars, schools stores, and other venues that offer food and beverages to students. In addition, nutrition education should be part of a comprehensive school health education curriculum.” Some of the consequences of a poor diet that the CDC provides are: “a poor diet can lead to energy imbalance (e.g., eating more calories than one expends through physical activity) and can increase one’s risk for overweight and obesity. A poor diet can increase the risk for lung, esophageal, stomach, colorectal, and prostate cancers. Individuals who eat fast food one or more times per week are at increased risk for weight gain, overweight, and obesity. Drinking sugar-sweetened beverages can result in weight gain, overweight, and obesity. Providing access to drinking water gives students a healthy alternative to sugar- sweetened beverages. Hunger and food insecurity (i.e., reduced food intake and disrupted eating patterns because a household lacks money and other resources for food) might increase the risk for lower dietary quality and undernutrition. In turn, undernutrition can negatively affect overall health, cognitive development and school performance.” The CDC states that most United States youth, “do not meet the recommendations for eating 2 ½ cups to 6 ½ cups of fruits and vegetables each day; do not eat the minimum recommended amounts of whole grains (2-3 ounces each day); and eat more than the recommended maximum daily intake of sodium (1,500- 2,300 mg each day)”. The CDC also discovered that, “empty calories from added sugars and solid fats contribute to 40% of daily calories for children and adolescents aged 2-18 years old, affecting the overall quality of their diets. Approximately half of these empty calories come from six sources: soda, fruit drinks, dairy desserts, grain desserts, pizza, and whole milk”. Another important discovery that the CDC found was that, “adolescents drink more full-calorie soda per day than milk. Males aged 12-19 years drink an average of 22 ounces of full-calorie soda per year, more than twice their intake of fluid milk (10 ounces), and females drink an average of 14 ounces of full-calorie soda and only 6 ounces of fluid milk”. The CDC states the correlation between diet and academic performance is, “eating a healthy breakfast is associated with improved cognitive function (especially memory), reduced absenteeism, and improved mood.” According to the article, Nutrition Quality and Education in K-12 Schools, in the 2005 Journal of the American Dietetic Association, “In 2003, 61% of US schools had no nutrition education coordination program. With recent emphasis on students meeting standardized test scores, few teachers can spare any time to teach nutrition in the classroom. As a result, our children are missing out on valuable knowledge that is essential to creating lifelong healthful habits.” After surveying the nutrition education of 1,409 US public schools, it was discovered that, “Approximately half (52%) of respondents have had formal training to teach nutrition in the classroom, yet 88% reported that they taught nutrition lessons to students. [Also] the mean number of hours in a school year spent on teaching nutrition education was 13. (According to the survey authors, 50 hours is the minimum amount of time believed to be necessary for impact on behavior.) Nutrition was taught as a separate subject by 35% of respondents, whereas other respondents (39% and 33%, respectively) integrated the lessons into health/physical education and science curricula. [Lastly, they also discovered that] approximately 21% reported not having enough materials for all students in the classroom.” The 2006 SHPPS found the percentage of middle schools in which teachers taught nutrition and dietary behavior topics as part of required instruction: 67% of middle schools taught students the topic of Dietary Guidelines for Americans, 76.1% of middle schools taught students the topic of food guidance using MyPyramid, and 75.9% of middle schools taught students the topic of preparing healthy meals and snacks. However, this study also found that “among classes in which nutrition and dietary behavior was taught, the median number of hours of required instruction teachers provided on nutrition and dietary behavior decreased from 4.6 in 2000 to 3.4 in 2006 among middle school classes”. They also found that “19% of middle schools offered brand-name fast foods from companies such as Pizza Hut, Taco Bell, or Subway”. Another important statistic they found was that “71.3% of middle schools had either a vending machine or school store, canteen, or snack bar where students could purchase foods or beverages”. This survey also found that: “4% of state and 6.6% of districts required that schools make fruits or vegetables available to students whenever food was offered or sold. 18.4% of states required and 17% of districts required that schools make healthful beverages such as bottled water or low-fat milk available to students whenever beverages were offered or sold. 25.4% of middle schools allowed students to purchase foods and beverages high in fat, sodium, or added sugars from a vending machine or in a school store, canteen, or snack bar during lunch periods. 28.7% of middle schools allowed students to buy soda pop, fruit drinks that are not 100% juice, or sports drinks from a vending machine or in a school store, canteen, or snack bar during lunch periods. Only 12.9% of middle schools in the United States provide students the opportunity to purchase 1% or skim milk from vending machines or school stores. Only 15.4% of middle schools provide students the option to purchase 2% of whole milk from vending machines or school stores. Only 41.1% of middle schools give students the option to purchase 100% fruit juice from vending machines or school stores. Only 63.2% of middle schools give students the option to purchase water from vending machines or school stores. Only 8.7% of middle schools give students the option to purchase fruits or vegetables from the vending machine or school stores”. This survey also discovered that when organizations sold specific foods and beverages for fund-raising in middle schools 56.2% was chocolate candy, 55.8% was baked goods not low in fat, 42.6% was non-chocolate candy, 30.3% was soda pop or fruit drinks that were not 100% juice, 24.0% was sports drinks, and only 20.7% was fruits and vegetables.

State Level: According to the research article, Dietary and Physical Activity Behaviors of Middle School Youth: The Youth Physical Activity and Nutrition Survey, in the January 2008 Journal of School Health, “the Florida Department of Health developed the Youth Physical Activity and Nutrition Survey (YPANS) for monitoring middle school students’ knowledge and practices related to physical activity and nutrition”. There were 73 participating middle schools in the 2003 survey. This survey found data for dietary behaviors, such as the consumption of fruits and vegetables, milk consumption, soda consumption, daily breakfast consumption and nutrition knowledge. When they looked specifically at the consumption of fruits and vegetables they discovered that, “slightly less than one fourth (22.8%) of respondents reported consuming 5 or more fruits and vegetables per day. [They also found some significant differences between grade levels of middle school students.] More sixth-grade middle school peers (26.6%) consumed 5 or more fruits and vegetables per day than their seventh-grade (23.9%) and eighth-grade (18.6%) middle school peers.” When they looked specifically at milk consumption, they found that, “just more than one fifth (21.9%) of survey respondents reported that they drank 3 or more glasses of milk per day during the past 7 days. There were statistically significant differences for sex. More boys (27.5%) than girls (16.0%) drank 3 or more glasses of milk per day during the previous 7 days. When asked what kind of milk they usually drank (respondents could select more than 1 response), the most common answers were whole milk (40%), chocolate milk (34%), and 2% milk (25.8%). About 1 (9.2%) of 10 respondents did not know what kind of milk they drank.” When they looked specifically at soda consumption they discovered that,” approximately one fourth (26%) of middle school students drank 2 or more sodas per day during the previous 7 days. Among students, 12.9% did not drink any soda during the previous 7 days, 50.4% drank some soda, but less than 1 per day, and 10.7% drank 1 soda per day.” When they looked specifically at daily breakfast consumption they found that, “Almost half (46.6%) of middle school students reported eating breakfast every day during the previous 7 days. There were statistically significant differences for sex and grade level. More boys (52.4%) than girls (40.9%) ate breakfast every day during the previous 7 days. More sixth graders (52.3%) reported eating breakfast every day during the previous week compared to seventh graders (45.9%) and eighth graders (41.7%).” When they specifically looked at nutrition knowledge they discovered that, “when youth were asked about the expert recommendations for daily fruit and vegetable consumption, les than one fifth (17.8%) correctly identified consumption of 5 or more servings per day. About one fifth (20.8%) were not sure, and 61.4% answered between 1 and 4 servings per day. When asked to indicate where they had learned about eating healthy (youth could indicate more than one response), 62.2% reported learning from their parents, 56.7% reported learning from school, 42.7% said learning from a doctor or nurse, 31.2% reported learning from television, and 13.7% answered learning from some other source.” The Florida Department of Health administered the Youth Physical Activity and Nutrition Survey again in 2005. This time 70 middle schools participated in the survey. They looked again at the nutrition knowledge and dietary behaviors of middle school students. They found, “[When] students were asked where they learned about healthy eating, the most common responses were: parents 63.2% and schools 60.7%. The role of the schools in providing healthy nutrition information is quite clear. [When] students were asked in which class they learned about eating healthy, the most common responses were: health education 42.3%, science 37.3%, and physical education 28.8%. [When] students were asked how many fruits and vegetables experts recommend that they should eat in a day, 22.8% correctly identified five. [When] students were asked the question: ‘Do you read food labels for ‘low fat’, or ‘less calories’, or ‘low carbs’ before you choose or buy food or snacks?’, overall 34.5% responded never and an additional 15.7% responded hardly ever. More males (42%) than females (27.1%) responded never. More eighth graders (37%) than sixth graders (30.7%) responded never.” They also discovered that, “overall, 22% of students consumed five fruits and vegetables a day. More males (23.6%) than females (20.3%) consumed five fruits and vegetables a day. More sixth graders (24.2%) than eighth graders (20.6%) consumed five fruits and vegetables each day. [When] asked how many times [they] drink punch, sports drinks, or other fruit-flavored drinks that are not 100 percent fruit juice, 28.5% [said they] drank fruit-flavored drinks two or more times per day. More males (25.5%) than females (24.4%) consumed these drinks. [When] asked a question about soda consumption (both diet and regular soda), 22.9% consumed two or more sodas each day during the past seven days. More males (25.9%) then females (19.8%) consumed two or more sodas each day. More eighth graders (25.8%) than both seventh graders (22%) and sixth graders (20.8%) consumed two or more sodas each day. [When] asked the question ‘during the past seven days, how many glasses of milk did you drink? (Include milk you drank in a glass or cup, from a carton, or with cereal. A milk shake counts as a glass of milk. Count the half pint served at school as equal to one glass.)’, 19% of students drank three or more glasses of milk each day. More males (24.6%) than females (13.3%) drank three or more glasses of milk each day. More sixth graders (22.3%) than eighth graders (16.3%) drank three or more glasses of milk each day.” When they asked students about eating breakfast, “less than half (44.2%) of middle school students ate breakfast every day during the previous seven days. More males (51.2%) than females (37.2%) ate breakfast every day during the previous seven days. More sixth graders (49.5%) than either seventh graders (41.6%) or eighth graders (41.7%) ate breakfast every day during the previous days.” They also discovered that, “more than half of the students (51.1%) ate at a fast food restaurant on two or more days during the previous seven days. More eighth graders (53.7%) and seventh graders (51.7%) than sixth graders (47.8%) ate at fast food restaurant on two or more days during the previous seven days. [When] asked the question, ‘during the past five school days, how many days did you buy a la carte or single items instead of the school lunch?’, 34.1% of middle school students bought a la carte instead of the school lunch on one or more days during the past five school days. The major reasons for buying a la carte items were: I don’t like the lunch offered (32.6%) and I the food better than the line lunch (17.4%). Overall, 58.4% of middle school students had a snack vending machine from which they could buy snacks. Of those who had a snack vending machine at school, 20.4% purchased one of more snacks each day during the previous five school days. Of those who purchased snacks from a vending machine, the types of snack purchased most often were: chips, pretzels, or crackers (42.1%) and candy bars (18.2%). Overall, 47.8% of middle school students, when they purchased snacks from a vending machine, thought about whether or not it is a healthy snack always or sometimes. More sixth graders (54%) than either seventh (46.4%) or eighth (42.5%) graders thought about whether or not the snack that they are purchasing was healthy. Approximately 86% had a drink vending machine from which they could buy drinks. Of those who had a drink vending machine at school, 31.6% purchased one or more drinks each day during the previous five school days. The most common drinks purchased from the vending machine at school were soda (33.2%) and sports drinks (33.1%). Overall, 19.5% of middle school students bought a snack or drink form the vending machine instead of buying lunch or eating lunch brought from home on one or more days during the past five schools days. [When] asked the question, ‘does your teacher or the staff at your school give you candy or sweets as a reward for good or extra work?’, 65.2% answered sometimes. More females (71.7%) answered sometimes than males (58.9%). More sixth graders (68%) than eighth graders (63.5%) were given candy or sweets as a reward. The last question on dietary behaviors, ‘do you sell candy to raise money for your school, your school band, or a school sport?’ Overall, 27.9% of middle school students sold candy. More females (33.1%) than males (22.8%) sold candy. After examining the results of the 2003 and 2005 Youth Physical Activity and Nutrition Surveys separately, it is also important to look at the trend that progressed within those two years. Although the nutritional patterns of the middle school youth did not get any worse per say, there wasn’t any improvement either. They both discovered that school is one of the main places that these students learn about nutrition. The schools need to continue to strive to do more and more to help these students understand the importance of nutrition. In 2009, the Florida YRBS found that among high school students, “78% ate fruit and vegetables less than five times per day during the 7 days before the survey; 67% ate fruit or drank 100% fruit juices less than two times per day during the 7 days before the survey; 87% ate vegetables less than three times per day during the 7 days before the survey; and 29% drank a can, bottle, or glass of soda or pop at least one time per day during the 7 days before the survey”. Even though we are not specifically working with high school students it is important to notice that the percentage of students not eating the recommended amounts of healthy foods continues to rise from middle school to high school. The trends these students picked up in middle school seem to be sticking with them throughout high school and possibly throughout the rest of their life. This is why nutrition education should be started at the middle school level when the students are able to make their own decisions about food, but can still change their dietary patterns before they are set in stone. The 2010 Profiles produced data for the Florida secondary schools on nutrition information. They found that: the “percentage of schools that always offered fruits or non-fried vegetables in vending machines and school store, canteens, or snack bars, and during celebrates when food and beverages are offered was 16.7%; the percentage of schools that used at least 3 different strategies to promote healthy eating was only 28.5%; and the percentage of schools that taught 14 key nutrition and dietary behavior topics in a required health education course was 58.3%”. In 2006, SHHPS produced a school health program report card for the state of Florida. Some of the important findings for the state of Florida were: the state required the schools to offer three or more different types of milk each day for breakfast, but it was only recommended or encouraged that this was also offered to the students at lunch time; the state did not require, recommend, nor encourage that schools offer two or more different fruits or types of 100% fruit juice each day for lunch; the state did not require, recommend, nor encourage that schools offer two or more different entrees or main courses each day for lunch; the state did not require, recommend, nor encourage that schools offer two or more different non-fried vegetables each day for lunch; the state did not require, recommend, nor encourage that schools make fruits or vegetables available to students whenever other food was offered or sold; the state did not require, recommend, nor encourage that schools make healthful beverages available to students whenever other beverages were offered or sold; the state did not require, recommend, nor encourage that schools prohibit junk food in the following school setting: after-school or extended day programs, a la carte during breakfast or lunch periods, concession stands, meetings attended by students’ family members, school stores, canteens, snack bars, staff meetings, students parties, or vending machines; the state did not require, recommend, nor encourage that schools restrict times of day junk foods can be sold in any venue; the state did not require, recommend, nor encourage that schools prohibit the selling of junk foods for fundraising; the state did not require, recommend, nor encourage that schools prohibit advertising for candy, fast food restaurants, or soft drinks on school property; the state did not require, recommend, nor encourage that middle or high schools prohibit some student access to vending machines; the state did not prohibit nor discourage the using food or food coupons as a reward. Although middle school students are old enough to make their own decisions about what is healthy or not, the school environment and the choices offered to the students still have a huge impact on what they choose to eat during school.

Local Level: The 2009 Florida YRBS also produced specific data for Duval County, Florida. Twenty- seven middle schools participated in the survey, which found that, “about 55% of students drink at least one soda per day; and less than 15% of students ate the recommended amount of fruits and vegetables”. Also, nineteen public high schools in Duval County participated in this survey finding that, “about 30% of students drink at least one soda per day; over twice as many males drank 3 or more glasses of milk than females; and less than 20% of students ate the recommended amount of fruits and vegetables”. The data provided for the Duval County high school students was further broken down to compare it to the United States. The study discovered that Duval County high school students were more likely to engage in poor dietary behaviors than the United States youth as a whole. Duval County high school students were more likely, “to eat fruits and vegetables less than five times per day; to not drink 100% fruit juice; to not eat fruit; to not eat green salad; to not eat carrots; to not eat other vegetables (excluding green salad, potatoes, or carrots); to drink less than three glasses per day of milk; to eat fruit or drink 100% fruit juices less than two times per day; and to eat vegetables less than three times per day”. Again, even though our target population is middle school students, it is important to look at how the trends continue throughout high school. This can give us valuable information about the impact that proper nutrition education can have on middle school students that will be progressing into high school soon. Middle school is the starting point when students start making their own decisions about what they eat and drink. It is important to teach them about nutrition education then so that we do not continue to see an increase in these numbers in the future. According to the Duval County’s Public Schools Wellness Program, which has been in effect since 2006, “At the secondary school level, Comprehensive Health Education classes shall continue to be taught by certified Health Education teachers as a separate course. At the middle school level, students are required to take one quarter (nine consecutive weeks) of Comprehensive Health Education in grades 6, 7 and 8. [They continue by saying that] health education classes shall have an appropriate student/teacher ratio and shall be taught in a classroom conducive to learning. [Also,] teachers shall be encouraged to integrate age & developmentally appropriate nutrition education into other core curriculum area such as math, science, social studies, and physical education and language arts as applicable.” It is really important to understand that middle school students are at the age where they are really under a lot of pressure whether it is to fit in with their friends or to do well in school. So the big question to ask about this is nine consecutive weeks of Comprehensive Health Education enough for these students? Looking over the multitude of research provided above, it does not appear to be enough. Comprehensive Health Education should not only be offered to these students for nine weeks in the entire school year. To really have an impact, these students need more than just the required nine consecutive weeks that the county is mandating.

Data Available: While examining the data available on the dietary behaviors of the adolescents, most of the information was found by giving surveys to middle and high school aged students during normal school hours. Most adolescents in the United States attend schools that could potentially participate in these kinds of surveys if they so elected to. This type of data seems to work best for this topic and this specific age group. The surveys have been given to the students while they are in school so we have a better chance of almost all the students at these schools to participate as long as they were present the day the surveys were given. These surveys also seem to work best for this age group because when students get to middle school or high school they are more likely to buy their food or make their own snacks or meals when they get home from school. By asking them to fill out the survey they can give us a more accurate perspective of what they have had to eat and drink over the course of the past week. Surveys about adolescent dietary behaviors are readily available. Two important surveys that have been used to investigate middle school students’ dietary behaviors are the Youth Physical Activity and Nutrition Survey and the YRBS. The Youth Physical Activity and Nutrition Survey takes place every two years at participating middle schools throughout the state of Florida. Once the survey is conducted the data is then investigated and published in journals. This survey only produces data at the state level though. The YRBS investigates adolescents’ dietary behaviors by conducting a survey, which includes some questions about the students’ normal nutritional intake. These surveys are usually completed every two years to access the needs of the students in the school, county, state, and nation.

Priority Population: Adolescent youth ages 11-14 (middle school), 7th grade

■ According to the Youth Risk Behavior Surveillance Survey completed in 2009, data shows that there are high rates of poor nutrition and obesity when looking at statistics among adolescents 15-19 years old, therefore the target population needs to be younger adolescents in order to prevent the occurrence of these health problems. Youth ages 11-14 however are old enough to understand the importance of nutrition and be able to apply it. ■ According to the Duval County’s Public School’s Wellness program adolescent youth are at an age where they are becoming independent and are in more control of what they eat and their nutrition. They are at an age where they can be educated on proper nutrition in order to reduce the occurrence of obesity and increase the use of proper nutrition. This will give them the tools to prevent an array of illnesses that are associated with poor nutrition and obesity.

Initial Assumptions:

Nutrition health is very important for all individuals. We as a group feel that children between the ages of 11-14 would be most impacted and have a greater likelihood of making changes to their eating lifestyles if they are taught good dietary habits and choices now rather than in the future. We feel that poor nutrition is impacting young adolescents for a variety of reasons such as: the convenience and swiftness of unhealthy food (fast foods) as well as their cost-effective prices in comparison to healthier foods. There are many adolescents who choose unhealthy snacks from vending machines or through the lunch line and many that arrive at home in the afternoon before a parent gets there leaving them to make unhealthy choices in regards to eating. Many adolescents may experience stress and peer pressure which can also contribute to unhealthy eating habits as a coping measure. Intrapersonal and interpersonal factors play a role in the poor nutritional decisions made by those in the 11-14 age range as well; some intrapersonal factors are adolescents’ confidence level and self-worth. Interpersonal factors consist of the influence and support of parents and friends and the overall environment in which they interact and live in. Each of these factors along with many others plays an important role in what foods are available and consumed by adolescents. Goals & Objectives

Goal: Improve the nutrition knowledge of adolescents between the ages of 11 to 14 to reduce the rates of obesity

Objectives: 1. By completion of the program participants will be able to identify 80% of healthier food choices when given a questionnaire comparing two food options.

2. By completion of the program students will be able to complete the post food label exam with a minimum score of 80%.

3. By completion of the program, participants’ food logs will replicate portion control according to the Dietary Guidelines of America in 65% of their entries.

4. By completion of the program, participants will be able to identify the five core components of a balanced meal as identified by My Plate on their post exam.

5. By completion of the program, participants and their families will attend a banquet featuring dishes prepared by each family, utilizing the nutritional concepts learned throughout the program. Each participant will provide the recipe and methods of cooking to be evaluated based on nutritional factors. Program Development

The program will be implemented in the school system. It will be required for 7th graders to take this year long nutrition course. The course will meet two to three times a week. The instructor for the course will motivate and encourage participants to make healthier food choices by educating the participants on healthy foods, portion control, and how to read and understand food labels by utilizing many methods of teaching. The structure of the course will consist of questionnaires and Pretest and Posttest to evaluate the students’ knowledge over the period of the program as well as lectures and videos. The Tests will be implemented at the beginning, middle and end of the program. The program’s participants will be required to keep a journal of the food they eat on their “food logs”. The food logs will be due weekly containing a parent or guardian’s signature. Participants will also participate in activities conducted by the assigned health instructor these activities will include: compiling healthy food options for their lunch boxes, building a cookbook with healthy recipes they bring to class, and having guest speakers. The guest speakers will include a Pediatrician and a Nutritionist discussing the risks of obesity and other health problems due to poor nutrition. The program will also teach the importance of understanding and using MyPlate as well as learning the Dietary Guidelines of America; also during the program students will prepare healthy snacks to bring and share with the class as part of their Show and Tell. Parents will be involved with the Nutrition Program by attending the school’s open house where they will receive the students’ backpacks filled with workbooks and nutrition information. At the end of each semester there will be a banquet held where the students and parents work together to come up with a healthy dish to present as well as the nutritional information for that dish. The Banquet will be graded on participation and there will be awards given for the healthiest dishes. At the end of the program participants will write a Reflection Paper demonstrating what they have learned as well as how they have implemented that knowledge.

Timeline:

First Quarter:

1. Open House- Parents come and meet the Health Educator to gather material including backpacks and workbooks. 2. Administer Pretest 3. Introduce food logs and MyPlate 4. Start Working on Cookbook recipes due at end of the quarter 5. Show and Tell- Bring in a healthy snack to share with the class.

Second Quarter:

1. Continue with food logs 2. Guest Speaker- Pediatrician 3. Cookbook recipes due at end of Second Quarter 4. Process Evaluation (Mid-Term Evaluation Test) Given 5. First Banquet- Students and Parents prepare healthy dish and submit recipe. Awards will be given at the Banquet for most creative healthy dish

Third Quarter:

1. Continue with food logs 2. Guest Speaker- Pediatrician 3. Field Trip to Grocery store 4. Video on Supermarket Savvy 5. Show and Tell- Lunch party. Students will bring in one healthy dish along with the recipe. 6. Cookbook recipes due at end of Third Quarter

Fourth Quarter:

1. Continue with food logs 2. Questionnaire implemented for healthier food options 3. Finalize Cookbook compiled with students recipes 4. Reflection Paper Due 5. Post Test Implemented 6. Banquet- Students and Parents prepare healthy dish and submit recipe. Awards will be given at the Banquet for most creative healthy dish

Logic Model: Step 1: Long Term Outcomes and Problem Solution-Improve the nutrition knowledge of adolescents in 7th grade to reduce the rates of obesity throughout life. Step 2: Intermediates Outcomes (through customers) – · Improve nutrition knowledge by educating on dietary guidelines and portion sizes Step 3: Short-Term Outcomes- · Improved ability to read nutrition label · Improved ability to choose healthy food options · Improved ability to assess their progress through tracking food consumption Step 4: Clients: 7th grade students both male and female of diverse ethnic and racial backgrounds Step 5: Activities: · Pretest/Posttest · Food logs · Video Supermarket Savvy · MyPlate Worksheet · Questionnaire with healthy and not so healthy options · Banquets · Compile recipes for cookbook-4 times throughout the program · Show and Tell-Healthy Snack · Guest Speaker- Pediatrician · Guest Speaker- Nutritionist · Reflection Paper on changes in food log · Supermarket Field trip on how to shop for healthy foods · Lunch Party with healthy food choices · Food Label quiz · Backpacks with tools for parents and students Step 6: Resources: ● Backpacks ● Workbooks ● Worksheets ● Pretest/Posttest ● Video ● Questionnaire ● Guest Speakers ● Lectures ● Staff Step 7: External Factors ● Income/Socioeconomic Status ● Parental support/timing ● Child’s willingness to participate ● Extracurricular activity time commitment ● Peer acceptance of program ● School Policies

Evaluation Standards IVs DVs Evaluation Types of How will Design data/measur data be es needed collected (and how frequently) Long Term 1. How will 1. The Posttest Nutrition One group Pretest, Before Outcomes nutrition posttest will knowledge Pretest- midterm test, implementati knowledge measure their Posttest posttest on, midway, improvement increase in and end of be measured? nutrition program knowledge. posttest

2. How will 2. The food Program Program One group Food logs, Students will the log will be Curriculum materials Pretest- reflection turn logs participants used to provided to Posttest paper on food weekly change in monitor participants log changes food behavior consumption change. be observed? Intermediate 1. How will 1. Students’ Completion Program One group Completion Assigned due Outcomes student’s attitudes and of program creativity and Pretest- of required dates, attitudes and behaviors materials interactive Posttest coursework approximatel behaviors will be components y weekly toward the measured by program be their measured willingness to comply and actively participate in the program. 2. How will 2. Students Program Food logs One group Tracking of Weekly improvement will be Curricula and myplate Pretest- food logs of students’ required to worksheets Posttest nutrition demonstrate correct behaviors be portion sizes measured? for each component of myplate through their food log Short-term 1. How will 1. Students Program Scores of One group Post food Before Outcomes student’s will be Curricula 80% on post Pretest- label exam intervention ability to read required to (nutrition food label Posttest and After a food label pass the post lectures) exam Intervention be measured? food label exam with an 80% or higher.

2. How will 2. Students Program Scores of One group Healthy Before and student’s will be Curricula 80% on the Pretest- Choice after ability to required to healthy Posttest Questionnair intervention choose pass the choice e healthy food healthy questionnaire be evaluated? choice questionnaire with an 80% or higher. Participants/ 1. How will 1. Grade Level Participation One group Successful Enrollment in Clients participants Participants in the Pretest- completion the 7th grade be selected? will be in a program Posttest of the 6th 7th grade grade class in a public school in Duval County. 2. Have 2. Students FCAT Completion One group FCAT Scores Scores will participants will be of FCAT Pretest- be reviewed passed the required to Posttest the summer 6th grade have passed before 7 FCAT? the 6th grade grade FCAT to ensure complete comprehensi on of the program. Activities 1. Have 1. Completion Participation One group Completed Students will participants Participants of required of 95% of Pretest- program turn in completed will be curriculum activities Posttest activities assigned required required to activities activities? complete weekly 95% of the activities. 2. Are 2. The Program Grade One group Readability Curriculum activities program will Activities Level/Readin Pretest- level and materials will designed for encompass g Level Posttest successful be assessed comprehensi age completion for reading on at the th appropriate appropriate of 6 grade and grade grade level? activities that level can be realistically performed by the participants.

Resources 1. What 1. Staff will Staff Staff One group Staff degrees Degree/Certif credentials be required to delivering/tea certification Pretest- and ication will will the staff have a health ching the or degree Posttest certifications be collected be required to education program prior to have in order certification becoming to teach the or degree. staff program?

2. Is the 2. Program Age- One group Measured by Curriculum curriculum Curriculum Curricula Appropriate Pretest- 7th grade will be age and will be Posttest comprehensi assessed for development written at a on software comprehensi ally 7th grade on levels appropriate level of before for the target comprehensi program population? on. implementati on External 1. How will 1. Parental Parental Requirement One group Attendance Attendance Influences parental involvement Involvement of attendance Pretest- Record of of events will support be will be to program Posttest parents at be recorded encouraged measured by events events throughout and attendance of the program measured? school banquets and use of backpack materials. 2. How will 2. There will Peer School One group Involvement Participation peer rejection be school Acceptance support of the Pretest- and in events will of the wide support program Posttest participation be measured program be of the of school off minimized? nutrition attendance program. Program Evaluation Evaluation Design: One group Pretest Posttest Design E O1------X1(knowledge)----O2 X2(behavior)------O3

Evaluation Conduction:

Pretest/Posttest Scores from the Experimental group (7th grade class receiving implementation), Midterm evaluations, Food log checks

Data Collection:

We will develop our own measures which will include a survey, pretest, posttest, food logs, midterm test

Plans for Evaluation Findings:

The findings from the midterm test will be used to improve the program during the current implementation. The pretest and posttest will be used to improve the program for future intervention and prove its causality.

Used by: The stakeholders (school officials, school board, funders) and program evaluators will use the information from the evaluation. Others who want to implement a nutrition program among other 7th graders can utilize the information from the program evaluations. Pretest/Posttest: Nutrition Survey 7th Nutrition Class April 1, 2012

ID NUMBER: ______Purpose of this study This survey was designed to evaluate the nutrition knowledge of 7th grade students. This pretest will be used in comparison with the posttest administered at the end of the program to evaluate the overall effectiveness of the program in increasing nutrition knowledge. Risks There are no risks associated with filling out this survey. Confidentiality Your identity will be kept completely confidential and your results will not be recorded with your name. We will only use the ID number to compare pre and post test scores.

Instructions For the following questions select the answer that completes each statement best. These next questions will assess your general nutrition knowledge. 1. Milk and ______belong to the same food group.

a. Bread

b. Apple

c. Cheese

d. Both A and C

2. A balanced diet includes these basic nutrients:

a. Carbohydrates

b. Proteins

c. Fats

d. A, B, and C

3. ______foods are foods that do not provide protein

a. Green Vegetables

b. Meats

c. Milk Products

d. Kidney Beans

4. A healthy 7th grader should eat about ______calories a day.

a. 4000 to 5000

b. 1000 to 2000

c. 2400 to 2900

d. 500 to 1000 5. One serving of meat is about the size of a ______.

a. Deck of cards

b. Golf ball

c. Spoonful

d. Plate

6. ______is a good example of a healthy lunch for a 7th grader.

a. Peanut-butter sandwich, fresh apple, non-fat milk

b. Slice of pizza, celery sticks, soda

c. Double cheeseburger, French fries, chocolate milk

d. A, b and c

7. People who are overweight have more health problems than other people who are not overweight.

a. True b. False

8. French fries are a healthy vegetable option. a. True b. False

9. How many total servings of fruits and vegetables should you eat each day?

a. At least 2 servings b. At least 3 servings c. At least 4 servings d. At least 5 servings

10. What you eat can make a difference in your chances of getting heart disease or cancer. a. True b. False

11. People who are underweight are more likely to have a higher risk of health problems that people who are not underweight.

a. True b. False

12. Skipping meals such as breakfast or lunch affects my ability to do well in my classes.

a. True b. False

Instructions: After each statement, circle the word that best describes you. 13. I eat a nutritious, well-balanced lunch

a. Always

b. Often

c. Sometimes

d. Never

14. I eat vegetables at dinner

a. Always

b. Often

c. Sometimes

d. Never 15. I drink at least one glass of milk every day

a. Always

b. Often

c. Sometimes

d. Never

16. Being healthy is important to me

a. Always

b. Often

c. Sometimes

d. Never Instructions For the following questions select the answer that answers each statement best. These next questions will assess your nutrition label knowledge 17. How many servings of milk are in this package?

a. One

b. Two

c. Four

d. Eight

19. 20.

21. 22.

Instructions For the following questions select the answer that completes each statement best. These next questions will assess your MyPlate knowledge

23. What two food groups are balanced on MyPlate? a. Fruits and Vegetables b. Dairy and Protein c. Grains and Vegetables d. Protein and Grain

24. How many glasses of milk should you drink during a day to get the recommended amount of dairy? a. None b. 1 glass c. 2 glasses d. 3 or more 25. What is the minimum and maximum amount of serving of vegetables you should have every day? a. 1 b. 3 c. 4 d. 5 e.6 f. 7

26. Your plate should look like MyPlate at every meal. a. True b. False

27. What would be a great vegetarian source of protein? a. Steak b. Celery c. Onions d. Beans e. Peas f. Bread

28. How much sodium is the limit per day for most people 2 years to 50 years old? a. 1500mg b. 1700mg c. 2000mg d. 2200mg e. 2300mg f. 2500mg

29. What food will give you a large amount of protein with the least amount of fat? a. Egg yolk b. Steak c. Egg white d. Fried chicken For the following questions refer to the MyPlate Diagram

30. What food group is supposed to be in the green section? a. Grain b. Vegetables c. Protein d. Fruit e. Dairy

31. What food group is supposed to be in the red section? a. Grain b. Vegetables c. Protein d. Fruit e. Dairy

32. What food group is supposed to be in the purple section? a. Grain b. Vegetables c. Protein d. Fruit e. Dairy

33. What food group is supposed to be in the blue section? a. Grain b. Vegetables c. Protein d. Fruit e. Dairy 34. What food group is supposed to be in the brown section? a. Grain b. Vegetables c. Protein d. Fruit e. Dairy

35. What food can you eat that you burn more calories digesting then you get from consuming the food? a. Peas b. Celery c. Apples d. Pears e. Oranges f. Skinless Chicken

36. Trans fats raise the risk of heart disease a. True b. False

37. Trans fats are found in fruits. a. True b. False

38. Trans fats are manmade. a. True b. False Instructions

Circle the appropriate choices for each question below.

These next questions will assess your food group knowledge.

Thank you for taking the time to complete this survey. Question Response Options Variable being Scaled Origin of measured item 1. Milk and  Bread General nutrition No Adapted ______belong to  Apple knowledge from the same food group.  Cheese  Both A and C

2. A balanced diet  Carbohydrates General nutrition No includes these basic  Proteins knowledge nutrients:  Fats  A, B, and C  3. ______foods are  Green Vegetables General nutrition No foods that do not  Meats knowledge provide protein  Milk Products  Kidney Beans

4. A healthy 7th  4000 to 5000 General nutrition No grader should eat  1000 to 2000 knowledge about ______ 2400 to 2900 calories a day.  500 to 1000

5. One serving of  Deck of cards General nutrition No meat is about the size  Golf ball knowledge of a ______.  Spoonful  Plate

6. ______is a  Peanut-butter sandwich, General nutrition No good example of a fresh apple, non-fat milk knowledge healthy lunch for a 7th  Slice of pizza, celery sticks, grader. soda  Double cheeseburger, French fries, chocolate milk  A, b and c

7. People who are  True General nutrition No Adapted overweight have  False knowledge from CSC more health problems Broward than other people who are not overweight.

8. French fries are a  True General nutrition No Adapted healthy vegetable  False knowledge from CSC option. Broward 9. How many total  At least 2 servings General nutrition No Adapted servings of fruits and  At least 3 servings knowledge from CSC vegetables should  At least 4 servings Broward you eat each day?  At least 5 servings

10. What you eat can  True General nutrition No Adapted make a difference in  False knowledge from CSC your chances of Broward getting heart disease or cancer.

11. People who are  True General nutrition No Adapted underweight are more  False knowledge from CSC likely to have a Broward higher risk of health problems that people who are not underweight.

12. Skipping meals  True General nutrition No Adapted such as breakfast or  False knowledge from CSC lunch affects my Broward ability to do well in my classes.

13. I eat a nutritious,  Always Participant’s Yes. Designed to well-balanced lunch  Often current eating measure  Sometimes behaviors participant’s  Never eating behaviors 14. I eat vegetables at  Always Participant’s Yes. Designed to dinner  Often current eating measure  Sometimes behaviors participant’s  Never eating behaviors 15. I drink at least  Always Participant’s Yes. Designed to one glass of milk  Often current eating measure every day  Sometimes behaviors participant’s  Never eating behaviors 16. Being healthy is  Always Participant’s Yes. Designed to important to me  Often current eating measure  Sometimes behaviors participant’s  Never eating behaviors 17. How many  One Nutrition label No. servings of milk are  Two knowledge in this package?  Four  Eight 18. How many  70 Nutrition label No. calories are in one  125 knowledge serving of whole  150 milk?  240 19. What percent of  0% Nutrition label No. your recommended  6% knowledge daily value of  30% calcium will you get  100% from one serving of milk? 20. How many grams  8 grams Nutrition label No. of protein are in one  11 grams knowledge serving of milk?  12 grams  0 grams 21. Whole milk is a  Yes Nutrition label No. good source of  No knowledge Vitamin D 22. How many grams  0 grams Nutrition label No. of fat are in one  5 grams knowledge servings of skim milk  8 grams  12 grams 23. What two good  Fruits and Vegetables MyPlate No. groups are balanced  Dairy and Protein Knowledge on MyPlate?  Grains and Vegetables  Protein and Grain 24. How many  None MyPlate No. glasses of milk  1 glass Knowledge should you drink  2 glasses during a day to get  3 or more the recommended amount of dairy? 25. What is the  1 MyPlate No. minimum and  3 Knowledge maximum amount of  4 serving of vegetables  5 you should have  6 every day?  7 26. Your plate should  True MyPlate No. look like MyPlate at  False Knowledge every meal. 27. What would be a  Steak MyPlate No. great vegetarian  Celery Knowledge source of protein?  Onions  Beans  Peas  Bread 28. How much  1500mg MyPlate No. sodium is the limit  1700mg Knowledge per day for most  2000mg people 2 years to 50  2200mg years?  2300mg  2500mg 29. What food will  Egg Yolk MyPlate No. give you a large  Steak Knowledge amount of protein  Egg White with the least amount  Fried Chicken of fat? 30. What food group  Grain MyPlate No. is supposed to be in  Vegetables Knowledge the green section?  Protein  Fruit  Dairy 31. What food group  Grain MyPlate No. is supposed to be in  Vegetables Knowledge the red section?  Protein  Fruit  Dairy 32. What food group  Grain MyPlate No. is supposed to be in  Vegetables Knowledge the purple section?  Protein  Fruit  Dairy 33. What food group  Grain MyPlate No. is supposed to be in  Vegetables Knowledge the blue section?  Protein  Fruit  Dairy 34. What food group  Grain MyPlate No. is supposed to be in  Vegetables Knowledge the brown section?  Protein  Fruit  Dairy 35. What food can  Peas MyPlate No. you eat that you burn  Celery Knowledge more calories  Apples digesting then you  Pears get from consuming  Oranges the food?  Skinless Chicken

36. Trans fats raise  True MyPlate No. the risk of heart  False Knowledge disease. 37. Trans fats are  True MyPlate No. found in fruits.  False Knowledge 38. Trans fats are  True MyPlate No. manmade.  False Knowledge Food Group  Bread Food Group No. Adapted Questions:  Potato Knowledge from CSC 1. Circle the foods  Bananas Broward that are in the Grain  Pasta Group.  Cheese  Candy Bar 2. Circle the foods  Eggs Food Group No. Adapted that are in Vegetable  Lettuce Knowledge from CSC Group.  Carrots Broward  Orange  Cereal  Steak 3. Circle the foods  Corn Food Group No. Adapted that are in the Fruit  Muffin Knowledge from CSC Group  Strawberries Broward  Eggs  Plain Burger  Apple 4. Circle the foods  Yogurt Food Group No. Adapted that are in the Milk  Bananas Knowledge from CSC Group.  Eggs Broward  Peanut Butter  Cheese  Green Beans 5. Circle the foods  Chicken Food Group No. Adapted that are in Meat and  Pasta Knowledge from CSC Beans Group.  Ice Cream Broward  Eggs  Broccoli  Potato

Questions 7-12; 1-5 food groups http://www.cscbroward.org/docs/Repository/SummerChallengeGPNutrition.pdf

Questions: 1-6; 13-16 http://dentaleducation.pgschoolprograms.com/student-nutrition/pre-test.php Questions 17-22 http://www.quia.com/quiz/681988.html?AP_rand=973006736 Questions 23-38 http://www.proprofs.com/quiz-school/story.php?title=choose-my-plate-knowledge-quiz Plans for Reviewing of Questions To test our pretest/posttest instrument and check for validity we will have the instrument reviewed by officials from the Duval County Health Department. These individuals should be considered experts in the field of health and should be able to look at our instrument and determine the face and content validity of the questions on our survey. They will also be able to direct us to better formulate our questions should any of them be confusing or incomplete. In the event that our sample of questions is not wide enough they will be able to direct us to other instruments that have questions that cover the full spectrum of our topic. They can also verify the criterion validity of our survey by comparing its components to those components of established nutrition exams. To ensure that our instrument is indeed ready for implementation we will also have it reviewed by established experts in the field of nutrition outside of Duval County. We will have our pretest/posttest reviewed by Dr. Delores James of the University of Florida. Her credentials make her a reliable source to check content of our instrument and she can also verify the wording of our questions. Since this is a new curriculum, we will have to get the program and its instruments reviewed and approved by the Duval County School Board. We will have the health official for the school board review the questions in are pretest/posttest in order to ensure the questions are testing measurable outcomes and that they do relate to our overall outcome. Having a school board health official take our pretest/posttest will also help us to ensure that our questions are written at an understandable grade level for the students and that all answer choices are comprehensible. To sample our instrument before implementation we will also sample 20 seventh grade students in Duval County. We will have them take the pretest/posttest and explain any confusion they may have. They will check for wording of questions, comprehension, and any other errors or formatting issues they may find. After completing all of these steps, our instrument should be ready for implementation. Budget

Categories Cost

Personnel Teacher Level-1: Evaluators (or Principal Investigators) (full-time) Salary for Person 1 (% time on project) $37,300 Salary for Person 2 (% time on project) Assistants Assistant: Data transcriber (part-time ~25 hours/week @ $9.00/hour) Data entry person(s) $8,100 Consultants (paid ~ $100 to $200 x hour - no benefits)

Benefits (calculate at 35% of total salary) $13,055

Materials/Equipment $1,944.50

Incentives $0.00

Travel $0.00

TOTAL DIRECT COSTS $60,399.50

Indirect Costs (at 20% of total direct costs) $12,079.90

TOTAL $72,479.40

Reporting of Findings We will continually keep the stakeholders informed throughout the program showing the students improvements and the knowledge they have gained in implementing healthier choices. The stakeholders will be informed of the findings monthly through written reports. We will be holding formal meetings with the stakeholders after the midterm evaluation and posttest have been completed and the data has been compiled. We will present these finding to the stakeholders throughout the program by using the pretest, posttest, and food logs results. The pretest/posttest will be able to show the stakeholders the knowledge the students have gained, while the food logs will show the stakeholders the nutrition behavior the students engage in and whether or not their nutrition behavior has improved.