Insufficient consumption of fruits and vegetables among students in Michigan

PUBHLTH 511, Winter 2022

Final Project

Introduction

My topic of interest is the consumption of fruits and vegetables among students in

Michigan. I chose this population because now I am studying in Michigan, and I noticed

that the price of fruits and vegetables is generally higher compared to the price in my

country, thus I wondered whether the consumption of fruits and vegetables would be

insufficient due to the high price. Also with the process of learning, I gradually learned

that the education of nutrition remains inadequate among the general population. I will

propose an intervention called Adding Fruits and Vegetables to Your Plate to help

increase consumption of fruits and vegetables among Michigan students. The

intervention will involve strengthening the education of nutrition, it can be included in

state-level education requirements, setting photo walls to display benefits of fruits and

vegetables, and providing more fruits and vegetables in school meal plans. This

document will discuss the potential probability to help increase consumption of fruits

and vegetables among Michigan students.

Why do we care and what do we know?

As is known to all, high consumption of fruits and vegetables have many benefits

to various chronic diseases. Available evidence indicates that persons who consume
more fruits and vegetables often have lower prevalence of important risk factors for

CVD, including hypertension, obesity, and type 2 diabetes mellitus (Bazzano et al.,

2003). High levels of fiber in fruits and vegetables can ease digestive problems. And

high amounts of minerals and vitamins make fruits and vegetables essential for

human’s health. However, traditional American diets usually contain little or no fruits and

vegetables. According to the 2020-2025 Dietary Guidelines for Americans, it

recommends adults to consume 1.5-2 cups of fruits and 2-3 cups of vegetables daily

(“2020-2025 Dietary Guidelines—Health.gov,” n.d.). Unfortunately, most Americans do

not eat enough fruits and vegetables every day, and only about 10% of them meet the

recommendations based on the data provided by the Center for Disease Control and

Prevention (CDC) (Lee et al., 2022). And in Michigan, the situation is even worse.

Figure 1 (CDC, Behavioral Risk Factor Surveillance System, 2019) shows that the

percentage of adults consuming 2 or more cups of fruits and 3 or more cups of

vegetables daily drops from about 8% to 6.5% during 2017-2019.

Percentage of adults who reported consuming two or more fruits and three or more vegetables daily

● Michigan ∎ United States

 Figure 1. Trend: Fruit and Vegetable Consumption, Michigan, United States

Compared with adults, students seem to consume even less fruits and vegetables

daily. State-specific estimates of the percentage of students meeting fruit intake

recommendations ranged from 4.0% (Connecticut) to 9.3% (Louisiana), and the

percentage meeting vegetable intake recommendations ranged from 0.6% (Kansas) to

3.7% (New Mexico) (Lange, et al., 2021). And in Michigan, only 0.9-1.0% high school

students met U.S. Department of Agriculture fruit and vegetable intake

recommendations (Youth Risk Behavior Surveillance System, national and 33 states,

2017). But little research explores why the consumption of fruits and vegetables in

Michigan left behind the United States.

Insufficient fruits and vegetables intake in the long term can cause serious

results. A new study finds that insufficient intake of fruits and veggies is responsible for

around 23% of all cardiovascular (CVD) fatalities. Low fruit intake was associated with

nearly 1.8 million cardiovascular deaths in 2010, while low vegetable intake was

associated with 1 million deaths, according to researchers (Mihai, 2019 ). And it has

been shown that the risk of CVD can be lowered by changing eating habits, adding

more fruits and vegetables in the meal plan.

Since the majority of Americans are accustomed to diets consisting of few fruits

and vegetables, they do not take it as a serious problem. But if humans consume not

enough fruits and vegetables, many health problems will occur in the long term. Some

diseases will be caused by deficiency of vitamins and minerals including scurvy and

night blindness. The risk of heart disease among individuals taking more than five

servings of fruits and vegetables per day is estimated to be reduced by 20%, in

comparison to those who eat fewer than three servings per day (NM, 2020). A diet

containing rich fruits and vegetables may also lead to reduced risk of digestive

problems, metabolic disorders such as obesity and hypertension. However, a diet that is

deficient in fruits and vegetables cannot help to prevent these problems.

The CDC has made some strategies to encourage higher consumption of fruits

and vegetables. These include establishing policies to incorporate fruit and vegetable

activities into schools as a way to increase consumption, promoting food policy councils

as a way to improve the food environment at state and local levels, including fruits and

vegetables in emergency food programs and so on (CDC, Strategies to Increase the

Consumption of Fruits and Vegetables, 2011). There are also many nutrition programs

to educate people about the benefits of consuming more fruits and vegetables. But

some strategies may fall short since on one hand, people’s economic status makes

fruits and vegetables unavailable for them. On the other hand, it is hard to change

adults’ eating habits.

Who do we work with?

In this part I will discuss the stakeholders who will be involved in the Adding Fruits

and Vegetables to Your Plate program and possible funding resources.

Several groups of stakeholders are identified for this program. The first group of

stakeholders would be Michigan students themselves. Students are involved in the

program and they are the main beneficiaries. Some of the students will be selected

monthly during the program to complete the questionnaire about their daily consumption

of fruits and vegetables. Data will be recorded to see whether the program helps to
make a change. The second group of stakeholders would be members of the Michigan

Department of Education (MDE). The Superintendent of MDE advises the Legislature

on education policy and funding needs, as defined by the State Board of Education. The

Superintendent is responsible for the implementation of bills passed by the Legislature

and policies established by the State Board of Education (Office of superintendent,

MDE). Members in MDE should consider the pros and cons of setting nutritional

programs in schools, and whether the nutritional course can promote consumption of

fruits and vegetables among students. Although they are not influenced by

implementation of intervention, their approval should be needed for the construction of

nutrition courses. The third group of stakeholders would be nutrition educators and

teachers in Michigan school systems. They are important for the supporting and

implementation of intervention activities. They are expected to find suitable ways to

teach nutritional lessons, activating students’ interests in nutrition, making them realize

the importance of healthy diets, and encouraging them to increase consumption of fruits

and vegetables. The last group of stakeholders would be food service directors and

staff. They are responsible for designing and providing meal plans for students in

school. To promote consumption of fruits and vegetables among students, the directors

and staff can make some changes on meal plans, increasing the supply of fruits and

vegetables.

Considering the funding, the federal Department of Health and Human Services

(HHS) provides a range of funding to the public health system, including states,

territories, tribes, localities, and non-governmental organizations. Federal funding is

passed to these grantees through grants and contracts (Meit, et al., 2013). The HHS
may be one of the funding resources. Also, donations by some local non-governmental

organizations can be another resource. .

What can we do ?

To address the main mission of increasing consumption of fruits and vegetables

among Michigan students, we must focus on achieving specific goals and objectives.

General goals of the Adding Fruits and Vegetables to Your Plate program include

increasing the total intake of fruits and vegetables and increasing the nutrition

curriculum. More specific objectives in the program that will assist to accomplish goals

include the following.

1. Increase the vegetable intake to at least 2 cups per day among 80% students

within the first year of the program.

2. Increase the fruit intake to at least 1.5 cups per day among 80% students within

the first year of the program.

3. Set nutrition courses at least 2 times per week to guide students how to design a

healthy diet.

4. Increase students’ knowledge of nutrition by seeing an improvement in the

Healthy Plate Photo Method (HPP).

We have to consider the gaps that may exist in the program before thinking about

the solution. First, according to the 2010 census, nearly 80% of Michigan’s population is

white, 14% is Black, 3% is Asian, 5% is Hispanic. Given the variation of ethnicities,

cultural consideration about nutrition and eating habits should be fully understood.

Second, current nutrition education among Michigan students should be taken into
consideration. Now Michigan has The Michigan Model for Health (MMH), which is a

comprehensive health education curriculum that targets Pre-K through 12th grade

students utilizing a skills-based approach. The MMH curriculum teaches students the

knowledge and skills they need to build and maintain healthy behaviors and lifestyles

(Michigan Model for Health, 2020). However, we are not sure whether MMH has been

effectively taught to students. Understanding the overall status of how MMH improved

students’ eating habits will be critical to decide interventions to address the gaps in the

program.

To achieve these goals, I propose 3 interventions. The first method is to increase

the provision of fruits and vegetables in the school cafeteria. The Healthy-Hunger Free

Kids Act school meals is a program to require the school to provide more fruits and

vegetables for students. A recent Harvard study has concluded that, under the updated

standards, kids are now eating 16 percent more vegetables and 23 percent more fruit at

lunch. Over 90 percent of schools report that they are successfully meeting the updated

nutrition standards (USDA, 2014). Since students usually have lunch in school, school

personnel and cafeteria staff can design meal plans that contain large amounts of

vegetables and fruits. For instance, they can replace some fast food with salads. Or

they can offer minimal free fruits and vegetables (2-3 kinds) daily. Students can select

fresh fruits, canned fruits, raw vegetables or cooked vegetables for their daily lunch

time.

Setting photo walls to display the colored photos of fruits and vegetables. Schools

often utilize classroom walls or hallways to display some things. Several studies have

shown the way a school cafeteria is set up and what is on display can influence
students' food choices and increase students' willingness to choose and consume more

fruits and vegetables (Graziose, Ang, 2018). The photo wall can be set by students

themselves. The school can hold a fun game to encourage students to decorate the

photo wall. Attractive colored pictures of fruits and vegetables can be displayed on the

walls, and some brief introduction of the advantages of increased consumption of

vegetables and fruits can also be added. This will help students better understand and

memorize the benefits of fruits and vegetables.

Strengthening the education of nutrition at the state-level. A number of reviews

confirm that a well planned and behavior focused nutrition education intervention can

significantly improve behavior and health indicators (Pem D, Jeewon R, 2015). One of

our objectives is to ensure at least 2 times of nutrition course per week. Considering the

course schedule, one of the courses could be a recorded or online course that can be

arranged by students according to their schedule. If we can make students realize the

importance and advantages of increased consumption of fruits and vegetables, they

may be more willing to consume them. And from this main activity we can derive many

sub activities including designing appropriate teaching materials for teachers to use,

determining attractive ways to increase students’ engagement, developing some

programs such as nutrition games to enhance students’ knowledge of fruits and

vegetables.

In conclusion, the first two objectives aim at increasing fruits and vegetables

intake among students in Michigan. The other two objectives aim at increasing students’

knowledge of nutrition. The evaluate methods will be discussed in the below part.
 Did we make a difference?

Figure 2 shows the overall structure of the Adding Fruits and Vegetables to Your

Plate program. It includes the inputs, activities, outputs and outcomes of the

intervention. We can follow the logistic model to make program evaluation.

Figure 2. Logic Model framework for evaluation

To measure the implementation process of the program, the effectiveness of the

educational programs, the photo wall, and the meal plan provided by the school

cafeteria will be assessed. The effectiveness of nutrition education will be assessed by

testing students’ knowledge of nutrition at the start of the program, after one semester,

and after one school year of the program. Students’ knowledge can be evaluated

through the Healthy Plate Photo Method (HPP), which can be a practical and useful

nutrition assessment tool to use with youth from varied socioeconomic and racial/ethnic

backgrounds (Ashley, et al., 2018). Within the first semester, 80% students are

expected to see any degree of score increase. The attendance of nutrition courses
should also be recorded to make sure students are making full use of educational

resources. The effectiveness of the photo wall can be evaluated together with the meal

plan since both of them aim to affect students’ daily choices during lunch time. They will

be evaluated through a monthly FFQ and a food-tracking app. Consumption of fruits

and vegetables will be measured once at the beginning of the program (i.e. at the

beginning of 2022-2023 school year) and then again at the end of the initial intervention

(i.e. at the end of 2022-2023 school year). The FFQ will assess monthly dietary intake

and portion size. The food-tracking app can record daily meals. Both the data collected

from these two methods will be recorded and analyzed by program staff members.

The program will have three outcomes to be measured, including the short-term

effectiveness, medium-term effectiveness, and long-time effectiveness. To evaluate

short-term effectiveness of the program, we can use the course evaluation tool at the

end of one semester after the beginning of the program to see whether students are

satisfied with the nutrition education they have received. Changes can be made

according to students’ feedback. Whether the consumption of fruits and vegetables has

increased can be measured by FFQ and the food-tracking app as discussed above. To

evaluate medium-term effectiveness, the quality of students’ diets can be measured

monthly by The Healthy Eating Index (HEI) or the Diet Quality Index (DQI). An evident

increase of the score is expected to be seen among at least 80% students. And

students’ knowledge about nutrition can be evaluated by HPP as discussed before. To

evaluate long-term effectiveness, physical examination can be a good method to reflect

students’ health status. Weight changes, BMI and blood pressure can be used to see

whether increased consumption of fruits and vegetables helps to alleviate obesity

among students. Cardiac marker measurements including total cholesterol, LDL

cholesterol, and BPM can be measured from blood samples to determine the health

status of students. Since more consumption of fruits and vegetables is assumed to

relate to a lower risk of chronic disease and obesity, these results are expected to have

a general improvement among students.

Limitations

Some limitations in the Adding Fruits and Vegetables to Your Plate program

should be noticed. First of all, we plan to make one of the nutrition courses per week

available online, but two things need to be taken into consideration. Some students may

not have access to online courses if their economic conditions are not good, which

means that they cannot afford electronic devices to watch online courses. Also we

cannot make sure students indeed watch the online course. As a result, some students

may not receive as much nutrition education as we expect. Moreover, although the

school cafeteria increases the provision of fruits and vegetables in the meal plan, this

cannot ensure these foods will be chosen by students more frequently. And students

may not choose fruits and vegetables because of the price. Lastly, we use FFQ and the

food-tracking app to evaluate the effectiveness of the problem. But disadvantages of

FFQ include inaccuracy of absolute nutrient values, fluctuation of nutrient values

depending on instrument length and structure, lack of detail regarding specific foods,

and general imprecision (Kenneth, et al., 2000). FFQ also relies on long-term memory,

thus it may not be effective among primary school students. Disadvantages of the
food-tracking app include being difficult to achieve in low-income districts since some

students may not be able to afford smart devices.

Conclusions

Insufficient consumption of fruits and vegetables is a common public problem in

the United States. Because people consuming more fruits and vegetables often have a

lower risk of obesity, hypertension, cardiovascular disease, type 2 diabetes and other

chronic diseases, it is important to find suitable and effective methods to help increase

the consumption of fruits and vegetables. Adding Fruits and Vegetables to Your Plate is

a program that will help deal with the issue among Michigan students by increasing

provision of fruits and vegetables in the school cafeteria, setting photo walls to show

benefits of fruits and vegetables in school and strengthening nutrition education through

various activities. By collaborating with Michigan schools, the Adding Fruits and

Vegetables to Your Plate program will be able to make a positive change to the

consumption and fruits and vegetables among Michigan students and improve their

health status.

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