IMPACT OF GARDEN INTERVENTIONS ON FRUIT AND VEGETABLE INTAKE AND ATTITUDES IN PRESCHOOL-AGED POPULATIONS

By Julia Findley

A Senior Project submitted In partial fulfillment of the requirements for the degree of Bachelor of Science in Nutrition

Food Science and Nutrition Department California Polytechnic State University San Luis Obispo, CA

March 2014

Abstract Background: Adequate consumption of fruits and vegetables is important for overall nutrition and prevention of chronic disease and is significant in the context of high pediatric obesity prevalence rates. Children aged 6-19 years consumed half the recommended minimum of fruits servings and slightly more than half the recommended servings of vegetables. Garden-based interventions in K-12 populations have been widely used to promote fruit and vegetable intake in children. While these interventions have shown promising results, studies have suggested that it is in preschool-aged populations that interventions might have a greater and longer lasting effect. This literature review examined garden-based interventions in preschool-aged populations to determine if they promote intake, willingness to taste, and/or preference for fruits and vegetables. Method: Garden-based studies that focused on children aged between three and six years were included in this research review. Outcomes of interest needed to include at least one of the following: fruit and vegetable intake, willingness to try fruits and vegetables, or preference for fruits and vegetables. Articles were peer-reviewed and from English language journals. Six studies were identified. Results: Results were varied but showed an overall positive correlation between gardening programs or gardening activities and positive food related behaviors and attitudes. Conclusion: While these results provide some insight into the effectiveness of garden-based interventions, the small sample number of studies available and the limitations in evaluation methodology and study design compromises the ability of this review to make conclusions regarding causal or associative relationships between garden interventions and fruit and vegetable intake and attitudes in preschoolers.

Introduction According to the USDA from 1994 to 1996, children aged 6-19 years consumed half the recommended minimum of fruits servings (USDA Economic Research Service - USDA Fruit and Vegetable Program, n.d.). The same report found that children aged 6-11 years consumed slightly more than half the recommended servings of vegetables. Adequate consumption of fruits and vegetables is important for overall nutrition and prevention of chronic disease and is significant in the context of high pediatric obesity prevalence rates (Hoelscher, Kirk, Ritchie, & Cunningham-Sabo, 2013). In 2010 almost one in five children aged 6-19 years were obese (Ogden & Carroll, 2010). Pediatric obesity is associated with increased occurrence of diabetes mellitus, asthma, and psychological or psychiatric problems (Biro & Wien, 2010; Griffiths, Parsons, & Hill, 2010; Hoelscher et al., 2013). In addition children who are overweight and obese are at a greater risk of continuing to be overweight and obese later in childhood and in adulthood. (Biro & Wien, 2010; Whitaker, Wright, Pepe, Seidel, & Dietz, n.d.; Cunningham et al., 2014). This is a concern because obesity is a contributing factor for many other diseases and conditions and is associated with an increased use of healthcare services (Lehnert, Sonntag, Konnopka, Riedel-Heller, & Knig, 2012). A research review by the Brookings Institution in Washington DC estimates that economic costs associated with obesity in the U. S., both direct and indirect, exceed $215 billion annually (Hammond & Levine, 2010). This makes identifying an effective obesity intervention an important national public health issue. Consuming fruits and vegetables can prevent weight gain by replacing energy dense foods and through the satiating effect of their fiber content. (Ledoux, Hingle, & Baranowski, 2011; Ogden & Carroll, 2010). Identifying interventions that effectively promote fruit and
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vegetable intake may therefore be useful for narrowing down pediatric obesity preventions. One strategy that has, and is currently being used is garden-based interventions. Those that have been tried in K-12 schools have shown to be promising tools to promote intake, willingness to taste and preference for fruits and vegetables among youth whose current preference for fruits and vegetables is low (Langellotto & Gupta, 2012; Robinson-OBrien, Story, & Heim, 2009). While interest in garden-based interventions has stayed relatively constant (Langellotto & Gupta, 2012; Robinson-OBrien et al., 2009), research suggests that there may be a more appropriate target age group (L. Birch, Savage, & Ventura, 2007; Cunningham, Kramer, & Narayan, 2014; Rollins, Loken, & Birch, 2011). Early childhood (between the ages of 3 and 5) has been identified as a critical period for food habit formation (Birch & Fisher, 1998; Birch et al., 2007). It is a period in which food preferences are formed and predict consumption patterns later in life (Nicklaus, Boggio, Chabanet, & Issanchou, 2004; Rollins et al., 2011; Skinner, Carruth, Bounds, & Ziegler, 2002a; Ventura & Worobey, 2013). If garden-based programs are found to be effective in preschool-aged children it could prove to be an appropriate preventative intervention for pediatric obesity. This literature review will examine gardenbased interventions in preschool-aged populations to determine if they promote intake, willingness to taste, and/or preference for fruits and vegetables. Methods Search Strategy Databases used to find articles included PubMed, PsycINFO, Google Scholar and the Robert E. Kennedy Library Website. Various combinations of a few key terms were used to search the databases for articles. Terms included: gardens, gardening, garden-based, preschools,
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preschoolers, preschool-aged, childcare centers, care centers, three to five years and fruit and vegetable intake or consumption. Reference lists were also searched for additional citations. Inclusion and Exclusion Criteria Garden-based studies that focused on children aged between three and six years (at the start of the study) were included in this research review. Articles were peer-reviewed and from English language journals. Studies that referred to preschool, childcare center, home and community settings were included. The preschool and childcare center settings were similar, had trained intervention staff and identified their target populations as preschoolers. Thus the preschool and childcare center settings for the purpose of this review were considered interchangeable and were both referred to as preschool settings. Outcomes of interest needed to include at least one of the following: fruit and vegetable intake, willingness to try fruits and vegetables, or preference for fruits and vegetables. Two studies that only addressed vegetable intake were included as well due to the limited amount of studies addressing both fruit and vegetable intake. This inclusion was deemed acceptable due to the fact that vegetables tend to be the less preferred and accepted between fruits and vegetables and therefore any change in eating behaviors and attitudes toward them would likely predict a similar or greater change in fruit related behavior and attitude changes. This trend was manifest in studies included in this review. Given this criteria, six primary research articles were identified and reviewed (Cabalda, Rayco-Solon, Solon, & Solon, 2011; Castro, Samuels, & Harman, 2013; Farfan-Ramirez, Diemoz, Gong, & Lagura, n.d.; Miguel & Ivanovic, 2011; Namenek Brouwer & Benjamin Neelon, 2013; Nanney, Johnson, Elliott, & Haire-Joshu, 2007).

Garden-based interventions in preschool-aged populations History and Effectiveness of Garden-Based interventions in K-12 schools Using garden-based interventions in preschool-aged populations may be an effective method to promote positive fruit and vegetable related behaviors, however, most gardening programs and most of the pre-existing research has focused on K-12 school populations (Robinson-OBrien et al., 2009; Langellotto & Gupta, 2012). Such programs have included: The Edible School Yard California, The Youth Farm and Market Program, Community Design Center in Minnesota, The National Farm-to-School Program, and The National Gardening Association and Kids Gardening Initiative (Robinson-OBrien et al., 2009). Even in the UK there are more than 26,000 schools and nurseries that signed up for the Lets Grow! vegetable garden campaign (Dazeley et al., 2012). Two reviews have examined these interventions in K-12 schools over the last five years (Langellotto & Gupta, 2012; Robinson-OBrien et al., 2009). Both suggest that garden-based interventions are promising methods to promote positive fruit and vegetable related outcomes. Integrating them into preschool-aged populations could prove to be a more effective intervention strategy based on studies that have identified early childhood as a critical period for food habit formation (Rollins et al., 2011; Skinner, Carruth, Bounds, & Ziegler, 2002; Ventura & Worobey, 2013; Wofford, 2008) and baseline weight establishment. Preschool-Aged Children: A Critical Period for Intervention Food Preferences and Future Food Consumption Patterns. The early childhood years are a critical period for the development of food preferences (Hoelscher et al., 2013; Lakshman, Elks, & Ong, 2012; Ventura & Worobey, 2013; Wofford, 2008). Children are born with a predisposition for sweet and salty foods and an aversion for sour and bitter foods (Ventura &
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Worobey, 2013). These preferences are unlearned and likely adaptive, favoring foods that evolutionarily would have been advantageous. This adaptive behavior can be unfavorable in the current food environment where sweet and salty, energy-dense foods are in abundance and can cause weight gain (Ventura & Worobey, 2013). In addition, children aged two to five years often experience a phase of food neophobia or a fear of new foods (Gibson et al., 2012; Ventura & Worobey, 2013). This is thought to be an adaptive behavior as well, protecting young children as they are transitioning into new environments where new foods are being offered. This neophobia in combination with the predisposition for caloric foods can cause children to resist when their parents try to introduce them to new fruits and vegetables (Gibson et al., 2012; Ventura & Worobey, 2013). Unfortunately parents often react to this resistance by abandoning their efforts altogether. Left unchecked, unhealthy diet patterns may remain and continue into adulthood (Nicklaus et al., 2004; Rollins et al., 2011; Skinner et al., 2002a; Ventura & Worobey, 2013) Establishment of Baseline Weight. In the context of an energy-dense food environment, a child left to self-regulation is more likely to eat high calorie, sweet and salty foods, that are familiar and for which they have a predisposition (L. J. Cooke & Wardle, 2007). This could lead to excessive weight gain, which is significant in the context of growing evidence that early childhood is a period in which a childs baseline weight is set (Biro & Wien, 2010; Whitaker, Wright, Pepe, Seidel, & Dietz, n.d.; Cunningham et al., 2014). A recent longitudinal study followed more than 7000 children from kindergarten to age 11 (Cunningham et al., 2014). It found that a third of children who were overweight became obese, those who were very obese stayed that way and those whose weights were normal stayed normal. This implies that a
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childs weight status at five to six years will be their weight status at 11 years. If this is true, then the period before age five is immensely important for establishing interventions to prevent obesity. Even in the face of child resistance, it is essential that efforts be made during this early childhood period to expose children to fruits and vegetables in order to cultivate healthier food preferences that will predict a healthier weight status and dietary consumption pattern later in life (Nicklaus et al., 2004; Rollins et al., 2011; Skinner et al., 2002a; Ventura & Worobey, 2013). Gardening and behavioral outcomes Repetition of exposure Gardening programs may represent viable interventions during the preschool ages because they provide the repeated exposure that researchers have consistently found to be necessary for the cultivation of fruit and vegetable preferences (Anzman-Frasca, Savage, Marini, Fisher, & Birch, 2012; L L Birch & Marlin, 1982; L L Birch, McPhee, Shoba, Pirok, & Steinberg, 1987; L. Cooke, 2007; Schindler, Corbett, & Forestell, 2013; Wardle et al., 2003). For example, when 2-year-olds were offered unfamiliar fruits zero, two, five, ten, fifteen or twenty times over a 25-day period, preference for the fruits increased as the frequency that they were exposed increased (Birch & Marlin, 1982). Studies estimate that it can take 6-15 exposures to increase consumption and preference for new foods in children (Ventura & Worobey, 2013). Diet Diversity In addition, if planned well gardens can expose preschool-aged children to a variety of different fruits and vegetables. This is important because diet variety at ages less than five years has been associated with an increased willingness to try new foods at a later age (Dazeley
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et al., 2012; Skinner et al., 2002a; Skinner, Carruth, Bounds, Ziegler, & Reidy, 2002b). A longitudinal study in 2002 had children complete food frequency questionnaires at 2-3 years and at six, seven and eight years. It determined that varied fruit consumption in school-aged children was predicted by fruit variety in early childhood (Skinner et al., 2002a). Skinner et al., substantiated these findings in another experimental study with infants (Skinner et al., 2002b). The infants were fed either pureed carrots, potatoes or a carrot and vegetable mixture every day for 11 days. As expected, infants who were fed the carrot or the mixed vegetable puree ate more carrots after the exposure. More importantly, the children who were exposed to the vegetable mixture also consumed a pureed chicken meal which was an unfamiliar food to all of the participants. This suggests that exposure to a variety of flavors that may increase the acceptance of newly introduced foods or flavors (i.e. fruits and vegetables) in children later on. Sensory interactions The mechanism by which garden interventions influence childrens acceptance of fruits and vegetables is still unclear (Dazeley et al., 2012). Many past interventions have focused on taste as the mechanism by which increased acceptance is established (Johnson, McPhee, & Birch, 1991; Wardle et al., 2003), yet taste cannot be isolated from other senses such as sight, smell and texture of vegetables. It is difficult to determine to what degree each of these senses contributes to the familiarity and acceptance of new foods. Dazeley et al. (2012) theorized that intervention exposures that involve all of the senses may generate a greater acceptance of unfamiliar foods. He reviewed the literature related to the impact of non-taste properties of food on the willingness of children to eat them. He determined that there is promising evidence that visual and olfactory exposure is linked to subsequent eating behavior, but that there is
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insufficient research to determine the effect of sound and texture properties on food familiarity and acceptance. The hands-on and intimate nature of gardening may increase the stimulation of these senses and produce an increased willingness to try fruits and vegetables in preschoolaged children. In addition interventions that focus on the other senses may be an avenue worth exploring in the context of early childhood neophobia. Neophobia may cause children to experience anxiety when they are pressured to taste a new food, which could trigger a negative association with that food (Dazeley et al., 2012; Gaines & Turner, 2009) Gardening interventions incorporate other sensory interactions that may promote food familiarity without the associated anxiety. Knowledge of the origin of fruits and vegetables Beyond these aspects of gardening, it could be that it is simply a greater awareness of the origins of fruits and vegetables that contributes to their acceptance in children (Dazeley et al., 2012). Having an active participation in garden and harvesting may help reduce anxiety associated with neophobia. If a significant increase in positive behavioral outcomes is observed as a result of garden-based interventions in preschool-aged population, it could help narrow down appropriate fruit and vegetable intake interventions (L. Birch et al., 2007; Cunningham et al., 2014; Rollins et al., 2011). Fruit and Vegetable Intake and Weight Regulation Current recommendations for fruit and vegetable intake in preschool-aged children is 4-6 servings per day, however, according to an analysis of consumption patterns in preschoolers, intake is still lower than desired (Cole & Fox, 2008). Increasing positive fruit and vegetable
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related behavior in children is important because inadequate intake is associated with pediatric obesity in children (Brown, Kelly, & Summerbell, 2007; Ledoux et al., 2011; Rasmussen et al., 2006; Swinburn, Caterson, Seidell, & James, 2004; Volkow, Wang, Tomasi, & Baler, 2013). According to Flegal et al. (2012) about 10% of children aged two to five years were obese in 2007-2008, as defined by BMI for age greater than or equal to the 95 th percentile. The basic etiology of weight gain is caloric intake that has exceeded the needs of an individual. Dietary fat which is abundantly available in the current food environment contributes more energy per unit weight and takes less energy to metabolize than other macronutrients (Dazeley et al., 2012). By consuming the recommended servings of low-energy, nutrient dense fruits and vegetables, energy-dense foods such as fat may be displaced (Brown et al., 2007; Howarth, Saltzman, & Roberts, 2009; Ledoux et al., 2011). Ledoux et al. (2011) reviewed research to assess the relationship between fruit and vegetable consumption an adiposity. The 23 publications he analyzed included both longitudinal and experimental designs. The longitudinal studies showed a significant correlation between long-term, high fruit and vegetable consumption, and less or slower weight gain in study participants. This was seen in both child and adult populations, but to a lesser degree in children. Although there was less of an association seen in children, developing fruits and vegetable preferences in children is still important because it predicts consumption patterns later. (Rollins et al., 2011; Skinner, Ventura & Worobey, 2013). For both adults and children in the studies that were reviewed, observed decreases in energy intake co-occurred with a decrease in adiposity (Ledoux et al., 2011). As of yet there has been no correlation found between fruit and vegetable intake and reduced adiposity in isolation of decreased energy intake and increased physical activity (Ledoux et al.,
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2011; Slavin & Lloyd, 2012). It is therefore likely that it is through an indirect mechanism, such as fat displacement, that fruits and vegetables influence adiposity. Another indirect mechanism by which fruits and vegetables may decrease energy intake is through the satiating effect of their fiber content (Caroli et al., 2012; Ledoux et al., 2011; Walt, 2004; Wang, Bentley, Zhai, & Popkin, 2002). In the literature review by Ledoux et al. (2011) a trend of significant weight loss was seen in participants of studies who had increased fiber intake, without instructions to do so, and as a part of increased fruit and vegetable consumption. One of these studies examined specifically the ability of satiety readings and fruit and vegetable intake to predict decreases in energy intake and weight. It found that there was a significant negative association. Adequate fruit and vegetable intake may therefore play an essential role in weight regulation both because of its ability to displace energy-dense foods and the satiating effect of its fiber content. Results This review is organized by type of study design and setting of exposure or intervention. Of the six studies examined, two were cross-sectional and examined the impact of gardens in home settings. Three studies were of experimental design and examined the impact of garden-based interventions in preschool settings. The last was an experimental study that was completed in a community setting. All of these targeted preschool-aged populations and examined at least one of the following food-related behavioral outcomes: intake, preference and/or willingness to try fruits and/or vegetables. In the context of the studies examined in this review, intake of fruits and vegetables could also be expressed as frequency of consumption of fruits and vegetables, number of meals per day in which fruits and vegetables are consumed or number of servings of
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fruits and vegetables. In addition preference for fruits and vegetables may be expressed as number of fruits and vegetables that children liked to consume. A summary of the studies included in this review are shown in Table 1.

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Table 1. A summary of garden-based interventions and exposures in preschool-aged populations Author, year Cabalda et al., 2011 Study design Cross-sectional; in home setting Study population Children aged 2 to 5 years (n=200) with or without home gardens Children aged 2 to 5 years (n=1,603) Intervention or Exposure Exposure was presence of home garden in household, control was absence of home garden Almost always/always eats homegrown FV (n=207) vs sometimes eats homegrown FV (n=871) vs rarely or never eats home grown FV (n=525) Outcome Frequency of consumption of vegetables among children Total FV servings (excluding french fries) & preference for FV Results Statistically significant results showed that children in households with gardens were twice as likely to eat vegetables at least 5 times per day compared to households without gardens Children who always or almost always consumed compared to, rarely or never consumed homegrown FV, had a mean total intake of FV of about 6 servings, which was more than a whole serving greater than the group that reported rarely or never eating homegrown FV. Children from families who consumed homegrown FV preferred more FV (4.8 compared to 3.5). Both results were statistically significant Statistically significant (+3) increase in the mean number of vegetables that intervention preschoolers liked to consume. There were non-statistically significant increases in the number of preschoolers who ate vegetables in more than 1 meal a day (+8.6%) and who consumed vegetables daily (+5.1%)

Nanney et al., 2007

Cross-sectional; in home setting

Miguel & Ivanovic, 2011

Randomized, controlled trial; in preschool setting

Mother-preschooler dyads from Sao Paulo, Brazil; experimental group (n=60) vs. control group (n=38). High attrition rate due to parents not having time to complete forms

School vegetable garden program; 26 sessions; games and songs incorporated. 7 months

Number of daily meals vegetables are consumed; frequency vegetables are consumed; and number of vegetables preschoolers like to consume

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FarfanRamirez et al., 2011

Controlled, comparative pilot study; in preschool setting

Children aged 3-5 years; low income (n=26)

Gardening + nutrition education (11 lessons) (n=91) vs. nutrition education only (5 lessons) (n=94) vs control (n=81)

Willingness to try fruits and vegetables (figs, raspberries, roasted beets and blanched snap peas)

Statistically significant increase in preschoolers willingness to try figs (+0.58), raspberries (+0.27) and snap peas (+0.48) in the gardening + nutrition education group. The exclusively nutrition education group saw greater statistically significant increases in the willingness of children to try figs (+0.74) and raspberries (+0.38), but a smaller increase in willingness in to try snap peas (+0.45) Crude analysis found that there was a 0.25 serving increase in consumption of vegetables and 0.32 serving decrease in fruit consumption in the experimental group. In the control group there was a 0.18 serving decrease in vegetable consumption and 0.15 serving increase in fruit consumption.

Brouwer & Neelon, 2013

Randomized, controlled trial; in preschool setting

Children from four preschools (average of 19 children/ center).

FV garden, monthly curriculum, gardening support, and technical assistance. 4 months

Servings of FV consumed by three children per center. (pre- and postintervention children observed not necessarily the same)

Castro et al., 2013

Controlled trial; in a community setting

Children recruited at ages <6 years (n=120); low-income, 71% Latino

Weekly gardening session, a 7 week cooking and nutrition workshop, and social events for parents and children. No control.

Average number of fruit and vegetable servings eaten by children on a typical day.

Average number of fruit servings eaten on a typical day had a statistically significant increase of 28%. The average number of vegetable servings eaten on a typical day increased by 33%. This difference was also statistically significant.

FV=fruits and vegetables

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Cross-sectional study design, in home settings Nanney et al. (2007) studied the association between frequency of consumption of homegrown fruits and vegetables in preschool-aged children, and their overall intake of, and preference for, fruits and vegetables. A cross-sectional study design was used, consisting of 1,603 parents and their preschool children (aged 2-5 years). Recruitment of families was from one of sixteen Parents as Teachers program sites in Southeast Missouri counties. Eligibility was based on children being aged between two and five years. The exposure of interest was preschooler consumption of home grown fruits and vegetables. This was assessed by asking parents the question: How often do you and your family eat fruits and vegetables that have been homegrown? Four response choices included almost always/always, sometimes, rarely, and never. The outcomes of interest were fruit and vegetable intake and preferences. Data were collected using food frequency questionnaires (FFQ), with recall questions for 29 fruits and vegetables. In addition, parents were asked about their childs preferences for the certain foods, with the following response choices: favorite, likes it, hates it, or never had it. Data were collected via phone interviews of parents by trained, professional interviewers. Total response rate was 82%. The Saint Louis University FFQ for Kids was modified from previous work to be used in this study. Previous methods to develop a FFQ had acceptable validity and reliability and were repeated for this study. The FFQ used was customized specifically for foods most relevant to families living in the rural Midwest. The foods used, the average serving size, and nutrient content were based on amounts eaten by a nationally represented sample from 1994 and 1996-1997 Continuing Survey of Food Intake survey. The demographic characteristics of the parents were analyzed in relation to their frequency of eating homegrown vegetables.
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There was a significant difference in age, race, income and education between those who almost always or always ate homegrown vegetables and those who rarely or never ate homegrown vegetables. These variables were taken into account in the correlation analysis of child fruit and vegetable intake and preference, and frequency of eating homegrown fruits and vegetables. The study found that preschool children from households that reported almost always, or always eating homegrown fruits and vegetables, had a mean total intake of fruits and vegetables (excluding French fries) of about 6 servings. This was more than a whole serving greater than the group that reported rarely or never eating homegrown fruits and vegetables. These results were statistically significant. In addition children from families who consumed homegrown fruits and vegetables preferred more fruits and vegetables (4.8 compared to 3.5). This was also a statistically significant difference. Overall confidence in these results was strengthened by the 82% response rate, consideration for confounding variables, the use of trained professional interviewers for data collection and the use of a customized and validated FFQ. The FFQ was customized for the Missouri area and age group, and excluded French fries which have commonly been a culprit for misleading vegetable related results. The researchers validated the use of parents as proxies for their children. These precautions make it more likely that the data collected will represent the actual intake and preferences of children. This study was limited by its selection of children based on their parents participation in a Parent as Teachers program. This puts the study at risk for selection bias. The population of interest was also primarily those living in rural areas of Missouri and therefore may not be representative of Midwestern states and suburban areas.

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Another cross-sectional study examined gardens in home settings as well. Cabalda et al. (2011) examined the association between home gardening and frequency of vegetable consumption in preschoolaged children in the Phillipines. A controlled, cross-sectional study design was used. Eligible households (N=200) consisted of children aged two to five years. The exposure of interest was home gardens, as defined by an area around the home where vegetables, fruits and other plants are grown seasonally or throughout the year. Households in the Baras and Mahabang Parang provinces of the Philippines were grouped by household cluster assignment. The clusters were ranked randomly for each province and were then surveyed consecutively down the ranked list until 100 households had been surveyed from each area. Among the 200 households surveyed 105 had home gardens. The 95 households without gardens acted as the control group. There were no significant differences between households with and without gardens in relation to parents age, mothers educational attainment, income category, household size, food expenditure, and number of appliances. The fathers educational attainment did differ between groups. Those without gardens had more college education. There were no statistically significant differences in age, sex, anthropometric measurements or nutritional status between children in households with or without gardens. The frequency of consumption of vegetables among children was determined using a household survey form. Mothers were asked to estimate the number of times a child eats vegetables within a week. A Student t test was performed to compare means between the groups. There were statistically significant results that showed children in households with gardens were twice as likely to eat fruits and vegetables at least five times per day compared to

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households without gardens. The author concluded that there is a positive association between having a home garden and frequency of fruits and vegetables consumed. Confidence in this conclusion is strengthen by the use of randomization in the selection of household clusters to be surveyed and the use of statistical analysis to identify differences in the characteristics between households and preschoolers with and without gardens. This allowed for multiple, significant, child and parent confounding variables to be accounted for, such as educational backgrounds of parents and nutritional status of children. Although this study seems to be well structured it is difficult to say how much external validity a study with a focus on semiurban and rural farming areas in the Philippines, could have for American preschool-aged children. Both of the cross-sectional studies seemed to have used suitable methods and precautions, however, cross-sectional studies do not show causality and it cannot be known for sure if there wasnt some other variable or quality about the parents that would grow a garden that may also have influenced a child to eat or prefer more fruits and vegetables. In addition these studies did not measure the degree to which kids interacted with the gardens in their households. Knowing this aspect may help to determine which variable or variables are contributing to changes in child intake of and/or attitude towards fruits and vegetables. It could be the type of parent, the increased availability of food, the degree of garden interaction, or simply an increased awareness of where fruits and vegetables come from. Experimental study design, in preschool settings Miguel and Ivanovic (2011) evaluated the impact of a seven month school vegetable garden program on vegetable consumption of preschoolers and their mothers in So Paulo,

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Brazil. It was a controlled, qualitative-quantitative and comparative intervention study with a total population of 231 dyads that were randomly distributed into the experimental group or the control group. Inclusion criteria were preschoolers (4-6 years) of both sexes, who attended one of four educational establishments located in the southern part of So Paulo city. The control group (CG) and experimental group (EG) were paired by type of school, sex, socioeconomic status, and parents religion. Statistical analysis determined that age range for preschool participants was significantly higher in the experimental group and Adventists were more present in the control group. Of the 231 initial dyads who participated in the program 98 completed both pre- and post- data forms (CG, n=38 & EG, n=60). This high attrition rate was due to parents not being able to find time to complete the data forms. Those who did not complete the forms had similar characteristics to those who did. The exposure of interest was participation in a vegetable garden (preparing soil, sowing seeds, irrigating farming, and harvesting the vegetables). It consisted of 26 educational sessions in the garden, each approximately 60 minutes each. Students were allowed to consume the vegetables they planted. Other study components included: Informal talks conducted with preschoolers on the nutritional value of vegetables and their opinion of the gardening experience. In addition, games and songs related to each vegetable were incorporated. The control group did not participate in the garden program or any of the additional components. Data on food related behavior associated with vegetable consumption were collected during the baseline data collection and in the post-intervention period. Consumption behaviors of interest were frequency of consumption of vegetables (expressed as days per week), the number of daily meals in which vegetables were consumed and the number of vegetables that preschoolers

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liked to consume. Data were analyzed using non-parametric methods, means were compared using students paired t test, and data were processed using Statistical Analysis System (SAS) software. The religion of the parents were not taken into account as confounding variables. In the preschooler experimental group, the number of children who ate vegetables in more than one meal per day increased by 8.6% and the percentage of preschoolers who consumed vegetables daily increased by 5.1%. Neither increases were statistically significant, and the control group displayed similar increases. There was a statistically significant 94% increase in the mean vegetables that children liked to consume in the experimental group after the intervention. Despite the use of controlled, randomized method design, a validated assessment tool and a substantial sample size, confidence in the results of this study was reduced due to a high attrition rate. More than half of the subjects did not complete the study and although characteristics between those who did and did not finish were reported to be similar, the absence of an intention-to-treat design suggests randomization was not preserved. The generalizability of this study also may be limited to populations similar to the So Paulo population. In addition, while the researchers identified potential confounding variables in their analysis of experimental and control subject characteristics, they did not report accounting for them in their analysis of the primary outcomes within the experimental and control groups. These limitations make it difficult to isolate gardening as the primary variable affecting fruit and vegetable intake. Similarly, the multicomponent nature of the intervention used, also made it difficult to isolate gardening as the only dependent variable. Unlike the cross-sectional studies which did singular examinations of either the presence of home gardens (Nanney et al., 2007)

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or the consumption of home grown produce (Cabalda et al., 2011), this experimental study examined the combined effect of a garden intervention with educational lessons, games and songs. Extrapolating their individual contributions to changes in fruit and vegetable intake would be difficult and was not done in this study. The distinct effect of the garden component could therefore not be determined. Farfan-Ramirez et al. (2011) examined the ability of a garden program with a nutrition education component to effect fruit and vegetable intake in preschoolers, in comparison to nutrition education alone. A controlled intervention study design was used, assigning 36 childhood centers to either the garden and nutrition education program, the exclusively nutrition education program or the control group. Care centers needed to be ethnically and racially diverse to reflect the school districts population, have similar numbers of students in their classrooms, have no previous nutrition education interventions, and needed to have an existing garden. How they defined diversity in the care centers that were included was not defined. Preschoolers needed be from low-income families to participate in the study. Both intervention types included one to three activities connected to a specific objective of the lesson; a physical activity break; a fruit or vegetable taste-test; a list of age appropriate story books for each lesson and a parent letter to reinforce the activity at home. The gardening component provided in-classroom and outdoor gardening lessons. The nutrition education intervention consisted of only five lessons while the garden and nutrition education combination provided 11. The control centers did not participate in any garden or nutrition education interventions. Health educators provided support and technical assistance with lessons. Teachers participated in professional development and program training. No further

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description of site or participant characteristics were reported nor did the authors report randomized assignment of treatment and control groups. The eating behaviors of children were measured using a pre-test/post-test design. Trained observers conducted direct observations in the classrooms at regular snack times. Participants in both intervention groups and the control group were offered figs, raspberries, blanched snap peas, and roasted beets, one at a time, family style. A check list of five specific eating behaviors was used to record the subjects interactions with and responses to the fruits and vegetables of interest and was later converted into a willingness to try score. Behavior scores were analyzed using Microsoft Excel. The Excel template calculated pretest and posttest means, the difference between means, and P values for paired t tests. Teachers completed surveys after each meal to ensure that the teacher completed each component of an activity. Willingness to try fruits and vegetables was measured on a range of 0-4. The results of the study showed that there was a statistically significant increase in preschoolers willingness to try figs (+0.58), raspberries (+0.27) and snap peas (+0.48) in the gardening + nutrition education group. The exclusively nutrition education group saw greater statistically significant increases in willingness to try figs (+0.74) and raspberries (+0.38), but a smaller increase in willingness to try snap peas (+0.45). There was not a significant increase in any of the groups willingness to try beets. This study was significant because it compared the use of gardens and nutrition education against solely nutrition education and a control group. There was a greater increase in willingness to try fruits in the exclusively nutrition education group, but a smaller increase in willingness to try snap peas, as compared to the gardening plus nutrition education group. These conflicting changes make it hard to determine the garden interventions individual effect

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on preschoolers attitudes towards fruits and vegetables. While the results for fruit suggest that nutrition education alone has a greater effect, the snap pea results suggest that garden interventions have a greater effect. The ability of this study to demonstrate correlations between interventions and changes in outcome variables was limited by the use of only two fruits and two vegetables. Results associated with so few food items cannot confidently predict an association between an intervention and fruit and vegetable intake and attitudes overall. The use of less mainstream fruits and vegetables (beets, raspberries, figs, and snap peas) may help counter effect the limited fruits and vegetables used. Changes in fruit and vegetable intake or attitudes are more likely to appear if children have no pre-established preferences for the fruits and vegetables of interest. Theres more room for change. If they already are very willing to try a fruit they like, an intervention may not be able to increase their willingness to try them by any substantial amount. Other strengths included in this study were the use of a control, and trained teachers and observers, however, the authors did not report randomization nor an analysis of the characteristics of the three groups. Brouwer and Neelon (2013) assessed the Watch Me Grow garden-based intervention and its ability to promote fruit and vegetable consumption among three to five year olds. It used a randomized, control trial study design. Children were recruited from four licensed preschool centers in North Carolina. Eligibility of centers to participate was based on their ability to provide all food and beverages to children in care (i.e. no food from home) and have at least three children between the ages of three and five years in care on a regular basis. Each site had an average of 19 enrolled children. Beyond age, no inclusion or exclusion criteria for subject participation was reported. The randomization of centers to either the intervention or

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control conditions took place after baseline data were collected. Post intervention dietary assessment data were collected five months after the collection of baseline data. The only characteristic information collected about the subjects was their age and sex. The program had a crop of the month curriculum for care providers to use. The garden was designed to produce one crop per month, which included lettuce, strawberries, spinach and broccoli. Target crops were selected based on skill needed to grow them, child acceptance and palatability, and appropriateness in the growing climate. Classroom curriculum was designed to have four corresponding activities and lessons for each particular crop of the month including: an age appropriate story book about the target produce, a garden activity, a classroom lesson and a taste testing. Staff was encouraged to eat and say positive things about the target fruits and vegetables during taste tests. A structured dietary observation method, for use in preschoolaged children in childcare centers, was used to assess fruit and vegetable consumption. Three children within randomly selected classrooms were selected for dietary observation at intervention and control centers before and after the intervention. A trained registered dietitian, blinded to treatment group, observed and recorded what the 3 selected children from each site consumed, and wasted. The same three children may not have been observed preand post-intervention. Total fruit and vegetable servings (based on Dietary Guidelines for Americans 2005) were determined using Nutrition Data System for Research software. Difference scores and standard deviations of average daily vegetable and fruit servings consumed by children pre- and post-intervention were computed. Due to sample size limitations formal statistical analysis beyond crude differences in mean servings of fruits and vegetables were not calculated. The small sample size may have been due to the Watch Me

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Grow program being a pilot intervention. The mean serving of vegetables consumed by children in the experimental group, increased by a quarter serving post intervention. The mean servings of fruit consumed by children in the intervention centers decreased by about a third of a serving after the intervention. The author hypothesized that this decrease may be due to the fact that three of the four foods used were vegetables. Including additional fruit crops may change these results. This study was limited by its inability to perform formal statistical analysis and by the type and amount of fruits and vegetables used. This is likely due to it being a pilot study. Similar to the study by Farfan-Ramirez et al. (2011), the use of only a few fruits and vegetables (in this case only one fruit) makes it unlikely that the results are reliable or valid. In addition the produce used was chosen based on child acceptance and palatability. The authors did not specify whether they were focusing on well accepted, high palatable foods or less accepted, less palatable foods. Well accepted, high palatable foods would likely exhibit smaller, less significant changes after an intervention. The use of trained registered dietitians, blinded to treatment group, to measure outcome variables may have helped offset some of these limitations. In addition the use of randomized assignment to experimental or control group helped improve the integrity of the study, however no further effort was made to compare or analyze the characteristics of the two groups and no confounding variables were taken into account. Similar to the intervention evaluated by Miguel and Ivanovic (2011), this study examined a garden intervention with lesson and activity components. It did not analyze the individual contribution of each component and therefore the distinct effect of the garden component could not be determined.

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Experimental study design, in community settings Castro, Samuels and Harman (2013) evaluated the pilot community garden program, Growing Healthy Kids (GHK). The primary purpose of this study was to determine if a community garden intervention had an impact on BMI among young children, however the effect of a community garden on fruit and vegetable accessibility and consumption was also examined. Fifty-eight families reported on their childrens consumption of fruits and vegetables at the beginning and end of the familys participation in the GHK program. There were 120 child parti cipants. Fortynine percent were boys and 51 % were girls. There was no comparison or control group and therefore no randomization of sampling. Program enrollment was open to all families in the community with at least one child aged 6 years or less. Recruitment was from local schools, childcare centers, Head Start programs, healthcare centers, the public health department, Latino community centers, food pantries, word of mouth and referral. The only characterization provided was that ninety percent of families were at or below 75% of the state median income and 60% were Latino families. This was representative of the researchers population of interest: low income, Latino populations. Characteristics of the sample population in relation to fruit and vegetable intake were not taken into consideration. Three different community gardens provided opportunities for the children and their families to grow 22 different kinds of fresh fruits and vegetables. Of sixty participating families, 27 (45%) participated every week, 27 (45%) participated two to three times per month, and 4 (7%) participated once a month or less. Two families did not attend at all. Other components that were conducted included: a sevenweek cooking and nutrition workshop for both parents and children; social activities and events that focused on potluck dinners made from garden ingredients; and newsletters that

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emphasized the work of the gardeners, highlighted healthy recipes, and provided a childrens section. The outcome was measured as changes in servings of fresh, frozen, and canned fruits and vegetables consumed after the intervention. Data were collected from parents using surveys that were given at baseline and at the end of each year families participated. In the survey parents were asked about their childs typical weekday, intake of fruit and vegetable servings, including intake at preschool or daycare, and excluding flavored drinks, French fries and snacks. The mean change in servings was calculated in the post-intervention period. Standard deviations of the means and significance levels were also determined. A total of 48 families reported child consumption data. The average number of fruit servings eaten by children on a typical day by the end of the program period increased by 28% per day. This difference was statistically significant (P<0.001). The average number of vegetable servings eaten by children on a typical day by the end of the program period increased by 33%. This difference was also statistically significant (P<0.001). Although the results showed a considerable increase in the average number of fruits and vegetables eaten by children after participation in the community garden intervention, confidence in these results is reduced due to a lack of appropriate study structure and methods. Neither a comparison nor a control group was used, characteristics of the sample population were not analyzed and confounding variables were not taken into consideration. An important variable that was not taken into consideration was the frequency of participation of subjects in the gardening activities. The authors reported that families participated anywhere from every week to 2-3 times per month. The presence of these limitations is likely due to it being a pilot study. In addition, because the study population was 90% low income and 60%

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Latino the results may not be generalizable to other populations. A strength of this garden intervention was that it exposed participants to a greater number of fruits and vegetables. While the previous two studies exposed participants to only four fruits and vegetables, this one exposed its participants to twenty-two. This may allow for a more accurate representation of changes in fruits and vegetable intake. Summary of Results Out of the five studies that examined fruit and/or vegetable intake, three showed a statistically significant increase in intake of fruit and/or vegetables. Two more studies reported increases in only vegetable intake but one was not statistically significant and the other was analyzed using crude methods that did not evaluate statistical significance. The study that used crude analysis also saw a decrease in fruit intake. Only one study examined willingness to try fruits and vegetables and it found that garden-based interventions were associated with a statistically significant increase in willingness to try fruits and vegetables. Two studies examined fruit and/or vegetable preferences. Both showed statistically significant increases. These results were varied but showed an overall positive correlation between gardening programs and activities, and positive food related behaviors and attitudes. Conclusions and Implications for Future Practice and Research While these results provide some insight into the effectiveness of garden-based interventions, the small sample of studies examined and the limitations in evaluation methodology and study design compromises the ability of this review to make conclusions regarding causal or associative relationships between garden interventions and fruit and vegetable intake and attitudes in preschoolers. In addition, several of the studies focused on

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specific populations or areas, based on their population density, socioeconomic status and/or ethnicity or race. This may limit generalizability of study results. Furthermore, while increases in positive fruit and vegetable-related outcomes were seen, it is difficult to determine if these changes are substantial enough to warrant the time, money and resources necessary for garden-based interventions. Additional research would help determine if positive fruit and vegetable related outcomes remain at a significant level, when appropriate study design and methodology is used. Another challenge to further research is developing standardized garden interventions. Current study interventions are too diverse to conduct rigorous analysis of their effect in a review. The dependent relationship of gardens and garden programs on external factors such as climate, program support (faculty, parents, garden or nutrition specialists), and school or community resources make them difficult to homogenize. If future garden interventions could have similar study design, with similar crop type, setting, and curriculum, then conducting a rigorous and relevant evidence-based review would be more feasible.

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