Research Papers

Effects of a Nutrition Education Program on the Dietary

Behavior and Nutrition Knowledge of Second-Grade
and Third-Grade Students
Alicia Raby Powers, Barbara J. Struempler, Anthony Guarino, Sondra M. Parmer

ABSTRACT: This research investigated the effects of a nutrition education program on dietary behavior and nutrition knowledge
among elementary school–aged children participating in a Social Cognitive Theory–based nutrition education program. Participants
included 1100 second-grade and third-grade students selected by convenience-type sampling from public schools in Alabama. A
preassessment and postassessment control group design assessed dietary behavior and nutrition knowledge using Pizza Please,
a specially designed interactive evaluation tool. A 2 3 2 mixed analysis of variance was used to analyze data. Children in the
treatment group exhibited significantly (p , .001) greater improvement in overall dietary behaviors such as consumption of dairy
products, fruits, and vegetables, than children in the control group. Children in the treatment group exhibited significantly (p , .001)
greater improvement in nutrition knowledge, including Food Guide Pyramid understanding, nutrient-food association, and nutrient-
job association, than children in the control group. Results suggest that nutrition education programs that teach positive dietary
messages potentially can improve dietary behavior and increase nutrition knowledge in children. (J Sch Health. 2005;75(4):129-133)

Fsearchamily, peers, media, and environment influence the

health habits, especially eating habits, of children. Re-
has shown that eating habits developed during child-
1
hood continue into adulthood.2 Thus, childhood influences
should optimally have positive effects on the elementary
school–aged child. These positive influences will help
form a basis for good nutrition and physical activity habits
to be followed throughout an individual’s adolescent and
adult life.3,4
Nutrition-related problems in elementary school–aged
children include proper growth and development; immedi-
ate health problems such as dental caries and overweight;
and long-term health problems such as heart disease, can-
cer, and diabetes.1,2 By increasing consumption of low-fat
dairy products, fruits, and vegetables; decreasing consump-
tion of soft drinks; and increasing participation in regular
physical activity within the elementary school–aged popu-
lation, prevalence of these nutrition-related problems could
be reduced.
To facilitate dietary behavior changes, education is an
effective beginning. Nutrition educators must consider
certain factors to effectively reach children. They should
carefully determine the purpose and goals of a nutrition
education program. In addition, educators must determine
the theory used to develop and deliver nutrition education
topics.
After determining these strategic characteristics of a nu-
trition education program, educators should assess pro-
Alicia Raby Powers, MS, Graduate Research Assistant, (rabyali@auburn.
edu), 328 Spidle Hall; Barbara J. Struempler, PhD, Professor/Extension
Nutritionist, (struebj@auburn.edu), 328 Spidle Hall; Anthony Guarino,
PhD, Associate Professor, (guariaj@auburn.edu), 4036 Haley Center;
and Sondra M. Parmer, MS, Project Manager, (parmesm@auburn.edu),
Alabama Cooperative Extension Nutrition Education Program, 208 Duncan
Hall, Auburn University, Auburn, AL 36849.
gram effectiveness through evaluation. Literature explains
the need for impact, outcome, and process evaluations to
determine effectiveness and to allow for continued suc-
cess of a nutrition education program.5-12
This research determined the effects of a Social Cogni-
tive Theory–based nutrition education program on dietary
behavior and nutrition knowledge among second-grade and
third-grade students. The State Cooperative Extension Sys-
tem and State Department of Human Resources cospon-
sored the study, which was conducted through the State
Cooperative Extension Nutrition Education Program.
METHODS
Subjects
The study used a preassessment and postassessment
control group design consisting of 1100 (550 girls and
550 boys) second-grade and third-grade students from 64
schools in two thirds of the counties of Alabama. Students
were a convenience sample from schools where at least
51% of students received free or reduced-price meal
plans. Children in the treatment group (n = 702; mean
age = 7.58 6 0.71 years; 52.99% female; 60.40% Cauca-
sian) participated in a preassessment, 6 weekly nutrition
education classes, and a postassessment. Children in the
control group (n = 398; mean age = 7.58 6 0.72 years;
44.72% female; 48.74% Caucasian) participated in a pre-
assessment and postassessment only. Preassessments, post-
assessments, and nutrition education classes were conducted
by nutrition educators employed by the State Cooperative
Extension Nutrition Education Program.
Instruments
Pizza Please, a dynamic assessment method,13,14
was developed to collect impact data from elementary

Journal of School Health d April 2005, Vol. 75, No. 4 d 129

school–aged children. Pizza Please consisted of 2 parts, an
interactive game component and a developmentally appro-
priate questionnaire.
Pizza Please Game. The Pizza Please game component
included an interactive game board and 12 mealtime game
questions. The game board consisted of a life-size pizza
with detachable toppings and 4 place mats depicting
a table setting with an outline of a pizza slice on the
plate. The object of the game was to answer correctly the
most game questions. A pizza topping was awarded and
placed on the pizza slice found on the team’s place mat
for a correct response.
Pizza Please Questionnaire. The questionnaire included
24 dietary behavior and 16 nutrition knowledge questions
based on nutrition-related problems associated with ele-
mentary school–aged children and previous question-
naires.15 Dietary behavior was self-reported and assessed
using ‘‘yes/no’’ questions to determine whether a particular
food was consumed at a particular meal or snack. For ex-
ample, ‘‘On most school days do you drink milk at break-
fast?’’ This frequency question was used for breakfast,
lunch, dinner, and snack as well as individually for con-
sumption of milk, cheese, yogurt, juice, fruit, and vegetable.
Dietary consumption questions only detected frequency;
amounts were not assessed. Nutrition knowledge was as-
sessed using matching and item-elimination questions.
Topics included food-appropriate Food Guide Pyramid
food group, nutrient-food association, and nutrient-job
association.
To facilitate questionnaire completion, educators
received a prompt guide that included procedures for be-
ginning the assessment process, directions to be explained
to children after printed directions were read, and exam-
ples to be read as students individually answered a specific
question.
A pilot study was conducted to determine content val-
idity. Teachers in 19 classrooms presented the ques-
tionnaire to 300 participants using the prompt guide. A
process evaluation was provided to teachers to enable
them to detail strengths and weaknesses of the question-
naire. Careful consideration was given to suggestions
teachers made when the questionnaire was revised for the
final edition. University faculty, school administrators,
and parents also reviewed all materials.
Readability was assessed to ensure ease of completion,
validity, and reliability. A Flesch-Kincaid Readability
score for the questionnaire was approximately 2.3.16 In
addition, educators read aloud each question and answer
choice on the questionnaire to help children who read
below this level.
Evaluation Process. To begin the game, educators
placed the large pizza and 4 place mats on a display
board, divided students into teams of 4 to 6 players, and
distributed a questionnaire to each child. Teams alternated
answering game questions. A pizza topping was awarded
and placed on the team’s pizza slice for a correct answer
to a game question. Embedded within game questions
were 2 ‘‘Go To’’ questions that directed students to tem-
porarily stop playing the game as a team and to complete
a specific section of the questionnaire as an individual.
After the specific questionnaire section was completed,
children continued answering game questions. A bonus
round was played when all game and questionnaire
130 d Journal of School Health d April 2005, Vol. 75, No. 4
questions had been answered. The team with the most
toppings on their pizza slice at the end won the game.
Approximately 1 hour was needed to complete Pizza
Please.
Intervention
In between preassessment and postassessment, nutri-
tion educators conducted 6 weekly nutrition classes on
concepts assessed in the questionnaire, including dairy
consumption, fruit and vegetable consumption, Food
Guide Pyramid knowledge, nutrient-food association
knowledge, and nutrient-job association knowledge. To
ensure consistency, nutrition educators were provided
a curricula guide with specific curricula and materials
appropriate for the target audience. Materials were from
a variety of sources such as the Dairy Council,17 Wellness
Inc,18 and the American Heart Association.19
The 6 weeks of nutrition classes were based on tenets
of Social Cognitive Theory, which incorporates the inter-
dependent relationship between personal characteristics,
behavioral factors, and environmental influences.20 In this
study, nutrition educators taught skills to select healthy
foods both at school and home. Nutrition educators also
served as role models by eating with students in the lunch-
room. Nutrition concepts were reinforced with hands-on
activities and nutrition messages on bulletin boards and in
cafeterias.
Procedures
The study was conducted in accordance with current
policies and procedures of the Cooperative Extension Sys-
tem efforts of a land-grant university. To promote data
collection consistency, nutrition educators (n = 46) partici-
pated in a daylong training on implementation protocol in
summer 2003. Nutrition educators conducted the study
between August and December 2003 in second-grade and
third-grade classrooms in public school systems. For both
treatment and control groups, All About Me forms were
completed, which provided demographic information. In
addition, both groups completed a Pizza Please preassess-
ment and postassessment. For the treatment group, 6
weekly nutrition classes were conducted between preas-
sessment and postassessment. For the control group, no
nutrition classes were conducted in the 6 weeks between
assessments. Educators mailed all assessment materials to
the researcher.
Statistical Analysis
Data were analyzed using SPSS.21 Descriptive statistics
summarized demographic data from the All About Me
form. Cronbach’s coefficient alpha was used to determine
the reliability of dietary behavior and nutrition knowledge
questions on preassessment and postassessment.
Responses to 24 dietary behavior questions were
summed for an overall preassessment dietary behavior
score and an overall postassessment dietary behavior
score. Responses to behavior questions were then disag-
gregated into 2 clusters for further analyses. Responses to
12 questions concerning milk, cheese, and yogurt con-
sumption at each meal were used to calculate dairy con-
sumption preassessment and postassessment scores.
Responses to 12 questions concerning juice, fruit, and
vegetable consumption at each meal were used to calcu-
late fruit and vegetable consumption preassessment and
postassessment scores.
Responses to 16 nutrition knowledge questions were
summed for an overall preassessment nutrition knowledge
score and an overall postassessment nutrition knowledge
score. Responses to knowledge questions were then disag-
gregated into 3 clusters for further analyses. Overall
knowledge scores at preassessment and postassessment
were calculated for food-appropriate Food Guide Pyramid
food group from a 6-question cluster, food-nutrient asso-
ciation from a 5-question aggregate, and nutrient-job
association from a 5-question cluster.
To measure the overall impact of the intervention, gain
scores were calculated for overall dietary behavior, dairy
consumption, fruit and vegetable consumption, overall
nutrition knowledge, and specific knowledge categories.
For each student, a specific gain score was calculated by
subtracting the student’s preassessment score for a specific
category from the postassessment score for the same cate-
gory (Postscore ÿ Prescore = Gain score).
A 2 (treatment and control) 3 2 (preassessment and
postassessment) mixed analysis of variance determined
significant differences between overall dietary behavior
gains, dairy consumption gains, fruit and vegetable con-
sumption gains, overall nutrition knowledge gains, food-
appropriate Food Guide Pyramid food group knowledge
gains, nutrient-food association knowledge gains, and
nutrient-job association knowledge gains in treatment and
control groups. To determine specific dietary behavior
changes and nutrition knowledge changes within each
experimental group, paired t tests were performed on each
individual question for each group. A relationship between
dietary behavior changes and nutrition knowledge changes
was assessed. Overall dietary behavior gain scores and
overall nutrition knowledge gain scores were compared
using Pearson’s correlation coefficient.
RESULTS
Reliability
Internal consistency as calculated by Cronbach’s coef-
ficient alpha determined reliability of 24 dietary behavior
questions (preassessment a = .73; postassessment a = .74)
and 16 nutrition knowledge questions (preassessment
a = .61; postassessment a = .77). To determine consistency
of question responses over time, preassessment and post-
assessment alphas were reported.
Dietary Behavior Changes
Children in the treatment group exhibited significantly
greater improvements (F = 12.91, p , .001, g2 = .01) in
overall dietary behavior than children in the control group,
whose overall dietary behavior declined (Table 1).
The overall dietary behavior score was disaggregated
into 2 clusters: dairy consumption and fruit and vegetable
consumption (Table 1). Dairy consumption improved sig-
nificantly (F = 11.81, p = .001, g2 = .01) more in the treat-
ment group compared to a drop in the control group. Fruit
and vegetable consumption increased significantly (F = 5.82,
p = .016, g2 = .01) more in the treatment group compared to
a decline in the control group.
To determine specific behavior changes, 24 behavior
questions were analyzed individually by comparing each
question’s preassessment and postassessment answers
using paired t tests. Significant positive changes (p < .05)
between preassessment and postassessment were noted
for 5 questions within the treatment group: increased con-
sumption of juice at breakfast, increased consumption of
vegetables and cheese at lunch, increased consumption of
fruit at supper, and increased consumption of fruit at
snack. Item analysis confirmed that control students did not
significantly (p . .05) improve any nutrition behavior from
preassessment to postassessment.
Nutrition Knowledge Changes
Children in the treatment group exhibited significantly
greater improvements (F = 140.82, p , .001, g2 = .11) in
overall nutrition knowledge than children in the control
group (Table 1). The overall nutrition knowledge score was
separated into 3 sections: food-appropriate Food Guide Pyr-
amid food group, nutrient-food association, and nutrient-
job association. Ability to determine which food did not
belong to the appropriate Food Guide Pyramid food group
improved in the treatment group significantly (F = 24.20,
p , .001, g2 = .02) more than in the control group. Nutri-
ent-food association was significantly (F = 72.11, p , .001,
g2 = .06) greater in the treatment group than in the control
group. Knowledge of a specific nutrient’s job increased in
the treatment group significantly (F = 87.45, p , .001,
g2 = .07) more than in the control group.
To determine specific nutrition knowledge changes,
16 nutrition knowledge questions were analyzed individu-
ally by comparing each question’s preassessment and
postassessment answers using paired t tests. Within the
treatment group, significant positive changes (p , .001)
were found for all 16 nutrition knowledge questions. Stu-
dents in the control group demonstrated a significant (p ,
.001) increase in correctly answering 1 question from
Table 1
Gain Scores for Treatment (n = 702) and Control
(n = 398) Students Participating in an 8-Week,
Theory-Driven Nutrition Education Program
Treatment Control
Group Group
Topic Gain Scores Gain Scores p
Overall dietary behavior 0.41 6 4.56 ÿ0.62 6 4.58 ,.001
Dairy consumption 0.08 6 2.77 ÿ0.50 6 2.59 .001
Fruit and vegetable 0.31 6 2.75 ÿ0.11 6 2.80 .016
consumption
Overall nutrition 3.26 6 3.62 0.76 6 2.83 ,.001
knowledge
Food-appropriate 0.71 6 1.40 0.27 6 1.47 ,.001
Food Guide Pyramid
Food Group
Nutrient-food association 1.27 6 1.93 0.29 6 1.69 ,.001
Nutrient-job association 1.27 6 1.94 0.20 6 1.63 ,.001
Journal of School Health d April 2005, Vol. 75, No. 4 d 131
preassessment to postassessment, which was choosing the
food that did not belong to the grain group in the Food
Guide Pyramid.
Relationships Between Knowledge and Behavior
The correlation between gains in overall dietary behavior
and gains in overall nutrition knowledge [r(1098) = .097,
p , .001] was weak for the overall study group. In addition,
the correlation between gains in overall dietary behavior and
gains in overall nutrition knowledge [r(702) = .098, p = .009]
was weak for the treatment group.
DISCUSSION
This study investigated the effects of a nutrition educa-
tion program on dietary behavior and nutrition knowl-
edge among second-grade and third-grade students
participating in an 8-week nutrition education program. Re-
sults indicated that the intervention effectively improved
dietary behavior and increased nutrition knowledge. Simi-
lar findings were demonstrated in other studies.22-24 These
studies, like the present, included children in the same age
group and used the Social Cognitive Theory.
Dairy consumption has decreased in the past 20 years
and begins to decrease at ages 6 to 11 years.25 The 1977-
1978 US Department of Agriculture Continuing Survey of
Food Intakes by Individuals demonstrated that 99% of chil-
dren aged 6 to 8 years consumed milk or milk drinks.26 In
contrast, the 1994-1996, 1998 Continuing Survey of Food
Intakes by Individuals demonstrated that 86% of boys and
83% of girls aged 6 to 9 years consumed milk, milk drinks,
or yogurt.27
The present study suggests that nutrition education in
schools can lessen the dairy consumption decline among
elementary school–aged children. Children in the treatment
group demonstrated an increase in dairy consumption,
while children in the control group showed a decrease in
dairy consumption. Specifically, cheese consumption at
lunch increased significantly (p = .01) from preassessment
to postassessment in the treatment group. Conversely,
cheese consumption at lunch and snack decreased signifi-
cantly (p = .006 and p , .001, respectively) from preassess-
ment to postassessment in the control group. Thus, the
decrease in dairy consumption in children, including those
in this study’s control group, may be slowed by providing
school-based nutrition education.
While milk consumption has decreased in the past 20
years, fruit and vegetable consumption has remained
constant. The level of fruit consumption of children in
this study was consistent with findings at the national
level. A national survey in 1998 indicated that 62% of
children aged 6 to 11 years consumed at least 1 fruit item
on any given day.28 In the current study, 65% and 62% of
children in the treatment and control groups, respectively,
consumed at least 1 fruit item at postassessment. For vege-
table consumption, 82% of children aged 6 to 11 years con-
sumed at least 1 vegetable, which included fried white
potatoes, on any given day in 1998.28 In the current study,
49% and 43% of children in the treatment and control
groups, respectively, consumed at least 1 vegetable at post-
assessment. Although this value is lower than the national
132 d Journal of School Health d April 2005, Vol. 75, No. 4
average, one explanation may be that examples for vegeta-
bles in this study that were verbally given to children
during data collection consisted of green beans, tomatoes,
and potatoes. It is unknown whether second-grade and
third-grade students would consider ‘‘fried white potatoes’’
as ‘‘potatoes.’’ Moreover, data in this study were self-
reported as opposed to rigorously collected national intake
survey data.27
A more detailed analysis of data helps justify school-
based nutrition education. Similar to an increase in dairy
consumption in the treatment group, increases also were
found in fruit and vegetable consumption. Significant
(p = .01) improvements were seen in fruit and juice con-
sumption in the treatment group, while the control group
demonstrated a decrease in fruit and juice consumption.
In addition, significant (p , .05) improvements occurred
in vegetable consumption in the treatment group, while
the control group had a decreased vegetable consumption.
Further improvements in fruit and vegetable consumption
may occur with nutrition education.
Based on item analysis of behavior questions, the
change in dietary behavior for dairy and vegetable con-
sumption for the treatment group occurred during lunch.
This is noteworthy because both treatment and control
groups were within the same school and 75% of students
participated in the National School Lunch Program.29 This
suggests that the school-based nutrition education effort
may have affected behavior change since the 2 factors were
not confounding variables of the study. Perry et al30 demon-
strated a similar trend in which fruit and vegetable con-
sumption increased at lunch in the treatment group, which
received nutrition education.
The short duration of the study may have minimized
dietary behavior changes of students. The School Health
Education Evaluation found that a minimum of 50 hours
were needed to impact behavior.31,32 However, students
in this study only participated in a minimum of 6 hours
of nutrition education. Thus, changes in dietary behav-
ior were minimal, yet significant. Ideally, more instruc-
tion hours would yield a more positive impact on
behavior. In the present study, longer term education could
not be provided due to educational costs and time
restrictions.
In a review of numerous nutrition education study out-
comes, Lytle33 found that 71% of studies reporting on
knowledge outcomes demonstrated significant knowledge
gains for the treatment group compared to the control
group. Results in the present study concerning knowledge
gains were consistent with these findings. Furthermore, the
School Health Education Evaluation34 showed that 10 to 15
hours were needed to expect ‘‘large’’ effects in program-
specific knowledge. By participating in as few as 6 hours
of nutrition education in this study, the treatment group
demonstrated a statistically significant (p , .001) increase
in overall nutrition knowledge and other specific nutrition
knowledge categories (Table 1).
Findings from this study suggest programs similar in
constructs potentially can improve dietary behavior and
increase nutrition knowledge in second-grade and third-
grade students. Educators or other school health officials,
by implementing a similar nutrition education program,
can positively influence the dietary behavior and nutrition
knowledge of students. j
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