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Overview

Given that the nutrient intakes of low-income individuals are more likely to be inadequate compared with those of higher incomes, low income groups stand to gain the most from nutrition education (Palmeri et al., 1998; Campbell et al., 1999; Damron et al., 1999). Most low-income meal preparers are aware of some, but not all, key relationships between diet and health. For example, more then three-fourths of low-income women are aware of health problems related to overweight and between two-thirds and three-fourths are aware of health problems related to fat intake and cholesterol. Only half or less, however, are aware of health problems relating to insufficient fiber, calcium, iron, or excess saturated fat intake. Many low-income focus group participants report that they are unaware of current guidelines for healthy eating, uncertain about the healthfulness of their own diet, and open to trying new ways to feed their families healthier meals yet many said they believed these changes are difficult (Bradbard et al., 1997). Nutrition education for low-income groups of the relationship between diet and health can make positive impacts (Campbell et al., 1999; Kaul and Nidiry, 1999; Taylor et al., 2000). Messages should focus on simple ways to make healthful diet changes for entire families.

Ethnic and cultural traditions are strong factors in food choices and meal preparation, particularly for African-American and Hispanic food stamp recipients. Many African-American and Hispanic focus group participants buy and prepare culturally familiar foods and report that family members enjoy traditional meals and often react negatively when new foods or cooking methods are introduced. Cultural traditions and preferences of family members influence food stamp recipients to continue to serve high-fat meat products and other traditional foods. Low-income families devote just over one-third of their food expenditures to meat and report a need to have meat as a staple at all dinners (Bradbard et al., 1997). Nutrition education messages should associate with the ethnic identity of a population to satisfy biological, emotional and social needs (Airhihenbuwa et al., 2000; Bermudez et al., 2000). Messages should focus on lower-fat food choices and cooking methods.

In 2001, the South Carolina food banks provided emergency and commodity food supplies to 36,235 households. The audience includes the working poor, children, needy seniors, the homebound elderly, and the limited resource Hispanic population. According to the America's Second Harvest Hunger in America: National Report (2001) food pantry clients may be food insecure with hunger (36.4%) or without hunger (35.0%). Over 35% of food insecure households include children younger than age 18 and over 20% include seniors age 65 or older. Nutrition education materials addressing the special needs of these age groups may be distributed to food pantries. Similarly, 80% of adult clients who pick up food at a pantry report doing most of their shopping at supermarkets or grocery stores and food resource management education materials may help these individuals save money and store foods appropriately.
A review of the food resource management and food shopping behaviors of low-income households includes several key findings:

• Households with limited financial resources consume less per person for almost every major food group.
• The poor have more restricted access to stores than the non-poor due to lack of transportation of lack of access to a major supermarket, and are often forced to pay higher prices for food.
• Compared with food preparers who do not follow a strict budget, those who have a strict budget are less likely to make a shopping list, stock up on food when on sale, comparison shop among food stores, and redeem coupons.
• The most influential factor related to food shopping behavior of low-income households is income.
• Nearly two-thirds of low-income households prepare food in quantities that result in leftovers (Mullis et al., incomplete reference).
  

Effective strategies for resource conservation include menu planning, preparing a grocery list, redeeming coupons, looking in newspapers for specials, stocking up on sale items when possible, comparison shopping at different grocery stores, as well as appropriate food safety and storage.
Teaching low-income food shoppers these strategies may improve food resource management and food shopping behaviors.

Pre-schoolers, youth, and adolescents

Children should achieve healthful eating patterns and participate in regular physical activity to promote optimal physical and cognitive development, attain a healthful weight, and reduce the risk of chronic disease. The health status of children in the U.S. has generally improved over the last three decades as measured by lower rates of infant mortality and decreases in major deficiency diseases such as anemia. However, results from a recent FNS-funded study "Food for Thought: Children's Diets in the 1990s" (Gleason and Suitor, 2001) indicate that children ages 6-18 consume too much fat, sodium, and added sugars. While most children have adequate intakes of most vitamins and minerals, problem nutrients include vitamin E, folate, and magnesium. Most children fail to follow the Food Guide Pyramid when selecting food: 65% consume less than the recommended number of servings of fruit, 55% consume less than the recommended number of servings of vegetables, and 40% consume less than the recommended number of servings of dairy.

Other trends in children's diets include an increase in energy intake and a shift in beverage consumption from milk to soft drinks and fruit drinks. Energy intake is directly associated with the consumption of nondiet soft drinks and is inversely associated with milk and fruit juice consumption (Harnack et al., 1999). Increased energy intake has contributed to the overweight of an estimated 13% of children ages 6-11 and 14% of children ages 12-19. These results from the 1999 National Health and Nutrition Examination Survey (NHANES) represent a 2 to 3 percent increase over results from NHANES III (1988-1994). Overweight in adolescence is associated with overweight in adulthood. The alarming increased incidence of Type 2 diabetes mellitus, formerly known as adult-onset diabetes, in children and adolescents is directly correlated to the rise in obesity rates. Furthermore, two-thirds of children ages 5-10 who are overweight have at least one risk factor for cardiovascular disease such as high blood pressure or respiratory ailments. Socioeconomic status is closely related to the prevalence of overweight in some race and ethnic groups, particularly for poor white adolescents who are 2.6 times more like to be overweight than those in middle- or high-income families.

As many as 35% of girls and 16% of boys do not eat breakfast every day (Siega-Riz et al., 1998). It is well established that skipping breakfast can affect learning, memory, and physical well-being and that students who skip breakfast are not as efficient at selecting critical information for problem solving as their peers who have had breakfast (Meyers et al., 1989; Simeon et al., 1989). Studies have also found that children who skip breakfast have a lower overall intake of nutrients such as carbohydrates and proteins as well as such essential vitamins and minerals as vitamin C, calcium and iron (Sampson et al., 1995). These children often do not make up for this lower intake during the day (Nicklas et al., 1993). According to the American Dietetic Association, children who eat breakfast perform better in school through increased problem-solving ability, memory, verbal fluency and creativity and school breakfast programs reduce tardiness and absenteeism, particularly for those students nutritionally at risk.

The Healthy People 2010 plan contains 12 objectives addressing nutritional health of children and adolescents, including reducing incidence of overweight, obesity, and growth retardation, as well as increasing intake of healthful foods, increasing numbers of schools that provide health education to prevent unhealthy dietary patterns, and increasing the number of schools that offer healthful meals and snacks. Nutrition education plays a vital role in achieving these objectives (Perez-Rodrigo and Aranceta, 2001; Williams et al., 2002).
A substantial body of research has developed that demonstrates that nutrition education in schools can increase healthful eating behaviors of students and contribute to better school performance. Children provided with nutrition education in schools show improved knowledge, attitude, and behavior for healthy eating and physical activity (Devine et al., 1992; Stewart et al., 1995; Sahota et al., 2001). Indeed, nutrition education is needed in the elementary and middle school years to improve the food choices of children as they transition into adolescence (Lytle et al., 2000). There is a need for long-term contact with students to induce food and nutrition-related behavior changes and there is an advantage to using teachers specifically trained in nutrition (Auld et al., 1999). Nutrition education in schools coupled with community wide health promotion strategies can result in lasting improvement in knowledge and choices of healthful foods (Kelder et al., 1995).

Pregnant and Parenting Adolescents

According to the CDC, adolescent childbearing is a risk factor for poor health in childhood and is more common among mothers of lower socioeconomic status. Adolescent childbearing often leads to poor economic and social outcomes for teenage parents and their children. Adolescent mothers are far more likely than other mothers to live in poverty. Children born to teenage mothers have higher infant mortality rates and sequelae continue throughout childhood, including higher rates of poverty and neglect. Forty-three percent of women who began childbearing in adolescence were poor in their twenties, while only 16% had high incomes in their twenties.

Although the U.S. teen birth rate is declining and dropped to a record low in 2000, low birth weight has been on the rise since the 1980s (CDC, 2001). Birth weight is the single most important factor affecting neonatal mortality and is a significant determinant of postneonatal mortality. The mortality rate increases rapidly with decreasing birth weight for infants below 2500 grams. Hence, an important factor in reducing infant mortality is to find effective ways to prevent low birth weight. One way of preventing low birth weight is early identification of females at risk of bearing low birth weight infants. A review of the scientific literature presents a myriad of prenatal risk factors for low birth weight. These factors include sociodemographic variables, such as ethnicity, maternal age, marital status, and socioeconomic status, as well as nutrition and behavioral risk factors, such as weight gain, iron deficiency, smoking, and alcohol consumption.

South Carolina ranks 48th in infant mortality, with 9.6 deaths per 1000 live births, and much higher than the national average of 7.2 (National Center for Health Statistics). According to the CDC, birth defects are the leading cause of infant mortality in the U.S., accounting for 20% of infant deaths. It is well-established that increased folate intake reduces the risk of neural tube defects, other malformations, and possibly pregnancy complications (Refsum, 2001). 90% of females ages 14-18 have a usual folate intake below the EAR (Gleason and Suitor, 2001). Furthermore, some of the nutrients most essential for a healthy pregnancy are those most likely to be deficient in an adolescent's diet (Sargent et al., 1994). Nutrition education of pregnant adolescents in the areas of folate, iron, and calcium consumption as well as appropriate weight gain and alcohol abstinence may reduce the incidence of low birth weight, birth defects, and infant mortality.

The Healthy People 2010 plan includes 14 objectives related to nutritional health of adolescents including one addressing pre-conceptual folate-status, incidence of low birth weight infants, improving healthful eating patterns, decreasing alcohol use, increasing the number of schools that offer nutrition education, and increasing the number of schools that offer healthful meals and snacks.

Traditional nutrition education classes increase the nutrition knowledge of pregnant adolescents but may not necessarily improve food and nutrition related behaviors (Alley et al., 1995; Owen et al., 1997). It is possible that nine months or less of nutrition education can accomplish only the first step of many leading to diet change. It is also possible that teens do not have complete control over what they eat, especially if they live at home with a caregiver who does the shopping and cooking. However, pregnant adolescents want to have healthy infants, and this concern is a major influence in the change in pregnant adolescents' dietary behaviors (Pope et al., 1997). This desire should be viewed as a motivation for adolescents to improve their diets. However, if adolescents are to make dietary changes, nutrition recommendations must be made within the context of adolescents' everyday lives (Skinner et al., 1996).

Interactive, web-based, computer-tailored nutrition education can lead to changes in determinants of behavior, regardless of computer-literacy (Oenema et al., 2001). Interactive multimedia curricula can promote a shift to a more learner-directed education style, thus increasing the learner's sense of control and motivation to learn (Katims et al., 1997). Nutrition education for pregnant and parenting adolescents in a relevant, stimulating format will be a vital component to achieving the objectives described above.

Working Poor

The South has a disproportionately large share of the Nation's poor population. While 35% of the U.S. population lives in the South, 38% of persons below the poverty level live in the South. Fifteen percent of South Carolinians of all ages live in poverty, over 20% of children under 5 live in poverty. Twenty six percent of children under the age of 13 live in low-income families with one or more working parents. Income disparities in self-assessed health are prevalent: men and women in poor households are 7 and 5 times more likely, respectively, to report their health as fair or poor than their counterparts in the highest-income households (Eberhardt et al., 2001).

Chronic diseases such as heart disease are the major contributors to death in the adult population. Although heart disease mortality rates traditionally fit a pattern of higher socioeconomic status in the past, there has been a shift in the recent past to lower socioeconomic groups being more adversely affected (presumably because higher socioeconomic groups more quickly adopt practices to reduce the risk of chronic disease). Income gradients in heart disease mortality are similar across sex, race, and ethnic group; persons with incomes under $10,000 are 2.4-2.9 times more likely to die from heart disease as those with incomes of $15,000 or more. Risk factors for heart disease include high cholesterol (27% of South Carolinians), hypertension (25%), smoking (25%), overweight (12%), diabetes (7%), past heart attack (5%) and stroke (2%) (Diabetes Initiative of South Carolina).

Similarly, overweight adults are at increased risk for hypertension, heart disease, diabetes, and some types of cancer. A healthy diet is important for maintaining a healthy weight. The number of overweight and obese Americans has continued to increase since 1960, a trend that is not slowing down. Today, 55% of adult Americans (97 million) are categorized as being overweight or obese (American Obesity Association). According to the Behavioral Risk Factor Surveillance System (1991-2000) the prevalence of obesity in South Carolina is rapidly increasing, rising from 13.8% of adults in 1991 to 21.5% in 2000. Obesity rates are highest for black, non-Hispanics and Hispanics with less than or the equivalent of a high school degree. For men of all races there is little evidence of an income-related gradient in the prevalence of overweight. In contrast, there is a clear income gradient in overweight prevalence among women, with poor women being 1.5 times more likely to be overweight compared with women in other income gradients. For non-Hispanic white and Hispanic women, the prevalence of overweight for those in poverty is 1.3 times that of higher income women (Eberhardt et al., 2001). Nutrition education is an important component in improving knowledge, skills, and behaviors of participants in food and nutrition classes (Kaul and Nidiry, 1999; Taylor et al., 2000).

Diabetes is the 7th leading cause of death for all persons in the U.S. and in recent years mortality from diabetes has been increasing. Data from the National Longitudinal Mortality Study show a strong relationship between diabetes mortality and family income. The diabetes death rate for women in families with incomes below $10,000 was 3 times the death rate for those with incomes of $25,000 or more; among men, the death rate for the lowest income group was 2.6 times that of the highest income group (Eberhardt et al., 2001). In South Carolina, the incidence of diabetes varies disproportionately with income. While 7% of South Carolinians have diabetes, 9% of those with incomes $15,000-$24,999 and 17% of those with incomes <$15,000 have diabetes (Diabetes Initiative of South Carolina). Nutrition education (Miller et al., 1999; Miller et al., 2002) plays an important role in diabetes management and can be incorporated into general food and nutrition related education by trained paraprofessionals.

The Healthy People 2010 plan includes 13 objectives related to nutritional health of adults including reducing the prevalence of osteoporosis, cancer, diabetes, heart disease, stroke, blood pressure, cholesterol, obesity, as well as increasing healthful food and nutrient consumption, food security, oral health, food safety awareness, and reducing alcohol use. Nutrition education plays an important role in increasing the knowledge, skills, and behaviors associated with risk reduction of these diseases, safe food handling practices and food resource management for a variety of working poor sub-populations (Taylor et al., 2000; Burney and Haughton, 2002).

Elderly

The 65+ population in South Carolina increased by 22.3% between 1990 and 2000 to total 485,333 persons or 12.1% of the population. Of these persons, 12.6% lived below the poverty level in 1998-2000. More than half of the older population (54.4%) reports having at least one disability of some type and over a third (37.7%) report at least one severe disability. Consequently, 14.2% report difficulties with Activities of Daily Living such as eating and 21.6% report difficulties with Instrumental Activities of Daily Living such as preparing meals, shopping, and managing money. Furthermore, most older persons have at least one chronic nutrition-related condition and may have multiple conditions, the most frequent being hypertension, heart disease, overweight, and diabetes. Diabetes, stroke, coronary heart disease, and cancer have been among the leading causes of death in South Carolina for many years. (Administration on Aging, 2001).

Good nutritional status is vital to helping elderly individuals remain independent and maintain a good quality of life. Nutritionally inadequate diets can contribute to or exacerbate chronic and acute diseases and hasten the development of degenerative diseases associated with again. Access to safe and adequate food that provides essential nutrients is a daily challenge for many Americans, but may be a very significant challenge for the elderly if they are functionally impaired and/or poor. Data from NHANES III suggest that the elderly are at particular risk for malnutrition because of the presence of disease, physical disability, inability to chew food adequately, polypharmacy, living status, and limited income. Elderly men and women may have inadequate intakes of energy, vitamin E, vitamin B6, calcium, magnesium and zinc and poverty is related to significantly lower intakes of several of these nutrients (Weimer, 1998).

The Healthy People 2010 plan includes 10 objectives related specifically to nutrition and aging including increasing healthy eating behaviors, decreasing the incidence of foodborne illness, increasing food security, and increasing the number of elderly who are provided nutrition education to assist in management of chronic diseases.

Nutrition education research involving the elderly indicate that in addition to "how to" knowledge, the elderly benefit from programs that provide motivation to change and tailored feedback (Abusabha et al., 2001).

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