Volume 1: No. 1, January 2004
Increasing Fruit and
Vegetable Intake in Homebound Elders: The Seattle Senior Farmers’
Market Nutrition Pilot Program
Donna B. Johnson, RD, PhD, Sharon Beaudoin, MPH, RD, CD, Lynne T. Smith,
RD, PhD, MPH, Shirley A.A. Beresford, PhD, James P. LoGerfo, MD, MPH
Suggested citation for this article: Johnson DB,
Beaudoin S, Smith LT, Beresford SAA, LoGerfo JP. Increasing fruit and
vegetable intake in homebound elders: the Seattle Senior Farmers' Market
Nutrition Pilot Program. Prev Chronic Dis [serial online] 2004
Jan [date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2004/
Diets that are high in fruits and vegetables lower an individual's risk of chronic disease
and contribute to healthy aging. Homebound seniors often have low intake of
fruits and vegetables and limited access to fruits and vegetables with the
most protective nutrients and phytochemicals. From June through October
2001, the Seattle Senior Farmers' Market Nutrition Pilot Program delivered
bi-weekly market baskets that included a variety of fresh, locally grown
produce to 480 low-income Meals on Wheels participants. The purpose of this
study was to determine if the program increased fruit and vegetable intake
in individuals who received the baskets.
One hundred basket recipients were recruited to complete a telephone survey
before and at the end of the farmers' market basket season. Fifty-two low-income
homebound seniors who lived outside the project service area were recruited
to serve as control respondents. Fruit and vegetable intake was determined
with modified versions of the 6 fruits and vegetables questions in the
Behavior Risk Factor Surveillance System.
Seniors who received the baskets reported consuming an increase of 1.04 servings of
fruits and vegetables. The difference between the mean servings in the
seniors who received the baskets compared to the controls was 1.31 (95% CI,
0.68-1.95, P < .001). At baseline, 22% of the basket
recipients were consuming 5 or more servings of fruits and vegetables per day, but by
the end of the season, 39% reported consuming 5 or more per day.
Home delivery of fruits and vegetables is an effective way to increase
fruit and vegetable intake in homebound seniors.
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Evidence for the importance of fruit and vegetable intake to health and
quality of life with aging is widely recognized (1-3). Consuming fruits and vegetables
can reduce an individual's risk of cardiovascular disease (4) and many cancers (5,6).
and vegetables are important components of diets for the secondary
prevention of diabetes (7) and hypertension (8,9). Diets rich in nutrients
and phytochemicals found in fruits and vegetables have also been associated
with delay or decreased risk of conditions associated with aging such as
cataracts (10), diverticulosis (11), degeneration in neurological and
cognitive performance (12-14), decline in bone mass (15), and chronic
obstructive pulmonary disease (16).
In the 2000 edition of Dietary Guidelines for Americans (17),
consistent with Healthy People 2010 objectives (18), adults are
advised to choose a variety of fruits and vegetables and to consume at least
2 servings of fruits and 3 servings of vegetables each day. In those
individuals older than 60
years of age, 35% of women and 39% of men meet the objective for fruit
(18), and only 6% of both women and men older than 60 meet the objective for
vegetables. Data on homebound elders are limited. Posner and colleagues
reported that 22% to 40% of homebound elders eat 4 or more servings of fruit
and vegetables per day (19), and low fruit and vegetable intakes are common
findings in nutritional screenings (20,21).
A recent systematic review (22) of community-based interventions (23-25)
to increase fruit and vegetable consumption found that most interventions
have had very modest effects. Ciliska et al recommend that priority be
given to fruit and vegetable interventions that are "multipronged,
flexible, open to input from target groups, and theoretically based"
(22). One such program, conducted in a Michigan county, provided fresh
farmers' market produce to young
women and children (26). A
factorial design was used to evaluate, alone and in combination, an
education program on fruits and vegetables and distribution of farmers'
market coupons. More than 80% of the low-income women in this study
responded to both the pre-test and post-test. Results demonstrated that
coupons had a direct effect on fruit and vegetable consumption, independent
of education, but the strongest intervention effects on attitudes and
behavior were achieved through a combination of both education and coupons.
Large population-based surveys have been able to identify several factors
associated with fruit and vegetable intake on the individual level, but most
of the variance in fruit and vegetable intake remains unexplained (27).
Common theoretical constructs that are thought to contribute to decisions
about fruit and vegetable intake include self efficacy, social/intrapersonal
influence, demographic factors, attitudes, awareness, and perceived
benefits, barriers, and threats (27-29). Food choices in the elderly are
influenced by quality and freshness, efforts to eat healthily, price, and
financial difficulties (29,30). For homebound elders, barriers to fruit and
vegetable intake are likely to include difficulties with shopping, food
preparation, chewing, and swallowing (20,31,32).
Adequate fruit and vegetable intake is an important part of healthy
aging and an important component of treatment for health conditions that are
associated with aging. Eighty-seven percent of Medicaid beneficiaries over
the age of 65 have diabetes, hypertension, or dyslipidemia (33). A recent
Institute of Medicine report, The Role of Nutrition in Maintaining Health
in the Nation's Elderly; Evaluating Coverage of Nutrition Services in the
Medicare Population, established the clear need, efficacy, and
cost-effectiveness of providing nutrition services for seniors (33).
Congregate and home-delivered meals are provided to seniors through the
Elderly Nutrition Program, authorized by Congress under Title III of the
Older Americans Act. Program services leverage a wide range of supportive
resources that help to optimize health and maintain elders in their homes.
The Elderly Nutrition Program contributes to efforts to meet the Healthy
People 2010 developmental goal to increase the proportion of persons
with long-term care needs who have access to the continuum of long-term care
services (18). Congregate and home-delivered meal participants are better
nourished than matched nonparticipants (34). However, these meals provide
only 30% to 50% of participants' daily nutrient intake, and participants
must obtain at least half of their food through other sources.
Federal food assistance programs have had mixed effects on fruit and
vegetable consumption by low-income participants, and there is interest in
increasing promotional efforts for fruits and vegetables in federally funded
programs (3). One such effort is the Senior Farmers' Market Nutrition
Program that is administered by the Food and Nutrition Service of the United
States Department of Agriculture (http://www.fns.usda.gov/wic/SeniorFMNP/SFMNPmenu.htm).
Grants are awarded to states, territories, and tribal governments to provide
low-income seniors with foods from farmers' markets, roadside stands, and
community-supported agriculture programs. The purpose of the Senior Farmers'
Market Nutrition Program is to provide fresh, nutritious, unprepared,
locally grown fruits and vegetables to seniors, and to increase consumption
of agricultural commodities by developing and expanding markets. Most
grantees choose to use a coupon distribution system to meet these goals.
This system usually requires travel to a senior center to pick up coupons
and an additional trip to the market to obtain produce. Seniors report
increased fruit and vegetable consumption when they are provided with
coupons to use at farmers' markets, although most seniors do not report that
they try fruits or vegetables that they have never tried before (35,36).
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In the summer and fall of 2001 the Seattle Senior Farmers' Market
Nutrition Pilot Program provided an opportunity for 480 homebound seniors to
have increased access to fresh fruits and vegetables as part of the national
Senior Farmers' Market Nutrition Program. The Seattle market basket program
approach was unique. In Seattle, the program provided homebound
elders with home delivery of a market basket that contained a variety of
seasonal local produce. The program was a collaborative effort among 5
organizations: King County Area Agency on Aging, Public Health-Seattle &
King County, Pike Place Market Community Supported Agriculture, Senior
Services of Seattle/King County, and the University of Washington Health
Promotion Research Center. The King County Area Agency on Aging administered
the funding for the program and organized service delivery. Local farmers
were contracted by Pike Place Community Supported Agriculture to provide
fruits and vegetables in season. Volunteers were used to pack the baskets
each week. Market baskets were delivered to the homes of 480 low-income
seniors every 2 weeks from June through October by Meals on Wheels drivers.
Meals on Wheels participants were eligible for the baskets if they lived
within a specific catchment area in the city of Seattle, met income
guidelines, and requested basket delivery.
Over the 5-month basket delivery period, an average of 1.6 servings
of vegetables and 0.67 servings of fruit were provided per day. Each basket
included dark green or orange fruits and vegetables. The average daily
nutrients that were provided per day by the baskets over the 5 months of
delivery included 30% of the U.S. Recommended Dietary Allowance for vitamin
C, 40% for vitamin A, and 8% for folate. A newsletter that described the
produce, provided recipes for less common seasonal foods, and promoted
eating fruits and vegetables accompanied each basket.
The purpose of this study was to determine if the Seattle Senior Farmers'
Market Nutrition Pilot Program increased fruit and vegetable intake of
homebound seniors. This evaluation process began after the agency had
determined which Meals on Wheels recipients would receive the market
baskets. The study employed a quasi-experimental design to compare fruit and
vegetable intake in a subset of the 480 seniors who received the baskets
with a concurrent comparison group of low-income homebound seniors who lived
outside the project service area. Subjects for both the intervention and
control groups were recruited via flyers that were delivered by Meals on
Wheels drivers. Regulations protecting the rights of human subjects
precluded recruitment through direct contact with potential subjects by
program or evaluation staff. Seniors who wished to participate in the study
could either return a postage-paid postcard or call the Health Promotion
Research Center. Participation in the study segment of the program was
voluntary. Power calculations indicated that a sample size of 98
intervention subjects and 98 control subjects would detect an estimated
effect size of 1 serving at α = 0.05 and ß = 0.80. We attempted to
recruit 100 of the 480 basket recipients and 100 low-income homebound
seniors who were not receiving the baskets as control subjects. More than 500
recruitment flyers were distributed to potential control group participants,
but many replied that they did not understand why they should join the study
if they were not going to receive fresh fruits and vegetables themselves.
Both the basket recipients and control respondents were interviewed by
telephone before basket deliveries started and again at the end of the
market season. All respondents were required to be at least 60 years old,
have access to a phone, and be able to hear and comprehend the survey
questions. The Institutional Review Board of the University of Washington
approved this study.
The telephone survey included the following 6 fruit and vegetable
questions from the Behavioral Risk Factor Surveillance System (BRFSS) as modified by Wolfe and colleagues (37). For each
question, participants were given a choice of responses. They could provide
answers in number of times per day, per week, or per month; they could
respond with "never" or "don't know/not sure"; or they
could refuse to answer the question altogether. The 6 questions were:
- How often did you drink 100% juices such as orange juice, apple juice,
or tomato juice?
- Not counting juices, how often did you eat fruit, including fresh,
canned, frozen, or dried?
- How often did you eat green salad?
- How often did you eat white potatoes such as baked, boiled, mashed, or
in potato salad or mixed dishes? Do not include French fries, fried
potatoes, or potato chips.
- How often did you eat carrots? Include fresh, canned and frozen, and
carrots in mixed vegetables.
- Not counting carrots, white potatoes, or green salad, how often did
you eat other vegetables? Include fresh, canned, and frozen vegetables
and vegetables in casseroles and other mixed dishes, but do not include
legume-type beans such as pinto and kidney.
All participants were mailed a serving-size guide with pictures of
representative foods. Participants were required to have the guide with them
at the time of the telephone survey. At the end of the season, seniors who
received baskets were asked if they would like to participate in future
market basket programs.
An independent sample t-test was used to compare differences between means,
and paired sample t-tests were used to compare changes in means. ANOVA
analyses were used to measure relationships between demographic variables
and fruit and vegetable intake. Differences between the intervention and
control groups for gender, age, ethnic group, and races were were tested
using chi-square analysis.
In addition, data on fruit and vegetable consumption by intervention and
control participants were compared to BRFSS data from seniors in Washington
State as a whole (38).
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At baseline, 100 market basket recipients and 52 control respondents
completed surveys. After the 6-month market basket season, 87 basket
recipients and 44 control respondents completed the follow-up survey. One
intervention respondent and 2 control respondents died during the
intervention. Three intervention and 4 control group respondents could not
be reached. Three intervention and 2 control respondents either refused or
were unable to answer the questions at follow-up because of impaired
cognition, and 6 of the initial intervention respondents were screened out
as ineligible after further investigation of demographic data. Data are
presented only for those participants for whom there are both pre- and
post-data. Table 1 provides demographic data for those who completed surveys
in both the spring and fall.
Table 2 examines the change in fruit and vegetable intake between the
intervention and control groups. At baseline, the intervention group had a
lower fruit and vegetable intake than the control group, but by the end of
the market basket season, intake in the control group decreased from
baseline while those of the intervention group increased. The difference
between the change in mean daily servings was 1.31 (95% CI, 0.68-1.95, P
At baseline, age was associated with mean daily intake (P <
.05), with the oldest participants having the highest fruit and vegetable
intake (Table 3). Race, gender, and living situation were not significantly
associated with fruit and vegetable intake at baseline or with the magnitude
of increased intake in the intervention group.
Table 4 provides categorical information about servings of fruits and
vegetables consumed. Compared to seniors in Washington State as a whole,
fewer homebound seniors from either the intervention or the control group
reported consuming at least 5 fruits and vegetables at baseline. The
proportion of program participants who consumed 5 or more servings of fruits
and vegetables increased from 22% in the spring to 39% in the fall while the
proportion of seniors in the control group who consumed recommended levels
fell from 30% to 23%.
Eighty-two market basket participants stated that they would like to
receive market baskets in future seasons. One participant was unsure, and 4
said that they would not like to participate again because they had been
unable to use all the produce.
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At baseline, homebound seniors in this study had lower mean fruit and
vegetable intake than other seniors in Washington State, and most failed to
meet the recommendations for at least 5 servings of fruits and vegetables
each day. By the end of the season, participation in the market basket
program was associated with increased mean fruit and vegetable intake and
increased numbers of seniors meeting the recommendations for at least 5
servings of fruits and vegetables daily. Despite limitations in food
preparation and eating abilities, these homebound elders found ways to add
the produce to their diets and were eager to participate in the program for
another season. There were no significant differences in the impact of the
program based on gender, ethnicity, age, or living situation.
Measuring the impact of government food assistance programs is
challenging because it is seldom ethical or legal to randomly assign
individuals to receive assistance or join a control group that does not
receive assistance (39). Nevertheless, monitoring the effectiveness of food
assistance programs, especially pilot programs, is essential. In this study,
the control group was as similar as possible to the study group, but the
study was limited because group assignment was not random. It was not
possible to recruit the desired number of participants from the control
group, so control group numbers were low. These results may not be
generalizable to all homebound seniors. Market basket recipients were
required to request basket delivery, and survey respondents for both the
intervention and control survey respondents were volunteers. The fruit and
vegetable intake of the control subjects decreased between the baseline and
follow-up surveys. The study design does not allow us to explore the reasons
for this, but decreased consumption in the control group may be due to
decreased produce availability in late fall.
Interventions that focus on education and environmental changes at
worksites have had modest success in increasing fruit and vegetable intake
by approximately one quarter of a serving each day. Most food assistance
programs that simply provide foods or money for food have also had limited
success, with only 0.3-0.7 of a serving increase (3,23-25,40). The Seattle
Senior Farmers' Market Nutrition Pilot Program increased intake by more than
one serving per day. This program worked because it addressed the need for
increased fruits and vegetables for homebound seniors through innovative
partnerships and concurrent efforts at the individual, interpersonal,
institutional, community, and policy levels.
The results of this pilot program have implications for policy
development. Although the program was built on existing federal nutrition
programs, it was possible only through the combined efforts of several
organizations and volunteers. The program found an innovative way to remove
barriers to fruit and vegetable consumption for a targeted population.
Kaplan and colleagues, writing for the Institute of Medicine, state that the
interaction between biology, behavior, and the environment plays out over
the life course of individuals, families, and communities to determine
health and well-being (41). The fruit and vegetable consumption of homebound
low-income seniors is an example of this model. Many of the participants in
the market basket program were homebound because of longstanding
disabilities. Their access to fruits and vegetables was limited over several
years. If adequate intake of fruits and vegetables can decrease disease risk
of aging individuals, market basket programs can improve long-term quality
of life and reduce the need for medical treatment that is associated with
While the findings of this study are limited in significance because the
Seattle Senior Farmers' Market Nutrition Pilot Program was a pilot program,
they deserve further examination as part of a larger study, especially given
the positive reactions of the program participants in the qualitative
assessment of the program (42).
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This project was supported by Grant U48/CCU009654 from the Centers for
Disease Control and Prevention to the University of Washington Health
Promotion Research Center. We would like to thank the seniors who
participated in this study and our collaborators from Senior Services of
King County, Pike Place Market Community Supported Agriculture, King County
Area Agency on Aging, Public Health-Seattle & King County, and
Washington State Aging and Adult Services Administration, Aging and
Corresponding Author: Donna B. Johnson, RD, PhD, Interdisciplinary Program
in Nutritional Sciences & Center for Public Health Nutrition,
Nutritional Sciences, University of Washington, Box 353410, Seattle, WA
98195. Phone 206-685-1068. E-mail: firstname.lastname@example.org
Author Affiliations: Sharon Beaudoin, MPH, RD, CD, Healthy Mothers,
Healthy Babies Coalition of Washington, Seattle, Wash; Lynne T. Smith, RD, PhD,
MPH, Centers for Disease Control and Prevention, Community Guide Branch
Washington State Department of Health, Olympia, Wash; Shirley A.A. Beresford,
PhD, Department of Epidemiology, University of Washington, Seattle, Wash; James
P. LoGerfo, MD, MPH, Health Promotion Research Center, University of
Washington, Seattle, Wash.
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Dis [serial online] 2004 Jan.
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Characteristics of Study Respondents, Seattle Senior Farmers' Market
Nutrition Pilot Program, 2001
|Native American- Alaskan Native
|With adult children or other relatives
|With other adult such as caregiver
Mean Intake of Fruits and Vegetables at Baseline and After 5 Months of
Basket Deliveries, Seattle Senior Farmers' Market Nutrition Pilot Program,
||Baseline Mean Daily Intake (SD)*
||Follow-Up Mean Daily Intake (SD)
||Change in Mean Daily Intake
*SD indicates standard deviation.
Mean Intake of Fruits and Vegetables at Baseline and Change at Follow-up for
Basket Participants by Demographic Characteristics, Seattle Senior Farmers'
Market Nutrition Pilot Program, 2001
||Baseline Mean Daily Intake for all
|Change between Baseline and Follow-up for Seniors Who Received Market
| Living alone
| Living with adult children
||+0.70 ( 2.60)
| Living with spouse or partner
| Living with other relatives
| Living with adult caregiver
*SD indicates standard deviation.
†This demographic characteristic is associated with baseline fruit and vegetable intake (P