LA sprouts randomized controlled nutrition and gardening program reduces obesity and metabolic risk in Latino youth.

OBJECTIVE: To assess the effects of a 12-week gardening, nutrition, and cooking intervention ("LA Sprouts") on dietary intake, obesity parameters, and metabolic disease risk among low-income, primarily Hispanic/Latino youth in Los Angeles.
METHODS: The randomized controlled trial involved four elementary schools [two schools randomized to intervention (172 third-through fifth-grade students); two schools randomized to control (147 third-through fifth-grade students)]. Classes were taught in 90-minute sessions once a week to each grade level for 12 weeks. Data collected at pre- and postintervention included dietary intake via food frequency questionnaire (FFQ), anthropometric measures [BMI, waist circumference (WC)], body fat, and fasting blood samples.
RESULTS: LA Sprouts participants had significantly greater reductions in BMI z-scores (0.1-vs. 0.04-point decrease, respectively; P = 0.01) and WC (-1.2 cm vs. no change; P < 0.001). Fewer LA Sprouts participants had the metabolic syndrome (MetSyn) after the intervention than before, while the number of controls with MetSyn increased. LA Sprouts participants had improvements in dietary fiber intake (+3.5% vs. -15.5%; P = 0.04) and less decreases in vegetable intake (-3.6% vs. -26.4%; P = 0.04). Change in fruit intake before and after the intervention did not significantly differ between LA Sprouts and control subjects.
CONCLUSIONS: LA Sprouts was effective in reducing obesity and metabolic risk.

RCT Entities:   Population Interventions Outcomes

INTRODUCTION

The increased prevalence of childhood obesity in the US is concerning, and has led to projections that one in three male and two in five female children born in the year 2000 will develop diabetes in their lifetime [1]. Nearly one-third (31.8%) of US children and adolescents aged 2–19 years were either overweight or obese in 2011–2012, including 16.9% who were obese [2]. Pediatric obesity is associated with an increase in cardiovascular disease (CVD) risk factors, asthma, and psychological problems during childhood [3, 4].

Significant disparities in obesity prevalence exist by racial/ethnic group, with adolescent Hispanic/Latinos having higher rates of obesity than their Caucasian counterparts [2]. Socioeconomic status (SES) is an important determinant of access to healthy and affordable, high-quality fresh fruits, vegetables and other foods [5]. Low income residents of “food desert” neighborhoods in urban areas are less likely to have access to fresh and healthy foods than residents of higher income neighborhoods [6].

Low intakes of dietary fiber, specifically from fruits and vegetables, coupled with high consumption of refined grains and added sugar are linked to obesity and related disorders in Hispanic/Latino youth aged 8–18 years in Los Angeles (LA) [7, 8]. Interventions that target these dietary habits could be effective in reducing obesity risk in Hispanic/Latino youth [8].

It is known that food preferences are shaped when children are young [9], and children’s preferences for vegetables are strong predictors of vegetable consumption [10]. Studies suggest that having a direct experience with growing food enhances children’s understanding of foods and their relationship to health [11]. While many programs for children that involve both gardening and nutrition components exist, none have included experimental designs that would allow more rigorous evaluation of their impact on obesity and metabolic risk factors [11-22].

In 2010, we developed and pilot-tested a non-randomized 12-week gardening, nutrition/cooking intervention called “LA Sprouts” in predominantly low-income Hispanic/Latino elementary school children in LA. The LA Sprouts intervention was demonstrated to be effective in reducing body mass index (BMI) and systolic blood pressure (SBP) [13]. LA Sprouts also increased dietary fiber intake and preferences for target fruits and vegetables, and changed carbohydrate composition [23, 24]. Preliminary findings from our pilot program led us to conduct a larger randomized control experimental study of LA Sprouts in this population. This is the first experimental, randomized controlled study to date to examine the effects of an afterschool gardening, nutrition, and cooking program on dietary intake, obesity parameters and associated metabolic disease risk in Hispanic/Latino youth. We hypothesize that students participating in the LA Sprouts program compared to controls would experience a reduction in adiposity and metabolic risk factors and an increase in intake of dietary fiber, fruit, and vegetables.

METHODS AND PROCEDURES

Participants

A full description of our LA Sprouts randomized controlled trial (RCT) study design and sample is provided elsewhere [25]. Briefly, during 2011–13elementary schools within LA Unified School District (LAUSD) were eligible if they: 1) offered the LA’s BEST after-school care program, 2) had a student body ≥75% Hispanic/Latino, 3) had ≥75% of students in the free/reduced cost school meal program, 4) were located within 10 miles of University of Southern California (USC) Health Science Campus, 5) had expressed interest by school personnel in having a garden/hosting our program, and 6) could make an administrative commitment (including assisting with securing LAUSD approval and building parent support). Four elementary schools were identified, and all 3rd–5th grade students at the schools who were enrolled in LA’s BEST(n=409) were invited to participate; 375 (92%) agreed. Two schools (n=204 students) were randomized to receive the LA Sprouts intervention and two other schools were randomized to controls (n=171 students) receiving a delayed intervention. At least partial obesity/metabolic measures and questionnaire data were collected on 364 participants (n=198 intervention, n=164 controls) at baseline (pre-intervention). Follow-up (post-intervention) data was missing on 44 participants who changed schools, left the parent LA’s BEST program, or were absent on data collection days. Main analyses herein are based on 319 (88% of those with baseline data; n=172 intervention, n=147 controls; n= 130 3rd, n=103 4th, n=86 5th grade students) children for whom both baseline and follow-up data were available on our primary outcome, BMI(Figure 1). One hundred and sixty-nine children (46% of the total sample) participated in blood draws at baseline; 113 of these (67%; n=67 intervention, n=46 controls) returned for follow-up draws are included in analyses of blood measures. Six percent more children who provided a sample reported having internet access at home than those who did not provide a sample, otherwise that subset did not differ from the total sample in demographic or socioeconomic characteristics or BMI parameters.

Figure 1

Flow of participants through the LA Sprouts study.

Institutional Review Boards of USC, the University of Texas at Austin, Loma Linda University, and LAUSD approved the study. Informed written consent from parents and assent from children were obtained. ClinicalTrials.gov identifier NCT02291146.

Description of the Intervention

The LA Sprouts intervention was taught on campus at school gardens specifically constructed for the program. Each school garden design took into consideration the specific needs and challenges of the individual schools, and the design and planning process involved key stakeholders including school principals and teachers, afterschool staff, and LAUSD personnel. All gardens utilized raised bed garden planter boxes placed either on unpaved, grassy areas of the school yard or on areas where asphalt was removed. An area near the garden was designated as teaching space. Each school garden was outfitted with a minimum number of tools needed for gardening and cooking supplies for an outdoor kitchen. Intervention classes were taught in 90-minute sessions once a week to each grade level for 12 weeks during either a fall or winter/spring school semester. Sessions consisted of a 45-minute interactive cooking/nutrition lesson and a 45-minute gardening lesson taught by an educator with a nutrition or gardening background who was employed specifically for this intervention. Our program’s curriculum and theoretical framework is described in greater detail [13, 25, 26]. Students worked in small teams led by an educator to cook/prepare a recipe each week, which emphasized fruit and/or vegetable ingredients. The snack was eaten in a “family-style” manner, i.e., together at a table, with a tablecloth, non-disposable plates and silverware. The gardening activities also used a “hands-on” approach, where children participated in planting, growing and harvesting organic fruits and vegetables. A teacher to student ratio of 1: 3–6 was maintained.

Description of Control Group

Third, fourth and fifth grade students at the two control schools did not receive any nutritional/cooking or gardening information from investigators between pre- and post-testing, and schools were asked to refrain from augmenting their curriculum with similar lessons during the study period. After post-testing was completed, students at the control schools received the full LA Sprouts program (“delayed intervention”), including a school garden being built.

Data Collection

LA Sprouts and control participants completed questionnaires and had obesity and metabolic data collected at baseline and post intervention. Data collection occurred during the week prior to instruction being initiated (for baseline measures) or 7–14 days after the final day of instruction (for post-intervention measures), and took place during after-school sessions, in the morning before school or on weekends. Study personnel who were not blinded to group assignment were trained to perform data collection using standardized protocols. All staff were directed to review the protocols; participated in demonstrations of procedures by the principal investigator (PI) and or project manager (PM); and were observed to ensure a proper technique. A PI or PM was present to supervise data collection. We strove, whenever feasible, to schedule a given staff member to collect the same measurement at baseline and post-intervention.

Anthropometric and Metabolic Disease Risk Data

Height was measured with a free-standing stadiometer (Seca, Birmingham, UK); weight and percent body fat were measured via bioelectrical impedance (Tanita TBF 300A, Arlington Heights, IL). BMI z-scores and percentiles were determined using CDC cut-points for age and sex [27]. Blood pressure (BP) was measured with an automated monitor with appropriate child cuffs (Omron, Schaumberg, IL), and waist circumference (WC) measures followed NHANES protocol [28].

Child Questionnaires

The child questionnaire included items on demographics and socioeconomic status. Dietary intake was measured using the Block Kids Food Screener (“last week” version). This 41-item screener was developed and adapted from the Block Kids 2004 Food Frequency Questionnaire [29], and has been validated in youth living in a metropolitan area [30]. The screener was designed to assess intake by food group, and includes questions used to estimate intake of fruit and fruit juices, vegetables, potatoes, whole grains, meat/poultry/fish, dairy and added sugars. National dietary surveys such as NHANES were used to inform the selection of foods to query, and to apply appropriate portion sizes and nutrient composition.

Fasting Blood Sample

Optional fasting blood draws were collected during non-academic hours and off-campus from participants by bilingual, licensed phlebotomists with experience drawing blood in overweight children. Samples were processed and stored at USC until they were shipped for assays.

Glucose was assayed using a Yellow Springs Instruments analyzer (Yellow Springs, OH). Total cholesterol, high-density lipoprotein cholesterol (HDL), and triglyceride levels were measured using the enzymatic methods [31] on a Stanbio Sirrus analyzer (Stanbio Laboratory, Boerne, TX); Low-density lipoprotein (LDL) was calculated using the Friedwald equation. Insulin was quantified using an ELISA kit (EMD Millipore, St. Charles, MO). Homeostatic model assessment (HOMA-IR) was calculated as a measure of insulin resistance [32].

Metabolic Syndrome

Participants were identified as having the metabolic syndrome (MetSyn) following the work of Cook et al. [33], which provides recommendations for reference values to define cut-offs for component MetSyn factors.

Statistical Analysis

Anthropometric and metabolic data were screened for plausibility by conducting residual analyses examining how the baseline value of a given variable predicted the value of that variable at follow-up. Original data was checked to resolve possible measurement errors for participants with standardized residuals > |3|, otherwise, that observation was removed from analyses. For Block data, we selected for analysis variables for individual food questions as well as estimates of consumption of nutrients and food groups that were pertinent to our study hypotheses. We examined and excluded as implausible or outlying observations for which the change in reported intake between pre- and post-intervention was at or below the 1st, or at or above the 99th percentile. While the number of observations set to missing varied by analysis, fewer than a total of 2.2% of all observations were excluded. All variables were examined for normality and data transformations were attempted for SBP, HDL cholesterol and fasting insulin, but improvements were not substantial. Thus, analyses used the original untransformed data for these variables. Frequencies were tabulated for categorical socio-demographic variables at baseline; mean ± standard errors (SE) for continuous variables at baseline and follow-up were calculated, adjusting for age (continuous), sex, Hispanic/Latino (yes, no), English spoken at home (yes, no), school (Monte Vista, Loreto, Sierra Park, Euclid Elementary). Means for nutrients and foods/food groups were additionally adjusted for energy intake (kcal). Repeated measures analysis of variance (ANOVA) was used to assess whether mean changes in anthropometric, clinical and dietary (continuous) variables over the 12-week intervention period differed between intervention and control groups. Models were adjusted for the covariates as above. We did not include season (Fall, Winter/Spring) in models because it was explained by school. In sensitivity analyses, we examined the effect of additional adjustment for baseline BMI in models where dietary variables and clinical variables (other than BMI) were the dependent variable. We also restricted analyses to the overweight/obese subsample to examine whether results were similar to the total sample. All analyses used SAS version 9.4 (SAS Institute Inc., Cary, NC, USA.).

RESULTS

By design, the study population was ~89% Hispanic/Latino and ~90% eligible for free lunch at school (Table 1). The majority (>50%) were overweight (BMI ≥85th percentile), and more than one-third were obese (BMI ≥95th percentile). There were no differences at baseline between LA Sprouts participants and controls in age, sex, ethnicity, BMI and most sociodemographic factors examined. LA Sprouts participants were less likely to speak English at home than controls (p=0.06).

Table 1

Demographic characteristics of LA Sprouts and control participants at baseline

Characteristic,n (%) or mean ± SD		LA Sprouts(n=172)	Controls(n=147)	p-valuea
		Pre	Pre
Male		82 (47.7)	71 (48.3)	0.91
Hispanic/Latino		153 (89.0)	127 (88.8)	0.97
Age, years		9.3 ± 0.9	9.3 ± 0.9	0.9
Height, cm		135.0 ± 8.5	135.0 ± 8.5	0.96
Weight, kg		36.9 ± 10.6	38.1 ± 12.6	0.30
BMI, kg/m2		19.8 ± 4.1	20.6 ± 4.6	0.13
Overweight (≥85th percentile)		82 (51.3)	73 (53.3)	0.73
Obese (≥95th percentile)		54 (33.8)	54 (39.4)	0.31
Socioeconomic factors
No English spoken at home		48 (28.7)	27 (19.6)	0.06
No computer at home		42 (26.1)	32 (23.2)	0.56
No internet at home		39 (23.2)	32 (23.2)	0.99
Mother does not have own car		57 (34.3)	38 (27.1)	0.17
Eligible for free lunch at school		152 (90.5)	125 (89.3)	0.73

p-value for difference between groups from chi-square tests (categorical variables) or independent t-tests (continuous variables).

After the 12-week program, LA Sprouts participants had significantly greater reductions in BMI than controls (0.1 versus 0.04 decrease in BMI z-score, respectively; p=0.01). LA Sprouts participants had a 1.2 cm (1.7%) reduction in WC, while controls had no change after the intervention (p<0.001) (Table 2). The number of students overall who fit criteria for the MetSyn was small. However, there were fewer LA Sprouts participants with the MetSyn after (n=1) the intervention than before (n=7), while the number of controls with the MetSyn increased between pre- (n=3) and post-intervention (n=4). For percent body fat, SBP and DBP, and other blood measures, the change between pre- and post- intervention was not statistically different between LA Sprouts participants and controls. Adjustment for BMI did not appreciably alter the change estimates or impact our conclusions about the effect of the intervention on obesity or metabolic measures (data not shown). Results in the overweight/obese strata were similar to those in the total sample (data not shown).

Table 2

Adjusted mean ± SEa anthropometric and clinical characteristics of LA Sprouts participants and controls before and after intervention, and adjusted mean (percent) change between pre- and post-intervention

Characteristic, mean ± SE		LA Sprouts (n=172)				Controls (n=147)				p-valueb
		Pre	Post	Absolutechange	Percent change	Pre	Post	Absolutechange	Percentchange
Anthropometrics
BMI Percentile		75.6 ± 2.3	73.7 ± 2.3	−1.9	−2.5	74.8 ± 2.6	73.8 ± 2.6	−1.0	−1.3	0.13
BMI z-score		0.95 ± 0.09	0.85 ± 0.09	−0.1	−10.5	1.01 ± 0.10	0.97 ± 0.10	−0.04	−4.0	0.01
Waist circumference (WC), cm		70.3 ± 0.5	69.1 ± 0.5	−1.2	−1.7	71.6 ± 0.6	71.6 ± 0.6	0.0	0.0	<0.001
Body fat, %		24.7 ± 0.4	24.2 ± 0.4	−0.5	−2.0	25.2 ± 0.4	24.6 ± 0.4	−0.6	−2.4	0.82
Clinical characteristics
Systolic blood pressure, mmHg		109.4 ± 1.0	108.9 ± 1.0	−0.5	−0.5	112.0 ± 1.1	111.7 ± 1.1	−0.3	−0.3	0.87
Diastolic blood pressure, mmHg		64.7 ± 0.9	64.0 ± 0.9	−0.7	−1.1	66.2 ± 1.0	63.6 ± 1.0	−2.6	−3.9	0.28
Cholesterol
Total		156.8 ± 3.3	162.5 ± 3.5	5.7	3.6	158.5 ± 4.2	160.4 ± 4.6	1.9	1.2	0.32
LDL-C		84.6 ± 2.7	85.9 ± 2.9	1.3	1.5	86.9 ± 3.5	86.6 ± 3.8	−0.3	−0.3	0.62
HDL-C		58.0 ± 1.3	60.0 ± 1.4	2.0	3.4	57.3 ± 1.7	58.6 ± 1.8	1.3	2.3	0.42
Triglycerides		69.5 ± 3.5	73.8 ± 3.8	4.3	6.2	70.6 ± 4.5	72.6 ± 4.9	2.0	2.8	0.63
Insulin, µU/mL		10.7 ± 0.8	11.3 ± 0.9	0.6	5.6	10.9 ± 1.1	11.4 ± 1.2	0.5	4.6	0.90
HOMA-IR		2.4 ± 0.2	2.6 ± 0.2	0.2	8.3	2.5 ± 0.3	2.6 ± 0.3	0.1	4.0	0.85
Glucose, mg/dL		91.5 ± 0.8	93.6 ± 0.8	2.1	2.3	91.4 ± 0.9	92.8 ± 1.1	1.4	1.5	0.56
Metabolic Syndrome		7 (4.2)	1 (0.6)	−6	85.7	3 (2.1)	4 (2.72)	1
WC ≥90th percentile, age-and sex-specific		45 (27.4)	41 (24.4)	−4	−8.9	47 (34.1)	49 (34.0)	2	4.2
Fasting glucose ≥110mg/dL		0	0	-	-	0	1 (2.3)	1	100
Triglycerides ≥110mg/dL, age-specific		9 (10.5)	8 (12.9)	−1	−11.1	12 (19.4)	8 (18.2)	−4	−33.3
HDL-C ≤40 mg/dL		3 (3.5)	2 (3.2)	−1	−33.3	6 (9.7)	5 (11.4)	−1	−16.7
BP ≥90th percentile, age-,sex-and height-specific		66 (39.8)	56 (32.9)	−10	−15.2	72 (52.2)	68 (47.2)	−4	−5.6

Means are adjusted for age (continuous), sex, ethnicity (hispanic/latino versus not), english spoken at home (yes, no), school (Monte Vista, Loreto, Sierra Park, Euclid Elementary)

p-value for multiplicative interaction term indicating change from pre to post for each measure between groups from mixed effects regression models

LA Sprouts participants increased dietary fiber consumption by 0.4 g/d (3.5%), compared to a 2.0 g/d (15.5%) decrease in controls (p=0.04) (Table 3). LA Sprouts participants compared to controls had smaller decreases in vegetable intake per day (−0.03 CE/d or a 3.6% decrease, versus −0.2 CE/d, or a 26.4% decrease; p=0.04). LA Sprouts had increases in consumption of whole grains and green beans and peas, while controls decreased their intake of these foods (p ≤ 0.10). Change in fruit intake overall and intake of apples, bananas and oranges before and after the intervention did not significantly differ between LAS and control subjects.

Table 3

Adjusteda mean intake of select foods and nutrients of LA Sprouts and control participants before and after intervention, absolute and percent change between pre- and post-intervention

	LA Sprouts				Controls				p-valuec
Nutrient or Food,mean ± SE	Pre	Post	Absolutechange	Percentchange	Pre	Post	Absolutechange	Percentchange
Nutrient
Energy, kcalb	1265.1 ± 95.6	1261.3 ± 95.6	−3.8	−0.3	1389.0 ± 109.5	1239.3 ± 109.5	−149.7	−10.8	0.25
Protein, g/d	55.2 ± 2.2	54.1 ± 2.2	−1.1	−2.0	56.3 ± 2.5	47.1 ± 2.5	−9.2	−16.3	0.19
Fat, g/d	54.1 ± 2.1	52.1 ± 2.1	−2.0	−3.7	55.1 ± 2.4	47.3 ± 2.4	−7.8	−14.2	0.33
Carbohydrates, g/d	149.9 ± 5.2	154.3 ± 5.2	4.4	2.9	165.3 ± 5.9	153.9 ± 5.9	−11.4	−6.9	0.27
Added sugar, tsp/d	7.2 ± 0.5	8.0 ± 0.5	0.8	11.1	8.5 ± 0.5	7.8 ± 0.5	−0.7	−8.2	0.11
Dietary fiber, g/d	11.5 ± 0.5	11.9 ± 0.5	0.4	3.5	12.9 ± 0.6	10.9 ± 0.6	−2.0	−15.5	0.04
Food or Food Group
Meat, OEd	2.8 ± 0.2	2.7 ± 0.2	−0.1	−3.6	2.8 ± 0.2	2.2 ± 0.2	−0.6	−21.4	0.18
Dairy, CEe	1.4 ± 0.1	1.3 ± 0.1	−0.1	−7.1	1.5 ± 0.1	1.3 ± 0.1	−0.2	−13.3	0.56
Whole grains, OE	0.49 ± 0.03	0.53 ± 0.03	0.04	8.2	0.56 ± 0.04	0.48 ± 0.04	−0.1	−14.3	0.10
Vegetables, CE	0.83 ± 0.05	0.80 ± 0.05	−0.03	−3.6	0.91 ± 0.06	0.67 ± 0.06	−0.2	−26.4	0.04
Fruit, fruit juice, CE	1.3 ± 0.09	1.3 ± 0.09	0.0	0.0	1.5 ± 0.1	1.4 ± 0.1	−0.1	−6.7	0.56
Apples, bananas, oranges, CE	0.43 ± 0.04	0.45 ± 0.04	0.02	4.7	0.5 ± 0.04	0.42 ± 0.04	−0.1	−16.0	0.12
Lettuce salad, CE	0.18 ± 0.02	0.18 ± 0.02	0.0	0.0	0.20 ± 0.02	0.16 ± 0.02	−0.04	−20.0	0.28
Green beans, peas, CE	0.03 ± 0.01	0.04 ± 0.01	0.01	33.3	0.03 ± 0.01	0.02 ± 0.01	−0.01	−33.3	0.08
Tomatoes, CE	0.05 ± 0.01	0.04 ± 0.01	−0.01	−20.0	0.05 ± 0.01	0.03 ± 0.01	−0.02	−40.0	0.21

Means are adjusted for age (continuous), sex, ethnicity (hispanic/latino versus not), english spoken at home (yes, no), school (Monte Vista, Loreto, Sierra Park, Euclid Elementary)

not adjusted for energy(kcal)

p-value for multiplicative interaction term indicating change from pre to post for each measure between groups from mixed effects regression models

OE: ounce equivalent

CE: cup equivalent

DISCUSSION

LA Sprouts is the first randomized school gardening, nutrition, and cooking intervention to demonstrate effectiveness in reducing obesity (measured by BMI and WC) in predominantly Hispanic/Latino elementary school aged children. While the reductions were relatively small in magnitude (decreases of 0.1 in BMI z-score and 1.2 cm in WC), it is nonetheless notable that the study was able to show changes over a 12-week period. By extension, our findings suggest that similar interventions implemented over a longer term may expect greater change in reduction of these obesity parameters. Additional studies would be needed to evaluate this. For comparison, other more intensive RCTs such as those that included dietary modification, rigorous nutrition education, intense and monitored physical activity sessions, or a clinic-based component with or without healthcare professionals have demonstrated inconsistent success in achieving reductions in BMI [34, 35]. A 12-week behavioral modification program for Hispanic/Latino children aged 7–15 years and their families that provided alternative foods to substitute for those with high glycemic index, dietary prescription plans and physical activity sessions found a 0.156 point reduction in BMI z-score after 3 months [36]. The modest reduction in BMI associated with our educational program may be interpreted relative to the magnitude of those observed under more intense dietary and/or physical activity conditions. Furthermore, as the prevalence of overweight and obesity in our study population was higher than national averages for Hispanic youth [2] (which are higher than those for non-Hispanic Whites nationally), we believe this underscores the need to address disparities in obesity risk, and even small risk reductions in this high-risk population represent progress in tackling the problem. LA Sprouts was also effective in changing dietary intake, with an observed increase in dietary fiber intake among participants, which was an intention of the intervention design. LA Sprouts participants increased intake of whole grains and green beans/peas while controls decreased intake of these foods. Some [13, 15, 16, 18–20, 22], but not all [12, 14, 17, 19, 21] previous non-randomized studies of school-garden based educational programs have demonstrated an effect on increasing fruit or vegetable intake in children. It should be noted that with over 90% of students in the study eligible for free or reduced cost breakfast and lunch served at school, this likely implies that 2/3 of their daily dietary intake was determined by school availability, which was the same between LA Sprouts participants and controls. This further suggests that children had little control over food options for two of three of their meals, which further contextualizes an interpretation of the magnitude of change in dietary intakes associated with the intervention.

While the number of students overall who fit the definition of the MetSyn was small, we did observe a decrease in MetSyn among LA Sprouts participants and an increase in controls from pre- to post-intervention. While this finding should be interpreted with caution, it may suggest that LA Sprouts had an effect on the biochemical processes associated with this clustering of metabolic risk factors. While mean differences between pre- and post-intervention in the anthropometric and lipid variables that comprise the MetSyn were statistically significant only for WC, fewer LA Sprouts participants than controls met individual metabolic syndrome criteria after the intervention. The importance of our WC finding is further supported by the emphasis placed on the role of abdominal obesity for metabolic syndrome risk by the International Diabetes Foundation, who advocates that WC be used to identify children aged < 10 years to target weight reduction and be a required criterion to diagnose the MetSyn for children aged 10– <16 years [37].

Our intervention was designed to be culturally tailored, for example, by including recipes that targeted foods familiar to our study population such as salsas and vegetable quesadillas. We did not observe an effect of the intervention on fruit consumption, which is not in line with our study hypothesis but is concordant with some other non-randomized school-garden based educational interventions targeting fruit intake [14, 16, 17, 19]. The food screener used did not provide a broad assessment of vegetables and fruits, and particular fruits and vegetables which may be more commonly consumed by cultures reflected in our study population (i.e., papayas, nopales). Thus it is possible that our null findings for fruits may reflect inadequate sensitivity of our selected data collection instrument. Furthermore, FFQs are not able to precisely quantify intake of nutrient consumption or differences among varieties of foods that may be captured in a single food item question [38]. Funding, time and sample size limitations prevented collection of 24-hour dietary recalls, which would have provided a more accurate assessment of dietary intake [39]. Nevertheless, the Block screener demonstrated good validity against 3, 24-hour dietary recalls in 99 youth in a metropolitan area, with de-attenuated correlations between the two dietary assessment instruments ranging from 0.526 for vegetables to 0.878 for potatoes [30]. Furthermore, given that our analysis focused on comparisons between groups of participants and not individual assessments, we feel that the associated efficiency and cost savings afforded by automated data entry and analysis made the FFQ instrument an appropriate choice. Our intervention was developed to take place during the after school hours because this time is ideal for implementing such health programs. Students who remain on campus after school dismissal and prior to parent pick up are captive audiences for three to four hours. Local and national data suggest that 50% of school children in kindergarten through eighth grade aged 5–13 years are regularly in non-parental care before and after school [40], a statistic that likely differs by geographic region and sociodemographic factors. The afterschool hours are an opportunity to enhance students’ academic achievement as an extension of instructional time, while engaging students in topics or activities otherwise not part of the academic school day such as gardening or nutrition. Many after-school care providers include scheduled time for enrichment in their programming and seek activities that fulfill their needs. It is possible to incorporate “fun” “hands on” activities such as cooking or gardening that may not be feasible in a classroom setting. After school programs do not compete with required school day instruction and are not restricted by a requirement that they meet school standards. Nevertheless, our curriculum has mapped on school standards (i.e., math, science, language arts, and health) and could be utilized during the academic school day. Garden-based programs are multi-faceted, can be utilized during both school and after-school hours, and integrate academic subjects and other subjects such as health.

There were several limitations of our study. We do not have data on long-term sustainability of the program or maintenance of our results beyond the 12-week study period. Additional longer-term studies are needed to understand these issues and long-term health benefits of a garden-based intervention. We provided trained educators to teach our program, and it is uncertain whether similar results can be expected when the program is taught by afterschool staff. However, after the intervention we held several train-the-trainer workshops and provided all educational resources and supplies associated with our lessons to the schools to help sustain the program. We had a smaller sample size for blood measures, as these were optional, which could explain our lack of findings for these variables. While we recognized the importance of involving parents and offered parallel classes to them on mornings, evenings and weekends, these classes were poorly attended. Future efforts should be directed to increasing parental support for such programs, and should obtain evaluation measures on parents, as it is recognized that the home food environment reinforces material taught to children. While gardening is a source of physical activity for children, and the imbalance between energy intake and expenditure is at the root of obesity, future garden-based studies may want to supplement the exercise component of their programs to include more high intensity gardening activities such as digging and weeding, which were not as emphasized in our intervention.

In conclusion, LA Sprouts is the first school garden-based, nutrition, cooking and gardening experimental intervention developed, and which resulted in a decreased risk of obesity and metabolic disease and improvements in dietary intake in high-risk Hispanic/Latino youth. Our findings suggest that teaching children to grow, prepare, and eat fruits and vegetables is an efficacious approach to reducing disease risk. However, longer RCTs are warranted to understand the long-term effects of garden-based programs. In addition, more studies are needed to examine how to sustain such garden-based programs in school settings. Programs with a school garden component provide children access to healthy foods in otherwise food desert neighborhoods.