BEHOGR‘APEEC CEARACTERISTICS AND

THE NUT’RETIGNAL STATUS 0F HERMES

EKTEBKNG 'FBE EXPANDEEI NWRIIIOE
AND. FAME“ EEGGRAMS

Thaw-s ‘0? Has Dog?“ of M. S.
MICHEGAN 5TH}: UNIVERSE"
Mary Elisabeth Kerr
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ABSTRACT
DEMOGRAPHIC CHARACTERISTICS AND

THE NUTRITIONAL STATUS OF FAMILIES
ENTERING THE EXPANDED NUTRITION AND FAMILY PROGRAMS

By
Mary Elisabeth Kerr

The.Expanded Nutrition and Family Programs (EFNP) were started
in January, 1969, to improve the nutritional status of low-income
families. Several aspects of the program have been researched, but
none have objectively measured change within the family beginning
‘with family entry into the program. The present evaluation method,
the homemaker's Zh-hour food recall, is limited in its accuracy and
reliability.

This study provides the baseline data to describe the nutri-
tional status and demographic characteristics of 176 families as
they entered the program. The families were enrolled in their usual
manner by nutrition aides. Information on the family's grocery
shopping pattern, the homemaker's nutrition knowledge, and the
collection of random urine specimens were obtained in two home
interviews. Urine samples were collected from available family
members.‘ The urine specimens were analyzed for thiamin, riboflavin,
and creatinine. The excretion levels of the vitamins/gran. of
creatinine for each individual were classified as deficient, lo",
acceptable, or high using ICNND (1963) standards. Demographic
information, as well as the homemaker's 24-hour food recall, was
obtained from the family record form completed by the nutrition

aide at the time of enrollment.

Mary Elisabeth Kerr

The adequacy of the Zh-hour food recalls was determined by
comparison with Basic Four adult standard: ‘ two servings from the
mat group; two from the milk group; four from the fruit-vegetable
group; and four from the bread-cereal group. Based on the 21+-hour
food recalls, the diets of the homemakers were seriously inadequate.
The diets of most of the homemakers met only one out of four of
the food groups. The food group most frequently not was neat, and
the group most frequently lacking was fruit-vegetable. Milk was
also used infrequently. ‘

Hommakers did the majority-of the grocery shopping and
preferred to shop at supermarkets. Transportation was usually by
means of a family car or a friend or relative's car. Food purchases
were influenced most frequently by cost. Family preference, needing
a food item, and nutritional value followed in that order.

Biochemical results from urine specinns of all available
. family members showed.that thiamine nutriture appeared to be acceptable.
Over one-fourth of the families showed low or deficient levels of
riboflavin excretion. This may be a reflection of the inadequate

l1” Of‘m1ke
The responses to the nutrition statements revealed that the

homemakers had limited knowledge of nutrition. 'There is a great
opportunity for nutrition aides to expand the honmakers ' nutrition
knowledge and their families' eating patterns. '

DEMOGRAPHIC CHARACTERISTICS AND
THE NUTRITIONAL STATUS OF FAMILIES

ENTERING THE EXPANDED NUTRITION AND FAMILX PROGRAMS

By

Mary Elisabeth Kerr

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

Department of Food Science and Human Nutrition

1973

DEDICATION

To aw mother,
who first taught me

the importance of good nutrition

11

ACKNOWLEDGEMENTS

"Abide in me... for without me ye can do nothing."
John 15: 4, 5

'Without the Lord there would have been no research and
no thesis.

My deepest appreciation is extended to my committee members:
Dr. Portia Mbrris, for her interest, guidance, and patience though-
out this research and thesis writing; and Dr. Mary Zabik and Dr.,
Dorice Narins, for their excellent suggestions in the revision of
.this thesis. ‘ I

Special thanks go to Dr. Jo Lynn Cunningham, who also
guided in research efforts, data analysis, and thesis writing.

My delightful cadworkers in data collection made the task

enjoyable and interesting: Donna Duff, my "co-urine sample collector":

and Beverly Eubank and Susan Schram, who talked their mouths dry
interviewing homemakers. Other helpers were Mary Andrews and Judy
Vertalka who did a considerable amount of "pinch-hitting" on top
of their own responsibilities. I .

Grateful appreciation also go to Kathy Muiruri and Dr. Dale
Romsos for their long hours in a lonely lab analyzing urine specimens.

The tedious Job of coding and quality checking was done by
Barbara Kreutz, Joanne Keith, Beveraly Eubank, Susan Schram, and

Sally Trapp. Thank you for your tired eyes on my behalf!

iii

For writing the computer programs, I am indebted to Verda
Scheifley and Mary Andrews .'

My acknowledgements would not be complete unless I lauded '
all the nutrition aides and families who participated in this research.
Had it not been for each child who proudly surrendered his urine
sample or who diligently tried to donate a sample, there would have
been little data for this study.

Many thanks to you all.

iv

TABLE OF CONTENTS

Chapter
I INTRODUCTION . . . . . . . . . . . . . . . . . .
Objectives . . . . . . . . . . . . . . . . . . .
II LITERATURE REVIEW . . . . . . . . . . . . . . . .

Dietary Patterns in America . . .

Factors Affecting Nutrient Intake . . . . . . . e
USDA Nutrition Programs . . . . . . . . . . . . .
Urinary Excretion of Vitamins . . . . . . . . . .
Variability of Thiamin Excretion . . . . . . . .
Variability of Riboflavin Excretion . . . . . .

Relationship of Vitamins to Creatinine Excretion

Selection of the Sample . . . .
Instrument e e e e e e e e e e
Preparation for Data Collection
Data Collection . . . . . . . .
Analysis Of Data e e e e e e e

IV RESULTS ‘ O 0 O O O O O O O 0 O O O O O O O O I 0

Description of Sample . . . . .
Food Purchasing Practices . . e
Homemakers' 24-Hour FOOd Recall
Results of Biochemical Analysis
Nutrition Knowledge e e e e e e
Correlations e e e e e e e e e

V DISCUSSION 0 O O O O O O O O O I O O 0 O O O O 0

Limitations of the Present Research . . . . . . .
sumry and. conCIUSions . e o e e e e o e e e o e
Suggestions for Future Research e e e e e e e e e

BIBLImRAPHY O O O O O O O O O O O O O O O O O O O O O

’

Page

APPENDICES

C9C)U1>’

Aide's Family Enrollment Form . . .
Biological Data Recording Form . . . .
Nutrition Information Recording Form .
Interviewing Procedures

1. Interviewing Procedure for Biological Data .
2. Interviewing Procedure for Attitudinal Data
Other

1e PBPMZ’LSSlODSlipeeeeeeeeeeeeee
2. Physician Referral Slip e e e e e e e e e e

vi

Page
52
6O

65
66

Table

1.

ll.

12.

13.

14.

15.

16.

17.

18.

LIST OF TABLES

Residence, ethnic background, and education of the
hokaer O O O O O O O O O O O O O O O O O O O O O O O O

Aid received by family. e e e e e e e e e e e e e e e e e
Age of homemaker and family size and income . . . . . . e
Participation in SChOOl lunch e e e e e e e e e e e e e e

Food preparation equipment and utilities available to
homemaker e e e e e e e e e e e e e e e e e e e e e e e e

Grocery shopping data . . . . . . . . . . . . . . . . . e
Factors influencing food purchases . . . . . . . . . . .
Adequacy of food groups from 24-hour food recalls . . . .
Homemakers meeting Basic Four standard . . . . . . . . .

Dietary information on those meeting two and three of
the BfiSiC Four fOOd groups e e e e e.e e e e e e e e e e

Homemakers meeting one-half or more Basic Four standard .

Thiamin excretion levels by age group (based on ICNND
standards or RdGQUBCY) e e e e e e e e e e e e e e e e e

Thiamin excretion levels (meg/gram creatinine) . . . . .

Riboflavin excretion levels by age group (based on ICNND
Standards Of adequacy) e e e e e e e e e e e e e e e e e

Riboflavin excretion levels (meg/gram creatinine) . . . .

Nutrition statements missed by 75% or more of the
homemakers e e e e e e e e e e e e e e e e e e e e e e e

Nutrition statements answered appropriately by 75% of
more homemakers e e e e e e e e e e e e e e e e e e e e e

Correlations between six variables . . . . . . . . . . .

vii

Page

25
25
26
26

27
28
29
_ 30
31

31
32

33
33

35

. 36

A. 37

38

CHAPTER I

INTRODUCTION

Despite the general affluence of American society, there is
growing concern over the actual nutritional status of the American
family and more particularly, of the low-income family. The United
States Department of Agriculture has initiated several programs to.
aid low-income families in improving their nutrition, among which is
\the Expanded Family and Nutrition Education Program (EFNEP).

Davis (1968) reported that staff members of the Cooperative
Extension Service recognized that low-income families do not parti-
cipate in group activities, nor do they learn through bulletins or
other conventional educational materials. Personal and frequent
contact with these homemakers is necessary to induce any change
in their food consumption patterns. Because of the limited time of
professional staff, para-professionals, known as nutrition aides could
be used to provide personal assistance to these families.

Since its inception in January, 1969, various studies have
been done to determine the effectiveness and the needs of the Expanded
Nutrition Program on a national level. The USDA Economic Research
Service (1969) studied program operation from January through July}
1969, gathering data from seven sample locations. From the ZQ-hour
food recalls taken by the aides, they found an increased use of bread
and cereal foods, but more especially, an increase in the use of milk,

fruits, and vegetables. It was observed that "local programs have

1

little guidance on how to conduct self-evaluation and no systematically
use-tested procedures."

The USDA Federa1.Extension Service (1971) conducted a second
in-depth study of the Expanded Nutrition Program from April 1, 1970,
through March 31, 1971, at ten selected locations. The data was
collected from family records and interviews with program participants
and personnel. This study examined managerial aspects of the program,
as administration and personnel, more than examining changes in family
eating patterns. Data showed that nutrition related practices were
.being promoted, but there were only indirect means available for
demonstrating achievement. Data obtained from the 24-hour food recall
did indicate a shift toward greater use of milk, fruit, and vegetable
products and less use of bread and cereals. The authors concluded
that measures of the homemakers' nutritional knowledge needed to be
improved.

The USDA Economic Research Service (1972) published a report
based on information from approximately five percent of the families
enrolled before October, 1969. On the basis of data from initial
24-hour food recalls, more than 90% of the homemakers reported fewer
servings from at least one of the Basic Four food groups than is
recommended. The milk group and the fruit-vegetable group were most
often lacking.

Several groups have conducted isolated studies on specific
aspects of the EFNEP prOgram. Prichard and Hall (1971) in Nebraska
studied the attitudes of aides and clients toward the program.

Seoane (1971) studied the shopping practices of EFNEP families for

convenience foods. In Maryland, some of the changes resulting from

3
the Expanded Nutrition Program were that homemakers used new foods,
prepared some foods differently, and learned the principles of
planning balanced diets and wise food shopping. Although eating
habits improved, the majority had not yet attained adequate diets
(Hang and Ephross, 1970).

The reliability and validity of periodic 24-hour food recalls
of the homemaker's food intake for assessing the adequacy of the
family's diet has been questioned by several groups. Huenemann and
Turner (1942) emphasized the flexibility of the diet from.day to
day. Krehl and Hodges (1965) discussed the inaccuracies resulting
from insufficient knowledge of the quantity of food consumed by the
individual.

Beal (1967) believed it to be a memory test, valid only in
surveys where time, money, and personnel were limited. Eppright
and associates (1952) mentioned the importance of chasing a period
of time representing the usual behavior of the subjects, as well as
recognizing the fact that girls are more variable in their food intake
than are bqys.i Hunscher and Maqy(1951) stated several problems:
incomplete knowledge of food composition: the fact that common foods
vary widely in composition: and the variations that exist in methods
of preparing raw foods, which affect their nutrient content.

Trulson and McCann (1959) believed daily dietary records to be useful
only when the subjects were literate and reliable.

leverton (1960) noted two further problems with food recalls:
what happens to ingested food may be different from one individual
to another; and we don't really know what differences in nutritional

status mean in terms of performance and well-being of the individual.

a

s As a means of overcoming some of the inadequacies of the
dietary history, urinary excretion of thiamin and riboflavin has been
used to express nutritive status. The validity of assessing nutri-
tional status by means of random urine specimens is based on the
ability to analyze the vitamin levels and express them as a ratio
of the creatinine excretion. Clarke gt_gl (1966) and Lowry (1952)
concluded that random urine specimens could be used well for studies
of population groups, relating the vitamins to creatinine excretion
was convenient, and the use of creatinine tended to correct for the
size of the individual. Louhi 22 £1 (1952) concurred, suggesting
that the ratio of the thiamin per gram of creatinine could be used

as well as ZN-hour collection for a rough estimate of the nutriture

of the individual.

Objectives

.The main objective of this thesis was to develop a descriptive
profile of the demographic.characteristics and the nutritional status
of 176 families as they entered the Expanded Nutrition and Family
Programs (ENFP). This would provide baseline data from.which to
assess change. Among the areas of interest were family income,
age and education of the homemaker, size of the family, the home-
maker's 24-hour food recall, her responses to various statements
related to nutrition knowledge, and levels of vitamin excretion.

Another objective was to determine what relationships might
exist between 24-hour food recalls, vitamin levels, nutrition

knowledge, and income of the homemaker.

CHAPTER II
LITERATURE REVIEW

Dietary Patterns in America

Ethnic groups, income groups, age groups, and various population
groups have been studied to determine their nutritional status.

Beal (1955) studied upper middle-class Denver families to obtain a
‘picture of the nutrient intake of healthy children living at home
during the first five years of life. Using Zh-hour food recalls,

she found that thiamin intake increased steadily during the first 15
months, leveled until just after three years of age, then increased
again. The median intake was slightly above the RDA. Riboflavin,
after an initial rise in the first year, decreased in the second and
third years with decreased milk consumption, but then increased again.
More than 75% of the children consumed more riboflavin than recommended
by RDA standards during the first three years.

Further work by Beal (1961) among upper middle-income families
showed that healthy, growing children tend to have superior food and
nutrient intake more often than intakes that do not meet the
Recommended Dietary Allowance (RDA) standards. '

Calcium, iron, and vitamins A and c intakes are frequently
shown to be low in nutrition surveys. Brown and associates (1970),
studying two- and three-year old children of low- and middle-income

families in Honolulu, found low-income children more likely to have

6

low intakes of calcium, vitamin C, vitamin A (to a lesser extent)
and riboflavin than were middle-income children. ‘Both income groups
tended to show somewhat low calcium and iron intakes.

Ho and Brown's (1970) investigation of food intakes of
infants attending well-baby clinics in Honolulu indicated that .11
the nutrients met at least two-thirds of the RDA.except for iron.

The iron intake of slightly more than half of the infants was Just
below 50% of the RDA. Fox 93 2.1. (1971) concur. In their study of
pre-schoolers in twelve north central states, they found that calcium
and phosphorous compared favorably with the RDA, but iron was low.

Morgan (1959) reported that during 1914-1958, about 12,000
individuals in 39 states participated in a nutrition research project.
Seven-day food records were kept, and dietary adequacy was measured
by the 1958 National Research Council recommended daily intake of
nutrients. Physical examinations were provided, which included
biochemical analysis of blood and urine, and in some cases, dental
exams and x-rqys of bones and teeth.

Nutritional status,as measured by dietary intake, on the
whole was very good. qus from.5-12 years of age showed excellent
dietary intakes of all nutrients, while the calcium intake of girls
in this age group tended to be slightly lower. qus aged 13-20
showed adequate intake of all nutrients except vitamin C. Girls in
this age bracket showed borderline intakes of calories and protein,
and were seriously low in calcium, iron, thiamin, and vitamin 0.
Adult men showed high intakes of all nutriento except calories and
thiamin, while adult women showed good average intake of all nutrients
except calories, thiamin, calcium, and riboflavin. Morgan concluded

7

that vitamins A and C and the minerals calcium.and iron were lower
than the RDA more frequently than any other nutrients.~

Davis and associates (1969) found that a significant propor-
tion of the population had dietary intakes below one-half the RDA
in certain nutrients. After puberty males showed nutrient intakes
that were usually more adequate than females. There was evidence
that a substantial number of infants were poorly nourished, and this
situation existed in high-income groups as well as low. Economic
status was not necessarily a good predictor of nutrient intake except

in the cases of calcium and vitamins A and C.

Factors Affecting_Nutrient Intake
The factors influencing food consumption behavior and food
attitudes have been researched by several groups. Lund and Burk (1969)

pointed out that

we know in considerable detail what our population is

consuming and what the nutritive value of its consump-

tion is. What we don't know is why people choose the

foods they do, how food habits are established, and

how they can be modified. It is in our knowledge of

the behavioral aspects of nutrition that serious gaps

exist.
In their study of children's food consumption behavior, they found
that only about 20% of the families used mealtime for educating
children about food. Vitamin A intakes seemed most closely related
to food attitudes and experiences of mothers and children, but the
fathers' attitudes were not significant. In regard to vitamin C
intakes of children, the important factors in determining intake

were "parental attitudes toward critical foods and children's

behavior while eating."

8

An interesting study by Hardy and associates (1943) in the
Chicago area investigated the diets of two- to eight-year old
children from.different socioeconomic groups. They concluded that
economic conditions affected nutritional adequacy since there were
improvements in diets following a marked increased in the food
budget. The Negro population exhibited poor diets more frequently than
White children, and all the dietary inadequacies resulted most often
from lower consumption of fruits and vegetables. Inadequate use of
protein foods was seldom observed.

Fryer'gtflgl (1971) found that family income was not signi-
ficantly related to the intake of carbohydrates, protein, and fat
in the children they studied. Fox gt El (1971) stated that the
amount of money spent for food seemed more important than income or
education of the mother in positively influencing nutrient intake.

Eppright _e_t_ 5; (1970) concurred that the amount of money spent
for food was important in improving the diet. Hiemstra (1972)
pointed out that food or nutrient expenditures do not necessarily
increase with an increase in income.

Young and associates (1956) looked at homemakers' nutrition
knowledge in Syracuse and Rochester, New York. They found that the
educational level of the homemaker showed a greater relationship to
nutrition knowledge than did income. As educational level increased
‘within an income bracket, the percentage of homemakers using the
basic seven increased. This did not prove true as income increased
at an educational level. Nutritional knowledge did improve the
homemaker's performance in feeding her family, but many homemakers

performed better in feeding their families than their nutrition

knowledge would indicate.

9

The relationship between the educational level of the mother
and nutrition has been investigated further. Morse _e__t_ 5; (1967) found
that the more education the mother possessed, the better answers she
gave to practical nutrition questions, although there were exceptions
on both sides. A course in nutrition appeared to be directly bene-
ficial to nutrition knowledge without being related to higher education.
Studies by Hinton and associates (1963), Hendel gt 51 (1965), and
Eppright gt_§l (1970) suggested that the mother's education.was very
important in influencing her family's dietary intake. Dickens and
Ferguson (1958), on the other hand, in a study of homemakers' use of
dairy products, found a low relationship between a homemaker's use
and her knowledge of dairy products.

Allen.gt El (1970) approached the study of nutritional adequacy
from the standpoints of family commensality and academic performance.
Family commensality was determined from the number of meals eaten
together, what family member prepared the meals, and the quality of
the cooking. Family commensality was associated with increased food
likes, dietary adequacy, and good health. Correlations suggested a
positive influence on the childrens' academic performance.

I we must conclude from these facts that the daily routine
of the family sharing of meals-~breakfast, lunch, and
dinner--exerts a consistent positive and beneficial _
influence on the personal, academic, and social develop-

ment of the child and on his maturation and progress
toward vocational adequacy.

There appear to be other sociological factors which influence
the nutritional status of children. Hinton gt El (1963) found that
various social factors influenced the eating behavior and dietary
intake of girls 12-14 years old. The girls who scored best in

emotional stability, conformity, adjustment to reality, and family

10

relationships missed fewer meals and had better diets than girls
scoring less well in these areas. Girls maturing either early or
late had poor eating habits and demonstrated feelings of inadequacy
and isolation. If the girls considered health an important factor
in food selection, their diets were much more adequate than the
diets of those girls who considered the enjoyment of food an end in
itself.

Sims (1971) studiei nutritional status of pre-school children in
moderate-income families in relation to various environmental factors.
She grouped methers into two categories. Type I mothers were non-
authoritarian, valued freedom, possessed low feelings of powerlessness,
exhibited high family centrism or cohesiveness, felt a high regard
for education, and had attained high socioeconomic status. Type II
mothers were authoritarian, had some feelings of powerlessness,
prestige and religion were of high importance, and they tended to
possess lower socioeconomic status. Type I mothers felt nutrition
was very important, scored higher on nutrition tests and use of the
Basic Four, and spent less money on food than type II mothers.
Children in type I families had higher calcium and vitamin C intakes
than children of type II families, although the latter group tended
to consume more calories, carbohydrates, iron, and thiamin than the
former. Type II children were generally heavier for their height
than were type I children, who appeared to show a more balanced
physique. I

Meyers (1970) summarized some of the extra costs poor families
face which may make it more difficult for them to afford greater

food expenditures. They often cannot take advantage of seasonal

11

sales, and they may be limited to buying in their own neighborhood
where costs may be high. The quality of their purchase is limited I
to the quality they can afford at a particular time, and credit
costs are high. Their consumer education may also be limited, and
thus they don't know how to use certain foods or how to extend their
purchasing power.

Bryan and Lowenberg (1958) looked at the father's influence
on young children's food preferences. There was a slight correla-
tion between the fathers' and childrens' reactions to vegetables.
Eighty-nine percent of the mothers did not serve certain foods if
the father did not like them. Thus it appeared that the father's main
influence on the child's preferences was of limiting the variety of
food offered to the child. Sanjur and Scoma (1971) supported the
conclusion that foods unfamiliar to or disliked by the parents

were also unfamiliar to the child.

USDA Nutrition Programs

The effectiveness of the USDA school lunch and food stamp
programs in improving the nutrition of low-income families has been
investigated. Schaefer (1969) reported that in San Diego, Texas,
where over 90% of the children in the low-income area were served
free lunches, the nutritional status of children in that area was
far superior to other low-income areas surveyed. Callahan's (1971)
study in Massachusetts indicated that Type A lunches were nutri-
tionally superior to bag lunches or other alternatives. Madden
and Yoder (n.d.) reported that in rural areas of central Pennsylvania
total food expenditures could be increased by the food stamp program,

showijig higher intakes of iron and thiamin and riboflavin by stamp

12

recipients in one of two counties studied. Reese (1971) also
reported that food expenditures could be increased through the food
stamp program. ‘

Hiemstra (1972) summarized and evaluated some of the USDA food
programs. With every 10% increase in disposable income, consumers tend
to increase food expenditures by four to six percent. The difficulty,
however, is that in terms of nutrients or pounds of food, not much
additional food is purchased as income rises. Therefore, if nutrient
intake is to increase, there must be an incentive for the consumer
to buy food, or a restriction of other purchases to encourage food
buying. The food stamp program appeared to be making favorable

impacts on the nutrient intake of the families receiving the food

stamps.

Urinary Excretion 2quitamins

The difficulties in assessing nutriture by dietary recalls
or dietary records have been discussed in the introductory chapter.
Urinary excretion of thiamin and riboflavin has been used in
surveys to assess intakes of these vitamins.

Using Pearson's (1962) vitamin excretion tables, Meyers
gt_gl_(1968) found that 20% of the children in a depressed area of
urban Boston showed thiamin excretions in the low range. Riboflavin
excretions tended to be in the normal ranges. Owen gt_gl (1969),
on the other hand, found the urinary excretions of both thiamin and
riboflavin to be acceptable in 585 Mississippi pre-school children.
Brin et_gl (1965) studied thiamin and riboflavin excretions among
the elderly in New York state. He concluded that 18% of the subjects

were thiamin deficient using the ICNND (1963) tables, or 21% using

13

Pearson's tables (1962). None were deficient with respect to
riboflavin. Tzeng (1971) researched primary school children in
Danville, Illinois. Using ICNND (1963) values for urinary thiamin
and riboflavin, she determined that 9% of the males and 14% of the fe-
males had unacceptable thiamin values. With regard to race, 9% or the
whites and 16% of the non-whites showed unacceptable thiamin values.
Seven percent males, 10% females, 7% whites and 11% non-whites had
unacceptable values of riboflavin.

McGanity (1969) examined 4,497 individuals in Texas who
represented the lower 25% of socioeconomic status. Median urinary
values for thiamin and riboflavin were in the acceptable range.

The percentage of individuals showing low thiamin values was twice
as large in the non-Latin white subjects as in either Mexican
American or Negro American. Low riboflavin was seen one and one-half

times as often in non~Latin whites as in the other group8.

Variability_2£_Thiamin Excretion

Friedemann and his associates (19Q9) studied the utilization
of low and high thiamin and riboflavin intakes, examining the effects
of work and rest. The urinary excretions of thiamin and riboflavin
suggest that the tissue concentration of these vitamins may depend
on the physical state and the diet of the individual, as well as the
daily vitamin intake. Thiamin excretion was not related to riboflavin
excretion. The excretion of these vitamins was generally lower at
full activity than at rest or during limited activity.

Arroyave gt_gl_(l96u) investigated the excretion of thiamin
and riboflavin by 36 children in a home for poor children in Guatemala

City. Initial examinations of their diets diowed deficient intakes

1b

of these vitamins according to RDA standards of the National Research
Council. As the diets of these children were gradually increased to
meet the RDA standard, he observed a three-fold increase in ribo-
flavin excretion over a ten-week period. It was interesting, however,
that urinary thiamin decreased despite the increased uptake. Because
the diets were increased 100% in calories and 65% in carbohydrates,
Arroyave theorized that the increased demand for thiamin was greater
than the increased thiamin intake. '

Other groups have added to our knowledge of rates of thiamin
excretion. Mickelsen and associates (1947) found a linear relation-
ship between intake and excretion when the diets were varied to
include 0.6, 1.0, 1.8, and 2.0 mg/day of thiamin. Melnick gt §_1_ (1939)
noted that the percentage of available thiamin for urinary excretion
was a function of how great an excess was present. Mason and
Williams (l9u2), Ferrebee gt El (19u2), and Robinson 22 £1 (l9QO)
agree that deficient individuals generally excrete less thiamin than
normal subjects.

Several investigators have studied the relationships between
clinically diagnosed thiamin deficiency and urinary excretion levels.
Elson gt §l_(19U2) found that human subjects which showed clinical
signs of thiamin deficiency on intakes of 0.35 lug/1000 kcal had
average urinary excretions of #2 meg/day. Robinson, Melnick and
Field's (19Q0) study of thiamin deficient subjects showed that half
of the patients had urinary thiamin excretion levels which suggested
insufficient intake. Another interesting observation was that six
of the seven patients with organic heart disease had low excretion

levels. Patients on antacid or achlorhydra medication excreted small

15
small amounts of thiamin even when the diet was adequate. Tanphaichitr
and associates (1970) concluded that transketolase activity in ery-
throcytes was a better indicator of sub-clinical beriberi in Thailand
than was urinary thiamin, but urinary thiamin excretion was useful

for surveying large population groups.

Variability'gf Riboflavin Excretion

 

There is considerable evidence which relates riboflavin
excretion to nitrogen balance in human subjects. Pollack and
Bookman (1951) studied riboflavin excretion in normal, injured, and
diabetic individuals. Patients in positive nitrogen balance excreted
less than 50% of the ingested riboflavin, while patients in negative
nitrogen balance always excreted more than 50% of the dietary ribo-
flavin. They concluded that most of the riboflavin in the body is
probably bound as flavoproteins and that the excess urinary riboflavin
in negative nitrogen balance must be due to the breakdown of flavo-
proteins. Windmueller 9.2 e_]_._ (196a) also observed increased riboflavin
excretion in negative nitrogen balance.

Horwitt et_§l (1950) studied varying intakes of riboflavin
to assess correlation of urinary excretion with deficiency signs. At
excretion rates of less than 50 mcg/day or 27 mcg/gram of creatinine,
he observed riboflavin deficiency signs in the adults.

Tucker, Mickelsen, and Keyes (1960) examined the influence of
several factors on riboflavin excretion. Meals tended to increase,
and sleep to decrease, the rate of excretion. During short periods
of labor, they observed decreased excretion of riboflavin, but acute
starvation and hard physical labor for three and seven days increased

the excretion threefold and fivefold, respectively. Diuresis had no

16

effect on riboflavin excretion. Thiamin deficiency alone increased
riboflavin excretion. 'When riboflavin and thiamin were both deficient,
there was increased riboflavin excretion only after four weeks of
deprivation.. Five mg/day of thiamin brought the riboflavin excretion

rate to normal.

Relationship 22 Vitamins tequeatinine Excretion

‘Timed, Zfl-hour, and test doses of urine are difficult to
obtain from population groups; therefore, researchers frequently
resort to random specimens. Mason and Williams (19u2) believe that
random samples generally give about as much information as test doses.
Louhi gt_gl (1952) found that, as with thiamin, assessing riboflavin
excretion per gram of creatinine appeared to be quite constant,
making it a useful parameter to measure random urine samples collected
during population studies. Hegsted gt El (1956) demonstrated that
duplicate random samples obtained from individuals are more reliable
than single samples.

Folin (1905) wrote that ”the chief factor determining the
amount of kreatinine [sic] eliminated appears to be the weight of
the person." ‘Haterlow’gt_£l (1972) studied the effect of different
diets, infection, and age on creatine turnover in rats. Their
findings showed that turnover was not affected appreciably by age,
sex, or level of creatine intake. The turnover rate was increased,
however, by fasting five days and by severe infection.

vestergaard and Ieverett (1958) investigated the constancy
of urinary creatinine excretion in 18 individuals. Some individuals
tended to show fairly constant rates of excretion, while others did

not. They also found no correlation between meats eaten and~

creatinine excreted.

17

Groups have examined the advantages of random urine speci-
mens for nutrition surveys. Johnson and associates (l9u5) compared
fasting specimens, random specimens, and oral loading tests. They
concluded that all three tests could be used.we11 together, but that
a fasting specimen was preferred over oral load tests and random
samples. Plough and Consolazio (1959) also concluded that fasting
specimens were more accurate than random samples.

Kelsay (1969), Pearson (1962), and Stearns gt a; (1958) all
stressed the need for using separate interpretative guides of
thiamin and riboflavin status for children since children tend to
excrete lower levels of creatinine, and urinary thiamin per gram of

creatinine appeared to be higher for children than for adults.

CHAPTER III
EXPERIMENTAL PROCEDURES

Urinary excretion of thiamin and riboflavin by family members

, and the nutrition knowledge of the homemakers were the methods used

to describe the nutritional status of newly-enrolled Expanded Nutrition
Program families. This-chapter deals with the selection of the

sample families, the instruments used, and the collection and

analysis of the data.

Selection of the Sample
A sample of 176 newly-enrolled families was obtained from
four randomly selected Michigan counties: Lenawee, Saginaw, St. Joseph,
and.Hayne. The sample was randomized by including each consecutively
enrolled family within a specific time period. The time period
within a specific county began when the researcher started collecting
data in that county and ended when that county’s quota of families

was reached. The county quota was equivalent to six times the number

of full-time aides.

Instrument
Characteristics of families, the homemaker's Zu-hour food
recall, and information about households were obtained by the nutrition
aide on her initial visit to enroll the homemaker in the Expanded

Nutrition and Family Programs (ENFP). This information is required

18

19
by law of new families and is recorded on a special form (Appendix A).
To minimize the length of the interview and to avoid redundancy, this

information was copied .

Two interviews were required to collect data. on the first
interview random urine specimens were collected from available family
members, as well as additional information about the, family, such
as grocery shopping practices (Appendix B). During the second
interview, the homemaker's responses to various statements dealing
with nutrition knowledge were obtained (Appendix C).

The questionnaires were pre-tested on low-incom families
priorto actual data collection. Because of the large number of
Spanish-speaking families enrolled in the program, the questionnaire

was translated into Spanish.

Preparation for Data Collection
Researchers were trained in a specific interviewing procedure
(appendix D). All the researchers visited the county staffs before
initiation of data collection. During these visits county Extension
personnel learned about the project. In a later session with the ’
aides and Extension Home Economist, the project was explained in

detail through role-playing involving the aides .
Nutrition aides were asked to enroll families in their usual
manner, except to ask the hommaker for permission to bring someone

else on her second visit. The aides were asked not to explain the

evaluation project in any way.

Data Collection

Data collection began in November of 1972 and continued

through early April, 1973.

20

A researcher collecting biological data accompanied the aide
on her second visit to the homemaker. The researcher explained the
evaluation project to the homemaker and obtained her permission to
be included (Appendix E).

All available family members were provided with plastic
cups in which to collect urine specimens. The specimens were tested
imdiately for hemoglobin, ketones, glucose, albumin, and pH using
Labstix Reagent Strips, produced by the Ames Company, division of
Miles Laboratories. Positive tests were referred to physicians
using an explanatory referral slip (Appendix E). The urine was bottled
in brown bottles and acidified with l N HCl at 5 ml HCl per 50 m1
‘ urine. 1 Samples were brought back to the university and frozen
immediately until they could be analyzed.

The urine specimens were, analysed for creatinine, thiamin,
and riboflavin using a To chnicon Auto-Analyser with pump number one.
Technicon Auto-Analyzer method N-llb I/II was used for creatinine.
Thiamin was analyzed using Leveille's (1972) method as modified and
automated by Romsos (1973) and Kirk (1973). Riboflavin was determined
according to Kirk's automated method (1973). The urinalyses were run
by a university technician.

The thiamin and riboflavin levels were calculated as micrograms
of vitamin per grameof creatinine. To describe the vitamin adequacy
levels, the subjects were divided by age group and compared to the
ICNND (1963) standards for that age group.

The homemaker was asked several questions concerning the
family's use of vitamin supplements, her grocery shopping practices,

and available cooking equipment (Appendix B). Information on family

21

income, family size, education of the homemaker, the homemaker's
zu-hour food recall, and other pertinent information was obtained from
the aide's enrollment sheet (Appendix A).

On the aide's third visit to the homemaker, a second researcher
accompanied her to obtain attitudinal information related to the
homemaker's knowledge of nutrition. Each statement was read to the
homemaker, and she responded by either disagreeing strongly or

mildly or agreeing strongly or mildly (Appendix C).

Analysis gleata
Data from 176 families were examined. Due to incomplete data

for some of the families, N varied from one set of data to another.

Demographic data included residence location, age and ethnic
background of the homemaker, family size and income, aid received by
the family, grocery shopping variables, use of vitamin pills, and
availability of equipment and utilities for food preparation. For
analysis of the participation of children and families in school
lunch programs, families without school-age children were excluded.

Homemakers were grouped into three educational categories:
eighth grade or less; ninth through twelfth grades; and beyond high
school. For correlation purposes, these were assigned values of
one, two, and three in order of ascending educational levels.

For analysis of the adequacy of the homemakers' 24-hour food
recalls, the diets were compared to the Basic Four adult standard:
two servings from the meat group; two from the milk: four from the
fruit-vegetable group: four from the bread-cereal group daily} If a
food group was adequate in a homemaker's diet, it was assigned a score

of one; if it was inadequate, a score of zero. This information was

22

used to describe the adequacy of individual food groups. Scores from
each food group'were totalled, so that a homemaker receiving a

score of four had a diet meeting the Basic Four standard. A score of
two or three indicated she met two or three out of four of the food
groups}. Ratings of "A", ”B", "C", "D", and "B" were assigned to
diets which met four, three, two, one, and zero out of four food
groups, respectively.-

In an effort to determine the degree of inadequacy, the diets
were also scored according to their meeting one-half the Basic Four
adult standard, i.e., one serving from the meat group, one from the
milk group, two from the fruit-vegetable group, and two from the
bread-cereal group. If a homemaker met one-half the recommended number
of servings for each of the four food groups, the diet was assigned a
rating of "A/Z". Similarly, if the diet met one-half the recommended
number of servings for three, two, one, and zero of the four food
groups, the diets were assigned ratings of "B/2", "C/Z", "D/Z", and
"E/Z", respectively.

The nutrition statements were evaluated by the researcher and
her major professor by designating the most appropriate response to
each statement. This response was assigned a value of four. The
most appropriate response is underlined in Appendix C. The other
responses were assigned values of three, two, and one in descending
order of appropriateness. The statements were also analyzed separately,
'with a compilation of the number of homemakers responding "strongly
agree, mildly agree, mildly disagree, and strongly disagree" to each
statement. '

A correlation matrix was computed from all possible pairs of

six variables: family'income in dollars; homemaker's educational

23

level; adequacy of 24-hour food recall; her levels of thiamin and
riboflavin excretion; and her score on nutrition information
interview. 7

Data'for all the variables of the correlation matrix were
complete for only 121 homemakers. The reasons for such a reduction
from 176 families include missing data on the aide's enrollment form,
the inability or unwillingness of the homemaker to provide a urine
specimen, incomplete information on the urinalyses, and lack of the
honemaker's participation in the second interview.

Calculations were run on the Control Data Corporation (CDC)
6500 model computer, utilizing programs written by the research unit

'within the College of Human Ecology at Michigan State University.

CHAPTER IV

RESULTS

Description 9_f_‘ M33

The largest number of homemakers lived in an urban area and
had at least some high school education (Table 1). Nutrition aides
record the educational level of the homemaker by category, as
described previously, but it might have been more meaningful to
know the average grade completed by the homemakers, rather than
knowing that the majority'had some high school education.

The ethnic background of the homemaker showed a greater
number of white than of black or of Spanish Americanhomemakers
(Table 1). Yet there were about as many Spanish American and black
homemakers combined as there were white homemakers.

The majority of these families were receiving assistance
through the welfare program, including Aid to Dependent Children
and Aid to Dependent Children of the Unemployed, and through use of
food stamps (Table 2). Most of the families receiving welfare also
received food stamps, but there were some families who did not
receive both.

’ The homemakers ranged in age from 16 years to 70 years, with
a mean age of almost 29 years (Table 3). Approximately two-thirds

of the homemakers were within the age range of about 19.5 years and

38.5 years.

24

25

' Table 1.--Residenoe, ethnic background, and education

of the honemaker

 

 

Number i

A. Residence (N=l76) '

Urban 149 84.7

Rural non-farm 26 14.8

Farm 1 .5
B. Education (N=171).

No information 1 .6

Eighth grade or less 32 18.7

Ninth-twelfth grades 131 76.6

Eyond high school 7 “.1
C. Ethnic background (N=l75)

Caucasian 86 49.1

Negro 56 32.0

Spanish Anrican 29 16.6

Oriental 1 .6

.Anrican Indian 2 1.1

01:11.1. 1 06
Table 2.--aid received by family (N=17u)

Number %
Yes No Yes A No

USDA/FHA Assistance 7 166 4.0 96.0
Welfare 9'? 77 55.8 154.2
Social Security 10 161» 5.7 9+.3
Other 9 163 5.2 94.8

 

26

. The family size varied from one to twelve members, with the
mean family size of 4.5 (Table 3). The family income per month varied
widely as shown by the range and standard deviation. Two-thirds of

the families had incomes between $200 and $514 per month.

Table 3.--Age of homemaker and family size and income per month

 

N Min. Max. Mean Std. Dev.
Age 165 16 70 28.9 9.6
Family size 176 l 12 4.5 2.2
Income/month 165 $20 $1000 $357.76 $157.58

 

The appearance of some families whose income was above the
poverty level is explained by the fact that the majority of the aides
from.one county were employed under Emergency Employment Act funds.
They may not have been restricted to families of a certain income
bracket, even though they received guidance and administrative services
through the Expanded Nutrition Program.

Only slightly more than half of the families with school-age
children had at least one child participating in the school lunch
program (Table 4). For those with school-age children who did not
participate in school lunch, it is not known whether or not the lunch

program was available to them.

Table 4.--Participation in school lunch

Number %
A. Families with school—age children (N=69)
At least one child in school lunch 39 56.5
No children in school lunch 30 43.5

B. Children in school (N=209)
Children in school lunch 119 56.9
Children not in school lunch 90 43.1

A

27
The majority of the homemakers appeared to have adequate

cooking facilities (Table 5). Stoves, working ovens, refrigerators,
electricity, and running water were each present in homes more than
95% of the time. A freezer was counted only when it was a completely
separate unit from the refrigerator, which excluded all refrigerator-
freezer combination units. The presence of a piece of equipment,
such as an electric frying pan or a hot plate, does not mean that

it was used by the homemaker; it only indicates that it was available

to her in her home.

Table 5.--Food preparation equipment and utilities available to
homemaker (N=164)

 

Number %
Yes No Yes No
Electricity‘ 164 0 100.0 0.0
Running water 161 1 99.4 .6
Refri rator 162 1 99.4 .6
Stove range 163 1 99.4 .6
Oven , 156 6 96.3 3.7
Electric frying pan 56 98 36.4 63.6
Freezer 30 118 20.3 79.?
Hot plate 10 137 6.8 93.2
Icebox 2 120 1.6 98.4
Other 9 98 8.4 91.6

 

Food Purchasing Practices
The grocery shopping information revealed that the homemaker
herself did most of the food buying and that she preferred to buy at
a supermarket most of the time, although there was occasional use of
small, neighborhood stores (Table 6). The majority of the homemakers
were able to shop within five miles of their homes. A car, owned by
the family or some relative or friend, was the most frequently used

transportation.

28

Table 6.--Grocery shopping data (N=163)

A.

Person doing the shopping

Mother alone 139
Father alone 8
Children alone 0
Other relative 3
Non-relative 1
Mother & father tOgether 9
Other combination 3

B. Favorite grocery store
Supermarket 159
Small neighborhood store 3
Specialty food store 0
Other 1
C. Second choice grocery store
Supermarket 82
Small neighborhood store 60
Specialty food store 8
Other 13
D. Distance from favorite store
Less than 1 mile 57
1-5 miles 76
Greater than 5 miles 30
E. Transportation for grocery shopping
Family car 84
Neighbor, friend, relative's car 58
Walk 13
Taxi 6

Bus 2

75

 

29

The homemakers were asked to state two factors, if possible,
that influenced their food purchases° The homemakers reported
verbally. The researcher categorized these into the groups listed
in Table 7.

Since the homemakers did not necessarily state their responses
in the order of importance, both decisions of 163 responding home-
makers were grouped to compile Table 7. In a few cases the homemakers
were only able to indicate one factor; therefore, there were only
305 decisions rather than 326.

The cost of the food and family preference were mentioned
most frequently, and accounted for almost 50% of the responses
together. Needing a food item and nutritional value together repre-
sented almost 25% of the responses. The author considers it surprising

that convenience of preparation was mentioned by only three individuals.

Table 7.--Factors influencing food purchases (N=305

-

Number 1

Cost--I can afford it 80 26.2
The family likes it 71 23.3.
I'm out of it/need it 38 12.5
Nutrition--it's good for us 34 11.2
It's on my grocery list 20 6.6
It's on sale 16 5.2
It's a specific brand 8 2.6
It's a new product I wanted to try 6 1.9
Convenience--it's easy to prepare 3 1.0
It's in season 0 0.0
Other 21 6.8

8 2.6

No decision

 

Homemakers were also asked if they had a vegetable garden of
their own. Their response was not considered "yes" unless they had

grown some vegetables during the previous summer at their own home.

30
If they were planning on having a garden or had used produce from a
relative's garden, their response was considered "no", since there
was some question about the availability of food from others" gardens,
and since best intentions for planting a garden do not always come
to fruition. Of 160 responses, 24 or 15% of the homemakers had a

garden, and 136 or 85% did not.

. Homemakers' 24-Hour Food Recalls
The food recalls were analyzed first on adequacy of individual
food groups (Table 8). The meat group was adequate more frequently
than any other food group. This was particularly noteworthy,
considering the rising meat costs at the time of the research. The

fruit-vegetables group was most frequently inadequate.

Table 8.--Adequacy of food groups from.24-hour food recalls (N=l74)

Number
Adequate Inadequate Adequate Inadequate
Meat 119 55 68.4 31.6
Milk 40 134 23.0 77.0
Fruit-vegetables 23 151 13.2 86.8
Bread-cereal 44 130 25.3 74.7

 

The diets were next analyzed on the basis of total adequacy
for each homemaker (Table 9). Homemakers were grouped on the basis of
how many of the four food groups in their diets met the Basic Four
standard. Only'3.5% of the homemakers reported diets in which all of
the four food groups were met ("A" rating). The majority of the
homemakers (42.5%) had food recalls that met recommendations for only

one of the food groups ("D" rating). Dietary recalls rated "B", "C",

31
and "E" met recommendations for three, two,and none of the food

groups, as described in Chapter III, "Analysis of Data".

Table 9.-—Homemakers meeting basic four standard (N=l74)

 

Number of Food Rating Number of % Cum. %
Groups Met Homemakers
’4 Of a A 6 305 305
3 of 4 B 16 9.2 12.7
1 of 4 D 74 42.5 78.2
0 of44 E 38 21.8 100.0

Looking at the diets of those who met the minimum requirements
for three or two of the food groups ("B" and "C" rated diets) revealed
that, in both cases, the fruit-vegetable group was most frequently
inadequate. The milk group was adequate more often that the fruit-

vegetable group, but less often than the meat group or bread-cereal

group (Table 10).

Table 10.--Dietary information on those meeting two and three of the
Basic Four food groups

 

Number %
Adequate Inadequate Adequate Inadequate

A. Three groups not (N=16)

(B rating)

Meat 16 0 100.0 0.0
Milk 12 4 75.0 25.0
Fruit-vegetable 5 11 31.2 68.8
Bread-cereal 15 1 93.8 6.2

B. Two groups not (N=40)

(C rating)

Meat 36 4 90.0 10.0
Milk 16 24 40.0 60.0
Fruit-vegetable 10 30 25.0 75.0

Bread-cereal 18 22 45. O 55. O

 

32
In an effort to further describe dietary inadequacy, the

24-hour food recalls were examined to determine whether or not they
met one-half the Basic Four standard, as described under "Analysis
of Data", Chapter III. Only 25% had an A/2 rated diet, 1.6.. one
serving of meat or meat substitute, one serving of milk, two servings
of fruit-vegetables, and two servings of bread-cereals (Table 11).
On the basis of what the homemakers reported their previous day's
food intakes had been, the diets appear to be grossly inadequate.

Table ll.--Homemakers meeting one-half or more Basic Four
standard (N=l7u)

 

Number of Food Rating Number of % Cum. %
Groups Met Homemakers
4 of u A/2 44 25.3 25.3
3 of’4 B/2 71 no.8 66.1
2 of’4 C/2 37 21.3 87.4
l of # D/2 18 10.3 97.7
O of’# E/Z 4 2.3 100.0

 

Results of Biochemical Analysis

Urine Specimens were collected from family members who were
available. As a service to the family, these samples were tested
immediately at the home for hemoglobin, ketones, glucose, protein,
and pH. Out of 324 samples, only two tested positively for glucose.
These were referred to physicians for further examination.

The urine samples were brought back to the university where
they were analyzed by a technician for thiamin, riboflavin, and
creatinine.

Thiamin excretion levels per gram of creatinine were compared

by age group to ICNND standards (Table 12). All urinary thiamin levels,

33

except one adult, were judged to be acceptable or high. By far the

majority of samples fell within the range "high" (97.2%).

Table 12.--Thiamin excretion levels by age group
(based on ICNND standards of adequacy)

 

Age in Years Deficient Low Acceptable High
1-3: (N=54)
Number 0 O 4 50
Percent 0.0 0.0 7.4 92.6
h-6: (N=58)
. Number 0 O 2 56
Percent 0.0 0.0 3.“ 96.6
7-9: (N=24)
Number 0 0 0 24
Percent 0.0 0.0 0.0 ' 100.0
10-15: (N=27)
Number 0 0 l 26
Percent 0.0 0.0 3.7 96.3
16 & older (N=l6l)
Number 0 l l 159
Percent 0.0 0.6 0.6 98.8
Total number 0 l 8 315
Total percent 0.0 0.3 2.5 97.2

All age groups showed a wide range of levels, but the age group
10-15 years exhibited the narrowest range. There were, however, a

small number of samples (27) from this age range (Table 13).

Table 13.--Thiamin excretion levels (mcg/gram of creatinine)

Age in Years Min. Max. Mean Std. Dev.
1-3 (N=54) 232 13537 2302 2176
u-6 (N=58) 216 684a 1821 1362
7-9 (N=24) 431+ 8030 1809 17111

10-15 (N=27) 233 2997 1162 717

16 & older (N=161) 6M 8712 . 900 l3h2

 

Riboflavin excretion levels were assessed by age group

smallest sample.

Table l4.--Riboflavin excretion levels by age group
(based on ICNND standards of adequacy)

Age in Years

1-3:' (N=5”)
Number
Percent

4-6: (N=58)
Number
Percent

7-9: ' (N=24)
Number
Percent

10-15: (N=27)
Number
Percent

16 & older (N=161)
Number
Percent

Total number
Total percent

34

according to ICNND standards (Table 14).

Deficient

12.9

3.5

0.0

14.8

13
8.1

26
8.0

A total of 8.0% of the

Low

11
20.4

15
25-9

37-5

26.0

25
15.5

20.?

only group not showing a deficient subject, but it was also the

Acceptable.

15
27.8

10.3

29.2

14.8

70
43.5

102
31.5

individuals showed deficient levels, with 20.7% showing low levels.
In other words, over one-fourth of the sample population showed low

or deficient levels of riboflavin. The 7-9 years age group was the

High

21
38.9

35
60.3

33.3

12
44.4

53
32.9

129
39-8

 

35

The 7-9 year old group exhibited the narrowest range for
riboflavin excretion. Two individuals in the youngest and oldest
age group showed very high levels of riboflavin, probably the result

of using some vitamin supplement (Table 15).

Table 15. Riboflavin excretion levels (meg/gram creatinine)

 

Age in Years Min. Max. Mean. Std. Dev. ‘
1-3 (N=5u) ' 16 17927 1638 2753
4-6 (N=58) 18 8242 1503 1994

7-9 (N=24) 116 4444 ~ 656 885
1g-15 (N=27) 26 7005 716 1353

l & .

older (N=l6l) 5 20749 504 1757

The homemakers were asked if any family member had been using
some vitamin pills recently. Although the data does not show which
family members were using them, the information does tell that in
'69 (42.3%) of the families, there was at least one person using some

vitamin supplement.

Nutrition Knowledge

 

The homemakers were interviewed regarding their knowledge of
nutrition. 0n the basis of a score of four for the most appropriate
answer, and descending numbers to one for the least appropriate
answer, each homemaker's responses were evaluated. The mean score was
67.86%, with a range from‘49% to 92% and a standard deviation of
7.67%.

The responses were also examined individually to see what per-
centage of homemakers responded appropriately to each statement. I
Statements.evaluated inappropriately by 75% or more of the home-

makers are listed in Table 16.

36

Table l6.--Nutrition statements missed by 73% or more of the

homemakers (N=l63)

 

Statement
Number

17

19

22

21

l8

15

% Approp.
Responses

6.75

7.96

7.97

11.66

14.11

14.72

15.95

17.79

17.79
20.86

22.09

24.54

Statement

Adults should avoid fat in their diets in
order to prevent heart diseases and strokes.

Lemonade and orange juice have about the
same amounts of vitamin C.

Gelatin desserts are a good source of
protein.

School-age children need to have vitamin
pills every day for good health.

Eating bacon for breakfast is a very good
way to get the protein that is needed
for the day.

Apples have a lot of vitamin C.

A reducing diet should not contain bread
or potatoes.

Most fat children and adults have a
problem with their glands.

Milk is needed mainly by infants and
growing children.

Eating cheese causes constipation.
Healthy, active young children need some
sweets, such as candy or cake, each day

for energy.

Adding soda while cooking vegetables and
dried beans makes them easier to digest.

Eating carrots helps a person see better.

 

37

Nutrition statements answered appropriately by 75% or more

of the homemakers are listed in Table 17.

Table l7.--Nutrition statements answered appropriately by 75% or
more homemakers (N=l63) A

 

Statement % Approp.
Number Responses Statement
1 92.03 Meat, milk, and eggs all have lots of
nutrients which are needed for the
growth of small children.
13 ' ' 88.96 Year-old babies should eat different

kinds of foods, since drinking only milk
may not be enough for growth.

 

Correlations

 

Six.variables were correlated with each other in all possible
, pairs: income; education; adequacy of diet; thiamin; riboflavin:
and nutrition information score, as described in Chapter III, "Analysis
of Data". Nutrition information and educational level showed a
slight positive correlation (Table 18). Thiamin and riboflavin also
showed a positive relationship.

The correlation between educational level and nutrition know-
ledge was significant at the .01 level using regular two-variable
tables. Using tables designed for six variables, the correlation
was not significant.

The correlation between thiamin and riboflavin levels was
significant at the .05 level using a six-variable table. It was
significant at the .01 level using regular two-variable correlation

tables which do not adjust for randomization due to six variables.

38

Table 18.--Correlations between six variables

 

Income 1.0000

Educ. -.0975 1.0000

Diet -.0701 .0334 1.0000

Thia. -.0363 -.0086 .1102 1.0000

Ribo. .0320 .0585 .0762 .3316 1.0000

Nutr. Sc. .1051 .3035 .1341 .0027 .1825 1.000

Income Educ. Diet Thia. Ribo. Nutr. Sc.

 

CHAPTER V

DISCUSSION

The target audience of the Expanded Nutrition Program is
low-income families with young children. The percent distribution
of the families among ethnic groups appears to be consistent with
the Michigan Nutrition Survey (1971) for white families (49.1%) and
the 1967 Bureau of Census, which reported one-third of the poor
families are black. Over one-half of the families (55%) in this
study were receiving public assistance. Although the data is
inconclusive regarding the average age of children in the families,
the average family size (4.5 members) and the average age of the
homemaker (29) would seem to indicate there were young children
living at home.

Nutrition aides often report limited cooking and food storage
facilities. The data indicate that this is apparently not a major
problem with Michigan families. The Rural Electrification Program in
Michigan may account for the presence of electricity in 100% of
the families surveyed. Mothers receiving Aid to Dependent Children
(ADC) assistance are also eligible to be furnished with a refrigera-
tor. Many of the homemakers may be taking advantage of this provision.

The homemaker herself does, by far, the majority of the food
shopping. Nearly 98% were able to shop at a supermarket. The small,

expensive neighborhood stores were a second choice for only 37% of

39

40

the homemakers. This suggests that the low-income homemakers may
not be limited to buying in their own neighborhood, a problem poor
families sometimes face (Meyers, 1970). This was further verified
by the use of the family car or a friend's car by 87% of the home-
makers for grocery shopping. It would appear that these homemakers
were relatively free to shop where they wished.

The availability of a family car or friend or relative's
car for grocery shopping would also seem to refute the idea that
these homemakers were home-bound. The limited participation of
low-income families in group meetings is probably not due to trans-
portation problems, but to other factors.

Cost was the primary factor in influencing food purchases,
followed by family preference. Being "out of" a certain food was
mentioned third most frequently. These data imply that homemakers
may be limiting their food purchases to familiar items, seldom
experimenting with a new food or new method of preparation. Meyers
(1970) suggested that low-income homemakers may be limited in their
knowledge of how to use certain foods. Trying a new product was.
mentioned as influencing food purchases by only 2% of the homemakers.

Low-income families have difficulty taking advantage of
seasonal sales (Meyers, 1970). None of the homemakers surveyed
mentioned the seasonality of food as an influential factor.

Only 1% of the homemakers stated convenience as a factor
in food purchasing, although Seoane's (1971) study of shopping
practices of EFNEP families indicated wide use of convenience foods.
It may be that the homemakers surveyed in Michigan were also making

wide use of convenience items, but were not considering them as such.

41

Analysis of the homemakers' 24-hour food recalls indicated
agreement with other studies of low-income families. The examina-
tion of diets of EFNEP families by the USDA Economic Research
Service (1972) also indicated inadequate use of these feed groups.
Because of the limited use of milk and fruits and vegetables by .
these homemakers, one would expect the diets to be most limiting
in vitamins A and C and the minerals iron and calcium. These
nutrients were also seen to be most limiting in American diets by
Morgan (1959), Brown 6.2 g; (1970), and Hardy at 31 (1943).

These families appeared to have acceptable thiamin excretion
levels. This was surprising in that the Michigan Nutrition Survey
(1971) showed unacceptable thiamin levels for 6% of the population.
The mean levels of thiamin were higher in each age group of this
study than in each age group of the Ten-State Nutrition Survey (1972).
Meyers 23 51 (1968), Erin gt 2; (1965), and Tzeng (1971) also found
unacceptable thiamin excretion levels in their population groups.
Owen gt 3;]; (1969) did not find unacceptable levels.

The riboflavin excretion levels of over 25% of the sample were
low or deficient. This high prevalence of low and deficient values
is surprising because riboflavin levels in other studies were either
acceptable or less deficient than thiamin (Meyers gt_gl, 1968:

Owen 22 21, 1969; Brim gt_gl, 1965: Tzeng, 1971; McGanity, 1969).
The Ten-State Nutrition Survey (1972) revealed that there were
riboflavin deficiencies among blacks and among young people of all
ethnic groups. The mean levels of riboflavin excretions in each
age group were more than those found by this study; The Michigan

Nutrition Survey (1971) showed overall 14% deficient riboflavin

42

excretion levels. It would appear that the very low riboflavin
excretion levels for so many individuals may be due in part to
lower milk consumption.

There are few comparable studies with which to compare the
homemakers' responses to the nutrition statements. Cornely gt 31
(1963) did find that education of the respondent was closely
related to rejection of folk beliefs. Although the correlation
between education and nutrition score in this study does not appear
to be highly significant, this may have been due to the grouping of
homemakers into three educational categories, as explained previously.

It should also be mentioned that although less than 25% of
the homemakers responded appropriately for 13 of the 25 statements,
in several cases a large percentage gave a reaponse very close to
the appropriate one. This was true for the statement, "Adding soda
while cooking vegetables and dried beans makes them.easier to digest",
for which 58% responded either mildly or stronglyjdisagree. The
response "mildly disagree" was considered most appropriate for the
statement, "Milk is needed mainly by infants and growing children".
Although only 18% responded in this manner, 33% strongly disagreed.

One would have expected educational level to correlate with
dietary adequacy (Morse gt El! 1967; Hinton gt_gl, 1963; Hendel
gt 21, 1965; Eppright 22 El: 1970).. There is some evidence, however,
that education may not always be related to dietary adequacy or
nutrition knowledge (Young gt_gl, 1956). It was not surprising
that income did not correlate with dietary adequacy since other

studies have shown this lack of relationship (Young 23 31, 1956;

Hiemstra, 1972; Fryer 23 31, 1971).

43
Limitations 2: the Present Research

1. The inadequacies of the dietary recall have been examined
in the introductory chapter. It was also observed by the author
that different nutrition aides used somewhat different approaches in
obtaining this data. In some cases, the aides were careful to
secure information regarding snacking; in other, cases, they were
not. Nevertheless, the data obtained concur with other studies.

2. The 24-hour food recall data does give some information
regarding the homemaker's food intake, but it provides only a limited
picture of the children's and other family members' food intakes.

It mqy be valid to assume, however, that if the homemaker's diet is
adequate, other family members are likely to have adequate diets.

3. A picture of family nutriture has been obtained for the
vitamins thiamin and riboflavin. Since vitamins A and c and the
minerals iron and calcium are most frequently lacking in American
diets, it would have been desirable to obtain this information.
Since this would have involved a blood sample, it is doubtful that
the high percentage of cooperation would haveresulted.

4. Responses to the nutrition statements represent attitudes
of these homemakers. Although there are some responses which seem
more appropriate than others, the statements do not imply strictly
"right or wrong" answers. There is little with which to compare 3
the results. The nature of homemakers' responses suggest that a
statistical analysis of deviation from the appropriate response

might be very meaningful.

be,

Sums}: an_d Conclusions

This study has provided a picture of the nutritional status
of low-income families and nutrition attitudes of low-income home-
makers as they enter the Expanded Nutrition Program. It has also
revealed cone of the food shopping practices of these fanilies. I

The families did not appear to be restricted to purchasing
food in expensive, neighborhood stores, nor were they limited in
food preparation facilities. The homemaker herself did the majority
of the grocery shopping, and she most frequently chose to shop at a
supermarket. She was influenced by cost, family preference. needing
a food item, and nutritional value.

The diets of these homemakers appeared to be grossly inadequate
as measured by the 24-hour food recalls. Despite rising neat costs,
the majority of the. homemakers consumed the recommnded amount of
meat daily. Milk and fruit and vegetable consumption wasseriously
low. _

The family nutriture with regard to thiamin appeared to be
satisfactory. Riboflavin intake, however, seened to be. a problem
for over one-fourth of the individuals. This may be a reflection of
limited milk consumption. - ‘

I The responses to the nutrition statements revealed that
these horn-alters had limited knowledge of nutrition. There is a
great opportunity for nutrition aides to expand the homemakers '

knowledge a

45
Suggestions for Future Research

This study provided a picture of the Expanded Nutrition
Program families as they entered the program. Since the objective
of the program is to change the homemakers' nutrition practices and
knowledge, it is recommended that these families be re-surveyed after
an interval of six to nine months to assess change. Such a re-survey
is being included in a larger study.

Since the focal point of the Expanded Nutrition Program is
low-income families and families with young children, it is recom-
mended that the income for each family be examined in terms of
size and sex of head of household to determine how many of the
families are at or below the poverty level. Grouping the families
by ages of children would provide a picture of the number of

families with pro-school children.

The school lunch program has improved the nutritional status
of children in low-income areas (Schaefer, 1969; Callahan, 1971).
Determining the availability of a school lunch program would provide
4 direction to nutrition aides as they seek to help the homemakers

improve their families' diets.

BIBLIOGRAPHY

“5
Suggestions for Future Research

3 ’_ This study provided a picture of the Expanded Nutrition .
. Program families as they entered the program. Since the objectiveu
of the program is to change the homemakers' nutrition practices and
knowledge, it is recommended that these families be re-surveyed after
an interval of six to nine months to assess change. Such a re-survey
is being included in a larger study. '
. Since the focal point of the Expanded Nutrition Programis
low-income families and families with young children, it is recom-
mended that the income for each family be examined in terms of g ‘
size and sex of head of household to determine how many of the ‘
fhmilies are at or below the poverty level. Grouping the families
by ages of children would provide a picture of the number of
_ fhmilies with pro-school children.‘
- ' The school lunch program has improved the nutritional status
of children in low-income areas (Schaefer, 1969; Callahan, 197l)..
' hetermining the availability of a school lunch program would provide
. direction to nutrition aides as they seek to help the homemakers

improve their families' diets.

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l+8

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49

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50

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51

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APPENDICES

APPENDIX A

Aide's Family Enrollment Form

APPENDIX A

Aide's Family Enrollment Form'

A. - DESCRIPTION

1. Aide's Name 2. State Number 3. Unit Number

Fill Out For Each Family in Unit As Soon As Possible and Every 6
Months Thereafter. Keep in Family File After Review by Trainer - Agent.

 

 

 

 

 

 

 

 

 

 

4. Family ID Number 5. Date Family Enrolled
a. Name
b. Street 6. Family Received:
c. City d, State a. Food Stamps
e. Urban Rural nonfarm Farm b- FOOd Donation ___
-—— "' c. USDA/FHA Assis
d. welfare

 

 

Family'Members Age Male Female Now In Partic. in
(First Name) Yrs. School School Lunch
(7) (8) (9) (10) (11) Program Last

‘ Week (12) ‘

 

 

 

 

 

 

 

 

 

 

. (Number of Members ) Totals

 

 

 

 

 

13. Highest Grade in School Completed by Homemaker

 

8th grade or less 9th thru 12th Beyond h. s.
14. Check for homemaker
a. White d. American Indian
b. Negro or Black e. Oriental
c. Spanish Surname f. Other

 

15. Date Record Completed or Updated

52

53

B. HOMEMAKER FOOD CONSUMPTION,_FAMILY INCOME, AND FOOD EXPENDITURE
1. Food Record Number 2. Date Taken

 

 

3. What Did Homemaker Eat and Drink in the Last 24 Hours?
To be Filled Out by Aide on Homemaker

Trainer Agent

 

Kind of Food and Drink Milk at VBngr.“BrfEer.

 

 

Morning

 

Midmorning

 

Noon

 

Afternoon

 

Evening

 

Before Bed

 

 

 

 

 

 

income for family 11. Totals 1 or more
185t month servings of each
$ of four food gr. Yes NO
12. Totals—Z or more
servings milk/mid
4 or mere veg/fr
& br/cer. Yes No

 

 

 

 

5. How much did homemaker spend for food last month, including
cash and credit? $ (Do not include value of foods
received under Family Food Donation or other food assistance
programs. If in the Food Stamp Program, include only amount
spent to purchase food stamps or coupons.)

6. If in the Food Stamp Program, what was the value of bonus
stamps received? $

ATTENDIX B

Biological Data Recording Form

County Code __

Family ID Number

Part IIIe

APPENDIX 8

Biological Data Recording Form

 

Familyfilnterview
Date __
Time of dry _
Number of prior aide visits to family

Has anyone in your family been taking vitamin pills in
the last week or so?

no information

no

 

____y°5

If so, who has been taking the vitamin pills? no infor-
mation

YE: No
Pre-school children (ages 0-5) I
School-age children (ages 6-12)
Teen (3) (ages 13-18)
Adult (5) (19 and over)

Who does the grocery shopping for your family most of
the time?

no information children
mother other relative
father non-relative

55

ere do you (or other person) usually shop for your groceries?

3?

no information
supermarket

small neighborhood store
specialty food store

other (specify)

 

How far away from.your home is this store?

no information

less than 1 mile
1-5 miles
6 miles or more

How do you usually get to the store?

no information

family car

neighbor, friend, relative drives their car
walk ‘

{2’

taxi,
bicycle
other (specify) __g

Illlllll

Is there any other store where you occasionally buy groceries?

no information
supermarket
small neighborhood store.
specialty food store
other (specify)

 

56

When you go grocery shopping, there are many, many different kinds of
food you could buy. What kinds of things help you decide what to
(Record 2 responses)

buy?

no information

cost-~whether I can afford it

I or someone in my family likes it

it is

on my grocery list

I am out of it or need it for something special

it is

it is

it is

it is

it is

it is

Iother

on sale

easy to prepare--convenient

a new product someone wanted to try
good for us--nutrition

in season

a specific brand
(specify)

 

57

 

 

 

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County Code

 

Family ID Number

 

Part I. General Family Information

Date aide's first visit

 

Check for residence location: no information
urban
rural non-farm
farm
other

Check for aid received by family: no information

Yes No
USDA Food Stamps
USDA/FHA Assistance
Welfare
Social Security
Other (3 pe cify)

 

 

 

 

 

Total family income for last month $

 

Does the family have a garden? Yes No

Part II. Homemaker Information

Homemaker's age

Check for education of homemaker: no information
8th grade or 1633
9-12 grade
beyond high school
other (specify)

 

Check for background of homemaker:

no information Caucasian
Negro Spanish American
Oriental American Indian

Other (specify)

 

Check for homemaker: no information pregnant
non-pregnant lactating

59

Homemaker's 24-hour food recall (record actual number of servings)
No information

__ Meat group

_____ Milk group

_____.Fruit-vegetable group

Bread-cereal group

Check for equipment available: no information

.122. .E.9_
__ __ Stove/range
______ ______ Oven

Hot plate

Electric frying pan
Freezer
Refrigerator

Ice box
Electricity
Running water

Other (specify)

 

APPENDIX C

Nutrition Information Recording Form

l.

10.

11.

12.

‘ 13.

14 .

15.
16.

SA

SA

SA

SA

SA

SA
SA

SA

SA

SA

SA

SA

APPENDIX C

Nutrition Information Recording Form

SD

SD

SD

SD

Meat, milk, and eggs all have lots of nutrients
which are needed for the growth of small children.

When children have enough food to satisfy their
appetites, they are getting enough nutrients.

Gelatin desserts are a good source of protein.
It is better not to have orange juice and milk
in the same meal because the orange juice

causes the milk to curdle in the stomach.

Eating bacon for breakfast is a very good way to
get the protein that is needed for the day.

School-age children need to have vitamin pills
every day for good health.

A good easy to lose weight is to skip breakfast.

Apples have a lot of vitamin C.

Healthy, active young children need some sweets,
such as candy or cake, each day for energy.

It is best to avoid eating milk and fish together.

Adding soda while cooking vegetables and dried
beans makes them easier to digest.

Dried beans contain many of the same nutrients
as meat.

Year-old babies should eat different kinds of
foods, since drinking only milk may not be enough
for growth.

White bread and cereals that are enriched are
better for both children and adults than those

that are not.
Eating cheese causes constipation

It is important to eat many kinds of foods from
day to day.

60

147.
18.
19.
20.
21.
22.
23.

24,

25.

SA

SA

SA

SA

SA

SA

SA

“5

Ni

MD

SD

SD

SD

61

Adults should avoid fat in their diets in order
to prevent heart diseases and strokes.

Milk is needed mainly by infants and growing
children.

Lemonade and orange juice have about the same
amounts of vitamin C.

Peanut butter is a nutritious food for both
children and adults.

Most fat children and adults have a problem
with their glands.

A reducing diet should not contain bread or
potatoes.

Skim milk has about the same amount of minerals
and protein as whole milk.

Eating carrots helps a person see better.

If a person drinks enough orange juice, he
won't get a cold.

APPENDIX D
l. Interviewing Brocedure for Biological Data

2. Interviewing Procedure for Attitudinal Data

APPENDIX D-l

Interviewing Procedure for Biological Data

“Hello! I am ', a graduate student from
Michigan State University.

"We are adding Something new to the Expanded Nutrition
Program. It is something only for new families now being enrolled.
It is something you can participate in if you want to, but'you
don't- have to. We would like to provide a free mini-health check-up
for the new families. We do this with a urine sample.

"Now, if you've ever gone to the doctor, he's probably asked
you for a urine sample. He probably gave you a cup like this,

(show collection cup) for you to collect the urine in. Sen doctors
test urine with dip-sticks like these (show Labstix). He dips it
into the urine, then checks the colors against those on the bottle
here (show chart on bottle).

"This tells him a few things bout your general health: it
doesn't tell him everything. One thing it does check for is sugar,
though. It also tests for blood in the urine.

"This urine test is very quick and easy to do. We can do it
right here in your home and tell you the results right away. We
feel it is a very good thing to'have done. Would you be interested
in participating in this mini-health check? (Pause) Do you have
any questions? (Pause) I

“After we test the urine here, we would like to take the sample
back to Michigan State University and there we'll check it for
certain vitamins. Your sample will be given a number so no one will

know it's yours. We want to get an idea of how well families in the
62

63

Expanded Nutrition Program are getting these vitamins. We hope this
will help us make the program better for you and other families.
Do you have any questions?

"I would also like to weigh and measure your preschool children,
and I have just a few questions for you.

"Next week when the aide comes, she'd like to bring another '
girl with her. This girl will bring a series of statements about
things like nutrition, children, and education. These are statements
that people have many different opinions about. There are no right
and wrong answers; she'll just be interested in learning how you feel
about these things. Do you have any questions?

"The information which you give us will be combined with that
from other families, but it will never be identified as coming from
a particular person by name. We are interested in ggggp information.
After you hhve worked with the aide for about 9 months or so, I
would like to come back and visit with you again. Would you like to
participate in our project? (If 'yes', proceed.)

"I have to show my supervisor that I was here and have your
permission to do this. I'll read this statement (read permission
slip.) Since you want to participate, would you please sign here?

I'll have the aide sign also."

APPENDIX D-z

Interview Procedure for Attitudinal Data

"We are interested in knowing what you think or feel about
some things. These are things that a lot of people have different
ideas about, but that doesn't mean that any of them are right or
wrong. For example , you and your neighbor or best friend may not
agree about many of them: what we really want to know, then, is
what m think about. each one.

"For each item, I'd like for you to say'whether'you strongly
agree, mildly agree, mildly disagree, or strongly disagree. I have
some cards that have these different responses on them, so you can
look at them while you think about each item and then show me which
one is the closest to your opinion for that item. Here are the cards.
(Present cards in the order SA-MA-MD-SD, labeling each as it is
presented, so that the SA is on the respondent's left and the SD on
her right.)

"I'll also give you a copy of the statements so that you can
follow while I read them if you'd like.

”Let's try a sample item first. For example, if I gave you

this statement --

People generally base their decisions on
past experiences.

-- how would you respond to it? (Be sure that respondent indicates
her response by pointing to a card and verbalizing the response, if
possible, so that you are sure she understands the procedure.

Clarify if necessary.)
"Good. Are there any questions?

64

APPENDIX E
1. Permission Slip

2. Physician Referral Slip

APPENDIX E-l

Permission Slip

Permission--Proof of Home Call

The Expanded Nutrition Evaluation Project has been explained to me .

I am willing to participate and have numbers of my family participate
in the project.

I understand that I will be interview at agreed upon times, that
my young children (if I have any) may be weighed and measured, and
we will be asked to supply urine samples.

 

Homemaker

Aide

 

_Date

65

APPENDIX E-2

Physician Referral Slip

Date: Time:

 

 

To Whom It May Concern:
In doing a routine urinalysis for a research project of the.Expanded

Nutrition Program, subject showed a positive

 

test for . The test was made using Labstix

produced by the Ames Company, a division of the Miles Laboratories.

Signed:

 

Research Assistant

66

MICHIGAN STRTE UNIV. LIBRQRIES

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