Food-Based Science Curriculum Yields Gains in Nutrition Knowledge

Abstract

BACKGROUND:

Students may be receiving less than an average of 4 hours of nutrition instruction per year. Integrating nutrition with other subject areas such as science may increase exposure to nutrition education, while supporting existing academics.

METHODS:

During the 2009–2010 school year, researchers implemented the Food, Math, and Science Teaching Enhancement Resource (FoodMASTER) Intermediate (FMI) curriculum in 18 fourth-grade classrooms, whereas 16 classrooms served as comparison. FMI is a hands-on, integrative curriculum for children in grades 3–5 that uses food as a tool to teach mathematics and science. Researchers developed a 28-item multiple-choice questionnaire to assess students’ nutrition knowledge in 6 content areas. Students were evaluated at baseline and post-intervention. Data were analyzed using independent t tests. Analysis of covariance was employed to control for differences at baseline when assessing the effectiveness of the FMI curriculum to increase nutrition knowledge.

RESULTS:

A significant improvement was observed in total nutrition knowledge at post-intervention (adjusting for baseline) between groups (F [1] = 128.95; p < .01) and in all content areas post-intervention.

CONCLUSIONS:

Findings from this study suggest teachers were successfully able to integrate science and nutrition to meet multiple academic standards. More specifically, results showed implementation of the integrative FMI curriculum effectively improved fourth-graders’ nutrition knowledge compared with students not exposed to FMI.

School nutrition programs can take on many different forms;¹ however, 1 common element is to impact nutrition knowledge. The premise for student acquisition of nutrition knowledge is fundamentally aimed at improving one’s ability to make wise nutritional choices to support healthful living.^2,3 Unfortunately, K-12 education often places minimal emphasis on what students should know about nutrition upon completion of each grade level.⁴ Teaching traditional subject matter (English, mathematics, science, social studies, etc), preparing for end of grade testing, growing class sizes, and decreasing funding all contribute to competition for instructional time.⁵

In 2006, 72% of states required schools to teach concepts related to nutrition and dietary behaviors at the elementary level; however, on average, students received <4 hours of nutrition instruction per year.⁶ Research suggests at least 10–15 hours of classroom-based education is required to produce medium effects (0.51–0.80% of standard deviation) on health knowledge.^7,8 Whereas the aforementioned study specifically focused on general health education, past reviews on nutrition education have reported similar findings.^9,10 Nutrition educators must be creative to address challenges teachers face when teaching nutrition in their classrooms.¹¹

The White House Task Force on Childhood Obesity suggests nutrition concepts be taught through an interdisciplinary approach, for example examining caloric needs while teaching math skills. However, many teachers are not prepared to integrate nutrition concepts into their curricula and may lack basic nutrition knowledge.¹¹ One study reported the majority of teachers (92%) incorporate nutrition education into their classroom; however, 65% of those teachers reported teaching nutrition as a standalone topic.¹² Integrating nutrition with other subject areas such as science may be utilized to increase exposure to nutrition education, while supporting existing academics.¹³

Food and nutrition can serve as a foundation for integrative learning and provide teachers with a vehicle for teaching more difficult subjects to children.^14,15 Children encounter food on a daily basis, resulting in a preexisting contextual experience that creates the foundation for learning new academic content. Food as a teaching tool also allows teachers to use hands-on, integrative learning approaches that emphasize the interconnectedness of nutrition with other content areas, such as science.¹⁶ Despite promising evidence to support the use of food-based learning as a method to help children better understand how to make healthy dietary choices,^17–19 few programs use food in the classroom as a teaching tool. For this reason, there is limited research describing the specific impact of integrative, food-based programs on nutrition knowledge among students.

The current study provides an evaluation of the FMI (grades 3–5) curriculum to determine whether the curriculum positively impacts nutrition knowledge among fourth-grade students. FMI takes an integrative approach to incorporating nutrition education into the classroom. As a science-based curriculum, the program uses food as a teaching tool to engage students in integrative learning related to both science and nutrition content. Researchers hypothesized students exposed to the food-based FMI curriculum would show greater nutrition knowledge at post-intervention compared with children who were not exposed to FMI.

METHODS

During the 2009–2010 academic year, researchers used a quasi-experimental design to implement the FMI curriculum in fourth-grade classrooms in Ohio (OH) and North Carolina (NC). Researchers utilized a baseline/post-intervention method to assess the impact of the FMI curriculum on nutrition knowledge among fourth-grade students.

Participants

Researchers recruited 18 fourth-grade classrooms (OH=9; NC=9) to implement FMI curriculum (I=Intervention) and 16 fourth-grade classrooms (OH=8; NC=8) to act as comparison classrooms (C=Comparison). Of the participating schools, 16 classrooms were rural (I=8; C=8) and 18 classrooms were urban/suburban (I=10; C=8). School administrators (ie, principals, curriculum coordinators) recommended teachers who would be willing to volunteer for the study by implementing the FMI curriculum in their classroom. After identification of each teacher, researchers asked comparison teachers in the same school district, or a nearby district, to volunteer.

Researchers asked teachers to provide parents with informed consent explaining the FMI curriculum, purpose of the study, and data to be collected. Assent also was obtained from each consented student prior to data collection. Although all students from the 18 intervention classrooms were exposed to FMI activities, only students with signed parental consent and student assent forms were entered into the study. Teachers provided researchers with demographic information including sex, date of birth, and ethnicity for participating students. On average, students were 10 years of age (I=10.04, SD=0.56; C=9.90, SD=0.49) and just over half were female (I=54.0% female; C=52.3% female). Students also were classified primarily as white (75.1%), with the remaining the students being black/African American (17.4%), Hispanic or Latino (4.6%), and other (2.9%).

Researchers enrolled a total of 762 students in the study (NC=330; OH=432). Students in both the intervention and comparison classrooms completed researcher-developed nutrition knowledge questionnaires at baseline and post-intervention. At the beginning of the academic year, 684 students (I=396; C=288) completed the nutrition knowledge questionnaire, whereas 645 students (I=373; C=272) completed the questionnaire at the end of the year. Of the larger sample, authors included only data from students who completed both baseline and post-intervention questionnaires (N=473), resulting in 285 students in the intervention group and 188 students in the comparison group. On the basis of enrollment at the beginning of the academic year, the overall rate of usable instruments for the analysis was 72% for the intervention group and 65% for the comparison group. Reasons for not completing the nutrition knowledge questionnaire at both baseline and post-intervention were primarily due to student absenteeism on the day of questionnaire administration. Absenteeism can be attributed to factors such as illness, changing schools, entering the school midyear, or other excused reasons.

Instruments

Three Registered Dietitians collaborated to develop the 28-item multiple-choice questionnaire to assess student nutrition knowledge (Table 1). A complete review of the literature revealed no existing validated nutrition knowledge questionnaires for intermediate students that addressed all key nutrition concepts presented in the curriculum. Subsequently, researchers designed a questionnaire with 6 major subject content areas: food groups, whole-grains, fats, food safety, micronutrients, and food labels. Researchers developed 3 to 4 items for each content area, with the exception of food groups. Because the curriculum focused more heavily on food groups, 8 items were developed relating to classification of foods and identification of amounts needed per day. Reviewers of the FMI curriculum (1 pediatrician, 2 education professors, and 5 food and/or nutrition professors) also reviewed the questionnaire for content and face validity. Additionally, 10 fourth-grade teachers reviewed the tool for content and age appropriateness prior to administration.¹⁶ Minor revisions were made to the questionnaire and readability was assessed at a 3.4 grade level using the Flesh-Kincaid formula.

Table 1.

Nutrition Knowledge Percent (%) Correct Scores for Individual Items on Baseline and Post-Intervention (N=473)

	Baseline		Post-Intervention*
Questions	Intervention (%)	Control (%)	Intervention (%)	Control (%)
Food groups
1. Which food belongs to the grain group?	82.46	77.13	89.40	82.45
2. Which food belongs to the fruit group?	91.58	88.83	92.98	91.49
3. What meal has the most vegetables?	73.33	69.15	78.25	75.53
4. Which food belongs in the meat and beans group?	60.70	51.60	71.93	52.13
5. Which dinner has foods from all five-food groups?	64.56	50.53	75.44	67.02
6. Which meal has the most foods from the milk group?	83.16	81.38	88.07	83.51
7. How many cups of vegetables should you eat a day?	37.54	29.26	67.37	31.91
8. How many cups of milk should you drink a day?	40.35	36.17	58.95	37.77
Whole grains
9. Which ingredient is a whole grain?	38.95	35.11	70.18	44.15
10. Which food is a whole grain?	55.09	46.28	72.28	53.72
11. Which food is a good source of fiber?	47.37	38.83	47.02	48.94
12. Why is whole-wheat pasta healthier than regular pasta?	52.98	44.68	67.37	50.00
13. What are the parts of whole grain?	17.54	14.36	63.86	11.70
Fats
14. Which ground beef is healthier?	28.42	31.38	54.04	30.85
15. Which food is a good source of omega-3 fatty acids?	33.33	23.94	75.44	33.51
16. Which salad dressing is healthiest?	74.39	69.15	86.67	73.40
17. Which fat or oil is the healthiest?	43.16	39.36	54.04	41.49
Food safety
18. How long should you wash your hands?	63.16	51.06	94.39	62.23
19. Is it safe to eat raweggs?	10.88	11.70	13.33	24.47
20. What are the biggest movers of bacteria?	70.53	57.98	92.28	68.09
21. What is it called when someone gets sick from eating food containing harmful microorganisms?	36.84	40.43	60.35	43.09
Micronutrients
22. Which nutrient is found in milk?	45.96	40.96	64.56	44.15
23. Which vitamin is found in orange vegetables (such as carrots)?	43.51	40.43	53.33	22.87
24. Which food is a good source of calcium?	50.18	47.34	64.56	55.32
Food labels†
25. What is the serving size for Toasted Oats?	86.32	77.13	94.74	85.64
26. How many grams of fiber are in 1 serving of toasted oats cereal?	74.39	65.43	81.75	69.68
27. How many grams of total fat are in 1 serving of toasted oats cereal?	68.42	61.17	83.86	74.47
28. How many calories are in 1 serving of toasted oats cereal?	74.74	71.28	85.26	75.53

^*Post-intervention % correct scores do not control for baseline scores.

^†Items with content subscale was presented with a corresponding food label to assess label reading and comprehension skills.

Researchers evaluated nutrition knowledge at baseline and post-intervention in intervention and comparison classrooms. The knowledge assessment was group administered by participating teachers in each classroom and completed individually by students. To facilitate administration of the questionnaire, a standardized administration protocol was developed. The protocol gave specific instructions for administration including a standard script to be read aloud to students. Researchers instructed teachers to answer student questions if clarification was needed, but to not provide students with the answers. The questionnaire was administered in intervention classrooms prior to beginning the FMI curriculum to obtain baseline knowledge. Administration of the nutrition knowledge questionnaire at baseline and post-intervention was completed in comparison classroom in the same time frame as their paired intervention classroom.

Procedure

The FoodMASTER Initiative is a compilation of educational programs for K-12 students, including FMI, that integrate food and nutrition-based content with science learning. Authors rooted the educational foundation of the program in the constructivist learning theory, which states that knowledge is not transferred, but rather “constructed” from prior experiences and understanding.²⁰ Programs that build on children’s past experiences are more meaningful than programs that teach concepts that are not relevant to everyday life.²¹ A team of experts including dietitians, food scientists, and teachers, reviewed and developed the FMI curriculum. In 2007–2008, FMI was pilot-tested in 10 third-grade classrooms in southeast Ohio. Teachers and students reported the curriculum experience as meaningful and engaging. Participating teachers informed the revision and further development of the FMI curriculum.¹⁶ The final science-based resource is comprised of 10 chapters featuring 24, 45-minute hands-on lessons that cover basic concepts relevant to food and nutrition education: Measurement; Food Safety; Vegetables; Fruits; Milk and Cheese; Meat, Poultry and Fish; Eggs; Fats; Grains; and Meal Management (Figure 1). Each chapter contains at least 1 hands-on classroom experiment that illustrates a science concept related to food and nutrition.²²

Figure 1.

FoodMASTER Intermediate (FMI) Lesson Descriptions and Aligned National Science Education Standards (NSES).

All lessons met at least 1 national science education standard for grades 3 to 5.²² In addition to other science standards, FMI specifically aligns to the state-mandated National Science Education (NSE) content standard Science in Personal and Social Perspectives to integrate science and nutrition concepts. Within this standard, teachers are expected to provide students with an understanding of their personal health and skill sets that may help them better understand personal and social issues related to health, for example decision making skills.²³ Although there were no national standards for nutrition education at the time of the study, NC followed state-adopted Healthful Living Standards with content areas focused on a variety of health topics, for example alcohol, tobacco, nutrition, physical activity. Specific standards related to nutrition education were associated with MyPyramid, food safety, and label reading.²⁴ OH reportedly did not follow additional nutrition or health standards apart from those addressed in the NSE content standard previously described. Researchers did not assess the level to which comparison teachers followed and/or implemented science or nutrition content standards.

Intervention Classrooms

At the beginning of the academic year, researchers met with participating classroom teachers to describe the educational program components and evaluation procedures. Participating teachers committed to implementing all 24 food-based FMI lessons in their classrooms over the 2009–2010 academic year. FMI supplemented the existing fourth-grade curricula by engaging students in food-based activities that integrated science and nutrition content. To ensure fidelity of curriculum implementation, intervention teachers were provided with all materials needed to teach each lesson including a teacher’s manual, classroom set of student workbooks, online access to curricular materials, equipment (eg, toaster ovens, hotplates), kitchen supplies, nonperishable food items, and gift cards for purchasing perishable foods needed for lessons throughout the academic year. Intervention teachers were allowed to implement the curriculum at their own pace, but were asked to complete all the lessons 1 month before the end of the academic year.

Comparison Classrooms

At the beginning of the academic year, researchers visited comparison classrooms to describe the evaluation procedures. Comparison teachers did not incorporate the FMI curriculum into their lesson plans; however, eligible children within these classrooms completed the nutrition knowledge questionnaire at the beginning and end of the academic year. Students in the comparison group were only exposed to the existing fourth-grade curricula, as determined by individual teachers and state-mandated educational standards for science and nutrition content. Researchers did not document comparison classroom activities, such as nutrition-related lessons that may have been included in each teacher’s curricula. However, teachers verbally reported they did not use food as a tool to teach science and nutrition integratively in their classrooms. At the conclusion of the study, comparison teachers were provided with a FMI teacher’s manual, student workbook, and online access to curricular materials.

Data Analysis

Descriptive statistics were utilized to report student demographics and percent correct on individual questionnaire items. Correct answers received a score of 1 for a total possible score of 28; to obtain percentiles, total scores were divided by 28 to reflect percent correct. Researchers also conducted an independent t-test to explore the differences between the intervention and comparison groups at baseline for total nutrition knowledge scores. The groups were determined to be statistically different (p≤.05) at baseline. Therefore, authors employed analysis of covariance (ANCOVA) to control for differences at baseline when assessing the effectiveness of the FMI curriculum to increase nutrition knowledge. The dependent variable was students’ scores on the post-intervention version of the nutrition knowledge questionnaire and the independent variable was the level of intervention (intervention versus no intervention). Student baseline scores on the nutrition knowledge questionnaire were included as a covariate in this analysis. Researchers performed all statistical analyses using the IBM Statistical Package for the Social Sciences 21.0 (IBM SPSS, 2012). All p values less than or equal to .05 were considered statistically significant.

RESULTS

Table 1 presents the questions within the nutrition knowledge questionnaire (divided by subject content area) and summarizes the descriptive results of nutrition knowledge percent correct scores for individual items at baseline and post-intervention. Researchers reviewed percent correct to explore knowledge gains between baseline and post-intervention on individual questionnaire items in both groups. The intervention group showed an increase in 27 out of 28 items from baseline to post-intervention. Overall, in the intervention group, nutrition knowledge improved by an average of 16.75 percentage points, ranging from 1.4 (item 2) to 46.32% (item 13) (SD=11.53). One question showed a decline in knowledge by 0.35% (item 19). The comparison group displayed an average improvement of 6.23% (SD=3.66) on 25 questions, ranging from 0.53 (item 4) to 16.49 (item 5). Three questions showed a decline in knowledge, from 0.53 (item 14) to 17.56% (item 23) (μ = −6.74; SD=9.40).

After controlling for baseline scores, there was a statistically significant difference in nutrition knowledge scores between the intervention and comparison groups at post-test: F (df=1)=128.95, p<.001. The partial η-squared suggested that 21.5% of the variance in post-test nutrition knowledge scores was explained by the intervention received (FMI). Baseline and post-test scores for the intervention and comparison groups are reported in Figure 2. At baseline and post-test, the intervention group’s nutrition knowledge score was higher compared to the comparison group. Table 2 summarizes the results of nutrition knowledge scores by subject content area at baseline and post-intervention. The intervention group showed significantly higher knowledge in 4 content areas at baseline, and all 6 content areas at post-intervention relative to the comparison group. After controlling for the observed baseline differences, the intervention group still maintained significantly higher scores on all subject content areas compared to the comparison group (Table 3).

Figure 2.

Intervention Versus Comparison Group Total Nutrition Knowledge Scores at Baseline and Post-Intervention for Fourth-Grade Students (28 questions).

Table 2.

Nutrition Knowledge Mean Scores by Subject Content Area at Baseline and Post-Intervention (N=473)

		Baseline			Post-Intervention
		Intervention	Control		Intervention	Control
Subject Content Area	Total Possible Score	Mean (SD)		t†	Mean (SD)		t†
Food groups	8	5.34 (1.56)	4.84 (1.59)	3.36*	6.22 (1.55)	5.22 (1.52)	6.96**
Whole grains	5	2.11 (1.17)	1.79 (1.20)	2.94*	3.20 (1.39)	2.09 (1.19)	9.12**
Fats	4	1.79 (1.03)	1.64 (0.97)	1.63	2.70 (1.09)	1.79 (0.98)	9.24**
Food safety	4	1.81 (0.91)	1.61 (0.98)	2.29*	2.60 (0.69)	1.98 (0.99)	8.07**
Micronutrient	3	1.40 (0.90)	1.29 (0.99)	1.24	1.82 (0.97)	1.22 (0.92)	6.73**
Food labels	4	3.04 (1.07)	2.75 (1.18)	2.75*	3.46 (0.84)	3.05 (1.12)	4.46**

^*p<.05,

^**p<.001.

^†df=471.

Table 3.

Nutrition Knowledge Mean Scores by Subject Content Area for Post-Intervention (N=473) After Controlling for Baseline Scores

	Post-Intervention
	Intervention	Control
Subject Content Area	Mean (SE)	Mean (SE)	F†	η2‡
Food groups	6.15 (0.08)	5.34 (0.10)	36.61*	0.07
Whole grains	3.18 (0.08)	2.13 (0.09)	74.20*	0.14
Fats	2.69 (0.06)	1.81 (0.08)	82.11*	0.15
Food safety	2.58 (0.05)	2.01 (0.06)	59.16*	0.11
Micronutrient	1.81 (0.05)	1.24 (0.07)	25.67*	0.09
Food labels	3.42 (0.05)	3.12 (0.06)	13.02*	0.03

^*p≤.001.

^†df=2.1.

^‡η² is a measure of effect size for analysis of covariance.

DISCUSSION

The purpose of this study was to examine the impact of FMI, an integrative, food-based curriculum, on fourth-grade students’ nutrition knowledge. Whereas the school setting may be an ideal environment to implement nutrition education for children,²⁵ the growing pressure to demonstrate improved academics in traditional subjects, such as science and mathematics, leaves little time for supplemental content, such as nutrition education.²⁶ Serving a 2-fold purpose for public schools,²⁷ findings from this study suggest teachers were successfully able to integrate science and nutrition to meet multiple academic standards. More specifically, results showed implementation of the FMI curriculum effectively improved nutrition knowledge among fourth-grade students compared with classrooms where students did not experience FMI. Similar nutrition knowledge increases have been observed among elementary students exposed to school-based nutrition education programs.^28–32

Although the intervention group’s scores tended to be higher at baseline, review of individual items revealed the intervention group demonstrated greater improvement on most nutrition knowledge questions relative to the comparison group. More importantly, the intervention group also showed larger gains in nutrition knowledge within each subject content area. In the intervention group, the largest gains in knowledge were observed in Whole Grain, Fats, and Food Safety. These subject content areas may represent new topics in nutrition education for this grade level. This theory is partially supported by the standards for nutrition in NC’s Healthful Living Standards, which emphasize food safety concepts such as foodborne illness and hand washing.²⁴

Interestingly, both groups performed poorly on item 16 within the Food Safety content area at baseline and post-intervention. The comparison group demonstrated greater gains in knowledge for this item, whereas students exposed to the curricula showed only slight improvement (<3%). FMI includes a chapter emphasizing food safety within the curriculum; nevertheless, it is possible that FMI students were confused regarding raw egg consumption after also being exposed to another chapter featuring eggs. Throughout the chapter students are warned of the dangers of raw consumption and potential foodborne illness. However, based on our results, more education in the realm of raw egg consumption and foodborne illness may be needed for students and teachers when using food-based learning involving these food items.

The intervention group showed smaller gains in knowledge baseline to post-intervention in the content areas of Food Groups and Food Labels. Students’ showed higher levels of competency in these areas at baseline leaving little room for improvement; however, the gain in knowledge for Food Groups and Food Labels was still greater than the comparison group by 0.7 and 2.9%, respectively. Review of individual items also supports these findings; both groups performed highest on most of the Food Group questions at baseline, particularly item 2 (“Which food belongs to the fruit group?”). Other studies have reported food groups as one of the most common topics taught in the classroom.^12,28

The comparison group demonstrated much smaller gains in knowledge compared to the intervention group for all subject content areas. The largest gain in knowledge occurred in Food Safety (9%); however, this gain was still much smaller than the intervention group, which demonstrated a 20% gain in knowledge for the same content area. Interestingly, micronutrients demonstrated a decline in knowledge by approximately 2%, indicating no or ineffective education relating to this content area occurred in the comparison classrooms. The percent correct score in the intervention group was also lower compared to the other content areas at post-testing. However, the FMI curriculum was still effective at increasing knowledge of micronutrients, producing a 14% gain. Other studies have reported nutrients in food as a common topic taught in the classroom;¹² however, our results suggest micronutrients might be difficult for fourth-grade children to understand and/or may require greater curricular attention to improve educational outcomes. Further refinement of the curriculum may be needed to produce larger gains in knowledge within this content area.

Limitations

Students who received the FMI were exposed to an average of 18 hours of food-based education over the academic year, making dosage a strength in this study. The School Health Education Evaluation reported that 10–15 hours of education are needed to observe significant changes in program-specific knowledge.⁷ FMI students were exposed to an adequate amount of education to impact knowledge as evidenced by observed knowledge gains for overall nutrition knowledge (p<.001) and specific nutrition knowledge content areas. Integrating nutrition content into science likely enabled students to receive more nutrition education over the academic year. Authors are unsure how much nutrition education children in the comparison classrooms received; however, past research has indicated teachers are only providing an average of 3.4 hours of nutrition education per year.³³

Finally, this study was limited by 3 primary factors. First, randomized control studies are often not always feasible in K-12 settings. Teachers who volunteered to implement FMI may have characteristics different from nonparticipating teachers, including comparisons classrooms used in this study. These differences may affect our observed outcomes.³⁴ Second, researchers did not measure the academic activities of comparison classrooms, such as nutrition education that may have been provided as a component of each teacher’s curriculum. However, researchers are confident that these classrooms did not use food as a tool to teach science and nutrition integratively. Third, there are no specific national standards for fourth-grade nutrition knowledge making it difficult for researchers to develop a generalized questionnaire. The lack of nutrition education standards makes it challenging to develop evaluation materials.

Conclusions

After being exposed to the FMI curriculum, the intervention group displayed significant knowledge improvements relative to the comparison group, indicating a meaningful impact on the intervention group related to the FMI curriculum. Outcomes indicate the integrative FMI curriculum was more effective at educating students in the assessed subject content areas compared to comparison classrooms following traditional science curricula. Future research will explore the effectiveness of this integrative hands-on approach to improve student knowledge within other content areas and nutrition knowledge among students within other age groups.

IMPLICATIONS FOR SCHOOL HEALTH

The release of the new Math and English Language Arts Common Core Standards³⁵ and the Next Generation Science Standards,³⁶ provide the ideal environment for the creation of integrative standards for nutrition education. Nutrition educators may be more successful in promoting nutrition education in schools by using a guided integrative approach that is supportive of teacher’s academic goals.²⁷ Collaborations between nutrition professionals and teachers may be useful in the alignment of nutrition content with existing standards at the K-12 level, providing clear guidance for sequential nutrition education. Access to aligned nutrition education standards will enable teachers to provide the quality nutrition education needed to prepare students with the knowledge and skill sets necessary to lead healthy lives. Future research should assess the effectiveness of an integrative approach by exploring the impact of subject integration on the improvement of knowledge and skills in other subjects (eg, science, math). Additionally, research is needed to better understand the impact of an integrative approach to nutrition education in other grade levels.