Interventions designed to increase adult fruit and vegetable intake can be effective: a systematic review of the literature

Development of exchange lists for Mediterranean and Healthy Eating diets: implementation in an intervention trial

BACKGROUND

There has been little research published on the adaptation of diabetic exchange list diet approaches for the design of intervention diets in health research despite their clinical utility. The exchange list approach can provide clear and precise guidance on multiple dietary changes simultaneously. The present study aimed to develop exchange list diets for Mediterranean and Healthy Eating, and to evaluate adherence, dietary intakes and markers of health risks with each counselling approach in 120 subjects at increased risk for developing colon cancer.

METHODS

A randomised clinical trial was implemented in the USA involving telephone counselling. The Mediterranean diet had 10 dietary goals targeting increases in mono-unsaturated fats, n-3 fats, whole grains and the amount and variety of fruits and vegetables. The Healthy Eating diet had five dietary goals that were based on the US Healthy People 2010 recommendations.

RESULTS

Dietary compliance was similar in both diet arms, with 82-88% of goals being met at 6 months, although subjects took more time to achieve the Mediterranean goals than the Healthy Eating goals. The relatively modest fruit and vegetable goals in the Healthy Eating arm were exceeded, resulting in fruit and vegetable intakes of approximately eight servings per day in each arm after 6 months. A significant (P < 0.05) weight loss and a decrease in serum C-reactive protein concentrations were observed in the overweight/obese subgroup of subjects in the Mediterranean arm in the absence of weight loss goals.

CONCLUSIONS

Counselling for the Mediterranean diet may be useful for both improving diet quality and for achieving a modest weight loss in overweight or obese individuals.

Eight-month postprogram completion: change in risk factors for chronic disease amongst participants in a 4-month pedometer-based workplace health program

OBJECTIVE

To evaluate whether participation in a 4-month, pedometer-based, physical activity, workplace health program is associated with long-term sustained improvements in risk factors for type 2 diabetes and cardiovascular disease, 8 months after the completion of the program.

DESIGN AND METHODS

A sample size of 720 was required. 762 Australian adults employed in primarily sedentary occupations and voluntarily enrolled in a workplace program were recruited. Demographic, behavioral, anthropometric and biomedical measurements were completed at baseline, 4 and 12 months.

RESULTS

About 76% of participants returned at 12 months. Sustained improvements at 12 months were observed for self-reported vegetable intake, self-reported sitting time and independently measured blood pressure. Modest improvements from baseline in self-reported physical activity and independently measured waist circumference at 12 months indicated that the significant improvements observed immediately after the health program could not be sustained. Approximately half of those not meeting guidelines for physical activity, waist circumference and blood pressure at baseline, were meeting guidelines at 12 months.

CONCLUSIONS

Participation in this 4-month, pedometer-based, physical activity, workplace health program was associated with sustained improvements in chronic disease risk factors at 12 months. These results indicate that such programs can have a long-term benefit and thus a potential role to play in population prevention of chronic disease.

A 10-Week Multimodal Nutrition Education Intervention Improves Dietary Intake among University Students: Cluster Randomised Controlled Trial

The aim of the study was to evaluate the effectiveness of implementing multimodal nutrition education intervention (NEI) to improve dietary intake among university students. The design of study used was cluster randomised controlled design at four public universities in East Coast of Malaysia. A total of 417 university students participated in the study. They were randomly selected and assigned into two arms, that is, intervention group (IG) or control group (CG) according to their cluster. The IG received 10-week multimodal intervention using three modes (conventional lecture, brochures, and text messages) while CG did not receive any intervention. Dietary intake was assessed before and after intervention and outcomes reported as nutrient intakes as well as average daily servings of food intake. Analysis of covariance (ANCOVA) and adjusted effect size were used to determine difference in dietary changes between groups and time. Results showed that, compared to CG, participants in IG significantly improved their dietary intake by increasing their energy intake, carbohydrate, calcium, vitamin C and thiamine, fruits and 100% fruit juice, fish, egg, milk, and dairy products while at the same time significantly decreased their processed food intake. In conclusion, multimodal NEI focusing on healthy eating promotion is an effective approach to improve dietary intakes among university students.

Determinants of inadequate fruit and vegetable consumption amongst Portuguese adults

BACKGROUND

A low consumption of fruit and vegetables (F&V) represents a high burden on health. The present study evaluates sociodemographic, lifestyle and anthropometric determinants of an inadequate consumption of F&V (<5 servings per day).

METHODS

Participants were randomly selected within the adult Porto population (n = 2485). Those with normal cognitive function and information on key variables were analysed (n = 2362). Diet was assessed by a validated food frequency questionnaire. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by logistic regression, after sex stratification and controlling for age, education, marital status, smoking, regular physical exercise and total energy intake.

RESULTS

Older women and men had 37% and 67%, respectively, lower odds of inadequate F&V consumption (≥65 versus <40 years: OR = 0.63, 95% CI = 0.42-0.94; OR = 0.33, 95% CI = 0.20-0.56). More educated subjects (>12 versus <5 years) and those engaged in regular physical exercise had approximately 50% lower probability of F&V inadequacy compared to nonpractitioners, and this was similar in both sexes. On the other hand, female and male current smokers had 1.86- and 2.05-fold higher probabilities of having inadequate F&V consumption. Individuals consuming excessive alcohol (women: ≥15 g day(-1) ; men: ≥30 g day(-1) ) presented a two- and four-fold higher probability of having inadequate F&V consumption compared to nondrinkers (OR = 1.95, 95% CI = 1.38-2.77 in women; OR = 4.40, 95% CI = 2.70-7.18 in men).

CONCLUSIONS

In both sexes, an inadequate consumption of F&V was more frequently found in younger, less educated and less physically active subjects with smoking and drinking habits. Strategies aiming to increase F&V consumption should consider these target groups that present a clustering of unhealthy lifestyles.

Increased exposure to community-based education and 'below the line' social marketing results in increased fruit and vegetable consumption

OBJECTIVE

To determine if localised programmes that are successful in engaging the community can add value to larger fruit and vegetable mass-media campaigns by evaluating the results of the Eat It To Beat It programme.

DESIGN

The Eat It To Beat It programme is a multi-strategy intervention that uses community-based education and ‘below the line’ social marketing to increase fruit and vegetable consumption in parents. This programme was evaluated by a controlled before-and-after study with repeat cross-sectional data collected via computer-assisted telephone interviews with 1403 parents before the intervention (2008) and 1401 following intervention delivery (2011).

SETTING

The intervention area was the Hunter region and the control area was the New England region of New South Wales, Australia.

SUBJECTS

Parents of primary school-aged children (Kindergarten to Year 6).

RESULTS

The programme achieved improvements in knowledge of recommended intakes for fruit and vegetables and some positive changes in knowledge of serving size for vegetables. Exposure to the programme resulted in a net increase of 0.5 servings of fruit and vegetables daily for those who recalled the programme compared with those who did not (P = 0.004). Increased intake of fruit and vegetables was significantly associated with increasing exposure to programme strategies.

CONCLUSIONS

The Eat It To Beat It programme demonstrates that an increase in consumption of fruit and vegetables can be achieved by programmes that build on the successes of larger mass-media and social-marketing campaigns.This suggests that funding for localised, community-based programmes should be increased.

Diet and physical activity for the prevention of noncommunicable diseases in low- and middle-income countries: a systematic policy review

BACKGROUND

Diet-related noncommunicable diseases (NCDs) are increasing rapidly in low- and middle-income countries (LMICs) and constitute a leading cause of mortality. Although a call for global action has been resonating for years, the progress in national policy development in LMICs has not been assessed. This review of strategies to prevent NCDs in LMICs provides a benchmark against which policy response can be tracked over time.

METHODS AND FINDINGS

We reviewed how government policies in LMICs outline actions that address salt consumption, fat consumption, fruit and vegetable intake, or physical activity. A structured content analysis of national nutrition, NCDs, and health policies published between 1 January 2004 and 1 January 2013 by 140 LMIC members of the World Health Organization (WHO) was carried out. We assessed availability of policies in 83% (116/140) of the countries. NCD strategies were found in 47% (54/116) of LMICs reviewed, but only a minority proposed actions to promote healthier diets and physical activity. The coverage of policies that specifically targeted at least one of the risk factors reviewed was lower in Africa, Europe, the Americas, and the Eastern Mediterranean compared to the other two World Health Organization regions, South-East Asia and Western Pacific. Of the countries reviewed, only 12% (14/116) proposed a policy that addressed all four risk factors, and 25% (29/116) addressed only one of the risk factors reviewed. Strategies targeting the private sector were less frequently encountered than strategies targeting the general public or policy makers.

CONCLUSIONS

This review indicates the disconnection between the burden of NCDs and national policy responses in LMICs. Policy makers urgently need to develop comprehensive and multi-stakeholder policies to improve dietary quality and physical activity.

Reducing high calorie snack food in young adults: a role for social norms and health based messages

Background

Consumption of high calorie junk foods has increased recently, especially among young adults and higher intake may cause weight gain. There is a need to develop public health approaches to motivate people to reduce their intake of junk food.

Objective

To assess the effect of health and social norm messages on high calorie snack food intake (a type of junk food) as a function of usual intake of junk food.

Design

In a between-subjects design, 129 young adults (45 men and 84 women, mean age = 22.4 years, SD = 4.5) were assigned to one of three conditions: 1) a social norm condition, in which participants saw a message about the junk food eating habits of others; 2) a health condition, in which participants saw a message outlining the health benefits of reducing junk food consumption and; 3) a control condition, in which participants saw a non-food related message. After exposure to the poster messages, participants consumed a snack and the choice and amount of snack food consumed was examined covertly. We also examined whether usual intake of junk food moderated the effect of message type on high calorie snack food intake.

Results

The amount of high calorie snack food consumed was significantly lower in both the health and the social norm message condition compared with the control message condition (36% and 28%, both p < 0.05). There was no significant difference in snack food or energy intake between the health and social norm message conditions. There was no evidence that the effect of the messages depended upon usual consumption of junk food.

Conclusions

Messages about the health effects of junk food and social normative messages about intake of junk food can motivate people to reduce their consumption of high calorie snack food.

Increased consumption of fruit and vegetables for the primary prevention of cardiovascular diseases

EDITORIAL NOTE

This Cochrane Review has been superseded by a review entitled Vegan dietary pattern for the primary and secondary prevention of cardiovascular diseases (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013501.pub2/full) https://pubmed.ncbi.nlm.nih.gov/33629376/

BACKGROUND

There is increasing evidence that high consumption of fruit and vegetables is beneficial for cardiovascular disease (CVD) prevention.

OBJECTIVES

The primary objective is to determine the effectiveness of i) advice to increase fruit and vegetable consumption ii) the provision of fruit and vegetables to increase consumption, for the primary prevention of CVD.

SEARCH METHODS

We searched the following electronic databases: The Cochrane Library (2012, issue 9-CENTRAL, HTA, DARE, NEED), MEDLINE (1946 to week 3 September 2012); EMBASE (1980 to 2012 week 39) and the Conference Proceedings Citation Index - Science on ISI Web of Science (5 October 2012). We searched trial registers, screened reference lists and contacted authors for additional information where necessary. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials with at least three months follow-up (follow-up was considered to be the time elapsed since the start of the intervention) involving healthy adults or those at high risk of CVD. Trials investigated either advice to increase fruit and vegetable intake (via any source or modality) or the provision of fruit and vegetables to increase intake. The comparison group was no intervention or minimal intervention. Outcomes of interest were CVD clinical events (mortality (CVD and all-cause), myocardial infarction (MI), coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA), angiographically-defined angina pectoris, stroke, carotid endarterectomy, peripheral arterial disease (PAD)) and major CVD risk factors (blood pressure, blood lipids, type 2 diabetes). Trials involving multifactorial lifestyle interventions (including different dietary patterns, exercise) or where the focus was weight loss were excluded to avoid confounding.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias. Trials of provision of fruit and vegetables were analysed separately from trials of dietary advice.

MAIN RESULTS

We identified 10 trials with a total of 1730 participants randomised, and one ongoing trial. Six trials investigated the provision of fruit and vegetables, and four trials examined advice to increase fruit and vegetable consumption.The ongoing trial is examining the provision of an avocado-rich diet.The number and type of intervention components for provision, and the dietary advice provided differed between trials.None of the trials reported clinical events as they were all relatively short term. There was no strong evidence for effects of individual trials of provision of fruit and vegetables on cardiovascular risk factors, but trials were heterogeneous and short term. Furthermore, five of the six trials only provided one fruit or vegetable. Dietary advice showed some favourable effects on blood pressure (systolic blood pressure (SBP): mean difference (MD) -3.0 mmHg (95% confidence interval (CI) -4.92 to -1.09), diastolic blood pressure (DBP): MD -0.90 mmHg (95% CI -2.03 to 0.24)) and low-density lipoprotein (LDL) cholesterol but analyses were based on only two trials. Three of the 10 included trials examined adverse effects, which included increased bowel movements, bad breath and body odour.

AUTHORS' CONCLUSIONS

There are very few studies to date examining provision of, or advice to increase the consumption of, fruit and vegetables in the absence of additional dietary interventions or other lifestyle interventions for the primary prevention of CVD. The limited evidence suggests advice to increase fruit and vegetables as a single intervention has favourable effects on CVD risk factors but more trials are needed to confirm this.

ShopSmart 4 Health - protocol of a skills-based randomised controlled trial promoting fruit and vegetable consumption among socioeconomically disadvantaged women

Background

There is a need for evidence on the most effective and cost-effective approaches for promoting healthy eating among groups that do not meet dietary recommendations for good health, such as those with low incomes or experiencing socioeconomic disadvantage. This paper describes the ShopSmart 4 Health study, a randomised controlled trial conducted by Deakin University, Coles Supermarkets and the Heart Foundation, to investigate the effectiveness and cost-effectiveness of a skill-building intervention for promoting increased purchasing and consumption of fruits and vegetables amongst women of low socioeconomic position (SEP).

Methods/design

ShopSmart 4 Health employed a randomised controlled trial design. Women aged 18–60 years, holding a Coles store loyalty card, who shopped at Coles stores within socioeconomically disadvantaged neighbourhoods and met low-income eligibility criteria were invited to participate. Consenting women completed a baseline survey assessing food shopping and eating habits and food-related behaviours and attitudes. On receipt of their completed survey, women were randomised to either a skill-building intervention or a wait-list control condition. Intervention effects will be evaluated via self-completion surveys and using supermarket transaction sales data, collected at pre- and post-intervention and 6-month follow-up. An economic evaluation from a societal perspective using a cost-consequences approach will compare the costs and outcomes between intervention and control groups. Process evaluation will be undertaken to identify perceived value and effects of intervention components.

Discussion

This study will provide data to address the currently limited evidence base regarding the effectiveness and cost-effectiveness of skill-building intervention strategies aimed at increasing fruit and vegetable consumption among socioeconomically disadvantaged women, a target group at high risk of poor diets.

Trial registration

Current Controlled Trials ISRCTN48771770

Methods for the evaluation of the Jamie Oliver Ministry of Food program, Australia

Background

Community-based programs aimed at improving cooking skills, cooking confidence and individual eating behaviours have grown in number over the past two decades. Whilst some evidence exists to support their effectiveness, only small behavioural changes have been reported and limitations in study design may have impacted on results.

This paper describes the first evaluation of the Jamie Oliver Ministry of Food Program (JMoF) Australia, in Ipswich, Queensland. JMoF Australia is a community-based cooking skills program open to the general public consisting of 1.5 hour classes weekly over a 10 week period, based on the program of the same name originating in the United Kingdom.

Methods/Design

A mixed methods study design is proposed. Given the programmatic implementation of JMoF in Ipswich, the quantitative study is a non-randomised, pre-post design comparing participants undergoing the program with a wait-list control group. There will be two primary outcome measures: (i) change in cooking confidence (self-efficacy) and (ii) change in self-reported mean vegetable intake (serves per day). Secondary outcome measures will include change in individual cooking and eating behaviours and psycho-social measures such as social connectedness and self-esteem. Repeated measures will be collected at baseline, program completion (10 weeks) and 6 months follow up from program completion. A sample of 250 participants per group will be recruited for the evaluation to detect a mean change of 0.5 serves a day of vegetables at 80% power (0.5% significance level). Data analysis will assess the magnitude of change of these variables both within and between groups and use sub group analysis to explore the relationships between socio-demographic characteristics and outcomes.

The qualitative study will be a longitudinal design consisting of semi-structured interviews with approximately 10-15 participants conducted at successive time points. An inductive thematic analysis will be conducted to explore social, attitudinal and behavioural changes experienced by program participants.

Discussion

This evaluation will contribute to the evidence of whether cooking programs work in terms of improving health and wellbeing and the underlying mechanisms which may lead to positive behaviour change.

Trial registration

Australian and New Zealand Trial registration number: ACTRN12611001209987.

Microbiological survey of imported produce available at retail across Canada

Increasing consumption and year-round consumer demand for fresh, minimally processed green vegetables have been observed in Canada and other developed countries. However, in the past two decades, produce has been increasingly implicated in outbreaks and correspondingly recognized as a vector for the transmission of pathogenic microorganisms. To this end, we examined the microbiological quality of imported produce available at retail across Canada during a period of limited domestic availability. In total, 106 samples obtained from five Canadian cities were purchased from retail outlets and subjected to microbiological analyses, including aerobic plate (APC) and coliform counts, and enrichments for enterococci, indicator Escherichia coli, E. coli O157:H7 and Salmonella spp. Also, recovered Enterococcus faecalis and Enterococcus faecium were screened for antimicrobial resistance (AMR). Overall, samples included herbs (n=61), leafy greens (n=25), and spinach (n=20) deriving from five countries (Columbia, Dominican Republic, Guatemala, Mexico, and the United States [US]). APCs were consistent across commodities regardless of country, ranging from mean log10 CFU/g of 6.1 to 7.4, with no significant differences observed. Excluding a single leafy green sample from Guatemala, the lowest prevalence of coliforms was for Mexican herbs (22.2%), with a high of 66.7% on US leafy greens. With the exception of spinach, concentrations of coliforms varied widely, ranging from undetectable to too numerous to count (>8.5 log10 CFU/g). Of the commodities assessed, Mexican and US spinach had the lowest coliform concentrations (undetectable to 4.0 log10 CFU/g). Organic herbs and conventional leafy greens possessed significantly lower (p<0.05) prevalence of coliforms compared to conventional herbs and organic leafy greens, respectively. The most frequent recovery of indicator E. coli was observed for herbs, with 11.1, 8.3, and 3.7% prevalence observed in samples from Columbia, US, and Mexico, respectively. For spinach, 0 and 6.7% of Mexican and US samples tested positive, while no leafy green samples from either country were positive. No E. coli O157:H7 or Salmonella spp. were detected. E. faecium and E. faecalis were recovered from 15.1 and 5.7% of samples, respectively. Although no glycopeptide resistance was observed, resistance to other clinically relevant antibiotics was noteworthy in both species. Overall, though microbiological quality indicators were frequently high, E. coli O157:H7 and Salmonella were not detected. However, the presence of resistance and reduced susceptibility to clinically relevant antimicrobials in recovered enterococci demonstrate imported fresh produce may serve as a vehicle for the transmission of antimicrobial resistance across national borders.

Fruits and vegetables: measuring intake and encouraging increased consumption

A high intake of fruit and vegetables (FV) is associated with reduced risk of chronic disease, although the evidence base is mostly observational. Blood biomarkers offer an objective indicator of FV intake, potentially improving estimates of intakes based on traditional methods. A valid biomarker of overall FV intake would be able to confirm population intakes, more precisely evaluate the association between intakes and health outcomes and confirm compliance in FV interventions. Several substances have been proposed as biomarkers of FV intake: vitamin C, the carotenoids and polyphenols. Certain biomarkers are strong predictors of single FV; however, the proposed single biomarkers of FV consumption are only modestly predictive of overall FV consumption. This is likely to be due to the complexity of the FV food group. While accurately measuring FV intake is important in nutrition research, another critical question is: how best can an increase in FV intake be achieved? Increased FV intake has been achieved in efficacy studies using intensive dietary advice. Alternative, less intensive methods for encouraging FV consumption need to be developed and tested for population level intervention. Systematic reviews suggest peer support to be an effective strategy to promote dietary change. This review will describe the evidence for a link between increased FV intake and good health, outline possible novel biomarkers of FV consumption, present the most recently available data on population intake of FV and examine the usefulness of different approaches to encourage increased consumption of FV.

Fruit and vegetable purchasing patterns and preferences in South Delhi

This study examines associations between consumer characteristics, beliefs, and preferences and fruit and vegetable (FV) purchasing and intake in South Delhi, India. Home interviews were conducted with 245 households, using a structured questionnaire to assess FV consumption and purchasing frequency, spending, place of purchase, mode of travel, knowledge and attitudes toward organics, and beliefs about barriers to FV consumption. In-depth interviews with 62 experts and key informants validated survey findings that street vendors and markets are currently the dominant source of FV in South Delhi and that affordability, not accessibility, is the main barrier to increasing FV intake.

Developing a Multicomponent Model of Nutritious Food Access and Related Implications for Community and Policy Practice

Access to nutritious foods is limited in disenfranchised communities in the United States. Policies are beginning to focus on improving nutritious food access in these contexts; yet, few theories are available to guide this work. We developed a conceptual model of nutritious food access based on the qualitative responses of food consumers in 2 different regions of the American South. Five domains (economic, service delivery, spatial-temporal, social, and personal) and related dimensions of nutritious food access were identified. The conceptual model provides practical guidance to researchers, policy makers, and practitioners working to improve nutritious food access in communities.

Attractive Skin Coloration: Harnessing Sexual Selection to Improve Diet and Health

In this paper we review the mechanisms through which carotenoid coloration could provide a sexually selected cue to condition in species with elaborate color vision. Skin carotenoid pigmentation induced by fruit and vegetable consumption may provide a similar cue to health in humans (particularly light-skinned Asians and Caucasians). Evidence demonstrates that carotenoid-based skin coloration enhances apparent health, and that dietary change can perceptibly impact skin color within weeks. We find that the skin coloration associated with increased fruit and vegetable consumption benefits apparent health to a greater extent than melanin pigmentation. We argue that the benefits to appearance may motivate individuals to improve their diet and that this line of appearance research reveals a potentially powerful strategy for motivating a healthy lifestyle.

Promouvoir la consommation de légumes et de fruits chez des collégiens : application du protocole d’intervention mapping

Résumé:

L’objectif de cet article est de présenter le processus suivi lors du développement, de la mise en œuvre et de l’évaluation d’un programme de promotion de la consommation de légumes et de fruits destiné à des collégiens. Un total de 385 collégiens québécois du Canada âgés de 18 ans en moyenne ont accepté volontairement de participer à cette étude. Le modèle de planification en six étapes de Bartholomew et collaborateurs (2006) a été utilisé. Basée sur la théorie du comportement planifié (Ajzen,1991), l’évaluation des besoins a été effectuée avec un questionnaire auto-administré développé à partir d’une revue de la littérature et de groupes de discussion focalisée auprès de collégiens. Cette première étape a permis d’identifier les déterminants psychosociaux sur lesquels intervenir spécifiquement. Les résultats consistent en un programme d’une durée de quatre heures et demie, qui a été offert à 167 collégiens (groupe expérimental). Adaptées à cette clientèle, et sur des bases théoriques, les activités incluaient l’utilisation d’outils d’auto-évaluation de la consommation quotidienne de légumes et de fruits, le calcul de portions avec une nutritionniste, un quiz sur le web, la rédaction d’un plan pour implanter ses intentions, les démonstrations culinaires de recettes d’un pair avec dégustations et tests de goût. Le programme s’est avéré efficace pour augmenter l’intention comportementale ainsi que le nombre de participants à consommer au moins cinq portions de légumes et de fruits chaque jour, à la fin du programme. Ce protocole permet de structurer une intervention sur mesure visant un changement comportemental chez une clientèle ciblée. Le développement d’un partenariat milieu/université accroît les chances de succès, tant pour l’implantation du programme que pour son efficacité.

Applying research in nutrition education planning: a dietary intervention for Bangladeshi chronic kidney disease patients

BACKGROUND

Effective nutrition health interventions are theory-based, as well as being drawn from practice and research, aiming to successfully accomplish dietary behavioural changes. However, the integration of theory, research and practice to develop community dietary educational programmes is a challenge that many interventionists feel ill equipped to achieve.

METHODS

In the present study, a community-based education programme was designed for Bangladeshi patients with chronic kidney disease and hypertension. The goal of this programme was to reduce dietary salt intake in this population group, with a view to reducing their blood pressure and slowing kidney disease progression.

RESULTS

The present study sets out the first four steps of a six-step model for creating a behaviour change programme.

CONCLUSIONS

These four steps were concerned with the translation of theory and evidence into intervention objectives, and illustrate how a practical, community-based intervention was developed from behavioural theory, relevant research, knowledge of practice and the target patient group. Steps 5 and 6, which are concerned with implementation and evaluation, will be reported separately.

Improving the Comparability of National Estimates of Fruit and Vegetable Consumption for Cross-National Studies of Dietary Patterns

Background

Developing global approaches to the problem of low fruit and vegetable consumption requires cross-nationally comparable estimates of fruit and vegetable consumption. National differences in the definitions of fruits and vegetables and serving size amounts limit the comparability of estimates.

Objectives

To describe national differences in fruit and vegetable definitions, serving size amounts, and how these factors can influence the comparability of fruit and vegetable consumption estimates; and to provide a series of reporting recommendations that could facilitate cross-national studies of fruit and vegetable consumption.

Methods

A comprehensive review of national dietary guidelines, fruit and vegetable definitions, and fruit and vegetable consumption recommendations was undertaken for Canada, the United States, and the United Kingdom.

Results

To improve cross-national comparability, the findings suggest that researchers could report fruit and vegetable consumption separately, provide separate average fruit and vegetable intake amounts, report potato and legume or pulse consumption separately from vegetable consumption, and report consumption of 100% fruit juice separately from fruit consumption.

Conclusions

These four low-cost, high-value additions to conventional research reporting standards will aid in the development of cross-national research on global fruit and vegetable consumption and the design of global policies that can target low fruit and vegetable consumption in populations.

Fruits and vegetables intake and characteristics associated among adolescents from Southern Brazil

Background

Increased body weight has been associated with an unhealthy diet, low consumption of fruits and vegetables. Our objective was to investigate whether adolescents had low intake of fruits and vegetables, and whether gender, age and education could affect the feeding patterns.

Methods

A population-based sample of adolescents, aged 12–19 years, were randomly selected in southern Brazil and included in this cross-sectional study. The total daily consumption of fruits, vegetables, rice and beans were investigated in standardized household interviews, using a food frequency questionnaire and questions, being categorized as five or more servings per day as the five-a-day diet. ANOVA, ANCOVA, and modified Poisson regression were used in the analysis.

Results

Adolescents (n = 568) were included, 49.5% boys, 14.3% had overweight and 8.8% obesity. Approximately 23% of participants consumed five daily servings of fruits and vegetables. It was observed that 36.7% of boys and 31.0% of girls consumed less than one serving of fruit per day, and 58.4% and 44.6%, respectively, consumed less than one serving of vegetables. The consumption of vegetables, fruits, and rice and beans were not independently associated with gender. Overweight was associated with higher intake of five-a-day, independently of confounding factors.

Conclusions

Adolescents from southern Brazil have lower frequency of consumption of five servings a day of fruits and vegetables combined.

Food safety is a key determinant of fruit and vegetable consumption in urban Beninese adolescents

OBJECTIVE

To identify the determinants of fruit and vegetable consumption in urban Beninese adolescents and elements to develop a school-based fruit and vegetable program.

DESIGN

Sixteen focus groups conducted with a key word guide.

SETTING AND PARTICIPANTS

Two private and 2 public secondary schools in Cotonou, Benin. One hundred fifty-three students aged 13 to 19 years, 54% girls.

ANALYSIS

The focus groups were audiotaped, transcribed, and analyzed. Three a priori categories from the Social Cognitive Theory were used for the coding: socioenvironmental, personal, and behavioral factors. Additionally, the data were checked to determine whether new categories should be created.

RESULTS

Major determinants in the school were availability and accessibility of fruits and vegetables, nutrition education, and the competition of unhealthful foods. Food safety emerged as a strong barrier to the adolescents' fruit and vegetable consumption outside home and particularly at school.

CONCLUSIONS AND IMPLICATIONS

Except for food safety, the determinants of fruit and vegetable intake in Beninese adolescents were similar to those in high-income countries. The food safety of fruits and vegetables outside home is a key issue to be studied in detail and integrated in any intervention in Benin and potentially other low- and middle-income countries.

Evaluating the dissemination of Body & Soul, an evidence-based fruit and vegetable intake intervention: challenges for dissemination and implementation research

OBJECTIVE

To evaluate whether the evidence-based Body & Soul program, when disseminated and implemented without researcher or agency involvement and support, would achieve results similar to those of earlier efficacy and effectiveness trials.

DESIGN

Prospective group randomized trial.

SETTING

Churches with predominantly African American membership.

PARTICIPANTS

A total of 1,033 members from the 15 churches completed baseline surveys. Of these participants, 562 (54.4%) completed the follow-up survey 6 months later.

INTERVENTION

Church-based nutrition program for African Americans that included pastoral involvement, educational activities, church environmental changes, and peer counseling.

MAIN OUTCOME MEASURE

Daily fruit and vegetable (FV) intake was assessed at pre- and posttest.

ANALYSIS

Mixed-effects linear models.

RESULTS

At posttest, there was no statistically significant difference in daily servings of FVs between the early intervention group participants compared to control group participants (4.7 vs 4.4, P = .38). Process evaluation suggested that added resources such as technical assistance could improve program implementation.

CONCLUSIONS AND IMPLICATIONS

The disseminated program may not produce improvements in FV intake equal to those in the earlier efficacy and effectiveness trials, primarily because of a lack of program implementation. Program dissemination may not achieve public health impact unless support systems are strengthened for adequate implementation at the church level.

Evaluation of an intervention using a self-regulatory counselling aid: pre- and post- intervention results of the OPTIMAHL 60plus study

OBJECTIVES

The study covers development and evaluation of an innovative counselling aid in an intervention study. The main purpose of the study was to establish whether improvements in nutrition and physical activity behaviour according to standard recommendations can be demonstrated.

METHODS

OPTIMAHL 60plus is a quasi-experimental study in which participants were assigned in clusters to an intervention or control group. The study was conducted in low socio-economic-status districts in Bremen, Germany. 423 elderly participated at baseline and 369 after 3 months intervention. Face-to-face interviews (24-h recall and frequency questionnaire) were conducted at T0 and T1. χ (2)-tests, sign-test and logistic regression were used for statistical analyses.

RESULTS

No significant differences could be shown when comparing the intervention versus control group at T1. Significant changes from T0 to T1 in the intervention group were identified for daily fruit and vegetable (χ (2)-test, p = 0.04), and for weekly fish consumption (χ (2)-test, p = 0.04). However, similar results could also be shown for the control group.

CONCLUSIONS

A practical counselling aid for elderly was developed and evaluated. Changes in the health behaviour of elderly were identified, but effects could not be clearly traced to the intervention.

Intra-family role expectations and reluctance to change identified as key barriers to expanding vegetable consumption patterns during interactive family-based program for Appalachian low-income food preparers

Few Americans eat sufficient vegetables, especially the protective deep orange and dark green vegetables. To address this, a community-based wellness program to broaden vegetables served at evening meals targeting Appalachian food preparers and their families was tested in a randomized, controlled intervention. Food preparers (n=50) were predominately married (88%), white (98%), and female (94%), with several children living at home. Experimental food preparers (n=25) attended the program sessions and controls (n=25) were mailed relevant handouts and recipes. At program sessions, participants received nutrition information, hands-on cooking instruction, and prepared recipes to take home for family evaluation. As qualitative assessment, 10 couples from each treatment group (n=20 couples) were randomly selected for baseline and immediate post-intervention interviews to explore impact on the food preparer's family. These in-depth interviews with the food preparer and their adult partner were tape-recorded and transcribed verbatim. Two researchers conducted thematic analysis using constant comparison. Family flexibility about food choices was assessed using roles, rules, and power concepts from Family Systems Theory. Interviews at baseline revealed dinner vegetable variety was very limited because food preparers served only what everyone liked (a role expectation) and deferred to male partner and children's narrow vegetable preferences (power). Control couples reported no change in vegetable dinner variety post-intervention. Most experimental couples reported in-home tasting and evaluation was worthwhile and somewhat broadened vegetables served at dinners. But the role expectation of serving only what everyone liked and the practice of honoring powerful family members' vegetable preferences remained major barriers to change.

Position of the Academy of Nutrition and Dietetics: food and nutrition for older adults: promoting health and wellness

It is the position of the Academy of Nutrition and Dietetics that all Americans aged 60 years and older receive appropriate nutrition care; have access to coordinated, comprehensive food and nutrition services; and receive the benefits of ongoing research to identify the most effective food and nutrition programs, interventions, and therapies. Health, physiologic, and functional changes associated with the aging process can influence nutrition needs and nutrient intake. The practice of nutrition for older adults is no longer limited to those who are frail, malnourished, and ill. The population of adults older than age 60 years includes many individuals who are living healthy, vital lives with a variety of nutrition-related circumstances and environments. Access and availability of wholesome, nutritious food is essential to ensure successful aging and well-being for the rapidly growing, heterogeneous, multiracial, and ethnic population of older adults. To ensure successful aging and minimize the effects of disease and disability, a wide range of flexible dietary recommendations, culturally sensitive food and nutrition services, physical activities, and supportive care tailored to older adults are necessary. National, state, and local strategies that promote access to coordinated food and nutrition services are essential to maintain independence, functional ability, disease management, and quality of life. Those working with older adults must be proactive in demonstrating the value of comprehensive food and nutrition services. To meet the needs of all older adults, registered dietitians and dietetic technicians, registered, must widen their scope of practice to include prevention, treatment, and maintenance of health and quality of life into old age.

Acceptability of a theory of planned behaviour email-based nutrition intervention

This study investigated feasibility and acceptability of a new email-delivered intervention promoting fruit and vegetable consumption in a university-based population of Australian young adults. The study explored whether there are differences in the reported feasibility and acceptability between demographic groups within the population of interest and at three levels of intervention intensity. The email-delivered intervention program consists of an implementation intention 'planning task' and between 3 and 15 short email messages over a 15-day study period. The intervention program was developed using the Theory of Planned Behaviour and was designed to modify perceived behavioural control. One hundred and ten participants (mean age = 19.21 years, 25.6% male) completed the feasibility and acceptability questionnaire at Day 15. This questionnaire contained items about all intervention components. High acceptability and feasibility scores were found for all intervention parts and at all levels of intervention intensity. There were few significant differences in the reported acceptability of items between key demographic sub-groups, and no differences in reported acceptability at different levels of intervention intensity. These results suggest that this email-delivered intervention is an acceptable and feasible tool for promoting fruit and vegetable consumption for participants in the target population.

The Well London program--a cluster randomized trial of community engagement for improving health behaviors and mental wellbeing: baseline survey results

BACKGROUND

The Well London program used community engagement, complemented by changes to the physical and social neighborhood environment, to improve physical activity levels, healthy eating, and mental wellbeing in the most deprived communities in London. The effectiveness of Well London is being evaluated in a pair-matched cluster randomized trial (CRT). The baseline survey data are reported here.

METHODS

The CRT involved 20 matched pairs of intervention and control communities (defined as UK census lower super output areas (LSOAs); ranked in the 11% most deprived LSOAs in London by the English Indices of Multiple Deprivation) across 20 London boroughs. The primary trial outcomes, sociodemographic information, and environmental neighbourhood characteristics were assessed in three quantitative components within the Well London CRT at baseline: a cross-sectional, interviewer-administered adult household survey; a self-completed, school-based adolescent questionnaire; a fieldworker completed neighborhood environmental audit. Baseline data collection occurred in 2008. Physical activity, healthy eating, and mental wellbeing were assessed using standardized, validated questionnaire tools. Multiple imputation was used to account for missing data in the outcomes and other variables in the adult and adolescent surveys.

RESULTS

There were 4,107 adults and 1,214 adolescent respondents in the baseline surveys. The intervention and control areas were broadly comparable with respect to the primary outcomes and key sociodemographic characteristics. The environmental characteristics of the intervention and control neighborhoods were broadly similar. There was greater between-cluster variation in the primary outcomes in the adult population compared to the adolescent population. Levels of healthy eating, smoking, and self-reported anxiety/depression were similar in the Well London adult population and the national Health Survey for England. Levels of physical activity were higher in the Well London adult population but this is likely to be due to the different measurement tools used in the two surveys.

CONCLUSIONS

Randomization of social interventions such as Well London is acceptable and feasible and in this study the intervention and control arms are well-balanced with respect to the primary outcomes and key sociodemographic characteristics. The matched design has improved the statistical efficiency of the study amongst adults but less so amongst adolescents. Follow-up data collection will be completed 2012.

Components of the diet associated with child adiposity: a cross-sectional study

OBJECTIVE

This study sought to determine which components of youths' diets were related to adiposity while controlling for potential often-neglected confounders such as moderate to vigorous physical activity (MVPA) and dietary reporting error. Secondary goals of this study were to determine the extent to which MVPA confounded the associations between diet and adiposity and whether associations between diet and adiposity would differ depending on reporting error.

METHODS

An ethnically diverse urban sample of 342 children aged 9-10 years and 323 adolescents aged 17-18 years were recruited for this cross-sectional study. Body mass index (BMI) and waist circumference (WC) were measured in the school; dietary assessment included three 24-hour recalls via telephone in the evenings, and MVPA assessment included 5 days of accelerometry. Over (n = 68), under (n = 250), or plausible (n = 347) dietary intake reporters were identified with the Huang calculation method. Linear regression assessed the relationship between adiposity indicators (BMI z-score and WC) and components of the diet (energy intake, food groups, macronutrients) after controlling for reporting error, demographic variables, and MVPA.

RESULTS

When dietary reporting error and potential confounders such as MVPA and demographic variables were controlled, energy intake (EI), vegetables, refined grains, total fat, total protein, and total carbohydrate were positively related to BMI z-score and WC and artificially sweetened beverages to WC. MVPA was a significant confounder. For BMI z-score, but not WC, relationships and strength of these relationships differed depending on dietary reporting error group (plausible, underreporter, overreporter).

CONCLUSIONS

Among plausible reporters, as expected, EI, refined grains, and all macronutrients were positively related to adiposity; however, artificially sweetened beverages and vegetables, which are low-energy-dense foods, were also positively related to adiposity. Reporting error interfered with associations between diet and BMI z-score but not WC, suggesting WC is a more robust measure of adiposity in relation to diet.

The antioxidant effect of β-caryophyllene protects rat liver from carbon tetrachloride-induced fibrosis by inhibiting hepatic stellate cell activation

Plant-based whole foods provide thousands of bioactive metabolites to the human diet that reduce the risk of developing chronic diseases. β-Caryophyllene (CAR) is a common constituent of the essential oil of numerous plants, vegetables, fruits and medicinal herbs, and has been used as a flavouring agent since the 1930 s. Here, we report the antioxidant activity of CAR, its protective effect on liver fibrosis and its inhibitory capacity on hepatic stellate cell (HSC) activation. CAR was tested for the inhibition of lipid peroxidation and as a free radical scavenger. CAR had higher inhibitory capacity on lipid peroxidation than probucol, α-humulene and α-tocopherol. Also, CAR showed high scavenging activities against hydroxyl radical and superoxide anion. The activity of 5-lipoxygenase, an enzyme that actively participates in fibrogenesis, was significantly inhibited by CAR. Carbon tetrachloride-treated rats received CAR at 2, 20 and 200 mg/kg. CAR significantly improved liver structure, and reduced fibrosis and the expression of Col1a1, Tgfb1 and Timp1 genes. Oxidative stress was used to establish a model of HSC activation with overproduction of extracellular matrix proteins. CAR (1 and 10 μm) increased cell viability and significantly reduced the expression of fibrotic marker genes. CAR, a sesquiterpene present in numerous plants and foods, is as a natural antioxidant that reduces carbon tetrachloride-mediated liver fibrosis and inhibits hepatic cell activation.

Societal correlates of diabetes prevalence: An analysis across 94 countries

AIMS

To quantify relationships between societal-level factors and diabetes prevalence and identify potential policy responses.

METHODS

Using data from International Diabetes Federation, World Health Organization, World Bank, and Food and Agricultural Organization, we extracted recent estimates for country-level variables: total caloric availability; sugar, animal fat, fruit and vegetable availability; physical inactivity markers (vehicles per capita and value-added from service sector); gross domestic product per capita (GDP); imports; and age-adjusted mortality rate. We used generalized linear models to investigate relationships between these factors and diabetes prevalence.

RESULTS

Median global diabetes prevalence was 6.4% in 2010. Every additional percentage point of calories from sugar/sweeteners and from animal fats were associated with 5% (OR: 1.05, 95% CI 1.02-1.07) and 3% (OR: 1.03, 95% CI 0.99-1.06) higher diabetes prevalence, respectively, while each additional unit in fruit and vegetable availability was associated with 3% lower diabetes prevalence (OR: 0.97, 95% CI 0.93-0.99). One percent higher GDP from the service industry was associated with a 1% higher diabetes prevalence (OR: 1.01, 95% CI 0.99-1.02).

CONCLUSION

Macro-level societal factors are associated with diabetes prevalence. Investigating how these factors affect individual-level diabetes risk may offer further insight into policy-level interventions.

The efficacy of a brief, peer-led nutrition education intervention in increasing fruit and vegetable consumption: a wait-list, community-based randomised controlled trial

Objective

The objective of the present research was to test the efficacy of Fruit & Veg $ense sessions in increasing fruit and vegetable consumption.

Design

A wait-list randomised controlled trial was conducted (n 292). Intervention participants attended a Fruit & Veg $ense session and received newsletters at weeks 2 and 5 after attending the session. All participants completed an FFQ and a questionnaire measuring knowledge, attitudes, barriers and stage of change for fruit and vegetable consumption at baseline and 6 weeks.

Setting

Hunter region of New South Wales, Australia.

Subjects

Two hundred and ninety-two parents with children of primary school age.

Results

The intervention group significantly increased its mean consumption of fruit and vegetables by 0·62 servings compared with 0·11 in the control group (difference of 0·51, P = 0·001). Compared with the control group, there were significant increases in intervention participants’ knowledge of daily recommended servings (for fruit and vegetables) and serving size (for vegetables), improvement in stage of change for vegetable consumption and a decrease in the number of perceived barriers to fruit and vegetable consumption.

Conclusions

Fruit & Veg $ense is efficacious in increasing fruit and vegetable consumption among parents of primary-school children. The study adds significantly to the limited evidence regarding fruit and vegetable interventions and the feasibility of engaging peer educators to deliver community education sessions. A broader implementation trial to test the effectiveness of Fruit & Veg $ense is recommended.

Appealing to vanity: could potential appearance improvement motivate fruit and vegetable consumption?

Fruit and vegetable consumption is inadequate among adults in the United States; this contributes to preventable morbidity and mortality. More effective dietary intervention strategies are needed. Recently, interventions that advertise the consequences of behavior for appearance have been successful in modifying sun-exposure habits and tobacco use. Such an approach might also facilitate dietary improvement. Consumption of carotenoid-rich fruit and vegetables positively affects skin color, which influences perceptions of health and attractiveness, and promoting such an effect may motivate target audiences to increase consumption of this important food group. This approach represents a novel direction for the field and is potentially suitable for cost-effective, population-level dissemination through the visual media.

The Veggie Project: a case study of a multi-component farmers' market intervention

This case study provides an in-depth examination of process and feasibility factors associated with the development of a multi-component environmental intervention designed to increase access to fresh fruits and vegetables in four low-income, minority, urban communities with few healthy food retail outlets. The intervention, the Veggie Project, included three components: (a) onsite farmers' markets, (b) a Super Shopper voucher program, and (c) a Youth Leader Board. We analyzed receipts from sales transactions at the farmers' markets, close-ended surveys with participants, in-depth interviews with project stakeholders, and journal entries completed by youth participants. Thirty-four farmers' markets occurred, resulting in 1,101 sales transactions. Financial vouchers were used to purchased 63% of the produce. All of the youth Super Shoppers came to the market at least once and made significantly more purchase transactions than adults. The farmers' markets were never accessed by 38% of the adult Super Shoppers. The Veggie Project increased access to healthy foods, particularly among youth. More research is warranted to examine the relationship between market use and dietary behaviors as well as other factors (i.e., besides physical and economic) influencing food access among adults.

Community-based interventions for obesity prevention: lessons learned by Australian policy-makers

BACKGROUND

Interest in community-based interventions (CBIs) for health promotion is increasing, with a lot of recent activity in the field. This paper aims, from a state government perspective, to examine the experience of funding and managing six obesity prevention CBIs, to identify lessons learned and to consider the implications for future investment. Specifically, we focus on the planning, government support, evaluation, research and workforce development required.

METHODS

The lessons presented in this paper come from analysis of key project documents, the experience of the authors in managing the projects and from feedback obtained from key program stakeholders.

RESULTS

CBIs require careful management, including sufficient planning time and clear governance structures. Selection of interventions should be based on evidence and tailored to local needs to ensure adequate penetration in the community. Workforce and community capacity must be assessed and addressed when selecting communities. Supporting the health promotion workforce to become adequately skilled and experienced in evaluation and research is also necessary before implementation.Comprehensive evaluation of future projects is challenging on both technical and affordability grounds. Greater emphasis may be needed on process evaluation complemented by organisation-level measures of impact and monitoring of nutrition and physical activity behaviours.

CONCLUSIONS

CBIs offer potential as one of a mix of approaches to obesity prevention. If successful approaches are to be expanded, care must be taken to incorporate lessons from existing and past projects. To do this, government must show strong leadership and work in partnership with the research community and local practitioners.

Excess weight among colorectal cancer survivors: target for intervention

BACKGROUND

Healthy lifestyle might improve outcome among colorectal cancer (CRC) survivors. In this study we investigated the proportion of survivors who meet recommended lifestyle and weight guidelines and compared this to the general population. Factors that predict current behaviour were also assessed.

METHOD

A random sample of CRC survivors diagnosed between 1998 and 2007 were surveyed. Percentages of current smokers, alcohol consumers, excess weight and clustering of these variables were calculated. Using logistic regression we assessed demographical and clinical factors that predict current lifestyle and excess weight.

RESULTS

We included 1349 (74% response rate) survivors in this study of whom only 8 and 16% of male and female survivors met the recommended lifestyle and body weight. Among male survivors up to 10% had at least two unhealthy lifestyle factors and among women, up to 19%. The proportion of smokers and those who had ever consumed alcohol was lower compared to the general population (13 vs. 31%, 82 vs. 86% respectively), but excess weight (BMI at least 25 kg/m(2)) was more prevalent among survivors (69 vs. 53% respectively). Having received chemotherapy was significantly associated with being overweight (adjusted odd ratio 1.5, 95% confidence interval 1.05-2.3). Younger patients, male gender and survivors of lower socioeconomic status were more likely to show non-compliance to healthy lifestyle recommendations.

CONCLUSION

The observed clustering of unhealthy lifestyle warrants interventions targeting multiple behaviours simultaneously. Reducing excess weight should be one of the most important targets of interventions, particularly for males, those who had chemotherapy and survivors of lower socioeconomic status.

Increased consumption of fruit and vegetables for the primary prevention of cardiovascular diseases

This is the protocol for a review and there is no abstract. The objectives are as follows: The primary objective is to determine the effectiveness of i) advice to increase fruit and vegetable consumption ii) the provision of fruit and vegetables to increase consumption, for the primary prevention of CVD.

Who consumed 5 or more portions of fruit and vegetables per day in 1986-1987 and in 2000-2001?

OBJECTIVE

The aim of the study was to describe who ate 5 or more portions of fruit and vegetables per day ('compliers') in 1986-1987 and in 2000-2001.

DESIGN

We used data from the Dietary and Nutritional Surveys of British Adults. Each is a nationally representative dietary survey using 7 d weighed food records for men and women, aged 16-64 years, living in private households in Great Britain in 1986-1987 and in 2000-2001.

SETTING

Great Britain.

SUBJECTS

Data were analysed for 2197 adults in 1986-1987 and 1724 adults in 2000-2001.

RESULTS

In 1986-1987 12·7 % were classified as 'compliers' compared with 16·5 % in 2000-2001. Manual social classes, younger participants and people on benefits or outside paid employment were less likely to be 'compliers'. Being divorced, widowed or separated was negatively related to being a 'complier', as was being in a household with dependant children or a lone parent with dependant children. Between 1986-1987 and 2000-2001 improvements were seen across social class groups and differences between men and women and between regions were reduced.

CONCLUSIONS

Only 12·7 % participants in the Dietary and Nutritional Surveys of British Adults were classified as 'compliers' in 1986-1987 compared with 16·5 % in 2000-2001. There have been some important changes in the distribution of 'compliers', but the low levels overall support the need for a reinvigorated policy drive to improve compliance with fruit and vegetable goals.

Configuring health care for systematic behavioral screening and intervention

The United States Preventive Services Task Force recommends universal screening and intervention for tobacco use, excessive drinking, and depression. These services improve health outcomes, decrease health care costs, enhance public safety, and generate substantial return on investment. Given the prevalence rates of these behavioral conditions and the time necessary for evidence-based interventions, it will be challenging to integrate behavioral screening and intervention (BSI) into busy health care settings. Therefore, consistent with the principles of the medical home and the chronic care model, the health care team must be expanded to systematically provide BSI. A 2-tiered, stepped-care model is proposed. The first tier of services-consisting of assessment, intervention, and follow-up services-would address most mild-to-moderate behavioral risks or conditions. The second tier would include various specialty-based resources, which would be conserved for patients with greatest need and potential to benefit. With slight enhancement of their training, health educators would be excellent candidates to serve as cost-efficient providers of first-tier services. The proposed model would help the United States realize improved health outcomes and cost savings as health care benefits are expanded to a greater proportion of its population.

Parental and child fruit consumption in the context of general parenting, parental education and ethnic background

This study examines the association between parental and child fruit consumption in the context of general parenting, parental education and ethnic background. A cross-sectional study was performed among 1762 parent-child dyads. Mean age of the children was 8 years. One parent completed a questionnaire to measure their own and their child's fruit consumption, parenting style, education level and ethnicity. In mediation and moderation analyses, child fruit consumption was regressed on parental fruit consumption, parenting style, parental education and ethnicity. Participating children consumed on average 7.5 pieces of fruit per week. Fourteen percent met the recommended Dutch norm of two pieces of fruit per day. Parental and child fruit consumption were positively associated. The association was more pronounced under higher levels of psychological control and behavioural control, and among ethnic groups. Additionally, parental education and child fruit consumption were positively associated. Parental fruit consumption partially mediated this association. Interventions are needed to increase child fruit consumption. Interventions should focus on increasing parental fruit consumption and positive parental modelling, with particular focus on low-SES families. Additionally, interventions that combine positive modelling with positive general parenting skills (e.g. increasing behavioural control) may be more effective than interventions that focus on parental modelling alone.

Effects on nutrient intake of a family-based intervention to promote increased consumption of low-fat starchy foods through education, cooking skills and personalised goal setting: the Family Food and Health Project

Reducing the prevalence of fat-rich, energy-dense diets is a public health priority. The present parallel-designed randomised study compared three interventions aimed to increase intakes of low-fat starchy foods and to reduce fat intakes among 589 individuals from 169 families in the Family Food and Health Project (FFHP). Intervention A was education only, intervention B provided 'cook and eat' sessions only, whereas intervention C included personalised goal setting, 'cook and eat' and education. Diet was assessed at baseline (T0) and at 3 months (T1), 6 months (T2) and 18 months (T3) post-intervention. Retention rates were 75 % at T1, 63 % at T2 and 40 % at T3. ANCOVA (baseline intake as covariate) was assessed between intervention differences at T1, T2 and T3. At T1, individuals in intervention C consumed less fat (P = 0·02) and more total carbohydrate (P = 0·001), starch (P = 0·04) vitamin C (P = 0·002) and NSP (P = 0·01) than those in intervention A. Whereas similar dietary intakes were reported across interventions at T2, participants in intervention C had less energy-dense diets that contained more NSP and vitamin C at T3 than intervention A (P < 0·0001, P = 0·002 and P = 0·01, respectively). Across all intervention groups, the more socially deprived participants in the FFHP (n 119) consumed less fat (P = 0·01) and more total carbohydrate (P = 0·02) at T2 than the least socially deprived (n 240). These data demonstrate the importance of personalised goal setting to translate knowledge and practical cooking skills into healthier food choices, suggesting that low-fat starchy food-focused interventions may be effective in reducing fat intake.

Impact of fruit and vegetable vouchers and dietary advice on fruit and vegetable intake in a low-income population

BACKGROUND/OBJECTIVES

Lower-income subgroups consume fewer servings of fruit and vegetables (FVs) compared with their more advantaged counterparts. To overcome financial barriers, FV voucher delivery has been proposed.

SUBJECTS/METHODS

In a 12-month trial, 302 low-income adults 18-60 years old (defined by evaluation of deprivation and inequalities in health examination centers, a specific deprivation score) were randomized into two groups: dietary advice alone ('advice'), or dietary advice plus FV vouchers ('FV vouchers') (10-40 euros/month) exchangeable for fresh fruits and vegetables. Self-reported data were collected on FV consumption and socioeconomic status at baseline, 3, 9 and 12 months. Anthropometric and blood pressure measurements were conducted at these periods, as well as blood samples obtained for determination of vitamins. Descriptive analyses, multiple linear regression and logistic regression were performed to evaluate the impact of FV.

RESULTS

Between baseline and 3-month follow-up, mean FV consumption increased significantly in both the 'advice' (0.62±1.29 times/day, P=0.0004) and 'FV vouchers' groups (0.74±1.90, P=0.002), with no difference between groups. Subjects in the FV vouchers group had significantly decreased risk of low FV consumption (<1 time/day) compared with those in the advice group (P=0.008). No change was noted in vitamin levels (vitamin C and β-carotene). The high number of lost-to-follow-up cases did not permit analysis at 9 or 12 months.

CONCLUSION

In the low-income population, FV voucher delivery decreased the proportion of low FV consumers at 3 months. Longer-term studies are needed to assess their impact on nutritional status.

Supermarket Healthy Eating for Life (SHELf): protocol of a randomised controlled trial promoting healthy food and beverage consumption through price reduction and skill-building strategies

Background

In the context of rising food prices, there is a need for evidence on the most effective approaches for promoting healthy eating. Individually-targeted behavioural interventions for increasing food-related skills show promise, but are unlikely to be effective in the absence of structural supports. Fiscal policies have been advocated as a means of promoting healthy eating and reducing obesity and nutrition-related disease, but there is little empirical evidence of their effectiveness. This paper describes the Supermarket Healthy Eating for LiFe (SHELf) study, a randomised controlled trial to investigate effectiveness and cost-effectiveness of a tailored skill-building intervention and a price reduction intervention, separately and in combination, against a control condition for promoting purchase and consumption of healthy foods and beverages in women from high and low socioeconomic groups.

Methods/design

SHELf comprises a randomised controlled trial design, with participants randomised to receive either (1) a skill-building intervention; (2) price reductions on fruits, vegetables and low-joule soft drink beverages and water; (3) a combination of skill-building and price reductions; or (4) a control condition. Five hundred women from high and low socioeconomic areas will be recruited through a store loyalty card program and local media. Randomisation will occur on receipt of informed consent and baseline questionnaire. An economic evaluation from a societal perspective using a cost-consequences approach will compare the costs and outcomes between intervention and control groups.

Discussion

This study will build on a pivotal partnership with a major national supermarket chain and the Heart Foundation to investigate the effectiveness of intervention strategies aimed at increasing women's purchasing and consumption of fruits and vegetables and decreased purchasing and consumption of sugar-sweetened beverages. It will be among the first internationally to examine the effects of two promising approaches - skill-building and price reductions - on diet amongst women.

Trial Registration

Current Controlled Trials ISRCTN39432901

Food intake of European adolescents in the light of different food-based dietary guidelines: results of the HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) Study

Objective

Since inadequate food consumption patterns during adolescence are not only linked with the occurrence of obesity in youth but also with the subsequent risk of developing diseases in adulthood, the establishment and maintenance of a healthy diet early in life is of great public health importance. Therefore, the aim of the present study was to describe and evaluate the food consumption of a well-characterized sample of European adolescents against food-based dietary guidelines for the first time.

Design

The HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) Study is a cross-sectional study, whose main objective was to obtain comparable data on a variety of nutritional and health-related parameters in adolescents aged 12·5–17·5 years.

Setting

Ten cities in Europe.

Subjects

The initial sample consisted of more than 3000 European adolescents. Among these, 1593 adolescents (54 % female) had sufficient and plausible dietary data on energy and food intakes from two 24 h recalls using the HELENA-DIAT software.

Results

Food intake of adolescents in Europe is not optimal compared with the two food-based dietary guidelines, Optimized Mixed Diet and Food Guide Pyramid, examined in this study. Adolescents eat half of the recommended amount of fruit and vegetables and less than two-thirds of the recommended amount of milk (and milk products), but consume much more meat (and meat products), fats and sweets than recommended. However, median total energy intake may be estimated to be nearly in line with the recommendations.

Conclusion

The results urge the need to improve the dietary habits of adolescents in order to maintain health in later life.

Impact of a pedometer-based workplace health program on cardiovascular and diabetes risk profile

OBJECTIVE

To evaluate whether participation in a four-month, pedometer-based, physical activity, workplace health programme results in an improvement in risk factors for diabetes and cardiovascular disease.

METHODS

Adults employed within Australia in primarily sedentary occupations and voluntarily enrolled in a workplace programme, the Global Corporate Challenge®, aimed at increasing physical activity were recruited. Data included demographic, behavioural, anthropometric and biomedical measurements. Measures were compared between baseline and four-months.

RESULTS

762 participants were recruited in April/May 2008 with 79% returning. Improvements between baseline and four-months amongst programme participants were observed for physical activity (an increase of 6.5% in the proportion meeting guidelines, OR(95%CI): 1.7(1.1, 2.5)), fruit intake (4%, OR: 1.7(1.0, 3.0)), vegetable intake (2%, OR: 1.3(1.0, 1.8)), sitting time (-0.6(-0.9, -0.3) hours/day), blood pressure (systolic: -1.8(-3.1, -.05) mmHg; diastolic: -1.8(-2.4, -1.3) mmHg) and waist circumference (-1.6(-2.4, -0.7) cm). In contrast, an increase was found for fasting total cholesterol (0.3(0.1, 0.4) mmol/L) and triglycerides (0.1(0.0, 0.1) mmol/L).

CONCLUSION

Completion of this four-month, pedometer-based, physical activity, workplace programme was associated with improvements in behavioural and anthropometric risk factors for diabetes and cardiovascular disease. Long-term evaluation is required to evaluate the potential of such programmes to prevent the onset of chronic disease.

Tailored, iterative, printed dietary feedback is as effective as group education in improving dietary behaviours: results from a randomised control trial in middle-aged adults with cardiovascular risk factors

Background

Tailored nutrition interventions have been shown to be more effective than non-tailored materials in changing dietary behaviours, particularly fat intake and fruit and vegetable intake. But further research examining efficacy of tailored nutrition education in comparison to other nutrition education methods and across a wider range of dietary behaviours is needed. The Stages to Healthy Eating Patterns Study (STEPs) was an intervention study, in middle-aged adults with cardiovascular risk factors, to examine the effectiveness of printed, tailored, iterative dietary feedback delivered by mail in improving short-term dietary behaviour in the areas of saturated fat, fruit, vegetable and grain and cereal intake.

Methods

STEPs was a 3-month randomised controlled trial with a pre and post-test design. There were three experimental conditions: 1) tailored, iterative, printed dietary feedback (TF) with three instalments mail-delivered over a 3-month period that were re-tailored to most recent assessment of dietary intake, intention to change and assessment of self-adequacy of dietary intake. Tailoring for dietary intake was performed on data from a validated 63-item combination FFQ designed for the purpose 2) small group nutrition education sessions (GE): consisting of two 90-minute dietitian-led small group nutrition education sessions and 3) and a wait-listed control (C) group who completed the dietary measures and socio-demographic questionnaires at baseline and 3-months later. Dietary outcome measures in the areas of saturated fat intake (g), and the intake of fruit (serves), vegetables (serves), grain and cereals as total and wholegrain (serves) were collected using 7-day estimated dietary records. Descriptive statistics, paired t-tests and general linear models adjusted for baseline dietary intake, age and gender were used to examine the effectiveness of different nutrition interventions.

Results

The TF group reported a significantly greater increase in fruit intake (0.3 serves/d P = 0.031) in comparison to GE and the C group. All three intervention groups showed a reduction in total saturated fat intake. GE also had a within-group increase in mean vegetable intake after 3 months, but this increase was not different from changes in the other groups.

Conclusions

In this study, printed, tailored, iterative dietary feedback was more effective than small group nutrition education in improving the short-term fruit intake behaviour, and as effective in improving saturated fat intake of middle-aged adults with cardiovascular risk factors. This showed that a low-level dietary intervention could achieve modest dietary behaviour changes that are of public health significance.